Prepared

by:
Vincent Raphael V. Manarang
PHRN, UKRN, MAN
Definition
— This is a form of obtaining objective
data that involves the use of one’s sense
to obtain information about the
structure and function of an area being
observed or manipulated.
4 Basic
2 Considerations
Techniques

— I-nspection — Positioning
— P-alpation — Draping
— P-ercussion
— A-uscultation
 Inspection
— Visual examination (sense of sight)
— with the naked eye and with a lighted instrument.
— Other senses may be considered but Vision is the
most valuable tool.
Focuses on:
- overall appearance of health and illness
- signs of distress
-facial expression and mood
-body size, grooming and personal hygiene
Palpation
— Examination of the body using the
sense of touch.
fingertips – texture and consistency
dorsum – temperature
palm – vibration
 2 Types of Palpation
1. Light (superficial) – dominant hand fingers
presses gently downward while moving the hand
in a circular fashion.
2. Deep
a. Bimanual – dominant hand as light palpation
then finger pads of nondominant hand on the
dorsal surfaces of the distal interphalangeal joint
of the middle 3 fingers of dominant hand.
b. One-hand – fingerpads of dominant hand
press over the area to be palpated then the other
hand supports the mass or organ from below.
Percussion
— The body surface is struck to elicit
sounds that can be heard or vibrations
that can be felt.
— Used to determine whether a structure
is air-filled, fluid-filled or solid.
2 Types of Percussion
1. Direct – strikes directly with the pads of 2, 3
or 4 fingers or with the pad of middle finger.
- rapid and movement is from the wrist.
2. Indirect – middle finger of nondominant
hand (pleximeter) is place on client’s skin.
Using the tip of flexed middle finger of other
hand (plexor), strike the pleximeter at the
distal interphalangeal joint or between the
joints.
 Auscultation
— Listening for sounds produced within the body.
Stethoscope – amplifies the sound and
conveys them to the HCP’s ears.
4 Properties:
1. Frequency
2. Intensity
3. Duration
4. Quality
Health assessment begins with a general
survey that includes observation of the
client’s general appearance, mental status,
vital signs, height and weight.
Appearance
Assessment Normal Deviations
Body built, Proportionate Excessively thin or
height, and obese
weight

Posture and gait Relaxed, erect Tense, slouched, bent

(standing, sitting posture, coordinated posture,
and walking) movement uncoordinated
movement, tremors

Overall hygiene Clean and neat Dirty, unkempt

and grooming
 Assessment Normal Deviations
Body and breath No body odor or Foul body odor,
odor minor relative to ammonia odor,
work and exercise, acetone breath odor,
no breath odor foul breath odor

Signs of distress in No distress noted Bending over

posture or facial because of
expression abdominal pain,
wincing, or labored
breathing
Signs of health or Healthy appearance Pallor, weakness,
illness obvious illness
Mental Status
Assessment Normal Deviations

Level of Responds to Impaired, comatose

Consciousness stimuli

Orientation x3 x2, x1, not oriented

Attitude Cooperative Negative, hostile,

withdrawn
 Assessment Normal Deviation
Affect/ Mood Appropriate Inappropriate
Quantity of speech, Understandable, Rapid or slow pace.
quality and moderate pace, Lacks association,
organization thought association exhibits
confabulation

Relevance and Logical sequence, Illogical sequence,

organization of makes sense, sense flight of ideas,
thoughts of reality confusion
Assessment of Mental Status
Level of Consciousness – awareness and
responsiveness to surrounding environment
Glasgow Coma Scale - for high-risk
patients
Orientation –
X 1 – person (name)
X 2 – person and place (location)
X 3 – person, place and time
(time, day or date)
Mood
normal – happy or pleasant
elated or euphoric – unusually overjoyed
depressed – overly sad
labile – with rapid change of emotions
inappropriate affect – clearly out of context
with the situation
flat affect – few emotions
Inspection and Palpation
1. Color – may be pink, tan, brown, olive or
yellowish
2. Moisture
normal - dry
a abnormal – either extreme dryness or
diaphoretic ( excessive sweating)
3. Temperature – normally warm, hot may
indicate fever and cool may indicate poor
circulation
4. Texture – usually soft and rough over the
elbows, knees and heels of the feet.
5. Turgor – assesses the amount of fluid in the
tissues by pinching a small area of skin
(medial arm or anterior chest)
poor – remains or slowly resumes
position which may indicate
dehydration
 Thorax
Shape:
normal – AP (anterior-posterior) diameter is
approximately one half of the lateral diameter of the
chest
barrel-shaped – AP diameter is enlarged and equal
to lateral diameter
kyphosis – exaggerated convex of the spine
scoliosis – lateral deviation of the spinal curve
kyphoscoliosis - combination
Breathing Pattern
eupnea – normal tachypnea – too fast
Bradypnea – too slow hypoventilation – too shallow
hyperventilation – too deep
Cheyne- Stokes – irregular
Breathing Effort
normal – silent and effortless
Nasal flaring, facial straining and pursed lip breathing indicate
abnormal respiratory effort.
Chest Expansion – symmetric, indicating equal expansion of
both lungs
Auscultation
- Inhale deeply, exhale passively
Normal Breath Sounds
Bronchial – loud and high pitched (sound of
air blowing through a pipe)
location: trachea
Vesicular – soft and breezy
location: overall areas of lungs
Bronchovesicular – breezy but softer and
lower pitched than bronchial sounds
location: anterior chest over main
bronchi and posteriorly between scapulae
Adventitious Breath Sounds
Discontinuous
Crackles (rales) –
Fine – high pitched (hair rolling), do not clear with cough
- end of inpiration
Coarse (rhonchi) – low pitched rumbling, gurgling(I to ex)
Continuous
wheeze – musical noise sounding like a squeak, high pitched,
EX
Pleural friction rub – dry, rubbing or grating sound
(common on inh but can be both)
ASSESSMENT OF BREAST
1. Appearance – normally they appear rounded and
essentially symmetric although one breast is often
slightly larger than the other.
2. Skin – should be smooth and intact with areola
darker in color, round and symmetric
3. Nipple – should be everted and without discharge
or lesions. Abnormal findings include flattening,
redness and edema.
Palpation of Lymph Nodes and Breast
- Hands-of-the-clock or spokes-on-a-wheel
pattern
Concentric Circles Pattern Vertical strips
pattern
Precordium
— Normally, the only movement seen is in the
mitral valve area
PMI (Point of Maximal Impulse) – a visible
pulsation that occurs with ventricular
contraction as the left side of the heart
strikes the anterior chest wall
heave – forceful movement around the area
of the PMI
lift – anterior movement of the sternum
Heart Sounds
Assesment of Abdomen
Inspection
Auscultation
Percussion
Palpation
4 Quadrants
9 Abdominal Regions
Auscultation
— Normal bowel sounds are tinkling, gurgling
noises that occur every 5 to 20 seconds.

— Borborygmi – bowel sounds of increased

frequency and loudness or hyperactive bowel
sounds
Palpation
— Bladder
- deep
- light if obviously distended
— Liver
- deep
Female Genitalia
— Examine labia minora, labia majora, clitoris and
vaginal opening. The color should be pink with
some brown pigmentations.
— Normal vaginal secretions are white, colorless
and odorless.
— Foul-smelling, purulent drainage is abnormal.
Stages of Pubic Hair Dev’t for Female
— Stage 1. Preadolescence. No pubic hair except for fine body
hair.
— Stage 2. Usually occurs at ages 11 and 12. Sparse, long, slightly
pigmented curly hair develops along the labia.
— Stage 3. Usually occurs at ages 12 and 13. Hair becomes darker
in color and curlier and develops over the pubic symphysis.
— Stage 4 Usually occurs between ages 13 and 14. Hair assumes
the texture and curl of the adult but is not as thick and does
not appear on the thighs.
— Stage 5 Sexual maturity. Hair assumes adult appearance and
appears on the inner aspect of the upper thighs
Male Genitalia
— A man may be circumcised or
uncircumcised. If uncircumcised, gently
retract foreskin during examination and
return to original position after inspection.
— Smegma is a normal white discharge that
may collect around the glans especially in
uncircumcised.
— Scrotal sac is wrinkled with left scrotal sac
usually hanging lower than the right.
Tanner Stages of
Male Pubic Hair
and External
Genital
Development
(12 to 16 Years)
Muscle Strength
— Grading Scale:
0 – no detectable muscle contraction
1 – barely detectable contraction
2 – complete ROM with gravity eliminated
3 – complete ROM against gravity
4 – complete ROM against gravity and some
resistance
5 – complete ROM against gravity and full
resistance
Presence of Tremors
Tremor - involuntary trembling of a limb or
body part
Intentional Tremor – more apparent when
client attempts a voluntary movement
Resting Tremor – more apparent when resting
Sensory Assessment
— Evaluate sensory perception by observing
client’s response to:
1. light touch – touch various body
areas with a wisp of cotton
2. vibration – with a tuning fork
3. pain – with a toothpick
*Note any inability to sense stimuli and
affected location of the body.
Arterial Pulses
— Grading Scale for Pulses:
0 – absent
1 – diminished; thready; easily
obliterated
2 – normal
3 – increased; full volume
4 – bounding hyperkinetic
Deep Tendon Reflex
— Grading Reflect Response :
0 – no reflex
+ 1 – minimal activity
+ 2 – normal response
+ 3 – more activity than normal
+ 4 – hyperactive response
* Common reflexes being tested: biceps,
triceps, patellar and achilles
Capillary Refill
— It is a simple test of circulatory status that
uses nailbeds. Press down on the nailbed
until it turns white then note how quickly
the color returns after you release the
pressure.
— Normal refill time is 3 seconds or less; a
prolonged capillary refill time indicates poor
circulation.