History

Nursing taking
assessment Physical
Examination

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PHYSICAL ASSESSMENT

Pn. Nor Rosnita Che Ri

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 LEARNING OUTCOMES
At the end of the lesson student should be able
to:
1. Define physical assessment.
2. Explain the purpose of physical assessment.
3. Describe the technique used in physical
assessment.
4. Demonstrate the physical assessment from
head to toe.
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 DEFINITION
• Physical assessment Is a systematic data collection
method that used the sense of sight, hearing, smell
and touch to detect health problems

• Usually history taking is completed before physical

examination.

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 PURPOSE

1. To obtain baseline data about patient’s functional abilities

2. To supplement, confirm or refute data obtained in the nursing
history
3. To obtain data that will help establish nursing diagnosis and
plans of care.
4. To obtain baseline data about patient’s functional abilities
5. To supplement, confirm or refute data obtained in the nursing
history
6. To obtain data that will help establish nursing diagnosis and
plans of care
 Technique of assessment
• 4 technique used in physical assessment:-
 Inspection
 Percussion
 Auscultation
 Palpation

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 Inspection
• It’s used of vision to distinguish the normal from the abnormal
findings
• Body parts are inspected to identify colour, shape, symmetry,
movement, pulsation and texture.
• Principals of inspection
 Availability of adequate light
 Inspect each area for size, shape, colour, symmetry, position
and abnormalities
 Position and expose body part to view all surface ( expose
part by part)
 If possible compare each area inspected with the same area
on the opposite side.
 Use additional light to inspect
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 Palpation
• Involve use of hands to touch body parts for data
collection.
• Done with two hand (bimanually) Top hand press and
lower hand relax
• The nurse use fingertips and palm to determine the size,
shape and configuration of underlying body structure
and pulsation of the bld vessels.
• This technique help to detect the outline of organs such
as thyroid, spleen or liver and abnormality of masses
• It also detects body temperature, moisture, turgor,
texture, tenderness, thickness and distension.

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 Palpation…cont
• Principles of the palpation
Ensure pt relax and comfort because muscle
tension impairs effectiveness of assessment.
Advice pt to take slow deep breaths during
the palpation.
Rub hand to warm them, have short
fingernails and use gentle touch.

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 Percussion
• Is the technique in which one or both hands are used to
strike the body surface to produce a sound called percussion
note that travels through the body tissue.
• The character of the sound determines the location, size and
density of underlying structure to verify abnormalities.
• An abnormal sound suggest a mass or substance like air, fluid
in an organ or cavity.

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 Auscultation
• It involves listening to sound and a
stethoscope is mostly used.
• Various body systems like cardiovascular,
respiratory and gastrointestinal have
characterized sounds.
• Bowel, breath, heart and bld movement
sounds are heard using the stethoscope.
• It is important to know the normal sound to
distinguish from abnormal.
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 History Taking:
(refer to the topic of HISTORY
TAKING)

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 Physical Examination
( from head to toe assessment)

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 Preparation for the physical
examination
• Infection prevention
 Follow Infection prevention precaution through out the
procedure.
• Environment
 Physical assessment requires privacy and away from other
destructors throughout.
• Equipment
 Get all the necessary equipment needs to be warmed before
being placed on the body such as rubbing diaphragm of the
stethoscope briskly between hands.
• Patient preparation
 Prepare the pt physically and make the pt comfortable
throughout the physical assessment for successful exam.
 Explain to the pt everything
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to be done.
What is a Head-to-Toe Assessment

A head-to-toe assessment refers to a

physical examination or health
assessment, and it becomes one of the
many important components of
understanding a patient’s needs and
problems.
 Head-To-Toe Assessment Basics
• A complete health assessment is a detailed
examination that typically includes a thorough
health history and comprehensive head-to-
toe physical exam.

Remember!!!!!!!!!
 How to Prepare for the
Assessment
• The primary goal of standard precautions is to
prevent the exchange of blood and body fluids
and includes hand hygiene, use of personal
protective equipment, and safe handling and
cleaning of potentially contaminated
equipment or surfaces.”
 Equipment Checklist
• Basic equipment includes:
• Gloves
• Thermometer
• Blood pressure cuff
• Watch
• Scale
• Height wall ruler
• Tape measure,
• Penlight
• Stethoscope
 Additional equipment for more
comprehensive examinations would
include:
• Otoscope
• Ophthalmoscope
• Reflex hammer
• Tongue depressor
• Sterile soft sharp object (like toothpick or pin)
• Sterile soft object (like cotton ball)
• Something for the patient to smell (like an alcohol
swab)
Stethoscope Tongue depressor
Turning fork

Ophthalmoscope Otoscope
Reflex hammer
Equipment
 Head to toe assessment
General survey
• The assessment of the pt begins on the first contact.
• It includes apparent state of health, level of consciousness
and signs of distress.
• The general height, weight and build can be noted including
skin colour, dressing, grooming, personal hygiene, facial
expression, gait, odor, posture and motor activity

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Vital signs
Assessment of v/signs is the first in physical
assessment because positioning and
movement interferes with obtaining accurate
results.
Specific v/signs can be also obtained during
assessment of individual body system.
The assessment of vital sign include BP, pulse,
resp, temp, pain, pulse oximetry
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 Lower General
extremities assessment Vital
signs
Genitalia
Nose &
Abdomen Mouth & Skin
sinuses
pharynx
Upper
extremities Eyes Head
Lips & neck
Chest
ears Hair
Neck

HEAD TO TOE ASSESSMENT

NO STEPS
P
1 Verify, greet and explain the procedure to the patient. H
2 Provide privacy and wash hands. Y
3 Perform physical examination in the following sequence:- S
i. HEAD: ii. BODY: I
 Hair  Chest
C
 Eyes  Axilla A
 Nose  Breast L
 Ears  Abdomen
 Mouth E
 Neck X
4 Upper limbs A
5 Perineum M
6 Lower limb
I
N
7 Back
A
8 Perform physical examination systematically
T
9 Wash hands I
10 Document and report findings O
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Skin, hair, scalp and nails
 Inspect all skin surface 1st or gradually assessing the
systems.
 Use the skills of inspection, palpation, and olfactory
to assess the function.

SKIN
 Inspect the skin for colour, edema, lesions, scars and
vascularity.
 Temperature and skin turgor
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Hair and scalp
Assess and note type of hair eg long, coarse,
thick, brittle.
Note the colour, distribution, quantity,
thickness, texture and lubrication.
On inspection separate the hair to determine
to scalp.
Wear clean gloves if lesions and lice are
probable.
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Nails
The condition of the nail reflects the general
health, state of nutrition, occupation and level
of self care. Such as nail biting can reveal the
person’s psychological state.
Inspect the nail bed for colour, cleanliness,
length, texture, angle between nail and bed,
and folds around the nail.
Palpate the nail for information.
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Head
The assessment of the head include:
 Eyes
 Ears
 Nose
 Mouth
 Pharynx

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Eyes
Assess visual acuity, position and alignment of the
eyes, eyebrows and eyelids.
 Check conjunctive and sclera.
 Assess eye symmetry.
 Check vision with Snellen Chart

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Ears
It determine the integrity of the ear structures and
hearing acuity.
Inspect for sore and discharges.
Assess patient hearing with whisper test
Tuning Fork test (Weber’s test, Rinne test)
Look inside ear
Assess ear discharge and tympanic membrane

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Nose and sinuses
Assess the integrity of the nose and sinuses by
using inspection and palpation.
For nose observe for the shape, size, skin, colour
and presence of deformity or infection.
For the sinus – examination involves palpation.
Incase of allergy or infection the side is inflamed
and swollen, so we can palpate for tenderness.

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Mouth and pharynx
Assess mouth and pharynx to determine
overall health and hygiene.
Use pen light and tongue depressor to
assess oral cavity.

Lips
Inspect the lips for colour, texture,
hydration, contour, sores and lesions.
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Buccal mucosa, gums and teeth
Ask pt to clench teeth and smile to observe
teeth occlusion, symmetry. A symmetrical
smile shows normal nerve function.
Inspect teeth for the hygiene, position and
alignment.
Use tongue depressor to inspect the mucosa
for colour, moisture and sores.
Inspect gums for colour, edema, retraction,
bleeding and lesions.
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Tongue and floor of the mouth.
Carefully inspect tongue on all sides as well as
floor of mouth for colour, size, position, texture,
moisture sores and lesions.

Palate
Have pt to extend the head backwards, holding
the mouth open, inspect the hard and soft palate
for colour shape, texture and extra bonny
prominences or defects.
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Pharynx
• Let the pt tip the head back slightly, open
mouth wide and say ‘Ah’, and use pen light
inspect the uvula and soft palate, they should
rise centrally as the pt say ‘Ah’ . Its help to
determine the function of cranial (vagus)
nerve function.
• Check the uvula and tonsils for redness and
inflammation.
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Neck
The assessment include:
Lymph nodes
Carotid artery
Thyroid gland
Trachea

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Neck
Palpate the muscle, lymph nodes, carotid
artery veins for tenderness and distension.

Thyroid gland
Ask pt to hyperextend the neck and view the
thyroid and palpate for masses
Normally thyroid gland is not visible.
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Chest
Inspect the skin for scar, sore, colour, lesions, chest
movement and respiratory rate.
Palpate to notice any masses and tenderness in axilla
and breast.

Lungs
Auscultate to assess respiratory and sounds from the
lungs and chest cavity.
Percussion is done to detect accumulation of fluid or
air in the chest cavity.
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Heart
Auscultate to hear the sound
Inspect the breast for skin colour, scars and
lesions

Breast
Palpate to notice any presence of the
masses
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Extremities:
Upper and lower extremities
 Inspect hand and legs for symmetry, alignment, skin colour,
temperature, sore, scars, lesions inflammation and
varicosity.
 Palpate for tenderness, edema and pulsation of arteries. Use
the brachial, radial, ulna, femoral, popliteal, posterior tibia
and dorsal pedis pulses.
 Check capillary refill on nails (normal > 2 sec), clubbed toes/
fingers and joint mobility.
 Assess range of motion and strength in arms/legs/ankles

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Deep tendon reflexes.
Normally done on high risk pt and needs
specialized practice and special hammer to
assess the reflexes.
Area that are assessed are on biceps, triceps,
patella and Achilles.

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Abdomen
 Inspect the skin for colour, sores, lesions, scars, position of
umbilicus, distention and contours.
 Palpate for tenderness, masses and enlargement of other
organs like liver, spleen and kidney.
 Ask for bowel and bladder elimination.
 Percussion is used to detect the location of organs that are
normally palpable eg. Liver, spleen and intestines.
 Always auscultate before palpation or percussion because
touching can alter mobility of bowel and increase sound.
 Listen to 4 quadrants of abdomen for bowel sounds, pain,
tenderness or problem with bowel or bladder
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Genitalia
Start assessment of genitalia with asking
questions and do inspection to confirm any
abnormality.
 Female – ask about presence of
abdomen discharge, sore, warts, and
itching.
 Male – ask any presence of sore,
itching, warts and abnormal discharge.
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Rectum and anus
Inspect for the skin colour, sore,
haemorrhoid and lesions.
Do digital palpation to examine the anal
canal for masses and sphincters function
only when important.

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Back
Inspect the back for skin integrity, rash or
scar
Inspect the spinal alignment for deformities
to assess of spine scoliosis

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 Variation In Examination Technique
ELDERLY
 Allow extra time, be patient, relaxed and unhurried
with older adult
Plan several assessment times in order not to overtire
– look into energy level, physical limitations etc.
 Measure performance under the most favourable
conditions – take advantage of natural opportunities
for assessment eg during bathing or grooming
 Keep position changes to a minimum – limit patient
movement
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Variation In Examination Technique
ADULT
Be aware of normal physiologic changes
Be aware of stiffness of muscles and joints from
aging changes or history of orthopedic surgery
Expose only areas to be examined
Permit ample time to answer questions and
assume desired positions
Be aware of cultural differences
Arrange for interpreter if needed
Adapt techniques to any sensory impairment
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 Variation In Examination Technique
CHILDREN
Proceed from the least invasive or
uncomfortable to the more invasive
Gain a child’s trust before assessment – talk
and play with the child first
Initiate assessment from peripheral then
move to center – children feel more safer
Call children by their preferred name
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 Summary
• Complete assessment
 On admission.
 From head to toe.
• Perform PE systematically.
• Prepare patient.
 Inform to the pt (why, what)
 Confidentiality
 Position (using few types of position)
 Time convenient
 Provide privacy
• Draping - only open the area to assess and other part is covered.
 Instrument
 Clean
 Good working order NIETA
 References
• Behrman, A. Snyder, S. J. Frandsen,G (2016). Kozier & Erb’s
fundamentals of nursing : concepts, process and practice
(10th ed.). Slovakia, England. Pearson Education Limited
• Potter, P. A., Perry A. G. Stockert ,P.A. Hall,M.A (2017).
Fundamentals of nursing (9th Ed). St.Lous, Missouri,
USA.Elsevier.
• Potter, P. A (2011). Basic nursing (9th ed.). St. Louis, Mosby
Elsevier.
• Smeltzer, S. C. (eds.). (2014). Brunner & Suddarth's textbook
of medical surgical nursing (13th ed.). Pennsylvania, PA :
Lippincott Williams & Wilkins.

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Thank you
Nieta