COLLEGE OF NURSING

NCM 101- HEALTH ASSESSMENT RLE

PERFORMING PHYSICAL ASSESSMENT

PART 1

ASSIGNMENT

PROCEDURE NORMAL ABNORMAL FINDINGS

FINDINGS
1. Explain the purpose and procedure
2. Close the doors and/or place screen covering
examination table/bed.
3. Encourage the client to empty bladder.
4. Perform physical examination.
A. GENERAL EXAMINATION Recent and Recent and remote
Assess overall body appearance and mental status. remote memory memory not intact.
Observe the client’s ability to respond to verbal intact. The client The client is unable to
commands. may respond. react to verbal
in response to commands
spoken
commands
5. Observe the client’s level of consciousness (LOC) and The client is The client is drowsy.
orientation. Ask the client to state his/her own name, awake. The client is not aware.
current location, and approximate day, month, or The client is paying and are unable to
year. attention. respond
and reacts to appropriately
inquired about when questioned
The client reacts The client expects high
to quality.
stimuli that are stimulant to show
appropriate reaction.
6. Observe the client’s ability to think, remember, The client The client is unable to
process information, and communicate. communicates name familiar objects
Inspect articulation on speech style and contents of clearly. and has difficulty
speaking. as well as recalling and
coherence thinking
The client is able The client has
name is well- disorganized
known thoughts
objects and
memory
encounters with
no

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 difficulty
The client is able
express ideas in a
comprehensible
manner
Client expresses
himself
gradually and
repetitively
7. Observe client’s ability to see, hear, smell, and The client is able The client is unable to
distinguish tactile sensations. distinguish smell and the client is
between odors having difficulty
The client is able distinguishing
to recognize texture.
textures.
8. Observe signs of distress. The client's Client exhibits irregular
breathing is breathing patterns
normal.
at a typical and
relaxed tempo
9. Observe facial expression and mood. The client's face is Client expresses
relaxed, with unusually strong
appropriate levels emotions through facial
of emotion expressions Client fails
displayed. to maintain eye contact
The client or maintains excessive
maintains eye contact.
appropriate eye
contact.
10. Observe general appearance: posture, gait, and The client appears The client has a hunched
movement. relaxed and at posture. The client
ease. moves in a stiff and rigid
The client walks manner.
with proper
rhythm and
coordination.
11. Observe grooming, personal hygiene, and dress. The client appears The client dresses
to be clean and crudely and
well-groomed. inappropriately.
The client does not The client has an untidy
have an appearance.
unpleasant odor. The client emits an
unpleasant odor.
12. Measurement: Height is within The height is
 Height the normal range significantly above
1) Ask the client to remove shoes and stand for one's age, average range or the
with his/her back and heels touching the ethnicity, and height is significantly
wall genetic heritage. lower standard range.
2) Place a pencil flat on his/her head so that
it makes a mark on the wall. BMI is considered BMI is greater than 25
3) This shows his/her height measured with normal. or less than 18.
tape measure from the floor to the mark The body's weight Weight is not a
is within a 10% within acceptable
on the wall (or if available, measure the
acceptable range range.
height with measuring scale).
4) Record height.
 Weight

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 1) Weigh the client without shoes and much
clothing
2) Record weight.
13. Take the vital signs The body's The body's temperature
 Temperature temperature is is less than 36 degrees
 Pulse rate between 36.1 and Celsius or
 Respiration 37.2 degrees greater than 38 C
 Blood pressure Celsius. The pulse rhythm is
erratic and is
The pulse rhythm less than 60
is regular and beats/minute
consistent, ranging (dysrhythmia) or
between 60 and greater than 100
100 beats per beats/minute
minute. (tachycardia)
The respiratory rate is
The rate of less than 12
respiration is breaths/minute
between 12 and (dyspnea) or
20 breaths per greater than 20
minute. breaths/minute
(tachypnea)
The blood Blood pressure is
pressure reading is elevated.
120/80 mmHg. 90/60 is far too low.
or less
(hypertension)
excessively high with
140/90 or better
(hypertension)
14. SKIN ASSESSMENT Skin has little to Skin has strong foul
*Note for color, moisture, temperature, texture, mobility and no smell of smelling odor of sweat.
turgor, edema, and lesions. perspiration. The skin is rough and
1) Inspect the back and palms of the client’s The skin is flaky,
hands for skin color. Compare the right and undamaged. or itchy scars, burns, and
left sides. Make a similar inspection of the There are no abrasions
feet and toes, comparing the right and left reddened areas. Swelling or bruises
sides. Skin is smooth is visible in the
with no burns skin
2) Palpate the skin on the back and palms of the
observed
client’s hands for moisture and texture.
or bruising
3) Palpate the skin’s temperature with the back
of your hand.
4) Pinch and release the skin on the back of the
client’s hand.
5) Press suspected edematous areas with the
edge of your fingers for 10 seconds and
observe for the depression
6) Inspect the skin for lesions. Note the
appearance, size, location, presence, and
appearance of drainage.
15. HAIR ASSESSMENT Natural hair color Gray hair is observed.
*Note: Color of hair, texture, amount of hair, flaking, parasites, The scalp is clean. The scalp is flaky or
suitable drier scaly
1) Inspect and palpate the hair for color, texture, Typical presence Hair loss is a
growth, and distribution of hair. and the quantity problem observed and
2) Inspect the scaly, lumps, nevi, or other lesions. of Hair parasites exist.
3) Inspect the body, axillae, and pubic hair for hair at the end observed

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 amount and distribution as well as parasites. Hair is Hair is dull and brittle.
4) Inspect the scalp for lesions, flaking, and parasites appropriately Inappropriate
by separating the hair at 1- to 2-inch intervals. styled presence as well as
supple and healthy the quantity of
terminal illness
16. NAIL ASSESSMENT The nails are The nails are filthy,
*Note: Color, texture, shape, firm attachment to the nail bed, appropriate clean. shattered or jagged
and longitudinal bands of pigment. The nail color is The nails are
1) Inspect and palpate the fingernails and toenails. appropriate with inappropriately
2) Check the capillary refill by pressing the nail edge pinkish color discolored or pallid
to blanch and then release pressure quickly, Nails are tough
noting the return of color. and The presence of
firmly anchored enlarged nails
The nails are slick The nail plate is
and separated from the nail
firm bed
17. HEAD ASSESSMENT The head is The head is
1) Inspect the skull for size, shape, and symmetry. symmetricand is inappropriately
2) Inspect the scalp for tenderness, lesions, and located in the big or small
bumps. middle relating to Lesions are present.
3) Assess central neurologic function, vision, hearing the body. as well as humps
and mouth structures. The head is sized The presence of
appropriately enlargement or
The head is held tenderness. The mouth
erect does not
Head doesn’t have open and shut
lesions. There is no appropriately
presence of Stiffness of movement
enlargement or the teeth
tenderness.
The mouth opens
and closes
Appropriately.
Flowing
movement
between the jaws
18. NECK ASSESSMENT The thyroid gland Asymmetric or
*Note: Lymph node for size, shape, delimitation, (discrete or cricoid cartilage movement or
matted together), mobility, consistency, any tenderness; cartilage sways generalized enlargement
difference between lymph node and muscle or artery. upward of
1) Inspect anteriorly for symmetry, masses, enlarged as well as The thyroid gland is
lymph nodes, or deviation. symmetrically as observed.
2) Begin palpation – pads of the 2nd and 3rd fingers, the Prominence or
and palpate the preauricular nodes with a gentle client ingests. swellings other
rotary motion. Palpate head, neck and C7 is visible and than C7 is
subclavicular lymph nodes. palpable. observed.
3) Inspect trachea position. Neck movement is
4) Test sternomastoid and upper trapezius muscle smooth and. The neck has limited
strength. controlled mobility.
5) Test head and neck range of motion (flexion, Trachea is The trachea is not in the
extension, rotation, and lateral bends). in the midline. midline/
6) Inspect thyroid. Landmarks are Landmarks diverge
7) Palpate thyroid. (May be from front or back of positioned in the starting from the
patient) middle. midpoint.
8) The nurse will assess the following from the back Thyroid glandular Tissue that is coarse
of the patient: can be sensed or erratic

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  Assess the cervical spine (inspection, rising Consistency is essential.
palpation) directly beneath observed
 Assess for pain at the costovertebral anglethe Enlarged, swollen
(CVA tenderness) lobes and fingers tenderness,
and lobes are silky, toughness, as well as
rubbery and the inability to move
devoid of observed
nodules
There is no
swelling or
also enlargement
as there is no
tenderness of
Nodes of Lymph
observed
19. EYES ASSESSMENT Normal distant Myopia or presbyopia is
 Position and Alignment: visual observed
1) Eyes. acuity is
 Stand in front of the patient and 20/20 and normal The examiner's finger is
survey the eyes for position and near visual acuity raised.
alignment. If one or both eyes seem is observed.
to protrude, assess them from above. 14/14 Asymmetric
2) Eyebrows.
 Inspect the eyebrows, noting their The client was able the light's position
quantity and distribution and any to see
scaliness of the underlying skin. the examination's The reflex is observed.
3) Eyelids. at the same time
 Note the position of the lids in the examiner's Unprotected eye
relation to the eyeballs. time
 Inspect for the width of the palpebral notices it moved in order to
fissures—open area between the The mirrored establish
upper and lower eyelids image of
4) Lacrimal Apparatus. Light on the focus
 Inspect the region of the lacrimal corneas is
gland and lacrimal sac for swelling. in the same Failure of the eyes to
 Look for excessive tearing or dryness location on
of the eye. each of the eyes follow the movement
5) Conjunctiva and Sclera. The unprotected
 Ask the patient to look up as you eye in symmetry in
depress both lower lids with your remained constant
thumbs. ahead of you any or all of the six
 Inspect the sclera and palpebral Eye movement is
conjunctiva for color and note the defined as directions
vascular pattern against the white smooth and
sclera background. symmetric The client's upper body
 Ask the patient to look to each side all through 6
and down. directions lid droops
6) Cornea and Lens. The upper and
 With oblique lighting, inspect the lower limits The eyelids of the client
cornea of each eye for opacities and lids close quickly
note any opacities in the lens. and easily do not shut
7) Iris. meet entirely
 At the same time, inspect each iris. when completely
The markings should be clearly closed
defined. Lower eyelids are The eyelids are red.
 With the light shining directly from standing, and the

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 the temporal side, look for a eyelashes are The customer has
crescentic shadow on the medial side evenly distributed
of the iris. distributed protruded
8) Pupils. and extend
 In dim light, inspect the size, shape, outward eyeballs that
and symmetry of each pupil. Client's skin on
 Measure the pupils with a guide such both sides retracted
as a card or a flashlight with black There are no
circles of various sizes to facilitate eyelids. margins of the eyelids
measurement. the presence of
9) Pupillary Response to Light. redness The color of the
 Ask the patient to look into the Inflammation or
distance, and shine a bright light or lesions conjunctiva is a type of
penlight obliquely (from the side of The client's pupils conjunctiva.
the eye) into each pupil* are parallel in
 Remove it on the other side and sockets that are observed
observe how the pupil reacts not
 Repeat other side with same sinking or The customer has
procedure protruding
 Look for: Bulbar or cyanosis
 Direct reaction (pupillary constriction conjunctivitis
in the same eye) is clear, moist, and a tumor on the
 Consensual reaction (pupillary smooth
constriction in the opposite eye) Sclera is a white lower the lid
10) Coordination of Eye Movement (6 Extraocular substance.
Eye Movements /EOMs). both the lower as well as an outsider
 Hold an object at a distance from the and upper
client palpebral The client exhibits
 Ask him/her to keep his/head still The conjunctiva is
and follow the object with eyes only clear of swelling or erythema
 Making a wide “H” in the air, lead the swollen areas,
patient’s gaze: lesions of the tear duct
 To the patient’s extreme right or foreign bodies
 To the right and upward trauma. gland
 Down on the right
 Without pausing in the middle, to the The client does not a statement
extreme left have any
 To the left and upward swelling or dripping from the
 Down on the left erythema
11) Convergence Test. on the subject of puncta is discovered
 Ask the client to follow your finger or the
pencil as you move it in toward the Roughness zones
bridge of the nose. The converging the lacrimal gland
eyes normally follow the object to or lack of moisture on
within 5-8 cm of the nose. Cornea is a the
12) Snellen Eye Chart Test.
 Use the Snellen Eye Chart, which with no obscurity The cornea is observed.
includes objects, letters, or numbers
of different sizes in rows, under well- opacities and the Client has irregularly
light. lens shaped irises and pupil
 Position the client 20 feet from the size Both pupils do not
chart and ask him/her to identify the free of charge respond to light directed
items to the eye Swelling of
 Compare visual acuity of the client opacities the optic disc is
with normal vision observed The red reflex
There is no of the client has

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drainage. abnormalities Changes
in the blood supply to
taken note of from the retina is observed

when you use

punctuation

feeling the

the nasolacrimal
duct

Iris is a round, flat

flower.

and uniformly
colored

Pupils are typically

the same size

The optic disc

should be
replaced.

be oval to round

with distinct, well-

defined

borders

The client owns

four sets of

and arterioles

venules that flow

by means of the
optic

disc.

The red reflex of

The client's eye is

easily discernible

a pair of
ophthalmoscopes

and make an
appearance round

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 on a regular basis

borders

The macula has a

darker hue.

as well as the
previous

a chamber exists
20. EAR ASSESSMENT Ears are equal in Ears are smaller or
1) Using an otoscope, hold the helix, gently pull the size. larger than usual
pinna upward and backward toward the occiput. size on both sides The ears are misaligned.
2) Gently insert the otoscope and examine the ear. Earlobes are
3) Inspect the pinna, external canal, tympanic completely free The ear has lesions,
membrane, landmarks. hen inspecting the ear or attached nodules or lumps
canal, note any discharge, foreign bodies, redness soldered
of the skin, or swelling. Cerumen/ear wax varies in Tenderness is noticed in
color and consistency from yellow to flaky to The skin is silky the auricle, tragus,
brown and sticky or even to dark and hard, may smooth without mastoid procedure, as
wholly or partly obscure your view. any lesions, well as behind the ear.
4) Palpate pinna for tenderness, consistency of the nodules or lumps.
cartilage, and swelling. Other discharges are
*Hearing/Auditory Acuity Tests The auricle, tragus, observed to be present
a) Voice/Whisper Test: and mastoid Canal walls are
1) Test one ear at a time. process is not reddened and are
2) Stay 30-60 cm away from the client’s ear. tender Small swollen There is red
3) Whisper slowly some two-syllable words (e.g. amount of bulging of eardrum and
black shirt, blue wall). odorless cerumen yellowish membrane
b) Weber Test (512 Hz on top of head): (earwax) is the White spots,
1) Hold the tuning fork at its base. only discharge perforations, prominent
2) Activate it by tapping the fork gently against the normally present landmarks, and
back of your hand near the knuckles or by stroking The canal walls are obscured or absent
the fork between the thumb and the index finger pink and smooth, landmarks are observed
(soft ringing). without nodules. The membrane does not
3) Place the base of the lightly vibrating fork on top The tympanic flutter.
of the client’s head or midforehead. membrane is
4) Ask where the patient hears it: on one or both pearly, gray, shiny,
sides? Normally the sound is heard in the midline and translucent, Hearing/Auditory
or equally in both ears. with no bulging or Acuity Tests
5) If nothing is heard, try again, pressing the fork retraction. It is Client is unable to
more firmly on the head. Because patients with slightly concave, repeat the whispered
normal hearing may lateralize, this test should be smooth, and intact two syllable word.
restricted to those with hearing loss. Vibrations are not
c) Rinne Test (512 Hz on mastoid bone) Hearing/Auditory equally heard. The client
1) Hold the handle of the activated tuning fork in the Acuity Tests reports lateralization of
mastoid process of one ear until the client states Client is able to sound to the good ear
that the vibration can no longer be heard. correctly repeat Bone conduction sound
2) When the patient can no longer hear the sound, the two-syllable is heard by the client
quickly place the fork close to the ear canal and word as whispered longer or equally as long
ascertain whether the sound can be heard again. Vibrations are as the air conduction
Here the “U” of the fork should face forward, thus heard by client sound
maximizing its sound for the patient. equally well in
3) Immediately hold the still vibrating fork prongs in both ears. No

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 front of the client’s ear canal lateralization of
4) Ask whether the client now hears the sound. sound to either
ear Air conduction
sound is normally
heard longer by
the client than
bone conduction
sound (AC > BC).

A (92-100) Student’s Signature: _

A- (84-91.99) Clinical Instructor’s Signature:

B (76-83.99)

B- (68-75.99)

C (60-67.99)
F (<60)