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NUR1202 – NCM101 HEALTH ASSESSMENT
ASSESSING HEAD TO NECK (Part 2)

(Week No. 10)
INTRODUCTION
This module includes basic assessment of the head, neck, eyes,

ear, nose, and mouth being used by nurses in general practice. This
also includes basic structure, structures, and landmarks necessary in
the conduct of physical assessment.
LEARNING OUTCOME
1. Demonstrate knowledge of anatomy and physiology of head to neck.
2. Apply the different assessment techniques in assessing head to neck to an
actual client.
3. Identify and document normal and deviation from normal findings from the
different assessment techniques in assessing head to neck.
OUTLINE
1. Structure and Function
2. Head and Face Assessment
3. Nose Assessment
4. Mouth Assessment
5. Activity / Assessment
6. References
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Far Eastern University
Manila, Philippines
CONTENT
Nose Assessment
Structure and Function
The nose and paranasal sinuses constitute the first part of the
respiratory system and are responsible for receiving, filtering, warming, and
moistening air to be transported to the lungs. Receptors of cranial nerve I
(olfactory) are also located in the nose. These receptors are related to the
sense of smell.
Structure of the nose
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(A) Paranasal sinuses, anterior view. (B) Paranasal sinuses, lateral view
Nose Assessment
ASSESSMENT NORMAL FINDINGS DEVIATION FROM

PROCEDURES NORMAL
Inspect and palpate Color is the same as Nasal tenderness on
the external nose. the rest of the face; the palpation accompanies
Note nasal color, nasal structure is a local infection.
shape, consistency, and smooth and symmetric;
tenderness. the client reports no
tenderness.
Check patency of air Client is able to sniff Client cannot sniff
flow through the through each nostril through a nostril that
nostrils by occluding while other is occluded. is not occluded, nor can
one nostril at a time he or she sniff or
and asking client to blow air through the
sniff. nostrils. This may be a
sign of swelling,
rhinitis, or a foreign
object
obstructing the nostrils.
A line across the tip
of the nose just above
the fleshy tip is
common
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Manila, Philippines
PROCEDURES NORMAL
in clients with chronic
allergies.
Inspect the internal The nasal mucosa is Nasal mucosa is
nose. dark pink, moist, and swollen and pale pink
To inspect the internal free of exudate. The or bluish gray in clients
nose, use an otoscope nasal septum is intact with allergies. Nasal
with a short wide-tip and free of ulcers or mucosa is red and
attachment or you can perforations. swollen with upper
also use a nasal Turbinates are dark respiratory
speculum and penlight pink (redder than oral infection. Exudate is
mucosa), common with infection
moist, and free of and may range from
lesions. large amounts of
watery discharge to
thick yellow-green,
purulent discharge.
Purulent nasal
discharge is seen with
acute bacterial
rhinosinusitis. Bleeding
(epistaxis) or crusting
may be noted on the
lower anterior part of
the nasal septum with
local irritation.
Sinuses
Palpate the sinuses. Frontal and maxillary Frontal or maxillary
When an infection sinuses are nontender sinuses are tender to
is suspected, the nurse to palpation, and no palpation in clients with
can examine the crepitus is evident. allergies or acute
sinuses through bacterial rhinosinusitis.
palpation, percussion, If the client has a large
and amount of exudate, you
transillumination. may feel crepitus upon
Palpate the frontal palpation over the
sinuses by using your maxillary sinuses.
thumbs to press up on
the brow on each side
of nose
Percuss the sinuses. The sinuses are not The frontal and
tender on percussion maxillary sinuses are
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Manila, Philippines
PROCEDURES NORMAL
Lightly tap (percuss) tender upon percussion
over the frontal sinuses in clients with allergies
and over the maxillary or sinus infection.
sinuses for tenderness.
Palpating the frontal sinuses
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Palpating the maxillary sinuses
Mouth Assessment
The mouth and throat make up the first part of the digestive system and
are responsible for receiving food (ingestion), taste, preparing food for
digestion, and aiding in speech.
Cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and XII
(hypoglossal) assist with some of these functions.
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Manila, Philippines
Structures of the mouth
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Salivary glands
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Mouth Assessment

PROCEDURES NORMAL
Inspect the lips. Lips are smooth and Pallor around the lips
Observe lip consistency moist without lesions or (circumoral pallor) is
and color. swelling. seen in anemia and
shock. Bluish (cyanotic)
lips may result from
cold or hypoxia.
Reddish lips are seen in
clients with
ketoacidosis, carbon
monoxide poisoning,
and chronic obstructive
pulmonary disease
(COPD) with
polycythemia. Swelling
of the lips (edema) is
common in local or
systemic allergic or
anaphylactic reactions.
Inspect the teeth Thirty-two pearly Clients who smoke,

and gums. whitish teeth with drink large quantities
Ask the client to open smooth of coffee or tea, or
the mouth. Note the surfaces and edges. have an excessive
number Upper molars should intake
of teeth, color, and rest of fluoride may have
condition. Note any directly on the lower yellow or brownish
repairs such as crowns molars and the front teeth. Tooth decay
and any cosmetics such upper incisors should (caries) may appear as
as veneers. Ask the slightly override the brown dots or cover
client to bite down lower incisors. Some more extensive areas
as though chewing on clients normally have of
something and note the only 28 teeth if the four chewing surfaces.
alignment of the lower wisdom teeth do Missing teeth can affect
and upper jaws. not erupt. chewing as well as self-
image.
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Manila, Philippines
PROCEDURES NORMAL
Put on gloves and No decayed areas; no Receding gums are
retract the client’s lips missing teeth. abnormal in younger
and cheeks to check Client may have clients; in older clients,
gums for color and appliances on the teeth the teeth may appear
consistency. (e.g., braces). Client longer because of age-
may have evidence of related gingival
repair work done on recession, which is
teeth (e.g., fillings, common.
crowns, or cosmetics Red, swollen gums that
such as veneers). bleed easily are seen in
Gums are pink, moist, gingivitis, scurvy
and firm with tight (vitamin C deficiency),
margins to the tooth. and leukemia
No lesions or masses.
Inspect the buccal The buccal mucosa Leukoplakia may be

mucosa. should appear pink in seen in chronic
Use a penlight and light-skinned clients; irritation
tongue depressor to tissue pigmentation and smoking.
retract the lips and typically increases in
cheeks to check color dark skinned clients.
and consistency.
Inspect and palpate Tongue should be pink, Among possible

the tongue. moist, a moderate abnormalities are deep
Ask client to stick out size with papillae (little longitudinal fissures
the tongue. protuberances) seen in dehydration; a
Inspect for color, present. black tongue indicative
moisture, size, and A common variation is of bismuth (Pepto-
texture. a fissured, topographic- Bismol) toxicity: black,
Observe for map–like tongue, which hairy tongue
fasciculations (fine is not unusual in older
tremors), and check for clients.
midline protrusion. No lesions are present.
Palpate any lesions
present for induration
(hardness).
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Manila, Philippines
PROCEDURES NORMAL
Assess the ventral The tongue’s ventral Leukoplakia, persistent
surface of the surface is smooth, lesions, ulcers, or
tongue. shiny, nodules may indicate
Ask the client to touch pink, or slightly pale, cancer and should be
the tongue to the roof with visible veins and referred. Induration
of mouth, and use a no lesions. increases the likelihood
penlight to inspect the of cancer.
ventral surface of the
tongue, frenulum,
and area under the
tongue
Palpate the area if you The older client may The area underneath
see lesions, if the client have varicose veins on the tongue
is over age 50, or if the the ventral surface of is the most common
client uses tobacco or the tongue site of oral cancer
alcohol.
Note any induration.
Check also for a short
frenulum that limits
tongue motion (the
origin of “tongue-tied”).
Inspect for The frenulum is Abnormal findings
Wharton’s ducts - midline; Wharton’s include lesions, ulcers,
openings from the ducts are nodules, or
submandibular salivary visible, with salivary hypertrophied duct
glands - located on flow or moistness in the openings on either side
either side of the area. The client has no of frenulum.
frenulum on the floor of swelling, redness, or
the mouth. pain.
Observe the sides of No lesions, ulcers, or Canker sores may be
the tongue. nodules are apparent. seen on the sides of the
Use a square gauze pad tongue in clients
to hold the client’s receiving certain kinds
tongue of chemotherapy.
to each side. Palpate Leukoplakia, persistent
any lesions, ulcers, or lesions, ulcers, or
nodules for induration. nodules may indicate
cancer and should be
further evaluated
medically. Induration
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PROCEDURES NORMAL
increases the likelihood
of cancer
Check the strength The tongue offers Decreased tongue
of the tongue. strong resistance strength may occur
Place your fingers on with a defect of the
the external surface of twelfth cranial nerve—
the client’s cheek. Ask hypoglossal—or with a
the client to press the shortened frenulum
tongue’s tip against the that limits motion.
inside of the cheek to
resist pressure from
your fingers. Repeat
on the opposite cheek.
Inspect the hard The hard palate is pale A candidal infection
(anterior) and soft or whitish with firm, may appear as thick
(posterior) palates transverse rugae white plaques on the
and uvula. (wrinkle-like folds). hard palate. Deep
Ask the client to open Palatine tissues are purple, raised, or flat
the mouth wide while intact; the soft palate lesions may indicate a
you use a penlight to should be pinkish, Kaposi’s sarcoma (seen
look at the roof. movable, spongy, and in clients with AIDS)
Observe color and smooth A yellow tint to the
integrity. hard palate may
indicate
jaundice because
bilirubin adheres to
elastic tissue
(collagen). An opening
in the hard palate is
known as a cleft palate.
Note odor. No unusual or foul odor Fruity or acetone
While the mouth is is noted breath is associated
wide open, note any with diabetic
unusual or foul odor. ketoacidosis. An
ammonia odor is often
associated with kidney
disease. Foul odors
may indicate an oral or
respiratory infection, or
tooth decay. Alcohol or
tobacco use may be
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Manila, Philippines
PROCEDURES NORMAL
identified by breath
odor. Fecal breath odor
occurs in bowel
obstruction; sulfur odor
(fetor hepaticus) occurs
in end stage liver
disease.
Assess the uvula. The uvula is a fleshy, Asymmetric movement
Apply a tongue solid structure that or loss of movement
depressor hangs freely in the may occur after a
to the tongue (halfway midline. No redness of cerebrovascular
between the tip and or exudate from uvula accident (stroke).
back of the tongue) or soft palate. Midline Palate fails to rise and
and shine a penlight elevation of uvula and uvula deviates
into the client’s wide- symmetric elevation of to normal side with
open mouth. Note the the soft palate. cranial nerve X (vagus)
characteristics and A bifid uvula, common paralysis.
positioning of the in Native Americans,
uvula. Ask the client to looks like it is split in
say “aaah” and watch two or partially severed
for the uvula and soft
palate to move.
Inspect the tonsils. Tonsils may be present Tonsils are red,
Using the tongue or absent. They are enlarged (to 2+, 3+, or
depressor to keep the normally pink and 4+),
mouth open wide, symmetric and may be and covered with
inspect the tonsils for enlarged to 1+ in exudate in tonsillitis.
color, size, and healthy clients . No They also may be
presence exudate, swelling, or indurated with patches
of exudate or lesions. lesions should be of white or yellow
Grade the tonsils. present. exudate
Inspect the posterior Throat is normally pink, A bright red throat with
pharyngeal wall. without exudate or white or yellow exudate
Keeping the tongue lesions indicates pharyngitis.
depressor in place, Yellowish mucus on
shine the penlight on throat may be seen,
the back of the throat. with postnasal sinus
Observe the color of drainage.
the throat, and note
any
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PROCEDURES NORMAL
exudate or lesions.
Before inspecting the
nose, discard gloves
and perform hand
hygiene.
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Inspecting the buccal mucosa
Inspecting the tongue. (A) Inspecting the ventral surface of the tongue (B)
Inspecting the dorsal surface of the tongue
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Palpating area under the tongue
Inspecting the uvula
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In a client who has both tonsils and a sore throat, tonsillitis can be identified
and ranked with a grading scale from 1 to 4 as follows:
1+ Tonsils are visible.
2+ Tonsils are midway between tonsillar pillars and
uvula.
3+ Tonsils touch the uvula.
4+ Tonsils touch each other.
REFERENCES:
Weber, J. R., RN, EdD, & Kelly, J. H., RN, PhD. (2018). Health Assessment in
Nursing (6th ed.).
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier &Erb’s Fundamentals
of Nursing: Concepts, Process & Practice (10th ed.).
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Manila, Philippines
Assessing
Head to Neck
Head and neck assessment focuses on the

cranium, face, thyroid gland, and lymph
nodes contained within the head and neck
and the sensory organs (eyes, ears, nose,
and mouth)
The skull. (A) Anterior view. (B) Left lateral view
Structures of the neck
Neck muscles
and landmarks
Cervical vertebrae
Lymph nodes in the neck (left). Direction of lymph flow (right). Note: Lymph
nodes (green dots) that are covered by hair may be palpated in the scalp
under the hair.
Head and Face
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the head. Head size and shape An abnormally small
Inspect for size, vary, especially in head is called
shape, and accord with ethnicity. microcephaly.
configuration Usually the head is The skull and facial
symmetric, round, bones are larger and
erect, and in midline thicker in acromegaly.
and Acorn-shaped,
appropriately related enlarged skull bones
to body size are seen in Paget’s
(normocephalic). disease of the bone.
No lesions are visible.
Inspecting the head
microcephaly
Acorn-shaped skull bones
Head and Face
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for involuntary Head should be held Neurologic disorders
movement. still and upright may cause a horizontal
jerking movement.
An involuntary nodding
movement may be
seen in patients with
aortic insufficiency.
Head tilted to one side
may indicate unilateral
vision or hearing
deficiency or
shortening of the
sternomastoid muscle.
Head and Face
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the face. The face is symmetric Asymmetry, drooping,
Inspect for symmetry, with a round, oval, weakness, or paralysis
features, movement, elongated, or square on one side of the face
expression, and skin appearance. No
abnormal movements
condition
noted.
Head and Face
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the head. The head is normally Lesions or lumps on
Note consistency hard and smooth, the head may
without lesions. indicate
recent trauma or a
sign of cancer.
Head and Face
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the The temporal artery is The temporal artery is
temporal artery, elastic and not tender hard, thick, and tender
which is located with inflammation, as
between the top of seen with temporal
arteritis (inflammation
the ear and the eye
of the temporal
arteries that may lead
to blindness).
Palpating the temporal artery
Head and Face
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the Normally there is no Limited range of
temporomandibular swelling, tenderness, motion, swelling,
joint (TMJ). or crepitation with tenderness, or
To assess the TMJ, movement. Mouth crepitation may
opens and closes fully indicate TMJ
place your index
(3 to 6 cm between syndrome.
finger over the front
upper and lower
of each ear as you teeth). Lower jaw
ask the client to open moves laterally
the mouth 1 to 2 cm in each
direction.
Palpating the temporomandibular joint (TMJ)
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the neck. Neck is symmetric, Swelling, enlarged
Observe the client’s with head centered masses or nodules—
slightly extended and without bulging may indicate an
neck for position, masses. enlarged thyroid gland
inflammation of lymph
symmetry, and lumps
nodes, or a tumor.
or masses. Shine a
light from the side of
the neck across to
highlight any
swelling.
Diffuse enlargement of the thyroid gland
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect movement The thyroid cartilage, Asymmetric movement
of the neck cricoid cartilage move or generalized
structures. upward symmetrically enlargement of the
Ask the client to as the client swallows. thyroid gland is
considered abnormal.
swallow a small sip
of water. Observe the
movement of the
thyroid cartilage,
thyroid gland
Neck structures move. (A) Structures rising. (B) Structures falling.
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the cervical C7 (vertebrae Prominence or
vertebrae. prominens) is usually swellings other than
Ask the client to flex visible and palpable. the C7 vertebrae may
the neck (chin to be abnormal.
chest).
Cervical vertebrae
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect range of Normally neck Muscle spasms,
motion. movement should be inflammation, or
Ask the client to turn smooth and controlled cervical arthritis may
the head to the right with 45-degree flexion, cause stiffness, rigidity,
55-degree extension, and limited mobility of
and to the left
40-degree lateral the neck, which may
(chin to shoulder),
abduction, and 70- affect daily
touch each ear to the degree rotation. functioning.
shoulder, touch chin
to chest, and lift the
chin to the ceiling.
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the trachea. Trachea is midline. The trachea may be
Place your finger in pulled to the affected
the sternal notch. side in cases of large
Feel each side of the atelectasis, fibrosis
or pleural adhesions.
notch and palpate
The trachea is pushed
the tracheal rings.
to the unaffected side
The first upper ring in cases of a tumor,
above the smooth enlarged thyroid lobe,
tracheal rings is the pneumothorax, or
cricoid cartilage. with an aortic
aneurysm.
Palpating the trachea
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the thyroid Landmarks are Landmarks deviate
gland. positioned midline. from midline or are
Locate key obscured because of
landmarks with your masses or abnormal
growths.
index finger and
thumb
Palpating the thyroid gland using posterior approach
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Ask the client to Glandular thyroid Coarse tissue or
swallow as you tissue may be felt irregular consistency
palpate the right side rising underneath your may indicate an
of the gland. Reverse fingers. Lobes should inflammatory process.
feel smooth, rubbery, Nodules should be
the technique to
and free of nodules. described in terms of
palpate the left lobe
location, size, and
of the thyroid. consistency.
Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate the No bruits are A soft, blowing,
thyroid only if you auscultated. swishing sound
find an enlarged auscultated over the
thyroid gland during thyroid lobes is often
heard in
inspection or
hyperthyroidism
palpation. Place the
because of an increase
bell of the in blood flow through
stethoscope over the the thyroid arteries.
lateral lobes of the
thyroid gland. Ask
the client to hold his
or her breath.
Auscultating for bruits over the thyroid gland
Lymph Nodes of the Head and Neck
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the lymph There is no swelling or Head and neck cancer
nodes. enlargement and no includes cancers of
tenderness. the mouth, nose,
sinuses, salivary
glands, throat, and
lymph nodes in the
neck.
Enlarged nodes are
abnormal.
Palpating the tonsillar nodes and the submandibular nodes
Palpating the supraclavicular nodes
The eye transmits visual stimuli to the brain for

interpretation and, in doing so, functions as the
organ of vision.
The eyeball is located in the eye orbit, a round, bony
hollow formed by several different bones of the skull.
In the orbit, a cushion of fat surrounds the eye.
The bony orbit and fat cushion protect the eyeball.
External structures of the eye
The lacrimal apparatus consists of tear (lacrimal)
glands and ducts
Extraocular muscles control the direction of eye
movement
Anatomy of the eye
Evaluating Vision
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Test distant visual Normal distant visual Myopia (impaired far
acuity. acuity is 20/20 with or vision) is present when
without corrective the second number in
Position the client 20 the test result is larger
feet from the Snellen lenses. This means that
than the first (20/40).
the client can
or E-chart and ask The higher the second
distinguish what the number, the poorer the
her to read each line
person with normal vision. A client is
until she cannot vision can distinguish considered legally blind
decipher the letters from 20 feet away. when vision in the better
or their direction. eye with corrective
Document the lenses is 20/200 or less.
results. Refer any client with
vision worse than 20/30
for further evaluation.
Evaluating Vision
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Test near visual Normal near visual Presbyopia (impaired
acuity. acuity is 14/14 (with or near vision) is
Use this test for without corrective indicated when the
middle-aged clients and others
lenses). This means client moves the chart
who complain of difficulty
reading. that the client can read away from the eyes to
Give the client a hand-held what the normal eye focus on the print. It is
vision chart (e.g.,
Jaeger reading card, Snellen
can read from a caused by decreased
card, or comparable distance of 14 inches. accommodation.
chart) to hold 14 inches from
the eyes. Have the client cover
one eye with an opaque card
before reading from top (largest
print) to bottom (smallest
print). Repeat test
for other eye
Evaluating Vision
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Test visual fields for With normal peripheral A delayed or absent
gross peripheral vision, the client should perception of the
see the examiner’s finger examiner’s finger
vision. at the same time the
To perform the confrontation test, indicates reduced
position yourself approximately 2 examiner sees it. Normal
feet away from the client at eye
peripheral
visual field degrees are
level. Have the client cover the left
approximately as follows:
vision.
eye while you cover your right eye.
Look directly at each other with your • Inferior: 70 degrees Refer the client for
uncovered eyes. Next, fully extend
• Superior: 50 degrees further evaluation.
your left arm at midline and slowly
move one finger (or a pencil) upward • Temporal: 90 degrees
from below until the client sees your
finger (or pencil). Test the remaining
• Nasal: 60 degrees
three visual fields of the client’s right
eye (i.e., superior, temporal, and
nasal). Repeat the test for
the opposite eye.
Performing confrontation test to assess visual fields
Evaluating Vision
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform corneal The reflection of light on Asymmetric position of
light reflex test. the corneas should the light reflex
This test assesses parallel be in the exact same spot indicates deviated
alignment of the eyes. on each eye, which alignment of the eyes.
Hold a penlight indicates parallel
This may be due to
approximately 12 inches alignment. muscle weakness or
from the client’s face. paralysis
Shine the light toward
the bridge of the nose
while the client stares
straight ahead. Note the
light reflected on the
corneas.
Evaluating Vision
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform cover test. The uncovered eye The uncovered eye will
The cover test detects deviation should remain fixed move to establish
in alignment or strength and straight ahead. The
slight deviations in eye
focus when the
covered eye should opposite eye is
movement by interrupting
the fusion reflex that normally remain fixed straight
covered.
keeps the eyes parallel. ahead after being
Ask the client to stare straight uncovered.
When the covered eye
ahead and focus on a distant is uncovered,
object. Cover one of the
movement to
client’s eyes with an opaque
card. reestablish focus
As you cover the eye, observe occurs. Either of these
the uncovered eye for
movement. Now remove the
findings indicates a
opaque card and observe the deviation in alignment
previously covered eye for any of the eyes and muscle
movement. Repeat test on the
opposite eye. weakness
Performing cover test with (A) eye covered and (B) eye uncovered
Evaluating Vision
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform the Eye movement should be Failure of eyes to follow
smooth and symmetric movement symmetrically
positions test,
throughout all six in any or all directions
which assesses eye muscle
directions. indicates a weakness in
strength and cranial nerve
function. one or more extraocular
Instruct the client to focus muscles or dysfunction of
on an object you are holding the cranial nerve that
(approximately 12 inches innervates the particular
from the client’s face). Move muscle.
the object through Nystagmus—an oscillating
the six cardinal positions of (shaking) movement of the
gaze in a clockwise eye—may be associated
direction, and observe the with an inner ear disorder,
client’s eye movements multiple sclerosis, brain
lesions, or narcotics use.
Performing positions test
External Eye Structures
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the eyelids The upper lid margin Drooping of the upper
and eyelashes. should be between lid, called ptosis, may
the upper margin of the be attributed to
Note width and iris and the upper margin
position of palpebral oculomotor nerve
of the pupil. The lower lid
damage, myasthenia
fissures. margin rests on the lower
border of the iris. No
gravis, weakened
white sclera is seen muscle or tissue, or a
above or below the iris. congenital disorder.
Palpebral fissures may be Retracted lid margins,
horizontal. which allow for
viewing of the sclera
when the eyes are
open, suggest
hyperthyroidism.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess ability of The upper and lower lids Failure of lids to close
eyelids to close. close easily and meet completely puts client
completely when closed. at risk for corneal
damage.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Note the position of The lower eyelid is An inverted lower lid is a
the eyelids in upright with no inward condition called an
or outward turning. entropion, which may
comparison cause pain and injure
with the eyeballs. Eyelashes are evenly
the cornea as the eyelash
distributed and curve
Also note any brushes against the
outward along the lid conjunctiva and cornea.
unusual
margins. Ectropion, an everted
• Turnings
lower eyelid, results in
• Color exposure and drying of
• Swelling the conjunctiva. Both
• Lesions conditions interfere with
• Discharge normal tear drainage.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe for redness, Skin on both eyelids is Redness and crusting along
the lid margins suggest
swelling, discharge, without redness, seborrhea or blepharitis, an
swelling, or lesions.
or lesions. infection caused by
Staphylococcus aureus.
Hordeolum (stye), a hair
follicle infection,
causes local redness,
swelling, and pain. A
chalazion, an infection of
the meibomian
gland (located in the eyelid),
may produce extreme
swelling of the lid, moderate
redness, but minimal pain
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe the position Eyeballs are Protrusion of the
and alignment of symmetrically eyeballs accompanied
the eyeball in the aligned in sockets by retracted eyelid
eye socket. without protruding margins is termed
exophthalmos and is
or sinking.
characteristic of Graves’
disease (a type of
hyperthyroidism). A
sunken appearance
of the eyes may be seen
with severe
dehydration or chronic
wasting illnesses.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the bulbar Bulbar conjunctiva is Generalized redness of
conjunctiva and clear, moist, and smooth. the conjunctiva suggests
Underlying structures are conjunctivitis (pink eye).
sclera. clearly visible. Sclera is Areas of dryness are
Have the client keep white. associated with allergies
the head straight or trauma.
while looking from Episcleritis is a local,
side to side then up noninfectious
inflammation
toward the ceiling. of the sclera. The
Observe clarity, color, condition is usually
and texture. characterized by either a
nodular appearance
or by redness with
dilated vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the The lower and upper Cyanosis of the lower lid
palpebral palpebral conjunctivae suggests a heart or
are clear and free of lung disorder.
conjunctiva. swelling or lesions.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Evert the upper eyelid. Palpebral conjunctiva is A foreign body or lesion
Ask the client to look free of swelling, foreign may cause irritation,
down with his or her eyes bodies, or trauma. burning, pain and/or
slightly open. swelling of the upper
Gently grasp the client’s eyelid.
upper eyelashes and pull
the lid downward.
Place a cotton-tipped
applicator approximately
1 cm above the eyelid
margin and push down
with the applicator while
still holding the eyelashes
Inspecting the bulbar conjunctiva. Inspecting palpebral conjunctiva: lower eyelid
Everting the upper eyelid
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the lacrimal No swelling or redness Swelling of the lacrimal
apparatus. should appear over gland may be visible
areas of the lacrimal in the lateral aspect of
Assess the areas over gland. The puncta is the upper eyelid. This
the lacrimal glands visible without swelling may be caused by
(lateral aspect of or redness and is blockage, infection, or an
upper eyelid) and the turned slightly toward inflammatory condition.
puncta (medial the eye. Redness or swelling
around the puncta may
aspect of lower indicate an infectious or
eyelid). inflammatory condition.
Excessive tearing may
indicate a nasolacrimal
sac obstruction.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the lacrimal No drainage should be Expressed drainage from
apparatus. noted from the puncta the puncta on palpation
when palpating the occurs with duct
Put on disposable nasolacrimal duct. blockage.
gloves to palpate the
nasolacrimal duct to
assess for blockage.
Use one finger and
palpate just inside
the lower orbital rim
Palpating the lacrimal apparatus
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the cornea The cornea is Areas of roughness
and lens. transparent, with no or dryness on the
Shine a light opacities. cornea
from the side of the The oblique view are often associated
eye for an oblique shows a smooth and with injury or allergic
view. overall responses. Opacities
Look through the moist surface; the of the lens are seen
pupil to inspect the lens is free of with cataracts
lens. opacities.
Abnormalities of the Cornea and Lens
Abnormalities of the External Eye
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the iris and The iris is typically round, Typical abnormal
pupil. flat, and evenly colored. findings include
The pupil, round with a
Inspect shape and regular border, is centered
irregularly shaped
color of iris and size in the iris. Pupils are irises, miosis,
and shape of pupil. normally mydriasis, and
Measure pupils equal in size (3 to 5 mm). anisocoria.
against a gauge if An inequality in If the difference in
pupil size of less than 0.5
they appear larger mm occurs in 20%
pupil size changes
or smaller than of clients. This condition, throughout pupillary
normal called anisocoria, response tests, the
or if they appear to is normal. inequality of size is
be two different abnormal.
sizes.
Pupillary gauge for measuring pupil size
(dilation or constriction) in millimeters (mm)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Test pupillary The normal direct Monocular blindness
reaction to light. pupillary response is can be detected when
Test for direct response by constriction. light directed to the
darkening the room and blind eye results in no
asking the client to focus on response in either
a distant object. To test
direct pupil reaction, shine a pupil. When light is
light obliquely into one eye directed into the
and observe the pupillary unaffected eye, both
reaction. Shining the light pupils constrict.
obliquely into the pupil and
asking the client to focus on
an object in the distance
ensures that pupillary
constriction is a reaction
to light and not a near
reaction.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess consensual The normal consensual Pupils do not react at
response at the pupillary response is all to direct and
same time as direct constriction. consensual
response by shining a pupillary testing.
light obliquely into
one eye and
observing the
pupillary reaction in
the opposite eye.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Test accommodation The normal pupillary Pupils do not constrict;
of pupils. response is constriction eyes do not converge.
Accommodation occurs of the pupils and
when the client moves his convergence of the eyes
or her focus of vision from a when focusing on a near
distant point to a near object (accommodation
object, causing the pupils to and convergence).
constrict.
Hold your finger or a pencil
about 12 to 15 inches from
the client. Ask the client to
focus on your finger or
pencil and to remain
focused on it as you move it
closer in toward the eyes
Testing accommodation of pupils
The ear is the sense organ of hearing and
equilibrium.
It consists of three distinct parts: the external ear,
the middle ear, and the inner ear.
The tympanic membrane separates the external ear
from the middle ear.
Both the external ear and the tympanic membrane
can be assessed by direct inspection and by using an
otoscope.
The middle and inner ear cannot be directly
inspected. Instead, testing hearing acuity and the
conduction of sound assesses these parts of the ear.
The Ear
Structures in the outer, middle, and inner divisions
Pathways of hearing
External Ear Structures
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the auricle, Ears are equal in size Ears are smaller than 4
tragus, and lobule. bilaterally (normally 4–10 cm or larger than
cm). 10 cm.
Note size, shape, and The auricle aligns with Malaligned or low-set
position the corner of each eye ears may be seen with
and within a 10-degree genitourinary disorders
angle of the vertical or chromosomal
position. defects.
Earlobes may be free,
attached, or soldered
(tightly attached to
adjacent skin with no
apparent
lobe).
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Continue inspecting The skin is smooth, with Some abnormal findings
suggest various
the auricle, tragus, no lesions, lumps, or
disorders, including:
nodules. Color is • Enlarged preauricular and
and lobule. consistent with facial postauricular lymph nodes—
Observe for lesions, color. infection
discolorations, • Tophi (nontender, hard,
Darwin’s tubercle, which
cream-colored nodules on the
and discharge. is a clinically insignificant helix or antihelix, containing
projection, may be seen uric acid crystals)—gout
on the auricle. • Blocked sebaceous glands—
postauricular cysts
No discharge should be
• Ulcerated, crusted nodules
present. that bleed— skin cancer (most
often seen on the helix
due to skin exposure)
• Redness, swelling, scaling, or
itching—otitis externa
• Pale blue ear color—frostbite
Darwin’s tubercle
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the auricle Normally the auricle, A painful auricle or
and mastoid tragus, and mastoid tragus is associated
process. process are not with otitis externa or
tender. a postauricular cyst.
Tenderness over the
mastoid process
suggests mastoiditis.
Tenderness behind
the ear may occur
with otitis media.
Internal Ear
DEVIATION FROM
NORMAL FINDINGS
NORMAL
A small amount of Abnormal findings associated with
Inspect the external specific
auditory canal. odorless cerumen disorders include:
(earwax) is the only • Foul-smelling, sticky, yellow
Use the otoscope. discharge normally
discharge—otitis externa or
impacted foreign body
Note any discharge present. Cerumen • Bloody, purulent discharge—otitis
along with the color may be yellow, media with ruptured tympanic
membrane
color and orange, red, brown, gray, • Blood or watery drainage
or black. Consistency may (cerebrospinal fluid)—skull trauma
consistency of (refer client to physician
be soft, moist, dry, flaky, immediately)
cerumen or even hard. • Impacted cerumen blocking the
(earwax). view of the external ear canal—
conductive hearing loss
• Refer any client with presence of
foreign bodies such as bugs, plants,
or food to the health care
practitioner for prompt removal due
to possible swelling and infection.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe the color The canal walls should Abnormal findings in the
and consistency of be pink and smooth, ear canal may
without nodules. include:
the ear canal walls • Reddened, swollen
and inspect the canals—otitis externa
character of any • Exostoses
nodules. (nonmalignant nodular
swellings)
• Polyps may block the
view of the eardrum
Abnormalities of the External
Ear and Ear Canal
DEVIATION FROM
NORMAL FINDINGS
NORMAL
The tympanic membrane Abnormal findings in the tympanic
Inspect the membrane
tympanic membrane should be pearly, gray, may include:
shiny, and translucent, • Red, bulging eardrum and
(eardrum). with no bulging or
distorted, diminished, or absent
light reflex—acute otitis media
Note color, shape, retraction. • Yellowish, bulging membrane with
consistency, It is slightly concave, bubbles behind—serous otitis media
• Bluish or dark red color—blood
and landmarks. smooth, and intact. A behind the eardrum from skull
cone-shaped reflection of trauma
• White spots—scarring from
the otoscope light is infection
normally seen at 5 • Perforations—trauma from
infection
o’clock in the right ear • Prominent landmarks—eardrum
and 7 o’clock in the left retraction from negative ear
pressure resulting from an
ear. The short process obstructed eustachian tube
and handle of the • Obscured or absent landmarks—
malleus and the umbo eardrum thickening from chronic
otitis media
are clearly visible
Abnormalities of the Tympanic Membrane
Hearing and Equilibrium Tests
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform the whisper Able to correctly Unable to repeat the
test repeat the two-syllable two-syllable word after
With your head 2 feet word as two tries indicates
behind the client (so that whispered. hearing loss and
the client cannot see your requires
lips move), whisper a two-
syllable word such as follow-up testing by an
“popcorn” or “football.” Ask audiologist.
the client to repeat it back
to you. If the response is
incorrect the first time,
whisper the word one more
time. Identifying three out
of six whispered words is
considered passing the test.
Hearing and Equilibrium Tests
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform Weber’s Vibrations are heard With conductive hearing loss,
the client reports lateralization
test if the client equally well in both ears.
of sound to the poor
No lateralization of sound ear—that is, the client “hears”
reports diminished to either ear. the sounds in the poor ear. The
or lost hearing good ear is distracted by
in one ear background noise and
conducted air, which the poor
ear has trouble hearing. Thus
the poor ear receives most of
the sound conducted by bone
vibration.
With sensorineural hearing
loss, the client reports
lateralization of sound to the
good ear. This is because of
limited perception of the sound
due to nerve damage in the bad
ear, making sound seem louder
in the unaffected ear.
The Weber test
The test helps to evaluate the
conduction of sound waves
through bone to help distinguish
between conductive hearing
(sound waves transmitted by the
external and middle ear) and
sensorineural hearing (sound
waves transmitted by the inner
ear). Strike a tuning fork softly
with the back of your hand and
place it at the center of the
client’s head or forehead.
Centering is the important part.
Ask whether the client hears the
sound better in one ear or the
same in both ears.
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform the Rinne’s Air conduction sound is With conductive hearing
test. normally heard longer loss, bone conduction
Strike a tuning fork and than bone conduction (BC) sound is heard
place the base of the fork on sound (AC > BC). longer than or equally as
the client’s mastoid process. long as air conduction
Ask the client to tell you (AC) sound (BC ≥ AC).
when the sound is no longer
heard.
Move the prongs of the
tuning fork to the front of
the external auditory canal.
Ask the client to tell you if
the sound is audible after
the fork is moved.
The Rinne’s test compares air and bone conduction sounds
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform the Client maintains position Client moves feet apart
Romberg test. for 20 seconds without to prevent falls or starts
swaying or with minimal to fall from loss of
This tests the client’s swaying. balance. This may
equilibrium. Ask the indicate a vestibular
client to stand with disorder.
feet together, arms
at sides, and eyes
open, then with the
eyes closed.
Nose
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect and palpate Color is the same as the Nasal tenderness on
the external nose. rest of the face; the palpation accompanies
nasal structure is smooth a local infection.
Note nasal color, and symmetric; the client
shape, consistency, reports no tenderness.
and tenderness.
Nose
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Check patency of air Client is able to sniff Client cannot sniff
flow through the through each nostril through a nostril that
while other is occluded. is not occluded, nor can
nostrils by occluding he or she sniff or
one nostril at a time blow air through the
and asking client to nostrils. This may be a
sniff. sign of swelling, rhinitis,
or a foreign object
obstructing the nostrils.
A line across the tip
of the nose just above
the fleshy tip is common
in clients with chronic
allergies.
Nose
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the internal The nasal mucosa is dark Nasal mucosa is swollen and
pink, moist, and free of pale pink or bluish gray in
nose. clients with allergies. Nasal
To inspect the internal exudate. The nasal
mucosa is red and swollen
nose, use an otoscope septum is intact
with upper respiratory
with a short wide-tip and free of ulcers or
infection. Exudate is
attachment or you can perforations. common with infection and
also use a nasal speculum Turbinates may range from large
and penlight are dark pink (redder amounts of watery
than oral mucosa), discharge to thick yellow-
moist, and free of green, purulent discharge.
lesions. Purulent nasal discharge
is seen with acute bacterial
rhinosinusitis. Bleeding
(epistaxis) or crusting may
be noted on the lower
anterior part of the nasal
septum with local irritation.
Sinuses
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the sinuses. Frontal and maxillary Frontal or maxillary
When an infection sinuses are nontender sinuses are tender to
is suspected, the nurse to palpation, and no palpation in clients with
can examine the sinuses crepitus is evident. allergies or acute
through palpation, bacterial rhinosinusitis. If
percussion, and the client has a large
transillumination. amount of exudate, you
Palpate the frontal may feel crepitus upon
sinuses by using your palpation over the
thumbs to press up on maxillary sinuses.
the brow on each side of
nose
Palpating the frontal sinuses
Palpating the maxillary sinuses
Sinuses
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss the sinuses. The sinuses are not The frontal and maxillary
Lightly tap (percuss) tender on percussion sinuses are tender upon
over the frontal sinuses percussion in clients with
and over the maxillary allergies or sinus
sinuses for tenderness. infection.
Assessing Mouth,
Throat, Nose,
and Sinuses
The mouth and throat make up the first part of the digestive
system and are responsible for receiving food (ingestion),
taste, preparing food for digestion, and aiding in speech.
Cranial nerves V (trigeminal), VII (facial), IX
(glossopharyngeal), and XII (hypoglossal) assist with some of
these functions.
The nose and paranasal sinuses constitute the first part of the
respiratory system and are responsible for receiving, filtering,
warming, and moistening air to be transported to the lungs.
Receptors of cranial nerve I (olfactory) are also located in the
nose. These receptors are related to the sense of smell.
Structures of the mouth
Salivary glands
Nasal cavity and throat structures
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the lips. Lips are smooth and Pallor around the lips
moist without lesions (circumoral pallor) is
Observe lip
or swelling. seen in anemia and shock.
consistency Bluish (cyanotic) lips may
and color. result from cold or
hypoxia. Reddish
lips are seen in clients with
ketoacidosis, carbon
monoxide poisoning, and
chronic obstructive
pulmonary disease (COPD)
with polycythemia.
Swelling of the lips
(edema) is common in
local or systemic allergic or
anaphylactic reactions.
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the teeth Thirty-two pearly whitish Clients who smoke, drink
and gums. teeth with smooth large quantities
Ask the client to open the surfaces and edges. of coffee or tea, or have
mouth. Note the number Upper molars should rest an excessive intake
of teeth, color, and directly on the lower of fluoride may have
condition. Note any repairs molars and the front yellow or brownish
such as crowns and any upper incisors should teeth. Tooth decay
cosmetics such as veneers. slightly override the (caries) may appear as
Ask the client to bite down lower incisors. Some brown dots or cover
as though chewing on
clients normally have more extensive areas of
something and note the
only 28 teeth if the four chewing surfaces.
alignment of the lower and
upper jaws. wisdom teeth do Missing teeth can affect
not erupt. chewing as well as self-
image.
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Put on gloves and No decayed areas; no Receding gums are
retract the client’s missing teeth. abnormal in younger
Client may have clients; in older clients,
lips and cheeks to appliances on the teeth the teeth may appear
check gums for (e.g., braces). Client may longer because of age-
color and have evidence of repair related gingival
consistency. work done on teeth (e.g., recession, which is
fillings, crowns, or common.
cosmetics such as Red, swollen gums that
veneers). bleed easily are seen
Gums are pink, moist, in gingivitis, scurvy
and firm with tight (vitamin C deficiency),
margins to the tooth. No and leukemia
lesions or masses.
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the buccal The buccal mucosa Leukoplakia may be seen
mucosa. should appear pink in in chronic irritation
Use a penlight and light-skinned clients; and smoking.
tongue depressor to tissue pigmentation
retract the lips and typically increases in dark
cheeks to check color and skinned clients.
consistency.
Inspecting the buccal mucosa
Leukoplakia is a precancerous lesion, and the client should be
referred for evaluation. Whitish, curd-like patches that scrape
off over reddened mucosa and bleed easily indicate “thrush”
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
inspect and palpate Tongue should be pink, Among possible
the tongue. moist, a moderate abnormalities are deep
Ask client to stick out the size with papillae (little longitudinal fissures seen
tongue. protuberances) in dehydration;
Inspect for color, present. a black tongue indicative
moisture, size, and A common variation is a of bismuth (Pepto-
texture. fissured, topographic- Bismol) toxicity: black,
Observe for fasciculations map–like tongue, which hairy tongue
(fine tremors), and is not unusual in older
check for midline clients.
protrusion. Palpate any No lesions are present.
lesions present for
induration (hardness).
Inspecting the tongue. (A) Inspecting the ventral surface of the
tongue (B) Inspecting the dorsal surface of the tongue
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess the ventral The tongue’s ventral Leukoplakia, persistent
surface of the surface is smooth, shiny, lesions, ulcers, or
pink, or slightly pale, with nodules may indicate
tongue. visible veins and cancer and should be
Ask the client to touch no lesions. referred. Induration
the tongue to the roof of increases the likelihood
mouth, and use a of cancer.
penlight to inspect the
ventral surface of the
tongue, frenulum,
and area under the
tongue
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the area if The older client may have The area underneath the
you see lesions, if varicose veins on the tongue
ventral surface of the is the most common site
the client is over age tongue of oral cancer
50, or if the client
uses tobacco or
alcohol.
Note any induration.
Check also for a short
frenulum that limits
tongue motion (the
origin of “tongue-
tied”).
Tongue-tied
Palpating area
under the tongue
Fissured tongue Varicose veins on ventral
surface of the tongue
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for The frenulum is midline; Abnormal findings
Wharton’s ducts— Wharton’s ducts are include lesions, ulcers,
visible, with salivary flow nodules, or
openings from the or moistness in the hypertrophied duct
submandibular area. The client has no openings on either side
salivary glands— swelling, redness, or of frenulum.
located on either side pain.
of the frenulum on
the floor of the
mouth.
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe the sides of No lesions, ulcers, or Canker sores may be
the tongue. nodules are apparent. seen on the sides of the
tongue in clients
Use a square gauze receiving certain kinds of
pad to hold the chemotherapy.
client’s tongue Leukoplakia, persistent
to each side. Palpate lesions, ulcers, or
any lesions, ulcers, or nodules may indicate
cancer and
nodules for should be further
induration. evaluated medically.
Induration increases the
likelihood of cancer
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Check the strength The tongue offers strong Decreased tongue
of the tongue. resistance strength may occur
Place your fingers on the with a defect of the
external surface of the twelfth cranial
client’s cheek. Ask the nerve—hypoglossal—or
client to press the with a shortened
tongue’s tip against the frenulum that limits
inside of the cheek to motion.
resist pressure from your
fingers. Repeat
on the opposite cheek.
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the hard The hard palate is pale or A candidal infection may
(anterior) and soft whitish with firm, appear as thick white
transverse rugae plaques on the hard
(posterior) palates (wrinkle-like folds). palate. Deep purple,
and uvula. Palatine tissues are raised, or flat lesions may
Ask the client to open the intact; the soft palate indicate a Kaposi’s
mouth wide while you should be pinkish, sarcoma (seen in clients
use a penlight to look at movable, spongy, and with AIDS
the roof. Observe color smooth A yellow tint to the hard
and integrity. palate may indicate
jaundice because
bilirubin adheres to
elastic tissue (collagen).
An opening in the hard
palate is known as a cleft
palate.
Inspecting the side
of the tongue
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Note odor. No unusual or foul odor Fruity or acetone breath
While the mouth is wide is noted is associated with
open, note any unusual diabetic ketoacidosis. An
or foul odor. ammonia odor is often
associated with kidney
disease. Foul odors may
indicate an oral or
respiratory infection, or
tooth decay. Alcohol or
tobacco use may be
identified by breath odor.
Fecal breath odor occurs
in bowel obstruction;
sulfur odor (fetor
hepaticus) occurs in
endstage liver disease.
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess the uvula. The uvula is a fleshy, solid Asymmetric movement
Apply a tongue depressor structure that hangs or loss of movement
to the tongue (halfway freely in the midline. No may occur after a
between the tip and back redness of or exudate cerebrovascular accident
of the tongue) and shine from uvula or soft palate. (stroke). Palate fails to
a penlight into the client’s Midline elevation of rise and uvula deviates
wide-open mouth. Note uvula and symmetric to normal side with
the characteristics and elevation of the soft cranial nerve X (vagus)
positioning of the uvula. palate. paralysis.
Ask the client to say A bifid uvula, common in
“aaah” and watch for the Native Americans, looks
uvula and soft palate to like it is split in two or
move. partially severed
Inspecting the uvula Bifid uvula
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the tonsils. Tonsils may be present or Tonsils are red, enlarged
Using the tongue absent. They are (to 2+, 3+, or 4+),
depressor to keep the normally pink and and covered with
mouth open wide, symmetric and may be exudate in tonsillitis.
inspect the tonsils for enlarged to 1+ in healthy They also may be
color, size, and presence clients . No exudate, indurated with patches of
of exudate or lesions. swelling, or lesions white or yellow exudate
Grade the tonsils. should be present.
In a client who has both
tonsils and a sore throat,
tonsillitis can be identified
and ranked with a grading
scale from 1 to
4 as follows:
1+ Tonsils are visible.
2+ Tonsils are midway
between tonsillar pillars
and uvula.
3+ Tonsils touch the
uvula.
4+ Tonsils touch each
other.
Acute tonsillitis and pharyngitis
Mouth
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the posterior Throat is normally pink, A bright red throat with
pharyngeal wall. without exudate or white or yellow exudate
Keeping the tongue lesions indicates pharyngitis.
depressor in place, shine Yellowish mucus on
the penlight on the back throat may be seen, with
of the throat. postnasal sinus
Observe the color of the drainage
throat, and note any
exudate or lesions. Before
inspecting the nose,
discard gloves and
perform hand hygiene.
The normal tonsils and pharynx
CHEST TO ABDOMEN ASSESSMENT

(Weeks No. 11-13)
INTRODUCTION
An accurate physical assessment requires an organized and systematic

approach using the techniques of inspection, palpation, percussion, and
auscultation. It also requires a trusting relationship and rapport between the
nurse and the patient to decrease the stress the patient may have from
being physically exposed and vulnerable. The patient will be much more
relaxed and cooperative if you explain what will be done and the reason for
doing it. While the findings of a nursing assessment do sometimes contribute
to the identification of a medical diagnosis, the unique focus of a nursing
assessment is on the patient's responses to actual or potential problems.
LEARNING OUTCOME
After finishing this module, the student will be able to:

1. Describe the structure and function of thorax and lungs, breast and
lymphatic system, heart and neck vessel, and abdomen.
2. Define and identify acceptable medical terms for thorax and lungs,
breast and lymphatic system, heart and neck vessel, and abdomen.
3. Differentiate between normal and abnormal findings.
4. Perform physical assessment using the inspection, palpation,
percussion, auscultation.
5. Interpret and analyze assessment findings.
6. Document and record the assessment findings.
OUTLINE
1. Assessment of thorax and Lungs

a. Structure
b. Function
c. Assessment
d. Normal Findings
e. Deviation from normal
2. Posterior Thorax
3. Anterior Thorax
4. Assessment of Breast and Lymphatic System

Manila, Philippines
a. Structure
b. Function
c. Assessment
d. Normal Findings
e. Deviation from Normal
5. Female Breast
6. Male Breast
7. Abnormalities
8. Palpating the Breast
9. Palpating the Axillary Lymph nodes
10. Breast Self-Examination
11. Assessment of the Heart and Neck Vessel
a. Structure
b. Function
12. Neck Vessel
13. Heart
a. Precordium
14. Ventricular Impulses
15. Assessment of the Abdomen
a. Structure
b. Function
c. Normal Findings
d. Deviation from Normal
16. Abnormalities
a. Abdominal Distention
b. Abdominal Bulges
c. Enlarged Abdominal Organs
17. Test for Appendicitis
18. Assessment
19. References
Assessment of thorax and Lungs
The term thorax identifies the portion of the body extending from the base
of the neck superiorly to the level of the diaphragm inferiorly.
The lungs, distal portion of the trachea, and the bronchi are located in the
thorax and constitute the lower respiratory system. The outer structure of
the thorax is referred to as the thoracic cage.
The thoracic cavity contains the respiratory components.

Manila, Philippines
A thorough assessment of the lower respiratory system focuses on the

external chest as well as the respiratory components in the thoracic cavity.

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax

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Posterior Thorax
Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Anterior Thorax

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Assessment of Breast and Lymphatic System
The breasts are paired mammary glands that lie over the muscles of the
anterior chest wall, anterior to the pectoralis major and serratus anterior
muscles.
Depending on their size and shape, the breasts extend vertically from the
second to the sixth rib and horizontally from the sternum to the mid-axillary
line.
The male and female breasts are similar until puberty, when female breast
tissue enlarges in response to the hormone’s estrogen and progesterone,
which are released from the ovaries.
The female breast is an accessory reproductive organ with two functions: to
produce and store milk that provides nourishment for newborns and to aid in
sexual stimulation.
The male breasts have no functional capability.
For purposes of describing the location of assessment findings, the breasts are
divided into four quadrants by drawing horizontal and vertical imaginary lines
that intersect at the nipple.
The upper outer quadrant, which extends into the axillary area, is referred to
as the tail of Spence. Most breast tumors occur in this quadrant.
Lymph nodes are present in both male and female breasts. These structures
drain lymph from the breasts to filter out microorganisms and return water
and protein to the blood.

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Female Breasts

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Female Breasts

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Female Breasts

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Female Breasts

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Female Breasts

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Female Breasts

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Female Breasts
Palpating the Breasts
1. Ask the client to lie down and to place overhead the arm on the same
side as the breast being palpated. Place a small pillow or rolled towel
under the breast being palpated.
2. Use the flat pads of three fingers to palpate the client’s breasts.
3. Palpate the breasts using one of three different patterns. Choose one
that is most comfortable for you but be consistent and thorough with
the method chosen.
4. Be sure to palpate every square inch of the breast, from the nipple and
areola to the periphery of the breast tissue and up into the tail of
Spence. Vary the levels of pressure as you palpate.
Light - superficial
Medium - mid-level tissue
Firm - to the ribs
5. Use the bimanual technique if the client has large breasts. Support the
breast with your nondominant hand and use your dominant hand to
palpate.

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Patterns of palpating the breasts

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Female Breasts

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Female Breasts
Abnormalities Noted on Palpation of the Breast

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Female Breasts

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The Axillae

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Breast Self-Examination

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Male Breasts

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Assessment of Heart and Neck Vessel
The cardiovascular system is highly complex, consisting of the heart and a

closed system of blood vessels.
To collect accurate data and correctly interpret it, the examiner must have
an understanding of the structure and function of the heart, the great
vessels, the electrical conduction system of the heart, the cardiac cycle, the
production of heart sounds, cardiac output, and the neck vessels.

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Neck Vessels

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Neck Vessels

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Neck Vessels

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Neck Vessels

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Heart (Precordium)

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Heart (Precordium)

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Heart (Precordium)

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Heart (Precordium)

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Assessment of Abdomen
The abdomen is bordered superiorly by the costal margins, inferiorly by the

symphysis pubis and inguinal canals, and laterally by the flanks.
It is important to understand the anatomic divisions known as the abdominal
quadrants, the abdominal wall muscles, and the internal anatomy of the
abdominal cavity in order to perform an adequate assessment of the
abdomen.
Abdominal quadrants

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Abdomen

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Test for Appendicitis

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Test for appendicitis

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Test for appendicitis

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REFERENCES:
Nursing (6th ed.).
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s Fundamentals

Manila, Philippines
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Assessment of
Thorax, Breast, & Heart
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The term thorax identifies the portion of the body

extending from the base of the neck superiorly to the
level of the diaphragm inferiorly.
The lungs, distal portion of the trachea, and the bronchi
are located in the thorax and constitute the lower
respiratory system.
The outer structure of the thorax is referred to as the
thoracic cage.
A thorough assessment of the lower respiratory system
focuses on the external chest as well as the respiratory
components in the thoracic cavity.
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Anterior thoracic cage
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Posterior thoracic cage
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Anterior vertical lines (imaginary landmarks)
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Posterior vertical lines (imaginary landmarks)
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Lateral vertical lines (imaginary landmarks)
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Major structures of the
respiratory system
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(A) Anterior view of lung position. (B) Posterior view of lung position.
(C) Lateral view of left lung position. (D) Lateral view of right lung position.
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Mechanics of normal—
not deep, not shallow—
inspiration (left) and
expiration (right).
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect Scapulae are symmetric and Spinous processes that deviate
nonprotruding. laterally in the thoracic area
configuration. Shoulders and scapulae are may indicate scoliosis.
While the client Spinal configurations may have
at equal horizontal
respiratory implications. Ribs
sits with arms at the positions. The ratio of appearing horizontal at an angle
anteroposterior to greater than 45 degrees with
sides, stand behind transverse diameter is 1:2. the spinal column are
the client and Spinous processes appear frequently the result of an
observe the position straight, and thorax appears increased ratio between the
symmetric, with ribs sloping anteroposterior– transverse
of scapulae and the downward at approximately diameter (barrel chest). This
shape and condition is commonly the
a 45-degree angle in
result of emphysema due to
configuration of the relation to the spine. hyperinflation of the lungs.
chest wall
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Observing the posterior thorax
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe use of The client does not use Client leans forward
accessory muscles. accessory (trapezius/ and uses arms to
shoulder) muscles to
Watch as the client assist breathing. The
support weight and
breathes and note diaphragm is the major lift chest to increase
use of muscles. muscle at work. This is breathing capacity,
evidenced by expansion referred to as the
of the lower chest during tripod position.
inspiration.
This is often seen in
COPD
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Tripod position
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the client’s Client should be sitting Tender or painful areas
positioning. up and relaxed, may indicate inflamed
Note the client’s breathing easily with fibrous connective
posture and ability to arms at sides or in lap. tissue. Pain over the
support weight while intercostal spaces may
breathing comfortably. be from inflamed
pleurae.
Pain over the ribs,
especially at the costal
chondral junctions, is a
symptom of fractured
ribs.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for tenderness Client reports no Muscle soreness from
and sensation. tenderness, pain, or exercise or the
Palpation may be performed unusual sensations. excessive work of
with one or both hands, but the
sequence of palpation is Temperature should be breathing (as in COPD)
established. Use your fingers to equal bilaterally. may be palpated as
palpate for tenderness, warmth,
pain, or other sensations. Start
tenderness.
toward the midline at the level Increased warmth may
of the left scapula (over the be related to local
apex of the left lung) and move
your hand left to right,
infection.
comparing findings bilaterally.
Move systematically downward
and out to cover the lateral
portions of the lungs at the
bases.
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Sequence for palpating the posterior thorax
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for crepitus. The examiner finds no Crepitus can be palpated
Crepitus, also called palpable crepitus. if air escapes from the
subcutaneous lung or other airways into
emphysema, is a the subcutaneous tissue,
as occurs after an open
crackling sensation
thoracic injury, around a
(like bones or hairs chest tube, or
rubbing against each tracheostomy. It also may
other) that occurs be palpated in areas of
when air passes extreme congestion or
through fluid or consolidation. In such
exudate. Use your situations, mark margins
fingers and follow the and monitor to note any
sequence when decrease or increase in
palpating. the crepitant area.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate surface Skin and subcutaneous A physician or other
characteristics. tissue are free of appropriate
Put on gloves and use lesions and masses. professional should
your fingers to palpate evaluate any unusual
any lesions that you palpable mass.
noticed during
inspection.
Feel for any unusual
masses.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for fremitus. Fremitus is symmetric Unequal fremitus is
Following the sequence and easily identified usually the result of
described previously, use in the upper regions of consolidation (which
the ball or ulnar edge of the lungs. If fremitus increases fremitus)
one hand to assess is not palpable on either or bronchial obstruction,
for fremitus (vibrations of side, the client may need air trapping in
air in the bronchial to speak louder. A emphysema, pleural
tubes transmitted to the decrease in the intensity effusion, or
chest wall). of fremitus is normal as pneumothorax (which all
As you move your hand the examiner moves decrease fremitus).
to each area, ask the toward the base of the Diminished fremitus even
client to say “ninety- lungs. with a loud spoken voice
nine.” Assess all areas for However, fremitus should may indicate an
symmetry and intensity remain symmetric obstruction of the
of vibration. for bilateral positions. tracheobronchial tree.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess chest When the client takes Unequal chest expansion
expansion. a deep breath, the can occur with severe
(Diaphragmatic examiner’s thumbs atelectasis (collapse or
Excursion) should move 5 to 10 incomplete expansion),
pneumonia, chest
Place your hands on cm apart
trauma, or
the posterior chest wall symmetrically. pneumothorax (air in the
with your thumbs at pleural space).
the level of T9 or T10 Decreased chest
and pressing together excursion at the base of
a small skin fold. As the the lungs is characteristic
client takes a deep of COPD. This is due to
breath, observe the decreased diaphragmatic
movement of your function.
thumbs
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Starting position for
assessing symmetry of
chest expansion
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss for tone. Resonance is the Hyperresonance is
Start at the apices of percussion tone elicited in cases of
the scapulae and elicited over normal trapped air such as in
percuss across the tops lung tissue. Percussion emphysema or
of both shoulders. Then elicits flat tones over pneumothorax.
percuss the intercostal the scapula.
spaces across and
down, comparing
sides.
Percuss to the lateral
aspects at the bases
of the lungs,
comparing sides.
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Sequence for percussing the posterior thorax
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Normal percussion tones heard from the posterior thorax
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss for Excursion should be Dullness is present when
diaphragmatic equal bilaterally and fluid or solid tissue
replaces air in the lung or
excursion. measure 3–5 cm in occupies the pleural space,
Ask the client to exhale forcefully
and hold the breath. Beginning at
adults. such as in lobar pneumonia,
the scapular line (T7), percuss the The level of the pleural effusion, or tumor.
intercostal spaces of the right Diaphragmatic descent may
posterior chest wall. Percuss
diaphragm may be
be limited by atelectasis of
downward until the tone changes higher on the right the lower lobes or by
from resonance to dullness.
Mark this level and allow the client because of the position emphysema, in which
to breathe. Next ask the client to of the liver. diaphragmatic movement
inhale deeply and hold it. Percuss
the intercostal spaces from the mark In well-conditioned and air trapping are
downward until resonance changes
clients, excursion can minimal. The diaphragm
to dullness. Mark the level and allow remains in a low position on
the client to breathe. Measure the measure up to 7 or 8 inspiration and expiration.
distance between the two marks.
Perform this assessment technique
cm.
on both sides of the posterior
thorax. www.feu.edu.ph
Measuring diaphragmatic excursion
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for breath Three types of normal Diminished or absent breath
sounds. breath sounds may be sounds often indicate that
To begin, place the diaphragm little or no air is moving in
auscultated— or out of the lung area
of the stethoscope firmly and
directly on the posterior chest bronchial, being auscultated.
wall at the apex of the lung at bronchovesicular, In cases of emphysema, the
C7. Ask the client to breathe hyperinflated nature of the
deeply through the mouth for
and vesicular
lungs, together with a loss
each area of auscultation (each of elasticity of lung tissue,
placement of the stethoscope)
may result in diminished
in the auscultation sequence so
that you can best hear inspiratory breath sounds.
inspiratory and expiratory Increased (louder) breath
sounds. Be alert to the client’s sounds often occur when
comfort and offer times for rest consolidation or
and normal breathing if fatigue compression results in a
is becoming a problem. denser lung area.
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Sequence for auscultating the posterior thorax
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Location of breath sounds for the posterior thorax.
V, vesicular sounds; BV, bronchovesicular sounds
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for No adventitious Adventitious lung
adventitious sounds. sounds, such as sounds, such as
Adventitious sounds are crackles (discrete and crackles (formerly
sounds added or discontinuous sounds) called rales) and
superimposed over or wheezes (musical wheezes (formerly
normal breath sounds and continuous), are called rhonchi) are
and heard during
auscultated. evident.
auscultation. Be careful
to note the location on
the chest wall where
adventitious sounds are
heard as well as the
location of such sounds
within the respiratory
cycle.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate voice Voice transmission is The words are easily
sounds. soft, muffled, and understood and louder
indistinct. The sound of over areas of increased
Bronchophony: Ask the the voice may be density. This may
client to repeat the heard but the actual indicate consolidation
phrase “ninety-nine” phrase cannot be from pneumonia,
while you auscultate distinguished. atelectasis, or tumor.
the chest wall.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Egophony: Ask the Voice transmission will Over areas of
client to repeat the be soft and muffled consolidation or
letter “E” while you but the letter “E” compression,
listen over the chest should be the sound is louder
wall. distinguishable and sounds like “A.”
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Whispered Transmission of sound Over areas of
pectoriloquy: is very faint and consolidation or
Ask the client to muffled. It may be compression, the
whisper the phrase inaudible. sound is transmitted
“one–two–three” while clearly and distinctly.
you auscultate the In such areas, it sounds
chest wall. as if the client is
whispering directly
into the stethoscope.
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Anterior Thorax
Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for shape The anteroposterior Anteroposterior equals
and configuration. diameter is less than transverse diameter,
Have the client sit with the transverse resulting in a barrel
arms at the sides. diameter. The ratio of chest. This is often
Stand in front of the anteroposterior seen in emphysema
client and assess shape diameter to the because of
and configuration. transverse diameter hyperinflation of the
is 1:2. lungs.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect position of Sternum is Pectus excavatum is a
markedly sunken sternum
the sternum. positioned at midline and adjacent cartilages
Observe the sternum and straight. (often referred to as funnel
from an anterior and chest). It is a congenital
lateral viewpoint. malformation that seldom
causes symptoms other
than self-consciousness.
Pectus carinatum is a
forward protrusion of the
sternum causing the
adjacent ribs to slope
backward. Both conditions
may restrict expansion of
the lungs and decrease lung
capacity.
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Thoracic Deformities and Configurations
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Watch for sternal Retractions not Sternal retractions
retractions. observed. are noted, with
severely labored
breathing.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect slope of the Ribs slope downward Barrel-chest
ribs. with symmetric configuration results in
Assess the ribs from an intercostal spaces. a more horizontal
anterior and lateral Costal angle is within position of the ribs and
viewpoint. 90 degrees. costal angle of more
than 90 degrees. This
often results from
long-standing
emphysema.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe quality and Respirations are Labored and noisy
pattern of relaxed, effortless, and breathing is often seen
respiration. quiet. They are of a with severe asthma or
Note breathing regular rhythm and chronic bronchitis.
characteristics as well normal depth at a rate Abnormal breathing
as rate, rhythm, and of 10–20 per minute in patterns include
depth. adults. Tachypnea and tachypnea, bradypnea,
bradypnea may be hyperventilation,
normal in some clients. hypoventilation,
Cheyne-Stokes
respiration, and Biot’s
respiration.
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Respiration Patterns
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect intercostal No retractions or Retraction of the
spaces. bulging of intercostal intercostal spaces
Ask the client to spaces are noted. indicates an increased
breathe normally and inspiratory effort. This
observe the inter- may be the result of an
costal spaces. obstruction of the
respiratory tract or
atelectasis. Bulging of
the intercostal spaces
indicates trapped air
such as in emphysema
or asthma.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe for use of Use of accessory Neck muscles
accessory muscles. muscles (sternomastoid,
Ask the client to (sternomastoid and scalene, and trapezius)
breathe normally and rectus abdominis) is are used to facilitate
observe for use of not seen with normal inspiration in cases of
accessory muscles. respiratory effort. After acute or chronic airway
strenuous exercise obstruction or
or activity, clients with atelectasis. The
normal respiratory abdominal muscles
status may use neck and the internal
muscles for a short intercostal muscles are
time to enhance used to facilitate
breathing. expiration in COPD.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for No tenderness or pain Tenderness over
tenderness, sensation, is palpated over the thoracic muscles can
and surface masses. lung area with result from exercising
Use your fingers to respirations. (e.g., pushups)
palpate for tenderness especially in a
and sensation. Start previously sedentary
with your hand client.
positioned over the left
clavicle (over the apex
of the left lung) and
move your hand left to
right, comparing
findings bilaterally.
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Sequence for palpating the anterior thorax
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for Palpation does not Tenderness or pain
tenderness at elicit tenderness. at the costochondral
costochondral junction of the ribs is
junctions of ribs. seen with fractures,
especially in older
clients with
osteoporosis.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for crepitus No crepitus is palpated In areas of extreme
congestion or
consolidation, crepitus
may be palpated,
particularly in clients
with lung disease.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for any No unusual surface Surface masses or
surface masses or masses or lesions are lesions may indicate
lesions. palpated. cysts or tumors.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for fremitus. Fremitus is symmetric Diminished vibrations,
Using the sequence for and easily identified in even with a loud
the anterior chest the upper regions of spoken voice, may
described previously, the lungs. A decreased indicate an obstruction
palpate for fremitus intensity of fremitus is of the
using the same expected toward the tracheobronchial tree.
technique as for the base of the lungs. Clients with
posterior thorax. However, fremitus emphysema may have
should be symmetric considerably
bilaterally. decreased fremitus as
a result of air trapping.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate anterior Thumbs move outward Unequal chest
chest expansion. in a symmetric fashion expansion can occur
Place your hands on from the midline. with severe atelectasis,
the client’s pneumonia, chest
anterolateral wall with trauma, pleural
your thumbs along the effusion, or
costal margins and pneumothorax.
pointing toward the Decreased chest
xiphoid process. As the excursion at the bases
client takes a deep of the lungs is seen
breath, observe the with COPD.
movement of your
thumbs.
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Palpating anterior chest expansion
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss the apices percussion tone elicited in cases of
above the clavicles. elicited over normal trapped air such as in
Then percuss the lung tissue. Percussion emphysema or
intercostal spaces elicits dullness over pneumothorax.
across and down, breast tissue, the Dullness may
comparing sides heart, and the liver. characterize areas of
Tympany is detected increased density such
over the stomach, and as consolidation,
flatness is detected pleural effusion, or
over the muscles and tumor.
bones.
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Sequence for percussing the anterior thorax
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for anterior Refer to text in the posterior Refer to text in the posterior
breath sounds, thorax section for normal thorax section for abnormal
voice sounds. voice sounds.
adventitious sounds,
and voice sounds.
Place the diaphragm of the
stethoscope firmly and directly
on the anterior chest wall.
Auscultate from the apices of
the lungs slightly above the
clavicles to the bases of the
lungs at the sixth rib. Ask the
client to breathe deeply through
the mouth in an effort to avoid
transmission of sounds that
may occur with nasal breathing.
Listen at each site for at least
one complete respiratory cycle.
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Sequence for auscultating the anterior thorax
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Normal percussion tones heard from the anterior thorax
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Location of breath sounds for the anterior thorax.
B, bronchial sounds; V, vesicular sounds; BV, bronchovesicular sounds
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The breasts are paired mammary glands that lie over the
muscles of the anterior chest wall, anterior to the
pectoralis major and serratus anterior muscles.
Depending on their size and shape, the breasts extend
vertically from the second to the sixth rib and
horizontally from the sternum to the mid-axillary line.
The male and female breasts are similar until puberty,
when female breast tissue enlarges in response to the
hormones estrogen and progesterone, which are
released from the ovaries.
The female breast is an accessory reproductive organ
with two functions: to produce and store milk that
provides nourishment for newborns and to aid in sexual
stimulation.
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For purposes of describing the location of
assessment findings, the breasts are divided into four
quadrants by drawing horizontal and vertical
imaginary lines that intersect at the nipple.
The upper outer quadrant, which extends into the
axillary area, is referred to as the tail of Spence. Most
breast tumors occur in this quadrant.
Lymph nodes are present in both male and female
breasts. These structures drain lymph from the
breasts to filter out microorganisms and return water
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Anatomic breast landmarks and their position in the thorax.
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Breast quadrants. The upper outer quadrant is the area most
targeted by breast cancer
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Internal anatomy of the breast
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The lymph nodes drain impurities from the breasts
(arrows show direction)
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect size and Breasts can be a A recent increase in
symmetry. variety of sizes and are the size of one breast
Have the client disrobe somewhat round and may indicate
and sit with arms pendulous. One breast inflammation or an
hanging freely. Explain may normally be larger abnormal growth.
what you are observing than the other.
to help ease client
anxiety.
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Client should sit with arms hanging freely at sides during
assessment of breast size and symmetry.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect color and Color varies depending Redness is associated
texture. on the client’s skin with breast
Be sure to note client’s tone. Texture is inflammation.
overall skin tone when smooth, with no A pigskin-like or
inspecting the breast edema. orange-peel (peau
skin. Note any lesions. Linear stretch marks d’orange) appearance
may be seen during results from edema,
and after pregnancy or which is seen in
with significant weight metastatic breast
gain or loss. disease. The edema is
caused by blocked
lymphatic drainage.
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Abnormalities Noted on Inspection of the Breast
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect superficial Veins radiate either A prominent venous
venous pattern. horizontally and pattern may occur as a
Observe visibility and toward the axilla result of increased
pattern of breast veins. (transverse) or circulation due to a
vertically with a lateral malignancy. An
flare (longitudinal). asymmetric venous
Veins are more pattern may be due to
prominent during malignancy.
pregnancy.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the areolas. Areolas vary from dark Peau d’orange skin,
Note the color, size, pink to dark brown, associated with
shape, and texture of depending on the carcinoma, may be first
the areolas of both client’s skin tones. seen in the areola.
breasts. They are round and Red, scaly, crusty areas
may vary in size. Small are may appear in
Montgomery tubercles Paget’s disease
are present.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the nipples. Nipples are nearly A recently retracted
Note the size and equal bilaterally in size nipple that was
direction of the nipples and are in the same previously everted
of both breasts. Also location on each suggests malignancy.
note any dryness, breast. Nipples are Any type of
lesions, bleeding, or usually everted, but spontaneous discharge
discharge. they may be inverted should be referred for
or flat. cytologic study and
Supernumerary nipples further evaluation.
may appear along the
embryonic “milk line.”
present.
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Supernumerary nipple
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for The client’s breasts Dimpling or retraction
retraction and should rise is usually caused by a
dimpling. symmetrically, with no malignant tumor that
To inspect the breasts sign of dimpling or has fibrous strands
accurately for retraction and retraction. attached to the breast
dimpling, ask the client to tissue and the fascia of
remain seated while
performing several different
the muscles. As the
maneuvers. Ask the client to muscle contracts, it
raise her arms overhead; draws the breast tissue
then press her hands and skin with it,
against her hips. Next ask causing dimpling or
her to press her hands
together. These actions retraction.
contract the pectoral
muscles.
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During assessment for retraction and dimpling, the client first
(A) raises her arms over her head,
(B) then lowers them and presses them against the hips, and finally
(C) presses the hands together with the fingers of one hand pointing opposite to
the fingers of the other hand.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Ask the client to Breasts should hang Restricted movement
lean forward from freely and of breast or retraction
the waist. symmetrically. of the skin or nipple
The nurse should indicates fibrosis and
support the client by fixation of the
the hands or forearms. underlying tissues. This
This is a good position is usually due to an
to use in women who underlying malignant
have large, pendulous tumor.
breasts.
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Forward-leaning position for breast inspection
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate texture and Palpation reveals Thickening of the
elasticity smooth, firm, elastic tissues may with an
tissue. underlying malignant
tumor
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1. Ask the client to lie down and to place overhead the arm on the
same side as the breast being palpated. Place a small pillow or
rolled towel under the breast being palpated.
3. Palpate the breasts using one of three different patterns. Choose
one that is most comfortable for you, but be consistent and
thorough with the method chosen.
4. Be sure to palpate every square inch of the breast, from the
nipple and areola to the periphery of the breast tissue and up
into the tail of Spence. Vary the levels of pressure as you palpate.
Light - superficial
Firm - to the ribs
5. Use the bimanual technique if the client has large breasts.
Support the breast with your nondominant hand and use your
dominant hand to palpate.
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Circular or clockwise Wedged Vertical strip
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Using the flat pads of three
fingers to palpate breast
Bimanual palpation
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for A generalized increase Painful, tender breasts may
in nodularity and be indicative of fibrocystic
tenderness and breasts, especially right
temperature. tenderness may be a before menstruation.
normal finding However, pain may also
associated with the occur with a malignant
menstrual cycle or tumor. Therefore, refer the
client for further evaluation.
hormonal medications. Heat in the breasts of
Breasts should be a women who have not just
normal body given birth or who are not
temperature. lactating indicates
inflammation.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for masses. No masses should be Malignant tumors are
Note location, size in palpated. However, a most often found
centimeters, shape, firm inframammary in the upper outer
mobility, consistency, transverse ridge may quadrant of the breast.
and tenderness. Also normally be palpated They are usually
note the condition of at the lower base of unilateral, with
the skin over the mass. the breasts. irregular, poorly
delineated borders.
They are hard and
nontender and fixed to
underlying tissues.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
If you detect any lump, Fibrocystic breast tissue Fibroadenomas are usually 1–5
cm, round or oval, mobile, firm,
refer the client for that feels ropy, lumpy, or
solid, elastic, nontender, single
further evaluation. bumpy in texture is or multiple benign masses
referred to found in one or both breasts.
as “nodular” or Milk cysts (sacs filled with milk)
and infections (mastitis), may
“glandular” breast tissue.
turn into an abscess and occur
Benign breast disease if breastfeeding or recently
consists of bilateral, given birth.
multiple, firm, regular, Lipomas are a collection of fatty
tissue that may also appear as a
rubbery, mobile nodules
lump.
with well-demarcated Intraductal papilloma is a small
borders. Pain and fullness growth inside a milk duct of the
occurs just before breast, often near the areola. It
is harmless and occurs in
menses.
women ages 35 to 50.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the nipples. The nipple may Discharge may be seen in
become erect and the endocrine disorders and
Wear gloves to with certain medications
compress the nipple areola may pucker in (i.e., antihypertensives,
gently with your thumb response to tricyclic antidepressants,
and index finger. Note stimulation. A milky and estrogen). Discharge
any discharge. discharge is usually from one breast may
indicate benign intraductal
normal only during papilloma, fibrocystic
pregnancy and disease, or cancer of the
lactation. However, breast. Sometimes there is
some women may only a watery, pink
normally have a clear discharge from the nipple.
This should be referred to a
discharge. primary care provider
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Palpating nipples for masses and discharge
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The Axillae
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect and palpate No rash or infection Redness and
the axillae. noted. inflammation may be
Ask the client to sit up. seen with infection of
Inspect the axillary skin the sweat gland. Dark,
for rashes or infection. velvety pigmentation
of the axillae
(acanthosis nigricans)
may indicate an
underlying malignancy.
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acanthosis nigricans
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The Axillae
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Hold the client’s elbow No palpable nodes or Enlarged (greater than
with one hand, and use one to two small (less 1 cm) lymph nodes
the three fingerpads of than 1 cm), discrete, may indicate infection
your other hand to nontender, movable of the hand or arm.
palpate firmly the nodes in the central Large nodes that are
axillary lymph nodes area. hard and fixed to the
skin may indicate an
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Palpating the axillary lymph nodes
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Ask the client to Client may request
demonstrate how instructions on how to
she performs BSE perform the exam or
choose not to learn
how to perform the
exam. Either choice
needs to be accepted
by the examiner.
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Self Assessment:
Breast Awareness and
Self-examination
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Male Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect and palpate No swelling, nodules, Soft, fatty enlargement of
breast tissue is seen in
the breasts, areolas, or ulceration should be obesity. Gynecomastia, a
nipples, and axillae. detected smooth, firm, movable disc
Note any swelling, of glandular tissue,
nodules, or ulceration. may be seen in one breast
in males during puberty,
Palpate the flat disc of usually temporary. However,
undeveloped breast it may also be seen in
tissue under the nipple. hormonal imbalances, drug
abuse, cirrhosis, leukemia,
and thyrotoxicosis.
Irregularly shaped, hard
nodules occur in breast
cancer.
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Gynecomastia
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Gynecomastia
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The cardiovascular system is highly complex,
consisting of the heart and a closed system of blood
vessels.
To collect accurate data and correctly interpret it, the
examiner must have an understanding of the
structure and function of the heart, the great vessels,
the electrical conduction system of the heart, the
cardiac cycle, the production of heart sounds, cardiac
output, and the neck vessels.
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The heart and major blood vessels lie centrally in the
chest behind the protective sternum
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Heart chambers, valves, and
direction of circulatory flow
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Major neck vessels, including the carotid arteries and jugular veins.
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe the jugular The jugular venous Fully distended jugular
venous pulse. pulse is not normally veins with the client
Inspect the jugular venous visible with the client indicate increased
pulse by standing on the right sitting upright. This central venous
side of the client. The client
should be in a supine position position fully distends pressure that may be
with the the head and torso the vein, and the result of right
are on the same plane. Ask pulsations may or may ventricular failure,
the client to turn the head
slightly to the left. Shine a
not be discernible. pulmonary
tangential light source onto hypertension,
the neck to increase pulmonary emboli, or
visualization of pulsations as cardiac tamponade.
well as shadows. Next, inspect
the suprasternal notch or the
area around the clavicles for
pulsations of the internal
jugular veins.
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Evaluate jugular The jugular vein should Clients with
venous pressure. not be distended, obstructive pulmonary
Evaluate jugular venous bulging, or protruding disease may have
pressure by watching for
at 45 degrees or elevated venous
distention of the jugular vein. It
is normal for the jugular veins greater. pressure only during
to be visible when the client is expiration.
supine. To evaluate jugular vein
distention, position the client in
An inspiratory increase
a supine position with the head in venous pressure,
of the bed elevated 30, 45, 60, called Kussmaul’s sign,
and 90°. At each increase of the
elevation, have the client’s head may occur in clients
turned slightly away from the with severe
side being evaluated. Using
constrictive
tangential lighting, observe for
distention, protrusion, or pericarditis.
bulging.
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Assessing jugular venous pressure
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate the No blowing or swishing or A bruit, a blowing or
other sounds are heard. swishing sound caused by
carotid arteries Pulses are equally strong; a turbulent blood flow
if the client is middle- 2+ or normal with no through a narrowed vessel,
aged or older or if you variation in strength from is indicative of occlusive
suspect cardiovascular beat to beat. Contour is arterial disease. However, if
normally smooth and rapid the artery is more than 2/3
disease. Place the bell on the upstroke and slower occluded, a bruit may not
of the stethoscope over and less abrupt on the be heard.
the carotid artery and downstroke. The strength of Pulse inequality may
ask the client to hold the pulse is evaluated on a indicate arterial constriction
his or her breath for a scale from 0 to 4 or occlusion in one carotid.
Weak pulses may indicate
moment so that breath hypovolemia, shock, or
sounds do not conceal decreased cardiac output.
any vascular sounds A bounding, firm pulse may
indicate hypervolemia or
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Auscultating the carotid artery
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the carotid Arteries are elastic and Loss of elasticity may
arteries. no thrills are noted. indicate
Palpate each carotid atherosclerosis. Thrills
artery alternately by may indicate a
placing the pads of the narrowing of the
index and middle fingers artery.
medial to the
sternocleidomastoid
muscle on the neck. Note
amplitude and contour of
the pulse, elasticity of the
artery, and any thrills
(which feel similar to a
purring cat) .
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Palpating the carotid artery
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Palpate the carotid arteries
individually because bilateral
palpation could result in
reduced cerebral blood flow.
If you detect occlusion during

auscultation, palpate very
lightly to avoid blocking
circulation or triggering vagal
stimulation and bradycardia,
hypotension, or even cardiac
arrest.
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect pulsations. The apical impulse may Pulsations, which may
With the client in or may not be visible. If also be called heaves
supine position with apparent, it would be or lifts, other than the
the head of the bed in the mitral area. The apical pulsation are
elevated between 30° apical impulse is a considered abnormal
and 45° stand on the result of the left and should be
client’s right side and ventricle moving evaluated. A heave or
look for the apical outward during lift may occur as the
impulse and any systole. result of an enlarged
abnormal pulsations. ventricle from an
overload of work.
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the apical The apical impulse is The apical impulse may
impulse. palpated in the mitral be impossible to
Remain on the client’s area and may be the palpate in clients with
right side and ask the size of a nickel (1-2 cm). pulmonary
client to remain supine. Amplitude is usually emphysema. If the
small - like a gentle tap. apical impulse is larger
Use one or two finger
The duration is brief, than 1-2 cm, displaced,
pads to palpate the
lasting through the 1st more forceful, or of
apical impulse in the
2/3 of systole and often longer duration,
mitral area. less. In obese clients or
You may ask the client clients with large suspect cardiac
to roll to the left side to breasts, the apical enlargement.
better feel the impulse impulse may not be
using the palmar palpable.
surfaces of your hand.
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Locate the apical impulse with the finger pads (A);
then palpate the apical impulse with the palmar surface (B).
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for No pulsations or A thrill or a pulsation is
abnormal vibrations are palpated usually associated with
pulsations. in the areas of the a grade IV or higher
Use your palmar apex, left sternal murmur.
surfaces to palpate the border, or base.
apex, left sternal
border, and base.
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Ventricular Impulses
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate heart Rate should be 60-100 Bradycardia or
rate and rhythm. bpm with a regular tachycardia result in
Place the diaphragm of rhythm. A regularly decreased cardiac
the stethoscope at the irregular rhythm, such output. Refer clients
apex and listen closely as sinus arrhythmia with irregular rhythms
to the rate and rhythm when the heart rate (i.e., atrial contraction
of the apical impulse. increases with or premature
inspiration and ventricular) atrial
decreases with fibrillation and atrial
expiration, may be flutter with types of
normal in young irregular patterns may
adults. predispose the client
to decreased cardiac
output, heart
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Traditional Areas of Auscultation
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate to S1 corresponds with Accentuated or
identify S1 and S2. each carotid pulsation diminished S sounds.
Auscultate the first and is loudest at the
heart sound (S1 or apex of the heart.
“lub”) and the second S2 immediately follows
heart sound (S2 or after S1 and is loudest
“dubb”) at the base of the
heart.
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Listen to S1 A distinct sound is Accentuated,
Use the diaphragm of heard in each area but diminished, varying, or
the stethoscope to best loudest at the apex. split S1 are all
hear S1. May become softer abnormal findings
with inspiration. A split
S1 may be heard
normally in young
adults at the left lateral
sternal border.
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Palpating the carotid pulse while auscultating S1
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Listen to S2. Distinct sound is heard Any split S2 heard in
Use the diaphragm of in each area but is expiration is abnormal.
the stethoscope. Ask loudest at the base. The abnormal split can
the client to breathe be one of three types:
regularly wide, fixed, reverse
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Auscultating S2
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for extra Normally no sounds are Ejection sounds or clicks (mid-
heard systolic click associated with
heart sounds. A physiologic S3 heart mitral valve prolapsed)
Use the diaphragm sound is a benign finding
A friction rub may also be heard
first, then the bell to commonly heard at the during the systolic pause
auscultate over the beginning of the diastolic
pause in children, A pathologic S4 (ventricular
entire heart area. adolescents and young gallop) may be heard with
Note characteristics adults (rare after age 40) ischemic heart disease or
(e.g., location, timing) A physiologic S4 heart restrictive heart disease
of any extra sound sound may be heard near
A pathologic S4 (atrial gallop)
heard. Auscultate the end of diastole in well-
toward the left side of the
conditioned athletes and precordium may be heard with
during the systolic adults older than age 40 or coronary artery disease,
pause (space heard 50 with no evidence of hypertensive heart disease
between S1 and S2) heart disease
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Listening to heart sounds with the bell of the stethoscope
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for Normally no murmurs Pathologic mid-systolic,
murmurs. are heard Pansystolic and
A murmur is a swishing diastolic murmurs
sound caused by
turbulent blood flow
through the heart valves
or great vessels.
Use the diaphragm and
the bell of the
stethoscope in all areas
of auscultation because
murmurs have a variety
of pitches
Auscultate for murmurs
across the entire heart
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Assessing Abdomen
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Assessing Abdomen
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The abdomen is bordered superiorly by the costal

margins, inferiorly by the symphysis pubis and
inguinal canals, and laterally by the flanks.
It is important to understand the anatomic divisions
known as the abdominal quadrants, the abdominal
wall muscles, and the internal anatomy of the
abdominal cavity in order to perform an adequate
assessment of the abdomen.
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Left
Abdominal quadrants Abdominal regions
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Abdominal wall muscles
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Abdominal viscera
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Position of the kidneys
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Abdominal and vascular
structures (aorta and iliac
artery and vein)
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe the Abdominal skin may Purple discoloration at the
flanks (Grey-Turner sign)
coloration of the be paler than the indicates bleeding within the
skin. general skin tone abdominal wall, possibly from
trauma to the kidneys,
because this skin is pancreas, or duodenum or from
so seldom exposed pancreatitis.
The yellow hue of jaundice may
to the natural be more apparent on the
elements. abdomen.
Pale, taut skin may be seen with
ascites (significant abdominal
swelling indicating fluid
accumulation in the abdominal
cavity).
Redness may indicate
inflammation.
Bruises or areas of local
discoloration are also abnormal.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Note the vascularity of Scattered fine veins Dilated veins may be
the abdominal skin. may be visible. Blood seen with cirrhosis of
in the veins located the liver, obstruction of
above the umbilicus the inferior vena cava,
flows toward the head; portal hypertension, or
blood in the veins ascites.
located below the Dilated surface
umbilicus flows toward arterioles and
the lower body. capillaries with a
central star (spider
angioma) may be seen
with liver disease or
portal hypertension.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Note any striae New striae are pink or Dark bluish-pink striae
(stretch marks) bluish in color; old are associated with
due to past stretching striae are silvery, Cushing’s syndrome.
of the reticular skin white, linear, and Striae may also be
layers due to fast or uneven stretch marks caused by ascites,
prolonged stretching. from past pregnancies which stretches the
or weight gain. skin. Ascites usually
results from liver
failure or liver disease.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for scars. Pale, smooth, Nonhealing wounds,
Ask about the source of a minimally raised old redness, inflammation.
scar, and use a scars may be seen. Deep, irregular scars
centimeter ruler to may result from burns.
measure the scar’s Keloids (excess scar
length. Document the tissue) result from
location by quadrant and
trauma or surgery
reference lines, shape,
length, and any specific
characteristics (e.g., 3-cm
vertical scar in RLQ 4 cm
below the umbilicus and
5 cm left of the midline).
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Keloid beyond the border of surgical scar
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for lesions and Abdomen is free of Changes in moles
rashes. lesions or rashes. including size, color,
Flat or raised brown and border symmetry.
moles, however, are Bleeding moles or
normal and may be petechiae (reddish or
apparent. purple lesions) may
also be abnormal
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the Umbilical skin tones Cullen’s sign: A bluish
umbilicus. are similar to or purple discoloration
Note the color of surrounding abdominal around the umbilicus
the umbilical area. skin tones or even (periumbilical
pinkish. ecchymosis) indicates
intra-abdominal
bleeding.
Grey-Turner’s sign:
bluish of purplish
discoloration on the
abdominal flanks.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe umbilical Umbilicus is midline at A deviated umbilicus
location. lateral line. may be caused by
pressure from a mass,
enlarged organs,
hernia, fluid, or scar
tissue.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess contour of It is recessed (inverted) An everted umbilicus is
umbilicus. or protruding no more seen with abdominal
than 0.5 cm, and is distention. An
round or conical. enlarged, everted
umbilicus suggests
umbilical hernia.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect abdominal Abdomen is flat, A generalized protuberant
rounded, or scaphoid or distended abdomen may
contour. be due to obesity, air (gas),
Sitting at the client’s (usually seen in thin or fluid accumulation.
side, look across the adults; Distention below the
abdomen at a level Abdomen should be umbilicus may be due to a
full bladder, uterine
slightly higher than the evenly rounded. enlargement, or an ovarian
client’s abdomen. tumor or cyst.
Inspect the area Distention of the upper
between the lower ribs abdomen may be seen with
and pubic bone. masses of the pancreas or
gastric dilation.
Measure abdominal A scaphoid (sunken)
girth. abdomen may be seen with
severe weight loss.
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View abdominal contour from the client’s side. Many abdomens
are more or less flat; and many are round, scaphoid, or
distended.
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Abdominal contours
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess abdominal Abdomen is symmetric. Asymmetry may be
symmetry. seen with organ
Look at the abdomen enlargement, large
as the client lies in a masses, hernia,
relaxed supine diastasis recti, or
position. bowel obstruction.
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Abdominal Distention
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Abdominal Bulges
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Abdominal Bulges
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Enlarged Abdominal Organs and Other Abnormalities
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect abdominal Abdominal respiratory Diminished abdominal
movement when the movement may be respiration or change
client breathes seen, especially in to thoracic breathing in
(respiratory male clients. male clients may
movements). reflect peritoneal
irritation.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe aortic A slight pulsation of Vigorous, wide,
pulsations. the abdominal aorta, exaggerated pulsations
which is visible in the may be seen with
epigastrium, extends abdominal aortic
full length in thin aneurysm.
people.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe for peristaltic Normally, peristaltic Peristaltic waves are
waves. waves are not seen, increased and progress
although they may be in a ripple-like fashion
visible in very thin from the LUQ to the
people as slight ripples RLQ with intestinal
on the abdominal wall. obstruction (especially
small intestine). In
addition, abdominal
distention typically is
present with intestinal
wall obstruction.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for bowel A series of intermittent, soft “Hyperactive” bowel sounds
clicks and gurgles are heard that are rushing, tinkling, and
sounds. at a rate of 5–30 per high pitched may be abnormal
Use the diaphragm of the indicating very rapid motility
minute.
stethoscope and make sure heard in early bowel
Hyperactive bowel sounds obstruction, gastroenteritis,
that it is warm before you referred to as diarrhea, or with use of
place it on the client’s “borborygmus” may also be laxatives. “Hypoactive” bowel
abdomen. Apply light heard. sounds indicate diminished
pressure or simply rest the These are the loud, bowel motility. Common causes
stethoscope on a tender prolonged gurgles include paralytic ileus following
abdomen. Begin in the RLQ characteristic of one’s abdominal surgery,
and proceed clockwise, inflammation of the
“stomach growling.”
covering all quadrants. peritoneum, or late bowel
Listen for at least 5 minutes obstruction.
Decreased or absent bowel
before determining that no
sounds signify the absence of
bowel sounds are present bowel motility, which
and that the bowels are constitutes an emergency
silent. requiring immediate referral.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for Bruits are not normally A bruit with both systolic
heard over abdominal and diastolic components
vascular sounds. occurs when blood flow in
Use the bell of the aorta or renal, iliac, or an artery is turbulent or
stethoscope to listen femoral arteries. obstructed. This may
for bruits (low-pitched, However, bruits indicate an aneurysm or
confined to systole renal arterial stenosis (RAS).
murmur-like sound) When blood flows through a
over the abdominal may be normal in narrow vessel, it makes a
aorta and renal, iliac, some clients whooshing sound, called a
and femoral arteries depending on other bruit. However, the absence
differentiating factors. of this sound does not
exclude the possibility of
RAS.
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Vascular sounds and
friction rubs can
best be heard over
these areas.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Listen for venous Venous hum is not Venous hums are rare.
hum. normally heard over However, an
Using the bell of the the epigastric and accentuated venous
stethoscope, listen for umbilical areas. hum heard in the
a venous hum in the epigastric or umbilical
epigastric and areas suggests
umbilical areas. increased collateral
circulation between
the portal and systemic
venous systems, as in
cirrhosis of the liver.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for a No friction rub over Friction rubs are rare. If
heard, they have a high-
friction rub over the liver or spleen is pitched, rough, grating
liver and spleen. present. sound produced when the
Listen over the right large surface area of the
and left lower rib cage liver or spleen rubs the
peritoneum. They are heard
with the diaphragm of in association with
the stethoscope. 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,
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss for tone. Generalized tympany Accentuated tympany
Lightly and predominates over the or hyperresonance is
systematically percuss abdomen because of heard over a gaseous
all quadrants air in the stomach and distended abdomen.
intestines. Dullness is An enlarged area of
heard over the liver dullness is heard over
and spleen. an enlarged liver or
Dullness may also be spleen.
elicited over a non- Abnormal dullness is
evacuated descending heard over a distended
colon bladder, large masses,
or ascites.
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Abdominal percussion technique
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Abdominal percussion
pattern
sequences may proceed
clockwise or up and
down over the abdomen
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Normal percussion findings.
Blue indicates dullness.
Orange indicates tympany.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss the span or height On deep inspiration,
of the liver by the lower border of
determining its lower and liver dullness may
upper borders. descend from 1 to 4
To assess the lower border,
begin in the RLQ at the cm below the costal
midclavicular line (MCL) and margin.
percuss upward. Note the
change from tympany to
dullness. Mark this point: It is
the lower border of liver
dullness. To assess the
descent of the liver, ask the
client to take a deep breath
and hold; then repeat the
procedure. Remind the client
to exhale after percussing.
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Begin liver percussion in the RLQ and percuss upward
toward the chest.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
To assess the upper The upper border of The upper border of
border, percuss over the liver dullness is located liver dullness may be
upper right chest at the between the left fifth difficult to estimate if
MCL and percuss and seventh intercostal obscured by pleural
downward, noting the
spaces. fluid of lung
change from lung
resonance to liver
consolidation.
dullness. Mark this point:
It is the upper border of
liver dullness.
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Normal liver span
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Repeat percussion of The normal liver span An enlarged liver
the liver at the at the MSL is 4 – 8 cm. maybe roughly
midsternal line (MSL). estimated (not
accurately) when more
intense sounds outline
a liver span or borders
outside the normal
range.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss the spleen. The spleen is an oval Splenomegaly is
Begin posterior to the area of dullness characterized by an
left mid-axillary line approximately 7 cm area of dullness
(MAL), and percuss wide near the left greater than 7 cm
downward, noting the tenth rib and slightly wide. The enlargement
change from lung posterior to the MAL. may result from
resonance to splenic Normally, tympany (or traumatic injury, portal
dullness. resonance) is heard at hypertension, and
the last left interspace. mononucleosis.
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Last left interspace at the anterior axillary line
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform blunt Normally, no Tenderness elicited
percussion on the tenderness is elicited. over the liver may be
liver and the associated with
kidneys. inflammation or
This is to assess for infection (e.g.,
tenderness in difficult- hepatitis or
to-palpate structures. cholecystitis).
Percuss the liver by
placing your left hand
flat against the lower
right anterior rib cage.
Use the ulnar side of
your right fist to strike
your left hand.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform blunt Normally, no Tenderness or sharp
percussion on the tenderness or pain is pain elicited over the
kidneys at the elicited or reported by CVA suggests kidney
costovertebral angles the client. The infection
(CVA) over the twelfth examiner senses only a (pyelonephritis), renal
rib dull thud. calculi, or
hydronephrosis.
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Performing blunt
percussion over the
kidney.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform light Abdomen is nontender Involuntary reflex
palpation. and soft. There is no guarding is serious and
Light palpation is used to guarding. reflects peritoneal
identify areas of tenderness irritation. The abdomen
and muscular resistance. is rigid and the rectus
Using the fingertips, begin muscle fails to relax with
palpation in a nontender palpation when the client
quadrant, and compress to exhales. It can involve all
a depth of 1 cm in a dipping or part of the abdomen
motion. Then gently lift the
but is usually seen on the
fingers and move to the next
side (i.e., right vs. left
area. To minimize the
client’s voluntary guarding rather than upper or
(a tensing or rigidity of the lower) because of nerve
abdominal muscles usually tract patterns. Right-
involving the entire sided guarding may be
abdomen) due to cholecystitis.
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Performing light palpation
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Deeply palpate all Normal (mild) Severe tenderness or
quadrants to tenderness is possible pain may be related to
delineate abdominal over the xiphoid, trauma, peritonitis,
organs and detect aorta, cecum, infection, tumors, or
sigmoid colon, and enlarged or diseased
subtle masses.
ovaries with deep organs.
Using the palmar
palpation.
surface of the fingers,
compress to a maximum
depth (5–6 cm). Perform
bimanual palpation if
you encounter resistance
or to assess deeper
structures
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Performing deep bimanual palpation
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Normally palpable structures in the abdomen
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for masses. No palpable masses A mass detected in any
Note their location, size are present. quadrant may be due
(cm), shape, to a tumor, cyst,
consistency, abscess, enlarged
demarcation, organ, aneurysm, or
pulsatility, tenderness, adhesions.
and mobility. Do not
confuse a mass with an
organ or structure.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the Umbilicus and A soft center of the
umbilicus and surrounding area are umbilicus can be a
surrounding area free of swellings, potential for herniation.
for swellings, bulges, or masses. Palpation of a hard
nodule in or around the
bulges, or masses.
umbilicus may indicate
metastatic nodes from an
occult gastrointestinal
cancer.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the aorta. The aorta is A wide, bounding pulse
Use your thumb and approximately 2.5–3.0 may be felt with an
first finger or use two cm wide with a abdominal aortic
hands and palpate moderately strong and aneurysm. A
deeply in the regular pulse. Possibly prominent, laterally
epigastrium, slightly to mild tenderness may pulsating mass above
the left of midline. be elicited. the umbilicus with an
Assess the pulsation of accompanying audible
the abdominal aorta. bruit strongly suggests
an aortic aneurysm
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Palpating the aorta
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the liver. The liver is usually not A hard, firm liver may
Note consistency and palpable, although it indicate cancer. Nodularity
tenderness. To palpate may occur with tumors,
may be felt in some metastatic cancer, late
bimanually, stand at the
client’s right side and place
thin clients. If the cirrhosis, or syphilis.
your left hand under the lower edge is felt, it Tenderness may be from
client’s back at the level of should be firm, vascular engorgement (e.g.,
the eleventh to twelfth ribs. smooth, and even. congestive heart failure),
Lay your right hand parallel Mild tenderness may acute hepatitis, or abscess.
to the right costal margin A liver more than 1–3 cm
(your fingertips should point be normal. below the costal margin is
toward the client’s head). considered enlarged (unless
Ask the client to inhale, then pressed down by the
compress upward and diaphragm).
inward with your fingers
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Bimanual technique for liver palpation
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the urinary An empty bladder is A distended bladder is
bladder. neither palpable nor palpated as a smooth,
Palpate for a distended tender. round, and somewhat
bladder when the firm mass extending as
client’s history or other far as the umbilicus. It
findings warrant (e.g., may be further
dull percussion noted validated by dull
over the symphysis percussion tones.
pubis). Begin at the
symphysis pubis and
move upward and
outward to estimate
bladder borders
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Palpating distended bladder
(larger dotted line is area of
distention).
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Tests for Appendicitis
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for rebound No rebound The client has rebound
tenderness. tenderness is present. tenderness when the
If the client has abdominal client perceives sharp,
pain or tenderness, test for stabbing pain as the
rebound tenderness by examiner releases
palpating deeply at 90 pressure from the
degrees into the abdomen abdomen (Blumberg’s
away from the painful or sign). It suggests
tender area then suddenly peritoneal irritation (as
release pressure.
from appendicitis). If the
Listen and watch for the
client feels pain at an
client’s expression of pain.
Ask the client to describe area other than where
which hurt more - the you were assessing for
pressing in or the releasing - rebound tenderness,
and where on the abdomen consider that area as the
the pain occurred. source of the pain.
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Assessing for rebound tenderness:
palpating deeply (A); releasing pressure rapidly (B).
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Test for referred No rebound pain is Pain in the RLQ during
rebound tenderness. elicited. pressure in the LLQ is a
Palpate deeply in the positive Rovsing’s sign.
LLQ and quickly release It suggests acute
pressure. appendicitis.
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for psoas No abdominal pain is Pain in the RLQ (Psoas
sign. present. sign) is associated with
Ask the client to lie on irritation of the
the left side. iliopsoas muscle due to
Hyperextend the right appendicitis (an
leg of the client. inflamed appendix).
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Testing for psoas sign
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for obturator No abdominal pain is Pain in the RLQ
sign. present. indicates irritation of
Support the client’s the obturator muscle
right knee and ankle. due to appendicitis or
Flex the hip and knee, a perforated appendix.
and rotate the leg
internally and
externally
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Testing for obturator sign
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform The client feels no pain Pain or an exaggerated
hypersensitivity test. and no exaggerated sensation felt in the
Stroke the abdomen sensation. RLQ is a positive skin
with a sharp object hypersensitivity test
(e.g., broken cotton and may indicate
tipped applicator or appendicitis.
tongue blade) or grasp
a fold of skin with your
thumb and index finger
and quickly let go. Do
this several times along
the abdominal wall.
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Assessment of
Thorax, Breast, & Heart
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The term thorax identifies the portion of the body

extending from the base of the neck superiorly to the
level of the diaphragm inferiorly.
The lungs, distal portion of the trachea, and the bronchi
are located in the thorax and constitute the lower
respiratory system.
The outer structure of the thorax is referred to as the
thoracic cage.
A thorough assessment of the lower respiratory system
focuses on the external chest as well as the respiratory
components in the thoracic cavity.
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Anterior thoracic cage
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Posterior thoracic cage
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Anterior vertical lines (imaginary landmarks)
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Posterior vertical lines (imaginary landmarks)
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Lateral vertical lines (imaginary landmarks)
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Major structures of the
respiratory system
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(A) Anterior view of lung position. (B) Posterior view of lung position.
(C) Lateral view of left lung position. (D) Lateral view of right lung position.
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Mechanics of normal—
not deep, not shallow—
inspiration (left) and
expiration (right).
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect Scapulae are symmetric and Spinous processes that deviate
nonprotruding. laterally in the thoracic area
configuration. Shoulders and scapulae are may indicate scoliosis.
While the client Spinal configurations may have
at equal horizontal
respiratory implications. Ribs
sits with arms at the positions. The ratio of appearing horizontal at an angle
anteroposterior to greater than 45 degrees with
sides, stand behind transverse diameter is 1:2. the spinal column are
the client and Spinous processes appear frequently the result of an
observe the position straight, and thorax appears increased ratio between the
symmetric, with ribs sloping anteroposterior– transverse
of scapulae and the downward at approximately diameter (barrel chest). This
shape and condition is commonly the
a 45-degree angle in
result of emphysema due to
configuration of the relation to the spine. hyperinflation of the lungs.
chest wall
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Observing the posterior thorax
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe use of The client does not use Client leans forward
accessory muscles. accessory (trapezius/ and uses arms to
shoulder) muscles to
Watch as the client assist breathing. The
support weight and
breathes and note diaphragm is the major lift chest to increase
use of muscles. muscle at work. This is breathing capacity,
evidenced by expansion referred to as the
of the lower chest during tripod position.
inspiration.
This is often seen in
COPD
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Tripod position
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the client’s Client should be sitting Tender or painful areas
positioning. up and relaxed, may indicate inflamed
Note the client’s breathing easily with fibrous connective
posture and ability to arms at sides or in lap. tissue. Pain over the
support weight while intercostal spaces may
breathing comfortably. be from inflamed
pleurae.
Pain over the ribs,
especially at the costal
chondral junctions, is a
symptom of fractured
ribs.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for tenderness Client reports no Muscle soreness from
and sensation. tenderness, pain, or exercise or the
Palpation may be performed unusual sensations. excessive work of
with one or both hands, but the
sequence of palpation is Temperature should be breathing (as in COPD)
established. Use your fingers to equal bilaterally. may be palpated as
palpate for tenderness, warmth,
pain, or other sensations. Start
tenderness.
toward the midline at the level Increased warmth may
of the left scapula (over the be related to local
apex of the left lung) and move
your hand left to right,
infection.
comparing findings bilaterally.
Move systematically downward
and out to cover the lateral
portions of the lungs at the
bases.
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Sequence for palpating the posterior thorax
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for crepitus. The examiner finds no Crepitus can be palpated
Crepitus, also called palpable crepitus. if air escapes from the
subcutaneous lung or other airways into
emphysema, is a the subcutaneous tissue,
as occurs after an open
crackling sensation
thoracic injury, around a
(like bones or hairs chest tube, or
rubbing against each tracheostomy. It also may
other) that occurs be palpated in areas of
when air passes extreme congestion or
through fluid or consolidation. In such
exudate. Use your situations, mark margins
fingers and follow the and monitor to note any
sequence when decrease or increase in
palpating. the crepitant area.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate surface Skin and subcutaneous A physician or other
characteristics. tissue are free of appropriate
Put on gloves and use lesions and masses. professional should
your fingers to palpate evaluate any unusual
any lesions that you palpable mass.
noticed during
inspection.
Feel for any unusual
masses.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for fremitus. Fremitus is symmetric Unequal fremitus is
Following the sequence and easily identified usually the result of
described previously, use in the upper regions of consolidation (which
the ball or ulnar edge of the lungs. If fremitus increases fremitus)
one hand to assess is not palpable on either or bronchial obstruction,
for fremitus (vibrations of side, the client may need air trapping in
air in the bronchial to speak louder. A emphysema, pleural
tubes transmitted to the decrease in the intensity effusion, or
chest wall). of fremitus is normal as pneumothorax (which all
As you move your hand the examiner moves decrease fremitus).
to each area, ask the toward the base of the Diminished fremitus even
client to say “ninety- lungs. with a loud spoken voice
nine.” Assess all areas for However, fremitus should may indicate an
symmetry and intensity remain symmetric obstruction of the
of vibration. for bilateral positions. tracheobronchial tree.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess chest When the client takes Unequal chest expansion
expansion. a deep breath, the can occur with severe
(Diaphragmatic examiner’s thumbs atelectasis (collapse or
Excursion) should move 5 to 10 incomplete expansion),
pneumonia, chest
Place your hands on cm apart
trauma, or
the posterior chest wall symmetrically. pneumothorax (air in the
with your thumbs at pleural space).
the level of T9 or T10 Decreased chest
and pressing together excursion at the base of
a small skin fold. As the the lungs is characteristic
client takes a deep of COPD. This is due to
breath, observe the decreased diaphragmatic
movement of your function.
thumbs
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Starting position for
assessing symmetry of
chest expansion
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Start at the apices of percussion tone elicited in cases of
the scapulae and elicited over normal trapped air such as in
percuss across the tops lung tissue. Percussion emphysema or
of both shoulders. Then elicits flat tones over pneumothorax.
percuss the intercostal the scapula.
spaces across and
down, comparing
sides.
Percuss to the lateral
aspects at the bases
of the lungs,
comparing sides.
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Sequence for percussing the posterior thorax
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Normal percussion tones heard from the posterior thorax
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss for Excursion should be Dullness is present when
diaphragmatic equal bilaterally and fluid or solid tissue
replaces air in the lung or
excursion. measure 3–5 cm in occupies the pleural space,
Ask the client to exhale forcefully
and hold the breath. Beginning at
adults. such as in lobar pneumonia,
the scapular line (T7), percuss the The level of the pleural effusion, or tumor.
intercostal spaces of the right Diaphragmatic descent may
posterior chest wall. Percuss
diaphragm may be
be limited by atelectasis of
downward until the tone changes higher on the right the lower lobes or by
from resonance to dullness.
Mark this level and allow the client because of the position emphysema, in which
to breathe. Next ask the client to of the liver. diaphragmatic movement
inhale deeply and hold it. Percuss
the intercostal spaces from the mark In well-conditioned and air trapping are
downward until resonance changes
clients, excursion can minimal. The diaphragm
to dullness. Mark the level and allow remains in a low position on
the client to breathe. Measure the measure up to 7 or 8 inspiration and expiration.
distance between the two marks.
Perform this assessment technique
cm.
on both sides of the posterior
thorax. www.feu.edu.ph
Measuring diaphragmatic excursion
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for breath Three types of normal Diminished or absent breath
sounds. breath sounds may be sounds often indicate that
To begin, place the diaphragm little or no air is moving in
auscultated— or out of the lung area
of the stethoscope firmly and
directly on the posterior chest bronchial, being auscultated.
wall at the apex of the lung at bronchovesicular, In cases of emphysema, the
C7. Ask the client to breathe hyperinflated nature of the
deeply through the mouth for
and vesicular
lungs, together with a loss
each area of auscultation (each of elasticity of lung tissue,
placement of the stethoscope)
may result in diminished
in the auscultation sequence so
that you can best hear inspiratory breath sounds.
inspiratory and expiratory Increased (louder) breath
sounds. Be alert to the client’s sounds often occur when
comfort and offer times for rest consolidation or
and normal breathing if fatigue compression results in a
is becoming a problem. denser lung area.
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Sequence for auscultating the posterior thorax
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Location of breath sounds for the posterior thorax.
V, vesicular sounds; BV, bronchovesicular sounds
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for No adventitious Adventitious lung
adventitious sounds. sounds, such as sounds, such as
Adventitious sounds are crackles (discrete and crackles (formerly
sounds added or discontinuous sounds) called rales) and
superimposed over or wheezes (musical wheezes (formerly
normal breath sounds and continuous), are called rhonchi) are
and heard during
auscultated. evident.
auscultation. Be careful
to note the location on
the chest wall where
adventitious sounds are
heard as well as the
location of such sounds
within the respiratory
cycle.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate voice Voice transmission is The words are easily
sounds. soft, muffled, and understood and louder
indistinct. The sound of over areas of increased
Bronchophony: Ask the the voice may be density. This may
client to repeat the heard but the actual indicate consolidation
phrase “ninety-nine” phrase cannot be from pneumonia,
while you auscultate distinguished. atelectasis, or tumor.
the chest wall.
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Egophony: Ask the Voice transmission will Over areas of
client to repeat the be soft and muffled consolidation or
letter “E” while you but the letter “E” compression,
listen over the chest should be the sound is louder
wall. distinguishable and sounds like “A.”
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Posterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Whispered Transmission of sound Over areas of
pectoriloquy: is very faint and consolidation or
Ask the client to muffled. It may be compression, the
whisper the phrase inaudible. sound is transmitted
“one–two–three” while clearly and distinctly.
you auscultate the In such areas, it sounds
chest wall. as if the client is
whispering directly
into the stethoscope.
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Anterior Thorax
Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for shape The anteroposterior Anteroposterior equals
and configuration. diameter is less than transverse diameter,
Have the client sit with the transverse resulting in a barrel
arms at the sides. diameter. The ratio of chest. This is often
Stand in front of the anteroposterior seen in emphysema
client and assess shape diameter to the because of
and configuration. transverse diameter hyperinflation of the
is 1:2. lungs.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect position of Sternum is Pectus excavatum is a
markedly sunken sternum
the sternum. positioned at midline and adjacent cartilages
Observe the sternum and straight. (often referred to as funnel
from an anterior and chest). It is a congenital
lateral viewpoint. malformation that seldom
causes symptoms other
than self-consciousness.
Pectus carinatum is a
forward protrusion of the
sternum causing the
adjacent ribs to slope
backward. Both conditions
may restrict expansion of
the lungs and decrease lung
capacity.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Watch for sternal Retractions not Sternal retractions
retractions. observed. are noted, with
severely labored
breathing.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect slope of the Ribs slope downward Barrel-chest
ribs. with symmetric configuration results in
Assess the ribs from an intercostal spaces. a more horizontal
anterior and lateral Costal angle is within position of the ribs and
viewpoint. 90 degrees. costal angle of more
than 90 degrees. This
often results from
long-standing
emphysema.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe quality and Respirations are Labored and noisy
pattern of relaxed, effortless, and breathing is often seen
respiration. quiet. They are of a with severe asthma or
Note breathing regular rhythm and chronic bronchitis.
characteristics as well normal depth at a rate Abnormal breathing
as rate, rhythm, and of 10–20 per minute in patterns include
depth. adults. Tachypnea and tachypnea, bradypnea,
bradypnea may be hyperventilation,
normal in some clients. hypoventilation,
Cheyne-Stokes
respiration, and Biot’s
respiration.
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Respiration Patterns
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect intercostal No retractions or Retraction of the
spaces. bulging of intercostal intercostal spaces
Ask the client to spaces are noted. indicates an increased
breathe normally and inspiratory effort. This
observe the inter- may be the result of an
costal spaces. obstruction of the
respiratory tract or
atelectasis. Bulging of
the intercostal spaces
indicates trapped air
such as in emphysema
or asthma.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe for use of Use of accessory Neck muscles
accessory muscles. muscles (sternomastoid,
Ask the client to (sternomastoid and scalene, and trapezius)
breathe normally and rectus abdominis) is are used to facilitate
observe for use of not seen with normal inspiration in cases of
accessory muscles. respiratory effort. After acute or chronic airway
strenuous exercise obstruction or
or activity, clients with atelectasis. The
normal respiratory abdominal muscles
status may use neck and the internal
muscles for a short intercostal muscles are
time to enhance used to facilitate
breathing. expiration in COPD.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for No tenderness or pain Tenderness over
tenderness, sensation, is palpated over the thoracic muscles can
and surface masses. lung area with result from exercising
Use your fingers to respirations. (e.g., pushups)
palpate for tenderness especially in a
and sensation. Start previously sedentary
with your hand client.
positioned over the left
clavicle (over the apex
of the left lung) and
move your hand left to
right, comparing
findings bilaterally.
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Sequence for palpating the anterior thorax
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for Palpation does not Tenderness or pain
tenderness at elicit tenderness. at the costochondral
costochondral junction of the ribs is
junctions of ribs. seen with fractures,
especially in older
clients with
osteoporosis.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for crepitus No crepitus is palpated In areas of extreme
congestion or
consolidation, crepitus
may be palpated,
particularly in clients
with lung disease.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for any No unusual surface Surface masses or
surface masses or masses or lesions are lesions may indicate
lesions. palpated. cysts or tumors.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for fremitus. Fremitus is symmetric Diminished vibrations,
Using the sequence for and easily identified in even with a loud
the anterior chest the upper regions of spoken voice, may
described previously, the lungs. A decreased indicate an obstruction
palpate for fremitus intensity of fremitus is of the
using the same expected toward the tracheobronchial tree.
technique as for the base of the lungs. Clients with
posterior thorax. However, fremitus emphysema may have
should be symmetric considerably
bilaterally. decreased fremitus as
a result of air trapping.
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate anterior Thumbs move outward Unequal chest
chest expansion. in a symmetric fashion expansion can occur
Place your hands on from the midline. with severe atelectasis,
the client’s pneumonia, chest
anterolateral wall with trauma, pleural
your thumbs along the effusion, or
costal margins and pneumothorax.
pointing toward the Decreased chest
xiphoid process. As the excursion at the bases
client takes a deep of the lungs is seen
breath, observe the with COPD.
movement of your
thumbs.
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Palpating anterior chest expansion
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss the apices percussion tone elicited in cases of
above the clavicles. elicited over normal trapped air such as in
Then percuss the lung tissue. Percussion emphysema or
intercostal spaces elicits dullness over pneumothorax.
across and down, breast tissue, the Dullness may
comparing sides heart, and the liver. characterize areas of
Tympany is detected increased density such
over the stomach, and as consolidation,
flatness is detected pleural effusion, or
over the muscles and tumor.
bones.
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Sequence for percussing the anterior thorax
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Anterior Thorax
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for anterior Refer to text in the posterior Refer to text in the posterior
breath sounds, thorax section for normal thorax section for abnormal
voice sounds. voice sounds.
adventitious sounds,
and voice sounds.
Place the diaphragm of the
stethoscope firmly and directly
on the anterior chest wall.
Auscultate from the apices of
the lungs slightly above the
clavicles to the bases of the
lungs at the sixth rib. Ask the
client to breathe deeply through
the mouth in an effort to avoid
transmission of sounds that
may occur with nasal breathing.
Listen at each site for at least
one complete respiratory cycle.
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Sequence for auscultating the anterior thorax
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Normal percussion tones heard from the anterior thorax
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Location of breath sounds for the anterior thorax.
B, bronchial sounds; V, vesicular sounds; BV, bronchovesicular sounds
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The breasts are paired mammary glands that lie over the
muscles of the anterior chest wall, anterior to the
pectoralis major and serratus anterior muscles.
Depending on their size and shape, the breasts extend
vertically from the second to the sixth rib and
horizontally from the sternum to the mid-axillary line.
The male and female breasts are similar until puberty,
when female breast tissue enlarges in response to the
hormones estrogen and progesterone, which are
released from the ovaries.
The female breast is an accessory reproductive organ
with two functions: to produce and store milk that
provides nourishment for newborns and to aid in sexual
stimulation.
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For purposes of describing the location of
assessment findings, the breasts are divided into four
quadrants by drawing horizontal and vertical
imaginary lines that intersect at the nipple.
The upper outer quadrant, which extends into the
axillary area, is referred to as the tail of Spence. Most
breast tumors occur in this quadrant.
Lymph nodes are present in both male and female
breasts. These structures drain lymph from the
breasts to filter out microorganisms and return water
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Anatomic breast landmarks and their position in the thorax.
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Breast quadrants. The upper outer quadrant is the area most
targeted by breast cancer
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Internal anatomy of the breast
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect size and Breasts can be a A recent increase in
symmetry. variety of sizes and are the size of one breast
Have the client disrobe somewhat round and may indicate
and sit with arms pendulous. One breast inflammation or an
hanging freely. Explain may normally be larger abnormal growth.
what you are observing than the other.
to help ease client
anxiety.
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Client should sit with arms hanging freely at sides during
assessment of breast size and symmetry.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect color and Color varies depending Redness is associated
texture. on the client’s skin with breast
Be sure to note client’s tone. Texture is inflammation.
overall skin tone when smooth, with no A pigskin-like or
inspecting the breast edema. orange-peel (peau
skin. Note any lesions. Linear stretch marks d’orange) appearance
may be seen during results from edema,
and after pregnancy or which is seen in
with significant weight metastatic breast
gain or loss. disease. The edema is
caused by blocked
lymphatic drainage.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect superficial Veins radiate either A prominent venous
venous pattern. horizontally and pattern may occur as a
Observe visibility and toward the axilla result of increased
pattern of breast veins. (transverse) or circulation due to a
vertically with a lateral malignancy. An
flare (longitudinal). asymmetric venous
Veins are more pattern may be due to
prominent during malignancy.
pregnancy.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the areolas. Areolas vary from dark Peau d’orange skin,
Note the color, size, pink to dark brown, associated with
shape, and texture of depending on the carcinoma, may be first
the areolas of both client’s skin tones. seen in the areola.
breasts. They are round and Red, scaly, crusty areas
may vary in size. Small are may appear in
Montgomery tubercles Paget’s disease
are present.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the nipples. Nipples are nearly A recently retracted
Note the size and equal bilaterally in size nipple that was
direction of the nipples and are in the same previously everted
of both breasts. Also location on each suggests malignancy.
note any dryness, breast. Nipples are Any type of
lesions, bleeding, or usually everted, but spontaneous discharge
discharge. they may be inverted should be referred for
or flat. cytologic study and
Supernumerary nipples further evaluation.
may appear along the
embryonic “milk line.”
present.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for The client’s breasts Dimpling or retraction
retraction and should rise is usually caused by a
dimpling. symmetrically, with no malignant tumor that
To inspect the breasts sign of dimpling or has fibrous strands
accurately for retraction and retraction. attached to the breast
dimpling, ask the client to tissue and the fascia of
remain seated while
performing several different
the muscles. As the
maneuvers. Ask the client to muscle contracts, it
raise her arms overhead; draws the breast tissue
then press her hands and skin with it,
against her hips. Next ask causing dimpling or
her to press her hands
together. These actions retraction.
contract the pectoral
muscles.
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During assessment for retraction and dimpling, the client first
(A) raises her arms over her head,
(B) then lowers them and presses them against the hips, and finally
(C) presses the hands together with the fingers of one hand pointing opposite to
the fingers of the other hand.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Ask the client to Breasts should hang Restricted movement
lean forward from freely and of breast or retraction
the waist. symmetrically. of the skin or nipple
The nurse should indicates fibrosis and
support the client by fixation of the
the hands or forearms. underlying tissues. This
This is a good position is usually due to an
to use in women who underlying malignant
have large, pendulous tumor.
breasts.
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Forward-leaning position for breast inspection
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate texture and Palpation reveals Thickening of the
elasticity smooth, firm, elastic tissues may with an
tissue. underlying malignant
tumor
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1. Ask the client to lie down and to place overhead the arm on the
same side as the breast being palpated. Place a small pillow or
rolled towel under the breast being palpated.
3. Palpate the breasts using one of three different patterns. Choose
one that is most comfortable for you, but be consistent and
thorough with the method chosen.
4. Be sure to palpate every square inch of the breast, from the
nipple and areola to the periphery of the breast tissue and up
into the tail of Spence. Vary the levels of pressure as you palpate.
Light - superficial
Firm - to the ribs
5. Use the bimanual technique if the client has large breasts.
Support the breast with your nondominant hand and use your
dominant hand to palpate.
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Circular or clockwise Wedged Vertical strip
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Using the flat pads of three
fingers to palpate breast
Bimanual palpation
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for A generalized increase Painful, tender breasts may
in nodularity and be indicative of fibrocystic
tenderness and breasts, especially right
temperature. tenderness may be a before menstruation.
normal finding However, pain may also
associated with the occur with a malignant
menstrual cycle or tumor. Therefore, refer the
client for further evaluation.
hormonal medications. Heat in the breasts of
Breasts should be a women who have not just
normal body given birth or who are not
temperature. lactating indicates
inflammation.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for masses. No masses should be Malignant tumors are
Note location, size in palpated. However, a most often found
centimeters, shape, firm inframammary in the upper outer
mobility, consistency, transverse ridge may quadrant of the breast.
and tenderness. Also normally be palpated They are usually
note the condition of at the lower base of unilateral, with
the skin over the mass. the breasts. irregular, poorly
delineated borders.
They are hard and
nontender and fixed to
underlying tissues.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
If you detect any lump, Fibrocystic breast tissue Fibroadenomas are usually 1–5
cm, round or oval, mobile, firm,
refer the client for that feels ropy, lumpy, or
solid, elastic, nontender, single
further evaluation. bumpy in texture is or multiple benign masses
referred to found in one or both breasts.
as “nodular” or Milk cysts (sacs filled with milk)
and infections (mastitis), may
“glandular” breast tissue.
turn into an abscess and occur
Benign breast disease if breastfeeding or recently
consists of bilateral, given birth.
multiple, firm, regular, Lipomas are a collection of fatty
tissue that may also appear as a
rubbery, mobile nodules
lump.
with well-demarcated Intraductal papilloma is a small
borders. Pain and fullness growth inside a milk duct of the
occurs just before breast, often near the areola. It
is harmless and occurs in
menses.
women ages 35 to 50.
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Female Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the nipples. The nipple may Discharge may be seen in
become erect and the endocrine disorders and
Wear gloves to with certain medications
compress the nipple areola may pucker in (i.e., antihypertensives,
gently with your thumb response to tricyclic antidepressants,
and index finger. Note stimulation. A milky and estrogen). Discharge
any discharge. discharge is usually from one breast may
indicate benign intraductal
normal only during papilloma, fibrocystic
pregnancy and disease, or cancer of the
lactation. However, breast. Sometimes there is
some women may only a watery, pink
normally have a clear discharge from the nipple.
This should be referred to a
discharge. primary care provider
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Palpating nipples for masses and discharge
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The Axillae
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect and palpate No rash or infection Redness and
the axillae. noted. inflammation may be
Ask the client to sit up. seen with infection of
Inspect the axillary skin the sweat gland. Dark,
for rashes or infection. velvety pigmentation
of the axillae
(acanthosis nigricans)
may indicate an
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acanthosis nigricans
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The Axillae
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Hold the client’s elbow No palpable nodes or Enlarged (greater than
with one hand, and use one to two small (less 1 cm) lymph nodes
the three fingerpads of than 1 cm), discrete, may indicate infection
your other hand to nontender, movable of the hand or arm.
palpate firmly the nodes in the central Large nodes that are
axillary lymph nodes area. hard and fixed to the
skin may indicate an
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Palpating the axillary lymph nodes
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Ask the client to Client may request
demonstrate how instructions on how to
she performs BSE perform the exam or
choose not to learn
how to perform the
exam. Either choice
needs to be accepted
by the examiner.
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Self Assessment:
Breast Awareness and
Self-examination
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Male Breasts
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect and palpate No swelling, nodules, Soft, fatty enlargement of
breast tissue is seen in
the breasts, areolas, or ulceration should be obesity. Gynecomastia, a
nipples, and axillae. detected smooth, firm, movable disc
Note any swelling, of glandular tissue,
nodules, or ulceration. may be seen in one breast
in males during puberty,
Palpate the flat disc of usually temporary. However,
undeveloped breast it may also be seen in
tissue under the nipple. hormonal imbalances, drug
abuse, cirrhosis, leukemia,
and thyrotoxicosis.
Irregularly shaped, hard
nodules occur in breast
cancer.
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Gynecomastia
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Gynecomastia
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The cardiovascular system is highly complex,
consisting of the heart and a closed system of blood
vessels.
To collect accurate data and correctly interpret it, the
examiner must have an understanding of the
structure and function of the heart, the great vessels,
the electrical conduction system of the heart, the
cardiac cycle, the production of heart sounds, cardiac
output, and the neck vessels.
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The heart and major blood vessels lie centrally in the
chest behind the protective sternum
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Heart chambers, valves, and
direction of circulatory flow
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Major neck vessels, including the carotid arteries and jugular veins.
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe the jugular The jugular venous Fully distended jugular
venous pulse. pulse is not normally veins with the client
Inspect the jugular venous visible with the client indicate increased
pulse by standing on the right sitting upright. This central venous
side of the client. The client
should be in a supine position position fully distends pressure that may be
with the the head and torso the vein, and the result of right
are on the same plane. Ask pulsations may or may ventricular failure,
the client to turn the head
slightly to the left. Shine a
not be discernible. pulmonary
tangential light source onto hypertension,
the neck to increase pulmonary emboli, or
visualization of pulsations as cardiac tamponade.
well as shadows. Next, inspect
the suprasternal notch or the
area around the clavicles for
pulsations of the internal
jugular veins.
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Evaluate jugular The jugular vein should Clients with
venous pressure. not be distended, obstructive pulmonary
Evaluate jugular venous bulging, or protruding disease may have
pressure by watching for
at 45 degrees or elevated venous
distention of the jugular vein. It
is normal for the jugular veins greater. pressure only during
to be visible when the client is expiration.
supine. To evaluate jugular vein
distention, position the client in
An inspiratory increase
a supine position with the head in venous pressure,
of the bed elevated 30, 45, 60, called Kussmaul’s sign,
and 90°. At each increase of the
elevation, have the client’s head may occur in clients
turned slightly away from the with severe
side being evaluated. Using
constrictive
tangential lighting, observe for
distention, protrusion, or pericarditis.
bulging.
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Assessing jugular venous pressure
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate the No blowing or swishing or A bruit, a blowing or
other sounds are heard. swishing sound caused by
carotid arteries Pulses are equally strong; a turbulent blood flow
if the client is middle- 2+ or normal with no through a narrowed vessel,
aged or older or if you variation in strength from is indicative of occlusive
suspect cardiovascular beat to beat. Contour is arterial disease. However, if
normally smooth and rapid the artery is more than 2/3
disease. Place the bell on the upstroke and slower occluded, a bruit may not
of the stethoscope over and less abrupt on the be heard.
the carotid artery and downstroke. The strength of Pulse inequality may
ask the client to hold the pulse is evaluated on a indicate arterial constriction
his or her breath for a scale from 0 to 4 or occlusion in one carotid.
Weak pulses may indicate
moment so that breath hypovolemia, shock, or
sounds do not conceal decreased cardiac output.
any vascular sounds A bounding, firm pulse may
indicate hypervolemia or
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Auscultating the carotid artery
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Neck Vessels
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the carotid Arteries are elastic and Loss of elasticity may
arteries. no thrills are noted. indicate
Palpate each carotid atherosclerosis. Thrills
artery alternately by may indicate a
placing the pads of the narrowing of the
index and middle fingers artery.
medial to the
sternocleidomastoid
muscle on the neck. Note
amplitude and contour of
the pulse, elasticity of the
artery, and any thrills
(which feel similar to a
purring cat) .
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Palpating the carotid artery
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Palpate the carotid arteries
individually because bilateral
palpation could result in
reduced cerebral blood flow.
If you detect occlusion during

auscultation, palpate very
lightly to avoid blocking
circulation or triggering vagal
stimulation and bradycardia,
hypotension, or even cardiac
arrest.
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect pulsations. The apical impulse may Pulsations, which may
With the client in or may not be visible. If also be called heaves
supine position with apparent, it would be or lifts, other than the
the head of the bed in the mitral area. The apical pulsation are
elevated between 30° apical impulse is a considered abnormal
and 45° stand on the result of the left and should be
client’s right side and ventricle moving evaluated. A heave or
look for the apical outward during lift may occur as the
impulse and any systole. result of an enlarged
abnormal pulsations. ventricle from an
overload of work.
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the apical The apical impulse is The apical impulse may
impulse. palpated in the mitral be impossible to
Remain on the client’s area and may be the palpate in clients with
right side and ask the size of a nickel (1-2 cm). pulmonary
client to remain supine. Amplitude is usually emphysema. If the
small - like a gentle tap. apical impulse is larger
Use one or two finger
The duration is brief, than 1-2 cm, displaced,
pads to palpate the
lasting through the 1st more forceful, or of
apical impulse in the
2/3 of systole and often longer duration,
mitral area. less. In obese clients or
You may ask the client clients with large suspect cardiac
to roll to the left side to breasts, the apical enlargement.
better feel the impulse impulse may not be
using the palmar palpable.
surfaces of your hand.
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Locate the apical impulse with the finger pads (A);
then palpate the apical impulse with the palmar surface (B).
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for No pulsations or A thrill or a pulsation is
abnormal vibrations are palpated usually associated with
pulsations. in the areas of the a grade IV or higher
Use your palmar apex, left sternal murmur.
surfaces to palpate the border, or base.
apex, left sternal
border, and base.
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate heart Rate should be 60-100 Bradycardia or
rate and rhythm. bpm with a regular tachycardia result in
Place the diaphragm of rhythm. A regularly decreased cardiac
the stethoscope at the irregular rhythm, such output. Refer clients
apex and listen closely as sinus arrhythmia with irregular rhythms
to the rate and rhythm when the heart rate (i.e., atrial contraction
of the apical impulse. increases with or premature
inspiration and ventricular) atrial
decreases with fibrillation and atrial
expiration, may be flutter with types of
normal in young irregular patterns may
adults. predispose the client
to decreased cardiac
output, heart
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Traditional Areas of Auscultation
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate to S1 corresponds with Accentuated or
identify S1 and S2. each carotid pulsation diminished S sounds.
Auscultate the first and is loudest at the
heart sound (S1 or apex of the heart.
“lub”) and the second S2 immediately follows
heart sound (S2 or after S1 and is loudest
“dubb”) at the base of the
heart.
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Listen to S1 A distinct sound is Accentuated,
Use the diaphragm of heard in each area but diminished, varying, or
the stethoscope to best loudest at the apex. split S1 are all
hear S1. May become softer abnormal findings
with inspiration. A split
S1 may be heard
normally in young
adults at the left lateral
sternal border.
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Palpating the carotid pulse while auscultating S1
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Listen to S2. Distinct sound is heard Any split S2 heard in
Use the diaphragm of in each area but is expiration is abnormal.
the stethoscope. Ask loudest at the base. The abnormal split can
the client to breathe be one of three types:
regularly wide, fixed, reverse
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Auscultating S2
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for extra Normally no sounds are Ejection sounds or clicks (mid-
heard systolic click associated with
heart sounds. A physiologic S3 heart mitral valve prolapsed)
Use the diaphragm sound is a benign finding
A friction rub may also be heard
first, then the bell to commonly heard at the during the systolic pause
auscultate over the beginning of the diastolic
pause in children, A pathologic S4 (ventricular
entire heart area. adolescents and young gallop) may be heard with
Note characteristics adults (rare after age 40) ischemic heart disease or
(e.g., location, timing) A physiologic S4 heart restrictive heart disease
of any extra sound sound may be heard near
A pathologic S4 (atrial gallop)
heard. Auscultate the end of diastole in well-
toward the left side of the
conditioned athletes and precordium may be heard with
during the systolic adults older than age 40 or coronary artery disease,
pause (space heard 50 with no evidence of hypertensive heart disease
between S1 and S2) heart disease
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Listening to heart sounds with the bell of the stethoscope
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Heart (Precordium)
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for Normally no murmurs Pathologic mid-systolic,
murmurs. are heard Pansystolic and
A murmur is a swishing diastolic murmurs
sound caused by
turbulent blood flow
through the heart valves
or great vessels.
Use the diaphragm and
the bell of the
stethoscope in all areas
of auscultation because
murmurs have a variety
of pitches
Auscultate for murmurs
across the entire heart
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Assessing Abdomen
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Assessing Abdomen
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The abdomen is bordered superiorly by the costal

margins, inferiorly by the symphysis pubis and
inguinal canals, and laterally by the flanks.
It is important to understand the anatomic divisions
known as the abdominal quadrants, the abdominal
wall muscles, and the internal anatomy of the
abdominal cavity in order to perform an adequate
assessment of the abdomen.
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Left
Abdominal quadrants Abdominal regions
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Abdominal wall muscles
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Abdominal viscera
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Position of the kidneys
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Abdominal and vascular
structures (aorta and iliac
artery and vein)
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe the Abdominal skin may Purple discoloration at the
flanks (Grey-Turner sign)
coloration of the be paler than the indicates bleeding within the
skin. general skin tone abdominal wall, possibly from
trauma to the kidneys,
because this skin is pancreas, or duodenum or from
so seldom exposed pancreatitis.
The yellow hue of jaundice may
to the natural be more apparent on the
elements. abdomen.
Pale, taut skin may be seen with
ascites (significant abdominal
swelling indicating fluid
accumulation in the abdominal
cavity).
Redness may indicate
inflammation.
Bruises or areas of local
discoloration are also abnormal.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Note the vascularity of Scattered fine veins Dilated veins may be
the abdominal skin. may be visible. Blood seen with cirrhosis of
in the veins located the liver, obstruction of
above the umbilicus the inferior vena cava,
flows toward the head; portal hypertension, or
blood in the veins ascites.
located below the Dilated surface
umbilicus flows toward arterioles and
the lower body. capillaries with a
central star (spider
angioma) may be seen
with liver disease or
portal hypertension.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Note any striae New striae are pink or Dark bluish-pink striae
(stretch marks) bluish in color; old are associated with
due to past stretching striae are silvery, Cushing’s syndrome.
of the reticular skin white, linear, and Striae may also be
layers due to fast or uneven stretch marks caused by ascites,
prolonged stretching. from past pregnancies which stretches the
or weight gain. skin. Ascites usually
results from liver
failure or liver disease.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect for scars. Pale, smooth, Nonhealing wounds,
Ask about the source of a minimally raised old redness, inflammation.
scar, and use a scars may be seen. Deep, irregular scars
centimeter ruler to may result from burns.
measure the scar’s Keloids (excess scar
length. Document the tissue) result from
location by quadrant and
trauma or surgery
reference lines, shape,
length, and any specific
characteristics (e.g., 3-cm
vertical scar in RLQ 4 cm
below the umbilicus and
5 cm left of the midline).
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Keloid beyond the border of surgical scar
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for lesions and Abdomen is free of Changes in moles
rashes. lesions or rashes. including size, color,
Flat or raised brown and border symmetry.
moles, however, are Bleeding moles or
normal and may be petechiae (reddish or
apparent. purple lesions) may
also be abnormal
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the Umbilical skin tones Cullen’s sign: A bluish
umbilicus. are similar to or purple discoloration
Note the color of surrounding abdominal around the umbilicus
the umbilical area. skin tones or even (periumbilical
pinkish. ecchymosis) indicates
intra-abdominal
bleeding.
Grey-Turner’s sign:
bluish of purplish
discoloration on the
abdominal flanks.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe umbilical Umbilicus is midline at A deviated umbilicus
location. lateral line. may be caused by
pressure from a mass,
enlarged organs,
hernia, fluid, or scar
tissue.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess contour of It is recessed (inverted) An everted umbilicus is
umbilicus. or protruding no more seen with abdominal
than 0.5 cm, and is distention. An
round or conical. enlarged, everted
umbilicus suggests
umbilical hernia.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect abdominal Abdomen is flat, A generalized protuberant
rounded, or scaphoid or distended abdomen may
contour. be due to obesity, air (gas),
Sitting at the client’s (usually seen in thin or fluid accumulation.
side, look across the adults; Distention below the
abdomen at a level Abdomen should be umbilicus may be due to a
full bladder, uterine
slightly higher than the evenly rounded. enlargement, or an ovarian
client’s abdomen. tumor or cyst.
Inspect the area Distention of the upper
between the lower ribs abdomen may be seen with
and pubic bone. masses of the pancreas or
gastric dilation.
Measure abdominal A scaphoid (sunken)
girth. abdomen may be seen with
severe weight loss.
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View abdominal contour from the client’s side. Many abdomens
are more or less flat; and many are round, scaphoid, or
distended.
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Abdominal contours
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess abdominal Abdomen is symmetric. Asymmetry may be
symmetry. seen with organ
Look at the abdomen enlargement, large
as the client lies in a masses, hernia,
relaxed supine diastasis recti, or
position. bowel obstruction.
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Abdominal Bulges
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Abdominal Bulges
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect abdominal Abdominal respiratory Diminished abdominal
movement when the movement may be respiration or change
client breathes seen, especially in to thoracic breathing in
(respiratory male clients. male clients may
movements). reflect peritoneal
irritation.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe aortic A slight pulsation of Vigorous, wide,
pulsations. the abdominal aorta, exaggerated pulsations
which is visible in the may be seen with
epigastrium, extends abdominal aortic
full length in thin aneurysm.
people.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Observe for peristaltic Normally, peristaltic Peristaltic waves are
waves. waves are not seen, increased and progress
although they may be in a ripple-like fashion
visible in very thin from the LUQ to the
people as slight ripples RLQ with intestinal
on the abdominal wall. obstruction (especially
small intestine). In
addition, abdominal
distention typically is
present with intestinal
wall obstruction.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for bowel A series of intermittent, soft “Hyperactive” bowel sounds
clicks and gurgles are heard that are rushing, tinkling, and
sounds. at a rate of 5–30 per high pitched may be abnormal
Use the diaphragm of the indicating very rapid motility
minute.
stethoscope and make sure heard in early bowel
Hyperactive bowel sounds obstruction, gastroenteritis,
that it is warm before you referred to as diarrhea, or with use of
place it on the client’s “borborygmus” may also be laxatives. “Hypoactive” bowel
abdomen. Apply light heard. sounds indicate diminished
pressure or simply rest the These are the loud, bowel motility. Common causes
stethoscope on a tender prolonged gurgles include paralytic ileus following
abdomen. Begin in the RLQ characteristic of one’s abdominal surgery,
and proceed clockwise, inflammation of the
“stomach growling.”
covering all quadrants. peritoneum, or late bowel
Listen for at least 5 minutes obstruction.
Decreased or absent bowel
before determining that no
sounds signify the absence of
bowel sounds are present bowel motility, which
and that the bowels are constitutes an emergency
silent. requiring immediate referral.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for Bruits are not normally A bruit with both systolic
heard over abdominal and diastolic components
vascular sounds. occurs when blood flow in
Use the bell of the aorta or renal, iliac, or an artery is turbulent or
stethoscope to listen femoral arteries. obstructed. This may
for bruits (low-pitched, However, bruits indicate an aneurysm or
confined to systole renal arterial stenosis (RAS).
murmur-like sound) When blood flows through a
over the abdominal may be normal in narrow vessel, it makes a
aorta and renal, iliac, some clients whooshing sound, called a
and femoral arteries depending on other bruit. However, the absence
differentiating factors. of this sound does not
exclude the possibility of
RAS.
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Vascular sounds and
friction rubs can
best be heard over
these areas.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Listen for venous Venous hum is not Venous hums are rare.
hum. normally heard over However, an
Using the bell of the the epigastric and accentuated venous
stethoscope, listen for umbilical areas. hum heard in the
a venous hum in the epigastric or umbilical
epigastric and areas suggests
umbilical areas. increased collateral
circulation between
the portal and systemic
venous systems, as in
cirrhosis of the liver.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Auscultate for a No friction rub over Friction rubs are rare. If
heard, they have a high-
friction rub over the liver or spleen is pitched, rough, grating
liver and spleen. present. sound produced when the
Listen over the right large surface area of the
and left lower rib cage liver or spleen rubs the
peritoneum. They are heard
with the diaphragm of in association with
the stethoscope. 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,
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss for tone. Generalized tympany Accentuated tympany
Lightly and predominates over the or hyperresonance is
systematically percuss abdomen because of heard over a gaseous
all quadrants air in the stomach and distended abdomen.
intestines. Dullness is An enlarged area of
heard over the liver dullness is heard over
and spleen. an enlarged liver or
Dullness may also be spleen.
elicited over a non- Abnormal dullness is
evacuated descending heard over a distended
colon bladder, large masses,
or ascites.
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Abdominal percussion technique
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pattern
sequences may proceed
clockwise or up and
down over the abdomen
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Normal percussion findings.
Blue indicates dullness.
Orange indicates tympany.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss the span or height On deep inspiration,
of the liver by the lower border of
determining its lower and liver dullness may
upper borders. descend from 1 to 4
To assess the lower border,
begin in the RLQ at the cm below the costal
midclavicular line (MCL) and margin.
percuss upward. Note the
change from tympany to
dullness. Mark this point: It is
the lower border of liver
dullness. To assess the
descent of the liver, ask the
client to take a deep breath
and hold; then repeat the
procedure. Remind the client
to exhale after percussing.
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Begin liver percussion in the RLQ and percuss upward
toward the chest.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
To assess the upper The upper border of The upper border of
border, percuss over the liver dullness is located liver dullness may be
upper right chest at the between the left fifth difficult to estimate if
MCL and percuss and seventh intercostal obscured by pleural
downward, noting the
spaces. fluid of lung
change from lung
resonance to liver
consolidation.
dullness. Mark this point:
It is the upper border of
liver dullness.
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Normal liver span
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Repeat percussion of The normal liver span An enlarged liver
the liver at the at the MSL is 4 – 8 cm. maybe roughly
midsternal line (MSL). estimated (not
accurately) when more
intense sounds outline
a liver span or borders
outside the normal
range.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Percuss the spleen. The spleen is an oval Splenomegaly is
Begin posterior to the area of dullness characterized by an
left mid-axillary line approximately 7 cm area of dullness
(MAL), and percuss wide near the left greater than 7 cm
downward, noting the tenth rib and slightly wide. The enlargement
change from lung posterior to the MAL. may result from
resonance to splenic Normally, tympany (or traumatic injury, portal
dullness. resonance) is heard at hypertension, and
the last left interspace. mononucleosis.
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Last left interspace at the anterior axillary line
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform blunt Normally, no Tenderness elicited
percussion on the tenderness is elicited. over the liver may be
liver and the associated with
kidneys. inflammation or
This is to assess for infection (e.g.,
tenderness in difficult- hepatitis or
to-palpate structures. cholecystitis).
Percuss the liver by
placing your left hand
flat against the lower
right anterior rib cage.
Use the ulnar side of
your right fist to strike
your left hand.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform blunt Normally, no Tenderness or sharp
percussion on the tenderness or pain is pain elicited over the
kidneys at the elicited or reported by CVA suggests kidney
costovertebral angles the client. The infection
(CVA) over the twelfth examiner senses only a (pyelonephritis), renal
rib dull thud. calculi, or
hydronephrosis.
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Performing blunt
percussion over the
kidney.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform light Abdomen is nontender Involuntary reflex
palpation. and soft. There is no guarding is serious and
Light palpation is used to guarding. reflects peritoneal
identify areas of tenderness irritation. The abdomen
and muscular resistance. is rigid and the rectus
Using the fingertips, begin muscle fails to relax with
palpation in a nontender palpation when the client
quadrant, and compress to exhales. It can involve all
a depth of 1 cm in a dipping or part of the abdomen
motion. Then gently lift the
but is usually seen on the
fingers and move to the next
side (i.e., right vs. left
area. To minimize the
client’s voluntary guarding rather than upper or
(a tensing or rigidity of the lower) because of nerve
abdominal muscles usually tract patterns. Right-
involving the entire sided guarding may be
abdomen) due to cholecystitis.
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Performing light palpation
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Deeply palpate all Normal (mild) Severe tenderness or
quadrants to tenderness is possible pain may be related to
delineate abdominal over the xiphoid, trauma, peritonitis,
organs and detect aorta, cecum, infection, tumors, or
sigmoid colon, and enlarged or diseased
subtle masses.
ovaries with deep organs.
Using the palmar
palpation.
surface of the fingers,
compress to a maximum
depth (5–6 cm). Perform
bimanual palpation if
you encounter resistance
or to assess deeper
structures
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Performing deep bimanual palpation
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Normally palpable structures in the abdomen
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate for masses. No palpable masses A mass detected in any
Note their location, size are present. quadrant may be due
(cm), shape, to a tumor, cyst,
consistency, abscess, enlarged
demarcation, organ, aneurysm, or
pulsatility, tenderness, adhesions.
and mobility. Do not
confuse a mass with an
organ or structure.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the Umbilicus and A soft center of the
umbilicus and surrounding area are umbilicus can be a
surrounding area free of swellings, potential for herniation.
for swellings, bulges, or masses. Palpation of a hard
nodule in or around the
bulges, or masses.
umbilicus may indicate
metastatic nodes from an
occult gastrointestinal
cancer.
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the aorta. The aorta is A wide, bounding pulse
Use your thumb and approximately 2.5–3.0 may be felt with an
first finger or use two cm wide with a abdominal aortic
hands and palpate moderately strong and aneurysm. A
deeply in the regular pulse. Possibly prominent, laterally
epigastrium, slightly to mild tenderness may pulsating mass above
the left of midline. be elicited. the umbilicus with an
Assess the pulsation of accompanying audible
the abdominal aorta. bruit strongly suggests
an aortic aneurysm
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Palpating the aorta
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the liver. The liver is usually not A hard, firm liver may
Note consistency and palpable, although it indicate cancer. Nodularity
tenderness. To palpate may occur with tumors,
may be felt in some metastatic cancer, late
bimanually, stand at the
client’s right side and place
thin clients. If the cirrhosis, or syphilis.
your left hand under the lower edge is felt, it Tenderness may be from
client’s back at the level of should be firm, vascular engorgement (e.g.,
the eleventh to twelfth ribs. smooth, and even. congestive heart failure),
Lay your right hand parallel Mild tenderness may acute hepatitis, or abscess.
to the right costal margin A liver more than 1–3 cm
(your fingertips should point be normal. below the costal margin is
toward the client’s head). considered enlarged (unless
Ask the client to inhale, then pressed down by the
compress upward and diaphragm).
inward with your fingers
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Bimanual technique for liver palpation
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Abdomen
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the urinary An empty bladder is A distended bladder is
bladder. neither palpable nor palpated as a smooth,
Palpate for a distended tender. round, and somewhat
bladder when the firm mass extending as
client’s history or other far as the umbilicus. It
findings warrant (e.g., may be further
dull percussion noted validated by dull
over the symphysis percussion tones.
pubis). Begin at the
symphysis pubis and
move upward and
outward to estimate
bladder borders
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Palpating distended bladder
(larger dotted line is area of
distention).
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for rebound No rebound The client has rebound
tenderness. tenderness is present. tenderness when the
If the client has abdominal client perceives sharp,
pain or tenderness, test for stabbing pain as the
rebound tenderness by examiner releases
palpating deeply at 90 pressure from the
degrees into the abdomen abdomen (Blumberg’s
away from the painful or sign). It suggests
tender area then suddenly peritoneal irritation (as
release pressure.
from appendicitis). If the
Listen and watch for the
client feels pain at an
client’s expression of pain.
Ask the client to describe area other than where
which hurt more - the you were assessing for
pressing in or the releasing - rebound tenderness,
and where on the abdomen consider that area as the
the pain occurred. source of the pain.
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Assessing for rebound tenderness:
palpating deeply (A); releasing pressure rapidly (B).
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Test for referred No rebound pain is Pain in the RLQ during
rebound tenderness. elicited. pressure in the LLQ is a
Palpate deeply in the positive Rovsing’s sign.
LLQ and quickly release It suggests acute
pressure. appendicitis.
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for psoas No abdominal pain is Pain in the RLQ (Psoas
sign. present. sign) is associated with
Ask the client to lie on irritation of the
the left side. iliopsoas muscle due to
Hyperextend the right appendicitis (an
leg of the client. inflamed appendix).
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Testing for psoas sign
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess for obturator No abdominal pain is Pain in the RLQ
sign. present. indicates irritation of
Support the client’s the obturator muscle
right knee and ankle. due to appendicitis or
Flex the hip and knee, a perforated appendix.
and rotate the leg
internally and
externally
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Testing for obturator sign
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Perform The client feels no pain Pain or an exaggerated
hypersensitivity test. and no exaggerated sensation felt in the
Stroke the abdomen sensation. RLQ is a positive skin
with a sharp object hypersensitivity test
(e.g., broken cotton and may indicate
tipped applicator or appendicitis.
tongue blade) or grasp
a fold of skin with your
thumb and index finger
and quickly let go. Do
this several times along
the abdominal wall.
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MUSCULOSKELETAL ASSESSMENT
(Weeks No. 14-15)
INTRODUCTION
The musculoskeletal system is an organ

system that enables an organism to
move, support itself, and maintain
stability during locomotion.
The musculoskeletal system is made up

of the body’s bones (the skeleton),
muscles, cartilage, tendons, ligaments,
joints, and other connective tissue that
supports and binds tissues and organs
together. Its primary functions include
supporting the body, allowing motion,
and protecting vital organs.
The bones of the skeletal system provide
stability to the body analogous to a
reinforcement bar in concrete construction. Muscles keep bones in
place and also play a role in their movement. To allow motion,
different bones are connected by articulating joints, and cartilage
prevents the bone ends from rubbing directly onto each other.
LEARNING OUTCOME

1. Identify body parts related to the musculoskeletal system
2. Identify the appropriate techniques of assessment (IPPA) in assessing
the client.
3. Identify and document normal and deviation from normal findings
from the different assessment techniques in assessing head to neck
4. Demonstrate how to assess client pertaining to the musculoskeletal
system via video presentation.
5. Document findings accurately.
Far Eastern University 1

Manila, Philippines
OUTLINE
1. Structure and Function

2. Skeletal Muscle Movement
3. Bones Movement
4. Joints Movement
CONTENT
The musculoskeletal system encompasses the muscles, bones, and

joints.
The nurse usually assesses the musculoskeletal system for muscle
strength, tone, size, and symmetry of muscle development, and for
tremors.
A tremor is an involuntary trembling of a limb or body part. Tremors
may involve large groups of muscle fibers or small bundles of muscle
fibers.
An intention tremor becomes more apparent when an individual
attempts a voluntary movement, such as holding a cup of coffee.
A resting tremor is more apparent when the client is at rest and

diminishes with activity.
A fasciculation is an abnormal contraction of a bundle of muscle
fibers that appears as a twitch.
Bones are assessed for normal form.
Joints are assessed for tenderness, swelling, thickening, crepitation
(a crackling, grating sound), and range of motion.
Body posture is assessed for normal standing and sitting positions.
Skeletal muscle movements:

• Abduction: Moving away from midline of the body
• Adduction: Moving toward midline of the body
• Circumduction: Circular motion
• Inversion: Moving inward
• Eversion: Moving outward
• Extension: Straightening the extremity at the joint and
increasing the angle of the joint
• Hyperextension: Joint bends greater than 180 degrees
• Flexion: Bending the extremity at the joint and decreasing the
angle of the joint
• Dorsiflexion: Toes draw upward to ankle

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• Plantar flexion: Toes point away from ankle

• Pronation: Turning or facing downward
• Supination: Turning or facing upward
• Protraction: Moving forward
• Retraction: Moving backward
• Rotation: Turning of a bone on its own long axis
• Internal rotation: Turning of a bone toward the center of the
body
• External rotation: Turning of a bone away from the center of
the body
Body Parts Normal Findings

Inspect the muscles for size. Equal in size on both side of the body
Compare each muscle on one side of
the body to the same muscle on the
other side.
Inspect the muscles and tendons for No contracture
contractures.
Inspect the muscles for tremors. No fasciculations and tremors
Palpate muscles at rest to determine Normally firm
muscle tonicity.
Palpate muscles while the client is Smooth, coordinated movements
active and passive for flaccidity,
spasticity, and smoothness of

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movement.
Test muscle strength of the head & Equal in strength on each side
shoulders
Test muscle strength of upper Equal in strength on each side
extremities
Test muscle strength of lower Equal in strength on each side
extremities
Inspect the skeleton for normal No deformities
structure and deformities.
Palpate the bones to locate any areas No tenderness and or swelling
of edema or tenderness.
Inspect the joint for swelling. No swelling
Palpate each joint for tenderness, No tenderness, swelling, crepitation
smoothness of movement, swelling, or nodules. Joint moves smoothly
crepitation, and presence of nodules.
Assess joint range of motion of the Varies to some degree in accordance
head with person’s genetic makeup and
* Ask the client to move selected degree of physical activity.
body parts. If available, use a Full range of motion.
goniometer to measure the angle of
the joint in degrees.
Assess joint range of motion of body *Kindly see different angle

trunk results base on specific types of
joint movement
Assess joint range of motion of upper *Kindly see different angle
extremities results base on specific types of
joint movement
Assess joint range of motion of lower *Kindly see different angle
extremities results base on specific types of
joint movement
Document findings and observations.
Testing muscle Strength Description

Sternocleidomastoid Client turns the head to one side
against the resistance of your hand.
Repeat with the other side.
Trapezius Client shrugs the shoulders against
the resistance of your hands.
Deltoid Client holds arm up and resists while
you try to push it down.

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Biceps Client fully extends each arm and

tries to flex it while you attempt to
hold arm in extension.
Triceps Client flexes each arm and then tries
to extends it against your attempt to
keep in flexion
Wrist and Finger Muscles Client spreads the fingers and resists
as you attempt to push the fingers
together.
Grip Strength Client grasps your index finger and

middle fingers while you try to pull
the fingers out.
Hip muscles Client is supine, both legs extended;

client raises one leg at a time while
you attempt to hold it down.
Hip Abduction Client is supine, both legs extended.

Place your hands on the lateral
surface of each knee; client spreads
the legs apart against your
resistance.
Hip Adduction Client is in same position as in hip
abduction. Place your hands between
the knees; client brings the legs
together against your resistance.
Hamstrings Client is supine, both knees bent.

Client resists while you attempt to
straighten the legs.
Quadriceps Client is supine, knee partially

extended; client resists while you
attempt to flex the knee.
Muscles of the ankles and feet Client resists while you attempt to
dorsiflex the foot and and again
resists while you attempt to flex the
foot.

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Types of Joint Movement Description

Flexion Decreasing the angle of the joint
(e,g. bending the elbow)
Extension Increasing the angle of the joint
(e.g. straightening the arm at the
elbow)
Hyperextension Further extension or
straightening of a joint (e.g.
bending the head backward)
Abduction Movement of the joint away from
the midline of the body
Adduction Movement of the joint toward the
midline of the body
Rotation Movement of the body around tis
central axis
Circumduction Movement of the distal part of
the bone in a circle while the
proximal end remains fixed
Eversion Turning the sole of the foot
outward by moving the ankle
joint

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Inversion Turning the sole of the foot

inward by moving the ankle joint
Pronation Moving the bones of the forearm
so that the palm of the hand
faces downward when held
infront of the body
Supination Moving the bones of the forearm
so that the palm of the hand
faces upward when held infront
of the body

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REFERENCES
Nursing (6th ed.).

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Francis Obmerga, PhD, RN
Assessing
Musculoskeletal
System
Part 1 (Muscles & Bones)
The musculoskeletal system encompasses the
muscles, bones, and joints.
The nurse usually assesses the musculoskeletal
system for muscle strength, tone, size, and symmetry
of muscle development, and for tremors.
A tremor is an involuntary trembling of a limb or
body part. Tremors may involve large groups of
muscle fibers or small bundles of muscle fibers.
An intention tremor becomes more apparent when
an individual attempts a voluntary movement, such
as holding a cup of coffee.
A resting tremor is more apparent when the client is
at rest and diminishes with activity.
A fasciculation is an abnormal contraction of a
bundle of muscle fibers that appears as a twitch.
Bones are assessed for normal form.
Joints are assessed for tenderness, swelling,
thickening, crepitation (a crackling, grating sound),
and range of motion.
Body posture is assessed for normal standing and
sitting positions.
Major bones of the
skeleton.
The axial skeleton is shown
in yellow;
the appendicular skeleton
is shown in blue.
Skeletal muscle movements:
• Abduction: Moving away from midline of the
body
• Adduction: Moving toward midline of the body
• Circumduction: Circular motion
• Inversion: Moving inward
• Eversion: Moving outward
• Extension: Straightening the extremity at the
joint and increasing the angle of the joint
• Hyperextension: Joint bends greater than 180
degrees
• Flexion: Bending the extremity at the joint and
decreasing the angle of the joint
• Dorsiflexion: Toes draw upward to ankle
• Plantar flexion: Toes point away from ankle
• Pronation: Turning or facing downward
• Supination: Turning or facing upward
• Protraction: Moving forward
• Retraction: Moving backward
• Rotation: Turning of a bone on its own long axis
• Internal rotation: Turning of a bone toward the
center of the body
• External rotation: Turning of a bone away from
the center of the body
Muscles of the body
Understanding Major Joints
Muscles
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the muscles Equal size on both Atrophy (a decrease in
for size. sides of body size) or hypertrophy
Compare each muscle (an increased in size)
on one side of the body
to the same muscle on
the other side. For any
apparent
discrepancies, measure
the muscles with a
tape.
Muscle Atrophy
Muscle Hypertrophy
Muscles
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the muscles No contractures Malposition of body
and tendons for part (foot drop or foot
contractures. flexed forward)
Muscles
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the muscles No fasciculation or Presence of
for tremors. tremors fasciculation or tremors
Inspect any tremors of
the hands and arms by
having the client hold
arms out in front of
body.
Muscles
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate muscles at rest Normally firm Atonic (lacking tone)
to determine muscle
tonicity.
Palpate muscles while Smooth coordinated Flaccidity (weakness or
the client is active and movements laxness) or spasticity
passive for flaccidity, (sudden involuntary
spasticity, and muscle contraction)
smoothness of
movement.
Test muscle strength. Equal strength on each 25% or less muscle
Compare the right side body side strength
with left side.
Grading Muscle Strength
GRADE DESCRIPTION
100% of normal muscle strength; normal full movement
5
against gravity and against full resistance.
75% of normal strength; normal full movement against
4
gravity and against minimal resistance.
50% of normal strength; normal movement against
3
gravity.
25% of normal strength; full muscle movement against
2
gravity, with support.
10% of normal strength; no movement, contraction of
1
muscle is palpable or visible.
0 0% of normal strength; complete paralysis
1/7/2021 12:38 PM Lecturer: FRANCIS OBMERGA, 24

Sternocleidomastoid
Client turns the head to one side against the resistance of
your hand. Repeat with the other side.
Trapezius
Client shrugs the shoulders against the resistance of your
hands.
Deltoid
Client holds arm up and resists while you try to push it
down.
Biceps
Client fully extends each arm and tries to flex it while you
attempt to hold arm in extension.
Triceps
Client flexes each arm and then tries to extends it against
your attempt to keep in flexion
Wrist and Finger Muscles
Client spreads the fingers and resists as you attempt to
push the fingers together.
Grip strength
Client grasps your index finger and middle fingers while
you try to pull the fingers out.
Hip Muscles
Client is supine, both legs extended; client raises one leg
at a time while you attempt to hold it down.
Hip abduction
Client is supine, both legs extended. Place your hands on
the lateral surface of each knee; client spreads the legs
apart against your resistance.
Hip adduction
Client is in same position as in hip abduction. Place your
hands between the knees; client brings the legs together
against your resistance.
Hamstrings
Client is supine, both knees bent. Client resists while you
attempt to straighten the legs.
Quadriceps
Client is supine, knee partially extended; client resists
while you attempt to flex the knee.
Muscles of the ankle and feet

Client resists while you attempt to dorsiflex the foot and
and again resists while you attempt to flex the foot.
Bones
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the skeleton No deformities Bones misaligned
for normal structure
and deformities.
Palpate the bones to No tenderness of Presence tenderness of
locate any areas of swelling swelling
edema or tenderness.
Francis Obmerga, PhD, RN
Assessing
Musculoskeletal
System
Part 2 (Joints)
Joints
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Inspect the joint for No swelling One or more swollen
swelling. No tenderness, joints.
Palpate each joint for crepitation, or nodules Presence of
tenderness, tenderness, swelling,
smoothness of crepitation, or nodules
movement, swelling,
crepitation, and
presence of nodules.
Joints
DEVIATION FROM
NORMAL FINDINGS
NORMAL
Assess joint range of Varies to some degree Limited range of
motion. in accordance with motion in one or more
Ask the client to move person’s genetic joints
selected body parts. If makeup and degree of
available, use a physical activity.
goniometer to measure Full range of motion.
the angle of the joint in
degrees.
Flexion. Move the head from the upright midline position forward, so that
the chin rests on the chest; Extension. Move the head from the flexed
position to the upright position; Hyperextension. Move the head from the
upright position back as far as possible.
Neck-Pivot Joint
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Lateral flexion. Move the head laterally to the right and left shoulders
Neck-Pivot Joint
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Rotation. Turn the face as far as possible to the right and left
Neck-Pivot Joint
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Flexion. Raise each arm from a position
by the side forward and upward to a
position beside the head;
Extension. Move each arm from a
vertical position beside the head
forward and down to a resting position
at the side of the body;
Hyperextension. Move each arm from
a resting side position to behind the
body.
Shoulder-Ball-and-Socket Joint
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Abduction. Move each arm
laterally from a resting position at
the sides to a side position above
the head, palm of the hand away
from the head;
Adduction (anterior). Move each
arm from a position at the sides
across the front of the body as far
as possible. The elbow may be
straight or bent.
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Circumduction. Move each arm forward, up, back, and down in a full circle
1/7/2021 12:42 PM 16
External rotation. With each arm held
out to the side at shoulder level and the
elbow bent to a right angle, fingers
pointing down, move the arm upward
so that the fingers point up;
Internal rotation. With each arm held
out to the side at shoulder level and the
elbow bent to a right angle, fingers
pointing up, move the arm forward and
down so that the fingers point down
1/7/2021 12:42 PM 17
Flexion. Bring each lower arm forward and upward so that the hand is at the
shoulder;
Extension. Bring each lower arm forward and downward, straightening
Elbow-Hinge Joint
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Rotation for supination. Turn
each hand and forearm so that
the palm is facing upward;
Rotation for pronation. Turn
each hand and forearm so that
the palm is facing downward.
Elbow-Hinge Joint
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Flexion. Bring the fingers of each hand toward the inner aspect of the
forearm; Extension. Straighten each hand to the same plane as the arm.
Wrist-Condyloid Joint
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Hyperextension. Bend the fingers of each hand back as far as possible.
1/7/2021 12:42 PM 25
Radial flexion (abduction).
Bend each wrist laterally
toward the thumb side with
hand supinated;
Ulnar flexion (adduction).
Bend each wrist laterally
toward the fifth finger with
the hand supinated.
1/7/2021 12:42 PM 26
Flexion. Make a fist with each hand;
Extension. Straighten the fingers of each hand;
Hyperextension. Bend the fingers of each hand back as far as possible.
1/7/2021 12:42 PM 28
Abduction. Spread the fingers of
each hand apart;
Adduction. Bring the fingers of
each hand together.
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Flexion. Move each thumb across
the palmar surface of the hand
toward the fifth finger;
Extension. Move each thumb away
from the hand.
Thumb-Saddle Joint
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Abduction. Extend each thumb laterally;
Adduction. Move each thumb back to the hand.
Thumb-Saddle Joint
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Opposition. Touch each thumb to the top of each finger of the same hand.
The thumb joint movements involved are abduction, rotation, and flexion.
Thumb-Saddle Joint
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Flexion. Move each leg forward and upward. The knee may be extended or
flexed.
Hip-Ball-and-Socket Joint
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Extension. Move each leg back inside the other.
Hyperextension. Move each leg back behind the body.
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Abduction. Move each leg out to the side;
Adduction. Move each leg back to the other leg and beyond in front of it.
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Circumduction. Move each leg backward, up, to the side, and down in a
circle
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Internal rotation. Turn each
foot and leg inward so that
the toes point as far as
possible toward the other
leg; External rotation. Turn
each foot and leg outward so
that the toes point as far as
possible away from the other
leg.
1/7/2021 12:42 PM 41
Flexion. Bend each leg, bringing the heel toward the back of the thigh.
Extension. Straighten each leg, returning the foot to its position beside the
other foot.
Knee-Hinge Joint
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Extension (plantar flexion). Point the toes of each foot downward;
Flexion (dorsiflexion). Point the toes of each foot upward.
Ankle-Hinge Joint
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Eversion. Turn the sole of each laterally;
Inversion. Turn the sole of each foot medially.
Foot-Gliding
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Flexion. Curl the toe joints of each foot downward;
Extension. Straighten the toes of each foot.
Toes
1/7/2021 12:42 PM 45
Flexion. Bend the trunk
toward the toes;
Extension. Straighten the
trunk from a flexed position;
Hyperextension. Bend the
trunk backward.
Trunk-Gliding Joint
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Lateral flexion. Bend the
trunk to the right and to
the left.
Trunk-Gliding Joint
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Rotation. Turn the upper
part of the body from side
to side.
Trunk-Gliding Joint
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LABORATORY AND DIAGNOSTIC TESTS

(Week No. 16)
INTRODUCTION
Reviewing certain laboratory tests can yield valuable information

about the client’s health status. Laboratory information enables
healthcare professionals to make appropriate evidence-based
diagnostic or therapeutic decisions for their clients/patients. Clinical
laboratory services are the most cost effective, least invasive source
of the objective information used in clinical decision-making (The
American Society of Clinical Laboratory Science, 2005).
This module expounds on the value of laboratory and diagnostic test

procedures and results to a nurse in evaluating a person’s health
status and needs.
LEARNING OUTCOME

1. Familiarize self with common laboratory and diagnostic procedures.
2. Assume the specific roles of the nurse before, during, and after
laboratory and diagnostic test procedures.
3. Read and understand laboratory and diagnostic test results.
4. Identify normal findings and those that deviate from normal
values/standards.
5. Understand how laboratory and diagnostic findings contribute to the
evidence for identifying nursing health problems.
OUTLINE
• Diagnostic and Laboratory Overview
• Preparing for Diagnostic testing
• Blood Tests: Complete Blood Count (CBC) & Clinical Implications
• Blood Tests: Serum Electrolyte
• Blood Tests: Blood Chemistry & Clinical Implications
• Specimen Collecting and Testing: Stool Specimen
• Specimen Collecting and Testing: Urine Specimen
• Visualization Procedures: Electrocardiography
• Visualization Procedures: Stress Electrocardiography
• Visualization Procedures: Angiography
• Visualization Procedures: Computed Tomography (CT)

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• Visualization Procedures: Magnetic Resonance Imaging (MRI)
CONTENT
Diagnostic and Laboratory Tests

• commonly called laboratory tests
• are tools that provide information about the client.
• Tests may be used for basic screening as part of a wellness check.
• Frequently tests are used to help confirm a diagnosis, monitor an illness,
and provide valuable information about the client’s response to
treatment.
• Nurses require knowledge of the most common laboratory and
diagnostic tests because one primary role of the nurse is to teach the
client and family or significant other how to prepare for the test and the
care that may be required following the test.
• Nurses must also know the implications of the test results in order to
provide the most appropriate nursing care for the client.
• Diagnostic testing occurs in many environments. The traditional sites
include hospitals, clinics, and the primary care provider’s office.
• Many test sites, however, are moving to the community. Examples
include the home, workplace, shopping malls, and mobile units.
• Diagnostic testing involves three phases: pretest, intratest, and post-
test.
Preparing for Diagnostic Testing

• Instruct the client and family about the procedure for the diagnostic
testing ordered (e.g., whether food is allowed prior to or after testing,
and the length of time of the testing).
• Explain the purpose of the test.
• Instruct the client and family about activity restrictions related to testing
(e.g., remain supine for 1 hour after testing is completed).
• Instruct the client and family on the reaction the diagnostic test may
produce (e.g., flushing when the dye is injected).
• Provide the client with detailed information about the diagnostic testing
equipment.
• Inform the client and family of the time frame for when the results will
be available.
• Instruct the client and family to ask any questions so that the health
care provider can clarify information and allay any fears.

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Blood Tests
• Blood tests are commonly used diagnostic tests that can provide
valuable information about the hematologic system and many other
body systems.
• A venipuncture (puncture of a vein for collection of a blood specimen)
can be performed by various members of the health care team.
• A phlebotomist, a person from a laboratory who performs
venipuncture, usually collects the blood specimen for the tests ordered
by the primary care provider.
• In some institutions, nurses may draw blood samples. The nurse needs
to know the guidelines for drawing blood samples for the facility and
also the state’s nurse practice act.
Complete Blood Count

• Specimens of venous blood are taken for a complete blood count
(CBC), which includes hemoglobin and hematocrit measurements,
erythrocyte (red blood cells) count, leukocyte (white blood cell)
count, red blood cell indices, and a differential white cell count.
• The CBC is a basic screening test and one of the most frequently
ordered blood tests.
Complete Blood Count with Clinical Implications:

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Serum Electrolytes
• Serum electrolytes are often routinely ordered for any client admitted
to a hospital as a screening test for electrolyte and acid–base
imbalances.
• Serum electrolytes also are routinely assessed for clients at risk in the
community, for example, clients who are being treated with a diuretic
for hypertension or heart failure.
• The most commonly ordered serum tests are for sodium, potassium,
chloride, and bicarbonate ions.
Normal Electrolyte Values for Adults

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Blood Chemistry
• A number of other tests may be performed on blood serum (the liquid
portion of the blood). These are often referred to as a blood chemistry.
• Common chemistry examinations include determining certain enzymes
that may be present (including lactic dehydrogenase [LDH], creatine
kinase [CK], aspartate aminotransferase [AST], and alanine
aminotransferase [ALT]), serum glucose, hormones such as thyroid
hormone, and other substances such as cholesterol and triglycerides.
• These tests provide valuable diagnostic cues.
• For example, cardiac markers (e.g., CPK-MB, myoglobin, troponin T,
and troponin I) are released into the blood during a myocardial infarction
(MI, or heart attack).
• Elevated levels of these markers in the venous blood can help
differentiate between an MI and chest pain that is caused by angina or
pleuritic pain.
Common Blood Chemistry Tests with Clinical Implications

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Specimen Collection and Testing

• The nurse contributes to the assessment of a client’s health status by
collecting specimens of body fluids.
• All hospitalized clients have at least one laboratory specimen collected
during their stay at the health care facility.
• Laboratory examination of specimens such as urine, blood, stool,
sputum, and wound drainage provides important adjunct information for
diagnosing health care problems and also provides a measure of the
responses to therapy.
• Nurses often assume the responsibility for specimen collection.
Stool Specimens
• Analysis of stool specimens can provide information about a client’s
health condition.
• Some of the reasons for testing feces include the following:
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• To determine the presence of occult (hidden) blood.

• To analyze for dietary products and digestive secretions.
• To detect the presence of ova and parasites.
• To detect the presence of bacteria or viruses.
Urine Specimens
• The nurse is responsible for collecting urine specimens for a number of
tests:
• clean voided urine specimens for routine urinalysis,
• clean-catch or midstream urine specimens for urine culture, and
• timed urine specimens for a variety of tests that depend on the
client’s specific health problem.
• Urine specimen collection may require collection via straight catheter
insertion.
Specific gravity is an indicator of urine concentration, or the amount of

solutes (metabolic wastes and electrolytes) present in the urine. The
specific gravity of dis- tilled water is 1.00; the specific gravity of urine
normally ranges from 1.010 to 1.025.
Urinary pH is measured to determine the relative acidity or alkalinity of

urine and assess the client’s acid–base status. Urine normally is slightly
acidic, with an average pH of 6 (7 is neutral, less than 7 is acidic, greater
than 7 is alkaline).
Glucose. Urine is tested for glucose to screen clients for diabetes mellitus
and to assess clients during pregnancy for abnormal glucose tolerance.
Normally, the amount of glucose in the urine is negligible, although
individuals who have ingested large amounts of sugar may show small
amounts of glucose in their urine.
Protein molecules normally are too large to escape from glomerular

capillaries into the filtrate. If the glomerular membrane has been damaged,
however (e.g., because of an inflammatory process such as
glomerulonephritis), it can become “leaky,” allowing proteins to escape.
Urine testing for the presence of protein generally is done with a reagent
strip (commonly referred to as a dipstick).

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Visualization Procedures
Visualization procedures include indirect visualization (non-invasive) and
direct visualization (invasive) techniques for visualizing body organ and
system functions.
Electrocardiography
• provides a graphic recording of the heart’s electrical activity.
• Electrodes placed on the skin transmit the electrical impulses to an
oscilloscope or graphic recorder.
• With the wave forms recorded, the electrocardiogram (ECG) can then
be examined to detect dysrhythmias and alterations in conduction
indicative of myocardial damage, enlargement of the heart, or drug
effects.

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Stress electrocardiography
• uses ECGs to assess the client’s response to an increased cardiac
workload during exercise.
• As the body’s demand for oxygen increases with exercising, the cardiac
workload increases, as does the oxygen demand of the heart muscle
itself.
• Clients with coronary artery disease may develop chest pain and
characteristic ECG changes during exercise.

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Angiography
• is an invasive procedure requiring informed consent of the client.
• A radiopaque dye is injected into the vessels to be examined.
• Using fluoroscopy and x-rays, the flow through the vessels is assessed
and areas of narrowing or blockage can be observed.
Computed tomography (CT),

• also called CT scanning, computerized tomography, or computerized
axial tomography (CAT), is a painless, noninvasive x-ray procedure that
has the unique capability of distinguishing minor differences in the
density of tissues.
• The CT produces a three-dimensional image of the organ or structure,
making it more sensitive than the x-ray machine.

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Magnetic resonance imaging (MRI)

• is a noninvasive diagnostic scanning technique in which the client is
placed in a magnetic field.
• Clients with implanted metal devices (e.g., pacemaker, metal hip
prosthesis) cannot undergo an MRI because of the strong magnetic field.
• There is no exposure to radiation.
• Another advantage to the MRI is that it provides a better contrast
between normal and abnormal tissue than the CT scan. It is, however,
more costly.
• The MRI is commonly used for visualization of the brain, spine, limbs
and joints, heart, blood vessels, abdomen, and pelvis.
• The procedure involves the client lying on a platform that moves into
either a narrow, closed, high-magnet scanner, or into an open, low-
magnet scanner.
• The client must lie very still.
• Earplugs are offered to the client to reduce the discomfort from the loud
noises that occur during the test.
• The procedure lasts between 60 and 90 minutes

Manila, Philippines

Manila, Philippines
REFERENCES
Dunning, M. B., & Fischbach, F. T. (2011). Nurse’s quick reference to

common laboratory and diagnostic tests: Fifth edition. In Nurse’s Quick
Reference to Common Laboratory and Diagnostic Tests: Fifth Edition.
The American Society for Clinical Laboratory Science (2005, July). Value of
Clinical Laboratory Services in Health Care.
https://www.ascls.org/position-papers/177-value-of-clinical-
laboratory-services/153-value-of-clinical-laboratory-services
Nursing (6th ed.).

Manila, Philippines
www.feu.edu.ph
Diagnostic Testing
www.feu.edu.ph
Diagnostic and Laboratory Tests
• commonly called laboratory tests
• are tools that provide information about the client.
• Tests may be used for basic screening as part of a
wellness check.
• Frequently tests are used to help confirm a diagnosis,
monitor an illness, and provide valuable information
about the client’s response to treatment.
• Nurses require knowledge of the most common
laboratory and diagnostic tests because one primary
role of the nurse is to teach the client and family or
significant other how to prepare for the test and the
care that may be required following the test.
• Nurses must also know the implications of the test
results in order to provide the most appropriate
nursing care for the client.
www.feu.edu.ph
• Diagnostic testing occurs in many
environments. The traditional sites include
hospitals, clinics, and the primary care
provider’s office.
• Many test sites, however, are moving to the
community. Examples include the home,
workplace, shopping malls, and mobile
units.
• Diagnostic testing involves three phases:
pretest, intratest, and post-test.
www.feu.edu.ph
Preparing for Diagnostic Testing
• Instruct the client and family about the procedure for
the diagnostic testing ordered (e.g., whether food is
allowed prior to or after testing, and the length of
time of the testing).
• Explain the purpose of the test.
• Instruct the client and family about activity
restrictions related to testing (e.g., remain supine for
1 hour after testing is completed).
• Instruct the client and family on the reaction the
diagnostic test may produce (e.g., flushing when the
dye is injected).
www.feu.edu.ph
Preparing for Diagnostic Testing (continued…)
• Provide the client with detailed information about
the diagnostic testing equipment.
• Inform the client and family of the time frame for
when the results will be available.
• Instruct the client and family to ask any questions
so that the health care provider can clarify
information and allay any fears.
www.feu.edu.ph
Blood Tests
Blood tests are commonly used diagnostic tests that
can provide valuable information about the
hematologic system and many other body systems.
A venipuncture (puncture of a vein for collection of a
blood specimen) can be performed by various
members of the health care team.
A phlebotomist, a person from a laboratory who
performs venipuncture, usually collects the blood
specimen for the tests ordered by the primary care
provider.
In some institutions, nurses may draw blood
samples. The nurse needs to know the guidelines for
drawing blood samples for the facility and also the
state’s nurse practice act.
www.feu.edu.ph
Complete Blood Count
Specimens of venous blood are taken for a
complete blood count (CBC), which includes
hemoglobin and hematocrit measurements,
erythrocyte (red blood cells) count, leukocyte
(white blood cell) count, red blood cell indices,
and a differential white cell count.
The CBC is a basic screening test and one of
the most frequently ordered blood tests
www.feu.edu.ph
Complete Blood Count with Clinical Implications
www.feu.edu.ph
www.feu.edu.ph
Serum Electrolytes
Serum electrolytes are often routinely ordered for
any client admitted to a hospital as a screening test
for electrolyte and acid–base imbalances.
Serum electrolytes also are routinely assessed for
clients at risk in the community, for example, clients
who are being treated with a diuretic for
hypertension or heart failure.
The most commonly ordered serum tests are for
sodium, potassium, chloride, and bicarbonate ions.
www.feu.edu.ph
Normal Electrolyte Values for Adults
www.feu.edu.ph
Blood Chemistry
• A number of other tests may be performed on blood serum (the liquid portion
of the blood). These are often referred to as a blood chemistry.
• Common chemistry examinations include determining certain enzymes that
may be present (including lactic dehydrogenase [LDH], creatine kinase [CK],
aspartate aminotransferase [AST], and alanine aminotransferase [ALT]), serum
glucose, hormones such as thyroid hormone, and other substances such as
cholesterol and triglycerides.
• These tests provide valuable diagnostic cues.
• For example, cardiac markers (e.g., CPK-MB, myoglobin, troponin T, and
troponin I) are released into the blood during a myocardial infarction (MI, or
heart attack).
• Elevated levels of these markers in the venous blood can help differentiate
between an MI and chest pain that is caused by angina or pleuritic pain.
www.feu.edu.ph
Common Blood Chemistry Tests with Clinical Implications
www.feu.edu.ph
www.feu.edu.ph
www.feu.edu.ph
www.feu.edu.ph
Specimen Collection and Testing
• The nurse contributes to the assessment of a
client’s health status by collecting specimens of
body fluids.
• All hospitalized clients have at least one
laboratory specimen collected during their stay at
the health care facility.
• Laboratory examination of specimens such as
urine, blood, stool, sputum, and wound drainage
provides important adjunct information for
diagnosing health care problems and also
provides a measure of the responses to therapy.
• Nurses often assume the responsibility for
specimen collection.
www.feu.edu.ph
Stool Specimens
Analysis of stool specimens can provide information
about a client’s health condition.
Some of the reasons for testing feces include the
following:
oTo determine the presence of occult (hidden)
blood.
oTo analyze for dietary products and digestive
secretions.
oTo detect the presence of ova and parasites.
oTo detect the presence of bacteria or viruses.
www.feu.edu.ph
Urine Specimens
• The nurse is responsible for collecting urine
specimens for a number of tests:
• clean voided urine specimens for routine
urinalysis,
• clean-catch or midstream urine specimens for
urine culture, and
• timed urine specimens for a variety of tests that
depend on the client’s specific health problem.
• Urine specimen collection may require collection
via straight catheter insertion.
www.feu.edu.ph
Specific gravity is an indicator of urine
concentration, or the amount of solutes (metabolic
wastes and electrolytes) present in the urine. The
specific gravity of dis- tilled water is 1.00; the specific
gravity of urine normally ranges from 1.010 to 1.025.
Urinary pH is measured to determine the relative
acidity or alkalinity of urine and assess the client’s
acid–base status. Urine normally is slightly acidic,
with an average pH of 6 (7 is neutral, less than 7 is
acidic, greater than 7 is alkaline).
www.feu.edu.ph
Glucose. Urine is tested for glucose to screen clients
for diabetes mellitus and to assess clients during
pregnancy for abnormal glucose tolerance. Normally,
the amount of glucose in the urine is negligible,
although individuals who have ingested large
amounts of sugar may show small amounts of
glucose in their urine.
Protein molecules normally are too large to escape
from glomerular capillaries into the filtrate. If the
glomerular membrane has been damaged, however
(e.g., because of an inflammatory process such as
glomerulonephritis), it can become “leaky,” allowing
proteins to escape. Urine testing for the presence of
protein generally is done with a reagent strip
(commonly referred to as a dipstick).
www.feu.edu.ph
www.feu.edu.ph
Visualization Procedures
Visualization procedures include indirect visualization
(non-invasive) and direct visualization (invasive)
techniques for visualizing body organ and system
functions.
www.feu.edu.ph
Electrocardiography
• provides a graphic recording of the heart’s
electrical activity.
• Electrodes placed on the skin transmit the
electrical impulses to an oscilloscope or
graphic recorder.
• With the wave forms recorded, the
electrocardiogram (ECG) can then be
examined to detect dysrhythmias and
alterations in conduction indicative of
myocardial damage, enlargement of the
heart, or drug effects.
www.feu.edu.ph
Stress electrocardiography
• uses ECGs to assess the client’s response to
an increased cardiac workload during
exercise.
• As the body’s demand for oxygen increases
with exercising, the cardiac workload
increases, as does the oxygen demand of
the heart muscle itself.
• Clients with coronary artery disease may
develop chest pain and characteristic ECG
changes during exercise.
www.feu.edu.ph
www.feu.edu.ph
Angiography
• is an invasive procedure requiring informed
consent of the client.
• A radiopaque dye is injected into the
vessels to be examined.
• Using fluoroscopy and x-rays, the flow
through the vessels is assessed and areas of
narrowing or blockage can be observed.
www.feu.edu.ph
www.feu.edu.ph
Computed tomography (CT),
• also called CT scanning, computerized
tomography, or computerized axial
tomography (CAT), is a painless,
noninvasive x-ray procedure that has the
unique capability of distinguishing minor
differences in the density of tissues.
• The CT produces a three-dimensional
image of the organ or structure, making it
more sensitive than the x-ray machine.
www.feu.edu.ph
www.feu.edu.ph
www.feu.edu.ph
• is a noninvasive diagnostic scanning technique
in which the client is placed in a magnetic
field.
• Clients with implanted metal devices (e.g.,
pacemaker, metal hip prosthesis) cannot
undergo an MRI because of the strong
magnetic field.
• There is no exposure to radiation.
• Another advantage to the MRI is that it
provides a better contrast between normal
and abnormal tissue than the CT scan. It is,
however, more costly.
www.feu.edu.ph
• The MRI is commonly used for visualization of
the brain, spine, limbs and joints, heart, blood
vessels, abdomen, and pelvis.
• The procedure involves the client lying on a
platform that moves into either a narrow,
closed, high-magnet scanner, or into an open,
low-magnet scanner.
• The client must lie very still.
• Earplugs are offered to the client to reduce the
discomfort from the loud noises that occur
during the test.
• The procedure lasts between 60 and 90
minutes
www.feu.edu.ph
www.feu.edu.ph
www.feu.edu.ph
www.feu.edu.ph

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NUR1202 – NCM101 HEALTH ASSESSMENT

ASSESSING HEAD TO NECK (Part 2)

This module includes basic assessment of the head, neck, eyes,

Structure and Function

Structure of the nose

ASSESSMENT NORMAL FINDINGS DEVIATION FROM

Palpating the frontal sinuses

Palpating the maxillary sinuses

Structure and Function

Structures of the mouth

ASSESSMENT NORMAL FINDINGS DEVIATION FROM

Inspect the teeth Thirty-two pearly Clients who smoke,

Inspect the buccal The buccal mucosa Leukoplakia may be

Inspect and palpate Tongue should be pink, Among possible

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Palpating area under the tongue

Inspecting the uvula

Head and neck assessment focuses on the

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CHEST TO ABDOMEN ASSESSMENT

An accurate physical assessment requires an organized and systematic

After finishing this module, the student will be able to:

1. Assessment of thorax and Lungs

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Assessment of Breast and Lymphatic System

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Palpating the Breasts