2F Guidelines in Physical Assessment Part 1
2F Guidelines in Physical Assessment Part 1
2F Guidelines in Physical Assessment Part 1
1. Types of equipment and how to operate Wash your hands – before beginning
them for a particular examination the examination, immediately after
2. Preparation on the physical setting, self accidental direct contact with blood or
and the client other body fluids and after completing
3. Performance of the 4 assessment the physical examination
techniques (Inspection, Palpation,
Percussion, Auscultation) Wear gloves if:
- You have an open cut or skin
EQUIPMENT abrasion
- If the client has an open or
Prior to the examination, collect the
weeping cut
necessary equipment and place it in the
- If you are collecting body fluids for
area where the examination will be
a specimen
performed
- If you are handling contaminated
Why? To promote organization and
surfaces
prevents the nurse from leaving the
- When you are performing an
client to search for a piece of equipment
examination of the mouth, an open
Scientific Principle: Time & Energy
wound, genitalia or rectum.
PREPARING THE PHYSICAL SETTING
If pin or other sharp object is used to
The nurse should ensure that the examination assess sensory perception, discard the
setting meets the following conditions: pin and use a new one for your next
client
1. Comfortable, warm room temperature
2. Private area free of interruptions from
Wear a mask and protective eye
others
goggles if you are performing an
3. Quiet area free of distractions
examination in which you are likely to be
4. Adequate lighting (use of sunlight is
splashed with blood or other body
best) or good overhead lighting is
droplets
sufficient
Ex. If you are performing an oral
Ex. Portable lamp – for illuminating the
examination on a client who has a
skin
chronic productive cough
5. Firm examination table or bed at a
height that prevents stooping
6. A bedside table/tray to hold the
equipment needed for the examination
performing it – to ease client’s anxiety
and gain cooperation
Integrate health teaching and health
APPROACHING AN PREPARING THE promotion during the examination –
CLIENT ex: if you feel the skin is dirty, tell the
Establish a nurse-client relationship client it should be washed 3x a day.
during the client interview – physical Approach the client from the right –
examination hand side of the examination table or
Respect the client’s desires and bed
requests related to the physical (most examination techniques are
examination performed with the examiner’s right
Explain to the client the importance of hand)
the examination and the risk of missing *you may ask the client to change positions
important information if any part of the frequently, depending on the part or the
examination is omitted examination being performed
If a urine specimen is necessary,
explain to the client the purpose of a EQUIPMENT NEEDED FOR PHYSICAL
urine sample, provide him or her with a EXAMINATION
container to use
If a urine sample is not necessary, ask For all examinations:
the client to urinate before the 1. Use gloves – to protect the examiner in
examination - to promote an easier and any part of examination
more comfortable examination of the 2. For vital signs:
abdomen and genital areas a. Sphygmomanometer: to measure
Ask the client to undress and put on an diastolic and systolic pressure
examination gown
Allow him or her to keep an underwear b. Stethoscope – to auscultate blood
until just before the genital examination sounds when measuring blood
– to promote comfort and privacy pressure. (before auscultating, rub
*Leave the room while the client changes into the diaphragm first, so that it won’t
the gown and knock before re-entering the startle the patient).
room to ensure the client’s privacy c. Thermometer – to measure body
temperature
Begin the examination with the less d. Hand watch with second hand – to
intrusive / invasive / disturbing time pulse rate
procedures – allow the client to feel
more comfortable and help to ease 3. For anthropometric measurements:
client anxiety about the examination. a. Skinfold callipers – to measure
allows client to gain trust too and so that skinfold thickness and subcutaneous
he/she will cooperate in the next tissues
procedure.
Throughout the examination,
continue to explain what procedure
you are performing and why you are
b. Flexible tape measure – to
measure mid-arm circumference
c. Platform scale with height
attachment – to measure height and
weight