St.

Paul College of Ilocos Sur

( Member, St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

NCM 101: Health Assessment

Module 7

TECHNIQUES IN PHYSICAL
ASSESSMENT

Melanio P. Rojas Jr, MAN

Clinical Instructor

2024
Module No. 7

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 TECHNIQUES IN PHYSICAL ASSESSMENT

Learning Objectives:

After completing this module, the students will be able to:

1. Discuss the physical examination guidelines.

2. Demonstrates the 4 physical examination techniques.

3. Enumerate developmental consideration when performing physical assessment.

PHYSICAL ASSESSMENT TECHNIQUES

Preparation Guidelines for Physical Examination

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A. Setting
1. The examination table room should be adequately ventilated, comfortable, quite,
private with adequate lighting.
2. Position the table so that both sides of the patient are easily accessible.
3. The examination table should be at a height that prevents the examiner from
stooping and should be equipped to raise the head up to 45
degrees.
B. Equipment
1. Thermometer
2. Platform weighing scale with height attachment
3. Sphygmomanometer
4. Stethoscope with bell and diaphragm end pieces
5. Watch with second hand
6. Flashlight or penlight
7. Tongue depressor
8. Opthalmoscope
9. Otoscope
10. Tuning fork
11. Ruler and tape measure
12. Reflex ( percussion hammer)
13. Skin-marking pen
14. Nasal speculum
15. Cotton balls
16. Gloves and lubricant
17. Vaginal speculum
18. Equipment for cytological and
bacteriological study
19. Safety pin
20. Patient’s chart
21. Assessment forms
22. Paper, pen and pencil
C. The patient
1. Prepare the patient physically and psychologically to allay anxiety.
2. Provide privacy.
3. Provide adequate information about procedure.
4. Provide a new, clean gown.
PHYSICAL EXAMINATION GUIDELINES
1. Wash hands before the procedure.
2. The general sequence of performing the techniques of physical examination is as
follows: Inspection, Palpation, Percussion and Auscultation.
3. Explain each step in the examination and how the patient can cooperate.
4. Touch the patient’s hands, check the skin color, nail beds, metacarpophalangeal joints.
5. Write out the examination sequence and refer to it as needed, or use a printed form of
the procedure, initially.
6. Perform the procedure using head to toe sequence.

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7. The sequence of techniques for examination of the abdomen is as follows: Inspection,
Auscultation, Percussion and Palpation.
8. During examination of the abdomen, it is important to flex the patient’s knees to relax the
abdominal muscles.
9. The sequence of examining the quadrants of the abdomen is as follows: right lower
quadrant, right upper quadrant, left upper quadrant, left lower quadrant (RLQ, RUQ,
LUQ, and LLQ).
10. Avoid abdominal palpation among patients with tumor of the liver and tumor of the
kidneys.
11. Do auscultation of the abdomen for 5 minutes before concluding absence of bowel
sounds.
12. If ophthalmoscopy is done, darken the room for better illumination. Explain this to the
client. To prevent unnecessary anxiety.
13. If female patient will be examined by male nurse or by a male physician, a female nurse
must be in attendance. This ensures that the procedure is done in an ethical manner and
to prevent cases/ issues of sexual harassment.
TECHNIQUES IN PHYSICAL ASSESSMENT
A. Inspection
 It is concentrated watching. It involves the use of
the sense of sight.
 Observe the patient as a whole “general survey”
then each body system.
 It is the technique to be done when assessing
each body system.
 Inspect both sides of the body for symmetry.
B. Palpation
 It follows inspection. It applies sense of touch to assess the following factors:
texture, temperature, moisture, organ location, and size, any swelling, vibration
or pulsations, crepitation, presence of lumps or masses and presence of
tenderness or pain.
 Finger tips- best for fine tactile discrimination like skin, texture, swelling,
pulsations, and determining of presence of lumps.
 A grasping action of the fingers and thumb to detect the position, shape, and
consistency of an organ or mass.
 The back of hands and fingers. Best for determining temperature because the
skin here is thinner than on the palms.
 Base of the fingers (metacarpophalangeal joints or ulnar surface) of the hands-
best for vibration.
 Palpation should be done in slow, gentle and systematic manner.
 Warm hands by rubbing them together or holding them under warm water.
 Palpate tender areas last.
 Bimanual palpation involves use of both hands to envelope certain body parts or
organs, e.g., kidneys, uterus, liver.
4 TYPES OF PALPATION

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1. 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 pulses,
tenderness, surface skin texture, temperature
and moisture.
2. Moderate palpation. Depress the skin surface 1
to 2 cm (0.5 to 0.75 in) with your dominant hand,
and use a circular motion to feel for easily
palpable body organs and masses.
3. Deep palpation. Place your dominant hand on
the skin surface and your non-dominant hand on
top your dominant hand to apply pressure. This
should result in a surface depression between
2.5 and 5 cm (1 and 2 in). This allows you to feel
very deep organs or structures that are covered
by thick muscle.
4. Bimanual palpation. Use two hands, placing
one on each side of the body (e.g., uterus,
breasts, spleen) being palpated. Use one hand to apply pressure and the other hand to
feel structure. Note the size, shape, consistency, and mobility of the structures you
palpate.

Parts of the Hand to Use When Palpating

Hands part Sensitive to
Finger pads Fine discrimination pulses, texture, size,
crepitus
Ulnar or palmar surface Vibrations, thrills, fremitus
Dorsal (back) surface Temperature

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C. Percussion
 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.
 Percussion is done for the following purposes:
1. Mapping out the location and size of an organ.
2. Detecting the density (air, fluid or solid) of a structure by a characteristic note.
3. Detecting an abnormal mass, whether it is superficial or deep. The
percussion vibrations penetrate about 5 cm deep. A deeper mass would give
no charge in percussion.
4. Eliciting pain if the underlying structure is inflamed, as with sinus areas or
over the kidney.
5. Eliciting a deep tender reflex (DTR) using the percussion (reflex) hammer.
 There are two methods of percussion, namely:
a. Direct (immediate) percussion. The
striking hand directly contacts the body
wall. It produces a sound and is used in
percussing infant’s thorax or the adult’s
sinus. (e.g., above the eye for frontal
sinuses, on the cheeks for maxillary
sinuses).
b. Indirect (mediate) percussion.
Involves use of both hands. The striking
hand contacts the stationary hand fixed
on the patient’s skin.
 The stationary Hand
 Hyperextend the middle finger of the non-dominant hand (pleximeter)
and place only the distal portion firmly against the patient’s skin. Avoid
the patient’s ribs and scapulae. Percussing over the bone does not
give significant data- the sound produced will always be “dullness.”

 The striking hand

 Use the middle finger of the dominant hand as the striking finger
( plexor). Keep the upper arm and shoulder steady.
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  Strke just behind the nail bed to hit the portion of the fingers that is
pushing the hardest into the skin surface. The tip of the striking finger
not the finger pad makes contact with the stationary finger.
 Make sure, the striking finger does not miss stationary finger.
 Repeated practice is required to make hand placement precise and
make the ears learn to perceive the subtle difference percussion
sounds.
Each of the five percussion notes is differentiated by the following components:
1. Amplitude or intensity. Loud and soft sound may be produced, depending on the force
of the blow and the ability of the body part to vibrate.
2. Pitch or frequency. More vibrations produce a high-pitched tone. This is expressed in
terms of “cps” cycles per second or number of vibrations per second.
3. Quality or timbre. A pure tone is a sound of one frequency. Variations within a sound
wave produce overtones.
4. Duration. The lenght of time the note lingers. A structure with relatively more air ( e.g.,
lungs) produce a louder, deeper and longer sound becuase it vibrates freely. A denser,
more solid struture ( e.g., liver) gives a softer, higher, shorter sound because it does not
vibrate as easily.
Different Types of Percussion Notes and Their Characteristics
1. Resonant
Amplitude: Medium-low
Pitch: Low
Quality: Clear, hollow
Duration: Moderate
Location: Normal lung tissue
2. Hyperresonant
Amplitude: Louder
Pitch: Lower
Quality: Booming
Duration: Longer
Location: Normal over child’s lung. In
adult: over lungs with increased amount
of air ( emphysema)
3. Tympany
Amplitude: Medium-loud
Pitch: High
Quality: Musical, drum-like
Duration: Sustained longest
Location: Over air-filled organs, e.g., stomach, intestine
4. Dull
Amplitude: Medium-soft
Pitch: High
Quality: Muffled thud
Duration: Short
Location: Relatively dense organs, e.g, liver, spleen
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5. Flat:
Amplitude: Very soft
Pitch: High
Quality: A dead stop of sound; absolute dullness
Duration: Very short
Location: When no air is present, over thigh muscles, bone, or over tumor.

D. Auscultation
 Is listening to sound produced by the body with the use of stethoscope.
 The slope of the earpiece should point forward, toward the nose.
 The tubing should an internal diameter of 4 mm (1/8 inch), and about 36 to 46 cm
(14 to 18 inches) long.
 The two end pieces of the stethoscope are the
diaphragm and the bell.
 The diaphragm end piece has a flat edge. It is best
used for high-pitched sounds, breath, bowel, heart
sounds.
 Hold the diaphragm firmly against the patient’s skin-
firm enough to leave a slight ring afterward.
 The bell end piece has a deep, hollow cuplike shape. It
is best used for soft, low pitched sounds such as extra
sounds, mursmurs, blood pressure.
 Hold the bell ligthly against the patient’s skin- just
enough that it forms a perfect seal.
 Clean the stethoscope end piece with an alcohol swab. Do not let your stethoscope
become a “ steph-oscope!”
 Warm the end piece by rubbing it in your palm. A cold end piece causes discomfort.
 Never listen through a patient’s gown or clothing. Reach under a gown or clothing to
listen.
 Avoid breathing on the tubing or bumping of the tubing together. To prevent
producing “ artifact” sounds.

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DEVELOPMENTAL CONSIDERATIONS WHEN PERFORMING PHYSICAL ASSESSMENT
I. According to Erik Erikson, the INFANT establishing TRUST VS MISTRUST.
A. Position
1. Once the infant can sit without support ( around 6 months), most of the examination
should be performed while the
infant is in the parent’s lap.
2. By 9 to 12 months, the infant is
acutely aware of the surroundings.
B. Preparation
1. Time of examination should be 1 to
2 hours after feeding, when the
infant is not too drowsy or too
hungry.
2. Smile, a baby likes a smiling face.
3. Make sure your hands and
stethoscope end piece warm.
4. Let an older infant touch the stethoscope or tongue blade.
C. Sequence
1. Take opportunity with a sleeping baby to listen to heart, lung, and abdomen sound
first.
2. Perfrom least distressing steps first. Save the invasive steps of examination of the
eye, nose and throat, until last.
The sequence for examination of an infant are as follows:
1. Vital signs 7. Eyes
2. Measurement- weight, 8. Ears
lenght, head circumference 9. Nose
3. General appearance 10. Mouth and throat
4. Chest and heart 11. Neck
5. Abdomen 12. Upper extremities
6. Head and face 13. Lower extremities

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 14. Genitalia 16. Spine and rectum
15. Neuromuscular
17. Final procedure:
Use of otoscope to inspect the auditory canal and the tympanic membrane.
Elicit the Moro Relflex ( by letting the infant’s head and trunk drop back a short
way or by jarring the crib) or startle reflex by making a loud noise.

II. THE TODDLER

According to Erik Erikson, the is AUTONOMY VS SHAME AND DOUBT.
A. Position
1. The toddler should be sitting up on the parent’s
lap for all of the examination.
2. When the toddler must be supine, move chairs
to sit knee-to-knee with parent. Have the toddler
lie in the parent’s lap, with toddler’s legs in the
nurse’s lap.
B. Preparation
1. A security object such as a special blanket or
teddy bear may be helpful.
2. Begin by greeting the child and the parent/s by
name but with a child 1 to 6 years old, focus
more on the parent. By “ seemingly” ignoring the
child at first, the nurse allows the child to adjust
gradually and to size up the nurse from a safe
distance.
3. Praise the child when he or she is cooperative.
4. Demonstrate the procedures on the parent.
C. Sequence
1. Colllect some objective during the history, which is a less stressful time.
While focusing on the parent, he/she notes on the child’s gross motor and
fine motor skills and gait
2. Begin with “games” such as the Denver II test or cranial nerve testing.
3. Start with non-threatening areas. Save more stressing procedures- such
as examination of the head, ear, nose or throat-for last.

III. THE PRECHOOLER CHILD

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 The Preschool child is developing INITIATIVE VS GUILT. The preschool takes
on tasks independently and plans the task and finishes it. The child fears any
injury or mutilation, so he or she will recoil from
invasive procedure.
A. Position
1. For a 3- year old child, the parent should
be present and may hold the child on the
lap.
2. A 4 to 5 year old child usually feels
comfortable on the Big Girl or Big Boy
( examining) table, with the parent
present.

B. Preparation
1. Allow the child to play with equipment to reduce fears.
2. Use a slow, patient, deliberate approach. Do not rush.
3. Use games. Example, pretend to listen to the heart sounds of the child’s
teddy bear or doll first.
C. Sequence:
1. Examine the thorax, abdomen, extremities, and genitalia first.
2. Assess head, eye, ear, nose and throat last.
IV. THE SCHOOL AGE CHILD
The major task of the school age is INDUSTRY VS INFERIORITY. The child is
developing basic competency in school and in social networks. The school- age
childs desires for feelings of
achievement.
A. Position
1. The school age child should be
sitting on the examination table.
2. Maintain privacy.
B. Preparation
1. Divert the child’s attention with
small talk about family, school,
friends, music or sports.
C. Sequence
1. As with the adult, progress from head-to-toes.
V. THE ADOLESCENT
The adolescent achieves of SELF-IDENTITY VS ROLE CONFUSION. He or she
needs to feel satisfied and comfortable with who he or she is.
A. Position
1. The adolescent should be sitting on the examination table.
2. Examine the adolescent alone, without parent or sibling present.
B. Preparation
1. During the examination, the adolescent needs feedback that his or her
own body is healthy and developing normally.
2. Provide health teachings that can promote wellness.

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 C. Sequence
1. As with the adult, use head to toe approach.
2. Examine genitalia last, do it quickly.
VI. THE AGING ADULT
The aging adult is developing EGO INTEGRITY
VS DESPAIR-feeling that life has been
worthwhile and successful.
A. Position
1. The older adult should be sitting on the
examination table.
2. Arrange the sequence to allow as few
position changes as possible.
3. Allow rest periods when needed.
B. Preparation
1. Adjust examination pace to adapt to the
possible slowed pace of the aging person.
2. Use of physical touch.
3. Do not mistake diminished vision or hearing for confusion.
STANDARD PRECAUTIONS FOR USE WITH ALL PATIENTS
A. Wash hands after touching blood, body fluids, secretions, and contaminated items,
whether or not wearing gloves. Wash hands immediately after gloves are removed and
between patient contacts.
B. Wear clean gloves when touching blood, body fluids, secretions, excretions, and items
contaminated with these, mucous membranes and non-intact skin.
C. Wear a mask and eye protection to protect mucous membranes during procedures and
patient care activities that are likely to generate splashes of body, body fluids, secretions
and excretions.
D. Wear a gown ( clean, nonsterile, appropriate to activity) to protect skin and prevent
soiling of clothing during procedures and patient care activities that are likely to generate
splashes of blood, body fluids, secretions or excretions.
E. Take care with used patient care equipment, soiled with blood, body fluids, secretions,
and excretions; handle it in a manner that prevents skin and mucous membrane
exposure, contamination of clothing and transfer of microorganisms to other patient and
environments.
F. Design and follow adequate hospital or clinic procedures for routine care, cleaning and
disinfection of environmental surfaces, beds, bed rails, bedside equipment and other
frequently touched surfaces.

Positioning the Client:

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1. Standing position. This allow to examiner to assess posture, balance, and gait. This
position is also used to examine male genitalia.
2. Sitting or seated position. Back unsupported and legs hanging freely.
3. Sim’s-Semi prone position.
4. Prone. Facing lying position with the head turned to side. Also, abdomen-lying position.
5. Dorsal/Supine position. Back-lying position with or without a pillow.
6. Dorsal recumbent position. Back-lying position with knees flexed and hips externally
rotated.
7. Lithotomy position. Back-lying with feet supported with stirrups.
8. Lateral. Side-lying position
9. Genupectoral/knee-chest. Kneeling position with torso at 90-degree Celsius angle to hips.
10. Fowler’s
a. Semi-fowler’s position. Head of bed elevated at 15-45 degree Celsius.
b. High-fowler’s position. Head of bed elevated at 80-90 degree Celsius.

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