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Pediatrics (PAS2860L) Physical Assessment Exam Study Guide

John Marsh
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Physical Assessment Exam Study Guide

Miami Dade College

Pediatrics (PAS2860L)

Nursing Assessment
1. Part of Nursing Process
2. Nurses use physical assessment skills to:
a) Obtain baseline data and expand the data base from which subsequent phases of the
nursing process can evolve
b) To identify and manage a variety of patient problems (actual and potential)
c) Evaluate the effectiveness of nursing care
d) Enhance the nurse-patient relationship
e) Make clinical judgments
Gathering Data
Subjective data – Said by the client (S)
Objective data – Observed by the nurse (O)
Document: SOAPIER
Assessment Techniques:
The order of techniques is as follows (Inspect – Palpation – Percussion – Auscultation) except for the
abdomen which is Inspect – Auscultation – Percuss – Palpate.
A. Inspection – critical observation *always first*
1. Take time to “observe” with eyes, ears, nose (all senses)
2. Use good lighting
3. Look at color, shape, symmetry, position
4. Observe for odors from skin, breath, wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniques
B. Palpation – light and deep touch
1. Back of hand (dorsal aspect) to assess skin temperature
2. Fingers to assess texture, moisture, areas of tenderness
3. Assess size, shape, and consistency of lesions and organs
4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep
C. Percussion – sounds produced by striking body surface
1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
2. Used to determine size and shape of underlying structures by establishing their borders and
indicates if tissue is air-filled, fluid-filled, or solid
3. Action is performed in the wrist.
D. Auscultation – listening to sounds produced by the body
1. Direct auscultation – sounds are audible without stethoscope
2. Indirect auscultation – uses stethoscope
3. Know how to use stethoscope properly [practice skill]
4. Fine-tune your ears to pick up subtle changes [practice skill]
5. Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]
6. Flat diaphragm picks up high-pitched respiratory sounds best.
7. Bell picks up low pitched sounds such as heart murmurs.
8. Practice using BOTH diaphragms
General Assessment
A general survey is an overall review or first impression a nurse has of a person’s well being. This is
done head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. General
surveying is visual observation and encompasses the following.
Appearance appears to be reported age;
sexual development appropriate;
alert & oriented;
facial features symmetric;
no signs of acute distress
Body structure/mobility weight and height within normal range (refer to Center for Disease Control
and Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age and
gender forms [children]);
body parts equal bilaterally;
stands erect,
sits comfortably;
gait is coordinated;
walk is smooth and well balanced;
full mobility of joints
Behavior maintains eye contact with appropriate expressions;
comfortable and cooperative;
speech clear;
clothing appropriate to climate;
looks clean and fit;
appears clean and well-groomed
Deviations from what would generally be considered to be normal or expected should be documented
and may require further evaluation or action, including a report and/or referral.
Standardized and routine screening such as audiometric screening, scoliosis and vision screening
using the Snellen Test are usually discussed in General Survey areas.



Pediatrics (PAS2860L) Physical Assessment Exam Study Guide

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