3. It is the FIRST STEP of the Health Care Process. The following are its key
components:
Health Interview
Physical Examination
Laboratory or Diagnostic Examination
Records Review
4. A systematic way of
collecting objective data
from a client using the four
examination techniques in
order to assess or identify
current health status.
Different Approaches:
Cephalocaudal
Proximodistal
Mediolateral
Outer to Inner
/External to Internal
5. Obtain physical data about the client’s functional
abilities
Supplement, confirm, or refute data obtained in the
client’s health history
Obtain data that will help the nurse establish
diagnoses and plan the client’s care.
Evaluate the physiologic outcomes of health care and
thus the progress of a patient’s health problem
To identify areas for health promotion and disease
prevention
7. INSPECTION
Visual examination of the
patient done in a methodical,
deliberate, purposeful, and
systematic manner.
Assess moisture, color and texture of the body
surfaces, as well as shape, position, size, color,
and symmetry of the body.
8. PALPATION
Examination of the body using the sense of touch.
The use of hand to touch and feel the patient’s skin,
organs, mass, and other delineated structures in the
body
Assess temperature; turgor; texture; moisture; vibrations;
position, size, shape, consistency and mobility of organ or
masses; distention; pulsation; and the presence of pain
upon pressure(tenderness)
9. Palmar surfaces of
the examiner's
fingertips and finger
pads are used for
discriminatory
sensation, such as
texture, vibration,
presence of fluid, or
size and consistency
of a mass
The dorsum, or
back of the hand,
is used to assess
surface
temperature.
10. LIGHT PALPATION
Place the hand with fingers
together parallel to the skin
surface or area being
palpated, while moving the
hand in circle.
Light
palpation,
light
pressure is applied by
placing the fingers together
and depressing the skin and
underlying structures about
1/2 inch (1 cm).
Use to check muscle tone
and to assess for tenderness
11. Deep palpation is used with
caution because pressure
can damage internal organs.
The skin and underlying
structures are depressed
about 1 inch (2 cm).
To identify abdominal organs
and abdominal masses.
Two – handed deep palpation
place the fingers of one hand
on top of those of the other.
The top hand applies pressure
while the lower hand remains
relaxed to perceive the tactile
sensation.
12. Deep Palpation is done
with two hands
(bimanually) or one hand.
Usually not indicated in clients who
have acute abdominal pain or pain
that is not yet diagnosed
Deep Palpation using lower hand
to support the body while
the upper hand palpates the organ
13. PERCUSSION
Striking of the body surface with short, sharp
strokes in order to elicit palpable vibrations and
characteristic sound.
It is used to determine the location, size, shape,
and density of underlying structures; to detect
the presence of air or fluid in a body space; and
to elicit tenderness.
15. TYPES OF PERCUSSION
INDIRECT PERCUSSION
Using the finger of the one
hand to tap the finger of the
other hand.
plexor strikes the finger of the
examiner’s other hand, which is in
contact with the body surface being
percussed (pleximeter- the middle
finger of the nondominant hand).
Jing Salaria, RN,MD
16. Percussion is used to access the location, shape, size, and density of tissues.
(Left) The non-dominant hand is placed directly on the area to be percussed,
and the middle finger is placed firmly on the body surface.
(Right) The tip of the middle finger of the dominant hand strikes the joint of the
middle finger of the opposite hand
19. Stethoscope bell and diaphragm. Use the diaphragm of the stethoscope to
detect high-pitched sounds. The diaphragm should be at least 1.5 inches
wide for adults and smaller for children. Hold the diaphragm firmly against
the body part being auscultated. Use the bell of the stethoscope to detect
low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell
lightly against the body part being auscultated.
20. Introduce self to the client. Verify his identity. Explain the purpose why such
procedure is necessary and how he could cooperate (i.e. positioning).
Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder.
Ensure privacy by closing the doors or pulling the curtains around him.
Invite a relative or a significant other to stay with the client, as necessary.
21. Provide adequate lighting.
Gather the equipment:
height chart, weighing scale, Snellen’s chart, penlight, card board, sterile
gloves, tongue depressor, 4x4 Gauze, tuning fork, stethoscope, wrist watch,
tape
measure, marker/pencil, record
sheet & waste receptacle.
Ensure the examination table is at a comfortable working height. Perform hand
hygiene.
24. STANDING = assessment of posture, gait & balance
SITTING
= used to take vital signs
DORSAL RECUMBENT
= used in patient having difficulty maintaining
supine position
26. LITHOTOMY
= assessment of female
rectum and vagina.
(for a brief period only)
KNEE-CHEST
= assessment of
rectal area (for brief
period only)
27. SALIENT POINTS:
Subjective data should be documented in patient’s
own words.
Objective data should be specific.
generalizations and judgmental phrases
No
Data gathered in the nursing health history may be
confirmed or refuted by the nurse during the
interview or the physical assessment
29. PROCEDURE
I. Obtain vital signs & anthropometric measurement
(height/weight).
NOTE:
Given:
IBW= A-B
where, A= ht. in cm -100
B= (A) x 0.10
C= (IBW) x 0.10
N Range = IBW-C (Lower Limit)
= IBW+C (Upper Limit)
BMI= wt. in kg/ ht. in (m)2
34. II. Assess the General
Appearance:
A. Body build, height and
weight in relation to age,
lifestyle and health
B. Posture and Gait
C. Over-all hygiene and
grooming
D. Body and breath odor
E. Signs of distress
F. Mood / Affect
G. Quantity, Quality &
Organization of Speech
H. Relevance & Organization
of Thoughts
38. 1. SKIN COLOR
Normal
Deviations from Normal
• Varies from light • Pallor
to deep brown, • Cyanosis
from ruddy pink • Jaundice
to light pink
• Erythema
39. 2. Skin Color Uniformity
Normal
• Generally uniform
except in areas
exposed to sun; areas
of lighter pigmentation
in dark skinned
40. 2. Skin Color Uniformity
Deviations
• Hyperpigmentation
Birthmarks – abnormal
distribution of the melanin
41. 2. Skin Color Uniformity
Deviations
• Hypopigmentation
Vitiligo due to destruction
of melanocytes in the area
Albinism – complete or
partial lack of melanin
42. 3. Assess for Edema
• Excessive accumulation of fluid in body tissues
• Note the degree to which the skin remains
indented or pitted when pressed by a finger
Edema scale
1+ = barely detectable
2+ = indentation of less than 5 mm
3+ = indentation of 5 to 10 mm
4+ = indentation of more than 10 mm
ANASARCA
43. 4. Inspect, palpate, and describe skin
lesions
• According to type/structure, color, number,
distribution, location
TYPES:
Primary skin lesions – abscess, ulcer, tumor,
and open wound
Secondary skin lesion crusts, kelloids,
scars, etc.
50. 5. Observe and palpate skin
moisture
• Done by touching or palpating the skin of the
extremities
Normal
Moist
Deviations
Excessively dry
51. 6. Palpate skin temperature
Normal
Deviations
• Uniform; within • Generalized or localized;
normal range
hyperthermic or
hypothermic
52. 7. Palpate Skin Turgor
• Refers to fullness or elasticity
• Indicative of status of hydration of the body.
• Assessed by pinching the skin on an extremity.
Normal
Deviations
When pinched, skin
Skins stays pinched or
springs back to
indented or moves back
previous state in less
than 3 seconds
slowly.
53. Note that this is not as valid in elderly people as in
younger people because skin elasticity decreases
with age; thus, other parameters should be used,
such as: I&O, daily weight
55. 1. Inspect fingernail plate shape,
curvature & angle
Normal
– Colorless and a
convex curve.
Deviations from Normal
• Concave
• Clubbed fingernails (>180O) due
to chronic tissue hypoxia
– Angle between nail
and nail bed:
usually 160o
57. 2. Inspect and palpate finger & toenail
bed color
Normal
• Highly vascular and
pink in light skinned;
dark skinned may be
brown or black
Deviations from N
• Bluish or purplish
tinges;
• Pale
58. 3. Inspect tissues surrounding nails
Normal
• Intact epidermis
Deviations from N
• Hangnails (paronychia =
ingrown nail)
• Inflammation of
surrounding tissues
59. 4. Perform Blanch Test/Capillary
refill test
Normal
• Prompt return or pink
or usual color, less
than 2-4 seconds
Deviations
• Delayed return of pink
or usual color, usually
>4 seconds
62. 1. Inspect skull size, shape,
proportion & symmetry
Normal
Deviations from Normal
• Round and is of normal
• Disproportionate
size or head circumference • Asymmetric prominences
Normocephalic
• Increased head circumference
• In proportion w/ gross
body structure
• Frontal, parietal and
• Square-head
occipital prominences;
• Bulging / depressed bone
• Smooth skull contour
63. 2. Palpate skull nodules or masses
& depression
Normal
Deviations from Normal
• Smooth, uniform
• Sebaceous cysts; local
consistency; absence deformities from
of nodules/masses
trauma; masses;
or depression
nodules
64. 3. Inspect facial features
Normal
• Symmetric facial
features;
• Eye brow hair equally
distributed
• palpebral fissures equal
in size;
• symmetric nasolabial
folds
Deviations from N
• Asymmetric features
• Increased facial hair; thinning
of eyebrows; exopthalmos;
moon face;
65. 4. Inspect eyes for edema and
hollowness
Normal
• No edema, eyes not
sunken
66. 4. Inspect eyes for edema and
hollowness
Sunken eyes, cheeks
and temples
(indicative of
dehydration,
starvation, and
illness)
Deviations
• Periorbital edema
67. 5. Inspect symmetry of facial
movements
Normal
• Symmetric facial
movements
Deviations
• Asymmetric facial
movements, drooping of
lower eyelid and mouth;
involuntary facial movement
Raise or lower both
eyebrows
Blink both eyes
Close both eyes tightly
Smile and show the
teeth
Frown
Puff the cheeks
