PHYSICAL HEALTH ASSESSMENT

1. COMPLETE ASSESSMENT (E.G., WHEN A CLIENT IS ADMITTED TO A HEALTH CARE AGENCY),

2. EXAMINATION OF A BODY SYSTEM (E.G., THE CARDIOVASCULAR SYSTEM)
3. EXAMINATION OF A BODY AREA (E.G., THE LUNGS, WHEN DIFFICULTY WITH BREATHING IS
OBSERVED).

PURPOSES OF THE PHYSICAL EXAMINATION

 TO OBTAIN BASELINE DATA ABOUT THE CLIENT’S FUNCTIONAL ABILITIES.

 TO SUPPLEMENT, CONFIRM, OR REFUTE 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 PROBLEM
 TO MAKE CLINICAL JUDGMENTS ABOUT A CLIENT’S HEALTH STATUS.
 TO IDENTIFY AREAS FOR HEALTH PROMOTION AND DISEASE PREVENTION.

STEPS IN PHYSICAL HEALTH ASSESSMENT

1. PREPARING THE CLIENT

 EXPLAIN THE DETAILS ABOUT THE PHYSICAL HEALTH ASSESSMENT INCLUDE DETAILS ON WHEN AND
WHERE THE EXAMINATION WILL TAKE PLACE, WHY IT IS IMPORTANT, AND WHAT WILL HAPPEN.
 INSTRUCT THE CLIENT THAT ALL INFORMATION GATHERED AND DOCUMENTED DURING THE
ASSESSMENT IS KEPT CONFIDENTIAL
 ASSIST THE CLIENT AS NEEDED TO UNDRESS AND PUT ON A GOWN

NOTE:

CLIENTS SHOULD EMPTY THEIR BLADDERS BEFORE THE EXAMINATION. DOING SO HELPS THEM FEEL
MORE RELAXED AND FACILITATES PALPATION OF THE ABDOMEN AND PUBIC AREA. IF A URINALYSIS IS
REQUIRED, THE URINE SHOULD BE COLLECTED IN A CONTAINER FOR THAT PURPOSE. THE SEQUENCE
OF THE ASSESSMENT DIFFERS WITH CHILDREN AND ADULTS. WITH CHILDREN, ALWAYS PROCEED FROM
THE LEAST INVASIVE OR UNCOMFORTABLE ASPECT OF THE EXAM TO THE MORE INVASIVE.

POSITIONING

IN PREPARING THE CLIENT THERE ARE SEVERAL POSITIONS THAT ARE USED DEPENDING ON WHAT
BODY AREAS ARE BEING ASSESSED. THE CLIENT’S ABILITY TO ASSUME A POSITION, PHYSICAL
CONDITION, ENERGY LEVEL, AND AGE ARE CONSIDERED. SOME POSITIONS ARE EMBARRASSING AND
UNCOMFORTABLE AND THEREFORE SHOULD NOT BE MAINTAINED FOR LONG.

NOTE: THE ASSESSMENT IS ORGANIZED SO THAT SEVERAL BODY AREAS CAN BE ASSESSED IN ONE
POSITION, THUS MINIMIZING THE NUMBER OF POSITION CHANGES NEEDED
 POSITION DESCRIPTION AREAS ASSESSED CONTRAINDICATED
DORSAL RECUMBENT BACK-LYING POSITION FEMALE GENITALS, NOT TOLERATED BY
WITH KNEES FLEXED AND RECTUM, AND PATIENTS WITH
HIPS EXTERNALLY FEMALE CARDIOPULMONARY
ROTATED; SMALL PILLOW REPRODUCTIVE TRACT PROBLEMS
UNDER THE HEAD; SOLES
OF FEET ON THE
SURFACE
SUPINE (HORIZONTAL BACK-LYING POSITION HEAD, NECK, AXILLAE,
RECUMBENT) WITH LEGS EXTENDED; ANTERIOR
WITH OR WITHOUT THORAX, LUNGS,
PILLOW UNDER THE BREASTS, HEART,
HEAD VITAL SIGNS,
ABDOMEN,
EXTREMITIES,
PERIPHERAL PULSES
SITTING A SEATED POSITION, HEAD, NECK, ELDERLIES NEED SUPPORT
BACK UNSUPPORTED POSTERIOR AND
AND LEGS HANGING ANTERIOR THORAX,
FREELY LUNGS, BREASTS,
AXILLAE, HEART, VITAL
SIGNS, UPPER
AND LOWER
EXTREMITIES,
REFLEXES
LITHOTOMY BACK-LYING POSITION FEMALE GENITALS,
WITH FEET SUPPORTED RECTUM, AND
IN STIRRUPS; THE HIPS FEMALE
SHOULD BE IN LINE WITH REPRODUCTIVE TRACT
THE EDGE OF THE TABLE
SIMS’ SIDE-LYING POSITION RECTUM, VAGINA
WITH LOWERMOST ARM
BEHIND THE BODY,
UPPERMOST LEG FLEXED
AT HIP AND KNEE, UPPER
ARM FLEXED AT
SHOULDER AND ELBOW
PRONE LIES ON ABDOMEN WITH POSTERIOR THORAX,
HEAD TURNED TO THE HIP JOINT
SIDE, WITH OR WITHOUT MOVEMENT
A SMALL PILLOW

2. PREPARING THE ENVIRONMENT

 NEEDS TO BE WELL LIGHTED AND THE EQUIPMENT SHOULD BE ORGANIZED FOR EFFICIENT USE.
 ROOM SHOULD BE WARM ENOUGH TO BE COMFORTABLE FOR THE CLIENT.
 PROVIDE PRIVACY BY PLACING DRAPES AND BY LIMITING THE PEOPLE PRESENT INSIDE THE ROOM
UNLESS THE CLIENT ASKS FOR SOMEONE

DRAPING

DRAPES SHOULD BE ARRANGED SO THAT THE AREA TO BE ASSESSED IS EXPOSED AND OTHER BODY
AREAS ARE COVERED. EXPOSURE OF THE BODY IS FREQUENTLY EMBARRASSING TO CLIENTS. DRAPES
PROVIDE NOT ONLY A DEGREE OF PRIVACY BUT ALSO WARMTH. DRAPES ARE MADE OF PAPER, CLOTH,
OR BED LINEN.
 INSTRUMENTATION

SHOULD BE CLEAN, IN GOOD WORKING ORDER, AND READILY ACCESSIBLE. EQUIPMENT IS FREQUENTLY
SET UP ON TRAYS, READY FOR USE.

SUPPLIES PURPOSE
FLASHLIGHT OR PENLIGHT TO ASSIST VIEWING OF THE PHARYNX OR TO DETERMINE THE
REACTIONS OF THE
PUPILS OF THE EYE

OPHTHALMOSCOPE A LIGHTED INSTRUMENT TO VISUALIZE THE INTERIOR OF THE EYE

OTOSCOPE A LIGHTED INSTRUMENT TO VISUALIZE THE EARDRUM AND EXTERNAL
AUDITORY CANAL
(A NASAL SPECULUM MAY BE ATTACHED TO THE OTOSCOPE TO
INSPECT THE NASAL
CAVITIES)
PERCUSSION (REFLEX) AN INSTRUMENT WITH A RUBBER HEAD TO TEST REFLEXES
HAMMER
TUNING FORK A TWO-PRONGED METAL INSTRUMENT USED TO TEST HEARING ACUITY
AND VIBRATORY
SENSE
COTTON APPLICATORS TO OBTAIN SPECIMENS
GLOVES TO PROTECT THE NURSE
TONGUE BLADES TO DEPRESS THE TONGUE DURING ASSESSMENT OF THE MOUTH AND
(DEPRESSORS PHARYNX

METHODS OF EXAMINATION

1. INSPECTION
 VISUAL EXAMINATION, WHICH IS ASSESSING BY USING THE SENSE OF SIGHT.
 OLFACTORY (SMELL) AND AUDITORY (HEARING) CUES ARE NOTED.
 ASSESS MOISTURE, COLOR, AND TEXTURE OF BODY SURFACES, AS WELL AS SHAPE, POSITION, SIZE,
COLOR, AND SYMMETRY OF THE BODY.

2. PALPATION
 EXAMINATION OF THE BODY USING THE SENSE OF TOUCH.
 THE PADS OF THE FINGERS ARE USED BECAUSE THEIR CONCENTRATION OF NERVE ENDINGS MAKES
THEM HIGHLY SENSITIVE TO TACTILE DISCRIMINATION.
 DETERMINES :

TEXTURE SIZE, CONSISTENCY, AND MOBILITY OF

TEMPERATURE ORGANS OR MASSES
VIBRATION DISTENTION
POSITION PULSATION
TENDERNESS OR PAIN.

TWO TYPES OF PALPATION

1. LIGHT PALPATION

THE NURSE EXTENDS THE DOMINANT HAND’S FINGERS PARALLEL TO THE SKIN SURFACE AND PRESSES
GENTLY WHILE MOVING THE HAND IN A CIRCLE. IF IT IS NECESSARY TO DETERMINE THE DETAILS OF A
MASS, THE NURSE PRESSES LIGHTLY SEVERAL TIMES RATHER THAN HOLDING THE PRESSURE.

2. DEEP PALPATION
IN DEEP BIMANUAL PALPATION, THE NURSE EXTENDS THE DOMINANT HAND AS FOR LIGHT PALPATION,
THEN PLACES THE FINGER PADS OF THE NON-DOMINANT HAND ON THE DORSAL SURFACE OF THE
DISTAL INTERPHALANGEAL JOINT OF THE MIDDLE THREE FINGERS OF THE DOMINANT HAND. THE TOP
HAND APPLIES PRESSURE WHILE THE LOWER HAND REMAINS RELAXED TO PERCEIVE THE TACTILE
SENSATIONS

IN DEEP PALPATION USING ONE HAND, THE FINGER PADS OF THE DOMINANT HAND PRESS OVER THE
AREA TO BE PALPATED. OFTEN THE OTHER HAND IS USED TO SUPPORT FROM BELOW

CHARACTERISTICS OF MASSES

 LOCATION-SITE ON THE BODY, DORSAL/VENTRAL SURFACE

 SIZE-LENGTH AND WIDTH IN CENTIMETERS
 SHAPE-OVAL, ROUND, ELONGATED, IRREGULAR
 CONSISTENCY-SOFT, FIRM, HARD
 SURFACE-SMOOTH, NODULAR
 MOBILITY-FIXED, MOBILE
 PULSATILITY- PRESENT OR ABSENT
 TENDERNESS- DEGREE OF TENDERNESS TO PALPATION

3. PERCUSSION

THE ACT OF STRIKING THE BODY SURFACE TO ELICIT SOUNDS THAT CAN BE HEARD OR VIBRATIONS
THAT CAN BE FELT. IT IS USED TO DETERMINE THE SIZE AND SHAPE OF INTERNAL ORGANS BY
ESTABLISHING THEIR BORDERS. IT INDICATES WHETHER TISSUE IS FLUID FILLED, AIR FILLED, OR SOLID.

TWO TYPES OF PERCUSION

1. DIRECT PERCUSSION

THE NURSE STRIKES THE AREA TO BE PERCUSSED DIRECTLY WITH THE PADS OF TWO, THREE, OR FOUR
FINGERS OR WITH THE PAD OF THE MIDDLE FINGER. THE STRIKES ARE RAPID, AND THE MOVEMENT IS
FROM THE WRIST.

2. INDIRECT PERCUSSION

THE STRIKING OF AN OBJECT HELD AGAINST THE BODY AREA TO BE EXAMINED. THE MIDDLE FINGER OF
THE NONDOMINANT HAND, REFERRED TO AS THE PLEXIMETER, IS PLACED FIRMLY ON THE CLIENT’S
SKIN. ONLY THE DISTAL PHALANX AND JOINT OF THIS FINGER SHOULD BE IN CONTACT WITH THE SKIN.
USING THE TIP OF THE FLEXED MIDDLE FINGER OF THE OTHER HAND, CALLED THE PLEXOR, THE NURSE
STRIKES THE PLEXIMETER, USUALLY AT THE DISTAL INTERPHALANGEAL JOINT OR A POINT BETWEEN
THE DISTAL AND PROXIMAL JOINTS. THE STRIKING MOTION COMES FROM THE WRIST; THE FOREARM
REMAINS STATIONARY

FIVE SOUNDS ELICITED BY PERCUSSION

1. FLATNESS

AN EXTREMELY DULL SOUND PRODUCED BY VERY DENSE TISSUE, SUCH AS MUSCLE OR BONE.

2. DULLNESS

A THUDLIKE SOUND PRODUCED BY DENSE TISSUE SUCH AS THE LIVER, SPLEEN, OR HEART.

3. RESONANCE

IS A HOLLOW SOUND SUCH AS THAT PRODUCED BY LUNGS FILLED WITH AIR.

4. HYPERRESONANCE
IS NOT PRODUCED IN THE NORMAL BODY. IT IS DESCRIBED AS BOOMING AND CAN BE HEARD OVER AN
EMPHYSEMATOUS LUNG.

5. TYMPANY

IS A MUSICAL OR DRUMLIKE SOUND PRODUCED FROM AN AIR-FILLED STOMACH

4. AUSCULTATION

IS THE PROCESS OF LISTENING TO SOUNDS PRODUCED WITHIN THE BODY. A STETHOSCOPE IS USED
PRIMARILY TO LISTEN TO SOUNDS FROM WITHIN THE BODY, SUCH AS BOWEL SOUNDS OR VALVE
SOUNDS OF THE HEART AND BLOOD PRESSURE. THE DIAPHRAGM BEST TRANSMITS HIGH-PITCHED
SOUNDS AND THE BELL BEST TRANSMITS LOW-PITCHED SOUNDS SUCH AS SOME HEART SOUNDS.

TWO TYPES OF AUSCULTATION

1. DIRECT AUSCULTATION

IS PERFORMED USING THE UNAIDED EAR, FOR EXAMPLE, TO LISTEN TO A RESPIRATORY WHEEZE OR
THE GRATING OF A MOVING JOINT.

2. INDIRECT AUSCULTATION
PERFORMED USING A STETHOSCOPE, WHICH TRANSMITS SOUNDS TO THE NURSE’S EARS.