FINAL PERIOD

WEEK 13: ASSESSMENT OF THE ABDOMEN

 BY REGIONS
 the vertical lines
INTRAPERITONEAL ORGANS that extend
superiorly from
the midpoints of
the inguinal
ligaments and 2
horizontal lines,
one at the level of
the edge of the
lower ribs and the
other at the level
of the iliac crest

 Organs covered with peritoneum and held in

place by mesentery, it includes:
- Spleen
- bile duct
- gallbladder
- small intestine
- stomach
- large intestine
- liver

RETROPERITONEAL ORGANS
THE ABDOMINAL VISCERA
 organs situated behind the peritoneum and
without mesenteric attachment, it includes:
- pancreas
- ureters
- kidneys (ORGANS)
- bladder

ANATOMICAL MAPPING

2 Methods of dividing the abdominal cavity:

 BY QUADRANTS
 most common
assessment STOMACH
approach
 a vertical line from  J-shaped pouch like organ located in the left
the xiphoid upper quadrant of the abdomen beneath the
process to the diaphragm
pubic symphysis  lies to the right of the spleen and is partially
and a horizontal covered by the liver
line across the  Functions
umbilicus - reservoir
 The location of where the
organs by complex
quadrants mechanical
and
chemical processes of digestion occurs
- breaks down food particles into the
molecular form of digestion
 SMALL INTESTINE  synthesis and secretion
- bile production; 600 to 1000 ml/day
 tubular-shaped organ - formation of lymph bile salts
extending from the - plasma proteins
pyloric sphincter to the - fibrinogen
ileocecal valve at the - blood-clotting substances
opening of the large - antibodies
intestine
 can measure from 10 feet to 30 feet GALLBLADDER
 Segments
 Duodenum  pear-shaped sac located
in the right upper quadrant
- 1st and
of the abdomen
shortest
 Functions
section
- store and
- significant role in digestion
 jejunum concentrate bile
produced by the
- composed of circular mucosal
liver
folds that provide surface area
- contributes to fat
for nutrient absorption
 ileum digestion and
absorption
- absorbs bile salts Vitamin B12
- stores approximately 30 to 50 ml of bile
LARGE INTESTINE
PANCREAS
 tubular shaped organ extending from the
 elongated accessory
ileocecal valve to the anus
organ of digestion lies in
 greater diameter than
a transverse position
the small intestine
along the posterior
 Segments
abdominal wall
 Ascending –
 Functions
absorb the
 Exocrine
remaining
- secretes bicarbonate and
water and other
pancreatic enzymes which aid in
nutrients from the indigestible material
digestion
 Transverse – absorbs water
 Endocrine
 Descending – stores pieces that will
- secretes the hormone insulin,
eventually impede in the rectum
glucagon and gastrin
SIGMOID COLON
SPLEEN
 Functions
 largest lymph of the body
- form stool from
oval in shape found at the
cellulose, indigestible
upper left quadrant of the
fibers, fat, bacteria,
abdomen
cellular debris and
 Functions
inorganic materials
- serves the body as
- carry these intestinal contents to the end
filter and reservoir
of the GIT
for red blood cell mass
- absorption of water and electrolytes
VERMIFORM APPENDIX
LIVER
 finger-like shape
 largest solid organ in the
that extends off
body lies directly below the
the lower cecum
diaphragm
in the right lower
 located in the right upper
quadrant
quadrant but extends
across the midline into the KIDNEYS
left upper quadrant
 storage  bean-
- carbohydrates amino acids vitamins shaped
- minerals organs that
- blood lie tucked
 detoxification and filtration against the
- drugs hormones posterior
- bacteria abdominal wall
 metabolism  Functions
- carbohydrates - get rid of the body waste products
- proteins - acid base balance fluid and electrolyte
- fats balance
- ammonia to urea - arterial blood pressure
 URETERS 11. Watch the patient's face closely for signs of
discomfort or pain
 the passageway of urine from the kidneys 12. Help the patient relax by using unhurried
approach, diverting attention with questions and
so on
13. Ensure that your hands and the stethoscope are
warm to promote patient comfort

INSPECTION

Scaphoid (contour) – ABNORMAL

BLADDER

 stores urine can hold 200

to 400 ml of urine
CONTOUR

Distended/protuberant - ABNORMAL

ASSESSMENT PROPER

 Equipment
 Drapes
 Tape measure or small  Normal
ruler with centimeter - the abdominal
markings contour is flat
 Marking pen (straight
 Stethoscope horizontal line
from costal
ORDER OF ASSESSMENT margin to
symphysis
 Inspection
pubis)
 Auscultation
- rounded
 Percussion
(convexity of the abdomen from costal
 Palpation
margin to symphysis pubis)
GENERAL APPROACH TO ABDOMINAL - abdomen should be evenly rounded
ASSESSMENT  Deviations from normal
- generalized protuberant or distended
1. Greet the patient and explain the assessment abdomen may be due to obesity, air or
technique fluid accumulation
2. Ensure that the room is at a warm, comfortable - distended below umbilicus may be due to
temperature to prevent patient chilling and a full bladder, uterine enlargement, or an
shivering ovarian tumor or cyst
3. Use a quiet room that will be free from - distended upper abdomen may be due to
interruptions masses of pancreas or gastric dilation
4. Utilize an adequate light source. This includes a
bright overhead light and a freestanding lamp for SYMMETRY
tangential lightning
 Normal
5. Ask the patient to urinate before the exam
- abdomen
6. Drape the patient from the xiphoid process to the
should be
symphisis pubis then expose the patient's
symmetrical
abdomen
bilaterally
7. Position the patient comfortably in a supine
 Deviations from normal
position with knees flexed over a pillow or position
- asymmetry may be
the patient so that the arms are either folded
seen with organ
across the chest or at the sides to ensure
enlargement, large
abdominal relaxation
masses, hernia,
8. Stand to the right side of the patient for the
diastasis recti, or
examination
bowel obstruction
9. Visualize the underlying abdominal structures
during the assessment process in order to PIGMENTATION AND COLOR
accurately describe the location of any pathology
10. Have the patient point to tender areas; assess  Normal
these last. Mark these and other significant - abdominal skin may be paler than the
findings on the body diagram in the patient's chart general skin tone because it is seldom
exposed to the natural elements
 Deviations from normal MASSES / NODULES
- purple
discoloration at  Normal
the flanks (Grey - No masses or nodules are present
– Turner sign) UMBILICUS
indicates
bleeding within the abdominal wall,  Normal
possibly from trauma of abdominal - Depressed
organs (pancreas, kidneys, intestines, or and beneath
from pancreatitis the abdominal
- Pale, taut skin may be seen with ascites surface,
protruding not more than 0.5cm
- Round or conical
- Skin tones are similar to surrounding
abdominal skin tones
- Midline
- Redness may  Deviations from normal
indicate - Cullen sign
inflammation Indicates intra – abdominal bleeding
- Bruises or areas of
discoloration →

SCAR

 Normal - Deviated umbilicus

- Pale, smooth,
minimally raised
old scars may be
seen
 Deviations from normal
- Nonhealing
- Everted umbilicus
wounds,
redness,
inflammation
- Deep irregular
scars may result from burns

STRIAE

 Stretch Marks PULSATION

 Normal
- Ripples of
peristalsis may be
observed in thin
patient's
 Due to past stretching of the reticular skin layers
- Peristalsis movement slowly traverses
due to fast or prolonged stretching
the abdomen in a slanting downward
 Normal
direction
- Pink, bluish in
- Peristalsis – movement of the intestines
color if new striae
by constriction and relaxation, this
- Silvery, white,
pushes intestinal content forward
linear if old striae
- Uneven stretch AUSCULTATION
marks from past pregnancies or weight
gain
 Deviations from normal
- Dark bluish –
pink striae are
associated with
Cushing
syndrome
- Stretch marks
caused by ascites
BOWEL SOUNDS

 Heard as intermittent gurgling sounds throughout

the abdominal quadrants at a rate of 5 – 30 per
minute
 Normally, bowel sounds are always present at
the ileocecal valve area (RLQ)
 Normal hyperactive bowel sounds referred to as GENERAL ASSESSMENT
“borborygmus” may also be heard loud,
prolonged gurgles characterized of one’s  Normal
stomach growling  Tympany
 Deviations from normal - is predominant sound heard
because air is present in the
 Hyperactive bowel sounds
stomach and in the intestines
- Gastroenteritis
 Dullness
- Diarrhea
- is normally heard over organs
- use of laxatives
such as the liver or a distended
 Hypoactive bowel sounds
bladder
- paralytic ileus
- peritonitis
- bowel obstruction

VASCULAR SOUNDS

 BRUITS
 use bell of stethoscope
 low – pitched, murmur- like sound
 whooshing sound, blood flows through a
narrow vessel
 important if the client has hypertension or
if you suspect arterial insufficiency to the LIVER SPAN
legs
 auscultated over
the abdominal
aorta and renal,
iliac, and femoral
arteries best heard
over these areas
 not normally heard
- may
indicate  Lower Border
aneurysm - Begin liver percussion in the RLQ and
and or renal arterial stenosis percuss upward toward the chest
- Mark the percussion changes
 VENOUS HUM ↑
 Upper Border
 sounds produced by abdominal organs
- Percuss over the upper right chest at the
that suggests increased collateral
MCL and percuss downward
circulation heard over the umbilicus and
- Mark the percussion changes
epigastric area cirrhosis of the liver not
normally heard  Measure the distance between the two marks:
 collateral circulation is the alternate
circulation a round a blocked artery or
vein via another path, such as nearby
minor vessels
 FRICTION RUB ↑
 high-pitched grating sound produced by
large surface of an abdominal organ
(liver, spleen) rubs the peritoneum - this is the span of the liver
 associated with respiration rare, and not  Normal liver span at the MCL is 8 – 12cm greater
normally heard in men and taller clients, less in shorter clients
PERCUSSION  Normal liver span at the MSL is 4 – 8cm
 Deviations from normal
- HEPATOMEGALY,
a liver span that
exceeds normal
limits (enlarged), is
characteristic of
liver tumors, cirrhosis,
abscess, and vascular
engorgement
- ATROPHY of the liver is indicated by a
decreased span
- A liver in a LOWER POSITION than
PATTERNS normal may be caused by emphysema
- A liver in a HIGHER POSITION than
 Abdominal percussion sequences may proceed
normal may be caused by an
clockwise or up and down over the abdomen
abdominal mass, ascites, or a
 Cover all quadrants ↑
paralyzed diaphragm
 SPLEEN  Normal
- Abdomen should feel smooth and is
 Normal nontender and soft
- an oval area of dullness approximately 7 - There is no guarding
cm wide near the left tenth rib and slightly  Deviations from normal
posterior to the MAL
- Involuntary reflex guarding reflects
peritoneal irritation
- Right-side guarding may be due to
cholecystitis

DEEP PALPATION

- tympany (or resonance) is heard at the

last left interspace
 Deviations from normal
- Splenomegaly has an area of dullness
greater than 7cm wide
- enlargement may result from traumatic  Normal
injury, portal hypertension - (mild) tenderness is possible over the
mononucleosis xiphoid, aorta, cecum, sigmoid colon,
- Dullness at the anterior axillary line and ovaries with deep palpation
suggests enlargement of the spleen - No organ enlargement should be
palpable
KIDNEY
- No abnormal masses, bulges, or swelling
 Blunt Percussion - Only the aorta and the edge of the liver
are palpable
 Deviations from normal
- Severe tenderness or pain may be
related to trauma, peritonitis, infection,
tumors, or enlarged or diseased organs

LIVER

BIMANUAL TECHNIQUE

- To assess for tenderness in difficult-to-

palpate structures
- Normally, no tenderness or pain is
elicited or reported by the client
- Tenderness or sharp pain elicited over  Normal
the costovertebral angles (CVA) - the liver is not palpable, although it may
suggests kidney infection be felt in extremely thin adults
(pyelonephritis), renal calculi, or - liver edge presents as a firm, sharp,
hydronephrosis regular ridge with a smooth surface
PALPATION  Deviations from normal
- A hard, firm liver may indicate cancer
- Nodularity may occur with tumors,
metastatic cancer, late cirrhosis, or
 Normally syphilis
palpable - Tenderness may be from vascular
structures in the engorgement (e.g., congestive heart
abdomen failure), acute hepatitis, or abscess

SPLEEN

LIGHT PALPATION

 Normal
- Seldom palpable at the left costal margin
- If palpable, it should be soft and
nontender
  Deviations from normal  Arterial pulse
 Palpable spleen suggests enlargement - The surge of blood as a result from a
- Infections heartbeat which forces blood through the
- Trauma arterial vessels under high pressure
- chronic blood disorders
 Palpating the spleen in side – lying Major Arteries of the Arm
position  Brachial artery
NOTE: - Major artery that
- Be gentle when palpating the supplies the arm
spleen to avoid rupture and - Palpated medial
trauma of the organ to the biceps
KIDNEYS tendon in and
above the bend
of the elbow
- Divides near the
elbow to become the radial artery
(extending down the thumb side of the
arm) and the ulnar artery (extending
down the little-finger side of the arm)
 Normal  Both arteries provide blood to the
- Usually not palpable hand
- If palpated, it should feel firm, smooth  Radial artery
and rounded - Palpated on the lateral aspect of the wrist
 Deviations from normal  Ulnar artery
- An enlarged kidney may be due to a cyst, - Located on the medial aspect of the wrist
tumor, or hydronephrosis - A deeper pulse, not easily palpated

URINARY BLADDER Major Arteries of the Leg

 Femoral artery
- Major
supplier of
blood to the
legs
- Pulse
palpated
under the
inguinal
ligament
 Popliteal artery
- Pulse
 An empty bladder is neither palpable nor tender palpated behind the knee
 A moderately full bladder is smooth and round  Dorsalis pedis artery
and it is palpable above the symphysis pubis - Pulse palpated on the great-toe side of
 A full bladder is palpated above the symphysis the top of the foot
pubis and it may be close to the umbilicus  Posterior tibial artery
INGUINAL LYMPH NODES - Palpated behind the medial malleolus of
the ankle
 Normal
- Small, VEINS
movable and  Carry
palpable deoxygenated,
nodes are nutrient depleted,
less than waste-laden blood
1cm and are from the tissues
nontender back to the heart
 The veins of the
arms, upper trunk,
head, and neck carry
blood to the superior
ASSESSMENT OF THE PERIPHERAL VASCULAR
vena cava, where it
SYSTEM
passes into the right
STRUCTURE AND FUNCTION atrium
 Blood from the lower
ARTERIES trunk and legs drains
upward into the
 These are blood vessels that carry oxygenated,
inferior vena cava
nutrient rich blood from the heart to the capillaries
 Contain nearly 70% of the body’s blood volume
 A high-pressure system
 Walls are much thinner, low-pressure system
3 types COLLECTING SUBJECTIVE AND OBJECTIVE DATA

1. Deep veins Subjective data

- Femoral veins
- Popliteal veins  what are we to consider when collecting SD?
2. Superficial veins - Ask the client about the symptoms that
- Great and small saphenous veins client may consider inconsequential
3. Perforator (or communicator) veins - Ask about personal and family history of
- Connect the superficial veins with the vascular disease
deep veins - Evaluate aspects of the client’s lifestyle
and health factors
3 mechanisms of venous function
Objective data
 1st mechanism
- Structure of the veins  what are we to consider when collecting OD?
 2nd mechanism - Assess first the arms then legs, skin
- Muscular contraction color, temperature, major pulse sites,
lymph nodes
 rd
3 mechanism
- Inspection, palpation, auscultation
- Creation of a pressure gradient through
- Compare result of one extremity to
the act of breathing
another
- Problems can cause VENOUS STASIS –
impeded blood flow due to decreased Physical Examination
muscular activity
 The purpose is to identify any signs or symptoms
Risk factors of PVD including arterial insufficiency, venous
insufficiency, or lymphatic involvement
 Long periods of standing still, sitting, lying down
 Useful in acute care, extended care, and home
 Varicose veins
health care settings
 Damage to vein
 A complete peripheral vascular
CAPILLARIES examination involves INSPECTION,
PALPATION, and AUSCULTATION
 Small blood  When performing PE, the nurse should:
vessels that  Discuss risk factors for PVD with the
form the client.
connection  Accurately inspect arms and legs for
between the edema and venous patterning\
arterioles and  Observe carefully for signs of arterial and
venules venous insufficiency (skin color, venous
 Allow the pattern, hair distribution, lesions or
circulatory system to maintain the vital equilibrium ulcers) and inadequate lymphatic
between the vascular and interstitial spaces drainage
 Works with the lymphatic system to maintain fluid  Recognize characteristic clubbing
balance  Palpate pulse points correctly
 Prevents edema  Use the Doppler ultrasound instrument
correctly
LYMPHATIC SYSTEM
ASSESSMENT
 Works with the vascular system
 Lymphatic capillaries, lymphatic vessels, lymph (PROCEDURE)
nodes
 Functions ARMS
- Drain excess fluid and proteins (2 PROCEDURES – INSPECTION AND PALPATION)
- Immune system
- Absorb lipids INSPECTION
 Characteristics
Observe for the arm size and venous pattern, as well as
- Circular or oval
the presence of edema
- Small and
nonpalpable to 1-2  Normal findings
cm in diameter - Arms are bilaterally symmetric
- Can be deep and - No edema
superficial, grouped - No abnormal venous patterning
together  Abnormal findings
- Located near major - Lymphedema
joints
- Superficial lymph nodes is the only
accessible to examination
o Epitrochlear lymph nodes
o Axillary lymph nodes
o Superficial inguinal nodes
(horizontal and vertical chain of
nodes) - Prominent venous patterning with edema
Observe coloration of the hands and arms Palpate the ulnar pulses.

 Normal findings  Apply pressure with

- Color varies your first three
depending on fingertips to the
the client’s medial aspects of the
skin tone, inner wrists. The ulnar
although color pulses are not routinely assessed because they
should be the same bilaterally are located deeper than the radial pulses and are
 Abnormal findings difficult to detect. Palpate the ulnar arteries if you
 Raynaud disorder suspect arterial insufficiency.
- A vascular disorder caused by  Normal findings
vasoconstriction or vasospasm - The ulnar pulses may not be detectable
of the fingers or toes,  Abnormal findings
characterized by rapid changes - Obliteration of the pulse may result from
of color (pallor, cyanosis, and compression by external sources, as in
redness), swelling, pain, compartment syndrome. Lack of
numbness, tingling, burning, resilience or inelasticity of the artery wall
throbbing, and coldness may indicate arteriosclerosis.
PALPATION Palpate the brachial pulses.
Palpate the client’s fingers, hands, and arms, and note the  Do this by placing the
temperature first three fingertips of
each hand at the
 Normal findings
client’s right and left
- Skin is warm to the touch bilaterally from
medial antecubital
fingertips to upper arms
creases. Alternatively, palpate the brachial pulse
 Abnormal findings in the groove between the biceps and triceps.
- A cool extremity may be a sign of arterial
 Normal findings
insufficiency.
- Brachial pulses have equal strength
- Cold fingers and hands, for example, are
bilaterally
common findings with Raynaud’s
 Abnormal findings
Palpate to assess capillary refill time. - Brachial pulses are increased (3+),
diminished (1+), or absent (0)
 Compress the nailbed
until it blanches. Palpate the epitrochlear lymph
Release the pressure nodes
and calculate the time
 Normal findings
it takes for color to
- Epithrochlear
return. This test indicates peripheral perfusion
lymph nodes are not palpable
and reflects cardiac output.
 Abnormal findings
 Normal findings
- Enlarged lymph nodes
- Capillary beds refill (and, therefore, color
o Infection
returns) in 2 seconds or less
o Generalized lymphadenopathy
 Abnormal findings
o Lesion
- Capillary refill time exceeding 2 seconds
may indicate vasoconstriction, Perform the Allen test.
decreased cardiac output, shock, arterial
occlusion, or hypothermia  Evaluates patency of the radial or ulnar arteries.
It is done when patency is questionable or before
Palpate the radial pulse. such procedures as a radial artery puncture.
 When this is essential?
 Gently press the radial
- Arterial sampling (e.g., ABG extraction)
artery against the
- When patency is questionable
radius. Note elasticity
- Before a radial artery puncture
and strength.
 The test begins by
 Normal findings
assessing ulnar patency.
- Radial pulses are bilaterally strong (2+).
Have the client rest the
Artery walls have a resilient quality
hand palm side up on the
(bounce).
examination table and
 Abnormal findings
make a fist. Then use
- Increased radial pulse volume indicates
your thumbs to occlude the radial and ulnar
a hyperkinetic state (3+ or bounding
arteries.
pulse). Diminished (1+) or absent (0)
 Continue pressure to
pulse suggests partial or complete
keep both arteries
arterial occlusion (which is more
occluded and have
common in the legs than the arms). The
the client release the
pulse could also be decreased from
fist.
Buerger’s disease or scleroderma.
  Note that the palm remains
pale. Release the pressure
on the ulnar artery and watch
for color to return to the hand.
To assess radial patency, repeat the procedure
as before, but at the last step, release pressure
on the radial artery.
 Normal findings
- Pink coloration returns to the palms
within 3– 5 seconds if the ulnar artery is
patent.
- Pink coloration returns within 3–5
seconds if the radial artery is patent.
 Abnormal findings
- With arterial insufficiency or occlusion of
the ulnar artery, pallor persists.
- With arterial insufficiency or occlusion of
the radial artery, pallor persists.
LEGS
(3 PROCEDURES)
INSPECTION, PALPATION, AND AUSCULTATION
 Ask the client to lie supine. Then drape the groin
area and place a pillow under the client’s head for
comfort. Observe skin color while inspecting both
legs from the toes to the groin.
Inspect for edema.
 Inspect the legs for
unilateral or bilateral
edema. Note veins,
tendons, and bony
prominences. If the legs appear asymmetric, use
a centimeter tape to measure in four different
areas: circumference at mid-thigh, largest
circumference at the calf, smallest circumference
above the ankle, and across the forefoot.
Compare both extremities at the same locations.
 Normal findings
- Identical size and shape bilaterally; no
swelling or atrophy.
 Abnormal findings
- May be detected by the absence of
visible veins, tendons, or bony
prominences.
- Bilateral edema usually indicates a
systemic problem
- Unilateral edema is characterized by a 1-
cm difference in measurement at the
ankles or a 2-cm difference at the calf,
and a swollen extremity.
- A difference in measurement between
legs may also be due to muscular
atrophy.

Observe skin color while inspecting both legs from the
toes to the groin
 Normal findings
- Pink color for lighter-skinned clients and
pink or red tones visible under darker-
pigmented skin. There should be no
changes in pigmentation.
 Abnormal findings
- Pallor, especially when elevated, and
rubor, when dependent, suggests arterial
insufficiency.
- Cyanosis when dependent suggests
venous insufficiency.
- A rusty or brownish pigmentation around
the ankles indicates venous insufficiency
Inspect distribution of hair on legs
Palpate edema.
 Determine if it is pitting or nonpitting. Press the
edematous area with the tips of your fingers, hold
for a few seconds, then release. If the depression
does not rapidly refill and the skin remains
indented on release, pitting edema is present.
 Normal findings
- No edema (pitting or nonpitting) present
in the legs.
 Abnormal findings
- Pitting edema is associated with
systemic problems
- A 1+ to 4+ scale is used to grade the
severity of pitting edema, with 4+ being
most severe.

 Normal findings
- Hair covers the skin on the legs and
appears on the dorsal surface of the toes.
 Abnormal findings
- Loss of hair on the legs suggests arterial
insufficiency. Often thin, shiny skin is
Palpate bilaterally for temperature of the feet and legs.
noted as well.
 Use the backs of your
Inspect for lesions or ulcers.
fingers. Compare your
 Normal findings findings in the same
- Legs are free of areas bilaterally. Note
lesions or location of any
ulcerations. changes in
 Abnormal findings temperature.
- Ulcers with smooth, even margins that  Normal findings
occur at pressure areas, such as the toes - Toes, feet, and legs are equally warm
and lateral ankle, result from arterial bilaterally.
insufficiency. ↑  Abnormal findings
- Ulcers with irregular edges, bleeding, - Generalized coolness in one leg or
and possible bacterial infection that occur change in temperature from warm to cool
on the medial ankle result from venous as you move down the leg suggests
insufficiency. arterial insufficiency.
 - Increased warmth in the leg may be  Abnormal findings
caused by superficial thrombophlebitis - A weak or absent pulse may indicate
resulting from a secondary inflammation impaired arterial circulation.
in the tissue around the vein.
Palpate the posterior tibial
Palpate the femoral pulses. pulses.

 Ask the client to bend the  Palpate behind and just

knee and move it out to below the medial
the side. Press deeply malleolus (in the
and slowly below and groove between the ankle and the Achilles
medial to the inguinal ligament. Use two hands if tendon). Palpating both posterior tibial pulses at
necessary. Release pressure until you feel the the same time aids in making comparisons.
pulse. Repeat palpation on the opposite leg. Assess amplitude bilaterally.
Compare amplitude bilaterally  Normal findings
 Normal findings - The posterior tibial pulses should be
- Femoral pulses strong and equal strong bilaterally.
bilaterally.  Abnormal findings
 Abnormal findings - A weak or absent pulse indicates partial
- Weak or absent femoral pulses indicate or complete arterial occlusion.
partial or complete arterial occlusion.
Inspect for varicosities and thrombophlebitis.
Auscultate the femoral pulses.
 Ask the client to stand
 If arterial occlusion is because varicose veins
suspected in the femoral may not be visible when
pulse, position the the client is supine and not
stethoscope over the as pronounced when the
femoral artery and listen for bruits. Repeat for client is sitting. As the
other artery. client is standing, inspect
 Normal findings for superficial vein
- No sounds auscultated over the femoral thrombophlebitis. To fully
arteries. assess for a suspected
 Abnormal findings phlebitis, lightly palpate
- Bruits over one or both femoral arteries for tenderness. If
suggest partial obstruction of the vessel superficial vein
and diminished blood flow to the lower thrombophlebitis is present, note redness or
extremities. discoloration on the skin surface over the vein.
 Normal findings
Palpate the popliteal pulses. - Veins are flat and barely seen under the
 Ask the client to raise (flex) surface of the skin.
the knee partially. Place your  Abnormal findings
thumbs on the knee while - Varicose veins may appear as distended,
positioning your fingers deep nodular, bulging, and tortuous,
in the bend of the knee. depending on severity.
Apply pressure to locate the - Varicosities are common in the anterior
pulse. It is usually detected lateral thigh and lower leg, the posterior
lateral to the medial tendon. lateral calf, or anus (known as
 Normal findings hemorrhoids).
- It is not unusual for the popliteal pulse to - Superficial vein thrombophlebitis is
be difficult or impossible to detect, and marked by redness, thickening, and
yet for circulation to be normal. tenderness along the vein.
 Abnormal findings - Aching or cramping may occur with
- Although normal popliteal arteries may walking.
be nonpalpable, an absent pulse may CHARACTERISTICS OF ARTERIAL AND VENOUS
also be the result of an occluded artery. INSUFFICIENCY
Palpate the dorsalis pedis (A&VI)
pulses.
ARTERIAL INSUFFICIENCY
 Dorsiflex the client’s foot
and apply light pressure  Pain: Intermittent claudication to sharp,
lateral to and along the unrelenting, constant
side of the extensor tendon of the big toe. The  Pulses: Diminished or absent
pulses of both feet may be assessed at the same  Skin Characteristics: Dependent rubor
time to aid in making comparisons. Assess - Elevation pallor of foot
amplitude bilaterally. - Dry, shiny skin
 Normal findings - Cool-to-cold temperature
- Dorsalis pedis pulses are bilaterally - Loss of hair over toes and dorsum of foot
strong. - Nails thickened and ridged
  Ulcer Characteristics: ABNORMAL ARTERIAL FINDINGS
- Location: Tips of
toes, toe webs,  Necrotic great toes with blisters on toes and foot
heel or other  Raynaud Disease
pressure areas if - Blanching of fingers on both hands
confined to bed ABNORMAL VENOUS FINDINGS
- Pain: Very
painful  Superficial thrombophlebitis
- Depth of ulcer: - Often seen with unilateral localized pain,
Deep, often involving joint space achiness, edema, redness, and warmth
- Shape: Circular to touch
- Ulcer base: Pale black to dry and  Lymphedema
gangrene  Varicose veins
- Leg edema: Minimal unless extremity
kept in dependent position constantly to ANALYSIS OF DATA: SELECTED NURSING
relieve pain DIAGNOSIS

VENOUS INSUFFICIENCY

 Pain: Aching, cramping

 Pulses: Present but may
be difficult to palpate
through edema
 Skin Characteristics:
- Pigmentation in
gaiter area (area
of medial and
lateral
malleolus)
- Skin thickened and tough ANALYSIS OF DATA: SELECTED COLLABORATIVE
- May be reddish-blue in color PROBLEMS
- Frequently associated with dermatitis
 Ulcer Characteristics:
- Location: Medial malleolus or anterior
tibial area
- Pain: If superficial, minimal pain; but may
be very painful
- Depth of ulcer: Superficial
- Shape: Irregular border
- Ulcer base: Granulation tissue—beefy
red to yellow fibrinous in chronic long-
term ulcer
- Leg edema: Moderate to severe

TYPES OF PERIPHERAL EDEMA

Edema Associated with

Lymphedema

 Caused by abnormal or
blocked lymph vessels
 Nonpitting
 Usually bilateral; may be
unilateral
 No skin ulceration or pigmentation
ASSESSMENT OF THE HEART AND NECK VESSELS
Edema Associated with
Chronic Venous Insufficiency SALIENT POINTS OF THE CARDIOVASCULAR
SYSTEM
 Caused by obstruction or
insufficiency of deep  The cardiovascular system plays an important
veins role in the body
 Pitting, documented as: - It delivers oxygenated blood
 1+ = slight pitting - Removes waste products
 2+ = deeper than 1+  The autonomic nervous system controls how the
 3+ = noticeably deep pit; extremity looks heart pumps
larger  The vascular network the arteries, veins,
 4+ = very deep pit; gross edema in capillaries carries blood throughout the body,
extremity keeps the heart filled with blood and maintains
 Usually unilateral; may be bilateral blood pressure
 Skin ulceration and pigmentation may be present
 THE HEART 2. AORTIC SEMILUNAR VALVE lies between the
left ventricle and the Aorta prevents backflow of
blood from the aorta into the left ventricle

HEART SOUNDS

 produced by valve closure, therefore, opening of

valve is silent
 S1 – “lub”
 S2 – “dubb”
 Extra heart sounds
 S3 and S4
 Murmurs
 NORMAL HEART SOUNDS
 The heart and major blood vessels lie centrally in
the chest behind the protective sternum S1
 A cone-shaped muscle with four chambers
 A double pump about the size of a clenched fist  the first heart sound
(12 cm long and 9 cm wide) 250–390 g (8.8 13.8  “lub”
oz) in adult males 200–275 g (7.0–9.7 oz) in adult  the result of closure of the atrioventricular
females (AV) valves
 Pumps blood throughout circulatory system - the TRICUSPID VALVE
- the MITRAL VALVE
 correlates with the beginning of systole
 heard at the base and apex of the heart
- softer at the base
- louder at the apex (best heard)
o left MCL, 5th ICS

S2
Heart
Chambers,  the second heart sound
Valves and  “dubb”
Circulatory  results from closure of the semilunar valves
Flow - the AORTIC VALVE
- the PULMONIC VALVE
 correlates with the beginning of DIASTOLE
 best heard at the base of the heart
 EXTRA HEART SOUNDS
THE CHAMBERS OF THE HEART
S3 & S4
1. RIGHT ATRIUM receives DEOXYGENATED
 diastolic filling sounds
blood from the body via the superior and inferior
 result from ventricular vibration secondary to
vena cavae
rapid ventricular filling
2. RIGHT VENTRICLE receives blood from the right
atrium and pumps it to the lungs via the S3
pulmonary artery
3. LEFT ATRIUM receives OXYGENATED blood - ventricular gallop
from the lungs via four pulmonary veins - can be heard early in diastole, after S2
4. LEFT VENTRICLE receives OXYGENATED - when the mitral valve opens
blood from the lungs via the left atrium pumps
S4
blood into the systemic circulation via the aorta -
the largest and most muscular chamber - atrial gallop
- results from ventricular vibrations
THE VALVES OF THE HEART
secondary to ventricular resistance
ATRIOVENTRICULAR VALVES during atrial contraction
- can be heard late in diastole, just before
1. TRICUSPID VALVE located on the right side of S1
the heart, has three leaflets and prevents
backflow of blood from the right ventricle to the Murmurs
right atrium
 Blood NORMALLY flows silently through the
2. BICUSPID (MITRAL) VALVE located on the left
heart
side of the heart, has two leaflets and prevents
 In conditions of an audible and prolonged
backflow of blood from left ventricle to the left
sounds, murmurs are auscultated over the
atrium
precordium, a swooshing or blowing sound
SEMILUNAR VALVES resulting from turbulence created within the
vascular system
1. PULMONIC SEMILUNAR VALVE lies between  Conditions that contributes to turbulent blood
the right ventricle and the pulmonary artery and flow includes
prevents backflow of blood from pulmonary trunk - increased blood velocity;
to the right ventricle - structural valve defects;
 - valve malfunction; and
- abnormal chamber opening (septal
defect)
 increased flow through normal blood vessels,
creating frictional, audible sounds flow
through constricted blood vessels (e.g., aortic
stenosis).
 flow of blood into a dilated blood vessel from
one of normal size
CYCLES OF HEART SOUNDS
 PULMONIC AREA
- 2nd and 3rd left ICS close to sternum but
may be higher or lower
 LEFT ATRIAL AREA
- 2nd to 4th ICS at the left sternal border
 RIGHT ATRIAL AREA
- 3rd to 5th ICS at the right sternal border
 LEFT VENTRICULAR AREA
- 2nd to 5th ICS, extending from the left
sternal border to the left MCL
 RIGHT VENTRICULAR AREA
- 2nd to 5th ICS, centered over the sternum

KOROTKOFF’S SOUNDS

 Phase I:
- A faint, clear, rhythmic tapping noise that
gradually increases in intensity
 Phase II:
- A swishing sound that is heard as the
vessel distends with blood
 Phase III:
- Sounds become more intense
AUSCULTATING HEART SOUNDS - Vessel is open in systole but not in
diastole
(AREAS)  Phase IV:
- Sounds begin to muffle, and pressure is
THE TRADITIONAL 5 AREAS
closest to diastolic arterial pressure
 Aortic Area  Phase V:
- 2nd ICS at - Sounds disappear because vessel
the right remains open
sternal
ASSESSMENT PROPER
border
- base of You will use all four techniques of physical assessment to
the heart assess the cardiovascular system
 Pulmonic Area
- 2nd or 3rd  I
ICS at the left sternal border  P
- base of the heart  P
 Erb’s point  A
- 3rd to 5th ICS at the left sternal border
Perform the assessment in 3 positions
 Mitral (Apical)
- 5th ICS near the left MCL  sitting, supine, and left lateral
- apex of the heart
 Tricuspid Area
- 4th or 5th ICS at the left lower sternal
border
 Take Note!
 the 4 valve areas do not reflect the
anatomical position of the valves
 sounds always travel in the direction of INSPECTION
the blood flow NECK
 the areas described in the traditional
auscultation overlaps extensively and  Differentiate carotid arteries and jugular veins
sounds produced by the valves can be  Normal
heard all over the precordium - Carotids have visible pulsation
- Jugulars have undulated wave
THE ALTERNATIVE AREAS - Carotids have palpable pulsations
- Jugulars are obliterated
- Carotids not affected by respirations,
jugulars are
- Carotids not affected by position
- Jugulars normally only visible when client
is supine
 Deviations from normal
 Large, bounding visible pulsation in neck
of suprasternal notch:
 AORTIC AREA
- HTN, aortic stenosis, or
- right 2nd ICS to apex of heart
aneurysm
  Abnormal venous waveforms - Jugular distends and jugular
 Giant A waves wave disappears.
 Tricuspid stenosis, right ventricular
hypertrophy
- cor pulmonale
 Absent A wave
- atrial fibrillation

PRECORDIUM
3. Testing Abdominojugular (Hepatojugular) Reflux
 Look for pulsations on the precordium, paying  Position
particular attention to the apex area. patient at 45-
 Normal degree angle,
- Positive pulsation at apex place hands
- May note slight pulsations over base in over the
thin adults and children midabdominal
 Deviations from normal area and apply 20 to 30 mm Hg of
 Pulsations may occur pressure for about 15 to 30 sec.
- to right of sternum  Estimate the pressure by placing a
- epigastric area partially inflated BP cuff on the abdomen
- sternoclavicular areas under your hand.
 AORTIC ANEURYSM  Look at the jugular veins while applying
 Apical pulsation displaced toward axillary pressure
line - note increase vein distension
- left ventricular hypertrophy - return to normal upon release of
pressure
PALPATION
 Deviations from normal
 Cardiac Rate >100 bpm
- Sinus tachycardia
- Supraventricular tachycardia
(SVT)
- Paroxsymal tachycardia (PAT)
- Uncontrolled atrial fibrillation
- Ventricular tachycardia
CAROTID ARTERY ↑  causes include CHF
drugs, such as:
 Lightly palpate each carotid separately  atropine
 Note  nitrates
- Rate  epinephrine
- Rhythm  isoproterenol
- Amplitude  nicotine and caffeine
- Contour  HYPERCALCEMIA
- Symmetry  Cardiac Rate <60 bpm
- Elasticity - Sinus bradycardia heart block
- thrills - causes include MI drugs, such
as:
JUGULAR VEINS  digoxin
 quinidine
 Palpate jugular veins and check direction of fill.
 procainamide, and
3 ways  beta-adrenergic
inhibitors;
1. Occluding under the jaw, the jugular should  HYPERKALEMIA
flatten, but the wave form will become more  Irregular rhythm
prominent. - Arrhythmia
 Assessing Jugular Flow  abnormal pulses
- Compress jugular below jaw.  unequal pulses
- Jugular vein collapses and - obstruction or occlusion
jugular wave is more prominent  stiff, cordlike arteries
at supraclavicular area - Right – sided CHF
- tricuspid regurgitation
- tricuspid stenosis
- constrictive pericarditis
- cardiac tamponade
- inferior vena cava obstruction
- HYPERVOLEMIA
2. Occluding above the clavicle, the jugular normally
distends while the jugular wave diminishes. PRECORDIUM
 Checking Jugular Fill  Apex (left ventricular area) or mitral area
- Compress jugular above  5th ICS, MCL
clavicle.
 patient in left lateral recumbent
position
 Cause: Ventricular
enlargement, HTN,
aortic stenosis
- Sustained pulsation
 Cause:
 Normal  Hypertrophy
 Apex (left ventricular area):  HTN
- PMI is 1–2 cm  Overload
- Negative thrills  CMP
- Amplitude may normally be DEVIATIONS FROM NORMAL
increased in high-output states
SUCH AS EXERCISE  THRILLS
- Apical pulsation may not always - cause: murmur
be palpable  PALPABLE LIFTS OR HEAVES
- Left lateral displacement of PMI - cause: right ventricular hypertrophy
may occur during the last PULSATIONS FELT ON THE
trimester of pregnancy FINGERTIPS
 LLSB (tricuspid area) 4th to 5th ICS at left - cause: may come from the right ventricle,
sternal border indicating right ventricular hypertrophy
 LLSB  LARGE DIFFUSE EPIGASTRIC PULSATION
- May not be palpable, although - cause: abdominal aortic aneurysm
small, nonsustained, systolic  ACCENTUATED PULSATION IN PULMONIC
impulse may be palpated, AREA
especially in thin patients - cause: pulmonary HTN
- Negative thrills  ACCENTUATED PULSATION IN AORTIC AREA
 Base left - cause: HTN or aneurysm
(pulmonic area)
- 2nd ICS, PERCUSSION
left
 Dullness at 3rd, 4th, and 5th ICS to left of sternum
sternal
at MCL
border
 Left sternal border extends to midaxillary lines in
 Base right (aortic
an enlarged, dilated heart
area)
- 2nd ICS,
right
sternal
border
 Epigastric area
- Below the xyphoid process
- Normal
 Positive slight pulsation AUSCULTATION
may be normal, no
diffusion
 Palpations not palpable
 at base left, the
pulmonic area
 base right, the
aortic area
o except
NECK ↑
in thin
patients  Have client hold breath.
 Abnormal  Auscultate the carotid with the bell portion of the
- Enlargement and displacement stethoscope for bruits.
of PMI to left midaxillary line  Auscultate the jugulars with the bell portion of the
 Cause: Ventricular stethoscope for venous hums.
hypertrophy with dilation  Normal
- Apical impulse located on right - Positive carotid bruit may be normal in
side of precordium: children and is associated with high-
 DEXTROCARDIA output states
 Cause: a heart located - Negative venous hum
on the right side, often - Positive venous hum may be normal in
associated with children
congenital heart disease  Deviations from normal
- Enlarged apical pulsation
- Bruit suggests carotid stenosis
without displacement >2–2.5 cm - Murmurs can also radiate up to the neck
with patient supine or >3 cm with from the heart, as in aortic stenosis
 PRECORDIUM  Left ventricular heaves, pulsus alternans,
increased heart rate, displaced PMI, S3, S4,
dyspnea, crackles, orthopnea, dry, hacking
cough, PND
 Nocturia

CORONARY ARTERY DISEASE

 Auscultate at apex  A progressive narrowing of the coronary arteries
 Note rate, rhythm, extra sounds, or murmurs.  Atherosclerosis is the major cause of CAD
 Auscultate at each site (apex, LLSB, Erb’s point,  CAD can present as angina pectoris, acute MI, or
base left and base right). sudden cardiac death
 Note S1, S2, extra sounds, or murmurs.  MI is necrosis of myocardial tissue from ischemia
 Listen at each site with both the bell and the  Anxiety, dizziness, chest pain, fatigue
diaphragm.
 Skin pale to ashen, cool, diaphoretic, feverish
 The diaphragm of the stethoscope is best for
 Neck vein distension
detecting high-pitched sounds.
 Dyspnea, tachypnea, crackles, tachycardia or
 The bell is best for detecting low-pitched sounds.
bradycardia, arrhythmias, elevated BP initially,
 Use firm pressure with the diaphragm and light S3, S4, murmur, rubs, and diminished heart
pressure with the bell. sounds
 Apex (Mitral)  Nausea, vomiting, low urinary output
 Rate:
 Cool, pale, decreased pulses
- depends on age
 Chest pain aggravated by inspiration, coughing,
 Rhythm:
or movement
- Regular
 Fever
- S1 S2;
- high-pitched systolic  Friction rub at LLSB
- short duration PERICARDITIS
- No extra sounds
 Physiological S3 and S4 may be heard in  An inflammation of the visceral or parietal
children and young adults without heart pericardium, resulting in cardiac compression,
disease decreased ventricular filling and emptying, and
 Deviations from normal cardiac failure
- Bradycardia rates 60 BPM or tachycardia  Often occurs 2 to 3 days after MI
rates 100 BPM
- Irregular rhythm: Arrhythmia
- Quadruple rhythm, S3 S4 with fast rate is WEEK 14: NEUROLOGICAL ASSESSMENT
called a summation gallop
(1)
COMMON ABNORMALITIES
12 CRANIAL NERVES & THEIR FUNCTIONS
(FIVE DISEASE)

ANGINA PECTORIS

 Chest pain resulting from myocardial ischemia

- Anxiety, chest pain
- Skin pale, diaphoretic, cool, clammy
- Dyspnea, tachycardia, pulsus alternans,
arrhythmias, S4, S3
- Nausea, belching
- Weakness, paresthesias

CONGESTIVE HEART FAILURE

 Failure of the heart to pump sufficiently to meet

the demands of the body
 CHF can be right, left, or both.
 Right-Sided Failure
 Fatigue, weight gain, confusion
 Skin pale, cool
 Neck vein distension
 Tachycardia, right ventricular heaves, murmurs,
S3, right-sided pleural effusion
 Anorexia, bloating, RUQ tenderness,
hepatomegaly, ascites
 Edema, diminished hair growth

LEFT - SIDED FAILURE

 Fatigue, confusion
 Skin pale, dusky, cyanotic, cool
 Normal

 Client has 20/20 vision OD (right eye) and OS

(left eye) – (distance vision)

Deviations from normal

 difficulty reading Snellen chart

 missing letters
 squinting

NEAR VISION

 Ask the client to read a

newspaper or magazine
paragraph to assess near
ASSESSMENT PROPER vision
1. Ohhh Olfactory Normal
2. Ohhh Optic
3. Ohhh Occulomotor  reads print at 14 inches without difficulty
4. To Trochlear  until the patient is in the late 30s to the late 40s,
5. Touch Trigeminal reading is generally possible at a distance of 14
6. And Abducens inches
7. Feel Facial
8. A Acoustic Deviations from normal
9. Good Glossopharyngeal
 reads print by holding closer than 14 inches or
10. Velvet Vagus
holds print farther away as in presbyopia, which
11. Sooo Spinal Accessory
occurs with aging
12. Heaven Hypoglossal
VISUAL FIELDS
CN I – OLFACTORY NERVE
 Assess visual fields of
 Have client sit in a
each eye by
comfortable position at your
confrontation
eye level
 Ask the client to clear the Normal
nose to remove any mucus
 Close eyes, occlude one  normal peripheral vision
nostril, and identify a scented Deviations from normal
object that you are holding
such as soap, coffee, or  Loss of visual fields may be seen in
vanilla - retinal damage or detachment
 Repeat procedure for the other nostril - lesions of the optic nerve
- lesions of the parietal cortex
Normal
RETINA & OPTIC DISC BY OPHTHALMOSCOPE
 Client correctly identifies scent presented to each
nostril  Use an ophthalmoscope to view
 Some older clients’ sense of smell may be the retina and optic disc of each
decreased eye

Deviations from normal Normal

 Neurogenic Anosmia  optic disc

- inability to smell or identify the correct - 1.5 mm
scent - round or slightly oval
may indicate - well-defined margins
- olfactory tract lesion - creamy pink with paler physiologic cup
- frontal lobe tumor  Retina
- congenital, nasal or sinus problems - pink
- nerve tissue injury
Deviations from normal
- smoking and use of cocaine

CN II – OPTIC  papilledema
 optic atrophy
(2)
CN III, IV, VI – OCULOMOTOR, TROCHLEAR,
VISUAL ACUITY ABDUCENS

 Use a Snellen chart to Inspect margins of the eyelids of each eye

assess vision in each
eye  Assess extraocular movements
 Assess pupillary response to light (direct and
indirect) and accommodation in both eyes
Normal Normal

 Eyelid covers  Correctly identifies sharp and dull stimuli and light
about 2 mm of touch to the forehead, cheeks, and chin
the iris
Deviations from normal
 Eyes move in
a smooth,  Inability to feel and correctly identify facial stimuli
coordinated  lesions of the trigeminal nerve
motion in all  lesions in the spinothalamic tract or posterior
directions (the six cardinal fields) columns
 Bilateral illuminated pupils constrict
simultaneously TEST CORNEAL REFLEX
 Pupil opposite the one illuminated constricts
simultaneously  Ask the client to look away and
up while you lightly touch the
Deviations from normal cornea with a fine wisp of cotton.
 Repeat on the other side.
 Ptosis (drooping of the
eyelid) is seen with Normal
weak eye muscles
- myasthenia  Eyelids blink bilaterally
gravis Deviations from normal
 Possible causes of abnormal eye movements
- cerebellar disorders  Absent corneal reflex
- increased ICP  lesions of the trigeminal nerve
- paralytic strabismus  lesions of the motor part of cranial nerve VII
 Possible causes of pupil abnormalities (facial)
- oculomotor nerve paralysis
- Argyll Robertson pupils CN VII – FACIAL
- narcotics abuse (2)
- CN III damage
- lesions of the sympathetic nervous TEST MOTOR FUNCTION
system
- PNS or CNS dysfunction  Smile
- CN V lesion  Frown and wrinkle
forehead
CN V – TRIGEMINAL  Show teeth
 Puff out cheeks
(3)
 Purse lips
TEST MOTOR FUNCTION  Raise eyebrows
 Close eyes tightly against
 Ask the client to resistance
clench the teeth while
you palpate the Normal
temporal and
masseter muscles for  smiles, frowns, wrinkles forehead, shows teeth,
contraction puffs out cheeks, purses lips, raises eyebrows,
and closes eyes against resistance
Normal  movements are symmetric
 Temporal and masseter muscles contract Deviations from normal
bilaterally
 Inability to close eyes, wrinkle forehead, or raise
Deviations from normal forehead along with paralysis of the lower part of
the face on the affected side
 Decreased contraction in one of both sides
 Bell's Palsy
 Asymmetric strength in moving the jaw may be
seen with lesion or injury of the 5th cranial nerve
 Pain occurs with clenching of the teeth

TEST SENSORY FUNCTION

 Tell the client: “I am going to

touch your forehead, cheeks, and
 Paralysis of the lower part of the face on the
chin with the sharp or dull side of
opposite side affected may be seen with a central
this paper clip. Please close your
lesion that affects the upper motor neurons
eyes and tell me if you feel a
sharp or dull sensation. Also tell  Stroke
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 SENSORY FUNCTION Normal

 Not routinely tested, if testing is indicated,  Gag reflex intact

however, touch the anterior two-thirds of the  Some normal clients may have a reduced or
tongue with a moistened applicator dipped in salt, absent gag reflex
sugar, or lemon juice
 ask the client to identify the flavor Deviations from normal
 If the client is unsuccessful, repeat the test using  An absent gag reflex
one of the other solutions  lesions of cranial nerve IX (glossopharyngeal) or
 If needed, repeat the test using the remaining X (vagus)
solution
CHECK ABILITY TO SWALLOW
Normal
 Giving the client a drink of
 identifies correct flavor water
Deviations from normal  Note the voice quality also

 inability to identify correct flavor on anterior two- Normal

thirds of the tongue  Swallows without difficulty
 impairment of cranial nerve VII  No hoarseness noted
CN VIII – ACOUSTIC / VESTIBULOCOCHLEAR Deviations from normal
 Test the client’s  Dysphagia or hoarseness
hearing ability - lesion of cranial nerve IX
in each ear and (glossopharyngeal) or X (vagus)
perform the - neurologic disorder
Weber and
Rinne tests to CN XI – SPINAL ACCESSORY
assess the cochlear (auditory) component of
cranial nerve VIII (2)

Normal (1)

 Client hears whispered words from 1–2 feet  Ask the client to shrug
the shoulders against
 Weber test: Vibration heard equally well in both
resistance to assess the
ears
trapezius muscle
 Rinne test: AC > BC
Normal
Deviations from normal
 Symmetric
 Vibratory sound lateralizes to good ear in
 Strong contraction of the trapezius muscles
sensorineural loss
 Air conduction is longer than bone conduction Deviations from normal
CN IX, X – GLOSSOPHARYNGEAL, VAGUS  Asymmetric muscle contraction or drooping of the
shoulder
(3)
- paralysis or muscle weakness due to
TEST MOTOR FUNCTION neck injury or torticollis

 Ask the client to open mouth (2)

wide and say “ah” while you
 Ask the client to turn the head
use a tongue depressor on the
against resistance, first to the right
client’s tongue
then to the left, to assess the
Normal sternocleidomastoid muscle

 Uvula and soft palate rise Normal

bilaterally and symmetrically on
 strong contraction of sternocleidomastoid muscle
phonation
on the side opposite the turned face
Deviations from normal
Deviations from normal
 Soft palate does not rise
 Atrophy with fasciculations may be seen with
 bilateral lesions of cranial nerve X (vagus)
peripheral nerve disease
 Unilateral rising of the soft palate and deviation of
the uvula to the normal side CN XII – HYPOGLOSSAL
 unilateral lesion of cranial nerve X (vagus)
Assess strength and mobility of tongue
TEST GAG REFLEX
 Ask the client to protrude
 touch the posterior pharynx with the tongue tongue, move it to each side
depressor against the resistance of a tongue depressor, and
then put it back in the mouth
Normal  AKINESIA
- Complete or partial loss of voluntary
 Tongue movement is symmetric and smooth, and muscle movement
bilateral strength is apparent
 APHASIA
Deviations from normal - Absence or impairment of ability to
communicate through speech, writing, or
 Fasciculations and atrophy of the tongue signs
- peripheral nerve disease  APRAXIA
- Inability to carry out learned sequential
movements or commands
 CIRCUMLOCUTION
- Inability to name object verbally, so
patient talks around object or uses
gesture to define it
 Deviation to the affected side
 DYSARTHRIA
 unilateral lesion - Defective speech; inability to articulate
LEVEL OF CONSCIOUSNESS words; impairment of tongue and other
muscles needed for speech
 Alert  DYSPHASIA
- Follows commands in a timely fashion - Impaired or difficult speech
 Lethargic  DYSPHONIA
- Appears drowsy, may drift off to sleep - Difficulty with quality of voice;
during examination hoarseness
 Stuporous  NEOLOGISMS
- Requires vigorous stimulation (shaking, - Made-up, nonsense, meaningless words
shouting) for a response  PARAPHRASIA
 Comatose - Loss of ability to use words correctly and
- Does not respond appropriately to either coherently; words are jumbled or
verbal or painful stimuli misused
 TREMORS
GLASGOW COMA SCALE
- Involuntary movement of part of body
EYE OPENING RESPONSE  INTENSION TREMOR
Spontaneous opening 4 - Involuntary movement when attempting
To verbal command 3 coordinated movements
To pain 2  FASCICULATION
No response 1 - Involuntary contraction or twitching of
MOST APPROPRIATE VERBAL RESPONSE muscle fibers
Oriented 5
Confused 4 REFLEXES
Inappropriate words 3
 4+
Incoherent 2
- Hyperactive, very brisk, clonus,
No response 1
abnormal and indicative of a disorder
MOST INTEGRAL MOTOR RESPONSE (ARM)
Obeys verbal commands 6  3+
Localized pain 5 - More brisk or active than normal but not
Withdraws from pain 4 indicative of a disorder
Flexion (decorticate  2+
3 - Normal usual response
rigidity)
Extension (decerebrate  1+
2
rigidity) - Decreased and less active than normal
No response 1  0
- No response

BRACHIORADIALIS REFLEX

 Flex elbow with palm down

 Find the tendon above the
radius (usually 2 inch above
the wrist)
 Strike with the hammer (flat)
 Repeat on the other side
 Evaluates spinal levels C5 & C6
NEUROLOGICAL PROBLEMS
Normal
 AGNOSIA
- Visual Agnosia  Elbow extends, triceps contracts
- Tactile Agnosia  Ranges from 1+ to 3+
- Auditory Agnosia
Deviations from normal
 ASTEREOGNOSIS
- Inability to correctly identify objects  No response or an exaggerated response
 BICEPS REFLEX  Strike the Achilles
tendon with hammer
 Partially bend arm at (flat)
elbow with palm up
 Repeat on the other
 Place your thumb side
over the biceps
 Flex one knee and
tendon
support that leg against the other leg, dorsiflex
 Strike your thumb with the foot, tap the tendon using the flat side (client’s
the pointed side of the reflex hammer who cannot sit up)
 Repeat on the other side  Evaluates the function of spinal levels S1 and S2
 Evaluates the function of spinal levels C5 and C6
Normal
Normal
 In some older clients, the Achilles reflex may be
 Elbow flexes and contraction of the biceps absent or difficult to elicit
muscle
 Ranges from 1+ to 3+ Deviations from normal
 Forearm flexes and supinates
 No response or an exaggerated response
 Ranges from 1+ to 3+
PLANTAR REFLEX
Deviations from normal
 Stroke
 No response or an exaggerated response
lateral
TRICEPS REFLEX aspect of
the sole
 Ask client to hang arm freely from heel
support it w/ nondominant to ball of foot
hand  Use the end of the hammer
 Find tendon above the  Repeat on the other side
olecranon process  Evaluates the function of spinal levels L4, L5, S1,
 Tap it with the hammer (flat) and S2
 Repeat on the other side
 Evaluates the function of Normal
spinal levels C6, C7, and C8
 Flexion of toes
Normal
Deviations from normal
 Knee extends, quadriceps muscle contracts
 Toe adduction – (+) BABINSKI
 Ranges from 1+ to 3+
ABDOMINAL REFLEX
Deviations from normal
 Lightly stroke the abdomen on each side, above
 No response or exaggerated response and below the umbilicus
PATELLAR REFLEX  Evaluates the function of spinal levels T8, T9, and
T10 with the upper abdominal reflex
 Both legs hang freely off the side  Spinal levels T10, T11, and T12 with the lower
of the examination table abdominal reflex
 Find the patellar tendon (below
patella) Normal
 Strike with hammer (flat)  Abdominal muscles contract; the umbilicus
 Repeat on the other side deviates toward the side being stimulated
 Gently flex the knee and strike  Reflex concealed because of obesity or muscular
the patella (client’s who stretching from pregnancies
cannot sit up)
 Evaluates the function of Deviations from normal
spinal levels L2, L3, and L4
 Superficial reflexes may be absent with lower or
Normal upper motor neuron lesions

 Plantarflexion of the foot CREMASTERIC REFLEX

 Ranges from 1+ to 3+
 Lightly stroke the inner aspect of the upper thigh
Deviations from normal  Evaluates the function of spinal levels T12, L1,
and L2
 No response or an exaggerated response
Normal
ACHILLES REFLEX
 Scrotum elevates on stimulated side
 Both legs hang freely off
the side of the Deviations from normal
examination table,
dorsiflex the foot  Absence of reflex may indicate motor neuron
disorder
 TEST FOR MENINGEAL IRRITATION MUSCLES OF THE BODY – ANTERIOR

 Supine
 Place hands behind the patient’s head and flex
the neck forward until the chin touches the chest

Normal

 Neck is supple; client can easily

bend head and neck forward

Deviations from normal

 Pain in the neck and resistance to flexion can

arise from meningeal inflammation, arthritis, or
neck injury

BRUDZINSKI’S SIGN

 As you flex the neck watch the clients hips and

knees in reaction to your maneuver

Normal
MUSCLES OF THE BODY - POSTERIOR
 Hips and knees remain relaxed and motionless

Deviations from normal

 Pain and flexion of the hips and knees are

positive Brudzinski’s signs, suggesting
meningeal inflammation

KERNIG’S SIGN

 Flex the client’s leg at both hip and the knee, then
straighten the knee

Normal

 No pain is felt

Deviations from normal

 Pain and increased

resistance to extending
the knee are (+)
Kernig’s sign
 When bilateral = STRUCTURE AND FUNCTION
suspect meningeal
 The bones, muscles and joints make up the
irritation
musculoskeletal system.
 Controlled and innervated by the nervous system.

ASSESSMENT OF THE MUSKULO - SKELETAL BONES

(4)  Provide, structure, protection, serve as storage of

calcium and produced blood cells
MAJOR BONES OF THE SKELETON  206 bones: axial and appendicular skeleton
 Composed of osseous tissue
 Compact
- hard and dense, outer layer
 Spongy
- contains numerous spaces,
inner layer
 Osteoblasts
- bone formers
 Osteoclasts
- bone destroyers
 Red marrow
- produces blood cells
 Yellow marrow
- composed mostly of fats

SKELETAL MUSCLES

 Types: skeletal, smooth muscle, cardiac

 650 skeletal (voluntary) muscle, which are under  Protraction
conscious control - moving toward
 Assist with posture, produces body heat and  Retraction
allow body to move - moving backward

SKELETAL MUSCLE MOVEMENTS

 Abduction
- moving away from midline of the body
 Adduction
- moving toward midline of the body

 Rotation
- turning head to the right shoulder then
back to the midline, next turning the head
to left shoulder then back to midline

 Circumduction
- circular motion

JOINTS (ARTICULATION)

 Provide a variety of range of motion (ROM) for the

body parts

FIBROUS

- are joined by fibrous connective tissue

and are immovable
 (sutures bet. Skull bones)
 Inversion
- moving inward
 Eversion
- moving outward

CARTILAGINOUS

- are joined by cartilage

 joints bet. Vertebrae
 Extension
- straightening the extremity at the joint
and increasing the angle of the joint
 Flexion
- bending the extremity at the joint and
decreasing the angle of the joint

SYNOVIAL

 contain a space between the bones that is filled

 Pronation with synovial fluid, a lubricant that promotes a
- turning or facing downward sliding movement of the ends of the bones
 Supination
- turning or facing upward
 TEMPOROMANDIBULAR JOINTS  adduction
 radial and ulnar deviation
 open and closes the mouth
 projects and retracts the jaw
 moves jaw from side to side

 Fingers
 flexion, extension
 hyperextension
 abduction
 circumduction
 Thumb
 flexion, extension
 opposition
STERNOCLAVICULAR JOINTS

 has no obvious movements

 junction between the manubrium of the sternum
and the clavicle

ELBOW

 flexion and extension of the forearm

 supination and pronation of the forearm

SHOULDER

 Flexion and extension

 Abduction and adduction
 Circumduction
 Rotation (internal and external)

KNEE

 flexion and extension

HIP

 Flexion with knee flexed and with knee extended

 Extension and hyperextension
 Circumduction ANKLE AND FOOT
 Rotation (internal and external)
 Abduction and adduction  Ankle
 plantar flexion and dorsiflexion
 Foot
 inversion and eversion
 Toes
 flexion, extension
 abduction, adduction

WRISTS, FINGERS & THUMB

 Wrists
 flexion, extension
 hyperextension
 VERTEBRAE (LATERAL VIEW) Deviations from normal

 33 bones  atonic (lacking tone)

 C – 7 concave-shaped
 T – 12 convex-shaped
 L – 5 concave-shaped Palpate muscles while the client is active and passive for
 S–5 flaccidity, spasticity, and smoothness of movement
 Cx – 3-4 Normal Findings
 Flexion
 Hyperextension  smooth coordinated movements
 lateral bending
Deviations from normal
 rotation
 flaccidity (weakness or laxness) or spasticity
(sudden involuntary muscle contraction)

Test muscle strength. Compare the right side with left

side.

Normal

 equal strength on each body side

ASSESSMENT PROPER
Deviations from normal
(3)
 25% or less muscle strength
INSPECTION  GRADING MUSCLE STRENGTH
Inspect Muscles for Size

 Compare each muscle on one side of the body to

the same muscle on the other side
 For any apparent discrepancies, measure the
muscles with a tape

Normal

 equal size on both sides of body

Deviations from normal

 ATROPHY (a decrease in size) or

Sternocleidomastoid
HYPERTROPHY (an increased in size)
 Client turns the head to one side against the
resistance of your hand. Repeat with the other
Inspect Muscles and Tendons for Contractures
side.
Normal
Trapezius
 no contractures
 Client shrugs the shoulders against the
Deviations from normal resistance of your hands.

 Malposition of body part (foot drop or foot flexed Deltoid

forward)
 Client holds arm up and
resists while you try to
Inspect Muscles for Tremors push it down.

 Inspect any tremors of the hands and arms by Biceps

having the client hold arms out in front of body
 Client fully extends each
Normal arm and tries to flex it
while you attempt to
 no fasciculation or tremors hold arm in extension.
Deviations from normal Triceps
 presence of fasciculation or tremors  Client flexes each arm and
then tries to extends it
PALPATION against your attempt to
keep in flexion
Palpate muscles at rest to determine muscle tonicity
Wrist and Finger Muscles
Normal
 Client spreads the fingers and resists as you
 normally firm attempt to push the fingers together.
Grip Strength Deviation from normal

 Client grasps your index finger and middle fingers  one or more swollen joints
while you try to pull the fingers out.

Hip Muscles Palpate each joint for tenderness, smoothness of

movement, swelling, crepitation, and presence of
 Client is supine, both nodules.
legs extended; client
raises one leg at a time Normal Findings
while you attempt to hold it down.
 No tenderness, swelling, crepitation, or nodules
Hip Abduction
Deviation from normal
 Client is supine, both legs extended. Place your
hands on the lateral surface of each knee; client  Presence of tenderness, swelling, crepitation, or
spreads the legs apart against your resistance. nodules

Hip Adduction RANGE OF MOTION (ROM)

 Client is in same position as in hip abduction.  Ask the client to

Place your hands between the knees; client move selected body
brings the legs together against your resistance. parts. If available,
use a goniometer to
Hamstrings measure the angle of
the joint in degrees.
 Client is supine, both knees bent.
 Client resists while you Normal
attempt to straighten the
 Varies to some degree in accordance with
legs.
person’s genetic makeup and degree of physical
Quadriceps activity

 Client is supine, knee Deviations from normal

partially extended; client
 Presence of tenderness, swelling, crepitation, or
resists while you attempt to
nodules
flex the knee.
RANGE OF MOTIONS
Muscles of the Ankle and Feet
(1)
 Client resists while you attempt to dorsiflex the
foot and again resists while you attempt to flex the NECK-PIVOT JOINT
foot.

PALPATION & INSPECTION

(2)

BONES

Inspect the skeleton for normal structure and deformities.

Normal

 no deformities  Flexion
- Move the head from the upright midline
Deviation from normal position forward, so that the chin rests on
the chest
 bones misaligned
 Extension
- Move the head from the flexed position to
Palpate the bones to locate any areas of edema or the upright position
tenderness.  Hyperextension
- Move the head from the upright position
Normal back as far as possible
 no tenderness of swelling
 Lateral Flexion
Deviation from normal - Move the head laterally to the right and
left shoulders
 presence of tenderness of swelling

JOINTS

Inspect the joint for swelling.

Normal

 no swelling
 Rotation SHOULDER-BALL-SOCKET JOINT
- Move the head laterally to the right and
left shoulders  External Rotation
- With each arm
held out to the
side at shoulder
level and the
elbow bent to a
right angle,
fingers pointing
down, move the
arm upward so
that the fingers point up
 Internal Rotation
SHOULDER-BALL-SOCKET JOINT
- With each arm held out to the side at
 Flexion shoulder level and the elbow bent to a
- Raise each right angle, fingers pointing up, move the
arm from a arm forward and down so that the fingers
position by point down
the side
ELBOW-HINGE JOINT
forward and
upward to a  Rotation for
position supination
beside the - Turn each hand
head and forearm so
 Extension that the palm is
- Move each arm from a vertical position facing upward
beside the head forward and down to a  Rotation for pronation
resting position at the side of the body - Turn each hand
 Hyperextension and forearm so
- Move each arm from a resting side that the palm is
position to behind the body facing
downward
 Abduction
- Move each arm WRIST-CONDYLOID JOINT
laterally from a
 Flexion
resting position at
- Bring the
the sides to a side
fingers of
position above the
each hand
head, palm of the
toward the
hand away from
inner
the head
aspect of the forearm
 Adduction (Anterior)
 Extension
- Move each arm from a position at the
- Straighten each hand to the same plane
sides across the front of the body as far
as the arm
as possible
- The elbow may be straight or bent
 Hyperextension
- Bend the fingers of each hand back as far
 Circumduction
as possible
- Move each arm forward, up, back, and
down in a full circle

 Radial Flexion
ELBOW-HINGE JOINT
(Abduction)
 Flexion - Bend each wrist
- Move each arm laterally toward the
forward, up, back, thumb side with
and down in a full hand supinated
circle  Ulnar Flexion (Adduction)
 Extension - Bend each wrist
- Bring each lower laterally toward the
arm forward and downward, fifth finger with the
straightening hand supinated
 Flexion - Move each leg back to the other leg and
- Make a fist beyond in front of it.
with each
hand;
Extension.
Straighten the
fingers of each hand
 Hyperextension
- Bend the fingers of each hand back as far
as possible  Circumduction
- Move each leg
 Abduction backward, up, to the
- Spread the fingers of side, and down in a
each hand apart circle
 Adduction  Internal Rotation
- Bring the fingers of each - Turn each foot and
hand together leg inward so that
the toes point as far
THUM-SADDLE JOINT as possible toward
the other leg.
 Flexion
- Move each thumb across  External Rotation
the palmar surface of the - Turn each foot and
hand toward the fifth finger leg outward so that
the toes point as far
 Extension
as possible away from the other leg.
- Move each thumb away
from the hand KNEE-HINGE JOINT

 Abduction  Flexion
- Extend each thumb - Bend each leg,
laterally bringing the heel
 Adduction toward the back
- Move each thumb back to of the thigh.
the hand  Extension
 Opposition - Straighten each
- Touch each thumb to the leg, returning the
top of each finger of the foot to its
same hand. position beside the other foot.
- The thumb joint
ANKLE-HINGE JOINT
movements involved are
abduction, rotation, and  Flexion (dorsiflexion)
flexion. - Point the toes of
each foot
HIP-BALL-AND-SOCKET JOINT
upward.
 Flexion  Extension (plantar
- Move each leg forward and upward. flexion)
- The knee may be extended or flexed. - Point the toes of
each foot downward.

FOOT GLIDING

 Eversion
- Turn the sole of
each laterally
 Inversion
- Turn the sole of
each foot
 Extension
medially
- Move each
leg back TOES
inside the
other.  Flexion
 Hyperextension - Curl the toe joints of each foot downward
- Move each  Extension
leg back - Straighten the toes of each foot
behind the body.

 Abduction
- Move each leg out to the side.
 Adduction
 TRUNK-GLIDING JOINT  Tenosynovitis
- painful flexion of a finger (infection of the
 Flexion flexor tendon sheathes)
- Bend the trunk
toward the toes ABNORMALITIES OF FEET AND TOES
 Extension
- Straighten the  Acute – Gouty Arthritis
trunk from a flexed - metatarsophalangeal joint of the great
position toe is tender, painful, reddened, hot and
swollen
 Hyperextension
- Bend the  Callus
trunk backward - are non-painful, thickened skin that occur
at pressure points
 Lateral Flexion  Corn
- Bend the trunk to the right and to the left - are painful thickening of the skin that
occur over the bony prominences and at
pressure points
 Plantar Wart
- are painful warts (verruca vulgaris) that
often occur under a callus, appearing as
tiny dark spots
 Hallux Valgus
- the great toe is deviated laterally and
may overlap the second toe

 Rotation
- Turn the upper part of the body from side WEEK 15: ASSESSMENT OF THE MALE GENITALIA
to side ↓ AND RECTUM

(1)

INSPECTION

(1)

PUBIC HAIR

 Note hair distribution pattern

Normal

ABNORMALITIES AFFECTING THE WRIST, HANDS  Triangular

AND FINGERS  sparsely distributed on scrotum and inner thigh
 absent on penis
 Acute Rheumatoid Arthritis
 genital hair coarse
- tender, painful, swollen, stiff joints
 no nits or lice
 Chronic Rheumatoid Arthritis
- chronic swelling and thickening of the Deviations from normal
metacarpophalangeal and proximal
interphalangeal joints, limited ROM, and  sparse
finger deviation toward the ulnar side  absent hair (alopecia)
 Boutonniere and Swan-neck Deformities
PENIS
- flexion of the proximal interphalangeal
joint and hyperextension of the distal  Note color, lesions, swelling, discharge, or pubic
interphalangeal joint pediculosis on dorsal, lateral, and ventral sides
- hyperextension of the proximal  If UNCIRCUMCISED, retract foreskin.
interphalangeal joint with flexion of the  Note ease of retraction of foreskin and inspect
distal interphalangeal joint glans
 Thenar Atrophy
- atrophy of the thenar prominence due to Normal
pressure on the median nerve is seen in
 No lesions or inflammation
carpal tunnel syndrome
 Shaft skin loose and wrinkled without erection
 Ganglion
- non-tender, round, enlarged, swollen,  Glans smooth and free of lesions, swelling, or
fluid- filled cyst and commonly seen at inflammation
the dorsum of the wrist  No penile discharge
 Osteoarthritis  Dorsal vein sometimes visible
- hard, painless, nodule over the distal  If patient is uncircumcised,
interphalangeal joints (Heberden’s loose skin on the penis shaft
nodes) and over the proximal folds to cover glans, forming
interphalangeal joints (Bouchard’s the foreskin
nodes)  Foreskin retracts easily
Deviations from normal SCROTUM

 CHANCRE  Note color, hair distribution, lesions, size, shape,

 Signals primary and position
syphilis
- Painless Normal
- Ulcerated  Scrotal skin rugated, thin, and
- Exudative more deeply pigmented than body color
- papular lesion with an
 Skin firmer in young men and elongates with
erythematous halo surrounding flaccidity in older men
edema a friable base
 Skin free of lesions, nodules, swelling,
 CHANCROID inflammation, and erythema
 Caused by
 Scrotal size and shape vary greatly
Haemophilus
 Left scrotal sac lower than right
through small breaks
in epidermal tissue DEVIATIONS FROM NORMAL
 Pinhead papules to cauliflower – like
groupings of painful lesions  SCROTAL MASS
 PENILE LESIONS  Can arise from
benign or
malignant
conditions
 SCROTAL SWELLING
 CONDYLOMA ACUMINATUM (genital warts)  Seen with inguinal hernia, hydrocele,
 Caused by HPV infection varicocele, spermatocele, tumor, and
 Multifocal, wartlike, edema
maculopapular  HYDROCELE
lesions that are tan,  Nontender
brown, pink, violet, or ACCUMULATION OF
white FLUID between two
 CANDIDA layers of tunica
 Superficial mycotic vaginalis in scrotum
infection of moist  May be idiopathic
cutaneous sites (cause is unknown) or a result of trauma,
 Erythematous inguinal surgery, epididymitis, or tumor
plaques with scaling, papular lesions  Mass transilluminates
with sharp margins and occasionally  SPERMATOCELE
clear centers and pustules  Nontender, well-
 HERPETIC LESION defined CYSTIC MASS
 Herpes simplex on superior testis or
virus 1 and 2 cause epididymis caused by
painful eruptions of blockage of efferent
pustules and ductules of rete testis
vesicles that rupture  VARICOCELE
 Fever, headache, dysuria,  VARICOSE VEINS of
DYSPAREUNIA, and urinary retention spermatic cord that
may occur feel like a “bag of
 TINEA CRURIS worms” and slowly
 Fungal infection of collapse when scrotum
the groin often is elevated
referred to as jock  Caused by DILATED
itch VEINS in pampiniform plexus of
 PRIAPISM spermatic cord
 Often associated with  Right-sided may indicate obstruction at
leukemia, metastatic vena cava
carcinoma, or sickling  SEBACEOUS CYST
hemoglobinopathies  Round, firm,
- Removal of excess blood to nontender
tone down erection CUTANEOUS
CYST confined to scrotal skin
 CHORDEE
 Ventral or dorsal  May result from decrease in localized
curvature of penis circulation and closure of sebaceous
 Ventral chordee seen glands or ducts
mostly with epispadias URETHRAL MEATUS
 PHIMOSIS
 Occurs in  Note position of urinary
uncircumcised males meatus
 Foreskin is unable
to retract and may become swollen
Normal PENIS

 Located centrally on glans  Lightly palpate shaft with

 Pink in white males and darker pink in darker- thumb and index finger
skinned males  Note consistency,
 No discharge tenderness, masses, or
nodules
Deviations from normal
Normal
 EPISPADIAS
 Urethral meatus opens on dorsal  Pulsations on dorsal sides
(upper) side of penis  Nontender
 A congenital defect  No masses or firm plaques

Deviations from normal

 Diminished/absent palpable pulse:

 Possible vascular insufficiency
 Normal blood flow may be
affected by systemic disease,
localized trauma, or localized
 HYPOSPADIAS disease
 Urethral meatus opens on ventral  Priapism is associated with spinal cord lesions or
(under) side of penis sickle cell anemia
 A congenital defect

 Penis should not be enlarged in nonerect state

 Phimosis and paraphimosis

INGUINAL AREA

 Note condition
of skin, enlarged
lymph nodes
 Have patient URETHRAL MEATUS
bear down and
note any bulges  Note discharge

Normal Normal

 No swelling or bulges  No discharge and drainage

 Lymph nodes nonpalpable
Deviations from normal
Deviations from normal
 Purulent discharge or mucus
 Bulge shreds
 May indicate a hernia or enlarged lymph  Bacterial infection of GU
node tract
 Color, consistency, and
ASSESSMENT TECHNIQUES amount may vary
 Bacterial infection causes inflammation with
(1)
leukocytes, shedding tissue cells, and bacteria
ANUS

 Note skin condition,

lesions, rectal prolapse,
hemorrhoids, fissures,  Penile discharges
bleeding, or discharge

Normal

 Skin intact with slightly darker pigmentation

around anus
SCROTUM
 Anus intact; no lesions, hemorrhoids, fissures,
bleeding, or rectal prolapse  Use thumb and two fingers
Deviations from normal to gently palpate scrotum,
and note size, shape,
 STD lesions, warts, consistency, mobility,
hemorrhoids, fissures, tenderness, masses, or
bleeding, rectal prolapse nodules of testes
  Palpate the epididymis and vas  Red glow on transillumination
deferens on posterolateral  Serous fluid within
surface and note swelling or scrotal sac
nodules  Occurs in hydrocele
 Transillumination: and spermatocele

INGUINAL AREA

 Horizontal lymph nodes

 Palpate inguinal
- If a mass, lump, or swelling is present, area
shine light over area and note  Vertical lymph nodes
transmission of light  Palpate inner
aspect of thigh
Normal

 Scrotum contains a testicle

and epididymis on each  Hernias:
side  Place
 Testicles firm but not hard, gloved
oval, smooth, equal in size, index finger
and sensitive to pressure but not tender in scrotal
sac above
 Epididymis comma-shaped, distinguishable from
testicle and invaginate sac
testicle, and insensitive to pressure
 Follow spermatic cord to
 Spermatic cord smooth and round
Hesselbach’s triangle, advance
Deviations from normal through external inguinal ring, ask patient
to bear down, and feel for bulges
 A unilateral mass palpated
within or about the testicle is
abnormal
 Intratesticular masses are
nodular and painless and should be considered
malignant until proven otherwise
 Testicle that is enlarged, retracted, in a lateral Normal
position, and extremely sensitive
 Testicular torsion  No red glow on
transillumination
 Nodes if palpable should be
less than 1 cm and freely mobile
 No bulges present in inguinal area
 No palpable masses in inguinal
canal
 Indurated, swollen, tender  No portions of the bowel enter the
epididymis is abnormal scrotum
 Undescended testes is
abnormal
 Cryptorchidism (absence of
testes and epididymis in
scrotal sac):
 Related to testicular
 No palpable masses at femoral canal
failure, deficient
gonadotrophic
stimulation,
mechanical obstruction, or
gubernacular defects
 The undescended testes have a
histologic change by age 6, so refer
patient as early as possible
 Orchitis is acute, painful Deviations from normal
swelling of testicle and
warm scrotal skin  Unilateral or bilateral
 Patient may feel enlargement of inguinal
heaviness in scrotum lymph nodes
 Bacterial infection
 Atrophic testicle and scrotal edema are abnormal
Nodes may be
tender or painless
 Unilateral or bilateral enlargement of inguinal
lymph nodes:
- Metastatic disease
  Hernias
 Indirect inguinal
hernia comes down
inguinal canal and is
palpated at inguinal
ring or in scrotum

Deviations from normal

 Soft, nontender, enlarged prostate:

 BPH
- Related to aging and presence
of dihydroxy – testosterone
 Direct inguinal hernia bowel herniates
from behind and through the external
inguinal ring

 Firm, tender, or fluctuant mass on prostate:

 Acute bacterial prostatitis
- UTIs commonly occur
 Femoral hernia concurrently
where bowel - Increased risk for prostatic
herniates through abscess
the femoral ring and
canal
- It never travels into the scrotum,
and the inguinal canal is empty
- Common in females

 Extremely tender, warm prostate:

 Bacterial prostatitis
- Do not palpate vigorously. This
would be painful and might
cause bacteremia
 Firm, hard, or indurated single or multiple
nodules:
 Possible prostate cancer
RECTUM

 If indicated, change gloves and

apply water-soluble lubricant on
index finger
 Have patient bend over exam table
and bear down
 Gently insert finger into rectum, and note
sphincter tone, tenderness, masses,  Positive occult blood test
hemorrhoids, or bleeding warrants further evaluation
 Palpable mass or
nodule
- Polyp or
internal
hemorrhoid
 Hard mass
PROSTATE  Possible rectal cancer

 Note size, shape, symmetry,

consistency, mobility, ASSESSMENT OF THE FEMALE GENITALIA
nodules, tenderness
 Withdraw fingers; if stool DEVELOPMENT OF PUBIC HAIR
present, test for occult blood
STAGE 1
Normal
 Preadolescent: no pubic hair
 Rectum smooth and nontender with good anal except for fine body hair similar
sphincter tone to hair on abdomen
 Prostate small, smooth, mobile, and nontender
medial sulcus palpable negative occult blood
 STAGE 2  slightly pigmented skin without
- ecchymosis
 Sparse growth of long, slightly - excoriation
pigmented, downy hair, straight or - nodules
only slightly curled, mostly along - edema
labia. - rash
STAGE 3 - lesions

 Hair becomes darker, coarser, and
curlier and spreads sparsely over
pubic symphysis
CLITORIS
 Note position, redness or lesions
 Clitoris about 2 cm long and 0.5 cm in diameter
 No redness or lesions

STAGE 4

 Pubic hair is coarse and curly

in adults. It covers more area
than in stage 3 but not as
much as in adults
URETHRAL ORIFICE

 Use thumb on dominant hand to separate labia

STAGE 5 minora to expose urethral meatus, which is very
sensitive to touch
 Quality and quantity are  Note shape, color, and
consistent with adult pubic hair size
distribution and spread over  Note color, position,
medial surfaces of things but redness, edema,
not over abdomen lesions, or discharge
 Urethral opening slit-
ASSESSMENT PROPER like, midline, and free of discharge, swelling,
redness, or lesions
(1)
PERINEUM AND ANUS
INSPECTION
 Perineum is
smooth and
slightly
darkened
 A well-healed
episiotomy scar
SKIN is normal after
vaginal delivery
 With patient in lithotomy position  Anus is dark pink to brown and puckered
 note for pubic  Skin tags are common around anal area
hair distribution
 Note color, lesions, bulges, or hemorrhoids
 check skin for
lesions DEVIATIONS FROM NORMAL
 edema
 ecchymosis  Pubic lice, nits, or flecks of residual blood on skin
 pubic
pediculosis

Normal

 Pubic hair is
distributed in an
inverted triangular  Ecchymosis
pattern  May be caused by blunt trauma
 May be some growth
on abdomen and
upper inner thighs
 Diamond-shaped pattern
extending up to the
umbilicus  Labial varicosities
 No signs of infestation  Pregnancy or uterine tumor
 Skin over mons pubis is clear
 Older clients may have gray, thinning pubic hair
 Labia majora and minora
 symmetrical with smooth to moderately
wrinkled
 Edema  Swelling or redness around
 Hematoma meatus:
formation,  Possible infection of
obstruction of - Skene’s
lymphatic system gland
 Broken areas of skin - urethral
 Ulcerations or abrasions caused by caruncle
infection or - urethral carcinoma
trauma - prolapse of urethral mucosa
 Rash over mons pubis  Possible atrophy (area becomes smaller) from
and labia topical steroids and aging
 Chancre
 Primary syphilis.
Painless,
reddish, round ulcer with depressed
center and indurated edges
 Condylomata acuminatum
(venereal warts):
 White, dry, painful  Foul-smelling discharge that is not clear to slightly
growths with narrow pale white is abnormal
bases  Gonorrhea
 Cause  Chlamydia
- HPV  Candida
 Herpes simplex  Trichomonas
 Small, red,  Bacterial vaginosis
painful vesicles  Atrophic vaginitis
that progress to  Cervicitis
ulcer stage  External tear
 Pruritus may be  May indicate trauma from sexual activity
present or abuse
 Hypertrophy of clitoris
 May indicate female
PSEUDOHERMAPHRODITISM caused
by androgen excess

 Fissure
 May indicate congenital malformation or
childbirth trauma
 Cystocele is bulging of bladder into anterior
vaginal wall
 Chancroid
 Painful ulcer with rough floor and
purulent yellow exudate heals, leaving a
scar

 Cystourethrocele is bulging of anterior vaginal

wall, bladder, and urethra into vaginal introitus

 Discharge of any color from meatus

 May indicate UTI

 Fissure or tear of perineum:

 Trauma
 Abscess
 Unhealed episiotomy
 Female circumcision is removal of all or part of
the clitoris, labia minora, and labia majora,
usually in early childhood or early adolescence
 This practice is
widespread in
many African
countries and
among some Muslim groups
  Venous prominences in anal area
 May indicate external hemorrhoids
Normal
 Milking urethra no pain or urethral discharge
 Skene’s glands surround urethral meatus
 Bartholin’s glands deep in perineal structures

VAGINAL INTROITUS

 Keep your finger in the

vagina, and ask the patient
 Perineal Laceration to squeeze the vaginal
muscles around it

Normal

 Vaginal muscle tone tight

and strong in nulliparous
women and diminished in parous women
 Vaginal Necrosis / Ecchymosis
PERINEUM

 Partially remove your finger from the introitus until

it is posterior to the perineum, with your thumb
anterior to the perineum
 Rectocele  Assess tone and texture
 Prolapse of the front wall of the rectum to
Normal
the back wall of the vagina
 Perineum smooth, firm, and homogenous in
nulliparous women and thinner in parous women

DEVIATIONS FROM NORMAL

 Cystourethrocele  Swelling, redness, induration, or purulent
discharge from labial folds with hot, tender areas
 Bartholin’s gland infection
- Cause
 Gonococci
 Chlamydia trachomatis
PALPATION

(1)

LABIA

 Palpate each labium between thumb and index

finger of your dominant hand

 Pain and discharge

 Skene’s gland infection
- UTI
Normal

 Labia soft and uniform in structure with no

swelling, pain, induration, or purulent discharge

URETHRAL MEATUS, SKENE'S & BARTHOLIN'S

GLANDS

 Insert index finger of

your dominant hand
into vagina, and apply  Significantly diminished/absent muscle tone
pressure to anterior  Cause
aspect of vaginal wall - Injury
to milk urethra - Age
 Swab any discharge - childbirth
with cotton-tipped  Bulging from vagina
applicator for microscopic exam  Cystocele
 Rectocele
 Uterine prolapse
 Thin perineum, fissures, tears
 Atrophy
 Trauma
 Unhealed episiotomy
 ANUS AND RECTUM
(1)
INSPECTION
(1)
PERINEAL AREA
 Inspect the perianal area. Spread the client’s
buttocks and inspect the anal opening and
surrounding area for the following:
 Lumps
 Ulcers
 Lesions
 Rashes
 Redness
 Fissures
Normal findings
 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.
Abnormal findings
 Lesions may indicate STIs, cancer, or
hemorrhoids.
 A thrombosed external hemorrhoid appears
swollen.
 It is itchy, painful, and bleeds when the client
passes stool.
 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
 Thickening of the epithelium suggests repeated
trauma from anal intercourse
VALSALVA’S MANEUVER
 Ask the client to perform Valsalva’s maneuver by
straining or bearing down. Inspect the anal
opening for any bulges or lesions.
Normal findings
 No bulging or lesions appear.
Abnormal findings
 Bulges of red mucous membrane may indicate a
rectal prolapse.
 Hemorrhoids or an anal fissure may also be seen
PALPATION
(1)
ANUS
Palpate the anus.
 Inform the client that you are going to perform the
internal examination at this point.
 Explain that it may feel like her 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.
Normal findings
 Client’s sphincter relaxes, permitting entry
Abnormal findings
 Sphincter tightens, making further examination
unrealistic.
RECTUM
 Palpate the rectum.
 Insert your finger further into the rectum as far as
possible
 Next, turn your hand clockwise then
counterclockwise.
 This allows palpation of as much rectal surface as
possible.
 Note tenderness, irregularities, nodules, and
hardness.
Normal findings
 The rectal mucosa is normally soft, smooth,
nontender, and free of nodules
Abnormal findings
 Hardness and irregularities may be from scarring
or cancer. Nodules may indicate polyps or cancer
CERVIX
 Palpate the cervix through the anterior rectal wall.
Normal findings
 Cervix palpated as small round mass.
 May also palpate tampon or retroverted uterus.
 Should not have any bright red blood when
gloved finger is removed.
Abnormal findings
 Bright red blood on gloved finger when removed.
 Large mass palpated.
 Do not mistake tampon for mass.
WEEK 16: RELEVANT ETHICO-LEGAL GUIDELINES
IN CONDUCTING HEALTH ASSESSMENT
(1)
RELEVANT ETHICO-LEGAL CONSIDERATIONS IN
CONDUCTING HEALTH ASSESSMENT
(1)
PHILIPPINE NURSING CODE OF ETHICS
 Promulgated by the Philippine Regulatory Board
of Nursing
 Philippine Nurses Association and Association of
Nursing Service Administrators of the Philippines