NCM 101 LECTURE | Module 5 | Shane Ann Braga BSN 1N

Physical Assessment  Provide adequate information about the

procedure, what to expect during the
procedure, and what is expected of the client,
A. Skin, Hair, and Nails to gain his cooperation
B. Head and Neck  Provide a new clean gown
C. Eyes
D. Ears PREPERATION THE ENVIRONMENT FOR
E. Mouth, Throat, Nose and Sinuses PHYSICAL EXAMINATION
F. Thorax and Lungs  The examination room should be adequately
G. Breasts and Lymphatic System ventilated, comfortable, quiet, private with
adequate lighting
H. Heart and Neck Vessels
 Position the examination table so that both
I. Peripheral Vision sides of the patient are easily accessible
J. Abdomen  The examination table should be at a height
K. Musculoskeletal System that prevents the examiner from stooping and
L. Neurologic System should be equipped to raise the head up to 45
M. Male Genitalia, Anus and Rectum degrees.
N. Female Genitalia, Anus, and Rectum  A bedside stand or table should be available
to lay out all equipment needed.
PHYSICAL ASSESSMENT
 Systematic collection of objective information TECHNIQUES USED IN PHYSICAL
that is directly observed or is elicited through EXAMINATION
examination techniques  Inspection
 Defined as a complete assessment of a  Palpation
patient’s physical and mental status  Percussion
 Auscultation
PURPOSE
 To obtain baseline data about the client’s INSPECTION
functional abilities.  It is concentrated watching; involves the use
 To supplement, confirm, or refute data of sense of sight.
obtained in the nursing history.  Observe the patient as a whole then each
 To obtain data that will help establish nursing body system.
diagnoses and plans of care.  Done first when assessing each body system.
 To evaluate the physiological outcomes of  Inspect both sides for body symmetry.
health care and thus the progress of a client’s  It requires good lighting and adequate
health problem. exposure of body parts.
 It requires occasional use of certain
instruments.
PRINCIPLES INSPECTION FOCUSES ON
 Proceed in a systematic manner
 Overall appearance of health or illness
 Use a planned sequence
 Signs of distress
 Use a specific landmarks to locate areas to be
 Facial expression or mood
assessed
 Body size
 Grooming and personal hygiene
PREPARATIONS
PREPERATION THE CLIENT FOR PHYSICAL PALPATION
EXAMINATION  Process of examining the body by using the
 Prepare the patient physically and sense of touch to assess the characteristics of
psychologically to allay anxiety. the body structures underlying the skin:
 Provide privacy to prevent feelings of texture, temperature, moisture of the skin;
embarrassment organ location and size; any swelling;
vibration or pulsation; rigidity or spasticity;
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 NCM 101 LECTURE | Module 5 | Shane Ann Braga BSN 1N
crepitation; presence of lumps or masses; and
presence of tenderness or pain.
USING THE PARTS OF THE HAND
 Fingertips – tactile discrimination like skin
texture, swelling, pulsation, and presence of
lumps.
 Grasping Action of the Fingers and Thumb
– position, shape, and consistency of an organ
or mass.
 Back of Hands and Fingers – temperature
 Base of Fingers – best for vibration
PRINCIPLES
 You should have short fingernails.
 You should warm your hands prior to placing
them on the patient.
 Encourage the patient to continue to breathe
normally throughout the process.
 If pain is experienced during palpation,
discontinue immediately.
 Inform the client where, when and how the
touch will occur.
DEEP PALPATION
 In deep bimanual palpation, the nurse
extends the dominant hand then places the
finger pads of the nondominant hand on the
dorsal surface of the dominant hand
 For deep palpation using one hand, the finger
pads of the dominant hand press over the
area to be palpated
LIGHT (SUPERFICIAL) PALPATION
 The nurse extends the dominant hand’s
fingers parallel to the skin surface and
presses gently while moving the hand in a
circle
 If it is necessary to determine the details of a
mass, the nurse presses lightly several times
rather than holding the pressure.
PERCUSSION
 It is tapping the patient’s skin with short,
sharp strokes to assess underlying structures.
 The characteristic sound produced during
percussion depicts the location, size and
density of the underlying organ.
PURPOSE
 Mapping out the location and size of an organ.
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 Detecting the density (air, fluid or solid) of a
structure by a characteristic note.
 Detecting an abnormal mass, whether it is
superficial or deep.
 Eliciting pain if the underlying structure is
inflamed, as with sinus areas or over the
kidney.
 Eliciting a deep tendon reflex using the
percussion hammer.
INDIRECT PERCUSSION
 The middle finger of the nondominant hand,
referred to as the pleximeter, is placed firmly
on the client’s skin.
 Using the tip of the flexed middle finger of the
other hand, called the plexor, the nurse
strikes the pleximeter, usually at the distal
interphalangeal joint or a point between the
distal and proximal joints.
DIRECT PERCUSSION
 The nurse strikes the area to be percussed
directly with the pads of two, three, or four
fingers or with the pad of the middle finger
 The strikes are rapid, and the movement is
from the wrist.
DIFFERENTIATION OF PERCUSSION NOTES
 Amplitude
 Pitch
 Quality
 Duration
AMPLITUDE (Intensity)-is the loud or soft sound
may be produced, depending on the force of the blow
and the ability of the body part to vibrate.
PITCH (Frequency)-more rapid vibrations produced
a high pitched tone; slower vibrations yield a low
pitched tone. This is expressed in terms of “cps”
cycles per second or number of vibrations per
second.
QUALITY (TIMBRE)- ▪A pure tone is a sound of one
frequency. Variations within a sound wave produce
overtones.
DURATION - ▪ the length of time the note lingers. A
structure with relatively more air produces a louder,
deeper and longer sound because it vibrates freely. A
denser, more solid structure gives a softer, higher,
shorter sound because it does not vibrate as easily.
 NCM 101 LECTURE | Module 5 | Shane Ann Braga BSN 1N
 Papery or thin
 Leathery

PERCUSSION NOTES AND THEIR

CHARACTERISTICS ASSESS SKIN TEMPERATURE (Palpate)

 Cool and clammy

 Cold to touch
 Hot
\\ ASSESS SKIN TURGOR (Palpate)

AUSCULTATION
 Is listening to sounds produced by the body
with the use of stethoscopes.
 The two end pieces of the stethoscopes are
the diaphragm and bell.

PRINCIPLES
 Warm the end piece by rubbing it in your skin.
 Never listen through a patient’s gown or
clothing. ASSESS SKIN EDEMA (Palpate)
 Avoid on breathing on the tubing or bumping of
the tubing together.  Edema is the presence of excess interstitial
fluid
4 CAHARCTERISTICS OF SOUND
 Pitch
 Loudness
 Quality
 Duration

A. SKIN (I,P)
ASSESS SKIN FOR COLOR VARIATIONS  Pitting edema - applying pressure to the
swollen area causes an indention that persists
 Pallor for some time
 Cyanosis
 Jaundice
 Erythema
 Ecchymosis
 Petichiae
 Vitiligo

ASSESS SKIN TEXTURE (Palpate)

ASSESS SKIN LESIONS
 Dry or moist
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NCM 101 LECTURE | Module 5 | Shane Ann Braga BSN 1N
 When palpating lesions use thumb and index
finger
 Cancer Lesions (ABCDE)
○ Asymmetry
○ Border Irregularity
○ Color Variation
○ Diameter > 6 mm
○ Evolving

VASCULAR LESIONS

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 NCM 101 LECTURE | Module 5 | Shane Ann Braga BSN 1N
PALPATE NAIL TO ASSESS TEXTURE AND
CONSISTENCY, NOTING WHETHER NAIL PLATE IS
A. HAIR (I,P) ATTACHED TO NAIL BED
INSPECT THE SCALP AND HAIR FOR GENERAL
COLOR AND CONDITION  Smooth and firm
 Firmly attached to nail bed
INSPECT THE AMOUNT AND DISTRIBUTION OF
SCALP, BODY, AXILLAE, AND PUBIC HAIR TEST CAPILLARY REFILL

 Pink tone returns immediately (2 secs) to

blanched nail bed
Skull

 Lighter in color than the complexion.

 Can be moist or oily.
 No scars noted.
 Free from lice, nits and dandruff.
 No lesions should be noted.
 No tenderness or masses on palpation.
Hair
 Can be black, brown or burgundy depending
on the race.
 Evenly distributed covers the whole scalp (No
evidences of Alopecia)
 Maybe thick or thin, coarse or smooth.
 Neither brittle nor dry.
B. HEAD (I,P)
INSPECT THE HEAD
 Inspect for size, shape, and configuration
 Inspect for involuntary movement
 Palpate for consistency
NOTE CONSISTENCY, DISTRIBUTION, AND COLOR
OF HAIR
OBSERVE SYMMETRY, FEATURES, EXPRESSIONS,
CONDITION OF SKIN
HAVE CLIENT SMILE, FROWN, SHOW TEETH,
BLOW OUT CHEEKS, RAISE EYEBROWS, AND
TIGHTLY CLOSE EYES

A. NAIL (I,P)
INSPECT NAIL GROOMING AND CLEANLINESS

 Nails are clean and manicured

INSPECT NAIL COLOR AND MARKINGS

 Pink tone
 Longitudinal ridging is normal

INSPECT SHAPE OF NAILS

 160-degree angle between the nail base and

the skin
1. Observe the face for shape.
PALPATE NAIL TO ASSESS TEXTURE
2. Inspect for Symmetry
 Hard and immobile  Inspect for the palpebral fissure (distance
between the eye lids); should be equal in
both eyes.

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 NCM 101 LECTURE | Module 5 | Shane Ann Braga BSN 1N
 Ask the patient to smile, There should be
bilateral Nasolabial fold(creases
extending from the angle of the corner of
the mouth). Slight asymmetry in the fold
is normal.
 If both are met, then the Face is
symmetrical
3. Test the functioning of Cranial Nerves that
innervates the facial structures
CN V (Trigeminal)
Sensory Function
 Ask the client to close the eyes.
 Run cotton wisp over the fore head, check and
jaw on both sides of the face.
 Ask the client if he/she feel it, and where she
feels it.
 Check for corneal reflex using cotton
Motor function
 Ask the client to chew or clench the jaw
 The client should be able to clench or chew
with strength and force.
CN VII (Facial)
Sensory function (This nerve innervate the anterior
2/3 of the tongue).
 Place a sweet, sour, salty, or bitter substance
near the tip of the tongue.
 Normally, the client can identify the taste.
 To assess the temporomandibular joint (TMJ),
place your index finger over the front of each
ear as you ask the client to open her mouth
B. EYES (I,P)
ASSESS VISUAL FUNCTION. PERFORM VISUAL
ACUITY USING SNELLEN CHART
 Normal result of the Snellen Test is 20/20
 Numerator indicates distance of the patient
from the chart.
 Denominator indicates the distance at which
the normal eye can read the letter.
 If the denominator increased, the patient has
myopia.
 If the denominator decreased, the patient has
hyperopia.
 If the result is 20/200, the patient is legally
blind.
TEST PERIPHERAL VISION
 The client should see the examiner’s finger at
the same time the examiner sees it.
 Normal visual fields:
Inferior: 70 degrees
Superior: 50 degrees

Motor function
 Ask the client to smile, frown, raise eye brow,
close eye lids, whistle, or puff the cheeks.

TEST SENSATIONS OF THE FOREHEAD, CHEEKS

AND CHIN

 Instruct patient to close the eyes and let them

say yes if they feel anything on their face
 Let the patient describe the sensation

PALPATE TEMPORAL ARTERIES FOR ELASTICITY

AND TENDERNESS

 The temporal artery is elastic and not tender

PALPATE TEMPOROMANDIBULAR JOINT

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NCM 101 LECTURE | Module 5 | Shane Ann Braga BSN 1N

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