PHYSICAL ASSESSMENT: HEAD TO
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TOE
Physical assessment
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Is a process by which a nurse
obtains a data that describes a
client’s changing health status and
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person’s responses to actual or
potential health problems which is
analyzed to form pertinent
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diagnosis.
Is a head-to-toe review of each
body system that offers objective
information about the client and
allows the nurse to make clinical
judgment.
Importance of physical assessment
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To early detect and treat diseases
and disorders.
To identify actual and potential
health problems.
To establish a data based from
To make clinical judgments about a
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management.
To evaluate the physiological
outcome of care.
To obtain and gather data about
the client’s health basis of data
for future assessment.
An excellent way to evaluate an
individual’s current health status.
Four basic techniques in physical
assessment
1. Inspection
➢ It is the use of one’s senses of
vision and smell to consciously
observe the patient.
➢ It is also known as concentrated
watching.
➢ It is a close, careful scrutiny; first
of the individual as a whole and
then of each body system.
which the subsequent phases of
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the nursing evolve.
To assess the client’s impact of
2. Palpation
activity and exercise on the
client’s overall level of health.
To assess the client’s routine
exercise pattern and observe
➢ It is the act of touching a patient
in a therapeutic manner to elicit
specific information.
➢ It follows and often confirms
how the client’s body system
points you noted during inspection.
response to activity and exercise.
To establish the client-nurse
Palpation applies your sense of
relationship.
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To obtain information about the
client’s health including,
physiologic, psychological, sociocultural, cognitive,
developmental and spiritual
aspects.
To identify the client’s strength
and weaknesses.
Purpose of physical assessment
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To supplement, confirm or refute
data obtained in the nursing
history.
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To confirm and identify nursing
diagnosis.
touch to assess these factors
o
Texture
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o
Temperature
Moisture
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Organ location and size
Any swelling, vibration or
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pulsation
Rigidity or spasticity
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Crepitation
Presence of lumps or
masses
Presence of tenderness or
pain.
Two distinct types of palpation
a. Light palpation
➢ it is superficial, delicate
❖ The striking hand directly
and gentle.
contacts the body wall. This
➢ finger pads are used to gain
information of the patient’s
skin surface to a depth of
approximately ½ - 1 inch
below the surface.
➢ reveals information on skin
produces a sound and is used in
percussing the infant’s thorax
or the adult’s sinus areas.
II.
Mediate or Indirect Percussion
❖ It is used more often and
involves both hands. The
texture and moisture; overt
striking hand contacts the
large or superficial masses;
and fluid, muscle guarding
and superficial tenderness.
b. Deep palpation
III.
➢ it can reveal information
stationary hand fixed on the
person’s skin. This yields a
sound and a subtle vibration.
Direct Fist Percussion
❖ It is used to assess the
about the position of
organs and masses, as well
presence of tenderness in
internal organs, such as the
as their size, shape,
mobility, consistency, and
areas of discomfort.
➢ uses the hands to explore
liver or the kidneys. The
presence of pain in conjunction
with direct fist percussion
indicated inflammation of that
the body’s internal
structure to a depth of 1 to
organ or a strike of too high in
intensity.
2 inches or more.
➢ most often used for the
abdominal and male and
female reproductive
assessments.
IV.
Indirect Fist Percussion
❖ Its purpose is the same as
direct fist percussion. In fact,
the indirect method is
preferred over the direct
method. It is because in this
methods, the non dominant
hand absorbs some of the
force of the striking hand. The
resulting intensity should be
sufficient force to produce
3. Percussion
➢ It is the technique of striking or
tapping the person’s skin with
short, sharp strokes to assess
underlying structures.
➢ The strokes yield a palpable
vibration and a characteristic
sound that depicts the location,
size and density of the underlying
organ.
pain in the patient if organ
inflammation is present.
Percussion elicits five types of sounds
I.
II.
➢ These sounds also are diagnostic
of normal and abnormal findings.
➢ The thorax and abdomen are the
most frequently percussed
location.
Four types of percussion techniques
I.
Immediate or Direct
Percussion
Flatness (dull) – bone and muscle
Dullness (thud-like) – liver, spleen,
heart
III.
IV.
V.
Resonance (hollow) – air-filled lung
/ normal lung
Hyperresonance – emphysematous
lung
Tympany – stomach filled with gas
(air)
4.
Auscultation
▪
Introduce yourself to the patient.
➢ It is the act of active listening to
Enlist the patient’s cooperation by
the body organs to gather
information on patient’s clinical
status.
➢ includes listening to sounds that
are voluntarily and involuntarily
produced by the body such as the
explaining what you are about to
do, where it will be done, and how
it may feel.
Explain to the patient why you may
be spending a long time performing
one particular skill.
heart and blood vessels and the
lungs and abdomen.
➢ Auscultated sounds should be
analyzed in relation to their
relative intensity, pitch, duration,
quality, and location.
Two types of auscultation
a. Direct or Immediate auscultation
➢ It is the process of listening
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Do medical hand washing .
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Position the patient as dictated by
the body system being assessed.
Warm all instruments prior to
their use.
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DURING
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Conduct the assessment in a
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systematic fashion every time.
While performing each step in the
with the unaided ear. This can
physical assessment process, you
include listening to the patient
from some distance away or
placing the ear directly on the
may need to inform the patient of
what to expect, where to expect
it, and how it should feel.
patient’s skin surface. And
example is the wheezing that is
audible to the unassisted ear in
a person having a severe
asthmatic attack.
b. Indirect or Mediate auscultation
➢ It is the use of stethoscope,
▪
Avoid making crude or negative
remarks, be cognizant of your
facial expression when dealing
with malodorous and dirty patients
or with disturbing findings.
▪
Proceed from the least invasive to
the most invasive procedure for
which transmits the sounds to
the nurse’s ear.
each body system.
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Nursing responsibilities
BEFORE
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Always dress in clean professional
manner, make sure you have your
name pin or workplace
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identification.
Remove all bracelets, necklaces, or
earrings that can interfere during
the physical assessment.
▪
Be sure your hair will not fall
forward and obstruct your vision
or touch to the patient.
▪
Ensure that all necessary
equipment is ready for use and
within reach.
If the patient complains of
fatigue, continue the assessment
later.
AFTER
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Provide recognition to the patient
when the physical assessment
concluded; inform the patient what
will happen next.
Place patient in a comfortable
position.
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Do after care.
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Do medical hand washing.
Document assessment findings in
the appropriate section of the
patient record.
Materials and Instruments of Physical
Treatment
To depress the tongue during
assessment of the mouth and
1. Flashlight or penlight
- To assist in viewing of the
pharynx and cervix or to
determine the reaction of
the pupils of the eye.
2. Laryngeal or dental mirror
- To observe the pharynx and
oral cavity
3. Nasal septum
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To permit visualization of the
lower and middle turbinates;
usually a penlight is used for
illumination.
4. Ophthalmoscope
- A lighted instrument to
visualize the interior of the
eye
5. Otoscope
- A lighted instrument to
visualize the
eardrum and external auditory
canal (a
nasal speculum may be
attached to the
Otoscope to inspect nasal
cavities).
6. Percussion (reflex) hammer
- An instrument with a rubber
head to test reflexes
7. Tuning Fork
- A two-prolonged metal
instrument used
to test hearing acuity and
vibratory
sense.
8. Cotton applicators
- To obtain specimens.
9. Gloves
- To protect the nurse
10. Lubricant
- to ease the insertion of
instruments (ex.Vaginal
Speculum)
11. Tongue blades (depressors)
pharynx
Various positioning of the patient
❖ Dorsal recumbent
Back-lying position with
knees flexed and hips externally
rotated; small pillow under the
head; soles of feet on the surface.
Supine (horizontal recumbent)
Back-lying position with legs
extended; with or without pillow
under the head.
❖ Sitting
A seated position. The back
is unsupported and legs hanging
freely.
❖ Lithotomy
Back-lying position with
feet supported in stirrups; the
hips should be in line with the edge
of the table.
❖ Sims
Side-lying position with the
lowermost leg flexed at the hip
and knee, upper arm flexed at the
shoulder and elbow.
❖ Prone
Lies on the abdomen with
head turned to the side, with or
without a small pillow.
Various positioning of the patient