PHYSICAL ASSESSMENT

This RLE will enable the students to develop beginning skills in physical assessment which is an important
part of the nursing process.
Introduction:
Assessment is an important part of the nursing process because it provides data from which the nurse can
make the nursing diagnosis and plan, implement and evaluate nursing care. A complete physical assessment is
performed for:
1. Routine screening to promote preventive health care;
2. Determination of eligibility for health insurance, military service or a new job.
3. Admission to a hospital or long-term care agency.
I.

Purposes of Physical Assessment

The nurse conducts physical assessment to:
1. gather baseline data about the clients health;
2. supplement, confirm, or refute data obtained in the nursing history;
3. confirm and identify nursing diagnosis;
4. make clinical judgment about a clients changing health status and management, and
5. evaluate the physiological outcomes of care.

II.

Positioning the client for physical assessment

To conduct a thorough physical assessment effectively, the nurse assists the client to assume the various
positions necessary for an adequate exposure of the regions and aspects to be evaluated.

III.

1.

Sitting Position

A seated position, back unsupported and legs hanging freely; allows the
nurse to assess the head, thorax, breasts, upper and lower extremities,
vital signs, reflexes.

2.

Supine Position

The client lies on his back with legs stretched out together; used for the
examination of the breasts, anterior thorax, axillae and peripheral
pulses; the most comfortable position for most patient since it is the
most normally relaxed position.

3.

Dorsal Recumbent

The client lies on his back with knees flexed, legs separated, hips
externally rotated and soles of feet flat on the table; used to examine
abdomen, genitalia, and rectum.

4.

Lithotomy Position

The client lies on her back with the buttocks placed at the edge of the
table, knees are flexed, and feet are supported in stirrups; used for the
examination of the female genitalia, genital track, and rectum.

5.

Sims Position

Side-lying position with lower arm behind the body, upper arm placed
forward with elbow flexed and arm resting on a pillow; lower knee is
flexed slightly and upper knee is flexed sharply on the abdomen; used
for the digital examination if the rectum and the vagina.

6.

Knee-Chest or
Genupectoral Position

With the head turned to one side, the client rests on his
knees and chest, with his lower legs, perpendicular to his thighs, arms
are [placed on his head or flexed at the elbow; used for instrument
examination of the rectum.

Guiding Principles in Performing Physical Assessment

IV.

1.

Order of Examination

2.

Preparation of
Environment

The place where the physical assessment will be

done should provide privacy. Room curtains or dividers can be closed.
Adequate lighting is needed for proper illumination of body parts.

3.

Peparation of
Equipment

The equipment needed for physical assessment should be

readily available and arrange in order for easy use. It should be kept
warm. The diaphragm of the of the stethoscope may be briskly rubbed
between the hands before it is applied to the skin. Warm water should
run over the vaginal speculum. The nurses hands should be warmed.
All equipment must be checked to see that they function properly.

4.

Physical Preparation
of the Client

5.

Psychological Preparation

The clients physical comfort is very important.

before starting, the nurse asks the client to void. An empty bladder
facilitates examination of the abdomen. Physical preparation involves
being sure that the client is dressed and draped properly. The nurse,
therefore, should provide an examining gown and a draping sheet and
expose the regions to be examined once at a time.
The client can be prepared psychologically when the procedure is
explained to him before the examination starts, the nurse can alleviate
the clients anxiety by making him aware of what is going to be done,
the purpose and how the procedure will be conducted. The nurse should
prepare the client for a maneuver that usually produces discomfort.
Clients, young or old, are entitled to some explanation which can
prevent needless anxiety.

Instruments for Health Assessment

1.
2.
3.
4.
5.
6.
7.
8.
9.

V.

Four techniques are employed in physical assessment. They are,

according to their usual order in the procedure, inspection, palpation,
percussion and auscultation. An exception, however, to this order is the
examination of the abdomen where it is advisable to start with
inspection, and follow through with auscultation, palpation, and
percussion. Auscultation is done before palpation and percussion to
prevent altering the frequency of the bowel sound. An order of
examination also includes proceeding from general to specific and from
proximo-distal body parts.

penlight
weighing scale
stethoscope
sphygmomanometer and cuff
thermometer
tongue depressor
wristwatch with second hand
cardboard
Shellens chart per section

Skills of Physical Assessment

1. Inspection or Observation

Inspection is the visual examination, that is , assessing by the use of the

sense of sight. The nurse inspects with the naked eye and with a lighted
instrument. In some instances, the sense of smell and hearing are also
involved. To inspect body parts accurately, the nurse follows these
guidelines:
a.
b.
c.

Have good light source available.

Position and expose body parts to be examined. All surfaces
should be seen.
Inspect each area of size, shape, color, symmetry, position and
abnormalities.

d.
e.

Compare each area inspected with the same area on the

opposite side of the body.
Use additional light (e.g. penlight) to inspect body cavities.

2. Palpation
Palpation is the examination of the body using the sense of touch. The
nurse uses different parts of the hand to detect characteristics such as
texture,
temperature, vibration, position, size, consistency, and mobility
of organs or masses, and tenderness
of pain. For example, the nurse
uses the pads or balls of the fingers to detect the
pulsation, texture,
shape, size, and consistency; the dorsum of the hand to detect
vibration;
the fingertips to palpate small section of the body, such as the cervical
lymph node, because they cam make fine tactile discriminations; and
the fingers can be
used in a grasping movement to assess skin turgor.
3. Percussion Percussion is the technique of tapping a [part area of the body with the
fingertips or percussion hammer in order to elicit the character and
density of the underlying
tissues. It helps in determining whether the
underlying tissues are air filled, fluid-filled, or solid.
There are two (2) methods of percussion; the direct and indirect
percussion. In direct percussion, the nurse strikes or taps the body
surface directly with the index or middle finger of the non-dominant
hand (called the pleximeter) firmly against the body surface, keeping
the palm and the remaining fingers off the skin in order not do damp the
sound. The tip of the middle finger of the dominant hand (called plexor)
strikes the distal interphalangeal joint. In both methods, the strikes are
rapid, and the movement is from the wrist.
Percussion elicits five types of sounds:
a.
b.
c.
d.
e.
4.

VI.

Auscultation

flatness an extremely dull sound produced by a very dense tissue, such as

muscle or bone;
resonance a hollow sound such as that produced by lungs filled with air.
Hyperressonance not produced in the normal body; can be described as
booming and can be heard over an emphysematous lung
Tympany a musical or drum like sound produced from an air-filled stomach;
Dullness- a thud like sound produced by dense tissues such as the liver, spleen or
the heart.
Auscultation is the process of listening to sounds produced within the
body. It may be direct or indirect. Indirect auscultation is done with the
use of the unaided ear to listen for sounds. Direct auscultation involves
the use of a stethoscope which amplifies the sound and conveys them to
the nurses ears. The stethoscope should have both a flat-disc and bellshaped diaphragms. The flat-disc diaphragm best transmit high-pitched
sounds and bell-shaped diaphragm best transmit low-pitched sound.

Physical Measurements
1.

Height
the nurse measures height with a measuring stick (or tape measure)
attached to weight scale or to a wall. The client removes his shoes and stands erect, with
heels together. Buttocks and head against the measuring stick. The nurse raises the Lshaped sliding arm on the weighing scale until it rests on top of the clients head, or place
a small flat object, such as a ruler, on the clients. With this object placed level
horizontally at 90 degree angle to the measuring stick, the nurse measures height in
inches or cms.

2.

Weight
To measure the weight, the client is made to stand on a platform, and
the weight is read from a digital display panel or a balancing arm. Make sure the client
wears light clothing only and no shoes.

VII.

Organization of Physical Assessment

A complete physical assessment is generally conducted from the head to the toes, however, this
procedure can vary according to the age of the client, his condition, the preference of the nurse, the
agencys procedures.
A. General Appearance- includes the following:
1.
2.
3.
4.
5.
6.

mood and affect;

signs of distress;
posture;
body movement;
hygiene and grooming ; and
type of clothing.

B. Measurements
1.
2.

height and weight; and

vital signs.

C. Head to Toe Examination

1.

Head
a.
b.
c.
d.
e.
f.
g.
h.

2.
3.
4.
5.
6.
7.
8.

skull
scalp
hair
face
eyes
ears
nose
mouth

neck
anterior thorax
posterior thorax
abdomen
upper extremities
lower extremities
breasts

General Appearance
1.

Mood and Affect

Affect is the persons feelings as they appear to others. A persons

mood or emotional state is expressed verbally and non-verbally. Take
note it verbal expressions match non-verbal behavior. Observe facial
expression as questions are asked.

2.

Signs of Distress

Observe if there are obvious signs/symptoms of pain, difficulty in

breathing, or anxiety.

3.

Posture

Observe if client has a slumped, erect, or bent posture. Posture may

reflect mood or presence of discomfort. Tall straight posture may
indicate a high level of self-esteem and a sense of rejection, or a
structural deformity.

4.

Body movements

Observe if movements are purposeful, Note if there are tremors

involving the extremities. Observe it any body part is immobile.

5.

Hygiene and Grooming

6.

Type of Clothing

Note the clients level of cleanliness by observing the appearance of

hair, skin or fingernails. Note if his clothes are clean. Take note of
presence of body odor or bad breath.

Note if the type of clothing worn is appropriate for temperature and

weather conditions.

Head to Toe Examination

Body Parts

Technique

Normal Findings

Palpation
=======
size, shape or contour
symmetry and curvature

Proportional to the size of the body, round, with

prominence in the frontal area anteriorly and the
occipital are posteriorly symmetrical in
all planes, gently curved.

A. Head
1. Skull

2. Scalp

Inspection

white; clean; free from masses, lumps, soars,

lice, nits and dandruff and lesions.

Carefully separate the hair

at various locations.
Inspect for color, appearance,
presence of masses, lice, nits,
and dandruff

3. Hair

Palpation
======
areas of tenderness

no areas of tenderness

Inspection
=======
Inspect for the color
distribution,. thickness,
lubrication/appearance

black, evenly distributed and covers the

whole scalp, thick, shiny and free split
ends.

Palpation
======
palpate for texture

coarse or fine

Note:
Terminal Hair: is the long, thick and coarse hair of the body which is easily visible on the
scalp, axilla and the public area
Vellus Hair: is the soft, small, tiny hair that covers the whole body except for the palms and the soles.

Body Parts

Technique

Normal findings

4. Face

Inspection
========

5. Eyes

Inspection
========
observe for placement,
symmetry, protrusion,
and clarity and lacrimation

6. Eyebrows

Inspection
========
Observe for the color,
symmetry, quantity of hair
distribution and placement
or parallelism.

7. Eyelashes

Inspection

Oblong or oval or round or square or

heartshaped, symmetrical, facial expression
that is observe for the symmetry,
dependent on the mood or true
feelings, smooth shape, facial
expression, and free from wrinkles
and no involuntary movement and
appearance. muscle movements
Parallel and evenly place,
symmetrical, nonprotruding, with scant amount of
secretions,
both eyes bright and clear.

Black symmetrical, thick, raise and

lower
symmetrically, evenly distributed and
parallel
with each other.

Black, evenly distributed and turned

outward.

========
Observe for the color,
distribution and direction.
8. Eyelids

Inspection
========
As the client to close eyes
Observe for position and
symmetry, then ask him to
open eyes again

Upper lid covers a small portion of the

iris and the cornea and the sclera when
the eyes are open. When the eyes are
closed-the lids meet completely,
symmetrical.

Palpation
=======

Non-palpable, not tender

Using the tip of the index

finger, palpate the lacrimal
gland
9. Lower
Palpebral
Conjuctiva

10. Sclera

11. Sclera

12. Pupils

Inspection
=======
Ask client to look up and
Pull the lower lid down.
Observe for color and
appearance.

Salmon pink, shiny, moist

Inspection
=======
Note color and clarity

white and clear

Inspection
=======
Note clarity and texture

transparent, shiny and smooth

Inspection
=======
Note size, shape,
symmetry
Reaction to light and
*accommodation

Round, equal, and reacts to light and

accommodation constrict when lights is
Pointed to the eyes and dilate when
light
Is removed, constrict when object is
closed to
The eyes and dilate when object is
removed
Away.

*Accommodation the ability of the eyes to focus on an object in

order to produce a clear image at
various distances.
Note: To check for pupillary reaction to light, ask the client to look straight ahead,
then penlight and bring it from the
side of the clients face and direct the
light into the pupil.
To test accommodation, hold a finger 4 to 6 inches from the clients nose.
Ask client to gaze at the finger. Then
move the finger away. As the object is

moved farther, the pupil dilates

equally.
13. Iris

Testing for
Eye
Movement

Inspection
========
Note size, color, and
symmetry

Proportional to the size of the

Eyes, round, black/brown and
Symmetrical.

Inspection
========
Stand directly in front of
the
Client of the client and
hold
The finger at about one ft.
in from of the clients
eyes.
Able to move eyes in full rang
Ask client to refrain from
Moving his head and
Motion or able to move in all
follow
The direction of the
Direction.
examiner
Fingers with his eyes only.
Move the finger in a slow
orderly manner through
the cardinal fields of gaze.

Testing for

Stand 2-3 ft. from the

client.
Visual fields Ask him to cover one eye
Wit a card and to look
Straight at your nose.
Cover
Your eye directly opposite
The clients covered eye
and look straight at his
nose. Place your 2 fingers
at equal distance between
you and your client 90
degrees temporally, 60
degrees superiorly, 70

Able to see 60 degrees

Superiorly, 90 degrees
Temporally, 70 degrees
Inferiorly, and 50 degrees
Nasally.

degrees inferiorly and 50

degree nasally. Ask your
client if he can see your
moving fingers. Then test
the other eye.
Testing for
Visual
Acuity

Ask the client to stand

20ft from the Snellen
chart. Test right eye, then
thew left eye (cover the
eye not being tested), then
both eyes together. Ask
client to read aloud the
letters at the 20/30 or
20/40 line on the chart and
continue upward or
downward depending on
the clients ability to see. If
the client is able to see the
majority of the letter of
each line (3 of 4 or 4 of 6),
a passing score is given
fo0r that time.

20/20- this means a person is capable

of seeing an object at 20 feet which a
individual with normal acuity is
expected to be able to see.

*Visual Acuity - the ability to see a specific at a specific distance. The

numerator refers to the distance from the chart. The denominator
represents the last line the client read correctly.
Ears

Inspection
=======
Note parallelism,
symmetry size, position,
color and appearance.

Parallel, symmetrical, proportional to

the size of the head, bean-shaped, helix
is in line with the outer canthus of the
eye, skin is the same color as the
surrounding area, and is clean.
Firm cartilage

Palpation
Palpate for the firmness of
the cartilage of the
auricles.

Ear Canal

Hearing
Acuity

Inspection
=======
By using a penlight
examine the ear canal by
pilling the pinna up and
back for adults, down
and back for children.
Inspect for color,
appearance, presence of
cerumen, foreign bodies
and presence of cilia.

Pinkish, clean with scant amount of

cerumen and a few cilia.

Inspection
=======
Whisper from the clients Able to hear a whisper spoken 2 feet
ear at a distance of 2 feet
away.
(one ear at a time and then
at the back of the client for
both ears.
Instruct the client not to
move his head and to
repeat the words that you
will say.

Nose

Inspection
=======
Note placement,
symmetry and patency

In the midline, symmetrical and patent

NOTE: Ask client to close one nostril at a time and ask if he has
any difficulty in breathing while one nostril is covered.
Internal
Nares

Septum

Inspection
=======
Note appearance, color of
mucus membrane,
presence of cilia.
Inspection
Observe appearance

Clean, pinkish, with few cilia

straight

16. Mouth
Lips

Inspection
=======
Observe for color, shape,
symmetry, lip margin,
appearance.

Pinkish, symmetrical with lip margin

well-defined, smooth and moist

NOTE: Ask client to open his mouth wide and to move his
tongue if necessary for better visualization of the following parts.
Ask him to say Ah-h and depress the tongue at the side to see the
throat. A penlight maybe necessary.
Gums

Teeth

Tongue

Frenulum
Cheeks
(buccal
mucosa)
Palate
Soft
palate
Hard
palate

Inspection pinkish,
=========
Observe for color,
Appearance, discharge and
swelling or retraction
Inspection
========
Note number, color
alignment, general
condition, breath odor
Inspection
=======
Inspect for size, color
surface, appearance and
movement

Smooth, moist no receding, no

swelling and no discharge

32 permanent teeth, well-aligned, free

from caries or filling no halitosis

Large or medium, red or pink, slightly

rough on top, smooth along the lateral
margins, moist, shiny and freely
movable.

Inspection
Midline, straight and thin
========
position and appearance
Inspection
========
Pinkish, smooth and moist
Note color and appearance
Inspection
========
note color and appearance
Inspection
========

pinkish smooth and moist

Slightly pinkish

Uvula

Tonsils

Voice

16. Neck

17.
Muscular
Strength

18. Thorax

note color and appearance

Inspection
========
Note position, size
symmetry and mobility
Inspection
=======
Note color, size,
inflammation, exudates
Inspection
========
detect if there is
hoarseness of voice.
Inspection
========
note size, symmetry,
position
Palpation
=======
Palpate for lumps, masses
or areas of tenderness.
Palpate the Adams apple
(for male)
Range of Movement
===============
Ask to move chin to chest
and ear to shoulder.
Inspection
========
Note symmetry and
strength of the
sternocleidomastoid
muscle.
Force/strength of the
Trapezius muscle
Inspection
========
Note shape, position of the
spine, slope of ribs,
retraction of the ICS on
inspiration and expiration
and symmetry of chest
wall during respiration

At the center, symmetrical and freely

movable.
Pinkish, not inflamed

No hoarseness and well modulated

Proportional to the size of the body and

head, symmetrical and straight
No palpable lumps, masses or areas of
tenderness.
Palpable
Freely movable without difficulty

Symmetrical and able to resist applied

force (both muscles)
Able to resist applied force.
Symmetrical in structure of size and
muscular strength.

Chest symmetric, spine vertically

aligned, no retractions, wall intact,

Palpation
No lumps/masses or areas of
=======
tenderness on palpation
palpate for lumps, masses
and areas of tenderness
Measure chest excursion
Chest excursion equal/symmetrical.
by placing hands on the
Thumbs move apart in equal distance
lower rib cage with
at the same time (Normally thumbs
thumbs 2 inches apart
separate 1 to 2 inches during deep
pointing toward the spine inspiration.
so a small fold of the skin
appears between the
thumbs. Ask client to take
a few deep breaths.
Elicit tactile fremitus by
Bilateral symmetry of vocal fremitus.
placing the palms of the
It is normally decreased over heart &
hands bilaterally
breast tissue. Low pitched voices of
symmetrical on the chest
male are more readily palpated than
starting from the top of the higher pitched voices of females.
chest wall going down.
Each time the hands move
down, ask the client to say
ninety-nine or one-one
with the same intensity of
voice.
Percussion
Percussion notes resonate except over
========
scapula
Use indirect percussion in
the ICS over symmetrical
areas of the chest starting
from the supra clavicular
area. Compare one side of
the chest with the other.
(Note: if the posterior thorax is used , the clients arms should be folded forward
across the chest in a sitting position)
Auscultation
==========
Clear breath sounds heard.
Auscultate the chest using (bronchovesicular and vesicular sound)
a flat disc diaphragm
observing the same zigzag
procedure used in
percussion. Ask client to
take slow, deep breaths
through mouth.

19. Heart

Inspection
No pulsations noted in the aortic,
========
pulmonic and tricuspid areas.
Inspect and
simultaneously palpate the
valves of the heart with
the client in supine
position.

(Note: The health care provider stands on the clients right side and asks client
not to talk)
Place ball of 1-2 fingers
on the 2nd ICS at the right
of the angle of Louis for
the aortic valve.
Place ball of 1-2 fingers
on the 2nd ICS at the left
of the angle of Louis for
the pulmonic valve.
Move the fingers along
the clients left sternal
border to the 5th ICS for
the tricuspid valve
Move the fingers laterally
to the left-mid clavicular
line which is slightly
below the nipple for the
apical area.
Place fingers at the base
of the sternum for the
epigastric area.
Auscultation
=========
Auscultate the heart in all
anatomic areas: aortic,
pulmonic, tricuspid, and
apical. (Counts the cardiac
rate for 1 full minute at the
eapical area)

Apical pulsations visible in 50% of

adults and palpable in most.
Aortic pulsations in epigrastic area at
the base of sterrum.

S1 and S2 usually heard in all sites.

Cardiac rate range 60 90 beats per
minute

20. Breasts

Inspection
========
Inspect the breasts for
size, symmetry and
contour, shape, color,
retraction, or dimpling
Palpation
=======
Palpate the breasts for
lumps, masses, tenderness,
and consistency of breast
tissues using palmar
surfaces of the first three
fingers. Perform palpation
in a clockwise rotary
motion, from the borders
going inward.

Female: round in shape, slightly

unequal in size, generally symmetric,
Male: even with chest wall; if obese
may be similar in shape to female
breasts.
Uniform in color, smooth and intact
No lumps, masses or tenderness.

(Note: Client is in supine position with the hand placed under the head)
Areola

Nipples

21.
Abdomen

Inspection
========
Inspect for size, shape,
color and symmetry
Palpation
=======
Palpate for masses and
tenderness
Inspection
========
Inspect for size, shape,
position, discharges and
lesions
Palpation
=======
Compress the nipples
using thumb and index
finger to determine any
discharge
Inspection
========

Round or oval, bilaterally the same,

color varies widely from light pink to
dark brown
No masses and tenderness

Round, everted (inverted in some),

equal in size, similar in color, soft and
smooth

No discharges, masses or lesions

Unblemished skin, uniform color, may

be flat, rounded or scaphoid,

22. Upper
extremities

Inspect for skin integrity,

color, contour, symmetry,
movement or pulsation,
color and placement of
umbilicus
Auscultation
==========
Auscultate the quadrants
over all auscultation sites
Palpation
=======
Perform light palpation to
detect areas of tenderness,
muscle guarding, lumps,
masses, orgnomegally and
consistency of abdominal
wall using the finger pads
in circular motion.
Palpates all 4 quadrants.

symmetric contour, symmetric

movement caused by respiration,
umbilicus centrally located

Palpate the liver using

deep palpation Place left
hand on the posterior
thorax at about 11th or 12th
rib and then applies
upward pressure.
With the fingers of the
right hand on the RUQ
wall below the livers
border, then presses gently
until 1 inches deep
breath using abdominal
muscles. As he inhales,
palpate the liver edge.
Percussion
========
Percusses each of the
quadrants starting from
the LUQ going clockwise

May not be palpate. Liver border feels

smooth

Inspection
========
Inspect the appearance of

Bowel sounds present

No tenderness, relaxed abdomen, with

smooth, consistent tension. Tenderness
may be present near xyphoid process,
over cecum and over sigmoid colon

Tympany may be noted on an air field

stomach. Dullness in RUQ where liver
is located

Clean, no lesions, digits/fingers equal

in number; symmetrical, no

the hands; level of general abnormalities

hygiene, skin lesions and
number of digits inspect
for symmetry of size,
length and presence of
abnormalities extend arms
of client with palms facing
each other at the chest
level.
Palpation
=======
Palpate starting from
shoulders to the forearm
for tenderness, masses,
texture and temperature of
the skin
Nails

No tenderness, or masses; smooth and

temperature uniform

Inspection
=======
Convex in curvature
Inspect nails for shape and
color
Palpation
=======
Smooth in texture; prompt return of
Palpate nails for texture
usual color upon release of pressure
applies a little pressure on
the nailbed with the thumb
and then quickly realeses
the pressure

Mobility

Demonstrate to the client

the following and asks
client tot do the same:
a. arms- abduction and
adduction
Able to perform the different ranges of
b. shoulders- internal
motion
and external
rotation of the arm
c. elbows- flexion,
extension, pronation
and supination of
forearm

d. wrists- flexion,
extention, radial and
ulnar flexion
e. hands and fingersflexion, extension
Equality of strength noted
Holds clients hand
in a hand shake
manner and ask
client to press hard
as possible.
Compares right and
left muscle strength
23. Lower
Extremities

Inspection
========
Inspect for symmetry, size,
length and presence of
abnormalities. Note the
pattern of hair distribution,
color and presence of
varicose veins. Inspect for
cleanliness of feet and toes
including skin lesions and
number of toes.

Lower extremities are symmetrical/

equal in size, length. Hair distribution
variable. No varicosities. Feet clean, no
lesions, not polydactyl,

Texture smooth, temperature uniform

Palpation
========
Palpate from the thigh to
leg for temperature and
texture
Mobility

Demonstrate to the client

the following and asks
client tot do the same:
a. hips- flexion and
extension
b. knees- flexion,
extension, rotation
c. foot and toesflexion and
extension, rotation

Able to perform al, ranges of motion

without difficulty