NCM 101: Health Assessment

Topic: Collecting Objective Data (Physical Examination)

Reference: Health Assessment in Nursing by Weber and Kelley
SUMMARY NOTES

• What is an Objective Data?

- An objective data includes information about the client that is directly observed during interaction with
the client.
- Information elicited through physical assessment techniques.
• To be able to properly obtain an accurate physical assessment, a nurse must have knowledge in three basic areas:
1. Types and operation of equipment needed for a particular examination
Examples: Use of BP App, Tuning Fork, Thermometer, etc)
2. Preparation of the setting, oneself, and the client for the physical assessment
The physical setting must be considered for the comfort of the client and also the nurse. The physical setting
may affect the data elicited during a physical assessment
Examples: A setting too cold or too hot may affect results of body temperature
3. Performance of the four assessment techniques
Assessment techniques includes Inspection, Palpation, Percussion, and Auscultation
• Indications of Physical Assessment:
1. Routine screening
2. Eligibility prerequisite for health insurance, military service, job, sports, school
3. Admission to a hospital or long-term care facility
• Points to Remember:
1. Reviewing general information
2. Introduction to client
3. Obtaining the health history
4. Pain assessment
5. This is key to holistic approach

I. EQUIPMENT
Prior to examination, the necessary equipment must be prepared and placed in area of examination.

List of Equipment and Its Uses

EXAMINATION EQUIPMENT PURPOSE

All examination
Vital signs
Nutritional status examination
Skin, hair, and nail examination
Head and neck examination
Eye examination
Gloves and Gown Protect the examiner in any part of the examination.
Protects the examiner from any direct contact to
body fluids, blood, secretions, and contaminated
items.
Sphygmomanometer Measures blood pressure.
Stethoscope
Thermometer Measures body temperature
Watch with second hand Take pulse rate, cardiac heart
Pain rating scale Determine perceived pain level
Skin fold calipers Measure skinfold thickness of subcutaneous tissue
Tape measure Measure midarm circumference
Skin marking pen Mark measurements
Weighing scale with height Measure height and weight
attachment
Penlight Provide adequate lighting
Mirror Examine client’s skin
Metric ruler Measure size of skin lesions
Magnifying glass Enlarge visibility of lesions
Wood’s light Test for fungus
Braden scale Predict risk for pressure ulcer development
Pressure ulcer scale for healing Determine degree of healing of a pressure ulcer
Stethoscope Auscultate the thyroid
Small cup of water Help client swallow during a thyroid gland
examination
Penlight Test pupillary constriction
Snellen E chart Test distant vision
Newspaper Test near vision
Opaque card Test of strabismus
 NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley
Ear examination
Mouth, throat, nose, sinus Penlight
examination
Thoracic and lung examination
Heart and neck vessels
Peripheral vascular examination Sphygmomanometer
Abdominal examination
Musculoskeletal examination
Male genitalia and rectal Gloves and lubricant
examination
Female genitalia and rectal Vaginal speculum
examination
Neurologic examination
Ophthalmoscope View the red reflex and examine the retina of the eye
Tuning fork Test for bone and air conduction of sound
(Tuning fork test: rinne and
weber test which helps in
determining conductive and
sensorineural hearing loss)
Otoscope View the ear canal and tympanic membrane
(Eardrum- separates the outer ear from the middle
ear, and when sound reaches the tympanic
membrane it causes it to vibrate)
Transilluminate the sinuses (maxillary, ethmoid,
frontal, sphenoidal)
Gauze pad Grasp tongue to examine the mouth
Tongue depressor Depress tongue to view the throat, check looseness of
teeth, view cheeks, and strength of tongue
Otoscope with wide teeth View internal nose
attachment
Stethoscope Auscultate breath sounds (Abnormal breath sounds:
wheezes-high pitched sounds produced by narrowed
airways
rales-clicking bubbling sound
stridor- wheeze like sound
rhonchi-snoring sound
Ruler and Skin marking pen Measure diaphragmatic excursion (measure of the
movement of lung from its level during full exhalation
to full inhalation, normal: 3-5cm)
Stethoscope Auscultate heart sounds (Normal heart sounds: s1 and
s2, abnormal heart sounds: s3 and s4 but s3 may be
normal at time but may be pathologic)
S1-represents the closure of the atrioventricular
valves
S2-closure of the semilunar valves
S3-transition from rapid to slow ventricular filling
S4-late diastolic sound caused by forced atrial
contraction
Two metric rulers Measure jugular venous pressure
and Measure blood pressure and auscultate vascular
stethoscope sounds
Tape measure Measure size of edema at extremities
Tuning fork Detect vibratory sensation
Doppler ultrasound device Detect pressure and weak pulses
Stethoscope Detect bowel sounds (Borborygmi)
Tape measure and marker Measure size and mark area of percussion of organs
Two small pillows Place under knees to promote relaxation of abdomen
Tape measure Measure size of extremities
Goniometer Measure degree of joint flexion and extension
Promote comfort for client
Penlight Scrotal illumination
Specimen card Detect occult blood
Inspect cervix through dilation of vaginal canal
Bifid spatula, endocervical Obtain endocervical swab and cervical scrape and
broom vaginal pool sample
Large swabs Vaginal examination
Liquid pap medium Pap smear
Specimen card Detect occult blood
Cotton tip applicator Test taste and smell perception
Substances to smell and taste
Same equipment for eye exam Test vision and extraocular movement and pupillary
response
Object to feel Test for stereognosis (ability to recognize objects by
NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley
Percussion hammer
Tongue depressor
Tuning fork
Cotton ball and paper clip
touch)
Test deep tendon reflexes
Test for rise of uvula and gag reflex
Test for vibratory sensation
Test for light, sharp, and dull touch and two-point
discrimination

II. PREPARING FOR EXAMINATION

A. Preparing the Physical Setting

- The nurse must ensure that the examination setting meets the following conditions:
1. Comfortable, warm room temperature
o Provide warm blanket if room temperature cannot be adjusted
2. Private area
o Free of interruptions from others
o Close the door and curtains if possible
3. Quiet area
o Free of distractions
o Turn off the radio, television, or other noisy equipment
4. Adequate lighting
o Best to use sunlight
o Good overhead lighting may be sufficient
o A portable lamp is helpful for illuminating the skin and viewing shadows or contours
5. Firm examination table or bed
o A roll up stool may be useful when it is necessary for the examiner to sit for parts of assessments
6. A bedside table or tray
o To hold and prepare the equipment need for the examination

B. Preparing Oneself
- Assess your own feelings and anxieties before examining the client
- Self-confidence in performing physical assessment by practicing the techniques
- The transmission of infectious agents should be prevented during physical assessment
- General principles to keep in mind in performing physical assessment:
1. Wash hand before the examination, immediately after direct contact with any body fluids, blood, and
contaminated items, and after the examination.
o Wash hand in front of the patient to assure the patient of his or her concern with safety.
2. Always wear gloves
o Gloves must be worn at all times to prevent contact with any body fluids and contaminated items
o Gloves also serve as protection if the examiner have any open cut or skin abrasion
o Change gloves when moving from a contaminated to a clean body site and also in between patients
3. When using pin or other sharp object, always use a new one for the next patients
4. Wear a mask and protective eye googles to avoid being splashed with body fluids or blood
PERSONAL PROTECTIVE EQUIPMENT IS A MUST.

C. Approaching and Preparing the Client

1. Establish rapport with the client before the examination
o Alleviate tension and anxiety the client is experiencing
o Explain briefly the procedures that will be done to the client during examination
2. Respect the client’s desire and requests
o Explain the importance of each part of examination to the client
o A consent form before a physical examination may be provided
3. Provide privacy to the client
o Ask the client to undress and put on a gown
o Allow the patient to keep underwear until just before the genital exam to prevent anxiety
o Leave the room when the client changes into gown
o Knock before entering the room to ensure privacy
4. Begin the examination with the less intrusive procedures
o Nonintrusive procedures allow the client to feel more comfortable
o Continue to explain the procedure to the client and why it is being performed
o Integrate health teaching and health promotion during the examination
 NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley
D. Positioning the Client

Sitting ➢ The client should sit ➢ Head

Position upright on the side of ➢ Neck
the examination table. ➢ Lungs
➢ Permits full expansion ➢ Chest
of the lungs ➢ Back
➢ Allows examiner to ➢ Breast
assess symmetry of ➢ Axilla
upper body parts ➢ Heart
➢ Alternative position is ➢ Vital signs
to lie down with head ➢ Upper
elevated extremities

Supine ➢ Ask client to client to ➢ Head

position lie down with legs ➢ Neck
together on the bed ➢ Chest
➢ Small pillow is placed ➢ Breast
at head to promote ➢ Axilla
comfort ➢ Abdomen
➢ If with trouble ➢ Heart
breathing: slightly ➢ Lungs
raise head of the bed ➢ All extremities
➢ Allows abdominal
muscles to relax and
access site of
peripheral pulses
Dorsal ➢ Client lies down on ➢ Head
Recumbent the bed with knees ➢ Neck
position bent, legs separated ➢ Chest
and feet flat on bed ➢ Axilla
➢ The abdomen should ➢ Lungs
not be assessed with ➢ Heart
this position because ➢ Extremities
the abdominal ➢ Breast
muscles are ➢ Peripheral pulses
contracted
Sim’s Position ➢ Client lies on the left ➢ Rectum
or right side with the ➢ Vaginal area
lower arm placed
behind and upper arm
flexed at the shoulder
and elbow
➢ Lower leg is slightly
flexed and pulled
forward
 NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley
Standing ➢ Client stands still in ➢ Male genitalia
Position normal, comfortable,
resting posture
➢ Allows the examiner
to assess posture,
balance, and gait

Prone ➢ The client lies down ➢ Hip joint

Position on the abdomen with ➢ Back
head at the side
➢ Patients with cardiac
and respiratory
problems cannot
tolerate this position

Knee-Chest ➢ The client kneels on ➢ Rectum

Position the examination table
with the weight of the
body supported by
the chest and knees
➢ 90-degree angle
should exist between
body and hips
➢ Elderly and patients
with respiratory and
cardiac problems may
not tolerate this
position
Lithotomy ➢ The client lies on the ➢ Female genitalia
Position back with the hips at ➢ Reproductive
the edge of the tracts
examination table and ➢ Rectum
feet supported by
stirrups
➢ Keep the client well
draped during the
examination as this
position may cause
patient to feel
uncomfortable
NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley
PHYSICAL EXAMINATION TECHNIQUES

I. Inspection
❖ Involves using the senses of vision, smell, and hearing
❖ Used to observe and detect any normal and abnormal findings
❖ Use the following guidelines as you practice the technique of inspection:
1. Make sure the room is a comfortable temperature. A too cold or too-hot room can alter the normal
behavior of the client and the appearance of the client’s skin.
2. Use good lighting, preferably sunlight. Fluorescent lights can alter the true color of the skin. In addition,
abnormalities may be overlooked with dim lighting.
3. Look and observe before touching. Touch can alter appearance and distract you from a complete, focused
observation.
4. Completely expose the body part you are inspecting while draping the rest of the client as appropriate.
5. Note the following characteristics while inspecting the client: color, patterns, size, location, consistency,
symmetry, movement, behavior, odors, or sounds.
6. Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or both sides of any
individual body part.

II. Palpation
❖ Consists of using parts of the hand to touch
❖ Palpation is used to feel the following characteristics:
1. Texture (rough/smooth)
2. Temperature (warm/cold)
3. Moisture (dry/wet)
4. Mobility (fixed/movable/still/vibrating)
5. Consistency (soft/hard/fluid filled)
6. Strength of pulses (strong/weak/thready/bounding)
7. Size (small/medium/large)
8. Shape (well defined/irregular)
9. Degree of tenderness
❖ Principles of Accurate Palpation:
1. Fingernails should be short.
2. Use sensitive part of the hand.
3. Light to deep palpation.
4. Palpate the tender area at the end of the examination.
5. Let client take slow deep breaths to promote muscle relaxation.
6. Assess skin turgor by lightly grasping body part with fingertips.
❖ Three parts of the hands are used during palpation:
1. Fingerpads
2. Ulnar or palmar surface
3. Dorsal surface

Part of Hand Sensitive to

Fingerpads Fine discrimination
Pulses
Texture
Size
Consistency
Shape
Crepitus
NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley
Ulnar or palmar surface Vibrations
Thrills
Fremitus

Dorsal surface Temperature

❖ The depth of the structure being palpated and thickness of tissue determine what type of palpation to use.
❖ Types of palpation:
1. Light
- Place dominant hand lightly on the surface of the structure
- Little to no depression
- Use circular motion
- Used to feel pulses, tenderness, surface of skin texture, temperature, moisture

2. Moderate
- Depress skin surface 1 to 2 cm (0.5 to 0.75 in)
- Feel palpable body organs and masses
- Note the size, consistency, and mobility of structures
NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley

3. Deep palpation
- Place dominant hand on skin surface and nondominant hand on top of dominant hand to apply pressure
- Depress skin surface between 2.5 and 5 cm (1 and 2 in)
- Feel very deep organs or structures that are covered by thick muscle

4. Bimanual palpation
- Use two hands, place one on each side of the body part being palpated
- Use one hand to apply pressure and the other hand to feel the structure
- Note the size, shape, consistency, mobility of the structures
- Used in assessment of:
o Uterus
o Breast
o Spleen

III. Percussion
❖ Involves tapping body parts to produce sound waves
❖ Uses of percussion:
1. Eliciting pain:
- Percussion helps to detect inflamed underlying structures.
- If an inflamed area is percussed, the client’s physical response may indicate or the client will report that
the area feels tender, sore, or painful.
2. Determining location, size, and shape:
- Percussion note changes between borders of an organ and its neighboring organ can elicit information
about location, size, and shape.
3. Determining density:
- Percussion helps to determine whether an underlying structure is filled with air or fluid or is a solid
structure.
4. Detecting abnormal masses:
- Percussion can detect superficial abnormal structures or masses. Percussion vibrations penetrate
approximately 5 cm deep. Deep masses do not produce any change in the normal percussion vibrations.
5. Eliciting reflexes:
- Deep tendon reflexes are elicited using the percussion hammer.
❖ Types of Percussion:
1. Direct Percussion
- Direct tapping of body part with one or two fingertips to elicit possible
tenderness
NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley

2. Blunt Percussion
- Used to detect tenderness over organs by placing one hand flat on the body
surface and using the fist of the other hand to strike the back of the hand

3. Indirect or mediate percussion

- Most commonly used method of percussion
- Produces sound or tone that varies with the density of underlying structures
- As density increases, sound becomes quieter
- Solid tissue produces a soft tone, fluid produces a louder tone, air produces an
even louder tone
- performed by placing the middle finger of the examiner’s non dominant hand
“pleximeter hand” firmly against the body surface with palm and fingers remaining
off the skin, and the tip of the middle finger of the dominant hand “plexor” strikes the base of the distal
joint of the pleximeter.
- Use a quick & sharp stroke

Sound Intensity Pitch Length Quality Example of

Origin
Resonance Loud Low Long Hollow Normal lung
Heard over part
air and part solid
Hyper-resonance Very loud Low Long Booming Lung with
Heard over emphysema
mostly air
Tympany Loud High Moderate Drum-like Puffed-out cheek
Heard over air Gastric bubble
Dullness Medium Medium Moderate Thud-like Diaphragm
Heard over more Pleural effusion
solid tissue Liver
Flatness Soft High Short Flat Muscle
Heard over very Bone
dense tissue Sternum
Thigh

❖ The following techniques help to develop proficiency in the technique of indirect 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 (ensure that this fingernail is short) 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 carefully to the tone.
6. Use quick, sharp taps by quickly flexing your wrist, not your forearm.

IV. Auscultation
❖ Direct or Immediate Auscultation
- Accomplished by unassisted ear without amplifying device.
- Involves application of ear directly to a body surface.
❖ Mediate Auscultation
- Use of stethoscope in the detection of body sounds.
❖ A technique that requires the use of stethoscope
❖ Use to listen to:
1. Heart sounds
2. Movement of blood through cardiovascular system
3. Movement of bowel
4. Movement of air through the respiratory tract
NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley
❖ Stethoscope:
- When to use the Diaphragm and the Bell?
Diaphragm Bell
➢ Best for higher pitch sounds ➢ Best for lower pitch sounds
➢ For the breath sounds and normal heart sounds ➢ For some bowel sounds, heart murmurs, bruits
❖ These guidelines should be followed as you practice the technique of auscultation:
1. Eliminate distracting or competing noises from the environment (e.g., radio, television, machinery).
2. Expose the body part you are going to auscultate.
3. Do not auscultate through the client’s clothing or gown. Rubbing against the clothing obscures the body
sounds.
4. Use the diaphragm of the stethoscope to listen for highpitched sounds, such as normal heart sounds, breath
sounds, and bowel sounds, and press the diaphragm firmly on the body part being auscultated.
5. Use the bell of the stethoscope to listen for low-pitched sounds such as abnormal heart sounds and bruits
(abnormal loud, blowing, or murmuring sounds). Hold the bell lightly on the body part being auscultated.

Stethoscope

E. Olfaction
❖ Another skill that used during assessment, certain alteration is body function create characteristic body odors,
smelling can detect abnormalities that unrecognized by other means.
❖ Assessment of characteristic odors:
1. Alcohol odor from oral cavity means ingestion of alcohol.
2. Ammonia from urine means urinary tract infection.
3. Body odor from skin, particularly in areas where body parts rub together means poor hygiene, excess
perspiration (bromidrosis).
4. Feces odor from wound site means wound abscess.
5. Foul–smelling stools in infant from stool means mal absorption syndrome.
6. Halitosis from oral cavity means poor dental and oral hygiene, gum disease.
7. Sweet, fruity ketones from oral cavity may be from diabetic acidosis.
8. Musty odor from casted body part means infection inside cast.

CLIENT’S CHART
NCM 101: Health Assessment
Topic: Collecting Objective Data (Physical Examination)
Reference: Health Assessment in Nursing by Weber and Kelley

• Any relevant record made by a health care practitioner at the time of, or subsequent to, a consultation and/or
examination or the application of health management.
• A thorough record of a patient’s medical history and clinical data.
• Medical charts contain medically relevant events that have happened to a person.
• A good medical chart will paint a clear picture of the patient.
• Complete medical charts help ensure patients receive the best care possible.
• Medical charts provide healthcare providers a glimpse into a patient’s medical history and provide vital details
to help clinicians make sound care decisions.
• Good medical records – whether electronic or handwritten – are essential for the continuity of care of your
patients. For health professionals, good medical records are vital for defending a complaint or clinical negligence
claim; they provide a window on the clinical judgment being exercised at the time. The presence of a complete,
up-to-date and accurate medical record can make all the difference to the outcome.
• Includes:
1. Demographics – name, contact information, age, etc.
2. Developmental History – growth charts, motor development, cognitive development, social/emotional
development, language development, etc.
3. Immunization Records – vaccinations and dates
4. Medications
5. Medical allergies
6. Surgical history – operation dates, reports
7. Obstetric history – the number of pregnancies, complications, pregnancy outcomes
8. Family History – immediate family health status, the cause of death, common family diseases
9. Social History – past and current occupations, community support, etc.
10. Habits – alcohol consumption, exercise, diet, smoking, sexual history
• Who can access the client’s chart?
- Individual medical charts must be treated with extreme care.
- Only the patient and the healthcare team members involved in their care are allowed to view or add to a
medical chart.
- Medical charts belong to the patient.
- He or she has the right to make sure the chart is accurate and can grant another party access to the chart.

VALIDATION OF DATA

A. Purpose of Validation
❖ Validation is the process of confirming or verifying that the subjective and objective data collected are reliable
and accurate.
❖ Steps of Validation:
1. Deciding if the data needs validation
2. Determine ways to validate data
3. Identifying areas where data is missing

B. Data Requiring Validation

❖ Conditions that require data to be rechecked and validated:
1. Discrepancies or gap between subjective and objective data
2. Discrepancies or gaps between what the client says at one time versus another time
3. Finding highly abnormal or inconsistent with other findings

C. Methods of Validation
❖ Recheck own data through a repeat assessment
❖ Clarify data with the client by asking additional questions
❖ Verify the data with another health care professional
❖ Compare objective findings with subjective findings