PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
Nursing Assessment
1. Part of Nursing Process
2. Nurses use physical assessment skills to:
a) Obtain baseline data and expand the data base from which subsequent phases of the
nursing process can evolve
b) To identify and manage a variety of patient problems (actual and potential)
c) Evaluate the effectiveness of nursing care
d) Enhance the nurse-patient relationship
e) Make clinical judgments
Gathering Data
Subjective data - Said by the client (S)
Objective data - Observed by the nurse (O)
Document: SOAPIER
Assessment Techniques:
The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the
abdomen which is Inspect – Auscultation – Percuss – Palpate.
A. Inspection – critical observation *always first*
1. Take time to “observe” with eyes, ears, nose (all senses)
2. Use good lighting
3. Look at color, shape, symmetry, position
4. Observe for odors from skin, breath, wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniques
B. Palpation – light and deep touch
1. Back of hand (dorsal aspect) to assess skin temperature
2. Fingers to assess texture, moisture, areas of tenderness
3. Assess size, shape, and consistency of lesions and organs
4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep
C. Percussion – sounds produced by striking body surface
1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
2. Used to determine size and shape of underlying structures by establishing their borders and
indicates if tissue is air-filled, fluid-filled, or solid
3. Action is performed in the wrist.
D. Auscultation – listening to sounds produced by the body
1. Direct auscultation – sounds are audible without stethoscope
2. Indirect auscultation – uses stethoscope
3. Know how to use stethoscope properly [practice skill]
4. Fine-tune your ears to pick up subtle changes [practice skill]
5. Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]
6. Flat diaphragm picks up high-pitched respiratory sounds best.
7. Bell picks up low pitched sounds such as heart murmurs.
8. Practice using BOTH diaphragms
Page 1 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
, PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
General Assessment
A general survey is an overall review or first impression a nurse has of a person’s well being. This is
done head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. General
surveying is visual observation and encompasses the following.
Appearance appears to be reported age;
sexual development appropriate;
alert & oriented;
facial features symmetric;
no signs of acute distress
Body structure/mobility weight and height within normal range (refer to Center for Disease Control
and Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age and
gender forms [children]);
body parts equal bilaterally;
stands erect,
sits comfortably;
gait is coordinated;
walk is smooth and well balanced;
full mobility of joints
Behavior maintains eye contact with appropriate expressions;
comfortable and cooperative;
speech clear;
clothing appropriate to climate;
looks clean and fit;
appears clean and well-groomed
Deviations from what would generally be considered to be normal or expected should be documented
and may require further evaluation or action, including a report and/or referral.
Standardized and routine screening such as audiometric screening, scoliosis and vision screening
using the Snellen Test are usually discussed in General Survey areas.
***************************************************************************************************
Health History
A patient history should be done as indicated by the age specific prevention guidelines, usually set forth
by Center for Disease Control and Prevention (CDC), American Medical Association, American
Association of Pediatrics, and National Association of Pediatric Nurse Practitioners. The Healthy
People website (www.healthypeople.gov) provides an excellent source to determine benchmarks for
healthy living across the life span.
A comprehensive history, including chief complaint or reason for the visit, a complete review of
systems, and a complete past family and/or social history should be obtained on the first encounter with
a patient, regardless of setting and by a registered nurse. The history should be age and sex
appropriate and include all the necessary questions to enable an adequate delivery of services
according to prevention guidelines, scope of practice, patient need, visit requirement, and/or request.
Usually, completing a provider based Health History and Physical Examination Form will assist in the
assessment of the patient’s past and current health and behavior risk status. Certain health problems,
which may be identified on a health history, are more common in specific age groups and gender.
Page 2 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
, PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
An interval history (including an update of complaints, reason for visit, review of systems and past
family and/or social history) should be done. Usually family health histories are completed across three
generations looking specifically for patterns in genetic issues that negatively impact quality of life.
The health history gives picture of the patient’s current health and behavior risk status. Additional
information than what is on a form may be required depending on the specialized service(s) to be
provided or if the person presents with special needs or conditions. So a health history maybe may be
problem focused, expanded problem focused, detailed, or comprehensive. Regardless, documentation
must be completed for each visit and/or assessment.
Mental status evaluation may be done while doing health history (see neuro review).
***********************************************************************************************
Physical Examination
A comprehensive physical examination should be performed according to age specific preventive
health guidelines. American Medical Association clinical practice guidelines recognize the following
body areas and organ systems for purpose of the examination:
◊ Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen;
genitalia, groin, buttocks; Back (including spine); and each extremity.
◊ Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat;
Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal; Dermatological; Neurological;
Psychiatric; Hematological/lymphatic/immunological
◊ Integumentary: Both overall body and organ systems should have skin assessments integrated
into them. Integument includes skin, hair and nails.
Normal and abnormal findings should be recorded on a health history and physical examination form.
***********************************************************************************
Measurements
Body measurements include length or height, weight, and head circumference for children from birth to
36 months of age. Thereafter, body measurements include height and weight. The assessment of
hearing, speech and vision are also measurements of an individual’s function in these areas. The
Denver Development Screening Test measures an infant’s and young child’s gross motor, language,
fine motor-adaptive and personal-social development milestones. If developmental delay is suspected
based on an assessment of a parent’s development/behavior concern or if delays are suspected after a
screening of development benchmarks, a written referral is to a physician or pediatric nurse practitioner
is imperative.
A patient’s measurements can be compared with a standard, expected, or predictable measurement for
age and gender. Deviation from standards helps identify significant conditions requiring close
monitoring or referral to a physician or pediatric nurse practitioner.
The significance of measurements and actions to take when they deviate from normal expectations are
age-specific.
Page 3 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
, PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
How to measure Height:
1. Obtain height by measuring the recumbent length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary
headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used.
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are
extended. The foot piece is moved until it is firmly against the child’s heels. Read and
record the measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head
should be held by the parent and the knees held so that the hips and knees are extended,
mark the flat surface at the top of the head and tip of the heels. Move child and measure
the distance between the marks with a tape measure. Read and record the measurement
to the nearest 1/8 inch.
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36
months growth chart. When a standing height is obtained for a two year old, plot the finding on
the 2 year to 18 year chart. After plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer according to findings.
3. Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults,
using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have
the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees
are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The
flat surface of the stadiometer is lowered until it touches the crown of the head, compress the
hair. A measuring rod attached to a weight scale should not be used.
Measuring weight:
1. Balance beam or digital scales should be used to weigh patients of all ages. Spring type
scales are not acceptable. CDC recommends that all scales should be zero balanced and
calibrated. Scales must be checked for accuracy on an annual basis and calibrated in
accordance with manufacturer’s instructions.
2. Prior to obtaining weight measurements, make sure the scale is “zeroed”.
3. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing
outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal
clothing.
4. Place the patient in the middle of the scale. Read the measurement and record results
immediately. Plot measurements on age and gender specific growth charts and evaluate
accordingly
Measuring Body Mass Index.
1. The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a
weight-related illness.
2. Instructions for obtaining the BMI are included within the chart in this section for adults. To
calculate BMI for children, see BMI Tables for Children and Adolescents for guidance.
Measuring Head and Chest Circumference.
1. Obtain head circumference measurement on children from birth to 36 months of age by
extending a non-stretchable measuring tape around the broadest part of the child’s head.
For greatest accuracy, the tape is placed three times, with a reading taken at the right side, at
the left side, and at the mid-forehead, and the greatest circumference is plotted. The tape
should be pulled to adequately compress the hair.
2. Head circumference should be measured each visit.
3. Chest: This is measured at the nipple line.
4. In a newborn, the head circumference will be about 2 cm larger than the chest circumference. As
the child ages, the chest circumference becomes larger than the head circumference.
Page 4 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
Nursing Assessment
1. Part of Nursing Process
2. Nurses use physical assessment skills to:
a) Obtain baseline data and expand the data base from which subsequent phases of the
nursing process can evolve
b) To identify and manage a variety of patient problems (actual and potential)
c) Evaluate the effectiveness of nursing care
d) Enhance the nurse-patient relationship
e) Make clinical judgments
Gathering Data
Subjective data - Said by the client (S)
Objective data - Observed by the nurse (O)
Document: SOAPIER
Assessment Techniques:
The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the
abdomen which is Inspect – Auscultation – Percuss – Palpate.
A. Inspection – critical observation *always first*
1. Take time to “observe” with eyes, ears, nose (all senses)
2. Use good lighting
3. Look at color, shape, symmetry, position
4. Observe for odors from skin, breath, wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniques
B. Palpation – light and deep touch
1. Back of hand (dorsal aspect) to assess skin temperature
2. Fingers to assess texture, moisture, areas of tenderness
3. Assess size, shape, and consistency of lesions and organs
4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep
C. Percussion – sounds produced by striking body surface
1. Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
2. Used to determine size and shape of underlying structures by establishing their borders and
indicates if tissue is air-filled, fluid-filled, or solid
3. Action is performed in the wrist.
D. Auscultation – listening to sounds produced by the body
1. Direct auscultation – sounds are audible without stethoscope
2. Indirect auscultation – uses stethoscope
3. Know how to use stethoscope properly [practice skill]
4. Fine-tune your ears to pick up subtle changes [practice skill]
5. Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]
6. Flat diaphragm picks up high-pitched respiratory sounds best.
7. Bell picks up low pitched sounds such as heart murmurs.
8. Practice using BOTH diaphragms
Page 1 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
, PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
General Assessment
A general survey is an overall review or first impression a nurse has of a person’s well being. This is
done head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. General
surveying is visual observation and encompasses the following.
Appearance appears to be reported age;
sexual development appropriate;
alert & oriented;
facial features symmetric;
no signs of acute distress
Body structure/mobility weight and height within normal range (refer to Center for Disease Control
and Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age and
gender forms [children]);
body parts equal bilaterally;
stands erect,
sits comfortably;
gait is coordinated;
walk is smooth and well balanced;
full mobility of joints
Behavior maintains eye contact with appropriate expressions;
comfortable and cooperative;
speech clear;
clothing appropriate to climate;
looks clean and fit;
appears clean and well-groomed
Deviations from what would generally be considered to be normal or expected should be documented
and may require further evaluation or action, including a report and/or referral.
Standardized and routine screening such as audiometric screening, scoliosis and vision screening
using the Snellen Test are usually discussed in General Survey areas.
***************************************************************************************************
Health History
A patient history should be done as indicated by the age specific prevention guidelines, usually set forth
by Center for Disease Control and Prevention (CDC), American Medical Association, American
Association of Pediatrics, and National Association of Pediatric Nurse Practitioners. The Healthy
People website (www.healthypeople.gov) provides an excellent source to determine benchmarks for
healthy living across the life span.
A comprehensive history, including chief complaint or reason for the visit, a complete review of
systems, and a complete past family and/or social history should be obtained on the first encounter with
a patient, regardless of setting and by a registered nurse. The history should be age and sex
appropriate and include all the necessary questions to enable an adequate delivery of services
according to prevention guidelines, scope of practice, patient need, visit requirement, and/or request.
Usually, completing a provider based Health History and Physical Examination Form will assist in the
assessment of the patient’s past and current health and behavior risk status. Certain health problems,
which may be identified on a health history, are more common in specific age groups and gender.
Page 2 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
, PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
An interval history (including an update of complaints, reason for visit, review of systems and past
family and/or social history) should be done. Usually family health histories are completed across three
generations looking specifically for patterns in genetic issues that negatively impact quality of life.
The health history gives picture of the patient’s current health and behavior risk status. Additional
information than what is on a form may be required depending on the specialized service(s) to be
provided or if the person presents with special needs or conditions. So a health history maybe may be
problem focused, expanded problem focused, detailed, or comprehensive. Regardless, documentation
must be completed for each visit and/or assessment.
Mental status evaluation may be done while doing health history (see neuro review).
***********************************************************************************************
Physical Examination
A comprehensive physical examination should be performed according to age specific preventive
health guidelines. American Medical Association clinical practice guidelines recognize the following
body areas and organ systems for purpose of the examination:
◊ Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen;
genitalia, groin, buttocks; Back (including spine); and each extremity.
◊ Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat;
Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal; Dermatological; Neurological;
Psychiatric; Hematological/lymphatic/immunological
◊ Integumentary: Both overall body and organ systems should have skin assessments integrated
into them. Integument includes skin, hair and nails.
Normal and abnormal findings should be recorded on a health history and physical examination form.
***********************************************************************************
Measurements
Body measurements include length or height, weight, and head circumference for children from birth to
36 months of age. Thereafter, body measurements include height and weight. The assessment of
hearing, speech and vision are also measurements of an individual’s function in these areas. The
Denver Development Screening Test measures an infant’s and young child’s gross motor, language,
fine motor-adaptive and personal-social development milestones. If developmental delay is suspected
based on an assessment of a parent’s development/behavior concern or if delays are suspected after a
screening of development benchmarks, a written referral is to a physician or pediatric nurse practitioner
is imperative.
A patient’s measurements can be compared with a standard, expected, or predictable measurement for
age and gender. Deviation from standards helps identify significant conditions requiring close
monitoring or referral to a physician or pediatric nurse practitioner.
The significance of measurements and actions to take when they deviate from normal expectations are
age-specific.
Page 3 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
, PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE
How to measure Height:
1. Obtain height by measuring the recumbent length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary
headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used.
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are
extended. The foot piece is moved until it is firmly against the child’s heels. Read and
record the measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head
should be held by the parent and the knees held so that the hips and knees are extended,
mark the flat surface at the top of the head and tip of the heels. Move child and measure
the distance between the marks with a tape measure. Read and record the measurement
to the nearest 1/8 inch.
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36
months growth chart. When a standing height is obtained for a two year old, plot the finding on
the 2 year to 18 year chart. After plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer according to findings.
3. Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults,
using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have
the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees
are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The
flat surface of the stadiometer is lowered until it touches the crown of the head, compress the
hair. A measuring rod attached to a weight scale should not be used.
Measuring weight:
1. Balance beam or digital scales should be used to weigh patients of all ages. Spring type
scales are not acceptable. CDC recommends that all scales should be zero balanced and
calibrated. Scales must be checked for accuracy on an annual basis and calibrated in
accordance with manufacturer’s instructions.
2. Prior to obtaining weight measurements, make sure the scale is “zeroed”.
3. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing
outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal
clothing.
4. Place the patient in the middle of the scale. Read the measurement and record results
immediately. Plot measurements on age and gender specific growth charts and evaluate
accordingly
Measuring Body Mass Index.
1. The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a
weight-related illness.
2. Instructions for obtaining the BMI are included within the chart in this section for adults. To
calculate BMI for children, see BMI Tables for Children and Adolescents for guidance.
Measuring Head and Chest Circumference.
1. Obtain head circumference measurement on children from birth to 36 months of age by
extending a non-stretchable measuring tape around the broadest part of the child’s head.
For greatest accuracy, the tape is placed three times, with a reading taken at the right side, at
the left side, and at the mid-forehead, and the greatest circumference is plotted. The tape
should be pulled to adequately compress the hair.
2. Head circumference should be measured each visit.
3. Chest: This is measured at the nipple line.
4. In a newborn, the head circumference will be about 2 cm larger than the chest circumference. As
the child ages, the chest circumference becomes larger than the head circumference.
Page 4 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.
by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012
