HA LEC - Module 5

Module 5: Physical Assessment and General Survey of an Adult Client | HALEC2022 | AUF_CON
Physical Assessment and General Survey of an Adult Client's General Well-Being, Skin, Hair,
Nails, Head Eyes, Ears, Nose, Mouth and Neck
Sources: Module & Lecture (February 21 & 23, 2022)
Angeles University Foundation | 2nd Sem | 1st Cycle | Health Assessment (Lecture)
MODULE 5 OVERVIEW
• This self-instructional module is designed to aid students in understanding the principles of physical assessment
which is an indispensable aspect of health assessment is.
• Particularly, it focuses on the assessment of the skin, hair, nails, and head including the eyes, ears, mouth, and neck.
• Physical assessment of the skin, hair, and nails provides data that may reveal local or systemic problems or
alterations in a client’s self-care activities.
• Local irritation, trauma, or disease can alter the condition of the skin, hair, or nails.
• Systemic problems related to impaired circulation, endocrine imbalances, allergic reactions, or respiratory disorders
may also be revealed with alterations in the skin, hair, or nails.
• The appearance of the skin, hair, and nails also provides the nurse with data related to health maintenance and self-
care activities such as hygiene, exercise, and nutrition.
• Being able to perform an accurate and thorough physical examination is a key skill that is required of a nurse to have
to enable her/him to have a detailed assessment, which is part of the nursing process, of a client before plans and
interventions are made.
GENERAL SURVEY
• It begins with the opening moments of the encounter with the client.
• It is the first step in a head-to-toe assessment.
• The information gathered during the general survey provides clues about the overall health of the client.
COMPONENTS OF GENERAL SURVEY

• The general survey is the general impression of the client, especially of the obvious characteristics.
• Upon meeting the client, he should be observed from head to toe to note for any gross abnormality in appearance
and behavior.
• Vital signs taking (which is discussed in another module) is performed to obtain baseline data and determine deviation
from normal.
• Lastly, height and weight are also obtained to detect general growth and nutritional status.
o Includes BMI to check nutritional status.
o Abdominal circumference, arm, hips, and waist ratio (depends on the physician’s orders for pregnant clients
to check for abdominal girth or patients with fluid stasis).
GENERAL SURVEY
GENERAL APPEARANCE – The overall impression towards the client / Relates with criteria for judging.
NORMAL FINDINGS POSSIBLE ABNORMAL FINDINGS
• Sexual development is • Appears older/ younger for actual age.
appropriate for gender and • Sexual development is inappropriate for gender, age.
age. • Contraptions may be contraindicated in other
• There are clients who look 35 assessments such as vital signs.
PHYSICAL years old but their age is 19 • Presence of contraptions:
APPEARANCE years old o Intravenous lines
• Gender resectioning and o Catheters (venous, urinary, etc)
transitioning is very common. o Arterio-venous fistula
• Ask for verification for gender o Tubes (gastric, respiratory)
(male or female).
BUENAFLOR (BSN 1-A) | MAGCALAS (BSN 1-A) | DIZON (BSN 1-B) | VIRAY (BSN 1-B) | MANDAP (BSN 1-D) | 1
• Clean/ well-groomed • Dirty, unkempt with body odor

• Presence of jewelry, piercing • Dresses inappropriately
• Body Odor and breath • Bizarrely Halitosis, Acetone, Ammonia breath
• Dresses appropriately.
• Do not judge a client based on
what they wear. Ex: A client who
came from their home went to
the E.R to seek help.
• Clothing may depend on the
sociocultural demographic of
the client.
GROOMING,
• Clothing may be influenced by
HYGIENE
culture. Ex: Badjao and Muslim
Hijab
• Take note of patients with OCD
• Take note of patients with poor
hygiene. It may be a sign of
schizophrenia or any mental
health issues.
• Observe uncoordinated
clothing or extreme clothing
(ex: A person wearing a coat in
hot weather).
• Normal BMI • Observe unequal weight distribution.
• Normal fat distribution • Underweight, Emaciated/ Cachexic- may be
PHYSIQUE suggestive of marasmus, anorexia nervosa and other
(HEIGHT, muscle wasting disease.
WEIGHT, BMI) • Overweight, Obese
• Truncal fat, thin limbs- may be suggestive of
Cushing’s disease.
• No sign of distress • Distress is defined as where the client does not feel
any different or show any clinical signs.
• Cardiac
o Clutching of the chest
o Pallor
• Respiratory
o Cyanosis
o Dyspnea, Shortness of breath
SIGNS OF o Labored breathing
DISTRESS o Coughing
• Pain
o PQRST, pain scale, Wong and Baker pain scale for
children
o Physical signs: sweating, irritability,
o guarding behavior, crying
o Physical Sign: ask questions appropriate to age
o Guarding Behavior: Some patients may cover
other distress (e.g., Abdominal pain)
MENTAL STATUS – refers to the current state of mind.
• Is the client responsive?
• Is the client speaking normally?
• Is the client apathetic?
• Awake, Asleep •
Disoriented
• Oriented •
Lethargic – Lack of energy, sluggish / Low response
• Alert towards the environment.
• • Obtunded – state similar to lethargy in which the
You may ask the client his/her
name or age and verify through patient has a lessened interest in the environment,
the chart. slowed responses to stimulation, and tends to sleep
LEVEL OF
more than normal with drowsiness in between sleep
CONSCIOUSNESS • “Ma’am, do you know where you
are?” states.
• • Stuporous – Only vigorous and repeated stimuli will
You may ask for the time of the
day to check the mental status. arouse the individual, and when left undisturbed, the
• Observe the responsiveness of patient will immediately lapse back to the unresponsive
state.
the patient (e.g., call the name)
• Comatose – maybe present in neurologic conditions.
• Coherent • Confabulation – maybe present in dementia (gawa
• Logical sequence gawa stories)
• Clear, moderately paced2 • Incoherent
• Illogical sequence: ex: I picked up my dress that is
SPEECH
color transparent.
• Disorganized (loose association, aphasia, slurring,
etc) – may be suggestive of a neurologic affectation or
a psychiatric condition.
MOBILITY OF CLIENT – The way they move, their posture, and their gait.
• Body movement is very important.
• Action speaks better than words.
• Check the level of the shoulders.
• Erect/comfortable • Abnormal spine curvature (lordosis, kyphosis,
• Steady gait scoliosis)
• Leaning forward, slumped shoulders
• Preference in position
POSTURE AND
GAIT • Stiff/rigid, Immobility
• Rhythmic and coordinated • Uncoordinated/jerky movements – maybe

MOTOR ACTIVITY
movements suggestive of neurologic or degenerative conditions.
BEHAVIOR OF THE CLIENT
• Are they loud?
• Are they aggressive?
• Are they hostile?
• Observe the response of the patient.
• Be calm when encountering aggressive clients.
• Talk to the client at an eye-level.
• The windows of the soul can be seen through the eyes.
• Appropriate for situation • Anxious
o Fidgety, irritable, restless
o Cold moist palms
MOOD • Depressed
o Inexpressive, flat affect
o Poor eye contact
o Psychomotor slowing
• Eye contact, Blinking • No eye contact, Fear, Anxiety, Sadness

FACIAL
• Symmetric • Asymmetric
EXPRESSION
• Appropriate • Expressionless, Mask-like
AND AFFECT
• Flat, Inappropriate, Blunt
GENERAL • Cooperative, Purposeful • Uncooperative, Bizarre, Angry, Violent/Hostile,
BEHAVIOR Apathetic, Incongruent
PHYSICAL ASSESSMENT
SKIN
• Skin is the largest organ of the body.
• It is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, UVR,
and dehydration.
• It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity,
and vitamin D synthesis.
• The skin also provides individual identity to a person’s appearance.
• In the assessment of the skin, inspection and palpation are the methods utilized by the examiner.
• The areas being examined are exposed to proper lighting for accurate observation.
• Examination of skin may also be performed cephalo-caudal as the nurse progresses to the different regions of body.
• Inspection of the skin for odor, color, turgor (fullness/elasticity), the temperature should be performed properly.
• In the presence of normal or abnormal findings during the assessment of the skin, location should be indicated.
SKIN
• White, Fair, Dark complexion • Hyperpigmentation – suggestive of Addison’s
Intact skin disease.
• Normal skin variations: • Hypopigmentation – present in Albinism Skin
o Freckles breakdown.
o Striae/ stretch marks • Pallor (loss of color) is seen in arterial insufficiency,
o Moles decreased blood supply, and anemia. Pallid tones vary
o Vitiligo from pale to ashen without underlying pink.
o Scar • Flushed
o Birthmarks (Mongolian • Erythema
spots) • Petechiae
COLOR AND • Small amount of melanin is • Cyanosis may cause white skin to appear blue-tinged,
APPEARANCE present for fair skinned clients especially in the perioral, nail bed, and conjunctival
• For dark-skinned clients, most areas. Dark skin: blue, dull, lifeless in the same areas.
of their body parts are • Ecchymosis
pigmented such as the nipple • Jaundice – present in hepatic disease.
• The amount of pigment in the
skin accounts for the intensity of
the color hue of the client.
• To check for the paleness of an
African client/ dark-skinned,
you may check the palms, nail
beds, and oral cavity.
• Smooth, soft Warm, dry • Rough
• Palpate the temperature by • Excessively Dry, Moist, Oily Excessively warm-
using the dorsal part. seen in fever, hyperthyroidisms
TEXTURE, TEMP. • Palpate the texture by using • Excessively cold- seen in shock (perfused bleeding),
the palmar surface, 3 middle hypotension
fingers. • Colder skin may be accompanied by an arterial
• Use gloves to avoid infection. disease because of alterations or perfusions.
• Take note of the size of the • Warm skin – febrile or problems in thyroid.
lesion, mobility, texture, and • Skin is normally thin with the presence of calluses.
observe drainage. • Thin skin is normally found on patients with arterial
insufficiency on steroids that are prone to bruises
and infection.
• When assessing moisture, check the skin folds (e.g.,
axilla)
• Older clients have a decreased collagen fiber in the
skin.
• Good, poor skin turgor Odor, • Edema: pitting, non-pitting, brawny- suggestive of
Perspiration. cardiovascular, lymphatic or renal condition.
• Use two fingers to pinch the o Swelling caused by excess fluid trapped in your
skin. body's tissues.
HYDRATION, • To check the elasticity of the o Palpate using the thumb and press down.
TURGOR, skin, pinch the clavicle skin o When the skin rebounds and does not remain
ELASTICITY, (gently). indented when pressure is released, it is pitting
MOBILITY • Mobility refers on the ability of edema. It responds to pressure.
the skin to be pinched. o Non-pitting edema does not respond to pressure.
• Turgor refers to the skin’s There are no indentations.
elasticity and how quickly the
skin returns to its original shape.
SKIN LESIONS
PRIMARY LESIONS
• Macule: non-palpable lesion that are flat and colored (petechiae)
o Small, flat, nonpalpable skin color change (skin color may be brown, white, tan, purple,
red). Macules are less than 1 cm with a circumscribed border, whereas patches are
greater than 1 cm, and may have an irregular border. Examples include freckles, flat
moles, petechiae, rubella (pictured below), vitiligo, port wine stains, and ecchymosis.
• Papule: palpable lesions that are elevated and superficial (mole)
o Elevated, palpable, solid mass. Papules have a circumscribed border and are less than
0.5 cm; plaques are greater than 0.5 cm and may be coalesced papules with a flat top.
Examples of papules include elevated nevi, warts, and lichen planus. Examples of
plaques include psoriasis (psoriasis Vulgaris pictured below) and actinic keratosis.
• Vesicle: palpable lesions that are elevated and filled with fluid (chickenpox)
o Circumscribed elevated, palpable mass containing serous fluid. Vesicles are less than
0.5 cm; Examples of vesicles include herpes simplex/ zoster, varicella (chickenpox,
pictured below), poison ivy, and second-degree burn.
• Bulla: palpable lesions that are elevated and filled with fluid but larger than vesicles (blisters)
o Bullas are greater than 0.5 cm. Examples of bulla include pemphigus, contact
dermatitis, large burn blisters, poison ivy, and bullous impetigo.
• Pustule: palpable lesions that are elevated and filled with pus (acne)
o Pus-filled vesicle or bulla. Examples include acne (pictured below), impetigo, furuncles,
and carbuncles.
• Wheal: palpable lesions characterized by local edema (insect bite)

o Elevated mass with transient borders that is often irregular. Size and color vary.
Caused by movement of serous fluid into the dermis; it does not contain free fluid in a
cavity (e.g., vesicle). Examples include urticaria (hives, pictured below) and insect
bites.
SECONDARY LESIONS
Secondary Lesions
• Ulcer: skin surface loss which often bleeds
o Skin loss extending past epidermis, with necrotic tissue loss. Bleeding and scarring are
possible. Examples include stasis ulcer of venous insufficiency (stasis dermatitis with
venous stasis ulcer, pictured below) and pressure ulcer.
• Fissure: a linear crack
o Linear crack in the skin that may extend to the dermis and may be painful. Examples
include chapped lips or hands and athlete’s foot. Interdigital tinea pedis with fissures
and maceration is pictured below.
• Crust: dried residue of serum, pus or blood (scab)
• Scale: thin flake of exfoliated epidermis
• Lichenification: thickened roughened skin
VASCULAR AND PURPURIC LESIONS

• Spider angioma: bright red with radiating legs; blanches when pressure is applied at the center
o Red arteriole lesion with a central body with radiating branches. It is usually noted on
the face, neck, arms, and trunk. It is rare below the waist. Compression of the center
of the arteriole completely blanches the lesion. It is associated with liver disease,
pregnancy, and vitamin B deficiency.
• Spider vein: bluish, may have radiating legs
• Cherry angioma: ruby red, flat or raised

o Papular and round, red or purple lesion found on the trunk or extremities. It may blanch
with pressure. It is a normal age-related skin alteration and usually not clinically
significant.
• Petechia and Purpura: round red or purple macules

o Round red or purple macule that is 1–2 mm in size. It is secondary to blood
extravasation and associated with bleeding tendencies or emboli to skin.
• Ecchymosis: round or irregular macular lesion larger than petechia; color varies: black, purple,
yellow, green
o Round or irregular macular lesion that is larger than petechial lesion. The color varies
and changes: black, yellow, and green hues. It is secondary to blood extravasation and
associated with trauma and bleeding tendencies.
• Hematoma: Localized collection of blood creating an elevated ecchymosis. It is associated with
trauma
SKIN MALIGNANCY
• With the exception of malignant melanoma, most skin cancers are easily seen and easily cured, or at least
controlled.
• MALIGNANT MELANOMA can be deadly if not discovered and treated early, which is one reason why professional
health assessment and skin self-assessment can be life-saving procedures.
o Is usually evaluated according to the mnemonic ABCDE: A for asymmetrical; B for borders that are irregular
(uneven or notched); C for color variations; D for diameter exceeding 1/8 to 1/4 of an inch; and E for elevated,
not flat.
o Danger signs of malignant melanoma include any of these factors.

o However, smaller areas may indicate early-stage melanomas.
o Other warning signs include itching, tenderness, or pain, and a change in size or bleeding of a mole. New
pigmentations are also warning signs.
o The most commonly detected SKIN CANCERS include:
Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma
HAIR
• In the assessment of hair, inspection for the evenness of growth over the scalp; thickness; texture should be done.
HAIR
• Varies • Patchy gray areas – seen in nutritional deficiencies.
• Natural hair color, as opposed to • Copper-red hair – indicate severe nutrition among
chemically colored hair, varies African American children.
among clients from pale blond to • Excessive scaliness may indicate dermatitis.
black to gray or white. The color • Raised lesions may indicate infections or tumor
is determined by the amount of growth.
melanin present. • Dull, dry hair may be seen with hypothyroidism and
• Scalp is clean and dry. Sparse malnutrition.
dandruff may be visible. Hair is • Poor hygiene may indicate a need for client teaching
smooth and firm, somewhat or assistance with activities of daily living.
elastic.
COLOR • Individuals of black African
descent often have very dry
scalps and dry, fragile hair,
which the client may condition
with oil or a petroleum jelly–like
product. (This kind of hair is of
genetic origin and not related to
thyroid disorders or nutrition.
Such hair needs to be handled
very gently.)
• Inspect the scalp and hair for
general color and condition.
• At 1-inch intervals, separate the

hair from the scalp and inspect
and palpate the hair and scalp
for cleanliness, dryness or
oiliness, parasites, and lesions.
• Wear gloves if lesions are
suspected or if hygiene is poor.
• Evenly distributed, thick, silky • Alopecia, patches of hair loss
• Inspect amount and distribution
of scalp, body, axillae, and pubic
hair.
• Look for unusual growth
elsewhere on the body.
• Increased (hirsutism)/ decreased facial or body hair
– may indicate hormonal problems Varying hair length.
• Male pattern balding
DISTRIBUTION
• Excessive generalized hair loss may occur with

infection, nutritional deficiencies, hormonal disorders,
thyroid or liver disease, drug toxicity, hepatic or renal
failure.
• May also result fr/ chemotherapy or radiation therapy.
• No infection/ infestation • Pediculosis
SCALP • No scaling • Scaly, dry
• Gray scaly patches Dandruff
TEXTURE/ • Fine • Coarse, Brittle, Dry
THICKNESS
NAILS
• The nails should be inspected for color; shape and; texture; condition of the tissues surrounding nails.
• Part of the assessment of the nails, the BLANCH TEST, is performed to assess for circulatory impairment particularly
arterial hypoperfusion (all fingers can be tested).
o This test is performed by pressing the nails between thumb and index finger to check for the return of normal
pinkish color of the nail beds.
• The SCHAMROTH WINDOW TEST can be used to identify or confirm clubbing.
o If 2 opposing fingers are held back to back against each other, a diamond-shaped space should normally appear
between the nail beds and the nails of the 2 fingers. In clubbing, this space (or window) is missing.
NAIL
• Nails are clean and • Dirty, broken, or jagged fingernails may be seen with
NAIL GROOMING
manicured. poor hygiene.
AND
• They may also result from the client’s hobby or
CLEANLINESS.
occupation.
• Light brown to pinkish nail • Pale or cyanotic nails may indicate hypoxia or
beds anemia.
COLOR AND
• Pink tones should be seen. • Splinter hemorrhages may be caused by trauma.
APPEARANCE
• Some longitudinal ridging is • Beau’s lines – occur after acute illness and eventually
normal. grow out.
• Dark-skinned clients may have • Yellow discoloration may be seen in fungal infections
freckles or pigmented streaks in or psoriasis.
their nails. • Nail pitting is also common in psoriasis.
• Convex curve • Clubbing: 180° or more nail base angle, which is seen
• Round with 160° nail base in hypoxia.
• There is normally a 160-degree o Early clubbing (180-degree angle with spongy
angle between the nail base and sensation) and late clubbing (greater than 180-
the skin. degree angle) can occur from hypoxia.
SHAPE
• Spoon nails (koilonychia) (concave) which is seen in

iron deficiency anemia.
• Round, hard, immobile • Thickened
Smooth, intact epidermis • Paronychia – inflamed nail head.
• Onycholysis – detached nail plate from nail bed

starting distally.
TEXTURE/
THICKNESS • Terry’s nails – whitish with a distal band of reddish-
brown, seen in aging and some chronic disease.
• Leukonychia – white spots caused by trauma which

grow out with the nails.
CAPILLARY • Prompt return to usual color • Delayed return (more than 4 sec.)
REFILL in less than 4 seconds
HEAD
• HEAD: The framework of the head is the skull, which can be divided into two subsections: the cranium and the face.
o CRANIUM: The cranium houses and protects the brain and major sensory organs.
o FACE: Facial bones give shape to the face.
• In palpating for nodules or masses and depressions, use a gentle rotating motion with the fingertips.
• Begin at the front and palpate down the midline, then palpate each side of the head.
• In the assessment of the head, headache characteristics should be determined if this symptom is present.
• One should determine the intensity, location, radiation, duration triggering, & relieving factors of the head pain.
HEAD
• Rounded; normocephalic, • Increased skull size (e.g hydrocephalus)
and symmetrical • More prominent nose and forehead; longer mandible
• Head size and shape vary, • Abnormal shape of head
especially in accord with o An abnormally small head is called microcephaly.
SKULL SIZE,
ethnicity. • The skull and facial bones are larger and thicker in
SHAPE,
• Usually the head is symmetric, acromegaly.
SYMMETRY
round, erect, and in midline and • Acorn-shaped, enlarged skull bones are seen in
appropriately related to body Paget’s disease of the bone.
size (normocephalic).
• No lesions are visible.
• Hard, smooth, without • Bumpy, soft
CONSISTENCY lesions. • Lumps, Lesions on the head may indicate recent
trauma or a sign of cancer.
• Symmetrical • Asymmetrical
• The face is symmetric with a • Asymmetry in front of the earlobes occurs with
round, oval, elongated, or parotid gland enlargement from an abscess or tumor.
FACIAL square appearance. • Unusual or asymmetric orofacial movements may
SYMMETRY • No abnormal movements noted be from an organic disease or neurologic problem,
• Inspect the face. Inspect for which should be referred for medical follow-up.
symmetry, features, movement,
expression, and skin condition.
• Varies, symmetrical • Distorted:
o Mask-like face
o Tightened, hard face
o Sunken, hollow face
o Swollen face
o Moon-shaped face
• Palpate the temporal artery, • The temporal artery is hard, thick, and tender with
which is located between the top inflammation, as seen with temporal arteritis
of the ear and the eye. (inflammation of the temporal arteries that may lead to
o The temporal artery is blindness).
elastic and not tender.
FACIAL
• Palpate temporomandibular • Limited range of motion, swelling, tenderness, or
FEATURES
joint (TMJ). crepitation may indicate TMJ syndrome.
o To assess the TMJ, place o When assessing TMJ syndrome, be sure to
your index finger over the explore the client’s history of headaches, if any.
front of each ear as you ask
the client to open the mouth.
o Normally there is no
swelling, tenderness, or
crepitation with movement.
o Mouth opens and closes
fully (3 to 6 cm between
upper and lower teeth).
o Lower jaw moves laterally 1
to 2 cm in each direction.
FACIAL HAIR • Normal for gender • Increased/ Decreased
EYES
• Inspect eyebrows for hair distribution and alignment; skin quality and movement.
• Ask the client to raise and lower eyebrows to detect muscular affectation.
• Inspect the eyelashes for evenness of distribution and direction of the curl.
• Inspect eyelids for skin quality and texture, position in relation to the cornea, ability to blink, the frequency of blinking.
• Ask the client to close his eyes.
• Elevate eyebrows with thumb and index finger.
EYES
• Hair evenly distributed; skin • Loss of hair (madarosis)
intact; eyebrows symmetrically
aligned; equal movement
EYEBROWS
• Scaling and flakiness of skin

• Unequal alignment and movement of eyebrows
• Short, equally distributed; curled • Curls turned inward (inversion of the eyelid)
slightly outward
EYELASHES • Trichiasis is a common eyelid problem especially with

the elderly.
o The eyelashes grow inward to the eyes, the lashes
rub against the cornea, the conjunctiva, and the
inner surface of the eyelids. This irritates the eye.
• Skin intact, no discharge Moist • Redness, Swelling; Flaking; with discharge;
and pink • Presence of nodules, lesions
• Close symmetrically Involuntary • Lids close asymmetrically, absent, incompletely or
blinks: 15-20 /min. painfully.
• Less than 15 blinks per minute is a significance of
stuporous or neurological dysfunction
• More than 20 blinks per minute could be a
EYELIDS significance of dryness of the eyes, nutritional status of
the client, environment, or when the patient feels
anxious.
EYELID ABNORMALITIES:
• Ectropion: lower lids turn outward

• Entropion: Lower lids turn inward
• Chalazion: Inflammation of the meibomian glands
• Hordeolum: Sty or inflammation of the glands in lid
• Blepharitis: waxy white scales or inflammation of hair follicles
• Ptosis: drooping of the lids
• Sclera appears blue-white • Jaundiced sclera with petechiae
SCLERA
(yellowish in dark-skinned)
BULBAR • Transparent; capillaries • Excessively pale; reddened; the presence of lesions
CONJUNCTIVA sometimes evident
• Shiny, smooth, and pink • Extremely red (conjunctivitis)

• Pale (anemia)
• With lesions/nodules
PALPEBRAL
CONJUNCTIVA
• No edema or tearing • Swelling or tenderness Dacryocystitis –

inflammation of the lacrimal sac.
LACRIMAL
GLAND, SAC AND
NASOLACRIMAL
DUCT
CONJUNCTIVA ASSESSMENT
• In assessing the BULBAR CONJUNCTIVA, the color, texture, and presence of lesions must be inspected.
o Bulbar Conjunctiva is clear, moist and smooth and underlying tissue structures are visible.
o The eyelids are retracted with the thumb and index finger, exerting pressure over the upper and lower bony
orbits; the client is asked to look up and down, and from side to side.
• While for the PALPEBRAL CONJUNCTIVA, the color, texture, and presence of lesions are inspected.
o The lower lids are everted and the client is asked to look up; the lower lids are gently retracted with the index
fingers.
o Using the tip of the index finger, the lacrimal gland and the lower orbital rim near the inner canthus are palpated.
CORNEA ASSESSMENT
• During the assessment of the CORNEA, inspect for its clarity and texture.
• The corneal sensitivity test is used to determine the function of the 5th cranial nerve (trigeminal nerve).
o In this test, the client is asked to keep both eyes open and look straight ahead.
o The client is approached from behind and beside, the cornea is lightly touched with the corner of the gauze or a
cotton wisp.
• CORNEAL SENSITIVITY TEST
o CN V (trigeminal nerve)
o Keep both eyes open and look straight ahead.
o Client is approached from behind and beside
o Cornea is lightly touched with the corner of the gauze or a cotton wisp.
PUPILS ASSESSMENT
• In the assessment of the PUPILS, the color, shape, and symmetry of size in reaction to light and accommodation are
observed.
• Direct, consensual reaction to light determines the function of the 3rd (oculomotor) and 4th (trochlear) cranial nerves.
o When checking for this, the examination room is partially darkened and the client is asked to look straight ahead.
o Using a penlight and approaching from the side, light shone on the pupil and the response of the illuminated pupil
is observed.
o The same is observed on the other pupil.
• In checking for the reaction to accommodation, an object is held about 4 inches from the bridge of the client’s nose.
o The client is asked to look at the top of the object first, and then at a distant object (such as a far wall).
o Alternate the gaze from the near to the far object.
o Next, move the object towards the client’s nose.
PERIPHERAL VISUAL FIELD ASSESSMENT

• Assessment of the PERIPHERAL VISUAL FIELD is done to determine the function of the retina and neural pathways
to the brain and the 2nd (optic) cranial nerve.
• The client is asked to sit in front of you at a distance of 2-3 ft.
• The client is instructed to cover the right eye with a card and look directly at your nose.
• The examiner’s eye directly opposite the client’s covered eye is also covered and he/she must look directly at the
client’s nose.
• An object is held in your fingers, extend your arm and move the object into the visual field of various points in the
periphery.
• The client is informed to tell the examiner when the moving object is spotted.
• In assessing for near vision, ask the client to read from newsprint held at a distance of 14 in. while for distance vision,
ask the client to sit 20 ft. from the Snellen chart; cover the eye not being tested, and identify the 4 letters.
6 OCULAR MOVEMENTS ASSESSMENT

• Assessment of the 6 OCULAR MOVEMENTS is done to determine eye alignment and coordination.
• Stand directly in front of the client.
• Holding the penlight at a distance of 1 ft., ask the client to hold hand in a fixed position facing you and follow the
movement of the penlight with the eyes only, move the penlight slowly to the 6 cardinal fields of gaze, starting from
the center of the eye.
• The COVER-UNCOVER TEST is performed by covering one eye and observing the uncovered eye for movement.
o Uncovered eye should remain fixed or straight ahead, the covered eye should remain fixed or straight ahead after
being covered as well.
• OCULAR MOVEMENT TEST

o Stand directly in front of the client (2-3 ft.) to the client
o Have an object with you like a pencil or a finger, holding it approximately 12 inches from the client’s face.
o Holding penlight at a distance of 1 ft.
o Hold the head in a fixed position while their eyes just move from different directions.
o Follow the movement of the penlight to the 6 cardinal fields of gaze, starting from the center. The eyes should move
and should be smooth and symmetric to all of the 6 directions.
o There is no particular movement in the 6 cardinal directions. Refocus on the middle so that the patients will not
experience nausea.
o Move the object very slowly.
o Failure of eyes to follow the movement symmetrically in any or all directions indicates that there is already weakness
in one or more extraocular muscles or there might be a dysfunction in the cranial nerve that innervates a particular
muscle.
EYES
• Transparent, smooth, moist and • Opaque, rough, dry Lesions, foreign bodies
shiny • Inconsistent color, cloudy
• Details of iris are visible, with • One or both eyelids fail to respond
CORNEA, IRIS
uniform color
• The client blinks when the
cornea is touched
• Black and equal in size (3-7mm); • Cloudiness; bulging of the iris
smooth border; iris is flat and • Mydriasis - dilation is either the result from a collapse
round Illuminated pupil of the nervous system injury, circulatory collapse or
constricts. deep anesthesia (PACU). (stimulants: amphetamines,
• Non-illuminated pupil constricts. cocaine and mephedrone).
• Pupils constrict when looking at • Miosis - constriction possible results from narcotic
a near object, dilates at a far drugs or brain damage (oxycodone (oxycontin)
object. codeine, heroin, morphine, anti-psychosis)
• Pupils converge when objects • Unequal responses(anisocoria)
are moved towards the nose. o Pupils are in unequal size.
PUPILS o It is usually due to a nervous system damage.
o If anisocoria is greater in bright light compare to
the dim light this might be a cause of trauma.
o If anisocoria is greater in dim light compared to
bright light it might be caused by Horner syndrome
or paralysis of the cervical sympathetic nerves.
o If there is also a damage or paralysis in oculomotor
nerve there is also a possibility of having a
anisocoria.
• Neither pupil constricts
• One or both pupils fail to react
• When looking straight ahead, • Visual field smaller than normal; ½ vision in one or both
VISUAL FIELD the client can see objects in the eyes.
periphery.
• Both eyes coordinated, move in • Eye movements not coordinated or parallel; one or both
unison, with parallel alignment. eyes fail to follow a penlight in specific directions.
ABNORMAL EYE MOVEMENTS:
EXTRAOCULAR
• Phoria: A phoria is a misalignment of the eyes that only appears when binocular viewing is
MUSCLE TEST
broken and the two eyes are no longer looking at the same object.
• Nystagmus: jerky eye movement.
• Esotropia: turning in of the eyes.
• Exotropia: turning outward of the eyes.

• Strabismus: constant malalignment of the eyes.
• Able to read newsprint 20/20 • Inability to read newsprint

vision on the Snellen chart. • Denominator of 40 or more on the Snellen chart with
corrective lenses.
ALTERED VISION:
• Myopia: nearsightedness
• Hyperopia: farsightedness
• Presbyopia: impaired near vision, seen in client who moves reading materials farther away to
read owing to decreased accommodation of the lenses.
• Amblyopia: abnormal visual development early in life
VISUAL ACUITY SNELLEN CHART
• Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked
one above the other. The letters are large at the top and decrease in size from top to bottom.
The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20
feet from the chart and covers one eye with an opaque card (which prevents the client from
peeking through the fingers). Then the client reads each line of letters until he or she can no
longer distinguish them.
• Near Vision: Ask client to read from newsprint held at a distance of 14”
• Distance Vision: Ask the client to sit 20 ft. from the Snellen chart; cover the eye not being
tested, and identify letter.
EARS
• The ear is the sense organ of hearing and equilibrium. It consists of three distinct parts: the external ear, the middle
ear, and the inner ear.
• The tympanic membrane separates the external ear from the middle ear.
o Both the external ear and the tympanic membrane can be assessed by direct inspection and by using an otoscope.
o The middle and inner ear cannot be directly inspected. Instead, testing hearing acuity and the conduction of sound
assesses these parts of the ear.
• In the assessment of the auricles, the color, symmetry of size, and position is inspected.
• Palpation of the texture, elasticity, and areas of tenderness is done.
• The auricle is gently pulled upward, downward, and backward.
• The pinna is folded forward and pressure is applied to the mastoid process.
• For adults, when inspecting the ear canal, the pinna is pulled upward and backward, while for children, it is pulled
downward and backward.
WATCH TICK TEST

• In performing the WATCH TICK TEST, have the client occlude one ear.
• Out of the client’s sight, place a ticking watch 1-2 in. from the unoccluded ear.
• Ask what the client can hear.
• Repeat with the other ear.
WHISPER TEST
• Perform the WHISPER TEST by asking the client to gently occlude the ear not being tested and rub the tragus with a
finger in a circular motion.
• Start with testing the better hearing ear and then the poorer one.
• With your head 2 feet behind the client (so that the client cannot see your lips move), whisper a two-syllable word
such as “popcorn” or “football.”
• Ask the client to repeat it back to you. If the response is incorrect the first time, whisper the word one more time.
Identifying three out of six whispered words is considered passing the test.
• The whisper test has been studied in both pediatric and adult clients to evaluate hearing acuity and has been found to
have a high sensitivity and specificity.
WEBER’S TEST
• The WEBER’S TEST is used to assess bone conduction.
• Perform Weber’s test if the client reports diminished or lost hearing in one ear. The test helps to evaluate the conduction
of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external
and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear).
• It is performed by holding the tuning fork at its base.
• Activate the fork by tapping the fork gently against the back of your hand near the knuckle.
• Place the vibrating fork on top of the client’s head and ask where the client hears the noise.
o Strike a tuning fork softly with the back of your hand and place it at the center of the client’s head or forehead.
Centering is the important part. Ask whether the client hears the sound better in one ear or the same in both ears.
o Air conduction sound is normally heard longer than bone conduction sound.
RINNE TEST
• The RINNE TEST compares air conduction to bone conduction.
• The client is asked to block the hearing in one ear intermittently by moving a fingertip in and out of the ear canal.
• The handle of the activated tuning fork is held on the mastoid process of one ear until the client states that the vibration
can no longer be heard.
• Immediately hold the still vibrating fork prongs in front of the ear canal.
• Ask whether the client now hears the sound.
• Move the prongs of the tuning fork to the front of the external auditory canal. Ask the client to tell you if the sound is
audible after the fork is moved.
ROMBERG TEST
• The ROMBERG TEST is performed by asking the patient to stand with feet together and eyes open, then closed for 20
to 30 seconds.
• Mild swaying may normally be observed.
• In performing this test, the examiner must stay close to the client to prevent falls (put arms around client w/o touching).
EARS
• Color same as facial skin; • Bluish color of earlobes; excessive redness;
symmetrical; auricle aligned with asymmetrical; low-set ears.
outer canthus of eye, about 10˚ • Lesions; flaky, scaly skin; tenderness when moved or
AURICLES
from vertical Mobile, firm, and pressed.
not tender; pinna recoils as it is
folded.
• Distal end contains hair follicles; • Redness and discharge; scaling; excessive cerumen
EXTERNAL EAR dry cerumen, grayish–tan color; obstructing canal.
CANAL, or sticky, wet cerumen in various
TYMPANIC shades of brown.
MEMBRANE • Pearly gray color, • Pink to red, some opacity; yellow-amber.
semitransparent.
• Mild swaying when eyes are • Loss of balance that appears when eyes are closed
BALANCE closed (negative Romberg test). (Positive Romberg test) suggesting poor position
sense.
GROSS HEARING • Able to hear ticking in both ears. • Unable to hear ticking in one or both ears.
ACUITY
• Sound is heard on both ears or • Sound is heard better in impaired ear, indicating a
is localized at the center of the bone-conductive hearing loss.
WEBER’S
head (Weber negative). • Sound is heard better on ear without a problem,
indicating a sensorineural hearing loss.
• Air-conducted hearing is greater • Bone conduction time is equal to or longer than the air
RINNE than bone-conducted hearing conduction time (negative Rinne).
(positive Rinne).
NOSE AND SINUSES

• The external nose should be inspected for size, shape, color, and symmetry.
• Determine the patency of both nasal cavities by asking the client to close the mouth, exert effort on one naris and
breathe through the opposite naris; then repeat on the opposite naris.
• Inspection of the nasal cavities using a flashlight or a nasal speculum is also performed.
• On the other hand, the maxillary and frontal sinuses should be palpated and percussed.
• ASSESSMENT: Palpate for the sinuses in particular frontal and maxillary.
o It should be non-tender on palpation and hollow upon percussion.
o How do you percuss sinuses? You can have it percussed with slow or indirect percussion by putting one hand on
top of the other.
o If the client verbalizes discomfort upon palpation, it could be a sinus infection, rhinitis, or sinusitis.
o Transilluminate the frontal and maxillary sinuses using the penlight, a red-glow should transilluminate. This
integrates normal air-filled sinuses.
NOSE AND SINUSES

SKIN • Color: Same as face • Nodules, lesions, erythema, visible vasculature.
APPEARANCE
SHAPE • Symmetrical appearance • Asymmetry
• Symmetrical appearance; no • Asymmetry, flaring nares; discharge, crusting;
changes in nares with displaced septum
NARES
respiration; dry with no crusting;
septum midline
• Mucosa pink and moist with • Mucosa markedly red, dry or cracked; areas of
uniform color and no lesions discoloration; polyps, masses.
• Mucosa is swollen, pale pink or bluish-gray with
APPEARANCE allergies; nasal mucosa red and swollen with upper
respiratory infection; ulcers seen with trauma, infection,
nose picking, or cocaine use; polyps seen with chronic
allergies.
• Air is felt being exhaled through • Noisy or obstructed exhalation when the mouth is
PATENCY
opposite naris; noiseless closed and one naris is occluded
• Solid placement; no nodules, • Unstable placement; nodules or masses present; client
FIRMNESS OF
masses or pain reported on verbalizes pain on palpation. Nasal tenderness is seen
EXTERNAL NOSE
palpation with local infection.
SINUSES, BOTH • Nontender on palpation • Client verbalizes pain or discomfort on palpation with
FRONTAL AND allergies of sinus infection.
MAXILLARY
SINUSES FOR • Hollow tone elicited • Flat, dull tone elicited; client expresses pain on
RESONANCE percussion.
MOUTH AND OROPHARYNX

• Inspect the outer lips for symmetry, color, contour, and texture.
• Ask the client to purse lips as if to whistle.
• Inspect and palpate (while wearing gloves) the inner lips and buccal mucosa for color, moisture, and texture.
• Inspect the teeth and gums while examining the inner lips and buccal mucosa.
MOUTH
• Lips and surrounding tissue are • Asymmetrical mouth may indicate the neurologic
relatively symmetrical in net condition (eg Bell’s palsy, stroke, tumors, infections or
position and when smiling. dental abnormalities or poorly fitting dentures).
SYMMETRY AND • No lesions, swelling, drooping.
ALIGNMENT
• Upper teeth resting on top of • Malocclusion of teeth, separation of individual teeth, or
lower teeth with upper incisors protrusion of upper or lower incisors.
slightly overriding lower ones
LIPS
• In white skin: pink • Cyanotic pale lips in shock or anemia; reddish in
• In dark skin: may have bluish ketoacidosis or carbon monoxide poisoning.
hue or freckles like pigmentation • Always remember if you have determined a pallor
(paleness) particularly in the circumoral pallor, it is
COLOR
often caused by anemia or patients with cyanosis.
• Super red lips without any cosmetics applied, could
mean an indication of carbon monoxide poisoning.
• Moist, smooth with no lesions • Dry, cracked; nodules, fissures or lesions present;
cheilosis (cracking in the corners) seen in riboflavin
deficiencies.
• Broken vesicles w/ crusting in herpes simplex type 1
CONSISTENCY
• Scaly nodular lesions or ulcers occur with lip

carcinoma.
BUCCAL CAVITY
• Pink (increased pigmentation • Pale, cyanotic or reddened mucosa
COLOR often noted in dark-skinned • Ulcers, dry mucosa, bleeding, or white patches are
present.
clients) Smooth, moist, without o Leukoplakia: thick, elevated white patches that do
lesions. not scrape off are precancerous
• Dark skinned clients could have Leukoplakia (ventral surface)
different results from light
skinned clients.
Hairy leukoplakia (lateral surface)
o Thrush: (Candida albicans infection) white, curdy

patches that scrape off and bleed
o Koplik spots: red spots over red mucosa which

indicate measles.
o Canker sores: painful vesicles that erupt and are
seen with allergies and stress.
GUMS
• Pink • Pale, markedly reddened.
• Swollen gums that bleed are seen with gingivitis.
COLOR • Recessed red gums with tooth loss seen with
periodontitis.
• Bluish-black gum line present in lead poisoning.
• Moist, clearly defined margins • Dry, edema, ulcers, bleeding, white patches,
CONSISTENCY
tenderness.
TEETH
NUMBER • 32 teeth • Missing teeth
POSITION AND • Stable fixation, smooth surfaces • Loose or broken teeth, jagged edges, dental caries
CONDITION and edges
• Pearly white and shiny • Darkened, brown, or chalky white discoloration.
• Teeth may be yellow-brown in clients who use
COLOR
excessive coffee, tea, tobacco, or fluoride.
• A chalky white area is seen with a beginning cavity.
ASSESSMENT OF GUMS AND TEETH
• Inspect the teeth and the gums by asking the client to open their mouth; take note of the number of the teeth, the
color, the condition. Note any repair such as crowns, cosmetics (veneers).
• Ask the client to bite down as if they were chewing something and note the alignment of the lawyer and upper jaw.
• Some adults only have 28 teeth because their wisdom tooth/teeth is/are not yet developed.
• However, if the client is smoking and drinking large quantities of coffee and tea they might have a little bit of
staining (caffeine or nicotine staining).
• Some patients have swollen gums that bleed easily (gingivitis) this is due to the infection of the gums.
TONGUE
• Moist, papillae present; • Dry; nodules, ulcers present; papillae or fissures
symmetrical appearance; absent; asymmetrical.
midline fissures present. • Deep fissures are seen in dehydration; black, hairy
• Common variations: Fissured, tongue with the use of some antibiotics.
geographic tongue
• Carcinoma of tongue
SYMMETRY AND
TEXTURE
• Smooth, red, shiny tongue seen in niacin or Vitamin

B12 deficiency.
MOVEMENT • Smooth • Jerky or unilateral movement

COLOR • Pink • Markedly reddened, white patches, pale.
VENTRAL SURFACE OF THE TONGUE AND MOUTH FLOOR
COLOR • Pink, slightly pale • Markedly reddened, cyanotic or extreme pallor
SIDES OF THE • Pink, smooth, moist; no lesions • White or reddened areas, ulcerations or indurations
TONGUE FOR present.
COLOR AND • Leukoplakia indicates precancerous lesions, may see
LESIONS canker sores.
ASSESSMENT OF TONGUE
• Inspect the surface of the tongue for position, color, and texture.
• Ask the client to protrude the tongue. Inspect the tongue movement.
• Ask the client to roll the tongue upward and move it from side to side.
• Inspect the base of the tongue, the mouth floor, and the frenulum.
• Ask the client to place tip of the tongue against the roof of the mouth.
• To palpate the tongue, use a piece of gauze to grasp its tip, and with the index finger of your other hand, palpate
the back of the tongue, its borders and its base.
CONSIDERATIONS IN ASSESSING THE TONGUE
• Fasciculations are flickering contractions visible for a moment within the belly of the affected muscle or the tongue.
• Use a penlight to inspect the ventral surface of the tongue, the frenulum and the area under the tongue
• Observe also the sides of the tongue, use a gauze pad to check and to hold the client’s tongue on both sides; also
check for the resistance and strength of the tongue
• What if there is a decrease of strength on the tongue? This might be an indication of a cranial nerve 12 damage
which is the hypoglossal nerve, or if there is a shortened frenulum that limits its motion.
PALATE
• Hard palate: Pale • Extreme pallor, white patches, or markedly reddened
COLOR
• Soft palate: Pink areas.
• Hard palate: firm with irregular transverse rugae;
CONSISTENCY common variation: palatine torus (bony protuberance)
on hard palate
• Soft palate: spongy texture with symmetrical elevation

or phonation.
• Softened tissue over hard palate; lesions present;
absence of elevation; soft palate asymmetrical
elevation with phonation.
• Thick, white plaques are seen in Candida infection
• Deep, purple lesions may indicate Kaposi sarcoma.
ASSESSMENT OF PALATE
• Inspect the soft and hard palate for color, shape, and texture.
• Ask the client to open mouth wide and tilt his head backward.
• Then depress the tongue with a tongue blade as necessary.
• Inspect the uvula for position and mobility while examining the palates.
• To observe the uvula, ask the client to say “ah" so that the soft palate rises.
• For oropharynx and tonsils, inspect for color and texture. Inspect one side at a time to avoid eliciting the gag reflex.
• Inspect the tonsils for color, discharge, and size.
• If the client has a yellow-tinted hard palate this might be an indication of a jaundice because bilirubin adheres to
elastic tissues like collagen and an opening of a hard palate is known as a cleft palate.
OROPHARYNX
• Pink • Markedly reddened with exudates seen in pharyngitis;
COLOR
yellow mucus seen with post nasal sinus drainage.
• Tonsillar pillars symmetrical; • Enlarged tonsils (tonsils are red, enlarged, and covered
tonsils present (unless surgically with exudates in tonsillitis; asymmetrical; uvula
removed) and without exudates; deviates from midline; edema; ulcers; lesions.
uvula at midline and rises on
phonation
LANDMARKS
NECK
• The neck area should be inspected for appearance, texture, position, and movement.
OROPHARYNX
• Neck is symmetric, with the • Asymmetrical head position, masses, or scars present.
head centered and without • Swelling is seen in cancer, enlarged thyroid, or
bulging masses. inflamed lymph nodes.
APPEARANCE • A stiff neck is often a symptom of meningitis
(inflammation of meninges).
• If a female has an Adam’s apple it might be the
protrusion of thyroid.
• Smooth, controlled movements, • Rigid, jerky movements; ROM less than normal values;
range of motion (ROM) from pain on movement. Limited ROM, stiffness, and rigidity
upright position: are seen with muscle spasms, inflammation,
MOVEMENT o Flexion= 45° meningitis, cervical arthritis.
o Extension = 55°
o Lateral abduction = 40°
o Rotation = 70°
TRACHEA, THYROID, AND LYMPH NODES

• In the assessment of the trachea, thyroid, and lymph nodes, the examiner must stand behind the client and position
your hands with thumbs on the nape of the client’s neck.
• The client is asked to flex neck forward and to the right; use fingers of your left hand to displace thyroid to the right.
• Palpation of the right lobe using your right fingers while the client swallows – offer small sips of water- is done.
• The procedure was repeated to examine the left lobe.
TRACHEA
POSITION AND • The thyroid cartilage, cricoid • Asymmetrical
LANDMARKS cartilage moves upward • Position deviates from the midline with tumor, enlarged
(TRACHEAL RINGS, symmetrically as the client thyroid, aortic aneurysm, pneumothorax, atelectasis or
CRICOID AND
swallows. fibrosis.
THYROID
CARTILAGE) OF
THE TRACHEA
ASSESSMENT OF TRACHEA
• Palpate the trachea by placing the fingers in the sternal notch and feel the side of the notch.
• Auscultate only the thyroid only if you find an enlarged thyroid gland during inspection and palpation.
• Ask the client to hold his/her breath when auscultating.
• If there is a rapid malignancy, touch the thyroid or part of the trachea gently. DO NOT RUB IT, this might cause a
sudden increase of thyroid excretion of hormones this could also lead to palpitation that could affect the vital signs.
THYROID
• Midline position; symmetrical; • Deviates from the midline if obstructed by masses or
POSITION
landmarks identifiable growths.
• Smooth, firm, non-tender • Enlarged lobes, irregular consistency, tender on
CHARAC- palpation.
TERISTICS, • Diffuse enlargement is seen in hyperthyroidism
LANDMARKS • Grave’s disease, or endemic goiter, rapid
enlargement of a single nodule suggests malignancy.
CERVICAL LYMPH NODES – Have the client remain seated upright and palpate the lymph nodes with finger pads.
• Cervical lymph nodes are • Enlarged nodes with irregular borders.
usually not palpable. If palpable, • Enlarged nodes greater than 1 cm are seen in acute
they should be 1 cm or less and and chronic infection, autoimmune disorders, or
SIZE AND SHAPE
round. metastatic disease; hard, fixed, enlarged, unilateral
nodes are seen in metastasis.
• Enlarged occipital nodes are seen in HIV infection.
DELINEATION • Discrete • Confluent
MOBILITY • Mobile • Fixed to tissue
CONSISTENCY • Soft • Hard, firm
TENDERNESS • Nontender • Client verbalizes pain on palpation
LYMPH NODES
• Preauricular - in front of the ear
• Postauricular - behind the ears
• Occipital - at the base of the skull
• Submandibular - medial border of the mandible
• Submental - few cm behind the tip of the mandible
• Supraclavicular - over the clavicle
• You need to palpate all of the lymph nodes in a circular motion.

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Module 5: Physical Assessment and General Survey of an Adult Client | HALEC2022 | AUF_CON

COMPONENTS OF GENERAL SURVEY

• Clean/ well-groomed • Dirty, unkempt with body odor

• Rhythmic and coordinated • Uncoordinated/jerky movements – maybe

• Eye contact, Blinking • No eye contact, Fear, Anxiety, Sadness

• Wheal: palpable lesions characterized by local edema (insect bite)

• Scale: thin flake of exfoliated epidermis

• Lichenification: thickened roughened skin

VASCULAR AND PURPURIC LESIONS

• Cherry angioma: ruby red, flat or raised

• Petechia and Purpura: round red or purple macules

o Danger signs of malignant melanoma include any of these factors.

Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma

• At 1-inch intervals, separate the

• Excessive generalized hair loss may occur with

• Spoon nails (koilonychia) (concave) which is seen in

• Onycholysis – detached nail plate from nail bed

• Leukonychia – white spots caused by trauma which

• Scaling and flakiness of skin

EYELASHES • Trichiasis is a common eyelid problem especially with

• Ectropion: lower lids turn outward

• Shiny, smooth, and pink • Extremely red (conjunctivitis)

• No edema or tearing • Swelling or tenderness Dacryocystitis –

PERIPHERAL VISUAL FIELD ASSESSMENT

6 OCULAR MOVEMENTS ASSESSMENT

• OCULAR MOVEMENT TEST

• Exotropia: turning outward of the eyes.

• Able to read newsprint 20/20 • Inability to read newsprint

WATCH TICK TEST

NOSE AND SINUSES

NOSE AND SINUSES

MOUTH AND OROPHARYNX

• Broken vesicles w/ crusting in herpes simplex type 1

• Scaly nodular lesions or ulcers occur with lip

Hairy leukoplakia (lateral surface)

o Thrush: (Candida albicans infection) white, curdy

o Koplik spots: red spots over red mucosa which

• Smooth, red, shiny tongue seen in niacin or Vitamin

MOVEMENT • Smooth • Jerky or unilateral movement

• Soft palate: spongy texture with symmetrical elevation

TRACHEA, THYROID, AND LYMPH NODES

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