HA ILG Complete 2

MEDICAL COLLEGES OF NORTHERN PHILIPPINES
INSTRUCTIONAL LEARNING
GUIDE
NCM 101
HEALTH ASSESSMENT (Lecture)
FIRST SEMESTER F.Y. 2020-2021
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PREPARED BY:
FEVIE ANNE D. BANATAO

Clinical Instructor
College of Nursing and School of Midwifery
Medical College of Northern Philippines
REVIEWERS
LOUISE V. CABLING, RN, MAN, LPT, MST

Dean, College of Nursing and School of Midwifery
Medical College of Northern Philippines
WINNIE T. CANCEJO RRT, MPH

Quality Assurance Officer
OIC, Vice President of Academic Affairs
Medical Colleges of Northern Philippines
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PREFACE
This Instructional Learning Guide for the subject NCM 101 – Health Assessment has been
prepared to address the needs of our learners in the Distance Learning Strategy. The
contents of this guide has been carefully planned and reviewed to suit the learning styles of
our students. This guide is a collection of lectures from different authors of the basic
concepts of patient care that is deemed appropriate and useful for students to acquire
knowledge and skills for the course.
How to Use this Learning Guide:
This shall serve as guide of the students in the completion of the course. Lectures, activities
and evaluative assessment are provided in this material.
The learning outcomes are specified in each chapter which shall serve as checklist of the
knowledge and skills acquired by the students upon completion of the lessons and activities
given.
Lecture notes are also provided from the different references used for the subject to guide
the students in understanding the topics supplemented by teacher’s insight and videos.
Essay questions, case analysis and self-assessment exercises are provided to stir the critical
thinking skills of the students and to evaluate their understanding on the concepts given.
Moreover, the students are required to write a journal at the end of each term which
composed of their learnings, personal reflections and realizations of the concepts given. All
written outputs should be compiled in their learning portfolio to be submitted to the subject
teacher as part of the requirements of the course.
Features of the Instructional Learning Guide:

 Learning Outcomes
 Key Terms
 Lectures Notes
 Teachers Insight
 Application
 Self-reflection Questions
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 Other Activities (to be included in Portfolio Assessments)

 Appendices
 Summary of Additional References
 Bibliography
TABLE OF CONTENTS
I. PRELIMINARIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chapter 1: REVIEW OF NURSING PROCESS . . . . . . . . . . . . . . . . . . . . . .
1. Phases
A. Assessment
a. Purpose
b. Process
c. Types
d. Interview Technique
e. Health History
1. Guidelines
2. Health History Personal Profile (Chief Complaint of
Present Illness, Past Medical History , Medication
History, Family History, Social History)
f. Gordon’s 11 Functional Patterns
B. Diagnosis
C. Planning
D. Interventions
E. Evaluation
II. MIDTERMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chapter 2: PHYSICAL EXAMINATION. . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Preparation Guidelines
2. Physical Examination Guidelines
3. Cultural Considerations
4. Techniques in Physical Assessment
A. Inspection
B. Palpation
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C. Percussion
D. Palpation
5. Vital Signs
Chapter 3: REVIEW OF SYSTEMS (Adult)

Chapter 4: PHYSICAL ASSESSMENT PROCESS
1. Integumentary Assessment
2. Head and Scalp
A. Eye
B. Ear
C. Mouth
D. Throat
E. Nose
F. Sinus
3. Neck
III. SEMI FINALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chapter 4: PHYSICAL ASSESSMENT PROCESS (cont…)

4. Thoracic and lungs
A. Breath Sounds
5. Cardiovascular System
A. Heart and Great Vessels
6. Abdomen
7. Pelvis
8. BSE and TSE
IV. FINALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chapter 4: PHYSICAL ASSESSMENT PROCESS (cont…)
9. Musculoskeletal System
10. Peripheral Vascular System
11. Neurological System
A. Cranial Nerves
B. Functional Mental Health
APPENDICES
 Rubrics
 List of additional references
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 List of figures
 Acknowledgement and Disclaimer
COURSE DETAILS
Subject: NCM 101- Health Assessment Units: 3 No. of Class Hours: 3/wk
Section: _________ Year Level: First Course: Bachelor of Science in Nursing
Subject Teacher: Fevie Anne D. Banatao Contact Number: 09088173548
Schedule/Consultation hours: ___________________________________
Course Description:
The course deals with concepts, principles and techniques of history taking using various
tools, physical examination (head to toe), psychosocial assessment and interpretation of
laboratory findings to arrive at a nursing diagnosis on the client across the lifespan in
community and health settings.
Course Outcomes:
At the end of the course and given relevant actual or simulated situations/conditions, the
student will be able to:
1. Know the basic concepts essential in understanding the subject health assessment
2. Familiarize with the concepts in terms of techniques, methods and tools of
assessment to individual client with varying age group and development
3. Differentiate normal from abnormal assessment findings
Methodology of Implementation:
This is a distance learning strategy wherein the students will be provided with a copy of the
Instructional Learning Guide (ILG) or be enrolled in the Learning Management System (LMS)
to acquire the necessary knowledge skills, and attitude offered by the course. This is in
response to the new mode of delivering instruction without requiring the students to report
to school.
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The teacher shall conduct an orientation to the students via online platforms or text
message regarding the utilization of this material for them to be guided throughout the
duration of the course.
Topics shall be assigned based on the syllabus of the subject. Specific instructions on how
complete the activities per chapter will be given to the students. Activities are given at pre-
determined time to be completed by the students. At the completion of each topic, students
are required to take the evaluative examinations which shall be given by the teacher based
on the intended learning outcomes.
During the duration of the course, students can consult their teachers at a specified time to
address their difficulties or challenges they may encounter along the way.
The subjects are structured in sequential order. Course materials and references shall be
provided by the teacher in advance to facilitate teaching and learning process.
Delivery Mode:
1. Hard/soft copy of the Instructional Learning Guide (Offline)
2. Learning Management System (Online)
3. Audio / video materials
4. Downloaded links
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PRELIM COVERAGE
Specific Instructions in the completion of each Chapter:

1. Set your learning goals. Read and understand the Intended Learning Outcomes of
each chapter. This shall serve as your checklist of acquired knowledge and skills
after completing the entire chapter, likewise, the basis of the teacher in the
formulation of the summative evaluation given at the end of each chapter.
2. Lecture notes are provided for you. BE SURE NOT TO SKIP the lecture. Read and
understand before answering the activities. You can take note those concepts that
are not clear to you and refer to your subject teacher during the specified
consultation hours.
3. Read the teacher’s insight and watch the downloaded videos saved in the flash drive
to supplement the lecture notes.
4. As you go on, you will encounter exercises that will test your knowledge and
understanding as well as your critical thinking. Read the instructions carefully, and
write your answers to the space provided at the end of Midterm coverage.
5. Compile you outputs in your Learning Portfolio to be submitted on the date set by
your teacher.
6. Should you have any queries or clarifications with the topics, please contact your
subject teacher during consultation hours (please refer to the preliminaries of this
material).
CHAPTER 1
NURSING PROCESS
This chapter covers concepts in applying nursing process and its components in the
delivery of nursing care. At the same time Interview techniques and guidelines, health
history taking and using the Gordon’s 11 functional pattern are discussed in terms of
gathering data.
Duration: 12.0 hours
MAJOR TOPICS SUBTOPICS

I. Purpose And Advantages Of Nursing Process
II. Phases Of Nursing Process
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Assessment  Purpose
 Process
 Types of Data
 Sources of Data
 Interview Technique
 Health History
 Health History Personal Profile (Chief Complaint of
Present Illness, Past Medical History , Medication
History, Family History, Social History)
 Gordon’s 11 Functional Patterns
Diagnosis  Types of Diagnosis

 Examples
Planning  Purpose
 Characteristics
Interventions  Types of Interventions and Examples

 Guidelines
Evaluation
Activities:
1. Self-Assessment Exercises: MCQ type of questions

2. Critical Thinking Exercises: Short Essay
Before you proceed…
Intended Learning Outcomes:
1. Discuss the steps of the Nursing Process

2. Understand the guidelines in health history taking
3. Appreciate the purpose, structure and guidelines of an effective interview
4. Understand the components of health history
5. Differentiate physical and instrumental activities of daily living
6. Understand functional assessment tests for adults
7. Identify symptoms of each body system
Key Terms:
 Nursing Process
 Assessment
 Health History
 Interview
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 Data
 Diagnosis
 Planning
 Implementation
 Interventions
 Evaluation
 Goals
Let’s Begin!
BASIC CONCEPTS OF NURSING PROCESS
Definition of Nursing Process:

 Specific to the nursing profession
 A framework for critical thinking
 It’s purpose is to:“Diagnose and treat human responses to actual or potential health
problems”
 Organized framework to guide practice
 Problem solving method - client focused
 Systematic- sequential steps
 Goal oriented- outcome criteria
 Dynamic-always changing, flexible
 Involves looking at the whole patient at all times
It provides a "road map" that ensures good nursing care & improves patient
outcomes

Critical Thinking- nurses need to use Nursing process
- Always thinking about your thinking, and your actions, and your decisions
Basis in using Critical Thinking:
 Deal w/ complex problems on a daily basis
 Work w/ patient that are unique
 Provide holistic care
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Advantages of Nursing Process:
1. Provides individualized care

-Client is an active participant
2. Promotes continuity of care
3. Provides more effective
communication among nurses and
healthcare professionals
4. Develops a clear and efficient plan of
care
5. Provides personal satisfaction as you
see client achieve goals
6. Professional growth as you evaluate effectiveness of your interventions
PHASES OF NURSING PROCESS
A. ASSESSMENT
 First step of the Nursing Process

 systematic, deliberate process by which the nurse collects and analyzes data
about the patient
 Gather Information/Collect Data through Nursing Interview (history), Health
Assessment -Review of Systems, Physical Exam
 Entire plan is based on the data you collect, data needs to be complete and
accurate
 Make sure information is complete & accurate
 Process of Systematic Assessment

1. Collect data
2. Verify data
3. Organize data
4. Identify Patterns
5. Report & Record data
Comprehensive data collection:
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 Begins before you actually see the patient (Nurse report from ER, Chart
reviews)
 Continues with admission interview and physical assessment once you meet
patient.
 Other information resources include: family, significant others, nursing records,
old medical records, diagnostic studies, relevant nursing literature.
 Consider age, growth & development
 Types of Data:
a) Objective Data – signs; those that can be observed and measured

Ex. “I have a headache
b) Subjective Data – symptoms; those that described only by the person
experiencing it.
Ex. Vital signs: BP: 130/80, PR: 68, RR: 19 Temp: 37.0 C
 Sources of Data:
a) Primary – patient/client
b) Secondary – family members, patient’s record, health team members, related
literature
 Interview Technique
 The interview is a purposeful conversation, generally in a face-to-face meeting. It

involves at least two persons; the interviewer, the one who seeks information,
and the interviewee, the person from whom the information is sought.
 The interviewer is a verbal and non-verbal exchange that provides for the
beginning and development of a relationship. It is the second most common
method of gathering information next to questionnaire.
Categories of Interview:
1. Standardized/ Structured
- The interviewer is not permitted to change the specific wording of the
interview question schedule. He must endeavor to conduct each interview in
precisely the same manner and he cannot adapt questions for a specific
situation.
2. Non-Standardized
- The interviewer has complete freedom to develop each interview in the most
appropriate manner for each situation. He is not held to any specific questions.
3. Semi-Standardized
- The interviewer maybe required asking a number of specific questions, but
beyond these, he is free to probe as he chooses.
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4. Focused
- The interviewer approaches the respondent with a series of questions based
on previous understanding and knowledge of the problem or phenomenon
being studied. The interviewer is thus able to direct his questioning so as to
discover the kinds of backgrounds and experiences that have influenced the
subject.
5. Non-Directive
- The subject is given the opportunity to express his feelings without fear of
disapproval. There is freedom to discuss a topic without pressure from the
interviewer.
Interview Instruments
1. Interview Schedule
- A questionnaire is read to the respondent.
2. Interview Guide
- One that provides ideas but allows the interviewer freedom to pursue
relevant topics in depth.
Types Of Questions
1. Open-Ended Questions
- One aimed at eliciting response that is more than one or two words in
length. This type is effective in stimulating descriptive or comparative
responses.
2. Close-Ended Questions
- A type of inquiry that requires no more than one or two worded answer.
This might be an agreement or disagreement. The responses maybe yes
or no and maybe answered non-verbally by a nod of the head.
3. Biased Or Leading Questions
- Those that carry a suggestion of the kind of information that should be
included in the response.
4. Neutral Questions
- These are questions wherein a person can answer without direction or
pressure. It is often used in non-directive
interviews
Guidelines When Conducting An Interview
1. Initiation
a. Greet the respondent by name
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b. Introduce self
c. Explain the purpose of the interview
d. Put the respondent at ease (physical comfort)
2. Appropriate Use Of Non-Verbal Communication
a. Maintain good eye contact
b. Observe proper body posture
c. Use silence appropriately
d. Avoid distractions (chewing lips, gums, playing with pen)
3. Questioning
a. Speak clearly
b. Use simple language
c. Ask open-ended questions
d. Ask one question at a time
e. Wait for the respondent to answer
f. Ask appropriate probing questions
g. Control pace of interview
h. Control direction of the interview
i. Do not be judgmental
4. Focusing
a. Elicit information relevant to the purpose of the
interview
b. Have an organized sequence of questions
c. Follow the respondent’s verbal cues
d. Ask for clarification appropriately
e. Make appropriate transitional statements
5. Terminating The Interview
a. Ask the interviewee if he has any questions
b. Summarize what has been said
c. Thank the respondent and say goodbye appropriately
Teacher’s Insight
The purpose of interview itself is to gather data. It should be noted that during the
interview process, the interviewer asking questions should be focused and attentive to
the interviewee’s answers for the information to be accurate and truthful. In this light,
the interviewer must establish rapport or trust. Establishing rapport is the first most
important virtue in any manner of gathering data.
 Health History
 Taking a Patient’s history is arguably the most important aspect of patient

assessment, and is increasingly being undertaken by HCPs including midwives. The
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procedure allows patients to present their account of the problem and provides
essential information for the practitioner.
Preparing the environment

 The first part of any history-taking process and, indeed, most interactions with
patients is preparation of the environment
 HCPs can encounter patients in a variety of environments: accident and
emergency; general wards; department areas; primary care centres; health
centre clinics and the patient’s home.
 Respect for the patient as an individual is an important feature of assessment,
and this includes consideration of beliefs and values and the ability to remain
non-judgemental and professional
 Respect also involves maintenance of privacy and dignity; the environment should
be private, quiet and ideally, there should be no interruptions.
Communication
 The HCP should be able to gather information in a systematic, sensitive and

professional manner
 Good communication skills are essential.
 Introducing yourself to the patient is the first part of this process
 It is important to let patients tell their story in their own words while using active
listening skills. It is also important not to appear rushed, as this may interfere
with the patient’s desire to disclose information
 Practitioners should avoid the use of technical terms or jargon and, whenever
possible, use the patient’s own words.
Teacher’s Insight
The need to communicate is universal. People communicate to satisfy needs. Is the

means to establish a helping-healing relationships. Thus, it is also essential to the
hcp-patient relationship. It is the vehicle for establishing a therapeutic relationship
between the two parties. It is also the means by which an individual influences the
behavior of another, which leads to the successful outcome of nursing intervention.
Examples of non-verbal and verbal communication skills

Non-verbal Verbal
Eye contact Interested posture Nodding Appropriate language
of head Hand gestures Clothing Avoid jargon and technical terms Pitch
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Facial gestures Rate and intonation Volume
Consent
 Before any healthcare intervention, including history taking, informed consent
should be gained from the patient
 State that patients can only provide consent if they are able to act under their
own free will, have an understanding of what they have agreed to and have
enough information on which to base a decision
Teacher’s Insight
Health Care Providers have a legal duty to ensure they obtain informed consent from their
patients before carrying out any intervention or treatment. This is one of the requirements
of the Nursing Code of ethics, which sets out a mandatory framework of standards for
practice. They should all be aware of that requirement but they also need to understand
exactly what informed consent is, how it is underpinned by law, and what it means for
practice. Health Care Providers know they must have their patients’ informed consent
before giving any form of care or treatment. They assess patients’ health status and plan
care based on their observations, deciding which treatments and interventions best meet
patients’ needs. Regardless of the process used, the consensus is that decisions will be
based on information of one kind or another and will influence the outcomes for patients
The History Taking Process
1. The Presenting Complaint:

To elicit information about the presenting complaint start by using an open question, for
example: ‘What is the problem?’ or ‘Tell me about the problem?’ This should provide a
breadth of valuable information from the patient, but not necessarily in the order that you
would like. The patient should then be asked more specific details about his or her
symptoms, starting with the most important first. It is important to concentrate on
symptoms and not on diagnosis to ensure that no information is missed.
When a patient reports symptoms from a specific body system, all of the cardinal
symptoms in the system should be explored. For example, if a patient complains of
palpitations, then specific questions should be asked about chest pain, breathlessness,
ankle swelling and pain in the lower legs when walking to ensure that all cardinal
questions relating to the cardiovascular system have been covered.
Each symptom should be explored in more detail for clarification because this helps to
construct a more accurate description of the patient’s problems. Direct questions can be
used to ask about:
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 Onset – was it sudden, or has it developed gradually?

 Duration – how long does it last, minutes, days or weeks?
 Site and radiation – where does it occur? Does it occur anywhere else?
 Aggravating and relieving features – is there anything that makes it better or
worse?
 Associated symptoms – when this happens,does anything else happen with it,
such as nausea, vomiting or headache?
 Fluctuating – is it always the same?
 Frequency – have you had it before?
Direct questioning can be used to ask about the sequence of events, how things are
currently and any other symptoms that might be associated with possible differential
diagnoses and risk factors. Negative responses are also important, and it is vital to
understand how the symptoms affect the patient’s day-to-day activities.
2. Past Medical History

 Listing of illness unrelated to the present illness, experienced in the past
 Including childhood diseases
 Serious injuries and surgery not requiring hospitalization
 Mention of each disease with an approximate date, severity, duration, complications
and sequel (consequences) is essential
3. Medication History
This is crucially important and should consider not only what medication the patient
is currently taking but also what he or she might have been taking until recently.
Because of the availability of so many medications without prescription, known as
over-the-counter drugs, remember to ask specifically about any medications that have
been bought at the pharmacy or supermarket, including homeopathic and herbal
remedies. For each medication ask about: the generic name, if possible; dose; route of
administration; and any recent changes, such as increase or decrease in dose or change
in the amount of times the patient takes the medication. Finally, ask about any allergies
and sensitivities, especially drug allergies, such as allergy or sensitivity to penicillin. It is
important to find out what the patient experienced, how it presented in terms of symptoms,
when it occurred and whether it was diagnosed.
4. Family history
Some disorders are considered familial; a family history can reveal a strong history
of, for example, cerebrovascular disease or a history of dementia,that might help to
guide the management of the patient. Open questioning followed by closed questioning
can be used to gather information about any significance in the patient’s family history.
For example, start with an open question such as: ‘Are there any illnesses in the family?’
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Then ask specifically about immediate family – namely parents and siblings. For each
individual ask about diagnosis and age of onset and, if appropriate, age and cause of
death.
5. Social History
A patient’s ability to cope with a change in health depends on his or her social
wellbeing. A level of daily function should be established throughout the history taking.
The HCP should be mindful of this level of function and any transient or permanent
change in function as a result of past or current illness.
Questions about function should include the ability to work or engage in leisure
activities if retired; perform household chores, such as housework and shopping;
perform personal requirements, such as dressing, bathing and cooking. In particular,
with deteriorating health a patient may have needed to give up club or society
memberships, which may lead to a sense of isolation or loss.
HCPs should consider the whole of the family when exploring a social history.
Relationships to the patient should be explored, for example, is the patient
married, is his or her spouse healthy, do they have children and, if so, what age are
they? The health and residence to the patient should be known to understand actual
and potential support networks. Other support structures include asking about friends
and social networks, including any involvement of social services or support from
charities.
The social history should also include enquiry into the type of housing in which the
patient lives. This should include if the accommodation is owned, rented or leased, what
condition it is in and whether there have been any adaptations.
Alcohol In relation to the social history ask specifically about alcohol intake. The
HCP should ask about past and present patterns of drinking alcohol.
Smoking It is documented that smoking causes early death in the population and
no safe maximum or minimum limit, unlike alcohol, has been identified. HCPs should ask
questions that identify the history of the patient’s smoking.
Traditionally questions surrounding smoking include: ‘What age did you start smoking?’,
‘What kind of cigarettes do you smoke?’, ‘How many cigarettes a day do you smoke?’,
‘Do you use roll ups or filtered?’ and ‘Are they low or high tar content?’.
 Gordon’s 11 Functional Patterns
Marjorie Gordon was a nursing theorist and professor who proposed a nursing
assessment theory known as Gordon's 11 Functional Health Patterns in 1987. FHP's as a
guide, used by nurses in the nursing process for establishing a comprehensive nursing data
base as a result of nursing assessment of the patient. Gordon's Functional Health Pattern
include 11 categories, which make a systematic and standardized approach to data
collection possible, and enable the nurse to determine the following aspects of health and
human function:
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1 - Health Perception and Health Management Pattern.
 Data collection is focused on the person's perceived level of health and well-being,
and on practices for maintaining health. Habits that may be detrimental to health are
also evaluated, including smoking and alcohol or drug use. Actual or potential
problems related to safety and health management may be identified as well as
needs for modifications in the home or needs for continued care in the home.
Example of Health Perception and Health Management FHP Assessment Questions:

 What is your opinion about health?
 Are you immunized about seven target diseases?
 Last immunization?
 Do you have any allergy? If yes then type of allergy.
 Any surgery in past? What type of surgery?
 Last physical examination & for what purpose.
 Are you using any medicine recently?
 Do you know about these medicines?
2 - Nutrition and Metabolism Pattern
 Assessment is focused on the pattern of food and fluid consumption relative to

metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or
potential problems related to fluid balance, tissue integrity, and host defenses may
be identified as well as problems with the gastrointestinal system.
Example of Nutrition and Metabolism FHP Assessment Questions:

 Ask about their skin, scalp and nails?
 What is your diet menu?
 Any food restriction regarding disease point of view?
 Any food restriction regarding religious point of view?
 Any food like or dislike?
 Any food allergy?
3 - Elimination Pattern
 Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory

problems such as incontinence, constipation, diarrhea, and urinary retention may be
identified.
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Example of Elimination FHP Assessment Questions:

 Color of urine, amount, frequency, odor and any discharge.
 Any urinary problem, dysurea, Anurea, Oligourea, , polyuria.
 Are you using any laxative? If yes which?
 Any problem during passing defecation?
4 - Activity and Exercise Pattern
 Assessment is focused on the activities of daily living requiring energy expenditure,

including self-care activities, exercise, and leisure activities. The status of major body
systems involved with activity and exercise is evaluated, including the respiratory,
cardiovascular, and musculo-skeletal systems.
Example of Activity and Exercise FHP Assessment Questions:

 Do you any breathing problem? (In which apnea, hypoxia, hypoxemia, hypercapnia.)
 Do you have cough? (Productive or non-productive)
 Any changes in heart beat during exercise?
 Do you feel pale during exercise?
 What type of exercise you do or any problem during exercise?
5 - Cognition and Perception Pattern
 Assessment is focused on the ability to comprehend and use information and on the
sensory functions. Data pertaining to neurologic functions are collected to aid this
process. Sensory experiences such as pain and altered sensory input may be
identified and further evaluated.

 Orientation about time place and person.
 Any difficulty in sentence making?
 Loss of memory.
6 - Sleep and Rest Pattern
 Assessment is focused on the person's sleep, rest, and relaxation practices.

Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be
identified.
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 Sleeping hour?
 Are you using nap (evening type sleeping).
 What do you feel after waking? (Fresh, headache, drowsy).
 Are you using any medication for sleeping?
 Do you have any exercise or walking at night?
7 - Self-Perception and Self-Concept Pattern
 Assessment is focused on the person's attitudes toward self, including identity, body
image, and sense of self-worth. The person's level of self-esteem and response to
threats to his or her self-concept may be identified.
Example of Self-Perception and Self-Concept FHP Assessment Questions:

 What is your self-perception about yourself?
 Are you satisfied with your self-body image?
 Do you like grooming?
8 - Roles and Relationships Pattern
 Assessment is focused on the person's roles in the world and relationships with
others. Satisfaction with roles, role strain, or dysfunctional relationships may be
further evaluated.
Example of Roles and Relationships FHP Assessment Questions:

 What is your role in family?
 If you are in hospital then who will perform your responsibilities?
 All the family members are cooperative with you?
 Who is decision maker in your family?
9 - Sexuality and Reproduction Pattern
 Assessment is focused on the person's satisfaction or dissatisfaction with sexuality

patterns and reproductive functions. Concerns with sexuality may he identified.
Example of Sexuality and Reproduction FHP Assessment Questions:

 When you first notice changes in your menarche (first menses is called menarche)
 Do you have any sexual problem? (Loss of libido)
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 Active sex (direct sex with male and female)

 Passive sex (sex without male and female partner)
 Digital sex
 Reproductive: Infertility
10 - Coping and Stress Tolerance Pattern
 Assessment is focused on the person's perception of stress and on his or her coping
strategies Support systems are evaluated, and symptoms of stress are noted. The
effectiveness of a person's coping strategies in terms of stress tolerance may be
further evaluated.

 If you have stress then what is your coping mechanism towards stress?
 Crying, angry, violence, (what is your opinion regarding that)
11 - Values and Belief Pattern
 Assessment is focused on the person's values and beliefs (including spiritual beliefs),
or on the goals that guide his or her choices or decisions.

 What is your religion?
 Do you offer prayer?
22
Teacher’s Insight
Gordon’s functional health patterns is a method to be used by nurses in the
nursing process to provide a more comprehensive nursing assessment of the patient.
It is imperative that nurses must have an accurate data collection regarding these
patterns. It will establish baseline for re assessment of improvement or exacerbation
of certain problems indicative to each functional patterns.
B. DIAGNOSIS
 Second Step of the Nursing Process
23
 Provide a basis for selection of nursing interventions so that goals and outcomes
can be achieved
 Interpret & analyze clustered data
 Identify client’s problems and strengths
 Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis
Association)-Statement of how the client is RESPONDING to an actual or potential
problem that requires nursing intervention
 Responsible for recognizing health problems, anticipating complications, initiating
actions to ensure appropriate and timely treatment.
 Apply critical thinking to problem identification
 Requires knowledge, skill, and experience
NURSING DIAGNOSIS MEDICAL DIAGNOSIS

Within the scope of nursing practice Within the scope of medical practice
Identify responses to health and illness Focuses on curing pathology
Can change from day to day Stays the same as long as the disease is
present
 Formulating a Nursing Diagnosis:
1. Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)

2. Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)
3. Don’t state 2 separate problems in one diagnosis
4. Refer to NANDA list in a nursing text book ( North American Nursing Diagnosis
Association it formally identifies, develops, and classifies nursing diagnoses)
 Parts of Diagnosis Statement:
1. Problem statement ( Diagnostic Label)-based on your assessment of

clienT(gathered information),
a. pick a problem from the NANDA list
b. the client’s response to a problem
2. Etiology- what’s causing/contributing to the client’s problem
a. determine what the problem is caused by or related to (R/T)
3. Defining Characteristics- what’s the evidence of the problem
i. -then state as evidenced by (AEB) the specific facts the problem is
based on…
Example:
Ineffective therapeutic regimen management related to difficulty
maintaining lifestyle changes and lack of knowledge as evidenced by B/P= 160/90,
24
dietary sodium restrictions not being observed, and client statements of “ I don’t
watch my salt” “It’s hard to do and I just don’t get it”.
 Types Of Nursing Diagnosis:
1. Actual- Patient problem & Causes if known

- Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea,
and pain AEB height 5’5” weight 105 lbs.
2. Risk- Problem & Risk Factors
- patient is at risk for developing this problem
-Example: Risk for falls RT altered gait and generalized weakness
3. Wellness- (NANDA) describes human responses to levels of wellness in an
individual, family, or community that have a readiness for enhancement
-Example: Family coping: potential for growth RT unexpected birth of twins.
 Sources Of Diagnostic Error:
1. Patient response not medical diagnosis

2. NANDA diagnostic statement not symptom
3. Treatable cause or risk factor not a clinical sign or chronic problem that is not
treatable
4. Problem caused by the treatment or diagnostic study not the treatment or study
itself
5. Patient response to equipment not equipment itself
6. Patient's problems not your problems with nursing care
7. Patient problem not nursing intervention
8. Patient problem not goal of care
9. Professional not prejudicial judgments
10. Avoid illegally inadvisable statements
11. Problem and its cause to avoid a circular statement
12. Identify only one patient problem in the diagnostic statement
* When initiating an original care plan, place the highest-priority nursing diagnosis
first.The ordering of nursing diagnoses or patient problems using notions of urgency
and importance to establish a preferential order for nursing interventions.
C. PLANNING
 Third Step of the Nursing Process

 This is when the nurse organizes a nursing care plan based on the nursing
diagnoses.
 Nurse and client formulate goals to help the client with their problems
 Expected outcomes are identified
 Interventions (nursing orders) are selected to aid the client reach these goals.
25
 Begin by prioritizing client problems

 Prioritize list of client’s nursing diagnoses using Maslow
 Set your priorities of care, what needs to be done first, what can wait.
 Apply Nursing Standards, Nurse Practice Act, National practice guidelines,
hospital policy and procedure manuals.
 Identify your goals & outcomes, derive them from nursing diagnosis/problem.
 Determine interventions, based on goals.
 Record the plan (care plan/concept map)
 Client specific Priorities can change
 Developing a Goal and Outcome Statement:
1. Goal and outcome statements are client focused.

2. Worded positively
3. Measurable, specific observable, time-limited, and realistic
4. Goal = broad statement
5. Expected outcome = objective criterion for measurement of goal or Measurable
change that must be achieved to reach a goal
EXAMPLE:
Goal: Client will achieve therapeutic management of disease process….
Outcome Statement: as evidenced by B/P readings of 110-120 / 70-80 and
client statement of understanding importance of dietary sodium restrictions by
day of discharge.
 Types of Goals:
1. Short term- goal can be achieved in a reasonable amount of time ( few hours to
few days)
2. Long term- goals may take weeks/months to be achieved
3. Cognitive goals
4. Psychomotor goals
5. Affective goals
 Goals are patient-centered and SMART (Specific Measurable Attainable

Relevant Time Bound)
 Planning Select Interventions:
 Interventions are selected and written.

 The nurse uses clinical judgment and professional knowledge to select
appropriate interventions that will aid the client in reaching their goal.
 Interventions should be examined for feasibility and acceptability to the client
 Interventions should be written clearly and specifically.
26
*Always partner with patients when setting their individualized goals. Mutual goal
setting includes the patient and family (when appropriate) in prioritizing the goals of
care and developing a plan of action. Act as a patient advocate.
D. IMPLEMENTATION
 The Fourth Step in the Nursing Process

 This is the “Doing” step
 Interventions will be collaborative, combining nursing actions and physician
orders.
 Carrying out nursing interventions (orders) selected during the planning step
 This includes monitoring, teaching, further assessing, reviewing NCP,
incorporating physicians orders and monitoring cost effectiveness of interventions
 Intervention - are treatments or actions based on clinical judgment and

knowledge that nurses perform to enhance patient outcomes.
 3 Types Of Intervention:
1. Independent ( Nurse initiated )- any action the nurse can initiate without
direct supervision
2. Dependent ( Physician initiated )-nursing actions requiring MD orders
3. Collaborative- nursing actions performed jointly with other health care team
members
EXAMPLE:
1. Monitor Vital Sign q4h
2. Maintain prescribed diet (2 Gm Na)
3. Teach client amount of sodium restriction, foods high in sodium, use of
nutrition labels, food preparation and sodium substitutes
4. Teach potential complications of hypertension to instill importance of
maintaining Na restrictions
5. Assess for cultural factors affecting dietary regime
 Factors to Consider When Selecting Interventions:
 Desired patient outcomes

 Characteristics of the nursing diagnosis.
 Research-based knowledge for the intervention
 Feasibility of the interventions
 Acceptability to the patient
 Nurse's competency
 Tips For Making Decisions During Implementation:
27
1. Review the set of all possible nursing interventions for a patient's problem
2. Review all possible consequences associated with each possible nursing action
3. Determine the probability of all possible consequences
4. Judge the value of the consequence to the patient
E. EVALUATION
 To determine effectiveness of NCP

 Final step of the Nursing Process but also done concurrently throughout client
care
 A comparison of client behavior and/or response to the established outcome
criteria
 Step of the nursing process that measures the client’s response to nursing
actions and the client’s progress toward achieving goals
 Data collected on an on-going basis
 Supports the basis of the usefulness and effectiveness of nursing practice
 Involves measurement of Quality of Care
 Evaluation of individual plan of care includes determining outcome achievement
 Identify variables/factors affecting outcome achievement
 Decide where to continue/modify/terminate plan
 Continue/modify/terminate plan based on whether outcome has been met
(partially or completely)
 Evaluation of Goal Achievement:
 Measures and Sources: Assessment skills and techniques

 As goals are evaluated, adjustments of the care plan are made
 If the goal was met, that part of the care plan is discontinued
 Redefines priorities
 Reflection in Action:
 Once you deliver an intervention, you continuously examine results by gathering

subjective and objective data from the patient, family, and health care team
members.
 At the same time you review knowledge regarding a patient's current condition,
the treatment, and the resources available for recovery.
 By reflecting on previous experiences caring for similar patients, you are in a
better position to know how to evaluate your patient.
 Perform the following steps to objectively evaluate the degree of success

in achieving outcomes of care:
28
1. Examine
2. Evaluate
3. Compare
4. Judge
5. What is/are the barriers? why did they not agree?
 When do you discontinue a care plan?

 If the patient has met all goals and outcomes
 Modifying A Care Plan
1. Reassessment
2. Redefining diagnoses
3. Goals and expected outcomes
4. Interventions
Teacher’s Insight
The nursing process is described as being an individualised problem solving approach in
which patients receive nursing care. The nursing process is a very important tool that
nurses have in to make sure that they give adequate care to all their patients. It helps
them not only evaluate each patients’ needs individually but also allows the nurse to
prioritize which patient’s needs are more important to attend to first. Just like doctors
have a way of diagnosing patients, nurses also use this process to give their own form
of diagnosis. The significance of having the nursing process is to have a set way in
which each nurse gets a care plan for the patient.
End of Chapter 1….
Reminders: Before proceeding to the exercises, if you have other topics not fully clear to
you, feel free to browse again on the topics and you can also do additional readings from
other textbooks and references. No cheating in the self- assessment exercises. Answer it on
your own without looking at your notes. Good Luck!
29
END CHAPTER ACTIVITIES

I. Self- Assessment Exercises: Please answer the following questions and use the
answer sheet provided below this exercise.
1. Once a nurse assesses a client’s condition and identifies appropriate nursing

diagnoses, a:
A. Plan is developed for nursing care.

B. Physical assessment begins
C. List of priorities is determined.
D. Review of the assessment is conducted with other team members.
30
2. Planning is a category of nursing behaviors in which:
A. The nurse determines the health care needed for the client.
B. The Physician determines the plan of care for the client.
C. Client-centered goals and expected outcomes are established.
D. The client determines the care needed.
3. Priorities are established to help the nurse anticipate and sequence nursing
interventions when a client has multiple problems or alterations. Priorities are
determined by the client’s:
A. Physician
B. Non Emergent, non-life threatening needs
C. Future well-being.
D. Urgency of problems
4. A client centered goal is a specific and measurable behavior or response that

reflects a client’s:
A. Desire for specific health care interventions

B. Highest possible level of wellness and independence in function.
C. Physician’s goal for the specific client.
D. Response when compared to another client with a like problem.
5. For clients to participate in goal setting, they should be:
A. Alert and have some degree of independence.

B. Ambulatory and mobile.
C. Able to speak and write.
D. Able to read and write.
6. The nurse writes an expected outcome statement in measurable terms. An

example is:
A. Client will have less pain.

B. Client will be pain free.
C. Client will report pain acuity less than 4 on a scale of 0-10.
D. Client will take pain medication every 4 hours around the clock.
7. As goals, outcomes, and interventions are developed, the nurse must:
31
A. Be in charge of all care and planning for the client.

B. Be aware of and committed to accepted standards of practice from nursing and other
disciples.
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client.
8. When establishing realistic goals, the nurse:
A. Bases the goals on the nurse’s personal knowledge.

B. Knows the resources of the health care facility, family, and the client.
C. Must have a client who is physically and emotionally stable.
D. Must have the client’s cooperation.
9. To initiate an intervention the nurse must be competent in three areas, which

include:
A. Knowledge, function, and specific skills

B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.
10. Collaborative interventions are therapies that require:
A. Physician and nurse interventions.

B. Nurse and client interventions.
C. Client and Physician intervention.
D. Multiple health care professionals.
11. Well formulated, client-centered goals should:
A. Meet immediate client needs.

B. Include preventative health care.
C. Include rehabilitation needs.
D. All of the above.
12. The following statement appears on the nursing care plan for an
immunosuppressed client: The client will remain free from infection throughout
hospitalization. This statement is an example of a (an):
32
A. Nursing diagnosis
B. Short-term goal
C. Long-term goal
D. Expected outcome
13. The following statements appear on a nursing care plan for a client after a
mastectomy: Incision site approximated; absence of drainage or prolonged
erythema at incision site; and client remains afebrile. These statements are
examples of:
A. Nursing interventions
B. Short-term goals
C. Long-term goals
D. Expected outcomes.
14. The planning step of the nursing process includes which of the following
activities?
A. Assessing and diagnosing

B. Evaluating goal achievement.
C. Performing nursing actions and documenting them.
D. Setting goals and selecting interventions.
15. The nursing care plan is:
A. A written guideline for implementation and evaluation.

B. A documentation of client care.
C. A projection of potential alterations in client behaviors
D. A tool to set goals and project outcomes.
16. After determining a nursing diagnosis of acute pain, the nurse develops the
following appropriate client-centered goal:
A. Encourage client to implement guided imagery when pain begins.

B. Determine effect of pain intensity on client function.
C. Administer analgesic 30 minutes before physical therapy treatment.
D. Pain intensity reported as a 3 or less during hospital stay.
17. When developing a nursing care plan for a client with a fractured right tibia,
the nurse includes in the plan of care independent nursing interventions,
including:
33
A. Apply a cold pack to the tibia.

B. Elevate the leg 5 inches above the heart.
C. Perform range of motion to right leg every 4 hours.
D. Administer aspirin 325 mg every 4 hours as needed.
18. Which of the following nursing interventions are written correctly? Select all
that apply.
A. Apply continuous passive motion machine during day.

B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
19. A client’s wound is not healing and appears to be worsening with the current
treatment. The nurse first considers:
A. Notifying the physician.

B. Calling the wound care nurse
C. Changing the wound care treatment.
D. Consulting with another nurse.
20. When calling the nurse consultant about a difficult client-centered problem,
the primary nurse is sure to report the following:
A. Length of time the current treatment has been in place.

B. The spouse’s reaction to the client’s dressing change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current treatment plan.
21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a
difficult nursing problem. The primary nurse is obligated to:
A. Implement the specialist’s recommendations.

B. Report the recommendations to the primary physician.
C. Clarify the suggestions with the client and family members.
D. Discuss and review advised strategies with CNS.
22. After assessing the client, the nurse formulates the following diagnoses.
Place them in order of priority, with the most important (classified as high)
listed first.
34
A. Constipation
B. Anticipated grieving
C. Ineffective airway clearance
D. Ineffective tissue perfusion.
23. The nurse is reviewing the critical paths of the clients on the nursing unit. In
performing a variance analysis, which of the following would indicate the need
for further action and analysis?
A. A client’s family attending a diabetic teaching session.

B. Canceling physical therapy sessions on the weekend.
C. Normal VS and absence of wound infection in a post-op client.
D. A client demonstrating accurate medication administration following teaching.
24. The RN has received her client assignment for the day-shift. After making
the initial rounds and assessing the clients, which client would the RN need to
develop a care plan first?
A. A client who is ambulatory.

B. A client, who has a fever, is diaphoretic and restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has just received pain medication.
25. Which of the following statements about the nursing process is most
accurate?
A. The nursing process is a four-step procedure for identifying and resolving patient
problems.
B. Beginning in Florence Nightingale’s days, nursing students learned and practiced the
nursing process.
C. Use of the nursing process is optional for nurses, since there are many ways to
accomplish the work of nursing.
D. The state board examinations for professional nursing practice now use the nursing
process rather than medical specialties as an organizing concept.
ANSWER SHEET
1. ________________________
2. ________________________
35
3. ________________________
4. ________________________
5. ________________________
6. ________________________
7. ________________________
8. ________________________
9. ________________________
10.________________________
11.________________________
12.________________________
13.________________________
14.________________________
15. ________________________
16. ________________________
17.________________________
18. ________________________
19.________________________
20. ________________________
21. ________________________
22. ________________________
23. ________________________
24. ________________________
25. ________________________
II. Short Essay: Answer the following shortly. Please use the space provided for your
answers.
1. Discuss the difference between medical diagnoses to nursing diagnosis.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
36
2. Discuss the difference of the three types of nursing intervention.

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
III. NANDA classification system. Open your NANDA book and choose at least 3
nursing diagnosis. In each diagnosis identify the defining characteristic by encircling it. Find
the etiology of each diagnosis and underline it. Discuss briefly the relationship of the
etiology in the defining characteristic.
1.________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2.________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3.________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
THIS IS THE END OF THE PRELIMS COVERAGE
Before proceeding to the Midterms Coverage….
 Do not forget to write your reflective journal for this term regarding your
learnings, personal reflections and realizations of the different concepts
given. All written outputs should be compiled in your learning portfolio to
be submitted to the subject teacher as part of the requirements of the
course.
37
MIDTERMS COVERAGE

consultation hours.
38
your teacher.
material).
Chapter 2
PHYSICAL EXAMINATION
In this chapter physical techniques and guidelines necessary for the actual physical
exam will be discussed. Cultural considerations when having physical assessment will also
be discussed. Proper taking of vital signs and considerations will be discussed also. Vital
signs are very important in the nursing profession. It is one of the essential skills student
nurses should familiarize with.
Duration: 4.0 hours

MAJOR TOPICS
Physical Examination
A. Preparation guidelines
B. PE guidelines
C. Techniques in physical assessment
-Inspection
-Auscultation
-Percussion
-Palpation
D. Cultural Considerations
E. Vital Signs
Activities:
1. Self- Assessment Exercises: MCQ questions

2. Critical Thinking Exercises: Short Essay

1. State the different physical examination preparation guidelines
2. Describe and differentiate the techniques in physical assessment
3. Appreciate continuing assessment of vital signs including pain and fever
39
Key Terms:
 Inspection
 Auscultation
 Percussion
 Palpation
 Pulse
 Blood Pressure
 Vital Signs
 Heart Rate
 Temperature
 Respiratory Rate
 Fever
Let’s Begin!
PHYSICAL EXAMINATION
DEFINITION
 Conducted from head to toe (cephalo-caudal technique).
 Determine the mental status and level of consciousness (LOC) at the beginning of
examination.
PURPOSES
 Gather baseline data about the client’s health
 Supplement, confirm or refute data obtained in the midwifery history
 Confirm & identify midwifery diagnosis
 Make clinical judgments about a client's changing health status and management
 Evaluate the physiological outcomes of care
PREPARATION GUIDELINES
1. Explain the procedure
2. Inform the client the need to assume a special position
3. Tell the client that appropriate draping will be provided.
4. Control room temperature, and provide warm blanket.
5. Ask the client to empty the bladder.
6. Encourage the client to defecate.
7. Use a relaxed voice tone and facial expressions to put the client at ease.
8. Encourage the client to ask questions and report discomfort felt during the
examination.
40
9. Have a family member or a third person of the client’s gender in the room during
assessment of genitalia
10. At the conclusion of the assessment, ask the client if he or she has any concerns or
questions
POSITIONS:
Sitting
 Use this position for the assessment of head,neck,
back,posterior thorax,and lungs,breasts,axillae,heart,
vital signs,and upper extremities
 It provides full expansion of lungs, and provides better
visualization of symmetry of upper body part.
Supine
 back lying position with legs extended, without small
pillow under the head
 for the assessment of head,and neck, anterior thorax,
and lungs, breasts, axillae, heart, abdomen, extremities,
pulses, vital signs, vagina
 Most normally relaxed position. It provides easy access to pulse sites.
Dorsal recumbent
 back lying position with knees flexed and hips
externally rotated, with small pillow under the head.
 Head, neck, anterior thorax and lungs, breasts, axillae,
heart and abdomen, extremities, peripheral pulses,
vital signs and vagina.
 Position is used for abdominal assessment because it
promotes relaxation of abdominal muscles.
Lithotomy
 back lying position with feet supported in stirrups;
hips should be in line with the edge of the table
 for the assessment of female genitalia, rectum and
female reproductive tract
 Provides maximal exposure of genitalia and facilitates
insertion of vaginal speculum
Sim’s
 side-lying position with lowermost arm behind the body
and uppermost leg flexed.
41
 For the assessment of rectum and vagina

 Flexion of knee and hip improves exposure of rectal area
Prone
 face-lying position with or without a small pillow
 assessment of posterior thorax, hip movement
Knee-chest (Genu-pectoral)
 kneeling position with torso at a chest.
 Assessment of rectum
 Provides maximal exposure to rectal area
Fowler’s
 Semi-fowler’s – head of bed elevated at 15-45 degree angle.
 High Fowler’s – head of bed raised at 80-90 degree angle.
EQUIPMENTS USED FOR PHYSICAL EXAMINATION
42
EQUIPMENT USE
Cotton balls or wisps Test the sense of touch
Cotton-tipped applicators Obtain specimens
Culture media Obtain cultures of body fluids and drainage
Dental mirror Visualize mouth and throat structures
Doppler ultrasonic stethoscope Obtain readings of blood pressure, pulse, and fetal
heart rate
Flashlight Provide a direct source of light to view parts of the
body
Gauze squares Obtain specimens; collect drainage
Gloves Protect the nurse and client from contamination
Goggles Protect the nurse’s eyes from contamination by body
fluids
Lubricant Provide lubrication for vaginal or rectal examinations
Nasal speculum Dilate nares for inspection of the nose
Ophthalmoscope Inspect the interior structures of the eye
Otoscope Inspect the tympanic membrane and external ear
canal
Penlight Provide a direct light source and test pupillary reaction
Reflex hammer Test deep tendon reflexes
Ruler, marked in centimeters Measure organs, masses, growths, and lesions
Skin-marking pen Outline masses or enlarged organs
Slides Make smears of body fluids or drainage
43
Specimen containers Collect specimens of body fluids, drainage, or tissue

Sphygmomanometer Measure systolic and diastolic blood pressure
Sterile safety pin Test for sensory stimulation
Stethoscope Auscultate body sounds
Tape measure Measure the circumference of the
head, abdomen, and extremities in
centimeters
Test tubes Collect specimens
Thermometer Measure body temperature
Tongue blade Depress tongue during assessment of the mouth and
throat
Tuning fork Test auditory function and vibratory sensation
Vaginal speculum Dilate the vaginal canal for inspection of the cervix
Vision chart Test near and far vision
Watch with second hand Time heart rates, fetal pulse, or bowel sounds when
counting
TECHNIQUES OF PHYSICAL ASSESSMENT

1. INSPECTION
 visual examination
-Should be deliberate, purposeful, and systematic
-is concentrated watching
-it is close, careful scrutiny, first of the individual and as a whole and on each body
system
 begins the moment you first meet your client
 inspection always comes first
 the health care worker inspects with the naked eye and with a lighted instrument
 in addition to visual observations, olfactory and auditory cues are noted
 inspection is used to assess moisture, color, and texture if body surfaces as well as
shape , position ,size, symmetry of the body
 requires good lighting, adequate exposure, and occasional use of certain instruments
to enlarge your view.
Guidelines:
 Make sure the room has a comfortable temperature.
 Use good lighting, preferably sunlight.
 Look & observe before touching.
44
 Compare appearance of symmetric body parts or both sides of any individual body
part.
2. AUSCULTATION
 requires the use of stethoscope

 Guidelines:
1. Eliminate distracting noises
2. Expose the body part you are going to auscultate
3. Press the diaphragm firmly
Flipped Classroom: For additional reference, you can click

the actual video for method of auscultation in the chest:
https://www.youtube.com/watch?v=ypz1vUtmsdY
Auscultation using stethoscope
3. PALPATION
 Factors/ characteristics to assess are:

1. Texture
2. Temperature of skin area
3. Location/position, size, consistency, mobility of organs or masses
4. Distention
5. Pulsation
6. Presence of pain upon pressure
7. Presence of lumps
 Different parts of the hands are best suited for assessing different factors:
1. finger pads
2. grasping action of the fingers and thumb
3. dorsal
4. ulnar or palmar
 Types Of Palpation:
1. Light Palpation
-place dominant hand lightly on the surface of the structure
-there should be very little or no depression
-feel the surface using circular motion
-use this technique to feel for pulse, tenderness, surface, texture, temperature &
moisture
2. Moderate Palpation
-depress the skin surface 1-2 cm (.5-.75 in) with your dominant hand
45
-use circular motion to feel for easily palpable body organs and masses
-note for size, consistency and mobility of structures you palpate
3. Deep Palpation
-place your dominant hand on the skin surface and your non dominant hand on top
of your dominant hand to apply pressure
-surface depression should be 2.5 cm and 5 cm (1-2 in)
-allows you to feel very deep organs or structures that are covered by thick muscle
a. Bimanual Palpation
-use two hands, placing one on each side of the body part being palpated
-use one hand to apply pressure and the other hand to feel the structure
-note the size, shape, consistency and mobility of the structures you palpate
Moderate Palpation
Deep Palpation - bimanual Light Palpation - bimanual
4. PERCUSSION
 involves tapping body parts to produce sound waves that enable the examiner to
assess underlying structures
 Uses:
-Eliciting pain: percussion helps detect inflamed underlying structures.
-Determining location, size and shape
-Determining density
-Detecting abnormal masses
-Eliciting reflexes
 Types:
1.Direct Percussion
Direct Percussion
2. Indirect or mediate Percussion Indirect percussion
46
 Procedure:
a. place middle finger of non-dominant hand on body part you are going to percuss
b. use pad of middle finger of the other hand to strike the middle finger of non-
dominant hand that is placed on the body part
c.withdraw finger immediately
d. deliver 2 quick taps and listen carefully
e. use quick, sharp taps by flexing wrist
 Sounds Elicited by Percussion: -length: MODERATE

1. Resonance -quality: DRUMLIKE
-intensity: LOUD -PUFFED-OUT CHEEKS
-pitch: LOW 4. Dullness
-length: LONG -intensity: MEDIUM
-quality: HOLLOW -pitch: MEDIUM
-origin: NORMAL LUNG -length: MODERATE
2. Hyper-resonance -quality: THUDLIKE
-intensity:VERY,LOUD -DIAPHRAGM, PLEURAL
-pitch:LOW EFFUSION, LIVER
-length:LONG 5. Flatness
-quality:BOOMING -intensity: SOFT
-LUNG W/ EMPHYSEMA -pitch: HIGH
3. Tympany -length: SHORT
-intensity: LOUD -quality: FLAT
-pitch: HIGH -MUSCLE, BONE
Special Considerations:
1. The sequence of methods for physical examination of the abdomen is as follows:
Inspection, Auscultation, Percussion and Palpation (IAPePa). No abdominal palpation
among clients with tumor of the liver or the kidneys.
2. During physical examination of the abdomen, it is important to flex the knees to
relax the abdominal muscles , thereby facilitating the examination of abdominal
organs.
3. The sequence of examining the abdomen is as follows: right lower quadrant, right
upper quadrant, left upper quadrant and left lower quadrant (RLQ, RUQ, LUQ, LLQ).
4. The best position when examining the chest is sitting/upright position. This permits
the examination of both the anterior and posterior chest.
5. The best position when examining the back is standing position. This enables the
examiner to assess the posture, and the gait of the client.
6. If instrumental vaginal examination is done, pour warm water over the vaginal
speculum before use. To ensure comfort.
47
7. Is a female client is examined by a male doctor, a female staff must be in

attendance. This ensures that the procedure is done in ethical manner.
Organization of The Examination

1. History taking precedes physical examination.
2. The commonly used system is “head to toe” (cephalocaudal).
3. The extent of the examination depends on the purpose.
i. A client returning from surgery for repair of a fractured leg will require
assessment of the circulatory and musculoskeletal function rather than
a breast assessment or examination.
4. If client becomes fatigued, offer rest periods between assessments.
5. Record results of the examination in scientific terms so that any health professional
can interpret the findings.
The Examination
General Survey - The preliminary examination which includes the following:
A. Height and Weight
B. Vital Signs
1. Temperature
- Taken at what route.
2. Pulse
- Rhythm, volume and tension.
3. Respiration
- Rate, rhythm, symmetry, depth, character, color of the client
4. Blood Pressure
C. General Appearance and Behavior
1. Sex and Race
- A person’s sex affects the type of examination performed.
- Different physical features are related to sex and race.
2. Signs of Distress
- There maybe signs or symptoms indicating a problem such as pain, difficulty
of breathing, and anxiety.
3. Body Type
- The body type can reflect the level of health, age and lifestyle
- The HCP observes if the client appears trim, muscular, obese, or excessively
thin.
4. Posture
- Normal standing posture is an upright stance with parallel alignment of his
shoulders.
- Normal sitting posture involves some degree of rounding of the shoulders. --
Observe if the client has an erect, slumped, or a bent posture. Posture may
reflect mood or presence of pain. Many elderly persons assumed a stooped
position.
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5. Gait
- The manner of walking. Note if the movements are coordinated or
uncoordinated.
6. Body Movements
- Note for involuntary movements of body
7. Age
- It influences the normal features or physical characteristics of an individual.
The ability to participate n some parts of the examination will also be
influenced by age.
8. Hygiene and Grooming
- Note the client’s level of cleanliness by observing the appearance of the hair,
skin, or the fingernails.
9. Dress
- Note if the type of clothing worn is appropriate for the temperature and
weather condition.
10. Body Odor
- Assess is it from physical exercise, poor hygiene, or poor oral hygiene.
11. Mood and Affect/ Facial Expression
- At rest and in interaction with others.
12. Speech
- It includes the pace of speech, its pitch and clarity.

13. Level of Consciousness
- Including the speed of response to questions and apparent comprehension.
Teacher’s Insight
A physical examination is the evaluation of a body to determine its state of health. The
term annual physical examination has been replaced in most health care circles by periodic
health examination. The frequency with which it is conducted depends on factors such as
the age, gender, and the presence of risk factors for disease in the person being examined.
Health-care professionals often use guidelines that have been developed before or during
physical examination. Before Physical Examination, HCP will observe a person's overall
appearance, general health, and behaviour. Measurements of height and weight are made.
Vital signs such as pulse, breathing rate, body temperature, and blood pressure are
recorded. They assume certain positions with different types of Physical examination. Such
as sitting for the assessment of the thorax and heart. It is important to prepare the setting
and equipment aside from the patient to ensure a smooth flow of the procedure.
CULTURAL CONSIDERATIONS OF PHYSICAL ASSESSMENT

49
What you need to Why you need to know it

know
Ethnicity and • This information can be an indicator of the client’s culture,
country of birth traditions, customs, health beliefs and preferred languages.
Remember that:
Ethnicity may be more significant than country of birth. For
example, clients may have been born in a country where their
parents lived briefly.
Literacy • May affect the client’s capacity to respond to written
information provided during the assessment.
• May indicate the client’s social status and education level in
their previous country of residence or origin.
Remember that:
• Clients may rely on family members to read and explain written
information.
• Clients and their families may not be literate in the language they
prefer to speak.
Interpreter • Identifying an appropriate interpreter, and ensuring that the client
preferences is comfortable using an interpreter, is essential for clear and
appropriate communication.
Remember that:
• The client may not be familiar with using an interpreter: you
may need to explain the process.
• Clients may have concerns about the confidentiality of
interpreters.
• There is a small chance that the client may know the interpreter,
which may raise privacy concerns.
• Consider client preferences regarding the gender and
ethnicity of the interpreter, and whether an on-site or
telephone interpreter is preferred.
• Only qualified interpreters should be used: the client’s
family members should not be used as interpreters.
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Family and social • The responsibility for care may not lie only with the client:
support other people, including extended family, may assume
responsibility for care
Remember that:
• In some cultures, ‘family’ may include non-related individuals.
• A client’s social support networks may be limited.
• A client may be able to access support through community
organizations.
Religious practices • Clients may wish to access spiritual or religious leaders
• Particular times for prayer may be important
• Religious practices may occasionally conflict with treatment plans.
• Particular customs may need to be followed during birth, illness
and death and dying
Migration • Stress and trauma resulting from pre-migration, migration or
status and post-migration experiences can greatly affect a client’s health
experience and wellbeing.
• Visa status can affect access to subsidised health services.
Beliefs about • Clients’ beliefs and past experience affect the way they view
health and illness health, causes of illness and treatment.
• Understanding and acknowledging the client’s health
beliefs and practices is an important step in creating a
mutually acceptable care plan.
Understanding • Clients may not be familiar with the structure of the health
of the health service system or how to access various services.
system • Clients may not be familiar with health system processes (eg
waiting lists for hospitals, Medicare support, etc)
Dietary practices • There may be religious restrictions on food consumption

• Some foods may have cultural meanings for clients (eg the
belief that certain foods are beneficial or harmful to health)
51
Teacher’s Insight
Cultural awareness and sensitivity is vital to effective healthcare provision. Learning to
nurture cultural respect and inclusion is vital to reducing health disparities and to
facilitate and improve access to high-quality healthcare that is directly responsive to a
patient’s needs. In such manner, so is during Physical Examination. Some patients
may have different point of view in terms of health care provisions such as exposure
of certain body parts for specific examinations. Some may also be more apprehensive
than other people in sharing information needed for examination.
VITAL SIGNS
TEMPERATURE
1. Body temperature – the balance between the heat produced by the body and the
heat lost from the body.
Types of Body Temperature:
1. Core temperature – the temperature of the deep tissues of the body. Measured by
taking oral and rectal temperature.
2. Surface temperature – the temperature of the skin, subcutaneous tissue and fat.
Measured by taking axillary temperature.
Factors affecting the body’s heat production:

 Basal Metabolic Rate(BMR) – the younger the person, the higher the BMR; the older
the person, the lower the BMR. Therefore, the older persons, have lower body
temperature than the younger persons.
 Muscle Activity – exercise increases body heat production.
 Thyroxine Output – increases cellular metabolic rate. Hyperthyroidism is
characterized by increased body temperature.
 Epinephrine, norepinephrine, and sympathetic stimulation – increase the rate of
cellular metabolism. These in turn increase body temperature.
 Fever – increases the rate of cellular metabolism.
Processes Involved in Heat Loss:

a. Radiation-transfer of heat from the surface of one object to surface of another
without contact between two objects.
b. Conduction-transfer of heat from one molecule to a molecule of lower temperature.
c. Convection- dispersion of heat by air currents.
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d. Evaporation- continuous vaporization of moisture from the respiratory tract and

from the mucosa of the mouth and from the skin.
Factors affecting Body Temperature

1. Age – infant’s body temperature is greatly affected by the temperature of the
environment. Elder people are at risk of hypothermia due to decreased
thermoregulatory controls, decrease subcutaneous fat, inadequate diet, and sedentary
activity.
2. Diurnal Variations(Circadian Rhythms) – highest temperature is usually reached
between 8PM-12MN; and the lowest temperature is reached between 4-6 AM.
3. Exercise – strenuous increases BMR thus, the body temperature.
4. Hormones – e.g. progesterone, thyroxine, epinephrine and norepinephrine increase
body temperature; estrogen decreases body temperature.
5. Stress – sympathetic nervous system stimulation increases the production of
epinephrine and norepinephrine, thereby increasing the metabolic rate and heat
production.
Alterations in Body Temperature

1. Pyrexia/hyperthermia/fever – temperature above normal range.
2. Hyperpyrexia – very high fever, 41 degrees celcius (105.8 deg. Fahrenheit) and
above.
3. Hypothermia – subnormal core body temperature. This may be caused by excessive
heat loss, inadequate heat production or impaired hypothalamic function.
Types of Fever:
1. Intermittent Fever-the body temperature alternates at regular intervals between
periods of fever and periods of normal or subnormal temperatures.
2. Remittent Fever-a wide range of temperature fluctuations (more than 2C) occurs
over the 24-hour period, all of which are above normal.
3. Relapsing Fever-short febrile periods of a few days are interspersed with periods of 1
or 2 days of normal temperature.
4. Constant Fever-the body temperature fluctuates minimally but always remains above
normal.
Clinical Signs of Fever

1. Onset
– Increased heart rate
– Increased respiratory rate and depth
– Shivering
– Pallor, cold skin
– Complaints of feeling cold
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– Cyanotic nail beds

– “gooseflesh” appearance of the skin
– Cessation of sweating
2. Course
– Absence of Chills
– Glassy-eyed appearance
– Increased pulse and respiratory rate
– Increased thirst
– Mild to severe dehydration
– Drowsiness, restlessness, delirium or convulsions
– Herpetic lesions of the mouth
– Loss of appetite
– Malaise, weakness and aching muscles
4. Defervescence(fever abatement)
– Skin that appears flushed and feels warm
– Sweating
– Decreased shivering
– Possible dehydration
Interventions for Clients with Fever

1. Monitor vital signs.
2. Assess skin color and temperature.
3. Monitor WBC, hematocrit value, and other pertinent laboratory reports
4. Remove excess blankets when the client feels warm, but provide extra warmth when
the clients feels chilled.
5. Provide adequate nutrition and fluids
6. Measure I and O
7. Reduce physical activity
8. Provide oral hygiene
9. Provide a tepid sponge bath
10. Provide dry clothing and bed linens.
11. Administer antipyretics
Methods of Temperature Taking:

1. Oral – most accessible and convenient method.
 Allow 15 minutes to elapse between a client’s
 intake of hot or cold food or smoking and the
 measurement of oral temperature.
 Place thermometer under the tongue, directed
 towards the side.
 Wash the thermometer before use, from bulb to
54
 the stem, after use, from the stem to the bulb.

 This practice ensures medical asepsis.
 Contraindications:
a. Oral lesion or surgery
b. Cough
c. Nausea and vomiting
d. Very young children
e. Restless, disoriented
f. Seizure prone
2. Rectal – the most accurate method/reliable
 Procedure:
a. Provide privacy.
b. Position - Sim’s
c. Apply disposable gloves.
d. Squeeze liberal portion of lubricant.
e. With non-dominant hand, separate client’s
buttocks to expose the anus.
f. Ask client to breathe slowly and relax.
g. Gently insert thermometer into anus.
h. If resistance is felt during insertion, withdraw
thermometer immediately.
i. Once positioned, leave thermometer in place
j. Remove thermometer from anus.
k. Wipe with antiseptic solution.
l. Return thermometer to storage
m. Wipe client’s anal area with soft tissue to remove lubricant or feces and discard
tissue
n. Remove gloves and dispose.
 Contraindications:
a. Anal or rectal conditions or surgeries [hemorrhoids, hemorrhoidectomy]
b. Diarrhea
3. Axillary – safest and most non-invasive method of temperature taking.
 Procedure:
a. Pat dry the axilla
b. Place the thermometer on the client’s axilla
c. Place the arm tightly across the chest to
d. keep the thermometer in place
e. Remove from axilla.
f. Return thermometer to storage.
g. Perform hand hygiene
Normal body temperature: Axillary: 36.5-37.5 degrees celcius in all age groups.
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4. Temporal Artery – safe and non-invasive; very fast

- requires electronic equipment that may be expensive or unavailable.
PULSE
 Wave of blood created by contraction of the left ventricle of the heart.
Pulse sites:
1. Temporal - over the temporal bone of the head ; superior and lateral to the eye
2. Carotid - at the lateral aspect of the neck
3. Apical - at the left midclavicular line 5th intercostal space
4. Brachial - at the inner aspect of the upper arm (biceps muscles) or medially at the
antecubital space
5. Radial - on the thumb side of the inner aspect of the wrist.
6. Femoral - along side of the inguinal ligament
7. Posterior tibial- at the middle aspect of the ankle, behind the medial malleolus.
8. Pedal(dorsalis pedis)- at the dorsum of the foot.
9. Popliteal- at the back of the knee
Carotid Brachial Radial Femoral
Dorsalis Pedis Posterior tibial

Popliteal
Assessment of Pulse
Procedure:
1. Perform hand hygiene
2. Assess
3. Position
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4. Place tips of first two fingers of hand over groove along radial or thumb side of
client’s inner wrist
5. Lightly compress
6. Determine strength of pulse .
7. After pulse can be palpated regularly, look at the watch’s second hand and begin to
count
Rate- The normal PR per min are as follows:

 Newborn to 1 mo.: 120-160 beats/min
 1yr: 80- 140 bpm
 2yrs: 80-130 bpm
 6yrs: 75-120 bpm
 10 yrs: 50-90 bpm
 Adult: 60-100 bpm
Tachycardia – Pulse rate above 100 beats per minute (adult)

Bradycardia – Pulse rate below 60 beats per minute (adult)
Rhythm – pattern and intervals of beats
 DYSRHYTHMIA – irregular rhythm
Volume (amplitude) – strength of pulse
 Normal – moderate pressure
 Full or bounding pulse – can be obliterated only by great pressure
 Thready pulse (weak, feeble)– it can easily be obliterated
Factors Affecting Pulse Rate

1. Age – younger persons have higher pulse rate than older persons.
2. Sex/gender – after puberty, female have higher PR than the males.
3. Exercise – increases BMR, thereby increasing the pulse rate.
4. Fever – increases BMR, therefor the PR increases.
5. Medications – digitalis, beta blockers, decrease PR; epinephrine atropine sulfate
increase pulse rate.
6. Hemorrhage – increases pulse rate as compensatory mechanism for blood loss.
7. Stress – sympathetic nervous stimulation increases the activity of the heart.
8. Position changes – In sitting or standing position, there is decrease venous return to
the heart , decrease BP, therefore, increase in the heart rate.
RESPIRATION – act of breathing

3 Processes
1. Ventilation - movement of gases in and out of the lung
2. Diffusion - exchange of gases from an area of higher pressure to an area of
lower pressure
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3. Perfusion - the availability and movement of blood for transport of gases,

nutrients and metabolic waste products.
Two Types Of Breathing:

1. Costal (thoracic) – involves movement of the chest.
2. Diaphragmatic (Abdominal) – involves movement
Respiratory Centers:
Medulla Oblongata – primary center
- Pneumotaxic center – responsible for the rhythmic quality of breathing.
- Apneustic Center – responsible for deep, prolonged inspiration
Assessing respiration
 Procedure
1. Position client.
2. Place client’s arm in relaxed position across abdomen or lower chest, or place
hand directly over client’s upper abdomen
3. Observe complete respiratory cycle.
4. After cycle is observed, look at watch’s hand and begin to count
 Rate – normal:16-20 cycles/min (adult); 30-60 cycles per min (newborn)

– If BP is elevated – the RR becomes slow
– If BP is decreased – RR becomes rapid
 Depth – observe the movement of the chest
- may be normal, deep or shallow
 Rhythm – observe for regularity of exhalations and inhalations
 Quality or character – refers to respiratory effort and sound of breathing
Major Factors Affecting RR:

a. Exercise – increases RR
b. Stress – increases RR
c. Environment – increase temp. – decreases RR
decreased temperature – increases RR
Increased altitude – increases RR
Eupnea- normal respiration that is quiet, rhythmic, effortless

Tachypnea- rapid respiration marked by quick, shallow breaths.
Bradypnea -slow breathing
Hyperventilation- prolonged and deep breaths . carbon dioxide is excessively
exhaled.
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Hypoventilation- slow shallow respiration.

Dyspnea- difficult and labored breathing.
Orthopnea- ability to breath only in upright position.
BLOOD PRESSURE
 is a measure of the pressure exerted by the blood as it pulsates through the

arteries.
 Systolic pressure – pressure of blood as a result of contraction of the ventricles
 Diastolic pressure- the pressure when the ventricles are at rest (60-90 mmHg)
 Pulse pressure – the difference between systolic and diastolic pressure (normal:
30-40 mmHg)
Factors affecting BP:
• Age – older people have higher BP due to decreased elasticity of blood vessels.
• Exercise – increases cardiac output, hence the BP.
• Stress – Sympathetic nervous system
• Race – hypertension is one of the 10 leading causes of death among Filipinos.
• Obesity – BP is generally elevated among overweight and obese people.
• Sex/Gender
• Medications – some medications can increase or decrease BP.
• Diurnal variations – BP is lowest in the morning and highest in the late afternoon or
early evening.
• Disease Process – DM, renal failure, hyperthyroidism cause increase in BP.
Assessing BP
Procedure:
1. Ensure the client is rested
2. Allow 30 minutes to pass if the client had smoked or ingested caffeine before
taking the BP
3. Use appropriate size of BP cuff
4. Position the patient in sitting or supine position
5. Apply BP cuff snugly, 1 inch (2.5 cm) above the antecubital space
6. Use the bell shaped diaphragm of the stethoscope since the BP is a low-frequency
sound
7. Inflate deflate the cuff slowly, 2-3 mmHg at a time
8. Wait 1-2 mins before making further determinations
9. Document readings.
Classification of blood pressure for adults
Blood Pressure SBP DBP

59
Classification mmHg mmHg
Hypotension <90 <60
Normal 90- 120 Less than 80
Elevated 120–129 Less than 80
Stage 1 130-139 80-89

Hypertension
Stage 2 ≥140 ≥90

Hypertension
Hypertensive Crisis >180 >120

Recommended by American Heart Association
Teacher’s Insight
Vital signs reflect essential body functions, including your heartbeat,
breathing rate, temperature, and blood pressure. Your health care provider may
watch, measure, or monitor your vital signs to check your level of physical
functioning. Vital signs are useful in detecting or monitoring medical problems. Vital
signs can be measured in a medical setting, at home, at the site of a medical
emergency, or elsewhere.
Flipped Classroom: For additional reference, you can click the actual video for vital signs
monitoring. Https://Www.Youtube.Com/Watch?V=Guwj-6nl5-8
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I. Self- Assessment Exercises: Please answer the following questions and use the
answer sheet provided below this exercise.
Topic: Vital Signs

1. The most appropriate definition of Vital Signs:
A. Signs and symptoms of a disease
B. An indication of basic body functioning
C. A part of human composition
D. Physiology and anatomy
2. A proper assessment of vital signs will allow a nurse to: (select all that apply)
A. Learn about human behavior
B. Help evaluate improvement of patient condition
C. Implement planned interventions
D. Identify nursing diagnosis
3. An adult blood pressure reading of 120/80 mm Hg is:

A. Prehypertension
B. Hypotensive
C. Normal
D. Hypertensive
4. The following traits are typical among the older: Check all that apply:
A. Infection is often afebrile
B. Heart sounds are muffled
C. Skin is more fragile
D. Decreased heart rate at rest
E. Libido is normally heightened
5. Regulator of body temperature:

A. Medulla
B. Sebaceous glands
C. Hypothalamus
D. Wernicke's area
6. A rise of 1-degree Fahrenheit of temperature will increase the pulse rate by

how many beats per minute?
A. 3 B. 4 C. 5 D. 6
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7. Surface and Core:

A. Pulse
B. Temperature
C. Blood pressure
D. Pain
8. Decreased efficiency of respiratory muscles results in breathlessness at low

exercise levels:
A. True B. False
9. Factors affecting body temperatures: (select all that apply)

A. Stress
B. Age
C. Hormones
D. Smoking
E. Height
10. Constant, remittent and intermittent are classifications of:

A. Pain
B. Fever
C. Headache
D. Anxiety
11. A sudden drop in blood pressure because of positional changes is called

____________ ____________(two words)
12. Upon admission, the most appropriate person to check on a patient's vital
signs would be:
A. RN B. LPN C. PCT D. CNA
13. Which of the following statements about Fever is not true?

A. Fever is a sign of illness
B. It is the same as pyrexia or hyperthermia
C. It is reflected through an increase of body temperature
D. It does not do anything to defend the body
14. 96.0 to 99.5 degrees Fahrenheit is the normal temperature range of which
age group?
A. Toddler B. Adolescent C. Neonate D. Middle adult
15. When obtaining an oral temperature, after requesting the patient to open
the mouth, the probe is gently inserted into:
A. Anterior sublingual cavity
B. Lateral sublingual density
62
C. Superior lingual mucosity

D. Posterior sublingual pocket
16. The most appropriate position in obtaining a rectal temperature for an adult
would be:
A. Supine B. Fowler's C. Sim's D. Lateral
17. The colored probes of an electronic thermometer are indicative of:
A. Blue and red are both for oral
B. Blue is for rectal and red is for oral
C. Blue is for oral and red is for rectal
D. Blue and red are both for rectal
18. Resting in a supine position could cause to decrease the heart rate. What
cardiac condition does the same thing? _____ ______ (2 words)
19. When body temperature falls below 93.2 degrees Fahrenheit, the person is
suffering from the extreme:
A. Hyperthermia
B. Hypothermia
C. Orthopnea
D. Dypsnea
20. Considered the 5th vital sign:

A. Height and weight
B. Respiration
C. Body mass index
D. Pain
21. Older adults have an increase in systolic pressure related to what?

A. Increased vessel flexibility
B. Decreased vessel elasticity
C. Enlarged vessel dexterity
D. Diminished vessel porosity
22. Which time of day would we have the lowest temperature reading?
A. 4 pm to 6 pm
B. 4 am to 6 am
C. 8 pm to 12 midnight
D. 1 am to 4 am
23. A student nurse taking care of a patient with an abnormal body temperature
needs more training when he/she does what?
A. Monitor patient's temperature at least every 4 hours or PRN
B. Discourages a patient from drinking fluids to avoid excessive activity
63
C. Cover patient with more blankets, close room doors or windows

D. Further assess for possible site of localized infection
24. This condition may produce a subnormal temperature:

A. Cerebral palsy
B. Infection
C. Hypothyroidism
D. Fever
25. In assessing a tympanic temperature in a 20-year old male patient, which of

the following could result in the least accurate reading?
A. A plastic probe covers the tip of the thermometer
B. The patient has been outdoor for more than 30 minutes
C. The pinna is pulled backwards and up
D. The lens and the probe of the device are clean and intact
ANSWER SHEET
1. ________________________
2. ________________________
3. ________________________
4. ________________________
5. ________________________
6. ________________________
7. ________________________
8. ________________________
9. ________________________
10.________________________
11.________________________
12.________________________
13.________________________
14.________________________
15. ________________________
16. ________________________
17.________________________
18. ________________________
19.________________________
20. ________________________
21. ________________________
22. ________________________
23. ________________________
24. ________________________
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25. ________________________
II. Short Essay: Answer the following questions. Make use of the space provided for
each question.
1. Explain briefly why there is a need to consider the cultural differences and preferences
of patient during physical examination.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Give examples of cultural differences among different ethnic group wherein health care
providers need to have cultural awareness.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. What is/are the purpose why there is a need to assess the general appearance
including vital signs of patients before the actual head to toe physical assessment?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
65
Chapter 3
REVIEW OF SYSTEMS
In this chapter will be discussed the different topics
Duration: 2.0 hours
Activities:
1. Critical Thinking Inquiry Exercise: ROS data completion

1. Discuss the sequence of Review of System for adults
Key Terms:
 Organ Systems
 Review
 Vision
 General Questions
Let’s Begin!
ADULT REVIEW OF SYSTEMS

Overview
 The review of systems (or symptoms) is a list of questions, arranged by organ
system, designed to uncover dysfunction and disease. It can be applied in
several ways:
1. As a screening tool asked of every patient that the clinician encounters.

2. Asked only of patients who fall into particular risk categories (e.g. reserving
questions designed to uncover occult disease of the prostate to men over 50).
3. To better define the likely causes of a presenting symptom, as described in
the HPI section (e.g. patients w/a chief concern of "chest pain" would be
asked detailed cardiac and pulmonary ROS).
 It's important to realize that historical Q&A is just one piece of the clinical
puzzle. Patient's responses must be interpreted within the context of the rest of
66
their profile, including: risk factors, past history, and exam findings. For
example, a patient whose ROS is positive for chest pain, would then be asked
to define the dimensions of this symptom including: duration, precipitating
events, severity, characterization, radiation, associated symptoms, etc (or
questioning using OLD CARTS mnemonics). In addition, an assessment of
cardiac risk factors and an organized search for exam findings indicative of
vascular disease (e.g. elevated BP, diminished peripheral pulses, audible bruits,
etc) would be very relevant. On the basis of the sum of this data, the clinician
can come to an informed conclusion about the importance/cause of this
patient's chest pain (e.g. angina, heartburn, pulmonary embolism, etc), and
use it to guide their subsequent decision making.
 There is no ROS gold standard. The breadth of questions included is somewhat

arbitrary, based on the author's sense of the most commonly occurring
illnesses and their symptoms. There is planned redundancy, as the same
symptoms often apply to multiple organ systems. In addition, some sub-
specialty areas use an expanded ROS, specific to the conditions that they
evaluate and treat.
 I would like to highlight several important limitations:
a. The list of possible diagnoses that follows a question is not exhaustive. In

addition please realize that no patient responses are pathognomonic.
b. The symptoms in parentheses represent a partial listing of those most commonly
associated w/a particular disorder. They are based on general experience, not
discrete evidence.
c. The disease categorizations reflect rough groupings. There are many exceptions.
For example, disorders listed in the "acute" section may have chronic
presentations, those described as "upper abdominal" may present w/thoracic
symptoms, etc.
General
 Weight loss?
 Weight gain?
 Fatigue?
 Difficulty sleeping?
 Feeling well (or poorly) in general?
 Recent medical evaluations or treatments?
 Chronic pain?
 Fevers, chills, sweats, weight loss?
Vision
 Chronic or past eye disorders?
 Decrease/change in vision or blurriness? With or without pain?
67
 Double vision?
 Eye discharge (D/C)?
 Change in color of structures?
Head and Neck (H&N)
 Chronic or past head and neck disorders?
 Pain?
 Sores or non-healing ulcers in/around mouth?
 Masses or growths?
 Change in hearing acuity?
 Ear pain or discharge?
 Nasal discharge, post nasal drip?
 Change in voice/hoarseness?
 Tooth pain or problems
Pulmonary
 Chronic or past pulmonary disorders?
 Shortness of breath - @ rest or w/exertion?
 Chest pain?
 Cough?
 Hemoptysis (coughing up blood)?
 Wheezing?
 Snoring or stop breathing
Cardiovascular (C/V)
 Chronic cardiovascular disorders?
 Chest pain (CP) or pressure?
 Shortness of breath - @ rest or w/exertion?
 Orthopnea (short of breath lying down)?
 Paroxysmal Nocturnal Dyspnea (PND)? - sudden shortness of breath that
awakens pt from sleep
 Lower extremity edema?
 Sudden loss of consciousness (syncope)?
 Sense of rapid or irregular heart beat, palpatations?
 Calf/leg pain/cramps w/ambulation?
 Wounds/ulcers in feet? Difficult/slow to heal?
Gastrointestinal
 Chronic or past GI disorders?
 Heart burn/sub-sternal burning?
 Abdominal pain?
 Difficulty swallowing?
 Pain upon swallowing?
 Nausea or Vomiting?
 Abdominal swelling or distention?
 Jaundice (yellowish coloration of skin)?
68
 Vomiting blood (hematemasis)?

 Black/tarry stools?
 Bloody stools?
 Constipation?
 Diarrhea or other change in bowel habits?
Genito-Urinary
 Chronic or past GU disorders?
 Blood in urine?
 Burning with urination?
 Urination at night?
 Incontinence (unintentional loss of urine)?
 Urgency?
 Frequency?
 Incomplete emptying? Hesitancy? Decreased force of stream? Need to void soon
after urinating?
Hematology/Oncology
 Chronic or past Heme/Onc disease?
 Fevers, chills, sweats, weight loss?
 Abnormal bleeding/brusing?
 New/growing lumps or bumps?
 Hypercoaguability?
Ob/Gyn/Breast
 Chronic or past disease?
 Menstrual Hx?
 Sweats?
 Past pregnancies?
 Vaginal Discharge?
 # Sexual partners & type of sexual activity?
 Breast mass, pain or discharge?
 Therapeutic or spontaneous abortions?
 Hx STIs?
Neurological
 Known disease?
 Sudden loss of neurological function?
 Abrupt loss/change in level of consciousness?
 Witnessed seizure activity?
 Numbness?
 Weakness?
 Dizziness?
 Balance problems?
 Headache?
69
 Tremor?
Endocrine
 Known Endocrine disorder?
 Polyuria, polydypsia, polyphagia?
 Fatigue?
 Weight loss?
 Weight gain?
Infectious Diseases
 Known disease?
 Fevers, Chills, Sweats?
Musculoskeletal
 Known disease?
 Joint pain?
 Muscle ache?
 Joint swelling?
 Joint redness?
 Low back pain?
Mental Health
 Known mental health disorder?
 Do you feel sad or depressed much of the time?
 Alcohol, other substance abuse?
 Anxious much of the time?
 Memory problems?
 Confusion?
Skin and Hair
 Hair Loss
 Known disease?
 Skin eruptions/rashes?
 Growths?
 Sores that grow and/or don't heal?
 Lesions changing in size, shape, or color?
 Itching
Teacher’s Insight
A review of systems (ROS), also called a systems enquiry or systems
review, is a technique used by healthcare providers for eliciting a medical
history from a patient. It is often structured as a component of an admission
note covering the organ systems, with a focus upon the
subjective symptoms perceived by the patient (as opposed to the
objective signs perceived by the clinician). Along with the physical examination, it 70
can be particularly useful in identifying conditions that do not have precise
diagnostic tests.
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END CHAPTER ACTIVITY
CRITICAL THINKING INQUIRY EXERCISE: Using the pattern of ROS above make your
own ROS of a person/individual either among members of your family, friends or relatives.
Include all systems as aforementioned above. Make sure that during the interview observe
proper COVID protocols. Use the space provided for your output.
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73
Chapter 4
PHYSICAL ASSESSMENT
In this chapter physical assessment of the human body primarily integumentary
system and assessment of the head, face and neck will be discussed. Inclusive of subtopics
are assessment of the eyes and accessory structures, vision, ears, nose, face, scalp and
neck movements. Subtopics will include normal findings in each structures and techniques
used for assessing each area.
Duration: 6.0 hours

MAJOR TOPICS
Physical Assessment
1. Skin
2. Hair
A. Integumentary System 3. Nails
1. Eyes
B. Head and Neck 2. Ear
3. Mouth
4. Throat
5. Nose
6. Sinus
Activities:
1. Learning Activities
2. Labeling Activities
3. Critical Thinking Exercises

1. Discuss the sequence of physical assessment in the different parts of the body
2. To be able to identify normal and abnormal findings of a specific body area during
assessment
3. To be able to follow the proper method of physical assessment of the different body
areas
4 Properly utilize the different techniques of physical assessment and use specific
equipment for each body area
Key Terms:
 Eyes
 Skin
74
 Hair
 Nails
 Integument
 Head
 Neck
 Snellen’ s Chart
Let’s Begin!
INTEGUMENTARY SYSTEM
 Skin: The client’s skin is uniform in color, unblemished and no presence of any
foul odor. He has a good skin turgor and skin’s temperature is within normal limit.
 Hair: The hair of the client is thick, silky hair is evenly distributed and has a
variable amount of body hair. There are also no signs of infection and infestation
observed.
 Nails: The client has a light brown nails and has the shape of convex curve. It is
smooth and is intact with the epidermis. When nails pressed between the fingers
(Blanch Test), the nails return to usual color in less than 4 seconds.
Body Part Technique Findings
Inspection » When skin is pinched it goes to previous state

immediately (2 seconds).
Skin Palpation » With fair complexion.
» With dry skin
Inspection » Black, evenly distributed and covers the whole
Inspect for the scalp, thick, shiny, free from split ends.
» Coarse or fine.
color, distribution,
*Note:
thickness,
lubrication and Terminal Hair
Hair appearance.
- Its is the long, thick, and coarse hair of the
body which is easily visible on the scalp,
axilla, and the pubic area.
Palpation Vellus Hair
Palpate for - It is the soft, small, tiny hair that covers
texture. the whole body except for the palms and
75
Body Part Technique Findings
the soles.
Inspection » Smooth and has intact epidermis

With short and clean fingernails and toenails.
Nails
Convex and with good capillary refill time of
2 seconds.
1. WHEN ASSESSING SKIN, YOU SHOULD INSPECT EVERY INCH OF THE

PATIENT’S SKIN
a. Remove/lift gown
b. Remove socks
c. Look under dressings – unless contraindicated or have an order not to remove

dressing
Nursing Points
General
1. Integumentary assessments are often done simultaneously with other body systems
a. More efficient
b. Can observe/inspect skin while inspecting other aspects of that are
2. Supplies needed
a. Wound measurement tape/supplies
b. Dressing supplies as needed
Assessment
1.
1. Inspect
76
a. Color
i. Should be consistent with ethnicity
ii. Jaundice, cyanosis, pallor, erythema – may indicate a disease process
iii. In darker-skinned patients, look at sclera, lips, and nail beds for color
changes
b. Moisture
i. Diaphoresis may indicate fever, hypoglycemia, anxiety, or other disease

process
c. Wounds/lesions
i. Color
ii. Drainage
iii. Size
1. Length
2. Width
3. Depth
iv. Tunneling or undermining
v. Location
vi. Raised
vii. Texture
viii. ABCDE mnemonic to assess moles
d. Pressure areas
i. Back of head
77
ii. Hips
iii. Sacrum
iv. Heels
v. Shoulders
vi. Other bony prominences
e. Edema
i. If present, assess for pitting
ii. Note location and severity
iii. Can take circumference measurements
f. Hair growth
i. Present where it should be?
ii. Absent where it shouldn’t?
g. Nails
i. Color
ii. Shape
iii. Texture
2. Palpate
a. Edema – fluid accumulation under the skin
i. Press finger or thumb into edema to assess for pitting
b. Temperature – use the back of your hand to feel the skin
i. Should be warm to touch, but not hot
78
ii. Cool or cold skin may indicate perfusion issues
c. Turgor
i. Pinch skin over clavicle – it should rebound almost immediately
ii. Tight?
1. Can barely pinch
iii. Tenting?
1. Skin tents for >3 seconds
d. Moisture
e. Tenderness
3. Abnormal findings
a. Color changes
i. Hyperpigmentation
1. Addison’s disease
ii. Hypopigmentation
1. Vitiligo
iii. Erythema – redness
1. Inflammation
iv. Cyanosis – bluish color
1. Oxygenation issues
v. Pallor – whitish color
1. Perfusion issues
79
vi. Jaundice – yellowing of skin or eyes
1. Liver failure
b. Edema
i. Pitting edema scale
1. 1+ mild pitting (2mm, rebounds quickly)
2. 2+ moderate pitting (4mm, rebounds in 3-4 seconds)
3. 3+ severe (6mm, 10-15 seconds to rebound) – usually generalized

throughout extremity
4. 4+ extreme (8mm+, >20 seconds to rebound – sometimes minutes,

generalized throughout extremity, may have perfusion issues)
ii. Dependent
1. Found only on the lowest aspect (closest to the ground) of the body part
iii. Generalized (anasarca)
1. Edema throughout body, usually non-pitting
c. Absence of hair growth
i. May indicate chronic venous insufficiency
d. Lesions
i. Macule
1. A flat area of hyperpigmentation, usually less than 10mm.
ii. Patch
1. A larger macule (>10mm)
iii. Papule
80
1. A well-defined raised area with no visible fluid, usually less than 10 mm.
iv. Plaque
1. A large papule or group of them, usually greater than 10 mm, or a large

raised plateau-like lesion.
v. Nodules
1. Similar to a papule – raised area with no fluid – but is much deeper in the
dermis
vi. Vesicles
1. A small, well-defined raised area filled with fluid, usually <10mm.
2. Also known as a blister
vii. Bulla
1. A large vesicle, usually >10mm.
2. Also known as a blister
viii. Ulcers
1. Involve loss of the epidermis and some or all of the dermis
ix. Fissures
1. A crack in the skin that is usually narrow but deep.
x. Erosions
1. Involve full loss of the epidermis in a defined area.
e. Nail abnormalities
i. Clubbing
1. Hypoxia or hypoxemia
81
ii. Scoop-like nails
1. Anemia
iii. Pale nail beds
1. Perfusion issues
f. Turgor
i. Tight – may have swelling, edema, or venous insufficiency
ii. Tenting – dehydration
TYPES OF SKIN LESIONS
LESION DERCRIPTION
bulla raised, fluid-filled lesion larger than a vesicle (plural: bullae)
fissure crack or break in the skin
macule flat, colored spot
nodule solid, raised lesion larger than a papule; often indicative of systemic
82
disease
papule small, circular, raised lesion at the surface of the skin
plaque superficial, flat, or slightly raised differentiated patch more than 1 cm in
diameter
pustule raised lesion containing pus; often hair follicle or sweat pore
ulcer lesion resulting from destruction of the skin and perhaps subcutaneous
tissue
vesicle small, fluid-filled, raised lesion; a blister or bleb
wheal smooth, rounded, slightly raised area often associated with itching; seen
in ulticaria (hives), such as that resulting from allergy
B. HEAD AND NECK ASSESSMENT
Overview
1. Head and neck abnormalities are rare, but could indicate significant disease processes
Nursing Points
General
1. Small, barely noticeable asymmetry is normal
a. One ear may be ever-so-slightly higher than the other
2. Significant asymmetry or weakness on one side is considered abnormal
Assessment
1. Head
a. Inspect
i. General symmetry
1. Have patient make various faces to assess for asymmetry or one-sided

weakness
83
ii. Size
1. Abnormally large may indicate hydrocephalus, especially in children
iii. Shape
iv. Facial symmetry
1. Eyebrows
2. Nose
3. Mouth
4. Ears
v. Make note of any abnormal features or movements
1. i.e. twitching
b. Palpate
i. Scalp
1. Symmetrical
2. Mostly smooth
a. Small bumps are normal
3. Nontender
ii. Facial stability
1. If trauma is suspected, assess for fractures by gently pressing on the cheeks
2. Neck
a. Inspect
i. Symmetry
ii. Visible swelling or masses
1. Goiter – thyroid issues
iii. Trachea should be midline
84
iv. Range of Motion
1. Left to right
2. Chin up and down
3. Ears to shoulders
4. Should all be smooth and well-controlled without pain
b. Palpate
i. TMJ – have patient open and close jaw
1. Movement should be smooth with no clicking or tenderness
ii. Lymph nodes
1. Preauricular – in front of ear
2. Submandibular – below jaw
3. Supraclavicular – above clavicle
a. Almost always indicates malignancy
iii. Thyroid gland
1. Should be midline, not swollen, nontender
1. Head
 Head: The head of the client is rounded; normocephalic and symmetrical.

 Skull: There are no nodules or masses and depressions when palpated.
 Face: The face of the client appeared smooth and has uniform consistency and
with no presence of nodules or masses.
Eyes and Vision
 Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically

aligned and showed equal movement when asked to raise and lower eyebrows.
 Eyelashes: Eyelashes appeared to be equally distributed and curled slightly
outward.
85
 Eyelids: There were no presence of discharges, no discoloration and lids close

symmetrically with involuntary blinks approximately 15-20 times per minute.
 Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries
evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are
visible. The client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and
round. PERRLA (pupils equally round respond to light accommodation),
illuminated and non-illuminated pupils constricts. Pupils constrict when
looking at near object and dilate at far object. Pupils converge when
object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in
the periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14
inches.
Ears and Hearing
 Ears: The Auricles are symmetrical and has the same color with his facial skin.
The auricles are aligned with the outer canthus of eye. When palpating for the
texture, the auricles are mobile, firm and not tender. The pinna recoils when
folded. During the assessment of Watch tick test, the client was able to hear
ticking in both ears.
Nose and Sinus
 Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness
and lesions
 Mouth:
86
o The lips of the client are uniformly pink; moist, symmetric and have a
smooth texture. The client was able to purse his lips when asked to
whistle.
o Teeth and Gums: There are no discoloration of the enamels, no
retraction of gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist, soft,
glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist
and slightly rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has
a more irregular texture.
o The uvula of the client is positioned in the midline of the soft palate.
2. Neck
o The neck muscles are equal in size. The client showed coordinated,
smooth head movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend
during swallowing but are not visible.
THE HEAD TO TOE EXAMINATION (Head to Neck)
BODY PART TECHNIQUE NORMAL FINDINGS
A. HEAD » Proportional to the size of the body,

round, with prominences in the
Palpation frontal area anteriorly and the
Skull occipital area posteriorly,
symmetrical in all planes & gently
curved
Scalp Inspection
» White, clean, free from masses,
Separate the hair strands
lumps, scars, nits, dandruff, and
carefully to reveal the scalp.
lesions.
Inspect for color,
87
appearance, presence of
masses, lice, nits and dandruff
Palpation
Palpate for areas of
tenderness.
Face
» Oblong or oval or square or heart
Inspection shaped, symmetrical, facial
Observe for the symmetry, expression that is dependent on
shape, facial expression, the mood or true feelings, smooth
movement, and appearance. and free from wrinkles, no
involuntary muscle movements.
Eyes Inspection
Instruct the client to look
straight and refrain from » Parallel and evenly placed,
turning the head in different symmetrical, non-protruding, with
directions. Observe for scanty amount of secretions, both
placement, symmetry, eyes black and clear.
protrusion, clarity, and
lacrimation.
1. Eyebrows Inspection
Observe for the color,
symmetry, quantity of hair,
movement, distribution and
placement or parallelism.
» Black, symmetrical, thick can raise
lower eyebrows symmetrically and
without difficulty, evenly
*Note: To check for distributed and parallel with each
movement, let the client raise other.
and lower the eyebrows at the
same time at the cue of your
command or request.
88
2. Eyelashes Inspection
Observe for the color, » Black, evenly distributed and turned
distribution, and direction of outward
eyelashes
3. Eyelids » Upper lids cover a small portion of

Inspection
the iris, cornea and the sclera
Observe for position, (limbus) when the eyes are open.
symmetry, and color. » When the eyes are closed, the lids
meet completely.
Palpation. With the client’s eyes Symmetrical, color is the same as
closed, palpate for the lacrimal the surrounding skin.
gland if it’s palpable
» No palpable mass
4. Lid Margins Inspection
Observe for scaling, » Clear, without scalings or secretions,
lacrimal duct openings (puncta) are
secretions, erythema, and the
evident at the nasal ends of the
lacrimal duct openings
upper and lower lids.
(appearance)
5. Palpebral Inspection
Fissures
Inspect for the symmetry » Appear equal when the eyes are
(the longitudinal opening open.
between the eyelids)
6. Lower Inspection
palpebral » Salmon pink, shiny, moist and
Observe for color and
conjunctiva transparent
appearance
7. Sclera Inspection
Observe for color and » White and clear
appearance.
8. Iris Inspection
» Proportional to the size of the eye,
Note for size, shape, color, round, black/brown, and
symmetry symmetrical
9. Pupils Inspection » From pinpoint to almost the size of

the iris, round, symmetrical,
Note size, shape, symmetry, constrict with increasing light and
reaction to light and accommodation.
89
accommodation (PERRLA).
***To check for the eye’s
reaction to light, there is a
need to control the amount of
light that gets into the eyes.
Therefore, there is need to use
the penlight and while doing
so, the side of the eye opposite
the direction of the penlight
should be shielded by the
examiner’s hand. Note the
degree of constriction of the
pupils if they are symmetrical.
***Accommodation is the
ability of the lens to adjust to
objects of varying distances. To
check for accommodation, the
examiner instructs the client to
look straight into a photo shield
placed in different distances
from the eyes. Note the
reaction of the pupils as the
photo is near and when it is
held far.
10. Eye Inspection
Movement
Ask client to refrain from
» Able to move eyes in full range of
moving his head while he
motion or able to move in all
follows the direction of the
direction.
examiner’s fingers with his
eyes.
90
11. Visual Acuity Inspection

Let client read the letters of
the Snellen’s chart at a distance
of 20 feet.
Note: If the client has his
glasses, he should wear them,
but not if the glasses are
» 20- distance from the chart
intended only for reading. Test
» 20- distance at which a normal eye
each eye separately. Determine
can read.
the smallest line of print from
which he is able to identify
correctly more than half the
figures. Record the visual acuity
designated at the side of this
line.
12. Field of Inspection

Vision
Let the client look
straightforward without moving
» Able to see 60 degrees superiorly, 90
his eyes. By placing your
degrees temporally, and 70
fingers in different specific
degrees inferiorly.
directions, ask the client if he
could still see your moving
fingers.
Ears Inspection
Observe for parallelism,
» Parallel, symmetrical, proportional to
symmetry, size, shape,
the size of the head, bean-shaped,
position, color, and helix is in the line with the outer
appearance. canthus of the eye, skin is the
Palpation. Palpate for the same color as the surrounding
area, clean.
firmness of the cartilage of the
auricles.
1. Ear Canal Inspection

By using a penlight, examine » Pinkish, clean, with scant amount of
by pulling up and back for cerumen and a few cilia.
adults, down and back for
children. Inspect for color,
91
appearance, presence of
cerumen, foreign bodies, and
cilia.
2. Hearing Inspection
Acuity
Whisper from the client’s ear
at a distance of 2 feet (one ear
at a time) and then at the back
of the client for both ears.
» Able to hear whisper spoken 2 feet
Note: Instruct the client not to away.
move his head and to repeat
the words that you will say.
One direction at a time.
Nose Inspection
Observe for placement,
symmetry, patency.
Note: Ask client to close one » Midline, symmetrical, and patent
nostril at a time and ask if he
has any difficulty in breathing
while one nostril is covered.
1. Internal nares Inspection

Appearance, color of mucus » Clean, pinkish, with few cilia
membrane, presence of cilia.
2. Septum Inspection
» Straight
Note for appearance.
Mouth Inspection
1. Lips Observe for color, shape, » Pinkish, symmetrical, lip margin well
symmetry, lip margin, defined, smooth and moist
appearance.
2. Gums Inspection
Observe for color, » Pinkish, smooth, moist, no swelling,
appearance, discharge, and no retraction, no discharge
swelling or retraction.
92
3. Teeth Inspection
» 32 permanent teeth, well-aligned,
Number, color, alignment, free from caries or filling, no
general condition, breath. halitosis
4. Tongue Inspection
» Large, medium, red or pink, slightly
Inspect for size, color, rough on top, smooth along the
surface, appearance, and lateral margins, moist, and freely
movement. movable.
5. Frenulum Inspection
Note for position and » Midline, straight, and thin.
appearance.
6. Cheeks Inspection
» Pinkish, moist, and smooth
(Buccal Mucosa) Note color and appearance
7. Palate Inspection
Soft Palate
Inspect for color and » Pinkish, smooth and moist
Hard Palate appearance. » Slightly pinkish
8. Uvula Inspection
» At the center, symmetrical, and
Note for position, color, size,
freely movable
symmetry, and mobility.
9.Tonsils Inspection
Note for color, size, » Pinkish, non-inflamed, no exudates
inflammation, exudates
10. Voice Inspection

Detect if there is hoarseness » No hoarseness and well-modulated.
of voice
93
B. NECK Inspection » Proportional to the size of the body

and head, symmetrical, and
Note for size, symmetry, and straight
position
Palpation » No palpable lumps, masses, or areas

Palpate for lump, masses, or of tenderness
» Adam’s apple palpable.
areas of tenderness.
Palpate the Adam’s apple.
» Freely movable without difficulty.

Range of Motion.
Chin to chest and ear to
shoulder.
» Symmetrical and able to resist
applied force (both muscles)
» Able to resist applied force.
Muscular Strength Symmetrical in structure of size
Symmetry and strength of and muscular strength.
the sternocleidomastoid muscle
and the force and strength of
the trapezius muscles
COMMON EXAMINATIONS BEING USED DURING ASSESSMENT OF HEAD and

NECK
A. Snellen’s Chart for Visual Acuity
A Snellen chart is an eye chart that can be used to measure visual acuity. Snellen
charts are named after the Dutch ophthalmologist Herman Snellen, who developed the
chart in 1862.
The normal Snellen chart is printed with eleven lines of block letters. The first line consists
of one very large letter, which may be one of several letters, for example E, H, or N.
Subsequent rows have increasing numbers of letters that decrease in size. A person taking
the test covers one eye from 6 metres or 20 feet away, and reads aloud the letters of each
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row, beginning at the top. The smallest row that can be read accurately indicates the visual
acuity in that specific eye. The symbols on an acuity chart are formally known as
"optotypes".
In the case of the traditional Snellen chart, the optotypes have the appearance of block
letters, and are intended to be seen and read as letters. They are not, however, letters
from any ordinary typographer's font. They have a particular, simple geometry in which:
 the thickness of the lines equals the thickness of the white spaces between lines and
the thickness of the gap in the letter "C"
 the height and width of the optotype (letter) is five times the thickness of the line.
Only the nine letters C, D, E, F, L, O, P, T, Z are used in the common Snellen chart. The
perception of five out of six letters (or similar ratio) is judged to be the Snellen fraction.
Wall-mounted Snellen charts are inexpensive and are sometimes used for approximate
assessment of vision, e.g. in a primary-care physician's office. Whenever acuity must be
assessed carefully (as in an eye doctor's examination), or where there is a possibility that
the examinee might attempt to deceive the examiner (as in a motor vehicle license office),
equipment is used that can present the letters in a variety of randomized patterns.
B. Tuning Fork for Hearing Acuity/ Hearing Test (Rinne’s and Weber’s tests)
Background to the tuning fork tests
 The tuning fork tests provide a

reliable clinical method for
assessing hearing loss
 They are most useful in
patients with unilateral hearing
loss which is purely conductive
or purely sensorineural
 Patients with bilateral loss or
mixed losses are better
assessed with formal pure tone
audiometry
 These tests should be carried
out with a full examination
of the cranial nerves or the
ear
 The Rinne and Weber
tests help distinguish between
a conductive hearing loss (CHL)
and sensorineural Hearing Loss
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(SHL)
 Other tuning fork tests include the Schwabach and Bing tests, though these are not
used in routine practice
A. Introduction (WIIPPPE)
 Wash your hands

 Introduce yourself (name and position)
 Identity of patient (confirm name and date of birth)
 Permission (consent and explain examination: “I’m going to examine your
hearing using this tuning fork now, is that OK?”)
 Pain (especially over the mastoid)
 Position (sitting comfortably)
 Exposure
B. Equipment
 A 512 Hz tuning fork

 Note you should ideally be in a completely silent room for Rinne and Weber tests
C. How to do Weber’s Test
 To perform Weber’s test strike the fork against your knee or elbow, then place the
base of the fork in the midline, high on the patient’s forehead
o It is important to steady the patient’s head with your other hand so that
reasonably firm pressure can be applied
 Then ask the patient: “Do you hear the sound louder in one ear than the
other?”
o If so, in which ear is it louder?
o If the patient is unclear, you may ask if they hear it “everywhere.” Be careful
not to ask the question in a leading manner
D. Interpretation of Weber’s test
 Weber’s test will ‘lateralise’, i.e. move to one side, with a relatively small amount of
hearing loss (5dB)
 If a patient has a unilateral conductive hearing loss, the tuning fork sound will be
heard louder in the deaf ear
 If a patient has a unilateral sensorineural hearing loss, the tuning fork sound
will be heard louder in the normal ear
 In bilateral and symmetrical hearing loss of either type Weber’s test will be normal
 The various outcomes of Rinne and Weber tests are shown below
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E. Interpretation of Rinne’s and Weber’s tests
Conductive Hearing Sensorineural Hearing

Test Normal
Loss Loss
Rinne's Air louder than Bone Bone louder than Air Air louder than Bone
(Rinne’s Positive) (Rinne’s Negative) (Rinne’s false positive)
Weber's Sound heard in Sound heard in bad ear Sound heard in good ear
midline
F. How to do Rinne’s Test
 This test aims compare air conduction with bone conduction

o Rinne’s test has a high sensitivity (0.84) though this varies with the skill of the
examiner
o Rinne’s test can only detect a conductive hearing loss of at least 30dB
 Explain the test first:
o “I’m going to put this vibrating tuning fork in two positions, one touching the
bone near you ear, one a short distance from the ear. I want you to tell me
which position you hear the tuning fork loudest in”
 Begin by striking the tuning fork against your knee or elbow
 Hold the tuning fork in one hand and place the base against the patient’s
mastoid process (see video)
o Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity
of the sound
 Then promptly lift the fork off the mastoid process and place the vibrating
tips about 1cm from their external auditory meatus
o Leave it there again for a few seconds before taking the tuning fork away
from their ear
 Ask the patient in which of the positions they were able to hear the note the loudest
in
G. What is a positive and negative Rinne’s Test?
 A patient who hears the tuning fork loudest when held 1cm from the external
auditory meatus has a positive Rinne’s test
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 A patient who hears the fork loudest when it is held against the mastoid
process has a negative Rinne’s test
H. Interpretations of Rinne’s Test
 In a normal ear sound is conducted to the cochlear most efficiently via air
conduction. Sound can also be transmitted to the cochlea, less efficiently, via bone
 So…
o 1) If a patient can hear best when the tuning fork is in the air (positive
Rinne’s) then air conduction is better than bone conduction so there is no
significant conductive hearing loss
 Therefore in sensorineural hearing loss on the right, for example,
Rinne’s test should be positive on the right
o 2) If the patient can hear best when the tuning fork is on the mastoid
(negative Rinne’s) bone conduction is better than than air conduction,
demonstrating a conductive hearing loss
I. False negative Rinne’s Test
 The difficulty in interpreting Rinne’s test is in total unilateral sensorineural hearing

loss (i.e. a ‘dead’ ear)
 For example, imagine the right ear is ‘dead’. On testing bone conduction on the right
the sound travels to the good left (i.e. untested) ear and sounds louder than when
the fork is held next to the external auditory meatus on the side being tested
 The patient reports that bone conduction is better than air conduction giving a false
negative Rinne’s test
Flipped Classroom: For additional reference, you can click the actual video for
Webers and Rines Test:
https://www.youtube.com/watch?v=RVH4K4EcsiA&feature=emb_logo
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Teacher’s Insight
The head to toe physical assessment is the first step of the nursing process and is a
systemic approach of collecting objective (physical) and subjective (mental) data on the
patient that will help the nurse formulate nursing diagnoses and plan patient care. It is
also used to confirm or question data that was stated in the pt. previous history stated
in the charts and to evaluate the effectiveness of the nursing interventions that were
carried out on the patient. The main focus of the head-to-toe assessment is to focus on
what the patient is currently presenting with; the patient's responses to actual or
potential problems. The first body part for the actual physical assessment is the
assessment of the head and neck and the integumentary system.
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I. Learning Activities: Find an old age client, friend or relative who will let you examine
his or her skin, hair and nails. Record your findings. Find a young client, friend or relative
who will let you examine his or her skin, hairs and nails. Record your findings and compare
the elderly person’s findings with those of the younger person’s findings. Use your textbook
to differentiate between normal and abnormal findings. Use the space provided for your
answer. Use table for comparison.
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II. Labeling Activities: Label the following structures.
A. Skin Layer: Use space provided for answers.
ANSWERS:
1. ________________________________
2. ________________________________
3. ________________________________
4. ________________________________
5. ________________________________
6. ________________________________
7. ________________________________
8. ________________________________
9. ________________________________
10. _______________________________
11. _______________________________
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B. Parts of the Eye: Fill in the boxes.
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C. Parts of the Mouth: Use space provided for answers.
ANSWERS:
1. ________________________________
2. ________________________________
3. ________________________________
4. ________________________________
5. ________________________________
6. ________________________________
7. ________________________________
8. ________________________________
9. ________________________________
10. _______________________________
III. Critical Thinking Activities: Use space provided for your answers.
1. A 62 year old woman arrives for an eye examination complaining of blurred vision. You
find out from the nursing history that she has smoked half pack cigarettes a day for 30
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years and spends a lot of time at the beach. She also tells you that she is taking medication
for Hypertension but often forgets to take it.
Describe what are you will focus on during her eye examination, and analyze her risk
possible risk factors for eye disorders.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. Discuss what may be occurring if tenderness is noted when palpating the mastoid
process during the ear exam.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. Explain the meaning of the findings identified during a Weber Test and a Rinne Test.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4. Explain how head sizes and shapes vary among different cultures
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_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
5. Discuss how you will assess for pallor, cyanosis, jaundice and erythema in a dark
skinned client.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
THIS IS THE END OF THE MIDTERMS COVERAGE
Before proceeding to the Semi Finals Coverage….
course.
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SEMI FINALS COVERAGE

consultation hours.
your teacher.
material).
Chapter 4 (…continuation part 1)

PHYSICAL ASSESSMENT
In this chapter physical assessment of the human body primarily Thoracic and Lungs,
Cardiovascular System, Abdomen, Pelvis, Breast and Testicular Exams. Inclusive of
subtopics are breath sounds and great vessels. Subtopics will include normal findings in
each structures and techniques used for assessing each area.

MAJOR TOPICS
Physical Assessment (..continuation)
1. Thoracic and lungs
A. Breath Sounds
2. Cardiovascular System
A. Heart and Great Vessels
3. Abdomen
4. BSE and TSE
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Activities:
1. Critical Thinking Exercises: Case Scenarios

assessment
areas
Key Terms:
 Lungs
 Thorax
 Heart
 Abdomen
 Pelvis
Let’s Begin!
THORAX AND LUNGS ASSESSMENT
 How to measure the chest. Take the measurement at the nipple level with a
tape measure; observe for chest size, shape, movement of the chest with
breathing, and any retractions.
 Adolescents. In the older school-age child or adolescent, note evidence of
breast development.
 Assess respiratory characteristics. Evaluate respiratory rate, rhythm, and
depth; report any noisy or grunting respirations.
 How to assess breath sounds. Using a stethoscope, the nurse listens to breath
sounds in each lobe of the lung, anterior and posterior, while the patient inhales
and exhales; describe, document, and report absent or diminished breath sounds,
as well as unusual sounds such as crackling or wheezing.
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Thorax and Inspection. » The chest contour is symmetrical
Lungs and the chest is twice as wide as
Have the client sit
deep (anteroposterior diameter in
(Anterior and comfortably. Inspect for the a 1:2 ratio). The spine is straight.
Posterior) shape, position of the spine, Posteriorly the ribs tend to slope
slope of the ribs, retraction of across and down. The ribs are
the intercostal spaces (ICS) on prominent in a thin person. There
inspiration, and bulging of the is no bulging or retraction of the
ICS on expiration. ICS during breathing. The chest
wall moves symmetrically during
Observe for symmetry of the respiration.
chest wall during respiration
» No lumps, masses, areas of

Palpation tenderness.
» Sides of the thorax expand
Palpate for lumps, masses, symmetrically. The examiner’s
areas of tenderness. thumb separate approximately 3-5
centimeters during excursion.
Measure chest excursion (to
determine the depth of
breathing). Place hands on the
lower portion of the rib cage
with the thumbs 2 inches apart
pointing towards the spine and
fingers. » Vibrations are prominent over the
areas near the bronchi. It increases
with intensity of the voice.
Elicit tactile fremitus (a thrill Vibrations are strongest between
felt by the hand on the chest the first and second ribs along the
wall while the client is sternum anteriorly and between
speaking). Place the palms of the scapulae posteriorly.
the hand bilaterally symmetrical
on the chest. Start from the top
of the chest wall going down.
Each time the hands move, ask
the client to say “ninety-nine”
or “one--one—one” with the
same intensity of voice
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Percussion » Percussion note varies with the

thickness of the chest wall:
For the anterior thorax, the
client is preferably in a lying
position. For posterior thorax, » Resonance- sound created by air-
the client is in a sitting position filled lungs. It is clear, long, low
with the arms folded across the pitch.
chest. This position will
separate the scapulae to » Dull- short, high pitch, soft and
further expose the lungs for thudding, heard over the heart.
assessment. Using indirect
percussion, percuss in the ICS
» Flat- absolute dullness; absence of
over symmetrical areas of the
air in the underlying tissue.
chest starting from the
supraclavicular area. Compare
one side of the chest to » Tympany- moderately loud with
another. music quality with specific pitch.
Noted in the left upper quadrant of
the abdomen.
Location Percussion Note
L R
Supra-
clavicular Flat
1st ICS Resonant
2nd ICS Dull Resonant
3rd ICS Dull Resonant
4th ICS Dull Resonant
5th ICS Dull Resonant
6th ICS Resonant Resonant
7th ICS Tympanic Dull
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» Normal breath sounds differ in

character depending on the area of
the lung being auscultated.
» Bronchovesicular sounds are

medium-pitched sound or medium
intensity, heard posteriorly
between the scapulae. The sounds
Auscultation
have a blowing quality with the
To assess the movement of inspiratory phase equal to the
air through the expiratory phase.
tracheobronchial tree, room
must be quiet. » Vesicular sounds are heard over
the lung periphery. The sounds are
created by air moving through the
smaller airways. They are soft,
breezy, and low-pitched and the
inspiratory phase is about three
times longer than the expiratory
phase.
» Bronchial sounds are hollow high

pitched; whistling sounds which
are normal if heard over large
airways like the trachea.
Flipped Classroom: For additional reference, you can click the actual video for method of
assessing the thorax and the lungs:
https://www.youtube.com/watch?v=j5D9hkppDGY
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Overview
1. The thorax and lungs should be assessed anteriorly, posteriorly, and laterally
Nursing Points
General
1. Supplies needed
a. Stethoscope
Assessment
1. Anterior
a. Inspect
i. Size and shape of thorax
1. Anterior-Posterior diameter should be approximately ½ the lateral diameter
2. Barrel Chest – COPD
ii. Symmetry
1. Expansion should be symmetrical on inspiration
iii. Ribs should slope downward from the sternum outward
iv. Observe for signs of distress
1. Tachypnea
2. Retractions
3. Cyanosis
v. Observe the overall rate and rhythm of respirations
vi. Inspect skin color and condition on thorax
b. Palpate
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i. Using 2 fingers, press lightly on skin over anterior chest, feeling for crepitus –
feels like “rice crispies” under skin
1. Indicates subcutaneous air
c. Percuss
i. Starting at the Apex, percuss in the intercostal spaces moving left to right and
downward
ii. Should hear resonance
iii. May hear dullness over heart and liver
d. Auscultate
i. Listen for audible cough, wheezing, or stridor
ii. Lung sounds
1. Bronchial
a. Upper areas
b. High pitch
c. Insp < Exp
2. Bronchovesicular
a. Middle areas
b. Moderate pitch
c. Insp = Exp
3. Vesicular
a. Outer areas
b. Low pitch
c. Insp > Exp
iii. Listen from left to right starting at the apex and moving downward, including the
lateral areas.
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1. The only way to hear the right middle lobe is to listen near the axilla on the
right side.
iv. Should listen in 10-12 areas on the front
v. BEST heard with stethoscope directly on skin
vi. Listen to one full respiration in each area
vii. Make note of any adventitious sounds
1. Crackles
2. Rhonchi
3. Wheezes
4. Stridor
5. *See Lung Sounds lesson in Respiratory Course for details
2. Posterior
a. Inspect – same as anterior
b. Palpate – same as anterior, plus:
i. Tactile fremitus
1. Use the palm of your hands to palpate from the apex down in 5 places as the
patient says the word “ninety-nine”
2. Should feel vibrations equally bilaterally
1. Decreased vibration = fluid consolidation
ii. Expansion
1. Place hands on lower rib cage with thumbs touching, ask patient to inhale
deeply
2. Should see hands expand and return symmetrically
c. Percuss – same as anterior,
i. Avoid scapula
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d. Auscultate – same as anterior
i. Avoid scapula
ii. 8-10 locations
Teacher’s Insight
When physically assessing a client’s respiratory system, it is important for a nurse to
note that there are a number of important age-related differences. Consider these
age-related differences specific to the assessment of the respiratory system:
 The respiratory assessment of an infant or a young child who is crying is very

difficult, and is likely to produce inaccurate data. It is important that young children
are calm before a respiratory assessment is commenced.
 When undertaking a respiratory assessment with an older adult, it is important for
nurses to be aware that age-related structural problems may make the expansion
of the thorax more difficult.
Assessing a patient’s respirations and respiratory effort is a key part of the physical
examination of the respiratory system.
When auscultating a patient’s chest, it is essential that a nurse uses a systematic
process to ensure that all areas of the chest are heard.
HEART (CARDIAC) and GREAT VESSELS ASSESSMENT
Inspection of the Heart
 The chest wall and epigastrium is inspected while the client is in supine position.
Observe for pulsation and heaves or lifts
Normal Findings:
 Pulsation of the apical impulse may be visible. (this can give us some indication of
the cardiac size).
 There should be no lift or heaves.
Palpation of the Heart
 The entire precordium is palpated methodically using the palms and the fingers,
beginning at the apex, moving to the left sternal border, and then to the base of
the heart.
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Normal Findings:
 No, palpable pulsation over the aortic, pulmonic, and mitral valves.
 Apical pulsation can be felt on palpation.
 There should be no noted abnormal heaves, and thrills 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
 Anatomic areas for auscultation of the heart:

 Aortic valve – Right 2nd ICS sternal border.
 Pulmonic Valve – Left 2nd ICS sternal border.
 Tricuspid Valve – – Left 5th ICS sternal border.
 Mitral Valve – Left 5th ICS midclavicular line
Positioning the client for auscultation:
115
1. If the heart sounds are faint or undetectable, try listening to them with the
patient seated and leaning forward, or lying on his left side, which brings the
heart closer to the surface of the chest.
2. Having the client seated and leaning forward is best suited for hearing high-
pitched sounds related to semilunar valves problem.
3. The left lateral recumbent position is best suited low-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
aortic 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.
Auscultation of Heart Sounds

Normal Findings:
 S1 & S2 can be heard at all anatomic site.
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 No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).

 Cardiac rate ranges from 60 – 100 bpm.
HEART Inspection and Palpation

Place client in supine
position. Stand on the client’s
right side. Ask the client not to
talk. Inspect and palpate the
valve areas of the heart.
 Aortic Valve – found at

the 2nd ICS on the left of
the angle of Louis (felt as a  No pulsations
prominence on the
sternum)
 Pulmonic area – at the

2nd ICS on the left of the
angle of Louis.
 Tricupid area – move the

fingers along the client’s
 No pulsations
left sternal border to the 5th
ICS.
 Apical area – move the

fingers laterally to the left
mid-clavicular line (LMCL)
which is slightly below the  No pulsations
nipple. This point where
the apex touches the
anterior chest is known as
the point of maximal
impulse (PMIO)
117
 Epigastric area – at the  Pulsations visible and palpable

base of the sternum.
Auscultation
Auscultate the heart in all 4
anatomical sites: aortic,
pulomonic, tricuspid, and apical
(mitral). Eliminate all sources of
room noise.
Heart sounds are of low
intensity and other noise  Abdominal aortic pulsations visible
hinders the ability of the and palpable.
examiner to hear them.
Identify the 1st sound (S1).
This is a dull low – pitched
sound described as “lub”. Then
identify the 2nd sound (S2).
This is higher – pitched than
S1, described as “dub”. Use the
bell-shaped diaphragm.
Once S1 and S2 are identified
count the heart rate for one
minute. Each combination of S1
and S2 counts as one
heartbeats.
 The two sounds are audible in all
areas but loudest at apical area.
 Cardiac rate ranges from 60-100

beats/minute.
https://www.youtube.com/watch?v=G5CwcxF43KQ
118
Overview
1. Major heart assessments:
a. Sounds
b. Murmurs
c. Apical pulse
2. The great vessels to be assessed are:
a. Carotid arteries
b. Jugular veins
c. Aorta
Nursing Points
General
1. Supplies needed
a. Pen light
b. Stethoscope
Assessment
1. Inspect
a. Anterior chest for visible apical pulse
i. 5th ICS, Left MCL
b. Abdomen for pulsation
i. May indicate an abdominal aortic aneurysm
c. Jugular venous pulse
i. Lay patient at 30-45 degrees, turn head away
119
ii. Shine penlight on neck
iii. May see slight pulsation
iv. Jugular vein should flatten at 45 degrees or higher
v. Jugular venous distention (engorged at 30 degrees or higher) may indicate heart

failure and/or volume overload
2. Palpate
a. Carotid pulses – locate by sliding two fingers laterally from thyroid
i. ONE AT A TIME
ii. Compare bilaterally
b. Apical pulsation to locate point of maximum impulse (PMI)
i. Should be 5th ICS, Left MCL
3. Auscultate
a. Heart Sounds
i. APE To Man
1. Aortic
a. 2nd ICS, RSB
2. Pulmonic
a. 2nd ICS, LSB
3. Erb’s Point
a. 3rd ICS, LSB
4. Tricuspid
a. 4th ICS, LSB
5. Mitral
a. 5th ICS, Left MCL
ii. Listen with Diaphragm, then Bell (for murmurs)

120
iii. Make note of quality and timing, presence of extra sounds
b. Carotid bruit – listen over carotid with bell
c. Auscultate to count Apical pulse (5th ICS, Left MCL) for a full minute.
Teacher’s Insight
The cardiovascular system is one of the body's fundamental life-sustaining systems;
therefore, it is essential that nurses are able to accurately and comprehensively assess
this system. This chapter introduces the fundamental knowledge and skills nurses
require to do so. The chapter then explains the processes involved in collecting a
general health history for the cardiovascular system, and in performing a physical
examination of the cardiovascular system. This chapter also considers a number of
special observation and assessment techniques which may be used in the physical
examination of the cardiovascular system.
ABDOMINAL ASSESSMENT
 In abdominal assessment, be sure that the client has emptied the bladder for
comfort. Place the client in a supine position with the knees slightly flexed to relax
abdominal muscles.
Inspection of the abdomen
 Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and
umbilicus).
 Contour (flat, rounded, scaphoid)
 Distension
 Respiratory movement.
 Visible peristalsis.
 Pulsations
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Normal Findings:
 Skin color is uniform, no lesions.

 Some clients may have striae or scar.
 No venous engorgement.
 Contour may be flat, rounded or scaphoid
 Thin clients may have visible peristalsis.
 Aortic pulsation may be visible on thin clients.
Auscultation of the Abdomen
 This method precedes percussion because bowel motility, and thus bowel sounds,
may be increased by palpation or percussion.
 The stethoscope and the hands should be warmed; if they are cold, they may
initiate contraction of the abdominal muscles.
 Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits.
Intestinal sounds are relatively high-pitched, the bell may be used in exploring
arterial murmurs and venous hum.
Peristaltic sounds
 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.
 Listening to the bowel sounds (borborygmi) can be facilitated by following these
steps:
o Divide the abdomen into four quadrants.
o Listen over all auscultation sites, starting at the right lower quadrants,
following the cross pattern of the imaginary lines in creating the
abdominal quadrants. This direction ensures that we follow the direction
of bowel movement.
o Peristaltic sounds are quite irregular. Thus it is recommended that the
examiner listen for at least 5 minutes, especially at the periumbilical
area, before concluding that no bowel sounds are present.
o The normal bowel sounds are high-pitched, gurgling noises that occur
approximately every 5 – 15 seconds. It is suggested that the number of
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bowel sound may be as low as 3 to as high as 20 per minute, or roughly,

one bowel sound for each breath sound.
o Some factors that affect bowel sound:
 Presence of food in the GI tract.
 State of digestion.
 Pathologic conditions of the bowel (inflammation, Gangrene,
paralytic ileus, peritonitis).
 Bowel surgery
 Constipation or Diarrhea.
 Electrolyte imbalances.
 Bowel obstruction.
Percussion of the abdomen
 Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites),

gaseous distension, and masses, and in assessing solid structures within the
abdomen.
 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
6th or 9th rib just posterior to or at the midaxillary line on the left side.
 Percussion in the abdomen can also be used in assessing the liver span and size
of the spleen.
Percussion of the liver
 The palms of the left hand are placed over the region of liver dullness.
 The area is strucked lightly with a fisted right hand.
 Normally tenderness should not be elicited by this method.
 Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.
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Renal Percussion
 Can be done by either indirect or direct method.

 Percussion is done over the costovertebral junction.
 Tenderness elicited by such method suggests renal inflammation.
Palpation of the Abdomen

Light palpation
 It is a gentle exploration performed while the client is in supine position. With the
examiner’s hands parallel to the floor.
 The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm
without digging, but gently palpating with slow circular motion.
 This method is used for eliciting slight tenderness, large masses, and muscles,
and muscle guarding.
 Tensing of abdominal musculature may occur because of:
o The examiner’s hands are too cold or are pressed to vigorously or deep
into the abdomen.
o The client is ticklish or guards involuntarily.
o Presence of subjacent pathologic condition.
Normal Findings:
 No tenderness noted.
 With smooth and consistent tension.
 No muscles guarding.
Deep Palpation
 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.
 Deeper structures, like the liver, and retroperitoneal organs, like the kidneys, or
masses may be felt with this method.
 In the absence of disease, pressure produced by deep palpation may produce
tenderness over the cecum, the sigmoid colon, and the aorta.
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Liver palpation
 There are two types of bimanual palpation recommended for palpation of the liver.
The first one is the superimposition of the right hand over the left hand.
o Ask the patient to take 3 normal breaths.
o Then ask the client to breathe deeply and hold. This would push the
liver down to facilitate palpation.
o Press hand deeply over the RUQ
 The second methods:
o The examiner’s left hand is placed beneath the client at the level of the
right 11th and 12th ribs.
o Place the examiner’s right hands parallel to the costal margin or the
RUQ.
o An upward pressure is placed beneath the client to push the liver
towards the examining right hand, while the right hand is pressing into
the abdominal wall.
o Ask the client to breathe deeply.
o As the client inspires, the liver maybe felt to slip beneath the examining
fingers.
Normal Findings:
 The liver usually cannot be palpated in a normal adult. However, in extremely thin
but otherwise well individuals, it may be felt the coastal margins.
 When the normal liver margin is palpated, it must be smooth, regular in contour,
firm and non-tender.
ADBOMEN Divide the abdomen into 4

imaginary quadrants. Draw a
vertical line from the xiphoid
process to the symphysis pubis
and a horizontal line across the
umbilicus. These quadrants are
labeled right upper quadrant
(RUQ), left upper quadrant
(LUQ), right lower quadrant
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(RLQ), and left lower quadrant

(LLQ).
Ask client if he needs to void.

Drape the upper chest and
legs. Expose the abdomen
from the xiphoid process to the
symphsis pubis. The client lies
in supine position with arms
down at the sides a small pillow
may be placed under the head.
Inspection
Inspect the abdomen for skin
integrity, color, contour,
symmetry, movement or
pulsations and color and
placement of umbilicus.
» Skin is unblemished, no scars, color

is uniform, flat, rounded (convex),
or scaphoid (concave),
» Symmetrical movements caused by
respiration, aortic pulsation at
epigastric area visible in thin
persons
» Umbilicus is flat or concave,
positioned midway between the
xiphoid process and the
symphysis pubis
» Color is the same as the surrounding
skin.
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Auscultation
Warm the diaphragm of the
stethoscope. Cold stethoscope
may cause the client to » There are clicks and gurgles, the
contract the abdominal muscles frequency of which has been
and the contractions may be estimated at from 5-34 per minute.
heard during auscultation. Occasionally, borborygmi (loud
Diaphragm is used because prolonged gurgles of
intestinal sounds are high – hyperperistalsis) the familiar
“stomach growling” can be heard.
pitched sounds. Place the
diaphragm in each of the 4
quadrants over all auscultation
sounds.
Percussion
Reveals presence of air in the
stomach and abdomen.
To identify the boarders start
percussion at the right iliac rest » Tympany predominates because of
upward along the midclavicular the presence of air in the stomach
line. Percuss each quadrant and intestines
starting from the right » Percussion is dull at the liver’s lower
clockwise. boarder.
Palpation
Perform light palpation first
to detect areas of tenderness,
muscle guarding, (Voluntary
tightening of abdominal
muscles), lumps of masses,
consistency and organomegaly. » Soft abdomen, no tenderness, no
Depress the abdominal wall muscle guarding, no lumps, or
masses, or organomegaly.
lightly, about 1 cm. with the
pads of your fingers. Move the
finger pads in a slight circular
motion. Palpate all 4 quadrants.
Palpate the liver using deep
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palpation. Stand on the client’s

right side. Place your left hand
on the posterior thorax at
about the 11th or 12th rib and
then apply upward pressure.
With the fingers of the right
hand pointing upward, place
the hand on the RUQ well
below the liver’s lower boarder,
then press gently until you
reach the depth of 1 ½ - 2
inches. Ask the client to take a
deep breath using the
abdominal muscles. As he
inhales, try to palpate the
liver’s edge as it descends.
» Liver’s edge feels firm and not

tender.
Overview
1. Remember the order of assessment is different!
a. Inspect
b. Auscultate
c. Percuss
d. Palpate
Nursing Points
General
1. Supplies needed
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a. Stethoscope
b. Pen light (optional)
Assessment
1. Inspect
a. Shape and contour
i. Look across abdomen left to right
ii. Can use pen light to look for visible bulging or masses
iii. Look for distention
b. Umbilicus – discoloration, inflammation, or hernia
c. Skin texture and color
d. Lesions or scars
i. Note details – length, color, drainage, etc.
e. Visible pulsations
f. Respiratory movements (belly breather)
2. Auscultate
a. Start in RLQ → RUQ → LUQ → LLQ
i. This follows the large intestine
b. Use diaphragm of stethoscope to listen for 1 full minute per quadrant
i. Active – Should hear 5-30 clicks per minute
ii. Hypoactive
iii. Hyperactive
iv. Absent – must listen for 5 minutes per quadrant to confirm this
c. Use bell of stethoscope to listen for bruits
i. Aorta – over the epigastrium
ii. Iliac and femoral arteries – Inguinal are

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iii. Renal arteries – A few cm above and to the side of the umbilicus
1. Press firmly
iv. The presence of a bruit could indicate narrowing of the arteries – if this is a new
finding, report to provider
3. Percuss
a. Percuss x 4 quadrants, starting in RLQ as with auscultation
b. Expect to hear tympany
c. Dullness could indicate a mass, fluid-filled bladder, blood in the belly, or significant
adipose tissue
i. Exception – dullness over the liver is expected
d. CVA tenderness
i. Place nondominant hand flat over the costovertebral angle (flank).
ii. Strike your hand with the ulnar surface of your dominant hand
iii. Should be nontender
iv. Repeat bilaterally
4. Palpate
a. Light palpation – small circles in all 4 quadrants
i. Can do 4 small areas in each quadrant to be thorough
b. Deep palpation – deeper circles in all areas
c. Palpating for masses – make note of size, location, consistency, tenderness, and
mobility
d. Make note of any guarding or tenderness
e. Assess for rebound tenderness
i. Press down slowly and deeply
ii. Release quickly

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iii. Ask patient which hurt most (down or up)
iv. Rebound tenderness over RLQ could indicate appendicitis
f. If distended, perform Fluid-Wave test to look for ascites:
i. Place patient’s hand over umbilicus
ii. Place your hand on right flank, then tap or push on the left flank with your other
hand
iii. If you feel the tap/push on the opposite hand, that’s a Positive Fluid-Wave test
1. Indicates Ascites
iv. You may also see the patient’s hand ‘wave’ with the fluid
Nursing Concepts
1. Ask patient if they have had any difficulty with bowel movements
a. Frequency
b. Consistency
c. Color
i. Bleeding?
2. If a bowel movement is available, asses the stool for color, consistency, character
https://www.youtube.com/watch?v=4fxKy3ykiB8
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BREAST EXAMINATION
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.
o The client is seated with her arms on her side.
o The client is seated with her arms abducted over the head.
o The client is seated and is pushing her hands into her hips,
simultaneously eliciting contraction of the pectoral muscles.
o The client is seated and is learning over while the examiner assists in
supporting and balancing her.
 While the client is performing these maneuvers, the breasts are carefully
observed for symmetry, bulging, retraction, and fixation.
 An abnormality may not be apparent in the breasts at rest a mass may cause the
breasts, through invasion of the suspensory ligaments, to fix, preventing them
from upward movement in position 2 and 4.
 Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and
shortened suspensory ligaments.
Normal Findings:
 The overlying the breast should be even.

 May or may not be completely symmetrical at rest.
 The areola is rounded or oval, with same color, (Color varies from light pink to
dark brown depending on race).
 Nipples are rounded, everted, same size and equal in color.
 No “orange peel” skin is noted which is present in edema.
 The veins may be visible but not engorge and prominent.
 No obvious mass noted.
 Not fixated and moves bilaterally when hands are abducted over the head, or is
leaning forward.
 No retractions or dimpling.
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Palpation of the Breast
 Palpate the breast along imaginary concentric circles, following a clockwise rotary
motion, from the periphery to the center going to the nipples. Be sure that the
breast is adequately surveyed. Breast examination is best done 1-week post
menses.
 Each areolar areas are carefully palpated to determine the presence of underlying
masses.
 Each nipple is gently compressed to assess for the presence of masses or
discharge.
Normal Findings:
 No lumps or masses are palpable.

 No tenderness upon palpation.
 No discharges from the nipples.
 NOTE: The male breasts are observed by adapting the techniques used for female
clients. However, the various sitting position used for woman is unnecessary.
BREASTS Inspection Females: variable in size depending on

body build.
Ask client to remove the top
gown or drape to allow * obese - large and pendulous.
simultaneous visualization of
both breasts. Have the client sit
comfortably with arms at the *Slender - thin and small.
side. Inspect the breast for
size, symmetry and contour or
shape. Inspect the skin of the *Young clients - firms, elastic in
breast for color, retraction or consistency, cone shaped symmetrical,
dimpling. skin surface smooth.
*older women - breasts sag, nipples

lower, stringy and nodular.
Palpation
Assist the client in a supine
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position. This position allows Males: flat, symmetrical. If obese, may

the breast tissues to flatten be slightly rounded.
evenly against the chest wall
facilitating palpation. Ask client
to raise his/her hand and place
it under the head. Palpate the
» Color of the skin same with the
breasts for lumps or masses,
abdomen, no retraction, no
areas of tenderness, and
dimpling.
consistency of breast tissues.
» No mass or lump, no areas of

The palmar surface of the tenderness.
three fingers is used to
compress breast tissues against » In younger client, borders of the
the chest wall. breasts are clearly delineated. In
older client irregular consistency,
glandular/nodular.
Perform palpation in a » Lobular feel of glandular tissue is

clockwise rotary motion from normal.
the boarders going inward.
» The lower edge of the each breast
may feel firm and hard.
» Premenstrual fullness, nodularity and

tenderness may be present.
» Warm to touch and smooth.
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AREOLA
Inspection
Inspect the size, shape,
color, and symmetry.
» Round or oval, color darker than
surrounding skin, symmetrical.
» For dark – skinned client, color is
darker than other skin surfaces.
Palpation
» No masses and areas of tenderness.
Palpate for masses and areas
of tenderness.
NIPPLES Inspection
Inspect for size, shape
position, discharge, and lesions. » Round or inverted, equal in size,
similar in color, nipples point in one
direction, no discharge, no lesion,
no dimpling, and no crusting.
Palpation
» No masses, no tenderness, no
Using thumb and index discharge.
finger, compress the nipple to
determine any discharge.
https://www.youtube.com/watch?v=76g_tNWMhCE
MALE GENITALIA EXAMINATION ( Overview)

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Risk Factors for Testicular Cancer
1. Age 20-34 (15-35)

2. History of undescended testes
3. Early puberty
4. Family history
5. White race
6. Higher social class
7. Obesity
8. Never married or late marriage
9. Maternal use of oral contraceptives or diethylstilbestrol during early pregnancy
10. Maternal abdominal/pelvic x-ray during pregnancy
11. Mother or sisters with breast cancer
Warning Signs for Cancer of the Testicle
1. A small, hard, painless lump-about the size of a pea

2. Feeling of heaviness in the testicle
3. Enlargement of the testicle
4. Change in how the testicle feels to the touch
5. Sudden accumulation of fluid/blood in the scrotum
6. Dull ache in the groin
7. Swelling or tenderness in other parts of the body (groin, breast, neck)
Testicular Self-Examination
1. Perform after a warm bath/shower

2. Use both hands and start on right testicle
3. Place index and middle finger underneath testicle
4. Place thumb on top of testicle
5. GENTLY roll the testicle between thumbs and fingers
6. Check all sides of the right testicle and repeat procedure on left testicle
7. Find the epididymis on the top and back of each testicle.
8. Examine the testes in mirror while standing. Look for unusual contours and
swelling of testes (noting that one usually hangs lower than the other)
End of Chapter 4 (continuation part 1)….

136
137
Instructions: In a separate sheet of paper, answer the following case scenarios and
attach it to this section once you submit your portfolio and outputs.
Case Analysis
I. THORACIC AND LUNGS ASSESSMENT

Case 1: Nurse Maldita conducted her third home visit to a 60 year old man who was
discharged 10 days ago due to COPD. He stated he feels great today and was able to walk
outside for a few minutes today without his oxygen. He uses oxygen prn at 2 lpm via nc
when he has shortness of breath or during mild exercises. He reports chronic cough as
usual but denies sputum production.
You noted his facial color and lips are ruddy, but nail beds are pink. Breathing pattern is
regular, unlabored but tachypneic at 28 cycles per minute, which is his usual rate.
Examining his thorax, you note hew is barrel chested with a transverse to lateral ratio of
about 2.5 to 3. Although he is not using accessory muscles to breathe, you do note he has
slight intercostal bulging and rigidity upright posture in chair. While auscultating his lungs,
you note diminished breath sounds bilaterally in most of lower lobes and a small, discrete
area of coarse crackles in upper portion of left lower lobe. You also have noted the odor of
cigarette on his breath.
Tasks.
1. Based on the scenario, identify subjective and objective data.
2. You have assessed the clients’ lung sounds. Explain in order the proper way of
auscultating lung sounds in : a. Anterior Thorax b. Posterior Thorax
3. As per your assessment, you have noted slight intercostal bulging from the client.
Explain what does this indicate and support your answer basing on the clients’ current
health condition.
4. From the case scenario identify one specific nursing diagnosis and give 5 nursing
interventions needed to be conducted with its rationale based from your inference.
II. CARDIOVASCULAR ASSESSMENT

Case 2. A 45 year old black male who has HTN and past medical history of angina and
myocardial infarction is being examined in RPGMC ER. Although he is in no acute distress
and verbalization of being fine, physical assessment reveals: BP 210/110 right arm, pulse
88 regular and strong, and respirations 16 regular and moderately shallow, afebrile. Apical
pulse is also 88 and strong. S1 and S2 with no murmurs and clicks but S4 noted. Neck
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veins are flat at 45 degrees and no carotid bruits noted. Pedal pulses are strong but with 1
+ ankle edema present.
Tasks:
1. Discuss how you will validate the data from your assessment since there seems to be
incongruences from both subjective and objective data. Explain it basing from the case
scenario and site some additional assessment that needs to be done for validation.
2. Explain briefly how to auscultate heart sounds and how will you differentiate the S1
heart sound from S2 heart sound.
III. ABDOMINAL ASSESSMENT

Case 3. Nikki Yuan, a 22 year old student comes into clinic complaining of undifferentiated
abdominal discomfort. She stated she had not pass stool for the last 4 days. During the
interview, she described her dietary habit is terrible. She eats salty, high fat junk foods and
doesn’t drink water regularly. Instead he drinks lots or regular sodas. During the
examination the client’s abdomen reveals a moderately rounded, slightly firm nontender
abdomen with several small quartersized round firm masses in the LLQ. Bowel sounds are
active, moderate pitched gurgles in all four quadrants. The abdomen is mostly tympanic
upon percussion with scattered dullness in the LUQ. Patient’s abdomen is negative for
rebound tenderness upon palpation. A rectal examination reveals hard stools in the ampulla.
Tasks:
1. Explain comprehensively how to orderly auscultate bowel sounds and what are the
considerations to be taken before and during auscultation?
2. As per the case scenario, what is the implication of your assessment? Support your
answer basing from your assessment.
3. What would be your appropriate nursing interventions upon her reporting symptoms and
observed signs? Include rationale.
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THIS IS THE END OF THE SEMI FINALS COVERAGE
Before proceeding to the Semi Finals Coverage….
course.
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FINALS COVERAGE

consultation hours.
your teacher.
material).
Chapter 4 (…continuation part 2)

PHYSICAL ASSESSMENT
In this chapter physical assessment of the human body primarily Musculoskeletal,

Peripheral Vascular and Neurologic Assessment. Inclusive of subtopics are cranial nerves
and functional mental health. Subtopics will include normal findings in each structures and
techniques used for assessing each area.

MAJOR TOPICS
Physical Examination
1. Musculoskeletal System
2. Peripheral Vascular System
3. Neurological System
A. Cranial Nerves
B. Functional Mental Health
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Activities:
1. Critical Case Scenarios: Case Studies
assessment
areas
Key Terms:
 Cranial Nerves
 Musculoskeletal
 Vascular
 Peripheral
 Neurologic
 Reflexes
Let’s Begin!
MUSCULOSKELETAL ASSESSMENT
Inspection
 Observe for size, contour, bilateral symmetry, and involuntary movement.

 Look for gross deformities, edema, presence of trauma such as ecchymosis or
other discoloration.
 Always compare both extremities.
Palpation
 Feel for evenness of temperature. Normally it should be even for all the
extremities.
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 Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s

fingers and noting for equality of contraction).
 Perform range of motion.
 Test for muscle strength. (performed against gravity and against resistance)
 Table showing the Lovett scale for grading for muscle strength and functional
level
Functional level Lovett Scale Grade Percentage
of normal
No evidence of contractility Zero (Z) 0 0
Evidence of slight contractility Trace (T) 1 10
Complete ROM without gravity Poor (P) 2 25
Complete ROM with gravity Fair (F) 3 50
Complete range of motion against gravity with Good (G) 4 75

some resistance
Complete range of motion against gravity with full Normal (N) 5 100
resistance
Normal Findings
 Both extremities are equal in size.

 Have the same contour with prominences of joints.
 No involuntary movements.
 No edema
 Color is even.
 Temperature is warm and even.
 Has equal contraction and even.
 Can perform complete range of motion.
 No crepitus must be noted on joints.
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 Can counteract gravity and resistance on ROM.

UPPER
EXTREMITIES
Arms
Inspection
Support hands at chest level.
Note the color of skin, length,
hair distribution, presence of » Skin color varies (pinkish, tan, dark
visible veins. brown), symmetrical, fine hair
evenly distributed,
presence/absence of visible veins.
Palpation
Palpate arms for
temperature, moisture, lumps, » Warm, dry and elastic, no areas of
masses, and areas of tenderness. Muscle appears equal
tenderness. Note for muscle with good muscle tone.
size and tone.
Palms and
Inspection
Dorsal Surfaces » Palms pinkish (dorsal surface),
Note the color, temperature, warm; males – thick; females –
thickness, moisture, and turgor. softer; elastic.
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Nails Inspection
Inspect for color, thickness,
shape and curvature.
» Nails are transparent, smooth and
convex with pink nailbeds and
white translucent tips.
Count the number of fingers.

» Five fingers in each hand.
Palpation
Gently grasps the client’s » As pressure is applied to the nailbed,
fingers and observe the color of appears white or blanched, and
the nailbeds, then gently apply pink color returns immediately as
pressure with the thumb to the pressure is released.
nailbed quickly and release.
Manipulation – the process of moving or attempting to move the part being examined.
Limitation of movements can be discovered.
Shoulders
Range of motion
1. Raise both arms to vertical
position.
2. Place head behind the
» Performs with relative ease.
neck.
3. Place hands behind the
small of the back.
Arms Range of motion
1. Abduct – away from the
body » Performs with relative ease
2. Adduct – towards the body
3. Rotate – internal and
external (one arm at a » No relative difficulties
time)
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Elbows
Range of motion
1. Bend and straighten elbow » Performs with relative ease.
Hands and Range of motion
wrists
1. Extend and spread the
fingers
» Performs with relative ease
2. Make a fist, thumb across
the knuckles.
LOWER
EXTREMITIES
Inspection
Note the color of skin, hair
Legs distribution, and presence of
varicose veins, length, and » Skin color varies (pinkish, tan, dark
symmetry of muscle. brown) skin is smooth, fine hair
evenly distributed, absence of
varicose veins, muscles
symmetrical, length symmetrical.
Palpation
» Muscles appear equal, warm and
Let the client tiptoe. Palpate with good muscle tone.
the muscles for warmth and
strength.
Toes Inspection
Inspect for the number of » Five toes in each foot; sole and
toes, texture of sole and dorsal dorsal surface is smooth; with pink
surface, toe nails. nail beds and white translucent
tips.
Palpation
» As pressure is applied, the nailbed
Gently grasps the client’s appears white or blanched; pink
toenails nailbeds. Gently apply color returns when pressure is
pressure with the thumb to the released.
nailbed quickly and release.
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Legs (one leg at

a time)
Range of motion
1. Abduct
2. Adduct » Performs with relative ease
3. Rotate
4. Hop (both feet)
5. Walk to and from
Knees Range of motion

Let the client sit down on a
chair and bend foot at the » Performs with relative ease
knee
1. Bend and extend
Ankles
Range of motion
1. Flexion and extension » Performs with relative ease
2. Rotation (internal and
external)
Toes
Range of motion
» Performs with relative ease
1. Spread and wiggles
Overview
1. Musculoskeletal system involves the muscles, bones, and joints
2. This means we must assess structure AND function
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Nursing Points
General
1. If patient cannot stand, assessments should be performed in the bed to the best of your
ability
2. If they cannot perform Active Range of Motion (ROM), use Passive movements to
determine ROM
Assessment
1. For ALL joints:
a. Inspect
i. Muscle size/shape
ii. Skin color at joint
iii. Swelling, masses
iv. Deformity
v. Pain with ROM
b. Palpate
i. Crepitus during ROM
ii. Heat at joint
iii. Strength
2. Strength
a. Grading
i. 0 = no movement
ii. 1 = flicker
iii. 2 = passive movement only
iv. 3 = overcomes gravity
v. 4 = overcomes some resistance

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vi. 5 = overcomes strong resistance
b. Upper extremities – perform these tasks against resistance
i. Push hands
ii. Pull hands
iii. Raise arms to front and side
iv. Lower arms
v. Grip hands
c. Lower extremities – perform these tasks against resistance
i. Raise legs
ii. Lower legs
iii. Push with feet
iv. Pull toes back
3. Spine
a. Inspect and Palpate
i. Spinous processes should be in alignment vertically
ii. Look for any abnormal curvatures
1. Kyphosis – excessive thoracic curvature
2. Lordosis – excessive lumbar curvature
3. Scoliosis – excessive lateral curvature
b. Range of motion
i. Cervical
1. Chin to chest
2. Chin up
3. Head side to side
4. Ears to shoulders
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ii. Thoracic
1. Twist side to side
iii. Lumbar
1. Lean backwards
iv. All ROM should be smooth and coordinated without pain
4. Upper extremities
a. Shoulders
i. ROM
1. External and Internal Rotation
2. Abduction
3. Adduction
4. Forward and backward
5. Shrug
b. Elbows
i. ROM
1. Flexion
2. Extension
3. Supination
4. Pronation
c. Wrists
i. ROM
1. Flexion
2. Extension
3. Rotation
4. Supination
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5. Pronation
d. Hands/Fingers
i. ROM
1. Flexion
2. Extension
3. Grips
5. Lower extremities
a. Hips
i. ROM
1. Flexion
2. Extension
3. Internal rotation
4. External rotation
5. Abduction
6. Adduction
b. Knees
i. ROM
1. Flexion
2. Extension
c. Ankles
i. ROM
1. Dorsiflexion
2. Plantar flexion
3. Supination
4. Pronation
151
5. Rotation
d. Feet/Toes
i. ROM
1. Flexion
2. Extension
Nursing Concepts
1. Reflexes usually tested during neurologic assessment, but could be included here as
well
2. Could use a goniometer to assess degree of flexion or extension of joints
monitoring. https://www.youtube.com/watch?v=aUMTPa_9qlY
Teacher’s Insight
The musculoskeletal system assessment usually is conducted at the last part of a
comprehensive physical examination. It is important that nurses are able to
accurately and comprehensively assess this system. It is important because it shows
the physical ability of the patient to physical tasks and follow physical commands.
These may indicate normal functioning not only of the musculoskeletal aspect but also
the neurologic aspect of the patient.
PERIPHERAL VASCULAR ASSESSMENT
Assessing the peripheral vascular system includes measuring the blood pressure,
palpating peripheral pulses, and inspecting the skin and tissues to determine perfusion
152
(blood supply to an area) to the extremities. Certain aspects of peripheral vascular

assessment are often incorporated into other parts of the assessment procedure. For
example, blood pressure is usually measured at the beginning of the physical examination.
Peripheral Pulses
 Palpate the peripheral pulses on both sides of the client's body individually,
simultaneously (except the carotid pulse), and systematically to determine the
symmetry of the pulse volume. If you have difficulty palpating some of the
peripheral pulses, use a Doppler ultrasound probe. There should be symmetric pulse
volumes and full pulsations.
Peripheral Veins
 Inspect the peripheral veins in the arms and legs for the presence and/or
appearance of superficial veins when limbs are dependent and when limbs are
elevated. In dependent position, there is the presence of distention or nodular
bulges at calves. When limbs are elevated, veins collapse (veins may appear
tortuous or distended in older people).
 Assess the peripheral leg veins for signs of phlebitis.
 Inspect the calves for redness and swelling over vein sites.
 Palpate the calves for firmness of tension of the muscles, presence of edema over
the dorsum of the foot, and areas of localized warmth.
 Push the calves from side to side to test for tenderness.
 Firmly dorsiflex the client's foot while supporting the entire leg in extension
(Homan's test), or have the person stand or walk.
 Limbs should not be tender. The limbs should be symmetric in size.
Peripheral Perfusion
 Inspect the skin of the hands and feet for color, temperature, edema, and skin
changes.
 Assess the adequacy of arterial flow if arterial insufficiency is suspected.
 It is normal if the skin color is pink, the temperature is not excessively warm of cold,
no edema, and skin texture is resilient and moist.
Buerger's test
(Arterial Adecuacy test)
 Assist the client to a supine position. Ask the client to raise one leg or one arm about
30 cm or 1 ft above heart level, move the foot or hand briskly up and down for
about 1 minute, then sit up and dangle the leg or arm.
153
 Observe the time elapsed until return of original color and vein filling.
 It is normal if the original color returns in 10 seconds; and about 15 seconds for the
vein to fill in the hands or feet.
Capillary Refill Test
 Squeeze the client's fingernail and toenail between your fingers sufficiently to cause
blanching (about 5 seconds).
 Release the pressure, and observe how quickly normal color returns. Color normally
returns immediately (less than 2 seconds).
Deviations From Normal
 Asymmetric volumes (may indicate impaired circulation).

 Absence of pulsations may indicate arterial spasm or occlusion.
 Decreased, weak, thready pulsations may indicate impaired cardiac output.
 Increased pulse volume may indicate hypertension, high cardiac output, or
circulatory overload.
 Distended veins in the thigh and/or lower leg or on posterolateral part of calf from
knee to ankle.
 Tenderness on palpation.
 Pain in calf muscles with forceful dorsiflexion of the foot (positive Homan's test).
 Swelling of one calf or leg.
 Cyanotic (venous insufficiency)
 Pallor that increases with limb elevation
 Dependent rubor, a dusky red color when limb is lowered (arterial insufficiency).
 Brown pigmentation around ankles(arterial or chronic venous insufficiency)
 Skin cool (arterial insufficiency)
 Marked edema (venous insufficiency)
 Mild edema (arterial insufficiency)
 Skin thin and shiny or thick, waxy, shiny, and fragile, with reduced hair and
ulceration (venous or arterial insufficiency).
 Delayed color return or mottled appearance, delayed venous filling and marked
redness of arms and legs after Buerger's test. It indicates arterial insufficiency.
Overview
1. Peripheral vascular assessment includes portions of a skin assessment as well as pulses

and other indicators of perfusion
154
Nursing Points
General
1. Start with upper extremities, then move to lowers
Assessment
1. Upper extremities
a. Inspect
i. Color of skin and nail beds
ii. Lesions
iii. Edema
iv. Size of arms
1. Any difference bilaterally?
v. Presence of hair
b. Palpate
i. Temperature
ii. Texture
iii. Turgor
iv. Edema (pitting?)
1. See Integumentary assessment
c. Pulses
i. Brachial – medial aspect of elbow
ii. Radial – medial, anterior aspect of wrist, proximal to thumb joint
iii. Rating:
1. 0 = absent
2. +1 = weak
155
3. +2 = normal
4. +3 = strong
5. +4 = bounding
iv. Compare bilaterally
d. Capillary refill – press nail bed, see how long it takes for color to return
i. Should be less than 3 seconds
e. If patient has an AV graft or fistula
i. Palpate for a thrill
ii. Auscultate for a bruit
2. Lower extremities
a. Inspect
i. Color of skin and nail beds
ii. Lesions
iii. Edema
iv. Size of legs
1. Any difference bilaterally?
v. Presence or absence of hair
vi. Venous pattern
1. Tortuous or varicose veins
b. Palpate
i. Temperature
ii. Texture
iii. Edema (pitting?)
1. See Integumentary assessment
156
c. Pulses
i. Popliteal – medial aspect of posterior knee joint
ii. Dorsalis pedis – dorsal aspect of foot between 1st and 2nd metatarsal
iii. Posterior tibial – along the medial malleolus
iv. Rating:
1. 0 = absent
2. +1 = weak
3. +2 = normal
4. +3 = strong
5. +4 = bounding
v. Compare bilaterally
d. Capillary refill on toenails
i. Press nail bed, see how long it takes for color to return
1. Should be less than 3 seconds
3. Abnormal findings
a. Venous insufficiency
i. Dark discoloration of skin
ii. Absence of hair
iii. warm to touch
iv. Edema
v. Varicose veins
vi. “Tiredness” in legs
vii. Flaky skin
b. Arterial insufficiency
i. Erythematous skin
157
ii. Bright red ulcerations
iii. Edema
iv. Pain
v. Weakness
vi. Cool to touch
c. Absent pulses
i. Use doppler to confirm if truly absent
ii. Report to provider, especially if NEW finding
Nursing Concepts
1. Common to see peripheral vascular issues in patients with hyperlipidemia, diabetes, and
peripheral vascular disease
monitoring. https://www.youtube.com/watch?v=l_qgQub4cSQ
NEUROLOGICAL ASSESSMENT
SIX MAJOR CATEGORIES

A. Mental and Emotional Status
Mental and emotional status can be learned through interaction with client. The
nurse poses the questions throughout the examination to gather data and observe the
client at times to detect the appropriateness of emotions and ideas of thoughts expressed.
1. Level of Consciousness
a. Conscious
– responds to questions quickly
– perceives events occurring around him
– awareness of time, place, and people
b. Stupor
- unable to recall who, where he is or the time of the day
c. Comatose
158
- unresponsive to verbal and painful stimuli

2. Behavior and Appearance
- The client’s behavior, hygiene and grooming, and choice of dress reveal
pertinent information regarding mental status.
- Appearance reflects how a client feels about the self.
3. Language
The ability of an individual to understand spoken or written words and to
express the self through writing, words or gestures is a function of the cerebral
cortex. An injury to the cortex my result in a disorder known as aphasia. There are
three types of aphasia: 1.Sensory (or receptive), 2.Motor (or expressive), and
3.Global (mixed sensory and motor).
4. Intellectual Function
a. Memory
– Let the client recall past events such as birthday or an anniversary; previous
health history or instructions given earlier
*** Recent memory
– The nurse asks the client to recall events during the same day (but it
should be validated for accuracy)
*** Remote memory

– Ask client to recall previous medical history; ask client his birthday or
anniversary
*** Immediate memory
– The nurse asks the client to repeat a series of numbers or repeat a
series of numbers backward.
b. Knowledge
– Ask him what he knows about his health condition or the reason for seeking
health care.
c. Abstract Thinking
– Ask the client to explain a phrase and note whether the explanations are
relevant and concrete.
159
d. Association
– Finding similarities or association of concepts
e. Judgment
– The nurse asks the client to compare and evaluate facts and ideas to
understand their relationship to form appropriate conclusions.
B. Sensory Function
The sensory pathways of the central nervous system conduct sensations of pain,
temperature, vibrations, and crude and finely localized touch.
Normally, a client has sensory responses to all stimuli tested. All sensory testing is
performed with client’s eyes closed so he is unable to see when and where stimulus strikes
the skin.
C. Cerebellar Function
1. Coordination
– performing rapid, rhythmical, alternating movements. Note for symmetry
and speed of movement.
a. Pats hands against thigh as fats as he can
b. Touching each fingers with the thumb of the same hand in rapid succession
c. Point to point test
2. Balance
a. Stand with feet together, eyes closed (Romberg Test)
b. Have the client close eyes and stand on one foot and then the other
c. Ask the client to walk in a straight line by placing the heel of one foot directly
in front of the toes of the other foot
d. Heel and toe walking
e. Hop on one foot, then on the other
D. Motor Function
The examiner applies a gradual increase in pressure to a muscle group. The client
resists the pressure applied by the examiner by attempting to move against resistance.
The client resists until instructed to stop. The examiner varies the amount of pressure
applied, the joint moves.
160
1. Biceps – Pull down one forearm as client attempts to flex arms

2. Triceps – As client’s arm is flexed, apply pressure against the forearm.
Ask client to straighten arm
3. Ask client to squeeze your fingers with both hands
E. Reflexes
Type Procedure Normal Reflex
Biceps  Flex arm at the elbow with the palms

down. Flexion of the arm and
 Place the thumb in the antecubital fossa elbow
at the base of biceps tendon.
 Strike the thumb with the reflex hammer.
Triceps  Flex the client below, holding the upper
arm horizontally and allow the lower arm
to go limp. Extension of elbow
 Strike the lower triceps tendon just
above the elbow.
Patellar  Have the client sit with her legs hanging
freely over the side of the bed or chair or
have the client be in supine and support Extension of lower leg
his knee in flexed position.
 Briskly tap patellar tendon just below the
patella.
Plantar  Have the client lie in supine with legs
straight and feet relaxed.
 Take the handle of the hammer and
strike the lateral aspect of the sole from Flexion of the toe
the heel to the ball of the foot curving
across the ball of the foot towards the
big toe.
F. Cranial Nerves
Cranial
Name Type Function Assessment Method
Nerve
» Ask client to close eyes and

I Olfactory Sensory Smell identify different mild aromas,
such as coffee, tobacco,
161
vanilla, oil of cloves, peanut

butter, orange, lemon, lime,
chocolate
» Ask client to read Snellen chart,
Vision and visual check visual fields by
II Optic Sensory
fields confrontation and conduct an
opthalmoscopic exam
Extraocular eye
movement
(EOM);
movement of
III Oculomotor Motor sphincter of » Assess six ocular movement
pupil; and pupil reaction
movement of
ciliary mescles
of lens
EOM, specifically
moves eyeball
IV Trochlear Motor
downward and » Assess six ocular movement
laterally
Trigeminal
» While client looks upward,

a. Opthalmic lightly touch lateral sclera of
Sensation of eye to elicit blink reflex; to
Branch
cornea, skin of test light sensation, have
Sensory
face, and nasal client close eyes, wipe a wisp
mucosa of cotton over the client’s
forehead and paranasal
V sinuses; to test deep
sensation, use alternating
blunt and sharp ends of a
safety pin over same areas.
» Assess skin sensation as for

ophthalmic branch above
162
b. Maxillary Sensation of
Branch skin of face and
anterior oral
Sensory cavity (tongue » Ask client to clench teeth
and teeth)
Muscles of
mastication,
sensation of
c. Mandibular skin of face
Branch
Motor
and
Sensory
EOM; moves
VI Abducens Motor » Assess direction of gaze
eyeball laterally
» Ask client to smile, raise the

eyebrows, frown, puff out
Facial
cheek, close eyes tightly; ask
Motor expressions; client to identify various
VII Facial and taste (anterior tastes placed on tip and sides
Sensory 2/3 of the of tongue: sugar (sweet), salt
tongue) (salty), lemon juice (sour),
and quinine (bitter); identify
areas of taste.
Auditory
Equilibrium
Sensory » Assessment of same with
a. Vestibular cerebellar functions
VIII
Branch
Hearing
b. Cochlear Sensory » Assess clients ability to hear

spoken word and vibrations of
163
Branch tuning fork
Swallowing » Use tongue blade on posterior

ability and gag tongue while client says “ah”
Glosso- Motor to elicit gag reflex; apply
reflex, tongue
IX and tastes on posterior tongue for
phrayngeal movement,
Sensory identification; ask client to
taste (posterior
tongue) move tongue from side and
up and down.
Sensation of
pharynx and
Motor » Assessed with cranial nerve IX;
larynx;
X Vagus and Assess client’s speech for
swallowing;
Sensory hoarseness
vocal cord
movement
» Ask client to shrug shoulders

Head
against resistance from your
movement; hands and turn head to side
XI Accessory Motor
shrugging of against resistance from your
shoulders hand (repeat on the other
side)
Protrusion of » Ask client to protrude tongue at
XII Hypoglossal Motor midline, then move it side to
tongue
side.
Overview
1. Heavily based on interviewing the patient
2. Also involves direct or indirect assessment of cranial nerves
164
Nursing Points
General
1. Neuro assessment begins when you first walk in the room – during your general
assessment
2. To determine alertness:
a. Start by just walking in the room – if they open their eyes, that’s considered
“spontaneous” eye opening
b. If they don’t – call their name 2 or 3 times – if they open their eyes, it’s to “voice”
c. If they still haven’t roused – gently shake and progressively increase noxious or
painful stimuli until they arouse – “to pain”
3. Supplies needed
a. Pen light
b. Alcohol swab
c. Reflex hammer
d. Cotton-tipped applicator
e. Snellen chart if available
f. Cup of water
Assessment
1. Mental Status
a. Level of Consciousness
i. Normal
ii. Confused
iii. Delirious
iv. Somnolent
165
v. Obtunded
vi. Stuporous
vii. Comatose
b. Glasgow Coma Scale
i. Eye opening
1. 4 = spontaneous
2. 3 = to voice
3. 2 = to pain
4. 1 = no response
ii. Vocalization
1. 5 = oriented
2. 4 = confused
3. 3 = inappropriate
4. 2 = incomprehensible
5. 1 = no response
iii. Motor response
1. 6 = follows commands
2. 5 = localizes to pain
3. 4 = withdraws from pain
4. 3 = abnormal flexion
5. 2 = abnormal extension
6. 1 = no response
166
iv. *NOTE*
1. Much of this information is obtained throughout the rest of your assessment,

NOT as an individual assessment
c. Orientation
i. Person
1. “Can you tell me your name?”
2. Can be assessed when gathering 2 patient identifiers
ii. Place
i. “Where are we right now?” OR “What city are we in?”
iii. Time
. “Can you tell me what month it is?”
i. Asking the full date may be difficult for anyone
iv. Situation
. “What brings you into the clinic/hospital?”
i. This also helps assess recent memory
d. Thought process / Attention span
i. Are they following your line of questioning?
ii. Are they paying attention?
iii. Are their responses scattered?
iv. Logical thought process questions:
0. Will a stone float on water?
1. Are there fish in the sea?

167
2. Can you use a hammer to cut wood?
e. Memory/Judgment
i. Ask questions you can easily verify
ii. Common knowledge:
0. What must you do to water to make it boil?
1. When is Memorial Day?
2. What are the four seasons of the year?
iii. Personal remote memory:
0. Kids’ birthdays
1. Their birthday
iv. Judgment
0. Are they making safe/good decisions while hospitalized?
f. Destructive thoughts
i. “Are you having any thoughts of hurting yourself or anyone else?”
2. Cranial Nerve Testing
a. I – rarely tested, can ask patient if they have any difficulty identifyingsmells
i. Have them identify known smells (alcohol rub, coffee)
b. II, IV, and VI
i. Visual Acuity – use a Snellen chart 20 feet away if possible. Otherwise have the
patient read a sign on the wall
0. Allow them to use corrective lenses if they have them
ii. PERRLA = Pupils Equal, Round, Reactive to Light and Accommodation

168
0. Shine pen light in eyes bilaterally to assess constriction
1. Should be equal bilaterally
2. Right pupil should also contract when light shines in left pupil and vice versa
(accommodation)
3. Make note of pupil size
iii. Extraocular movements (EOM)
0. Ask pt to follow finger in 6 cardinal positions
c. V – motor and sensory function
i. Palpate masseter muscles while patient clenches jaw
0. Can also assess for TMJ at this point – clicking or pain
ii. Have pt close their eyes, lightly touch cheek, forehead, chin and ask pt to tell
you when they feel it and if it’s the same bilaterally
d. VII – facial motor function
i. Have patient smile, frown, close eyes tightly, raise eyebrows, and show teeth
ii. Look for symmetry of movement
e. VIII – hearing
i. Lightly rub fingers about a foot from patient’s ears and move closer until they
can hear
ii. Whisper test – whisper a 2-syllable word about 2 feet from the patient and see if
they can hear it
f. IX, X, XII – tongue
i. Swallow/gag reflex
169
0. If patient can swallow safely, nerves are intact
ii. Open mouth and say “Ah”- uvula should rise midline
iii. Stick out tongue – should be midline
g. XI –
i. Shrug shoulders against resistance
ii. Turn head left and right against resistance
3. Sensory / Reflexes
a. Use a cotton-tipped applicator with the wood split to test sharp and dull on 4
extremities
i. Show the patient “sharp” and “dull” first, then ask them to close their eyes and
tell you what they feel
ii. Compare side to side
b. Use reflex hammer to test reflexes:
i. Bicep
ii. Tricep
iii. Patellar
iv. Achilles
v. Graded:
0. 0 = no response
1. 1 = diminished
2. 2 = normal
3. 3 = brisk
170
4. 4 = hyperactive
c. Babinski reflex – pull the handle of the reflex hammer up and across the foot (like
an upside down J)
i. Should see toes curl
ii. If toes flare out, that’s a bad sign (positive babinski)
4. Balance / Coordination
a. Assess gait by having patient walk 5 feet away and back
i. Should be smooth and effortless
b. Romberg test
i. Have the patient stand with feet together, close eyes, and hold for 20 seconds
ii. Should be able to stay balanced without falling
iii. Some sway is normal
c. Finger to nose test
i. Have the patient touch your finger, then their nose, repeatedly as you move your
finger – in approximately 5-6 positions.
ii. Should be able to easily bring their hand back to their nose from any position
iii. Have them repeat with both hand
Nursing Concepts
1. There are MANY things that could cause barriers to this assessment
a. Use alternative assessments when needed
b. Document objectively
i. “Unable to assess” is appropriate
171
monitoring. https://www.youtube.com/watch?v=Sqb8icF6QhE
Teacher’s Insight
A neurological assessment/exam is an evaluation of a person’s nervous system, which
includes the brain, spinal cord, and the nerves that connect these areas to other parts
of the body. To ensure reliability of neurological assessment and use of the GCS, it is
important that all health professionals conducting these assessments are: Fully
educated and competent in the use of the GCS and neurological observation tools
being used within their health service. Neurological observations collect data on the
patient’s neurological status and can be used for many reasons, including in order to
help with diagnosis, as a baseline observation, following a neurosurgical procedure,
and following trauma. Therefore, it is important that all healthcare professionals are
efficient and accurate in assessing neurological functioning.
End of Chapter 4 (continuation part 2)….

Instructions: In a separate sheet of paper, answer the following case scenarios and
attach it to this section once you submit your portfolio and outputs.
172
Alimannao Hills Penablanca, Cagayan
COLLEGE OF NURSING
Case Analysis
I. MUSCULOSKELETAL ASSESSMENT
Case 1: Patient Leiru, 26-year-old, female, a vlogger from Manila, weighing 86kg, height
of 160cm, started working out during the enhanced community quarantine in an attempt
to decrease her waistline from 40 inches to 30 inches. She has been running at a pace of
8’5” every day for 2 months. Three days prior to consultation, she has been experiencing
knee pain around the patella after changing her training into more hill climbs and descents.
Upon interview, she said pain was located around the patella, non-radiating, described as
squeezing, rating it as 8/10, occurs during activity at any time of the day and relieved
immediately by rest. No known history of trauma. During physical assessment, on the way
to the well lit room, the patient was seen to be limping on the right. The knee was noted
to be red and tender.
Tasks.
2. Give 2 causes and explain why.
3. Give 6 risk factors based on the case scenario
4. From the case scenario identify two specific nursing diagnosis and give 5 nursing
interventions needed to be conducted with its rationale base from your inference.
II. NEUROLOGICAL ASSESSMENT

Case 2. Patient EB, 63 year old, male from Iguig came to the ER. During the interview,
the patient was said to be apparently well until 5 days prior to admission when the patient
fell on his back while walking on his way to his room. There was no loss of consciousness
and the patient was able to stand immediately. However, he felt numbness on both right
and left shoulders but no pain was noted on any other parts of the body. There was no
nausea, vomiting or blurring of visions noted. Hence, he went straight to bed and slept
immediately thereafter. 4 hours later, the patient was awaken by intense headache,
localizing it at the frontal area, characterized as pin-like, non-radiating, rated as 8/10,
continuous, and chest pain, localizing it at midchest, characterized as pin-like, non-
radiating, rated as 8/10, not continuous, aggravated by breathing and relieved by sitting.
The patient immediately took 1 capsule of Mefenamic Acid 500 mg. Pain continued for 30
minutes but was relieved thereafter. Therefore, he went back to sleep.
4 days PTA, the patient woke up like nothing happened. He palpated his head, found out
it was not tender nor does it have a mass but his shoulders felt numb and heavy. However,
173
COLLEGE OF NURSING
the patient was able to get up and do the daily routine until 3 hours after when he felt his
head was aching still localizing it at the frontal area, characterized as pin-like, non-
radiating, rated as 8/10, continuous, aggravated by fatigue and relieved by rest and intake
of 1 cap of Alaxan forte 500mg/cap. Days 2-3 PTA went the same as Day 4 PTA. The
same symptoms were felt and the same management were done. Few hours prior to
admission, the patient had the same headache. However, it was accompanied by chest
pain still localizing it at midchest, characterized as throbbing, non-radiating, rated as 7/10,
continuous, aggravated by breathing and relieved by rest. Patient was immediately rushed
to CVMC. Hence, admission.
Tasks:
2. Give 2 causes of the situation and explain why.
3. Give 6 risk factors based on the case scenario
4. From the case scenario identify two specific nursing diagnosis and give 5 nursing
interventions each needed to be conducted with its rationale base from your
inference each.
THIS IS THE END OF THE FINALS COVERAGE
174
COLLEGE OF NURSING

course.
SEE YOU NEXT SEMESTER!!!!
REFERENCES:
175
COLLEGE OF NURSING
Textbooks:
1. Lewis’s Medical Surgical Nursing Assessment and Management of Clinical Problems
8th edition by Borromeo, 2014
Other References:
1. Health Assessment of Nursing Practice 5th edition by Wilson, 2013
2. Health assessment in Nursing 4th edition by Weber, 2010
3. Lippincott Manual of Nursing Practice 1oth edition by Nettina, 2014
Journals :
1. American Journal of Nursing
2. Journal on Critical Care Nursing
3. Pediatric Nursing Journal
4. Nursing care management
Website:
1. www.amazon.ca/exec/obidos/ASIN/0071054804
2. www.harcourt-international.com/surgicalnursing
3. www.medicine.htm
4. www.nursingguide.htm
5. www.nursingscribd.com
Rubric for Critical Thinking Exercises
176
COLLEGE OF NURSING
5 4 3 2 1 0
Excellent Very Good Good Fair Poor Non-
Complia
nt
Correctnes Correct Answer Answer Answer Answer (No

s of answer is provided is provided is provided is given is answer
Answer given (right correct but similar not clear incorrect, Provided)
terminolog incomplete concept and has
y or with the no relation
concept) correct to the
answer. topic or
question
being
asked.
Concise Explanatio Explanation Explanatio Explanatio Explanatio No answer

explanation n is is correct but n is correct n is n is Provided
supported is not but missing the incorrect.
with supported supporting significant
appropriate with concepts is information
concepts. appropriate not .
concept. applicable.
Sentence Answer is Answer is Answer Answer is Sentences No answer

compositio presented presented does not too long are Provided
n briefly with briefly but follow the and lacks incompreh
correct with format significant ensible.
grammar grammatical provided. information
and errors. .
punctuatio
ns.
Rubric for Reflective Journal
177
COLLEGE OF NURSING
Completeness: 50%
Construction of Sentence : 45%
(organization of thoughts, grammar)
Creativity/Neatness: 5%
_____
Total: 100%
178

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MEDICAL COLLEGES OF NORTHERN PHILIPPINES

FEVIE ANNE D. BANATAO

LOUISE V. CABLING, RN, MAN, LPT, MST

WINNIE T. CANCEJO RRT, MPH

How to Use this Learning Guide:

Features of the Instructional Learning Guide:

 Other Activities (to be included in Portfolio Assessments)

Chapter 1: REVIEW OF NURSING PROCESS . . . . . . . . . . . . . . . . . . . . . .

Chapter 2: PHYSICAL EXAMINATION. . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 3: REVIEW OF SYSTEMS (Adult)

III. SEMI FINALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 4: PHYSICAL ASSESSMENT PROCESS (cont…)

Chapter 4: PHYSICAL ASSESSMENT PROCESS (cont…)

Specific Instructions in the completion of each Chapter:

Duration: 12.0 hours

MAJOR TOPICS SUBTOPICS

Diagnosis  Types of Diagnosis

Interventions  Types of Interventions and Examples

1. Self-Assessment Exercises: MCQ type of questions

Before you proceed…

Intended Learning Outcomes:

1. Discuss the steps of the Nursing Process

BASIC CONCEPTS OF NURSING PROCESS

Definition of Nursing Process:

Advantages of Nursing Process:

1. Provides individualized care

PHASES OF NURSING PROCESS

 First step of the Nursing Process

 Process of Systematic Assessment

Comprehensive data collection:

a) Objective Data – signs; those that can be observed and measured

 The interview is a purposeful conversation, generally in a face-to-face meeting. It

 Taking a Patient’s history is arguably the most important aspect of patient

Preparing the environment

 The HCP should be able to gather information in a systematic, sensitive and

The need to communicate is universal. People communicate to satisfy needs. Is the

Examples of non-verbal and verbal communication skills

Facial gestures Rate and intonation Volume

The History Taking Process

1. The Presenting Complaint:

 Onset – was it sudden, or has it developed gradually?

2. Past Medical History

 Gordon’s 11 Functional Patterns

1 - Health Perception and Health Management Pattern.

Example of Health Perception and Health Management FHP Assessment Questions:

2 - Nutrition and Metabolism Pattern

 Assessment is focused on the pattern of food and fluid consumption relative to

Example of Nutrition and Metabolism FHP Assessment Questions:

 Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory

Example of Elimination FHP Assessment Questions:

4 - Activity and Exercise Pattern

 Assessment is focused on the activities of daily living requiring energy expenditure,

Example of Activity and Exercise FHP Assessment Questions:

5 - Cognition and Perception Pattern

Example of Activity and Exercise FHP Assessment Questions:

6 - Sleep and Rest Pattern

 Assessment is focused on the person's sleep, rest, and relaxation practices.

Example of Activity and Exercise FHP Assessment Questions:

7 - Self-Perception and Self-Concept Pattern

Example of Self-Perception and Self-Concept FHP Assessment Questions:

8 - Roles and Relationships Pattern

Example of Roles and Relationships FHP Assessment Questions:

9 - Sexuality and Reproduction Pattern

 Assessment is focused on the person's satisfaction or dissatisfaction with sexuality