Page 364 - Saunders Comprehensive Review For NCLEX-RN

abdominal assessment).

B. Assessment techniques

1. Inspection
a. The first assessment technique, which
uses vision and smell senses while
observing the client
b. Requires good lighting, adequate body
exposure with draping, and possibly
the use of certain instruments such as
an otoscope or ophthalmoscope
2. Palpation
a. Uses the sense of touch; warm the
hands before touching the client.
b. Identify tender areas and palpate them
last.
c. Start with light palpation to detect
surface characteristics, and then
perform deeper palpation.
d. Light palpation is done with 1 hand by
pressing the skin gently with the tips
of 2 or 3 fingers held close together;
deep palpation is done by placing 1
hand on top of the other and pressing
down with the fingertips of both
hands.
e. Assess texture, temperature, and
moisture of the skin, as well as organ
location and size and symmetry if
appropriate.
f. Assess for swelling, vibration or
pulsation, rigidity or spasticity, and
crepitation.
g. Assess for the presence of lumps or
masses, as well as the presence of
tenderness or pain.
3. Percussion
a. Involves tapping the client’s skin to
assess underlying structures and to
determine the presence of vibrations
and sounds and, if present, their
intensity, duration, pitch, quality, and
location
b. Provides information related to the
presence of air, fluid, or solid masses
as well as organ size, shape, and
position
c. Descriptions of findings include

364