Physical assessment technique

 Platform weighing scale

 Reflex (percussion hammer)
with height attachment  Skin - marking pen
 Thermometer
 Nasal speculum
 Sphygmomanometer
 Cotton balls
 Stethoscope with belt and
 Gloves and lubricant
diaphragm end pieces  Bivalve vaginal speculum
 Watch with second hand
 Equipment for cytological and
 Skinfold calipers (optional)
bacteriological study (as needed)
Flashlight or penlight  Safety pin
 Tongue depressor
 Patient's Chart
 Ophthalmoscope
 Assessment Forms
 Otoscope
 Paper, pen, and pencil
 Tuning fork
 Ruler and tape measure
 Physical Examination Guidelines
 Wash hands before the procedure.
 The general sequence of performing the techniques of physical examination is as
follows:
Inspection, Palpation, Percussion and Auscultation (IPPA).
 Begin physical examination procedure by measuring the person’s height, weight, blood
pressure, temperature, pulse and respirations.
 Explain each step in the examination and how the patient can cooperate. Encourage the
patient to ask questions.
 Touch the patient’s hands, check the skin color, nail beds, metacarpophalangeal joints.
This is less threatening manner to ease a patient into being touched.
 Organize the steps of physical examination so the patient does not change position too
often and to avoid omissions.
 Write out the examination sequence and refer to it as needed, or use a printed form of
procedure, initially. Explain to the patient that making brief notations will ensure accuracy of
findings. As the nurse gains experience, he/she will find that he/she will glance at the form
less and less.
 Perform the procedure using head-to-toe sequence.
 The sequence of techniques for the abdomen is as follows: Inspection, Auscultation,
Percussion and Palpation (IAPP). Palpation is done as the last technique on the abdomen
because if the examiner happens to palpate a tender area, the patient may not be able to
relax anymore. And the patient may not want to finish the procedure. Palpation of the
abdomen may also disturb the bowel sounds at the start of the procedure. This may make
results of the examination inaccurate.
 During examination of the abdomen, it is important to flex the patient’s knees to relax the
abdominal muscles. This facilitates the examination of abdominal organs.
 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,LLQ)
 Avoid abdominal palpation among patients with tumor of the liver and tumor
of the kidneys.
 Do auscultation of the abdomen for 5 minutes before concluding absence
of bowel sounds.
 If ophthalmoscopy is done, darken the room for better illumination. Explain
this to the client. To prevent unnecessary anxiety.
 If a female patient will be examined by a 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. The ideal situation is, a female patient be examined by a
female nurse. Consider cultural beliefs and practice.
 TECHNIQUES IN
PHYSICAL ASSESSMENT
TECHNIQUES IN PHYSICAL ASSESSMENT:
I. 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.
 Inspect both sides of the body for symmetry.
 It requires good lighting, adequate exposure of body parts. Expose one
body part at a time.
 It requires occasional use of certain instruments – opthalmoscope,
otoscope, penlight, nasal and vaginal speculum to facilitate viewing.
I. 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 pulsation, rigidity or spasticity, crepitation,
presence of lumps or masses, and presence of tenderness or pain.
It may be done using different parts of the hands as follows:
a. Fingertips – best for fine tactile discrimination like skin texture, swelling, pulsation and determination
of presence of lumps.
b. A grasping action of the fingers and thumb to detect the position, shape, and consistency of an organ
or mass.
c. The back of hands and fingers – best for determining temperature because the skin here is thinner
than on the palms.
d. Base of 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.
.

Percussion is done for the following purposes:

a. Mapping out the location and size of the organ.
b. Detecting the density (air, fluid, or solid) of a structure by a characteristic note.
c. 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.
d. Eliciting pain if the underlying structure is inflamed, as with sinus areas or over
the kidney.
e. Eliciting a deep tender reflex (DTR) using the percussion (reflex) hammer.
There are two methods of percussion, namely:
 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 areas (e.g.,
above the eyebrows for frontal sinuses, on the cheeks for
maxillary sinuses).
 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 nondominant hand (pleximeter) and lace 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 the
shoulder steady.
 Strike just behind the nail bed to hit the portion of the finger 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.
 Repeated practice is required to make hand placement precise and make the ears learn to perceive the
subtle difference in percussion sounds.
 Production of Sound
o Percussing over a body part causes vibrations that produce characteristic waves heard as
“notes”.
o Each of the five percussion notes is differentiated by the following components:
1. Amplitude or Intensity. Loud or 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 rapid vibrations produce 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.
3. Quality or Timbre. A pure tone is a sound of one frequency. Variations within a sound wave produce
overtones.
4. Duration. The length of time the note lingers. A structure with relatively more air (e.g., the lungs) produces a
louder, deeper and longer sound because it vibrates freely. A denser, more solid structure (e.g., the liver)
gives a softer, higher, shorter sound because it does not vibrate as easily.
DIFFERENT TYPES OF PERCUSSION NOTES AND THEIR
CHARACTERISTICS

Resonant
Amplitude: Medium – loud
Pitch: Low
Quality: Clear, hollow
Duration: Moderate
Location: Normal lung tissue

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)
Tympany
Amplitude: Medium – loud
Pitch: High
Quality: Musical, drum-like
Duration: Sustained longest
Location: Over air-filled organs, e.g., stomach, intestine

Dull
Amplitude: Medium – soft
Pitch: High
Quality: Muffled thud
Duration: Short
Location: Relatively dense organs, e.g., liver, spleen
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.

Watch:

https://www.youtube.com/watch?v=FPnva3asE20
https://youtu.be/P4Ryk5IKf_4
I. AUSCULTATION

 Is listening to sounds produced by the body with the use of stethoscope.

 The slope of the earpiece should point forward, toward the nose.
 The tubing should have an internal diameter of 4mm (1/8 inch), and about 36 to 46 cm (14-18 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 heart sounds, murmurs, blood pressure.
 Hold the bell lightly against the patient’s skin just enough that it forms the perfect seal.
 Clean the stethoscope end piece with an alcohol swab.
 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. To prevent
producing extra sound that may be mistaken as body sound.
 Avoid breathing on the tubing or bumping of the tubing together. To prevent producing “artifact” sounds.
 Remember: repeated practice promotes refinement of the skill.
https://youtu.be/2NvBk61ngDY
The Infant
A. Position
1.The parent/s should be present to understand normal growth
and development and for the infant’s feeling of security.
2.Place the infant flat on a padded examination table. The infant
may be held against the parent’s chest for some steps.
3.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.

By 9 to 12 months, the infant is acutely aware of the

surroundings. Anything outside the infant’s range of vision is
“lost”, so the parent must be in full view.
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.Maintain a warm environment, for comfort of the infant.
3.An infant will not object for being nude. Have the patient remove outer clothing,
but leave a diaper on a boy.
4.Make sure your hands and stethoscope end piece are warm.
5.Use a soft, crooning voice during the examination; the infant responds more to
the feeling in the tone of the voice than to what is actually said.
6.An infant likes eye contact; lock eyes from time to time.
7.Smile, a baby likes a smiling face. The nurse may not be aware that he/she
looks serious or stern. Take time to play.
8.Keep movements smooth and deliberate, not jerky.
9.Use a pacifier for crying or during invasive steps.
10.Offer brightly colored toys for distraction when the infant is fussy.
11.Let an older infant touch the stethoscope or tongue blade.
C. Sequence
1. Take the opportunity with a sleeping baby to listen to heart, lung, and abdomen
sounds first.
2.Perform least distressing steps first. Save the invasive steps of examination of the
eye, ear, nose, and throat, until last.
The sequence for examination of an infant are as follows:
 Vital signs
 Measurement – weight, length, head circumference
 General appearance
 Chest and heart
 Abdomen
 Head and face
 Eyes
 Ears
 Nose
 Mouth and throat
 Neck
Upper extremities
 Lower extremities
 Genitalia
 Neuromuscular
 Spine and rectum
 Final Procedure:
oUse otoscope to inspect the auditory canal and the tympanic
membrane.

oElicit the Moro Reflex (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.

(These procedures are done at the end of the examination because

these may cause the infant to cry).
II. The Toddler
A.Position
1. The toddler should be sitting up on the parent’s lap for all 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 the toddler’s
legs in the nurse’s lap.
3. Have the parent/s help position the toddler during invasive
procedures. The child’s legs may be placed between the parent’s
legs. An arm of the parent can encircle the child’s had, holding it
against the chest, and the other arm can hold the child’s arms.
B.Preparation
1.A security object such as a special blanket or teddy bear can 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.A 2-year old child does not like to take off his or her clothes; have the
parent undress the child one part at a time.
4.Children 1 to 2 years of age likes to say “No.” Do not offer a choice when
there is really none.
5.Also, a 1 or 2 year old child likes to make choices. When possible,
enhance autonomy by offering the limited option: “Shall I listen to your heart
next, or your tummy?”
6.Demonstrate the procedure on the parent.
7.Praise the child when he or she is cooperative.
C.Sequence

1.Collect some objective data during the history, which is a

less stressful time. While the nurse is focusing on the
parent, he/she notes on the child’s gross motor and fine
motor skills and gait (manner of walking).
2.Begin with “games” such as the Denver II test or cranial
nerve testing.
3.Start with non-threatening area. Save more stressing
procedures-such as examination of the head,ear,nose,or
throat – for last.
The sequence for examination of a toddler is as follows:

 The health history (focus on the parent as the child plays with a toy)
 General Appearance
 Measurement -height, weight, head circumference
 Chest and heart
 Abdomen
 Genitalia
 Lower extremities
 Upper extremities
 Head and neck
 Eyes
 Nose
 Mouth and throat
 Ears
III.The Preschool child
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 or 5 year old child usually feels comfortable on the big girl or big boy (examining) table, with the
parent present.
B.Preparation
1.A preschooler is capable of verbal communication, which is helpful during examination. However,
the child’s understanding is still limited.
2.The preschool is usually willing to undress, Leave the underpants on until the genital examination.
3.Talk to the child and explain the steps in the examination exactly.
4.Do not allow a choice if there is none.
5.As with the toddler. Enhance the autonomy of the preschooler by offering choice when possible.
6.Allow the child to play with equipment to reduce fears.
7.A preschooler likes to help; have the child hold the stethoscope for you.
8.Use games. Example, pretend to listen to the heart sounds of the child teddy bear and doll first.
9.Use a slow, patient deliberate approach. Do not rush
10.Guide feedback and reassurance to the child e.g. “your tummy feels just fine”
11.Compliment the child on his or her cooperation.
C.Sequence

1.Examine the thorax, abdomen,

extremities, and genitalia first.
2.Assess head, eye, ear, nose and throat
last.
The School Age Child
A.Position
1.The school-age child should be sitting on the examination table.
2.A 5- year old child has a sense of modesty.
3.To maintain privacy, let the older child ( 11 or 12 year old child) decide whether
parents or siblings should be present.

B.Preparation
1.Divert the child’s attention with small talk about family, school, friends, music or
sports.
2.Allow the child to undress himself/herself, leave underpants on, and use a grown
or drape.
3.Demonstrate equipment- a school-age is curious to know how equipment works.
4.Comment on the body and how it works. An 8 or 9 year old child is interested to
learn more on how the body works. It is rewarding to see the child’s eyes light up
when he or she hears the heart sound.
C.Sequence
As with the adult, progress from the
head to toes.
V.The adolescent
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 examination, the adolescent needs feedbacks that his or her own
body is heathy and developing normally.
2.Reassure the adolescent of the wide variation on the rate of the growth
and development during this stage.
3.Communicate with some care. Do not treat the adolescent like a child, but
do not overestimate and treat him or her an adult either.
4.Provide heath teachings that can promote wellness. Positive attitudes
developed at this stage may last through adult life.
C.Sequence
1.As with the adult, use head-to-toe approach.
Examine genitalia last, and do it quickly.
The Aging Adult
A.Position
1.The older should be sitting on the examination table. A frail older adult may need to be
supine.
2.Arrange the sequence to allow as few position changes as possible. To prevent postural
hypotension.Allow rest periods when needed. To prevent exhaustion.
B.Preparation
1.Adjust examination pace to adapt to the possible slowed pace of the aging person. The
complete examination may be done in several short visits.
2.Use physical touch. This is usually appreciated by aging person because other senses
such as vision and hearing may be diminished.
3.Do not mistake diminished vision or hearing for confusion.
4.Be aware that aging years contain more of life’s stress – loss of love ones (friends,
spouse), loss of financial security, declining energy level, changes in physical appearance of
the face and body, etc. How the patient adapts to these changes and loses significantly
affects health assessment.
C.Sequence
1.Use the head – to – toe approach as in the younger adult.
The ill Person
The position of the ill person during examination should
be adapted to his/her condition. Example: a person with
shortness of breath or earache may want to sit up.
Whereas, a person with faintness or severe fatigue may
want to lie supine.

Initially, it may be necessary to examine just the body

areas appropriate to the current problem, collecting a
mini-data base. Once, the initial distress is resolved, the
nurse may return to finish a complete assessment.
Standard Precautions for use with all patients

 Wash Hands
 Wear clean gloves
 Wear a mask and eye protection
 Wear a gown
 Take care with used patient care equipment
 Design and follow adequate hospital or clinic procedures
 Take care with used linens
 Prevent injuries due to blood borne pathogens.
 Place in private room