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OBJECTIVES
Identify and explain the process of Physical Assessment.
Identify the four physical assessment techniques.
Understand the different guidelines involve during
physical examination.
Collecting Objective Data:
THE PHYSICAL EXAMINATION 4. Enumerate the importance of physical assessment
techniques.
PURPOSE OF PHYSICAL ASSESSMENT
PHYSICAL EXAMINATION
1. Obtain physical data about the client’s
functional abilities
A systematic way of
collecting objective data 2. Supplement, confirm, or refute data
from a client using the four
examination techniques. obtained in the client’s health history
3. Obtain data that will help the nurse
establish diagnoses and plan the client’s care
To assess or identify
current health status
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PURPOSE OF PHYSICAL ASSESSMENT
4. Evaluate the physiologic outcomes of health
care and thus the progress of a patient’s health
problem
5. To make clinical judgments about a client’s
health status
6. To identify areas for health promotion and
disease prevention
BASIC KNOWLEDGE
IN 3 AREAS A NURSE MUST HAVE!
BASIC KNOWLEDGE IN A. EQUIPMENT
3 AREAS A NURSE MUST HAVE!
To become proficient with physical assessment skills, the nurse Each part of the physical examination
must know these basic things: requires specific pieces of equipment.
A. Types and operation of equipment needed for the particular Prior to examination, collect the
examination.
necessary equipment and place it in
B. Preparation of the setting, oneself, and the client for physical the area where the examination will
assessment. be performed.
*This promotes organization and prevents
C. Performance of the four assessment techniques: inspection, the nurse from leaving the client to search for
palpation, percussion, and auscultation. a piece of equipment.
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B1. PREPARING THE PHYSICAL SETTING B2. PREPARING ONESELF
1. Assess your own feelings and anxieties before examining
1. Comfortable, warm room temperature. the client.
2. Private area free of interruptions from others.
2. Wash your hands before beginning the examination.
3. Quiet area free of distractions.
3. Always wear gloves if there is a chance that you will come
in direct contact with blood or other body fluids.
4. Adequate lighting
4. If a pin or other sharp object is used to assess sensory
5. Firm examination table or bed at a height that perception, discard the pin and use a new one for your next
prevents stooping. client
6. A bedside table/ tray to hold the equipment needed 5. Wear a mask and protective eye goggles if you are
for the examination performing an examination in which you are likely to be
splashed with blood or other body fluid droplets
C. PERFORMANCE OF THE 4 ASSESSMENT
TECHNIQUES
Inspection
Palpation
Percussion
Auscultation
A. PREPARATION GUIDELINES
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PREPARATORY PHASE PREPARATORY PHASE
1. Introduce self to the client. Verify his identity. 4. Invite a relative or a significant other to stay with
Explain the purpose why such procedure is necessary the client, as necessary
and how he could cooperate (i.e. positioning).
5. Provide adequate lighting.
2. Help him put on a clean gown and offer a bedpan
or a urinal to empty his bladder. 6. Gather the Materials or Equipment.
3. Ensure privacy by closing the doors or pulling the 7. Ensure the examination table is at a comfortable
curtains around him. working height. Perform hand hygiene.
The examiners hand are
the “primary
equipment” for
assessment
B. MATERIALS/
EQUIPMENT NEEDED
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Cotton ball Cotton tipped-
Applicators
& Paper clip
• Test the sense • Obtain Specimens
of touch
Dental 4x4
Mirror Gauze
• Visualize mouth and throat
structures. • Obtain specimens;
• Collect drainage
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Examination Gloves/ Clean gloves
Gloves Sterile gloves
Goggles
• Protect the nurse’s eyes from
contamination by body fluids
• Protect the nurse and patient
from contamination
Goniometer Lubricant
• Measure degree of flexion • Provide lubrication for
and extension of joints vaginal or rectal examination
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Opthalmoscope
Nasal • Inspect the interior
Speculum structures of the eye
• Dilate nares for inspection of
the nose
Otoscope Penlight
• Inspect the tympanic • Provide a direct light
membrane and source and test pupillary
external ear canal. reaction.
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Reflex Hammer Ruler, Marked in cm
• Test deep tendon reflexes • Measure organs, masses,
growths, and lesions
Skin- marking pen Specimen containers
• Outline masses or enlarged • Collect specimens of body
organs fluids, drainage, or tissue.
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Sphygmomanometer Stethoscope
• Measure systolic and • Auscultate body sounds
diastolic blood pressure.
Stadiometer Tape Measure
• Measure the height of the • Measure the circumference
patient. of the head, abdomen, and
extremities.
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Thermometer Tongue Blade
• Measure body temperature • Depress the tongue during
assessment of the mouth
and throat.
Vision chart
Tuning Fork (Snellen Chart)
• Test Auditory function and • Test near and far vision
vibratory sensation.
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Watch with
Weighing Scale second hand
• Measure the weight of the • Time heart rate, fetal pulse,
patient or bowel sounds when
counting
1. STANDING
POSITIONING (The client stands still in a normal,
comfortable, resting posture)
YOUR CLIENT
FOR: assessment of posture, gait &
balance.
CONTRAINDICATION: Patients who
are weak, disabled, or paralyzed may
need assistance or may not be able to
assume this position.
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Semi- Fowler’s Position
2. SITTING 30-45 degrees
FOR: Head, neck, posterior and
anterior thorax, breast, axillae,
heart, vital signs, upper extremities
lower, extremities and reflexes
High Fowler’s Position
90 degrees
CONTRAINDICATION: Elderly and
weak clients may require support
3. DORSAL RECUMBENT
(The client lies down on the examination table 4. SUPINE
or bed with the knees bent, the legs FOR: head, neck, axillae, anterior
separated, and the feet flat on the table or thorax, lungs, abdomen,
bed) extremities, peripheral pulses
FOR: Head and neck, axillae, anterior thorax, CONTRAINDICATION: Tolerated
lungs, breasts, heart, extremities, peripheral poorly by clients with
pulses, vital signs and vagina cardiovascular and respiratory
problems
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5. PRONE POSITION 6. SIM’S POSITION
(The client lies on the right or left side with the
(The client lies down on the abdomen lower arm placed behind the body and the
with the head to the side.) upper arm flexed at the shoulder and elbow.
FOR: Posterior thorax, hip joint The lower leg is slightly flexed at the knee while
movement the upper leg is flexed at a sharper angle and
CONTRAINDICATION: Often not tolerated pulled forward.)
by the elderly and people with FOR: assessment of rectum and vagina
cardiovascular and respiratory problem CONTRAINDICATION: Difficult for elderly and
people with limited joint movement
7. LITHOTOMY POSITION 8. KNEE CHEST POSITION
(The client lies on the back with the hips (The client kneels on the examination table
at the edge of the examination table and with the weight of the body supported by the
the feet supported by stirrups) chest and knees. A 90-degree angle should
FOR: assessment of female rectum and exist between the body and the hips. The arms
vagina. are placed above the head, with the head
turned to one side)
CONTRAINDICATION: May be
FOR: assessment of rectal area (for brief
uncomfortable and tiring for elderly
period only)
people. Often embarrassing
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ANATOMICAL DIRECTIONAL TERMINOLOGY
Example:- Point A is SUPERIOR to point B
-Point C is INFERIOR to point B
Further away from Closer to where arm
where arm or leg or leg inserts into
inserts into body body
*ONLY use when describing 2 points on the SAME limb (arm or leg).
Example: Wrist is DISTAL to elbow
Example: Umbilicus is on ANTERIOR Knee is PROXIMAL to ankle
(ventral) surface of the body
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SYMMETRICAL ASYMMETRICAL
THANK YOU!
Prof. Rosanna P. Suva, MAN, RN, PhD N(c)
Our Lady of Fatima University
College of Nursing
Valenzuela Campus
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