HEALTH ASSESSMENT.

• A health assessment is a set of questions, answered by patients, that asks about

personal behaviors, risks, life-changing events, health goals and priorities, and
overall health.
• Health assessments are usually structured screening and assessment tools used
in primary care practices to help the health care team and patient develop a plan
of care.
• Health assessment information can also help the health care team understand
the needs of its overall population of patients. Health assessments can vary in
length and scope.
• it is systematic and continuous collection, validation and communication of client
data as compared to what is standard/normal.
• It includes the client’s perceived needs, health problems, related experiences,
health practices, values and lifestyles
FOUR Types of Assessment
• Initial assessment – assessment performed within a specified time on admission
• Ex: nursing admission assessment
• Problem-focused assessment – use to determine status of a specific problem
identified in an earlier assessment
• Ex: problem on urination-assess on fluid intake & urine output hourly
• Emergency assessment – rapid assessment done during any physiologic crisis of
the client to identify life threatening problems.
• Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.
• Time-lapsed assessment – reassessment of client’s functional health pattern
done several months after initial assessment to compare the client’s current
status to baseline data previously obtained.
Data Collection

• Gathering of information about the client

• It includes;
• current/present problems of client (pain, nausea, sleep pattern, religious
practices, meds or treatment the client is taking now)
• past health history of client (allergies, past surgeries, chronic diseases, use
of folk healing methods)
Types of Data
1. Subjective data
• also referred to as Symptom/Covert data
• Information from the client’s point of view or are described by the person experiencing it.
• Information supplied by family members, significant others; other health professionals are
considered subjective data.
• Example: pain, dizziness, ringing of ears/Tinnitus
2. Objective data
• also referred to as Sign/Overt data
• Those that can be detected or observed or measured/tested using accepted standard or
norm.
• Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin
Methods of Data Collection

1. Interview
• A planned, purposeful conversation/communication with the client to get information,
identify problems, evaluate change, to teach, or to provide support or counseling.
• it is used while taking the nursing history of a client
2. Observation
• Use to gather data by using the 5 senses and instruments.
3. Examination
• Systematic data collection to detect health problems using unit of measurements, physical
examination techniques (IPPA), interpretation of laboratory results.
• should be conducted systematically:
• Cephalocaudal approach – head-to-toe assessment
• Body System approach – examine all the body system
• Review of System approach – examine only particular area affected
Source of data

1. Primary source – data directly gathered from the client using

interview and physical examination.
2. Secondary source – data gathered from client’s family members,
significant others, client’s medical records/chart, other members of
health team, and related care literature/journals.
• In the Assessment Phase, obtain a Nursing Health History – a structured
interview designed to collect specific data and to obtain a detailed health
record of a client.
Components of a Nursing Health History:

• Biographic data – name, address, age, sex, martial status, occupation, religion.
• Reason for visit/Chief complaint – primary reason why client seek consultation
or hospitalization.
• History of present Illness – includes: usual health status, chronological story,
disability assessment. (To be discussed in detailed in slide 16)
• Past Health History – includes all previous immunizations, experiences with
illness (medical and surgical) and use of medications ,allergies.
• Family History – reveals risk factors for certain disease diseases (Diabetes,
hypertension, cancer, mental illness).
• Review of systems – review of all health problems by body systems
• Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily
living, recreation or hobbies.
• Social data – include family relationships, ethnic and educational background,
economic status, home and neighborhood conditions.
• Psychological data – information about the client’s emotional state.
• Pattern of health care – includes all health care resources: hospitals, clinics,
health centers, family doctors.
 Gordon’s Functional Health Patterns:
Organization of health needs
• Gordon’s Functional Health Patterns organizes health needs as follows
• Health perception-health management pattern.
• Nutritional-metabolic pattern
• Elimination pattern
• Activity-exercise pattern
• Sleep-rest pattern
• Cognitive-perceptual pattern
• Self-perception-concept pattern
• Role-relationship pattern
• Sexuality-reproductive pattern
• Coping-stress tolerance pattern
Analyze data

Compare data against standard and identify significant cues.

Standard/norm are generally accepted measurements, model, pattern:
Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic
values, normal growth and development pattern
Communicate /record/document data

• Nurse records all data collected about the client’s health status
• Data are recorded in a factual manner not as interpreted by the nurse
• Record subjective data in client’s word; restating in other words what client says
might change its original meaning.
Interview
• The purpose of an interview is to gather and provide information, identify
problems of concerns, and provide teaching and support.
• The goals of an interview are to develop a rapport with the client and to collect
data
• An interview has 3 major stages:
• Opening: purpose is to establish rapport by creating goodwill and trust; this is often
achieved through a self – introduction, nonverbal gestures (a handshake), and small talk
about the weather, local sports team, or recent current event; the purpose of the
interview is also explained to the client at this time.
• Body: during this phase, the client responds to open and closed-ended questions asked by
the nurse.
• Closing: either the client or the nurse may terminate the interview, it is important for the
nurse to try to maintain the rapport and trust that was developed thus far during the
interview process.
Types of questions
• Closed questions used in directive interview
• short factual answers; e.g. “Do you have pain?”
• Answers usually reveal limited amounts of information
• Useful with clients who are highly stressed and/or have difficulty communicating
• Open-ended questions used in nondirective interview
• Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping
lately?’
• Specify the broad area to be discussed and invite longer answers
• Useful at the start of an interview or to change the subject
• Leading questions
• Direct the client’s answer; e.g. “You don’t have any questions about your medications, do you?”
• Suggests what answer is expected
• Can result in client giving inaccurate data to please the nurse
• Can limit client choice of topic for discussion
Physical assessment
• Systematic collection of information about the body systems through the use of
observation, inspection, auscultation, palpation and percussion
• A body system format for physical assessment is found below:
• General assessment
• Integumentary system
• Head, ears, eyes, nose, throat
• Breast and axillae
• Thorax and lungs
• Cardiovascular system
• Nervous system
• Abdomen and gastrointestinal system
• Anus and rectum
• Genitourinary system
• Reproductive system
• Musculoskeletal system
 Purposes of assessment
• Assessment is part of each activity the nurse does for and with the patient. The
purposes is
• To validate a diagnosis
• To provide basis for effective nursing care.
• It helps in effective decision making
• Basis for accurate diagnosis
• It promote holistic nursing care
• To provide effective and innovative nursing care (1. To collecting data for nursing research 2. To
evaluation of nursing care)
Components of t history taking
3. History of presenting illness.
This is best achieved by assessing the patient's symptoms; this can be done using a
strategy remembered by the mnemonic 'OLD CARTS':
O = onset
• When did the symptoms begin?
• Did they develop suddenly or over time?
• Where was the patient / what were they doing when the symptoms started?

L = location
• Are the symptoms located in a specific area?
• Is this area specific or generalised?
• Does the symptom radiate to another location?
D = duration
• How long do the symptoms last?
• Are they changing over time?
• Are they constant? If so, does their severity fluctuate? (Describe).
• Are they intermittent? If so, how often do they occur, and what happens in
between episodes?

C = characteristics
• Describe what the symptom feels like (i.e. the sensation - stabbing, dull, aching,
throbbing, itching, tingling, etc.).
• Describe what the symptom looks like (i.e. colour, texture, composition, etc.)
A = aggravating / alleviating factors
• What makes the symptoms worse?
• What makes the symptoms better?
• (E.g. physical factors [activity, position, etc.], psychological factors [anxiety, etc.],
environmental factors, etc.).
R = related symptoms
• Do other symptoms occur at the same time (e.g. pain, nausea, fever,
etc.).
T = treatment
• What treatments have you tried?
• How effective have these treatments been?

S = severity
• Describe the size, extent or amount.
• Rate the symptom on a scale of 0 to 10.
• Does the symptom interrupt the person's activities of daily living?
4. Past medical/surgical history.
• Significant childhood illnesses.
• Previous hospitalizations for surgery, accidents, illnesses, etc.
• Immunization status.
• Most recent physical examinations, and findings.
• Blood donations.
5. Family history

• Diseases affecting biological relatives - parents, grandparents, aunts /

uncles, siblings and children.
• Genetic conditions known to be present in the family.
6. Personal and psychosocial history

• Educational status (e.g. level of education, occupation, etc.).

• The patient's important family / social relationships.
• The patient's diet / nutrition and exercise status.
• The patient's functional ability and mental health.
• The environment in which the patient lives / works / learns.
• The patient's health-related values, beliefs and attitudes.
• The socioeconomic, cultural and other factors impacting on health.
• The patient's willingness / capacity to make health-related changes.
7. A review of the patient's body
systems
The patient should be questioned about abnormalities or concerns in each of their
body systems: the integumentary system, the cardiovascular system, the immune /
lymphatic system, the endocrine system, the nervous system, the reproductive
system, the respiratory system, the musculoskeletal system, the digestive system
and the urinary system.
The patient should also be asked about any general or systematic symptoms they
experience (e.g. fatigue, etc.).
Physical examination
By the end of the topic learners should be able to:
• Define physical assessment
• Describe the four techniques used in physical assessment
• Know how to do a head to toe assessment
Physical assessment

• a systematic data collection method that uses the senses of sight, hearing, smell
and touch to detect health problems.
• There are four techniques used in physical assessment and these are:
• Inspection, palpation, percussion and auscultation.
• Usually history taking is completed before physical examination
Inspection
It’s the use of vision to distinguish the normal from the abnormal findings.
Body parts are inspected to identify color, shape, symmetry, movement, pulsation
and texture.
Principles of inspection
• Availability of adequate light
• Position and expose body part to view all surfaces
• Inspect each area for size, shape, color, symmetry, Position and abnormalities.
• If possible compare each area inspected with the same area on the opposite side.
• Use additional light to inspect body cavities
Palpation
• It involves use of hands to touch body parts for data collection.
• The nurse uses fingertips and palms to determine the size, shape, and
configuration of underlying body structure and pulsation of blood vessels.
• It help to detect the outline of organs such as thyroid, spleen or liver and mobility
of masses.
• It detects body temperature, moisture, turgor, texture, tenderness, thickness, and
distention.
Principles of palpation
• Help client to relax and be comfortable because muscle tension impairs effective
assessment.
• Advise client to take slow deep breaths during palpation
• Palpate tender areas last and note nonverbal signs of discomfort.
• Rub hands to warm them, have short fingernails and use gentle touch.
Percussion
• It is the technique in which one or both hands are used to strike the body surface
to produce a sound called percussion note that travels through body tissue.
• The character of the sound determines the location, size and density of
underlying structure to verify abnormalities.
• An abnormal sound suggest a mass or substance like air, fluid in an organ or
cavity.
Auscultation
• It involves listening to sounds and a stethoscope is mostly used.
• Various body systems like cardiovascular, respiratory and gastrointestinal have
characterized sounds.
• Bowel, breath, heart and blood movement sounds are heard using the
stethoscope.
• It is important to know the normal sound to distinguish from abnormal.
Preparation for physical exam

• Infection prevention– Follow IP precaution through out procedure

• Environment– P/A requires privacy and away from other destructors throughout
• Equipment– Get all the necessary equipment, other equipment needs to be
warmed before being placed on the body e.g. rubbing diaphragm of the
stethoscope briskly between hands.
• Patient preparation– Prepare the patient physically and make the patient
comfortable throughout the physical assessment for successful exam.Explain to
the patient everything to be done.
General survey/General Appearance.

• The assessment of the patient/client begins on the first contact.

• It includes apparent state of health , level of consciousness, and signs of distress.
• The general height, weight, and build can be noted including skin color, dressing,
grooming, personal hygiene, facial expression, gait, odor, posture and motor
activity.
NOTE: If there is a sign of acute distress comprehensive health assessment is
deferred until when patient is stable.
Vital signs
• Assessment of vital signs is the first in physical assessment because positioning
and moving the client during examination interferes with obtaining accurate
results.
• Specific vital signs can be also obtained during assessment of individual body
system.
• Adult normal vital signs
• Blood pressure: 90/60 mm Hg to 120/80 mm Hg.
• Breathing: 12 to 18 breaths per minute.
• Pulse: 60 to 100 beats per minute.
• Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C, SPO2
above 90%.
• Other measurements-weight, height.
Normal vitals for pediatrics
Skull, Scalp & Hair
• Observe / inspect the size, shape and contour of the skull.
• Observe scalp in several areas by separating the hair at various
locations; inquire about any injuries. Note presence of lice, nits,
dandruff or lesions.
• Palpate the head by running the pads of the fingers over the entire
surface of skull; inquire about tenderness upon doing so. (wear gloves
if necessary)
• Observe and feel the hair condition.
Normal Findings:
Skull
• Generally round, with prominences in the frontal and occipital area.
(Normocephalic).
• No tenderness noted upon palpation.
Scalp
• 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.
• No tenderness or masses on palpation
Hair
• Can be black, brown or burgundy depending on the race.
• Evenly distributed covers the whole scalp (No evidences of Alopecia)
• Maybe thick or thin, coarse or smooth.
• Neither brittle nor dry.
Face
• Observe the face for shape.
• Inspect for Symmetry.
• Inspect for the palpebral fissure (distance between the eye lids); should be equal in
both eyes.
• Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending
from the angle of the corner of the mouth). Slight asymmetry in the fold is normal.
• If both are met, then the Face is symmetrical
• Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)
• 1. Sensory Function
• Ask the client to close the eyes.
• Run cotton wisp over the fore head, check and jaw on both sides of the face.
• Ask the client if he/she feel it, and where she feels it.
• Check for corneal reflex using cotton wisp.
• The normal response in blinking.
2. Motor function
• Ask the client to chew or clench the jaw.
• The client should be able to clench or chew with strength and force.
CN VII (Facial)
1. Sensory function (This nerve innervate the anterior 2/3 of the
tongue).
• Place a sweet, sour, salty, or bitter substance near the tip of the
tongue.
• Normally, the client can identify the taste.
2. Motor function
• Ask the client to smile, frown, raise eye brow, close eye lids, whistle,
or puff the cheeks.
Normal Findings
• Shape maybe oval or rounded.
• Face is symmetrical.
• No involuntary muscle movements.
• Can move facial muscles at will.
• Intact cranial nerve V and VII.
Eyebrows, Eyes and Eyelashes
• All three structures are assessed using the modality of inspection.
Normal findings
Eyebrows
• Symmetrical and in line with each other.
• Maybe black, brown or blond depending on race.
• Evenly distributed.
Eyes
• Evenly placed and inline with each other.
• None protruding.
• Equal palpebral fissure.
Eyelashes
• Color dependent on race.
• Evenly distributed.
• Turned outward.
Eyelids and Lacrimal Apparatus
1. Inspect the eyelids for position and symmetry.
2. Palpate the eyelids for the lacrimal glands.
• To examine the lacrimal gland, the examiner, lightly slide the pad of the
index finger against the client’s upper orbital rim.
• Inquire for any pain or tenderness.
• 3. Palpate for the nasolacrimal duct to check for obstruction.
• To assess the nasolacrimal duct, the examiner presses with the index
finger against the client’s lower inner orbital rim, at the lacrimal sac,
NOT AGAINST THE NOSE.
• In the presence of blockage, this will cause regurgitation of fluid in the
puncta
Normal Findings
• Eyelids
• Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes
are open.
• No PTOSIS noted. (Drooping of upper eyelids).
• Meets completely when eyes are closed.
• Symmetrical.
Lacrimal Apparatus
• Lacrimal gland is normally non palpable.
• No tenderness on palpation.
• No regurgitation from the nasolacrimal duct.
Conjunctivae
The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the client look
up, down and to each side. When separating the lids, the examiner should exert NO PRESSURE against the
eyeball; rather, the examiner should hold the lids against the ridges of the bony orbit surrounding the eye.
In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow:
• Ask the client to look down but keep his eyes slightly open. This relaxes the levator muscles, whereas closing
the eyes contracts the orbicularis muscle, preventing lid eversion.
• Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes outward or upward; this,
too, causes muscles contraction.
• Place a cotton tip application above the lid margin and push gently downward with the applicator while still
holding the lashes. This everts the lid.
• Hold the lashes of the everted lid against the upper ridge of the bony orbit, just beneath the eyebrow, never
pushing against the eyebrow.
• Examine the lid for swelling, infection, and presence of foreign objects.
• To return the lid to its normal position, move the lid slightly forward and ask the client to look up and to blink.
Normal Findings:
• Both conjunctivae are pinkish or red in color.
• With presence of many minutes capillaries.
• Moist
• No ulcers
• No foreign objects
Sclerae
• The sclerae is easily inspected during the assessment of the
conjunctivae.
Normal Findings
• Sclerae is white in color (anicteric sclera)
• No yellowish discoloration (icteric sclera).
• Some capillaries maybe visible.
• Some people may have pigmented positions
Cornea
• The cornea is best inspected by directing penlight obliquely from
several positions.
Normal findings
• There should be no irregularities on the surface.
• Looks smooth.
• The cornea is clear or transparent. The features of the iris should be
fully visible through the cornea.
• There is a positive corneal reflex.
Anterior Chamber and Iris
• The anterior chamber and the iris are easily inspected in conjunction with the
cornea. The technique of oblique illumination is also useful in assessing the
anterior chamber.
Normal Findings:
• The anterior chamber is transparent.
• No noted any visible materials.
• Color of the iris depends on the person’s race (black, blue, brown or green).
• From the side view, the iris should appear flat and should not be bulging
forward. There should be NO crescent shadow casted on the other side when
illuminated from one side.
Pupils
• Examination of the pupils involves several inspections, including assessment of the
size, shape reaction to light is directed is observed for direct response of
constriction. Simultaneously, the other eye is observed for consensual response of
constriction.
The test for papillary accommodation is the examination for the change in papillary
size as it is switched from a distant to a near object.
• Ask the client to stare at the objects across room.
• Then ask the client to fix his gaze on the examiner’s index fingers, which is placed 5
– 5 inches from the client’s nose.
• Visualization of distant objects normally causes papillary dilation and visualization
of nearer objects causes papillary constriction and convergence of the eye.
Normal Findings
• Pupillary size ranges from 3 – 7 mm, and are equal in size.
• Equally round.
• Constrict briskly/sluggishly when light is directed to the eye, both directly
and consensual.
• Pupils dilate when looking at distant objects, and constrict when looking at
nearer objects.
• If all of which are met, we document the findings using the notation
PERRLA, pupils equally round, reactive to light, and accommodate
Cranial Nerve II (optic nerve)
• The optic nerve is assessed by testing for visual acuity and peripheral vision.
• Visual acuity is tested using a snellen chart, for those who are illiterate and
unfamiliar with the western alphabet, the illiterate E chart, in which the letter E
faces in different directions, maybe used.
• The chart has a standardized number at the end of each line of letters; these
numbers indicates the degree of visual acuity when measured at a distance of 20
feet.
• The numerator 20 is the distance in feet between the chart and the client, or the
standard testing distance. The denominator 20 is the distance from which the
normal eye can read the lettering, which correspond to the number at the end of
each letter line; therefore the larger the denominator the poorer the version.
• Measurement of 20/20 vision is an indication of either refractive error or some
other optic disorder.
In testing for visual acuity you may refer to the following:
• The room used for this test should be well lighted.
• A person who wears corrective lenses should be tested with and without them to
check fro the adequacy of correction.
• Only one eye should be tested at a time; the other eye should be covered by an
opaque card or eye cover, not with client’s finger.
• Make the client read the chart by pointing at a letter randomly at each line;
maybe started from largest to smallest or vice versa.
• A person who can read the largest letter on the chart (20/200) should be checked
if they can perceive hand movement about 12 inches from their eyes, or if they
can perceive the light of the penlight directed to their yes.
Peripheral Vision or visual fields
• The assessment of visual acuity is indicative of the functioning of the macular
area, the area of central vision. However, it does not test the sensitivity of the
other areas of the retina which perceive the more peripheral stimuli. The Visual
field confrontation test, provide a rather gross measurement of peripheral vision.
• The performance of this test assumes that the examiner has normal visual fields,
since that client’s visual fields are to be compared with the examiners.
Follow the steps on conducting the test:
• The examiner and the client sit or stand opposite each other, with the eyes at the
same, horizontal level with the distance of 1.5 – 2 feet apart.
• The client covers the eye with opaque card, and the examiner covers the eye that
is opposite to the client covered eye.
• Instruct the client to stare directly at the examiner’s eye, while the examiner
stares at the client’s open eye. Neither looks out at the object approaching from
the periphery.
• The examiner hold an object such as pencil or penlight, in his hand and gradually
moves it in from the periphery of both directions horizontally and from above and
below.
• Normally the client should see the same time the examiners sees it. The normal
visual field is 180 degrees.
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
• All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular
Movement (EOM) or the six cardinal position of gaze.
• Follow the given steps:
• Stand directly in front of the client and hold a finger or a penlight about 1 ft from
the client’s eyes.
• Instruct the client to follow the direction the object hold by the examiner by eye
movements only; that is with out moving the neck.
• The nurse moves the object in a clockwise direction hexagonally.
• Instruct the client to fix his gaze momentarily on the extreme position in each of
the six cardinal gazes.
• The examiner should watch for any jerky movements of the eye (nystagmus).
• Normally the client can hold the position and there should be no nystagmus.
Ears
• Inspect the auricles of the ears for parallelism, size position, appearance and skin
color.
• Palpate the auricles and the mastoid process for firmness of the cartilage of the
auricles, tenderness when manipulating the auricles and the mastoid process.
• Inspect the auditory meatus or the ear canal for color, presence of cerumen,
discharges, and foreign bodies.
• For adult pull the pinna upward and backward to straiten the canal.
• For children pull the pinna downward and backward to straiten the canal
• Perform otoscopic examination of the tympanic membrane, noting the color and
landmarks.
Normal Findings
• The ear lobes are bean shaped, parallel, and symmetrical.
• The upper connection of the ear lobe is parallel with the outer canthus of the
eye.
• Skin is same in color as in the complexion.
• No lesions noted on inspection.
• The auricles are has a firm cartilage on palpation.
• The pinna recoils when folded.
• There is no pain or tenderness on the palpation of the auricles and mastoid
process.
• The ear canal has normally some cerumen of inspection.
• No discharges or lesions noted at the ear canal.
• On otoscopic examination the tympanic membrane appears flat, translucent and
Nose and Paranasal Sinuses
The external portion of the nose is inspected for the following:
• Placement and symmetry.
• Patency of nares (done by occluding nosetril one at a time, and noting for
difficulty in breathing)
• Flaring of alae nasi
• Discharge
The external nares are palpated for:
• Displacement of bone and cartilage.
• For tenderness and masses
The internal nares are inspected by hyper extending the neck of the client, the
ulnar aspect of the examiners hard over the fore head of the client, and using the
thumb to push the tip of the nose upward while shining a light into the nares.
Inspect for the following:
• Position of the septum.
• Check septum for perforation. (Can also be checked by directing the lighted
penlight on the side of the nose, illumination at the other side suggests
perforation).
• The nasal mucosa (turbinates) for swelling, exudates and change in color.
Paranasal Sinuses
• Examination of the paranasal sinuses is indirectly. Information about their
condition is gained by inspection and palpation of the overlying tissues. Only
frontal and maxillary sinuses are accessible for examination.
• By palpating both cheeks simultaneously, one can determine tenderness of the
maxillary sinusitis, and pressing the thumb just below the eyebrows, we can
determine tenderness of the frontal sinuses.
Normal Findings
• Nose in the midline
• No Discharges.
• No flaring alae nasi.
• Both nares are patent.
• No bone and cartilage deviation noted on palpation.
• No tenderness noted on palpation.
• Nasal septum in the mid line and not perforated.
• The nasal mucosa is pinkish to red in color. (Increased redness turbinates are
typical of allergy).
• No tenderness noted on palpation of the paranasal sinuses.
Cranial Nerve I (Olfactory Nerve)
To test the adequacy of function of the olfactory nerve:
• The client is asked to close his eyes and occlude.
• The examiner places aromatic and easily distinguish nose. (E.g. coffee).
• Ask the client to identify the odor.
• Each side is tested separately, ideally with two different substances.
Mouth and Oropharynx Lips
Inspected for:
• Symmetry and surface abnormalities.
• Color
• Edema
Normal Findings:
• With visible margin
• Symmetrical in appearance and movement
• Pinkish in color
• No edema
Temporomandibular
Palpate while the mouth is opened wide and then closed for:
• Crepitous
• Deviations
• Tenderness
Normal Findings:
• Moves smoothly no crepitous.
• No deviations noted
• No pain or tenderness on palpation and jaw movement.
Gums
• Inspected for:
• Color
• Bleeding
• Retraction of gums.
Normal Findings:
• Pinkish in color
• No gum bleeding
• No receding gums
Teeth
• Inspected for:
• Number
• Color
• Dental carries
• Dental fillings
• Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).
• Tooth loss
• Breath should also be assessed during the process.
Normal Findings:
• 28 for children and 32 for adults.
• White to yellowish in color
• With or without dental carries and/or dental fillings.
• With or without malocclusions.
Tongue
• Palpated for:
• Texture
Normal Findings:
• Pinkish with white taste buds on the surface.
• No lesions noted.
• No varicosities on ventral surface.
• Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue.
• Gag reflex is present.
• Able to move the tongue freely and with strength.
• Surface of the tongue is rough.
Uvula
Inspected for:
• Position
• Color
• Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that
the uvula will move upward and forward.
Normal Findings:
• Positioned in the mid line.
• Pinkish to red in color.
• No swelling or lesion noted.
• Moves upward and backwards when asked to say “ah”
Tonsils
• Inspected for:
• Inflammation
• Size
A Grading system used to describe the size of the tonsils can be used.
• Grade 1 – Tonsils behind the pillar.
• Grade 2 – Between pillar and uvula.
• Grade 3 – Touching the uvula
• Grade 4 – In the midline.
Neck
• The neck is inspected for position symmetry and obvious lumps visibility of the
thyroid gland and Jugular Venous Distension
Normal Findings:
• The neck is straight.
• No visible mass or lumps.
• Symmetrical
• No jugular venous distension (suggestive of cardiac congestion).
• The neck is palpated just above the suprasternal note using the thumb and the
index finger.
Normal Findings:
• The trachea is palpable.
• It is positioned in the line and straight.
• Lymph nodes are palpated using palmar tips of the fingers via systemic circular
movements. Describe lymph nodes in terms of size, regularity, consistency,
tenderness and fixation to surrounding tissues.
Normal Findings:
• May not be palpable. Maybe normally palpable in thin clients.
• Non tender if palpable.
• Firm with smooth rounded surface.
• Slightly movable.
• About less than 1 cm in size.
• The thyroid is initially observed by standing in front of the client and
asking the client to swallow. Palpation of the thyroid can be done
either by posterior or anterior approach.
Posterior Approach:
• Let the client sit on a chair while the examiner stands behind him.
• In examining the isthmus of the thyroid, locate the cricoid cartilage and directly
below that is the isthmus.
• Ask the client to swallow while feeling for any enlargement of the thyroid
isthmus.
• To facilitate examination of each lobe, the client is asked to turn his head slightly
toward the side to be examined to displace the sternocleidomastoid, while the
other hand of the examiner pushes the thyroid cartilage towards the side of the
thyroid lobe to be examined.
• Ask the patient to swallow as the procedure is being done.
• The examiner may also palate for thyroid enlargement by placing the thumb deep
to and behind the sternocleidomastoid muscle, while the index and middle
fingers are placed deep to and in front of the muscle.
Anterior approach:
• The examiner stands in front of the client and with the palmar surface of the
middle and index fingers palpates below the cricoid cartilage.
• Ask the client to swallow while palpation is being done.
• In palpating the lobes of the thyroid, similar procedure is done as in posterior
approach. The client is asked to turn his head slightly to one side and then the
other of the lobe to be examined.
• Again the examiner displaces the thyroid cartilage towards the side of the lobe to
be examined.
• Again, the examiner palpates the area and hooks thumb and fingers around the
sternocleidomastoid muscle.
Normal Findings:
• Normally the thyroid is non palpable.
• Isthmus maybe visible in a thin neck.
• No nodules are palpable.
• Auscultation of the Thyroid is necessary when there is thyroid enlargement. The
examiner may hear bruits, as a result of increased and turbulence in blood flow in
an enlarged thyroid.
• Check the Range of Movement of the neck
Thorax (Cardiovascular System)
• Inspection of the Heart
• The chest wall and epigastrum is inspected while the client is in supine position.
Observe for pulsation and heaves or lifts
Normal Findings:
• Pulsation of the apical impulse maybe visible. (this can give us some indication of
the cardiac size).
• There should be no lift or heaves.
Palpation of the Heart
• The entire precordium is palpated methodically using the palms and
the fingers, beginning at the apex, moving to the left sternal border,
and then to the base of the heart.
Normal Findings:
• No, palpable pulsation over the aortic, pulmonic, and mitral valves.
• Apical pulsation can be felt on palpation.
• There should be no noted abnormal heaves, and thrills felt over the
apex.
Percussion of the Heart
• The technique of percussion is of limited value in cardiac assessment. It can
be used to determine borders of cardiac dullness.
Auscultation of the Heart
Anatomic areas for auscultation of the heart:
• Aortic valve – Right 2nd ICS sternal border.
• Pulmonic Valve – Left 2nd ICS sternal border.
• Tricuspid Valve – – Left 5th ICS sternal border.
• Mitral Valve – Left 5th ICS midclavicular line
Positioning the client for auscultation:
• If the heart sounds are faint or undetectable, try listening to them with the
patient seated and learning forward, or lying on his left side, which brings the
heart closer to the surface of the chest.
• Having the client seated and learning forward s best suited for hearing high-
pitched sounds related to semilunar valves problem.
• The left lateral recumbent position is best suited low-pitched sounds, such as
mitral valve problems and extra heart sounds.
Auscultating the heart:
• Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
• Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar
valve). S1 sound is best heard over the mitral valve; S2 is best heard over the
aortric valve.
• Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
• Count heart rate at the apical pulse for one full minute.
Normal Findings:
• S1 & S2 can be heard at all anatomic site.
• No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
• Cardiac rate ranges from 60 – 100 bpm.
Breast
Inspection of the Breast
There are 4 major sitting position of the client used for clinical breast examination.
Every client should be examined in each position.
1. The client is seated with her arms on her side.
2. The client is seated with her arms abducted over the head.
3. The client is seated and is pushing her hands into her hips, simultaneously
eliciting contraction of the pectoral muscles.
4. The client is seated and is learning over while the examiner assists in supporting
and balancing her.
While the client is performing these maneuvers, the breasts are
carefully observed for symmetry, bulging, retraction, and fixation.
An abnormality may not be apparent in the breasts at rest a mass may
cause the breasts, through invasion of the suspensory ligaments, to fix,
preventing them from upward movement in position 2 and 4.
Position 3 specifically assists in eliciting dimpling if a mass has
infiltrated and shortened suspensory ligaments.
Normal Findings:
• The overlying the breast should be even.
• May or may not be completely symmetrical at rest.
• The areola is rounded or oval, with same color, (Color varies form light pink to
dark brown depending on race).
• Nipples are rounded, everted, same size and equal in color.
• No “orange peel” skin is noted which is present in edema.
• The veins maybe visible but not engorge and prominent.
• No obvious mass noted.
• Not fixated and moves bilaterally when hands are abducted over the head, or is
learning forward.
• No retractions or dimpling.
Palpation of the Breast
• Palpate the breast along imaginary concentric circles, following a clockwise rotary
motion, from the periphery to the center going to the nipples. Be sure that the
breast is adequately surveyed. Breast examination is best done 1 week post
menses.
• Each areolar areas are carefully palpated to determine the presence of underlying
masses.
• Each nipple is gently compressed to assess for the presence of masses or
discharge
Normal Findings:
• No lumps or masses are palpable.
• No tenderness upon palpation.
• No discharges from the nipples.
NOTE: The male breasts are observed by adapting the techniques used for female
clients. However, the various sitting position used for woman is unnecessary.
Abdomen
In abdominal assessment, be sure that the client has emptied the bladder for comfort.
Place the client in a supine position with the knees slightly flexed to relax abdominal
muscles.
Inspection of the abdomen
• Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).
• Contour (flat, rounded, scapold)
• Distension
• Respiratory movement.
• Visible peristalsis.
• Pulsations
Normal Findings:
• Skin color is uniform, no lesions.
• Some clients may have striae or scar.
• No venous engorgement.
• Contour may be flat, rounded or scapoid
• Thin clients may have visible peristalsis.
• Aortic pulsation maybe visible on thin clients
Auscultation of the Abdomen
• This method precedes percussion because bowel motility, and thus bowel
sounds, may be increased by palpation or percussion.
• The stethoscope and the hands should be warmed; if they are cold, they may
initiate contraction of the abdominal muscles.
• Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits.
Intestinal sounds are relatively high-pitched, the bell may be used in exploring
arterial murmurs and venous hum.
Peristaltic sounds
• These sounds are produced by the movements of air and fluids through the
gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the
motility of bowel.
Listening to the bowel sounds (borborygmi) can be facilitated by following these
steps:
• Divide the abdomen in four quadrants.
• Listen over all auscultation sites, starting at the right lower quadrants, following
the cross pattern of the imaginary lines in creating the abdominal quadrants. This
direction ensures that we follow the direction of bowel movement.
• Peristaltic sounds are quite irregular. Thus it is recommended that the examiner
listen for at least 5 minutes, especially at the periumbilical area, before
concluding that no bowel sounds are present.
• The normal bowel sounds are high-pitched, gurgling noises that occur
approximately every 5 – 15 seconds. It is suggested that the number of bowel
sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel
sound for each breath sound.
Some factors that affect bowel sound:
• Presence of food in the GI tract.
• State of digestion.
• Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus,
peritonitis).
• Bowel surgery
• Constipation or Diarrhea.
• Electrolyte imbalances.
• Bowel obstruction.
Percussion of the abdomen
• Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites),
gaseous distension, and masses, and in assessing solid structures within the
abdomen.
• The direction of abdominal percussion follows the auscultation site at each
abdominal guardant.
• The entire abdomen should be percussed lightly or a general picture of the areas
of tympany and dullness.
• Tympany will predominate because of the presence of gas in the small and large
bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the
6th or 9th rib just posterior to or at the mid axillary line on the left side.
• Percussion in the abdomen can also be used in assessing the liver span and size of
the spleen.
Percussion of the liver
• The palms of the left hand are placed over the region of liver dullness.
• The area is strucked lightly with a fisted right hand.
• Normally tenderness should not be elicited by this method.
• Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.
Renal Percussion
• Can be done by either indirect or direct method.
• Percussion is done over the costovertebral junction.
• Tenderness elicited by such method suggests renal inflammation.
Palpation of the Abdomen
Light palpation
• It is a gentle exploration performed while the client is in supine position. With the
examiner’s hands parallel to the floor.
• The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm
without digging, but gently palpating with slow circular motion.
• This method is used for eliciting slight tenderness, large masses, and muscles, and
muscle guarding.
Tensing of abdominal musculature may occur because of:
• The examiner’s hands are too cold or are pressed to vigorously or deep into the
abdomen.
• The client is ticklish or guards involuntarily.
• Presence of subjacent pathologic condition.
Normal Findings:
• No tenderness noted.
• With smooth and consistent tension.
• No muscles guarding.
Deep Palpation
• It is the indentation of the abdomen performed by pressing the distal half of the
palmar surfaces of the fingers into the abdominal wall.
• The abdominal wall may slide back and forth while the fingers move back and
forth over the organ being examined.
• Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or
masses may be felt with this method.
• In the absence of disease, pressure produced by deep palpation may produce
tenderness over the cecum, the sigmoid colon, and the aorta.
Liver palpation
• There are two types of bi manual palpation recommended for palpation of the
liver. The first one is the superimposition of the right hand over the left hand.
• Ask the patient to take 3 normal breaths.
• Then ask the client to breath deeply and hold. This would push the liver down to
facilitate palpation.
• Press hand deeply over the RUQ (right upper quadrant)
The second methods:
• The examiner’s left hand is placed beneath the client at the level of the right 11th
and 12th ribs.
• Place the examiner’s right hands parallel to the costal margin or the RUQ.
• An upward pressure is placed beneath the client to push the liver towards the
examining right hand, while the right hand is pressing into the abdominal wall.
• Ask the client to breath deeply.
• As the client inspires, the liver maybe felt to slip beneath the examining fingers.
Normal Findings:
• The liver usually can not be palpated in a normal adult. However, in
extremely thin but otherwise well individuals, it may be felt the costal
margins.
• When the normal liver margin is palpated, it must be smooth, regular in
contour, firm and non-tender.
Extremities
Inspection
• Observe for size, contour, bilateral symmetry, and involuntary movement.
• Look for gross deformities, edema, presence of trauma such as ecchymosis or
other discoloration.
• Always compare both extremities.
Palpation
• Feel for evenness of temperature. Normally it should be even for all the
extremities.
• Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s
fingers and noting for equality of contraction).
• Perform range of motion.
• Test for muscle strength. (performed against gravity and against resistance)
Nursing is not for everyone. It takes a very strong,
intelligent, and compassionate person to take on the ills
of the world with passion and purpose and work to
maintain the health and well-being of the planet. No
wonder we’re exhausted at the end of the day!~Donna
Wilk Cardillo