Head (Skull, Scalp, Hair) 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. Normal Findings: Skull · Generally round, with prominences in the frontal and occipital area. (Normocephalic). · No tenderness noted upon palpation. Scalp · Lighter in color than the complexion. · Can be moist or oily. · No scars noted. · Free from lice, nits and dandruff. · No lesions should be noted. · No tenderness nor masses on palpation. Hair · Can be black, brown or burgundy depending on the race. · Evenly distributed covers the whole scalp (No evidences of Alopecia) · Maybe thick or thin, coarse or smooth. · Neither brittle nor dry.

Face 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 a. CN V (Trigeminal) 1. Sensory Function · Ask the client to close the eyes. · Run cotton wisp over the fore head, check and jaw on both sides of the face. · Ask the client if he/she feel it, and where she feels it. · Check for corneal reflex using cotton wisp. · The normal response in blinking.

· Non protruding. salty. Eyebrows. All three structures are assessed using the modality of inspection. Intact cranial nerve V and VII.2. · Evenly distributed. CN VII (Facial) 1. frown. Motor function · Ask the client to smile. No involuntary muscle movements. close eye lids. b. Can move facial muscles at will. Eyes · Evenly placed and inline with each other. · Place a sweet. · Evenly distributed. · Maybe black. sour. brown or blond depending on race. brown or blond depending on race. Normal findings: Eyebrows · Symmetrical and in line with each other. . · Maybe black. · Evenly distributed. Normal findings: Eyebrows · Symmetrical and in line with each other. or bitter substance near the tip of the tongue. · Turned outward. whistle. · The client should be able to clench or chew with strength and force. Eyelashes · Color dependent on race. Motor function · Ask the client to chew or clench the jaw. Face is symmetrical. or puff the cheeks. Sensory function (This nerve innervate the anterior 2/3 of the tongue). raise eye brow. Eyes and Eyelashes All three structures are assessed using the modality of inspection. Normal Findings: · · · · · Shape maybe oval or rounded. the client can identify the taste. · Normally. Eyes · Evenly placed and inline with each other. · Equal palpebral fissure. 2.

b. 2. Ask the client if he hears anything If the client says yes. Inspect the auricles of the ears for parallelism. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles. Inspect the auditory meatus or the ear canal for color. 4. Perform otoscopic examination of the tympanic membrane. B. · There is no pain or tenderness on the palpation of the auricles and mastoid process. noting the color and landmarks. · No lesions noted on inspection. 3 5 7 ) for the client to repeat. The examiner stands 2 ft. 3. 5. parallel. Watcher test 1. Normal Findings: · The ear lobes are bean shaped. presence of cerumen. size position. · No discharges or lesions noted at the ear canal. Vestibulochoclear Nerve (cranial nerve VIII) Examination of the cranial nerve VIII involves testing for hearing acuity and balance. · The ear canal has normally some cerumen of inspection. 3. · Turned outward. ears 1. translucent and pearly gray in color. The examiner then covers the mouth. on the side of the ear to be tested. appearance and skin color. tenderness when manipulating the auricles and the mastoid process. whispers nonsequential number (e. Ask the client to close the eyes. Place a mechanical watch 1 ± 2 inches away the client¶s ear. · Evenly distributed.· Non protruding. Normally the client will be able to hear and repeat the number. 2. the examiner should validate by asking at what are you hearing and at . · The upper connection of the ear lobe is parallel with the outer canthus of the eye. and symmetrical.g. a. Repeat the procedure at the other ear. 3. Instruct the client to occlude the ear canal of the other ear. and foreign bodies. and using a soft spoken voice. discharges. · On otoscopic examination the tympanic membrane appears flat. · Equal palpebral fissure. Voice test 1. Eyelashes · Color dependent on race. · The pinna recoils when folded. 4. Hearing Acuity A. · The auricles are has a firm cartilage on palpation. · Skin is same in color as in the complexion. For children pull the pinna downward and backward to straiten the canal 4. For adult pull the pinna upward and backward to straiten the canal.

a. Repeat the procedure on the other ear. Describe lymph nodes in termsof size. Vibrating tuning fork placed on the mastoid process b. Normally the client can identify the sound and at what side it was heard.what side. Sensorineural loss ± Sound lateralizes on better ear. 2. There are 2 types of tuning fork test being conducted: 1. 2. The neck is palpated just above the suprasternal note using the thumb and the index finger. c. Normal: hear sounds equally in both ears (No Lateralization of sound) Conduction loss ± Sound lateralizes to defective ear (Heard louder on defective ear) as few extraneous sounds are carried through the external and middle ear. Sensorineural loss: Sound is heard longer by air conduction than by bone conduction NECK The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension. Instruction client to inform the examiner when he no longer hears the tuning fork sounding. Normal: Sound should be heard when tuning fork is placed in front of the ear canal as air conduction< bone conduction by 2:1 (positive rinne test) Conduction loss: Sound is heard longer by bone conduction than by air conduction.  Lymph nodes are palpated using palmar tips of the fingers via systemic circular movements. 5. The neck is palpated just above the suprasternal note using the thumb and the index finger. 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). consistency. Normal Findings: 1. The trachea is palpable. Normal Findings: . regularity. Normal Findings: 1. 2. tenderness and fixation to surrounding tissues. 6. It is positioned in the line and straight. Symmetrical No jugular venous distension (suggestive of cardiac congestion). 4. The neck is straight. Position in the tuning fork in front of the client¶s ear canal when he no longer hears it. Weber¶s test ± assesses bone conduction. Rinne Test ± Compares bone conduction with air condition. No visible mass or lumps. this is a test of sound lateralization. vibrating tuning fork is placed on the middle of the fore head or top of the skull. 3.

locate the cricoid cartilage and directly below that is the isthmus. 2. Firm with smooth rounded surface. 3. the client is asked to turn his head slightly toward the side to be examined to displace the sternocleidomastoid. No nodules are palpable. while the index and middle fingers are placed deep to and in front of the muscle.  Check the Range of Movement of the neck. similar procedure is done as in posterior approach. Ask the patient to swallow as the procedure is being done.1. The examiner may hear bruits. Palpation of the thyroid can be done either by posterior or anterior approach. The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the sternocleidomastoid muscle. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be 7. 5. 6. 2. 2. Auscultation of the Thyroid is necessary when there is thyroid enlargement. as a result of increased and turbulence in blood flow in an enlarged thyroid. May not be palpable. 1. 4. In examining the isthmus of the thyroid. Ask the client to swallow while feeling for any enlargement of the thyroid isthmus. Anterior approach: The examiner stands in front of the client and with the palmar surface of the middle and index fingers palpates below the cricoid cartilage. . 1. Normally the thyroid is non palpable. 3. The inferior borders of the lungs cross the sixth rib at the midclavigular line. 2. 4. the apices of the lungs extend for approximately 3 ± 4 cm above the clavicles. Maybe normally palpable in thin clients. Non tender if palpable. Lung borders In the anterior thorax. Again. A. 3. Posterior Approach: Let the client sit on a chair while the examiner stands behind him. examined. 6. 3. Slightly movable. Normal Findings: 1. The client is asked to turn his head slightly to one side and then the other of the lobe to be examined. while the other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid lobe to be examined. Then the procedure is repeated on the other side. 5. The thyroid is initially observed by standing in front of the client and asking the client to swallow. Ask the client to swallow while palpation is being done. 4. the examiner palpates the area and hooks thumb and fingers around thesternocleidomastoid muscle. 5. A. To facilitate examination of each lobe. About less than 1 cm in size. Isthmus maybe visible in a thin neck. In palpating the lobes of the thyroid.

Expiration is usually longer the inspiration. 3. Palpation of the Thorax . laterally it is at the 8th rib at the midaxillary line. In the Lateral Thorax. the client should be sitting upright without support and uncovered to the waist. There should be no scoliosis. Moves symmetrically on breathing with no obvious masses.5 cm downward. Retractions at the ICS on inspiration. abnormal masses. or cardiomegaly. No bulging at the ICS must be noted as this may obstruction on expiration. 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. 4. substernal) Bulging structures at the ICS during expiration. Breathing maybe diaphragmatically of costally. Lung Fissures The right oblique (diagonal) fissure extend from the area of the spinous process of the 3rdthoracic vertebra. with slightly curvature in the thoracic area. kyphosis. Anteriorly. laterally and downward unit it crosses the 5th rib at the midaxillary line. 6. Posteriorly. On inspiration the diaphragm moves approximately 1. the diaphragm is at the level of the spinous process of T10. the lungs extend from the apex of the axilla to the 8th rib of the midaxillary line. Thoracic configuration. the anteroposterior diameter is less than the transverse diameter at approximately a ratio of 1:2. on expiration. the apices extend of T10 on expiration to the spinous process of T12 on inspiration. 5. (suprasternal. The spine should be straight. Shape of the thorax and its symmetry. Borders of the Diaphragm. 1. Inspection of the Thorax For adequate inspection of the thorax. on expiration. 2. It then continues ant medially to end at the 6th rib at the midclavicular line. or lordosis. No fail chest which is suggestive of rib fracture. The examiner should observe: A. Normal Findings:          The shape of the thorax in a normal adult is elliptical. 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 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. position of the spine. No chest retractions must be noted as this may suggest difficulty in breathing. costal.In the posterior thorax. pattern of respiration.

or collapse of lungs. moving left to right to left. Each time the hands move down. Instruct the client to exhale first. Repeat the procedure at the posterior thoracic wall. Place the palm or the ulnar aspect of the hands bilaterally symmetrical on the chest wall starting from the top. (Percuss over the ICS. General palpation ± The examiner should specifically palpate any areas of abnormality. then to inhale deeply. B. the examiner¶s hands are placed over the anterolateral chest with the thumbs extended along the costal margin. Percussion of the Thorax Anterior thorax: A. 1. Whispered Pectorioquy ± Ask the client top whisper ³1-2-3´ Over normal lung tissue it would almost be indistinguishable. near the area of bronchial bifurcation. ask the client to say ninety-nine. tactile fremitus should be bilaterally symmetrical.1. decreased tactile fremitus may be suggestive of obstructions. D. then at then medial thoracic wall. Percuss systematically at about 5 cm intervals from the upper to lower chest. C. Posteriorly. 2. Use indirect percussion starting at the apices of the lungs. Inspection of the Heart The chest wall and epigastrum is inspected while the client is in supine position. and at the anterolateral B. The examiner the amount of thoracic expansion during quiet and deep inspiration and observe for divergence of the thumbs on expiration. Low pitched voices of males are more readily palpated than higher pitched voices of females. Basic abnormalities like increased tactile fremitus maybe suggestive of consolidation. A. C. Palpate for lumps. the thumbs are placed at the level of the 10th rib and the palms are placed on the posterolateral chest. Palpate for thoracic expansion or lung excursion. Normally. A. thickening of pleura. Most intense in the 2ndICS at the sternal border. D. Observe for pulsation and heaves or lifts Normal Findings: . symmetry of respiration between the left and right hemithoraces should be felt as the thumbs are separated are separated approximately 3 ± 5 cm (1 ± 2 inches) during deep inspiration. pointing to the xyphoid process. Palpate for the tactile fremitus. C. B. The temperature and turgor of the skin should be assessed. over consolidated lung it would be loud and clear. masses and areas of tenderness. avoiding the ribs. Normally. The examiner notes the sound produced during each percussion. Anteriorly. E. Patient maybe placed on a supine position.

and mitral valves. Auscultation of the Heart Anatomic areas for auscultation of the heart: Aortic valve ± Right 2nd ICS sternal border. such as mitral valve problems and extra heart sounds. Listen for abnormal heart sounds e. Murmurs. 3. S3 & S4).1. beginning at the apex. There should be no lift or heaves. Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. Having the client seated and learning forward s best suited for hearing high-pitched sounds related to semilunar valves problem.   Auscultating the heart A. Apical pulsation can be felt on palpation. No. There should be no noted abnormal heaves. Count heart rate at the apical pulse for one full minute. Auscultate the heart in all anatomic areas aortic. Pulsation of the apical impulse maybe visible. S1 & S2 can be heard at all anatomic site. and Murmurs.g. and thrills felt over the apex. S2 closure of semilunar valve). moving to the left sternal border. Percussion of the Heart The technique of percussion is of limited value in cardiac assessment. Cardiac rate ranges from 60 ± 100 bpm. 2. 2. S1 sound is best heard over the mitral valve. Palpation of the Heart The entire precordium is palpated methodically using the palms and the fingers. Tricuspid Valve ± ± Left 5th ICS sternal border. pulmonic. Normal Findings: 1. palpable pulsation over the aortic.g. 3. Normal Findings: 1. pulmonic. (this can give us some indication of the cardiac size). tricuspid and mitral 2. 4. S4. . try listening to them with the patient seated and learning forward. The left lateral recumbent position is best suited low-pitched sounds. Pulmonic Valve ± Left 2nd ICS sternal border. S2 is best heard over the aortric valve. Listen for the S1 and S2 sounds (S1 closure of AV valves. or lying on his left side. Mitral Valve ± Left 5th ICS midclavicular line Positioning the client for auscultation:  If the heart sounds are faint or undetectable. S3. which brings the heart closer to the surface of the chest. 1. No abnormal heart sounds is heard (e. and then to the base of the heart. 2. 3. It can be used to determine borders of cardiac dullness. Every client should be examined in each position.

Breast examination is best done 1 week post menses.  An abnormality may not be apparent in the breasts at rest a mass may cause the breasts. The client is seated and is learning over while the examiner assists in supporting and balancing her. Be sure that the breast is adequately surveyed. Not fixated and moves bilaterally when hands are abducted over the head. 2. No discharges from the nipples. following a clockwise rotary motion. Palpation of the Breast  Palpate the breast along imaginary concentric circles.      Normal Findings: NOTE: The male breasts are observed by adapting the techniques used for female clients. same size and equal in color. and fixation. The client is seated with her arms on her side. The areola is rounded or oval. Each areolar areas are carefully palpated to determine the presence of underlying masses. No tenderness upon palpation. 5. No retractions or dimpling. 3. through invasion of the suspensory ligaments. No lumps or masses are palpable.  While the client is performing these maneuvers. The client is seated with her arms abducted over the head. 4. with same color. May or may not be completely symmetrical at rest.ies form light pink to dark brown depending on race). bulging. 6. 2. However. everted. 8. the breasts are carefully observed for symmetry. The client is seated and is pushing her hands into her hips. to fix. The veins maybe visible but not engorge and prominent. .  Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory ligaments. retraction. (Color va. the various sitting position used for woman is unnecessary.1. Each nipple is gently compressed to assess for the presence of masses or discharge. 3. The overlying the breast should be even. simultaneously eliciting contraction of the pectoral muscles. or is learning forward. Nipples are rounded. preventing them from upward movement in position 2 and 4. 9. 7. from the periphery to the center going to the nipples. No ³orange peel´ skin is noted which is present in edema. Normal Findings: 1. 4. No obvious mass noted.

the bell may be used in exploring arterial murmurs and venous hum. following the cross pattern of the imaginary lines in creating the abdominal quadrants. Visible peristalsis. and thus bowel sounds. and umbilicus). Aortic pulsation maybe visible on thin clients. before concluding that no bowel sounds are present. Thus it is recommended that the examiner listen for at least 5 minutes. 4. scapold) Distension Respiratory movement. Listen over all auscultation sites. starting at the right lower quadrants. Peristaltic sounds are quite irregular. This method precedes percussion because bowel motility. especially at the periumbilical area. Contour (flat. Intestinal sounds are relatively high-pitched. Contour may be flat. if they are cold. veins.abdomen In abdominal assessment. scars. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles. This direction ensures that we follow the direction of bowel movement. Divide the abdomen in four quadrants. be sure that the client has emptied the bladder for comfort. Some clients may have striae or scar. Inspection of the abdomen                Inspect for skin integrity (Pigmentation. Peristalsis can provide diagnostic clues relevant to the motility of bowel. It is suggested that the number of . they may initiate contraction of the abdominal muscles. Listening to the bowel sounds (borborygmi) can be facilitated by following these steps: 1. 3. no lesions. The stethoscope and the hands should be warmed. Normal Findings: Auscultation of the Abdomen Peristaltic sounds These sounds are produced by the movements of air and fluids through the gastrointestinal tract. lesions. Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. The normal bowel sounds are high-pitched. No venous engorgement. rounded. rounded or scapoid Thin clients may have visible peristalsis. 2. Pulsations Skin color is uniform. striae. gurgling noises that occur approximately every 5 ± 15 seconds. may be increased by palpation or percussion.

Some factors that affect bowel sound: 1. . Can be done by either indirect or direct method. Pathologic conditions of the bowel (inflammation. The area is strucked lightly with a fisted right hand. and in assessing solid structures within the abdomen. Gangrene. 3. or roughly. Bowel obstruction. With the examiner¶s hands parallel to the floor. paralytic ileus. 4. and muscles. The examiner¶s hands are too cold or are pressed to vigorously or deep into the abdomen. Percussion of the abdomen     Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites). Percussion is done over the costovertebral junction. Presence of subjacent pathologic condition. The client is ticklish or guards involuntarily. at each quadrant. Percussion in the abdomen can also be used in assessing the liver span and size of the spleen. 3. Constipation or Diarrhea. gaseous distension. Electrolyte imbalances. Palpation of the Abdomen Light palpation    It is a gentle exploration performed while the client is in supine position. but gently palpating with slow circular motion. State of digestion. and masses. 6. 2. spleen at the 6 or 9 rib just posterior to or at the mid axillary line on the left side. such as liver in the RUQ. peritonitis). The fingers depress the abdominal wall. 2. Tenderness elicited by such method suggests renal inflammation. 3. by approximately 1 cm without digging. Presence of food in the GI tract. 2. Solid masses will percuss as dull. Normally tenderness should not be elicited by this method. Tensing of abdominal musculature may occur because of: 1. 1. 7. th th  Percussion of the liver The palms of the left hand is placed over the region of liver dullness. Renal Percussion 1. Bowel surgery 5. The direction of abdominal percussion follows the auscultation site at each abdominal guardant. 2. large masses. one bowel sound for each breath sound. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis. 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.bowel sound may be as low as 3 to as high as 20 per minute. 3. and muscle guarding. This method is used for eliciting slight tenderness.

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. while the right hand is pressing into the abdominal wall. and involuntary movement. 2. 5. Feel for evenness of temperature. 4. firm and nontender. it must be smooth. like the kidneys. 3. Liver palpation: There are two types of bi manual palpation recommended for palpation of the liver. . 2. Deeper structures. Then ask the client to breath deeply and hold. An upward pressure is placed beneath the client to push the liver towards the examining right hand. contour. The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined. The first one is the superimposition of the right hand over the left hand. Ask the patient to take 3 normal breaths. 3. Press hand deeply over the RUQ The second methods: 1. This would push the liver down to facilitate palpation. it may be felt a the costal margins. 2. regular in contour. Always compare both extremities. 2. As the client inspires. bilateral symmetry. the liver maybe felt to slip beneath the examining fingers. Extremeties Inspection 1. When the normal liver margin is palpated. pressure produced by deep palpation may produce tenderness over the cecum. However. In the absence of disease. or masses may be felt with this method. and the aorta. edema. Ask the client to breath deeply. The examiner¶s left hand is placed beneath the client at the level of the right 11th and 12thribs. Place the examiner¶s right hands parallel to the costal margin or the RUQ. Normal Findings:   The liver usually can not be palpated in a normal adult. Palpation 1. 3. 3. the sigmoid colon. Observe for size. in extremely thin but otherwise well individuals. No tenderness noted.Normal Findings: 1. presence of trauma such as ecchymosis or other discoloration. Look for gross deformities. Normally it should be even for all the extremities. like the liver. 1. and retro peritoneal organs. With smooth and consistent tension.

Have the same contour with prominences of joints. No crepitus must be noted on joints. 3.2. . Tonicity of muscle. No involuntary movements. Can perform complete range of motion. Has equal contraction and even. (Can be measured by asking client to squeeze examiner¶s fingers and noting for equality of contraction). 4. (performed against gravity and against resistance) Table showing the Lovett scale for grading for muscle strength and functional level Functional level Lovett Scale Grade Percentage of normal No evidence of Zero (Z) 0 0 contractility Evidence of slight Trace (T) 1 10 contractility Complete ROM Poor (P) 2 25 without gravity Complete ROM Fair (F) 3 50 with gravity Complete range of Good (G) 4 75 motion against gravity with some resistance Complete range of Normal (N) 5 100 motion against gravity with full resistance Normal Findings:           Both extremities are equal in size. Temperature is warm and even. Test for muscle strength. Perform range of motion. No edema Color is even. Can counter act gravity and resistance on ROM.

Sign up to vote on this title
UsefulNot useful