HEALTH ASSESSMENT

INTRODUCTION

Health assessment is a conscious and an on-going process in all health care settings. With the
increased emphasis on prevention, more importance is given to the periodic health examination.
Physical examination is an integral part of health examination and nurses play an important role in
doing physical examinations in varied situations. The accuracy of the nurses' assessment influences
the choice of therapies the client receives and the evaluation of the responses of these therapies.

A complete health assessment involves a nursing history and behavioral and physical
examination. A physical examination is a head-to-toe review of body systems that offers objective
information about the patient. Continuity in health care improves when we make ongoing, objective,
and comprehensive assessments.

DEFINITION

Health is a state of well-being. WHO defined it as "State of complete physical, mental and social
well-being and not merely the absence of disease and infirmity.” Health is a positive quality of life
which helps us to live life to its fullest and serve our fellowmen to the best of our ability. Health is a
condition of being sound in body, mind or spirit, especially freedom from physical disease or pain.

Assessment (ANA) "a systematic, dynamic process by which the nurse through interaction with
chient, significant others and health care providers, collects and analyzes data about client.”

Assessment refers to the collection and interpretation of clinical information. It focuses on

gathering the data about a client's state of wellness, functional ability, physical status, strengths and
responses to actual and potential health problems (Gordon, 1987; 1994)

It is systematic and continuous collection, validation and communication of client data as compared
to what is standard/norm. It includes the client's perceived needs, health problems, related
experiences, health practices, values and lifestyles.

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PURPOSES OF HEALTH ASSESSMENT

 To establish a database for the client's normal abilities, risk factors and any current alteration
in function.
 To plan strategies to encourage continuation of healthy patterns, prevent potential health
problems and alleviate or manage existing health problems.
 To provide a holistic view of the client.
 To formulate a conclusion or a problem statement such as a nursing diagnosis.
 To provide an essential foundation for the care of the client.
 To develop (obtain baseline data) and expand the database from which subsequent phases of
the nursing process can evolve.
 To identify and manage a variety of patient problems (actual and potential).
 To evaluate the effectiveness of nursing care.
 To enhance the nurse-patient relationship.
 To make clinical judgments.
 To collect data about physical, mental and social well-being of client.

COMPONENTS OF HEALTH ASSESSMENT

History Physical
taking + examination = Health assessment

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 HEALTH HISTORY

It is collecting information about the person, his family, socio-economic background, nutrition,
previous medical and surgical history, accidents and present illness, etc. History taking is getting the
subjective information. It helps to establish rapport with the client. It is a collection of subjective data
(in detail) regarding client's health in a chronological order.

Health History is a structured interview designed to collect specific data and to obtain a detailed
health record of a client. The health history is a collection of subjective data that includes information
on both the client's past and present health status.

PURPOSES OF HEALTH HISTORY

 To gather subjective data from client.

 To develop nursing diagnosis.
 To plan actions for
- Promoting health
- Preventing disease
 Alleviating acute problems.
 Minimize chronic health problems.
 To meet client's expectations for health.
 To compare client's health status with optimum health.

FACTORS AFFECTING THE COLLECTION OF SUBJECTIVE DATA

FACTORS AFFECTING COLLECTION OF SUBJECTIVE DATA

Physical Setting

Client's Personality and Behavior

Problem

Communication Skills

Nurse's Personality and Behavior

Nurse's Knowledge and Skill

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Favorable Conditions for Collecting Data

1) A relaxed environment should be provided i.e. introduce yourself to client, wish him.
 Call client with his name.
 Maintain eye to eye contact while communicating.
 Sit comfortably by maintaining a distance.
 Environment: provide room temperature, noise free environment.
2) Collect the information according to problem i.e.
 Client with acute problem: Information will be collected related to development of present
symptoms and associated difficulties.
 Healthy client come for routine medical checkup, information should be collected for taking
preventive measures, maintenance and promotion of health, identifying need for
immunization, eye and dental care etc.
3) Nurse must have up to date knowledge and skill especially communication i.e. active listener,
restate, pinpoint, confront, clarify ambiguity etc.
4) Nurse's personality behavior: Nurse should behave professionally with client. She should have
empathetic approach. Always treat client as human being regardless of his personality and
behaviour.

FORMAT OF HEALTH HISTORY

. FORMAT OF HEALTH HISTORY

Biographic Data
.
History of Present Illness

Past Health History

Family History

Occupational and Environmental History

Psychosocial History

Review of Body Systems

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1) Biographical data: The data is collected as soon as nurse encounters the client first time. It
includes Name, Age, Gender, Bed No., Ward, Medical Diagnosis, Surgery (if performed),
Religion, Education, Occupation, Family and Contact person.
2) Chief complaint: It is the brief statement of client's problem for which client seeks medical care.
- It should be written in client's statement.
- In case of multiple problems, ask client to indicate the priority of complaint.
- Write problems in chronological order.
- Avoid using medical terminology.

E.g. Client is complaining of general weakness from one month, cough from two weeks and fever
from two days, headache today, headache X 1 day.
Chief complaint:
 Fever X 2 days
 Cough X 14 days
 General weakness X 30 days

3) History related to Present Illness: It includes the expansion of chief complaints. We should
elaborate the present chief complaints in chronological order. It should include location, quality,
quantity, chronology, setting, exaggerating and relieving factors, associated symptoms, effect on
sleep, daily activities.
 Location: In which area of head, headache occurs.
 Quality:
- Whether the onset is sudden, gradual.
- Whether the pain is stabbing, dull, throbbing, and aching
- Is pain intermittent or continuous?
 Quantity: Degree of fever, severity of pain using 1-100 pain scale.
 Chronology: When these symptoms start, how frequently they occur.
 Setting: Where were you when symptom appears e.g. home, hospital, job etc. We should ask
about associated factors e.g. stress, rush, smoking, inhaling toxic fumes, factors which cause
symptoms.
 Associated symptoms: Does these symptoms disturb other body areas: Appetite, sleep
pattern, weakness, body ache.
 Exaggerating factors: Does symptoms occurrence is linked with activity such as smoking,
speaking loudly, eating, climbing, and change of body position.

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  Relieving factors: How the symptoms subside: i.e. doing meditation, taking rest, eating, home
remedies, and medications.

4) Past Health History: It is the collecting information regarding client's previous experience with
any disease, surgery. It is the overall assessment of client's health prior to present illness. It is
very important to collect information in this regard as previous illness may have impact/
associated with present illness.
Past health history includes:
 Allergies: Food (wheat), drugs (Betadine), chemicals (soap), environmental factors (pollution)
etc.
 Medical disease: Ask the client about his exposure to any medical problem such as
Hypertension, Diabetes, TB, Anemia, Seizures, Arthritis, Heart disease, Glaucoma etc. If
client suffered from these diseases, ask up to which level his daily activities are affected.
 Surgery: Ask the client for any previous surgery i.e. hysterectomy, valve replacement, knee
replacement etc. along with complete date. Also collect information regarding client's
response to surgery.
 Trauma, Injury: Fracture, abdominal trauma, burns, blunt / penetrating injury, altered
consciousness level.
 Hospitalization: Collect information whether client ever admitted in hospital, if yes why and
how long.
 Childhood diseases and immunization: Whether client is immunized for Tetanus, Hepatitis,
Diphtheria, Mumps, rubella, pertusis, polio etc.
 Obstetric History: Number of live births, abortions, mode of delivery, post-partum care etc.
 When last time, client undergone for investigation: dental problem, ESR, Blood count.

5) Family History: Gather information regarding health & first blood relatives, spouse and
children, as genetics and environmental factors contribute to occurrence of disease. It is
important to ask about family's health history. E.g. Sickle cells anemia, Hypertension, Diabetes
mellitus, Psychiatric problem, seizures, Malignancy, Kidney disease, Endocrine problems etc.
Along with this, ask about general health of family members. If all are alive, write their gender
and age. Occupational and Environmental History: It includes collecting data regarding
client's occupation, life style in job, working environment etc. Purpose of collecting such
information is to identify the risk factors or disease producing substances in the environment.

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Collecting information includes designation, location of work, exposure to hazardous material,
residing near mines, farms, factories or shipyard. Congestion, overcrowding, may spread
communicable diseases.

Physical and developmental

• Perception of health status
• Past health problems and therapies
• Present health therapies
• Risk factors
• Activity and coordination
• Review of systems
• Developmental stage
• Effect of health status on developmental stage
• Members of household marital problems
• Growth and maturation
• Occupation
• Ability to complete activities of daily living (ADL)

Emotional Intellectual
• Behavioral and • Intellectual pertormance
emotional status • Problem solving
• Support systems Client's • Educational level
• Self-concept health • Communication patterns
• Body image history • Attention span
• Mood • Long-term and recent
• Sexuality memory
• Coping mechanisms

Social
• Financial status Spiritual
• Recreational activities • Beliefs and meaning
• Primary language • Religious experiences
• Cultural role • Rituals and practices
• Cultural influences • Fellowship
• Community resources • Courage
• Environmental risk factors
• Social relationships

Fig: Dimensions for gathering data for a healthy history.

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6) Psychosocial History: It includes collecting the data regarding client's awareness about himself,
his relationship with other human beings. Focus of data is on client's education, life style,
personal relationships, working relations, social relation, schooling, marriage, siblings etc.,
client's knowledge about his disease. The impact of disease on his occupation, relation with
others, cause of AIDS, Hepatitis can be identified by gathering psychosocial history. This data
also gives clue about client's personality, his interests, emotional status, perception of life, drug
addiction, substance abuse, dietary pattern.
• Sleep and resting pattern: includes asking him about
- Hours of sleep, naps,
- Difficulty in sleeping,
- Any medicine intake for inducing sleep.
• Dietary pattern:
- Time of meal, likings: Spicy, fatty, any restrictions on diet, vegetarian or non-vegetarian,
vitamin supplement.

Ask client about his sexual behaviour whether illness has impact on sexual activity of client. About
sexual behaviour, data is gathered in the last stage of interview, because up to this stage, client feels
comfortable to express his feelings.

7) Review of systems: Information is gathered system wise to identify the problems which may be
ignored while taking present and past medical history, in routine, if body systems are reviewed
from head down to toe. Summarization of Health History is depicted as follows:

Health History

1. Biographical data:
a) Name
b) Gender
c) Date of birth
d) Place of birth
e) Sex
f) Age
g) Religion
h) Native language
i) Nationality

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 j) Marital status
k) Bed No.
l) IP No.
m) Address
n) Phone number
o) Name of the person living with the client, address, phone number, relationship (person to
be contacted in an emergency)
p) Occupation
q) Education
2. Health and illness patterns:
a) Chief complaints (reason for seeking health care)
b) History of present illness:
 Onset
 Location of symptoms
 Duration
 Precipitating factors
 Associated symptoms
 Treatments
 Current medications: Ask the client to list all the prescribed medications and over the
counter drugs he/she is taking. Record all substances, names and their doses. Ask if the
client is taking any herbs, vitamins and adopting home remedies. Ask if the client has any
side effects of medications.
c) Past health history:
 Childhood illnesses (dates and types)
 Immunizations
 Allergies
 Serious accidents and injuries (year/duration)
 Major adult illnesses (type and year/duration)
 Behavioral problems
 Surgical procedures (types and year/duration)
 Other hospitalizations (types and year/duration)
 Environmental hazards:
- Home
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 - Work
- Community
 Blood transfusions (given or received, dates).
d) Obstetric history:
 Age at menarche duration of menstrual cycle
 Age at marriage
 No. of children
 Date of menopause
e) Family health status:
 Type of family
 No. of members in the family
 Significant illness in the family

Family health patterns

Sl. Name of the Age Sex Marital Education Occupation Relation Health
no. family member status with client status

f) Personal habits and patterns of living:

 Work: Type, hours of work
 Duration of employment
 Stresses
 Rest and sleep: How much, when
 Exercise and ambulation
 Recreation, leisure, hobbies: Type and amount
 Nutritional patterns: Time, foods, fluids and amount for all meals (24 hour recall), snacks,
any changes in appetite, special diet.
 Alcohol and other drugs.
 Tobacco: Type, amount/day, duration of use.
 Allergies: Medicine, pollens, dust, cold, odema, etc.

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  Urinary and bowel activity
 Sexual activity.
g) Activities of daily living (ADL): Ask about the client's ability to perform (alone or with help)
the following activities:
 Physical activities of daily living:
- Ambulating
- Dressing
- Grooming
- Bathing
- Toileting
- Eating
 Instrumental activities of daily living:
- Doing laundry
- Housekeeping
- Obtaining access to the community
- Driving
- Purchasing foods
- Preparing meals
- Using the telephone
- Managing money
 Taking medications correctly
 Shopping
h) Psychosocial history: It is important and involves the client's relationship to others such as
family members, friends, neighbors, religious groups, colleagues and friends in social and
civic organizations in the community. Inquire about the following and document:
 Significant others, relationship, proximity
 Support systems needed and available
 Satisfaction with social contacts
 Typical 24 hour week day
 Satisfaction with employment/occupation/household responsibilities.
 Recreational activities enjoyed
 Leisure time activities pursued
 Sports enjoyed

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 i) Living arrangements:
 Alone, with family members or with others
 Number of rooms
 Number and ages of other individuals
 Feelings about home arrangements
j) Significant stressors:
 Coping ability
 Feelings about self: Self-concept, functional status, independence, body image, mental
status, sexuality.
 History of interpersonal trauma: Rape, incest, abuse as child or spouse, other personal
tragedies.
 Understanding and feelings about current illnesses.
k) Spiritual concerns and needs:
 Concept of God
 Source of strength
 Values based on religious practices and rituals
 Spiritual adviser
 Role and relationship with an organized religious group.

Document the health history clearly and concisely. Personal biases and opinions should be omitted.
Avoid specific descriptions that label a finding as normal. Record pertinent negatives, e.g. client
denies family history of diabetes. Summary of significant health history data should be written
because it forms a source of nursing diagnoses.

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 PHYSICAL EXAMINATION

Physical assessment is an organized systemic process of collecting objective data based

upon a health history and head to -toe or general system examination.. It provides the foundation for
the nursing care plan. It can be a complete physical assessment, an assessment of a body system or a
body.

The physical examination involves the gathering of objective, observable information

undistorted by client perceptions. The examiner looks for abnormalities that may yield information
about past, present, and future health problems. The physical examination is conducted after the
nursing health his-tory so that historical data can be verified. In addition, new data are obtained
during the examination.

DEFINITION

According to Wilson and Giddens ,2005 , defined Physical examination as a process of collecting
observable data by the nurse using techniques of inspection , palpation , percussion and auscultation .

According to Kozier , A physical examination is an evaluation of the body and its functions using
inspection , palpation ( feeling with the hands) , percussion (tapping with the fingers) , percussion
(tapping with the fingers) , and auscultation (listening ) . A Complete health assessment also includes
gathering information about a person’s medical history and lifestyle , doing laboratory tests, and
screening for disease .

PURPOISES OF PHYSICAL EXAMINATION

1. It helps to gather baseline information/data regarding the client's health status at the time of
hospitalisation.
2. To supplement, conform and add to data obtained from nursing history.
3. The purpose of physical assessment is to identify normal and deviations from normal.
4. Nurses use the information to identify deviations in health patterns of the patient.
5. It is also used to derive nursing diagnosis on which planning; nursing interventions and evaluation
are based.
6. It is used as a health maintenance procedure for people who are well (e.g. self-examination of
breasts in early
7. detection of cancer).
8. It offers an opportunity for health teaching, e.g. breast and testicular self-examination.

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PREREQUISITES FOR PHYSICAL ASSESSMENT

1. COMPETENCY SKILLS NEEDED FOR PHYSICAL EXAMINATION

Medical personal working in Hospital must be medically fit. He must have intact all the senses:

 Hearing
 Viewing
 Touching
 Tasting
 Smelling

2) Thoroughness: Physical examination must be done systematically and thoroughly. Thoroughness

means collect information by examining all body systems.

3) Knowledge: Examiner must be confident. He should have upto date knowledge as well as skill in
examining client as well as detecting the problems.

4) Concentration: Do the examination with full concentration. Dedication towards work is very
important.

5) Accurate technique: Make sure that accurate technique is used to collect information. Follow all
the steps of procedure. It helps in avoiding errors in detecting problem.

6) Objectivity: Avoid personal judgments, bias, clues while examining the client. Make

inference based upon findings.

2. CULTURAL SENSITIVITY

Respect the cultural sensitivity among patients from a variety of backgrounds when completing an
examination. It is important to remember that cultural differences influence patient behaviors.
Consider the patient's health beliefs, use of alternative therapies, nutrition habits, relationships with
family, and comfort with physical closeness during the examination and history. .Be culturally aware
and avoid stereotyping on the basis of gender, race, education or other cultural factors. There is a
difference between cultural and physical characteristics. Learn to recognize common characteristics
and disorders among members of ethnic populations within the community.

3. PREPARING THE ENVIRONMENT

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It is important to prepare the environment before starting the assessment. The time for the physical
assessment should be convenient to both the client and the nurse. The environment needs to be well
lighted and the equipment should be organized for efficient use. A client who is physically relaxed
will usually experience little discomfort. The room should be warm enough to be comfortable for the
client.

4. PRIVACY

Providing privacy is important. Culture, age, and gender of both the client and the nurse influence
how comfortable the client will be and what special arrangements might be needed. For example, if
the client and nurse are of different genders, the nurse should ask if it is acceptable to perform the
physical examination or if a nurse of the same gender is preferred. Family and friends should not be
present unless the client asks for someone.

5. POSITIONING

Several positions are frequently required during the physical assessment. It is important to consider
the client's ability to assume a position. The client's physical condition, energy level, and age should
also be taken into consideration. Some positions are embarrassing and uncomfortable and therefore
should not be maintained for long. The assessment is organized so that several body areas can be
assessed in one position, thus minimizing the number of position changes needed

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6. DRAPING

Drapes should be arranged so that the area to be assessed is exposed and other body areas are covered.
Exposure of the body is frequently embarrassing to clients. Drapes provide not only a degree of
privacy but also warmth. Drapes are made of paper, cloth, or bed linen.

7. INSTRUMENTATION

All equipment required for the health assessment should be clean, in good working order, and readily
accessible. Equipment is frequently set up on trays, ready for use.

EQUIPMENT AND SUPPLIES FOR PHYSICAL ASSESSMENT

 Cervical brush or broom (if needed )

 Cotton applicators
 Disposable pad/ paper towels
 Drapes
 Eye chart ( eg. Snellen chart )

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 Flashlight and spot light
 Forms ( eg. Physical , laboratory )
 Gloves ( sterile or clean )
 Gown for patient
 Ophthalmoscope
 Otoscope
 Papanicolaou (Pap) liquid prep (if needed)
 Percussion ( reflex hammer )
 Pulse oximeter
 Ruler
 Scale with height measurement rod
 Specimen containers , slides , wooden or plastic spatula , and cytologic fixative ( if needed)
 Sphygmomanometer and cuff
 Sterile swabs
 Stethoscope
 Tape measure
 Thermometer
 Tissues
 Tongue depressors
 Tuning fork
 Vaginal speculum ( if needed)
 Water soluble lubricant
 Wrist watch with second hand or digital display

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8.PHYSICAL PREPARATION

The patient's physical comfort is vital for a successful examination. Before starting,

 Ask if the patient needs to use the restroom. An empty bladder and bowel facilitate examination of
the abdomen, genitalia, and rectum. If needed, collect urine or fecal specimens at this time. Be sure
to explain the proper method for collecting specimens, and make sure to label each specimen
properly.
 Physical preparation involves being sure the patient is dressed and draped properly. The patient in
the hospital will be wearing a simple gown. An outpatient will have to undress and wear a light
cover gown. If the examination is limited to certain body systems, it is not always necessary for the
patient to undress completely.
 Provide the patient privacy and plenty of time during undressing.
 Walking into the room as the patient undresses causes embarrassment. Drapes and gowns are
made of linen or disposable paper. After patients have undressed and put on a gown, they sit or lie
down on the ex- amination table with the drape over the lap or lower trunk.
 Make sure the patient stays warm by eliminating drafts, controlling room temperature, and
providing warm blankets. Routinely ask if the patient is comfortable.

9. PSYCHOLOGICAL PREPARATION

Many experience anxiety about possible findings. A thorough explanation of the purpose and steps of
each assessment lets patients know what to expect and what to do so that they can cooperate.

 Keep explanations simple and clear. Help patients feel free to ask questions and mention any
discomfort.
 As the patients examine each body system, give a more detailed explanation.
 Convey an open, professional and relaxed approach. A stilt, formal approach will inhibit the
patient's ability to communicate, but being too casual will not give the patient confidence in your
ability (Seidel and others, 2006).
 When the patient and nurse are of opposite gender, It helps to have a third person of the patient's
gender in the room. The presence of a third person assures the patient that you will behave
ethically. This person is also a witness to the conduct of the examiner and the patient.
 During the examination, watch the patient's emotional responses. Observe whether the patient's
facial expression shows fear or concern and if body movements show anxiety. Remain calm, and

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 explain each step clearly. It is sometimes necessary to stop the examination and ask how the
patient feels. Do not force a patient to continue.
 Postponing the examination is advantageous because the findings will be more accurate when the
patient can cooperate and relax. If the Patient's fears result from misconceptions, clarify the
purpose of the examination and how you will perform it.

METHODS OF EXAMINING

Four primary techniques are used in the physical examination :

 Inspection
 Palpation
 Percussion
 Ausculatation
 Olfaction
 Manipulation
1.INSPECTION

Inspection is the visual examination, that is, assessing by using the sense of sight. It should be
deliberate, purposeful, and systematic. The nurse inspects with the naked eye and with a lighted
instrument such as an otoscope (used to view the ear). In addition to visual observations, olfactory
(smell) and auditory (hearing) cues are noted. Nurses frequently use visual inspection to assess
moisture, color, and texture of body surfaces, as well as shape, position, size, color, and symmetry of
the body.

Lighting must be sufficient for the nurse to see clearly; either natural or artificial light can be used.
When using the auditory senses it is important to have a quiet environment for accurate hearing.
Observation can be combined with the other assessment techniques.

2.PALPATION
Palpation is the examination of the body using the sense of touch. The pads of the fingers are used
because their concentration of nerve endings makes them highly sensitive to tactile discrimination.
Different parts of the hands are used for palpating certain areas

Part of hand Types of palpation

Finger tips To assess texture, shape , size , consistency and

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 palpation
Dorsum of hand and fingers To assess temperature
Palm of hand To assess vibrations
Pinching of fingers To assess turhor consistency and position

A Palpation is used to determine

(a) texture (e.g., of the hair);
(b) temperature (e.g., of a skin area);
(c) vibration (e.g., of a joint);
(d) position, size, consistency, and mobility of organs or masses;
(e) distention (e.g., of the urinary bladder);
(f) pulsation; and
(g) the presence of pain upon pressure.
TYPES OF PALPATION
There are two types of palpation: light and deep.
Light (superficial) palpation
 It should always precede deep palpation because heavy pressure on the fingertips can dull the
sense of touch. For light palpation, the nurse extends the dominant hand's fingers parallel to
the skin surface and presses gently while moving the hand in a circle .
 With light palpation, the skin is slightly depressed about 1 cm ( ½ inch ) . If it is necessary to
determine the details of a mass, the nurse presses lightly several times rather than holding the
pressure.

Deep palpation

 It is done with two hands (bimanually) or one hand and depressed for 2.5 cm or ( 1 inch)

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 In deep bimanual palpation, the nurse extends the dominant hand as for light palpation, then
places the finger pads of the nondominant hand on the dorsal surface of the distal
interphalangeal joint of the middle three fingers of the dominant hand

Fig : Deep bimanual palpation

 The top hand applies pressure while the lower hand remains relaxed to perceive the tactile
sensations.
 For deep palpation using one hand, the finger pads of the dominant hand press over the area
to be palpated. Often the other hand is used to support a mass or organ from below

Figure showing deep palpation with one dominant hand and other supporting the organ .

 Deep palpation is usually not done during a routine examination and requires significant
practitioner skill. It is performed with extreme caution because pressure can damage internal
organs. It is usually not indicated in clients who have acute abdominal pain or pain that is not
yet diagnosed.
 To test skin temperature, it is best to use the dorsum or back of the hand and fingers, where
the examiner's skin is thinnest.
 To test for vibration, the nurse should use the palmar surface of the hand.

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General guidelines for palpation include the following:
1. The nurse's hands should be clean and warm, and the fingernails short.
2. Areas of tenderness should be palpated last.
3. Deep palpation should be done after superficial palpation.
The effectiveness of palpation depends largely on the client's relaxation. Nurses can assist a client to
relax by
(a) gowning and/or draping the client appropriately,
(b) positioning the client comfortably, and
(c) ensuring that their own hands are warm before beginning. During palpation, the nurse should be
sensitive to the client's verbal and facial expressions indicating discomfort.

3.PERCUSSION
Percussion is the act of striking the body surface to elicit sounds that can be heard or vibrations that
can be felt. There are two types of percussion: direct and indirect and blunt percussion .
A. In direct percussion
The nurse strikes the area to be percussed directly with the pads of two, three, or four fingers or with
the pad of the middle finger. The strikes are rapid, and the movement is from the wrist

Figure showing direct percussion. This technique is not generally used to percuss the thorax but is
useful in percussing an adult's sinuses.

B. Direct Percussion

It is the striking of an object (e.g., a finger) held against the body area to be examined. In this
technique, the middle finger of the nondominant hand, referred to as the pleximeter, is placed firmly
on the client's skin. Only the distal phalanx and joint of this finger should be in contact with the skin.

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 Using the tip of the flexed middle finger of the other hand, called the plexor, the nurse strikes the
pleximeter, usually at the distal interphalangeal joint

Figure showing indirect percussion

 Some nurses may find a point between the distal and proximal joints to be a more comfortable
pleximeter point. The motion comes from the wrist; the forearm remains stationary. The angle
between the plexor and the pleximeter should be 90 degrees, and the blows must be firm, rapid,
and short to obtain a clear sound.
 Percussion is used to determine the size and shape of internal organs by establishing their borders. It
indicates whether tissue is fluid filled, air filled, or solid. Percussion elicits five types of sound:
flatness, dullness, resonance, hyperresonance, and tympany.
- Flatness is an extremely dull sound produced by very dense tissue, such as muscle or bone.
- Dullness is a thudlike sound produced by dense tissue such as the liver, spleen, or heart.
- Resonance is a hollow sound such as that produced by lungs filled with air.
- Hyperresonance is not produced in the normal body. It is described as booming and can be heard
over an emphysematous lung.
- Tympany is a musical or drumlike sound produced from an air-filled stomach. On a continuum,
flatness reflects the most dense tissue ( the least amount of air ) and tympany the least dense tissue
( the greatest amount of air ) . A percussion sound is described according to its intensity , pitch ,
duration and quality .
C. Blunt Percussion

In this , the nurse strikes the ulnar surface of her fist against the body surface . Alternatively , she may
used both hands by placing the palm of one hand over the area to be percussed . Then , making a fist
with the other hand and using it to strike the back of the first hand . Both techniques are aimed to
elicit tenderness not to create a sound over such organs as kidneys, gall bladder ,or liver . ( another

25
blunt percussion method , used in the neurological examination , involves tapping a rubber tipped
hammer against aa tendon to create a reflex muscle contraction . )

PERCUSSION SOUND

1. Tympany sounds like a drum and is heard over air pockets

2. Resonance is a hollow sound heard over areas where there is a solid structure and some air
(lungs the lungs )
3. Hyperresonance is a booming sound heard over air such as in emphysema .
4. Dullness is heard over solid organs or masses
5. Flatness is heard over dense tissues including muscle and bone.
.
4. AUSCULTATION
Auscultation is the process of listening to sounds produced within the body. Auscultation may be
direct or indirect.
Direct auscultation is the use of the unaided ear . for example, to listen to a respiratory wheeze or
the grating of a moving joint.
Indirect auscultation is the use of a stethoscope, which transmits the sounds to the nurse's ears. A
stethoscope is used primarily to listen to sounds from within the body, such as bowel sounds or
valve sounds of the heart and blood pressure.
- The stethoscope tubing should be 30 to 35 cm (12 to 14 in.) long, with an internal diameter
of about 0,3 cm (1/8 in.). It should have both a flat disc diaphragm and a bell-shaped
amplifier

- The diaphragm best transmits high-pitched sounds (e.g., bronchial sounds), and the bell best
transmits low-pitched sounds such as some heart sounds. The earpieces of the stethoscope
should fit comfortably into the nurse's ears, facing forward.

26
 - The amplifier of the stethoscope is placed firmly but lightly against the client's skin. If the
client has excessive hair, it may be necessary to dampen the hairs with a moist cloth so that
they will lie flat against the skin and not interfere with clear sound transmission.
Auscultated sounds are described according to their pitch, intensity, duration, and quality.
 The pitch is the frequency of the vibrations (the number of vibrations per second).
 Low-pitched sounds, such as some heart sounds, have fewer vibrations per second than high-
pitched sounds, such as bronchial sounds.
 The intensity (amplitude) refers to the loudness or softness of a sound.
Some body sounds are loud, for example, bronchial sounds heard from the trachea; others are soft,
for example, normal breath sounds heard in the lungs. The duration of a sound is its length (long or
short). The quality of sound is a subjective description of a sound, for example, whistling, gurgling,
or snapping.
5.OLFACTION
Olfaction helps to detect abnormalities not recognised by other means and this can help to detect
serious abnormalities. Assessment of characteristic odors is presented in Table

SITE / SOURCE ODOUR CAUSE

Oral cavity alcohol Ingestion of alcohol

Urine Ammonia Urinary tract infection

Skin Body odour Poor hygiene

Wound site Foul smelling Wound abscess

Vomitus Foul smelling Bowel obstruction

Rectal area Foul smelling Faecal incontinent

Stool Foul smelling Mal absorption syndrome

Oral cavity Halitosis sweet fruity / Poor dental hygiene / diabetic acidosis
acetone

Skin Stale urine Uremic acidosis

Draining wound Sweet heavy thing odour Pseudomonas infection

Casted body part Musty odour Infection inside cast

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6. MANIPULATION
It is the moving of a part of the body to note its flexibility . Limitation of movement is
discovered by this movement . Manipulation is the act, process, or an instance of manipulating
especially a body part by manual examination and treatment especially : adjustment of faulty
structural relationships by manual means (as in the reduction of fractures or dislocations or the
breaking down of adhesions).
Eg . The use of deep massage, spinal alignment, and joint manipulation to stimulate tissues.
Manipulation should be performed only after conducting a thorough subjective examination,
medical exam, and neurological exam to rule out the presence of sinister or red flag
conditions.

The word “manipulation” can mean many things in the health care field, some good and some
bad. To highlight an example of a good meaning of manipulation, we peer into its essence in
physical therapy. This term specifically refers to applying mobilizations to joints at varying
degrees of needed intensity. If gentle mobilizations are required to heal the patient, that is
what is performed. If the patient needs a stronger movement (aggressive mobilization or
manipulation), it can be performed in effective ways with varying speeds and amplitudes,
including a small amplitude/ high-velocity therapeutic movement within or at end range of
motion.

28
 VITAL SIGNS

INTRODUCTION

The vital signs or cardinal signs are body temperature, pulse, respirations, and blood pressure. These
signs should be looked at in hotel , to monitor the vital functions of the body . The signs should be
looked at in total , to monitor the vital functions of the body . The signs reflect changes in functions
that otherwise it might not be observed .

Vital signs are the measurements that provide data and can be used to determine the patient’s usual
state of health .

PURPOSES TO MONITOR VITALS SIGNS

1. To assess the health-status of an individual.

2. To plan and implement the nursing care.

3. To understand the effectiveness of the treatment.

4. To modify or change the mode of treatment.

5. Routine part of complete physical assessment.

6. It helps to understand the present problem.

TIMINGS OF TAKING VITALS

1. On patient's admission to a health care facility.

2. In hospital, on routine schedule according physician's order or hospital policy.
3. During patient's visit to clinic or physician's office.
4. Before and after any surgical procedure.
5. Before and after any invasive diagnostic procedure.
6. Before and after administration of medication that affect cardiovascular, respiratory and
temperature control function.
7. When the patient's general physical condition changes, e.g. loss of consciousness or increase in
intensity of pain.
8. Before and after nursing interventions influencing any one of the vital signs, e.g. before
ambulating a patient previously on bed rest or before patient performs range of motion exercises.

29
9. Whenever patient reports to nurse any non-specific symptoms of physical distress, e.g. "feeling
funny or different.
PRINCIPLES
1. Vital signs are governed by vital organs and often reveal even the slightest deviation from the
normal body functions.
2. The changes in the condition of the patient improvement or regression may be detected by the
observation of these signs.
3. .Significant variations in these findings may indicate problems regarding to insufficient
consumption.
4. Through vital signs, specific information may be obtained that will help in the diagnosis
treatment medications and nursing care.
5. Patients emotional state may also cause a significant variation in these symptoms.

METHODS OF MEASUREMENT
- Inspection: Inspection means observing with the eye and is associated with light and seeing.
- Percussion: Percussion is tapping an area to elicit sounds.
- Auscultation: Auscultation is listening to sounds within the body with a stethoscope.
- Palpation: Palpation is the art of feeling with the hand.
NORMAL VALUES
1. Temperature-
2. 98.6°F or 37°C in adults.
3. Pulse-_-72 beats/minute in adults.
4. Respiration-16 breaths/ minute in adults.
5. Blood pressure-120/80 mm Hg in adults.
GUIDELINES FOR TAKING VITAL SIGNS
1. The primary nurse caring for the client is the best one to take vital signs, interpret their
significance and make decisions about care.
2. Equipment used to measure vital signs must be appropriate and work properly to ensure accurate
finding.
3. Knowing the normal range for all vital signs helps the nurse detect abnormalities.
4. A client's normal range may differ from the standard range for that age or physical state.
Normal values for a client serve as a baseline for comparing in condition over time.
5. Know the client's medical history and therapies or medication, for vital sign changes.

30
6. Control or minimize environmental factors that may affect vital signs. Measuring a pulse after
client experiences an emotional upset, many yield values that are not clear indicators of the
client's current status.
7. An organized, systematic approach when taking vital signs ensures, accuracy of findings.

TEMPERATURE

Temperature is a measurement of heat expressed in degrees. Body temperature may be defined as

the degree of heat maintained by the body. Temperature means the degree of warmth or balance
maintained between the heat produced (thermogenesis) and heat lost (thermolysis) in the body.

Temperature is defined as measuring/monitoring patient's body temperature using clinical

thermometer.

PURPOSES

1. To determine body temperature.

2. To assist in diagnosis.

3. To evaluate the patients recovery from illness.

4. To plan immediate nursing interventions.

5. To evaluate the patients response.

6. To recognize any variation from the normal and its significant.

INDICATIONS

1. Routine part of assessment on admission for establishing a baseline data.

2. As per agency policy to monitor any change in patient condition.

3. Before, during and after administration of any drug that affects temperature control function.

4. When general condition of patient changes.

5. Before and after any nursing intervention that affects temperature of the patient.

31
NORMAL BODY TEMPERATURE FOR ADULTS

Oral: 37°C or 98.6°F

Rectal: 37.6°C or 99.6°F

Axilla: 36.4°C or 97.6°F

FACTORS INFLUENCING HEAT PRODUCTION

1. Metabolism- oxidation of food.

2. Muscle activity- exercise
3. Strong emotional- excitement anxiety and nervousness
4. Change in atmospheric temperature.
5. Disease condition-_bacterial invasion.
6. Sympathetic stimulation -epinephrine and norepinephrine.

FACTORS INFLUENCING HEAT LOSS

1. Sleep: Body temperature is low.

2. Fasting: Leads to decreased heat production.
3. Illness and lower vitality: Due to depressed nervous system, the heat production is lowered.
4. Prolonged exposure to cold.
5. Use of narcotic drugs.

BODY HEAT IS LOST THROUGH

 Conduction: Transfer of heat from body to substance (air,water and cloths) directly in contact.
 Radiation: Transfer of heat from body to heat waves which travel through the space.
 Evaporation: Transfer of heat from body in form of vapors (liquid is converted into vapors)
 Convection: Transfer of heat from the surface of one subject to the surface, such as skin of
another by movements of heated air or fluid particles.

PREPARATION

1. If a thermometer is included in the admission pack, keep it at the patient's bedside and, on
discharge, allow him to take home.
2. Otherwise, obtain a thermometer from the nurse's station or central supply department.
3. If use an electronic thermometer, make sure it is been recharged.

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EQUIPMENTS

1. Mercury or electronic thermometer, chemical dot thermometer or tympanic thermometer.

2. Water soluble lubricant or petroleum jelly (for rectal temperature).

3. Facial tissue.

4. Disposable thermometer sheath or probe cover.

5. Alcohol sponge.

COMMON SITES FOR TAKING BODY TEMPERATURE

1. Mouth.

2. Axilla.

3. Groin.

4. Vagina.

5. Rectum.

CONTRAINDICATIONS

 Oral Method

1. Patients who are not able to hold thermometer in their mouth.

2. Patients who may bite the thermometer like psychiatric patients.

3. Infants and small children.

4. Surgery / infection in oral cavity.

5. Trauma to face/ mouth.

6. Mouth breathers.

7. Patients with history of convulsion.

8. Unconscious/ semiconscious/ disoriented patients.

9. Patient with chills

10. Uncooperative patients

33
 11. Patients who cannot follow instructions

 RECTAL METHOD
1. Patients after rectal surgery
2. Any rectal pathology (piles/ tumor)
3. Patients having difficulty in assuming required position .
4. Acute cardiac patient
5. Patients having diarrhea
6. Reduced platelet count
 AXILLARY METHOD
1. Any surgery / lesion in axilla

PROCEDURE FOR TAKING TEMPERATURE AT DIFFERENT SITES

A. ORAL TEMPERATURE

Temperature check by the oral cavity .

PURPOSE

1. To determine the body temperature of the patient.

2. To aid in making diagnosis.

GENERAL INSTRUCTIONS

1. Position the tip of the thermometer under the patient's tongue, as far back as possible on either
side of the frenulum linguae.
2. Placing the tip in this area promotes contact with superficial blood vessels and contributes to an
accurate reading.
3. Instruct the patient to close his lips, but to avoid biting down with his teeth
4. Biting can break the thermometer, cutting the mouth or lips or causing ingestion of broken
glass or mercury
5. Leave a mercury thermometer in place for at least 2 minutes or a chemical dot thermometer in
place for 45 seconds to register temperature, for an electronic thermometer; wait until the
maximum temperature is displayed.

34
 6. For a mercury thermometer, remove and discard the disposable sheath then read the
temperature at eye level, noting it before shaking down the thermometer, note the temperature
and then remove and discard the probe cover.
7. For the chemical dot thermometer, read the temperature as the last dye dot that has changed
color or fired, then discard the thermometer and its dispenser case.

PRELIMINARY ASSESSMENT

1. Determine the need to measure client's body temperature.

2. Assemble equipment.
3. Identify the patient, greet the patient and explain the procedure.
4. Place the client in comfortable position, assess site
5. Most appropriate for temperature measurement. Wait 20 to 30 minutes before measuring oral
temperature, if client has ingested hot or cold liquid or foods.

EQUIPMENTS

1. Oral clinical thermometer.

2. Swab in a container.
3. Kidney basin or thermometer container.
4. Blue pen.
5. Watch with second hand.
6. Graphic TPR chart to check temperature, pulse and respiration
7. Paper bag.

PROCEDURES

1. Hold the color coded end or system glass thermometer with finger tips
2. If thermometer stored in disinfectant solution, rinse in cold water before using.
3. Take swab and wipe thermometer bulb end towards fingers in rotating fashion. Dispose off
tissue.
4. Read mercury level while holding thermometer horizontally and gently rotating at eye level. If
mercury is above desired level, grasp at the tip of thermometer securely and sharply flick wrist
down ward. Continue shaking until reading is below 35.5°C
5. Ask client to open mouth and gently place thermometer under tongue in posterior sublingual,
lateral to center of lower jaw.
6. Ask client to hold thermometer with lips closed .Caution against biting down on thermometer.

35
7. Leave thermometer in place for 2 minutes or according to agency policy
8. Carefully remove thermometer and read at eye level while holding thermometer horizontally.

36
 AFTERCARE

1. Wipe secretions from thermometer with soft tissue. Wipe in rotating fashion from fingers
towards bulb. Dispose of tissue.
2. Wash thermometer in lukewarm water, rinse in cool water, dry and replace in container.
3. Record the temperature on the chart.
4. Wash hands.
5. Report any unusual variation to the charge nurse.

CONTRAINDICATIONS

1. Injuries, inflammation and surgeries of oral cavity. Infants, children below 6 years and
patients who cannot retain thermometer in mouth.
2. Unconscious, delirious, non-cooperative and mentally disturbed patients
3. Patients with mouth breathing, convulsions, oxygen masks, frequent and severe cough.

A. AXILLARY TEMPERATURE

The temperature is sometimes taken by axilla when it cannot be taken by mouth or contraindicated to
check oral temperature.

PURPOSES

1. To determine the body temperature of the patient.

2. To aid in making diagnosis.

GENERAL INSTRUCTIONS

1. Position the patient with the axilla exposed.

2. Gently pat the axilla dry with a facial tissue because moisture conducts heat. Avoid harsh
rubbing, which generates heat.
3. Ask the patient to reach across his chest and grasp his opposite shoulder and to lower his elbow
and hold it against his chest. This promotes skin contact with the thermometer.
4. Remove a mercury thermometer after 10 minutes; remove an electronic thermometer when it
displays the maximum temperature. Axillary temperature takes longer to register than oral or
rectal temperature because the thermometer is not closed in a body cavity.
5. Grasp the end of the thermometer and remove it from the axilla.

37
PRELIMINARY ASSESSMENTS

1. Determine the need to measure client's body temperature.

2. Assemble equipment.
3. Identify the patient, greet the patient and explain the procedure.
4. Place the client in comfortable position, assess site most appropriate for temperature
measurement.
5. Wait 20 to 30 minutes before measuring oral temperature, if client has ingested hot or cold
liquid or foods.
6. Hold the color coded end or system glass thermometer with finger tips.
7. If thermometer stored in disinfectant solution, rinse in cold water before using
8. Take swab and wipe thermometer bulb end towards fingers in rotating fashion. Dispose off
tissue.
9. Read mercury level while holding thermometer horizontally and gently rotating at eye level. If
mercury is above desired level, grasp at the tip of thermometer securely and sharply flick wrist
downward. Continue shaking until reading is below 35.5°C.

EQUIPMENTS

1. Oral clinical thermometer.

2. Swab in a container.
3. Kidney basin or thermometer container.
4. Blue pen.
5. Watch with second hand.
6. Graphic PR chart to check temperature, pulse and respiration.
7. Paper bag.

38
PROCEDURES

1. Dry the axilla.

2. Insert thermometer into center of axilla, low the arm over thermometer, and place arm across
client's chest.
3. Leave the thermometer in place for 3 minutes or according to agency policy.
4. Remove the thermometer from the axilla
5. Wipe the thermometer using a spirit swab from stem to bulb use a firm twisting motion.

AFTERCARE

1. Discard the used swab into the paper bag.

2. Read the thermometer by holding it horizontally at the eye level and rotate it until the mercury
column is seen.
3. Place thermometer in the kidney basin.
4. Record the temperature on the chart using blue pen and mention axillary.
5. Wash hands.
6. Report any unusual variations to the charge nurse.
7. Recording and reporting. Record temperature on vital sign flow sheet's or nurse's notes. Also
record any signs or symptoms of temperature alterations.
B. RECTAL TEMPERATURE

Rectal temperature measurement is a technique used to measure body temperature by placing a

thermometer in the rectum.

PURPOSES

1. To determine body temperature mainly for infants, young children, adult, unconscious patient
and postoperative patient.
2. To aid in making diagnosis.

INDICATIONS

1. Unconscious patient.
2. Neonates.

3. Malignant--hyperthermia.

39
GENERAL INSTRUCTIONS

1. Position the patient on his side with his top leg flexed and drape him to provide privacy. Then
fold back the bed linens to expose the anus.
2. Squeeze the lubricant onto a facial tissue to prevent contamination of the lubricant supply.
3. Lubricate about ½ inch of the thermometer tip for an infant, 1 inch for a child or about for an
adult. Lubrication reduces friction and thus eases insertion. This step may be unnecessary when
using disposable rectal sheaths because they are pre lubricated.
4. Lift the patient's upper buttock and insert the thermometer about 1.3 cm for an infant 3.8 cm for
an adult. Gently direct the thermometer along the rectal wall towards the umbilicus. This will
avoid perforating the anus or rectum or breaking the thermometer. It also will help ensure an
accurate reading because the thermometer will register hemorrhoid artery temperature instead of
fecal temperature.
5. Hold the mercury thermometer in place for 2 to 3 minutes or the electronic thermometer until the
maximum temperature is displayed. Holding the thermometer prevents damage to rectal tissues
caused by displacement or loss of the thermometer.
6. Carefully remove the thermometer, wiping it as necessary. Then wipe the patient's anal area to
remove any lubricant or feces.

PRELIMINARY ASSESSMENTS

1. Determine the need to measure client's body temperature.

2. Assemble equipment.
3. Identify the patient, greet the patient and explain the procedure.
4. Place the client in comfortable position, assess site most appropriate for temperature
measurement.
5. Wait 20 to 30 minutes before measuring oral temperature, if client has ingested hot or cold liquid
or foods. Hold the color coded end or system glass thermometer with finger tips.
6. If thermometer stored in disinfectant solution, rinse in cold water before using.
7. Take swab and wipe thermometer bulb end towards fingers in rotating fashion. Dispose off
tissue.
8. Read mercury level while holding thermometer horizontally and gently rotating at eye level. If
mercury is above desired level, grasp at the tip of thermometer securely and sharply flick wrist
down ward.
9. Continue shaking until reading is below 35.5°C.

40
41
EQUIPMENTS

1. Oral clinical thermometer.

2. Swab in a container.
3. Kidney basin or thermometer container.
4. Blue pen.
5. Watch with second hand
6. Graphic TPR chart.

7. Paper bag.

PROCEDURES

1. Draw curtain around client's bed or close room door. Assist client to Sims position with upper
leg flexed. Move aside bed linen to expose only anal area.
2. Squeeze liberal portion of lubricant on tissue. Dip thermometer's bulb end in to lubricant,
covering 2.5 to 3.5 cm (1-1.5 inch) for adult or 1.2 to 2.5 cm (0.5-1 inch) for infant.
3. With non-dominant hand, separate client's buttocks to expose anus. Ask client to breathe slowly
and relax.
4. Gently insert thermometer into anus in direction of umbilicus insert 1.2 cm (0.5 inch) for infant
and 3.5 cm (1.5 inches) for adult do not force thermometer. If resistance is felt during insertion
withdraw thermometer immediately.
5. Hold thermometer in place for 2 minutes or according to agency policy.
6. Carefully remove thermometer and wipe off secretions with tissue. Wipe in rotating fashion
from fingers towards bulb. Dispose of tissue.
7. Read thermometer at eye level rotate until scale appears.
8. Wipe client's anal area to remove lubricant or feces and discard tissue help client return to
comfortable position.

AFTERCARE

1. Wipe secretions from thermometer with soft tissue. Wipe in rotating fashion from fingers
towards bulb.
2. Dispose of tissue.
3. Wash thermometer in lukewarm water, rinse in cool water, dry and replace in container.Record
the temperature on the chart.
4. Wash hands.

42
5. Report any unusual variation to the charge nurse.

CONTRAINDICATIONS

1. Injury, inflammation and surgeries of rectum.

2. Fecal impaction.

3. Chronic diarrhea.

4. Patients requiring bowel wash / enema.

TYPES OF THERMOMETER

1. Clinical Thermometer

Clinical thermometer is an instrument used for measuring temperature of bodily heat or cold in
which the mercury remains stationary at registration point until shaken down.

2. Electronic Thermometer

Electronic thermometer consist of a battery powered display unit, a thin wire cord and a temperature
sensitive probe covered by a disposable plastic sheath to prevent transmission of infection separate
probes are available for oral and rectal insertion.

3. Disposable Thermometer

Disposable thermometer is a single use thermometer, made of thin plastic strips with chemically
impregnated paper, they are used for children to take oral and axillary temperature only 45 second
are needed to record temperature it is less accurate.

4. Tympanic Membrane Thermometer

These are small hand-held devices similar to hodoscopes. With disposable speculum. Infrared-
sensing electronic and liquid crystal displays. Results are displayed within 1 to2 seconds after
placing their speculum in the outer third of the ear canal. It is accurate.

REASON FOR MERCURY USED IN THE THERMOMETER

1. Very sensitive to small changes in temperature.

2. Silver appearance helps in easy visible.

3. Its boiling point is 357°C (675°F) and freezing point is 4°C (39°F).

43
4. The expansion of mercury is uniform.

5. Mercury is 13.5 times heavier than water, so small glass tube can be used.

CARE OF THERMOMETER

1. Grasp the thermometer securely by the upper end of the stem, never hold it by bulb.
2. Shake it down by quick movement of the wrist.

3. Move away from articles before shaking the thermometer.

4. Be careful that the thermometer will not fall or strike against anything.

5. Thermometer is never washed with hot water because heat expands the mercury.

6. The used thermometer should be washed with soap and water and should be disinfected with a
disinfectant.

7. Advantages of using mercury are low price, wide availability reliable accuracy.

8. Disadvantages are delay for recording and easy breakability.

44
PULSE

Pulse is the wave of expansion and recoil occurring in an artery is response to the pumping action of
the heart. Pulse is the heart beat, conveniently felt at the wrist over the bone and at any point where
an artery passes superficially

Pulse is defined as checking rate, rhythm and volume of throbbing of an artery against a bony
prominence.

PURPOSE

1. To determine number of heart beats per minute

2. To evaluate amplitude ( strength ) of pulse .
3. To assess the vascular status of limbs .
4. To assess response of heart to cardiac medications , activity ,blood volume and gas exchange.
5. To assess hearts ability to deliver blood to distant area of the body .
6. To obtain information about heart rhythm and patterns of beats .

NORMAL RATES

1. Newborn-140 beats/minute
2. Infant-120 beats/minute.
3. 2-3 years-100 beats/ minute.
4. 5-10 years-90 beats/ minute.
5. Adults 70 to 80 beats/ minute (average is 72/ minute),
6. Old age--may be slower.
7. Extremely old age -may be more rapid.

45
 SITES OF TAKING PULSE

SITE LOCATION REASONS FOR USE

1. RADICAL Inner aspect of the wrist on thumb side Easily accessible

2. TEMPORAL Site superior (above ) and lateral to ( away from the Used when radial pulse is not
midline ) the eye accessible . Easily accessible
pulse in children

3. CAROTID At the side of the trachea where the carotid artery To assess cerebral perfusion
runs between the trachea and the
sternocleidomastoid muscle
4. APICAL Left side of the chest in the 4 th , 5th or 6th intercostal Used to find out discrepancies
space in the midclavicular line with radial pulse

5. BRACHIAL Medially in the antecubital space Used to monitor blood

pressure and assess for lower
arm circulation

6. FEMORAL Below inguinal ligament , midway between To assess circulation to lower

symphysis pubis and anterosuperior iliac spine hip

7. POPLITEAL Medial or lateral to the popliteal fossa with knees Used to determine circulation
slightly flexed . to the leg . To take blood
pressure in the lower limb

8. POSTERIOR On the medial surface of the ankle behind the medial To assess circulation to the
TIBIAL malleolus foot
9. DORSALIS Along dorsum of foot between extensor tendons of To assess circulation to the
PEDIS great and first toe foot
10. ULNAR On the little finger side , outer aspect of the wrist To assess circulation to ulnar
PULSE side of hand . To perform
allen’s test .

46
FACTORS AFFECTING THE PULSE

1. Age: Very old age people have slow pulse rate and children will have faster beat.

2. Sex: It is slower in men than in women.

3. Stature: Itis slower in tall people than in short people

4. Position: The pulse rate is slower than at rest or asleep than in standing position.

5. Emotions: Anger or excitement increases the pulse rate temporarily.

6. Exercise: It is much faster during exercise.

CHARACTERISTICS OF PULSE

1. Rate: Number of beats / minute, corresponds with age (above 100- tachycardia, below 60 -
bradycardia).
2. Rhythm: It is the regularity of beats. The distance between beats (regular).
3. Volume: It is the fullness of artery. It is the force of blood felt at each beat (full/large/small).
4. Tension: It is the degree of compressibility (high/ low).

ABNORMAL PULSE

1. Tachycardia: The pulse rate is more than 100 beats per minute. It is commonly found in
patients with fevers. Thyrotoxicosis, organic heart diseases, nervous disorders and intake of
drugs like belladonna and alcoholism cause tachycardia.
2. Bradycardia: Pulse rate less than 60 beats per minute. Caused by opium poisoning heart
muscle disorder, cerebral tumors and myxedema.
3. Abnormal rhythms: These are intermittent pulse, extra- systoles, atrial fibrillation, ventricular
fibrillation, sinus arrhythmia.
4. Abnormal volume: This causes pulses alternate, full bounding pulse and feeble pulse.
Abnormal tension may be low or high tension. Low tension causes thready or feeble pulse and
dicrotic pulse in which there is one heart and two arterial pulsations giving the sensation of a
double beat it is due to flabby weak arterial pulse.
5. Water hammer pulse or Corrigan's pulse: It is a full volume pulse. This type of pulse is found
in aortic regurgitation. When the blood is forced into the artery, then leaks back in to the
ventricle due to the non-closure of the aortic valve.

47
GENERAL INSTRUCTION FOR TAKING PULSE

1. Count the pulse for one full minute. Especially when there is irregularity.
2. Observe rate, rhythm, volume and tension of pulse.
3. Pulse should not be taken immediately after exercise in emotional stress or after a painful
treatment.
4. Record pulse immediately.
5. Choose suitable site for taking pulse. Nurse to be aware if patient is on any medication that
can interfere with heart rate.
6. To check pulse after 10 to 15 minutes , after strenuous physical exercise .
7. Notify physician if pulse rate is below < 60/ min or above > 100/min normal and abnormal
patterns (missing beats). Record in TPR record.

EQUIPMENTS

1. Watch with second hand.

2. Red pen.

3. PR sheet.

PROCEDURES

1. Wash hands.
2. If in a supine position, place client's forearm across lower chest with wrist extended straight. If
sitting, bend client's elbow 90 degrees and support lower arm on chair or on nurse's arm.
Slightly extend wrist with palm down.
3. Place tips of the first two or middle three fingers of the hand over groove along radial or
thumb side of client's.
4. Lightly compress your fingers against radius obliterates pulse initially and then releases
pressure so pulse becomes easily palpable.
5. When pulse is easily palpable, look at watch's second hand and begin to count rate: When
sweep hand hits number on dial, start counting with zero, then one, two and so on.
6. If pulse is regular, count rate for 30 seconds and multiply total by 2.
7. If pulse is irregular count for one full minute.
8. Assess regularity and frequency of any dysrhythmia.
9. Determine strength of pulse. Note whether thrust of pulse against fingertips is bounding,
strong, weak or thread.

48
 10. 10. Assist client in returning to comfortable position.

AFTERCARE

1. Wash hands.
2. If pulse is assessed for first time establish as base- line.
3. Assess pulse again by having another nurse conduct measurement, if pulse character is
abnormal or irregular.
4. Record characteristic of pulse in nursing progress sheet or vital sign flow sheet. Also record
any accompanying signs and symptoms of pulse alterations
5. Report abnormal findings to the nurse in charge or physician.

C.RESPIARTION

Respiration monitoring is an involuntary process of inspiration (inhalation), expiration (exhalation) in

a patient. Respiration is the act of breathing in and breathing out. It includes inspiration and
expiration. The exchange of gases between the blood and lungs is called external or pulmonary
respiration. The exchange of gases between the blood and cell is called internal respiration.

Respiration is the act of breathing. It includes the intake of oxygen and the output of carbon dioxide,
i.e. respiration consist of inspiration and expiration.

The characteristics of commonly observed respiratory patterns is given below

49
PURPOSES

1. To determine the respiratory status of the patient

2. To determine number of respiration occurring per minute.
3. To gather information about rhythm and depth.
4. To assess response of patient to any related therapy / medication.

TYPES OF RESPIRATION

External Respiration

The exchange of gases between the blood and the air in the lungs is called as external or pulmonary
respiration.,

Internal Respiration

The exchange of gases between the blood and the tissue cells is called as internal or tissue respiration.

Regulation of Respiration

It is a rhythmic movement's respiration is regulated by respiratory center and in the brain called
medulla oblongata, nerve fibers of the autonomic nervous system and the chemical composition of the
blood

NORMAL RATES

1. At birth--30 to 40 breaths/ minute.

2. 1 year-26 to 30 breaths / minute.
3. 2 to 5 years--20 to 26 breaths/ minute.
4. Adolescence-20 breaths/ minute.
5. Adults-16 to 20 breaths/minute.
6. Old age-10 to 24 breaths/ minute.

FACTORS INFLUENCING RESPIRATION

 Sex: Female has slightly rapid respiration than the male.

 Exercise: Exertion of any type increase the metabolic rate and stimulate respiration.
 Rest and sleep: During rest and sleep metabolism is decreased so respiration rate is normal or
decreased.
 Emotions: Sudden stressful condition such as fear and anxiety influences the respiratory rate.

50
  Changes in atmospheric pressure: In high altitudes the content of oxygen in the atmosphere
is very low. So, rate of respiration is increased and the increased demand of oxygen is
fulfilled.

CHARACTERISTICS OF RESPIRATION

1. Normal breathing is effortless.

2. It is painless, quiet and automatic.
3. Normal respiration consists of rhythmical rising and falling of the chest wall.
4. Respiratory rate in resting adult is 16 to 18 breaths, minute.
5. Eupnea-it is regular, even and produces no noise.

ABNORMAL RESPIRATION

 Strider respiration: It is noisy shrill and vibrating respiration. It is due to obstruction in the
upper air way. It is commonly seen in laryngitis and foreign body in the respiratory tract.
 Wheezing: Expiration is difficult and louder. It is due to partial obstruction of the smaller
bronchi and bronchioles. It is seen in asthma or emphysema.
 Apnea: This is a temporary cessation of breathing due to excessive oxygen and lack of carbon
dioxide.
 Dyspnea: This is forced, difficult or labored breathing. It may be accompanied by pain and
cyanosis; it is seen in heart diseases, respiratory diseases, convulsions, etc.
 Orthopmea: The patient can breathe only in upright position. Commonly found in congestive
cardiac failure.
 Cheyne-Stokes respiration: This is respiration which gradually increases in rate and volume
until it reaches a climax. Then slowly pause occurs and breathing stops for 5 to 30 seconds
and then cycle begins again. It is a periodic breathing usually found in the patients who are
near death.
 Asphyxia: It is a state of suffocation when the lungs do not get a sufficient supply of fresh air
to the vital organs and they are deprived of oxygen.
 Cyanosis: It is the blueness or discoloration of the skin and mucus membrane due to lack of
oxygen in the tissues.
 Rale: An abnormal rattling or bubbling sound caused by the mucus in the air passages as seen
in the bronchitis of pneumonia.
 Kussmaul's respiration: Respiration is abnormally deep but regular, rate is increased. It is seen
in diabetic ketoacidosis.
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  Biot's respiration: It is shallow breathing interrupted by irregular periods of apnea, seen in
central nervous system disorders.

GENERAL INSTRUCTIONS

1. Patient to be unaware of the nurse counting respiration.

2. Inform to physician incase of bradypnea, tachypnea or other abnormal respiratory patterns
noticed.
3. Maintain half hourly checking of respiration and pulse when indicated.

PRELIMINARY ASSESSMENTS

1. Determine the need to assess client's respiration.

2. If client has been active, wait 5 minutes or 10 minutes before assessing respiration.
3. Assess respirations as first vital sign in infant or child.
4. Assess respiration after pulse measurement in adult.
5. Be sure client is in a comfortable position, preferably sitting.
6. Be sure client's chest movement is visible. If necessary remove bed linen or gown.

EQUIPMENTS

1. Wrist watch with second hand or digital display.

2. Pen and flow sheet or record form.
3. TPR chart.

PROCEDURES

1. Place client's arm in relaxed, a position across the abdomen or lower chest.
2. Observe complete respiratory cycle (one inspiration and one expiration).
3. After cycle is observed, look at watch's second hand and begin to count rate, when sweep hand
hits number on dial, begins time frame, counting one with first full respiratory cycle.
If rhythm is regular in adult, count number of respirations in 30 seconds and multiply by 2. In
infant or young child count respirations for one full minute. If adult has irregular rhythm or
abnormally slow or fast rate, count for one full minute.
4. Note depth of respirations. This can be assessed subjectively by observing degree of chest wall
movement while counting rate.

52
 5. Note rhythm of ventilatory cycle. Normal breathing is regular and uninterrupted. Infants
breathe less regularly. Young child may breathe slowly and then suddenly breath fastens.
6. Replace client's gown and cover with bed linen.

AFTERCARE

1. Wash hands.

2. Compare client's respirations with previous baseline and normal respiratory rate for age group.

3.Record any accompanying signs and symptoms of respiratory alterations in nurse's notes or flow

sheet.

D.BLOOD PRESSURE

Blood pressure (BP) is the pressure that blood exerts against the walls of the vessels in which it is
contained. Blood pressure may be defined as the force exerted by blood against the walls of the
vessels in which it is contained. Differences in blood pressure between different areas of the
circulation provide the driving force that keeps the blood moving through the body.

PURPOSES

1. To obtain baseline date for diagnosis and treatment.

2.To compare with subsequent changes that may occur during care of patient.

3. To assist in evaluating status of patients blood volume. Cardiac output and vascular system.

4. To evaluate patients response to change in physical condition as a result of treatment with fluids or
medications.

INDICATIONS

1. To determine baseline, BP. recording and monitor fluctuation.

2. To aid in the assessment of cardiovascular system
3. To aid in the diagnostic disease.

PRELIMINARY ASSESSMENT

1. Identify the patient.

2. Check the diagnosis, reason for taking BP schedule frequency of obtaining BP.

53
 3. Previous measurement and range of BP.
4. Physical and mental state of the patient. Postpone BP taking, on a patient who is angry,
anxious or in pain or a crying child.
5. Assess the arm on which the BP can be taken. Do not take BP reading on a patient's arm if:
 The arm has an intravenous infusion on it
 The arm is injured or diseased
 The arm has a shunt or fistula for the renal dialysis
 On the same side of the body where a female patient had a radical mastectomy.

PREPARATION OF THE ARTICLE

1. Sphygmomanometer.

2. Stethoscope.

3. Piece of paper.

PREPARATION OF THE PATIENT

1. Explain the procedure to the patient to gain the confidence and cooperation of the patient.
2. Place the patient in a comfortable position either lying down with the arm resting on the bed or
sitting with the arm supported on the table at heart level to ensure accurate reading.
3. Patient should be resting at least 5 to 10 minutes prior to taking BP.

PROCEDURES

1. Wash hands.
2. Take the equipment to the bedside.
3. Apply deflated cuff evenly with rubber bladder over the brachial artery, the lower edge being
2 inch above the antecubital fossa. The two tubes turning towards the palm.
4. Palpate the brachial artery with the finger tips. Place the bell of the stethoscope on the
brachial pulse. The stethoscope must hang freely from the ears.
5. Close the valve on the pump by turning the knob clockwise. Pump up air in the cuff until the
sphygmomanometer registers about 20 mm Hg above the point at which the radial pulsation
disappears.
6. Open the valve slowly by turning the knob anti clockwise. Permit the air to escape very
slowly. Not the number on the manometer where sound firs begins. This is the systolic
pressure.

54
 7. Continue to release the pressure slowly. The sound become louder and clearer. Note the point
on the manometer where the sound ceases. This is the diastolic pressure.
8. Allow the air to escape and the mercury to fall zero. Wait for 1 minute with the cuff deflated.
9. Repeat the procedure if there is any doubts about the reading.
10. Do not take BP more than three times in succession on reading the same arm.

AFTERCARE

1. Remove the cuff by rolling it and replace it in the box.

2. Assist the patient to cover the arm, which was exposed.
3. Take the apparatus to the duty room and keep it safely in the cupboard.
4. Wash hands and record the readings immediately, with the date and time.

55
 HEAD TO TOE PHYSICAL EXAMINATION

The examination is carried out in a systematic manner focusing upon one area of the body at a time .
The observation of the patient starts as the patient walks into the examination room , eg. A limp may
be noted as the patient walks in . The following observations are made .

1. INTEGUMENTARY SYSTEM

The integumentary system refers to the skin, hair, scalp and nails. To assess the integument, you first
gather a health history to guide our examination and use the techniques of inspection and palpation.

SKIN

Begin an assessment of the skin by focusing on the history of changes in skin : dryness, pruritus,
sores, rashes, lumps, color, texture, odor and lesion that does not heal. The physical examination
begins with an inspection of all visible skin surfaces; the less visible surfaces are assessed when you
examine other body systems. Use the senses of sight, smell and touch while performing inspection
and palpation of the skin.

COLOR:

Skin color varies from body part to body part and from person to person. Despite individual
variations, it is usually uniform over the body. Some common variation are as follows

COLOR CONDITION CAUSES ASSESSMENT LOCATIONS

Bluish Increased amount of Heart or Lung Nail beds, lips, mouth, skin
(Cyanosis ) deoxygenated hemoglobin disease, cold (severe cases)
(associated with hypoxia) environment
Pallor Reduced amount of Anemia Face, conjunctivae, nail beds,

56
 ( decrease in oxyhemoglobin Reduced palms of hands skin, nail
color) visibility of oxyhemoglobin beds, conjunctivae, lips
Reduced visibility of Shock
oxyhemoglobin resulting
from decreased blood flow.
Loss of Vitiligo Congenital or Patchy areas on skin over
pigmentatio autoimmune face, hands, arms
n condition causing
lack of pigment
Yellow- Increased deposit of bilirubin Liver disease, Sclera, mucous membranes,
orange in tissues destruction of red skin
(jaundice ) blood cells
Red Increased visibility of Fever, direct trauma, Face, area of trauma, sacrum,
(erythema) oxyhemoglobin caused by blushing, alcohol shoulders other common sites
dilation or increased blood intake for pressure ulcers.
flow
Tan- brown Increased amount of melanin Suntan, pregnancy Areas exposed to sun: face,
arms, areolas, nipples.

Physical findings of the skin indicative of Substance Abuse

Skin Finding Commonly Associated Drug

Diaphoresis Sedative hypnotic (including alcohol )
Spider angiomas Alcohol , stimulants
Bruns (especially fingers ) Alcohol
Needs marks Opioids
Contusion, abrasions , cuts , scars Alcohol, other sedative hypnotics, intravenous (IV) opioids
Homemade tattoos Cocaine, IV opioids (prevents detection of injection sites)
Vasculitis Cocaine
Red, dry skin Phencyclidine (PCP)

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MOISTURE
The hydration of skin and mucous membranes helps to reveal body fluid imbalances, changes in the
environment of the skin and regulation of body temperature. Moisture refers to wetness and oiliness.
The skin is normally smooth and dry. Skinfolds such as the axillae are normally moist. Observe for
dullness, dryness, crusting, and flaking that resembles dandruff when skin surface is lightly
Excessive dryness worsens existing skin condition such as eczema and dermatitis. Patients with large
abdominal skinfolds are at high risk for moisture within the skinfolds. Excessive moisture may cause
maceration of the skin or softening of the tissue, resulting in an increased risk for breakdown.
TEMPERATURE
The temperature of the skin depends on the amount of blood circulating through the dermis.
Increased or decreased skin temperature indicates an increase or decrease in blood flow. An increase
in skin temperature often accompanies localized erythema or redness of the skin. A reduction in skin
temperature often accompanies pallor and reflects a decrease in blood flow. It is important to
remember that a cold or excessively warm examination room can cause changes in the patient's skin
temperature and color
Accurately assess temperature by palpating the skin with the dorsum or back of the hand. Compare
symmetrical body parts. Normally the skin temperature is warm. Sometimes it is the same throughout
the body, and other times it varies in one area. Always assess skin temperature for patients at risk of
having impaired circulation such as after a cast application or vascular surgery.
TEXTURE
Texture refers to the character of the surface of the skin and how the deeper layers feel. By palpating
lightly with the fingertips, you determine whether the patient’s skin is smooth or rough, thin or thick,
tight or supple, and indurated (hardened) or soft. The texture of the skin is normally smooth, soft,
even, and flexible in children and adults. However, the texture is usually not uniform throughout,
with
thicker texture over the palms of the hand and soles of the feet. In older adults the skin becomes
wrinkled and leathery because of a decrease in collagen, subcutaneous fat, and sweat glands.
TURGOR

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Turgor refers to the elasticity of the skin. Normally the skin loses its elasticity with age, but fluid
balance can also affect skin turgor. Edema or dehydration diminishes turgor. To assess skin turgor,
grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release .Since the
skin on the back of the hand is normally loose and thin, turgor is not assessed reliably at that site
Normally the skin lifts easily and falls immediately back to its resting position. When turgor is poor,
it stays pinched and shows tenting.

VASCURAITY

The circulation of the skin affects color in localized areas and leads to the appearance of superficial
blood vessels. Vascularity occurs in localized pressure areas when patients remain in one position.
Vascularity appears reddened, pink, or pale with aging capillaries become fragile and more easily
injured. Petechiae are nonblanching, pinpoint-size, red or purple spots on the skin caused by small
hemorrhages in the skin layers. Many petechiae have no known cause; but some may indicate serious
blood-clotting disorders, drug reactions, or liver disease.

EDEMA

Areas of the skin become swollen or edematous from a buildup of fluid in the tissues. Direct trauma
and impairment of venous return are two common causes of edema. Inspect edematous areas for
location, color, and shape. The formation of edema separates the surface of the skin from the
pigmented and vascular layers, masking skin color, Edematous skin also appears stretched and shiny.
Palpate edematous areas to determine mobility, consistency, and tenderness.

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LESIONS

The term lesion refers broadly to any unusual finding of the skin surface. Normally the skin is
free of lesions, except for common freckles or age- related changes such as skin tags, senile keratosis
(thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. Lesions that are primary
occur as an initial spontaneous sign of a pathological process such as with an insect bite.

60
 Secondary lesions result from later formation or trauma to a primary lesion such as occurs with a
pressure ulcer. When you find a lesion, collect standard information about its color, location, texture,
size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). Next
observe for any exudate, odor, amount, and consistency. Measure the size of the lesion in centimeters
by using a small, clear, flexible ruler. Measure each lesion for height, width, and depth.

Skin (cutaneous) malignancies are the most common neoplasms in patients. For this reason the
examiner should incorporate a thorough skin assessment on all patients. Cancerous lesions have
distinct features and over time undergo changes in color and size.

HAIR AND SCALP

Two types of hair cover the body : soft, fine, vellus hair, which covers the body; and coarse, long
thick terminal hair, which is easily visible on the scalp, axillae, and pubic areas and in the facial beard
on men. First obtain health history information from the following

Assessment Rational
Ask patient if he or she is wearing a wig or Wigs or hairpieces interfere with inspection of
hairpiece and ask him or her to remove it. hair and scalp,
Determine if patient has noted change in Change often occurs slowly over time
growth, loss of hair, or change in texture or
color.
Identify type of hair-care products used for Excessive use of chemical agents and burning
grooming of hair causes drying and brittleness

61
 Determine if patient has had chemotherapy Chemotherapeutic agents kill cells that rapidly
multiply such as tumor and normal hair cells.

Fig: Head lice infestation

Inspection

During inspection explain that it is necessary to separate parts of the hair to detect abnormalities.
Wear a pair of clean gloves if open lesions or lice are noted.

 First inspect the color, distribution, quality, thickness, texture and lubrication of body hair.
Scalp hair is coarse or fine and curly or straight; and it should be shiny , smooth and pliant.
Color varies from very light blond to black to gray and is sometimes altered by rinses or dyes.
In older adults the hair becomes dull grey, white or yellow.
 Normally the scalp is smooth and inelastic with even coloration. Carefully separate strands of
hair and thoroughly inspect the scalp for lesions.
 Moles on the scalp are common , but they can bleed as a result of vigorous combing or
brushing. Dandruff or psoriasis frequently causes scaliness or dryness of the scalp.
NAILS
The condition of the nails reflects a person’s general health, state of nutrition, occupation and self-
care. The most visible part of the nail is the nail plate, the transparent layer of epithelial cells covering
the nail bed. The vascularity of the nail bed creates the underlying color of the nail. The semilunar
whitish area at the base of the nail bed is called the lunula, from which the nail plate grows.
Inspection and palpation:
 Inspect the nail bed for color, length, symmetry, cleanliness and configuration. The shape and
condition of the nails can give clues to pathophysiological problems.

62
  Assess the thickness and shape of the nail, its texture, the angle between the nail and the nail
bed and the condition of the lateral and proximal nail folds around the nail.
 When inspecting the nails you gather a sense of the patient’s hygiene practices.
 When palpating, expect to find a firm nail base and check for any abnormalities such as
erythema or swelling.
 To palpate, gently grasp the patient’s finger and observe the color of the nail bed

Fig: Abnormalities of nail bed

HEAD

An examination of the head and neck includes assessment of the head, eyes, ears, nose, mouth,
pharynx and neck ( lymph nodes, carotid arteries, thyroid gland and trachea). During assessment of
peripheral arteries also assess the carotid arteries. Assessment of the head and neck uses inspection,
palpation and auscultation with inspection and palpation often used simultaneously.
HEAD
Inspection and Plalpation
 Inspect the patient’s head, noting the position, size, shape and contour.
 Holding it tilted to one side acts as a behavioural indicator of a potential unilateral hearing or
visual loss or is a physical indicator of muscle weakness in the neck.
 A horizontal jerking or bobbing indicated a tremor.

63
  Note the patient’s facial features, looking at the eyelids, eyebrows, nasolabial folds and mouth
for shape and symmetry.
 Examine the size, shape and contour of the skull. The skull is generally round with
prominences in the frontal area anteriorly and the occipital area posteriorly.some adults have
enlarged jaws and facial bones resulting from acromegaly , a dirorder caused by excessive
secretion of growth hormone.
Nursing history for Head Assessment
 Determine if patient experienced recent head trauma. If so, assess atate of consciousness after
injury (immediately on return and 5 minutes later), duration of unciousness and predisposing
factors (e.g. seizure, poorvision, blackout).
 Ask if patient has history of headache ; note onset, duration, character, pattern and associated
symptoms
EYES

Examination of the eyes includes assessment of visual acuity, visual fields, extraocular
movements, and external and internal eye struc- tures. The eye assessment detects visual
alterations and determines the general level of assistance that patients require when ambulating or
performing self-care activities.

Nursing history for Eye assessment

 Determine if patient has history of eye disease (e.g., glaucoma, retinopathy, cataracts), eye
trauma, diabetes, hypertension, or eye surgery
 Determine problems that prompted patient to seck health care. Ask patient about eye pain,
photophobia (sensitivity to light), burning or itching, excess tearing or crusting, diplopia
(double vision) or blured vision, awareness of a "film" or curtain" over field of vision, floaters
(smal, black spots that seem to float across field of vision), flashing lights, or halos around
lights.

64
  Determine whether there is family history of eye disorders or diseases.

VISUAL ACUITY

 The assessment of visual acuity (i.e., the ability to see small details) tests central vision. The
easiest way to assess near vision is to ask patients to read printed material under adequate
lighting.
 Assessment of distant vision requires using a Snellen chart (paper chart or projection screen).
 Have the patient sit or stand 6.1 m (20 feet) away from the chart and try to read all of the
letters beginning at any line with both eyes open.
 Then have the patient read the line with each eye separately (patient covers the opposite eye
with an index card or eye cover to avoid applyıng pressure to the eye).
 Note the smallest line for which the patient is able to read all of the letters correctly and record
the visual acuity for that line.
 Repeat the test with the patient wearing corrective lenses.

EXTRAOCULAR MOVEMENTS

Six small muscles guide the movement of each eye. Both eyes move parallel to one another in each
of the six directions of gaze .

 To assess extraocular movements, a patient sits or stands, and the nurse faces the patient from
60 cm (2 feet) away.
 The nurse holds a finger at a comfortable distance (15 to 31 cm [6 to 12 inches|) from the
patient's eyes, While the patient maintains his or her head in a fixed position facing forward,
the nurse directs him or her to follow with the eyes only as the nurse's finger imoves to the
right, lett, and diagonally up and down to the left and right. The nurse moves the finger
smoothly and slowly within the normal field of vision.

65
VISUAL FIELDS

As a person looks straight ahead, he or she normally is able to see all objects in the periphery. To
assess visual fields-

 Direct the patient to stand or sit 60 cm (2 feet) away at cye level. The patient gently closes or
covers one eye (e.g., the let) and looks at your eye directly opposite. You close your opposite
eye (in this case the right) so the field of vision is superimposed on that of the palient.
 Next move a finger equidistant between you and the patient outside the field of vision and
slowly bring it back into the visual field.
 The patient reports when he or she is able to see the finger. If you see the finger before the
paticnt does, a part of the patient's visual field is reduced.

EXTERNAL EYE STRUCTURES

To inspect external eye structures, stand directly in front of the patient at eye level and ask him or her
to look at your face.

Position and Alignment

 Assess the position of the eyes in relation to one another. Normally they are parallel to one
another.
 Bulging eyes (exophthalmos) usually indicate hyperthyroidism. Crossed eyes (strabismus)
result from neuromuscular injury or inherited abnormalities.
 Tumors or inflammation of the orbit often cause abnormal eye protrusion.For the remainder of
the eye examination have the patient remove contact lenses.

Eyebrows

 Inspect the eyebrows for size, extension, texture of hair, alignment and movement.
 Normally the eyebrows are symmetrical , coarseness of hair and failure to extend beyond the
temporal canthus possibly revels hypothyroidism.
 The brows normally raise and lower symmetrically, an inability to move them indicated a
facial nerve paralysis (cranial nerve VII).

Eyelids

66
  Inspect the eyelids for position, color and condition of the surface ; condition and direction of
the eyelashes , and the patient’s ability to open, close and blink.
 Inspect for having ptosis ( an abnormal drooping of the lid over the pupil )
 To inspect the surface of the upper lids ask the patient to close his or her eyes while observing
for lid tremors
 Normally lids are smooth and the samr color as the surrounding skin if redness , it indicates
inflammation or infection.
 Inspect for having lid edema, any lesions for typical characteristics and discomfort or
drainage.
 Wear clean gloves if drainage is present

Lacrimal Apparatus

 The lacrimal gland located in the upper outer wall of the anterior part of the orbit, is
responsible for tear production.
 Inspect the lacrimal gland for edema and redness and any site of tumors or infections.
 Palpate the gland gently to detect tenderness.
 Observe for evidence of edema in the inner canthus.

Conjunctivae and Sclerae

 The bulbar conjunctiva covers the exposed surface of the eyeball up to the outer edge of the
cornea.
 Observe the sclera under the bulbar conjunctiva; normally it has the color of white porcelain in
light-skinned patients and is light yellow in dark skinned patients.
 Sclerae become pigmanted and appear either yellow or green if liver disease is present.
 Gently retract both lids, with the thumb and index finger pressed against the lower and upper
bony orbits.
 Ask the patient to look up, down and from side to side.
 Inspect for color, texture and presence of edema or lesions.
 The presence of redness indicates an allergic or infectious conjunctivitis.
 Bright red blood in a localized area surrounded by normal- appearing conjunctiva usually
indicates subconjunctival hemorrhage.
 Performing proper hand hygiene is necessary before and after the examination

Corneas

67
  The cornea is the transparent , colorless part of the eye covering the pupil and iris.
 While the patient looks straight ahead, inspect the cornea for clearity and texture while shinig
a penlight obliquely across its entire surface.
 Any irregularity in the surface indicates an abrasion or tear that requires further examination
by a health care provider.
 Note the color and details of the underlying iris.

Pupils and Irises

 Observe the pupils for size, shape, equality, accomodation and reaction to light.
 They are normally black, round, regular and equal in size ( 3 to 7 mm in diameter)
 The iris should be clearly visible
 Cloudy pupils indicates cataracts
 Dilated pupils results from glaucoma, trauma, neurological disorders , eye medications( e.g.,
atropine )or withdrawal from opioids.
 Inflammation of iris or use of drugs causes constricted pupils.
 Pintpoint pupils are a common sign of opioid intoxication.
 A directly illuminated pupil constricts and the opposite pupil constricts consensually.
 Observe the quickness and equality of te reflex, repeat the examination for the opposite eye
 To test for accomodation, ask the patient to gaze at a distant object (the far wall).and then at a
test object ( finger or pencil) held approximately 10 cm (4 inchs) from the bridge of his or her
nose.
 If assessment of pupillary reaction is normal in all tests, record the abbreviation PERRLA
( Pupils equal, round, reactive to light and accomodation).

Internal Eye Structures

 The examination of the internal eye structures through the use of an ophthalmoscope is
beyond the scope of new graduate nurses ‘ practice.
 Advance nurse practitioners use the ophthalmoscope to inspect the fundus which includes the
retina, choroid, optic nerve disc, macula, fovea centralis and retinal vessels.
 Patient is greatest need of an examination are those with diabetes, hypertension and
intracranial disorders.

EARS

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The ear assessment determines the intrigity of ear structures and hearing acquity. The three parts of
the ear are the external, middle and inner ear.

 Area to be assessed are auricles, ear canal, internal ear canula and tympanic membrane.
 Inspect auricles for colour, size, configuration, location and angle of attachment.
 Inspect the internal ear canal for impacted cerumen, foreign bodies, discharge, masses, redness
and swelling.

Nursing history of Ear assessment

 Ask if the patient has experienced ear pain, itching, discharge, vertigo, tinnitus or change in
hearing.
 Assess risk for hearing problems like frequent exposure to loud music from concerts, car
radios and cell phone or ipods while wearing headphone, earbuds or other device.
 Assess if patient take large doses of aspirin or other ototoxic drugs.

AURICLES

 With the patient sitting comfortably, inspect the size, shape, symmetry, landmarks, position
and color of the auricle.
 Palpate the auricles for texture, tenderness and skin lesions.
 Inspect the opening of the ear canal for size and presence of discharge.
 Yellow or green, foul smelling discharge indicates infection or a foreign body.

EAR CANALS AND EARDRUMS

 Observe the deeper structures of the esternal and middle ear with the use of an otoscope.
 Turn on the otoscope by rotating the dial at the top of the handle. To insert the specculum
properly, ask the patient to tip the head slightly toward the opposite shoulder.
 Insert the speculum slightly down and forward 1 to 1.5 cm (1/2 inch) into the ear canal.
 The light from the otoscope allows visualization of the tympanic membrane. Know the
common anatomical landmarks and their appearance.
 Gently move the otoscope so the entire tympanic membrane and its periphery are visible.
 The normal tympanic membrane is translucent , shiny and pearly gray.

HEARING ACUITY

 Have the patient remove any hering aid if worn, note his or her response to questions.
 If a hearing loss is suspected, check the patient response to the whispered voice.

69
  Test one ear at a time while the patient occludes the other aer with a finger, ask him or her to
gently move the fingers up and down during the test in response to the whispered sound.
 While standing 31 to 60 cm (1 to 2 feet) from the testing ear, speak while covering the mouth
so the patient is unable to read lips.
 If hearing loss is present, test the hearing usig a tunning fork, A tunning fork of 256 to 512
hertz (Hz) is most commonly used.

Perform the test for hearing by the following methods

Webbers Test

To perform the Webbers test of lateralisation place the stem of the vibrating Tunning Fork in the
centre of the forehead; ask the person where the sound is heard best. Normally, the sound is heard
equally well in both ears as it is conducted through the bones. Note any lateralisation of sound i. e.
sound heard in any one ar better than the other.

Rinnies Test (air and bone conduction test)

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Hold the vibrating tuning fork’s arms, parallel to the auricles and their tip 2 cm away from the
external meatus. Then place vibrating tuning fork’s stem on the nest bony process of the mastoid
bone.Ask the client to inform which of the sound conduction was better, when kept near the external
meatus i.e. air conduction or by when kept over the meatoid bone i.e. bone conduction.

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NOSE AND SINUSES

Use inspection and palpation to assess the integrity of the nose and sinuses. A penlight allows
forgross examination of each naris. A more detailed examination requires use of a nasal speculum to
inspect the deeper nasal tubinates.

NOSE

 When inspecting the external nose, observe for shape, size, skin, color and the presence of
deformity or inflammation.
 If swelling or deformities exist , gently palpate the ridge and soft tissue of the nose by placing
one finger on each side of the nasal arch and gentlly moving the fingers from the nasal bridge
to the tip.
 Note any tenderness , masses or underlying deviations.
 To assess patency of the nares, place a finger on the side of the patient,s nose and occlude one
naris, place a finger on the side of the patient’s nose occlude one naris, Ask the patient to
breathe with the mouthlosed, repeat the procedure for the other naris.
 While illuminating the anterior nares, inspect the mucosa for color, lesions, discharge,
swelling and evidence of bleeding, If discharge is present, apply gloves.Pale mucosa with
clear discharge indicates allergy
 A sinus infection results in yellowish or greenish discharge.
 To view the septum and turbinates, have the patient tip the head back slightly to provie a clear
view, illuminate the septum and observ for alignment, perforation or bleeding.Perforation of
the septum often occurs after repeated use of intranasal cocaine, note any polyps or purulent
drainage.

SINUSES

 Examination of the sinuses involves palpation. In cases of allergies or infection, the interior of
the sinuses becomes inflamed and swollen.
 The most effective way to assess for tenderness is by externally palpating the frontal and
maxillary facial areas.
 Palpate the frontal sinus by exerting presure with the thumb up and under the patient’s
eyebrow.
 Gentle, upward pressure elicits tenderness easily if sinus irritation is present.

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Frontal sinuses: Direct manual pressure upwards towards the wall of sinus. Avoid pressure on eyes.

Maxillary sinuses: Bony prominence of the upper cheek . Normally, sinuses are not painful when
palpated. Pain is suggestive of infection or obstruction.

MOUTH AND PHARYNX

 Assess the mouth and pharynx to detect signs of overall health.

 Determine the patient’s oral hygiene needs and therapies needed if he or she has dehydration,
restricted intake, oral trauma or oral airway obstruction.
 To assess the oral cavity use a penlight and tongue depressor or gauze square.

LIPS

 Inspect the lips for color, texture, hydration, contour and lesions.
 With the patient’s mouth closed, view the lips from end to end, normally they are pink, moist,
symmetrical and smooth.
 Have female patients remove their lipstick before the examination .
 Anemia causes pallor of the lips, with cyanosis caused by respiratory or cardiovascular
problems.
 Cherry colored lips indicate carbon monoxide poisoning, when you inspect any lesion,
consider the potential of it being an infection, irritation or skin cancer.

BUCCAL MUCOSA, GUM AND TEETH

 Ask the patient to clench the teeth and smile to observe teeth occlusion. A symmetrical smile
reveals normal facial nerve function.

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  Inspect the teeth to determine the quality of dental hygiene, note the position and alignment of
the teeth.
 To examine the posterior surface of the teeth, have the patient open the mouth with the lips
relaxed.
 Use a tongue depressor to retract the lips and cheeks, especially when viewing the
molars ,note the color of the teeth and presence of dental caries.
 To inspect the buccal mucosa, ask the patient to open the mouth and then gently retract the
cheeks with a tongue depressor, view the surface of the mucosa from right to left and top to
bottom.
 Normal mucoa is glistening, pink, soft, moist and smooth.
 Inspect the gums ( gingivae) for color, edema, retraction, bleeding and lesions while retracting
the cheeks,healthy guma are pink, smooth and moist and fit tightly around each tooth.

TONGUE AND FLOOR OF MOUTH

 Carefully inspect the tongue on all sides and floor of the mouth, have the patient relax the
mouth and stick the tongue out halfway, note any deviation, tremor, or limitation in
movement.
 To test for tongue mobility, ask the patient to raise it up and move it from side to side, it
should move freely.
 Using a penlight for illumination, examine the tongue for color, size, position, texture and
coatings or lesions, a normal tongue is medium or dull red in color, moist, slightly rough on
the top surface and smooth along the lateral margins.
 The patient lifts the tongue by placing its tip on the palate behind the uper incisors, inspect for
color, swelling and lesions such as nodules or cysts.
 To palpate the tongue, explain the procedure and ask the patient to protrude it.
 With a gloved hand palpate the full length of the tongue and base for any areas of hardening or
ulceration.

PALATE

 Have the patient extend the head backward, holding the mouth open to inspect the hard and
soft palates.
 The whitish hard palate is dome shape, the soft palate extends posteriorly towards the
pharynx, it is normally light pink and smooth.

74
 Observe the palate for color, shape, texture and extra bony prominances or defects, a bony
growth or exostosis between the two palates is common.

75
PHARYNX

 Perform an examination of pharyngeal structures to rule out infection, inflammation or

lesions, have the patient tip the head back slightly, open the mouth wide and say “ah” while
you place the tip of a tongue depressor on the middle third of the tongue.take care not to press
the lower lip against the teeth.
 With a penlight first inspect the ulva and soft palate.
 Examine the anterior and posterior pillars, soft palate and uvula.
 View the tonsils in the cavities between the anterior and posterior pillars and note the presence
or absence of tissue.
 Patients with chronic sinus problems frequently exhibit a clear exudate that drains along the
wall of the posterior pharynx, yellow or green exudate indicates infection.
 A patient with a typical sore throat has a red and edematous uvula and tonsillar pillars with
possible presence of yellow exudate.

NECK

 Assess the neck muscles, lumph nodes of the head and neck, carotid arteries, jugular veins,
thyroid gland and trachea.
 Inspect and palpate the neck to determine the integrity of its structures and examine the
lymphatic system, an abnormality of superficial lymph nodes sometimes reveals the presence
of an infection or mlignancy.

Nursing history for neck assessment

 Assess for history of recent cold, infection, or enlarged lumph nodes or exposure to radiation
or toxic chemicals
 Ask if patient has had history of neck pain with restriction in movement.
 Ask patient has history of hypothyroidism or hyperthyroidism, takes thyroid medication or has
a family history of thyroid disease.
 NECK MUSCLES
 First inspect the neck in the usual anatomical position, with slight hyperextension.
 Observe for symmetry of the neck muscles
 Ask the patient to flex the neck with the chin to the chest, hyperextend the neck backward, and
move the head laterally to each side and then sideways with the ear moving toward the
shoulder.

76
77
 LYMPH NODES

 Check each node methodically in the following sequence: occipital nodes at the base of the
skull, postauricular nodes over the mastoid , preauricular nodes just in front of the ear,
retropharyngeal nodes at the angle of the mandible, submandibular nodes and submental nodes
in the midline behind the mandibular tip.
 Try to detect enlargement and note the location size, shape surface characteristics,
consistency, mobility, tenderness, and warmth of the nodes.If skin is mobile, move it over the
area of the nodes.
 Palpate supraclavicular nodes by hooking the index and third finger over the clavicle lateral to
the sternocleidomastoid muscle.
 Palpate the deep cervical nodes only with the fingers hooked around the sternocleidomastoid
muscle.
 Lymph nodes that are large, fixed, inflamed or tender indicate a problem such as local
infection, systemic disease or neoplasm.
 Tenderness always indicates inflammation, a peoblem involving a lymph node of the head and
neck means an abnormality in the mouth, throat, abdomen, breasts, thorax or arms, these are
the areas drained by the head and neck nodes.

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 THYROID GLAND
 Inspect the lower neck overlying the thyroid gland for obvious masses, symmetry, and any
subtle fullness at the base of the neck, ask the patient to hyperextend the neck, which helps
tighten the skin for better visualization.
 Offer the patient a glass of water and while observing the neck, have him or her swallow.
 CAROTID ARTERY AND JUGULAR VEIN

 For carotid artery palpate one carotid artey at a time just below the upper border of the thyroid
cartilage ( avoid palpation of carotid sinus at the level of carotid cartilage just below the angle
of the jaw, which may decrease the heart rate.)
 For external Jugular vein , observe with the client sitting and then lying at 30 -40 degree angle
without flexing the neck . Normally , jugular veins are at the level of right atrium and with
good light pulsation can be seen.

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 THORAX AND LUNGS :

Physical assessment of the thorax and lungs requires an in depth review of the ventilatory and respiratory
functions of the lungs. If disease is affecting the lungs, it will affect other body systems as well. For example,
reduced oxygenation causes changes in mental alertness because of the brain's sen sitivity to lowered oxygen
levels. You will use data from all body systems to determine the nature of pulmonary alterations.

i.POSTERIOR THORAX:

Begin examination of the posterior thorax by observing for any signs or symptoms in other body systems that
indicate pulmonary problems. Reduced mental alertness, nasal flaring, somnolence (sleepiness), and cyanosis
are examples of symptoms or findings that indicate oxygenation problems.

Inspection of the posterior thorax :

 By observing the shape and symmetry of the chest from the patient's back and front.
 Note the anteroposterior diameter. Body shape or posture significantly impairs ventilatory movement.
Normally the chest contour is symmetrical, with the antero posterior diameter one third to one half the size of
the transverse or side-to-side diameter.

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 A barrel-shaped chest (anteroposterior diameter equals transverse) characterizes aging and chronic lung
disease. Infants have an almost round shape.
 Congenital and postural alterations cause abnormal contours.
 Standing at a midline position behind the patient, look for deformities, position of the spine, slope of the
ribs, retraction of the intercostal spaces during inspiration, and bulging of the intercostal spaces during
expiration.
 The scapulae are normally symmetrical and closely attached to the thoracic wall. The normal spine is
straight without lateral deviation.
 Posteriorly, the ribs tend to slope across and down. The ribs and intercostal spaces are easier to see in a thin
person. Normally no bulging or active movement occurs within the inter costal spaces during breathing.
 Bulging or retraction ind cates that the patient is using great effort to breathe.
 To assess the rate and rhythm of breathing at this time.
Breathing pattern: Normally, it is smooth, even, ranging from 18-20 breaths in a minute without use of
accessory muscles.
 Breathing rate : Normal, tachypnea, bradypnea, apnea.
 Pulsations, lifts, retractions :
 Apical impulse : Can be seen in hyper-thyroidism.
 The thorax normally expands and relaxes with equality (symmetry) of movement bilaterally
 Check for any skeletal deformities:
 Kyphosis (an exaggerated curvature of the thoracic vertebrae).
 Scoliosis (a lateral curvature of the spine).
 Lordosis (an exaggerated curvature of the lumber vertebrae).

ii.PALPATE THE POSTERIOR THORAX:

 Palpate with the thoracic muscles and skeleton for lumps, masses, pulsations, and un usual movement.
 Avoid deep palpation if you note pain or tenderness.
 Fractured rib fragments could be displaced against vital organs.
 Normally the chest wall is not tender. If you find a suspicious mass or swollen area, lightly palpate it for
size, shape, and typical qualities of a lesion.
 To measure chest excursion or depth of breathing, stand behind the patient and place the thumbs along the
spinal processes at the tenth rib, with the palms lightly contacting the posterior lateral surfaces. Place thumbs
about 5 cm (2 inches) apart, pointing toward the spine and fingers point ing laterally. (Figure 15-23, A).
 Press the hands toward the spine so that a small skin fold appears between the thumbs.

81
  Do not slide the hands over the skin.
 Instruct the patient to take a deep breath after exhaling.
 Note movement of the thumbs (Figure 15-23, B). Chest excursion should be symmetrical, separating the
thumbs 3 to 5 cm (11/4 to 2 inches). Reduced chest excursion is caused by pain, postural deformity, or fatigue.
 In older adults, chest excursion normally declines because of costal cartilage calcification and respiratory
muscle atrophy.

iii. PERCUSSION OF THE POSTERIOR THORAX:

To determine whether the inderlying tissue is air filled, fluid filled or solid. The lung should be air filled,
producing a resonance sound that is jow pitched, of loud intensity and of long duration.
The percussion sounds in relation to pitch, intensity and duration

Percussion Sounds with Examples

Percussion Example
Percussion Sounds Intensity Pitch

Flatness soft High Thigh , muscle

Dullness (thud like) Medium Moderate Liver
Resonance (hollow) Loud Low Normal lung
Hyper Resonance Very loud Lower Emphysematous lung
(booming)
Tympany (druin like) Loud Higher Puffed out check, gastrie

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 air bubble

IV.AUSCULTATION POSTERIOR THORAX :

 Auscultation assesses the movement of air through the tracheobronchial tree and detects mucus or obstructed
air ways. Normally air flows through the airways in an unob structed pattern. Recognizing the sounds created
by normal air flow allows for detection of sounds caused by airway obstruction.
 Place the diaphragm of the stethoscope firmly on the skin, over the posterior chest wall between the ribs.
 The patient folds the arms in front of the chest and keeps the head bent forward while taking slow, deep
breaths with the mouth slightly open.
 Listen to an entire inspiration and expiration at each position of the stethoscope (Figure 15-24, A).
 If sounds are faint, as in an obese patient, ask the patient to breathe harder and faster temporarily. Breath
sounds are much louder in children because of their thin chest walls.
 In children the bell works best because of their small chest.
 Use a systematic pattern comparing the sounds in one region on one side of the body with sounds in the same
region on the opposite side.
 Auscultate for normal breath sounds and abnormal or adventitious sounds.
 Normal breath sounds differ in character, depending on the area you auscultate.
 Bronchovesicular and vesicular sounds are normally heard over the posterior thorax.
 Bronchovesicular sounds are medium-pitched blowing sounds normally heard between the scapulae. The
sounds have equal inspiratory and expiratory phases.
 The character of bronchovesicular sounds is created by air moving through large airways.
 Vesicular sounds are normally heard over the periphery of the lungs.
 Air moving through the smaller air ways creates these sounds.
 Vesicular sounds are soft, breezy, and low pitched, and the inspiratory phase is about three times longer than
the expiratory phase.
 Abnormal sounds result from air passing through moisture, mucus, or narrowed airways.
 They also result from alveoli suddenly reinflating or from an inflammation between the pleural linings of the
lung.
 Adventitious sounds often occur superimposed over normal sounds.
 The four types of adventitious sounds are
 Crackles: sine, short interrupted sound heard during inspiration and expiration. Example: respiratory
distress.
 Rhonchi: low-pitched continuous musical sound heard during expiration and clears with coughing.
Example: pneumonia.

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 Wheeze: high-pitched continuous musical sound heard during inspiration or expiration and does not clear
with coughing. Example: pneumonia.
 Pleural friction rub: grating type of sound heard during inspiration and does not clear with coughing.
Example empyma.
During auscultation note the location and characteristics of the sounds, and listen for the absence of breath
sounds (found in patients with collapsed or surgically removed lobes).

LATERAL THORAX:
Extend the assessment of the posterior thorax to the lateral sides of the chest (Figure 15-24, B). The patient
sits during examination of the lateral chest. Have the patient raise the arms, to improve access to lateral
thoracic structures. Use inspection, palpation, and auscultation skills to examine the lateral thorax, Normally
the breath sounds you hear are vesicular.
ANTERIOR THORAX :

Inspection:

 Inspect the anterior thorax for the same features as the posterior thorax. The patient sits or lies down with
the head elevated. Observe the accessory muscles of breathing:
 sternocleidomastoid,
 trapezius, and
 abdominal muscles.
 Observe the width of the costal angle. It is usually larger than 90 degrees between the two costal margins.
 Observe the breathing pattern. Assess respiratory rate and rhythm anteriorly (see Chapter 14). The male
patient's respirations are usually diaphragmatic, whereas the female's are more costal.
Palpation:
 Palpate the anterior thoracic muscles and skeleton for lumps, masses, tenderness, or unusual
movement. The sternum and xiphoid are relatively inflexible.
 To measure chest excursion anteriorly, place the thumbs parallel along the costal margin 6 cm (2 ½
inches) apart with the palms touching the anterolat eral chest.
 Push the thumbs toward the midline to create a skin fold.
 As the patient inhales deeply, the thumbs normally separate approximately 3 to 5 cm (1 ¼ to 2
inches), with each side expanding equally.
 Chest excursion can be measured posteriorly from the lower lung border if breast tissue or a patient's
large abdomen make anterior measurement difficult.

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 Auscultation :
 The patient sit, if possible, to maximize chest expansion.
 Pay special attention to the lower lobes, where mucous secretions commonly gather.
 Listen for bronchovesicular and vesicular sounds above and below the clavicles and along the lung
periphery.
 Auscultate for bronchial sounds, which are loud, high pitched, and hollow sounding, with expiration
lasting longer than inspiration (3:2 ratio), it is normally hear this sound over the trachea.
HEART:

Inspection and palpitation:

In heart, inspection and palpation are used simultaneously. Inspect the heart site for any bulging or
pulsation at aortic and pulmonic areas. Palpate for any thrill or pulsation. In mitral area palpate for apical
beat. Palpable thrill indicates cardiac murmur. Various precordial points of the heart are shown in Figure

Fig: Pericardial points of the Heart

The Mid-clavicular line : Palpation of the precordial points of the chest are palpated for any abnormal
pulsations, thrills, apical impulses, aortic pulsations etc. You may decide to palpate as you inspect each area.
A thrill is a palpable cardiac murmur.

Percussion : Cardiac dullness is located in the third to fifth inter-coastal spaces.

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Auscultation technique assesses the normal heart sound (S1and S2), extra heart sounds (S3, S4 split Sl and
split S2) and murmurs.

o First heart sound (S1) is produced by the closure of the mitral and tricuspid heart valves. It is best
heard at the apex of the heart.
o Second heart sound (S2) is produced by the closure of the aortic and pulmonic heart valves. It is best
heard at the base of the heart (aortic area).
o S1, and S2, are both high-pitched sounds, so use the stethoscope's diaphragm to listen.
o Third heart sound (S3) - ventricular gallop, is a low-pitched sound heard in the cardiac cycle
immediately after S2 (diastole). It is normal in children and young adults. It is considered abnormal in
adults over 30 years of age. It is best heard in the mitral area.
o Fourth heart sound S4 (atrial gallop) is a low-pitched sound heard in the cardiac cycle just before S 1.
Using the bell of the stethoscope, auscultate for S 4 in the mitral area with the person in the left lateral
horizontal position. S4 may be nornal in children and trained athletes. It is considered abnormal in
most adults.

Split first heart gallop (split S1) occurs when the mitral and tricuspid heart valves are not closing together.

Split second heart sound (split S2) occurs when the aortic and pulmonic heart valves are not closing
together.

Heart murmur is a harsh, rumbling, blowing sound caused by blood flow across a defective valve, or the
shunting of blood through an abnormal passage. A heart murmur is assessed for timing, location,
radiation, intensity, quality and pitch.

Intensity of a murmur refers to the loudness and is graded on the following scale :
 Grade I : very faint
 Grade II: quiet but audible
 Grade III: moderately loud
 Grade IV: loud Grade
 Grade V : very loud
 Grade VI: very loud (may even be audible when the stethoscope is off the chest wall)

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 ASSESSMENT OF THORAX AND LUNGS:

POSTERIOR THORAX:

ASSESSMENT NORMAL FINDINGS DEVIATIONS

FROM NORMAL
1. Inspect the shape and symmetry of the thorax Anteroposterior to Barrel chest increased
from posterior and lateral views. Compare the transverse diameter in anteroposterior to
anteroposterior diameter to the transverse diameter. ratio of 1:2. transverse diameter
Chest symmetric. Chest symmetric.

2. Inspect the spinal alignment for deformities. Spine vertically aligned. Exaggerated spinal
Have the client stand. From a lateral position, curvature (kyphosis,
observe the three normal curvatures: cervical, lordosis)
thoracic, and lumbar.
 To assess for lateral deviation of spine Spinal column is straight, Exaggerated spinal
(scoliosis), observe the standing client from right and left shoulders curvatures (kyphosis,
the rear. Have the client bend forward at the and hips are at same lordosis)
waist and observe from behind. height.

3. Palpate the posterior thorax.

 For clients who have no respiratory Skin intact; uniform Skin lesions; areas of
complaints, rapidly assess the temperature and temperature hyperthermia
integrity of all chest skin.
 For clients who do have respiratory Chest wall intact; no Lumps, bulges;
complaints, palpate all chest areas for tenderness; no masses depressions; areas of
bulges, tenderness, or abnormal movement. ten derness; movable
structures (e.g., rib)

4. Palpate the posterior chest for respiratory excursion Full andsymmetric chest Asymmetric and/ or
(thoracic expansion). Place the palms of both your expansion (ie, when the decreased chest
hands over the lower thorax with your thumbs client takes a deep expansion
breath, your thumbs

87
adjacent to the spine and your fingers stretched should move apart an
laterally. equal dis tance and at
the same time; normally
 Ask the client to take a deep breath while you the thumbs separate 3 to
observe the movement of your hands and any 5 cm (1 1/2 to 2 in.)
lag in movement. ( fig.1) during deep inspiration)

Bilateral symmetry of
vocal fremitus Decreased or absent
5. Palpate the chest for vocal (tactile) fremitus, the Fremitus is heard most fremitus (associated
faintly perceptible vibration felt through the chest wall clearly at the apex of with pneumothorax)
when the client speaks. the lungs Increased fremitus
(associated with con
solidated lung tissue,
as in pneumonia)
Low-pitched voices of .
 Place the palmar surfaces of your fingertip or males are more readily
ulnar aspect of your hand or closed fist on the palpated than higher
posterior , chest, starting near the apex of the pitched voices of
lungs ( fig.2) females

 . Ask the client to repeat such words as “blue

moon" or "one, two, three"
 Repeat the two steps, moving your hands
sequentially to the base of the lungs, through
positions B-E in ( fig.2)

 Compare the fremitus on both lungs and

between the apex and the base of each lung,
using either one hand and moving it from one
side of the client to the corresponding area on
the other side or using two hands that are
placed simultaneously on the corresponding

88
 areas of each side of the chest

. 10. Percuss the thorax. Percussion notes

 Percussion of the thorax is performed to resonate, except over Asymmetry in

determine whether underlying lung tissue is scapula percussion

filled with air, liquid, or solid material and to Areas of dullness or

determine the posi tions and boundaries of Lowest point of flatness over lung tis

certain or gans. Because percussion penetrates resonance is at the di sue (associated with

to a depth of 5 to 7 cm (2 to 3 in), it detects aphragm (i.e., at the consolidation of lung

superficial rather than deeple sions Percussion level of the eighth to tissue or a mass)

sounds and tones are deschbed in Table 30-4, tenth rib posteriorly)

carlier ( fig.3)
Note: Percussion on a
rib normally elicits
dullness.
• Ask the client to bend the head and fold the arms
forward across the chest Rationale: This
seporates the scapulo and exposes more lung
tissue to percussion

 Percuss in the intercostal spaces at about 5

cm (2 in.) intervals in a systematic
sequence. ( fig.4)
 Compare one side of the lung with the
other.
 Percuss the lateral thorax every few inches,
starting at the axilla and working down to
the eighth rib. 11. Restricted excursion
(associated with lung
Excursion is 3 to 5 cm disorder)
6. Percuss for diaphragmatic excursion (movement
(11/2 to 2 in.) bilat erally
of the diaphragm during maximal inspiration and
in women and 5 to 6 cm (2

89
expiration). to 3 in.) in men

Diaphragm is usually
 Ask the client to take a deep breath and
slightly higher on the right
hold it while you per cuss downward along side
the scapular line until dullness is produced
at the level of the diaphragm. Mark this
point with a marking pencil, and repeat the
procedure on the other side of the chest.
 Ask the client to take a few normal breaths
and then expel the last breath completely
and hold it while you percuss upward from
the marked point to assess and mark the
diaphragmatic excursion during deep
expiration on each side.
Adventitious breath
 Measure the distance between the two
sounds (e.g., crackles,
marks. Vesicular and
gurgles, wheeze,
bronchovescular breath
sound. friction rub; see Table
7. Auscultate the chest using the flat disc diaphragm
30–8)
of the stethoscope (best for transmitting the high
Absence of breath
pitched breath sounds). .
sounds

 Use the systematic zigzag procedure used in

percussion
 Ask the client to take slow, deep breaths
through the mouth. Listen at each point to the
breath sounds during a complete inspiration
and expiration.
 Compare findings at each point with the
corresponding point on the opposite side of
the chest.

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 Abnormal breathing
ASSESSMENT OF ANTERIOR THORAX: and sound.
Quiet, rhythmic, and
effortless respirations
8. Inspect breathing patterns (eg, respiratory rate and Costal angle is
rhythm). widened (associated
Costal angle is less than
with chronic
90%, and the ribs
9.Inspect the costal angle (angle formed by the obstructive
insert into the spine at
intersection of the costal margins) and the angle pulmonary disease)
approximately a 45"
at which the ribs enter the spine,
angle.

10. Palpate the anterior chest (see pos terior chest

Asymmetric and/or
palpation)
decreased respiratory
Full symmetric excursion;
excursion
11. Palpate the anterior chest for respiratory thumbs normally separate
excursion. 3 to 5 cm (11/2 to 2 in.)

 Place the palms of both your hands on the lower

thorax, with your fingers laterally along the lower
rib cage and your thumbs along the costal margins.
( fig.5)

.
• Ask the client to take a deep breath while you
observe the movement of your hands.
Same as posterior
fremritus
Same as posterior vocal
12. Palpate tactile fremitus in the same manner as for the fremitus; fremitus is
posterior chest and using the sequence shown in. ( fig.6) If normally decreased over
Asymmetry in
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the breasts are large and can not be retracted adequately for heart and breast tissue percussion notes
pal pation, this part of the examination is usually omitted.

Areas of dullness or
Percussion notes flatness over lung
13. Percuss the anterior chest systematically. resonate down to the tissue
 Begin above the clavicles in sixth rib at the level of
the supraclavicular space, and
the diaphragm but are
proceed downward to the diaphragm.( fig.7)
flat over areas of
 Compare one side of the lung to the other. heavy muscle and
 Displace female breasts for bone, dull on areas
proper examination. over the heart and the
liver, and tympanic
over the underlying
14. Auscultate the trachea. stomach. Adventitious breath
sounds
15. Auscultate the anterior chest. Use the sequence
used in percussion , beginning over the bronchi Adventitious breath
between the sternum and the clavicles. Bronchial and tubular sounds
16.. Document findings in the client record using breath sounds
forms or check-lists supplemented by narrative notes Bronchovesicular and
when appropriate. vesicular breath sounds.

Fig. 1 Position of Nurses hands for assessing

respiratory excursion of the posterior thorax.

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Fig, 3. Normal percussion sounds on the posterior
chest Fig.4 Sequence for percussion.

Fig. 6 Areas and sequence for palpating

Fig.5. Position of nurse's hands when assessing tactile itus on the anterior chest.
respiratory excursion on the anterior thorax.

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 BREASTS ASSESSMENT:
It is important to examine the breasts of female and male patients, Males have a small amount of
glandular tissue, a potential site for the growth of cancer cells, in the breast.

ASSESSMENT OF FEMALE BREAST:

Purposes: There are many good reasons for doing breast self-examination each month. One reason is that it is easy to
do and the more you do it, the better you will get at it. When you get to know how your breasts normally feel, you will
quickly be able to feel any change and early detection is the key to successful treatment and cure. Remember: A breast
self examination could save your breast- and save your life. Most breast lumps are found by women themselves, but,
in fact, most lumps in the breast are not cancer. Be sure to be safe.
not tender or swollen.
The American Cancer Society (2009b) recommends it following guidelines for the early detection of breast
cancer :
1. Monthly BSE is an option for women in their 20s.
2. Women 20 years of age and older need to report any breast changes to a health care provider
immediately.
3. Women need a clinical breast examination by a health care provider every 3 years from ages 20 to 40,
and yearly for women over age 40.
4. Women with a family history of breast cancer need a yearly examination by a health care provider.
5. Asymptomatic women need a screening mammogram by age 40; women age 40 and over need an
annual mammogram.
6. For women with an increased risk, the ACS recommends discussion of screening options and
additional testing with a health care provider.
The patients history reveals normal development changes, as well as signs of breast disease. Because of this
glandular structure, the breast undergoes changes during a woman's

94
 INSPECTION: While inspecting the breasts, explain the characteristics you see. Teach the patient
the significance of abnormal signs or symptoms.

 To remove the patient top gown or drape to allow simultaneous visualization of both breasts. Have the
patient stand or sit with her arms hanging loosely at her sides. If possible, place a mirror in front of the
patient during inspection so she sees what to look for when performing BSE.
 To recognize abnormalities, the patient needs to be familiar with the normal appearance of her breasts.
 Describe observations or findings in relation to imaginary lines that divide the breast into four quadrants
and a tail.
 The lines cross at the center of the nipple.
 Each tail extends outward from the upper outer quadrant (Figure 15-43).
 Inspect the breasts for size and symmetry.
 Normally the breasts extend from the third to the sixth ribs, with the nipple at the level of the fourth
intercostal space. It is common for one breast to be smaller. However, inflammation or a mass can cause a
difference in size.
 With age, the ligaments supporting the breast tissue weaken, causing the breasts to say and the nipples to
lower.
 Observe the contour or shape of the breasts, and note masses, flattening, retraction, or dimpling, Breasts
vary in shape from convex to pendulous or conical.
 Retraction or dimpling results from invasion of underlying ligaments by tumors.
 The ligaments fibrose and pull the overlying skin inward toward the tumor.
 Edema also changes the contour of the breasts.
 To bring out the presence of retraction or changes in the shape of the breasts, ask the patient to assume
three positions: raise arms above the head, press hands against the hips, and extend arms straight ahead
while sitting and leaning forward. Each maneuver causes a contraction of the pectoral muscles, which will
accentuate the presence of any re traction.
 Carefully inspect the skin for color; venous pattern; and presence of edema, lesions, or inflammation.
 Lift each breast when necessary to observe lower and lateral aspects for color and texture changes.
 The breasts are the color of neighboring skin, and venous patterns are the same bilaterally. Venous patterns
are easily visible in thin or pregnant women.
 Women with large breasts often have redness and excoriation of the undersurface caused by rubbing of
skin surfaces.
 Inspect the nipple and areola for size, color, shape, dis charge, and the direction the nipples point. The
normal areolae are round or oval and nearly equal bilaterally.

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 Color ranges from pink to brown.
 In light-skinned women the areola turns brown during pregnancy and remains dark.
 In dark-skinned women the areola is brown before pregnancy (Seidel and others, 2006). Normally the
nipples point in symmetrical directions, are everted, and have no drainage.
 If the nipples are inverted, ask if this has been present since birth.
 A recent inversion or inward turning of the nipple indicates an underlying growth, Rashes or ulcerations
are not normal of the breast or nipples.
 Note any bleeding or discharge from the nipple.
 Clear yellow discharge 2 days after childbirth is common.

PALPATION:
Palpation assesses the condition of underlying breast tissue and lymph nodes. Breast tissue consists of
glandular tissue, fibrous supportive ligaments, and fat. Glandular tissue is organized into lobes that end in
ducts opening onto the nipple's surface. The largest portion of glandular tissue is in the upper outer quadrant
and tail of each breast. Suspensory ligaments connect to skin and fascia underlying the breast to support the
breast and maintain its upright position. Fatty tissue is located superficially and to the sides of the breast.
 To palpate lymph nodes have the patient sit with arms at her sides and muscles relaxed.
 While facing the patient and standing on the side you are examining, support the patient's arm in a flexed
position and abduct the arm from the chest wall.
 Place the free hand against the patient's chest wall and high in the axillary hollow (Figure 15-45).
 With finger tips press gently down over the surface of the ribs and muscles.
 Palpate the axillary nodes with the fingertips gently rolling soft tissue.

Palpate four areas of the axilla: at the edge of the pectoralis major muscle along the anterior axillary
line, the chest wall in the midaxillary area, the upper part of the humerus, and the anterior edge of the
latissimus dorsi muscle along the posterior axillary line.

 Normally lymph nodes are not palpable. Note the number, consistency, mobility, and size
of palpable nodes.
 A palpable node feels like a small mass that is hard, tender, and immobile. Also palpate
along the upper and lower clavicular ridges.
 Reverse the procedure for the patient's other side.
 Perform palpation of breast tissue with the patient lying supine and one arm behind the head (alternating
with each breast). The supine position allows the breast tissue to flatten evenly against the chest wall.

96
 The patient raises her hand and places it behind the neck to further stretch and position breast tissue
evenly.
 Place a small pillow or towel under the patient's shoulder blade to further position breast tissue.
 If the patient complains of a mass, examine the opposite breast first to ensure an objective comparison of
normal and abnormal tissue.
 Use the pads of the first three fingers to com press breast tissue gently against the chest wall, noting
tissue consistency (Fig.).
 Perform palpation systematically in one of three ways:
(1) using a vertical technique with the fingers moving up and down each quadrant;
(2) clockwise or counter clockwise, forming small circles with the fingers along each quadrant and the tail; or
(3) palpating from center of the breast in a radial fashion, returning to the areola to begin each spoke ( fig.)
 Whatever approach you use, be sure to cover the entire breast and tail, directing attention to
any areas of tenderness.
 During palpation note the consistency of breast tissue, which varies widely.
 The breasts of a young patient are firm and elastic.
 In an older patient the tissue may feel stringy and nodular.
 The lower edge of each breast feels firm and hard.
 This is the normal inframammary ridge and is not a tumor.
 It helps to move the patient's hand so she feels normal tissue variations.
 Palpate abnormal masses to determine location in relation to quadrants, diameter in centimeters, shape
(es. round or discoid), consistency (soft, firm, or hard), tender ness, mobility, and discreteness (clear or
unclear borders).
 Cancerous lesions are hard, fixed, nontender, irregular in shape, and usually unilateral.
 Give special attention when palpating the nipple and areola. Palpate the entire surface gently. Use the
thumb and index finger to compress the nipple, and note any discharge
 During the examination of the nipple and areola, the nipple may become erect with wrinkling of the
areola. These changes are normal.
 After completing the examination, have the patient demonstrate self-palpation. Observe the patient's
technique, and emphasize the importance of a systematic approach.

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MALE BREASTS ASSESSMENT:

 Male Breasts Examination of the male breast is relatively easy.

 Inspect the nipple and areola for nodules, edema, and ulceration.
 An enlarged male breast results from obesity or glandular en largement.
 Breast enlargement in young males results from steroid use.
 Fatty tissue feels soft, whereas glandular tissue is firm.
 Use the same techniques to palpate for masses used in examination of the female breast.
 Because male breast cancer is relatively rare, routine self-examinations are unnecessary.
 However, men with a first-degree relative (e.g., mother) with breast cancer are at increased risk for the
development of breast cancer and should perform regular breast self examinations.
ABDOMEN

Assessment of the abdomen involves inspecton, auscultation, percussion and palpation. The
examination includes an assessment of structures of the lower gastrointestinal (GI) tract in addition to
the Liver, stomach uterus, ovaries, kidneys and bladder.

INSPECTION

- To inspect the abdomen for abnormal movement or shadows, atand on the patient’s right side
and inspect from above the abdomen.
 SKIN
- Inspect the skin over the abdomen for colour, scars, rashes ,venous patterns, lesions, and striae
(stretch marks)
 UMBILICUS
- Note the position; shape; colour and signs of inflammation, discharge or protruding masses.
- A normal umblicus is flat or concave with the colour the same as that of the surrounding skin.
- Underlying masses cause displacement of the umbilicus.
- An everted (pouched -out) umbilicus usually indicates distention.
- Hernias cause upward protrution of the umbilicus.

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  CONTOUR AND SYMMETRY
- Inspect for contour, symmetry and surface motion of the abdomen, noting any masses, bulging
or distention.
- If the shape of the abdomen is normal if it is symmetrical.
- The presence of masses on only one side, or asymmetry, possibly indicates an underlying
pathological condition.
- Intestinal gas, a tumour, or fluid in the abdominal cavity causes distention (swelling), when
distention is generalizes, the entire abdomen protrudes.
- The skin often appears taut, as if it were stretched over the abdomen.
- When gas causes distention, the flanks ( side muscles) do not bulge.ask the patient to roll onto
one side.
- Be careful not to confuse distension with obesity.
 ENLARGED ORGANS OR MASSES
- Observe the contour of the abdomen while asking the patient to take a deep breath and hold it.
- Perform a closer examination with palpation, to evaluate the abdominal musculature have the
patient raise the head. This position causes superficial abdominal wall masses, hernias and
muscle separations to become more apparent.

AUSCULTATION

 Auscultate before palpation during the abdominal assessment because manipulation of the
abdomen alters the frequency and intensity of bowel sounds.
 Patients with GI tubes connected to suction need them temporarily turned off before beginning
an examination.
 The best time to auscultate is between meals.
 Auscultate for bowel sounds (normal, hyper- or hypo-active) and bruits.
 Begin by dividing the abdomen into 4 quadrants, by drawing an imaginary line vertically and
horizontally across the abdomen, to intersect at the umbilicus. This will divide the abdomen
into:
• Right Upper Quadrant (RUQ)
• Left Upper Quadrant (LUQ)
• Right Lower Quadrant (RLQ)
• Left Lower Quadrant (LLQ)

99
  Auscultati
on should
begin in
the right
lower
quadrant.
If bowel
sounds are
not heard,
in order to
determine
if bowel
sounds are truly absent, listen for a total of five minutes (Jarvis, 2012).

VASCULAR SOUNDS

 Bruits indicate narrowing of the major blood vessels and disruption of blood flow.
 The presence of bruits in the abdominal area can reveal aneurysms or stenotic vessels.
 Use the bell of the stethoscope to auscultate in the epigastric region and each of the four
quadrants

KIDNEY TENDERNESS
 With the patient sitting or standing erect, use direct or indirect percussion to assess for kidney
inflammation.
 With the ulnar surface of the partially closed fist, percuss posteriorly the costovertebral angle
at the scapular line, if the kidneys are inflamed, the patient feels tenderness during percussion.

AORTIC PULSATION

 Palpate with the thumb and forefinger of one hand deeply into the upper abdomen just left of
the midline to assess pulsation.
 If the aorta is enlarged because of ananeurysm the pulsation expands laterally. Do not palpate
a pulsating abdominal mass.
 In obese patients it is often necessary to palpate with both hands, one on each side of the aorta.

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PALPATION:

• Palpate lightly then deeply noting any muscle guarding, rigidity, masses or tenderness (tender
areas last)
• Palpate the liver margins (often it is not palpable)
• Palpate the spleen (enlargement occurs with mononucleosis and trauma)
• Palpate the kidneys (enlargement may indicate a mass)
• Assess for rebound tenderness (pain on release of pressure to the abdomen usually indicates
peritoneal irritation)
• When acute abdominal pain is present perform the iliopsoas muscle test and obturator test.

Percussion:

• Percuss for general tympany, liver span, splenic dullness (dullness over the spleen),
costovertebral angle tenderness, presence of fluid wave and shifting dullness with ascites.

BACK:
 Any deformities like kyphosis, scoliosis, lordosis, and pain.
FEMALE GENITALIA AND REPRODUCTIVE TRACT
Examination of the female genitalia is embarrassing to a patient unless you use a calm, relaxed
approach. The gynaecological examination is one of the most difficult experiences for adolescents.

Preparation of the patient

 Make sure that the equipment is ready before the examination begins. Ask the patient to empty
her bladder so the uterus and ovaries are readily palpable.
 Assist the patient to the lithotomy position in bed or on an examination table for the external
genitalia assessment.
 Assist her into stirrups for a speculum examination.

EXTERNAL GENITALIA

 The perineum is sensitive and tender; do not touch the area suddenly without warning the
patient.
 Determine if patient has had previous illness or surgery involving reproductive organs,
including STIs

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  Assess if patient has signs and symptoms of vaginal discharge, painful or swollen perianal
tissues, or genital lesions.
 Ask if the patient has had signs of bleeding outside of normal menstrual period or after
menopause or gas had unusaual vaginal discharge.
 Inspect surface characteristics of the labia majora.
 The labia majora can be gaping or closed, appear dry or moist, and are usually symmetrical.
 After childbirth the labia majora separate, causing the labia minora to become more
prominent.
 Inspect the urethral orifice carefully for color and position.
 Inspect the vaginal orifice for inflammation, edema, discolouration, discharge and lesions.
 While inspecting the vaginal orifice, note the condition of the hymen, which is just inside the
opening.
 Inspecct the anus, looking for lesions and haemorrhoids

SPECULUM EXAMINATION OF INTERNAL GENITALIA

 The examinaiton involves use of a plastic or metal speculum consisting of two blades and an
adjustment device.
 The examiner inserts the speculum into the vagina to assess the internal genitalia for
cancerous lesions and other abnormalities.

During the examination the examiner collects a specimen for a papanicolaou (pap) test for cervical
and vaginal cancer .
ASSESSING THE MALE GENITAL AND INGUINAL AREA

ASSESSMENT NORMAL FINDING DEVIATION FROM NORMAL

PUBIC HAIR: Triangular distribution, often

Scan amount or absence of hair
Inspect the distribution, amount spreading up the abdomen
and characteristic
PENIS:
 Inspect the penile shaft and Penile skin intact Presence of lesions, nodules,
glans penis for lesions, nodules, Foreskin easily retractable from
swellings or inflammation.
swellings, and inflammation. glans penis.

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  Inspection for urethral meatus Small amount of thick white Inflammation, discharge.
for swelling, inflammation and smegma between the glans
discharge. and foreskin.

 Palpate for tenderness or any Smooth and semifirm Presence of tenderness, thickening
nodules or nodules.

SCORTUM:
 Inspection for appearance, Darker in colour than that of Discolouration
size, and symmetry. rest of the body and is loose.
Size is varies
Asymmetric ( left is lower Symmetry in size
than right).

 Palpate the assess status of Testicles are rubbery, Enlarged with uneven surface
underlying testes, epidermis, smooth, and free of nodules ( tumor)
and spermatic cord. and masses. Epididyrmis is nonresilient and
painful.
INGUINAL AREA:
Inspect both inguinal area for No swelling or bulges. Swelling or bulge( possible inguinl or
bulges. femoral hernia)

THE RECTUM AND ANUS

Rectal examination, an essential part of every comprehensive physical examination, involves
inspection and palpation (digital examination). The extent of the assessment of the rectum and anus
depends on the rectal problems stated by the client in the nursing history. In many practice settings,
the nurse perform, only inspection of the anus.

ASSESSING THE RECTUM AND ANUS

PLANNING

103
 Delegation

Assessment of the rectum and anus is not delegated to UAP. However, many aspects are observed
during usual care and may be recorded by persons other than the nurse. Abnormal findings must be
validated and interpreted by the nurse.

EQUIPMENT

 Clean gloves.
 Water-soluble lubricant

IMPLEMENTATION

1. Prior to performing the procedure, introduce self and verify the client's identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can
cooperate. Discuss how the results will be used in planning further care or treatments. Because digital
examination can cause apprehension and embarrassment in the client, it is important that the nurse
help the client relax by encouraging the client to take slow, deep breaths (tension can cause spasms of
the anal sphincters, making the examination uncomfortable) and inform the client about potential
sensations such as feelings of defecation or passing gas.

2. Perform hand hygiene, apply gloves, and observe appropriate infection control procedures for all
rectal examinations.

3. Provide for client privacy. Drape the client appropriately to prevent undue exposure of body parts.

4. Inquire if the client has any history of the following: bright blood in stools, tarry black stools,
diarrhea, constipation, abdominal pain, excessive gas, hemorrhoids, or rectal pain; family history of
colorectal cancer; when last stool specimen for occult blood was performed and the results; and for
males, if not obtained during the genitourinary examination, signs or symptoms of prostate
enlargement (e.g., slow urinary stream, hesitance, frequency, dribbling, and nocturia).

5. Position the client. In adults, a left lateral or Sims' position with the upper leg acutely flexed is
required for the examination. For females, a dorsal recumbent position with hips externally rotated
and knees flexed or a lithotomy position may be used. For males, a standing position while the client
bends over the examining table may also be used. This position is commonly used to examine the
prostate gland.

ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM

104
 NORMAL
Inspect the anus and Intact perianal skin; usually Presence of fissures (cracks),
surrounding tissue for color, slightly more pigmented ulcers, excoriations,
integrity, and skin lesions. than the skin of the buttocks. inflammations, abscesses,
Then, ask the client to bear Anal skin is normally more protruding hemorrhoids (dilated
down as though defecating. pigmented, coarser, and veins seen as reddened
Bearing down creates slight moister than perianal skin protrusions of the skin), lumps or
pressure on the skin that may and is usually hairless. tumors, fistula openings, or rectal
accentuate rectal fissures, prolapse (varying degrees of
rectal prolapse, polyps, or protrusion of the rectal mucous
internal hemorrhoids. membrane through the anus).
Describe the location of all
abnormal findings in terms of
a clock, with the 12 o'clock
position toward the pubic
symphysis.

Palpate the rectum for anal Anal sphincter has good Hypertonicity of the anal
sphincter tonicity, nodules, tone. sphincter (may occur in the
masses, and tenderness. presence of an anal fissure or
• Lubricate your gloved index other lesion that causes
finger, and instruct the client contraction).
to bear downward as though Hypotonicity of anal sphincter
having a (may occur after rectal surgery or
bowel movement. result from a neurologic
Rationale: This relaxes the deficiency).
anal sphincter.
• Slowly insert your finger
into the anus and into the
rectum in the direction of the
umbilicus. The anal canal
(distance from the anal
opening to the anorectal

105
 junction) is short (less than 3
cm [about 1 inch.]). The
posterior wall of the rectum
follows the curve of the
coccyx and sacrum. The
nurse's finger is usually able
to palpate a distance of 6 to
10 cm (2 to 4 inch.).
• Never force digital insertion.
If lesions are painful or
bleeding occurs, discontinue
the examination.
Ask the client to tighten the
anal sphincter around your
finger, and note the tone of
the anal sphincter.
 Rotate the pad of the index Rectal wall is tender and nodular
finger along the anal and the Rectal wall is smooth and
rectal walls, feeling for not tender
nodules, masses, and
tenderness.
 Note the location of any
abnormalities of the rectum
(e.g., "anterior wall, 2 cm
proximal to the internal anal
sphincter).

On withdrawing the finger Brown color Presence of mucus, blood, or

from the rectum and anus, black tarry stool
observe it for feces. If
ordered, perform a test for
occult blood on the stool.

106
Document findings in the client record using forms or checklists supplemented by narrative notes
when appropriate.

EVALUATION

 Perform a detailed follow-up examination based on findings that deviated from expected or
normal for the client. Relate findings to previous assessment data if available.
 Report significant deviations from normal to the primary care provider.

EXTREMITIES:
 Upper and lower are assessed for size and symmetry, various patterns, color and texture of skin
and nail beds, hair distribution on hands, legs, feet and toes.
 Observe for pigmentation, rashes, scars, ulcers and oedema.
 Range of motion and exercise are possible or not possible in both the extremities, brachial, radial,
ulnar pulsation of upper extremities and femoral, poplitial, tibial, pedal pulsation of lower
extremities, any abnormality like polydactyly (more than 5 fingers per hand or 5 toes per foot),
synductyly (abnormal connection of 2 or more fingers) or amputated limbs.

Fig: Polydactyly Fig: Syndactyly

107
 Test for Homan’s Sign, an indicator of phlebitis in which pain and soreness are present in the calf
area when the foot is dorsi flexed. The person’s flexed leg is supported from the calf with your non
– dominant hand. Note any pain or soreness in the calf area. If present, this would be a positive
Homan’s Sign, indicating the possibility of phlebitis.
i.Motor system:
 Inspect the voluntary muscles for atropy, fasiculations (uncontrollable twitching) and
involuntary movements. In addition, assess gait, Rombergs sign for mucles strength and
coordination.

ii.Gait:

 Gait is a person’s style of walking.

 To assess gait, instruct the person to walk across the room, turn and walk back towards you.
 Observe the person’s balance and posture.
 Ataxia is an uncoordinated gait that results from cerebellar disease or intoxication.
Romberg’s test:
 Romberg’s test is a test of sensory equilibrium.
 Instruct the person to stand with the feet fit together and eye open.
Note the person balance. Then have the person close the eyes. Normally, you will
observe only minimal swaying. A positive test will suggest cerebellar ataxia.

iii. Reflexes of muscles:

Tests of muscle strength and assessment of common reflexes,

Type Procedure Normal reflex

Biceps Flex the client’s arm at elbow with palms Flexion of arm at elbow (knee
down. Place your thumb in antecubital fossa at Jerk)
the base of biceps tendon. Strike the thumb
with a reflex hammer.
Triceps Flex the client’s elbow, holding arm across the Extension at elbow
chest, or hold the upper arm horizontally and
allow the lower arm to go limp. Strike triceps
tendon just above the elbow.
Patellar Make the client sit with legs hanging freely Extension of lower leg at knee
over the side of the bed or chair or have the (knee jerk)

108
 client lie supine and support knee in a flexed
position. Briskly tap patellar tendon just below
patellar.
Plantar Have the client lie supine with legs straight Bending of toes downward
(babinski’s) and feet relaxed. Take handle end of the reflex
hammer and stroke lateral aspect of the sole
from the heel to the ball of the foot, curving
across the ball of the foot toward the big toe.
Achilles Make the client assume lie supine with legs Plantar flexion of foot
straight and feet relaxed. Slightly dorsiflex the
client’s ankle by grasping toes in the palm of
your hand. Strike Achilles tendon just above
the heel.
Cutaneous Have the client assume side – lying positions, Contraction of anal sphincter
reflexes spread buttocks apart and lightly stimulate the
Gluteal perineal area with a cotton applicator.
Abdominal Have the client stand or lie supine. Stroke Contraction of rectus
abdominal skin with the base of a cotton abdominis muscles with
applicator over lateral border of rectus pulling of umbilicus towards
abdominis muscles towards midline. Repeat stimulated side.
test in each abdominal quadrant.

THE NEUROLOGIC SYSTEM

A thorough neurologic examination may take 1 to 3 hours; however, routine screening tests are usually done
first. If the results of these tests raise questions, more extensive evaluations are made. Three major
considerations determine the extent of a neurologic exam:

(a) the client's chief complaints

(b) the client's physical condition (ie., level of consciousness and ability to ambulate) because many
parts of the examination require movement and coordination of the extremities

(c) the client's willingness to participate and cooperate.

Examination of the neurologic system includes assessment of :

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(a) mental status including level of consciousness

(b) the cranial nerves

(c) reflexes

(d) motor function

(e) sensory function.

Parts of the neurologic assessment are performed throughout the health examination. For example, the
nurse per forms a large part of the mental status assessment during the taking of the history and when
observing the client's general appearance. Also, the nurse assesses the function of cranial nerves. Cranial
nerves II, III, IV. V. and VI (ophthalmic branch) are assessed with the eyes and vision, and cranial nerve
VIII (cochlear branch) is assessed with the ears and hearing.

MENTAL STATUS

Assessment of mental status reveals the client's general cerebral function. These functions include
intellectual (cognitive) as well as emotional (affective) functions. If problems with use of language,
memory, concentration, or thought processes are noted during the nursing history, a more extensive
examination is required during neurologic assessment. Major areas of mental status assessment include
language, orientation, memory, and attention span and calculation.

Language

Any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend
spoken or written language due to disease or injury of the cerebral cortex, is called aphasia. Aphasias can
be categorized as sensory or receptive aphasia, and motor or expressive aphasia.

Sensory or receptive aphasia is the loss of the ability to comprehend written or spoken words. Two types
of sensory aphasia are auditory (or acoustic) aphasia and visual aphasia. Clients with auditory aphasia
have lost the ability to understand the symbolic content associated with sounds. Clients with visual
aphasia have lost the ability to understand printed or written figures.

Motor or expressive aphasia involves loss of the power to ex press oneself by writing, making signs, or
speaking. Clients may find that even though they can recall words, they have lost the ability to combine
speech sounds into words.

Orientation

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 This aspect of the assessment determines the client's ability to recognize other persons (person),
awareness of when and where they presently are (time and place), and who they, themselves, are (self).

Memory

The nurse assesses the client's recall of information presented seconds previously (immediate recall),
events or information from curlier in the day or examination (recent memory), and knowledge recalled
from months or years ago (remote or long term memory).

Attention Span and Calculation

This component determines the client's ability to focus on a mental task that is expected to be able to be
performed by persons of normal intelligence.

LEVEL OF CONSCIOUSNESS
Level of consciousness (LOC) can lie anywhere along a continuum from a state of alertness to coma. A
fully alert client responds to questions spontaneously: a comatose client may not respond to verbal
stimuli. The Glasgow Coma Scale was originally developed to predict recovery from a head injury:
however, it is used by many professionals to assess LOC. It tests in three major areas: eye response,
motor response, and verbal response. An assessment totaling 15 points indicates the client is alert and
completely oriented. A comatose client scores 7 or less.

LEVELS OF CONSCIOUSNESS- GLASGOW COMA SCALE

FACULTY MEASURED RESPONSE SCORE

Eye opening Spontaneous 4
To verbal command 3
To pain 2
No response 1
Motor response To verbal command 6
To localized pain 5
Flexes and withdraws 4
Flexes abnormally 3
Extends abnormally 2
No response 1
Verbal response Oriented, converses 5

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 Disoriented, converses 4
Uses inappropriate words 3
Makes incomprehensible2
sounds
No response 1

CRANIAL NERVES

The nurse needs to be aware of specific nerve functions and assessment methods for each cranial nerve to
detect abnormalities. In some cases, each nerve is assessed; in other cases only selected nerve functions are
evaluated.

CRANIAL NERVE FUNCTIONS AND ASSESSMENT METHODS

CRANIAL NAME TYPE FUNCTION ASSESSMENT METHOD

NERVE
I Olfactory Sensory Smell Ask client to close eyes and
identify different mild aromas,
such as coffee, vanilla, peanut
butter, orange, lemon, chocolate.
II Optic Sensory Vision and visual Ask client to read Snellen-type
fields chart; check visual fields by
confrontation; and conduct an
ophthalmoscopic examination.
III Oculomotor Motor Extraocular eye Assess six ocular movements and
movement(EOM); pupil reaction.
movement of
ciliary muscles of
lens
IV Trochlear Motor Assess six ocular movements.
EOM;
specifically,
moves
eyeball
downward

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 and
laterally
V Trigeminal
Ophthalmic branch Sensory Sensation of While client looks upward,
cornea, skin of lightly touch the lateral sclera of
face, and nasal the eye with sterile gauze to elicit
mucosa. blink reflex. To test light
sensation, have client close eyes,
wipe a wisp of cotton over
client’s forehead and paranasal
sinuses. To test deep sensation,
use alternating blunt and sharp
ends of a safety pin over same
areas.
Maxillary Sensory Sensation of skin Assess skin sensation as for
branch of face and ophthalmic branch above.
anterior oral
cavity (tongue
and teeth).
Mandibular Motor and Muscles of Ask client to clench teeth.
branch sensory mastication;
sensation of skin
of face.
VI Abducens Motor EOM; moves Assess directions of gaze.
eyeball laterally.
VII Facial Motor and Facial expression; Ask client to smile, raise the
sensory taste (anterior eyebrows, frown, puff out cheeks,
two-thirds of close eyes tightly. Ask client to
tongue). identify various tastes placed on
tip and sides of tongue: sugar
(sweet), lemon juice (sour), and
quinine (bitter); identify areas of
taste.

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 VIII Auditory
Vestibular branch Sensory Equilibrium Romberg test.
Cochlear branch Sensory Hearing Assess client’s ability to hear
spoken word and vibrations of
tuning fork.
IX Glossopharyngeal Motor and Swallowing Apply tastes on posterior tongue
sensory ability, tongue for identification. Ask client to
movement, taste move tongue from side to side
(posterior and up and down.
tongue).
X Vagus Motor and Sensation of Assessed with cranial neve IX,
sensory pharynx and assess client’s speech for
larynx; hoarsness.
swallowing; vocal
cord movement.
XI Accessory Motor Head movement;Ask client to shrug shoulders
shrugging ofagainst resistance from your
shoulders. hands and turn head to side
against resistance from your
hand (repeat for other side).
XII Hypoglossal Motor Protrusion of tongue;Ask client to protrude tongue at
moves tongue up andmid-line, then move it side to
down and side to side.side.

REFLEXES

A reflex is an automatic response of the body to a stimulus. It is not voluntarily learned or conscious. The
deep tendon reflex (DTR) is activated when a tendon is stimulated (tapped) and its associated muscle
contracts. The quality of a reflex response varies among individuals and by age. As a person ages, reflex
responses may become less intense.

Reflexes are tested using a percussion hammer. The response is described on a scale of 0 to 14. Experience is
necessary to determine appropriate scoring for an individual. Several reflexes are normally tested during the
physical examination:

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(a) the bi ceps reflex

(b) the triceps reflex

(c) the brachioradialis reflex

(d) the patellar reflex

(e) the Achilles reflex

(f) the plantar (Babinski) reflex.

By comparing one side of the body with the other evaluating the symmetry of response as:

 No reflex response 0
 Minimal activity (hypoactive) +1
 Normal response +2
 More active than normal +3
 Maximal activity (hyperactive) +4

Biceps Reflex

 The biceps reflex tests the spinal cord level C-5, C-6.
 Partially flex the client's arm at the elbow, and rest the forearm over the thighs, placing the palm of
the hand down.
 Place the thumb of your nondominant hand horizontally over the biceps tendon.
 Deliver a blow (slight downward thrust) with the percussion hammer to your thumb.
 Observe the normal slight flexion of the elbow, and feel the bicep's contraction through your
thumb.

Triceps Reflex

The triceps reflex tests the spinal cord level C-7, C-8.

 Flex the client's arm at the elbow, and support it in the palm of your nondominant hand.
 Palpate the triceps tendon about 2 to 5 cm (1 to 2 in.) above the elbow.
 Observe the normal slight extension of the elbow
 Deliver a blow with the percussion hammer directly to the tendon.
 Observe the normal slight extension of the elbow.

Brachioradialis Reflex

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 The brachioradialis reflex tests the spinal cord level C -5, C-.6

 Rest the client's forearm in a relaxed position externally rotated on a firm surface.
 Deliver a blow with the percussion hammer directly on the radius 2 to 5 cm (1 to 2 in) above the
wrist or the styloid process, the bony prominence on the thumb side of the wrist.
 Observe the normal flexion and supination of the fore arm. The fingers of the hand may also
extend slightly.

Patellar Reflex

The patellar reflex tests the spinal cord level L-2, L-3, L - 4 .

 Ask the client to sit on the edge of the examining table so that the legs hang freely.
 Locate the patellar tendon directly below the patella (kneecap).
 Deliver a blow with the percussion hammer directly to the tendon.
 Observe the normal extension or kicking out of the leg as the quadriceps muscle contracts.
 If no response occurs and you suspect the client is not relaxed, ask the client to interlock the
fingers and pull.
 Rationale: This action often enhances relaxation so that a more accurate responses obtained.

Achilles Reflex

The Achilles reflex tests the spinal cord level S-1, S-2.

 With the client in the same position as for the patellar reflex slightly dorsiflex the client's ankle by
supporting the ball of the foot lightly in the hand.
 Deliver a blow with the percussion hammer directly to the Achilles tendon just above the heel.
 Observe and feel the normal plantar flexion (downward jerk) of the foot.

Plantar (Babinski) Reflex

 The plantar, or Babinski, reflex is superficial. It may be absent in adults without pathology or
overridden by voluntary control.
 Use a moderately sheep object, such as the handle of the percussion hammer, a key, or an
applicator stick.
 Stroke the lateral border of the sole of the client's foot, starting at the heel continuing to the ball of
the foot, and then proceeding across the ball of the foot toward the big toe.

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  Observe the response. Normally, all five toes bend downwards; this reaction is negative Babinski
response the toes spread outward and the tip of toes moves upward.

Cutaneous Reflexes Gluteal

 Have the client assume side-lying positions, spread buttocks apart and lightly stimulate the
perineal area with a cotton applicator.
 There will be contraction of the anal sphincter.

MOTOR FUNCTION
Neurologic assessment of the motor system evaluates proprioception and cerebellar function Structures
involved in proprioception are the proprioceptors, the posterior columns of the spinal cord, the
cerebellum, and the vestibular apparatus (which is innervated by cranial nerve VIII) in the labyrinth of
the internal ear.

Proprioceptors are sensory nerve terminals, occurring chiefly in the muscles, tendons, joints, and the
internal ear, that give information about movements and the position of the body. Stimuli from the
proprioceptors travel through the posterior columns of the spinal cord. Deficits of function of the
posterior columns of the spinal cord result in impairment of muscle and position sense. Clients with such
an impairment often must watch their own arm and leg movements to ascertain the position of the limbs,
The cerebellum
(a) helps to control posture
(b) acts with the cerebral cortex to make body movements smooth and coordinated
(c) controls skeletal muscles to maintain equilibrium.
MUSCLE TONE

1. Ask the patient to relax.

2. Flex and extend the patient’s fingers, wrist and elbow.
3. Flex and extend patient’s ankle and knee.
4. There is normally a small, continuous resistance to passive movement.
5. Observe for decreased (flaccid) or increased (rigid/spastic) tone.
MUSCLE STRENGTH
1. Test strength by having the patient move against your resistance.
2. Always compare one side to the other.
3. Grade strength on a scale from 0 to 5 “out of five”.

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 GRADING OF MOTOR STRENGTH

GRADE DESCRIPTION
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint.
2/5 Movement at the joint, but not against gravity.
3/5 Movement against gravity, but not against added resistance.
4/5 Movement against resistance, but less than normal.
5/5 Normal strength.

MOTOR FUNCTION ASSESSMENT

ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NORMAL
Gross Motor and Balance
Tests
Generally the Romberg best
and one other gross motor
function and balance tests are
used
Walking Gait Has upright posture and Has poor posture and unsteady,
Ask the client to walk across steady gait with opposing irregular staggering gat with wide
the room and back and assess arm swing; walks stance; bends legs only from hips, has
the client's gait unaided, maintaining rigid or no arm movements.
balance.
Romberg Test Negative Romberg: may Positive Romberg : cannot maintain
Ask the client to stand with sway slightly but is able foot stance, moves the feet apart to
feet together and arms resting to maintain upright maintain stance.
at the sides first with eyes posture and foot stance. If client cannot maintain balance with
open then closed. Stand close the eyes shut, client may have sensory
during this test to prevent the ataxia (lack of coordination of the
client from falling. voluntary muscles).
If balance cannot be maintained
whether the eyes are open or shut,
client may have cerebellar ataxia.
Standing on One Foot with Maintains stance for at Cannot maintain stance for 5 seconds

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Eyes Closed least 5 seconds
Ask the client to close the
eyes and stand on one foot.
Repeat on the other foot.
Stand close to the client
during this test.
Heel-Toe Walking Maintains heel-toe along Assumes a wider foot get to stay
Ask the client to wait a a straight line. upright
straight line, placing the heel
of one foot directly in front
of the toes of the other foot.
Toe or Heel Walking Able to walk several steps Cannot maintain balance on toes and
Ask the client to walk several on toes of heels heels.
steps on the toes and then on
the heels
Finger-To-Nose Test Repeatedly and Misses the nose or gives slow
Ask the client to abduct and rhythmically touches the response
extend the arms at shoulder nose
height and then rapidly touch
the nose alternately with one
index finger and then the
other. The client repeats the
test with the eyes closed if
the test is performed easily.
Alternating Supination and Can alternately supinate Performs with slow, clumsy
Pronation of Hands on and pronate hands at rapid movements and irregular timing; has
Knees pace difficulty alternating from supination
Ask the client to pat both to pronation.
knees with the palms of both
hands and then with the
backs of the hands alternately
at an ever increasing rate.
Finger to nose and to the Performs with Misses the finger and moves slowly
Nurse's finger coordination and rapidity

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Ask the client to touch the
nose and then your index
finger, held at a distance of
about 45cm, at arapid and
increasing rate.

Fingers To Fingers Performs with accuracy Moves slowly and is unable to touch
Ask the client to spread the and rapidity fingers consistently
arms broadly at shoulder
height and then bring the
fingers together at the mid-
line, first with the eyes open
and then closed, first slowly
and then rapidly.
Fingers to Thumb (Same Rapidly touches finger to Cannot co-ordinate this fine discrete
Hand) thumb with each hand. movement with either one or both
Ask the client to touch each hands.
finger of one hand to the
thumb of the same hand as
rapidly as possible.
Fine motor tests for the lower
extremities
Ask the client to lie supine
and to perform these tests.
Heel down opposite shin Demonstrates bilateral Has tremors or is awkward; heel
Ask the client to place the equal coordination moves off shin
heel of one foot just below
the opposite knee and run the
heel down the shin to the
foot. Repeat with the other
foot. The client may also use
a sitting position for this test.

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Toe or Ball of Foot to the Moves smoothly, with co- Misses your finger, cannot co-
Nurse's Finger ordination. ordinate movement.
Ask the client to touch your
finger with the large toe of
each foot.

SENSORY FUNCTION

Sensory functions include touch, pain, temperature, position. and tactile discrimination. The first three
are routinely tested. Generally, the face, arms, legs, hands, and feet are tested for touch and pain,
although all parts of the body can be tested. If the client complains of numbness, peculiar sensations, or
paralysis, the practitioner should check sensation more carefully over flexor and extensor surfaces of
limbs, mapping out clearly any abnormality of touch or pain by examining responses in the area about
every 2 cm (1 in.). This is a lengthy procedure and may be performed by a specialist. Abnormal
responses to touch stimuli include loss of sensation (anesthesia); more than normal sensation
(hyperesthesia); less than normal sensation hypoesthesia); or an abnormal sensation such as burning,
pain, or an electric shock (paresthesia).

A variety of common health conditions, including diabetes and arteriosclerotic heart disease, result in
loss of the protective sensation in the lower extremities. This loss can lead to severe tissue damage. In
efforts to identify clients at increased risk for damage to the feet, the Bureau of Primary Health Care of
the US government has established the Lower Extremity Amputation Prevention (LEAP) program. The
most important aspect of LEAP is assessment of sensation using a special monofilament that delivers 10
grams of force. Health care providers should perform an initial foot screen on all clients with diabetes
and at least annually thereafter. Clients who are at risk should have their feet and shoes evaluated at least
four times a year to help prevent foot problems from occurring.

A detailed neurologic examination includes position sense, temperature sense, and tactile discrimination.
Three types of tactile discrimination are generally tested: one- and two-point discrimination, the ability to
sense whether one or two areas of the skin are being stimulated by pressure, stereognosis, the act of
recognizing objects by touching and manipulating them; and extinction, the failure to perceive touch on
one side of the body when two symmetric areas of the body are touched simultaneously.

 Light touch/superficial pain- using a wisp of cotton and a safety pin alternatively, touch the distal
and proximal portions of the upper and lower extremities.

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  The temperature test can be done by asking the patient to touch and identify the hot and cold test
tube filled with hot and cold test tube filled with hot and cold water respectively.
 Vibration is assessed by tapping a tuning fork and placing it firmly on a person’s inter-phallengial
joint of the finger and great toe. Ask the patient to describe the sensation and to identify when the
sensation ends.
 Two-point discrimination- when assessing two-point discrimination, touch the person
alternatively with one or two safety pins on a particular body part, such as the finger pads. Ask
the patient if one or two sensations are felt.
 Point localisation is assessed by touching various parts of the person’s body with a wisp of cotton.
The person is instructed to open the eyes after having felt the touch and point to the area.

ASSESSMENT NORMAL FINDINGS DEVIATION FROM NORMAL

Light-Touch Sensation Light tickling or touch Anesthesia, hyperesthesia, hypoesthesia

Compare the light-touch sensation. or paresthesia.
sensation of symmetric
areas of the body.
Rationale: Sensitivity to
touch varies among
different skin areas.
 Ask the client to close
the eyes
 and to respond by saying
"yes" or "now whenever
the client feels the
cotton wisp touching the
skin.
 With a wasp of cotton,
lightly touch one
specific spot and then
the same spot on the
other side of the body.
 Test areas on the
forehead, cheek, hand,

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 lower arm, abdomen,
foot and lower leg.
 Check a distal area of
the limb first (ie, the
hand before the am and
the foot before the leg).
 Rationale: The sensory
nerve may be assumed
to be intact if sensation
is felt at its most distal
part.
 Ask the client to point to
the spot where the touch
was felt.
 Rationale: This
demonstrates whether
the client is able to
determine tactile
location (point
localization), i.e, can
accurately perceive
where the client was
touched.
 If areas of sensory
dysfunction are found,
determine the
boundaries of sensation
by testing responses
about every 2.5 cm (1
in) in the area. Make a
sketch of the sensory
loss area for recording
purposes.

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Pain Sensation Able to discriminate Areas of reduced, heightened, or
Assess pain sensation as “sharp” and “dull” absent sensation (map them out for
follows: sensations. recording purposes).
 Ask the client to close
the eyes and to say
"sharp" "dull" or "don't
know” when the sharp
or dull end of the broken
tongue depressor is felt.
 Alternately, use the
sharp and dull end to
lightly prick designated
anatomic areas at
random, eg hand,
forearm, foot, lower leg,
abdomen. The face is
not tested in this
manner.
 Allow at least 2 seconds
between each test to
prevent summation
effects of stimuli i.e.,
several successive
stimuli perceived as one
stimulus.
Temperature Sensation Able to discriminate Areas of dulled or lost sensation
Temperature sensation is between “hot” and “cold” s (when sensations of pain are dulled,
not routinely tested if pain sensations. temperature sense is usually also impaire
sensation is found to be d because distribution of these nerves over
within normal limits. If pain the body is similar).
sensation is not normal or is
absent, testing sensitivity to
temperature may prove

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more reliable.
Touch skin areas with test
tubes filled with hot or cold
water.
Have the client respond by
saying “hot”, “cold”, or
“don’t know”.

Position or Kinesthetic Can readily determine the Unable to determine the position of one
Sensation position of fingers and toes. or more fingers or toes.
Commonly, the middle
fingers and the large toes
are tested for the kinesthetic
sensation (sense of
position).
To test the fingers support
the client's arm and hand
with one hand. To test the
toes, place the clients heels
on the examining table.
Ask the client to close the
eyes.
Grasp a middle finger or
big toe firmly between your
thumb and index finger, and
exert the same pressure on
both sides of the finger or
the toe while moving it.
Move the finger or toe until
it is up, down, or straight
out, and ask the client to
identity the position.
Use a series of brisk up and

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down movement before
bringing the finger or the
toe suddenly to rest in one
of the three positions.
Tactile Discrimination
For all tests, the client’s
eyes need to be closed.
One- and Two-Point Perception varies widely in Unable to sense whether one or two areas
Discrimination adults over different parts of the skin are being stimulated by pressure.
Alternately stimulate the of the body. Normally, a
skin with two pins person can distinguish
simultaneously and then between a one- and two-
with one pen. Ask whether point stimulus within the
the client feels one or two following minimum
pinpricks. distances:
Fingertips, 2.8 mm
Palms of hands, 8-12 mm
Chest, forearm, 40 mm
Back, 50-70 mm
Upper arm, thigh 75 mm
Toes, 3-8 mm
Stereognosis (Ability to Recognizes common Unable to recognize common objects.
Recognize Objects by objects.
Touching Them)
Place familiar objects, such
as a key, paper dip, or coin,
in the clients hand, and ask
the client to identity them. Unable to identify numbers or letters written
If the client has a motor on palm.
impairment of the hand and Able to identify numbers or
is unable to manipulate an letters written on palm.
object, write a number on
the client’s palm using a
blunt instrument, and ask
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the client to identify it
(graphesthesia).
Extinction Phenomenon Both points of stimulus are Failure to perceive touch on one side
Simultaneously stimulate felt. of the body when two symmetric areas
two symmetric areas of the of the body are touched simultaneously
body, such as the thighs, the ( frequently noted in clients with lesions
cheeks, or the hands. of the sensory cortex).

Document findings in the

client record using forms or
check lists supplemented by
narrative notes when
appropriate. Describe any
abnormal findings in
objective terms, e.g. "When
asked to count backwards
by threes, client made seven
errors and completed the
task in 4 minutes.

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 2. MUSCULOSKELETAL SYSTEM

The musculoskeletal assessment can be performed as a separate examination or integrated with other
parts of the total physical examination. In addition, you can assess the patient's movements while
performing other nursing care measures such as bathing or positioning. The assessment of
musculoskeletal function focuses on determining range of joint motion, muscle strength and tone, and
joint and muscle condition. Assessing musculoskeletal integrity is especially important when a patient
reports pain or loss of function in a joint or muscle. Because muscular disorders are often the result of
neurological disease, you may choose to perform a simultaneous neurological assessment.

For a complete examination expose the muscles and joints so they are tree to move. Have the patient
assume a sitting, supine, prone, or standing position while assessing specific muscle groups.

General Inspection

 Observe the patient's gait when he or she enters the examination room. When the patient is
unaware of the nature of your observation, gait is more natural. Later a more formal test has
the patient walk in a straight line away from and returning to the point of origin. Note how the
patient walks, sits, and rises from a sitting position.
 Normally patients walk with the arms swinging freely at the sides and the head leading the
body.
 Older adults often walk with smaller steps and a wider base of support.
 Note foot dragging, limping, shuffling, and the position of the trunk in relation to the legs.
 Observe the patient from the side and while facing him or her in a standing position. The
normal standing posture is upright with parallel alignment of the hips and shoulders.
 While observing from the side of the patient, note the normal cervical, thoracic, and lumbar
curves. Holding the head erect is normal. As the patient sits, some degree of rounding of the
shoulders is normal. Older adults tend to
assume a stooped, forward-bent posture
with the hips and knees somewhat flexed
and arms bent at the elbows, raising the
level of the arms.
 Common postural abnormalities include
kyphosis, lordosis, and scoliosis.

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 Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine.
Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called
scoliosis.
 Loss of height is frequently the first clinical sign of osteoporosis, in which height loss occurs
in the trunk as a result of vertebral fracture and collapse.
 Osteoporosis is a systemic skeletal condition that is noted to have both decreased bone mass
and deterioration of bone tissue, making bones fragile and at risk for fracture (Nelson et al.,
2010).
 Osteopenia, characterized by low bone mass of the hip, puts people at risk for osteoporosis,
fractures, and potential complications later in life. During general inspection look at the
extremities for overall size, gross deformity, bony enlargement, alignment, and symmetry.
Normally there is bilateral symmetry in length, circumference, alignment, and position and in
the number of skinfolds (Ball et al., 2015).

Palpation

 Apply gentle palpation to all bones, joints, and surrounding muscles during a complete
examination. For a focused assessment only examine the involved area.
 Note any heat, tenderness, edema, or resistance to pressure. The patient should not feel any
discomfort when we palpate.
 Muscles should be firm.

Range of Joint Motion

 The examination includes comparison of both active and passive ROM.

 We should ask the patient to put each major joint through active and passive full ROM.
 We should learn the correct terminology for the movements that the joints are capable of
making and teach the patient how to move through each ROM.

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TERMINOLOGY FOR NORMAL RANGE-OF-MOTION POSITIONS

Term Range of Motion Examples of Joints

Flexion Movement decreasing angle between two adjoining Elbow, fingers, knee
bones; bending of limb

Extension Movement increasing angle between two adjoining Elbow, knee, fingers
bones

Hyperextension Movement of body part beyond its normal resting Head

extended position

Pronation Movement of body part so front or ventral surface Hand, forearm

faces downward

Supination Movement of body part so front or ventral surface Hand, forearm

faces upward

Abduction Movement of extremity away from midline of body Leg, arm, fingers

Adduction Movement of extremity toward midline of body Leg, arm, fingers

Internal rotation Rotation of joint inward Knee, hip

External rotation Rotation of joint outward Knee, hip

Eversion Turning of body part away from midline Foot

Inversion Turning of body part toward midline Foot

Dorsiflexion Flexion of toes and foot upward Foot

Plantar flexion Bending of toes and foot downward Foot

 Demonstrate ROM to the patient when possible. To assess ROM passively, ask the patient to
relax and then passively move the extremities through their ROM.
 Compare the same body parts for equality in movement.

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  Do not force a joint into a painful position. Know the normal range of each joint and the extent
to which you can move the patient's joints.
 ROM is equal between contralateral joints. Ideally assess the patient's normal range to
determine a baseline for assessing later change.
 A goniometer, frequently used by physical and occupational therapists, measures the precise
degree of motion in a particular joint and is mainly for patients who have a suspected
reduction in joint movement. The instrument has two flexible arms with a 180-degree
protractor in the center.
 Position the center of the protractor at the center of the joint we are measuring. The arms
extend along the body parts on each side of the protractor.
 Measure the joint angle before moving the joint. After taking the joint through a full ROM,
measure the angle again to determine the degree
of movement.
 Compare the reading with the normal degree of
joint movement.
 Tints are typically free from stiffness,
instability, swelling, or inflammation. There
should be no discomfort when applying pressure
to bones and joints.
 In older adults joints often become swollen and
stiff with reduced ROM resulting from cartilage
erosion and fibrosis of synovial membranes. If a
joint appears swollen and inflamed, palpate it for warmth.

Muscle Tone and Strength

 Assess muscle strength and tone during ROM measurement. Integrate these findings with
those from the neurological assessment.
 Note muscle tone, the slight muscular resistance felt as we move the related extremity
passively through its ROM.
 Ask the patient to allow an extremity to relax or hang limp. This is often difficult, particularly
if the patient feels pain in it.
 Support the extremity and grasp each limb, moving it through the normal ROM.
 Normal tone causes a mild even resistance to movement through the entire range.

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  If a muscle has increased tone, or hypertonicity, there is considerable resistance with any
sudden passive movement of a joint.
 Continued movement eventually causes the muscle to relax.
 A muscle that has little tone (hypotonicity) feels flabby. The involved extremity hangs loosely
in a position determined by gravity.
 For assessment of muscle strength, have the patient assume a stable position. He or she
performs maneuvers demonstrating strength of major muscle groups. Use a grading scale of "0
to 5" to compare symmetrical muscle pairs for strength.
 The arm on the dominant side normally is stronger than the arm on the non-dominant side. In
older adults a loss of muscle mass causes bilateral weakness, but muscle strength remains
greater in the dominant arm or leg.

ASSESSING THE MUSCULOSKELETAL SYSTEM

SL. ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM

NO. NORMAL

Muscles

1. Inspect the muscles for size. Compare Equal size on both Atrophy (a decrease in size)
the muses on one side of the body sides of body or hypertrophy (an increase
(e.g., of the arm, thigh, and calf) to the in size), asymmetry
same muscle on the other side. For
any discrepancies, measure the
muscles with a tape.

2. Inspect the muscles and tendons for No contractures Malposition of body part,
contractures (shortening). e.g., foot drop (foot flexed
downward)

3. Inspect the muscles for tremors, for No tremors Presence of tremor

example by having the client hold the
arms out in front of the body.

4. Palpate muscles at rest to determine Normally firm Atonic (lacking tone)

muscle tonicity (the normal condition

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 of tension, or tone, of a muscle at
rest).

5. Palpate muscles while the client is Smooth coordinated Flaccidity (weakness or

active and passive for flaccidity, movements laxness) or spasticity (sudden
spasticity, and smoothness of involuntary muscle
movement. contraction)

6. Test muscle strength. Compare the Equal strength on each 25% or less of normal
right side with the left side. body side strength

Sternocleidomastoid: Client turns the Grading Muscle Strength

head to one side against the resistance
0:0% of normal strength;
of your hand. Repeat with the other
complete paralysis
side.

1:10% of normal strength; no

Trapezius: Client shrugs the shoulders
movement, contraction of
against the resistance of your hands.
muscle is palpable or visible
Deltoid: Client holds arm up and
2:25% of normal strength;
resists while you try to push it down.
full muscle movement
Biceps: Client fully extends each arm against gravity, with support
and tries to flex it while you attempt
3:50% of normal strength;
to hold arm in extension.
normal movement against
Triceps: Client flexes each arm and gravity
then tries to extend it against your
4:75% of normal strength;
attempt to keep arm in flexion.
normal full movement
Wrist and finger muscles: Client against gravity and against
spreads the fingers and resists as you minimal resistance
attempt to push the fingers together.
5:100% of normal strength;
Grip strength: Client grasps your normal full movement
index and middle fingers while you against gravity and against
try to pull the fingers out. full resistance

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 Hip muscles: Client is supine, both
legs extended; client raises one leg at
a time while you attempt to hold it
down.

Hip abduction: Client is supine, both

legs extended. Place your hands on the
lateral surface of each knee; client
spreads the legs apart against your
resistance.

Hip adduction: Client is in same

position as for hip abduction. Place
your hands between the knees; client
brings the legs together against your
resistance.

Hamstrings: Client is supine, both

knees bent. Client resists while you
attempt to straighten the legs.

Quadriceps: Client is supine, knee

partially extended; client resists while
you attempt to flex the knee.

Muscles of the ankles and feet: Client

resists while you attempt to dorsiflex
the foot and again resists while you
attempt to flex the foot.

Bones

7. Inspect the skeleton for structure. No deformities Bones misaligned

8. Palpate the bones to locate any areas No tenderness or Presence of tenderness or

of edema or tenderness. swelling swelling (may indicate

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 fracture, neoplasms, or
osteoporosis)

Joints

9. Inspect the joint for swelling. Palpate No swelling One or more swollen joints
each joint for tenderness, smoothness
No tenderness, Presence of tenderness,
of movement, swelling, crepitation,
swelling, crepitation, swelling, crepitation, or
and presence of nodules.
or nodules nodules

Joints move smoothly

10. Assess joint range of motion. Varies to some degree Limited range of motion in
in accordance with one or more joints
 Ask the client to move selected
person's genetic
body parts. The amount of joint
makeup and degree of
movement can be measured by a
physical activity
goniometer, a device that
measures the angle of the joint in
degrees.

11. Document findings in the client record using forms or checklists supplemented by narrative
notes when appropriate.

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CONCLUSION
Health assessment is important for everyone. It is an assessment in which we judge the mental and
physical quality of the person. In this we plan of care that identifies the specific need of the person
and how healthcare system will fulfill those needs. It is an evaluation in which we detect a disease in
the person who look and feel well by taking a physical exam. Hence, it is differ from the diagnostic
test in which symptoms are already known. The technique of assessment involves inspection,
palpation, percussion and auscultation.

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