2. OBJECTIVES
By the end of the topic students
should be able to:-
1. Define physical assessment
2. Describe the four techniques used
in physical assessment
3. Know how to do a head to toe
assessment
3. Physical assessment is a systematic data
collection method that uses the senses of
sight, hearing, smell and touch to detect
health problems.
There are four techniques used in physical
assessment and these are:- Inspection,
palpation, percussion and auscultation.
Usually history taking is completed before
physical examination
4. Inspection
It’s the use of vision to distinguish the
normal from the abnormal findings.
Body parts are inspected to identify
color, shape, symmetry, movement,
pulsation and texture.
5. Principals of inspection
• Availability of adequate light
• Position and expose body part to view all
surfaces
• Inspect each area for size, shape, color,
symmetry, Position and abnormalities.
• If possible compare each area inspected
with the same area on the opposite side.
• Use additional light to inspect body cavities
6. Palpation
It involves use of hands to touch body parts for
data collection.
The nurse uses fingertips and palms to determine
the size, shape, and configuration of underlying
body structure and pulsation of blood vessels.
It help to detect the outline of organs such as
thyroid, spleen or liver and mobility of masses.
It detects body temperature, moisture, turgor,
texture, tenderness, thickness, and distention.
7. Principles of palpation
• Help client to relax and be comfortable
because muscle tension impairs
effective assessment.
• Advise client to take slow deep breaths
during palpation
• Palpate tender areas last and note
nonverbal signs of discomfort.
• Rub hands to warm them, have short
fingernails and use gentle touch
8. Percussion
It 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 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.
9. Auscultation
It involves listening to sounds and a
stethoscope is mostly used.
Various body systems like cardiovascular,
respiratory and gastrointestinal have
characterized sounds.
Bowel, breath, heart and blood movement
sounds are heard using the stethoscope.
It is important to know the normal sound
to distinguish from abnormal.
10. Preparation for physical
exam
Infection prevention
Follow IP precaution through out
procedure
Environment
P/A requires privacy and away from other
destructors throughout
Equipment
Get all the necessary equipment, other
equipment needs to be warmed before
being placed on the body e.g. rubbing
diaphragm of the stethoscope briskly
between hands.
11. Preparation cont…
Patient preparation
Prepare the patient physically and
make the patient comfortable
throughout the physical assessment
for successful exam.
Explain to the patient everything to be
done.
12. HEAD TO TOE
ASSESSMENT
General survey
The assessment of the patient/client
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 color,
dressing, grooming, personal hygiene,
facial expression, gait, odor, posture
13. NOTE: If there is a sign of acute
distress comprehensive health
assessment is deferred until when
patient is stable.
14. Vital signs
Assessment of vital signs is the first in
physical assessment because
positioning and moving the client
during examination interferes with
obtaining accurate results.
Specific vital signs can be also
obtained during assessment of
individual body system.
15. Skin, Hair, scalp and
Nails
Inspect all skin surfaces first or
gradually while assessing the
systems.
Use the skills of inspection, palpation,
and olfactory to assess the function.
Skin
Inspect skin for color, edema, lesions,
scars and vascularity.
Palpate to notice moisture,
temperature, and skin turgor,
16. Hair and scalp
Assess and note type of hair i.e. long,
coarse, thick, brittle.
Note the color, distribution, quantity,
thickness, texture and lubrication.
On inspection separate the hair to
determine the scalp.
Wear clean gloves if lesions and lice
are probable.
17. Nails
The condition of the nails reflects the
general health, state of nutrition,
occupation, and level of self care.
Nail biting can reveal the person’s
psychological state.
Inspect the nail bed for color,
cleanliness, length, texture, angle
between nail and nail bed and folds
around the nail.
18. Head and neck
The assessment of the head includes:-
eyes, ears, nose, mouth and pharynx.
The assessment of the neck includes:-
lymph nodes, carotid artery, thyroid
gland and trachea.
19. Eyes
Assess visual acuity, position and
alignment of the eyes, eyebrows and
eyelids.
Note any abnormal discharges and
color of conjunctiva and sclera.
Ears
It determines the intergrity of the ear
structures and hearing acuity.
Inspect for sore and discharges
20. Nose and sinuses
Assess the integrity of the nose and
sinuses by using inspection and
palpation.
Nose
Observe for shape, size, skin color, and
presence of deformity or inflammation.
Sinuses
The exam involves palpation. Incase of
allergy or infection the inside is
inflamed and swollen so palpate for
tenderness
21. 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 lips for color, texture,
hydration, contour, sores and lesions.
22. Buccal mucosa, gums, and teeth
Ask client to clench teeth and smile to
observe to observe teeth occlusion,
symmetry. A symmetrical smile shows
normal nerve function.
Inspect teeth for hygiene, position, and
alignment.
Let client open with lips relaxed, use
tongue depressor to inspect the mucosa
for color, moisture and sores.
Inspect gums for color, edema,
retraction, bleeding and lesions.
23. Tongue and floor of mouth
Carefully inspect tongue on all sides as
well as floor of mouth for color, size,
position, texture, moisture sores and
lesions.
Palate
Have client extend the head
backwards, holding the mouth open,
inspect the hard and soft palate for
color, shape, texture and extra bonny
24. Pharynx
Let the client tip the head back
slightly, open mouth wide and say
“Ah”, with penlight inspect the uvula
and soft palate, they should rise
centrally as the client say “Ah” to
determine the function of cranial(
vagus ) nerve function.
Check the uvula and tonsils for redness
and inflammation.
25. Neck
Palpate the muscles, lymph nodes,
carotid artery jugular veins for
tenderness and distention.
Thyroid gland
Ask client to hyperextend the neck and
view the thyroid and palpate for
masses.
Normally thyroid gland is not visible.
26. Chest
Inspect the skin for scars, sores, color,
lesions, chest, movement and
respiratory rate.
Palpate to notice any masses, and
tenderness in axillae 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.
27. Heart
Auscultate to hear the heart sound.
Learn to know the normal heart sound
to be able to detect the abnormal
Breast
Inspect the breast for skin color,
scars and lesions.
Palpate to notice any presence of
masses.
28. Extremities
Upper and lower extremities
Inspect hand and legs for symmetry,
alignment, skin color, temperature,
sores, scars, lesions inflammation and
varicosity.
Palpate for tenderness, edema and
pulsation of arteries. Use the brachial,
radial, ulna, femoral, popliteal, posterior
tibia and dorsalis pedis pulses.
Check capillary refill on nails, clubbed
toes /fingers and joint mobility.
29. Deep tendon reflexes
Normally done on high risk patients and
needs specialized practice and special
hammer to assess the reflexes.
Areas that are assessed are on biceps,
triceps, patella, and Achilles.
30. Abdomen
Inspect the skin for color, 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 e.g.
liver, spleen and intestines.
Always auscultate before palpation or
percussion because touching can alter
31. Genitalia
Start assessment of genitalia with
asking questions and do inspection to
confirm a positive answer.
Female
Ask about presence of abnormal
discharge, sores, warts and itching
Male
Ask any presence of sores, itching,
warts and abnormal discharge.
32. Rectum and anus
Inspect for the skin color, sores,
hemorrhoids and lesions.
Do digital palpation to examine the anal
canal for masses and sphincters
function only when important.
33. Reference
1. Ruth F. Craven Constance J. Hirnle,
Fundamentals of Nursing, Human
Health and Function, sixth
edition(2009), Lippincott Williams &
Wilkins.
2. Potter. Perry, Fundamentals of
Nursing, 7th edition(2009) Mosby
Elsevier.
3. Barbara F. Weller, Nurses