HEALTH
ASSESSMENT
AND
PHYSICAL
EXAMINATIO
N
DEFINITIONS:
• Health Assessment is the
collection of subjective data
about an individual's health.
• Physical examination is a
head-to-toe review of each
body system that offers
objective information about
the patient and allows the
health care provider to make
clinical judgement.
GOALS:
Health Assessment
1. To identify the strengths
of the patient in promoting
health.
2. To identify patient's
needs, clinical problems.
3. To obtain baseline data
about a patient's functional
abilities.
GOALS:
Physical Examination
1. To gather baseline data about the
patient's health status.
2. To supplement, confirm, or refute
subjective data obtained in the
nursing history.
3. To identify and confirm nursing
diagnoses.
4. Make clinical decisions about a
patient's changing health status
and management.
5. To evaluate outcomes of care.
OVERALL GOAL FOR
HEALTH ASSESSMENT AND
PHYSICAL EXAMINATION:
TO PERFORM AN
ASSESSMENT IN WHICH
THE PATIENT
PARTICIPATES AND
DEMONSTRATES A
DECREASED IN ANXIETY
LEVEL RELATED TO
ASSESSMENT AND
THE COMPLETE
HEALTH
ASSESSMENT
AND PHYSICAL
EXAMINATION:
PUTTING IT ALL
TOGETHER
PREPARATION:
I. PATIENT
1. Ensure proper identification of the patient.
Rationale: For patient's safety and to establish rapport.
2. Prepare the patient physically and psychologically.
Rationale: To allay anxiety.
3. Provide privacy to prevent feelings of embarrassment. Close the door of the
patient's room or curtain the unit as necessary.
Rationale: To prevent feelings of embarrassment.
4. Provide adequate information about the procedure, what to expect during th
procedure, and what is expected of the patient.
Rationale: To gain the patient's cooperation.
5. Provide a new, clean gown.
Rationale: To facilitate performance of the procedure.
II. EQUIPMENT AND
SUPPLIES FOR PHYSICAL
ASSESSMENT
•PLATFORM SCALE
• HAND HYGIENE
EQUIPMENT AND •GOWN FOR PATIENTS •DRAPES/ COVER WITH HEIGHT
ARTICLES ATTACHMENT
II. EQUIPMENT AND
SUPPLIES FOR PHYSICAL
ASSESSMENT
•SKINFOLD CALIPER •
SPHYGMOMANOMETER
• STETHOSCOPE • THERMOMETER
II. EQUIPMENT AND
SUPPLIES FOR PHYSICAL
ASSESSMENT
• FLASHLIGHT OR
PENLIGHT •OTOSCOPE /
OPHTHALMOSCOPE
•TUNING FORK • NASAL SPECULUM
II. EQUIPMENT AND
SUPPLIES FOR PHYSICAL
ASSESSMENT
• TONGUE DEPRESSOR • STERILE SWABS • POCKET VISION •SKIN MARKING
SCREENER PEN
II. EQUIPMENT AND
SUPPLIES FOR PHYSICAL
ASSESSMENT
•TAPE MEASURE • REFLEX HAMMER • COTTON BALLS •CLEAN GLOVES
II. EQUIPMENT AND
SUPPLIES FOR PHYSICAL
ASSESSMENT
• TISSUES • PULSE OXIMETER
• SPECIMEN
CONTAINERS
FOR ADVANCED
PRACTICE
• Bivalve Vaginal Speculum
• Materials for Cytologic
study
• Lubricant
• Fecal Occult Blood Test
Materials
III. A CLEAN FIELD FOR
EQUIPMENT AND SUPPLIES
• To have a clean and convenient place for
equipment and supplies
• To ensure smooth performance of physical
examination.
• Do not let your stethoscope become "staph-
oscope"
• Infection control: Wear gloves during
SEQUENCE OF THE PERFORMING THE
COMPLETE PHYSICAL ASSESSMENT:
1. THE HEALTH HISTORY [Link] Data
[Link] for Seeking Care
• To collect subjective data [Link] Health or History
• Use techniques of of Present Illness
communication (Interview [Link] History
Techniques) 5.l Review of Systems
• Assume "Equal- status [Link] Assessment
seating" with the patient of Activities of Daily
• Use History Forms: Living (ADLS)
BIOGRAPHIC SOURCE OF
DATA: HISTORY
• Examples:
• Patient himself/herself,
• Name who seems reliable.
• Address
• Patient's son, Harry
• Phone number Nograles, who seems
reliable.
• Age and
birthdate • Mrs. Rocky Roque,
interpreter for Mrs. Susan
• Birthplace Enriquez who does not
speak English/ Tagalog
(Visayan only or Ilocano
REASON FOR SEEKING PRESENT HEALTH OF
CARE HISTORY OF PRESENT
ILLNESS
• Use patient's exact words.
• In the past, it was
• "Chest pain for two hours." known as "chief
complaint' - which is
• "Needs yearly physical now avoided
examination for work."
because it labels the
• "Wants to start jogging person as a
and need checkup. complainer and does
not include wellness
needs.
DOCUMENTATION PAST HEALTH HISTORY
(May have residual effects on the
• For Well Patient: current health state).
• Childhood illnesses.
R.D., a 54 year old male • Accidents or injuries
accountant claims to have • Serious or chronic illnesses
"good health and had no • Hospitalizations
• Operations
major health • Obstetric History (as applicable)
problem/hospitalization for • Immunizations
the past 5 years. • Last examination date (physical,
dental, vision, hearing, ECG,
chest X-Ray examinations)
• For ill Patient: • Allergies (allergens and
reactions)
• Current medications
"Please tell me all about (prescription, OTCs, Herbal)
your chest pain, from the
FAMILY HISTORY: REVIEW OF SYSTEMS:
• Heart disease • Head-to-toe
• High blood pressure • Limited to patient
• Stroke statements or
• Diabetes subjective data
• Arthritis
• To evaluate the past
• Allergies
• Obesity
and present health
• Alcoholism state.
• Mental illness • To double- check in
• Seizure disorder case any significant
• Kidney disease data were omitted in
• Tuberculosis the present illness
section.
• To evaluate patient's
health promotion
[Link]
ASSESSMENT: ADLS ( Activities of Daily
• Bathing Living)
• Measures a person's self- • Dressing
care ability in the areas of • Toileting
general health or in the • Eating
• Walking
absence of illness.
LADS( Instrumental Activities
of Daily Living)
• May be supported by • Housekeeping
Standardized Instruments • Shopping
• Cooking
(Katz, Barthel, Lawton, • Doing laundry
etc.) • Using the telephone
• Managing finances
[Link]
Perception of
ASSESSMENT: • "HowHealth:
do you define health?"
• Nutrition/ Elimination • "How do you view your
situation now?"
• Social Relationships/
Resources • "What are your concerns?"
• Self-concept and • "What do you think will happen
Coping in the future?"
• Home Environment • "What are your health goals?
• "What do you expect from us---
nurses, physicians?
2. GENERAL ▪︎Gait
▪︎Use of assistive devices
APPEARANCE: ▪︎ROM of joints
• Appears stated age ▪︎Any involuntary
• Level of Consciousness movement/s
▪︎Able to rise from a seated
• Skin color
position easily
• • Facial expression
Nutritional status
• Mood and affect
• Obvious Physical
• Speech: articulation, pattern,
Deformities content appropriate, native
• Mobility language
• Hearing
• Personal Hygiene and
3. 4. SKIN:
MEASUREMENS:
• Weight • Examine both hands and
inspect the nails
• Height
• Compute Body Mass Index • Examine skin with
corresponding regional
(BMI)
examination
5. VITALSIGNS:
• Temperatur
• Vision using snellen's e
eye chart • Radial
Pulse
• Respiration
6. HEAD AND 7. EYE:
FACE: • Test visual fields by confrontation
(Cranial nerves II)
• Inspect and palpate scalp, hair, • Test extraocular muscles (EOMs):
and cranium corneal light reflex, six cardinal
positions of gaze (Cranial nerves
• Palpate the temporal artery, III, IV, VI)
• Inspect external eye structures
then the temporomandibular
• Inspect conjunctivae, sclerae,
joint as the person opens and corneas, irises
closes the mouth. • Test pupils: size, response to light
and accommodation
• Palpate the maxillary sinuses • Darken the room. Using an
ophthalmoscope, inspect ocular
and the frontal sinuses
fundus: red reflex, disc, vessels,
8. EAR: [Link]:
• Inspect the external ear: • Inspect the external
position and alignment, skin nose: symmetry,
condition and auditory
lesions
meatus
• Move auricle and push tragus
• Inspect facial
for tenderness symmetry (Cranial
• With an otoscope, inspect the nerves VII)
canal, then the tympanic • Test the patency of
membrane for color, position, each nostril
landmarks and integrity
• With the speculum,
• Test hearing:
• Whispered voice test inspect the nares:
• Tuning fork tests: Weber and nasal mucosa,
10. MOUTH:
• WITH A PENLIGHT, INSPECT • NOTE MOBILITY OF UVULA AS
THE MOUTH: BUCCAL THE PERSON PHONATES
MUCOSA, TEETH AND GUMS, "AHH," AND TEST GAG REFLEX
TONGUE, FLOOR OF MOUTH, (CRANIAL NERVES IX AND X)
PALATE AND UVULA
• Ask the person to stick out his
tongue (Cranial nerves XII)
• Grade tonsils if present
(grade 1 to 4) • With a gloved hand,
bimanually palpate the mouth
if indicated.
11. NECK:
• INSPECT THE NECK: SYMMETRY, LUMPS, PULSATIONS
• Palpate the cervical lymph nodes
• Inspect and palpate the carotid pulse, one side at a time. If indicated,
listen for carotid bruits
• Palpate the trachea in midline
• Test ROM and muscle strength against your resistance: head forward and
back, head turned to each side, and shoulder shrug (Cranial nerves XI
• Step behind the person, taking your stethoscope, ruler, and marking pen
with you.
• Palpate thyroid gland, posterior approach.
12. CHEST ( POSTERIOR
AND ANTERIOR)
• .INSPECT THE POSTERIOR CHEST: CONFIGURATION OF THE THORACIC CAGE,
SKIN CHARACTERISTICS, AND SYMMETRY OF SHOULDERS AND MUSCLES.
• Palpate symmetric expansion; tactile fremitus; lumps or tenderness
• Palpate length of spinous processes
• Percuss over all lung fields, percuss diaphragmatic excursion
• Percuss costovertebral angle, noting tenderness.
• Auscultate breath sounds; note any adventitious sounds
• Move around to face the patient; the patient remains sitting. For a female
breast examination, ask permission to lift gown to drape on the shoulders,
exposing the anterior chest; for a male, lower the gown to the lap.
13. CHEST 14. HEART
(ANTERIOR) RATE :
• INSPECT: RESPIRATIONS • ASK THE PATIENT
AND SKIN TO LEAN
CHARACTERISTICS FORWARD AND
• Palpate tactile fremitus, EXHALE BRIEFLY;
lumps or tenderness AUSCULTATE
• Percuss anterior lung CARDIAC BASE
fields FOR ANY
• Auscultate breath sounds MURMURS.
15. UPPER 16. FEMALE
• INSPECT FOR SYMMETRY, MOBILITY AND
EXTREMITIES BREASTS:
DIMPLING AS THE WOMAN LIFTS ARMS OVER
THE HEAD, PUSHES THE HANDS ON THE
• TEST ROM AND MUSCLE HIPS, AND LEANS FORWARD
STRENGTH OF HANDS,
• Inspect supraclavicular and infraclavicular
ARMS AND SHOULDERS.
areas
• Palpate the epitrochlear • Help the woman to lie supine with head at a
nodes. flat to 30-degree angle. Stand at the
• Palpate skin temperature, patient's right side drape the gown up
across shoulders and place an extra sheet
capillary refill. across lower abdomen
• Compare radial and • Palpate each breast, lifting the same side
brachial pulses. arm up over head. Include the Tail of Spence
and areola
• Palpate each nipple for discharge
• Support the patient's arm and palpate axilla
and regional lymph nodes
• Teach breast self- examination - (BSE)
17. MALE BREASTS:
• INSPECT AND PALPATE THE BREASTS WHILE
19. HEART:
• INSPECT THE PRECORDIUM FOR
PALPATING THE ANTERIOR CHEST WALL
PULSATIONS OR HEAVES (LIFT)
• Supporting each arm, palpate the axilla and
regional nodes • Palpate the apical impulse and note
the location
18. NECK VESSELS: • Auscultate apical rate and rhythm
• Auscultate with the diaphragm of the
• INSPECT EACH SIDE OF NECK FOR stethoscope to study heart sounds,
JUGULAR VENOUS PULSE, TURNING inching from the apex up to the base
THE PATIENT'S HEAD SLIGHTLY TO THE
OTHER SIDE
or vice versa
• Estimate venous pressure, if indicated • Auscultate the heart sounds with the
bell of the stethoscope, again inching
through all locations
• Turn the patient over to the left side
while again auscultating apex with the
bell
20. ABDOMEN:
• YOUR PARAGRAPTHE PATIENT SHOULD BE SUPINE, WITH THE BED OR
TABLE FLAT
• INSPECT: CONTOUR, SYMMETRY, SKIN CHARACTERISTICS, UMBILICUS,
AND PULSATIONS
• AUSCULTATE BOWEL SOUNDS OVER THE AORTA AND RENAL ARTERIES
• PERCUSS ALL QUADRANTS
• PERCUSS HEIGHT OF THE LIVER SPAN IN RIGHT MIDCLAVICULAR LINE
• PERCUSS THE LOCATION OF THE SPLEEN
• PALPATE: LIGHT PALPATION THEN DEEP PALPATION IN ALL QUADRANTS
• PALPATE FOR LIVER, SPLEEN, KIDNEYS, AND AORTA
21. INGUINAL22. LOWER
AREA: EXTREMITIES:
• INSPECT: CONTOUR, SYMMETRY, SKIN
CHARACTERISTICS, AND HAIR
DISTRIBUTION.
• YOUR PARAGRAPH
• Palpate pulses: popliteal, posterior tibial,
PALPATE EACH GROIN FOR
dorsalis pedis
THE FEMORAL PULSE AND
THE INGUINAL NODES. • Palpate for temperature of skin, and
LIFT THE DRAPE TO pretibial edema
EXPOSE THE [Link] • Separate toes and inspect
• Test ROM and muscle strength of hips,
knees, ankles and feet
• Ask the patient to sit up and to dangle the
legs off the bed or table. Keep the gown
and the drape over the lap.
23.
MUSCULOSKELETAL:
• ASSESS THE MUSCLE
STRENGTH AS THE PATIENT
SITS UP
24. NEUROLOGIC:
• YOUR PARAGRAPTEST SENSATION IN SELECTED AREAS ON FACE,
ARMS, HANDS, LEGS, AND FEET: SUPERFICIAL SKIN, LIGHT TOUCH
AND VIBRATION
• TEST POSITION CHANGE OF FINGER, ONE HAND
• TEST STEREOGNOSIS
• TEST CEREBELLAR FUNCTION OF THE UPPER EXTREMITIES USING
FINGER-TO- NOSE TEST OR RAPID- ALTERNATING MOVEMENTS TEST
• TEST THE CEREBELLAR FUNCTION OF THE LOWER EXTREMITIES BY
ASKING THE PATIENT TO RUN EACH HEEL DOWN THE OPPOSITE
SHIN
• ELICIT DEEP TENDON REFLEXES: BICEPS, TRICEPS,
BRACHIORADIALIS, PATELLAR, AND ACHILLES
• TEST THE BABINSKI REFLEX
• ASK THE PATIENT TO STAND WITH THE GOWN ON. STAND CLOSE TO
THE PATIENT. INSPECT THE LEGS TO VALIDATE PRESENCE OF
VARICOSE VEINH TEXT
25. MUSCULOSKELETAL/
NEUROLOGIC:
• YOUR PARAGRAASK THE PATIENT TO WALK ACROSS THE ROOM IN HIS/HER
REGULAR WALK, TURN, THEN WALK BACK TOWARD YOU, IN HEEL TO TOE FASHION
• ASK THE PATIENT TO WALK ON THE TOES FOR A FEW STEPS, THEN TO WALK ON
THE HEELS FOR A FEW STEPS
• STAND CLOSE AND CHECK ROMBERG SIGN
• ASK THE PATIENT TO HOLD THE EDGE OF THE BED AND TO PERFORM A SHALLOW
KNEE BEND, ONE FOR EACH LEG
• STAND BEHIND AND CHECK THE SPINE-AS THE PERSON TOUCHES THE TOES
• STABILIZE THE PELVIS AND TEST THE ROM OF THE SPINE AS THE PERSON HYPER-
EXTENDS, ROTATES, AND LATERALLY BENDPH TEXT
26. MALE GENITALIA:
• INSPECT THE PENIS AND SCROTUM
• Palpate the scrotal content
• Check for inguinal hernia
• Teach testicular self- examination
27. MALE RECTUM:
• INITIALLY, ASSIST OR OBSERVE A PHYSICIAN PERFORM THIS PART
OF THE EXAMINATION UNDER THE GUIDANCE OF YOUR CLINICAL
INSTRUCTOR.
• In an adult male, ask him to bend over the examination table,
supporting the torso with forearms on the table. Assist the
bedfast male to a left lateral position, with the right leg drawn
up.
• Inspect the perianal area
• With a gloved lubricated finger, palpate the rectal walls and
prostate gland
• Save a stool specimen for an occult blood test
28. FEMALE GENITALIA:
• WATCH A VIDEO SHOWING ON ASSESSING THE
FEMALE GENITALIA.
• Assist or observe a Physician perform this part
of the examination under the guidance of your
Clinical Instructor.
OKAY NA
TOH!
PRESENTED BY:
BUSTILLOS ANGELICA, SANTOS AUDREY,
ANDREA CELSO, MIAME ANDAYA,
DIMPLE MUYANO, ANABELLE RAFAEL
SAN JUAN, ANGHELO CLOUD