Physical Assessment Handouts

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Physical Assessment Handouts

1. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 1  Is the use of hand to touch for the purpose of determining temperature, moisture, size,
shape, position, texture, consistency, and movement. TYPES OF PALPATION Light Palpation  To check muscle tone and assess for tenderness Techniques: Place the hand with fingers
together parallel to the area being palpated. Press down 1 to 2 cm. Repeat in ever-widening circles until the area to be NURSING SKILLS examined is covered. Physical Assessment
Lecturer: Mark Fredderick R. Abejo R.N, M.A.N PHYSICAL ASSESSMENT Objectives: Deep Palpation  Obtain physical data about the client’s functional  To identify abdominal organs
and abdominal masses. abilities Techniques:  Supplement, confirm, or refuse data obtained in the With fingers together, approach the area to nursing history be examined at a 60
degree angle and use the pads and  Obtain data that will help the nurse data establish tips of the fingers of one hand to press in 4 cm. nursing diagnoses and plan the client’s care. 
Evaluate the physiologic outcomes of health care and Two – handed Deep Palpation place the fingers of one thus the progress of a patient’s health problem hand on top of those of
the other.  Screen presence of cancer CEPHALOCAUDAL ORDER OF EXAMINATION AREAS  HEENT  NECK  UPPER EXTREMITIES  CHEST AND BACK  BREAST AND AXILLAE 
ABDOMEN  GENITALS PERCUSSION  ANUS AND RECTUM  Striking of the body surface with short, sharp strokes  LOWER EXTREMITIES in order to produce palpable vibrations and
Note: SKIN IS CHECK THROUGHTOUT THE characteristic sound. ASSESSMENT  It is used to determine the location, size, shape, and density of underlying structures; to detect the
presence General Concepts: of air or fluid in a body space; and to elicit tenderness. Approach the client calmly and confidently. TYPES OF PERCUSSION Provide privacy. Direct
Percussion Make sure that all needed instruments are available  Percussion in which one hand is used and the striking before starting the physical assessment finger (plexor) of the
examiner touches the surface Several positions are frequently required during the being percussed. assessment. Consider the client’s ability to assume a Techniques: position. Using
sharp rapid movements from the wrist, strike Be systematic and organized when assessing the the body surface to be percussed with the pads of two, client. (Inspection, Palpation,
Percussion, Auscultation three, or four fingers or with the pad of the middle If a client is seriously ill, assess the systems of the finger alone. Primarily used to assess sinuses in the body
that are more at risk adult. Perform painful procedures at the end of the Indirect Percussion examination  Percussion in which two hands are used and the plexor strikes the finger of
the examiner’s other hand, which METHODS OF EXAMINING is in contact with the body surface being percussed (pleximeter).  INSPECTION Techniques:  PALPATION Strike at a right
angle to the pleximeter using quick,  PERCUSSION sharp but relaxed wrist motion.  AUSCULTATION Withdraw the plexor immediately after the strike to avoid damping the vibration.
Strike each are twice and INSPECTION then move to a new area  Visual examination of the patient done in a methodical and deliberate manner. Blunt  Ulnar surface of the hand or
fist is used in place of the PALPATION fingers to strike the body surface, either directly or indirectly. Foundations of Nursing Abejo Physical Assessment
2. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 2 PERCUSSION SOUNDS Procedure: 1. Inspects skin surfaces RESONANCE – Hollow sound. Ex.
normal lung. 1. 2. Palpates with fingertips for edema and skin turgor HYPERRESONANCE – Booming sound. Ex. 2. 3. Palpates skin temperature contra-laterally using back
Emphysematous lung of hands 3. TYMPANY – musical or drum sound. Ex. Stomach and intestines Assessment: 4. DULLNESS – Thud sound. Ex. Enlarged spleen, full bladder, liver.
Health History 5. FLATNESS – extremely dull sound. Ex. Muscle or  Presenting problem bone  Changes in the color and texture of the skin, hair AUSCULTATION and nails.  Listening
to sounds produced inside the body  Pruritus  Infections  Tumors and other lesions EQUIPMENTS FOR PHYSICAL  Dermatitis EXAMINATION  Ecchymoses  Dryness 
Sphygmomanometer and stethoscope  Lifestyle practices  Thermometer  Hygienic practices  Nasal Speculum  Skin exposure  Ophthalmoscope  Nutrition / diet  Otoscope
 Intake of vitamins and essential nutrients  Vaginal Speculum  Water and Food allergies  Tongue depressor/blade  Use of medications  Penlight  Steroids  Cotton
Applicators  Antibiotics  Tuning fork  Vitamins  Reflex hammer  Hormones  Clean gloves  Chemotherapeutic drugs  Lubricant  Past medical history  Renal and hepatic
disease  Collagen and other connective tissue diseases GENERAL SURVEY  Trauma or previous surgery  Food, drug or contact allergies VITAL SIGNS  Family medical history
GENERAL SURVEY  Diabetes mellitus  Allergic disorders 1. Physical Appearance  Blood dyscrasias 2. Level of Conciousness/ awareness  Specific dermatologic problems 
Alertness– Patient is awake and aware of self  Cancer and environment.  Lethargy – When spoken to in a loud voice, Physical Examination patient appears drowsy but opens eye,
and look  Color at you, responds to questions, then falls asleep.  Areas of uniform color  Obtundation – When shaken gently, patient  Pigmentation opens eye and looks at you
but responds  Redness slowly and is somewhat confused.  Jaundice  Stupor – Patient arouses from sleep only after  Cyanosis painful stimuli.  Vascular changes  Coma –
Despite repeated painful stimuli,  Purpuric lesions patient remains unarousable with eyes closed.  Ecchymoses  Petechiae 3. Apperance in relation to chronological age  Vascular
lesions 4. Signs of distress  Angiomas 5. Nutritional status  Hemangiomas 6. Body structure  Venous stars 7. Obvious physical deformities  Lesions 8. Mobility  Color 9. Behavior
 Type 10. Odors of body and breath  Size 11. Facial Expression  Distribution 12. Mood & affect  Location 13. Speech  Consistency  Grouping  Annular SYSTEMS ASSESSMENT 
Linear  Circular INTEGUMENTARY SYSTEM  Clustered Functions of the Skin:  Edema (pitting or non-pitting)  Protection  Moisture content  Absorption  Temperature
(increased or decreased;  Regulation distribution of temperature changes)  Synthesis  Texture  Sensory  Mobility / Turgor Foundations of Nursing Abejo Physical Assessment
3. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 3 Hypertrophic scar on the other hand does not Effects of Aging in the Skin overgrow the
wound boundaries.  Skin vascularity and the number of sweat and Fibrosis or sclerosis describes dermal sebaceous glands decrease, affecting scarring/thickening reactions.
thermoregulation. Milium is a small superficial cyst containing keratin  Inflammatory response and pain perception diminish. (usually <1-2 mm in size  Thinning epidermis and
prolonged wound healing make elderly more prone to injury and skin infections. Vascular Skin Lesions  Skin cancer more common. Petechiae is a round or purple macule,
associated with Primary Lesions of the Skin bleeding tendencies or emboli to skin Ecchymosis a round or irregular macular lesion larger Macule is a small spot that is not palpable and
is less than petechiae, color varies and changes from black, than 1 cm in diameter yellow and green hues. Associated with trauma and Patch is a large spot that is not palpable & that
is > 1 bleeding tendencies. cm. Cherry Angioma, popular and round, red or purple, Papule is a small superficial bump that is elevated & may blanch with pressure and a normal age-
related that is < 1 cm. skin alteration. Plaque is a large superficial bump that is elevated & > Spider Angioma is a red, arteriole lesion, central 1 cm. body with radiating branches.
Commonly seen on Nodule is a small bump with a significant deep face,neck,arms and trunk. Associated with liver component & is < 1 cm. disease, pregnancy and vitB deficiency.
Tumor is a large bump with a significant deep Telangiectasia , shaped varies: spider-like or linear, component & is > 1 cm. bluish in color or sometimes red. Does not blanch Cyst is a
sac containing fluid or semisolid material, ie. when pressure applied. Secondary to superficial cell or cell products. dilation of venous vessels and capillaries. Vesicle is a small fluid-
filled bubble that is usually superficial & that is < 0.5 cm. Bulla is a large fluid-filled bubble that is superficial or Edema - the presence of large amounts of fluid in the interstitial deep &
that is > 0.5 cm. spaces. Usually due to fluid collecting in the subcutaneous Pustule is pus containing bubble often categorized tissue. Edema may be localized or generalized.
according to whether or not they are related to hair follicles:  follicular - generally indicative of local A. Some causes are lymphatic obstruction, infection increased vascular
permeability, decreased  folliculitis - superficial, generally multiple oncotic pressure due to low levels of plasma  furuncle - deeper form of folliculitis proteins (especially albumin),
or renal or  carbuncle - deeper, multiple follicles cardiac disease. coalescing B. Collections of edema are named according to the site: Secondary lesions of the Skin 1. Anasarca -
massive generalized edema Scale is the accumulation or excess shedding of the 2. Ankle stratum corneum. 3. Ascites - peritoneal cavity  Scale is very important in the differential 4.
Hydrothorax - thoracic cavity diagnosis since its presence indicates that the 5. Periorbital - around the eyes epidermis is involved. 6. Sacral - lower back  Scale is typically present
where there is C. Edema occurs in dependent areas first. epidermal inflammation, ie. psoriasis, tinea, D. Edema is graded on a scale considering the eczema depth of the indentation
and the length of Crust is dried exudate (ie. blood, serum, pus) on the time to return to normal. Assessment: Press skin surface. firmly with finger for 5 seconds. Excoriation is a loss of
skin due to scratching or picking. Rating Assessment Lichenification is an increase in skin lines & creases 1+ 5mm depth, recovers immediately from chronic rubbing. 2+ 8-10 mm,
duration 10-15 sec. Maceration is raw, wet tissue. 3+ 11-20 mm, duration 15-30 sec. Fissure is a linear crack in the skin; often very 4+ >20 mm, duration >30 sec. painful. Erosion is a
superficial open wound with loss of epidermis or mucosa only HEAD Ulcer is a deep open wound with partial or complete loss of the dermis or submucosa Procedure: Distinct Lesions
of the Skin 1. Observe the size, shape and contour of the skull. 2. Observe scalp in several areas by separating the hair at Wheal or hive describes a short lived (< 24 hours), various
locations; inquire about any injuries. Note edematous, well circumscribed papule or plaque seen presence of lice, nits, dandruff or lesions. in urticaria. 3. Palpate the head by running
the pads of the fingers Burrow is a small threadlike curvilinear papule that is over the entire surface of skull; inquire about virtually pathognomonic of scabies. tenderness upon doing
so. (wear gloves if necessary) Comedone is a small, pinpoint lesion, typically 4. Observe and feel the hair condition. referred to as “whiteheads” or “blackheads.” 5. Test Cranial Nerve
VII Atrophy is a thinning of the epidermal and/or dermal 6. Test Cranial Nerve V tissue. Keloid overgrows the original wound boundaries and is chronic in nature. Foundations of
Nursing Abejo Physical Assessment
4. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 4 Normal Findings: 1. Sensory function (This nerve innervate the anterior 2/3 of the tongue). 1.
Skull · Place a sweet, sour, salty, or bitter substance near the tip of · Generally round, with prominences in the frontal and the tongue. occipital area. (Normocephalic). · Normally, the
client can identify the taste. · No tenderness noted upon palpation. 2. Scalp 2. Motor function · Lighter in color than the complexion. · Ask the client to smile, frown, raise eye brow,
close eye lids, · Can be moist or oily. whistle, or puff the cheeks. · No scars noted. · Free from lice, nits and dandruff. Normal Findings: · No lesions should be noted. · Shape maybe oval
or rounded. · No tenderness nor masses on palpation. · Face is symmetrical. 3. Hair · No involuntary muscle movements. · Can be black, brown or burgundy depending on the · Can
move facial muscles at will. race. · Intact cranial nerve V and VII. · Evenly distributed covers the whole scalp (No evidences of Alopecia) · Maybe thick or thin, coarse or smooth. EYE /
EYEBROW / EYELASHES · Neither brittle nor dry. Normal findings: FACE Eyebrows · Symmetrical and in line with each other. · Maybe black, brown or blond depending on race. 1.
Observe the face for shape. · Evenly distributed. 2. Inspect for Symmetry. Eyes a. Inspect for the palpebral fissure (distance between the · Evenly placed and inline with each other. eye
lids); should be equal in both eyes. · Non protruding. b. Ask the patient to smile, There should be bilateral · Equal palpebral fissure. Nasolabial fold (creases extending from the angle
of the corner of the mouth). Slight asymmetry in the fold is normal. Eyelashes c. If both are met, then the Face is symmetrical · Color dependent on race. · Evenly distributed. · Turned
outward 3. Test the functioning of Cranial Nerves that innervates the facial structures EYELIDS / LACRIMAL APPARATUS CN V (Trigeminal) 1. Inspect the eyelids for position and
symmetry. 2. Palpate the eyelids for the lacrimal glands. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the client’s upper orbital rim.
Inquire for any pain or tenderness. 3. Palpate for the nasolacrimal duct to check for obstruction. To assess the nasolacrimal duct, the examiner presses with the index finger against
the client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE. 1. Sensory Function In the presence of blockage, this will cause · Ask the client to close the eyes.
regurgitation of fluid in the puncta · Run cotton wisp over the fore head, check and jaw on both sides of the face. Normal Findings: · Ask the client if he/she feel it, and where she feels
it. · Check for corneal reflex using cotton wisp. · The normal response in blinking. Eyelids · Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open. 2.
Motor function · No PTOSIS noted. (drooping of upper eyelids). · Ask the client to chew or clench the jaw. · Meets completely when eyes are closed. · The client should be able to clench
or chew with strength and · Symmetrical. force. Lacrimal Apparatus CN VII (Facial) · Lacrimal gland is normally non palpable. · No tenderness on palpation. · No regurgitation from the
nasolacrimal duct. CONJUNCTIVAE The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the client look up, down and to each side. When
separating the lids, the examiner should exert no NO PRESSURE against the eyeball; rather, the Foundations of Nursing Abejo Physical Assessment
5. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 5 examiner should hold the lids against the ridges of the bony Normal findings: orbit
surrounding the eye. · There should be no irregularities on the surface. In examining the palpebral conjunctiva, everting the upper · Looks smooth. eyelid in necessary and is done as
follow: · The cornea is clear or transparent. The features of the iris should be fully visible through the cornea. 1. Ask the client to look down but keep his eyes slightly open. · There is a
positive corneal reflex. This relaxes the levator muscles, whereas closing the eyes contracts the orbicularis muscle, preventing lid eversion. ANTERIOR CHAMBER / IRIS 2. Gently grasp
the upper eyelashes and pull gently downward. Do not pull the lashes outward or upward; this, too, causes The anterior chamber and the iris are easily inspected muscles
contraction. in conjunction with the cornea. The technique of oblique 3. Place a cotton tip application about I can above the lid illumination is also useful in assessing the anterior
chamber. margin and push gently downward with the applicator while still holding the lashes. This everts the lid. 4. Hold the lashes of the everted lid against the upper ridge of
Normal Findings: the bony orbit, just beneath the eyebrow, never pushing against the eyebrow. · The anterior chamber is transparent. 5. Examine the lid for swelling, infection, and
presence of · No noted any visible materials. foreign objects. · Color of the iris depends on the person’s race (black, blue, 6. To return the lid to its normal position, move the lid slightly
brown or green). forward and ask the client to look up and to blink. The lid · From the side view, the iris should appear flat and should not returns easily to its normal position. be
bulging forward. There should be NO crescent shadow casted on the other side when illuminated from one side. PUPIL Examination of the pupils involves several inspections,
including assessment of the size, shape reaction to light is directed is observed for direct response of constriction. Simultaneously, the other eye is observed for consensual response
of constriction. The test for papillary accommodation is the examination for the change in papillary size as the is switched from a distant to a near object. Normal Findings: 1. Ask the
client to stare at the objects across room. 2. Then ask the client to fix his gaze on the examiner’s index · Both conjunctivae are pinkish or red in color. fingers, which is placed 5 – 5
inches from the client’s nose. · With presence of many minutes capillaries. 3. Visualization of distant objects normally causes papillary · Moist dilation and visualization of nearer
objects causes papillary · No ulcers constriction and convergence of the eye. · No foreign objects Normal Findings: SCLERAE · Pupillary size ranges from 3 – 7 mm, and are equal in size.
The sclerae is easily inspected during the assessment of the · Equally round. conjunctivae. · Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual.
· Pupils dilate when looking at distant objects, and constrict when looking at nearer objects. If all of which are met, we document the findings using the notation PERRLA, pupils
equally round, reactive to light, and accommodate Normal Findings: · Sclerae is white in color (anicteric sclera) · No yellowish discoloration (icteric sclera). · Some capillaries maybe
visible. · Some people may have pigmented positions. CORNEA The cornea is best inspected by directing penlight obliquely from several positions. Foundations of Nursing Abejo
Physical Assessment
6. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 6 The assessment of visual acuity is indicative of the functioning of the macular area, the area
of central vision. However, it does not test the sensitivity of the other areas of the retina which perceive the more peripheral stimuli. The Visual field confrontation test, provide a
rather gross measurement of peripheral vision. The performance of this test assumes that the examiner has normal visual fields, since that client’s visual fields are to be compared
with the examiners. Follow the steps on conducting the test: 1. The examiner and the client sit or stand opposite each other, with the eyes at the same, horizontal level with the
distance of 1.5 – 2 feet apart. 2. The client covers the eye with opaque card, and the examiner covers the eye that is opposite to the client covered CRANIAL NERVE II ( OPTIC NERVE )
eye. 3. Instruct the client to stare directly at the examiner’s eye, while the examiner stares at the client’s open eye. Neither looks The optic nerve is assessed by testing for visual acuity
out at the object approaching from the periphery. and peripheral vision. 4. The examiner hold an object such as pencil or penlight, in his hand and gradually moves it in from the
periphery of both Visual acuity is tested using a snellen chart, for those directions horizontally and from above and below. who are illiterate and unfamiliar with the western alphabet,
the 5. Normally the client should see the same time the examiners illiterate E chart, in which the letter E faces in different sees it. The normal visual field is 180 degress directions,
maybe used. The chart has a standardized number at the end of each line of letters; these numbers indicates the CRANIAL NERVE III, IV & VI degree of visual acuity when measured at a
distance of 20 feet. ( Oculomotor,Trochlear,Abducens ) The numerator 20 is the distance in feet between the All the 3 Cranial nerves are tested at the same time by chart and the client,
or the standard testing distance. The assessing the Extra Ocular Movement (EOM) or the six cardinal denominator 20 is the distance from which the normal eye can position of gaze.
read the lettering, which correspond to the number at the end of each letter line; therefore the larger the denominator the poorer the version. Measurement of 20/20 vision is an
indication of either refractive error or some other optic disorder. Follow the given steps: 1. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the client’s
eyes. In testing for visual acuity you may refer to the following: 2. Instruct the client to follow the direction the object hold by the examiner by eye movements only; that is with out
moving 1. The room used for this test should be well lighted. the neck. 2. A person who wears corrective lenses should be tested with 3. The nurse moves the object in a clockwise
direction and without them to check fro the adequacy of correction. hexagonally. 3. Only one eye should be tested at a time; the other eye 4. Instruct the client to fix his gaze
momentarily on the should be covered by an opaque card or eye cover, not with extreme position in each of the six cardinal gazes. client’s finger. 5. The examiner should watch for any
jerky movements of the 4. Make the client read the chart by pointing at a letter eye (nystagmus). randomly at each line; maybe started from largest to smallest or 6. Normally the client
can hold the position and there should vice versa. be no nystagmus. 5. A person who can read the largest letter on the chart (20/200) should be checked if they can perceive hand
movement about 12 inches from their eyes, or if they can perceive the light of the penlight directed to their yes. Peripheral Vision or visual fields Foundations of Nursing Abejo Physical
Assessment
7. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 7 This test is useful in determining whether the client has a conductive hearing loss (problem
of external or middle ear) or a perceptive hearing loss (sensorineural). There are 2 types of tuning fork test being conducted: Test for Accomodation 1. Weber’s test – assesses bone
conduction, this is a test of sound lateralization; vibrating tuning fork is placed on the EAR middle of the fore head or top of the skull. 1. Inspect the auricles of the ears for parallelism,
size position, appearance and skin color. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when manipulating the auricles and
the mastoid process. 3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodies. a. For adult pull the pinna upward and backward
to straighten Normal: hear sounds equally in both ears (No Lateralization of the canal. sound) b. For children pull the pinna downward and backward to straighten the canal
Conduction loss – Sound lateralizes to defective ear (Heard louder on defective ear) as few extraneous sounds are carried 4. Perform otoscopic examination of the tympanic
membrane, through the external and middle ear. noting the color and landmarks. Sensorineural loss – Sound lateralizes on better ear. Normal Findings: 2. Rinne Test – Compares bone
conduction with air condition. · The ear lobes are bean shaped, parallel, and symmetrical. · The upper connection of the ear lobe is parallel with the outer a. Vibrating tuning fork
placed on the mastoid process canthus of the eye. b. Instruction client to inform the examiner when he no longer · Skin is same in color as in the complexion. hears the tuning fork
sounding. · No lesions noted on inspection. c. Position in the tuning fork in front of the client’s ear canal · The auricles are has a firm cartilage on palpation. when he no longer hears it.
· The pinna recoils when folded. · There is no pain or tenderness on the palpation of the auricles and mastoid process. · The ear canal has normally some cerumen of inspection. · No
discharges or lesions noted at the ear canal. · On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color. VESTIBULOCHOCLEAR NERVE (
CRANIAL NERVE VII ) Examination of the cranial nerve VIII involves testing for hearing acuity and balance. Normal: Sound should be heard when tuning fork is placed in front of the ear
canal as air conduction< bone conduction by 2:1 Hearing Acuity (positive rinne test) A. Voice test Conduction loss: Sound is heard longer by bone conduction than by air conduction. 1.
The examiner stands 2 ft. on the side of the ear to be tested. 2. Instruct the client to occlude the ear canal of the other ear. Sensorineural loss: Sound is heard longer by air conduction
than 3. The examiner then covers the mouth, and using a soft by bone conduction spoken voice, whispers non-sequential number (e.g. 3 5 7 ) for the client to repeat. 4. Normally the
client will be able to hear and repeat the NOSE AND PARANASAL SINUSES number. 5. Repeat the procedure at the other ear. The external portion of the nose is inspected for the
following: B. Watcher test 1. Placement and symmetry. 2. Patency of nares (done by occluding nosetril one at a time, 1. Ask the client to close the eyes. and noting for difficulty in
breathing) 2. Place a mechanical watch 1 – 2 inches away the client’s ear. 3. Flaring of alaenasi 3. Ask the client if he hears anything 4. Discharge 4. If the client says yes, the examiner
should validate by asking at what are you hearing and at what side. The external nares are palpated for: 5. Repeat the procedure on the other ear. 6. Normally the client can identify
the sound and at what side 1. Displacement of bone and cartilage. it was heard. 2. For tenderness and masses Turning Fork Test Foundations of Nursing Abejo Physical Assessment
8. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 8 The internal nares are inspected by heperextending the neck of 3. No flaring alae nasi. the
client, the ulnar aspect of the examiner’s hard over the fore 4. Both nares are patent. head of the client, and using the thumb to push the tip of the 5. No bone and cartilage deviation
noted on palpation. nose upward while shining a light into the naris. 6. No tenderness noted on palpation. 7. Nasal septum in the mid line and not perforated. 8. The nasal mucosa is
pinkish to red in color. (Increased redness turbinates are typical of allergy). 9. No tenderness noted on palpation of the paranasal sinuses. OLFACTORY NERVE To test the adequacy of
function of the olfactory nerve: 1. The client is asked to close his eyes and occlude. 2. The examiner places aromatic and easily distinguish nose. (e.g. coffee). 3. Ask the client to
identify the odor. 4. Each side is tested separately, ideally with two different substances. Inspect for the following: MOUTH 1. Position of the septum. 2. Check septum for perforation.
(can also be checked by Mouth and Oropharynx Lips are inspected for: directing the lighted penlight on the side of the nose, illumination at the other side suggests perforation). 1.
Symmetry and surface abnormalities. 3. The nasal mucosa (turbinates) for swelling, exudates and 2. Color change in color. 3. Edema Normal Findings: Paranasal Sinuses 1. With visible
margin 2. Symmetrical in appearance and movement 3. Pinkish in color 4. No edema Palpate the temporomandibular while the mouth is opened wide and then closed for: 1.
Crepitous 2. Deviations 3. Tenderness Normal Findings: Examination of the paranasal sinuses is indirectly. 1. Moves smoothly no crepitous. Information about their condition is gained
by inspection and 2. No deviations noted palpation of the overlying tissues. Only frontal and maxillary 3. No pain or tenderness on palpation and jaw sinuses are accessible for
examination. movement. By palpating both cheeks simultaneously, one can Gums are inspected for: determine tenderness of the maxillary sinusitis, and pressing the thumb just
below the eyebrows, we can determine tenderness of 1. Color the frontal sinuses. 2. Bleeding 3. Retraction of gums. Normal Findings: 1. Pinkish in color 2. No gum bleeding 3. No
receding gums Teeth are inspected for: 1. Number 2. Color 3. Dental carries 4. Dental fillings Normal Findings: 5. Alignment and malocclusions (2 teeth in the space for 1, or
overlapping teeth). 1. Nose in the midline 6. Tooth loss 2. No Discharges. 7. Breath should also be assessed during the process. Foundations of Nursing Abejo Physical Assessment
9. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 9 Normal Findings: Normal Findings: 1. 28 for children and 32 for adults. 1. The trachea is
palpable. 2. White to yellowish in color 2. It is positioned in the line and straight. 3. With or without dental carries and/or dental fillings. 4. With or without malocclusions. 5. No
halitosis. Tongue is palpated for: Texture Normal Findings: 1. Pinkish with white taste buds on the surface. 2. No lesions noted. 3. No varicosities on ventral surface. 4. Frenulum is thin
attaches to the posterior 1/3 of the ventral aspect of the tongue. 5. Gag reflex is present. 6. Able to move the tongue freely and with strength. 7. Surface of the tongue is rough. mph
nodes are palpated using palmar tips of the fingers via systemic circular movements. Describe lymph nodes in termsof Uvula is inspected for: size, regularity, consistency, tenderness
and fixation to surrounding tissues. 1. Position 2. Color 3. Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the uvula will move upward and forward.
Normal Findings: 1. Positioned in the mid line. 2. Pinkish to red in color. 3. No swelling or lesion noted. 4. Moves upward and backwards when asked to say “ah” Tonsils are inspected
for: 1. Inflammation 2. Size A Grading system used to describe the size of the tonsils can be used. Normal Findings: Grade 1 – Tonsils behind the pillar. Grade 2 – Between pillar and
uvula. 1. May not be palpable. Maybe normally palpable in thin Grade 3 – Touching the uvula clients. 2. Non tender if palpable. Grade 4 – In the midline. 3. Firm with smooth rounded
surface. 4. Slightly movable. NECK 5. About less than 1 cm in size. 6. The thyroid is initially observed by standing in front The neck is inspected for position symmetry and obvious
lumps of the client and asking the client to swallow. visibility of the thyroid gland and Jugular Venous Distension. Palpation of the thyroid can be done either by posterior or anterior
approach. Normal Findings: Indication of Lymph Nodes 1. The neck is straight. 2. No visible mass or lumps.  Occipital: Head infection 3. Symmetrical  Submental: Dental
Carriections, Oral inf 4. No jugular venous distension (suggestive of cardiac  SubMandibular: Infection congestion).  SCM Upper: Lymphoma  Supraclavicular: Cancer The neck is
palpated just above the suprasternal note using the thumb and the index finger. Posterior Approach: The neck is palpated just above the suprasternal note using the 1. Let the client sit
on a chair while the examiner stands thumb and the index finger. behind him. 2. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is the
isthmus. Foundations of Nursing Abejo Physical Assessment
10. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 10 3. Ask the client to swallow while feeling for any then continues ant medially to end at the
6th rib at the enlargement of the thyroid isthmus. midclavicular line. 4. To facilitate examination of each lobe, the client is asked to turn his head slightly toward the side to be The
right horizontally fissure extends from the 5th rib examined to displace the sternocleidomastoid, while slightly posterior to the right midaxillary line and runs the other hand of the
examiner pushes the thyroid horizontally to thee area of the 4th rib at the right sternal border. cartilage towards the side of the thyroid lobe to be examined. 5. Ask the patient to
swallow as the procedure is being The left oblique (diagonal) fissure extend from the done. spinous process of the 3rd thoracic vertebra laterally and 6. The examiner may also palate
for thyroid enlargement downward to the left mid axillary line at the 5th rib and by placing the thumb deep to and behind the continues anteriorly and medially until it terminates at
the 6th rib sternocleidomastoid muscle, while the index and in the midclavicular line. middle fingers are placed deep to and in front of the muscle. Borders of the Diaphragm. 7. Then
the procedure is repeated on the other side. Anteriorly, on expiration, the right dome of the diaphragm is located at the level of the 5th rib at the midclavicular line and he left dome is
at the level of the 6th rib. Posteriorly, on expiration, the diaphragm is at the level of the spinous process of T10; laterally it is at the 8th rib at the midaxillary line. On inspiration the
diaphragm moves Anterior approach: approximately 1.5 cm downward. 1. The examiner stands in front of the client and with the Inspection of the Thorax palmar surface of the
middle and index fingers palpates below the cricoid cartilage. 2. Ask the client to swallow while palpation is being For adequate inspection of the thorax, the client should be sitting
done. upright without support and uncovered to the waist. 3. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach. The client is asked to The
examiner should observe: turn his head slightly to one side and then the other of the lobe to be examined. 1. Shape of the thorax and its symmetry. 4. Again the examiner displaces
the thyroid cartilage 2. Thoracic configuration. towards the side of the lobe to be examined. 3. Retractions at the ICS on inspiration. 5. Again, the examiner palpates the area and hooks
(suprasternal, costal, substernal) thumb and fingers around the sternocleidomastoid 4. Bulging structures at the ICS during muscle. expiration. 5. position of the spine. Normal
Findings: 6. pattern of respiration. 1. Normally the thyroid is non palpable. Normal Findings: 2. Isthmus maybe visible in a thin neck. 3. No nodules are palpable. The shape of the
thorax in a normal adult is elliptical; the anteroposterior diameter is less than the transverse Auscultation of the Thyroid is necessary when there is thyroid diameter at approximately
a ratio of 1:2. enlargement. The examiner may hear bruits, as a result of Moves symmetrically on breathing with no obvious increased and turbulence in blood flow in an enlarged
thyroid. masses. No fail chest which is suggestive of rib fracture. Check the Range of Movement of the neck. No chest retractions must be noted as this may suggest difficulty in
breathing. No bulging at the ICS must be noted as this may obstruction on expiration, abnormal masses, or THORAX cardiomegaly. The spine should be straight, with slightly
curvature in the thoracic area. Lung borders There should be no scoliosis, kyphosis, or lordosis. Breathing maybe diaphragmatically of costally. In the anterior thorax, the apices of the
lungs extend for approximately 3 – 4 cm above the clavicles. The inferior Expiration is usually longer the inspiration. borders of the lungs cross the sixth rib at the midclavigular line.
Palpation of the Thorax In the posterior thorax, the apices extend of T10 on expiration to the spinous process of T12 on inspiration. In the Lateral Thorax, the lungs extend from the
apex of the axilla to the 8th rib of the midaxillary line. Lung Fissures The right oblique (diagonal) fissure extend from the area of the spinous process of the 3rd thoracic vertebra,
laterally and downward unit it crosses the 5th rib at the midaxillary line. It Foundations of Nursing Abejo Physical Assessment
11. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 11 1. General palpation – The examiner should specifically palpate any areas of abnormality.
The temperature and turgor of the skin should be assessed. Palpate for lumps, masses and areas of tenderness. 2. Palpate for thoracic expansion or lung excursion. A. Anteriorly, the
examiner’s hands are placed over the anterolateral chest with the thumbs extended along the costal margin, pointing to the xyphoid process. Posteriorly, the thumbs are placed at the
level of the 10th rib and the palms are placed on the posterolateral chest. B. Instruct the client to exhale first, then to inhale deeply. C. The examiner the amount of thoracic expansion
during quiet and deep inspiration Whispered Pectorioquy – Ask the client top whisper “1-2-3” and observe for divergence of the thumbs on Over normal lung tissue it would almost be
indistinguishable, expiration. over consolidated lung it would be loud and clear D. Normally, symmetry of respiration between the left and right hemithoraces should be felt as the
thumbs are separated are separated approximately 3 – 5 cm (1 – 2 inches) during deep inspiration. 1. Palpate for the tactile fremitus. Percuss the diaphragmatic excursion A. Place the
palm or the ulnar aspect of the hands bilaterally symmetrical on the chest wall starting from the top, then at then medial thoracic wall, and at the anterolateral B. Each time the hands
move down, ask the client to say ninety-nine. C. Repeat the procedure at the posterior thoracic wall. D. Normally, tactile fremitus should be bilaterally symmetrical. Most intense in the
2nd ICS at the sternal border, near the area of bronchial bifurcation. Low pitched voices of males are more readily palpated than higher pitched voices of females. E. Basic
abnormalities like increased tactile Auscultation of the Thorax fremitus maybe suggestive of consolidation; decreased tactile fremitus may be suggestive of obstructions, thickening of
pleura, or collapse of lungs. Percussion of the Thorax Anterior thorax: Normal Breath Sound A. Patient maybe placed on a supine position. B. Percuss systematically at about 5 cm
intervals from Vesicular Soft, low pitch Lung periphery the upper to lower chest, moving left to right to left. Broncho-vesicular Medium pitch Larger airway (Percuss over the ICS,
avoiding the ribs. Use indirect blowing percussion starting at the apices of the lungs. Bronchial Loud, high pitch Trachea C. The examiner notes the sound produced during each
percussion. Abnormal Breath Sound Crackles Dependent lobes Random, sudden reinflation of alveoli fluids Rhonchi Trachea, bronchi Fluids, mucus Foundations of Nursing Abejo
Physical Assessment
12. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 12 Wheezes All lung fields Severely narrowed 1. Position the patient supine with the head of
the table bronchus slightly elevated. Pleural Friction Lateral lung field Inflamed Pleura 2. Always examine from the patient's right side. Rub 3. Inspect for precordial movement.
Tangential lighting will make movements more visible. 4. Palpate for precordial activity in general. You may Elderly: feel "extras" such as thrills or exaggerated ventricular Physical
Changes of Thorax and Breathing Patterns impulses. 5. Palpate for the point of maximal impulse (PMI or  Kyphosis apical pulse). It is normally located in the 4th or 5th 
Anteroposterior diameter of the chest widens intercostal space just medial to the midclavicular line  Breathing rate and rhythm are unchanged at rest and is less than the size of a
quarter.  Inspiratory muscles become less powerful, and 6. Note the location, size, and quality of the impulse. inspiration reserve volume decreases.  Expiration may require the use
of accessory muscles  Deflation of the lung is incomplete Palpation of the Heart  Small airways lose their cartilaginous support and elastic recoil The entire precordium is palpated
methodically using the palms  Elastic tissue of the alveoli loses its stretchability and and the fingers, beginning at the apex, moving to the left sternal changes to fibrous tissue.
Exertional capacity also border, and then to the base of the heart. decreases.  Cilia in the airways decrease in number and are less Normal Findings: effective in removing mucus,
therefore they are at greater risk for pulmonary infections. 1. No, palpable pulsation over the aortic, pulmonic, and mitral valves. 2. Apical pulsation can be felt on palpation. 3. There
should be no noted abnormal heaves, and thrills CARDIOVASCULAR SYSTEM felt over the apex. Percussion of the Heart The technique of percussion is of limited value in cardiac
assessment. It can be used to determine borders of cardiac dullness. Auscultation of the Heart : Inspection of the Heart The chest wall and epigastrum is inspected while the client is
in supine position. Observe for pulsation and heaves or lifts Normal Findings: 1. Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size). 2.
There should be no lift or heaves. Jugular Venous Pressure Anatomic areas for auscultation of the heart 1. Position the patient supine with the head of the table elevated 30 degrees. 2.
Use tangential, side lighting to observe for venous Aortic valve – Right 2nd ICS sternal border. pulsations in the neck. Pulmonic Valve – Left 2nd ICS sternal border. 3. Look for a rapid,
double (sometimes triple) wave with Tricuspid Valve – – Left 5th ICS sternal border. each heart beat. Use light pressure just above the Mitral Valve – Left 5th ICS midclavicular line
sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin. 4. Adjust the angle of table elevation to bring out the Positioning the client for auscultation: venous
pulsation. 5. Identify the highest point of pulsation. Using a If the heart sounds are faint or undetectable, try horizontal line from this point, measure vertically listening to them with
the patient seated and learning from the sternal angle. forward, or lying on his left side, which brings the 6. This measurement should be less than 4 cm in a heart closer to the surface
of the chest. normal healthy adult. Having the client seated and learning forward s best suited for hearing high-pitched sounds related to semilunar valves problem. Precordial
Movement Foundations of Nursing Abejo Physical Assessment
13. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 13 The left lateral recumbent position is best suited low- BREAST pitched sounds, such as
mitral valve problems and extra heart sounds. Auscultating the heart 1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral 2. Listen for the S1 and S2
sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound is best heard over the mitral valve; S2 is best heard over the aortric valve. 3. Listen for abnormal heart sounds
e.g. S3, S4, and Murmurs. 4. Count heart rate at the apical pulse for one full minute. Normal Findings: 1. S1 & S2 can be heard at all anatomic site. 2. No abnormal heart sounds is heard
(e.g. Murmurs, S3 & S4). 3. Cardiac rate ranges from 60 – 100 bpm. Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. Every
client should be examined in each position. 1. The client is seated with her arms on her side. PERIPHERAL CIRCULATION 2. The client is seated with her arms abducted over the head.
Inspect: 3. The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction of the pectoral muscles.  Color 4. The client is seated and is learning over
while the  Edema examiner assists in supporting and balancing her.  Stasis ulcers/lesions  Varicosities  Hair/nail changes While the client is performing these maneuvers, the
breasts are carefully observed for symmetry, bulging, Palpate: retraction, and fixation. An abnormality may not be apparent in the breasts at rest a mass may cause the breasts,
through invasion of  Temperature the suspensory ligaments, to fix, preventing them from  Edema upward movement in position 2 and 4.  Tenderness  Symmetry of pulses
Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory ligament Chronic Venous Insufficiency Chronic Arterial Insufficiency Pain None to
aching pain on dependency Pain Intermittent claudication Pulse Normal Pulse Decreased Normal to cyanotic; petechiae or brown Color pigmentation Color Pale Temperature Warm
Temperature Cool Present Edema Absent or mild Edema Skin Thin, shiny atrophic skin, hair loss, Skin Changes Dermatitis skin pigmentation Changes thickened nails Ulceration
Toes/points of trauma Ulceration Medial side of ankle Gangrene May develop Gangrene Does not develop Normal Findings: 1. The overlying the breast should be even. Foundations of
Nursing Abejo Physical Assessment
14. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 14 2. May or may not be completely symmetrical at rest. 3. The areola is rounded or oval, with
same color, (Color va,ies form light pink to dark brown depending on race). 4. Nipples are rounded, everted, same size and equal in color. 5. No “orange peel” skin is noted which is
present in edema. 6. The veins maybe visible but not engorge and prominent. 7. No obvious mass noted. 8. Not fixated and moves bilaterally when hands are abducted over the head,
or is learning forward. Auscultation of the Abdomen 9. No retractions or dimpling. Palpation of the Breast This method precedes percussion because bowel motility, and thus bowel
sounds, may be increased by palpation or percussion. Palpate the breast along imaginary concentric circles, The stethoscope and the hands should be warmed; if following a
clockwise rotary motion, from the they are cold, they may initiate contraction of the periphery to the center going to the nipples. Be sure abdominal muscles. that the breast is
adequately surveyed. Breast Light pressure on the stethoscope is sufficient to detect examination is best done 1 week post menses. bowel sounds and bruits. Intestinal sounds are
Each areolar areas are carefully palpated to determine relatively high-pitched, the bell may be used in the presence of underlying masses. exploring arterial murmurs and venous
hum. Each nipple is gently compressed to assess for the Peristaltic sounds presence of masses or discharge. These sounds are produced by the movements of air and fluids through
the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel. Normal Findings: Listening to the bowel sounds (borborygmi) can be facilitated by
following these steps: No lumps or masses are palpable. No tenderness upon palpation. No discharges from the nipples.  Divide the abdomen in four quadrants.  Listen over all
auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary NOTE: The male breasts are observed by adapting the lines in creating the
abdominal quadrants. This direction techniques used for female clients. However, the various sitting ensures that we follow the direction of bowel movement. position used for
woman is unnecessary.  Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 ABDOMEN minutes, especially at the periumbilical area,
before concluding that no bowel sounds are present.  The normal bowel sounds are high-pitched, gurgling noises In abdominal assessment, be sure that the client has emptied the
that occur approximately every 5 – 15 seconds. It is bladder for comfort. Place the client in a supine position with the suggested that the number of bowel sound may be as low as
knees slightly flexed to relax abdominal muscles. 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound. Inspection of the abdomen Some factors that
affect bowel sound: Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). 1. Presence of food in the GI tract. Contour (flat, rounded, scapold) 2. State of
digestion. Distension 3. Pathologic conditions of the bowel (inflammation, Respiratory movement. Gangrene, paralytic ileus, peritonitis). Visible peristalsis. 4. Bowel surgery
Pulsations 5. Constipation or Diarrhea. 6. Electrolyte imbalances. 7. Bowel obstruction. Normal Findings: Percussion of the abdomen Skin color is uniform, no lesions. Some clients
may have striae or scar. Abdominal percussion is aimed at detecting fluid in No venous engorgement. the peritoneum (ascites), gaseous distension, and Contour may be flat, rounded
or scapoid masses, and in assessing solid structures within the Thin clients may have visible peristalsis. abdomen. Aortic pulsation maybe visible on thin clients. The direction of
abdominal percussion follows the auscultation site at each abdominal guardant. The entire abdomen should be percussed lightly or a general picture of the areas of tympany and
dullness. Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the Foundations
of Nursing Abejo Physical Assessment
15. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 15 6th or 9th rib just posterior to or at the mid axillary line Deeper structures, like the liver, and
retro peritoneal on the left side. organs, like the kidneys, or masses may be felt with Percussion in the abdomen can also be used in this method. assessing the liver span and size of
the spleen. In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the Percussion of the liver sigmoid colon, and the aorta. The
palms of the left hand is placed over the region of liver dullness. 1. The area is strucked lightly with a fisted right hand. 2. Normally tenderness should not be elicited by this method. 3.
Tenderness elicited by this method is usually a result of hepatitis or cholecystitis. Renal Percussion 1. Can be done by either indirect or direct method. 2. Percussion is done over the
costovertebral junction. Liver palpation: 3. Tenderness elicited by such method suggests renal inflammation. There are two types of bi manual palpation recommended for palpation
of the liver. The first one is the superimposition of the right hand over the left hand. 1. Ask the patient to take 3 normal breaths. 2. Then ask the client to breath deeply and hold. This
would push the liver down to facilitate palpation. 3. Press hand deeply over the RUQ The second methods: 1. The examiner’s left hand is placed beneath the client at the level of the
right 11th and 12th ribs. 2. Place the examiner’s right hands parallel to the costal margin or the RUQ. Palpation of the Abdomen 3. An upward pressure is placed beneath the client to
push the liver towards the examining right hand, while Light palpation the right hand is pressing into the abdominal wall. 4. Ask the client to breath deeply. 5. As the client inspires,
the liver maybe felt to slip It is a gentle exploration performed while the client is beneath the examining fingers. in supine position. With the examiner’s hands parallel to the floor. The
fingers depress the abdominal wall, at each Normal Findings: quadrant, by approximately 1 cm without digging, but gently palpating with slow circular motion. The liver usually can
not be palpated in a normal This method is used for eliciting slight tenderness, adult. However, in extremely thin but otherwise well large masses, and muscles, and muscle guarding.
individuals, it may be felt a the costal margins. When the normal liver margin is palpated, it must be Tensing of abdominal musculature may occur because of: smooth, regular in
contour, firm and non-tender. 1. The examiner’s hands are too cold or are pressed to MUSCULOSKELETAL vigorously or deep into the abdomen. 2. The client is ticklish or guards
involuntarily. 1. Assess the patient’s posture, stance, and gait 3. Presence of subjacent pathologic condition. 2. Prepare the patient for the examination 3. Inspect for any gross
abnormalities. Normal Findings: 4. Inspect and palpate the temporomaddibular joint and jaw. 5. Inspect and palpate the neck and spine 1. No tenderness noted. 6. Assess the ROM of
the neck 2. With smooth and consistent tension. 7. Assess the ROM of the spine 3. No muscles guarding. 8. Inspect and palpate the upper and lower extremities, assessing each joint
and muscle. Deep Palpation RANGE OF MOTION It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal
wall. The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined. Foundations of Nursing Abejo Physical Assessment
16. Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 16 TEMPORAL MADIBULAR JOINT AND JAW RANGE OF MOTION: ELBOW RANGE OF MOTION:
NECK RANGE OF MOTION:SHOUDLERS RANGE OF MOTION:WRISTS RANGE OF MOTION:ANKLES RANGE OF MOTION: FINGERS Foundations of Nursing Abejo Physical Assessment
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