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FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Tel. Number 085-3421830 local 4853
Nursing Program

Name: _______________________________________________ Section: ________

Health Assessment
NURSING LECTURE RETURN GRADE
DEMONSTRATION DEMONSTRATION
PROCEDURES DATE CI’s SIGNATURE DATE CI’s SIGNATURE
Assessing the:
Appearance and Mental Status;
Skin, Hair and Nails
Skull and Face; Eye Structure;
Visual Acuity; Ears and
Hearing; Nose and Sinuses;
Mouth and Oropharynx; Neck
Thorax and Lungs; Heart and
Central Vessels; and the
Peripheral Vascular System
Abdomen

Musculoskeletal System

Neurologic System

Remarks:

Checked by: ____________________________________________ Date: _________

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Name: _________________________________________ Date of Lecture Demo: ________

Assessing the Thorax and Lungs; Heart and Central Vessels; and the Peripheral Vascular
System

Basic Concept: Assessing the thorax and lungs is a thorough examination of the respiratory
system. The thorax comprises the lungs, rib cages, cartilages and intercostal muscles, wherein all
the four assessment/ examination techniques will be used. This nursing skill also recognizes and
identifies normal and abnormal breath sounds, a crucial component of the lung assessment
(Lynn, P. 2008).

Assessing the heart and central vessels is one of the most complex and important
aspect of physical examination. This nursing skill utilizes the palpation, inspection and
auscultation techniques for the assessment of the heart, pulmonary, coronary and neck arteries.

Assessing the peripheral vascular system includes measuring the blood pressure,
palpating peripheral pulses and inspecting skin and tissues to determine perfusion to the
extremities (Berman, et.al. 2015).

Objectives:
1. To check for any deviations of the thorax and lungs and breath sounds; heart and central
vessels; and the peripheral vascular system.
2. To acquire information and accurate nursing history of the lungs or respiratory, cardiovascular
and peripheral vascular systems of the client.
3. To be able to formulate nursing diagnosis, collaborative problem and referral.

Preparation:

1. Assemble equipment:
Stethoscope
Skin marker/pencil
Centimeter ruler
2. Introduce yourself, and verify the client’s identity. Explain to the client what you are going
to do, why is it necessary, and how the client can cooperate.
3. Perform hand hygiene, and observe other appropriate infection control procedures.
4. Provide for client privacy.

PROCEDURE RATIONALE
1. Inquire if client has any history of the
following:
Family history of illness, including
cancer
Allergies
Tuberculosis
Lifestyle habit such as smoking, and
occupational hazards
Any medications being taken
Current problems such as swellings,
coughs, wheezing, pain.
Posterior thorax:
2. Inspect the shape and symmetry of the
thorax from posterior and lateral
views. - Compare the anteroposterior
diameter to the transverse diameter.
3. Inspect the spinal alignment for
deformities.
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-Have the client stand.

- From a lateral position, observe the
three normal curvatures: cervical,
thoracic, and lumbar.
- To assess for lateral deviation of the
spine (scoliosis), observe the standing
client from the rear.
- Have the client bend forward at the
waist, and observe from behind.
4. Palpate the posterior thorax.
- For clients who have no respiratory
complaints, rapidly assess the
temperature and integrity of all chest
skin.
- For clients who do not have
respiratory complaints, palpate all
chest areas for bulges, tenderness, or
abnormal movements.
- Avoid deep palpation for painful
areas, especially if a fractured rib is
suspected.
5. Palpate the posterior chest for
respiratory excursion.
- Place the palms of both your hands
over the lower thorax, with your
thumbs adjacent to the spine and your
fingers stretched laterally.
- Ask the client to take deep breath
while you observe the movement of
your hands and any lag in movement.
6. Palpate the chest for vocal (tactile)
fremitus.
- Place the palmar surfaces of your
fingertips or the ulnar aspect of your
hand or closed fist on the posterior
chest, starting near the apex of the
lungs.
- Ask the client to repeat such words
as “blue moon” or “one, two, three”.
- Repeat the two steps, moving your
hands sequentially to the base of the
lungs.
- Compare the fremitus on both lungs
and between the apex and the base of
each lung, either:
1) using one hand and moving it from
one side of the client to the
corresponding area on the other side or
2) using two hands that are placed
simultaneously on the corresponding
areas of each side of the chest.
7. Percuss the thorax.
8. Percuss for diaphragmatic excursion.
9. Auscultate the chest using the flat-disc
diaphragm of the stethoscope.
- Use the systematic zigzag procedure
used in percussion.
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- Ask the client to take slow, deep

breaths through the mouth.
- Listen at each point to the breath
sounds during a complete inspiration
and expiration.
- Compare findings at each point with
the corresponding point on the
opposite side of the chest.
Anterior thorax:
10. Inspect breathing patterns.
11. Inspect the costal angle and the angle
at which the ribs enter the spine.
12. Palpate the anterior chest.
13. Palpate the anterior chest for
respiratory excursion.
- Place the palms of both your hands
on the lower thorax, with your fingers
laterally along the lower rib cage and
your thumbs along the costal margins.
- Ask the client to take a deep breath
while you observe the movement of
your hands.
14. Palpate tactile fremitus in the same
manner as for the posterior chest.
- If the breast is large and cannot be
retracted adequately for palpation, this
part of the examination usually is
omitted.
15. Percuss the anterior chest
systematically.
- Begin above the clavicles in the
supraclavicular space, and proceed
downward to the diaphragm.
- Compare one side of the lung to the
other.
- Displace female breasts for proper
examination.
16. Auscultate the anterior trachea.
17. Auscultate the anterior chest.
- Use the sequence used in percussion,
beginning over the bronchi between
the sternum and the clavicles.
18. Perform hand hygiene.
19. Document findings in the client record.

Assessing the Heart and Central Vessels

Preparation:

1. Assemble equipment:
Stethoscope
Centimeter ruler

PROCEDURE RATIONALE
1. Inquire if the client has any history of Note: Italicize step/s is excluded in the return
the following: demonstration routine; however, the student
Family history of incidence and age of is required to state or mention the step.
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heart disease, high cholesterol levels,

high blood pressure, stroke, obesity,
congenital heart disease, arterial
disease, hypertension, and rheumatic
fever.
Client’s past history of rheumatic
fever, heart murmur, heart attack,
varicosities, or heart failure
Present symptoms indicative of heart
disease
Presence of diseases that affect the
heart
Lifestyle habits that are risk factors for
cardiac disease
2. Simultaneously inspect and palpate the
precordium for the presence of
abnormal pulsations, lifts, or heaves.
- Inspect and palpate the aortic and
pulmonic areas, observing them at an
angle and to the side, to note the
presence or absence of pulsations.
- Inspect and palpate the tricuspid area
for pulsations and heaves or lifts.
Inspect and palpate the apical area for
pulsation, noting its specific location
(it may be displaced laterally or lower)
and diameter.
- If displaced laterally, record the
distance between the apex and the
MCL in centimeters.
- Inspect and palpate the epigastric
area at the base of the sternum for
abdominal aortic pulsations.
3. Auscultate the heart in all four
anatomic sites: aortic, pulmonic,
tricuspid, and apical (mitral).
Carotid Arteries
4. Palpate the carotid artery. Use extreme
caution.
5. Auscultate the carotid artery.
Jugular Veins
6. Inspect the jugular veins for
distension.
- The client is placed in a semi-
Fowler’s position, with the head
supported on a small pillow.
7. If jugular distention is present, assess
the jugular venous pressure (JVP).
- Locate the highest visible point of
distension of the intern jugular vein.
- Measure the vertical height of this
portion in centimeters from the sterna
angle, the point at which the clavicles
meet.
- Repeat the steps above on the other
side.
8. Perform hand hygiene.
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9. Document findings in the client record.

Assessing the Peripheral Vascular System

PROCEDURE RATIONALE
1. Inquire if the client has any history of
the following:
Heart disorders, varicosities, arterial
disease, and hypertension
Lifestyle patterns, specifically exercise
patterns, activity patterns, and
tolerance.
Smoking and use of alcohol
Peripheral pulses:
2. Palpate the peripheral pulses on both
sides of the client’s body individually,
simultaneously (except the carotid
pulse), and systematically to determine
the symmetry of pulse volume.
- If you have difficulty palpating some
of the peripheral pulses, use a Doppler
ultrasound probe.
Peripheral veins:
3. Inspect the peripheral veins in the
arms and legs for the presence and/or
appearance of superficial veins when
limbs are dependent and when limbs
are elevated.
4. Assess the peripheral leg veins for
signs of phlebitis.
- Inspect calves for redness and
swelling over vein sites.
- Palpate the calves for firmness or
tension of the muscles, edema over the
dorsum of the foot, and areas of
localized warmth.
- Push the calves from side to side.
- Firmly dorsiflex the client’s foot
while supporting entire leg in
extension, or have the person stand or
walk.
Peripheral perfusion:
5. Inspect the skin of the hands and feet
for color, temperature, edema, and
skin changes.
6. Assess the adequacy of arterial flow if
arterial insufficiency is suspected.
7. Perform hand hygiene.
8. Document findings in the client
record.
Adopted from Kozier and Erb’s Fundamentals of Nursing (2015).
Berman, Audrey, et.al. (2015). Kozier and Erb’s Fundamentals of Nursing: Concept, Process and Practice, 10th ed.
Weber, Janet R., et.al. (2014). Health Assessment in Nursing, 5th ed.
Lynn, P.(2008). Taylor’s Clinical Nursing Skills , 2nd ed.
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PERFORMANCE CHECKLIST

Name: __________________________________________ Date of Return Demo: __________

Assessing the Thorax and Lungs; Heart and Central Vessels; and the Peripheral Vascular
System

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent
attitude and gives the correct rationale of the step/ procedure to be performed. Answers the
question/s correctly and analyzes the situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing
assistance. Shows very satisfactory attitude and gives the correct rationale of the step/ procedure
to be performed but occasionally needing follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and
explanations. Has knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and
direction to be able to perform the step/ procedure correctly and appropriately. There is a need to
improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/
procedure to be performed; cannot answer the question raised by the supervising clinical
instructor based on the step or procedure to be performed; unable to grasp understanding of the
topic or procedure; unable to perform the required step and state the rationale after being
instructed, guided or directed. Student’s behavior is inappropriate and potentially harmful to the
client.

1 2 3 4 5
ASSESSMENT
1. Verifies the client’s identity.
PLANNING
1. Reviews previously learned concepts and principles.
2. Introduces self.
3. Explains the procedure to the client and how the client can cooperate.
4. Provides client privacy.
5. Prepares and assembles all equipment.
IMPLEMENTATION
1. Introduces self.
2. Provides client privacy.
3. Inquires if client has any history of the following:
Family history of illness, including cancer
Allergies
Tuberculosis
Lifestyle habit such as smoking, and occupational hazards
Any medications being taken.
Current problems such as swellings, coughs, wheezing, pain.
Posterior thorax:
4.a. Inspect the shape and symmetry of the thorax from posterior and
lateral views.
b. Compares the anteroposterior diameter to the transverse diameter.
5. Inspects the spinal alignment for deformities.
a. Have the client stand.
b. From a lateral position, observes the three normal curvatures: cervical,
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thoracic, and lumbar.

c. To assess for lateral deviation of the spine (scoliosis), observes the
standing client from the rear.
d. Asks the client bend forward at the waist, and observes from behind.
6. Palpates the posterior thorax.
a. For clients who have no respiratory complaints, rapidly assesses the
temperature and integrity of all chest skin.
b. For clients who do not have respiratory complaints, palpates all chest
areas for bulges, tenderness, or abnormal movements.
c. Avoids deep palpation for painful areas, especially if a fractured rib is
suspected.
7. Palpates the posterior chest for respiratory excursion.
a. Places the palms of both your hands over the lower thorax, thumbs
adjacent to the spine and fingers stretched laterally.
b. Asks the client to take deep breath while observing the movement of
hands and any lag in movement.
8. Palpates the chest for vocal (tactile) fremitus.
a. Places the palmar surfaces of fingertips or the ulnar aspect of hand or
closed fist on the posterior chest, starting near the apex of the lungs.
b. Asks the client to repeat such words as “blue moon” or “one, two,
three”.
c. Repeats the two steps, moving hands sequentially to the base of the
lungs.
d. Compares the fremitus on both lungs and between the apex and the
base of each lung, either:
d.1. Using one hand and moving it from one side of the client to the
corresponding area on the other side or
d.2. Using two hands that are placed simultaneously on the
corresponding areas of each side of the chest.
9. Percusses the thorax.
10. Percusses for diaphragmatic excursion.
11. Auscultates the chest using the flat-disc diaphragm of the
stethoscope.
a. Uses the systematic zigzag procedure used in percussion.
b. Asks the client to take slow, deep breaths through the mouth.
c. Listens at each point to the breath sounds during a complete
inspiration and expiration.
d. Compares findings at each point with the corresponding point on the
opposite side of the chest.
Anterior thorax:
12. Inspects breathing patterns.
13. Inspects the costal angle and the angle at which the ribs enter the
spine.
14. Palpates the anterior chest.
15. Palpates the anterior chest for respiratory excursion.
a. Places the palms of both hands on the lower thorax, with fingers
laterally along the lower rib cage and thumbs along the costal margins.
b. Asks the client to take a deep breath while observing the movement of
hands.
16. Palpates tactile fremitus in the same manner as for the posterior
chest.
a. If the breast is large and cannot be retracted adequately for palpation,
this part of the examination usually is omitted.
17. Percusses the anterior chest systematically.
a. Begins above the clavicles in the supraclavicular space, and proceeds
downward to the diaphragm.
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b. Compares one side of the lung to the other.

c. Displaces female breasts for proper examination.
18. Auscultates the anterior trachea.
19. Auscultates the anterior chest.
a. Uses the sequence used in percussion, beginning over the bronchi
between the sternum and the clavicles.
Assessing the heart and central vessels:
20. Inquires if the client has any history of the following:
a. Family history of incidence and age of heart disease, high cholesterol
levels, high blood pressure, stroke, obesity, congenital heart disease,
arterial disease, hypertension, and rheumatic fever.
b. Client’s past history of rheumatic fever, heart murmur, heart attack,
varicosities, or heart failure
c. Present symptoms indicative of heart disease
d. Presence of diseases that affect the heart
e. Lifestyle habits that are risk factors for cardiac disease
21. Simultaneously inspects and palpates the precordium for the presence
of abnormal pulsations, lifts, or heaves.
a. Inspects and palpates the aortic and pulmonic areas, observing them at
an angle and to the side, to note the presence or absence of pulsations.
b. Inspects and palpates the tricuspid area for pulsations and heaves or
lifts.
c. Inspects and palpates the apical area for pulsation, noting its specific
location (it may be displaced laterally or lower) and diameter.
d. If displaced laterally, records the distance between the apex and the
MCL in centimeters.
e. Inspects and palpates the epigastric area at the base of the sternum for
abdominal aortic pulsations.
22. Auscultates the heart in all four anatomic sites: aortic, pulmonic,
tricuspid, and apical (mitral).
Carotid Arteries:
23. Palpates the carotid artery.
a. Uses extreme caution.
24. Auscultates the carotid artery.
Jugular Veins:
25. Inspects the jugular veins for distension.
a. The client is placed in a semi-Fowler’s position, with the head
supported on a small pillow.
b. If jugular distention is present, assesses the jugular venous pressure
(JVP).
c. Locates the highest visible point of distension of the internal jugular
vein.
d. Measures the vertical height of this portion in centimeters from the
sterna angle, the point at which the clavicles meet.
e. Repeats the steps above on the other side.
Assessing the peripheral vascular system;
26. Inquire if the client has any history of the following:
a. Heart disorders, varicosities, arterial disease, and hypertension
b. Lifestyle patterns, specifically exercise patterns, activity patterns, and
tolerance.
c. Smoking and use of alcohol
Peripheral pulses:
27. Palpates the peripheral pulses on both sides of the client’s body
individually, simultaneously (except the carotid pulse), and
systematically to determine the symmetry of pulse volume.
a. If there is a difficulty palpating some of the peripheral pulses, uses a
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Doppler ultrasound probe.

Peripheral veins:
28. Inspects the peripheral veins in the arms and legs for the presence
and/or appearance of superficial veins when limbs are dependent and
when limbs are elevated.
29. Assesses the peripheral leg veins for signs of phlebitis.
a. Inspects calves for redness and swelling over vein sites.
b. Palpates the calves for firmness or tension of the muscles, edema over
the dorsum of the foot, and areas of localized warmth.
c. Pushes the calves from side to side.
d. Firmly dorsiflexes the client’s foot while supporting the entire leg in
extension, or have the person stand or walk.
Peripheral perfusion:
30. Inspects the skin of the hands and feet for color, temperature, edema,
and skin changes.
31. Assesses the adequacy of arterial flow if arterial insufficiency is
suspected.
32. Performs hand hygiene.
33. Documents findings in the client record.
EVALUATION
1. Observes appropriate infection control measures in the performance of
the procedure.
2. Applies related and relevant principles / concepts.
3. Distinguishes what is normal findings and deviation to normal
findings,
4. Relates findings or assessment to client’s culture, socioeconomic
status and current circumstances, certain condition or disorder.
5. Shows understanding of the terms, description or findings stated.
6. Performs the procedure with mastery and confidence.
7. Shows a positive and caring attitude towards the client.

Comments and Suggestions:

Rating: ______
Signature of Supervising Clinical Instructor: ___________________