Physical Assessment Handouts

Nursing Skills
Physical Assessment
Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 1

 Is the use of hand to touch for the purpose of
determining temperature, moisture, size, shape,
position, texture, consistency, and movement.

TYPES OF PALPATION
Light Palpation
 To check muscle tone and assess for tenderness
Techniques:
Place the hand with fingers together parallel
to the area being palpated. Press down 1 to 2 cm.
Repeat in ever-widening circles until the area to be
NURSING SKILLS examined is covered.
Physical Assessment

Lecturer: Mark Fredderick R. Abejo R.N, M.A.N

PHYSICAL ASSESSMENT

Objectives: Deep Palpation
 Obtain physical data about the client’s functional  To identify abdominal organs and abdominal masses.
abilities Techniques:
 Supplement, confirm, or refuse data obtained in the With fingers together, approach the area to
nursing history be examined at a 60 degree angle and use the pads and
 Obtain data that will help the nurse data establish tips of the fingers of one hand to press in 4 cm.
nursing diagnoses and plan the client’s care.
 Evaluate the physiologic outcomes of health care and Two – handed Deep Palpation place the fingers of one
thus the progress of a patient’s health problem hand on top of those of the other.
 Screen presence of cancer

CEPHALOCAUDAL ORDER OF EXAMINATION
AREAS

 HEENT
 NECK
 UPPER EXTREMITIES
 CHEST AND BACK
 BREAST AND AXILLAE
 ABDOMEN
 GENITALS PERCUSSION
 ANUS AND RECTUM  Striking of the body surface with short, sharp strokes
 LOWER EXTREMITIES in order to produce palpable vibrations and
Note: SKIN IS CHECK THROUGHTOUT THE characteristic sound.
ASSESSMENT  It is used to determine the location, size, shape, and
density of underlying structures; to detect the presence
General Concepts: of air or fluid in a body space; and to elicit tenderness.

Approach the client calmly and confidently. TYPES OF PERCUSSION
Provide privacy. Direct Percussion
Make sure that all needed instruments are available  Percussion in which one hand is used and the striking
before starting the physical assessment finger (plexor) of the examiner touches the surface
Several positions are frequently required during the being percussed.
assessment. Consider the client’s ability to assume a Techniques:
position. Using sharp rapid movements from the wrist, strike
Be systematic and organized when assessing the the body surface to be percussed with the pads of two,
client. (Inspection, Palpation, Percussion, Auscultation three, or four fingers or with the pad of the middle
If a client is seriously ill, assess the systems of the finger alone. Primarily used to assess sinuses in the
body that are more at risk adult.
Perform painful procedures at the end of the
Indirect Percussion
examination
 Percussion in which two hands are used and the plexor
strikes the finger of the examiner’s other hand, which
METHODS OF EXAMINING
is in contact with the body surface being percussed
(pleximeter).
 INSPECTION
Techniques:
 PALPATION
Strike at a right angle to the pleximeter using quick,
 PERCUSSION
sharp but relaxed wrist motion.
 AUSCULTATION
Withdraw the plexor immediately after the strike to
avoid damping the vibration. Strike each are twice and
INSPECTION
then move to a new area
 Visual examination of the patient done in a methodical
and deliberate manner.
Blunt
 Ulnar surface of the hand or fist is used in place of the
PALPATION
fingers to strike the body surface, either directly or
indirectly.
Foundations of Nursing Abejo
Physical Assessment

Nursing Skills
Physical Assessment

PERCUSSION SOUNDS Procedure:
1. Inspects skin surfaces
RESONANCE – Hollow sound. Ex. normal lung.
1. 2. Palpates with fingertips for edema and skin turgor
HYPERRESONANCE – Booming sound. Ex.
2. 3. Palpates skin temperature contra-laterally using back
Emphysematous lung of hands
3. TYMPANY – musical or drum sound. Ex. Stomach
and intestines Assessment:
4. DULLNESS – Thud sound. Ex. Enlarged spleen, full
bladder, liver. Health History
5. FLATNESS – extremely dull sound. Ex. Muscle or  Presenting problem
bone  Changes in the color and texture of the skin, hair
AUSCULTATION and nails.
 Listening to sounds produced inside the body  Pruritus
 Infections
 Tumors and other lesions
EQUIPMENTS FOR PHYSICAL  Dermatitis
EXAMINATION  Ecchymoses
 Dryness
 Sphygmomanometer and stethoscope  Lifestyle practices
 Thermometer  Hygienic practices
 Nasal Speculum  Skin exposure
 Ophthalmoscope  Nutrition / diet
 Otoscope  Intake of vitamins and essential nutrients
 Vaginal Speculum  Water and Food allergies
 Tongue depressor/blade  Use of medications
 Penlight  Steroids
 Cotton Applicators  Antibiotics
 Tuning fork  Vitamins
 Reflex hammer  Hormones
 Clean gloves  Chemotherapeutic drugs
 Lubricant  Past medical history
 Renal and hepatic disease
 Collagen and other connective tissue diseases
GENERAL SURVEY  Trauma or previous surgery
 Food, drug or contact allergies
VITAL SIGNS  Family medical history
GENERAL SURVEY  Diabetes mellitus
 Allergic disorders
1. Physical Appearance  Blood dyscrasias
2. Level of Conciousness/ awareness  Specific dermatologic problems
 Alertness– Patient is awake and aware of self  Cancer
and environment.
 Lethargy – When spoken to in a loud voice, Physical Examination
patient appears drowsy but opens eye, and look  Color
at you, responds to questions, then falls asleep.  Areas of uniform color
 Obtundation – When shaken gently, patient  Pigmentation
opens eye and looks at you but responds  Redness
slowly and is somewhat confused.  Jaundice
 Stupor – Patient arouses from sleep only after  Cyanosis
painful stimuli.  Vascular changes
 Coma – Despite repeated painful stimuli,  Purpuric lesions
patient remains unarousable with eyes closed.  Ecchymoses
 Petechiae
3. Apperance in relation to chronological age  Vascular lesions
4. Signs of distress  Angiomas
5. Nutritional status  Hemangiomas
6. Body structure  Venous stars
7. Obvious physical deformities  Lesions
8. Mobility  Color
9. Behavior  Type
10. Odors of body and breath  Size
11. Facial Expression  Distribution
12. Mood & affect  Location
13. Speech  Consistency
 Grouping
 Annular
SYSTEMS ASSESSMENT  Linear
 Circular
INTEGUMENTARY SYSTEM  Clustered

Functions of the Skin:  Edema (pitting or non-pitting)
 Protection  Moisture content
 Absorption  Temperature (increased or decreased;
 Regulation distribution of temperature changes)
 Synthesis  Texture
 Sensory  Mobility / Turgor

Physical Assessment

Nursing Skills
Physical Assessment

Hypertrophic scar on the other hand does not
Effects of Aging in the Skin overgrow the wound boundaries.
 Skin vascularity and the number of sweat and Fibrosis or sclerosis describes dermal
sebaceous glands decrease, affecting scarring/thickening reactions.
thermoregulation. Milium is a small superficial cyst containing keratin
 Inflammatory response and pain perception diminish. (usually <1-2 mm in size
 Thinning epidermis and prolonged wound healing
make elderly more prone to injury and skin infections. Vascular Skin Lesions
 Skin cancer more common.
Petechiae is a round or purple macule, associated with
Primary Lesions of the Skin bleeding tendencies or emboli to skin
Ecchymosis a round or irregular macular lesion larger
Macule is a small spot that is not palpable and is less than petechiae, color varies and changes from black,
than 1 cm in diameter yellow and green hues. Associated with trauma and
Patch is a large spot that is not palpable & that is > 1 bleeding tendencies.
cm. Cherry Angioma, popular and round, red or purple,
Papule is a small superficial bump that is elevated & may blanch with pressure and a normal age-related
that is < 1 cm. skin alteration.
Plaque is a large superficial bump that is elevated & > Spider Angioma is a red, arteriole lesion, central
1 cm. body with radiating branches. Commonly seen on
Nodule is a small bump with a significant deep face,neck,arms and trunk. Associated with liver
component & is < 1 cm. disease, pregnancy and vitB deficiency.
Tumor is a large bump with a significant deep Telangiectasia , shaped varies: spider-like or linear,
component & is > 1 cm. bluish in color or sometimes red. Does not blanch
Cyst is a sac containing fluid or semisolid material, ie. when pressure applied. Secondary to superficial
cell or cell products. dilation of venous vessels and capillaries.
Vesicle is a small fluid-filled bubble that is usually
superficial & that is < 0.5 cm.
Bulla is a large fluid-filled bubble that is superficial or Edema - the presence of large amounts of fluid in the interstitial
deep & that is > 0.5 cm. spaces. Usually due to fluid collecting in the subcutaneous
Pustule is pus containing bubble often categorized tissue. Edema may be localized or generalized.
according to whether or not they are related to hair
follicles:
 follicular - generally indicative of local A. Some causes are lymphatic obstruction,
infection increased vascular permeability, decreased
 folliculitis - superficial, generally multiple oncotic pressure due to low levels of plasma
 furuncle - deeper form of folliculitis proteins (especially albumin), or renal or
 carbuncle - deeper, multiple follicles cardiac disease.
coalescing B. Collections of edema are named according
to the site:
Secondary lesions of the Skin 1. Anasarca - massive generalized
edema
Scale is the accumulation or excess shedding of the 2. Ankle
stratum corneum. 3. Ascites - peritoneal cavity
 Scale is very important in the differential 4. Hydrothorax - thoracic cavity
diagnosis since its presence indicates that the 5. Periorbital - around the eyes
epidermis is involved. 6. Sacral - lower back
 Scale is typically present where there is C. Edema occurs in dependent areas first.
epidermal inflammation, ie. psoriasis, tinea, D. Edema is graded on a scale considering the
eczema depth of the indentation and the length of
Crust is dried exudate (ie. blood, serum, pus) on the time to return to normal. Assessment: Press
skin surface. firmly with finger for 5 seconds.
Excoriation is a loss of skin due to scratching or
picking. Rating Assessment
Lichenification is an increase in skin lines & creases 1+ 5mm depth, recovers immediately
from chronic rubbing. 2+ 8-10 mm, duration 10-15 sec.
Maceration is raw, wet tissue. 3+ 11-20 mm, duration 15-30 sec.
Fissure is a linear crack in the skin; often very 4+ >20 mm, duration >30 sec.
painful.
Erosion is a superficial open wound with loss of
epidermis or mucosa only HEAD
Ulcer is a deep open wound with partial or complete
loss of the dermis or submucosa Procedure:

Distinct Lesions of the Skin 1. Observe the size, shape and contour of the skull.
2. Observe scalp in several areas by separating the hair at
Wheal or hive describes a short lived (< 24 hours), various locations; inquire about any injuries. Note
edematous, well circumscribed papule or plaque seen presence of lice, nits, dandruff or lesions.
in urticaria. 3. Palpate the head by running the pads of the fingers
Burrow is a small threadlike curvilinear papule that is over the entire surface of skull; inquire about
virtually pathognomonic of scabies. tenderness upon doing so. (wear gloves if necessary)
Comedone is a small, pinpoint lesion, typically 4. Observe and feel the hair condition.
referred to as “whiteheads” or “blackheads.” 5. Test Cranial Nerve VII
Atrophy is a thinning of the epidermal and/or dermal 6. Test Cranial Nerve V
tissue.
Keloid overgrows the original wound boundaries and
is chronic in nature.

Physical Assessment

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Physical Assessment

Normal Findings: 1. Sensory function (This nerve innervate the anterior 2/3 of
the tongue).
1. Skull · Place a sweet, sour, salty, or bitter substance near the tip of
· Generally round, with prominences in the frontal and the tongue.
occipital area. (Normocephalic). · Normally, the client can identify the taste.
· No tenderness noted upon palpation.
2. Scalp 2. Motor function
· Lighter in color than the complexion. · Ask the client to smile, frown, raise eye brow, close eye lids,
· Can be moist or oily. whistle, or puff the cheeks.
· No scars noted.
· Free from lice, nits and dandruff. Normal Findings:
· No lesions should be noted. · Shape maybe oval or rounded.
· No tenderness nor masses on palpation. · Face is symmetrical.
3. Hair · No involuntary muscle movements.
· Can be black, brown or burgundy depending on the · Can move facial muscles at will.
race. · Intact cranial nerve V and VII.
· Evenly distributed covers the whole scalp (No
evidences of Alopecia)
· Maybe thick or thin, coarse or smooth. EYE / EYEBROW / EYELASHES
· Neither brittle nor dry.
Normal findings:
FACE Eyebrows
· Symmetrical and in line with each other.
· Maybe black, brown or blond depending on race.
1. Observe the face for shape. · Evenly distributed.
2. Inspect for Symmetry.
Eyes
a. Inspect for the palpebral fissure (distance between the · Evenly placed and inline with each other.
eye lids); should be equal in both eyes. · Non protruding.
b. Ask the patient to smile, There should be bilateral · Equal palpebral fissure.
Nasolabial fold (creases extending from the angle of
the corner of the mouth). Slight asymmetry in the fold
is normal. Eyelashes
c. If both are met, then the Face is symmetrical · Color dependent on race.
· Evenly distributed.
· Turned outward
3. Test the functioning of Cranial Nerves that innervates the
facial structures
EYELIDS / LACRIMAL APPARATUS
CN V (Trigeminal)
1. Inspect the eyelids for position and symmetry.
2. Palpate the eyelids for the lacrimal glands.
To examine the lacrimal gland, the examiner, lightly
slide the pad of the index finger against the client’s
upper orbital rim.
Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
To assess the nasolacrimal duct, the examiner presses
with the index finger against the client’s lower inner
orbital rim, at the lacrimal sac, NOT AGAINST THE
NOSE.
1. Sensory Function In the presence of blockage, this will cause
· Ask the client to close the eyes. regurgitation of fluid in the puncta
· Run cotton wisp over the fore head, check and jaw on both
sides of the face.
Normal Findings:
· Ask the client if he/she feel it, and where she feels it.
· Check for corneal reflex using cotton wisp.
· The normal response in blinking. Eyelids
· Upper eyelids cover the small portion of the iris, cornea, and
sclera when eyes are open.
2. Motor function
· No PTOSIS noted. (drooping of upper eyelids).
· Ask the client to chew or clench the jaw.
· Meets completely when eyes are closed.
· The client should be able to clench or chew with strength and
· Symmetrical.
force.
Lacrimal Apparatus
CN VII (Facial) · Lacrimal gland is normally non palpable.
· No tenderness on palpation.
· No regurgitation from the nasolacrimal duct.

CONJUNCTIVAE

The bulbar and palpebral conjunctivae are examined
by separating the eyelids widely and having the client look up,
down and to each side. When separating the lids, the examiner
should exert no NO PRESSURE against the eyeball; rather, the
Physical Assessment

Nursing Skills
Physical Assessment

examiner should hold the lids against the ridges of the bony Normal findings:
orbit surrounding the eye.
· There should be no irregularities on the surface.
In examining the palpebral conjunctiva, everting the upper · Looks smooth.
eyelid in necessary and is done as follow: · The cornea is clear or transparent. The features of the iris
should be fully visible through the cornea.
1. Ask the client to look down but keep his eyes slightly open. · There is a positive corneal reflex.
This relaxes the levator muscles, whereas closing the eyes
contracts the orbicularis muscle, preventing lid eversion. ANTERIOR CHAMBER / IRIS
2. Gently grasp the upper eyelashes and pull gently downward.
Do not pull the lashes outward or upward; this, too, causes The anterior chamber and the iris are easily inspected
muscles contraction. in conjunction with the cornea. The technique of oblique
3. Place a cotton tip application about I can above the lid illumination is also useful in assessing the anterior chamber.
margin and push gently downward with the applicator while still
holding the lashes. This everts the lid.
4. Hold the lashes of the everted lid against the upper ridge of Normal Findings:
the bony orbit, just beneath the eyebrow, never pushing against
the eyebrow. · The anterior chamber is transparent.
5. Examine the lid for swelling, infection, and presence of · No noted any visible materials.
foreign objects. · Color of the iris depends on the person’s race (black, blue,
6. To return the lid to its normal position, move the lid slightly brown or green).
forward and ask the client to look up and to blink. The lid · From the side view, the iris should appear flat and should not
returns easily to its normal position. be bulging forward. There should be NO crescent shadow casted
on the other side when illuminated from one side.

PUPIL

Examination of the pupils involves several
inspections, including assessment of the size, shape reaction to
light is directed is observed for direct response of constriction.
Simultaneously, the other eye is observed for consensual
response of constriction.

The test for papillary accommodation is the
examination for the change in papillary size as the is switched
from a distant to a near object.

Normal Findings: 1. Ask the client to stare at the objects across room.
2. Then ask the client to fix his gaze on the examiner’s index
· Both conjunctivae are pinkish or red in color. fingers, which is placed 5 – 5 inches from the client’s nose.
· With presence of many minutes capillaries. 3. Visualization of distant objects normally causes papillary
· Moist dilation and visualization of nearer objects causes papillary
· No ulcers constriction and convergence of the eye.
· No foreign objects
Normal Findings:
SCLERAE
· Pupillary size ranges from 3 – 7 mm, and are equal in size.
The sclerae is easily inspected during the assessment of the · Equally round.
conjunctivae. · Constrict briskly/sluggishly when light is directed to the eye,
both directly and consensual.
· Pupils dilate when looking at distant objects, and constrict
when looking at nearer objects.

If all of which are met, we document the findings
using the notation PERRLA, pupils equally round, reactive to
light, and accommodate

Normal Findings:

· Sclerae is white in color (anicteric sclera)
· No yellowish discoloration (icteric sclera).
· Some capillaries maybe visible.
· Some people may have pigmented positions.

CORNEA

The cornea is best inspected by directing penlight obliquely
from several positions.
Physical Assessment

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Physical Assessment

The assessment of visual acuity is indicative of the
functioning of the macular area, the area of central vision.
However, it does not test the sensitivity of the other areas of the
retina which perceive the more peripheral stimuli. The Visual
field confrontation test, provide a rather gross measurement of
peripheral vision.

The performance of this test assumes that the
examiner has normal visual fields, since that client’s visual
fields are to be compared with the examiners.

Follow the steps on conducting the test:

1. The examiner and the client sit or stand opposite each
other, with the eyes at the same, horizontal level with the
distance of 1.5 – 2 feet apart.
2. The client covers the eye with opaque card, and the
examiner covers the eye that is opposite to the client covered
CRANIAL NERVE II ( OPTIC NERVE ) eye.
3. Instruct the client to stare directly at the examiner’s eye,
while the examiner stares at the client’s open eye. Neither looks
The optic nerve is assessed by testing for visual acuity
out at the object approaching from the periphery.
and peripheral vision.
4. The examiner hold an object such as pencil or penlight, in
his hand and gradually moves it in from the periphery of both
Visual acuity is tested using a snellen chart, for those directions horizontally and from above and below.
who are illiterate and unfamiliar with the western alphabet, the 5. Normally the client should see the same time the examiners
illiterate E chart, in which the letter E faces in different sees it. The normal visual field is 180 degress
directions, maybe used. The chart has a standardized number at
the end of each line of letters; these numbers indicates the
CRANIAL NERVE III, IV & VI
degree of visual acuity when measured at a distance of 20 feet.
( Oculomotor,Trochlear,Abducens )

The numerator 20 is the distance in feet between the
All the 3 Cranial nerves are tested at the same time by
chart and the client, or the standard testing distance. The
assessing the Extra Ocular Movement (EOM) or the six cardinal
denominator 20 is the distance from which the normal eye can
position of gaze.
read the lettering, which correspond to the number at the end of
each letter line; therefore the larger the denominator the poorer
the version.

Measurement of 20/20 vision is an indication of either
refractive error or some other optic disorder.

Follow the given steps:

1. Stand directly in front of the client and hold a finger or a
penlight about 1 ft from the client’s eyes.
In testing for visual acuity you may refer to the following: 2. Instruct the client to follow the direction the object hold by
the examiner by eye movements only; that is with out moving
1. The room used for this test should be well lighted. the neck.
2. A person who wears corrective lenses should be tested with 3. The nurse moves the object in a clockwise direction
and without them to check fro the adequacy of correction. hexagonally.
3. Only one eye should be tested at a time; the other eye 4. Instruct the client to fix his gaze momentarily on the
should be covered by an opaque card or eye cover, not with extreme position in each of the six cardinal gazes.
client’s finger. 5. The examiner should watch for any jerky movements of the
4. Make the client read the chart by pointing at a letter eye (nystagmus).
randomly at each line; maybe started from largest to smallest or 6. Normally the client can hold the position and there should
vice versa. be no nystagmus.
5. A person who can read the largest letter on the chart
(20/200) should be checked if they can perceive hand movement
about 12 inches from their eyes, or if they can perceive the light
of the penlight directed to their yes.

Peripheral Vision or visual fields

Physical Assessment

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Physical Assessment

This test is useful in determining whether the client
has a conductive hearing loss (problem of external or middle
ear) or a perceptive hearing loss (sensorineural). There are 2
types of tuning fork test being conducted:
Test for Accomodation
1. Weber’s test – assesses bone conduction, this is a test of
sound lateralization; vibrating tuning fork is placed on the
EAR middle of the fore head or top of the skull.

1. Inspect the auricles of the ears for parallelism, size position,
appearance and skin color.
2. Palpate the auricles and the mastoid process for firmness of
the cartilage of the auricles, tenderness when manipulating the
auricles and the mastoid process.
3. Inspect the auditory meatus or the ear canal for color,
presence of cerumen, discharges, and foreign bodies.

a. For adult pull the pinna upward and backward to straighten Normal: hear sounds equally in both ears (No Lateralization of
the canal. sound)
b. For children pull the pinna downward and backward to
straighten the canal Conduction loss – Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried
4. Perform otoscopic examination of the tympanic membrane, through the external and middle ear.
noting the color and landmarks.
Sensorineural loss – Sound lateralizes on better ear.
Normal Findings:
2. Rinne Test – Compares bone conduction with air condition.
· The ear lobes are bean shaped, parallel, and symmetrical.
· The upper connection of the ear lobe is parallel with the outer a. Vibrating tuning fork placed on the mastoid process
canthus of the eye. b. Instruction client to inform the examiner when he no longer
· Skin is same in color as in the complexion. hears the tuning fork sounding.
· No lesions noted on inspection. c. Position in the tuning fork in front of the client’s ear canal
· The auricles are has a firm cartilage on palpation. when he no longer hears it.
· The pinna recoils when folded.
· There is no pain or tenderness on the palpation of the auricles
and mastoid process.
· The ear canal has normally some cerumen of inspection.
· No discharges or lesions noted at the ear canal.
· On otoscopic examination the tympanic membrane appears
flat, translucent and pearly gray in color.

VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )

Examination of the cranial nerve VIII involves testing for
hearing acuity and balance.
Normal: Sound should be heard when tuning fork is placed in
front of the ear canal as air conduction< bone conduction by 2:1
Hearing Acuity (positive rinne test)

A. Voice test Conduction loss: Sound is heard longer by bone conduction than
by air conduction.
1. The examiner stands 2 ft. on the side of the ear to be tested.
2. Instruct the client to occlude the ear canal of the other ear. Sensorineural loss: Sound is heard longer by air conduction than
3. The examiner then covers the mouth, and using a soft by bone conduction
spoken voice, whispers non-sequential number (e.g. 3 5 7 ) for
the client to repeat.
4. Normally the client will be able to hear and repeat the NOSE AND PARANASAL SINUSES
number.
5. Repeat the procedure at the other ear. The external portion of the nose is inspected for the following:

B. Watcher test 1. Placement and symmetry.
2. Patency of nares (done by occluding nosetril one at a time,
1. Ask the client to close the eyes. and noting for difficulty in breathing)
2. Place a mechanical watch 1 – 2 inches away the client’s ear. 3. Flaring of alaenasi
3. Ask the client if he hears anything 4. Discharge
4. If the client says yes, the examiner should validate by
asking at what are you hearing and at what side. The external nares are palpated for:
5. Repeat the procedure on the other ear.
6. Normally the client can identify the sound and at what side 1. Displacement of bone and cartilage.
it was heard. 2. For tenderness and masses

Turning Fork Test
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Physical Assessment

The internal nares are inspected by heperextending the neck of 3. No flaring alae nasi.
the client, the ulnar aspect of the examiner’s hard over the fore 4. Both nares are patent.
head of the client, and using the thumb to push the tip of the 5. No bone and cartilage deviation noted on palpation.
nose upward while shining a light into the naris. 6. No tenderness noted on palpation.
7. Nasal septum in the mid line and not perforated.
8. The nasal mucosa is pinkish to red in color. (Increased
redness turbinates are typical of allergy).
9. No tenderness noted on palpation of the paranasal sinuses.

OLFACTORY NERVE

To test the adequacy of function of the olfactory nerve:

1. The client is asked to close his eyes and occlude.
2. The examiner places aromatic and easily distinguish
nose. (e.g. coffee).
3. Ask the client to identify the odor.
4. Each side is tested separately, ideally with two
different substances.
Inspect for the following:
MOUTH
1. Position of the septum.
2. Check septum for perforation. (can also be checked by Mouth and Oropharynx Lips are inspected for:
directing the lighted penlight on the side of the nose,
illumination at the other side suggests perforation).
1. Symmetry and surface abnormalities.
3. The nasal mucosa (turbinates) for swelling, exudates and
2. Color
change in color.
3. Edema

Normal Findings:
Paranasal Sinuses

1. With visible margin
2. Symmetrical in appearance and movement
3. Pinkish in color
4. No edema

Palpate the temporomandibular while the mouth is opened
wide and then closed for:

1. Crepitous
2. Deviations
3. Tenderness

Normal Findings:

Examination of the paranasal sinuses is indirectly. 1. Moves smoothly no crepitous.
Information about their condition is gained by inspection and 2. No deviations noted
palpation of the overlying tissues. Only frontal and maxillary 3. No pain or tenderness on palpation and jaw
sinuses are accessible for examination. movement.

By palpating both cheeks simultaneously, one can Gums are inspected for:
determine tenderness of the maxillary sinusitis, and pressing the
thumb just below the eyebrows, we can determine tenderness of 1. Color
the frontal sinuses. 2. Bleeding
3. Retraction of gums.

Normal Findings:

1. Pinkish in color
2. No gum bleeding
3. No receding gums

Teeth are inspected for:

1. Number
2. Color
3. Dental carries
4. Dental fillings
Normal Findings: 5. Alignment and malocclusions (2 teeth in the space for
1, or overlapping teeth).
1. Nose in the midline 6. Tooth loss
2. No Discharges. 7. Breath should also be assessed during the process.

Physical Assessment

Nursing Skills
Physical Assessment

Normal Findings: Normal Findings:

1. 28 for children and 32 for adults. 1. The trachea is palpable.
2. White to yellowish in color 2. It is positioned in the line and straight.
3. With or without dental carries and/or dental fillings.
4. With or without malocclusions.
5. No halitosis.

Tongue is palpated for:

Texture

Normal Findings:

1. Pinkish with white taste buds on the surface.
2. No lesions noted.
3. No varicosities on ventral surface.
4. Frenulum is thin attaches to the posterior 1/3 of the
ventral aspect of the tongue.
5. Gag reflex is present.
6. Able to move the tongue freely and with strength.
7. Surface of the tongue is rough.
mph nodes are palpated using palmar tips of the fingers via
systemic circular movements. Describe lymph nodes in termsof
Uvula is inspected for:
size, regularity, consistency, tenderness and fixation to
surrounding tissues.
1. Position
2. Color
3. Cranial Nerve X (Vagus nerve) – Tested by asking the
client to say “Ah” note that the uvula will move
upward and forward.

Normal Findings:

1. Positioned in the mid line.
2. Pinkish to red in color.
3. No swelling or lesion noted.
4. Moves upward and backwards when asked to say “ah”

Tonsils are inspected for:

1. Inflammation
2. Size

A Grading system used to describe the size of the tonsils can be
used.
Normal Findings:
Grade 1 – Tonsils behind the pillar.
Grade 2 – Between pillar and uvula. 1. May not be palpable. Maybe normally palpable in thin
Grade 3 – Touching the uvula clients.
2. Non tender if palpable.
Grade 4 – In the midline.
3. Firm with smooth rounded surface.
4. Slightly movable.
NECK 5. About less than 1 cm in size.
6. The thyroid is initially observed by standing in front
The neck is inspected for position symmetry and obvious lumps of the client and asking the client to swallow.
visibility of the thyroid gland and Jugular Venous Distension. Palpation of the thyroid can be done either by
posterior or anterior approach.
Normal Findings:
Indication of Lymph Nodes
1. The neck is straight.
2. No visible mass or lumps.  Occipital: Head infection
3. Symmetrical  Submental: Dental Carriections, Oral inf
4. No jugular venous distension (suggestive of cardiac  SubMandibular: Infection
congestion).  SCM Upper: Lymphoma
 Supraclavicular: Cancer
The neck is palpated just above the suprasternal note using the
thumb and the index finger. Posterior Approach:

The neck is palpated just above the suprasternal note using the 1. Let the client sit on a chair while the examiner stands
thumb and the index finger. behind him.
2. In examining the isthmus of the thyroid, locate the
cricoid cartilage and directly below that is the isthmus.
Physical Assessment

Nursing Skills
Physical Assessment

3. Ask the client to swallow while feeling for any then continues ant medially to end at the 6th rib at the
enlargement of the thyroid isthmus. midclavicular line.
4. To facilitate examination of each lobe, the client is
asked to turn his head slightly toward the side to be The right horizontally fissure extends from the 5th rib
examined to displace the sternocleidomastoid, while slightly posterior to the right midaxillary line and runs
the other hand of the examiner pushes the thyroid horizontally to thee area of the 4th rib at the right sternal border.
cartilage towards the side of the thyroid lobe to be
examined.
5. Ask the patient to swallow as the procedure is being The left oblique (diagonal) fissure extend from the
done. spinous process of the 3rd thoracic vertebra laterally and
6. The examiner may also palate for thyroid enlargement downward to the left mid axillary line at the 5th rib and
by placing the thumb deep to and behind the continues anteriorly and medially until it terminates at the 6th rib
sternocleidomastoid muscle, while the index and in the midclavicular line.
middle fingers are placed deep to and in front of the
muscle. Borders of the Diaphragm.
7. Then the procedure is repeated on the other side.
Anteriorly, on expiration, the right dome of the
diaphragm is located at the level of the 5th rib at the
midclavicular line and he left dome is at the level of the 6th rib.
Posteriorly, on expiration, the diaphragm is at the level of the
spinous process of T10; laterally it is at the 8th rib at the
midaxillary line. On inspiration the diaphragm moves
Anterior approach: approximately 1.5 cm downward.

1. The examiner stands in front of the client and with the Inspection of the Thorax
palmar surface of the middle and index fingers
palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation is being For adequate inspection of the thorax, the client should be sitting
done. upright without support and uncovered to the waist.
3. In palpating the lobes of the thyroid, similar procedure
is done as in posterior approach. The client is asked to The examiner should observe:
turn his head slightly to one side and then the other of
the lobe to be examined. 1. Shape of the thorax and its symmetry.
4. Again the examiner displaces the thyroid cartilage 2. Thoracic configuration.
towards the side of the lobe to be examined. 3. Retractions at the ICS on inspiration.
5. Again, the examiner palpates the area and hooks (suprasternal, costal, substernal)
thumb and fingers around the sternocleidomastoid 4. Bulging structures at the ICS during
muscle. expiration.
5. position of the spine.
Normal Findings: 6. pattern of respiration.

1. Normally the thyroid is non palpable. Normal Findings:
2. Isthmus maybe visible in a thin neck.
3. No nodules are palpable.
The shape of the thorax in a normal adult is elliptical;
the anteroposterior diameter is less than the transverse
Auscultation of the Thyroid is necessary when there is thyroid diameter at approximately a ratio of 1:2.
enlargement. The examiner may hear bruits, as a result of Moves symmetrically on breathing with no obvious
increased and turbulence in blood flow in an enlarged thyroid. masses.
No fail chest which is suggestive of rib fracture.
Check the Range of Movement of the neck. No chest retractions must be noted as this may suggest
difficulty in breathing.
No bulging at the ICS must be noted as this may
obstruction on expiration, abnormal masses, or
THORAX cardiomegaly.
The spine should be straight, with slightly curvature in
the thoracic area.
Lung borders
There should be no scoliosis, kyphosis, or lordosis.
Breathing maybe diaphragmatically of costally.
In the anterior thorax, the apices of the lungs extend
for approximately 3 – 4 cm above the clavicles. The inferior Expiration is usually longer the inspiration.
borders of the lungs cross the sixth rib at the midclavigular line.
Palpation of the Thorax
In the posterior thorax, the apices extend of T10 on
expiration to the spinous process of T12 on inspiration.

In the Lateral Thorax, the lungs extend from the apex
of the axilla to the 8th rib of the midaxillary line.

Lung Fissures

The right oblique (diagonal) fissure extend from the
area of the spinous process of the 3rd thoracic vertebra, laterally
and downward unit it crosses the 5th rib at the midaxillary line. It

Physical Assessment

Nursing Skills
Physical Assessment

1. General palpation – The examiner should specifically
palpate any areas of abnormality. The temperature and
turgor of the skin should be assessed. Palpate for
lumps, masses and areas of tenderness.
2. Palpate for thoracic expansion or lung excursion.

A. Anteriorly, the examiner’s hands are placed
over the anterolateral chest with the thumbs
extended along the costal margin, pointing
to the xyphoid process. Posteriorly, the
thumbs are placed at the level of the 10th rib
and the palms are placed on the
posterolateral chest.
B. Instruct the client to exhale first, then to
inhale deeply.
C. The examiner the amount of thoracic
expansion during quiet and deep inspiration Whispered Pectorioquy – Ask the client top whisper “1-2-3”
and observe for divergence of the thumbs on Over normal lung tissue it would almost be indistinguishable,
expiration. over consolidated lung it would be loud and clear
D. Normally, symmetry of respiration between
the left and right hemithoraces should be felt
as the thumbs are separated are separated
approximately 3 – 5 cm (1 – 2 inches)
during deep inspiration.

1. Palpate for the tactile fremitus. Percuss the diaphragmatic excursion

A. Place the palm or the ulnar aspect of the
hands bilaterally symmetrical on the chest
wall starting from the top, then at then
medial thoracic wall, and at the anterolateral
B. Each time the hands move down, ask the
client to say ninety-nine.
C. Repeat the procedure at the posterior
thoracic wall.
D. Normally, tactile fremitus should be
bilaterally symmetrical. Most intense in the
2nd ICS at the sternal border, near the area of
bronchial bifurcation. Low pitched voices of
males are more readily palpated than higher
pitched voices of females.
E. Basic abnormalities like increased tactile Auscultation of the Thorax
fremitus maybe suggestive of consolidation;
decreased tactile fremitus may be suggestive
of obstructions, thickening of pleura, or
collapse of lungs.

Percussion of the Thorax

Anterior thorax:
Normal Breath Sound
A. Patient maybe placed on a supine position.
B. Percuss systematically at about 5 cm intervals from Vesicular Soft, low pitch Lung periphery
the upper to lower chest, moving left to right to left. Broncho-vesicular Medium pitch Larger airway
(Percuss over the ICS, avoiding the ribs. Use indirect blowing
percussion starting at the apices of the lungs. Bronchial Loud, high pitch Trachea
C. The examiner notes the sound produced during each
percussion. Abnormal Breath Sound

Crackles Dependent lobes Random, sudden
reinflation of alveoli
fluids
Rhonchi Trachea, bronchi Fluids, mucus
Physical Assessment

Nursing Skills
Physical Assessment

Wheezes All lung fields Severely narrowed 1. Position the patient supine with the head of the table
bronchus slightly elevated.
Pleural Friction Lateral lung field Inflamed Pleura 2. Always examine from the patient's right side.
Rub 3. Inspect for precordial movement. Tangential lighting
will make movements more visible.
4. Palpate for precordial activity in general. You may
Elderly:
feel "extras" such as thrills or exaggerated ventricular
Physical Changes of Thorax and Breathing Patterns
impulses.
5. Palpate for the point of maximal impulse (PMI or
 Kyphosis apical pulse). It is normally located in the 4th or 5th
 Anteroposterior diameter of the chest widens intercostal space just medial to the midclavicular line
 Breathing rate and rhythm are unchanged at rest and is less than the size of a quarter.
 Inspiratory muscles become less powerful, and 6. Note the location, size, and quality of the impulse.
inspiration reserve volume decreases.
 Expiration may require the use of accessory muscles
 Deflation of the lung is incomplete Palpation of the Heart
 Small airways lose their cartilaginous support and
elastic recoil The entire precordium is palpated methodically using the palms
 Elastic tissue of the alveoli loses its stretchability and and the fingers, beginning at the apex, moving to the left sternal
changes to fibrous tissue. Exertional capacity also border, and then to the base of the heart.
decreases.
 Cilia in the airways decrease in number and are less
Normal Findings:
effective in removing mucus, therefore they are at
greater risk for pulmonary infections.
1. No, palpable pulsation over the aortic, pulmonic, and
mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and thrills
CARDIOVASCULAR SYSTEM felt over the apex.

Percussion of the Heart

The technique of percussion is of limited value in cardiac
assessment. It can be used to determine borders of cardiac
dullness.

Auscultation of the Heart

:

Inspection of the Heart

The chest wall and epigastrum is inspected while the client is in
supine position. Observe for pulsation and heaves or lifts

Normal Findings:

1. Pulsation of the apical impulse maybe visible. (this
can give us some indication of the cardiac size).
2. There should be no lift or heaves.

Jugular Venous Pressure

Anatomic areas for auscultation of the heart
1. Position the patient supine with the head of the table
elevated 30 degrees.
2. Use tangential, side lighting to observe for venous Aortic valve – Right 2nd ICS sternal border.
pulsations in the neck. Pulmonic Valve – Left 2nd ICS sternal border.
3. Look for a rapid, double (sometimes triple) wave with Tricuspid Valve – – Left 5th ICS sternal border.
each heart beat. Use light pressure just above the Mitral Valve – Left 5th ICS midclavicular line
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin.
4. Adjust the angle of table elevation to bring out the Positioning the client for auscultation:
venous pulsation.
5. Identify the highest point of pulsation. Using a If the heart sounds are faint or undetectable, try
horizontal line from this point, measure vertically listening to them with the patient seated and learning
from the sternal angle. forward, or lying on his left side, which brings the
6. This measurement should be less than 4 cm in a heart closer to the surface of the chest.
normal healthy adult.
Having the client seated and learning forward s best
suited for hearing high-pitched sounds related to
semilunar valves problem.
Precordial Movement

Physical Assessment

Nursing Skills
Physical Assessment

The left lateral recumbent position is best suited low- BREAST
pitched sounds, such as mitral valve problems and
extra heart sounds.

Auscultating the heart

1. Auscultate the heart in all anatomic areas aortic,
pulmonic, tricuspid and mitral
2. Listen for the S1 and S2 sounds (S1 closure of AV
valves; S2 closure of semilunar valve). S1 sound is
best heard over the mitral valve; S2 is best heard over
the aortric valve.
3. Listen for abnormal heart sounds e.g. S3, S4, and
Murmurs.
4. Count heart rate at the apical pulse for one full minute.

Normal Findings:

1. S1 & S2 can be heard at all anatomic site.
2. No abnormal heart sounds is heard (e.g. Murmurs, S3
& S4).
3. Cardiac rate ranges from 60 – 100 bpm. Inspection of the Breast

There are 4 major sitting position of the client used for clinical
breast examination. Every client should be examined in each
position.

1. The client is seated with her arms on her side.
PERIPHERAL CIRCULATION 2. The client is seated with her arms abducted over the
head.
Inspect: 3. The client is seated and is pushing her hands into her
hips, simultaneously eliciting contraction of the
pectoral muscles.
 Color
4. The client is seated and is learning over while the
 Edema
examiner assists in supporting and balancing her.
 Stasis ulcers/lesions
 Varicosities
 Hair/nail changes While the client is performing these maneuvers, the
breasts are carefully observed for symmetry, bulging,
Palpate: retraction, and fixation.
An abnormality may not be apparent in the breasts at
rest a mass may cause the breasts, through invasion of
 Temperature
the suspensory ligaments, to fix, preventing them from
 Edema
upward movement in position 2 and 4.
 Tenderness
 Symmetry of pulses Position 3 specifically assists in eliciting dimpling if a
mass has infiltrated and shortened suspensory
ligament

Chronic Venous Insufficiency
Chronic Arterial Insufficiency
Pain None to aching pain on dependency
Pain Intermittent claudication
Pulse Normal
Pulse Decreased
Normal to cyanotic; petechiae or brown
Color
pigmentation Color Pale

Temperature Warm Temperature Cool

Present Edema Absent or mild
Edema
Skin Thin, shiny atrophic skin, hair loss,
Skin Changes Dermatitis skin pigmentation Changes thickened nails

Ulceration Toes/points of trauma
Ulceration Medial side of ankle Gangrene May develop

Gangrene Does not develop
Normal Findings:

1. The overlying the breast should be even.
Physical Assessment

Nursing Skills
Physical Assessment

2. May or may not be completely symmetrical at rest.
3. The areola is rounded or oval, with same color, (Color
va,ies form light pink to dark brown depending on
race).
4. Nipples are rounded, everted, same size and equal in
color.
5. No “orange peel” skin is noted which is present in
edema.
6. The veins maybe visible but not engorge and
prominent.
7. No obvious mass noted.
8. Not fixated and moves bilaterally when hands are
abducted over the head, or is learning forward.
Auscultation of the Abdomen
9. No retractions or dimpling.

Palpation of the Breast This method precedes percussion because bowel
motility, and thus bowel sounds, may be increased by
palpation or percussion.
Palpate the breast along imaginary concentric circles, The stethoscope and the hands should be warmed; if
following a clockwise rotary motion, from the they are cold, they may initiate contraction of the
periphery to the center going to the nipples. Be sure abdominal muscles.
that the breast is adequately surveyed. Breast Light pressure on the stethoscope is sufficient to detect
examination is best done 1 week post menses. bowel sounds and bruits. Intestinal sounds are
Each areolar areas are carefully palpated to determine relatively high-pitched, the bell may be used in
the presence of underlying masses. exploring arterial murmurs and venous hum.
Each nipple is gently compressed to assess for the Peristaltic sounds
presence of masses or discharge.
These sounds are produced by the movements of air and fluids
through the gastrointestinal tract. Peristalsis can provide
diagnostic clues relevant to the motility of bowel.
Normal Findings:
Listening to the bowel sounds (borborygmi) can be facilitated by
following these steps:
No lumps or masses are palpable.
No tenderness upon palpation.
No discharges from the nipples.  Divide the abdomen in four quadrants.
 Listen over all auscultation sites, starting at the right lower
quadrants, following the cross pattern of the imaginary
NOTE: The male breasts are observed by adapting the lines in creating the abdominal quadrants. This direction
techniques used for female clients. However, the various sitting ensures that we follow the direction of bowel movement.
position used for woman is unnecessary.  Peristaltic sounds are quite irregular. Thus it is
recommended that the examiner listen for at least 5
ABDOMEN minutes, especially at the periumbilical area, before
concluding that no bowel sounds are present.
 The normal bowel sounds are high-pitched, gurgling noises
In abdominal assessment, be sure that the client has emptied the
that occur approximately every 5 – 15 seconds. It is
bladder for comfort. Place the client in a supine position with the
suggested that the number of bowel sound may be as low as
knees slightly flexed to relax abdominal muscles.
3 to as high as 20 per minute, or roughly, one bowel sound
for each breath sound.
Inspection of the abdomen
Some factors that affect bowel sound:
Inspect for skin integrity (Pigmentation, lesions, striae,
scars, veins, and umbilicus). 1. Presence of food in the GI tract.
Contour (flat, rounded, scapold) 2. State of digestion.
Distension 3. Pathologic conditions of the bowel (inflammation,
Respiratory movement. Gangrene, paralytic ileus, peritonitis).
Visible peristalsis. 4. Bowel surgery
Pulsations 5. Constipation or Diarrhea.
6. Electrolyte imbalances.
7. Bowel obstruction.
Normal Findings:
Percussion of the abdomen
Skin color is uniform, no lesions.
Some clients may have striae or scar. Abdominal percussion is aimed at detecting fluid in
No venous engorgement. the peritoneum (ascites), gaseous distension, and
Contour may be flat, rounded or scapoid masses, and in assessing solid structures within the
Thin clients may have visible peristalsis. abdomen.
Aortic pulsation maybe visible on thin clients. The direction of abdominal percussion follows the
auscultation site at each abdominal guardant.
The entire abdomen should be percussed lightly or a
general picture of the areas of tympany and dullness.
Tympany will predominate because of the presence of
gas in the small and large bowel. Solid masses will
percuss as dull, such as liver in the RUQ, spleen at the

Physical Assessment

Nursing Skills
Physical Assessment

6th or 9th rib just posterior to or at the mid axillary line Deeper structures, like the liver, and retro peritoneal
on the left side. organs, like the kidneys, or masses may be felt with
Percussion in the abdomen can also be used in this method.
assessing the liver span and size of the spleen. In the absence of disease, pressure produced by deep
palpation may produce tenderness over the cecum, the
Percussion of the liver sigmoid colon, and the aorta.

The palms of the left hand is placed over the region of liver
dullness.

1. The area is strucked lightly with a fisted right hand.
2. Normally tenderness should not be elicited by this
method.
3. Tenderness elicited by this method is usually a result
of hepatitis or cholecystitis.

Renal Percussion

1. Can be done by either indirect or direct method.
2. Percussion is done over the costovertebral junction.
Liver palpation:
3. Tenderness elicited by such method suggests renal
inflammation.
There are two types of bi manual palpation recommended for
palpation of the liver. The first one is the superimposition of the
right hand over the left hand.

1. Ask the patient to take 3 normal breaths.
2. Then ask the client to breath deeply and hold. This
would push the liver down to facilitate palpation.
3. Press hand deeply over the RUQ

The second methods:

1. The examiner’s left hand is placed beneath the client
at the level of the right 11th and 12th ribs.
2. Place the examiner’s right hands parallel to the costal
margin or the RUQ.
Palpation of the Abdomen 3. An upward pressure is placed beneath the client to
push the liver towards the examining right hand, while
Light palpation the right hand is pressing into the abdominal wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip
It is a gentle exploration performed while the client is
beneath the examining fingers.
in supine position. With the examiner’s hands parallel
to the floor.
The fingers depress the abdominal wall, at each Normal Findings:
quadrant, by approximately 1 cm without digging, but
gently palpating with slow circular motion. The liver usually can not be palpated in a normal
This method is used for eliciting slight tenderness, adult. However, in extremely thin but otherwise well
large masses, and muscles, and muscle guarding. individuals, it may be felt a the costal margins.
When the normal liver margin is palpated, it must be
Tensing of abdominal musculature may occur because of: smooth, regular in contour, firm and non-tender.

1. The examiner’s hands are too cold or are pressed to MUSCULOSKELETAL
vigorously or deep into the abdomen.
2. The client is ticklish or guards involuntarily. 1. Assess the patient’s posture, stance, and gait
3. Presence of subjacent pathologic condition. 2. Prepare the patient for the examination
3. Inspect for any gross abnormalities.
Normal Findings: 4. Inspect and palpate the temporomaddibular joint and
jaw.
5. Inspect and palpate the neck and spine
1. No tenderness noted.
6. Assess the ROM of the neck
2. With smooth and consistent tension.
7. Assess the ROM of the spine
3. No muscles guarding.
8. Inspect and palpate the upper and lower extremities,
assessing each joint and muscle.
Deep Palpation
RANGE OF MOTION
It is the indentation of the abdomen performed by
pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall.
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined.

Physical Assessment

Nursing Skills
Physical Assessment

TEMPORAL MADIBULAR JOINT AND JAW

RANGE OF MOTION: ELBOW

RANGE OF MOTION: NECK
RANGE OF MOTION:SHOUDLERS

RANGE OF MOTION:WRISTS

RANGE OF MOTION:ANKLES

RANGE OF MOTION: FINGERS

Physical Assessment

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