CHAPTER 1 BODY MECHANICS
Knees held easy, neither flexed nor rigidly
DEFINITION: It is the coordinated use of body parts
to produce motion and maintain equilibrium in
relation to skeletal, muscular and visceral system
under neurological association.
PURPOSES:
1. To maintain good body posture.
2. To help promote good physiological functions of
the body.
3. To use the body correctly and to maintain its
effectiveness.
4. To prevent injury or for limitation of the
musculoskeletal system.
GENERAL CONDITIONS:
1. Work close to an object to prevent unnecessary
straining of muscles.
2. Place feet apart in order to provide a wide base
of support when increased stability of the body is
necessary.
3. Use the longest and strongest muscles of the
arms and legs to help provide the power needed for
strenuous activities.
4. Use the internal girdle (made by contracting the
gluteus muscles downward and abdominal muscles
upward) and a long midriff (done by stretching the
muscles in the waist) to stabilize and protect the
abdominal viscera when stopping, reaching, lifting,
and pulling.
5. Push and pull, slide or roll an object to the
surface rather than lift it.
6. Use the weights of the body as a force for pulling
or pushing by rocking on the feet or falling forward
or backward.
PERSONAL BODY MECHANICS OF A NURSE
Good posture is the skillful use of the body to
assure greater efficiency to lessen fatigue and
protect or prevent back strain.
CRITERIA FOR GOOD POSTURE:
A. Standing
1. Body erect, with body segment balance one over
the other.
2. Feet, 3-4 inches apart wide base of support with
weight on outer borders.
3.
extended.
4. Abdominal muscles retracted (pulled in), gluteal
muscles contracted (pinched together) constituted
“inner girdle” for pelvis, back and abdomen.
5. Chest forward, back of head held high, chin up.
6. Shoulders in even position.
B. Sitting
1. Trunk and head same as in standing position.
2. Hips flexed at right angle to trunk and place
along back of chair with thighs rest on seat of chair.
3. Feet flat on the floor, one ahead of the other.
C. Posture in Activity
1. Prepare for load before beginning to lift by
tightening the girdle and prepare to use heavy thigh
and hip muscles for the task.
2. To lift heavy objects, place feet close to object to
be lifted. Assume feet forward position to give
good base, flex knees and hips and keep back
straight.
3. Carry objects close to body.
4. Have equipment at good height for working.
When the equipment is not ideal, adjust to working
height by flexing hips and knees rather than by
bending the back.
5. Avoid torsion (twisting or bending sideways from
waist to hips) for any activity.
Proper Alignment when Standing:
1. The head is erect and midline.
2. The shoulders and hips are straight and parallel.
3. The vertebral column is straight.
4. When observed laterally, the spine curves
forming a reversed “S”.
5. The abdomen is tucked in and the knees and
ankles are slightly flexed.
6. The arms hang comfortably at the person’s sides.
7. The feet are slightly apart to form a wide base of
support, with the toes pointed forward.
8. The center of gravity is midline from the middle
of the forehead to a midpoint between the feet.
Proper Alignment when sitting in a Chair, 8. Lock the wheels of the bed, wheelchair, or
Wheelchair OR Rehabilitation Chair: stretcher so that they do not slide about while you
are moving the client.
1. The head is erect, and the neck and vertebral 9. Observe the principles of the body mechanics
column are straight. while you work to prevent injuring yourself.
2. Body weight is evenly distributed on the buttocks 10. Be sure the client is in good alignment while
and thighs. moved and lifted to protect the client from strain
3. The feet are supported on the floor or a
and muscle injury.
footstool.
4. There is a 2 to 4 cm. space between the edge of 11. Support the client’s body well. Use large muscle
the chair and the popliteal space on the posterior groups. Avoid grabbing and holding an extremity by
surface of the knee. its muscle.
5. The forearms are supported on the armrests, on 12. Avoid causing friction on the client’s skin during
the lap, or on a table in front of the chair. moving.
6. Avoid using pillows at the back since they might 13. Friction can be reduced by sprinkling powder or
interfere with proper alignment.
corn starch on bed linens and on the client’s skin.
Proper Alignment when Lying: 14. Avoid lifting if he can be rolled; move him
1. The vertebrae are in straight alignment without towards you rather than pushing him away,
curves. avoid reaching across the bed to do treatment.
2. The joints are slightly flexed and supported. 15. Work with feet, head and body towards the
3. There should be support at the feet to prevent
area of activity.
plantar flexion, commonly referred as to foot drop.
4. The top leg should be flexed and brought slightly 16. Avoid lifting heavy objects alone.
forward for balance. 17. Practice good body mechanics even when
Nursing Guidelines when Moving and Positioning performing light tasks in order to minimize
Patients: exertion and strain.
1. Know the client’s diagnosis, capabilities & any
movement not allowed.
2. Explain to the client what you plan to do. Then,
encourage the client/patient to assist in moving and
positioning to their greatest potential.
3. If the client is in pain, administer the prescribed
analgesic sufficiently in advance of the transfer to
allow the client to participate in the moves
comfortably.
4. Position the bed at a height that reduces back
pain, and is comfortable and safe for you.
5. Move the patient closer to one side of the bed.
6. Assess the amount of assistance necessary to
safely move the patient.
7. Use aids in moving patients such as:

a) Pull sheets or turn sheets.

b) Overhead trapeze
c) Slings
ASSISTING A CLIENT WITH TURNING IN BED
Individuals who are forced into inactivity by illness
or injury are at high risk for serious health
complications.
EQUIPMENT:
• Friction-reducing sheet or draw sheet
• Bed surface that inflates to aid in turning
• Pillows or other supports to help the patient
maintain the desired position after turning and to
maintain correct body alignment for the patient
• Additional caregivers to assist, based on
assessment
• Nonsterile gloves, if indicated; other PPE as
indicated
General Notes:
• This is not a 1-person task; do not pull from head
of bed.
• When pulling a patient up in bed, the bed should
be flat or in a Trendelenburg position, with the side
rail down.
• For patients with stage III or IV pressure ulcers,
care must be taken to avoid shearing force.
• The height of the bed should be appropriate for
staff safety (at the elbows).
• If the patient can assist when repositioning up in
bed, ask him to flex the knees and push on the count
of 3.
• During any patient-handling task, if the caregiver is
required to lift more than 35 lbs. of a patient’s
weight, then the patient should be considered to be
fully dependent and assistive devices should be
used.
NURSING DIAGNOSIS
• Activity Intolerance
• Acute Pain
• Risk for Activity Intolerance
• Chronic Pain
• Fatigue
• Risk for Impaired Skin Integrity
• Risk for Injury
• Impaired Skin Integrity
• Impaired Bed Mobility
IMPLEMENTATION:
PROCEDURE:
1. Review the physician’s orders and nursing plan of
care for patient activity. Identify any movement
limitations and the ability of the patient to assist
with turning. Consult patient handling algorithm, if
available, to plan appropriate approach to moving
the patient.
▪ RATIONALE: Checking the physician’s order
and plan of care validates the correct
patient and correct procedure.
2. Gather any positioning aids or supports, if
necessary
▪ Having aids readily available promotes
efficient time management
3. Perform hand hygiene. Put on PPE, as indicated.
4. Identify the patient. Explain the procedure to the
patient.
▪ Patient identification validates the correct
patient and correct procedure.
5. Close the curtains around bed and close the door
to the room, if possible. Position at least one nurse
on either side of the bed.
▪ Closing the door or curtain provides
privacy.
▪ Proper bed height helps reduce back strain
while performing the procedure.
▪ Proper positioning and lowering the side
rails facilitate moving the patient and
minimize strain on the nurses.
6. If not already in place, position a friction-
reducing sheet under the patient.
▪ Sheets aid in preventing shearing and in
reducing friction and the force required to
move the patient.
7. Using the friction-reducing sheet, move the
patient to the edge of the bed, opposite the side to
which he or she will be turned. Raise the side rails.
▪ Raising side rails ensures patient safety.
8. If the patient is able, have the patient grasp the
side rail on the side of the bed toward which he or
she is turning. Alternately, place the patient’s arms
across his or her chest and cross his or her far leg
over the leg nearest you.
9. If available, activate the bed mechanism to I. TEMPERATURE
inflate the side of the bed behind the patient’s
back. It is the difference between heat produced and
heat lost by the body and is measured through the
▪ This helps avoid straining the nurse’s lower use of a digital thermometer. Body temperature
back. readings vary depending on where on the body a
person takes the measurements.
10. The nurse on the side of the bed toward which
the patient is turning should stand opposite the ▪ Rectal readings are higher than oral
patient’s center with his or her feet spread about readings, while axilla readings tend to be
shoulder width and with one foot ahead of the lower.
other. Tighten your gluteal and abdominal muscles
and flex your knees. Use your leg muscles to do the Normal Body Temperature
pulling. The other nurse should position his or her
Type of 0-2 years 3-10 11-65 Over 65
hands on the patient’s shoulder and hip, assisting
Reading years years years
to roll the patient to the side. Instruct the patient
to pull on the bed rail at the same time. Use the Oral 35.5-37.5 35.5-37.5 36.4-37.6 35.8-36.9
friction reducing sheet to gently pull the patient
95.9-99.5 95.9-99.5 97.6-99.6 96.4-98.5
over on his or her side.
Axilla 34.7-37.3 35.9-36.7 35.2-36.9 35.6-36.3
11. Use a pillow or other support behind the 94.5-99.1 96.6-98.0 95.3-98.4 96.0-97.4
patient’s back. Pull the shoulder blade forward and
Rectal 36.6-38 36.6-38 37.0-38.1 36.2-37.3
out from under the patient.
97.9-100.4 97.9-100.4 98.6-100.6 97.1-99.2
▪ Pillow will provide support and help the
Tympanic 36.4-38 36.1-37.8 35.9-37.6 35.8-37.5
patient maintain the desired position.
97.5-100.4 97.0-100.0 96.6-99.7 96.4-99.5
Positioning the shoulder blade removes
pressure from the bony prominence.

12. Make the patient comfortable and position in Types of thermometer:

proper alignment, using pillows or other supports
under the leg and arm, as needed. Readjust the
pillow under the patient’s head. Elevate the head of
the bed as needed for comfort.
13. Place the bed in the lowest position, with the
side rails up. Make sure the call bell and other
necessary items are within easy reach.
▪ Adjusting the bed height ensures patient
safety.
14. Clean transfer aids, per facility policy, if not
indicated for single patient use. Remove gloves and
other PPE, if used. Perform hand hygiene.
▪ Proper cleaning of equipment between
patient use prevents the spread of
microorganisms.
CHAPTER 2 CHECKING THE VITAL SIGNS
DEFINITION: Temperature, pulse, respiration, and
blood pressure give some indication of the state of
health of an individual. They represent interrelated
physiologic systems of the body.
1. Electronic thermometer.
2. Tympanic membrane thermometer.
3. Disposable paper thermometer; the dots change
color to indicate temperature.
4. Temporal artery thermometer.
Normal body temperature readings will vary within
these ranges depending on the following factors:
1. A person’s age and sex
2. The time of day, typically being lowest in the
early morning and highest in the late afternoon
3. High or low activity levels
4. Food and fluid intake
5. For females, the stage in their monthly menstrual
cycle
6. The method of measurement such as oral
(mouth), rectal (bottom), or axilla (armpit) readings
Procedure
1.Read the chart. Wash hands.
▪ To obtain data; to eliminate the spread of
microorganism.
2.Determine any previous activity that would
interfere with the accuracy of temperature
measurement.
▪ Smoking or oral intake of foods/fluids can
cause false temperature taking.
3.Bring the tray to the bedside and explain the
procedure to the patient.
4. Take the thermometer out of its holder. Clean the
probe (pointed end) of the thermometer with cotton
balls with rubbing alcohol in twisting motion up to
the stem.
5. Place the thermometer under the patient’s tongue
on one side of his/her mouth and instruct him/her to
close his/her lips.
6. Leave the thermometer in place until the
thermometer signals it is finished.
7. Remove the thermometer carefully and read the
temperature on the digital display.
8. Clean the stem to the probe (tip) with cotton balls.
Put the thermometer cover and place the
thermometer in its container. Dispose cotton balls
in a trash bin, record and wash hands.
II. AXILLARY METHOD (UNDER THE ARMPIT)
Procedure:
▪ Read the chart. Wash hands.
▪ Determine any previous activity that would
interfere with the accuracy of temperature
measurement.
▪ Bring the tray to the bedside and explain
the procedure to the patient.
▪ Take the thermometer out of its holder.
Clean the probe (pointed end) of the
thermometer with cotton balls with rubbing
alcohol in twisting motion up to the stem.
▪ Pat the patient’s axilla dry with bathroom
tissue or patient’s clean towel. Place the
thermometer into the center of axilla. Bring
the patient’s arm down close to his body
and place his forearm over his chest.
▪ Leave the thermometer in place until the
thermometer signals it is finished.
▪ Remove the thermometer carefully and
read the temperature on the digital display.
▪ Clean the stem to the probe (tip) with
cotton balls. Put the thermometer cover
and place the thermometer in its container.
Dispose cotton balls in a trash bin, record
and wash.
III. RECTUM METHOD (IN THE RECTUM OR ANUS)
Procedure:
▪ Read the chart. Wash hands and bring the
equipment to the bedside and explain the
procedure to the patient (adult) or
significant other’s (infant/child).
▪ Place the patient in lateral position/sim’s
position.
▪ Drape patient exposing only the rectum.
▪ Don gloves. -Working gloves are used to
avoid contact with bodily secretions and to
reduce transmission of microorganisms.
▪ Take the thermometer out of its holder.
Clean the probe (pointed end) of the
thermometer with cotton balls with rubbing
alcohol in twisting motion up to the stem.
▪ Lubricate the end of the probe with small
amount of lubricating jelly.
▪ With the dominant hand, hold the
thermometer. With the non-dominant
hand, raise the upper buttocks to expose
the anus.
▪ Instruct the patient to take deep breath.
Gently insert the thermometer into the
anus (infant –1.2cm/0.5 inch); (adult –
3.5cm/1.5 inches). If resistance is felt, do
not force insertion. Release buttocks to
allow fall in place.
▪ Hold the thermometer in place until it
beeps then remove the thermometer. Read
the temperature result on the display.
▪ Wipe anal area with tissue to remove
lubricant or feces and cover patient.
Dispose soiled tissue in the trash bin.
IV. TYMPANIC METHOD (IN THE EAR)
▪ Read the chart. Wash hands and bring the
equipment to the bedside and explain the
procedure to the patient (adult) or
significant other’s (infant/child).
▪ Place the patient in lateral position.
▪ Don gloves.
▪ Take the thermometer out of its holder.
Clean the probe (pointed end) of the
thermometer with cotton balls with rubbing
alcohol in twisting motion up to the stem.
▪ With the dominant hand, hold the
thermometer. With the non-dominant
hand, gently tug on the ear pulling it back.
 ▪ Instruct the patient to take deep breath.
Gently insert the thermometer until the ear
canal is fully sealed off.
▪ Hold the thermometer in place until it
beeps then remove the thermometer. Read
the temperature result on the display.
▪ Clean the stem to the probe (tip) with
cotton balls. Put the thermometer cover
and place the thermometer in its container.
PULSE
DEFINITION: It is the regular beating or throbbing
caused in the arteries by each ventricular
contraction.
downward. Or place arm on top of the patient’s
upper abdomen
2. While the fingertips are still placed after counting
the pulse rate, observe the patient’s respiration.
3. Note the rise and fall of the patient’s chest with
each respiration and expiration. This observation can
be made without disturbing the patient’s
bedclothes.
4. Using a watch with second hand, count the
number of respirations for one whole minute.
5. If respirations are abnormal in any way, repeat to
determine accurately the rate and the characteristics
of the breathing and record.

Where the pulse can be obtained: OBTAINING THE CARDIAC RATE OR APICAL PULSE
1. Radial artery If a peripheral pulse is irregular, weak, or difficult to
2. Facial artery assess accurately, the apical rate may be assessed.
3. Temporal artery Used to assess newborn, infants, and young
4. Dorsalis pedis artery children.
5. Femoral artery
6. Popliteal artery 1. Explain the procedure.
7. Carotid 2. Position the patient on supine and drape
8. Apical him.
9. Brachial 3. Raise patient’s gown to expose sternum and
left side of the chest.
Normal Pulse Rate per minute: 4. Cleanse ear pieces and diaphragm of
▪ Newborn 120-140 stethoscope using alcohol swab.
▪ 1 year old115-130 5. Warm the diaphragm of the stethoscope
▪ 2 years old 100-115 with your hand before applying it to the
▪ 7 yrs. old 85-90 patient’s chest.
▪ Male 70-80 6. Place the diaphragm of the stethoscope
▪ Female 80-90 over the apex of the heart, located at the
fifth intercostal space, left midclavicular line
What to take note when taking the pulse: then insert the ear pieces in your ears.
1. Rate- no. of heart beats per minute. 7. Move the diaphragm to the site of the
2. Rhythm- throbbing of arteries loudest beats. Count the beats for 60
3. Tension or compressibility- corresponds to seconds and note their rhythm and volume.
diastolic blood pressure. Low tension pulse (pulsus Also evaluate the intensity (loudness) of
mollis), High tension pulse (pulsus durus). heart sounds.
4. Volume 8. Remove the stethoscope and make the
patient presentable, comfortable, record.
Normal Respiratory Rate per minute:
RESPIRATORY RATE
• Newborn 30-40 Definition: Number of breaths per minute, is a
• Children 20-25 clinical sign that represents ventilation (the
• Adult 16-20 movement of air in and out of the lungs).
OBTAINING THE RADIAL PULSE RATE AND THE BLOOD PRESSURE
RESPIRATORY RATE
DEFINITION: Blood pressure is the force exerted by
1. Have the patient rest his arm alongside his body the blood against the walls of the artery.
with wrist extended and all the palm of the hand
PURPOSE:
1. As an aid in diagnosis
2. As a means of observing changes in patient’s
condition.
Sites for taking the Blood Pressure:
1. Either arm on the antecubital space.
2. Either leg on the popliteal space or dorsalis pedis.
Normal Ranges:
• Infant 50/40-80/50 mmhg
• Children 87/48-117/64 mmhg
• Adult 110/70-130/90 mmhg
Procedure:
1. Place the 1st and 2nd and the 3rd fingers
along the radial artery and press gently
against the radius; rest the thumb on the
back of the patient’s wrist.
2. Place the cuff directly above the patient’s
elbow, keeping the antecubital area free.
3. Place the stethoscope on the brachial artery
on the antecubital space. Where the pulse
was noted.
4. Use the fingertips to feel for a strong
pulsation on the antecubital space.
5. Place the stethoscope on the brachial artery
on the antecubital space. Where the pulse
was noted.
6. Pump the bulb of manometer until it rises
to approximately 30mm above the point
where it is anticipated that systolic pressure
should be.
7. Using valve on the bulb, release air
gradually and note on the manometer the
point at which the first sound is heard;
record this figure as the systolic pressure.
8. Continue to release air gradually from the
cuff. Note the reading of the manometer
when the last distinct loud sound is heard
with the stethoscope. Record this figure as
the diastolic pressure.
After Care of Equipment’s:
1. Roll cuff of sphygmomanometer and place in case.
2. Wash ear pieces of the bell of the stethoscope
with soap and water and dry.
3. Return equipment’s to proper place.
CHAPTER 3 BASIC PHYSICAL ASSESSMENT
A. Physical Examination
PURPOSES:
1. Routine screening.
2. Eligibility for employment, school
activities, physical activities, medical
insurance, military service.
3. Hospital admission.
4. Establishing a database for the patient.
5. Identifying patient problems requiring
intervention.
6. Evaluating the effectiveness of care.
7. Developing credibility for promoting the
nurse/patient relationship.
DRAPING during Physical Assessment
Purposes:
▪ To prevent unnecessary exposure
▪ To provide privacy
▪ To keep the client warm
Considerations:
• The method of draping varies with the
position of the patient, examination being
done, and the room temperature.
• As the examination is conducted, only those
body parts being assessed are exposed.
• Draping should be loose enough to allow
quick change of position but anchored
securely to prevent unnecessary exposure.
Techniques necessary for an accurate physical
examination
▪ Observation, measurement and history
taking.
1. INSPECTION - visual and olfactory inspection to
observe color, odor, size, shape, symmetry &
movement.
2. PALPATION – using the sense of touch
simultaneously with inspection to identify softness,
rigidity, temperature, and to determine position,
size, texture, consistency and moisture.
3. PERCUSSION – striking body surfaces, producing
sounds to determine if underlying tissues are
airfilled, fluid-filled, or solid. Percussion sounds
include:
a) Flat: non resonant; soft tissues
b) Dull: thud like; solid organs
c) Resonant: hollow
d) Hyper resonant: booming Tympanic: over gas filled;
drum like
4. AUSCULTATION – listening to sounds (usually with
stethoscope) produced as to their frequency,
intensity, quality and duration. Low pitched sounds.
C. Preparation for the Examination
The environment must be suitable and all equipment
complete before the examination begins.
1. Preparation of the environment.
a) The examination is performed in privacy.
b) Adequate lighting is required for proper
illumination of body parts, observation, and
inspection.
c) The examination room should be
soundproof if possible; if not, all extraneous
noise should be eliminated.
d) The examination table should be
comfortable to the patient.
2. Preparation of equipment.
a) Equipment and hands should be clean and
be kept warm.
b) All equipment should function properly.
c) All equipment should be gathered prior to
the beginning of the examination and
should be kept within easy reach of the
examiner.
3. Physical preparation of the patient.
a) The patient should be asked to void
prior to the examination.
b) The reason for the specimen collection
should be explained to the patient.
c) The patient should be properly
positioned and draped for examination.
d) The patient should be kept warm and
out of drafts; seriously ill patients are
more susceptible to chills.
e) The patient should be provided with
privacy and adequate time to dress and
undress.
4. Psychological preparation of the patient.
a) Provide reassurance and support
to decease patient anxiety and
embarrassment.
b) Explain actions clearly and in detail
using simple explanations.
c) Acquire a third person to be in the
examination room when the
patient &examiner are of the
opposite sex.
d) Monitor the patient’s emotional
responses throughout the
examination.
D. Positioning for Physical Examination
Considerations:
1. It is important to consider the client’s energy
level and privacy.
2. Clients who are weak may require
assistance with positioning.
3. Uncomfortable or embarrassing positions
should not be maintained for long periods.
4. The examination should be organized so
that several body systems can be assessed
with the client in one position.
1) SITTING POSITION
A. Purposes:
(1) Sitting upright provides good visualization of
the symmetry of the upper body.
(2) Allows full lung expansion.
B. Areas used to assess, include:
(1) Head and neck
(2) Anterior and posterior thorax and lungs
(3) Breast
(4) Axilla
(5) Heart
(6) Upper extremities
(7) To take vital signs
C. Considerations:
(1) The client may sit upright in a chair, on the
side of an examining table or bed.
(2) Physically weak patients may not be able to sit.
• A supine position with the head of the
bed elevated can be used instead.
D. Procedure:
(1) Position the buttocks against the back of
the chair. Hips and knees are flexed at right
angle to the trunk.
(2) Keep trunk and head as in standing position.
(3) Place feet flat on the floor at a 90-degree
angle to the lower legs.
• If the chair has arms, flex the elbows and
place the forearms on the armrest to
avoid shoulder strain.
 2) SUPINE POSITION (2) On the I.E. table
a) Bring buttocks of the client to extreme
C. Considerations: edge of the examining table and place
the feet on extension.
(1) This position allows relaxation of b) Drape is placed diagonally over the
abdominal muscles. patient with opposite corners in place
(2) The supine position may be difficult for between the legs.
patients experiencing shortness of breath. c) Place Kelly or disposable pad under
D. Procedure: patient’s buttocks
d) The corner of the drape between the
(1) The patient lies flat on the back with legs
patient’s legs raised on folded back on the
together but extended and slightly flexed at
abdomen to expose the part being
the knees.
examined.
(2) The head may be supported with a small pillow.
2) SIMS POSITION
3) DORSAL RECUMBENT POSITION A. Purpose: Used to assess the rectum or vagina.
A. Purposes:
(1) Vaginal examination B. Consideration: Joint deformities may prevent
(2) Digital examination the patients from assuming this position.
(3) Pelvic examination C. Procedure:
(4) Catheterization
(1) Place top sheet.
(2) The client lies on either the right or left side.
(3) The lower arm is behind the body and the
upper arm is flexed at the shoulder and elbow.
(4) The knees are both flexed, with the
uppermost leg more accurately flexed.

B. Areas used to assess, include:

(1) Head and neck

(2) Anterior thorax and lungs
(3) Breast and axilla 3) PRONE POSITION
(4) Heart A. Purposes:
(1) It is used to assess the hip joint.
(5) Extremities
(2) Can be used to assess the posterior thorax.
(6) Peripheral pulses
B) Consideration:
C. Considerations: This position is difficult to assume for many
(1) Bending the knees in the dorsal recumbent clients.
position may be more comfortable for patients
with painful disorders. C. Procedure:
(2) This position cannot be used to assess the (1) Place top sheet.
abdomen since it promotes contracture of (2) The client lies on the abdomen, flat on the bed,
the abdominal muscles. with the head turned to one side.

D. Procedure:
(1) The patient lies on the back with legs
separated, knees bent, and soles of the feet flat on
the bed.
4) LITHOTOMY POSITION
A. Purposes:
(1) Examination of the rectum and female
genitalia.
(2) Delivery of the new born.
(3) Cystoscopic examination.
B. Considerations:
(1) It is uncomfortable for the older clients.
(2) It is often embarrassing, so time spent in
this position should be minimized.
(3) Lithotomy position provides the greatest
exposure of genitalia and allows insertion of
the vaginal speculum.
5) KNEE – CHEST OR GENU – PECTORAL POSITION
A. Purpose:
• The position is used for the examination of
the rectal area.
B. Consideration:
• The same precautions should be used as
with the lithotomy position.
c) Procedure:
(1) The client kneels, using the knees & chest to
bear the weight of the body.
(2) The body is at a 90-degree angle to the hips,
the back straight, the arms above the head, and
the head turned to one side.
E. Instruments Needed for Physical Examination
1. Sphygmomanometer
2. Stethoscope
3. Ophthalmoscope
4. Otoscope
5. Vaginal Speculum
6. Tuning Fork
7. Nasal Speculum
8. Percussion Hammer 9. Snellen Chart
10. Weighing Scale 11. Neurologic
Hammer Equipment's and
Supplies
1. Alcohol swabs
2. Cotton applicators
3. Disposable pad
4. Cotton balls with antiseptic solution
5. Gauze dressing (4x4)
6. Drape
7. Gloves (sterile & non-sterile/clean)
8. Lubricant
9. Penlight
10. Safety pin
11. Cologne/perfume (testing sense of smell)
12. Tape measure
13. Thermometer
14. Tongue depressor
15. Kidney basin 16. Tissue paper
17. Lab. Slides/Test tubes 18. Clean white towel
Assessing Appearance and Mental Status
Procedure:
1. Explain to the client what you are going to
do, why is it necessary, and how he/she can
cooperate.
2. Wash hands and observe other appropriate
infection control procedures.
3. Provide for client privacy.
Assessment:
1. Observe body build, height, and weight in
relation to the client’s age, lifestyle, and
health.
2. Observe the client’s posture and gait,
standing, sitting, and walking.
3. Observe the client’s overall hygiene and
grooming. Relate these to the person’s
activities prior to the assessment.
4. Note body and breath odor in relation to
activity level.
5. Observe for signs of distress in posture or
facial expression.
6. Note obvious signs of health or illness.
7. Assess the client’s attitude.
8. Note the client’s affect/mood; assess the
appropriateness of the client’s responses.
9. Listen for quantity, quality, and organization
of speech.
10. Listen for relevance and organization of
thoughts.
11. Document findings in the client record.
Assessment (Integumentary System) Assessing (Head, Face, and Check)
Procedure: Procedure:

1. Assemble equipment and supplies. 1. Explain to the client what you are going to
2. Explain to the client what you are going to do, why is it necessary, and how he/she can
do, why is it necessary, and how he/she can cooperate.
cooperate. 2. Wash hands and observe other appropriate
3. Wash hands and observe other appropriate infection control.
infection control. 3. Provide for client’s privacy.
4. Provide for client’s privacy. 4. Determine client’s history.
5. Determine client’s history.
Assessing the head:
Assessing the skin:
1. Inspect the skull for size, shape, and
1. Inspect skin color. symmetry.
2. Inspect uniformity of skin color. 2. Palpate the skull for nodules or masses and
3. Assess edema, if present. depressions.
4. Observe for any lesions and palpate the skin 3. Inspect the facial features.
moisture. 4. Inspect the eyes for edema and hollowness.
5. Palpate skin temperature. Compare the two 5. Note symmetry of facial movements. Ask the
feet and the two hands, using the backs of client to elevate the eyebrows, frown, or
your fingers. lower the eyebrows, close the eyes tightly,
6. Note skin turgor. puff the cheeks, and smile and show the
teeth.
Assessing the hair:
Assessing the face: (Assessing the nose)
1. Inspect the evenness of the growth over the
scalp. 1. Inspect the external nose for any deviations
2. Inspect hair thickness or thinness. in shape, size, or color and flaring, or
3. Inspect and palpate hair texture and oiliness. discharge from the nares.
Note presence of infections or infestations by 2. Lightly palpate the external nose to
parting the hair in several areas and determine any areas of tenderness, masses,
checking behind the ears and along the and displacements of bone and cartilage.
hairline at the neck. 3. Determine patency of both nasal cavities.
4. Inspect amount of body hair. Ask the client to close the mouth, exert
pressure on one naris, and breathe through
Assessing the nails:
the opposite naris. Repeat the procedure to
1. Inspect fingernail plate shape to determine assess patency of the opposite naris.
its curvature and angle. 4. Inspect the nasal cavities using a flashlight
2. Inspect fingernail and toenail texture. or a nasal speculum.
3. Inspect fingernail and toenail bed color then 5. Observe for the presence of redness,
palpate the nail. swelling, growths, and discharge.
4. Inspect tissues surrounding nails. 6. Inspect the nasal septum between the nasal
5. Perform blanch test of capillary refill. chambers.
6. Document all pertinent findings in the client 7. Palpate the maxillary and frontal sinuses for
record noting especially negative findings. tenderness.
Assessing the Mouth and Oropharynx:
Procedure:
1. Inspect the outer lips for symmetry of
contour, color, and texture.
2. Inspect and palpate the inner lips and
buccal mucosa for color, moisture, texture,
and the presence of lesions.
3. Inspect the teeth and gums while examining
the inner lips and buccal mucosa.
4. Inspect the dentures.
5. Inspect the surface of the tongue for
position, color, and texture.
6. Inspect tongue movement.
7. Inspect the base of the tongue, the mouth
floor, and the frenulum.
8. Palpate the tongue and floor of the mouth
for any nodules, lumps, or excoriated areas.
9. Inspect salivary duct openings for any
swelling or redness.
10. Inspect the hard and soft plate for color,
shape, texture, and the presence of body
prominences.
11. Inspect the hard and soft palate for color,
shape, texture, and the presence of body
prominences.
12. Inspect the uvula for position and mobility
while examining the palates.
13. Inspect the oropharynx for color and
texture.
14. Inspect the tonsils for color, discharge, and
size.
Assessing the neck:
1. Inspect the neck muscles (sternocleidomastoid
and trapezius) for abnormal swellings or masses.
2. Palpate the entire neck for enlarged lymph nodes.
3. Palpate the trachea for lateral deviation.
4. Inspect the thyroid gland.
5. Palpate the thyroid gland for smoothness.
6. If enlargement of the gland is suspected:
Auscultate over the thyroid area.
7. Document findings in the client record.
Assessment (Eyes)
1. Inspect the eyebrows for hair distribution and
alignment and for skin quality and movement.
2. Inspect the eyelashes for evenness of distribution
and direction of curl.
3. Inspect the eyelids for surface characteristics,
position in relation to the cornea, ability to blink,
and frequency of blinking. Inspect the lower eyelids
while the client’s eyes are closed.
4. Inspect the palpebral conjunctiva by everting the
lids.
5. Evert the upper lids if a problem is suspected.
6. Inspect and palpate the lacrimal gland.
7. Inspect and palpate the lacrimal sac and
nasolacrimal duct.
8. Inspect the cornea for clarity and texture.
9. Perform the corneal sensitivity (reflex) test to
determine the function of the fifth (trigeminal)
cranial nerve.
10. Inspect the anterior chamber for transparency
and depth. Use the same oblique lighting used when
testing the cornea.
11. Inspect the pupils for color, shape, and symmetry
of size.
12. Assess each pupil’s direct and consensual
reaction to light.
13. Assess the peripheral visual fields.
14. Assess six ocular movements to determine eye
alignment and coordination.
15. Assess near vision and distance vision.
16. Perform functional vision tests if the client is
unable to see the top line (20/200) of Snellen’s
chart. Document all pertinent findings.
ASSESSMENT OF FEMALE GENITALIA
Assess for the:
• History of present health concern.(Menstrual cycle,
menopausal, vaginal discharge, pain, masses,
urination and sexual dysfunction)
• Past health history. (Gynecologic problems, Pelvic
exam, Treatment, STIs, and pregnancy)
• Family History. (Reproductive or genital cancer)
• Lifestyle and Health Practices. (Smoking, sexual
practices and partners, use of contraceptives,
hygiene.)
POSSIBLE NURSING DIAGNOSIS:
• Readiness for enhanced health management of the
genitalia.
• Risk of Ineffective Therapeutic Regimen
Management.
• Risk for Infection
• Risk for Disturbed Body Image
• Ineffective Sexuality Pattern • Acute Pain
• Anticipatory Grieving
• Ineffective Sexuality Pattern
PREPARATIONS
1. The client should be told ahead of time not to
douche for 48 hours before a gynecologic
examination.
2. Ask the client to urinate before the examination.
3. Ask the client to remove her underwear and to
put on a gown with opening in the back.
4. The nurse should leave the room while the patient
changes.
5. The nurse should help the patient in dorsal
lithotomy position.
6. Ask the client to relax her arms at her sides.
7. If possible, offer the client the mirror so she can
view the examination.
KEY POINTS:
1. Respect the client’s privacy
2. Wash hands, wear gloves, be sure equipment is
between room and body temperature.
3. Inspect and palpate female external and internal
structures correctly.
4. Use examination and laboratory equipment
properly.
5. Recognize the difference between common
variations and abnormal findings.
PROCEDURE:
External Genitalia:
1. Inspect the Mons Pubis.
a. Wash your hand and put on gloves. As you begin
the examination, note the distribution of pubic hair.
Also be alert for signs of infestation.
Normal Findings: Pubic hair is distributed in an
inverted triangular pattern and there are no signs of
infestation.
Abnormal Findings: Absence of pubic hair in adult
client. Lice or nits at the base of the pubic hairs
indicate infestation with pediculosis pubis. Referred
to as “crabs” is most often transmitted by sexual
contact.
2. Observe and palpate inguinal lymph nodes.
Normal: There should be no enlargement or swelling
of the lymph nodes. Abnormal: Enlarged inguinal
nodes may indicate a vaginal infection or may be the
result of irritation from shaving pubic hair.
2. Observe and palpate inguinal lymph nodes.
Normal: There should be no enlargement or swelling
of the lymph nodes. Abnormal: Enlarged inguinal
nodes may indicate a vaginal infection or may be the
result of irritation from shaving pubic hair.
3. Inspect the labia majora and perineum.
a. Observe the labia majora and perineum for
lesions, swelling, excoriation.
Normal: Equal in size and free of lesions, swelling
and excoriation. A healed tear or episiotomy scar
may be visible if the client has given birth. Perineum
should be smooth. Abnormal: Lesions may be from
an infectious disease such as herpes or syphilis.
4. Inspect the labia minora, clitoris, urethral meatus
and vaginal opening.
a. Use your gloved hand to separate the labia
majora and inspect for lesions, excoriation, swelling
and/or discharge.
Normal: The labia minora appear symmetric, dark
pink and moist. The clitoris is a small mound of
erectile tissue, sensitive to touch and the size varies.
The urethral meatus is small and slitlike. Abnormal:
Asymmetric labia may indicate abscess. Lesions,
swelling, bulging in the vaginal opening and
discharge are abnormal findings.
5. Palpate Bartholin’s glands.
a. Palpate Bartholin’s glands for swelling,
tenderness and discharge.
b. Place your index finger in the vaginal opening
and your thumb on the labia majora.
c. With a gentle pinching motion, palpate from the
inferior portion of the posterior labia majora to the
anterior portion.
d. Repeat on the opposite side.
6. Palpate the urethra. If the client reports urethral
symptoms or urethritis:
a. Insert your gloved index finger into the superior
portion of the vagina and milk the urethra from the
inside, pushing up and out.
Normal: No drainage should be noted from the
urethral meatus. The area is normally soft and
nontender. Abnormal: Drainage from the urethra
indicates possible urethritis. Any discharge should be
cultured.
Internal Genitalia:
1. Inspect the size of the vaginal opening and the
angle of the vagina.
a. Insert your gloved index finger into the vagina,
noting the size of the opening.
b. Then attempt to touch the cervix. This will help
you to establish the size of the speculum you need
to use for your examination and the angle to insert
it.
c. While maintaining tension, gently pull the labia
majora outward. Note: hymenal configuration and
transections.
Normal: Vaginal opening varies in size according to
clients age, sexual history or has given birth
vaginally. Can be tilted posteriorly at a 45-degree
angle.
Abnormal: Loss of hymenal tissue between the 3-o-
clock and 9-o-clock position indicates trauma in
children. This finding is not relevant in adult.
2. Inspect the vaginal musculature.
a. Keep your index finger inserted in the client’s
vaginal opening.
b. Ask the client to squeeze around your finger.
Normal: Client should be able to squeeze around the
examiner’s finger. Abnormal: Absent or decreased
ability to squeeze the examiner’s finger indicates
decreased muscle tone.
c. Use your middle and index fingers to separate
the labia minora. Ask the client to bear down.
Normal: No bulging and no urinary discharge.
Abnormal: Bulging of the anterior wall may indicate
a cystocele. Bulging of the posterior wall indicates a
rectocele. If cervix or uterus protrudes down, the
client may have uterine prolapse. If urine leaks out,
the client may have stress incontinence.
3. Inspect the cervix.
a. With the speculum inserted in position to
visualize the cervix, observe cervical color, size and
position. Look for discharge and lesions as well.
Normal: Cervical OS normally appears as a small,
round opening in the nulliparous women and
appears slit-like in parous women. Secretions are
clear or white and without unpleasant odor. In
pregnant, cervix appears blue.
Abnormal: Cervical enlargement or projection into
the vagina more than 3cm may be from prolapse or
tumor. Asymmetric, reddened areas, strawberry
spots and white patches, malodorous or irritating
discharge. Cervical lesions may result from polyps,
cancer or infection.
4. Inspect the vagina.
a. Unlock the speculum and slowly rotate and
remove it.
b. Inspect vagina as you remove it. Note for color,
surface, consistency and any discharge.
Normal: The vagina should appear pink, moist,
smooth and free of any colored, malodorous
discharge.
Abnormal: Reddened areas, lesions and colored,
malodorous discharge may indicate vaginal
infection.
Bimanual Examination
1. Palpate the vaginal wall.
a. Explain the procedure to the client.
b. Apply water-soluble lubricant to the gloved index
finger and middle fingers of your dominant hand.
c. Stand and approach the client at correct angle.
d. Place your non-dominant hand on the client’s
lower abdomen.
e. Insert your index and middle finger fingers into
the vaginal opening.
f. Apply pressure to the posterior wall and wait for
the vaginal opening to relax before palpating the
vaginal walls for texture and tenderness.
Normal: Vaginal wall should feel smooth, and the
client should not report any tenderness.
Abnormal: Tenderness and lesions may indicate
infection
2. Palpate the cervix.
a. Advance your fingers until they touch the cervix
and run fingers around the circumference.
b. Palpate for contour, consistency, mobility and
tenderness.
Normal: The cervix should feel firm and soft. It is
rounded and can be moved somewhat from side to
side without eliciting tenderness.
Abnormal: Hard, immobile cervix indicate cancer.
Pain with movement of the cervix indicate infection.
3. Palpate the uterus.
a. Move your fingers intravaginal into the opening
above the cervix and gently press the hand resting
on the abdomen downward, squeezing the uterus
between the two hands.
b. Note uterine size, position, shape and
consistency.
Normal: The fundus is normally round, firm and
smooth. In most women, it is at the level of the
pubis.
Abnormal: Enlarged uterus above the level of the
pubis. An irregular shape suggests abnormalities
such as myoma or endometriosis.
c. Attempt to bounce the uterus between your two
hands to assess mobility and tenderness.
Normal: Uterus moves freely and is not tender.
Abnormal: A fixed or tender uterus may indicate
fibroids, infection or masses.
4. Palpate the ovaries.
a. Slide your intravaginal fingers toward the left
ovary in the left lateral fornix and place your
abdominal hand on the left lower abdominal
quadrant.
b. Press your abdominal hand toward your
intravaginal fingers and attempt to palpate the
ovary.
Normal: Ovaries are approximately 3x2x1 cm or the
size of a walnut and almond shape.
Abnormal: Enlarged size, masses, immobility and
extreme tenderness are abnormal.
c. Slide your intravaginal fingers to the right lateral
fornix and attempt to palpate the right ovary.
d. Note size shape, consistency, mobility and
tenderness.
Normal: Ovaries are firm, smooth, mobile and
somewhat tender on palpation. A clear minimal
amount of drainage appearing on the glove from the
vagina is normal.
Abnormal: Large amount of colorful, frothy or
malodorous secretions are abnormal. Ovaries that
are palpable 3-5 years after menopause are also
abnormal.
e. Withdraw your intravaginal hand and inspect the
glove for secretions.
Rectovaginal Examination:
1. Explain the procedure to the client.
2. Forewarn the client that she may feel
uncomfortable as if she wants to move her bowels
but that she will not.
3. Encourage the patient to relax.
4. Change the glove on your dominant hand, if
necessary and lubricate your index and middle
fingers with water-soluble lubricant.
5. Ask the client to bear down.
6. Insert your index finger into the vaginal orifice and
your middle finger into the rectum.
7. While pushing down on the abdominal wall with
your other hand, palpate the internal reproductive
structures through the anterior rectal wall.
8. Pay particular attention to the area behind the
cervix and posterior uterine wall.
9. Withdraw your vaginal finger and continue with
the rectal examination.
Normal: The rectovaginal septum is normally
smooth, thin, movable and firm. The posterior
uterine wall is normally smooth, firm, round,
movable and nontender.
Abnormal: Masses, thickened structures, immobility
and tenderness are abnormal.
ASSESSMENT OF MALE GENITALIA15
PREPARATION:
1. Before the examination, instruct the client to
empty his bladder.
2. If a urine specimen is necessary, provide the client
with a container.
3. If the client is not wearing an examination gown
for total physical examination, provide a drape and
ask him to lower pants and underwear.
4. Explain to the client that he will be asked to stand
(if able) for most of the examination.
KEY POINTS:
1. Wear disposable gloves.
2. Provide client’s privacy.
3. Inspect and palpate penis, scrotum and inguinal
area for inflammation, infestations, rashes, lesions,
and lumps.
4. During the testicular examination, describe the
importance of testicular self-examination and
explain how to perform the examination as you are
performing it.
PROCEDURE (Penis)
1. Inspect the base of the penis and pubic hair. a.
Sit on the stool with the client facing you and
standing.
b. Ask the client to raise his gown or drape.
c. Note pubic hair growth pattern and any
excoriation, erythema, or infestation at the base of
the penis and within the pubic hair.
Normal Findings: Pubic hair is coarser than scalp
hair. The normal pubic hair pattern in adults is hair
covering the entire groin area, extending to the
medial thighs and up the abdomen towards the
umbilicus. No excoriation, erythema and infestation
noted.
Abnormal Findings: Absence and scarcity of pubic
hair. Lice or nit infestation at the base of the penis.
2. Inspect the skin of the shaft.
a. Observe for rashes, lesions or lumps.
Normal: The skin of the penis is wrinkled and hairless
and is free of rashes, lesions and lumps.
Abnormal: Rashes, lesions or lumps may indicate STD
or cancer.
3. Palpate the shaft.
a. Palpate any abnormalities noted during the
inspection. Also note any hardened or tender areas.
Normal: The penis in a nonerect state is usually soft,
flaccid and nontender.
Abnormal: Hardness along the ventral surface may
indicate cancer or a urethral stricture. Tenderness
may indicate inflammation or infection.
4. Palpate the foreskin.
a. Observe for color, location, and integrity of the
foreskin in uncircumcised men.
Normal: The foreskin, is intact and uniform in color
with the penis.
Abnormal: Discoloration of the foreskin may indicate
scarring and infection.
5. Inspect the glans.
a. Observe for size, shape, and lesions or redness.
Normal: The glans size and shape vary, appearing
rounded, broad or even pointed. The surface of the
glans is normally smooth, free of lesions and redness.
Abnormal: Chancres from syphilis, venereal warts
and pimple-like lesions from herpes are detected.
b. if the client is not circumcised, ask him to retract
his foreskin (if the client is unable to do so, the
nurse may retract it) to allow observation of the
glans. This may be painful.
Normal: The foreskin retracts easily. A small amount
of whitish material, called smegma, normally
accumulates under the foreskin. Abnormal: A tight
skin cannot be retracted is called phimosis. Chancres
from syphilis and venereal warts are detected.
c. Note the location of the urinary meatus on the
glans.
Normal: The urinary meatus is slit-like and normally
found in the center of the glans.
Abnormal: Displacement of the urinary meatus.
6. Palpate the urethral discharge.
a. Gently squeeze the glans between your index
finger and thumb.
Normal: The urinary meatus is normally free of
discharge.
Abnormal: A yellow discharge is usually associated
with gonorrhea. A clear or white discharge is usually
associated with urethritis.
Scrotum
1. Inspect the size, shape, and position.
a. Ask the client to hold his penis out of the way.
b. Observe for swelling, lumps or bulges.
Normal: The scrotum varies in size and shape. The
scrotal sac hangs below or at the level of the penis.
The left side of the scrotal sac usually hangs lower
than the right side.
Abnormal: An enlarge scrotal sac may result from
fluid (hydrocele), blood (hematocele), bowel (hernia)
or tumor (cancer).
2. Inspect the scrotal skin.
a. Observe color, integrity and lesions or rashes. b.
To perform an accurate inspection, you must
spread out the scrotal folds of skin.
c. Lift the scrotal sac to inspect the posterior skin.
Normal: Scrotal skin is thin and rugated with little
hair dispersion. Its color is slightly darker than that of
the penis. Lesions and rashes are not present.
However, sebaceous cyst is a normal finding.
Abnormal: Rashes, lesions and inflammations.
3. Palpate the scrotal contents.
a. Palpate each testes and epididymis between
your thumb and first two fingers.
b. Note size, shape, consistency, nodules and
tenderness.
Normal: Testes are ovoid, approximately 3.5-5 cm
long, 2.5 cm wide and 2.5 cm deep, and equal
bilaterally in size and shape. They are smooth, firm,
rubbery, mobile, free of nodules and rather tender to
pressure. The epididymis is nontender, smooth and
softer than the testes.
Abnormal: Absence of testis suggest cryptorchidism.
Painless nodule may indicate cancer. Tenderness and
swelling may indicate acute orchitis or hernia.
c. Palpate each spermatic cord and vas deferens
from the epididymis to the inguinal ring. The
spermatic cord will lie between your thumb and
finger.
d. Note any nodules, swelling or tenderness.
Normal: The spermatic cord and vas deferens should
feel uniform on both sides. The cord is smooth,
nontender and ropelike.
Abnormal: Palpable tortuous veins suggest
varicocele. A beaded or thickened cord indicates
infection or cysts. If you can get your fingers above
the mass, suspect hydrocele.
e. Continue the examination of a scrotal mass by
auscultating with a stethoscope.
4. Trans illuminate the scrotal contents.
a. If an abnormal mass or swelling was noted in the
scrotum, trans illumination should be performed. b.
Darken the room and shine a light from the back of
the scrotum through the mass. Look for a red glow.
Inguinal Area
1. Inspect for inguinal and femoral hernia.
a. Inspect the inguinal and femoral areas for bulges.
b. Ask the client to turn head and cough or to bear
down as if having a bowel movement, and continue
to inspect the areas.
2. Palpate for inguinal hernia and inguinal nodes.
a. Ask the client to shift his weight to the left for
palpation of the right inguinal canal and vice versa.
b. Place your right index finger into the client’s right
scrotum and press upward, invaginating the loose
folds of the skin.
c. Palpate up the spermatic cord until you reach the
triangular shaped, slit-like opening of the external
inguinal ring.
d. Try to push your finger through the opening and,
if possible, continue palpating up the inguinal canal.
e. When your finger is in the canal or at the external
ring, ask the client to bear down or cough. Feel for
any bulges against your finger.
f. Then, repeat the procedure on the opposite side.
3. Palpate inguinal lymph nodes.
a. If nodes are palpable, note size, consistency,
mobility or tenderness.
4. Palpate for femoral hernia.
a. Palpate on the front of the thigh in the femoral
canal area.
b. Ask the client to bear down or cough. Feel for
bulges.
c. Repeat on the opposite thigh.
5. Inspect and palpate for scrotal hernia.
a. If you discovered a mass during inspection and
palpation of the scrotum and you suspect it may be a
hernia, ask the client to lie down. Note whether the
bulge disappears.
b. If the bulge remains, auscultate it for bowel
sounds.
c. Finally, gently palpate the mass and try to push it
upward into the abdomen.
Normal: If the bulges disappear, no scrotal hernia is
present.
Abnormal: If the bulge disappears when the client
lies down, a scrotal hernia is present. Bowel sounds
auscultated over the mass indicate the presence of
bowel and thus a scrotal hernia.
ASSESSMENT OF NEUROLOGICAL SYSTEM17
The focus of the following assessment is integration
of the findings from the neurologic system. In
assessing the neurologic system, ask the patient to
respond to a series of questions that will enable you
to obtain data related to overall cognitive function.
In addition, evaluate sensation in different areas of
the body as well as selected cranial nerves and deep
tendon reflexes (DTR).
ASSESSMENT:
• History of numbness, tingling, or tremors
• History of seizures • History of headaches
• History of dizziness
• History of trauma to the head or spine
• History of infections of the brain
• History of stroke
• Changes in the ability to hear, see, taste, or smell
• Loss of ability to control bladder and bowel
• Family history of Alzheimer’s disease, epilepsy
• Exposure to environmental hazards (e.g., lead,
insecticides)
PROCEDURE
1. Perform hand hygiene and put on PPE, if
indicated. Rationale: Hand hygiene and PPE prevent
the spread of microorganisms. PPE is required based
on transmission precautions.
2. Identify the patient. Rationale: Identifying the
patient ensures the right patient receives the
intervention and helps prevent errors .
3. Close curtains around bed and close the door to
the room, if possible. Explain the purpose of the
neurologic examination and what you are going to
do. Answer any questions. Rationale: This ensures
the patient’s privacy. Explanation relieves anxiety
and facilitates cooperation.
4. Begin with a survey of the patient’s overall
hygiene and physical appearance. Rationale: This
provides initial impressions of the patient. Hygiene
and appearance can provide clues about the
patient’s mental state and comfort level.
5. Assess the patient’s mental status.
a. Evaluate the patient’s orientation to person,
place, and time. This helps identify the patient’s level
of awareness.
b. Evaluate level of consciousness. The patient should
be awake and alert. Patients with altered level of
consciousness may be lethargic, stuporous, or comatose.
c. Assess memory (immediate recall and past
memory).
d. Assess abstract reasoning by asking the patient
to explain a proverb, such as “The early bird
catches the worm.”
e. Evaluate the patient’s ability to understand
spoken and written word. Memory problems may
indicate neurologic impairment.
6. Test cranial nerve (CN) function.
a. Ask the patient to close the eyes, occlude one
nostril, and then identify the smell of different
substances, such as coffee, chocolate, or alcohol.
Repeat with other nostril.
b. Test visual acuity and pupillary constriction
c. Move the patient’s eyes through the six cardinal
positions of gaze.
d. Ask the patient to smile, frown, wrinkle
forehead, and puff out cheeks.
e. Test hearing
f. Test the gag reflex by touching the posterior
pharynx with the tongue depressor. Explain to
patient that this may be uncomfortable.
g. Place your hands on the patient’s shoulders
while he or she shrugs against resistance. Then
place your hand on the patient’s left cheek, then
the right cheek, and have the patient push against
it.
7. Ask patient to extend arms forward and then
rapidly turn palms up and down.
8. Ask the patient to close his or her eyes. Using
your finger or applicator, trace a one-digit number
on the patient’s palm and ask him or her to identify
the number. Repeat on the other hand with a
different number.
9. Ask the patient to close his or her eyes. Place a
familiar object, such as a key, in the patient’s hand
and ask him or her to identify the object. Repeat
using another object for the other hand.
10. As needed, assist the patient to a standing
position. Observe the patient as he or she walks
with a regular gait, on the toes, on the heels, and
then heel to toe.
11. Perform the Romberg’s test; ask the patient to
stand straight with feet together, both eyes closed
with arms at side. Wait 20 seconds and observe for
patient swaying and ability to maintain balance. Be
alert to prevent patient fall or injury related to losing
balance during this assessment. This test checks
cerebellar functioning and evaluates balance,
equilibrium, and coordination. Slight swaying is
normal, but patient should be able to maintain
balance.
12. Assist the patient to a comfortable position.
13. Remove PPE, if used. Perform hand hygiene.
Continue with assessments of specific body
systems, as appropriate, or indicated. Initiate
appropriate referral to other healthcare
practitioners for further evaluation, as indicated.
ASSESSMENT OF ANUS AND RECTUM18
PREPARATION: Client positioning is important for
this examination and several different positions can
be assumed.
1. Female- Lithotomy is most logical.
2. Male- Standing and bends over the examining
table with hips flexed is the easiest.
3. Other positions:
Left Lateral- most frequently used, more
comfortable
Knee-Chest Squatting
4. Determine if the client is as comfortable as
possible in that position.
5. Drape the client’s torso and legs can be draped
during the examination.
6. For left lateral position, ask the patient to lie on
the left side, with the buttocks as close to the edge
of the examining table as possible, and to bend the
right knee.
KEY POINTS:
1. Understand the structures and functions of the
anorectal region.
2. Prepare the client thoroughly for the physical
examination to put the client at the greatest ease.
3. Perform the examination professionally and
preserve the client’s modesty.
4. Remember to wear gloves.
PROCEDURE Anus and Rectum
1. Inspect the perianal area.
a. Spread the client’s buttocks and inspect the anal
opening and surrounding area for the following:
Lumps, Ulcers, Lesions, Rashes, Redness, Fissures
and thickening of the epithelium. Normal Findings:
The anal opening should appear hairless, moist and
tightly closed. The skin around the anal opening is
coarser and more darkly pigmented. Free of redness,
lumps, ulcers, lesions and rashes. Abnormal Findings:
Lesions may indicate STD, cancer or hemorrhoids. A
painful mass that is hardened and reddened suggests
a perianal abscess.
2. Inspect the skin of the shaft.
a. Observe for rashes, lesions or lumps.
3. Palpate the shaft.
a. Palpate any abnormalities noted during the
inspection. Also note any hardened or tender areas.
b. Ask the client to perform Valsalva’s maneuver by
straining or bearing down. Inspect the anal opening
for any bulges or lesions.
2. Inspect the sacrococcygeal area.
a. Inspect this area for any signs of swelling,
redness, dimpling or hair.
3. Palpate the anus.
a. Inform the client that you are going to perform
the internal examination at this point. Explain that
it may feel like his bowels are going to explode but
will not.
b. Lubricate your gloved index finger; ask client to
bear down.
c. As the client bears down, place the pad of your
index finger on the anal opening.
d. When you feel the sphincter relax, insert your
finger gently with the pad facing down.
e. Ask the client to tighten the external sphincter;
note the tone.
Normal: The client can normally close the sphincter
around the gloved finger.
Abnormal: Poor sphincter tone may be the result of a
spinal cord injury, previous surgery, trauma, or a
prolapsed rectum. Tightened sphincter tone may
indicate anxiety, scarring or inflammation.
f. Rotate finger to examine the muscular anal ring.
Palpate for tenderness, nodules and hardness.
Normal: The anus is normally smooth, nontender and
free of nodules and hardness.
Abnormal: Tenderness may indicate hemorrhoids,
fistula or fissure. Nodules may indicate polyps or
cancer. Hardness may indicate scarring or cancer.
4. Palpate the rectum.
a. Insert your finger further into the rectum as far
as possible.
b. Turn your hand clockwise then counterclockwise.
c. Note tenderness, irregularities, nodules and
hardness.
5. Palpate the peritoneal cavity.
a. In men, palpate above the prostate gland in the
area of the seminal vesicles on the anterior surface
of the rectum.
b. In women, palpate on the anterior rectal surface
in the area of the rectouterine pouch.
c. Note tenderness or nodules.
Normal: This area is normally smooth and
nontender.
Abnormal: A peritoneal protrusion into the rectum,
called a rectal shelf may indicate a cancerous lesion
or peritoneal metastasis. Tenderness may indicate
peritoneal inflammation.
Prostate Glands
1. In male clients, palpate the prostate.
a. Palpate on the anterior surface of the rectum by
turning the handfully counterclockwise so the pad
of your index finger faces toward the client’s
umbilicus. b. Move the pad of your index finger
over the prostate gland, trying to feel the sulcus
between the lateral lobes.
c. Note the size, shape and consistency of the
prostate and identify any nodules or tenderness.
Normal: The prostate is normally nontender and
rubbery. It has two lobes.
Abnormal: A swollen, tender prostate may indicate
acute prostatitis. An enlarged smooth, firm, slightly
elastic prostate that may not have a median sulcus
suggest BPH. A hard area on the prostate or hard, fixed,
irregular nodules on the prostate suggest cancer.
2. Inspect the stool.
a. Withdraw your gloved finger.
b. Inspect any fecal matter on your glove.
c. Assess the color, and test the feces for occult
blood.
d. Provide the client with a towel to wipe the
anorectal area. Normal: Stool is normally semi-solid,
brown, and free of blood. Abnormal: Black stool may
indicate upper gastrointestinal bleeding, gray or tan
stool results from the lack of bile pigment, and
yellow stool suggests steatorrhea. Blood detected in
the stool may indicate cancer of the rectum or colon.
Assessing Peripheral Vascular System
(Peripheral Pulses)
•Palpate the peripheral pulses (except the carotid
pulse) on both sides of the client’s body individually ,
simultaneously, and systematically to determine the
symmetry of pulse volume.
Rationale: Weak and narrow pulses is a cause of
Heart failure.
 a. Edge of the pectoral muscle along the
anterior axillary line.
b. Thoracic wall in the in the mid axillary line
c. Upper part of the humerus
d. Anterior edge of the latissimus dorsi muscle
along the posterior axillary line.

7. Palpate the breast for tenderness and any

(Peripheral Veins)
•Inspect the peripheral veins in the arms and legs for
the presence/ or appearance of superficial veins
when limbs are dependent and when limbs are
elevated.
Rationale:
• Presence of superficial veins are indicative of poor
venous return/ venous insufficiency.
•Assess the peripheral leg veins for signs of phlebitis.
discharge from the nipples.
8. Palpate the areola and nipples for masses.
Compress the nipples to determine for any signs of
discharges.
9. If discharge is present, milk the breast along its
radius to identify the discharge producing lobe.
10. Assess any discharge for color, amount,
consistency and odor.
11. Note any tenderness during palpation.
12. Document findings in the client’s record.

(Peripheral Perfusion)
•Inspect the skin of the hands and feet for color,
temperature , edema and skin changes .
•Perform capillary refill test to determine perfusion
by blanching or pressing the end of a finger or nail.
(normal is 2 seconds or less)
•Document findings in the client’s record.

Assessment of Breast and Axilla

1. Inspect for size, color and symmetry,
Breast abnormalities:
contour or shape while the client is in
sitting position. 1. Inverted nipple
2. Inspect the skin of the breast for localized 2. Breast mass
discoloration, hyperpigmentation, 3. Lesions
retraction or dimpling, swelling or edema. 4. Breast Abscess
3. Inspect the areola size, symmetry, color
surface characteristics or any masses or Assessment of the Abdomen
lesion.
Techniques of Physical Assessment:
4. Inspect the nipple size, symmetry, color
(Sequence for Abdominal Exam)
surface characteristics or any masses or
lesion. ▪ Inspection
5. Palpate the axillary sub clavicular and ▪ Auscultation
supraclavicular lymph nodes ▪ Percussion
6. Use the flat surfaces of fingertips to palpate ▪ Light Palpation
the four areas of the axilla: ▪ Deep Palpation
Inspection - be sure patient has an empty bladder, abnormal aorta
lying comfortably and abdomen fully exposed. - Lymph nodes – inguinal and femoral areas
1. Observe the general contour of the abdomen –
Note: Palpation is not done in the abdomen if
flat, protuberant, scaphoid, concave, local budges,
contraindicated (e.g. aortic aneurysm)
symmetry, visible peristalsis aortic pulsations.
2. Umbilicus – contour, hernia Four Quadrants of Abdomen:
3. Skin – scars, rashes, lesions, pigmentation, etc.

A. Auscultation – abdomen have the familiar

“growing” sound. It has 5 -35 bowel per
minute. There should be no rubs or bruits.
1. Bowel sound – pitch, duration,
absence, increase, gurgling
2. Bruit – aorta and renal arteries-
abnormal blood flow

Regions of the Abdomen:

B. Percussion - Note tympani and dullness

(tympani normally predominate) - Masses;
fluids level.
▪ Dull sounds- solid or fluid-filled
structures
▪ Resonant sounds- structures
containing air or gas.
C. Palpation (light) - Determine muscle tension
and resistance, tenderness and superficial
masses or organ enlargement
- Skin fold test for dehydration (skin turgor)
D. Palpation (deep)
- Masses – size, shape, consistency,
mobility, location
- Abnormal distension – 6fs – fluids, fat,
flatus, fetus, feces, fetal growths
- Area of tenderness, deep and rebound
tenderness
- Palpable organs: liver, kidney, cecum and
Assessment procedure:
1. Assemble all the equipment and supplies needed.
2. Ask the patient’s name
3. Explain the procedure to the patient.
4. Ask the client to urinate.
5. Assist the client to a supine position with arms
placed comfortably at sides.
6. Place pillows beneath the knees and head.
7. Expose only the client’s abdomen from chest line
to the pubic area.
8. Inspect the abdomen for skin integrity.
9. Inspect the abdomen for contour and symmetry
10. Observe the abdominal contour while standing
at the client’s side when the client is in supine
position. To note the abnormality in shape.
11. Ask the client to take a deep breath and hold it.
12. Assess the symmetry and contour while standing
at the foot of the bed.
13. If distention is present, measure the abdominal
girth by placing a tape measure around the
abdomen at the level of the umbilicus.
14. Observe abdominal movements associated with
respirations, peristalsis or aortic pulsation.
15. Observe the vascular pattern.
AUSCULTATION OF THE ABDOMEN
1. Auscultate the abdomen for bowel sounds,
vascular sounds and peritoneal friction rubs.
2. Perform light palpation to deter areas of
tenderness and or muscle guarding.
3. Systematically explore all four quadrants.
4. Perform deep palpation over all quadrants.
PERCUSSION OF THE LIVER
1. Percuss the liver to determine its size.
2. Palpate the liver to detect enlargement and
tenderness.
PALPATION OF THE BLADDER
1. Palpate the area above the pubic
symphysis if the client’s history
indicates possible urinary retention.
2. Document pertinent findings in the
client’s record.
ASSESSING THE THORAX AND LUNGS
A. Assessment
1. Inspect the shape and symmetry of the
thorax from the posterior and lateral views.
2. Inspect spinal alignment from deformities.
Make the client stand from a lateral
position. Observe the standing client from
the rear. Have the client bend forward at
the waist and observe from behind.
3. Palpate the posterior thorax. For clients
who have no respiratory complaints, rapidly
assess the temperature and integrity of all
chest skin.
For clients who do have respiratory complaints,
palpate all chest areas for bulges, tenderness or
abnormal movements. Avoid deep palpation for
painful areas especially if fractured rib is
suspected.
4. Palpate the posterior chest for respiratory
excursion.
▪ Place the palms of both hands over
the lower thorax, with your
thumbs adjacent to the spine and
your fingers stretched laterally. Ask
the client to take deep breath
while you observe the movement
of your hands and any lag in
movement.
5. Palpate the chest for vocal (tactile)
fremitus, instruct to say 1,2,3. Place the
palmar surfaces of your fingertips or the
ulnar aspect of your hand or closed fist on
the posterior chest starting near the apex of
the lungs.
6. Ask the client to repeat such words as “blue
moon” or “one, two, three”
7. Repeat the two steps moving your hand
sequentially to the base of the lungs.
8. Compare the fremitus on both lungs and
between the apex and the base of each lung
either: 1.) using one hand and moving it
from one side of the client to the
corresponding area on the other side 2.)
using two hands that are placed
simultaneously on the corresponding areas
of each side of the chest.
9. Percuss the thorax.
10. Percuss for diaphragmatic excursion.
11. Auscultate the chest using the flat disc
diaphragm of the stethoscope. Warm the
diaphragm and instruct the client to take
slow deep breaths.
12. Use the systematic zigzag procedure used in
percussion.
13. Ask the client to take slow, deep breaths
through the mouth. Listen at each point to
the breath sounds during a complete
inspiration and expiration.
14. Compare findings at each point with the
corresponding point at the opposite side of
the chest.
Anterior Thorax
15. Inspect breathing patterns
16. Inspect the costal angle and the angle at
which ribs enter the spine.
17. Palpate the anterior chest.
18. Palpate the anterior chest for respiratory
excursion.
▪ Place the palm of both hands of
your hand on the lower thorax
with your fingers laterally along
the lower rib cage and your
thumbs along the costal margins.
Ask the client to take a deep
breath while you observe the
movement of your hands.
19. Palpate tactile fremitus in the same manner
as for the posterior chest. Is the breasts
being large and cannot be retracted
adequately for palpation, this part is usually
omitted.
20. Percuss the anterior chest systematically.
▪ Begin above the clavicles in the
supraclavicular space and proceed
downward to the diaphragm.
21. Compare one side of the lung to the other.
22. Displace female breasts for proper
examination.
23. Auscultate the trachea.
24. Auscultate the anterior chest.
▪ Use the sequence used in
percussion beginning over the
bronchi between the sternum and
the clavicles.
25. Document the findings in the client’s
record.
ASSESSING THE HEART AND THE CENTRAL
VESSELS
Posterior Thorax
1. Simultaneously inspect and palpate the
pericardium for the presence of abnormal
pulsations, lifts or heaves.
▪ Inspect and palpate the aortic and
pulmonic areas, observing them at
an angle and to the side to note for
the presence or absence of
pulsations.
▪ Inspect and palpate the tricuspid
area for pulsations and heaves or
lifts.
▪ Inspect and palpate the apical
area for pulsation. Noting its
specified location and diameter. If
displaced laterally, record the
distance between the apex and the
MCL in centimeters.
▪ Inspect and palpate the epigastric
area at the base of the sternum for
abdominal aortic pulsations.
2. Auscultate the heart in all four anatomical sites:
Aortic, pulmonic, tricuspid and apical (mitral).
Carotid Arteries
3. Palpate the carotid artery. Use extreme caution.
4. Auscultate the carotid artery.
Jugular Veins
5. Inspect for jugular vein distention. Place the client
in a semi-fowler’s position, with the head supported
on a small pillow.
6. If jugular vein distention is present, assess the
Jugular venous pressure (JVP).
▪ Assemble equipment and supplies:
Millimeter ruler, examination gloves and
magnifying glass.
7. Locate the highest visible point of distention of
the internal jugular vein.
8. Document pertinent findings in the patient’s
chart.
ASSESSMENT OF MUSCULOSKELETAL SYSTEM
Structures:
▪ Bones
▪ Joints
▪ Ligaments
▪ Bursae
▪ Muscles
▪ Tendons
▪ Cartilage
Functions:
▪Cartilage: supports and shapes; acts as a shock
absorber.
▪Bursae: sacs filled with synovial fluid; cushion and
reduce friction between joints.

Types of Joints:
▪Pivot ▪Condyloid ▪Ball and socket ▪Hinge
▪Plane/gliding ▪Saddle

Movements:
▪Extension ▪Flexion ▪Hyperextension ▪Abduction
▪Adduction ▪Circumduction ▪Internal rotation
▪External rotation ▪Pronation ▪Supination
▪Protraction ▪Retraction ▪Depression ▪Elevation
▪Opposition ▪Reposition ▪Inversion ▪Eversion ▪Ulnar
deviation ▪Radial deviation

What developmental variations of the

musculoskeletal system might be seen with:
▪ Children ▪ Pregnant patients ▪ Older adults

What cultural variations of the musculoskeletal

system might be seen with:
▪African Americans ▪Asians ▪Native Americans
▪Whites

What can the history tell you about the

musculoskeletal system?
▪ Biographical data ▪ Current health status
▪ Past health history ▪ Family history
▪ Review of systems ▪ Psychosocial history

What symptoms would signal a problem with the

musculoskeletal system?
▪Pain ▪Weakness ▪Stiffness ▪Balance and
coordination problems ▪Other related symptoms
Physical Assessment 7. Inspect the muscles and tendons for contractures.
▪Approach: inspection, palpation, percussion 8. Inspect the muscles for fasciculation and tremors.
▪Position: standing, sitting, supine Inspect any tremors of the hands and arms by having
▪Tools: tape measure, goniometer the client hold the arms out in front of the body.
▪General survey and head-to-toe scan 9. Palpate muscles at rest.
10. Palpate muscles while the client is active and
Inspection
passive. Rationale: To check for flaccidity, spasticity
▪Posture: head position, alignment
and smoothness of the movement.
▪Normal spinal curves: cervical, thoracic, lumbar,
11. Test muscle strength. Compare the right side
sacral,
with left side.
▪Spinal deformities: kyphosis, scoliosis, lordosis
▪Gait: phase, cadence, arm swing, toeing, base of Bones:
support, stride length. 12. Inspect the skeleton for normal structure and
deformities. Rationale: Inspection provides
Cerebellar Function
information about abnormalities, tenderness, and
Coordination:
range of motion.
▪ Rapid alternating movements
13. Palpate the bones to locate any areas of edema
▪ Finger thumb opposition
or tenderness. Rationale: Palpation provides
▪ Toe tapping
information about abnormalities, tenderness and
▪ Heel down shin
range of motion of the musculoskeletal systems.
Accuracy of movements:
▪ Finger to nose ▪ Point to point localization Joints:
13. Inspect the joint for swelling. Palpate each joint
Inspection
for tenderness, smoothness of movement, swelling
Measurements:
crepitation and presence of nodules. Rationale: Joint
▪ Arm lengths ▪ Leg lengths
swelling limits the range of motion of the client.
▪ Arm circumferences ▪ Leg circumference
14. Assess joint range of motion. Ask the client to
PROCEDURE: move selected body parts. If available, use a
goniometer to measure the angle of the joint in
1. Assemble equipment and supplies. degrees. Rationale: This maneuver assesses ROM
2. Explain to the client what you are going to do, why and provides information about joint problems.
is it necessary, and how can she cooperate.
15. Document findings in the client record.
3. Wash hands and observe other appropriate
Rationale: Written information is a permanent
infection control procedures. record of the care provided for the client and serves
4. Provide for clients privacy. as record necessary to perform appropriate referral
5. Determine client’s history of the following:
to other members of the health care team, as
▪ History or presence of muscle pain: onset, needed, for further evaluation.
location, character, associated phenomena
and aggravating and alleviating factors.
▪ Any limitations to move or inability to
perform activities of daily living.
▪ Previous sports injuries.
▪ Any loss of function without pain.

MUSCLES:

6. Inspect the muscles for size. Compare each muscle

on one side of the body to the same muscle on the
other side. For any apparent discrepancies, measure
the muscle with a tape.