Physical assessment

PHYSICAL
EXAMINATI
ON
Physical examination is an important tool in assessing the
patient’s health status. About 15% of the information used in the
assessment comes from the physical examination. It is a
performed to collect objective data, and to correlate it with
subjective data
Purposes of Physical Examination

• To obtain baseline data about the client’s functional

abilities.

• To obtain data that will help the nurse establish nursing

diagnosis and plan the client’s care.
• To elevate the physiological outcomes of health care and thus the
progress of a client’s health problems.

• To make clinical judgements on a client’s health status.

• To determine the client’s eligibility for health insurance, military

service or a new job.
 Methods of Physical Examination

• Generally cephalocaudal approach e.g. head to toe approach is

used.
• The procedure can vary according to the age of the individual,
the severity of the illness, the preferences of the nurse, location
of the examination and the agency’s priorities and procedure.
 Methods of Examination
• Inspection
• Palpation
• Percussion
• Auscultation
• Smelling
• Clinical measurement
 Inspection
• Is the visual examination, which is assessing by using the sense of
the sight to discover any signs of illness.
• The nurse inspects with the naked eyes.
• Visual inspection to assess moisture, colour and texture of the body
surfaces as well as shape, position, size, colour and symmetry of the
body.
 Palpation
• Palpation is the examination of the body using the sense of touch.
• The pads of the fingers are used because their concentration of nerve endings
makes them highly sensitive to tactile discrimination.
• Palpation is used to determine
(a) texture (e.g., of the hair)
(b) temperature (e.g., of a skin area)
(c) vibration (e.g., of a joint)
(d) position, size, consistency, and mobility of organs or masses;
(e) distention (e.g., of the urinary bladder)
(f) pulsation and
(g) tenderness or pain.
• There are two types of palpation: light and deep.
• Light (superficial) palpation should always precede deep palpation
because heavy pressure on the fingertips can dull the sense of touch.
• For light palpation, the nurse extends the dominant hand’s fingers
parallel to the skin surface and presses gently while moving the hand
in a circle , with skin slightly depressed.
• If it is necessary to determine the details of a mass, the nurse presses
lightly several times rather than holding the pressure.
• Deep palpation is done with two hands (bimanually) or one hand.
• The nurse extends the dominant hand as for light palpation, then
places the finger pads of the nondominant hand on the dorsal surface
of the distal interphalangeal joint of the middle three fingers of the
dominant hand .
• The top hand applies pressure while the lower hand remains relaxed
to perceive the tactile sensations.
• For deep palpation using one hand, the finger pads of the dominant
hand press over the area to be palpated.
• Often the other hand is used to support from below .
 Palpation is Used to
Determine
• Texture e.g. the hair, skin etc.
• Vibration e.g. of a joint
• Position, size, consistency, and mobility of
organs or masses
• Distention e.g. of the urinary bladder,
abdomen
• Pulsation and the presence of pain upon
pressure.
 Percussion
• Percussion is the act of striking the body surface to elicit sound that
can be heard or vibrations that can be felt when they are tapped with
the fingers.
• There are two types of percussion: direct and indirect.
• In direct percussion, the nurse strikes the area to be percussed directly
with the pads of two, three, or four fingers or with the pad of the
middle finger.
• The strikes are rapid, and the movement is from the wrist.
• Indirect percussion is the striking of an object (e.g., a finger) held against the
body area to be examined.
• PLEXIMETER - the middle finger of the nondominant hand is placed firmly
on the client’s skin. Only the distal phalanx and joint of this finger should be
in contact with the skin.
• PLEXOR - Using the tip of the flexed middle finger of the other hand, the
nurse strikes the pleximeter, usually at the distal interphalangeal joint or a
point between the distal and proximal joints.
• The striking motion comes from the wrist; the forearm remains stationary.
• The angle between the plexor and the pleximeter should be 90°, and the
blows must be firm, rapid, and short to obtain a clear sound.
Percussion Produces 5
Types Of Sounds
• Tympany:- it is a musical or drum like sound produced from an air filled
stomach.
• Resonance:- it is a hollow sound such as that produced by lunges filled
with air.(normal lungs sound).
• Dullness:- it is the thud like sound produced by dense tissue such as the
liver, spleen, heart etc.
• Flatness:- flatness is an extremely dull sound produced by very dense
tissue, such as muscle or bone.
 Auscultation
• Auscultation (based on the Latin verb auscultare "to listen") is the
term for listening to the internal sounds of the body, usually using a
stethoscope.
• Auscultation is performed for the purposes of examining the circulatory
system and respiratory heart sound and breath sounds), as well as the
gastrointestinal system(bowel sounds).
Fig. of Auscultation
Auscultation May Be Direct Or Indirect

• Direct auscultation is the use of the unaided ear for example, to

listen to a respiration wheeze or the grating of the moving joint.

• Indirect auscultation is the use of a stethoscope, which amplifies the

sound conveys them to the nurse’s ears.
Note: The stethoscope should always be placed
on the naked skin because clothing obscures
sound. It require concentration and practice.
 Smelling
Smelling means discovering the odours given off by various parts of
the body. The nurse should smell the patient's breath and other body
discharges like sputum, vomits, faeces, urine, etc. to detect unusual
odours, which may indicate any abnormalities.
 Clinical Measurement

Clinical measurement such as height, weight, blood

pressure, temperature, pulse, respiration, etc. also helps
to assess the patient’s status.
Preparing A Patient For
A Physical Assessment
a. Establish a Positive Nurse/Patient Rapport. This relationship
will decrease the stress the patient may have in anticipation of
what is about to be done to him.
b. Explain the Purpose for the Physical Assessment. The purpose
of the nursing assessment is to gather information about the
patient's health so that you can plan individualized care for that
patient.
c. Obtain an Informed, Verbal Consent for the Assessment. The chief
source of data is usually the patient unless the patient is too ill, too
young, or too confused to communicate clearly. Patients often
appreciate detailed concern for their problems and may even enjoy the
attention they receive.
d. Ensure Confidentiality of All Data.
• If possible, choose a private place where others cannot overhear or see the
patient.
• Explain what information is needed and how it will be used. It is also
important to convey where the data will be recorded and who will see it.
• In some situations, you should explain to the patient his rights to
privileged communication with health care providers.
e. Provide Privacy From Unnecessary Exposure. Assure as much
privacy as possible by using drapes appropriately and closing doors.
f. Communicate Special Instructions to the Patient. As you proceed with
the examination, inform the patient of what you intend to do and how
he can help, especially when you anticipate possible embarrassment or
discomfort.
Steps of Doing Physical Examination

• Take clinical measurements like height, weight

and vital signs.

• Prepare the patient for physical examination

by:-
Explaining the purposes and procedure for physical examination.
Telling the patient how long examination will take.
Asking him to urination
Arranging for a quiet, private area for assessment.
Asking the patient to remove his clothes and giving him to drape to cover.
Inspect the patient’s general appearance
Assess the physical status of the patient in a systematic way by using
various methods of physical examination.
After completing the physical examination, allow the patient to put on
his clothes.
Explain the findings to the patient.
Record the relevant findings of physical examination on the patient’s
assessment form.
 HOW TO PERFORM
PHYSICAL EXAMINATION
Equipments Required
1. Tray (1)
2.Watchwith a seconds hand (1)
3.Height scale (1)
4.Weight scale (1)
5. Thermometer (1)
6.Stethoscope (1)
7. Sphygmomanometer (1)
8.Measuring tape (1)
9. Scale (1)
10.Tourch light or penlight (1)
11. Spatula (1)
12 Reflex hammer (1)
13.Otoscope if available (1 set)
14.Disposable gloves (1 pair)
15. Cotton swabs and cotton gauze pad
16. Examination table
17. Record form
18. Ballpoint pen, pencils
Procedure
 A. General examination

Assess overall body appearance and mental status

Inspection
1. Observe the client’s ability to respond to verbal commands.(Responses
indicate the client’s speech and cognitive function.)
Normal findings
• The client responds appropriately to commands.

Abnormal findings
• The client confused, disoriented, or inappropriate responses.
 2. Observe the client’s level of consciousness( ; LOC) and orientation.
Ask the client to state his/her own name, current location, and approximate
day, month, or year.
(Responses indicate the client’s brain function. LOC is the degree of
awareness of environmental stimuli. It varies from full wakefulness and
alertness to coma. Orientation is a measure of cognitive function or the
ability to think and reason. )
Normal findings
• The client is fully awake and alert:
Eyes are open and follow people or objects. The client is attentive to
questions and responds promptly and accurately to commands.
If he/she is sleeping, he/she responds readily to verbal or physical stimuli
and demonstrates wakefulness and alertness.
• The client is aware of who he/she is orientation to person, place
and time
Abnormal findings
• Client has lowered LOC and shows irritability, short attention
span, or dulled perceptions.
• He/she is uncooperative or unable to follow simple commands or
answer simple questions.
• At a lowered LOC, he/she may respond to physical stimuli only. The
lowest extreme is coma, when the eyes are closed and the client fails
to respond to verbal or physical stimuli, when no voluntary
movement.
• If LOC is between full awareness and coma, objectively note the
client’s eye movement: voluntary, withdrawal to stimuli or
withdrawal to noxious stimuli( pain) only.
3. Observe the client’s ability to think, remember, process information,
and communicate. These processes indicate cognitive functioning.)
Inspect articulation(action of producing a sound or word clearly in
speech) on speech, style and contents of speaking.
Normal findings

• The client is able to follow commands and repeat and

remember information.

• smooth/ appropriate native language

Abnormal findings
• Dysphasia (partial or complete impairment of ability to
communication)
• Dysarthria`(muscle problem and it make difficult to pronounce)
• Memory loss
• Disorientation
• Hallucinations
• not clear/ not smooth/ inappropriate contents
4. Observe the client’s ability to see, hear, smell and distinguish tactile
sensations.
Normal findings
• The client can hear even though the speaker turns away.

• He/she can identify objects or reads a clock in the room and

distinguish between sharp and soft objects.
Abnormal findings

• The client can not hear low tones and must look directly at the
speaker.

• He/she cannot read a clock or distinguish sharp from soft

5. Observe signs of distress (Alert the examiner to immediate concerns. If you
note distress, the client may require healthcare interventions before you
continue the exam. )
Abnormal findings
The client shows labored breathing, wheezing, coughing, wincing, sweating,
guarding of body part (suggests pain), anxious facial expression, of
fidgety(nervous or bored) movements
6. Observe facial expression and mood (These could be effected by
disease or ill condition)

Normal findings
• Eyes are alert and in contact with you.
• The client is relaxed, smiles or frowns appropriately and has a
calm demeanour. (behaviour)
Abnormal findings

• Eyes are closed or averted.

• The client is frowning or

grimacing.(annoyed/disgusted)

• He/she is unable to answer questions

7. Observe general appearance: posture, gait, and movement(To
identify obvious changes).
Normal findings
• Posture is upright
• Gait is smooth and equal for the client’s age and development.
Limb movements are bilateral.
Abnormal findings

• Posture is stopped or twisted.

• Limbs movements are uneven or unilateral

8. Observe grooming, personal hygiene, and dress (Personal appearance can
indicate self-comfort. Grooming suggests his/her ability to perform self-care.)
Normal findings
• Clothing reflects gender, age, and climate.
• Hair, skin, and clothing are clean, well-groomed, and appropriate for the
occasion.
Abnormal findings

• He/she wears unusual clothing for gender,

age, or climate.
• Hair is poor groomed, lack of cleanliness
• Excessive oil is on the skin.
• Body odour is present
 Measurement
Height
• Ask the client to remove shoes and stand
with his/her back and heels touching the
wall.
• Place a pencil flat on his/her head so that
it makes a mark on the wall.
• This shows his/her height measured with
cm tape from the floor to the mark on the
wall(or if available, measure the height
with measuring scale)

• >140(or 145)cm in female (normal

finding)
• <140(or 145) cm in female (abnormal
findings)
Weight
• Weigh him/her without shoes and much
clothing.

• Body Mass index (; BMI) is used to

assess the status of nutrition using
weight and height in the world. Formula
for BMI =weight(kg)/ height (m)2
Take vital signs
(Vital signs provide baseline data)
1. Temperature
36-37 ℃ (normal)
Abnormal
• hypothermia < 35 ℃
• pyrexia 38-40 ℃
• hyperpyrexia > 40.1 ℃
2. Pulse(rate/minute)
• Take the pulse rate and check the beats
Normal findings
• Rate/minute in adult 60-80 /min.
• Regular and steady
Abnormal findings
• Bradycardia – pulse rate fewer than 60 bpm.
• Tachycardia- pulse rate higher than 100 bpm
• Pulse deficit- difference between the apical
and peripheral pulse rates
3. Respiration
• Count the breaths without giving notice

Normal findings
• Breaths /minute 16-20/min.
• clear sound of breaths
• regular and steady
Abnormal findings
• bradypnea <10/min.
• tachypnea >20/min.
Blood pressure
• Take blood pressure under quiet and warm room.

• Hypotension: In normal adults < 95/60

• Hypertension
Normal SBP(mmHg)<120 and DBP(mmHg) <80
Pre-hypertension SBP(mmHg)120-139 80-89
Grade 1SBP(mmHg)140-159 and DBP(mmHg)
90-99
Grade 2SBP(mmHg)160-179 and DBP(mmHg)
100-109
Grade 3SBP(mmHg)>/= 180 and DBP(mmHg) /=
110
 B. Skin Assessment
Assess integumentary structures(skin, hair
nails) and function
Skin Inspection and palpation
1. Inspect the back and palms of the client’s
hands for skin colour. Compare the right and
left sides. Make a similar inspection of the feet
and toes, comparing the right and left sides.
(Extremities indicate peripheral cardiovascular
function)
Normal findings
The colour varying from black brown or
fair depending upon the genetic factors
• Colour variations on dark
• pigmented skin may be best seen in the
mucous membranes, nail beds, sclera, or
lips.
Abnormal findings

Loss of
Erythema Cyanosis Pallor
pigmentation

Jaundice
 2. Palpate the skin on the back and palms
of the client’s hands for:-
a. moisture
b. texture
Normal findings
• slight moist, no excessive moisture or
dryness
• firm, smooth, soft, elastic skin
Abnormal findings
• Excessive dryness indicates
hypothyroidism
• Oiliness in acne.
• Roughness in hypothyroidism
• Velvety(soft) texture in hyperthyroidism
• Flaking(easily breakable)
• perspiration (diaphoresis)
3. Palpate the skin’s temperature with the back
of your hand.

Normal findings
• Warmth

Abnormal findings
• Generalized warmth in fever local warmth
• Coolness in hypothyroidism
 4. Pinch and release the skin on the
back of the client’s hand. (This
palpation indicates the skin’s degree of
hydration and turgor.)
Normal findings
• Pinched skin that promptly or gently
returns to its previous state when
released signifies normal turgor.
Abnormal findings
• Pinched skin is very slow to return to
normal position.
 5. Press oedematous areas with
the edge of your fingers for
10 seconds, and observe for
the depression. Two types of
edema:
• Pitting –leave indentation
• Non pitting- does not leave
indentation
Normal findings
• Depression recovers quickly
• Depression
Abnormal findings
• recovers slowly or remains.
Oedema indicates fluid
retention, a sign of circulatory
disorders
6. Inspect the skin for lesions. Note the
appearance, size, location, presence and
appearance of drainage. (Locate abnormal
cell, growths, or trauma that suggests
abnormal physiologic processes.)
Normal findings
• Skin is intact, without reddened areas but with variations in
pigmentation and texture, depending on the area’s location
• And exposure to light and pressure. Freckles, moles, warts(small
lump) are normal.
Abnormal findings
• Erythema
• Echymosis
• Lesions includes rashes
• macules, papules, vesicles, wheals,
nodules, pustules, tumours, or ulcers.
• Wounds include incisions, abrasions,
lacerations, pressure ulcers
Nail
• Inspect and palpate the finger nails and toe
nails. Note colon, shape and any lesions.

• Check capillary refill by pressing the nail

edge to blanch and then release pressure
quickly, noting the return of colour.
• Normally colour return is instant(<3
seconds)
Normal findings
• Pink colour
• Longitudinal bands of pigment may be
seen in the nails of normal people.
• Nails should have no discoloration, ridges,
pitting, thickening, or separation from the
edge
Abnormal findings

clubbing Beau’s line

koilonichyia
Cyanosis
Hair and scalp
1. Inspect the hair for colour, texture,
growth, distribution

Normal findings
• Colour may vary from pale blonde to total
black.
• Texture varies fine to coarse and looks
straight to curly.
Abnormal findings
• Hair is excessively dry or oily
• Excessive hair loss (alopecia) or coarse
hair in hypothyroidism
• fine silky hair in hyperthyroidism
• pediculosis
• dandruff
2. Inspect the scaly, lumps, nevi, or other
lesions.
Normal findings
• All area should be clean and free of any
lesions, scaly, lumps, and nevi.
Abnormal findings
• redness and scaling in seborrhoea
dermatitis
• psoriasis
 C. Head Assessment
Assess central neurologic function,
vision, hearing, and mouth structures.
Skull

• Observe for the size, shape, and

symmetry.

• Palpate and note any deformities,

depressions, lumps, or tenderness
 Normal findings
• Head is symmetrical, round, and erect in
the midline

Abnormal findings
• Enlarged skull in hydrocephalus, Paget’s
diseases(enlarged & misshapen bones) of
bone.
• Redness after trauma
Face
• Inspect the client’s facial expression,
asymmetry, involuntary movements,
edema, and masses

Normal findings
• relaxed facial expression
• He/she doesn’t have involuntary
movement
Abnormal findings
• Moon face with red cheeks in Cushing’s
syndrome
• Oedematous face around the eyes (in the
morning ) and pale in nephritic syndrome
• Decreased facial mobility and blunt
expression in Parkinson’s disease
Eyes

1. Position and alimentation: Stand in

front of the client and inspect the both
eyes for position and alignment.

2. Eyebrows: Inspect the eyebrows ,

noting their quantity and distribution
and any scaliness
3. Eyelids: Inspect the position, presence
of edema, lesions, condition and direction
of the eyelashes, and adequacy with
eyelids doze.(sleep)

Normal findings
• No deviation and abnormal profusion
Abnormal findings
• Inward and outward deviation
• Scaliness in seborrheic dermatitis

ectropian Ptosis Entropian Chalazion and

stye
4. Lacrimal apparatus inspect the region
of the lacrimal gland and lacrimal sac for
swelling. Look for excessive tearing or
dryness of the eye

Normal findings
• No lumps and swelling around the eyes
Abnormal findings
• Lumps and swelling
• Excessive tearing may be due to
increased production, drainage of tear and
infection ( such as conjunctiva
inflammation and corneal irritation)
5. Conjunctiva and sclera
• Expose the sclera and conjunctiva
• Inspect the colour of palpebral conjunction, vascular
pattern against the white sclera background and any
nodules or swelling.
Normal findings
• Transparent white colour of sclera
• Dark pink colour of conjunctiva
• No paleness
• No nodules or swelling and redness
Abnormal findings

A yellow sclera indicates

jaundice

Paleness in palpebral conjunctiva

indicates the anaemia

Local redness due to Infection

Inspection conjunctiva and
sclera
6. Cornea and Lens
With oblique lighting inspect the
cornea of each eye for opacities
and note any opacities in the lens.

Normal findings
• Transparent, no abrasions and
white spots
Abnormal findings
• Opacities in the lens due to cataract.
• A superficial greyish veiled opacity in the cornea due
to old injury or to inflammation
7. Pupils
Assess each pupil’s direct and consensual reaction to light to
determine the function of the third (oculomotor) and fourth
(trochlear) cranial nerves.
• Partially darken the room.
• Ask the client to look straight ahead.
• Using a penlight and approaching from the side, shine a light
on the pupil.
• Observe the response of the illuminated pupil. It should
constrict (direct response).
• Shine the light on the pupil again, and observe the response of
the other pupil. It should also constrict (consensual response).
Normal findings
Assess each pupil’s reaction to accommodation.
• Hold an object (a penlight or pencil) about 10 cm (4 in.) from
the bridge of the client’s nose.
• Ask the client to look first at the top of the object and then at
a distant object (e.g., the far wall) behind the penlight.
Alternate the gaze from the near to the far object. Observe the
pupil response.
• Next, ask the client to look at the near object and then move
the penlight or pencil toward the client’s nose.
Normal Findings
• Pupils constrict when looking at near object; pupils dilate when
looking at far object.
• Pupils converge when near object is moved toward nose. To record
normal assessment of the pupils, use the abbreviation PERRLA (pupils
equally round and react to light and accommodation).
Abnormal findings
• One or both pupils fail to constrict, dilate, or converge
VISUAL FIELDS
Assess peripheral visual fields to determine function of the retina and neuronal
visual pathways to the brain and second (optic) cranial nerve.
• Have the client sit directly facing you at a distance of 60 to 90 cm (2 to 3 ft).
• Ask the client to cover the right eye with a card and look directly at your nose.
• Cover or close your eye directly opposite the client’s covered eye (i.e., your left
eye), and look directly at the client’s nose.
• Hold an object (e.g., a penlight or pencil) in your fingers, extend your arm, and
move the object into the visual field from various points in the periphery.
• The object should be at an equal distance from the client and yourself. Ask the
client to tell you when the moving object is first spotted.
a. To test the temporal field of the left eye, extend and move your right
arm in from the client’s right periphery.
b. To test the upward field of the left eye, extend and move the right
arm down from the upward periphery.
c. To test the downward field of the left eye, extend and move the right
arm up from the lower periphery.
d. To test the nasal field of the left eye, extend and move your left arm
in from the periphery.
• Repeat the above steps for the right eye, reversing the process.
Normal findings
When looking straight ahead, client can see objects in the periphery
Abnormal findings
Visual field smaller than normal (possible glaucoma); one-half vision in
one or both eyes (possible nerve damage)
Extraocular muscle test
• Assess six ocular movements to determine eye
alignment and coordination.
• Stand directly in front of the client and hold the
penlight at a comfortable distance, such as 30 cm (1
ft) in front of the client’s eyes.
• Ask the client to hold the head in a fixed position
facing you and to follow the movements of the
penlight with the eyes only
• Move the penlight in a slow, orderly manner through the six cardinal
fields of gaze, that is, from the center of the eye along the lines of the
arrows in and back to the center.
• Stop the movement of the penlight periodically so that nystagmus can
be detected
• Normal Findings
cover test
Have client fixate on a near or far object. Cover one eye and observe for
movement in the uncovered eye
Normal findings
Uncovered eye does not move
Abnormal findings
If misalignment is present, when dominant eye is covered, the
uncovered eye will move to focus on object
10. Convergence test
• Ask the patient to sit straight and fix the eye in one
point/ tip of the pen or pencil.
• Move the pen near to the nose from 20 cm far.
• Move near to the closer point and ask the patient
repeatedly for double vision.
• Fix the most closer point of patient’s double vision
and measure the point of double vision from the
bridge of the patient’s nose.
Normal findings
• Good convergence at 8-10 cm.
Visual acuity test
• Use Snellen chart (if available)/ Counting the finger
• Hold up the finger 30 cm / 1 foot from the patient’s face and ask the
patient to count the finger.

Normal Findings:
• Vision 20/20 (6/6) for Snellen chart.
• Can easily count the finger.
Ears
Inspect the auricles for color, symmetry of size,
and position. To inspect position, note the level
at which the superior aspect of the auricle
attaches to the head in relation to the eye. Draw
an imaginary line from outer canthus of eye to
the occipital protuberance.
Normal findings
Color same as facial skin
SymmetricalAuricle aligned with outer canthus of eye, about 10°, from vertical
Abnormal findings
Bluish color of earlobes (e.g., cyanosis); pallor (e.g., frostbite); excessive redness
(inflammation or fever)
Asymmetry
Low-set ears (associated with a congenital abnormality, such as Down syndrome)
Cont..
Palpate the auricles for texture, elasticity, and areas of tenderness.
• Gently pull the auricle upward, downward, and backward.
• Fold the pinna forward (it should recoil).
• Push in on the tragus.
• Apply pressure to the mastoid process
Normal findings
• No pain while moving the pinna , pushing the tragus,
and palpating mastoid process
Abnormal findings

• Pain with movement occurs with otitis externa

• Pain at the mastoid process may indicate
mastoiditis or lymphadenitis of the posterior
auricular node.
Gross hearing acuity test
• Assess client’s response to normal voice tones. If client has difficulty hearing the
normal voice, proceed with the following tests.
• Perform the whisper test to assess high-frequency hearing.
• Have the client occlude one ear.
• Out of the client’s sight, at a distance of 0.3 to 0.6 m (1 to 2 ft), whisper a simple
phrase such as
“The weather is hot today.”
• Ask the client to repeat the phrase.
• Repeat with the other ear using a different phrase
Normal findings
• Able to repeat the phrases correctly in both ears
Perform the tuning fork test
Weber’s test
Place the patient in sitting position.
Vibrate the tuning fork on elbow of examiner
Place the base of the vibrating fork on the top of the
patient’s head ( middle of the frontal bone)
Ask the patient to hear the sound
Normal Finding:
Sound is heard in both ears equally
Cont..
Rinne test
• Vibrate the tuning fork and place the base of the vibrating tuning fork
on the mastoid bone.
• Ask the patient to hear the sound.
• When the patient no longer hear the sound quickly place the tuning
fork close to the ear canal.
• Ask the patient whether the sound can be heard again.
Normal Finding:
Air conduction is more than bone conduction.
Nose
 Inspect the location, symmetry, nasal deviation,
deformity, size and flaring.
 Assess the nasal patency
Ask the patient to breath in pressing the each
nostril.
 Inspect inside the nose with torch.
Normal findings
• No pain
• Symmetry in size
• Nostril uniform in size
• No flare
• no obstruction in both Vestibule
Abnormal findings
• Tenderness of nasal tip or ala suggests local
infection
• Asymmetry in size
• Flaring nostrils
• Obstruction in right vestibule by polyp.
Assess smelling test
• Ask the patient to close eyes
• Make them smell the familiar convenient and
non-noxious smell( soap/ alcohol swab)
• Ask the patient to identify.
Palpate the sinus
Maxillary sinus - laterally slightly inferiorly
to the nasal cavity/ above the maxillary
bone.
Frontal sinus – located within the frontal
bone at the supraorbital ridge.
• Palpate the sinus using the thumb by
applying
gentle pressure.
• Ask the patient for pain.
Pressing over the frontal sinuses
Pressing over the maxillary sinuses
Normal findings
• No tenderness

Abnormal findings
• Local tenderness, together with symptoms
such as pain, fever and nasal discharge, suggest
acute sinusitis involving the frontal or
maxillary sinuses
Mouth and throat
Inspect lips for color, moisture, ulcers and cracking.
• Remove dentures if present
Inspect tongue for color, texture of dorsum, papillae
symmetry
Palpate gum.
• Wear the clean gloves
• Palpate the gums with four fingers of hands
Inspect oral mucosa and gum for color, presence of
ulcer, swelling, white patches and nodules.
Inspect the teeth for discoloration, dental carries and
missing teeth
Normal findings
• Pink, moist and intact skin
• No bluish, discoloration, cracks and ulcers.
Abnormal findings
• Lips bluish(: cyanosis) and pallor
• Cracks, ulcer
Abnormal findings

Koplik’s spot

Aphthous ulcer, Yellowish spots

Leukoplakia

Gingivitis
Abnormal findings
• Missing or looseness of teeth
• Dental caries
• Attrition of teeth
• Erosion of teeth
• Abrasion of teeth with notching
Inspect the base of the tongue, floor of the mouth and frenulum.
• Ask the patient to open the mouth and move the tongue
upward, side to side and roll the tongue.
• Ask to place the tip of the tongue against the roof of the mouth.
Assess the taste sensation
• Ask the patient to close the eye.
• Provide edible and familiar taste ( sugar/salt)
• Ask to identify the taste.
Normal findings
• Pink, moist and papillae
• Midline fissure presents and
• be symmetrical.
Abnormal findings
• Hairy tongue
• Fissured(deep crack) tongue
• Smooth tongue
• Whitening coating tongue
• Red or pale, dry papillae fissure absent
• Asymmetric protrusion suggests a lesion
(laceration or cut) of cranial nerve XII
Pharynx
Assess the soft palate anterior and posterior
pillars,
uvula, tonsils, and pharynx
• Ask the patient to open their mouth.
• Press the tongue with tongue spatula to make
the pharynx visible.
• Ask to say ‘ aaaaaaaaa’
• Assess the swallowing reflex
Normal findings

• Pink throat
• Pink and small tonsils
• No swelling, exudates, and ulceration
• No difficulty in swallowing
Abnormal findings
• Exudative tonsillitis(red and enlarged
tonsils)
• Throat with white exudates
• Redness and vascularity of the pillars and
uvula in
• Pharyngitis
• Throat is dull red and gray exudates is present
in uvula,pharynx and tongue, which cause
airway obstruction
• Difficulty in swallowing
• In CN X paralysis, the soft palate fails to rise
and the uvula deviates to the opposite site.
Neck
Inspect the neck muscles (sternocleidomastoid and trapezius) for
abnormal swellings or masses.
Ask the client to hold the head erect
Normal Findings
Muscles equal in size; head centered
Abnormal findings
Unilateral neck swelling; head tilted to one side (indicates presence
of masses, injury, muscle weakness, shortening of
sternocleidomastoid muscle, scars)
• Observe head movement. Ask client to:
• Move the chin to the chest to determine function of the
sternocleidomastoid muscle. Normally Head flexes 45°.
• Move the head back so that the chin points upward to determine
function of the trapezius muscle. Normally head hyperextends 60°.
• Move the head so that the ear is moved toward the shoulder on each
side to determine function of the sternocleidomastoid muscle.
Normally Head laterally flexes 40°.
• Turn the head to the right and to the left to determine function of the
sternocleidomastoid muscle. Normally Head laterally rotates 70°.
Abnormal findings
• Pain at any particular movement, limited movement due to cervical arthritis
or inflammation on of the neck muscles
• Rigid neck with arthritis
Assess muscle strength.
• Ask the client to turn the head to one side against the resistance of
your hand. Repeat with the other side.
• Ask the client to shrug the shoulders against the resistance of your
hands.
LYMPH NODES
• Palpate the entire neck for enlarged lymph nodes.
• Face the client, and bend the client’s head forward slightly or toward
the side being examined.
• Palpate the nodes using the pads of the fingers. Move the fingertips in
a gentle rotating motion.
• When examining the submental and submandibular nodes, place the
fingertips under the mandible on the side nearest the palpating hand,
and pull the skin and subcutaneous tissue laterally over the mandibular
surface so that the tissue rolls over the nodes.
• When palpating the supraclavicular nodes, have the client bend the head
forward to relax the tissues of the anterior neck and to relax the shoulders
so that the clavicles drop.
• Use your hand nearest the side to be examined when facing the client (i.e.,
your left hand for the client’s right nodes). Use your free hand to flex the
client’s head forward if necessary.
• Hook your index and third fingers over the clavicle lateral to the
sternocleidomastoid muscle.
• When palpating the anterior cervical nodes and posterior cervical nodes,
move your fingertips slowly in a forward circular motion against the
sternocleidomastoid and trapezius muscles, respectively.
• To palpate the deep cervical nodes, bend or hook your fingers around the
sternocleidomastoid muscle
Lymph Nodes of the Head and Neck
TRACHEA
• Palpate the trachea for lateral deviation.
• Place your fingertip or thumb on the trachea in the suprasternal notch
and then move your finger laterally to the left and the right in spaces
bordered by the clavicle, the anterior aspect of the sternocleidomastoid
muscle, and the trachea.
Normal findings
Central placement in midline of neck;spaces are equal on both sides
Cont..
Inspect the thyroid gland for symmetry and visible masses.
•Stand in front of the patient.
• Observe lower half of the neck.
• Ask the patient to extend the head and swallow.
Cont..
Palpate the thyroid gland
• Stand behind the patient.
• Place both hands around the patient’s neck with the finger tip on lower
half of the neck over the trachea.
• Push the trachea to the right side with the finger of the left hand and
feel the thyroid gland with the finger of the right hand to palpate right
side of the thyroid.
• Repeat the procedure vice versa for the left side of thyroid
Posterior approach to Thyroid gland
 Chest and Lung
Examine the anterior chest completely (inspection, palpation,
percussion and auscultation) and then posterior chest.
Inspect the chest for shape, size and expansion , symmetry ,
intercostal space of the chest, scars, vertebral column and location
of sternum.
• Ask the patient to sit on the side of the bed/ supine position with
arms abducted.
• Remove the patient’s clothes.
• Ask the patient to take deep breath.
Cont..
Measure the chest diameters.
• Landmark
• For the lateral diameter, right mid axillary line to left midaxillary line.
• For anterior-posterior diameter from posterior axillary line to anterior
axillary line.
Normal findings
• Lateral diameter is greater than the anterior posterior diameter. (Ratio:
1:2)
 Cont..
Normal findings:
•In healthy adults, the thorax is oval. Its anteroposterior diameter is half its
transverse diameter.
The overall shape of the thorax is elliptical; that is, its transverse diameter
is smaller at the top than at the base.
In older adults, kyphosis and osteoporosis alter the size of the chest cavity
as the ribs move downward and forward
Abnormal findings
• Pigeon chest (pectus carinatum) - A narrow transverse diameter, an
increased anteroposterior diameter, and a protruding sternum
characterize pigeon chest.
• A funnel chest (pectus excavatum) - a congenital defect, is the
opposite of pigeon chest in that the sternum is depressed, narrowing
the anteroposterior diameter.
• A barrel chest, in which the ratio of the anteroposterior to transverse
diameter is 1 to 1.
• Scoliosis is a lateral deviation of the spine.
• Palpate the posterior thorax for respiratory excursion (thoracic expansion).
• Place the palms of both your hands over the lower thorax with your
thumbs adjacent to the spine and your fingers stretched laterally.
• Ask the client to take a deep breath while you observe the movement of
your hands and any lag in movement
Normal findings
Full and symmetric thorax expansion (i.e., when the client takes a deep
breath, your thumbs should move apart an equal distance and at the same
time; normally the thumbs separate 3 to 5 cm [1.2 to 2 in.] during deep
inspiration)
Cont..
• Palpate the thorax for vocal (tactile) fremitus, the faintly perceptible
vibration felt through the chest wall when the client Speaks.
• Place the palmar surfaces of your fingertips or the ulnar aspect of your
hand or closed fist on the posterior thorax, starting near the apex of the
lungs .
• Ask the client to repeat such words as “99” or “one, two, three.”
• Repeat the two steps, moving your hands sequentially to the base of
the lungs, through positions.
Cont..
• Percuss the thorax. Percussion of the thorax is performed to determine
whether underlying lung tissue is filled with air, liquid, or solid
material and to determine the positions and boundaries of certain
organs.
• Because percussion penetrates to a depth of 5 to 7 cm (2 to 3 in.), it
detects superficial rather than deep lesions.
• Ask the client to bend the head and fold the arms forward across the
chest to separate the scapula and exposes more lung tissue to
percussion.
• Percuss in the intercostal spaces at about 5-cm (2-in.) intervals in a
systematic sequence.
• Compare one side of the lung with the other.
• Percuss the lateral thorax every few inches, starting at the axilla and
working down to the eighth rib.
Normal findings
• Percussion notes resonate, except over scapula
• Lowest point of resonance is at the diaphragm (i.e., at the level of the 8th
to 10th rib posteriorly)
• Note: Percussion on a rib normally elicits dullness.
 Cont..

Normal findings

• Resonance is normal lung sound: except heart area because heart

normally produces dullness bound, liver produces dullness stomach
produces tympany, muscles and bone produces flat
 Cont..
Abnormal findings
• Dullness replaces resonance when fluid or solid tissue replaces air
containing lung or occupies the pleural space, e.g., pneumonia, pleural
effusion, atelectasis, or tumor.
• Hyperresonance is found in COPD and asthma
• Hyperresonant or tympanitic in Pneumothorax
Auscultation
Auscultate the thorax using the flat-disk diaphragm of the stethoscope
for transmitting the high-pitched breath sounds.
Use the systematic zigzag procedure used in percussion.
• Ask the client to take slow, deep breaths through the mouth. Listen at
each point to the breath sounds during a complete inspiration and
expiration.
• Compare findings at each point with the corresponding point on the
opposite side of the thorax
Abnormal findings
 E.Heart/Precordium

Place the patient in supine with the head elevated 30°

Inspect the skin color of the trunk and neck vein for
Enlargement
Inspect the anterior chest for pulsation
• Assess the pulsation at the mid-clavicular line at the level of
fifth intercostal space.
 Cont..
Palpation/measurement
Palpate the apical pulse (4th -5th intercostal space in mid-
clavicular area).
Best palpated at left lateral position.
Assess the jugular venous pressure (JVP),only if distended.
• Locate the highest visible point of jugular vein.
• Locate the sternal angle, the point at which the clavicle meets.
• Measure the vertical height from the sternal angle to the visible
point of jugular vein.
Normal findings –
Less than 2.5 cm.
Abnormal findings
Bilateral measurements above 3 to 4 cm (1.2 to 1.6 in.) are
considered elevated (may indicate right-sided heart failure)
Unilateral distention (may be caused by local obstruction)
Cont…

Auscultation
• Second right intercostal space – aortic valve area
• Second left intercostal pace- pulmonic valve area
• Left lower sternal border- tricuspid valve area
• Fifth interspace at around left midclavicular line- mitral valve area
Cont..
• Inspect and palpate the precordium for the presence of abnormal pulsations, lifts, or
heaves.
• Locate the valve areas of the heart:
• Locate the angle of Louis . It is felt as a prominence on the sternum.
• Move your fingertips down each side of the angle until you can feel the second
intercostal spaces.
• The client’s right second intercostal space is the aortic area, and the left second
intercostal space is the pulmonic area.
• From the pulmonic area, move your fingertips down three left intercostal spaces
along the side of the sternum.
• The left fifth intercostal space close to the sternum is the tricuspid or right
ventricular area.
• From the tricuspid area, move your fingertips laterally 5 to 7 cm (2 to 3 in.) To the
left midclavicular line. This is the apical or mitral area.
• Auscultate the heart in all four anatomic sites: aortic, pulmonic, tricuspid,
and apical (mitral).
• Keep the client in a supine position with head elevated 15° to 45°.
• Use both the diaphragm and the bell to listen to all areas.
• Count a serial measurement (one after the other) of apical beat and radial
pulse.
• In every area of auscultation, distinguish both S1 and S2 sounds
Normal findings
• Rate ranges normally from 60 -100 beats/minute
• The rhythm should be regular, although sinus arrhythmia occurs normally
is young adult and children
Abnormal findings
• A pathologic S3 (ventricular gallop) occurs until heart failure
• A pathologic S4 (atrial gallop) occurs with coronary artery disease.
Listen for murmurs
If you hear a murmur, describe it by indicating these characteristics:
timing, loudness (Grade i- vi), pitch, pattern, quality, location.
radiation, and posture
• Palpate the carotid artery, using extreme caution. Palpate only one carotid
artery at a time to ensure adequate blood flow through the other artery to the
brain.
• Avoid exerting too much pressure or massaging the area which might enhance
bradycardia.
• Ask the client to turn the head slightly toward the side being examined to make
it more accessible.
• Auscultate the carotid artery on one side and then the other.
• Listen for the presence of a bruit. If you hear a bruit, gently palpate the artery to
determine the presence of a thrill.
• Presence of bruit in one or both arteries (suggests occlusive artery disease)
Peripheral pulse
• 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.
• Assess the peripheral leg veins for signs of phlebitis.
• Inspect the calves for redness and swelling over vein sites.
• Palpate the calves for firmness or tension of the muscles, the 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 (Homans’ test), or have the person stand or walk.
Normal findings
• Symmetric in size
• Limbs not tender
Abnormal findings
• Swelling of one calf or leg
• Tenderness on palpation
• Pain in calf muscles with forceful dorsiflexion of the foot (positive
Homans’ test)
• Warmth and redness over vein
 F. Breasts and Axillae

Inspect the breasts for size, symmetry, and contour or shape while the client is in a sitting
position.
Normal Findings
• Females: rounded shape; slightly unequal in size; generally symmetric
• Males: breasts even with the chest wall; if obese, may be similar in shape to female
breasts
Inspect the skin of the breast for
• localized discolorations or hyperpigmentation, retraction or dimpling, localized
hypervascular areas, swelling or edema.
Emphasize any retraction by having the client:
• Raise the arms above the head.
• Push the hands together, with elbows flexed.
• Press the hands down on the hips.
• Inspect the areola area for size, shape, symmetry, color, surface
characteristics, and any masses or lesions.
• Inspect the nipples for size, shape, position, color, discharge, and
lesions.
Palpate the breasts in circulation from center to outer to the axilla.
• Place the patient in supine position.
• Place small pillow under the patient’s shoulder.
• Ask to raise her arms over the head.
• Palpate the breast by using the pad of three fingers gentle rotatory motion.
• Start at one point for palpation and move symmetrically to the end point.
• Ensure that all the breast surface are assessed.
• Palpate the areola and nipples.
• Palpate the axillary lymph nodes.
Method for the palpation
• Vertical strip pattern
• Spoke of wheel
• Circular pattern
Abnormal findings
 G. Abdomen
Preparation
• Expose the abdomen to be visible fully
• The client should be emptied the bladder
(To prevent discomfort)
• Keep the room warm. The stethoscope
end piece , your hands must be warm (To
avoid chilling and tensing of muscles)
• Position the client supine, with the head
on a pillow, the knees bent or on pillow,
and arms at the sides or across the chest (
To enhance abdominal wall relaxation)
• Inquire about any painful areas and
examine such an area last (To avoid any
muscle guarding)
Nnine

Fig. The four abdominal

quadrants Fig. The nine abdominal regions
Inspect the abdomen for skin integrity
Normal findings
Unblemished skin, Uniform color
Silver-white striae (stretch marks) or surgical scars.
Inspect the abdomen for contour and symmetry:
• Observe the abdominal contour (profile line from the rib margin
to the pubic bone) while standing at the client’s side when the
client is supine.
• Ask the client to take a deep breath and to hold it as it makes an
enlarged liver or spleen more obvious.
• Assess the symmetry of contour while standing at the foot of
the bed.
• If distention is present, measure the abdominal girth by placing a tape
around the abdomen at the level of the umbilicus.
• If girth will be measured repeatedly, use a skin-marking pen to outline
the upper and lower margins of the tape placement for consistency of
future measurements.
• Observe abdominal movements associated with respiration, peristalsis,
or aortic pulsations.
• Observe the vascular pattern.
Normal findings
• Flat, rounded (convex), or scaphoid (concave)
• No evidence of enlargement of liver or spleen
• Symmetric contour
• Symmetric movements caused by respiration.
• Visible peristalsis in very lean people
• Aortic pulsations in thin people at epigastric area.
• No visible vascular pattern
Auscultate Bowel sounds and Vascular sounds
Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal
friction rubs.
Warm the hands and the stethoscope diaphragms.
For Bowel Sounds
Use the flat-disk diaphragm as Intestinal sounds are relatively high pitched and
best accentuated by the diaphragm. Light pressure with the stethoscope is
adequate.
Ask when the client last ate.
Shortly after or long after eating, bowel sounds may normally increase, loudest
when a meal is long overdue.
Four to 7 hours after a meal, bowel sounds may be heard continuously over the
ileocecal valve area (right lower quadrant)
• Place diaphragm of the stethoscope in each of the four quadrants of the
abdomen.
• Listen for active bowel sounds—irregular gurgling noises occurring about every
5 to 20 seconds.
The duration of a single sound may range from less than a second to more than
several seconds
For Vascular Sounds
• Use the bell of the stethoscope over the aorta, renal arteries, iliac arteries, and
femoral arteries.
• Listen for bruits.
Peritoneal Friction Rubs
• Peritoneal friction rubs are rough, grating sounds like two pieces of leather
rubbing together. Friction rubs may be caused by inflammation, infection, or
abnormal growths.
PERCUSSION OF THE ABDOMEN
• Percuss several areas in each of the four quadrants to determine presence of
tympany (sound indicating gas in stomach and intestines) and dullness (decrease,
absence, or flatness of resonance over solid masses or fluid).
• Use a systematic pattern: Begin in the lower right quadrant, proceed to the upper
right quadrant, the upper left quadrant, and the lower left quadrant.
 Normal findings
• Tympany should predominate because of gas in gastrointestinal tract
• Scattered (spread) area of dullness from fluid and faeces
• Normal dullness in the liver and spleen
Abnormal findings
Large dull areas (associated with presence of fluid or a tumor)
Perform palpation
• Perform light palpation first to detect areas of tenderness and/or
muscle guarding.
• Systematically explore all four quadrants.
• Ensure that the client’s position is appropriate for relaxation of
the abdominal muscles, and warm the hands as Cold hands can
elicit muscle tension and thus impede palpatory evaluation
 Light palpation
Hold the palm of your hand slightly above the client’s abdomen, with your
fingers parallel to the abdomen.
• Depress the abdominal wall lightly, about 1 cm or to the depth of the
subcutaneous tissue, with the pads of your fingers.
• Move the finger pads in a slight circular motion.
• Note areas of tenderness or superficial pain, masses, and muscle guarding. To
determine areas of tenderness, ask the client to tell you about them and
watch for changes in the client’s facial expressions.
• If the client is excessively ticklish, begin by pressing your hand on top of the
client’s hand while pressing lightly. Then slide your hand off the client’s and
onto the abdomen to continue the examination.
Normal findings
• No abdominal mass
• No tenderness
Abnormal findings
• Mass
• Tenderness
• Involuntary rigidity indicates acute peritoneal inflammation
 Deep palpation
Perform deep palpation

1) Perform deep palpation using the same technique described

earlier, but push down 5 to 8 cm(2 to 3 inches)
2) Moving clockwise, explore the entire abdomen
3) To over come the resistance of a very large or obese abdomen, use
a bimanual technique
① The top hand does the pushing
② The bottom hand is relaxed and can concentrate on the sense of
palpation
Normal findings
• Normally palpable structure: xiphoid process, normal liver edge,
right kidney, rectus muscles, sacral promontory, sigmoid colon,
uterus, full bladder.
• Mild tenderness is normally present when palpating the sigmoid colon

Abnormal findings
• Tenderness occurs with local inflammation, with inflammation of the
peritoneum or underlying organ, and with an enlarged organ whose capsule
is stretched.
Liver
1) Stand on the client’s right side
2) Place your left hand under the client’s back parallel to the 11th and
12th ribs
3) Lift up to support the abdominal contents
4) Place your right hand on the RUQ, with fingers parallel to the midline.
5) Push deeply down and under the right costal margin
6) Ask the client to take a deep breath
7) Feel for liver sliding over the fingers as the client inspires
8) Note any enlargement or tenderness.
Palpation the liver in the RUQ
Normal findings
• Liver is not usually palpable
• People may be palpable the edge of the liver bump immediately below
the costal margin as the diaphragm pushes it down during inhalation: a
smooth structure with a regular contour, firm and sharp edge
Abnormal findings
• Liver palpable as soft get around or irregular outline
• Except with a depressed diaphragm, a liver palpated more than 1 to 2
cm below the right costal margin is enlarged
• If enlarged, estimate the amount of enlargement beyond the right costal
margin. Express it in centimetres with its consistency and tenderness
Spleen: In supine position:
1) Reach your left hand over the abdomen and behind the left side at the
11th and 12th ribs
2) Lift up for support
3) Place your right hand obliquely on the LUQ with the fingers pointing
toward the left axilla and just inferior to the rib margin
4) Push your hand deeply down and under the left costal margin
5) Ask the client to take a deep breath
Normal findings
• Normally spleen is not palpable
• No enlargement and Tenderness
Abnormal findings
• The spleen must be enlarged three times its normal size to be felt
• The enlarged spleen is palpable about 2 cm below the left costal
margin on deep inspiration
In right lateral position:
1) Roll the client onto his/her right side to displace the spleen more
forward and downward.
2) Palpate as described earlier
Palpation the spleen in supine
position
Palpation the spleen in right lateral
position
Kidneys
Palpation in the right kidney:
1) Place the client in the supine position
2) Place your left hand on the client between lowest rib and the pelvic
bone
3) Place your right hand on the client’s side below the lowest rib or in the
RUQ. Your hands are placed together in a “duck-bill” position at the
client’s right flank.
4) Ask the client to take a deep breath
5) At the peak of inspiration, press your right hand and deeply into the RUQ,
just below the coastal margin
6) Try to capture the kidney between two hands
7) Note the enlargement or tenderness.
Normal findings
• Both kidneys are not usually palpable
• A normal right kidney may be palpable in well-relaxed women
Abnormal findings
• Enlarged kidney, tenderness, kidney mass
• Causes of kidney enlargement include hydronephrosis, cyst or tumors
• Bilateral enlargement suggests polycystic kidney disease
Right kidney palpation
Palpation in the left kidney:
1) Search for the left kidney by reaching your left hand across the abdomen
and behind the left flank for support.
2) push your right hand deep into the abdomen
3) Ask the client to take a deep breath
4) Feel the change while inspiring
Left kidney palpation
Inguinal area
1) Lift the drape or cloth to expose the inguinal area and legs
2) Inspect and palpate each groin for the femoral pulse and the inguinal
nodes
Normal findings
• Normally no palpable nodules
Abnormal findings
• Palpable nodes swollen, tenderness
Bladder
1) The bladder normally cannot be examined unless it is distended above
the symphysis pubis on palpation.
2) Check for tenderness
3) Use percussion to check for dullness and to determine how high the
bladder rises above the symphysis pubis
Normal findings
• Normally not palpable and tenderness
• The dome of distended bladder feels smooth and round
Abnormal findings
• Bladder distension from outlet obstruction
• Supra pubic tenderness in bladder infection
 Musculoskeletal system
Inspection the muscle and joints
1)Ask the client to stand
2) Inspect his/her neck , shoulder, arms, hands, hips, knees, legs, ankle and feet.
3) Compare one side with other side
4) Inspect the muscles and tendons for contractures (shortening).
5) Inspect the muscles for tremors, for example by having the client hold the
arms
out in front of the body.
4) Note the size and contour of the joint, skin and tissues over
the joints for colour, swelling, and any masses or deformities

Normal findings
• No bone or joint deformities
• No redness or swelling of joints
• No muscle wasting
Abnormal findings
• Presence of bone deformities or joint deformities
• Redness or swelling is significant and signals joint irritation
• Muscle wasting
• Swelling may be due to excess joint fluid, thickening of the synovial
lining, inflammation of surrounding soft tissue or bony enlargement
• Deformities include dislocation, contracture.
Test muscle strength compare right side with left side
Range of motion(; ROM)
Sternocleidomastoid: Client turns the head to one side against the
resistance of your hand. Repeat with the other side.
Trapezius: Client shrugs the shoulders against the resistance of your
hands.
Deltoid: Client holds arm up and resists while you try to push it down.
Biceps: Client fully extends each arm and tries to flex it while you
attempt to hold arm in extension.
Triceps: Client flexes each arm and then tries to extend it against your
attempt
to keep arm in flexion.
Wrist and finger muscles: Client spreads the fingers and resists as you
attempt
to push the fingers together.
Grip strength: Client grasps your index and middle fingers while you try
to pull the fingers out.
Hip muscles: Client is supine, both legs extended; client raises one leg at
a time while you attempt to hold it down.
Hip abduction: Client is supine, both legs extended. Place your hands
on the lateral surface of each knee; client spreads the legs apart against
your resistance.
Hip adduction: Client is in same position as for hip abduction. Place
your hands between the knees; client brings the legs together against
your resistance.
Hamstrings: Client is supine, both knees bent. Client resists while you
attempt to straighten the legs.
Quadriceps: Client is supine, knee partially extended; client resists
while you attempt to flex the knee.
Muscles of the ankles and feet: Client resists while you attempt to
dorsiflex the foot and again resists while you attempt to flex the foot.
Normal findings
Equal strength on each body side
Abnormal findings
0: 0% of normal strength; complete paralysis
1: 10% of normal strength; no movement, contraction of muscle is
palpable or visible
2: 25% of normal strength; full muscle movement against gravity, with
support
3: 50% of normal strength; normal movement against gravity
4: 75% of normal strength; normal full movement against gravity and
against minimal resistance
5: 100% of normal strength; normal full movement against gravity and
against full resistance
Bones and joints
Palpation
1) Palpate each joint, including its skin for tenderness, its muscles, bony
articulations, and area of joint capsule
2) Note any heat, tenderness, swelling or masses.
3) If any tenderness occur, try to localize it to specific anatomic
structure(skin, muscle, ligaments, tendons, fat pads or joint capsule)
4) Holding the each joint one by one, ask the client to move these
areas. note the range of motion and for any rough sensation at the
joint
Normal findings
• No swelling, tenderness or redness in joint Normal temperature
• The synovial membrane normally is not palpable
• A small amount of fluids is present in the normal joint, but not
palpable
• Full range of joint movement, smooth joint movement
Abnormal findings
• Redness, swelling or tenderness Limited joint movement
• Hard muscle with muscle spasm
• Increased, temperature over the joint
• Palpable fluid, limited joint movement
• Rough sensation(crepitation) in moving a joint
Peripheral vascular examination
Inspection and palpation
• 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 pulse volume.
• 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.
Normal findings
• In dependent position, presence of distention and nodular bulges at
calves
• When limbs elevated, veins collapse (veins may appear tortuous or
distended in older people)
A pulse may be measured in nine sites:
• Temporal, where the temporal artery passes over the temporal bone of
the head. The site is superior (above) and lateral to (away from the
midline of) the eye.
• Carotid, at the side of the neck where the carotid artery runs between
the trachea and the sternocleidomastoid muscle.
• Apical, at the apex of the heart. In an adult, this is located on the left
side of the chest, about 8 cm (3 in.) to the left of the sternum
(breastbone) at the fifth intercostal space (area between the ribs).
• Brachial, at the inner aspect of the biceps muscle of the arm or medially in
the antecubital space.
• Radial, where the radial artery runs along the radial bone, on the thumb side
of the inner aspect of the wrist.
• Femoral, where the femoral artery passes alongside the inguinal ligament.
• Popliteal, where the popliteal artery passes behind the knee.
• Posterior tibial, on the medial surface of the ankle where the posterior tibial
artery passes behind the medial malleolus.
• Dorsalis pedis, where the dorsalis pedis artery passes over the bones of the
foot, on an imaginary line drawn from the middle of the ankle to the space
between the big and second toes
• Assess the peripheral leg veins for signs of phlebitis.
• Inspect the calves for redness and swelling over vein sites.
• Palpate the calves for firmness or tension of the muscles, the 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 (Homans’ test), or have the person stand or walk.
Normal findings
• Symmetrical in size and shape
• No edema, no lesion
• No changes in skin colours, normal pulse rate
• Symmetrical in size and shape
• Warm and equal bilaterally
• Not palpable nodes and non tenderness
Abnormal findings
• Edema of upper extremities
• Increased or decreased pulse
• Pallor with vasoconstriction Cyanosis
• Varicose vein, A unilateral cool foot or leg occurs
• With arterial deficit, Enlarged nodes, tender or fixed
• A bruit occurs with turbulent blood flow indicating
partial occlusion
Palpation
1) Press the skin gently and firmly at the arms, hands over the
skin of the tibia, ankles and feet for 5 seconds, and then
release .
2) Note whether the finger leaves an impression on the skin
indication edema
3) Ask the client to stand so that you assess the venous system
4) Note any visible dilated and tortuous veins

Normal findings
• No impression left on the skin when pressed
• Pit edema commonly is seen if the person has been standing all
day or during pregnancy
Abnormal findings
• Bilateral pitting edema occurs with heart failure, diabetic neuropathy, or
hepatic cirrhosis
• Unilateral edema occurs with occlusion of a deep vein
• Uni- or bilateral énéma occurs with lymphatic obstruction
• Varicosities occur in the saphenous veins
Muscles strengthen
1) Push against the client’s hands, and then feet
2)Ask him/her to resist the push
Normal finding
• Equal strengthen is both hands and feet
• No muscular weakness
Abnormal findings
• Muscular weakness on one or both hands and feet
Nervous system
Inquire if the client has any history of the following:
presence of pain in the head, back, or extremities,
disorientation to time, place, or person;
speech disorder;
loss of consciousness, fainting, convulsions, trauma, tingling or numbness,
tremors or tics, limping, paralysis, uncontrolled muscle movements, loss of
memory, mood swings;
or problems with smell, vision, taste, touch, or hearing
Language
If the client displays difficulty speaking:
• Point to common objects, and ask the client to name them.
• Ask the client to read some words and to match the printed and written
words with pictures.
• Ask the client to respond to simple verbal and written commands (e.g.,
“point to your toes” or “raise your left arm”).
Orientation
Determine the client’s orientation to time, place, and person by tactful questioning. More
direct questioning may be necessary for some people (e.g., “Where are you now?” “What
day is it today?”)
Memory
three categories of memory are tested: immediate recall, recent memory, and remote
memory.
Immediate Recall
• Ask the client to repeat a series of three digits (e.g., 7–4–3), spoken slowly.
• Gradually increase the number of digits (e.g., 7–4–3–5, 7–4–3–5–6, and 7–4–3–5–6–7–
2) until the client fails to repeat the series correctly.
• Start again with a series of three digits, but this time ask the client to repeat them
backward.
The average person can repeat a series of five to eight digits in sequence and four to six
digits in reverse order.
Recent Memory
• Ask the client to recall the recent events of the day, such as what did he have
on breakfast.. This information must be validated, however.
• Ask the client to recall information given early in the interview (e.g., the
name of a doctor).
• Provide the client with three facts to recall (e.g., a color, an object, and an
address) or a three-digit number, and ask the client to repeat all three. Later in
the interview, ask the client to recall all three items.
Remote Memory
• Ask the client to describe a previous illness or surgery (e.g., 5 years ago) or a
birthday or anniversary.
Attention Span and Calculation
Test the ability to concentrate or maintain attention span by asking the
client to recite the alphabet or to count backward from 100.
Test the ability to calculate by asking the client to subtract.
 Cranial nerves
Cranial Name Type Function Assessment Method
Nerve
i Olfactory Sensory Smell Ask client to close eyes and identify
different mild aromas.
ii Optic Sensory Vision and visual fields Ask client to read Snellen-type chart; check
visual fields by confrontation; and conduct
an ophthalmoscopic examination
iii Oculomot Motor Extraocular eye movement (EOM); Assess six ocular movements and pupil reaction
or
iv Trochlear Motor EOM; specifically, moves eyeball Assess six ocular movements
downward and laterally
V Trigeminal Sensory Sensation of cornea, skin of face, While client looks upward, lightly touch the
Ophthalmi and nasal mucosa lateral sclera of the eye with sterile gauze to
c branch elicit blink reflex.
To test light sensation, have client close eyes,
wipe a wisp of cotton over client’s forehead and
paranasal sinuses.
To test deep sensation, use alternating blunt
and sharp ends of a safety pin over same areas.
VI Abducens Motor EOM; moves eyeball laterally Assess directions of gaze.
VII Facial Motor and sensory Facial expression; taste (anterior Ask client to smile, raise the eyebrows,
two thirds of tongue) frown, puff out cheeks, close eyes tightly.
Ask client to identify various tastes placed
on tip and sides of tongue: identify areas of
taste.
VIII Auditory
Vestibular Sensory Equilibrium Romberg test
branch
Cochlear Sensory Hearing Assess client’s ability to hear spoken word
branch and vibrations of tuning fork.

IX Glosso Motor and sensory Swallowing ability, tongue Apply tastes on posterior tongue for
pharyngeal movement, taste (posterior tongue) identification. Ask client to move tongue
from side to side and up and down.
X Vagus Motor and sensory Sensation of pharynx and larynx; Assessed with cranial nerve IX; assess
swallowing; vocal cord movement client’s speech for hoarseness

XI Accessory Motor Head movement; shrugging of Ask client to shrug shoulders against
shoulders resistance from your hands and turn head to
side against resistance from your hand
(repeat for other side).
XII Hypoglossal Motor Protrusion of tongue; moves tongue Ask client to protrude tongue at midline,
up and down and side to side then move it side to side
Deep tendon reflex (To elicit the intactness of the arc at specific spinal
level)
Biceps reflex(C5 to C6)
1) Support the client’s forearm on yours
2) Place your thumb on the biceps tendon and strike a blow on your
thumb
3)Observe the response
Normal findings
• Normal response is contraction of the biceps muscle and flexion of the
Forearm
Abnormal findings
• Hyperreflexia
• Hyporeflexia
Triceps reflex(C7 to C8)
1) Tell the client to let the arm “just go dead” as you suspend it by
holding the upper arm
2) Strike the triceps tendon directly just above the elbow
3)Observe the response
Normal response is extension of the forearm
Brachioradialis reflex(C5 to C6)
1) Hold the client’s thumb to suspend the forearms in relaxation
2) Strike the forearm directly, about 2 to 3 cm above the radial styloid
process
3)Observe the response
Normal findings
• Normal response is flexion and supination of the forearm
Quadriceps reflex(“Knee jerk”) (L2 to L4)
1) Let the lower legs dangle freely to flex the knee stretch the tendons
2) Strike the tendon directly just below the patella
3) Observe the response and palpate contraction of the quadriceps
Normal findings
• Normal response is extension of the lower leg
Achilles reflex(“Ankle jerk”) (L5 to S2)
1) Position the client with the knee flexed and hip externally rotated
2)Hold the foot in dorsi flexion
3) Strike the Achilles tendon directly
4) Feel the response
Normal findings
• Normal response is the foot planter flexes against your hand
Superficial reflex Planter reflex (L4 to S2)
1) Position the thigh in slight external rotation
2) With the reflex hammer, draw a light stroke up the lateral side
of the sole of the foot and inward across the ball of the foot
3)Observe the response
Normal findings
• Normal response is planter flexion of all the toes and inversion and
flexion of the forefoot

Abnormal findings
• Babinski sign: this occurs with upper motor neuron disease
Motor function
WALKING GAIT
• Ask the client to walk across the room and back, and assess the client’s
gait.
• Has upright posture and steady gait with opposing arm swing; walks
unaided, maintaining balance.
ROMBERG TEST
• Ask the client to stand with feet together and arms resting at the sides,
first with eyes open, then closed. Stand close during this test.
• Negative Romberg: may sway slightly but is able to maintain upright
posture and foot stance
STANDING ON ONE FOOT WITH EYES CLOSED
• Ask the client to close the eyes and stand on one foot. Repeat on the
other foot. Stand close to the client during this test.
• Maintains stance for at least 5 seconds.
HEEL-TOE WALKING
Ask the client to walk a straight line, placing the heel of one foot
directly in front of the toes of the other foot.
Maintains heel-toe walking along a straight line
TOE OR HEEL WALKING
• Ask the client to walk several steps on the toes and then on the heels.
• Able to walk several steps on toes or heels Cannot maintain balance
on toes and heels.
FINGER-TO-NOSE TEST
• Ask the client to abduct and extend the arms at shoulder height and
then rapidly touch the nose alternately with one index finger and then
the other.
• Repeatedly and rhythmically touches the nose
ALTERNATING SUPINATION AND PRONATION OF HANDS ON KNEES
• Ask the client to pat both knees with the palms of both hands and
then with the backs of the hands alternately at an ever-increasing
rate.
• Can alternately supinate and pronate hands at rapid pace.
FINGER-TO-NOSE AND TO THE NURSE’S FINGER
• Ask the client to touch the nose and then your index finger, held at a
distance of about 45 cm (18 in.), at a rapid and increasing rate.
HEEL DOWN OPPOSITE SHIN
• Ask the client to place the heel of one foot just below the opposite knee
and run the heel down the shin to the foot. Repeat with the other foot.
• The client may also use a sitting position for this test.
• Demonstrates bilateral equal coordination.
Light-Touch Sensation
• Compare the light-touch sensation of symmetric areas of the body.
• Ask the client to close the eyes and to respond by saying “yes” or “now”
whenever the client feels the cotton wisp touching the skin.
 J. Anus
• Inspect the perineal area for any irritation, cracks, fissure or enlarged
vessels
Normal findings
• No irritation, fissure, cracks
• No enlarged blood vessels in Anus
Abnormal findings
• Presence of anal irritation, anal fissure, enlarged and blood vessels
 K.MaleGenitalia
Inspect and palpate the penis
1) Inspect the skin, and urethral meatus
2) If you note urethral discharge, collect a smear for microscopic
examination and a culture
3) Palpate the shaft of penis between your thumb and first two
fingers
Normal findings
• The skin normally looks wrinkled, hairless, and without
lesions. The dorsal vein may be apparent
• Foreskin easily retractable
• The urethral meatus is positioned just about centrally
• Normally the penis feels smooth, semifirm, and non-tender
Abnormal findings
• Inflammation
• Lesions
• Presence of sore or lump
• Phimosis: unable to retract the foreskin
• Edges that are red, everted, edematous, along with
purulent discharge, suggested urethritis
• Nodule tenderness on the penis
Inspect and palpate the scrotum
1) Inspect the scrotum
2) Palpate gently each scrotal half between your thumb and
first two fingers
Normal findings
• Asymmetry is normal, with the left scrotal half usually
lower than the right, No scrotal lesions
• The skin of scrotum is thin and loose
• No lump, no tenderness, Testes are equal in size
 L. Female genitals
External genitalia Inspection
1)Note skin colour, hair distribution, labia majora, any
lesions, clitoris, labia minora, urethral opening, vaginal
opening, perineum, and anus.
Normal findings
• Labia are of the same colour and size
• No redness or swelling in labia
• Urethral opening appears stellate and in midline
• Vaginal opening may appear as a vertical slit
• Perineumis smooth
• Anus has coarse skin increased pigmentation
Abnormal findings
• Excoriation, nodules, rash, or lesions
• Inflammation
• Polyp in urethral opening
• Foul-smelling, white, yellow, green discharge from
vagina
• Bleeding
2) Look for any discharge or bleeding, prolapse, from
the vagina

Abnormal findings
• No usual discharge from the vagina
• No prolapse
• No bleeding from the vagina except during
mensturation