The document provides guidance on performing a physical assessment, including objectives, preparation, techniques, and equipment. It discusses: - The 4 basic techniques of inspection, palpation, percussion, and auscultation - Preparing the patient and environment for assessment - Standard precautions to follow - Various positions patients can be in for different parts of the exam - How to perform each technique, including using different types of palpation and percussion - Developmental considerations for different patient populations The overall document serves as a guide for nurses on correctly and thoroughly performing a comprehensive physical assessment of patients.

1. Physical Assessment
Strategies and
Techniques Trimester 1,
2022-2023
Ass.Lect. MUSTAFA ISMAEEL

2. Learning
Objectives
 Apply standard precautions and infection control to
the examination process.
 Correctly obtain baseline data and describe the meaning
of the findings.
 Differentiate various types of equipment used for
physical examination.
 Describe the purpose and the correct use of various
types of equipment used for physical examination.
 Identify the four basic techniques techniques applied
during a physical examination.
 Describe the purpose of various techniques used during
physical examination.
 Demonstrate correct application of the various techniques
used during physical examination.
27-2

3. Assessment
1 Interview
2 Health history
3 Physical examination

4. Introduction
 A head to toe physical assessment is a vital
aspect of nursing  should be done each
time you encounter a patient for the first
time.
 It includes: the assessment of physical,
emotional, and mental aspects of all body
systems as well as the environmental issues
affecting the patient.

5. Physical Assessment
Requires:
√ Technical skills
√ A knowledge base
The skills are
performed
√ One skill at a time
√ In a specific order
5

6. Planning for Physical Assessment
Explain
Equipment
The environment
(setting) and the
client
Use all senses; sight,
smell, touch, and
hearing
6

7. Preparing the Physical Environment
Set the room temperature at a
warm comfortable, quiet, private
level.
Provide sufficient lighting.
 Reduce noise (such as radio, TV or people
talking)
Remove distracting objects.
27-7

8. Preparing the Physical Environment
Maintain the distance between you and
the patient at 4 to 5 feet (twice an arm's
length).
 Arrange equal-status seating.
 Avoid sitting behind a desk or bedside
table placed so that it looks like a barrier.
 Avoid standing.
27-8

9. Standard Precautions during
physical examination
 Wash hands
 Wear a clean gloves
 Wear mask and eye protection
 Follow hospital policy and standard of infection
control
 Change the linens between patient and another
 Prevent injuries due to blood borne pathogens

10. Equipment for PE
Platform scale with height Otoscope- ophthalmoscope
attachment.
Skin fold calipers Nasal speculum
Sphygmomanometer Tongue depressor
Stethoscope with bell and
diaphragm end-pieces
Vaginal speculum
Lubricant
Clean gloves
Thermometer Skin-marking pen.
Penlight Flexible tape measure
Tuning fork Reflex hammer

11. Equipment needed

30. Sitting/ seated
• The client can sit on the edge of a chair or
bed  cover lap & legs
• This position is good for evaluating what ?
(Ball et al. 2015, p. 32)

31. Supine
• The client can lie down on back with the legs
together on the examination table. Arms at
the side.
• A small pillow may be placed under the head
to promote comfort
• This position is good for evaluating what ?

32. Dorsal Recumbent
• The client lies down on the examination table or
bed with the knees bent, the legs separated, and
the feet flat on the table or bed.
• This position is good for evaluating what ?
For rectal and genital areas exam.

33. SIMS' Position
• The client lies on his or her right or left side
with the lower arm placed behind the body
and the upper arm flexed at the shoulder
and elbow.
• This position is good for evaluating what ?
For rectum exam or rectal
temperature.

34. Standing Position
• The client stands still in a normal,
comfortable, resting posture.
• This position allows the examiner to
assess?
posture, balance, gait and the
male genitalia.

35. Prone Position
• The client lies down on his or her abdomen
with the head to the side.
• This position is good for evaluating what ?
Special maneuvers as part of musculoskeletal
exam.

36. Knee-Chest Position [Lateral Recumbent]
• The client kneels on the examination table with
the weight of the body supported by the chest and
knees.
• A90-degree angles should exist between the body and
the hips. A small pillow may be used to provide comfort.
• This position is good for evaluating what ?
Listening to the heart or palpating the spleen

37. Lithotomy Position
• The client lies on his or her back with the
hips at the edge of the examination table
and the feet supported by stirrups.
• This position is good for evaluating what ?
For pelvic examination

38.  Infants and children
 The Toddler and Preschool child
 The school-age child
 Adolescent
 The aging adult
 The Ill person
Developmental Consideration

39. Definition of PE
 Physical examination: the process by which a
nurse investigates the body of a patient for
signs of disease
 Purposes of PE
 It follows taking the medical history and
account of the symptoms as experienced by
the patient.

40. Using your senses in PE
• Vision:
• Smell:
• Hearing
• Touch:

41. Physical examination skills.
1. Inspection
3.
Percussion
2.
Palpation
4.
Auscultation

42. Physical Examination: Four basic techniques
• Always first − do not rush
• Focused inspection − takes time & yields a
surprising amount of data
• Slow and systematic technique
• Start with light palpation −
surface characteristics
• Deep palpation, bimanual palpation
• Need: stethoscope −
diaphragm and bell
• Tapping the patient’s skin −
short, sharp strokes
• Stationary hand
• Striking hand
Palpation
Inspection
Percussion
Auscultation
24

43. N.B.
 The sequence of the physical techniques are
inspection, palpation, percussion, and
auscultation for all system
 Except the abdominal system  Starts by
inspection, auscultate, percuss and palpate

44. 1.
Inspection
 Is the concentrated watching
 Is done first to the patient as a whole;
then for each body system
 Begins the moment you first meet the
person; then as you proceed through
the
examinatio
n

45. 1. Inspection: Principles
1. Take time to observe
2. Position and expose body parts for optimal viewing
3. Ensure good lighting & warm temperature
4. Compare the right and left side of the body
5. Inspect for size, shape, color, symmetry, pattern,
location, position consistency, movement, behavior,
odors

46. 1. Inspection: Equipment
 Otoscope
 Ophthalmoscope
 Penlight
 Nasal Speculum
 Vaginal speculum

47. 2. Palpation
Applies senses of touch and feel
 Using touch to
√ detect variations in normal
√ investigate abnormalities
√ assess various parts of the body
√ helps to confirm findings that are noted on
inspection
 Should be
√ slow &
√ systematic
 Approach:
√ Gentle, calm approach starting with light palpation

48. 2.
Palpation…
In palpation you assess the following characteristics:
 Texture: Quality, Surface, rough / smooth
 Temperature: warm / cold
 Moisture: dry / wet, moist
 Mobility: fixed / movable / still/ vibrating
 Consistency: soft / hard / fluid filled
 Pulse strength: strong/weak/ thready/ bounding
 Size: small / medium / large
 Shape: well defined / irregular
 Degree of tenderness
 organ location, swelling, masses, degree of tenderness,
measurement of chest rising

49. 2. Palpation
Remember:
 Use dry, warm hands
 Any tender areas should be
palpated last
 Be alert; short nails

50. Palpation: hand parts
•Learn to use the various parts of the
fingers. Each one best for what purpose?
 Fingertips
 Grasping action of fingers & thumb
 Dorsal (backs) of hands & fingers
 Base of fingers or ulnar surface of
hand

51. Palpation: Sense of
Touch
FINGERTIPS-
√ Fine tactile discrimination-skin
texture, swelling, lumps
DORSA of hands
√ Temperature detection
BASE of fingers or ULNAR surface of
hands
√ vibration

53. Types of palpation
1. Light palpation
2. Moderate palpation
3. Deep palpation
4. Bimanual palpation

54. Warm your hand
Palpate any tender area Last
Avoid
any situation could cause internal
injury or pain.

55. Palpation:Types of
Palpation
Light Palpation:
 feel for pulses,
 check muscle tone,
 assess for
tenderness,
 surface skin
texture,
 temperature and
 moisture
Moderate Palpation:
 Depress the skin
surface from 1-2
cm.
 To palpate the
body organs and
masses
 - note the
◦ → size,
◦ → consistency and
◦ → mobility of
the structure.

56. Palpation…
Deep Palpation:
 surface depression
between 2.5-5 cm
 = to identify
abdominal organs or
 structures that are:
 → covered by thick muscles
and
abdominal masses

57. Palpation…
Bimanual Palpation:
 use two hands
 → placing one on each
side of the body part (e.g.,
uterus, spleen, and
breast)
 → use one hand to apply
pressure and other to feel
the structure
Bimanual palpation to
capture certain body
parts as breast, kidney,

58. 3. Percussion
 Percussion: tapping (rhythm) the person's skin
with short, sharp strokes to produce sound
waves and assess underlying structures.
 The strokes produce a palpable vibration and
characteristic sound that indicate: The location,
size and density of underlying organ

59. Percussion
= the striking of the body surface with short, sharp
strokes in order to produce:
√ palpable vibrations and
√ characteristic
sounds It relies on the
senses of
√ touch and
√ hearing
It maps out the location and size of an
organ To determine / detect:
√ tissue density &
√ the presence of air, fluids, or solids
√ abnormal superficial mass
Inflamed underlying structure Produces pain
Using the hammer Produces the deep tendon reflex

60. 3- Percussion…
The goal is to
Determine Location
Identify organ shape & position
Determine density
Detecting abnormal masses
Elicit pain
Eliciting reflexes

61. Percussion
Stationary Hand 1
Striking Hand 2
3
4

62. CHARACTERISTIC OF PERCUSSION
NOTES

63. Position of Stationary Hand to Percuss Position of Striking Finger to Percuss
Percussion

64. Types of Percussion
1. Direct (immediate)
2. Blunt
3. Indirect (mediate)
.

65. 3 Types of Percussion: direct vs. indirect vs. blunt
Direct Percussion
• one hand is used &
• the striking finger
of the examiner
touches the surface
being percussed
Indirect Percussion
• two hands are used &
• the plexor (middle
finger) strikes the
finger of the examiner's
other hand, which is in
contact with the body
surface being percussed
Blunt Percussion
• the ulnar surface of
the hand or fist is
used in place of the
fingers to strike the
body surface
• either directly or
indirectly

66. Types of Percussion…
3. Indirect (mediate).
• It involves both hands.
• The striking hand contact
stationary hand fixed on the
person's skin  this yields a
sound and a restrained vibration.

67. Normal percussion sounds
As density increases, the sound of the tone
becomes quieter.
• Solid tissue  a soft tone
• Fluid  a louder tone
• Air  an even louder tone

68. Percussion: Characteristics of the sound waves
Intensity (amplitude)
 √ a loud or soft sound
 √ the louder the sound the greater the amplitude
Pitch (frequency): the number of vibration per second
Quality (timbre), a subjective difference due to a sound’s distinctive
tones.
Duration
√ The length of time the note
linger
Tones
√ Resonance
√ Flatness
√ Dullness
√Tympani
√ Hyper-resonance
 Remember
 √ use dry, warm hands
 √ your nails must be
short
 √ keep the room quiet

69. Indirect Percussion
Term Definition
Intensity
(Amplitude)
How loud or soft a sound is
Duration Length of time
Pitch
(frequency)
Number of vibration (or cycles) per second
Quality
(timbre)
A subjective difference in sound as a result of the
sound’s distinctive overtones

70. Normal percussion sounds
Sound Intensity Pitch length quality Example of
origin
Resonance
(heard over part air)
Loud Low Long Hollow Normal Lung
Hyper resonance
(heard over mostly air)
Very Loud Low Long Booming Emphysema
Tympany
(heard over air)
Loud High Moderate Drum like Gastric bubble
Dullness
(Heard over more solid
tissue)
Medium Medium Moderate Thud like Pleural effusion,
liver
Flatness
Heard over very dense
tissue)
Soft High Short Flat Muscle, bone,
sternum, thigh

71. Percussion: Tones vs. Sounds
Tones Sounds
Resonanc
e
• Heard over: lung
• Clear and hollow
• Heard over : part air and part solid.
• A hollow sound - over normal lung
Hyper-resonance:
• Heard over mostly air.
• A booming sound - lung with emphysema
Tympany • Heard over:
stomach
•Musical and drum
like
• Heard over: air-filled viscous
• A musical or drum like sound produced by stomach
• Puffed out cheek, gastric bubble.
Dullness • Heard over: liver
• Muffled (quiet) thud
(dull sound)
• Heard over: more solid tissue.
• Thud sound produced by dense structures such as liver,
enlarged spleen, or a full bladder.
Flatness • Heard over: bone
• Dead stop
• Heard over: very dense tissue.
• An extremely dull sound like that produced by very
dense (thick) structures such as muscle or bone

72. 4. Auscultation
• Listening to sounds produced by organs such as:
 Heart sounds
 Lungs sounds (movement of air through the Resp. tract)
 Blood vessels (movement of blood through the cvs)
 Intestines (movement of the bowel)
• It is essential to know:
– the characteristics of normal sounds
• WHY: to evaluate your findings

73. Auscultation: Stethoscope
√ does not magnify sounds but blocks out extraneous
room sounds
√ amplify sounds
How to Use
√ Keep instrument clean
√ Warm chest-piece before using
√ Ear pieces − point toward your nose
√ Better to listen under a gown than through a gown
√ Close eyes during listening for more concentration
√ Friction of the end piece from a man’s hairy chest cause
a crackles sound = mimics an abnormal breath sound
Remember:
Become familiar
with bell &
diaphragm
Avoid your own “artifact”

74. 4- Auscultation
Components vs. Type of Sound
Diaphragm
 best for high pitched sounds
 Press firmly on body part
 Heart sound
 Lungs sound
 Bowel sound
Bell
• best for soft, low-pitched
sounds
• Press lightly over body
part
 Abnormal sounds
 Extra heart
sounds or murmur
Bruit (Blood
vessels)

75. The sounds detected using auscultation are
classified according to:
Intensity (loud or soft)
Pitch (high or low)
Duration (length)
Quality (musical, crackling, raspy)
4. Auscultation

76. Standard Precautions
• Review Guidelines (P. 140, Table 8-2)
• Take all steps to avoid any possible transmission of
infection between patients or between patient and
examiner
• SINGLE MOST IMPORTANT STEP  to decrease risk
of microorganism transmission
= to wash your hands

77. REMEMBER: First Impressions
 Start with vital sign assessment
 Determine level of consciousness and orientation
 Assess affect and mood
 Assess grooming and hygiene
 Inspect skin surfaces

78. SITTING
• Warm
• Comfortable
• Quiet
• Private
• Well lit

79. EQUIPMENT
To complete assessment steps, the nurse must use
special equipment

80. CLEAN VS. USED

81. A SAFER ENVIRONMENT
Hand hygiene
• Before and after every physical patient encounter;
• After contact with blood, body fluids, secretions,
and excretions
• After contact with any equipment contaminated
with body fluids
• After removing gloves

82. Summary
• Introduction
• Preparing the Physical Environment
• Standard Precautions during physical examination
• Equipment for PE
• Positioning the client
• Developmental Consideration
• Physical Examination: Four basic techniques
• References

83. • When performing a physical assessment, the technique the nurse
will always use first is:
– palpation.
– inspection.
– percussion.
– auscultation.
When percussing over the liver of a patient, the nurse notices a dull
sound. The nurse should:
• consider this a normal finding.
• palpate this area for an underlying mass.
• reposition the hands and attempt to percuss in this area again.
• consider this an abnormal finding and refer the patient for additional
treatment.

84. References
• Jarvis, C. (2016). Physical examination & health
assessment (7th ed.) St. Louis, Missouri: Saunders
Elsevier. (Chapter 8)
• Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S. &
Stewart, R.W. (2015). Seidel’s guide to physical
examination (8th ed.). St. Louis, Missouri: Mosby,
Saunders/ Elsevier. (Chapter 3)