Physical assessment  includes client’s perceptions, feelings,

thoughts, and expectations. It cannot

 Systematic evaluation of individual’s be directly observed and can be
health status through the health history discovered only asking questions.
and physical exam.
 Cost-effective and foresight potential Objective data:
problems for health promotion  Detectable, tangible and observable by
 Health History- obtained through an observer
interview and record review.  Obtained by observation of client
 Physical exam- accomplished by tools behavior, medical records, lab and
and techniques diagnostic tests, data collected by
 Head to Toe- systematic collection of physical exam
data starting with the head and working
downward.
 General survey- General appearance
o Vital signs Health History
o Height and weight  obtained through interview and record
review.
Guidelines for Physical Assessment  Biographical Data:
1. Acquire accurate patient information o Name, Age, Sex, Race
 Chief Complaint
o Answer to “What brought you
to the hospital?” This should be
2. Secure the environment and equipment told in the client’ s own words
needed and establishes the purpose of
the contact. Client should be
encouraged to discuss
symptoms specific to the
3. Acquire patient’s consent and establish complaint.
rapport
History of the Present Illness (HPI):
 A clear, chronological account of the
events that led the client to seek care
4. Proper patient care (onset, s/s, occurrence of symptoms,
and response to treatment).

Family History:
5. Be professional  Reveals risk factors for disease- focus
on diabetes mellitus, heart disease,
HTN; TB; cancer.

6. Confidentiality Preparing the Patient for Physical Assessment

 Consider the physiological and
psychological needs of the patient.
Data Collection  Explain the process to the patient.
Subjective data:  Explain that physical assessments will
 Apparent only to person affected not be painful (decrease patient fear
and anxiety).
  Ask the patient to change into a gown bell is used for low-pitched sounds (abnormal
and empty bladder. heart sounds).
 Answer patient questions directly and
honestly. Characteristics of Masses Determined by
Equipment for Physical Assessment Palpation
 Tuning fork — tests auditory function  Shape – round, ovoid, tubular, irregular
and vibratory perception  Size- measured in centimeters
 Reflex hammer — tests deep tendon  Consistency – firm, edematous, spongy,
reflexes and determine tissue density cystic
 Ophthalmoscope — visualizes the  Surface – smooth, nodular, granular
interior structures of the eye  Mobility – fixed or nonmobile, mobile
 Otoscope — examines the external ear  Tenderness – amount of tenderness to
canal and tympanic membrane touch
 Snellen’s chart — screens for distant  Pulsatile – pulsation can or cannot be
vision felt in the mass
 Nasal speculum — visualizes the lower Types of Sounds Heard When Using Percussion
and middle turbinates of nose  Flat — soft, e.g., thigh area
 Vaginal speculum — examines the  Dull — medium, e.g., liver
vaginal canal and cervix  Resonance — loud, e.g., normal lung
Assessment techniques  Hyperresonance — very loud, e.g.,
1. Inspection emphysematous lung
 visual examination and objective  Tympany — loud, e.g. puffed-out cheek
description Positions Used During a Physical Assessment
 Ex: Rashes, wounds, scars  Standing — assessment of posture, gait,
2. Palpation and balance
 examination using the sense of touch  Sitting — used to take vital signs
 determine temperature, position  Supine — allows relaxation of
(location), size, texture (masses, fluids), abdominal muscles
vibration (joints), tenderness/pain,  Dorsal recumbent — used for patients
rate(pulse). having difficulty maintaining supine
 Light touch (.5-1”) position, also for pelvic examinations
 deep touch (1.5-2”)  Sim’s — assessment of rectum or vagina
3. Percussion  Prone — assessment of hip joint and
 method by which the body is struck posterior thorax
indirectly to elicit sounds Integument
 Sounds produced: flatness (bone);  Involves the hair, skin and nails
 dullness (liver); resonance (lungs);  Assessed by inspection and palpation.
hyper resonance (emphysema/lung);  Presence of rashes and lesions
tympani (abdomen). May be performed Eyes and Vision
directly or indirectly.  external structures,
4. Auscultation  ocular movement: evaluation of the
 Listening to sounds in body; movement of the eyes while the head
 direct (use of ear) or indirect with a remains still
stethoscope.  visual fields: how much a person see in
 diaphragm (flat) is used for high-pitched the periphery
sounds (breath, normal heart sounds,
bowel sounds).
  visual acuity: degree up to the person The Neurological System
can discen an image through Snellen’s  mental status: reveals general cerebral
chart function including cognitive
Ears (intellectual) and affective (emotional)
function.
 Exam includes inspection/palpation of  level of consciousness: a continuum
external parts; inspection of canal and from alert to coma
drum with otoscope and auditory  motor system: gait and posture- erect;
acuity. balanced, coordinated gain, arm
Thorax, Lungs, Heart swinging.
Chest landmarks:
 sensory system: Does client complain of
 Anterior imaginary lines: Midsternal, any numbness, tingling or any unusual
midclavicular, anterior axillary. feeling in an extremity (parestheses
 Posterior imaginary lines: L or R  Reflexes: Automatic response to
scapular, vertebral. stimulus- common one is knee jerk
 Lateral: Posterior axillary, midaxillary  cranial nerves
and anterior axillary.
 2nd and 5th intercostals space (ICS).
The Abdomen
 RUQ: liver, gall bladder, duodenum,
colon, kidney, head of pancreas.
 LUQ: stomach, spleen, colon, kidney,
pancreas.
 RLQ: appendix, ovary, urethra, colon,
uterus.
 LLQ: sigmoid colon, ovary, urethra,
uterus.
Use of inspection, auscultation, palpation,
and percussion.

The Musculoskeletal System

 Approach: The completeness of the
exam depends to a certain extent on
the needs and problems of the client.
 Muscles are inspected for strength,
tone, size and symmetry. Muscle
strength is graded on a 0-5 scale.
 Impaired strength is called paresis;
hemi paresis refers to weakness on one
half of the body.
 Bones for normalcy and form.
 Joints for ROM, tenderness, swelling,
crepitating and nodules.