Midwife Licensure Exam Health Assessment — Health History & Physical Examination TechniquesSummary

Information reported directly by the client that only they can know and describe. Examples include pain ('My chest feels like an elephant is sitting on it'), nausea, dizziness, fatigue, or anxiety. Subjective data cannot be verified by the nurse's direct observation but is critically important because it reflects the client's perception of their health status. In the nursing process, subjective data shapes the Assessment phase and feeds into problem identification and nursing diagnosis formulation.

Observable, measurable information gathered through the nurse's senses and use of instruments. Examples include vital signs (temperature 38.5°C, pulse 102/min), physical findings (a 2 cm × 3 cm red, warm, tender swelling over the right knee), skin color (pallor, cyanosis, jaundice), respiratory rate, and laboratory values. Objective data can be verified by any trained observer and provides concrete evidence for clinical decision-making.

Initial (comprehensive) assessment involves a complete head-to-toe history and examination performed on admission to establish baseline data and identify all actual and potential health problems. Focused (problem-oriented) assessment targets a specific complaint or system—for example, a respiratory-focused assessment for a client reporting dyspnea. Emergency assessment uses the ABCs (Airway, Breathing, Circulation) priority in acute situations. Ongoing assessment monitors changes in status over hours, days, or weeks. Shift-to-shift assessment, performed by each shift's nurse, tracks immediate changes in vital signs, mental status, or symptoms and is critical in busy Philippine hospital settings where handovers are frequent.

The preparatory phase involves reviewing available records, ensuring privacy, and preparing the environment. The introductory phase establishes rapport, introduces the nurse, explains the purpose, and obtains consent—critical in the Philippine context where respect (pagpapahalaga) and informed consent are valued. The working phase systematically collects data using therapeutic communication. The closing phase summarizes findings, invites the client to add information, and explains next steps. A fifth phase (follow-up) may include clarifying ambiguous information or revisiting the client's concerns. Each phase sets the tone for the interview and the nurse–client relationship.

Open-ended questions ('Tell me about your pain'; 'How has this affected your daily life?') encourage narrative responses and rich detail. Closed-ended questions ('Do you have chest pain?' 'How many times did you vomit?') elicit specific facts and are useful for clarifying. Reflection ('You seem worried') and clarification ('When you say shortness of breath, do you mean you can't catch your breath when you walk?') deepen understanding. Paraphrasing restates in the nurse's own words what the client has said. Focusing directs attention to the most relevant information. Strategic silence allows the client time to think and feel safe. In Filipino settings, culturally sensitive communication means respecting the role of family members in decision-making, using respectful pronouns ('po' and 'opo'), and being aware of hiya—a sense of shame or reticence that may prevent frank discussion of sensitive topics like sexual health, mental health, or family violence.

Leading questions ('You don't smoke, do you?') plant a suggestion. 'Why' questions ('Why didn't you take your medication?') often sound accusatory, triggering defensiveness. Giving false reassurance ('Everything will be fine') dismisses the client's concerns. Changing the subject avoids difficult topics. Using medical jargon ('Do you have orthopnea?' instead of 'Do you wake up short of breath at night?') confuses clients. Offering premature judgment ('That was a foolish thing to do') damages the therapeutic relationship.

Biographic data includes name, age, sex, address, marital status, occupation, and contact information. Chief complaint (CC) is the reason for seeking care, stated in the client's own words and typically documented as a brief phrase or one sentence. History of present illness (HPI) analyzes the chief complaint systematically using mnemonics: OLD CARTS (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) for general symptoms; PQRST (Provocation/Palliation, Quality, Region/Radiation, Severity, Timing) for pain. Past health history documents childhood illnesses, adult illnesses, surgeries, hospitalizations, injuries, immunization status, and allergies (including type of reaction). Family health history identifies heritable conditions (hypertension, diabetes, cancer), communicable diseases, and genetic patterns; often displayed as a genogram. Review of systems (ROS) is a systematic, head-to-toe series of questions about each body system—a screening tool that may uncover problems the client did not initially mention. Psychosocial and lifestyle data explore diet, sleep and rest, activity and exercise, substance use (tobacco, alcohol, illicit drugs), occupation and stress, coping mechanisms, social support, and functional patterns (activities of daily living).

When a client presents with a symptom (e.g., abdominal pain), use OLD CARTS to analyze it: Onset (when did it start?), Location (where exactly?), Duration (how long does it last?), Character (sharp, dull, cramping, burning?), Aggravating factors (what makes it worse?), Relieving factors (what makes it better?), Timing (constant, intermittent, related to meals?), Severity (on a scale of 0–10). For pain specifically, PQRST is often preferred: Provocation/Palliation (what triggers or relieves it?), Quality (how does it feel?), Region/Radiation (where is it and does it spread?), Severity (0–10), Timing (when, how often, how long?). These frameworks ensure that symptom questions are comprehensive and yield data that support differential diagnosis.

The general survey begins the moment you see the client and continues throughout the interview and examination. It documents: (1) physical appearance—apparent age versus stated age (does the client look older or younger than stated?), hygiene and grooming (clean, unkempt, inappropriate dress for weather?), and visible signs of distress (grimacing, anxiety, agitation); (2) body structure and nutrition—stature (tall, short, average), body proportions, symmetry, and signs of malnutrition or obesity; (3) mobility—gait (smooth, shuffling, unsteady?), coordination, ROM, and involuntary movements (tremor, fasciculations?); (4) behavior—level of consciousness (alert, drowsy, unresponsive?), facial expression (appropriate to situation?), mood (happy, sad, anxious?), affect (flat, labile?), speech (clear, slurred, pressured?), and cooperation with the examination.

Temperature (Temp): 36.5–37.5 °C is the adult normal range for oral measurement (approximately 37 °C is the standard average). Rectal temperature runs about 0.5 °C higher; axillary (armpit) runs about 0.5 °C lower. Pulse (HR): 60–100 beats per minute, regular rhythm. Tachycardia (>100) may indicate fever, pain, anxiety, or cardiac pathology. Bradycardia (<60) may indicate athletic conditioning or cardiac conduction disease. Respirations (RR): 12–20 breaths per minute in adults, regular and unlabored. Tachypnea (>20) suggests fever, hypoxia, pain, or metabolic acidosis. Bradypnea (<12) suggests CNS depression or hypothermia. Blood Pressure (BP): <120/80 mmHg is considered normal. Systolic 120–129 with diastolic <80 is elevated (Stage 1 hypertension begins at ≥130/80). Oxygen saturation (SpO2): 95–100% on room air is normal; <95% suggests hypoxemia. Pain: assessed as the 'fifth vital sign' using a numeric scale (0–10), Wong-Baker FACES scale for children, or other institution-specific tools. Record pain location, character, and relieving measures.

BMI = weight (kg) / height (m²). For example, a 70 kg adult who is 1.70 m tall has a BMI of 70 / (1.70)² = 70 / 2.89 = 24.2 kg/m². Normal BMI is 18.5–24.9 kg/m². Underweight (<18.5) may indicate malnutrition or chronic disease. Overweight (25.0–29.9) carries increased cardiovascular and metabolic risk. Obese Class I (30.0–34.9), Class II (35.0–39.9), and Class III (≥40.0) carry progressively higher health risks. In the Philippine context, where economic hardship and food insecurity affect some populations, underweight is a common concern, while in affluent urban areas, overweight and obesity are rising.

Inspection is deliberate, systematic visual (and sometimes olfactory and auditory) observation of the client. It begins during the interview and continues throughout the examination. Ensure good lighting (natural light or bright, non-glare artificial light), adequate exposure of the area being examined, and bilateral comparison for symmetry. Document color (pink, pale, flushed, cyanotic, jaundiced), size (normal, enlarged, atrophied), shape (round, oval, irregular), symmetry (one side matching the other), position (midline, deviated), movement (spontaneous, restricted, tremulous), and any lesions, discharge, or abnormalities. For example, when inspecting the abdomen, note: Is it flat, distended, or scaphoid? Are there visible veins, surgical scars, or striae? Does it move with respiration?

Palpation uses the sense of touch to assess texture, temperature, moisture, turgor, thickness, consistency, pulsations, masses, tenderness, and organ size. Different parts of the hand are optimized for different properties: Fingertips (finger pads) have fine tactile discrimination and assess texture, size, consistency, pulses, and edema. The dorsum (back) of the hand is more sensitive to temperature because the skin there is thinner; use it to compare temperature bilaterally. The palmar surface and base of the fingers detect vibration (e.g., tactile fremitus on the chest). Grasping fingers assess the position and consistency of a mass. Light palpation (approximately 1 cm depth, using a gentle pressing motion) is performed first for surface characteristics and client comfort. Deep palpation (approximately 4 cm depth, using firmer pressure) assesses organs, masses, and deep tenderness and is performed after light palpation. Always palpate tender areas last. Warm your hands before palpating. Use a slow, methodical approach, watching the client's face for signs of discomfort.

Percussion strikes the body surface to create vibrations that produce audible sounds, revealing the density of underlying tissue. Technique: place the middle finger of your non-dominant hand (called the plexor finger) firmly on the body surface, and strike it sharply with the tip of the middle finger of your dominant hand (the pleximeter), using a quick wrist snap. Listen to both the pitch and the duration of the sound. Percussion sounds: Tympany is loud, drum-like, hollow—heard over air-filled organs (stomach, gas-filled intestines). Resonance is low-pitched, hollow, and prolonged—heard over normal, air-filled lung tissue (the expected sound in the chest). Hyperresonance is booming, louder than resonance—heard over hyperinflated lungs (e.g., emphysema) or air trapping (pneumothorax); abnormal in adults. Dullness is medium-pitched, thud-like, short—heard over dense organs like the liver, spleen, or heart. Dullness over a lung field is abnormal and suggests consolidation (pneumonia), pleural effusion, or atelectasis. Flatness is very short, soft—heard over very dense tissue such as muscle or bone.

Auscultation listens to internal body sounds using a stethoscope. The stethoscope has two earpieces, a Y-shaped tubing, and two surfaces: the diaphragm (flat, larger surface) and the bell (cup-shaped, smaller surface). The diaphragm transmits high-pitched sounds—normal breath sounds (vesicular, bronchovesicular, bronchial), heart sounds (S1 and S2), normal bowel sounds (clicks and gurgles), and carotid bruits. The bell transmits low-pitched sounds—extra heart sounds (S3, S4), heart murmurs, and vascular bruits; apply it lightly without pressing to avoid stretching the skin and increasing resistance. Before auscultating, warm the stethoscope between your palms or on your clothing. Place it on bare skin—listening through clothing muffles sounds. Eliminate environmental noise. Auscultate systematically, moving from one location to the next, and listen for at least one full respiratory cycle or heartbeat at each site.

For most body regions (chest, heart, extremities, head and neck), the sequence is Inspection → Palpation → Percussion → Auscultation. However, for the abdomen only, the sequence is Inspection → Auscultation → Percussion → Palpation. Why the difference? Palpating or percussing the abdomen first can stimulate or inhibit bowel motility and artificially alter bowel sounds, leading to false assessment findings (false hyperactive sounds or false absent sounds). Auscultating early—before any manipulation—preserves the integrity of bowel sounds. Only after auscultating and assessing bowel sounds do you percuss to detect abnormal fluid (ascites) or organs, then palpate to assess tenderness, masses, and organ size. This is a high-yield NLE point that must be memorized and understood.

Positioning affects both the accuracy of findings and the client's comfort and safety. Sitting or Fowler's position (head elevated 45–90 degrees) is used for examining the head, neck, anterior thorax, heart, lungs, and upper extremities. Supine (lying flat on back) is used for abdominal examination and anterior chest examination. Dorsal recumbent (lying on back with knees bent and feet flat on the bed) is used for a relaxed abdominal examination. Sims' position (left side-lying with right leg flexed) is used for rectal examination. Lithotomy (dorsal recumbent with hips and knees flexed and feet in stirrups) is the standard position for female pelvic examination and is necessary for proper visualization and access. Standing or upright position is used to assess gait, balance, posture, and spine. Always consider the client's tolerance, energy level, and ability to maintain the position; reposition frail or dyspneic clients as needed to prevent fatigue or respiratory distress.

Assessment quality depends on a well-prepared environment and readily available equipment. Environment: Ensure privacy by closing doors and drawing curtains. Maintain a warm, comfortable room temperature (cold environments cause vasoconstriction and may distort findings). Use adequate lighting—natural light is ideal, but bright non-glare artificial lighting is acceptable. Minimize noise and interruptions. Have a quiet, calm atmosphere to facilitate therapeutic communication. Equipment should be clean, in working order, and within easy reach: stethoscope, sphygmomanometer (blood pressure cuff), penlight or flashlight, thermometer, tape measure, reflex hammer, tuning fork, otoscope and ophthalmoscope, gloves (non-latex if the client has a latex allergy), hand sanitizer, and documentation tools. Before starting, ask the client to empty the bladder (full bladder makes abdominal palpation uncomfortable and prevents deep palpation). Explain what you will do to reduce anxiety. Obtain informed consent. Drape the client appropriately, exposing only the area being examined to maintain dignity.

Findings must be documented objectively, accurately, and completely, using institutional format (narrative, SOAP, PIE, focus/DAR). Use precise, measurable language: '2 cm × 3 cm firm, non-tender, mobile mass in the right axilla' is far better than 'lump in armpit.' Avoid charting interpretations or conclusions as if they were observations—write 'skin warm and dry' not 'skin in good condition.' Avoid vague terms like 'normal' or 'good' without specifying what was assessed. Document findings promptly (within the same shift, before memory fades). Under RA 9173 (Philippine Nursing Act of 2002) and the Code of Ethics for Registered Nurses, nurses are accountable for accurate, timely, complete, and confidential records. Documentation serves as a legal record and should be factual, objective, and professional. Never alter records; if a mistake is made, draw a single line through the error, write 'error' and the date, and initial. Keep the client's privacy and confidentiality by handling records securely and never discussing findings in areas where unauthorized persons might overhear.

Assessment must be culturally competent to be effective and respectful. In the Philippine context: (1) Hiya (shame/reticence) is a cultural value that may prevent clients from discussing sensitive topics like sexual health, substance use, mental health, or family violence. Build trust, use gentle phrasing ('Some people experience...'), and offer privacy before asking sensitive questions. (2) Family involvement: Filipinos often involve family in healthcare decisions. The elderly (lola, lolo) may be deferred to for major decisions. Don't view this as lack of autonomy; instead, facilitate family participation and engage the family as part of the care team. (3) Respect for elders: Use respectful language ('po' and 'opo' when addressing elders), allow extra time for responses, and involve elder family members in discussions. (4) Fatalism and spirituality: Some Filipino clients may attribute illness to 'God's will' or view health through a spiritual lens; respect these beliefs while also educating about preventive health. (5) Language: If the client's primary language is not English or Filipino, use a qualified interpreter (professional interpreter preferred over family members, who may not accurately convey medical terms or may filter information).

Common errors include: (1) Failing to compare findings bilaterally (e.g., comparing one lung to the other, one knee to the other), which hides asymmetry and subtle changes. Always compare both sides. (2) Listening to the client through clothing, which muffles sounds and leads to inaccurate auscultation findings. Always place the stethoscope on bare skin. (3) Percussing or palpating the abdomen before auscultating, which artifactually distorts bowel sounds. Remember: Inspect → Auscultate → Percuss → Palpate for the abdomen. (4) Rushing the interview, which erodes rapport, yields incomplete subjective data, and may miss important concerns. Take time, use active listening, and allow silence. (5) Neglecting hand hygiene between clients, which spreads infection. Wash hands or use hand sanitizer before and after client contact. (6) Ignoring non-verbal cues—if a client grimaces during palpation, they are in pain; asking 'Does this hurt?' after they've already shown discomfort damages your credibility. Observe before, during, and after each part of the examination. (7) Failing to respect privacy and dignity—expose only the area being examined, knock before entering, and maintain professional draping.

A client's subjective report (e.g., 'I feel hot and sweaty') directs the nurse's objective assessment (e.g., measure temperature, observe perspiration, assess skin color). The subjective complaint guides where to focus the objective examination.

Therapeutic communication (open-ended questions, active listening, reflection) yields rich, detailed subjective data. Non-therapeutic blocks (leading questions, dismissal) yield incomplete or biased data. The quality of communication directly predicts the quality of the health history.

A structured interview (preparatory → introductory → working → closing) builds trust step by step. Skipping or rushing phases erodes rapport and reduces client openness, especially around sensitive topics. Filipino clients, valuing hiya and respect, particularly need the time and safety that a well-paced interview provides.

Vital signs reflect the body's physiologic responses. A constellation of findings (fever + tachycardia + tachypnea + elevated BP) suggests a different problem than isolated tachycardia. Abnormal vital signs guide the focus of the physical examination and alert the nurse to escalate care or report to the provider.

The correct sequence (and the abdominal exception) ensures that assessment maneuvers do not distort findings. For example, palpating the abdomen first would stimulate bowel sounds artificially; auscultating first captures the true baseline state.

Observations during the general survey (e.g., apparent age older than stated, signs of distress) alert the nurse to focus the detailed examination on specific systems. A client who appears acutely ill warrants a more intensive cardiovascular and respiratory examination.

Starting with light palpation acclimates the client to touch, assesses surface abnormalities, and allows the nurse to identify tender areas before applying deeper pressure. This builds trust and prevents guarding (voluntary muscle tensing that prevents deep palpation).

Privacy ensures that the client shares sensitive information. Adequate lighting enables accurate inspection. Warmth promotes client comfort and prevents artifacts (e.g., shivering, vasoconstriction). Minimal noise facilitates auscultation. A well-prepared environment supports both the physical and psychological dimensions of assessment.

Respecting Filipino cultural values (hiya, family involvement, respect for elders) creates psychological safety, especially around sensitive topics. Clients who feel respected and understood share more complete and honest information. Lack of cultural competence leads to guarded responses and incomplete data.

Clustering of subjective and objective data forms the basis for identifying actual or potential health problems and selecting nursing diagnoses from NANDA-I taxonomy. Incomplete assessment leads to missed diagnoses and inappropriate care planning.

Timely, objective, accurate documentation ensures that all healthcare team members (nurses on subsequent shifts, physicians, allied health professionals) have access to the same data and can make informed decisions. Poor documentation can be used as evidence of negligence in a legal claim; under RA 9173, the nurse is accountable for the quality of their records.

The sound produced by percussion correlates directly to the density and air content of underlying structures. Learning the relationship between sound and tissue type (resonance = aerated lung, dullness = solid organ or consolidated lung) allows the nurse to infer organ pathology from audible findings.