2. HEALTHCARE PROCESS
Assessment
Diagnosis
Evaluation
Implementation
Planning

3. It is the FIRST STEP of the Health Care Process. The following are its key
components:
 Health Interview
 Physical Examination
 Laboratory or Diagnostic Examination
 Records Review

4. A systematic way of
collecting objective data
from a client using the four
examination techniques in
order to assess or identify
current health status.
Different Approaches:
 Cephalocaudal
 Proximodistal
 Mediolateral
 Outer to Inner
/External to Internal

5.  Obtain physical data about the client’s functional
abilities
 Supplement, confirm, or refute data obtained in the
client’s health history
 Obtain data that will help the nurse establish
diagnoses and plan the client’s care.
 Evaluate the physiologic outcomes of health care and
thus the progress of a patient’s health problem
 To identify areas for health promotion and disease
prevention

6. METHODS OF EXAMINATION
I.P.P.A. Technique

7. INSPECTION
Visual examination of the
patient done in a methodical,
deliberate, purposeful, and
systematic manner.
Assess moisture, color and texture of the body
surfaces, as well as shape, position, size, color,
and symmetry of the body.

8. PALPATION
Examination of the body using the sense of touch.
The use of hand to touch and feel the patient’s skin,
organs, mass, and other delineated structures in the
body
Assess temperature; turgor; texture; moisture; vibrations;
position, size, shape, consistency and mobility of organ or
masses; distention; pulsation; and the presence of pain
upon pressure(tenderness)

9. Palmar surfaces of
the examiner's
fingertips and finger
pads are used for
discriminatory
sensation, such as
texture, vibration,
presence of fluid, or
size and consistency
of a mass
The dorsum, or
back of the hand,
is used to assess
surface
temperature.

10. LIGHT PALPATION
Place the hand with fingers
together parallel to the skin
surface or area being
palpated, while moving the
hand in circle.
Light
palpation,
light
pressure is applied by
placing the fingers together
and depressing the skin and
underlying structures about
1/2 inch (1 cm).
Use to check muscle tone
and to assess for tenderness

11. Deep palpation is used with
caution because pressure
can damage internal organs.
The skin and underlying
structures are depressed
about 1 inch (2 cm).
To identify abdominal organs
and abdominal masses.
Two – handed deep palpation
place the fingers of one hand
on top of those of the other.
The top hand applies pressure
while the lower hand remains
relaxed to perceive the tactile
sensation.

12. Deep Palpation is done
with two hands
(bimanually) or one hand.
Usually not indicated in clients who
have acute abdominal pain or pain
that is not yet diagnosed
Deep Palpation using lower hand
to support the body while
the upper hand palpates the organ

13. PERCUSSION
Striking of the body surface with short, sharp
strokes in order to elicit palpable vibrations and
characteristic sound.
It is used to determine the location, size, shape,
and density of underlying structures; to detect
the presence of air or fluid in a body space; and
to elicit tenderness.

14. TYPES OF
PERCUSSION
DIRECT PERCUSSION
- Using one hand to strike
the surface of the body
Jing Salaria, RN,MD

15. TYPES OF PERCUSSION
INDIRECT PERCUSSION
Using the finger of the one
hand to tap the finger of the
other hand.
plexor strikes the finger of the
examiner’s other hand, which is in
contact with the body surface being
percussed (pleximeter- the middle
finger of the nondominant hand).
Jing Salaria, RN,MD

16. Percussion is used to access the location, shape, size, and density of tissues.
(Left) The non-dominant hand is placed directly on the area to be percussed,
and the middle finger is placed firmly on the body surface.
(Right) The tip of the middle finger of the dominant hand strikes the joint of the
middle finger of the opposite hand

18. AUSCULTATION
Listening to sounds produced within the body.

19. Stethoscope bell and diaphragm. Use the diaphragm of the stethoscope to
detect high-pitched sounds. The diaphragm should be at least 1.5 inches
wide for adults and smaller for children. Hold the diaphragm firmly against
the body part being auscultated. Use the bell of the stethoscope to detect
low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell
lightly against the body part being auscultated.

20.  Introduce self to the client. Verify his identity. Explain the purpose why such
procedure is necessary and how he could cooperate (i.e. positioning).
 Help him put on a clean gown and offer a bedpan or a urinal to empty his bladder.
 Ensure privacy by closing the doors or pulling the curtains around him.
 Invite a relative or a significant other to stay with the client, as necessary.

21.  Provide adequate lighting.
 Gather the equipment:
height chart, weighing scale, Snellen’s chart, penlight, card board, sterile
gloves, tongue depressor, 4x4 Gauze, tuning fork, stethoscope, wrist watch,
tape
measure, marker/pencil, record
sheet & waste receptacle.
 Ensure the examination table is at a comfortable working height. Perform hand
hygiene.

22. Materials Needed

23. Position and drape the client
appropriately


24. STANDING = assessment of posture, gait & balance
SITTING
= used to take vital signs
DORSAL RECUMBENT
= used in patient having difficulty maintaining
supine position

25. SUPINE
SIM’s = assessment of rectum and vagina
PRONE = assessment of hip and posterior thorax

26. LITHOTOMY
= assessment of female
rectum and vagina.
(for a brief period only)
KNEE-CHEST
= assessment of
rectal area (for brief
period only)

27. SALIENT POINTS:
 Subjective data should be documented in patient’s
own words.
 Objective data should be specific.
generalizations and judgmental phrases
No
 Data gathered in the nursing health history may be
confirmed or refuted by the nurse during the
interview or the physical assessment

28. PROCEDURE
I. Obtain vital signs & anthropometric measurement
(height/weight).

29. PROCEDURE
I. Obtain vital signs & anthropometric measurement
(height/weight).
NOTE:
Given:
IBW= A-B
where, A= ht. in cm -100
B= (A) x 0.10
C= (IBW) x 0.10
N Range = IBW-C (Lower Limit)
= IBW+C (Upper Limit)
BMI= wt. in kg/ ht. in (m)2

30. BMI Interpretation
<18 = Underweight
18-24 = Normal
>25 = Obese

31. Example computation
A = 134.62 -100
= 34.62
B = 34.62 x 0.10
= 3.46
IBW = 34.62 – 3.46
= 31.16

32. Example computation
To get the normal range:
C = 31.16 x0.10
= 3.12
Upper limit = 31.16 + 3.12
= 34.28
Lower limit = 31.16 – 3.12
= 28.04

33. Example computation
BMI = 55 / (1.346)2
= 29.7  30

34. II. Assess the General
Appearance:
A. Body build, height and
weight in relation to age,
lifestyle and health
B. Posture and Gait
C. Over-all hygiene and
grooming
D. Body and breath odor
E. Signs of distress
F. Mood / Affect
G. Quantity, Quality &
Organization of Speech
H. Relevance & Organization
of Thoughts

35. Scoliosis
Kyphosis
Lordosis

36. ASSESSMENT OF THE
INTEGUMENTARY SYSTEM
• Skin
• Nails
• Hair
• Scalp

37. Part 1. Anatomical Parts of the Skin

38. 1. SKIN COLOR
Normal
Deviations from Normal
• Varies from light • Pallor
to deep brown, • Cyanosis
from ruddy pink • Jaundice
to light pink
• Erythema

39. 2. Skin Color Uniformity
Normal
• Generally uniform
except in areas
exposed to sun; areas
of lighter pigmentation
in dark skinned

40. 2. Skin Color Uniformity
Deviations
• Hyperpigmentation
 Birthmarks – abnormal
distribution of the melanin

41. 2. Skin Color Uniformity
Deviations
• Hypopigmentation
 Vitiligo due to destruction
of melanocytes in the area
 Albinism – complete or
partial lack of melanin

42. 3. Assess for Edema
• Excessive accumulation of fluid in body tissues
• Note the degree to which the skin remains
indented or pitted when pressed by a finger
Edema scale
1+ = barely detectable
2+ = indentation of less than 5 mm
3+ = indentation of 5 to 10 mm
4+ = indentation of more than 10 mm
ANASARCA

43. 4. Inspect, palpate, and describe skin
lesions
• According to type/structure, color, number,
distribution, location
TYPES:
Primary skin lesions – abscess, ulcer, tumor,
and open wound
Secondary skin lesion  crusts, kelloids,
scars, etc.

44. Primary and Secondary
Lesions

45. PRIMARY SKIN LESIONS

46. PRIMARY SKIN LESIONS

47. PRIMARY SKIN LESIONS

48. Cyst

50. 5. Observe and palpate skin
moisture
• Done by touching or palpating the skin of the
extremities
Normal
 Moist
Deviations
 Excessively dry

51. 6. Palpate skin temperature
Normal
Deviations
• Uniform; within • Generalized or localized;
normal range
hyperthermic or
hypothermic

52. 7. Palpate Skin Turgor
• Refers to fullness or elasticity
• Indicative of status of hydration of the body.
• Assessed by pinching the skin on an extremity.
Normal
Deviations
 When pinched, skin 
Skins stays pinched or
springs back to
indented or moves back
previous state in less
than 3 seconds
slowly.

53.  Note that this is not as valid in elderly people as in
younger people because skin elasticity decreases
with age; thus, other parameters should be used,
such as: I&O, daily weight

54. Let’s have a break…

55. 1. Inspect fingernail plate shape,
curvature & angle
Normal
– Colorless and a
convex curve.
Deviations from Normal
• Concave
• Clubbed fingernails (>180O) due
to chronic tissue hypoxia
– Angle between nail
and nail bed:
usually 160o

56. Examples of Nail Abnormalities

57. 2. Inspect and palpate finger & toenail
bed color
Normal
• Highly vascular and
pink in light skinned;
dark skinned may be
brown or black
Deviations from N
• Bluish or purplish
tinges;
• Pale

58. 3. Inspect tissues surrounding nails
Normal
• Intact epidermis
Deviations from N
• Hangnails (paronychia =
ingrown nail)
• Inflammation of
surrounding tissues

59. 4. Perform Blanch Test/Capillary
refill test
Normal
• Prompt return or pink
or usual color, less
than 2-4 seconds
Deviations
• Delayed return of pink
or usual color, usually
>4 seconds

60. (Skull and Face)

61. Part 3. Structures of the Skull

62. 1. Inspect skull size, shape,
proportion & symmetry
Normal
Deviations from Normal
• Round and is of normal
• Disproportionate
size or head circumference • Asymmetric prominences
Normocephalic
• Increased head circumference
• In proportion w/ gross
body structure
• Frontal, parietal and
• Square-head
occipital prominences;
• Bulging / depressed bone
• Smooth skull contour

63. 2. Palpate skull nodules or masses
& depression
Normal
Deviations from Normal
• Smooth, uniform
• Sebaceous cysts; local
consistency; absence deformities from
of nodules/masses
trauma; masses;
or depression
nodules

64. 3. Inspect facial features
Normal
• Symmetric facial
features;
• Eye brow hair equally
distributed
• palpebral fissures equal
in size;
• symmetric nasolabial
folds
Deviations from N
• Asymmetric features
• Increased facial hair; thinning
of eyebrows; exopthalmos;
moon face;

65. 4. Inspect eyes for edema and
hollowness
Normal
• No edema, eyes not
sunken

66. 4. Inspect eyes for edema and
hollowness
Sunken eyes, cheeks
and temples
(indicative of
dehydration,
starvation, and
illness)
Deviations
• Periorbital edema

67. 5. Inspect symmetry of facial
movements
Normal
• Symmetric facial
movements
Deviations
• Asymmetric facial
movements, drooping of
lower eyelid and mouth;
involuntary facial movement
Raise or lower both
eyebrows
Blink both eyes
Close both eyes tightly
Smile and show the
teeth
Frown
Puff the cheeks

68. Assessing the Hair

69. 1. Evenness of growth of
hair over scalp
Normal
• Evenly distributed
Deviations from Normal
• Patches of hair loss, i.e.
alopecia

70. 2. Hair thickness or thinness
Normal
• Thick Hair
Deviations from Normal
• Very thin hair (hypothyroidism)

71. 3. Hair Texture and
Oiliness
Normal
Deviations from Normal
 Silky, resilient hair  Brittle hair (poor nutrition)
 excessively oily or dry hair

72. 4. Note presence of
infection / infestation
Normal
• No infection/
infestation
Deviations from Normal
• Flaking, sores, lice, nits