PHYSICAL ASSESSMENT

1. SKIN

· Examination of the skin is correlated with the information gathered in the history and other parts
of the physical examination.

· Examine the skin as you proceed though each body system.

· Initially, examine both hands and inspect the nails

Inspection

Observe for: skin color pigmentation, lesions (distribution, type, configuration, size), jaundice, cyanosis,
scars superficial vascularity, moisture, edema, color of mucous membranes, hair distribution, nails.

Check for capillary refill – depress the nail edge to blanch and then release, noting the return of color –
color return is instant, within 1 to 3 seconds. Capillary refill is an index of peripheral perfusion and
cardiac output.

Palpation
Examine the skin for temperature, texture, elasticity turgor.

Note: Skin turgor is usually not examined among elderly (those who are over 65 years of age because
their skin is normally wrinkled).

1. HEAD and FACE

Inspection and Palpation

· Inspect and palpate scalp for masses, hair color, texture, and cranium.

· Inspect face: symmetry, expression

· Palpate the temporal artery, then the tempo-mandibular joint as the patient opens and closes the
mouth.

· Palpate the maxillary sinuses and the frontal sinuses for tenderness.
2. EYES

Inspection

a. Eyeballs (globes) for protrusion.

b. Palpebral fissures (longitudinal openings between the eyelids) – for width and symmetry.

c. Lid margins for scaling, secretions erythema (redness), position of lashes

d. Bulbar and palpebral conjunctivae – for congestion and color.

Bulbar conjunctiva – membranous covering of the sclera. Contains blood vessels.

§ Palpebral conjunctiva – membranous covering of the inside of the upper and lower lids. Contains
blood vessels.

a. Sclera – for color; iris – for color

b. Pupils – for size, shape, symmetry, reaction to light and accommodation (ability of the lens to
adjust to objects and varying distances)

c. Eye movement – extraocular muscles (six cardinal positions – Cranial Nerves III, IV, VI), nystagmus,
convergence. (See neurologic examination).

§ Nystagmus: rapid lateral, horizontal, or rotary movement of the eye.

§ Convergence: ability of the eye to turn in and focus on a very close object.

Visual Acuity – check with a Snellen Chart (with and without eyeglasses)

§ The Snellen’s Eye Chart

Ø The Snellen alphabet chart is used to measure visual acuity. It has lines of letters arranged in
decreasing size.

Ø Position the patient 20 feet away from the chart.

Ø Ask the patient to cover one eye with opaque card. Test right eye first, then the left eye.

Ø If the patient wears eyeglasses or contact lenses, leave them on. Remove only reading glasses because
they will blur distance vision.

Ø Ask the patient to read through the chart for the smallest line possible.

Note: Use a Snellen picture chart for people who cannot read letters
Ø Record the result using numeric fraction at the end of the last successful line read. Indicate if some
letters were missed or if corrective lenses were worn. Example: “O.D.” 20/30 – 2 with glasses (Note O.D.
means right eye).

Palpation

· Determine the strength of the upper eyelids by attempting to open closed lids against resistance.

· Palpate eyeballs (globes) through closed lids for tenderness and tension.

EARS

MOUTH, THROAT, NOSE and SINUSES

A nurse can inspect the nasal passages very simply with a flashlight. However, a nasal speculum and a
penlight or an otoscope with a nasal attachment facilitates examination of the nasal cavity. Assessment
of the nose includes inspection and palpation of the external nose (the upper third of the nose is bone;
the remainder is cartilage); patency of the nasal cavities; and inspection of the nasal

Performance

1. Prior to performing the procedure, introduce self and verify the client's identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can
participate. Discuss how the results will be used in planning further care or treatments.

2. Perform hand hygiene and observe other appropriate infection prevention procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following: allergies, difficulty breathing through the
nose, sinus infections, injuries to nose or face, nosebleeds; medications taken; changes in sense of smell.

5. Position the client comfortably, seated if possible.

ASSESSMENT NORMAL FINDINGS DEVIATION FROM NORMAL
NOSE
6. Inspect the external nose for Symmetric and straight Asymmetric
any deviations in shape, size, or No discharge or flaring Discharge from nares
color and flaring or discharge Uniform color Localized areas of redness or
from the nares. presence of skin lesions
7.Lightly palpate the external Not tender; no lesions Tenderness on palpation;
nose to determine any areas of presence of lesions
tenderness, masses, and
displacements of bone and
cartilage.
8.Determine patency of both Air moves freely as the client Air movement is restricted in
nasal cavities. breathes through the nares one or both nares
Ask the client to close the
mouth, exert pressure on one
naris, and breathe through
the opposite naris. Repeat the
procedure to assess patency of
the opposite naris.
9. Inspect the nasal cavities
using a flashlight or a nasal
speculum.

• Hold the speculum in your The nasal septum, inferior and

right hand to middle turbinates' of
inspect the client’s left nostril the nasal passage.
and your left
hand to inspect the client’s right
nostril.
• Tip the client’s head back.
• Facing the client, insert the tip
of the
speculum about 1 cm (0.4 in.).
Care
must be taken to avoid pressure
on the
sensitive nasal septum.
• Inspect the lining of the nares
and the
integrity and the position of the
nasal
septum. ❶
10. Observe for the presence of Mucosa pink
redness, swelling, Clear, watery discharge
growths, and discharge No lesions