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PHYSICAL ASSESTMENT
Objectives:
After 4 hours of classroom Discussion and Demonstration the Level II students will be able to:
I. Define the FF. terms:
a. Nursing Assessment
b. Physical Assessment
c. Anthropometric Measurement
d. Health History
e. Health
f. Reflexes
g. Visual Activity
h. Interview
i. Signs
j. Symptoms
II. Know the importance of Physical Assessment
III. Purpose of Physical Assessment
IV. Four basic techniques in Physical Assessment
V. Principles involved in Physical Assessment
VI. Nursing responsibilities before, during and after Physical Assessment
VII. Materials and Equipment used in Physical Assessment and demonstrate Beginning Skills in
Physical Assessment.
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Define the Following terms:
A. Nursing Assessment
-Is a major component of nursing care.
-Is a process which includes both physical and psychological aspect to evaluate clients
condition.
-Enables the nurse to make a judgment about the clients health status, ability to manage
his/her health care and need for nursing.
B. Physical Assessment
-Is a process by which a nurse obtains a data that describes a persons responses to actual or
potential health problems which is analyzed to form pertinent diagnosis.
-Is a head to toe review of each body system that offers objective information about the client
and allows the nurse to make clinical judgment.
C. Anthropometric Measurement
-Comparative measurements of the body. Anthropometric measurements are used in
nutritional assessments. Those that are used to assess growth and development in infants,children, and adolescents include length, height, weight, weight-for-length, and head
circumference (length is used in infants and toddlers, rather than height, because they are
unable to stand). Individual measurements are usually compared to reference standards on a
growth chart. Measurement of size weight and proportion of the body.
-Most commonly used anthropometric measured are height, weight, triceps, skinfold thickness,
elbow breadth and arm and head circumference.
D. Health
-State of being physically fit, mentally stable and socially comfortable.
- It encompasses more than the state of being free of disease.
E. Health History
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-defined as the systematic collection of subjective data (stated by the client) and objective data
(observed by the nurse) used to determine a clients functional health pattern status.
F. Reflexes
-Bent, turned or directed back; or produced by a reflex without intervention of consciousness.
- Is an involuntary and nearly instantaneous movement in response to a stimulus.
G. Visual Acuity
-The degree of detail the eye can discern an image.
-Is a quantitative measure of the ability to identify black symbols on a white background at a
standardized distance as the size of the symbols is varied.
-Is acuteness or clearness of vision, especially form vision, which is dependent on the sharpnessof the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain.
H. Interview
-An interview is a conversation between two or more people (the interviewer and the
interviewee) where questions are asked by the interviewer to obtain information from the
interviewee. "Interview" word is derived from french word "entirevior" it means "glimpse" to
each other.
-Therapeutic interaction that has a purpose.
I. Signs
-A sign is the physical manifestation of an illness, injury or other bodily disorder. A sign is
objective and can be observed.
-Signs can be felt, heard, seen, and measured by the diagnostician or nurse. These include
pulse, respirations, blood pressure, and physical evidence such as bleeding, broken skin,
bruising etc.
J. Symptoms
-Subjective evidence of a disease of physical disturbance observed by the patient.
-Is a departure from normal function or feeling which is noticed by a patient, indicating the
presence of disease or abnormality. A symptom is subjective, observed by the patient, and not
measured.
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Importance of Physical Assessment:
To early detect and treat diseases and disorders.
To identify actual and potential health problems.
To establish a data based from which the subsequent phases of the nursing evolve.
To assess the clients impact of activity and exercise on the clients overall level of health.
To assess the clients routine exercise pattern and observe how the clients body system
response to activity and exercise.
To establish the client-nurse relationship
To obtain information about the clients health including, physiologic, psychologic,
sociocultural, cognitive, developmental and spiritual aspects.
To identify the clients strength and weaknesses.
Purpose of Physical Assessment
To supplement, confirm or refute data obtained in the nursing history.
To confirm and identify nursing diagnosis.
To make clinical judgments about a clients changing health status and management.
To evaluate the physiological outcome of care.
Toobtain and gather data about the clients health basis of data for future assessment.
An excellent way to evaluate an individuals current health status.
Four Basic Techniques in Physical Assessment
I. Inspection
It is the use of ones senses of vision and smell to consciously observe the patient. It is
also known as concentrated watching. It is a close, careful scrutiny; first of the individual as a
whole and then of each body system. Inspection begins the moment you first meet the
individual and develop a general survey. Then as you proceed through the examination, start
the assessment of each body system with inspection.
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II. Palpation
It is the act of touching a patient in a therapeutic manner to elicit specific information. It
follows and often confirms points you noted during inspection. Palpation applies your sense of
touch to assess these factors: texture, temperature, moisture, organ location and size, as well
as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses and presence of tenderness or pain.
Two distinct types of palpation: Light and deep palpation
Light palpation
It is superficial, delicate and gentle. In light palpation, the finger pads are used to gain
information of the patients skin surface to a depth of approximately -1 inch below the
surface. Light palpation reveals information on skin texture and moisture; overt large or
superficial masses; and fluid, muscle guarding and superficial tenderness.
Deep palpation
It can reveal information about the position of organs and masses, as well as their size,
shape, mobility, consistency, and areas of discomfort. Deep palpation uses the hands to explore
the bodys internal structure to a depth of 1 to 2 inches or more. This technique is most often
used for the abdominal and male and female reproductive assessments. Variations in this
technique are single handed and bimanual palpations.
III. Percussion
It is the technique of striking or tapping the persons skin with short, sharp strokes to
assess underlying structures. The strokes yield a palpable vibration and a characteristic sound
that depicts the location, size and density of the underlying organ. These sounds also are
diagnostic of normal and abnormal findings. Any part of the body can be percussed, but only
limited information can be obtained in specific areas such as heart. The thorax and abdomen
are the most frequently percussed location.
Four types of percussion techniques: Immediate or direct, mediate or indirect, direct fist
and indirect fist percussion:
A. Immediate or Direct Percussion
The striking hand directly contacts the body wall. This produces a sound and is used in
percussing the infants thorax or the adults sinus areas.
B. Mediate or Indirect Percussion
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It is used more often and involves both hands. The striking hand contacts the stationary
hand fixed on the persons skin. This yields a sound and a subtle vibration.
C. Direct Fist Percussion
It is used to assess the presence of tenderness in internal organs, such as the liver or thekidneys. The presence of pain in conjunction with direct fist percussion indicated inflammation
of that organ or a strike of too high in intensity.
D. Indirect Fist Percussion
Its purpose is the same as direct fist percussion. In fact, the indirect method is preferred
over the direct method. It is because in this methods. The non-dominant hand absorbs some of
the force of the striking hand. The resulting intensity should be sufficient force to produce pain
in the patient if organ inflammation is present
Percussion elicits five types of sounds:
1) Flatness (dull) bone and muscle
2) Dullness (thudlike) liver, spleen, heart
3) Resonance (hollow) air-filled lung/ normal lung
4) Hyperresonance emphysematous lung
5) Tympany stomach filled with gas (air)
IV. Auscultation
It is the act of active listening to the body organs to gather information on patients
clinical status. Auscultation includes listening to sounds that are voluntarily and involuntarily
produced by the body such as the heart and blood vessels and the lungs and abdomen.
Auscultated sounds should be analyzed in relation to their relative intensity, pitch, duration,
quality, and location.
Two types of auscultation: Indirect and direct auscultation:
1) Direct of Immediate auscultation
It is the process of listening with the unaided ear. This can include listening to the
patient from some distance away or placing the ear directly on the patients skin surface. An
example is the wheezing that is audible to the unassisted ear in a person having a severe
asthmatic attack.
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2) Indirect or Mediate auscultation
It is the use of stethoscope, which transmits the sounds to the nurses ear.
Principles involved in physical assessment:
Anatomy & Physiology
One has to know the different parts and functions of the body in order to do a thorough
and detailed assessment.
Psychology
Through Psychology, we are able to make good assessments because we can
differentiate a normal mental state and an abnormal one. Privacy must be ensured during the
Physical Assessment to avoid the client from being anxious or uncomfortable.
Microbiology
Do medical handwashing before and after the procedure. Instrument should be sterile.
Time and energy
Starts from lesser to the most sensitive part
Body mechanics
Nurse and patient should maintain proper body mechanics.
Nursing responsibilities before, during and after Physical assessment:
Before
Always dress in clean professional manner, make sure you have your name pin or workplace
identification.
Remove all bracelets, necklaces, or earrings that can interfere during the physical assessment.
Be sure your hair will not fall forward and obstruct your vision or touch to the patient.
Ensure that all necessary equipment is ready for use and within reach.
Introduce yourself to the patient. Enlist the patients cooperation by explaining what you are
about to do, where it will be done, and how it may feel.
Explain to the patient why you may be spending a long time performing one particular skill.
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Do medical hand washing
Position the patient as dictated by the body system being assessed.
Warm all instruments prior to their use
During
Conduct the assessment in a systematic fashion every time.
While performing each step in the physical assessment process you may need to inform the
patient of what to expect, where to expect it, and how it should feel.
Avoid making crude or negative remarks, be cognizant of your facial expression when dealing
with malodorous and dirty patients or with disturbing findings.
Proceed from the least invasive to the most invasive procedure for each body system.
If the patient complains of fatigue, continue the assessment later.
After
Provide recognition to the patient when the physical assessment concluded; inform the
patient what will happen next.
Place patient in a comfortable position.
Do after care.
Do medical hand washing.
Document assessment findings in the appropriate section of the patient record.
Materials and Instruments of Physical Treatment
Instrument/Material Purpose
Flashlight or penlight To assist in viewing of the pharynx and cervix
or to determine the reaction of the pupils of
the eye.
Laryngeal or dental mirror To observe the pharynx and oral cavity.
Nasal septum To permit visualization of the lover and middle
turbinates; usually a penlight is used for
illumination.
Ophthalmoscope A lighted instrument to visualize the interior of
the eye.
Otoscope A lighted instrument to visualize the eardrum
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and external auditory canal (a nasal speculum
may be attached to the Otoscope to inspect
nasal cavities).
Percussion (reflex) hammer An instrument with a rubber head to test
reflexes.
Tuning Fork A two-prolonged metal instrument used totest hearing acuity and vibratory sense.
Cotton applicators To obtain specimens.
Gloves To protect the nurse
Lubricant To ease the insertion of instruments
(ex.Vaginal Speculum)
Tongue blades
(depressors)
To depress the tongue during assessment of
the mouth and pharynx.
Various positioning of the patient
Dorsal recumbent
Back-lying position with knees flexed and hips externally rotated; small pillow under the
head; soles of feet on the surface.
Supine (horizontal recumbent)
Back-lying position with legs extended; with or without pillow under the head
Sitting
A seated position. The back is unsupported and legs hanging freely.
Lithotomy
Back-lying position with feet supported in stirrups; the hips should be in line with the
edge of the table.
Sims
Side-lying position with the lowermost leg flexed at the hip and knee, upper arm flexed
at the shoulder and elbow.
Prone
Lies on the abdomen with head turned to the side, with or without a small pillow.
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BODY PARTS
Assessment of Body Parts
Head & NeckHead
Inspection:
For size, shape & symmetry
Palpation:
For contour, masses, depressions.
Hair
Inspection:
For color, evenness of growth over the scalp,
presence of parasites, amount of body hair.
Palpation:
Thickness or thinness texture and oiliness.
Scalp
Inspection:
For Color, oiliness, presence of scars, lice and
dandruff.
Palpation:
For lesions or masses tenderness.
Forehead
Inspection:
For symmetry, skin appearance, presence of
rushes, scars or pimples.
Palpation:
For masses, lumps and tenderness
Face
Inspection:
For shape and symmetry, presence of scars,
pimples or acne
Normal Findings
The head should be round
(normocephalic) and symmetrical.
The normal skull is smooth, and without
masses or depressions, non-tender.
Can be black, brown or burgundy
depending on the race, evenly
distributed covers the whole scalp
(no evidences of Alopecia), no parasites, and
the amount is variable.
Maybe thick or thin, coarse smooth neither
brittle nor dry.
Lighter in color than the complexion, can be
moist or oily, no scars noted, free from lice,nits and dandruff.
NO lesions should be noted, neither
tenderness nor masses.
Symmetrical, light to dark brown, no rushes,
scars and pimples.
Non-tender, no lumps and absence of masses.
The shape of the face can be oval, round, or
slightly square, the face is symmetrical,
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Palpation:
For any swelling, masses, lumps, and the four
sinuses (sphenoidal sinuses, frontal sinuses,ethmoid sinuses and maxillary sinuses).
Eyes
Inspection:
For symmetry.
Eyebrows
Inspection:
For hair distribution and alignment and skinquality and movement, presence of pimples,
dandruff and color of the hair.
Palpation:
For the presence of lumps, pain and nodules.
Eyelashes
Inspection:
For evenness of distribution and direction of
curl and color
Sclera
Inspection:
For color, moisture, texture and the presence
of lesions.
Conjunctivae
Inspection:
For lesions, swelling, color and moisture.
Palpation:
Presence of pain
Cornea
Inspection:
absence of scars, pimples or acne. There
should be no edema, disproportionate
structures, or involuntary movements.
No lumps and swelling of the face, absence of
masses and there is no pain felt duringpalpation of face
Symmetrical or evenly placed and in line with
each other. Non-protruding and equal
palpebral fissure.
Hair evenly distributed; skin intact. Eyebrowssymmetrically aligned; equal movement,
absence of pimples and dandruff, maybe black
brown or blond depending on race.
No lumps, no nodules and no pain felt during
palpation.
Equally distributed; curled slightly outward
and black in color.
The sclera appears white, although blacks
occasionally have a grayblue or muddy color
to sclera. It should be moist and without
lesions.
Both conjunctivae are shiny, smooth, and pinkor red, absence of swelling, no lesions and it
should be moist.
There should be no pain felt during palpation.
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For clarity, texture and moisture
Iris
Inspection:
For appearance, coloration and shape.
Pupil
Inspection:
For color size, shape and equality of the pupils
Muscle function
Corneal Light Reflex or the Hirschberg Test
(Observe the location of reflectedlight on the cornea)
Cover Test
This test detects small degrees of deviated
alignment by interrupting the fusion reflex
that normally keeps two eyes parallel.
(Observe the cover eye for movement)
Diagnostic Position test
Leading the eye through the six cardinal
positions of gaze will elicit any muscleweakness during movement. (Observe for
convergence of gaze).
Muscle balance
Test for pupilary light reflex(Cardinal Fields of
Gaze)
Test for Accommodation
The corneal surface should be moist, shiny and
transparent, with no discharges and
cloudiness.
The iris is normally appears flat, with a regularshape and even coloration.
Black in color; appears round, regular, smooth
border and of equal size in both eyes,
normally 3-7 mm in diameter.
The reflected light (light reflexes) should be
seen symmetrically in the centers of thecornea.
If the eyes are in alignment, there will be no
movement of the either eye.
A normal response is parallel tracking of the
object with both eyes. Both eyes should movesmoothly and symmetrically in each of the six
fields gaze and convergence on the held
object as it moves toward the nose.
Normally you will see:
-Constriction of the same-sided pupil (a direct
light reflex).
-Simultaneously (a consensual light reflex).
A normal response includes:
-Papillary constriction.
-Convergence of the axes of the eye.
Record the normal response to all
these maneuver as:
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Visual Acuity
Snellen eye Chart
The Snellen eye chart is the most commonly
used and accurate measure of visual acuity.
Peripheral Vision
Test Visual Fields
Confrontation Test
Nose
External Inspection:
Inspect the nose nothing any bleeding,
inflammation, or lesions, masses, swelling, andsymmetry, discharges and color, sense of
smell.
External Palpation:
For tenderness and presence of pain.
Internal Inspection:
Inspect for nasal septum for deviation,
perforation, lesions and bleeding.
Frontal Sinuses
Inspection:
For any swelling around the eyes
P - Pupils
E - Equal
R - Round
R - React to
L - Light and
A - Accommodation
Normal Visual is 20/20 The Top number
(numerator) indicates the distance the person
is standing from the chart, while the
denominator gives the distance at which a
normal eye could have read that particular
line. Thus 20/20 means you can read that 20
ft. with the normal eye could have read at 20ft.
The patient is able to see the stimulus at
about 90 degrees temporally, 60 degrees
nasally, 50 degrees superiorly, and 70 degrees
inferiorly.
The shape of the external nose can vary
greatly among individual. Normally, it islocated symmetrically on the midline of the
face that is without swelling, bleeding, lesions,
or masses. No discharge or flaring and uniform
color, there is a sense of smell.
Non-tender; absence of pain
The nasal mucosa should be pink or dull red
without swelling. The septum is at the midlineand without perforation, lesions or bleeding,
the small amount of watery discharge is
normal.
There is no evidence of swelling around the
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Palpation:
Presence of pain and tenderness
Percussion:
Note any sound
Maxillary Sinuses
Inspection:
For any swelling around the eyes
Palpation:
Presence of pain and tenderness
Percussion:
Note any sound
Transillumination of the sinuses
You may use this technique in the frontal and
maxillary sinuses when you suspect sinus
inflammation, although it is of limited
usefulness.
Mouth
Lips
Inspection:For color, texture, cracking, symmetry, lesions
and hydration
Palpation:
For any presence of pain, lumps and
tenderness.
Gums
Inspection:
For color, texture, swelling, bleeding,retraction form the teeth
Palpation:
For the presence of pain, tenderness and
lumps.
Teeth
eyes.
The patient should not feel pain during
palpation and no tenderness felt.
The sound should be flat or dull.
There is no evidence of swelling around the
nose and eyes.
The patient should not feel any pain and
tenderness during palpation.
The sound should be flat or dull.
The glow on each side is equal, indication air-
filled frontal and maxillary sinuses.
The lips should be pink, soft moist, smooth
texture with no evidence of lesions or
inflammation. Not crack and symmetrical.
There is no presence of lumps and pain. It is
tender.
The gums should be pink, moist, firm texture,
no retraction, no swelling or bleeding. Thegum margins at the teeth are tight and well-
defined.
There should be no pain felt during palpation,
no lumps and non-tender.
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Inspection:
For discoloration, numbers of tooth and
texture.
TongueInspection:
For color, texture, surface characteristics,
symmetry, presence of lesions, and sense of
taste.
Palpation:
For any nodules, lumps and presence of pain
Frenulum
Inspection:
For the color, texture.
Sublingual Area
Inspection:
For color, moisture and presence of lesion.
Hard palate
Inspection:
For color, shape, texture, presence of lesions
and malformation.
Soft Palate
Inspection:
For color, shape, texture, presence of lesions,
malformation
Uvula
Inspection:
For position, mobility and color.
Tonsils
Inspection:
The adult normally has 32 teeth, which should
be white, straight and smooth edges in proper
alignment or evenly placed, clean and free of
debris or decay.
The tongue is in the midline of the mouth, the
dorsal surface should be pink, moist, rough
and without lesions. The tongue is
symmetrical and moves freely. The strength of
the tongue is symmetrical and strong. The
ventral surface of the tongue has prominent
blood vessels and should be moist without
lesions, looks smooth and glistening. There is a
sense of taste.
There should be no presence of nodules,
lumps and pain.
It should be attached to the tongue, pinkish in
color and moist.
It should be pink in color, moist and no
presence of lesions.
The hard palate is concave and lighter in pink
in color, it has many ridges and it is moist,
without any lesion or malformation.
The soft palate is also concave and light pink in
color, it is smooth and no lesions or
malformations noted.
It normally looks like a flesh pendant hanging
in the midline of soft palate.
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For color, shape, size and discharge.
Palpation:
Presence of pain
Ears
External ear
Inspection:
For position, color, size, shape, any
deformities, inflammation, or lesions
Palpation:
Presence of pain, tenderness, and lumps.
Auditory Acuity
Voice-Whisper test
Tuning fork test
Webers Test
Rinnes Test
Tonsils are present and pink in color.
It is pink in color and smooth. Oval in shape.
No discharge. Of normal size or not visible, no
inflammation, and not swollen.
There should be no pain felt during palpation.
The ear matches the flesh color of the rest of
the patients skin and should be positioned
centrally and in proportion to the head. The
top of the ear should cross an imaginary line
drawn from the outer canthus of the eye tothe occiput with no swelling or thickening.
Cerumen should be moist and not obscure the
lympanic membrane. There should be no
foreign bodies, redness, drainage, deformities,
nodules or lesions.
They should feel firm (not tender) and
movement produce pain.
The patient should be able to repeat words
whispered from a distance of 2 feet.
Measures hearing by air conduction (AC) or by
bone conduction (BC), in which the sound
vibrates through the cranial bones to the inner
ear.
The patient should perceive the sound equally
in both ears or in the middle. Nolateralization of sound is known as negative
Webster test.
Air conduction is heard twice as long a bone
conduction when the patient hears the sound
through the external auditory canal (air) after
it is no longer heard at the mastoid process
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Neck
Inspection:
For symmetry of the sternocleidomastoid
muscles anteriorly, and the trapeziusposteriorly.
Palpation:
For the presence of masses and tenderness.
Lymph Nodes
Inspection:For any enlargement or inflammation.
Palpation:
For size, shape, dellimination, mobility,
consistency, and tenderness
Trachea
Palpation:
Thyroid Gland
Inspection:
For symmetry and visible masses.
Palpation:
For nodules or enlargement and tenderness.
Thorax
Chest Anterior
Inspection: For the breathing patterns, rate,
depth, the coastal angle, shape of patients
chest, and color.
(bone). This is denoted as AC>BC.
The muscles of the neck are symmetrical with
the head at a central position. The patient isable to move head through a full range of
motion without complaint of discomfort or
noticeable limitation. The patient may be
breathing through a stoma or tracheostomy.
The muscles are symmetrical without palpable
masses or spasm.
Lymph nodes should not be visible or
inflamed.
Normally, lymph nodes should not be palpable
in the healthy adult patient; however, small,
discrete, movable nodes are sometimes
present but are of no significance.
Space should be systemic on both sides or on
central placement in midline of neck; spacesare equal on both sides.
Thyroid tissue moves up with swallowing but
often the movement is so small it is not visible
on inspection. In males, the thyroid cartilage,
or Adams apple, is more prominent than in
females.
No enlargement, masses, or tendernessshould be noted on palpation.
Quiet, rhythmic, and effortless respirations.
Breathing pattern should be smooth. Costal
angle is less than 90, and the ribs insert into
the spine at approximately a
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Palpation:
For respiratory excursion. Tenderness, masses
and temperature.
Percussion:
For its different sound
Auscultation:
For full two breaths and sounds
Lungs
Inspection:For breath sounds over the following:
Trachea
Alveolar Tube (-large-stem bronchi)
Lung Field (lung periphery)
Heart
Palpation:
45 angle. Normal rate of breathing in adult is
46/16 per min. red patches present, ribs
sloping downward with symmetric
interspaces. Colors should be even and
consistent with the color of the patients face.
Shoulder should be at the same height. shapeof thorax
elliptical shape
It should be full symmetric excursion; thumbs
normally separate to 3-5 cm (1 to 2 in).
Equal expansion, no tenderness, no masses,
skin should be warm and dry, no pulsation
should be present. Fremitus is normally
decreased over heart and breast tissue.
Normal lung tissue-resonant sound, rib flat
sound.
Air brushing through the respiratory tract
during inspiration expiration generates
different breath sounds.
Bronchial (loud, tubular) breath sounds heard
over trachea; expiration longer than
inspiration; short silence between inspiration
and expiration.
Bronchovesicular breath sound heard over
main stem bronchi: below clavicles and
between scapulae (inspiratory phase equal toexpiatory phase).
Vesicular (low, soft, breezy) breath sounds
heard over lung periphery (inspiration longer
than expiration).
No pulsation palpable over aortic and
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Auscultation:
For murmurs and sound
Chest Posterior
Inspection:
For shape and symmetry, spinal alignment for
deformities, color, abnormal inspiratory.
Palpation:
For clients who have no respiratory
complaints, temperature.For clients who have respiratory complaints.
For respiratory excursion
For vocal and tactile fremitus
Percussion:
For sounds
For diaphragm excursion
Auscultation:
For sounds
pulmonic areas.
Apical has the loudest sound; it should be 60-
80 beats/min. No murmurs should be heard.
Anteroposterior to transverse diameter in
ratio of 1.2; chest symmetric; spine column
vertically aligned. No patches, no abnormal
inspiratory retraction of interspaces.
The skin should be intact; uniform
temperature.
The chest wall intact; uniform temperature.
Full and symmetric chest expansion. [Ex.
When the client takes a deep breath, your
thumbs should be move apart an equal
distance and at the same time; normally the
thumbs separate 3 to 5 cm (1 to 2 in.) during
deep palpation].
Bilateral symmetry of vocal fremitus. Fremitus
is heard most clearly at the apex of the lungs.Low-pitched voices of males are more readily
palpated than higher pitched voices of
females.
Percussion notes resonate except over
scapula.
Lowest point of resonance is at the
diaphragm. (Note: percussion on a rib
normally elicits dullness)
Excursion is 3-5 cm (1 to 2 in.) bilaterally in
women and 5-6 (2 to 3 in.) in men. Diaphragm
is usually slightly higher on the right side.
Vesicular and bronchovesicular breathe
sounds.
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Abdomen
Inspection:
-Color
-Scars
-Striae
-Dilated Veins
-Rashes and lesions
-Umbilicus
-The contour of the abdomen
-Hair distribution
-Symmetry
-Respiratory movement
Auscultation:
Auscultate the four quadrants for basic
sounds. Auscultate over the aorta, renal, iliac
and femoral arteries. (Vascular sounds)
Percussion:
Percuss the four quadrants to as tympany and
dullness.
Right Upper Quadrant:
- liver
- gallbladder
- duodenum
- head of pancreas
- right kidney and adrenal
- hepatic flexure of colon- Part of ascending and transverse
colon
Right Lower Quadrant:
-Cecum
-Appendix
-Right ovary and tube
-Surface is uniform in color and in
pigmentation.
-Flawless no scars is present. If scars are
present draw its location in the personsrecord indicating the length in cm.
-No striae / stretch marks are present.
-A few small veins may be visible normally.
-No rashes or lesions are present.
-Is normally in the midline and inverted with
no sign of inflammation, discoloration or
hernia.
-Normally range from flat to rounded.
-Diamond shape in adult males, inverted
triangular shape in adult female.-Symmetric bilaterally and smooth.
-The abdomen rises with inspiration and falls
with expiration.
High pitched, irregular gurgles (5-35 times/
min) present equally in all four quadrants. No
bruits, no venous hums, no friction.
Tympany is usually predominating because of
air in the stomach and intestines. Dull soundsare heard over solid masses such as liver,
spleen, and kidneys.
Left Upper Quadrant:
- stomach
- spleen
- left lobe of liver
- body of pancreas
- left kidney and adrenal
- spleen flexure of colon- part of transverse & descending
colon
Left Lower Quadrant:
-Part of descending colon
-Sigmoid colon
-Left ovary and tube
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-Right ureter
-Right spermatic cord
Midline:
-Aorta
-Uterus(if enlarged)-bladder(if enlarged)
Palpation:
Perform palpation to judge the size, location
and consistency of certain organs and to
screen for an abnormal mass or tenderness.
Light Palpation (1/2 - 1 inch) on all areas of
abdomen moving clockwise and in rotary
motion.
Deep Palpation (2-3 inches) on all areas on the
abdomen moving clockwise and in rotary
motion.
Liver Palpation:
Located in the RUQ (Right Upper
Quadrant).Place your left hand under the
persons back parallel to the 11th and 12th
ribs and lift up to support the abdominal
contents. Place your right hand on the RUQwith fingers parallel to the midline. Push
deeply down and under the right costal
margin then ask the person to take a deep
breath.
Hooking Technique
An alternative method of palpating the liver.
Stand up at the persons shoulder and swivel
your body to the right so that you face the
persons feet. Hook your fingers over thecostal margin from above.
Ask the person to take a deep breath then try
to feel the liver edge bump from your
fingertips.
Spleen Palpation:
Search spleen by reaching your left hand over
-Left ureter
-Left spermatic cord
Normally there is no pain, tenderness, rigidity
and muscle guarding
Normally there is no pain, tenderness, rigidity
and muscle guarding
It feels like a firm rectangular ridge. Often the
liver is not palpable and you feel nothing firm.
Normally you should feel nothing firm. When
enlarged the spleen extends into the lower
quadrants.
A person normally feels a thud but no pain.
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the abdomen and behind the left side at the
11th and 12th
ribs. Lift for support. Place your
hand obliquely on the LUQ with the fingers
pointing toward the left axilla and just inferior
to the rib margin. Push your hand deeply
down and under the left costal margin and askthe person to take a deep breath.
Kidney
Percussion:
Indirect fist percussion causes the
tissues to vibrate instead of producing a
sound. Locate kidney by placing hand over the
12th rib at the costoverbral angle on the back.
Thump that hand with the ulnar edge of your
other fist.
Palpation:
locate kidney by placing your hand together in
a duck-bill position at the persons right flank.
Press your two hands together firmly (you
need deeper palpation than that used to liver
and spleen) then ask the person to take a
deep breath.
Palpation:
Light palpation in all 4 quadrantsDeep palpation in all 4 quadrants
Extremities
Upper and Lower
Inspection:
-Observe for size, color, contour, symmetry
and involuntary movement
-Look for deformities, edema, and presence of
lesions.
- Always compare both extremities
Palpation:
-Feel evenness of temperature. Normally it
should be even for all the extremities.
Sharp pain occurs with inflammation of
kidneys or paranephric area.
Lower pole of the kidney is round, smooth
mass slide in between your fingers.
Both extremities are equal in size
Have the same contour with prominences of
joints.
No involuntary movements. No edema. Color
is even.
Temperature is warm and even. Has equal
contraction.
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- Perform range of motion
-Test for muscle strength
Can perform complete range of motion
Can counter act gravity and resistance in ROM
Balance Test
Gait
Observe as the person walk 10-20 feet, turns and returns to the starting point. Normally,
the person moves with a sense of freedom. The gait is smooth, rhythmic, and effortless, the
opposing arm swing is coordinated, and the turns are smooth.
Rombergs Test
Ask the person to stand up with feet together and arms at the side. Once in a stable
position, ask the person to close the eyes and to hold the position. Wait about 20 seconds.
Normally, a person can maintain posture and balance even with the visual orienting
information blocked, although slight swaying may occur. (Stand close to catch the person in
case he or she falls)
Tandem Walking
Ask the person to walk straight line in a heel-to-toe fashion. This decreases the base ofsupport and will accentuate any problem with coordination. Normally, the person can walk
straight and stay balance.
Coordination and Skilled Movements
Rapid Altering Movements (RAM)
Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the
knees with the backs of the hands. Then ask the person to do this faster. Normally, this is done
with equal turning and a quick rhythmic pace.
Finger-to-nose Test
Ask the person to close the eyes and to stretch out the arms. Ask the person to touch
the tip of his nose or her nose with each index finger, alternating hands and increasing speed.
Normally, this is done with equal turning & a quick rhythmic pace.
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Heel-to-shin Test
Test lower extremity coordination by asking the person who is in a supine position, to
place the heel on the opposite knee, and run it down the shin from to the ankle. Normally, the
person moves the heel in a straight line down the skin.
Reflex
It is an automatic response of the body to a stimulus. It is not voluntarily learned or
conscious. Reflexes are tested using a percussion hammer. The response is described from 0 to
4. Experience is necessary to determine appropriate scoring of an individual. Several reflexes
are normally tested during the physical examination: a) the biceps reflex, b) the triceps reflex, c)
the brachioradialis reflex, d) the patellar reflex, e) Achilles reflex, f) the plantar reflex.
Test the Reflex
The reflex response is guided on a 4 point scale:
4+ very brisk, hyperactive
3+ brisker than average, may indicate disease
2+ average, normal
1+ diminished, low normal
0 no response
Upper Extremity
Biceps Reflex (Flexion)
Support the persons forearm on yours; this position relaxes, as well as partially flexes,
the persons arm. Place your thumb on the biceps tendon and strike a blow on your thumb. You
can feel as well as see the normal response, which are contraction of the biceps muscle and the
flexion of the forearm.
Triceps Reflex (Extension)
Tell the person to let the arm just go dead as you suspend it by holding the upper arm.
Strike the triceps tendon directly just above the elbow. The normal response is extension of the
forearm.
Brachioradialis Reflex (Flexion and Supination of the arm)
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Hold the persons thumbs to suspend the forearm in relaxation. Strike the forearm
directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and
supination of the arm.
Lower Extremity
Quadriceps Reflex (patellar or knee jerk reflex)
Let the lower legs dangle freely to flex the knee and stretch the tendons. Strike the
tendon directly just below the patella. Extension of the lower legs is the expected response.
Achilles Reflex
Position the person with the knee flexed and the hip externally rotated. Hold the foot in
dorsiflexion, and strike the Achilles tendon directly. Feel the normal response as the foot
plantar flexes against your hand.
Plantar Reflex
Position the thigh in slight external rotation. With the reflex hammer, draw a light stroke
up the lateral side of the sole of the foot and inward across the ball of the foot, like an upside-
down J. The normal response is plantar flexion if all the toes and inversion and flexion of the
forefoot.