Head-To-Toe Assessment

Group Members: Binay, Rizalyn Busa, Ana Marie Cabiltes, Claitte Diano, Christine Nasayao, jannin Ramos, Sunny


Head-To-Toe Assessment After 3 hours of classroom Discussion and Demonstration the Level I students will be able to: I. Define the FF. terms: a. Nursing Assessment b. Physical Assessment c. Anthropometric Measurement d. Health History e. Health f. Reflexes g. Visual Activity h. Interview i. Signs j. Symptoms II. a. Importance of Physical Assessment b. Purpose of Physical Assessment c. Four basic techniques in Physical Assessment d. Principles involved in Physical Assessment e. Nursing responsibilities before, during and after Physical Assessment f. Materials and Equipment used in Physical Assessment III. Demonstrate Beginning Skills in Physical Assessment.


Head to Toe Assessment Define the Following terms: A. Nursing Assessment - Is a major component of nursing care. - Is a process which includes both physical and psychological aspect to evaluate client’s condition. - Enables the nurse to make a judgment about the client’s health status , ability to manage his/her health care and need for nursing. B. Physical Assessment - Is a process by which a nurse obtains a data that describes a person’s responses to actual or potential health problems shich is analyzed to form pertinent diagnosis. - Is a head to toe review of each body system that offers objective information about the client and allows the nurse to make clinical judgment. C. Anthropometric Measurement

Comparative measurements of the body. Anthropometric measurements are used in nutritional assessments. Those that are used to assess growth and


development in infants, children, and adolescents include length, height, weight, weight-for-length, and head circumference (length is used in infants and toddlers, rather than height, because they are unable to stand). Individual measurements are usually compared to reference standards on a growth chart. Measurement of size weight and proportion of the body. - Most commonly used anthropometric measured are height, weight, triceps, skinfold thickness, elbow breadth and arm and head circumference. D. Health - State of being physically fit, mentally stable and socially comfortable. - It encompasses more than the state of being free of disease. E. Health History - defined as the systematic collection of subjective data (stated by the client) and objective data (observed by the nurse) used to determine a client’s functional health pattern status. F. Reflexes - Bent, turned or directed back; or produced by a reflex without intervention of consciousness. - Is an involuntary and nearly instantaneous movement in response to a stimulus. G. Visual Acuity


- The degree of detail the eye can discern an image. - Is a quantitative measure of the ability to identify black symbols on a white background at a standardized distance as the size of the symbols is varied. - Is acuteness or clearness of vision, especially form vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain. H. Interview

An interview is a conversation between two or more people (the interviewer and the interviewee) where questions are asked by the interviewer to obtain information from the interviewee. "Interview" word is derived from french word "entirevior" it means "glimpse" to each other.

- Therapeutic interaction that has a purpose. I. Signs

A sign is the physical manifestation of an illness, injury or other bodily disorder. A sign is objective and can be observed

- Signs can be felt, heard, seen, and measured by the diagnostician or nurse. These include pulse, respirations, blood pressure, and physical evidence such as bleeding, broken skin, bruising etc. J. Symptoms - Subjective evidence of a disease of physical disturbance observed by the patient.

confirm or refute data obtained in the nursing history. A symptom is subjective. Purpose of Physical Assessment • To supplement. cognitive. psychologic. • To identify actual and potential health problems. • To establish the client-nurse relationship • To obtain information about the client’s health including. sociocultural. and not measured. developmental and spiritual aspects. Importance of Physical Assessment: • To early detect and treat diseases and disorders. • To establish a data based from which the subsequent phases of the nursing evolve. • To assess the client’s impact of activity and exercise on the client’s overall level of health.6 . • To confirm and identify nursing diagnosis. .Is a departure from normal function or feeling which is noticed by a patient. indicating the presence of disease or abnormality. • To identify the client’s strength and weaknesses. physiologic. observed by the patient. • To assess the client’s routine exercise pattern and observe how the client’s body system response to activity and exercise.

It follows and often confirms points you noted during inspection. Inspection begins the moment you first meet the individual and develop a “general survey”. Palpation applies your sense of touch to assess these factors: texture. Four Basic Techniques in Physical Assessment I. II. • To evaluate the physiological outcome of care. . moisture. Then as you proceed through the examination. It is a close. Inspection It is the use of ones senses of vision and smell to consciously observe the patient. as well as any swelling. presence of lumps or masses and presence of tenderness or pain. start the assessment of each body system with inspection. temperature.7 • To make clinical judgments about a client’s changing health status and management. rigidity or spasticity. first of the individual as a whole and then of each body system. careful scrutiny. • To obtain and gather data about the client’s health basis of data for future assessment. organ location and size. • An excellent way to evaluate an individual’s current health status. It is also known as concentrated watching. Palpation It is the act of touching a patient in a therapeutic manner to elicit specific information. crepitation. vibration or pulsation.

consistency. The thorax and abdomen are the most frequently percussed location. Variations in this technique are single handed and bimanual palpations. and areas of discomfort. sharp strokes to assess underlying structures. overt large or superficial masses. shape. but only limited information can be obtained in specific areas such as heart. the finger pads are used to gain information of the patient’s skin surface to a depth of approximately ½ . mobility.1 inch below the surface.8 Two distinct types of palpation: Light and deep palpation • Light palpation It is superficial. III. delicate and gentle. These sounds also are diagnostic of normal and abnormal findings. Deep palpation uses the hands to explore the body’s internal structure to a depth of 1 to 2 inches or more. Any part of the body can be percussed. In light palpation. The strokes yield a palpable vibration and a characteristic sound that depicts the location. Light palpation reveals information on skin texture and moisture. muscle guarding and superficial tenderness. This technique is most often used for the abdominal and male and female reproductive assessments. Percussion It is the technique of striking or tapping the person’s skin with short. as well as their size. . and fluid. size and density of the underlying organ. • Deep palpation It can reveal information about the position of organs and masses.

heart . Mediate or Indirect Percussion It is used more often and involves both hands. B. Indirect Fist Percussion Its purpose is the same as direct fist percussion. In fact. The non dominant hand absorbs some of the force of the striking hand. spleen. mediate or indirect. The resulting intensity should be sufficient force to produce pain in the patient if organ inflammation is present Percussion elicits five types of sounds: 1) Flatness (dull) – bone and muscle 2) Dullness (thudlike) – liver.9 Four types of percussion techniques: Immediate or direct. the indirect method is preferred over the direct method. It is because in this methods. D. The presence of pain in conjunction with direct fist percussion indicated inflammation of that organ or a strike of too high in intensity. Direct Fist Percussion It is used to assess the presence of tenderness in internal organs. Immediate or Direct Percussion The striking hand directly contacts the body wall. The striking hand contacts the stationary hand fixed on the person’s skin. direct fist and indirect fist percussion A. such as the liver or the kidneys. This yields a sound and a subtle vibration. C. This produces a sound and is used in percussing the infant’s thorax or the adult’s sinus areas.

Auscultated sounds should be analyzed in relation to their relative intensity. 2) Indirect or Mediate auscultation It is the use of stethoscope. pitch. Two types of auscultation: Indirect and direct auscultation: 1) Direct of Immediate auscultation It is the process of listening with the unaided ear. which transmits the sounds to the nurse’s ear. Principles involved in physical assessment: Anatomy & Physiology . quality.10 3) Resonance (hollow) – air-filled lung/ normal lung 4) Hyperresonance – emphysematous lung 5) Tympany – stomach filled with gas (air) IV. Auscultation includes listening to sounds that are voluntarily and involuntarily produced by the body such as the heart and blood vessels and the lungs and abdomen. duration. and location. This can include listening to the patient from some distance away or placing the ear directly on the patient’s skin surface. And example is the wheezing that is audible to the unassisted ear in a person having a severe asthmatic attack. Auscultation It is the act of active listening to the body organs to gather information on patient’s clinical status.

necklaces. Nursing responsibilities before. Instrument should be sterile. we are able to make good assessments because we can differentiate a normal mental state and an abnormal one. during and after Physical assessment Before • Always dress in clean professional manner. • Be sure your hair will not fall forward and obstruct your vision or touch to the patient. Time and energy Starts from lesser to the most sensitive part Body mechanics Nurse and patient should maintain proper body mechanics. or earrings that can interfere during the physical assessment.11 One has to know the different parts and functions of the body in order to do a thorough and detailed assessment. Microbiology Do medical handwashing before and after the procedure. • Remove al bracelets. Psychology Through Psychology. make sure you have your name pin or workplace identification. Privacy must be ensured during the Physical Assessment to avoid the client from being anxious or uncomfortable. .

• While performing each step in the physical assessment process you may need to inform the patient of what to expect. • Explain to the patient why you may be spending a long time performing one particular skill. • If the patient complains of fatigue. be cognizant of your facial expression when dealing with malodorous and dirty patients or with disturbing findings. where to expect it. . • Do medical hand washing • Position the patient as dictated by the body system being assessed. and how it should feel. where it will be done. • Warm all instruments prior to their use During • Conduct the assessment in a systematic fashion every time. • Proceed from the least invasive to the most invasive procedure for each body system. Enlist the patient’s cooperation by explaining what you are about to do. • Avoid making crude or negative remarks. continue the assessment later. and how it may feel.12 • Ensure that all necessary equipment is ready for use and within reach. • Introduce yourself to the patient.

A lighted instrument to visualize the eardrum and external auditory canal (a nasal speculum may be attached to the Percussion (reflex) Otoscope to inspect nasal cavities). An instrument with a rubber head to . A lighted instrument to visualize the interior of the eye. usually a penlight is Ophthalmoscope Otoscope used for illumination.13 After • Provide recognition to the patient when the physical assessment concluded. • Document assessment findings in the appropriate section of the patient record. inform the patient what will happen next. • Do after care. mirror Nasal septum To permit visualization of the lover and middle turbinates. • Place patient in a comfortable position. • Do medical hand washing. Materials and Instruments of Physical Treatment Supplies Flashlight or penlight Purpose To assist in viewing of the pharynx and cervix or to determine the reaction of the pupils of the eye. Laryngeal or dental To observe the pharynx and oral cavity.

soles of feet on the surface. Various positioning of the patient Cotton applicators Gloves Lubricant Tongue blades (depressors) Dorsal recumbent Back-lying position with knees flexed and hips externally rotated. with or without pillow under the head Sitting A seated position. the hips should be in line with the edge of the table. Sims Side-lying position with the lowermost leg flexed at the hip and knee. Lithotomy Back-lying position with feet supported in stirrups. To obtain specimens. A two-prolonged metal instrument used to test hearing acuity and vibratory sense. Supine (horizontal recumbent) Back-lying position with legs extended. To protect the nurse To ease the insertion of instruments (ex.Vaginal Speculum) To depress the tongue during assessment of the mouth and pharynx. The back is unsupported and legs hanging freely. . upper arm flexed at the shoulder and elbow. small pillow under the head.14 hammer Tuning Fork test reflexes.

no scars noted. and without masses or depressions. Normal Findings The head should be round (normocephalic) and symmetrical. Body Parts Assessment of Body Parts Head & Neck Head Inspection: For size. masses. The normal skull is smooth. non tender. and the amount is variable. depressions. nits and dandruff. free from lice. can be moist or oily. presence of parasites. Hair Inspection: For color. . oiliness.15 Prone Lies on the abdomen with head turned to the side. evenly distributed covers the whole scalp (no evidences of Alopecia). presence of scars. Can be black. Maybe thick or thin. Scalp Inspection: For Color. evenness of growth over the scalp. Palpation: Lighter in color than the complexion. shape & symmetry Palpation: For contour. no parasites. with or without a small pillow. amount of body hair. brown or burgundy depending on the race. coarse or smooth neither brittle nor dry. Palpation: Thickness or thinness texture and oiliness. lice and dandruff.

Forehead Inspection: For symmetry. skin appearance. skin intact. frontal sinuses. light to dark brown. no lumps and absence of masses. No lumps. equal movement. presence of pimples. round. presence of rushes. Hair evenly distributed. and the four sinuses (sphenoidal sinuses. dandruff and color of the hair. or slightly square. Eyes Inspection: For symmetry. Symmetrical. There should be no edema.16 For lesions or masses tenderness. Palpation: For the presence of lumps. pain and nodules. disproportionate structures. no rushes. Non protruding and equal palpebral fissure. absence of scars. presence of scars. masses. no nodules and no pain felt during palpation . Symmetrical or evenly placed and inline with each other. Eyebrows symmetrically aligned. Eyebrows Inspection: For hair distribution and alignment and skin quality and movement. Palpation: For masses. the face is symmetrical. scars or pimples. lumps and tenderness Face Inspection: For shape and symmetry. absence of masses and there is no pain felt during palpation of face Palpation: For any swelling. The shape of the face can be oval. neither tenderness nor masses. No lumps and swelling of the face. absence of pimples and dandruff. ethmoid sinuses and maxillary sinuses). pimples or acne NO lesions should be noted. Non-tender. pimples or acne. scars and pimples. or involuntary movements. lumps. maybe black brown or blond depending on race.

17 Eyelashes Inspection: For evenness of distribution and direction of curl and color Equally distributed. Palpation: Presence of pain Cornea Inspection: For clarity. with no discharges and cloudiness. although presence of lesions. It should be moist and without lesions Conjunctivae Inspection: For lesions. The corneal surface should be moist. texture and moisture Iris Inspection: For appearance. The iris is normally appears flat. moisture. texture and the The sclera appears white. Sclera Inspection: For color. shape and equality of the pupils Black in color. no lesions and it should be moist. normally 37 mm in diameter. smooth. Pupil Inspection: For color size. Both conjunctivae are shiny. There should be no pain felt during palpation. coloration and shape. smooth border and of equal size in both eyes. curled sightly outward and black in color. appears round. regular. Muscle function Corneal Light Reflex or the Hirschberg Test . swelling. with a regular shape and even coloration. blacks occasionally have a grayblue or “muddy” color to sclera. shiny and transparent. absence of swelling. and pink or red. color and moisture.

The reflected light (light reflexes) should be seen symmetrically in the centers of the cornea. If the eyes are in alignment. there will be no movement of the either eye. -Simultaneously (a consensual light reflex).Equal R . Normally you will see: -Constriction of the same-sided pupil (a direct light reflex). Both eyes should move smoothly and symmetrically in each of the six fields gaze and convergence on the held object as it moves toward the nose.18 (Observe the location of reflected light on the cornea) Cover Test This test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps two eyes parallel.Round R .React to L . A normal response is parallel tracking of the object with both eyes. -Convergence of the axes of the eye. (Observe the cover eye for movement) Diagnostic Position test Leading the eye through the six cardinal positions of gaze will elicit any muscle weakness during movement. Record the normal response to all these maneuver as: P .Pupils E .Accommodation Visual Acuity Snellen eye Chart The Snellen eye chart is the most Normal Visual is 20/20 . (Observe for convergence of gaze). Muscle balance Test for pupilary light reflex(Cardinal Fields of Gaze) Test for Accommodation A normal response includes: -Papillary constriction.Light and A .

Peripheral Vision Test Visual Fields Confrontation Test Nose External Inspection: Inspect the nose nothing any bleeding. and symmetry. Thus 20/20 means you can read that 20 ft. it is located symmetrically on the midline of the face that is without swelling. 50 degrees superiorly. . perforation. with the normal eye could have read at 20 ft. or masses. The patient is able to see the stimulus at about 90 degrees temporally. No discharge or flaring and uniform color. Normally. and 70 degrees inferiorly. or lesions. discharges and color. The nasal mucosa should be pink or dull red without swelling. The Top number (numerator) indicates the distance the person is standing from the chart. 60 degrees nasally. there is a sense of smell. Frontal Sinuses Inspection: For any swelling around the eyes Palpation: There is no evidence of swelling around the eyes. swelling. inflammation. Non-tender.19 commonly used and accurate measure of visual acuity. lesions and bleeding. lesions. sense of smell. lesions or bleeding. The shape of the external nose can vary greatly among individual. Internal Inspection: Inspect for nasal septum for deviation. while the denominator gives the distance at which a normal eye could have read that particular line. masses. bleeding. The septum is at the midline and without perforation. absence of pain External Palpation: For tenderness and presence of pain. the small amount of watery discharge is normal.

texture. cracking. soft moist. The glow on each side is equal. There is no evidence of swelling around the nose and eyes. firm texture. Mouth Lips Inspection: For color. The sound should be flat or dull. . The patient should not feel any pain and tenderness during palpation. Not crack and symmetrical. no lumps and nontender. tenderness and lumps. no retraction. retraction form the teeth The patient should not feel pain during palpation and no tenderness felt. indication air-filled frontal and maxillary sinuses. lumps and tenderness. There is no presence of lumps and pain. The sound should be flat or dull. The gum margins at the teeth are tight and well-defined. smooth texture with no evidence of lesions or inflammation. symmetry. lesions and hydration Palpation: For any presence of pain. although it is of limited usefulness. Gums Inspection: For color. The lips should be pink. moist. texture. There should be no pain felt during palpation. Palpation: For the presence of pain. no swelling or bleeding. swelling. It is tender. bleeding. The gums should be pink.20 Presence of pain and tenderness Percussion: Note any sound Maxillary Sinuses Inspection: For any swelling around the eyes Palpation: Presence of pain and tenderness Percussion: Note any sound Transillumination of the sinuses You may use this technique in the frontal and maxillary sinuses when you suspect sinus inflammation.

texture. moisture and presence of lesion. presence of lesions. lumps and presence of pain Frenulum Inspection: For the color. shape. Tongue Inspection: For color. lumps and pain. texture. presence of lesions and malformation. The hard palate is concave and lighter in pink in color. straight and smooth edges in proper alignment or evenly placed. It should be pink in color. and sense of taste. shape.21 Teeth Inspection: For discoloration. Palpation: For any nodules. The ventral surface of the tongue ahs prominent blood vessels and should be moist without lesions. looks smooth and glistening. There should be no presence of nodules. There is a sense of taste. moist. it is smooth and no lesions or malformations noted. The tongue is in the midline of the mouth. surface characteristics. Soft Palate Inspection: For color. pinkish in color and moist. the dorsal surface should be pink. clean and free of debris or decay. Hard palate Inspection: For color. rough and without lesions. moist and no presence of lesions. texture. The tongue is symmetrical and moves freely. which should be white. numbers of tooth and texture. texture. without any lesion or malformation. malformation It should be attached to the tongue. symmetry. The soft palate is also concave and light pink in color. Sublingual Area Inspection: For color. it has many ridges and it is moist. presence of lesions. The strength of the tongue is symmetrical and strong. . The adult normally has 32 teeth.

The patient should be able to repeat words whispered from a distance of 2 feet. Oval in shape. redness. drainage. and not swollen. Tonsils Inspection: For color. Palpation: Presence of pain. It normally looks like a flesh pendant hanging in the midline of soft palate. size. and lumps. Tonsils are present and pink in color. or lesions It is pink in color and smooth. Palpation: Presence of pain Ears External ear Inspection: For position. There should be no pain felt during palpation. Of normal size or not visible. any deformities. inflammation. The ear matches the flesh color of the rest of the patient’s skin and should be positioned centrally and in proportion to the head. shape. No discharge. nodules or lesions. size and discharge. color.22 Uvula Inspection: For position. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye to the occiput with no swelling or thickening. Cerumen should be moist and not obscure the lympanic membrane. There should be no foreign bodies. tenderness. deformities. They should feel firm (not tender) and movement produce pain. mobility and color. Auditory Acuity Voice-Whisper test . shape. no inflammation.

Weber’s Test Rinne’s Test Neck Inspection: For symmetry of the sternocleidomastoid muscles anteriorly. Lymph Nodes Inspection: For any enlargement or inflammation. The patient is able to move head through a full range of motion without complaint of discomfort or noticeable limitation. mobility. No lateralization of sound is known as negative Webster test.23 Tuning fork test Measures hearing by air conduction (AC) or by bone conduction (BC). consistency. and Lymph nodes should not be visible or inflamed. shape. Palpation: For size. dellimination. The patient should perceive the sound equally in both ears or “in the middle”. This is denoted as AC>BC. Normally. The patient may be breathing through a stoma or tracheostomy. The muscles are symmetrical without palpable masses or spasm. lymph nodes should not be palpable in the healthy adult . and the trapezius posteriorly. Air conduction is heard twice as long a bone conduction when the patient hears the sound through the external auditory canal ( air ) after it is no longer heard at the mastoid process ( bone ). The muscles of the neck are symmetrical with the head at a central position. in which the sound vibrates through the cranial bones to the inner ear. Palpation: For the presence of masses and tenderness.

no tenderness. Normal rate of breathing in adult is 46/16 per min. Equal expansion. small. Trachea Palpation: Space should be systemic on both sides or on central placement in midline of neck. masses. and color. discrete. rate. No enlargement. Thyroid tissue moves up with swallowing but often the movement is so small it is not visible on inspection. shape of patient’s chest. . and the ribs insert into the spine at approximately a 45° angle. however. depth. movable nodes are sometimes present but are of no significance.24 tenderness patient. rhythmic. shape of thorax – elliptical shape It should be full symmetric excursion. Colors should be even and consistent with the color of the patients face. masses and temperature. or Dm’s apple. In males. ribs sloping downward with symmetric interspaces. no masses. spaces are equal on both sides. the thyroid cartilage. red patches present. Tenderness. is more prominent than in females. Palpation: For nodules or enlargement and tenderness. the coastal angle. Quiet. Shoulder should be at the same height. and effortless respirations. Breathing pattern should be smooth. or tenderness should be noted on palpation. Costal angle is less than 90°. thumbs normally separate to 3-5 cm (1 ½ to 2 in). Palpation: For respiratory excursion. Thorax Chest Anterior Inspection: For the breathing patterns. skin should Thyroid Gland Inspection: For symmetry and visible masses.

it should be 60-80 beats/min. rib flat sound. Apical has the loudest sound. expiration longer than inspiration. spinal alignment for deformities. Anteroposterior to transverse diameter in ratio of 1. No murmurs should be heard. Bronchovesicular breath sound heard over main stem bronchi: below clavicles and between scapulae (inspiratory phase equal to expiatory phase). Percussion: For its different sound Auscultation: For full two breaths and sounds Normal lung tissue-resonant sound. soft. tubular) breath sounds heard over trachea. Vesicular (low. Lungs Inspection: For breath sounds over the following: Trachea Bronchial (loud.2. Fremitus is normally decreased over heart and breast tissue. Air brushing through the respiratory tract during inspiration expiration generates different breath sounds. Alveolar  Tube (large-stem bronchi)  Lung Field (lung periphery) Heart Palpation: Auscultation: For murmurs and sound Chest Posterior Inspection: For shape and symmetry. short silence between inspiration and expiration. No pulsation palpable over aortic and pulmonic areas. color. breezy) breath sounds heard over lung periphery (inspiration longer than expiration). no pulsation should be present.25 be warm and dry. chest .

) bilaterally in women and 5-6 (2 to 3 in. The chest wall intact. Diaphragm is usually slightly higher on the right side. Full and symmetric chest expansion. No patches. normally the thumbs separate 3 to 5 cm (1½ to 2 in. spine column vertically aligned. Low-pitched voices of males are more readily palpated than higher pitched voices of females. Bilateral symmetry of vocal fremitus. (Note: percussion on a rib normally elicits dullness) Excursion is 3-5 cm (1½ to 2 in. temperature. Vesicular and bronchovesicular breathe sounds. Palpation: For clients who have no respiratory complaints. Fremitus is heard most clearly at the apex of the lungs.) during deep palpation]. For clients who have respiratory complaints. The skin should be intact. When the client takes a deep breath. Lowest point of resonance is at the diaphragm.) in men. [Ex. your thumbs should be move apart an equal distance and at the same time. uniform temperature. For respiratory excursion For vocal and tactile fremitus Percussion: For sounds For diaphragm excursion Auscultation: For sounds Abdomen .26 abnormal inspiratory. Percussion notes resonate except over scapula. no abnormal inspiratory retraction of interspaces. symmetric. uniform temperature.

27 Inspection: -Color -Scars -Striae -Dilated Veins -Rashes and lesions -Umbilicus -The contour of the abdomen -Hair distribution -Symmetry -Respiratory movement -Surface is uniform in color and in pigmentation. (Vascular sounds) Percussion: Percuss the four quadrants to as tympany and dullness. inverted triangular shape in adult female.gallbladder . No bruits.spleen . -The abdomen rises with inspiration and falls with expiration. Left Upper Quadrant: . -Diamond shape in adult males. -A few small veins may be visible normally. and kidneys. Dull sounds are heard over solid masses such as liver. no friction. Tympany is usually predominating because of air in the stomach and intestines.body of pancreas Right Upper Quadrant: . High pitched. no venous hums. If scars are present draw its location in the person’s record indicating the length in cm. -Flawless no scars is present.head of pancreas . renal. irregular gurgles (535 times/ min) present equally in all four quadrants. discoloration or hernia.stomach . iliac and femoral arteries. -No rashes or lesions are present. -Is normally in the midline and inverted with no sign of inflammation. -No striae / stretch marks are present.duodenum . Auscultation: Auscultate the four quadrants for basic sounds. -Symmetric bilaterally and smooth. -Normally range from flat to rounded. Auscultate over the aorta.left lobe of liver . spleen.liver .

Often the liver is not palpable and you feel nothing firm. areas of abdomen moving clockwise tenderness. rigidity and muscle and in rotary motion.28 .hepatic flexure of colon . rigidity and muscle guarding It feels like a firm rectangular ridge.1 inch) on all Normally there is no pain. Hooking Technique An alternative method of palpating Normally there is no pain. guarding Deep Palpation (2-3 inches) on all areas on the abdomen moving clockwise and in rotary motion. Light Palpation (1/2 .part of transverse & descending colon Left Lower Quadrant: -Part of descending colon -Sigmoid colon -Left ovary and tube -Left ureter -Left spermatic cord Normally you should feel nothing .Place your left hand under the person’s back parallel to the 11th and 12th ribs and lift up to support the abdominal contents. tenderness.spleen flexure of colon . location and consistency of certain organs and to screen for an abnormal mass or tenderness.right kidney and adrenal . . Liver Palpation: Located in the RUQ (Right Upper Quadrant).Part of ascending and transverse colon Right Lower Quadrant: -Cecum -Appendix -Right ovary and tube -Right ureter -Right spermatic cord Midline: -Aorta -Uterus(if enlarged) -bladder(if enlarged) Palpation: Perform palpation to judge the size. Push deeply down and under the right costal margin then ask the person to take a deep breath.left kidney and adrenal . Place your right hand on the RUQ with fingers parallel to the midline.

Place your hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. Ask the person to take a deep breath then try to fell the liver edge bump from your fingertips. Kidney Percussion: Indirect fist percussion causes the tissues to vibrate instead of producing a sound.s right flank. Palpation: locate kidney by placing your hand together in a duck-bill position at the person. Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. Lower pole of the kidney is round.29 the liver. Palpation: Light palpation in all 4 quadrants Deep palpation in all 4 quadrants firm. Lift for support. smooth mass slide in between your fingers. Press your two hands together firmly (you need deeper palpation than that used to liver and spleen) then ask the person to take a deep breath. . Hook your fingers over the costal margin from above. When enlarged the spleen extends into the lower quadrants. A person normally feels a thud but no pain. Thump that hand with the ulnar edge of your other fist. Stand up at the persons’ shoulder and swivel your body to the right so that you face the person’s feet. Spleen Palpation: Search spleen by reaching your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Sharp pain occurs with inflammation of kidneys or paranephric area. Locate kidney by placing hand over the 12th rib at the costoverbral angle on the back.

No involuntary movements. ask the person to close the eyes and to hold the position.30 Extremities Upper and Lower Inspection: -Observe for size. the person moves with a sense of freedom.Always compare both extremities Palpation: -Feel evenness of temperature. Romberg’s Test Ask the person to stand up with feet together and arms at the side. and the turns are smooth. symmetry and involuntary movement -Look for deformities. No edema. . Can perform complete range of motion Can counter act gravity and resistance in ROM Balance Test Gait Observe as the person walk 10-20 feet. and presence of lesions. a . color. Normally. Wait about 20 seconds. contour. . Normally it should be even for all the extremities. Temperature is warm and even.Perform range of motion -Test for muscle strength Both extremities are equal in size Have the same contour with prominences of joints. turns and returns to the starting point. Once in a stable position. The gait is smooth. Color is even. the opposing arm swing is coordinated. Has equal contraction. Normally. edema. rhythmic. and effortless.

alternating hands and increasing speed. although slight swaying may occur. the person can walk straight and stay balance. lift up. turn hands over. Normally. and pat the knees with the backs of the hands. to place the heel on the opposite knee.31 person can maintain posture and balance even with the visual orienting information blocked. Heel-to-shin Test Test lower extremity coordination by asking the person who is in a supine position. (Stand close to catch the person in case he or she falls) Tandem Walking Ask the person to walk straight line in a heel-to-toe fashion. Ask the person to touch the tip of his nose or her nose with each index finger. the person moves the heel in a straight line down the skin. Finger-to-nose Test Ask the person to close the eyes and to stretch out the arms. this is done with equal turning and a quick rhythmic pace. Coordination and Skilled Movements Rapid Altering Movements (RAM) Ask the person to pat the knees with both hands. Reflex . This decrease the base of support and will accentuate any problem with coordination. Normally. this is done with equal turning & a quick rhythmic pace. Normally. and run it down the shin from to the ankle. Then ask the person to do this faster. Normally.

Place your thumb on the biceps tendon and strike a blow on your thumb. b) the triceps reflex. Experience is necessary to determine appropriate scoring of an individual. The response is described from 0 to 4. this position relaxes. Test the Reflex The reflex response is guided on a 4 point scale: 4+ 3+ 2+ 1+ 0 very brisk. d) the patellar reflex. may indicate disease average. Triceps Reflex (Extension) Tell the person to let the arm “just go dead” as you suspend it by holding the upper arm. You can feel as well as see the normal response. Reflexes are tested using a percussion hammer. hyperactive brisker than average. normal diminished. the person’s arm.32 It is an automatic response of the body to a stimulus. e) Achilles reflex. low normal no response Upper Extremity Biceps Reflex (Flexion) Support the person’s forearm on yours. c) the brachioradialis reflex. as well as partially flexes. It is not voluntarily learned or conscious. f) the plantar reflex. Strike the triceps tendon directly just . which are contraction of the biceps muscle and the flexion of the forearm. Several reflexes are normally tested during the physical examination: a) the biceps reflex.

With the reflex hammer. The normal response is extension of the forearm. like an upside-down J. and strike the Achilles tendon directly. The normal response is plantar flexion if all the toes and inversion and flexion of the forefoot.33 above the elbow. The normal response is flexion and supination of the arm. Strike the forearm directly. . Feel the normal response as the foot plantar flexes against your hand. Plantar Reflex Position the thigh in slight external rotation. Brachioradialis Reflex (Flexion and Supination of the arm) Hold the person’s thumbs to suspend the forearm in relaxation. Strike the tendon directly just below the patella. Hold the foot in dorsiflexion. about 2 to 3 cm above the radial styloid process. Extension of the lower legs is the expected response. draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot. Achilles Reflex Position the person with the knee flexed and the hip externally rotated. Lower Extremity Quadriceps Reflex (patellar or knee jerk reflex) Let the lower legs dangle freely to flex the knee and stretch the tendons.

34 Appendices .

35 Equipment and supplies used for a Health Examination Flashlight or Penlight Otoscope Dental Mirror Opthalmoscope Tuning Fork Cotton Applicators Tongue Depressors Lubricant Nasal Speculum Gloves Percussion Hammer .

36 Various Positioning of the Client Dorsal Recumbent Lithotomy Sims Horizontal Recumbent or Supine Sitting or High Fowlers Prone .

37 Basic Techniques used in Physical Assessment Direct Percussion Indirect Percussion Deep Palpation .

38 Light Palpation Parts of the Eye .

39 Snellen Eye Chart .

40 Sinus’ Locations Side View .

41 Structures of the Mouth Front View .

42 Structures of the Ear Lymph Nodes of the Head and Neck .

43 External & Internal Lymphatic Drainage Areas to Auscultate and Palpate on Chest .

44 Palpation of Thoracic Expansion Posterior Anterior Intercostal Landmarks for Percussion & Auscultation of Thorax Posterior Normal Percussive Notes (Posterior) .

45 Anterior Normal Percussive Notes (Anterior) Respiration Patterns .

May be noted in elderly positions during sleep not related to any disease process. anxiety or exercise. Can occur with medication induced depression of the respiratory system.46 Type Normal Tachypnea Description 12 to 20/min & regular >24/min & shallow Pattern Clinical Indication Normal Breathing Pattern May be normal response to fever. fear or anxiety Kussmauls’ respiration is a type of hyperventilation associated with diabetic ketoacidosis. drug overdose. pneumonia or pleurisy May be normal in well conditioned athletes. Usually occurs with extreme exercise. an overdose of drug salicylate or severe anxiety Usually associated with overdose of narcotics of anesthetics May result from severe congestive heart failure. alkalosis. May be seen with meningitis or severe brain damage Bradypnea <10/min & regular Hyperventila tion Increased rate & depth Hypoventilati on CheyneStokes Respiration Decreased rate & depth. coma. can occur with respiratory insufficiency. Other causes of Hyperventilation include disorders of the central nervous system. irregular pattern Regular pattern characterized by alternating periods of deep rapid breathing followed by periods of apnea Irregular pattern characterized by varying depth and Biot’s Respiration . diabetic. increased intracranial pressure or renal failure. neurological damage.

bubbly sounds heard during inspiration not cleared with coughing Are loud low – pitched. rumbling coarse sounds heard most often during inspiration and expiration. grating quality heard best during inspiration. sudden reinflation of groups of alveoli. can be heard over most lung fields Can be heard all over lung fields Muscular spasm. cause turbulence. disruptive passage of air Character Fine crackles are highpitched fine short interrupted crackling sounds heard during end of inspiration. Coarse crackles are loud. usually not cleared with coughing. right and left lung bases. parietal Has dry. Ronchi (sonorous wheeze) Wheezes (sibilant wheeze) Are primarily heard over trachea and bronchi. usually louder on expiration Pleural Friction Rub Is heard over anterior Inflamed pleura. High – velocity airflow through severely narrowed bronchus Are high-pitched continuous musical sounds like a squeak heard continuously during inspiration.47 rate of respirations followed by periods of apnea Adventitious Sounds Sound Crackles Site Auscultated Are most commonly heard in dependent lobes. not cleared with coughing. Moist crackles are lover. or expiration. more moist sounds heard during the middle of inspiration. Cause Random. if loud enough. may be cleared by coughing. does not clear . fluid or mucus in larger airways.

Palpation of the Heart Locate the apical pulse with the palmar surface.48 lateral lung field (if patient is sitting upright) pleura rubbing against visceral pleura with coughing. heard loudest over lower lateral anterior surface. Palpate the apical pulse with the fingerpad. .

49 Abdominal Viscera and Vascular Structures Abdominal Viscera and Vascular Structures Abdominal Quadrants Vascular sounds and friction rubs can best be heard over these areas .

50 Palpation of the liver Spleen Palpation Kidney Palpation .

51 Common Tests for Coordination Finger-to-nose test Heel-to-sheen test .

52 Testing rapid alternating movements of palms Common Tests for Reflexes Briceps Reflex Brachioradialis Reflex Triceps Reflex .

53 Testing for ankle clonus Plantar Reflex .

54 Expected Auscultation Sounds (Anterior) Sites for Auscultating the Abdomen Sites for Auscultating the Abdomen .

55 Percussion Sites for all Quadtrants Tactile Fremitus (Posterior) Expected Auscultation Sounds (Posterior) .

56 Diaphragmatic Excursion .

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