OBJECTIVES

 Identify the purpose of physical examination

 Explain the four techniques used in physical
examination.
 List the guidelines of Health Assessment of the
adult.
 Introduction
 Health assessment may be conducted starting at the
head and proceeding in a systemic manner downward
toward toe.
 Varies according to the
 Age
 Severity of illness
 Preference of nurse
 Hospital policy
 ASSESSING HEALTH
 Assessing client’s health status is a major component of
nursing care.
 Has 2 aspects:
1. Nursing Health history
2. Physical Examination
3 Types of Physical Examination:
1. A complete assessment (head to toe)
2. Examination of a body system (e.g., digestive)
3. Examination of a body area (e.g., left leg)
PURPOSES:
 To obtain baseline data about the client’s
functional abilities;
 To supplement and confirm or disprove data
obtained in the nursing history;
 To obtain data that will help establish nursing
diagnoses and plans of care;
 To evaluate the physiological outcomes of health
care and thus the progress of a client’s health
problems.
 To make clinical judgments about client’s health;
 Methods of Examining
 Inspection
 Palpation
 Percussion
 Auscultation
 1. INSPECTION

 The visual examination by using sense of sight.

 Inspects with naked eye / may use instruments for

proper viewing
eg: Using otoscope and tongue depressor

 Assess moisture, color, texture, size, shape, position

and symmetry of the body.
Inspection
 2. PALPATION
 Using the sense of touch.
 Pads of fingers are used because the nerve endings
will be highly sensitive to tactile discrimination.
 This is used to determine:
 Texture (e.g. of the hair)

 Temperature (e.g. of a skin area)

 Movement of the joint

 Position, size, consistency of organs

 Distension (urinary bladder)

 Pulsation

 Tenderness or pain
Palpation
Two types of palpation:

1. Light palpation
2. Deep palpation (contra indicated for
abdominal pain)

Guidelines for palpation:

• Nurses' hands should be clean & warm.

• Areas of tenderness should be palpated last.
• Deep palpation to be done after light palpation.
 3.PERCUSSION
 Act of striking the body surface to
elicit sounds & vibration.
2 types of Percussion:
1. Direct percussion: Using 1-4 pads of
fingers to strike the surface of the
body
2. Indirect percussion: Using a finger of
one hand to tap the finger of the
nondominant hand
Percussion
 4. AUSCULTATION

 Listening to sounds produced within the body.

2 types:
1. Direct auscultation: uses unaided ear

(e.g., wheeze, grating of a moving joint)

2. Indirect auscultation: uses Stethoscope

(e.g., bronchial, heart sounds)

 Auscultation
 Auscultation with Auscultation with a
flat-disc bell-shaped
diaphragm diaphragm
Reflexes examination
 Reflex tests are performed as part of
a neurological exam.

Purpose of Reflexes Examination

 A mini-exam done to quickly
confirm integrity of the spinal cord
or a more complete exam performed
to diagnose the presence and
location of spinal cord injury or
neuromuscular disease.
Some Types of Reflexes:
 Biceps reflex : Slight flexion of the elbow
 Triceps reflex: Slight extension of the elbow
 Brachioradialis: Normal flexion & supination of
forearm
 Achilles reflex: Normal plantar flexion
 Plantar reflex: Five toes bend downward
Note:
Absence of a reflex indicates for a spinal cord, nerve root, peripheral nerve, or
muscle injury/damage.
How to calculate the body mass index?
Weight in Kilogram
Formula: -----------------------------------
(Height in meters)2
Ranges Description
< 18.5 Under weight

18.5-24.9 Normal

25-29.9 Overweight
30-34.9 High Obesity
35-39.9 Very High Obesity

>40 Extremely Obese

 EQUIPMENT & USES
EQUIPMENT USES
1 Flash / pen light To view pharynx, cervix, & to
determine the reactions of the pupil.
2 Laryngeal mirror To observe pharynx & oral cavity.

3 Nasal speculum To visualize the lower & middle

turbinate.
4 Ophthalmoscope To visualize the interior of the eye.

5 Otoscope To visualize the eardrum & external

auditory canal.
6 Percussion/reflex/ To test reflexes.
knee hammer
 EQUIPMENT & USES
EQUIPMENT USES
7 Tuning fork To test hearing acuity &
vibratory sense.
8 Cotton applicators To obtain specimens

9 Gloves To protect the nurse and the

client
10 Lubricant To ease insertion of
instruments
11 Tongue blades/ To depress the tongue during
depressors assessment of mouth
12 Vaginal speculum To assess the cervix & vagina
 EQUIPMENT & USES
EQUIPMENT USES
13 Weighing scale To get the weight of the client

14 Measuring tape To measure vital statistics of

the body
15 Snellen’s Chart To test distance vision

16 Stethoscope To listen to the sound of the

heart, lungs and abdomen.
17 Sphygmomanometer Used to measure blood
pressure
18 Thermometer To measure body temperature