HEALTH ASSESSMENT PREPARING ONSELF

2F: GUIDELINES IN PHYSICAL  Assess your own feelings and anxieties

EXAMINATION before examining the client
 Have self-confidence, practice the
techniques on physical assessment
Collecting Objective Data  Know what to do to prevent the
transmission of infectious agents
The nurse should have the basic knowledge in
the following areas: GENERAL PRINCIPLES TO KEEP IN MIND

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

4. For skin, Hair and Nail assessment:

a. Ruler with centimetre markings – 7. For ear examination:
to measure the size of skin lesions a. Otoscope – to view ear canal and
b. Magnifying glass – to enlarge tympanic membrane
visibility of lesions
c. Wood’s light – to test for fungus

b. Turning fork – to test for bone and

air conduction of sound. (mastoid
process)

5. For head and neck examination

a. Small cup of water – to help client to
swallow during the examination of
the thyroid gland
8. For mouth, throat, nose and sinuses
6. For eye examination: examination
a. Penlight – to test papillary a. Penlight – to provide light to view
constriction the mouth and throat
b. Snellen’s chart – to test distant - To transilluminate the sinuses
vision. To test for far vision. b. Tongue depressor – to depress the
tongue to:
- view the throat
- check looseness of teeth
- view cheeks
- check the strength of tongue
c. Opthalmoscope – to view
c. piece of small gauze – to grasp the
the red reflex and examine
tongue to examine mouth
the retina of the eye

d. Cover card – to test

strabismus. Strabismus is a
problem with eye muscles.
d. otoscope w/wide tip
e. Newspaper or Rosenbaum pocket
attachment – to view the
screener – to test near vision. 14
internal nose
inches away.
 a. Lubricating Jelly – to promote
9. For thoracic and lung assessment comfort for the client
a. Stethoscope (diaphragm) – to b. Specimen container – to test for
auscultate breath sounds occult blood. (Occult blood is you
cant see the blood in the stool)

14. For peripheral/Vascular Examination

a. Stethoscope and
10. For Heart and Neck Vessel sphygmomanometer – to
Assessment auscultate vascular sounds and
a. Stethoscope (bell and diaphragm) measure blood pressure
– to auscultate heart sounds
b. Flexible tape measure – to
11. For Abdominal Examination measure size of extremities for
a. Stethoscope – to detect bowel edema (edema means swelling.
sounds When the fluid leaks nearby tissues).
b. Marking pencil and ruler (w/cm c. Doppler ultrasound probe blood –
markings) – to mark area of to detect pressure and weak pulses
percussion of organs to measure not easily heard with a stethoscope
size
c. Two small pillows – to place under
knees and head to promote
relaxation of the abdomen
15. For Musculoskeletal examination
12. For Genitalia Assessment
a. Tape measure – to measure size
a. Vaginal Speculum and Lubricant –
extremities
to inspect cervix through dilatation of
b. Goniometer – to measure degree of
the vaginal wall
flexion and extension of joints

b. Slides or specimen container,

bifid spatula and cotton tipped 16. For Neurologic examination:
applicator – to obtain endocervical a. Turning fork – to test for vibratory
swab and cervical scrape and sensation
vaginal pool sample b. Cotton wisp, paper clip – to test for
light, sharp and dull touch and two
point discrimination
c. Salt, sugar, lemon pickle juice - to
test for taste perception
d. Tongue depressor – to test for rise
13. For Anus, rectum and Prostate of uvula and gag reflex
Assessment e. Reflex hammer - to test deep
tendon reflexes
f. Coin or Key – to test for
stereognosis (ability to recognize
objects by touch)