Physical Assessment Health Assessment An integral part of nursing care and is the basis of the nursing process Is used

to plan, implement, and evaluate teaching and care in order to promote an optimal level of health to prevent illness, restore health, and facilitate coping with disabilities Purposes:


Comprehensive ‡ With a health history and complete physical examination Done when patient enters a health care setting

‡ 2.

Ongoing Partial ‡ Conducted at regular intervals during care of patient Focuses on the identified health problems

‡ ‡ Obtain physical data about the client s functional abilities 3. ‡ Supplement, confirm, or refute data obtained in the client s health history Obtain data that will help the nurse establish diagnoses and plan the client s care. Focused ‡

Used to assess specific problem


4. Emergency ‡ ‡ Rapid focused assessment Determines potentially fatal situations

Evaluate the physiologic outcomes of health care and thus the progress of a patient s health problem To make clinical judgments about a client s health status To identify areas for health promotion and disease prevention Components of Health Assessment Health history - focused on interviewing skills Physical assessment - head-to-toe sequence, system sequence Factors to Assess During a Health History Biographic Data Chief Complaint History of Present Illness Past medical history Family History Lifestyle Types of Assessment

Preparing the Client Consider client s physiologic and psychological needs Explain the procedure to the client to lower the anxiety Ask relevant questions (health concerns, health habits, lifestyle) Answer client s questions directly and honestly Provide comfort and privacy to the client Ask client to empty bladder Ask client to change gown; help in undressing if necessary Positions Used in Physical Assessment Sitting - used to take vital signs Supine - allows relaxation of abdominal muscles Dorsal recumbent - used for patients having difficulty maintaining supine position Sim s - assessment of rectum and vagina 1 PE

Prone - assessment of hip joint and posterior thorax Lithotomy - assessment of female rectum and vagina; used for brief period only Knee-chest - assessment of rectal area; used for brief period only Standing - assessment of posture, gait and balance Preparing the Environment Agree on the time for assessment Schedule should not interfere with meals and daily routines of the client Client should be as free of pain as possible If possible, choose a quiet, well-lit, warm, and private room Make sure that the equipment are complete and in good condition For Your Information: Make sure to complete the health history of the client before proceeding with the physical assessment Physical assessment is being done to validate the subjective data gathered during the health interview In doing physical assessment, ensure client s safety, privacy, and comfort (eg. Expose only the area being examined) Compare findings on one side of the body to the other side Equipment Needed: Stethoscope Sphygmomanometer Thermometer Weighing scale Stadiometer / tape measure Wrist watch Snellen chart / Newspaper

Penlight Gloves Cardboard Tongue depressor Tuning fork Cotton balls Gauze pad Cotton applicator Alcohol Glass of water Ophthalmoscope / Otoscope Receptacle Paper and pen Techniques in Physical Assessment: Inspection Process of performing deliberate, purposeful observations in a systematic manner Use of different senses such as sight, hearing, and smell Begins with the initial contact and continues all throughout the assessment Assess color, size, shape, position and symmetry Palpation Assessment technique that uses the sense of touch Assess temperature, turgor, texture, moisture, vibrations and shape Dorsum surface: gross measure of temperature Palmar surface: texture, shape, fluid, size, consistency, and pulsation Nurse s hand should be warm; fingernails must be short Types of Palpation 2 PE

g.loud. Auscultation (except for abdomen) Components of Physical Assessment: General Survey Appearance 3 PE . or long Order of Physical Assessment Cephalocaudal (head-to-toe) Least Invasive to Most invasive Inspection.Light Palpation Hand should be parallel to the area being palpated 1-2 cm To check muscle tone and assess for tenderness Deep Palpation Hand should be at a 60 degree angle to the area being palpated 4 cm To identify abdominal organs and abdominal masses NOTE: should be done with EXTREME CAUTION Characteristics of Masses Determined by Palpation Shape Size Consistency Surface Mobility Tenderness Pulsatile Percussion Act of striking one object against another to produce sound Used to assess the location.g.g.g.g. very low-pitched. size.very loud.e. Percussion. heart) Resonance . high-pitched. medium.ranging from high to low Loudness . muscle. emphysematous lung) Tympany . liver.short. gurgling or swishing Duration . Palpation. and long in duration (e. moderate duration (e.ranging from soft to loud Quality . and moderate in duration (e.soft. stomach filled with gas) Auscultation Act of listening with a stethoscope to sounds produced within the body Bell side: low-pitched sound (BELL-ow) Ex: heart sounds Diaphragm: high-pitched sound Ex: bowel sounds Characteristics of Sound Heard When Using Auscultation Pitch . bone) Dullness . loud.g. high-pitched.medium in intensity and pitch. normal lung) Hyperresonance . shape. and density of tissue Types of Percussion Direct Percussion Primarily used to assess sinuses in the adult Indirect Percussion Two hands are used (plexor and pleximeter) Types of Sounds Heard When Using Percussion Flatness . and very long in duration (e. low-pitched. and short in duration (e.musical.

4. obvious illness Attitude Normal Findings: Cooperative Deviations from Normal: Negative. posture. ammonia odor. erect or slumped posture. varies with lifestyle Deviations from Normal: Excessively thin or obese Posture and gait. bent. orientation. eye contact. Cognitive processes (speech content and patterns. appropriate verbal response) Body built. unkempt Body and Breath Odor Normal Findings: No body odor or minor body odor relative to work or exercise No breath odor Deviations from Normal: Foul body odor. 3. and weight in relation to age. pattern of gait) Hygiene. wincing. weakness. neat Deviations from Normal: . ability to relax. Affect.1. standing. withdrawn Mood and Affect Normal Findings: Appropriate to situation Deviations from Normal: Inappropriate to situation 4 PE 2. Erect posture. and gait (proportion of height to weight. acetone breath odor. attitude. behavior) 5. mood (speech. foul breath Signs of distress in posture and facial expression Normal Findings: No distress noted Deviation from Normal: Bending over because of abdominal pain. uncoordinated movement. coordination of movements. lifestyle and health Normal Findings: Proportionate. slouched. Body build. or labored breathing Obvious signs of health or illness Normal Findings: Healthy Appearance Deviation from Normal: Pallor. hostile. height. coordinated movement Deviations from Normal: Tense. grooming (cleanliness. body odors) Signs of illness Dirty. sitting and walking Normal Findings: Relaxed. facial expressions. tremors Overall Hygiene and Grooming Normal Findings: Clean.

and scalp Assessed by observation and palpation Normal Findings: . albinism.10 N Range= DBW-C (Lower Limit) = DBW+C (Upper Limit) BMI= wt. Pulse Rate. has sense of reality Deviations from Normal: Deviations from Normal: Pallor (paleness of the skin) Illogical sequence. makes sense. Respiratory Rate. Ruddy pink to light pink. Quality. hair. moderate pace. Blood Pressure) Measurement of Height and Weight Cyanosis (bluish or grayish discoloration of the skin) Erythema (redness of the skin) Illustration: Skin Color Abnormalities Skin: Inspect Uniformity of Color Normal Findings: Generally uniform except in areas exposed to the sun. confusion Jaundice (yellow color of the skin) Measurement of Vital Signs (Temperature. in (m)2 Assessment of the Integument Skin: Inspect skin vascularity Integumentary structures assessed are the skin.B where.10 . uses generalizations. nails. Vitiligo. edema) Illustration: Abnormalities in Skin Uniformity hypopigmentation hyperpigmentation (Refer to Height and Weight Table) NOTE: Given: DBW= A. flight of ideas. Yellow overtones to olive Logical sequence. and Organization of Speech Normal Findings: Understandable. exhibits thought association Deviations from Normal: Begins with an overall inspection of the skin s condition Can be assessed during other body system assessments Skin: Inspect for skin color Assessment Findings Rapid or slow pace. Areas of lighter pigmentation (palms. lacks association. in kg/ ht. A= ht.Quantity.Absence of bruising/ bleeding on the skin Deviations from Normal: 5 PE areas of either hyperpigmentation or hypopigmentation (eg. in cm -100 B= (A) * . nail beds) in dark-skinned people Deviations from Normal: C= (DBW) * . exhibits confabulation Relevance and Organization of Thoughts Normal Findings: Normal Findings: varies from light to deep brown. lips.

In shock). In dehydration) Skin Turgor (Fullness or elasticity of the skin) 6 PE . ie.) Illustration: Common Skin lesions corneum Crust is dried exudate (ie. assess location. Fever). pustule. Scale is the accumulation or excess shedding of the stratum Localized hypothermia (eg. body temperature. and size Illustration: Abnormalities on Skin Vascularity Ecchymosis (collection of blood in the subcutaneous tissues causing purplish discoloration) Petechiae (small hemorrhagic spots caused by capillary bleeding) Skin: Inspect skin lesions Normal Findings: Freckles. some flat and raised nevi (moles). In infection).5 cm A bulla is a large fluid-filled bubble that is superficial or deep & that is > 0. nodule. tinea. and activity) Deviations from Normal: Excessive moisture (eg. Within normal range Macule A macule is a small spot that is not palpable & that is < 1 cm Deviations from Normal: Generalized hyperthermia (eg. blood.Ecchymosis Petechiae NOTE: If present. tumor. some birthmarks. color. A papule is a small superficial bump that is elevated & that is < 1 cm A vesicle is a small fluid-filled bubble that is usually superficial & that is < 0. eczema. Localized hyperthermia (eg. serum. In arteriosclerosis) Skin Moisture Normal Findings: Moisture in skin folds and the axillae (varies with environmental temperature and humidity.5 cm A pustule is pus containing bubble often categorized according to whether or not they are related to hair follicles A cyst is a sac containing fluid or semisolid material Scale is typically present where there is epidermal inflammation. etc. often very painful A wheal or hive describes a short lived (< 24 hours). psoriasis. pus) on the skin surface Excoriation is a loss of skin due to scratching or picking Lichenification is an increase in skin lines & creases from chronic rubbing A fissure is a linear crack in the skin. well circumscribed papule or plaque seen in urticaria Petechiae or purpura or ecchymosis describes red blood cells that are outside the vessel walls & areas are nonblanchable Skin Temperature Normal Findings: Uniform. Deviations from Normal: Various interruptions in skin integrity (eg. papule. Macule. In hyperthermia) Excessive dryness (eg. Generalized hypothermia (eg. No abrasions and other lesions. edematous. wheal. vesicle.

Hair and Scalp: Inspect hair thickness or thinness Nails: Inspect Nail Bed Color Normal Findings: Normal Findings: Thick hair Highly vascular and pink in light-skinned clients.Normal Findings: When pinched: skin springs back to previous state Dark.skinned client may have brown or black pigmentation in longitudinal streaks Deviations from Normal: (good skin turgor) Bluish or purplish tint (my reflect cyanosis). Clubbing (180 degrees or >) Nails: Inspect Nail Texture Normal Findings: Smooth texture Deviations from Normal: Excessive thickness. In dehydration) In edema. an indention may remain after the pressure is released Illustrations: Abnormalities in Skin Elasticity Nails: Inspect Nail plate shape (Curvature and Angle) Normal Findings: Convex curvature. Angle between nail and nail bed of about 160 degrees Deviations from Normal: Spoon nail. there would be difficulty in lifting the skin fold. Beau s line Deviations from Normal: Illustrations: Abnormalities in Nail Shape and Texture Cont. Deviations from Normal: 7 PE Patches of hair loss (eg. excessive thinness or presence of grooves or furrows.. Deviations from Normal: Pallor (may reflect poor arterial circulation) Skin stays pinched or tented or moves back slowly (eg. Paronychia (inflammation) Nails: Perform Blanch Test for Capillary Refill Nails: Capillary Refill Normal Findings: Prompt return of pink or usual color Deviations from Normal: Delayed return of pink or usual color (may indicate circulatory impairment) Hair and Scalp: Inspect the evenness of growth over the scalp . Alopecia) Hair and Scalp: Inspect the evenness of growth over the scalp Normal Findings: Evenly distributed hair Illustration: Abnormalities in Nail Bed Color Nails: Inspect Tissues Surrounding Nails Normal Findings: Intact epidermis Deviations from Normal: Hangnails. If there is pitting edema.

Exophthalmus. lice. In hypothyroidism). nose. Asymmetric features. and lymph nodes Skull and Face: Inspect the skull for size. ring worm Hair and Scalp: Inspect amount of body hair Normal Findings: Variable Deviations from Normal: Hirsutism (excessive hairiness in women and children) Assessment of the Head and Neck . nits (louse eggs). Symmetry of structures and of the distribution of hair) Normal Findings: Symmetric or slightly asymmetric facial features. trachea. mouth and pharynx. sores. In hypothyroidism) Hair and Scalp: Inspect hair texture and oiliness Normal Findings: Silky. Palpebral fissures equal in size. resilient hair Deviations from Normal: Brittle hair (eg. face. parietal. Excessively oily or dry hair Hair and Scalp: Note presence of infection or infestations Normal Findings: No infection or infestation Deviations from Normal: Flaking. uniform consistency. Shape. with frontal. Thinning of eyebrows. Symmetric nasolabial folds Deviations from Normal: Increased facial hair. thyroid gland. ears. Longer mandible (may indicate excessive growth hormone or increased bone thickness) Illustration: Abnormality in Skull Size. Local deformities from trauma Skull and Face: Inspect the facial features (eg.Very thin hair (eg. and symmetry Normal Findings: Increased skull size with more prominent nose and forehead. shape. and Symmetry Skull and Face: Palpate the skull for nodules or masses and depressions Normal Findings: Smooth. sinuses. eyes. face. Rounded (Normocephalic and symmetric. Absence of nodules or masses Deviations from Normal: Sebaceous cysts.includes the skull. Moon face Illustrations: Abnormalities in facial features Skull and Face: Inspect the eyes for edema and hollowness Normal Findings: 8 PE . and occipital prominences) Smooth skull contour Deviations from Normal: Lack of symmetry. Myxedema facies.

bilateral blinking. scaling and flakiness of skin. Approximately 15-20 involuntary blinks/ min. When lids open. Lids close asymmetrically. absent. skin intact. incompletely. flaking. lesions. Skin quality and texture. plaques. Eyes: Inspect the eyelashes for evenness of distribution and direction of curl Normal Findings: Equally distributed. Sclera appears white (yellowish in dark-skinned clients) Deviations from Normal: Jaundiced sclera. or infrequent blinking. or painfully. swelling. Lesions or nodules Illustrations: Abnormalities of Conjuctiva 9 PE . texture.Absence of edema Deviations from Normal: Periorbital edema. and smile and show the teeth Normal Findings: Symmetric facial movements Deviations from Normal: Asymmetric facial movements (eg. no discoloration. discharge. Ptosis. Rapid. and upper and lower borders of cornea are slightly covered Deviations from Normal: Redness. Reddened sclera. Tics or tremors) Assessment of the Eyes Eyes: Inspect the eyebrows for hair distribution and alignment and skin quality and movement Normal Findings: Hair evenly distributed. position in relation to the cornea. Eye on affected side cannot close completely). or lower the eyebrows. puff the cheeks. Excessively pale sclera. Capillaries sometimes evident.. rim of sclera visible between lid and iris Illustrations: Abnormalities of the Eyelids Eyes: Inspect the bulbar conjunctiva (lying over the sclera) for color. Unequal alignment and movement of eyebrows. no discharge. Curled slightly outward Deviations from Normal: Turned inward Eyes: Inspect the eyelids for surface characteristics (eg. and frequency of blinking) Normal Findings: Skin intact. monocular. Involuntary facial movements (eg. ability to blink. and presence of lesions Normal Findings: Transparent. Eyebrows symmetrically aligned. entropion. Drooping of lower eyelid and mouth. close the eyes tightly. equal movement Deviation from Normal: Loss of hair. Sunken eyes Skull and Face: Note symmetry of facial movements . no visible sclera above corneas.ask the client to elevate the eyebrows. crusting. nodules. Lids close symmetrically. frown. ectropion.

Eyes: Inspect the palpebral conjuctiva (lining the eyelids) by everting the lids Eyes: Inspect the palpebral conjuctiva (lining the eyelids) by everting the lids. . and the presence of lesions. Eyes: Inspect and palpate the lacrimal sac and nasolacrimal sac Normal Findings: No edema or tearing Normal Findings: Deviations from Normal: Black in color. Evidenced of increased tearing. smooth. texture. details of the iris are visible. In older people. surface not smooth (may be the result of trauma or abrasion). 3-7 mm diameter. Equal in size. smooth border. shiny and smooth. anisocoria. grayish white ring around the margin. and pink or red Deviations from Normal: Extremely pale (possible anemia). Swelling or tenderness over lacrimal glands Crescent-shaped shadows on far side of iris. and symmetry of size. Regurgitation of fluid on palpation of lacrimal sac Round. iris flat and round Eyes: Inspect the cornea for clarity and texture Deviations from Normal: Normal Findings: Transparent. a thin. Note color. shape. Opaque. called arcus senilis. Arcus senilis in clients under age 40 is abnormal Eyes: Perform the corneal sensitivity (reflex) test to determine the function of the 5th (Trigeminal) Cranial Nerve Normal Findings: Client blinks when the cornea is touched. myosis (constriction of pupils) . mydriasis (dilation of the pupil). Normal Findings: Shiny. Bulging of iris toward cornea Illustrations: Normal and Abnormal Pupils Eyes: Assess each pupil s direct and consensual reaction to light 10 PE Shallow chamber Eyes: Inspect the pupils for color. indicating that the trigeminal nerve is intact Deviations from Normal: Extremely red (inflammation). maybe evident Deviations from Normal: Cloudiness. One or both eyelids fail to respond Nodules or other lesions Inspection of Sclera Conjunctiva Inspection of Eyes: Inspect the anterior chamber for transparency and depth Normal Findings: Eyes: Inspect and palpate the lacrimal gland No shadows of light on iris Normal Findings: Depth of about 3mm No edema or tenderness over lacrimal glands Deviations from Normal: Deviations from Normal: Cloudy.

such as strabismus (cross-eye or squint) Extraocular Movements Cont. indicating it is not well aligned before other was covered. Normal Findings: One or both eyes fail to follow a penlight in specific directions. or converge Accommodation Convergence Eyes: Assess peripheral visual fields Eyes: Assess peripheral visual fields Normal Findings: When looking straight ahead.Normal Findings: Illuminated pupil constricts (direct response) Non-illuminated pupil constricts (consensual response) Deviations from Normal: Neither pupil constricts Unequal responses Visual fields Cont. Eyes: Assess six ocular movements to determine eye alignment and coordination Normal Findings: Both eyes coordinated. it is shifting from lateral to central gaze. move in unison. Pupils constrict when looking at near object Pupils dilate when looking at far objects Pupils converge when near object is moved towards nose Deviations from Normal: One or both pupils fail to constrict. One half vision in one or both eyes (indicates nerve damage) Uncovered eye does not move from fixed point when the other eye is covered Newly uncovered eye. dilate. if well aligned. indicating it was not well aligned when covered Eyes: Perform the corneal light reflex test to determine eye alignment Normal Findings: Light reflection appears at symmetric spots in both eyes Deviations from Normal: 11 PE Illustrations: Abnormalities Eyes: Perform the cover-uncover patch test to determine eye alignment. client can see objects in the periphery Deviations from Normal: Visual fields smaller than normal (possible glaucoma). with parallel alignment Deviation from Normal: Absent responses Eye movements not coordinated or parallel. Deviations from Normal Uncovered eye moves to focus on fixed point. .. Illustrations: Normal Pupil reaction to Light Illustrations: Abnormal Reaction of Pupil to Light Eyes: Assess each pupil s reaction to accommodation and convergence Normal Findings: Cont.. Newly uncovered eye moves to focus on fixed point. does not move when index card is removed..

wet cerumen in various shades of brown Deviations from Normal: Redness and discharge Scaling Excessive cerumen obstructing canal Ears: Inspect the tympanic membrane for color and gloss 12 PE . Pallor (eg.). inspect the external canal Ears: Using an otoscope. downward and backward (<3 y. firm.Push in on the tragus . and not tender Pinna recoils after it is folded Deviations from Normal: Lesions (eg. grayish-tan color. pus and blood and the tympanic membrane for color Normal Findings: Distal third contains hair follicles and glands Dry cerumen.o. elasticity. Line drawn from lateral angle of the eye to point where top part of auricle joins head is horizontal Deviations from Normal: Bluish color of earlobes (eg.Apply pressure to the mastoid process Normal Findings: Mobile. scaly skin Tenderness when moved or pressed (may indicate inflammation or infection of external ear) Ears: Using otoscope. Cyst) Flaky. and position Normal Findings: Color same as facial skin Symmetric position. skin lesions. inspect the external ear canal for cerumen.Pull the auricle upward and backward (>3 y. or sticky.o. the poorer the vision Test for visual acuity Charts used to assess visual acuity PERRLA Pupils Equally Round and Reactive to Light and Accommodation Assessment of the Ears Ears: Inspect the auricles for color. and areas of tenderness . such as Down syndrome) Illustrations: Abnormalities in Auricles Ears: Palpate the auricles for texture. Cyanosis). Excessive redness (inflammation or fever) Low-set ears associated with congenital anomaly. Frostbite).Light reflection appears at different spots in each eye (asymmetric) Eyes: Assess visual acuity (near vision) Normal Findings: Able to read newsprint at a distance of 36 cm (14 in) Deviations from Normal: Difficult reading newsprint unless due to aging process Eyes: Assess visual acuity (distance vision) Normal Findings: 20/20 vision on Snellen chart Interpretation: Client can read the letters/objects in 20 ft which a normal sighted person can read at 20 ft Deviations from Normal: Denominator of 40 or more on Snellen chart with corrective lenses Note: The higher the denominator.Pull the pinna forward (it should be recoil) . symmetry of size.) .

Repeat with the other ear. BC>AC or BC=AC (negative Rinne. turn the head. or the hearing center in the brain Mixed hearing loss . that is.the result of interrupted transmission of sound waves through the outer and middle ear structures Sensorineural hearing loss . Increase the loudness of the whisper until the client can identify at least 50% of the numbers. indicating a sensorineural disturbance Note findings as Weber positive and indicate whether right or left ear Ears: Conduct the Rinne test Ears: Conduct the Rinne test to compare air conduction to bone conduction Normal Findings: Air-conducted (AC) hearing is greater than boneconducted (BC) hearing. some opacity Yellow amber White Blue or deep red Dull surface Able to hear ticking in both ears Deviations from Normal: Unable to hear ticking in one or both ears Ears: Perform Weber s Test Ears: Perform Weber s test Normal Findings: Sound is heard in both ears or is localized at the center of the head (Weber negative) Deviations from Normal: Ears: Assess gross hearing acuity tests Ears: Assess client s response to normal voice tones Normal Findings: Normal voice tones audible Deviations from Normal: Normal voice tones not audible (eg. Requests nurse to repeat words or statement. that is. indicating a bone-conductive hearing loss (eg. . Ask the client to occlude one ear by putting a finger in it. indicates a conductive hearing loss) Types of Hearing Loss: Conduction hearing loss .Stand 30 to 60 cm (1-2 ft) from the client in a position where the client cannot read your lips.result of damage to the inner ear.Whisper some nonconsecutive numbers and have the client tell you what was heard.Place ticking watch 2 to 3 cm (1-2 in) from the unoccluded ear Normal Findings: Assessment of the Nose 13 PE Sound is heard better in impaired ear. the auditory nerve. or speaks in loud tone of voice) Ears: Assess client s response to whispered voice .Normal findings: Pearly gray color. Normal Findings: Able to repeat nonconsecutive numbers Deviations from Normal: Unable to repeat 50% of numbers whispered Ears: Perform the watch tick test .combination of conduction and sensorineural loss . or sound is heard better in ear without a problem. leans toward the speaker. cups the ears. semitransparent Deviations from Normal: Pink to red. Due to obstruction). AC>BC (positive Rinne) Deviations from Normal: Bone conduction time is equal to or longer than the air conduction time.

size. and breathe through the opposite naris. and displacements Normal Findings: No tenderness No lesions Deviations from Normal: Tenderness on palpation Presence of lesion Nose: Determine patency of both nasal cavities . Purulent_ Presence of lesions (eg. contain air. exert pressure on one naris.Nose: Inspect the external nose for any deviations in shape. masses.Place penlight against the inner aspect of the supraorbital ridge of the frontal bone . Repeat on the opposite naris. Polyps) Septum deviated Nose: Palpate facial sinuses Palpating the sinuses Nose: Palpate the maxillary and frontal sinuses for tenderness Normal Findings: Not tender Deviations from Normal: Tenderness in one or more sinuses Nose: Transilluminate the frontal sinuses . and light up equally Deviations from Normal: Fluid in sinuses appears darker on transillumination Nose: Transilluminate the maxillary sinuses .Place a penlight in the mouth and shine it to the left and to the right Normal Findings: As above 14 PE . edematous Abnormal discharge (eg.Ask the client to close the mouth. watery discharge No lesions Nasal septum intact and in midline Deviations from Normal: Mucosa red. or color and flaring or discharge from the nares Normal Findings: Symmetric and straight No discharge or flaring Uniform color Deviations from Normal: Asymmetric Discharge from nares Localized areas of redness or presence of skin lesions Nose: Lightly palpate the external nose Nose: Lightly palpate the external nose to determine any areas of tenderness. Normal Findings: Air moves freely as the client breathes through the nares Deviations from Normal: Air movement is restricted in one or both nares Nose: Inspect the nasal cavities Nose: Inspect the nasal cavities Normal Findings: Mucosa pink done in a darkened room Normal Findings: Sinuses are well-outlined.

texture. generalized or localized swelling. and the presence of lesions Normal Findings: Uniform pink color (freckled brown pigmentation in dark-skinned clients) Moist. and texture 15 PE Brown or black discoloration of the enamel (may indicate staining or the presence of caries) Excessively red gums Spongy texture. firm texture to gums No retraction of gums (pulling away from the teeth) Symmetry of contour Deviations from Normal: Ability to purse lips Missing teeth Deviations from Normal: Ill-fitting dentures Pallor. color. abrasions. swelling that partially covers the teeth Mouth and Pharynx: Inspect the dentures . Bluish hue.Deviations from Normal: As above Assessment of the Mouth and Pharynx Mouth and Pharynx: Inspect the outer lips for symmetry of contour. in Mediterranean groups and dark-skinned clients) Soft. noting broken or worn areas Normal Findings: Smooth. color. irritations from dentures. glistening. soft. shiny tooth enamel Pink gums (bluish or dark patches in dark-skinned clients) Moist. moisture. nutritional deficiency. and texture Normal Findings: Uniform pink color (darker. smooth texture Mouth and Pharynx: Inspect teeth and gums . or scales (may result from excessive moisture. bleeding. nodules Mouth and Pharynx: Inspect the surface of the tongue Mouth and Pharynx: Inspect the surface of the tongue for position. cyanosis Blisters. fissures. eg. intact dentures Deviations from Normal Ill-fitting dentures . ulcerations.can be done while examining the inner lips and buccal mucosa Normal Findings: 32 adult teeth Smooth. or fluid deficit) Inability to purse lips (indicative of facial nerve damage) Mouth and Pharynx: Inspect and palpate the inner lips and buccal mucosa Mouth and Pharynx: Inspect and palpate the inner lips and buccal mucosa for color. crusts. white patches (leukoplakia) Excessive dryness Mucosal cysts. tenderness (may indicate periodontal disease) Receding atrophied gums.Inspect their condition.Ask client to remove complete or partial dentures . and elastic texture (drier oral mucosa in elderly due to decreased salivation) Deviations from normal: Irritated and excoriated area under dentures Pallor. white. smooth. moist.

the mouth floor. lateral margins. texture. discolorations (white or red areas). thin whitish coating Smooth.Normal Findings: Central position Pink color (some brown pigmentation on tongue borders in dark-skinned clients). more irregular texture Deviations from Normal: Discoloration (eg. shape.ask the client to place the tip of the tongue against the roof of the mouth Normal Findings: Smooth tongue base with prominent veins Varicosities (tiny bluish-black or purple swollen areas) in elderly people Deviations from normal: Swelling Ulcerations Mouth and Pharynx: Palpate the tongue and floor of the mouth for any nodule. lumps. and the presence of bony prominences Normal Findings: Light pink.use gauze to grasp tip of the tongue Normal Findings: Smooth with no palpable nodules Deviations from Normal: Swelling. smooth. Vit B12. soft palate Lighter pink hard palate. moist. Immobility (may indicate damage to trigeminal or 5th or vagus or 10th cranial nerve 16 PE . or Vit B3 deficiency) Dry. Jaundice or pallor) Plated the same color Irritations Bony growths (exostoses) growing from the hard palate Mouth and Pharynx: Inspect the uvula for position and mobility while examining the palates Normal Findings: Positioned in midline of soft palate Deviations from Normal: Deviation to one side from tumor or trauma. nodules Illustration: Abnormality of the Tongue Mouth and Pharynx: Inspect salivary duct openings for any swelling or redness Normal Findings: Same as color of buccal mucosa and floor of mouth Deviations from Normal: Inflammation (redness and swelling) Mouth and Pharynx: Inspect the hard and soft palate for color. areas of tenderness Mouth and Pharynx: Inspect tongue movement Normal Findings: Moves freely No tenderness Deviations from Normal: Restricted mobility Mouth and Pharynx: Inspect the base of the tongue. and the frenulum . slightly rough. . ulcerations. furry tongue (associated with fluid deficit) Nodes. or exoriated areas. no lesions Deviations from Normal: Deviated from center (may indicate damage to hypoglossal or 12th cranial nerve) Smooth red tongue (may indicate iron.

involuntary movements (eg. injury. presence of lesions. or exudate Mouth and Pharynx: Inspect the tonsils for color. smooth movements with no discomfort Deviations from Normal: Unilateral neck swelling Head tilted to one side (indicates presence of masses. scars) . discharge. Up-and-down nodding movements associated with Parkison s disease) Neck: Assess muscle strength . or stiffness Limited range of motion. spasm.Turn the head to one side against the resistance of your hand . plaques.Shrug the shoulders against the resistance of your hands Normal Findings: Equal strength Deviations from Normal: Unequal strength Neck: Observe head movement ask client to: move the chin to the chest move the head back so that the chin points upward move the head so that the ear is moved toward the shoulder on each side turn the head to the right and to the left Normal Findings: Coordinated.Mouth and Pharynx: Inspect the oropharynx for color and texture Normal Findings: Neck: Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal swellings or masses Normal Findings: Pink and smooth posterior wall Muscles equal in size Deviations from Normal: Head centered Reddened or edematous. shortening of sternocleidomastoid muscle. muscle weakness. and size Normal Findings: Pink and smooth No discharge Of normal size Deviations from Normal: Inflamed Presence of discharge Swollen Illustrations: Inspecting tonsils for tonsillitis Grading System for Tonsilitis Deviations from Normal: Grade 1 (Normal) The tonsils are behind the tonsillar pillars Grade 2 between the pillars and the uvula Grade 3 tonsils touch the uvula Grade 4 one or both tonsils extend to the midline of the oropharynx Mouth and Pharynx: Elicit gag reflex Normal Findings: Present Deviations from Normal: Absent (may indicate problems with glossopharyngeal or vagus nerves) Assessment of the Neck 17 PE Muscle tremor. painful movements.

auscultate over the thyroid area for a bruit bruit . Supraclavicular 9. 3. use bell side of stethoscope Normal Findings: Absence of bruit Deviations from Normal: Presence if bruit Illustrations: Abnormalities of the Thyroid and Parotid Glands POSTERIOR THORAX 1. thyroid enlargement. Anterior or deep cervical chain Solitary nodules Neck: Palpate the entire neck for enlarged lymph nodes Normal Findings: Not palpable Deviations from Normal: Enlarged. NORMAL FINDINGS Anteroposterior to transverse diameter is 1:2 ratio Chest symmetric DEVIATIONS 18 PE Neck: If enlargement of the gland is suspected. Posterior Approach Anterior Approach 2. Posterior Cervical 10. 2. Tonsillar / Superficial anterior cervical 8. and rise freely with swallowing Deviations from Normal: 6. Inspect the shape and symmetry of the thorax from posterior and lateral view. Submental Not visible on infection Deviations from Normal: Visible diffuseness or local enlargement Submaxillary / Submandibular Neck: Palpate the thyroid gland for smoothness Parotid (not a lymph node) 1. palpable. Occipital 7.Neck: Palpate the entire neck for enlarged lymph nodes 1. lobes are small. 4. indicating possible neck tumor. centrally located.a soft rushing sound created by turbulent blood flow. auscultate over the thyroid area for a bruit . painless. Postauricular Neck: Palpate the thyroid gland for smoothness Normal Findings: Lobes may not be palpated If palpated. enlarged lymph nodes Neck: Inspect the thyroid gland Normal Findings: Neck: If enlargement of the gland is suspected. Preauricular 5. smooth. possibly tender (associated with infection and tumors) Neck: Palpate the trachea for lateral deviation Neck: Palpate the trachea for lateral deviation Normal Findings: Central placement in midline of neck Spaces are equal on both sides Deviations from Normal: Deviation to one side.

For clients who have respiratory complaints. observe the standing client from the rear. Ask ct to repeat words blue moon . tenderness or abnormal movement. 19 PE .5 to 2 inches) thumb separation @ inspiration DEVIATIONS Asymmetric/decreased chest expansion 5. bulges. Place the palms of both your hands over the lower thorax with your thumbs adjacent to the spine and your fingers stretched laterally. palmar surface of your fingertips aspect of your hand or closed fist . For clients who have no respiratory symptoms. R and L shoulders and hips at same height DEVIATIONS Lordosis forward curvature of lumbar spine Kyphosis. Ask the client to take a deep breath while you observe the movement of your hands and any lag in movement CHEST EXCURSION /CHEST EXPANSION NORMAL FINDINGS Symmetrical chest expansion 3-5 cm or (1. Spinal column straight. Repeat the two steps moving your hands sequentially to the base of the lungs. Inspect spinal alignment for deformities Have the client stand in a lateral position. Place hands on the posterior chest starting near the apex of the lungs. Palpate vocal tactile fremitus (a thrill felt by the hand on the chest wall while the client is speaking) a . c. b. Have the client bend forward and observe from NORMAL FINDINGS Spine vertically aligned. depressions. angular curvature of thoracic spine Scoliosis lateral curvature of spine. masses areas of tenderness DEVIATIONS Areas of hyperthermia (+)lesions Lumps. 1. rapidly assess the temperature and integrity of all chest skin.ulnar a. 3 . movable structures (eg ribs) Asymmetric/decreased chest expansion 4. palpate all chest area for bulges. Palpate the posterior thorax Uniform temperature Skin intact Chest wall intact No lumps. 2. tenderness. c.Barrel chest (1:1) APL ratio Chest asymmetric BARREL CHEST 2. Palpate the posterior chest for respiratory excursion (thoracic expansion). Avoid deep palpation for painful areas (ie fractured rib) NORMAL FINDINGS b. observe the 3 normal curvatures: cervical. thoracic and lumbar To assess the lateral deviation of spine .hunchback. shoulders/ hips not even LORDOSIS KYPHOSIS SCOLIOSIS 3.

Auscultate chest using flat disc diaphragm of the stethoscope. Ask ct to bend and fold arms across chest. Percuss the thorax to determine whether underlying lung tissue is air-. to separate scapula and expose more lung tissue b. Asymmetry on percussion NORMAL FINDINGS 20 PE 8-10th Use systematic zigzag procedure used in percussion. Ask ct to take a slow deep breath thru the mouth. Percuss lateral thorax every few inches from axilla th down to 8 for transmitting high pitched sounds. b. Percuss in intercostals spaces at 5cm (2in) intervals in systematic sequence. Ask ct to take few normal breaths then expel last breath completely and hold it while percussing upward from marked point to assess/mark diaphragmatic excursion @ deep expiration on both sides.(+) dullness / flatness over diapghram lung tissue d. c.5 . to determine positions and boundaries of certain organs. Compare each point with the . Ask ct to take deep breath and hold it while you percuss downward along scapular line until to point of dullness @ diaphragm level. DEVIATIONS fremitus (pneumothorax) fremitus (pneumonia) SEQUENCE IN GETTING THE VOCAL FREMITUS 6. Compare the fremitus on both lungs and b/w the apex and the base of each lung. NORMAL FINDINGS Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs. NORMAL FINDINGS Resonance except over Lowest resonance (consolidation of posterior rib) Dullness over ribs corresponding point on the opposite side DEVIATIONS of the chest. b. Compare both sides of the lungs. c. lung tissue/mass 7. Listen at each point to the breath sounds during complete inspiration and expiration.3 in) *bilaterally usually slightly higher on R side DEVIATIONS Restricted excursion (r/t lung disorder) 8. water. a. SEQUENCE OF POSTERIOR LUNG PERCUSSION a. Measure distance b/w 2 marks DIAPHRAGMATIC PERCUSSION SEQUENCE NORMAL FINDINGS Females: 3-5 cm (1. either using one hand and moving it from one side of the client to the corresponding area on the other side or using 2 hands simultaneously on corresponding areas of each side of chest.or solidmaterial filled. Percuss for diaphragmatic excursion (movement of diaphragm @ maximal inspiration & expiration) a. Mark this point and repeat on other side.2 in) Males: 6 cm (2 .

movable structures (eg ribs) 4.Palpate the anterior chest. Displace female breast for proper examination NORMAL FINDINGS 21 PE * Omit this procedure if the breasts are large and cannot be retracted adequately for palpation NORMAL FINDINGS . rhythmic and DEVIATIONS effortless respiration. 2. Compare one side of the lung to the other. DEVIATIONS fremitus (pneumothorax) fremitus (pneumonia) 6. b. patterns. Fremitus is heard most clearly at the apex of the lungs. rate). 3 . Asymmetric or excursion Deviations : Abnormal RR. rhonchi. ANTERIOR VOCAL FREMITUS characteristics. wheeze. Lumps. Palpate anterior chest for respiratory excursion. Place the palms of both hands on lower thorax with fingers laterally along lower rib cage and thumbs along costal margin. depressions.Adventitious sounds (crackles. Inspect the costal angle (angle formed by intersection of costal margins) and the angle at which the ribs enter the spine. NORMAL FINDINGS Bilateral symmetry of vocal fremitus. b. Percuss anterior chest systematically. tenderness. friction rub) a. and proceed downward to the diaphragm. depth. fremitus over heart and breast tissue. rate. (same with post. chest) Normal Findings : Uniform temperature Skin intact Chest wall intact No lumps. Begin above the clavicles in the supraclavicular space. 5. Inspect breathing patterns (RR. a. Palpate tactile fremitus in the same manner as for the posterior chest. masses areas of tenderness Deviations: Areas of hyperthermia (+)lesions. bulges. Costal angle is < 90 Ribs insert into spine at 45 angle DEVIATIONS Widened costal angle (r/t COPD) 3.5 inches bilateral thumb separation Normal findings : Quiet. c. Ask ct to take a deep breath while you observe the movement of your hands NORMAL FINDINGS Absent breath sounds (lung collapse or surgical lung lobe removal) ANTERIOR THORAX Full and symmetric 1.

lesions. which can tense the abdominal muscles. with arms placed comfortably at the sides a. striae. Auscultate the trachea.9 Regions (imagine 2 vertical lines that extend superiorly from the midpoints of the inguinal ligaments. creating false results. scars. uniform color (no lesion) Silver-white striae(stretch marks) or surgical scars Abnormal Findings (+) rash and other lesions tense. Auscultate the anterior chest Use the sequence used in percussion beginning over the bronchi between the sternum and the clavicles. glistening skin (ascites. Normal Findings: Bronchovesicular and vesicular breath sounds. Pigmentation. Place small pillows beneath the knees and the head to tension in the abdominal muscles. b. DEVIATIONS Asymmetry (+) dull/flat over lung tissue SEQUENCE ANTERIOR LUNG PERCUSSION 7. veins and umbilicus 1. one at the edge of the lower ribs and the other at the level of the iliac crests 22 PE Normal Findings Unblemished skin. 2 common methods in subdividing the abdomen (imagine 2 lines: A vertical line from the xiphoid process to the pubic symphysis and a horizontal line across the umbilicus . which can bowel motility and thus bowel sounds. Expose only the ct s abdomen from chest line to the pubic area to avoid chilling and shivering. th .Resonance down to 6 rib @ diaphragm level Flat over heavy muscles and bone Dull over the heart and the liver Tympanic over underlying stomach. Assist ct to a supine position. Inspect abdomen for skin integrity. and two horizontal lines.Auscultation done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel. edema) purple striae (Cushing s stretchmarks ascites stretchmarks Thank You! 2. Deviations: Adventitious breath sounds Sequence of Modalities: IAPPa . Normal Findings: Bronchial/tubular breath sounds Deviations : Adventitious breath sounds 8.

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