HEALTH

ASSESSMENT
HEAD TO TOE PHYSICAL
EXAMINATION
HEALTH ASSESSMENT

DEFINITION:
Health assessment or clinical examination (more
popularly known as a check-up) is the process by
which a doctor investigates the body of a patient for
signs of disease.





HEALTH
HISTORY
PHYSICAL
ASSESSMENT
HEALTH HISTORY
A health history is the collection of subjective data
that provides a detailed profile of the patient health
status.
Therapeutic communication skill and interview
technique used to gather health history.
It helps to identify actual and potential health
problem.
Physical examination is an integral part of health
examination and it includes head to toe examination
of the patient to rule out any deviation from the
normal.
PHYSICAL EXAMINATION
PURPOSE


To gather baseline data.
To confirm the alterations, disease or inability to
perform the activities of daily living.
To supplement data obtained in the nursing history.
To make nursing diagnosis.
To make clinical judgments about the clients
changing health status and management.
To evaluate the effectiveness of health care.





.
PREPARATIONS

Comfort
Position,
gowning
Height of
examination
table
Light
sources
Eliminate
distractions
Equipments:
clean & in
working
condition
INSTRUMENTS
SUPPLIES PURPOSE
Flash light or
penlight
To assist viewing of the pharynx and
cervix or to determine the reactions
of the pupils of the eye
Nasal speculum to visualization of the lower and
middle turbinates
Opthalmoscope To visualize the interior of the eye
Otoscope To visualized the ear drum and
external auditory canal
Knee hammer To test reflex
INSTRUMENTS
SUPPLIES PURPOSE
Tuning fork To test hearing acuity and vibratory sense.
Vaginal speculum To assess cervix and vagina
Cotton applicator To obtain specimens
Gloves To prevent contamination
Lubricant To ease insertion of instruments
Tongue depressors To depress the tongue
Stethoscope To auscultate heart, lung, abdomen and
cardiovascular sound.
Thermometer To check the temperature
POSITIONS OF PATIENT
2. PRONE POSITION:
1. SUPINE POSITION:
3. SITTING POSITION:



4. SEMI FOWLERs POSITION:
5. SIMs POSITION:





6. KNEE-CHEST POSITION:
7. DORSAL RECUMBENT POSITION:




8. LITHOTOMY POSITION:

9. TRENDELENBERGs POSITION:
METHODS OF EXAMINING:

1. Inspection:
A method of systematic observation. Inspection
should begin with general observation of the patient
progressing to specific body areas.
2. Palpation:
Process of examining patients by application of the
hands.
Used to determine:
Consistency of tissue.
Alignment and intactness
of structures.
Symmetry of body parts.
Areas of warmth and
tenderness.
Parts of hands used for various
palpation:
Part of hand Type of palpation
Finger tips To assess texture, shape,
size, consistency and
palpation
Dorsum of hand and
fingers
To assess temperature
Palm of hand To assess vibration
Pinching of fingers To assess turgor,
consistency and position
For light palpation, press the skin gently with the tips of
two or three fingers held close together.
3. Percussion:
Tapping of the body lightly but sharply to determine
consistency of tissues and/or organs through
vibration `& areas of tenderness.
PERCUSSION
The sounds may be:
Resonance: a low pitched and loud sound
heard over the normal lung tissues.
Hyper resonance: very loud , very low
pitched sound longer than resonance
signifies emphysema.
Tympany : a drum like sound heard over
the air filled tissues such as gastric air
bubble.
Dull: A medium pitched sound with a
medium duration without resonance
heard over solid tissues such as heart ,
liver.

Percussion sound with examples:
Percussion
sounds
Intensity Pitch Percussion
example
Dullness Medium Moderate Liver
Resonance Loud Low Normal lung
Hyper
resonance
Very loud Lower Emphysematous
lung
Tympany Loud Higher Puffed out cheek
, gastric air
bubble
4. Auscultation:
Process of listening for sounds over body cavities to
determine presence and quality of heart, lung, and
bowel sounds.
TYPES OF AUSCULTATION

Direct auscultation: use of
unaided ear
Indirect auscultation:
use of
stethoscope

PROCESS OF HEALTH
ASSESSMENT:

I. GENERAL APPEARANCE & BEHAVIOR:
i) Gender and race: Certain illnesses are more likely to
affect the specific gender and race. Eg. Risk of having
skin cancer is 20% higher in whites than in blacks.

ii) Age: Age influences the normal physical
characteristics.
iii) Signs of distress: There may be obvious signs and
symptoms indicating pain, difficulty in breathing or
anxiety.



iv) Body type: Trim, muscular, obese or excessively thin.


v) Posture: Observe whether the client has a slumped,
erect or bent posture.





vi) Gait: Observe the walking pattern of the client. Not
whether the movements are coordinated or
uncoordinated.


vii) Body movements: Note for any tremors involving the
extremities.
viii) Hygiene and grooming: Note the appearance of hair,
skin and finger nails. Also observe for the clothing.
ix) Affect and mood: Affect is a persons feelings as they
appear to others.
x) Speech: An abnormal pace may be caused by emotions
and neurological impairments.
xi) Substance abuse: Check for the history of substance
abuse.

VITAL SIGNS:

Equipment Needed:
A Stethoscope
A Blood Pressure Cuff
A Watch Displaying Seconds
A Thermometer

1. Temperature:
Temperature can be measured is several different ways:
Oral
Axillary
Aural
Rectal.
2. Respiration:
In adults, normal resting
respiratory rate is between
16-24 breaths/minute.

3. Pulse:

A normal adult heart rate is between 60 and 100
beats per minute. A pulse greater than 100
beats/minute is defined to be tachycardia. Pulse less
than 60 beats/minute is defined to be bradycardia.
4. Blood Pressure:
Record the blood pressure as
systolic over diastolic
(Eg. "120/70" ).

HEIGHT, WEIGHT AND
CIRCUMFERENCE:

A persons general level of health can be reflected in
the ratio of height to weight.
Weight is a routine measure during health visits.
A clients weight will normally vary daily because of
fluid loss or retention.
Progressive weight gain is
` expected during pregnancy.
Head, chest and abdominal
circumference should be
assessed in case of infants.

PHYSICAL EXAMINATION:

Look
(Inspection)
Listen
(auscultation)
Feel
(palpation)
Tap
(percussion)
Smell
(olfaction)
SKILLS OF PHYSICAL EXAMINATION

HEAD TO TOE ASSESSMENT

A. THE INTEGUMENT:
The integument includes skin, hair and nails. The
examination begins with a generalized inspection using
a good source of lighting.
1. SKIN: Assessment of the skin involves inspection and
palpation.
Pallor/Jaundice
Cyanosis
Erythema
Edema
Cynosis






Erythema
2. HAIR: Inspect the hairs for colour, alopecia (hair loss) and
the cleanliness of the scalp.
3. NAILS: Nails are inspected for nail plate shape, angle
between the nail and the nail bed, nail texture, nail bed
colour and the intactness of the tissues around the nails.
Clubbing is a condition in which
the angle between the nail and
nail bed is 180 degree or greater.
It may be caused by long term
lack of oxygen.


NORMAL NAIL SHAPE

Technique: view the index finger note the angle of
the nail base it should be above 160 degree.



ABNORMAL NAIL SHAPES

Early clubbing





Late clubbing
B. HEAD:

a. Eyes: Examine the conjunctiva,
sclera. Test pupils for irregularity,
accommodation, and reaction.
Evaluate visual fields and visual
acuity.

Vision
Visual activity(ability to see small
detail): by snellens chart.

Peripheral vision:

b. Ears: Examine the pinna and peri-auricular tissues. Test
auditory acuity, perform Weber and Rinne tests.

EARS
Examination of ears: Pull the ears backward and
upward.
Instrument used: Auto scope
External ears: Crusts, discharges, lesions etc.
Tympanic membrane: Normally it is shiny, translucent,
with a pearl grey color. See for any perforation,
lesions, bulging.
Hearing: There are 3 ways for testing the hearing.

Weber's test
It is used to assess the conductive
hearing loss.
Technique: Place a vibrating tuning
fork in the midline of the persons
skull and ask if he can hear the
sounds same in both the ears or
better in one ear.
Result :
The person should hear the tone
produced by bone conduction
equally in both ears, is the positive
test result
Rinne test
This is a test to compare the air conduction and the
bone conduction sounds.
Technique:
Place the stem of the vibrating tuning fork on
persons mastoid process and ask him or her to signal
when the sound disappears note the time in
seconds. Invert the tuning fork so the vibrating end is
near the ear canal he should hear the sound.
Note the time in seconds.
Results : AC : BC = 2 : 1
c. Nose: Connect the nasal speculum to the otoscope and examine the nares,
noting the condition of the mucosa, septum and turbinate's.
d. Mouth: Examine the oral mucosa, the
tongue and teeth. Evaluate the
function of cranial nerves IX, X,
and XII.

e. Face: Evaluation of symmetry, smile, frown, and jaw movement will provide
information about motor divisions of cranial nerves V and VII.

C. Neck:
Palpate the neck with emphasis on the salivary glands,
lymph nodes, and thyroid. Look for tracheal deviation.
Identify the carotid arteries and auscultate for bruits.
Lymph nodes are assessed by palpating with the pad of the
finger for enlargement , tenderness and mobility .
Normally nodes are not palpable. If palpable they should
be small, mobile, smooth and non tender.

LYMPH NODES
Thyroid : palpation for size , symmetry ,
tenderness and nodules.
Trachea: Palpation for alignment and position:
unequal space between trachea and sterno-cleido
mastoid muscle on each side is abnormal, indicative
of trachea displacement.
CAROTID ARTERY :

Palpate one carotid
artery at a time just
below the upper
border of the thyroid
cartilage.

RESPIRATORY ASSESSMENT:

Funnel chest (Pectus excavatum
describes an abnormal formation
of the rib cage that gives the chest
a caved-in or sunken appearance.)
Pigeon chest (Pectus carinatum, is
a deformity of the chest
characterized by a protrusion
of the sternum and ribs.)
D. CHEST AND LUNGS:

i) Inspection:
Observe the rate, rhythm, depth, and effort of breathing.
Listen for abnormal sounds such as wheezes.
Observe for retractions.
ii) Palpation:
Identify any areas of tenderness.
Assess expansion and symmetry
of the chest.
Check for tactile fremitus.

iii) Percussion:
Percuss from side to side and top to bottom .
Categorize what you hear as normal, dull, or hyper
resonant.
INTERPRETATION:Percussion Notes and Their Meaning:

Flat or Dull Pleural Effusion or Lobar
Pneumonia
Normal Healthy Lung or Bronchitis
Hyper resonant Emphysema or Pneumothorax
iv) Auscultation:
Use the diaphragm of the stethoscope to auscultate
breath sounds. Note the location and quality of the
sounds you hear.

Areas of Auscultation
:





ABNORMAL BREATH SOUNDS :
Crepts : fine, short interrupted sound heard during
inspiration and expiration. Example : Respiratory distress.
Rhonchi : low pitched continuous musical sound heard
during expiration and clears with coughing. Example :
Pneumonia.
Wheeze : high pitched continuous musical sound heard
during inspiration or expiration and does not clear with
coughing. Example : Pneumonia .
Pleural friction Rub : grating type of sound heard during
inspiration and does not clear with coughing, example :
Empyema .
CARDIAC ASSESSMENT:
Inspection of the Heart
The chest wall and epigastrium is
inspected while the client is in
supine position. Observe for
pulsation and heaves or lifts.
Normal Findings:
There should be no lift or heaves.

PALPATION OF THE HEART
The entire pre-cordium (anterior surface of the body covering
the heart and lower thorax) is palpated methodically using the
palms and the fingers, beginning at the apex, moving to the
left sternal border , and then to the base of the heart.
NORMAL FINDINGS:
No, palpable pulsation over the
aortic, pulmonary, and mitral valves.
Apical pulsation can be felt on
palpation.
There should be no noted abnormal
heaves, and thrills felt over the apex.

Percussion of the Heart
The technique of percussion is of
limited value in cardiac assessment. It
can be used to determine borders of
cardiac dullness.
Auscultation of the Heart
Aortic valve Right 2
nd
intercostal
space (ICS) sternal border.
Pulmonary Valve Left 2
nd
ICS sternal
border.
Mitral Valve Left 5
th
ICS
midclavicular line.
Tricuspid Valve Left 5
th
ICS sternal
border
AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonic
and aortic
Auscultating the heart

Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and
mitral.
Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of
semi-lunar valve).
Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
Count heart rate at the apical pulse for one full minute.
Normal Findings:
S1 & S2 can be heard at all anatomic site.
No abnormal heart sounds is heard (e.g. Murmurs, S3 &
S4).
Cardiac rate ranges from 60 100 beats per min.

ABDOMINAL ASSESSMENT
E. ABDOMINAL ASSESSMENT:

Abdomen is divided into 4 main quadrants:
Right Upper Quadrant (RUQ)
Right Lower Quadrant (RLQ)
Left Upper Quadrant (LUQ)
Left Lower Quadrant (LLQ)

i) Inspection:
Look for scars, striae, hernias, vascular changes, lesions, or
rashes, movement associated with peristalsis or pulsations.
Note the abdominal contour. Is it flat, scaphoid, or
protuberant?
ii) Auscultation:
Place the diaphragm lightly on the
abdomen, listen for bowel sounds.
Listen for bruits over the renal
arteries, iliac arteries, and aorta.

iii) Percussion:
Percuss in all four quadrants using proper technique.
Categorize what you hear as tympanitic or dull.
Tympany is normally present over most of the
abdomen in the supine position. Unusual dullness
may be a clue to an underlying abdominal mass.


Liver Span
Percuss downward from the chest in the right mid-
clavicular line until you detect the top edge of liver
dullness.
Percuss upward from the abdomen
in the same line until you detect the
bottom edge of liver dullness.
Measure the liver span between these
two points. This measurement should
be 6-12 cm in a normal adult.


Splenic Dullness
Percuss the lowest costal interspace
in the left anterior axillary line.
This area is normally tympanitic.
Ask the patient to take a deep
breath and percuss this area again.
Dullness in this area is a sign of
splenic enlargement.

vi) Palpation:
Palpation of the Liver
a. Standard Method:
Place your fingers just below the
right costal margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against your
fingers. Or it may slide under your hand as the patient
exhales. A normal liver is not tender.


b. Alternate Method:

This method is useful when the patient is obese or
when the examiner is small compared to the patient.
Stand by the patient's chest.
"Hook" your fingers just below
the costal margin and press
firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against your
fingers.

GENITALIA AND RECTUM:
Providing privacy
Not prolonging the examination
Warming instruments i.e. vaginal speculum
Using lubricants to minimize discomfort
Wear gloves during genital & rectal examination
Empty the bladder before examination
Male genitals
Inspect the skin of glance penis. Observe for any
lesions, color, discharge or inflammation.
Assess secondary sex characteristics , observe the
penis and testes for size and shape, color, texture of
scrotal skin symmetry and the distribution of pubic
hair , position of meatus and circumcision.
Palpate the penis using your thumb and first two
fingers. Note any tenderness or nodules. Normally,
testes feel firm and not hard with similar
consistency.
Female genitalia
Female genitalia is examined by inspection and
palpation.
Inspect the external genitalia. Separate the labia and
inspect the labia minora, clitoris, urethral orifice and
vaginal opening.
Observe for inflammation, discharge, ulceration,
varicose veins, swelling and nodules.
In internal inspection, observe cervix for color,
position, bleeding.
EXTREMITIES:
Upper and lower Extremities are assessed for size and
symmetry , various patterns , colour and texture of
skin and nail beds , hair distribution on hands , lower
legs , feet and toes . Observe for pigmentation , rashes
, scars , ulcers and edema.
HOMANS SIGN
Test for homans sign, an indicator of phlebitis in which
pain and soreness are present in the calf area when the
foot is dorsiflexed . The persons dorsiflexed leg is
supported from calf with your non dominant hand . Note
any pain or soreness in the calf area. If present this would
be a positive homans sign ,indicating the possibility of
phlebitis .

MOTOR SYSTEM:
Inspect the voluntary muscles for atrophy,
fasciculation (uncontrollable twitching)and
involuntary movements. In addition assess gait ,
Romberg's sign for muscle strength and
coordination.
Gait : is a persons style of walking. To assess gait,
instruct the person to walk across the room, turn and
walk back towards you . Observe the persons balance
and posture . Ataxia is an uncoordinated gait that
result from cerebellar disease or intoxication.
Rombergs test : Rombergs test is a test of sensory equilibrium.
Instruct the person to stand with the feet together and eyes
open . Note the persons balance . Then have the person close
the eyes. Normally you will observe only minimal swaying . A
positive test will suggest cerebellar ataxia.
REFLEXES OF MUSCLES:

Tests of muscle strength and
assessment of common reflexes
Type Procedure Normal
reflex
Deep
tendon
reflexes
Biceps Flex the clients arm at elbow with
palms down. Place your thumb in
antecubital fossa at the base of
biceps tendon . Strike the thumb
with the reflex hammer .
Flexion of
arm at
elbow.
Triceps Flex the clients elbow , holding arm
across the chest , or hold the upper
arm horizontally and allow the
lower arm to go limp. Strike triceps
tendon just above the elbow .
Extension
at elbow.
Patellar Make the client sit with legs hanging
freely over the side of the bed or
chair or have the client lie supine
and support knee in a flexed
position . Briskly tap patellar tendon
just below patellar.
Extension
of lower leg
at knee.
Procedures Normal
reflex
Achilles Make the client assume the same
position as for patellar reflex. Slightly
dorsiflex the clients ankle by grasping
toes in the palm of your hand . Strike
achilles tendon just above the heel.
Plantar
flexion of
foot .
Babinsk
is
Have the client lie supine with legs
straight and feet relaxed . Take the
handle end of the reflex hammer and
stroke lateral aspect of the sole from
the heel to the ball of the foot , curving
across the ball of the foot toward the
big toe.
Bending of
toe
downwards.
Maneuvers to assess muscle strength:
Muscle group Maneuver
Neck Place your hand firmly against the clients upper jaw .ask the
client to turn head laterally against resistance.
Shoulder Place your hand over the midline of the clients shoulder ,
exerting firm pressure . Have the client raise shoulder against
resistance.
Elbow,
Biceps,
Triceps.
Pull down the forearm as the client attempts to flex the arm. As
the clients arm is flexed ,apply pressure against the forearm
.ask the client to straighten his/her arm.
Hip ,
Quadriceps
When the client is sitting apply downward pressure to thigh .
Ask the client to raise his leg up from the table.
The client sits, holding shin of the flexed leg . Ask him to
straighten his leg against the resistance.
MUSCLE STRENGTH
To grade or quantify muscle strength, assess the patient as
follow:

Grade Description
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint
2/5 Movement at the joint, but not against gravity
3/5 Movement against gravity, but not against added resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength
SENSORY SYSTEM:

Light touch/ superficial pain: Using a wisp of cotton
and a safety pin alternatively , touch the distal and
proximal portions of the upper and lower
extremities.
The temperature test can be done by asking the
patient to touch and identify the hot and cold test
tube filled with hot and cold water respectively.
Vibration is assessed by tapping a tuning fork and
placing it firmly on a persons inter-phallengial joint
of the finger and great toe. Ask the patient to
describe the sensation and to identify when the
sensation ends.
Two point discrimination: When assessing two point
discrimination , touch the person alternatively with
one or two safety pins on a particular body part,
such as the finger pads . ask the patient if one or two
sensations are felt.
Point localization is assessed by touching various
parts of the persons body with a wisp of cotton. The
person is instructed to open the eyes after having felt
the touch and point to the area.
CONSCIOUSNESS
Assessment of consciousness begins with noting
whether the client is awake and alert . If the person
has altered the level of consciousness , assess whether
the person is demonstrating stupor or coma . Glasgow
coma scale to be maintained for the patient with
altered sensorium and in that three points are
observed: eye open response, verbal response and
motor response .
AFTER CARE:
When the physical examination is over, remove the
drape & help the person to put on cloths. Be sure the
patient is safe and comfortable.
DISMANTLING OF ARTICLES:
Articles should be sent for sterilization. Disposable
articles should be immediately disposed off and
replacement of all the articles should be done to the
area specified.
POINTS TO BE REMEMBER:

Ensure that adequate privacy is provided during the
observation.
Always take help in case of pediatric /unconscious
patient / uncooperative patient .
Ensure adequate light.
Inform the patient / relatives before
and after the physical examination .
Record all the observations and
preserve in safe custody .
Inform any abnormal findings
to senior nurse/doctor.