1. Elizabeth M. Long, DNP, APRN, GNP-BC, CNS, 2016
Assessment Review
Elizabeth M. Long, DNP, APRN, GNP-BC, CNS, 2016

2. NCLEX Questions: Client Needs
Four Major Categories
Safe and Effective Care Environment
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity

3. Assessment: Nursing Process
Assessment is always first step
Look at the question
Asking nurse to monitor and observe-assessment?
Asking nurse to take action?

4. Example Question describing a client with respiratory issues
What assessment would nurse carry out?
What intervention would nurse perform?

5. Assessment and Equipment
Always assess patient not equipment first

6. Assessment: Prioritizing
Maslow’s Hierarchy of Needs
Physiological
Safety
Love and Belonging
Self-Esteem
Self-Actualization

7. Ask Yourself
Normal?
Okay?
Abnormal?
Not Okay?

8. Delegation
Assessment
Never delegated to LVN or CNA

9. Common Words Associated with Assessment
Observe
Gather
Collect
Distinguish
Identify
Display
Indicate
Describe
Differentiate
Assess
Recognize
Detect

10. Nurses Use Assessment Skills To
Obtain baseline data on a client
Obtain additional information as a client condition changes
To identify and manage a variety of patient problems (actual and potential)
To evaluate the effectiveness of nursing care
To enhance the nurse-patient relationship and
To Make clinical judgments

11. Assessment Order
Inspection
Palpation
Percussion
Auscultation

12. Abdominal Assessment
Inspection
Auscultation
Percussion
Palpation

13. Inspection Observation Observe with eyes, ears, nose-all your senses
Look at color, shape, symmetry, position
Use good lighting
Done alone and in combination with other assessment techniques

14. Palpation Light and deep touch
Back of hand (dorsal aspect) to assess skin temperature
Fingers to assess texture, moisture, areas of tenderness
Assess size, shape, and consistency of lesions

15. Percussion Sounds produced by striking a body surface
Produces different notes depending on underlying mass (dull, resonant, flat, tympani)
Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air- filled, fluid-filled, or solid

16. Auscultation Listening to sounds produced by body
Direct auscultation – sounds are audible without stethoscope
Indirect auscultation – uses stethoscope

17. Final Thoughts Know normal range assessment values for all ages
Practice, practice , practice questions