COLLEGE OF NURSING

NCM 101- HEALTH ASSESSMENT RLE

PERFORMANCE RATING SCALE

PERFORMING PHYSICAL ASSESSMENT
PART 3
PERFORMANCE EVALUATION CRITERIA

SCALE DESCRIPTION INDICATORS

4 Very Good Student performs behaviors/tasks affecting the highest
level of performance: consistent, independent, effective
3 Good Student performs behaviors/tasks reflecting mastery of
performance with minimal supervision
2 Fair Student performs behaviors/tasks reflecting
development and movement toward mastery of
performance: with help or direct supervision in some
aspects
1 Needs Improvement Student performs behaviors/tasks reflecting beginning
level of performance; tasks not done properly majority
of the time but demonstrate understanding of concepts
involved with tasks.

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

1. Assemble the equipment. Continuous procedure if
equipment is complete
and ready.
2. Introduce yourself and verify client’s Is able to identify them
identity. Explain the client what you are correctly. Client is alert
going to do, why it is necessary and how and is oriented. No
the client can cooperate. distress observed.
3. Perform hand hygiene and observe other Client is able to sit
appropriate infection control procedures. comfortably with no signs
of distress.
4. Provide for client privacy. Client is calm.
5. Determine the client’s history of the - The client did not
following: experience any
 Incidence of abdominal pain: its abdominal pain.
location, onset, sequence and The client has
chronology; its quality, its regular bowel
frequency; associated and the movements as she
symptoms poops about twice
 Bowel movements a day. The client
 Incidence of constipation or did not show any
diarrhea signs and
 Change in appetite symptoms of an
 Food intolerances illness. There were
May lead to incomplete
assessment if some
equipment are absent
and the nurse could
leave the patient
unattended if there are
missing equipment.
Distress is observed.
Client is in a confused
state. Client is not alert,
does not maintain
appropriate eye contact,
and does not maintain
appropriate eye contact.
Shows signs of distress.
Client is showing signs of
distress.
Has incidence of
abdominal pain. Has an
abnormal frequency of
bowel movements such
as less than 3 times a
week, which is
considered constipation.
Has incidence of
constipation or diarrhea.
Experiences changes in
appetite and food
intolerances. Shows

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  Foods ingested in the last 24 hours no previous signs and symptoms.
 Specific signs and symptoms problems and
 Previous problems and treatment treatments
experienced and
there were no
incidennce of
constipation or
diarrhea.

6. Assist the client to a supine position, with Client is able to carry and Client is having a hard
the arms placed comfortable at the sides. position themselves into time to move
a) Place small pillows beneath the the supine position with themselves into the
knees and the head to reduce minimal assistance from supine position.
tension in the abdominal muscles. the nurse.
b) Expose only the client’s abdomen
from the chest line to the pubic
area to avoid chilling and shivering,
which can tense the abdominal
muscles.
Peripheral Vascular System
ARMS
Inspection. Inspect both arms from the fingertips to Shows no sign of obvious Asymmetry is observed.
the shoulders. Note: abnormalities.
1. Their size, symmetry, swelling, and any Arms are bilaterally Lymphedema usually
lesions symmetric with only affects one extremity; it
minimal variation in both causes induration and
size and shape. Absence of nonpitting edema.
edema. Blocked lymphatic
circulation, which may
be caused by breast
surgery, results in
lymphedema.
2. The venous pattern No prominent venous Venous obstruction may
patterning present. be indicated by
existence of prominent
venous patterning with
edema.
3. The color of the skin and nail beds and the Skin color can depend on Raynaud’s disorder is a
texture of the skin several factors such as vascular disorder and is
client’s ethnicity, however characterized by rapid
skin color should be same changes in color,
bilaterally. swelling, numbness,
tingling, burning,
throbbing, and coldness.
This disorder usually
occurs bilaterally.
Palpation
1. Palpate the temperature of the arms and The skin should be warm Cool extremity can
hands simultaneously with the backs of bilaterally from the indicate arterial
your fingers. Compare the temperature of fingertips to the upper insufficiency.
the arms simultaneously. arms.
2. Palpate the radial pulse with the pads of Radial pulses are Hyperkinetic state can
your fingers on the flexor surface of the bilaterally strong (2+) and be indicated by an
wrist laterally. Partially flexing the patient’s artery walls have resilient increase in radial pulse
wrist quality or bounce. volume (3+ or bounding
pulse). Partial or

2

Recommended Grading of Pulses Bilaterally strong (2+)
3 Bounding
2 Brisk, expected (normal)
1 Diminished, weaker than expected
0 Absent, unable to palpate
Legs
The patient should be lying down and draped so Patient feels comfortable
that the external genitalia are covered and the legs and safe
fully exposed. A good examination is impossible
through stockings or socks! Patient willingly
cooperates
Inspection. Inspect both legs from the groin and Pink color for lighter-
buttocks to the feet. skinned clients and pink or
Note: red tones visible under
darker pigmented skin.
No changes in
pigmentation should
occur.
1. Their size, symmetry, and edema. Measure Shape and size are
leg circumferences in centimeters if bilateral
discrepancy is suspected.
No swelling or atrophy
2. The venous pattern and any venous Veins are flat and slightly
enlargement or varicosities visible under the surface
of the skin
3. Pigmentation, rashes, scars, or ulcers Legs are free of lesions or
ulcerations
complete arterial
occlusion can be
indicated by diminished
(1+) or absent (0) pulse.
Buerger’s disease or
scleroderma can also
cause a decrease in
pulse.
Decreased (1+), absent
(0) or bounding (3+)
pulse.
Patient feels anxiety or
discomfort
No cooperation is given
Pallor, especially when
elevated, and rubor,
suggests arterial
insufficiency
Dark-colored toes and
blisters are seen with
arterial insufficiency and
gangrene which are
visible in ulcerations that
are slow to heal, dry, or
shriveled skin.
There may or may not
be pain felt
Difference in
measurement between
legs is a result from
muscular atrophy
Cyanosis when
dependent suggests
venous insufficiency
Varicose veins may
appear nodular, bulging,
and torturous depending
on severity.
Varicosities are common
in the anterior lateral
thigh and lower leg,
posterior lateral calf, or
anus known as
hemorrhoids
Ulcers with smooth
edges that occur at
3

No changes in
pigmentation
4. The color and texture of the skin and the Feet pink to slightly pale in
color of the nail beds color in light-skinned
clients with elevation
pressure areas indicate
arterial insufficiency
Ulcers with irregular
edges, bleeding, and
possible bacterial
infection on the medial
ankle results from
venous insufficiency
Persistent rubor (dusky
redness) of toes and feet
with legs suggests
arterial insufficiency

5. The distribution of hair on the lower legs, The client has enough hair Loss of hair indicates
feet, and toes. to cover the skin on the arterial insufficiency
legs.

Hair appears on the dorsal

of the toes.
6. Look for brownish areas (or increased No changes in Rusty, ruddy, or
pigmentation on dark-skinned clients) near pigmentation brownish pigmentation
the ankles. The brown discoloration is around the ankles
caused by hemosiderin released from the Pink or red tones are indicate venous
red blood cells that seep into the skin with visible under darker- insufficiency or
edema and break down. pigmented skin hemosiderin deposits
7. Note the location, size, and depth of any Legs are free of lesions or Ulcers with smooth
ulcers in the skin. Are the edges of the ulcerations edges that occur at
wound well demarcated? Is there pressure areas indicate
bleeding? arterial insufficiency

Ulcers with irregular

edges, bleeding, and
possible bacterial
infection on the medial
ankle results from
venous insufficiency
Palpation The client’s legs, toes and Change in temperature
1. Palpate the temperature of both legs and feet are warm. from warm to cool while
feet simultaneously with the backs of your moving down the leg
hands. Compare the temperature of the indicates arterial
legs. Bilateral coolness is most often insufficiency.
caused by a cold environment or anxiety.
Increased warmth on
one leg indicates
superficial
thrombophlebitis which
results from a secondary
inflammation in the
tissue around the vein
2. Palpate for edema. Compare one foot and No edema, whether pitting Pitting edema indicates
leg with the other, noting their relative size or non-pitting, present in systemic problems, such
and the prominence of veins, tendons, and the legs as heart failure. It is
bones caused by venous stasis
from insufficiency,
obstruction, prolonged

4
 standing or sitting
3. Feel the thickness of the skin. There are no textures on Difference in
the skin, and its thickness measurement between
is around 2mm thick. legs is a result from
muscular atrophy
4. Palpate areas of local redness, noting the Toes, feet, and legs are Increased warmth on
skin temperature, and then gently palpate equally warm bilaterally one leg indicates
for the firm cord of a thrombosed vein in superficial
the area. The calf is most often involved. thrombophlebitis which
results from a secondary
inflammation in the
tissue around the vein

5. Palpate the pulses to assess the arterial
circulation.
The client’s femoral pulses Absent pulse may
are strong enough to be indicate complete
detected. arterial occlusion,
occluded artery, or
The client’s popliteal pulse impaired arterial
is a bit weak but can be circulation.
detected.

The dorsalis pedis pulses

are strong enough to be
detected.

6. Palpate the superficial inguinal nodes, No tenderness, movable Larger lymph nodes than
including both the horizontal and the lymph nodes are up to 1 usual, may result from a
vertical groups. Note their size, or 2 cm are commonly local infection or
consistency, and discreteness, and note palpated generalized
any tenderness. Nontender, discrete lymphadenopathy
inguinal nodes up to 1 cm or even 2 cm in
diameter are frequently palpable in normal
people.
Evaluating the Arterial Supply to the Hand. Pulses have equal strength Pulses are increased,
1. To assess for arterial insufficiency in the bilaterally. diminished, or absent.
arm or hand, try to feel the ulnar pulse as
well as the radial and brachial pulses. Feel
for it deeply on the flexor surface of the
wrist medially. Partially flexing the
patient’s wrist may help you. The pulse of a
normal ulnar artery, however, may not be
palpable.
Allen Test.
2. The Allen test gives further information.
This test is also useful to ensure the
patency of the ulnar artery before
puncturing the radial artery for blood Pink coloration returns to With arterial
samples or arterial lines. The patient the palms within 3–5 insufficiency or occlusion
should rest with hands in lap, palms up. seconds if the ulnar and of the ulnar and radial
3. Ask the patient to make a tight fist with radial artery is patent. artery, pallor persists.
one hand; then compress both radial and
ulnar arteries firmly between your thumbs
and fingers.
4. Next, ask the patient to open the hand into
a relaxed, slightly flexed position. The palm

5
 is pale.
5. Release your pressure over the ulnar
artery. If the ulnar artery is patent, the
palm flushes within 3 to 5 seconds.
6. Patency of the radial artery may be tested
by repeating the test and releasing the
radial artery while still compressing the
ulnar artery.
Evaluating Arterial Supply to the Legs. Feet pink to slightly pale
1. If pain or diminished pulses suggest arterial in color in the
insufficiency, look for postural color light-skinned client with
changes. With the patient lying down, raise elevation. Inspect the
both legs, as shown to about 60° until soles in the dark-skinned
maximal pallor of the feet develops— client, although it is more
usually within a minute. Have the patient difficult to see subtle color
flex the ankles up and down to drain changes in darker skin.
venous blood. In light-skinned persons, When the client sits up Marked pallor with legs
either maintenance of normal color, as and dangles the legs, a elevated is an indication
seen in this right foot, or slight pallor is pinkish color returns to of arterial insufficiency.
normal. In dark-skinned persons, evaluate the tips of the toes in 10 Return of pink color that
the soles of the feet or nail beds for pallor. seconds or less. The takes longer than 10
superficial veins on top ofseconds and superficial
the feet fill in 15 secondsveins that take longer
or less. than 15 seconds to fill
2. Then ask the patient to sit up and dangle Normal responses with suggest arterial
the legs over the side of the examination absent pulses suggest insufficiency. Persistent
table. Compare both feet, noting the time that an adequate rubor (dusky redness) of
required for: collateral circulation toes and feet with legs
● Return of pinkness to the skin, normally has developed around an dependent also suggests
about 10 seconds or less arterial occlusion. arterial insufficiency
● Filling of the veins of the feet and ankles,
normally about 15 seconds

This right foot has normal color and the

veins on the foot have filled. These normal
responses suggest an adequate circulation.

Look for any unusual rubor (dusky redness)

to replace the pallor of the dependent
foot. Rubor may take a minute or more to
appear.

Normal responses accompanied by

diminished arterial pulses suggest that a
good collateral circulation has developed
around an arterial occlusion.
ANKLE –BRACHIAL INDEX
1. Patient should avoid caffeine and tobacco Patient has no coffee Inaccurate results will
for at least 1 hour prior to the procedure. intake nor tobacco use lead to a misdiagnosis.
atleast 1 hour prior to the
ABI.
2. Explain the procedure to the patient and The client should be lying Increased pressure on
position him or her in the supine position. horizontally with his or her the back of the head
The client should rest supine for 10 to 20 face and chest looking up may occur if the
minutes before the procedure. in a normal supine procedure is performed
position. in the supine position for

6

3. Apply the blood pressure cuff to the The cuff is placed one inch
patient’s arm and feel for the brachial above the elbow bend on
pulse. the patient's naked upper
arm.
an extended period of
time.
Improper placement can
result in a 10-50 point
increase in
measurement.

4. Apply a small mound of gel over the pulse; During the process, the
turn on the Doppler. interarm systolic pressure
should be kept to a
minimum (less than 10
mm Hg).
5. 5. Place the tip of the Doppler probe in the Precision frequency and
gel at a 45° angle and listen for the velocity data are derived
“whooshing” sound, indicating the pulse. from the 30–60-degree
(The probe may be adjusted between 30° angles.
and 60° to maximize the sound.)
6. Inflate the blood pressure cuff until the An auscultatory gap is
sound is no longer heard, and then inflate avoided with a 20-30mm
it 20 to 30 mm Hg above that point. Hg inflation.
Without a lubricant, the
doppler's friction on the
skin will generate too
much static, interfering
with the pulse's sound
Doppler alignment
issues might skew data
and lead to incorrect
blood pressure readings.
An extreme increase in
pressure causes over-
inflation, which causes
pain.

7. Deflate the cuff at a rate of 2 to 4 mm The systolic blood
Hg/second until the sound returns. This is pressure is accurately
the systolic blood pressure. Repeat the measured by continuing to
procedure in the other arm. deflate at the
predetermined rate of 2-4
mm.
Pausing during deflation
can be used to create a
"skipped" beat by
manipulating the
absence of sound.

8. Place the ankle blood pressure cuff just A normal range can be If the posterior tibial
above the malleoli. Locate the posterior found just posterior to the pulse cannot be
tibial pulse with the Doppler and inflate the medial malleolus. palpated, that may
cuff 20–30 mm Hg above the number the indicate peripheral
pulse is last heard. Slowly release the vascular disease. A weak
pressure until the pulse is heard. This is the dorsalis pedis artery
systolic pressure. Repeat the procedure pulse may be a sign of
using the dorsalis pedis pulse. an underlying circulatory
condition, such as
peripheral artery
disease.
9. Obtain the systolic pressure for both pulses The normal range of the An abnormal
on the opposite ankle. blood pressure of the measurement is less
NOTE: The ankle blood pressure cuff must ankle is than 0.90.
be the appropriate size in order to obtain >175 mmHg.
accurate readings. Artery pressure is
measured at the site of the cuff; if the cuff
is placed higher on the leg a false high
systolic reading will be obtained.
Divide the higher systolic pressure from each leg by The normal finding is an Abnormal findings
the higher brachial systolic pressure. interpretation of 1.0 point. include an interpretation
Interpretation ABI Interpretation of points less than 1.0,
1.0 Normal more than or equal to
≤0.9 Mild ischemia 0.9 and 0.49, 0.6-0.8,
0.6–0.8 Borderline perfusion and 0.50-0.75.
0.50–0.75 Severe ischemia
≤0.49 Critical ischemia, rest

7
pain, or gangrene
>1.0 Unreliable. Calcium in
arterial walls prevents
compression of the
artery during the test.
Frequently seen in
diabetic patients. Refer
for a toe–brachial index
test. Toe arteries rarely
have calcified walls.
Bonham
Evaluating the Competency of Venous Valves
1. By the retrograde filling (Trendelenburg) If the patient's valves are
test, you can assess the valvular functioning properly,
competency in both the communicating there will be no pulsations
veins and the saphenous system. Start with and no evidence of
the patient supine. Elevate one leg to retrograde filling before
about 90° to empty it of venous blood. and after the manual
compressions or
tourniquet are removed.
Valvular competence is
ideal since it inhibits
retrograde filling.
Furthermore, the
saphenous system's veins
are typically 2 - 2.5 mm in
diameter in their natural
state, with the superficial
veins spanning the length
of the body at roughly 3
mm.
2. Next, occlude the great saphenous vein in Normally the saphenous
the upper thigh by manual compression or vein will fill from below in
tourniquet, using enough pressure to 30 seconds with no signs
occlude this vein but not the deeper of pulsations.
vessels. Ask the patient to stand. While you Furthermore, the
keep the vein occluded, watch for venous diameters of the great
filling in the leg. Normally the saphenous saphenous and refluxed
vein fills from below, taking about 35 great saphenous vein
seconds as blood flows through the should be 5.0 + 2.4 mm
capillary bed into the venous system. and 6.4 + 2.0 mm
respectively. With the
tourniquet on and after it
is removed as the blood
flows through the venous
system.
3. After the patient stands for 20 seconds, No pulses are felt which
release the compression and look for suggests that the patient’s
sudden additional venous filling. Normally valves are competent.
there is none; competent valves in the
saphenous vein block retrograde flow. Rapid filling is not
Slow venous filling continues. observed after the
removal of the manual
compression or the
tourniquet in 30 seconds.
Pulsations will be felt
and symptoms of
retrograde filling will be
visible before and after
the manual
compressions or
tourniquet are removed
if the patient's valves are
incompetent.
Furthermore, there will
be regurgitant valves
that do not fully seal,
resulting in retrograde
filling..
When the patient stands
up, there will be filling
from above while the
tourniquet is still in
place, indicating valvular
incompetency.
Additionally, pulsations
may be detected upon
palpation, indicating
incompetency and poor
venous circulation.
Pulses will be felt which
suggests that the
patient’s valves are
incompetent.
The filling of the
saphenous veins when
the patient is standing
while manual
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 The filling of the varicose compression or
veins from above slowly is tourniquet is still
a sign that the valves are present may indicate
competent and are that the valves are
functioning properly. ineffective and are not
working properly. After
the manual compression
or tourniquet is removed
rapid filling of the
superficial varicose veins
from above shows
retrograde filling which
indicates defective and
incompetent valves.
4. When both steps of this test are normal, There are no pulsations During palpation
the response is termed negative–negative. felt during palpation, pulsations are felt which
Negative–positive and positive–negative indicating that the is a sign that the valves
responses may also occur. patient's valves are in are incompetent.
good working order.
Filling in the veins from
above while the manual
In 30 seconds, the compression or
saphenous veins below fill tourniquet is in while
up. After removing the the patient is in a
manual compression or standing position may
tourniquet, there will be indicate incompetency
no quick filling, indicating of the valves in the
competent valves. saphenous vein.
Furthermore, the rapid
filling of the superficial
varicose veins after the
removal of the manual
compression or
tourniquet indicates
retrograde filling which
is a sign of incompetent
valves.
Pulsus Alternans
1. In pulsus alternans, the rhythm of the Normal Pulse is observed Pulsus alternans
pulse remains regular, but the force of the with no alternating strong accompanied with
arterial pulse alternates because of and weak ventricular alternating strong and
alternating strong and weak ventricular contractions observed. weak impulses is
contractions. Pulsus alternans almost observed which
always indicates severe left-sided heart indicates a significant
failure and is usually best felt by applying left-sided heart failure or
light pressure on the radial or femoral left ventricular
arteries.7 Use a blood pressure cuff to dysfunction. This occurs
confirm your finding. After raising the cuff in patients who have a
pressure, lower it slowly to the systolic dilated cardiomyopathy
level—the initial Korotkoff sounds are the and have a blockage in
strong beats. As you lower the cuff, you their left ventricular
will hear the softer sounds of the outflow.
alternating weak beats
Paradoxical Pulse
1. If you have noted that the pulse varies in The difference between The discrepancy
amplitude with respiration or if you the first and second between the first and

9
 suspect pericardial tamponade (because of measurement is no second readings is more
increased jugular venous pressure, a rapid greater than 3- or 4-mm than 12 millimeters of
and diminished pulse, and dyspnea, for Hg. mercury.
example), use a blood pressure cuff to
check for a paradoxical pulse. This is a
greater than normal drop in systolic
pressure during inspiration. As the patient
breathes, quietly if possible, lower the cuff
pressure slowly to the systolic level. Note
the pressure level at which the first sounds
can be heard. Then drop the pressure very
slowly until sounds can be heard
throughout the respiratory cycle. Again
note the pressure level. The difference
between these two levels is normally no
greater than 3 or 4 mm Hg.
ABDOMEN
1. Prepare the equipment: gloves, measuring Equipment that is It causes distraction to
tape, stethoscope. completely prepared and the nurse while doing
organized by the examiner the procedure.
ensures smooth flow
whilst the doing the
procedure without any
interruptions and he/she
can proceed to other steps
directly.

2. Inspect the abdomen for skin integrity. The client’s abdomen has
an unblemished skin.  The
client’s abdomen is
9uniform in color as
compared to the client’s
other body parts.  The
client’s abdomen has
silver-white striae (stretch
marks) or surgical scars if
present.
3. Inspect for contour, pulsations, bulges, and Abdomen is flat rounded
skin integrity. or scaphoid.  abdomen
a) Observe the abdominal contour while should be evenly rounded.
standing at the client’s side when the
client is supine.
b) Ask the client to take a deep breath and
to hold it in.
c) Assess the symmetry of contour while
standing at the foot of the bed.
The client’s skin is
different from their
other skin areas. purple  
discoloration at  the
flanks Indicates bleeding
within the abdominal
wall period,  possibly
from trauma to the
kidneys pancreas or
duodenum or from the
pancreatitis.
 the yellow hue of
jaundice maybe more
apparent on the
abdomen
redness may indicate
inflammation
 bruises or areas of local
discoloration are also
abnormal
A distended abdomen
may be due to obesity,
air or fluid accumulation.
Distention below the
umbilicus may be due to
a full bladder uterine
enlargement or an
ovarian tumor or cyst.

10
 d) If distention is present, measure the
abdominal girth by placing a tape around
the abdomen at the level of the
umbilicus.
4. Observe abdominal movements associated Male clients, in particular,
with respiration, peristalsis, or aortic may exhibit abdominal
pulsations. respiratory movement.
In thin persons, the light
ball station of the
abdominal aorta, which is
visible in the epigastrium,
extends to its entire
length.
5. Observe the vascular pattern. There were no
contractures and tremors
present.
6. Auscultate for bowel sounds, aortic Bruits are not normally
pulsation, and peritoneal friction rubs. heard  over abdominal
aorta or renal iliac for
femoral arteries. however
bruits confined to systole
may be normal in some
clients depending on other
differentiating factors
7. Percuss several areas in each of the four Generalized tympany
quadrants to determine presence of predominates over the
tympany and dullness. abdomen because of air in
 Use a systematic pattern: begin in the the stomach and
left lower quadrant, then proceed to the intestines.  dullness is
right lower quadrant, then upper right heard over the liver and
quadrant, and lastly, the left upper spleen
quadrant.
8. Percuss the liver to determine its size. The lower border of liver
dullness is located at the
costal margin 1 -2 cm
below
9. Abdominal reflex. Lightly stroke inward in all The client's abdomen is
quadrants. non tender and soft
without the presence of
guarding.
Diminished abdominal
respiration or change
the thoracic breathing in
male clients may reflect
peritoneal irritation.
 vigorous wide
exaggerated pulsations
may be seen with
abdominal aortic
aneurysm.
decreased or absent
sounds signify that
absence of bowel
motility which
constitutes an
emergency requiring
immediate referral.
A bruits if both systolic
and diastolic
components occurs
when blood flow in an
artery is turbulent or
obstructed.  this may
indicate an aneurysm or
renal arterial stenosis
Accentuated timpani or
hyperresonance is heard
over acacius distended
abdomen.
 an enlarged area of
dullness is heard over an
enlarged liver or spleen
if you cannot find the
lower border of the liver
keep in mind that the
lower border of liver
dullness may be difficult
to estimate when
obscured by intestinal
gas.
The client's abdomen is
a bit hard and has the
presence of carding this
may indicate health-
11

10. Systematically and lightly palpate all four no palpable masses are
quadrants noting masses, tenderness, and present
patient’s expression.
11. Deeply palpate all four quadrants noting No mass, tenderness or
masses, tenderness, and patient’s pain expressed by the
expression. (note for murphy’s sign) patient is visible.
12. Palpate for the liver, kidneys, and spleen. The liver is not usually
palpable also it may be felt
in some thin clients if the
lower edge is felt it should
be firm smooth and even.
 This plane is seldom
palpable at the left costal
margin; rarely the tip is
palpable in the presence
of a low flat diaphragm or
with deep diaphragm
descent on inspiration.
 The kidneys are usually
not palpable; sometimes
the lower pole of the right
kidney may be palpable by
the capture method
because of its lower
position.
13. Palpate the area above the pubic No tenderness is present
symphysis if the client’s history indicates
possible urinary retention.
MUSCULOSKELETAL SYSTEM
1. Prepare equipment: tape measure, Nurse does the procedure
goniometer, skin marking pen. efficiently and comes
prepared with the
necessary materials
2. Inquire if client has any history of: Has no history of muscle
 Muscle pain: onset, location, pain, injuries, and
character, associated phenomena difficulties in movement.
and aggravating and alleviating
factors
 Any limitations to movement or
inability to perform activities of
daily living
 Previous sports injuries
 Any loss of function without pain
3. During general inspection look at the normal and acceptable
extremities for overall size, gross size, with no noticeable
deformity, bony enlargement, alignment, irregularities and
and symmetry. Note any joint deformities deformities found during
or malalignment of bones. inspection. and overall
close in symmetry
4. Inspect the muscles for size. muscle size observed are
Compare each muscle on one side of the in normal size and is
related problems such as
Peritoneal irritation
a mass detected in any
quadrant may be due to
a tumor cyst abscess and
enlarged organ
aneurysm or adhesions.
Mass is detected in four
quadrants and murphy's
sign is visible.
a hard firm liver may
indicate cancer
tenderness may be from
vascular and gorge
meant acute hepatitis or
abscess
 A  palpable spleen
suggests enlargement.
An enlarged kidney may
be due to a cyst tumor
or hydronephrosis.
There is a marked
increase in the height of
the dullness
Nurse comes
unprepared during the
start of the assessment
and has difficulty doing
the procedure.
Patient has a record of
muscle pain, movement
limitations, and previous
injuries before the
assessment.
asymmetrical.
deformities and
irregularities are found
during the assessment.
muscle sizes are
significantly
12
 body to the same muscle on the other side. symmetrical to each other, asymmetrical with
For any apparent discrepancies, measure with no significant significant differences in
the muscles with a tape. irregular findings to take measurement.
note of. Significant irregularities
that are noteworthy is
found
5. Inspect the muscle for contractures and findings during noticeable and abnormal
tremors. Inspect tremors in the hands and observation indicate a tremors found with
arms by having the client hold arms out in normal with muscle still patients also showing
front of the body. showing mobility and only lack of mobility in these
having little to no areas of the muscles.
noticeable tremors.
6. Palpate muscle for tonicity which is best Significant muscle Find for irregularities.
assessed by feeling the muscle’s resistance contraction with almost Dysfunction in these
to passive stretch. no minimal movement is networks can cause
a) Persuade the patient to relax. the normal finding. hypertonia or hypotonia,
b) Take one hand with yours and, Movement of the limbs, which are muscular tone
while supporting the elbow, flex and not against gravity. It disorders. Hypertonia is
and extend the patient’s fingers, is possible to move caused by the lack of
wrist, and elbow, and put the despite gravity but not supraspinal control
shoulder through a moderate against resistance. systems, resulting in
range of motion. Movement in the face of spasm or stiffness.
c) On each side, note muscle tone— at least considerable
the resistance offered to your resistance from the
movements. Tense patients may examiner.
show increased resistance.
7. Palpate muscles while client is active and muscles during this muscles of patient may
passive for flaccidity, spasticity, and process are relaxed and still be stiff in some
smoothness of movement. smooth with no bumps, areas and bumps found
stiffness, and irregularities during palpation may
found. indicate muscle knots
8. Test muscle strength by asking the patient Muscles are responsive Patient is significantly
to move actively against your resistance or and are active. Patient weak with lack of muscle
to resist your movement. shows significant contraction detected
When documenting muscle strength, resistance and muscle during the process. may
indicate the scale* used (e.g., muscle strength during the test indicate poor or lack of
strength 3 out of 5 or 3/5). endurance in the
muscles
*Muscle strength is graded on a 0 to 5 scale:
0—No muscular contraction detected
1—A barely detectable flicker or trace of
contraction
2—Active movement of the body part with gravity
eliminated
3—Active movement against gravity
4—Active movement against gravity and some
resistance
5—Active movement against full resistance without
evident fatigue. This is normal muscle strength.
9. Inspect the skeleton for normal structure The skeleton seems to The skeleton feels
and deformities. have no signs of fractures abnormal or has visible
or deformities. or palpable deformities.
10. Palpate the bones to locate any areas of There were no signs of Edema and swelling are
edema or tenderness. edema or tenderness found
observed.
11. Inspect the joint for swelling. Palpate each There were no signs of Joints are painful when

13
 joint for tenderness, smoothness of swelling, tenderness, and moving and are tender
movement, swelling, crepitation, and presence of nodules to the touch.
presence of nodules. observed..
12. Palpate lightly for signs of inflammation No signs of swelling, Seems to be swelling,
and arthritis: Normal warmth and not cold to the touch,
 Swelling. Palpable swelling may involve (1) cold, no tenderness, and tender, and visible
the synovial membrane, which can feel normal coloration to the redness of the skin
boggy or doughy; (2) effusion from excess skin indication inflammation
synovial fluid within the joint space; or (3) near the joints.
soft-tissue structures such as bursae,
tendons, and tendon sheaths.
 Warmth. Use the backs of your fingers to
compare the involved joint with its
unaffected contralateral joint, or with
nearby tissues if both joints are involved.
 Tenderness. Try to identify the specific
anatomic structure that is tender. Trauma
may also cause tenderness.
 Redness. Redness of the overlying skin is
the least common sign of inflammation
near the joints.
13. Test range of motion and maneuvers: Temporomandibular Joint Temporomandibular
 Temporomandibular joint. ask the patient Joint
-  In a typical client,
to demonstrate opening and closing,
snapping and clicking -  Arthritis can cause
protrusion and retraction (by jutting the
may be felt and heard. decreased range of
jaw forward), and lateral, or side-to-side,
1–2-inch opening in the motion, swelling,
motion.
mouth (distance discomfort, or crepitus.
 Shoulder girdle. The six motions of the
between upper and Muscular and joint
shoulder girdle are flexion, extension,
lower teeth). The client's illness causes a loss of
abduction, adduction, and internal and
mouth effortlessly opens muscle strength. TMJ
external rotation.
and shuts. Jaw shifts 1–2 dysfunction can cause a
 Elbow. Range of motion includes flexion
cm to the side. Jaw reduction in ROM as well
and extension at the elbow and pronation
readily protrudes and as a clicking, cracking, or
and supination of the forearm.
retracts. grating sound.
 Wrist. Range of motion includes flexion,
extension, adduction (radial deviation), and Shoulder Girdle Shoulder Girdle
abduction (ulnar deviation). -  A rotator cuff rupture
 Fingers and Thumbs. Assess flexion, -  Extent of forward flexion causes pain and
extension, abduction, and adduction of the should be 180 degrees; restricted abduction, as
fingers. The fingers should open and close hyperextension, 50 well as muscular
easily. degrees; adduction, 50 weakening and atrophy.
 Neck. Instruct client to bring chin to chest degrees; and abduction With rotator cuff
for flexion. Next, tell him/her to look up at 180 degrees. tendinitis, the client
the ceiling for extension. Then, Then, let Elbow experiences acute spikes
patient to look over one shoulder and the - Normal ranges of motion of pain when lifting his
other. Finally, tell patient to bring his ear to are 160 degrees of flexion, hands upwards. Calcified
his shoulder and then the other side. 180 degrees of extension, tendinitis causes chronic
 Spinal Column. Instruct patient to bend 90 degrees of pronation, discomfort and
forward and try to touch his toes. Next, let and 90 degrees of significant limitations in
him bend back as far as possible. Then let supination. Some clients all shoulder movements.
patient rotate from side to side. Lastly, tell may lack 5–10 degrees or Elbow
patient to bend to the side from the waist. have hyperextension. -  With joint or muscle
 Hip. Instruct patient to bend his knee to his Wrist illness or injury, ROM
chest and pull it against his abdomen. Next,
let patient to lie face down, and then bend - 90 degrees of flexion, 70 against resistance is
his knee and lift it up. Then, lying flat, let degrees of reduced.

14
patient to move his lower leg away from hyperextension, 55 Wrist
the midline. Then ask patient to bend his degrees of ulnar deviation,
knee and move his lower leg toward the and 20 degrees of radial -    In rheumatoid
arthritis, ulnar deviation
midline. Also, tell him to bend his knee and deviation are considered
turn his lower leg and foot across the normal ranges of motion. of the wrist and fingers
is common, as is
midline. Finally, let patient bend his knee Against resistance, the
and turn his lower leg and foot away from client should have full reduced range of
motion.
the midline. range of motion.
Fingers and Thumbs Fingers and Thumbs
-    Dupuytren's
 20 degrees of
abduction, complete contracture is
characterized by the
adduction of fingers
(touching), 90 degrees inability to stretch the
ring and little fingers.
of flexion, and 30
degrees of Tenosynovitis (infection
of the flexor tendon
hyperextension are all
considered normal sheaths) can cause
painful finger extension.
ranges. The thumb
should be able to Neck
readily move apart
from the other fingers, -    The most prevalent
and thumb flexion of cause of neck pain is
50 degrees is cervical strain. It is
considered typical. characterized by limited
range of motion and
Neck neck discomfort caused
by anomalies in the soft
-   The cervical spine is tissue (muscles,
flexed 45 degrees. The ligaments, and nerves)
cervical spine is extended as a result of neck strain
45 degrees. or injury. Strains can be
-The client can normally caused by sleeping in
bend 40 degrees to the the improper posture,
left and 40 degrees to the lugging a large baggage,
right. or being involved in a
Spinal Column vehicle accident.
-    Flexion of 75–90
degrees, smooth Spinal Column
movement, flattening of
the lumbar concavity, and -    In functional scoliosis,
alignment of the spinal lateral curvature lessens,
processes. but in structural
-    Flexion of 75–90 scoliosis, unilateral
degrees, smooth excessive thoracic
movement, flattening of convexity rises. The
the lumbar concavity, and spinal processes are out
alignment of the spinal of alignment.
processes. -    Injury to soft tissues in
the low back is a typical
Hip cause of limited range of
-    90 degrees of hip motion and discomfort
flexion with the knee in the lumbar and
straight and 120 degrees thoracic areas.
of hip flexion with the Osteoarthritis,
knee bent and the other ankylosing spondylitis,
leg straight are considered and congenital

15
 normal ranges of motion. anomalies that influence
the spinal vertebral
Standard ROM: spacing and mobility are
-    Abduction angle of some of the other
45–50 degrees reasons for decreased
-    Adduction of 20–30 ROM in the lumbar and
degrees thoracic regions.
-   Internal hip rotation of Hip
40 degrees  Osteoarthritis or a
-  External hip rotation of femoral neck stress
45 degrees. fracture can cause
-    Hip hyperextension of pain and a reduction
15 degrees. in internal hip
rotation. Bursitis of
the hip is indicated
by pain on palpation
of the greater
trochanter and
discomfort as the
client transitions
from standing to
lying down.

FEMALE GENITALIA, INGUINAL AREA, AND

RECTUM
1. Prepare a good light and two pairs of
gloves. The necessary equipment The nurse is unprotected
is complete and ready, as he/she lacks gloves
allowing a continuous and the examination
procedure with a clear room is obscure.
access given the good
lighting.

1. Perform hand hygiene, apply gloves and

observe other appropriate infection control The spread of bacteria and If hand hygiene is not
procedures. the possibility of infections performed and not
will be prevented. wearing gloves the
transmission of
microorganisms to client
may lead to infection.

2. Provide for client privacy period request Client will feel

the presence of another woman if desired, Client feels protected and
required by agency policy or requested by will cooperate and
client. participate during the
examination. Nurse
establishes rapport and
trust with the client.
discomfort and most
likely not cooperate,
participate, or withdraw
from the examination.
Nurse was unable to
establish rapport and
trust with the client.

3. Determine the client’s history of the Undergoing menarche is Client went through
following close (whichever is applicable to reported (ages 12-16). menarche in her late
your client): Menstrual cycles that last teens or hasn't gone
 Age of onset of menstruation 3-5 days are reported, through it yet (adult).
 Last menstrual period (LMP) with no to mild pain Menstrual irregularities,
 Regularity of cycle, duration, throughout menstruation. possibly due to

16
 amount of daily flow, and whether The customer does not oligomenorrhea or
menstruation is painful express pain during amenorrhea, have been
 Incidence of pain during intercourse. Vaginal reported. There have
intercourse discharge ranges from been reports of severe
 Vaginal discharge clear to milky white. There discomfort throughout
 Number of pregnancies have been no previous the menstrual cycle,
 Number of live births labor or delivery. Urgency dysmenorrhea, or during
 Labor and delivery complications is reported to be low, and intercourse. It was
 Urgency and frequency of urination nighttime urination is discovered that there
at night noticeable. Urinating with had been a previous
 Blood in urine blood is not reported. labor complication that
 Painful urination Defecation and urination resulted in a miscarriage
 Incontinence are under the client's or delivery issues. There
 History of sexually transmitted voluntary control. There is has been a lot of talk
disease (past and present) no history of sexually about nocturia, or
transmitted diseases. nighttime urination. The
client describes a
bloody/brown, yellow,
hazy, pinkish, thick,
white, gray, or cheesy
discharge with a terrible
odor. The client has
noticed blood in his pee,
which could indicate
hematuria or bladder
cancer. Urinary pain and
bladder incontinence
have been reported. It is
discovered that the
patient has a history of
STDs.
4. Drape the patient appropriately and then The client is calm, The client is showing
assist her into the lithotomy position. comfortable, and feels signs of distress.
a) Help her to place one heel and safe.
then the other into the stirrups.
She will be more comfortable with
shoes or socks on than with bare
feet.
b) Then ask her to slide all the way
down the examining table until her
buttocks extend slightly beyond
the edge.
c) Her thighs should be flexed,
abducted, and externally rotated at
the hips.
d) A pillow should support her head.
5. Inspect the distribution, amount, and Clear with normal hair
characteristics of the pubic hair. distribution. No nits or Lice or nits at the base of
lice. the pubic hairs indicate
infestation with
pediculosis pubis.

Known as "crabs," they

are most commonly
transmitted through
sexual contact.

17
 6. Examine the External Genitalia. Warn the
patient that you will be touching her
genital area. Inspect the mons pubis, labia,
and perineum. Separate the labia and
inspect:
 labia minora
 clitoris
 urethral meatus
 vaginal opening, or introitus
Note any inflammation, ulceration,
discharge, swelling, lacerations,
bruising, or nodules.
The clitoris is a small
mound of erectile tissue,
sensitive to touch. The
normal size of the clitoris
varies. And the urethral
meatus is a slit-like
opening in the urethra.
The urethral meatus is
located below the vaginal
orifice.
Atypical features include
lesions, swelling, bulging
in the vaginal orifice,
and discharge. Clients
may have excoriation as
a result of scratching or
self-treating a perineal
discomfort.

7. Palpate the inguinal lymph nodes. There were no signs of

enlargement or swelling of
the inguinal lymph nodes.
Enlargement of inguinal
nodes indicates vaginal
infection or may be the
result of irritation from
hair removal.

8. Position the client to a left lateral or Sim’s A proper Sim’s position
position with the upper leg acutely flexed. has the patient assuming a
Change gloves. semi-prone position being
halfway between lateral
and prone; in this case,
the upper leg will be
gently flexed to allow
more access to the area.
9. Inspect the anus and surrounding tissue for Hairless, moist, and tightly
color, integrity, and skin lesions. closed in anal openings
are important. Around the
anal hole, the skin is
coarser and darker in
color. There should be no
redness, lumps, ulcers,
lesions, and rashes in the
perianal area.
10. Palpate the rectum for anal sphincter The mucosa of the rectal
tonicity, nodules, masses, and tenderness. hole is generally soft,
smooth, non-tender, and
nodule-free.
MALE GENITALIA, INGUINAL AREA, AND RECTUM
1. Prepare a good light and two pairs of The necessary equipment
gloves. is complete and ready,
allowing a continuous
procedure with a clear
access given the good
lighting.
The intrinsic and
extrinsic risk factors
include the development
of pressure sores when
assuming this position.
Rashes could be caused
by STIs, cancer, or
hemorrhoids. An
external hemorrhoid
that has thrombosed
seems enlarged. When
the client passes feces, it
is itchy, unpleasant, and
bleeds. The skin tag of a
previously thrombosed
hemorrhoid protrudes
from the anus.
Hardness and
irregularities may be
from scarring or cancer.
Nodules may indicate
polyps or cancer.
The nurse is unprotected
as he/she lacks gloves
and the examination
room is obscure.

2. Perform hand hygiene, apply gloves and The nurse has properly The absence of gloves
observe other appropriate infection control observed hand hygiene, and ignorance of the

18
 procedures.
3. Provide for client privacy period request
the presence of another person if desired,
required by agency policy or requested by
client.
4. Inquire if the client has any history of the
following (whichever is applicable to your
client):
 Usual voiding patterns and any
changes, bladder control, urinary
incontinence, frequency, or
urgency
 Abdominal pain
 Symptoms of sexually transmitted
disease
 Swellings that could indicate the
presence of hernia
 Family history of nephritis,
malignancy of the prostate or
malignancy of the kidney
5. Gloves should be worn. Occasionally male
patients have erections during the
examination or a procedure where the
penis is touched. If this happens explain
that this is a normal response, and finish
your examination with an unruffled
demeanor.
6. In positioning the male client for genital
examination, the examiner sits and the
client stands.
7. Inspect the distribution, amount, and
characteristics of pubic hair.
8. Inspect the penis, including:
 Skin
 Prepuce (foreskin). If present,
retract the prepuce or ask the
patient to retract it. Smegma, a
cheesy, whitish material, may
accumulate normally under the
foreskin.
 Glans. Look for any ulcers, scars,
nodules, or signs of inflammation.
a) Check the skin around the base of
the penis for excoriations or
wears gloves, and
proficiently applies skills
on the appropriate
infection control
procedures.
The patient's privacy is
protected.
no history of any voiding
patterns, any changes in
bladder control, urinary
incontinence, frequency,
or urgency.
no abdominal pain
no symptoms of any STDs
no swellings
no family history of
nephritis, malignancy of
the prostate or
malignancy of the kidney
Wearing gloves
The client is standing and
the examiner is sitting
down
The pubic hair is covering
the entire groin area.
The client’s pubic hair has
good hygiene.
Hair on the pubic area is
coarser than hair on the
scalp. Hair covers the
entire groin area,
extending to the medial
thighs and up the
abdomen to the umbilicus
in the usual pubic hair
pattern in adults.
The pubic hair and the
base of the penis are
hand hygiene and crucial
infection control
procedures causes an
exposure to bacterial
infection.
The patient experiences
discomfort.
has history of any
voiding patterns, any
changes in bladder
control, urinary
incontinence, frequency,
or urgency.
abdominal pain
symptoms of any STDs
swellings that indicate
the presence of hernia
has a family history of
nephritis, malignancy of
the prostate or
malignancy of the kidney
Not wearing gloves
The client is sitting/lying
down and the examiner
is standing
abnormal distribution of
pubic hair
Less pubic hair, or
abundant in pubic hair
Clients undergoing
chemotherapy may
experience a lack of
pubic hair or a scarcity
of pubic hair. Pediculosis
pubis is a lice or nit
infestation at the root of
the penis or pubic hair.
This is referred to as
"crabs" by most people.
19
 inflammation. devoid of excoriation,
b) Look for nits or lice at the bases of erythema, and infestation
the pubic hairs.
c) Note the location of the urethral
meatus and inspect for swelling,
inflammation and discharge.
9. Palpate the penis for tenderness, In a nonerect condition, Tenderness, thickening,
thickening and nodules. Use your thumb the penis is normally and nodules are present.
and first two fingers. mushy, flaccid, and
nontender
10. Inspect the scrotum, including:
a) Skin. Lift up the scrotum so that Scrotal skin is darker in Discolorations: any
you can see its posterior surface. color than that of the rest tightening of skin (may
b) Scrotal contours. Note any of the body and is loose indicate edema or mass)
swelling, lumps, or veins.
c) Palpate both testes simultaneously Size varies with Marked asymmetry in
for comparative purposes. temperature changes (the size
dartos muscles contract
when the area is cold and
relax when the area is
warm) Scrotum appears
asymmetric (left testis is
usually lower than right
testis)
11. Inspect both inguinal areas for bulges while No swelling or bulges Swelling or bulge
the client is standing, if possible. (possible inguinal or
a) First, have the client remain at rest. femoral hernia)
b) Next, have the client hold his
breath and strain or bear down as
though having a bowel movement.
12. Inspect the inguinal and femoral areas for No swelling and bulging Swelling and bulging
bulging and asymmetry. occurs
13. As you observe, ask the client to strain and There were no bulging or Bulges in the abdominal
bear down (the Valsalva maneuver) to lesions observed. wall
increase intra-abdominal pressure, making
it easier to observe a hernia.
14. Palpate for hernias. Smooth and symmetric Rough and not
symmetric
15. Ask the patient to remain standing and to Client was able to bend Client was not able to
bend over the examination table. Change over to be properly bend over, and that the
gloves. assessed. health care provider
can’t properly assessed
the patient.
16. Inspect the anus and surrounding tissues Intact perianal skin; Presence of fissures
for color, integrity, and skin lesions. usually slightly more (cracks), ulcers,
pigmented than the skin excoriations,
of the buttocks inflammations,
abscesses, protruding
Anal skin is normally more hemorrhoids (dilated
pigmented, coarser, and veins seen as reddened
moister than perianal skin protrusions of the skin),
and is usually hairless lumps or tumors, fistula
openings, or rectal
prolapse (varying
degrees of protrusion of
the rectal mucous

20
 membrane through the
anus)
17. Palpate the rectum for anal sphincter The client’s rectal mucosa Masses, nodules, and
tonicity, nodules, masses, and tenderness. is generally soft, smooth, tenderness occur.
nontender, and nodule-
free.
18. Document all findings in the client record. To give correct Incorrect information
information and given.
document
TOTAL SCORE

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)

Reference:
Hogan-Quigley, B., Palm, M. L., Bickley, L. S., & Bates, B. (2012). Bates' nursing guide to physical
examination and history taking. Philadelphia:  Wolters Kluwer Health/Lippincott Williams &
Wilkins.

21