Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite
🕿(046) 415-0010 / 🖷(046) 415-0011
www.cvsu.edu.ph
cvsu.op206@gmail.com

COLLEGE OF NURSING

HEALTH ASSESSMENT AND PHYSICAL EXAMINATION

DEFINITION

● Health assessment is the collection of data about an individual’s health. Physical examination is a
head to toe review of each body system that offers objective information about the client and
allows the health care provider to make clinical judgment.

PURPOSE

● Health Assessment
1. To make a clinical judgment or diagnosis about the individual’s health state or condition
2. To obtain baseline data about the client’s functional abilities.
● Physical Examination
1. For routine screening to determine the client’s eligibility for health insurance.
2. For acquiring a new job
3. For client’s admission to the hospital.
EQUIPMENT
● BP apparatus
● Thermometer
● Penlight
● Drape
● Screen
● Tongue Depressor
● Nose Speculum
● Otoscope
● Stethoscope
● Percussiion Hammer
● Vaginal Speculum
● Gloves
● Gowns
 PROCEDURE
1. Assess the client’s physical and psychological
aspect before and during examination.
2. Review the body areas to be examined.
3. Make a physical and environmental
preparation before examination:
1. Environment
A. Infection control - wear gloves during
palpation to reduce contact with microorganisms.
RATIONALE
● Allows health care provider to gather complete
data about the client’s health status.
● Helps examiner (healthcareprovider) identify
which part of the body is to be examined
systematically.
● Proper preparation of the environment, client
and equipment ensures smooth physical
examination with few interruptions.

B. Environmental – client requires privacy. A

well equipped examination room is preferable and
adequate lighting is needed.

C. Equipment – handwashing is done before

examination. Equipment should be clear and
ready for use.

2. Physical preparation involve :

A. Ensuring that client is dressed and properly

draped. If examination is limited to a certain part of
the body it is unnecessary to undress the client
completely.

B. Positioning – health care provider assumes

proper positioning so that the body parts are
accessible and client feels comfortable.

C. Psychological preparation – explaining the

procedure to be done reduces anxiety. The health
care provider should convey an open, receptive
and a professional approach.
4. Gather and take the health history of the client. ● To have a comparison with previous
illness/es and present health condition.
1. Personal history
2. Family history
3. History of present illness
4. History of past illness
5. Conduct physical examination from head to toe ● To assess, determine and identify abnormal
(cephlocaudal) using the four skills in assessment. findings in the body system.

1. Inspection – the process of observation (

sense of sight)
2. Palpation – assessment through the sense
of touch . Through palpation the hands can make
sensitive physical signs which include roughness,
texture and mobility.
3. Percussion – involve tapping the body with
the fingertips to evaluate the size, borders and
consistency of the body organs and to discover
body fluids and body cavities.
4.Auscultation – is listening to the sounds
produced by the body with the aid of stethoscope.

Note the general appearance, level of

consciousness, skin color , nutritional status,
 posture , mobility, facial expression, speech,
hearing and personal hygiene.
PROCEDURE
A. Assessing the skin
1. Skin color
2. Uniformity of skin color
3. Skin lesions
4. Skin moisture
5. Skin turgor
B. Assessing the nails
1. Nail texture
2. Nail plate shape
3. Nail bed color
C. Assessing the head
1. Hair – evenness of growth
over the scalp.
a. evenness
b. texture and oiliness
c. thickness/ thinness
d. infection and infestation (lice)
2. Assesing the skull and face.
a. Skull for size, shape and
symmetry
b. skull for nodules or masses
and depression
c. symmetry of facial movement.
3. Assessing the eye, structure
and visual acuity.
a. Inspect the eyebrows for hair
distribution.
METHODS USED RATIONALE
Inspection ● Varies from light to deep
● Generally uniform except
in areas of lighter
pigmentation (palms,
lips, nail, and beds) in
dark skinned people.
● Freckles, some
birthmark, some flat and
raised nevi (moles) ,
abrasions other lesions.
Palpation ● Moisture in skin folds and
axillae (varies with
environmental
temperature and activity).
● When pinched, skin
springs back to previous
state.
Inspection ● Smooth texture.
● Convex curvature; angle
between nail and nail
bed.
● Highly vascular and pink
in light skinned clients. Dark
skinned clients may have brown
or black pigmentation.
Inspection ● Evenly distributed.
● Silky, resilient hair ,dull
● Thick hair.
● No infection or
infestation.
Inspection/ Palpation ● Rounded (
normocephalic and
symmetric with frontal ,
parietal and occipital
prominences) smooth
contour.
Palpation ● Smooth, uniform
consistency absence of
nodules or masses.
● Symmetrical facial
movement.
Inspection ● Hair evenly distributed,
skin, intact,
symmetrically aligned,
equal movement.
● Skin intact ; no
discharge; no
discoloration.
b. eyelids – ability of blinking.
c. Conjunction (lining the eyelids
by reverting the lids. )
d. Cornea – clarity and texture
e. pupil for color and symmetry of
size.
f. pupil reaction to light.
g. Reaction to accommodation.
4. Assessing the ears.
a. Auricles – color symmetry
b. Auricles for elasticity and area
for tenderness.
c. Hearing acuity :
- Client’s response to normal
voice tones.
- Client’s response to whisperd
voice – nonconsecutive numbers.
5. Assessing the nose
a. External nose for any deviation
in shape, size or in color and
flaring or discharge from the
nares.
b. External nose to determine
any area of tenderness , masses
and displacement of bone and
cartilage
c. Patency of both nasal cavities
6. Assessing the mouth and
oropharynx
a. Lips and buccal mucosa.
b. teeth and gums
c. Tongue/ floor of the mouth.
D. Tongue movement
● Lids close symmetrical.
● Shiny, smooth, pink or
red.
● Transparent, shiny,
smooth, details or iris are
visible.
● Black in color, equal in
size ; normally 3-7 mm in
diameter , round smooth
border, it is flat and
round.
● Illuminated pupil
constricts (directed
response). Non-
illuminated pupil
constricts.
● Pupils constrict when
looking at near object ;
pupils dilate when
looking at far object;
pupils converge when
near object is moved
toward nose.
Inspection ● Color same as facial skin
Palpation ● Mobile firm and not
tender ; pinna recoils
after it is folded.
● Normal voice tones
audible.
● Able to repeat
nonconsecutive numbers
Inspection ● Symmetric and straight.
● No discharge or flaring
● Uniform color.
Palpation ● Not tender, no Lesions
● Air movement is
restricted in one or both
nares
Inspection ● Uniform pink color
(darker in bluish hue in
Mediterranean groups
and dark – skinned
clients
● Pinkish gum, smooth
white, shiny tooth
enamel.
● Central position.
● Moves freely; no
tenderness.
e. Oropharynx and tonsils – ● Pink and smooth
inspect the oropharynx for color posterior wall.
and texture
D. Assessing the neck.
1. Inspect the neck muscles. Inspection ● Muscle equal in size;
head centered.
2. Observe head movement. ● Coordinated, smooth
movement with no
discomfort.
3. Palpate the thyroid glands for Palpation ● Lobes may not be
smoothness palpated.
E. Assessing the thorax and
lungs.
1. Shape symmetry of the thorax Inspection ● Symmetrical chest
from posterior and lateral views.
2.Palpate the posterior thorax Palpitation ● Skin intact ; uniform
temperature
3. Palpate the posterior chest for ● Full and symmetric chest
respiratory excursion . expansion. When the
clients take a deep
breath, your thumb
should move apart an
equal distance and the
separate 3-5cm during
deep inspiration.
4. Anterior thorax. Inspect the Inspection ● Regular rhythm rate
breathing pattern. 16-20/ min.
5. Breath Sounds. Auscultation ● Normal Breath sounds-
vesicular broncho
vesicular and bronchial.
F. Assessing the abdomen.
1 . Inspect the abdomen for skin ● Unblemished skin;
integrity. uniform color.

2. Inspect the abdomen for ● Flat rounded ( convex or

contour and symmetry. scaphoid) concave
3. Auscultate the abdomen for Auscultation ● Audible bowel sounds.
vowel sounds.

4. Palpate the liver Palpation ● May not be palpable.

G. Musculoskeletal
1. Inspect the muscles for size. Inspection ● Equal in size both sides
of the body.
2. Inspect joints for swelling Inspection ● No swelling
3. Palpate each joint for Palpation ● No swelling/ tenderness/
tenderness, smoothness of no nodules.
movement, swelling, and
presence of nodules.
4. Palpate the bones to locate Palpation ● No swelling / tenderness.
any area of edema or tenderness
H. Neurological
1. Bicep reflex- the partners Percussion ● The contraction of the
elbow is slightly bent and the biceps can be seen and
palm faces downward. felt.
2. Triceps reflex- the partners Percussion ● The contraction of the
elbow is sharply bent; forearm is triceps can be seen as
placed across the chest wall with the elbow.
the palm turned toward the body.
The triceps muscle is struck with
the percussion hammer just
above the elbow.
3. Knee – patient is in the sitting Percussion ● The contraction of the
position. The patella is struck quadriceps causes the
with the percussion hammer. If knee to extend.
patient is lying down, the reflex is
tested while the examiners hands
are placed under the knees to
bend them.
4. Ankle – legs bent at the knee Percussion ● The foot jerks and moves
and the foot is supported in a downward.
walking position. The Achilles
tendon is struck with the
percussion hammer.
5. Plantar – the lateral aspect of Percussion ● The toes bend or curl.
the sole of the foot is stroked with
an object.