INTRODUCTION TO HEALTH ASSESSMENT

HEALTH
defined as being “a state of complete physical, mental, and social well- being and not merely the absence of
disease or infirmity.”
It is a relative state in which a person is able to live to his or her potential and includes “8 facets”

Physical wellness takes into consideration Social wellness is a sense of inclusiveness and
multiple areas including activity level and connection. If a patient feels isolated, figuring
exercise, proper nutrition, and sleep. out family dynamics and a potential support
system are important.

Emotional health is the ability to
handle life and its challenges that may
arise. The ability to be resilient and use
coping mechanisms effectively.
EMOTIONAL
PHYSICAL SOCIAL Spiritual health involves a person’s sense
of values and beliefs. A patient may wish to
speak with a spiritual advisor or may utilize
meditation or some other form of self-care.
SPIRITUAL

Occupational ENVIRONMENTAL
Occupational wellness involves the Environmental wellness encompasses the
work milieu, including the type of job, patient’s surroundings, which may be in the
relationships with coworkers, and home or outside and can affect health.
Financial Intellectual
management.

. Financial aspects of health are often stressful. Intellectual wellness is the ability to
Finances for the basics such as shelter, food, and advance knowledge and is different for each
health care may be lacking. person.

2 COMPONENT OF HEALTH ASSESSMENT

HEALTH ASSESSMENT
HEALTH HISTORY – asks pertinent questions to
▪ Entails both a comprehensive health history and a gather data from the patient and/or family.
complete physical examination that uses to evaluate
Past medical records may also be utilized to
the health status of a person.
▪ The ability to gather information, understand the collect additional information.
findings and apply knowledge. PHYSICAL EXAMINATION – uses a structured
▪ Involves a systematic data collection that provides head-to-toe examination to identify changes in
information to facilitate a plan to deliver the best care the patient’s body systems
for the patient.

PURPOSE OF HEALTH ASSESSMENT

▪ To determine a patient’s status, risk factors, and need for health education as basis for
developing a plan of care.
▪ Overall goal: to extrapolate (conclude) the findings, prioritize them & finally implement the
care.
HEALTH HISTORY
▪ Demographic Data - the name of client, age, birthday, etc.
▪ Chief Complaint - why the patient visited your clinic. For example, because of pain.
▪ History of Present Illness - Three days prior to admission, the patient experienced pain in
the lower abdomen.
▪ Past Medical History - did the patient undergo some surgical procedures in the past?

1
 ▪ Past Psychological Issues - if the patient had psychological problems
▪ Family History - is there anyone in the family that has some types of illnesses like
hypertension, diabetes.
▪ Personal/Social History - employment status, etc.
▪ Cultural History - patient’s ethnicity and nationality
▪ Spiritual Beliefs - patient’s religion
▪ Review of Systems - general to physical examination
PHYSICAL EXAMINATION
▪ Structured head-to-toe examination
▪ Identify changes in patient’s body systems
▪ Unusual or abnormal findings may support history
▪ data or trigger new questions
▪ Document all findings in a clear, concise manner
▪ Collate all information with medical records
THE NURSING PROCESS
The nursing process is the broad systematic framework that
provides a methodical base for the practice of nursing. This The goal of Nursing process:
problem-solving approach addresses the human responses ▪ Extrapolate the findings
and needs of each patient, family, and community.
▪ Prioritize the findings
▪ Formulate the plan of care
▪ Implement the plan of care

STEPS OF NURSING PROCESS

1. ASSESSMENT – all assessment involves collecting two kinds of Data: subjective and
objective. The health history gathers subjective Data about the patient.

Objective Data subjective Data

▪ Are observed ▪ Provided by the patient

▪ Are verifiable ▪ Verified only by the patient
▪ Include findings such a red, ▪ Include statements such as “my
swollen arm in a patient with head hurts” or “I have trouble
arm pain. sleeping”

2. DIAGNOSIS - Once you have the assessment data, you can now formulate a nursing
diagnosis
• Nursing diagnosis is the priority problem that a nurse should address, and then
from there, the plan must be created.
• Nursing diagnosis is different from a medical diagnosis
• When diagnosing, you can use your NANDA Book to check some nursing
diagnosis that is related to the data gathered from the assessment.
• Nursing diagnosis is the priority problem that a nurse should address, and then
from there, the plan must be created.
3. PLANNING/OUTCOME - Planning is devising the best course of action to address the
patient’s analyses.

2
 • During planning, the nurse and patient select goals for each analysis in order
to alleviate, decrease, or prevent the problems addressed in the nursing
analysis.
• There should be a short-term goal (STG) and a long-term goal (LTG) with
realistic time frames incorporated.
• Developing a successful plan requires good interpersonal skills and sensitivity
to the patient’s goals, economic means, competing responsibilities, and family
structure and dynamics.
• A plan must be S.M.A.R.T. (Specific, Measurable, Attainable, Realistic, and
Time-bound.
4. IMPLEMENTATION - Implementation of the interventions can be completed by the patient,
the family, or members of the health care team.

5. EVALUATION - Evaluation is a continuing process to determine if the goals have been

attained.
• The nursing care plan is revised based on the patient’s condition and whether
the goals are realistic or appropriate for the patient.
• The intervention and evaluation process is ongoing and confirms that the
nursing care is relevant.
IDENTIFYING PROBLEMS AND MAKING NURSING DIAGNOSES: STEPS IN CLINICAL REASONING
• Identify abnormal or positive findings. Make a list of the patient’s symptoms, the
signs you observed during the physical examination, and any laboratory reports
available to you. Also identify positive responses during the health history.
• Cluster the findings. This step may be easy. The symptom of a scratchy throat and
the sign of an erythematous inflamed pharynx, for example, clearly localize the
problem to the pharynx. A complaint of headache leads you quickly to the structures
of the skull and brain. However, do not forget to include information on the patient’s
stress level due to being laid off work and lack of income. When localizing findings, be
as specific as your data allow, but bear in mind that you may have to settle for a body
region

3
 • Interpret findings in terms of probable process. Patient problems stem from
different causes. It is important to differentiate a problem that should be treated by a
nurse versus one that should be referred to another health care professional.
• Make hypotheses about the nature of the patient’s problem. Draw on all the
knowledge and experience you can muster; it is in this step that reading is most useful

INTERVIEWING AND COMMUNICATION

is very important in doing your health assessment
because you are gathering data.
• Health history interview is a conversation
with your patient with a purpose because
you are gathering data about your client,
that will serve as your baseline for your
nursing care plan.
• It is different from social conversation
wherein in doing so, you are free enough
to talk about your feelings and interests,
but in a health interview or health history
interview, the primary goal is to improve
the well-being of the patient.
• The purpose of a health history interview
is to establish a trusting and supportive
therapeutic relationship with your client to
gather information and to offer
information.
2 FORMATS OF INTERVIEWING
1. The health history format is a structured
framework for organizing patient
information in written, electronic, or
verbal form to communicate effectively
with other health care providers.
2. The interviewing process that actually
generates the health information is
much more fluid and demands effective
communication and relational skills. It
requires not only knowledge of the data
needed but also the ability to elicit
accurate information and the
interpersonal skills that allow you as
the nurse to respond to the patient’s
feelings and concerns.

MOTIVATIONAL INTERVIEWING
is an evidence-based method of therapeutic communication that enhances the nurse–patient
relationship and the patient’s understanding of their health needs. It helps patients identify, create,
and implement changes in behaviors to improve or maintain health.
• Open-ended questions - Invite the patient to tell their story in their own words. Avoid
“why” questions, which may seem judgmental to the patient. “Tell me about…” will
sound nonjudgmental.
• Affirmation- When the patient reveals a healthy habit or good decision, affirm this
choice. For example, when a patient reports they taped a medication reminder to the
bathroom mirror, affirm that is a good way not to forget to take medication.
• Reflective listening - To ensure you understand the correct meaning of a patient
statement or the emotion the patient is feeling, you can reflect back the statement or
feeling you hear. For example, “It sounds like you are feeling hopeless since your
cancer returned.”
• Summarize and teach back - Summarize what the patient said, especially any
strengths or plans the patient has told you regarding their problem. If you made a plan
with the patient, ask them to repeat the information to reinforce it and make sure they
understood the plan correctly.

4
COMPONENTS OF HEALTH HISTORY

5
 4 PHASES OF INTERVIEWING

• Self-reflection • Put the patient at • Obtain patient • Summarize

• Review patient ease and establish information important points
record trust • Invite the patient’s • Discuss plan of
• Set interview goals • Greet the patient story (You can ask
care
(What are the data and establish your client “Can you
that you need) rapport tell me more about
• Review own clinical • Establish the your pain?”)
behavior and agenda for the • Identify and respond
appearance (the interview (Asking to emotional cues
way you react, talk, an open-ended (You have to be
dress) question– “how attentive; show that
• Adjust the can I help you?” you are interested in
environment the patient)
(adjust the • Expand and clarify
temperature, the patient’s story
lighting, noise- ➔ OLD CART
reduction) ➔ OPQRST - These
• Take notes (jot two are the seven
down vital attributes of the
information) symptoms.

OLD CARTS
1. Onset: When did (does) it start; setting in which it occurs, including environmental factors, personal
activities, emotional reactions, or other
circumstances that may have contributed.
2. Location: Where is it? Does it radiate?
3. Duration: How long does it last?
4. Characteristic symptoms: What is it like?
5. How severe is it? (For a subjective symptom
like pain, ask the patient to rate it on a scale
of 1 to 10.)
6. Associated manifestations: Have you
noticed anything else that accompanies it?
7. Relieving/exacerbating factors: Is there
anything that makes it better or worse?
8. Treatment: What have you done to treat
this? Was it effective?

Generating and Testing Diagnostic Hypotheses

The skills of diagnostic reasoning are developed over time with practice. As the history is gathered,
one develops and tests hypotheses about the patient problem or problems. Identifying the attributes
and details of the patient’s symptoms is fundamental to

6
 THERAPEUTIC COMMUNICATION TECHNIQUES
ACTIVE LISTENING
The process of paying close attention to what
the patient is communicating, being aware of
the patient’s emotional state and using verbal
and non-verbal skills.
GUIDED QUESTIONING
There are several ways you can ask for more
information from the patient without
interfering with the flow of the patient’s
story.
NON - VERBAL COMMUNICATION
Communication that does not involve speech
occurs continuously and provides important
clues to feelings and emotions. Becoming
sensitive to nonverbal messages allows the
nurse to both “read the patient” more
effectively and send messages.
REASSURANCE
When you are talking with patients who are
anxious or upset, it is tempting to try to
reassure them. Saying, “Don’t worry.
Everything is going to be alright” may
reassure the patient about the wrong thing and
provide false reassurance.
EMPATHIC RESPONSES
Conveying empathy greatly strengthens patient
rapport. As patients talk, they may express—with
or without words—feelings they may or may not
have consciously acknowledged. To provide
empathy, first identify the patient’s feelings.
VALIDATION
Another important way to make a patient feel
affirmed is to validate or acknowledge the
legitimacy of the emotional experience.
SUMMARIZING
Giving a capsule summary of the patient’s story
during the course of the interview serves several
different functions. It communicates to the
patient that you have been listening carefully.
TRANSITIONS
Patients have many reasons to feel vulnerable
during a health care visit. To put them more at
ease, tell them when you are changing directions
during the interview. Just as clear signs along
the highway give a sense of confidence, this “sign
posting” gives patients a greater sense of
control.
7
 ADAPTING THE INTERVIEW FOR SPECIFIC PATIENTS
THE SILENT PATIENT
Novice interviewers are often uncomfortable with periods of silence and feel obligated to keep the
conversation going. Silence has many meanings and many purposes. Patients frequently fall silent
for short periods to collect thoughts, remember details, or decide whether you can be trusted with
certain information.
CONFUSING PATIENT
Some patients present a confusing array of multiple symptoms. They seem to have every symptom
that you ask about. With these patients, focus on the meaning or function of the symptom,
emphasizing the patient’s perspective, and guide the interview into a psychosocial assessment.
There is little profit to exploring each symptom in detail. Although the patient may have several
illnesses, a psychological disorder may also be present.
PATIENT WITH ALTERED CAPACITY
Some patients cannot provide their own histories because of delirium from illness, dementia, or
other health or mental health conditions. Others are unable to relate certain parts of their histories,
such as events related to febrile illnesses or seizures. Under these circumstances, you need to
determine whether the patient has decision-making capacity which is the ability to understand
information related to health, to make health choices based on reason and a consistent set of values
and to declare preferences about treatments. The term “capacity” is preferable to the term
“competence,” which is a legal term. You do not need to consult a colleague in psychiatry to assess
capacity unless mental illness impairs decision making. For many patients with psychiatric
conditions or even cognitive impairments, their ability to make decisions remains intact.

TALKATIVE PATIENT
The garrulous, rambling patient may be difficult to interview, especially when faced with limited time
and the need to “get the whole story.” Several techniques are helpful. Give the patient free rein for
the first 5 or 10 minutes, listening closely to the conversation. Perhaps the patient simply needs a
good listener and is expressing pent-up concerns, or the patient’s style is to tell stories. In some
cultures, social conversation of various lengths before “getting down to business” is considered
polite.

CRYING PATIENT
Crying signals strong emotions, ranging from sadness to anger or frustration. If the patient is on the
verge of tears, pausing, gentle probing, or responding with empathy gives the patient permission to
cry. Usually crying is therapeutic, as is your quiet acceptance of the patient’s distress or pain. Offer
a tissue and wait for the patient to recover. Make a supportive remark like, “I am glad you were able
to express your feelings.”

ANGRY OR DISRUPTIVE PATIENT

Accept angry feelings from patients. Allow them to express such emotions without getting angry in
return. Avoid joining such patients in their hostility toward another provider or the agency, even when
privately you may feel sympathetic. You can validate their feelings without agreeing with their
reasons: “I understand that you felt frustrated by the long wait and answering the same questions
over and over.
DYING PATIENT
Dying patients rarely want to talk about their illnesses at every encounter, nor do they wish to confide
in everyone they meet. Give them opportunities to talk, and listen, but if they choose to stay at a
social level, respect their preference. Remember that illness—even a terminal one—is only a part
of the total person. A smile, a touch, an inquiry about a family member, a comment on the day’s

8
events, or even some gentle humor affirms and sustains the unique individual for whom you are
caring.

CULTURAL ASSESSMENT
• Cultural assessment is part of the foundation for every
patient’s plan of care. It provides valuable data for setting Culture - culture is the system of shared
mutual goals, planning care, intervening, and evaluating
the care
• Cultural assessment is a systematic, comprehensive
examination of individuals, families, groups, and
communities regarding their health-related cultural
beliefs, values, and practices.
Cultural humility
ideas, rules, and meanings that influences
how we view the world.
Ethnicity - composed of “individuals who
self-identify membership with or belong to
a group with shared values, ancestry, and
experiences”
Race - concept of dividing people into

• is defined as a “process that requires humility as populations or groups on the basis of

various sets of physical characteristics,
individuals continually engage in self-reflection and self-
usually based on genetic ancestry.
critique as lifelong learners and reflective practitioners”.
• It is a process that includes “examining cultural beliefs
and cultural systems of both patients and nurses to locate the points of cultural dissonance
or synergy that contribute to patients’ health outcomes”
Cultural Diversity
• It is the variety and differences that exist in the world, a society or an institution. It is having a group
of people in one place. People working or living together that have different cultures.
Cultural Sensitivity
• Being aware that cultural differences and similarities exist and that they have an effect of behavior,
values, and learning. It also means to be aware and tolerant of these differences and acknowledging
them when interacting with others
Cultural Bias
• To give an advantage to one culture over another. To ignore the differences between culture and
impose understanding based on the study of one culture to other cultures. To think one culture has
precedence of the other
Culture Influences on Healthcare
• Physiologic characteristics – physical aspect
• Psychologic characteristics
• Reactions to pain – may umiiyak, may hindi
• Gender roles
• Language and communication
• Orientation to space (personal space, ft away) and time (karma, past, present, future)
• Food and nutrition
• Socioeconomic factors
Culturally competent nursing care
• providing culturally competent card means that care is planned and implemented in a way that is
sensitive to the needs of individuals, families, and groups from a diverse populations within society.
• Cultural assessment
• Guidelines for care
Cultural Assessment
• When caring for patients from a different culture, it is important to find out how they want to be treated
based on their cultural values and beliefs. An effective way go identify specific factors that influence
a patient’s behavior is to perform a cultural assessment.
Guidelines for care
• Cultural competency is a process and takes time. It involves developing awareness, acquiring
knowledge, and practicing skills. As defined by Campinha-Bacote (2003), the nurses should answer
the following questions when caring for culturally diverse patients.
o Am I aware of my personal biases and prejudices toward cultural groups different from mine?
o Do I have the skill to conduct a cultural assessment in a sensitive manner?
o Do I have knowledge of the patient’s worldview?
o How many encounters have I had with the patients from diverse cultural backgrounds?

9
 PHYSICAL ASSESSMENT
assemble the equipment required for the physical MEASURING BLOOD PRESSURE
examination. After that, perform a general survey ▪ Position your patient with his upper
to get a first impression of the patient. Obtain arm at heart level and his palm turned
baseline information on vital signs, height, and up.
weight. The rest of your assessment will be guided ▪ Apply the cuff snugly, 1 (2.5 cm)
by this information. above the brachial pulse.
▪ Position the manometer at your eye
level.
▪ Palpate the brachial or radial pulse
with your fingertips while inflating
▪ Cotton balls
the cuff.
▪ Gloves
▪ Inflate the cuff to 30 mm Hg above the
▪ Metric ruler (clear)
▪ Near-vision and visual point where the pulse disappears.
acuity charts ▪ Place the bell of your stethoscope
▪ Ophthalmoscope ▪ over the point where you felt the
▪ Otoscope pulse, as shown in the photo.
▪ Penlight
▪ Percussion hammer
▪ Paper clip
▪ Scale with height
(Using the bell will help you better
measurement
hear Korotkoff’s sounds, which
▪ Skin calipers
indicate pulse.)
▪ Specula (nasal and
▪ Release the valve slowly and note the
vaginal)
▪ Sphygmomanometer point at which Korotkoff’s sounds
▪ Stethoscope reappear. The start of the pulse sound
▪ Tape measure (cloth or indicates the systolic pressure.
paper) ▪ The sounds will become muffled and
▪ Thermometer then disappear. The last Korotkoff’s
▪ Tuning fork sound you hear is the diastolic
▪ Wooden tongue blade pressure.

■ Analyze vital signs at the same time. Two or more abnormal values may provide clues to the patient’s
problem. For example, a rapid, thready pulse along with low blood pressure may signal shock.
■ Remember that normal readings vary with the patient’s age. For example, temperature decreases with age,
and respiratory rate can increase with age.
■ Remember that an abnormal value for one patient may be a normal value for another, which is why
baseline values are so important.
10
PURPOSE OF AN ANNUAL PHYSICAL EXAM
A physical examination helps the physician to determine the general status of health. The
exam also gives a chance to the patient to talk to the medical personnel about any ongoing
pain or symptoms that they are experiencing or any other health concerns that might have

RESPONSIBITIY OF THE NURSE

Are duties of a nurse while doing the physical assessment which include preparing the client.
Preparing the environment, positioning, draping and instrument.

1. PREPARING THE CLIENT

In preparing the client nurse’s role is to ensure the comfortability of the patient. According
to the Health Insurance Portability and Accountability Act (HICPA), only health providers
who have legitimate need to know the client’s information will have access to it.
Psychological Preparation
The nurse should explain when and where the examination will take place, why it is important, and
what will happen. Always ensure safety of the client.
Physical Preparation
The nurse should ensure physical comfort of the patient by asking if the client needs to use the toilet.
Positioning
The nurse assists the client in ensuring the proper positions so that the body is accessible and the
client stays comfortable. Client’s positioning may vary depending on their physical strength and
degree of wellness
2.PREPARING THE ENVIRONMENT
● Time should be convenient for nurses and clients.
● Area should be well lighted
● Equipment should be organized.
● Provide privacy
● Room should be warm enough to be comfortable for the client.
● Family and friends should not be present unless client ask for some
one
3. POSITIONING

DORSAL RECUMBENT POSITION

Lies on abdomen with head turned to the side, with or
without a small pillow

Areas assessed: posterior thorax, hip joint movement

SIMS POSITION
Side-lying with lowermost arm behind the body,
uppermost leg flexed at hip and knee, upper arm flexed at
shoulder and elbow.

Areas assessed: rectum and vagina

11
 LITHOTOMY POSITION
Back-lying position with feet supported in stirrups; the
hips should be in line with the edge of the table

Areas assessed: female genitals, rectum and female

reproductive tract.

SITTING POSITION
A seated position, back unsupported and legs hanging
freely.

Areas assessed: head, neck posterior and anterior thorax,

lungs, breast, axillae, heart and vital signs.

DORSAL RECUMBENT POSITION

Back-lying position with knees flexed and hips externally
rotated; small pillow under the bed; soles of foot on the
surface.

Areas assessed: female genitals, rectum and female

reproductive tract.

KNEE-CHEST POSITION
The patient rests on the knees and the chest. The body is
at 90degree angle to the hips with back straight, the arm
above the head, and the head turned to one side. The
abdomen remains unsupported

Areas assessed: female genitals, rectum and female

reproductive tract.

12
 PHYSICAL ASSESSMENT TECHNIQUES
When you perform the physical assessment, you’ll use four techniques:
inspection, palpation, percussion, and auscultation. Use these
techniques in this sequence except when you perform an
abdominal assessment.

1
Guidelines to achieve the best result during inspection:

INSPECTION • make sure that adequate lighting is available, either

Inspect each body system using vision, smell,
and hearing to assess normal conditions and
deviations. Observe for color, size, location,
movement, texture, symmetry, odors, and
sounds as you assess each body system.
direct or tangential
• use direct lighting source to inspect body cavities
• inspect each area for size, shape, color, symmetry,
position, and abnormality
• position and expose body parts as needed so all
surfaces can be viewed but privacy can be maintained
• when possible, check for side-to-side symmetry by
comparing each area with its match
• on the opposite side of the body

2
• validates finding with the patients

PALPATION

Palpation requires you to touch the patient with different parts of your hands, using varying degrees
of pressure. Because your hands are your tools, keep your finger nails short and your hands warm.
Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender
areas last.

TYPES OF PALPATION
LIGHT PALPATION
• Use this technique to feel for
surface abnormalities.
• Depress the skin 1/2 to 3/4
(1.5 to 2 cm) with your finger
pads, using the lightest touch
possible.
• Assess for texture,
tenderness, temperature,
moisture, elasticity,
pulsations,
• superficial organs, and
masses.
DEEP PALPATION
• Use this technique to feel
internal
• organs and masses for size,
shape, tenderness,
symmetry, and mobility.
• Depress the skin 11/2 to 2
(4 to 5 cm) with firm, deep
pressure.
• Use one hand on top of the
other to exert firmer
pressure, if needed.

13
 3
PERCUSSION

Percussion involves tapping your fingers or hands

quickly and sharply against parts of the patient’s
body to help you locate organ borders, identify organ
shape and position, and determine if an organ is
solid or filled with fluid or gas.
Percussion sound can be analyzed according to:
intensity(amplitude) - refers to the relative
loudness or softness of the sound
duration - percussed sound describes the time
period over which a sound is heard when elicited
pitch(frequency) - the concept of pitch is described
by the frequency
quality - the quality of a sound is its timbre, or how
one perceives it musically
location - refers to the area where the sound is
produced and heard

4
TYPES OF PERCUSSION

DIRECT PERCUSSION INDIRECT PERCUSSION AUSCULTATION

This technique reveals This technique elicits sounds that
tenderness; it’s commonly used give clues to the makeup of the
to assess an adult patient’s underlying tissue. Auscultation involves listening for
sinuses. Here’s how to do it: various breath, heart, and bowel
Here’s how to do it: • Press the distal part of sounds with a stethoscope.
• Using one or two the middle finger of your
fingers, tap directly on nondominant hand firmly
the body part. on the body part. HOW TO AUSCULTATE
• Ask the patient to tell • Keep the rest of your
you which areas are hand off the body • Provide a quiet environment.
painful, and watch his surface. • Warm the stethoscope head
in your hand.
face for signs of • Flex the wrist of your
discomfort. • Close your eyes to help focus
dominant hand.
your attention.
• Using the middle finger of How to auscultate
your dominant hand, tap
• Use the diaphragm to pick up
quickly and directly over high-pitched sounds, such as
the point where your first (S1) and second (S2)
other middle finger heart sounds. Hold the
touches the patient’s diaphragm firmly against the
skin. patient’s skin, enough to
leave a slight ring on the skin
afterward.
• Use the bell to pick up low-
pitched sounds, such as third
(S3) and fourth (S4) heart
sounds. Hold the bell lightly
against the patient’s skin, just
enough to form a seal.
Holding the bell too firmly
causes the skin to act as a
diaphragm, obliterating low-
pitched sounds.
• Listen to and try to identify the
characteristics of one sound
at a time.

14
 DOCUMENTATION

Get to know your stethoscope

Your stethoscope should have snug-fitting ear
tips, which you’ll position toward your nose. The Documenting initial assessment findings
stethoscope should also have tubing no longer
than 15 (38.1 cm) with an internal diameter not
greater than 1/8 (0.3 cm). It should have both a
diaphragm and bell. The parts of a stethoscope
are labeled below

15
 ANATOMY OF SKIN, HAIR AND NAILS

The skin covers and protects the internal structures of the body.
It consists of two distinct layers: the epidermis and the dermis.
Subcutaneous tissue lies beneath these layers

The skin keeps the body in homeostasis despite daily assaults from the environment.
The skin:
1. provides a barrier protecting the body from:
a. injury secondary to mechanical, chemical, thermal, and ultraviolet (UV) light sources.
b. penetration by microorganisms.
c. loss of water and electrolytes, thereby preventing dehydration.
2. regulates body temperature by allowing heat dissipation through sweat glands and heat
storage through subcutaneous insulation.
3. synthesizes vitamin D from cholesterol by the action of UV light.
4. allows sensory perception via end sensory organs for touch, pain, temperature, and pressure.
5. provides nonverbal communication, such as posture, facial movements, or vasomotor
responses such as blushing.
6. provides identity through skin color and facial features.
7. allows wound repair through cell replacement of surface injuries.
8. allows excretion of metabolic wastes, such as electrolytes, minerals, sugar, or uric acid.

16
HAIR
Hair is formed from keratin produced by matrix cells
in the dermal layer of the skin. Each hair lies in a
hair follicle.
Adults have two types of hair: vellus hair, which is
short, fine, inconspicuous, and relatively unpigmented;
and terminal hair, which is coarser, thicker, more
conspicuous, and usually pigmented. Scalp hair and
eyebrows are examples of terminal hair.

NAILS
Nails are formed when epidermal cells
are converted into hard plates of keratin.

Nails protect the distal ends of the fingers and toes. The firm,
rectangular, and usually curving nail plate gets its pink color from the
vascular nail bed to which the plate is firmly attached. Note the white
moon, or lunula, and the white free edge of the nail plate. Roughly one
fourth of the nail plate (the nail root) is covered by the proximal nail
fold. The cuticle extends from the fold and functioning as a seal,
protects the space between the fold and the plate from external
moisture. Lateral nail folds cover the sides of the nail plate. Note that
the angle between the proximal nail fold and nail plate is normally less
than 180 degrees.

17
 ASSESSMENT OF SKIN, HAIR AND NAILS
SKIN MOISTURE
Observe the skin’s overall appearance. Then inspect Observe the skin’s moisture content.
and palpate the skin area by area, focusing on color, The skin should be relatively dry, with
moisture, texture, turgor, and temperature a minimal amount of perspiration

COLOR TEXTURE AND TURGOR

Look for localized areas of bruising, Inspect and palpate the skin’s
cyanosis, pallor, and erythema. Check texture, noting its thickness and
for uniformity of color and hypopigmented mobility. It should look smooth and
or hyperpigmented areas be intact

CYANOSIS EDEMA ERYTHEMA JAUNDICE PALLOR PETECHIAE RASHES

Examine Examine Palpate Examine Examine Examine Palpate
the the area for the the sclerae the sclerae, areas of the area
conjunctive decreased area for and hard conjunctiva lighter for skin
palms, color and warmth. palate in e, buccal pigmentatio
texture
soles, palpate for mucosa, n
natural, not changes.
lips, tongue, such as the
buccal tightness. fluorescent nail beds, abdomen.
mucosa, , light if palms, and Look for
and possible. soles. Look tiny,
tongue. Look for a for an purplish red
Look for yellow ashen color. dots.
dull, dark color.
color.

Assessing skin
turgor in an adult
Gently squeeze the skin on the forearm or sternal
area between your thumb and forefinger, as shown.

If the skin quickly returns to its original shape, the patient

has normal turgor. If it returns to its original shape slowly over
30 seconds or maintains a tented position, as shown, the skin
has poor turgor.

Temperature
Palpate the skin bilaterally for temperature
using the dorsal surface of your hands and
fingers. The dorsal surface is the most sensitive to
temperature changes. Warm skin suggests normal
circulation; cool skin, a possible
underlying disorder. 18
Hair
When assessing the hair, note the distribution, quantity, texture, and color. Hair should be evenly
distributed.
Nails
Examine the nails for color, shape, thickness, consistency, and contour.
Nail color is pink in light-skinned people and brown in dark-skinned people. The nail
surface should be slightly curved or flat and the edges
smooth and rounded

SKIN ABNORMALITIES
Lesions
When evaluating a lesion, you’ll need to classify
it as primary (new) or secondary (a change in
a primary lesion). Then determine if it’s solid or
fluid-filled and describe its characteristics,
pattern, location, and distribution. Include
a description of symmetry, borders, color,
configuration, diameter, and drainage.

Lesion distribution
Generalized — Distributed all
over the body
Regionalized — Limited to one
area of the body
Localized — Sharply limited to
a specific area
Scattered — Dispersed either
densely or widely
Exposed areas — Limited to
areas exposed to the air or sun
Intertriginous — Limited to
areas where skin color.

TYPES OF SKIN LESIONS

19
 Benign versus cancerous lesions
Lesions may be benign, such as a benign nevus, or mole.
However, changes in an existing growth on the skin
or a new growth that ulcerates or doesn’t heal could
indicate cancer or a precancerous lesion

20
COMMON SKIN DISORDERS

21
SUSPECTED DEEP TISSUE INJURY

22
23
 HAIR ABNORMALITIES

NAIL ABNORMALITIES
Although many nail abnormalities are harmless,
some point to serious underlying problems.
Nail abnormalities include clubbed fingers,
splinter hemorrhages of the nail bed,
and Muehrcke’s lines.

24
 ANATOMY OF EYES AND EARS
The eyes are delicate sensory organs equipped with many extraocular and intraocular structures.
Some structures are easily visible, whereas others can only be viewed with special instruments,
such as an ophthalmoscope

25
Eye Structures
• Upper eyelid – covers a portion of the iris but did not touch
the pupil
• Palpebral fissure – opening between the eyelids
• Conjunctiva – clear mucous membrane with two easily
visible components.
→ Bulbar conjunctiva(sclera) – covers most of the
anterior eyeball,
→ Palpebral conjunctive – lines the eyelids.
• Tarsal plates – firm strips of connective tissue, containing
parallel row of meibomian glands that open on the lid
margin.
• Levator palpebrae – the muscle that raises the upper
eyelid innervated by

oculomotor nerve
A film of tear fluid
protects the
conjunctiva and cornea
from drying, inhibits
microbial growth, and
gives a smooth optical
surface to the cornea.
This fluid comes from
the meibomian glands,
conjunctival glands,
and lacrimal gland. The
lacrimal gland lies mostly within the bony orbit, above and lateral to the eyeball. The tear fluid
spreads across the eye and drains medially through two tiny holes called lacrimal puncta. The
tears then pass into the lacrimal sac and into the nose through the nasolacrimal duct. You can
easily find a punctum atop the small elevation of the lower lid medially. The lacrimal sac rests in a
small depression inside the bony orbit and is not visible.
• Vitreous humor – clear gel that fills the space between
the lens and retina.
• Aqueous humor – a clear liquid that fills the anterior
and posterior chambers of the eye and produced by:
• ciliary body – circulates from posterior chamber
through the pupil into anterior chamber
• Canal of Schlemm – where AQ drains
• Fundus – posterior part of the eye seen through an
ophthalmoscope.
Visual Fields
A visual field is the entire area seen by an eye when it looks
at a central point. Fields are typically diagrammed on circles
from the patient’s point of view. The center of the circle represents the focus of gaze. The
circumference is 90 degrees from the line of the gaze.
Visual Fields
A visual field is the entire area seen by an eye when it looks at a central point. Fields are typically
diagrammed on circles from the patient’s point of view. The center of the circle represents the focus
of gaze. The circumference is 90 degrees from the line of the gaze.

26
Visual pathways

Pupillary Reactions
Pupillary size changes in response to light and to the effort of focusing on a near object.
The Light Reaction
A light beam shining onto one retina causes pupillary constriction both in that eye, termed the direct
reaction to light, and in the contralateral (opposite) eye, the consensual reaction to light. The initial
sensory pathways are similar to those described for vision: retina, optic nerve (CN II), and optic tract
which diverges in the midbrain. Impulses back to the constrictor muscles are transmitted through
the oculomotor nerve, CN III, to the constrictor muscles of the iris of each eye and then transmitted
through the oculomotor nerve, CN III.
Pupillary Reactions
Pupillary size changes in response to light and to the effort of
focusing on a near object.
The Light Reaction
A light beam shining onto one retina causes pupillary constriction
both in that eye, termed the direct reaction to light, and in the
contralateral (opposite) eye, the consensual reaction to light. The
initial sensory pathways are similar to those described for vision:
retina, optic nerve (CN II), and optic tract which diverges in the
midbrain. Impulses back to the constrictor muscles are
transmitted through the oculomotor nerve, CN III, to the
constrictor muscles of the iris of each eye and then transmitted
through the oculomotor nerve, CN III.

Common or concerning symptoms:

Changes in vision:
→ Hyperopia- is a refractive error, which means that the eye does not bend or refract light
properly to a single focus to see images clearly. In hyperopia, distant objects look somewhat
clear, but close objects appear more blurred.
→ Presbyopia - Presbyopia is when your eyes gradually lose the ability to see things clearly up
close. It is a normal part of aging. In fact, the term ―presbyopia‖ comes from a Greek word
which means ―old eye. ‖ You may start to notice presbyopia shortly after age 40.
→ Myopia - is a common vision condition in which you can see objects near to you clearly, but
objects farther away are blurry. It occurs when the shape of your eye causes light rays to
bend (refract) incorrectly, focusing images in front of your retina instead of on your retina.
→ Scotomas- is an area of partial alteration in the field of vision consisting of a partially
diminished or entirely degenerated visual acuity that is surrounded by a field of normal – or
relatively well-preserved – vision.
• Double vision or diplopia
• Strabismus - is when your eyes are not lined up properly and they point in different directions
• Blurring
• Redness
• Itching
• Discharge
• Pain
• Tearing
27
 • Edema
• Lesions
• Visual disturbances
• Photophobia
Areas of History Interview
• Eye History
• Family History
• Lifestyle Habits
Physical Examination
The components of the eye examination include:
• Vision tests: distal, near, and peripheral Inspection of the eye, eyebrows, lids, conjunctiva
and sclera, cornea, lens, iris, and pupils Inspection and palpation of the lacrimal apparatus.
• Extraocular movements: assessment of cardinal fields, convergence, corneal light test,
cover–uncover test.
Equipment for Examination
• Snellen chart or ―E‖ card
• Rosenbaum, near-vision card
• Index card
• Penlight
• Ophthalmoscope
Visual Acuity
• Visual acuity is expressed as two numbers (e.g., 20/30): the numerator indicates the
distance of the patient from the chart and this number should always be 20 unless the patient
moved closer to see, and the denominator is the distance at which a normal eye can read
the line of letters.
Near Vision
• Testing near vision with a special hand-held card, the Rosenbaum chart, helps identify the
need for reading glasses or bifocals in patients older than 45 years. This card can be utilized
to test visual acuity at the bedside. Held 14 inches from the patient’s eyes, the card simulates
a Snellen chart. However, patients may choose their own distance.
External Eye Examination
• Position and Alignment of the Eyes. Stand in front of the patient and survey the eyes for
position and alignment. If one or both eyes seem to protrude, assess them from above.
• Eyebrows. Inspect the eyebrows, noting their quantity and distribution and any scaliness of
the underlying skin.
• Eyelids. Note the position of the lids in relation to the eyeballs.
Inspect for the following:
• Width of the palpebral fissures—open area between the upper and lower eyelids
• Edema of the lids
• Color of the lids
• Lesions
• Condition and direction of the eyelashes
• Adequacy with which the eyelids close. Look for this especially when the eyes are unusually
prominent, when there is facial paralysis, or when the patient is unconscious.
Internal Eye Examination
• Cornea and Lens. With oblique lighting, inspect the cornea of each eye for opacities and note
any opacities in the lens that may be visible through the pupil.
• Iris. At the same time, inspect each iris. The markings should be clearly defined. With your
light shining directly from the temporal side, look for a crescentic shadow on the medial side
of the iris. Because the iris is normally fairly flat and forms a relatively open angle with the
cornea, this lighting casts no shadow.

28
 • Pupils. Inspect the size, shape, and symmetry of the pupils. If the pupils are large (5 mm),
small (<3 mm), or unequal, measure them. A pupil guide with black circles of varying sizes
facilitates measurement.
• Test the pupillary reaction to light. Ask the patient to look into the distance, and shine a bright
light obliquely into each pupil in turn.
Ophthalmic Examination
• The nurse would examine the patient’s eyes without dilating the pupils. The view is therefore
limited to the posterior structures of the retina. To see more peripheral structures, to evaluate
the macula well, or to investigate unexplained visual loss, ophthalmologists dilate the pupils
with mydriatic drops unless this is contraindicated.
Extraocular Muscles
• Assess the extraocular movements, looking for:
• The normal conjugate movements of the eyes in each direction, or any deviation from normal
• Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extreme
lateral gaze are normal. If you see it, bring your finger in to within the field of binocular vision
and look again.
• Lid lag as the eyes move from up to down.

Special Techniques
• Nasolacrimal Duct Obstruction. This test helps identify the cause of excessive tearing. Ask
the patient to look up. Press on the lower lid close to the medial canthus, just inside the rim
of the bony orbit— this compresses the lacrimal sac. Look for fluid regurgitated out of the
puncta into the eye. Avoid this test if the area is inflamed and tender.
Health Promotion, Disease Prevention and Education
• Vision screening
• Eye protection
• Care of contact lenses
Vision Screening
• Changes in vision shift with age. Amblyopia, also known as ―lazy eye‖, affects approximately
2–4% or preschool children. This loss of vision is due to an alteration in neural pathways in
the developing brain which in turn decreases use of the affected eye.
• Strabismus is eye misalignment; these are found most frequently in infants and children up
to 5 years old. Screening tests for detecting strabismus and amblyopia include simple
inspection, the cover uncover test, corneal light reflex and visual acuity tests.
Eye protection
• Eye injuries and trauma can occur in the home, during recreational activities, and in the place
of employment. Protective eyewear should be utilized when there is a chance of injury to the
eye. Eye injury can result from numerous causes, for example: chemical splashes from
cleaning supplies, metal shards or rocks flying when mowing the lawn, sports (e.g., lacrosse)
injuries, body fluids entering the eye—the list is endless. The activities and environment in
which people work and play should be assessed and precautions taken to avoid eye injury
and promote healthy habits.
Care of Contact Lenses
• Infections can occur and injure the eye if contact lenses are not taken care of properly.
Patients should remember to wash their hands when inserting or removing lenses, to wear
and remove them as prescribed by the health care provider, and to keep them clean and not
share contacts. If patients are using solutions, they should discard unused portions at the
expiration date.

29
 ASSESSMENT OF THE EYE

DISTANCE VISION
To measure distance vision:
• Have the patient sit or stand
20’ (6.1 m) from the chart.
• Cover his left eye with an
opaque object.
• Ask him to read the letters on
one line of the chart and then
to move downward to
increasingly smaller lines until
he can no longer discern all of
the letters.
• Have him repeat the test
covering his right eye.
• Have him read the smallest
line he can read with both
eyes uncovered to test his
binocular vision.
• If the patient wears corrective
lenses, have him repeat the
test wearing them.
• Record the vision with and
without correction.

Recording results
Visual acuity is recorded as a
fraction. The top number (20) is the
distance between the patient and the
chart. The bottom number is the
lowest line
on which the patient correctly
identified the majority of the letters.
The larger
the bottom number, the poorer the
patient’s vision.

30
NEAR VISION
To measure near-vision:
• Cover one of the patient’s eyes
with an opaque object.
• Hold the Rosenbaum card 14’
(35.6 cm) from the eyes.
• Have the patient read the line
with the smallest letters he can
distinguish.
• Repeat the test with the other
eye.
• If the patient wears corrective
lenses, have him repeat the test
while wearing them.
• Record the visual
accommodation with and
without corrective lenses

INSPECTING THE EYES

31
Inspecting the conjunctiva and sclera
To inspect the bulbar conjunctiva, ask the
patient to look up and gently pull the lower
eyelid down. Then have the patient look
down and lift the upper lid to examine the
palpebra conjunctiva
Testing the pupils
Slightly darken the room. Then test the pupils
for direct
response (reaction of the pupil you’re testing)
and consensual response (reaction of the
opposite pupil) by holding a
penlight about 20 (51 cm) from the patient’s
eyes,
directing the light at the eye from the side.
Next, test accommodation by placing your
finger
about 4 (10 cm) from the bridge of the
patient’s nose.
Ask him to look at a fixed object in the
distance and then to
look at your finger. His eyes should converge
and his pupils
should constrict

Assessing eye muscle function

Corneal light reflex.
Ask the patient to look straight ahead; then shine
a penlight on the bridge of his nose
from 12’ to 15’ (30.5 to 38 cm) away. The light
should fall at the same spot on each cornea. If it
doesn’t, the eyes aren’t being held in the same
plane by the extraocular muscles. The patient
likely lacks muscle coordination, a condition
called strabismus.

Cardinal positions of gaze

Cardinal positions of gaze evaluate the
oculomotor, tri geminal, and abducens cranial
nerves and the extraocular muscles.

32
EYE ABNORMALITIES

33
34
ANATOMY OF THE EAR

35
The external Ear:
Pinna(auricle)
→ pinna consists chiefly of cartilage covered by skin and has
a firm elastic consistency.
→ The function of the pinna is to gather sound waves and
funnel them down the ear canal to assist in localization of
sound.
Helix – curved outer range
Antihelix – parallel and anterior to the helix
Lobule- freshly projection of the earlobe
Tragus- a triangular nodular area pointing backward over the
entrance to the canal

External ear canal

→ Meatus (the passage leading into the ear) curves inward and is made up of cartilage and
bone
→ The skin in this area is hairy and contains glands that produce cerumen (wax).
Mastoid process – palpable behind the lobule
Tympanic membrane – a thin, semitransparent membrane the divides the external and middle ear.
The Middle Ear (tympanic cavity)
- The middle ear is an air-filled cavity that transmits sound
by way of three tiny bones, the ossicles: the malleus
(hammer), the incus (anvil), and the stapes (stirrup). The
ossicles transform sound vibrations into mechanical waves
for the inner ear. The proximal end of the Eustachian tube
connects the middle ear to the nasopharynx.
OSSICLES
1. Mallus (hammer) – attached to the medial TM
Umbo – where the eardrum meets the tip of the mallus
Cone of light – light reflection fans downward and
anteriorly
Flaccida- a small portion of the eardrum located above the short process.
Pars tensa – remainder of the TM
2. incus- can sometimes be seen through the drum
3. stapes – not visible.

The Inner Ear

The inner ear includes the cochlea, the semicircular canals, and the distal end of the auditory nerve,
which is also known as the vestibulocochlear nerve, or acoustic nerve, cranial nerve (CN) VIII.
Movements of the stapes vibrate the perilymph in the labyrinth of the semicircular canals and the
hair cells and endolymph in the ducts of the cochlea, producing electrical nerve impulses transmitted
by the auditory nerve to the brain. The inner ear functions to conduct sound to the central nervous
system and to assist with balance.
Much of the middle ear and all of the inner ear are inaccessible to direct examination. Some
inferences concerning their condition can be made, however, by testing auditory function.
Hearing Pathways
Conductive Phase - The first part of the hearing pathway, from
the external ear through the middle ear
Sensorineural Phase - The second part of the pathway,
involving the cochlea and the cochlear nerve.
Air conduction - describes the normal first phase in the hearing
pathway
Bone conduction- alternate pathway, bypasses the external and
middle ear and is used for testing purposes

36
A vibrating tuning fork, placed on the head, sets the bone of the skull into vibration and stimulates
the cochlea directly. In a person with intact hearing, air conduction is more sensitive than bone
conduction.
Equilibrium
The labyrinth within the inner ear senses the position and movements of the head and helps maintain
balance.
THE HEALTH HISTORY (EAR)
Ear History
• Try to distinguish between two basic types of hearing impairment: conductive loss, which
results from problems in the external or middle ear, and sensorineural loss, from problems in
the inner ear, the cochlear nerve, or its central connections in the brain.
• Hearing loss may also be congenital, from single gene mutations
• People with sensorineural loss have particular trouble understanding speech, often
complaining that others mumble; noisy environments make hearing worse. In conductive
loss, noisy environments may help.
• Medications that affect hearing include aminoglycosides, aspirin, nonsteroidal anti-
inflammatory drugs (NSAIDs), quinine, furosemide, and others.
• Symptoms associated with hearing loss, such as earache or vertigo, help you to assess likely
causes. In addition, inquire specifically about medications that might affect hearing and ask
about sustained exposure to loud noise.
Earache
• Otalgia is also known as ear pain. There are two types of otalgia. Primary otalgia occurs
within or around the ear such as otitis externa, otitis media, mastoiditis, or auricular
infections.
• Complaints of earache, or pain in the ear, are especially common. Ask about associated
fever, sore throat, cough, and concurrent upper respiratory infection.
• Pain suggests a problem in the external ear, such as otitis externa, or, if associated with
symptoms of respiratory infection, in the inner ear, as in otitis media.2 It may also be
referred from other structures in the mouth, throat, or neck.
Discharge
• Cerumen (wax) is normally found in the ear. The earwax tends to be yellowish to dark brown
in color and of a sticky consistency.
• Ask about discharge from the ear, especially if associated with earache or trauma.
• Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through
a perforated eardrum may be secondary to acute or chronic otitis media.
• Discharge from the ear, if associated with an earache or trauma, is cause for additional
assessment. Acute otitis externa and acute or chronic otitis media with perforation usually
present with a yellow-green or purulent discharge. In general, the ear is painful and once a
“pop” is felt, drainage occurs and the pain will resolve.
Tinnitus
• Tinnitus is a perceived sound that has no external stimulus and commonly is heard as musical
ringing or a rushing or roaring noise. It can involve one or both ears. Tinnitus may accompany
hearing loss and often remains unexplained.
• Occasionally, popping sounds originate in the temporomandibular joint, or vascular noises
from the neck may be audible.
• Tinnitus is a common symptom, increasing in frequency with age. When associated with
hearing loss and vertigo, it suggests Ménière’sdisease.
Vertigo
• Vertigo refers to the perception that the patient or the environment is rotating or spinning.
These sensations point primarily to a problem in the labyrinths of the inner ear, peripheral
lesions of cranial nerve (CN) VIII, or lesions in its central pathways or nuclei in the brain.

37
 ASSESSMENT OF THE EAR
External observation
Observe the ears for position and
symmetry. The top of the ear should
line up with the outer corner of the
eye, and the ears should look
symmetrical, with an angle of attachment
of no more than 10 degrees.
Inspect the auricle for lesions,
drainage, nodules, or redness. Pull
the helix back and note if it’s tender,
which may indicate otitis externa.
Inspect and palpate the mastoid
area behind each auricle, noting
tenderness, redness, or warmth.
Finally, inspect the opening of
the ear canal, noting discharge, redness,
odor, or the presence of nodules or cysts.
Patients normally have
varying amounts of hair and cerumen
(earwax) in the ear canal

38
Hearing acuity tests
Test the patient’s hearing using Weber’s test and the Rinne test. These tests assess conduction
hearing loss, impaired sound transmission to the inner ear, sensorineural hearing loss, and
impaired auditory nerve conduction or inner ear function

39
 ANATOMY OF THE NOSE
The lower two-thirds of the external nose consists of flexible cartilage, and the upper one-third is
rigid bone. Posteriorly, the internal nose merges with the pharynx, which is divided into the
nasopharynx, oropharynx, and laryngopharynx. Anteriorly, it merges with the external nose. More
than just the sensory organ of smell, the nose also plays a key role in the respiratory system by
filtering, warming, and humidifying inhaled air. The internal and external nose are divided vertically
by the nasal septum. Kiesselbach’s area, the most common site of nosebleeds, is located in the
anterior portion of the septum. Air entering the nose passes through the vestibule, which is lined
with coarse hair that helps filter dust

THE NOSE AND PARANASAL SINUSES

Approximately the upper third of the nose is supported by bone, the
lower two thirds by cartilage. Air enters the nasal cavity through the
anterior naris on either side, passes into the wider area known as the
vestibule, and on through the narrow nasal passage to the
nasopharynx.
The medial wall of each nasal cavity is formed by the nasal septum,
which, like the external nose, is supported by both bone and cartilage. It
is covered by a mucous membrane well supplied with blood. The
vestibule, unlike the rest of the nasal cavity, is lined with hair-bearing
skin, not mucosa.

40
Laterally, the anatomy is more complex. Curving
bony structures, the turbinates, covered by a highly
vascular mucous membrane protrude into the nasal
cavity. Below each turbinate is a groove, or meatus,
each named according to the turbinate above it. The
nasolacrimal duct drains into the inferior meatus and
most of the paranasal sinus drains into the middle
meatus. Their openings are not usually visible.

Common or Concerning Symptoms of the Nose and Sinuses

Rhinorrhea
• Rhinorrhea refers to drainage from the nose
and is often associated with nasal congestion,
a sense of stuffiness or obstruction. These
symptoms are frequently accompanied by
sneezing, watery eyes, and throat discomfort,
and also by itching in the eyes, nose, and
throat.
• Causes include viral infections, allergic
rhinitis (“hay fever”), and vasomotor
rhinitis. Itching favors an allergic cause.
• Relation to seasons or environmental contacts
suggests allergy.
• Excessive use of decongestants can worsen
symptoms, causing rhinitismedicamentosa.

Congestion
• The symptoms usually appear after an upper respiratory infection. Together these suggest
acute bacterial sinusitis. Sensitivity and specificity are highest for symptoms appearing after
a URI (90% and 80%).
Epistaxis
• Epistaxis means bleeding from the nose. The blood usually originates from the nose itself,
but may come from a paranasal sinus or the nasopharynx.
• Local causes of epistaxis include trauma (especially nose picking), inflammation, drying and
crusting of the nasal mucosa, tumors, and foreign bodies.
• Bleeding disorders may contribute to epistaxis.

SINUSES
Four pairs of paranasal sinuses open into the
internal nose:
Maxillary sinuses, located on the cheeks
below the eyes
Frontal sinuses, located above the eyebrows
ethmoidal and sphenoidal sinuses, located
behind the eyes and nose in the head.
The sinuses serve as resonators
for sound production and provide mucus.
You’ll be able to assess the maxillary and
frontal sinuses, but the ethmoidal and
sphenoidal sinuses aren’t readily accessible

41
MOUTH AND THROAT
The mouth is bounded by the lips, cheeks, palate, and tongue and contains the teeth. The throat,
or pharynx, contains the hard and soft palates, the uvula, and the tonsils.

Neck
The neck is formed by the cervical vertebrae,
the major neck and shoulder muscles,
and their ligaments. Other important
structures of the neck include the trachea,
thyroid gland, and chains of lymph nodes.
The thyroid gland lies in the anterior neck,
just below the larynx. Its two cone-shaped
lobes are located on either side of the
trachea and are connected by an isthmus
below the cricoid cartilage, which gives the
gland its butterfly shape.

42
 ASSESSMENT OF NOSE AND SINUSES
• Observe the patient’s nose for position, symmetry, and color. Note variations, such as
discoloration, swelling, or deformity. Variations in size and shape are largely caused by
differences in cartilage and in the amount of fibroadipose tissue.
• Observe for nasal discharge or flaring. If discharge is present, note the color, quantity, and
consistency. If you notice flaring, observe for other signs of respiratory distress.
• Then inspect the nasal cavity. Check patency by occluding one nostril and asking the
patient to breathe in through the other nostril. Repeat on the other side. Examine the
nostrils by direct inspection using a nasal speculum, a penlight or small flashlight, or an
otoscope with a short, wide-tip attachment.

Palpating the nose

Palpate the patient’s nose with your
thumb and forefinger, assessing for
pain, tenderness, swelling, and
deformity.

Examining the sinuses

Begin by checking for swelling around the eyes, especially
over the sinus area. Then palpate the sinuses, checking for
tenderness. If the patient complains of tenderness during
sinus palpation, transilluminate the sinuses to see if they’re
filled with fluid or pus. Transillumination can also help
reveal tumors and obstructions.
To perform transillumination, darken the room and have the
patient close his eyes. Place a penlight under the eyebrow
and direct the light upward to illuminate the frontal sinuses.
Place the penlight on the patient’s cheekbone just below
the eye and ask the patient to open his mouth. A red glow
inside the oral cavity indicates normal maxillary sinuses.

43
 MOUTH AND THROAT
Inspect the patient’s lips, noting any lumps
or surface abnormalities. Then, using a
tongue blade and a bright light, inspect the
mouth. Have the patient open his mouth; Inspecting the tongue
then place the tongue blade on top of his
Ask the patient to raise the tip of her tongue
tongue. Observe the gingivae, or gums. Then
and touch her palate directly behind her front
inspect the teeth; note their number, condition, teeth. Inspect the ventral surface of the
and whether any are missing or crowded. tongue and the floor of the mouth. Next, wrap
If the patient is wearing dentures, ask a piece of gauze around the tip of the tongue
him to remove them so you can inspect the and move the tongue first to one side then the
gums underneath. Next, inspect the tongue other to inspect the lateral borders.
and oropharynx

Lips Oral mucosa

The lips should be pink, moist,
symmetrical, and without
lesions. They may have a
bluish hue or flecked
pigmentation in dark-skinned
patients.
The oral mucosa should be
pink, smooth, moist, and free
from lesions and unusual
odors. Increased pigmentation
may occur in dark-skinned
patients.

Gingivae (gums)
The gums should be pink,
smooth, and moist, with
clearly defined margins at
each tooth. They shouldn’t be
retracted, red, or inflamed.

INSPECTING THE OROPHARYNX

Inspect the patient’s oropharynx by asking him to open his mouth while you shine the penlight on the uvula
and palate. You may need to insert a tongue blade into the mouth and depress the posterior tongue. Place
the tongue blade slightly off center to avoid eliciting the gag reflex. Ask the patient to say “Ahhh.” Observe
for movement of the soft palate and uvula. Note lumps, lesions, ulcers, or edema of the lips or tongue.

44
 TONGUE
The tongue should be midline,
moist, pink, and free from
lesions. It should have a
smooth posterior surface and
slightly rough anterior surface
with small fissures. It should
move easily in all directions
and lie straight to the front at
rest.
OROPHARYNX AND TONSILS
UVULA
The tonsils should be pink and
without hypertrophy.
These structures should be
pink and moist, without
inflammation or exudates.

NECK
Inspection
Observe the patient’s neck. It should be symmetrical, and the skin should be intact. Note any scars. No
visible pulsations, masses, swelling, venous distention, or thyroid gland or lymph node enlargement should
be present. Ask the patient to move his neck through the entire range of motion and to shrug his shoulders.

Palpation
Palpate the patient’s neck using the finger pads of both hands. Assess the lymph nodes for size, shape,
mobility, consistency, temperature, and tenderness, comparing nodes bilaterally.

Palpating the lymph nodes

Using the finger pads of both hands, bilaterally palpate the chain of lymph nodes in the following sequence:
■ preauricular—in front of the ear
■ postauricular—behind the ear, superficial to the mastoid process
■ occipital—at the base of the skull
■ tonsillar—at the angle of the mandible
■ submandibular—between the angle and the tip of the mandible
■ submental—behind the tip of the mandible
■ superficial cervical—superficially along the sternomastoid muscle
■ posterior cervical—along the edge of the trapezius muscle
■ deep anterior cervical—deep under the sternomastoid muscle
■ supraclavicular—just above and behind the clavicle, in the angle formed by the clavicle and
sternomastoid muscle.

45
MOUTH ABNORMALITIES

46
47
THROAT ABNORMALITIES

48
NECK ABNORMALITIES

49
 ANATOMY OF RESPIRATORY

THE LARANX
The larynx houses the vocal cords.
It’s the transition point between the
upper and lower airways. The
epiglottis, a flap of tissue that closes
over the top of the larynx when the
patient swallows, protects the patient
from aspirating food or fluid into the
lower airways.

50
Lungs
The right lung has three lobes: upper, middle, and lower. The left lung is smaller and has only an upper and
a lower lobe. The lungs share
space in the thoracic cavity with
the heart and great vessels, the
trachea, the esophagus, and
the bronchi. The space between
the lungs is called the
mediastinum. The medulla’s
respiratory center initiates each
breath by sending messages
via the phrenic nerve to the
primary
respiratory muscles.

Thorax
The bony thorax includes the
clavicles, sternum, scapula, 12
sets of ribs, and 12 thoracic
vertebrae.

Respiratory muscles
The diaphragm and the external
intercostal muscles are the
primary muscles used in
breathing. They contract when
the patient inhales and relax
when the patient exhales.
Accessory inspiratory muscles
include the trapezius, sterno
cleidomastoid, and scalenes,
which combine to elevate the
scapulae, clavicles, sternum,
and upper ribs.

51
 ASSESSMENT
Begin your respiratory assessment by first
observing the patient’s general appearance. Then
use inspection, palpation, percussion, and
auscultation to perform a physical examination.
Examine the back of the chest first, comparing one
side with the other. Then examine the front of the
chest using the same sequence. Observe the chest
from the side as well. The diameter of the thorax
should be greater from side-to-side than from front-
to-back.

Inspecting the chest

Inspect for chest-wall symmetry. Note masses or
scars that indicate trauma or surgery

Respiratory rate and pattern

Count the number of breaths for a full
minute. Adults normally breathe at a rate of
12 to 20 breaths/minute. An infant’s breathing rate
may reach 40 breaths/minute. The
respiratory pattern should be even, coordinated,
and regular, with occasional sighs (long, deep
breaths). Accessory muscle use Observe the
diaphragm and the intercostal muscles with
breathing. Frequent use of accessory muscles may
indicate a respiratory problem, particularly when
the patient purses his lips and flares his nostrils
when breathing

Palpating the chest

The chest wall should feel smooth, warm, and dry. Gentle palpation shouldn’t
cause the patient pain. Pain may be caused by costochondritis, rib or
vertebral fractures, or sore muscles as a result of protracted coughing.
Crepitus, which feels like puffed-rice cereal crackling under the skin, indicates
that air
is leaking from the airways or lungs. Also palpate for tactile fremitus, palpable
vibrations caused by the transmission of air through the bronchopulmonary
system. Then evaluate chest-wall symmetry and expansion.

52
53
AUSCULTATING THE CHEST
As air moves through the bronchi, it creates
sound waves that travel to the chest wall. The
sounds produced by breathing change as air
moves from larger airways to smaller airways.
Sounds also change if they pass through fluid,
mucus, or narrowed airways. Auscultation of
these sounds helps you to determine the
condition of the alveoli and surrounding pleura.
Classify each sound you hear according to its
intensity, location, pitch, duration, and
characteristic. Note whether the sound occurs
when the patient inhales, exhales, or
both.

Assessing voice sounds

Check the patient for vocal fremitus —
voice sounds resulting from chest vibrations
that occur as the patient speaks. Abnormal
transmission of voice sounds may occur
over consolidated areas. The most common
abnormal voice sounds are bronchophony,
egophony, and whispered pectoriloquy.

54
55
ABNORMAL FINDINGS
Chest-wall abnormalities may
be congenital or acquired. As
you examine a patient for chest-wall
abnormalities, keep in mind that a patient with a
deformity of the chest wall might have completely
normal lungs and that the lungs might be
cramped within the chest. The patient might have
a smaller than-normal lung capacity and limited
exercise tolerance, and he may more easily
develop respiratory failure from a respiratory tract
infection

Abnormal respiratory patterns

Common abnormal respiratory patterns include
tachypnea, bradypnea, apnea, hyperpnea,
Kussmaul’s respirations, Cheyne-Stokes
respirations, and Biot’s respirations.

56
 ANATOMY OF CARDIOVASCULAR
The heart is a hollow, muscular organ about the size of a closed fist. It’s located between the lungs in the
mediastinum, behind and to the left of the sternum. The heart spans the area from the second to the fifth
intercostal space. Its right border aligns with the right border of the sternum. The left border aligns with the
left midclavicular line

PERICARDIUM
The pericardium is a thin sac with an
inner, or visceral, layer that forms the
epicardium and an outer, or parietal,
layer that protects the heart. The
space between the two layers (the
pericardial space) contains 10 to
20 ml of serous fluid, which lubricates
and cushions the surface of the
heart and prevents friction between
the layers as the heart pumps

Atria and Ventricles

The heart has four chambers — two atria and two
ventricles — separated by a cardiac septum.
The upper atria have thin walls and serve as
reservoirs for blood. They also boost the
amount of blood moving into the lower
ventricles, which fill primarily by gravity.
The left ventricle pumps blood against a much
higher pressure than the right ventricle,
so its wall is two and one-half times thicker.

57
Vessels
Leading into and out of the heart are the great vessels: the inferior vena cava, the superior vena cava, the
aorta, the pulmonary artery, and four pulmonary veins.

CARDIAC CIRCULATION

1
Deoxygenated venous
blood returns to the right
atrium through the
superior vena cava,
inferior vena cava, and
coronary sinus.

2
Blood in the right atrium
empties Into the right
ventricle, which contracts.

3
Blood is ejected through
the pulmonic valve into
the pulmonary artery,
then travels to the lungs
to be oxygenated

4
from the lungs, blood
travels to the left atrium
through the pulmonary
veins

5
The left atrium empties
the blood into the left
ventricle, which then
pumps the blood with
each contraction through
the aortic valve into the
aorta and throughout the
body.

58
Valves
Valves in the heart keep blood flowing in only one direction through the heart. Healthy valves open and
close passively as pressure changes within the four heart chambers.

59
 PHYSIOLOGY OF THE HEART
Contractions of the heart occur in a rhythm — called the cardiac cycle — and are regulated by impulses
that normally begin at the sinoatrial (SA) node.

The heart’s conduction system begins with the heart’s pacemaker, the SA node. When an impulse leaves
the SA node, it travels through the atria along Bachmann’s bundle and the internodal pathways on its way
to the atrioventricular (AV) node and the ventricles. After the impulse passes through the AV node, it travels
to the ventricles, first down the bundle of His, then along the bundle branches and, finally, down the
Purkinje fibers.
ANATOMY OF THE CARDIOVASCULAR SYSTEM
The cardiac cycle consists of systole, the period when the heart contracts and sends blood on its outward
journey, and diastole, the period when the heart relaxes and fills with blood.

60
61
62
 Assessment
As with assessment of other body systems, you’ll
Evaluating jugular vein distention
inspect, palpate, percuss, and auscultate
during your assessment of the cardiovascular system.
Assessing general appearance
First, take a moment to assess the patient’s general
appearance. Is he overly thin? Obese?
Alert? Anxious? Note skin color, temperature, turgor,
and texture. Are his fingers clubbed?
(Clubbing is a sign of chronic hypoxia caused by a
lengthy cardiovascular or respiratory
disorder.) If the patient is dark-skinned, inspect his
mucous membranes for pallor.
Assessing the neck vessels
Inspect the vessels in the patient’s
neck. The carotid artery should appear to have a
brisk, localized pulsation. The internal jugular vein
has a softer, undulating pulsation. Unlike
the pulsation of the carotid artery, pulsation of the
internal jugular vein changes in response to position
and breathing. The vein normally protrudes when the
patient is lying down and lies flat when he stands.
Palpation
To palpate the carotid artery, lightly place your
fingers just medial to the trachea and below the
angle of the jaw. The pulse should be regular in
rhythm and have equal strength in the right and
left carotid arteries. You shouldn’t be able to
detect any palpable vibrations, known as thrills.
Don’t palpate both carotid arteries at the same
time or press too firmly. If you do, the patient
may faint or become bradycardic.
Auscultation
Normally, you should hear no vascular
sounds over the carotid arteries upon
auscultation using the bell of the
stethoscope. If you detect a blowing,
swishing sound, this is a bruit that
results from turbulent blood flow.
A bruit can occur in patients with
arteriosclerotic plaque formation.
■ With the patient in a supine position,
position him so that you can visualize
jugular vein pulsations reflected from the
right atrium.
■ Elevate the head of the bed 30 to 45
degrees.
■ Locate the angle of Louis (sternal notch).
To do so, palpate the clavicles where they
join the sternum (the suprasternal notch).
Place your first two finger son the
suprasternal notch. Then, without lifting
them from the skin, slide them down the
sternum until you feel a bony
protuberance—this is the angle of Louis.
■ Find the internal jugular vein. (It indicates
venous pressure more reliably than the
external jugular vein.)
■ Shine a flashlight across the patient’s
neck to create shadows that highlight his
venous pulse. Be sure to distinguish jugular
vein pulsations from carotid artery
pulsations. You can do this by palpating the
vessel: Arterial pulsations continue,
whereas venous pulsations disappear with
light finger pressure. Also, venous
pulsations increase or decrease with
changes in body position; arterial pulsations
remain constant.
■ Locate the highest point along the vein
where you can see pulsations.
■ Using a centimeter ruler, measure the
distance between the high point and the
sternal notch. Record this finding as well as
the angle at which the patient was lying. A
finding greater than 11/4 to 11/2 (3 to 4 cm)
above the sternal notch, with the head of
the bed at a 45-degree angle, indicates
jugular vein distention.
63
 Assessing the heart
Inspection
Inspect the chest. Note landmarks you can use to describe your findings as well as structures underlying
the chest wall. Look for pulsations, symmetry of movement, retractions, or heaves (strong outward thrusts
of the chest wall that occur during systole). Note the location of the apical impulse. This is also usually the
point of maximal impulse and should be located in the fifth intercostal space at or just medial to the left
midclavicular line. You’ll notice it more easily in children and in patients with thin chest walls. To find the
apical impulse in a woman with large breasts, displace the breasts

Palpation
Maintain a gentle touch when you palpate
so that you won’t obscure pulsations or
similar findings. Follow a systematic
palpation sequence covering the
sternoclavicular, aortic, pulmonic, tricuspid,
and epigastric areas.

Percussion
Percuss at the anterior axillary line and
continue toward the sternum along the fifth
intercostal space. The sound changes from
resonance to dullness over the left border
of the heart, normally at the midclavicular
line. The right border of the heart is usually
aligned with the sternum and can’t be percussed.

64
Auscultation
Use a zigzag pattern over the precordium. Be sure to listen over the entire precordium, not just over the
valves. Note the heart rate and rhythm. Identify the first and second heart sounds (S1 and S2), then listen
for adventitious sounds, such as third and fourth heart sounds (S3 and S4), murmurs, and pericardial
friction rubs (scratchy, rubbing
sounds).

Positioning the patient for auscultation

Auscultate for heart sounds with the patient in three positions: lying in a supine position with the head of the
bed raised 30 to 45 degrees, lying on his left side, and sitting up. For the supine position, have the patient
lie on his back with the head of the bed elevated 30 to 45 degrees. Begin auscultation at the aortic area.
Listen over all heart valve sites and the entire precordium. Use the diaphragm of the stethoscope to listen
as you go in one direction, and use the bell as you come back in the other direction.

AUSCULTATING FOR THE HEART SOUND

1
Begin auscultating over the aortic area,
placing the stethoscope over the second intercostal
space, along the right sternal border

2
then move to the pulmonary area, located at
the second intercostal space, at the left
sternal border.

3
Next, assess the tricuspid area,
which lies over the fourth and
fifth intercostal spaces, along
the left sternal border.

4
Finally, listen over the mitral
area, located at the fifth
intercostal space, near the
midclavicular line

65
 ASSESSING THE VASCULAR SYSTEM
Inspection
Start by making general observations. Are the arms equal in size? Are the legs symmetrical? Then note
skin color, body hair distribution, and lesions, scars, clubbing, and edema of the extremities. If the patient is
confined to bed, check the sacrum for swelling. Examine the fingernails and toenails for abnormalities.

Palpation
First, assess skin temperature, texture, and turgor. Then assess capillary refill in the nail beds on the
fingers and toes. Refill time should be no more than 3 seconds, or long enough to say “capillary refill.”
Palpate the patient’s arms and legs for temperature and edema. Then palpate arterial pulses

66
 ABNORMAL FINDING

Edema
Swelling, or edema, may indicate heart failure or venous insufficiency. Right-sided heart failure may cause
swelling in the lower legs. Edema may also result from varicosities or thrombophlebitis.

Abnormal pulsations
A weak arterial pulse may indicate decreased cardiac output or
increased peripheral vascular resistance; both point to arterial
atherosclerotic disease. Strong or bounding pulsations usually
occur in a patient with a condition that causes increased cardiac
output.

67
ABNORMAL PULSE

68
 ANATOMY OF BREAST AND AXILLAE

The breast, also called Mammary glands in women, lie on the anterior chest wall. They’re located
vertically between the second or third and the sixth or seventh ribs over the pectoralis major muscle and
the serratus anterior muscle, and horizontally between the sternal border and the midaxillary line.

What lies beneath

Beneath the skin are glandular, fibrous, and fatty
tissues that vary in proportion with age, weight,
gender, and other factors, such as pregnancy. A
small triangle of tissue, called the tail of Spence,
projects into the axilla. Attached to the chest wall
musculature are fibrous bands, called Cooper’s
ligaments, that support each breast.

69
LYMPH NODES
The breasts hold several lymph node chains, each serving different areas. The pectoral lymph nodes drain
lymph fluid from most of the breast and anterior chest. The brachial nodes drain most of the arm. The
subscapular nodes drain the posterior chest wall and part of the arm. The midaxillary nodes located near
the ribs and the serratus anterior muscle high in the axilla are the central draining nodes for the pectoral,
brachial, and subscapular nodes. In women, the internal mammary nodes drain the mammary lobes. The
superficial lymphatic vessels drain the skin.

70
As time goes on
In females, the breasts start to change
at puberty and continue changing
during the reproductive years,
pregnancy, and menopause.

Changes during puberty

Breast development is an early sign of
puberty in girls and usually starts with
the breast and nipple protruding as a
single mound of flesh between ages 8
and 13. Development of breast
tissue in girls younger than age 8 is
abnormal.

Changes during the

reproductive years
During the reproductive years, a
woman’s breasts may become full or
tender in response to hormonal
fluctuations during the menstrual
cycle. During pregnancy, breast
changes occur in response to
hormones from the corpus luteum and
the placenta.

Changes after menopause

After menopause, estrogen levels
decrease, causing glandular tissue to
atrophy and be replaced with fatty
deposits.

71
 ASSESSMENT OF THE BREAST
Inspection
Inspect the skin of the breast. It
should be smooth, undimpled,
and the same color as the rest
of the skin. Check for edema,
which can accompany
lymphatic obstruction and may
signal cancer. Note breast size
and symmetry. Asymmetry may
occur normally in some adult
women, with the left breast
usually larger than the right.
Inspect the nipples, noting their
size and shape. If a nipple is
inverted, dimpled, or creased,
ask the patient when she first
noticed the abnormality. Next,
inspect the patient’s breasts
while she holds her arms over
her head, and then again while
she has her hands on her hips.
These positions may help you
detect skin or nipple dimpling
that wasn’t obvious before. If
the patient has large or
pendulous breasts, have her
stand with her hands on the
back of a chair and lean
forward. This position helps
reveal subtle breast or nipple
asymmetry.

Palpation
Ask the patient to lie in a supine
position, and place a small
pillow under her shoulder on the side you’re examining. Have the patient put her hand behind her head on
the side you’re examining. This spreads the breast evenly across the chest and makes finding nodules
easier. If her breasts are small, she can leave her arm at her side

BREAST PALPATION METHOD

Three methods may be used to palpate the breasts during a clinical examination: circular, wedged, or
vertical strip. According to the American Cancer Society, the vertical strip method is the most effective
method to ensure that the entire breast is palpated. Whatever method you use, be consistent and palpate
the entire breast, including the periphery, tail of Spence, and the areola.

72
IDENTIFYING LOCATIONS OF BREAST LESIONS
Mentally divide the breast into four quadrants and a fifth segment, the tail of Spence. Describe your findings
according to the appropriate quad rant or segment. You can also think of the breast as a clock, with the
nipple in the center. Then specify locations according to the time (2 o’clock, for example). Either way,
specify the location of a lesion or other findings by the distance in centimeters from the nipple.

Documenting a breast lump

If you palpate a lump, record these
characteristics:
• size in centimeters
• shape — round, discoid,
regular, or irregular
• consistency — soft, firm, or
hard
• mobility
• degree of tenderness
• location, using the quadrant or
• clock method.

EXAMINING THE AXILLAE

Inspection
With the patient sitting or standing, inspect the skin of the axillae for rashes, infections, or unusual
pigmentation.

Palpation
Ask the patient to relax her arm on the side you’re examining. Support her elbow with one of your
hands. Cup the fingers of your other hand, and reach high into the apex of the axilla. Place your
fingers directly behind the pectoral muscles, pointing toward the midclavicle.

ASSESSING THE AXILLARY NODES

Palpate the central nodes by pressing your fingers downward and in toward the chest wall. You
can usually palpate one or more of the nodes, which should be soft, small, and nontender. If you
feel a hard, large, or tender lesion, try to palpate the other groups of lymph nodes for comparison.

ASSESSING THE CLAVICULAR NODES

If the axillary nodes appear abnormal, assess the nodes in the clavicular area. To do this, have the
patient relax her neck muscles by flexing her head slightly forward. Stand in front of her and hook
your fingers over the clavicle beside the sternocleidomastoid muscle. Rotate your fingers deeply
into this area to feel the supraclavicular nodes.
73
ABNORMAL FINDINGS

74
75
76