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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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