OBJECTIVES
Identify the purpose of physical examination
Explain the four techniques used in physical
examination.
List the guidelines of Health Assessment of the
adult.
Introduction
Health assessment may be conducted starting at the
head and proceeding in a systemic manner downward
toward toe.
Varies according to the
Age
Severity of illness
Preference of nurse
Hospital policy
ASSESSING HEALTH
Assessing client’s health status is a major component of
nursing care.
Has 2 aspects:
1. Nursing Health history
2. Physical Examination
3 Types of Physical Examination:
1. A complete assessment (head to toe)
2. Examination of a body system (e.g., digestive)
3. Examination of a body area (e.g., left leg)
PURPOSES:
To obtain baseline data about the client’s
functional abilities;
To supplement and confirm or disprove data
obtained in the nursing history;
To obtain data that will help establish nursing
diagnoses and plans of care;
To evaluate the physiological outcomes of health
care and thus the progress of a client’s health
problems.
To make clinical judgments about client’s health;
Methods of Examining
Inspection
Palpation
Percussion
Auscultation
1. INSPECTION
The visual examination by using sense of sight.
Inspects with naked eye / may use instruments for
proper viewing
eg: Using otoscope and tongue depressor
Assess moisture, color, texture, size, shape, position
and symmetry of the body.
Inspection
2. PALPATION
Using the sense of touch.
Pads of fingers are used because the nerve endings
will be highly sensitive to tactile discrimination.
This is used to determine:
Texture (e.g. of the hair)
Temperature (e.g. of a skin area)
Movement of the joint
Position, size, consistency of organs
Distension (urinary bladder)
Pulsation
Tenderness or pain
Palpation
Two types of palpation:
1. Light palpation
2. Deep palpation (contra indicated for
abdominal pain)
Guidelines for palpation:
• Nurses' hands should be clean & warm.
• Areas of tenderness should be palpated last.
• Deep palpation to be done after light palpation.
3.PERCUSSION
Act of striking the body surface to
elicit sounds & vibration.
2 types of Percussion:
1. Direct percussion: Using 1-4 pads of
fingers to strike the surface of the
body
2. Indirect percussion: Using a finger of
one hand to tap the finger of the
nondominant hand
Percussion
4. AUSCULTATION
Listening to sounds produced within the body.
2 types:
1. Direct auscultation: uses unaided ear
(e.g., wheeze, grating of a moving joint)
2. Indirect auscultation: uses Stethoscope
(e.g., bronchial, heart sounds)
Auscultation
Auscultation with Auscultation with a
flat-disc bell-shaped
diaphragm diaphragm
Reflexes examination
Reflex tests are performed as part of
a neurological exam.
Purpose of Reflexes Examination
A mini-exam done to quickly
confirm integrity of the spinal cord
or a more complete exam performed
to diagnose the presence and
location of spinal cord injury or
neuromuscular disease.
Some Types of Reflexes:
Biceps reflex : Slight flexion of the elbow
Triceps reflex: Slight extension of the elbow
Brachioradialis: Normal flexion & supination of
forearm
Achilles reflex: Normal plantar flexion
Plantar reflex: Five toes bend downward
Note:
Absence of a reflex indicates for a spinal cord, nerve root, peripheral nerve, or
muscle injury/damage.
How to calculate the body mass index?
Weight in Kilogram
Formula: -----------------------------------
(Height in meters)2
Ranges Description
< 18.5 Under weight
18.5-24.9 Normal
25-29.9 Overweight
30-34.9 High Obesity
35-39.9 Very High Obesity
>40 Extremely Obese
EQUIPMENT & USES
EQUIPMENT USES
1 Flash / pen light To view pharynx, cervix, & to
determine the reactions of the pupil.
2 Laryngeal mirror To observe pharynx & oral cavity.
3 Nasal speculum To visualize the lower & middle
turbinate.
4 Ophthalmoscope To visualize the interior of the eye.
5 Otoscope To visualize the eardrum & external
auditory canal.
6 Percussion/reflex/ To test reflexes.
knee hammer
EQUIPMENT & USES
EQUIPMENT USES
7 Tuning fork To test hearing acuity &
vibratory sense.
8 Cotton applicators To obtain specimens
9 Gloves To protect the nurse and the
client
10 Lubricant To ease insertion of
instruments
11 Tongue blades/ To depress the tongue during
depressors assessment of mouth
12 Vaginal speculum To assess the cervix & vagina
EQUIPMENT & USES
EQUIPMENT USES
13 Weighing scale To get the weight of the client
14 Measuring tape To measure vital statistics of
the body
15 Snellen’s Chart To test distance vision
16 Stethoscope To listen to the sound of the
heart, lungs and abdomen.
17 Sphygmomanometer Used to measure blood
pressure
18 Thermometer To measure body temperature
