NURSING HEALTH ASSESSMENT

Jan Michael G. Laraño, RN

Classroom Instructor
LEARNING OBJECTIVES
1. Describe how to prepare oneself, the physical
environment and the client for a physical
examination,
2. List the equipment needed for an
examination,
3. Describe various client positions used for
different parts of the physical examination.
PHYSICAL ASSESSMENT
COMPLETE PHYSICAL ASSESSMENT
✓ General Survey
✓ Vital Sign Measurement
✓ Assessment of Height and Weight
✓ Physical Examination of all structures, organs
and body systems

FOCUSED PHYSICAL ASSESSMENT

✓ Zeros in in the acute problem (unstable, time
constraint)
EQUIPMENT
EXAMINATION EQUIPMENT PURPOSE
All examinations Gloves and gown Protect examiner in any part
of the examination
Vital Signs Sphygmomanometer Measure diastolic and
systolic blood pressure
Thermometer Measure body temperature
Watch with second Take heart rate, pulse rate
hand
Pain rating scale Determine perceived pain
level
EXAMINATION EQUIPMENT PURPOSE
Nutritional status Skinfold calipers Measure skinfold thickness pf
subcutaneous tissue
Flexible tape Measure midarm circumference
measure
Skin-marking pen Mark measurements
Platform scale with Measure height and weight
height attachment
Skin, hair and nail Examination light, Provide adequate lighting
penlight
Mirror Client’s self-examination of the skin

Metric ruler Measure size of skin lesions

Magnifying glass Enlarge visibility of lesion

Wood’s light Test for fungus

Braden scale Predict one’s risk to develop pressure
sore
EXAMINATION EQUIPMENT PURPOSE
Head and neck Stethoscope Auscultate the thyroid
Small cup of water Help client swallow
Eye examination Penlight Test pupillary constriction
Snellen E chart Test distant vision
Newspaper Test near vision
Opaque card Test for strabismus
Ophthalmoscope View the red reflex and examine
retina of the eye
Ear examination Tuning fork Test for bone and air conduction of
sound
Otoscope View the ear canal and tympanic
membrane
Thoracic and lung Stethoscope Auscultate breath sounds
examination
Metric ruler and skin Measure diaphragmatic excursion
marking pen
EXAMINATION EQUIPMENT PURPOSE
Mouth, throat, Penlight Provide light to view the mouth and
nose and sinus the throat
4 x 4 small gauze pad Grasp tongue to examine mouth
Tongue depressor Depress tongue to view throat, check
looseness of teeth view cheeks and
check strength of tongue
Otoscope with wide View internal nose
tip attachment
Heart and neck Stethoscope Auscultate heart sounds
vessel
Two metric rulers Measure jugular venous pressure
Peripheral Sphygmomanometer Measure blood pressure and
vascular and stethoscope auscultate vascular sounds
Flexible metric Measure size of extremities for edema
measuring tape
Tuning fork Detect vibratory sensation
Doppler ultrasound Detect pressure and weak pulses
EXAMINATION EQUIPMENT PURPOSE
Abdominal Stethoscope Detect bowel sounds
Flexible metric Measure size and mark the area of
measuring tape and percussion of organs
skin marking pen
Two small pillows Place under knees and head to
promote relaxation of abdomen
Musculoskeletal Flexible metric Measure size of extremities
examination measuring tape
Goniometer Measure degree of flexion and
extension of joints
Neurologic Cotton-tip applicator Test taste/smell perception
Objects to feel Test for stereognosis
Reflex hammer Test deep tendon reflexes
Cotton ball and clip Test for light , sharp and dull touch
Tongue depressor Test for gag reflex and rise of uvula
Tuning fork Vibratory sensation
EXAMINATION EQUIPMENT PURPOSE
Male genitalia Gloves and water Promote comfort for client
and rectum soluble lubricant
Penlight Scrotal illumination
Specimen card Detect occult blood
Female genitalia Vaginal speculum Inspect cervix through dilatation of the
and rectum and water soluble vaginal canal
lubricant
Bifid spatula, Obtain endocervical swab and
endocervical broom cervical scrape and vaginal pool
sample
Large swabs Vaginal examination
Liquid pap medium Pap smear
Specimen card Detect occult blood
PHYSICAL SETTING
• Comfortable, warm room temperature
• Provide warm blanket if the room temperature
cannot be adjusted
• Private area free of interruptions from
others
• Close the door or pull the curtains if possible
• Quiet area free of distractions
• Turn-off radio, television, or other noisy
equipment
• Adequate lighting
• Sunlight or portable lamp
PHYSICAL SETTING
• Firm examination table or bed at a height
that prevents stooping
• Roll-up stool may be useful when it is necessary
for the examiner to sit for parts of the
assessment

• Bedside table/ tray to hold the equipment

needed for the procedure
TECHNIQUES
INSPECTION

PALPATION

PERCUSSION

AUSCULTATION
INSPECTION
❑ Involves using the senses
of vision, smell and
hearing to observe and
detect any normal or
abnormal findings

❑ Most frequently used

technique

❑ DO NOT RUSH THE

PROCESS
PALPATION
❑ Using sense of touch to collect data
❑ Three parts: Fingerpads (fine sensation, pulsation),
ulnar/palmar (vibration), dorsal surface
(temperature)
❑ LIGHT – very little or no
depression (less than 1cm)
for pulses, temperature
❑ MODERATE – depress the
skin surface1 to 2 cm for
palpable masses or
organs
❑ DEEP – depress the skin
surface between 2.5 to 5
cm for deep organs
PERCUSSION
❑ Used to assess density of
underlying structures,
areas of tenderness and
deep tendon reflexes

❑ Includes assessment of
the following:
❑ Eliciting pain
❑ Determining location, size,
and shape
❑ Determining density
❑ Detecting abnormal
masses
❑ Eliciting reflexes
PERCUSSION
❑ FACTORS influencing the sound produced
❑ THICKNESS of the surface being percussed
❑ TECHNIQUE

❑ TYPES of Percussion
❑ DIRECT PERCUSSION – directly tapping your hand or
fingertip over a body surface to elicit tenderness
❑ BLUNT PERCUSSION – used to detect tenderness over
organs by using one hand flat on the body surface and
using a fist of the other hand to strike the back of the
hand flat on the surface
❑ INDIRECT PERCUSSION – most commonly used method.
PERCUSSION
1. Place the middle finger of your nondominant
hand on the body part you are going to percuss
2. Keep your other fingers off the body part being
percussed because they will damp the tone you
elicit
3. Use the pad of your middle finger of the other
hand to strike the middle finger of your
nondominant hand that is placed on the body
part
4. Withdraw your finger immediately to avoid
damping the tone
5. Deliver two quick taps and listen to the tone
6. Use quick, sharp taps by flexing your wrists
AUSCULTATION
❑ Requires the use of a stethoscope to listen for
heart sounds, movement of air through respiratory
system, movement of blood through
cardiovascular system, and movement of bowel

❑ DIAPHRAGM – detect
high-pitched sounds

❑ BELL – detect low-

pitched sounds
POSITION
SITTING DORSAL
RECUMBENT
SUPINE LEFT LATERAL
RECUMBENT
SIMS’
KNEE-CHEST
PRONE
LITHOTOMY
STANDING
 AREAS ASSESSED
SITTING ❖Head and neck
❖Anterior and posterior
chest for respiratory,
cardiac and breast
exam
❖Vital signs and upper
extremities
PROS/CONS
▪ Provides good
visualization
▪ Allows full expansion
for respiratory
assessment
SUPINE

AREAS ASSESSED
❖Anterior chest for respiratory, cardiac, and
breast exams
❖Pulses and extremities
SIMS’

AREAS ASSESSED
❖Female pelvic and rectal areas: Best
alternative if patient is unable to assume
lithotomy position
PRONE

AREAS ASSESSED
❖Musculoskeletal system
❖Hip joint
DORSAL RECUMBENT

AREAS ASSESSED
❖More comfortable position when pain at the
back is felt
❖Head, neck, chest, axillae, lungs, heart,
extremities, breasts and peripheral pulses
LEFT LATERAL RECUMBENT
KNEE-CHEST

AREA ASSESSED
❖Rectum
LITHOTOMY

AREA ASSESSED
❖ Female genitalia
❖ Reproductive tracts and Rectum
This includes measurement of temperature,
pulse rate, respiratory rate and blood pressure.
It is considered as the most frequent
assessment reflecting cardiopulmonary
function and over all functioning of the body.

A. Documentation
B. General Survey
C. Vital Signs
D. Physical Assessment
Discuss the following terms:

✓ Hyperthermia VS Hypothermia
✓ Tachycardia VS Bradycardia
✓ Inspiration VS Expiration
✓ Hypertension VS Hypotension
✓ Eupnea VS Apnea
✓ Bradypnea VS Tachypnea
You are working on a night shift and while
making rounds to your patient who is 30 years
old, what would you expect the normal heart
rate to be?

A. 55 BPM
B. 80 BPM
C. 165 BPM
D. 150 BPM
Muchisimas Gracias!

Jan Michael G. Laraño, RN

Classroom Instructor