Physical Assessment 1

ST.
FERDINAND COLLEGE
COLLEGE OF HEALTH SCIENCES
Calamagui 1 , Ilagan 3300, Isabela
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Tel. No. (078) 622-3110
“ CHS – is a holistic department with dynamic staff that intend to produce a globally competitive health care
provider”
PHYSICAL ASSESSMENT
Head-to-Toe Assessment
SUBMITTED TO:
Valery Cruz Lim RN, MSN
SUBMITTED BY:
Cjay Adorna & Eds Anjel Ortiz
ST. FERDINAND COLLEGE
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INTRODUCTION
A comprehensive head-to-toe assessment is done on patient admission, at the beginning

of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and
the context. The head-to-toe assessment includes all the body systems, and the findings will
inform the health care professional on the patient’s overall condition. Any unusual findings
should be followed up with a focused assessment specific to the affected body system.
A physical examination involves collecting objective data using the techniques of
inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013).
ASSESSMENT TECHNIQUES
To make your head-to-toe assessment systematic, you need to know about the four basic
assessment techniques. These techniques are inspection, palpation, percussion, and auscultation.
● Inspection involves using the senses of vision, smell, and hearing to observe and detect
any normal or abnormal findings.
● Palpation consists of using parts of the hand to touch and feel for the following
characteristics: texture, temperature, moisture, mobility, consistency, the strength of
pulses, size, shape, and degree of tenderness.
● Percussion involves tapping body parts to produce sound waves. These sound waves or
vibrations enable the examiner to assess underlying structures.
● Auscultation involves the use of a stethoscope to listen for heart sounds, movement of
blood through the cardiovascular system, movement of the bowel, and movement of air
through the respiratory tract.
VITAL SIGN
Assessment of vital signs is the first in physical assessment because positioning and moving the
client during examination interferes with obtaining accurate results.
Specific vital signs can be also obtained during assessment of individual body system.
Physical Assessment Guide

This section is where we’ll start the head-to-toe assessment. We’ll start with the general survey
and identify the patient’s chief complaint, then the assessment of each body system.
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NOTE: Remember to use the COLDSPA mnemonic (Character, Onset, Location,

Duration, Severity, Patterns, and Associated Factors) to investigate and collect information for
each symptom the client shares.
General Appearance/Survey
The general appearance or general survey is the first step in a head-to-toe assessment. The
information gathered during the general survey provides clues about the overall health of the
client. The general survey includes the overall impression of the client, mental status exam, and
vital signs.
Chief Complaint
The chief complaint is the main reason why a client is seeking medical attention. It is the
symptom or problem that is most concerning to the patient and is the focus of their visit. It is
typically the first thing the healthcare provider asks about when seeing a patient, as it helps to
provide context and background for the rest of the assessment and treatment.
Health History
The health history is an excellent way to begin the assessment process because it lays the
groundwork for identifying nursing problems and provides a focus for the physical examination.
The importance of health history lies in its ability to provide information that will assist the
examiner in identifying areas of strength and limitation in the individual’s lifestyle and current
health status.
Assessment of the Integument
The skin, hair, and nails are external structures that serve a variety of specialized
functions. Diseases and disorders of the skin, hair, and nails can be local or they
may be caused by an underlying systemic problem. To perform a complete and
accurate assessment, the nurse needs to collect data about current symptoms, the
client’s past and family history, and lifestyle and health practices.
Area Method Used Normal Findings Abnormal findings Rationale

Assessed
SKIN Inspect for skin color, Varies from light to deep Pallor, cyanosis, Pallor (loss of color): arterial
color variations, skin brown; from ruddy to light jaundice, acanthosis insufficiency, decreased blood
nigricans supply, anemia. Cyanosis
integrity, and lesions pink, from yellow overtone
(blue-tinged perioral, nail bed,
to olive Generally uniform. conjunctival areas): central –
● Observe the skin Evenly colored skin tones cardiopulmonary problems
surface to detect without unusual or prominent (appears in the oral mucosa),
discolorations *Low melanin in peripheral – vasoconstriction.
abnormalities.
light skin, high in darker skin, Jaundice (yellowing of the
carotene may also account for a sclera, oral mucosa, palms,
soles) – liver diseases,
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yellowish tinge. hemolytic diseases.

Acanthosis nigricans
(roughened, darkened skin in
localized areas) – insulin
resistance
Malar rashes,
Suntanned areas, freckles, Malar rashes (butterfly rash
erythema
vitiligo (white patches, different across the bridge of the
amounts of melanin), albinism nose and cheeks) – SLE
(generalized loss of melanin) Erythema (skin redness,
*dark skinned individuals have warmth) – inflammation,
lighter palms, soles, nail beds, allergy, trauma.
lips; freckle-like or dark streaks
of pigmentation are common in
the sclera and nail beds *Light
skinned individuals have darker
pigments around the nipples,
lips, and genitalia.
Reddened areas
Skin is intact, without reddened Breakdown is initially noted
as a reddened area on the skin
areas.
that may progress to serious
and painful pressure ulcers.
*Common areas: occiput, ear,
scapula, elbow, sacrum,
greater trochanter, ischial
tuberosities, medial condyle of
tibia, fibular head, medial
malleolus, lateral malleolus,
heel.
Paronychia, Local vs systemic problems.

Skin is smooth without lesions. onycholysis Primary lesions – irritation or
Stretch marks, healed scars, disease, Secondary lesions –
changes in primary lesions,
freckles, moles, birthmarks are
Vascular lesions (reddish-
common finding. bluish lesions) –
*Scarifications from hot metal bleeding,venous pressure,
burn or cutting with a knife aging, liver disease,
pregnancy. Cancerous lesions
– either primary or secondary
(SCC, BCC, MM).
Palpate skin for texture. Rough, flaky, dry skin,

Skin is smooth and even dry, itchy skin Rough, flaky, dry skin –
● Use the palmar hypothyroidism. Dry,
surface of the itchy skin – obese
three middle
fingers to
palpate skin
texture.
Palpate skin for
Very thin Very thin skin – arterial
thickness.
Skin is normally thin, calluses insufficiency, steroid therapy
● If lesions are are rough, thickened sections of Tender lesion, non

the epidermis which are mobile and fixed Infected lesions are tender
noted when common on areas of the body lesion on palpation. Nonmobile,
assessing skin exposed to constant pressure fixed lesions may be
thickness, put No lesions palpated cancer
gloves on and
palpate the
lesions between
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the thumb and

finger; observe
the drainage or
other
characteristics.
Palpate skin for
moisture.
● Check under Depends on the area assessed.

Recent activity or a warm
Oily, dry Increased moisture or
skin folds and in diaphoresis may occur in
environment may cause
unexposed fever or hyperthyroidism.
increased moisture. *Older
areas. individual’s skin may be dreyer Decrease occurs with
due to decreased sebum dehydration or
Palpate skin for production. hypothyroidism.
temperature. Warm
● Use the dorsal Clammy skin, cold

skin, cool skin, very Clammy skin – shock,
surfaces of the hypotension Cold skin –
warm skin
hands to palpate shock, hypotension Cool skin
the skin. – arterial disease Very Warm
skin – fever,
Palpate skin for hyperthyroidism.
mobility and turgor.
Mobile, with elasticity and
Decreased mobility, Decreased mobility –
● Ask the client to returns to original shape
decreased turgor edema Decreased turgor
lie down; using quickly *Older client’s skin
loses skin turgor due to (>30 sec) – dehydration
two fingers,
decreased elasticity and
gently pinch the
collagen fibers. Sagging
skin on the appears in the facial, breast,
sternum or and scrotal areas
under the
clavicle.
Palpate skin for edema.
Skin rebounds and does not
● Use your
remain indented when Indentations on the
thumbs to press pressure is released skin
down on the
skin or the feet
or ankles to
check for
edema.
HAIR
Inspect scalp for lesions ✔ Can be black, brown or ● Flaking, sores,

Check hair for the
burgundy depending on lice, nits, and
and hair and scalp for presence of lice and/or nits
the race, evenly ring worms.
presence of lice and/or (eggs), which are oval in
nits. distributed covers the ● Very thin shape and adhere to the
whole scalp (no evidence (hypothyroidis hair shaft. Brittle or
● Palpation: of Alopecia), no parasites, m), brittle hair broken hair shafts may
and the amount is excessively indicate endocrine or
Thickness or variable. oily or dry metabolic dysfunction.
thinness texture hair.
✔ Thick, silky, and resilient Lice or nits may be on the
and oiliness hair. hair shaft. The closer to
✔ Scalp is clean and dry. the scalp the nit is located,
the more recent the
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Sparse dandruff may be infestation. Excessive

visible. hair is smooth and dryness and scaling of the
firm, somewhat elastic scalp are often present in
✔ Terminal hair covers the seborrheic dermatitis.
scalp auxiliary body and
pubic areas, according to ● Excessive Excessive scaliness -
Dermatitis. Raise lesions -
normal gender scaliness,
infections to more growth.
distribution.Normal male Raise lesions Dull dry hair,
pattern building ● pustules with hypothyroidism,
symmetric. hair loss in malnutrition. Poor hygiene.
✔ Older clients have thinner patches pustules with hair loss in
hair due to decreased hair patches - Tinea capitis.
● pustules
pustules surrounded by
follicles. Alopecia is seen surrounded by Erythema - folliculitis.
in men. Older woman Erythema Excessive generalized hair
may have terminal hair
growth on the chin, owing
● Excessive loss - Infection, nutritional
generalized deficiencies, hormonal
to hormonal changes disorders, thyroid or liver
hair loss,
Patchy hair diseases, drug toxicity,
hepatic or renal failure,
loss, hirsutism
chemotherapy, radiation
therapy.. Patchy hair loss- Is
scalp infection,
chemotherapy. hirsutism -
Cushing’s hormonal
imbalance, steroids
NAILS Significant irregularities in

Nails are smooth, color, shape, and structure
translucent, and consistent in splitting of nail tips, may point to underlying
.Inspection of the nails
color and thickness. thickened nails, and problems or previous trauma
● Inspect nail Longitudinal ridging is discoloration of the or infection. Unusual nail
common in aging patients. nail bed. color may suggest disorders
grooming and like infection,
cleanliness. Longitudinal pigmentation in
dark-skinned patients is a anemia,cyanosis, and pallor.
● Inspect nail normal variant. Inflammation and
color markings. detachment of nail plate from
nail bed indicates infection or
● Inspect the
trauma. Thickened nails may
shape of nails. be caused by decreased
circulation. Delayed return of
pink or usual nail color may
indicate circulatory
impairment
Excessive dryness may be

Moisture is consistent from frequent bathing or
Excessive dryness, hyperthyroidism. Excessive
throughout, with evenly excessive moisture, moisture may signify a
Palpation of the nails smooth skin texture. Hard, cracked or fissured problem with temperature
immobile. (Dark-skinned skin. Thickened nails. regulation. Cracked or
● Palpate nail to clients may have thicker paronychia, fissured skin may indicate
assess texture. nails. older clients may have onycholysis . hydration disorders,
● Palpate to assess thickened, yellow, brittle
nails due to decreased
Slow (>2sec) Capillary infections, or chemical
injuries. Thickened nails-
texture and refill.
circulation in the decreased circulation,
consistency. onychomycosis. paronychia
extremities). Smooth, firm,
● Test capillary nail plate firmly attached to (inflammation) - local
refill. the nail bed infection. onycholysis
( detachment of nail plate) -
Pink tone returns
infections, trauma
immediately to blanched
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Seal beds when pressure is Slow capillary refill -

released. hypoxia from respiratory or
cardiovascular disease.
Assessment of the Head and Neck
Head and neck assessment focuses on the cranium, face, thyroid gland, and lymph
node structures contained within the head and neck.
Area Method Used Normal Findings Abnormal Rationale

Assessed findings
HEAD Inspection ● The head should be ● Hydrocephalus, Facial asymmetry
may indicate damage
● Inspect the head. round skull depression to CN VII or stroke.
from trauma Headache is a
Inspect for size, ● (normocephalic) and common symptom
shape, and ● Facial paralysis; that always requires
symmetrical.
configuration. careful evaluation
flat affect of
● The normal skull is because a small
● Inspect for depression,
fraction of headaches
smooth, and moods such as
involuntary arise from life-
anger, sadness threatening
movement. Head
● without masses or conditions.
should be held still
and upright. depressions,
Changing or
progressively severe
● Inspect the face. ● non tender. headaches increase
Inspect for the likelihood of
tumor, abscess, or
symmetry, features,
other mass lesion.
movement,
Extremely severe
expression, and skin headaches suggest
condition. subarachnoid
hemorrhage or
meningitis.
Palpation
Hard or soft masses in
● Palpate the head. Pilar cysts,
Uniform consistency, smooth, cranial bones
Palpate for psoriasis,
absence of nodules and masses
consistency; the head pigmented nevi
is normally hard and
smooth without
lesions.
● Palpate the
temporal artery. Temporal arteritis A biopsy is needed
This should be The temporal artery pulse is 2 to for diagnosis of
located between the 3 on a 4-point scale temporal arteritis,
top of the ear and the painful inflammation
eye. of the temporal
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NECK artery.
Inspection ● Lumps
Fever, pharyngeal
● Inspect the neck. exudates, and
● “swollen
Observe the client’s ● Muscles are equal in anterior cervical
slightly extended neck glands”
size and head is on the lymphadenopathy,
for position, symmetry, midline. especially without
● goiter
and lumps or masses. cough, suggest
Shine a light from the streptococcal
side of the neck across ● pain
pharyngitis, or
to highlight any “strep throat”.
swelling. ● stiffness Muscle spasms,
inflammation, or
● Inspect the movement ● With coordination and cervical arthritis
of the neck structures. no may cause
Ask the client to restriction/discomfort. stiffness, rigidity,
swallow a small sip of and limited
water. Observe the mobility of the
movement of the neck.
thyroid cartilage and
thyroid gland.
Landmarks deviate
● Inspect the cervical from midline or are
vertebrae. Ask the obscured because
client to flex the neck of masses or
(chin to chest, ear to abnormal growths.
shoulder, twist left to In cases of diffuse
right and right to left, enlargement, such
and backward and as
forward. hyperthyroidism,
Grave’s
● Inspect range of
disease, or an
motion. Ask the client
endemic goiter, the
to turn the head to the
thyroid gland may
right and to the left
be palpated. An
(chin to shoulder), touch
enlarged, tender
each ear to the shoulder, \\ gland may result
touch chin to chest, and
from thyroiditis.
lift the chin to the
Multiple nodules
ceiling.
of the thyroid may
be seen in
metabolic
Palpation processes.
● Palpate the trachea.

Place your finger in the
sternal notch. Feel each
Enlarged and tender
side of the notch and
gland, palpated gland
palpate the tracheal
rings. The first upper
ring above the smooth
tracheal rings is the
cricoid cartilage.
A soft, blowing,
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● Palpate the thyroid ● A soft, blowing, swishing sound

● Central placement in
auscultated over
gland. Locate key the midline of the swishing sound
the thyroid lobes is
landmarks with your neck. auscultated over
often heard in
index finger and thumb; the thyroid lobes.
hyperthyroidism
ask the client to
because of an
swallow as you palpate
increase in blood
flow through the
LYMPH ● Enlarges, palpable thyroid arteries.
NODES Auscultation possibly tender
OF ● Auscultate the thyroid
THE gland only if you find
an enlarged thyroid If palpable, the thyroid is
HEAD gland during smooth, rubbery, nontender,
AND inspection or symmetrical, and barely
NECK palpation. Place the palpable beneath the
bell of the stethoscope Lymph nodes
over the lateral lobes of sternocleidomastoid. become swollen in
the thyroid gland; ask response to illness,
the client to hold his infection, or stress.
breath (to obscure any Swollen lymph
tracheal breath sounds nodes are one sign
while you auscultate). that your
lymphatic system
Neck supple with full range of is working to rid
motion (ROM). No masses or your body of the
tenderness. Jugular venous responsible agents.
Palpation distension (JVD) normal. Swollen lymph
● Palpate the Trachea midline. Thyroid not glands in the head
preauricular nodes, palpable (or: normal size and and neck are
postauricular nodes, consistency). Carotic pulses normally caused
occipital nodes. There are full and equal, without by illnesses such
should be no swelling or bruits. Lymph Nodes: as:
enlargement and no occipital, pre- and ear infection, the
tenderness. cold or flu, sinus
postauricular, submandibular,
infection, HIV
● Palpate the tonsillar anterior or posterior cervical,
infection, infected
nodes. Palpate the or supraclavicular nodes not tooth,
tonsillar nodes at the enlarged. mononucleosis
angle of the mandible (mono), skin
on the anterior edge of infection, strep
the sternomastoid throat
muscle.
● Palpate the submental Behind the ear, over or in
nodes, which are a few front of the mastoid process In
centimeters behind the front of the tragus of the ear.
tip of the mandible.
● Palpate the superficial
cervical nodes in the
area superficial to the
sternomastoid muscle. ● Behind the ear, over
● Palpate the posterior or in front of the
cervical nodes in the mastoid process In
area posterior to the front of the tragus of
sternomastoid and the ear.
anterior to the trapezius
in the posterior triangle.
● Palpate the deep
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cervical chain nodes

deeply within and
around the
sternomastoid muscle.
● Palpate the ● Alone and anterior to
supraclavicular nodes the
by hooking your fingers externocleidomastoid.
over the clavicles and Along the trapezius
feeling deeply between muscle. Above the
the clavicles and clavicle.
sternomastoid muscles.
Assessment of the Eye and Vision
To perform a thorough assessment of the eye, one needs a good understanding of the external
structures of the eye, the internal structures of the eye, the visual fields and pathways, and the
visual reflexes.
Evaluation of Vision
● Test distant visual acuity. Position the client 20 feet from the Snellen or E chart and ask
her to read each line until she cannot decipher the letters or their direction.
● Test near visual acuity. Use this test for middle-aged clients and others who complain of
difficulty reading. Give the client a hand-held vision chart to hold 14 inches from the
eyes. Have the client cover one eye with an opaque card before reading from top to
bottom.
● Test visual fields for gross peripheral vision. To perform the confrontation test,
position yourself approximately 2 feet away from the client at eye level. Have the client
cover his left eye while you cover your right eye. Look directly at each other with your
uncovered eyes. Next fully extend your left arm at midline and slowly move one finger
upward from below until the client sees your finger

Assessed
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VISION Inspection Eyebrows show no Seborrheic dermatitis Redness and irritation

unexplained hair loss. of the eyelid margins
External Inspect the eyelids and Sty, chalazion,
Lashes curve outward ectropion, ptosis, (affecting one or both
eye eyelashes. Note the width and
away from the eyes and xanthelasma. Eyebrows: eyes), often with scales
structures position of palpebral fissures.
are distributed evenly Unexplained hair loss; adhering to the base of
Assess the ability of eyelids to
along the lid margins. with normal aging, the the lashes, occurs in
close. Note the position of the
Eyelids open and close outer third of the blepharitis. Some
eyelids in comparison with the eyebrow thins.
completely, with eyelashes may be either
eyeballs. Observe for redness, Eyelashes: Curved
spontaneous blinking absent or distorted,
swelling, discharge, or lesions. inward away toward the
every few seconds. sometimes pointing
eye, distributed inwards and irritating
unevenly along lid
the surface of the
margin, or both.
Eyelids:Incomplete
eye.Spasm or atony of
opening or closing; no the orbital muscles
spontaneous blinking; causes the lids to invert,
Observe the position and improper positioning known as entropion or to
alignment of the eyeball in the with respect to iris and evert, or to irritate the
eye socket. Eyeballs are limbus eye.
symmetrically aligned in
sockets without protruding or If one eye is turning out,
sinking this is called exotropia
Exotropia, esotropia
whereas if the eye is
turning in it is called
esotropia. The
conjunctiva on the
eyeball should be
equally white in both
eyes.
Erythema, cobblestone
appearance, or both may
indicate allergy or
infection.
Sharply defined bright red

blood
Inspect the bulbar conjunctiva
indicates a subconjunctival
and sclera. Have the client keep
hemorrhage. Scleral
her head straight while looking abnormalities include
from side to side and then up Erythema, cobblestone jaundice, bluing, and
toward the ceiling. Observe drainage.
clarity, color, and texture. appearance, Sharply
defined bright red A small amount of
Inspect the palpebral blood. jaundice, bluing, fluorescein dye is applied
conjunctiva. Put on gloves for and drainage to the ocular surface, and
this assessment procedure. First, light with blue filter is used
inspect the palpebral to detect areas of increased
conjunctiva of the lower eyelid stain uptake, indicative of
damaged epithelium.
by placing your thumbs
bilaterally at the level of the
lower bony orbital rim and
gently pulling down to expose
the palpebral conjunctiva. An enlarged lacrimal
apparatus is rare. If you
palpate an enlarged
Bulbar conjunctiva is lacrimal apparatus, evert
normally transparent the eyelid and inspect
with small blood the gland. Suspect
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Inspect the lacrimal vessels visible. Sclera conditions such as

apparatus. Assess the areas is clear, smooth, and sarcoid disease and
over the lacrimal glands (lateral white Sjögren’s syndrome.
aspect of upper eyelid) and the
puncta (medial aspect of lower
eyelid).
enlarged lacrimal A narrow angle indicates
apparatus glaucoma. Cloudiness of
the lens can indicate a
cataract, which is
associated with increased
age, smoking, alcohol

intake, and sunlight
exposure. Risk factors for
Inspect the cornea and cataracts are primarily
lens. Shine a light from the side environmental.
of the eye for an oblique view.
Look through the pupil to
inspect the lens.
Test pupillary reaction to narrow angle, Accommodation is
light. Test for direct response by Cloudiness of the lens necessary for far-to-near
darkening the room and asking focus. Documentation of
this sequence of
the client to focus on a distant
assessments is easily
object.
accomplished with the
acronym PERRLA: Pupils
Equal, Round, Reactive to
Test accommodation of Absent in paralysis of Light, and
pupils. Hold your finger or a CN III Accommodation. Several
pencil about 12 to 15 inches abnormalities can be seen
from the client. Ask the client to in the pupil during
focus on your finger or pencil assessment.
and to remain focused on it as
you move it closer toward the
Lacrimal apparatus is Palpation of the lacrimal
eyes
not enlarged or tender Useful in tonic sac can reveal distention
(Adie’s) versus Argyll or expression of fluid
Robertson pupils: from the puncta, thus
. constriction slows in diagnosing obstruction,
tonic pupil; absent in patent canaliculi and
Argyll Robertson blockage proximal to
pupils of syphilis; the lacrimal sac or
poor convergence in nasolacrimal duct.
Palpation
hyperthyroidism Further probing should
be avoided to
Palpate the lacrimal prevent iatrogenic
apparatus. Put on disposable scarring.
gloves to palpate the Critical for the
nasolacrimal duct to assess for diagnosis of open
blockage. Use one finger and angle glaucoma
palpate just inside the lower because usually
An enlarged lacrimal
orbital rim. glaucomatous optic
apparatus is rare.
Suspect conditions nerve damage firstly
Internal such as sarcoid occurs in the optic disc
eye disease and Sjögren’s before detectable
A normal angle allows visual field defects
structures full illumination of the
syndrome.
become apparent.
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iris. Lens is identify if there is a

transparent. blockage and what type
of blockage and how
Inspection much the damage has
gotten, blockage can
cause blurry vision and
Inspect the optic disc. Keep the even blindness.
light beam focused on the pupil and Inspecting retina can
move closer to the client from a 15- provide diagnosis in
degree angle. You should be very Pupils constrict high blood pressure,
-Optic disc edema
close to the client’s eye (about 3 to directly and diabetes, increased
5 cm), almost touching the consensually - Palpilledema pressure in the brain and
eyelashes. Note the shape, color, infections like
size, and physiologic cup. - Glaucomatous endocarditis. Inspecting
Cupping the fovea and macula is
Inspect the retinal
vessels. Remain in the same - Optic Atrophy to screen for eye
position as described previously. diseases.
Inspect the sets of retinal vessels by - Ocular Fundi
following them out to the periphery
- Age-related Macular
of each section of the eye. Note the
Degeneration
number of sets of arterioles and
venules. - Retinopathy
Pupils constrict
Inspect retinal (accommodation) and - Retinitis Pigmentosa
background. Remain in the same eyes cross (converge).
position described previously and - Copper Wiring
search the retinal background from
the disc to the macula, noting the - Arterio-Venous
color and the presence of any Nicking
lesions. - Cotton wool spots
Inspect the fovea (sharpest
area of vision) and
macula. Remain in the same
position described previously.
Shine the light beam toward the
side of the eye or ask the client to
look directly into the light. Observe
the fovea and the macula that
surrounds it.
Inspect the anterior

chamber. Remain in the same
position and rotate the lens wheel
slowly to +10, +12, or higher to
inspect the anterior chamber of the
eye.
Lacrimal apparatus is
not enlarged or tender.
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Disc is yellowish orange

to creamy pink.
Disc vessels are tiny.
Disc margins are sharp
(except perhaps
nasally).
Arteries are light red
- Veins are dark red
No exudates or
hemorrhages
- color : red to purplish
oo vessels are noted

around Macula
- It may be slightly
pigmented
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The anterior chamber

is transparent.
Assessment of the Ear
Beginning when the nurse first meets the client, the assessment of hearing provides important
information about the client’s ability to interact with the environment.

Assessed
EAR Inspection and Palpation - Enlarged lymph - Enlarged lymph nodes
nodes indicate pathology or
External Inspect the auricle, tragus,
● Color sames as inflammation.
ear and lobule. Note size, shape, - Pain with palpation
and position. Observe for facial skin. - Pain with palpation
structures Symmetric - Microtia, macrotia,
lesions. discolorations, and indicates otitis externa or
position. edematous ears,
discharge. furuncle.
cartilage pseudomonas
Palpate the auricle and ● Mobile, firm, infection, carcinoma
mastoid process. Normally on auricle, cyst, and
not tender,
the auricle, tragus, and mastoid frostbite
pinna recoils
process are not tender.
after it is
folded.
Inspection
Internal
ear Inspect the external auditory ● Distal 3rd
structures canal. Use the otoscope. A small
amount of odorless cerumen is the contains hair
only discharge normally present. follicles, and
glands.Dry
Inspect the tympanic cerumen,
membrane (eardrum). Note grayish-tan
color, shape, consistency, and color, or sticky,
landmarks. wet serumen in
Perform Weber’s test if the various shades
of brown.
client reports diminished or
lost hearing in one ear. Strike
-Unilateral
a tuning fork softly with the back
of your hand and place it in the
identification of the
● Pearly gray in sound/did not hear or
center of the client’s head or
forehead. Ask whether the client color, had reduced sound
hears the sound better in one ear transparent
perception.
or the same in both ears.
● The patient
Perform the Rinne test. The
Rinne test compares air and bone hears the sound
conduction. Strike a tuning fork in both ears
and place the base of the fork on and at equal
the client’s mastoid process. Ask intensity
the client to tell you when the
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sound is no longer heard. Move - BC that is longer or

the prongs of the tuning fork to the same as AC is
the front of the external auditory evidence of conductive
canal. Ask the client to tell you if hearing loss.
● - AC has less - These tests help
the sound is audible after the fork
is moved. distinguish between
resistance than
sensorineural and
BC.
conductive hearing loss.
● - AC is twice
as long as BC.
The use of a tuning fork in

the
Rinne’s test helps establish if
hearing is equal in both ears

and if there is either a
conductive or sensorineural
hearing loss by allowing
comparison of the difference
in bone conduction (BC)
versus air conduction (AC).
AC has less resistance than
BC.
Assessment of the Mouth, Throat, Nose, Sinus
Subjective data related to the mouth, throat, nose, and sinus can aid in detecting diseases and
abnormalities that may affect the client’s activities of daily living.

Assessed findings
MOUTH Inspection and Palpation ● Uniform pink ● Dry mucous ● Dryness or cracking
Inspect the lips. Observe may be from
color. Soft, membranes
lip consistency and color. moist and of oral inadequate hydration.
smooth cavity. Lesions or aphthous
Inspect the teeth and texture ulcers may be with
gums. Ask the client to open ● White, viral infection. Lip
Symmetry of
their mouth. Note the contour, raised swelling or edema
number, color, condition, ability to patches on suggests allergy. Oral
and alignment of the teeth. pursue lip. the tongue, incompetence may
buccal occur in cleft lip.
Inspect the buccal mucosa. mucosa, soft ● Poor oral hygiene has
Use a penlight and tongue palate, and
depressor to retract the lips ● Uniform pink been linked to pneumonia.
pharynx. Inflamed buccal mucosa
and cheeks to check color in color.
Freckled suggests infection. White
and consistency. Also, note
● Leukoplakia patches (leukoplakia) may
Stenson’s ducts (parotid brown
(chalky suggest a growth or
ducts) located on the buccal darkened skin.
white raised lesion.Ulceration may
mucosa across from the
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second upper molars. patches) represent viral infection or

tumor. Petechiae or small
Inspect and palpate the ● Whitish,cur
red spots resulting from
tongue. Ask the client to d-like blood, which escapes the
stick out the tongue. Inspect patches capillaries, may occur
for color, moisture, size, and ● Koplik with trauma, infection, or
texture. Observe for decreased platelet counts
● Smooth spots
fasciculations (fine tremors), Redness or swelling of
and check for midline tongue base ● Canker Stensen’s duct may
protrusions. Palpate any with sores represent infection or
lesions present for prominent blockage of the parotid
induration. veins. Same gland. Swelling or redness
color with of Wharton’s duct
Assess the ventral surface buhccal suggests inflammation of
of the tongue. Ask the mucosa and the submandibular gland.
client to touch the tongue to floor of the
the roof of the mouth, and mouth. Light
use a penlight to inspect the pink, smooth
ventral surface of the soft palate,
tongue. lighter pink
hard palate.
Inspect for Wharton’s
ducts. These are openings
from the submandibular
salivary glands located on
either side of the frenulum
on the floor of the mouth.
● Raised whitish feathery
Observe the sides of the areas on sides of tongue
tongue. Use a square gauze that cannot be scraped off
pad to hold the client’s suggest hairy
tongue to each side. Palpate ● Smooth, lateral
● Swelling
leucoplakias seen in HIV
margins; no lesions infection and AIDS.
for any lesions, ulcers, or
nodules for induration. ● Redness ● Loss of taste
discrimination occurs
Check the strength of the with trauma, viral
tongue. Place your fingers infections, sinusitis and
on the external surface of polyposis,increasing
the client’s cheek. Ask the ● Raised papillae age, neurologic
client to press the tongue’s (taste buds) illnesses such as
tip against the inside of the ● The tongue offers Parkinson’s or
strong resistance. Alzheimer’s; and zinc
cheek to resist pressure from ● Nodes, deficiency, or use of
your fingers. ulcerations, certain medication that
discolorations, affect smell threshold
Check the anterior (white or red
tongue’s ability to taste by areas); areas of
placing drops of sugar and tenderness
salty water on the tip and
sides of the tongue with a ● The client can
tongue depressor. distinguish between
sweet and salty.
Inspect the hard (anterior)
and soft (posterior) palates
and uvula. Ask the client to ● Raised whitish
open the mouth wide while feathery areas on
you use a penlight to look at sides of tongue
the roof. Observe color and ● The hard palate is ● Weakness or
integrity. pale or whitish with fatigue
firm, transverse
Note odor. While the mouth rugae. No redness of
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is wide open, note any or exudate from

unusual or foul odor. uvula or soft palate ● With cleft palate,
nasopharyngeal
Assess the uvula. Apply a
incompetence may
tongue depressor to the be present along
tongue and shine a penlight with resultant
into the client’s wide-open nasal air leak
mouth. Note the ● No redness of or during speech.
characteristics and exudate from uvula or ● A candida infection may
positioning of the uvula. soft palate appear as thick white
Ask the client to say “Aaah” plaques on the hard
and watch for the uvula and palate. Deep
soft palate to move. ● Uvula may be purple,raised or flat
swollen. It may be lesions may indicate a
Inspect the tonsils. Using bifid or have a Kaposi Sarcoma
the tongue depressor to keep notch or cleft ● Uvula may be swollen
the mouth open wide, with allergic reactions. It
Inspect the tonsils for color, may be bifid or have a
size, and presence of notch or cleft.
exudate or lesions. Tonsils ● Pink and smooth,
should be graded. No discharge, Of
normal size or not
Inspect the posterior visible
pharyngeal wall. Keeping ● Pink without ● Tonsils are red,
the tongue depressor in exudate or lesions enlarged and
place, shine the penlight on covered with
the back of the throat. exudate in
Observe the color of the tonsilitis. They
throat, and note any exudate also maybe
or lesions. indurated with
patches of white
or yellow exudate.
● Acute tonsillitis,
tonsilloliths,
peritonsillar
abscess
Inspection and Palpation

NOSE Inspect and palpate the
external nose. Note nasal
color, shape, consistency,
and tenderness. External nose is
symmetrical with no
Check the patency of discolouration,
airflow through the nostrils by swelling or If tender, maybe due to local
occluding one nostril at a time malformations. Nasal ● Bright red infection.
and asking the client to sniff. mucosa is pinkish red nasal If nasal mucosa is swollen,
with no mucosa with and pale pink of bluish gray
Inspect the internal nose. discharge/bleeding, purulent in color it is caused by
To inspect the internal nose, swelling,
use an otoscope with a short
discharge allergies.Nasal mucosa is red
malformations or ● Tender and swollen may indicate
wide-tip attachment. Use your
foreign bodies. upper respiratory infection.
non-dominant hand to stabilize ● Swollen and
and gently tilt the client’s head red
back. Insert the short wide tip
● Swollen and
of the otoscope into the client’s
pale pink in
nostril without touching the
bluish gray
sensitive nasal septum.
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Inspect and palpate the
SINUSES external nose. Note nasal
color, shape, consistency, and
tenderness.
Check the patency of

airflow through the nostrils by Color is the same as
occluding one nostril at a time the rest of the face;
and asking the client to sniff. the nasal structure is
smooth and
Inspect the internal nose. symmetric. No
To inspect the internal nose,
● tenderness If tender, may suggest
tenderness. Client is on allergies or acute bacterial
use an otoscope with a short able to sniff through
wide-tip attachment. Use your
palpation rhinosinusitis.
each nostril while
non-dominant hand to stabilize other is occlude. The ● discharge Acute or chronic infection of
and gently tilt the client’s head nasal mucosa is dark ● alterations one or more paranasal
back. Insert the short wide tip in color and sinuses
pink, moist, and free resulting from allergy,
of the otoscope into the client’s of exudate shape of the
nostril without touching the nose irritants, chemicals, or
sensitive nasal septum. inflammation
● lesions secondary to GERD. The
patient has facial pain or
pressure,
thick nasal discharge, fever,
cough, halitosis, and redness
and inflammation of nasal
mucosa.
Assessment of the Thoracic and Lungs

Subjective data related to the thoracic and lung assessment provide many clues about underlying
respiratory problems and associated nursing diagnoses, as well as clues about the risk for the
development of lung disorders

Assessed
Posterior Inspection Patients in respiratory
thorax distress may look anxious
Inspect for nasal flaring Kyphoscoliosis
or show nasal
and pursed lip breathing.
Retraction in airway ● Look anxious
Nasal flaring is not observed flaring. Patients with
obstruction
in normal findings. COPD may have pursed
● Nasal flaring lips. Signs of respiratory
Observe the color of the
problems include
face, lips, and chest. The Disease of the ● Cyanosis
cyanosis, pallor, grayness,
client has an evenly colored underlying lung or
● Pallor rubor, or erythema.
skin tone without unusual or
prominent discoloration. pleura, phrenic nerve
palsy ● Grayness
Inspect the color and shape Patients with disease that
of the nails. Pink tones Fractured ribs ● Rubor
impedes outflow may have
should be seen in the
Masses, sinus tracts ● Erythema forced expiration.
nailbeds. There is normally a
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160-degree angle between Impairment, both sides Guarding may accompany

the nail base and the skin. in COPD and respiratory pain.
Inspect configuration. restrictive lung disease
While the client sits with her
Patients with respiratory
arms at her sides, stand Local or generalized ● Funnel chest distress may use accessory
behind her and observe the decrease or increase
muscles.
position of the scapulae and ● Kyphoscoliosis
the shape and configuration Dullness when fluid or
of the chest wall. solid tissue replaces ● Barrel chest
normally air-filled
Observe the use of lung; hyperresonance ● Pigeon chest
accessory muscles. Watch in emphysema or
as the client breathes and pneumothorax ● Flail chest
does not use it.
Inspect the client’s
positioning. Note the
client’s posture and ability to
support weight while
breathing comfortably.
Palpation
Palpate for tenderness and
sensation. Palpation may be
performed with one or both
hands; however, the Tender or painful areas may
sequence of palpation is indicate inflamed fibrous
established. Start toward the connective tissue. Pain over
midline at the level of the the intercostal spaces may
left scapula and move your be from inflamed pleurae.
hand from left to right, Pain over the ribs ,
comparing findings especially at the costal
bilaterally. Move condral junctions is a
systematically downward symptom of fractured ribs.
Tender
and out to cover the lateral Asymmetrical movements
portions of the lungs at the Pain in palpation
bases. indicate collapse or
blockage
Palpate for crepitus.
Crepitus, also called of lung. Patients with
subcutaneous emphysema, is muscle
a crackling sensation that weakness, respiratory
occurs when air passes disease,
through fluid or exudate. Use
your fingers and follow the recent surgery, chest wall
above sequence when No tenderness, pain or Decreased or absent abnormalities, or obesity
unusual sensations fremitus may have
palpating.
reported by client.
Increased fremitus reduced chest expansion.
Palpate surface Warmth should be
characteristics. Use gloves equal bilaterally Asymmetrical
and your fingers to palpate movement
any lesions you noticed Nontender
during the inspection. Reduced chest
thorax has no lesions,
expansion
Palpate for fremitus. lumps,
Following the above masses, or crepitus.
sequence, use the ball or
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ulnar edge of one hand to

assess for fremitus
(vibrations of air in the
bronchial tubes transmitted
to the chest wall.
wide- ranging
Assess chest expansion.
Place your hands on the Thumbs move apart
posterior chest wall with symmetrically, 5 to 10
your thumbs at the level of cm.
T9 or T10 and press together
a small skin fold.
Percussion
Percuss for tone. Start at the
apices of the scapulae and
percuss across the tops of
both shoulders. Then percuss
the intercostal spaces across
and down, comparing sides.
Percuss the lateral aspects at
the bases of the lungs, Percussion may be dull
comparing sides. with
Percuss for diaphragmatic lobar pneumonia,

excursion. Ask the client to hemothorax,
exhale forcefully and hold
tumor, empyema, or
their breath. Beginning at the
pleural
scapular line, percuss the
intercostal spaces of the right effusion. Generalized
posterior chest wall. Percuss hyperresonance may be
downward until the tone heard with COPD or
changes from resonance to Dull emphysema. Unilateral
dullness. Next, ask the client hyperresonance may be
to inhale deeply and hold it. Hyperresonance with pneumothorax.
Percuss the intercostal Unilateral
spaces from the mark hyperresonance
downward until resonance
changes to dullness.
Reduced excursion
Auscultation Lag in expansion
Auscultate for breath

sounds. To begin, place the
diaphragm of the stethoscope
firmly and directly on the
posterior chest wall at the
apex of the lung at C7. Ask
the client to breathe deeply
through his or her mouth for
each area of auscultation in
the auscultation sequence so
you can best hear inspiratory This may indicate
and expiratory sounds. obstruction within the
Auscultate for adventitious lungs as a result of
secretions, mucus plug, or
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sounds. Adventitious sounds foreign object.

are sounds added or Abnormalities of pleural
superimposed over normal space like pleural effusion,
breath sounds and heard pneumothorax
during auscultation.
Auscultate voice sounds.
Bronchophony, egophony,
Bronchophony: Ask the
and
client to repeat the phrase Healthy Breath sounds outside
“ninety-nine” while you normal location. whispered pectoriloquy
auscultate the chest wall. lung tissue sounds are all
resonant. Diminished or absent
Other Assessment breath sounds found with increased
Techniques Down 1 or 2 more rib consolidation or
spaces until the sound is compression, as with lobar
Egophony: Ask the client to dull again;the difference
Crackles (fine and pneumonia, atelectasis, or
repeat the letter E while you should be 1 or 2 rib
coarse) and continuous tumor.
listen over the chest wall. spaces, or 3 to
sounds (wheezes and Airless lung
Whispered Pectoriloquy: 5 cm and 7 to 8 cm in rhonchi)
Ask the client to whisper the well-conditioned adults.
phrase “one-two-three” Words are easily
while you auscultate the Vesicular, understood and louder
chest wall. bronchovesicular, or over increased density
bronchial breath sounds areas
Anterior No adventitious breath Louder and change to
Thorax Inspection sound “A”
Inspect for shape and Sounds are muffled and Clearly and distinctly.
configuration. Have the difficult As if the client is
client sit with her arms at her whispering directly into
sides. Stand in front of the to distinguish.
the stethoscope
client and assess shape and
Soft and muffled, the
configuration.
“E” is distinguishable
Inspect the position of the
Faint and muffled and
sternum. Observe the
may be inaudible.
sternum from an anterior and
lateral viewpoint. Watch for
sternal retraction.
Inspect the slope of the
ribs. Assess the ribs from an
anterior and lateral
viewpoint.
Observe the quality and
pattern of respiration. Note To determine the ratio of
breathing characteristics as anteroposterior diameter to
well as rate, rhythm, and transverse diameter
depth. (normally 1:2)
Inspect intercostal spaces. Both pectus excavatum and
Ask the client to breathe pectus carinatum conditions
normally and observe the may restrict expansion of
intercostal spaces. the lungs capacity.
Observe for use of Barrel chest configuration
accessory muscles. Ask the often results from long-
client to breathe normally standing emphysema.
and observe for use of
accessory muscles. Often seen with severe
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asthma or chronic
bronchitis, tachy/bradypnea,
Palpation
hyper/hypoventilation,
Palpate for tenderness, cheyne-strokes respiration,
sensation, and surface Biot’s respiration
masses. Use your fingers to
palpate for tenderness and
sensation. Start with your Obstructed airways
hand positioned over the left
clavicle and move your hand
left to right, comparing
findings bilaterally. Move
your hand systematically Use of neck muscles
downward toward the facilitate inspiration in cases
midline at the level of the of acute or chronic airway
breasts and outward at the obstruction or atelectasis.
base to include the lateral Anteroposterior diameter
aspect of the lung. equals transverse
diameter, resulting in a
Palpate for fremitus. Using barrel chest.
the sequence for the anterior
chest above, palpate for Pectus excavatum, pectus
fremitus using the same carinatum
technique as for the posterior
thorax.
Barrel chest results in
Palpate anterior chest more horizontal position.
expansion. Place your hands
on the client’s anterolateral
wall with your thumbs along Labored and noisy
the costal margins and breathing
pointing toward the xiphoid The anteroposterior Tenderness over the thoracic
process. diameter is less than the
muscles can result from
transverse diameter
Percussion exercising ( push-ups and
Sternum midline and the like) especially in
Percuss for tone. Percuss straight Retractions or bulging of previously sedentary client.
the apices above the intercostal spaces are Tenderness or pain at
clavicles. Then percuss the present. costachondral junction of
intercostal spaces across and Rib slope downward with the ribs is seen with
Neck muscles
down, comparing sides. symmetric intercostal fractures, especially in older
(sternomastoid, scalene
spaces and trapezius) are used clients with osteoporosis.
Respirations are relaxed,

effortless and quiet.
Auscultation Regular rhythm and
Auscultate for anterior normal depth.
breath sounds, adventitious No retractions or bulging
breath sounds, and voice of intercostal spaces
May indicate an obstruction
sounds. Place the diaphragm noted. of the tracheobronchial tree
of the stethoscope firmly and
directly on the anterior chest Use of accessory muscles
wall. Auscultate from the is not seen with normal
apices of the lungs slightly respiration.
above the clavicles to the Unequal chest expansion can
bases of the lungs at the occur with severe atelectasis,
sixth rib. Listen at each site pneumonia, chest trauma,
for at least one respiratory pleural effusion or
cycle. Follow the sequence pneumothorax. Decreased
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for anterior auscultation. chest excursion at the bases of

the lungs is seen with COPD
Tender pectoral muscles,

costochondritis
Hyperresonance-in cases
of trapped air such as
emphysema,
pneumothorax. Dullness
may be characterizing
areas of increased density
such as consolidation,
No tenderness or pain pleural effusion or tumor.
palpated over the lung
area with respirations.
Abnormal findings are

similar to
those for the posterior
chest.
Diminished vibrations,
Fremitus is decreased or
even with a loud spoken
absent over the
voice.
precordium. Fremitus is
greatest over large
airways in the second
and third ICS.
Thumbs move outward

in a symmetric fashion Decreased or unequal
from the midline. chest expansion
Hyperresonance
Resonance is the
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percussion tone elicited Dullness

over normal lung tissue.

similar to
similar to those for the
those for the posterior posterior chest.
chest
Assessment of the Breast and Lymphatic System

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This chapter covers the examination of non-pregnant women’s breasts. Remember, if the client
reports any symptoms, you need to explore further by performing a symptom analysis using the
following guide
Assessed Findings
Female Inspection A description of A breast lump seems One breast is sk the
Breasts symmetry, contour, and to have changed — patient with pendulous
Inspect size and symmetry.
the presence of any it gets bigger or breasts to lean forward
Have the client disrobe and sit
lesions. Normal tissue is feels different. with her arms on her hips
with arms hanging freely.
usually soft and may be significantly
Explain what you are observing
finely granular. underdeveloped.
to help ease client anxiety.
You have discharge
Wide variation exists, Change from everted to
Inspect color and texture. Be from your nipple.
from small to very large inverted or in angle the
sure to note the client’s overall
(pendulous). The left nipple points may
skin tone when inspecting the
breast is often slightly indicate cancer
breast skin. Note any lesions.
larger.
Inspect superficial venous You notice skin
pattern. Observe the visibility changes on your
and pattern of breast veins. Contour is uninterrupted breast, such as
on both sides. redness or crusting.
Inspect the areolas. Note the
color, size, shape, and texture of
the areolas of both breasts.
Areola is round or oval
Inspect the nipples. Note the and pink to dark brown or
size and direction of the nipples black. Most nipples are
of both breasts. Also note any everted; it may be normal
dryness, lesions, bleeding, or for one or both nipples to
discharge. be inverted.
Inspect for retraction and
dimpling. To inspect the breasts
Flattening, dimpling
accurately for retraction and
dimpling, ask the client to
remain seated while performing
several different maneuvers. Ask
the client to raise her arms
overhead, then press her hands
against her hips. Next, ask her to
press her hands together.
Palpation
Palpate texture and elasticity. Retractions or dimpling
Smooth, firm, elastic tissue is a may occur with breast
normal finding. Tenderness or pain cancer
in the breast
Palpate tenderness and Breasts are often tender
temperature. A generalized during the premenstrual
increase in nodularity and period.
tenderness may be a normal
finding associated with the Discharge is evident
menstrual cycle or hormonal Breast tissue is soft and
medications. homogeneous.
Palpate for masses. Note
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location, size in centimeters, Tenderness or pain in the

shape, mobility, consistency, and breast at other times may
tenderness. Also, note the be from infection or
condition of the skin over the trauma.
mass.
Dimpling, retraction, or a
Palpate the nipples. Wear
retracted or displaced
gloves to compress the nipple
nipple can be signs of
gently with your thumb and
cancer.
index finger. Note any discharge.
Palpate mastectomy or
lumpectomy site. If the client
has had a mastectomy or
No masses or tenderness.
lumpectomy, it is still important
to perform a thorough
examination. Palpate the scar
and any remaining breast and
axillary tissue for redness,
lesions, lumps, swelling, or
tenderness.
Axillae Inspection and Palpation Nipple without discharge.
Inspect and palpate the axillae.

Ask the client to sit up. Inspect
the axillary skin for rashes or
infections. Hold the client’s
elbow with one hand, and use
the three fingerpads of your
other hand to palpate firmly the
axillary lymph nodes. First,
palpate high into the axillae, No lymphadenopathy.
moving downward against the
ribs to feel for the central nodes.
Continue to move down the
posterior axillae to feel for the
posterior nodes. Firm, hard, enlarged
nodes
(>1 cm) fixed to
Male
Inspection and Palpation underlying tissues or skin
Breasts
suggest malignancy.
Inspect and palpate the
breasts, areolas, nipples, and Tender, warm, enlarged
axillae. Note any swelling, nodes
nodules, or ulceration. Palpate One or more small, soft,
the flat disc of underdeveloped nontender nodes are suggest infection of the
Gynecomastia, mass breast,
breast tissue under the nipple. common findings. The
suspicious for
other axillary lymph nodes
arm, or hand.
are difficult to palpate. cancer, fat
Pectoral nodes are inside Enlarged axillary lymph
the border of the pectoral nodes
muscle. Lateral nodes are
along the upper are sometimes mistaken
for
humerus, high in the
axilla. Subscapular nodes nodules in the tail of
are best felt with the Spence and
examiner standing behind
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the patient, feeling inside vice versa.

the posterior axillary fold
The overlying the breast should

Firm, glandular tissue
be even. May or may not be
completely symmetrical at rest. (gynecomastia) may
The areola is rounded or oval, occur when there is an
with same color, (Color vaies imbalance of estrogen
form light pink to dark brown and androgen. An ulcer or
depending on race). Nipples are hard, irregular mass
rounded, everted, same size and suggests cancer.
equal in color. No “orange peel”
skin is noted which is present in
edema. The veins maybe visible
but not engorge and prominent.
No obvious mass noted. Not
fixated and moves bilaterally
when hands are abducted over
the head, or is learning forward.
No retractions or dimpling.
Assessment of the Heart and Neck Vessels
Subjective data collected about the heart and neck vessels helps the nurse to identify abnormal
conditions that may affect the client’s ability to perform activities of daily living and to fulfill his
role and responsibilities.
Assessed
Neck Inspection
Vessels
Observe the jugular The carotid pulse has one Distended veins
venous pulse. Inspect pulsation and a prominent
Flat neck veins Distended veins can
the jugular venous ascent with systole. extend all the way to
pulse by standing on the ear. Patients with
the right side of the dehydration or
client. The client volume depletion
should be in a supine have barely visible
position with the torso neck veins, described
elevated 30 to 45 as flat neck veins.
degrees. Ask the client
to turn the head slightly
to the left. Shine a
tangential light source
onto the neck to
increase visualizations
of pulsations as well as
shadows.
Evaluate jugular
venous pressure.
Evaluate jugular Elevated JVP in
venous pressure by right-sided heart
watching for the failure; decreased
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provider”
distention of the jugular JVP in hypovolemia

vein. from dehydration or
gastrointestinal
bleeding.
Auscultation and
Palpation
Auscultate the carotid
arteries. Auscultate the
carotid arteries if the Up to 3 cm above the >3 cm above the sternal Carotid bruits
client is middle-aged or sternal angle suggest
older or if you suspect atherosclerotic
angle.
cardiovascular disease. narrowing and
Place the bell of the increase stroke risk.
stethoscope over the
carotid artery and ask
the client to hold his or
her breath for a
moment so breath
sounds do not conceal
any vascular sounds.
No sounds or bruits are
Palpate the carotid heard.
arteries. Palpate each
carotid artery
alternately by placing
the pads of the index
Bruits (swooshing sounds A diminished or
and middle fingers similar to the sound of thready pulse
medial to the blood pressure)
sternocleidomastoid may accompany
muscle on the neck. decreased stroke
volume. Pulse
strength may be
reduced with heart
HEART Inspection
failure,
Inspect pulsations. atherosclerosis,
with the client in a exercise, or stress.
supine position with the
Strength is 2+ or
head of the bed
moderate.
elevated between 30
and 45 degrees, stand Pulses are equal
on the client’s right bilaterally.
side and look for the
apical impulse and
abnormal pulsations.
Palpation
Palpate the apical
pulse. Remain on the
client’s right side and
ask the client to remain
supine. Use the palmar
A score of 0-3 points
surfaces of your hand Diminished or thready
indicates that the
to palpate the apical pulse
patient has a low risk
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Tel. No. (078) 622-3110
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impulse in the mitral of having an acute

area. coronary syndrome
Palpate for abnormal

pulsations. Use your
palmar surfaces to
palpate the apex, left
sternal border, and
base.
Abnormal ECG readings,

elevated troponin levels,
and other factors that
increase the risk of MACE.
However, it is important to
note that the HEART
assessment is not a
diagnostic tool and should
be used in conjunction with
other diagnostic tests
Assessment of the Peripheral Vascular System
It is important for the nurse to ask questions about the symptoms that the client may consider
inconsequential. It is also important for the nurse to ask about personal and family history of
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Tel. No. (078) 622-3110
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vascular disease. It is especially important to evaluate aspects of the client’s lifestyle and health
factors that may impair peripheral vascular health.

Assessed findings
ARMS Inspection Arms are bilaterally Lymphedema Pallor indicates arterial
symmetric with minimal results from
Observe arm size and venous insufficiency. Erythema
variation in size and blocked lymphatic
pattern; also look for edema. may
shape. No edema or circulation.
Arms are bilaterally symmetric
prominent venous accompany
with minimal variation in size and Venous obstruction
patterning. Color varies thrombophlebitis
shape. No edema or prominent
depending on the client’s Pallor
venous patterning. or DVT.
skin tone, although color
should be the same Erythema
Observe the coloration of the Lymphedema may be
hands and arms. Color varies bilaterally. Raynaud’s disease caused by breast surgery.
depending on the client’s skin Prominent venous
tone, although color should be the patterning with edema may
same bilaterally. indicate venous
obstruction.
Palpation
Palpate the client’s fingers, Skin is warm to the touch
hands, and arms, and note the bilaterally from fingertips
temperature. Skin is warm to the to upper arms.
touch bilaterally from fingertips to
upper arms. A cool extremity may be a
Palpate to assess capillary refill sign of arterial
time. Compress the nailbed until it Capillary beds refill in 2 insufficiency.
blanches. release the pressure and seconds or less
calculate the time it takes for the
color to return. Cold to touch
Palpate the radial pulse. Gently
press the radial artery against the >2 sec may indicate
radius. Note elasticity and vasoconstriction, decreased
strength. Radial pulses are cardiac output, shock, arterial
bilaterally strong(2+). occlusion, or hypothermia.
Palpate the ulnar pulses. Apply Artery walls have a
Pulse suggests partial or
pressure with your first three resilient quality (bounce). Greater than 2 complete arterial occlusion.
fingertips to the medial aspects of
The ulnar pulses may not seconds
the inner wrists.
be detectable.
Obliteration of the pulse may
result from compression by
Palpate the brachial pulses if external sources, as in
you suspect arterial Hyperkinetic state compartment syndrome. Lack
insufficiency. Do this by placing (3+ or bounding of resilience or inelasticity of
the first three fingertips of each pulse) the artery wall may indicate
hand at the client’s right and left arteriosclerosis.
medial antecubital creases. - Diminished (1+)
Brachial pulses have equal
Palpate the epitrochlear lymph strength bilaterally. - or absent (0)
nodes. Take the client’s left hand Non elastic
in your right hand as if you were
shaking hands. Flex the client’s
elbow about 90 degrees. Use your
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Tel. No. (078) 622-3110
provider”
left hand to palpate behind the

elbow in the groove between the
biceps and triceps muscles.
Perform the Allen test. The Allen
test evaluates the patency of the Epitrochlear lymph nodes
radial or ulnar arteries. The test are not palpable.
begins by assessing ulnar patency. Brachial pulses are
Have the client rest the hand palm increased,
Enlarged epitrochlear lymph
side-up on the examination table diminished or
nodes may indicate an
and make a fist. Then use your absent. infection in the hand or
thumbs to occlude the radial and forearm, or they may occur
ulnar arteries. Note that the palm with generalized
remains pale. Release the pressure lymphadenopathy.
on the ulnar artery and watch for Color returns within Allen test to assess patency of
color to return to the hand. the collateral circulation of the
2 to 5 seconds.
Enlarged hands.
epitrochlear lymph
Inspection, Palpation, nodes.
and Auscultation
LEGS Observe skin color while
inspecting both legs from the
toes to the groin. Ask the client to
lie supine. Then drape the groin Color takes more
area and place a pillow under the than 5 seconds to
client’s head for comfort. return.
Inspect the distribution of
hair. Hair covers the skin on the
legs and appears on the dorsal
surface of the toes.
Inspect for lesions or
ulcers. Legs are free of lesions or Pink color for lighter-
ulcerations. skinned and pink or red
tones visible under darker-
pigmented skin.
Inspect for edema. Inspect the Pallor may indicate

legs for unilateral and bilateral arterial insufficiency.
edema. Note veins, tendons, and Cyanosis suggest venous
bony prominences. insufficiency. A rusty or
brownish pigmentation
Pallor, cyanosis, around the ankle indicates
rusty or brownish venous insufficiency.
Hair covers the skin on
the legs, appears on the
dorsal surface of toes. Loss of hair on the legs
suggests arterial
Palpate edema. If edema is noted insufficiency.Often thin,
during inspection, palpate the area shiny skin is noted as well.
to determine if it is pitting or
nonpitting. Press the edematous Legs are free of lesions or
area with the tips of your fingers, ulcerations.
hold for a few seconds, then
release. Ulcers with smooth and
even margins, and with
Palpate bilaterally for the Loss of hair, Thin
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Tel. No. (078) 622-3110
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temperature of the feet and hair irregular edges, bleeding,

legs. Use the backs of your and possible bacterial
fingers. Compare your findings in infection result from
the same areas bilaterally. arterial insufficiency.
Palpate the superficial inguinal Identical size and shape Ulcers with smooth
lymph nodes. First, expose the bilaterally; no swelling or and even margins or
with irregular edges. Bilateral edema may be due
client’s inguinal area, keeping the atrophy.
to the absence of visible
genitals draped. Feel over the
veins, tendons, or bony
upper medial thigh for the vertical
prominences.Unilateral
and horizontal groups of
edema is usually caused by
superficial inguinal lymph nodes.
venous stasis due to
Palpate the femoral pulses. Ask insufficiency or an
the client to bend the knee and obstruction.
move it out to the side. Press unilateral edema,
deeply and slowly below and bilateral edema
medial to the inguinal ligament.
Release pressure until you feel the
pulse.
Auscultate the femoral pulses. If
arterial occlusion is suspected in
the femoral pulse, position the
stethoscope over the femoral Pitting edema is associated
artery and listen for bruits. with systemic problems,
such as congestive heart
Palpate the popliteal pulses. Ask failure or hepatic cirrhosis,
No edema (pitting or
the client to raise the knee and local causes such as
nonpitting)present in the
partially. Place your thumbs on the venous stasis.
legs.
knee while positioning your
fingers deep in the bend of the
knee. Apply pressure to locate the
pulse.
Palpate the dorsalis pedis
pulses. Dorsiflex the client’s foot Cooler extremity indicates
and apply light pressure lateral to arterial occlusion. A warm,
and along the side of the extensor Pitting edema edematous, and tender
tendon of the big toe. extremity indicates DVT.
Toes, feet, and legs are
Palpate the posterior tibial equally warm bilaterally
pulses. Palpate behind and just
Nodes >2 cm may be from
below the medial malleolus.
local
Palpating both posterior tibial
pulses at the same time aids in (eg, trauma and wounds) or
They may be palpable
making comparisons.
and up to 2 cm, movable, generalized
Inspect for and nontender. (lymphadenopathy)
varicosities and thrombophlebitis.
Ask the client to stand because conditions.
varicose veins may not be visible One extremity is
when the client is supine and not cooler than the
as pronounced when the client is other.
sitting. As the client is standing,
inspect for superficial
vein thrombophlebitis. Loss of pulses in acute
arterial occlusion and
>2 cm or arteriosclerosis obliterans
They may be palpable Lymphadenopathy
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Tel. No. (078) 622-3110
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and up to 2 cm, movable, in genital

and nontender. infections,
lymphoma, AIDs
Suggest partial obstruction

of the vessel and
diminished blood flow to
No sounds auscultated Weak or absent
the lower extremities
over the femoral arteries femoral pulses
Although normal popliteal

arteries may be
nonpalpable, an absent
pulse may also be the result
More diffuse pulse and of an occluded artery.
can be difficult to localize
Bruits over one or

both femoral
arteries
A weak or absent pulse
may indicate impaired
arterial circulation
Bruit with
Dorsalis pedis pulses are
turbulent blood
bilaterally strong.
flow
A weak or absent pulse

indicates partial or
complete arterial occlusion
The posterior tibial pulses

should be strong
bilaterally. Weak or absent
pulse
Varicose veins may appear

as distended,nodular,
bulging, and tortuous,
depending on severity.
Superficial vein
thrombophlebitis is marked
Veins are flat and barely by redness, thickening, and
seen under the surface of Weak or absent tenderness along the vein
the skin. pulse
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Tel. No. (078) 622-3110
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Varicose veins,
Superficial vein
thrombophlebitis
Assessment of the Abdomen
The nurse may collect subjective data concerning the abdomen as part of a client’s overall health
history interview or as a focused history for a current abdominal complaint. The data focus on
symptoms of particular abdominal organs and the function of the digestive system along with
aspects of nutrition, usual bowel habits, and lifestyle.

Assessed
Abdomen Inspection
Observe the coloration Skin color is uniform. Redness, jaundice Redness: localized
of the skin. Abdominal inflammation
skin may be paler than the
general skin tone because
this skin is so seldom
exposed to the elements.
No venous
Note the vascularity of
engorgement.
the abdominal
skin. Scattered fine veins
may be visible.
Note any striae. Old,
silvery, white striae or
stretch marks from past
pregnancies or weight Some clients may have
gain are normal. striae or scar.
Inspect for scars. Ask
about the source of a scar,
and use a centimeter ruler Rapid or prolonged
Old silver striae, recent
stretching as in
to measure the scar’s striae are pink or blue
pregnancy or excessive
length. Document the
weight gain
location by quadrant and
reference lines, shape, Surgical scars alerts for
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Tel. No. (078) 622-3110
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length, and specific possible presence of

characteristics. underlying adhesions
excess fibrous tissue
Assess for lesions and no lesions
rashes. The abdomen is
free of lesions or rashes.
Flat or raised brown
moles, however, are
normal and may be cases of hives
apparent.
Inspect the
umbilicus. Note the color
of the umbilical area.
Observe the umbilical
location. Assess the
contour of the umbilicus.
Inspect abdominal
contour. Look across the
abdomen at eye level from
the client’s side from
behind the client’s head,
and from the foot of the
bed. Measure abdominal
girth as indicated.
Assess abdominal
symmetry. Look at the
client’s abdomen as she
lies in a relaxed supine
position.
Inspect abdominal
movement when the
client
breathes. Abdominal midline and inverted,
Everted (with ascites),
no sign of discoloration
respiratory movement deeply sunken
may be seen, especially in (obesity), bluish
male clients. (intraabdominal
everted, deeply sunken, bleeding), enlarged and
Observe aortic everted (umbilical
bluish, enlarged and
pulsations. A slight everted hernia)
pulsation of the abdominal
aorta, which is visible in
the epigastrium, extends Distension could be
full length in thin people. present due to masses,
tumors, disease,
Observe for peristaltic Contour may be flat,
hepatomegaly,
rounded or scapoid
waves. Normally splenomegaly.
peristaltic waves are not
seen, although they may
Bulging flanks or a
be visible in very thin
suprapubic bulge
people as slight ripples on
the abdominal wall.
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Tel. No. (078) 622-3110
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Auscultation
Auscultate for bowel
sounds. Use the Unusual masses may
diaphragm of the show contingent upon
stethoscope and make sure The abdomen should area.
that it is warm before you be symmetric bilaterally
place it on the client’s
abdomen.
Bulges, masses, hernias
Auscultate for vascular
sounds. Use the bell of pulsation present
the stethoscope to listen
for bruits over the Aortic pulsation may
abdominal aorta and renal, signify an abdominal
iliac, and femoral arteries. aortic aneurysm.
Auscultate for a friction Aortic pulsation maybe

rub over the liver and visible on thin clients.
spleen. Listen over the
right and left lower rib
cage with the diaphragm
of the stethoscope.
Percussion
Percuss for tone. Lightly
and systematically percuss
all quadrants.
Percuss the span or
height of the liver by
determining its lower
and upper borders. To
assess the lower border,
begin in the RLQ at the A peristaltic wave may
mid-clavicular line and
press upward. Note the indicate obstruction.
change from tympany to
dullness. To assess the Thin clients may have
upper border, percuss over visible peristalsis.
the upper right chest at the
MCL and percuss
downward, noting the Increase in GI
change from lung obstruction
resonance to liver
dullness.
Percuss the spleen. Begin
posterior to the left mid- Increased sounds occur
axillary line (MAL), and with diarrhea and early
percuss downward, noting intestinal obstruction.
the change from lung Decreased sounds occur
High pitched, gurgling, with dynamic ileus and
resonance to splenic cascading sounds
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Tel. No. (078) 622-3110
provider”
dullness. occurring irregularly peritonitis
Perform blunt Hyperactive or hypoactive

percussion on the liver. sounds, increased or
Percuss the liver by decreased motility
placing your left hand flat
against the lower right
ribcage. Use the ulnar side
of your right fist to strike Hepatic bruits indicate
liver cancer or alcoholic
your left hand.
hepatitis. Bruits over the
aorta or renal arteries
indicate partial
Palpation obstruction.
Perform light palpation. Usually, no such sounds
Using the fingertips, begin are present
palpation in a non-tender
quadrant, and compress to Hepatic bruit, arterial bruit These may indicate liver
a depth of 1cm in a tumor,splenic infarction,
dipping motion. Then or peritoneal
gently lift your fingers and inflammation.
move to the next area.
Deeply palpate all
quadrants to delineate
abdominal organs and
detect subtle masses.
Using the palmar surface Mo friction rub
of the fingers, compress to
a maximum depth (5 to 6
cm). Perform bimanual Dullness may be heard
palpation if you encounter over organs,masses or
resistance or assess deeper fluid, such as ascites, GI
structures. obstruction, pregnant
uterus, and an ovarian
Palpate the aorta. Use tumor
your thumb and first
finger or two hands and
palpate deeply in the Hepatomegaly- liver
epigastrium, slightly to the enlargement
left of the midline. Assess
Tympany should
the pulsation of the predominate due to air in
abdominal aorta. intestine rising to surface
Palpate the liver. Note
consistency and Dullness is heard over
tenderness. To palpate solid organs, distended
bladder, adipose
bimanually, stand at the Liver span is 6 to 12 cm.
tissue,fluid, or mass
client’s right side and If liver span in the MCL
place your left hand under is >12 cm, measure it in
the client’s back at the the midsternal line.
level of the eleventh to Midsternal liver span is
twelfth ribs. Lay your 4 to 8 cm. Abnormal findings
right hand parallel to the include hepatomegaly and
right costal margin. Ask the firm edge of cirrhosis.
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Tel. No. (078) 622-3110
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the client to inhale, then

compress upward and
inward with your fingers.
Palpate the spleen. Stand
at the client’s right side,
reach over the abdomen
with your left arm, and
place your hand under the
posterior lower ribs. Pull
up gently. Place your right
Dullness at the MAL is
hand below the left costal
indicative
margin with the fingers
pointing toward the of splenomegaly.
client’s head. Ask the
client to inhale and press
inward and upward as you
provide support with your
other hand.
Palpate the kidneys. To Dullness of the normal
palpate the right kidney, spleen is noted around
the 9th to 11th rib.
support the right posterior
flank with your left hand
and place your right hand
in the RUQ just below the
Dullness
costal margin at the MCL.
Palpate the urinary
bladder. Palpate for a
distended bladder when
the client’s history or
other findings warrant.
Involuntary guarding is
a sign of possible
peritoneal
inflammation and
should be carefully
evaluated.
Size and changes over

time offer insight into
pathology and the
extent of involvement
No abdominal mass
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Tel. No. (078) 622-3110
provider”
No tenderness
Involuntary guarding
An enlarged aorta (>3

cm) or one with lateral
palpable pulsations can
Tenderness may be indicate an abdominal
noted near the aortic aneurysm.
xiphoid process, over

the cecum, or over the
sigmoid colon
Mass
An enlarged liver may

indicate a tumor or
cirrhosis.
Pulsations are palpable;

the aorta measures 2
cm.
enlarged aorta (>3 cm)
The liver is often not

palpable, and you feel
nothing firm
Enlarged spleen occurs

with mononucleosis,
HIV, cancers of the
blood and lymph,
infectious hepatitis,
and red blood cell
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Tel. No. (078) 622-3110
provider”
abnormalities of
spherocytosis, sickle
liver palpated more than
cell
1 to 2 cm below the right
costal margin anemia, and
thalassemia.
not palpable
Kidneys enlarged from

hydronephrosis or
tumors may be
palpable.
can palpate the spleen tip

in an enlarged spleen.
A palpable bladder is
either full or enlarged
from an underlying
mass. A tender bladder
usually indicates a
UTI.
It is common to be
unable to
palpate the kidneys
except in
slender patients.
Palpable kidney
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Tel. No. (078) 622-3110
provider”
The empty bladder is

neither tender nor
palpable.
Palpable bladder
Assessment of the Female Genitalia
When interview topics turn to the reproductive system and female genitalia, keep in mind the
sensitivities of the client as well as your own feelings regarding body image, fear of cancer,
sexuality, and the like.
Assessed
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Tel. No. (078) 622-3110
provider”
External Inspection
female
Inspect the Mons Pubis. Hair is evenly distributed Presence of lice or nits Pediculosis pubis
genitalia and grows downward. No at the base of pubic hairs presents with itching.
Wash your hands and put on
gloves. As you begin the lice or nits are seen.
examination, note the
distribution of pubic hair.
Also, be alert for signs of
infestation.
Observe and palpate
inguinal lymph nodes.
There should be no No enlargement or swelling
enlargement or swelling of of the lymph nodes.
the lymph nodes.
Inspect the labia majora.
Observe the labia majora and
perineum for lesions, Enlarged inguinal nodes
swelling, and excoriation. Enlarged inguinal
Inspect the labia minora, No protrusions are seen. nodes indicate vaginal
clitoris, urethral meatus, perineum should be smooth infection
and vaginal opening. Use
your gloved hand to separate
the labia majora and inspect
for lesions, excoriation, Lesions, asymmetric Lesions may be herpes
swelling, and/or discharge. labia, excoriation or or syphilis.
swelling from Asymmetry labia
Symmetric labia minora, scratching or self- indicate abscess.
vaginal opening is treatment of lesions
positioned below the
Palpation urethral meatus. No
drainage from the urethral Swelling and bulging
Palpate Bartholin’s glands. of vaginal opening
meatus.
If the client has labial Ulceration in herpes
swelling or a history of it, simplex, syphiliti
chancre; inflammation in
palpate Bartholin’s glands Bartholin’s cyst.
for swelling, tenderness, and Enlarged in
discharge. Place your index masculinization.
finger in the vaginal opening Urethral caruncle or
and your thumb on the labia prolapse;
majora. With a gentle tenderness in interstitial
pinching motion, palpate Soft - Nontender - Drainage
cystitis. Imperforate
from the inferior portion of hymen
free
the posterior labia majora to
the anterior portion.
Palpate the urethra. If the
client reports urethral
symptoms or urethritis, or if Swelling, pain and
you suspect inflammation of discharge result from
infection or abscess
Skene’s glands, insert your swelling, pain and
gloved index finger into the discharge
superior portion of the
vagina and milk the urethra
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Tel. No. (078) 622-3110
provider”
from the inside, pushing up

and out.
Inspection
Inspect the size of the
Internal
vaginal opening and the
female
angle of the vagina. Insert
genitalia
your gloved index finger into
drainage from urethra
the vagina, noting the size of indicates urethritis
the opening. Then attempt to
touch the cervix. Next, while
maintaining tension, gently
pull the labia majora
outward. Note hymenal No drainage
configuration and
transections.
Inspect the vaginal
musculature. Keep your
index finger inserted in the
client’s vaginal opening. Ask
drainage from urethra
the client to squeeze around
your finger. Use your middle
and index fingers to separate
the labia minora. Ask the Vaginal atrophy –
client to bear down. vagina becomes
thinner and dryer.
Inspect the cervix. With the Occurs when body
speculum inserted in lacks estrogen
position to visualize the The vaginal opening
cervix, observe the cervical varies in size. (According
color, size, and position. to age and sexual history).
Also, observe the surface The vagina is tilted
and the appearance of the os. posteriorly at a 45-degree
angle and feel moist
Look for discharge and
lesions as well.
Inspect the vagina. Unlock
the speculum and slowly rotate
and remove it. Inspect the vagina
as you remove the speculum. Note
the vaginal color, surface,
Vaginal atrophy
consistency, and any discharge.
Cystocele, bulging of
The client should be able to anterior wall. Rectocele
squeeze around examiner’s – bulging of the
posterior wall Uterine
finger
prolapse – cervix or
uterus protrudes down
Stress incontinence –
urine leaks out.
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Tel. No. (078) 622-3110
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Smooth, pink, even,

midline in position; projects
1-3 cm into the vagina. In
pregnant: it appears blue Bluish cervix
(Chadwick’s sign). Small (nonpregnant) –
round opening cervical os. indicate cyanosis.
Pale cervix
(nonmenopausal) –
indicate anemia
Redness –
Pink, Moist, Smooth, Free Cystocele, Rectocele, inflammation..
of lesions and irritation, Uterine prolapse, Stress
Free of discharge and incontinence
malodorous discharge
Reddened areas, lesions,

and colored, malodorous
discharge indicate
vaginal infection.
Bluish cervix, pale

cervix, redness
Reddened areas, lesions,

and colored, malodorous
discharge
Assessment of the Male Genitalia
When interviewing the male client for information regarding his genitalia, keep in mind that this
may be a very sensitive topic for the client and for the examiner as well. Moreover, the examiner
should be aware of his own feelings regarding body image, fear of cancer, and sexuality.

Assessed
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Tel. No. (078) 622-3110
provider”
PENIS Inspection and Palpation Genital Warts (condylomata

Inspect the base of the penis and Hair is diamond acuminata) Candidiasis causes
pubic hair. Sit on a stool with the shaped or in an ●Appearance: Single or crusty,
client facing you and standing. Ask escutcheon pattern, multiple
the client to raise his gown or drape. multiple, red, round
appears coarser than at papules or plaques of variable
Note pubic hair growth pattern and erosions
the scalp, and has no
shapes; may be round,
any excoriation, erythema, or parasites. and pustules. Tinea
infestation at the base of the penis acuminate (or pointed), or thin
curis (“jock
and within the pubic hair. and slender. May be raised,
flflat, itch”) is a fungal
Inspect the skin of the shaft. infection with
or cauliflflowerlike
Observe for rashes, lesions, or The shaft feels smooth (verrucous).
lumps. large red, scaly,
without lesions or ● Incubation: weeks to months;
Palpate the shaft. Palpate any pain.
infected contact may have no
abnormalities noted during the
visible warts.
inspection. Also, note any hardened
or tender areas. Normal variations ● Can arise on penis, scrotum,
include ectopic
Inspect the foreskin. Observe the groin, thighs, anus; usually
sebaceous glands that Urethral stricture or
color, location, and integrity of the appear as tiny, whitish- asymptomatic, occasionally cancer
foreskin in uncircumcised men. yellow papules.
cause itching and pain.
● May disappear without
Inspect the glans. Observe for size, treatment.
shape, lesions, or redness. It retracts easily. Smegma Genital Herpes Simplex Phimosis
(thin, white, cheesy
substance) may surround ●Appearance: Small scattered
or
the corona.
Palpate the urethral discharge. grouped vesicles, 1 to 3 mm in
Gently squeeze the glans between
size, on glans or shaft of penis.
your index finger and thumb.
Appear as erosions if vesicular
It is glistening pink, smooth
in texture, and bulbous. membrane breaks. Balanitis, chancre, herpes,
●Primary episode may be warts, cancer
asymptomatic; recurrence
usually less painful, of shorter

Inspection
SCROTU duration.
M Inspect the size, shape, and The urinary meatus is
normally free of ●Associated with fever,
position. Ask the client to hold malaise, Hypospadias, discharge of
discharge urethritis
his penis out of the way. headache, arthralgias; local
Observe for swelling, lumps, or pain a yellow discharge is
bulges. usually associated with
and edema, lymphadenopathy.
gonorrhea, clear or white
Inspect the scrotal skin. discharge is usually
associated with urethritis.
Observe color, integrity, and Any discharge should be
lesions or rashes. To perform an cultured
accurate inspection, you must The scrotum varies in
spread out the scrotal folds of the size (according to
skin. Lift the scrotal sac to temperature) and shape.
inspect the posterior skin. The scrotal sac hangs
an enlarged scrotal sac may
below or at the level of
result from fluid
the penis. The left side of (hydrocele), blood
the scrotal sac usually (hematocele), bowel
Palpation hangs lower than the (hernia), or tumor (cancer).
right side A varicocele may cause
Palpate the scrotal contents. enlarged scrotal sac, low sperm production and
Palpate each testis and varicocele is an decreased sperm quality,
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Tel. No. (078) 622-3110
provider”
epididymis between your thumb Scrotal skin is thin and enlargement of the which can cause infertility
and first two fingers. Note size, rugated, (crinkled) veins within the
shape, consistency, nodules, and with little hair scrotum.
tenderness. dispersion, color is
slightly darker than
that of the penis,
lesions and rashes are
not normally present
rashes, lesions, and
inflammation
Testes are ovoid,

approximately 3.5-5
Inspection cm long, 2.5 cm wide,
and 2.5 cm deep, and
INGUINA Inspect for inguinal or femoral
equal bilaterally in size
L AREA hernia. Inspect the inguinal and and shape. They are
femoral areas for bulges. Ask the smooth, firm, rubbery,
client to turn their head and mobile, free of Absence of a testis
cough or to bear down as if nodules, and rather suggests
having a bowel movement, and tender to pressure. The cryptorchidism (an
continue to inspect the areas. epididymis is Absence of a testis, undescended testicle).
nontender, smooth, Painless nodules, Painless nodules may
and softer than the Tenderness and indicate cancer.-
testes swelling Tenderness and
Palpation swelling may indicate
Palpate for inguinal hernia acute orchitis, torsion
of the spermatic cord,
and inguinal nodes. Ask the
a strangulated hernia,
client to shift his weight to the
or epididymitis.-If the
left for palpation of the right client has
inguinal canal and vice versa. epididymitis, passive
Place your right index finger into elevation of the testes
the client’s right scrotum and may relieve the scrotal
press upward, invaginating the pain (Prehn's sign).
loose folds of skin. Palpate up
the spermatic cord until you
reach the triangular-shaped, free from bulges
slitlike opening of the external
inguinal ring. Try to push your
finger through the opening and,
if possible, continue palpating up
the inguinal canal.
Palpate inguinal lymph nodes.
If nodes are palpable, note size,
Bulges that appear at the
consistency, mobility, or external inguinal ring Bulges that appear at
tenderness. the external inguinal
ring or at the femoral
Palpate for femoral hernia. canal when the client
Palpate on the front of the thigh bears down may
in the femoral canal area. Ask signal a hernia.
the client to bear down or cough.
st
Tel. No. (078) 622-3110
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Feel for bulges. Repeat on the

opposite thigh. bulging or masses are not
normally palpated
Inspect and palpate for scrotal
bulging or masses are
hernia. Ask the client to lie palpated
down; note whether the bulge
disappears. If the bulge remains,
auscultate it for bowel sounds.
Finally, gently palpate the mass
and try to push it upward into the bulge or mass may
abdomen. indicate a hernia
no enlargement or
tenderness
bulges or masses are

not normally palpated Enlarged or tender
lymph nodes
May indicate an
inflammatory process or
infection of the penis or
scrotum.
bulge or mass palpated
the anal opening should as client bears down or
appear hairless, moist, coughs
and tightly closed, the
skin around the anal
opening is coarser and
more darkly pigmented,
the surrounding perianal
area should be free of
redness, lumps, ulcers,
lesions, and rashes
Lesions, thrombosed
external hemorrhoid
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Tel. No. (078) 622-3110
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lesions may indicate

STIs, cancer, or
hemorrhoids-a
thrombosed external
hemorrhoid appears
swollen-it is itchy,
painful, and bleeds when
the client passes stool
Assessment of the Anus, Rectum, Prostate
The data gathered during subjective assessment provide clues to the client’s overall health and
whether he is at risk for diseases and disorders of the anus, rectum, or prostate

Assessed
Anus Inspection
and
Inspect the perianal
Rectum
area. Spread the client’s
● Pilonidal External Hemorrhoids
buttocks and inspect the cyst or sinus
anal opening and (Thrombosed).
surrounding area. Dilated hemorrhoidal
Inspect the ● Hemorrhoids, veins that originate below
sacrococcygeal area. warts, herpes, the pectinate line,
chancre, covered with skin; a
Inspect this area for any
cancer, tender, swollen, bluish
signs of swelling, redness, fissures from ovoid mass is visible at
dimpling, or hair. proctitis or the anal margin
Crohn’s
disease
Palpation
Palpate the anus. Inform
the client that you are
going to perform the
internal examination at
this point. Lubricate your
gloved index finger; ask ● Lax sphincter
the client to bear down. tone in some
As the client bears down, neurologic
place the pad of your disorders;
index finger on the anal tightness in
proctitis
opening. When you feel
st
Tel. No. (078) 622-3110
provider”
the sphincter relax, insert

your finger gently with the
pad facing down.
Palpate the rectum.
Insert your finger further
into the rectum as far as
possible. Next, turn your
hand clockwise. This
allows palpation of as
much rectal surface as
possible. Note tenderness,
irregularities, nodules, and
hardness.
Palpate the peritoneal
cavity. This area may be
palpated in men above the
prostate gland in the area
of the seminal vesicles on
the anterior surface of the
rectum. In women, this
area may be palpated on ● Cancer of the
rectum,
the anterior rectal surface polyps
in the area of the Polyps of the Rectum. A
rectouterine pouch Note soft
tenderness or nodules.
mass that may or may not
be on
Prostate a stalk; may not be
Palpation
Gland palpable
In male clients, palpate
Benign Prostatic
the prostate. The prostate
can be palpated on the Hyperplasia. An
anterior surface of the enlarged,
rectum by turning the
nontender, smooth, fifirm
hand fully but
counterclockwise so the
pad of your index finger slightly elastic prostate
gland;
faces toward the client’s ● Prostate
umbilicus. Note the size, nodule or can cause symptoms
shape, and consistency of cancer; BPH; without
tenderness in
the prostate, and identify
prostatitis palpable enlargement
any nodules or tenderness.
Acute Prostatitis. A
Inspect the stool. prostate
Withdraw your gloved
finger. Inspect any fecal that is very tender,
matter on your glove. swollen, and
Assess the color, and test fifirm because of acute
the feces for occult blood. infection
Provide the client with a
Cancer of the Rectum.
towel to wipe the
Firm,
anorectal area.
st
Tel. No. (078) 622-3110
provider”
nodular, rolled edge of an

ulcerated cancer
Heart shaped with a

weight of
approximately 20 to
25 g. Cancer of the Prostate. A
hard area in the prostate that
may or may not feel nodular
Assessment of the Musculoskeletal System
Assessment of the musculoskeletal system helps to evaluate the client’s level of functioning with
activities of daily living.
Area Assessed Method Used Normal Findings Abnormal findings Rationale
GAIT Inspection
Observe gait. Observe the
client’s gait as the client enters
and walks around the room.
Assess for the risk of falling
backward in the older or
handicapped client by
performing the “nudge test”.
Stand behind the client and put
your arms around the client
while you gently nudge the
sternum.

Inspect and palpate the TMJ.
Temporomandibular
Have the client sit, and put your
Joint
index and middle fingers just
anterior to the external ear
opening. Ask the client to open
the mouth as widely as possible;
move the jaw from side to side;
and protrude and retract the jaw.
Test range of motion. Ask the
client to open the mouth and
move the jaw laterally against
resistance. Next, as the client
clenches the teeth, feel for the
contraction of the temporal and
masseter muscles to test the
integrity of cranial nerve V.
st
Tel. No. (078) 622-3110
provider”

With the client sitting, inspect
the sternoclavicular joint for
Sternoclavicular Joint
location in midline, color,
swelling, and masses. Then
palpate for tenderness or pain.

● Two forward
Observe the cervical, thoracic,
Cervical, Thoracic, curves seen in
and lumbar curves from the
Lumbar Spine the neck
side and then from behind.
Have the client standing erect ● Low back
with the gown positioned to
allow an adequate view of the ● Normal
spine. Observe for symmetry, kyphosis is the
noting differences in height of two backward
the shoulders, the iliac crests, curves seen in
and the buttock areas. the chest. hip
areas
Palpate the spinous processes
and the paravertebral muscles on
both sides of the spine for
tenderness or pain.
Test ROM of the cervical
spine. Test ROM of the cervical
spine by asking the client to
touch the chin to the chest and to
look up at the ceiling.
Test ROM of the thoracic and
lumbar spine. Ask the client to
bend forward and touch the toes.
Observe for symmetry of
shoulders, scapula, and hips.
Test for back and leg pain. If
the client has low back pain that
radiates down the back, perform
Lasegue’s test (straight leg
raising) to check a herniated
nucleus pulpous. Ask the client
to lie flat and raise each relaxed
leg independently to the point of
pain. At the point of pain,
dorsiflex the client’s foot.
Measure leg length. If you
suspect the client has one leg
longer than the other, measure
them. Ask the client to lie down
with their legs extended. With a
tape, measure the distance
between the anterior superior
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Tel. No. (078) 622-3110
provider”
iliac spine and the medial

malleolus, crossing the tape on
the medial side.

Inspect and palpate shoulders
and arms. With the client
standing or sitting, inspect
Shoulders, Arms, anteriorly and posteriorly
Elbows symmetry, color, swelling, and
masses. Palpate for tenderness,
swelling, or heat.
Test ROM. Ask the client to
stand with both arms straight
down at the sides. Nest, ask him
to move the arms forward and
then backward with elbows
straight. Then have the client
bring both hands together
overhead, elbows straight,
followed by moving both hands
in front of the body past the
midline with elbows straight.
Inspect for size, shape,
deformity, redness, or
swelling. Inspect elbows in both
flexed and extended positions.
flex the elbow and bring the
hand to the forehead, straighten
the elbow, hold the arm out, turn
the palm down, then turn the
palm up.

Inspect wrist size, shape,
symmetry, color, and swelling.
Then palpate for tenderness and
nodules. Palpate the anatomic
Hands, Wrists,
snuffbox (the hollow area on the
Fingers
back of the wrist at the base of
the fully extended thumb.
bend their wrist down and back.
Next, have the client hold the
wrist straight and move the hand
outward and inward.
Test for carpal tunnel
syndrome. Perform Phalen’s
test. Ask the client to place the
backs of both hands against each
st
Tel. No. (078) 622-3110
provider”
other while flexing the wrists 90

degrees downward. Have the
client hold this position for 60
seconds
Inspect size, shape, symmetry
swelling, and color. Palpate the
fingers from the distal end
proximally, noting tenderness,
swelling, bony prominences,
nodules, or crepitus of each
interphalangeal joint.
spread the fingers apart, make a
fist, bend the fingers down and
then up, move the thumb away
from other fingers, and touch the
thumb to the base of the small
finger.

With the client standing,
inspect the symmetry and shape
of the hips. Palpate for stability,
tenderness, and crepitus.
Test ROM. With the client
supine, ask the client to: Raise
the extended leg; flex the knee
HIPS up to the chest while keeping the
other leg extended; move an
extended leg away from the
midline of the body as far as
possible and then toward the
midline of the body as far as
possible. Bend the knee and turn
the leg inward and then outward.

With the client standing,
inspect the symmetry and shape ● Tenderness
of the hips. Palpate for stability, if meniscus
tenderness, and crepitus. tear
KNEES ● Stumbling or
Test ROM. With the client “giving way” ● Tenderness
supine, ask the client to: Raise during heel if MCL tear
the extended leg; flex the knee strike in (LCL
up to the chest while keeping the quadriceps injuries less
other leg extended; move an weakness or common)
extended leg away from the abnormal
midline of the body as far as ● Swelling
patellar
possible and then toward the over the
st
Tel. No. (078) 622-3110
provider”
midline of the body as far as tracking patella in

possible. Bend the knee and turn prepatellar
the leg inward and then outward. ● Bowlegs, bursitis
knock-knees; (“housemaid
flexion ’s knee”)
contractures in
limb paralysis ● Tenderness
or hamstring or inability
tightness to extend the
leg in partial
● Quadriceps or complete
atrophy with tear of the
patellofemoral patellar
disorder tendon
● Pain,
crepitus, and
a history of
knee pain in
patellofemor
al disorder
● Pain during
Inspection and Palpation contraction
of
With the client sitting, standing, quadriceps
and walking, inspect position, in
alignment, shape, and skin. chondromal
Ankles and Feet
Palpate ankles and feet for acia
tenderness, heat, swelling, and
nodules. Palpate the toes from
the distal end proximally, noting
tenderness, swelling, boney
prominences, nodules, or
crepitus of each interphalangeal
joint.
point toes upward then
downward, turn soles outward
then inward, rotate foot outward
then inward, turn toes under foot
and then upward.

Physical Assessment 1

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ST.

Tel. No. (078) 622-3110

Tel. No. (078) 622-3110

A comprehensive head-to-toe assessment is done on patient admission, at the beginning

Physical Assessment Guide

Tel. No. (078) 622-3110

NOTE: Remember to use the COLDSPA mnemonic (Character, Onset, Location,

Assessment of the Integument

Area Method Used Normal Findings Abnormal findings Rationale

Tel. No. (078) 622-3110

yellowish tinge. hemolytic diseases.

Paronychia, Local vs systemic problems.

Palpate skin for texture. Rough, flaky, dry skin,

● If lesions are are rough, thickened sections of Tender lesion, non

Tel. No. (078) 622-3110

the thumb and

● Check under Depends on the area assessed.

● Use the dorsal Clammy skin, cold

Inspect scalp for lesions ✔ Can be black, brown or ● Flaking, sores,

Tel. No. (078) 622-3110

Sparse dandruff may be infestation. Excessive

NAILS Significant irregularities in

Excessive dryness may be

Tel. No. (078) 622-3110

Seal beds when pressure is Slow capillary refill -

Assessment of the Head and Neck

Area Method Used Normal Findings Abnormal Rationale

Tel. No. (078) 622-3110

● Palpate the trachea.

Tel. No. (078) 622-3110

● Palpate the thyroid ● A soft, blowing, swishing sound

Tel. No. (078) 622-3110

cervical chain nodes

Assessment of the Eye and Vision

Area Method Used Normal Findings Abnormal findings Rationale

Tel. No. (078) 622-3110

VISION Inspection Eyebrows show no Seborrheic dermatitis Redness and irritation

Sharply defined bright red

Tel. No. (078) 622-3110

Inspect the lacrimal vessels visible. Sclera conditions such as

age, smoking, alcohol

Tel. No. (078) 622-3110

iris. Lens is identify if there is a

Inspect the anterior

Tel. No. (078) 622-3110

Disc is yellowish orange

Arteries are light red

- Veins are dark red

oo vessels are noted

Tel. No. (078) 622-3110

The anterior chamber

Assessment of the Ear

Area Method Used Normal Findings Abnormal findings Rationale

Tel. No. (078) 622-3110

sound is no longer heard. Move - BC that is longer or

The use of a tuning fork in

Rinne’s test helps establish if

hearing is equal in both ears

Assessment of the Mouth, Throat, Nose, Sinus

Area Method Used Normal Findings Abnormal Rationale

Tel. No. (078) 622-3110

second upper molars. patches) represent viral infection or