Head-To-Toe

Assessment

Group Members:

Binay, Rizalyn

Busa, Ana Marie

Cabiltes, Claitte

Diano, Christine

Nasayao, jannin

Ramos, Sunny

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Head-To-Toe Assessment

After 3 hours of classroom Discussion and Demonstration the

Level I students will be able to:

I. Define the FF. terms:

a. Nursing Assessment

b. Physical Assessment

c. Anthropometric Measurement

d. Health History

e. Health

f. Reflexes

g. Visual Activity

h. Interview

i. Signs

j. Symptoms

II.

a. Importance of Physical Assessment

b. Purpose of Physical Assessment

c. Four basic techniques in Physical Assessment

d. Principles involved in Physical Assessment

e. Nursing responsibilities before, during and after

Physical Assessment

f. Materials and Equipment used in Physical Assessment

III.

Demonstrate Beginning Skills in Physical Assessment.

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Head to Toe Assessment

Define the Following terms:

A. Nursing Assessment

- Is a major component of nursing care.

- Is a process which includes both physical and

psychological aspect to evaluate client’s condition.

- Enables the nurse to make a judgment about the

client’s health status , ability to manage his/her health

care and need for nursing.

B. Physical Assessment

- Is a process by which a nurse obtains a data that

describes a person’s responses to actual or potential

health problems shich is analyzed to form pertinent

diagnosis.

- Is a head to toe review of each body system that offers

objective information about the client and allows the

nurse to make clinical judgment.

C. Anthropometric Measurement

- Comparative measurements of the body.

Anthropometric measurements are used in nutritional

assessments. Those that are used to assess growth and

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development in infants, children, and adolescents

include length, height, weight, weight-for-length, and

head circumference (length is used in infants and

toddlers, rather than height, because they are unable to

stand). Individual measurements are usually compared

to reference standards on a growth chart. Measurement

of size weight and proportion of the body.

- Most commonly used anthropometric measured are

height, weight, triceps, skinfold thickness, elbow

breadth and arm and head circumference.

D. Health

- State of being physically fit, mentally stable and

socially comfortable.

- It encompasses more than the state of being free of

disease.

E. Health History

- defined as the systematic collection of subjective data

(stated by the client) and objective data (observed by

the nurse) used to determine a client’s functional

health pattern status.

F. Reflexes

- Bent, turned or directed back; or produced by a reflex

without intervention of consciousness.

- Is an involuntary and nearly instantaneous movement

in response to a stimulus.

G. Visual Acuity

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- The degree of detail the eye can discern an image.

- Is a quantitative measure of the ability to identify black

symbols on a white background at a standardized

distance as the size of the symbols is varied.

- Is acuteness or clearness of vision, especially form

vision, which is dependent on the sharpness of the

retinal focus within the eye and the sensitivity of the

interpretative faculty of the brain.

H. Interview

- An interview is a conversation between two or more

people (the interviewer and the interviewee) where

questions are asked by the interviewer to obtain

information from the interviewee. "Interview" word is

derived from french word "entirevior" it means

"glimpse" to each other.

- Therapeutic interaction that has a purpose.

I. Signs

- A sign is the physical manifestation of an illness, injury

or other bodily disorder. A sign is objective and can be

observed

- Signs can be felt, heard, seen, and measured by the diagnostician or

nurse. These include pulse, respirations, blood pressure, and physical

evidence such as bleeding, broken skin, bruising etc.

J. Symptoms

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- Subjective evidence of a disease of physical

disturbance observed by the patient.

- Is a departure from normal function or feeling which is

noticed by a patient, indicating the presence of disease

or abnormality. A symptom is subjective, observed by

the patient, and not measured.

Importance of Physical Assessment:

To early detect and treat diseases and disorders.

To identify actual and potential health problems.

To establish a data based from which the subsequent phases

of the nursing evolve.

To assess the client’s impact of activity and exercise on the

client’s overall level of health.

To assess the client’s routine exercise pattern and observe

how the client’s body system response to activity and

exercise.

To establish the client-nurse relationship

To obtain information about the client’s health including,

physiologic, psychologic, sociocultural, cognitive,

developmental and spiritual aspects.

To identify the client’s strength and weaknesses.

Purpose of Physical Assessment

To supplement, confirm or refute data obtained in the

nursing history.

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To confirm and identify nursing diagnosis.

To make clinical judgments about a client’s changing health

status and management.

To evaluate the physiological outcome of care.

To obtain and gather data about the client’s health basis of

data for future assessment.

An excellent way to evaluate an individual’s current health

status.

Four Basic Techniques in Physical Assessment

I. Inspection

It is the use of ones senses of vision and smell to

consciously observe the patient. It is also known as concentrated

watching. It is a close, careful scrutiny; first of the individual as a

whole and then of each body system. Inspection begins the

moment you first meet the individual and develop a “general

survey”. Then as you proceed through the examination, start the

assessment of each body system with inspection.

II. Palpation

It is the act of touching a patient in a therapeutic

manner to elicit specific information. It follows and often confirms

points you noted during inspection. Palpation applies your sense

of touch to assess these factors: texture, temperature, moisture,

organ location and size, as well as any swelling, vibration or

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pulsation, rigidity or spasticity, crepitation, presence of lumps or

masses and presence of tenderness or pain.

Two distinct types of palpation: Light and deep palpation

Light palpation

It is superficial, delicate and gentle. In light palpation,

the finger pads are used to gain information of the patient’s skin

surface to a depth of approximately ½ - 1 inch below the surface.

Light palpation reveals information on skin texture and moisture;

overt large or superficial masses; and fluid, muscle guarding and

superficial tenderness.

Deep palpation

It can reveal information about the position of organs

and masses, as well as their size, shape, mobility, consistency,

and areas of discomfort. Deep palpation uses the hands to

explore the body’s internal structure to a depth of 1 to 2 inches or

more. This technique is most often used for the abdominal and

male and female reproductive assessments. Variations in this

technique are single handed and bimanual palpations.

III. Percussion

It is the technique of striking or tapping the person’s

skin with short, sharp strokes to assess underlying structures. The

strokes yield a palpable vibration and a characteristic sound that

depicts the location, size and density of the underlying organ.

These sounds also are diagnostic of normal and abnormal

findings. Any part of the body can be percussed, but only limited

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information can be obtained in specific areas such as heart. The

thorax and abdomen are the most frequently percussed location.

Four types of percussion techniques: Immediate or direct,

mediate or indirect, direct fist and indirect fist percussion

A. Immediate or Direct Percussion

The striking hand directly contacts the body wall. This produces a

sound and is used in percussing the infant’s thorax or the adult’s

sinus areas.

B. Mediate or Indirect Percussion

It is used more often and involves both hands. The striking

hand contacts the stationary hand fixed on the person’s skin. This

yields a sound and a subtle vibration.

C. Direct Fist Percussion

It is used to assess the presence of tenderness in internal

organs, such as the liver or the kidneys. The presence of pain in

conjunction with direct fist percussion indicated inflammation of

that organ or a strike of too high in intensity.

D. Indirect Fist Percussion

Its purpose is the same as direct fist percussion. In fact, the

indirect method is preferred over the direct method. It is because

in this methods. The non dominant hand absorbs some of the

force of the striking hand. The resulting intensity should be

sufficient force to produce pain in the patient if organ

inflammation is present

Percussion elicits five types of sounds:

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1) Flatness (dull) – bone and muscle

2) Dullness (thudlike) – liver, spleen, heart

3) Resonance (hollow) – air-filled lung/ normal lung

4) Hyperresonance – emphysematous lung

5) Tympany – stomach filled with gas (air)

IV. Auscultation

It is the act of active listening to the body organs to gather

information on patient’s clinical status. Auscultation includes

listening to sounds that are voluntarily and involuntarily

produced by the body such as the heart and blood vessels

and the lungs and abdomen. Auscultated sounds should be

analyzed in relation to their relative intensity, pitch, duration,

quality, and location.

Two types of auscultation: Indirect and direct auscultation:

1) Direct of Immediate auscultation

It is the process of listening with the unaided ear. This

can include listening to the patient from some distance

away or placing the ear directly on the patient’s skin

surface. And example is the wheezing that is audible to

the unassisted ear in a person having a severe

asthmatic attack.

2) Indirect or Mediate auscultation

It is the use of stethoscope, which transmits the sounds

to the nurse’s ear.

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Principles involved in physical assessment:

Anatomy & Physiology

One has to know the different parts and functions of the

body in order to do a thorough and detailed assessment.

Psychology

Through Psychology, we are able to make good assessments

because we can differentiate a normal mental state and an

abnormal one.

Privacy must be ensured during the Physical Assessment to

avoid the client from being anxious or uncomfortable.

Microbiology

Do medical handwashing before and after the procedure.

Instrument should be sterile.

Time and energy

Starts from lesser to the most sensitive part

Body mechanics

Nurse and patient should maintain proper body mechanics.

Nursing responsibilities before, during and after Physical

assessment

Before

Always dress in clean professional manner, make sure you

have your name pin or workplace identification.

Remove al bracelets, necklaces, or earrings that can

interfere during the physical assessment.

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Be sure your hair will not fall forward and obstruct your

vision or touch to the patient.

Ensure that all necessary equipment is ready for use and

within reach.

Introduce yourself to the patient. Enlist the patient’s

cooperation by explaining what you are about to do, where it

will be done, and how it may feel.

Explain to the patient why you may be spending a long time

performing one particular skill.

Do medical hand washing

Position the patient as dictated by the body system being

assessed.

Warm all instruments prior to their use

During

Conduct the assessment in a systematic fashion every time.

While performing each step in the physical assessment

process you may need to inform the patient of what to

expect, where to expect it, and how it should feel.

Avoid making crude or negative remarks, be cognizant of

your facial expression when dealing with malodorous and

dirty patients or with disturbing findings.

Proceed from the least invasive to the most invasive

procedure for each body system.

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If the patient complains of fatigue, continue the assessment

later.

After

Provide recognition to the patient when the physical

assessment concluded; inform the patient what will happen

next.

Place patient in a comfortable position.

Do after care.

Do medical hand washing.

Document assessment findings in the appropriate section of

the patient record.

Materials and Instruments of Physical Treatment

Supplies Purpose

Flashlight or

penlight

To assist in viewing of the pharynx and

cervix or to determine the reaction of

the pupils of the eye.

Laryngeal or dental

mirror

To observe the pharynx and oral cavity.

Nasal septum To permit visualization of the lover and

middle turbinates; usually a penlight is

used for illumination.

Ophthalmoscope A lighted instrument to visualize the

interior of the eye.

Otoscope A lighted instrument to visualize the

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eardrum and external auditory canal (a

nasal speculum may be attached to the

Otoscope to inspect nasal cavities).

Percussion (reflex)

hammer

An instrument with a rubber head to

test reflexes.

Tuning Fork A two-prolonged metal instrument used

to test hearing acuity and vibratory

sense.

Cotton applicators To obtain specimens.

Gloves To protect the nurse

Lubricant To ease the insertion of instruments

(ex.Vaginal Speculum)

Tongue blades

(depressors)

To depress the tongue during

assessment of the mouth and pharynx.

Various positioning of the patient

Dorsal recumbent

Back-lying position with knees flexed and hips externally

rotated; small pillow under the head; soles of feet on the surface.

Supine (horizontal recumbent)

Back-lying position with legs extended; with or without pillow

under the head

Sitting

A seated position. The back is unsupported and legs hanging

freely.

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Lithotomy

Back-lying position with feet supported in stirrups; the hips

should be in line with the edge of the table.

Sims

Side-lying position with the lowermost leg flexed at the hip

and knee, upper arm flexed at the shoulder and elbow.

Prone

Lies on the abdomen with head turned to the side, with or

without a small pillow.

Body Parts

Assessment of Body PartsHead & NeckHeadInspection:For size, shape & symmetry

Palpation:For contour, masses, depressions.

HairInspection:For color, evenness of growth over the scalp, presence of parasites, amount of body hair.

Palpation:Thickness or thinness texture and oiliness.

Scalp

Normal Findings

The head should be round (normocephalic) and symmetrical.

The normal skull is smooth, and without masses or depressions, non tender.

Can be black, brown or burgundy depending on the race, evenly distributed covers the whole scalp (no evidences of Alopecia), no parasites, and the amount is variable.

Maybe thick or thin, coarse or smooth neither brittle nor dry.

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Inspection:For Color, oiliness, presence of scars, lice and dandruff.

Palpation:For lesions or masses tenderness.

ForeheadInspection:For symmetry, skin appearance, presence of rushes, scars or pimples.

Palpation:For masses, lumps and tenderness

FaceInspection:For shape and symmetry, presence of scars, pimples or acne

Palpation:For any swelling, masses, lumps, and the four sinuses (sphenoidal sinuses, frontal sinuses, ethmoid sinuses and maxillary sinuses).

EyesInspection:For symmetry.

EyebrowsInspection:For hair distribution and alignment and skin quality and movement, presence of pimples, dandruff and color of the hair.

Lighter in color than the complexion, can be moist or oily, no scars noted, free from lice, nits and dandruff.

NO lesions should be noted, neither tenderness nor masses.

Symmetrical, light to dark brown, no rushes, scars and pimples.

Non-tender, no lumps and absence of masses.

The shape of the face can be oval, round, or slightly square, the face is symmetrical, absence of scars, pimples or acne. There should be no edema, disproportionate structures, or involuntary movements.

No lumps and swelling of the face, absence of masses and there is no pain felt during palpation of face

Symmetrical or evenly placed and inline with each other. Non protruding and equal palpebral fissure.

Hair evenly distributed; skin intact. Eyebrows symmetrically aligned; equal movement, absence of pimples and dandruff,

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Palpation:For the presence of lumps, pain and nodules.

EyelashesInspection:For evenness of distribution and direction of curl and color

ScleraInspection:For color, moisture, texture and the presence of lesions.

ConjunctivaeInspection:For lesions, swelling, color and moisture.

Palpation:Presence of pain

CorneaInspection:For clarity, texture and moisture

IrisInspection:For appearance, coloration and shape.

PupilInspection:For color size, shape and equality of the pupils

maybe black brown or blond depending on race.

No lumps, no nodules and no pain felt during palpation

Equally distributed; curled sightly outward and black in color.

The sclera appears white, although blacks occasionally have a gray-blue or “muddy” color to sclera. It should be moist and without lesions

Both conjunctivae are shiny, smooth, and pink or red, absence of swelling, no lesions and it should be moist.

There should be no pain felt during palpation.

The corneal surface should be moist, shiny and transparent, with no discharges and cloudiness.

The iris is normally appears flat, with a regular shape and even coloration.

Black in color; appears round, regular, smooth border and of equal size in both eyes, normally

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Muscle functionCorneal Light Reflex or the Hirschberg Test(Observe the location of reflected light on the cornea)

Cover TestThis test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps two eyes parallel. (Observe the cover eye for movement)

Diagnostic Position testLeading the eye through the six cardinal positions of gaze will elicit any muscle weakness during movement. (Observe for convergence of gaze).

Muscle balanceTest for pupilary light reflex(Cardinal Fields of Gaze)

Test for Accommodation

3-7 mm in diameter.

The reflected light (light reflexes) should be seen symmetrically in the centers of the cornea.

If the eyes are in alignment, there will be no movement of the either eye.

A normal response is parallel tracking of the object with both eyes. Both eyes should move smoothly and symmetrically in each of the six fields gaze and convergence on the held object as it moves toward the nose.

Normally you will see:-Constriction of the same-sided pupil (a direct light reflex).-Simultaneously (a consensual light reflex).

A normal response includes:-Papillary constriction.-Convergence of the axes of the eye.Record the normal response to all these maneuver as:P - PupilsE - EqualR - RoundR - React toL - Light andA - Accommodation

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Visual AcuitySnellen eye ChartThe Snellen eye chart is the most commonly used and accurate measure of visual acuity.

Peripheral VisionTest Visual FieldsConfrontation Test

NoseExternal Inspection:Inspect the nose nothing any bleeding, inflammation, or lesions, masses, swelling, and symmetry, discharges and color, sense of smell.

External Palpation:For tenderness and presence of pain.

Internal Inspection:Inspect for nasal septum for deviation, perforation, lesions and bleeding.

Frontal SinusesInspection:

Normal Visual is 20/20The Top number (numerator) indicates the distance the person is standing from the chart, while the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/20 means you can read that 20 ft. with the normal eye could have read at 20 ft.

The patient is able to see the stimulus at about 90 degrees temporally, 60 degrees nasally, 50 degrees superiorly, and 70 degrees inferiorly.

The shape of the external nose can vary greatly among individual. Normally, it is located symmetrically on the midline of the face that is without swelling, bleeding, lesions, or masses. No discharge or flaring and uniform color, there is a sense of smell.

Non-tender; absence of pain

The nasal mucosa should be pink or dull red without swelling. The septum is at the midline and without perforation, lesions or bleeding, the small amount of watery discharge is normal.

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For any swelling around the eyes

Palpation:Presence of pain and tenderness

Percussion:Note any sound

Maxillary SinusesInspection:For any swelling around the eyesPalpation:Presence of pain and tenderness

Percussion:Note any sound

Transillumination of the sinusesYou may use this technique in the frontal and maxillary sinuses when you suspect sinus inflammation, although it is of limited usefulness.

MouthLipsInspection:For color, texture, cracking, symmetry, lesions and hydration

Palpation:For any presence of pain, lumps and tenderness.

GumsInspection:For color, texture, swelling, bleeding, retraction form the teeth

Palpation:

There is no evidence of swelling around the eyes.

The patient should not feel pain during palpation and no tenderness felt.

The sound should be flat or dull.

There is no evidence of swelling around the nose and eyes.The patient should not feel any pain and tenderness during palpation.

The sound should be flat or dull.

The glow on each side is equal, indication air-filled frontal and maxillary sinuses.

The lips should be pink, soft moist, smooth texture with no evidence of lesions or inflammation. Not crack and symmetrical.

There is no presence of lumps and pain. It is tender.

The gums should be pink, moist, firm texture, no retraction, no swelling or bleeding. The gum margins at the teeth are tight and well-defined.

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For the presence of pain, tenderness and lumps.

TeethInspection:For discoloration, numbers of tooth and texture.

TongueInspection:For color, texture, surface characteristics, symmetry, presence of lesions, and sense of taste.

Palpation:For any nodules, lumps and presence of pain

FrenulumInspection:For the color, texture.

Sublingual AreaInspection:For color, moisture and presence of lesion.

Hard palateInspection:For color, shape, texture, presence of lesions and malformation.

Soft PalateInspection:

There should be no pain felt during palpation, no lumps and non-tender.

The adult normally has 32 teeth, which should be white, straight and smooth edges in proper alignment or evenly placed, clean and free of debris or decay.

The tongue is in the midline of the mouth, the dorsal surface should be pink, moist, rough and without lesions. The tongue is symmetrical and moves freely. The strength of the tongue is symmetrical and strong.The ventral surface of the tongue ahs prominent blood vessels and should be moist without lesions, looks smooth and glistening. There is a sense of taste.

There should be no presence of nodules, lumps and pain.

It should be attached to the tongue, pinkish in color and moist.

It should be pink in color, moist and no presence of lesions.

The hard palate is concave and lighter in pink in color, it has many ridges and it is moist, without any lesion or malformation.

The soft palate is also concave

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For color, shape, texture, presence of lesions, malformation

UvulaInspection: For position, mobility and color.

TonsilsInspection: For color, shape, size and discharge.

Palpation:Presence of pain

EarsExternal earInspection: For position, color, size, shape, any deformities, inflammation, or lesions

Palpation: Presence of pain, tenderness, and lumps.

Auditory AcuityVoice-Whisper test

and light pink in color, it is smooth and no lesions or malformations noted.

It normally looks like a flesh pendant hanging in the midline of soft palate. Tonsils are present and pink in color.

It is pink in color and smooth. Oval in shape. No discharge. Of normal size or not visible, no inflammation, and not swollen.

There should be no pain felt during palpation.

The ear matches the flesh color of the rest of the patient’s skin and should be positioned centrally and in proportion to the head. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye to the occiput with no swelling or thickening. Cerumen should be moist and not obscure the lympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules or lesions.

They should feel firm (not tender) and movement produce pain.

The patient should be able to repeat words whispered from a

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Tuning fork test

Weber’s Test

Rinne’s Test

NeckInspection: For symmetry of the sternocleidomastoid muscles anteriorly, and the trapezius posteriorly.

Palpation: For the presence of masses and tenderness.

Lymph NodesInspection: For any enlargement or inflammation.

Palpation:For size, shape, dellimination,

distance of 2 feet.

Measures hearing by air conduction (AC) or by bone conduction (BC), in which the sound vibrates through the cranial bones to the inner ear.

The patient should perceive the sound equally in both ears or “in the middle”. No lateralization of sound is known as negative Webster test. Air conduction is heard twice as long a bone conduction when the patient hears the sound through the external auditory canal ( air ) after it is no longer heard at the mastoid process ( bone ). This is denoted as AC>BC.

The muscles of the neck are symmetrical with the head at a central position. The patient is able to move head through a full range of motion without complaint of discomfort or noticeable limitation. The patient may be breathing through a stoma or tracheostomy.

The muscles are symmetrical without palpable masses or spasm.

Lymph nodes should not be visible or inflamed.

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mobility, consistency, and tenderness

TracheaPalpation:

Thyroid GlandInspection:For symmetry and visible masses.

Palpation:For nodules or enlargement and tenderness.

ThoraxChest AnteriorInspection: For the breathing patterns, rate, depth, the coastal angle, shape of patient’s chest, and color.

Palpation:For respiratory excursion. Tenderness, masses and temperature.

Normally, lymph nodes should not be palpable in the healthy adult patient; however, small, discrete, movable nodes are sometimes present but are of no significance.

Space should be systemic on both sides or on central placement in midline of neck; spaces are equal on both sides.

Thyroid tissue moves up with swallowing but often the movement is so small it is not visible on inspection. In males, the thyroid cartilage, or Dm’s apple, is more prominent than in females.

No enlargement, masses, or tenderness should be noted on palpation.

Quiet, rhythmic, and effortless respirations. Breathing pattern should be smooth. Costal angle is less than 90°, and the ribs insert into the spine at approximately a 45° angle. Normal rate of breathing in adult is 46/16 per min. red patches present, ribs sloping downward with symmetric interspaces. Colors should be even and consistent with the color of the patients face. Shoulder should be at the same height. shape of thorax – elliptical shape

It should be full symmetric excursion; thumbs normally separate to 3-5 cm (1 ½ to 2

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Percussion: For its different sound

Auscultation:For full two breaths and sounds

LungsInspection:For breath sounds over the following:Trachea

Alveolar Tube (large-stem bronchi)

Lung Field (lung periphery)

HeartPalpation:

Auscultation: For murmurs and sound

Chest PosteriorInspection:For shape and symmetry, spinal alignment for deformities, color,

in). Equal expansion, no tenderness, no masses, skin should be warm and dry, no pulsation should be present. Fremitus is normally decreased over heart and breast tissue.

Normal lung tissue-resonant sound, rib flat sound.

Air brushing through the respiratory tract during inspiration expiration generates different breath sounds.

Bronchial (loud, tubular) breath sounds heard over trachea; expiration longer than inspiration; short silence between inspiration and expiration.

Bronchovesicular breath sound heard over main stem bronchi: below clavicles and between scapulae (inspiratory phase equal to expiatory phase).

Vesicular (low, soft, breezy) breath sounds heard over lung periphery(inspiration longer than expiration).

No pulsation palpable over aortic and pulmonic areas.

Apical has the loudest sound; it should be 60-80 beats/min. No murmurs should be heard.

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abnormal inspiratory.

Palpation:For clients who have no respiratory complaints, temperature.For clients who have respiratory complaints.For respiratory excursion

For vocal and tactile fremitus

Percussion:For sounds

For diaphragm excursion

Auscultation: For sounds

Abdomen

Anteroposterior to transverse diameter in ratio of 1.2; chest symmetric; spine column vertically aligned. No patches, no abnormal inspiratory retraction of interspaces.

The skin should be intact; uniform temperature.

The chest wall intact; uniform temperature. Full and symmetric chest expansion. [Ex. When the client takes a deep breath, your thumbs should be move apart an equal distance and at the same time; normally the thumbs separate 3 to 5 cm (1½ to 2 in.) during deep palpation].

Bilateral symmetry of vocal fremitus. Fremitus is heard most clearly at the apex of the lungs. Low-pitched voices of males are more readily palpated than higher pitched voices of females.

Percussion notes resonate except over scapula.

Lowest point of resonance is at the diaphragm. (Note: percussion on a rib normally elicits dullness)

Excursion is 3-5 cm (1½ to 2 in.) bilaterally in women and 5-6 (2 to 3 in.) in men. Diaphragm is usually slightly higher on the right side. Vesicular and bronchovesicular breathe sounds.

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Inspection:-Color

-Scars

-Striae

-Dilated Veins

-Rashes and lesions-Umbilicus

-The contour of the abdomen

-Hair distribution

-Symmetry-Respiratory movement

Auscultation:Auscultate the four quadrants for basic sounds.Auscultate over the aorta, renal, iliac and femoral arteries. (Vascular sounds)

Percussion: Percuss the four quadrants to as tympany and dullness.

Right Upper Quadrant:- liver- gallbladder- duodenum- head of pancreas- right kidney and adrenal

-Surface is uniform in color and in pigmentation.-Flawless no scars is present. If scars are present draw its location in the person’s record indicating the length in cm.-No striae / stretch marks are present.-A few small veins may be visible normally.-No rashes or lesions are present.-Is normally in the midline and inverted with no sign of inflammation, discoloration or hernia.-Normally range from flat to rounded.-Diamond shape in adult males, inverted triangular shape in adult female.-Symmetric bilaterally and smooth.-The abdomen rises with inspiration and falls with expiration.

High pitched, irregular gurgles (5-35 times/ min) present equally in all four quadrants. No bruits, no venous hums, no friction.

Tympany is usually predominating because of air in the stomach and intestines. Dull sounds are heard over solid masses such as liver, spleen, and kidneys.

Left Upper Quadrant:- stomach- spleen- left lobe of liver

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- hepatic flexure of colon- Part of ascending and transverse colon

Right Lower Quadrant:-Cecum-Appendix-Right ovary and tube-Right ureter-Right spermatic cord

Midline:-Aorta-Uterus(if enlarged)-bladder(if enlarged)

Palpation:Perform palpation to judge the size, location and consistency of certain organs and to screen for an abnormal mass or tenderness.

Light Palpation (1/2 - 1 inch) on all areas of abdomen moving clockwise and in rotary motion.

Deep Palpation (2-3 inches) on all areas on the abdomen moving clockwise and in rotary motion.

Liver Palpation:Located in the RUQ (Right Upper Quadrant).Place your left hand under the person’s back parallel to the 11th and 12th ribs and lift up to support the abdominal contents. Place your right hand on the RUQ with fingers parallel to the midline. Push deeply down and under the right costal margin then ask the person to take a deep breath.

Hooking TechniqueAn alternative method of palpating the liver. Stand up at

- body of pancreas- left kidney and adrenal- spleen flexure of colon- part of transverse & descending colon

Left Lower Quadrant:-Part of descending colon-Sigmoid colon-Left ovary and tube-Left ureter-Left spermatic cord

Normally there is no pain, tenderness, rigidity and muscle guarding

Normally there is no pain, tenderness, rigidity and muscle guarding

It feels like a firm rectangular ridge. Often the liver is not palpable and you feel nothing firm.

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the persons’ shoulder and swivel your body to the right so that you face the person’s feet. Hook your fingers over the costal margin from above. Ask the person to take a deep breath then try to fell the liver edge bump from your fingertips.

Spleen Palpation:Search spleen by reaching your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift for support. Place your hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. Push your hand deeply down and under the left costal margin and ask the person to take a deep breath.

KidneyPercussion:Indirect fist percussion causes the tissues to vibrate instead of producing a sound. Locate kidney by placing hand over the 12th rib at the costoverbral angle on the back. Thump that hand with the ulnar edge of your other fist.

Palpation:locate kidney by placing your hand together in a duck-bill position at the person;s right flank. Press your two hands together firmly (you need deeper palpation than that used to liver and spleen) then ask the person to take a deep breath.

Palpation:Light palpation in all 4 quadrantsDeep palpation in all 4 quadrants

Normally you should feel nothing firm. When enlarged the spleen extends into the lower quadrants.

A person normally feels a thud but no pain.Sharp pain occurs with inflammation of kidneys or paranephric area.

Lower pole of the kidney is round, smooth mass slide in between your fingers.

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ExtremitiesUpper and LowerInspection:-Observe for size, color, contour, symmetry and involuntary movement

-Look for deformities, edema, and presence of lesions.

- Always compare both extremities

Palpation:-Feel evenness of temperature. Normally it should be even for all the extremities.

- Perform range of motion

-Test for muscle strength

Both extremities are equal in size

Have the same contour with prominences of joints.

No involuntary movements. No edema. Color is even.

Temperature is warm and even. Has equal contraction.

Can perform complete range of motion

Can counter act gravity and resistance in ROM

Balance Test

Gait

Observe as the person walk 10-20 feet, turns and

returns to the starting point. Normally, the person moves with a

sense of freedom. The gait is smooth, rhythmic, and effortless,

the opposing arm swing is coordinated, and the turns are smooth.

Romberg’s Test

Ask the person to stand up with feet together and arms

at the side. Once in a stable position, ask the person to close the

eyes and to hold the position. Wait about 20 seconds. Normally, a

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person can maintain posture and balance even with the visual

orienting information blocked, although slight swaying may occur.

(Stand close to catch the person in case he or she falls)

Tandem Walking

Ask the person to walk straight line in a heel-to-toe fashion. This

decrease the base of support and will accentuate any problem

with coordination. Normally, the person can walk straight and stay

balance.

Coordination and Skilled Movements

Rapid Altering Movements (RAM)

Ask the person to pat the knees with both hands, lift up, turn

hands over, and pat the knees with the backs of the hands. Then

ask the person to do this faster. Normally, this is done with equal

turning and a quick rhythmic pace.

Finger-to-nose Test

Ask the person to close the eyes and to stretch out the arms. Ask

the person to touch the tip of his nose or her nose with each index

finger, alternating hands and increasing speed. Normally, this is

done with equal turning & a quick rhythmic pace.

Heel-to-shin Test

Test lower extremity coordination by asking the person who is in

a supine position, to place the heel on the opposite knee, and run

it down the shin from to the ankle. Normally, the person moves

the heel in a straight line down the skin.

Reflex

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It is an automatic response of the body to a stimulus. It is not

voluntarily learned or conscious.

Reflexes are tested using a percussion hammer. The response is

described from 0 to 4. Experience is necessary to determine

appropriate scoring of an individual. Several reflexes are normally

tested during the physical examination: a) the biceps reflex, b)

the triceps reflex, c) the brachioradialis reflex, d) the patellar

reflex, e) Achilles reflex, f) the plantar reflex.

Test the Reflex

The reflex response is guided on a 4 point scale:

4+ very brisk, hyperactive

3+ brisker than average, may indicate disease

2+ average, normal

1+ diminished, low normal

0 no response

Upper Extremity

Biceps Reflex (Flexion)

Support the person’s forearm on yours; this position relaxes, as

well as partially flexes, the person’s arm. Place your thumb on the

biceps tendon and strike a blow on your thumb. You can feel as

well as see the normal response, which are contraction of the

biceps muscle and the flexion of the forearm.

Triceps Reflex (Extension)

Tell the person to let the arm “just go dead” as you suspend it by

holding the upper arm. Strike the triceps tendon directly just

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above the elbow. The normal response is extension of the

forearm.

Brachioradialis Reflex (Flexion and Supination of the arm)

Hold the person’s thumbs to suspend the forearm in relaxation.

Strike the forearm directly, about 2 to 3 cm above the radial

styloid process. The normal response is flexion and supination of

the arm.

Lower Extremity

Quadriceps Reflex (patellar or knee jerk reflex)

Let the lower legs dangle freely to flex the knee and stretch the

tendons. Strike the tendon directly just below the patella.

Extension of the lower legs is the expected response.

Achilles Reflex

Position the person with the knee flexed and the hip externally

rotated. Hold the foot in dorsiflexion, and strike the Achilles

tendon directly. Feel the normal response as the foot plantar

flexes against your hand.

Plantar Reflex

Position the thigh in slight external rotation. With the reflex

hammer, draw a light stroke up the lateral side of the sole of the

foot and inward across the ball of the foot, like an upside-down J.

The normal response is plantar flexion if all the toes and inversion

and flexion of the forefoot.

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Appendices

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Equipment and supplies used for a Health Examination

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Flashlight or Penlight Otoscope

Dental MirrorOpthalmoscope

Tuning ForkCotton Applicators

Tongue DepressorsGloves

Lubricant Percussion HammerNasal Speculum

Various Positioning of the Client

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Dorsal RecumbentLithotomy

SimsHorizontal Recumbent or Supine

Sitting or High FowlersProne

Basic Techniques used in Physical Assessment

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Direct PercussionIndirect Percussion

Deep Palpation

Parts of the Eye

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Light Palpation

Snellen Eye Chart

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Sinus’ Locations

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Side View

Structures of the Mouth

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Front View

Structures of the Ear

Lymph Nodes of the Head and Neck

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External & Internal Lymphatic Drainage

Areas to Auscultate and Palpate on Chest

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Palpation of Thoracic Expansion

Intercostal Landmarks for Percussion & Auscultation of Thorax

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PosteriorAnterior

Posterior Normal Percussive Notes (Posterior)

Respiration Patterns

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AnteriorNormal Percussive Notes (Anterior)

Type Description Pattern Clinical IndicationNormal 12 to 20/min &

regularNormal Breathing Pattern

Tachypnea >24/min & shallow

May be normal response to fever, anxiety or

exercise; can occur with respiratory insufficiency, alkalosis, pneumonia or

pleurisyBradypnea <10/min &

regularMay be normal in well

conditioned athletes; Can occur with medication induced depression of

the respiratory system, diabetic, coma,

neurological damage.Hyperventila

tionIncreased rate &

depthUsually occurs with

extreme exercise, fear or anxiety

Kussmauls’ respiration is a type of hyperventilation associated with diabetic

ketoacidosis.Other causes of

Hyperventilation include disorders of the central

nervous system, an overdose of drug

salicylate or severe anxiety

Hypoventilation

Decreased rate & depth, irregular

pattern

Usually associated with overdose of narcotics of

anestheticsCheyne-Stokes

Respiration

Regular pattern characterized by

alternating periods of deep rapid breathing

followed by periods of apnea

May result from severe congestive heart failure, drug overdose, increased intracranial pressure or

renal failure. May be noted in elderly positions during sleep not related to any disease process.

Biot’s Respiration

Irregular pattern characterized by

varying depth and

May be seen with meningitis or severe

brain damage

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rate of respirations followed by

periods of apnea

Adventitious SoundsSound Site

AuscultatedCause Character

Crackles Are most commonly heard in

dependent lobes; right

and left lung bases.

Random, sudden

reinflation of groups of alveoli;

disruptive passage of

air

Fine crackles are high-pitched fine short

interrupted crackling sounds heard during end of

inspiration, usually not cleared with coughing.

Moist crackles are lover, more moist sounds heard

during the middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds

heard during inspiration not cleared with coughing

Ronchi(sonorous wheeze)

Are primarily

heard over trachea and bronchi; if

loud enough, can be

heard over most lung

fields

Muscular spasm, fluid or mucus in

larger airways, cause

turbulence.

Are loud low – pitched, rumbling coarse sounds heard most often during

inspiration and expiration; may be cleared by

coughing.

Wheezes(sibilant wheeze)

Can be heard all over lung

fields

High – velocity airflow through severely narrowed bronchus

Are high-pitched continuous musical sounds

like a squeak heard continuously during

inspiration, or expiration; usually louder on expiration

Pleural Friction Rub Is heard over

anterior

Inflamed pleura, parietal

Has dry, grating quality heard best during

inspiration; does not clear

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lateral lung field (if

patient is sitting

upright)

pleura rubbing against visceral pleura

with coughing, heard loudest over lower lateral

anterior surface.

Palpation of the Heart

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Locate the apical pulse with the palmar surface.

Palpate the apical pulse with the fingerpad.

Abdominal Viscera and Vascular Structures

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Abdominal Viscera and Vascular Structures

Abdominal Quadrants

Vascular sounds and friction rubs can best be heard over these areas

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Palpation of the liver Spleen Palpation

Kidney Palpation

Common Tests for CoordinationFinger-to-nose test

Heel-to-sheen test

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Testing rapid alternating movements of palms

Common Tests for Reflexes

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Briceps ReflexBrachioradialis Reflex

Triceps Reflex

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Testing for ankle clonus

Plantar Reflex

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Expected Auscultation Sounds (Anterior)

Sites for Auscultating the Abdomen

Sites for Auscultating the Abdomen

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Tactile Fremitus (Posterior) Expected Auscultation Sounds (Posterior)

Percussion Sites for all Quadtrants

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Diaphragmatic Excursion