Nursing process:

Introduction: The nursing process enables you to organize and deliver appropriate
nursing care to a client. To successfully apply the nursing process, you need to integrate
elements of critical thinking to make judgments and take reasoned action. The nursing
process is used to identify, diagnose and treat human responses to health and illness
(American Nursing Association, 1995). The process includes five steps: assessment,
nursing diagnosis, planning, implementation, evaluation.
Purpose of nursing process: To establish a database about the client’s response to
health concerns or illness or the ability to manage health care needs.
Activities:
Establish a database
 Obtain health history
 Conduct physical assessment
 Review client records
 Review literature
 Consult support persons
 Consult health professionals
Update data as needed
Organize data
Validate data
Communicate/document data
HEALTH ASSESSMENTS
Introduction:
Nursing assessment includes two steps. First, collect and verify data from a primary
source (the client) and secondary sources (family, health professionals). Then analyze
those data as a basis for developing nursing diagnoses and an individualized plan of.
Nursing care. The purpose of the assessment is to establish a database about the client's
perceived needs, health problems, and responses to these problems. in addition, the data
reveal related experiences, health practices, goals, values, lifestyle e, and expectations
from the health care system.

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An assessment must be relevant to a client's particular health problem. You apply critical
thinking to determine what is relevant to include in your client's assessment.
For example, if a woman comes to an urgent care setting because of a possible ankle
fracture, you consider the implications of a musculoskeletal injury, associated pain, and
immobility to focus your assessment. You do not need her childbirth or surgical history.
Your assessment will focus on the ankle injury and its effects on the client.
Definition:
Assessment is a continuous process carried out during all phase of the nursing process.
For example, in the evaluation phase, assessment is done to determine the outcomes of
the nursing strategies and to evaluate goal achievement. All phases of nursing process
depend on the accurate and complete collection data (information).
Purpose:
To establish a database (all the information about the client):
 Nursing health history.
 Physical assessment.
 The physician’s history & physical exanimation
 Results of laboratory & diagnostic tests.
 Material from other health personnel.
Types of Assessment:
a. Initial comprehensive assessment
An initial assessment, also called an admission assessment, is performed when the client
enters a health care from a health care agency. The purpose is to evaluate the client's
health status to identify functional health patterns that problematic, and to provide an in-
depth, comprehensive database, which is critical for evaluating changes in the client's
health status in subsequent assessments.
b. Problem-focused assessment
A problem focus assessment collects data about a problem that has already been
identified. This type of assessment has a narrower scope and a shorter timeframe than the
initial assessment. In focus assessments, nurse determines whether the Problems still
exists and whether the status of the problem has changed (i.e. improved, worsened, or

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resolved). This Assessment also includes the appraisal of any new, overlooked, or
misdiagnosed problems. Intensive care units, may perform focus assessment every few
minutes.
c. Emergency assessment
Emergency assessment takes place in life- threatening situations in which the
preservation of life is the top priority. Time is of the essence in rapid identification of and
intervention for the client's health problems. Often the client's difficulties involve airway,
breathing and circulatory problems (the ABCs). Abrupt changes in self-concept (suicidal
thoughts) or roles or relationships (social conflict leading to violent acts) can also initiate
an emergency. Emergency assessment focuses on essential health patterns and is not
comprehensive.
d. Time-lapsed assessment or ongoing assessment
Time lapsed reassessment, another type of assessment, takes place after the initial
assessment to evaluate any changes in the client’s functional health. Nurses perform
time-lapsed reassessment when substantial periods of time have elapsed between
assessments (e. g., periodic output patient clinic visits, home health visits, and health and
development screenings).
Steps of assessment:
1. Collection of data
 Subjective data
 Objective data
2. Validation of data
3. Organization of data
4. Recording/documentation of data
Collection of data
Data collection includes the gathering of subjective and objective data from or about your
client.
Subjective data are your clients ‘perceptions about their health problems, only clients
can provide this kind of information.
For example, a client's report of headache pain is a subjective finding. Only the client
can provide information about its frequency, duration, location, and intensity. Subjective

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data usually include Feelings of anxiety, physical discomfort, or mental stress. Subjective
data are more difficult to measure
Objective data is based on an accepted standard, such as a thermometer, on which the
Fahrenheit or Celsius scale is the standard unit of measure for body temperature.
For example, when assessing headache pain, you further assess your client for areas of
stress and lifestyle issues. During the assessment you obtain data about your client’s job
related stressors and lack of exercise that may contribute to frequent headaches. You only
minimally assess areas like skin condition and nutrition, because they do not relate to the
client’s headache.
Methods of data collection
Interview: an interview is an planned communication or a conversation with a purpose,
for example, to give information, identify problems with mutual concern, evaluate
change, teach, provide support, or provide counselling or therapy.
The first step in establishing a database is to collect subjective information by
interviewing the client. An interview is an organized conversation with the client to
obtain the client's health history and information about the current illness. During the
interview you have the opportunity to
1. Introduce yourself to the client, explain your role, and
the role of others during care,

". Establish a therapeutic relationship with the client

3. Gain insight about the client's concerns and v[orries
4. Determine the client's goals and expectations of the
5. 0btain cues about which Parts of the data collection
phase require in-depth investigation

Your interview includes the orientation, working, and ter-

mination phases. During the orientation phase of the inter-
v iew, introduce yourself, your position, and tell the client the
Purpose of the interview (Figure 6-2).
Ex) lain to the client why the data are being collected and

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assure the client that an]r information obtained will remain
confidential and will be used only by heillth care prohssion-

Preparation of the environment

To prepare for physical examinations, ensure that the environment is private, quite,
comfortable, and well lighted. An examinations is may be conducted in a special room in
an office clinic.

Preparation of equipment:
Assemble all necessary equipment before beginning. Arrange equipment in order of sue
to facilitate examination.
Preparation of the client:
The client is prepared physically and psychologically for the physical examination.
Before beginning the examination, the nurse instructs the client to empty the bladder. If
clvine specimen is needed the client is instructed in the technique for collection at this
time. An empty the bladder facilitates examination of the omega, genital and rectum.
Draping
Physical preparation also includes instructing the client to dress according to the type and
extent of examination to be conducted. A hospital gowns cloths provide privacy.

Positioning
During the examination the client is assisted in assuming different positions – like. The
client is kept in these positions only as long as required and is draped to patient
unnecessary exposure.
Positions as follows:
1. Sitting position. 2. Supine position. 3. Dorsal recumbent position. 4. Lithotomy
position. 5. Prone position. 6. Knee chest position.
Preparation of the examiner:

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The nurse begins the physical examination on meting the client by focusing on the
client’s appearance, movements, position and reaction to the assessment process. A
mental plan (check list) is helpful.
SEQUENCE OF EXAMINATION:
The importance of organizing the physical examination systematically follows.
Definition: The physical examination is performed after the history interview. Physical
examination skills require use of eyes, ears and Senses of touch and Smell. Repeated
Practice reinforces integration of these skills. Learn the techniques and correct use of
equipment as well as how to discriminate “Normal” from “abnormal” findings.
Physical examinations is used in many settings. Health fairs, screening-clinics,
Physicians’ offices, independent practice clinics, health care and hospitals are some
examples.
Purpose: The Purpose of physical examination is to differentiate normal form abnormal
physical findings. A foundation of basic anatomy (Structure) and physiology (function0
is key to developing skill, expertise, and an appreciation for the wide rang of findings that
are considered normal. In addition to collecting base line data, use assessment skills to
make clinical Judgements about health status and to evaluate the effectiveness of health
care interventions.
Levels of Physical Examinations:
Physical examinations are available, depending on client need.
(1) A screening physical examination is an organized, superficial check of major
body systems for detecting abnormalities or possible findings.
(2) If a problem is detected the examination focuses on a regional or branching
examination, which is an in depth assessment of a specific body system.
(3) A complete physical examination which includes ancillary procedures such as x-
ray studies and clinical laboratory tests, etc.
Accuracy of Physical Examination:
The Physical examination helps to validate data collected during the health history
interview. As with the health history, strike to collect accurate, through data. If you
encounter difficulty with an assessment technique or question the accuracy of a findings,
consult with colleagues.

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Physical examination and the Nursing Process:
An accurate data base is essential for formulating individualized nursing diagnosis. It
may be misleading to diagnose a problem on the basis of one assessment finding. A
complete assessment is necessary before data can be grouped and a cause determined.
The initial physical assessment is the baseline for the client’s functional ability. Physical
assessment is also used as intervention (e.g. monitoring lung sounds) to evaluate changes
in the client’s physical condition and to determine whether expected outcomes have been
achieved.
TECHNIQUES OF PHYSICAL EXAMINATION:
Four primary techniques are used in physical assessment inspection, palpation,
percussion and auscultation. These techniques are enhance the data collected by
observations of ears, eyes, and senses of touch and smell and are use as indicated during
the examination of each body region.
 Inspection
Inspection is the systematic, deliberate visual examination of the entire client or a region.
Inspection yields information about size, shape, color, texture, symmetry, position and
deformities.
During Inspection, compare observations with the known parameters of normal finding in
clients of age, sex, race and ethnicity.
Inspection is enhanced with special instruments such as a penlight, otoscope,
ophthalmoscope, and various speculum. That permits visual access to body cavities.
Others equipment includes tongue blades, a marking pen, a ruler, a tape-measure, skin
fold calipers, agoniometer and eye charts.
 Palpation:
Palpation is the use of touch. During palpation, exert varying amounts of pressure to
determine information about masses, pulsation, organ size, tenderness or pain swelling
and moisture, in addition use palpation to asset masses for position, size, shape,
consistency and nobility.
Technique: Use the most sensitive parts of your hands and fingers to palpate specific
characters. E.g.: The finger tips to palpate pulses, lymph nodes and breast tissue. Back of
the hand and fingers are used to discriminate changes in skin temperature.

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Levels of Palpation:
Light Palpation: It depress the underlying tissue approximately 1 to 2 cm. After the
palpation use deep palpation to determine size and condition of underlying structures,
such as abdominal organs.
Deep palpation: It depress the underlying tissue approximately 4 to 5cm.
Bimanual palpation: Place hand sensing hand lightly on the client’s skin and place the
other hand over the sensing hand to apply pressure.
 Percussion:
Percussion is a technique to asses tissue density by sound produced from striking the
skin. With this step which is usually the 3rd technique in physical assessment 3 to 5 cm of
tissue depth care be examined. If the body structure containing air, fluid, & solids
produces various sounds depending on their density.
Methods:
1) Direct: It involves striking the body surface with either one or Two Fingers or the
first.
2) Indirect: Is placed firmly on the body’s surface.
 Auscultation:
It is the listening to internal body sounds to assess normal sounds and detect abnormal
sounds.
Types:
Pitch: Is the number or frequency of sound wake cycles per second, by varying the
frequency one may alter the pitch.
1) Intensity: The amplitude of a sound wake, the greater the amplitude, the louder the
sound. The lower the amplitude, the softer the sound.
2) Duration: The length of time a sound endures: It may be long, medium or short.
3) Quality: A description of a sound’s character, such as “gurgling”, “blowing”,
“whistling”, a) “snaping”.

ASSESSING GENERAL APPEARANCE AND MENTAL STUATUS

General Appearance Normal Function Devited from Normal

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Observe body build, Height Varies with life style Excessively thin or obese.
and Weight in relation to
the clients age, life style and
Health.

Observe the clients posture Relaxed, erect posture: Co- Tense, slouched bent
and gait, standing sitting ordinated Movement. posture Uncoordinated
and walking. movement tremors.

Observe the clients overall Clean, Neat Dirty un kept.

hygiene and grooming.
Relate these person’s
activities prior to the
assessment.

Note body and breathe odor No body odor/Minor body Foul body odor:
in relation to activity level. odor relative to work or Ammonia odor:
exercise: No breath odor. Acetone breath odor:
Foul breath.

Observe for signs of distress Healthy appearance Pallor: weakness: obvious

in posture (bending door illness
therefore pain)
Facial expression (winching
labored breathing. Co-operative vegetate,hostile, withdrawn.
Note obvious signs of Appropriate to situation. Inappropriate to the
health or illness. (e.g.: in situation.
skin breathing).

Mental Status Understandable moderate Rapid / slow pace use

Assess the client’s attitude pace exhibit and through generalizations lack

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 association. association; Exhibits
confabulation (i.e dells
Note the client’s stories that are untrue.)
affect/mood: assess the
appropriateness of the client Logical sequence makes Flight of ideas: confusion.
response. sense: has sense of reality.

Listen for quantity of

speech (amount and pace)
quality (loudness, clarity, Varies from light to deep Areas of either hyper
inflection) and organization brown: from ruddy pink to pigmentation or hypo
vagueness. light pink: from yellow over pigmentation (vitiligo,
honest olive. albinism, edema.
Listen for relevance and
organization of thoughts. Moisture of skin folds and Excessive moisture (in
the oxialar (various with hypothermia) Excessive
environment temperature dryness (in dehydration).
and unidity, body
Assessing the Skin temperature and activity)
Inspect the skin color (best
assessed under natural light
and on areas not exposed to
the sun. Observe and
palpate skin moisture.

Palpate the skin temperature Uniform: with in normal Generalized hypothermia

compare the two feet and (in fever), in shock,
two hands using the backs localized hypothermia,
of your figures. (infection, arteriosclerosis)

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Hair and Scalp
Inspect the evenness of Evenly distributed. Patched of hair loss (i.e.
growth occur the scalp. alopecia)

Inspect hair thickness o Thick hair. Very thin hair (in

thinness. hypothyroidism).

Inspect hair texture and Silky, Resilient hair. Brittle hair

oiliness. (hypothyroidism)
excessively oily or Dry hair.

Inspect among of body hair. Variable. Hirsutism (excessive

hairiness) on come in and
children.

Nail Convex curvature: angel Spoon nail: clubbing (of

Inspect nail plate shape to between nail and nail bed of degrees or preater)
determine its curvature and about 160 degrees.
angle.

Excessive thickness (result

of poor circulation iron
deficiency anemia).
Excessive thinness or
presence of grooves or
sorrows (in iron deficient
Inspect nail texture. Smooth texture. anemia) Bean’s lines
(transfer white lines or
process.

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Inspect nail bed color. Highly vascular and pink in Bluish or purplish --- (may
light skinned clients, dark affect cyanosis). Pallor may
skinned clients, dark reflect poor arterial
skinned clients may have circulation.
brown or black
pigmentation in longitudinal
streaks.

Inspect tissues surrounding Intact epidermis. Hang nails: Paronychia

nails. (inflammation).

Head Rounded (Normocepthalic Lack of symmetric,

Inspect the skull for size, and symmetric with frontal, increased skull size with
shape and symmetry. If partial, and occipital more prominent nose and
skull is abnormal size, prominences) smooth skull forehead; longer mandible
measure it’s circumference contour. 9may indicate excessive
just above the eyebrows. growth hormone or
increased bone thickness).

Palpate the skull for nodules Smooth, uniform constancy: Sebaceous cyst: local

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or masses and depressions absence of nodules or deformities from trauma.
use a gentle rotating motion mosses.
with the figure tips begin of
the front and palpate down
the middling, then palpate
each side of the head.

Inspect the facial features Symmetric/ slightly Increased facial hair:

(symmetry of structures and asymmetric facial features: thinning of eyebrows
of the distribution of hair). facial features palpable asymmetric features:
fissures equal in size: Exophthalmus: Myxedema
symmetric nasolabial folds. facies: moon face.

Note facial movements. Symmetric facial Asymmetric facial

movement. movements.

Inspective eyes for edema ----- Periorbital edema sunken

and hollowness. eyes.

Inspect the eyelashes for Equally distributed: curled Turned inward.

even ness of distribution slightly out ward.
and direction of curl.

Inspect the eyebrows for Hair evenly distributed: Loss of hair: scaling and
hair distribution and skin skin intact eyebrows flankness of skin. Unequal
quality and movement. symmetrically aligned equal alignment and movement of
movement. eyebrows.

Inspect eyelids for surface Sink intact: no discharge: Redness, swelling, claking

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characteristics. no discoloration lids close crusting, plaques, discharge,
symmetrically. Nodules, lesions, lids close
asymmetrically,
incompletely or painfully.

Inspect the bulbar Transparent: capillaries Jaundiced sclera (liver

conjunctiva for color.
Visual acuity
Assess near vision.
sometimes evident; sclera disease): excessively pale
appears white (yellowish in sclera (anemia): Reddened
dark skinned clients). sclera: lesions or nodules
(may indicate damage by
mechanical, chemical,
allergic or bacterial agents).
Able to read newsprint. Difficult reading newsprint
unless due to aging process.

Assess distance vision. 20/20 vision on snellen Denominator of 40 or move

chart from age 6 onward. on snellen chart with
corrective lenses.

Auricles
Inspect the auricles for Color same as facial skin. Bluish color of earlobes
color, symmetry of size and (cyanosis):excessive
position. redness inflammation or
fever.
Assess client’s response to Normal voice tones audible. Normal voice tone not
normal voice tones. audible.

Nose
Inspect the external nose for Symmetric and no Asymmetric, Discharge
any deviations in shape, discharge of flaring uniform from naves localized areas

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size, or color and flaring or color. of redness or presence of
discharge from the naves. Uniform pink color, soft, skin lesions.
moist, smooth texture. Cyanosis blisters:
Symmetry of contour. generalized or localized
swelling: fissures, crasts or
scales. My result form
excessive moisture,
nutritional deficiency at
Inspect the Nasal cavities. finial deficit).
Mouth
Inspect the outer lips for Smooth, intact dentures. Ill-fitting dentures: irritated
symmetry of contour, color, and excovietal area under
and texture. dentures.

Teeth
Inspect the dentures. Central position. Deviated from center (may
indicate damage to
hypoglossasl) 12th I.C.N.

Tongue
Inspect the surface of the Pink color slightly rough, Smooth red tongue (may
tongue for position color thin whitish coating. indicate iron, bit B12 or
and texture. vitamin B3 deficiency) Dry,
furry tongue (associated
with fluid deficit).

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Inspect the movements. Moves freely: no Restricted nobility.
tenderness.

Neck:
Inspect the neck muscles. Muscles equal in size: head Unilateral neck swelling:
centered. head tilted to one side
(indicates presence of
masses injury, muscle
weakness, scars.)

Head Movement. Smooth movements with no Muscle tremor, spasm

discounter. stiffness.

Palpate the entire neck for Not palpable. Enlarged, palpable, possibly
enlarged lymph nodes. tender (associated with
infection and tumors).
Palpate the posterior thorax Skin intact: uniform Skin lesions: areas of
No resp-complaints. temperature. hypothermia.

A resp: Complaints. Chest wall intact: note Lumps, bulges, depressions

tenderness: no masses areas of tenderness.
Movable structures (vib)

Palpate the posterior chest Full and Symmetric chest Asymmetric and or
for respiratory expansion. expansion. decreased chest expansion.

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Auscultate the chest. Vesicular and branch Adventitious breath sounds
vesicular breath sounds. (crackles, rhonchi, wheeze,
friction rab, Absence of
breath sounds associated
with collapsed and surficial
removed lung lobes.

Anterior thorax
Inspect breathing patter Normal Abnormal breathing pattern
(RR, Rhythm) and sounds.

Auscultate the lungs by Low, sufficed, blowing Abnormal breath sounds are
placing a stethoscope over sound throughout the lungs rates rhonchi, or crackles
the posterior inter costal field. wheezes, a strider.
spaces.
Heart
Asscultate the heart in all S1: usually heard at all sites Increased or decreased
four anatomic sites: usually louder at apical intensity varying intensity
area. with different beats.

(Aortic, pulmonic, tricuspid S2: usually heard at all sites Decreased intensity at aortic
and apical mistral. usually louder at base of area increased intensity at
heart. pulmonic area sharp
sounding ejection clieks.

Systole:
Silent interval slightly
shorter durakon tdhan
diastole at normal H.R(60-
90 beats/min).

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 Diastole: Silent internal S3 in older adults 40-65.
slightly longer duration than
systole at normal heart
rates.

S3: in children and young

adults.

S4: in many older adults.

ABDOMEN
Inspect the abdomen for Flat, rounded (convex or Distended
contour and symmetry. Scaphoid (concave).

-observe the abdominal No evidence of enlargement Evidence of enlargement of

contour. of liver of spleen. liver or spleen.

-Ask the client to take a Symmetric movement Limited movements utopian

deep breath and to expand caused by respiration. or disease process.
it.

Observe abdominal Visible peristalsis in very Visible peristaltic in on lean

movements (associated with lean people Aortic clients (with bowel
respiration, peristalsis or pulsations in thin persons at obstructing) loud brait over
aortic pulsation. epigastric area. aortic area (possible
aneurysm)
Anus:
Inspect the anus and Anal skin is normally nor Presence of fissures

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surrounding issues for pigmented, coarser, and (cracks), ulcers,
color, integrity and skin moister than perineal skin inflammations, abscess,
lesions. and is usually hairless. protruding hemorrhoids
(dilated veins seen as
reddened protrusions of the
skin). Lumps, fistula
openings or tumors.

Palpate the rectum for anal Anal sphincter has good Hypertonicity of the anal
sphincter tenacity, nodules tone. sphincter. (May occur in the
masses and tenderness. presence of an anal fissure
or other lesion that causes
contraction)

Equal size on both sides of Hypotonicity of anal

body. sphincter (may occur after
rectal surgery or result from
a neurologic deficiency.
No contractions. Rectal wall is tender and
Normally firm nodular.Rectal wall is
smooth and not tender.

Upper Extremities / Lower

Extremities Muscles.
Inspect the muscles for size. Equal strength on each body Atrophy or Hypertrophy.
side.
Inspect the muscles and No deformities. Malposition of body part (--
tendons for contextures a foot fixed in dorsifi----
(shortening).

Palpate the muscle at rest to Atonic (lacking lane)

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determine muscle tenacity.

Test muscle strengths Less of normal strength.

compare the right side with
left side.

Bones:
Inspect Skeleton for normal No deformities. Deformities.
structure and deformities.

Palpate the bones to locate No tenderness or swelling. Presence of tenderness or

any areas of edema or swelling (may indicate #,
Tenderness. neoplasm o osteoporosis.

Joints:
Inspect the joint for No swelling. One or more swollen joints.
swelling.

Palpate the joints for No tenderness swelling, Presence of Tenderness

tenderness, Smoothness of crepitating, or Nodules. swelling, crepitation, or
movement, swelling, Nodules.
crepitating, and presence of
nodules.

Assess the joint range of Range of motion is good. Limited range of motion in
motion. (physical activity is food) one or more joints.

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8. Genitalia & rectum:
For a male patient, the complete head to toe assessment concludes with examination on
genitalia & rectum.
 Detailed Examination of these structures is done by specialist particularly if
the patient had specific genitor-urinary complaint.
 If you must perform this part of the assessment
o Plan to inspect & palpate the penis & scrotum
o Inspect the perianal area
o Palpate the anus, rectum & prostate gland.
For a female patient, Examination of these structures is done by specialist. If you must
perform this part of the assessment-
o Inspect & palpate the external structures
o Examine the internal structures- with speculum
o Collect specimens- appropriate
o Perform recto-vaginal exam.
 For a male or a female patient, wipe out any excess sslubricant after
withdrawing your fingers. If you find stool on glove, test it for occult
blood
NEUROLOGICAL ASSESSMENT:

1. FIRST(Olfactory) Nerve
If the patient complains of loss of ability to smell during the health
history test the olfactory nerve by having him identifies smell with his
eyes closed.
2. SECOND (Optic) Nerve-
a. Visual acuity-

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  Visual acuity by Snellen’s chart (If patient normally wears lenses,
he can use those here now)
 With the patient 20 ft from the eye chart, opening both the eyes,
cover one eye with the card & read the smallest line of the type
that you can see.
 Numerator- Always 20 ft... Denominator- the distance at which
patient can read. Normal -20/20
b. Visual fields-
 To test accommodation hold your finger 4 inches from the
patient’s nose, Then ask him to look at your finger, At the wall
behind you & back in to the finger. His pupils should constrict
when they focus on your finger.

c. Optic disc-
 Before assessing the internal structures of the eyes, Prepare the
ophthalmoscope by selecting the lens size turning on the
ophthalmoscope & adjusting the largest beam of light.
 To examine the patient left eye, Use your left eye holding it in left
hand with index finger on the lens selected. Have the patient look
at straight ahead from about 15 inches away shine the light on his
pupil. You should see the red reflex- reddish glow that fills the
pupil caused by light reflection on the retina. Keep looking at the
red reflex as you move towards the patient, as retinal details
become sharper follow the vessels until they converge at optic disc
on nasal side of the retina.
 The disc should look like a creamy yellow or pink circle with
distinct margins. Use one disc diameter for 1DD to measure any
retinal background lesions.
 Also observe the physiologic cup which should be about half the
size of the disc, retinal vessels which should pair lighter & thinner
artery with each vein, fundus which should be light red to brown

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 red & free of lesions & macula, which should about 1 dd temporal
to the optic disc & should have no blood vessels. Always view the
macula last because shining the light on it may cause tearing &
papillary constriction.
3. THIRD (oculomotor) FOURTH (Trochlear) SIXTH(Abducens) nerves
i. Check extra-ocular movements to assess the extra-ocular
muscles & innervations of the occulomotor, trochlear &
abducens nerves.
ii. Place your finger 12 inches from the patient’s eye, Ask him to
watch your finger as you move to UR,FR,LR,UL,FL,LL.
iii. Test the occulomotor nerve by asking the patient to close his
eyes. The eyelids should move symmetrically without tremors

4. FIFTH (Trigeminal ) Nerve-

a. Motor-
 Have the patient clench his teeth while palpating the temporal &
masseter muscles of the jaws with both hands- Muscle strength in
the face should be present & should be symmetric.
b. Sensory
 To assess the sensory portion of the trigeminal nerve, assess the
patient ability to identify simple touch. (Using the cotton ball or
paper clip has the patient tell you when he feels the object touch
him.) Check for simple touch sensations on both sides on forehead
cheeks and jaw. The patient should feel the sensations equally.
5. SEVENTH (Facial) Nerve
To check Facial muscles, Facial & Trigeminal nerves
a. Have the patient raise & lower his eyebrows
b. Bear the teeth
c. Smile broadly.
d. Puff out his cheeks.
e. Ask to keep mouth closed & try to open it

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 All of these movements should be symmetrical
6. EIGHTH (acoustic) Nerve –a. Cochlear
 Hearing acuity tests- Voice, Weber, Rinne test
 Voice test- gently occlude one ear with your finger, stand 1 to 2 ft
away from the patient’s other side, gently shake your finger while
you tell two words like “football” or “fourteen”. He should be able to
repeat the word,
 Weber test- Use the tuning fork 512-1024 Hz. Hold stem & strike it
on palm. Place stem on mid-line of skull. If he hears the sound
equally in both ears, he has normal hearing bone conduction (BC).
 Rinne test- Strike & place it on mastoid process. Count the seconds
up to the patient no longer hears the sound- BC. Immediately place
the vibrating TF in front of the ear. Count the seconds again until the
patient says he no longer hears the sound- Air conduction(AC)-
Normally AC=2BC
b. Vestibular
 Roomberg test- Have the patient to close his eyes, his arms at side,
stand with his feet together. Observe for 20 seconds standing close to
the patient. He may sway slightly but should not lose his balance to
fall- this simple test assess the acoustic nerve, cerebellar function,
position sense & muscle strength.

7. NINTH (Glossopharyngeal)
 Tell the patient that you are going to check Gag-reflex which
assesses the glossopharyngeal nerve. Lightly touch at the back of his
tongue with the tongue blade. The patient should gag.
8. TENTH (Vagus) Nerves

 Also check vagus nerves by depressing the tongue having the

patient say aaaaaaaaaahhhhhh............ The soft palate should rise

24
 symmetrically & uvula should remain midline. While the patient
says aaaaaaaaa.hhhh again

9. ELEVENTH(Spinal accessory nerve)-

 Assess the accessory nerves by providing resistance as the patient
lifts his shoulders. The shoulder muscles should be symmetrical &
able to overcome resistance.
 Now have the patient turn his head, apply resistance & ask him to
turn back to the centre. His movements should be equal & he should
be strong enough to overcome resistance
10. TWELTH (Hypoglossal) nerve-
 The nerve immervates muscle of the tongue. It is tested by noting
articulation & by having the patient stick out his tongue, noting any
deviation or symmetry- Symmetric & non deviated
BIBILIOGRAPHY

1. Black J.M., Hawks JH, Keene AM. Medical surgical Nursing. Clinical
management for positive out comes. 6th ed. Pennsylvania: Saunders; 2003
P-163.
2. Kozier B, Erb G, Blais K, Wilkinson JM. Fundamentals of Nursing, concepts,
process, and practice. 5th ed. Addison – wisely 1995. P-466.
3. BT Basavanthappa Medical-Surgical Nursing, 1st ed. New Delhi; 2005 P-22.
4. BT Basavanthappa Fundamentals of Nursing 1st ed., New Delhi; 2002 P-204.

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INDEX

Sl. No. Contents Page No.

26
 Introduction

1 Definition

2 Purpose of the Physical Examination

3 Levels of Physical Examination

4 Accuracy of Physical Examination

5 Physical Examination and Nursing

process.
6 Techniques of Physical Examination
i) Inspection
ii) Palpation
iii) Percussion
iv) Auscultation
7 Preparation of the Equipment

8 Preparation of Equipment

9 Draping

10 Positioning

11 Preparation of Examiner.

12 Sequence of Physical Examination

13 General Physical Examination (Head to

toes)

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