PHYSICAL HEAD-TO-

TOE ASSESSMENT
ASSESSMENT PROCESS:

• Assessing the integumentary system

• Assessing the Head, Face and Neck
• Assessing the Eyes and Ears
• Assessing the Respiratory System
• Assessing the Breast
• Assessing the Abdomen
 SKIN
ASSESSMENT
 DEGREE OF WOUND CONTAMINATION
AND DEPTH:
• Clean wounds are uninfected wounds/closed wounds.
• Clean-contaminated wounds are surgical wounds that shows no evidence of infection.
• Contaminated wounds include open, accidental, and surgical wounds, it show evidence of inflammation.
• Dirty or infected wounds include wounds with evidence of a clinical infection, such as purulent drainage
or necrosis.
• Partial thickness wounds are confined to the skin, that is, the dermis and epidermis, and heal by
regeneration.
• Full thickness wounds involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone,
and require connective tissue repair.
INCISION
CONTUSION
ABRASION
PUNCTURE
LACERATION
PENETRATING WOUND
AVULSION
 3 TYPES OF EXUDATES

• Serous
• Purulent
• sanguineous
WHERE TO ASSESS PRESSURE POINTS
STAGES OF WOUND ULCERATION
STAGES OF WOUND ULCERATION
STAGES OF WOUND ULCERATION
 STAGES OF WOUND ULCERATION

https://www.youtube.com/watch?v=IWx69BBSYdU
 HEAD
ASSESSMENT
HEAD
Inspection
• Observe for: symmetry of face, configuration of skull, hair color
and distribution, scalp
Palpation
• Examine: hair texture, masses, swelling or tenderness of scalp,
configuration of skull.
EYES & VISION
ASSESSMENT
EYES AND VISION

• Equipment:
Ophthalmoscope
 Inspection

• Globes – for protrusion.

• Palpebral fissures
(longitudinal openings between
the eyelids) for width and
symmetry.
 INSPECTION

• Upper lid – covers a small portion of the iris and cornea.

• Lower lid – margin is just below the conjunction of the cornea and sclera.
• Ptosis – drooping of eyelids.
 INSPECTION

• Lid margins – for scaling, secretions,

erythema, position of lashes. Lid
margins are clear; the lacrimal duct
openings are evident at the nasal ends
of Upper and lower lids.
• Eye lashes – normally are evenly
distributed and turn outward.
 INSPECTION

• Bulbar and Palpebral conjunctiva – for congestion and

color.
• Bulbar conjunctiva – membranous covering of the inside of
the upper and lower lids. Consist of transparent red blood
vessels which may become dilated and produce the
characteristic “blood shot” eye.
• Palpebral conjunctiva – membranous covering of the inside
of the upper and lower lids. Usually pink and clear.
CONJUNCTIVITIS – inflammation of the
conjunctival surfaces
 INSPECTION

• Sclera – for color; iris –for color.

Sclera should be white and clear.
• Pupils – for size, shape, symmetry,
reaction to light and accommodation.
 INSPECTION

• Eye movement – extraocular

movements, nystagmus, convergence
Nystagmus: is the rapid, lateral,
horizontal, or rotary movement of the
eye. Maybe seen normally as a result of
fatigue.
INSPECTION

• Convergence:
ability of the eye
to turn in and
focus on a very
close object.
 INSPECTION

• Extraocular
movement –
movement of the
eyes in conjugate
fashion.

https://www.youtube.com/watch?app=desktop&v=GeQZlxACBY0
 INSPECTION

Gross visual fields – by

confrontation
Peripheral vision – is full
(medially and laterally, superiorly
and inferiorly) in both eyes.
 INSPECTION

• Visual acuity – check with

Snellen’s chart (with or
without glasses)
• Normal vision – 20/20 distance
of the eyes from the chart.
• Myopia – nearsightedness
• Hyperopia – farsightedness
 PALPATION

Determine strength of upper lids by attempting to

open closed lids against resistance.

Palpate globes through closed lid for tenderness and

tension
• Globes are not normally tender when palpated.
 PUPILS

• It is frequently necessary for

the nurse to observe the pupils
and their reaction to light.
Usually performed as a part of
“Neuro Vital Signs.”
 PROCEDURES FOR ASSESSMENT OF THE PUPILS

1. Determine the need for examination of the pupils. It may be part of an

overall general assessment or part of an examination focused on neurologic
assessment.
2. Obtain a penlight.
3. Assess each of the patient’s pupils
• Inspect size, shape, and equality of pupils
• Inspect the pupillary reaction to light. Hold the lid open with one hand and shine a
light on one pupil at a time, bringing the light in from the side.
b.1. Observe what happens to the pupil. It should constrict rapidly.
Slow (“sluggish”) constriction or failure to constrict are abnormal
responses.
b.2. Observe what happens to the opposite eye when the light is shined
into one pupil. The normal pupil has a consensual reaction: that is, it
constricts along with the eye that is exposed to light.
b.3. Repeat steps 1 to 3 on the other eye. Are the reactions the same.
 c. Test the pupillary reaction to accommodation (this is not routinely done in all settings). Ask the patient
to look at an object at a distance, then at your fingers, which are held 5 to 10 cm from the bridge of the
patient’s nose.

c.1. Note the pupillary constriction (the pupils should constrict as they attempt to accommodate)
c.2. Note whether the pupils converge (stay focused on the finger and thus move toward the nose
and toward one another).
d. Observe for voluntary, rapid, rhythmic movement (horizontal, vertical, Rotary, or mixed) of the eyeball.
This condition is called nystagmus and should be noted on the assessment record.

4. Document your observations on the patient’s record. The abbreviations PERL (pupils equal and
reactive to light) are commonly used in charting pupillary observations.
https://www.youtube.com/watch?v=pgSj3l9iV6k
EARS & HEARING
ASSESSMENT
INSPECTION

1. Pinna – examine for size, shape, color, lesions and masses.

2. External Canal – examine with otoscope for discharge,
impacted cerumen, inflammation, masses, or foreign bodies.
Normally clear with perhaps minimal cerumen
3. Tympanic membrane – examine for color, luster, shape,
position, transparency, integrity, and scarring.
PALPATION

Pinna – examine for tenderness, consistency of

cartilage, swelling
https://www.youtube.com/watch?v=FV6-d3FxBAs
NOSE & SINUSES
ASSESSMENT
EQUIPMENT

• Otoscope, nasal speculum

 INSPECTION
1.Observe for general deformity
2.With nasal speculum (with otoscope, if speculum is unavailable ) examine for:
• Nasal Septum (position and perforation): Normally straight and not perforated
• Discharge (anteriorly and posteriorly): None should be present
• Nasal obstruction and airway patency: Airways are patent
• Mucous membranes for color: Mucous membranes are normally pink
• Nasal turbinates for color and swelling: Three bony projections on each lateral wall
of the nasal cavity covered with well vascularized, mucous-secreting membranes. They
warm the air going into the lungs and may become swollen and pale with cold allergies.
 PALPATION

• Sinuses (frontal maxillary) for

tenderness
• Frontal – direct manual pressure upward
toward wall of sinus. Avoid pressure on
eyes.
• Maxillary – with thumbs, direct pressure
upward over lower edge of maxillary bones.
 MOUTH
ASSESSMENT
EQUIPMENT:

• Penlight, tongue depressor, gloves, gauze sponges

 INSPECTION

1. Observe lips for color, moisture, pigment, masses, ulcerations, fissure

2. Use tongue depressor and penlight to examine:
A. Teeth – number, arrangement, general condition
• The adult normally has 32 teeth

B. Gums – for color, texture, discharge, swelling or retraction

• Commonly recedes in adults. Bleeding is fairly common and may result
from trauma, gingival disease, or systematic problems (less common).
 INSPECTION

C. Buccal Mucosa – for discoloration, vesicles, ulcers, masses

D. Pharynx – for inflammation, exudates, and masses
E.Tongue (Protruded) for size, color, thickness, lesions, moisture, symmetry,
deviations from midline, fasciculations
Normally midline and covered with papillae, which vary in size from the tip of the
tongue to the back (The circumvallate papillae are large and posterior.
 INSPECTION

F. Salivary glands – for patency

f.1. Parotid glands – open in the Buccal pouch at the
level of the upper teeth halfway back
f.2. Sublingual and submaxillary glands – open
underneath the tongue
g. Uvula – for symmetry when the patient says “ah”
 INSPECTION

h. Tonsils – for size, ulceration, exudates,

inflammation
- can often be seen on the posterior
portion of the tongue
i. Odor of breath
• May indicate dental caries

j. Voice – for hoarseness

 PALPATION

1. Examine oral cavity with gloved hand for masses and

ulceration. Palpate beneath tongue and explore
laterally the floor of the mouth.
2. Grasp tongue with gauze sponge to retract; inspect
the sides and undersurface of tongue and floor of
mouth.
 NECK
ASSESSMENT
EQUIPMENT

Stethoscope
 INSPECTION

1. Inspect all areas of the neck anteriorly

and posteriorly for muscular symmetry,
masses, unusual swelling or pulsations, and
range of motion.
2. Thyroid – ask the patient to swallow and
observe for movement of an enlarged
thyroid at the suprasternal notch.
 MUSCULAR STRENGTH

a. Cervical Muscles – have the patient turn

the chin forcefully against your hand.
b.Trapezius muscles – exert on the
patient’s shoulder while he shrugs his
shoulders.
3. External jugular veins – observe with
patient sitting and then lying at 30o-40o
angles, patient’s neck should not be flexed.
 PALPATION

1. Cervical nodes and salivary glands

• In the adult, the cervical lymph nodes are not normally palpable
unless the patient is very thin, in which case the nodes are felt
as small, freely movable masses. Tender nodes suggest
inflammation; hard, fixed nodes suggest malignancy.

2.Trachea – Palpate at the sternal notch. Stand behind patient

and allow the middle finger of each hand to glide off the head of
the clavicle into the sternal notch.
 PALPATE FOR DEVIATION AND TRACHEAL TUG.
Trachea should be midline.
https://www.youtube.com/watch?v=TG9-lmnWuUk
• Thyroid
a) Wash your hands.
b) stand behind the patient and have him flex the neck to relax the cervical muscles.
c) Place the fingertips of your left hand behind the left sternocleidomastoid muscle adjacent to the trachea just below the
larynx.
d) Palpate the area over the trachea and to the left of the trachea to discern the outline of the isthmus of the left lobe of the
thyroid gland.
e) Note any enlargement, nodules, masses, consistency.
f) Reverse the procedure and examine the right lobe of the thyroid.
g) Because the thyroid gland moves upward on swallowing, have the patient swallow to facilitate.
h) Do examination again
i) Wash hands.
PALPATION

4. Carotid arteries
j) Palpate the carotids one side at a time.
k) The carotids lie anterolaterally in the neck – avoid palpating the
carotid sinuses at the level of the thyroid cartilage just below the angle
of the jaw because this may cause slowing of the heart rate.
l) Note symmetry of pulsations, strength, and amplitude.
LYMPH NODES
ASSESSMENT
INSPECTION

• Note size, shape, mobility,

consistency, tenderness, and
inflammation.
 PALPATION

• Cervical, supra-and infraclavicular nodes.

• Cervical nodes and supra – and infraclavicular
nodes are normally not palpable. Enlargement
may indicate a thoracic problem.

https://www.youtube.com/watch?v=SOACjGGAeTY
 https://www.youtube.com/watch?v=MUcQ344kWRM

2. Axillary nodes
a. Wash hands.
b. Examine while the patient is sitting
c. Place the patient’s arm at this side and insert the examining fingers to the apex of the
patient’s axilla. (Use the finger of your right hand to examine the left axilla and vice
versa.
d. Rotate the examining hands so the finger can palpate the anterior and posterior lower
case fossa pressing against the chest wall. Press against the humerus in the axilla to
examine the lateral fossa for nodes. Conclude examination of the axilla by moving the
fingers from the apex of the axilla downward in the midline along the chest wall. Axillary
nodes are not normally palpable, Enlargement may occur with a breast or lung problem.
e. Wash hands.
3. Inguinal nodes are located in the inguinal canal and
are usually examined when the abdomen is examined.
A few inguinal nodes may be felt, but are small,
movable, and nontender. Enlargement may indicate a
genital or lower extremity problem.
4. Epitrochlear nodes are palpated just above the
olecranon process. Not usually palpable. Enlargement
may indicate an arm or systematic problem.

https://www.youtube.com/watch?v=WSi42C9Nzv8
 HEART
ASSESSMENT
 DETERMINE CLIENT’S HISTORY OF THE
FOLLOWING:
• Family history of incidence and age of heart disease, high cholesterol levels, high blood
pressure, stroke, obesity, congenital heart disease, arterial disease, hypertension, and
rheumatic fever
• Client’s past history of rheumatic fever, heart murmur, heart attack, varicosities, or
heart failure
• Present symptoms indicative of heart disease
• Present symptoms that affect heart’s irregular rhythm
• Lifestyle habits that are risk factors for cardiac disease
1. The examiner must visualize the position of the heart under the sternum and the ribs
and now certain landmarks for identification of specific structures and significant findings.
2. It is also important to identify those “areas” on the chest wall that will yield the most
information initially about the function of the heart and its valves.
a. In locating the intercostal spaces, begin by identifying the angle of Louis, which is felt as a
slight ridge approximately 1 inch below the sternal notch, where the manubrium and the
body of the sternum are joined.
b. The 2nd ribs extend to the right and left of this angle.
c. Once the 2nd rib is located, palpate downward and obliquely away from the sternum to
identify the remaining ribs and intercostals spaces.
 INSPECTION

1. Inspect the precordium for any bulging, heaving, or thrusting.

• Normally there are no bulges.

2. Look for the apical impulse approximately in the 5th or 6th intercostal
space at or just medial to the midclavicular line.
• An apical pulse may or may not be observable.

3. Note any other pulsations. Tangential lighting is most helpful in detecting

pulsations.
• There should be no other pulsations.
Palpation
1. Use the ball of the hand to detect vibrations, or “thrills,” which may be caused by murmurs.
• There should be no thrills or other pulsations. (Thrills are vibrations caused by the
turbulence of blood moving through valves that are transmitted through skin feels similar to
a purring cat)
2. Proceed methodically through the examination so no area is omitted. Palpate for thrills
and pulsations in each (aortic, pulmonic, tricuspid, mitral)
a. Begin in the aortic area (2nd right intercostal space, close to the sternum) and proceed
downward to the apex of the heart (The mitral area is considered the apex of the heart.
Palpation
b. In the tricuspid area, use the palm of the hand to detect any heaving or thrusting of the
precordium (tricuspid area-5th intercostal space next to the sternum)
c. In the mitral area (5th intercostal space, at or just medial to the midclavicular line) palpate for
the apical beat; identify the point of maximal impulse (PMI) and note its size and force.
The apical pulse should be felt approximately in the 5th intercostal space, at or just medial to the
midclavicular line. In the young, thin person, it is a sharp, quick impulse no larger than the
intercostal space. In the older person,
the impulse may be less sharp and quick.
 https://www.youtube.com/watch?v=mkamxhvA91Q

PERCUSSION

1. Outline the border of the heart or area of

cardiac dullness.
a. The left border generally does not extend beyond 4, 7, and 10 cm left of the
midsternal line in the 4th, 5th, and 6th intercostal spaces, respectively.
b. The right border usually lies under the sternum.
2. Percuss outward from the sternum with the stationary finger parallel to the
intercostal space until dullness is no longer hear. Measure the distance from the
midsternal line in centimeters.
 AUSCULTATION
https://www.youtube.com/watch?v=x4zKiy_q918

1. Place the stethoscope in the pulmonic or

aortic area.
2. Begin by identifying the 1st (SI) and (S2)
heart sounds.
• The two sounds are separated by a short systolic
interval; each pair of sounds is separated from the
next pair by a longer, diastolic interval. Normally,
two sounds are heard-“lub,” “dub.”
• S1 is caused by the closing of the tricuspid and mitral valves.
• In the aortic and pulmonic areas. S2 usually louder than S1. In this way, each of the
paired sounds can be distinguished from the other.
• S2 results from the closing of the aortic and pulmonary valves.
• In the tricuspid area, S1 and S1 are of almost equal intensity, and, in the mitral area, S1
is often slightly louder than S2.
3. Once the heart sounds are identified, count the rate and note the rhythm as
discussed until vital signs. If there is an irregularity, try to determine if there is any
pattern to the irregularity in relation to the intervals, heart sounds, or respirations.
 https://www.youtube.com/watch?v=mkamxhvA91Q

AUSCULTATION

4. Once rate and rhythm are determined, listen in each of the four areas and at Erb’s point (3rd
left interspace, close to the sternum) systematically, first with the diaphragm (which detects
higher pitched sounds) and then with the bell (detects lower pitched sounds). In each area, listen
to S1 and then to S2 for intensity and splitting.
• An extra sound between S1 and S2 or S2 and S1 of longer duration indicates a systolic or
diastolic murmur. Note the area of its greatest intensity (aortic, pulmonic, mitral, tricuspid). An
extra sound of short duration usually indicated an S3 or S4 gallop.
• Occasionally, there may be a splitting of S2 in the pulmonary area. This is normal. Splitting of
S2 (two contiguous sounds are heard instead of one) is best heart at the end of inspiration,
when right ventricular stroke volume is sufficiently increased to delay closure of the pulmonic
valve slightly behind closure of the aortic valve)
THORAX AND LUNGS
ASSESSMENT
TAKE CLIENT’S HISTORY REGARDING THE
FOLLOWING:
• Family history of illness, including cancer
• Allergies
• Tuberculosis
• Smoking and occupational hazards
• Any medications being taken
• Current problems such as swelling, lower case cough, wheezing, pain
1. Methodical inspection of the thorax requires reference to established
“landmarks” to locate specific structures and to report significant
findings.
2. The same structural landmarks are used in examining both the lung and
the heart.
3. It is important to visualize the underlying structures and organs when
examining the thorax.
•
POSTERIOR THORAX AND LUNGS
(Begin the examination with the patient seated; examine posterior chest and lungs).

Inspection

1) Wash hands .

2) Inspect the spine for mobility and any structural deformity

3) Observe the symmetry of the posterior chest and the posture and mobility of the thorax on respiration. Note any bulges or
retractions of the costal interspace on respiration or any impairment of respiratory movement. The thorax is normally
symmetric; it moves easily and without impairment on respiration. There are no bulges or retractions of the intercostals
spaces.

4) Note the anteroposterior diameter in relation to the lateral diameter of the chest. The anteroposterior (AP) diameter of the
thorax in relation to the lateral diameter is approximately 1:2.

5) Wash hands.
 PALPATION
1. Wash hands.
2. Palpate the posterior chest with the patient sitting; identify areas of
tenderness, masses, inflammation.
3. Palpate the ribs and costal margins for symmetry, mobility, and tenderness
and the spines for tenderness and vertebral position.
• On the palpation, there should be no tenderness; chest movement should be
symmetrical and without lag or impairment. Tenderness may indicate
musculoskeletal strain, fracture, or other problems.
4. To assess respiratory excursion-place the thumbs at the level of the 10th
vertebra; with hands held parallel to the 10th ribs as they grasp the lateral rib
cage, ask the patient to inhale deeply. Observe the movement of the thumbs
while feeling the range, and observe the symmetry of the hands.
• To elicit vocal tactile fremitus (Palpable vibrations transmitted through the
broncho-pulmonary system on speaking)
Posteriorly, fremitus is generally equal throughout
the lung fields.
a. Ask the patient to say “tres-tres”; palpate and
compare symmetric areas of the lungs with the ball of
one hand.
b. Note any areas of increased or decreased fremitus.
c. If the fremitus is faint, ask the patient to speak louder
and in a deeper voice.
 PERCUSSION
(As with palpation, the posterior chest is percussed with the patient sitting)
1. Wash hands.
2. Percuss symmetric areas, comparing sides. Percussion sound may be altered
by poor posture and/or presence of excessive tissue.
3. Begin across the top of each shoulder and proceed down between the
scapulate and then under the scapula, both medially and laterally in the
Axillary lines.
4. Note and localize any abnormal percussion sound.
5. For diaphragmatic excursion, Percuss by placing the stationary finger parallel
to the approximate level of the diaphragm below the right scapula.
 WATCH VIDEO ON HOW TO PERCUSS AND AUSCULTATE
https://www.youtube.com/watch?v=E3FW11Mbb0I

a. Ask the patient to inhale deeply and hold his breath; Percuss downward to the
point of dullness. Mark this point.
b. Let the patient breath normally and then ask him to exhale deeply; Percuss
upward from the mark to the point of resonance.
c. Mark this point and measure between the two marks-normally 2 to 2.3 inches).
d. Repeat this procedure medially and laterally on the right and left sides of the
chest.
 AUSCULTATION
(Aids in assessing air flow through the lungs, the presence of fluid or mucus,
and the condition of the surrounding pleural space and lungs.
1. Wash hands.
2. Have a patient sit erect.
3. With a stethoscope, listen to the lungs as the patient breathes
somewhat more deeply that normally with mouth open.
4. Place the stethoscope in the same areas on the chest wall as those
percussed, and listen too a complete inspiration and expiration in
trachea.

5. Compare symmetric areas methodically from the apex to the lung

bases.
6. Wash hands.
Breath Sounds
• On auscultation, breath sounds vary according to proximity
of the large bronchi.
a. They are louder and coarser and near the large bronchi
and over the anterior.
b. They are softer and much finer (vesicular) at the
periphery over the alveoli.
• Breath sounds also vary in duration with inspiration and expiration.
ANTERIOR THORAX AND LUNGS
(The patient should be recumbent with arms at sides and slightly abducted.)
Inspection

1. Inspect the chest for any deformity.

2. Note the width of the costal angle.
The angle at the tips of the sternum is determined by the right and left rib margins at the xiphoid process.
Normally, the angle is less than 90o.

3. Observe the rate and rhythm of breathing, any bulging or retraction of intercostal spaces on respiration, use of
accessory muscles or respiration (sternocleidomastoid and abdominal muscles on expiration)
The thorax is normally symmetrical and moves easily without impairment on respiration. There are no bulges or
retractions of the intercostal spaces.
4. Note any symmetry of chest wall movement on respiration.
 PALPATION
(Serves the same purpose in examining the anterior chest as in the
posterior chest)
1. To assess diaphragmatic excursion, place hands along the costal
margins and note symmetry and degree of expansion as the
patient inhales deeply.
2. Palpate for fremitus with the ball of the hand anteriorly and
laterally.
(Underlying structures (Heart, liver, etc.) may damp, or
decrease, fremitus)
3. If necessary, displace the female breast gently.
 PERCUSSION
1. With patient’s arms resting comfortably at his sides, examiner percusses the anterior
and lateral chest.
• Begin just below the clavicles and press downward from one interspace to the next,
comparing the sound from the interspace on one side with that of the contralateral
interspace.

2. Displace the female breast so breast tissue does not dampen the vibration. Continue
downward, noting the intercostals space where hepatic dullness is percussed on the
right and cardiac dullness on the left.
3. Note the effect of underlying structures.
Percussion over the heart will produce a dull sound. The upper border of the
liver will be percussed on the right side, producing a dull note.
AUSCULTATION

• (Listen to the chest

anteriorly and laterally
for the distribution of
resonance and any
abnormal or adventitious
sounds).
BREASTS (MALE AND FEMALE)
ASSESSMENT
 TAKE THE HISTORY OF CLIENT REGARDING THE
FOLLOWING:
• Alcohol consumption
• Breast self-examination; technique used and
performed in relation to the menstrual cycle • High-fat diet

• Breast masses, and what was done about them • Obesity

• Any pain or tenderness in the breasts and • Use of oral contraceptives

relation to the woman’s menstrual cycle • Menarche before age 12
• Any discharge from the nipple • Menopause after age 55
• Medication history • Pregnancy after age 30
• Estrogen replacement therapy • Any surgery done on the breast including
diagnosis and date of surgery
 FEMALE BREAST (With the patient sitting, arms relaxed at sides).
INSPECTION
1. Inspect the areola and nipples for position, pigmentation, inversion, discharge, crusting, and masses. Extra or supernumerary, nipples may
occur most commonly in the anterior axillary region or just below the normal breasts

• The nipples should be at the same level and protrude slightly. An inverted nipple (one that turns inward), if present since puberty, may be
normal.

A supernumerary nipple usually consists of a nipple and a small areola and may be mistaken for a mole.

2. Examine the breast tissue for size, shape, color, symmetry, surface, contour, skin characteristics, and level of breasts. Note any retraction
of dimpling of the skin.

In the female, it is not uncommon to find a difference in the size of the two breasts. Normal asymmetry has usually been present
since puberty and is not a recent phenomenon.

3. Ask the patient to elevate her hands over her head; repeat the observation.

If there is a mass attached to the pectoral muscles, contracting the muscles will cause retraction of breast tissue.
FEMALE BREAST (With the patient sitting, arms relaxed at sides).
INSPECTION
 PALPATION (This is best done with the patient recumbent)

1. The patient with pendulous breasts should be given a pillow to place under the ipsilateral scapula being palpated so the
tissue is distributed more evenly over the chest wall.
2. The arm on the side of the breast being palpated should be raised above the patient’s head.

3. Palpate one breast at a time, beginning with the “asymptomatic” breast if the patient complains of symptoms.
This allows the examiner to palpate the “normal” breast first and then compare “symptomatic” breast to it.
4. To palpate, use the palmar aspect of the fingers in a rotating motion, compressing the breast tissue against the chest wall.
(This is done quadrant by quadrant until the entire breast has been palpated-including the “tall” of the breast tissue which
extends into the Axillary region in the upper outer quadrant of the breast.

a. In young females, tissue is fairly soft and homogeneous; in postmenopausal women, tissue may feel nodular and stringy.
b. Consistency also varies with menstrual cycle, being more nodular and edematous just prior to menstruation.
5. Note skin texture, moisture, temperature, or mass
• If a mass is palpated, its location, size, shape, consistency, mobility, and associated tenderness are reported.
 PALPATION

6. Gently squeeze the nipple and note

any expressible discharge.
In the normal nonpregnant or
nonlactating female, there is no nipple
discharge.
7. Repeat examination on the opposite
breast and compare findings.
 (This is best done with the patient recumbent)
PALPATION
 MALE BREAST

Examination of the male breast can be brief and should never be omitted.

1. Observe the nipple and areola for ulceration, nodules, swelling, or discharge.
• There should be no discharge.

2. Palpate the areola for nodules and tenderness.

 PERIPHERAL
CIRCULATION
 JUGULAR VEINS

• Evaluation of jugular venous distention is

most useful in patients with suspected
compromise of cardiac function.

Inspection
• Inspect neck for internal jugular venous
pulsations.
 INTERNAL JUGULAR
CAROTID PULSATIONS
PULSATION

Rarely palpable Palpable

Soft, undulating quality, 2 or 3
components
Pulsations eliminated by light pressure on
the vein just above the sterna end of the
clavicle
A more vigorous thrust with a single
outward component
Pulsations not limited

Level of pulsation usually descends with Pulsations not affected by inspiration

inspiration

Pulsations vary with position Pulsations are unchanged by position

EXTREMITIES
 INSPECTION

1. Observe skin over extremities for color,

pallor, rubor, hair distribution
• Extremities should be symmetrical, even in
color, warmth, and moisture, without swelling.
• Swelling of feet may occur after prolonged
standing or sitting, but will disappear readily
when extremity is elevated.
 PALPATION
1. Wash hands

2. Note temperature of skin over extremities, comparing one side to the

other.
3. Palpate pulses (radial, femoral, posterior tibial, dorsalis pedis), comparing
symmetry from side to side.
‫٭‬There should be no arterial bruits.

4. Palpate skin over the tibia for edema by pressing skin between thumb and index finger for 30 seconds to 1
minute. Then run pads of fingers over the area pressed and note indentation. If indentation is noted, repeat
procedure, moving up the extremity, and note the point at which no more swelling is present.
5. Edema is usually graded from trace to 3+ or 4+ pitting. Trace is a slight indentation that disappears in a short
time. Grade 3+ or 4+, depending on the scale, is deep pitting edema that does not disappear readily.
6. Wash hands.
ABDOMEN
 TAKE THE CLIENT’S HISTORY REGARDING
THE FOLLOWING:
• Incidence of abdominal pain: its location, onset, sequence, and chronology; its quality (description); its
frequency; associated symptoms
• Bowel habits
• Incidence of constipation or diarrhea
• Change in appetite
• Food intolerance
• Foods ingested in last 24 hours
• Specific signs and symptoms
• Previous problems and treatment
1. Wash hands
2. Be sure the patient has an empty bladder.
3. The patient should be lying comfortably with arms at the side. Often, bending the knees
slightly will help to relax the abdominal muscles and make palpation easier.
4. Expose the abdomen fully. Make sure your hands and the stethoscope diaphragm are
warm.
5. Be methodical in visualizing the underlying organs as you inspect, auscultate; percuss, and
palpate each quadrant or region of the abdomen.
6. Wash hands.
 INSPECTION

1. Wash hands.
2. Observe the general contour of the abdomen (flat,
protuberant, scaphoid, or concave, local bulges). Also not
symmetry, visible peristalsis, aortic
The abdomen may or may not have any scars and should
be flat or slight rounded in the nonobese person.
3. Check the umbilicus for contour or hernia and the skin for
rashes, striae, and scars.
4. Wash hands.
 AUSCULTATION

1. This is done before percussion and palpation because palpation

may alter the character of bowel sounds.
2. Note the frequency and character of bowel sounds (pitch,
duration) Anywhere from 5 to 35 bowel sounds/minute. May
have familiar sound of “growling.”
3. Listen over the aorta and renal arteries (either side of the
umbilicus) for bruits.
4. Wash hands. ‫٭‬There should be no bruits or rubs.
 PERCUSSION

1. Wash hands.
2. Percussion provides a general orientation to the abdomen.
3. Proceed methodically from quadrant to quadrant, noting
tympany and dullness.
Tympany usually predominates, possibly with scattered areas
of dullness due to fluid and feces.
4. In right upper quadrant (RUQ) in the midclavicular line, percuss
the borders of the liver.
 HTTPS://WWW.YOUTUBE.COM/WATCH?V=-99ZVPGPE4K

Percussion of the liver should help guide subsequent palpation. The liver in the
midclavicular line should normally range from 6 -12 cm (2.3 -4.6 inches)
a) Begin at the point of tympany in the midclavicular line of the right lower quadrant
(RLQ) and percuss upward to the point of dullness (the lower liver border).
Mark.
b) Percuss downward from the point of lung resonance above the RUQ to the point
of dullness (the upper border of the liver) Mark the point.
c) Measure in centimeters the distance between the two marks in the midclavicular
line (the liver span)
d) Tympany of the gastric air bubble can be percussed in the left upper quadrant
(LUQ) over the anterior lower border of the rib cage.
 PALPATION
1. Wash hands.
2. Perform light palpation in an organized manner to detect any muscular resistance
(guarding), tenderness, or superficial organs or masses.
3. Perform deep palpation to determine location, size, shape, consistency, tenderness,
pulsations, and mobility of underlying organs and masses.
Rebound tenderness (pain on quick withdrawal of the fingers following
palpation suggests peritoneal irritation, as in acute appendicitis).
4. Move slowly and gently from one quadrant to the next to relax and reassure the
patient.
5. Use two hands if the abdomen is obese or muscular, with one hand on top of the other.
The upper hand exerts pressure downward while the lower hand feels the abdomen.
6. Wash hands.
LIVER
1. Wash hands.
2. Palpate the liver by placing the left hand under the patient’s lower right lower rib cage
and the right hand on the abdomen below the level of liver dullness. Press gently inward
and upward with your finger while the patient takes a deep breath.
A normal liver edge may be palpable as a smooth, sharp, regular surface. An enlarged
liver will be palpable and may be tender, hard, or irregular.
3. Wash hands.
4. https://www.youtube.com/watch?v=-99ZvPGpe4k
SPLEEN
1. Wash hands
2. Place your left hand around and under the patient’s lower rib care and press your right hand
below the left costal margin inward toward the spleen while the patient takes a deep breath.
A normal spleen is usually not palpable
3. Double check for an enlarged spleen by percussing in the lowest interspace in the left anterior
axillary line as the patient takes a deep breath. An enlarged spleen will cause a change in
percussion note from tympany to dullness.
Be sure to start low enough so as not to miss the border of an enlarged spleen.
4. Wash hands.
5. https://www.youtube.com/watch?v=00yA5DVwncw
KIDNEY
1. Wash hands

2. Next palpate for the left and right kidneys

3. Place the left hand under the patient’s back between the rib cage and the iliac crest.

4. Support the patient while you palpate the abdomen with the right palmar surface of the fingers facing the left side of the body.

5. Palpate by brining the left and right hands together as much as possible slightly below the level of the umbilicus on right and left.

6. If the kidney is felt, describe its size and shape, and any tenderness.

7. Costal Vertebral Angle (CVA) tenderness is palpated with the patient sitting usually during the examination of the posterior chest. Locate
the CVA in the flank region and strike firmly with the ulnar surface of your hand. Note any tenderness over the area.

8. Wash hands.

• ‫٭‬There should be no CVA tenderness.

AORTA
1. Wash hands.
2. Next, palpate for the aorta with the thumb and index finger. The aorta
is soft and pulsatile.
3. Press deeply in the epigastric region (roughly in the midline) and feel
with the fingers for pulsations, as well as for the contour of the aorta.
4. Wash hands.
https://www.youtube.com/watch?v=uuDDiT_1iJU
 OTHER FINDINGS

1. Palpation of the RLQ may reveal that part of the bowel called the
cecum
The cecum will be soft.
2. The sigmoid colon may be palpated in the LLQ.
The sigmoid colon is ropelike and vertical, and if filled with feces will be
firm.
3. The inguinal and femoral areas should be palpated bilaterally for lymph
nodes.
MALE GENITALIA
AND HERNIAS
 TAKE THE CLIENT’S HISTORY ON THE
FOLLOWING:
• Usual voiding patterns and any changes, bladder control, urinary incontinence, frequency, or urgency

• Abdominal pain

• Any symptoms of sexually transmitted disease

• Any swellings that could indicate presence of hernia

• Family history of nephritis, malignancy of the prostate, or malignancy of the kidney

• Sexual patterns and preferences

(This part of the examination, especially for hernias, is best done with the patient standing. A hernia is the protrusion of a
portion of the intestine through an abnormal opening)

1. Drape the patient’s chest and abdomen.

2. Expose the groin and genitalia.

• Note: All patients should be accompanied by a watcher or a nurse when undergoing an examination .
 INSPECTION
1. Inspect the pubic hair distribution and the skin of the penis.

2. Retract or have the patient retract the foreskin, if present.

The foreskin of the penis, if present, should be easily retractable.
3. Observe the glans penis and the urethral meatus. Note any ulcers, masses, or scars.The skin of the glans penis is
smooth, without ulceration.
4. Note the location of the urethral meatus and any discharge.
The urethral meatus normally is located ventrally at the end of the penis.
Normally, there is no discharge in the urethra.

5. Observe the skin of the scrotum for ulcers, masses, redness, or swelling. Note size, contour, and symmetry. Lift the
scrotum to inspect the posterior surface. The scrotum descends approximately 1.5 inches in the adult; the left side is
often the larger than the right.
6. Inspect the inguinal areas and groin for bulges (without and with the patient bearing down-as though having a bowel
movement.
Palpation : Wear gloves
1. Palpate any lesions, nodules, or masses, noting tenderness, contour, size, and induration. Palpate the shaft of the
penis for any induration (firmness in relation to surrounding tissues)
2. Palpate each testis and epididymis separately between the thumb and the first two fingers, noting size, shape,
consistency, and undue tenderness (pressure on the testis normally produces pain)
3. Also palpate the spermatic cord, including the vas deferens within the cord, from testis to the inguinal ring.
Note any nodules or tenderness.
4. Palpate for inguinal hernias, using the left hand to examine the patient’s left side and the right hand to examine
the patient’s right side. Normally, there is no palpable herniating mass in the inguinal area.
• Insert the right index finger laterally, invaginating the scrotal sac to the external inguinal ring.
• If the external ring is large enough, insert the finger along the inguinal canal toward the internal ring and ask the patient to
strain down, noting any mass that touches the finger.

5. Also palpate the anterior thigh for a herniating mass in the femoral canal. Ask the patient to strain down.
Ordinarily, there is no palpable mass in the femoral area.
6. Wash hands.
FEMALE GENITALIA
ASSESSMENT
 TAKE CLIENT’S HISTORY REGARDING THE
FOLLOWING:
• Age onset of menstruation
• Last menstrual period (LMP)
• Regularity of cycle, duration, amount of daily
flow, and whether menstruation is painful
• Incidence of pain during intercourse
• Vaginal discharge
• Number of pregnancies
• Number of live births
• Labor or delivery complications
• Urgency and frequency of urination at
night
• Bloody urine
• Painful urination
• Incontinence (during strenuous activities,
coughing, any accompanying circumstance
)
• Sexual patterns and preferences
• History of sexually transmitted disease,
past and present
 EQUIPMENT
• Disposable gloves, lubricant, excellent direct lighting

The patient’s bladder should be empty.

1. The patient should lie in the lithotomy position with her buttocks extending slightly over the end of the examining table.

2. Her thighs are flexed and abducted; her feet are in the stirrups.

3. Her arms are at her sides or crossed over her chest.

4. The examination will be most successful if the patient is relaxed. This can best be accomplished by draping well so that the
drape extends over the knees.

5. Explain each step of the procedure and avoid any quick, unexpected movements.

6. Be sure that your hands are warm.

7. Wash hands.
 INSPECTION AND PALPATION
(These are performed almost simultaneously through the course of the examination)
1. Wash hands.
2. Begin with the inspection of the pubic hair distribution.
Normally, the pubic hair is distributed in an inverted triangle over the symphysis pubis.
3. Inspect the labia majora, the mons pubis, and the perineum (the tissue between the anus and the vaginal opening)
In the virgin, the labia majora are full and rounded. They become thinner in older and multiparous women.
4. With gloved hand, separate the labia majora and inspect the clitoris, urethral meatus, and vaginal opening. Note skin color,
ulcerations, nodules, discharges, or swelling.
The labia minora and the prepuce around the clitoris are pinkish.
5. Note the area of the Skene’s and Bartholin’s glands. If there is any history of swelling of the latter, palpate the glands by placing
the index finger in the vagina at the posterior end of the opening and the thumb outside the posterior portion of the vagina.
Palpate between the finger and thumb for nodules, tenderness, or swelling. Repeat on each side of the posterior vaginal opening.
The hymen, or membranous fold that may partially occlude the vaginal opening, may or may not be present.
6. Wash hands.
Palpation (Bimanual Examination)
Ask the patient to breathe through the mouth or count so as to relax the muscles.
1. Lubricate the index and middle finger of the gloved hand and insert them into the vagina, noting nodules, masses, or irregularities anteriorly and
posteriorly.
2. Locate the cervix and fornices and note tenderness, shape, size, consistency, regularity, and mobility of the cervix. The cervix of the nonpregnant
women is smooth, firm, and slightly movable. It is nontender. The uterus is firm, smooth, and nontender.
3. Place the gloved finger in the posterior fornix and the ungloved hand on the abdomen approximately midway between the umbilicus and
symphysis pubis.
4. Press the two hands toward one another and palpate the uterus, noting its size, shape, regularity, consistency, mobility and tenderness, and any
masses.
5. Next, place the gloved fingers in the fight lateral fornix and the ungloved hand in the right lower quadrant. Palpate the ovaries, if possible, noting
shapes, sizes, consistency, regularity, mobility, pain (the ovary is usually tender), or masses.
Repeat the procedure on the left side.
6. Next, withdraw the gloved hand, leaving the index finger in the vagina and placing the middle finger in the rectum. Repeat the procedure of the
bimanual examination. Explain what you are doing because this is uncomfortable for the patient and may produce the sensation of
wanting to defecate.
7. If possible, press the uterus downward toward the rectal finger so as much of the posterior surface of the uterus as possible can be examined.
8. Proceed with the rectal examination.
9. On completing the examination, wipe genitalia and perineum with a tissue or offer the patient one so she may do it herself.
10. Wash hands.
RECTUM

Take the client’s history regarding the following:

• History of bright blood in stools, tarry black stools, diarrhea, constipation, abdominal pain,
excessive gas, hemorrhoids or rectal pain
• Family history of colorectal cancer
• When last stool specimen for occult blood was performed, and the results
• For males, if not obtained during the genitourinary examination, any signs of symptoms of
prostate
•
Equipment
Glove, lubricant
MALE
1. Wash hands
2. If the patient is ambulatory, have him stand and bend over the edge of the table.
3. It is also possible to examine the anus and rectum with the patient lying on his left
side, knees drawn up and buttocks close to the edge of the table. (This is generally an
uncomfortable position, and the patient should be told that he may feel as though he
wants to move his bowels.)
4. The patient should be draped so only his buttocks are exposed.
5. Wash hands.
Inspection
• Wash hands
• Spread the buttocks and inspect the anus, perineal region, and sacral region for inflammation, nodules,
scars, lesions, ulcerations, or rashes. Ask the patient to bear down; note any bulges.
• In males and females, the perineal and sacro-coccygeal areas should be dry, with varying amounts of hair
covering them. In the sacro-coccygeal region, it is not uncommon to find a small opening or sinus
surrounded by a tuft of hair. This is a pilonidal cyst; it should be non-tender and non-inflamed.
• Wash hands.
•
Palpation
1. Wash hands.
2. Palpate any abnormal area noted on inspection.
3. Lubricate the index finger of the gloved hand. Rest the finger over the anus as the patient bears down and, as the sphincter relaxes,
insert finger slowly into the rectum.
4. Note sphincter tone, any nodules or masses, or tenderness.
The anal canal is approximately 1-inch long; it is bordered by the external and internal anal sphincters, which are normally firm and
smooth.
5. Insert the finger further and palpate the walls of the rectum laterally and posteriorly while rotating your index finger. Note
irregularities, masses, nodules and tenderness. The wall of the
rectum in males and females is smooth and moist.
6. Anteriorly, palpate the two lateral lobes of the prostate gland and its median sulcus for irregularities, nodules, swelling, or tenderness.
The male prostate gland is approximately 1 inch long, smooth, regular, non-movable, non-tender, rubbery.
7. If possible, palpate the superior portion of the lateral lobe, where the seminal vesicles are located. Note induration, swelling, or
tenderness.
8. Just above the prostate anteriorly, the rectum lies adjacent to the peritoneal cavity. If possible,
palpate this region for peritoneal masses and tenderness.
9. Continue to insert the finger as far as possible and have the patient bear down so more of the bowel can be palpated.
10. Gently withdraw your finger.
11. Wash hands.
FEMALE

1. The examination is usually performed following a pelvic examination with the patient
still in the lithotomy position.
2. If only the rectal examination is done, the patient may be positioned laterally.
3. The technique is basically the same for the female as in the male.
4. Anteriorly, the cervix, and perhaps a retroverted uterus, may be felt.
Anteriorly, the cervix is round and smooth.
MUSCULOSKELETAL SYSTEM

Take the client’s history regarding the following:

• History or presence of muscle pain: onset, location, character, associated phenomena, and
aggravating and alleviating factors
• Any limitations to movement of inability to perform activities of daily living
• Previous sports injuries
• Any loss of function without pain
•
1. Wash hands
2. Examine the muscles and joint, keeping in mind the structure and functions of each.
3. This discussion will center on the technique for examining the patient who is asymptomatic and, therefore will not present in detail the
techniques for inspecting and palpating joints that are symptomatic and deformed.
4. It is important to ask in the history and to note in the examination whether the patient has difficult performing activities of daily living:
a. Bathing
b. Dressing (buttoning, using zippers, tying shoelaces)
c. Combing hair
d. Brushing the teeth
e. Walking up and down stairs
f. Bending
g. Sitting
h. Grasping and holding items without dropping them
i. Standing from a sitting position, unaided

5. Once the above facts have been ascertained, the examination proceeds. Observe and palpate
joints and muscles for symmetry and then examine each joint individually as indicated.
6. The examination is performed with the joints both at rest and in motion-moving through a full range of motion; joints and supporting
muscles and tissues are noted.
7. Wash hands.
•
Inspection
1. Wash hands
2. Inspect the upper and lower extremities for size, symmetry, and deformity, and muscle mass.
3. Inspect the joints for range of motion (in degrees), enlargement, redness.
4. Note gait and posture; observe the spine for range of motion, lateral curvature, or any abnormal
curvature.
5. Observe the patient for signs of pain during the examination.
6. Wash hands.
Palpation
1. Palpate the joint of the upper and lower extremities and the neck for tenderness, swelling,
temperature, and range of motion.
2. Hold the palm of the hand over the joint as it moves, or move the joint through the fullest
range of motion and not any crepitation (crackling feeling within the joint)
3. Palpate the muscles for size, tone, strength, and tenderness.
4. Palpate the spine for bony deformities and crepitation. Gently tap the spine with the ulnar
surface of your first from the cervical to the lumbar region and note any pain or
tenderness.