NLE Health Assessment — Health History & Physical Examination TechniquesRevision Notes

Exam Tips

• If the scenario says 'a client is admitted for the first time' — the answer is INITIAL/COMPREHENSIVE assessment.
• If the scenario says 'the nurse is checking on a post-op client every hour' — the answer is ONGOING assessment.
• If the scenario describes a sudden collapse or respiratory arrest — the answer is EMERGENCY assessment.
• Subjective = Symptom = Client Says it (S-S-S). Objective = Observable/Overt (O-O).

Key Points

• Assessment is the FIRST step of the nursing process — it feeds ALL subsequent steps (diagnosis, planning, implementation, evaluation).
• Data collected is classified as SUBJECTIVE (symptoms/covert — what the client says) or OBJECTIVE (signs/overt — what the nurse observes and measures).
• Initial/Comprehensive Assessment: complete history + head-to-toe exam done on ADMISSION to establish a baseline database.
• Focused/Problem-Oriented Assessment: targeted to a specific complaint (e.g., respiratory assessment for a client complaining of dyspnea).
• Emergency Assessment: rapid ABC evaluation — Airway, Breathing, Circulation — during a crisis. Speed is priority.
• Ongoing/Time-Lapsed Assessment: periodic reassessment to monitor changes in client status over time.
• NLE TIP: Know which TYPE of assessment to use in a given clinical scenario — the board loves to test this distinction.

Definitions

Section Title

Types of Nursing Assessment

Common Mistakes

• Confusing subjective with objective data — pain score reported by the client is SUBJECTIVE even though it uses a number; the number only quantifies the client's perception.
• Selecting a comprehensive assessment when a focused or emergency approach is clinically indicated (and vice versa).
• Forgetting that ongoing assessment is CONTINUOUS — it occurs with every nurse-client interaction, not just at shift change.

Exam Tips

• The NLE often tests which communication technique is THERAPEUTIC vs. NON-THERAPEUTIC. The top non-therapeutic blocks to memorize: leading questions, 'why' questions, false reassurance, changing the subject, giving advice prematurely.
• OLD CARTS and PQRST — know both; boards may present a scenario and ask which question corresponds to which component.
• Family health history is best documented using a GENOGRAM (a family tree showing health conditions and relationships).
• The Chief Complaint is always in QUOTES — it is the client's own words, not the nurse's interpretation.
• The working phase is the LONGEST phase of the interview — it is where all components of the health history are collected.

Key Points

• The interview is a PURPOSEFUL, THERAPEUTIC conversation — its quality depends on communication skill as much as on the questions asked.
• Four phases: Preparatory → Introductory (Opening) → Working (Body) → Closing (Termination).
• PREPARATORY phase: review available records, ensure privacy, prepare the environment (comfortable temperature, good lighting, minimal noise) BEFORE meeting the client.
• INTRODUCTORY phase: introduce yourself, explain the purpose, establish rapport, obtain informed consent — set the tone of trust.
• WORKING phase: systematic data collection using open-ended and closed-ended questions, therapeutic communication techniques.
• CLOSING phase: summarize findings, allow the client to add information, explain next steps — never end abruptly.
• Cultural Sensitivity in Philippine Context: Respect for elders (use of 'po' and 'opo'), family involvement in decision-making, and 'hiya' (shame/reticence) can limit disclosure — especially for sexual health and mental health topics. Build trust first.
• Open-ended questions ('Tell me what brought you here today') elicit RICH narrative data; use these to START an interview.
• Closed-ended questions ('Do you take aspirin daily?') obtain SPECIFIC facts; use these after open-ended questions.
• Symptom Analysis Mnemonics: OLD CARTS (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) and PQRST (Provocation/Palliation, Quality, Region/Radiation, Severity, Timing) for pain.

Definitions

Section Title

The Health History Interview

Common Mistakes

• Using 'why' questions — they sound accusatory (e.g., 'Why didn't you take your medication?') and are NON-THERAPEUTIC.
• Asking leading questions — these suggest the expected answer and bias the data (e.g., 'Your pain is sharp, isn't it?').
• Giving false reassurance — ('Don't worry, everything will be fine') is non-therapeutic and unethical.
• Using medical jargon with the client — say 'heart attack' not 'myocardial infarction' when communicating with lay clients.
• Documenting ROS data as OBJECTIVE — ROS is always subjective (what the client reports), not what the nurse observes.
• Rushing the closing phase — ending the interview abruptly damages trust and may miss important last-minute disclosures.

Exam Tips

• The NLE may present Gordon's 11 Functional Health Patterns and ask which pattern a specific behavior or complaint belongs to.
• Drug allergy vs. drug intolerance: allergy = immune-mediated reaction (e.g., urticaria, anaphylaxis); intolerance = non-immune adverse effect (e.g., GI upset from aspirin).
• Biographic data is the FIRST component collected because it establishes client identity before any clinical information is recorded.
• The CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) screens for alcohol use disorder — may appear in psychosocial history questions.

Key Points

• 1. Biographic Data: name, age, sex, civil status, address, occupation, religion, contact person.
• 2. Chief Complaint (CC): client's own words about why they sought care.
• 3. History of Present Illness (HPI): analyzed with OLD CARTS or PQRST.
• 4. Past Health History: childhood/adult illnesses, injuries, surgeries, hospitalizations, immunizations, allergies (especially drug allergies — always assess).
• 5. Family Health History: heritable and communicable conditions in immediate family; document with a GENOGRAM.
• 6. Review of Systems (ROS): systematic questioning about each body system — SUBJECTIVE data only.
• 7. Lifestyle and Psychosocial Data: diet, activity level, sleep patterns, substance use (CAGE questionnaire for alcohol), occupation, stress, coping patterns, support systems, and Gordon's 11 Functional Health Patterns.
• Gordon's 11 Functional Health Patterns: Health Perception-Management, Nutritional-Metabolic, Elimination, Activity-Exercise, Sleep-Rest, Cognitive-Perceptual, Self-Perception-Self-Concept, Role-Relationship, Sexuality-Reproductive, Coping-Stress Tolerance, Value-Belief.
• Allergies documentation is CRITICAL — drug allergies must always be assessed and prominently documented before any medication administration.

Definitions

Section Title

Components of a Complete Health History

Common Mistakes

• Omitting allergy assessment — this is a PATIENT SAFETY priority and a legal responsibility under RA 9173.
• Confusing ROS (subjective, questions asked) with the Physical Examination (objective, what the nurse finds).
• Forgetting that immunization history is part of PAST health history — relevant for both adults and children in the Philippine Expanded Program on Immunization (EPI) context.

Formulas

Exam Tips

• Temperature mnemonics: Rectal = Richest (highest); Axillary = Always lower (lowest); both differ from oral by 0.5°C.
• SpO2 below 95% = concern. Below 90% = emergency. Below 85% = critical — initiate oxygen therapy immediately.
• Pain is the 5th vital sign — the NLE expects nurses to assess pain with EVERY set of vital signs.
• BMI normal = 18.5–24.9. Remember: 18.5 is the FLOOR, 24.9 is the CEILING of normal.
• The general survey is NOT a separate step — it begins passively from first observation and provides context for all subsequent assessments.

Key Points

• The general survey begins the MOMENT you see the client — it is your overall impression and frames the entire physical examination.
• General Survey covers: Physical Appearance (apparent vs. stated age, hygiene, grooming, signs of distress), Body Structure and Nutrition (stature, weight, symmetry, posture), Mobility (gait, range of motion, involuntary movements), and Behavior (LOC, mood, affect, speech, cooperation).
• VITAL SIGNS — Adult Normal Ranges (memorize these exactly):
• Temperature: 36.5–37.5°C. Oral average ~37°C. Rectal = oral + 0.5°C (HIGHEST). Axillary = oral – 0.5°C (LOWEST). Tympanic ≈ rectal.
• Pulse: 60–100 beats/min, regular rhythm.
• Respirations: 12–20 breaths/min, regular and unlabored.
• Blood Pressure: NORMAL = less than 120/80 mmHg. ELEVATED = systolic 120–129 with diastolic less than 80. Stage 1 HTN = 130–139/80–89. Stage 2 HTN = 140+/90+ mmHg.
• Oxygen Saturation (SpO2): 95–100% on room air. Below 90% = clinical emergency.
• Pain (5th Vital Sign): 0–10 Numeric Rating Scale for adults; Wong-Baker FACES for children or non-verbal clients.
• BMI Formula: BMI = weight (kg) ÷ height (m²). Normal = 18.5–24.9 kg/m². Underweight less than 18.5. Overweight = 25–29.9. Obese = 30 and above.
• Level of Consciousness: Alert, Verbal, Pain, Unresponsive (AVPU scale); or GCS (Eye 4 + Verbal 5 + Motor 6 = maximum 15).

Definitions

Section Title

The General Survey and Vital Signs

Common Mistakes

• Confusing temperature route normal values — the NLE frequently tests whether rectal is higher or lower than oral.
• Using an inappropriate pain scale — the numeric 0–10 scale requires the client to conceptualize numbers; use Wong-Baker FACES for children, cognitively impaired, or non-English speakers.
• Forgetting to classify BP using current standards — normal is LESS THAN 120/80 (not 140/90 as in the old JNC 7 cutoff that appeared in older NLE review materials).
• Calculating BMI using height in centimeters without converting to meters first.
• Assessing respirations while the client knows they are being counted — the client unconsciously alters breathing rate. Count RR after pulse, keeping your fingers on the wrist.

Exam Tips

• ABDOMINAL ORDER is the #1 most-tested IPPA fact: Inspection → Auscultation → Percussion → Palpation (IAPA).
• Hand surface for temperature = DORSUM. Hand surface for texture/pulses = FINGERTIP PADS. Hand surface for vibration/fremitus = ULNAR EDGE or PALMAR BASE.
• Diaphragm = High-pitched (D for Diaphragm = D for 'De High'). Bell = Low-pitched (B for Bell = B for 'Baba' low).
• Light before deep, non-tender before tender — always a two-step approach for palpation.
• Fist percussion (blunt percussion) is used to assess tenderness over the LIVER (right lower thorax) and KIDNEYS (costovertebral angle — CVA tenderness) — key for detecting hepatomegaly and pyelonephritis.

Key Points

• IPPA = Inspection → Palpation → Percussion → Auscultation. This is the standard sequence for ALL body regions EXCEPT the abdomen.
• ABDOMINAL SEQUENCE EXCEPTION: Inspection → AUSCULTATION → Percussion → Palpation (IAPA). Palpating or percussing the abdomen FIRST alters bowel sounds — this is the most frequently tested IPPA fact on the NLE.
• INSPECTION is ALWAYS first — it is the most used technique and begins even during the interview.
• PALPATION uses touch; always warm hands before touching the client. Light palpation (1 cm depth) BEFORE deep palpation (4 cm). Palpate TENDER areas LAST.
• PERCUSSION produces sounds that reveal underlying tissue density; classified as tympany, resonance, hyperresonance, dullness, or flatness.
• AUSCULTATION uses a stethoscope; DIAPHRAGM for high-pitched sounds, BELL for low-pitched sounds.
• Always examine bilaterally to compare for symmetry — asymmetry is often the finding that leads to a diagnosis.

Definitions

Section Title

The Four Physical Examination Techniques (IPPA)

Common Mistakes

• MOST COMMON NLE MISTAKE: Applying the standard IPPA order to the ABDOMEN. The abdomen uses IAPA — auscultation before percussion and palpation.
• Using the dorsum of the hand to assess texture — the dorsum is for TEMPERATURE (not texture). Use FINGERTIP PADS for texture, pulses, and fine discrimination.
• Performing deep palpation before light palpation — this causes muscle guarding and gives false readings.
• Palpating or percussing a tender area first — always save the most tender area for LAST to preserve client cooperation.
• Listening through clothing with a stethoscope — clothing creates artifact sounds that mask true auscultatory findings.
• Applying the bell too firmly — heavy pressure stretches the skin under the bell, converting it to function like the diaphragm and filtering out low-pitched sounds.

Exam Tips

• Memory trick: T-D-V-G (Temperature = Dorsum; Texture = fingertip pads; Vibration = ulnar/palmar base; Grasping = mass consistency).
• Warm hands = warm the hands before palpation. This is also a CARING behavior consistent with holistic nursing care.
• Pitting edema scale: 1+ = 2mm; 2+ = 4mm; 3+ = 6mm; 4+ = 8mm. The bigger the pit and slower the rebound, the higher the grade.

Key Points

• Different parts of the hand are more sensitive for different properties — using the right surface improves accuracy.
• FINGERTIP PADS (finger pads): fine tactile discrimination — texture, size, shape, consistency of masses, capillary refill, pulses, edema pitting.
• DORSUM (back of the hand): temperature — skin here is THINNER and more sensitive to heat differences; use this when comparing skin temperature bilaterally.
• PALMAR SURFACE / ULNAR EDGE (base of fingers and ulnar side): vibration — use for tactile/vocal fremitus (feeling vibrations when the client says '99'); also for thrills (vibrating murmurs felt on chest wall).
• GRASPING WITH FINGERS: assess position and consistency of a mass — whether it is mobile or fixed, soft or firm.
• Always WARM hands before palpation — cold hands cause involuntary muscle guarding and give inaccurate findings.

Definitions

Section Title

Palpation — Hand Surfaces and Their Uses

Common Mistakes

• Using the palm to assess temperature instead of the dorsum — the palmar skin is thicker and less thermosensitive.
• Using the fingertips to assess vibration/fremitus — the fingertip pads are less sensitive to vibration than the ulnar edge.

Exam Tips

• Memory order from densest to least dense: Flatness (bone) → Dullness (liver) → Resonance (normal lung) → Hyperresonance (trapped air) → Tympany (stomach/bowel).
• NLE scenario: 'Percussion of the right lower lobe reveals dullness' — this suggests PLEURAL EFFUSION or CONSOLIDATION (pneumonia). Resonance is lost, dullness replaces it.
• NLE scenario: 'Percussion reveals hyperresonance over the left chest' — suspect PNEUMOTHORAX. Urgent assessment needed.
• Shifting dullness test: percuss the flank in supine position (dull), turn the client 45 degrees, repercuss — if the dullness shifts to the dependent side, ASCITES is present (positive test).

Key Points

• Percussion sounds are produced by striking the body surface and are classified by their pitch, intensity, duration, and quality.
• TYMPANY: LOUD, drum-like, high-pitched. Normal location: over air-filled hollow organs — stomach, gas-filled intestines, distended bladder. Example: percuss the left lower thorax (stomach bubble area) or a distended abdomen.
• RESONANCE: Low-pitched, hollow, moderate duration. Normal location: over air-filled LUNG tissue. This is the normal lung percussion note.
• HYPERRESONANCE: BOOMING, louder and lower than resonance, abnormal in adults. Found over hyperinflated lungs — emphysema (barrel chest), or pneumothorax (trapped air). This is always ABNORMAL in adults.
• DULLNESS: Medium pitch, thud-like, moderate to soft. Normal location: over DENSE organs — liver, spleen, full bladder, heart. ABNORMAL when found over lung fields (indicates consolidation/pneumonia or pleural effusion).
• FLATNESS: Soft, very short, high-pitched. Normal location: over VERY dense tissue — muscle, bone (femur). Abnormal over lung = massive effusion or atelectasis.
• Clinical Application: Shifting dullness and fluid wave are percussion/palpation techniques for detecting ASCITES.
• CVA tenderness: fist percussion over costovertebral angle — positive finding (pain) indicates KIDNEY PATHOLOGY (pyelonephritis, renal calculi).

Definitions

Section Title

Percussion Sounds — Classification and Clinical Significance

Common Mistakes

• Confusing where tympany and resonance are normally heard — RESONANCE is normal lung, TYMPANY is normal stomach/bowel.
• Forgetting that DULLNESS over the lung is ABNORMAL (it is only normal over solid organs like the liver and spleen).
• Confusing hyperresonance with resonance — hyperresonance is always abnormal in adults and suggests air trapping.
• Not practicing the percussion technique (pleximeter and plexor) — striking the middle phalanx of the middle finger, NOT the fingertip.

Exam Tips

• Diaphragm = High-pitched = Normal sounds (S1, S2, breath sounds, bowel sounds). Bell = Low-pitched = Extra/abnormal heart sounds (S3, S4, murmurs, bruits).
• S3 in adults = HEART FAILURE (think: 'S3 = Slosh' of fluid in a dilated ventricle).
• Absent bowel sounds + abdominal distension + no flatus = PARALYTIC ILEUS — a major post-operative complication requiring immediate reporting.
• Stridor = EMERGENCY. Wheezing = Urgent. Crackles = Assess further and intervene.
• Rhonchi clear with coughing (mucus moves); crackles do NOT clear with coughing (fluid in alveoli/small airways).

Key Points

• DIAPHRAGM (flat, larger side): transmits HIGH-PITCHED sounds. Use for: normal breath sounds (vesicular, bronchovesicular, bronchial), bowel sounds, and normal heart sounds (S1 and S2).
• BELL (smaller, cup side): transmits LOW-PITCHED sounds. Use for: extra heart sounds (S3 gallop, S4 gallop), murmurs, vascular bruits. Apply the bell LIGHTLY — too much pressure converts it into a diaphragm.
• Always place the stethoscope on BARE SKIN — never through clothing.
• Warm the stethoscope before placing on the client — cold diaphragm/bell causes involuntary muscle tensing.
• Normal Breath Sounds: Vesicular (soft, low-pitched) over peripheral lung tissue. Bronchovesicular (moderate) over major bronchi. Bronchial/tracheal (loud, high-pitched) over the trachea only.
• Abnormal (Adventitious) Breath Sounds: CRACKLES (rales) — fine or coarse popping sounds; fluid in airways (pneumonia, pulmonary edema). RHONCHI — low-pitched gurgling/snoring; secretions in large airways. WHEEZES — high-pitched musical; bronchospasm (asthma). STRIDOR — high-pitched inspiratory sound; upper airway obstruction (croup, epiglottitis — emergency). PLEURAL FRICTION RUB — leathery, grating sound; inflamed pleural surfaces rubbing.
• Normal Bowel Sounds: 5–34 clicks/gurgles per minute. HYPERACTIVE (greater than 34/min) = diarrhea, early bowel obstruction. HYPOACTIVE or ABSENT (no sounds for 3–5 min per quadrant) = paralytic ileus, post-op, peritonitis.
• Listen to each quadrant for at least 1 full minute before reporting absent bowel sounds.
• Heart Sounds: S1 (lub) = mitral/tricuspid valve CLOSURE (beginning of systole). S2 (dub) = aortic/pulmonic valve CLOSURE (beginning of diastole). S3 (ventricular gallop) = volume overload (heart failure in adults — abnormal). S4 (atrial gallop) = stiff/non-compliant ventricle (hypertension, hypertrophy).

Definitions

Section Title

Auscultation — Stethoscope Use and Breath/Heart/Bowel Sounds

Common Mistakes

• Using the DIAPHRAGM to listen for S3, S4, or murmurs — these are LOW-PITCHED and require the BELL.
• Pressing the BELL too firmly — converts it to a diaphragm function, filtering out low-pitched sounds.
• Listening through clothing — rustling fabric creates sounds indistinguishable from crackles or rubs.
• Reporting absent bowel sounds after listening for only 30 seconds — must listen for at least 1 full minute per quadrant (or 3–5 minutes total before declaring absent).
• Confusing rhonchi with crackles — rhonchi are CONTINUOUS and may CLEAR with coughing; crackles are DISCONTINUOUS and do NOT clear with coughing.

Exam Tips

• Lithotomy position = female pelvic exam/Pap smear (remember: L for Lithotomy = L for Ladies' Pelvic exam).
• Sims' position = rectal exam and enema (the left-lateral position puts gravity on the side that relaxes the sigmoid colon).
• Dorsal recumbent vs. Supine: both are lying flat, but dorsal recumbent has knees BENT → relaxes abdominal muscles → better for abdominal assessment.
• Standing position is used for GAIT assessment, Romberg test (balance), and scoliosis screening — remember the clinical context.
• The NLE may test the nurse's FIRST action before an examination: always EXPLAIN the procedure and obtain consent FIRST (therapeutic communication and ethical principle of autonomy).

Key Points

• ENVIRONMENT: ensure PRIVACY (close doors/curtains), warm temperature, quiet room, and adequate lighting. Have all equipment within reach before starting.
• Essential equipment: stethoscope, sphygmomanometer, thermometer, penlight, tape measure, reflex hammer, tuning fork, otoscope, ophthalmoscope, gloves (standard precautions).
• CLIENT PREPARATION: explain the procedure, obtain INFORMED CONSENT, ask client to empty the bladder before abdominal or pelvic examination, and drape appropriately (expose ONLY the region being examined to maintain dignity).
• STANDARD PRECAUTIONS: perform hand hygiene BEFORE and AFTER every client contact. Wear gloves when contact with body fluids or non-intact skin is anticipated. Follows RA 9173 accountability standards.
• KEY EXAMINATION POSITIONS:
• SITTING/FOWLER'S (45–90°): head, neck, thorax, heart, upper extremities — allows full chest expansion for respiratory assessment.
• SUPINE (lying flat): abdomen, anterior chest; client must be relaxed.
• DORSAL RECUMBENT (supine with knees flexed): RELAXES abdominal muscles — better for abdominal palpation in anxious or obese clients.
• SIMS' (left lateral/side-lying with top knee flexed): rectal examination, enema administration.
• LITHOTOMY (supine, legs in stirrups): female pelvic examination, Pap smear, urinary catheterization.
• PRONE (face down): posterior trunk, spine.
• STANDING: gait assessment, balance (Romberg test), spinal curvature (scoliosis screening).
• Consider the client's TOLERANCE — reposition frail, elderly, dyspneic, or post-surgical clients carefully and frequently.

Definitions

Section Title

Client and Environment Preparation; Examination Positions

Common Mistakes

• Forgetting to ask the client to void before an abdominal exam — a full bladder is mistaken for a mass or causes inaccurate percussion of the pelvic region.
• Fully undressing the client — expose ONLY the region being examined. Completely undressing the client unnecessarily is a violation of dignity.
• Skipping hand hygiene between clients or between dirty and clean procedures — this is the #1 cause of healthcare-associated infections and a legal/ethical breach under RA 9173.
• Performing the examination without explaining it first — informed consent and explanation reduce anxiety and improve client cooperation.

Exam Tips

• The NLE tests documentation scenarios frequently. OBJECTIVE = what the nurse measures/observes. SUBJECTIVE = what the client reports.
• In SOAP: the Assessment (A) component is where the nursing diagnosis goes — not a medical diagnosis.
• RA 9173 is the Philippine Nursing Act of 2002 — know that the Board of Nursing (under PRC) is the regulatory body. The law covers scope of practice, licensure requirements, and nursing ethics.
• Falsifying records is an ETHICAL and LEGAL violation — potential grounds for license revocation under Section 28 of RA 9173.
• Documentation must be timely, legible, accurate, and complete — these four standards are tested in NLE situational questions.

Key Points

• All findings must be documented OBJECTIVELY, ACCURATELY, and PROMPTLY following the examination.
• Use PRECISE, MEASURABLE descriptions: '2 cm × 3 cm firm, nontender, mobile mass in the right axilla' — NOT vague terms like 'a lump in the armpit'.
• Do NOT chart INTERPRETATIONS as OBSERVATIONS — document what you SEE, HEAR, FEEL; not what you think it means.
• Documentation formats: SOAP (Subjective, Objective, Assessment, Plan), DAR/Focus Charting (Data, Action, Response), or narrative — follow institutional format.
• Under RA 9173 (Philippine Nursing Act of 2002), the nurse is legally and professionally accountable for: accurate and timely documentation, client confidentiality (no disclosure without consent), and practicing within the scope of nursing practice.
• The Code of Ethics for Registered Nurses (Board Resolution 220, 2004) mandates respect for client rights, truthful documentation, and confidentiality.
• Inaccurate, delayed, or falsified documentation is grounds for disciplinary action by the PRC Board of Nursing.
• Document OBJECTIVE findings from physical examination separately from SUBJECTIVE findings from the health history.
• Errors in documentation: use a single line through the error, write 'error' and sign — NEVER erase or use correction fluid (Wite-Out) on legal documents.

Definitions

Section Title

Documentation and Legal/Ethical Considerations under RA 9173

Common Mistakes

• Documenting interpretations: writing 'client appears anxious about surgery' when the observation was 'client states I am worried, hands trembling, voice quivering' — document the OBSERVATIONS.
• Delayed documentation — charting hours after an assessment creates legal vulnerabilities and risks patient safety.
• Using eraser or correction fluid on paper records — this destroys the legal integrity of the document.
• Sharing client information verbally or in writing without consent — violates confidentiality under RA 9173 and the Data Privacy Act (RA 10173).