ASSESSING EYES
PROCEDURE
1. Gather equipment.
2. Introduce yourself and verify To build rapport and gain
the client’s identity using
agency protocol.
3. Explain to the client what
you are going to do, why it is about the procedure that
necessary, and how he or
she can participate.
4. Provide privacy.
5. Wash hands.
Perform Vision Tests
6. Test distant visual acuity.
(with Snellen chart, normal
acuity is 20/20 with or without
corrective lenses).
7. Test near visual acuity
8. Test for visual fields.
(Test visual fields for gross
peripheral vision)
Perform Extraocular Muscle Function Tests
RATIONALE NORMAL FINDINGS ABNORMAL FINDINGS
- To avoid delay and to
make assessment
possible.
trust from the patient
-To give client knowledge
the nurse is about to
perform
-To build rapport and gain
trust from patient
-To prevent transfer of
infection and bacteria
used to determine the Normal distant visual Myopia (impaired vision) is
smallest letters you can acuity is 20/20 with or present when the second
read on a standardized without corrective number in the test result is
chart (Snellen chart) or a lenses. This means the larger than the first (20/40).
card held 20 feet (6 client can distinguish The higher the second
meters) away what the person with number, the poorer the
normal vision can vision. A client is
distinguish from 20 feet considered legally blind
away when vision in the better
eye with corrective lenses is
20/200 or less. Any client
with vision worse than 20/30
should be referred for
further evaluation
Used to measure our Normal near vision Presbyopia (impaired near
ability to see smallTest
details
for near
acuityvisual
is 14/14
acuity
(with
(with
or avision)
handheld
is indicated
vision chart,
whennormal
the a
up close without corrective client moves the chart away
lenses) This means the from the eyes to focus on
client can read what the the print. It is caused by
normal eye can read decreased accommodation
from a distance of 14 (common for ages >45)
inches
Confrontation Test - 2 With normal peripheral A delayed or absent
feet away at eye level. vision, the client should perception of the examiner’s
Measures how far the see the examiner’s finger indicates reduced
eye sees in any direction finger at the same time peripheral vision
without moving and how the examiner sees it.
sensitive the vision is in Normal visual field
different parts of the degrees are
visual field. approximately as follows:
Inferior: 70 degrees
Superior: 50 degrees
Temporal: 90 degrees
Nasal: 60 degrees
 9. Perform the corneal light
reflex (using a penlight to
observe parallel alignment of
light reflection on corneas).
Shine at the bridge of nose
9. Perform the cover test
(Ask the client to stare straight slight deviations in eye
ahead and focus on a distant movement by interrupting covered eye should
object. Cover one of the client’s the fusion reflex that
eyes with an opaque card . As normally keeps the eyes
you cover the eye, observe the
uncovered eye for movement).
10. Perform the positions test
(observing for eye movement).
Instruct the client to focus on
an object you are holding
(Approximately 12 inches from
the client’s face). Move the
object through the six cardinal
positions of gaze in a clock-
wise direction, and observe the
client’s eye movements.
External Eye Structures
12. Wear gloves.
checks for eye alignment The reflection of light on Asymmetric position of the
by observing how light is the corneas should be light reflex indicates
reflected from the cornea in the exact same spot deviated alignment of the
of the eyes. on each eye, which eyes. This may be due to
indicates parallel muscle weakness or
alignment paralysis
detects deviation in The uncovered eye The uncovered eye will
alignment or strength and should remain fixed move to establish focus
straight ahead. The when the opposite eye is
covered. When the covered
remain fixed straight eye is uncovered,
ahead after being movement to re-establish
parallel. uncovered focus occurs. Either of
these findings indicates a
deviation in alignment of the
eyes and muscle weakness.
Pseudostrabismus -
Normal in young Phoria - misalignment that
children, the pupils will occurs only when fusion
appear at the inner reflex is blocked.
canthus (due to the
epicanthic Strabismus is constant
fold). malalignment of the eyes
Tropia is a specific type of
misalignment: esotropia is
an inward turn of the eye,
exotropia is an outward turn
of the eye.
assesses eye muscle Eye movement should Failure to follow movement
strength and cranial be smooth and symmetrically is weakness
nerve function symmetric throughout in one or more extraocular
all six directions muscles or dysfunction of
the cranial nerve that
innervates the particular
muscle
Nystagmus an oscillating
(shaking) movement of the
eye may be associated with
an inner ear disorder,
multiple sclerosis, brain
lesions, or narcotics use
To prevent transfer of
infection and bacteria
13. Inspect eyelids and
lashes (width and position of
palpebral fissures, ability to
close eyelids, direction of
eyelids in comparison with
eyeballs, color, swelling,
lesions, or discharge).
Assess ability of eyelids to close
The upper lid margin
should be between the
upper margin of the iris
and the upper margin of
the pupil. The lower lid
margin rests on the
lower border of the iris. Drooping of the upper lid,
Now white sclera is called ptosis, may be
seen above or below attributed to oculomotor
the iris. Palpebral nerve damage, myasthenia
fissures may be gravis, weakened muscle or
horizontal tissue, or a congenital
disorder. Retracted lid
The upper and lower margins, which allow for
lids close easily and viewing of the sclera when
meet completely when the eyes are open, suggest
closed. hyperthyroidism
Skin on both eyelids is Entropion - inverted lower
without redness, lid cause pain & inj. Cornea
swelling, or lesions
Ectropion - an everted
lower eyelid, exposure and
drying of the conjunctiva
Redness and crusting along
the lid margins suggest
seborrhea or blepharitis
an infection caused by
staphylococcus aureus
Hordeolum (stye), a hair
follicle infection, causes
local redness, swelling, and
pain
A chalazion an infection of
the meibomian gland
(located in the eyelid) may
produce extreme swelling of
the lid, moderate redness,
but minima
14. Inspect positioning of
eyeballs (alignment in sockets,
protruding or sunken).
15. Inspect bulbar conjunctiva
and sclera (clarity, color, and
texture
16. Inspect the palpebral
conjunctive (eversion of upper
eyelid is usually performed only
with complaints of eye pain or
sensation of something in eye).
Pull down - Look up
17. Inspect the lacrimal
apparatus over the lacrimal
glands (lateral aspect of upper
eyelid) and the puncta (medial
aspect of lower eyelid).
Observe swelling, redness, or
drainage.
18.Palpate the lacrimal
apparatus, noting drainage
from the puncta when palpating
the nasolacrimal duct.
19.Inspect the cornea and lens
by shining a light to determine
transparency.
Shine a light from the side of
Eyeballs are Protrusion of the eyeballs
symmetrically aligned in accompanied by retracted
sockets without eyelid margins is termed
protruding or sinking exophthalmos and is
characteristic of Grave’s
disease.
A sunken appearance of the
eyes may be seen with
severe dehydration or
chronic wasting illnesses
Have the client keep the Bulbar conjunctiva is Generalized redness of the
head straight while clear, moist, and conjunctiva suggests
looking from side to side smooth. Underlying conjunctivitis (pink eye)
then up toward the structures are clearly Areas of dryness are
ceiling. Observe clarity, visible. Sclera is white associated with allergies or
color, and texture. trauma Episcleritis is a
local, non-infectious
inflammation of the sclera.
The condition is usually
Inspect bulbar conjunctiva and sclera (clarity, color,
characterized and texture).
by either a
nodular appearance or by
redness with dilated vessels
The lower and upper Cyanosis of the lower lid
palpebral conjunctivae suggest a heart or lung
are clear and free of disorder
swelling or lesions
A foreign body or lesion
may cause
Inspect the palpebral conjunctiva (eversion irritation,
of upper eyelid is usua
burning, pain and/or
swelling of the upper eyelid.
No swelling or redness Swelling of the lacrimal
should appear over gland may be visible in the
areas of the lacrimal lateral aspect of the upper
gland. The puncta is eyelid. This may be caused
visible without swelling by blockage, infection, or an
or redness and is inflammatory condition.
turned slightly toward Redness or swelling around
the eye the puncta may indicate an
infectious or inflammatory
condition. Excessive tearing
may indicate a nasolacrimal
sac obstruction
No drainage should be Expressed drainage from
noted from the puncta the puncta on palpation
when palpating the occurs with duct blockage
Palpate the nasolacrimal
lacrimal apparatus,
duct noting drainage from the puncta w
The cornea is Areas of roughness or
transparent with no dryness on the cornea are
opacities. The oblique often associated with injury
view shows a smooth or allergic responses.
and overall moist Opacities of the lens are
 the eye for an oblique view.
Look through the pupil to
inspect the lens.
20.Inspect the iris and pupil for
shape and color of the iris and
size and shape of the pupil.
21.Test pupillary reaction to
light (in a darkened room, have
the client focus on a distant
object, shine a light obliquely
into the pupil, and observe the
pupil’s reaction to light—
normally, pupils constrict).
consensual response -observe
pupillary reaction in opp. eye.
22. Test accommodation of
pupils by shifting gaze from far pencil about 12 to 15 response is constriction
to near (normally, pupils
constrict).
Internal Eye Structure
23.Inspect the red reflex by
using an ophthalmoscope to
shine the light beam toward the
client’s pupil (normally, a red
reflex is easily seen and should
appear round with regular
borders).
surface; the lens is free seen with cataract
of opacities.
Arcus senilis - normal
condition in older
clients, a white arc
around the limbus
The iris typically round, Typical abnormal findings
flat, and evenly colored include irregularly shaped
Inspect the iris and pupil for shape irises,
and color
miosis,
of the
mydriasis,
iris and size an
The pupil, round with a and anisocoria.
regular border, is Miosis - constricted and
centered in the iris fixed pupils
Pupils are normally
equal in size (3 to 5
mm). an inequality in
pupil size of less than Anisocoria - unequal size
0.5 mm occurs in 20%
of clients. This
condition , called Mydriasis - dilated and
anisocoria, is normal fixed pupils
If the difference in pupil size
changes throughout
pupillary reponses tests, the
inequality of size is
abnormal
The top (or first) number The normal direct Monocular blindness can
indicates the pupil’s eye pupillary response is be detected when light
at rest, and the bottom constriction. directed to the blind eye
(or second) number results in no response in
indicates the constricted The normal consensual either pupil. When light is
size; for example, O.S. pupillary response is directed into the unaffected
(left eye, oculus sinister) constriction. eye, both pupils constrict.
3/2; O.D. (right eye,
oculus dexter) 3/1.
Hold your finger or a Normal pupillary Pupils do not constrict; eyes
do not converge.
inches from the client. of pupils & convergence
Ask the client to focus on of eyes when focusing
your finger on near object
The red reflex should Abnormalities of the red
be easily visible through reflex most often result from
the ophthalmoscope. cataracts. These usually
The red area should appear as black spots
appear round with against the background of
regular borders the red light reflex

24.Inspect the optic disc. Keep
the light beam focused on the
pupil and move closer to the
client from a 15-degree angle.
25.Inspect the retinal vessels
using the above technique
(observe vessels for numbers
of sets, color, diameter,
arteriovenous ratio, and
arteriovenous crossings).
Two types of age related
cataracts are nuclear
cataracts and peripheral
cataracts
The optic disc should Papilledema or swelling of
be round to oval with the optic disc, appears as a
sharp, well-defined swollen disc with blurred
Inspect the optic borders
disc by using the ophthalmoscope
margins, a hyperemic
focused on the
(blood-filled) appearance,
The nasal edge of the more visible and more
optic disc may be numerous disc vessels, and
blurred. The disc is lack of visible physiologic
normally creamy, cup. The condition may
yellow-orange to pink, result from hypertension or
and approximately 1.5 increased intracranial
mm wide pressure
The physiologic cup, The intraocular pressure
the point at which the associated with glaucoma
optic nerve enters the interferes with the blood
eyeball, appears on the supply to optic structures
optic disc as slightly and results in the following
depressed and a lighter characteristics: an enlarged
color than the disc physiologic cup that
occupies more than half of
The cup occupies less the disc’s diameter, a pale
than half of the disc’s base of enlarged
diameter physiologic cup, and
The disc’s border may obscured or displaced
be surrounded by rings retinal vessels
and crescents, Optic atrophy is evidenced
consisting of white by the disc being white in
sclera or black-retinal color and a lack of disc
pigment. These normal vessels. This condition is
variations are not caused by the death of optic
considered are not nerve fibers
considered in the optic
disc’s diameter
Four sets of arterioles Changes in the blood
and venules should supply to the retina may be
pass through the optic observed in constricted
disc arterioles, dilated veins, or
absence of major vessels
Arterioles are bright red
and progressively Initially hypertension may
narrow as they move cause a widening of the
away from the optic arterioles’ light reflex and
disc. Arterioles have a the arterioles take on a
light reflex that appears copper color. With long-
as a thin, white line in standing hypertension,
the center of the arteriole walls thicken and
arteriole appear opaque or silver
Venules are darker red Arterial nicking, tapering,
and larger than and banking are abnormal
arterioles. They also AV crossings caused by
progressively narrow as hypertension or
 they move away from arteriosclerosis
optic disc

The ratio of arterioles

diameter to vein
diameter (AV ratio) is
2:3 or 4:5

In a normal AV
crossing, the vein
passing underneath the
arteriole is seen right up
to the column of blood
on either side of the
arteriole (the arteriole
wall itself is normally
transparent)

26. Inspect retinal background General background Cotton-wool patches (soft-

for color and the presence of appears consistent in exudates) and gard
lesions. texture. The red-orange exudates from diabetes and
color of the background hypertension appear as
is lighter near the optic light-colored spots on the
disc retinal background

Hemorrhages and
microaneurysms appear as
red spots and streaks on
the retinal background

27.Inspect the fovea and The macula is the Excessive clumped pigment
macula for lesions. darker area, one disc, appears with detached
diameter in size, retinas or retinal injuries.
located to the temporal Macular degeneration may
side of the optic disc. be due to hemorrhages,
Within this area is a exudates, or cysts
starlike light reflex
called fovea

28.Inspect anterior chamber. The anterior chamber is Hyphemia occurs when

Remain in the same position transparent injury causes red blood cells
and rotate the lens wheel to collect in the lower half of
slowly to +10, +12, or higher to the anterior chamber.
inspect the anterior chamber of Hypopyon usually results
the eye. Inspect the anterior chamber for transparency.
from an inflammatory
response in which white
blood cells accumulate in
the anterior chamber and
produce cloudiness in front
of the iris

26. Remove gloves.

27. Wash hands. -To avoid transfer of

infection and bacteria to
the nurse.
28. Document findings. -To remember
assessment results.
-To add information to the
patient's record.
 ASSESSING HEAD AND NECK
PROCEDURE RATIONALE NORMAL FINDING ABNORMAL FINDING
- To avoid delay and
1. Gather equipment. to make assessment
possible.
2. Introduce yourself and verify the To build rapport and
client’s identity using agency gain trust from the
protocol. patient
3. Explain to the client what you are -To give client
going to do, why it is necessary, knowledge about the
and how he or she can procedure that the
participate. nurse is about to
perform
4. Provide privacy. To build rapport and
gain trust from patient
5. Wash hands. To prevent transfer of
infection and bacteria
6. Don gloves. To prevent transfer of
infection and bacteria
HEAD

7. Inspect head for size, shape, and The skull and facial bones
configuration. are larger and thicker in
Head size and shape
acromegaly, which occurs
vary, especially in accord
when there is an
with ethnicity. Usually the
increased production of
head is symmetric, round,
growth hormone. Acorn-
erect, and in midline. No
shaped, enlarged skull
lesions are visible
bones are seen in Paget’s
disease of the bone.

8. Palpate head for consistency The head is normally Lesions or lumps on the
while wearing gloves. hard and smooth without head may indicate recent
lesions. trauma or cancer.

9. Inspect face for symmetry, Asymmetry in front of the

features, movement, expression, earlobes occurs with
and skin condition. parotid gland
enlargement from an
abscess ortumor.

Unusual or asymmetric
orofacial movements may
The face is symmetric
be from an organic
with a round,oval,
disease or neurologic
elongated, or square
problem, which should be
appearance. No
referred for medical
abnormal movements
follow-up.
noted.
Drooping of one side of
the face may result from a
stroke or Bell’s palsy.

A “masklike” face marks

Parkinson’s disease;
a“sunken” face with
depressed eyes and
 hollow cheeks is typical of
cachexia;

a pale, swollen face may

result from nephrotic
syndrome.

10. Palpate temporal artery for The temporal artery is

tenderness and elasticity. hard, thick, and tender
with inflammation as seen
The temporal artery is
with temporal arteritis
elastic and not tender.
(inflammation of the
temporal arteries that
may lead to blindness).

11. Palpate temporomandibular Normally there is no

joint for range of motion, swelling, swelling, tenderness, or
tenderness, or crepitation by crepitation with
Limited range of motion,
placing index finger over the front of movement. Mouth opens
swelling, ten- derness, or
each and asking client to open and closes fully (3 to 6
crepitation may indicate
mouth. Ask if client has history of cm between upper and
TMJ syndrome.
frequent headaches. lower teeth). Lower jaw
moves laterally 1 to 2 cm
in each direction

Neck

12. Inspect neck while it is in a slightly

Swelling,
extended
enlarged
position (and u
masses, or nodules may
Neck is symmetric with
indicate an enlarged
head centered and
thyroid gland ,
without bulging masses.
inflammation of lymph
nodes,or a tumor.

13. Inspect
thyroid
movement
gland of
move
thyroid and cricoid cartilage and thyro
the thyroid gland is
upward symmetrically as
considered abnormal.
the client swallows.

14. Inspect cervical vertebrae by having

Prominence
client flex
or neck.
swellings
C7 (vertebrae prominens)
other than the C7
is usually visible and
vertebrae may be
palpable.
abnormal.

15. Inspect
Normally
neck range
neckofmovement
motion byMuscle
having spasms,
client turn
chin to right and left shoulder, touch should be smooth and inflammation, or cervical
each ear to the shoulder, touch chin controlled with 45-degree arthritis may cause
to chest, and lift chin to ceiling. flexion, 55-degree stiffness, rigidity, and
extension, 40-degree limited mobility of the
lateral abduction, and 70- neck, which may affect
degree rotation. daily functioning.

16. Palpate trachea by placing your The

finger
trachea
in the may
sternal
be notch, f
pulled to one side in
cases of a tumor, thyroid
Trachea is midline. gland enlargement, aortic
aneurysm,
pneumothorax,
atelectasis, or fibrosis.
 17. Palpate the thyroid gland. Landmarks deviate from
Landmarks are midline or are obscured
positioned midline. because of masses or
abnormal growths.

18. Palpate lymph nodes for A normal lymph node is

size/shape, delimitation, mobility, small, approximately 3-7
consistency, and tenderness. mm, usually spool-
shaped, smooth, sharply
edged, elastic in
consistency, not fused
with the skin or
underlying tissues and is
not painful during
palpation. A normal
lymph node in the neck is
barely perceptible. During
palpation they feel like
elastic marbles

19. Remove gloves. -To avoid transfer of

infection and bacteria
to the nurse.
20. Wash hands. -To avoid transfer of
infection and bacteria
to the nurse.
21. Document findings. -To remember
assessment results.
-To add information to
the patient's record.
 ASSESSING EARS
PROCEDURE RATIONALE NORMAL FINDING ABNORMAL FINDING

To avoid delay and to

1. Gather equipment.
2. Introduce self and verify the
client’s identity using agency
protocol.
make assessment
possible.
To build rapport and gain
trust from the patient

3. Explain to the client what you -To give client knowledge

are going to do, why it is
necessary, and how he or she
can participate.
4. Provide privacy.
5. Wash hands.
6. Don gloves.
External Ear Structures
about the procedure that
the nurse is about to
perform
-To build rapport and
gain trust from patient
-To prevent transfer of
infection and bacteria
-To prevent transfer of
infection and bacteria

7. Inspect the auricle, tragus,
and lobule for size and shape,
position, lesions/discoloration,
and discharge.
Most African Americans Ears are smaller than 4
and Caucasians have cm or larger than 10 cm
free lobes, whereas most Ears are equal in size
Asians have attached or bilaterally (normally 4 to Malaligned or low-set ears
soldered lobes, although 10 cm) may be see with
any type is possible in all genitourinary disorders or
cultural groups The auricle aligns with the chromosomal defects
corner of each eye and
The older client often has within a 10-degree angle Some abnormal findings
elongated earlobes with of the vertical position suggest various disorders,
linear wrinkles including:
Earlobes may be free,
attached, or soldered • Enlarged preauricular
(tightly attached to and postauricular lymph
adjacent skin with no nodes—infection
apparent)
• Tophi (nontender, hard,
The skin is smooth with cream-colored nodules on
no lesions, lumps, or the helix or antihelix,
nodules containing uric acid
crystals)—gout

Color is consistent with
facial color.
Darwin’s tubercle, which
is clinically insignificant
projection, may be seen
on the auricle
• Blocked sebaceous
gland--postauricular cysts
• Ulcerated, crusted
nodules that bleed--skin
cancer (most often seen of
the helix due to skin
exposure)

No discharge should be • Redness, swelling,

present scalling or itching---otitis
extera

• Pale blue ear color--

frostbite
 8. Palpate the auricle and
mastoid process for tenderness.
Otoscopic Examination
Inspect the external
auditory canal with the
otoscope for discharge,
color and consistency of
cerumen, color and
consistency of canal walls,
and nodules.
9. Inspect the tympanic membrane,
using the otoscope, for color and
shape, consistency, and landmarks.
Hearing and Equilibrium Tests
10. Perform the whisper test by
having the client place a finger on
the tragus of one ear. Whisper a
two-syllable word 30.4–60.9 cm (1–
2 ft) behind the client. Repeat on
the other ear.
occlude the ear not being tested
and rub the tragus with a finger in a the portable audioscope.
circular motion.
Start with testing the better hearing
ear and then the poorer one. With
your head 2 feet behind the client
A painful auricle or tragus is
associated with otitis
Normally the auricle, externa or a postauricular
tragus, and mastoid cyst. Tenderness over the
process are not tender mastoid process suggests
mastoiditis. Tenderness
behind the ear - otitis media
A small amount of
odorless cerumen
(earwax) is the only
discharge normally
present. Cerumen color
may be yellow, orange,
red, brown, gray, or black.
Consistency may be soft,
moist, dry, flaky, or even
hard.
The canal walls should be pink
and smooth, without nodules.
Red, bulging eardrum and
distorted, diminished, or
Inspect the tympanic membrane, using absent
the otoscope,
light reflex---acute
for color an
otitis media
The tympanic membrane
should be pearly, gray, Yellowish, bulging
shiny, and translucent membrane with bubbles
with no bulging or behind---serous otitis
The older client’s media
retraction. It is slightly
eardrum may appear
concave , smooth ,and
cloudy. The landmarks Bluish or dark red color--
intact. A cone shaped
may be more prominent blood behind the eardrum
reflection of the otoscope
because of atrophy of the from the skull trauma
light is normally seen at 5
tympanic membrane
o’clock in the right ear and White spots--scarring from
associated with the
at 7 o’clock in the left ear. infections Perforations--
normal process of aging.
The short process and trauma from infections
handle of the malleus and
the umbo are clearly Prominent landmarks--
visible eardrum retraction from
negative ear pressure
resulting from an
obstructed eustachian
tube
Unable to repeat the two-
test for detecting hearing
Client is able to hear and syllable word after two
impairment and
state the whispered tries indicates hearing loss
compares favourably with
words. and requires follow-up
testing by an audiologist.
(so that the client cannot see your
lips move), whisper a two-syllable
word such as “popcorn” or
“football.” Ask the client to repeat it
back to you. If the response is
incorrect the first time, whisper the
word one more time. Identifying
three out of six whispered words is
considered passing the test.

11. Perform the Weber test by Conductive hearing

using a tuning fork placed on the
center of the head or forehead and
asking whether the client hears the
sound better in one ear or the same test for evaluating
in both ears. hearing loss. The test
Strike a tuning fork softly with the can detect unilateral
back of your hand and place it at conductive and
the center of the client’s head or sensorineural hearing
forehead. Centering is the important loss.
part. Ask whether the client hears
the sound better in one ear or the The test helps to
same in both ears. evaluate the conduction
of sound waves through
bone to help distinguish
between conductive
hearing (sound waves
transmitted by the
external and middle ear)
and sensorineural
hearing (sound waves
transmitted by the inner
ear).
loss- the client reports
lateralization of sound to
the poor ear--that is, the
client “hears” the sounds
in the poor ear. The good
ear is distracted by the
background noise,
conducted air, which the
poor ear has troubled
hearing. Thus the poor ear
Vibrations are heard receives most of the
equally well in both ears. sound conducted by bone
No lateralization of sound vibration
to either ear.
Sensorineural hearing
loss--the client reports
lateralization of sound to
the good ear. This is
because of limited
perception of the sound
due to nerve damage in
the bad ear, making sound
seem louder in the
unaffected ear

12Perform the Rinne test by using a With sensorineural

tuning fork and placing the base on
the client’s mastoid process. When
the client no longer hears the
sound, note the time interval, and
move it in front of the external ear.
When the client no longer hears a differentiates sound
sound, note the time interval.
hearing loss, air
conduction sound is heard
longer than bone
conduction sound (AC >
BC) if anything is heard at
all.
transmission via air
Air conduction sound is With conductive hearing
conduction from sound loss, bone conduction
normally heard longer
transmission via bone sound is heard longer than
than bone conduction
conduction. It can serve or equally as long as air
sound (AC BC)
as a quick screen for conduction sound
conductive hearing loss. (BC>AC) With
sensorineural hearing
loss, air conduction sound
is heard longer than bone
conduction sound
(AC>BC) if anything is
heard at all

17. Perform the Romberg test to test that measures your Client maintains position Client moves feet apart to
evaluate equilibrium. With feet sense of balance. It's for 20 seconds without prevent falls or starts to
 together and arms at the side, typically used to swaying or with minimal fall from loss of balance.
close eyes for 20 seconds. diagnose problems with swaying This may indicate a
Observe for swaying. your balance, which is vestibular disorder
composed of your visual,
When performing this test, put your vestibular (inner ear), and
arms around the client without proprioceptive (positional
touching him or her to prevent falls. sense) systems during a
neurological exam.

17. Remove gloves. -To avoid transfer of

18. Wash hands.
19. Document findings.
infection and bacteria to
the nurse.
-To avoid transfer of
infection and bacteria to
the nurse.
-To remember
assessment results.
-To add information to
the patient's record.
 ASSESSING THE MOUTH, THROAT, NOSE, AND SINUSES
PROCEDURE
1. Gather equipment.
2. Introduce self and verify
the client’s identity using
agency protocol.
3. Explain to the client what
you are going to do,
why it is necessary, and
how he or she can
participate.
4. Provide privacy.
5. Wash hands.
6. Don gloves.
MOUTH
7. Note any distinctive odors.
8. Inspect and palpate lips,
buccal mucosa, gums, and
tongue for color variations
(pallor, redness, white
patches, bluish hue),
moisture, tissue consistency,
or lesions (induration,
roughness, vesicles, crusts,
plaques, nodules, ulcers,
cracking, patches, bleeding,
Koplik spots, cancer sores),
Stensen and Wharton ducts.
9. Inspect gums for
hyperplasia, blue-black line.
Put on gloves and retract the
client’s lips and cheeks to
check gums for color and
consistency
RATIONALE NORMAL FINDING ABNORMAL FINDING
- To avoid delay and to
make assessment
possible.
To build rapport and
gain trust from the
patient
To give client
knowledge about the
procedure that the
nurse is about to
perform
-To build rapport and
gain trust from patient
-To prevent transfer of
infection and bacteria
-To prevent transfer of
infection and bacteria
No unusual or foul odor is Fruity or acetone breath is
noted. associated with diabetic
ketoacidosis. An ammonia
odor is often associated
with kidney disease. Foul
odors may indicate an oral
or respiratory infection, or
tooth decay. Alcohol or
tobacco use may be
identified by breath odor.
Fecal breath odor occurs in
bowel obstruction; sulfur
odor (fetor hepaticus)
Occurs in endstage liver
disease.
Halitosis (bad breath)
Uniform pink color
Pallor, cyanosis
(darker, e.g, bluish hue ,
Blisters; generalized or
in mediterranean groups
localized swelling; fissures,
and dark skinned clients)
crust, or scales (may result
It is soft, moist, and has a
from excessive moisture,
smooth texture.
nutritional deficiency, or
Symmetry of contour
fluid deficit)
There is no retraction of Hyperplasia present
gums and the gums are Gingival hyperplasia, also
pink in color, moist, and referred to as gingival
with thight margins with enlargement, is the
the tooth. Hyperplasia is overgrowth of gum tissue
also absent. around your teeth.
A bluish-black or grey-white
line along the gum line is
seen in lead poisoning
 10. Inspect teeth for
number and shape, color
(white, brown, yellow,
chalky white areas),
occlusion.
Missing teeth; ill fitting
dentures
32 adult teeth Brown or black
Smooth, white, shiny discoloration of enamel
tooth enamel (may indicate staining or
the presence of caries)

11. Inspect and palpate Uniform pink in

tongue for color, texture,
and consistency (black,
hairy, white patches,
smooth, reddish, shiny
without papillae),
moisture, and size
(enlarged or very small).
THROAT
12. Inspect the throat for
color, consistency, torus
palatinus, uvula (singular).
13. Inspect the tonsils for
color and consistency;
grading scale (1+, 2+, 3+,
4+).
color( freckled brown
pigmentation in dark Pallor;leukoplakia( white
skinned clients) patches), red,bleeding
moist, smooth, soft excessive dryness mucosal
glistening, and elastic cyst; irritations from
Texture( dryer oral dentures; abrasions,
mucosa in older clients ulceration; nodules
due to decreased
salivation)
Throat is moist and pink,
no inflammation or Reddened or edematous;
exudate noted, uvula is presence of lesions,
freely hanging and normal plaques, or drainage
in appearance and size.
inflamed presence of
discharge
Swollen:
Grade 2: the tonsils are
between the pillars and the
Bilateral tonsils pink and
uvula
symmetric, grade 1+
Grade 3: the tonsil touches
the uvula.

Grade 4: one or both

NOSE
14. Inspect and palpate
the external nose for
color, shape, consistency,
tenderness, and patency
of airflow.
15. Inspect the internal
nose for color, swelling,
exudate, bleeding, ulcers,
perforated septum, or
polyps.
SINUSES
16. Palpate the sinuses for
tenderness.
17. Percuss and trans-
illuminate the sinuses for
air versus fluid or pus.
Nose is symmetrical and
aligned, is of same color
and texture as the rest of
patients face, and there is
no report of tenderness.
Both nostrils are patent.
Internal nostrils are free of discharge (e.g., pus)
exudate or lesions.
Sinuses are not tender to
touch and no crepitus is
noted
Red glow noted on
transillumination, free of
pus or fluid.
tonsils extend to the midline
of the oropharynx
Asymmetric discharge from
nares. Localized areas of
redness or presence of skin
lesions
Tenderness on palpation;
presence of lesions
Mucosa red, edematous;
Presence of lesions (e.g.,
polyps)
Tenderness in one or more
sinuses
Absence of red glow
indicate a sinus filled with
fluid
18. Remove gloves. -To prevent transfer of
infection and bacteria
19. Wash hands. -To prevent transfer of
infection and bacteria
20. Document findings. To remember
assessment results.
-To add information to
the patient's record.
 ASSESSING THE INTEGUMENTARY SYSTEM (Skin, Hair, and
Nails)

PROCEDURE RATIONALE NORMAL FINDINGS ABNORMAL

FINDINGS

1. Gather equipment. - To avoid delay and

to make assessment
possible.

2. Introduce self and verify the -To build rapport

client’s identity using agency and gain trust from
protocol. the patient

3. Explain to the client what you -To give client

are going to do, why it is knowledge about
necessary, and how he or she the procedure that
can participate. the nurse is about to
perform

4. Ask the client to put on a gown. -To make the

assessment more
accessible.

5. Provide privacy. -To build rapport

and gain trust from
patient

6. Wash hands and wear gloves as -To prevent transfer

needed. of infection and
bacteria

SKIN

7. Note any distinctive odor. -Uncontrolled body Client has slight or no A strong odor of
odor or excessive or odor of perspiration, perspiration or foul
insufficient depending on activity odor may indicate
perspiration may disorder of sweat
indicate an glands. Poor hygiene
abnormality of the practices may
sweat glands or an indicate a need for
endocrine problem client teaching or
such as assistance with
hypothyroidism or activities of daily
hyperthyroidism. living.
Poor hygiene
practices may
account for body
odor, and health
education may be
indicated.
8. Inspect for generalized color
variations (brownness, yellow,
redness, pallor, cyanosis,
jaundice, erythema, vitiligo).
-Inspecting any Common variations Abnormal findings
abnormalities that include suntanned include rashes, such
may indicate any areas, freckles, or as the reddish (in
systemic or major white patches known light-skinned people)
organ problem, skin as vitiligo.The or darkened (in dark-
carcinoma, low variations are due to skinned people)
oxygen and different amounts of butterfly rash (also
hemoglobin level or melanin in certain called Malar rash)
any infectious areas. A generalized across the bridge of
diseases. loss of pigmentation is the nose and cheeks
seen in albinism. characteristic of
Dark-skinned clients systemic lupus
have lighter-colored erythematosus (SLE).
palms, soles, nail female-to-male ratio
beds, and lips. and is more common
Freckle-like or dark in black and Hispanic
streaks of people Erythema
pigmentation are also (skin redness and
common in the sclera warmth) is seen in
and nail beds of dark- inflammation, allergic
skinned clients. reactions, or trauma.

9. Inspect for skin breakdown. Note -Inspecting any Skin is intact, and -Skin breakdown is
size, shape, location, distribution, pressure sores or there are no reddened initially noted as a
and configuration ulcers and skin areas reddened area on the
shears from friction. skin that may
progress to serious
and painful pressure
ulcers.
-Depending on the
color of the client’s
skin, reddened areas
may not be
prominent, although
the skin may feel
warmer in the area of
breakdown than
elsewhere.

10. Palpate lesions. -Palpating to feel -Skin is smooth, -Lesions may indicate
Lesions that may without lesions. - local or systemic
itch, bleed, hurt, or Stretch marks (striae), problems. -Primary
be filled with fluid healed scars, lesions arise from
that might indicate freckles, moles, or normal skin due to
local or systemic birthmarks are irritation or disease.
problems. common findings. - Secondary lesions
Freckles or moles arise from changes in
may be scattered over primary lesions. -
the skin in no Vascular lesions,
particular pattern. reddish-bluish
lesions, are seen with
bleeding, venous
 pressure, aging, liver
disease, or
pregnancy. -
Cancerous lesions
can be either primary
or secondary lesions
and are classified as
squamous cell
carcinoma, basal cell
carcinoma, or
malignant melanoma.

11. Palpate texture (rough, smooth) -Palpating texture -Skin is smooth and - Rough, flaky, dry
of skin, using the palmar surface of looking for even. skin is seen in
Three middle fingers. abnormalities that hypothyroidism.
may indicate Obese clients often
hypothyroidism. report dry, itchy skin.

12. Palpate temperature (cool, -Checking Skin is normally a -Cold skin may
warm, hot) and moisture temperature that warm temperature. accompany shock or
(dry, sweaty, oily) of skin, may indicate low hypotension. Cool
using the dorsal side of blood pressure skin may accompany
hand. (hypotension) or low arterial disease.
glucose level -Very warm skin may
(hypoglycemia) indicate a febrile
state or
hyperthyroidism.

13. Palpate for the thickness of skin. Inspecting for Skin is normally thin -Very thin skin may
normal range but calluses (rough, be seen in clients
findings, but also thick sections of with arterial
checking for epidermis) are insufficiency or in
abnormal findings. common on areas of those on steroid
the body that are therapy.
exposed to constant -Infected lesions may
pressure. be tender to palpate.
-No lesions palpated. Nonmobile, fixed
lesions may be
cancer.

14. Palpate mobility and turgor
by pinching up skin over
sternum.
-Note that if mobility -Normally, the skin is -Decreased mobility
is decreased it can mobile, with elasticity is seen with edema. -
be indicative of and returns to its Decreased turgor (a
edema. Also note original shape quickly. slow return of the skin
that poor skin turgor -older client’s skin to its normal state
is indicative of loses its turgor taking longer than 30
dehydration because of a seconds) is seen in
decrease in elasticity dehydration.
and collagen fibers.
Sagging or wrinkled
skin appears in the
facial, breast, and
scrotal areas.

15. Palpate for edema, pressing - Noting for any -Skin rebounds and -Indentations on the
thumbs over feet or ankles. abnormalities such does not remain skin may vary from
as leaving a dent in indented when slight to great and
the finger after pressure is released. may be in one area
palpating can be or all over the body.
indicative of edema
SCALP AND HAIR

16. Inspect color, amount and -Inspecting for Natural hair color, as Nutritional
distribution. Absent or sparse opposed to chemically deficiencies may
hair might be a sign colored hair, varies cause patchy gray
of Hypotrichosis among clients from hair in some clients.
pale blond to black to -Excessive scaliness
gray or white. The may indicate
color is determined by dermatitis. Raised
the amount of melanin lesions may indicate
present. infections or tumor
-Scalp is clean and growth. Dull, dry hair
dry. Sparse dandruff may be seen with
may be visible. Hair is hypothyroidism and
smooth and firm, malnutrition.
somewhat elastic -Poor hygiene may
indicate a need for
client teaching or
assistance with
activities of daily
living.

17. Inspect and palpate for
thickness, texture, oiliness,
lesions, and parasites.
Looking for anything - thin/thick; Hair loss associated
abnormal such as straight/curly; with excessive
atrophic(shiny skin, fine/course; shedding results in a
very thin) when shiny/resilient; should positive “gentle hair
inspecting and not come out in pull” test. Grasp a
palpating. clumps when gently lock of hairs to
pulled (> 5 strands) determine if any can
-Normal male and be extracted with firm
female pattern of pull. Normally 0-2
baldness is hereditary telogen hairs can be
extracted
-Lice or parasites are
present.

NAILS (nail polish should be

removed before assessing the nails)

18. Inspect for grooming and
cleanliness.
-Nail care gives the patient -Clean and neat -Dirty, Long, Sharp
a neat appearance and trim of the nails. fingernails.
helps prevent them from
scratching themselves.
Regular nail care can
remove bacteria from
underneath the fingernails
to help prevent infections.

19. Inspect for color, markings, and
shape.
-Note for things such as -Nails are -Nail irregularities
pink tones should be soon. colorless and Long nails, Curved
Pale or cyanotic nails may have a convex nails, Nail clubbing,
indicate hypoxia or anemia. curve. Pincer nail and nails
- Noting for any -Has a pinkish ingrown.
abnormalities of nails such nail bed.
as clubbing which can be
indicative of congenital
cyanotic heart disease

20. Palpate for the texture and -Noting for any Nails are smooth -Nail pitting, Nail
 consistency. abnormalities of nails such and firm; nail ridge,Nail
as nail pitting may indicate plates should be notching,Nail
eczema, psoriasis and firmly attached to Grooving,
alopecia areata. the nail bed. Onychogryphosis
Crumbling nails,Nail
Melanoma.

21. Test for capillary refill. - Depress the nail edge Pink tone returns There is slow
briefly to blanch, and then immediately to (greater than 2
release. blanched nail seconds) capillary
-This test is to monitor beds when nail bed refill (return
dehydration and blood pressure is of pink tone) with
supply. released respiratory or
cardiovascular
diseases that cause
hypoxia.

22. Remove gloves and wash -To avoid transfer of

hands. infection and bacteria to the
nurse.

23. Document findings. -To remember assessment

results.
-To add information to the
patient's record.

Heart and Central Vessels

PROCEDURE Able to Able to Unable to
perform perform with perform
(3) assistance (2) (1)

1. Introduce self and verify client’s To build rapport and gain

identity. trust from the patient

2. Explain the procedure to the client -To give client knowledge

and discuss how the results will about the procedure that
be used. the nurse is about to
perform

3. Gather appropriate equipment. - To avoid delay and to

make assessment
possible.

4. Perform hand hygiene and observe To prevent transfer of

other appropriate infection prevention infection and bacteria
procedures.

5. Help the patient undress, if needed, This is to ensure that the

and provide a patient gown. Provide assessment will be
for client privacy. smooth and comfortable
for the client

6. Assist the patient to a supine -To make the

position with the head elevated assessment more
 about 30 to 45 degrees and accessible.
expose the anterior chest. Use the
bath blanket to cover any
exposed area other than the one
being assessed.

7. Examine the jugular vein. Have the -Veins not visible -Veins visibly
patient turn away from you distended
slightly, and then using tangential
lighting, inspect the jugular veins
on the right side. Inspect the neck
for jugular vein distention,
observing for pulsations.

8. Assess the jugular venous pressure -JVP up to 3cm -Bilateral

and perform hepatojugular reflex above the sternal measurements
as needed. angle = CVP of 8 above 3-4 cm are
mmHg considered elevate
Unilateral distention

9. Inspect and palpate the carotid -Pulses are equal If the pulse is
arteries one at a time. bilaterally diminished
unilaterally/bilaterally
the cause may be
carotid stenosis from
atherosclerosis

10. Auscultate the carotid arteries -No bruit heard on -Presence of bruit in
using the bell of the stethoscope. auscultation one/both arteries

11. To examine the heart, stand at the -Impulse are -Enlarged heart
patient’s right side. Inspect the absent or located displaces the PMI
precordium noting for presence of in the 4th-5th ICS laterally & inferiorly
any pulsations, lifts, or heaves. at the MCL with Enlarged ventricles
Look for the apical impulse. no lifts/heaves.
-lifts and heaves are
notes and there’s an
enlarged ventricle

12. Palpate across precordium. No pulsation Pulsations are

Palpate for pulsations or heart present present
sounds in the right 2nd intercostal
space, left 2nd intercostal space,
and left 3rd intercostal space. While
keeping one finger in the 3rd
interspace, place additional
fingertips in the 4th and 5th
intercostal spaces. If an impulse is
palpable note its location, duration,
and amplitude.

13. Palpate the apical impulse, if it is Point of maximal PULMONARY

not visible feel for its location using impulse is EMPHYSEMA -
palm and fingers. Localize the tapping, 7cm impossible to
apical impulse precisely using one lateral to the palpate
or two finger pads. Advise or turn midsternal line in CARDIAC
the patient to the left side to better the 5th intercostal ENLARGEMENT -
feel the impulse. Note size, space medial to apical impulse is
duration, force, and location in the mid clavicular larger than 1 to 2 cm
 relationship to the midclavicular line, and brief in
line. duration, that lasts
less than two
thirds of systole

14. Percuss the chest to estimate the Cardiac When heart is

heart’s size. percussion show enlarged, the left
dullness to lateral border of the
percussion from heart is percussed
the sternum to laterally and
approximately inferiorly to the
6cm lateral to the normal location
left of the sternum

You shoukld hear

resonan to dull

15. Auscultate the heart: beginning at -Heart rate is 60- -Rhythm is irregular
the aortic area, moving to the 100 beats/min
pulmonic area, then to Erb’s point, and regular
then to the tricuspid area, and to
the mitral area. Auscultate all over
the precordium using both the
diaphragm and the bell to listen to
all areas.

a. Identify S1 and S2 sounds. S1 is greater than S1: Fixed split

Identify the heart rate and S2 in the mitral Wide splitting
rhythm. and tricuspid Paradoxical split
areas.S2 is S2: Split S2 may
greater than S1 in occur from pulmonic
the aortic and valve closing slightly
pulmonic areas. after the aortic it may
S1 is equal to S2 be heard in the
in the Erb’s point. pulmonic valve area
during inspiration in
children

b. Auscultate for extra sounds and No murmurs, Murmur is heard

murmurs. gallops or rubs

c. Reexamine the heart while the No S3 and S4 S3 and S4 is heard

client is in an upright sitting
position.

16. Assist patients in dressing and into

a comfortable position.

17. Wash hands. To prevent transfer of

infection and bacteria

18. Document findings. -To remember

assessment results.
-To add information to
the patient's record.

Breast and Axillae

PROCEDURE RATIONALE NORMAL ABNORMAL
FINDINGS FINDINGS
1. Verify physician’s order.

2. Gather equipment. To avoid delay and to

make assessment
possible

3. Introduce yourself and verify the To build rapport and

client’s identity using agency gain trust from the
protocol. patient

4. Explain the procedure to the client. -To give client

knowledge about the
procedure that the nurse
is about to perform

5. Provide privacy. -To build rapport and

gain trust from patient

6. Ask the client to put on a gown. This is to ensure that the

assessment will be
smooth and comfortable
for the client

7. Wash hands and perform other To prevent transfer of

precautionary measures based on infection and bacteria
institutional protocol.

8. Inspect the breasts SIZE AND SIZE AND

a. Size and symmetry SYMMETRY SYMMETRY
b. Color and texture Breasts can be a A recent increase in
c. Superficial venous patterns variety of sizes the size of one breast
d. Retraction and dimpling and are may indicate
e. Bilaterally; note color, size, somewhat round inflammation or an
shape, and texture of areolas and pendulous. abnormal growth.
f. Bilaterally; note size and direction One breast may
of nipples normally be larger
than the other.

COLOR AND
TEXTURE COLOR AND
Color varies TEXTURE
depending on the b.redness is
client’s skin tone. associated with
Texture is breast inflammation.
smooth, with no A pigskin-like or
edema. Linear orange-peel (peau
stretch marks d’orange)
may be seen appearance results
during and after from edema, which is
pregnancy or with seen in metastatic
significant weight breast disease The
gain or loss. edema is caused by
blocked lymphatic
drainage.

SUPERFICIAL
SUPERFICIAL VENOUS PATTERN
VENOUS A prominent venous
PATTERN pattern may occur as
Veins radiate a result of increased
either horizontally circulation due to a
and toward the malignancy. An
axilla (transverse) asymmetric venous
or vertically with a pattern may be due
lateral flare to malignancy.
(longitudinal).
Veins are more
prominent during
pregnancy.

RETRACTION AND
RETRACTION DIMPLING
AND DIMPLING Dimpling or retraction
The client’s is usually caused by
breasts should a malignant tumor
rise that has fibrous
symmetrically, strands attached to
with no sign of the breast tissue and
dimpling or the fascia of the
retraction. muscles. As the
muscle contracts, it
draws the breast
tissue and skin with
it, causing dimpling
or retraction.

BILATERALLY (E)
BILATERALLY
(E) Peau d’orange skin,
Areolas vary from associated with
dark pink to dark carcinoma, may be
brown, depending first seen in the
on the client’s areola. Red, scaly,
skin tones. They crusty areas may
are round and appear in Paget’s
may vary in size. disease.
Small
Montgomery
tubercles are
present.

BILATERALLY (F)
BILATERALLY A recently retracted
(F) nipple that was
Nipples are previously everted
nearly equal suggests malignancy.
bilaterally in size Any type of
and are in the spontaneous
same location on discharge should be
each breast. referred for cytologic
Nipples are study and further
 usually everted, evaluation
but they may be
inverted or flat.
No discharge
should be
present.

9. Palpate the breasts TEXTURE AND TEXTURE AND

a. Texture and elasticity ELASTICITY ELASTICITY
b. Tenderness and temperature a.
c. Masses: noting location, size in smooth and a. thickening of the
centimeters, shape, mobility, firm, and tissue underlying
consistency, and tenderness elastic tissue tumor
d. Palpate nipples by compressing
nipple gently between thumb
and index finger; observe for
discharge
e. Palpate mastectomy site, if
applicable, observing the scar
and any remaining breast or
axillary tissue for redness,
lesions, lumps, swelling, or
tenderness TENDERNESS TENDERNESS AND
AND TEMPERATURE
TEMPERATURE
A generalized Painful, tender
increase in breasts may be
nodularity and indicative of
tenderness may fibrocystic breasts,
be a normal especially right
finding associated before Menstruation.
with the However, pain may
menstrual cycle also occur with a
or hormonal malignant tumor.
medications. Therefore, refer the
Breasts should be client for further
a normal body evaluation. Heat in
temperature. the breasts of
women who have not
just given birth or
who are not lactating
indicates
inflammation.

MASSES MASSES
No masses Malignant tumors are
should be most often found in
palpated. the upper outer
However, a firm quadrant of the
inframammary breast. They are
transverse ridge usually unilateral,
 may normally be with irregular, poorly
palpated at the delineated borders.
lower base of the They are hard and
breasts. nontender and fixed
to underlying tissues.

NIPPLES NIPPLES
The nipple may Discharge may be
become erect and seen in endocrine
the areola may disorders and with
pucker in certain medications.
response to Discharge from one
stimulation. A breast may indicate
milky discharge is benign intraductal
usually normal papilloma, fibrocystic
only during disease, or cancer of
pregnancy and the breast.
lactation. Sometimes there is
However, some only a watery, pink
women may discharge from the
normally have a nipple.
clear discharge

MASTECTOMY MASTECTOMY
Scar is whitish Redness and
with no redness inflammation of the
or swelling. No scar area may
lesions, lumps, or indicate infection.
tenderness noted. Any lesions, lumps,
or tenderness should
be referred for further
evaluation.

Axillae

10. Inspect for rashes or infection. There are no Rashes are present as
rashes and well as infection.
infection

11. Hold the elbow with one hand and Small freely Enlarged lymph
use the three fingerpads of your movable lymph nodes, tenderness
other hand to palpate firmly the nodes are upon palpation is
axillary lymph nodes. palpable , there present.
are no enlarged
lymph nodes
and the clients
lymph nodes are
not tender upon
palpation

12. Palpate high into the axillae, moving

downward against the ribs to feel
for the central nodes. Continue
down the posterior axillae to feel for
 the posterior nodes.

13. Use bimanual palpation to feel for

the anterior axillary nodes.

14. Palpate down the inner aspect of

the upper arm.

15. Wash hands. To prevent transfer of

infection and bacteria

16. Document findings. -To remember

assessment results.
-To add information to
the patient's record.

Lungs and Thorax

PROCEDURE RATIONALE NORMAL ABNORMAL FINDING
FINDING

1. Introduce self and verified client’s To build rapport and gain

identity. trust from the patient

2. Explain procedure to client and To give client knowledge

discuss how results will be used. about the procedure that
the nurse is about to
perform

3. Wash hands. To prevent transfer of

infection and bacteria

POSTERIOR THORAX

4. Assist patient on sitting position -Eupnea - -Bradypnea, tachypnea,

then ask patient to breathe normal Hyperpnea
normally. Observe the breathing breathing -The AP transverses 1:1
pattern. Assess for the pattern -Scoliosis, Kyphosis,
anteroposterior and transverse -AP to Barrel chest
diameter of the chest. transverse ratio
1:2

5. Palpate the spinous process. -Spinous -Misaligned

process is Bent spinous process
aligned and at
the midline
-No masses

6. Assess for symmetrical chest -The thumb -Asymmetrical chest

expansion. move apart expansion
symmetrically,
approximately 5-
10cm

7. Assess for tactile fremitus as the -Fremitus is -Decreased or absent

patient repeats the phrase symmetrical. tactile fremitus
“ninety-nine”. -Increased tactile
fremitus

8. Perform systematic percussion. -Lungs resonant - Percussion sounds

are dull when fluid
 or solid tissue
replaces the lungs
- Generalized
hyperresonance
- Unilateral
hyperresonance
- Flat sounds

9. Assess for diaphragmatic Excursion 3- - Diaphragmatic

excursion. Measure the distance 5cm, excursion is
between the set of marks you symmetrical reduced
made in each side while
assessing for diaphragmatic
- Limited
diaphragmatic
excursions (normal measurement
excursion
should be 3-5 cm).
- Asymmetrical
excursion

10. Instruct your patient to breathe - No -

deeply and fully with his mouth crackles,
when you perform the
- Crackles
wheezes
auscultation technique. and rhonchi
- Wheezes
- Rhonchi

11. Auscultate breathe sounds using - Breath - Coarse breath

the diaphragm of your sounds sounds
stethoscope. Auscultation method
should move systematically
vesicular - Decreased or
without diminished lung
comparing lung sounds for side to adventitious sounds
side down the patient’s back. sound
- Absent breath
sounds
- Adventitious
breath sounds

12. Auscultate for: - No - The word ninety-

a. bronchophony bronchopho nine is clear and
b. egophony ny noted louder over
c. pectoriloquy
- No denser area as if
egophony the patient is
noted speaking directly
into the
- No
pectoriloquy stethoscope
-The sound “e e e” is
. Normal
loud like “ a a a”
sounds are
-Sounds are louder
faint,
and clearer than the
muffled, and
difficult to whispered sounds, as
if the patient is directly
hear.
whispering into the
stethoscope

ANTERIOR THORAX

13. Begin with the bones and -No accessory -Respiratory distress
muscles, identify the breathing muscle use -Use of accessory
pattern (use of accessory muscles -No nasal flaring muscle
 and nasal flaring). -Nasal flaring

14. Palpate the thorax with your finger -No nodules -Nodules
pads and assess for nodules. -No tenderness, -Tenderness
lesions or
masses

15. Place your hands on the chest of -Excursion 3-5 -Asymmetrical chest
the patient along the costal cm, symmetrical excursion
margins linking your thumbs on
the xyphoid process to assess
the respiratory excursion then
instruct the patient to breathe
deeply.

16. Assess for tactile fremitus. -Fremitus is -Decreased or absent

symmetrical tactile fremitus
-Increased tactile
fremitus

17. Perform percussion over the -Lungs resonant. -Dullness percussion

lungs starting from the clavicle. over lung tissue

18. Auscultate the trachea. -Breath sounds -Coarse breath sounds

vesicular without -Decreased or
adventitious diminished lung
sound sounds
-Absent breath sounds
-Adventitious breath
sounds

19. Assess the lungs using -No crackles, -Crackles

auscultations method. wheezes and -Wheezes
rhonchi -Rhonchi

20. Wash hands To prevent transfer of

infection and bacteria

21. Document your findings -To remember

assessment results.
-To add information to the
patient's record.

Abdomen

PROCEDURE RATIONALE NORMAL FINDING ABNORMAL FINDING

1. Wash your hands and This is to prevent the

do other infection transfer of bacteria
control measures.

2. Assemble the equipment. - To avoid delay and

to make assessment
possible.

3. Explain the procedure to the -To build rapport and

patient. gain trust of the
patient and give client
knowledge about the
procedure that the

4. Ask the client to empty
the bladder. Ask the client
to put on a gown. Provide
privacy.
5. Assist the client in a
comfortable position.
6. Inspect the contour, shape,
size, skin lesions and
symmetry of the
abdomen.
7. Inspect abdominal
movement, noting for
aortic pulsations
and/or peristaltic
waves
8. Measure the
abdominal girth with
nurse is about to
perform
This is to ensure that
the assessment will
be smooth and
comfortable for the
client
-To make the
assessment more
accessible.
To check for any The abdomen is flat from Asymmetric contour, e.g.,
distention, bulging or the xiphoid to the localized protrusions
any lesions present symphysis pubis, the around umbilicus, inguinal
umbilicus is at the ligaments, or scars
abdominal center, no (possible hernia
visible mass, no lesions or tumor)
and no scars. the
abdomen is symmetric.
Redness may indicate
inflammation.
Bruises or areas of local
Discoloration are also
abnormal.
Non Healing scars,
redness, inflammation.
Deep, irregular
scars may result from
burns.
Any bleeding moles or
petechiae (reddish or
purple lesions) may also
be abnormal.
To inspect for any Diminished abdominal
abnormal and Normal abdominal respiration or change to
exaggerated respiration is seen, slight thoracic breathing in male
movements. pulsations of the clients may reflect
abdominal aorta are seen peritoneal irritation.
in epigastrium and
peristaltic waves are not Vigorous, wide,
seen exaggerated pulsations
may be seen with
abdominal aortic
aneurysm.
Peristaltic waves are
increased and progress in
a ripple-like fashion from
the LUQ to the RLQ with
intestinal obstruction
 a tape measure.

9. Auscultate the four
quadrants for bowel
sounds, vascular
sounds, peritoneal
friction rub sounds.
This is to assess for Normal and gurgling Decreased or absent
any abnormal bowel bowel sounds are heard bowel
sounds in the 4 quadrants of the sounds signify the
abdomen every 5-10 absence of
seconds. Bruits are not bowel motility, which
heard over his abdominal constitutes an emergency
aorta, renal iliac, and requiring immediate
femoral arteries. NO referral.
friction rub over liver or
spleen Absent bowel sounds
may be
Hyperactive bowel associated with peritonitis
sounds that may be heard or
normally are the paralytic ileus. High
loud, prolonged gurgles pitched
characteristic of stomach tinkling and rushes of high
growling. pitched sounds with
abdominal
cramping usually indicate
obstruction.

10. Perform percussion
starting on the right lower
quadrant (RLQ).
percuss for tone, lightly
percuss all quadrants
This is to assess for Tympanic sound is heard
tone over his abdomen
because of air in the
stomach and intestines.
, normal dullness is heard
over liver and spleen
Accentuated tympany or
hyperresonance is heard
over a gaseous distended
abdomen.
An enlarged area of
dullness is heard over an
enlarged liver or
spleen. Abnormal
dullness is heard over a
distended bladder, or
large masses

11. Perform liver span test.
The purpose of this is 8-12cm in the right
to get an approximate midclavicular line and 4-
liver size. 8cm in the midsternal
line.
The upper border of liver
dullness may be difficult
to estimate if obscured by
pleural fluid of lung
Consolidation

Hepatomegaly, a liver
span that exceeds normal
limits (enlarged), is
characteristic of liver
tumors, cirrhosis,
abscess, and vascular
engorgement

12. Assess the approximate
size of the spleen
begin posterior to the left mid-
axillary line (MAL), and percuss
downward, noting the change
from lung resonance to splenic
dullness
The purpose of this is The spleen has an oval
to get an approximate area of dullness
spleen size. approximately 7 cm wide
near the
left tenth rib and slightly
posterior to
the MAL
Dull tone is heard over
the 9th-11th ribs (spleen
An enlarged spleen
(splenomegaly) is
defined by an area of
dullness exceeding
7 cm. When enlarged, the
spleen
progresses downward
and in toward the
midline
 is located)

Tympanic and resonant

sound are heard when the
last intercostal space is
percussed.

13. Perform light palpation
using the pads of your
fingertips, beginning with
the non-tender quadrant.
Gently depress 1 cm in a
dipping motion. Remove
fingers and move to the
other areas.
This is to assess any Abdomen is nontender Involuntary reflex
tenderness that can and soft. There is no guarding is serious and
often manifest with guarding. reflects peritoneal
those who have Irritation.
peritonitis (redness
and swelling and The abdomen is rigid and
inflammation of the the rectus muscle fails to
tissue that lines your relax with palpation when
belly or abdomen.) the client
and appendicitis exhales.

14. Palpate the kidney This is to palpate for The kidneys are normally An enlarged kidney may
on each side of the any abnormal not palpable.If palpated, it be due to a cyst, tumor, or
abdomen..ask the enlargement of kidney should feel firm, smooth, hydronephrosis.
client to which can be a sign and rounded. The kidney
inhale.Ask the of tumor or cysts. may or may not be slightly
client to exhale tender.
and hold the
breath briefly.

15. Palpate for the liver on
the right part of the body
noting for consistency
and tenderness. Stand at
the client’s right side
and place your left
hand under the client’s
back at the level of the
eleventh to twelfth ribs.
This is to palpate for The liver is usually not
any hardness of the palpable, although it may
liver which can be a be felt in some thin
sign of liver cancer or clients. If the lower edge
tumors. is felt, it should be firm,
smooth, and even. Mild
tenderness may be
normal
A hard, firm liver may
indicate cancer.
Nodularity may occur with
tumors, metastatic
cancer, late cirrhosis, or
syphilis.

16. Palpate for the spleen on the
left side (noting consistency
and tenderness).
This is to look for The spleen is seldom
any tenderness palpable at the left costal
and splenic margin;If the edge of the
enlargement. spleen can be palpated, it
should be soft and
nontender.
Splenomegaly is
characterized
by an area of dullness
greater than 7 cm wide.
The enlargement may
result from traumatic
injury, portal
hypertension, and
mononucleosis.

17. Palpate the umbilical
area for swelling,
bulges, or masses.
This is to palpate free of swellings, bulges, A soft center of the
for any defect, or masses. umbilicus can be a
mass, or umbilical potential for herniation.
hernia. Palpation of a hard
nodule in or around the
umbilicus may indicate
metastatic nodes from an

18. Wash your hands.
19. Document all your findings.
Musculoskeletal System
PROCEDURE
1. Gather equipment (tape
measure,
goniometer).
2. Explain the procedure to
the client.
3. Ask the client to put on a
gown.
Gait
1. Observe gait for base,
weight-bearing
stability, feet position,
stride, arm swing, and
posture.
Temporomandibular Joint
1. Inspect, palpate, and test
ROM.
occult gastrointestinal
cancer.
To prevent
transfer of
infection and
bacteria
-To remember
assessment
results.
-To add
information to the
patient's record.
RATIONALE NORMAL FINDING ABNORMAL FINDING
- To avoid delay and
to make the
assessment
possible
-To give client
knowledge about the
procedure that the
nurse is about to
perform
This is to ensure
that the assessment
will be smooth and
comfortable for the
client
Evenly distributed weight. Uneven weight bearing
Client able to stand on heels is evident. Client cannot
and toes. Toes point straight stand on heels or toes.
ahead. Equal on both sides. Toes point in or out.
Posture erect, movements Client limps, shuffles,
coordinated and rhythmic, propels forward, or has
arms swing in opposition, wide-based gait.
stride length appropriate.
Snapping and clicking may be Decreased ROM,
felt and heard in the normal swelling, tenderness, or
client. Mouth opens 1–2 crepitus may be seen in
inches (distance between arthritis. Decreased
upper and lower teeth). The muscle strength with
client’s mouth opens and muscle and joint
closes smoothly. Jaw moves disease. Decreased
laterally 1–2 cm. Jaw ROM, and a clicking,
protrudes and retracts easily popping, or grating
sound may be noted with
TMJ dysfunction.
Sternoclavicular Joint
1. Inspect and palpate for
midline location, color,
swelling, and masses.
Spine
1. Inspect and palpate
cervical, thoracic, and
lumbar spine for pain
and tenderness.
2. Test ROM of cervical
spine.
3. Test ROM of thoracic and
lumbar spine.
4. Test for leg and back
pain.
5. Measure leg length.
Shoulders
1. Inspect and palpate
shoulders for symmetry,
color, swelling, and
masses.
There is no visible bony
overgrowth, swelling, or
redness; joint is nontender.
Nontender spinous
processes; well-developed,
firm and smooth, nontender
paravertebral muscles. No
muscle spasm.
Flexion of the cervical spine is Cervical strain is the
45 degrees. Extension of the
cervical spine is 45 degrees.
Normally the client can bend
40 degrees to the left side
and 40 degrees to the right
side
There should be no pain in
the leg or back.
Measurements are equal or
within 1 cm. If the legs still
look unequal, assess the
apparent leg length by
measuring from a nonfixed
point (the umbilicus) to a fixed
point (medial malleolus) on
each leg
Shoulders are symmetrically
round; no redness, swelling,
or deformity or heat. Muscles
are fully developed. Clavicles
and scapulae are even and
Swollen, red, or enlarged
joint or tender, painful
joint is seen with
inflammation of the joint
Compression fractures
and lumbosacral muscle
strain can cause pain
and tenderness of the
spinal processes and
paravertebral muscles
most common cause of
neck pain. It is
characterized by
impaired ROM and neck
pain from abnormalities
of the soft tissue
(muscles, ligaments, and
nerves) due to straining
or injuring the neck.
Causes of strains can
include sleeping in the
wrong position, carrying
a heavy suitcase, or
being in an automobile
crash
Limited ROM is seen
with neck injuries,
osteoarthritis,
spondylosis, or with disc
degeneration
We performed the
straight leg test and
observed herniated
nucleus pulposus.
Unequal leg lengths are
associated with
scoliosis. Equal true leg
lengths but unequal
apparent leg lengths are
seen with abnormalities
in the structure or
position of the hips and
pelvis.
Flat, hollow, or less-
rounded shoulders are
seen with dislocation.
Muscle atrophy is seen
with nerve or muscle
 symmetric. The client reports
no tenderness.
2. Test ROM of shoulders. Extent of forward flexion
should be 180 degrees;
hyperextension, 50 degrees;
adduction, 50 degrees; and
abduction 180 degrees.
Elbows
1. Inspect and palpate Elbows are symmetric,
elbows for size, shape, without deformities, redness,
deformities, redness, or swelling.
or swelling.
2. Test ROM of elbows. Normal ranges of motion are
160 degrees of flexion, 180
degrees of extension, 90
degrees of pronation, and 90
degrees of supination. Some
clients may lack 5–10
degrees or have
hyperextension.
Wrists
1. Inspect and palpate Wrists are symmetric, without
wrists for size, shape, redness, or swelling. They are
symmetry, color, nontender and free of
swelling, tenderness, nodules.
and nodules.
2. Test ROM of wrists. Normal ranges of motion are
90 degrees of flexion, 70
degrees of hyperextension, 55
degrees of ulnar deviation,
and 20 degrees of radial
deviation. Client should have
full ROM against resistance.
damage or lack of use.
Tenderness, swelling,
and heat may be noted
with shoulder strains,
sprains, arthritis, bursitis,
and degenerative joint
disease (DJD)
Painful and limited
abduction accompanied
by muscle weakness
and atrophy are seen
with a rotator cuff tear.
Client has sharp catches
of pain when bringing
hands overhead with
rotator cuff tendinitis.
Chronic pain and severe
limitation of all shoulder
motions are seen with
calcified tendinitis.
Redness, heat, and
swelling may be seen
with bursitis of the
olecranon process due
to trauma or arthritis.
Decreased ROM against
resistance is seen with
joint or muscle disease
or injury.
Swelling is seen with
rheumatoid arthritis.
Tenderness and nodules
may be seen with
rheumatoid arthritis. A
nontender, round,
enlarged, swollen, fluid-
filled cyst (ganglion) may
be noted on the wrists
Ulnar deviation of the
wrist and fingers with
limited ROM is often
seen in rheumatoid
arthritis.
3. Test for carpal tunnel No tingling, numbness, or
syndrome. pain result from Phalen’s test
or from Tinel’s test.
Hands and Fingers
1. Inspect and palpate Hands and fingers are
hands and fingers for symmetric, nontender, and
size, shape, without nodules. Fingers lie in
symmetry, swelling, straight line. No swelling or
color, tenderness, deformities. Rounded
and nodules. protuberance noted next to
the thumb over the thenar
prominence. Smaller
protuberance seen adjacent
to the small finger.
2. Test ROM of hands and Normal ranges are 20
fingers. degrees of abduction, full
adduction of fingers
(touching), 90 degrees of
flexion, and 30 degrees of
hyperextension. The thumb
should easily move away from
other fingers and 50 degrees
of thumb flexion is normal.
Hips
1. Inspect and Buttocks are equally sized;
palpate hips for iliac crests are symmetric in
shape and height. Hips are stable,
symmetry. nontender, and without
crepitus
2. Test ROM of hips. Normal ROM: 90 degrees of
hip flexion with the knee
straight and 120 degrees of
hip flexion with the knee bent
and the other leg remaining
straight.
Knees
1. Inspect and palpate Knees symmetric, hollows
knees for size, shape, present on both sides of the
symmetry, patella, no swelling or
deformities, pain, and deformities. Lower leg in
alignment. alignment with the upper leg.
If symptoms develop
within a minute with
Phalen’s test, carpel
tunnel syndrome is
suspected. Client may
report tingling,
numbness, and pain with
carpal tunnel syndrome.
Pain, tenderness,
swelling, shortened
finger, depressed
knuckle and/or inability
to move the finger is
seen with finger
fractures.
Inability to extend the
ring and little fingers is
seen in Dupuytren’s
contracture. Painful
extension of a finger
may be seen in
tenosynovitis .
Instability, inability to
stand, and/or a
deformed hip area are
indicative of a fractured
hip. Tenderness, edema,
decreased ROM, and
crepitus are seen in hip
inflammation and DJD.
Inability to abduct the hip
is a common sign of hip
disease.
Knees turn in with knock
knees (genu
valgum) and turn out
with bowed legs
(genu varum). Swelling
above or next to the
patella may indicate fluid
in the knee joint or

2. Test knees for swelling. No bulge of fluid appears on
If small amount of fluid medial side of knee.
present, do “bulge test.”
If large amount of fluid
present, do
“ballottement test.”
3. Test ROM of knees. Normal ranges: 120–130
degrees of flexion; 0 degrees
of extension to 15 degrees of
hyperextension.
4. Perform McMurray test No pain or clicking noted.
if client complains of
“clicking” in knee.
Ankles and Feet
1. Inspect and palpate Toes usually point forward
ankles and feet for and lie flat; however, they
position, alignment, may point in (pes varus) or
shape, skin, point out (pes valgus). Toes
tenderness, and feet are in alignment with
temperature, swelling, the lower leg. Smooth,
or nodules. rounded medial malleolar
prominences with prominent
heels and
metatarsophalangeal joints.
Skin is smooth and free of
corns and calluses.
Longitudinal arch; most of the
weight bearing is on the foot
midline.
2. Test ROM of ankles and Normal ranges: • 20 degrees
toes. dorsiflexion of ankle and foot
and 45 degrees plantarflexion
of ankle and foot. • 20
degrees of eversion and 30
degrees of inversion. • 10
degrees of abduction and 20
thickening of the
synovial membrane.
Bulge of fluid appears on
medial side of knee, with
a small amount of joint
effusion.
Osteoarthritis is
characterized by a
decreased ROM with
synovial thickening and
crepitation. Flexion
contractures of the knee
are characterized by an
inability to extend knee
fully.
Pain or clicking is
indicative of a torn
meniscus of the knee.
A laterally deviated great
toe with possible
overlapping of the
second toe and possible
formation of an
enlarged, painful,
inflamed bursa (bunion)
on the medial side is
seen with hallux valgus.
Common abnormalities
include feet with no
arches (pes planus or
“flat feet”), feet with high
arches (pes cavus);
painful thickening of the
skin over bony
prominences and at
pressure points (corns);
nonpainful thickened
skin that occurs at
pressure points
(calluses); and painful
warts (verruca vulgaris)
that often occur under a
callus.
Decreased strength
against resistance is
seen in muscle and joint
disease. Hyperextension
of the
metatarsophalangeal
joint and flexion of the
degrees of adduction. • 40 proximal interphalangeal
degrees of flexion and 40 joint is apparent in
degrees of extension. hammer toe
 ASSESSING NEUROLOGIC SYSTEM

PROCEDURE RATIONALE/DES NORMAL FINDING ABNORMAL FINDING

C.

1. Gather equipment, such - To avoid delay

as examination gloves, and to make
pencil and paper, cotton- assessment
tipped applicators, possible.
newsprint to read,
ophthalmoscope, paper
clip, penlight, Snellen
chart, sterile cotton ball,
substances to smell and
taste, tongue blade, tuning
fork, tape measure, cotton
balls, objects to feel, test
tubes with hot and cold
water, tuning fork (low
pitched), and reflex
hammer.

2. Explain the procedure to To build rapport

client. and gain trust of
the patient and give
client knowledge
about the
procedure that the
nurse is about to
perform

3. Ask the client to put on a This is to ensure

gown. that the
assessment will be
smooth and
comfortable for the
client

Mental Status

1. Assess level of
consciousness.
Ask the client his or her
name, address, and phone
number. Ask the client to
identify
where you currently are (e.g.,
hospital, clinic), the day, and
the approximate time of day.
If the client does ▪ Awake, alert, and ▪Disorientation may be
not respond oriented to time, physical in origin
appropriately, call place, and person ▪Disorientation can also be
the client’s name (AAO x 3) psychiatric in origin
and note the ▪ Responds to (schizophrenia)
response. If the external stimuli ▪Lathargic or somnolent
client does not ▪Obtunded
respond, call the GCS score of 14 ▪Stupor
name louder. If indicates an optimal level ▪Coma
necessary, shake of consciousness.
the client gently. If Client with lesions of the
the client still does corticospinal tract draws
not respond, apply hands up to chest
a painful stimulus. (decorticate or abnormal
flexor posture) when
VERBAL-TACTILE- stimulated.
PAINFUL

2. Observe appearance and
behavior.
3. Observe mood, feelings,
and expressions.
Use Quick Inventory of
Depressive Symptomatology
(Self-Report) ) to
determine if the client is at
risk for depression and needs
to be referred to a primary
care health provider for
further evaluation.
Inventory scores of 0–5 = No
The client appears to be
relaxed, with shoulders
and back erect when
standing or sitting. Gait is
rhythmic and coordinated,
with arms swinging at
sides.
▪good grooming,
▪dress in appropriate
to temperature &
weather,
▪no offensive or
unpleasant odor
▪ hair well kept or
tied
▪Verbal expressions
match with the
nonverbal behavior
▪Standing in upright
stance with parallel
alignment of hips &
shoulders
Client is cooperative and
purposeful in his or
her interactions with
others.
Ask client “How are ▪Mood is appropriate
you feeling today?” to the situation
and “What are your Cooperative or friendly,
plans for the expresses feelings
future?” appropriate to situation,
verbalizes positive
feelings regarding others
and the future, expresses
positive coping
mechanisms (support
groups, exercise, sports,
hobbies, counseling).
Client with lesions of the
diencephalon, midbrain, or
pons extends arms and legs,
arches neck, and rotates
hands and arms internally
(decerebrate or abnormal
extensor posture) when
stimulated
Glasgow Coma Scale score
of less than 14 indicates
some impairment in the level
of consciousness. A score of
3, the lowest possible score,
indicates deep coma.
▪Poor hygiene
▪Unpleasant or
offensive body odor
▪Slumped posture:
- Depression if psychological
in origin; or stroke with
hemiparesis if physiological
in origin.
Uncooperative, bizarre
behavior may be seen in
the angry, mentally ill, or
violent client.
Prolonged, euphoric
laughing is typical of mania
Unusually meticulous
grooming and finicky
mannerisms may be seen in
obsessive-compulsive
disorder.
▪Lack of facial expression
- Possible psychological
disorder (e.g., depression or
schizophrenia) or neurologic
impairment affecting cranial
nerves.
▪Masklike expressionless:
- Parkinson’s disease.
Depression - expression of
prolonged negative, gloomy,
despairing feelings.
 risk of depression
Inventory scores of
6–10 = Mild
11–15 = Moderate
16–20 = Severe
21–27 = Very Severe
4. Observe thought
processes and perceptions.
Observe thought processes
for clarity, content, and
perception by inquiring about
client’s thoughts and
perceptions expressed. Use
statements such as “Tell me
more about what you just
said” or “Tell me what your
understanding is of the
current situation or your
health.”
5. Observe cognitive abilities
Assess orientation. Ask for
the client’s name and names of
family members (person), the
time such as hour, day, date, or
season (time), and where the
client lives or is now (place).
Assess concentration. Give
the client directions such as
“Please pick up the pencil with
your left hand, place it in your
right hand, then hand it to me.”
Assess recent memory. Ask
the client “What did you have to
eat today?” or “What is the
weather like today?”
Assess remote memory. Ask
the client: “When did you get
your first job?” or “When
is your birthday?”
Assess use of memory to
Client expresses full, free-
flowing thoughts; follows
directions accurately;
expresses realistic
perceptions; is easy to
understand and makes
sense; does not voice
suicidal thoughts.
▪Inability to
calculate at level
appropriate to age, Client is aware of self,
education, and others, time, home
language ability address, and current
requires evaluation location.
for neurologic
impairment.
Client listens and can
follow directions without
difficulty.
Recalls recent events
without difficulty
Client correctly recalls
past events.
Client is able to recall
Manic Phases - Expression
of elation and grandiosity,
high energy level, and
engagement in high-risk but
pleasurable activities
Anxiety or Obsessive-
compulsive disorders -
Excessive worry
Schizophrenia - Eccentric
moods not appropriate
to the situation
Abnormal processes include
persistent repetition of ideas,
illogical thoughts,interruption
of ideas, invention of words,
or repetition of phrases, as
in schizophrenia; rapid
flight of ideas, repetition of
ideas, and use of rhymes
and punning, as in manic
phases of bipolar disorder;
continuous, irrational fears,
and avoidance of an object
or situation, as in phobias;
delusion, extreme
apprehension; compulsions,
obsessions, and illusions are
also abnormal.Confabulation
(making up of answers to
cover for not knowing) is
seen in Korsakoff’s
syndrome.
Clients who have depression
early in life have a twofold
increased risk for dementia
Reduced degree of
orientation may be seen
with organic brain disorders
or psychiatric illness such as
withdrawal from chronic
alcohol use or schizophrenia
Distraction and inability to
focus are in anxiety, fatigue,
ADDs, and impaired states
due to alcohol or drug
intoxication.
Inability - delirium, dementia,
depression, and anxiety
Inability - cerebral cortex
disorders
Inability to recall words after
learn new information. Ask
the client to repeat four
unrelated words. Have the
client repeat these words in 5
minutes, again in 10 minutes,
and again in 30 minutes.
Assess abstract reasoning.
Ask the client to compare
objects. For example, “How are
an apple and orange the same?
Assess visual, perceptual
and constructional ability.
Ask the client to draw the face
of a clock or copy simple
figures
Use the SLUMS
Dementia/Alzheimer’s
Test Exam if time is limited and
a quick measure is
needed to evaluate cognitive
function.
If further assessment is needed
to distinguish delirium from
other types of cognitive
impairment, use The
Confusion Assessment
Method
Cranial Nerves -
For all assessments of the cranial nerves, have client sit in a comfortable position at your eye level.
1. Test cranial nerve I—
olfactory.
Ask the client to clear the
nose to remove any
mucus, then to close eyes,
occlude one nostril, and
identify a scented object that
you are holding such as
soap, coffee, or vanilla .
Repeat procedure for the
other nostril.
2. Test cranial nerve II—
optic.
Use a Snellen chart to
assess vision in each eye
Ask the client to read a
newspaper or magazine
paragraph to assess near
vision.
Assess visual fields of each
eye by confrontation.
words correctly after a a delayed period is seen in
5-, a 10-, and a 30-minute anxiety, depression, or
period. Alzheimer’s disease.
Client explains similarities
and differences between
objects and proverbs
correctly. The client with
limited education can joke
and use puns correctly
Can copy simple figures.
A score between 27–30
for clients with a high
school education and a
score of 20–30 for clients
with less than a high
school education is
considered normal.
To test for smell Client correctly identifies
reception and scent presented to each
interpretation Nostril.
Some older clients’ sense
of smell may be decreased
To test for visual
acuity and fields
Client has 20/20 vision
OD and OS.
Client reads print at 14
inches without difficulty.
Full visual fields
Inability to compare and
contrast objects
correctly - schizophrenia,
mental retardation,
delirium, and dementia.
Inability to copy simple
figures correctly is seen with
mental retardation,
dementia, or parietal lobe
dysfunction of the cerebral
cortex.
With high school education -
20–27 score indicates mild
cognitive impairment (MCI)
1-19 indicates dementia
less than high school
education- 14–19 indicates
MCI, 1-14 indicates
dementia.
A diagnosis of delirium by CAM
requires the presence of features 1
and 2 and either 3 or 4 under the
CAM Diagnostic Algorithm
Inability to smell
(neurogenic anosmia) or
identify the correct scent
may indicate olfactory
tract lesion or tumor or
lesion of the frontal lobe.
Loss of smell may also be
congenital or due to other
causes such as nasal
disease, smoking, and use
of cocaine
Abnormal - difficulty reading
Snellen chart, missing
letters, and squinting
Holding closer than
14 inches or holds farther
away as in presbyopia, w/c
occurs with aging.
Loss of visual fields may be
seen in retinal damage or
detachment, with lesions of

Use an ophthalmoscope to
view the retina and optic disc
of each eye.
3. Test cranial nerve III—
oculomotor.
Assess CN III (oculomotor),
IV (trochlear), and VI
(abducens)
Inspect margins of the
eyelids of each eye.
Assess EOM. If nystagmus is
noted, determine the
direction of the fast and slow
phases of movement
Assess pupillary response to
light (direct and indirect) and
accommodation in both eyes
4. Test cranial nerve IV—
trochlear.
the optic nerve, or with
Round red reflex is lesions of parietal cortex.
present, optic disc is 1.5
mm, round or slightly Papilledema (swelling of the
oval, well-defined optic nerve) results in
margins, creamy pink with blurred optic disc margins
paler physiologic cup. and dilated, pulsating veins.
Retina is pink Papilledema occurs with
increased intracranial
pressure from intracranial
hemorrhage or a brain
tumor. Optic atrophy occurs
with brain tumors
To test for Eyelid covers about 2 mm Ptosis (drooping of the
extraocular eye of the iris. eyelid) is seen with weak
movements, eye muscles such as in
pupillary reaction to Eyes move in a smooth, myasthenia Gravis
light, and coordinated motion
accomodation in all directions (the six Some abnormal eye
reflex cardinal fields). movements and possible
causes follow:
Bilateral illuminated pupils - Nystagmus (rhythmic
constrict simultaneously. oscillation of the eyes):
Pupil opposite the one cerebellar disorders
illuminated constricts - Limited eye movement
simultaneously through the six cardinal
fields of gaze: increased
Both eyes coordinated, intracranial pressure
move in union, with - Paralytic strabismus:
parallel alignment paralysis of the
occulomotor , trochlear,
Pupillary reaction to light and abducens nerves.
is normal. Illuminated
pupil constricts when Abnormal eye movements
looking at near object and consist of the horizontal
pupils dilate when looking and, occasionally, the
at far objects vertical jerking
movements that are
Accomodation is normal, seizure manifestations,
The pupils constrict when ocular bobbing, paroxysmal
looking at near objects downgaze or upgaze,
and pupils dilate when opsoclonus, ocular flutter,
looking at far objects. and nystagmus.
Also the pupils converge Anisocoria. ... If there is a
when near object is good reaction to light in both
moved toward the nose eyes but a poor, slow or
absent dilation in the dark (ie
the anisocoria is enhanced),
the affected pupil is
abnormally small
To test for
extraocular eye
movements,
pupillary reaction to
light, and
accomodation
reflex
 5. Test cranial nerve V—
trigeminal.
Test motor function. Ask the
client to clench the teeth
while you palpate the
temporal and masseter
muscles for contraction
Test sensory function. Tell
the client: “I am going to
touch your forehead, cheeks,
and chin with the sharp or
dull side of this paper clip.
Please close your eyes and
tell me if you feel a sharp or
dull sensation. Also tell me
where you feel it”. Vary the
sharp and dull stimulus in the
facial areas and compare
sides. Repeat test for light
touch with a wisp of cotton
Test corneal reflex. Ask the
client to look away and up
while you lightly touch the
cornea with a fine wisp of
cotton. Repeat on the other
side.
6. Test cranial nerve VI—
abducens.
7. Test cranial nerve VII—
facial.
Test motor function. Ask the
client to:
- Smile
- Frown and wrinkle forehead
- Show teeth
- Puff out cheeks
- Purse lips
- Raise eyebrows
- Close eyes tightly against
resistance
Sensory - touch the anterior
two-thirds of the tongue with a
moistened applicator dipped in
salt, sugar, or lemon juice. Ask
the client to identify the flavor.
8. Test cranial nerve VIII—
acoustic
(vestibulocochlear).
To test for
sensation of face,
scalp, cornea, and
oral and nasal
mucous
membrane.
Chewing
movements of the
jaw
To test for
extraocular eye
movements,
pupillary reaction to
light, and
accomodation
reflex
To test on taste on
the anterior ⅔ of
tongue, facial
movements, labial
speech.
Make sure that the client
leaves the tongue
protruded to identify the
flavor. Otherwise, the
substance may move to
the posterior third of the
tongue (vagus nerve
innervation). The
posterior portion is tested
similarly to evaluate
functioning of cranial
nerves IX and X. The
client should rinse the
mouth with water
between each taste test.
To test for hearing
and balance
Temporal and masseter - Bilateral muscle weakness
muscles contract is seen with
Bilaterally peripheral or central
nervous system
The client correctly dysfunction. Unilateral
identifies sharp and dull weakness may indicate
stimuli and light touch to a lesion or injury of cranial
the forehead, cheeks, nerve V (trigeminal). Pain
and chin. occurs with clenching of the
teeth.
Eyelids blink bilaterally.
- Inability to feel and
correctly identify facial
The client is able to stimuli occurs with lesions of
clench the teeth, able to the trigeminal nerve or
discriminate and locate lesions in the spinothalamic
sharp and blunt stimuli, tract or posterior columns.
client blinks whenever the
sclera is lightly touched. -An absent corneal reflex
may be noted with lesions of
the trigeminal nerve or
lesions of the motor part of
cranial nerve VII (facial).
Client smiles, frowns, Inability to close eyes,
wrinkles forehead, shows wrinkle forehead, or raise
teeth, puffs out cheeks, forehead along with
purses lips, raises paralysis of the lower part of
eyebrows, and closes the face on the affected side
eyes against resistance. is seen with Bell’s palsy (a
Movements are peripheral injury to cranial
symmetrical. nerve VII [facial]). Paralysis
of the lower part of the face
Client identifies correct on the opposite side affected
flavor. may be seen with a central
lesion that affects the upper
motor neurons such as from
stroke.
Inability - impairment of
cranial nerve VII (facial)
Client hears whispered Vibratory sound lateralizes
words from 1 to 2 feet. to good ear in
Weber test: Vibration sensorineural loss. Air
heard equally well in both conduction is
 Perform Whisper, Weber, and
Rinne Tests
9. Test cranial nerve IX—
glossopharyngeal.
Test motor function. Ask the
client to open mouth wide
and say “ah” while you use a
tongue depressor on the
client’s tongue.
. hoarseness of speech is
10. Test cranial nerve X—
vagus.
Test the gag reflex by
touching the posterior
pharynx with the tongue
depressor
Check the client’s ability to
swallow by giving the client a
drink of water. Also note the
client’s voice quality.
11. Test cranial nerve XI—
spinal accessory.
Ask the client to shrug the
shoulders against resistance to
assess the trapezius muscle
Ask the client to turn the head
against resistance, first to the right
then to the left, to assess the
sternocleidomastoid muscle
12. Test cranial nerve XII—
hypoglossal
To assess strength and
mobility of the tongue, ask
the client to protrude tongue,
move it to each side against
the resistance of a tongue
depressor, and then put it
back in the mouth.
ears. longer than bone conduction
Rinne test: AC>BC (air but not twice as long, in a
conduction is twice as sensorineural loss.
long as bone(conduction).
The client swallows
without any delay and
difficulty and as the client
says “aaaa” the uvula
elevates and the palate is
symmetrical. Uvula and
soft palate rise bilaterally
and symmetrically on
phonation.The
absent in the client and
the client has a positive
gag reflex.
Gag reflex intact. Some
normal clients may have
a reduced or absent gag
reflex.
Client swallows without
difficulty. No hoarseness
noted.
To test for the There is symmetric,
strength and strong contraction of the
movement of the trapezius muscles.
trapezius and
sternocleidomastoi
d muscle
There is strong
contraction of
sternocleidomastoid on
the side opposite the
turned face.
Test for tongue Tongue movement is
movement for symmetric and smooth
speech, sound and bilateral strength is
articulation and apparent.
swallowing
Soft palate does not rise
with bilateral lesions of
cranial nerve X (vagus).
Unilateral rising of the soft
palate and deviation of the
uvula to the normal side are
seen with a unilateral lesion
of cranial nerve X (vagus).
An absent gag reflex may be
seen with lesions of cranial
nerve IX (glossopharyngeal)
or X (vagus)
Dysphagia or hoarseness
may indicate a lesion of
cranial nerve IX
(glossopharyngeal) or X
(vagus) or other neurologic
disorder.
Asymmetric muscle
contraction or drooping of
the shoulder may be seen
with paralysis or muscle
weakness due to neck injury
or torticollis.
Atrophy with fasciculations
may be seen with peripheral
nerve disease.
Fasciculations and atrophy
of the tongue may be seen
with peripheral nerve
disease. Deviation to the
affected side is seen with a
unilateral lesion.
 Motor and Cerebellar Systems
1. Test condition and
movement of muscles.
Assess the size and
symmetry of all muscle
groups. Assess the strength
and tone of all muscle
groups.
Note any unusual involuntary
movements such as
fasciculations, tics, or
tremors.
2. Test balance.
Ask the client to walk naturally
across the room. Note posture,
freedom of movement,
symmetry, rhythm, and
balance
Ask the client to walk in heel-
to-toe fashion (tandem
walking), next on the heels,
then on the toes. Demonstrate
the walk first; then stand close
by in case the client loses
balance.
Perform the Romberg test.
Ask the client to stand erect
with arms at side and feet
together. Note any
unsteadiness or swaying. Then
with the client in the same
body position, ask the client to
close the eyes for 20 seconds.
Again note any imbalance or
swaying
ask the client to stand on one
foot and to bend the knee of
the leg the client is standing
Some older clients Muscles are fully
may normally have developed and symmetric
hand or head in size (bilateral sides
tremors or may vary 1 cm from each
dyskinesia other).
(repetitive
movements of the -Older: reduced muscle
lips, jaw, or tongue) mass from degeneration
of muscle fibers.
Relaxed muscles contract
voluntarily and show mild,
smooth resistance to
passive movement. All
muscle groups equally
strong against resistance,
without flaccidity,
spasticity, or rigidity
No fasciculations, tics, or
tremors are noted.
Some older clients Gait is steady; opposite
may have a slow arm swings
and uncertain gait.
The base may
become wider and
shorter and the hips
and knees may be Client maintains balance
flexed for a bent- with tandem walking.
forward appearance Walks on heels and toes
with little difficulty.
For some older clients,
this examination may be
very difficult.
Client stands erect with
minimal swaying with
eyes both open and
closed
Bends knee while
standing on one foot;
hops on each foot without
Muscle atrophy - lower
motor neurons or muscle
disorders
Injury of the central spinal
cord - extremity weakness.
Loss of motor function, pain
and temperature - anterior
cord syndrome.
Loss of proprioception seen
in posterior cord
syndrome. A loss of
strength, proprioception,
pain and temperature is
seen in BrownSéquard
syndrome
Tremors - Parkinson’s dis.
Cerebral Palsy - Slow,
twisting movements in the
extremities and face.
Slower twisting movements
associated with spasticity
(athetosis)
Huntington’s chorea -
Brief, rapid, irregular, jerky
movements (at rest)
Gait and balance can be
affected by disorders of the
motor, sensory, vestibular,
and cerebellar systems.
Therefore, athorough
examination of all systems is
necessary when an uneven
or unsteady gait is noted
An uncoordinated or
unsteady gait that
did not appear with the
client’s normal walking
may become apparent
with tandem walking or
when walking on heels
and toes.
Positive Romberg test:
Swaying and
moving feet apart to
prevent fall is seen
with disease of the
posterior columns,
vestibular dysfunction, or
cerebellar disorders.
Inability to stand or hop on
one foot is seen with muscle
weakness or disease of the
on. Then ask the client to hop losing balance. cerebellum.
on that foot. Repeat on the
other foot.

3. Test coordination.

Demonstrate the finger-to-nose Client touches finger to Loss of positional sense

test to assess accuracy of
movements, then ask the client
to extend and hold arms out to
the side with eyes open. Next,
say, “Touch the tip of your
nose first with your right index
finger, then with your left index
finger. Repeat this three
times”. Next, ask the client to
repeat these movements with
eyes closed.
nose with smooth, and inability to touch tip of
accurate movements with nose are seen with
little hesitation. cerebellar disease.
Normally the client’s
dominant side may be
more coordinated than
the nondominant side

Have the client sit down. First,
ask the client to touch each
finger to the thumb and to
increase the speed as the
client progresses. Repeat with
the other side.
Client touches each finger Inability to perform rapid
to thumb rapidly Alternating movements may
be seen with cerebellar
disease, upper motor neuron
weakness, or extrapyramidal
disease.

Next, ask the client to put the
palms of both hands down on
both legs, then turn the palms
up, then turn the palms down
again. Ask the client to
increase the speed.
Client rapidly turns palms
up and down.
Uncoordinated movements
or tremorsare abnormal
findings. They are seen
with cerebellar disease
(dysdiadochokinesia).

Next, ask the client to put the Client is able to run each Deviation of heel to one
palms of both hands down on heel smoothly side or the other may be
both legs, then turn the palms down each shin. seen in cerebellar disease.
up, then turn the palms down
again. Ask the client to
increase the speed.

Sensory System

1. Test light touch, pain, and LIGHT TOUCH LIGHT TOUCH

temperature sensation.
Close eyes, tell what they feel
Scatter stimuli over distal and
proximal parts of all extremities
and trunk to cover most
dermatomes.
Client correctly identifies
light touch.
(In some older clients,
light touch and pain
sensations may be
decreased.)
Peripheral Neuropathies
(due to diabetes mellitus,
folic acid deficiencies, and
alcoholism) and lesions of
the ascending spinal cord,
the brain stem, cranial
nerves, and cerebral cortex.

Light touch sensation - use PAIN

wisp of cotton
Pain sensation - blunt and
sharp ends of safety pin or
paper clip.
Temperature sensation - test
Client correctly
differentiates between
dull and sharp sensations
and hot and cold
temperatures over
various body parts.
PAIN
Client reports
• Anesthesia (absence of
touch sensation)
• Hypesthesia (decreased
sensitivity to touch)
• Hyperesthesia (increased
tubes filled with hot and cold
water (only if abnormalities are
found in the client’s ability to
perceive light touch and pain
sensations. Temperature and
pain sensations travel in the
lateral spinothalamic tract, thus
temperature need not be tested
if pain sensation is intact)
2. Test vibratory sensations.
Strike a low pitched tuning fork
on heel of your hand and hold
the base on distal radius,
forefinger tip, medial malleolus,
and, the tip of the great toe.
Ask the client to indicate what
he or she feels. Repeat on the
other side.
If vibratory sensation is intact
distally, then it is intact proximally
3. Test position sensations.
Close eyes. Hold the client’s
toe or a finger on the lateral
sides and move it up or down.
Ask the client to tell you the
direction it is moved. Repeat
on the other side.
If position sense is intact distally,
then it is intact proximally.
4. Test tactile discrimination
(fine touch).
To test stereognosis, place a
familiar object such as a
quarter, paper clip, or key in
the client’s hand and ask the
client to identify it. Repeat with
another object in the other
hand.
To test point localization,
briefly touch the client and ask
the client to identify the points
touched.
To test graphesthesia, use a
blunt instrument to write a
number, such as 2, 3, or 5, on
the palm of the client’s hand.
Ask the client to identify the
number. Repeat with another
number on the other hand.
Two-point discrimination can
be determined on the
fingertips, forearm, dorsal
Client correctly identifies
sensation.
Vibratory sensation at the
ankles usually decreases
after age 70 but vibration
sense is more likely to be
absent at the great toe
and preserved at the
ankle bones
Client correctly identifies
directions of movements.
In some older clients, the
sense of position of great
Toe may be reduced.
Client correctly identifies
Object.
Client correctly identifies
area touched.
Correctly identifies
number written.
Identifies two points on:
- Fingertips: 2-5 mm apart
- Forearm: 40 mm apart
- Dorsal hands: 20-30 mm
- Back: 40 mmapart
- Thighs: 70 mm apart
sensitivity to touch)
• Analgesia (absence of pain
sensation)
• Hypalgesia (decreased
sensitivity to pain)
• Hyperalgesia (increased
sensitivity to pain)
Inability to sense
vibrations may be seen
in posterior column
disease or peripheral
neuropathy (e.g., as seen
with diabetes or chronic
alcohol abuse).
Inability to identify the
directions of the
movements may be seen
in posterior
column disease or
peripheral neuropathy
(e.g., as seen with
diabetes or chronic
alcohol abuse).
Inability to correctly
identify objects
(astereognosis), area
touched, number written in
hand, discriminate between
two points, or identify areas
simultaneously touched may
be seen in lesions of the
sensory cortex.
hands, back, or thighs. Ask the
client to identify the number of
points (one or two) felt when
touched with the EKG calibers.
Measure the distance
between the two points when
the client can no longer
distinguish the two points as
separate (client states only one
point is felt).

To test extinction,
simultaneously touch the client
in the same area on both sides
of the body at the same point.
Ask the client to identify the Correctly identifies points
area touched. touched.

Reflexes

1. Test deep tendon reflexes If deep tendon Normal reflex scores Absent or markedly
(biceps, brachioradialis, reflexes are range from 1+ (present decreased (hyporeflexia)
triceps, patellar, Achilles, diminished or but decreased) to 2+ deep tendon reflexes (rated
and ankle clonus). absent, two (normal) to 3+ (increased 0) occur when a component
reinforcement or brisk, but not of the lower motor neurons
Sitting pos. Use reflex hammer techniques may be pathologic). or reflex arc is impaired; may
used to enhance be seen with spinal cord
their response. injuries. Markedly
Test biceps reflex. Ask the When testing the hyperactive (hyperreflexia)
client to partially bend arm at arm reflexes, have deep tendon reflexes (rated
elbow with palm up. Place your the client clench the 4) may be seen with lesions
thumb over the biceps tendon teeth. When testing of the upper motor neurons
and strike your thumb with the the leg reflexes, and when the higher cortical
pointed side of the reflex have the client BICEPS levels are impaired.
hammer. Repeat on the other interlock the hands. Elbow flexes and
side. (Evaluates C5 and C6.) contraction of the biceps BICEPS
Older clients muscle is seen or felt. No response or an
Assess brachioradialis reflex. usually have deep Ranges from 1 to 3. exaggerated response
Ask the client to flex elbow with tendon reflexes is abnormal.
palm down and hand resting intact, although a
on the abdomen/lap. Use the decrease in
flat side of the reflex hammer reaction time may
to tap the tendon at the radius slow the response
about 2 inches above the wrist.
Repeat on other side. BRACHIORADIALIS
BRACHIORADIALIS
(Evaluates fx of C5 and C6.) No response or
Forearm flexes and
exaggerated response.
supinates. Ranges
Test triceps reflex. Ask the
from 1 to 3.
client to hang the arm freely
(“limp, like it is hanging from
a clothesline to dry”) while you
support it with your
nondominant hand. With the
elbow flexed, use the flat side
of the reflex hammer to tap the
tendon above the olecranon
process. Repeat on the other TRICEPS TRICEPS
side. Evaluates C6, C7, & C8. Elbow extends, triceps No response or
contracts. Ranges exaggerated response.
from 1+ to 3+.
Assess patellar reflex. Ask the
client to let both legs hang
freely off the side of the
examination table. Using the
flat side of the reflex hammer,
tap the patellar tendon, which
is located just below the
patella. Repeat on the other
side. For the client who
cannot sit up, gently flex the
knee and strike the patella.
Evaluates fx of L2, L3, and L4.
Test Achilles reflex. With the
client’s leg still hanging freely,
dorsiflex the foot. Tap the
Achilles tendon with the flat
side of the reflex hammer .
Repeat on the other side.
For assessing the reflex in
the client who cannot sit up,
have the client flex one knee
and support that leg against
the other leg. Dorsiflex the foot
and tap the tendon using the
flat side of the reflex hammer.
Evaluates fx of S1 and S2.
Test ankle clonus when the
other reflexes tested have
been hyperactive. Place one
hand under the knee to support
the leg, then briskly dorsiflex
the foot toward the client’s
head. Repeat on the
other side
2. Test superficial reflexes
(plantar, abdominal,
cremasteric).
Assess plantar reflex. With
the end of the reflex
hammer, stroke the lateral
aspect of the sole from the
heel to the ball of the foot,
cur. Repeat on the other
side. Evaluates fx of L4, L5,
S1, and S2.
Test abdominal reflex.
Lightly stroke the abdomen on
PATELLAR
Knee extends, quadriceps
muscle contracts. Ranges
from 1+ to 3+.
ACHILLES
Normal response is
plantar flexion of the
foot. Ranges from 1 to 3.
In some older clients, the
Achilles reflex may be
absent or difficult to elicit.
ANKLE CLONUS
No rapid contractions or
oscillations (clonus) of the
ankle are elicited.
Use the handle end
of the reflex
hammer to elicit
superficial reflexes,
whose receptors
are in the skin
rather than the
muscles. PLANTAR
Flexion of the toes occurs
(plantar response;
In some older adult
clients, flexion of
the toes may be difficult
to elicit and
may be absent.
ABDOMINAL
Abdominal muscles
PATELLAR
No response or an
exaggerated response
is abnormal.
ACHILLES
No response or an
exaggerated response
is abnormal.
ANKLE CLONUS
Repeated rapid contractions
or oscillations of the ankle
and calf muscle are seen
with lesions of the upper
motor neurons
PLANTAR
Except in infancy, extension
(dorsiflexion) of the big toe
and fanning of all toes
(positive Babinski response)
are seen with lesions of
upper motor neurons.
Unconscious states resulting
from drug and alcohol
ntoxication, brain injury, or
subsequent to an epileptic
seizure may also cause it.
ABDOMINAL
Superficial reflexes may be
each side, above and below
the umbilicus. Evaluates the
function of spinal levels T8,
T9, and T10 with the upper
abdominal reflex and spinal
levels T10, T11, and T12 with
the lower abdominal reflex.
Test cremasteric reflex in
male clients. Lightly stroke the
inner aspect of the upper
thigh. Evaluates T12, L1, and
L2.
3. Test for meningeal
irritation/inflammation
(Brudzinski and Kernig signs
if indicated)
If you suspect that the client
has meningeal irritation or
inflammation from infection or
subarachnoid hemorrhage,
assess the client’s neck
mobility. First, make sure that
there is no injury to the cervical
vertebrae or cervical cord.
Then, with the client supine,
place your hands behind the
patient’s head and flex the
neck forward until the chin
touches the chest if possible.
Test for Brudzinski’s sign. As
you flex the neck, watch the
hips and knees in reaction to
your maneuver.
Test for Kernig’s sign. Flex
the client’s leg at both the hip
and the knee, then straighten
the knee.
contract; umbilicus
deviates toward the side
being stimulated.
CREMASTERIC
Scrotum elevates on
stimulated side
Neck is supple; client can
easily bend head
and neck forward.
BRUDZINSKI
Hips and knees remain
relaxed and motionless
KERNIG
No pain is felt. Discomfort
behind the knee during
full extension occurs in
many normal people.
absent with lower or upper
motor neuron lesions.
Caution: The abdominal
reflex may be concealed
because of obesity or
muscular stretching from
pregnancies. This is not an
abnormality
CREMASTERIC
Absence of reflex may
indicate motor
neuron disorder.
Pain in the neck and
resistance to flexion can
arise from meningeal
inflammation, arthritis, or
neck injury.
BRUDZINSKI
Hips knees contract
KERNIG
Pain and increased
resistance to extending the
knee are a positive Kernig’s
sign. When Kernig’s sign is
bilateral, the examiner
suspects meningeal
irritation.
 ASSESSING FEMALE GENITALIA AND RECTUM
PROCEDURE RATIONALE NORMAL ABNORMAL
FINDINGS FINDINGS

1. Gather equipment (stool, light, speculum, emesis basin filled To avoid delay and to make assessment
with warm tap water, Surgilube, cotton-tipped applicators, possible.
Chlamydia culture tube, culturette, test tube with water, sterile
gloves, Ayre spatula [wood stick], and feminine napkins).

2. Explain the procedure to the client. -To build rapport and gain trust of the patient and give client knowledge
about the procedure that the nurse is about to perform

3. Ask the client to put on a gown. This is to ensure that the assessment will be smooth and comfortable
for the client

External Genitalia

1. Inspect the mons pubis. Note Pubic hair is Absence of pubic hair
pubic hair distribution, signs of distributed in in the adult client is
infestation. an inverted abnormal. Lice or nits
triangular (eggs) at the base of
pattern and the pubic hairs indicate
there are no infestation with
signs of pediculosis pubis. This
infestation. condition, commonly
referred to as “crabs,”
is most often
transmitted by sexual
contact

2. Inspect the labia majora and The labia Lesions may be from
perineum. Note lesions, swelling, majora are an infectious disease,
excoriation. equal in size such as herpes or
and free of syphilis
lesions,
swelling, and
excoriation.

3. Inspect the labia minora, clitoris, The labia Asymmetric labia may
urethral meatus, minora appear indicate abscess.
and vaginal opening. Note lesions, symmetric, Lesions, swelling,
excoriation, swelling, discharge. dark pink, and bulging in the vaginal
moist. The opening, and discharge
clitoris is a are abnormal findings
small mound of
erectile tissue,
sensitive to
touch. The
normal size of
the clitoris
varies. The
urethral meatus
is small and
slit-like. The
vaginal
opening is
positioned
below the
urethral
 meatus.

4. Palpate the Bartholin glands (if Bartholin’s Swelling, pain, and

history of swelling or current glands are discharge may result
swelling noted). Note swelling, usually soft, from infection and
tenderness, discharge. nontender, and abscess
drainage free

5. Palpate the urethra (if client No drainage Drainage from the

complains of urethral symptoms should be urethra indicates
or urethritis, or inflammation of noted from the possible urethritis.
Skene glands is suspected) by urethral
inserting gloved index finger into meatus. The
the superior portion of the vagina area is
and milking the urethra from the normally soft
inside, pushing up and out. and nontender.
Observe for drainage.

Internal Genitalia

1. Inspect the size of the vaginal
opening and the angle of the
vagina by moistening gloved index
finger with warm water and gently
inserting the finger into the
vagina.
The normal vaginal A condition in which the
opening varies in size vagina becomes
according to the thinner and dryer is
client’s age, sexual vaginal atrophy. This
history, and whether occurs when the body
she has given birth lacks estrogen.
vaginally. The vagina
is tilted posteriorly at a
45-degree angle and
should feel moist.

2. Assess the vaginal musculature by The client should be Absent or decreased

keeping index finger inserted in
the vaginal opening and asking
the client to squeeze around your
finger. Using middle and index
fingers to separate the labia
minora, ask client to bear down.
Observe for bulging or discharge
of urine.
able to squeeze ability to squeeze the
around the examiner’s examiner’s finger
finger. Typically, the indicates decreased
nulliparous woman muscle tone.
can squeeze tighter Bulging of the anterior
than the multiparous wall may indicate a
woman cystocele. Bulging of
No bulging and no the posterior wall may
urinary discharge. indicate a rectocele

3. Position the patient and perform

the speculum examination.

a. Inspect the cervix for color, size,
position, surface, os, discharge,
or lesions.
The surface of the In a nonpregnant
cervix is normally woman, a bluish cervix
smooth, pink, and may indicate cyanosis;
even. Normally, it is in a nonmenopausal
midline in position and woman, a pale cervix
projects 1–3 cm into may indicate anemia.
the vagina Redness may be from
inflammation.

b. Obtain specimens for the Pap Cervical secretions are Colored, malodorous,
smear and, if indicated, cultures normally clear or white or irritating discharge is
to test for STDs. and without abnormal
unpleasant odor

c. Inspect the vagina, unlocking the The vagina should Reddened areas,
 speculum and inspecting the
vagina as the partially open
speculum is slowly rotated and
removed. Note color, surface,
consistency, and discharge.
appear pink, moist, lesions, and colored,
smooth, and free of malodorous discharge
lesions and irritation. It are abnormal and may
should also be free of indicate vaginal
any colored or infections, STIs, or
malodorous discharge. cancer

4. Perform the bimanual examination Ovaries are almond Large amounts of

by placing nondominant hand on shaped and firm, colorful, frothy, or
lower abdomen and inserting smooth, mobile, and malodorous secretions
gloved lubricated index and middle somewhat tender on are abnormal. Ovaries
fingers into the vaginal opening, palpation. that are palpable 3–5
applying pressure to the posterior A clear, minimal years after menopause
wall, and waiting for the opening amount of drainage are also abnormal.
to relax. Palpate the ovaries by appearing on the glove
sliding your intravaginal fingers to from the vagina is
the right lateral fornix and normal.
attempting to palpate the left and
then the right ovaries. Note size,
shape, consistency, mobility, and
tenderness. Observe for
secretions as fingers are
withdrawn.

5. Perform the rectovaginal The rectovaginal Masses, thickened

examination by changing gloves septum is normally structures, immobility,
on dominant hand and lubricating smooth, thin, movable, and tenderness are
index and middle fingers. Ask and firm. The posterior abnormal.
client to bear down. Insert index uterine wall is normally
finger into the vagina and middle smooth, firm, round,
finger into the rectum. While movable, and
pushing down on the abdominal nontender.
wall with the other hand, palpate
the internal reproductive
structures through the anterior
rectal wall, with attention to the
area behind the cervix, the
rectovaginal septum, the cul-de-
sac, and the posterior uterine
wall.

Anus and Perianal Area

1. Inspect for lumps, ulcers, lesions, The anal opening Lesions may indicate
rashes, redness (note size, should appear STIs, cancer, or
shape, location, distribution, and hairless, moist, and hemorrhoids. A
configuration). tightly closed. The skin thrombosed external
around the anal hemorrhoid appears
opening is more swollen
coarse and more . Redness and
darkly pigmented. The excoriation may be
surrounding perianal from scratching an area
area should be free of infected by fungi or
redness, lumps, pinworms. A small
ulcers, lesions, and opening in the skin that
rashes surrounds the anal
opening may be an
anorectal fistula

2. Inspect the sacrococcygeal area Area is normally A reddened, swollen, or

 for swelling, redness, dimpling, or
presence of hair in pilonidal area.
3. Inspect for rectal prolapse with
Valsalva maneuver.
4. Palpate for anal sphincter tone,
tenderness, nodules, or hardness.
Rectum
1. Palpate rectal mucosa for
tenderness, irregularities,
nodules, and hardness.
2. Palpate peritoneal cavity for
tenderness or nodules, or “rectal
shelf.”
3. Inspect the feces for blood and
perform occult blood test.
smooth, and free of dimpled area covered
redness and hair by a small tuft of hair
located midline on the
lower sacrum suggests
a pilonidal cyst
No bulging or lesions Bulges of red mucous
appear. membrane may
indicate a rectal
prolapse. Hemorrhoids
or an anal fissure may
also be seen
The client can Examination finger
normally close the cannot enter the anus
sphincter around the Poor sphincter tone
gloved finger. may be the result of a
Examination finger spinal cord injury,
enters anus. previous surgery,
trauma, or a prolapsed
rectum. Tightened
sphincter tone may
indicate anxiety,
scarring, or
inflammation.
The rectal mucosa is Hardness and
normally soft, smooth, irregularities may be
nontender, and free of from scarring or cancer.
nodules. Nodules may indicate
polyps or cancer
This area is normally A peritoneal protrusion
smooth and into the rectum, called a
nontender. rectal shelf
Stool is normally semi- Black stool may indicate
solid, brown, and free upper gastrointestinal
of blood. bleeding, gray or tan
stool results from the
lack of bile pigment,
and yellow stool
suggests steatorrhea
(increased fat content).
Blood detected in the
stool may indicate
cancer of the rectum or
colon. Refer the client
for an endoscopic
examination of the
colon.
 ASSESSING MALE GENITALIA AND RECTUM
PROCEDURE
Preparation
1. Gather equipment (gloves,
stool, gown, penlight).
2. Explain the procedure to the To build rapport and gain trust of the patient and give client knowledge about the
client. procedure that the nurse is about to perform
3. Ask the client to put on gown.
Penis
1. Inspect the base of penis
and pubic hair for growth
pattern and excoriation,
erythema, or infestation
(client is standing while
you sit).
2. Inspect the skin of the
shaft for rashes, lesions,
or lumps.
3. Palpate the shaft for
hardened areas or areas
of tenderness.
4. Inspect the foreskin (if
present) for color,
location, and integrity in
uncircumcised men.
5. Inspect the glans for size,
shape, lesions or
redness, and location of
the urinary meatus on
the glans (if
uncircumcised, ask him to
retract his foreskin to
allow for observation).
RATIONALE NORMAL FINDINGS
- To avoid delay and to make assessment possible.
This is to ensure that the assessment will be smooth and comfortable for the client
Sit on a stool with the The pubic hair distribution
client facing you and is triangular and coarse
Standing. Ask the and extends up to the
client to raise his abdomen and there’s no
gown or drape. infestation, excoriation
and erythema.
Pubertal rites in some The skin of the penis is
cultures include wrinkled and hairless and
slitting the penile is normally free of rashes,
shaft, leaving an lesions, or lumps.
opening that may
extend the entire
length of the shaft
The penis in a non-erect
state is usually soft,
flaccid, and nontender.
The foreskin, which Discoloration of the foreskin
covers the glans in an may indicate scarring or
uncircumcised male client, infection.
is intact and uniform in
color with the penis.
If pubertal mutilation The glans size and
has occurred, actual shape vary, appearing
discharge of urine rounded, broad, or even
and semen will occur pointed. The surface of
at the location of the the glans is normally
shaft opening. smooth, free of lesions
and redness
Foreskin retracts
easily. A small amount of
whitish material, called
smegma, normally
accumulates under the
foreskin.
The urinary meatus is slit-
like and normally found in
the center of the glans.
ABNORMAL FINDINGS
Absence or scarcity of
pubic hair may be seen in
clients receiving
chemotherapy. Lice or nit
(eggs) infestation at the
base of the penis or pubic
hair is known as pediculosis
pubis. This is commonly
referred to as “crabs.”
There is a presence of
rashes, lesions, or lumps
that may indicate STI
(sexually transmitted
infections) or cancer
Tenderness may indicate
inflammation or infection.
Chancres (red, oval
ulcerations) from syphilis,
genital warts, and pimple-
like lesions from herpes are
sometimes detected on the
glans and under foreskin.
A tight foreskin that cannot
be retracted is called
phimosis. A foreskin that,
once retracted, cannot be
returned to cover the glans
is called paraphimosis
Hypospadias is
displacement of the urinary

6. Palpate for urethral
discharge by gently
squeezing the glans
between the index finger
and the thumb.
Scrotum
1. Inspect the size, shape,
and position (penis is
held out of the way).
Ask the client to hold his
penis out of the way
2. Observe for swelling,
lumps, or bulges.
3. Inspect the scrotal skin
for color, integrity, and the
presence of lesions or
rashes. (Spread out the
scrotal folds of skin to
perform an accurate
inspection. Lift the sac to
inspect the posterior
skin.)
4. Palpate the scrotal
contents (testes and
epididymis) between your
thumb and first two
fingers. Note size, shape,
consistency, and
presence of tenderness
or nodules. Palpate each
spermatic cord and vas
deferens from epididymis
to the inguinal ring, noting
nodules, swelling, or
tenderness.
The urinary meatus is
normally free of
discharge.
The scrotum varies in size
(according to
temperature) and shape.
The scrotal sac hangs
below or at the level of the
penis. The left side of the
scrotal sac usually hangs
lower than the right side
There’s no presence of
swelling, lumps or bulges
Scrotal skin is thin and
rugated (crinkled) with
little hair dispersion. Its
color is slightly darker
than that of the penis.
Lesions and rashes are
not normally present.
However, sebaceous
cysts (small, yellowish,
firm, nontender, benign
nodules) are a normal
finding.
Do not apply too Testes are ovoid,
much pressure to the approximately 3.5–5 cm
testes because this long, 2.5 cm wide, and 2.5
will cause pain. cm deep, and equal
bilaterally in size and
Testes do not get shape. They are smooth,
smaller with normal firm, rubbery, mobile, free
aging, although they of nodules, and rather
may decrease in size tender to pressure. The
with long-term illness. epididymis is nontender,
smooth, and softer than
the testes.
The spermatic cord and
vas deferens should feel
uniform on both sides.
The cord is smooth,
meatus to the ventral
surface of the penis.
Epispadias is
displacement of the urinary
meatus to the dorsal
surface of the penis
A yellow discharge is
usually associated with
gonorrhea. A clear or white
discharge is usually
associated with urethritis.
Any discharge should be
cultured.
An enlarged scrotal sac
may result from fluid
(hydrocele), blood
(hematocele), bowel
(hernia), or tumor (cancer)
Bulges may indicate
inflammation
Rashes, lesions, and
inflammation are abnormal
findings.
Absence of a testis
suggests cryptorchidism
(an undescended testicle).
Painless nodules may
indicate cancer. Tenderness
and swelling may indicate
acute orchitis, torsion of the
spermatic cord, a
strangulated hernia, or
epididymitis.
If the client has
epididymitis, passive
elevation of the testes may
relieve the scrotal pain
(Prehn’s sign)

4. Trans-illuminate the
scrotal contents (if a mass
or swelling was noted).
Look for a red glow.
shine a light from the back of
the scrotum through the mass.
If during inspection and
palpation of the scrotal
contents, you palpated a scrotal
mass, ask the client to lie down.
Note whether the mass
disappears. If it remains,
auscultate it for bowel sounds.
Finally, gently palpate the mass
and try to push it upward into
the abdomen.
Inguinal Area
1. Inspect for inguinal and
femoral hernia, watching
for bulges while the client
bears down.
2. Palpate for inguinal
hernia, observing for
bulges or masses. Have
the client shift weight to
the left to palpate the right
inguinal canal. Place
index finger into the right
scrotum and press
upward to the slit-like
opening of the external
inguinal ring. With finger
in canal or external
inguinal ring, ask him to
bear down or cough.
Repeat for left side.
3. Palpate for femoral hernia
on the front of the thigh
in the femoral canal area.
Ask him to bear down or
cough while feeling for
nontender, and rope-like
Palpable, tortuous veins
suggest varicocele. A
beaded or thickened cord
indicates infection or cysts.
A cyst suggests hydrocele
of the spermatic cord.
Normally scrotal contents Swellings or masses that
do not transilluminate. contain serous fluid—
hydrocele, spermatocele—
light up with a red glow.
Swellings or masses that are
solid or filled with blood—
tumor, hernias, or
varicocele—do not light up
with a red glow.
If the client complains If the bulge disappears, no
of extreme scrotal hernia is present, but
tenderness or the mass may result from
nausea, do not try to something else. Refer the
push the mass up into client for further evaluation.
If you cannot push the mass into
the abdomen. the abdomen, suspect an
incarcerated hernia. A hernia is
strangulated when its blood supply
is cut off. The client typically
complains of extreme tenderness
and nausea. If you suspect that
the client has a strangulated
hernia, refer the client
immediately to the physician and
prepare him for surgery.
Ask the client to turn The inguinal and femoral Bulges that appear at the
head and cough or to areas are normally free external inguinal ring or at
bear down as if having a from bulges. the femoral canal when the
bowel movement, and client bears down may
continue to inspect the
signal a hernia
areas.
Bulging or masses are not A bulge or mass may
normally palpated. indicate a inguinal hernia.
Bulging or masses are not A bulge or mass may
normally palpated. indicate a femoral hernia.
 bulges. Repeat on the
other side.
4. Inspect and palpate for
scrotal hernia (if a mass
was detected during
inspection or palpation of
the scrotum). Ask the
client to lie down, and
note whether the bulge
disappears. If it remains,
auscultate it for bowel
sounds. Then gently
palpate the mass and try
to push it up into the
abdomen unless it is too
tender.
Anus and Perianal Area
1. Inspect the perianal area
for lumps, ulcers, lesions,
rashes, redness ,
fissures, thickening of the
epithelium (note size,
shape, location,
distribution, and
configuration). Spread the
client’s buttocks.
2. Inspect sacrococcygeal
area for swelling,
redness, dimpling, or
presence of hair in
pilonidal area.
3. Inspect for rectal prolapse
with Valsalva
maneuver. (Ask client to
strain or bear down)
4. Palpate for anal sphincter
tone, tenderness,
nodules, or hardness.
Inform the client that you
are going to perform the
internal examination at this
There's no presence of
scrotal hernia
The anal opening should
appear hairless, moist,
and tightly closed. The
skin around the anal
opening is more coarse
and more darkly
pigmented. The
surrounding perianal area
should be free of redness,
lumps, ulcers, lesions,
and rashes
Area is normally smooth,
and free of redness and
hair
No bulging or lesions
appear.
Never use your
fingertip—this causes
the sphincter to
tighten and, if forced
into the rectum, may Client’s sphincter relaxes,
cause pain. permitting entry.
A bulge or a mass in the
scrotum may indicate
scrotal hernia
Lesions may indicate STIs,
cancer, or hemorrhoids. A
thrombosed external
hemorrhoid appears
swollen.
A painful mass that is
hardened and reddened
suggests a perianal
abscess. A swollen skin tag
on the anal margin may
indicate a fissure in the
anal canal.Redness and
excoriation may be from
scratching an area infected
by fungi or pinworms. A
small opening in the skin
that surrounds the anal
opening may be an
anorectal fistula
A reddened, swollen, or
dimpled area covered by a
small tuft of hair located
midline on the lower sacrum
suggests a pilonidal cyst
Bulges of red mucous
membrane may indicate a
rectal prolapse.
Hemorrhoids or an anal
fissure may also be seen
Sphincter tightens, making
further examination
unrealistic.
point. Explain that it may feel
like his bowels are going to
move but that this will not
happen. Lubricate your gloved
index finger; ask the client to
bear down. As the client bears
down, place the pad of your
index finger on the anal
opening and apply slight
pressure; this will cause
relaxation of the sphincter.

When you feel the sphincter Examination finger enters Examination finger cannot
relax, insert your finger gently anus. enter the anus
with the pad facing down.

If the sphincter does not relax

and the client reports severe
pain, spread the gluteal folds
with your hands in close
approximation to the anus and
attempt to visualize a lesion Poor sphincter tone may be
that may be causing the pain. the result of a spinal cord
If tension is maintained on the injury, previous surgery,
gluteal folds for 60 seconds, trauma, or a prolapsed
the anus will dilate normally. rectum. Tightened sphincter
tone may indicate anxiety,
Ask the client to tighten the The client can normally scarring, or inflammation.
external sphincter; note the close the sphincter around
tone. the gloved finger. Tenderness may indicate
hemorrhoids, fistula, or
Rotate finger to examine the The anus is normally fissure. Nodules may
muscular anal ring. Palpate smooth, nontender, and indicate polyps or cancer.
for tenderness, nodules, and free of nodules and Hardness may indicate
hardness. hardness. scarring or cancer.

Rectum and Prostate

1. Palpate rectal mucosa for The rectal mucosa is Hardness and irregularities
tenderness, irregularities, normally soft, smooth, may be from scarring or
nodules, and hardness. nontender, and free of cancer. Nodules may
Insert your finger further into nodules. indicate polyps or cancer
the rectum as far as possible.
Turn your hand clockwise
then counterclockwise. This
allows palpation of as much
rectal surface as possible.

2. Palpate peritoneal cavity
for tenderness or
nodules, or “rectal shelf.”
This area may be This area is normally A peritoneal protrusion into
palpated in men smooth and nontender. the rectum, called a rectal
above the prostate shelf may indicate a
gland in the area of cancerous lesion or
the seminal vesicles peritoneal metastasis.
on the anterior Tenderness may indicate
surface of the rectum. peritoneal inflammation.
Note tenderness or
nodules

2. Palpate the prostate The prostate can be The prostate is normally A swollen, tender prostate
gland for tenderness, palpated on the nontender and rubbery. It may indicate acute
 size, shape, texture, or anterior surface of the has two lateral lobes that prostatitis. An enlarged
irregularities. rectum by turning the are divided by a median smooth, firm, slightly elastic
hand fully sulcus. The lobes are prostate that may not have
counterclockwise so normally smooth, 2.5 cm a median sulcus suggests
that the pad of your long, and heart-shaped. benign prostatic
index finger faces hypertrophy (BPH). A hard
toward the client’s area on the prostate or
umbilicus hard, fixed, irregular
nodules on the prostate
suggest cancer

4. Inspect the feces for Inspect the stool. Stool is normally semi- Black stool may indicate
blood and perform occult Withdraw your gloved solid, brown, and free of upper gastrointestinal
blood test. finger. Inspect any blood. bleeding, gray or tan stool
fecal matter on your results from the lack of bile
glove. Assess the pigment, and yellow stool
color, and test the suggests steatorrhea
feces for occult blood. (increased fat content).
Provide the client with Blood detected in the stool
a towel to wipe the may indicate cancer of the
anorectal area. rectum or colon. Refer the
client for an endoscopic
examination of the colon.