ASSESSMENT TECHNIQUES AND
THE CLINICAL SETTING
HEALTH ASSESSMENT TEAM
Learning Objectives
• At the end of the discussion students will be able to:
• differentiate between physical examination techniques
• understand rational between various examination techniques
• understand how to apply the techniques of physical exam in
terms of sequencing
The Physical Examination
• The health history provides the subjective data for health
assessment
• The physical examination provides the objective data
• Together, the complete health history and the comprehensive
physical examination comprise data base and represents the
Assessment Phase of the Nursing Process
Requirements
• Examiner must develop technical skills and a knowledge base
• Technical skills are the tools you use to gather the data
• You will relate that data to your knowledge base and to your
previous experience (critical thinking)
Look “FOR” rather than “AT”
• German poet Goethe (18th century)
“We see only what we know”
To recognize a significant finding, you need to know what to
look for
You need to know what findings you should expect
inspect, palpate, percuss and auscultate
You need to know ‘normal’ in order to know that something is
abnormal
PE Skills
• What are the techniques or skills requisite for conducting the
physical examination?
• In what order are these skills performed?
• What is the one body system exception? Why?
I- INSPECTION
• Concentrated watching
• Whole person, then each
•
•
•
•
body system
MUST inspect!!!!
Begins at moment you meet
the patient “General
Survey”
Train yourself not to rush;
confine hands in your pocket
Compare one side of body to
the other
I- INSPECTION
• Guidelines for Effective Inspection
• Be systematic
• Fully expose the area to be
•
•
•
•
inspected
• cover other body parts to
respect the client's modesty
Use good light, preferably natural
light.
Maintain comfortable room
temperature.
Observe color, shape, size,
symmetry, position, and movement
Compare bilateral structures for
similarities and differences.
Umbilical Hernia
HEPATOMEGALY
ASCITES
Cyanosis of Nailbeds
Same umbilical hernia while patient
performs valsalva maneuver
OBESE ABDOMEN
II- PALPATION
• Confirm points you noted
during inspection
• Applies your sense of touch:
• Texture
• Temperature
• Moisture
• organ location
• Size
• swelling
• Vibration
• Pulsation
• Rigidity
• Crepitation
• lumps, masses and pain
Palpation Techniques
•
•
•
•
Slow and systematic
Calm, gentle approach
Warm hands
Identify tender areas; palpate them
last
• Light palpation
• depress the skin about 1cm
• Deep palpation
• push down about 5-8cm
• Bimanual palpation
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Bimanual palpation
•requires the use of both
hands to envelop or capture
certain body parts or organs
such as the
• kidneys, uterus, or adnexa
PALPATION
•Palpation uses the sense of
touch
•Ask the Client for permission first
•explain to your client what
you intend to examine
•Establish client trust with being
professional
•Please remember to use warm
hands
•Any tender areas should be
palpated last
Palpation: Specific Uses for particular parts of the hand
• What parts of the hands are used for
• Fingertips
• best for fine tactile discrimination, as of
skin texture, swelling, pulsation, and
determining presence of lumps
assessing:
 Tactile discrimination, swelling, pulsation,
presence of lumps?????
 Detecting the position, shape, and consistency • A grasping action of the fingers and
of an organ or mass?????
thumb
• to detect the position, shape, and
 Temperature??????
consistency of an organ or mass
 Vibration???????
• The dorsa (backs) of hands and
fingers
• best for determining temperature
because the skin here is thinner than on
the palms
• Base of fingers
(metacarpophalangeal joints) or
ulnar surface of the hand
• best for vibration
III- PERCUSSION
•
•
•
•
•
What is percussion?
Why is it done?
How is it done
Why not use X-ray instead?
Why are short nails
imperative?
• What is Direct Percussion?
Where?
• What is Indirect Percussion?
Where?
III- PERCUSSION
•Percussion is the striking of the body surface
with short, sharp strokes
•in order to produce palpable vibrations and
characteristic sounds
•It is used to determine:
• the location, size, shape, and density of
underlying structures
•To detect the presence of air or fluid in a body
space
•To elicit tenderness
•Note:
•When examining Abdomen
•you auscultate first followed by percussion
then palpation
Stationary Hand
•Hyperextend the middle finger
(pleximeter) and place distal
phalanx firmly against the patient’s
skin
•Avoid ribs and scapulae
•Percussing over bone yields no data
•always dull
•Left rest of hand off patient’s body
or resting hand will damper the
sound
Striking Hand
• Middle finger of dominant hand
(plexor)
• Action in wrist
• Must be relaxed
• Bounce middle finger off
stationary finger (pleximeter)
• Aim for just under nail bed at DIP
joint
• Percuss 2 times
• Maintain technique and move
from side to side
• Body thickness may require
more force
Types of Percussion
1.Direct Percussion:
•Percussion in which one hand is used
•striking finger of the examiner touches
the surface being percussed
•Sinuses, infant’s thorax
2. Indirect Percussion:
• Percussion in which two hands are
used
• the plexor strikes the finger of the
examiner's other hand
• which is in contact with the body
surface being percussed
• More common
Types of Percussion
3. Blunt Percussion:
• Percussion which the ulnar surface of
the hand or fist is used in place of the
fingers
• to strike the body surface, either
directly or indirectly
CVA Tenderness
Percussion Sounds
Basic Principle
•Structures with more air
(lungs)
•produce a louder, deeper,
and longer sound because it
vibrates more freely
•Solid, more dense organs
(liver)
•gives softer, higher, a shorter
sound because it does not
vibrate as easily
•Sound depends on nature of
underlying structure and
thickness of body wall you
are examining
IV- AUSCULTATION
•Auscultation is listening to sounds
produced inside the body
•include breath sounds, heart sounds,
vascular sounds, and bowel sounds
•It is used to detect the presence of
normal and abnormal sounds
•Assess them in terms of loudness, pitch,
quality , frequency and duration
•Note:
•when examining Abdomen
•you auscultate first followed by
percussion then palpation
What exactly are you listening for and
what is its significance?
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2 Sides of Stethoscope…
Diaphragm
• used for high pitched sounds
• breath, bowel and normal heart
sounds
• hold firmly against skin
• leave a mark
Bell
• used for murmurs or low pitched
sounds
• hold it lightly against the skin
• If hold too tightly it will obliterate
the low pitched sounds
Successful Auscultation
• Quiet room/setting
• Keep room warm
• Warm stethoscope (“Chandelier’s
•
•
•
•
•
•
sign”)
Wet down a hairy chest (crackles or
rales)
Never listen over clothing or hospital
gown!
Avoid your own “artifact”
Learn sound you are supposed to be
hearing
Be patient with yourself…requires
practice
If need to listen longer or re-examine
or have someone else listen…explain
to the patient
The Setting
Warm, comfortable, quiet,
private and well lit
Natural daylight is best
Both sides of patient
should be easily accessible
Exam Room
Prepare all of your
equipment
Equipment
•Platform scale with height
attachment
•Sphygmomanometer
•Stethoscope with diaphragm
and bell
•Thermometer
•Pulse oximeter (in hospital
setting)
•Flashlight or penlight
•Otoscope/ophthalmoscope
•Tuning fork
•Nasal speculum
•Tongue depressor
Equipment
• Pocket vision screener
• Skin-marking pen
• Flexible tape measure and ruler
• Reflex hammer
• Sharp object (split tongue blade)
• Cotton balls
• Bivalve vaginal speculum
• Clean gloves
• Materials for cytologic study
• Lubricant
• Fecal occult blood test materials
Otoscope
• Funnels light into the ear
canal and onto the
tympanic membrane
• Use tip:
• largest one able to
comfortably fit into the
ear canal
Ophthalmoscope
• Illuminates the internal eye
structures
• System of lenses and mirrors
• Look through the pupil at the
fundus (background) of the
eye
• Similar to looking out a peep
hole or keyhole
General Approach
• Consider your anxiety and that of the patient
• Explain what you are going to do
• Ask for permission to touch the patient
• Proceed in an orderly systematic manner
• Begin with non-threatening aspects such as
vital signs, height/weight, eye chart, etc
• Concentrate: One system at a time!
• Explain what you will be doing “tapping you on
the back”
• Do not be afraid to use a form/checklist and
briefly document as you go along
• Take opportunities to teach
• Explain if something takes a longer time or if
you need someone else to examine
Developmental Consideration
Older Patient
 Can sit; frail may need to be supine
 Arrange sequence to limit position
changes
 Allow rest periods
 Do not rush; use head to toe
sequence
 Use physical touch unless culturally
contraindicated
 Don’t mistake changes in senses for
confusion
Developmental Consideration
Ill Patient
 If in distress, alter position during
exam
 May be necessary to examine the
body areas appropriate to the
problem: collecting a “mini data
base”
 May return after distress subsides
Precautions
• Standard precautions
• applies to blood, all body fluids
except for sweat
• non intact skin, and mucous
membranes
• Transmission based
• for patients with documented or
suspected transmissible infections
• Designed to be used in addition to
standard precautions
• Airborne, droplet and contact
• Wash hands before and after gloves,
and between patient contacts
The General Survey, Measurement, Vital Signs
Learning Objectives
• At the end of the discussion
students will:
 articulate the purpose and
significance of the general
survey
 describe the elements of the
general survey
 identify the significance of
vital signs and their meaning
related to the health history
and physical examination
What is the General Survey?
What does it include?
• Physical appearance
• Age
• Sex
• Level of consciousness
• Skin color
• Facial features
• Behavior
• Facial expression
• Mood and affect
• Speech
• Dress
• Personal hygiene
• Body structure
• Stature
• Nutrition
• Symmetry
• Posture
• Position
• Body build, contour
• Mobility
• Gait
• Range of motion
The General Survey
• A study of the whole person
When to launch a general survey ?
• covering the general health state
and any obvious physical
characteristics
• It is an introduction to the physical
examination that will follow
• It provides the “gestalt” of the
person (overall impression)
• Objective parameters are used to
form general survey
• but these apply to whole person,
not just to one body system
• At the moment of your first
•
•
•
•
•
encounter
What leaves an immediate
impression on you?
How does the person look?
How is the gait?
How does the person respond to
being called?
What is his/her handshake like?
Four Areas of General Survey: PHYSICAL APPEARANCE
•Age
•person appears his or her stated age?
•Sex
•Development appropriate for gender/age?
•Level of Consciousness (LOC)
•Alert & oriented?
•Attends to questions?
•Responds appropriately?
•Skin Color
•tone even, skin intact, lesions?
•pigmentation varying with genetic
background
•Facial features
•symmetric with movement
•Signs of acute distress?
Four Areas of General Survey: BODY STRUCTURE
• Stature
• height within normal range for
age/genetics?
• Nutrition
• Weight proportionate with height and
body build
• body fat distribution even?
• Symmetry
• Body parts look equal bilaterally & in
relative proportion?
• Posture• Person stands comfortably erect as
appropriate for age?
• Note normal “plumb line” through
anterior ear, shoulder, hip, patella, ankle
• Aging person who may be stooped with
kyphosis
• Position• Person sits comfortably in chair or on bed
or examining table, arms relaxed at sides,
head turned to examiner
Four Areas of General Survey: BODY STRUCTURE
•Body Build; Contour:
proportions are correct
•Arm span
•fingertip to fingertip = height
•Body length from crown to
pubis
•=length from pubis to sole
•Obvious physical deformities
•note any congenital or
acquired defects
Four Areas of General Survey: MOBILITY
• Gait• normally the base is as
wide as the shoulder
width
• FOOT PLACEMENT
• walk is smooth, even and
well balanced; associated
movements (symmetric
arm swings) are present
• ROM
• Note full mobility all
joints; movement
deliberate, accurate,
smooth and coordinated
• No involuntary
movement
Four Areas of General Survey: BEHAVIOR
• Facial Expression
• Maintains eye contact (unless cultural)
• expressions appropriate to situation
• Mood and Affect• Patient is comfortable and cooperative
• interacts pleasantly
• Speech• Speech is clear and understandable
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•
•
•
Stream of talking is fluent, with an even pace
Conveys ideas clearly
Word choice appropriate to culture and education
Person communicates in prevailing language easily by
himself or herself or with interpreter
• Dress• appropriate to climate, looks clean and fits body
• appropriate to person’s culture and age group
• Personal Hygiene
• person appears clean and groomed appropriately for his
or her age, occupation, and socioeconomic group
General Survey Also Includes:
Height
Weight
Complete set of Vital
Signs
Life style modification
teaching
Measurement: WEIGHT
•Use a standardized balance or electronic standing
scale
•Instruct person to remove his or her shoes and
heavy outer clothing before standing on scale
•When sequence of repeated weights is necessary
•aim for approximately same time of day and
same type of clothing worn each time
•Record weight in kilograms and pounds
•Show person how his or her weight matches up to
recommended range for height
•Compare person’s current weight with previous
visit
•Recent weight loss may be explained by
successful dieting
•Weight gain usually reflects overabundant
caloric intake, unhealthy eating habits, and
sedentary lifestyle
Measurement: HEIGHT
•Use wall-mounted device or measuring pole
on scale
•Align extended headpiece with top of head
•Person should be
•shoeless, standing straight, looking
straight ahead, with feet and shoulders on
hard surface
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Measurement: BODY MASS INDEX
•practical marker of optimal weight for height and an indicator of obesity or
protein-calorie malnutrition
Measurement: WAIST-TO-HIP RATIO
•Assesses body fat distribution as
indicator of health risk
•Measure at end of gentle expiration
•Waist circumference
•measured in inches at smallest
circumference below rib cage and
above iliac crest
•ALONE can be used to predict greater
health risk
•Important independent risk factor for
disease
•Hip circumference
•measured in inches at largest
circumference of buttocks
Waist >35in in women; >40 in men
= risk for type2 DM
Measurement: WAIST-TO-HIP RATIO
•ANDROID obesity
•Obese persons with a greater
proportion of fat in upper
body, especially in abdomen
•GYNOID obesity
•Obese persons with most of
fat in hips and thighs
Vital Signs: TEMPERATURE
•Hypothalamus as thermostat mechanism
•Influences on temperature
•Diurnal cycle
•1° F to 1.5° F, with trough occurring in early morning
hours
•peak occurring in late afternoon to early evening
•Menstrual cycle
•progesterone secretion, occurring with ovulation at
mid-cycle,
•causes a 0.5° F to 1.0° F rise in temperature that
continues until menses
•Exercise
•moderate to hard exercise increases body
temperature
•Age
•wider normal variations occur in infant and young
child due to less effective heat control mechanisms
•older adults: temperature usually lower than in
other age groups, with a mean of 36.2° C (97.2° F)
Vital Signs: TEMPERATURE
•Routes of temperature measurement
•Oral
•accurate and convenient
•Oral sublingual site has rich blood supply
from carotid arteries that quickly responds to
changes in inner core temperature
•37C (98.6F)
•Range: 35.8-37.3C (96.4-99.1F)
•Electronic thermometer
•advantages of swift and accurate
measurement (usually in 20 to 30seconds) as
well as safe, unbreakable, disposable probe
covers
•Axillary
•safe and accurate for infants and young
children when environment is reasonably
controlled
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Vital Signs: TEMPERATURE
•Routes of temperature measurement
•Rectal
•0.4-0.5C ( 0.7-1F) higher
•only when other routes are not practical
•comatose or confused persons
•persons in shock
•cannot close mouth because of breathing or
oxygen tubes, wired mandible
•other facial dysfunction or if no tympanic
membrane thermometer equipment is
available
•Tympanic membrane thermometer
•senses infrared emissions of tympanic
membrane (eardrum)
•noninvasive, nontraumatic device,
extremely quick, and efficient
•Gently place covered probe tip in person’s
ear canal; temperature can be read in 2 to
3 seconds
•Minimal chance of cross-contamination
•used with unconscious patients
•unable or unwilling to cooperate with
traditional techniques
Vital Signs: TEMPERATURE
•Report temperature in
degrees Celsius unless your
agency uses Fahrenheit scale
•Use this conversion
•Degrees C = 5⁄9 (F - 32)
•Degrees F = (9⁄5 X C) + 32
•Familiarize yourself with both
scales
•NORMAL ADULT TEMP?
Vital Signs: PULSE
•Stroke volume: 70 mL (every heartbeat)
•Technique of measurement
•Radial pulse usually palpated while vital
signs measured
•Using pads of the first three fingers
•palpate radial pulse at flexor aspect
of wrist laterally along radius bone
•Push until strongest pulsation is felt
Vital Signs: PULSE
•If rhythm is regular
•count number of beats in 30 seconds and multiply
by 2
•Although 15-second interval is frequently
practiced
•any one-beat error in counting results in a
recorded error of four beats per minute
•The 30-second interval
•most accurate and efficient when heart rates
are normal or rapid and when rhythms are
regular
•If rhythm irregular
•count for full minute
•As you begin counting interval
•start your count with “zero” for first pulse felt
•Second pulse felt is “one,” and so on
Vital Signs: PULSE
•Force
•strength of heart’s stroke volume
•
•
Weak, thready pulse
•
decreased stroke volume
Full, bounding pulse
•
increased stroke volume, as with anxiety, exercise,
and some abnormal conditions
• Pulse force recorded using three-point
scale
•3+ full, bounding
•2+ normal
•1+ weak, thready
•0 Absent
•Elasticity
•With normal elasticity, artery feels springy,
straight, resilient
•Rate
•Normal rate for age group- resting adult
60-100BPM
•Bradycardia
•less than 60 BPM
•Well-trained athletes
•Tachycardia
•more than 100 BPM
•Anxiety
•Increased exercise
•Rhythm•Sinus arrhythmia: common in
children & young adult
•heart rate varies with respiratory
cycle
•speeding up at peak of inspiration
•decreased SV from left side of heart,
HR increases
•slowing to normal with expiration
Vital Signs: RESPIRATIONS
•Normally, person’s breathing is relaxed,
regular, automatic, and silent
•HOW to measure?
•do not mention that you will be counting
respirations
•sudden awareness may alter normal
pattern
•Instead, maintain your position of
counting radial pulse and unobtrusively
count respirations
•Count for 30 seconds, or full minute if
you suspect an abnormality
•Avoid 15-second interval
•the result can vary by a factor of + or - 4,
which is significant with small number
•constant ratio of pulse rate to respiratory
rate 4:1 exist
Vital Signs: BLOOD PRESSURE
•force of blood pushing against side of its
container, vessel wall
•Systolic pressure
•maximum pressure felt on artery during left
ventricular contraction, or systole
•Diastolic pressure
•elastic recoil, or resting, pressure that blood
exerts constantly between each contraction
•Pulse pressure: Reflects stroke volume (sv)
•difference between systolic and diastolic
(SBP-DBP)
•Mean arterial pressure (MAP)
•pressure forcing blood into tissues, averaged
over cardiac cycle
•MAP= 2DBP + SBP/2
JNC 8 Desired Blood Pressure
For people >60:
• Below 150/90
For people younger <60:
• Below 140/90
According to Joint National Committee 8 (JNC 8)
guidelines:
• Patients whose blood pressures
are above these goals should be
treated with drug therapy (James
et al., 2013)
Adult patients with specific risk factors for developing
hypertension should be treated at any age
Vital Signs: BLOOD PRESSURE
•Influences on blood pressure
•Age
•Gender
•after puberty, females show a lower BP
than males
•after menopause, females higher than
males
•Race
•Weight
•higher in obese persons
•Emotions
•rises with fear, anger, and pain
•Diurnal rhythm
•daily cycle climbs to high in late afternoon
or early evening
•declines to an early morning low
•Stress
•Elevated: continual tension, lifestyle,
occupational stress, life problems
Vital Signs: BLOOD PRESSURE
•Physiologic factors controlling blood
pressure
•Cardiac output
•Increase CO=Increase BP
•Peripheral vascular resistance
•Smaller, constricted vessel = Increase
PVR= Increase BP
•Volume of circulating blood
•Increase contents= Increase BP
•Viscosity
•Thicker= Increase BP
•Elasticity of vessel walls
•Stiff & rigid= Increase BP
Vital Signs: BP MEASUREMENT
•Sphygmomanometer
•Cuff width and size
•Width=40% of arm circumference
•Length of bladder= 80% of this circumference
•Blood pressure measurement in the arm
•Position of person
•bare arm supported at heart level
•Palpate brachial artery
•Proper inflation and deflation technique
•with cuff deflated, center it about 2.5 cm (1 in)
above brachial artery and wrap it evenly
•Palpate brachial or radial artery
•Inflate cuff until artery pulsation obliterated and
then 20 to 30 mm Hg beyond
•Deflate cuff quickly and completely
•wait 15 to 30 seconds before reinflating so blood
trapped in veins can dissipate
Vital Signs: BP MEASUREMENT
•Proper inflation and deflation technique
•Place bell of stethoscope over site of
brachial artery, making a light but airtight
seal
•Diaphragm endpiece usually adequate,
but bell designed to pick up low-pitched
sounds of blood pressure reading
•Rapidly inflate cuff to maximal inflation
level you determined
•Then deflate the cuff slowly and evenly,
about 2 mm Hg per heartbeat
•Note points at which you hear first
appearance of sound, muffling of sound,
and final disappearance of sound
Vital Signs: BLOOD PRESSURE
•Korotkoff’s sounds
•phases I, IV, and V of
Korotkoff’s sounds
•I=systolic pressure
•IV=muffling of sounds
•V=diastolic pressure
Vital Signs: BLOOD PRESSURE
•Common errors in blood pressure measurement
•Orthostatic (or postural) hypotension
•volume depletion
•hypertension or taking antihypertensive
medications
•fainting or syncope
•Have person rest supine for 2 or 3 minutes
•take baseline readings of pulse and BP
•then repeat with person sitting and then standing
•For person who is too weak or dizzy to stand
•assess BP supine and then sitting with legs
dangling
Vital Signs: BLOOD PRESSURE
•Common errors in blood pressure
measurement
•Blood pressure measurement
in the thigh
•When BP measured at arm excessively
high, compare it with thigh pressure to
check for coarctation of aorta
•NORMALLY=Thigh pressure higher than
in the arm
•HOW?
•If possible, turn person into prone
position on abdomen
•Wrap large cuff around lower third of
thigh, centered over popliteal artery on
back of the knee
•Auscultate popliteal artery for reading
•Normally, systolic value is 10 to 40 mm
Hg higher in thigh than in arm, and
diastolic pressure is same
Life Style Modification
•Lose weight if >10%
•Limit alcohol
•1 oz ethanol/day
•24 oz beer
•10 oz wine
•2 oz whiskey (1/2 for women)
•Regular exercise
•Reduce sodium
• Include potassium, magnesium,
calcium in diet
• Stop smoking
• Reduce intake of fat and
cholesterol