Physical Assessment (Part 1)
both one’s self and one’s surroundings
Procedure:
1. Observe Standard Protocol
- Verify doctor’s orders regarding
restrictions and/or limitations.
- Perform hand washing and observe other
appropriate infection control procedure
(PPE)
- Apply Principles of Body Mechanics
2. Prepare the Patient
- Introduce self and verify client’s identity
- Explain the procedure to the patient
- Maintain comfort and safety of the patient
- Always keep the privacy of the patient
throughout the procedure
3. Prepare the Materials Needed
- Facemask
- Stethoscope
- Tongue Depressor
- Gloves, gown and Goggles or face shield, if
appropriate
- Penlight
- Otoscope
General Appearance
4. have the patient seated comfortably
5. observe and describe the general
appearance of the patient.
6. note the patient's sex, race, body build
and any obvious deformities or
distinguishing characteristics.
Example: “the client is a 33 year-old Caucasian
with a full head of black hair, wearing hospital
gown, average height and weight, no
deformities, wearing eye glasses, with
intravenous infusion at left hand”
9. Assess Level of Consciousness, posture
and body movements, speech, facial
expressions, moods feelings and
expressions.
10. Check client’s Orientation to time,
place, and person.
Sternum rub – application of painful stimulus
with the knuckles of closed fist to the center
chest of a patient who is not alert and does not
respond to verbal stimuli.
CONSCIOUSNESS: being awake and aware of
LEVEL OF CONSCIOUSNESS: is a measurement
of a person’s arousability and responsiveness to
stimuli from the environment
 When you’re documenting your
findings, be specific and objective
ALERTNESS: Is the patient fully aroused and
aware of the environment and herself? Look at
her response to her environment and document
the normal or abnormal data as you see it:
- Pt. awake, alert, and oriented to time,
place, and person; well groomed; makes
eye contact; speech clear and appropriate;
feeding self without difficulty
CONFUSION: Note if her actions or speech are
appropriate:
- Pt. stated correct name, but disoriented to
time and place; attempting to get out of
bed and stated, “I'm at the supermarket. I
need to catch the bus because I'm going to
the movies.”
LETHARGY: Note slowed or sluggish speech,
mental processes, or motor activities:
- Pt. awakens to her name; oriented to time,
place, and person; will not initiate a
conversation; answers questions slowly
and then falls asleep
OBTUNDATION: Document any decrease in the
patient's awareness and her response to her
environment:
 - Pt. aroused by gently shaking her arm and
repeatedly calling her name; responds with
one-word answers; follows simple
commands; disoriented to time and place.
STUPOR: Note if she's aroused by vigorous
stimulation and seems confused during periods
of arousal:
- Unable to arouse pt. via verbal stimulation;
required stimulation (nail bed pressure).
Confusion noted when aroused;
incomprehensible sounds; purposeful
response to painful stimuli.
COMA: Note no spontaneous movement, any
non - purposeful movement with stimulation
only, and no verbalization:
- Unable to arouse pt.; no response to
verbal stimulation; no response to
stimulation; no spontaneous movements
noted.
11. Throughout the examination, assess the
skin for color, variations, texture,
temperature, turgor, edema, lesions.
12. Inspect and palpate head: Note hair for
texture, brittleness and moisture, color,
consistency and distribution.
13. Observe face for symmetry. features,
expressions, condition of skin.
 “masklike” face marks Parkinson’s disease
 “sunken” face with depressed eyes and
hollow cheeks is typical of cachexia
(emaciation or wasting)
 pale, swollen face may result from
nephrotic syndrome.
14. Have the client smile, frown, show
teeth, blow out cheeks, raise eyebrows,
and tightly close eyes. (CN VIII-facial)
15. Test sensation of forehead, cheeks and
chin (CN V - Trigeminal)
MOTOR FUNCTION:
- Palpate temporal & masseter muscle as
patient clenches teeth.
- Try to separate jaw by pushing down on
chin
SENSORY FUNCTION:
- Test light sensation with cotton ball over
- Forehead; Cheeks; Chin Sensation intact
and equal bilaterally.
16. Palpate temporal arteries or elasticity
and tenderness.
- strength of the pulsation of the temporal
artery may be decreased in the older
client.
- temporal artery is elastic and not tender.
17. Palpate temporomandibular joint,
Palpate groove in front of ears
Check ROM:
 Open and close
 Protrusion and retraction
 Lateral side to side motion
- TMJ with full ROM. No popping, clicking or
tenderness note
18. Assess visual function: Inspect external
eye
19. Inspect for Bilateral symmetry, shape,
and placement of eye in relation to the
ears.
20. Inspect the Conjunctiva, and eyelids for
inflammation, color and discharge
21. Test pupillary reaction to light and
accommodation
- Accommodation occurs when the client
moves his focus of vision from a distant
point to a near object, causing the pupils
to constrict.
- Accommodation occurs when the client
moves his focus of vision from a distant
point to a near object, causing the pupils
to constrict.
o Hold your finger or a pencil about 12 to
15 inches from the client. Ask the client
to focus on your finger or pencil and to
remain focused on it as you move it
closer in toward the eyes
Normal Pupil Reaction
P – pupils
E – equal
R – round
R – responsive to
L – light and
A – accommodation
Isocoric pupil – pupils are the same size,
technically 1mm in diameter.  - Palpate the maxillary sinuses, gently press
Anisocoria – difference of 0.4 mm or
more between the sizes of the pupils of the
eyes
Swinging light test:
22. Assess corneal reflex (CN VII)
- Only perform if patient with abnormal
facial sensation or movement
- Remove contact lenses
- Lightly touch cornea with wisp of cotton
from side
23. Assess Hearing function: Inspect
auricle, tragus and lobule
24. Inspect ears for symmetry, shape and
position (dysmorphic or malposition
ears)
25. Observe for any external trauma,
obvious cerumen, inflammation,
redness or exudate, any obvious
discharge
26. Palpate auricle and mastoid process
27. Use otoscope or pen light to inspect
auditory canal and tympanic membrane
Auditory canal – pababa (bata)
- Pataas (matanda)
28. Assess sense of smell: Inspect external
nose
29. Inspect nose for symmetry, septal
deviation, masses or foreign bodies,
note the color of the mucosal lining, any
swelling, discharge, dryness or bleeding.
30. Palpate external nose for tenderness
- Press along the bridge of the nose feeling
body skeleton and skin thickness
- Press on the tip of the nose to elicit
tenderness
Palpating the maxillary sinuses
your thumbs on each side of the nose
below the cheekbone
31. Occlude each nostril and ask client to
smell for soap, coffee or vanilla (CNI-
olfactory)
- With pt. eyes closed
- Ask patient to smells, if so identify it
- Compare both sides (abnormal side
should be examine first)
- Substances: cloves, coffee, cinnamon
32. Use penlight/otoscope to inspect
internal nose
- Look for masses or foreign bodies, note
the color of the mucosal lining, any
swelling, discharge, dryness or bleeding.
33. Assess the mouth: Put on gloves
34. Inspect lips for shape, symmetry, color,
dryness, and fissures at the corners of
the mouth
Note any: Fissures; cracking; ulceration; any
mass
35. Inspect teeth for number present,
condition, color, alignment, and caries.
36. Insert Tongue depressor and check
gums and buccal mucosa
37. Inspect hard and soft palates. Inspect
gingival tissue noting color and
condition.
38. Observe uvula and tonsils
In a client who has both tonsils and a sore
throat, tonsillitis can be identified and ranked
with a grading scale from 1 to 4 as follows:
 1+ Tonsils are visible.
 2+ Tonsils are midway between tonsillar
pillars and uvula.
 3+ Tonsils touch the uvula.
 4+ Tonsils touch each other
39. Assess for gag reflex (CN X)
GAG REFLEX: involuntary contraction of muscle
of the soft palate or pharynx that results in
retching
40. Inspect and palpate tongue
- Examine the ventral surface of tongue
 - Ask patient to place the tip of the tongue 48. Auscultate and palpate carotid
on the palate arteries/pulse
- Palpate the tongue to feel for any
growths AUSCULTATION
 Listen for presence of bruit (blowing or
41. Assess tongue strength (CNIX and X) swishing sound)
- asks the client to push the tongue against  Apply bell or diaphragm of the
a tongue depressor held vertically a few stethoscope (at the angle of jaw,
centimeters in front of the client's lips. midcervical area and base of the neck
42. Check taste sensation (CN VII and IX)  Person take a breath, exhale, and hold
- Instruct the patient to identify familiar while you listen
liquids (i.e., sugar water, salt water,
lemon juice) placed on tongue with a PALPATION
sterile cotton swab or sterile medicine  Carotid artery is palpated in the neck by
dropper. gentle compression with one or two
- Test the anterior 2/3's of the tongue (CN fingers
VII) by alternately placing two to three  Quality of pulse is assessed and
familiar liquids on each side of the compared with the opposite side
anterior 2/3's of the tongue  Never palpated together
- Also, test the posterior 1/3 of the tongue
(CN IX) in a similar manner. 49. Document all the results
Special Instructions or Considerations
 Use stimulus tastes in very small
quantities
 Use a separate swab or dropper for
each stimulus taste
 Avoid stimulus materials that are
contraindicated secondary to food
allergies or medical conditions
43. Assess Neck: Inspect appearance of
neck
- Neck is symmetric with head centered
and without bulging masses.
44. Test range of motion (ROM) of neck
45. Palpate preauricular, post auricular,
occipital, tonsillar, submandibular and
submental nodes
46. Inspect/ Palpate trachea
Inspection: should be midline
Palpate: place finger in sternal notch and slip
each side
- Trachea is in the midline
47. Palpate thyroid gland
- Auscultate the thyroid only if you find an
enlarged thyroid gland during inspection
or palpation.
- Place the bell of the stethoscope over the
lateral lobes of the thyroid gland