HEALTH ASSESSMENT

- Reveal: skin texture, moisture, large or superficial masses,

NURSING ASSESSMET
fluid, muscle guarding, and superficial tenderness
- MAJOR COMPONENT OF NURSING CARE
- Process which includes both physical and psychological aspect to B. DEEP PALPATION
evaluate client’s condition - DEPTH: 1 – 2 inches or more
- Enables the nurse to make a judgment about the client’s health status, - Reveals: position of organs and masses, organ size, shape,
ability to manage their health care and need for nursing mobility, consistency, areas of discomfort
- Commonly used: female and male reproductive and
PHYSICAL ASSESSMET abdominal assessment

- Process by which nurse obtains data that describes a person’s actual PERCUSSION
responses to actual or potential health problems such is analyzed to - Striking or tapping the person’s skin with short, sharp strokes to
form pertinent diagnosis assess underlying structures.
- Head-To-Toe review of each body system - Strokes will yield palpable vibrations and a characteristic sound that
- Elicits OBJECTIVE INFORMATION depicts location, size, and density of underlying organ.

IMPORTANCE OF HEALTH ASSESSMENT FOUR TYPES OF PERCUSSION

1. Early detection A. IMMEDIATE OR DIRECT PERCUSSION
- Identification of actual or potential health problems - Striking hand (plexor) directly contacts the body wall
2. Establish data - Used in percussing infant’s thorax or adult’s sinus areas
3. Assess impact of activity on client’s overall health
4. Establish nurse-client relationship B. MEDIATE OR INDIRECT PERCUSSION
5. Obtain information in the client’s general health: Physiologic, - Used more often; involves both hands
Psychologic, Sociocultural, Cognitive, Developmental and Spiritual - The striking hand (plexor) contacts the stationary hand
6. Identify strengths and weaknesses (pleximeter) fixed on the person’s skin.

PURPOSE OF PHYSICAL ASSESSMENT C. DIRECT FIST PERCUSSION

1. Supplement, confirm, or refute data obtained in nursing history - Assesses the presence of tenderness in internal organs such as
2. Confirm and identify a nursing diagnosis liver and kidneys
3. Make clinical judgments - (+) PAIN = POSSIBLE INFLAMMATION
4. Evaluate outcome of care D. INDIRECT FIST PERCUSSION
5. Obtain and gather baseline data for future assessment - More preferred because the non-dominant hand absorbs some of
6. Evaluate an individual’s current health status the force of the striking hand.

THE BASIC 4: I – P – P – A PERCUSSION ELICITS FIVE TYPES OF SOUNDS

1. FLATNESS (DULL) – bone and muscle
INSPECTION 2. DULLNESS (THUD LIKE) – liver, spleen, heart
- Uses senses specifically vision and smell to observe patient 3. RESONANCE (HOLLOW) – air-filled lung/normal lung
- “CONCENTRATED WATCHING” 4. HYPERRESONANCE – emphysematous lung
- Starts during general survey 5. TYMPANY – stomach filled with gas (air)
- Assessments always start with inspection
AUSCULTATION
PALPATION - Active listening to body organs to gather information on patient’s
- Touching therapeutically to elicit information clinical status
- Often confirms points noted during inspection - Listening to sounds that are voluntarily or involuntarily produced by
- Uses the sense of touch the body such as heart & blood vessels
- Listen to intensity, pitch, duration, quality and location
FOR PALPATION OBSERVE:
 Texture TWO TYPES OF AUSCULTATION
 Temperature 1. DIRECT OR IMMEDIATE AUSCULTATION
 Moisture - Unaided ear
 Organ location - Listening to a patient from some distance or placing directly on
 Organ size the patient’s skin surface
 Swelling - EX: wheezing that is audible during a severe asthma attack
 Vibration
 Crepitation
 Presence of lumps and masses
 Tenderness of pain

TYPES OF PALPATION 2. INDIRECT OR MEDIATE AUSCULTATION

A. LIGHT PALPATION - With the use of stethoscope
- LIGHT PALPATION: depth 1 – ½ inch below the surface SIDE NOTES
- Superficial and gentle - Tubing – should be 30-35 cm long
 - Diaphragm – flat disk used to listen for high pitched sounds 1. Flashlight or penlight
(bronchial sounds) 2. Ophthalmoscope
- Bell – used to transmit low pitched sounds (heart sounds) 3. Otoscope
4. Percussion (reflex hammer)
DESCRIPTION OF AUSCULTATED SOUNDS 5. Tuning fork
1. PITCH – frequency of vibrations (number of vibrations per 6. Cotton applicators
second) 7. Gloves
2. INTENSITY – aka amplitude; refers to the loudness or 8. Tongue blades (depressors)
softness of a sound
3. DURATION – length of a sound POSITIONING
4. QUALITY – subjective description of a sound 1. Dorsal recumbent
2. Supine
ADDITIONAL NOTES 3. Sitting
- Low pitched sounds such as heart sounds have fewer vibrations than 4. Lithotomy
high pitched sounds such as bronchial sounds 5. Sims
- 2. for example: bronchia sounds are heard louder in the trachea 6. Prone
- Quality can be whistling, gurgling, snapping etc.
INTEGUMENT - SKIN, HAIR AND
NURSING NAILS
RESPONSIBILITIES SKIN ASSESSMENT
BEFORE, DURING, AND AFTER - Assessment of the skin involves inspection and palpation.
BEFORE - Olfactory sense may also be used to detect unusual odors; usually
1. Always dress in clean professional manner, make sure you have most evident in skin folds or the axillae.
your name pin or workplace identification. - The entire surface may be assessed at one time or as each aspect the
2. Remove all bracelets, necklaces, or earrings that can interfere body
during physical assessment. - Pungent body odors are frequently related to poor hygiene;
3. Be sure your hair will not fall forward and obstruct your vision or hyperhidrosis (excessive perspiration); or bromhidrosis (foul-
touch to the patient. smelling perspiration)
4. Ensure that all necessary equipment is ready for use and within
reach. SKIN ASSESSMENTS
5. Introduce yourself to the patient. Enlist the patient’s cooperation by  PALLOR – result of inadequate circulating blood or hemoglobin
explaining what you are about to do, where it will be done, and how and subsequent reduction in tissue oxygenation.
it may feel. - DARK SKINNED CLIENTS: readily seen in the buccal
6. Explain to the patient why you may be spending a long time mucosa
performing one particular skill. - BROWN SKINNED CLIENTS: usually seen as yellowish-
7. Do medical hand washing. brown tinge
8. Position the patient as dictated by the body system being assessed. - BLACK SKINNED CLIENTS: appear ashen-gray
9. Warm all instruments prior to their use. - SEEN/OBSERVED IN: conjunctiva, oral mucous
membranes, nail beds, palms of the hands, soles of the feet.
DURING  CYANOSIS – bluish tinge
1. Conduct the assessment in a systematic fashion every time. - Most evident in the nail beds, lips, and buccal mucosa.
2. While performing each step in the physical assessment process you - DARK SKINNED CLIENTS: seen in the palpebral
may need to inform the patient of what to expect, where to expect it, conjunctiva (lining of the eyelids), palms, and soles.
and how it should feel.  JAUNDICE – yellowish tinge
3. Avoid making crude or negative remarks, be cognizant of your - First evident in the sclera of the eyes and then in the mucous
facial expression when dealing with malodorous and dirty patients membranes and then skin.
or with disturbing findings. - Dark skinned client: posterior part of the hard palate
4. Proceed from the least invasive to the most invasive procedure for - Nurses should be careful not to confuse the normal yellowish
each body system. tone of a dark-skinned client’s sclera
5. If the patient complains of fatigue, allow patient to rest and “KAYA ANG CHINE CHECK IF YOU SUSPECT
continue later. JAUNDICE IS THE POSTERIOR PART OF THE
HARD PALATE”
 ERYTHEMA – skin redness associated with rashes or other
AFTER conditions.
1. Provide recognition to the patient when physical assessment  VITILIGO – patches of hypopigmented skin caused by
concluded; inform the patient what will happen next. destruction of melanocytes.
2. Place patient in a comfortable position.  EDEMA – presence of excess interstitial fluid; appears shiny,
3. Do after care. swollen, and taut.
4. Do medical hand washing.
5. Document the assessment findings in the appropriate section of the SIDE NOTES
patient record. • Localized areas of hyperpigmentation or hypopigmentation may
occur as a result of changes in the distribution of melanin (dark
MATERIALS AND INSTRUMENTS USED IN THE HEALTH pigment) or in the function of the melanocytes in the epidermis.
ASSESSMENT An example of hyperpigmentation is birth mark.
 • Other localized color changes may indicate a problem such as - HYPERTHYROIDISM causes EXOPHTHALMOS, a protrusion
edema or a localized infection. of eyeballs with elevation of the upper eyelids
• Dark skinned clients usually have areas of lighter pigmentation, - HYPOTHYROIDISM or myxedema can cause a dry, puffy face
such as the palms, lips and nail beds. with dry skin, and coarse features and thinning of scalp hair &
• Generalized edema is most often an indication of impaired eyebrows
venous circulation and in some cases reflect cardiac dysfunction - MOON FACE: results from increased adrenal hormone or
or venous abnormalities. administration of steroids; characterized as round face with
 PRIMARY SKIN LESIONS – appear initially in response to reddened cheeks
some change in the internal and external environment of the skin. - CUSHING – causes moon face
 SECONDARY SKIN LESIONS – appear as a result from - PROLONGED ILLNESS, STARVATION, AND
modifications such as chronicity, trauma, or infection of the DEHYDRATION: results in sunken eyes, cheeks, and temples
primary lesion.
- Ex: a vesicle or blister (primary lesion) may rupture and EYES AND VISION
cause erosion (secondary lesion) - It is recommended that people under age 40 have their eyes tested
- Nurses are responsible for describing skin lesions accurately every 3 to 5 years or more of there is a family history of diabetes,
in terms of location (ex: face), distribution (ex: body hypertension, blood dyscrasia, or eye disease.
regions involved), configuration (arrangement or position of - After age 40, eye exam is recommended every 2 years
lesions), as well as color, shape, size, firmness, texture and - Pupils are normally black, equal in size (3-7mm in diameter), round,
characteristics of individual lesions. smooth boarders.
- MYDRIASIS (enlarged pupils): indicates injury or glaucoma or
HAIR ASSESSMENT result from certain drugs (atropine, cocaine, amphetamines)
- NORMAL: RESILIENT AND EVENLY DISTRIBUTED - MIOSIS (constricted pupils): indicates inflammation of the iris;
- IN KWASHIORKOR: Kwashiorkor is severe protein deficiency. results from such drugs as morphine or heroin and other narcotics,
Hair color is faded, appears reddish or bleached, texture is coarse and barbiturates, or pilocarpine; sometimes age-related change in older
dry adults
- Some patients may also have ALOPECIA. - ANISOCORIA: unequal pupils; result from CNS disorders
- Examples of patients who have alopecia: patients undergoing chemo
- HYPOTHYROIDISM causes very thin and brittle hair COMMON REFRACTIVE ERRORS
- MYOPIA: nearsightedness
NAIL ASSESSMENT - HYPEROPIA: farsightedness
- NORMAL NAIL PLATE: COLORLESS AND HAS A CONVEX - PRESBYOPIA: loss of elasticity of the lens thus loss of ability to
CURVATURE see close objects
- NORMAL ANGLE: 160 DEGREES - ASTIGMATISM: uneven curvature of the cornea prevents
- SPOON SHAPED NAIL: nail curves upward from the nail bed horizontal and vertical rays from focusing on the retina
(seen in Iron Deficiency Anemia)
- Nails are inspected for nail plate shape, angle between fingernail SIDE NOTES
and the nail bed, nail texture, nail bed color, and the intactness of • Examination of the eye includes assessment of the external
the tissues around the nails structures, visual acuity (the degree of detail the eye can
- CLUBBING: angle is 180 degrees or greater; caused by discern in an image), ocular movement, and visual fields (the
long-term lack of oxygen area an individual can see when looking straight ahead)
- NORMAL NAIL TEXTURE: smooth • Most eye assessment procedures involve inspection
- EXCESSIVELY THICK NAILS can be seen in older • Consider the developmental changes and to individual hygienic
adults, presence of poor circulation or in chronic fungal practices, if the client wears contact lenses or has an artificial
infection eye
- EXCESSIVELY THIN NAILS or presence of grooves or • Most people wear corrective lenses like eyeglasses or contact
furrows can reflect prolonged iron deficiency anemia. lenses to correct common refractive errors
- BEAU’S LINES: horizontal depressions; are a result of • Presbyopia begins at about 45 years of age. People notice that
injury or deserve illness they have difficulty reading newsprint
- BLUISH OR PURPLE TINT IN THE NAIL BED: may • Astigmatism is a common problem that may occur in
reflect cyanosis; pallor may reflect poor arterial circulation conjunction with myopia and hyperopia; may be corrected with
- ONYCHOMYCOSIS – nail fungus should be referred to a glasses or surgery
podiatrist or derma for proper fungal treatment
- BLANCH TEST: carried out to test the capillary refill which INFLAMMATORY VISUAL PROBLEMS
determines adequacy of peripheral circulation - CONJUNCTIVITIS – inflammation of the bulbar and palpebral
- NORMAL CAPILLARY REFILL TIME: 2-3 seconds conjunctiva; results from foreign bodies, chemicals, allergenic
agents, bacteria or viruses. Redness, itching, tearing, and
mucopurulent discharge may occur; during sleep, eyelids may
become encrusted and matted together
- DACRYOCYSTITIS – inflammation of the lacrimal duct.
HEAD Manifested by tearing and discharge from the nasolacrimal duct
- HORDEOLUM (STY) – redness, swelling, and tenderness of the
SKULL AND FACE hair follicle and glands that empty at the edge of the eyelids
- Normal head size is referred to as NORMOCEPHALIC.
- Kidney or cardiac disease can cause edema of the eyelids.
 - IRITIS – inflammation of the iris. Results from local or systemic between external atmosphere and the middle ear, thus
infections and results in pain, tearing, and photophobia (sensitivity to preventing rupture of the tympanic membrane and discomfort
light) produced by marked pressure differences
- CONTUSIONS OR HEMATOMAS – “black eye”; results from • Inner ear: cochlea, a seashell-shaped structure essential for
injury sound transmission and hearing, and the vestibule and
semicircular canals, which contain the organs of equilibrium
OTHER EYE PROBLEMS
- CATARACTS: tend to occur in individuals over 65-year-old TYPES OF HEARING LOSS
although they may be present at any age; opacity of lens or its 1. CONDUCTIVE HEARING LOSS: result of interrupted
capsule blocks light rays. transmission of sound waves through the outer and middle ear
- JUVENILE CATARACTS – cataracts in pediatric; related to structures. Possible causes are a tear in the tympanic membrane, an
genetic conditions such as down syndrome; infections picked up by obstruction, due to swelling or other causes in the auditory canal
the mother during pregnancy including rubella and chickenpox - Rinne’s Test: BC > AC
- CATARACTS are usually removed through surgery or the lens or - Weber’s Test: Loud in the bad ear
replaced by a lens implant
- GLAUCOMA: disturbance in the circulation of aqueous fluid, which 2. SENSORINEURAL HEARING LOSS: damage to the inner ear,
causes an increase in intraocular pressure. Often the cause of the auditory nerve, or the hearing center in the brain.
blindness over age 40 y/o, can be controlled if diagnosed early, - Rinne’s Test: AC > BC
danger signs include blurred or foggy vision, loss of peripheral - Weber’s Test: Loud in the good ear
vision, difficulty focusing on close objects, difficulty adjusting to - Normally: Weber’s sa gitnaRinne’s Test: Air > Bone min. 2x
dark rooms, and seeing rainbow colored rings around lights the length
- PTOSIS: upper eyelids that lie at or below the pupil margin; usually
associated with aging, edema from drug allergy or systemic disease NOSE AND SINUSES
(ex: kidney disease), congenital lid muscle dysfunction, - Assessment of the nose includes inspection and palpation of the
neuromuscular disease (ex: myasthenia gravis) and 3rd cranial nerve external nose; patency of the nasal cavities, inspection of the nasal
impairment cavities.
- If the client reports difficulty in smell, the nurse tests the client’s
NORMAL INTRAOCULAR PRESSURES: 10-20 mmhg; above 22 is olfactory sense by asking the client to identify common odors such as
abnormal coffee or mint.
- Nasal passages can be inspected with a flashlight.
- The upper third of the nose is bone; the remainder is cartilage
- The nurse also inspects and palpates the facial sinuses.

EARS AND HEARING

- The external ear canal is curved, about 2.5 cm long in an adult, and
ends at the tympanic membrane; it is covered with skin that has many MOUTH AND OROPHARYNX
fine hairs, glands and nerve endings - Composed of the lips, oral mucosa, tongue, floor of the mouth,
teeth and gums, hard and soft palate, uvula, salivary glands,
SIDE NOTES tonsillar pillars and tonsils.
• Assessment of the ear includes direct inspection and palpation - NORMAL: 32 TEETH
of the external ear, inspection of the internal parts of the ear by
an otoscope; determination of auditory acuity SIDE NOTES:
• The ear is divided into 3 parts: external, middle, inner • Parotid gland: largest and empties through Stensen’s duct
• External: auricle or pinna, the external auditory canal, and the opposite the second molar
tympanic membrane (eardrum). Landmarks of the auricle • Submandibular gland: empties through Wharton’s duct, which
include the lobule (earlobe), helix (the posterior curve of the is situated on either side of the frenulum on the floor of the
auricles upper aspect), antihelix, tragus, triangular fossa, and mouth
external auditory meatus (entrance to the ear canal); although • Sublingual salivary gland: lies in the floor of the mouth and has
not part of the ear, the mastoid, a bony prominence behind the numerous openings
ear, is another important landmark
• The middle ear is an air-filled cavity starts at the tympanic PROBLEMS YOU MAY SEE
membrane and contains ossicles (bones of sound transmission) - DENTAL CARIES (CAVITIES) AND PERIODONTAL
• Malleus (hammer); incus (anvil); stapes (stirrups) DISEASE (PYORRHEA): frequent problems that affect the teeth.
• Eustachian tube, another part of the middle ear, connects the Commonly associated with plaque and tartar deposits.
middle ear to nasopharynx; the tube stabilizes the air pressure
 - PLAQUE: invisible soft film that adheres to the enamel surface of • The point where the apex touches the anterior chest wall and
the teeth. Consists of bacteria, molecules of saliva, and remnants of heart movements are most easily observed and palpated is
epithelial cells and leukocytes. When plaque is unchecked, tartar known as the point of maximal impulse or (PMI)
forms.
- TARTAR: visible, hard deposit of plaque and dead bacteria that CENTRAL VESSELS
forms in the gum lines. Buildup can alter the fiber that attach the - JUGULAR VEIN: drain blood from the head and neck directly into
teeth to the gum and eventually disrupt bone tissue. the superior vena cava and right side of the heart
- GINGIVITIS: red, swollen gum, bleeding, receding gum lines, and - By inspecting the jugular veins for pulsations and distention, the
formation of pockets between teeth and gums. nurse can the adequacy of function of the right side of the heart and
- GLOSSITIS: inflammation of the tongue venous pressure
- STOMATITIS: inflammation of the oral mucosa - Normally, external neck veins are distended and visible when a
- PAROTITIS: inflammation of the parotid salivary gland person lies down; flat and not as visible when a person stands up
- SORDES: accumulation of foul matter (food, microorganisms, and because gravity encourages venous drainage
epithelial elements) - BILATERAL JUGULAR VENOUS DISTENTION (JVD) may be
indicate right-sided heart failure
NECK - Assessment includes measuring blood pressure, palpating peripheral
pulses, and inspecting the skin and tissues to determine perfusion
- Examination of the neck includes muscles, lymph nodes, trachea, (blood supply to an area) to the extremities.
thyroid gland, carotid arteries, and jugular veins. - Certain aspects of peripheral vascular assessment are often
incorporated into other parts of the assessment procedure
THORAX AND
LUNGS BREASTS AND
- The assessment of thorax and lungs is critical in assessing a client’s AXILLAE
oxygenation status - In females, the largest portion of glandular breast tissue is located in
the upper outer quadrant of each breast.
CHEST SHAPE AND SIZE - Axillary tail of Spence: projection of breast tissue from this quadrant
In healthy adults, the thorax is oval. The anteroposterior diameter is half that extends into the axilla.
its transverse diameter, the overall shape of the thorax is elliptical. The - Men have some glandular tissue beneath each nipple, a potential site
transverse is smaller at the top than at the base. In older adults, kyphosis for malignancy, whereas mature women have glandular tissue
and osteoporosis alter the size of the chest cavity as the ribs move throughout the breast
downward and forward. - MOST ACCURATE: 5-7 days AFTER menstruation; for
- PIGEON CHEST (PECTUS CARINATUM) – may be caused by menopausal females: same day each month
rickets; permanent derfomity; rickets is caused by lack of dietary
calcium thus resulting in abnormal bone formation ABDOMEN
- FUNNEL CHEST (PECTUS EXCAVATUM) – a congenital
defect, opposite of the pigeon chest in that the sternum is depressed, ABNORMAL ABDOMINAL SOUNDS
narrowing AP diameter. Because the sternum points posteriorly in SOUND AND DESCRIPTION
clients with funnel chest, abnormal pressure on the heart may result Hyperactive Diarrhea,
in altered function bowel sounds laxative use, or
Any quadrant
- BARRELL CHEST: AP to transverse diameter ratio is 1:1; seen in (unrelated to early intestinal
hunger) obstruction
patients with kyphosis or emphysema Hypoactive,
Paralytic ileus or
then absent Any quadrant
peritonitis
sounds
CARDIOVASCULAR AND PERIPHERAL VASCULAR
Intestinal fluid
HEART High-pitched and air under
Any quadrant
tinkling sounds tension in a
- Nurses assess the heart through inspection, palpation, and dilated bowel
auscultation (in that sequence) High pitched
- Precordium: area of the chest overlying the heart rustling sounds
Intestinal
- Lift & heave: rising along the sternal boarder with each heartbeat; a coinciding with Any quadrant
obstruction
abdominal
lift occurs when cardiac action is forceful. Confirmed by palpation
cramps
with the palm of the hand. Enlargement or overactivity of the left Partial arterial
produces a heave lateral to the apex, whereas enlargement of the right Over abdominal obstruction or
ventricle produces a heave at or near the sternum aorta turbulent blood
Vascular flow
SIDE NOTES blowing sounds Over renal Renal artery
resembling artery stenosis
• In average adult, most of the heart lies behind and to the left of cardiac murmurs Over iliac artery Hepatomegaly
the sternum Arterial
Over femoral
• A small portion (the right atrium) extends to the right of the insufficiency in
artery
sternum the legs
• The upper portion of the heart (both atria); referred to as it’s
base, lies toward the back ABNORMAL ABDOMINAL SOUNDS
• The lower portion (the ventricles), referred as apex points
anteriorly SOUND AND DESCRIPTION
VENOUS HUM: Continuous, medium-pitched tone created blood flow in - LANGUAGE: assessed for any defects in or loss of the power to
a large engorged vascular organ such as the liver express oneself by speech, writing, or signs, or to comprehend
LOCATION: Epigastric and umbilical regions spoken or written language is called aphasia
POSSIBLE CAUSE: Increased collateral circulation between portal - Aphasia is caused by a damage or injury in the cerebral cortex
systemic venous systems, as in cirrhosis - Sensory or receptive aphasia: loss of the ability to comprehend
written or spoken words.

FRICTION RUB: Harsh, grating sound like two pieces of sandpaper MENTAL STATUS
rubbing together - Motor or expressive aphasia: loss of power to express oneself by
LOCATION: Over liver and spleen writing, making signs or speaking.
POSSIBLE CAUSE: Inflammation of the peritoneal surface of the liver - ORIENTATION: determines the client’s ability to recognize people
(tumor) or of the spleen (infarct) (person), awareness of when and where they presently are (time &
place), and who they, themselves, are (self)
TYPES OF ABDOMINAL PAIN - Usually charted as awake, alert, oriented x3 (person, time, and place)
1. BURNING – Due to peptic ulcer, GERD - MEMORY: assess ability of client to recall information present
2. CRAMPING – Due to biliary colic, irritable bowel syndrome, seconds previously (immediate recall), events or information from
diarrhea, constipation, flatulence earlier in the day (recent memory), and knowledge recalled from
3. SEVERE CRAMPING – Due to appendicitis, Crohn’s disease, months or years ago (remote memory)
diverticulitis - Short term: prefrontal cortex in the frontal lobe
4. STABBING – Due to pancreatitis, cholecystitis - Long term: hippocampus in the temporal lobe

MUSCULOSKELETAL DTR
SYSTEM MEANING
GRADE
- Composed of the bones, muscles, and joints.
- The nurse assesses the MSK for muscle strength, tone, size, and 0 No reflex response
symmetry of muscle development and tremors. +1 Minimal activity (hypoactive)
- TREMOR: involuntary trembling of a limb or body part.
- INTENTIONAL TREMOR: apparent when an individual attempt a +2 Normal response
voluntary movement +3 More active than normal
- RESTING TREMOR: apparent when client is relaxed and
diminishes with activity +4 Maximal activity (hyperactive)
- FASCICULATION: abnormal contraction of a bundle of muscle
fibers that appears as a twitch

GRADE INTERPRETATION
0 0% of normal strength; complete paralysis
10% of normal strength; no movement, contraction of muscle
1
is palpable or visible

25% of normal strength; full muscle movement against

2
gravity, with support

3 50% of normal strength; normal movement against gravity

75% of normal strength; normal full movement against

4
gravity and against minimal resistance

- Bones are assessed for normal form.

- Joints are assessed for tenderness, swelling, thickening, crepitation (a
crackling, grating sound), and range of motion.
- Body posture is assessed for normal standing and sitting positions.

NEUROLOGIC
SYSTEM
Assessment of the neurologic system includes:
a. Mental status including LOC
b. Cranial nerves
c. Reflexes
d. Motor function
e. Sensory function