health assessment
TRANSCRIPT
IN PARTIAL FULLFILLMENT FOR THE REQUIREMENTS
IN THE SUBJECT HEALTH ASSESSMENT
Submitted to:
Mr. Jefferson Colon
Submitted by:
Julian, Jana Rio M.
BSN I-IV
1. Performing Hand Hygiene
*Wash your hands for a minimum of 15 to 20 seconds following the correct sequence or areas
to be washed first. Rinse properly and dry off using a clean towel. If possible, try not touching the faucet
or any handle in the washroom.
2. Gather all equipment need
*Be sure to clean the equipment before going to the client. The equipment varies depending on
what area will be assessed.
3. Identify client and explain the procedure
*The rationale of doing this is to make sure that you have the correct client that will be assessed
and giving him/her knowledge on what you are about to do.
4. Instruct client to void before doing the exam
*The rationale of doing this is to make sure that the area involved will be assessed properly and
to make client more comfortable with an empty bladder.
5. Assist client to change into hospital gown and provide privacy
*Wearing a hospital gown is the most convenient attire when assessing a client. Make sure that
you will be giving privacy as to maintain dignity of client.
GENERAL SURVEY
6. Physical Appearance
Normal Abnormal Other Cases:
Age Appears like stated age Appears older or
younger
Turner’s Syndrome
Gender Sexual development is
appropriate to gender
and age
Delayed or advanced
puberty
Level of Consciousness Alert, oriented,
responds appropriately
Confused, drowsy,
lethargic
Skin Color Skin tone is even, intact
with no obvious lesions
Palor, Cyanosis,
Jaundice, Erythema
(redness), presence of
lesions
Facial Features Symmetrical with
movement
Immobile, mask-like,
asymmetric, drooping
Overall No signs of acute
distress
Respiratory signs:
Shortness of breath,
wheezing
Pain: Grimace,
holding/guarding body
part, knees drawn up
over the abdomen
7. Body Structure
Normal Abnormal Other Cases
Structure Height appears within
normal range, for age,
genetic heritage.
Excessively short or tall Gigantism: experienced
by children
Aromegaly: experienced
by people 18 >
Simmonds: low growth
hormone
Nutrition Weight appears within
normal range for
height, body build, fat
distribution.
Emaciated, Cachectic
(Tissue wasting), Obese,
Fat concentration in
face, neck, trunk, arms,
and legs
Cushing’s Syndrome:
Thin extremeties, with
buffalo hump
Symmetry Body parts look equal
bilaterally and are in
relative proportion to
each other.
Body parts are not
proportioned
Unilateral Atrophy: Loss
of muscle volume
Hypertrophy: Increased
muscle volume
Posture Clients stand
comfortably erect.
Stiff, tense, with fidgety
movement, shoulders
humped, looks
depressed
Position Client comfortably sits
on a chair or on the bed
with arms relayed at
the sides, head turned
to the examiner.
Client is curled up in
fetal position; leaning
forward with arm
braced on chair
Body Build and Contour Slender, medium build,
stocky or muscular.
Thin; muscle wasting;
obese
*Things to remember:
1. Endomorph: fat
2. Mesomorph: normal
3. Ectomorph: thin
8. Mobility
Normal Abnormal Other Cases
Gait Base is wide as the
shoulders; foot
placement is accurate
Exceptionally wide
base, staggered,
stumbling, limping with
injury
1. Spastic
2. Scissor
3. Propulsive
4. Steppage
5. Waddling
Range of Motion Full mobility of each
joint; movements are
Paralysis; jerky,
uncoordinated
deliberate and accurate movments
9. Behaviour
Normal Abnormal Other Cases
Facial expression Client maintains eye
contact, expressions are
appropriate to the
situation
Flat, depressed, angry,
sad, anxious
Mood and Affect Client is cooperative;
comfortable with
examiner; interacts
pleasantly.
Hostile, distrustful,
suspicious, crying
Speech Client speaks clearly;
stream of talking is
fluent, even; word
choice is appropriate
Difficulty in talking;
abnormal pitch or
volume; voice is hoarse
or whispered; slurred
speech; constant talking
Dress Clothing is appropriate
to the climate and age
group; looks clean and
fits the body;
Trousers are too large
and held by belt; looks
unclean;
Personal Hygiene Appears clean and
groomed; appropriate
for age, occupation, and
socio-economic group;
hair is brushed or
groomed.
Unkept hair; Absent
makeup
INTEGUMENTARY SYSTEM
10. Inspect skin for color, pigmentation, and lesions.
Normal Abnormal Other Cases
Color
Whitish pink, or brown
color; Depends on
race.
Cyanotic (bluish);
Jaundice (yellowish)
1. Pallor: decreased
visibility of normal
oxyhemoglobin
2. Carotenemia:
excessive carotene
3. Hyperemia:
increased blood
flow
4. Erythema: redness
of skin
5. Xanthoma Striata:
Yellowish
discoloration of
palmar and digital
creases
6. Addison’s disease:
bronze-like skin
due to deficit in
cortisol
7. Acanthosis
Nigricans:
brownish skin due
to use of steroids
and obesity
8. Albinism:
generalized
whiteness;
9. Vitiligo: absence of
melanin
10. Erythematosus:
“butterfly rash”
11. Cloasma and Linea
nigra: seen in
pregnant women
Temperature
For Palpation:
Palpate all
nonmucosal skin
surfaces using dorsal
surfaces of hands.
Warm and equal
bilaterally; hands and
feet maybe cooler
than rest of body.
Hyperthermia
11. Inspect hair distribution, texture, moisture all over the body.
Normal Abnormal Other Cases
Distribution Body is covered with
vellus hair; terminal
hair is found in
eyebrows, eyelashes,
scalp and in axilla and
pubic hair areas.
Absence of pubic hair
(unless purposely
removed)
1. Traction Alopecia:
hair loss in linear
formation
2. Hirsotism: excess
facial and body hair
3. Trichotillomania:
areas of broken-off
hair in irregular
patterns
Texture
Evaluate texture using
Feels smooth, even,
and firm except when
Roughness on exposed
areas; Hyperkeratosis
finger pads, check
abdomen and medial
surfaces of arms first.
there is significant hair
growth.
and silk-like
Moisture
For Palpation:
Palpate all non-
mucous membrane
skin surfaces using
dorsal surfaces of
hands and fingers.
Skin is dry with
minimum
perspiration, moisture
vary from one area to
another.
Excessive dryness;
profuse sweating
1. Xerosis
2. Diaphoresis
12. Inspect nails for characteristic, color, texture, shape and configuration.
*Note for capillary refill.
Color
Abnormalities:
1. Leukonychia: white striations in the nail bed
2. Leukonychia totalis: nail bed is white due to hypercalcemia
3. Melanonychia: brown color of nail plate
4. Cyanotic: bluish nails
5. Splinter hemorrhage: red or brown linear streaks nail bed
6. Lindsey’s Nails: white proximal end and pink distal portion of nailbed
7. Onychomycosis: yellow or white hue
8. Terry’s Nails: whitish band
Shape and Configuration
Abnormalities:
1. Koilonychia: thin spoon nail with cuplike depression
2. Clubbing: Angle of nailbed is 160 degrees
3. Beau’s Line: transverse furrow in the nail plate
4. Oncholysis: separate of nail from nail bed
5. Caronychia: painful red swelling
6. Sublingual hematoma: purpura or ecchymosis under nail plate
7. Onychocryptosis: distal portion of nail plate is embedded in periungal tissue
8. Eggshell nails: curved under nail edge
9. Onychatrophia: nail atrophy or shrinking
10. Onychorrhixis: nail is split in lengthwise
11. Pterygium: abnormal cuticle that overgrows the nail
Texture
*Nailbase must be firm
*Clubbing is due to prolonged hypoxia (chronic bronchitis, emphysema, heart disease)
13. Palpate for temperature, texture and moisture.
Normal Abnormal
Temperature
Palpate all nonmucosal skin
surfaces using dorsal surfaces of
hands.
Warm and equal bilaterally;
hands and feet maybe cooler
than rest of body.
Hyperthermia
Feels smooth, even, and firm
except when there is significant
hair growth.
Roughness on exposed areas;
Hyperkeratosis and silk-like
Moisture
For Palpation:
Palpate all non-mucous
membrane skin surfaces using
dorsal surfaces of hands and
fingers.
Skin is dry with minimum
perspiration, moisture vary from
one area to another.
1. Xerosis
2. Diaphoresis
14. Perform skin turgor/skin pinch and mobility.
Procedure Normal Abnormal
Palpate skin turgor at dorsal
surface which reflects the skin’s
state of hydration
Should return to its original
contour rapidly. It takes about 1-
2 seconds.
Poor skin turgor; Does not go
back immediately.
HEAD AND FACE
15. Inspect the skull for shape, size, masses, nodules, and lumps.
Procedure Abnormalities
1. Have patient sit in a comfortably position.
2. Face the patient with client’s head in level
with yours.
3. Inspect for symmetry.
Normal Shape: Normocephalic
1. Hydrocephalus: enlargement of head
without enlargement of facial structure
2. Acromegaly: abnormal enlargement of
skull with bony facial structure
3. Craniosynostosis: abnormal shape of skull
at right angles
4. Anencephaly: absence of brain and skull
5. Microcephaly: circumference of head is
smaller than average.
Normal Abnormal Other Cases
Face Symmetrical; Palpebral
fissure should be equal
*Slight variations are
common
Structures are
deformed; Asymmetry
of face
Shape No edema;
Disproportionate
structures
Slanted eyes with inner
epicanthal folds; a short
flat nose and a thick
protruding tongue;
Facial skin is shiny,
contracted and hard;
face is immobile and
expressionless
Hypertelorism:
abnormally wide
distance between the
eyes.
16. Inspect face for symmetry~ CN5.
17. Perform test for CN7.
Facial Motor Exam Abnormalities
*Forehead and Upper lid Innervation
1. Eyebrow elevation
2. Forehead wrinkling
3. Frowning
4. Tight Closing of the eyes
*Lower Face innervation
1. Showing teeth
2. Whistling
3. Puffing cheeks
4. Natural smile
5. Test or inquire about Taste
Sensation
1. Unless bilateral lesion, does not affect
forehead
2. Mouth paralysis is overcome by
emotional expression
3. Ipsilateral forehead and lower face
paralysis
18. Inspect and palpate scalp, hair, and cranium.
Normal Abnormal Other Cases
Scalp Scalp should be pale
white to pink in light-
skinned people and
light brown in dark-
skinned people.
Infestation, dandruff Head lice (Pediculosis
Capitis)
Hair Dark to pale blonde Patches of gray hair
that are isolated or
occur in conjunction
with scar
19. Palpate temporal artery – CN5 Motor
20. Palpate frontal and maxillary sinuses for tenderness.
21. Percuss frontal and maxillary sinuses for tenderness.
22. Auscultate temporal artery for bruits.
EYES
23. Inspect eyebrows and eyelashes for hair distribution and alignment.
Normal Abnormal
Eyelashes
Eybrows
Symmetrical; evenly distributed;
bilateral
Absence of eyelashes; infection
near areas
24. Inspect lids for skin characteristics, color, and position.
Normal Abnormal Other Cases
Eyelids Symmetrical; client can
move both eyelids;
normal lid margins are
smooth with lashes
evenly distributed
Drooping; infections;
tumors; excessive
blinking; swelling
1. Lagophthalmos:
inability to bring
about complete lid
closure
2. Eyophthalmos:
disparity of
palpebral fissure
3. Enophthalmos:
disparity in size of
globe
4. Entropion:
inversion of lower
lid
5. Ectropion: eversion
of lower lid
6. Hordeolum: acute
inflammation
7. Chalazion: chronic
inflammation
8. Belpharitis:
bilateral
inflammation
25. Inspect bulbar and palpebral conjunctiva, note for color sclera and iris.
Normal Abnormal
1. Gently pull down
eyelashes and place a
sterile cotton-tipped
applicator above the lid
margin.
2. Gently exert downward
pressure.
3. Inspect Palpebral
Conjunctiva for infection
and swelling
4. Return eyelid to its
normal position.
Increased lacrimation; reddish
bulbar conjunctiva
Pinguecula: yellow nodule on the
nasal side of bulbar conjunctiva
Pterygium: unilateral/bilateral
triangle shaped encroachment
Sclera White sclera; small blood
vessels; tiny brown patches
Jaundice; bluish sclera
(Osteogenesis Imperfecta)
26. Inspect and palpate the lacrimal gland, asses for color, swelling and exudates.
Normal Abnormal Other Cases
Lacrimal apparatus No enlargement,
swelling, redness,
exudates; minimal
tearing
Mucopurulent
discharge; overflowing
tears (Epiphora)
1. Dacroadenitis:
acute
inflammation
2. Dacrocystisis:
inflammation and
painful swelling
beside nose and
near inner
canthus
27. Test for corneal reflex (Blinking and tearing)
Procedure
1. Instruct the client to look straight ahead.
2. Focus a penlight on the corneas from a distance of 12 to 15 inches away from
midline.
3. Observe location of reflected light on the cornea.
Normal Abnormal
Reflected light should be seen in the center of
each cornea
1. Strabismus: deviation of one eye
2. Esotropia: inward turning of the eye
3. Exotropia: Outward evading of eye
28. Inspect pupils for size, shape and symmetry.
Normal Abnormal
Pupils Black pupils, round, and of equal
diameter, ranging from 2-6mm;
brisk constriction to direct light;
1. Miotic Pupils (<2mm
constriction)
2. Mydriatic Pupils (>6mm
dilation)
Pupils with irregular shape
Asses Client’s
29. Direct and consensual reaction to light and accommodation.
30. Visual fields by confrontation (CN II).
31. Six cardinal gaze (EOM).
Normal Abnormal
Procedure:
1. Place client in sitting
position, facing you.
2. Place non-dominant
hand just under the
client’s chin as a
reminder to keep the
head still.
3. Ask client to follow an
object with eyes.
4. Move object through the
six fileds of gaze in a
smooth and steady
manner.
5. Note client’s ability to
move eyes in each
direction.
6. Move the object forward
5 inches away from face.
7. Observe for convergence
of gaze
Both eyes should move smoothly
and symmetrically in each of the
six fields of gaze
Lack of symmetrical mov’t;
abnormal eye mov’t;
1. Opthalmoplegia:
paralysis of one/more
optic muscles
2. Vertical gaze: paralysis
of upward gaze
3. Paralysis of horizontal
gaze
32. Asses visual acuity (Snellen’s)
Procedure
1. Ask client to remove corrective lenses if he/she wears them.
2. Cover one eye.
3. Ask him to read letters on one line going downward until he can no longer discern the letters.
EARS
33. Inspect and palpate auricle/pinna for color, symmetry, position, and palpate for tenderness.
Normal Abnormal Other Cases
External Ear Same color; pain Pale, cyanotic;
tenderness; edema
1. Microtia:
abnormally large
ears
2. Auricular
hematoma:
damaged/mutilat
ed ear.
3. Perichondritis:
edematous,
painful ear.
4. Carcinoma: tumor
on external ear
5. Battle’s sign:
hematoma behind
ear over mastoid
bone
34. Inspect external auditory canal for color, patency. Note color and gloss and state characteristics of
tympanic membrane.
35. Assess client’s hearing acuity (Voice whisper).
Normal Abnormal
Client is able to repeat 2 syllable word Client is unable to hear the word
36. Perform Weber’s Test.
Normal Abnormal
Client should perceive the sound equally in both
ears; No lateralization of sound is known as a
negative Weber’s Test.
Sound localizes on unaffected ear
37. Perform Rinne’s test.
Normal Abnormal
Air conduction is heard twice as long as bone
conduction when client hears through the external
auditory canal is no longer heard.
Client hears the sound longer through the bone
conduction.
NOSE
38. Inspect external nose for color, shape, size, flaring and discharges, deviations.
Normal Abnormal
Air can move through nostrils Air cannot move through nostrils
39. Inspect the nasal cavities for color, swelling, edema, discharges, growth with the use of nasal
speculum.
Normal Abnormal
Nasal Mucosa should be pink/dull; without
swellings or polyps
Red mucosa; swollen width copeus; clear water
discharge; edematous
40. Palpate for tenderness or mass.
Normal Abnormal
Client should experience no discomfort during
palpation; sinuses should be air filled, therefore
resonant to percussion
Nasal Polyps: Smoot, round masses that are pale
and shiny and are noted protruding from middle
meatus
Nasal Septal Perforation: nasal mucosa is inflamed.
41. Check for patency of both nostrils.
42. Check for CN 1 (Smell Test).
MOUTH AND THROAT
43. Inspect the outer lips for color symmetry, and texture. Palpate for lesions.
Normal Abnormal
Lips should be pink and moist with no lesions or
inflammation
Lips are pale; inflamed
1. Herpes Simplex
2. Chancre
3. Wart
4. Nodule
44. Examine oral mucosa, gums, teeth, using the tongue blade and penlight.
Normal Abnormal Other Cases
Oral Mucosa Color may vary
according to race;
should be moist,
smooth and free of
lesions
Inflamed; lesions 1. Leukoplakia:
leathery,
painless, white,
pointed-looking
palates
2. Apthous ulcer:
small, round
white ulcers.
3. Stomatitis:
reddish mucosa
4. Xerostoma:
excessive
dryness of
mucosa
Gums Lightly colored; gum
margins should be well
defined with no pockets
existing between gums
and teeth
Inflamed Gingivitis: red,
tender, swollen
and bleeding
gingiva
Teeth Presence of 32< teeth Absence/loss of teeth 1. Dental Carries:
white/black
patches on the
surface of the
tooth
2. Dead tooth:
darker in color
and insensitive
to cold
3. Hutchinson’s
Incissors: teeth
with serrated
edges
45. Inspect the outer lips for color, moisture, size, and position. Inspect the hard and soft palates.
Normal Abnormal Other Cases
Palate Hard and soft palates
are concave and pink;
hard palate has many
ridges, soft palate is
smooth
Infection 1. Torus Platinus:
bony ridge in
the middle of
hard palate
2. Palatine
Perforation:
hole in hard
palate
46. Inspects the uvula for position, Oropharynx for color.
47. Inspect the tonsils for color, discharge, and size.
48. Perform taste test (CN7- Sensory).
49. Palpates tongue for nodules and lumps.
Normal Abnormal Other Cases
Tongue is in midline of mouth,
dorsum of tongue is pink, moist,
ruoght.
Tongue is enlarged, red, smooth,
w/ absent papillae
1. Glossitis: reddish tongue
with absent papillae.
2. Candidiasis: thick, white,
crudlike coating on
tongue.
50. Note tongue movement and strength (CN 12).
51. Elicits the gag reflex (CN IX and X)
NECK
52. Inspect neck muscles and assesses head movement and strength (CN11)
Normal
Muscles of neck are symmetrical with head in a central position. Patient is able t move the head,
through a full range of motion.
53. Inspect and palpates for location of trachea.
54. Palpates thyroid gland to identify enlargement, nodule and tenderness.
Procedure:
1. Stand behind patient.
2. Have the patient lower the chin slightly.
3. Place your thumb at back of patient’s neck.
4. Move finger pads over tracheal ring.
5. Instruct patient to swallow- palpate for nodules or enlargement.
55. Palpate and identify lymph nodes.
56. Observes for carotid artery pulsation and jugular vein distention.
THORAX AND LUNGS
57. Inspects the size, shape and symmetry of the thorax and note for spinal deformities.
Normal Abnormal Other Cases
Chest Elliptical in shape with
lateral diameter that is
larger than the AP
diameter.
AP is larger than lateral
diameter
1. Barrel Chest:
the AP diameter
is equal to the
lateral diameter
2. Funnel Chest
(Pectus
Excavatum):
depression of
the sternum
3. Pigeon Chest
(Pectus
Carinatum):
forward
displacement of
the sternum
4. Scoliosis: lateral
curvature and
rotation of
thoracic and
lumbar spine
5. Kyphosis:
exaggerated
posterior
curvature of
thoracic spine
58. Palpate the posterior chest (Spinous process) for tenderness and spacing.
Normal Abnormal
Posterior Chest Muscle mass should be firm; no
lesions; non tender; movement
and pressure of chest against
your hands should feel smooth.
Tender; lesions; delay in
expansion may indicate
fibrotic/obstructive lung disease.
59. Assess for tactile fremitus.
Normal Abnormal
Symmetrical vibration a. Decreased/Absent fremitus: soft voice,
thick chest wall, COPD, pleural effusion
b. Increased fremitus: fluid in lungs or
infection
60. Note for diaphragmatic excursion (Posterior).
*Abnormal: Dull sounds
61. Percuss the posterior thorax.
Normal Abnormal
3-5 cm distance between marks and even on each
side. Right side maybe 1-2cm higher because of
the location of the liver.
Shortened excursion (lungs are not fully
expanding).
62. Performs respiratory excursion (Anterior).
63. Auscultate the chest using the systematic zigzag method (both anerior and posterior chest and
identifies the location and type of the normal breath sounds).
Normal Abnormal
Muffled sounds Sound is loud and more distinct
HEART
64. Simultaneously inspect and palpates the precordium for abnormal pulsations heaves/lifts ( using Z
technique)
Normal Abnormal
No visible pulsations, except at the PMI (Point of
Maximal Impulse) or where the apical pulse is
located, visible as a pulsation or thrust.
Neck distention and or visible pulsations in the
precordial area except @ the PMI.
65. Auscultates the aortic, pulmonic, tricuspid and mitral areas at proper locations for heart sounds
noting for S1 and S2 sounds; PMI.
Normal Abnormal Other Cases
S1- first heart sound (LUB);
S2-2nd
heart sound (DUB)
S3-normally present under 34
years and below
S4-may occur on young people
with thin chest wall
Chest pain indicates inadequate
myocardial tissue oxygenation;
pulse deficit
1. Dyspnea:
labored/difficulty in
breathing
2. Orthopnea:
breathlessness that
prevents client from
lying down
3. Fatigue: worse at night
due to decreased cardiac
output
4. Cyanosis/Pallor: due t
decreased CO that
results to decreased
tissue perfusion
5. Dependent Edema:
indicates heart failure
6. Jugular Vein Distention:
indicates heart failure
BREAST AND AXILLA
66. Inspect each breast and axilla while client’s hands are resting on her side, placed on hips, above the
head. Note for contour, size, symmetry, discolorations, and dimpling.
Normal Abnormal Other Cases
Smooth; w/o lesions; dense
breast tissue; nipple usually
everted out in the same
direction; no discharge
Increased vascularity of breast;
nipple discharge; scaling around
nipple
Gynecomstia: breast
enlargement for males.
67. Performs breast-self examination, palpates the breast in a systematic manner and notes for masses,
tenderness and texture.
Normal Abnormal Other Cases
Nodular and granular
consistency; inferior aspect of
breast is firm; non-tender
Lumps; unilateral granulation;
mass; itching; swelling;
tenderness
Peau d’ orange:
thickening/edema of breast
tissue/nipple with enlarged skin
pores.
68. Assess for lymph nodes. (Axillary)
Normal Abnormal
Non-tender; less than 1cm in diameter Fixed; more than 1cm; painful; enlarged; matted
together
ABDOMEN
69. Observe for the contour and inspect the symmetry of abdomen.
Normal Abnormal
Contour: Flat, rounded/scaphoid
Contours:
1. Flat
2. Rounded/Convex
3. Scaphoid/Concave
4. Protruberant
Protruberant abdomen (normal in pregnant
women)
*Ascites: accumulation of fluid in abdominal
cavity.
Symmetry: Without bulging/masses Assymetrical
70. Check umbilicus for contour or hernia, observe skin characteristics.
Normal Abnormal
Located at the center; inverted or protruding;
clean and free of inflammation or drainage
Displaced umbilicus; For non preggo’s: indicates an
abdominal mass/distended urinary bladder
Hernia: for children
71. Note for pulsations, visible peristalsis, and movement.
72. Auscultate for bowel sounds in the four quadrants. Note the character and frequency.
Normal Abnormal
5-30/min or 10/sec (Borborygmi); no vascular
sounds/friction rubs; irregular, gurgling and high
pitched bowel sounds
Hypoactive: 1/15 sec
Hyperactive: 1/sec
73. Percuss the abdomen.
Normal Abnormal
a. Tympany: stomach
b. Dullness: liver and spleen
Dullness: distended urinary bladder or ascites
Liver: approximately 5-10cm (2-4 in)
Size at midsternal line: 4-9 cm (1.5-3 inc)
Spleen: tympanic sound Dull sound
74. Palpate surface and deep areas, assess size, location, consistency of abdominal organs, screen mass
or tenderness-light/deep.
Normal Abnormal
Stomach: Soft, smooth, non-tender, pain free Masses; tumors; or obstructions during palpation
Liver: Non-palpable; lower border of the liver is
smooth, firm and non-tender
Pain; nodules occur with cirrhosis
Spleen: Non palbable Splenomegaly
75. Perform special procedure (rebound tenderness, Murphy’s sign, Iliopsoas muscle, Obturator test)
MUSKULO-SKELETAL- UPPER EXTREMITIES
76. Inspects nail beds for color, shape, texture and surrounding tissues.
77. Performs the capillary test/blanch test.
Normal Abnormal
Nail bed should regain usual color in 1-2 seconds. Nail bed regains own color after more than 2
seconds
78. Inspect muscles for size, notes for symmetry, palpates for muscle tone while client is active and then
passive, palpate joints.
Normal Abnormal
Symmetrical hands and arms; absence of muscle
wasting; no edema; no tenderness, redness or
increased heat
Assymetry or deformity of fingers in rheumatoid
arthritis
79. Test for muscle strength bilaterally.
Normal Abnormal
Fingers: Equal strength on both hands
Wrist joint: No enlargement or discomfort or pain;
symmetrical muscle strength
Enlargement along joints or discomfort/pain;
Unequal strength which may indicate weakness on
either side
*Stereognosis: able to identify an object
80. Check for ROM asking client to move selected body parts and names exercises done.
Normal Abnormal
Full, without difficulty Presence of pain
81. Elicits reflexes (Biceps, Triceps, Brachioradialis)
Normal
Biceps Reflex 2+
Contraction of biceps muscles with flexion of the
elbow
Triceps Reflex 2+
Contraction of triceps muscle with extension of
forearm
Brachio-radialis or supinator Reflex 2+
Flexion and supination of forearm
82. Conducts fine motor test.
83. Conducts light touch sensation and notes for pain and temperature sensation.
Normal Abnormal
Light Touch Sensation: Client is able to feel the
touch as light or soft on either side
Decreased/absent sensation
Pain Sensation: Client is able to tell the sensation
as sharp or dull
Client has difficulty feeling sensation
Conducts tactile discrimination
84. One and two point
Normal Abnormal
Acceptable standard of distance that a client can
no longer feel the distance bet/ two points or
object is 5 millimeters
Increased distance between the 2 points felt
suggests lesions in sensory cortex
85. Stereognosis
Normal
Client is able to identify the given object correctly.
86. Extinction phenomenon
Normal Abnormal
Client is able to feel both touches and is able to
directly point the correct location of touch
Feels only one stimulus suggests lesions of the
sensory cortex
87. Graphestesia
Normal Abnormal
Able to identify number Inability to identify the number written which may
indicate a lesion on the sensory cortex
LOWER EXTREMITIES
88. Inspect legs together, note skin color, distribution, venous pattern, size, lesions.
89. Measure calf circumference along legs down to the feet.
Normal
Symmetrical and equal circumference, size, and length.
90. Palpate skin temperature along legs down to the feet.
Normal
No inflammations or enlargement or pain
91. Assess for Romberg, tandem walking, heel to shin.
Normal
Able to do this in a straight line without losing balance
92. Assess for Homan’s sign.
93. Check for pretibial edema.
94. Check for reflexes.
Reflex Normal
Quadriceps reflex/Patellar reflex Quadriceps contract, lower leg extends
Achilles reflex Plantar flexion
Plantar/Babniski reflexes Plantar flexion without toe fanning or great toe
dorsiflexion
95. Check for muscle strength.
Normal
Toes Good muscle strength
Both legs No limitation of movement