PHYSICAL ASSESSMENT

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

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

Duration: 12.0 hours

MAJOR TOPICS
Physical Examination
1. Musculoskeletal System
2. Peripheral Vascular System
3. Neurological System
A. Cranial Nerves
B. Functional Mental Health

Activities:

1. Critical Case Scenarios: Case Studies

Before you proceed…

Intended Learning Outcomes:

1. Discuss the sequence of physical assessment in the different parts of the body
2. To be able to identify normal and abnormal findings of a specific body area during
assessment
3. To be able to follow the proper method of physical assessment of the different
body areas
4 Properly utilize the different techniques of physical assessment and use specific
equipment for each body area

Key Terms:

 Cranial Nerves
 Musculoskeletal
 Vascular
 Peripheral
 Neurologic
 Reflexes

Let’s Begin!
 MUSCULOSKELETAL ASSESSMENT

Inspection

 Observe for size, contour, bilateral symmetry, and involuntary movement.

 Look for gross deformities, edema, presence of trauma such as ecchymosis
or other discoloration.
 Always compare both extremities.

Palpation

 Feel for evenness of temperature. Normally it should be even for all the
extremities.
 Tonicity of muscle. (Can be measured by asking client to squeeze
examiner’s fingers and noting for equality of contraction).
 Perform range of motion.
 Test for muscle strength. (performed against gravity and against
resistance)
 Table showing the Lovett scale for grading for muscle strength and
functional level
Functional level Lovett Scale Grade Percentage
of normal

No evidence of contractility Zero (Z) 0 0

Evidence of slight contractility Trace (T) 1 10

Complete ROM without gravity Poor (P) 2 25

Complete ROM with gravity Fair (F) 3 50

Complete range of motion against gravity with Good (G) 4 75

some resistance

Complete range of motion against gravity with full Normal (N) 5 100
resistance
Normal Findings

 Both extremities are equal in size.

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

BODY PART TECHNIQUE NORMAL FINDINGS

UPPER
EXTREMITIES

Arms
Inspection
Support hands at chest » Skin color varies (pinkish, tan,
level. Note the color of skin, dark brown), symmetrical, fine
length, hair distribution, hair evenly distributed,
presence/absence of visible
presence of visible veins.
veins.

Palpation
Palpate arms for » Warm, dry and elastic, no areas
temperature, moisture, of tenderness. Muscle appears
lumps, masses, and areas equal with good muscle tone.
of tenderness. Note for
muscle size and tone.
Palms and Inspection
Dorsal Surfaces » Palms pinkish (dorsal surface),
Note the color,
warm; males – thick; females
temperature, thickness,
– softer; elastic.
moisture, and turgor.

Nails Inspection
Inspect for color,
» Nails are transparent, smooth
thickness, shape and
and convex with pink nailbeds
curvature.
and white translucent tips.

Count the number of » Five fingers in each hand.

fingers.

Palpation
Gently grasps the client’s » As pressure is applied to the
fingers and observe the nailbed, appears white or
color of the nailbeds, then blanched, and pink color
returns immediately as
gently apply pressure with
pressure is released.
the thumb to the nailbed
quickly and release.

Manipulation – the process of moving or attempting to move the part being

examined. Limitation of movements can be discovered.

Shoulders
Range of motion
1. Raise both arms to
vertical position.
2. Place head behind the
» Performs with relative ease.
neck.
3. Place hands behind the
small of the back.
Arms Range of motion
1. Abduct – away from the
body » Performs with relative ease
2. Adduct – towards the
 body
3. Rotate – internal and
» No relative difficulties
external (one arm at a
time)
Elbows Range of motion
1. Bend and straighten
» Performs with relative ease.
elbow
Hands and Range of motion
wrists
1. Extend and spread the
fingers
» Performs with relative ease
2. Make a fist, thumb
across the knuckles.
LOWER
EXTREMITIES
Inspection
Note the color of skin,
Legs hair distribution, and
presence of varicose veins, » Skin color varies (pinkish, tan,
length, and symmetry of dark brown) skin is smooth,
muscle. fine hair evenly distributed,
absence of varicose veins,
muscles symmetrical, length
symmetrical.

Palpation
» Muscles appear equal, warm and
Let the client tiptoe. with good muscle tone.
Palpate the muscles for
warmth and strength.

Toes Inspection
Inspect for the number of » Five toes in each foot; sole and
toes, texture of sole and dorsal surface is smooth; with
dorsal surface, toe nails. pink nail beds and white
translucent tips.

Palpation » As pressure is applied, the

Gently grasps the client’s nailbed appears white or
blanched; pink color returns
toenails nailbeds. Gently
when pressure is released.
apply pressure with the
thumb to the nailbed
 quickly and release.

Legs (one leg

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

Knees Range of motion

Let the client sit down on a
chair and bend foot at the » Performs with relative ease
knee
1. Bend and extend
Ankles Range of motion
1. Flexion and extension » Performs with relative ease
2. Rotation (internal and
external)
Toes
Range of motion
» Performs with relative ease
1. Spread and wiggles

Overview

1. Musculoskeletal system involves the muscles, bones, and joints

2. This means we must assess structure AND function

Nursing Points
General

1. If patient cannot stand, assessments should be performed in the bed to the best
of your ability
2. If they cannot perform Active Range of Motion (ROM), use Passive movements to
determine ROM
Assessment

1. For ALL joints:

a. Inspect

i. Muscle size/shape

ii. Skin color at joint

iii. Swelling, masses

iv. Deformity

v. Pain with ROM

b. Palpate

i. Crepitus during ROM

ii. Heat at joint

iii. Strength

2. Strength

a. Grading

i. 0 = no movement

ii. 1 = flicker

iii. 2 = passive movement only

iv. 3 = overcomes gravity

v. 4 = overcomes some resistance

vi. 5 = overcomes strong resistance

b. Upper extremities – perform these tasks against resistance

i. Push hands

ii. Pull hands

iii. Raise arms to front and side

iv. Lower arms

 v. Grip hands

c. Lower extremities – perform these tasks against resistance

i. Raise legs

ii. Lower legs

iii. Push with feet

iv. Pull toes back

3. Spine

a. Inspect and Palpate

i. Spinous processes should be in alignment vertically

ii. Look for any abnormal curvatures

1. Kyphosis – excessive thoracic curvature

2. Lordosis – excessive lumbar curvature

3. Scoliosis – excessive lateral curvature

b. Range of motion

i. Cervical

1. Chin to chest

2. Chin up

3. Head side to side

4. Ears to shoulders

ii. Thoracic

1. Twist side to side

iii. Lumbar

1. Lean backwards

iv. All ROM should be smooth and coordinated without pain

4. Upper extremities

a. Shoulders

i. ROM
 1. External and Internal Rotation

2. Abduction

3. Adduction

4. Forward and backward

5. Shrug

b. Elbows

i. ROM

1. Flexion

2. Extension

3. Supination

4. Pronation

c. Wrists

i. ROM

1. Flexion

2. Extension

3. Rotation

4. Supination

5. Pronation

d. Hands/Fingers

i. ROM

1. Flexion

2. Extension

3. Grips

5. Lower extremities

a. Hips

i. ROM

1. Flexion
 2. Extension

3. Internal rotation

4. External rotation

5. Abduction

6. Adduction

b. Knees

i. ROM

1. Flexion

2. Extension

c. Ankles

i. ROM

1. Dorsiflexion

2. Plantar flexion

3. Supination

4. Pronation

5. Rotation

d. Feet/Toes

i. ROM

1. Flexion

2. Extension
Nursing Concepts

1. Reflexes usually tested during neurologic assessment, but could be included here
as well

2. Could use a goniometer to assess degree of flexion or extension of joints

Flipped Classroom: For additional reference, you can click the actual video for vital
signs monitoring. https://www.youtube.com/watch?v=aUMTPa_9qlY
 PERIPHERAL VASCULAR ASSESSMENT

Assessing the peripheral vascular system includes measuring the blood

pressure, palpating peripheral pulses, and inspecting the skin and tissues to
determine perfusion (blood supply to an area) to the extremities. Certain aspects of
peripheral vascular assessment are often incorporated into other parts of the
assessment procedure. For example, blood pressure is usually measured at the
beginning of the physical examination.
Peripheral Pulses

 Palpate the peripheral pulses on both sides of the client's body individually,
simultaneously (except the carotid pulse), and systematically to determine the
symmetry of the pulse volume. If you have difficulty palpating some of the
peripheral pulses, use a Doppler ultrasound probe. There should be
symmetric pulse volumes and full pulsations.

Peripheral Veins

 Inspect the peripheral veins in the arms and legs for the presence and/or
appearance of superficial veins when limbs are dependent and when limbs are
elevated. In dependent position, there is the presence of distention or nodular
bulges at calves. When limbs are elevated, veins collapse (veins may appear
tortuous or distended in older people).
 Assess the peripheral leg veins for signs of phlebitis.
 Inspect the calves for redness and swelling over vein sites.
 Palpate the calves for firmness of tension of the muscles, presence of edema
over the dorsum of the foot, and areas of localized warmth.
 Push the calves from side to side to test for tenderness.
 Firmly dorsiflex the client's foot while supporting the entire leg in extension
(Homan's test), or have the person stand or walk.
 Limbs should not be tender. The limbs should be symmetric in size.

Peripheral Perfusion

 Inspect the skin of the hands and feet for color, temperature, edema, and
skin changes.
 Assess the adequacy of arterial flow if arterial insufficiency is suspected.
 It is normal if the skin color is pink, the temperature is not excessively warm
of cold, no edema, and skin texture is resilient and moist.

Buerger's test

(Arterial Adecuacy test)

 Assist the client to a supine position. Ask the client to raise one leg or one
arm about 30 cm or 1 ft above heart level, move the foot or hand briskly up
and down for about 1 minute, then sit up and dangle the leg or arm.
 Observe the time elapsed until return of original color and vein filling.
 It is normal if the original color returns in 10 seconds; and about 15 seconds
for the vein to fill in the hands or feet.
Capillary Refill Test

 Squeeze the client's fingernail and toenail between your fingers sufficiently to
cause blanching (about 5 seconds).
 Release the pressure, and observe how quickly normal color returns. Color
normally returns immediately (less than 2 seconds).

Deviations from Normal

 Asymmetric volumes (may indicate impaired circulation).

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

Overview

1. Peripheral vascular assessment includes portions of a skin assessment as well as

pulses and other indicators of perfusion

Nursing Points
General

1. Start with upper extremities, then move to lowers

Assessment

1. Upper extremities

a. Inspect

i. Color of skin and nail beds

ii. Lesions

iii. Edema

iv. Size of arms

1. Any difference bilaterally?

v. Presence of hair

b. Palpate

i. Temperature

ii. Texture

iii. Turgor

iv. Edema (pitting?)

1. See Integumentary assessment

c. Pulses

i. Brachial – medial aspect of elbow

ii. Radial – medial, anterior aspect of wrist, proximal to thumb joint

iii. Rating:

1. 0 = absent

2. +1 = weak

3. +2 = normal

4. +3 = strong

5. +4 = bounding

iv. Compare bilaterally

d. Capillary refill – press nail bed, see how long it takes for color to return

i. Should be less than 3 seconds

 e. If patient has an AV graft or fistula

i. Palpate for a thrill

ii. Auscultate for a bruit

2. Lower extremities

a. Inspect

i. Color of skin and nail beds

ii. Lesions

iii. Edema

iv. Size of legs

1. Any difference bilaterally?

v. Presence or absence of hair

vi. Venous pattern

1. Tortuous or varicose veins

b. Palpate

i. Temperature

ii. Texture

iii. Edema (pitting?)

1. See Integumentary assessment

c. Pulses

i. Popliteal – medial aspect of posterior knee joint

ii. Dorsalis pedis – dorsal aspect of foot between 1st and 2nd metatarsal

iii. Posterior tibial – along the medial malleolus

iv. Rating:

1. 0 = absent

2. +1 = weak

3. +2 = normal

4. +3 = strong
 5. +4 = bounding

v. Compare bilaterally

d. Capillary refill on toenails

i. Press nail bed, see how long it takes for color to return

1. Should be less than 3 seconds

3. Abnormal findings

a. Venous insufficiency

i. Dark discoloration of skin

ii. Absence of hair

iii. warm to touch

iv. Edema

v. Varicose veins

vi. “Tiredness” in legs

vii. Flaky skin

b. Arterial insufficiency

i. Erythematous skin

ii. Bright red ulcerations

iii. Edema

iv. Pain

v. Weakness

vi. Cool to touch

c. Absent pulses

i. Use doppler to confirm if truly absent

ii. Report to provider, especially if NEW finding

Nursing Concepts

1. Common to see peripheral vascular issues in patients with hyperlipidemia,

diabetes, and peripheral vascular disease
Flipped Classroom: For additional reference, you can click the actual video for vital
signs monitoring. https://www.youtube.com/watch?v=l_qgQub4cSQ