LICEO DE CAGAYAN UNIVERSITY, PASEO DEL RIO CAMPUS

BACHELOR OF SCIENCE IN NURSING – 1A

HEALTH ASSESSMENT MIDTERM LECTURE
TRANSES BY: RHARA MAALAM

COLLECTING OBJECTIVE DATA

- Information about the client that the nurse directly observes during interaction
and the information elicited through PHYSICAL ASSESSMENT techniques.
- Knowledge on the 3 basic areas:
 Types of and Operation of equipment needed
 Preparation of the setting, oneself and the client for PA
 Performance of the 4 assessment techniques (Inspection, Palpation,
Percussion, and Auscultation)

 EQUIPMENT
 Collect all the necessary equipment – promotes organization and
prevents the nurse from leaving the client to search for a piece of
equipment.

 SETTING
 Hospital room, outpatient clinic, physician’s office, school health office,
employee health office, client’s home.

 CONDITION
 Comfortable, warm room temperature – warm blanket
 Private area free from interruptions – close door, pull curtains
 Quiet area free from distractions – turn off the radio, television or other
noisy equipment
 Adequate lighting – sunlight, portable lamp
 Firm examination table or bed at a height that prevents stooping. Roll up
stool prn
 A bedside table/tray to hold the equipment needed

 PREPARING ONESEF
 Assess your own feelings
 Self-confidence in performing PA

 GENERAL PRINCIPLES
 Wash hands, if possible in the examination room in front of the client.
Wear gloves if necessary – assures the client that you are concerned about
his/her safety.
 Wear gloves if you have an open cut or skin abrasion or if the client has
an open or weeping cut, collecting fluids, handle contaminated surfaces,
or examining mouth, genitalia, vagina, or rectum.
 If using pin or other sharp objects is used – discard and use a new one for
the next client.
 Wear mask and protective eye googles – likely splash with blood or other
bloody fluids, cough
 APPROACHING AND PREPARING THE CLIENT
 Nurse-Client relationship (establish to alleviate tension/anxiety)
 Explain the PA will follow and describe what the examination will involve
 Change into gown – remove underwear prn
 Respect the client’s desires prn and requests related to PA
 Explain – importance.
 Begin with the less intrusive procedures
 Approach from the right side – most examination techniques are
performed with the examiner’s right hand.

 4 TECHNIQUES IN PHYSICAL EXAMINATION

1. INSPECTION
 Involves using the senses of vision, smell, and hearing to observe and
detect any normal or abnormal findings
 Precedes palpation, percussion, and auscultation
 Uses of senses- body senses require special equipment

 GUIDELINES:
o Make sure the room is a comfortable temperature, a too cold or
too hot temperature can alter the normal behavior and the
appearance of the client’s skin
o Used good lighting, preferably sunlight. Fluorescent light can alter
the true color of the skin. In addition, abnormalities may be
overlooked with the dim lighting.
o Look and observe before touching
o Completely expose the body part you are inspecting while draping
the rest of the client as appropriate
o Note the following characteristics while inspecting color, patterns,
size, location, consistency, symmetry movement, behavior, odors,
and sounds
o Compare the appearance of symmetric body parts or both sides of
any individual body part

2. PALPATION
 Uses parts of the hands to touch and feel

TEXTURE ROUGH-SMOOTH
TEMPERATURE WARM-COLD
MOISTURE DRY-WET
MOBILITY FIXED-MOVABLE OR STILL-
VIBRATING
CONSISTENCY SOFT-HARD OR FLUID FILLED
STRENGTH STRONG-WEAK-THREADY
SIZE S-M-L
SHAPE WELL-DEFINDE OR IRREGULAR
 3 parts of the hands:
o FINGERPADS – fine discriminations, pulses, texture, size,
consistency, shape and crepitus.
o ULNAR OR PALMAR SURFACES – vibrations, thrills and fremitus
o DORSAL (BACK) SURFACE – temperature
 CREPITUS: Grating, crackling popping sounds and sensation experienced
under the joint or skin
 FREMITUS: palpable vibration
 STANDARD PRECAUTIONS: if applicable; Light palpation (safest) and the
most comfortable to moderate palpation to deep palpation.
 INSTRUCTIONS:
o 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 the technique to feel for pulses, tenderness, and surface
of skin structure, temperature and moisture.
o Moderate Palpation
- Depress the skin surface 1-2 cm with your dominant hand
and use a circular motion to feel easily palpable body organs
and masses
- Note size, consistency, and mobility of structures you
palpate
o Deep Palpation
- Place your dominant hand on the skin surface and your non-
dominant hand on the top of your dominant hand to apply
pressure
- Result in surface depression between 2.5-5 cm
- Allows you to feel very deep organics or structures that are
covered by thick muscles
o Bimanual Palpation
- Uses 2 hands, placing one on each side of the body (uterus,
breasts and spleen) being palpated
- Use the other hand to apply pressure and the other hand to
feel the structure
- Note size, shape, consistency and mobility of structure you
palpate.
3. PERCUSSION
 Involves tapping the body parts to produce sound waves
 These sound waves or vibrations enables the examiner to assess underlying
structures
 USES:
o Eliciting pain
o Determining location, size, and shape
o Determining density
 3 types of percussion:
o Direct – direct with 1 or 2 fingertips
o Blunt – place one hand flat and using the fist of the other hand to
strike
o Indirect – produces sound variation
 Different percussion sounds:
o Flatness (bones, such as clavicle, ribs, and sternum)
o Dullness (dense organs such as the liver, spleen and heart)
o Resonance (adult lung)
o Hyperresonance (child lung)
o Tympany (abdominal area such as intestines and stomach)
o Percussion (sound of thigh)
o Percussion sound when puffed-out cheek is tympanic sound
o Air then resonance
o Fluid is dull sound

4. AUSCULTATION
 Requires to use stethoscope to listen classified according to: intensity, pitch,
duration, and quality.
 GUIDELINES:
o Eliminate distracting or competing noises from environment
o Expose – do not auscultate through clothing and rubbing against the
clothing obscures body sounds
o Diaphragm – listen to high pitch sounds such as heart, breath and
bowel sounds
o Bell – low-pitched sounds such as bruits-abnormal loud, blowing or
murmuring heart sound.

 GENERAL SURVEY
 First step in a head to toe assessment
 Info will provide clues about the overall health status of the client
 Includes: Overall impression of the client, mental status, Vital signs.
 Level of consciousness – if it is the patient is aware and alert the
environment. Ask name, address, phone number, date and time.

 VITAL SIGNS
 Non-invasive
 Provide data that reflect the status of several body parts
 Temperature: first and puts the client at ease and remain still for several
minutes
  Peripheral Pulse, respirations, and BP: influenced by anxiety and activity-
accurate.

1. TEMPERATURE
 Increase during:
o Strenuous exercise
o Stress
o Ovulation
o Lowest in early morning (4 – 6 am)
o Highest in evening (8pm to midnight)
 Hypothermia – below 36.5 degree Celsius
o Prolonged exposure to cold
o Hypoglycemia
o Hypothyroidism
o Starvation
 Hyperthermia – above 38.0 degree Celsius
o Viral or bacterial infection
o Malignancies
o Trauma
o Blood, endocrine and immune disorders

2. PULSE
 Radial – gives a good overall picture of the client’s health status.

3. RESPIRATIONS
 Additional clues to the client’s overall status.

4. BLOOD PRESSURE
 Distensibility of arteries – increases BP if with more effect to push blood
through stiffened arteries.
 General impression:
o Observe physical and sexual development
o Compare age with apparent age
o Observe dress
o Observe hygiene
o Observe posture and gait

5. PAIN
 Acute – less than 6 months or recent injury
 Chronic – more than 6 months and have specific cause/injury
 Cancer Pain – compression

 NUTRITIONAL ASSESSMENT
 Anthropometric measurements: helps evaluate the client’s physical,
developmental and nutritional status
 First: obtain height and weight and compare to a standard table
 Hydration affected by:
- Exposure to excessively high environmental temperature
 - Inability to access adequate fluid, sugar rich, caffeine, and soft
drinks
- Impaired thirst mechanism
- Taking diuretics
- Severe hyperglycemia
- High fever

1. SKIN
 As you perform each part of the head to toe assessment, assess skin
variation, texture, temperature, turgor, edema, and lesions
 PHYSICAL EXAMINATION OF THE SKIN PROCEDURE:
o Inspect the skin to evaluate color and pigmentation
o NORMAL FINDINGS: Lighter pigmented races versus darker-pigmented
races
o Hyperpigmentation is a common finding to light-skinned people
o DEVIATIONS FROM NORMAL: suggest compromises in metabolism,
circulation, or oxygenation such as pallor, jaundice, cyanosis and
erythema.

 INSPECT AND PALPATE THE SKIN TO EVALUATE TEXTURE AND THICKNESS

NORMAL FINDINGS:
o Smooth (unexposed areas), rough
 DEVIATION FROM NORMAL:
o Rough skin, friable, and easily broken or disrupted in integrity
 EVALUATE SKIN TURGOR BY LIFTING A FOLD OF SKIN BETWEEN YOUR
THUMB AND FOREFINGER:
o NORMAL FINDINGS – elastic and rapidly returns to its original
shape when group between thumb and forefinger.
o DEVIATION FROM NORMAL – Poor skin turgor (slow to resume its
original shape when pitched. Loss of turgor)