29777256 physical assessment

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Nursing Skills

Physical Assessment

Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 1

Foundations of Nursing Abejo

NURSING SKILLS

Physical Assessment

Lecturer:Mark Fredderick R. Abejo R.N, M.A.N

PHYSICAL ASSESSMENT

Objectives:

Obtain physical data about the clients functionalabilities

Supplement, confirm, or refuse data obtained in thenursing history

Obtain data that will help the nurse data establishnursing diagnoses and plan the clients care.

Evaluate the physiologic outcomes of health care andthus the progress of a patients health problem

Screen presence of cancerCEPHALOCAUDAL ORDER OF EXAMINATION

AREAS

HEENT NECK UPPER EXTREMITIES CHEST AND BACK BREAST AND AXILLAE ABDOMEN GENITALS ANUS AND RECTUM LOWER EXTREMITIESNote: SKIN IS CHECK THROUGHTOUT THEASSESSMENT

General Concepts:

Approach the client calmly and confidently.

Provide privacy.

Make sure that all needed instruments are availablebefore starting the physical assessment

Several positions are frequently required during the

assessment. Consider the clients ability to assume aposition.

Be systematic and organized when assessing the

client. (Inspection, Palpation, Percussion, Auscultation

If a client is seriously ill, assess the systems of the

body that are more at risk

Perform painful procedures at the end of the

examination

METHODS OF EXAMINING

INSPECTION PALPATION PERCUSSION AUSCULTATION

INSPECTION Visual examination of the patient done in a methodical

and deliberate manner.

PALPATION Is the use of hand to touch for the purpose of

determining temperature, moisture, size, shape,

position, texture, consistency, and movement.

TYPES OF PALPATION

Light Palpation

To check muscle tone and assess for tendernessTechniques:

Place the hand with fingers together parallelto the area being palpated. Press down 1 to 2 cm.

Repeat in ever-widening circles until the area to beexamined is covered.

Deep Palpation

To identify abdominal organs and abdominal masses.Techniques:

With fingers together, approach the area to

be examined at a 60 degree angle and use the pads andtips of the fingers of one hand to press in 4 cm.

Two handed Deep Palpation place the fingers of one

hand on top of those of the other.

PERCUSSION

Striking of the body surface with short, sharp strokesin order to produce palpable vibrations andcharacteristic sound.

It is used to determine the location, size, shape, anddensity of underlying structures; to detect the presenceof air or fluid in a body space; and to elicit tenderness.

TYPES OF PERCUSSION

Direct Percussion Percussion in which one hand is used and the striking

finger (plexor) of the examiner touches the surface

being percussed.Techniques:

Using sharp rapid movements from the wrist, strikethe body surface to be percussed with the pads of two,three, or four fingers or with the pad of the middle

finger alone. Primarily used to assess sinuses in theadult.

Indirect Percussion

Percussion in which two hands are used and the plexorstrikes the finger of the examiners other hand, whichis in contact with the body surface being percussed(pleximeter).

Techniques:

Strike at a right angle to the pleximeter using quick,

sharp but relaxed wrist motion.Withdraw the plexor immediately after the strike toavoid damping the vibration. Strike each are twice and

then move to a new area

Blunt Ulnar surface of the hand or fist is used in place of the

fingers to strike the body surface, either directly orindirectly.


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PERCUSSION SOUNDS

1. RESONANCEHollow sound. Ex. normal lung.2. HYPERRESONANCE Booming sound. Ex.

Emphysematous lung3. TYMPANY musical or drum sound. Ex. Stomach

and intestines4. DULLNESSThud sound. Ex. Enlarged spleen, full

bladder, liver.5. FLATNESS extremely dull sound. Ex. Muscle or

bone

AUSCULTATION

Listening to sounds produced inside the body

EQUIPMENTS FOR PHYSICALEXAMINATION

Sphygmomanometer and stethoscope Thermometer Nasal Speculum Ophthalmoscope Otoscope Vaginal Speculum Tongue depressor/blade Penlight Cotton Applicators Tuning fork Reflex hammer Clean gloves Lubricant

GENERAL SURVEY

VITAL SIGNSGENERAL SURVEY

1. Physical Appearance

2. Level of Conciousness/ awareness AlertnessPatient is awake and aware of self

and environment. Lethargy When spoken to in a loud voice,

patient appears drowsy but opens eye, and look

at you, responds to questions, then falls asleep. Obtundation When shaken gently, patient

opens eye and looks at you but respondsslowly and is somewhat confused.

StuporPatient arouses from sleep only afterpainful stimuli.

Coma Despite repeated painful stimuli,patient remains unarousable with eyes closed.

3. Apperance in relation to chronological age4. Signs of distress5. Nutritional status

6. Body structure7. Obvious physical deformities8. Mobility9. Behavior

10. Odors of body and breath11. Facial Expression12. Mood & affect13. Speech

SYSTEMS ASSESSMENT

INTEGUMENTARY SYSTEM

Functions of the Skin:

Protection Absorption Regulation Synthesis Sensory

Procedure:

1. Inspects skin surfaces2. Palpates with fingertips for edema and skin turgor3. Palpates skin temperature contra-laterally using back

of hands

Assessment:

Health History Presenting problem

Changes in the color and texture of the skin, hairand nails.

Pruritus Infections Tumors and other lesions Dermatitis Ecchymoses Dryness

Lifestyle practices Hygienic practices Skin exposure

Nutrition / diet Intake of vitamins and essential nutrients Water and Food allergies

Use of medications Steroids Antibiotics Vitamins Hormones Chemotherapeutic drugs

Past medical history Renal and hepatic disease Collagen and other connective tissue diseases Trauma or previous surgery Food, drug or contact allergies

Family medical history Diabetes mellitus Allergic disorders Blood dyscrasias Specific dermatologic problems Cancer

Physical Examination

Color Areas of uniform color Pigmentation Redness Jaundice Cyanosis

Vascular changes

Purpuric lesions Ecchymoses Petechiae

Vascular lesions Angiomas Hemangiomas Venous stars

Lesions Color Type Size Distribution Location Consistency Grouping

Annular Linear Circular Clustered

Edema (pitting or non-pitting) Moisture content Temperature (increased or decreased;

distribution of temperature changes)

Texture Mobility / Turgor


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Effects of Aging in the Skin

Skin vascularity and the number of sweat andsebaceous glands decrease, affectingthermoregulation.

Inflammatory response and pain perception diminish. Thinning epidermis and prolonged wound healing

make elderly more prone to injury and skin infections. Skin cancer more common.

Primary Lesions of the Skin

Macule is a small spot that is not palpable and is lessthan 1 cm in diameterPatch is a large spot that is not palpable & that is > 1cm.

Papule is a small superficial bump that is elevated &that is < 1 cm.Plaque is a large superficial bump that is elevated & >1 cm.

Nodule is a small bump with a significant deepcomponent & is < 1 cm.

Tumor is a large bump with a significant deepcomponent & is > 1 cm.Cyst is a sac containing fluid or semisolid material, ie.

cell or cell products.Vesicle is a small fluid-filled bubble that is usuallysuperficial & that is < 0.5 cm.Bulla is a large fluid-filled bubble that is superficial ordeep & that is > 0.5 cm.Pustule is pus containing bubble often categorizedaccording to whether or not they are related to hair

follicles: follicular- generally indicative of local

infection folliculitis - superficial, generally multiple furuncle - deeper form of folliculitis carbuncle - deeper, multiple follicles

coalescing

Secondary lesions of the Skin

Scale is the accumulation or excess shedding of thestratum corneum. Scaleis very important in the differential

diagnosis since its presence indicates that theepidermis is involved.

Scale is typically present where there isepidermal inflammation, ie. psoriasis, tinea,

eczemaCrust is dried exudate (ie. blood, serum, pus) on the

skin surface.Excoriation is a loss of skin due to scratching or

picking.Lichenification is an increase in skin lines & creasesfrom chronic rubbing.Maceration is raw, wet tissue.Fissure is a linear crack in the skin; often verypainful.Erosion is a superficial open wound with loss ofepidermis or mucosa onlyUlcer is a deep open wound with partial or completeloss of the dermis or submucosa

Distinct Lesions of the Skin

Wheal or hive describes a short lived (< 24 hours),edematous, well circumscribed papule or plaque seenin urticaria.

Burrow is a small threadlike curvilinear papule that isvirtually pathognomonic of scabies.Comedone is a small, pinpoint lesion, typically

referred to as whiteheads or blackheads.

Atrophy is a thinning of the epidermal and/or dermaltissue.Keloid overgrows the original wound boundaries andis chronic in nature.

Hypertrophic scar on the other hand does notovergrow the wound boundaries.Fibrosis or sclerosis describes dermal

scarring/thickening reactions.Milium is a small superficial cyst containing keratin(usually 20 mm, duration >30 sec.

HEAD

Procedure:

1. Observe the size, shape and contour of the skull.2. Observe scalp in several areas by separating the hair at

various locations; inquire about any injuries. Notepresence of lice, nits, dandruff or lesions.

3. Palpate the head by running the pads of the fingersover the entire surface of skull; inquire abouttenderness upon doing so. (wear gloves if necessary)

4. Observe and feel the hair condition.5. Test Cranial Nerve VII6. Test Cranial Nerve V


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Normal Findings:

1. Skull Generally round, with prominences in the frontal and

occipital area. (Normocephalic). No tenderness noted upon palpation.

2. Scalp Lighter in color than the complexion. Can be moist or oily. No scars noted.

Free from lice, nits and dandruff. No lesions should be noted. No tenderness nor masses on palpation.

3. Hair Can be black, brown or burgundy depending on therace. Evenly distributed covers the whole scalp (Noevidences of Alopecia)

Maybe thick or thin, coarse or smooth.

Neither brittle nor dry.

FACE

1. Observe the face for shape.2. Inspect for Symmetry.

a. Inspect for the palpebral fissure (distance between theeye lids); should be equal in both eyes.

b. Ask the patient to smile, There should be bilateralNasolabial fold (creases extending from the angle of

the corner of the mouth). Slight asymmetry in the foldis normal.

c. If both are met, then the Face is symmetrical3. Test the functioning of Cranial Nerves that innervates thefacial structures

CN V (Trigeminal)

1. Sensory Function Ask the client to close the eyes. Run cotton wisp over the fore head, check and jaw on both

sides of the face. Ask the client if he/she feel it, and where she feels it. Check for corneal reflex using cotton wisp. The normal response in blinking.

2. Motor function Ask the client to chew or clench the jaw.

The client should be able to clench or chew with strength andforce.

CN VII (Facial)

1. Sensory function (This nerve innervate the anterior 2/3 ofthe tongue). Place a sweet, sour, salty, or bitter substance near the tip ofthe tongue. Normally, the client can identify the taste.

2. Motor function Ask the client to smile, frown, raise eye brow, close eye lids,whistle, or puff the cheeks.

Normal Findings:

Shape maybe oval or rounded. Face is symmetrical.

No involuntary muscle movements. Can move facial muscles at will. Intact cranial nerve V and VII.

EYE / EYEBROW / EYELASHES

Normal findings:Eyebrows

Symmetrical and in line with each other. Maybe black, brown or blond depending on race. Evenly distributed.

Eyes

Evenly placed and inline with each other. Non protruding. Equal palpebral fissure.

Eyelashes Color dependent on race.

Evenly distributed. Turned outward

EYELIDS / LACRIMAL APPARATUS

1. Inspect the eyelids for position and symmetry.2. Palpate the eyelids for the lacrimal glands.

To examine the lacrimal gland, the examiner, lightlyslide the pad of the index finger against the clientsupper orbital rim.

Inquire for any pain or tenderness.3. Palpate for the nasolacrimal duct to check for obstruction.

To assess the nasolacrimal duct, the examiner presseswith the index finger against the clients lower inner

orbital rim, at the lacrimal sac, NOT AGAINST THENOSE.

In the presence of blockage, this will cause

regurgitation of fluid in the puncta

Normal Findings:

Eyelids

Upper eyelids cover the small portion of the iris, cornea, andsclera when eyes are open. No PTOSIS noted. (drooping of upper eyelids).

Meets completely when eyes are closed. Symmetrical.

Lacrimal Apparatus Lacrimal gland is normally non palpable.

No tenderness on palpation. No regurgitation from the nasolacrimal duct.

CONJUNCTIVAE

The bulbar and palpebral conjunctivae are examinedby separating the eyelids widely and having the client look up,down and to each side. When separating the lids, the examinershould exert no NO PRESSURE against the eyeball; rather, the


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examiner should hold the lids against the ridges of the bonyorbit surrounding the eye.

In examining the palpebral conjunctiva, everting the uppereyelid in necessary and is done as follow:

1. Ask the client to look down but keep his eyes slightly open.This relaxes the levator muscles, whereas closing the eyes

contracts the orbicularis muscle, preventing lid eversion.2. Gently grasp the upper eyelashes and pull gently downward.Do not pull the lashes outward or upward; this, too, causesmuscles contraction.

3. Place a cotton tip application about I can above the lidmargin and push gently downward with the applicator while stillholding the lashes. This everts the lid.4. Hold the lashes of the everted lid against the upper ridge of

the bony orbit, just beneath the eyebrow, never pushing againstthe eyebrow.5. Examine the lid for swelling, infection, and presence offoreign objects.

6. To return the lid to its normal position, move the lid slightly

forward and ask the client to look up and to blink. The lidreturns easily to its normal position.

Normal Findings:

Both conjunctivae are pinkish or red in color.

With presence of many minutes capillaries. Moist No ulcers No foreign objects

SCLERAE

The sclerae is easily inspected during the assessment of the

conjunctivae.

Normal Findings:

Sclerae is white in color (anicteric sclera) No yellowish discoloration (icteric sclera). Some capillaries maybe visible.

Some people may have pigmented positions.

CORNEA

The cornea is best inspected by directing penlight obliquelyfrom several positions.

Normal findings:

There should be no irregularities on the surface. Looks smooth. The cornea is clear or transparent. The features of the irisshould be fully visible through the cornea. There is a positive corneal reflex.

ANTERIOR CHAMBER / IRIS

The anterior chamber and the iris are easily inspectedin conjunction with the cornea. The technique of obliqueillumination is also useful in assessing the anterior chamber.

Normal Findings:

The anterior chamber is transparent. No noted any visible materials. Color of the iris depends on the persons race (black, blue,

brown or green).

From the side view, the iris should appear flat and should notbe bulging forward. There should be NO crescent shadow castedon the other side when illuminated from one side.

PUPIL

Examination of the pupils involves severalinspections, including assessment of the size, shape reaction to

light is directed is observed for direct response of constriction.Simultaneously, the other eye is observed for consensualresponse of constriction.

The test for papillary accommodation is theexamination for the change in papillary size as the is switched

from a distant to a near object.

1. Ask the client to stare at the objects across room.

2. Then ask the client to fix his gaze on the examiners indexfingers, which is placed 55 inches from the clients nose.3. Visualization of distant objects normally causes papillarydilation and visualization of nearer objects causes papillaryconstriction and convergence of the eye.

Normal Findings:

Pupillary size ranges from 37 mm, and are equal in size.

Equally round.

Constrict briskly/sluggishly when light is directed to the eye,both directly and consensual. Pupils dilate when looking at distant objects, and constrictwhen looking at nearer objects.

If all of which are met, we document the findingsusing the notation PERRLA, pupils equally round, reactive tolight, and accommodate


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CRANIAL NERVE II ( OPTIC NERVE )

The optic nerve is assessed by testing for visual acuityand peripheral vision.

Visual acuity is tested using a snellen chart, for those

who are illiterate and unfamiliar with the western alphabet, theilliterate E chart, in which the letter E faces in different

directions, maybe used. The chart has a standardized number atthe end of each line of letters; these numbers indicates thedegree of visual acuity when measured at a distance of 20 feet.

The numerator 20 is the distance in feet between the

chart and the client, or the standard testing distance. Thedenominator 20 is the distance from which the normal eye can

read the lettering, which correspond to the number at the end ofeach letter line; therefore the larger the denominator the poorerthe version.

Measurement of 20/20 vision is an indication of either

refractive error or some other optic disorder.

In testing for visual acuity you may refer to the following:

1. The room used for this test should be well lighted.2. A person who wears corrective lenses should be tested with

and without them to check fro the adequacy of correction.3. Only one eye should be tested at a time; the other eye

should be covered by an opaque card or eye cover, not withclients finger.4. Make the client read the chart by pointing at a letterrandomly at each line; maybe started from largest to smallest or

vice versa.5. A person who can read the largest letter on the chart

(20/200) should be checked if they can perceive hand movementabout 12 inches from their eyes, or if they can perceive the lightof the penlight directed to their yes.

Peripheral Vision or visual fields

The assessment of visual acuity is indicative of the

functioning of the macular area, the area of central vision.However, it does not test the sensitivity of the other areas of theretina which perceive the more peripheral stimuli. The Visualfield confrontation test, provide a rather gross measurement ofperipheral vision.

The performance of this test assumes that the

examiner has normal visual fields, since that clients visualfields are to be compared with the examiners.

Follow the steps on conducting the test:

1. The examiner and the client sit or stand opposite eachother, with the eyes at the same, horizontal level with thedistance of 1.52 feet apart.

2. The client covers the eye with opaque card, and theexaminer covers the eye that is opposite to the client coveredeye.

3. Instruct the client to stare directly at the examiners eye,while the examiner stares at the clients open eye. Neither looksout at the object approaching from the periphery.

4. The examiner hold an object such as pencil or penlight, inhis hand and gradually moves it in from the periphery of bothdirections horizontally and from above and below.5. Normally the client should see the same time the examiners

sees it. The normal visual field is 180 degress

CRANIAL NERVE III, IV & VI

( Oculomotor,Trochlear,Abducens )

All the 3 Cranial nerves are tested at the same time by

assessing the Extra Ocular Movement (EOM) or the six cardinalposition of gaze.

Follow the given steps:

1. Stand directly in front of the client and hold a finger or a

penlight about 1 ft from the clients eyes.

2. Instruct the client to follow the direction the object hold bythe examiner by eye movements only; that is with out movingthe neck.3. The nurse moves the object in a clockwise direction

hexagonally.4. Instruct the client to fix his gaze momentarily on theextreme position in each of the six cardinal gazes.5. The examiner should watch for any jerky movements of the

eye (nystagmus).6. Normally the client can hold the position and there shouldbe no nystagmus.

Test for Accomodation

EAR

1. Inspect the auricles of the ears for parallelism, size position,appearance and skin color.

2. Palpate the auricles and the mastoid process for firmness ofthe cartilage of the auricles, tenderness when manipulating theauricles and the mastoid process.

3. Inspect the auditory meatus or the ear canal for color,presence of cerumen, discharges, and foreign bodies.


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a. For adult pull the pinna upward and backward to straightenthe canal.b. For children pull the pinna downward and backward tostraighten the canal

4. Perform otoscopic examination of the tympanic membrane,noting the color and landmarks.

Normal Findings:

The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outercanthus of the eye.

Skin is same in color as in the complexion. No lesions noted on inspection.

The auricles are has a firm cartilage on palpation. The pinna recoils when folded. There is no pain or tenderness on the palpation of the auriclesand mastoid process.

The ear canal has normally some cerumen of inspection. No discharges or lesions noted at the ear canal.

On otoscopic examination the tympanic membrane appearsflat, translucent and pearly gray in color.

VESTIBULOCHOCLEAR NERVE

( CRANIAL NERVE VII )

Examination of the cranial nerve VIII involves testing forhearing acuity and balance.

Hearing Acuity

A. Voice test

1. The examiner stands 2 ft. on the side of the ear to be tested.2. Instruct the client to occlude the ear canal of the other ear.3. The examiner then covers the mouth, and using a softspoken voice, whispers non-sequential number (e.g. 3 5 7 ) for

the client to repeat.4. Normally the client will be able to hear and repeat thenumber.5. Repeat the procedure at the other ear.

B. Watcher test

1. Ask the client to close the eyes.2. Place a mechanical watch 12 inches away the clients ear.

3. Ask the client if he hears anything4. If the client says yes, the examiner should validate byasking at what are you hearing and at what side.5. Repeat the procedure on the other ear.

6. Normally the client can identify the sound and at what sideit was heard.

Turning Fork Test

This test is useful in determining whether the clienthas a conductive hearing loss (problem of external or middleear) or a perceptive hearing loss (sensorineural). There are 2types of tuning fork test being conducted:

1. Webers testassesses bone conduction, this is a test of

sound lateralization; vibrating tuning fork is placed on themiddle of the fore head or top of the skull.

Normal: hear sounds equally in both ears (No Lateralization ofsound)

Conduction lossSound lateralizes to defective ear (Heardlouder on defective ear) as few extraneous sounds are carriedthrough the external and middle ear.

Sensorineural lossSound lateralizes on better ear.

2.Rinne TestCompares bone conduction with air condition.

a. Vibrating tuning fork placed on the mastoid processb. Instruction client to inform the examiner when he no longer

hears the tuning fork sounding.c. Position in the tuning fork in front of the clients ear canalwhen he no longer hears it.

Normal: Sound should be heard when tuning fork is placed infront of the ear canal as air conduction< bone conduction by 2:1(positive rinne test)

Conduction loss: Sound is heard longer by bone conduction thanby air conduction.

Sensorineural loss: Sound is heard longer by air conduction thanby bone conduction

NOSE AND PARANASAL SINUSES

The external portion of the nose is inspected for the following:

1. Placement and symmetry.2. Patency of nares (done by occluding nosetril one at a time,

and noting for difficulty in breathing)3. Flaring of alaenasi

4. Discharge

The external nares are palpated for:

1. Displacement of bone and cartilage.2. For tenderness and masses

The internal nares are inspected by heperextending the neck ofthe client, the ulnar aspect of the examiners hard over the forehead of the client, and using the thumb to push the tip of thenose upward while shining a light into the naris.


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Inspect for the following:

1. Position of the septum.2. Check septum for perforation. (can also be checked bydirecting the lighted penlight on the side of the nose,illumination at the other side suggests perforation).

3. The nasal mucosa (turbinates) for swelling, exudates andchange in color.

Paranasal Sinuses

Examination of the paranasal sinuses is indirectly.Information about their condition is gained by inspection and

palpation of the overlying tissues. Only frontal and maxillarysinuses are accessible for examination.

By palpating both cheeks simultaneously, one candetermine tenderness of the maxillary sinusitis, and pressing thethumb just below the eyebrows, we can determine tenderness of

the frontal sinuses.

Normal Findings:

1. Nose in the midline2. No Discharges.3. No flaring alae nasi.

4. Both nares are patent.5. No bone and cartilage deviation noted on palpation.6. No tenderness noted on palpation.

7. Nasal septum in the mid line and not perforated.8. The nasal mucosa is pinkish to red in color. (Increased

redness turbinates are typical of allergy).9. No tenderness noted on palpation of the paranasal sinuses.

OLFACTORY NERVE

To test the adequacy of function of the olfactory nerve:

1. The client is asked to close his eyes and occlude.2. The examiner places aromatic and easily distinguish

nose. (e.g. coffee).3. Ask the client to identify the odor.4. Each side is tested separately, ideally with two

different substances.

MOUTH

Mouth and Oropharynx Lips are inspected for:

1. Symmetry and surface abnormalities.2. Color3.

Edema

Normal Findings:

1. With visible margin2. Symmetrical in appearance and movement3. Pinkish in color4. No edema

Palpate the temporomandibular while the mouth is openedwide and then closed for:

1. Crepitous2. Deviations3. Tenderness

Normal Findings:

1. Moves smoothly no crepitous.2. No deviations noted3. No pain or tenderness on palpation and jaw

movement.

Gums are inspected for:

1. Color2. Bleeding3. Retraction of gums.

Normal Findings:

1. Pinkish in color2. No gum bleeding3. No receding gums

Teeth are inspected for:

1. Number2. Color3. Dental carries4.

Dental fillings5. Alignment and malocclusions (2 teeth in the space for1, or overlapping teeth).

6. Tooth loss7. Breath should also be assessed during the process.

Normal Findings:

1. 28 for children and 32 for adults.2. White to yellowish in color3. With or without dental carries and/or dental fillings.4. With or without malocclusions.5. No halitosis.

Tongue is palpated for:

Texture

Normal Findings:

1. Pinkish with white taste buds on the surface.2. No lesions noted.3. No varicosities on ventral surface.4. Frenulum is thin attaches to the posterior 1/3 of the

ventral aspect of the tongue.


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5. Gag reflex is present.6. Able to move the tongue freely and with strength.7. Surface of the tongue is rough.

Uvula is inspected for:

1.

Position2. Color3. Cranial Nerve X (Vagus nerve)Tested by asking the

client to say Ah note that the uvula will moveupward and forward.

Normal Findings:

1. Positioned in the mid line.2. Pinkish to red in color.3. No swelling or lesion noted.4. Moves upward and backwards when asked to say ah

Tonsils are inspected for:

1. Inflammation2. Size

A Grading system used to describe the size of the tonsils can beused.

Grade 1Tonsils behind the pillar.

Grade 2Between pillar and uvula.

Grade 3Touching the uvula

Grade 4In the midline.

NECK

The neck is inspected for position symmetry and obvious lumpsvisibility of the thyroid gland and Jugular Venous Distension.

Normal Findings:

1. The neck is straight.2. No visible mass or lumps.3. Symmetrical4. No jugular venous distension (suggestive of cardiac

congestion).

The neck is palpated just above the suprasternal note using the

thumb and the index finger.

The neck is palpated just above the suprasternal note using thethumb and the index finger.

Normal Findings:

1. The trachea is palpable.2. It is positioned in the line and straight.

mph nodes are palpated using palmar tips of the fingers viasystemic circular movements. Describe lymph nodes in termsofsize, regularity, consistency, tenderness and fixation tosurrounding tissues.

Normal Findings:

1. May not be palpable. Maybe normally palpable in thinclients.

2. Non tender if palpable.3. Firm with smooth rounded surface.4. Slightly movable.5. About less than 1 cm in size.6. The thyroid is initially observed by standing in frontof the client and asking the client to swallow.

Palpation of the thyroid can be done either byposterior or anterior approach.

Indication of Lymph Nodes

Occipital: Head infection Submental: Dental Carriections, Oral inf SubMandibular: Infection SCM Upper: Lymphoma Supraclavicular: Cancer

Posterior Approach:

1. Let the client sit on a chair while the examiner standsbehind him.

2. In examining the isthmus of the thyroid, locate thecricoid cartilage and directly below that is the isthmus.

3. Ask the client to swallow while feeling for anyenlargement of the thyroid isthmus.

4. To facilitate examination of each lobe, the client isasked to turn his head slightly toward the side to be

examined to displace the sternocleidomastoid, whilethe other hand of the examiner pushes the thyroidcartilage towards the side of the thyroid lobe to beexamined.

5. Ask the patient to swallow as the procedure is beingdone.

6. The examiner may also palate for thyroid enlargementby placing the thumb deep to and behind the

sternocleidomastoid muscle, while the index andmiddle fingers are placed deep to and in front of themuscle.

7. Then the procedure is repeated on the other side.


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Anterior approach:

1. The examiner stands in front of the client and with thepalmar surface of the middle and index fingerspalpates below the cricoid cartilage.

2. Ask the client to swallow while palpation is beingdone.

3. In palpating the lobes of the thyroid, similar procedureis done as in posterior approach. The client is asked toturn his head slightly to one side and then the other of

the lobe to be examined.4. Again the examiner displaces the thyroid cartilage

towards the side of the lobe to be examined.5. Again, the examiner palpates the area and hooks

thumb and fingers around the sternocleidomastoidmuscle.

Normal Findings:

1. Normally the thyroid is non palpable.2. Isthmus maybe visible in a thin neck.3. No nodules are palpable.

Auscultation of the Thyroid is necessary when there is thyroidenlargement. The examiner may hear bruits, as a result of

increased and turbulence in blood flow in an enlarged thyroid.

Check the Range of Movement of the neck.

THORAX

Lung borders

In the anterior thorax, the apices of the lungs extendfor approximately 34 cm above the clavicles. The inferiorborders of the lungs cross the sixth rib at the midclavigular line.

In the posterior thorax, the apices extend of T10 onexpiration to the spinous process of T12 on inspiration.

In the Lateral Thorax, the lungs extend from the apexof the axilla to the 8th rib of the midaxillary line.

Lung Fissures

The right oblique (diagonal) fissure extend from the

area of the spinous process of the 3rd thoracic vertebra, laterallyand downward unit it crosses the 5th rib at the midaxillary line. Itthen continues ant medially to end at the 6th rib at themidclavicular line.

The right horizontally fissure extends from the 5th rib

slightly posterior to the right midaxillary line and runshorizontally to thee area of the 4th rib at the right sternal border.

The left oblique (diagonal) fissure extend from thespinous process of the 3rd thoracic vertebra laterally anddownward to the left mid axillary line at the 5th rib andcontinues anteriorly and medially until it terminates at the 6 th ribin the midclavicular line.

Borders of the Diaphragm.

Anteriorly, on expiration, the right dome of thediaphragm is located at the level of the 5th rib at themidclavicular line and he left dome is at the level of the 6th rib.Posteriorly, on expiration, the diaphragm is at the level of the

spinous process of T10; laterally it is at the 8 th rib at themidaxillary line. On inspiration the diaphragm movesapproximately 1.5 cm downward.

Inspection of the Thorax

For adequate inspection of the thorax, the client should be sittingupright without support and uncovered to the waist.

The examiner should observe:

1. Shape of the thorax and its symmetry.2. Thoracic configuration.3. Retractions at the ICS on inspiration.

(suprasternal, costal, substernal)4. Bulging structures at the ICS during

expiration.

5. position of the spine.6. pattern of respiration.

Normal Findings:

The shape of the thorax in a normal adult is elliptical;the anteroposterior diameter is less than the transverse

diameter at approximately a ratio of 1:2.

Moves symmetrically on breathing with no obviousmasses.

No fail chest which is suggestive of rib fracture.

No chest retractions must be noted as this may suggestdifficulty in breathing.

No bulging at the ICS must be noted as this mayobstruction on expiration, abnormal masses, or

cardiomegaly.

The spine should be straight, with slightly curvature inthe thoracic area.

There should be no scoliosis, kyphosis, or lordosis.

Breathing maybe diaphragmatically of costally.

Expiration is usually longer the inspiration.

Palpation of the Thorax

1. General palpationThe examiner should specificallypalpate any areas of abnormality. The temperature andturgor of the skin should be assessed. Palpate forlumps, masses and areas of tenderness.

2. Palpate for thoracic expansion or lung excursion.A. Anteriorly, the examiners hands are placed

over the anterolateral chest with the thumbs

extended along the costal margin, pointingto the xyphoid process. Posteriorly, thethumbs are placed at the level of the 10th riband the palms are placed on the

posterolateral chest.B. Instruct the client to exhale first, then toinhale deeply.

C. The examiner the amount of thoracicexpansion during quiet and deep inspirationand observe for divergence of the thumbs onexpiration.

D. Normally, symmetry of respiration betweenthe left and right hemithoraces should be feltas the thumbs are separated are separatedapproximately 35 cm (12 inches)during deep inspiration.


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Physical Assessment



1. Palpate for the tactile fremitus.A. Place the palm or the ulnar aspect of the

hands bilaterally symmetrical on the chestwall starting from the top, then at thenmedial thoracic wall, and at the anterolateral

B. Each time the hands move down, ask theclient to say ninety-nine.

C. Repeat the procedure at the posteriorthoracic wall.

D. Normally, tactile fremitus should bebilaterally symmetrical. Most intense in the

2nd ICS at the sternal border, near the area ofbronchial bifurcation. Low pitched voices of

males are more readily palpated than higherpitched voices of females.

E. Basic abnormalities like increased tactilefremitus maybe suggestive of consolidation;

decreased tactile fremitus may be suggestiveof obstructions, thickening of pleura, orcollapse of lungs.

Percussion of the Thorax

Anterior thorax:

A. Patient maybe placed on a supine position.B. Percuss systematically at about 5 cm intervals from

the upper to lower chest, moving left to right to left.(Percuss over the ICS, avoiding the ribs. Use indirectpercussion starting at the apices of the lungs.

C. The examiner notes the sound produced during eachpercussion.

Whispered PectorioquyAsk the client top whisper 1-2-3Over normal lung tissue it would almost be indistinguishable,over consolidated lung it would be loud and clear

Percuss the diaphragmatic excursion

Auscultation of the Thorax

Normal Breath Sound

Vesicular Soft, low pitch Lung periphery

Broncho-vesicular Medium pitch Larger airwayblowing

Bronchial Loud, high pitch Trachea

Abnormal Breath Sound

Crackles Dependent lobes Random, suddenreinflation of alveolifluids

Rhonchi Trachea, bronchi Fluids, mucusWheezes All lung fields Severely narrowed

bronchus

Pleural Friction

Rub

Lateral lung field Inflamed Pleura

Elderly:

Physical Changes of Thorax and Breathing Patterns

Kyphosis Anteroposterior diameter of the chest widens Breathing rate and rhythm are unchanged at rest Inspiratory muscles become less powerful, and

inspiration reserve volume decreases.

Expiration may require the use of accessory muscles Deflation of the lung is incomplete Small airways lose their cartilaginous support and

elastic recoil Elastic tissue of the alveoli loses its stretchability and

changes to fibrous tissue. Exertional capacity also

decreases. Cilia in the airways decrease in number and are less

effective in removing mucus, therefore they are atgreater risk for pulmonary infections.


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Nursing Skills

Physical Assessment



CARDIOVASCULAR SYSTEM

Inspection of the Heart

The chest wall and epigastrum is inspected while the client is insupine position. Observe for pulsation and heaves or lifts

Normal Findings:

1. Pulsation of the apical impulse maybe visible. (thiscan give us some indication of the cardiac size).

2. There should be no lift or heaves.Jugular Venous Pressure

1. Position the patient supine with the head of the tableelevated 30 degrees.

2. Use tangential, side lighting to observe for venouspulsations in the neck.

3. Look for a rapid, double (sometimes triple) wave witheach heart beat. Use light pressure just above the

sternal end of the clavicle to eliminate the pulsationsand rule out a carotid origin.

4. Adjust the angle of table elevation to bring out thevenous pulsation.

5. Identify the highest point of pulsation. Using ahorizontal line from this point, measure vertically

from the sternal angle.6. This measurement should be less than 4 cm in a

normal healthy adult.

Precordial Movement

1. Position the patient supine with the head of the tableslightly elevated.2. Always examine from the patient's right side.

3. Inspect for precordial movement. Tangential lightingwill make movements more visible.

4. Palpate for precordial activity in general. You mayfeel "extras" such as thrills or exaggerated ventricularimpulses.

5. Palpate for the point of maximal impulse (PMI orapical pulse). It is normally located in the 4th or 5th

intercostal space just medial to the midclavicular lineand is less than the size of a quarter.

6. Note the location, size, and quality of the impulse.

Palpation of the Heart

The entire precordium is palpated methodically using the palms

and the fingers, beginning at the apex, moving to the left sternalborder, and then to the base of the heart.

Normal Findings:

1. No, palpable pulsation over the aortic, pulmonic, andmitral valves.

2. Apical pulsation can be felt on palpation.

3. There should be no noted abnormal heaves, and thrillsfelt over the apex.

Percussion of the Heart

The technique of percussion is of limited value in cardiac

assessment. It can be used to determine borders of cardiacdullness.

Auscultation of the Heart

:

Anatomic areas for auscultation of the heart

Aortic valveRight 2nd ICS sternal border.

Pulmonic ValveLeft 2nd ICS sternal border.Tricuspid ValveLeft 5th ICS sternal border.

Mitral ValveLeft 5th ICS midclavicular line

Positioning the client for auscultation:

If the heart sounds are faint or undetectable, try

listening to them with the patient seated and learningforward, or lying on his left side, which brings theheart closer to the surface of the chest.

Having the client seated and learning forward s bestsuited for hearing high-pitched sounds related to

semilunar valves problem.

The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems and

extra heart sounds.

Auscultating the heart

1. Auscultate the heart in all anatomic areas aortic,pulmonic, tricuspid and mitral

2. Listen for the S1 and S2 sounds (S1 closure of AVvalves; S2 closure of semilunar valve). S1 sound isbest heard over the mitral valve; S2 is best heard over

the aortric valve.3. Listen for abnormal heart sounds e.g. S3, S4, and

Murmurs.4. Count heart rate at the apical pulse for one full minute.

Normal Findings:

1. S1 & S2 can be heard at all anatomic site.2. No abnormal heart sounds is heard (e.g. Murmurs, S3

& S4).3. Cardiac rate ranges from 60100 bpm.


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Physical Assessment



PERIPHERAL CIRCULATION

Inspect:

Color Edema

Stasis ulcers/lesions Varicosities Hair/nail changes

Palpate:

Temperature Edema Tenderness Symmetry of pulses

BREAST

Inspection of the Breast

There are 4 major sitting position of the client used for clinicalbreast examination. Every client should be examined in eachposition.

1. The client is seated with her arms on her side.

2. The client is seated with her arms abducted over thehead.

3. The client is seated and is pushing her hands into herhips, simultaneously eliciting contraction of thepectoral muscles.

4. The client is seated and is learning over while theexaminer assists in supporting and balancing her.

While the client is performing these maneuvers, thebreasts are carefully observed for symmetry, bulging,retraction, and fixation.

An abnormality may not be apparent in the breasts atrest a mass may cause the breasts, through invasion ofthe suspensory ligaments, to fix, preventing them fromupward movement in position 2 and 4.

Position 3 specifically assists in eliciting dimpling if amass has infiltrated and shortened suspensoryligament

Normal Findings:

1. The overlying the breast should be even.2. May or may not be completely symmetrical at rest.3. The areola is rounded or oval, with same color, (Color

va,ies form light pink to dark brown depending on

race).4. Nipples are rounded, everted, same size and equal in

color.5. No orange peel skin is noted which is present in

edema.

6. The veins maybe visible but not engorge andprominent.

7. No obvious mass noted.8. Not fixated and moves bilaterally when hands are

abducted over the head, or is learning forward.9. No retractions or dimpling.

Palpation of the Breast

Palpate the breast along imaginary concentric circles,following a clockwise rotary motion, from theperiphery to the center going to the nipples. Be surethat the breast is adequately surveyed. Breastexamination is best done 1 week post menses.

Each areolar areas are carefully palpated to determinethe presence of underlying masses.

Each nipple is gently compressed to assess for thepresence of masses or discharge.

Chronic Arterial Insufficiency

Pain Intermittent claudication

Pulse Decreased

Color Pale

Temperature Cool

Edema Absent or mild

SkinChanges

Thin, shiny atrophic skin, hair loss,thickened nails

Ulceration Toes/points of trauma

Gangrene May develop

Chronic Venous Insufficiency

Pain None to aching pain on dependency

Pulse Normal

ColorNormal to cyanotic; petechiae or brownpigmentation

Temperature Warm

Edema Present

Skin Changes Dermatitis skin pigmentation

Ulceration Medial side of ankle

Gangrene Does not develop


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Normal Findings:

No lumps or masses are palpable.

No tenderness upon palpation.

No discharges from the nipples.

NOTE: The male breasts are observed by adapting thetechniques used for female clients. However, the various sittingposition used for woman is unnecessary.

ABDOMEN

In abdominal assessment, be sure that the client has emptied thebladder for comfort. Place the client in a supine position with theknees slightly flexed to relax abdominal muscles.

Inspection of the abdomen

Inspect for skin integrity (Pigmentation, lesions, striae,

scars, veins, and umbilicus).Contour (flat, rounded, scapold)

Distension

Respiratory movement.

Visible peristalsis.

Pulsations

Normal Findings:

Skin color is uniform, no lesions.

Some clients may have striae or scar.

No venous engorgement.

Contour may be flat, rounded or scapoid

Thin clients may have visible peristalsis.

Aortic pulsation maybe visible on thin clients.

Auscultation of the Abdomen

This method precedes percussion because bowelmotility, and thus bowel sounds, may be increased by

palpation or percussion.

The stethoscope and the hands should be warmed; ifthey are cold, they may initiate contraction of theabdominal muscles.

Light pressure on the stethoscope is sufficient to detectbowel sounds and bruits. Intestinal sounds are

relatively high-pitched, the bell may be used inexploring arterial murmurs and venous hum.

Peristaltic sounds

These sounds are produced by the movements of air and fluidsthrough the gastrointestinal tract. Peristalsis can providediagnostic clues relevant to the motility of bowel.

Listening to the bowel sounds (borborygmi) can be facilitated byfollowing these steps:

Divide the abdomen in four quadrants.

Listen over all auscultation sites, starting at the right lowerquadrants, following the cross pattern of the imaginarylines in creating the abdominal quadrants. This direction

ensures that we follow the direction of bowel movement. Peristaltic sounds are quite irregular. Thus it is

recommended that the examiner listen for at least 5minutes, especially at the periumbilical area, before

concluding that no bowel sounds are present. The normal bowel sounds are high-pitched, gurgling noises

that occur approximately every 5 15 seconds. It issuggested that the number of bowel sound may be as low as3 to as high as 20 per minute, or roughly, one bowel soundfor each breath sound.

Some factors that affect bowel sound:

1. Presence of food in the GI tract.2. State of digestion.3. Pathologic conditions of the bowel (inflammation,

Gangrene, paralytic ileus, peritonitis).

4. Bowel surgery5. Constipation or Diarrhea.6. Electrolyte imbalances.7. Bowel obstruction.

Percussion of the abdomen

Abdominal percussion is aimed at detecting fluid inthe peritoneum (ascites), gaseous distension, andmasses, and in assessing solid structures within the

abdomen.

The direction of abdominal percussion follows the

auscultation site at each abdominal guardant.

The entire abdomen should be percussed lightly or ageneral picture of the areas of tympany and dullness.

Tympany will predominate because of the presence of

gas in the small and large bowel. Solid masses willpercuss as dull, such as liver in the RUQ, spleen at the

6th or 9th rib just posterior to or at the mid axillary lineon the left side.

Percussion in the abdomen can also be used inassessing the liver span and size of the spleen.

Percussion of the liver

The palms of the left hand is placed over the region of liverdullness.

1. The area is strucked lightly with a fisted right hand.2. Normally tenderness should notbe elicited by thismethod.

3. Tenderness elicited by this method is usually a resultof hepatitis or cholecystitis.

Renal Percussion

1. Can be done by either indirect or direct method.2. Percussion is done over the costovertebral junction.3. Tenderness elicited by such method suggests renal

inflammation.


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Palpation of the Abdomen

Light palpation

It is a gentle exploration performed while the client is

in supine position. With the examiners hands parallel

to the floor.The fingers depress the abdominal wall, at eachquadrant, by approximately 1 cm without digging, butgently palpating with slow circular motion.

This method is used for eliciting slight tenderness,large masses, and muscles, and muscle guarding.

Tensing of abdominal musculature may occur because of:

1. The examiners hands are too cold or are pressed tovigorously or deep into the abdomen.

2. The client is ticklish or guards involuntarily.3. Presence of subjacent pathologic condition.

Normal Findings:

1. No tenderness noted.2. With smooth and consistent tension.3. No muscles guarding.

Deep Palpation

It is the indentation of the abdomen performed bypressing the distal half of the palmar surfaces of the

fingers into the abdominal wall.

The abdominal wall may slide back and forth whilethe fingers move back and forth over the organ being

examined.Deeper structures, like the liver, and retro peritonealorgans, like the kidneys, or masses may be felt with

this method.

In the absence of disease, pressure produced by deeppalpation may produce tenderness over the cecum, thesigmoid colon, and the aorta.

Liver palpation:

There are two types of bi manual palpation recommended for

palpation of the liver. The first one is the superimposition of theright hand over the left hand.

1.

Ask the patient to take 3 normal breaths.2. Then ask the client to breath deeply and hold. Thiswould push the liver down to facilitate palpation.

3. Press hand deeply over the RUQThe second methods:

1. The examiners left hand is placed beneath the clientat the level of the right 11th and 12th ribs.

2. Place the examiners right hands parallel to the costalmargin or the RUQ.

3. An upward pressure is placed beneath the client topush the liver towards the examining right hand, whilethe right hand is pressing into the abdominal wall.

4. Ask the client to breath deeply.5. As the client inspires, the liver maybe felt to slip

beneath the examining fingers.

Normal Findings:

The liver usually can not be palpated in a normaladult. However, in extremely thin but otherwise wellindividuals, it may be felt a the costal margins.

When the normal liver margin is palpated, it must besmooth, regular in contour, firm and non-tender.

MUSCULOSKELETAL

1. Assess the patients posture, stance, and gait2. Prepare the patient for the examination3. Inspect for any gross abnormalities.4. Inspect and palpate the temporomaddibular joint andjaw.5. Inspect and palpate the neck and spine6. Assess the ROM of the neck7. Assess the ROM of the spine8. Inspect and palpate the upper and lower extremities,

assessing each joint and muscle.

RANGE OF MOTION

TEMPORAL MADIBULAR JOINT AND JAW

RANGE OF MOTION: NECK


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Physical Assessment



RANGE OF MOTION:WRISTS

RANGE OF MOTION: FINGERS

RANGE OF MOTION: ELBOW

RANGE OF MOTION:SHOUDLERS

RANGE OF MOTION:ANKLES

RANGE OF MOTION:KNEES

RANGE OF MOTION:HIPS


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Neurological AssessmentEXTREMITIES

Observation

Involuntary Movements Muscle Symmetry Left to Right Proximal vs. Distal

Atrophy Pay particular attention to the hands, shoulders, and

thighs. Gait

A. Muscle Tone

1. Ask the patient to relax.2. Flex and extend the patient's fingers, wrist, and elbow.3. Flex and extend patient's ankle and knee.4. There is normally a small, continuous resistance to

passive movement.

5. Observe for decreased (flaccid) or increased(rigid/spastic) tone.

B. Muscle Strength

Test strength by having the patient move against your resistance.

Always compare one side to the other.Grade strength on a scale from 0 to 5 "out of five":

Grading Motor Strength

Grade Description

0/5 No muscle movement

1/5 Visible muscle movement, but no movement at the joint

2/5 Movement at the joint, but not against gravity

3/5Movement against gravity, but not against addedresistance

4/5 Movement against resistance, but less than normal

5/5 Normal strength

Test the following:

1. Flexion at the elbow (C5, C6, biceps)2. Extension at the elbow (C6, C7, C8, triceps)3. Extension at the wrist (C6, C7, C8, radial nerve)4. Squeeze two of your fingers as hard as possible

("grip," C7, C8, T1)5. Finger abduction (C8, T1, ulnar nerve)6. Oppostion of the thumb (C8, T1, median nerve)7. Flexion at the hip (L2, L3, L4, iliopsoas)8. Adduction at the hips (L2, L3, L4, adductors)9. Abduction at the hips (L4, L5, S1, gluteus medius and

minimus)

10. Extension at the hips (S1, gluteus maximus)11. Extension at the knee (L2, L3, L4, quadriceps)12. Flexion at the knee (L4, L5, S1, S2, hamstrings)13. Dorsiflexion at the ankle (L4, L5)14. Plantar flexion (S1)

Pronator Drift

1. Ask the patient to stand for 20-30 seconds with botharms straight forward, palms up, and eyes closed.

2. Instruct the patient to keep the arms still while you tapthem briskly downward.

3. The patient will not be able to maintain extension andsupination (and "drift into pronation) with upper motorneuron disease.

C. Coordination and Gait

Rapid Alternating Movements

1. Ask the patient to strike one hand on the thigh, raisethe hand, turn it over, and then strike it back down asfast as possible.

2. Ask the patient to tap the distal thumb with the tip ofthe index finger as fast as possible.

3. Ask the patient to tap your hand with the ball of eachfoot as fast as possible.

Point-to-Point Movements

1. Ask the patient to touch your index finger and theirnose alternately several times. Move your finger aboutas the patient performs this task.

2. Hold your finger still so that the patient can touch itwith one arm and finger outstretched. Ask the patientto move their arm and return to your finger with theireyes closed.

3. Ask the patient to place one heel on the opposite kneeand run it down the shin to the big toe. Repeat with thepatient's eyes closed.

Romberg

1. Be prepared to catch the patient if they are unstable.2. Ask the patient to stand with the feet together and eyes

closed for 5-10 seconds without support.3. The test is said to be positive if the patient becomes

unstable (indicating a vestibular or proprioceptiveproblem).

Gait

Ask the patient to:

1. Walk across the room, turn and come back2. Walk heel-to-toe in a straight line3. Walk on their toes in a straight line4. Walk on their heels in a straight line5. Hop in place on each foot6. Do a shallow knee bend7. Rise from a sitting position

D. Reflexes

Deep Tendon Reflexes

The patient must be relaxed and positioned properlybefore starting.

Reflex response depends on the force of yourstimulus. Use no more force than you need to provokea definite response.

Reflexes can be reinforced by having the patientperform isometric contraction of other muscles(clenched teeth).

Reflexes should be graded on a 0 to 4 "plus" scale:


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Tendon Reflex Grading Scale

Grade Description

0 Absent

1+ or + Hypoactive

2+ or ++ "Normal"

3+ or +++ Hyperactive without clonus

4+ or ++++ Hyperactive with clonus

Biceps (C5, C6)

1. The patient's arm should be partially flexed at theelbow with the palm down.

2. Place your thumb or finger firmly on the bicepstendon.

3. Strike your finger with the reflex hammer.4. You should feel the response even if you can't see it.

Triceps (C6, C7)

1. Support the upper arm and let the patient's forearmhang free.

2. Strike the triceps tendon above the elbow with thebroad side of the hammer.

3. If the patient is sitting or lying down, flex the patient'sarm at the elbow and hold it close to the chest.

Brachioradialis (C5, C6)

1. Have the patient rest the forearm on the abdomen orlap.

2. Strike the radius about 1-2 inches above the wrist.3. Watch for flexion and supination of the forearm.

Abdominal (T8, T9, T10, T11, T12)

1. Use a blunt object such as a key or tongue blade.2. Stroke the abdomen lightly on each side in an inward

and downward direction above (T8, T9, T10) andbelow the umbilicus (T10, T11, T12).

3. Note the contraction of the abdominal muscles anddeviation of the umbilicus towards the stimulus.

Knee (L2, L3, L4)

1. Have the patient sit or lie down with the knee flexed.2. Strike the patellar tendon just below the patella.3. Note contraction of the quadraceps and extension of

the knee.

Ankle (S1, S2)

1. Dorsiflex the foot at the ankle.2. Strike the Achilles tendon.3. Watch and feel for plantar flexion at the ankle.

Clonus

If the reflexes seem hyperactive, test for ankle clonus:

1. Support the knee in a partly flexed position.2. With the patient relaxed, quickly dorsiflex the foot.3. Observe for rhythmic oscillations.

Plantar Response (Babinski)

1. Stroke the lateral aspect of the sole ofeach foot with the end of a reflexhammer or key.

2. Note movement of the toes, normallyflexion (withdrawal).

3. Extension of the big toe with fanning ofthe other toes is abnormal. This isreferred to as a positive Babinski.

E. Sensory

General

Explain each test before you do it. Unless otherwise specified, the patient's eyes

should be closed during the actual testing. Compare symmetrical areas on the two sides of the

body.

Also compare distal and proximal areas of theextremities. When you detect an area of sensory loss map out

its boundaries in detail.

1. Vibration

Use a low pitched tuning fork (128Hz).

1. Test with a non-vibrating tuning fork first toensure that the patient is responding to the correctstimulus.

2. Place the stem of the fork over the distalinterphalangeal joint of the patient's index fingers

and big toes.3. Ask the patient to tell you if they feel the vibration.

If vibration sense is impaired proceed proximally: ++

1. Wrists2. Elbows3. Medial malleoli4. Patellas5. Anterior superior iliac spines6. Spinous processes7. Clavicles

2. Subjective Light Touch

Use your fingers to touch the skin lightly on both sidessimultaneously.

Test several areas on both the upper and lower

extremities.

Ask the patient to tell you if there is difference from

side to side or other "strange" sensations.

3. Position Sense

1. Grasp the patient's big toe and hold it away from theother toes to avoid friction.

2. Show the patient "up" and "down."3. With the patient's eyes closed ask the patient to

identify the direction you move the toe.4. If position sense is impaired move proximally to test

the ankle joint.5. Test the fingers in a similar fashion.6. If indicated move proximally to the

metacarpophalangeal joints, wrists, and elbows.
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4. Dermatomal Testing

If vibration, position sense, and subjective light touch arenormal in the fingers and toes you may assume the rest of thisexam will be normal.

5. Pain

Use a suitable sharp object to test "sharp" or "dull" sensation.Test the following areas:

1. Shoulders (C4)2. Inner and outer aspects of the forearms (C6 and T1)3. Thumbs and little fingers (C6 and C8)4. Front of both thighs (L2)5. Medial and lateral aspect of both calves (L4 and L5)6. Little toes (S1)

5. Temperature

Often omitted if pain sensation is normal.

Use a tuning fork heated or cooled by water and ask

the patient to identify "hot" or "cold."

Test the following areas:


6. Light Touch

Use a fine whisp of cotton or your fingers to touch theskin lightly.

Ask the patient to respond whenever a touch is felt.

Test the following areas:


7. Discrimination

Since these tests are dependent on touch and position sense, theycannot be performed when the tests above are clearly abnormal.

Graphesthesia

1. With the blunt end of a pen or pencil, draw a largenumber in the patient's palm.

2. Ask the patient to identify the number.Stereognosis

1. Use as an alternative to graphesthesia. ++2. Place a familiar object in the patient's hand (coin,

paper clip, pencil, etc.).3. Ask the patient to tell you what it is.

Two Point Discrimination

1. Use in situations where more quantitative data areneeded, such as following the progression of acortical lesion. ++

2. Use an opened paper clip to touch the patient'sfinger pads in two places simultaneously.

3. Alternate irregularly with one point touch.4. Ask the patient to identify "one" or "two."5. Find the minimal distance at which the patient can

discriminate.

SAMPLE CHARTING

Ms. X is a young, healthy-appearing woman, well-groomed, fit,and in good spirits. Height is 54, weight 135 lbs, BP 120/80,HR 72 and regular, RR 16, temperature 37.50C.

SKIN: Color good. Skin warm and moist. Nails withoutclubbing or cyanosis.

EENT:

Headskull is normocephalic/atraumatic(NC/AT). Hair withaverage texture.

Eyesvisual acuity 20/20 bilaterally. Sclera white; conjunctivapink. Pupils constrcit 4 mm to 2 mm, equally round and reactiveto light and accommodations.

Earsacuity good. Weber midline. Nosenasal mucosa pink,septum midline, no sinus tenderness. Throat(mouth)oralmucosa pink; dentition good; pharynx without exudates.

Necktrachea midline. Neck supple; thyroid isthmus palpable,

lobe not felt.

Lymph nodesno cervical adenopathy.

THORAX AND LUNGS:

INSPECTION- A-P diameter not increased- Lips, nailbeds pink- Thorax slightly asymmetrical- Full expansion equal bilaterally

PALPATION- No tenderness- No enlargement of lymph nodes- Fremitus equal bilaterally

PERCUSSION- Lung field resonant- Diaphragmatic excursion4cm bilaterally

AUSCULTATION

- Breath sounds clear- No rales, rhonchi, or rubs- BREAST AND AXILLAE:- Breast symmetric and without masses. Nipples

without discharge.- No axillary adenopathy

CARDIOVASCULAR EXAM:- PMI is tapping, 2 cm lateral to the midsternal line in

the 5th ICS.- Good S1 and S2- No murmurs or extra sounds

ABDOMEN:- Abdomen is protuberant with active bowel sounds. It

is soft and non-tender; no masses orhepatosplenomegaly. Liver span is 7cm; edge issmooth and palpable 1 cm below the right costalmargin. Spleen and kidneys not felt.

MUSCULOSKELETAL SYSTEM:- Good range of motion in all joints. No evidence of

swelling or deformity.- Mental status: alert, relaxed, and cooperative. Thought

process coherent. Oriented to person, place, and time.- Cranial nerves: IXII intact.- Motor: Good muscle bulk and tone. Strength 5/5

throughout.

- Cerebellar: RAM, intact. Gait with normal base.Rombergmaintains balance with eyes closed. Nopronator drift.

- Sensory: Pinprick, light touch, position intact.- Reflexes: 2+ and symmetric
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