Health Assessment

Health Assessment
ANATOMY: SPECIAL SENSES | SENSE OF HEARING | EARS
HEARING
- Sense of hearing and equilibrium
MECHANORECEPTORS
- Detect sound waves (touch & hearing)
 OUTER EAR
PINNA | AURICLE
- The only visible part of the ear with its special helical shape
EXTERNAL AUDITORY CANAL | EXTERNAL ACOUSTIC MEATUS
- A tube running from the outer ear to the middle ear
TYMPANIC MEMBRANE
- Thin, cone-shaped membrane that separates the external ear from the middle ear
 MIDDLE EAR
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TYMPANIC CAVITY
- An air chamber
- It contains a chain of movable bones which transmits the vibrations of the tympanic membrane
across the cavity to the middle ear
MASTOID ANTRUM | TYMPANIC ANTRUM
- An airspace in the petrous portion of the temporal bone
AUDITORY TUBE | EUSTACHIAN TUBE
- Equalizes the pressure between the outer and inner ear

- EQUALIZES THE PRESSURE BETWEEEN THE INNER EAR AND THE ATMOSPHERE
- Methods we use when we feel pressure inside our ear: swallowing yawning, and chewing
(happens here)
AUDITORY OSSICLES
1. MALLEUS | HAMMES
- Transmits sound vibrations from the eardrums to the incus
2. INCUS | ANVIL
- The middle bone; connects to the malleus and to the stapes
3. STAPES | STIRRUP
- Transmits sound vibrations from the incus to the oval window
- It connects middle ear to the inner ear
 INNER EAR
COCHLEA
- Receives sounds in the form of vibrations

- Transforms vibrations of the cochlear liquids and associated structures into a neural signals
- Organ of hearing
VESTIBULE
- Detect changes in gravity and linear accelerations

- Responsible in balance
- Contains utricle and saccule
1. UTRICLE
- Changes in velocity when traveling (horizontal & vertical)
2. SACCULE
- Acceleration & Deceleration
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A. OVAL WINDOW | VESTIBULAR WINDOW
- Transmits the vibrations to the inner ear
B. ROUND WINDOW | COCHLOEAR WINDOW
SEMICIRCULAR CANALS (ANTERIOR, POSTERIOR, LATERAL)
- Helps maintain balance when turning spinning, or tumbling

- Fluid filled tubes in your inner ear that helps you keep your balance
FLUIDS IN THE EAR
- Help in transmission of the sound

- Are separated from each other
- Chemically different
1. PERILYMPH
- Fluid outside
2. ENDOLYMPH
- Fluid inside
NOTES:
FLUID
- The flow of fluid in the ear counter flows the movement of our body to maintain balance
CERUMINOUS GLANDS
- Produces earwax
EARWAX | CERUMEN
- Helps keep the skin in the ear canal soft

- Keeps the bugs out
CUPULA
- Hair-like structure
- It helps the movement of the fluid; Endolymph
VESTIBULOCOCHLEAR NERVE VII
- VESTIBULAR – maintain balance

- COCHLEAR – auditory sense
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SENSE OF HEARING
- Last sense that is last to leave the body when you die
- First to return when you wake up
AUDITORY PATHWAY
1. AURICLE
2. EXTERNAL AUDITORY CANAL
3. TYMPANIC MEMBRANE
4. AUDITORY OSSICLE
5. COCHLEAR FLUID is disturbed
6. Ripple disturbs hair cells in the ORGAN OF CONTI/COCHLEA
7. COCHLEAR NERVE
8. BRAIN STEM
9. THALAMUS
10. AUDITORY NERVE OF TEMPORAL LOBE
ASSESING THE EAR/HEARING
Position
- Alignment of pinna with the corner of the eye and within 10 degree angle of vertical position
 INFANTS
Inspection:
- Top of the pinna should match on imaginary line extending from the corner of the eye to the occiput
- Should be positioned 10 degrees of vertical
- New born: hasn’t yet developed the cartilage that will give shape and firmness of shape of the
external ear
- Folded/misshape ears are normal for infants
Skin Conditions:
- Smooth without nodules
- Colour pink
- Consistent with the patient’s facial colour
- Intact on the skin with no lesions
To Assess:
- To assess gross hearing, ring a bell from behind the infant or;
- Have the parent call the child’s name to check for a response
- If there is response to the sound the infant may open eyes wider
- 3 -4 months of age, the child will turn head toward the sound
- There are many variations in size and shape of the ear
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Palpation:
Palpate the external ear;
- Normal: non tender auricle, tragus
Mastoid process for;
- Normal: no tenderness, warm to touch, mastoid process easily palpated
- Tenderness, temperature, oedema
 Deviations
 Hypoplastic ear
- Can be genetic
 Ear tag
- The infant’s external part of the ear are the first areas to develop inside a pregnant mother
- Associated with loss of hearing in babies
- It may indicate that the internal ear didn’t form correctly inside
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 Lop ear
- Can be treated – treatment: ear moulding
 TINITUS
- is the perception of noise or ringing in the ears
- it's a symptom of an underlying condition, such as age-related hearing loss, ear injury or a circulatory
system disorder
At risk:
- seniors / older adults
- military personnel
- musicians
- construction workers
 TESTS
 Whisper Test
- to assess high-frequency hearing

- have the patient occlude one ear
- go out of the patient’s sight, at distance of 1-2 ft. , whisper
- ask the patient to repeat the phrase
- the patient should be able to repeat the phrases correctly
Conductive Hearing Loss
- is the result of interrupted transmission of sounds through the external and middle structure of the ear
- a tear/obstruction in tympanic membrane
Sensorineural Hearing Loss
- damage to the inner ear, auditory ear, hearing centre in the brain (cochlea)
Mixed Hearing Loss
- combination of conduction and sensorineural hearing loss
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- external to inner ear
 OTOSCOPY
- an examination that involves looking into the ear with an instrument called an otoscope (or auriscope)
- performed in order to examine the 'external auditory canal' – the tunnel that leads from the outer ear
(pinna) to the eardrum
 WEBER TEST
- Ernst Heinrich Weber
- Using a tuning fork
- Quick screen test for hearing
- When holding a vibrating tuning fork, always hold the fork by its base preferable as low as possible
- Generally performed first and assess for lateralization of sound or whether sound is heard louder in one
ear
Normal: sound is heard equally in both ears (WEBER NEGATIVE)
Deviation: sound is better in impaired ear, including a bone-conductive hearing loss
sound is heard better in ear without a problem indicating a sensorineural disturbance (WEBER
POSITIVE)
- If the result is WEBER NEGATIVE no need to perform additional test
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 RINNE TEST
- In the event of sound lateralization perform Rinne Test
- Helps to determine in what area have deviation
- Sound lateralizes to the ear with a conductive hearing loss
- Masking effect of air conduction has been lost
Expected: sound is heard by both air conduction and bone conduction, air conducted sound can
mask the bone conducted sound
- Bone Conductive Deficit: ossicles respond to the direct stimulation of the vibrations and not any sound
that is transmitted by air conduction
- Ear with Conductive Hearing Loss: does not receive any air conduction sound to ask or dilute bone
conduction and sound is lateralized to that ear
- Compare air conduction to bone conduction
- Normal: air conduction of sound is generally louder and heard twice as long as bone conduction
ACBC 2:1
- Thus if the patient heard the sound by bone conduction for 8 seconds, sound should be heard by air
conduction by 16 seconds
- Ask whether the patient now hears the sound, sound conducted by air is heard more readily
- Normal: AC>BC
- Deviation: BC>AC or BC = AC – indicates a conduction hearing loss
GENERALLY:
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ANATOMY: EYE
 MUSCLES OF THE EYE

SUPERIOR RECTUS Rolls eyeballs upward
INFERIOR RECTUS Rolls eyeballs downward
MEDIAL RECTUS Rolls eyeballs medially
LATERAL RECTUS Rolls eyeballs laterally
SUPERIOR OBLIQUE Rolls eyeballs on axis
INFERIOR OBLIQUE Rolls eyeballs on axis
3 LAYERS OF THE EYE
1. SCLERA 2. CHOROID 3. RETINA

Hardest part Highly pigmented Avascular / no blood
Serves as an Contains lots of blood Photoreceptors and very fragile
attachment vessels | Vascular
Helps maintain Middle layer Innermost layer
shape
Outermost layer RODs – acts night-time, detects colour (black,
white, and gray), functions in peripheral vision
CONEs – acts daytime, detects various/all
colours, functions best in bright light
3 types of CONES (BLUE: 16%) (GREEN: 10%)
(RED: 74%)
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LACRIMAL GLAND
- Produces tears
FOVEA CONTRALIS
- Small central pit composed of closely packed cones in the eye

- Located in the center of the macula lutea of the eye
MEIBOMIAN GLAND
- Produce and oily substance that keeps the eyes moist
CONJUNCTIVA
- Mucous membrane, lines the inner surface of the eyelids

- Transparent, coral pink, may visible small vessels
CORNEA
- Avascular
- Most exposes and transparent
- Nothing protects cornea
- Protective window for which the light passes
IRIS
- Makes the constriction and dilation of pupils

- Iris muscle
- CIRCULAR MUSCLE – when contracts it constricts the pupil (parasympathetic)
- RADIAL MUSCLE – when contracts it dilate the pupil (sympathetic)
PUPIL
- Protective reflex
- Prevents excessively bright light from damaging the delicate photoreceptor
- ACCOMODATION PUPILLARY EFFECT – pupil constrict to increase depth of focus of the eye by blocking
the light
- PUPILLARY LIGHT REFLEX – the reflex of the eye to the brightness or dimness of the light
CORNEAL LIGHT REFLEX

- asymmetrical placement of the corneal light reflex indicates that the eye are not in the proper
alignment
- can be due to strabismus
- generally caused by weakness or paralysis of eye muscle
LENS
- Avascular like the cornea

- 65% water 35% protein
- To focus light rays on the retina by accommodation
- Distant object – the lens flattens
- Near object – the lens gets rounder and thicker
MACULA LUTEA OR FUVEA
- Contains very high concentration of cones
CILLARY BODY
- Controls the shape of the lens (cilliary muscle)

- Cillary epithelium – produces aqueous humor
- Vitreous humor – produced in the non-pigmented portion of the cillary body
AQUEOUS HUMOR
- Help with the movement of the eye

- Anterior
- Nourishing the cornea and the lens by supplying nutrition such as amino acids and glucose, the
aqueous humour will: Maintain intraocular pressure.
VITREOUS HUMOR
- Fillers of the eyeball behind the lens

- Posterior
NORMAL INTRAOCULAR PRESSURE (IOP)
- Ranges from - 12 – 21 mm Hg
CANAL OF SCHLEMM
- Circular canal lying in the substance of the schlerocorneal junction of the eye and;
- Draining the aqueous humor from the anterior chamber
- Aqueous humor circulation.
 VISUAL PATHWAY
1. LIGHT
2. CORNEA
3. PUPIL
4. CLEAR LENS
5. RETINA
6. RODS & CONES
7. OPTIC NERVE
8. BRAIN
AQUEOUS HUMOR CIRCULATION
1. CILLIARY BODY
2. POSTERIOR CHAMBER OF THE EYE
3. ANTERIOR CHAMBER OF THE EYE
4. CANAL OF SCHLEMM
ASSESSING THE EYES
PALPEBRAL FISSURES
- Length : Endocanthion to Exocanthion

- the elliptic space between the medial and lateral canthi of the two open lids
- In adults, this measures about 10mm vertically and 30mm horizontally.
EYELIDS
- Overlaps the superior area of / part of the iris and approximate completely with the lower lids when
close.
 INFANTS
- First week after birth and up to 3 months, baby can focus only on objects and people that are
close up, about 10 – 12 inches from her face
- Four to six months when the baby is able to see colour and perceive depth
- Baby is able to develop the ability to focus on objects/people – 6 months
- 8 months – infants can now almost see to the level of an adult with regards to clarity and depth
perception, and able to recognize faces
- Infants do not have tears until – 3 months
- By 6 months, average infant’s vision is already 20/20
*Binocular fixation pattern
 DEVIATIONS
 Infantile Esotropia
- A form of ocular motility disorder where there is an inward turning of one or both eyes, commonly
referred to as crossed eyes.
- It occurs during the first 6 months of life in an otherwise neurologically normal child.
 Periorbital area – Periorbital Oedema

- a term for swelling around the eyes
 Purpura
- discoloration - around the eye
 Ptosis
- Droopy eyelid caused by more serious conditions such as stroke, brain tumour, or cancer of the
nerves or muscle
- Uneven opening of the eyes
 Lid Lag
- static situation in which the upper eyelid is higher than normal with the globe in downgaze
- most often a sign of thyroid eye disease, but may also occur with cicatricial changes to the eyelid
or congenital ptosis
 Hordeolum/Sty
- Most often caused by staphylococcus bacteria
- Usually lived around the surface of the eyelid without causing any harm
- When a gland becomes clogged with dead skin cells or old oil, these can become trapped and
cause infection
- Found on the sides of the eye
 Chalazion
- Found at the middle
- Caused by non-infectious meibomian gland occlusion, whereas a hordeolum usually caused by
infection
 Conjunctivitis
- Aka sore eyes
 Subconjunctival haemorrhage
- bleeding underneath the conjunctiva
- the conjunctiva contains many small, fragile blood vessels that are easily ruptured or broken
- when this happens, blood leaks into the space between the conjunctiva and sclera
 Foreign Object
- something that enters the eye from outside the body
 Pterygium
- Growth of the conjunctiva that occurs the white part of your eye over the cornea
- Shape : wedge shape
- CAUSE: unknown, too much sun/UV exposure
 Jaundice Sclera
- The conjunctiva of the eye are one of the first tissues to change color as bilirubin levels rise in
jaundice.
- This is sometimes referred to as scleral icterus.
- The sclera themselves are not "icteric" (stained with bile pigment), however, but rather the
conjunctival membranes that overlie them.
- CAUSE: High bilirubin levels
 Red Sclera
- caused by dilation of tiny blood vessels that are located between the sclera and the overlying
clear conjunctiva of the eye
- usually are caused by allergy, eye fatigue, over-wearing contact lenses or common eye infections
such as pink eye (conjunctivitis)
 Strabismus
- one eye looks directly at the object you are viewing, while the other eye is misaligned
- inward (esotropia, "crossed eyes" or "cross-eyed")
- outward (exotropia or "wall-eyed")
- upward (hypertropia)
- downward (hypotropia)
 TESTS
 SNELLEN’S CHART
- Children are tested with snellen letter chart (ages 7 – 8 years old)
- To assess the quality of the eyesight of the patient
- Expected visual activity is 20/20
Numerator – indicating distance from the chart, it is constant
Denominator – representing the distance a person with normal vision could see and interpret
symbol
- Its score is recorded L 20/40
- The patient is 20ft from the eye chart and reads with the left eye at 20ft what the “normal” eye
visualizes at 40ft
- The patient visual acuity is determined by what line the patient can read correctly
 FIXATION TEST
- Used to screen vision in children 6 months to 2½ years and for those children up to 3 years cannot
be tested with picture eye *
- Used : Penlight & colourful object (RED)
- Cover one eye and hold the light 1 ½ ft. away from the child
- Move the light/toy from midline, side-to-side
- Normally the child will track the light or toy with both eyes
- It fails when he objects
 TESTING VISUAL FIELDS

- Measure peripheral vision
50 – Upward field
90 – Temporal field
60 – Nasal Field
70 – Downward field
- Considered a neurological rather than ocular
- It assesses the integrity of the optic nerve and its appropriate pathways
- Deviation: homonymous hemianopia
 HIRSCHBERG TEST
- Muscle strength and position of the eye can also be determined
- The light reflex should be in the same position bilaterally
- DEVIATION: Strabismus
 PUPILLARY ASSESSMENT
- To assess pupillary size in a darkened room, illuminate the face from below. Slowly move the light up
to the patient's eye level and check the pupillary response
 ACCOMODATION OF PUPIL
- The normal pupillary response is constriction of the pupils and convergence of the eyes
 PUPILLARY ASSESSMENT
Fixed, pinpoint pupils:
- Indicate PONS involvement or the use of opiates/drugs
CN III – Oculomotor – constriction of the eye – Originates from the midbrain
Tumour, Clotted blood, Oedema, Aneurysm

- Compression of the nerve may result in dilation on the side of the lesion or the area affected
Cataract
- The lens are affected
- Number 1 cause is AGING
Arcus Senilis
- Cause: lipid/cholesterol (those who are fat or obese) deposits in the periphery of the cornea stromal
layer
 ADDITIONAL/S
PERRLA
Normal Pupil size: 3-5 mm

Response to light
- Brisk, sluggish, non-reactive or fixed
- Normally constrict when exposed directly to light
- Consensual response
- Have at least 10 seconds interval between assessment of each eye
 Older adults
- Visual acuity decreases
- the eye ages and become more opaque and loses elasticity
- peripheral vision diminishes
- eyeball may appear sunken
- Less absorption of vitamin B12 in the ileum which may result in PALE CONJUNCTIVA
ASSESSING THE FACE & SKULL AND NECK
FACE
2 Structures of the face that are important in assessing for symmetry

1. Nasolabial Folds
2. Palpebral Fissures
HEAD AND NECK
- Framework of the head is the skull
- Normal size of the skull (infant) ranges from 32-38 with an average of 34 – 55-57 in adult
- All of the facial bones are immovable except for mandible
- The face also consist of many muscles that produce facial movements and expressions
NECK
- Composed of muscles, ligaments, and the cervical vertebrae

- Hyoid bone, several blood vessels, larynx, trachea, thyroid gland
LYMPH NODES OF THE HEAD AND NECK
- Lymph nodes produces lymphocytes and antibodies as defence against invasion by foreign
substances
- Size and shape of lymph nodes vary ; but are buried deep in the connective tissue
- Normally lymph nodes are either not palpable or they may feel like small beads
Order in assessing the lymph nodes
1. Pre-auricular
2. Post auricular
3. Occipital
4. Submental
5. Submandibular
6. Jugulodigastric/tonsilar
7. Superficial cervical
8. Deep cervical
9. Posterior cervical
10. Supraclavicular
 DEVIATIONS
 Acromegaly
- Enlargement of the facial features (nose,eyes) and the hands and feet
 Microcephaly
- Small head
 Anencephaly
- No brain
 Hydrocephalus
- Abnormal enlargement of the head
 Cushing’s Syndrome
- May present with a moon shaped face with reddened cheeks and increased facial hair
 Scleroderma
- Tightened-face with thinning facial skin
- Autoimmune disease
- Unknown cause
 Bell’s Palsy
- Paralysis of the facial nerve (7)
- Symptoms may include twitching, weakness, paralysis, drooping eyelid and corner of the mouth,
drooling
 Hyperthyroidism
- Enlarged thyroid gland (goiter)
 Exopthalmus
- Bulging of the eye
 Jugular Vein Distention

- ccurs when the pressure inside the vena cava increases and appears as a bulge running down the
right side of a person's neck
 NVE
- Pressure in the right side of the heart is high
Normal Characteristics of the Thyroid Gland
- Smooth surface
- Firm consistency
- Nontender to gentle pressure
Bruit sound
- An indicator of thyroid hyperplasia

- Best heard with the bell of a stethoscope
- A soft, pulsatile, whooshing, blowing sound
- This bruit is not present normally
PHYSICAL EXAMINATION
Inspection
- It is a visual examination
- This examination must be systematic to assess colour, body shape, wounds, facial expression, motor
behaviours and some area to be examined
Palpation
- Used to validate your inspection

- It is an examination using the sense of touch. The pads of the fingers are used because the
concentration of nerve endings are highly sensitive to tactile discrimination
 Light Palpation
 Deep Palpation
Percussion
- The examiner places one hand on the patient and then taps a finger on that hand, with the index
finger of the other hand
- It can determine the position, size, and consistency of an internal organ
- Based on the auditory and tactile perception, the notes heard can be categorized as follows:
• Tympanic
• Hyperresonant (pneumothorax)
• Normal resonance/ Resonant
• Impaired resonance (mass, consolidation)
• Dull (consolidation)
• Stony dull (pleural effusion)
Auscultation
- Technical term for listening to the internal sounds of the body, usually using a stethoscope; based on
the Latin verb auscultare "to listen"
- To auscultate heart, lungs, abdomen
 Palpation
 PRINCIPLES
- Have short nails
- Warm your hands prior to placing them on the patient
- Encourage the patient to breathe normally throughout the palpation
- If pain is experienced during the palpation, discontinue the palpation immediately
- Inform the patient what you are going to do and why it is necessary
 TYPES OF PALPATIONS
Light Palpation
- Light pressure is applied by placing the fingers together and depressing the skin and underlying
structures about ½ inch (1cm)
- Used to check the muscle and tenderness
Deep Palpation
- It is used/done with caution because pressure can damage internal organs

- Depresses the skin 2cm or deeper
Hooking Technique
- To know the size of the liver
Fingertips
- used for localized pulsations
Thrills
- is felt from light palpation over the chest wall
Lifts
- is a slight movement – a palpable vibration due to strong heart murmur (like a purring cat)
Heaves
- is more vigorous movement than the lift, a vibratory sensation felt on the skin overlying an area of
turbulence
 Percussion
- Used to determine the size and shape of internal organs by establishing their border
- The detect the presence of air, fluid, enlargement of organ
BONE – flat sound
Lungs / PRESENCE OF AIR – resonance
ORGANS / WATER – dull
ABDOMEN – tympanitic
 Auscultation
- the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as
a part of medical diagnosis
Diaphragm
- breathe sounds
- bowel sounds
- normal heart sounds
Bell
- murmur
- bruit
# Most used position when auscultating are – sitting position and supine
Instruments used in physical examination
BASIC
- Stethoscope
- Opthalmoscope
- Dermatoscope
- Otoscope
- Tape measure
- Reflex hammer
- Monofilament
- Tuning fork
STANDARD PRECAUSIONS
Nosocomial Infection
- Infection acquired during hospitalization
Hand Washing / Hand Hygiene
- Before and after physical contact with each patient

- After inadvertent contact (blood, body fluids, secretions, excretions)
- After handling any equipment w/ body fluids
- Before and after gloving
Gloves
- Use when you’re going to be in contact with;

- Blood and Body Fluids
- Excretions and Secretions
- And any contaminated things
Gown
- Wear in doing any procedure to protect yourself
Linen / Laundry
- Are placed in a private room and linens from patients with infectious disease/s are separated
SKIN ASSESSMENT
SKIN: FUNCTIONS
1. Regulates body temperature.

2. Prevents loss of essential body fluids, and penetration of toxic substances.
3. Protection of the body from harmful effects of the sun and radiation.
4. Excretes toxic substances with sweat.
5. Mechanical support.
6. Immunological function mediated by Langerhans cells.
7. Sensory organ for touch, heat, cold, socio-sexual and emotional sensations.
8. Vitamin D synthesis from its precursors under the effect of sunlight and introversion of steroids.
 Infants and Children

- Have very smooth skin – lack of exposure to environmental variables
- Subcutaneous is poorly developed thus predisposing infants to hypothermia
Vernix Caseosa
- Cheese-like substance (sebum)

- For the skin not to be easily macerated
- Creamy substance on newborn’s skin and has anti-microbial and moisturizing qualities that
help protect them in their new environment
Lanugo
- The baby’s body (esp. shoulders and back) are covered with fine silky hair
- (if present) it disappear 10 – 15 days
Apocrine Glands
- Do not function at this age resulting in odourless perspiration

- Makes the skin with a less oily texture
Merocrine
- Begins to function about 4 weeks

- Merocrine is a term used to classify exocrine glands and their secretions in the study of
histology. A cell is classified as merocrine if the secretions of that cell are excreted via
exocytosis from secretory cells into an epithelial-walled duct or ducts and thence onto a bodily
surface or into the lumen
Eccrine Glands
- Perspiration – present after 1 hour (after birth)
INSPECTION
 Skin Colour  Skin Uniformity

Erythema – reddening of the skin - Skin’s generally uniform except in
Cyanosis – bluing areas exposed to the sun and
Pallor – paling of the skin areas prone to friction (armpit,
Jaundice – yellowing of the skin groins, etc.)
- Areas with lighter pigmentation
(esp. noticeable in dark skinned
people) – palms, lips, nail beds
 Deviations – Abnormal
HYPERPIGMENTATION
- Abnormal distribution of melanin

- Freckles, birthmarks, Mongolian blue spots – etc
Cutis Marmorata
- Skin has a pinkish blue mottled or marbled appearance when subjected to cold temperature
- It loses when exposed to warm temperature / normal temperature again (Rewarming)
Senile Lentigines
- spots that appears when you get old (hyperpigmentation)
Freckles
- Indication of sun damage

- When the skin produces more melanin pigmentation (UV RAYS)
- Light brown spots (face, neck, and shoulders)
- More prominent to Caucasians
Addison’s Disease
- Also known as primary adrenal insufficiency, result from the insufficient production of these two
hormones, cortisol and aldosterone. Major symptoms include fatigue, gastrointestinal
abnormalities, and changes in skin colour (pigmentation).
HYPOPIGMENTATION
- Pallor
- Partial or complete absence of melanin
Vitiligo
- Destruction of melanocytes in the area (most prominent in Africans)
Albinism
- Complete or partial lack of melanin

- A congenital disorder
- (white) skin, hair, and eyes
- Associated with a number of vision defects; photophobia, nystagmus, amblyopia)
- They are more prone to sunburn and skin cancer
Physiological Jaundice
- RBC / Hemoglobin in the blood is divided to HEME and GLOBIN, HEME is divided into BILIVERDIN
and ****** which are then converted to BILURUBIN. BILIRUBIN is collected by the liver, since the
new born or infants (physiological jaundice) have undeveloped/not fully developed LIVER,
since they don’t have fully developed liver they don’t have the capability to collect the
unneeded BILIRUBIN, which then causes the yellowing of the skin of the new born / infant
(JAUNDICE)
- Yellowing of the skin, sclera and mucous membranes
- Occurs at 3rd – 4th day of life – normal
- Reaches its maximal intensity (3-6 days)
- Subside (10 days – 2 weeks)
- Jaundice occurring in the first 24 hours of life is abnormal –
PALPATION
 Temperature
- The skin should be warm (to touch) and the temperature should be equal bilaterally
Hypothermia
- Generalized or localized coolness

- May cause immobilized extremity
- Happens when limb is in cast
Hyperthermia
- High temperature
- When you have; fever, infection, trauma
 Skin Turgor
- Ability of the skin to change shape and return to normal after pinching (turgor)
- A sign commonly used by health workers to assess fluid loss of dehydration
Edema
- Swelling
- abnormal accumulation of fluid in certain tissues within the body
- Edema happens when your small blood vessels leak fluid into nearby tissues
INSPECTION | PALPATION
Lesions
- Uses inspection and palpations to describe skin lesions;

- Colour, elevation, size, location
Pedunculated Lesions
- small wound that have its own blood vessels
 Shape or Pattern
Annular Lesions
- The term “annular” stems from the Latin word “annulus,” meaning ringed
- The lesions appear as circular or ovoid macules or patches with an erythematous periphery
and central clearing.
Confluent Lesions Linear Lesions
 Size
- Size in centimetres : use ruler to measure
 Location and Distribution

- Any exudate – note any color
- Palpate lesions
- Gently scrape a scale to see if it comes off, or if it bleeds when the scale comes off
- Do the lesions blanching
**Tumbler Test
- Used to check if the lesion is pressed a glass and non-blanchable it could be; Erythema, herpes
zoster, etc.
Herpes Zoster or Shingles – highly infectious
Macule
- Flat, cannot be palpated, skin colour may change (brown, white, tan, purple, red)
- Note the colour
- Less than 1cm with circumscribed border
Patches
- Bigger than macule

- More than 1cm and may have an irregular border
- Freckles, flat moles, petechiae, rubella, vitiligo
Papule
- Small, containing solid mass, elevated

- Have circumscribed border and are less than 0.5cm
Plaque
- Small flat (small little deviation)

- Coming together
Petechiae
- Small red spots - are tiny, circular, non-raised patches that appear on the skin or in a mucous
or serous membrane.
- They occur as the result of bleeding under the skin
Purpura
- Ex. Meningitis, snake bites

- Purplish spots
Ecchymosis
- Hemorraghic blotching due to pooling of blood under the skin or mucous membrane
Comedone
- Increased in sebaceous gland activity, creates increase oiliness

- Common skin problem of adolescence (7-8)
- Peak (14-16 in girls, 16-19 in boys)
Pustule
- Puss-filled vesicle or bulla
Wheals/Hives
- Ex. Allergies, urticarial, insect bites

- Elevated mass with transient borders that is often irregular
- Size and color vary
Urticarial
- Characterized by elevated lesions caused by local edema
Acrochordons
- Skin tags
- Common in areas where there is skin friction
- Neck, axilla cheeks and trunk
Nodule
- They feel like large peas under the surface of the skin.
Tumour
- extremely common as people get older

- Some common benign tumors include: Warts (skin tumor resulting from a virus) Seborrheic
keratoses (growths on the skin ranging from light skin color to dark brown)
Vesicles
- small, fluid-filled sacs that can appear on your skin

- The fluid inside these vesicles may be clear, white, yellow, or mixed with blood
Bulla
- fluid-filled sac or lesion that appears when fluid is trapped under a thin layer of your skin
- It's a type of blister
Cyst
- Cysts are noncancerous, closed pockets of tissue that can be filled with fluid, pus, or other
material.
- can develop as a result of infection, clogging of sebaceous glands (oil glands), or around
foreign bodies, such as earrings
Cherry Angioma
- Red moles
- They're usually found on people aged 30 and older
- The collection of small blood vessels inside a cherry angioma give them a reddish appearance
 Hair
- Color – texture (fine, straight, curly, kinky)
- In young, should be shiny
- Oiliness is natural (not excessive)
- Note for any scalp lesions;
- Lice, loss of hair (alopecia)- autoimmune disease
 Nails
- Inspect and palpate the nails
- Blanching
- Shape
- Curvature (Convex, 160 c)
ADULT/AGED
- drier skin and less perspiration

- thinning and nuttering epidermis
- risk for injury
- greying of hair
- nail growth slows down
- the toenails; thicker, hard, brittle and yellowing appearance
ASSESSING THE HEART AND NECK VESSELS
- When beginning the examination, the ideal location to stand is on the right side
INSPECTION
 General Appearance
 Skin Colour
- Skin; warm to touch
- Homogenous in colouring
- Without significant moisture
 Capillary Refill
- The capillary nail refill test is a quick test done on the nail beds. It is used to monitor dehydration and
the amount of blood flow to tissue.
 Heaves or Lifts
- A parasternal heave (or lift) is a precordial impulse that may be felt (palpated) in patients with cardiac
or respiratory disease. Precordial impulses are visible or palpable pulsations of the chest wall, which
originate on the heart or the great vessels.
 Pulsations (apical) – left ventricle on the 5th ICS, left MCL
- Jugular Venous Pulsation / Distention
< is connected to superior vena cava
**NVE – Neck Vein Engorgement
 Deviations
Skin Pallor & Cyanosis
- May suggest poor tissue perfusion
Skin Diaphoresis
- May result from SNS stimulation as a result of diminished cardiac output
Cyanosis
- Best seen in the lips, earlobes, mucous membranes, or where the skin is thin
 Hands and Fingernails
Schamroth’s Test
- Detects fingers clubbing
- Normal: small diamond-shaped “window” is typically apparent between the nail beds
- Deviation: increased convexity
< loss of normal – 165 degrees between the nail bed and cuticle
< may indicate endocarditis or a classic indicator of Cyanotic Congenital Heart Disease (CCHD)
<< CCHD – cardiac malformations that commonly affect the atrial or ventricular walls, heart valves,
or large blood vessels
<< Endocarditis – inflammation of the heart’s inner lining (endocardium)
< TB, Chronic Hypoxia, Liver Cirrhosis, IBD
 Anterior Chest
- For visible pulsations or movements
- Apical impulse / apex beat / Point of Maximal Impulse (PMI)
< Location: 5th ICS, left MCL
- Generally not observed in healthy individuals (unless the patient is thin)
 Internal Jugular Vein & External Jugular Vein
IJV_bigger_anteriori EJV_posterior
- Normal: pressure on the left side of the heart is always higher than the right
- Deviation: Jugular Vein Distention (JVD)
< occurs when the pressure inside the vena cava increases and appears as a bulge down the right
side of a person’s neck
< sign of increases Central Venous Pressure (CVP)
<< CVP – measurement of the pressure inside the vena cava
Indicates how much blood is flowing back into your heart and how well your heart can move that
blood into your lungs and the rest of your body
- Occurs when CVP increases above a normal/healthy level
- Can be caused by Right-sided heart failure
<often occurs due to left-sided heart failure, when the weakened and/or stiff left ventricle loses power
to efficiently pump blood to the rest of the body. As a result, fluid is forced back through the lungs,
weakening the heart's right side, causing right-sided heart failure
(READ MORE) LINK: https://www.healthline.com/health/jvd
JUGULAR VEIN ASSESSMENT

1. Examine position
- Head of bed elevated at 45 degree angle
- Head turned to right
2. Identify top of venous pulsation in neck (JVP)

- Jugular Venous Pulsations are inward
- Contrast with outward Carotid Artery pulsations
3. Identify the sternal angle (Angle of Louis)

- Located at superior edge or notch of Sternum
4. Measure distance between top of pulsation and Sternum

- Measured in centimetres
PRECORDIUM
- Book – anterior chest area that overlies the heart and great vessels
- The region or the thorax immediately in front of the heart
- Front of the chest wall over the heart
PALPATION
- Patient should be in supine position

- Be on his/her right side to gain easy access to the apex of the precordium
- Pulsation
- Heaves
- Thrills
- Displacement of the apex beat is often associated with ventricular enlargement / cardiomegaly
< abnormal enlargement of the heart
 THRILLS
- Palpable murmurs – vibratory sensations
- Felt from light palpation over the chest wall
- Deviation: loud heart murmur – caused by an incompetent heart valve
 LIFTS
- A slight movement
 HEAVES
- More vigorous movement
- Sustained forceful thrusting of the ventricle during systole
- Palpable lifting sensation under the sternum and anterior chest left sternal border suggest a central
precordial heave associated with RVH
< Right Ventricular Hypertrophy – affecting right ventricle – right side of the heart is enlarged
Caused by either congenital heart conditions or high blood pressure in the lungs / pulmonary
hypertension
****MUST TO KNOW****
Left Lateral Decubitus Position (LLDP)
- Patient is lying on his/her left side

- To bring the heart (nearer) to the chest wall to listen/feel for the sounds/vibrations better
Tissue Perfusion
- Flow of blood
**a parasternal heave or lift is a precordial impulse that may be felt (palpated) in patients with cardiac or
respiratory disease
**Precordial impulse are visible or palpable pulsations of the chest wall, which originate on the heart or the
great vessel
2nd Part Palpations
- Peripheral Pulses – rate, rhythm, quality

- Thrills, Heaves, Lifts
- Apex Beat (PMI) – Point of Maximal Impulse
- Aortic Pulsation
< Deviation: 6th ICS – Posterior Axillary Line
< Runs from the heart, down to the centre of the chest, and into the abdomen
Abdominal Aortic Aneurism (AAA)
< occurs in the part of the abdomen
< Thoracic Aortic Aneurism – occur in the part of the aorta located in the chest area
 Capillary Refill Time (CRT)

- Refers to the amount of time it takes for capillary circulation to return to the fingertips after capillary
circulation is obliterated
- A common indicator of peripheral tissue perfusion
- Normal: less than 3 seconds / position above heart level / pinch/blanch finger nails, in older adults –
it can be longer than 3 seconds, in neonates – pressure is exerted in the sternum for 5 seconds
SIGNIFICANCE
- Prolonged CRT is suggestive of hypoperfusion and/or dehydration
< decreased blood flow through an organ cerebral hypoperfusion
(may cause pallor?)
- In adults prolonged CRT is also suggestive to CHF and/or PVD
< CHF Congestive Heart Failure – failure of heart to pump blood with normal efficiency
Heart is unable to provide adequate blood flow to other organs, such as the brain, liver, and kidneys
< PVD Peripheral Vascular Disease – blood circulation disorder that causes the blood vessles outside
the heart to narrow, block, or spasm
< Peripheral Artery Disease (PAD) – common cause ATHEROSCLEROSIS

<< gradual process in which a fatty material builds up inside the arteries
Less common cause: blood clots, injury to the limbs
PERCUSSION
- To estimate heart size
AUSCULTATION
- Blood Pressure
- Carotid Bruit
- Heart Sounds
- Normal: no sound should be heard
- Essential that auscultation of heart sounds be done in a quiet environment as possible
- Avoid a cold stethoscope on an exposed skin
- Auscultate the CAROTID ARTERY for the presence of bruit

< supplies the brain with blood
<< RIGHT COMMON CAROTID ARTERY – originates from brachiocephalic trunk the left from the aortic
arch in the thorax
- Presence of bruit indicates atherosclerosis plaque, build up on the interior lumen
< means a clogged/plagued/ presence of clotted blood
<< Thrombus – causes stroke, clogged artery/vein
<< Embolus – the clotted blood travels through the blood vessels
 There would be a presence of a bruit sound when there is/are – fats, blood clot
 PENUMBRA - Occlusion of the MCA with irreversibly affected or dead tissue in black and tissue at
risk or penumbra in red.
CARDIAC OUTPUT
- Amount of blood ejected by the heart in 1 minute

- 5-8 litres per minute
- 20% of the blood goes to the brain
STROKE VOLUME
- Amount of blood ejected by the valves/heart per contraction
FORMULA:
CO = SV x HR/PR
SV – constant: 70cc
CONDUCTION SYSTEM OF THE HEART
Step 1: Pacemaker Impulse Generation
The first step of cardiac conduction is impulse generation. The sinoatrial (SA) node (also referred to as the
pacemaker of the heart) contracts, generating nerve impulses that travel throughout the heart wall. This
causes both atria to contract. The SA node is located in the upper wall of the right atrium. It is composed of
nodal tissue that has characteristics of both muscle and nervous tissue.
Step 2: AV Node Impulse Conduction
The atrioventricular (AV) node lies on the right side of the partition that divides the atria, near the bottom of
the right atrium. When the impulses from the SA node reach the AV node, they are delayed for about a tenth
of a second. This delay allows atria to contract and empty their contents into the ventricles prior to ventricle
contraction.
Step 3: AV Bundle Impulse Conduction
The impulses are then sent down the atrioventricular bundle. This bundle of fibers branches off into two bundles
and the impulses are carried down the center of the heart to the left and right ventricles.
Step 4: Purkinje Fibres Impulse Conduction

At the base of the heart, the atrioventricular bundles start to divide further into Purkinje fibers. When the
impulses reach these fibers they trigger the muscle fibers in the ventricles to contract. The right ventricle sends
blood to the lungs via the pulmonary artery. The left ventricle pumps blood to the aorta.
Cardiac Conduction and the Cardiac Cycle
Cardiac conduction is the driving force behind the cardiac cycle. This cycle is the sequence of events that
occur when the heart beats. During the diastole phase of the cardiac cycle, the atria and ventricles are
relaxed and blood flows into the atria and ventricles. In the systole phase, the ventricles contract sending
blood to the rest of the body.
Cardiac Conduction System Disorders
Disorders of the heart's conduction system can cause problems with the heart's ability to function effectively.
These problems are typically the result of a blockage that diminishes the rate of speed at which impulses are
conducted. Should this blockage occur in one of the two atrioventricular bundle branches that lead to the
ventricles, one ventricle may contract more slowly than the other. Individuals with bundle branch block
typically don't experience any symptoms, but this issue can be detected with an electrocardiogram (ECG).
A more serious condition, known as heart block, involves the impairment or blockage of electrical signal
transmissions between the heart's atria and ventricles. Heart block electrical disorders range from first to third
degree and are accompanied by symptoms ranging from light-headedness and dizziness to palpitations and
irregular heartbeats.
 DIASTOLE s2
- During ventricular diastole, the AV valves are open and the ventricles are relaxed. This causes
higher pressure in the atria than in the ventricles. Therefore, blood rushes through the atria into the
ventricles. This early, rapid, passive filling is called early or protodiastolic filling. This is followed by a
period of slow passive filing. Finally, near the end of ventricular diastole, the atria contract and
complete emptying blood out of the upper chambers by propelling it into the ventricles. This final
active filling phase is called preystole, atrial systole, or sometimes the “atrial kick”. This action raises
left ventricular pressure.
 SYSTOLE s1
- The filling phases during diastole result in large amount of blood in the ventricles, causing the
pressure in the ventricles to be higher than in the atria. This causes the AV valves (mitral and
tricuspid) to shut. Closure of the AV valves produces the first heart sound (s1), which is the
beginning of systole. This valve closure also prevents blood from flowing backward (a process
known as regurgitation) in the atria during ventricular contraction. At this point in systole, all four
valves are closed and the ventricles contract (isometric contraction). There is now high pressure
inside the ventricles, causing the aortic valve to open on the right side of the heart. Blood is ejected
rapidly through these valves. With ventricular emptying the ventricular pressure falls and the
semilunar valves close. This closure produces the second heart sound (s2), which signals the end
of systole. After closure of the semilunar valves, the ventricles relax. Atrial pressure is now higher
than the ventricular pressure, causing the AV valves to open and diastolic filling to begin again.
 ABNORMAL HEART SOUND s3

- Normally diastole is silent
- DEVIATION: when ventricular filling creates vibration \
- Resistant to filling during the early rapid filling phase
- Occurs immediately after s2
- Low pitched, quiet sound – difficult to hear
- Cause: Myocardium is RIGID
- When present in adults, s3 is considered pathological indicating decreased ventricular
compliance
- May be produced by either the right or left side of the heart and is often initial of heart failure
ANATOMY OF RESPIRATORY SYSTEM
 LUNGS
- Have a lower and upper compartment
- 3 lobes on the right, 2 lobes in the left
 Diaphragm
- Major muscle for respiration
- Separates the thoracic from the abdominal region
- INHALATION – down
- EXHALATION – up
- Rests on the lobe of the liver
-
 UPPER RESPIRATORY
o Passageway for respiration
o Moistens incoming air
o Receptors for smell
 Nose
 Nasopharynx
 Oropharynx
 Laryngopharynx
 Larynx (voice box)
 NOSTRILS
- Filters the air we breathe and the debris from the air
 NASAL CAVITY
- The nasal cavity is a hollow space within the nose and skull that is lined with hairs and mucus
membrane.
- The function of the nasal cavity is to warm, moisturize, and filter air entering the body before it
reaches the lungs.
 TURBINATE
- These structures are responsible for warming, humidifying, and filtering the air we
breathe.
- Normally there are three turbinates including the superior (upper), middle, and inferior
(lower) turbinates.
o Pulmonary Ventilation
o Internal and External Respiration
o Cleanse the airs, warms the air, moisture
 PHARYNX
o Is also called the throat.
o Is the passageway for both air and food and forms a resonating chamber for speech sounds
o It serves as both a connection between the mouth and the digestive tract and as a
connection between the nose and respiratory system.
o It is divided into three portions:
o Nasopharynx – It has 4 openings in its walls: the 2 internal nares and 2 openings that lead to
the auditory or Eustachian tubes.
o Oropharynx – It has only 1 opening called Fauces which connects to the mouth; It is a common
passageway for both food and air.
o Laryngopharynx/Hypopharynx – Connects with the esophagus
posteriorly and with the larynx anteriorly.
 LARYNX
o Is also called the Voice box.
o It connects the pharynx to the trachea.
o Thyroid Cartilage – It is the largest piece in the larynx. It is
also known as the Adam’s apple which is larger in males than in females.
o Epiglottis – Allows food to go down to the oesophagus; It closes the trachea.
o Vestibular Folds/ False Vocal Cords.
o Vocal Folds/ True Vocal Cords.
 EPIGLOTTIS
- SUPRAEPIGLOTTIS – GLOTTIS (VOCAL CHORDS) – SUBGLOTTIS
- Closes the trachea for the food and water to enter the oesophagus
 TRACHEA
o Is also referred to as the windpipe.
o It is the passageway for air.
o Goblet Cells – Produces mucus and the Ciliated Cells provide the same protection against
dust particles.
 ANATOMY OF THE LUNGS

o PLEURAL MEMBRANE – It encloses and protects each lung.
o PARIETAL PLEURA – It is the outer layer that attaches the lung to the wall of the thoracic
cavity.
o VISCERAL PLEURA – It is the inner layer which covers the lungs.
o PLEURAL CAVITY – Is the space between the parietal and visceral pleura which contains
pleural cavity.
o PLEURAL CAVITY – It is a pleural fluid that prevents friction between the two membranes and
allows them to slide past each other during breathing, as the lungs and thorax change
shape.
THE BRONCHI AND THE BRONCHIAL TREE
BRONCHI
- Passageway of air
- Has goblet cells that produce mucus
- Contains mucus that traps foreign bodies
1. The trachea terminates in the chest by dividing into a:

o Right Primary Bronchus – Goes to the right lung.
o Left Primary Bronchus – Goes to the left lung.
2. On entering the lungs, the primary bronchi divide to form smaller bronchi called the:
o Secondary or Lobar Bronchi – The right lung has 3 lobes and the left lung has 2 lobes.
3. The secondary bronchi continue to branch forming even smaller bronchi called:
o Tertiary or Segmental Bronchi
4. And tertiary bronchi divide into smaller branches called:

o Bronchioles
5. Bronchioles finally branch into smaller tubes called:
o Terminal Bronchioles
 THE ALVEOLI
- The actual exchange of respiratory gases between the lungs and the blood occurs by
diffusion across the ALVEOLI and the walls of the capillary network that surrounds it.
 ALVEOLAR-CAPILLARY MEMBRANE – The membrane through which the respiratory gases move.
- The blood–air barrier in the gas exchanging region of the lungs. It exists to prevent air bubbles from
forming in the blood, and from blood entering the alveoli.
 SURFACTANT
o Is a fluid that coats the surface of the membrane inside each alveolus.
o It helps reduce surface tension (the force of attraction between water molecules) of the fluid.
o Breaks the bond of water molecules
o Helps prevent alveoli from collapsing or sticking shut as air moves in and out during breathing.
o It is produced by Alveolar Type 2 Cells.
o During inspiration, when alveoli expand, the molecules move apart.
o During expiration when lungs shortened, molecules move together and become
concentrated thus surface tension is reduced.
 RESPIRATION PROCESS
Carbon Dioxide
- Product of metabolism
Metabolism – use of carbohydrates, proteins, glucose, etc. of the body
- RBC carries the OXYGEN and CARBON DIOXIDE and brings it to the lungs
Breathing In (Inhalation)
a. When you breathe in, or inhale, your diaphragm contracts (tightens) and moves downward. This
increases the space in your chest cavity, into which your lungs expand. The intercostal muscles
between your ribs also help enlarge the chest cavity. They contract to pull your rib cage both upward
and outward when you inhale.
b. As your lungs expand, air is sucked in through your nose or mouth. The air travels down your windpipe
and into your lungs. After passing through your bronchial tubes, the air finally reaches and enters the
alveoli (air sacs).
c. Through the very thin walls of the alveoli, oxygen from the air passes to the surrounding capillaries (blood
vessels). A red blood cell protein called hemoglobin (HEE-muh-glow-bin) helps move oxygen from the
air sacs to the blood.
d. At the same time, carbon dioxide moves from the capillaries into the air sacs. The gas has traveled in
the bloodstream from the right side of the heart through the pulmonary artery.
e. Oxygen-rich blood from the lungs is carried through a network of capillaries to the pulmonary vein. This
vein delivers the oxygen-rich blood to the left side of the heart. The left side of the heart pumps the
blood to the rest of the body. There, the oxygen in the blood moves from blood vessels into surrounding
tissues.
Breathing Out (Exhalation)
A. When you breathe out, or exhale, your diaphragm relaxes and moves upward into the chest cavity.
The intercostal muscles between the ribs also relax to reduce the space in the chest cavity.
B. As the space in the chest cavity gets smaller, air rich in carbon dioxide is forced out of your lungs and
windpipe, and then out of your nose or mouth.
ASSESSING THE LUNGS AND THORAX
ASSESS
SHAPE AND CONFIGURATION
- Thorax is oval, its AP Diameter is half its transverse diameter
FACIAL EXPRESSION
- Should be relaxed
LEVEL OF CONSCIOUSNESS
- Should be alert and cooperative

- Brain cells are affected by lack of oxygen
SKIN COLOR AND CONDITION
- Lips and nail beds are free from pallor and cyanosis
QUALITY OF RESPIRATION
- Automatic, effortless, regular and even, produces no noise

- Chest expands symmetrically
INSPECT
COLOR
- Lesions (scars, stretch marks), use of accessory muscle, over prominence of the ribs (
may indicate respiratory problems)
SYMMETRY
- Nares
- Bulges
- Asymmetry
AP DIAMETER and TRANSVERSE DIAMETER

- Anterioposterior Diameter – side
- Should be half the size of the transverse diameter
- The anteroposterior diameter should be less than the transverse diameter. The ratio of
anteroposterior to transverse diameter is from 1:2 to 5:7. AP = transverse diameter, or
“barrel chest.” Ribs are horizontal, chest appears as if held in continuous inspiration.
 AGED
- AP Diameter is more than half the transverse
TAKE THE RESPIRATORY RATE
- NORMAL – 12-20 RR ADULT | 30-60 RR INFANT
SPINAL ALIGNMENT
- Impedes the space of the lung/s

Kyphosis - is an abnormally excessive convex curvature of the spine as it occurs in the
thoracic and sacral regions – KUBA
Lordosis - is defined as an excessive inward curve of the spine, It differs from the spine's
normal curves at the cervical, thoracic, and lumbar regions, which are, to a degree,
either kyphotic (near the neck) or lordotic (closer to the low back) – LIYAD
Scoliosis - is a medical condition in which a person's spine has a sideways curve. The
curve is usually "S"- or "C"-shaped
PALPATE
- Warm your hands before palpating or percussing

- When palpating and percussing ask the patient to cross arms and bow head, to see
the spinal column better
- No tenderness, masses, bulges, pulsation
 LANDMARKS
 Anterior Axillary Line

 Midclavicular Line
 Midsternal Line
Accessory Muscles
- Trapezius
- Scalene Muscle
Respiratory Excursion
- Thumbs on the xiphoid process and fingers on the 10th ribs

- Exhale and inhale – distance between the thumbs should be (5 – 10 cm)
- If obese – pinch the skin
Fremitus
- vibratory tremors that can be felt through the chest by palpation

- ask the patient to say “99”, “blue moon”, “tres, tres”
- palpated using the balls of hand or the ulnar side of the hand
PLEURAL EFFUSION
- accumulation of water in the pleural cavity between visceral pleura and parietal
pleura
Diaphragmatic Excursion
- movement of the thoracic diaphragm during breathing

- 3 – 5 cm distance
- Checking the diaphragm muscle
- Measuring the contraction of the muscle
- Resonance and dullness
 DEVIATIONS
ATELECTASIS
- Collapsed lungs or closure of a lung resulting in reduced or absent gas exchange.

- It may affect part or all of a lung.
- It is usually unilateral. It is a condition where the alveoli are deflated down to little or no
volume, as distinct from pulmonary consolidation, in which they are filled with liquid.
PNEUMONIA
- Swelling (inflammation) of the tissue in one or both lungs. It's usually caused by a
bacterial infection. At the end of the breathing tubes in your lungs
POSTOPERATIVE GUARDING
- shallow breathing due to pain
Nasal Flaring
- Difficulty and noisy breathing

- Increased RR
- Use of accessory muscle
PECTUS CARINATUM
- Pigeon chest
- breastbone protrudes outward abnormally
PECTUS EXCAVATUM
- funnel chest
- sternum and rib cage are shaped abnormally
- these can be familial
- most common in boys than girls
- interferes with the functions of the lungs
Barrel Chest
- is normal with infants

- deviations in adult
- MAIN CAUSE: SMOKING
- Too much accumulation of air
- COPD
- Pneumothorax – not with barrel chest
- EMPHYSEMA – Alveoli is destroyed
Accessory Muscles
- Trapezius
- Scalene
- Sternocleidomastoid
- Note any tenderness, superficial lumps or masses

- Note skin mobility and turgor, temperature and moisture
PERCUSSION
- intercostal spaces
- liver located at the 5th rib to 10th rib
- intercostal margin
o Resonance – presence of air
o Hyperesonance – too
o Dull – organ (Liver – right, Heart – middle)
o Tympanitic - stomach
o Flat – bones
Common Characteristics of New Born
- Nose breather
- 30-53 or 40-60 breathes per minute
- Irregular breathing
- THORAX – rounded, diameter from the front is equal, barrel chest

- AP Diameter is equal to the transverse diameter
- 30 – 36 cm is the newborn chest, 2 cm smaller that the head circumference
- Ribs and xiphoid process are prominent
- Chest wall is thin
- 85% water
- 6 years old, AP Diameter has decreased in proportion to the Transverse Diameter 1:2
ratio
Tend to breathe normally as with the adult
BREATH SOUNDS
- BRONCHIAL
- BRONCHOVESICULAR
- VESICULAR
AUSCULTATION
Using a stethoscope, the doctor may hear normal breathing sounds, decreased or absent breath sounds,
and abnormal breath sounds.
Absent or decreased sounds can mean:
 Air or fluid in or around the lungs (such as pneumonia, heart failure, and pleural effusion)
 Increased thickness of the chest wall
 Over-inflation of a part of the lungs (emphysema can cause this)

 Reduced airflow to part of the lungs
There are several types of abnormal breath sounds. The 4 most common are:
 Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in
(inhales). They are believed to occur when air opens closed air spaces. Rales can be further described as
moist, dry, fine, and coarse.
 Rhonchi. Sounds that resemble snoring. They occur when air is blocked or air flow becomes rough through
the large airways.
 Stridor. Wheeze-like sound heard when a person breathes. Usually it is due to a blockage of airflow in the
windpipe (trachea) or in the back of the throat.
 Wheezing. High-pitched sounds produced by narrowed airways. Wheezing and other abnormal sounds can
sometimes be heard without a stethoscope.
ALVEOLAR HYPOXIA
- Less oxygen in lungs
Smooth Muscles
- Surround the airways in wheezing
 AGED
- Prone to kyphosis – because of osteoporosis and changes in cartilage
- Respiratory muscle strength declines after age 50 and continues to decrease into the
70s
- Small airways, lose their cartilaginous support and elastic recoil; as a result, they tend
to close, particularly in basal or dependent portions of the lungs
- CILIA in the airways decreases in number and are less effective in removing mucus
- Greater risk for pulmonary infections
ASSESSING THE NOSE AND MOUTH
NOSE
- Centre of the face

- The colour should be consistent with the face
- Has plenty of arteries
- Nasal Septum – should be in the midline
BREATHING
- Infants are nose breathers

- Audible effort to breathe
- Inability to such is an indicator of obstruction
NASAL CAVITY
- Moist
- Dark pink
Turbinate
- Pulmonary ventilation
- Cleanse the air, warms the air, moisture
- Inferior and middle turbinate should be the same colour in the surrounding area
Sinuses
- Produce mucus to moisturize the inside of the nose

- Protects from pollutants, microorganisms
- Allow for voice resonance
- Adds moisture to any air that is inhaled
Mucous
- Traps foreign bodies

- Humidifies the air we breathe
 DEVIATIONS
Nasal Flaring
- indicates difficulty in breathing, commonly seen in children and infants (normal)
Epistaxis
- nose bleed
Dyspnoea
- difficulty in breathing
Dysphagia
- difficulty in swallowing
MOUTH
Tongue
- light pink with light coating, smooth and moist

- rough surface due to presence of papillae
- moves the food
- identify the object in the mouth
- should protrude midline, if not there can be weakness or paralysis
NORMAL – light pink with light coating, no cracks, ulcers, or teeth marks
- surface: rough (presence of papillae), smooth and moist, surrounded by anterior and lateral teeth
- ABNORMAL – pallor, cyanosis, redness
VENTRAL TONGUE – should glisten – and a network of small vessel
Frenulum
- Is midline,
- Should allow tongue to reach the roof of the mouth
Uvula
- Midline, in between the tonsils

- Cone shaped
- Large amounts of thin saliva produced by the uvula serves to keep the throat well lubricated
- Functions in speech as well
- Should lean towards the area with deviation
Soft Palate
- Soft palate and uvula Move together to close off the nasopharynx and prevent food from entering
the nasal cavity
- NORMAL - Smooth, mobile
Pharynx
- Fluid and food passageway
Epiglottis
- A flap in the throat that keeps food from entering the windpipe and the lungs
Buccal Mucosa
- NORMAL – Pink and moist

- inside lining of the cheeks and floor of the mouth and is part of the lining mucosa
 DEVIATIONS
Exudative Tonsillitis
- accumulation of pus between the tonsil and its capsule
Ankyloglossia
- Tongue-tie
- congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an unusually
short, thick lingual frenulum
- may interfere with breast feeding in infants
Oral Leukoplakia
- HIV positive patient

- Fungus
Pernicious Anaemia
- a condition in which the body can't make enough healthy red blood cells because it doesn't have
enough vitamin B12
- caused by autoimmune destruction of gastric parietal cells
- The appearance of the tongue in vitamin B12 deficiency is described as "beefy" or "fiery red and sore"
- Macrocytic – vitamin B-12 and folate deficiencies can be treated and cured with diet and
supplements
- Microcytic –
White Coating
- Dehydration or poor hygiene, bad oral care

- Common with patients in the ICU
Yellowing of tongue
- Liver or gallbladder problems

- Digestive system disorder
Vagus Paralysis
- Failure of the soft palate to rise symmetrically

- Uvula will deviate towards the affected side
PARESIS
- Weakness
PLEGIA
- Paralysis of the nerve or muscle

ASSESSMENT
- Elevation of the soft palate

- When you say ‘ah’ the movement of the soft palate upwards
PALPATION
Gums, Teeth, Tongue
- Should feel firm, no soft areas, no tenderness
LIPS
Mentolabial Suculus
- Is a permanent crease between the inner lip and the chin, which plays a significant role in movement
of the lower lip and in facial
NORMAL – vertically and horizontally symmetrical, both are at rest and with movement
Vermillion Border
- Should be well defined without any evidence of cracking, swelling, and lesions
INSPECTION
- Lips should be – PINK to RED

- Vertically and horizontally symmetrical
 DEVIATIONS
Chapped Lips
- Bad oral hygiene
- Dehydration
Pale Lips
- Anemia
- Dehydration
Dry, Craked Lips
- Dehydration
- Overexposure to cold temperature
Cold Sores
- STD
- Herpes simplex
- Syphilis
Cheilosis | Cheilitis
- Scaling, painful fissures

- painful inflammation and cracking of the corners of the mouth
- sometimes occurs on only one side of the mouth, but usually involves both sides
- Vitamin B12 deficiency
Aphthous Stomatitis
- benign and non-contagious mouth ulcers
Oral Cancer
- which includes cancers of the lips, tongue, cheeks, floor of the mouth, hard and soft palate, sinuses,
and pharynx (throat), can be life threatening if not diagnosed and treated early
White Patches – Leukoplakia
Red/White Patches – Erythroleukoplakia
Red Patches – Erthryplakia
Addison’s Disease
- Hormonal Imbalance
Halitosis
- Bad breath
Xerostomia
- dry mouth resulting from reduced or absent saliva flow

- decrease in saliva production occurs with age, the gums may get thinner and begin to recede
TEETH
- good oral care will increase, production of saliva, contains antibodies, kills the bacteria in the mouth
and cleanses the mouth
Front teeth – pointed and sharp, for biting and tearing
Back Teeth – flat, for crushing and grinding
 Children - Infant
Deciduous Teeth
- begin to erupt by 6 months

- by 2 years all 20 teeth should be present
- begins to be lost around 6 years of age
- by ages 14-15 they are replaced with 32 permanent teeth (same as with the adults)
TETRACYCLINE and DOXYCYLINE
- should not be administered with children below 8 years old

- cause tooth discoloration in the infant by affecting enamel development
 AGED
- Decrease in saliva production occurs with age, causes (XEROSTOMIA)
Tooth Enamel
- tends to weak away with aging, making the teeth vulnerable to damage and decay
 DEVIATIONS
Cavities
- Poor oral hygiene

- Bottled water does not have fluoride added so the individual may be missing
GUMS
- NORMAL – healthy gums are pink in colour, firm, margins of the gums should be tight and well defined
- NOT NORAML – red, swollen and have tendency to bleed or even have pus
- most fragile part of the body
Gingival Hyperplasia
- Swollen gums, oedematous
- Sodium Dilantin (medication given to patients with seizure) – may cause this deviation – side effect
Gingivitis
- Red and puffy gums that bleeds easily

- Common type of periodontal disease
- Often resolves with oral hygiene
Malocclusion
- Affect the chewing efficiency as well as the choice of foods

- This has potential to result in malnutrition and gastric alterations
 OLDER ADULTS
- Nasal hair becomes coarser, stiffer and more visible
Air filtration may not be as effective
- Reduction in the sense of smell, reduction of olfactory nerve fibres
- Loss of sense of taste due to loss of papillae
- Reduction of saliva
- Gradual loss of teeth, drift causing malocclusion, affects the chewing efficiency and choice of foods
ASSESSING THE PERIPHERAL VASCULAR SYSTEM
HEMOGLOBIN in RBC brings oxygen
 Ischemia
- an inadequate blood supply to an organ or part of the body, especially the heart muscles
 Albumin
- Responsible for maintaining the osmotic pressure
- helps keep fluid in your bloodstream so it doesn't leak into other tissues
- also carries various substances throughout your body, including hormones, vitamins, and enzymes
- MADE BY THE LIVER
 Diffusion
- Movement of solute, or particles from a greater to lower concentrated solution
 Osmosis
- Movement of water molecules from lesser to greater concentrated solution
 Oedema
- There is inflammation
- Increased capillary permeability
 Capillary membrane
- are very thin blood vessels
- They bring nutrients and oxygen to tissues and remove waste products
- They have thin walls/single layer – so that exchange of substances will be easy (oxygen,
electrolytes, nutrients)
 5 CARDINALS OF MANIFESTATION
1. REDNESS
2. PAIN
3. WARM TO TOUCH
4. LOSS OF FUNCTION
5. OEDEMA/SWELLING
>> If there is a tissue injury caused by an inflammation (cut, fall, trauma, incision, injury) – SNS will be stimulated
– it will stimulate adrenal glands in the adrenal medulla to release CATECOLOMINES – EPINEPHRINE (increases
Cardiac Rate – more than 100) and NOREPINEPHRINE (increase Blood Pressure 120/80 – arteries constrict)
CHEMICAL MEDIATORS will be released due to tissue injury;
CHEMICAL MEDIATORS
- Will be released if there is tissue injury
Increases capillary permeability

- Pores in the capillary membrane becomes bigger;
- Intravascular space decreases, Albumin goes out, there will be swelling/oedema because the
water comes out to the interstitial space/third space from the intravascular space.
 Histamine – (more) When we come into contact with an allergen, such as pollen or animal dander,
histamine is released by the body to the site of contact | vasodilator
- Brings more blood to the injured site which causes the skin to be warm to touch | causes
redness/rubor
- Injured site such as; surgery, appendectomy, incision
 Bradykinin - an inflammatory mediator | a peptide that causes blood vessels to dilate (enlarge), and
therefore causes blood pressure to fall
 Prostaglandin – one of the more potent mediators that cause increased blood flow, chemotaxis
(chemical signals that summon white blood cells), and subsequent dysfunction of tissues and organs
 Serotonin - increases vascular permeability, dilates capillaries, and causes contraction of nonvascular
smooth muscle
{VEINS: clotted blood – gives redness in colour – warm to touch}
{ARTERY: lipids – gives pallor in colour – cold to touch}
WALLS OF THE BLOOD VESSELS
1. Tunica Adventitia
2. Tunica Media
3. Tunica Intima
ARTERY
- Blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries
- Arterial network is a high-pressure system
- Blood is propelled under pressure from the left ventricle of the heart
- There is high pressure, arterial wall must be thick and strong; the arterial walls also contain elastic fibres
so that they can stretch
COLOUR CHANGE TEST
- Arterial occlusion
- Elevate the leg 12 inches above the client’s <3
-
- NORMAL: it will return to its normal pinkish colour; 15 seconds – veins | 10 seconds or less – artery
**IF occlusion has been shown in developing, there will likely be;
- muscle atrophy
- skin atrophy
- loss of hair growth
BUERGER TEST
- Arterial insufficiency
- This test can be carried out to further demonstrate poor lower limb perfusion.
1. Ensure the patient is positioned supine
2. Standing at the bottom of the bed, raise both of the patient’s feet to 45º for 2-3 mins:
- Observe for pallor – emptying of the superficial veins
- If a limb develops pallor, note at what angle this occurs e.g. 20º (known as Buerger’s angle)
- A healthy leg’s toes should remain pink, even at 90º
- A Buerger’s angle of less than 20º indicates severe limb ischaemia
3. Once the time limit has been reached, ask patient to place their legs over the side of the bed:
- Observe for a reactive hyperaemia – this is where the leg first returns to its normal pink colour, then becomes
red in colour – this is due to arteriolar dilatation (an attempt to remove built up metabolic waste)
VEINS
- Blood vessels that carry deoxygenated, nutrient-depleted, waste laden blood from the tissues back
to the heart
- The vein contain nearly 70% of the body’s volume
Mechanisms
- 1st - Contains VALVES – permit blood to pass through them on the way to the heart and prevent blood
from returning through them in the opposite direction.
- 2nd – muscular contraction
- 3rd – creation of a pressure gradient through the act of breathing – inspiration decreases intrathoracic
pressure while increasing abdominal pressure, thus producing pressure gradient
 Deep Veins
 Iliac vein
 Femoral vein
 Popliteal vein
 Tibial vein
 Superficial Veins
 Greater Saphenous Vein
 Lesser Saphenous Vein
INSPECTION
SKIN COLOUR
- There should be no localized colour changes
SKIN
- Should be mobile and elastic and able to be pinched

- Extremities should be bilaterally equal in size
- Veins should not be visible on the surface or through the skin
- If any veins are visible, elevate the lower extremities; if veins and valves are not compromised ?
LESIONS
- Petechiae – smaller, tiny red spots | dengue

- Ecchymosis – medical term for bruises
- Purpura – bigger, purplish colour | snake bites, venous insufficiency
HAIR DISTRIBUTION
- Should be equally distributed bilaterally

 DEVIATIONS
DEEP VEIN THROMBOSIS
- a blood clot that forms in a vein deep in the body

- Most deep vein clots occur in the lower leg or thigh
- If the vein swells, the condition is called thrombophlebitis
- A deep vein thrombosis can break loose (called
EMBOLUS) and cause a serious problem in the lung, called
a pulmonary embolism (patient can die after 1 hour)
 Valves are not closing completely or incompetent
 Veins will be distended
 EARLY SIGNS: accumulation of blood – causes-redness
 UNILATERAL SWELLING
VARICOSITY
- Valves incompetent – allowing blood to backflow distending the vein – increasing the pressure –
pushing the blood outside the interstitial space/third space – haemoglobin will be released and
become haemosiderin – which causes discoloration
 TESTS
TRENDELENBURG TEST
- To perform this test, elevate the patient’s leg until all of the congested superficial veins collapse (to
drain blood | elevate 90 degrees) | Elevate the leg, put tourniquet between femoral and popliteal
vein (to temporarily stop blood flow)
- Apply direct pressure to occlude the superficial veins below the point of suspected reflux from the
deep system into the superficial varicosity.
- With the occlusion still in place, have the patient stand. If the distal varicosity remains empty or fills
slowly, quickly remove the occluding hand or tourniquet
- *** Tourniquet is applied to prevent 1. Backflow of blood, 2. To temporarily stop the blood flow
NORMAL: slow filling of blood due to competent valves

ABNORMAL: incompetent valves allows rapid venous filling causing rubor
 Deep Vein – if there is engorgement in the vein before releasing the tourniquet within 5 seconds
 Superficial Vein – rapid filling of blood after removing the tourniquet within 30 seconds causing rubor
CAPILLARY REFILL TEST
- 2 seconds is normal – prolonged in PVD
ALLEN TEST
Assesses for the;

- COMPETENCY
- PATENCY
- ADEQUATE collateral circulation of blood supply
 PALPATION
1. RATE
2. RYTHYM
3. QUALITY
RADIAL & DORSALIS PEDIS ARTERY
- Two most distal pulses

- Palpate using the 1st and 2nd fingers or finger pads
 AMPLITUDE
- Quality pulse is the measurement of the force of left ventricular contraction that produces the pulse
wave
- Contraction of the heart is slow
- Integrity of the arterial wall will also have effect on the quality of the pulse wave
The pulse quality is measured on a +3 scale

+3 = full/bounding pulse
+2 = expected
+1 = diminished/barely
0 = absent pulse
ASSESSING THE BRAIN AND NERVES
INFANTS
- The nervous system begins to form within the first 3 weeks of fetal development
- At birth, the nervous system is quite immature
- There is still no BBB (astrocyte) *develops 5-6 years
- Responses by the newborn are primarily primitive reflexes that are present – should subside while
growing up, if not, it indicates an abnormality
 Reflexes
- The disappearance of these reflexes is a measurement of nervous system maturation
- Persistence of these reflexes – indication of CNS dysfunction
- Observe the child’s gait – the child just beginning to walk will have a wide-based gait
- By 4 years of age the child should be able to balance on one foot for about 5 seconds and by age 5
should be able to balance for 8-10 seconds
 Tonic Neck Reflex

- Appears at birth
- Disappear – 5-7 mos.
- Fencing Reflex
 Babinski Reflex
- Normal up to 2 years
 Rooting Reflex
- Disappear: 4 mos.
 Landau Reflex
- Horizontal prone position
- Appears 6 mos. and hypotonicity (low tone) indicates motor system deficit
- Appears 3 mos. after birth – last up to 12-24 mos. of age
 Moro Reflex
- Consists of rapid abduction and extension of arms with the opening of hands
- The arms then come together as in embrace
- Any sudden movement of the neck initiates the reflex
- Elicit by pulling the baby half-way to a sitting position
- Disappear: 4-6 mos.
 Grasp Reflex | Palmar Grasp Reflex

- Appear – at birth
- Disappear – 8-10 mos.
 Sucking Reflex
- Probably one of the most important reflex – paired with rooting reflex – secretes for a food source
INSPECTION
1. LEVEL OF CONSCIOUSNESS (LOC)

- Awareness is determined by the patient’s orientation to a person, place and time
PERSON – who the patient is and recognition of other individuals
PLACE – where located at this time
TIME – day, month, and year
- Early manifestation, agitation, drowsy, confusion – probably caused by a lung problem – lack of blood
supply (oxygenated) to the brain
- ASSESSING:
Observe the patient’s ability to follow commands
Ask the patient to squeeze the examiner’s two fingers
NORMAL FINDINGS
- Awake, alert, and responds appropriately to verbal and environmental stimuli

- Should be able to follow a simple command and grasp the examiner’s finger
- When conducting a neurological exam, cranial nerve assessment is the first component of the exam
- Testing CN III (Oculomotor) is the MOST important – because it is an indicator of brain function
- The remaining 11 CNs are not generally tested unless there is a specific reason to do so
GLASGOW COMA SCALE (GCS)
- Assesses the LOC
CRANIAL NERVES
- Brainstem – consists of most the cranial nerves
- The 12 pairs of CNS are part of the peripheral nervous system
- Can be sensory and/or motor (function)
 CLASSIFICATIONS
 SENSORY CRANIAL NERVES – contain only afferent (sensory) fibres

CN 1 OLFACTORY
CN 2 OPTIC
CN 8 VESTIBULOCOCHLEAR
 MOTOR CRANIAL NERVES – contain only efferent (motor) fibres

CN 3 OCULOMOTOR
CN 4 TROCHLEAR
CN 6 ABDUCENS
CN 11 ACCESSORY
CN 12 HYPOGLOSSAL
 MIXED CRANIAL NERVES – contain both sensory and motor fibres

CN 5 TRIGEMINAL
CN 7 FACIAL
CN 9 GLOSSOPHARYNGEAL
CN 10 VAGUS
LINK: https://teachmeanatomy.info/head/cranial-
nerves/summary/?fbclid=IwAR3PzR4ixfyNnJmkvH7STgBpkG8gx0tJpRwjbKpwQTc-HjuQLzmbAguWgp8
LINK: https://www.kenhub.com/en/library/anatomy/the-12-cranial-nerves
CRANIAL NERVE 1 OLFACTORY NERVE
- SENSORY/AFFERENT - innervates the olfactory mucosa within the nasal cavity

- ORIGIN: CEREBRUM
- FUNCTION: Responsible for the sense of smell
Smell is an important component of the appreciation of tasks
- Loss of sense of smell – as a result of
TRAUMA INFECTION AGING
- Do not test routinely
Test with:
REPORT OF LOSS OF SMELL
HEAD TRAUMA
SUSPECTED INTRACRANIAL PRESSURE (ICP)
First: assess patency by occluding one nostril at a time and asking the person to sniff – with the person’s
eyes closed
Use familiar smells, conveniently obtainable and non-noxious smells; coffee, toothpaste orange,
peppermint.
*Alcohol wipes smell are familiar and are easy to find but are irritating
- Normally, a person can identify an odour on each side of the nose
- Sense of smell normally decreased bilaterally with aging
- Any asymmetry is an indication of an abnormality
CRANIAL NERVE 2 OPTIC NERVE
- SENSORY/AFFERENT - innervates the retina of the eye and brings visual information to the brain
- ORIGIN: CEREBRUM
- Test Visual Acuity: Snellen’s Chart for distant vision, newspaper/magazine for near vision
- Test Visual Fields: Confrontation
CRANIAL NERVE 3 OCULOMOTOR
- MOTOR/EFFERENT - both a somatic and visceral efferent motor nerve

- ORIGIN: MIDBRAIN-PONTINE JUNCTION
- FUNCTION: Helps in moving eyeballs in different direction
TEST: Six Cardinal Movements of the Eye
TEST: Pupillary Light Reflex
Shine a direct light or the pupil – Pupillary constriction
**Symptoms of Nerve Damage

Double Vision – diplopia, the affected eye turns outward when the unaffected eye looks straight
ahead
Ptosis – eyelid droop
Pupil may be dilated
Affected eye can move only to the middle when looking inward and cannot look upward and
downward
CRANIAL NERVE 4 TROCHLEAR NERVE
- MOTOR/EFFERENT
- ORIGIN: posterior side of the MIDBRAIN
It has the longest intracranial length of all the cranial nerves.
- Superior oblique muscle – eye
- TEST: Six Cardinal Movements of the Eye
CRANIAL NERVE 5 TRIGEMINAL NERVE
- SENSORY & MOTOR / AFFERENT & EFFERENT

- ORIGIN: PONS
3 Branches/Divisions
OPTHALMIC (CN V1) - leaves through the superior orbital fissure
MAXILLARY (CN V2) - through the foramen rotundum
MANDIBULAR (CN V3) - exits via the foramen ovale
- Temporal and masseter muscles are examined by palpating the muscles and attempts to resist the
jaw by applying pressure
- Testing pain, thermal, and other sensations in the area supplied by the trigeminal nerve
TEST: The Corneal Reflex test – wisp of cotton (Normal: smooth, transparent, involuntary blinking)
CRANIAL NERVE 6 ABDUCENS
- MOTOR/EFFERENT
- ORIGIN: PONTINE-MEDULLA JUNCTION - originates from the brainstem and exits the skull via the superior
orbital fissure
- FUNCTION: lateral eye movements (lateral rectus muscle) – abducts the eye; thus the name abducens
Test for Convergence (far and near object)
- DEVIATION: Strabismus
CRANIAL NERVE 7 FACIAL NERVE

- ORIGIN: PONTINE-MEDULLA JUNCTION
- FUNCTION: Once the facial nerve reaches the face it enables many functions, such as facial
expression, secretion of glands and taste sensation.
- Motor – note mobility and facial symmetry as the person responds to these requests;
FROWNING
SMILING
- Sensory – test only when you suspect facial nerve injury
When indicated, test sense of taste – salt, lemon,
- TEST: Inspect for NASOLABIAL FOLDS AND PALPEBRAL FISSURES
- DEVIATION: Inability to close eyelid, Drooping of mouth
CRANIAL NERVE 8 VESTIBULOCOCHLEAR
- SENSORY/AFFERENT - comprised of two parts: the vestibular nerve and the cochlear nerve.
- ORIGIN: PONTINE-MEDULLA JUNCTION
- FUNCTION: The cochlear component enables hearing, while the vestibular part mediates balance
and motion.
- TESTS: Whisper test, Rinne Test, Balance and Hearing
CRANIAL NERVE 9 GLOSSOPHARYNGEAL

- MEDULLA OBLONGATA - It originates from the brainstem and leaves the skull through the jugular
foramen.
- FUNCTION: It enables swallowing, salivation, and taste sensation, as well as visceral and general
sensation in the oral cavity.
- TEST: Perform – Gag Reflex Test (observe: soft palate & uvula)
- DEVIATION: Nerve damage – dysphagia
CRANIAL NERVE 10 VAGUS

- ORIGIN: MEDULLA OBLONGATA - It originates from multiple nuclei in the brainstem, and exits the skull
through the jugular foramen.
It is the longest cranial nerve and the only one to leave the head and neck region.
- The vagus nerve travels into the thoracic and abdominal cavities, providing parasympathetic supply
to visceral organs.
- FUNCTION: The vagus nerve controls a large number of functions, including gland secretion, peristalsis,
phonation, taste, visceral and general sensation of the head, thorax and abdomen.
CRANIAL NERVE 11 ACCESSORY
- MOTOR/EFFERENT
- ORIGIN: MEDULLA OBLONGATA - originating from the brainstem and spinal cord
- FUNCTION: Acting to enable phonation and movements of the head and shoulders.
CRANIAL NERVE 12 HYPOGLOSSAL
- MOTOR/EFFERENT
- ORIGIN: MEDULLA OBLONGATA Anterior to the olive
- FUNCTION: Its function is to enable tongue movements.
- extremely important for smooth daily functioning of every person, as it plays a significant role in
important mouth functions such as speech and swallowing
 PROPRIOCEPTION
- Unconscious perception of movement and spatial orientation arising from stimuli within the body
- In humans, these stimuli are detected by nerves within the body itself, as well as the semicircular canals
 TESTS
CEREBELLAR EXAMINATION
- Assess motor activity by the patient’s ability for muscle movement and coordination
- Should run the test in smooth, rapid, accurate, straight line and coordinated movement
 FINGER-TO-NOSE TEST
 HANDFLIP TEST
 THUMB-TO-FINGER TEST
 HEEL-TO-SHIN TEST
ALTERED MOTOR RESPONSE
- Uncoordinated actions, misses touching the nose/body part several times
 DEVIATIONS
 DYSDIADOCHOKINESIS
- Inability to perform rapidly alternation movements (may be an indication of multiple sclerosis)
 DYSMETRIA
- Inability to perform point to point movements by over-or-under projection of the fingers
- Lose of motor strength or proprioception
- May indicate – Cerebellar lesions
SENSORY
SUPERFICIAL POINT
- With the patient’s eyes closed, touch the patient’s skin lightly with sharp and dull points of a; bent
paper clip, pen, broken tongue blade
- Before testing, it is helpful to touch the patient on both sides
LIGHT TOUCH
- Use; cotton ball, cotton tip swab

- Wait 2 seconds between each touch
- Instruct the patient to indicate where the sensation is felt
BALANCE AND EQUILIBRIUM (CN 8 AND CEREBELLUM)
ROMBERG TEST
- Patient should stand with his/her feet together and arms at the side
- Instruct the patient to close eyes (approx. 30 secs.)
- Observe the patient’s ability to maintain upright position
- Patient may demonstrate slight swaying back and forth, without the danger of falling
- Expected: patient is able to maintain balance and equilibrium within 30 seconds
POSITIVE ROMBERG indicates the possibility of;

CEREBELLAR ATAXIA
- Cerebellum becomes inflamed or damaged
- Cerebellum: responsible for controlling gait and muscle coordination
- Ataxia: lack of fine motor or voluntary movements
VESTIBULAR DYSFUNCTION
SENSORY LOSS
CEREBELLAR LESIONS
- In some instances, the patient will lose balance with the eyes closed but be able to regain balance
when the eyes are opened (cerebellar lesions)
TANDEM GAIT
- A gait (method of walking or running) where the toes of the back foot touch the heel of the front foot
each step
- Ask the person to walk a straight line in a heel-to-toe fashion
- This decreases the base of support and will accentuate any problem with coordination
- NORMALLY the person can walk straight and stay balanced
- Methods – STATIC BALANCE
 REFLEXES
- Subconscious actions and reactions that are vital defense mechanisms of the nervous system.
- Initiates immediate response to alert and protect the patient
REFLEX ARC
- Neural pathway that controls the action reflex

- A reflex, or reflex action, is an involuntary and nearly instantaneous movement in response to a
stimulus.
- A reflex is made possible by neural pathways called reflex arcs which can act on an impulse before
that impulse reaches the brain.
DEEP TENDON REFLEXES
- Monosynaptic spinal segmental reflexes

- Easily assessed by tapping the tendon
 BICEP REFLEX
- Antecubital fossa
 TRICEPS REFLEX
- Identify the triceps tendon, a discrete, broad structure that can be palpated (and often seen) as it
extends across the elbow to the body of the muscle, located on the back of the upper arm.
 BRACHIORADIALIS REFLEX
- Identify the triceps tendon, a discrete, broad structure that can be palpated (and often seen) as it
extends across the elbow to the body of the muscle, located on the back of the upper arm.
 PATELLAR REFLEX
- LOCATION: Just below the kneecap
- Striking – will/should cause
- contraction of the quadriceps muscle – extension of the lower leg
 ACHILLES REFLEX
- LOCATION: Directly behind the ankle
- Striking Achilles tendon causes contraction of gastrocnemius muscle – resulting in plantar flexion of the
foot
- DEVIATION: lack of reflex – indicates – neuropathy (lower motor neuron)
SUPERFICIAL TENDON REFLEXES
- Any withdrawal reflex elicited by noxious or tactile stimulation of the skin, cornea, or mucous
membrane, including the corneal, pharyngeal, and cremasteric reflexes.
 PLANTAR REFLEX
- plantar flexion of the foot when the ankle is grasped firmly and the lateral border of the sole is stroked
or scratched from the heel toward the toes
- The reflex can take one of two forms.
In healthy adults, the plantar reflex causes a downward response of the hallux (flexion).
- DEVIATION: dorsiflexion of the great toe with or without forming BABINSKI-POSITIVE (this is normal to
children under 2y/o)
 ABDOMINAL REFLEX
- A superficial neurological reflex stimulated by stroking of the abdomen around the umbilicus.
- It can be helpful in determining the level of a CNS lesion.
 CREMASTERIC REFLEX
- A superficial reflex found in human males that is elicited when the inner part of the thigh is stroked.
- Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward
the inguinal canal.
- DEVIATION: TESTICULAR TORSION - It happens when the spermatic cord, which provides blood flow to
the testicle, rotates and becomes twisted.
The twisting cuts off the testicle's blood supply and causes sudden pain and swelling.
OLDER ADULTS
- Have less blood supply (20% - ages 60^)

- Gradual atrophy of the brain occurs due to the loss of neurons in the brain and spinal cord
- By 80 years of age, brain has lost 15% of its weight
- Speed of nerve conduction decreases – causing the reaction time of the elderly to decrease
- Decreased in the speed of learning and processing information
- There is an increased delay at the synapses, resulting in a slower traveling time for an impulse
This may result in a diminished sense of smell and taste as well as decreased sensation of pain and
touch
- These,, therefore are the probable reason why older adults/aged are prone to Alzheimer’s
- There is an overall loss of muscle bulk that reduces muscle strength
GATE CONTROL THEORY
- Open Gate -> T-cell -> brings the stimulus to the brain -> the brain (hypothalamus) will interpret it to
pain
SG – Substantia Gelatinosa
- a collection of cells in the gray area (dorsal horns) of the spinal cord
- found at all levels of the cord
- it receives direct input from the dorsal (sensory) nerve roots, especially those fibers from pain and
thermoreceptors
WHAT OPENS THE GATE
- Lack of sleep
- Stressful lifestyle
- Fear and anxiety about pain
- Depression
- Physical activity / tired
- Mentally focusing on pain
- Hypoglycemia (Normal: 80/100 mg/dl of blood)
- Serotonin and Endorphin deficit
- Consumption of nutrients that increase inflammation (such as fried and oily foods)
WHAT CLOSES THE GATE
- Relaxation
- Exercise
- Medications (Pain relievers, Opioids – Morphin, Demerol)
- Distractions from pain
- Positive Thoughts
- Endorphin
- Avoiding nutrients that increases inflammation (such as fried and oily foods)
- Acupuncture
- Serotonin (consumption of food rich in serotonin such as banana)
- Adequate sleep
PAIN
Transmission
- Impulses from afferent – CNS – Neurons – Spinal Cord –

- Thalamus – relay station for sensory input –
- Midbrain – signals cortex to raise awareness of the stimuli
PAIN TOLERANCE
- Amount and duration of pain a person can stand before seeking relief
- Can vary between different individuals in the same situations
TOLERANCE
- A state of adaptation in which exposure to a drug induces charges that result in a decrease in
one or more of the drug’s effects over time
PAIN THRESHOLD
- Point at which each person recognizes pain

- Tends to be the same among healthy persons
INCREASE TOLERANCE
- Alcohol
- Drugs
- Hypnosis
- Strong beliefs
- Distractions
- Rubbing
DECREASE TOLERANCE
- Fatigue
- Anger
- Boredom
- Anxiety
- Stress
- Depression
** Anxiety and Stress can stimulate or inhibit urination and may provoke urgency and frequency
** Schwann Cells = PNS Oligodendrocytes = CNS = MYELIN SHEATH
 Specific Types of Pain
 REFFERED PAIN
- Discomfort
- Perceived in a general area of the body but not in the exact site where an organ is anatomically
located
 VISCERAL PAIN
- Arises from internal organs that are diseased or injured
- Usually accompanied by ANS symptoms
- Sharp or dull, aching cramping pain
 SOMATIC PAIN
- (e. g a hot stove) Pain may originate in the skin tissues
SUPERFICIAL PAIN
- Sharp, pricking, burning
DEEP SOMATIC PAIN
- Muscles or bones, sharp, dull and aching
 NEUROPATHIC PAIN
- Caused by damage to the CNS or Peripheral nerves
- Damage: vertebrae – causes pressure to the root nerve causing pain
- Damage; to myelin sheath – damaged by our own antibody / autoimmune
- PHANTON PAIN
ENDORPHINS
- Endogenous chemicals that act like opioids to inhibit pain impulses in the spinal cord and brain
- They degrade too quickly
 TYPES OF PAIN
ACUTE
- Tachy – increased bp
- Associated with SNS
CHRONIC
- No changes in Vital Signs

- Assessment of chronic pain should focus on impact of the pain and on patients’ function and daily
activities
**DANGERS OF UNRELIEVED PAIN
- Pain causes shallow breathing and cough suppression -> prevention of pulmonary secretions ->
pneumonia
PAIN
- may delay the return of normal gastric and bowel function

- Peristalsis – inhibited
- Suppress the immune system and heighten susceptibility to illness
CHRONIC PAIN
- Lowers the pain threshold as a result of the depletion of SEROTONIN and ENDORPHIN
 DRUG THERAPHY
Non-Opioid Analgesics
- First line therapy for mild to moderate pain

- Do not produce tolerance or physical or psychological dependence
- Works primarily at the site of injury rather than the CNS
- They do not have antipyretic effect
Opioid Analgesics
- Given when pain is moderate in intensity (PS: 7-10)

- Also for mild but persistent pain
Non-Pharmacologic Methods of Pain Management
- Massage. A lot of people find relief from gentle massage, and some hospice agencies have
volunteers who are trained in massage therapy. Several studies have found that massage is
effective in relieving pain and other symptoms for people with serious illness.
- Relaxation techniques. Guided imagery, hypnosis, biofeedback, breathing techniques, and
gentle movement such as tai chi. Relaxation techniques are often very effective, particularly when
a patient -- or a caregiver -- is feeling anxious.
- Acupuncture. Several studies have found that acupuncture can be helpful in relieving pain for
people with serious illnesses such as cancer.
- Physical therapy. If a person has been active before and is now confined to bed, even just moving
the hands and feet a little bit can help.
- Pet therapy. If you have bouts of pain that last 5, 10, or 15 minutes, trying to find something pleasant
-- like petting an animal's soft fur -- to distract and relax yourself can be helpful.
- Gel packs. These are simple packs that can be warmed or chilled and used to ease localized pain.
PAIN DICRIMINATION – eyes closed

Health Assessment

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Health Assessment

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Health Assessment

ANATOMY: SPECIAL SENSES | SENSE OF HEARING | EARS

- Detect sound waves (touch & hearing)

EXTERNAL AUDITORY CANAL | EXTERNAL ACOUSTIC MEATUS

- A tube running from the outer ear to the middle ear

MASTOID ANTRUM | TYMPANIC ANTRUM

- An airspace in the petrous portion of the temporal bone

AUDITORY TUBE | EUSTACHIAN TUBE

- Equalizes the pressure between the outer and inner ear

- Receives sounds in the form of vibrations

- Detect changes in gravity and linear accelerations

SEMICIRCULAR CANALS (ANTERIOR, POSTERIOR, LATERAL)

- Helps maintain balance when turning spinning, or tumbling

FLUIDS IN THE EAR

- Help in transmission of the sound

- Helps keep the skin in the ear canal soft

VESTIBULOCOCHLEAR NERVE VII

- VESTIBULAR – maintain balance

ASSESING THE EAR/HEARING

- to assess high-frequency hearing

Conductive Hearing Loss

Sensorineural Hearing Loss

Mixed Hearing Loss

- combination of conduction and sensorineural hearing loss

 MUSCLES OF THE EYE

3 LAYERS OF THE EYE

1. SCLERA 2. CHOROID 3. RETINA

- Small central pit composed of closely packed cones in the eye

- Produce and oily substance that keeps the eyes moist

- Mucous membrane, lines the inner surface of the eyelids

- Makes the constriction and dilation of pupils

CORNEAL LIGHT REFLEX

- Avascular like the cornea

MACULA LUTEA OR FUVEA

- Contains very high concentration of cones

- Controls the shape of the lens (cilliary muscle)

- Help with the movement of the eye

- Fillers of the eyeball behind the lens

NORMAL INTRAOCULAR PRESSURE (IOP)

AQUEOUS HUMOR CIRCULATION

ASSESSING THE EYES

- Length : Endocanthion to Exocanthion

 Periorbital area – Periorbital Oedema

 TESTING VISUAL FIELDS

Tumour, Clotted blood, Oedema, Aneurysm

Normal Pupil size: 3-5 mm

ASSESSING THE FACE & SKULL AND NECK

2 Structures of the face that are important in assessing for symmetry

HEAD AND NECK

- Composed of muscles, ligaments, and the cervical vertebrae

LYMPH NODES OF THE HEAD AND NECK

Order in assessing the lymph nodes

 Jugular Vein Distention

- An indicator of thyroid hyperplasia

- Used to validate your inspection

- It is used/done with caution because pressure can damage internal organs

- To know the size of the liver

- used for localized pulsations

- is felt from light palpation over the chest wall

BONE – flat sound

Lungs / PRESENCE OF AIR – resonance

- Infection acquired during hospitalization

Hand Washing / Hand Hygiene