Hirsutism – excessive body hair in a masculine distributional pattern as

a result of heredity, hormonal dysfunction, porphyria or medication.

Treatment of the specific cause usually stops growth of more hair.

Inspection - is the visual examination that is, assessing by using the

sense of sight. It should be deliberate, purposeful and systematic.

Intensity – amplitude. It refers to the loudness or softness of sound.

Nystagmus – rapid involuntary eye movement. The other at end point

may indicate neurologic impairment. It is an involuntary, rhythmic
movement of the eyes. The oscillations may be horizontal, vertical,
rotary, or mixed.

*Jerking Nystagmus – characterized by faster movements in one

direction than in the opposite direction.

*Pendular Nystagmus – has oscillations that are approximately

equal rate in both directions.

*Labyrinthe Vestibular Nystagmus – most frequently rotary is

usually accompanied by vertigo and nausea.

*Verticular Nystagmus – is considered pathognomonic disease of

the tegmentum of the brain stem.

*Seesaw Nystagmus – in which one eye moves up and the other

down may be observed in bilateral hemianopia.

Nursing Assessment – is identification by a nurse of the needs,

preferences and abilities of the patient. It is an integral component of
holistic care and of the nursing process. Assessment of the dimensions
of a person are used to initiate and maintain individualized plans for
care to promote wellness, prevent illness, restore health and facilitate
coping, thereby facilitating an optimal level of wellness.

It has two components:

*Nursing History
*Nursing Examination

It is a continuous and ongoing component of caring for others.

Olfaction – the act of smelling; the sense of smell

Palpation – is the examination of the body using the sense of touch.
The pads of the fingers are used because their concentration of nerve
endings makes them highly sensitive to tactile discrimination. It is used
to determine texture, temperature, vibration, position, size,
consistency and mobility of organs or masses, distention, pulsation and
the presence of pain upon pressure.

Percussion – is the act striking the body surface to elicit sounds that
can be heard or vibrations that can be felt.

Physical Assessment – the part of the health assessment representing

a synthesis of the information obtained in a physical examination. It
involves the detailed examination of the body from head to toe using
the techniques of observation, palpation, inspection, percussion and
auscultation.

Pitch – is the frequency of the vibrations. It refers to the highness or

the lowness of sound. It is also the quality of a tone or a sound
dependent on the perception of the relative rapidity of the vibrations
by which it is produced.

Pleximeter – a mediating device such as a percussor or finger used to

receive light taps in percussion.

Plexor – using the tip of the flexed middle finger of the other hand. It is
a stroke or to strike. A device used to tap a mediating device (i.e.
pleximeter) or to tap the body directly during percussion.

Vocal Fremitus – the vibration of the chest wall as a person speaks or

sings that allows the person’s voice to be heard by auscultation of the
chest with a stethoscope.

SOURCE:

• MOSBY’S POCKET DICTIONARY OF MEDICINE, NURSING AND

ALLIED HEALTH (FOURTH EDITION)
• FUNDAMENTALS OF NURSING (KOZIER AND ERB)
Purposes of Physical Health Assessment

• To obtain baseline data about the client’s functional abilities

• To supplement, confirm, or refute data obtained in the nursing
history
• To obtain data that will help establish diagnoses and plan of
care
• To obtain the physiologic outcomes of health care and thus
the progress of a client’s health problem
• To make clinical judgments about a client’s health status
• To identify areas for health promotion and disease prevention
• To determine the location of the problem
• To determine the onset and duration of the problem
• To determine the quality ( for pain, it might be sharp, dull
piercing, throbbing)
• To determine the intensity or severity
• To determine other factors affecting the symptom
• To determine the patient’s perception of the problem or
symptom, which may range from insignificant to requiring a
career change to life-threatening

SOURCE:

MODULES FOR BASIC NURSING SKILLS, 7TH EDITION BY ELLIS, J.R. AND
BENTZ P.M.
Equipments:

Pen and paper - used for documenting observations

Marking pen – used to mark names and location of certain body parts
and etc.

Clean Gloves – sterile or clean, fitted coverings for the hands usually
with separate sheath for each finger and thumb

*Clean Gloves are used to protect health care personnel from urine,
stool, blood, saliva and drainage from wounds and lesions of patients
and to protect patients from health care personnel who may have cuts.

*Sterile Gloves are worn when there is contact with sterile instruments
or a patient’s sterile part.
Penlight or Flashlight – used to provide focused light during the
assessment at any point at which the examiner desires one.

*The penlight has many uses during a physical assessment. It may be

used to illuminate the inside mouth or the nose, highlight a lesion, or
evaluate papillary constriction. It is most important that the penlight
have a bright light source. If the examiner does not have a penlight,
the light transmitted from the otoscope may be substituted as a
focused light source.

Scale - used to measure a person’s total body weight

• if unavailable, you may need to walk the patient to a central
location if a scale cannot be brought to the patient’s room

Thermometer – used to assess the functional status of the body’s

tissues and cells

Four types of thermometers used to evaluate body temperature:

1. Mercury-in-glass
The most inexpensive, consists of a glass tube sealed at one end with
mercury – filled with bulb at the other. Exposure of the bulb to heat
causes mercury to rise in the enclosed tube. These thermometers may
be calibrated in either Fahrenheit or Celsius and may be used to
measure oral, axillary or rectal temperature.

2. Electronic Thermometer
It consists of a battery-powered display unit, a thin wire cord, and a
temperature sensitive probe. The probe must be covered with a
disposable sheath before use.

3. Tympanic Thermometer
This is a very popular thermometer in all clinical settings. Taking the
client’s temperature requires less than 5 seconds and is very easy.
This device works when the temperature-sensitive probe, covered with
a disposable sheath is inserted into the client’s ear. The probe
measures the temperature of the blood flowing near the tympanic
membrane.
 4. Disposable, single-use thermometer strips
These are thin strips of plastic with chemically impregnated paper.
They are frequently used for temperature evaluation in children.
Chemical dots of the strip change color, representing the highest
temperature. The strips are configured so that the examiner can
identify the highest colored dot and correlate that with the
temperature reading.

Sphygmomanometer – an instrument for indirect measurement of

blood pressure. It consists of a inflatable cuff that fits around a limb, a
bulb for controlling air pressure within the cuff and a mercury or
aneroid manometer. Pressure in the compressed arteries is estimated
by the column of mercury it balances when the cuff is inflated.
Tongue depressor – tongue blade; used to displace the cheek laterally
and expose the surface.

Stethoscope – used to hear sounds within the body that is not easily
heard with the naked ear.

There are several types of stethoscopes:

• Acoustic Stethoscope – a closed cylinder that transmits sound
waves from the source through the tube to the examiner’s
ears. It does not magnify sound but, by blocking our
extraneous room noise. It permits difficult-to-hear sounds can
be more heard.
• Electronic Stethoscope – a stethoscope which is almost the
same as the acoustic. But, it requires conversion of acoustic
sound waves to electrical signals which can then be amplified
and processed for optimal listening.

• Recording Stethoscope – an electronic stethoscope that is

connect to a direct audio output that can be used with an
external recording device, such as a laptop or MP3 recorder.
The same connection can be used to listen to the previously-
recorded auscultation through the stethoscope headphones,
allowing for more detailed study for general research as well
as evaluation and consultation regarding a particular patient's
condition and telemedicine, or remote diagnosis.
• Fetal Stethoscope - A fetal stethoscope or fetoscope is an
acoustic stethoscope shaped like a listening trumpet. It is
placed against the abdomen of a pregnant woman to listen to
the heart sounds of the fetus. The fetal stethoscope is also
known as a Pinard's stethoscope or a pinard, after French
obstetrician Adolphe Pinard (1844–1934).