Unit IV

PHYSICAL
EXAMINATION
Assessment of the Eye
Assessment Procedures Normal Findings
Evaluating Vision. Test the visual acuity. Normal distant visual acuity is 20/20. A person
who is 20 feet from an eye chart can read a 20
size font of letters.
 Abnormal Findings
Nearsightedness (myopia) is a common vision Presbyopia is the gradual loss of the eyes' ability
condition in which the client can see objects that to focus on nearby objects.
are near.
 Assessment Procedures Normal Findings
Test visual fields for gross
peripheral vision. With normal
peripheral vision, the client should
see the examiner’s finger at the
same time the nurse sees it.
 Abnormal Findings
A delayed or absent perception of the examiner’s
finger indicates reduced peripheral vision.

Causes of decreased peripheral vision loss

include: Glaucoma (damage of optic nerve), eye
occlusions, detached retina,
brain damage from stroke, disease or injury and
compressed optic nerve due to tumor or
hemorrhage.
 Assessment Procedures Normal Findings
Testing Extraocular Muscle Functions.
Abnormal Findings
Abnormal Findings
 Assessment Procedures Normal Findings
The Hirschberg test (also known as the corneal The reflection of light on the corneas should be
light reflex test) is a quick and simple way to in exact same spot on each eye.
check ocular alignment. This is also used as an
initial screening for strabismus. This indicates parallel alignment.
• Hold a penlight 12 inches from the
client’s face
• Shine the light while the client stares
straight ahead.
 Assessment Procedures Normal Findings
Perform cover and uncover test is useful to
identify a tropia and differentiate it from a phoria.
Assessment Procedures Normal Findings
The uncovered eye should remain straight
ahead. The covered eye should remained fixed
straight ahead after being uncovered.

This is to test also the CN III, IV and VI.

 Abnormal Findings
Asymmetric position of the light reflex indicates deviated alignment of the eyes.
Abnormal Findings
 Assessment Procedures
INSPECTION AND PALPATION OF
EXTERNAL EYES. Inspect the eyelids and
eyelashes for its width and position of palpebral
fissures.
Normal Findings
Upper lid margin should be between the upper
margin of the iris and the upper margin of the
pupil.
The lower lid margin rests on the lower border
of the iris.
No white sclera is seen above or below the iris.
Palpebral fissures may be horizontal.
 Abnormal Findings
Drooping of the upper lid called ptosis in oculomotor nerve damage or in myasthenia gravis.

Ptosis Exophthalmos

Eyelid Infection Cyst of the eyelids

 Assessment Procedures Normal Findings
Assess the ability of the eyelids to close. The upper and lower lids close easily and meet
completely when closed.

Abnormal Findings
Failure of lids to close
completely maybe
indicative of corneal
damage.
 Assessment Procedures Normal Findings
Note the position of the eyelids in comparison of Lower eyelid is upright with no inward and
the eyeballs. Note for turnings, color, swelling, outward turning. Eye-lashes are well
lesions and discharge. distributed.

Abnormal Findings
Xanthelasma, raised yellow plaques located
most often near the inner canthus are
normal with age and high lipid levels.
 Abnormal Findings

An inverted lower lid is a condition called entropion, which may cause pain and can injure the
cornea.

Ectropion, an inverted lower eyelid results in exposure and drying of the conjunctiva. Ectropion and
entropion interfere with normal tear drainage
 Assessment Procedures Normal Findings
Observe the position and alignment of the eyeball Eyeballs are symmetrically aligned in sockets
in the eye socket. without protrusion.

Abnormal Findings

Protrusion of the eyeballs Sunken eyeballs

(exophthalmos) is significant
in hyperthyroidism.
 Assessment Procedures Normal Findings
Inspect the bulbar conjunctiva and sclera Bulbar conjunctiva is clear and moist.
Underlying structures are visible. Sclera is white
Abnormal Findings

Redness of conjunctiva is significant

to conjunctivitis or pink eye.

Areas of dryness are

significant in allergies or trauma.
Abnormal Findings

Eye injuries
Abnormal Findings

Infections of the Eye

 Assessment Procedures Normal Findings
Inspect the palpebral conjunctiva. Lower and upper palpebral conjunctiva are clear
and free of swelling and lesions.
 Abnormal Findings

Cyanosis of the lower lid is

significant with heart or lung
disorders.

Pyogenic granuloma
 Assessment Procedures Normal Findings
Inspect and palpate the lacrimal apparatus. No swelling or redness. Puncta is visible.
Assess the areas over lacrimal glands and puncta.
 Abnormal Findings
Drainage from the puncta is significant when there is blocked duct.
 Assessment Procedures Normal Findings
Inspect the cornea and lens. Shine a light from Cornea is transparent with no opacities.
the side of the eye. Look through the pupil to
inspect the lens.

Abnormal Findings
Areas of roughness or dryness is significant with allergy, injury and fatigue.
 Abnormal Findings

Opacities of the lens are indicative of cataracts

Abnormal Findings
 Abnormal Findings

Keratoconus is a progressive eye disease in which the normally round cornea thins and begins to
bulge into a cone-like shape combination of genetic susceptibility along with environmental and
hormonal influences
 Assessment Procedures Normal Findings
Inspect the iris and pupil for its color, shape and Iris is round, flat, and evenly colored. Pupil is
size. Measure iris. also round and is the center of the iris. Pupils are
normally 3 – 5 mm.

Abnormal Findings
Typical iris findings include the following
abnormalities:
* irregular shaped iris
During the second month of
fetal development, a seam-
like structure (optic fissure)
closes to form the eye.
When it doesn't fuse, it
results in coloboma.
 Abnormal Findings
Typical iris findings include
the following abnormalities:
* Miosis and mydriasis
When the client’s pupils
dilate in an unusual way
it is called mydriasis &
when the iris constricts
to cause very small
or pinpoint pupils, it is
called miosis.
 Abnormal Findings

Anisocoria refers to the pupil of one eye differs in size from the pupil of the other eye.
Due to aneurysm / bleeding in the brain, head injury, brain tumor or abscess, excess pressure in one
eye and increased intracranial pressure
 Assessment Procedures Normal Findings
Test pupillary reaction to light. Shine a light obliquely into one eye and observe pupillary reaction to
light.
 Test pupillary reaction to light: Interpretation
A consensual response is any reflex
observed on one side of the body In abnormal
when the other side has been findings: Pupils do
not constrict; eyes do
stimulated. not converge.

Like, when light shines on the right

eye, constriction of the right pupil
will occur, as well as the left pupil.

The direct response is the change

in pupil size in the eye to which the
light is directed (e.g., if the light is
shone in the right eye, the right
pupil constricts)
Assessment of the Ears
Assessment Procedures Normal Findings
Inspect external ear structures like the auricles, Ears are equal in size bilaterally (4 to 10 cm).
tragus, and lobule. Note the size, shape and The auricle aligns with the corner of each eye
position. and within a 10-degree angle of the vertical
position. Earlobes are free and attached.
 Abnormal Findings
Malalignment or low set ears may be significant in client with chromosomal defects.

.
Smaller Ears Larger Ears
 Abnormal Findings

Malalignment or low set ears

 Abnormal Findings

.
 Assessment Procedures Normal Findings
Inspect the auricle (pinna), tragus, and The skin is smooth with no lesions, lumps or
lobule. nodules. Presence of Darwin’s tubercle is
insignificant.

Projection, maybe seen on the auricle. No

discharge should be present.
 Abnormal Findings
Some abnormal findings suggest various disorders including enlarged preauricular and
postauricular lymph nodes – infection.

.
 Abnormal Findings

Tophi (nontender, hard,

cream-colored
nodules Auricular cyst
containing uric acid
crystals)

Massive otitis
Cancer of the ear media
 Assessment Procedures Normal Findings
Palpate the auricle and mastoid process. Auricle, tragus and mastoid process are not
tender.
 Abnormal Findings
A painful auricle or tragus is significant for a client with otitis externa or postauricular cyst.
Tenderness in the mastoid process is significant with mastoiditis. Tenderness behind the ear is
significant in otitis media.

Acute Mastoiditis
 Assessment Procedures Normal Findings
Inspect the external auditory canal. Note the A small amount of odorless cerumen is the only
color of the cerumen using an otoscope (if discharge normally present. Cerumen maybe
available). yellow, orange, brown, gray.
Foreign bodies in the Ear
 Assessment Procedures Normal Findings
Inspect tympanic membrane and note its color, Tympanic membrane should be pearly,, gray,
consistency and landmarks. shiny, and translucent with no bulging or
retraction. It is slightly concave.
 Abnormal Findings

Red, bulging and distorted membrane in acute otitis media.

Yellow and bulging with bubbles in serous otitis media. Bluish
or dark color – blood in the eardrum is significant from skull
trauma. White spots significant for scarring with infection.
 Assessment Procedures & Normal Findings
Test for hearing performed to detect unilateral (one-sided) conductive hearing loss (middle ear
hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss). Named after Ernst
Heinrich Weber.
For normal hearing, air conduction is heard better than bone conduction (Rinne positive) For
conductive hearing loss, bone conduction is heard better than air conduction (Rinne negative)
Assessment Procedures Normal Findings
Assessment Procedures Normal Findings
.
 Abnormal Findings

.
Assessment Procedures Normal Findings
Assessment of the Thorax (Lungs)
Landmarks
 Abnormal Findings

.
 Assessment Procedures Normal Findings
Inspect for nasal flaring and pursed lip The diaphragm and the external diaphragm
breathing. intercostal muscles do most of breathing.
 Abnormal Findings
Nasal flaring is significant with labored or dyspnea
and is indicative of hypoxia.
Pursed lip breathing is significant in asthma,
CHF, COPD.
.
Barrel-chest clients is indicative of
emphysema (gradual thinning and
destruction of the alveoli or air sacs)
due to hyperventilation of the lungs.
 Assessment Procedures Normal Findings
Observe the client’s positioning The client does not use accessory
(trapezius/shoulder) muscles to assist breathing.
 Abnormal Findings

.
 Abnormal Findings

.
 Posterior Thorax
Assessment Procedures
Inspect configuration while the client sits with
arms at her sides. The nurse should stand
behind her and observe the position of scapula
its shape and configuration of the chest wall.
Normal Findings
Scapula are symmetric and not protruding.
Shoulders and scapula are at equal horizontal
positions.

Abnormal Findings
.
 Assessment Procedures Normal Findings
Palpate posterior thorax for tenderness. Palpate Client reports no tenderness, pain, or unusual
also crepitus and fremitus (vibrations of air in sensations.
the bronchial tubes transmitted to the chest
wall). Ask client to say 99.
 Abnormal Findings
Unequal fremitus is usually significant in bronchial obstruction (foreign body, tumor, thick
secretions, spasm), air trapping in emphysema (thinning and destruction of alveoli), pleural
effusion (water in the lungs) and pneumothorax (air leakage).

.
 Assessment Procedures Normal Findings
Assess chest expansion, helps identify which side of lungs has an abnormality. Normally, a 2-5"
of chest expansion can be observed.
 Abnormal Findings
Unequal chest expansion is significant in clients with the following disorders:
1. Severe atelectasis, collapse or incomplete expansion
2. Pneumonia, lung infection
3. Chest trauma
4. Pneumothorax
5. COPD
.
 Assessment Procedures Normal & Abn Findings
Percuss for tones.
 Assessment Procedures Normal Findings
Auscultate posterior thorax.
Assessment Procedures Normal Findings
3. Validating data
Double checking or verifying
NORMAL BREATH SOUNDS SOUNDS
the data
whether it is factual or accurate
Vesicular Breath Sounds https://www.youtube.com/watch?v=VtnMRG0ORLs

Bronchovesicular Breath Sounds https://www.youtube.com/watch?v=E9iNwFF6R1Y

Record in Breath
Bronchial factual
Sounds manner NOT
https://www.youtube.com/watch?v=WfkWMfE9VTY

interpretation
Tracheal Breath Sounds https://www.youtube.com/watch?v=p9eWmOHgySE

Recording the breakfast as “ate 2 pieces of

bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
 Anterior Thorax
Assessment Procedures Normal Findings
Inspect for shape and configuration of the Side to side symmetric chest shape. Distance
anterior thorax and its relation to the posterior from the front to the back of the chest (anterior-
thorax. posterior diameter) less than the size of the chest
from side to side (transverse diameter.
 Abnormal Findings
Pectus carinatum is a
deformity of the chest
wall where there is an
unusual bulging of
the anterior thoracic
wall.
. Pectus excavatum is a
deformity of the
anterior thoracic wall
which produces a
caved-in or sunken
appearance of the
chest.
 Assessment Procedures
Observe quality and pattern of respiration.
Note breathing characteristics as well as rate,
rhythm and depth.
Normal Findings
Respirations are relaxed, effortless, and quiet.
They are of a regular rhythm and normal depth
at a rate of 10 to 20 per minute in adults.
Tachycardia and bradycardia may be normal in
some clients.

Abnormal Findings

ABNORMAL BREATH SOUNDS

www.youtube.com/watch?v=0fEy-EDHP5Q&t=48s
 Assessment Procedures Normal Findings
Inspect intercostal spaces. Ask the client to No retractions or bulging of intercostal spaces
breath normally and observe the intercostal are noted.
spaces.

Abnormal Findings
Retraction of thoracic cage is significant in increased inspiratory effort. Bulging is indicative in
trapped air like asthma.
Assessment of the Heart
Assessment Procedure Normal Findings
Inspect pulsations with the client in supine The apical pulse may or may not be visible.
position with head elevated between 30 and 45
degrees. The nurse should stand on the client’s
right side.

Abnormal Findings
Pulsations or hives or lifts are abnormal and should be evaluated further.
 Assessment Procedure Normal Findings
Using palmar area, palpate the apical impulse. The apical impulse is palpated in the mitral
Then use finger pad to feel the beat. area about 1 – 2 cm. It is felt like a gentle
tap. In obese client, the apical impulse may
not be palpable.
 Abnormal Findings
The apical pulse may be impossible to palpate in clients with emphysema. If the heart is
larger than 1 – 2 cm, displaced, more forceful or of longer duration, this is indicative of
cardiomegaly.

A thrill, which feels similar to a purring cat, or pulsation is usually associated with grade IV or
higher murmur.
 Assessment Procedures Normal and Abnormal Findings
Palpate for tenderness, sensation, and surface No tenderness or pain is palpated over the lung
masses. area.

Tenderness is significant to frequent use of

muscles or sedentary lifestyle.
 Assessment Procedures Normal Findings
Palpate anterior thorax for chest expansion. As Thumbs move outward in symmetric fashion
the client takes a deep breath, observe the from the midline.
thumbs movement.
 Assessment Procedures Normal and Abnormal Findings
Percuss the apices above the clavicles. Resonance is the percussion tone elicited over
normal lung tissue.

Hyperresonance is significant in trapped air

such as in emphysema, pneumothorax. Dullness
is indicative of pleural effusion / tumor.
 Assessment Procedures Normal Findings
Auscultate for anterior breath sounds,
adventitious sounds and voice sounds.
 Assessment Procedure Normal Findings
Auscultate HR and rhythm. Rate should be 60 to 100 bpm with regular
rhythm. Normally the PR in females is 5 to
10 bpm faster than in males.
 Abnormal Findings
Diminished S2 means that S2 is softer than S1. This is significant in weaken valves.
The two major sounds of the
normal heart sound like "lub dub".
The "lub" is the first heart
sound, termed S1, and is caused
by turbulence caused by the
closure of mitral and tricuspid
valves at the start of systole.
 Abnormal Findings
The second heart sound, "dub" or S2, is
caused by the closure of the aortic and
pulmonic valves, marking the end of
systole.
Wide split S2 splitting is heard when
aortic and pulmonic valves close at
slightly different times.
 Assessment Procedure Normal Findings
If the nurse detect an irregular rhythm, The radial and apical pulse rates should be
auscultate for a pulse rate deficit. This is done identical.
by palpating the radial pulse while auscultating
the apical pulse. Count for 1 min.

Abnormal Findings
A pulse deficit (difference between the apical and radial pulse) is indicative of the following
abnormal conditions:
Irregular, rapid heart rate like heart palpitations,
fatigue, and shortness of breath which occurs
when the atria beat out of rhythm.
 Assessment Procedure
Auscultate to identify S1 and S2 using the
diaphragm of the stethoscope. These two
sounds make up the cardiac cycle of systole
and diastole.
Normal Findings
S1 corresponds with each carotid pulsation
and is loudest at the apex of the heart. S2
follows after S1 and is loudest at the base of
the heart.

Abnormal Findings
Different abnormal heart sounds

Normal and Abnormal Heart Sounds during Auscultation

https://www.youtube.com/watch?v=dBwr2GZCmQM
Abnormal Findings
Assessment of the Breasts
Breast Landmarks
 Assessment Procedures
Female breasts. Inspect the size, color, texture,
symmetry and superficial venous pattern with the
client sitting with arms hanging freely at the side.
Normal Findings
Breasts can be a variety of sizes and are
somewhat round, pendulous and smooth.
One breast may normally be larger than the
other.
Color varies on client’s skin tone. Texture is
smooth with no edema.
Veins are present horizontally and vertically.
Prominent during pregnancy.
 Abnormal Findings

Increase in breasts size is indicative of infection or tumor. Pigskin-like or peau d’orange

appearance is significant when there is edema due to blocked lymphatic drainage.
 Assessment Procedures Normal Findings
Inspect the areola. Note for color, size, shape, Areolas vary from dark pink to dark brown,
texture of both breasts. depending on skin tones. They are round and
vary in
size. Small
montgometry
tubercles
are present.
 Abnormal Findings

Peau d’ orange skin is Red scaly, crusty area

significant with breasts is significant of Paget’s
cancer. disease (malfunction of
osteoblasts and
osteoclasts).
 Assessment Procedures Normal Findings
Inspect for retraction and dimpling. The client’s breasts should rise symmetrically
with no sign of dimpling or retractions.
Raise arms over head

Press hands against hips

Press hands together

 Abnormal Findings

This is indicative of presence of tumor. As the muscle contracts, it draws the tissues causing
dimpling and retraction.
 Assessment Procedures Normal
Findings
Palpate breast’s texture, elasticity, tenderness, Breasts are smooth, firm, elastic tissue. A
temperature and presence of mass using the four generalized increase in nodularity and
quadrants. tenderness is a normal finding maybe associated
with menstruation. Breasts should be of normal
temperature with no mass palpated

Abnormal Findings
Painful breasts may be indicative of
benign or malignant disease. Heat
in the breasts who are not lactating
indicates inflammation. Tumors are
present.
 Abnormal Findings

.
 Assessment Procedures
Palpate the nipples.
Normal
Findings
The nipple may become erect and the areola
may pucker in response to stimulation. A milky
discharge is normal only during pregnancy.
Some women may normally have a clear
discharge.
 Abnormal Findings
Discharges may be seen in
endocrine disorders.
Discharge from one breast is
significant in benign
intraductal papilloma

.
 Assessment Procedures Normal Findings
Palpate post mastectomy or lumpectomy sites Scar is whitish with no redness or swelling
(if the client has had these operations).

Abnormal Findings
Redness and inflammation of the scar is indicative of infection or possible recurrence of lumps or
mass.
 Assessment Procedures Normal Findings
Inspect and palpate the axillae for rashes or No rash or infection
infection.

Abnormal Findings
 Assessment Procedures Normal Findings
Palpate axillary lymph nodes No palpable nodes or one to two small, discrete,
nontender, movable nodes in the central area.
 Abnormal Findings
Enlarged nodes is significant that there infection of the hand/arm.

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Self – Breasts Examination