HEALTH ASSESSMENT

INTRODUCTION-
Physical assessment or the physical examination, is an integral part of nursing assessment. The physical
examination is usually performed after the health history is performed. It is carried out in a well -
lighted ,warm area. An organized and systematic examination is the key to obtaining appropriate data in
the shortest time .the person’s health history provides the examiner with a health profile that guides all
aspects of the physical examination .although the sequence of physical examination depends on the
circumstances and on the patient’s reasons for seeking health care.
A complete health assessment involves a more detailed review of a client’s condition.
DEFINTION-
“Physical assessment is a head to toe review of each body system that offers information about
the client’s condition”.
PURPOSES –
There are following reasons to do physical assessment-
1) To gather baseline data about the client’s health.
2) To supplement, confirm or refute data obtained in the nursing history.
3) To confirm & identify nursing diagnoses.
4) To make clinical judgments about the client’s changing health status & management.
5) To evaluate the physiological outcomes of care.

SKILLS OF PHYSICAL ASSESSMENT –

The basic tools of the physical examination are vision, hearing ,touch , and smell. The four fundamental
techniques used in the physical examination are :
1. Inspection
2. Palpation
3. Percussion and
4. Auscultation
1. INSPECTION:-
General inspection begins with the first contact with the patient. Than the specific observations are
documented in the patient’s chart or health record .the following are to be observed.
POSTURES:-
The posture that a person assumes often provides valuable information.
1) For ex : Patients who have breathing difficulties secondary to cardiac disease prefer to sit and
may report feeling short of breath when lying flat for even brief time .
 2) Patients with obstructive pulmonary disease not only sit upright but may also thrust their arms
forward and laterally onto the edge of the bed (tripod position) to place accessory respiratory
muscles at an optimal mechanical advantage.
BODY MOVEMENTS:-
Abnormalities of body movements are of two kinds:
1) Generalized disruption of voluntary or involuntary movement.
For ex.tremors of a wide variety; some tremors may occur at rest (Parkinson’s disease), where as others
occur only on voluntary movement (cerebral ataxia ). Other tremors may exist during rest and activity
(alcohol withdrawal syndrome ).
2) Asymmetry of movement; in which only one side of the body is affected, may occur with the
disorders of the central nervous system.
For ex. cerebrovascular accident.
NUTRITIONAL STATUS :-
Nutritional status is important to note, For example; obesity may be specifically localized to the
trunk in patients who have an endocrine disorder (Cushing’s disease) or who have been taking
corticosteroids for long period. Loss of weight may be generalized as a result of inadequate calorie
intake, or it may be seen in loss of muscle mass with disorders that affect protein synthesis.
SPEECH PATTERN :-
Speech may be slurred because of damage of cranial nerve .recurrent damage to the laryngeal
nerve results in hoarseness, so this all to be noted down.
VITAL SIGNS: -
The recording of vital signs is the part of every physical examination, those are-
 blood pressure
 respiratory rate
 pulse rate
 body temperature
 pain
The “fifth vital sign” pain , is also assessed and documented , if indicated any acute changes and values
that deviates significantly from a patient’s normal values are brought to the attention of the physician .
2. PALPATION:
Palpation is the vital part of the physical examination. Many structures of the body, although not
visible, may be accessed through the techniques of light and deep palpation.
For example - the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and
pelvis, and rectum. When the abdomen is examined, auscultation is performed before palpation and
percussion to avoid altering bowel sounds.
3. PERCUSSION:
The technique of percussion translates the application of physical force into sound this technique
provides much information about disease processes in the chest and abdomen.
Percussion allows the examiner to assess such normal anatomic details as the borders of the heart and
the movement of the diaphragm during inspiration .it is also possible to determine the level of a pleural
effusion and the location of a consolidated area caused by pneumonia or atelectesis.
4. AUSCULTATION:
Auscultation is the skill of listening to sounds produced within the body created by the movement of air
or fluid.
For example;
 Breath sounds
 The spoken voice
 Bowel sounds
 Heart sounds and
 Cardiac murmur
SYSTEMIC PHYSICAL EXAMINATION:-
A systemic physical examination includes assessment of the following ;
 Vital signs
 Height $ weight
 Head to toe examination
 Reflex examination
 Neurologic, mental and emotional examination
 Extremities
HEAD TO TOE ASSESSMENT CRITERIA:
1) General appearance:
Observation- gender , age, race ,signs of distress, body type, posture, gait, body movements, hygiene &
grooming, dress, body odor, affect & mood, speech, client abuse(alcoholism, drug abuse), nutritional
status, general health assessment ,development, height & weight.
Color- pink , pale ,red ,jaundiced ,mottled , blanched , cyanotic.
Skin – color, pigmentation, moisture, vascularity , temperature , texture , turgor , lesion ,bleeding , scars
edema .
2) Vital signs :
 Temperature – normal temperature, high, low grade fever etc.
 Blood pressure – supine, sitting, right & left arms.
 Pulse – apical, radial, brachial, carotid, temporal.
  Respiratory rate.

3) HEAD& FACE:
Size- Contour, symmetry, color, pain, tenderness, lesion, edema
Scalp – Color, texture, inflammation, dryness, lesion, dandruff, lice, injury etc.
Face – Movement, expression, pigmentation ,acne ,tremors, moisture, dryness, wrinkles, scar,
symmetry, deformity etc .
EYES- Acuity –visual loss, glasses, diplopia, myopia, hypertropia, glaucoma etc.
Eye lids – color, ptosis, styes, exophthalmoses.
Conjunctiva – color, discharge, vascular changes.
Sclera – color, integrity etc.
Pupils –Size, shape, reaction to light.
EAR -
Acuity – Hearing loss, pain, tinnitus, sensitivity to sound.
External ear – Lobe, auricle, canal, wax, pinna, deformity .
Inner ear – Vertigo, eardrums, integrity, inflammation.
NOSE-
Symmetry- Septum, nostrils, Smell, nasal size, flaring, sneezing, deformities.
Mucosa – Colour, edema, bleeding, pain, tenderness, polyp, nasal bleeding (epistaxis).
MOUTH AND THROAT:
Odour- Pain, ability to speak, chews, swallow, taste.
Lips – Colour, symmetry, hydration, fever blisters, cracking, numbness, drooling.
Gums – Color, bleeding, retraction, pain.
Teeth- Number, missing, caries, dentures, sensitivity to heat, cold, pallor, plaque.
Tongue – symmetry , color , size , hydration , markings , protrusion , ulcers , burning ,taste, coating .
Throat – Gag reflex, soreness cough , sputum , hemoptysis
Voice – Hoarseness, loss, change in pitch.
NECK
Symmetry- Movement, range of motion, masses, scars, pain, stiffness.
Trachea – Deviation
Thyroid – Size, shape, symmetry, tenderness, enlargement, nodules, scars .
Lymph nodes –Size, shape, mobility, tenderness , enlargement.
CHEST:
Size - Shape, symmetry, deformities, pain, tenderness.
Skin – Color ,rashes ,scars ,hair distribution,turgor , temperature, edema, crepitation.
Breast – contour, symmetry, color, size, shape, inflammation, masses pain, engorgement, tenderness,
hair growth, etc.
Nipples –discharge, ulceration, bleeding, inversion, pain, cracked nipples.
Axilla – nodes, enlargement, tenderness, rash ,inflammation.
LUNGS:
Breathing pattern – rate,regularity ,depth, normal or adventitious fremitus, use of accessory muscles,
crackles sound, whizzing, expansion, position of ribs etc .
HEART:
Position, auscultate for S1 S2 & S3 (extra sound), loud sound, slow sound.
Cardiac pattern – rate, rhythm, regularity, extra – beats, point of maximum impulse, Right and left
boarder, implanted pacemaker, any abnormality.
VASCULAR SYSTEM:
Blood pressure- arteries & veins, carotid arteries, jugular vein, peripheral veins & arteries, arterial
pulse, tissue perfusion, lymphatic system, DVT, thrombosis etc.
ABDOMEN:
Size, color, contour, symmetry, fat, muscle tone, turgor, hair distribution, scars, umbilicus, striae, fetus ,
rashes, distension, abnormal pulsation, enlargement of any abdominal organ, ascitis, gases, peristaltic
movement etc .
Bowel Sounds: Absent, present, hypoactive, hyperactive, normal, bruits.
Liver border- Gastric air bubble , splenic dullness, air fluid , muscle spasm rigidity, tenderness, pain,
rebound, bladder distension, enlargement.
KIDNEY:
Urinary output- (amount, color, odor, sediment) frequency, urgency, hesitancy, burning, pain,
dribbling, incontinence, hematuria, nocturia, oliguria, blood in urine.
Bladder position- tenderness, storage of urine, difficulty in urination, no abnormality in urethra etc.
GENITALIA:
Female – labia majora&minora , urethral & vaginal orifices , discharge, swelling, ulceration,
nodules ,masses ,tenderness, pain, bartholin gland, polyp, urethra & vagina & anal orifice in a
sequence, perineum intact, clitoris, its size, shape, fibroid in uterus etc.
Male – penis,discharge ,ulceration , pain, scrotum, color, size , swelling, tenderness, symmetry, node,
shape, erectile disorder, BPH etc.

RECTUM:
Pigmentation, hemorrhoids ,excoriation, rashes, abscess, pilonidal cysts, masses, lesions, tenderness,
pain, itching, burning, injury, bleeding etc.
MUSCULOSKELATAL SYSTEM:
Inspect the posture, gait, foot dragging, limping, shuffling, arm swinging, parallel alignment, cervical,
lumber, Thoracic curve, shoulders, symmetry, shape, kyphosis.
 Range of motion-Movements, joints mobility, adduction, abduction, flexion, extension, hyperextension,
pronation, supination, internal rotation, eversion, inversion, dorsiflexion, planter flexion etc.
Muscle tone – strength – muscular resistance, limb grasped, resistance to movement, hypertonicity,
hypotonicity, symmetrical muscle pair, muscle body’s circumference etc.
NEUROLOGICAL SYSTEM:
Co-ordination of movement, reception, perception, control of speech, emotional status, mental status,
level of consciousness, behavior & appearance, language, intellectual function, memory, knowledge,
abstract thinking, association, judgment, cranial nerve function, sensory function, motor function, co
ordination, reflexes, balance etc.
The following equipment needed to examine neurological function –
I. Reading material
II. Vial containing aromatic substances
III. Safety pins
IV. Penlight
V. Snellen chart
VI. Vial containing sugar & salt
VII. Tongue blade
VIII. Two test tubes, one filled with hot water & one with cold water
IX. Tuning fork
X. Reflex hammer
Other equipments are-
1. Cotton applications
2. Drapes
3. Snellen chart
4. Flashlight &spoylight
5. Forms (physical, laboratory)
6. Gloves
7. Gown for client
8. Lubricant
9. Ophthalmoscope
10. Otoscope
11. Paper towels
12. Percussion hammer
13. Scale with height measurement rod
14. Spatula
15. Specimen container
16. Sphygmomanometer & cuff
 17. Tape measure
18. Thermometer
19. Tongue depressor
20. Vaginal speculum
21. Wrist watch with second hand

CONCLUSION-
Physical examination or clinical examination is the process by which a doctor investigates the
body of a patient for signs of disease. It generally follows the taking of the medical history — an account
of the symptoms as experienced by the patient. Together with the medical history, the physical
examination aids in determining the correct diagnosis and devising the treatment plan. This data then
becomes part of the medical record.

BIBLIOGRAPHY

BOOK REFERANCES:-
1. Potter & perry, fundamentals of nursing, 3rd edition, publication mosby, page no 507-608.
2. Brunner & suddharth, textbook of medical surgical nursing, edition 3 rd published by jaypee brothers,
page no. 130-135.
3. Le MoneBurke, medical surgical nursing, edition 4 th, published by Pearson education, page no.125-
127.
4. Joyce M. black & Hawk, medical surgical nursing, edition 8 th volume 1st, published by mosby, page
no. 167-169.
5. Barbara cozier, medical surgical nursing, edition 4th, published by Mosby, page no. 113-119.
6. Lippincott, Mannual of nursing practice, edition 5th, published by mosby, page no. 144-152.
7. Saunders, textbook of medical surgical nursing, edtion 3 rd, published by jaypee brothers, page no. 54-
57.
8. BT Basawantthappa, medical surgical nursing, published by jaypee, edtion 4th page no. 78-81
JOURNALS
 The journal of nursing research August 2004, “physical examination”, page no.9
 The Indian Journal of Nursing Research,January 2003, “PHYSICAL ASSESSMENT ”, volume no.3,
page no. 16.
NET REFERANCES:-
www.google.com,www.editorial.com, “physical assessment”.