Nursing Tips: Health Assessment

Assessing skin turgor should be done by gently pinching/lifting the skin on the sternum. If the skin "tents," (i.e., stays lifted for a prolonged period and doesn't quickly return to its original place) it could indicatedehydration.

When assessing the eyes, the sclera should be white. The tympanic membrane of the ears, however, should be pearly gray.

Asking the patient to stick out their tongue and move it side to side is an effective way to assess the function of Cranial Nerve XII (Hypoglossal).

When assessing for "Accommodation," ask the patient to focus their eyes on a distant object, then to a near object. The pupils should constrict when focusing on the near object!

"Vesicular" breath sounds are a normal finding upon auscultation (i.e., the sound air makes flowing in and out of lungs). "Adventitious" breath sounds are always abnormal!

A patient is POSITIVE for orthostatic hypotension if: The SBP decreases more than 20mmHg when changing position AND/OR the DBP decreases more than 10mmHg

Nociceptive pain is caused by tissue damage or inflammation. Neuropathic pain is caused by nerve damage.

Order of physical assessment: Inspect, palpate, percuss, auscultate. EXCEPT for assessing the abdomen: Inspect, auscultate, percuss, palpate (to avoid altering bowel sounds).