HA-RLE-Week 1

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Second Week Lecture

Physical Examination (based on Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.)
Definition - Physical examination is the process of evaluating objective anatomic findings through the use of observation,
palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history
and pathophysiology. Moreover, it is a unique situation in which both patient and physician understand that the interaction is
intended to be diagnostic and therapeutic. The physical examination, thoughtfully performed, should yield 20% of the data
necessary for patient diagnosis and management.
Purposes:
Ascertain client’s level of health & physiological function
Identify important factors
Confirm alterations disease or inability to perform ADLs
Identify need for additional testing/examination
Aid in evaluating outcome of treatment/therapy
Subjective and Objective Data:
Subjective Data
History — what the patient tells/communicates to you
Objective Data
Exam — what you discover through your physical assessment
Materials Required (only to) Phys. Exam
For All Examinations

Gloves - To protect examiner in any part of the examination when the examiner may have contact with blood, body
fluids, secretions, excretions, and contaminated items or when disease causing agents could be transmitted to or from the
client.
For Vital Signs

Sphygmomanometer - To measure diastolic (S2) and systolic (S1) blood pressure
Stethoscope - To auscultate blood sounds when measuring blood pressure
Thermometer (oral, rectal, tympanic) - To measure body temperature

Watch with second hand - To time heart rate, pulse rate
Pain rating scale - To determine perceived pain level
For Anthropometric Measurements (Nutritional Status)

Skinfold calipers - To measure skinfold thickness of subcutaneous tissue
Flexible tape measure - To measure mid-arm circumference
Platform scale with height attachment - To measure height and weight
Marker - Skin marking pen to mark measurements
For Skin, Hair, and Nail Examination

Ruler with centimeter markings - To measure size of skin lesions
Magnifying glass - To enlarge visibility of lesion
Pen light - For the measurement of pupil dilation
Examination light - For additional lighting

Mirror - For client’s self examination of skin
Wood’s light - To test for fungus
Braden Scale for Predicting Pressure Sore Risk
Second Week Lecture 1

Pressure Ulcer Scale for Healing (PUSH)
For Head and Neck Examination

Small cup of water - To help client swallow during examination of the thyroid gland
Stethoscope - To auscultate the thyroid (pulses; for hyperplasia)
For Eye Examination
Penlight - To test pupillary constriction

Snellen E chart - To test distant vision
Ophthalmoscope - To view the red reflex and to examine the retina of the eye
Cover card/Opaque card - To test for strabismus
Newspaper or Rosenbaum Pocket Screener - To test near vision
For Ear Examination
Otoscope - To view the ear canal and tympanic membrane

Tuning fork - To test for bone and air conduction of sound
For Mouth, Throat, Nose, and Sinus Examination
Penlight - To provide light to view the mouth and throat and to transilluminate the sinuses
Tongue depressor - To depress tongue to view throat, check looseness of teeth, view cheeks, and check strength of
tongue
Piece of small gauze - To grasp tongue to examine mouth

Otoscope with wide-tip attachment - To view the internal nose
For Thoracic and Lung Examination

Stethoscope (diaphragm) - To auscultate breath sounds
Marking pencil and centimeter ruler - To measure diaphragmatic excursion
For Heart and Neck Vessel Examination
Stethoscope (bell and diaphragm) - To auscultate heart sounds

Two centimeter rulers - To measure jugular venous pressure
For Abdominal Examination
Stethoscope - To detect bowel sounds

Marking pencil and tape measure with centimeter markings - To mark area of percussion of organs to measure size
Two small pillows - To place under knees and head to promote relaxation of abdomen
For Female Genitalia Examination
Vaginal speculum and lubricant - To inspect cervix through dilatation of the vaginal canal
Slides or specimen container, bifid spatula, and cotton-tipped applicator - To obtain endocervical swab and cervical
scrape and vaginal pool sample
For Anus, Rectum, Prostate Examination

Lubricating jelly - To promote comfort for client
Specimen container - To test for occult blood
For Peripheral Vascular Examination

Stethoscope and sphygmomanometer - To auscultate vascular sounds and measure blood pressure
Flexible tape measure - To measure size of extremities for edema

Cotton ball and paper clip - To detect light, blunt, and sharp touch
Tuning fork - To detect vibratory sensation
Doppler ultrasound probe blood - To detect pressure and weak pulses not easily heard with a stethoscope
For Musculoskeletal Examination
Tape measure - To measure size of extremities

Goniometer - To measure degree of flexion and extension of joints continued

For Neurologic Examination
Tuning fork - To test for vibratory sensation
Cotton wisp, paper clip - To test for light, sharp, and dull touch and two-point discrimination
Soap, coffee - To test for smelling perception
Salt, sugar, lemon, pickle juice - To test for taste perception
Tongue depressor - To test for rise of uvula and gag reflex
Reflex hammer - To test deep tendon reflexes

Coin or key - To test for stereognosis (ability to recognize objects by touch)
Steps of Phys. Exam (Preparation)
Nurse should develop a systematic approach to physical examination
Heat to toe approach
Starting at the head and neck, progressing down the body and examining the feet last
Body system approach
Examining each system in a predetermined order (Eg. Musculoskeletal system, cardiovascular, and neurological
system)
Prepare yourself (nurse)
Theoretical knowledge of Anatomy and Physiology
Examination techniques and equipment
Therapeutic communication and documentation
Seek help from your instructor, fellow students, and other health care professionals
Prepare the environment
Time should be convenient for nurse and client
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
Prepare the client
Positioning
Planning the person in a proper body alignment for the purpose of preventive, promotive, curative, and
rehabilitative aspects of health
Placing the patient in good body alignment as needed therapeutically
Draping
Drapes should be arranged so that the area to be assessed is exposed and other body are covered
Exposing the body frequently embarrassing to clients is a red flag
Drapes are made of paper, cloth, or bed linen
Provide warmth and privacy
Procedure of covering a patient and surrounding areas with a sterile barrier to create and maintain a sterile field
during a physical examination. This is done to ensure the privacy of the patient
To provide comfort and privacy during physical examination
Planning & Implementation
1. The methods of draping vary with the condition of the client, the position of the client, the examination to be
done and the room temperature.
2. The draping should be loose enough to allow the quick change of position

Action
Introduce self (to avoid anxiety)
Explain the procedure to the client
Adjust height of bed
Rationale
This reduces the anxiety of the clients thus encouraging cooperation
To avoid undue strain on both examiner and client
Instrumentation
Psychological Preparation
Remain calm
Explain each procedures
Allow client to feel free to ask questions and mention any discomfort
1. Patient's comfort
a. Be certain that the patient is in a relaxed position, properly gowned or draped.
2. The optimal environment
a. The examination surface should be at a height appropriate for the examiner.
b. Light sources and curtains should be optimally arranged. Television sets, radios, and other noisy distractions should
be eliminated.
3. Vital signs and general inspection
a. Evaluate the radial pulse for rate and rhythm. Measure brachial blood pressure. Inspect nails, skin, and hair. Note the
general appearance, body habitus, hair distribution, muscle mass, movement coordination, odors, and breathing
pattern.
4. Head
a. Eyes: Examine the conjunctiva, sclera, cornea, and iris of each eye. Test pupils for irregularity, accommodation, and
reaction. Evaluate visual fields and visual acuity (cranial nerve II). Assess extraocular movements (cranial nerves
III, IV, VI). Test the corneal reflex (cranial nerve V).
b. Ears: Examine the pinnae and periauricular tissues, Test auditory acuity, perform Weber and Rinne maneuvers
(cranial nerve VIII).
c. Ophthalmo-otoscopy: The ophthalmoscope can now be used after darkening the room to examine the interior of the
eye through the pupillary aperture. Particular emphasis should be placed on the retina, optic disc, vessels, and
macula lutea. Attention must be given to the media, lens, and cornea. Keeping the room darkened, attach the
otoscope head and observe the auditory canals and tympani.
d. Nose: Connect the nasal speculum to the otoscope and examine the nares, noting the condition of the mucosa,
septum and turbinates.
e. Mouth: Examine the vermilion border, the oral mucosa, the tongue. Identify the salivary duct papillae. Assess the
dentition for decay, repair, condition of bite. View the pharynx. Evaluate the function of cranial nerves IX, X, and
XII. If appropriate, evaluate sensory divisions of cranial nerves V, VII.
f. Face: Evaluation of symmetry, smile, frown, and jaw movement will provide information about motor divisions of
cranial nerves V and VII.
5. Neck
a. Palpate the neck with emphasis on the salivary glands, lymph nodes, and thyroid. Look for tracheal deviation.
Identify the carotid arteries and auscultate for bruits. Note jugular venous distention. Reexamine the thyroid from
behind the patient. Certain parts of evaluation of this area, jugular venous filling, may warrant review with the
patient reclining. Test shoulder strength of the sternocleidomastoid and trapezius muscles (cranial nerves XI and
XII).
6. Anterior torso
a. With the patient sitting, examine the epitrochlear and axillary nodes. Examine the breasts. Define the PMI and
examine the heart, having the patient lean forward if necessary.

7. Posterior torso
a. Observe for spinal curvature or chest deformity. Evaluate the vertebral column and the costovertebral areas.
Auscultate the posterior and lateral lung fields.
8. Completion of the "sitting" portion of the examination
a. Evaluate proximal and distal motor strength, deep tendon reflexes, distal pulses and sensation.
9. With the patient supine
a. Thorax: Examine the breasts; reexamine the heart, turning the patient to the left lateral decubitus position if
appropriate. Auscultate the anterior lung structures.
b. Abdomen: After inspection, auscultate, listening for bowel sounds and bruits. Next inspect, percuss, and palpate the
abdomen, taking special notice of hepatic or splenic enlargements.
c. Proximal lower extremities: Examine the inguinal, femoral, and popliteal regions for adenopathy and pulses.
Evaluate range of motion of hips, knees, and ankles.
10. With the patient standing
a. Examine external genitalia of the male.
b. In both male and female, evaluate station and gait.
11. Pelvic and rectal examination
a. In females, the pelvic examination should be performed on an examining table provided with stirrups.
b. Rectal examination and occult blood testing should be done simultaneously.
c. In males, the rectal examination is best performed with the patient in the bent forward position.
Positions of Patients During Phys. Exam
Techniques that maximize patient comfort ant dignity
Involves properly maintaining a patient’s a neutral body alignment by preventing hyperextension and extreme lateral
rotation from avoiding complication of immobility and injury
Draping lets your patient know you are concerned for their privacy and modesty. It sends a message that you are working
clinically when providing hands on care
Draping prevents inadvertent soiling during bedside activities. Positioning and draping patients is an essential aspect of
nursing practice and a responsibility of the registered nurse
Sitting
The client should sit upright on the side of the examination table.
In the home or office setting, the client can sit on the edge of a chair or bed.
This position is good for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper
extremities.
This position is also useful because it permits full expansion of the lungs and it allows the examiner to assess
symmetry of upper body parts.

Some clients may be too weak to sit up for the entire examination. They may need to lie down (supine position) and
rest throughout the examination. Other clients may be unable to tolerate the position for any length of time. An
alternative position is for the client to lie down with his or her head elevated.
Supine (Lying)
Ask the client to lie down with the legs together on the examination table (or bed if in a home setting).
A small pillow may be placed under the head to promote comfort.
If the client has trouble breathing, the head of the bed may need to be raised.
This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites.
Areas assessed with the client in this position may include head, neck, chest, breasts, axillae, abdomen, heart, lungs,
and all extremities.
The patient lies flat on their back with their head and shoulders slightly elevated using a pillow unless
contraindicated. Supine is the most widely used posture for general examinations and physical assessments. The
head and neck, axillae, anterior thorax, lungs, breasts, heart, belly, and various extremities are all assessed in this
posture
Fowler’s Position
The fowlers position is the most overall posture for patients who can relax peacefully in thier beds In most cases the
fowlers patient placement evaluates the head, shoulder, neck, posterior and anterior thorax, lungs, breasts axillae
haet virtal sings upper and lower limbs and the reflexes of the patients
Dorsal Recumbent
The client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the
table or bed.
This position may be more comfortable than the supine position for clients with pain in the back or abdomen.
Areas that may be assessed with the client in this position include head, neck, chest, axillae, lungs, heart,
extremities, breasts, and peripheral pulses. The abdomen should not be assessed because the abdominal muscles are
contracted in this position.

Health care professionals, such as physicians or nurse practitioner, can use this position to examine the anterior and
ventral portions of their patient’s anatomy, including the head, neck, thorax/chest (heart and lungs), abdomen,
genitals, and rectum
Sims’ (left lateral recumbent)
The client lies on his or her right or left side with the lower arm placed behind the body and the upper arm flexed at
the shoulder and elbow.
The lower leg is slightly flexed at the knee while the upper leg is flexed at a sharper angle and pulled forward.
This position is useful for assessing the rectal and vaginal areas.
The client may need some assistance getting into this position. Clients with joint problems and elderly clients may
have some difficulty assuming and maintaining this position.
In Sims laterl positon, the patient adopts a midway between the lateral and prone position. Neither arm is flexed at
the shoulder pr the elbow on the either side. At the hip and the knee, the upper leg is more acutely flexed than the
lower leg. This is typically used for rectal examinations, treatments, enemas, and examining women for vagianl wall
prolapse, among other applications
Standing
The client stands still in a normal, comfortable, resting posture
This position allows the examiner to assess posture, balance, and gait
This position is also used for examining the male genitalia
This is the optimal position for the musculoskeletal system. It evaluates the health of several body parts, including
the spine and joints. It is utilized for various purposes, including neurological examination, gait analysis, and
cerebral function evaluation
Prone
The client lies down on his or her abdomen with the head to the side.
The prone position is used primarily to assess the hip joint.
The back can also be assessed with the client in this position. Clients with cardiac and respiratory problems cannot
tolerate this position.
In the prone position, the patient lies on their stomach, with the head turned to one side and the hips not flexed at the
hip join. Positioning the body in this manner allows you to check various body parts such as the posterior thorax,

hips, and joints
Knee-Chest
The client kneels on the examination table with the weight of the body supported by the chest and knees.
A 90-degree angle should exist between the body and the hips.
The arms are placed above the head, with the head turned to one side.
A small pillow may be used to provide comfort.
The knee chest position is useful for examining the rectum.
This position may be embarrassing and uncomfortable for the client, and, therefore, the client should be kept in the
position for as limited a time as possible. Elderly clients and clients with respiratory and cardiac problems may be
unable to tolerate this position.
Knee-chest position is assumed for a gynecologic or rectal examination. An individual’s posture is supported by the
knees and chest resting on a bed. This is not suitable for senior citizens and weak patients with underlying
conditions
Lithotomy
The client lies on his or her back with the hips at the edge of the examination table and the feet supported by
stirrups.
The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum.
The client may require assistance getting into this position. It is an exposed position, and clients may feel
embarrassed. In addition, elderly clients may not be able to assume this position for very long or at all. Therefore, it
is best to keep the client well draped during the examination and to perform the examination as quickly as possible.
The lithotomy posture is widely employed to examine the vagina, penis, rectum, or anus regions. Low, standard,
high and extremes lithotomy positions are all variations on the essential lithotomy position, determined by how high
the lower body is raised or elevated for the process.
General Considerations for Examining Older Adults
Some positions may be very difficult or impossible for the older client to assume or maintain because of decreased
joint mobility and flexibility. Therefore, try to perform the examination in a manner that minimizes position
changes.
It is a good idea to allow rest periods for the older adult, if needed.
Some older clients may process information at a slower rate. Therefore, explain the procedure and integrate teaching
in a clear and slow manner.
Physical Examination Techniques (inspection, palpation, percussion, auscultation)
Introduction - Four basic techniques must be mastered before you can perform a thorough and complete assessment of the
client. These techniques are inspection, palpation, percussion, and auscultation. After performing each of the four assessment

techniques, the examiner should ask herself questions that will facilitate analysis of the data and determine areas in which
more data may be needed. These questions include:
Did I inspect, palpate, percuss, or auscultate any deviations from the normal findings?
If there is a deviation, is it a normal physical, gerontologic, or cultural finding; an abnormal adult finding; or an
abnormal physical, gerontologic, or cultural finding?
Based on my findings, do I need to ask the client more questions to validate or obtain more information about my
inspection, palpation, percussion, or auscultation findings?
Based on my observations and data, do I need to focus my physical assessment on other related body systems?
Should I validate my inspection, palpation, percussion, or auscultation findings with my instructor or another
practitioner?
Should I refer the client and data findings to a primary care provider?
Physical assessment is a systematic data collection method that uses the senses of sight, hearing, smell and touch to detect
health problems.
When you perform the physical assessment, you’ll use four techniques which is known as IPPA
Use these techniques in this sequence except when you perform an abdominal assessment
Because palpation and percussion can alter bowel sounds. Use sequence for assessing the abdomen is inspection,
auscultation, percussion, and palpation. (IAPP)
Inspection
Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings.
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.
Gait — inspect for the client walk
Principles of Accurate Inspection:
Good lightening either day light or artificial light is suitable
Exposed body parts being observed only
Look before touching
Warm room for the examination of the client “not cold not hot”
Compare each area inspected with the opposite
Side of body if possible
This technique is used from the moment that you meet the client and continues throughout the examination.
Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the
appearance of what is being inspected.
Although most of the inspection involves the use of the senses only, a few body systems require the use of special
equipment (e.g., ophthalmoscope for the eye inspection, otoscope for the ear inspection). Use the following guidelines as
you practice the technique of inspection:
Make sure the room is a comfortable temperature. A too cold or too-hot room can alter the normal behavior of the
client and the appearance of the client’s skin.
Use good lighting, preferably sunlight. Fluorescent lights can alter the true color of the skin. In addition,
abnormalities may be overlooked with dim lighting.
Look and observe before touching. Touch can alte appearance and distract you from a complete, focused
observation.
Completely expose the body part you are inspecting while draping the rest of the client as appropriate.
Palpation
Palpation consists of using parts of the hand to touch and feel for the following characteristics: texture (rough/smooth),
temperature (warm/cold), moisture (dry/wet), mobility (fixed/movable/still/vibrating), consistency (soft/hard/fluid filled),
strength of pulses (strong/weak/thready/bounding), size (small/medium/large), shape (well defined/irregular), and degree
of tenderness.

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 fingernails short and your hands warm.
Wear gloves when palpating mucous membranes or areas in contact with body fluids.
Palpate tender areas last.
Touch and feel with hands to determine:
Texture — use fingertips
Temperature — use back of hand
Moisture
Organ location and size
Slow and systematic
Light to deep
Light palpation (tenderness)
Deep palpation (abdominal organs/masses)
Principles of Accurate Palpation
Examiner finger nails should be short
Use sensitive part of your hand
Light palpation precedes deep palpation
Start with light then deep palpation
Tender area are palpated last
Client must be relax during palpation
Tell client to take slow deep breath to enhance muscle relaxation
Examine condition of the abdominal organs
Depressed areas must be approximately “2cm”
Assess turgor of skin measured by lightly grasping the body part with finger tips
Three different parts of the hand—the finger pads, ulnar/palmar surface, and dorsal surface—are used during palpation.
Each part of the hand is particularly sensitive to certain characteristics. The depth of the structure being palpated and the
thickness of the tissue overlying that structure determine whether you should use light, moderate, or deep palpation.
Bimanual palpation is the use of both hands to hold and feel a body structure.
Note the following characteristics while inspecting the client: color, patterns, size, location, consistency, symmetry,
movement, behavior, odors, or sounds. Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or
both sides of any individual body part.
Hand Parts Sensitive To
Fine discriminations: pulses, texture, size, consistency, shape,

Finger pads
crepitus
Ulnar or palmar surface Vibrations, thrills, fremitus
Dorsal (back) surface Temperature
In general, the examiner’s fingernails should be short and the hands should be a comfortable temperature. Standard
precautions should be followed if applicable. Proceed from light palpation, which is safest and the most comfortable for
the client, to moderate palpation and finally to deep palpation. Specific instructions on how to perform the four types of
palpation follow:
Light palpation: To perform light palpation, place your dominant hand lightly on the surface of the structure. There
should be very little or no depression (less than 1 cm). Feel the surface structure using a circular motion. Use this
technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture.
Moderate palpation: Depress the skin surface 1 to 2 cm (0.5 to 0.75 inch) with your dominant hand, and use a
circular motion to feel for easily palpable body organs and masses. Note the size, consistency, and mobility of
structures you palpate.

Deep palpation: Place your dominant hand on the skin surface and your nondominant hand on top of your dominant
hand to apply pressure. This should result in a surface depression between 2.5 and 5 cm (1 and 2 inches). This
allows you to feel very deep organs or structures that are covered by thick muscle.
Bimanual palpation: Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being
palpated. Use one hand to apply pressure and the other hand to feel the structure. Note the size, shape, consistency,
and mobility of the structures you palpate.
Percussion
Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to
assess underlying structures. Percussion has several different assessment uses, including:
Eliciting pain: Percussion helps to detect inflamed underlying structures. If an inflamed area is percussed, the
client’s response may indicate or the client will report that the area feels tender, sore, or painful.
Determining location, size, and shape: Percussion note changes between borders of an organ and its neighboring
organ can elicit information about location, size, and shape
Determining density: Percussion helps to determine whether an underlying structure is filled with air or fluid or is a
solid structure.
Detecting abnormal masses: Percussion can detect superficial abnormal structures or masses. Percussion vibrations
penetrate approximately 5 cm deep. Deep masses do not produce any change in the normal percussion vibrations.
Eliciting reflexes: Deep tendon reflexes are elicited using the percussion hammer.
The three types of percussion are direct, blunt, and indirect.
Direct percussion is the direct tapping of a body part with one or two fingertips to elicit possible tenderness (e.g.,
tenderness over the sinuses).
Blunt percussion is used to detect tenderness over organs (e.g., kidneys) by placing one hand flat on the body
surface and using the fist of the other hand to strike the back of the hand flat on the body surface.
Indirect or mediate percussion is the most commonly used method of percussion. The tapping done with this type of
percussion produces a sound or tone that varies with the density of underlying structures. As density increases, the
sound of the tone becomes quieter. Solid tissue produces a soft tone, fluid produces a louder tone, and air produces
an even louder tone. These tones are referred to as percussion notes and are classified according to origin, quality,
intensity, and pitch.
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.
The following techniques help to develop proficiency in the technique of indirect percussion:
Place the middle finger of your nondominant hand on the body part you are going to percuss.
Keep your other fingers off the body part being percussed because they will damp the tone you elicit.
Use the pad of your middle finger of the other hand (ensure that this fingernail is short) to strike the middle finger of
your nondominant hand that is placed on the body part.
Withdraw your finger immediately to avoid damping the tone.
Deliver two quick taps and listen carefully to the tone.
Use quick, sharp taps by quickly flexing your wrist, not your forearm.
Sounds (Tones) Elicited by Percussion
Sound Intensity Pitch Length Quality Example of Origin
Resonance (heard
over part air and part Loud Low Long Hollow Normal Lung
solid)
Hyper-resonance
Lung with
(heard over mostly Very Loud Low Long Booming
emphysema
air)
Tympany (heard Puffed-out cheek,

Loud High Moderate Drum-like
over air) gastric bubble
Dullness (heard over Diaphragm, pleural

Medium Medium Moderate Thud-like
more solid tissue effusion, liver

Sound Intensity Pitch Length Quality Example of Origin
Flatness (heard over Muscle, bone,

Soft High Short Flat
very dense tissue sternum, thigh
Auscultation
Auscultation is a type of assessment technique that requires the use of a stethoscope to listen for heart sounds, movement
of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract.
A stethoscope is used because these body sounds are not audible to the human ear.
The sounds detected using auscultation are classified according to the intensity (loud or soft), pitch (high or low),
duration (length), and quality (musical, crackling, raspy) of the sound.
Involves listening for various breath, heart, and bowel sounds with a stethoscope (pitch, loudness, quality, duration)
Getting ready for auscultation:
Provide a quiet environment
Make sure the area to be auscultated is exposed (auscultating over a gown or bed linens can interfere with sounds)
Warm the stethoscope head in your hand
Close your eyes to help focus your attention
The following guidelines should be followed as you practice the technique of auscultation:
Eliminate distracting or competing noises from the environment (e.g., radio, television, machinery).
Expose the body part you are going to auscultate. Do not auscultate through the client’s clothing or gown. Rubbing
against the clothing obscures the body sounds.
Use the diaphragm of the stethoscope to listen for high pitched sounds, such as normal heart sounds, breath sounds,
and bowel sounds, and press the diaphragm firmly on the body part being auscultated.
Use the bell of the stethoscope to listen for low-pitched sounds such as abnormal heart sounds and bruits (abnormal
loud, blowing, or murmuring sounds heard during auscultation). Hold the bell lightly on the body part being
auscultated.
How to Use the Stethoscope
The stethoscope is used to listen for (auscultate) body sounds that cannot ordinarily be heard without amplification
(eg, lung sounds, bruits, bowel sounds, and so forth). To use a stethoscope, follow these guidelines:
1. Place the earpieces into the outer ear canal. They should fit snugly but comfortably to promote effective sound
transmission. The earpieces are connected to binaural (metal tubing), which connect to rubber or plastic
tubing. The rubber or plastic tubing should be flexible and no more than 12 inches long to prevent the sound
from diminishing.
2. Angle the binaural down toward your nose. This will ensure that sounds are transmitted to your eardrums.
3. Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should be at least 1.5
inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being
auscultated.
4. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1 inch wide. Hold the
bell lightly against the body part being auscultated.
Some Do’s and Don’ts
Warm the diaphragm or bell of the stethoscope before placing it on the client’s skin.
Explain what you are listening for and answer any questions the client has. This will help to alleviate anxiety.
Do not apply too much pressure when using the bell—too much pressure will cause the bell to work like the
diaphragm.
Avoid listening through clothing, which may obscure or alter sounds.
Order of Assessment Technique
Gastrointestinal (IAPP)
Musculoskeletal
Cardiac

Basic Guidelines for Physical Assessment
Obtain a nursing history
Maintain privacy
Explain the procedure and purpose of each examined part of the client
Follow a planned order of examination for each body system
Inspect, palpate, percuss, and then auscultate, except in the abdomen auscultate then percuss to avoid alteration
in the bowel sounds
Compare symmetrical sides of the body and organs
Assess both structure and function of each body part and organ e.g. (the appearance and condition of the ear as
well as its hear function)
If there is abnormality assess for further data e.g. radiation of pain, effect on eating? bowels? ADLs?
Assess self physical assessment (e.g. exam of the breast, testicular exam, for care for the diabetic)
Allow time for client questions
“Remember: the most important guideline for adequate physical assessment is, continuous practice of physical
assessment skills”
Infection Control (environment & equipment)
Standard Precaution - Assume that every person is potentially infected or colonized with an organism that could be
transmitted in the health care setting, and apply the following infection control practices during the delivery of health care.
Hand Hygiene
During the delivery of health care, avoid unnecessary touching of surfaces in close proximity to the patient to
prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from
contaminated hands to surfaces.
When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids,
wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water.
If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water,
decontaminate hands. The preferred method of hand decontamination is with an alcohol-based hand rub.
Alternatively, hands may be washed with an antimicrobial soap and water. Frequent use of alcohol-based hand rub
immediately following hand washing with nonantimicrobial soap may increase the frequency of dermatitis. Perform
hand hygiene:
Before having direct contact with patients
After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings
After contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure or lifting a patient)
If hands will be moving from a contaminated body site to a clean body site during patient care
After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
After removing gloves
Wash hands with nonantimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g.,
Clostridium difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing
hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic
agents have poor activity against spores.
Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection
and associated adverse outcomes (e.g., those in ICUs or operating rooms).
Develop an organizational policy on the wearing of nonnatural nails by health care personnel who have direct
contact with patients outside of the groups specified in the preceding text.
Personal Protective Equipment (PPE)
Observe the following principles of use:
Wear PPE (gloves, gown, mouth/nose/eye protection) when the nature of the anticipated patient interaction
indicates that contact with blood or body fluids may occur
Prevent contamination of clothing and skin during the process of removing PPE.

Before leaving the patient’s room or cubicle, remove and discard PPE.
Gloves
Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials,
mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or
urine) could occur.
Wear gloves with fit and durability appropriate to the task.
Wear disposable medical examination gloves for providing direct patient care.
Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical
equipment.
Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using
proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one
patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of
pathogens.
Change gloves during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a
clean body site (e.g., face).
Gowns
Wear a gown that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during
procedures and patient care activities when contact with blood, body fluids, secretions, or excretions is anticipated.
Wear a gown for direct patient contact if the patient has uncontained secretions or excretions.
Remove gown and perform hand hygiene before leaving the patient’s environment
Do not reuse gowns, even for repeated contacts with the same patient.
Routine donning of gowns upon entrance into a high-risk unit (e.g., ICU, NICU, or HSCT unit) is not indicated.
Mouth, nose, eye protection
Use PPE to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient care
activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Select
masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed.
During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract [if not using in-line
suction catheters], endotracheal intubation) in patients who are not suspected of being infected with an agent for
which respiratory protection is otherwise recommended (e.g., Mycobacterium tuberculosis, SARS‡, or hemorrhagic
fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with
attached shield, or a mask and goggles (in addition to gloves and gown).
Respiratory hygiene/cough etiquette
Educate health care personnel on the importance of source control measures to contain respiratory secretions to
prevent droplet and fomite transmission of respiratory pathogens, especially during seasonal outbreaks of viral
respiratory tract infections (e.g., influenza, RSV, adenovirus, parainfluenza virus) in communities.
Implement the following measures to contain respiratory secretions in patients and accompanying individuals who
have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a health care setting
(e.g., triage, reception and waiting areas in emergency departments, outpatient clinics, and physician offices).
Post signs at entrances and in strategic places (e.g., elevators, cafeterias) within ambulatory and inpatient
settings with instructions to patients and other persons with symptoms of a respiratory infection to cover their
mouths/noses when coughing or sneezing, to use and dispose of tissues, and to perform hand hygiene after
hands have been in contact with respiratory secretions.
Provide tissues and no-touch receptacles (e.g., pedal operated lid or open, plastic-lined waste basket) for
disposal of tissues.
Provide resources and instructions for performing hand hygiene in or near waiting areas in ambulatory and
inpatient settings; provide conveniently located dispensers of alcohol-based hand rubs and, where sinks are
available, supplies for hand washing.
During periods of increased prevalence of respiratory infections in the community (e.g., as indicated by
increased school absenteeism or increased number of patients seeking care for a respiratory infection), offer
masks to coughing patients and other symptomatic persons (e.g., persons who accompany ill patients) upon

entry into the facility or medical office and encourage them to maintain special separation, ideally a distance of
at least 3 ft., from others in common waiting areas. Some facilities may find it logistically easier to institute this
recommendation year-round as a standard of practice.
Patient placement
Include the potential for transmission of infectious agents in patient placement decisions. Place patients who pose a
risk for transmission to others (e.g., uncontained secretions, excretions, or wound drainage; infants with suspected
viral respiratory or gastrointestinal infections) in a single-patient room when available
Determine patient placement based on the following principles:
Route(s) of transmission of the known or suspected infectious agent
Risk factors for transmission in the infected patient
Risk factors for adverse outcomes resulting from an HAI in other patients in the area or room being considered
for patient placement
Availability of single-patient rooms
Patient options for room sharing (e.g., cohorting patients with the same infection)
Patient care equipment and instruments/devices
Establish policies and procedures for containing, transporting, and handling patient care equipment and
instruments/devices that may be contaminated with blood or body fluids.
Remove organic material from critical and semi-critical instrument/devices using recommended cleaning agents
before high-level disinfection and sterilization to enable effective disinfection and sterilization processes.
Wear PPE (e.g., gloves, gown), according to the level of anticipated contamination, when handling patient care
equipment and instruments/devices that are visibly soiled or may have been in contact with blood or body fluids.
Care of the environment
Establish policies and procedures for routine and targeted cleaning of environmental surfaces as indicated by the
level of patient contact and degree of soiling.
Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close
proximity to the patient (e.g., bed rails, overbed tables) and frequently touched surfaces in the patient care
environment (e.g., door knobs, surfaces in and surrounding toilets in patients’ rooms), on a more frequent schedule
compared to that for other surfaces (e.g., horizontal surfaces in waiting rooms).
Use EPA-registered disinfectants that have microbiocidal (i.e., killing) activity against the pathogens most likely to
contaminate the patient care environment, in accordance with the manufacturer’s instructions.
Review the efficacy of in-use disinfectants when evidence of continuing transmission of an infectious agent (e.g.,
rotavirus, C. difficile, norovirus) may indicate resistance to the in-use product and change to a more effective
disinfectant as indicated.
In facilities that provide health care to pediatric patients or have waiting areas with child’s play toys (e.g., obstetric/
gynecology offices and clinics), establish policies and procedures for cleaning and disinfecting toys at regular
intervals. Use the following principles in developing this policy and procedures:
Select toys that can be easily cleaned and disinfected
Do not permit use of stuffed furry toys if they will be shared
Clean and disinfect large stationary toys (e.g., climbing equipment) at least weekly and whenever visibly soiled
If toys are likely to be mouthed, rinse with water after disinfection; alternatively, wash in a dishwasher
When a toy requires cleaning and disinfection, do so immediately or store in a designated labeled container
separate from toys that are clean and ready for use
Include multiuse electronic equipment in policies and procedures for preventing contamination and for cleaning and
disinfecting, especially those items that are used by patients, those used during delivery of patient care, and mobile
devices that are moved in and out of patient rooms frequently (e.g., daily).
No recommendation for use of removable protective covers or washable keyboards. Unresolved issue
Textiles and laundry
Handle used textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons.

If laundry chutes are used, ensure that they are properly designed, maintained, and used in a manner to minimize
dispersion of aerosols from contaminated laundry
Safe injection practices
The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable,
intravenous delivery systems.
Use aseptic technique to avoid contamination of sterile injection equipment.
Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe
is changed. Needles, cannulas, and syringes are sterile, single-use items; they should not be reused for another
patient or used to access a medication or solution that might be intended for a subsequent patient.
Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) for one patient only,
and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used
to enter or connect to a patient’s intravenous infusion bag or administration set.
Use single-dose vials for parenteral medications whenever possible.
Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover
contents for later use.
If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must
be sterile.
Do not keep multidose vials in the immediate patient treatment area and store in accordance with the
manufacturer’s recommendations; discard if sterility is compromised or questionable.
Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
Infection control practices for special lumbar puncture procedures
Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e.,
during myelograms, lumbar puncture, and spinal or epidural anesthesia).
Worker safety
Adhere to federal and state requirements for protection of health care personnel from exposure to bloodborne
pathogens.
General Survey (Height, Weight, Viral Signs, Behavior)
Introduction
Make sure to wash your hands before starting the procedure
Assessment begins when the nurse first meets the client
The nurse determines the reason the client is seeking health care
The examination begins with a general survey that includes observation of general appearance and behavior, vital signs,
and height, and weight measurements
A general survey provides information about characteristics of an illness, a clients hygience and body image
Equipment used:
Standing platform scale with hiehgt masureing attachment
Thermometer
Sphygmomanometer and cuff
Stethoscope
Watch with second hand
Physical Appearance
Age
Gender
Skin Color
Facial Features
Guest Appearance

Assessment Procedure Normal Findings Abnormal Findings
Observe physical & sexual development
Compare client’s stated age with her

apparent age and developmental stage
Observe skin condition and color
Body Structure
Stature
The general survey is the first part of the physical exam that begins the moment the nurse meets the client. It requires the
nurse to use all of her observational skills while interviewing and interacting with the client. These observations will lead to
clues about the health status of the client. The outcome of the general survey provides the nurse with an overall impression of
the client’s whole being. The general survey includes observation of the client’s:
Physical development and body build
Gender and sexual development
Apparent age as compared to reported age
Skin condition and color
Dress and hygiene
Posture and gait
Level of consciousness
Behaviors, body movements, and affect
Facial expression
Speech
Vital signs
The client’s vital signs (pulse, respirations, blood pressure, temperature, and pain) are the body’s indicators of health. Usually
when a vital sign (or signs) is abnormal, something is wrong in at least one of the body systems. Traditionally, vital signs
have included the client’s pulse, respirations, blood pressure, and temperature.
Today, “pain” is considered to be the “fifth vital sign” (Flaherty, 2001). Pain is inexpensive to assess and does not involve the
use of fancy instruments, yet it can be an early predictor of impending disability. For example, early and correct assessment
of a client’s chest pain may promote early treatment and prevention of complications and the high cost of cardiovascular
damage and/or failure.
Overall Impression of the Client
The first time you meet a client, you tend to remember certain obvious characteristics. Forming an overall impression
consists of a systematic examination and recording these general characteristics and impressions of the client. If possible,
try to observe the client and environment quickly before interacting with the client. This gives you the opportunity to
“see” the client before she assumes a social face or behavior and allows you to glimpse any distress, sadness, or pain
before the client, knowingly or unknowingly, may mask it. When you meet the client for the first time, observe any
significant abnormalities in the client’s skin color, dress, hygiene, posture and gait, physical development, body build,
apparent age, and gender. If you observe abnormalities, you may need to perform an in-depth assessment of the body
area that appears to be affected (e.g., an unusual gait may prompt you to perform a detailed musculoskeletal assessment).
You should also generally assess the client’s level of consciousness, level of comfort, behavior, body movements, affect,
facial expression, speech and mental acuities. If you detect any abnormalities during your general impression
examination, you will need to do an in-depth mental status examination. Additional preparation involves creating a
comfortable, non-threatening atmosphere to relieve anxiety in the client.
Vital Signs
The nurse usually begins the “hands-on” physical examination by taking vital signs. This is a common, non-invasive
physical assessment procedure that most clients are accustomed to. Vital signs provide data that reflect the status of
several body systems including but not limited to the cardiovascular, neurological, peripheral vascular, and respiratory
systems. Measure the client’s temperature first, followed by pulse, respirations, and blood pressure. Measuring the

temperature puts the client at ease and causes him or her to remain still for several minutes. This is important because
pulse, respirations, and blood pressure are influenced by anxiety and activity. By easing the client’s anxiety and keeping
him or her still, you help to increase the accuracy of the data.
Temperature
For the body to function on a cellular level, a core body temperature between 36.5°C and 37.7°C (96.0°F and
99.9°F orally must be maintained. An approximate reading of core body temperature can be taken at various
anatomic sites. None of these is completely accurate; they are simply a good reflection of the core body
temperature. Several factors may cause normal variations in the core body temperature. Strenuous exercise,
stress, and ovulation can raise temperature.
Body temperature is lowest early in the morning (4 to 6 AM) and highest late in the evening (8 PM to
midnight). Hypothermia (lower than 36.5°C or 96.0°F) may be seen in prolonged exposure to the cold,
hypoglycemia, hypothyroidism, or starvation. Hyperthermia (higher than 38.0°C or 100°F) may be seen in viral
or bacterial infections, malignancies, trauma, and various blood, endocrine, and immune disorders. In the older
adult, temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously
elevated temperature with an infection or be considered hypothermic below 96°F.
Pulse
A shock wave is produced when the heart contracts and forcefully pumps blood out of the ventricles into the
aorta. The shock wave travels along the fibers of the arteries and is commonly called the arterial or peripheral
pulse. The body has many arterial pulse sites. One of them—the radial pulse—gives a good overall picture of
the client’s health status. Several characteristics should be assessed when measuring the radial pulse— rate,
rhythm, amplitude and contour, and elasticity. Amplitude can be quantified as follows:
1+ Thready or weak (easy to obliterate)
2+ Normal (obliterate with moderate pressure)
3+ Bounding (unable to obliterate or requires very firm pressure
Respirations
The respiratory rate and character are additional clues to the client’s overall health status. Respirations can be
easily observed without alerting the client by watching chest movement before removing the stethoscope after
you have completed counting the apical beat.
Blood Pressure
Blood pressure reflects the pressure exerted on the walls of the arteries. This pressure varies with the cardiac
cycle, reaching a high point with systole and a low point with diastole. Therefore, blood pressure is a
measurement of the pressure of the blood in the arteries when the ventricles are contracted (systolic blood
pressure) and when the ventricles are relaxed (diastolic blood pressure). Blood pressure is expressed as the ratio
of the systolic pressure over the diastolic pressure. A client’s blood pressure is affected by several factors:
Cardiac output—Blood pressure increases with increased cardiac output and decreases with decreased
cardiac output.
Distensibility of the arteries—Blood pressure increases when more effort is required to push blood through
stiffened arteries.

Blood volume—Blood pressure increases with increased volume and decreases with decreased volume.
Blood velocity—Blood pressure increases when blood flow is slowed due to resistance and decreases when
blood flow meets no resistance.
Blood viscosity (thickness)—Blood pressure increases when the blood is thickened and decreases with
thinning of the blood
A client’s blood pressure will normally vary throughout the day due to external influences. These include the
time of day, caffeine or nicotine intake, exercise, emotions, pain, and temperature. The difference between
systolic and diastolic pressure is termed the pulse pressure. The pulse pressure should be determined after the
blood pressure is measured because it reflects the stroke volume—the volume of blood ejected with each
heartbeat.
Blood pressure may also vary depending on the positions of the body and of the arm. Blood pressure in a
normal person who is standing is usually slightly higher to compensate for the effects of gravity. Blood pressure
in a normal reclining person is slightly lower because of decreased resistance.
Pain
Pain screening is very important in developing a comprehensive plan of care for the client. Therefore, it is
essential to assess for pain at the initial assessment.
When pain is present, it is important to identify the location, intensity, quality, duration, and any alleviating or
aggravating factors to the client.
Pain intensity measurement tools such as a 1 to 10 Likert scale may be used.
Pain quality may be described as “dull,” “sharp,” “radiating,” or “throbbing.” The mnemonic device
“COLDSPA” may help you to remember how to further assess pain if present.
COLDSPA Symptom Analysis Mnemonic (identical to clitoris mnemonic)
During the general survey, the COLDSPA mnemonic may be particularly helpful in exploring unusual signs and
symptoms or problems reported, as you and the client ask and answer various questions during the health
history interview.
Mnemonic Question
Describe the sign or symptom (feeling, appearance, sound,

Character
smell, or taste if applicable).
Onset When did it begin?
Location Where is it? Does it radiate? Does it occur anywhere else?
Duration How long does it last? Does it recur?
Severity How bad is it? How much does it bother you?
Pattern What makes it better or worse?
Associated factors/How it Affects the client What other symptoms occur with it? How does it affect you?
Complete Physical Assessment
Complete Medical History
General Survey
Patient's weight height
Body build
Posture
Gait
Obvious signs of distress
Level of hygiene and grooming
Skin integrity
Vital signs
Oxygen saturation
Patient's actual age compared and contrasted to the age that the patient actually appears like

Complete Physical Assessment
Vital signs
The pulse, blood pressure, bodily temperature and respiratory rate are measured and documented.
The assessment of the thorax and lungs including lung sounds
Assessments
Thorax
Inspection: The anterior and posterior thorax is inspected for size, symmetry, shape and for the presence of any skin
lesions and/or misalignment of the spine; chest movements are observed for the normal movement of the diaphragm
during respirations.
Palpation: The posterior thorax is assessed for respiratory excursion and fremitus.
Percussion: For normal and abnormal sounds over the thorax.
Lungs
Auscultation: The assessment of normal and adventitious breath sounds.
Percussion: For normal and abnormal sounds. Normal breath sounds like vesicular breath sounds, bronchial breath
sounds, bronchovesicular breath sounds are auscultated and assessed in the same manner that adventitious breath
sounds like rales, wheezes, friction rubs, rhonchi, and abnormal bronchophony, egophony, and whispered
pectoriloquy are auscultated, assessed and documented.
The assessment of the cardiovascular system including heart sounds
Assessment
Inspection: Pulsations indicating the possibility of an aortic aneurysm

Auscultation: Listening to systolic heart sounds like the normal S1 heart sound and abnormal clicks, the diastolic
heart sounds of S2, S3, S4, diastolic knocks and mitral valve sounds, all of which are abnormal with the exception of
S2 which can be normal among clients less than 40 years of age.
The assessment of the head (face, skull, eyes, ears, nose, mouth, throat, neck, trachea, thyroid)
Assessments
Face and Skull

Inspection: The size, shape and symmetry of the face and skull, facial movements and symmetry are inspected.
Palpation: The presence of any lumps, soreness, and masses are assessed.
Eyes
Inspection: Pupils in reference to their bilateral equality, reaction to light and accommodation, the presence of any
discharge, irritation, redness and abnormal eye movement are assessed.
Standardized Testing: The Snellen Chart for visual acuity
Ears
Inspection: The auricles are inspected in terms of color, symmetry, elasticity and any tenderness or lesions; the
external ear canal is inspected for color and the presence of any drainage and ear wax; and the tympanic membrane
in terms of color, integrity and the lack of any bulging is also assessed.
Standardized Testing: The Rinne test and the Weber test for the assessment of hearing can be done using a tuning
fork.
Nose
Inspection: The color, size, shape, symmetry, and any presence of drainage, flaring, tenderness, and masses are
assessed; the nasal passages are assessed visually using an otoscope of the correct size for an infant, child and adult;
the sense of smell is also assessed.
Palpation: The sinuses are assessed for any signs of tenderness and infection.
Mouth

Inspection: The lips are visualized for their symmetry and color; the buccal membranes, the gums and the tongue
are inspected for color, any lesions and their level of dryness or moisture; the tongue is inspected for symmetry of
movement; teeth are inspected for the presence of any loose or missing teeth; the uvula is assessed for movement,
position, size and color; the salivary glands are examined for signs of inflammation or redness; the oropharynx,
tonsils, hard and soft palates are also inspected for color, redness and any lesions. Lastly, the gag reflex is assessed.
The mouth and the throat are assessed using a tongue blade and a light source.
The assessment of the neck
Assessment
Inspection: The neck and head movement is visualized; the thyroid gland is inspected for any swelling and also for
normal movement during swallowing.
Palpation: The neck, the lymph nodes, and trachea are palpated for size and any irregularities
Auscultation: The thyroid gland is assessed for bruits
The integumentary system assessment (hair, skin, nails)
Assessment
Inspection: The color of the skin, the quality, distribution and condition of the bodily hair, the size, the location,
color and type of any skin lesions are assessed and documented, the color of the nail beds, and the angle of curvature
where the nails meet the skin of the fingers are also inspected.
Palpation: The temperature, level of moisture, turgor and the presence or absence of any edema or swelling on the
skin are assessed.
The assessment of the peripheral vascular system
Assessment
Inspection: The extremities are inspected for any abnormal color and any signs of poor perfusion to the extremities,
particularly the lower extremities. While the client is in a supine position, the nurse also assesses the jugular veins
for any bulging pulsations or distention.
Auscultation: The nurse assesses the carotids for the presence of any abnormal bruits.
Palpation: The peripheral veins are gently touched to determine the temperature of the skin, the presence of any
tenderness and swelling.
The peripheral vein pulses are also palpated bilaterally to determine regularity, number of beats, volume and
bilateral equality in terms of these characteristics.
The assessment of the breast and axillae
Assessment
Inspection: The breasts are visualized to assess the size, shape, symmetry, color and the presence of any dimpling,
lesions, swelling, edema, visible lumps and nipple retractions. The nipples are also assessed for the presence of any
discharge, which is not normal for either gender except when the female is pregnant or lactating.
Palpation: The nurse performs a complete breast examination using the finger tips to determine if any lumps are
felt. The lymph nodes in the axillary areas are also palpated for any enlargement or swelling.
The assessment of the abdomen
Assessment
Inspection: The abdomen is visualized to determine its size, contour, symmetry and the presence of any lesions. As
previously mentioned, the abdomen is also inspected to determine the presence of any pulsations that could indicate
the possible presence of an abdominal aortic aneurysm.
Auscultation: The bowel sounds are assessed in all four quadrants which are the upper right quadrant, the upper left
quadrant, the lower right quadrant and the lower left quadrant.
Palpation: Light palpation, which is then followed with deep palpation, is done to assess for the presence of any
masses, tenderness, pain, guarding and rebound tenderness.
The assessment of the musculoskeletal system
Assessment
Inspection: The major muscles of the body are inspected by the nurse to determine their size, and strength, and the
presence of any tremors, contractures, muscular weakness and/or paralysis. All joints are assessed for their full range

of motion. The areas around the bones and the major muscle groups are also inspected to determine any areas of
deformity, swelling and/or tenderness.
Palpation: The muscles are palpated to determine the presence of any spasticity, flaccidity, pain, tenderness, and
tremors.
The assessment of the neurological system including all the reflexes
Assessments
Of all of the bodily systems that are assessed by the registered nurse, the neurological system is perhaps the
most extensive and complex. Some of the terms and terminology relating to the neurological system and
neurological system disorders that you should be familiar with include those below:
Acalculia: Acalculia is the client's loss of ability to perform relatively simple mathematical calculations
like addition and subtraction.
Agnosia: Agnosia is defined as the loss of a client's ability to recognize and identify familiar objects using
the senses despite the fact that the senses are intact and normally functioning. The different types of
agnosia, as based on each of the five senses, are auditory agnosia, visual agnosia, gustatory agnosia,
olfactory agnosia, and tactile agnosia.
Agraphia: Agraphia, simply defined, is the Inability of the client to write. Agraphia is one of the four
hallmark symptoms of Gerstmann's syndrome. The other symptoms of Gerstmann's syndrome are acalculia,
finger agnosia, and an inability to differentiate between right and left.
Alexia: Alexia, which is a type of receptive aphasia, occurs when the client is unable to process, understand
and read the written word. This neurological disorder is also referred to as word blindness and optical
alexia.
Anhedonia: Anhedonia is a loss of interest in life experiences and life itself as the result of the
neurological deficit.
Anomia: Anomia is a lack of ability of the client to name a familiar object or item.
Anosagnosia: Anosagnosia is characterized with the client's inability to perceive and have an awareness of
an affected body part such as a paralyzed or missing leg. Anosagnosia is closely similar to hemineglect and
hemiattention
Anosdiaphoria: Anosdiaphoria is an indifference to one's illness and disability
Aphasia: Aphasia includes expressive aphasia and receptive aphasia. Expressive aphasia is characterized
by the client's inability to express their feelings and wishes to others with the spoken word; and receptive
aphasia is the client's inability to understand the spoken words of others.
Asomatognosi: Asomatognosia is the inability of the client to recognize one or more of their own bodily
parts.
Astereognosia: Astereognosia is the client's inability to differentiate among different textures with their
sense of touch and also the inability of the client to identify a familiar object, like a button, with their tactile
sensation.
Asymbolia: Asymbolia is the loss of the client's inability to respond to pain even though they have the
sensory function to feel and perceive the pain. Asymbolia is also referred to as pain dissociation and pain
asymbolia.
Autotopagnosia: Autotopagnosia is the inability of the client to locate their own body parts, the body parts
of another person, or the body parts of a medical model.
Balint's syndrome: Balint's syndrome includes ocular apraxia, optic ataxia and simultanagnosia, which
consist of impaired visual scanning, visusopatial ability and attention.
Boston Diagnostic Aphasia Examination: The Boston Diagnostic Aphasia Examination is a standardized
comprehensive assessment tool that assess and measures the client's degree of aphasia in terms of the
client's perceptions, processing of these perceptions and responses to these perceptions while using problem
solving and comprehension skills.
Broca’s aphasia: Broca’s aphasia entails the client's lack of ability to form and express words even though
the client's level of comprehension is intact.
Color agnosia: Color agnosia reflects the client's lack of ability to recognize and name different colors.

Conduction aphasia: Conduction aphasia is the client's lack of ability to repeat phrases and/or write brief
dictated passages despite the fact that the client has intact speech abilities, comprehension abilities, and the
ability to name familiar objects.
Constructional apraxia: Constructional apraxia is the inability of the client to draw and copy simple
shapes on paper.
Dressing apraxia: Dressing apraxia occurs when the person is not able to appropriately dress oneself
because of some neurological dysfunction.
Dysgraphaesthesia: Dysgraphaesthesia impairs the client's ability to sense and identify a letter or number
that is tactily drawn on the client's palm.
Dysgraphia: Dysgraphia is similar to agraphia; however, dysgraphia is difficulty in terms of writing and
agraphia is the client's complete inability to write.
Environmental agnosia: Environmental agnosia is the lack of ability of the client to recognize familiar
places, like the US Supreme Court, by looking at a photograph of it.
Finger agnosia: Finger agnosia occurs when the person is not able to identify what finger is being touched
by the person performing the neurological assessment.
Geographic agnosia: Geographic agnosia is the lack of ability of the client to recognize familiar counties,
like Canada or Mexico, when viewing a world map.
Gerstmann's Syndrome: Gerstmann's Syndrome consists of dyscalculia or acalculia, finger agnosia, one
sided disorientation and dysgraphia or agraphia.
Hemiasomatognosia: Hemiasomatognosia is the neurological disorder that occurs when the client does not
perceive one half of their body and they act in a manner as if that half of the body does not even exist.
Homonymous hemianopsia: Homonymous hemianopsia occurs when the person has neurological
blindness in the same visual field of both eyes bilaterally.
Ideomotor apraxia: Ideomotor apraxia is a neurological deficit that affects the client's ability to pretend
doing simple tasks of everyday living like brushing one's teeth.
Misoplegia: Misoplegia is a hatred and distaste for an adversely affected limb.
Motor alexia: Motor alexia occurs when the client is not able to comprehend the written word despite the
fact that the client can read it aloud.
Musical alexia: Musical alexia is a client's inability to recognize a familiar tune like "The National
Anthem" or "Silent Night".
Movement agnosia: Movement agnosia is a neurological deficit that is characterized with a client's lack of
ability to recognize an object's movement.
Ocular apraxia: Ocular apraxia is the neurological deficit that occurs when the person is no longer able to
rapidly move their eyes to observe a moving object.
Optic ataxia: Optic ataxia is characterized with the client's inability to reach for and grab an object.
Phonagnosia: Phonagnosia is the client's lack of ability to recognize familiar voices such as those of a
child or spouse.
Prosopagnosia: Prosopagnosia is a lack of ability to recognize familiar faces, like the face of a spouse or
child.
Simultanagnosia: Simultanagnosia is a neurological disorder that occurs when the client is not able to
perceive and process the perception of more than object at a time that is in the client's visual field.
Somatophrenia: Somatophrenia occurs when the client denies the fact that their body parts are not even
theirs, but instead, these body parts belong to another.
The Two-Point Discrimination Test: This test measures and assesses the client's ability to recognize more
than one sensory perception, such as pain and touch, at one time.
Visual agnosia: Visual agnosia is the client's lack of ability to recognize and attach meaning to familiar
objects.
Wechsler Memory Scale IV: Wechsler Memory Scale IV: This measurement tool is a standardized
comprehensive method to assess verbal and visual memory, including immediate memory, delayed
memory, auditory memory, visual memory and visual working memory.

The neurological system is assessed with:
Inspection
Balance, gait, gross motor function, fine motor function and coordination, sensory functioning,
temperature sensory functioning, kinesthetic sensations and tactile sensory motor functioning, as well
as all of the cranial nerves are assessed.
Balance is assessed using the relatively simple Romberg test. The Romberg test is the test that law
enforcement use to test people for drunkenness. Gait can be assessed by simply observing the client as
they are walking or by coaching the person to walk heal to toe as the nurse observes the client for their
gait.
Gross motor functioning is bilaterally assessed by having the client contract their muscles; and fine
motor coordination and functioning is observed for both the upper and the lower extremities as the
client manipulates objects.
Sensory functioning is determined by touching various parts of the body, bilaterally, with a pen or
another blunt item while the client has their eyes closed. The client is prompted to report whether or
not they feel the blunt item as the nurse touches the area. Similarly, a hot and cold object is placed on
the skin on various parts of the body to assess temperature sensory functioning. The client will then
report whether they feel heat, cold or nothing at all.
Kinesthetic sensations are assessed to determine the client's ability to perceive and report their bodily
positioning without the help of visual cues.
Tactile sensory functioning is assessed for the client's ability to have stereognosis, extinction, one point
discrimination and two point discrimination. One and two point discrimination relates to the client's
ability to feel whether or not they have gotten one or two pin pricks that the nurse gently applies.
Stereognosis is the client's ability to feel and identify a familiar object while their eyes are closed. For
example, the nurse may place a pen, a button or a paper clip in the client's hand to determine whether
or not the client can identify the object without any visual cues. Extinction is the client's ability to
identify whether or not they are being touched by the person doing the assessment with either one or
two bilateral touches. For example, the nurse may touch both knees and then ask the client if they felt
one or two touches while the client has their eyes closed.
Reflexes
Reflexes are automatic muscular responses to a stimulus. When reflexes are absent or otherwise
altered, it can indicate a neurological deficit even earlier than other signs and symptoms of the
neurological deficit appear.
Reflexes can be described as primitive and long term. Primitive reflexes are normally present at the
time of birth and these reflexes normally disappear as the baby grows older; neurological deficits are
suspected when these primitive reflexes remain beyond the point in time when they are expected to
disappear. Reflexes, other than the primitive reflexes remain intact and active during the entire life
span, under normal conditions.
The primitive reflexes are the:
Rooting reflex: The infant will turn their head in the direction of the side of the face that is being
gently stroked and, then, the infant will begin a sucking action.
Sucking reflex: The sucking reflex is demonstrated when the infant performs sucking actions
when anything like a nipple or a finger tip comes in contact with the infant's mouth.
Tonic neck reflex: The tonic neck reflex, also referred to as the fencing reflex, is demonstrated
when the infant's body takes on the appearance of a fencer's position when the infant's head is
turned to the right or to the left.
Galant or truncal incurvation reflex: This reflex is seen when the infant moves their hips toward
the direction of gentle tap on their back near the spine when the infant is in the prone position.
Grasp reflex: Newborns grasp fingers and other objects that are placed in their palm. They will
also tighten their grasp as the finger or another object is slowly removed.
Moro or startle reflex: This reflex normally occurs with a sudden noise such as clapping of
hands. The infant will jerk when the sound is heard. The infant's head and legs will extend and the
arms will move upward.

Step reflex: Newborns will perform walking like movements when the soles of the infant's feet
touch a surface such as a floor. The reflex disappears in about six to eight weeks of age.
Parachute reflex: The baby extends their arms forward as if to break a fall when a person holds
the infant and rotates their body rapidly.
The other reflexes are the:
Pupil reflex: Pupil reflexes include pupil dilation and pupil accommodation. The "PERLA"
mnemonic for pupil reflexes stands for Pupils Equally Reactive to Light and Accommodation
which is a normal finding. The pupil reflexes for their reactions to light are assessed by using a
flash light in a darkened room. Pupils will normally dilate as the light is withdrawn and they will
normally constrict when the light is brought close to the pupils. The pupils are assessed not only
for their reaction to light, they are also assessed in terms of their accommodation. Normally, the
pupils will dilate when an object is moved away from the eye and they will constrict as the object
is being brought closer to the eye.
Plantar reflex: The plantar reflex is elicited when the person performing this assessment strokes
the bottom of the foot and the client's toes curl down. The Babinski sign occurs when the foot goes
into dorsiflexion and the great toe curls up; this sign is an abnormal response to this stimulation
and it can indicate the presence of deep vein thrombosis.
Biceps reflex: This reflex is assessed by placing the thumb on the biceps tendon while the person
is in a sitting position and then tapping the thumb with the Taylor hammer.
Triceps reflex: This reflex is elicited by tapping the triceps tendon with the Taylor hammer above
the elbow while the client has their hands on their legs when the client is in a sitting position.
Patellar tendon reflex: This reflex, often referred to as the knee jerk reflex, is elicited by tapping
the patellar area with the Taylor hammer.
Calcaneal reflex: This reflex, often referred to as the Achilles reflex, is assessed with tapping on
the calcaneal reflex on the ankle with the Taylor hammer.
Gag reflex: The gag reflex is elicited when the back of the mouth and the posterior tongue is
stimulated with a tongue blade.
Sneeze reflex: Sneezing occurs to rid the nasal passages of irritants.
Blinking reflex: This reflex is elicited when the eyes are touched or they are stimulated a sudden
bright light or an irritant.
Cough reflex: Coughing occurs when the airway is stimulated.
Yawn reflex: Yawning occurs as the result of the body's increased need for oxygen.
All reflexes should be done bilaterally in rapid succession so that all differences between the right and
the left reflexes can be determined and assessed. For example, when the person who is performing
these assessments should assess the biceps reflex of the right arm and then immediately assess the
biceps reflex of the left arm so that any differences or inequalities can be assessed and documented.
Lastly, the nurse assesses the twelve cranial nerves. Some of these twelve cranial nerves are only
sensory or motor nerves, and others have both sensory and motor functions.
Number Name Classification Function
Transmits the sense of smell

1 Olfactory Sensory from the olfactory foramina
of the nose.
Transmits the sense of

2 Optic Sensory vision from the retina to the
brain.
Controls eye movements,

the sphincter of the pupils
3 Oculomotor Motor
and the ciliary body
muscles.
Innervates eye ball

4 Trochlear Motor movement and the superior
oblique muscle of the eyes.

Number Name Classification Function
Controls the muscles that

5 Trigeminal Motor and Sensory
are used for chewing food.
Innervates and controls the

6 Abducens Motor abduction of the eye using
the lateral rectus muscle.
Controls facial movements,

some salivary glands, and
7 Facial Motor and Sensory gustatory sensations from
the anterior part of the
tongue.
Senses and transmits the

sense of hearing and it also
8 Acoustic Sensory
senses gravity and maintains
balance and equilibrium.
Gives us the sense of taste

from the posterior tongue,
9 Glossopharyngeal Motor and Sensory
and it also innervates the
parotid glands.
Controls laryngeal and

pharyngeal muscles and
damage to this nerve can
lead to swallowing
disorders. Also controls the
10 Vagus Motor and Sensory
parasympathetic nervous
system to the thoracic and
abdominal organs and it
controls the resonance of the
voice.
In interaction with the vagus

nerve, controls the trapezius
11 Spinal Accessory Motor
and sternocleidomastoid
muscles.
The hypoglossal cranial

12 Hypoglossal Motor nerve controls the tongue,
speech and swallowing.
The assessment of the male and female genitalia and inguinal lymph nodes
Assessment
Inspection: The rectum, anus and the surrounding area is examined for any abnormalities.
Palpation: With a gloved hand, the rectal sphincter is palpated for muscular tone, and the presence of any blood,
tenderness, pain or nodules.
The assessment of the rectum and anus
Assessment
Inspection: The rectum, anus and the surrounding area is examined for any abnormalities.
Palpation: With a gloved hand, the rectal sphincter is palpated for muscular tone, and the presence of any blood,
tenderness, pain or nodules.
Differences between Asians & Caucasians
Caucasian is a word that is used to refer to people belonging to many different parts of the world, including Asia. In fact,
Caucasians include people from western, central, and southern Asia. On the other hand, Asians refers to people belonging to
Asia, no matter which part of Asia they hail from. There are thus many similarities between Caucasians and Asians though
there are also differences as there can be Asians not included in the definition of the Caucasian race of human beings.
The term Caucasian is still used by common people to refer to people belonging to America, North Africa, West, Central, and
South Asia. In US, the term is reserved for people having white skin. By Asian, people of US mostly mean people who have
different facial features from white people and south Asians which refer to countries like Japan, China, Korea, Thailand,
Vietnam, Malaysia, and so on.


HA-RLE-Week 1

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HA-RLE-Week 1

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Second Week Lecture

Ascertain client’s level of health & physiological function

Identify important factors

Confirm alterations disease or inability to perform ADLs

Identify need for additional testing/examination

Aid in evaluating outcome of treatment/therapy

Subjective and Objective Data:

History — what the patient tells/communicates to you

Exam — what you discover through your physical assessment

Materials Required (only to) Phys. Exam

For All Examinations

For Vital Signs

Thermometer (oral, rectal, tympanic) - To measure body temperature

For Anthropometric Measurements (Nutritional Status)

For Skin, Hair, and Nail Examination

Examination light - For additional lighting

Wood’s light - To test for fungus

Braden Scale for Predicting Pressure Sore Risk

Second Week Lecture 1

For Head and Neck Examination

Stethoscope - To auscultate the thyroid (pulses; for hyperplasia)

For Eye Examination

Penlight - To test pupillary constriction

Newspaper or Rosenbaum Pocket Screener - To test near vision

For Ear Examination

Otoscope - To view the ear canal and tympanic membrane

For Mouth, Throat, Nose, and Sinus Examination

Piece of small gauze - To grasp tongue to examine mouth

For Thoracic and Lung Examination

Marking pencil and centimeter ruler - To measure diaphragmatic excursion

For Heart and Neck Vessel Examination

Stethoscope (bell and diaphragm) - To auscultate heart sounds

For Abdominal Examination

Stethoscope - To detect bowel sounds

For Female Genitalia Examination

For Anus, Rectum, Prostate Examination

Specimen container - To test for occult blood

For Peripheral Vascular Examination

Flexible tape measure - To measure size of extremities for edema

For Musculoskeletal Examination

Tape measure - To measure size of extremities

Second Week Lecture 2

Tuning fork - To test for vibratory sensation

Salt, sugar, lemon, pickle juice - To test for taste perception

Tongue depressor - To test for rise of uvula and gag reflex

Reflex hammer - To test deep tendon reflexes

Steps of Phys. Exam (Preparation)

Nurse should develop a systematic approach to physical examination

Heat to toe approach

Body system approach

Prepare yourself (nurse)

Theoretical knowledge of Anatomy and Physiology

Examination techniques and equipment

Therapeutic communication and documentation

Prepare the environment

Time should be convenient for nurse and client

Area should be well lighted

Equipment should be organized

Room should be warm enough to be comfortable for the client

Prepare the client

Placing the patient in good body alignment as needed therapeutically

Exposing the body frequently embarrassing to clients is a red flag

Drapes are made of paper, cloth, or bed linen