Ashley Jane C.

Macapayad NCM 101- RLEF

BSN 1- NF

ACTION & RATIONALE NORMAL FINDINGS ABNORMAL FINDINGS

- The lack of information provided

1. Explain the purpose and
procedure.
R: Providing information
fosters his/her cooperation
and allays anxiety.
- The patient shows will make the patient feel restless,
complete readiness and and may decline the procedure.
alertness.
- Patient is unprepared and shows
- The patient is fully aware self-distrust for the procedures
and informed of the and activities that will be
following procedures conducted to him
that will be conducted to
him.

2. Close doors and put screen.
R: To provide privacy.
- The lack of privacy makes the
- Patient shows that he is patient feel anxious and conscious
comfortable since at the same time which can lead to
inaccuracy of findings.
privacy is provided and
could help encourage the
patient. - Patient shows signs that he feels
ashamed or embarrassed
- When dignity is
present people feel in
control, valued,
confident, comfortable
and able to make
decisions for themselves.

3. Encourage the client to

The patient is able to perform the
empty bladder.
process that should be done and
R: A full bladder makes The patient will feel uncomfortable and
is comfortable; and as a result,
him/her uncomfortable. could also alter the results.
accurate and normal results will
show.
4. Perform physical
examination.
A. General
Examination
Assess overall body
appearance and mental status.
Inspection
Observe the client’s ability to
respond to verbal commands.
R: Responses indicate the
client’s speech and cognitive
function.
Appearance Appearance
● Hygiene: clean, good ● Hygiene: bad body odor
body odor, shaven, ● Dress: dirty, ragged
grooming ● Other: Prominent scars
● Dress: clean, neat,
climate appropriate
Speech
•General: stuttering, lisp
•Rate: fast
Speech
•Volume: loud, very soft
● General: clarity
•Intonations: decreased
● Rate: normal
● Volume: normal
Behavior
● Intonations: normal •Eye contact: decreased, excessive

Thinking
Behavior Thought Content
•Eye contact: normal •Suicidal ideation
•Fearful
Thinking •Homicidal ideation
Thought Processes

● Logical, goal oriented

Thought Content
● Future oriented

5. Observe the client’s level The client is fully awake and Client has lowered LOC and shows
of consciousness (LOC) and alert: eyes are open and follow irritability, short attention span, or unable
orientation. Ask the client topeople or objects. The client is to follow simple commands or answer
state his/her own name, attentive to questions and simple questions. At lowered LOC, he or
current location, and responds promptly and accurately she may respond to physical stimuli only
approximate day, month, or to commands; he or she moves (such as deep pain). The lowest extreme is
year. willingly. If the client has been deep coma, when the eyes are closed and
R: Responses indicate the sleeping, he or she responds to the client fails to respond to verbal or
client’s brain function. LOC verbal or physical stimuli and physical stimuli, with no voluntary
is the degree of awareness of demonstrates wakefulness and movements. If LOC is below full awareness
environmental stimuli. It alertness. The client is aware of but above coma, objectively note the
varies from full wakefulness who he or she is (orientation to client’s eye movements, respond to
and alertness to coma. person), where he or she is commands and type of movement:
Orientation is a measure of (orientation to place), when it is voluntary, withdrawal to stimuli or
cognitive function or the (orientation to time) withdrawal to noxious stimuli (pain) only.
ability to think and reason.
6.Observe client’s ability to
think, remember, process
information and
communicate.
R: These processes indicate
cognitive functioning. Inspect
articulation on speech style
and contents of speaking.
The client is able to follow
commands and repeat and
remember information. He or she
is able to see and identify objects
within the room.
Abnormal findings include dysphasia
(difficulty in understanding or expressing
language), dysarthria (inability to speak),
memory loss, disorientation, or
hallucinations. The client may also be
voluntarily mute (in psychiatry).

7.Observe the client’s ability The client can hear even though
to see, hear, smell and the speaker turns away. He or she
distinguish tactile sensations. identifies objects or reads a clock
in the room, and distinguishes
between sharp and soft objects.
The nose is centered; the ears are
symmetrical on the sides of the
head; the lids open and close in
command.
The client cannot hear low or very high
tones and must look directly at the speaker
to distinguish what is being said. He or she
cannot read a clock or distinguish sharp
from soft. Eyes, ears, nose, or mouth are
asymmetrically placed. Redness or swelling
appears around the eyelids or eyes.
Excessive tears, exudate (abnormal
drainage from eyes or ears), or
conjunctivitis (redness of eyes) is present.

8.Observe signs of distress. R: Well developed, well nourished,

Alert the examiner to
immediate concerns. If you
note distress, the client may
require healthcare
interventions before you
continue the exam.
9. Observe facial expression
and mood.
R: These could be
affected by disease or
ill condition.
Development of inappropriate or bizarre
alert and cooperative, and appears
responses, such as talking off the subject
to be in no acute distress.
and rambling or laughing inappropriately.
Changes from a person’s previous
behavior.
More generally tense, sad, or disheveled
appearance
Abrupt change in mood (often with
irritability/agitation) in times of acute
distress
Eyes are closed or averted. The client is
Eyes are alert and in contact with frowning or grimacing. He or she is unable
the examiner, as is culturally or unwilling to answer questions, avoids
appropriate. The client smiles or answering, or is fidgety, and appears
frowns appropriately and has a anxious. Note if the client does not speak
calm demeanor. The client is able English.
to converse easily. Note if the
client needs an interpreter.

Posture is upright. Gait is smooth Posture is stooped or twisted. Limbs

10. Observe general
and equal for the client’s age and movements are uneven or unilateral.
appearance: posture, gait, and
development. Client is limping.
movement.
Limb movements are bilateral.
R: To identify obvious
changes.
11. Observe grooming, Clothing reflects gender, age, and The client wears unusual clothing for
personal hygiene, and dress. climate. Hair, skin, and clothing gender, age, or climate. Hair is unkept.
R: Personal appearance can are clean, groomed, and Excessive oil or perspiration is on the skin.
indicate self-comfort. appropriate for the occasion. Body odor is present.
Grooming suggests his/her Body or mouth odor is absent.
ability to perform self-care.
 Dwarfism
12. M easurement Proportionate, varies with
lifestyle Adult height ranging from 3 feet (91 cm) to
● Height
just over 4 feet (122 cm)
1. Ask the client to
Gigantism
remove shoes and stand with
his/her back and heels Adult height ranging from
touching the wall.
2. Place a pencil flat 7 to 9 ft (2.1 to 2.7 m) in h eight.
on his/her head so that it
makes a mark on the wall. 3.
This shows his/her
height measured with cm tape
(or if available, measure the
height with measuring scale).

13. Weight depends on the age and the

· Weight Weight is dependent with the age patient’s lifestyle.
Weight also varies with lifestyle
him/her Obesity, emaciation (physical wasting of
without shoes tissue) , or uneven fat distribution over the
and clothing client’s trunk is observed. Client reports
significant unintentional weight gain/loss in
short time.

14. Take Vital signs RANGES IN ADULTS:

● Temperature Temperature
Blood pressure: 90/60 mm Hg to
● Pulse ● Above 38 degrees may result to
120/80 mm Hg
● Respiration pyrexia
● Blood pressure ● Below 36 degrees may result to
hypothermia
R: vital signs provide baseline
Breathing: 12 to 20 breaths per
minute
Pulse
● Above 100 beats per minute is
tachycardia
Pulse: 60 to 100 beats per minute ● Below 6o beats per minute
bradycardia

Blood pressure
Temperature: 97.8°F to 99.1°F ● Greater than 120 is hypertension
(36.5°C to 37.3°C)/average ● BP falls to 90 mm Hg and below
98.6°F (37°C) is hypotension

Breathing
● If higher than 20 breaths per
minute, patient may have
hyperoxia which is excessive
oxygen supply
● If lower than 12 breaths per
minute patient may have hypoxia
which is insufficient oxygen
 B. Skin Assessment Asses
integumentary structures
(skin,hair, nails)
and function
SKIN
Inspection and Palpation
15. Inspect the back and
palms of the client’s hands
for skin color. Compare the
right and left sides. Make
similar inspection of feet
and toes, comparing the
right and left sides R:
Extremities indicate
peripheral cardiovascular
function
16. Palpate the skin on the
back and palms of the client’s scaliness and the skin thickness is texture and skin is not supple
hands for moisture,texture.
17. Palpate the skin’s Skin is normally warm in
temperature with the back of temperature
your hand.
SKIN SKIN
● skin is not dry or oily ● Dry, oil, excessive sweating
and there is no ● Vascular lesions or erythema
excessive sweating
NAILS
● No vascular lesions or ● blemishes or discolour
erythema are observed ● Cracks
● Skin and nails occur changes
NAILS
●
Pink and transparent HAIR
without blemishes or ● Brittle, hair fall
discolouring
●
Smooth and
paliable,convex
without cracks
●
Curves are pulling
away from the corners
●
Skin around nails
shows no changes and
nails looks well cared
HAIR
●
No recent changes of
characteristics of the
hair
●
Hair is shiny and not
brittle
Skin is smooth, there is no S kin is not smooth may be scaliness in the
normal
The skin is supple and there are
no observable signs of
dehydration or oedema
Increase skin temperature is often
accompanied by localized erythema or
redness in the skin.
Reduction in skin temperature often
accompanies by pallor and reflects a
decrease on blood flow.
18. Pinch and release the skin
on the back of the client’s
hand.
R: This palpation indicates
the degree of hydration and
turgor.
19. Press suspected
edematous areas with the
edge of your fingers for 10
seconds and observe for the
depression.
20. Inspect the skin for
lesions. Note the appearance, age-related changes such as skin
size location, presence, and tags or senile keratosis, cherry
appearance of drainage.
R : Locate abnormal cell
growths or trauma that
suggests abnormal
physiologic processes.
N AIL
21. Inspect and palpate the
fingernails and toenails. Note
color, shape and lesions.
Skin turgor is the skin's elasticity.
It is the ability of skin to change
shape and return to normal. Skin
with normal turgor snaps rapidly
spring back to its normal position
with a second or two.
When pressure from finger leaves
skin surface, no depression or pit When pressure from your finger leaves skin
will occur and skin will resume surface, a depression will occur known as
its original form
Skin is normally free of lesions
except for common freckles or
angiomas and atrophic warts.
Pink tones; normally a 160-
degree angle between
the nail base and the skin;
smooth; immobile
The skin is excessively dry or flaking.
Moisture, perspiration (diaphoresis).
Pinched skin is very slow to return to
normal position. Slow return of skin to
normal position often indicates
dryness(dehydration).
pitting edema, indicating the presence of
edema.
depth of pitting (in mm) determines degree
of edema
There are two categories of skin lesions that
are known; primary and secondary skin
lesions. Primary Lesions: this includes
skin conditions that are apparent at birth or
are developed over an individual’s lifetime
such as:
birthmarks & macules or flat moles.
Secondary Lesions: occur when primary
skin lesions have been irritated. An
example of this is if an individual were to
scratch a mole until bled, a secondary skin
lesion, crust, would develop. This includes:
- Scars
- Skin ulcer (bacterial infection)
- Crust (scab created by dry blood)
- Scale (areas of skin where skin
cells culminate and then drop off
of the skin)
Spoon shape, in which the nail curves
upward from the nail bed
22.Check capillary refill by
pressing the nail edge to
blanch and release pressure
quickly, noting the return of
color.
HAIR and SCALP
23. Inspect the hair for
color, texture, growth,
distribution.
Used to monitor
DEHYDRATION and the
amount of BLOOD FLOW to
tissue.
-If there is good blood flow to the
nail bed, a pink color should
return in less than 2 seconds
(adults) after pressure is removed
- Natural hair color and
shiny appearance. The
color depends by the
amount of melanin
present Smooth texture
Growth of hair is
around half an inch
- a month Hair is
evenly distributed
-
- deficiency, commonly of protein or
Capillary refill time of more than 2 seconds
indicates poor perfusion due to peripheral
vasoconstriction, which is also an indicator
for peripheral vascular disease (PVD). CRT
of more than 2 seconds shows a response to
poor low circulating blood volume and
reduced oxygen delivery to vital tissues,
such as patients in shock, are hypovolemic
or dehydrated. CRT of less than 1 second
is suggestive of a hyperdynamic state and
vasodilation such as in cases of
hyperthermia, heat stroke or systemic
inflammation.
Excessive Dandruff
-dead, scaly flakes of epidermal cells;
occurs with psoriasis or seborrheic
dermatitis. Dandruff should be
distinguished from head lice.
Gray Hair
-May be influenced by genetics and may
begin as early as the late teens; graying in
patches may indicate a nutritional
copper.
Pediculosis capitis
-head lice; signaled by tiny, white, oval
eggs (nits) that adhere to the hair shaft.
 24. Inspect the scaly, lumps,
nevi or other lesions.
-
- scaly, lumps, and other
B. Head and Neck
Assessment
Assess central neurologic
function, vision, hearing and
mouth structures.
SKULL
25. Observe for the size,
shape and symmetry.
- - clump together to form white or
grey flakes of dandruff
- shade of brown to black,
congenital melanocytic nevi can
The scalp is normally be reddish.
smooth and inelastic
with even coloration.
By carefully separating
strands of hair,
thoroughly examine the
scalp for lumps,nevi or
other lesions. The
lesions should be
present, if lumps and
bruises are found, ask if
the patient has
experience recent head
traumas.
• An abnormally small head is
called microcephaly, while an enlarged
head is called macrocephaly.
- Round • The skull and facial bones are
(normocephalic and larger and thicker in acromegaly
symmetric with frontal,
parietal, and occipital • Acorn-shaped, enlarged skull
prominences), erect, and bones are seen in Paget disease of the bone.
in midline and
appropriately related to
body size
- no lesion are
visible
- smooth skull contour
26. Palpate and note any
deformities, depression,
lumps or tenderness.
FACE
27. Inspect the client’s facial consistency and with no presence
expression, asymmetry,
involuntary movements,
edema and masses.
EYES
28. Position:
Stand in front of the client
and inspect both eyes for
position and alignment.
29. Eyebrows:
Inspect the eyebrow, noting
their quantity and distribution
and any scaliness.
30. Eyelids:
Inspect the position, presence No redness, swelling or lesions. abnormal blinking or twitching.
of edema and masses.
There are no signs of injury
which may occur as a depression -For babies soft spots should be relatively
or a prominent lump on the firm and curve ever so slightly inward. A
surface. There should be no pain
soft spot with a noticeable inward curve is
felt upon palpation having
applied light to moderate pressure known as a sunken fontanel. This condition
on the surface. There are no requires immediate medical attention.
abnormal bone growths felt on
the surface and should follow the
normal anatomy and surface -Abnormal growth or swelling of bone. The
structure. Sutures, prominent the skull becomes enlarged, brittle and
areas, and major cranial bones warped. It is a sign of Fibrous dysplasia.
must be symmetrical without any This rare disorder is usually diagnosed in
unusual alteration on one or either childhood or early adulthood and can affect
side. Rigidity should be normal one or several bones.
and
having no signs of softening.
The face of the client appeared When there is asymmetrical facial
smooth and has uniform movement such as drooping of eyelids and
mouth, involuntary facial movement,
of nodules or masses. sebaceous cyst, local deformities from
trauma, or masses and nodules.
Eyeballs are symmetrical in size If the reflex on one eye is more medial, the
and position. The eyeballs are in patient may have e xotropia; if more lateral,
the same plane as eyebrow and the patient may have e sotropia . To
maxilla. evaluate position, inspect for outward
deviation, called e xophthalmos.
Eyebrows and eyelashes concur
Total absence of eyebrows and lashes can
with patient’s age and genetic
be due to illness, inheritance, or it can
history. There is no absence of
indicate serious neurotic behavior in that
pigment and no infection of the
the patient in unconsciously plucking them
hair follicles.
out. Observe possible infections of the
eyelash follicles.
Eyelids that turn in or out, droop or has
The eyelids shut completely and
there is no evidence of of ptosis,
ectropion or entropion. The eyes
blink six to ten times a minute.
31. Lacrimal apparatus: No swelling or tenderness of the There is an inflammation of the lacrimal
● Inspect the region lacrimal sac and gland are gland and sac; irregular and excessive
of the lacrimal gland present. No discharge from the tearing.
and lacrimal sac for lacrimal sac, and lacrimation is
swelling. normal.
● Look for excessive
tearing or dryness of
the eye.

32. Conjunctiva and Sclera: Conjunctiva

● Expose the sclera -Moist, shinny, smooth
and conjunctiva. and pink or red Conjunctiva
● Inspect the color of Sclera -Extremely pale (posible anemia) -
palpebral -appears white, moist, and no Extremely red (Inflammation) -Nodules or
conjunctiva, vascular lesions other lesions.
pattern against the Sclera
white scleral -Jaundiced sclera (Liver Disease)
background and any -Excessively Pale sclera (Anemia) -
nodules or swelling. Reddened sclera; lesions or nodules (may
indicate damage by mechanical, chemical,
allergic, or bacterial agents)

33. Cornea and Lens: With CORNEA

oblique lighting, inspect the
cornea of each eye for
opacities in the lens.
LENS
- the cornea should have a
lustrous surface and be
crystal clear, allowing a (Cornea)
crisp
and lucid view of
the iris
- Clear, bright, smooth
surface
- Lens is bright, even red
reflex.
- Cloudy (iris may be
difficult to see)
- Scarring (milky line, localised
capacity)
- Foreign body (objects like metal,
glass, plastic, sand and etc. either
superficially adherent to or
embedded in the cornea)
- Rust ring (when a metal
particle is stuck in the cornea, the
metal particle could have been
removed but tears caused the
metal to rust and form a stain in
the cornea)
- Corneal ulcer (painful, red eye
with mild to severe eye discharge
and reduced
vision)
- Laceration
- Dendritic (shaped like a tree)
Ulcer
 Abnormal Findings (Lens)
- Dull or absent red reflex (suggests
sight-threatening pathology called
cataract)
- White pupil or Leukocoria
(abnormal light reflection in the
eye)
- Shadows in red reflex

34. Pupils: The eyes do not turn inwards or Pupils are unequal in size and are not
Inspect the size, shape, and outwards and there is no visible symmetrical in shape and position.
compare symmetry. prominence. Both pupils should
be the same shape and size.

35. Pupillary response to The pupils constrict to direct The pupil is abnormal if it fails to dilate to
light: illumination (direct response) and the dark or fails to constrict to light or
● Ask the client to to illumination of the opposite accommodation.
look into distance eye (consensual response). The
and light a penlight pupil dilates in the dark. Both
from the side of the pupils constrict when the eye is
eye. focused on a near object
(accommodative response).
● Remove it on the
other side to observe
how pupil reacts.
● Repeat other side
with same procedure.

36. Coordination of eye Both eyes should be able to Both or one of the eyes will have difficulty
movements: smoothly follow the object focusing on the object and following its
● Hold an object at a without difficulty. path. Eye movements can be asymmetrical.
distance from the client.
● Ask him/her to
keep his/her head
still and follow the
object with the eyes
only.
● Move the object
towards his/her right
and left eye, then
towards the ceiling
and floor.

37. Convergence test: The eyes move together and be ● Isolated lesions of a cranial nerve
● Ask the client to able to easily and smoothly ● Strabismus - “cross-eyes” present
follow your finger or follow the finger. or eye movement asymmetrical.
a pencil as you move
it in towards the
● Eyelids are dropping or have
bridge of the nose. asymmetrical movements.
38. Snellen Eye Chart Test: Pupils are able to see objects both ● Diplopia (double vision) or
● Use the Snellen near and far away. blurring of vision.
Eye Chart, which
includes objects, Pupils are equal, round and
letters or numbers of responsive to light. ● Pupils are unequal and/or
different sizes in unresponsive or sluggishly
rows, under well- responsive to light .
light.
● Position the client
20 ft from the chart
and ask the client to
identify the items.
● Compare the visual
acuity of the client
with normal vision.

EAR & HEARING
39. Using otoscope,
hold the helix, gently pull the
pinna upward and backward
toward the occiput.
40. Gently insert the
otoscope and examine the
ear.
Auditory canal Pinna and Post Auricular Area
● Some hair, often with ● Obvious deformities or abnormal
yellow to brown cartilaginous fragments
cerumen. ● Scars or skin changes
o Including for skin malignancies ●
Tympanic Membrane Signs of inflammation
● Lateral process of
malleus o An inflamed mastoid may push
● Cone of light the pinna forward

● Pars tensa and pars a) erythema – suppurative Otitis

flaccida Media. purulent drainage.

b) Dull, non transparent gray –

serous otitis media with effusion

Abnormal Tympanic Membrane

● Perforations
● Tympanosclerosis
● Red and bulging membrane
● Retraction of the membrane
41. Inspect the pinna, external
canal, tympanic membrane,
landmarks
(lobules, helix, antihelix,
tragus, triangular fossa,
mastoid process)
Pinna - abnormal shape or position of the
outer ear (pinna or auricle).
External Canal - Patient has
external otitis which is an acute infection of
Pinna - no deformity or skin
the ear canal skin caused by bacteria
changes.
Tympanic Membrane - Patient
External Canal - has some hair,
positive for myringitis because of inflamed
often lined with yellow to brown
TM
wax. Tympanic Membrane -
pearly grey, shiny, translucent,
with no bulging or retraction.
Lateral process of malleus.

pearly grey, shiny, translucent,

with no bulging or retraction

42. Palpate the pinna for There is no swelling. It is not hot

tenderness, consistency of the and painful when touched. Mastoiditis - mucosal lining become
cartilage, and swelling. reddened, swollen, hot, and often painful
Auricular hematoma - cauliflower ear

43. Voice Test Able to correctly repeat Ototoxicity - a drug or chemical-related

○ Test one the two-syllable word as damage to the inner ear, resulting in
ear at a whispered within two tries: damage to the organs responsible for
time. doesn’t indicate hearing hearing and balance.
○ Stay loss and isn’t required to
30-60 cm do a follow-up testing by Unilateral hearing loss (single sided
from an audiologist. deafness) - c aused by viral infections,
Meniere's disease, head or ear injuries, or
client’s ear. through surgical intervention to remove
○ Whisper brain tumours.
slowly
some two
syllable
words.
44.Do mechanical testing: Weber test :
WEBER and RINNE WEBER TEST:
Testing.
- Vibrations are heard ● Conductive loss will cause the
WEBER TEST: to assess equally well in both ears. No sound to be heard best in the
bone conduction by testing lateralization of sound to either
the lateralization of sounds. ear. abnormal ear.
● Hold the tuning fork ● Sensorineural loss will cause
at its base. Activate
the sound to be heard best in
it by tapping the fork
gently against the the normal ear.
back of your hand
near the knuckles or RINNE TEST:
by stroking the fork
between the thumb
- Air conduction sound is Rinne Test:
and the index finger.
normally heard longer than bone
It should be made to
conduction sound (AC > BC).
ring softly.
● In conductive hearing loss, the
● Place the base of
the vibrating fork on bone conduction is heard
top of the longer than the air conduction
client’s head and ask sound.
where the
● In sensorineural hearing loss,
air conduction is heard
 longer than bone conduction,
client hears the but may not be twice as long.
noise

RINNE TEST: to compare

air conduction to bone
conduction.
● Hold the handle of
the activated tuning
fork in 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
client’s ear canal.
Ask
whether the client
now hears the sound.
Sound
conducted by air is
heard more readily
than sound
conducted by bone.
The tuning fork
vibrations conducted
air is normally heard
longer.

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