 To make clinical judgments about
client's health status
Assessing a client's health is a major
component of nursing care and has 2
aspects:
1. Nursing health history
2. Physical examination
A physical examination can be:
1. Complete assessment (when
admitted to a hospital)
2. Examination of a body system
3. Examination of a body area
Physical Health Assessment
 A complete health assessment can
be conducted at the head and
proceeding in a systematic manner
(head-to-toe assessment)
 It should be conducted in a
systematic and efficient manner
that results in the fewest position
changes
Purpose of the physical examination:
 To obtain data about the client's
functional abilities
 To supplement, confirm, or refute
data obtain in the nursing history
 To obtain data that will help
establish nursing diagnoses and plans
of care
 To evaluate physiological outcomes
of health care and thus the progress
of a client's health problem
 To identify areas for health
promotion and disease prevention
Preparing the Client
 Client can be assured during physical
examination by explanations at each
step
 Instruct that all information
gathered and documented during
assessment is kept confidential
 It is important to determine in
advance any positions that are
contraindicated for a particular
patient
 The nurse assists the client as
needed to undress and put on a gown
 Clients should empty their bladders
before examination
• helps them feel relaxed
• facilitates palpation of the
abdomen and pubic area
• when U/A is required: urine
should be collected in a sterile
container
!TN: The sequence of the assessment
differs with children and adults.
Preparing the Environment
 The environment needs to be
well-lighted
 Equipment should be organized
for efficient use
 The room should be warm enough
to be comfortable for the client
 Providing privacy is important
  The environment needs to be
well-lighted
 Equipment should be organized
for efficient use
 The room should be warm enough
to be comfortable for the client
 Providing privacy is important
Health Assessment of the Adult
 Be aware of normal physiological
changes that occur with aging.
 Be aware of stiffness of muscles and
joints from aging or history of
orthopedic surgery.
• The client's physical condition,
energy level, and age should be taken
into consideration
• Some positions are embarrassing and
uncomfortable
➢ Therefore, should not be
maintained for long
Dorsal Recumbent
 back lying with knees flexed and hips
externally rotated
 small pillow under the head
 soles of feet on the surface
o For examination of:
✓ female genitalia
✓ rectum
✓ female reproductive tract
 May be contraindicated for clients
who have cardiopulmonary problems
Supine (Horizontal Recumbent)
 back-lying with legs extended
 with or without pillow under the
head
o Used for assessing:
✓ head, neck, axillae, anterior
thorax, lungs, breasts, heart,
abdomen, extremities,
peripheral pulses
 Tolerated poorly by clients with
cardiovascular and respiratory
problems
Sitting
 a seated position
 back unsupported
 legs hanging freely
o Used for assessing:
✓ head, neck, posterior and
anterior thorax, lungs breasts,
axillae, heart, vital signs, upper
and lower extremities, reflexes
 Older adults and weak clients may
require support
Lithotomy Prone

 lies on the abdomen with head

turned to the side
 with or without a small pillow
 back-lying position with feet
o Used to assess:
supported in stirrups
✓ posterior thorax, hip joint
 the hips should be in line with edge
movement
of the table
 Often not tolerated by older
o Used to assess:
adults and people with
✓ female genitals, rectum, and
cardiovascular and respiratory
female reproductive tract
problems
 May be uncomfortable and tiring
for older adults and often
embarrassing

Sims'

 Drapes should be arranged so that

 side-lying with lowermost arm behind
the body
 uppermost leg flexed at hip and knee
 upper arm flexed at shoulder and
elbow
o Used to assess:
✓ rectum, vagina
 Difficult for older adults and
people with limited joint
movement
the area to be assessed is exposed
and other body areas are covered
 Drapes provide not only a degree of
privacy
Equipment and Supplies Used
for a Health Examination
Flashlight or penlight
o Used to:
✓ assist viewing of the pharynx
✓ determine the reactions of the
pupils of the eye
 Percussion or Reflex Hammer

✓ An instrument with rubber head to

test reflexes

Ophthalmoscope

✓ A lighted instrument to visualize the

interior of the eye

Tuning fork

✓ A two-pronged metal instrument

used to test hearing acuity and
vibratory sense

Otoscope

✓ A lighted instrument to visualize the

eardrum and external auditory canal
 a nasal speculum may be attached
to the otoscope to inspect the
nasal cavities

Cotton applicator

✓ Used to obtain specimens

Gloves ✓ color
✓ texture of body surfaces
✓ To protect the nurse
✓ shape
✓ position
✓ size
✓ symmetry of the body

 Lighting must be sufficient, either

natural or artificial
 When using auditory senses, a quiet
environment is important
Tongue Blade (Depressors)  Inspection can be combined with
✓ To depress the tongue during other assessment techniques
assessment of the mouth and
pharynx
Palpation (Light and Deep)

 The examination of the body using

Methods of Examining the sense of touch
Inspection  Pads of the fingers are used
 highly sensitive to tactile
 It is the visual examination, which is
discrimination due to rich
assessing by using the sense of sight
concentration of nerve endings
 deliberate, purposeful, and
systematic used to determine:
 can be with the naked eye or ✓ texture (hair)
lighted instrument (otoscope and ✓ temperature (skin)
ophthalmoscope) ✓ vibration (joints)
 Olfactory and auditory cues are also ✓ position, size, consistency and
noted mobility of organs or masses
✓ distention (urinary bladder)
✓ pulsation
✓ tenderness or pain
o used to assess:
✓ moisture
a) Light (Superficial) Palpation
 The nurse extends the dominant
hand's fingers parallel to the skin
surface and presses while moving
the hand in circle
 The skin is slightly depressed
 Should always precede deep
palpation
 heavy pressure on the fingertips
can dull the sense of touch
 If it is necessary to determine
the details of the mass:
✓ the nurse must press lightly
several times rather than
holding the pressure
b) Deep Palpation
 It is done with two hands (bimanual)
or one hand
o In deep bimanual palpation:
✓ the nurse extends the dominant
hand
✓ then places the finger pads of
the non-dominant hand on the
dorsal surface of the distal
interphalangeal joint of the
middle 3 fingers of the dominant
hand
 The top hand applies pressure while the
lower hand remains relaxed to perceive
the tactile sensations
o For deep palpation using one
hand:
✓ the finger pads of the dominant
hand press over the area to be
palpated
✓ often the other hand is used to
support from below
!TN:
 Deep palpation is usually not done during
a routine examination and requires
significant practitioner skill.
 It is performed with extreme caution
because pressure can damage internal
orans.
 It is usually NOT indicated in clients
who have acute abdominal pain or pain
that is not yet diagnosed
➢ To test skin temperature:
 It is best to use the dorsum of the
hand and fingers
 • the examiner's skin is thinnest Percussion

➢ To test for vibration:

 The act of striking the body surface to
 Used the palmar surface of the hand
elicit sounds that can be heard or
vibrations that can be felt
 It can be direct or indirect percussion

a) Direct Percussion

General Guidelines for Palpation:

 The nurse's hands should be clean

and warm, and the fingernails short.
 Areas of tenderness should be
palpated last.  The nurse strikes the area to be
 •Deep palpation should be done after percussed directly with the pads of
superficial palpation. two, three, or four finger or with the
 The effectiveness of palpation pad of the middle finger
depends largely on the client's  The strikes are rapid, and movement is
relaxation. from wrist
o A client can be relaxed by:  Generally, not used to percuss
✓ gowned or draped appropriately the thorax but useful in
✓ positioned comfortably percussing adult sinuses
✓ ensuring that the nurse's hands
are before beginning
 During palpation the nurse should be
sensitive to client's verbal and facial
expression indicating discomfort
 b) Indirect Percussion o It elicits 5 types of sounds:
✓ flatness
✓ dullness
✓ resonance
✓ hyperresonance
✓ tympany

Flatness
 The striking of the object held against
 An extremely dull sound produced by
the body area to be examined
very dense such as muscle or bone
 The middle finger of the non-dominant
hand (pleximeter) is placed firmly on Dullness
the client's skin
 A thud like sound produced by dense
 only the distal phalanx and joint
tissue such as the liver, spleen, or
of this finger should be in
heart
contact with the skin
 Using the tip of the of the flexed Resonance
middle finger of the other hand  A hollow sound such as that
(plexor), the nurse strikes the
produced by lungs filled with air
pleximeter

Hyperresonance

✓ The striking motion comes from

the wrist; the forearm remain
stationary
✓ The angle between the plexor and
pleximeter should be 90º  Not produced in the normal body
✓ Blows should be firm, rapid, and  Described as booming and can be
short to obtain a clear sound heard over an emphysematous lung

 Percussion is used to determine the size Tympany

and shape of the internal organs by  A musical or drumlike sound
establishing their borders produced from air-filled stomach
 It indicates whether tissue is fluid, air - Flatness the densest; tympany the
filled, or solid least dense tissue
Auscultation o Auscultated sounds are described
according to:
 The process of listening to sounds
✓ pitch
produced within the body
✓ intensity
✓ duration
✓ quality
a) Direct Auscultation
 Performed using unaided ear
✓ listening to a respiratory wheeze or
Pitch
the grating of a moving joint
 The frequency of the vibration
(number of vibrations per second)
b) Indirect Auscultation ✓ Low-pitched sounds (heart
sounds) have fewer vibrations per
second than high-pitched sounds

Intensity

 Refers to the loudness or softness

of a sound

loud sounds: bronchial sounds over the

trachea

 Performed using a stethoscope, soft sounds: normal breath sounds over the
which transmits sounds to the lungs
nurse’s ears.

Duration
A stethoscope is used primarily to listen to
 Is the length of a sound (short or
sounds from within the body
long)
✓ The diaphragm (flat) best transmits
high-pitched sounds (bronchial
sounds) Quality
✓ The bell best transmits low-pitched
 A subjective description of a sound
sounds (heart sounds)
✓ whistling
✓ gurgling
✓ snapping
 The amplifier of the stethoscope is
placed firmly but lightly against the
client's skin
 if a client has excessive hair, it
may be necessary to dampen the
hairs with moist cloth
 INTEgUMENTARY

 The integument includes the skin,

hair, and nails
 Examination begins with a
generalized inspection using a good
source of lighting, preferably  In brown-skinned clients:
indirect natural light
➢ may appear as yellowish-brown tinge

 In black-skinned clients:
Skin
➢ the skin may appear ashen gray
 Assessment techniques: inspection
and palpation

o Can be examined at one time or as

each aspect of the body is assessed

o Olfactory sense is also used to

detect unusual skin odor (skin fold
of the axillae)
o Pungent body odor is frequently
related to poor hygiene,
hyperhidrosis (excessive
perspiration), or bromhidrosis (foul-
smelling perspiration)
 Pallor in all is usually most evident in
areas with less pigmentation such as:
➢ conjunctiva
➢ oral mucous membranes
➢ nail beds

➢ palms of the hand

Pallor ➢ soles of the feet

 The result of inadequate circulating

blood or hemoglobin and subsequent
reduction in tissue oxygenation

 In dark skin client:

➢ characterized by the absence of

underlying red tones in the skin

➢ may be mostly seen in the buccal Cyanosis

mucosa
 Bluish tinge most evident in nail beds,
lips, and buccal mucosa
 In dark-skinned clients:
 ➢ close inspection of the palpebral
conjunctiva and palms and soles
may also show evidence of cyanosis
Vitiligo
 Seen as patches of hypopigmented
skin, caused by the destruction of
melanocytes in the area

 Albinism is the complete or partial

lack of melanin in the skin, hair, and
eyes

Jaundice
 Yellowish tinge may first be evident
in the sclera of the eye and then in
the mucous membranes and skin
Edema
➢ not to confuse jaundice with the
 The presence of excess interstitial
normal yellowish pigmentation in
fluid
the sclera of dark-skinned client
 The area appears:

➢ swollen

➢ shiny

➢ taut and tends to blanch the skin

color
 If jaundice is suspected: ➢ if accompanied by inflammation,
➢ inspect the posterior part of the may redden the skin
hard palate for a yellowish color
tone

Erythema
 Skin redness associated with a
variety of rashes and other
 Can be pitting
conditions
 Can also be non-pitting

 Can also be bilateral/bipedal or

unilateral
 Primary Lesions
Macule
 Flat, unelevated change in color

 1 mm to 1 cm (0.04 to 0.4 in) in size

and circumscribed

Examples:
Pitting Edema Scale:
➢ freckles

➢ measles

➢ petechiae

➢ flat moles

Patches
 Larger than 1 cm (0.4 in) and may
have an irregular shape

Examples:
Skin Lesion ➢ port wine
 An alteration in a client's normal ➢ birthmark
skin appearance.
➢ vitiligo
 Primary Skin Lesions - are those
that appear initially in response ➢ rubella
to some changes in the external
or internal environment of the
skin.

 Secondary Skin Lesions - are

those that do not appear initially
but result from modifications
such as chronicity, trauma, or
infection of the primary lesions.
Papule ➢ squamous cell carcinoma

 Circumscribed, solid elevation ➢ fibroma

 Less than 1 cm (0.4 in)

Examples:

➢ warts

➢ acne

➢ pimples

➢ elevated moles
Tumor
 Are larger than 2 cm (0.8 in)

 May have irregular border

Examples:

➢ malignant melanoma

➢ hemangioma
Plaque
 Larger than 1 cm (0.4in)

Examples:

➢ psoriasis

➢ rubeola

Pustule
 Vesicle or bulla filled with pus

Examples:

➢ acne vulgaris

➢ impetigo

Nodule
 Elevated solid, hard mass that
extends deeper into the dermis than
a papule

 Nodules have a circumscribed border

and are 0.5 cm to 2 cm (0.2 to 0.8 in)

Examples:
Vesicle from the subcutaneous tissue or
dermis
 A circumscribed, round or oval
Examples:
 Thin translucent mass
➢ sebaceous cyst
 Less than 0.5 cm (0.2 in)
➢ epidermoid cyst
Examples:
➢ chalazion of the eyelids
➢ herpes simplex

➢ early chickenpox

➢ small burn blister

Wheal
 A reddened, localized collection of
edema fluid

Bullae  Irregular in shape

 Larger than 0.5 cm (0.2 in)  Size varies

Examples: Ex:

➢ large blister ➢ hives

➢ second-degree burn ➢ mosquito bites

➢ herpes simplex

Secondary Lesion
Atrophy
Cyst  A translucent, dry, paper-like,
sometimes wrinkled skin surface
 Larger, elevated, encapsulated,
resulting from thinning or wasting of
fluid-filled or semi-solid mass arising
the skin due to loss of collagen and
elastin
Example: ➢ chronic dermatitis

➢ striae

➢ aged skin

Scales
 Shedding flakes of greasy,
keratinized skin tissue
Erosion  Color may be white, gray, or silver
 Wearing away of the superficial  Texture may vary from fine to thick
epidermis causing a moist, shallow
depression

 Because erosions do not extend into

the dermis, they heal without
scarring

Example:

➢ scratch marks

➢ ruptured vesicles Crust

 Dry blood, serum, or pus left on the
skin surface when vesicles or
pustules burst

 Can be red-brown, orange, or yellow

 Large crusts that adhere to the skin

surface are called scabs

Ex:
Lichenification
➢ eczema, impetigo, herpes, scabs
 Rough thickened, hardened area of following abrasion
the epidermis resulting from chronic
irritation such as scratching or
rubbing

Example:
Ulcer
 Deep, irregularly shaped area of skin Scar
loss extending into the dermis or
subcutaneous tissue  Flat, irregular area of connective
tissue left after a lesion or wound
 May bleed healed
 May leave scar  New scars may be red or purple
Ex:  Older scars may be silvery or white
➢ pressure ulcer Ex:
➢ statis ulcer ➢ healed surgical wound or injury
➢ chancres ➢ healed acne

Fissure
 Linear crack with sharp edges,
extending into the dermis
Ex:
➢ cracks at the corners of the
mouth, or in the hands
➢ athlete's foot
Keloid
 Elevated, irregular, darkened area of
excess scar tissue caused by
excessive collagen formation during
healing
 Extends beyond the site of the
original injury
 Higher incidence in people of
African descent

Ex:
 ➢ keloid from ear piercing or  Some therapies cause alopecia (hair
surgery loss)

 Some disease conditions and

medications affect the coarseness
of hair

Ex:

➢ hypothyroidism can cause very

thin and brittle hair
Hair
o Inspect the hair, considering
developmental changes and ethnic Lifespan Considerations:
differences Infants
o Determine the individual's hair
 It is normal for infants to have
care practices and factors
either very little or great deal of
influencing them
body and scalp hair.
 Normal hair is resilient and evenly
Children
distributed
 As puberty approaches, axillary and
pubic hair will appear.

Older Adults

 May experience a loss of scalp,

pubic, and axillary hair.

 Hairs of the eyebrows, ears, and

nostrils become bristle-like and
 In people with severe protein
coarse.
deficiency (kwashiorkor):

➢ hair color is faded and appears

reddish or bleached Nails
➢ the texture is coarse and dry  Inspect for:

➢ nail plate

➢ angle between the fingernail and

the nail bed

➢ nail bed color

➢ intactness of the tissues around

the nails

 The nail plate is normally colorless
and has a convex curve
 The angle between the fingernail and
the nail bed is normally 160 degrees
 One nail abnormality is the spoon
shape nail (koilonychia)
➢ seen in clients with iron
deficiency anemia
 Clubbing is a condition in which the
angle between the nail and the nail
bed is 180 degrees, or greater
➢ caused by a long-term lack of
oxygen
 Nail texture is normally smooth
 Excessively thick nails can appear in
➢ older adults
➢ in the presence of poor
circulation
➢ in relation to a chronic fungal
infection
 Excessively thin nails or the
presence of grooves or furrow can
reflect prolonged iron deficiency
anemia
 Beau's line are horizontal
depressions in the nail that can
result from injury or severe illness
 The nailbed is highly vascular, a
characteristic that accounts for its
color
➢ bluish or purplish tint to the nail
bed may reflect cyanosis (due to
decreased oxygenation)
➢ pallor may reflect poor
circulation
 Onychomycosis (nail fungal infection) pink or their usual color when
requires referral to the podiatrist pressure is released
or dermatologist for treatment
➢ a slow rate of capillary refill may
 Symptoms:
indicate circulatory problems
➢ brittleness

➢ discoloration

➢ thickening

➢ distortion of nail shape

➢ crumbling of the nail

➢ loosening (detaching) of the nail

Lifespan Considerations:

Infants

 Newborn nails grow very quickly, are

extremely thin, and tear easily.

 The tissue surrounding the nails is Children

normally intact epidermis
 Bent, bruised, or ingrown toenails
 Paronychia is an inflammation of the may indicate shoes that are too
tissue surrounding a nail tight.

➢ the tissue appears inflamed and  Nail biting should be discussed with
swollen, and tenderness is usually an adult family member because it
present may be a symptom of stress.

Older Adults

 The nails grow more slowly and

thicken.

 Longitudinal bands commonly

develop, and the nails tend to split.

➢ toenail fungus is more common

and difficult to eliminate
(although not dangerous to
 Blanch test can be carried out to health).
test the capillary refill, that is the
peripheral circulation

➢ normal bed capillaries blanch

when pressed, but quickly turn
 Head
Skull and Face
 A normal head size is referred to as
normocephalic
 Measurements more than two
standard deviations from the norm
of age, sex, and race are abnormal
and should be reported to the  Newborns can lift their head slightly
primary care provider and turn them from side to side.
 Voluntary head control is well
established by 4 to 6 months
Lifespan Considerations

Infants:

 Newborn delivered vaginally can have

elongated, molded head, which take
on more rounded shapes after a
week or two.
 Infants born by cesarian section
tend to have smooth, rounded heads.

 The posterior fontanel (soft spot) is

about 1 cm (0.4 in) in size and usually
closes by 8 weeks.
 The anterior fontanel is larger,
about 2 to 3 cm (0.8 to 1.2 in) in
size, closes by 18th months.