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OBJECTIVE DATA For Musculoskeletal Examination - Tape
- include information about the client that the
nurse directly observes during interaction
with him and information elicited through
physical assessment (examination)
techniques.
EQUIPMENTS
- Each part of the physical examination
requires specific pieces of equipment; Prior
to the examination, collect the necessary
equipment and place it in the area where the
examination will be performed. This
promotes organization and prevents the
nurse from leaving the client to search for a
piece of equipment.
For All Examinations – Gloves
For Vital Signs – Sphygmomanometer;
Stethoscope; Thermometer (oral, rectal,
tympanic); Watch with second hand; Pain rating
scale; For Anthropometric Measurements;
Skinfold calipers; Flexible tape measure;
Platform scale with height attachment
For Skin, Hair, and Nail Examination - Ruler
with centimeter markings; Magnifying glass;
Wood’s light
For Head and Neck Examination - Small cup of
water
For Eye Examination – Penlight; Snellen chart;
Ophthalmoscope; Cover card; Newspaper or
Rosenbaum Pocket Screener
For Ear Examination – Otoscope; Tuning fork
For Mouth, Throat, Nose, and Sinus
Examination – Penlight; Tongue depressor;
Piece of small gauze; Otoscope with wide-tip
attachment
For Thoracic and Lung Examination -
Stethoscope (diaphragm); Marking pencil and
centimeter ruler
For Heart and Neck Vessel Examination -
Stethoscope (bell and diaphragm); Two-
centimeter rulers
For Abdominal Examination – Stethoscope’
Marking pencil and tape measure with centimeter
markings; Two small pillows
For Female Genitalia Examination - Vaginal
speculum and lubricant; Slides or specimen
container, bifid spatula, and cotton-tipped
applicator
For Anus, Rectum, Prostate Examination -
Lubricating jelly; Specimen container; For
Peripheral Vascular Examination; Stethoscope
and sphygmomanometer; Flexible tape measure;
Cotton ball and paper clip; Tuning fork; Doppler
ultrasound probe blood
PRENZ JOMAR L. TAGUIBAO | BACHELOR OF SCIENCE IN NURSING
measure; Goniometer
For Neurologic Examination - Tuning fork;
Cotton wisp, paper clip; Soap, coffee; Salt, sugar,
lemon, pickle juice; Tongue depressor; Reflex
hammer; Coin or key
PREPARING FOR THE EXAMINATION
1. Preparing the Physical Setting
2. Preparing Oneself
3. Approaching and Preparing the Client
The nurse–client relationship should be
established during the client interview before the
physical examination takes place. This is important
because it helps to alleviate any tension or anxiety
that the client is experiencing. At the end of the
interview, explain to the client that the physical
assessment will follow and describe what the
examination will involve.
Begin the examination with the less intrusive
procedures such as measuring the client’s
temperature, pulse, blood pressure, height, and
weight.
Approach the client from the right-hand side of the
examination table or bed because most
examination techniques are performed with the
examiner’s right hand (even if the examiner is left-
handed). You may ask the client to change
positions frequently, depending on the part of the
examination being performed
PHYSICAL EXAMINATION TECHNIQUE (IPPA)
• Inspection – involves using the senses of
vision, smell, and hearing to observe and
detect any normal or abnormal findings. This
technique is used from the moment that you
meet the client and continues throughout the
examination; Inspection precedes palpation,
percussion, and auscultation because the
latter techniques can potentially alter the
appearance of what is being inspected.
Although most of the inspection involves the
use of the senses only, a few body systems
require the use of special equipment
• Palpation - Palpation consists of using parts
of the hand to touch and feel for the following
characteristics: texture (rough/smooth),
temperature (warm/cold), moisture (dry/wet),
mobility (fixed/movable/still/ vibrating),
consistency (soft/hard/fluid filled), strength of
pulses (strong/weak/thready/bounding), size
(small/medium/large), shape (well
defined/irregular), and degree of tenderness.
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PARTS OF HANDS TO USE WHEN PALPATING
• Fingerpads - Fine discriminations: pulses,
texture, size, consistency, shape, crepitus
• Ulnar or palmar surface - Vibrations, thrills,
fremitus
• Dorsal (back) surface - Temperature
FOUR TYPES OF PALPATION
• Light palpation: To perform light palpation,
place your dominant hand lightly on the
surface of the structure; There should be very
little or no depression (less than 1 cm). Feel
the surface structure using a circular motion.
Use this technique to feel for pulses,
tenderness, surface skin texture, temperature,
and moisture
• Moderate palpation: Depress the skin
surface 1 to 2 cm (0.5 to 0.75 inch) with your
dominant hand, and use a circular motion to
feel for easily palpable body organs and
masses. Note the size, consistency, and
mobility of structures you palpate
• Deep palpation: Place your dominant hand on
the skin surface and your nondominant hand
on top of your dominant hand to apply
pressure (Fig. 3-2). This should result in a
surface depression between 2.5 and 5 cm (1
and 2 inches). This allows you to feel very
deep organs or structures that are covered by
thick muscle.
• Bimanual palpation: Use two hands, placing
one on each side of the body part (e.g., uterus,
breasts, spleen) being palpated (Fig. 3-3). Use
one hand to apply pressure and the other hand
to feel the structure. Note the size, shape,
consistency, and mobility of the structures you
palpate.
PRENZ JOMAR L. TAGUIBAO | BACHELOR OF SCIENCE IN NURSING
• Percussion - involves tapping body parts to
produce sound waves. These sound waves
or vibrations enable the examiner to assess
underlying structures
USES OF PERCUSSION
• Eliciting Pain
• Determining location, size, and shape
• Determining density
• Determining Abnormal Masses
• Eliciting Reflexes
TYPES OF PERCUSSION
• Direct Percussion - direct tapping of a body part
with one or two fingertips to elicit possible
tenderness
• Blunt Percussion - detect tenderness over
organs (e.g., kidneys) by placing one hand flat
on the body surface and using the fist of the
other hand to strike the back of the hand flat on
the body surface
• Indirect Percussion - most commonly used
method of percussion. The tapping done with
this type of percussion produces a sound or
tone that varies with the density of underlying
structures.
• Auscultation - requires the use of a
stethoscope to listen for heart sounds,
movement of blood through the
cardiovascular system, movement of the
bowel, and movement of air through the
respiratory tract
POSITIONING THE CLIENT
• SITTING POSITION - The client should sit
upright on the side of the examination table.
In the home or office setting, the client can sit
on the edge of a chair or bed. This position is
good for evaluating the head, neck, lungs,
chest, back, breasts, axillae, heart, vital
signs, and upper extremities; This position is
also useful because it permits full expansion
of the lungs and it allows the examiner to
assess symmetry of upper body parts. Some
clients may be too weak to sit up for the entire
examination. They may need to lie down
(supine position) and rest throughout the
examination. Other clients may be unable to
tolerate the position for any length of time. An
alternative position is for the client to lie down
with his or her head elevated
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• SUPINE POSITION - Ask the client to lie
down with the legs together on the
examination table (or bed if in a home
setting). A small pillow may be placed under
the head to promote comfort. If the client has
trouble breathing, the head of the bed may
need to be raised. This position allows the
abdominal muscles to relax and provides
easy access to peripheral pulse sites. Areas
assessed with the client in this position may
include head, neck, chest, breasts, axillae,
abdomen, heart, lungs, and all extremities
• DORSAL RECUMBENT POSITION - The
client lies down on the examination table or
bed with the knees bent, the legs separated,
and the feet flat on the table or bed. This
position may be more comfortable than the
supine position for clients with pain in the
back or abdomen. Areas that may be
assessed with the client in this position
include head, neck, chest, axillae, lungs,
heart, extremities, breasts, and peripheral
pulses. The abdomen should not be
assessed because the abdominal muscles
are contracted in this position
• SIM’S POSITION - The client lies on his or
her right or left side with the lower arm placed
behind the body and the upper arm flexed at
the shoulder and elbow. The lower leg is
slightly flexed at the knee while the upper leg
is flexed at a sharper angle and pulled
forward. This position is useful for assessing
the rectal and vaginal areas. The client may
need some assistance getting into this
position. Clients with joint problems and
elderly clients may have some difficulty
assuming and maintaining this position.
• KNEE-CHEST POSITION - The client kneels
on the examination table with the weight of
the body supported by the chest and knees.
A 90-degree angle should exist between the
body and the hips. The arms are placed
above the head, with the head turned to one
side. A small pillow may be used to provide
comfort. The knee–chest position is useful for
examining the rectum. This position may be
embarrassing and uncomfortable for the
client, and, therefore, the client should be
kept in the position for as limited a time as
possible. Elderly clients and clients with
respiratory and cardiac problems may be
unable to tolerate this position
• LITHOTOMY POSITION - The client lies on
his or her back with the hips at the edge of
the examination table and the feet supported
by stirrups. The lithotomy position is used to
examine the female genitalia, reproductive
tracts, and the rectum. The client may require
assistance getting into this position. It is an
exposed position, and clients may feel
embarrassed. In addition, elderly clients may
not be able to assume this position for very
long or at all. Therefore, it is best to keep the
client well draped during the examination and
to perform the examination as quickly as
possible.
SMALL TEST: Identify the Positions

• STANDING POSITION - The client stands

still in a normal, comfortable, resting posture.
This position allows the examiner to assess
posture, balance, and gait. This position is
also used for examining the male genitalia.

• PRONE POSITION - The client lies down on

his or her abdomen with the head to the side.
The prone position is used primarily to
assess the hip joint. The back can also be
assessed with the client in this position.
Clients with cardiac and respiratory problems
cannot tolerate this position.

PRENZ JOMAR L. TAGUIBAO | BACHELOR OF SCIENCE IN NURSING 3