Download - Lect 1 physical assessment hand outs
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 1
Foundations of Nursing Abejo
Physical Assessment
NURSING SKILLS
Physical Assessment
Lecturer Mark Fredderick R Abejo RN MAN
PHYSICAL ASSESSMENT
Objectives
Obtain physical data about the clientrsquos functional
abilities
Supplement confirm or refuse data obtained in the
nursing history
Obtain data that will help the nurse data establish
nursing diagnoses and plan the clientrsquos care
Evaluate the physiologic outcomes of health care and
thus the progress of a patientrsquos health problem
Screen presence of cancer
CEPHALOCAUDAL ORDER OF EXAMINATION
AREAS
HEENT
NECK
UPPER EXTREMITIES
CHEST AND BACK
BREAST AND AXILLAE
ABDOMEN
GENITALS
ANUS AND RECTUM
LOWER EXTREMITIES
Note SKIN IS CHECK THROUGHTOUT THE
ASSESSMENT
General Concepts
Approach the client calmly and confidently
Provide privacy
Make sure that all needed instruments are available
before starting the physical assessment
Several positions are frequently required during the
assessment Consider the clientrsquos ability to assume a
position
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 tenderness
Techniques
Place the hand with fingers together parallel
to the area being palpated Press down 1 to 2 cm
Repeat in ever-widening circles until the area to be
examined 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 and
tips of the fingers of one hand to press in 4 cm
Two ndash 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 strokes
in order to produce palpable vibrations and
characteristic sound
It is used to determine the location size shape and
density of underlying structures to detect the presence
of air or fluid in a body space and to elicit tenderness
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 strike
the 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 the
adult
Indirect Percussion
Percussion in which two hands are used and the plexor
strikes the finger of the examinerrsquos other hand which
is 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 to
avoid 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 or
indirectly
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 2
Foundations of Nursing Abejo
Physical Assessment
PERCUSSION SOUNDS
1 RESONANCE ndash Hollow sound Ex normal lung
2 HYPERRESONANCE ndash Booming sound Ex
Emphysematous lung
3 TYMPANY ndash musical or drum sound Ex Stomach
and intestines
4 DULLNESS ndash Thud sound Ex Enlarged spleen full
bladder liver
5 FLATNESS ndash extremely dull sound Ex Muscle or
bone
AUSCULTATION
Listening to sounds produced inside the body
EQUIPMENTS FOR PHYSICAL
EXAMINATION
Sphygmomanometer and stethoscope
Thermometer
Nasal Speculum
Ophthalmoscope
Otoscope
Vaginal Speculum
Tongue depressorblade
Penlight
Cotton Applicators
Tuning fork
Reflex hammer
Clean gloves
Lubricant
GENERAL SURVEY
VITAL SIGNS
GENERAL SURVEY
1 Physical Appearance
2 Level of Conciousness awareness
Alertnessndash Patient is awake and aware of self
and environment
Lethargy ndash When spoken to in a loud voice
patient appears drowsy but opens eye and look
at you responds to questions then falls asleep
Obtundation ndash When shaken gently patient
opens eye and looks at you but responds
slowly and is somewhat confused
Stupor ndash Patient arouses from sleep only after
painful stimuli
Coma ndash Despite repeated painful stimuli
patient remains unarousable with eyes closed
3 Apperance in relation to chronological age
4 Signs of distress
5 Nutritional status
6 Body structure
7 Obvious physical deformities
8 Mobility
9 Behavior
10 Odors of body and breath
11 Facial Expression
12 Mood amp affect
13 Speech
SYSTEMS ASSESSMENT
INTEGUMENTARY SYSTEM
Functions of the Skin
Protection
Absorption
Regulation
Synthesis
Sensory
Procedure
1 Inspects skin surfaces
2 Palpates with fingertips for edema and skin turgor
3 Palpates skin temperature contra-laterally using back
of hands
Assessment
Health History
Presenting problem
Changes in the color and texture of the skin hair
and 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 3
Foundations of Nursing Abejo
Physical Assessment
Effects of Aging in the Skin
Skin vascularity and the number of sweat and
sebaceous glands decrease affecting
thermoregulation
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 less
than 1 cm in diameter
Patch is a large spot that is not palpable amp that is gt 1
cm
Papule is a small superficial bump that is elevated amp
that is lt 1 cm
Plaque is a large superficial bump that is elevated amp gt
1 cm
Nodule is a small bump with a significant deep
component amp is lt 1 cm
Tumor is a large bump with a significant deep
component amp is gt 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 usually
superficial amp that is lt 05 cm
Bulla is a large fluid-filled bubble that is superficial or
deep amp that is gt 05 cm
Pustule is pus containing bubble often categorized
according 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 the
stratum corneum
Scale is very important in the differential
diagnosis since its presence indicates that the
epidermis is involved
Scale is typically present where there is
epidermal inflammation ie psoriasis tinea
eczema
Crust 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 amp creases
from chronic rubbing
Maceration is raw wet tissue
Fissure is a linear crack in the skin often very
painful
Erosion is a superficial open wound with loss of
epidermis or mucosa only
Ulcer is a deep open wound with partial or complete
loss of the dermis or submucosa
Distinct Lesions of the Skin
Wheal or hive describes a short lived (lt 24 hours)
edematous well circumscribed papule or plaque seen
in urticaria
Burrow is a small threadlike curvilinear papule that is
virtually pathognomonic of scabies
Comedone is a small pinpoint lesion typically
referred to as ldquowhiteheadsrdquo or ldquoblackheadsrdquo
Atrophy is a thinning of the epidermal andor dermal
tissue
Keloid overgrows the original wound boundaries and
is chronic in nature
Hypertrophic scar on the other hand does not
overgrow the wound boundaries
Fibrosis or sclerosis describes dermal
scarringthickening reactions
Milium is a small superficial cyst containing keratin
(usually lt1-2 mm in size
Vascular Skin Lesions
Petechiae is a round or purple macule associated with
bleeding tendencies or emboli to skin
Ecchymosis a round or irregular macular lesion larger
than petechiae color varies and changes from black
yellow and green hues Associated with trauma and
bleeding tendencies
Cherry Angioma popular and round red or purple
may blanch with pressure and a normal age-related
skin alteration
Spider Angioma is a red arteriole lesion central
body with radiating branches Commonly seen on
faceneckarms and trunk Associated with liver
disease pregnancy and vitB deficiency
Telangiectasia shaped varies spider-like or linear
bluish in color or sometimes red Does not blanch
when pressure applied Secondary to superficial
dilation of venous vessels and capillaries
Edema - the presence of large amounts of fluid in the interstitial
spaces Usually due to fluid collecting in the subcutaneous
tissue Edema may be localized or generalized
A Some causes are lymphatic obstruction
increased vascular permeability decreased
oncotic pressure due to low levels of plasma
proteins (especially albumin) or renal or
cardiac disease
B Collections of edema are named according
to the site
1 Anasarca - massive generalized
edema
2 Ankle
3 Ascites - peritoneal cavity
4 Hydrothorax - thoracic cavity
5 Periorbital - around the eyes
6 Sacral - lower back
C Edema occurs in dependent areas first
D Edema is graded on a scale considering the
depth of the indentation and the length of
time to return to normal Assessment Press firmly with finger for 5 seconds
Rating Assessment
1+ 5mm depth recovers immediately
2+ 8-10 mm duration 10-15 sec
3+ 11-20 mm duration 15-30 sec
4+ gt20 mm duration gt30 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 Note
presence of lice nits dandruff or lesions
3 Palpate the head by running the pads of the fingers
over the entire surface of skull inquire about
tenderness upon doing so (wear gloves if necessary)
4 Observe and feel the hair condition
5 Test Cranial Nerve VII
6 Test Cranial Nerve V
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 4
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 Skull middot Generally round with prominences in the frontal and
occipital area (Normocephalic)
middot No tenderness noted upon palpation
2 Scalp middot Lighter in color than the complexion
middot Can be moist or oily
middot No scars noted
middot Free from lice nits and dandruff
middot No lesions should be noted
middot No tenderness nor masses on palpation
3 Hair middot Can be black brown or burgundy depending on the
race
middot Evenly distributed covers the whole scalp (No
evidences of Alopecia)
middot Maybe thick or thin coarse or smooth middot Neither brittle nor dry
FACE
1 Observe the face for shape 2 Inspect for Symmetry
a Inspect for the palpebral fissure (distance between the
eye lids) should be equal in both eyes
b Ask the patient to smile There should be bilateral
Nasolabial fold (creases extending from the angle of
the corner of the mouth) Slight asymmetry in the fold
is normal c If both are met then the Face is symmetrical
3 Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)
1 Sensory Function
middot Ask the client to close the eyes
middot Run cotton wisp over the fore head check and jaw on both
sides of the face
middot Ask the client if heshe feel it and where she feels it
middot Check for corneal reflex using cotton wisp
middot The normal response in blinking
2 Motor function
middot Ask the client to chew or clench the jaw
middot The client should be able to clench or chew with strength and force
CN VII (Facial)
1 Sensory function (This nerve innervate the anterior 23 of
the tongue)
middot Place a sweet sour salty or bitter substance near the tip of
the tongue
middot Normally the client can identify the taste
2 Motor function
middot Ask the client to smile frown raise eye brow close eye lids whistle or puff the cheeks
Normal Findings
middot Shape maybe oval or rounded
middot Face is symmetrical
middot No involuntary muscle movements
middot Can move facial muscles at will middot Intact cranial nerve V and VII
EYE EYEBROW EYELASHES
Normal findings
Eyebrows
middot Symmetrical and in line with each other
middot Maybe black brown or blond depending on race middot Evenly distributed
Eyes
middot Evenly placed and inline with each other
middot Non protruding
middot Equal palpebral fissure
Eyelashes
middot Color dependent on race
middot Evenly distributed middot 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 lightly
slide the pad of the index finger against the clientrsquos
upper 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 presses
with the index finger against the clientrsquos lower inner
orbital rim at the lacrimal sac NOT AGAINST THE
NOSE
In the presence of blockage this will cause
regurgitation of fluid in the puncta
Normal Findings
Eyelids
middot Upper eyelids cover the small portion of the iris cornea and
sclera when eyes are open
middot No PTOSIS noted (drooping of upper eyelids)
middot Meets completely when eyes are closed
middot Symmetrical
Lacrimal Apparatus
middot Lacrimal gland is normally non palpable
middot No tenderness on palpation
middot No regurgitation from the nasolacrimal duct
CONJUNCTIVAE
The bulbar and palpebral conjunctivae are examined
by separating the eyelids widely and having the client look up
down and to each side When separating the lids the examiner
should exert no NO PRESSURE against the eyeball rather the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 5
Foundations of Nursing Abejo
Physical Assessment
examiner should hold the lids against the ridges of the bony orbit surrounding the eye
In examining the palpebral conjunctiva everting the upper eyelid 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 causes
muscles contraction
3 Place a cotton tip application about I can above the lid
margin and push gently downward with the applicator while still
holding 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 against
the eyebrow
5 Examine the lid for swelling infection and presence of
foreign 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 lid returns easily to its normal position
Normal Findings
middot Both conjunctivae are pinkish or red in color
middot With presence of many minutes capillaries
middot Moist
middot No ulcers middot No foreign objects
SCLERAE
The sclerae is easily inspected during the assessment of the conjunctivae
Normal Findings
middot Sclerae is white in color (anicteric sclera)
middot No yellowish discoloration (icteric sclera)
middot Some capillaries maybe visible
middot Some people may have pigmented positions
CORNEA
The cornea is best inspected by directing penlight obliquely from several positions
Normal findings
middot There should be no irregularities on the surface
middot Looks smooth
middot The cornea is clear or transparent The features of the iris
should be fully visible through the cornea
middot There is a positive corneal reflex
ANTERIOR CHAMBER IRIS
The anterior chamber and the iris are easily inspected
in conjunction with the cornea The technique of oblique illumination is also useful in assessing the anterior chamber
Normal Findings
middot The anterior chamber is transparent
middot No noted any visible materials
middot Color of the iris depends on the personrsquos race (black blue
brown or green)
middot From the side view the iris should appear flat and should not
be bulging forward There should be NO crescent shadow casted on the other side when illuminated from one side
PUPIL
Examination of the pupils involves several
inspections 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 consensual response of constriction
The test for papillary accommodation is the
examination 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 examinerrsquos index
fingers which is placed 5 ndash 5 inches from the clientrsquos nose
3 Visualization of distant objects normally causes papillary
dilation and visualization of nearer objects causes papillary
constriction and convergence of the eye
Normal Findings
middot Pupillary size ranges from 3 ndash 7 mm and are equal in size
middot Equally round
middot Constrict brisklysluggishly when light is directed to the eye
both directly and consensual
middot Pupils dilate when looking at distant objects and constrict
when looking at nearer objects
If all of which are met we document the findings
using the notation PERRLA pupils equally round reactive to light and accommodate
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 6
Foundations of Nursing Abejo
Physical Assessment
CRANIAL NERVE II ( OPTIC NERVE )
The optic nerve is assessed by testing for visual acuity and peripheral vision
Visual acuity is tested using a snellen chart for those
who are illiterate and unfamiliar with the western alphabet the
illiterate E chart in which the letter E faces in different
directions maybe used The chart has a standardized number at
the end of each line of letters these numbers indicates the degree 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 The
denominator 20 is the distance from which the normal eye can
read the lettering which correspond to the number at the end of
each letter line therefore the larger the denominator the poorer the version
Measurement of 2020 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 with
clientrsquos finger
4 Make the client read the chart by pointing at a letter
randomly at each line maybe started from largest to smallest or
vice versa
5 A person who can read the largest letter on the chart
(20200) should be checked if they can perceive hand movement
about 12 inches from their eyes or if they can perceive the light of 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 the
retina which perceive the more peripheral stimuli The Visual
field confrontation test provide a rather gross measurement of peripheral vision
The performance of this test assumes that the
examiner has normal visual fields since that clientrsquos visual fields are to be compared with the examiners
Follow the steps on conducting the test
1 The examiner and the client sit or stand opposite each
other with the eyes at the same horizontal level with the
distance of 15 ndash 2 feet apart
2 The client covers the eye with opaque card and the
examiner covers the eye that is opposite to the client covered
eye
3 Instruct the client to stare directly at the examinerrsquos eye
while the examiner stares at the clientrsquos open eye Neither looks
out at the object approaching from the periphery
4 The examiner hold an object such as pencil or penlight in
his hand and gradually moves it in from the periphery of both
directions 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 amp VI
( OculomotorTrochlearAbducens )
All the 3 Cranial nerves are tested at the same time by
assessing the Extra Ocular Movement (EOM) or the six cardinal position 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 clientrsquos eyes
2 Instruct the client to follow the direction the object hold by
the examiner by eye movements only that is with out moving
the neck
3 The nurse moves the object in a clockwise direction
hexagonally
4 Instruct the client to fix his gaze momentarily on the
extreme 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 should be no nystagmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 7
Foundations of Nursing Abejo
Physical Assessment
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 of
the cartilage of the auricles tenderness when manipulating the
auricles and the mastoid process
3 Inspect the auditory meatus or the ear canal for color presence of cerumen discharges and foreign bodies
a For adult pull the pinna upward and backward to straighten
the canal
b For children pull the pinna downward and backward to
straighten the canal
4 Perform otoscopic examination of the tympanic membrane
noting the color and landmarks
Normal Findings
middot The ear lobes are bean shaped parallel and symmetrical
middot The upper connection of the ear lobe is parallel with the outer
canthus of the eye
middot Skin is same in color as in the complexion
middot No lesions noted on inspection
middot The auricles are has a firm cartilage on palpation
middot The pinna recoils when folded
middot There is no pain or tenderness on the palpation of the auricles
and mastoid process
middot The ear canal has normally some cerumen of inspection
middot No discharges or lesions noted at the ear canal
middot On otoscopic examination the tympanic membrane appears flat translucent and pearly gray in color
VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )
Examination of the cranial nerve VIII involves testing for
hearing 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 soft
spoken voice whispers non-sequential number (eg 3 5 7 ) for
the client to repeat
4 Normally the client will be able to hear and repeat the
number 5 Repeat the procedure at the other ear
B Watcher test
1 Ask the client to close the eyes
2 Place a mechanical watch 1 ndash 2 inches away the clientrsquos ear
3 Ask the client if he hears anything
4 If the client says yes the examiner should validate by
asking 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 side it was heard
Turning Fork Test
This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural) There are 2
types of tuning fork test being conducted
1 Weberrsquos test ndash assesses bone conduction this is a test of
sound lateralization vibrating tuning fork is placed on the middle of the fore head or top of the skull
Normal hear sounds equally in both ears (No Lateralization of sound)
Conduction loss ndash Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried through the external and middle ear
Sensorineural loss ndash Sound lateralizes on better ear
2 Rinne Test ndash Compares bone conduction with air condition
a Vibrating tuning fork placed on the mastoid process
b 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 clientrsquos ear canal when he no longer hears it
Normal Sound should be heard when tuning fork is placed in
front of the ear canal as air conductionlt bone conduction by 21
(positive rinne test)
Conduction loss Sound is heard longer by bone conduction than by air conduction
Sensorineural loss Sound is heard longer by air conduction than by 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 2
Foundations of Nursing Abejo
Physical Assessment
PERCUSSION SOUNDS
1 RESONANCE ndash Hollow sound Ex normal lung
2 HYPERRESONANCE ndash Booming sound Ex
Emphysematous lung
3 TYMPANY ndash musical or drum sound Ex Stomach
and intestines
4 DULLNESS ndash Thud sound Ex Enlarged spleen full
bladder liver
5 FLATNESS ndash extremely dull sound Ex Muscle or
bone
AUSCULTATION
Listening to sounds produced inside the body
EQUIPMENTS FOR PHYSICAL
EXAMINATION
Sphygmomanometer and stethoscope
Thermometer
Nasal Speculum
Ophthalmoscope
Otoscope
Vaginal Speculum
Tongue depressorblade
Penlight
Cotton Applicators
Tuning fork
Reflex hammer
Clean gloves
Lubricant
GENERAL SURVEY
VITAL SIGNS
GENERAL SURVEY
1 Physical Appearance
2 Level of Conciousness awareness
Alertnessndash Patient is awake and aware of self
and environment
Lethargy ndash When spoken to in a loud voice
patient appears drowsy but opens eye and look
at you responds to questions then falls asleep
Obtundation ndash When shaken gently patient
opens eye and looks at you but responds
slowly and is somewhat confused
Stupor ndash Patient arouses from sleep only after
painful stimuli
Coma ndash Despite repeated painful stimuli
patient remains unarousable with eyes closed
3 Apperance in relation to chronological age
4 Signs of distress
5 Nutritional status
6 Body structure
7 Obvious physical deformities
8 Mobility
9 Behavior
10 Odors of body and breath
11 Facial Expression
12 Mood amp affect
13 Speech
SYSTEMS ASSESSMENT
INTEGUMENTARY SYSTEM
Functions of the Skin
Protection
Absorption
Regulation
Synthesis
Sensory
Procedure
1 Inspects skin surfaces
2 Palpates with fingertips for edema and skin turgor
3 Palpates skin temperature contra-laterally using back
of hands
Assessment
Health History
Presenting problem
Changes in the color and texture of the skin hair
and 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 3
Foundations of Nursing Abejo
Physical Assessment
Effects of Aging in the Skin
Skin vascularity and the number of sweat and
sebaceous glands decrease affecting
thermoregulation
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 less
than 1 cm in diameter
Patch is a large spot that is not palpable amp that is gt 1
cm
Papule is a small superficial bump that is elevated amp
that is lt 1 cm
Plaque is a large superficial bump that is elevated amp gt
1 cm
Nodule is a small bump with a significant deep
component amp is lt 1 cm
Tumor is a large bump with a significant deep
component amp is gt 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 usually
superficial amp that is lt 05 cm
Bulla is a large fluid-filled bubble that is superficial or
deep amp that is gt 05 cm
Pustule is pus containing bubble often categorized
according 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 the
stratum corneum
Scale is very important in the differential
diagnosis since its presence indicates that the
epidermis is involved
Scale is typically present where there is
epidermal inflammation ie psoriasis tinea
eczema
Crust 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 amp creases
from chronic rubbing
Maceration is raw wet tissue
Fissure is a linear crack in the skin often very
painful
Erosion is a superficial open wound with loss of
epidermis or mucosa only
Ulcer is a deep open wound with partial or complete
loss of the dermis or submucosa
Distinct Lesions of the Skin
Wheal or hive describes a short lived (lt 24 hours)
edematous well circumscribed papule or plaque seen
in urticaria
Burrow is a small threadlike curvilinear papule that is
virtually pathognomonic of scabies
Comedone is a small pinpoint lesion typically
referred to as ldquowhiteheadsrdquo or ldquoblackheadsrdquo
Atrophy is a thinning of the epidermal andor dermal
tissue
Keloid overgrows the original wound boundaries and
is chronic in nature
Hypertrophic scar on the other hand does not
overgrow the wound boundaries
Fibrosis or sclerosis describes dermal
scarringthickening reactions
Milium is a small superficial cyst containing keratin
(usually lt1-2 mm in size
Vascular Skin Lesions
Petechiae is a round or purple macule associated with
bleeding tendencies or emboli to skin
Ecchymosis a round or irregular macular lesion larger
than petechiae color varies and changes from black
yellow and green hues Associated with trauma and
bleeding tendencies
Cherry Angioma popular and round red or purple
may blanch with pressure and a normal age-related
skin alteration
Spider Angioma is a red arteriole lesion central
body with radiating branches Commonly seen on
faceneckarms and trunk Associated with liver
disease pregnancy and vitB deficiency
Telangiectasia shaped varies spider-like or linear
bluish in color or sometimes red Does not blanch
when pressure applied Secondary to superficial
dilation of venous vessels and capillaries
Edema - the presence of large amounts of fluid in the interstitial
spaces Usually due to fluid collecting in the subcutaneous
tissue Edema may be localized or generalized
A Some causes are lymphatic obstruction
increased vascular permeability decreased
oncotic pressure due to low levels of plasma
proteins (especially albumin) or renal or
cardiac disease
B Collections of edema are named according
to the site
1 Anasarca - massive generalized
edema
2 Ankle
3 Ascites - peritoneal cavity
4 Hydrothorax - thoracic cavity
5 Periorbital - around the eyes
6 Sacral - lower back
C Edema occurs in dependent areas first
D Edema is graded on a scale considering the
depth of the indentation and the length of
time to return to normal Assessment Press firmly with finger for 5 seconds
Rating Assessment
1+ 5mm depth recovers immediately
2+ 8-10 mm duration 10-15 sec
3+ 11-20 mm duration 15-30 sec
4+ gt20 mm duration gt30 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 Note
presence of lice nits dandruff or lesions
3 Palpate the head by running the pads of the fingers
over the entire surface of skull inquire about
tenderness upon doing so (wear gloves if necessary)
4 Observe and feel the hair condition
5 Test Cranial Nerve VII
6 Test Cranial Nerve V
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 4
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 Skull middot Generally round with prominences in the frontal and
occipital area (Normocephalic)
middot No tenderness noted upon palpation
2 Scalp middot Lighter in color than the complexion
middot Can be moist or oily
middot No scars noted
middot Free from lice nits and dandruff
middot No lesions should be noted
middot No tenderness nor masses on palpation
3 Hair middot Can be black brown or burgundy depending on the
race
middot Evenly distributed covers the whole scalp (No
evidences of Alopecia)
middot Maybe thick or thin coarse or smooth middot Neither brittle nor dry
FACE
1 Observe the face for shape 2 Inspect for Symmetry
a Inspect for the palpebral fissure (distance between the
eye lids) should be equal in both eyes
b Ask the patient to smile There should be bilateral
Nasolabial fold (creases extending from the angle of
the corner of the mouth) Slight asymmetry in the fold
is normal c If both are met then the Face is symmetrical
3 Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)
1 Sensory Function
middot Ask the client to close the eyes
middot Run cotton wisp over the fore head check and jaw on both
sides of the face
middot Ask the client if heshe feel it and where she feels it
middot Check for corneal reflex using cotton wisp
middot The normal response in blinking
2 Motor function
middot Ask the client to chew or clench the jaw
middot The client should be able to clench or chew with strength and force
CN VII (Facial)
1 Sensory function (This nerve innervate the anterior 23 of
the tongue)
middot Place a sweet sour salty or bitter substance near the tip of
the tongue
middot Normally the client can identify the taste
2 Motor function
middot Ask the client to smile frown raise eye brow close eye lids whistle or puff the cheeks
Normal Findings
middot Shape maybe oval or rounded
middot Face is symmetrical
middot No involuntary muscle movements
middot Can move facial muscles at will middot Intact cranial nerve V and VII
EYE EYEBROW EYELASHES
Normal findings
Eyebrows
middot Symmetrical and in line with each other
middot Maybe black brown or blond depending on race middot Evenly distributed
Eyes
middot Evenly placed and inline with each other
middot Non protruding
middot Equal palpebral fissure
Eyelashes
middot Color dependent on race
middot Evenly distributed middot 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 lightly
slide the pad of the index finger against the clientrsquos
upper 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 presses
with the index finger against the clientrsquos lower inner
orbital rim at the lacrimal sac NOT AGAINST THE
NOSE
In the presence of blockage this will cause
regurgitation of fluid in the puncta
Normal Findings
Eyelids
middot Upper eyelids cover the small portion of the iris cornea and
sclera when eyes are open
middot No PTOSIS noted (drooping of upper eyelids)
middot Meets completely when eyes are closed
middot Symmetrical
Lacrimal Apparatus
middot Lacrimal gland is normally non palpable
middot No tenderness on palpation
middot No regurgitation from the nasolacrimal duct
CONJUNCTIVAE
The bulbar and palpebral conjunctivae are examined
by separating the eyelids widely and having the client look up
down and to each side When separating the lids the examiner
should exert no NO PRESSURE against the eyeball rather the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 5
Foundations of Nursing Abejo
Physical Assessment
examiner should hold the lids against the ridges of the bony orbit surrounding the eye
In examining the palpebral conjunctiva everting the upper eyelid 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 causes
muscles contraction
3 Place a cotton tip application about I can above the lid
margin and push gently downward with the applicator while still
holding 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 against
the eyebrow
5 Examine the lid for swelling infection and presence of
foreign 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 lid returns easily to its normal position
Normal Findings
middot Both conjunctivae are pinkish or red in color
middot With presence of many minutes capillaries
middot Moist
middot No ulcers middot No foreign objects
SCLERAE
The sclerae is easily inspected during the assessment of the conjunctivae
Normal Findings
middot Sclerae is white in color (anicteric sclera)
middot No yellowish discoloration (icteric sclera)
middot Some capillaries maybe visible
middot Some people may have pigmented positions
CORNEA
The cornea is best inspected by directing penlight obliquely from several positions
Normal findings
middot There should be no irregularities on the surface
middot Looks smooth
middot The cornea is clear or transparent The features of the iris
should be fully visible through the cornea
middot There is a positive corneal reflex
ANTERIOR CHAMBER IRIS
The anterior chamber and the iris are easily inspected
in conjunction with the cornea The technique of oblique illumination is also useful in assessing the anterior chamber
Normal Findings
middot The anterior chamber is transparent
middot No noted any visible materials
middot Color of the iris depends on the personrsquos race (black blue
brown or green)
middot From the side view the iris should appear flat and should not
be bulging forward There should be NO crescent shadow casted on the other side when illuminated from one side
PUPIL
Examination of the pupils involves several
inspections 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 consensual response of constriction
The test for papillary accommodation is the
examination 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 examinerrsquos index
fingers which is placed 5 ndash 5 inches from the clientrsquos nose
3 Visualization of distant objects normally causes papillary
dilation and visualization of nearer objects causes papillary
constriction and convergence of the eye
Normal Findings
middot Pupillary size ranges from 3 ndash 7 mm and are equal in size
middot Equally round
middot Constrict brisklysluggishly when light is directed to the eye
both directly and consensual
middot Pupils dilate when looking at distant objects and constrict
when looking at nearer objects
If all of which are met we document the findings
using the notation PERRLA pupils equally round reactive to light and accommodate
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 6
Foundations of Nursing Abejo
Physical Assessment
CRANIAL NERVE II ( OPTIC NERVE )
The optic nerve is assessed by testing for visual acuity and peripheral vision
Visual acuity is tested using a snellen chart for those
who are illiterate and unfamiliar with the western alphabet the
illiterate E chart in which the letter E faces in different
directions maybe used The chart has a standardized number at
the end of each line of letters these numbers indicates the degree 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 The
denominator 20 is the distance from which the normal eye can
read the lettering which correspond to the number at the end of
each letter line therefore the larger the denominator the poorer the version
Measurement of 2020 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 with
clientrsquos finger
4 Make the client read the chart by pointing at a letter
randomly at each line maybe started from largest to smallest or
vice versa
5 A person who can read the largest letter on the chart
(20200) should be checked if they can perceive hand movement
about 12 inches from their eyes or if they can perceive the light of 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 the
retina which perceive the more peripheral stimuli The Visual
field confrontation test provide a rather gross measurement of peripheral vision
The performance of this test assumes that the
examiner has normal visual fields since that clientrsquos visual fields are to be compared with the examiners
Follow the steps on conducting the test
1 The examiner and the client sit or stand opposite each
other with the eyes at the same horizontal level with the
distance of 15 ndash 2 feet apart
2 The client covers the eye with opaque card and the
examiner covers the eye that is opposite to the client covered
eye
3 Instruct the client to stare directly at the examinerrsquos eye
while the examiner stares at the clientrsquos open eye Neither looks
out at the object approaching from the periphery
4 The examiner hold an object such as pencil or penlight in
his hand and gradually moves it in from the periphery of both
directions 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 amp VI
( OculomotorTrochlearAbducens )
All the 3 Cranial nerves are tested at the same time by
assessing the Extra Ocular Movement (EOM) or the six cardinal position 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 clientrsquos eyes
2 Instruct the client to follow the direction the object hold by
the examiner by eye movements only that is with out moving
the neck
3 The nurse moves the object in a clockwise direction
hexagonally
4 Instruct the client to fix his gaze momentarily on the
extreme 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 should be no nystagmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 7
Foundations of Nursing Abejo
Physical Assessment
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 of
the cartilage of the auricles tenderness when manipulating the
auricles and the mastoid process
3 Inspect the auditory meatus or the ear canal for color presence of cerumen discharges and foreign bodies
a For adult pull the pinna upward and backward to straighten
the canal
b For children pull the pinna downward and backward to
straighten the canal
4 Perform otoscopic examination of the tympanic membrane
noting the color and landmarks
Normal Findings
middot The ear lobes are bean shaped parallel and symmetrical
middot The upper connection of the ear lobe is parallel with the outer
canthus of the eye
middot Skin is same in color as in the complexion
middot No lesions noted on inspection
middot The auricles are has a firm cartilage on palpation
middot The pinna recoils when folded
middot There is no pain or tenderness on the palpation of the auricles
and mastoid process
middot The ear canal has normally some cerumen of inspection
middot No discharges or lesions noted at the ear canal
middot On otoscopic examination the tympanic membrane appears flat translucent and pearly gray in color
VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )
Examination of the cranial nerve VIII involves testing for
hearing 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 soft
spoken voice whispers non-sequential number (eg 3 5 7 ) for
the client to repeat
4 Normally the client will be able to hear and repeat the
number 5 Repeat the procedure at the other ear
B Watcher test
1 Ask the client to close the eyes
2 Place a mechanical watch 1 ndash 2 inches away the clientrsquos ear
3 Ask the client if he hears anything
4 If the client says yes the examiner should validate by
asking 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 side it was heard
Turning Fork Test
This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural) There are 2
types of tuning fork test being conducted
1 Weberrsquos test ndash assesses bone conduction this is a test of
sound lateralization vibrating tuning fork is placed on the middle of the fore head or top of the skull
Normal hear sounds equally in both ears (No Lateralization of sound)
Conduction loss ndash Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried through the external and middle ear
Sensorineural loss ndash Sound lateralizes on better ear
2 Rinne Test ndash Compares bone conduction with air condition
a Vibrating tuning fork placed on the mastoid process
b 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 clientrsquos ear canal when he no longer hears it
Normal Sound should be heard when tuning fork is placed in
front of the ear canal as air conductionlt bone conduction by 21
(positive rinne test)
Conduction loss Sound is heard longer by bone conduction than by air conduction
Sensorineural loss Sound is heard longer by air conduction than by 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 3
Foundations of Nursing Abejo
Physical Assessment
Effects of Aging in the Skin
Skin vascularity and the number of sweat and
sebaceous glands decrease affecting
thermoregulation
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 less
than 1 cm in diameter
Patch is a large spot that is not palpable amp that is gt 1
cm
Papule is a small superficial bump that is elevated amp
that is lt 1 cm
Plaque is a large superficial bump that is elevated amp gt
1 cm
Nodule is a small bump with a significant deep
component amp is lt 1 cm
Tumor is a large bump with a significant deep
component amp is gt 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 usually
superficial amp that is lt 05 cm
Bulla is a large fluid-filled bubble that is superficial or
deep amp that is gt 05 cm
Pustule is pus containing bubble often categorized
according 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 the
stratum corneum
Scale is very important in the differential
diagnosis since its presence indicates that the
epidermis is involved
Scale is typically present where there is
epidermal inflammation ie psoriasis tinea
eczema
Crust 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 amp creases
from chronic rubbing
Maceration is raw wet tissue
Fissure is a linear crack in the skin often very
painful
Erosion is a superficial open wound with loss of
epidermis or mucosa only
Ulcer is a deep open wound with partial or complete
loss of the dermis or submucosa
Distinct Lesions of the Skin
Wheal or hive describes a short lived (lt 24 hours)
edematous well circumscribed papule or plaque seen
in urticaria
Burrow is a small threadlike curvilinear papule that is
virtually pathognomonic of scabies
Comedone is a small pinpoint lesion typically
referred to as ldquowhiteheadsrdquo or ldquoblackheadsrdquo
Atrophy is a thinning of the epidermal andor dermal
tissue
Keloid overgrows the original wound boundaries and
is chronic in nature
Hypertrophic scar on the other hand does not
overgrow the wound boundaries
Fibrosis or sclerosis describes dermal
scarringthickening reactions
Milium is a small superficial cyst containing keratin
(usually lt1-2 mm in size
Vascular Skin Lesions
Petechiae is a round or purple macule associated with
bleeding tendencies or emboli to skin
Ecchymosis a round or irregular macular lesion larger
than petechiae color varies and changes from black
yellow and green hues Associated with trauma and
bleeding tendencies
Cherry Angioma popular and round red or purple
may blanch with pressure and a normal age-related
skin alteration
Spider Angioma is a red arteriole lesion central
body with radiating branches Commonly seen on
faceneckarms and trunk Associated with liver
disease pregnancy and vitB deficiency
Telangiectasia shaped varies spider-like or linear
bluish in color or sometimes red Does not blanch
when pressure applied Secondary to superficial
dilation of venous vessels and capillaries
Edema - the presence of large amounts of fluid in the interstitial
spaces Usually due to fluid collecting in the subcutaneous
tissue Edema may be localized or generalized
A Some causes are lymphatic obstruction
increased vascular permeability decreased
oncotic pressure due to low levels of plasma
proteins (especially albumin) or renal or
cardiac disease
B Collections of edema are named according
to the site
1 Anasarca - massive generalized
edema
2 Ankle
3 Ascites - peritoneal cavity
4 Hydrothorax - thoracic cavity
5 Periorbital - around the eyes
6 Sacral - lower back
C Edema occurs in dependent areas first
D Edema is graded on a scale considering the
depth of the indentation and the length of
time to return to normal Assessment Press firmly with finger for 5 seconds
Rating Assessment
1+ 5mm depth recovers immediately
2+ 8-10 mm duration 10-15 sec
3+ 11-20 mm duration 15-30 sec
4+ gt20 mm duration gt30 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 Note
presence of lice nits dandruff or lesions
3 Palpate the head by running the pads of the fingers
over the entire surface of skull inquire about
tenderness upon doing so (wear gloves if necessary)
4 Observe and feel the hair condition
5 Test Cranial Nerve VII
6 Test Cranial Nerve V
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 4
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 Skull middot Generally round with prominences in the frontal and
occipital area (Normocephalic)
middot No tenderness noted upon palpation
2 Scalp middot Lighter in color than the complexion
middot Can be moist or oily
middot No scars noted
middot Free from lice nits and dandruff
middot No lesions should be noted
middot No tenderness nor masses on palpation
3 Hair middot Can be black brown or burgundy depending on the
race
middot Evenly distributed covers the whole scalp (No
evidences of Alopecia)
middot Maybe thick or thin coarse or smooth middot Neither brittle nor dry
FACE
1 Observe the face for shape 2 Inspect for Symmetry
a Inspect for the palpebral fissure (distance between the
eye lids) should be equal in both eyes
b Ask the patient to smile There should be bilateral
Nasolabial fold (creases extending from the angle of
the corner of the mouth) Slight asymmetry in the fold
is normal c If both are met then the Face is symmetrical
3 Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)
1 Sensory Function
middot Ask the client to close the eyes
middot Run cotton wisp over the fore head check and jaw on both
sides of the face
middot Ask the client if heshe feel it and where she feels it
middot Check for corneal reflex using cotton wisp
middot The normal response in blinking
2 Motor function
middot Ask the client to chew or clench the jaw
middot The client should be able to clench or chew with strength and force
CN VII (Facial)
1 Sensory function (This nerve innervate the anterior 23 of
the tongue)
middot Place a sweet sour salty or bitter substance near the tip of
the tongue
middot Normally the client can identify the taste
2 Motor function
middot Ask the client to smile frown raise eye brow close eye lids whistle or puff the cheeks
Normal Findings
middot Shape maybe oval or rounded
middot Face is symmetrical
middot No involuntary muscle movements
middot Can move facial muscles at will middot Intact cranial nerve V and VII
EYE EYEBROW EYELASHES
Normal findings
Eyebrows
middot Symmetrical and in line with each other
middot Maybe black brown or blond depending on race middot Evenly distributed
Eyes
middot Evenly placed and inline with each other
middot Non protruding
middot Equal palpebral fissure
Eyelashes
middot Color dependent on race
middot Evenly distributed middot 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 lightly
slide the pad of the index finger against the clientrsquos
upper 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 presses
with the index finger against the clientrsquos lower inner
orbital rim at the lacrimal sac NOT AGAINST THE
NOSE
In the presence of blockage this will cause
regurgitation of fluid in the puncta
Normal Findings
Eyelids
middot Upper eyelids cover the small portion of the iris cornea and
sclera when eyes are open
middot No PTOSIS noted (drooping of upper eyelids)
middot Meets completely when eyes are closed
middot Symmetrical
Lacrimal Apparatus
middot Lacrimal gland is normally non palpable
middot No tenderness on palpation
middot No regurgitation from the nasolacrimal duct
CONJUNCTIVAE
The bulbar and palpebral conjunctivae are examined
by separating the eyelids widely and having the client look up
down and to each side When separating the lids the examiner
should exert no NO PRESSURE against the eyeball rather the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 5
Foundations of Nursing Abejo
Physical Assessment
examiner should hold the lids against the ridges of the bony orbit surrounding the eye
In examining the palpebral conjunctiva everting the upper eyelid 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 causes
muscles contraction
3 Place a cotton tip application about I can above the lid
margin and push gently downward with the applicator while still
holding 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 against
the eyebrow
5 Examine the lid for swelling infection and presence of
foreign 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 lid returns easily to its normal position
Normal Findings
middot Both conjunctivae are pinkish or red in color
middot With presence of many minutes capillaries
middot Moist
middot No ulcers middot No foreign objects
SCLERAE
The sclerae is easily inspected during the assessment of the conjunctivae
Normal Findings
middot Sclerae is white in color (anicteric sclera)
middot No yellowish discoloration (icteric sclera)
middot Some capillaries maybe visible
middot Some people may have pigmented positions
CORNEA
The cornea is best inspected by directing penlight obliquely from several positions
Normal findings
middot There should be no irregularities on the surface
middot Looks smooth
middot The cornea is clear or transparent The features of the iris
should be fully visible through the cornea
middot There is a positive corneal reflex
ANTERIOR CHAMBER IRIS
The anterior chamber and the iris are easily inspected
in conjunction with the cornea The technique of oblique illumination is also useful in assessing the anterior chamber
Normal Findings
middot The anterior chamber is transparent
middot No noted any visible materials
middot Color of the iris depends on the personrsquos race (black blue
brown or green)
middot From the side view the iris should appear flat and should not
be bulging forward There should be NO crescent shadow casted on the other side when illuminated from one side
PUPIL
Examination of the pupils involves several
inspections 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 consensual response of constriction
The test for papillary accommodation is the
examination 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 examinerrsquos index
fingers which is placed 5 ndash 5 inches from the clientrsquos nose
3 Visualization of distant objects normally causes papillary
dilation and visualization of nearer objects causes papillary
constriction and convergence of the eye
Normal Findings
middot Pupillary size ranges from 3 ndash 7 mm and are equal in size
middot Equally round
middot Constrict brisklysluggishly when light is directed to the eye
both directly and consensual
middot Pupils dilate when looking at distant objects and constrict
when looking at nearer objects
If all of which are met we document the findings
using the notation PERRLA pupils equally round reactive to light and accommodate
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 6
Foundations of Nursing Abejo
Physical Assessment
CRANIAL NERVE II ( OPTIC NERVE )
The optic nerve is assessed by testing for visual acuity and peripheral vision
Visual acuity is tested using a snellen chart for those
who are illiterate and unfamiliar with the western alphabet the
illiterate E chart in which the letter E faces in different
directions maybe used The chart has a standardized number at
the end of each line of letters these numbers indicates the degree 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 The
denominator 20 is the distance from which the normal eye can
read the lettering which correspond to the number at the end of
each letter line therefore the larger the denominator the poorer the version
Measurement of 2020 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 with
clientrsquos finger
4 Make the client read the chart by pointing at a letter
randomly at each line maybe started from largest to smallest or
vice versa
5 A person who can read the largest letter on the chart
(20200) should be checked if they can perceive hand movement
about 12 inches from their eyes or if they can perceive the light of 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 the
retina which perceive the more peripheral stimuli The Visual
field confrontation test provide a rather gross measurement of peripheral vision
The performance of this test assumes that the
examiner has normal visual fields since that clientrsquos visual fields are to be compared with the examiners
Follow the steps on conducting the test
1 The examiner and the client sit or stand opposite each
other with the eyes at the same horizontal level with the
distance of 15 ndash 2 feet apart
2 The client covers the eye with opaque card and the
examiner covers the eye that is opposite to the client covered
eye
3 Instruct the client to stare directly at the examinerrsquos eye
while the examiner stares at the clientrsquos open eye Neither looks
out at the object approaching from the periphery
4 The examiner hold an object such as pencil or penlight in
his hand and gradually moves it in from the periphery of both
directions 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 amp VI
( OculomotorTrochlearAbducens )
All the 3 Cranial nerves are tested at the same time by
assessing the Extra Ocular Movement (EOM) or the six cardinal position 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 clientrsquos eyes
2 Instruct the client to follow the direction the object hold by
the examiner by eye movements only that is with out moving
the neck
3 The nurse moves the object in a clockwise direction
hexagonally
4 Instruct the client to fix his gaze momentarily on the
extreme 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 should be no nystagmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 7
Foundations of Nursing Abejo
Physical Assessment
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 of
the cartilage of the auricles tenderness when manipulating the
auricles and the mastoid process
3 Inspect the auditory meatus or the ear canal for color presence of cerumen discharges and foreign bodies
a For adult pull the pinna upward and backward to straighten
the canal
b For children pull the pinna downward and backward to
straighten the canal
4 Perform otoscopic examination of the tympanic membrane
noting the color and landmarks
Normal Findings
middot The ear lobes are bean shaped parallel and symmetrical
middot The upper connection of the ear lobe is parallel with the outer
canthus of the eye
middot Skin is same in color as in the complexion
middot No lesions noted on inspection
middot The auricles are has a firm cartilage on palpation
middot The pinna recoils when folded
middot There is no pain or tenderness on the palpation of the auricles
and mastoid process
middot The ear canal has normally some cerumen of inspection
middot No discharges or lesions noted at the ear canal
middot On otoscopic examination the tympanic membrane appears flat translucent and pearly gray in color
VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )
Examination of the cranial nerve VIII involves testing for
hearing 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 soft
spoken voice whispers non-sequential number (eg 3 5 7 ) for
the client to repeat
4 Normally the client will be able to hear and repeat the
number 5 Repeat the procedure at the other ear
B Watcher test
1 Ask the client to close the eyes
2 Place a mechanical watch 1 ndash 2 inches away the clientrsquos ear
3 Ask the client if he hears anything
4 If the client says yes the examiner should validate by
asking 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 side it was heard
Turning Fork Test
This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural) There are 2
types of tuning fork test being conducted
1 Weberrsquos test ndash assesses bone conduction this is a test of
sound lateralization vibrating tuning fork is placed on the middle of the fore head or top of the skull
Normal hear sounds equally in both ears (No Lateralization of sound)
Conduction loss ndash Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried through the external and middle ear
Sensorineural loss ndash Sound lateralizes on better ear
2 Rinne Test ndash Compares bone conduction with air condition
a Vibrating tuning fork placed on the mastoid process
b 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 clientrsquos ear canal when he no longer hears it
Normal Sound should be heard when tuning fork is placed in
front of the ear canal as air conductionlt bone conduction by 21
(positive rinne test)
Conduction loss Sound is heard longer by bone conduction than by air conduction
Sensorineural loss Sound is heard longer by air conduction than by 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 4
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 Skull middot Generally round with prominences in the frontal and
occipital area (Normocephalic)
middot No tenderness noted upon palpation
2 Scalp middot Lighter in color than the complexion
middot Can be moist or oily
middot No scars noted
middot Free from lice nits and dandruff
middot No lesions should be noted
middot No tenderness nor masses on palpation
3 Hair middot Can be black brown or burgundy depending on the
race
middot Evenly distributed covers the whole scalp (No
evidences of Alopecia)
middot Maybe thick or thin coarse or smooth middot Neither brittle nor dry
FACE
1 Observe the face for shape 2 Inspect for Symmetry
a Inspect for the palpebral fissure (distance between the
eye lids) should be equal in both eyes
b Ask the patient to smile There should be bilateral
Nasolabial fold (creases extending from the angle of
the corner of the mouth) Slight asymmetry in the fold
is normal c If both are met then the Face is symmetrical
3 Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)
1 Sensory Function
middot Ask the client to close the eyes
middot Run cotton wisp over the fore head check and jaw on both
sides of the face
middot Ask the client if heshe feel it and where she feels it
middot Check for corneal reflex using cotton wisp
middot The normal response in blinking
2 Motor function
middot Ask the client to chew or clench the jaw
middot The client should be able to clench or chew with strength and force
CN VII (Facial)
1 Sensory function (This nerve innervate the anterior 23 of
the tongue)
middot Place a sweet sour salty or bitter substance near the tip of
the tongue
middot Normally the client can identify the taste
2 Motor function
middot Ask the client to smile frown raise eye brow close eye lids whistle or puff the cheeks
Normal Findings
middot Shape maybe oval or rounded
middot Face is symmetrical
middot No involuntary muscle movements
middot Can move facial muscles at will middot Intact cranial nerve V and VII
EYE EYEBROW EYELASHES
Normal findings
Eyebrows
middot Symmetrical and in line with each other
middot Maybe black brown or blond depending on race middot Evenly distributed
Eyes
middot Evenly placed and inline with each other
middot Non protruding
middot Equal palpebral fissure
Eyelashes
middot Color dependent on race
middot Evenly distributed middot 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 lightly
slide the pad of the index finger against the clientrsquos
upper 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 presses
with the index finger against the clientrsquos lower inner
orbital rim at the lacrimal sac NOT AGAINST THE
NOSE
In the presence of blockage this will cause
regurgitation of fluid in the puncta
Normal Findings
Eyelids
middot Upper eyelids cover the small portion of the iris cornea and
sclera when eyes are open
middot No PTOSIS noted (drooping of upper eyelids)
middot Meets completely when eyes are closed
middot Symmetrical
Lacrimal Apparatus
middot Lacrimal gland is normally non palpable
middot No tenderness on palpation
middot No regurgitation from the nasolacrimal duct
CONJUNCTIVAE
The bulbar and palpebral conjunctivae are examined
by separating the eyelids widely and having the client look up
down and to each side When separating the lids the examiner
should exert no NO PRESSURE against the eyeball rather the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 5
Foundations of Nursing Abejo
Physical Assessment
examiner should hold the lids against the ridges of the bony orbit surrounding the eye
In examining the palpebral conjunctiva everting the upper eyelid 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 causes
muscles contraction
3 Place a cotton tip application about I can above the lid
margin and push gently downward with the applicator while still
holding 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 against
the eyebrow
5 Examine the lid for swelling infection and presence of
foreign 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 lid returns easily to its normal position
Normal Findings
middot Both conjunctivae are pinkish or red in color
middot With presence of many minutes capillaries
middot Moist
middot No ulcers middot No foreign objects
SCLERAE
The sclerae is easily inspected during the assessment of the conjunctivae
Normal Findings
middot Sclerae is white in color (anicteric sclera)
middot No yellowish discoloration (icteric sclera)
middot Some capillaries maybe visible
middot Some people may have pigmented positions
CORNEA
The cornea is best inspected by directing penlight obliquely from several positions
Normal findings
middot There should be no irregularities on the surface
middot Looks smooth
middot The cornea is clear or transparent The features of the iris
should be fully visible through the cornea
middot There is a positive corneal reflex
ANTERIOR CHAMBER IRIS
The anterior chamber and the iris are easily inspected
in conjunction with the cornea The technique of oblique illumination is also useful in assessing the anterior chamber
Normal Findings
middot The anterior chamber is transparent
middot No noted any visible materials
middot Color of the iris depends on the personrsquos race (black blue
brown or green)
middot From the side view the iris should appear flat and should not
be bulging forward There should be NO crescent shadow casted on the other side when illuminated from one side
PUPIL
Examination of the pupils involves several
inspections 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 consensual response of constriction
The test for papillary accommodation is the
examination 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 examinerrsquos index
fingers which is placed 5 ndash 5 inches from the clientrsquos nose
3 Visualization of distant objects normally causes papillary
dilation and visualization of nearer objects causes papillary
constriction and convergence of the eye
Normal Findings
middot Pupillary size ranges from 3 ndash 7 mm and are equal in size
middot Equally round
middot Constrict brisklysluggishly when light is directed to the eye
both directly and consensual
middot Pupils dilate when looking at distant objects and constrict
when looking at nearer objects
If all of which are met we document the findings
using the notation PERRLA pupils equally round reactive to light and accommodate
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 6
Foundations of Nursing Abejo
Physical Assessment
CRANIAL NERVE II ( OPTIC NERVE )
The optic nerve is assessed by testing for visual acuity and peripheral vision
Visual acuity is tested using a snellen chart for those
who are illiterate and unfamiliar with the western alphabet the
illiterate E chart in which the letter E faces in different
directions maybe used The chart has a standardized number at
the end of each line of letters these numbers indicates the degree 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 The
denominator 20 is the distance from which the normal eye can
read the lettering which correspond to the number at the end of
each letter line therefore the larger the denominator the poorer the version
Measurement of 2020 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 with
clientrsquos finger
4 Make the client read the chart by pointing at a letter
randomly at each line maybe started from largest to smallest or
vice versa
5 A person who can read the largest letter on the chart
(20200) should be checked if they can perceive hand movement
about 12 inches from their eyes or if they can perceive the light of 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 the
retina which perceive the more peripheral stimuli The Visual
field confrontation test provide a rather gross measurement of peripheral vision
The performance of this test assumes that the
examiner has normal visual fields since that clientrsquos visual fields are to be compared with the examiners
Follow the steps on conducting the test
1 The examiner and the client sit or stand opposite each
other with the eyes at the same horizontal level with the
distance of 15 ndash 2 feet apart
2 The client covers the eye with opaque card and the
examiner covers the eye that is opposite to the client covered
eye
3 Instruct the client to stare directly at the examinerrsquos eye
while the examiner stares at the clientrsquos open eye Neither looks
out at the object approaching from the periphery
4 The examiner hold an object such as pencil or penlight in
his hand and gradually moves it in from the periphery of both
directions 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 amp VI
( OculomotorTrochlearAbducens )
All the 3 Cranial nerves are tested at the same time by
assessing the Extra Ocular Movement (EOM) or the six cardinal position 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 clientrsquos eyes
2 Instruct the client to follow the direction the object hold by
the examiner by eye movements only that is with out moving
the neck
3 The nurse moves the object in a clockwise direction
hexagonally
4 Instruct the client to fix his gaze momentarily on the
extreme 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 should be no nystagmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 7
Foundations of Nursing Abejo
Physical Assessment
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 of
the cartilage of the auricles tenderness when manipulating the
auricles and the mastoid process
3 Inspect the auditory meatus or the ear canal for color presence of cerumen discharges and foreign bodies
a For adult pull the pinna upward and backward to straighten
the canal
b For children pull the pinna downward and backward to
straighten the canal
4 Perform otoscopic examination of the tympanic membrane
noting the color and landmarks
Normal Findings
middot The ear lobes are bean shaped parallel and symmetrical
middot The upper connection of the ear lobe is parallel with the outer
canthus of the eye
middot Skin is same in color as in the complexion
middot No lesions noted on inspection
middot The auricles are has a firm cartilage on palpation
middot The pinna recoils when folded
middot There is no pain or tenderness on the palpation of the auricles
and mastoid process
middot The ear canal has normally some cerumen of inspection
middot No discharges or lesions noted at the ear canal
middot On otoscopic examination the tympanic membrane appears flat translucent and pearly gray in color
VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )
Examination of the cranial nerve VIII involves testing for
hearing 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 soft
spoken voice whispers non-sequential number (eg 3 5 7 ) for
the client to repeat
4 Normally the client will be able to hear and repeat the
number 5 Repeat the procedure at the other ear
B Watcher test
1 Ask the client to close the eyes
2 Place a mechanical watch 1 ndash 2 inches away the clientrsquos ear
3 Ask the client if he hears anything
4 If the client says yes the examiner should validate by
asking 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 side it was heard
Turning Fork Test
This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural) There are 2
types of tuning fork test being conducted
1 Weberrsquos test ndash assesses bone conduction this is a test of
sound lateralization vibrating tuning fork is placed on the middle of the fore head or top of the skull
Normal hear sounds equally in both ears (No Lateralization of sound)
Conduction loss ndash Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried through the external and middle ear
Sensorineural loss ndash Sound lateralizes on better ear
2 Rinne Test ndash Compares bone conduction with air condition
a Vibrating tuning fork placed on the mastoid process
b 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 clientrsquos ear canal when he no longer hears it
Normal Sound should be heard when tuning fork is placed in
front of the ear canal as air conductionlt bone conduction by 21
(positive rinne test)
Conduction loss Sound is heard longer by bone conduction than by air conduction
Sensorineural loss Sound is heard longer by air conduction than by 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 5
Foundations of Nursing Abejo
Physical Assessment
examiner should hold the lids against the ridges of the bony orbit surrounding the eye
In examining the palpebral conjunctiva everting the upper eyelid 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 causes
muscles contraction
3 Place a cotton tip application about I can above the lid
margin and push gently downward with the applicator while still
holding 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 against
the eyebrow
5 Examine the lid for swelling infection and presence of
foreign 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 lid returns easily to its normal position
Normal Findings
middot Both conjunctivae are pinkish or red in color
middot With presence of many minutes capillaries
middot Moist
middot No ulcers middot No foreign objects
SCLERAE
The sclerae is easily inspected during the assessment of the conjunctivae
Normal Findings
middot Sclerae is white in color (anicteric sclera)
middot No yellowish discoloration (icteric sclera)
middot Some capillaries maybe visible
middot Some people may have pigmented positions
CORNEA
The cornea is best inspected by directing penlight obliquely from several positions
Normal findings
middot There should be no irregularities on the surface
middot Looks smooth
middot The cornea is clear or transparent The features of the iris
should be fully visible through the cornea
middot There is a positive corneal reflex
ANTERIOR CHAMBER IRIS
The anterior chamber and the iris are easily inspected
in conjunction with the cornea The technique of oblique illumination is also useful in assessing the anterior chamber
Normal Findings
middot The anterior chamber is transparent
middot No noted any visible materials
middot Color of the iris depends on the personrsquos race (black blue
brown or green)
middot From the side view the iris should appear flat and should not
be bulging forward There should be NO crescent shadow casted on the other side when illuminated from one side
PUPIL
Examination of the pupils involves several
inspections 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 consensual response of constriction
The test for papillary accommodation is the
examination 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 examinerrsquos index
fingers which is placed 5 ndash 5 inches from the clientrsquos nose
3 Visualization of distant objects normally causes papillary
dilation and visualization of nearer objects causes papillary
constriction and convergence of the eye
Normal Findings
middot Pupillary size ranges from 3 ndash 7 mm and are equal in size
middot Equally round
middot Constrict brisklysluggishly when light is directed to the eye
both directly and consensual
middot Pupils dilate when looking at distant objects and constrict
when looking at nearer objects
If all of which are met we document the findings
using the notation PERRLA pupils equally round reactive to light and accommodate
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 6
Foundations of Nursing Abejo
Physical Assessment
CRANIAL NERVE II ( OPTIC NERVE )
The optic nerve is assessed by testing for visual acuity and peripheral vision
Visual acuity is tested using a snellen chart for those
who are illiterate and unfamiliar with the western alphabet the
illiterate E chart in which the letter E faces in different
directions maybe used The chart has a standardized number at
the end of each line of letters these numbers indicates the degree 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 The
denominator 20 is the distance from which the normal eye can
read the lettering which correspond to the number at the end of
each letter line therefore the larger the denominator the poorer the version
Measurement of 2020 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 with
clientrsquos finger
4 Make the client read the chart by pointing at a letter
randomly at each line maybe started from largest to smallest or
vice versa
5 A person who can read the largest letter on the chart
(20200) should be checked if they can perceive hand movement
about 12 inches from their eyes or if they can perceive the light of 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 the
retina which perceive the more peripheral stimuli The Visual
field confrontation test provide a rather gross measurement of peripheral vision
The performance of this test assumes that the
examiner has normal visual fields since that clientrsquos visual fields are to be compared with the examiners
Follow the steps on conducting the test
1 The examiner and the client sit or stand opposite each
other with the eyes at the same horizontal level with the
distance of 15 ndash 2 feet apart
2 The client covers the eye with opaque card and the
examiner covers the eye that is opposite to the client covered
eye
3 Instruct the client to stare directly at the examinerrsquos eye
while the examiner stares at the clientrsquos open eye Neither looks
out at the object approaching from the periphery
4 The examiner hold an object such as pencil or penlight in
his hand and gradually moves it in from the periphery of both
directions 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 amp VI
( OculomotorTrochlearAbducens )
All the 3 Cranial nerves are tested at the same time by
assessing the Extra Ocular Movement (EOM) or the six cardinal position 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 clientrsquos eyes
2 Instruct the client to follow the direction the object hold by
the examiner by eye movements only that is with out moving
the neck
3 The nurse moves the object in a clockwise direction
hexagonally
4 Instruct the client to fix his gaze momentarily on the
extreme 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 should be no nystagmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 7
Foundations of Nursing Abejo
Physical Assessment
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 of
the cartilage of the auricles tenderness when manipulating the
auricles and the mastoid process
3 Inspect the auditory meatus or the ear canal for color presence of cerumen discharges and foreign bodies
a For adult pull the pinna upward and backward to straighten
the canal
b For children pull the pinna downward and backward to
straighten the canal
4 Perform otoscopic examination of the tympanic membrane
noting the color and landmarks
Normal Findings
middot The ear lobes are bean shaped parallel and symmetrical
middot The upper connection of the ear lobe is parallel with the outer
canthus of the eye
middot Skin is same in color as in the complexion
middot No lesions noted on inspection
middot The auricles are has a firm cartilage on palpation
middot The pinna recoils when folded
middot There is no pain or tenderness on the palpation of the auricles
and mastoid process
middot The ear canal has normally some cerumen of inspection
middot No discharges or lesions noted at the ear canal
middot On otoscopic examination the tympanic membrane appears flat translucent and pearly gray in color
VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )
Examination of the cranial nerve VIII involves testing for
hearing 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 soft
spoken voice whispers non-sequential number (eg 3 5 7 ) for
the client to repeat
4 Normally the client will be able to hear and repeat the
number 5 Repeat the procedure at the other ear
B Watcher test
1 Ask the client to close the eyes
2 Place a mechanical watch 1 ndash 2 inches away the clientrsquos ear
3 Ask the client if he hears anything
4 If the client says yes the examiner should validate by
asking 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 side it was heard
Turning Fork Test
This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural) There are 2
types of tuning fork test being conducted
1 Weberrsquos test ndash assesses bone conduction this is a test of
sound lateralization vibrating tuning fork is placed on the middle of the fore head or top of the skull
Normal hear sounds equally in both ears (No Lateralization of sound)
Conduction loss ndash Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried through the external and middle ear
Sensorineural loss ndash Sound lateralizes on better ear
2 Rinne Test ndash Compares bone conduction with air condition
a Vibrating tuning fork placed on the mastoid process
b 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 clientrsquos ear canal when he no longer hears it
Normal Sound should be heard when tuning fork is placed in
front of the ear canal as air conductionlt bone conduction by 21
(positive rinne test)
Conduction loss Sound is heard longer by bone conduction than by air conduction
Sensorineural loss Sound is heard longer by air conduction than by 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 6
Foundations of Nursing Abejo
Physical Assessment
CRANIAL NERVE II ( OPTIC NERVE )
The optic nerve is assessed by testing for visual acuity and peripheral vision
Visual acuity is tested using a snellen chart for those
who are illiterate and unfamiliar with the western alphabet the
illiterate E chart in which the letter E faces in different
directions maybe used The chart has a standardized number at
the end of each line of letters these numbers indicates the degree 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 The
denominator 20 is the distance from which the normal eye can
read the lettering which correspond to the number at the end of
each letter line therefore the larger the denominator the poorer the version
Measurement of 2020 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 with
clientrsquos finger
4 Make the client read the chart by pointing at a letter
randomly at each line maybe started from largest to smallest or
vice versa
5 A person who can read the largest letter on the chart
(20200) should be checked if they can perceive hand movement
about 12 inches from their eyes or if they can perceive the light of 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 the
retina which perceive the more peripheral stimuli The Visual
field confrontation test provide a rather gross measurement of peripheral vision
The performance of this test assumes that the
examiner has normal visual fields since that clientrsquos visual fields are to be compared with the examiners
Follow the steps on conducting the test
1 The examiner and the client sit or stand opposite each
other with the eyes at the same horizontal level with the
distance of 15 ndash 2 feet apart
2 The client covers the eye with opaque card and the
examiner covers the eye that is opposite to the client covered
eye
3 Instruct the client to stare directly at the examinerrsquos eye
while the examiner stares at the clientrsquos open eye Neither looks
out at the object approaching from the periphery
4 The examiner hold an object such as pencil or penlight in
his hand and gradually moves it in from the periphery of both
directions 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 amp VI
( OculomotorTrochlearAbducens )
All the 3 Cranial nerves are tested at the same time by
assessing the Extra Ocular Movement (EOM) or the six cardinal position 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 clientrsquos eyes
2 Instruct the client to follow the direction the object hold by
the examiner by eye movements only that is with out moving
the neck
3 The nurse moves the object in a clockwise direction
hexagonally
4 Instruct the client to fix his gaze momentarily on the
extreme 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 should be no nystagmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 7
Foundations of Nursing Abejo
Physical Assessment
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 of
the cartilage of the auricles tenderness when manipulating the
auricles and the mastoid process
3 Inspect the auditory meatus or the ear canal for color presence of cerumen discharges and foreign bodies
a For adult pull the pinna upward and backward to straighten
the canal
b For children pull the pinna downward and backward to
straighten the canal
4 Perform otoscopic examination of the tympanic membrane
noting the color and landmarks
Normal Findings
middot The ear lobes are bean shaped parallel and symmetrical
middot The upper connection of the ear lobe is parallel with the outer
canthus of the eye
middot Skin is same in color as in the complexion
middot No lesions noted on inspection
middot The auricles are has a firm cartilage on palpation
middot The pinna recoils when folded
middot There is no pain or tenderness on the palpation of the auricles
and mastoid process
middot The ear canal has normally some cerumen of inspection
middot No discharges or lesions noted at the ear canal
middot On otoscopic examination the tympanic membrane appears flat translucent and pearly gray in color
VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )
Examination of the cranial nerve VIII involves testing for
hearing 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 soft
spoken voice whispers non-sequential number (eg 3 5 7 ) for
the client to repeat
4 Normally the client will be able to hear and repeat the
number 5 Repeat the procedure at the other ear
B Watcher test
1 Ask the client to close the eyes
2 Place a mechanical watch 1 ndash 2 inches away the clientrsquos ear
3 Ask the client if he hears anything
4 If the client says yes the examiner should validate by
asking 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 side it was heard
Turning Fork Test
This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural) There are 2
types of tuning fork test being conducted
1 Weberrsquos test ndash assesses bone conduction this is a test of
sound lateralization vibrating tuning fork is placed on the middle of the fore head or top of the skull
Normal hear sounds equally in both ears (No Lateralization of sound)
Conduction loss ndash Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried through the external and middle ear
Sensorineural loss ndash Sound lateralizes on better ear
2 Rinne Test ndash Compares bone conduction with air condition
a Vibrating tuning fork placed on the mastoid process
b 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 clientrsquos ear canal when he no longer hears it
Normal Sound should be heard when tuning fork is placed in
front of the ear canal as air conductionlt bone conduction by 21
(positive rinne test)
Conduction loss Sound is heard longer by bone conduction than by air conduction
Sensorineural loss Sound is heard longer by air conduction than by 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 7
Foundations of Nursing Abejo
Physical Assessment
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 of
the cartilage of the auricles tenderness when manipulating the
auricles and the mastoid process
3 Inspect the auditory meatus or the ear canal for color presence of cerumen discharges and foreign bodies
a For adult pull the pinna upward and backward to straighten
the canal
b For children pull the pinna downward and backward to
straighten the canal
4 Perform otoscopic examination of the tympanic membrane
noting the color and landmarks
Normal Findings
middot The ear lobes are bean shaped parallel and symmetrical
middot The upper connection of the ear lobe is parallel with the outer
canthus of the eye
middot Skin is same in color as in the complexion
middot No lesions noted on inspection
middot The auricles are has a firm cartilage on palpation
middot The pinna recoils when folded
middot There is no pain or tenderness on the palpation of the auricles
and mastoid process
middot The ear canal has normally some cerumen of inspection
middot No discharges or lesions noted at the ear canal
middot On otoscopic examination the tympanic membrane appears flat translucent and pearly gray in color
VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )
Examination of the cranial nerve VIII involves testing for
hearing 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 soft
spoken voice whispers non-sequential number (eg 3 5 7 ) for
the client to repeat
4 Normally the client will be able to hear and repeat the
number 5 Repeat the procedure at the other ear
B Watcher test
1 Ask the client to close the eyes
2 Place a mechanical watch 1 ndash 2 inches away the clientrsquos ear
3 Ask the client if he hears anything
4 If the client says yes the examiner should validate by
asking 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 side it was heard
Turning Fork Test
This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural) There are 2
types of tuning fork test being conducted
1 Weberrsquos test ndash assesses bone conduction this is a test of
sound lateralization vibrating tuning fork is placed on the middle of the fore head or top of the skull
Normal hear sounds equally in both ears (No Lateralization of sound)
Conduction loss ndash Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried through the external and middle ear
Sensorineural loss ndash Sound lateralizes on better ear
2 Rinne Test ndash Compares bone conduction with air condition
a Vibrating tuning fork placed on the mastoid process
b 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 clientrsquos ear canal when he no longer hears it
Normal Sound should be heard when tuning fork is placed in
front of the ear canal as air conductionlt bone conduction by 21
(positive rinne test)
Conduction loss Sound is heard longer by bone conduction than by air conduction
Sensorineural loss Sound is heard longer by air conduction than by 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 8
Foundations of Nursing Abejo
Physical Assessment
The internal nares are inspected by heperextending the neck of
the client the ulnar aspect of the examinerrsquos hard over the fore
head of the client and using the thumb to push the tip of the
nose upward while shining a light into the naris
Inspect for the following
1 Position of the septum
2 Check septum for perforation (can also be checked by
directing the lighted penlight on the side of the nose
illumination at the other side suggests perforation)
3 The nasal mucosa (turbinates) for swelling exudates and
change 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 maxillary sinuses are accessible for examination
By palpating both cheeks simultaneously one can
determine tenderness of the maxillary sinusitis and pressing the
thumb just below the eyebrows we can determine tenderness of
the frontal sinuses
Normal Findings
1 Nose in the midline
2 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 (eg 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 Color
3 Edema
Normal Findings
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color 4 No edema
Palpate the temporomandibular while the mouth is opened wide and then closed for
1 Crepitous
2 Deviations 3 Tenderness
Normal Findings
1 Moves smoothly no crepitous
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement
Gums are inspected for
1 Color
2 Bleeding
3 Retraction of gums
Normal Findings
1 Pinkish in color
2 No gum bleeding 3 No receding gums
Teeth are inspected for
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for
1 or overlapping teeth)
6 Tooth loss 7 Breath should also be assessed during the process
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 9
Foundations of Nursing Abejo
Physical Assessment
Normal Findings
1 28 for children and 32 for adults
2 White to yellowish in color
3 With or without dental carries andor 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 13 of the
ventral aspect of the tongue
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 Position
2 Color
3 Cranial Nerve X (Vagus nerve) ndash Tested by asking the
client to say ldquoAhrdquo note that the uvula will move upward 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 ldquoahrdquo
Tonsils are inspected for
1 Inflammation 2 Size
A Grading system used to describe the size of the tonsils can be
used
Grade 1 ndash Tonsils behind the pillar
Grade 2 ndash Between pillar and uvula
Grade 3 ndash Touching the uvula
Grade 4 ndash In the midline
NECK
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings
1 The neck is straight
2 No visible mass or lumps
3 Symmetrical
4 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 the thumb 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 via
systemic circular movements Describe lymph nodes in termsof
size regularity consistency tenderness and fixation to surrounding tissues
Normal Findings
1 May not be palpable Maybe normally palpable in thin
clients
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 front
of the client and asking the client to swallow
Palpation of the thyroid can be done either by
posterior 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 stands
behind him
2 In examining the isthmus of the thyroid locate the
cricoid cartilage and directly below that is the isthmus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 10
Foundations of Nursing Abejo
Physical Assessment
3 Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus
4 To facilitate examination of each lobe the client is
asked to turn his head slightly toward the side to be
examined to displace the sternocleidomastoid while
the other hand of the examiner pushes the thyroid
cartilage towards the side of the thyroid lobe to be
examined
5 Ask the patient to swallow as the procedure is being
done
6 The examiner may also palate for thyroid enlargement
by placing the thumb deep to and behind the
sternocleidomastoid muscle while the index and
middle fingers are placed deep to and in front of the
muscle 7 Then the procedure is repeated on the other side
Anterior approach
1 The examiner stands in front of the client and with the
palmar surface of the middle and index fingers
palpates below the cricoid cartilage
2 Ask the client to swallow while palpation is being
done
3 In palpating the lobes of the thyroid similar procedure
is done as in posterior approach The client is asked to
turn 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 sternocleidomastoid muscle
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 thyroid
enlargement 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 extend
for approximately 3 ndash 4 cm above the clavicles The inferior
borders of the lungs cross the sixth rib at the midclavigular line
In the posterior thorax the apices extend of T10 on expiration to the spinous process of T12 on inspiration
In the Lateral Thorax the lungs extend from the apex of 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 laterally
and downward unit it crosses the 5th rib at the midaxillary line It
then continues ant medially to end at the 6th rib at the midclavicular line
The right horizontally fissure extends from the 5th rib
slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border
The left oblique (diagonal) fissure extend from the
spinous process of the 3rd thoracic vertebra laterally and
downward to the left mid axillary line at the 5th rib and
continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line
Borders of the Diaphragm
Anteriorly on expiration the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular 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 8th rib at the
midaxillary line On inspiration the diaphragm moves
approximately 15 cm downward
Inspection of the Thorax
For adequate inspection of the thorax the client should be sitting
upright 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 12
Moves symmetrically on breathing with no obvious
masses
No fail chest which is suggestive of rib fracture
No chest retractions must be noted as this may suggest
difficulty in breathing
No bulging at the ICS must be noted as this may
obstruction on expiration abnormal masses or
cardiomegaly
The spine should be straight with slightly curvature in
the 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
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 11
Foundations of Nursing Abejo
Physical Assessment
1 General palpation ndash The examiner should specifically
palpate any areas of abnormality The temperature and
turgor of the skin should be assessed Palpate for
lumps masses and areas of tenderness 2 Palpate for thoracic expansion or lung excursion
A Anteriorly the examinerrsquos hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin pointing
to the xyphoid process Posteriorly the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest
B Instruct the client to exhale first then to
inhale deeply
C The examiner the amount of thoracic
expansion during quiet and deep inspiration
and observe for divergence of the thumbs on
expiration
D Normally symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 ndash 5 cm (1 ndash 2 inches) during deep inspiration
1 Palpate for the tactile fremitus
A Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top then at then
medial thoracic wall and at the anterolateral
B Each time the hands move down ask the
client to say ninety-nine
C Repeat the procedure at the posterior
thoracic wall
D Normally tactile fremitus should be
bilaterally symmetrical Most intense in the
2nd ICS at the sternal border near the area of
bronchial bifurcation Low pitched voices of
males are more readily palpated than higher
pitched voices of females
E Basic abnormalities like increased tactile
fremitus maybe suggestive of consolidation
decreased tactile fremitus may be suggestive
of obstructions thickening of pleura or collapse 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 indirect
percussion starting at the apices of the lungs
C The examiner notes the sound produced during each percussion
Whispered Pectorioquy ndash Ask the client top whisper ldquo1-2-3rdquo
Over 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 airway
blowing
Bronchial Loud high pitch Trachea
Abnormal Breath Sound
Crackles Dependent lobes Random sudden
reinflation of alveoli
fluids
Rhonchi Trachea bronchi Fluids mucus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 12
Foundations of Nursing Abejo
Physical Assessment
Wheezes 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 at greater risk for pulmonary infections
CARDIOVASCULAR SYSTEM
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine position Observe for pulsation and heaves or lifts
Normal Findings
1 Pulsation of the apical impulse maybe visible (this
can 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 table
elevated 30 degrees
2 Use tangential side lighting to observe for venous
pulsations in the neck
3 Look for a rapid double (sometimes triple) wave with
each heart beat Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin
4 Adjust the angle of table elevation to bring out the
venous pulsation
5 Identify the highest point of pulsation Using a
horizontal 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 table
slightly elevated
2 Always examine from the patients right side
3 Inspect for precordial movement Tangential lighting
will make movements more visible
4 Palpate for precordial activity in general You may
feel extras such as thrills or exaggerated ventricular
impulses
5 Palpate for the point of maximal impulse (PMI or
apical pulse) It is normally located in the 4th or 5th
intercostal space just medial to the midclavicular line
and 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 sternal
border and then to the base of the heart
Normal Findings
1 No palpable pulsation over the aortic pulmonic and
mitral valves
2 Apical pulsation can be felt on palpation
3 There should be no noted abnormal heaves and thrills felt 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 cardiac
dullness
Auscultation of the Heart
Anatomic areas for auscultation of the heart
Aortic valve ndash Right 2nd ICS sternal border
Pulmonic Valve ndash Left 2nd ICS sternal border
Tricuspid Valve ndash ndash Left 5th ICS sternal border
Mitral Valve ndash Left 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 learning
forward or lying on his left side which brings the
heart closer to the surface of the chest
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 13
Foundations of Nursing Abejo
Physical Assessment
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 AV
valves S2 closure of semilunar valve) S1 sound is
best heard over the mitral valve S2 is best heard over
the aortric valve
3 Listen for abnormal heart sounds eg S3 S4 and
Murmurs 4 Count heart rate at the apical pulse for one full minute
Normal Findings
1 S1 amp S2 can be heard at all anatomic site
2 No abnormal heart sounds is heard (eg Murmurs S3
amp S4) 3 Cardiac rate ranges from 60 ndash 100 bpm
PERIPHERAL CIRCULATION
Inspect
Color
Edema
Stasis ulcerslesions
Varicosities Hairnail changes
Palpate
Temperature
Edema
Tenderness Symmetry of pulses
BREAST
Inspection of the Breast
There are 4 major sitting position of the client used for clinical
breast examination Every client should be examined in each position
1 The client is seated with her arms on her side
2 The client is seated with her arms abducted over the
head
3 The client is seated and is pushing her hands into her
hips simultaneously eliciting contraction of the
pectoral muscles
4 The client is seated and is learning over while the examiner assists in supporting and balancing her
While the client is performing these maneuvers the
breasts are carefully observed for symmetry bulging
retraction and fixation
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts through invasion of
the suspensory ligaments to fix preventing them from
upward movement in position 2 and 4
Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory ligament
Normal Findings
1 The overlying the breast should be even
Chronic Arterial Insufficiency
Pain Intermittent claudication
Pulse Decreased
Color Pale
Temperature Cool
Edema Absent or mild
Skin
Changes
Thin shiny atrophic skin hair loss
thickened nails
Ulceration Toespoints of trauma
Gangrene May develop
Chronic Venous Insufficiency
Pain None to aching pain on dependency
Pulse Normal
Color Normal to cyanotic petechiae or brown
pigmentation
Temperature Warm
Edema Present
Skin Changes Dermatitis skin pigmentation
Ulceration Medial side of ankle
Gangrene Does not develop
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 14
Foundations of Nursing Abejo
Physical Assessment
2 May or may not be completely symmetrical at rest
3 The areola is rounded or oval with same color (Color
vaies form light pink to dark brown depending on
race)
4 Nipples are rounded everted same size and equal in
color
5 No ldquoorange peelrdquo skin is noted which is present in
edema
6 The veins maybe visible but not engorge and
prominent
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 the
periphery to the center going to the nipples Be sure
that the breast is adequately surveyed Breast
examination is best done 1 week post menses
Each areolar areas are carefully palpated to determine
the presence of underlying masses
Each nipple is gently compressed to assess for the presence of masses or discharge
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 the
techniques used for female clients However the various sitting position used for woman is unnecessary
ABDOMEN
In abdominal assessment be sure that the client has emptied the
bladder for comfort Place the client in a supine position with the knees 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 bowel
motility and thus bowel sounds may be increased by
palpation or percussion
The stethoscope and the hands should be warmed if
they are cold they may initiate contraction of the
abdominal muscles
Light pressure on the stethoscope is sufficient to detect
bowel sounds and bruits Intestinal sounds are
relatively high-pitched the bell may be used in
exploring arterial murmurs and venous hum
Peristaltic sounds
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract Peristalsis can provide
diagnostic clues relevant to the motility of bowel
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps
Divide the abdomen in four quadrants
Listen over all auscultation sites starting at the right lower
quadrants following the cross pattern of the imaginary
lines 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 5
minutes 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 ndash 15 seconds It is
suggested that the number of bowel sound may be as low as
3 to as high as 20 per minute or roughly one bowel sound for 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 surgery
5 Constipation or Diarrhea
6 Electrolyte imbalances 7 Bowel obstruction
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in
the peritoneum (ascites) gaseous distension and
masses 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 a
general 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 will
percuss as dull such as liver in the RUQ spleen at the
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 15
Foundations of Nursing Abejo
Physical Assessment
6th or 9th rib just posterior to or at the mid axillary line
on the left side
Percussion in the abdomen can also be used in assessing the liver span and size of the spleen
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness
1 The area is strucked lightly with a fisted right hand
2 Normally tenderness should not be elicited by this
method
3 Tenderness elicited by this method is usually a result of 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
Palpation of the Abdomen
Light palpation
It is a gentle exploration performed while the client is
in supine position With the examinerrsquos hands parallel
to the floor
The fingers depress the abdominal wall at each
quadrant by approximately 1 cm without digging but
gently 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 examinerrsquos hands are too cold or are pressed to
vigorously 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 by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined
Deeper structures like the liver and retro peritoneal
organs like the kidneys or masses may be felt with
this method
In the absence of disease pressure produced by deep
palpation may produce tenderness over the cecum the
sigmoid 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 the
right hand over the left hand
1 Ask the patient to take 3 normal breaths
2 Then ask the client to breath deeply and hold This
would push the liver down to facilitate palpation 3 Press hand deeply over the RUQ
The second methods
1 The examinerrsquos left hand is placed beneath the client
at the level of the right 11th and 12th ribs
2 Place the examinerrsquos right hands parallel to the costal
margin or the RUQ
3 An upward pressure is placed beneath the client to
push the liver towards the examining right hand while
the 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 normal
adult However in extremely thin but otherwise well
individuals it may be felt a the costal margins
When the normal liver margin is palpated it must be smooth regular in contour firm and non-tender
MUSCULOSKELETAL
1 Assess the patientrsquos posture stance and gait
2 Prepare the patient for the examination
3 Inspect for any gross abnormalities
4 Inspect and palpate the temporomaddibular joint and
jaw
5 Inspect and palpate the neck and spine
6 Assess the ROM of the neck
7 Assess the ROM of the spine
8 Inspect and palpate the upper and lower extremities
assessing each joint and muscle
RANGE OF MOTION
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 16
Foundations of Nursing Abejo
Physical Assessment
TEMPORAL MADIBULAR JOINT AND JAW
RANGE OF MOTION NECK
RANGE OF MOTIONWRISTS
RANGE OF MOTION FINGERS
RANGE OF MOTION ELBOW
RANGE OF MOTIONSHOUDLERS
RANGE OF MOTIONANKLES
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 17
Foundations of Nursing Abejo
Physical Assessment
RANGE OF MOTIONKNEES
RANGE OF MOTIONHIPS
Neurological Assessment
EXTREMITIES
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 patients fingers wrist and elbow
3 Flex and extend patients ankle and knee
4 There is normally a small continuous resistance to
passive movement
5 Observe for decreased (flaccid) or increased (rigidspastic) 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
05 No muscle movement
15 Visible muscle movement but no movement at the joint
25 Movement at the joint but not against gravity
35 Movement against gravity but not against added
resistance
45 Movement against resistance but less than normal
55 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 both
arms straight forward palms up and eyes closed
2 Instruct the patient to keep the arms still while you tap
them briskly downward
3 The patient will not be able to maintain extension and
supination (and drift into pronation) with upper motor neuron disease
C Coordination and Gait
Rapid Alternating Movements
1 Ask the patient to strike one hand on the thigh raise
the hand turn it over and then strike it back down as
fast as possible
2 Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible
3 Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point-to-Point Movements
1 Ask the patient to touch your index finger and their
nose alternately several times Move your finger about
as the patient performs this task
2 Hold your finger still so that the patient can touch it
with one arm and finger outstretched Ask the patient
to move their arm and return to your finger with their
eyes closed
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 18
Foundations of Nursing Abejo
Physical Assessment
3 Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe Repeat with the patients 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 proprioceptive problem)
Gait
Ask the patient to
1 Walk across the room turn and come back
2 Walk heel-to-toe in a straight line
3 Walk on their toes in a straight line
4 Walk on their heels in a straight line
5 Hop in place on each foot
6 Do a shallow knee bend
7 Rise from a sitting position
D Reflexes
Deep Tendon Reflexes
The patient must be relaxed and positioned properly
before starting
Reflex response depends on the force of your
stimulus Use no more force than you need to provoke
a definite response
Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth)
Reflexes should be graded on a 0 to 4 plus scale
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 patients arm should be partially flexed at the
elbow with the palm down
2 Place your thumb or finger firmly on the biceps
tendon
3 Strike your finger with the reflex hammer 4 You should feel the response even if you cant see it
Triceps (C6 C7)
1 Support the upper arm and let the patients forearm
hang free
2 Strike the triceps tendon above the elbow with the
broad side of the hammer
3 If the patient is sitting or lying down flex the patients arm at the elbow and hold it close to the chest
Brachioradialis (C5 C6)
1 Have the patient rest the forearm on the abdomen or
lap
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) and
below the umbilicus (T10 T11 T12)
3 Note the contraction of the abdominal muscles and deviation 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 of
each foot with the end of a reflex
hammer or key
2 Note movement of the toes normally
flexion (withdrawal)
3 Extension of the big toe with fanning of
the other toes is abnormal This is referred to as a positive Babinski
E Sensory
General
Explain each test before you do it
Unless otherwise specified the patients 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 the
extremities
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 to
ensure that the patient is responding to the correct
stimulus
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 19
Foundations of Nursing Abejo
Physical Assessment
2 Place the stem of the fork over the distal
interphalangeal joint of the patients 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 Wrists
2 Elbows
3 Medial malleoli
4 Patellas
5 Anterior superior iliac spines
6 Spinous processes 7 Clavicles
2 Subjective Light Touch
Use your fingers to touch the skin lightly on both sides
simultaneously
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 patients big toe and hold it away from the
other toes to avoid friction
2 Show the patient up and down
3 With the patients 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
4 Dermatomal Testing
If vibration position sense and subjective light touch are
normal in the fingers and toes you may assume the rest of this exam 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
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)
6 Light Touch
Use a fine whisp of cotton or your fingers to touch the
skin lightly
Ask the patient to respond whenever a touch is felt
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)
7 Discrimination
Since these tests are dependent on touch and position sense they cannot be performed when the tests above are clearly abnormal
Graphesthesia
1 With the blunt end of a pen or pencil draw a large
number in the patients palm 2 Ask the patient to identify the number
Stereognosis
1 Use as an alternative to graphesthesia ++
2 Place a familiar object in the patients 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 are
needed such as following the progression of a
cortical lesion ++
2 Use an opened paper clip to touch the patients
finger 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 5rsquo4rdquo weight 135 lbs BP 12080
HR 72 and regular RR 16 temperature 3750C
SKIN Color good Skin warm and moist Nails without
clubbing or cyanosis
EENT
Head ndash skull is normocephalicatraumatic(NCAT) Hair with
average texture
Eyes ndash visual acuity 2020 bilaterally Sclera white conjunctiva
pink Pupils constrcit 4 mm to 2 mm equally round and reactive
to light and accommodations
Ears ndash acuity good Weber midline Nose ndash nasal mucosa pink
septum midline no sinus tenderness Throat(mouth) ndash oral
mucosa pink dentition good pharynx without exudates
Neck ndash trachea midline Neck supple thyroid isthmus palpable
lobe not felt
Lymph nodes ndash no cervical adenopathy
THORAX AND LUNGS
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric
Nursing Skills
Physical Assessment
Prepared by Mark Fredderick R Abejo RN MAN 20
Foundations of Nursing Abejo
Physical Assessment
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 excursion ndash 4cm 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 or
hepatosplenomegaly Liver span is 7cm edge is
smooth and palpable 1 cm below the right costal
margin 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 I ndash XII intact
- Motor Good muscle bulk and tone Strength 55
throughout
- Cerebellar RAM intact Gait with normal base
Romberg ndash maintains balance with eyes closed No
pronator drift
- Sensory Pinprick light touch position intact
- Reflexes 2+ and symmetric