Cebu Doctors' University College of Nursing: Module 1F: Group Worksheet

Cebu Doctors’ University
College of Nursing
1 Dr. P. V. Larrazabal Jr. Avenue, North Reclamation, 6014 Mandaue City, Cebu, Philippines
Tel. No +63 (32) 238-8746 Web: www.cebudoctorsuniversity.edu Email: cdu-cn@cebudoctorsuniversity.edu
NCM101: HEALTH ASSESSMENT
MODULE 1F: GROUP WORKSHEET
Group C7:
Leader: Fernandez, Philip Anthony F.

Onil, Raymond Reave A.
Pepito, Lynber Crystal B.
Quinones, Kristine Marie H.
Rocamora, Al Trisha Nicole M.
Tejada, Whel Marie S.
Vasquez, Jonah Mae D.
Submitted to: Dr. Armand K. Cuasito

Date Submitted: March 15, 2021
Instruction:
College of Nursing
1. In tabular format, name the body parts to be assessed systematically from head
to toe, including the materials/ equipment needed on the given physical exam
technique and enumerate its normal and abnormal findings.
2. A collated output is to be submitted by the leader of the group in the assignment

tab of CeLO+ which will be submitted on day 2 of the module delivery
Learner no. 1
Inspection
Body Part Normal Findings Abnormal Findings
Skin Inspect general skin

Materials: coloration.
● Gloves ● Inspection reveals ● Pallor (loss of color)
● Mirror evenly colored skin is seen in arterial
● Magnifying glass tones without insufficiency,
● Penlight unusual or decreased blood
● Ruler with prominent supply, and anemia.
centimeter mark discolorations Palid tones may
vary from pale to
ashen without
underlying pink.
● Cyanosis may cause
white skin to appear
blue-tinged,
especially in the
perioral, nail bed,
and conjunctival
areas. Dark skin
may appear blue,
dull, and lifeless in
the same areas.
● Central cyanosis
results from a
cardiopulmonary,
whereas peripheral
cyanosis may be a
College of Nursing
local problem
resulting from
vasoconstriction.
While inspecting skin

coloration, note any odors
emanating from the skin.
● Client has slight or ● A strong odor of
no odor of perspiration or foul
perspiration, odor may indicate
depending on disorder of sweat
activity. glands. Poor
hygiene practices
may indicate a need
for client teaching or
assistance with
activities of daily
living.
Inspect for color variations
● Common variations ● Rashes such as
include suntanned reddish or darkened
areas, freckles, or butterfly rash across
white patches the bridge of the
known as vitiligo. nose and cheeks,
The variations are characteristics of
due to different systemic lupus
amounts of melanin erythematosus
in certain areas. A (SLE) is seen in a
generalized loss of 9:1 female-to-male
pigmentation is seen ratio and is more
as albinism. Dark common in black
skinned clients have and Hispanic
lighter-colored people.
palms, soles, nail
beds and lips.
Freckle-like or dark
streaks of
pigmentation are
also common in the
College of Nursing
sclera and nail beds

of dark-skinned
clients.
Inspect the lesions

● Skin is smooth, ● Primary and
without lesions. Secondary Lesions.
Stretch marks, Vascular lesions,
healed scars, reddish-bluish
freckles, moles or lesions, are seen
birth-marks are with bleeding,
common findings. venous pressure,
Freckles or mole aging, liver disease
may be scattered or pregnancy.
over the skin in no ● Cancerous lesions
particular pattern. can be either
primary or
secondary lesions
and are classified as
squamous cell
carcinoma, basal cell
carcinoma, or
malignant
melanoma.
Scalp and Hair ● Natural hair color, ● Nutritional

Materials: as opposed to deficiencies may
● Gloves chemically colored cause patchy gray
● Mirror hair varies among hair in some clients.
● Magnifying glass clients from pale Severe malnutrition
● Penlight blond to black to in African American
● Ruler with gray or white. The children may cause
centimeter mark color is determined a copper-red hair
by the amount of color.
melanin present. ● Excessive scaliness
may indicate
dermatitis. Raised
lesions may indicate
infections or tumor
College of Nursing
growth. Dull, dry

hair may be seen
with hypothyroidism
and malnutrition.
Poor hygiene may
indicate a need for
client teaching or
assistance with
activities of daily
living.
● Pustules with hair
loss in patches are
seen in tinea capitis,
a contagious fungal
disease.
● Infections of the
hair follicle
(folliculitis) appear
as pustules
surrounded by
erythema.
Inspect amount and

distribution of scalp, body,
axillae, and pubic hair.
● Varying amounts of ● Excessive
terminal hair cover generalized hair loss
the scalp, axillae, may occur with
body, and pubic infection, nutritional
areas according to deficiencies,
normal gender hormonal disorders,
distribution. Fine thyroid or liver
vellus hair covers disease, drug
the entire body toxicity, hepatic or
except for the soles, renal failure. It may
palms, lips, and also result from
nipples. Normal chemotherapy or
male pattern balding radiation therapy.
is symmetric.
College of Nursing
● Patchy hair loss may

result from
infections of the
scalp, discoid or
systemic lupus
erythematosus, and
some types of
chemotherapy.
● Individuals may
shave or chemically ● Hirsutism (facial hair
remove axillary and on females) is a
genital hair. Some characteristic of
individuals, both Cushing disease and
male and female polycystic ovary
may also remove all syndrome (PCOS)
body hair. and results from an
imbalance of
adrenal hormones
or it may be a side
effect of steroids.
Nails Inspect nail grooming and ● Dirty, broken, or

Materials: cleanliness. jagged fingernails
● Gloves ● Nails are clean and may be seen with
● Mirror manicured. poor hygiene. They
● Magnifying glass may also have
● Penlight results from the
● Ruler with client’s hobby or
centimeter mark occupation
Inspect nail color and
markings.
● Pink tones should be
seen. Some ● Pale or cyanotic
longitudinal ridging nails may inculcate
is normal hypoxia or anemia.
● Dark-skinned clients Splinter
may have freckles hemorrhages may
or pigmented be caused by
streaks in their nails trauma. Beau lines
College of Nursing
occur after acute

illness and
eventually grow out.
Yellow discoloration
may be seen in
fungal infection or
psoriasis. Nail pitting
is also common in
psoriasis.
Inspect shape of nails

● There is normally a ● Early clubbing (180-
160-degree angle degree angle with
between the nail spongy sensation)
base and the skin. and late clubbing.
Head Inspect the head

Materials: ● Head size and shape ● An abnormally small
● Stethoscope vary, especially in head is called
● Small cup of water accord with microcephaly.
for client to drink ethnicity. Usually ● The skull and facial
the head is bone are larger and
symmetric, round, thicker in
erect, and in midline acromegaly.
and appropriately ● Acorn-shaped,
related to body size. enlarged skull bones
No lesions are are seen in Paget
visible. disease of the bone
Inspect movement of the

neck structures
● The thyroid cartilage ● Asymmetric
and cricoid cartilage movement or
move upward generalized
symmetrically as the enlargement of the
client swallows. thyroid gland is
considered
abnormal.
College of Nursing
Inspect the cervical ● Prominence or

vertebrae. swelling other than
● C7 (vertebra the C7 vertebrae
prominens) is may be abnormal.
usually visible and
palpable.
● Muscle spasms,
Inspect range of motion. inflammation, or
● Neck movement cervical arthritis may
should be smooth cause stiffness,
and controlled with rigidity and limited
45-degree flexion, mobility of the neck,
55-degree which may affect
extension, 40- daily functioning.
degree lateral ● A stiff neck is often
abduction, and 70- a late symptom
degree rotation. seen in meningitis.
External Eyes Structures Inspect the eyelids and

Materials: eyelashes
● Cover card ● The upper lid ● Drooping of the
● Gloves margin should be upper lid, called
● Newspaper print or between the upper ptosis, may be
Rosenbaum pocket margin of the iris attributed to
screener and the upper oculomotor nerve
● Ophthalmoscope margin of the pupil. damage, Myasthenia
● Penlight The lower lid margin gravis, weakened
● Snellen chart rests on the lower muscle or tissue, or
border of the iris. a congenital
No white sclera is disorder. Retracted
seen above or below lid margins, which
the iris. Palpebral allow viewing of the
fissures may be sclera when the
horizontal. eyes are open,
suggests
hyperthyroidism.
College of Nursing
Inspect the bulbar

conjunctiva and sclera.
● Bulbar conjunctiva is
clear, moist, and ● Redness of the
smooth. Underlying conjunctiva is called
structures are conjunctivitis (pink
clearly visible. Sclera eye)
is white.
Inspect the palpebral

conjunctiva
● The lower and
upper palpebral ● Cyanosis of the
conjunctiva are clear lower lid suggests a
and free of swelling heart or lung
or lesions disorder
● Palpebral
conjunctiva is free ● A foreign body or
of swelling, foreign lesion may cause
bodies, or trauma. irritation, burning,
pain, and/or
swelling of the
upper eyelid.
Inspect the lacrimal
apparatus
● No swelling or
redness should ● Swelling of the
appear over areas of gland may be
the lacrimal gland. caused by blockage,
The puncta is visible infection, or an
without swelling or inflammatory
redness and is condition. Redness
turned slightly or swelling around
toward the eye. the puncta may
indicate an
infectious or
inflammatory
condition. Excessive
tearing may indicate
College of Nursing
Inspect the cornea and a nasolacrimal sac

lens. obstruction.
● The cornea is
transparent, with no
opacities. The
oblique view shows ● Areas of roughness
a smooth and or dryness on the
overall moisture cornea are often
surface; the lens is associated with
free from opacities injury or allergic
responses. Opacities
Inspect the iris and pupil of the lens are seen
● Iris is typically with cataracts.
round, flat and
evenly colored. The
pupil, round with a ● Irregularly shaped
regular border, is irises, miosis,
centered in the iris. mydriasis, and
Pupils are normally anisocoria.
equal in size (3- ● If the difference in
5mm). An inequality pupil size changes
in pupil size of less throughout pupillary
than 0.5 mm occurs response tests, the
in 20% of clients. inequality of size is
This condition is abnormal.
called anisocoria
and it is normal.
Inspect the retinal vessels

● Four sets of
arterioles and
venules should pass
through the optic ● Changes in the
disc. blood supply to the
retina may be
observed in
● Arterioles are bright constricted
red and arterioles, dilated
progressively veins, or absence of
College of Nursing
narrow as they major vessels

move away from the ● Hypertension may
optic disc. Arterioles cause a widening of
have a light reflex the arterioles’ light
that appears as a reflex and the
thin, white line in arterioles take on a
the center of the copper color. With
arteriole. Venules long-standing
are darker red and hypertension,
larger than arteriole wall thicken
arterioles. They also and appear opaque
progressively or silver.
narrow as they
move away from the
optic disc.
● The ratio of arteriole
diameter to vein
diameter (AV ratio)
is 2:3 or 4:5
● In a normal AV
crossing, the vein
passing underneath
the arteriole is seen ● Arterial nicking,
right up to the tapering, and
column of blood on banking are
either side of the abnormal AV
arteriole (the crossings caused by
arteriole wall itself is hypertension or
normally arteriosclerosis.
transparent).
Inspect retinal background

● General background
appears consistent
in texture. The red-
orange color of the ● Cotton-wool patches
background is (soft exudates) and
lighter near the hard exudates from
optic disc. diabetes and
College of Nursing
hypertension appear
a s light-colored
spots on the retinal
background.
Hemorrhages and
microaneurysms
appear as red spots
and streaks on the
retinal background.
Inspect fovea and macula
● The macula is the
darker area, one
disc diameter in ● Excessive clumped
size, located to the pigment appears
temporal side of the with detached
optic disc. Within retinas or retinal
the area is a star- injuries. Macular
like reflex called degeneration may
fovea be due to
hemorrhages,
exudates or cysts.
Inspect anterior chamber
● The anterior
chamber is ● Hyphema and
Internal Eye Structure transparent. Hypopyon
Inspect the optic disc.

● The optic disc
should be round to ● Papilledema or
oval with sharp, swelling of the optic
well-defined disc may result from
borders. hypertension or
increased
intracranial pressure
● The intraocular
pressure associated
with glaucoma
interferes with the
blood supply to
College of Nursing
optic structures and

results in the
following
characteristics: an
enlarged physiologic
up that occupies
more than half of
the disc’s diameter,
pale base of
enlarged physiologic
cup, and obscured
or displaced retinal
vessels.
● Optic atrophy is
evidenced by the
disc being white in
color and a lack of
disc vessels. This
condition is caused
by the death of the
optic nerve fibers.
Neck Inspect the neck muscles

Materials: (sternocleidomastoid and
● Stethoscope trapezius) for abnormal
● Small cup of water swellings or masses. Ask
for client to drink the client to hold the head
erect.
● Muscles equal in  Unilateral neck
size; head centered swelling; head tilted
to one side
(indicates presence
of masses, injury,
muscle weakness,
shortening of
sternocleidomastoid
muscle, scars)
Inspect the thyroid gland.
College of Nursing
● Not visible on ● Visible diffuseness

inspection or local enlargement
Ears Inspect the auricle, tragus,

Materials: and lobule.
● Otoscope ● Ears are equal in ● Ears are smaller
● Tuning fork size bilaterally.The than 4 cm or larger
● Watch with second auricle aligns with than 10 cm. Microtia
hand the corner of each is a congenital
eye. Earlobes may deformity in which
be free, attached, or the external ear and
soldered. sometimes the ear
canal are not fully
developed. Macrotia
is a congenital
excessive
enlargement of the
external ear.
Inspect the external

auditory canal.
● A small amount of ● Bloody, purulent
odorless cerumen discharge- otitis
(ear wax) is the only media.Blood or
discharge normally watery discharge-
present. skull trauma.
Inspect the tympanic

membrane.
● The tympanic ● Red, bulging
membrane should eardrum and
be pearly Gray, distorted,
shiny, and diminished, or
translucent, with no absent light reflex-
bulging or acute otitis media.
retraction. Yellowish, bulging
membrane with
bubbles behind-
College of Nursing
serous otitis media.
Nose Inspect the external nose

Materials: for any deviations in
● 4x4-in gauze pad shape, size, or color and
● Penlight flaring or discharge from
● Short, wide-tipped the nares.
speculum attached ● Symmetric and ● Asymmetric
to the head of an straight No Discharge from
otoscope or nasal discharge or flaring nares Localized
speculum with Uniform color areas of redness or
penlight presence of skin
● Tongue depressor lesions
● Inspect the nasal ● Septum deviated to

septum between the ● Nasal septum intact the right or to the
nasal chambers. and in midline left
Mouth Inspect the outer lips for

Materials: symmetry of contour,
● 4x4-in gauze pad color, and texture. Ask the
● Penlight client to purse the lips as if
● Short, wide-tipped to whistle.
speculum attached ● Uniform pink color ● Pallor; cyanosis
to the head of an (darker, e.g., bluish Blisters; generalized
otoscope or nasal hue, in or localized swelling;
speculum with Mediterranean fissures, crusts, or
penlight groups and dark- scales (may result
● Tongue depressor skinned clients) from excessive
Soft, moist, smooth moisture, nutritional
texture Symmetry of deficiency, or fluid
contour Ability to deficit) Inability to
purse lips purse lips (may
indicate facial nerve
College of Nursing
damage)
Inspect the teeth and

gums while examining the
inner lips and buccal
mucosa.
● 32 adult teeth
Smooth, white, ● Excessively red
shiny tooth enamel gums
● Missing teeth; ill-
fitting dentures
● Brown or black
discoloration of the
enamel (may
indicate staining or
the presence of
caries)
Inspect the dentures. Ask
the client to remove
complete or partial
dentures. Inspect their
condition, noting in
particular.
● No retraction of
gums ● Spongy texture;
bleeding;
tenderness (may
indicate periodontal
disease) Receding,
atrophied gums;
swelling that
partially covers the
teeth
● Ill-fitting dentures;
irritated and
excoriated area
Inspect tongue movement. under dentures
● Ask the client to roll
College of Nursing
the tongue upward

and move it from ● Restricted mobility
side to side
Inspect the base of the

tongue, the mouth floor,
and the frenulum. Ask the
client to place the tip of
the tongue against the roof
of the mouth
● Smooth tongue base
with prominent
veins ● Swelling, ulceration
Thorax and Lungs Inspect the shape and

Materials: symmetry of the thorax
● Client gown and from posterior and lateral
draping sheet views. Compare the
● Gloves and masks anteroposterior diameter to
(for nurse if client is the transverse diameter.
actively coughing) ● Anteroposterior to ● Barrel chest;
● Metric ruler transverse diameter increased
● Skin marking pen in ratio of 1:2 anteroposterior to
● Stethoscope transverse diameter
(diaphragm) ● Thorax symmetric ● Thorax asymmetric
Inspect the spinal

alignment for deformities if
the client can stand. From
a lateral position, observe
the three normal
curvatures: cervical,
thoracic, and lumbar.
● Spine vertically ● Exaggerated spinal

aligned curvatures
(kyphosis, lordosis)
Breasts and Axillae Inspect the breasts for

College of Nursing
● Client gown size, symmetry, and

● Gloves for nurse contour or shape while the ● Recent change in
● Small pillow client is in a sitting breast size;
● Metric ruler position. swellings; marked
● Breast self- ● Females: rounded asymmetry
examination shape; slightly
teaching pamphlet unequal in size;
generally symmetric
Males: breasts even
with the chest wall;
if obese, may be
similar in shape to
female breasts
Inspect the skin of the

breast for localized
discolorations or
hyperpigmentation,
retraction or dimpling,
localized hypervascular
areas, swelling or edema ● Localized
● Skin uniform in color discolorations or
(similar to skin of hyperpigmentation
abdomen if not Retraction or
tanned) Skin dimpling (result of
smooth and intact scar tissue or an
Diffuse symmetric invasive tumor)
horizontal or vertical Unilateral, localized
vascular pattern in hypervascular areas
light-skinned people (a ssociated with
Striae (stretch increased blood
marks); moles and flow) Swelling or
nev edema appearing as
pig skin or orange
peel due to
exaggeration of the
pores
College of Nursing
Heart and Central Inspect and palpate the

Vessels aortic and pulmonic areas,
Materials: observing them at an angle
● Client draping sheet and to the side, to note the
● Metric rulers (two) presence or absence of
● Penlight pulsations. Observing
● Small pillow these areas at an angle
● Stethoscope increases the likelihood of
● Watch with second seeing pulsations. ● Pulsations
hand ● No pulsations
Inspect and palpate the

tricuspid area for
pulsations and heaves or
lifts ● Pulsations
● No pulsations ● Diffuse lift or heave,
● No lift or heave indicating enlarged
or overactive right
ventricle
Inspect and palpate the

epigastric area at the base
of the sternum for
abdominal aortic
pulsations. ● Bounding abdominal
● Aortic pulsations pulsations (e.g.,
aortic aneurysm)
Abdomen Inspect the abdomen for

Materials: skin integrity
● Client drape ● Unblemished skin ● Presence of rash or
● Metric ruler Uniform color other lesions Tense,
● Skin marking pen glistening skin (may
● Small pillows indicate ascites,
College of Nursing
● Stethoscope edema)
Inspect the abdomen for

contour and symmetry:
● Flat, rounded
(convex), or ● Distended
scaphoid (concave)
Musculoskeletal System Inspect the muscles for

Materials: size. Compare the muscles
● Flexible metric tape on one side of the body
measure (e.g., of the arm, thigh,
● Goniometer and calf) to the same
muscle on the other side.
For any discrepancies,
measure the muscles with
a tape ● Atrophy (a decrease
● Equal size on both in size) or
sides of body hypertrophy (an
increase in size),
asymmetry
Inspect the muscles and

tendons for contractures
(shortening). ● Malposition of body
● No contractures part, e.g., foot drop
(foot flexed
downward)
Inspect the muscles for

tremors, for example by
having the client hold the
arms out in front of the
body.
College of Nursing
● Presence of tremor
● No tremors
Female Genitals and Inspect the distribution,

Inguinal Area amount, and
Materials: characteristics of pubic
● Gloves (non-sterile) hair.
● Light ● There are wide ● Scant pubic hair
● Hand-held mirror variations; generally (may indicate
● Vaginal speculum kinky in the hormonal problem)
● Water-soluble menstruating adult,
lubricant thinner and
● Bifid spatula, straighter after
endocervical broom menopause
● Large swabs for Distributed in the
vaginal examination shape of an inverse
● Specimen container triangle
● pH paper
● Feminine napkins Inspect the skin of the
pubic area for parasites,
inflammation, swelling, and
lesions. To assess pubic
skin adequately, separate
the labia majora and labia
minora ● Hair growth should
● Pubic skin intact, no not extend over the
lesions Skin of vulva abdomen Lice,
area slightly darker lesions, scars,
than the rest of the fissures, swelling,
body Labia round, erythema,
full, and relatively excoriations,
symmetric in adult varicosities, or
females leukoplakia
Inspect the clitoris,

urethral orifice, and vaginal
orifice when separating the
labia minora.
College of Nursing
● Clitoris does not ● Presence of lesions

exceed 1 cm (0.4
in.) in width and 2
cm (0.8 in.) in
length Urethral
orifice appears as a
small slit and is the
same color as
surrounding tissues
No inflammation,
swelling, or
discharge
Male Genitals and Inspect the distribution,

Inguinal Area amount, and
Materials: characteristics of pubic
● Gloves hair. ● Scant amount or
● Water-soluble ● Triangular absence of hair
lubricant distribution, often
● Flashlight spreading up the
● Specimen card abdomen
Inspect the penile shaft

and glans penis for lesions,
nodules, swellings, and
inflammation ● Presence of lesions,
● Penile skin intact nodules, swellings,
Appears slightly or inflammation
wrinkled and varies Foreskin not
in color as widely as retractable Large
other body skin amount, discolored,
Foreskin easily or malodorous
retractable from the substance
glans penis
Inspect the urethral

meatus for
College of Nursing
swelling,inflammation, and ● Inflammation;

discharge. discharge Variation
● Pink and slit like in meatal locations
appearance (e.g., hypospadias,
Positioned at the tip on the underside of
of the penis the penile shaft, and
epispadias, on the
upper side of the
penile shaft)
Inspect the scrotum for

appearance, general size, ● Discolorations; any
and symmetry. tightening of skin
● Scrotal skin is (may indicate
darker in color than edema or mass)
that of the rest of Marked asymmetry
the body and is in size
loose Size varies
with temperature
changes (the dartos
muscles contract
when the area is
cold and relax when
the area is warm)
Scrotum appears
asymmetric (left
testis is usually
lower than right
testis)
Anus ● Intact perianal skin; ● Presence of fissures

usually slightly more (cracks), ulcers,
pigmented than the excoriations,
skin of the buttocks inflammations,
abscesses, protruding
Anal skin is normally
hemorrhoids (dilated
more pigmented,
veins seen as
coarser, and moister reddened protrusions
than perianal skin of the skin), lumps or
College of Nursing
and is usually tumors, fistula

hairless openings, or rectal
prolapse (varying
degrees of protrusion
of the rectal mucous
membrane through
the anus)
Learner no. 2 and 3
Palpation
Skin, Hair and Nails Palpate skin to assess

Materials: texture:
● Gloves ● Skin is smooth and ● Rough, flaky, dry
● Mirror even. skin is seen in
● Magnifying lens hypothyroidism.
● Penlight Palpate to assess
● Ruler with centimeter thickness: ● Very thin may be
markings ● Skin is normally thin seen in clients with
● Skin marking pen but calluses arterial insufficiency
(rough,thick or in those on
sections of steroid therapy.
epidermis)are
common in areas of
the body that are
exposed to constant
pressure.
● Increased moisture
Palpate to assess moisture: or diaphoresis may
● Skin surfaces are occur in conditions
very dry depending such as fever or
on the area hyperthyroidism.
assessed. Recent
activity or warm
environments may
College of Nursing
cause increased
moisture.
● Cold skin may
Palpate to assess accompany shock or
temperature: hypotension. Cool
● Skin is normally a skin may
warm temperature. accompany arterial
disease.
Palpate to assess mobility

and turgor: ● Decreased mobility
● The skin is mobile, is seen with edema.
with elasticity and
returns to original
shape quickly.
Palpate to detects edema: ● Indentation on the

● Skin rebounds and skin may vary from
does not remain slight to great and
indented when may be in one area
pressure is released. or all over the body.
Palpate nail to assess ● Thickened nails may

texture: be caused by
● Nails are hard and decreased
basically immobile. circulation, and are
also seen in
onychomycosis.
Palpate ton assess texture

and consistency, nothing
whether a nail plate is
attached to nail bed. ● Paronychia indicates
● Nails are smooth local infection.
and firm; the nail Detachment of nail
plate should be plate from nail bed
firmly attached to is seen in infections
the nail bed. or trauma.
College of Nursing
Test capillary refill in nail

beds by pressing the nail
tip briefly: ● There is a slow
● Pink tone returns to capillary nail bed
blanched nail beds refill with respiratory
when pressure is or cardiovascular
released. disease that causes
hypoxia.
Head and Neck Palpate the head:

Materials: ● The head is ● Lesions or lumps on
● Stethoscope normally hard and the head may
● Small cup of water for smooth, without indicate recent
client to drink lesions. trauma or a sign of
cancer.
Inspect the face:
● The face is ● Asymmetric anterior
symmetric with a to the earlobes
round, oval, occurs with parotid
elongated, or square enlargement from
appearance. abscess or tumor.
Unusual or
asymmetric orofacial
movements may be
from an organic
disease or
neurologic problem.
Palpate the temporal

artery: ● An acute urgent
● The temporal artery condition is seen
is elastic and not when the temporal
tender. artery is hard, thick
and tender with
inflammation, as
seen with temporal
College of Nursing
arteritis.
Palpate the
temporomandibular joint: ● Limited range of
● Normally there is no motion, swelling,
swelling, tenderness, or
tenderness, or crepitation may
crepitation with indicate TMJ
movement. Mouth syndrome.
open closes fully.
Palpate the trachea: ● The trachea may be

● Trachea is midline. pulled to the
affected side in
cases of large
atelectasis, fibrosis
or pleural
adhesions.
Palpate the thyroid gland: ● Landmarks deviate

● Landmarks are from midline or are
positioned midline. obscured because of
masses or abnormal
growths.
Eyes Palpate the lacrimal

Materials: apparatus:
● Cover card ● No drainage should ● Expressed drainage
● Gloves be noted from the from the puncta on
● Newspaper print or puncta when palpation occurs
Rosenbaum pocket palpating the with duct blockage.
screener nasolacrimal duct.
● Ophthalmoscope
● Penlight
● Snellen chart
Mouth Inspect and palpate the

Materials: tongue:
College of Nursing
● Penlight ● Tongue should be ● Dry; nodules, ulcers

● Tongue depressor pink,moist, a present; papillae or
moderate size with fissures absent;
papillae present. asymmetrical. Deep
longitudinal fissures
are seen in
dehydration; black
hairy tongue seen
with condition
causing
hyposalivation,
heavy smoking,
alcohol intake, use
of antibiotics that
inhibit normal
bacteria leading to
fungus, use of
mouthwashes.
Sinuses Palpate the sinuses:

Materials: ● Frontal and ● Frontal or maxillary
● 4 x 4-in gauze pad maxillary sinuses sinuses are tender
● Penlight are nontender to to palpation in
palpation, and no clients with allergies
crepitus is evident. or acute bacterial
rhinosinusitis. If the
client has a large
amount of exudate,
you may feel
crepitus on
palpation over the
maxillary sinuses.
This may also be
present with a viral
upper respiratory
infection.
Posterior Thorax Palpate for tenderness and

Materials: sensation: ● Muscle soreness
College of Nursing
● Client gown and ● Client reports no from exercise or the

draping sheet tenderness, pain, or excessive work of
● Gloves and mask unusual sensation. breathing (as in
● Metric ruler Temperature should COPD) may be
● Skin marking pen be equal bilaterally. palpated as
● Stethoscope tenderness.
Palpate for crepitus: ● Crepitus can be

● The examiner finds palpated if air
no palpable crepitus escapes from the
lung or other airway
into the
subcutaneous
tissues, as occurs
after an open
thoracic injury,
around a chest tube
or tracheostomy.
Palpate surface
characteristics: ● A physician or other
● Skin and appropriate
subcutaneous tissue professional should
are free of lesions evaluate any
and masses. unusual palpable
mass.
Palpate for fremitus: ● Unequal fremitus is

● Fremitus is usually the result of
symmetric and consolidation or
easily identified in bronchial
the upper regions of obstruction, air
the lungs. If trapping in
fremitus is not emphysema, pleural
palpable on either effusion or
College of Nursing
side, then the client pneumothorax.

may need to speak Diminished fremitus
louder. A decrease even with a loud
in the intensity of spoken may indicate
fremitus is normal an obstruction of
as the examiner the tracheobronchial
moves toward the tree.
base of the lungs.
Assess chest expansion: ● Unequal chest

● When the client expression can
takes a deep breath, occur with severe
the examiner’s atelectasis,
thumbs should pneumonia, chest
move 5-10 cm trauma, or
apart. pneumothorax.
Anterior Thorax Palpate for tenderness and

Materials: sensation: ● Muscle soreness
● Client gown and ● Client reports no from exercise or the
draping sheet tenderness, pain, or excessive work of
● Gloves and mask unusual sensation. breathing (as in
● Metric ruler Temperature should COPD) may be
● Skin marking pen be equal bilaterally. palpated as
● Stethoscope tenderness.
Palpate for crepitus:

● The examiner finds ● Crepitus can be
no palpable crepitus palpated if air
escapes from the
lung or other airway
into the
subcutaneous
tissues, as occurs
after an open
thoracic injury,
around a chest tube
or tracheostomy.
College of Nursing
Palpate surface
characteristics:
● Skin and ● A physician or other
subcutaneous tissue appropriate
are free of lesions professional should
and masses. evaluate any
unusual palpable
mass.
Palpate for fremitus:
● Fremitus is ● Unequal fremitus is
symmetric and usually the result of
easily identified in consolidation or
the upper regions of bronchial
the lungs. If obstruction, air
fremitus is not trapping in
palpable on either emphysema, pleural
side, then the client effusion or
may need to speak pneumothorax.
louder. A decrease Diminished fremitus
in the intensity of even with a loud
fremitus is normal spoken may indicate
as the examiner an obstruction of
moves toward the the tracheobronchial
base of the lungs. tree.
Assess chest expansion:

● When the client ● Unequal chest
takes a deep breath, expression can
the examiner’s occur with severe
thumbs should atelectasis,
move 5-10 cm pneumonia, chest
apart. trauma, or
pneumothorax.
Palpate for crepitus as you

would on the posterior
thorax: ● In areas of extreme
College of Nursing
● No crepitus is congestion or
palpated. consolidation,
crepitus may be
palpated,
particularly in clients
with lung disease.
Palpate for any surface

masses or lesions: ● Surface masses or
● No unusual surface lesions may indicate
masses or lesions cysts or tumors.
are palpated.
Palpate for fremitus: ● Diminished

● Fremitus is vibration, even with
symmetric and a loud spoken voice,
easily identifies the may indicate an
upper regions of the obstruction of the
lungs. A decreased tracheobronchial
intensity of fremitus tree.
is expected toward
the base of the
lungs.
Palpate anterior chest

expansion: ● Unequal chest
● Thumbs move expansion can occur
outward in a with severe
symmetric fashion atelectasis,
from the outline. pneumonia,chest
trauma, pleural
effusion or
pneumothorax.
College of Nursing
Breast and Lymphatic FEMALE BREAST FEMALE BREAST

system
Palpate texture and Palpate texture and
Materials: elasticity: elasticity:
● Client gown ● Palpation reveals ● Thickening of the
● Gloves for nurse smooth, firm, elastic tissue may occur
● Small pillow tissue. with an underlying
● Metric ruler malignant tumor.
● Breast self-
examination teaching Palpate for tenderness and Palpate for tenderness and
pamphlet temperature: temperature:
● Generalized increase ● Painful, tender

in modularity and breast that might
tenderness. the indicate fibro-cystic
breast should have breasts especially
a normal right before
temperature menstruation.
Palpate for masses:

Palpate for masses:
● Malignant masses or
● No masses that can tumors that are
be palpated but a found in the upper
firm inframammary outer quadrant of
transverse ridge the breast. The
could be palpated at masses are usually
the lower base of hard, immobile and
the breasts. fixed to surrounding
skin and soft tissues
with poorly defined
or irregular margins.
● There are
● Fibrocystic breast Fibroadenomas, milk
tissue feels ropy, cysts, lipomas, and
lumpy or bumpy in intraductal
texture referred to papilloma found.
as “nodular” or
College of Nursing
“glandular” breast
tissue. Palpate the nipples:
Palpate the nipples: ● Nipple discharge

may be bloody
● The nipple might (from papilloma in
erect and the areola the duct),greenish
may pucker in (from draining
response to breast cyst) or clear
stimulation. ( might be
associated with
● Milky discharge, cancer).
normal if pregnant.
Palpate mastectomy or Palpate mastectomy or

lumpectomy: lumpectomy:
● The scar is whitish ● Redness and

with no redness or inflammation of the
swelling. scar area that might
indicate infection.
● No lesions, lumps or
tenderness noted. ● Lesions, lumps or
tenderness might be
found and needs to
be evaluated.
Inspect and palpate the Inspect and palpate the

axillae: axillae:
● No rash or infection. ● Enlarged lymph

nodes greater than
● No palpable nodes, 1 cm.
discrete, nontender,
movable nodes in
the central area.
College of Nursing
MALE BREAST MALE BREAST

Inspect and palpate the Inspect and palpate the
breasts, areola, nipples breasts, areola, nipples
and axillae: and axillae:
● No swelling, nodules ● Soft, fatty

or ulceration enlargement of
detected. breast tissues.
● Gynecomastia,
smooth and firm
movable disc of
glandular tissue.
College of Nursing
Peripheral vascular Palpate the client;s fingers, Palpate the client;s fingers,
system hands, and arms and note hands, and arms and note
the temperature: the temperature:
Materials:
● Client gown ● The skin is warm to ● Cold fingers and
● Doppler ultrasound touch bilaterally hands
device and from fingertips to
conductivity gel upper arms.
● Flexible metric tape
measure Palpate to assess capillary Palpate to assess capillary
● Gauze or tissue refill time: refill time:
● Skin marking pen
● Sphygmomanometer ● Capillary beds refill, ● Capillary refill time
● Stethoscope the color returns in exceeding 2 seconds
● Tourniquet 2 seconds or less.
● Analog watch
Palpate the ulnar pulses: Palpate the ulnar pulses:
● Ulnar pulses may ● Obliteration of the

not be detectable pulse
● Lack of resilience or
inelasticity of the
artery wall
Palpate the epitrochlear Palpate the epitrochlear

lymph: lymph:
● Epitrochlear lymph ● Enlarged

nodes not palpable epitrochlear lymph
nodes
Palpate the brachial pulses
if you suspect arterial Palpate the brachial pulses
insufficiency: if you suspect arterial
insufficiency:
● Brachial pulses have
equal strength ● Brachial pulses are
bilaterally increased,
diminished or
absent
Palpate edema:
College of Nursing
Abdomen Perform light palpation: Perform light palpation
Materials: ● Abdomen is ● Involuntary reflex

● Client drape nontender and soft, guarding is serious
● Metric ruler no guarding and reflects
● Skin marking pen peritoneal irritation.
● Small pillows ● Abdomen is rigid
● stethoscope and rectus muscle
fails to relax with
palpation when
exhaling
Deeply palpate all

quadrants to delineate Deeply palpate all
abdominal organs and quadrants to delineate
detect subtle masses: abdominal organs and
detect subtle masses:
● Normal tenderness
over the xiphoid, ● Severe tenderness
aorta, cecum, or pain
sigmoid, colon and
ovaries
Palpate for masses:

Palpate for masses:
● No palpable masses
are present ● Mass is detected in
any quadrant
Palpate the umbilicus and
the surrounding area for Palpate the umbilicus and
swellings, bulges or the surrounding area for
masses: swellings, bulges or
masses:
● Free from swelling,
bulges, or masses ● A soft center of the
umbilicus, palpation
of a hard nodule in
or around the
umbilicus
College of Nursing
Palpate the aorta:

Palpate the aorta
● Approx. 2.5-3.0 cm
wide with a ● Wide bounding
moderately strong pulse with
and regular pulse abdominal aortic
aneurysm, pulsating
mass above the
umbilicus with an
abdominal aortic
aneurysm,
prominent laterally
pulsating mass
above the umbilicus.
Palpate the liver:
● Usually not Palpate the liver:

palpable, if felt it
should be firm, ● Hard firm liver,
smooth and even nodularity occurs
and mild with tumors, and
tenderness. metastatic cancer.
● The liver is more
than 1-3 cm below
the costal margin.
Palpate the spleen:
Palpate the spleen:
● The spleen is
seldom palpable at ● A palpable spleen,
the left costal the splenic notch
margin but rarely may be felt and
palpated that should splenic enlargement
be soft and may not always be
nontender. pathological.
● The spleen feels
softwitha rounded
edge.
College of Nursing
Palpate the kidneys: Palpate the kidneys:
● Usually not ● enlarged kidney is

palpable, if palpated visible.
it’s firm, smooth,
and rounded and
the kidney is not
slightly tender.
Palpate the urinary Palpate the urinary

bladder: bladder:
● Empty bladder is ● A distended bladder

neither palpable nor is palpated as
tender. smooth and round
and firm mass
extending as far as
the umbilicus.
Musculoskeletal Palpate the TMJ: Palpate the TMJ::
Materials: ● Snapping and ● Decreased ROM,

● Flexible metric tape clicking may be felt swelling, tenderness
measure and heard. or crepitus may be
● Goniometer seen.
Palpate shoulders and Palpate shoulders and

arms: arms:
● No redness, swelling ● Flat, hollow, or less

or deformity or rounded shoulders
heat. are seen. Muscle
atrophy is seen with
nerve or muscle
damage.
Palpate the anatomic

College of Nursing
Palpate the anatomic snuffbox on the back of

snuffbox on the back of the wrist at the base of the
the wrist at the base of the fully extended thumb:
fully extended thumb:
● Snuffbox tenderness
● No tenderness is felt.
palpated in
anatomic snuffbox.
Palpate ankles and feet for
tenderness, heat, swelling
Palpate ankles and feet for or nodules:
tenderness, heat, swelling
or nodules: ● Sprained ankles,
tender, painful,
● No pain, heat, reddened, hot and
swelling or nodules swollen
are noted. metatarsophalangea
l joint. Nodules of
the posterior ankle
may be palpated.
Male genitalia and Palpate the shaft:

rectum Palpate the shaft:
● Tenderness maybe
Materials: ● In a non-erect state felt.
● Gloves it’s soft, flaccid, and
● Water-soluble nontender.
lubricant Palpate for urethral
● Flashlight Palpate for urethral discharge:
● Specimen card discharge:
● A yellow, clear or
● Urinary meatus is white discharge.
free of discharge.
Palpate the scrotal
Palpate the scrotal contents:
contents:
● Absence of testis,
● Testes are ovoid, painless nodules,
approx. 3.5-5cm tenderness and
College of Nursing
long, 2.5 cm wide swelling.

and 2.5 deep and
equal bilaterally in
size and shape.
Smooth, firm,
rubbery, mobile and
pressure. Epididymis
is not tender,
smooth and softer.
Palpate for inguinal hernia
Palpate for inguinal hernia and inguinal nodes:
and inguinal nodes:
● A bulge or mass is
● Bulging or masses visible.
not normally
palpated.
Palpate the inguinal lymph
Palpate the inguinal lymph nodes:
nodes:
● Enlarged or tender
● No enlargement or lymph nodes are
tenderness. seen.
Palpate for femoral hernia:

Palpate for femoral hernia:
● Bulge or mass
● Bulges or masses palpated as the
are not palpated. client bears down or
cough.
Palpate the rectum:

Palpate the rectum:
● Hardness and
● The rectal mucosa is irregularity.
soft, smooth,
nontender and free
of nodules.
Palpate the peritoneal
Palpate the peritoneal cavity:
College of Nursing
cavity:
● A peritoneal
● Smooth and protrusion into the
nontender. rectum called rectal
shelf
College of Nursing
Female genitalia, anus Palpate bartholin glands: Palpate bartholin glands:

and rectum
● Soft, nontender and ● Swelling, pain, and
Materials: drainage free. discharge.
● Gloves (non sterile)
● Light Palpate the urethra: Palpate the urethra:
● Hand-held mirror
● Vaginal speculum ● No drainage from ● Drainage from the
● Water-soluble urethral meatus and urethra.
lubricant it’s soft and tender.
● Bifid spatula
● Endocervical brooms Palpate the vaginal wall: Palpate the vaginal wall:
● Large swabs
● Specimen container ● Smooth, and no ● Tenderness or
● Ph paper tenderness. lesions are visible.
● Feminin napkins
Palpate the cervix: Palpate the cervix:
● Firm and soft. ● Hard, immobile and

Rounded and can be painful.
moved side to side.
Palpate uterus: Palpate uterus:
● The fundus, the ● Enlarged uterus

large, upper end of above the level of
the uterus is round, the pubis.
firm and smooth.
Palpate the ovaries: Palpate the ovaries:
● Ovaries approx. the ● Enlarged size,

size of a walnut and masses, immobility
shaped like almond. and extreme
tenderness.
Palpate the anus: Palpate the anus:
● Clients’ sphincter ● Sphincter tightens.

relaxes, permitting
College of Nursing
Learner no. 4 and 5
Percussion
Anterior thorax Percuss for tone ● Hyperresonance is

Materials: ● Resonance is the elicited in cases of
● Client gown and percussion tone trapped air such as
draping sheet elicited over normal in emphysema or
● Gloves and mask lung tissue. pneumothorax.
● Metric ruler ● Percussion elicits Dullness may
● Skin marking pen dullness over breast characterize areas
● Stethoscope tissue, the heart and of increased density
(diaphragm) the liver. Tympany such as
is detected over the consolidation,
stomach, and pleural effusion or
flatness is detected tumor.
over the muscles
and bones.
Posterior thorax Percuss for tone

Materials: ● Resonance the ● Hyperresonance is
● Client gown and percussion tone elicited in cases of
draping sheet elicited over normal trapped air such as
● Gloves and mask lung tissue. in emphysema or
● Metric ruler pneumothorax.
● Skin marking pen Percuss for diaphragmatic
● Stethoscope excursion
(diaphragm) ● Excursion should be ● Dullness is present
equal bilaterally and when fluid or solid
measure 3-5 cm in tissue replaces air in
adults the lung or occupies
the pleural space
such as in lobar
pneumonia, pleural
effusion or tumor.
College of Nursing
Sinuses Percuss the sinuses

Materials: ● The sinuses are ● The frontal and
● 4 x 4-in gauze pad not tender on maxillary sinuses
● Penlight percussion. are tender upon
percussion in
clients with
allergies or sinus
infection.
Abdomen Percuss for tone.
Materials: ● Generalized ● Accentuated
● Client drape tympany tympany or
● Metric ruler predominates over hyperresonance is
● Skin marking pen the abdomen heard over a
● Small pillows because of air in the gaseous distended
● Stethoscope stomach and abdomen.
intestines. Dullness
is hear over the liver
and spleen
● Dullness may also ● An enlarged dullness

be elicited over a is heard over an
non-evacuated enlarged spleen or
descending colon. liver.
● Abnormal dullness is
heard over a
distended bladder,
large masses, or
ascites.
● If you suspect
ascites, perform the
shifting dullness and
fluid wave tests.
These special
techniques are
described later.
College of Nursing
Percuss the span or height

of the liver by determining
its lower and upper
borders. ● The upper border of
● The lower border of liver dullness may
liver dullness is be difficult to
located at the costal estimate if obscured
margin to 1-2 cm by pleural fluid of
below. lung consolidation.
● On deep inspiration, ● Hepatomegaly, a

the lower border of liver span that
liver dullness may exceeds normal
descend from 1 to 4 limits (enlarged), is
cm below the costal characteristic of liver
margin. tumors, cirrhosis,
abscess, and
vascular
engorgement.
● The upper border of ● Atrophy of the liver

liver dullness is is indicated by a
located between the decreased span.
left fifth and
seventh intercostal
spaces.
● A liver in a lower
● The normal liver position than normal
span at the MCL is may be caused by
6-12 cm (greater in emphysema,
men and taller whereas a liver in a
clients, less in higher position than
shorter clients). normal may be
caused by an
abdominal mass,
ascites, or a
paralyzed
diaphragm. A liver in
a lower or higher
College of Nursing
position should have

a normal span, but
an enlarged liver
may be higher,
lower, or both.
● An enlarged liver
● The normal liver may be roughly
span at the MSL is estimated (not
4-8 cm. accurately) when
more intense
sounds outline a
liver span or borders
outside the normal
range.
Percuss the spleen.

● The spleen is an ● Splenomegaly is
oval area of dullness characterized by an
approximately 7 cm area of dullness
wide near the left greater than 7 cm
tenth rib and slightly wide. The
posterior to the enlargement may
MAL. result from
traumatic injury,
portal hypertension,
and mononucleosis.
● On inspiration,
● Tympany (or dullness at the last
resonance) is heard left interspace at the
at the last left AAL suggests an
interspace. enlarged spleen.
Perform blunt percussion

on the liver and the
kidneys. ● Tenderness is
● No tenderness is elicited over the
College of Nursing
elicited. liver may be

associated with
inflammation or
infection
● No tenderness or ● Tenderness or sharp

pain is elicited or pain elicited over
reported by the the CVA suggests
client. The examiner kidney function
senses only a dull (pyelonephritis),
thud. renal calculi, or
hydronephrosis.
College of Nursing
Learner no. 6 and 7
Auscultation
Peripheral Vascular Auscultate the femoral

System pulses:
Materials: ● No sounds ● Bruits over one or
● Client Gown auscultated over both femoral
● Doppler Ultrasound the femoral arteries suggest
Device and arteries. partial obstruction of
Conductivity Gel the vessel and
● Flexible Metric Tape diminished blood
Measure flow to the lower
● Gauze or Tissue extremities.
● Skin Marking Pen
● Sphygmomanometer
● Stethoscope
● Tourniquet
● Watch with Second
Hand
Abdomen Auscultate for bowel

sound:
Materials: ● A series of ● “Hyperactive” bowel
● Client drape intermittent, soft sounds that are
● Metric ruler clicks and gurgles rushing, tinkling,
● Skin marking pen are heard at a rate and high pitched
● Small pillows of 5-30 per minute. may be abnormal
● Stethoscope Hyperactive bowel indicating very rapid
sounds referred to motility heard in
as “borborygmus” early bowel
may also be heard. obstruction,
These are loud gastroenteritis,
sounds, prolonged diarrhea, or with
gurgles use of laxatives.
characteristic of “Hypoactive” bowel
College of Nursing
one’s “stomach sounds indicate

growling.” diminished bowel
motility. Common
causes include
paralytic ileus
following abdominal
surgery,
inflammation of
peritoneum, or late
bowel obstruction.
May also occur in
pneumonia.
Auscultate for Vascular
Sounds:
● Bruits are not
normally heard ● A bruit with both
over abdominal systolic and Diastolic
aorta or renal, iliac, components occurs
or femoral arteries. when blood flow in
However, bruits an artery is
confined to systole turbulent or
may be normal in obstructed. This
some clients may indicate an
depending on other aneurysm or renal
differentiating arterial stenosis
factors. (RAS). When blood
flows through a
narrow vessel, it
makes a whooshing
sound, called a
bruit. However, the
absence of this
sound does not
Auscultate for a friction exclude the
rub over the liver and possibility of RAS.
spleen:
● No friction rub over
the liver or spleen ● Friction rubs are
is present. rare. If heard, they
College of Nursing
have a high pitched,

rough, grating
sound produced
when the large
surface area of the
liver or spleen rubs
the peritoneum.
They are heard in
association with
respiration.
● A friction rub heard
over the lower right
costal area is
associated with
hepatic abscess or
metastases.
● A rub heard at the
anterior axillary line
in the lower left
costal area is
associated with
splenic infarction,
abscess infection, or
tumor.
Posterior Thorax and For the lungs, the normal Abnormal breathing sounds
Lungs sounds for auscultation of for the lungs are:
Material: breathing sounds are:
● Stethoscope ● vesicular (low ● Wheezing which is a
pitch) which can be whistling sound
heard in a normal caused by the
lung narrowing of the
● broncho-vesicular lower airways.
(medium pitch) ● Grunting where it
that can be heard can mostly be heard
over mainstream from children due to
bronchi breathing a partially
● Bronchial or closed epiglottis
tracheal (high ● Stridor that is
College of Nursing
pitch) that can be basically a high-

heard normally in pitched sound
the trachea
Adventitious sound
auscultation:
Adventitious sound ● Adventitious sound
auscultation: is heard which
● Adventitious sound refers to as an
should not be additional sound to
heard for a normal the expected breath
finding sounds
● Rhonchi can
possibly be a sign of
bronchitis. This is a
low-pitched
wheezing sound
upon exhaling
● Wheezing can be
heard when
breathing in or out
● Crackles is an
abnormal sound
where a sound of
crumpled cellophane
can be heard
Auscultation for voice

sounds:
Auscultation for voice ● Bronchophony - the
sounds: words the patient
● Bronchophony - the uttered can be
patient is advised easily understood
to say “ninety-nine” and is loud
repeatedly and the therefore,
voice transmission bronchophony is
College of Nursing
of the patient present

should be soft ● Egophony - Instead
of hearing the vowel
● Egophony - the letter “E,” a louder
patient is advised sound appears with
to repeat the vowel the a letter “A”
“E” and the letter e sound in it
should be heard if
the lung tissue is
normal ● Whispered
pectoriloquy - the
● Whispered whispered sound is
pectoriloquy - the clearly heard and is
patient should distinct
whisper the words
“one-two-three”
and for normal
findings, only faint
sounds and
inaudible words
should be heard
Heart Identifying S1 and S2 Identifying S1 and S2

Material: sounds and extra heart sound and extra heart
● Stethoscope sounds: sounds:
● Both S1 and S2 can ● S4 heart sound
be heard for a should not be heard
S1 is the single sound “lub” normal finding.
and S2 is the closure of Sometimes, S3 can
semilunar valves in which also be normal but
“dub” sound is heard may be pathologic
S3 is sometimes normal Murmurs:

pathologically but is often a ● Murmurs should Murmurs:
sign of systolic heart failure not be heard for a ● Whooshing or
while S4 is an atrial gallop normal finding blowing sounds are
that is always abnormal ● Physiologic commonly heard in
midsystolic a heart murmur.
murmurs may be ● Murmur is an
College of Nursing
present at time for abnormal sound that

a healthy patient can be heard
between heartbeats
Auscultate in a different
position: Auscultate in a different
● Both S1 and S2 are position:
normally present ● S3 and S4 can be
present and the
sound of a heart
murmur
Neck Vessels Auscultate the carotid

arteries of the client is
Materials: middle-aged or older or if
● Client draping sheet you suspect
● Metric rulers (two) cardiovascular disease:
● Penlight ● Blowing or swishing ● A bruit, blowing or
● Small pillow or other sounds are swishing sound
● Stethoscope not heard. caused by turbulent
● Watch with second blood flow through
hand a narrowed vessel,
is indicative of
occlusive arterial
disease. However, if
the artery is more
than two-thirds
occluded, a bruit
may not be heard.
Auscultate HR and
rhythm: ● Bradycardia (less
● Rate should be 60- than 60 beats/min)
100 beats/min, or tachycardia
with regular (more than 100
rhythm. A regularly beats/min may
irregular rhythm, result in decreased
such as sinus CO. Refer clients
arrhythmia when with irregular
the HR increases rhythms (i.e.,
College of Nursing
with inspiration and premature atrial

decreases with contraction or
expiration, may be premature
normal in young ventricular
adults. contractions, atrial
fibrillation, atrial
flutter with varying
blocks) for further
evaluation. These
types of irregular
patterns may
predispose the client
to decreased CO,
heart failure, or
emboli.
REFERENCES:
Weber, J., & Kelley, J. (2017). Health Assessment in Nursing (6th ed.). Wolters Kluwer.

Cebu Doctors' University College of Nursing: Module 1F: Group Worksheet

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cebu Doctors' University College of Nursing: Module 1F: Group Worksheet

Uploaded by

Copyright:

Available Formats

Cebu Doctors’ University

NCM101: HEALTH ASSESSMENT

MODULE 1F: GROUP WORKSHEET

Leader: Fernandez, Philip Anthony F.

Submitted to: Dr. Armand K. Cuasito

2. A collated output is to be submitted by the leader of the group in the assignment

Body Part Normal Findings Abnormal Findings

Skin Inspect general skin

While inspecting skin

sclera and nail beds

Inspect the lesions

Scalp and Hair ● Natural hair color, ● Nutritional

growth. Dull, dry

Inspect amount and

● Patchy hair loss may

Nails Inspect nail grooming and ● Dirty, broken, or

occur after acute

Inspect shape of nails

Head Inspect the head

Inspect movement of the

Inspect the cervical ● Prominence or

External Eyes Structures Inspect the eyelids and

Inspect the bulbar

Inspect the palpebral

Inspect the cornea and a nasolacrimal sac

Inspect the retinal vessels

narrow as they major vessels

Inspect retinal background

Inspect the optic disc.

optic structures and

Neck Inspect the neck muscles

● Not visible on ● Visible diffuseness

Ears Inspect the auricle, tragus,

Inspect the external

Inspect the tympanic

serous otitis media.

Nose Inspect the external nose

● Inspect the nasal ● Septum deviated to

Mouth Inspect the outer lips for

Inspect the teeth and

the tongue upward

Inspect the base of the

Thorax and Lungs Inspect the shape and

Inspect the spinal

● Spine vertically ● Exaggerated spinal

Breasts and Axillae Inspect the breasts for

● Client gown size, symmetry, and

Inspect the skin of the

Heart and Central Inspect and palpate the

Inspect and palpate the

Inspect and palpate the

Abdomen Inspect the abdomen for

Inspect the abdomen for

Musculoskeletal System Inspect the muscles for

Inspect the muscles and

Inspect the muscles for

Female Genitals and Inspect the distribution,

Inspect the clitoris,

● Clitoris does not ● Presence of lesions

Male Genitals and Inspect the distribution,

Inspect the penile shaft

Inspect the urethral

swelling,inflammation, and ● Inflammation;