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Physical Assessment Handouts
 

Physical Assessment Handouts

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    Physical Assessment Handouts Physical Assessment Handouts Document Transcript

    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 1  Is the use of hand to touch for the purpose of determining temperature, moisture, size, shape, position, texture, consistency, and movement. TYPES OF PALPATION Light Palpation  To check muscle tone and assess for tenderness Techniques: Place the hand with fingers together parallel to the area being palpated. Press down 1 to 2 cm. Repeat in ever-widening circles until the area to be NURSING SKILLS examined is covered. Physical Assessment Lecturer: Mark Fredderick R. Abejo R.N, M.A.N PHYSICAL ASSESSMENTObjectives: Deep Palpation  Obtain physical data about the client’s functional  To identify abdominal organs and abdominal masses. abilities Techniques:  Supplement, confirm, or refuse data obtained in the With fingers together, approach the area to nursing history be examined at a 60 degree angle and use the pads and  Obtain data that will help the nurse data establish tips of the fingers of one hand to press in 4 cm. nursing diagnoses and plan the client’s care.  Evaluate the physiologic outcomes of health care and Two – handed Deep Palpation place the fingers of one thus the progress of a patient’s health problem hand on top of those of the other.  Screen presence of cancer CEPHALOCAUDAL ORDER OF EXAMINATION AREAS  HEENT  NECK  UPPER EXTREMITIES  CHEST AND BACK  BREAST AND AXILLAE  ABDOMEN  GENITALS PERCUSSION  ANUS AND RECTUM  Striking of the body surface with short, sharp strokes  LOWER EXTREMITIES in order to produce palpable vibrations and Note: SKIN IS CHECK THROUGHTOUT THE characteristic sound. ASSESSMENT  It is used to determine the location, size, shape, and density of underlying structures; to detect the presenceGeneral Concepts: of air or fluid in a body space; and to elicit tenderness. Approach the client calmly and confidently. TYPES OF PERCUSSION Provide privacy. Direct Percussion Make sure that all needed instruments are available  Percussion in which one hand is used and the striking before starting the physical assessment finger (plexor) of the examiner touches the surface Several positions are frequently required during the being percussed. assessment. Consider the client’s ability to assume a Techniques: position. Using sharp rapid movements from the wrist, strike Be systematic and organized when assessing the the body surface to be percussed with the pads of two, client. (Inspection, Palpation, Percussion, Auscultation three, or four fingers or with the pad of the middle If a client is seriously ill, assess the systems of the finger alone. Primarily used to assess sinuses in the body that are more at risk adult. Perform painful procedures at the end of the Indirect Percussion examination  Percussion in which two hands are used and the plexor strikes the finger of the examiner’s other hand, whichMETHODS OF EXAMINING is in contact with the body surface being percussed (pleximeter).  INSPECTION Techniques:  PALPATION Strike at a right angle to the pleximeter using quick,  PERCUSSION sharp but relaxed wrist motion.  AUSCULTATION Withdraw the plexor immediately after the strike to avoid damping the vibration. Strike each are twice andINSPECTION then move to a new area  Visual examination of the patient done in a methodical and deliberate manner. Blunt  Ulnar surface of the hand or fist is used in place of thePALPATION fingers to strike the body surface, either directly or indirectly.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 2 PERCUSSION SOUNDS Procedure: 1. Inspects skin surfaces RESONANCE – Hollow sound. Ex. normal lung. 1. 2. Palpates with fingertips for edema and skin turgor HYPERRESONANCE – Booming sound. Ex. 2. 3. Palpates skin temperature contra-laterally using back Emphysematous lung of hands 3. TYMPANY – musical or drum sound. Ex. Stomach and intestines Assessment: 4. DULLNESS – Thud sound. Ex. Enlarged spleen, full bladder, liver. Health History 5. FLATNESS – extremely dull sound. Ex. Muscle or  Presenting problem bone  Changes in the color and texture of the skin, hairAUSCULTATION and nails. Listening to sounds produced inside the body  Pruritus  Infections  Tumors and other lesionsEQUIPMENTS FOR PHYSICAL  DermatitisEXAMINATION  Ecchymoses  Dryness  Sphygmomanometer and stethoscope  Lifestyle practices  Thermometer  Hygienic practices  Nasal Speculum  Skin exposure  Ophthalmoscope  Nutrition / diet  Otoscope  Intake of vitamins and essential nutrients  Vaginal Speculum  Water and Food allergies  Tongue depressor/blade  Use of medications  Penlight  Steroids  Cotton Applicators  Antibiotics  Tuning fork  Vitamins  Reflex hammer  Hormones  Clean gloves  Chemotherapeutic drugs  Lubricant  Past medical history  Renal and hepatic disease  Collagen and other connective tissue diseasesGENERAL SURVEY  Trauma or previous surgery  Food, drug or contact allergiesVITAL SIGNS  Family medical historyGENERAL SURVEY  Diabetes mellitus  Allergic disorders 1. Physical Appearance  Blood dyscrasias 2. Level of Conciousness/ awareness  Specific dermatologic problems  Alertness– Patient is awake and aware of self  Cancer and environment.  Lethargy – When spoken to in a loud voice, Physical Examination patient appears drowsy but opens eye, and look  Color at you, responds to questions, then falls asleep.  Areas of uniform color  Obtundation – When shaken gently, patient  Pigmentation opens eye and looks at you but responds  Redness slowly and is somewhat confused.  Jaundice  Stupor – Patient arouses from sleep only after  Cyanosis painful stimuli.  Vascular changes  Coma – Despite repeated painful stimuli,  Purpuric lesions patient remains unarousable with eyes closed.  Ecchymoses  Petechiae 3. Apperance in relation to chronological age  Vascular lesions 4. Signs of distress  Angiomas 5. Nutritional status  Hemangiomas 6. Body structure  Venous stars 7. Obvious physical deformities  Lesions 8. Mobility  Color 9. Behavior  Type 10. Odors of body and breath  Size 11. Facial Expression  Distribution 12. Mood & affect  Location 13. Speech  Consistency  Grouping  Annular SYSTEMS ASSESSMENT  Linear  CircularINTEGUMENTARY SYSTEM  ClusteredFunctions of the Skin:  Edema (pitting or non-pitting) Protection  Moisture content Absorption  Temperature (increased or decreased; Regulation distribution of temperature changes) Synthesis  Texture Sensory  Mobility / TurgorFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 3 Hypertrophic scar on the other hand does notEffects of Aging in the Skin overgrow the wound boundaries.  Skin vascularity and the number of sweat and Fibrosis or sclerosis describes dermal sebaceous glands decrease, affecting scarring/thickening reactions. thermoregulation. Milium is a small superficial cyst containing keratin  Inflammatory response and pain perception diminish. (usually <1-2 mm in size  Thinning epidermis and prolonged wound healing make elderly more prone to injury and skin infections. Vascular Skin Lesions  Skin cancer more common. Petechiae is a round or purple macule, associated withPrimary Lesions of the Skin bleeding tendencies or emboli to skin Ecchymosis a round or irregular macular lesion larger Macule is a small spot that is not palpable and is less than petechiae, color varies and changes from black, than 1 cm in diameter yellow and green hues. Associated with trauma and Patch is a large spot that is not palpable & that is > 1 bleeding tendencies. cm. Cherry Angioma, popular and round, red or purple, Papule is a small superficial bump that is elevated & may blanch with pressure and a normal age-related that is < 1 cm. skin alteration. Plaque is a large superficial bump that is elevated & > Spider Angioma is a red, arteriole lesion, central 1 cm. body with radiating branches. Commonly seen on Nodule is a small bump with a significant deep face,neck,arms and trunk. Associated with liver component & is < 1 cm. disease, pregnancy and vitB deficiency. Tumor is a large bump with a significant deep Telangiectasia , shaped varies: spider-like or linear, component & is > 1 cm. bluish in color or sometimes red. Does not blanch Cyst is a sac containing fluid or semisolid material, ie. when pressure applied. Secondary to superficial cell or cell products. dilation of venous vessels and capillaries. Vesicle is a small fluid-filled bubble that is usually superficial & that is < 0.5 cm. Bulla is a large fluid-filled bubble that is superficial or Edema - the presence of large amounts of fluid in the interstitial deep & that is > 0.5 cm. spaces. Usually due to fluid collecting in the subcutaneous Pustule is pus containing bubble often categorized tissue. Edema may be localized or generalized. according to whether or not they are related to hair follicles:  follicular - generally indicative of local A. Some causes are lymphatic obstruction, infection increased vascular permeability, decreased  folliculitis - superficial, generally multiple oncotic pressure due to low levels of plasma  furuncle - deeper form of folliculitis proteins (especially albumin), or renal or  carbuncle - deeper, multiple follicles cardiac disease. coalescing B. Collections of edema are named according to the site:Secondary lesions of the Skin 1. Anasarca - massive generalized edema Scale is the accumulation or excess shedding of the 2. Ankle stratum corneum. 3. Ascites - peritoneal cavity  Scale is very important in the differential 4. Hydrothorax - thoracic cavity diagnosis since its presence indicates that the 5. Periorbital - around the eyes epidermis is involved. 6. Sacral - lower back  Scale is typically present where there is C. Edema occurs in dependent areas first. epidermal inflammation, ie. psoriasis, tinea, D. Edema is graded on a scale considering the eczema depth of the indentation and the length of Crust is dried exudate (ie. blood, serum, pus) on the time to return to normal. Assessment: Press skin surface. firmly with finger for 5 seconds. Excoriation is a loss of skin due to scratching or picking. Rating Assessment Lichenification is an increase in skin lines & creases 1+ 5mm depth, recovers immediately from chronic rubbing. 2+ 8-10 mm, duration 10-15 sec. Maceration is raw, wet tissue. 3+ 11-20 mm, duration 15-30 sec. Fissure is a linear crack in the skin; often very 4+ >20 mm, duration >30 sec. painful. Erosion is a superficial open wound with loss of epidermis or mucosa only HEAD Ulcer is a deep open wound with partial or complete loss of the dermis or submucosa Procedure:Distinct Lesions of the Skin 1. Observe the size, shape and contour of the skull. 2. Observe scalp in several areas by separating the hair at Wheal or hive describes a short lived (< 24 hours), various locations; inquire about any injuries. Note edematous, well circumscribed papule or plaque seen presence of lice, nits, dandruff or lesions. in urticaria. 3. Palpate the head by running the pads of the fingers Burrow is a small threadlike curvilinear papule that is over the entire surface of skull; inquire about virtually pathognomonic of scabies. tenderness upon doing so. (wear gloves if necessary) Comedone is a small, pinpoint lesion, typically 4. Observe and feel the hair condition. referred to as “whiteheads” or “blackheads.” 5. Test Cranial Nerve VII Atrophy is a thinning of the epidermal and/or dermal 6. Test Cranial Nerve V tissue. Keloid overgrows the original wound boundaries and is chronic in nature.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 4Normal Findings: 1. Sensory function (This nerve innervate the anterior 2/3 of the tongue). 1. Skull · Place a sweet, sour, salty, or bitter substance near the tip of · Generally round, with prominences in the frontal and the tongue. occipital area. (Normocephalic). · Normally, the client can identify the taste. · No tenderness noted upon palpation. 2. Scalp 2. Motor function · Lighter in color than the complexion. · Ask the client to smile, frown, raise eye brow, close eye lids, · Can be moist or oily. whistle, or puff the cheeks. · No scars noted. · Free from lice, nits and dandruff. Normal Findings: · No lesions should be noted. · Shape maybe oval or rounded. · No tenderness nor masses on palpation. · Face is symmetrical. 3. Hair · No involuntary muscle movements. · Can be black, brown or burgundy depending on the · Can move facial muscles at will. race. · Intact cranial nerve V and VII. · Evenly distributed covers the whole scalp (No evidences of Alopecia) · Maybe thick or thin, coarse or smooth. EYE / EYEBROW / EYELASHES · Neither brittle nor dry. Normal findings:FACE Eyebrows · Symmetrical and in line with each other. · Maybe black, brown or blond depending on race.1. Observe the face for shape. · Evenly distributed.2. Inspect for Symmetry. Eyes a. Inspect for the palpebral fissure (distance between the · Evenly placed and inline with each other. eye lids); should be equal in both eyes. · Non protruding. b. Ask the patient to smile, There should be bilateral · Equal palpebral fissure. Nasolabial fold (creases extending from the angle of the corner of the mouth). Slight asymmetry in the fold is normal. Eyelashes c. If both are met, then the Face is symmetrical · Color dependent on race. · Evenly distributed. · Turned outward3. Test the functioning of Cranial Nerves that innervates thefacial structures EYELIDS / LACRIMAL APPARATUSCN V (Trigeminal) 1. Inspect the eyelids for position and symmetry. 2. Palpate the eyelids for the lacrimal glands. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the client’s upper orbital rim. Inquire for any pain or tenderness. 3. Palpate for the nasolacrimal duct to check for obstruction. To assess the nasolacrimal duct, the examiner presses with the index finger against the client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE.1. Sensory Function In the presence of blockage, this will cause· Ask the client to close the eyes. regurgitation of fluid in the puncta· Run cotton wisp over the fore head, check and jaw on bothsides of the face. Normal Findings:· Ask the client if he/she feel it, and where she feels it.· Check for corneal reflex using cotton wisp.· The normal response in blinking. Eyelids · Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.2. Motor function · No PTOSIS noted. (drooping of upper eyelids).· Ask the client to chew or clench the jaw. · Meets completely when eyes are closed.· The client should be able to clench or chew with strength and · Symmetrical.force. Lacrimal ApparatusCN VII (Facial) · Lacrimal gland is normally non palpable. · No tenderness on palpation. · No regurgitation from the nasolacrimal duct. CONJUNCTIVAE The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the client look up, down and to each side. When separating the lids, the examiner should exert no NO PRESSURE against the eyeball; rather, theFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 5examiner should hold the lids against the ridges of the bony Normal findings:orbit surrounding the eye. · There should be no irregularities on the surface.In examining the palpebral conjunctiva, everting the upper · Looks smooth.eyelid in necessary and is done as follow: · The cornea is clear or transparent. The features of the iris should be fully visible through the cornea.1. Ask the client to look down but keep his eyes slightly open. · There is a positive corneal reflex.This relaxes the levator muscles, whereas closing the eyescontracts the orbicularis muscle, preventing lid eversion. ANTERIOR CHAMBER / IRIS2. Gently grasp the upper eyelashes and pull gently downward.Do not pull the lashes outward or upward; this, too, causes The anterior chamber and the iris are easily inspectedmuscles contraction. in conjunction with the cornea. The technique of oblique3. Place a cotton tip application about I can above the lid illumination is also useful in assessing the anterior chamber.margin and push gently downward with the applicator while stillholding the lashes. This everts the lid.4. Hold the lashes of the everted lid against the upper ridge of Normal Findings:the bony orbit, just beneath the eyebrow, never pushing againstthe eyebrow. · The anterior chamber is transparent.5. Examine the lid for swelling, infection, and presence of · No noted any visible materials.foreign objects. · Color of the iris depends on the person’s race (black, blue,6. To return the lid to its normal position, move the lid slightly brown or green).forward and ask the client to look up and to blink. The lid · From the side view, the iris should appear flat and should notreturns easily to its normal position. be bulging forward. There should be NO crescent shadow casted on the other side when illuminated from one side. PUPIL Examination of the pupils involves several inspections, including assessment of the size, shape reaction to light is directed is observed for direct response of constriction. Simultaneously, the other eye is observed for consensual response of constriction. The test for papillary accommodation is the examination for the change in papillary size as the is switched from a distant to a near object.Normal Findings: 1. Ask the client to stare at the objects across room. 2. Then ask the client to fix his gaze on the examiner’s index· Both conjunctivae are pinkish or red in color. fingers, which is placed 5 – 5 inches from the client’s nose.· With presence of many minutes capillaries. 3. Visualization of distant objects normally causes papillary· Moist dilation and visualization of nearer objects causes papillary· No ulcers constriction and convergence of the eye.· No foreign objects Normal Findings:SCLERAE · Pupillary size ranges from 3 – 7 mm, and are equal in size.The sclerae is easily inspected during the assessment of the · Equally round.conjunctivae. · Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual. · Pupils dilate when looking at distant objects, and constrict when looking at nearer objects. If all of which are met, we document the findings using the notation PERRLA, pupils equally round, reactive to light, and accommodateNormal Findings:· Sclerae is white in color (anicteric sclera)· No yellowish discoloration (icteric sclera).· Some capillaries maybe visible.· Some people may have pigmented positions.CORNEAThe cornea is best inspected by directing penlight obliquelyfrom several positions.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 6 The assessment of visual acuity is indicative of the functioning of the macular area, the area of central vision. However, it does not test the sensitivity of the other areas of the retina which perceive the more peripheral stimuli. The Visual field confrontation test, provide a rather gross measurement of peripheral vision. The performance of this test assumes that the examiner has normal visual fields, since that client’s visual fields are to be compared with the examiners. Follow the steps on conducting the test: 1. The examiner and the client sit or stand opposite each other, with the eyes at the same, horizontal level with the distance of 1.5 – 2 feet apart. 2. The client covers the eye with opaque card, and the examiner covers the eye that is opposite to the client coveredCRANIAL NERVE II ( OPTIC NERVE ) eye. 3. Instruct the client to stare directly at the examiner’s eye, while the examiner stares at the client’s open eye. Neither looks The optic nerve is assessed by testing for visual acuity out at the object approaching from the periphery.and peripheral vision. 4. The examiner hold an object such as pencil or penlight, in his hand and gradually moves it in from the periphery of both Visual acuity is tested using a snellen chart, for those directions horizontally and from above and below.who are illiterate and unfamiliar with the western alphabet, the 5. Normally the client should see the same time the examinersilliterate E chart, in which the letter E faces in different sees it. The normal visual field is 180 degressdirections, maybe used. The chart has a standardized number atthe end of each line of letters; these numbers indicates the CRANIAL NERVE III, IV & VIdegree of visual acuity when measured at a distance of 20 feet. ( Oculomotor,Trochlear,Abducens ) The numerator 20 is the distance in feet between the All the 3 Cranial nerves are tested at the same time bychart and the client, or the standard testing distance. The assessing the Extra Ocular Movement (EOM) or the six cardinaldenominator 20 is the distance from which the normal eye can position of gaze.read the lettering, which correspond to the number at the end ofeach letter line; therefore the larger the denominator the poorerthe version. Measurement of 20/20 vision is an indication of eitherrefractive error or some other optic disorder. Follow the given steps: 1. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the client’s eyes.In testing for visual acuity you may refer to the following: 2. Instruct the client to follow the direction the object hold by the examiner by eye movements only; that is with out moving1. The room used for this test should be well lighted. the neck.2. A person who wears corrective lenses should be tested with 3. The nurse moves the object in a clockwise directionand without them to check fro the adequacy of correction. hexagonally.3. Only one eye should be tested at a time; the other eye 4. Instruct the client to fix his gaze momentarily on theshould be covered by an opaque card or eye cover, not with extreme position in each of the six cardinal gazes.client’s finger. 5. The examiner should watch for any jerky movements of the4. Make the client read the chart by pointing at a letter eye (nystagmus).randomly at each line; maybe started from largest to smallest or 6. Normally the client can hold the position and there shouldvice versa. be no nystagmus.5. A person who can read the largest letter on the chart(20/200) should be checked if they can perceive hand movementabout 12 inches from their eyes, or if they can perceive the lightof the penlight directed to their yes.Peripheral Vision or visual fieldsFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 7 This test is useful in determining whether the client has a conductive hearing loss (problem of external or middle ear) or a perceptive hearing loss (sensorineural). There are 2 types of tuning fork test being conducted: Test for Accomodation 1. Weber’s test – assesses bone conduction, this is a test of sound lateralization; vibrating tuning fork is placed on theEAR middle of the fore head or top of the skull.1. Inspect the auricles of the ears for parallelism, size position,appearance and skin color.2. Palpate the auricles and the mastoid process for firmness ofthe cartilage of the auricles, tenderness when manipulating theauricles and the mastoid process.3. Inspect the auditory meatus or the ear canal for color,presence of cerumen, discharges, and foreign bodies.a. For adult pull the pinna upward and backward to straighten Normal: hear sounds equally in both ears (No Lateralization ofthe canal. sound)b. For children pull the pinna downward and backward tostraighten the canal Conduction loss – Sound lateralizes to defective ear (Heard louder on defective ear) as few extraneous sounds are carried4. Perform otoscopic examination of the tympanic membrane, through the external and middle ear.noting the color and landmarks. Sensorineural loss – Sound lateralizes on better ear.Normal Findings: 2. Rinne Test – Compares bone conduction with air condition.· The ear lobes are bean shaped, parallel, and symmetrical.· The upper connection of the ear lobe is parallel with the outer a. Vibrating tuning fork placed on the mastoid processcanthus of the eye. b. Instruction client to inform the examiner when he no longer· Skin is same in color as in the complexion. hears the tuning fork sounding.· No lesions noted on inspection. c. Position in the tuning fork in front of the client’s ear canal· The auricles are has a firm cartilage on palpation. when he no longer hears it.· The pinna recoils when folded.· There is no pain or tenderness on the palpation of the auriclesand mastoid process.· The ear canal has normally some cerumen of inspection.· No discharges or lesions noted at the ear canal.· On otoscopic examination the tympanic membrane appearsflat, translucent and pearly gray in color.VESTIBULOCHOCLEAR NERVE( CRANIAL NERVE VII )Examination of the cranial nerve VIII involves testing forhearing acuity and balance. Normal: Sound should be heard when tuning fork is placed in front of the ear canal as air conduction< bone conduction by 2:1Hearing Acuity (positive rinne test)A. Voice test Conduction loss: Sound is heard longer by bone conduction than by air conduction.1. The examiner stands 2 ft. on the side of the ear to be tested.2. Instruct the client to occlude the ear canal of the other ear. Sensorineural loss: Sound is heard longer by air conduction than3. The examiner then covers the mouth, and using a soft by bone conductionspoken voice, whispers non-sequential number (e.g. 3 5 7 ) forthe client to repeat.4. Normally the client will be able to hear and repeat the NOSE AND PARANASAL SINUSESnumber.5. Repeat the procedure at the other ear. The external portion of the nose is inspected for the following:B. Watcher test 1. Placement and symmetry. 2. Patency of nares (done by occluding nosetril one at a time,1. Ask the client to close the eyes. and noting for difficulty in breathing)2. Place a mechanical watch 1 – 2 inches away the client’s ear. 3. Flaring of alaenasi3. Ask the client if he hears anything 4. Discharge4. If the client says yes, the examiner should validate byasking at what are you hearing and at what side. The external nares are palpated for:5. Repeat the procedure on the other ear.6. Normally the client can identify the sound and at what side 1. Displacement of bone and cartilage.it was heard. 2. For tenderness and massesTurning Fork TestFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 8The internal nares are inspected by heperextending the neck of 3. No flaring alae nasi.the client, the ulnar aspect of the examiner’s hard over the fore 4. Both nares are patent.head of the client, and using the thumb to push the tip of the 5. No bone and cartilage deviation noted on palpation.nose upward while shining a light into the naris. 6. No tenderness noted on palpation. 7. Nasal septum in the mid line and not perforated. 8. The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy). 9. No tenderness noted on palpation of the paranasal sinuses. OLFACTORY NERVE To test the adequacy of function of the olfactory nerve: 1. The client is asked to close his eyes and occlude. 2. The examiner places aromatic and easily distinguish nose. (e.g. coffee). 3. Ask the client to identify the odor. 4. Each side is tested separately, ideally with two different substances.Inspect for the following: MOUTH1. Position of the septum.2. Check septum for perforation. (can also be checked by Mouth and Oropharynx Lips are inspected for:directing the lighted penlight on the side of the nose,illumination at the other side suggests perforation). 1. Symmetry and surface abnormalities.3. The nasal mucosa (turbinates) for swelling, exudates and 2. Colorchange in color. 3. Edema Normal Findings:Paranasal Sinuses 1. With visible margin 2. Symmetrical in appearance and movement 3. Pinkish in color 4. No edema Palpate the temporomandibular while the mouth is opened wide and then closed for: 1. Crepitous 2. Deviations 3. Tenderness Normal Findings: Examination of the paranasal sinuses is indirectly. 1. Moves smoothly no crepitous.Information about their condition is gained by inspection and 2. No deviations notedpalpation of the overlying tissues. Only frontal and maxillary 3. No pain or tenderness on palpation and jawsinuses are accessible for examination. movement. By palpating both cheeks simultaneously, one can Gums are inspected for:determine tenderness of the maxillary sinusitis, and pressing thethumb just below the eyebrows, we can determine tenderness of 1. Colorthe frontal sinuses. 2. Bleeding 3. Retraction of gums. Normal Findings: 1. Pinkish in color 2. No gum bleeding 3. No receding gums Teeth are inspected for: 1. Number 2. Color 3. Dental carries 4. Dental fillingsNormal Findings: 5. Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).1. Nose in the midline 6. Tooth loss2. No Discharges. 7. Breath should also be assessed during the process.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 9Normal Findings: Normal Findings: 1. 28 for children and 32 for adults. 1. The trachea is palpable. 2. White to yellowish in color 2. It is positioned in the line and straight. 3. With or without dental carries and/or dental fillings. 4. With or without malocclusions. 5. No halitosis.Tongue is palpated for: TextureNormal Findings: 1. Pinkish with white taste buds on the surface. 2. No lesions noted. 3. No varicosities on ventral surface. 4. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue. 5. Gag reflex is present. 6. Able to move the tongue freely and with strength. 7. Surface of the tongue is rough. mph nodes are palpated using palmar tips of the fingers via systemic circular movements. Describe lymph nodes in termsofUvula is inspected for: size, regularity, consistency, tenderness and fixation to surrounding tissues. 1. Position 2. Color 3. Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the uvula will move upward and forward.Normal Findings: 1. Positioned in the mid line. 2. Pinkish to red in color. 3. No swelling or lesion noted. 4. Moves upward and backwards when asked to say “ah”Tonsils are inspected for: 1. Inflammation 2. SizeA Grading system used to describe the size of the tonsils can beused. Normal Findings: Grade 1 – Tonsils behind the pillar. Grade 2 – Between pillar and uvula. 1. May not be palpable. Maybe normally palpable in thin Grade 3 – Touching the uvula clients. 2. Non tender if palpable. Grade 4 – In the midline. 3. Firm with smooth rounded surface. 4. Slightly movable.NECK 5. About less than 1 cm in size. 6. The thyroid is initially observed by standing in frontThe neck is inspected for position symmetry and obvious lumps of the client and asking the client to swallow.visibility of the thyroid gland and Jugular Venous Distension. Palpation of the thyroid can be done either by posterior or anterior approach.Normal Findings: Indication of Lymph Nodes 1. The neck is straight. 2. No visible mass or lumps.  Occipital: Head infection 3. Symmetrical  Submental: Dental Carriections, Oral inf 4. No jugular venous distension (suggestive of cardiac  SubMandibular: Infection congestion).  SCM Upper: Lymphoma  Supraclavicular: CancerThe neck is palpated just above the suprasternal note using thethumb and the index finger. Posterior Approach:The neck is palpated just above the suprasternal note using the 1. Let the client sit on a chair while the examiner standsthumb and the index finger. behind him. 2. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is the isthmus.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 10 3. Ask the client to swallow while feeling for any then continues ant medially to end at the 6th rib at the enlargement of the thyroid isthmus. midclavicular line. 4. To facilitate examination of each lobe, the client is asked to turn his head slightly toward the side to be The right horizontally fissure extends from the 5th rib examined to displace the sternocleidomastoid, while slightly posterior to the right midaxillary line and runs the other hand of the examiner pushes the thyroid horizontally to thee area of the 4th rib at the right sternal border. cartilage towards the side of the thyroid lobe to be examined. 5. Ask the patient to swallow as the procedure is being The left oblique (diagonal) fissure extend from the done. spinous process of the 3rd thoracic vertebra laterally and 6. The examiner may also palate for thyroid enlargement downward to the left mid axillary line at the 5th rib and by placing the thumb deep to and behind the continues anteriorly and medially until it terminates at the 6th rib sternocleidomastoid muscle, while the index and in the midclavicular line. middle fingers are placed deep to and in front of the muscle. Borders of the Diaphragm. 7. Then the procedure is repeated on the other side. Anteriorly, on expiration, the right dome of the diaphragm is located at the level of the 5th rib at the midclavicular line and he left dome is at the level of the 6th rib. Posteriorly, on expiration, the diaphragm is at the level of the spinous process of T10; laterally it is at the 8th rib at the midaxillary line. On inspiration the diaphragm movesAnterior approach: approximately 1.5 cm downward. 1. The examiner stands in front of the client and with the Inspection of the Thorax palmar surface of the middle and index fingers palpates below the cricoid cartilage. 2. Ask the client to swallow while palpation is being For adequate inspection of the thorax, the client should be sitting done. upright without support and uncovered to the waist. 3. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach. The client is asked to The examiner should observe: turn his head slightly to one side and then the other of the lobe to be examined. 1. Shape of the thorax and its symmetry. 4. Again the examiner displaces the thyroid cartilage 2. Thoracic configuration. towards the side of the lobe to be examined. 3. Retractions at the ICS on inspiration. 5. Again, the examiner palpates the area and hooks (suprasternal, costal, substernal) thumb and fingers around the sternocleidomastoid 4. Bulging structures at the ICS during muscle. expiration. 5. position of the spine.Normal Findings: 6. pattern of respiration. 1. Normally the thyroid is non palpable. Normal Findings: 2. Isthmus maybe visible in a thin neck. 3. No nodules are palpable. The shape of the thorax in a normal adult is elliptical; the anteroposterior diameter is less than the transverseAuscultation of the Thyroid is necessary when there is thyroid diameter at approximately a ratio of 1:2.enlargement. The examiner may hear bruits, as a result of Moves symmetrically on breathing with no obviousincreased and turbulence in blood flow in an enlarged thyroid. masses. No fail chest which is suggestive of rib fracture. Check the Range of Movement of the neck. No chest retractions must be noted as this may suggest difficulty in breathing. No bulging at the ICS must be noted as this may obstruction on expiration, abnormal masses, orTHORAX cardiomegaly. The spine should be straight, with slightly curvature in the thoracic area.Lung borders There should be no scoliosis, kyphosis, or lordosis. Breathing maybe diaphragmatically of costally. In the anterior thorax, the apices of the lungs extendfor approximately 3 – 4 cm above the clavicles. The inferior Expiration is usually longer the inspiration.borders of the lungs cross the sixth rib at the midclavigular line. Palpation of the Thorax In the posterior thorax, the apices extend of T10 onexpiration to the spinous process of T12 on inspiration. In the Lateral Thorax, the lungs extend from the apexof the axilla to the 8th rib of the midaxillary line.Lung Fissures The right oblique (diagonal) fissure extend from thearea of the spinous process of the 3rd thoracic vertebra, laterallyand downward unit it crosses the 5th rib at the midaxillary line. ItFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 11 1. General palpation – The examiner should specifically palpate any areas of abnormality. The temperature and turgor of the skin should be assessed. Palpate for lumps, masses and areas of tenderness. 2. Palpate for thoracic expansion or lung excursion. A. Anteriorly, the examiner’s hands are placed over the anterolateral chest with the thumbs extended along the costal margin, pointing to the xyphoid process. Posteriorly, the thumbs are placed at the level of the 10th rib and the palms are placed on the posterolateral chest. B. Instruct the client to exhale first, then to inhale deeply. C. The examiner the amount of thoracic expansion during quiet and deep inspiration Whispered Pectorioquy – Ask the client top whisper “1-2-3” and observe for divergence of the thumbs on Over normal lung tissue it would almost be indistinguishable, expiration. over consolidated lung it would be loud and clear D. Normally, symmetry of respiration between the left and right hemithoraces should be felt as the thumbs are separated are separated approximately 3 – 5 cm (1 – 2 inches) during deep inspiration. 1. Palpate for the tactile fremitus. Percuss the diaphragmatic excursion A. Place the palm or the ulnar aspect of the hands bilaterally symmetrical on the chest wall starting from the top, then at then medial thoracic wall, and at the anterolateral B. Each time the hands move down, ask the client to say ninety-nine. C. Repeat the procedure at the posterior thoracic wall. D. Normally, tactile fremitus should be bilaterally symmetrical. Most intense in the 2nd ICS at the sternal border, near the area of bronchial bifurcation. Low pitched voices of males are more readily palpated than higher pitched voices of females. E. Basic abnormalities like increased tactile Auscultation of the Thorax fremitus maybe suggestive of consolidation; decreased tactile fremitus may be suggestive of obstructions, thickening of pleura, or collapse of lungs.Percussion of the ThoraxAnterior thorax: Normal Breath Sound A. Patient maybe placed on a supine position. B. Percuss systematically at about 5 cm intervals from Vesicular Soft, low pitch Lung periphery the upper to lower chest, moving left to right to left. Broncho-vesicular Medium pitch Larger airway (Percuss over the ICS, avoiding the ribs. Use indirect blowing percussion starting at the apices of the lungs. Bronchial Loud, high pitch Trachea C. The examiner notes the sound produced during each percussion. Abnormal Breath Sound Crackles Dependent lobes Random, sudden reinflation of alveoli fluids Rhonchi Trachea, bronchi Fluids, mucusFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 12Wheezes All lung fields Severely narrowed 1. Position the patient supine with the head of the table bronchus slightly elevated.Pleural Friction Lateral lung field Inflamed Pleura 2. Always examine from the patients right side.Rub 3. Inspect for precordial movement. Tangential lighting will make movements more visible. 4. Palpate for precordial activity in general. You mayElderly: feel "extras" such as thrills or exaggerated ventricularPhysical Changes of Thorax and Breathing Patterns impulses. 5. Palpate for the point of maximal impulse (PMI or  Kyphosis apical pulse). It is normally located in the 4th or 5th  Anteroposterior diameter of the chest widens intercostal space just medial to the midclavicular line  Breathing rate and rhythm are unchanged at rest and is less than the size of a quarter.  Inspiratory muscles become less powerful, and 6. Note the location, size, and quality of the impulse. inspiration reserve volume decreases.  Expiration may require the use of accessory muscles  Deflation of the lung is incomplete Palpation of the Heart  Small airways lose their cartilaginous support and elastic recoil The entire precordium is palpated methodically using the palms  Elastic tissue of the alveoli loses its stretchability and and the fingers, beginning at the apex, moving to the left sternal changes to fibrous tissue. Exertional capacity also border, and then to the base of the heart. decreases.  Cilia in the airways decrease in number and are less Normal Findings: effective in removing mucus, therefore they are at greater risk for pulmonary infections. 1. No, palpable pulsation over the aortic, pulmonic, and mitral valves. 2. Apical pulsation can be felt on palpation. 3. There should be no noted abnormal heaves, and thrillsCARDIOVASCULAR SYSTEM felt over the apex. Percussion of the Heart The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders of cardiac dullness. Auscultation of the Heart :Inspection of the HeartThe chest wall and epigastrum is inspected while the client is insupine position. Observe for pulsation and heaves or liftsNormal Findings: 1. Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size). 2. There should be no lift or heaves.Jugular Venous Pressure Anatomic areas for auscultation of the heart 1. Position the patient supine with the head of the table elevated 30 degrees. 2. Use tangential, side lighting to observe for venous Aortic valve – Right 2nd ICS sternal border. pulsations in the neck. Pulmonic Valve – Left 2nd ICS sternal border. 3. Look for a rapid, double (sometimes triple) wave with Tricuspid Valve – – Left 5th ICS sternal border. each heart beat. Use light pressure just above the Mitral Valve – Left 5th ICS midclavicular line sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin. 4. Adjust the angle of table elevation to bring out the Positioning the client for auscultation: venous pulsation. 5. Identify the highest point of pulsation. Using a If the heart sounds are faint or undetectable, try horizontal line from this point, measure vertically listening to them with the patient seated and learning from the sternal angle. forward, or lying on his left side, which brings the 6. This measurement should be less than 4 cm in a heart closer to the surface of the chest. normal healthy adult. Having the client seated and learning forward s best suited for hearing high-pitched sounds related to semilunar valves problem.Precordial MovementFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 13 The left lateral recumbent position is best suited low- BREAST pitched sounds, such as mitral valve problems and extra heart sounds.Auscultating the heart 1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral 2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound is best heard over the mitral valve; S2 is best heard over the aortric valve. 3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs. 4. Count heart rate at the apical pulse for one full minute.Normal Findings: 1. S1 & S2 can be heard at all anatomic site. 2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4). 3. Cardiac rate ranges from 60 – 100 bpm. Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. Every client should be examined in each position. 1. The client is seated with her arms on her side.PERIPHERAL CIRCULATION 2. The client is seated with her arms abducted over the head.Inspect: 3. The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction of the pectoral muscles.  Color 4. The client is seated and is learning over while the  Edema examiner assists in supporting and balancing her.  Stasis ulcers/lesions  Varicosities  Hair/nail changes While the client is performing these maneuvers, the breasts are carefully observed for symmetry, bulging,Palpate: retraction, and fixation. An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through invasion of  Temperature the suspensory ligaments, to fix, preventing them from  Edema upward movement in position 2 and 4.  Tenderness  Symmetry of pulses Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory ligament Chronic Venous Insufficiency Chronic Arterial InsufficiencyPain None to aching pain on dependency Pain Intermittent claudicationPulse Normal Pulse Decreased Normal to cyanotic; petechiae or brownColor pigmentation Color PaleTemperature Warm Temperature Cool Present Edema Absent or mildEdema Skin Thin, shiny atrophic skin, hair loss,Skin Changes Dermatitis skin pigmentation Changes thickened nails Ulceration Toes/points of traumaUlceration Medial side of ankle Gangrene May developGangrene Does not develop Normal Findings: 1. The overlying the breast should be even.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 14 2. May or may not be completely symmetrical at rest. 3. The areola is rounded or oval, with same color, (Color va,ies form light pink to dark brown depending on race). 4. Nipples are rounded, everted, same size and equal in color. 5. No “orange peel” skin is noted which is present in edema. 6. The veins maybe visible but not engorge and prominent. 7. No obvious mass noted. 8. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward. Auscultation of the Abdomen 9. No retractions or dimpling.Palpation of the Breast This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion. Palpate the breast along imaginary concentric circles, The stethoscope and the hands should be warmed; if following a clockwise rotary motion, from the they are cold, they may initiate contraction of the periphery to the center going to the nipples. Be sure abdominal muscles. that the breast is adequately surveyed. Breast Light pressure on the stethoscope is sufficient to detect examination is best done 1 week post menses. bowel sounds and bruits. Intestinal sounds are Each areolar areas are carefully palpated to determine relatively high-pitched, the bell may be used in the presence of underlying masses. exploring arterial murmurs and venous hum. Each nipple is gently compressed to assess for the Peristaltic sounds presence of masses or discharge. These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel.Normal Findings: Listening to the bowel sounds (borborygmi) can be facilitated by following these steps: No lumps or masses are palpable. No tenderness upon palpation. No discharges from the nipples.  Divide the abdomen in four quadrants.  Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginaryNOTE: The male breasts are observed by adapting the lines in creating the abdominal quadrants. This directiontechniques used for female clients. However, the various sitting ensures that we follow the direction of bowel movement.position used for woman is unnecessary.  Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5ABDOMEN minutes, especially at the periumbilical area, before concluding that no bowel sounds are present.  The normal bowel sounds are high-pitched, gurgling noisesIn abdominal assessment, be sure that the client has emptied the that occur approximately every 5 – 15 seconds. It isbladder for comfort. Place the client in a supine position with the suggested that the number of bowel sound may be as low asknees slightly flexed to relax abdominal muscles. 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.Inspection of the abdomen Some factors that affect bowel sound: Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). 1. Presence of food in the GI tract. Contour (flat, rounded, scapold) 2. State of digestion. Distension 3. Pathologic conditions of the bowel (inflammation, Respiratory movement. Gangrene, paralytic ileus, peritonitis). Visible peristalsis. 4. Bowel surgery Pulsations 5. Constipation or Diarrhea. 6. Electrolyte imbalances. 7. Bowel obstruction.Normal Findings: Percussion of the abdomen Skin color is uniform, no lesions. Some clients may have striae or scar. Abdominal percussion is aimed at detecting fluid in No venous engorgement. the peritoneum (ascites), gaseous distension, and Contour may be flat, rounded or scapoid masses, and in assessing solid structures within the Thin clients may have visible peristalsis. abdomen. Aortic pulsation maybe visible on thin clients. The direction of abdominal percussion follows the auscultation site at each abdominal guardant. The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness. Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at theFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 15 6th or 9th rib just posterior to or at the mid axillary line Deeper structures, like the liver, and retro peritoneal on the left side. organs, like the kidneys, or masses may be felt with Percussion in the abdomen can also be used in this method. assessing the liver span and size of the spleen. In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, thePercussion of the liver sigmoid colon, and the aorta.The palms of the left hand is placed over the region of liverdullness. 1. The area is strucked lightly with a fisted right hand. 2. Normally tenderness should not be elicited by this method. 3. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.Renal Percussion 1. Can be done by either indirect or direct method. 2. Percussion is done over the costovertebral junction. Liver palpation: 3. Tenderness elicited by such method suggests renal inflammation. There are two types of bi manual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand over the left hand. 1. Ask the patient to take 3 normal breaths. 2. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation. 3. Press hand deeply over the RUQ The second methods: 1. The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs. 2. Place the examiner’s right hands parallel to the costal margin or the RUQ.Palpation of the Abdomen 3. An upward pressure is placed beneath the client to push the liver towards the examining right hand, whileLight palpation the right hand is pressing into the abdominal wall. 4. Ask the client to breath deeply. 5. As the client inspires, the liver maybe felt to slip It is a gentle exploration performed while the client is beneath the examining fingers. in supine position. With the examiner’s hands parallel to the floor. The fingers depress the abdominal wall, at each Normal Findings: quadrant, by approximately 1 cm without digging, but gently palpating with slow circular motion. The liver usually can not be palpated in a normal This method is used for eliciting slight tenderness, adult. However, in extremely thin but otherwise well large masses, and muscles, and muscle guarding. individuals, it may be felt a the costal margins. When the normal liver margin is palpated, it must beTensing of abdominal musculature may occur because of: smooth, regular in contour, firm and non-tender. 1. The examiner’s hands are too cold or are pressed to MUSCULOSKELETAL vigorously or deep into the abdomen. 2. The client is ticklish or guards involuntarily. 1. Assess the patient’s posture, stance, and gait 3. Presence of subjacent pathologic condition. 2. Prepare the patient for the examination 3. Inspect for any gross abnormalities.Normal Findings: 4. Inspect and palpate the temporomaddibular joint and jaw. 5. Inspect and palpate the neck and spine 1. No tenderness noted. 6. Assess the ROM of the neck 2. With smooth and consistent tension. 7. Assess the ROM of the spine 3. No muscles guarding. 8. Inspect and palpate the upper and lower extremities, assessing each joint and muscle.Deep Palpation RANGE OF MOTION It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall. The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 16 TEMPORAL MADIBULAR JOINT AND JAW RANGE OF MOTION: ELBOW RANGE OF MOTION: NECK RANGE OF MOTION:SHOUDLERS RANGE OF MOTION:WRISTS RANGE OF MOTION:ANKLES RANGE OF MOTION: FINGERSFoundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 17 Always compare one side to the other. Grade strength on a scale from 0 to 5 "out of five": Grading Motor Strength RANGE OF MOTION:KNEES 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 Movement against gravity, but not against added 3/5 resistance 4/5 Movement against resistance, but less than normal 5/5 Normal strength Test the following: 1. Flexion at the elbow (C5, C6, biceps) 2. Extension at the elbow (C6, C7, C8, triceps) 3. Extension at the wrist (C6, C7, C8, radial nerve) 4. Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1) 5. Finger abduction (C8, T1, ulnar nerve) 6. Oppostion of the thumb (C8, T1, median nerve) 7. Flexion at the hip (L2, L3, L4, iliopsoas) 8. Adduction at the hips (L2, L3, L4, adductors) 9. Abduction at the hips (L4, L5, S1, gluteus medius and minimus) 10. Extension at the hips (S1, gluteus maximus) 11. Extension at the knee (L2, L3, L4, quadriceps) 12. Flexion at the knee (L4, L5, S1, S2, hamstrings) 13. Dorsiflexion at the ankle (L4, L5) 14. Plantar flexion (S1) RANGE OF MOTION:HIPS Pronator Drift Neurological Assessment 1. Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed. 2. Instruct the patient to keep the arms still while you tap them briskly downward.EXTREMITIES 3. The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motorObservation neuron disease.  Involuntary Movements C. Coordination and Gait  Muscle Symmetry   Left to Right Rapid Alternating Movements   Proximal vs. Distal  Atrophy  Pay particular attention to the hands, shoulders, and 1. Ask the patient to strike one hand on the thigh, raise thighs. the hand, turn it over, and then strike it back down as  Gait fast as possible. 2. Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible. 3. Ask the patient to tap your hand with the ball of each foot as fast as possible.A. Muscle Tone 1. Ask the patient to relax. 2. Flex and extend the patients fingers, wrist, and elbow. Point-to-Point Movements 3. Flex and extend patients ankle and knee. 4. There is normally a small, continuous resistance to passive movement. 1. Ask the patient to touch your index finger and their 5. Observe for decreased (flaccid) or increased nose alternately several times. Move your finger about (rigid/spastic) tone. as the patient performs this task. 2. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patientB. Muscle Strength to move their arm and return to your finger with their eyes closed.Test strength by having the patient move against your resistance.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 18 3. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the 1. Have the patient rest the forearm on the abdomen or patients eyes closed. lap. 2. Strike the radius about 1-2 inches above the wrist.Romberg 3. Watch for flexion and supination of the forearm. 1. Be prepared to catch the patient if they are unstable. Abdominal (T8, T9, T10, T11, T12) 2. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support. 1. Use a blunt object such as a key or tongue blade. 3. The test is said to be positive if the patient becomes 2. Stroke the abdomen lightly on each side in an inward unstable (indicating a vestibular or proprioceptive and downward direction above (T8, T9, T10) and problem). below the umbilicus (T10, T11, T12). 3. Note the contraction of the abdominal muscles andGait deviation of the umbilicus towards the stimulus.Ask the patient to: Knee (L2, L3, L4) 1. Walk across the room, turn and come back 1. Have the patient sit or lie down with the knee flexed. 2. Walk heel-to-toe in a straight line 2. Strike the patellar tendon just below the patella. 3. Walk on their toes in a straight line 3. Note contraction of the quadraceps and extension of 4. Walk on their heels in a straight line the knee. 5. Hop in place on each foot 6. Do a shallow knee bend Ankle (S1, S2) 7. Rise from a sitting position 1. Dorsiflex the foot at the ankle.D. Reflexes 2. Strike the Achilles tendon. 3. Watch and feel for plantar flexion at the ankle.Deep Tendon Reflexes  The patient must be relaxed and positioned properly Clonus before starting.  Reflex response depends on the force of your stimulus. Use no more force than you need to provoke If the reflexes seem hyperactive, test for ankle clonus: a definite response.  Reflexes can be reinforced by having the patient 1. Support the knee in a partly flexed position. perform isometric contraction of other muscles 2. With the patient relaxed, quickly dorsiflex the foot. (clenched teeth). 3. Observe for rhythmic oscillations.  Reflexes should be graded on a 0 to 4 "plus" scale: Tendon Reflex Grading Scale Plantar Response (Babinski) Grade Description 1. Stroke the lateral aspect of the sole of 0 Absent each foot with the end of a reflex 1+ or + Hypoactive hammer or key. 2. Note movement of the toes, normally 2+ or ++ "Normal" flexion (withdrawal). 3+ or +++ Hyperactive without clonus 3. Extension of the big toe with fanning of the other toes is abnormal. This is 4+ or ++++ Hyperactive with clonus referred to as a positive Babinski. E. SensoryBiceps (C5, C6) General 1. The patients arm should be partially flexed at the elbow with the palm down. 2. Place your thumb or finger firmly on the biceps  Explain each test before you do it. tendon.  Unless otherwise specified, the patients eyes 3. Strike your finger with the reflex hammer. should be closed during the actual testing. 4. You should feel the response even if you cant see it.  Compare symmetrical areas on the two sides of the body.  Also compare distal and proximal areas of the extremities.Triceps (C6, C7)  When you detect an area of sensory loss map out its boundaries in detail. 1. Support the upper arm and let the patients forearm hang free. 1. Vibration 2. Strike the triceps tendon above the elbow with the broad side of the hammer. 3. If the patient is sitting or lying down, flex the patients Use a low pitched tuning fork (128Hz). arm at the elbow and hold it close to the chest. 1. Test with a non-vibrating tuning fork first toBrachioradialis (C5, C6) ensure that the patient is responding to the correct stimulus.Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 19 2. Place the stem of the fork over the distal 5. Medial and lateral aspect of both calves (L4 and L5) interphalangeal joint of the patients index fingers 6. Little toes (S1) and big toes. 3. Ask the patient to tell you if they feel the vibration. 6. Light Touch If vibration sense is impaired proceed proximally: ++ Use a fine whisp of cotton or your fingers to touch the 1. Wrists skin lightly. 2. Elbows Ask the patient to respond whenever a touch is felt. 3. Medial malleoli 4. Patellas Test the following areas: 5. Anterior superior iliac spines 6. Spinous processes 7. Clavicles 1. Shoulders (C4) 2. Inner and outer aspects of the forearms (C6 and T1) 3. Thumbs and little fingers (C6 and C8) 4. Front of both thighs (L2)2. Subjective Light Touch 5. Medial and lateral aspect of both calves (L4 and L5) 6. Little toes (S1) Use your fingers to touch the skin lightly on both sides simultaneously. Test several areas on both the upper and lower 7. Discrimination extremities. Ask the patient to tell you if there is difference from side to side or other "strange" sensations. Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal.3. Position Sense Graphesthesia 1. Grasp the patients big toe and hold it away from the other toes to avoid friction. 1. With the blunt end of a pen or pencil, draw a large 2. Show the patient "up" and "down." number in the patients palm. 3. With the patients eyes closed ask the patient to 2. Ask the patient to identify the number. identify the direction you move the toe. 4. If position sense is impaired move proximally to test Stereognosis the ankle joint. 5. Test the fingers in a similar fashion. 1. Use as an alternative to graphesthesia. ++ 6. If indicated move proximally to the 2. Place a familiar object in the patients hand (coin, metacarpophalangeal joints, wrists, and elbows. paper clip, pencil, etc.). 3. Ask the patient to tell you what it is.4. Dermatomal Testing Two Point DiscriminationIf vibration, position sense, and subjective light touch are 1. Use in situations where more quantitative data arenormal in the fingers and toes you may assume the rest of this needed, such as following the progression of aexam will be normal. cortical lesion. ++ 2. Use an opened paper clip to touch the patients5. Pain finger pads in two places simultaneously. 3. Alternate irregularly with one point touch. 4. Ask the patient to identify "one" or "two."Use a suitable sharp object to test "sharp" or "dull" sensation. 5. Find the minimal distance at which the patient canTest the following areas: discriminate. 1. Shoulders (C4) 2. Inner and outer aspects of the forearms (C6 and T1) SAMPLE CHARTING 3. Thumbs and little fingers (C6 and C8) 4. Front of both thighs (L2) Ms. X is a young, healthy-appearing woman, well-groomed, fit, 5. Medial and lateral aspect of both calves (L4 and L5) and in good spirits. Height is 5’4”, weight 135 lbs, BP 120/80, 6. Little toes (S1) HR 72 and regular, RR 16, temperature 37.50C. SKIN: Color good. Skin warm and moist. Nails without clubbing or cyanosis.5. Temperature EENT: Head – skull is normocephalic/atraumatic(NC/AT). Hair with average texture. Often omitted if pain sensation is normal. Eyes – visual acuity 20/20 bilaterally. Sclera white; conjunctiva Use a tuning fork heated or cooled by water and ask pink. Pupils constrcit 4 mm to 2 mm, equally round and reactive the patient to identify "hot" or "cold." to light and accommodations. Ears – acuity good. Weber midline. Nose – nasal mucosa pink, septum midline, no sinus tenderness. Throat(mouth) – oralTest the following areas: mucosa pink; dentition good; pharynx without exudates. Neck – trachea midline. Neck supple; thyroid isthmus palpable, 1. Shoulders (C4) lobe not felt. 2. Inner and outer aspects of the forearms (C6 and T1) Lymph nodes – no cervical adenopathy. 3. Thumbs and little fingers (C6 and C8) THORAX AND LUNGS: 4. Front of both thighs (L2)Foundations of Nursing AbejoPhysical Assessment
    • Nursing SkillsPhysical AssessmentPrepared by: Mark Fredderick R. Abejo R.N, M.A.N 20 INSPECTION - A-P diameter not increased - Lips, nailbeds pink - Thorax slightly asymmetrical - Full expansion equal bilaterally PALPATION - No tenderness - No enlargement of lymph nodes - Fremitus equal bilaterally PERCUSSION - Lung field resonant - Diaphragmatic excursion – 4cm bilaterally AUSCULTATION - Breath sounds clear - No rales, rhonchi, or rubs - BREAST AND AXILLAE: - Breast symmetric and without masses. Nipples without discharge. - No axillary adenopathyCARDIOVASCULAR EXAM: - PMI is tapping, 2 cm lateral to the midsternal line in the 5th ICS. - Good S1 and S2 - No murmurs or extra soundsABDOMEN: - Abdomen is protuberant with active bowel sounds. It is soft and non-tender; no masses or hepatosplenomegaly. Liver span is 7cm; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt.MUSCULOSKELETAL SYSTEM: - Good range of motion in all joints. No evidence of swelling or deformity. - Mental status: alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. - Cranial nerves: I – XII intact. - Motor: Good muscle bulk and tone. Strength 5/5 throughout. - Cerebellar: RAM, intact. Gait with normal base. Romberg – maintains balance with eyes closed. No pronator drift. - Sensory: Pinprick, light touch, position intact. - Reflexes: 2+ and symmetricFoundations of Nursing AbejoPhysical Assessment