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Health Assessment

Assessing clients health status


- A major component of nursing care
- Has 2 aspects
> Nursing health history
> Physical examination
Physical examination
- Can be any of these types :
> Complete assessment
> Examination of a body system
> Examination of a body area
Assessment
- Broad term used in applying the nursing process to health data
Examination
- Physical process used to gather data
PHYSICAL HEALTH ASSESSMENT

May be conducted starting at the head and proceeding in a systematic manner downward (head-totoe assessment)
Procedure can vary acc. to
o
Age
o
Severity of illness
o
Preferences of nurse
o
Location of the examination
o
Agencys priorities and procedures

Regardless of the procedure , they are needed to be considered:


o
Pt energy
o
Pt time

Conducted in a systemic and efficient manner that results in the fewest position changes for the
client
Purposes
o
To obtain baseline data about pt functional abilities
o
To supplement, confirm, or refute data obtained in nursing history
o
To obtain data that will help establish nursing diagnoses and plans of care
o
To evaluate physiologic outcomes of health care and thus the progress of a clients health
problem
o
To make clinical judgments about a pt health status
o
To identify areas for health promotion and disease prevention

Nurses use national guidelines and evidence-based practice to focus health assessment on specific
conditions

PREPARING THE CLIENT

Nurse should explain :


o When and Where the examination will take place
o Why it is important
o What will happen
o All information gather and documented during assessment is kept confidential
Nurse should determine any positions that are contraindicated for a particular pt
Nurse assists the client as needed to undress and put on a gown
Client should empty their bladders before examination
With children, Always proceed from the least invasive to the more invasive

Health Assessment of the Adult

Be aware of the normal physiologic changes that occur w/ age


Be aware of stiffness of muscle and joints from aging changes or history of
orthopedic surgery, pt may need modification of the usual positioning necessary for
examination and assessment
Expose only areas of the body to be examined in order to avoid chilling
Permit ample time for pt to answer your questions and assume the required positions
Be aware of cultural differences. Pt may want a family member present during
disrobing
Arrange for an interpreter if pts language differs from that of nurse
Ask clients how they wish to be addressed
Adapt assessment techniques to any sensory impairment
If pt are elderly and or frail it is wise to plan several assessment times in order to
not overtire them

PREPARING THE ENVIRONMENT

Time for physical assessment should be convenient to both client and nurse
Environment needs to be well lighted
Equipment should be organized for efficient use
Room should be warm enough to be comfortable for client
Providing privacy is important; Most people are embarrassed if their bodies are
exposed or if others can overhear or view them during assessment
Culture, gender and age of both client and nurse influence how comfortable the client
will be and what special arrangements might be needed
Family and friends should not be present unless the client ask for someone

POSITIONING

It is important to consider the clients ability to assume a position


The ff should also be taken into consideration :
o Clients physical condition, energy, level
o Age
Some positions are embarrassing and uncomfortable and therefore should not be
maintained for long
Assessment must be organized so less number of position changes are needed

DRAPING

Should be arranged so that area to be assessed is exposed and


other body areas are covered
Exposure of the body is frequently embarrassing to clients
Provide not only a degree of privacy but also warmth
Made of paper, cloth or bed linen

INSTRUMENTATION

Should be
o
Clean
o
In good working order
o
Readily accessible
Frequently set up on trays and ready for use
Supplies :
o
Flashlight/penlight
o
Nasal speculum
o
Ophthalmoscope
o
Otoscope

o
o
o
o
o
o
o

Percussion (reflex) hammer


Tuning fork
Vaginal speculum
Cotton applicators
Gloves
Lubricant
Tongue blades (depressors)

METHODS OF EXAMINING

Inspection

Palpation

Visual examination
Nurse inspects w/ the naked eye and w/ a lighted instrument
Should be deliberate, purposeful and systematic
Olfactory and Auditory cues are also noted
Used to assess
o Moisture
o Size
o Color
o Symmetry
o Texture
o Shape
o Position
Light must be sufficient for the nurse to see clearly
Observation can be combined w/ the other assessment techniques

Examination of the body using the sense of touch


Pads of finger are used because their concentration of nerve endings make them highly sensitive to tactile discrimination
Used to determine
o Texture
o Temperature
o Vibration
o Position, size, consistency
o Mobility of organs or masses
o Distention
o Pulsation
o Presence of pain upon pressure

2 Types
1. Light palpation
Nurse extends the dominants hands finger parallel to the skin surface and presses gently while moving the hand in a circle
Skin is lightly depressed
2.

Deep palpation
Done w/ two hands (bimanually) or one hand
Usually not done during a routine examination
Requires a significant practitioner skill
Performed w/ extreme caution because pressure can damage internal organs
Usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
Effectiveness depends largely on pts relaxation
Nurse can assist a pt to relax by :
o Gowning the pt appropriately
o Positioning the pt comfortably
o Ensuring that their own hands are warm before beginning
During this, nurse should be sensitive to pt verbal and facial expressions indicating discomfort
Deep bimanual palpation
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
Top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations
Deep palpation using one hand
Finger pads of the dominant hand press over the area to be palpated
Other hand is used to support a mass or organ from below
To Test Skin temperature
It is best to use the dorsum (back) of the hand and fingers , where the examiners skin is thinnest
To Test for vibration

Nurse should use the palmar surface of the hand

General Guidelines for Palpation :


Nurses hands should be clean and warm and fingernails short
Areas of tenderness should be palpated last
Deep palpation should be done after superficial palpation

Percussion

Act of striking the body surface to elicit sounds that can be heard or vibrations the can be felt
Used to determine size and shape of internal organs by establishing their borders
Indicates whether tissue is
o Fluid filled
o Air filled
o Solid

2 Types
1. Direct percussion
Nurse strikes the area to be percussed directly w/ the pads of 2, 3 or 4 fingers or w/ the pad of the middle finger
Strikes are rapid and movement is from the wrist
Not generally used to percuss thorax
Useful in percussing adults sinuses
2.

Indirect percussion
Striking of finger held against the body area to be examined
Pleximeter ,middle finger of the nondominant hand is placed firmly on the pts skin
Using the plexor , the tip of the flexed middle finger of the other hand , nurse strikes usually at the distal interphalangeal joint of
the pleximeter
Angle bet. plexor and pleximeter should be 90 degrees
Blows must be firm, rapid and short to obtain a clear sound
Types of Sounds
Describe acc. to its intensity, pitch, duration, and quality
1. Flatness
Extremely dull
Produced by very dense tissue (least amt. of air) such as muscle or bone
2. Dullness
Thudlike sound
Produced by dense tissue such as liver, spleen, heart
3. Resonance
Hollow sound
Produced by a lungs filled w/ air /normal lung
4.

Hyperresonance
Booming sound
Not produced in the normal body
Can be heard over an emphysematous lung

5. Tympany
Musical or drumlike sound
Produced from an air-filled stomach

Auscultation

Process of listening to sounds produced within the body


2 Types
o Direct Auscultation- Use of unaided ear
o Indirect Auscultation - Use of stethoscope

Stethoscope
o Tubing should be 30 to 35 cm
o W/ an Internal diameter of about 0.3 cm
o Diaphragm best transmits high-pitched sounds such as bronchial sounds
o Bell best transmits low-pitched sounds such as some heart sounds
o Earpieces should fit comfortably into nurses ears , facing forward
o Amplifier is placed firmly but lightly against clients skin

Auscultated Sounds are described acc. to:


o Pitch Frequency of the vibrations /number of vibrations per sec

o
o
o

Intensity Amplitude ; loudness or softness of sound


Duration Length ; long or short
Quality Subjective description of a sound

GENERAL SURVEY
> General Appearance
> Mental Status
> Vital Signs
> Height
> Weight

GENERAL APPERANCE and MENTAL STATUS


- Must be assessed in relationship to
> Culture
> Educational level
> Socioeconomic status
> Current circumstances

Assessment

Normal findings

Deviations

Body build, height, weight in relation to pts


age, lifestyle, and health

o
o

Proportionate
Varies w/ lifestyle

o
o

Excessively thin
Excessively obese

Posture, Gait, Standing, Sitting, Walking

o
o
o

Relaxed
Erect posture
Coordinated movement

o
o
o
o
o

Tense
Slouched
Bent posture
Uncoordinated movement
Tremors

Overall hygiene, Grooming

o
o

Clean
Neat

o
o

Dirty
Unkempt

Body and Breath Odor

o
o
o

No body odor
Minor body odor r/t work or exercise
No breath odor

o
o
o
o

Foul body odor


Ammonia odor
Acetone breath odor
Foul breath

Signs of distress in posture or facial


expression

No distress noted

o
o
o
o

Bending over because of abdominal pain


Wincing
Frowning
Labored breathing

Signs of health or illness

Healthy appearance

o
o
o

Pallor
Weakness
Lesions

Attitude

o
o

Cooperative,
Able to follow instructions

o
o
o

Negative
Hostile
Withdrawn

Appropriate to situation

Inappropriate to situation

Quantity , Quality and Organization of speech

o
o
o
o

Understandable
Moderate pace
Clear tone and Inflection
Exhibits thought association

o
o
o
o

Rapid or Slow pace


Overly loud or soft
Uses generalizations
Lacks association

Relevance and Organization of thoughts

o
o
o

Logical sequence
Makes sense
Has sense of reality

o
o
o
o

Illogical sequence
Flight of ideas
Confusion
Vague

Affect/Mood

THE INTEGUMENT
> Skin
> Hair
> Nails
SKIN
- Involves inspection and palpation
- Nurse may also use the olfactory sense to detect unusual skin odors w/c are usually most evident in skinfolds or in axillae
- Pungent body odor is frequently r/t :
> Poor hygiene
> Hyperhidrosis (Excessive perspiration)
> Bromhidrosis (Foul-smelling perspiration)

Pallor

Result of inadequate circulating blood and subsequent reduction in tissue oxygenation


Most evident in areas w/ lest pigmentation such as :
o Conjunctiva
o Oral mucous membranes
o Nail beds
o Palms of the hand
o Soles of the feet

Cyanosis

Bluish tinge
Most evident in nail beds, lips and buccal mucosa

Jaundice

Yellow tinge
Evident in
o Sclera of eyes
o Mucous membranes
o Skin
Nurses should take care not to confuse jaundice w/ the normal yellow pigmentation in sclera of a dark-skinned
client
If suspected, posterior part of hard palate should also be inspected for a yellowish color tone

Redness associated w/ a variety of rashes

Occur as a result of changes in distribution of melanin or in function of melanocytes in the epidermis

Erythema

Localized Areas of
Hypo/Hyperpigmentation

Hyperpigmentation
Increased pigmentation
Ex : birthmark
Hypopigmentation
Decreased pigmentation
Ex: vitiligo
Vitiligo
Patches of hypopigmented skin
Caused by destruction of melanocytes in the area
Albinism
Complete or partial lack of melanin in skin, hair and eyes

Edema

Presence of excess interstitial fluid


Appears as
o Swollen
o Shiny
o Taut
o Tends to blanch skin color
o May reddened the skin if accompanied by inflammation

Generalized edema

Most often an indication of impaired venous circulation


In some cases, reflects cardiac dysfunction or venous abnormalities

Skin lesion
- Alteration in clients normal skin appearance

Primary Skin lesions

Appear initially in response to some change in the external or internal environment of the skin
o Macule, Patch
o Papule
o Plaque
o Nodule , Tumor
o Pustule
o Vesicle, Bulla
o Cyst
o Wheal

Secondary Skin lesions

Do not appear initially


Result from modifications such as
o Chronicity
o Trauma
o Infection of the primary lesion
o
o
o
o
o
o
o
o
o
o

Atrophy
Erosion
Lichenification
Scales
Crust
Ulcer
Fissure
Scar
Keloid
Excoriation

Describing Skin lesions


Type or Structure

Size, shape, texture

o
o

Color

Primary
Secondary

Note size in mm
o Circumscribed or Irregular
o Round or Oval
o Flat, Elevated or Depressed
o Solid, Soft or Hard
o Rough or Thickened
o Fluid filled or Has flakes

o
o
o
o
o

No discoloration
One discrete color
Several colors
Circumscribed When color changes are limited to the edges of a lesion
Diffuse When spread over a large area

Distribution

Acc. to location of lesion


o Symmetry
o Asymmetry

Configuration

Arrangement of lesions in relation to each other


o Annular (arrange in circle)
o Clustered /grouped
o Linear (arrange in line)

o
o
o
o
o

Arc or bow shaped


Merged together
Indiscrete
May follow the course of cutaneous nerves
Meshed in the form of a network

Inquire if pt has any history of the ff :

Pain or Itching
Stress
Presence and spread of lesions, bruises, abrasions, pigmented spots
Previous experience w/ skin problems
Occupation
Family history
Medications
Presence of problems in other family members
Recent travel
Related systemic conditions
Housing
Use of medications , lotions, home remedies
Recent contact w/ allergens
Excessively dry or moist feel to the skin
Association of the problem to season of year
Tendency to bruise easily

Assessment

Normal findings

Deviations

Skin color

o
o
o

light to deep brown


ruddy pink to light pink
yellow overtones to olive

o
o
o
o

Pallor
Cyanosis
Jaundice
Erythema

Uniformity of skin color

Generally uniform except in areas exposed to the


sun
Areas of lighter pigmentation (palms, lips, nail
beds) in dark-skinned people

Areas of either
hypo/Hyperpigmentation

Edema

No edema

o
o
o
o

+1 (2mm)
+2 (4mm)
+3 (6mm)
+4 (8mm)

Skin lesions

o
o
o
o

Freckles
Some birth marks
Some flat and raised nevi
No abrasions or other lesions

o
o
o
o

Various interruptions in skin integrity


Irregular
Multicolored
Raised nevi

Skin moisture

Moisture in skin folds or axillae varies w/


environmental temp and humidity, body temp and
activity

o
o

Excessive moisture (e.g. hyperthermia)


Excessive dryness (e.g. dehydration)

Skin temperature

o
o

Uniform
Within normal range

o
o
o
o

Generalized hyperthermia (e.g. fever)


Generalized hypothermia (e.g. shock)
Localized hyperthermia (e.g. infection)
Localized hypothermia (e.g.
arteriosclerosis)

Skin turgor

o
o

When pinched, skin springs back to previous state


May be slower in elder

Skin stays pinched or tented or moves


back slowly (e.g. dehydration)

HAIR
- Consideration :
> Developmental changes
> Ethnic differences
> Individuals hair care practices

Kwashiorkor

Severe protein deficiency


Persons hair is faded and appears reddish or bleached , texture is coarse and dry

Alopecia

Hair loss

Hypothyroidism

Associated w/ dry , brittle hair

Inquire if pt has any history of the ff:

Recent use of hair dyes , rinses or curling or straightening preparations


Recent chemotherapy (if alopecia is present)
Presence of disease

Assessment

Normal findings

Deviations

Evenness of growth over the scalp

Evenly distributed

Patches of hair loss / alopecia

Thickness or thinness

Thick hair

Very thin hair (e.g. in hypothyroidism)

Texture or Oiliness

o
o

Silky
resilient

o
o

Brittle hair (e.g. hypothyroidism)


Excessively oily or dry hair

Presence of infections or infestations

No infection or
infestation

o
o
o
o
o

Flaking
Sores
Lice
Nits
Ringworm

Amount of body hair

Variable

o
o

Hirsutism in women
Naturally absent or Sparse leg hair
(poor circulation)

NAILS
Nail plate
- Normally colorless
- Has convex curve
- Angle bet. the fingernail and nail bed is normally 160 degrees
Nail bed
- Highly vascular , a characteristic that accounts for its color
- Bluish or purplish tint may reflect cyanosis
- Pallor may reflect poor arterial circulation
Nail Abnormalities :

Spoon shape

Koilonychia
Nail curves upward from the nail bed
May be seen in clients w/ iron deficiency anemia

Early Clubbing

Angle bet. the nail and nail bed is 180 degrees

Late Clubbing

Angle bet. the nail and nail bed is greater than 180 degrees
May be caused by long term lack of oxygen

Beaus line

Horizontal depressions in nail


Can result from injury or severe illness

Excessively thick
nails

Can appear in elders in the presence of poor circulation or in relation to a chronic fungal
infection

Excessively thin
nails

Reflect prolonged iron deficiency anemia

Nail fungus

Onychomyocosis
Symptoms :
o Brittleness
o Crumbling of the nail
o Discoloration
o Detaching of the nail
o Thickening
o Distortion of nailshape

Paronychia

Often known as ingrown nail)


Inflammation of the tissues surrounding a nail
Tissues appear inflamed, swollen and tenderness is usually present

Blanch Test

Carried out to test the capillary refill i.e the peripheral circulation
Normal nail bed capillaries blanch when pressed but quickly turn pink or their usual color
when pressure is released
Slow rate of capillary refill may indicate circulatory problems

Inquire if pt has any history of the ff :

Presence of DM
Peripheral circulatory disease
Previous injury or severe illness

Assessment

Normal findings

Deviations

Nail plate Shape

o
o

Convex curvature
Angle of nail plate about 160 degrees

o
o

Spoon nail
Clubbing

Nail Texture

Smooth texture

o
o
o
o

Excessive thickness or thinness


Presence of grooves or furrows
Beaus lines
Discolored or detached nail

Nail bed Color

o
o

Bluish or purplish tint


Pallor

Highly vascular and pink in light skinned


clients
Dark-skinned clients may have brown or
black pigmentation in longitudinal
streaks intact epidermis

Intact epidermis

o
o

Hangnails
Paronychia

Tissues surrounding nails

Capillary refill

Prompt return of pink or usual color

Delayed return of pink or usual color

THE HEAD
> Skull

> Ears

> Face

> Nose

> Eyes

> Sinuses

> Mouth and Pharynx

SKULL and FACE


Normocephalic
- A normal head size
Names of Areas of the head are derived from names of underlying bones

Frontal
Mandible
Parietal
Maxilla
Occipital
Zygomatic
Mastoid process

Many disorders cause a change in facial shape or condition :


Kidney /Cardiac disease

Can cause edema of the eyelids

Hyperthyroidism

Can cause exophthalmos, a protrusion of the eyeballs w/ elevation of the upperlids

Hypothyroidism/Myxedema

Can cause a dry, puffy face w/ dry skin and coarse features and thinning of scalp hair and eyebrows

Increased adrenal hormone


production /administration

Can cause a round face w/ reddened cheeks (moonface) and Excessive hair growth on the upper lips , chin
and sideburn areas

Prolonged illness,
Starvation, Dehydration

Can result in sunken eyes, cheeks and temples

Inquire if client has any history of the ff :

Past problems w/ lumps


Itching
Scaling or dandruff
History of loss of consciousness, dizziness, seizures, headache, facial pain or
injury
When and How any lumps occurred
Length of time any other problem existed
Any known cause of problem
Associated symptoms , treatment, and recurrences

Assessment

Skull size, shape, and symmetry

Normal findings

o
o

Rounded
Smooth skull contour

Deviations

o
o
o

Lack of symmetry
Increased skull size w/ more prominent
nose and forehead
Longer mandible (may indicate excessive
growth hormone or increased bone

thickness)

Skull nodules or masses and


depressions

Use a gentle rotating motion w/ fingertips


Begin at front, and palpate down the midline,
then palpate each side of head
o
Smooth
o
Uniform consistency
o
Absence of nodules or masses

o
o
o
o

Sebaceous cysts
Local deformities from trauma
Masses
Nodules

Facial features / Eyes for edema


and hollowness

o
o
o
o

Symmetric
Slightly asymmetric facial features
Palpebral fissures equal in size
Symmetric Nasolabial folds

o
o
o
o
o
o
o
o

Increased facial hair


Thinning of eyebrows
Asymmetric features
Exophthalmos
Myxedema facies
Moon face
Periorbital edema
Sunken eyes

Symmetry of facial movements

Symmetric facial movements

o
o
o

Asymmetric facial movements


Drooping of lower eyelid and mouth
Involuntary facial movements

EYES and VISION


It is recommended that people
Under age 40 have their eyes tested every 3 to 5 years
After age 40 have their eyes tested every 2 years
Examination of eyes include assessment/inspection of :
> External structures
> Visual acuity (degree of detail the eye can discern in an image)
> Ocular movement
> Visual fields (area an individual can see when looking straight ahead)
Consideration :
> Developmental changes
> Individual hygienic practices
Pupil
- Normally black , are equal in size (about 3 to 7 mm in diameter)
- Have round, smooth boarders
- Cloudy pupils may often indicative of cataracts
Iris
- Normally flat and round
- Bulging toward the cornea can indicated increased intraocular pressure

Common Refractive errors of the lens of the eye

Myopia Nearsightedness
Hyperopia Farsightedness
Presbyopia Loss of elasticity of the lens and thus loss of ability to see close objects
Astigmatism An uneven curvature of the cornea that prevents horizontal and vertical rays
from focusing on the retina ; May be corrected w/ glasses or surgery

Types of Eye charts

Preschool childrens chart


Snellen Standard chart
Snellen E chart

Common Inflammatory Visual problems


Conjunctivitis

Inflammation of the bulbar and palpebral conjunctiva


May result from :
o Foreign bodies
o Chemicals
o Allergic agents
o Bacteria
o Viruses
Could lead to :
o Redness
o Itching
o Tearing
o Discharge
During sleep, eyelids may become encrusted and
matted together

Dacrocystitis

Inflammation of the Lacrimal sac


Manifested by
o Tearing
o Discharge from the nasolacrimal duct

Hordeolum (sty)

Manifested by
o Redness
o Swelling
o Tenderness of the hair follicle and glands that
empty at the edge of the eyelids

Iritis

Inflammation of the iris


May be caused by Local or systemic infections
Results in
o Tearing
o Pain
o Photophobia

Contusions / Hematomas

Black eyes resulting from injury

Other problems :

Cataracts

Tend to occur in person over 65 years of age


Opacity of the lens or its capsule w/c blocks the light rays is
frequently removed and replaced by lens implant
May also occur in infants due to malformation of the lens if the
mother contracted rubella in the 1st tri. of pregnancy

Glaucoma

Disturbance in the circulation of aqueous fluid w/c causes an increase in intraocular pressure
Most frequent cause of blindness in people over 40
Can be controlled if diagnosed early
Danger signs :
o Blurred or foggy vision
o Loss of peripheral vision
o Difficulty focusing on close
objects
o Difficulty adjusting to dark
rooms
o Seeing rainbow-colored rings
around lights

Ptosis

Eyelids that lie at or below the pupil margin


Usually associated w/
o Aging
o Edema from drug allergy or systemic diseases
o Congenital lid muscle dysfunction
o Neuromuscular disease
o Third cranial nerve impairment

Ectropion

Eversion
Outturning of the eyelid

Entropion

Inversion
Inturning of the lid

Mydriasis

Enlarged pupils
May indicate:
o Injury
o Glaucoma
May result from:
o Certain drugs (e.g. atropine)

Miosis

Anisocoria

Constricted pupils
An age related change in older adults
May indicate :
o Inflammation of the iris
May result from :
o Some drugs (e.g. morphine, pilocarpine)
Unequal pupils
May result from :
o CNS disorder

Inquire if the client has any history of the ff :


Family history of diabetes, hypertension, blood dyscrasia or eye disease , injury or surgery
Clients last visit to an ophthalmologist
Current use of eye medications
Use of contact lenses or eye glasses
Hygienic practices for corrective lenses
Current symptoms of eye problems :
Changes in visual acuity
Blurring of vision
Tearing
Spots
Photophobia
Itching or pain

I. External Eye Structures

Assessment
Eyebrows hair distribution and
alignment, skin quality and movement

Normal findings

Eyelashes evenness of distribution


and direction of curl

Eyelids surface characteristics (e.g.


skin quality and texture), Position in
relation to the cornea, Ability to
blink, Frequency of blinking

Bulbar conjunctiva (lying over the


sclera) color, texture, and presence
of lesions

Ask client to raise and lower the eyebrows


o
Hair evenly distributed
o
Skin intact
o
Eyebrows symmetrically aligned
o
Equal movement

o
o
o

Loss of hair
Scaling and flakiness of skin
Unequal alignment and movement of eyebrows

Turned inward

For proper visual examination of upper eyelids , elevate


the eyebrows w/ your thumb and index fingers and have
the client close the eyes
While the clients eyes are close , inspect for lower eyelids
o
Skin intact
o
No discharge
o
No discoloration
o
Lids close symmetrically
o
App. 15 to 20 involuntary blinks per min.
o
Bilateral blinking
o
When lids open , no visible sclera above corneas and
upper and lower borders of cornea are slightly
covered

o
o
o
o
o
o
o
o
o
o
o
o
o
o

Redness
Swelling
Flaking
Crusting
Plaques
Discharge
Nodules
Lesions
Lids close asymmetrically, incompletely or
painfully
Rapid, Monocular, absent or infrequent blinking
Ptosis
Ectropion
Entropion
Rim of sclera visible bet. lids and iris

Retract the eyelids w/ your thumb and index finger,


exerting pressure over the upper and lower bony orbits
Ask the client to look up, down, and from side to side
o
Transparent
o
Capillaries sometimes evident

o
o
o
o

Jaundiced sclera
Excessively pale sclera
Reddened sclera
Lesions or nodules

o
o

Deviations

Equally distributed
Curled slightly outward

Palpebral conjunctiva (lining the


eyelids)

Evert the upper Lids if a problem is


suspected

Sclera appears white (darker or yellowish and w/


small brown macules in dark-skinned clients)

Evert both lower lids


Ask the client to look up
Gently retract the lower lids w/ index fingers
o
Shiny
o
Smooth
o
Pink or Red

o
o
o

Extremely pale
Extremely Red
Nodules or other Lesions

Using the tip of your index finger, palpate the lacrimal


gland
Observe for edema bet. the lower lid and the nose
o
No edema or tenderness over Lacrimal gland

Swelling or tenderness over Lacrimal gland

Observe for evidence of increased tearing


Using the tip of index finger, palpate inside the lower
orbital rim near the inner canthus
o
No edema or tearing

o
o

Evidence of increased tearing


Regurgitation of fluid on palpation of Lacrimal
sac

Ask the client to look down while keeping the eyes slightly
open
Rationale : Closing the eyelids contracts the orbicular muscle

w/c prevents lid eversion

Gently grasp the clients eyelashes w/ the thumb and index


finger
Pull the lashes gently downward
Rationale : Upward or outward pulling on the eyelashes causes

muscle contraction

Place a cotton-tipped applicator stick about 1 cm above


the lid margin
Push it gently downward while holding the eyelashes
Rationale : These actions evert the lid, that is , flip the lower

part of the lid over on top of itself

Lacrimal gland

Lacrimal sac and Nasolacrimal duct

Hold the margin of the everted lid or the eyelashes


against the ridge of the upper bony orbit w/ the
applicator stick or the thumb
Inspect the conjunctiva for color, texture, lesions, and
foreign bodies
To return the lid to its normal position, gently pull the
lashes forward , and ask the client to look up and blink

Cornea clarity and texture

Ask the client to look straight ahead


Hold a penlight at an oblique angel to the eye and move the
light slowly across the corneal surface
o
Transparent
o
Shiny and Smooth
o
Details of iris are visible
o
In older people, a thin , grayish white ring around
the margin (arcus senilis) may be evident

o
o
o

Opaque
Surface not smooth
Arcus senilis under age 40

Perform the Corneal Sensitivity test

To determine the function of the 5th (trigeminal) cranial


nerve
Ask the client to keep both eyes open and look straight
ahead
Extend your hand behind the clients field of vision , then
bring the gauze toward the outer canthus
Lightly touch the cornea w/ a corner of the gauze
o
Client blinks when the cornea is touched, indicating
that the trigeminal nerve is intact

One or both eyelids fail to respond

Anterior chamber transparency and


depth

Use the same oblique lighting as used to test the cornea


o
Transparent
o
No shadows of light on iris
o
Depth of about 3mm

o
o
o
o
o
o
o

Cloudy
Crescent-shaped shadows on far side of iris
Cloudiness,
Mydriasis
Miosis
Anisocoria
Bulging of iris toward cornea

Pupils direct and consensual


reaction to the light

To determine the function of 3 rd (oculomotor) and 4th


(trochlear) cranial nerves
Partially darken the room
Ask the client to look straight ahead
Using a penlight and approaching from the side, shine a
light on the pupil
Observe the response of the illuminated pupil . It should
constrict (direct response)
Shine the light on the pupil again, and observe the
response of the other pupil . It should also constrict
(consensual response)
o
Illuminated pupil constricts (direct response)
o
Nonilluminated pupil constricts (consensual
response)

o
o
o

Neither pupil constricts


Unequal responses
Absent responses

One or both pupils fail to constrict , dilate or


converge

Pupils reaction to accommodation

Hold an object (penlight or pencil) about 10 cm from the


bridge of the clients nose
Ask the client to look first at the top of the object and
then at a distant object behind the penlight
Alternate the gaze from the near to far object
Observe the pupil response.
o
Pupil should constrict when looking at the near
object
o
Dilate when looking at the far object
Move the penlight or pencil toward the clients nose . The
pupil should converge .
o
PERRLA pupils equally round and react to light and
accommodation
o
Pupils constrict when looking at near object
o
Pupils dilate when looking at far object

Pupils converge when near object is moved toward


nose

II.

Visual Fields

Assessment

Normal findings

Assess Peripheral visual fields

To determine function of
o Retina
o Neuronal visual pathways to the brain
o 2nd (optic) cranial nerve

Deviations
o
o

Visual field smaller than normal (possible


glaucoma)
One half vision in one or both eyes
(possible nerve damage)

Have the client sit directly facing you at a distance of 2 to


3 ft
Ask the client to cover the R eye w/ a card and look directly
at your nose
Cover or close your eye directly opposite the clients
covered eye (i.e your left eye) and look directly at the
clients nose
Hold an object in your fingers , extend your arm and move
the object into the visual field from various points in the
periphery
Object should be at an equal distance from the client and
yourself
Ask the client to tell you when the moving is first spotted

To Test the temporal field of the left eye


Extend and move your right arm in from the clients right
periphery
Temporally , peripheral objects can be seen at right angles
(90 degrees) to the central point of vision
To Test the upward field of the left eye
Extend and move the right arm down from the upward
periphery
The upward field of vision is normally 50 degrees because
the orbital ridge is in the way
To Test the downward field of the left eye
Extend and move the right arm up from the lower periphery
The downward field of vision is normally 70 degrees because
the cheekbone is in the way
To Test the nasal field of the left eye
Extend and move your left arm in from the periphery
The nasal field of vision is normally 50 degrees away from
the central point of vision because the nose is in the way
*Repeat the above steps for the R eye , reversing the process
o

III.

When looking straight ahead, client can see objects


in the periphery

Extraocular Muscle Tests

Assessment
Assess Six ocular movements

Normal findings

To determine
o Eye alignment
o Eye coordination
Stand directly in front of the client and hold the penlight at a
comfortable distance such as 30 cm/ 1 ft in front of the clients
eyes
Ask the client to follow the movements of the penlight w/ the
eyes only
Move the penlight in a slow, orderly manner through the 6 cardinal

Deviations
o
o

Eye movements not coordinated or


parallel
One or both eyes fail to follow a penlight
in specific directions (e.g
strabismus/cross eye)
Nystagmus (rapid involuntary rhythmic
eye movement) other than at end point
may indicate neurologic impairment

fields of gaze from the center of the eye along the lines of the
arrows and back to the center
1. Superior rectus (CN III)
(CN IV)
2. Lateral rectus (CN VI)
III)
3. Inferior rectus (CN III)
III)
o
o

4. Superior oblique
5. Medial rectus (CN
6. Inferior oblique (CN

Both eyes coordinated


Move in unison w/ parallel alignment

Hirschberg Test

Assess for location of light reflex by shining penlight on pupil in


corneal surface
o
Light falls symmetrically on both pupils

Light falls off center on one eye


(indicates misalignment)

Cover Test

Have the client fixate on a near or far object


Cover one eye and observe for movement in the uncovered eye
o
Uncovered eye does not move

If misalignment is present, when


dominant eye is covered, the uncovered
eye will move to focus on object

IV. Visual Acuity

Assessment
Near vision

Normal findings

Distance vision

functional vision tests

Deviations

Provide adequate lighting


Ask the client to read from a magazine or newspaper held at a
distance of 36 cm/14 in
If client normally wears corrective lenses, the glasses or lenses
should be worn during the test
o
Able to read newsprint

Difficulty reading newsprint unless due


to aging process

Ask the client to wear corrective lenses unless they are used for
reading only , i.e for distances of only 36 cm /12 to 14 in
Ask the client to stand or sit 6m /20 ft from a Snellen chart
Cover the eye not being tested and identify the letters in the
chart
Take 3 readings :
o
Right eye
o
Left eye
o
Both eyes

Denominator of 40 or more on Snellentype chart w/ corrective lenses

Functional vision only (e.g. light


perception, hand movements, counting
fingers at 1 ft)

Record the readings


o
Numerator : Distance the person stands from the chart
o
Denominator : Distance from w/c the normal eye can read
the chart
o
s-c : w/o correction
o
c-c : w/ correction
o
20/20 vision on Snellen-type chart (normal)

If the client is unable to see even the top line (20/200) of the
Snellen type chart

NOSE

Inquire

if client has any history of the ff :


Allergies
Injuries to nose or face
Difficulty breathing through the nose
Sinus infection
Nosebleeds
Medications taken
Changes in sense of smell

Assessment

Normal findings

External nose

Patency of both nasal cavities

o
o
o
o
o

Ask client to close the mouth


Exert pressure on one naris and breathe through the
opposite naris
o

Inspect nasal cavities using a


flashlight or a nasal speculum

Symmetric and Straight


No discharge or flaring
Uniform color
No tender
No lesions

Deviations
o
o
o
o
o

Asymmetric
Discharge from nares
Localized areas of redness or presence of
skin lesions
Tenderness on palpation
Presence of lesions

Air movement is restricted in one or both


nares

Air moves freely as the client breathes through


the nares

Inspect the floor of the nose (vestibule) , anterior


portion of the septum, middle meatus and middle
turbinates

Presence of Redness, Swelling,


Growths, and Discharge

o
o
o

Mucosa pink
Clear, watery discharge
No lesions

o
o
o
o

Mucosa red
Edematous
Abnormal discharge (e.g pus)
Presence of lesions (e.g polyps)

Nasal septum bet. the nasal


chambers

Nasal septum intact and in midline

Septum deviated to the right or to the left

Maxillary and frontal sinuses


tenderness

Not tender

Tenderness in one or more sinuses

MOUTH and OROPHARYNX


Composed of a number of structures :
- Lips

- Tongue

- Inner and buccal mucosa


- Gums

- Hard and Soft palate

- Teeth

- Floor of the mouth

- Uvula

-Salivary glands

- Tonsillar pillars
- Tonsils
3 Pairs Salivary glands :
Parotid gland

Largest
Empties through the Stensens duct opposite the second molar

Submandibular gland

Empties through Whartons duct w/c is situated on either side of frenulum

Sublingual gland

Lies on the floor of the mouth


Has numerous openings

Dental caries (cavities)


and Periodontal
disease (pyorrhea)

Problems that most frequently affect the teeth


Commonly associated w/ plaque and tartar deposits

Invisible soft film that adheres to the enamel surface of the teeth
Consists of :
o Bacteria
o Molecules of saliva
o Remnants of epithelial cells and leukocytes

Tartar

When plaque is unchecked , dental calculus or tartar forms


Visible, hard deposit of plaque and dead bacteria that forms at the gum lines
Its build up can alter the fibers that attach the teeth to the gum and eventually disrupt the bone tissue

Gingivitis

Red, Swollen gingiva or gum


Bleeding , receding gum lines and formation of pockets bet. teeth and gums

Glossitis

Inflammation of the tongue

Stomatitis

Inflammation of the oral mucosa

Parotitis

Inflammation of the parotid salivary gland

Sordes

Accumulation of foul matter (food, microorganisms, and epithelial elements) on teeth and gums

Plaque

Inquire if client has any history of the ff :


Routine pattern of dental care
Medications client is receiving
Last visit to dentist
Length of time ulcers or other lesions have been present
Denture discomfort

I. Lips and Buccal Mucosa


Assessment

Normal findings

Deviations

Outer Lips symmetry of contour,


color and texture

Ask the client to purse as if to whistle


o Uniform pink color
o Bluish hue in dark-skinned clients
o Soft, Moist, Smooth texture
o Symmetry of contour
o Ability to purse lips

o
o
o
o
o
o
o
o

Pallor
Cyanosis
Blisters
Generalized or Localized swelling
Fissures
Crusts
Scales
Inability to purse lips (may indicate
facial nerve damage)

Inner Lips and Buccal Mucosa color,


moisture, texture, and presence of
lesions

Apply clean gloves


Ask client to relax the mouth
For better visualization, pull the lip outward and away from the
teeth
Grasp the lip on each side bet. the thumb and index finger
Palpate any lesions for size, tenderness, and consistency
Inspect the front teeth and gums
o Uniform pink color
o Moist, smooth, soft, glistening and elastic texture
o Drier oral mucosa in elderly due to decreased salivation

o
o
o
o
o
o
o
o
o
o

Pallor
Leukoplakia (white patches)
Red
Bleeding
Excessive dryness
Mucosal cysts
Irritations from dentures
Abrasions
Ulcerations
Nodules

II. Teeth and Gums


Inspect the teeth and gums while examining the inner lips and buccal mucosa
- Using tongue depressor, retract the cheek
- View the surface of buccal mucosa from top to bottom and back to front
- A penlight will help illuminate the surface
Examine the back teeth

Use the index fingers of both hands to retract the cheek


Ask client to relax the lips and first close, then open, the
jaw
Rationale : Closing the jaw assists in observation of tooth

alignment and loss of teeth


Opening the jaw assists in observation of dental
fillings and caries

Teeth number, color, state of fillings,


dental caries, and tartar along the
base of teeth

o
o

32 adult teeth
Smooth, white, shiny tooth enamel

o
o

Missing teeth
Brown or black discoloration of the
enamel (may indicate staining or
presence of caries)

Gum bleeding , color , texture,


retraction, edema and lesions

o
o
o
o

Pink gums
Bluish in dark-skinned clients
Moist, firm texture
No retractions of gums (pulling away from teeth)

o
o
o
o
o
o

Excessively red gums


Spongy texture
Bleeding
Tenderness
Receding, Atrophied gums
Swelling that partially covers the teeth

Dentures

Ask client to remove complete or partial dentures


Inspect their condition , noting particular broken or worn
areas
o
Smooth, intact dentures

Ill-fitting dentures
Irritated and excoriated area under
dentures

o
o

III. Tongue /Floor of Mouth

Tongue position, color , and


texture

Tongue movement

o
o
o
o
o
o
o
o

o
o
o
o
o

Deviated from center (may indicate damage


to hypoglossal [12th crania] nerve )
Excessive trembling
Smooth red tongue (may indicate iron, vit.
B12 or vit. B3 deficiency
Dry, furry tongue (associated w/ fluid
deficit)
White coating (may be oral yeast infection)
Nodes
Ulcerations
Discolorations
Areas of tenderness

Restricted mobility

o
o

Swelling
Ulceration

o
o

Swelling
Nodules

o
o
o
o

Ask the client to roll the tongue upward and move it from side to
side
o
Moves freely
o
No tenderness

Base of tongue, Mouth floor, and


Frenulum

Tongue and floor of mouth


nodules, lumps, excoriated areas

Central position
Pink color
Moist, slightly rough
Thin whitish coating
Smooth
Lateral margins
No lesions
Raised papillae (taste buds)

Smooth tongue base w/ prominent veins

To palpate the tongue , use a piece of gauze to grasp its tip and
w/ index finger , palpate the back of tongue , its borders and its
base
o
Smooth w/ no palpable nodules

IV. Salivary glands

Salivary duct openings

Same as color of buccal mucosa and floor of mouth

Inflammation (Redness and Swelling)

V. Palates and Uvula

Hard and Soft palate color,


shape, texture and presence of
bony prominences

Ask client to open mouth wide and tilt the head backward
Depress tongue w/ a tongue depressor
Use a penlight for app. visualization
o
Light pink, Smooth ,soft palate
o
Lighter pink hard palate , more irregular texture

Uvula position and mobility

Positioned in midline of soft palate

o
o
o
o

Discoloration
Palates the same color
Irritations
Exostoses (bony growths) growing from the
hard palate

o
o

Deviation to one side from tumor or trauma


Immobility (may indicate damage to
trigeminal [fift cranial] nerve or vagus
[tenth cranial] nerve)

VI. Oropharynx and Tonsils

Oropharynx color and texture

Pink and Smooth posterior wall

Reddened

o
o

Tonsil color, discharge, size

Gag Reflex

o
o
o
o

Pink and Smooth


No discharge
Of normal size
Grade 1 (normal ) : Tonsils are behind the tonsillar pillars

Press the posterior tongue w/a tongue depressor


o
Present

Edematous
Presence of lesions, plaques, drainage

o
Inflamed
o
Presence of discharge
o
Swollen
Grade 2 : Tonsils are bet. the pillars and uvula
Grade 3 : Tonsils touch the uvula
Grade 4 : One or both tonsils extend to the midline
of the oropharynx

Absent (may indicate problems w/


glossopharyngeal [ninth cranial] nerve or vagus
[tenth cranial] nerve)

EARS
Ear is divided into 3 parts :

External ear

Includes :
o Auricle/pinna
o External auditory canal
o Tympanic membrane/ Eardrum

External Auditory canal


2.5 cm (1 in.) long in adult ; Ends at the tympanic membrane
Covered w/ skin that has many fine hairs, glands, and nerve endings
Glands secrete cerumen (earwax) w/c lubricates and protects ear canal
Curvature differs w/ age : Upward curvature in infant and toddle , Downward curvature in adult

Middle ear

Landmarks of auricle :
o Lobule - Earlobe
o Helix Posterior curve of the auricles upper aspect
o Antihelix Anterior curve of the auricles upper aspect
o Tragus Cartilaginous protrusion at the entrance to the ear canal
o Triangular fossa A depression of the antihelix
o External auditory meatus Entrance to the ear canal

An air- filled cavity that starts at the tympanic membrane


Contains three ossicles (bones of sound transmission :
o Malleus (hammer)
o Incus (anvil)
o Stapes (stirrups)

Eustachian tube
Connects the middle ear to the nasopharynx
Stabilizes the air pressure bet. the external atmosphere and middle ear thus preventing rupture of the
tympanic membrane and discomfort produced by marked pressure differences

Inner ear

Contains :
o Cochlea A seashell-shaped structure essential for sound transmission and hearing
o Vestibule
o Semicircular canals Contains the organs of equilibrium

Sound can be transmitted by :


1. Air conduction
2. Bone conduction

Air conducted
transmission

Occurs by :
o A sound stimulus enters the external canal and reaches the tympanic membrane
o The sound waves vibrate the tympanic membrane and reach the ossicles
o Sound waves travel from the ossicles to the opening in the inner ear (oval window)
o The cochlea receives the sound vibrations
o Stimulus travels to the auditory nerve (eight cranial nerve) and the cerebral cortex

Bone conducted
transmission

Occurs when skull bones transport sound directly to the auditory nerve

Conduction hearing
loss

Result of interrupted transmission of sound waves through the outer and middle ear structures
Possible causes :
o Tear in the tympanic membrane
o Other causes in auditory canal
o Obstruction due to swelling

Sensorineural
hearing loss

Result of damage to the inner ear , auditory nerve, or the hearing center in brain

Mixed hearing loss

Combination of conduction and sensorineural loss

Inquire if client has any history of the ff :


Family history of hearing problems or loss
Hearing difficulty
Presence of ear problems or pain
Use of corrective hearing device
Medication history

I. Auricles
Assessment

Normal findings

Deviations

Color, Symmetry of size, Position

Note the level at w/c superior aspect of the auricle


attaches to the head in relation to the eye
o
Color same as facial skin
o
Symmetrical
o
Auricle aligned w/ outer canthus of eye about 10
degree from vertical

o
o
o

Bluish color of earlobes (e.g cyanosis)


Pallor (e.g frostbite)
Excessive redness (inflammation or fever)

Texture, Elasticity and areas of


tenderness

Gently pull the auricle upward, downward, and backward


Fold the pinna forward (it should recoil)
Push in on the tragus
Apply pressure to the mastoid process
o
Mobile
o
Firm
o
Not tender
o
Pinna recoils after it is folded

o
o
o

Lesions
Flaky, Scaly skin
Tenderness when moved or pressed

o
o
o
o

Redness
Discharge
Scaling
Excessive cerumen obstructing canal

II. External Ear Canal and Tympanic Membrane

External ear canal cerumen, skin


lesions, pus, and blood

Attach a speculum to the otoscope . Use the largest


diameter that will fit the ear canal w/o causing
discomfort
Rationale : This achieves maximum vision of the entire ear

canal and tympanic membrane

Tip the clients head away from you and straighten the
ear canal
For an adult, straighten the ear canal by pulling the pinna
up and back
Rationale : Straightening the ear canal facilitates vision of

the ear canal and tympanic membrane

Hold the otoscope either


o
Right side up Your fingers bet. the otoscope
handle and clients head
o
Upside down Your fingers and ulnar surface of
your hand against clients head
Rationale : Stabilizes the head and protects the eardrum and

canal from injury if a quick head movement occurs

Gently insert the tip of the otoscope into the ear canal,
avoiding pressure by the speculum against the either side
of the ear canal
Rationale : The inner two-thirds of the ear canal is bony; if

the speculum is pressed against either side, the client will


experience discomfort
o
o
o

Distal third contains hair follicles and glands


Dry cerumen
Grayish-tan color or sticky wet cerumen in various

shades of brown

Tympanic membrane color and gloss

o
o

Pearly gray color


Semitransparent

o
o
o
o
o

Pink to red , some opacity


Yellow amber
White
Blue or deep red
Dull surface

Normal voice tones audible

Normal voice tones not audible (e.g requests


nurse to repeat words , leans toward the
speaker, turns the head, cups the ears, speaks
in loud tone of voice)

Ticking of a watch has a higher pitch than the human voice


Have the client occlude one ear
Out of the clients sight, place a ticking watch 2 to 3 cm (1
to 2 in)
Ask what the client can hear
o
Able to hear ticking in both ears

Unable to hear ticking in one or both ears

To assess bone conduction by examining the lateralization


/sideward transmission of sounds
Hold the tuning fork at its base
Activate it by tapping the fork gently against the back of
your hand near the knuckles or by stroking the fork bet.
your thumb and index fingers
Place the base of the vibrating fork on top of the clients
head
Ask where the client hears the noise
o
Sound is heard in both ears or is localized at the
center of the head
Weber Negative

Sound is heard better in impaired ear


indicating a bone-conductive hearing loss
Sound is heard better in ear w/o a problem
indicating a sensorineural disturbance
Weber Positive

To compare air conduction to bone conduction


Ask client to block the hearing in one ear intermittently
by moving a fingertip in and out of the ear canal
Hold the handle of the activated tuning fork on the
mastoid process of one ear until the client states that the
vibration can no longer be heard
Immediately hold the still vibrating fork prongs in front
of the clients ear canal
Ask whether client now hears the sound
o
Sound conducted by air is heard more readily than
sound conducted by bone
o
Tuning fork vibrations conducted by air are
normally heard longer
o
Air-conducted (AC) hearing is greater than Boneconducted (BC) hearing Positive rinne

III. Gross Hearing Acuity Test

Clients response to normal voice


tones

If client has difficulty hearing the normal voice , proceed w/ the ff tests :

Watch Tick Test

Webers Test

Rinne Test

Bone conduction time is equal to or longer than


the air conduction time Negative rinne
indicates a conductive hearing loss

THE NECK
- Examination of the neck includes :
> Muscles

> Thyroid gland

> Lymph nodes

> Carotid arteries

> Trachea

> Jugular veins

Sternocleidomastoid muscles
- Divide each side of the neck into two triangles (posterior and anterior)
- Anterior triangle includes :
> Trachea

> Carotid artery

> Thyroid gland


> Anterior cervical nodes
- Posterior triangle includes the posterior lymph nodes
- Each extends from the upper sternum and medial third of the clavicle to the mastoid process of the temporal bone behind the ear
- Responsible for turning and flexing laterally of the head
Trapezius muscle
- Extends from the occipital bone of the skull to the lateral third of the clavicle
- Draw the head to the side and back , elevate the chin and elevate the shoulders to shrug them
Chains
- Lymph nodes in the neck that collect lymph from the head and neck structures that are grouped serially
HEAD

Occipital

Location : At the posterior base of the skull


Area drained : Occipital region of the scalp and deep structures of the back of the neck

Postauricular (mastoid)

Location : Behind the auricle of the ear or in front of the mastoid process
Area drained : Parietal region of the head and part of the ear

Preauricular

Location : Front of the tragus of the ear


Area drained : Forehead and Upper face

FLOOR OF THE MOUTH

Submandibular
/submaxillary

Submental

Location : Along the medial border of the mandible, halfway bet. the angle of the jaw and the chin
Area drained : Chin, Upper lip, Cheek, Nose, Teeth, Eyelids, Part of tongue, and of the floor of the mouth

Location : Behind the tip of the mandible in the midline, under the chin
Area drained : Anterior third of the tongue. Gums, and Floor of the mouth

NECK

Superficial anterior
cervical (tonsillar)

Location : Along the mandible, anterior to the sternocleidomastoid muscle


Area drained : Skin and Neck

Posterior cervical

Location : Along the anterior aspect of the trapezius muscle


Area drained : Posterior and lateral regions of the neck, occiput, and mastoid

Deep cervical

Location : Under the sternocleidomastoid muscle


Area drained : Larynx, Thyroid gland, Trachea, Upper part of esophagus

Supraclavicular

Location : Above the clavicle, in angle bet. the clavicle and sternocleidomastoid muscle
Area drained : Lateral regions of the neck and lungs

Inquire if the client has any history of the ff :

Neck lumps
When and How any lumps occurred
Neck pain
Previous diagnoses of thyroid problems
Stiffness
Other treatments provided

I . Neck Muscles

Assessment
Neck muscles (sternocleidomastoid and
trapezius) for abnormal swellings or
masses

Normal findings
Ask client to hold the head erect
o Muscles equal in size
o Head centered

o
o

Head movement

Coordinated
Smooth movements w/ no discomfort

Deviations
o
o

Unilateral neck swelling


Head tilted to one side (indicates presence of
masses, injury, muscle weakness, shortening of
sternocleidomastoid muscle, scars)

o
o
o

Muscle tremor
Spasm
Stiffness

o
o

Limited range of motion


Painful movements
Involuntary movements (e.g up-and-down
nodding movements associated w/ Parkinsons
disease)

Head hyperextends less than 60 degrees

Head laterally flexes less than 40 degrees

Head laterally rotates less than 70 degrees

Unequal strength

Unequal strength

Ask client to move the chin to the chest


Rationale : Determines the function of sternocleidomastoid

muscle

Head flexes 45 degree

Move the head back so that the chin points upward


Rationale: Determines function of the trapezius muscle
o
Head hyperextends 60 degrees
Move the head so that the ear is moved toward the
shoulder on each side
Rationale :Determines function of the sternocleidomastoid

muscle

Head laterally flexes 40 degrees

Turn the head to the right and to the left


Rationale: Determines function of the sternocleidomastoid

muscle

Muscle strength

Head laterally rotates 70 degrees

Ask the client to turn the head to one side against


the resistance of your hand
Rationale: Determines the strength of the

sternocleidomastoid muscle
o

Equal strength

Ask the client to shrug the shoulders against the


resistance of your hands
Rationale: Determines the strength of the trapezius muscle

II. Lymph Nodes

Equal strength

Enlarged lymph nodes

Palpate the entire neck for enlarged lymph nodes


o
Not palpable

o
o
o

Bend the clients head forward slightly or toward the side being examined
Rationale: This relaxes the soft tissue and muscles

Palpate the nodes using pads of the fingers. Move the fingertips in gently
rotating motion

When examining the submental and submandibular nodes


o Place the fingertips under the mandible on the side nearest the
palpating hand
o Pull the skin and subcutaneous tissue laterally over the mandibular
surface so that the tissue rolls over the nodules

When palpating the supraclavicular nodes


o Use your hand nearest the side to be examined when facing the client
o Use your free hand to flex the clients head forward if necessary
o Hook your index and third fingers over the clavicle lateral to the
sternocleidomastoid muscle

When palpating the anterior cervical nodes and posterior cervical nodes
o Move your fingertips slowly in a forward circular motion against the
sternocleidomastoid and trapezius muscle

To palpate the deep cervical nodes


o Bend or hook your fingers around the sternocleidomastoid muscle

Place your fingertip on the trachea in the suprasternal notch


Move your finger laterally to the left and right in spaces bordered
by clavicle, anterior aspect of the sternocleidomastoid muscle and
trachea
o Central placement in midline of the neck
o Spaces are equal on both sides

Enlarged
Palpable
Possibly tender
(associated w/ infection
and tumors)

III. Trachea

lateral deviation

Deviation on one side (indicating


possible neck tumor, thyroid
enlargement, enlarged lymph
nodes)

o
o

Visible diffuseness
Local enlargement

Gland is not fully movable w/


swallowing

Solitary nodules

IV. Thyroid Gland

Thyroid gland

Stand in front of the client


Observe the lower half of the neck overlying the thyroid gland for
symmetry and visible masses
o Not visible on inspection

Ask the client to extend the head and swallow


Rationale: Determines how thyroid and cricoid cartilages move and whether

swallowing causes a bulging of the gland


o

smoothness, enlargement , masses or


nodules

Gland ascends during swallowing but is not visible

Stand in front or behind the client

Ask the client to lower the chin slightly


Rationale: Lowering the chin relaxes the neck muscles , facilitating palpation
o Lobes may not be palpated
o If palpated, lobes are small, smooth, centrally located,
painless, and rise freely w/ swallowing
Posterior approach

Place your hands around the clients neck w/ your fingertips on the
lower half of the neck over the trachea

Ask the client to swallow and feel for any enlargement of the
thyroid isthmus as it rises

(Isthmus lies across the trachea below the cricoid cartilage )

To examine the R thyroid lobe


o Have the client lower the chin slightly and turn the head
slightly to the right (side being examined)
o With your left fingers, displace the trachea slightly to the
right
o With your right fingers, palpate the R thyroid lobe
o Have the client swallow while you are palpating
(Repeat in reverse to examine the L thyroid lobe)

Anterior Approach

Place the tips of your index and middle fingers over the trachea
Palpate the thyroid isthmus as the client swallows

To examine the R thyroid lobe


o Have the client lower the chin slightly and turn the head
slightly to the right
o With your right fingers, displace the trachea slightly to the
clients right (your left)
o With your left fingers, palpate the R thyroid lobe
(Repeat in reverse to examine the L thyroid lobe)

Enlargement of gland
Auscultate over the thyroid area for a bruit , a soft rushing sound
created by turbulent blood flow
Use the bell of the stethoscope
Rationale: Bell transmits this low frequency sound better than the diaphragm

does

Absence of bruit

Presence of bruit

THORAX and LUNGS


CHEST LANDMARKS
- Nurse must be familiar w/ :
> Series of imaginary lines
> Position of each rib
> Position of some spinous processes
- Help the nurse to :
> Identify the position of underlying organs
> Record abnormal assessment findings

ANTERIOR CHEST

Midsternal line

vertical line running through the center of the sternum

Midclavicular lines

R and L ; vertical lines from the midpoints of the clavicles

Anterior Axillary
lines

R and L ; vertical lines from the anterior Axillary folds

Posterior Axillary line

vertical line from the posterior Axillary fold

Midaxillary line

vertical line from the apex of the axilla

Vertebral line

vertical line along the spinous processes from c7 to T12

Scapular lines

R and L ; vertical lines from the inferior angles of the scapulae

LATERAL CHEST

POSTERIOR CHEST

DIVISION OF LUNG

Each lung is first divided into upper and lower lobes by an oblique fissure that
runs from the level of the spinous process of the third thoracic vertebra (T-3)
to the level of the sixth rib at the Midclavicular line

Abbreviation :
o Right Upper lobe (RUL)
o Left Upper lobe (LUP)
o Right Lower lobe (RLL)
o Left Lower lobe (LLL)

Right lung is further divided by a minor fissure into right upper lobe and right
middle lobe (RML) . This fissure runs anteriorly from the right midaxillary line
at the level of fifth rib to the level of fourth rib

Angle of Louis

Starting point for locating the ribs anteriorly


Junction bet. the body of sternum (breastbone) and manubrium

Manubrium

Handlelike superior part of the sternum that joins w/ the clavicle


Nurse can identify this by first palpating the clavicle and following its course to its attachment at the Manubrium

Intercostal spaces (ICS)

Numbered acc. to the number of rib immediately above the space

Rib identification

When palpating for this, nurse should palpate along the


Midclavicular line rather than sterna border because the rib
cartilages are very close at the sternum
Counting of ribs is more difficult on the posterior than on the
anterior thorax
True Ribs (1-7)
False Ribs (8-10)
Floating Ribs (11-12)
Only the first seven ribs attach directly to the sternum
T-1 to T-4 is adjacent to the corresponding rib number
o T-1 is adjacent to the first rib
o T-2 is adjacent to the second rib
o T-3 is adjacent to the third rib
o T-4 is adjacent to the fourth rib
T-5 and so on .. spinous processes project obliquely causing the spinous process of the vertebra to lie , not over its
corresponding numbered rib , but over the rib below
o T-5 lies over the body of T-6 and is adjacent to the sixth rib

Lung lobe identification

Pertinent landmark is T-3


Starting point for locating T3 is the spinous process of the seventh cervical vertebra (C-7)
When the client flexes the head anteriorly , a prominent process can be observed and palpated (C-7); if two spinous process
are observed , superior one is C-7 and inferior one is the spinous process of the first thoracic vertebra (T-1)
Nurse then palpates and counts the spinous processs from C-7 to T-3

CHEST SHAPE AND SIZE


Deformities of the Chest :

Pigeon chest (pectus carinatum)

A permanent deformity
May be caused by rickets
Characteristics :
o Narrow transverse diameter
o Increased anteroposterior diameter
o Protruding sternum

Funnel chest (pectus excavatum)

A congenital defect
Characteristics :
o Sternum is depressed
o Narrowed anteroposterior diameter
o Because the sternum points posteriorly , abnormal pressure on hear
may result altered function

Barrel chest

Ratio of anteroposterior to transverse diameter is 1 to 1


Seen in clients w/ thoracic kyphosis and emphysema (chronic
pulmonary condition in w/c air sacs or alveoli are dilated and
distended)

Kyphosis

Excessive convex curvature of the thoracic spine

Scoliosis

A lateral deviation of the spine

BREATH SOUNDS
Adventitious breath sounds
- Abnormal breath sounds
- Occur when :
> Air passes through narrowed airways or airways filled w/ fluid or mucus
> Pleural linings are inflamed

Crackles/ Rales / Crepitations

Description :
Fine , Short, Interrupted crackling sounds
High-pitched
Can be stimulated by rolling a lock of hair near the ear
Best heard on inspiration but can be heard on both inspiration and expiration
May not be cleared by coughing
Cause :
Air passing through fluid or mucus in any air passage
Location :
Most commonly heard in the bases of the lower lung lobes

Gurgles/ Ronchi

Description :
Continuous
Low-pitched
Coarse
Gurgling
Harsh
Louder sounds w/ a moaning or snoring quality
Best heard on expiration but can be heard on both inspiration and expiration
May be altered by coughing
Cause :
Air passing through narrowed air passages as a result of secretions, swelling, tumors
Location :
Most lung areas but predominate over the trachea and bronchi

Friction rub
Description :

Superficial grating
Creaking sounds
Heard during inspiration and expiration
Not relieved by coughing
Cause :
Rubbing together of inflamed pleural surfaces
Location :
Heard most often in areas of greatest thoracic expansion (e.g lower anterior and lateral chest)

Wheeze
Description :
Continuous
High-pitched
Squeaky musical sound
Best heard on expiration
Not usually altered by coughing
Cause :
Air passing through a constricted bronchus as a result of secretions , swelling, tumors
Location :
Heard over all lung fields

Absence of breath sounds

Associated w/ :
Collapsed
Surgically removed lobes
Severe pneumonia

Normal Breath Sounds

Vesicular

Description :
Soft intensity
Low pitched
Gentle sighing sounds created by air moving through smaller airways (bronchioles and alveoli)
Location :
Over peripheral lung
Best heard at the base of lungs
Characteristics :
Best heard on inspiration w/c is about 2.5 times longer than expiratory phase (5:2ratio)

Broncho-vesicular

Description :
Moderate-intensity
Moderate pitched
Blowing sounds created by air moving through larger airway (bronchi)
Location :
Between the scapulae
Lateral to the sternum at the first and second intercostals spaces
Characteristics :
Equal inspiratory and expiratory phases (1:1 ratio)

Bronchial (tubular)

Description :
High-pitched
Loud
Harsh sounds created by air moving through the trachea
Location :
Anteriorly over the trachea
Not normally heard over lung tissue
Characteristics :
Louder than vesicular sounds
Have a short inspiratory phase and long expiratory phase (1:2 ratio)

Inquire

if client has any history of the ff :


Family history of illness (cancer, allergies, TB)
Lifestyle habits
Medications being taken
Occupational hazards
Current problems (e.g swellings, coughs, wheezing, pain)

I. Posterior Thorax

Assessment
Shape and Symmetry of thorax from
posterior and lateral view

Normal findings
Compare the anteroposterior diameter to the transverse diameter
o Anteroposterior to transverse diameter in ratio of 1:2
o Chest symmetric

Deviations

o
o
o

Spinal alignment deformities

Have the client stand .


From a lateral position , observe the three normal curvatures :
cervical, thoracic, and lumbar
o
o
o

Palpate the posterior thorax

Spine vertically aligned


Spinal column is straight
Right and left shoulders and hips are at the same height

For clients who have no respiratory complaints , rapidly assess the


temp. and integrity of all chest skin
o Skin intact
o Uniform temperature

For clients who do have respiratory complaints :


Palpate all chest areas for bulges, tenderness, or abnormal
movements
Avoid deep palpation for painful areas , esp. if a fractured rib is
suspected . In such cases , it could lead to displacement of bone
fragment against the lungs
o Chest wall intact
o No tenderness and Masses

Palpate the chest for respiratory


excursion (thoracic expansion)

Palpate chest for vocal (tactile)


fremitus , the perceptible vibration
felt through the chest wall when the
client speaks

Percuss the thorax

Barrel chest
Increased anteroposterior to
transverse diameter
Chest asymmetric

Place the palms of both your hands over the lower thorax w/ your
thumbs adjacent to the spine and your fingers stretched laterally
Ask client to take a deep breath while you observe the movement
of your hands and any lag in movement
o Full and symmetric chest expansion

Place the palmar surfaces of your fingertips on the posterior


chest , starting near the apex of the lungs
Ask the client to repeat words (e.g one, two, three)
Repeat the above 2 steps , moving your hands sequentially to the
base of the lungs (zigzag position)
Compare the fremitus on both lungs and bet. apex and base of
each lung
o Bilateral symmetry of vocal fremitus
o Fremitus is heard most clearly at the apex of the lungs
o Low-pitched voice of males are more readily palpated than
higher pitched voices of females

To determine
o Whether underlying lung tissue is filled w/ air, liquid, or

o
o

Exaggerated spinal curvatures


(kyphosis, lordosis)
Spinal column deviates to one side
Shoulders or Hips not even

o
o

Skin lesions
Areas of hyperthermia

o
o
o
o
o

Lumps
Bulges
Depressions
Areas of tenderness
Movable structures (e.g rib)

o
o

Asymmetric
Decreased chest expansion

Decreased or absent fremitus


(associated w/ pneumothorax)
Increased fremitus (associated w/
consolidated lung tissue as in
pneumonia)

solid material
Positions and boundaries of certain organs

Ask client to bend head and fold the arms forward across the
chest
Rationale: This separates the scapula and exposes more lung tissue to

percussion

Percuss in the ICS at about 5 cm (2in) intervals in a systematic


sequence
Compare one side of the lung w/ the other
Percuss the lateral thorax every few inches starting at the axilla
and working down to the eight rib
o
o

Percuss for diaphragmatic excursion


(movement of diaphragm during
maximal inspiration and expiration)

Excursion is 3 to 5 cm bilaterally in women and 5 to 6 cm in


men
Diaphragm is usually slightly higher on the right side

Asymmetry in percussion
Areas of dullness or flatness over
lung tissue (associated w/
consolidation of lung tissue or
mass)

Restricted excursion (associated


w/ lung disorder)

o
o

Adventitious breath sounds


Absence of breath sounds

Use diaphragm of the stethoscope because it is best for


transmitting the high-pitched breath sounds
Use the systemic zigzag procedure used in percussion
Ask client to take slow, deep breaths through the mouth
Listen to each point of breath sounds during a complete inspiration
and expiration
o

Vesicular and Bronchovesicular breath sounds

o
o
o

Quiet
Rhythmic
Effortless respirations

II. Anterior Thorax

Breathing patterns

o
o

Ask client to take a deep breath and hold it while you Percuss
downward along the scapular line until dullness is produced at the
level of diaphragm
Mark this point w/ a marking pen and repeat procedure on the
other side of the chest
Ask client to take a few normal breath 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
Measure the distance bet. the 2 marks
o

Auscultate the chest

Percussion notes resonate, except over scapula


Lowest point of resonance is at the diaphragm (i.e at the
level of eight to tenth rib posteriorly) *Percussion on a rib
normally elicits dullness

Inspect Costal angle and Angle at w/c


the ribs enter the spine

o
o

Costal angle is less than 90 degrees


Ribs insert into spine at app. a 45 degree angle

Costal angle is widened (associated w/


COPD)

Palpate the anterior chest

Same manner as for posterior chest

Palpate the anterior chest for


respiratory excursion

Same manner as for posterior chest


o Full symmetric excursion
o Thumbs normally separate 3 to 5 cm

o
o

Asymmetric
Decreased respiratory excursion

Palpate tactile fremitus

Same manner as for posterior chest


o Same as posterior vocal fremitus
o Fremitus is normally decreased over heart and breast
tissue

Same as posterior fremitus

Percuss the anterior chest


systematically

Begin above the clavicle in the Supraclavicular space and


proceed downward to the diaphragm
Compare one side of the lung to the other
Displace female breasts for proper examination
o Percussion notes resonate down to the sixth rib at
the level of the diaphragm
o Flat over areas of heavy muscle and bone
o Dull on areas over the heart and liver
o Tympanic over the underlying stomach

o
o

Asymmetry in percussion notes


Areas of dullness or flatness over lung
tissue

Adventitious breath sounds

Adventitious breath sounds

Auscultate the trachea

Auscultate the anterior chest

Bronchial and tubular breath sounds

Use the sequence used in percussion beginning over the


bronchi bet. the sternum and clavicles
o
Bronchovesicular and vesicular breath sounds

THE BREASTS and AXILLAE


- Men have some glandular tissue beneath each nipple , a potential site for malignancy
- Women have glandular tissue throughout the breast
Four breast quadrants

Upper outer quadrant


o
Contain the largest portion of glandular breast tissue
o
Majority of breast tumors are located in this quadrant including the tail of Spence
Upper inner quadrant
Lower outer quadrant
Lower inner quadrant
Axillary tail of Spence
o
A projection of breast tissue from the upper outer quadrant w/c extends into the axilla

Inquire if the client has any history of the ff :


Masses and what was done about them
Pain or tenderness in breast and relation to womans menstrual cycle
Discharge from the nipple
Medication history
Risk factors that may be associated w/ development of breast cancer
Mother, Sister or Aunt w/ breast cancer
Use of oral contraceptives
Alcohol consumption
Menarche before age 12
High-fat diet
Menopause after age 55
Obesity
Age 30 or more at first pregnancy
Inquire if the client performs
Breast self examination
Technique used
When performed in relation the menstrual cycle

Assessment
Inspect Breast for size, symmetry,
contour or shape

Normal findings

Inspect skin of the breast for :


Localized discolorations or
hyperpigmentation , Retraction or
dimpling, localized hypervascular areas,
Swelling or edema

Client is in sitting position


o Female : Rounded shape, Slightly unequal in size,
Generally symmetric
o Male : Breasts even w/ the chest wall , If obese , may
be similar in shape to female breasts

o
o
o
o

Skin uniform in color


Skin smooth and intact
Diffuse symmetric horizontal or vertical vascular
pattern in light-skinned people
Striae , Moles, Nevi

Deviations
o
o
o

Recent change in breast size


Swellings
Marked asymmetry

Localized discoloration or
Hyperpigmentation
Retraction or dimpling (result of scar
tissue or an invasive tumor)
Unilateral, Localized hypervascular areas
(associated w/ increased blood flow)
Swelling or Edema appearing as pig skin
or orange peel due to exaggeration of the
pores

o
o
o

Emphasize any retraction by having the


client :

Inspect Areola for size, shape,


symmetry, color, surface
characteristics, any masses or lesions

Raise the arms above the head


Push the hands together w/ elbows flexed
Pressed the hands down on the hips

o
o
o

Round or Oval
Bilaterally the same
Color varies widely : from light pink to dark brown

o
o
o

Any asymmetry
Mass
Lesion

Inspect Nipple for size, shape,


position, color, discharge, lesions

Irregular placement of sebaceous glands on surface of


the areola (Montgomerys tubercles)

o
o
o
o
o
o
o

Round
Everted
Equal in size
Similar in color
Soft, smooth
Both nipples point in same direction
No discharge except from pregnant or breast-feeding
females
Inversion of one or both nipples that is present from
puberty

Palpate Axillary, Subclavicular,


Supraclavicular lymph nodes

Palpate Breast for masses ,


tenderness, any discharge from nipples

o
o
o

Asymmetrical size and color


Presence of discharge, crusts, or cracks
Recent inversion of one or both nipples

o
o
o
o

Tenderness
Masses
Nodules
Nipple discharge

o
o

Tenderness
Masses

Client sits w/ the arms abducted and supported on the


nurses forearm
Use flat surfaces of all fingertips to palpate the 4 areas of
the axilla :
o The edge of the greater pectoral muscle (musculus
pectoralis major) along the anterior Axillary line
o The thoracic wall in the midaxillary area
o The upper part of the humerus
o Anterior edge of the latissimus dorsi muscle along the
posterior Axillary line

Client in Supine position


Rationale : Breasts flatten evenly against the chest wall,

facilitating palpation

To enhance flattening of the breast:


Instruct the client to abduct the arm
Place her arm behind her head
Place a small pillow or rolled towel under the clients
shoulder
For palpation :
Use the palmar surface of the middle three fingertips held
together
Make a gentle rotary motion on the breast
Pay particular attention to the upper outer quadrant area
and the tail of Spence
Patterns for palpation :
Hands-of-the-clock
Concentric circles
Vertical strips pattern
Normal findings:
o
No tenderness
o
No masses
o
No nodules
o
No nipple discharge
If mass is detected, record the ff data :

Areola and Nipple masses

Location Exact location relative to the quadrants and


Axillary tail and distance from nipple in cm
Size Length, Width, Thickness (cm)
Shape Round, Oval, Lobulated, Indistinct, Irregular
Consistency Hard, Soft
Mobility Movable, Fixed
Skin over the lump Reddened, Dimpled, Retracted
Nipple Displaced , Retracted
Tenderness- Whether palpation is painful

- Compress each nipple to determine presence of any discharge


- If discharge is present, assess it for amount, color, consistency,
and odor
- Note tenderness on palpation
o
No tenderness

o
o
o
Teach the client the technique of
breast self examination

No masses
No nodules
No nipple discharge

o
o

Nodules
Nipple discharge

THE ABDOMEN
- Methods of subdividing the abdomen :
> Quadrants
> Regions
Quadrants

To divide abdomen into quadrants, nurse imagines 2 lines :


o Vertical line from the xiphoid process to the pubic symphysis
o Horizontal line across the umbilicus

Right upper quadrant


Left upper quadrant

Regions

Right Lower quadrant


Left Lower quadrant

Nurse imagines :
o 2 vertical lines that extend superiorly from the midpoints of the inguinal ligaments
o 2 horizontal lines , one at the level of the edge of the lower ribs and the other at the level of the iliac crests

Certain landmarks to locate abdominal signs and symptoms :

Xiphoid process of the sternum


Inguinal ligaments (Pouparts ligaments)
Costal margins
Superior margin of the pubic symphysis
Anterosuperior iliac spine

Assessment of the Abdomen involves :

Inspection (first)
Auscultation
Percussion
Palpation

4 ABDOMINAL QUADRANTS

RIGHT UPPER QUADRANT

LEFT UPPER QUADRANT

Liver
Gallbladder
Duodenum
Head of pancreas
R adrenal gland
Upper lobe of R kidney
Hepatic flexure of colon
Section of ascending colon
Section of transverse colon

L lobe of liver
Stomach
Spleen
Upper lobe of L kidney
Pancreas
L adrenal gland
Splenic flexure of colon
Section of tranverse colon
Section of descending colon

RIGHT LOWER QUADRANT

LEFT LOWER QUADRANT

Lower lobe of R kidney


Cecum
Appendix
Section of ascending colon
R ovary, R fallopian tube
R ureter, R spermatic cord
Part of uterus

Lower lobe of L kidney


Sigmoid colon
Section of descending colon
L ovary
L fallopian tube
L ureter
L spermatic cord
Part of uterus

9 ABDOMINAL REGIONS

RIGHT HYPOCHONDRIAC

EPIGASTRIC

LEFT HYPOCHONDRIAC

R lobe of liver
Gallbladder
Part of duodenum
Hepatic flexure of colon
Upper half of R kidney
Suprarenal gland

Aorta
Pyloric end of stomach
Part of duodenum
Pancreas
Part of liver

Stomach
Spleen
Tail of pancreas
Splenic flexure of colon
Upper half of L kidney
Suprarenal kidney

RIGHT LUMBAR

UMBILICAL

LEFT LUMBAR

Ascending colon
Lower half of R kidney
Part of duodenum and jejunum

Omentum
Mesentery
Lower part of duodenum
Part of jejunum and ileum

Descending colon
Lower half of R kidney
Part of jejunum and ileum

HYPOGASTRIC (PUBIC)

LEFT INGUINAL

RIGHT INGUINAL
Cecum
Appendix
Lower end of ileum
R ureter
R spermatic cord
R ovary

Ileum
Bladder
Uterus

Sigmoid colon
L ureter
L ovary

Inquire

if client has any history of the ff :


Incidence of abdominal pain
Food intolerances
Bowel habits
Foods ingested in last 24 hrs
Incidence of constipation or diarrhea
Previous problems and treatment
Change in appetite
Specific signs and symptoms (e.g heartburn, flatulence, belching, difficulty swallowing, hematemesis
[vomiting blood], blood or mucus in stools)

Assist client to a supine position , w/ arms placed comfortably at the sides


Place small pillows beneath the knees and head to reduce tension in the abdominal muscles
Expose clients abdomen only from the chest line to the pubic area to avoid chilling and shivering, w/c can
tense the abdominal muscles

I. Inspection of the Abdomen

Assessment

Normal findings

Skin Integrity

Contour and Symmetry

o
o
o
o

Unblemished skin
Uniform color
Silver-white striae (stretch marks)
Surgical scars

Observe abdominal contour (profile line from the rib margin to


the pubic bone) while standing at the clients side when the
client is supine
Ask the client to take a deep breath and to hold it
Rationale: This makes an enlarged liver or spleen more obvious
Assess symmetry of contour while standing at the foot of the
bed
If distention is present, measure the abdominal girth by
placing a tape around the abdomen at the level of the umbilicus
o Flat, rounded (convex) or scaphoid (concave)
o No evidence of enlargement of liver or spleen
o Symmetric contour

Abdominal movements associated w/


respiration , peristalsis, or aortic
pulsations

o
o
o

Symmetric movements caused by respiration


Visible peristalsis in very lean people
Aortic pulsations in thin persons at epigastric area

Deviations
o
o
o

o
o
o

o
o
o

Vascular pattern

II.

No visible vascular pattern

Auscultation of the Abdomen

Auscultate abdomen for bowel


sounds, vascular sounds and
peritoneal friction rubs

Warm the hands and stethoscope diaphragms


Rationale : Cold hands and stethoscope may cause the client to

contract the abdominal muscles and these contractions may be


heard during auscultation
FOR BOWEL SOUNDS
Use the flat disc diaphragm
Rationale: Intestinal sounds are relatively high pitched and best

accentuated by the diaphragm

Ask when the client last ate

Presence of rash or other lesions


Tense, glistening skin (may indicate
ascites, edema)
Purple striae (associated w/ Cushings
disease or rapid weight gain and loss)

Distended
Evidence of enlargement of liver or
spleen
Asymmetric contour (e.g localized
protrusions around umbilicus , inguinal
ligaments, or scars [possible hernia or
tumor])

Limited movement due to pain or disease


process
Visible peristalsis in nonlean clients
(possible bowel obstruction)
Marked aortic pulsations

Visible venous pattern (dilated veins) is


associated w/ liver disease, ascites and
venocaval obstruction

Rationale: Shortly after or long after eating , bowel sounds may

normally increase . They are loudest when a meal is long overdue . 4


to 7 hrs after a meal, bowel sounds may heard continuously over the
ileocecal valve area while the digestive contents from the small
intestine empty through the valve into the large intestine

Place the diaphragm of the stethoscope in each of the four


quadrants of the abdomen over all of the auscultatory sites :
o Aorta
o Iliac artery
o Renal artery
o Femoral artery
Listen for active bowel sounds (irregular gurgling noise
occurring about every 5 to 20 sec.)

FOR VASCULAR SOUNDS


Use the bell of the stethoscope over the aorta, renal arteries,
iliac arteries and femoral arteries
Listen for bruits

FOR PERITONEAL FRICTION RUBS


They are rough, grating sounds like two pieces of leather
rubbing together
May be caused by inflammation, infection, or abnormal growths

TO AUSCULTATE :
Splenic site
Place the stethoscope over the left lower rib cage in the
anterior Axillary line and ask client to take a deep breath
Deep breath may accentuate the sound of a friction rub area
Liver site
Place the stethoscope over the lower right rib cage
o
o
o

Audible bowel sounds


Absence of arterial bruits
Absence of friction rub

Hypoactive sounds
Extremely soft and infrequent (e.g one
per min.)
- Indicate decreased motility
- Usually associated w/ manipulation of
the bowel during surgery, inflammation,
paralytic ileus, late bowel destruction

Hyperactive sounds
- High pitched, loud, rushing sound
- Occur frequently (e.g every 3 sec)
- Also known as borborygmi
- Indicate increased intestinal motility
- Usually associated w/ diarrhea, an early
bowel obstruction, use of laxatives

True absence of sounds


- None heard in 3 to 5 min.
- Indicates a cessation of intestinal
motility

Loud bruit over aortic area (possible


aneurysm)
Bruit over renal or iliac arteries

III. Percussion of the Abdomen

Percuss several areas in each of the


4 quadrants

To determine presence of tympany (gas in stomach and


intestines) and dullness (decrease, absence, or flatness of
resonance over solid masses or fluid)
Use a systemic pattern :
o Begin in lower R quadrant
o Proceed to upper R quadrant
o Then, to upper L quadrant

Lastly, lower L quadrant

o
o

Tympany over the stomach and gas-filled bowels


Dullness esp. over the liver and spleen or a full bladder

-o

Large dull areas (associated w/ presence


of fluid or a tumor)

Enlarged size (associated w/ liver


disease)

o
o
o

Tenderness and Hypersensitivity


Superficial masses
Localized areas of increased tension

Generalized or localized areas of


tenderness
Mobile or fixed masses

IV. Percussion of the Liver

Percuss the liver to determine its


size

Begin in the R Midclavicular line below the level of the


umbilicus
o Percuss upward over tympanic areas until a dull percussion
sound indicates the lower liver border. Mark the site
o Then, percuss downward at the R Midclavicular line
beginning from an area of lung resonance and progressing
downward until a dull percussion sound indicates the
upper liver border (usually at the 5th to 7th interspace) .
Mark the site
o Measure the distance bet. the two marks (upper and
lower liver border) in cm to establish liver span or size
o Repeat at the Midsternal line

-o
o

6 to 12 cm in the Midclavicular line


4 to 8 cm in Midsternal line

V. Palpation of the Abdomen

Perform Light palpation first to


detect Areas of tenderness /
Muscle guarding

Warm the hands


Rationale: Cold hands can elicit muscle tension and thus impede

palpatory evaluation
o
o

Perform deep palpation

No tenderness
Relaxed abdomen w/ smooth, consistent tension

Palpate sensitive areas last


Check for rebound tenderness :
o
With one hand, press slowly and deeply over the area
indicated and then lift the hand quickly
o
If the client does not complain of pain during the deep
pressure but indicates pain at the release of the pressure
, rebound tenderness is present
o
Positive rebound tenderness can indicate peritoneal
inflammation and should be reported immediately

-o

Tenderness may be present near xiphoid process , over


cecum, and over sigmoid colon

o
VI. Palpation of the Liver
Palpate the liver to detect
enlargement and tenderness

2 Bimanual approaches are used in palpation of liver :


1. First Method
Place one hand along the anterior rib cage and the other hand
on the posterior rib cage
o Stand on the clients R side
o Place your L hand on the posterior thorax at about the
11th or 12th rib . This hand is used to push upward and
provide support of underlying structures for the
subsequent anterior palpation
o Place your R hand along the rib cage at about 45 degree
angle to the right of the rectus abdominis muscle or
parallel to the rectus muscle w/ the fingers pointing
toward the rib cage
o While the client exhales, exert a gradual and gentle
downward and forward pressure beneath the costal

margin until you reach a depth of 4 to 5 cm . During


expiration, abdominal wall relaxes, facilitating deep
palpation
Maintain your hand position, and ask client to inhale
deeply . This makes the liver border descend and moves
the liver into a palpable position
While the client inhales, feel the liver border move
against your hand. It should feel firm and have a regular
contour.
If you do not palpate the liver initially , ask the client to
take 2 or 3 more deep breaths while you maintain or
apply slightly more palpation or pressure

Livers are harder to palpate in obese, tense or very physically


fit people
If liver is enlarged , that is palpable below the costal margin :
o Measure the num. of cm it extends below the costal
region

2. Second Method
Bimanual palpation method in w/c one hand is superimposed on
the other
-o
o

May not be palpable


Border feels smooth

o
o
o

Enlarged (abnormal finding , even if liver


is smooth and tender)
Smooth but tender
Nodular or hard

VII. Palpation of the Bladder

Palpate the bladder

Palpate the area above the pubic symphysis if clients history


indicates possible urinary retention
o Not palpable

o
o

Distended
Palpable as smooth, round, tense mass
(indicates urinary retention)

THE MUSCULOSKELETAL SYSTEM


- Encompasses :
> Muscles
> Bones
> Joints
Tremor
- Involuntary trembling of a limb or body part
- May involve large groups of muscle fibers or small bundles of muscle fibers
Intention tremor
- Becomes more apparent when an individual attempts a voluntary movement
Resting tremor
- More apparent when client is at rest and diminishes w/ activity

Inquire if client has any history of the ff :


Presence of muscle pain
Loss of function w/o pain
Limitations to movement or inability to perform ADL
Previous sports injuries

I. Muscles

Assessment
Inspect muscle for size

Normal findings

Compare muscles on one side of the body to the same muscle on other
side
For any discrepancies, measure the muscles w/ a tape
o Equal size on both sides of body

Deviations
o
o
o

Atrophy (decrease in size)


Hypertrophy (increase in size)
Asymmetry

Inspect muscles and tendons for


contractures (shortening)

No contractures

Malposition of body part

Inspect muscles for tremors

No tremors

Presence of tremor

Palpate muscles at rest to


determine muscle tonicity (the
normal condition of tension, or tone
of a muscle at rest)

Normally firm

Atonic (lacking tone)

Palpate muscles while the client is


active and passive for flaccidity ,
spasticity and smoothness of
movement

Smooth coordinated movements

o
o

Flaccidity (weakness or laxness)


Spasticity (sudden involuntary
muscle contraction)

25 % or less of normal strength

Test Muscle strength :

Sternocleidomastoid
Client turns the head to one side against the resistance of your
hand
Repeat w/ the other side
Trapezius

Client shrugs the shoulders against the resistance of your hands


Deltoid
Client holds arm up and resists while you try to push it down
Biceps
Client fully extends each arm and tries to flex it while you attempt
to hold arm in extension

Triceps
Client flexes each arm and then tries to extend it against your
attempt to keep arm in flexion
Wrist and finger muscles
Client spreads the fingers and resists as you attempt to push the
fingers together
Grip strength
Client grasps your index and middle fingers while you try to pull
fingers out
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 bet. 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 leg
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
o

Equal strength on each body side

Inspect skeleton for structure

No deformities

Bones misaligned

Palpate the bones to locate any


areas of edema or tenderness

No tenderness or swelling

Presence of tenderness or swelling


(may indicate fracture, neoplasms or
osteoporosis)

o
o

No swelling
No tenderness, crepitation or nodules

o
o

One or more swollen joints


Presence of tenderness, swelling,
crepitation or nodules

Limited range of motion in one or


more joints

II. Bones

III. Joints

Inspect joint for swelling

Assess joint range of motion

Ask client to move selected body parts


Amount of joint movement can be measured by a goniometer , a
device that measures the angle of the joint in degrees
o
Varies to some degree in accordance w/ persons genetic
make up and degree of physical activity

LEVEL OF CONSCIOUSNESS : GLASGOW COMA SCALE


FACULTY MEASURED

Eye Opening

Motor Response

Verbal Response

RESPONSE

SCORE

Spontaneous

To verbal command

To pain

No response

To verbal command

To localized pain

Flexes and withdraws

Flexes abnormally

Extends abnormally

No response

Oriented, converses

Disoriented, converses

Uses inappropriate words

Makes incomprehensible sounds

No response

CRANIAL NERVE FUNCTIONS AND ASSESSMENT METHODS

CRANIAL NERVE

NAME

TYPE

FUNCTION

ASSESSMENT METHOD

Olfactory

Sensory

Smell

- Ask client to close eyes and


identify diff. mild aromas

Optic

Sensory

Vision and visual fields

- Ask client to read Snellentype chart ; Check visual fields


by confrontation, and conduct
an ophthalmoscopic
examination

Oculomotor

Motor

Extraocular eye movement

- Assess six ocular movements


and pupil reaction

II

III

Movement of sphincter of
pupil
Movement of ciliary muscles of
lens

IV
Trochlear

Motor

EOM
Moves eyeball downward &
laterally

- Assess six ocular movements

Sensation of cornea, skin of


face

- While client looks upward,


lightly touch the lateral sclera
of the eye w/ sterile gauze to
elicit blink reflex

V
Trigeminal

Sensory

Ophthalmic branch

To test light sensation : Have


client close eyes, wipe a wisp
of cotton over clients
forehead and paranasal sinuses
To test deep sensation : Use
alternating blunt and sharp
ends of a safety pin over same
areas
Maxillary branch

Sensory
Sensation of skin of face and
anterior oral cavity (tongue
and teeth)

- Assess skin sensation as for


ophthalmic branch above

Muscles of mastication
Sensation of skin of face

- Ask client to clench teeth

EOM
Moves eyeball laterally

- Assess directions of gaze

Facial expression
Taste (anterior 2/3 of tongue)

- Ask client to smile, raise the


eyebrows, frown, puff out

Mandibular branch
Motor and Sensory

VI
Abducens

Motor

Facial

Motor and Sensory

VII

cheeks, close eyes tightly.


Ask client to identify various
tastes placed on tip and sides
of tongue
Identify areas of taste
VIII
Auditory
Vestibular branch

Sensory

Equilibrium

- Romberg test

Cochlear branch

Sensory

Hearing

- Assess clients ability to hear


spoken word and vibrations of
tuning fork

Glossopharyngeal

Motor and Sensory

Swallowing ability
Tongue movement
Taste (posterior tongue)

- Apply tastes on posterior


tongue for identification

IX

Ask client to move tongue


from side to side and up and
down
X
Vagus

Motor and Sensory

Sensation of pharynx and


larynx
Swallowing
Vocal cord movement

- Assessed w/ cranial nerve IX


Assess clients speech for
hoarseness

XI
Accessory

Motor

Head movement
Shrugging of shoulders

- Ask client to shrug shoulders


against resistance from your
hands and turn head to side
against resistance from your
hand

Hypoglossal

Motor

Protrusion of tongue
Moves tongue up and down and
side to side

- Ask client to protrude


tongue at midline , then move
it side to side

XII

THE NEUROLOGIC SYSTEM


Major considerations determine the extent of a neurologic exam :
> Clients chief complaints
> Clients physical condition (LOC and ability to ambulate)
> Clients willingness to participate and cooperate
Examination of the neurologic system includes assessment of :
> Mental status including LOC
> Cranial nerves
> Reflexes
> Motor function
> Sensory function
MENTAL STATUS
- Reveals the clients general cerebral function (intellectual [cognitive] and emotional [affective])
- Major areas of mental status assessment :

Language

Aphasia
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
Categories :
I. Sensory or receptive aphasia
Loss of the ability to comprehend written or spoken words
2 types :
o Auditory aphasia have lost the ability to understand the symbolic content associated w/ sounds
o Visual aphasia have lost the ability to understand printed or written figures
II. Motor or expressive aphasia
Involves loss of the power to express oneself by writing, making signs or speaking
Pt have lost the ability to combine speech sounds into words

Orientation

Determines the :
Clients ability to recognize other persons
Awareness of when and where they presently are
Awareness of who they , themselves are

Memory
Nurse

Attention Span and


Calculation

LOC

assesses the clients recall of :


Information presented seconds previously (immediate recall)
Events or information from earlier in the day or examination (recent memory)
Knowledge recalled from months or years ago (remote or long-term memory)

Determines clients ability to focus on a mental task that is expected to be able to be performed by persons of normal
intelligence

Fully alert client


Responds to questions spontaneously
Comatose client
May not respond to verbal stimuli
Glasgow coma scale
Developed to predict recovery from a head injury
Used by many professionals to assess LOC
It tests 3 major areas :
o Eye response
o Motor response
o Verbal response
15 points : Indicates client is alert and completely oriented
7 or less : Comatose client

REFLEXES

An automatic response of body to stimulus


Not voluntarily learned or conscious
Tested using a percussion hammer

Deep tendon reflex (DTR)


Activated when a tendon is stimulated and its associated muscle contracts
Quality of a reflex response varies among individuals and by age

MOTOR FUNCTION

Neurologic assessment of motor system evaluates :


Proprioception function
Cerebellar function
Structures involved in proprioception :
Proprioceptors
Posterior columns of the spinal cord
Cerebellum
Vestibular apparatus (innervated by nerve VIII) in the labyrinth of the internal ear
Proprioceptors
Sensory nerve terminals occurring chiefly in muscles, joints, tendons and internal ear
Give information about movements and the position of the body
Stimuli from Proprioceptors travel through the posterior columns of the spinal cord
Deficits of function of the posterior columns of spinal cord result in impairment of muscle and position
sense
Cerebellum
Helps to control posture
Acts w/ the cerebral cortex to make body movements smooth and coordinated
Controls skeletal muscles to maintain equilibrium
SENSORY FUNCTION

Include

:
Touch
Position
Pain
Tactile disrimination
Temperature

Abnormal responses to touch stimuli :


Anesthesia : Loss of sensation
Hyperesthesia : More than normal sensation
Hypoesthesia : Less than normal sensation
Paresthesia : Abnormal sensation such as burning, pain or an electric shock
3 types of tactile discrimination are generally tested :
One-and two-point discrimination : Ability to sense whether one or two areas of the skin are being stimulated by
pressure
Stereognosis : Act of recognizing objects by touching and manipulating them
Extinction : Failure to perceive touch on one side of the body when two symmetric areas of the body are touched
simultaneously

Inquire if client has any history of the ff :


Presence of pain in the head, back or extremities
Disorientation to time, place, or person
Speech disorder
History of loss of consciousness, fainting, convulsions, trauma , tingling or numbness, tremors, limping, paralysis,
uncontrolled muscle movements, loss of memory, mood swings, or problems w/ smell, vision, taste, touch or
hearing

I. Language
II. Orientation
- Determine clients orientation to person, time and place
III. Memory
- Assess immediate recall , recent memory, and remote memory
IV. Attention Span and calculation
V. Level of consciousness
- Apply the Glasgow coma scale
VI. Cranial Nerves
VII. Reflexes
- Test reflexes using a percussion hammer
- Compare one side of the body w/ the other
- Evaluate the symmetry of response :
O No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity
1. Biceps reflex tests the spinal cord level C-5 , C-6
2. Triceps reflex tests the spinal cord level C-7, C-8
3. Brachioradialis reflex tests the spinal cord level C-5, C6
4. Patellar reflex tests the spinal cord level L-2, L-3, L-4
5. Achilles reflex tests the spinal cord level S-1, S-2
6. Plantar (Babinski) reflex is superficial ; may be absent in adults w/o pathology, or overridden by voluntary control
VIII. Motor Function

Gross Motor and Balance tests

Walking Gait
Ask the client to walk across the room and back, and assess the
clients gait
o
Has upright posture and steady gait w/ opposing arm swing
o
Walks unaided
o
Maintaining balance
Romberg Test
Ask the client to stand w/ feet together and arms resting at the
sides, first w/ eyes open , then closed
Stand close during this test to prevent the client from falling
o
Negative Romberg : may sway slightly but is able to maintain
upright posture and foot stance

o
o
o
o

Has poor posture


Unsteady, irregular, staggering
gait w/ wide stance
Bends legs only from hips
Has rigid or no arm movements

-o

Positive Romberg : cannot maintain


foot stance , moves the feet apart
to maintain stance
If client cannot maintain balance
w/ the eyes shut , client may have
sensory ataxia (lack of

Standing on One foot w/ Eyes Closed


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
o Maintains stance for at least 5 sec.
Heel-Toe-Walking
Ask the client to walk a straight-line, placing the heel of one foot
directly in front of the toes of the other foot
o Maintains heel-toe-walking along a straight line

Toe or Heel Walking


Ask the client to walk several steps on the toes and then on the heels
o Able to walk several steps on toes or heels

Fine Motor Tests for the Upper


Extremities

coordination of the voluntary


muscles)
If balance cannot be maintained
whether the eyes are open, client
may have cerebral ataxia

Cannot maintain stance for 5 sec.

Assumes a wider foot gait to stay


upright

Cannot maintain balance on toes


and heels

Misses the nose or gives slow


response

Performs w/ slow , clumsy


movements and irregular timing
Has difficulty alternating from
supination to pronation

--

--

--

Finger-To-Nose Tests
Ask the client to abduct and extend the arms at shoulder height and
then rapidly touch the nose alternately w/ one index finger and then
the other
The client repeats the test w/ eyes closed if the test is performed
easily
o Repeatedly and rhythmically touches the nose

Alternating Supination and Pronation of Hands on Knees


Ask the client to pat both knees w/ the palms of the hands and then
w/ the back of the hands alternately at an ever increasing rate
-o

Can alternately supinate and pronate hands at rapid pace

o
Finger to Nose and to the Nurses finger
Ask the client to touch the nose and then your index finger , held at
a distance of about 45 cm at a rapid and increasing rate
o Performs w/ coordination and rapidity

-o

Misses the finger and moves slowly

Moves slowly and is unable to touch


fingers consistently

Cannot coordinate this fine


discrete movement w/ either one
or both hands

o
o

Has tremors or is awkward


Heel moves off shin

Fingers to Fingers
Ask the client to spread the arms broadly at shoulder height and
then bring the fingers together at the midline , first w/ eyes open
and then closed, first slowly and then rapidly
-o

Performs w/ accuracy and rapidity

Fingers to Thumb (Same hand)


Ask the client to touch each finger of one hand to the thumb of the
same hand as rapidly as possible
o Rapidly touches each finger to thumb w/ each hand

Fine Motor Tests for the Lower


Extremities

Ask the client to lie supine


Heel down Opposite Shin
Ask the client to place the heel of one foot just the below the
opposite knee and run the heel down the shin to the foot
Repeat w/ the other foot
The client may also use a sitting position for this test
o Demonstrates bilateral equal coordination

--

Toe or Ball of Foot to the Nurses finger


Ask the client to touch your finger w/ the large toe of each foot
o Moves smoothly, w/ coordination

-o
o

Misses your finger


Cannot coordinate movement

Light Touch Sensation

Light tickling or touch sensation

o
o
o
o

Anesthesia
Hyperesthesia
Hypoesthesia
Paresthesia

Pain sensation

Able to discriminate sharp and dull sensations

Areas of reduced , heightened or


absent sensation

Temperature sensation

Able to discriminate bet. hot and cold sensations

Areas of dulled or lost sensation


(when sensations of pain are dulled,
temp. sense is usually also impaired
because distribution of these
nerves over the body is similar

Position or kinesthetic sensation

Can readily determine the position of fingers and toes

Unable to determine the position


of one or more fingers or toes

Unable to sense whether one or


two areas of the skin are being
stimulated by pressure

Unable to recognize common


objects

Failure to perceive touch on one


side of the body when two
symmetric areas of the body are
touched simultaneously

Tactile discrimination

- For all tests, clients eyes need to be closed

ONE- AND TWO-POINT DISCRIMINATION


Alternately stimulate the skin w/ 2 pins simultaneously and then w/
one pin
Ask whether client feels one or two pins
o
Perception varies widely in adults over different parts of the
body
o
Normally , a person can distinguish bet. a one-and two-point
stimulus w/ the following minimum distances :
Fingertips , 2.8 mm
Palms of the hands , 8-12 mm
Chest, forearm , 40 mm
Back , 50-70 mm
Upper arm, thigh, 75 mm
Toes , 3-8 mm
-STEREOGNOSIS (ability to recognize objects by touching them)
o
Recognizes common objects

EXTINCTION PHENOMENON
Simultaneously stimulate two symmetric areas of the body , such as
thighs , the cheeks or the hands
o
Both points of stimulus are felt

--

THE MALE GENITALS and INGUINAL AREA


Hernia
- Protrusion of the intestine through the inguinal wall or canal
Cancer of the prostate gland
- Most common cancer in adult men
- Occurs primarily in men over age 50
Testicular cancer
- Much rarer than prostate cancer
- Occurs primarily in young men ages 15 to 35
- Most commonly found on anterior and lateral surfaces of the testes

Inquire

if client has any history of the ff :


Usual voiding patterns and changes
Symptoms of STD
Bladder control
Swellings that could indicate presence of hernia
Urinary incontinence
Family history of nephritis
Abdominal pain
Malignancy of the prostate
Malignancy of the kidney

I. Pubic Hair
Assessment
Distribution , Amount , and
Characteristics

Normal findings

Deviations

Triangular distribution , often spreading up the


abdomen

o
o

Scant amount
Absence of hair

Inspect the penile shaft and glans


penis for lesions , nodules, swellings ,
and inflammation

Penile skin intact, appears slightly wrinkled and varies


in color as widely as other body skin
Foreskin easily retractable from the glans penis
Small amount of thick white smegma between the glans
and foreskin

o
o
o
o

Lesions
Nodules
Swelling
Inflammation

Inspect the urethral meatus for


swelling , inflammation and discharge

o
o

Pink and slitlike appearance


Positioned at the tip of the penis

o
o
o

Inflammation
Discharge
Variation in meatal locations (e.g
hypospadias [on the underside of the
penile shaft] and epispadias [on the upper
side of the penile shaft])

Palpate the penis for tenderness,


thickening, and nodules

o
o
o

Smooth
Semifirm
Slightly movable over the underlying structures

o
o
o
o

Tenderness
Thickening
Nodules
Immobility

II.

Penis

III. Scrotum

o
o

Appearance, General size and


symmetry

o
o
o
o

Palpate to assess status of underlying


testes, Epididymis, and spermatic cord

Scrotal skin is darker in color than that of the rest of


the body
Loose
Size varies w/ the temperature changes
Appears asymmetric ( L testis is usually lower than R
testis)

o
o
o

Discolorations
Any tightening of skin (may indicate
edema or mass)
Marked asymmetry in size

Testes
During assessment of male adolescents , note the
undescended testes
Epididymis
Located at the top of the testis and extends behind it
Spermatic cord
Found at the top lateral portion of the scrotum and feels
firm
If swelling or irregularities are detected:
Attempt to Transilluminate the lesion
Done by darkening the room and shining a flashlight behind
the scrotum through the mass
Rationale: Serous fluid causes the light to show a red glow ;

Tissue or blood does not transilluminate

Describe all scrotal masses in terms of :


Size
Placement
Tenderness
Shape
Consistency
Presence of transillumination
o
o
o
o

Testicles are rubbery, smooth, and free of nodules and


masses
Testis is about 2 x 4 cm
Epididymis is resilient, normally tender and softer
than the spermatic cord
Spermatic cord is firm

o
o

Testicles are enlarged , w/ uneven


surface (possible tumor)
Epididymis is nonresilient and painful

IV. Inguinal Area

Inspect for bulges while the client is standing


First, have the client remain at rest
Next, have the client hold his breath and train or bear
down as though having a bowel movement . Bearing down
may make the hernia more visible
o
No swelling or bulges

Swelling or bulge (possible inguinal or


femoral hernia)

THE FEMALE GENITALS and INGUINAL AREA


Papanicolaou test (Pap test)
- Used to detect cancer of the cervix
Specimens should be taken
- If there is an increased or abnormal vaginal discharge
- To check for STD
Examination of the internal genitals involves :

Inquire

Palpating the Skenes and Bartholins glands


Assessing the pelvic musculature
Inserting a vaginal speculum to inspect cervix and vagina
Obtaining a Papanicolaou test

regarding the ff :
Age of onset of menstruation
Whether menstruation is painful
Number of live births
Painful urination
LMP
Incidence of pain during intercourse
Labor or delivery complications
Incontinence
Regularity of cycle
Vaginal discharge
Urgency and Frequency of urination at night
Duration and Amount of daily flow
Number of pregnancies
Blood in urine
History of STD

Position the client :


Supine w/ feet elevated on stirrups
Alternatively , Dorsal recumbent position

Assessment

Normal findings

Inspect the distribution , amount and


characteristics of pubic hair

Deviations

o
o
o
o

There are wide variations


Generally kinky in the menstruating adult
Thinner and straighter after menopause
Distributed in the shape of an inverse triangle

Inspect the skin of the pubic area for


parasites, inflammation, swelling, and
lesions

o
o
o
o

Pubic skin intact


No lesions
Skin of vulva area slightly darker than the rest of the body
Labia round , full and relatively symmetric in adult females

o
o
o
o
o
o
o
o
o

Lice
Lesions
Scars
Fissures
Swelling
Erythema
Excoriations
Varicosities
Leukoplakia

Inspect the clitoris, urethral orifice ,


and vaginal orifice , when separating
the labia minora

o
o

Clitoris does not exceed 1 cm in width and 2 cm in length


Urethral orifice appears as a small slit and is the same color as
surrounding tissues
No inflammation, swelling or discharge

o
o
o
o

Lesions
Inflammation
Swelling
Discharge

Enlargement and tenderness

Palpate the inguinal lymph nodes

Scant pubic hair (may indicate


hormonal problem)
Hair growth should not extend
over the abdomen

Use the pads of fingers in a rotary motion


Note any enlargement or tenderness
o

No enlargement or tenderness

THE RECTUM and ANUS


- Physical examination involves inspection and palpation
- Extent of assessment depends on the rectal problems stated by the client

Digital examination can cause apprehension and embarrassment in pt, help the client relax by encouraging the client to
take a slow , deep breaths because tension can cause spasms of the anal sphincter making the examination
uncomfortable
Inform the client about potential sensations such as feelings of defecation or passing gas
Drape client appropriately

Inquire if client any history of the ff :


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 results
In males, if not obtained during genitourinary examination, the signs and symptoms of prostate enlargement (e.g slow
urinary stream, hesistance, frequency, dribbling, and nocturia)
Position the client :

Left lateral or Sims position (adult)


Dorsal recumbent (female)
Standing position while the client bends over the examining table (males)

Assessment
Inspect anus and surrounding tissue
for color, integrity, and skin lesions

Normal findings

Palpate the rectum for anal


sphincter tonicity , nodules, masses
and tenderness

Ask the client to bear down as though defecating because


bearing down creates slight pressure on the skin that may
accentuate rectal fissures, rectal prolapse, polyps or internal
hemorrhoids
Describe the location of all abnormal findings in terms of a clock,
w/ the 12 oclock position toward the pubic symphysis
o
Intact perineal skin
o
Usually slightly more pigmented than the skin of the
buttocks
o
Anal skin is normally more pigmented , coarser, and
moister than perineal skin
o
Usually hairless

Deviations
Presence of
o
Fissures
o
Ulcers
o
Excoriations
o
Inflammations
o
Abscesses
o
Protruding hemorrhoids (dilated veins
seen as reddened protrusions of the
skin)
o
Lumps
o
Tumors
o
Fistula openings
o
Rectal prolapse (varying degrees of
protrusion of the rectal mucous
membrane through the anus)

Lubricate your gloved index finger


Instruct the client to bear downward as though having a bowel
movement
Rationale: This relaxes the anal sphincter

Slowly insert your finger into the anus and rectum in the
direction of the umbilicus
o
The anal canal (distance from the anal opening to the
anorectal junction) is short (less than 3 cm /about 1 inch)
o
The posterior wall of the rectum follows the curve of the
coccyx and sacrum
o
Nurses finger is usually able to palpate a distance of 6 to
10 cm (2 to 4 in)
Never force digital insertion . If lesions are painful or bleeding
occurs, discontinue the examination
o

Anal sphincter has good tone

Ask the client to tighten the anal sphincter around your finger
and note the tone of the anal sphincter

Hypertonicity of the anal sphincter


(may occur in the presence of an anal
fissure or other lesion that causes
contraction)
Hypotonicity of anal sphincter (may
occur after rectal surgery or result
from a neurologic deficiency )

On withdrawing the finger from


rectum and anus, observe it for
feces

Rotate the pad of index finger along the canal and rectal walls ,
feeling for nodules, masses and tenderness
Note the location of any abnormalities of the rectum
o
Rectal wall is smooth and not tender

If ordered, perform a test for occult blood on the stool


o
Brown color

Rectal wall is tender and nodular

Presence of mucus, blood or black tarry


stool