The document discusses the process of health assessment in nursing. It defines health assessment as collecting both subjective and objective data about a client through interview and physical examination. The purposes of health assessment are outlined as establishing a baseline on a client's health and abilities, identifying risks or problems, and forming the basis for a care plan. The key components of health assessment are described as the health history, physical examination, review of records and tests. Specific techniques used in physical examination like inspection, palpation, percussion, and auscultation are also explained. The document provides details on preparing the client and environment for examination and lists the typical sequence of a physical assessment.

1. BY JONES H.M- MBA/DMS

3. Health Assessment
• Assessment includes collecting
subjective data through
interviewing the client and
obtaining objective data by
physically examining the client.

4. Health Assessment
• Subjective data are those symptoms,
feelings, perceptions, preferences, values
and information that only the client can
state and validate.
• Objective data can be directly observed or
measured such as vital sig or appearance.

5. Purpose of health assessment
• Establish a database for the client’s normal
abilities, risk factors, and any current
alteration in function.
• Plan strategies to encourage continuation of
healthy patterns.
• prevent potential health problems, and
alleviate or manage existing health problems.
• Provide a holistic view of the client.
• Formulate a conclusion or a problem
statement such as a nursing diagnosis.
• Provide an essential foundation for the care
of the client.

6. Health Assessment Components
• Nursing health history
• Physical examination
• Records and reports
• Review of lab and diagnostic test results

8. Cont’
• Clinical Interview
• Nursing health history
• History taking

10. Physical assessment/examination
Physical assessment/examination is a
head-to-toe review of each body system
that offers objective information about
the client and allows the nurse to make
clinical judgments.

11. PURPOSES OF PHYSICAL EXAMINATION
To gather baseline data about the client’s
health.
To supplement, confirm, or refute data
obtained in the nursing history.
To confirm and identify nursing diagnoses.
To make clinical judgments about a client’s
changing health status and management.

12. Cont’
 To evaluate the physiological outcomes
of care

16. SKILLS/TECHNIQUES OF PHYSICAL EXAMINATION
1. INSPECTION
 Inspection is the process of observation
with a purpose. The nurse inspects body
parts to detect normal characteristics or
significant physical signs.
 The skill involves use of vision, hearing
and smell senses.

17. Cont.
Principles of inspection include:-
 Inspection is from general to specific.
 Make sure there is good lighting
 Position and expose body parts so that
all surfaces can be viewed.
 Inspect each area for size, shape, colour,
symmetry, position, and abnormalities.

18. Cont.
 If possible, compare each area inspected
with the same area on the opposite side
of the body.
 Use additional light (e.g a penlight) to
inspect body cavities.
 Do not hurry inspection. Pay attention to
details.

19. Cont.
PALPATION
 The body is examined using the sense of
touch to determine the characteristics of
tissues and organs.
 The presence/absence and/or nature of
masses, swelling, spasms, tenderness
and pain, stiffness, enlargement,
elasticity, crepitations, texture and fluid,
temperature can be determined.

20. Cont.
Palpation techniques
 The hands must be warm
 Short fingernails
 Gentle approach
 Ask patient to take slow, deep breaths to
enhance relaxation of muscles
 Tender areas must be palpated last

21. Cont.
a) Light palpation
 Slight pressure is placed on the client’s
skin using fingertips to a depth of 1-2cms
from the body surface.
 Used to ascertain slight tenderness and
muscle tone.

22. Cont.
b) Deep palpation
 Used to examine the condition of organs,
such as those in the abdomen.
 Fingers are stretched out with the
fingertips slightly angled, pressure is
exerted on the skin.

23. Cont.
Ballottement
 Used to determine freely mobile masses
beneath the abdominal wall. Quick
pressure causes solid tissues to move.

24. Cont.
PERCUSSION
 Involves tapping the body with the
fingertips to evaluate the size, borders,
and consistency of body organs and to
discover fluid in body cavities.
 Sound waves are heard as percussion
tones arising from vibrations 4-6cms
deep in the body tissues.

25. Cont.
a) Direct percussion
 Involves striking the body surface directly
with one or two fingers.
 Used to percuss a baby’s thorax or an
adult’s sinuses.

26. Cont.
b) Indirect percussion
 Used for examining the thorax and
abdomen.
 Performed by placing the middle finger of
the non-dominant hand (pleximeter)
firmly against the body surface, keeping
the palm and remaining finger off the
skin.

27. Cont.
 The tip of the middle finger of the
dominant hand (called the plexor) strikes
the base of the distal joint of the
pleximeter.
 Percussion produces 5 types of sound:
tympany, resonance, hyper resonance, -
dullness
- Flatness

28. cont.
c) Fist percussion
 one hand is placed flat on the body
surface and then struck with the lateral
aspect of a clenched fist.
 Primarily used on the lower aspect of the
back to determine the presence of pain
or tenderness due to renal, liver or gall
bladder problems.

29. cont
AUSCULTATION
 Auscultation is listening to sounds
produced by the body.
 The technique is carried out last, except
during the abdominal examination after
the other techniques have provided
information that will assist in interpreting
what is heard.

30. PREPARATION FOR EXAMINATION
1. Infection control
 Standard precautions should be used
throughout the examination as appropriate.
2. Environment
 Privacy
 Adequate lighting
 Eliminate sources of noise
 Warm room

31. Preparation for Examination
3. Equipment
 Cotton applicators
 Drapes
 Nasal speculum
 Reflex/percussion hammer
 Ophthalmoscope
 Otoscope
 Taste testing substances

32. Preparation for Examination
Equipment…
 Flash light with transilluminator
 Disposable vaginal speculum
 Disposable gloves
 Sphygmomanometer
 Stethoscope with diaphragm and bell
 Centimeter ruler
 Gown

33. Preparation for Examination
Equipment…
 Sharp and dull objects for sensory exam
 Visual acuity screening charts for near
and far vision
 Odorous substances
 Penlight
 Lubricant
 Tongue depressor

34. Preparation for Examination
Equipment…
 Cotton buds
 Gauze swabs
 Marking pen
 thermometer
 Tuning fork
 Tape measure

35. Preparation for Examination
Equipment…
 Specimen containers e.g glass slides,
pap smear slides, culture media etc
 Wrist watch.

36. Preparation for Examination
4. Physical preparation of the client.
 Ensure comfort
 Patient to open bowels and empty
bladder
 Client must be dressed in a gown and
draped properly
 Keep client warm

37. Preparation for Examination
4. Physical preparation of the client.
 Positioning
 Psychological care

38. PREPARATION FOR EXAMINATION
Infection control
• Standard precautions should be used
throughout the examination as
appropriate.

39. CONT.
Environment
• Privacy
• Adequate lighting
• Eliminate sources of noise
• Warm room

40. Cont.
Equipment
• Cotton applicators
• Drapes
• Nasal speculum
• Reflex/percussion hammer
• Ophthalmoscope
• Otoscope
• Taste testing substances

41. Cont.
• Flash light with transilluminator
• Disposable vaginal speculum
• Disposable gloves
• Sphygmomanometer
• Stethoscope with diaphragm and bell
• Centimeter ruler
• Gown

42. Equipment…
• Sharp and dull objects for sensory exam
• Visual acuity screening charts for near and
far vision
• Odorous substances
• Penlight
• Lubricant
• Tongue depressor

43. Cont.
• Cotton buds
• Gauze swabs
• Marking pen
• thermometer
• Tuning fork
• Tape measure
• Specimen containers e.g. glass slides,
pap smear slides, culture media etc
• Wrist watch.

44. Cont.
Physical preparation of the client.
• Ensure comfort
• Patient to open bowels and empty bladder
• Client must be dressed in a gown and
draped properly
• Keep client warm
• Positioning
• Psychological care

45. PHYSICAL EXAMINATION SEQUENCE
• The General Survey
• Appearance and Mental Status
• Patient Instructions
• Measurements
• Vital Signs
and Mental Status

71. References
• Smeltzer and Bare (2004): Medical surgical
nursing. Lippincott Williams, Philadelphia.
• Lewis et al (2004): Medical surgical nursing.
Mosby publisher, st Louis, Missouri.
• Potter A.P. and Perry G.A. (2005):
Fundamentals of nursing. Elsevier Mosby, st
Louis, Missouri.
• http://www.slideshare.net/mahmoudgomyozo/
health-assessment-for-nursing-student.
• http://www.slideshare.net/byronrn17/nursing-
fundamentals-health-assessment-
presentation.