CEBU TECHNOLOGICAL UNIVERSITY

In consortium with
CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

HEALTH ASSESSMENT
Module 3: Physical Examination
Physical Examination Supine – back lying
 teaches a systematic approach for position with legs
examining the patient extended.
 procedure can vary according to the age of Sitting
the individual, the severity of the illness, Lithotomy – back
the preference of the nurse, the location lying position with legs
of the examination, and the agency’s supported with
priorities and procedures stirrups
 contributes to a smooth, flowing process Sim’s – side lying
that minimizes the number of times the position
patient must change positions, conserves Prone – lies on
the patient's energy, and gathers abdomen with head
information that is pertinent to the turned to the side.
patient's status.
4. Draping a) arranged so that the
A. PREPARATION GUIDELINES area to be assessed is
“P.P.P.D.I” exposed
b) it provide not only a
1. Preparing the a. explain when and degree of privacy but
Client where the also warmth
examination will take
place 5. Instrumentation a) all equipment
b. why is it important should be clean, in
c. what will happen good working order,
and readily accessible
2. Preaparing the a) time should be
Environment convenient to both
client and the nurse  Equipment/instruments used for P. E.
b) well lighted and the
equipment should be Penlight − assist
organized for efficient viewing of
use the pharynx
c) room should be or to
warm determine
d) provide privacy the
reactions of
3. Position a) consider the ability the pupils
to assume position of the eyes
b) physical condition,
energy level and age
c) client’s different Percussion hammer − an
positions like; instrument
Dorsal recumbent - with rubber
back-lying position head to test
with knees flexed and reflexes
hips externally
rotated. Tuning fork − 2-pronged
metal
 instrument internal
used to test diameter of
hearing about 0.3 cm
acuity and (1/8in).
vibratory → have both a
sense flat-disk
Tongue blades − to depress diaphragm
the tongue and a bell-
during shaped
assessment amplifier
of the ▪ diaphragm
mouth and – best for
pharynx transmitting
Cotton applicators − to obtain high-
specimens pitched
sound
▪ bell–detects
low
frequency
sounds
→ The
amplifier –
Gloves − to protect placed
the nurse firmly but
lightly
against the
client’s skin
→ earpiece –
should fit
comfortably
into the
Ophthalmoscope − a lighted nurse’s
instrument ears, facing
to visualize forward
the interior
of the eye Doppler Ultrasonic − uses
Stethoscope ultrasonic
Stethoscope − to evaluate waves to
sounds that detect
are difficult sounds that
to hear with are difficult
human ear. to hear with
Use to a regular
auscultate stethoscope
body Otoscope − lighted
sounds. instrument
Parts: to visualize
1. Tubing should the
be 30 to 35cm eardrum
(12 to 14 in.) and
long, with an external

PILONES,RISHELLE MAE M.
 auditory f. Arrange for an interpreter if the
canal client’s language differs from that of
the nurse.
g. Ask clients how they wish to be
addressed.
h. Adapt assessment techniques to any
sensory impairment.
i. If clients are older or frail, it is wise to
conduct the assessment in several
Snellen’s chart − used as a segments in order not to overtire
screening them.
test for
vision C. METHODS OF EXAMINATION
(I.P.P.A)
A. Inspection
 begins the moment the nurse meets
the client & continues until the end of
the client-nurse interaction
 uses the sense of seeing, smelling,
hearing
Nasal speculum − an
● Techniques of Inspection
instrument
1. position & expose body parts being
that allows
observed
visualization
2. always look before touching
of the lower
3. use sufficient lighting (natural or
and middle
artificial light)
turbinate of
4. observe for color, size, location,
the nose
texture, symmetry, odors, moisture,
shape, and sounds
5. compare each area inspected
Vaginal speculum − used to 6. provide a warm room for examination
examine of the client
the vaginal 7. use additional light to inspect body
canal & cavities
cervix 8. don’t hurry inspecting

B. Palpation
B. Physical Examination Guidelines  the skill of assessing the client through
1. Adult Guidelines the sense of touch
a. Be aware of normal physiological Finger pads
changes that occur with aging. − highly sensitive to tactile
b. Be aware of the stiffness of muscles discrimination
and joints from aging or history of Palmar surface of the fingers
orthopedic surgery. − used to determine position, size,
c. Be aware of cultural differences. consistency and mobility of
d. Expose only areas of the body to be organs or masses; texture (hair);
examined in order to avoid chilling. distention (urinary bladder);
e. Permit ample time for the client to pulsation; tenderness or pain
answer your questions and assume Dorsum surface of the hand & fingers
the required positions. − most sensitive to temperature
Ulnar surface of the hand and fingers
− most sensitive to vibrations
PILONES,RISHELLE MAE M.
 a. Direct percussion 1. the nurse strikes
● Techniques in Palpation the area to be
1. examiner’s finger nails should be cut percussed
short. No jewelries. directly with the
2. nurse’s hands should be warm and pad of middle
gentle touch finger.
3. client should be relaxed & positioned 2. strikes are rapid,
comfortably & the movement
4. place arms along side of the body is from the wrist
5. light palpation precedes deep
b. Indirect percussion 1. striking of an
palpation
object held
6. areas of tenderness is palpated last
against the body
7. During palpation, the nurse should be
area to be
sensitive to the client’s verbal and
examined
facial expressions indicating
2. the middle finger
discomfort.
of the non-
dominant hand
● Types of Palpation
(pleximeter), is
placed firmly on
a. Light − used to assess
theclient’s skin
(superficial)palpation surface
3. only the distal
characteristics
phalanx and joint
such as: skin
of this finger
texture, pulse,
should be in
tender
contact with the
inflamed area
skin.
near the
4. using the tip of
surface of the
the flexed middle
skin
finger of the
− depress a
other hand
depth of 1cm
(plexor), the
b. Deep palpation → done with 2
nurse strikes
hands
5. the pleximeter,
(bimanually)
usually at the
→ used to
distal
palpate an
interphalangeal
organ that lies
joint or point
deep within a
between the
body cavity.
distal
→ Depressed a
6. and proximal
depth of 2 – 4
joints
cm
7. striking motion
comes from the
C. Percussion wrists; the
 the act of striking the body surface to forearm remains
elicit sounds that can be heard or stationary
vibration that can be felt. ● Percussion elicits 5 types of sound
 used to determine the size and shape a. Flatness – an extremely dull sound
of internal organs by establishing their produced by very dense tissue, like muscle
borers orbone.
● Types of Percussion
PILONES,RISHELLE MAE M.
b. Dullness – thud like sound produced by
dense tissue like liver, spleen or heart.
c. Resonance – hollow sound like that
produced by lungs filled with air.
d. Hyper resonance – is not produced in the
normal body, described as booming and
Can be heard over an emphysematous lung.
e. Tympany – musical or drum like sound
produced by an air filled stomach

D. Auscultation
 process of listening for various sounds
produced within the body
● Types of Auscultation
Direct auscultation → performed
using the
unaided ear

Indirect auscultation → performed

using a
stethoscope,
which
transmits
sounds to
the nurse’s
ears
● Auscultated sound are described
according to
1. Pitch – the frequency of the vibrations
2. Intensity (amplitude) – refers to the loudness
or softness of a sound.
3. Duration – its length (long & short)
4. Quality – is subjective description of a sound.

PILONES,RISHELLE MAE M.