TOMAS CLAUDIO MEMORIAL COLLEGE

COLLEGE OF NURSING

NAME: SCORE:
Date:
PHYSICAL EXAMINATION
INTEGUMENTARY SYSTEM
AREA OF ASSESSMENT
KEY FINDINGS 5 4 3 2 1 REMARKS
NORMAL FINDINGS
SKIN: Inspect and Palpate
1. COLOR: Inspect variations in skin
color under natural sunlight to ensure
accuracy in findings.
The presence or absence
Color varies from light to ruddy pink
of certain substances in the
or dark brown, or is yellow with olive
circulatory system skin is
overtones, with uniform skin color except
indications of disease
in sun-exposed areas or the deposition of
processes.
substances in the normally light
pigmented areas (nailbeds, palms, lips)
in dark-skinned people.

Vascular and purpuric

2. LESIONS: Note color, size, and
lesions. Primary Skin
anatomical location and distribution;
lesions, such as vesicle, can
palpate the lesions with finger pads for
give rise to Secondary
mobility, contour (flat, raised or
lesions, for example erosion
depressed), and consistency (soft or
and crusting, as in
durable).
chickenpox. The ABCDE
No lesions should be present except
mnemonic is useful for
for freckles, skin tags in elderly, and
useful for evaluating skin
some types of birthmarks and moles.
lesions.

Excessive moisture or
perspiration (hyperhidrosis)
is usually caused by
hyperthermia, infection,
3. MOISTURE: (wetness and oiliness);
hyperthyroidism, strong
note amount and distribution.
emotions, menopause;
It varies with activity, body and
excessive dryness often
environmental temperature, and humidity
occurs in dehydration.
in skin folds and the axillae.
Bromidrosis (body odor) is
usually caused by bacterial
decomposition of
perspiration on the skin.

4. TEMPERATURE: Palpate with back

(dorsum) of hand, noting uniformity of Generalized hyperthermia
warmth. is seen in fever; generalized
Temperature should be uniform and hypothermia is seen in
within normal range. shock; localized
 hyperthermia is seen with an
infection; localized
hypothermia is characteristic
of arteriosclerosis.

5. TEXTURE: (quality, thickness,

suppleness); Palpate with finger pads in
different areas.
Texture is not uniform; (e.g.) palms
and soles are usually thicker than other Generalized roughness is
areas, which are smooth, soft, and seen in hypothyroidism.
flexible. Wrinkled, leathery skin in
elderly results from the normal aging
process, with decreased collagen,
subcutaneous fat, and sweat glands.

6. MOBILITY & TURGOR (elasticity):

Assessing mobility and turgor measures
the elasticity of skin to determine the
degree of dehydration.
a. Palpate dependent areas (sacrum, feet,
Dependent edema gives
and ankles) for mobility by applying
the skin a stretched, shiny
pressure with fingers, noting degree of
appearance. The degree of
indentation. If indentation occurs,
pitting edema reflects the
firmly apply pressure with your thumb
depth of indentation.
for 5 seconds: rate the degree of edema
EDEMA is usually caused
(accumulation of fluid in intercellular
by direct trauma or
spaces) by assessing the depth of
impairment of venous return.
indentation. Edema may be described
Failure of the skin to
on a scale as follows: 0 = no pitting, 1+
reassume its normal contour
= trace/mild (2mm) pitting, 2+ =
or shape after being pinched
moderate (4mm) pitting, 3+ =
indicates dehydration, which
deep/severe (6mm) pitting, 4+ very
places the client at risk for
deep/severe (greater than 8mm) pitting.
skin breakdown.
Become familiar with the agency’s
edema rating scale.
TENTING is the term
b. Pinch a fold of skin on the sternal area
used to describe skin that
using your thumb and forefinger. Note
remains in a pinched
the speed with which it turns into place
position.
(turgor)
Absence of indentation in
dependent areas and the resilience of
the skin to spring back to its previous
state after being pinched.

HAIR: Inspect and Palpate

1. Color & Distribution of Scalp Hair: As melanin production
Eyebrows, eyelashes, and on body decreases, hair turns gray.
surface. Color may be chemically
Color varies from dark black to pale changed. Alopecia (hair loss)
blonde based on the amount of melanin and hirsutism (excessive
present. body hair are considered
abnormal. Hair loss maybe
the result of chemotherapy,
radiation therapy, infection,
hormone disorders, or

2. Texture & Oiliness: Thin, straight,
coarse, thick, or curly. Shiny and
resilient.
3. Note Infestation: Free of infestation.
SCALP: Inspect and Palpate
1. Part the hair repeatedly all over the scalp
and inspect for scaliness and scars.
The scalp should be shiny and smooth
without lesions, lumps, or masses.
2. Place the finger pads on the scalp at the
front and palpate down the midline and
each side for tenderness, lesions, lumps,
or masses.
Absence of redness or scaliness.
NAILS: Inspect and Palpate
1. Note the nail color, shape, and texture.
Nailbed is highly vascular with a pink
color in light-skinned clients and
longitudinal streaks of brown or black
pigmentation in dark skinned clients.
Angle between the fingernail and base is
about 160O. When palpated, the nail
base is firm.
2. Test for capillary refill by pressing two or
more nails between your thumb and
index finger. Note the degree of
blanching and return to normal color.
When pressure is released from nail it
promptly returns to its normal color.
3. Inspect the tissue surrounding nails for
lesions.
Tissue surrounding the nails is intact.
inadequate nutrition. Vellus
hair loss may be due to
decreased oxygenation of
peripheral tissues. Excessive
hair growth may be due to
hormone disorders.
Thin, brittle, dull hair
may be indicative of
malnutrition,
hyper/hypothyroidism,
chemicals or infections.
Pediculus capitis, P.
corporis and P. pubis are
lice that adhere to head,
body, and pubic hair. The
eggs are white avoid nits.
Sebaceous cysts or
trauma deformities.
Dry flaking, scaling
occurs in seborrhea
(dandruff) and psoriasis (red
patches covered by thick,
dry, swelling, adherent scales
that result from excessive
development of epithelial
cells.
Note for abnormalities or
variations of the nailbed
Delayed return of nailbed
color may indicate
circulatory impairment.
Paronychia (inflammation
of the skin around the nail),
Koilonychia (spoon-shape
nails, Beau’s line (transverse
 depression in the nails.

TOMAS CLAUDIO MEMORIAL COLLEGE

COLLEGE OF NURSING

NAME: SCORE:
Date:

PHYSICAL EXAMINATION
HEAD and NECK
AREA OF ASSESSMENT
KEY FINDINGS 5 4 3 2 1 REMARKS
NORMAL FINDINGS
SKULL: Inspect and Palpate
1. Inspect skull for shape, symmetry, size in Assymmetry enlarged
proportion to body and position. skull size may be indicative
Rounded, symmetrical, of hydrocephalus and Paget’s
normocephalic, upright. disease.

Hard or soft masses are

abnormal and may be
2. Palpate with fingerpads, beginning in indicative or carcinomas or
frontal area and continuing over parietal, lymphomas. Softening of
temporal, and occipital areas for contour, outer bone layer may be
masses, depressions, and tenderness. caused by hydrocephalus or
Smooth, nontender, free of masses or demineralization of bones
depressions. secondary to rickets,
hypervitaminosis A, or
syphilis.

FACE: Inspect
Asymmetry may be
1. Inspect facial features for expression, indicative of cranial nerve
shape and symmetry of eyebrows, VII damage, a stroke, or
nasolabial fold, and placement of nose, Bell’s palsy.
eyes, and ears.
May be oval, round, or square. Sunken temples, eyes,
Symmetrical facial features and and cheeks are indicative of
movement. dehydration and
malnutrition.

Puffy swollen appearance

anterior to ear lobes and
2. Inspect for edema and masses. above angles of jaw may
indicate parotid gland
enlargement.

EYES: Inspect and Palpate

1. Assess Visual Acuity: A value of 20/40 means
a. Position Snellen Chart 20 feet in front that a client can read at a
of client. distance of 20 feet what a
 b. Remove corrective lenses. If person with normal vision
appropriate. can read at a distance of 40
c. Instruct client to cover one eye and feet.
read lines, starting with top of chart
from left to right; note the line where
the client correctly reads more than
half the letters.
d. Record results as a fraction sc (without
correction), 20/distance number, and
the number of letters missed for the eye
test.
a. Repeat Steps a-d for other eye.
b. If appropriate, repeat Steps a-e with
client wearing corrective lenses, record
result cc (with correction).
Normal vision, based on the Snellen
Chart, is 20/20 (at a distance of 20 feet
the normal eye can read the chart)

2. Test Extraocular Muscle Movements: Asymmetrical movement

a. Place the client in sitting position or the presence of nystagmus
facing you. results from local injury to
b. Instruct client to hold head still. eye muscles and supporting
c. Ask client to follow an object (finger, structures or may indicate
pen, and penlight) with eyes. neurological impairment.
d. Move object through six fields of gaze.
e. Observe for parallel eye movement.
f. Pause during upward and lateral gaze
fields to detect involuntary rhythmic
oscillation of eyes.
g. Note the position of upper eyelid in
relation to the iris and eyelid lag as the
client’s eyes move from up to down.
h. Move the object forward to about 5
inches in front of the client’s nose at
the midline and observe for
convergence.
i. Record results.
Eye movements should be symmetrical
as both eyes follow the direction of the gaze
and converge on the ‘held object as it
moves toward the nose. The upper eyelids
cover only the uppermost part of the iris
and are free from nystagmus (involuntary,
rhythmic, oscillation of the eyes). A few
beats of nystagmus with extreme lateral
gaze can be normal.

3. External Anatomical Structures: Upper eyelid should not

a. Observe upper eyelid. overlap pupil.
Upper eyelid should overlap iris.

b. Check eyes and eyelids for Red lid margins with

inflammation, crusting, edema, or yellowish scales result from
masses. an inflammation of the
Eyes and eyelids should be free eyelids (blepharitis).
 from inflammation, crusting, edema or
masses.
c. Inspect and palpate lacrimal glands and
sacs for swelling. If lacrimation is
excessive;
 Check for blockage of the
nasolacrimal duct by pressing
against inner orbital rim of
lacrimal sac.
 Inspect duct blockage by palpating
on the lacrimal sac and observing
for regulation of fluid.
Lacrimal gland should not be
palpable. Tears flow freely from the
lacrimal gland over the cornea and
conjunctiva to the lacrimal duct.
d. Inspect bulbar and palpebral
conjunctiva and sclera.
 Instruct client to look upward
while you depress lower lid with
your thumb.
 Inspect for color, redness,
swelling, exudate, or foreign
bodies.
Bulbar is transparent with small
blood vessel visible. Palpebral
conjunctiva, covering the inside of the
upper and lower eyelids, is pink and
moist. Sclera should be white with
some superficial blood vessels.
e. Inspect cornea, lens, pupil, iris &
anterior chamber.
 Stand in front of client.
 Shine penlight directly on cornea.
 Move light laterally and view
cornea from that angle; note color,
discharge, and lesions.
 Look at pupil and note the size and
shape.
 Shine penlight directly on pupil to
assess the lens and its color.
Presence of inflammation,
crusting, edema, or masses
may indicate acute
hordeolum (sty), a painful,
red infection of a hair follicle
of the eyelashes; chalazion
(chronic inflammatory lesion
of the meibomian gland); or
basal cell carcinoma (papule
with a pearly border and a
depressed or ulcerated
center) of the lower lid.
Swelling of lacrimal sac
indicates dacrocyanostitis
(inflammation) or tumor.
Regurgitation of tears
through the puncta indicates
blockage of lacrimal duct.
Bright red conjunctiva
with crusty drainage occurs
with conjunctivitis
(contagious infection of the
conjunctiva). It may be
bacterial, viral, or allergic. A
pale conjunctiva usually
indicates anemia. Bright red
patch on the exposed bulbar
conjunctiva is a
subconjunctival hemorrhage
that may result from trauma
or sudden increase in venous
pressure possibly due to
coughing, sneezing,
anticoagulant therapy, or
uncontrolled hypertension.
A grayish, ulcerated area
on cornea is abnormal; it
may be due to a bacterial
infection. Arcus senilis, a
bilateral, benign
degeneration of the
peripheral cornea and normal
variation with aging clients,
presents as hazy gray ring, 2
mm in width around the
limbus. Opacity of the lens
(loss of transpency) occurs
  Look at iris for size, and ability of with cataracts, caused most
the pupils to react to light. commonly by aging. Cloudy
 Anterior chamber is the pupils occur with cataracts.
compartment between the cornea If the angle is too narrow, or
and iris. This space between must drainage is inadequate, the
be adequate enough to let aqueous pressure of the aqueous fluid
fluid out of the eye. Shine a light in the anterior chamber
obliquely through the anterior increases, and glaucoma
chamber from lateral side toward develops.
nasal side. Observe the
distribution of light in the anterior
chamber.
Cornea are moist, shiny, and clear;
lenses are transparent; pupils are
black, round, and equal diameter,
ranging from 2-6mm. Entire iris
should illuminate when shining light
laterally to nasally.
f. Test pupillary responses to light and Altered pupillary reaction
reaction to accommodation in a dimly in time and equality occur
lit room. with increased intracranial
 Instruct client to look straight pressure lesions involving
ahead. the third cranial nerve,
 Bring the penlight from the side of trauma, or some medications.
the client’s face to directly in front Pupillary constriction occurs
of the pupil. with inflammation of the iris
 Note the quickness of response to or in response to medication
light. (pilocarpine, morphine).
 Shine light into same eye, Pupillary dilation may occur
observing response of opposite with trauma, neurological
pupil for equality of size. disorders, glaucoma, or in
 Repeat steps 2-4 with opposite response to medication
eye. (atropine)
 Instruct client to gaze at your
finger held 4-6 inches from her
nose, then to glance at a distant
object while you note pupillary
reflex.
 Move the finger toward the bridge
of the client’s nose, noting
responses of both pupils.
 Record results PERRLA (pupils
equal, round, reactive to light and
accommodation).
Pupil should constrict quickly in
direct response to light and the
opposite pupil should also constrict.
Pupil should be equal in size.
Pupillary accomodation causes
constriction in response to objects that
are near, and dilation occurs to
accommodate distant vision, with
symmetrical convergence of eyes.

4. Test Visual Fields (Confrontation Test) Defects in the visual field

 a. Sit or stand 2 feet in front of client with can be associated with
your eyes at the same level as the tumors, strokes, glaucoma,
client’s. vascular diseases,
b. Instruct the client to cover the right eye inflammatory processes, and
while you cover your left eye, and ask retinal diseases,
client to look, into your eye directly inflammatory processes, and
opposite to create one vision field. retinal disease or
c. Hold your free hands at arm’s length, detachment.
equidistant from you and the client’s
field of vision from nasal, temporal,
superior, and inferior and oblique
angles.
d. Instruct client to tell you when your
finger becomes visible.
e. Note if you see the finger before the
client does.
f. Repeat Steps c and d for each field
vision.
g. Indicate results indicating eye tested.
h. Repeat Step b-g with other eye.
Consensual peripheral vision should
occur when your finger comes into the
client’s visual field.
Changes in color, size, or
5. Inspect fundus with Opthalmoscope.
clarity of the margins of the
(Fundus examination requires advanced
optic disc or the
assessment skills of a Nurse practitioner.)
identification of lesions
a. Set ophthalmoscope at diopsters.
should be recorded and
b. Instruct client to gaze at a designated
reported; a follow-up
point on the far wall, keeping both eyes
examination by an
open during the examination.
ophthalmologist should be
c. With your right hand, hold the
scheduled.
ophthalmoscope 10 inches from the
client and use your right eye to
examine the client’s right eye. Rest
your left hand on client’s forehead.
d. Shine the light on the pupil and locate
the red reflex (bright, orange, glow).
e. Slowly move the ophthalmoscope
closer until the retina is seen. While
rotating the lens dial to focus on the
internal structure.
f. Assess the size, color, and clarity of the
optic disc.
g. Carefully follow the blood vessel
central to the optic disc into each of the
four quadrants, observing for lesions
(hemorrhage or exudates).
h. Inspect the appearance of the macula,
lateral to optic disc.
i. Repeat Steps a-h using your left eye
and left hand to examine the client’s
left eye.
j. Record findings.
Red reflex is present. Optic disc is
pinkish orange, with a yellow white
 excavated center known as the
physiological cup. The ratio of the cup
diameter to that of the entire disc is 1:3.
Disc border may be sharp, or rounded to
a more blended border. Four main
vascular branches come from the disc;
each branch consists of an arteriole and
venule. Venules are darker in color and
four times the size of the arterioles.
Arterial to venous width is a ratio of 2:3
or 4:5.
EARS: Inspect and Palpate
Ears set below lateral
canthus occur with
1. Examine external ears, called auricle or
congenital anomalies (e.g.,
pinna, for placement, symmetry, color,
Down Syndrome). Redness
discharge and swelling.
indicates inflammation or
Symmetrical, with upper attachment
fever. Yellow or green
eye corner level (lateral canthus), flesh
discharge, itching, or pain
color.
occurs with middle ear
infections (otitis media).

Auricular pain is common

with acute otitis externa
(external air infection).
2. Palpate the auricle between thumb and Mastoid tenderness is
index finger, noting lesions or tenderness associated with middle ear
by moving auricle up and down. With inflammation (mastoiditis).
index and middle fingers, palpate Tragus swelling or
mastoid tip, noting any tenderness. Press tenderness may indicate
inward on tragus, noting any tenderness. inflammation of the external
Firm, smooth, free from lesions and or middle ear. Keloids (scar
pain. tissue) on the ear lobe may
result from ear piercing.
Yellow or green discharge
may indicate infection.

3. Otoscopic Examination Build up cerumen, a

a. Select largest speculum to comfortably
fit the client’s ear canal.
b. Tip client’s head away from the ear
being assessed and straighten ear canal
by grasping and pulling the auricle
upward, back and slightly outward, if
client is older than 3 years old. For
infants and children under the edge of
3, pull auricle down and back.
c. Hold otoscope securely in dominant
hand, rest back of dominant hand
against side of client’s face, and slowly
insert speculum.
d. Examine the canal for earwax, foreign
bodies, discharge, scaliness, redness or
swelling. If wax or a foreign body is
present, stop the examination and make
normal moist, waxy yellow
substance that turns hard,
dry, and dark yellow brown
when impacted, may cause
temporary hearing loss.
Swollen or reddened canal
with discharge occurs with
infection. Nontender,
nodular swelling deep in the
ear canal suggests osteoma
(usually a benign tumor
composed of bone tissue).
Red, bulging tympanic
membrane indicates acute
purulent otitis media; whitish
appearance on tympanic
membrane results from pus
 referral to qualified specialist.
e. Inspect the tympanic membrane by
sliding speculum slightly down and
forward. If membrane is not visible,
gently pull the auricle slight farther to
straighten the canal. in the middle ear.
f. Identify the color, light reflex, umbo, Perforations of the tympanic
the short process, and long handle of membrane result from
the malleus. Note perforations, lesions infection or trauma. Scarring
bulging or retraction of the membrane, may be a result from chronic
dilation of blood vessels, bubbles, or ear infections.
fluid level. Tympanostomy tubes may be
g. Gently withdraw the speculum and surgically placed for
repeat procedure in opposite ear prolonged otitis media with
Cerumen, a waxy yellow or brown effusion.
substance, is normal. Ear canal is
pinkish and dry. Intact tympanic
membrane, translucent or pearly gray.
Light reflex is seen at 5 o’clock in right
ear and 7 o’clock in left ear.

4. Test Auditory Acuity

a. WHISPERED VOICE Test:
 Instruct client to occlude one ear
with finger and repeat the words
when heard.
 Nurse stands 1-2 feet away from
client, out of view to avoid client lip-
reading, and softly whispers
numbers on side of open ear.
Increase voice volume until client
identifies words correctly.
 Repeat procedure on other ear.
 Record Results.
Client should be able to repeat
whispered words.
b. WEBER’S TEST:
 Strike tuning for (512 Hz) against
your first or pinch the prongs
together.
 Hold the base (handle) of the
vibrating fork with your thumb and
index finger and place the base of the
fork on the top of the head at the
midline.
 Ask client if the sound was heard
centrally or toward one side.
 Record results.
Sound perceived equally in both ears;
results indicate a “negative” Weber Test.
Inability to hear words
may indicate a high
frequency hearing loss (e.g.,
resulting from excessive
exposure to loud noises).
Result “positive” from
Weber Test when sound
lateralizes to affected ear
with a unilateral conductive
hearing loss. Occurs with
impacted cerumen,
perforated tympanic
membrane, serum or pus in
the middle ear, or fusion of
the ossicles. Sound can also
lateralize to unaffected ear
with sensorineural hearing
loss. Occurs with inner ear
disorders, auditory nerve
damage, or results from
repeated, prolonged loud
noise or effects of ototoxic
drugs.
 c. RINNE TEST:
 Vibrate prongs of tuning fork and
place base of fork on mastoid
process of ear being tested and note
the time on your watch. Instruct the
client to indicate if the sound is
heard, and ask the client to tell you
when the sound stops.
 When the client says that the sound
has stopped, move the vibrating fork
in front of the ear canal, noting the
length of time is heard.
 Record Results. Repeat test, opposite
ear.
Sound heard longer in front of the
right auditory meatus than on the
mastoid process because air conduction
is twice as long as bone.
NOSE & SINUSES: Inspect and Palpate & Percuss
1. Inspect the nose for symmetry,
deformity, flaring, or inflammation and
discharge from the nares.
Located symmetrically, midline of the
face, and is without swelling, bleeding,
lesions, or masses.
2. Test patency of each nostril.
a. Instruct the client to close the mouth
and apply pressure on one naris and
breathe.
b. Repeat test on opposite naris.
Each nostril is patent.
3. Inspect the nasal cavities with a penlight.
a. Tilt the client’s head an extended
position.
b. Place nondominant hand on client’s
head. Using your thumb, lift the tip of
the nose.
c. With the lit penlight, assess, nasal
septum for deviation, perforation,
lesions, or bleeding, and inspect for
swelling, discharge.
Mucosa is a pink or dull red without
swelling or polyps. Septum is a midline
and intact. A small amount of clear
watery discharge is normal.
Bone conduction is equal
or greater than air
conduction. Occurs with
conductive hearing loss
resulting from diseases,
obstruction, or damage to
outer or middle ear.
Swollen or broken as a
result of trauma or surgery.
Air cannot move through
the nostril. May occur with a
deviated septum, foreign
body, upper respiratory
infection, allergies, or nasal
polyps
Rhinitis, red, swollen
mucosa with copious clear,
watery discharge occurs with
a cold. Discharge becomes
purulent if a secondary
bacterial infection develops.
Pale, edematous mucosa
with clear, watery discharge
occurs with allergies or hay
fever. A normal mucosa with
clear, watery nasal discharge
that tests positive for glucose
following head injury or
nasal, sinus, or dental
surgery usually indicates the
leakage of cerebrospinal
fluid. If present, stop the
exam and make a referral to
a qualified specialist
immediately.
4. Palpate the nasal sinuses by applying
gentle, upward pressure on frontal and
maxillary areas, avoiding pressure on the
eyes. Percuss area with middle or index
finger and note the sound.
Nontender, air-filled cavities,
resonant to percussion.
Pain or tenderness may be
caused by viral, bacterial, or
allergic processes that cause
inflammation and
obstruction, eliciting a dull
sound.

MOUTH & PHARYNX: Inspect and Palpate

1. Stand 12-18 inches in front of client and
smell the breathe.
Breath should smell fresh.
Halitosis (foul smelling
breath) occurs with tooth
decay or disease of gums,
tonsils, or sinuses or with
poor oral hygiene.

2. Observe the lips for color, moisture,

swelling, or lesions. Instruct client to
Pale or cyanotic lips may
open mouth. With a tongue depressor,
indicate systemic
retract the buccal mucosa and note the
hypoxemia. Dry, cracked lips
color, hydration, inflammation, or
occur with dehydration or
tensions. Invert lower lip with your
exposure to weather.
thumbs on inner oral mucosa, note
Swollen lips (angioneurotic
muscle tone; repeat with upper lips using
edema) result from allergic
thumbs and index fingers.
reactions (e.g., medication or
Lips and mucosa should be pink, firm,
food)
and moist without inflammation or
lesions.

3. If present, remove dentures. Retract the

cheeks with a tongue depressor and
inspect gums (gingivae). Note color, Pale gums that bleed
edema, retraction, bleeding, and lesions. easily may indicate
Palpate the gums, with the tongue blade periodontal disease or
for texture. Vitamin C deficiency.
Gums are pink, smooth, moist, and
firm.

4. Instruct the client to clench teeth. Note Chalky white

position and alignment. Inspect teeth: use discoloration of teeth’s
tongue depressor to expose the molars. enamel indicates early
Note tartar, cavities, extraction, and formation of dental caries
color. (cavities). Brown or black
Properly aligned, smooth, white and discoloration indicates
shiny. formation of caries.

5. Instruct client to protrude the tongue. Enlarged tongue may

a. Inspect dorsum of tongue. Note color, indicate glossitis or
hydration, texture, symmetry, presence stomatitis or may occur with
or absence of fasciculation. myxedema, acromegaly, or
b. With penlight, inspect sides and ventral amyloidosis. Deep red,
surface. Note size, texture, nodules, or smooth surface occurs with
ulcerations. glossitis caused by Vitamin
c. Grasp tongue with gauze. Gently pull it B12, iron, or niacin
to one side and palpate the full length deficiency or as a side effect
of tongue. from chemotherapy. Thick
 d. With penlight, inspect floor of mouth,
salivary glands, and duct openings.
When protruded, tongue lies midline, white coating with red, raw
medium red or pink in color, moist and surface is candidiasis
smooth along lateral margins, with free (thrush) indicating
mobility. The dorsal surface is slightly immunosupression. Lesions
rough (taste buds) and free of lesions. on the lateral surface may
The ventral surface is highly vascular, indicate cancer.
smooth, moist, and free of lesions.

6. Inspect the hand and soft palate with

penlight.
Client palate (maxillary
a. Instruct client to extend head backward
processes fail to fuse
and hold mouth open.
prenatally) is a congenital
b. Inspect the hard palate (roof of mouth),
defect. Red, swollen, tender
located anteriorly, and the soft palate,
palates, indicate infection.
which extends posteriorly to pharynx.
Eroded lesion on hard palate
Note color, shape, lesions.
may indicate cancer.
Palates are concave and pink, hard
palate has ridges; soft palate is smooth.

7. Inspect the pharynx using a tongue

depressor and penlight.
a. Explain procedure to the client.
b. Instruct client to tilt head back and
open mouth.
c. With your nondominant hand, place
tongue depressor on middle third of Reddened, edematous
tongue. With dominant hand, shine uvula and tonsilar pillars
light into back of throat. with yellow exudates
d. Instruct client to say “ah”. Note the indicate pharyngitis.
position, size, and appearance of Swollen, gray membranes
tonsils and uvula. and tonsilar enlargement
e. If palate and uvula fail to rise may result from acute
symmetrically with phonation, inform tonsillitis, infectious
client about eliciting gag reflex (touch mononucleosis, or
the posterior one-third of tongue with diphtheria.
blade to stimulate the gag reflex) and
inspect as stated.
With phonation, the soft palate and
uvula rise symmetrically. The pharynx is
pink, vascular, lesion-free. Tonsil size is
evaluated using grading scale.

NECK: Inspect, Palpate and Auscultation

1. Inspect for symmetry and musculature. Pain with flexion or
Instruct client to: rotation of head is associated
a. Flex chin to chest and to each side and with muscle spasm that may
shoulder to test anterior be caused by inflammation
sternocleidomastoid muscle. of muscles, meninges, or
b. Hyperextend the neck backward to test diseases of the vertebrae.
posterior trapezia. Prominent lateral deviation
Muscles are symmetrical with head in of sternocleidomastoid
central position. Movement through full muscle (torticollis) is
range of motion without complaint of commonly associated with
discomfort or limitation. inflammation of viral
 myositis or trauma (e.g.,
sleeping with head in
unusual position). Decreased
range of motion is
commonly associated with
degenerative osteoarthritis.

2. Palpate lymph nodes. Instruct the client

to relax and flex neck slightly forward.
a. Stand in front of seated client.
b. Methodically palpate both sides of face
and neck simultaneously. With gentle
pressure, move pads and tips of middle
three fingers in small circular motion.
Follow a systematic sequence Palpate nodes may result
beginning with the preauricular, from a variety of diseases,
postauricular, occipital, submental, most commonly an
submandibular, and tonsilar nodes. infectious process or
Move down to the neck, palpate malignancy.
anterior cervical chain, the posterior
cervical chain, and the supraclavicular
nodes.
c. Note size, shape, mobility, consistency,
and tenderness.
Lymph nodes should not be palpable.
Small, movable nodes are insignificant.

3. Inspect and Palpate trachea.

a. Note position.
Lateral displacement may
b. Place thumbs and index fingers on
be caused by a neck or
sides of trachea. Apply gentle pressure
mediastinum mass or
and palpate.
pulmonary disorders.
Midline position above the
suprasternal notch.
Masses or enlargement
4. Palpation of the thyroid may be
during swallowing may
approached anterior or posterior to the
indicate a goiter (enlarged
seated client.
thyroid gland) or thyroid
a. POSTERIOR APPROACH
nodules indicating thyroid
 Stand behind client, place thumbs on
disease. Vibrations or bruits
nape of neck and bring fingers
heard on auscultation occur
anteriorly around neck with their tips
with increased turbulence in
resting over tracheal rings.
a vessel and are caused by
 Ask client to tilt chin forward to increased vascularization of
relax neck muscles and swallow. the gland (enlarged toxic
 Palpate the isthmus rise under your goiter).
fingers and feel each lateral lobe
before and while client swallows.
 Ask client to flex neck forward and
to left, and displace thyroid cartilage
to right with tips of your left fingers.
Note any bulging of gland.
 Press fingers of left hand against left
side of thyroid cartilage to stabilize it
while palpating with the fingers of
your right hand while the client
 swallows.
 Note consistency, nodularity, or
tenderness as gland moves upward.
 Repeat Steps 4 through 6 on the
opposite side.

b. ANTERIOR APPROACH
 Stand in front of client.
 Instruct client not to tilt chin
forward, and place your right thumb
on thyroid cartilage and displace the
cartilage to the right.
 Grasp the elevated, displaced right
lobe with thumb and fingers of left
hand and palpate for consistency,
nodularity, or tenderness as client
swallows.
 Repeat Steps 2 and 3 on the opposite
side.
 If gland appears enlarged, place the
bell of the stethoscope over gland
and listen for vascular sounds such
as soft, rushing sound, or bruit.
Thyroid cannot be visualized. It may
or may not be felt. It felt, it should be
smooth, soft, nontender, and not
enlarged.
 TOMAS CLAUDIO MEMORIAL COLLEGE
COLLEGE OF NURSING

NAME: SCORE:
Date:
PHYSICAL EXAMINATION
THORAX AND LUNGS
AREA OF ASSESSMENT
KEY FINDINGS 5 4 3 2 1 REMARKS
NORMAL FINDINGS
POSTERIOR CHEST: Inspect, Palpate, Percuss & Auscultate
Place client in a sitting position, arms
folded across chest (separates scapulae),
and back exposed. Structural changes that
1. Inspect posterior thorax: occur in the thorax. Defined
a. Assess shape and symmetry. Note rate horizontal slope of ribs
and rhythm of respirations, movement occurs with emphysema.
of chest wall with deep inspiration and Bulging in the intercostal
full expiration, and signs of distress. spaces indicates increased
b. Estimate the anteroposterior diameter effort of breathing (e.g.,
in proportion to lateral diameter. emphysema). Retraction of
Respirations are quiet, effortless, and intercostal spaces during
regular, 12-20 breaths per minute. inspiration indicates airway
Thorax rises and falls in unison with obstruction (e.g., asthma).
respiratory cycle. Ribs slope across and Impairment in respiratory
down, without movement or bulging in movement occurs with lung
the intercostal spaces. The adult ratio of or pleural disease.
anteroposterior to lateral diameter
ranges from 1:2-5:7.
Tenderness may result
2. PALPATE:
from a fractured rib.
a. Lesions or areas of pain; palpate and
Unilateral decreased thoracic
note tenderness.
expansion occurs on the
b. Thoracic expansion at 10th rib: place
affected side (e.g.,
thumbs close to client’s spine and
pneumonia or
spread hands over thorax. Note
pneumothorax). Bilateral
divergence of thumbs; feel for range
decreased expansion occurs
and symmetry of movement during
when alveoli do not fully
deep inhalation and full exhalation.
expand (e.g., emphysema or
c. Place ulnar aspect of your open hand at
pleurisy). Absent or decrease
right apex of lung and place the hand at
fremitus occurs when voice
each location.
is decreased, in presence of
d. Instruct client to say “99” and palpate
bronchus obstruction, or by
for tactile fremitus (vibrations created
fluid, air, or solid tissue in
by sound waves). Note areas of
the pleural space. Fremitus is
increased or decreased fremitus.
increased over areas of
e. Move hands from side to side, from
consolidated lung.
right to left, with client repeating the
 words with the same intensity every
time you place your hands on the back.

Thumbs should separate an equal

distance (3-5cm) and in the same
direction during thoracic expansion and
meet in the midline on expiration.
Posterior thorax is free from tenderness,
lesions, and pulsations. Fremitus is equal
on both sides of thorax, strongest at the
level of tracheal bifurcation.

3. PERCUSS Chest symmetrically:

a. Start at lung apices. Move hands from
side to side across the top of each
Hyperresonance in adults
shoulder. Note sound produced from
occurs in pneumothorax,
each percussion strike and compare
emphysema, or asthma. Dull
with contralateral sound.
sound is created in solid or
b. Continue downward and posterolateral
fluid-filled structures (e.g.,
every other intercostal space. Note
pneumonia, pleural effusion,
intensity, pitch, duration, and quality of
or tumors). Pleural fluid
percussion.
sinks to lowest part of
Air filled lungs create a resonant
pleural space (posteriorly in
sound. Identify contralateral sound;
a supine client).
(e.g., ribs, spine) create a flat sound.
Thorax is more resonant in children and
thin adults.

4. Auscultate posterior and lateral surfaces.

a. Place diaphragm of stethoscope on
right lung apex. Instruct client to inhale
and exhale deeply and slowly when the
stethoscope is felt on the back. Repeat
on left lung apex.
b. Move downward every other Decreased breath sounds
intercostal space and auscultate, caused by inability to inhale
placing stethoscope in the same and exhale deeply (e.g.,
position on both sides. emphysema or by an
c. Auscultate the lateral aspect by placing obstruction; Atelectasis or
the stethoscope directly below the right foreign object). Absent
axilla, instructing the client to breathe breathe sounds (e.g.,
only through the mouth and to inhale empyema, hemothorax,
and exhale deeply and slowly. Precede pneumothorax, or
downward, every other intercostal pneumonectomy).
space on the same side.
d. Repeat step C on left side.
Posterior sounds: bronchovesicular
and vesicular sounds; lateral; vesicular
sounds. A large chest will produce
decreased breath sounds.

ANTERIOR CHEST: Inspect, Palpate, Percuss & Auscultate

Place client in a sitting or supine One scapula higher than
position. the other occurs with

1. Instruct client to inhale deeply and exhale
fully. Inspect anterior thorax for:
a. Symmetry and depth of movement.
b. Rhythm of respirations.
c. Slope of ribs and musculoskeletal
deformities.
Scapula at same height. Thorax rises
and falls in unison with respiratory
cycle, ribs at a 45O angle with sternum.
Inspiratory breath sounds are not
audible at a distance of more than 2-3cm
from the mouth.
scoliosis. Rib angle less than
45O occurs with emphysema,
bronchiectasis, and cystic
fibrosis. Bulging of
intercostal spaces on
expiration occurs with an
expiratory obstruction (e.g.,
emphysema, tension
pneumothorax, and tumors).
Retraction on inspiration
obstructs free inflow of air
(e.g., asthma, trachea /
laryngeal obstruction, or
tumor).

Pulsations may indicate a

thoracic aortic aneurysm.
2. PALPATE
Tenderness may result from
a. Place fingerpads on right apex, above
a fractured rib. Unilateral
the clavicle. Proceed downward to
decreased thoracic expansion
each rib and intercostal space and note
occurs on the affected side
tenderness, pulsation, masses, and
(e.g., pneumonia or
crepitance. Repeat on left side.
pneumothorax). Bilateral
b. Assess respiratory excursion by
decreased expansion occurs
placing your thumbs along each costal
when alveoli do not fully
margin with hands on lateral rib cage.
expand (e.g., emphysema or
Instruct client to inhale deeply; note
pleurisy). Crepitus (a
divergence of thumbs on expansion;
grating or crackling
feel range and symmetry of respiratory
sensation caused by two
movement.
rough surfaces rubbing
c. Palpate for tactile fremitus. Repeat
together, as in subcutaneous
steps discussed above for posterior
emphysema) occurs when air
palpation for tactile fremitus, gently
escapes the lung and is
displacing female breasts as necessary.
trapped in subcutaneous
Note that fremitus is usually decreased
tissue. It is palpated as a
or absent over the precordium.
crackling sound from any
Same as normal findings for posterior
condition that interrupts the
palpation.
pleurae (e.g., pneumothorax
or thoracic surgery).
Dullness over lung tissue
3. Symmetrically percuss as anterior
indicates fluid-filled or solid
surface.
areas (e.g., pneumonia or
a. Percuss 2 or 3 strikes along right lung
tumors). Because pneumonia
apex; repeat on the left lung apex.
typically occurs in right
Proceed downward, percussing in
middle lobe, unless you
every other intercostal space going
displace the breast, you may
from right to left in same position on
miss the abnormal
both sides. Displace breast tissue as
percussion note.
necessary.
b. Assess in each thoracic area.
 Resonant lung field.
 Cardiac dullness: 3rd – 5th intercostal
spaces left of sternum.
 Liver dullness: place your pleximeter
finger parallel to upper border of
expected liver dullness in right
 midclavicular line; percuss
downward.
 Gastric air bubble: repeat procedure
performed for liver dullness on left
side.
Resonant sound over lung tissue
(hyperresonance in children and thin
adults). Cardiac, liver, and gastric
silhouettes emit dull sound. Ribs sound
flat.

4. Auscultate anterior surface: Instruct

client to breathe through mouth and
compare symmetrical areas of the lungs,
from above downward. Decreased breath sounds
a. Listen to breath sounds. Note intensity caused by an ability to inhale
and identify variations from normal. and exhale deeply (e.g.,
b. Identify any added sounds by location emphysema or by an
on chest wall and time in the obstruction; Atelectasis or
respiratory cycle. foreign object). Absent
c. If breath sounds are diminished, ask breath sounds (e.g.,
client to breathe hard and fast with empyema, hemothorax,
mouth open. pneumothorax, or
Anterior sounds: bronchial, pneumonectomy).
bronchovesicular, and vesicular sounds.
A large chest will produce decreased
breath sounds.
 TOMAS CLAUDIO MEMORIAL COLLEGE
COLLEGE OF NURSING

NAME: SCORE:
Date:
PHYSICAL EXAMINATION
HEART AND VASCULAR SYSTEM
AREA OF ASSESSMENT
KEY FINDINGS 5 4 3 2 1 REMARKS
NORMAL FINDINGS
HEART: Inspect, Palpate, & Auscultate
Place client in supine or slightly
elevated position. Expose anterior thorax
using a drape. Stand at client’s right side
with light shining from opposite side to
eliminate shadows.

Visible pulsations,
heaves, or retractions require
1. Inspect anterior thorax, precordium area:
additional inspection with
note pulsations, heaves, or retractions.
palpation to identify exact
Absence of visible pulsations, heaves,
location and timing in
or retractions.
relation to cardiac cycle
(systole or diastole).

2. Inspect and palpate each of the cardiac

landmarks for apical impulses. Use
fingerpads to palpate pulsations and ball Thrill may indicate aortic
of the hand to palpate thrills or heaves. and pulmonic stenosis or
a. Aortic Area: note pulsation, thrill or regurgitation.
vibration of aortic valve closure.
b. Pulmonic Area: note pulsation, thrill, Erb’s point pulsations
or vibration of pulmonic valve closure. may indicate a left
c. 3rd left ICS: note pulsation, thrill, or ventricular aneurysm or
vibration of pulmonic valve closure. enlarged right ventricle.
d. Right ventricular area (left lower half
of sternum and parasternal area): assess Thrill may indicate a
for a diffuse lift, heave, or thrill. tricuspid stenosis or
e. Apex of heart (5th ICS just medial to regurgitation; a heave may
midclavicular line) note pulsation, also be present.
thrill or heave.
No pulsations, thrills, or heaves Thrill may indicate mitral
should be palpated in aortic, pulmonic, stenosis or regurgitation. A
Erb’s point, or tricuspid areas. An apical heave (sustained apex beat)
impulse (heard after first heart sound, may result from left
lasting for half of systole) occurs in 50% ventricular hyperthrophy.
of adult population. Mitral thrill or
heave is absent.
3. Palpate high in epigastric region for
pulsations.
Strong pulsations thrusting upward
against the fingertips are caused by the
aorta.
4. Begin auscultation using the diaphragm
of stethoscope for transmission of high
frequency sounds. Listen to several “lub
dub” cycles in all five cardiac landmarks
twice: First identify S1 and S2, the listen
for S3 and S4 and murmurs and friction
rubs.
a. Locate aortic valve landmark (second
ICS, right sternal border) and listen for
S2.
b. Auscultate pulmonic valve (second
ICS, left sternal border), listening for
S2.
Regular intervals of time occur with a
regular rhythm: time between S1 and S2
(systole) and then the time between S2
and the next S1 (diastole) with a distinct
silent pause between S1 and S2. Aortic S2
herald onset of diastole, corresponds
with “dub” sound, and is louder than S1.
In the pulmonic area a split of the S 2
sound is usually heard every fourth or
fifth beat (aortic and pulmonic
components). Splitting of S2 occurs on
inspirations because of a greater
negative intrathoracic pressure when the
venous return to the right side of the
heart increases; thus, pulmonic closure
is delayed because of the extra time
needed for increased blood volume to
pass through the valve. Aortic S2 is
louder than pulmonic S2 because of the
greater pressures in the left side of the
heart.
c. Erb’s point (third left intercostal
space): auscultate for murmurs.
d. Tricuspid area: assess for S1. Instruct
client to hold his breath.
S1 is split because the mitral valve
closes slightly before the tricuspid valve.
When the client holds her breath, the
splitting disappears.
e. Mitral area: assess for S1. If you are
unable to distinguish between S1 and
Large pulsations and a
mass may indicate an
abdominal aortic aneurysm.
Notify the nursing supervisor
immediately if you detect
signs of an aneurysm.
Diminished S2 may
indicate aortic stenosis and
an intensified S2 may
indicate arterial
hypertension. Ejection click
following S1 can be heard
with aortic stenosis caused
by calcified valve.
A split S2 that is
abnormally wide on
inspiration indicates delayed
closure of the pulmonic
valve resulting from a delay
in the electrical stimulation
of the right ventricle (e.g.,
right bundle branch block).
A pulmonic ejection click
(heard loudest on expiration)
is caused by the opening of a
diseased pulmonic valve. A
loud pulmonic S2 is caused
by an elevated pressure in
the pulmonary artery. A
diminished pulmonic S2
occurs with a calcified or
thickened valve (e.g.,
pulmonic stenosis). A spilt
pulmonic S2 that is
abnormally wide or occurs
with every S2 is usually
indicative of an abnormality.
Murmurs may indicate
stenosis or regurgitation of a
valve.
A wide split S 1, during
inspiration that is still heard
on expirations is due to an
electrical malfunction (e.g.,
right bundle branch block or
a structural alteration, mitral
stenosis).
A variance S1 sound (soft
or loud) occurs when
diastolic filling time varies
 S2. Palpate carotid artery while (e.g., tachycardia or atrial
assessing mitral landmark; you will fibrillation).
hear S1 with each carotid pulse beat.
S1 heralds the onset of systole (”lub”
sound) and is louder than S2 at this
landmark.

5. Place client on left side. Use the bell of

stethoscope (low-pitched sounds) and S3 (ventricular gallop)
assess all five anatomical areas for extra occurs after S2 at the end of
heart sounds (S3 and S4 gallops, clicks ventricular diastole and may
and rubs). be one of the earliest clinical
S3 is heard in children and young findings of cardiac
adults under the age of 30 or in the third dysfunction (e.g., CHF). S4
trimester of pregnancy. S4 may occur may indicate cardiac
without any evidence of cardiac decompensation (e.g., CAD
decompensation gallops, clicks, and rubs or MI).
are absent.

6. Epigastric Ares: Place client in supine A bruit in the epigastric

position. Place bell of stethoscope over area indicates turbulent
visible aortic pulsations and auscultate blood flow as seen in the
for 10-15 seconds. presence of an aneurysm.
Bruits are absent.
VASCULAR SYSTEM: Inspect, Palpate, & Auscultate
Place client in supine position with head
of bed elevated 30O-45O. Use a drape and
uncover only those areas that are being
assessed. If skin is not assessed as a
separate system, inspect the skin for color,
texture, temperature, and edema during this
part of the examination.

1. Assess for carotid pulse:

a. Inspect right carotid artery along Kinking or bulging may
margin of the sternocleidomastoid indicate hypertension or
muscle. arteriosclerotic artery.
Absence of kings or bulging.
b. Palpate carotid artery at lower half of Decreased pulsations may
neck (to avoid carotid sinus) by indicate arterial narrowing or
instructing client to turn head toward occlusion.
right side (relaxes sternomastoid
muscle) and placing fingerpads of
index and middle fingers around
medial edge of sternocleidomastoid
muscle.
c. Auscultate carotid artery with bell of Bruits may indicate
stethoscope. Instruct client to hold distribution of blood flow
breath and listen for bruits. from arterial narrowing or
d. Repeat steps a-c on left side. occlusion.
Pulses are equal in rate and rhythm
with a strong, thrusting quality. No
blowing or swishing sound is heard on
auscultation.
2. Identify bilateral external and internal
(deep, along carotid artery) jugular veins
with head of bed elevated 45O (avoid
hyperextension or flexion of neck).
a. Inspect right internal jugular vein.
b. Measure the vertical distance in
centimeters from the sternal angle
(Angle of Louis) to top of distended
neck vein to obtain an indirect jugular
venous pressure.
c. Repeat steps 1-2 on left side.
Measurement of 1-2 cm above the
angle of Louis with head of bed elevated
45O.
3. Assess blood pressure (BP).
4. Inspect and palpate bilateral peripheral
pulses. Starting with the temporal artery,
proceed in a sequential pattern with the
upper extremities (brachial, radial, and
ulnar pulses), then the lower extremities
(femoral, posterior tibial, and dorsalis
pedis pulses). Note rate, quality, rhythm,
and volume of pulses. If you are unable
to palpate a pulse, use a Doppler or
ultrasound stethoscope to amplify the
sound.
Bilateral equality and symmetry of
peripheral pulses.
5. Assess tissue perfusion:
a. Perform Allen’s Test to determine
patency of radial and ulnar arteries.
Instruct client to rest hands in lap.
 Compress both the radial and ulnar
arteries.
 Firmly compress arteries and instruct
client to open the hand.
 Note color of palms.
 Release one artery and note the color
of the palm.
 Repeat steps 1-4 to the other artery
on the same hand. The procedure is
then performed on the other hand.
Palms should turn pink promptly.
b. Inspect both legs from the groin and
buttocks to feet. Note venous
enlargement, redness or discoloration,
and ulcers over saphenous veins.
Skin intact, free from venous
engorgement and pain.
c. Check for Homan’s sign by slightly
bending client’s knee and sharply
Distended jugular veins
(>2cm) with client in a
sitting position may be
related to fluid volume
overload (rapid infusion of
an intravenous solution).
Elevated jugular venous
pressure, when accompanied
with a third heart sound is
the most specific signs of
heart failure.
Markedly diminished or
absent pulses may indicate
arterial occlusion, for
example. Buerger’s disease
(thromboangitis obliterans).
Persistence of pallor
when one artery (e.g., is
manually compressed
indicates occlusion of the
other artery – for example,
ulnar.
Edema or ulceration is
indicative of venous stasis.
Tenderness or pain, warmth,
redness, or discoloration
indicates superficial
thrombophlebitis. Dilated
and tortuous veins are
varicosities.
A positive Homan’s Sign
may indicate
 dorsiflexing the client’s foot. If client thrombophlebitis or deep
feels pain in calf area of the leg, the vein thrombosis (DVT).
test is positive. Repeat on opposite leg.
Absence of calf pain.

LYMPATHIC SYSTEM: Inspect, Palpate, & Auscultate

1. Assess for epitrochlear nodes.
a. Client may be seated or supine.
If palpable node is
b. Support client’s hand; with other hand,
present, note its size, shape,
reach behind the elbow and place your
consistency, tenderness, and
fingerpads in the groove between the
mobility. Enlarged,
biceps and the triceps muscles superior
hardened, tender nodes may
to medical condyle of humerus.
be indicative of infection or
c. Palpate for presence of nodes on both
metastatic disease.
upper extremities.
Normally not palpable.

2. Assess superficial inguinal nodes.

a. Client is in supine. If client is obese,
place in frog leg position to gain access
to inguinal nodes.
b. Palpate in the groin area, moving
downward toward the inner thigh. The
vertical group of nodes lies close to the
upper portion of the great saphenous
vein. The horizontal group lies below
the inguinal ligament.
Normally not palpable.
If palpable node is
present, note its size, shape,
consistency, tenderness, and
mobility. Enlarged,
hardened, tender nodes may
be indicative of infection or
metastatic disease.
 TOMAS CLAUDIO MEMORIAL COLLEGE
COLLEGE OF NURSING

NAME: SCORE:
Date:
PHYSICAL EXAMINATION
ABDOMEN
AREA OF ASSESSMENT
KEY FINDINGS 5 4 3 2 1 REMARKS
NORMAL FINDINGS
ABDOMEN: Inspect, Auscultate, Percuss and Palpate
Place client in a supine position with
knees flexed over a pillow, hands at sides
Promotes relaxation of
or across chest. Undrape client from
the abdominal muscles.
xiphoid process to symphysis pubis to
expose the abdomen.

1. Stand at right side of client: A convex symmetrical

a. Inspect abdomen from rib profile reveals either a
margin to pubic bone. Note contour protuberant abdomen (results
and symmetry (observing for of poor muscle tone from
peristalsis, pulsations, scars, striae or inadequate exercise or
masses). obesity) or distension (taut
b. Inspect umbilicus for stretching of skin across
contour, location, signs of abdominal wall). Asymmetry
inflammation, or hernia. may indicate a mass, bowel
c. Observe for smooth, even obstruction, enlargement of
respiratory movement. abdominal organs or
d. Observe for surface scoliosis. Umbilicus bulging
motion (visible peristalsis) may indicate a hernia. Old
e. Inspect epigastric area for scars are flat with a shiny
pulsations. appearance, blending with
client’s pigmentation; new
Contour is flat or rounded and scars are raised and
bilaterally symmetrical. Umbilicus is reddened. Atrophic line or
depressed and beneath the abdominal streaks reveals linea
surface. Abdomen rises with inspirations albicantes (striae) that occur
and falls with expiration, free from with tumors, obesity, ascites,
respiratory retractions. Visible and pregnancy. Engorged or
peristalsis slowly transverses the dilated veins around the
abdomen in a slanting downward umbilicus are associated with
movement as observed in thin clients. circulatory obstruction of
Pulsations of the abdominal aorta are superior or inferior vena
visible in the epigastric area in thin cava. Uneven respiratory
clients. movement with retractions
may indicate appendicitis.
Strong peristaltic movement

2. Auscultate the abdominal
quadrants for bowel sounds (high-
pitched) using the diaphragm of the
stethoscope..
a. Begin by placing the
diaphragm on the RLQ. Listen for a
full minute to the frequency and
character of the bowel sounds.
b. Repeat step a, proceeding
in sequence to RUQ, LUQ, and LLQ.
c. Listen at least 5 minutes
before concluding the absence of
bowel sounds.
High-pitched sounds, heard every 5-
15 seconds as intermittent gurgling
sounds in all four quadrants as a result
of air and fluid movement in the GIT.
Bowel sounds should always be heard at
the ileocecal valve area
3. Auscultate with bell of stethoscope
over the aorta, epigastric area. Renal
arteries, and femoral arteries. Note bruits
over each area.
Free from audible bruits.
4. Percuss all quadrants in a
systematic fashion. Begin percussion in
RLQ, move upward to RUQ, cross over
to LUQ, and down to LLQ. Note when
tympany changes to dullness.
Tympany is heard of air in the stomach
and intestines. Dullness is heard over the
organs.
5. Perform light palpation. Never
palpate over areas where bruits are
auscultated.
may indicate intestinal
obstruction. Marked
pulsations in epigastric area
may indicate an aortic
aneurysm.
Hypoactive or diminished
bowel sounds are soft and
low and widely separated so
that only one or two are
heard in a 2 minute interval.
Hypoactive bowel sounds are
normal the first few hours
after general anesthesia.
Hypoactive sounds may
indicate decreased motility
of the bowel, such as occurs
with peritoneal irritation or
paralytic ileus. Absent
bowel sounds (none heard
for 3-5 minutes may signal
paralytic ileus, peritonitis or
an obstruction. Hyperactive
(loud, audible, gurgling
sounds similar to stomach
growling; sounds also called
borborygmi) may occur with
diarrhea or hunger. Rushed,
high-pitched, or tingling
sounds suggest air or fluid
under pressure; this may
occur in the early stages of
an intestinal blockage when
heard in the portion of the
bowel that precedes the
obstruction.
A bruit over an abdominal
vessel reveals turbulent
blood flow suggestive of an
aortic aneurysm or partial
obstruction (e.g., renal or
femoral stenosis).
Dullness over the
stomach or intestines may
indicate a mass or tumor,
ascites (excessive fluid
accumulation in the
abdominal cavity), or full
intestines.
Tenderness and increased
skin temperature may
indicate inflammation. Large
masses may be due to
 a. Instruct client to cough. If
client experiences a sharp twinge of
pain in a quadrant, palpate that area
last.
b. With client’s hands and
forearms on a horizontal plane, use tumors, feces, or enlarged
fingerpads to depress the abdominal organs.
wall 1cm all four quadrants. Note
texture and consistency of underlying
tissue.
Should feel smooth with consistent
softness.
 TOMAS CLAUDIO MEMORIAL COLLEGE
COLLEGE OF NURSING

NAME: SCORE:
Date:
PHYSICAL EXAMINATION
MUSCULOSKELETAL SYSTEM
AREA OF ASSESSMENT
KEY FINDINGS 5 4 3 2 1 REMARKS
NORMAL FINDINGS
MUSCULOSKELETAL SYSTEM: Inspect, and Palpate
Place client in sitting position to provide
comfort.

1. Assess the head and neck.

a. Ask client to open mouth as you apply Tenderness, limited
light pressure with fingerpads of ROM, and crepitus reveal
dominant hand 2-3 inches away from temporomandibular joint
temporomandibular joint. Listen for dysfunction that occurs
crepitation and note any limitation of secondary to arthritis,
ROM of jaw. malocclusion, dislocation,
poorly fitting dentures, and
myofacial dysfunction.

b. Inspect neck, noting symmetry, Lateral tilting of the head

deformities, and abnormal posture. and neck indicates
degenerative joint disease.

c. Palpate cervical spine, paravertebral Aching pain and tightness

muscles, and trapezil for tenderness. of muscles may be
associated with chronic
postural strain, tension, or
depression.

d. Assess ROM of neck. Pain and limited

A click occurs when mouth opens. movement may be caused by
Lower jaw protrudes without deviating to herniation of a cervical
the side and moves 1-2cm with lateral intervertebral disc, arthritis,
movement. Head and neck are erect and or degenerative joint disease.
straight. Alignment is straight in the
cervical spine. Movements done with
ease.
2. Assess hands and wrists.
a. Inspect for swelling, redness, nodules,
deformity, or muscular atrophy.
b. Test ROM.
c. Assess strength of hand grasp.
 Place your dominant index and
middle fingers in the client’s
dominant hand and your
nondominant index and middle
fingers in the client’s nondominant
hand.
 Instruct the client to squeeze your
fingers as hard as possible.
 Release grasp on client’s hand.
d. Palpate medial and lateral aspects of
each interphalangeal joint between
your thumb and index finger. Note
tenderness, bony enlargement,
swelling, or bogginess.
e. Use your thumb to palpate the
metacarpophalangeal joints, just distal
to and on each side of the knuckles.
f. Palpate each wrist joint with your
fingers underneath the client’s hands
and your thumbs on the dorsum of
client’s hands.
Move your thumbs on the dorsum
from side to side. Fingers, hands and
wrists are straight. Joints are smooth,
movement is easy, and strength is felt
on grasp.
Hard, painless nodules on
the dorsolateral aspects of
the distal interphalangeal
joints (Herberden’s nodes)
are the main sign of
degenerative joint disease or
osteoarthritis.
Flexion contracture that
affects the little, ring, and
middle fingers (Dupuytren’s
contracture) may limit full
extension of the fingers.
Limited movement of all
fingers is associated with
arthritis.
Weakness of opposition
of thumb and ipsilateral
fingers against resistance
indicates median nerve
disorders.
Enlargement of
interphalangeal distal joints
is associated with
degenerative joint disease.
Bony enlargement with
tender, swollen
interphalangeal proximal
joints is associated with
acute rheumatoid arthritis.
Painful, swollen, and
boggy metatcarpophalangeal
joints, with ulnar deviation
of deformed fingers, are
associated with chronic
rheumatoid arthritis.
Bilateral swelling of wrist
suggests rheumatoid arthritis.
Round, nontender swelling
near the tendon sheaths or
joint capsules that is more
prominent on the dorsum of
the hand and wrist when
flexed is a ganglia (cystic
growth).

3. Assess elbows.
a. Support the client’s forearm, elbow
partially flexed.
 Inspect and palpate and each elbow,
extensor surface of ulna, and
olecranon process. Note tenderness,
swelling, or nodules.
 Palpate both sides of olecranon
groove for tenderness or swelling.
 Palpate the lateral epicondyle for
tenderness.
b. Assess ROM
Elbows are at the same height and
symmetrical in appearance. Movements
should be done with ease.
4. Assess shoulders.
a. Inspect anterior shoulder and girdle for
symmetry. Note swelling, atrophy, or
deformity.
b. Inspect and palpate scapulae and
related muscles posteriorly.
c. Palpate the following areas on each
side and note tenderness.
 Sternoclavicular joint,
acromioclavicular joint, shoulder,
biceps groove, greater tubercle of the
humerus.
d. Assess ROM
Shoulders are equal in height, and
movements should be done with ease.
5. Assess feet and ankles with client in a
supine position.
a. Inspect for swelling, calluses, corns,
nodules, or deformity.
b. Palpate anterior surface of ankle joint.
Note tenderness, bogginess, or
swelling. Palpate the Achilles tendon
for nodules.
c. Palpate metatarsophalangeal joints and
metatarsal head in the sole of each
Painful, asymmetrical
elbow with forearm out of
alignment is associated with
a dislocation or subluxation
of the elbow. Red, warm,
swollen, and tender
olecranon process indicates
arthritis. A boggy soft, or
fluctuant swelling with
tenderness in the grooves
between the olecranon
process and the epicondyles
on either side indicates a
synovial inflammation.
Localized tenderness and
pain during ROM indicate
epicondylitis (inflammation
of muscle tissue surrounding
elbow) that results from
repetitive motion (e.g.,
swinging a racquet, tennis
elbow).
Increased outward
prominence of scapula is
indicative of a serratus
anterior muscle injury or
weakness. Painful, decreased
movement with swelling and
asymmetry are associated
with degenerative joint
disease, arthritis, or injury
which may trigger bursitis
(an inflammation of the
bursa). Pain with selling at
the distal end of clavicle is
associated with an
acromioclavicular joint
separation (separated
shoulder). Shoulder
subluxation and dislocation
are common athletic injuries
that result when the
glenohumeral joint pops out
of the socket.
Nontender thickening of
skin on sole of foot is a
callus, which is caused by
pressure. Painful, conical
thickening of skin over bony
prominences is a corn (also
caused by pressure). Painful,
swollen, red, and warm first
metatarsophalangeal joint
usually indicates acute gouty
 arthritis. Ankle pain
foot, compressing joint between thumb
decreased ROM, and
and finger for tenderness.
crepitation occurs with a
d. Assess ROM
sprain or fracture secondary
Foot is in alignment with lower leg.
to injury.

6. Assess knees.
a. Inspect for contour, alignment, and
deformity; atrophy of quadriceps
muscles; and loss of normal hollows
Bilateral inward deviation
around patella.
toward midline of the knees
b. Palpate suprapatellar pouch on each
is genu valgum (knock
side of quadriceps. Note tenderness,
knees). Bilateral outward
thickening, or bogginess. Compress
deviation away from the
suprapatellar pouch.
midline is genu varum (bow
c. Palpate each side of patella over joint
legs). Thickening, bogginess,
space and near femoral epicondyle for
or swelling indicates
structural abnormalities, tenderness,
synovial effusion (excessive
thickening or edema.
synovial joint fluid.
Knees are in alignment with each
other and do not protrude medially or
laterally.

7. Assess hips and spine with the client in a

standing position.
a. Inspect for symmetry of the iliac crests
and buttocks.
b. Observe the client’s posture and gait.
Note position of trunk in relation to
legs; foot drop; shuffling or limp;
cervical, thoracic and lumbar curves.
c. Place client in supine position and
palpate the hips.
d. Test ROM.
Iliac crest and buttocks are
symmetrical with each other. Stance is
upright, with parallel alignment of hips
and shoulders. Gait is natural, with arms
swinging freely at sides and head leading
the body. Spine has a cervical concavity,
thoracic convexity, and lumbar
concavity.
Unequal iliac crests and
lateral curvature of the
thoracic or lumbar vertebrae
is scoliosis. The chin tilted
downward onto the chest,
with abdominal protrusion,
indicates kyphosis (excessive
convexity of the thoracic
spine). Excessive concavity
of the lumbar spine is
lordosis.