Nursing Skills

Physical Assessment
Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 1

TYPES OF PALPATION
Light Palpation
 To check muscle tone and assess for tenderness
Techniques:
Place the hand with fingers together parallel
to the area being palpated. Press down 1 to 2 cm.
Repeat in ever-widening circles until the area to be
NURSING SKILLS examined is covered.

Physical Assessment

Lecturer: Mark Fredderick R. Abejo R.N, M.A.N

PHYSICAL ASSESSMENT

Deep Palpation
Objectives:  To identify abdominal organs and abdominal masses.
 Obtain physical data about the client’s functional Techniques:
abilities With fingers together, approach the area to
 Supplement, confirm, or refuse data obtained in the be examined at a 60 degree angle and use the pads and
nursing history tips of the fingers of one hand to press in 4 cm.
 Obtain data that will help the nurse data establish
nursing diagnoses and plan the client’s care. Two – handed Deep Palpation place the fingers of one
 Evaluate the physiologic outcomes of health care and hand on top of those of the other.
thus the progress of a patient’s health problem
 Screen presence of cancer

CEPHALOCAUDAL ORDER OF EXAMINATION

AREAS

 HEENT
 NECK
 UPPER EXTREMITIES
 CHEST AND BACK
 BREAST AND AXILLAE PERCUSSION
 ABDOMEN  Striking of the body surface with short, sharp strokes
 GENITALS in order to produce palpable vibrations and
 ANUS AND RECTUM characteristic sound.
 LOWER EXTREMITIES  It is used to determine the location, size, shape, and
Note: SKIN IS CHECK THROUGHTOUT THE density of underlying structures; to detect the presence
ASSESSMENT of air or fluid in a body space; and to elicit tenderness.

General Concepts: TYPES OF PERCUSSION

Direct Percussion
Approach the client calmly and confidently.  Percussion in which one hand is used and the striking
Provide privacy. finger (plexor) of the examiner touches the surface
Make sure that all needed instruments are available being percussed.
before starting the physical assessment Techniques:
Several positions are frequently required during the Using sharp rapid movements from the wrist, strike
assessment. Consider the client’s ability to assume a the body surface to be percussed with the pads of two,
position. three, or four fingers or with the pad of the middle
Be systematic and organized when assessing the finger alone. Primarily used to assess sinuses in the
client. (Inspection, Palpation, Percussion, Auscultation adult.
If a client is seriously ill, assess the systems of the
body that are more at risk Indirect Percussion
Perform painful procedures at the end of the  Percussion in which two hands are used and the plexor
examination strikes the finger of the examiner’s other hand, which
is in contact with the body surface being percussed
METHODS OF EXAMINING (pleximeter).
Techniques:
 INSPECTION Strike at a right angle to the pleximeter using quick,
 PALPATION sharp but relaxed wrist motion.
 PERCUSSION Withdraw the plexor immediately after the strike to
 AUSCULTATION avoid damping the vibration. Strike each are twice and
then move to a new area
INSPECTION
 Visual examination of the patient done in a methodical Blunt
and deliberate manner.  Ulnar surface of the hand or fist is used in place of the
fingers to strike the body surface, either directly or
PALPATION indirectly.
 Is the use of hand to touch for the purpose of
determining temperature, moisture, size, shape,
position, texture, consistency, and movement.
Foundations of Nursing Abejo
 PERCUSSION SOUNDS Procedure:
1. Inspects skin surfaces
1. RESONANCE – Hollow sound. Ex. normal lung. 2. Palpates with fingertips for edema and skin turgor
2. HYPERRESONANCE – Booming sound. Ex. 3. Palpates skin temperature contra-laterally using back
Emphysematous lung of hands
3. TYMPANY – musical or drum sound. Ex. Stomach
and intestines Assessment:
4. DULLNESS – Thud sound. Ex. Enlarged spleen, full
bladder, liver. Health History
5. FLATNESS – extremely dull sound. Ex. Muscle or  Presenting problem
bone  Changes in the color and texture of the skin, hair
AUSCULTATION and nails.
 Listening to sounds produced inside the body  Pruritus
 Infections
 Tumors and other lesions
EQUIPMENTS FOR PHYSICAL  Dermatitis
EXAMINATION  Ecchymoses
 Dryness
 Sphygmomanometer and stethoscope  Lifestyle practices
 Thermometer  Hygienic practices
 Nasal Speculum  Skin exposure
 Ophthalmoscope  Nutrition / diet
 Otoscope  Intake of vitamins and essential nutrients
 Vaginal Speculum  Water and Food allergies
 Tongue depressor/blade  Use of medications
 Penlight  Steroids
 Cotton Applicators  Antibiotics
 Tuning fork  Vitamins
 Reflex hammer  Hormones
 Clean gloves  Chemotherapeutic drugs
 Lubricant  Past medical history
 Renal and hepatic disease
 Collagen and other connective tissue diseases
GENERAL SURVEY  Trauma or previous surgery
 Food, drug or contact allergies
VITAL SIGNS
 Family medical history
GENERAL SURVEY
 Diabetes mellitus
 Allergic disorders
1. Physical Appearance
 Blood dyscrasias
2. Level of Conciousness/ awareness
 Alertness– Patient is awake and aware of self  Specific dermatologic problems
and environment.  Cancer
 Lethargy – When spoken to in a loud voice,
patient appears drowsy but opens eye, and look Physical Examination
at you, responds to questions, then falls asleep.  Color
 Obtundation – When shaken gently, patient  Areas of uniform color
opens eye and looks at you but responds  Pigmentation
slowly and is somewhat confused.  Redness
 Stupor – Patient arouses from sleep only after  Jaundice
painful stimuli.  Cyanosis
 Coma – Despite repeated painful stimuli,  Vascular changes
patient remains unarousable with eyes closed.  Purpuric lesions
 Ecchymoses
3. Apperance in relation to chronological age  Petechiae
4. Signs of distress  Vascular lesions
5. Nutritional status  Angiomas
6. Body structure  Hemangiomas
7. Obvious physical deformities  Venous stars
8. Mobility  Lesions
9. Behavior  Color
10. Odors of body and breath  Type
11. Facial Expression  Size
12. Mood & affect  Distribution
13. Speech  Location
 Consistency
SYSTEMS ASSESSMENT  Grouping
 Annular
 Linear
INTEGUMENTARY SYSTEM  Circular
 Clustered
Functions of the Skin:
 Protection  Edema (pitting or non-pitting)
 Absorption  Moisture content
 Regulation
 Temperature (increased or decreased;
 Synthesis distribution of temperature changes)
 Sensory  Texture
 Mobility / Turgor
 Hypertrophic scar on the other hand does not
Effects of Aging in the Skin overgrow the wound boundaries.
 Skin vascularity and the number of sweat and Fibrosis or sclerosis describes dermal
sebaceous glands decrease, affecting scarring/thickening reactions.
thermoregulation. Milium is a small superficial cyst containing keratin
 Inflammatory response and pain perception diminish. (usually <1-2 mm in size
 Thinning epidermis and prolonged wound healing
make elderly more prone to injury and skin infections. Vascular Skin Lesions
 Skin cancer more common.
Petechiae is a round or purple macule, associated with
Primary Lesions of the Skin bleeding tendencies or emboli to skin
Ecchymosis a round or irregular macular lesion larger
Macule is a small spot that is not palpable and is less than petechiae, color varies and changes from black,
than 1 cm in diameter yellow and green hues. Associated with trauma and
Patch is a large spot that is not palpable & that is > 1 bleeding tendencies.
cm. Cherry Angioma, popular and round, red or purple,
Papule is a small superficial bump that is elevated & may blanch with pressure and a normal age-related
that is < 1 cm. skin alteration.
Plaque is a large superficial bump that is elevated & > Spider Angioma is a red, arteriole lesion, central
1 cm. body with radiating branches. Commonly seen on
Nodule is a small bump with a significant deep face,neck,arms and trunk. Associated with liver
component & is < 1 cm. disease, pregnancy and vitB deficiency.
Tumor is a large bump with a significant deep Telangiectasia , shaped varies: spider-like or linear,
component & is > 1 cm. bluish in color or sometimes red. Does not blanch
Cyst is a sac containing fluid or semisolid material, ie. when pressure applied. Secondary to superficial
cell or cell products. dilation of venous vessels and capillaries.
Vesicle is a small fluid-filled bubble that is usually
superficial & that is < 0.5 cm.
Bulla is a large fluid-filled bubble that is superficial or Edema - the presence of large amounts of fluid in the interstitial
deep & that is > 0.5 cm. spaces. Usually due to fluid collecting in the subcutaneous
Pustule is pus containing bubble often categorized tissue. Edema may be localized or generalized.
according to whether or not they are related to hair
follicles:
 follicular - generally indicative of local A. Some causes are lymphatic obstruction,
infection increased vascular permeability, decreased
 folliculitis - superficial, generally multiple oncotic pressure due to low levels of plasma
 furuncle - deeper form of folliculitis proteins (especially albumin), or renal or
 carbuncle - deeper, multiple follicles cardiac disease.
coalescing B. Collections of edema are named according
to the site:
Secondary lesions of the Skin 1. Anasarca - massive generalized
edema
Scale is the accumulation or excess shedding of the 2. Ankle
stratum corneum. 3. Ascites - peritoneal cavity
 Scale is very important in the differential 4. Hydrothorax - thoracic cavity
diagnosis since its presence indicates that the 5. Periorbital - around the eyes
epidermis is involved. 6. Sacral - lower back
 Scale is typically present where there is C. Edema occurs in dependent areas first.
epidermal inflammation, ie. psoriasis, tinea, D. Edema is graded on a scale considering the
eczema depth of the indentation and the length of
Crust is dried exudate (ie. blood, serum, pus) on the time to return to normal. Assessment: Press
skin surface. firmly with finger for 5 seconds.
Excoriation is a loss of skin due to scratching or
picking. Rating Assessment
Lichenification is an increase in skin lines & creases 1+ 5mm depth, recovers immediately
from chronic rubbing. 2+ 8-10 mm, duration 10-15 sec.
Maceration is raw, wet tissue. 3+ 11-20 mm, duration 15-30 sec.
Fissure is a linear crack in the skin; often very 4+ >20 mm, duration >30 sec.
painful.
Erosion is a superficial open wound with loss of
epidermis or mucosa only HEAD
Ulcer is a deep open wound with partial or complete
loss of the dermis or submucosa Procedure:

Distinct Lesions of the Skin 1. Observe the size, shape and contour of the skull.
2. Observe scalp in several areas by separating the hair at
Wheal or hive describes a short lived (< 24 hours), various locations; inquire about any injuries. Note
edematous, well circumscribed papule or plaque seen presence of lice, nits, dandruff or lesions.
in urticaria. 3. Palpate the head by running the pads of the fingers
Burrow is a small threadlike curvilinear papule that is over the entire surface of skull; inquire about
virtually pathognomonic of scabies. tenderness upon doing so. (wear gloves if necessary)
Comedone is a small, pinpoint lesion, typically 4. Observe and feel the hair condition.
referred to as “whiteheads” or “blackheads.” 5. Test Cranial Nerve VII
Atrophy is a thinning of the epidermal and/or dermal 6. Test Cranial Nerve V
tissue.
Keloid overgrows the original wound boundaries and
is chronic in nature.
Nursing Skills
Physical Assessment
Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 4

Normal Findings: 1. Sensory function (This nerve innervate the anterior 2/3 of
the tongue).
1. Skull · Place a sweet, sour, salty, or bitter substance near the tip of
· Generally round, with prominences in the frontal and the tongue.
occipital area. (Normocephalic). · Normally, the client can identify the taste.
· No tenderness noted upon palpation.
2. Scalp 2. Motor function
· Lighter in color than the complexion. · Ask the client to smile, frown, raise eye brow, close eye lids,
· Can be moist or oily. whistle, or puff the cheeks.
· No scars noted.
· Free from lice, nits and dandruff.
Normal Findings:
· No lesions should be noted.
· Shape maybe oval or rounded.
· No tenderness nor masses on palpation.
· Face is symmetrical.
3. Hair
· No involuntary muscle movements.
· Can be black, brown or burgundy depending on the
· Can move facial muscles at will.
race.
· Intact cranial nerve V and VII.
· Evenly distributed covers the whole scalp (No
evidences of Alopecia)
· Maybe thick or thin, coarse or smooth. EYE / EYEBROW / EYELASHES
· Neither brittle nor dry.
Normal findings:
FACE Eyebrows
· Symmetrical and in line with each other.
· Maybe black, brown or blond depending on race.
1. Observe the face for shape.
· Evenly distributed.
2. Inspect for Symmetry.

Eyes
a. Inspect for the palpebral fissure (distance between the
· Evenly placed and inline with each other.
eye lids); should be equal in both eyes.
· Non protruding.
b. Ask the patient to smile, There should be bilateral
· Equal palpebral fissure.
Nasolabial fold (creases extending from the angle of
the corner of the mouth). Slight asymmetry in the fold
is normal. Eyelashes
c. If both are met, then the Face is symmetrical · Color dependent on race.
· Evenly distributed.
· Turned outward
3. Test the functioning of Cranial Nerves that innervates the
facial structures
EYELIDS / LACRIMAL APPARATUS
CN V (Trigeminal)
1. Inspect the eyelids for position and symmetry.
2. Palpate the eyelids for the lacrimal glands.
To examine the lacrimal gland, the examiner, lightly
slide the pad of the index finger against the client’s
upper orbital rim.
Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
To assess the nasolacrimal duct, the examiner presses
with the index finger against the client’s lower inner
orbital rim, at the lacrimal sac, NOT AGAINST THE
NOSE.
1. Sensory Function In the presence of blockage, this will cause
· Ask the client to close the eyes. regurgitation of fluid in the puncta
· Run cotton wisp over the fore head, check and jaw on both
sides of the face.
· Ask the client if he/she feel it, and where she feels it. Normal Findings:
· Check for corneal reflex using cotton wisp.
· The normal response in blinking. Eyelids
· Upper eyelids cover the small portion of the iris, cornea, and
2. Motor function sclera when eyes are open.
· Ask the client to chew or clench the jaw. · No PTOSIS noted. (drooping of upper eyelids).
· The client should be able to clench or chew with strength and · Meets completely when eyes are closed.
force. · Symmetrical.

Lacrimal Apparatus
CN VII (Facial) · Lacrimal gland is normally non palpable.
· No tenderness on palpation.
· No regurgitation from the nasolacrimal duct.

CONJUNCTIVAE

a The bulbar and palpebral conjunctivae are examined

by separating the eyelids widely and having the client look up,
down and to each side. When separating the lids, the examiner
should exert no NO PRESSURE against the eyeball; rather, the
Found Abejo

of Nursing
examiner should hold the lids against the ridges of the bony Normal findings:
orbit surrounding the eye.
· There should be no irregularities on the surface.
In examining the palpebral conjunctiva, everting the upper · Looks smooth.
eyelid in necessary and is done as follow: · The cornea is clear or transparent. The features of the iris
should be fully visible through the cornea.
1. Ask the client to look down but keep his eyes slightly open. · There is a positive corneal reflex.
This relaxes the levator muscles, whereas closing the eyes
contracts the orbicularis muscle, preventing lid eversion. ANTERIOR CHAMBER / IRIS
2. Gently grasp the upper eyelashes and pull gently downward.
Do not pull the lashes outward or upward; this, too, causes The anterior chamber and the iris are easily inspected
muscles contraction. in conjunction with the cornea. The technique of oblique
3. Place a cotton tip application about I can above the lid illumination is also useful in assessing the anterior chamber.
margin and push gently downward with the applicator while still
holding the lashes. This everts the lid.
4. Hold the lashes of the everted lid against the upper ridge of Normal Findings:
the bony orbit, just beneath the eyebrow, never pushing against
the eyebrow. · The anterior chamber is transparent.
5. Examine the lid for swelling, infection, and presence of · No noted any visible materials.
foreign objects. · Color of the iris depends on the person’s race (black, blue,
6. To return the lid to its normal position, move the lid slightly brown or green).
forward and ask the client to look up and to blink. The lid · From the side view, the iris should appear flat and should not
returns easily to its normal position. be bulging forward. There should be NO crescent shadow casted
on the other side when illuminated from one side.

PUPIL

Examination of the pupils involves several

inspections, including assessment of the size, shape reaction to
light is directed is observed for direct response of constriction.
Simultaneously, the other eye is observed for consensual
response of constriction.

The test for papillary accommodation is the

examination for the change in papillary size as the is switched
from a distant to a near object.

Normal Findings: 1. Ask the client to stare at the objects across room.
2. Then ask the client to fix his gaze on the examiner’s index
fingers, which is placed 5 – 5 inches from the client’s nose.
· Both conjunctivae are pinkish or red in color. 3. Visualization of distant objects normally causes papillary
· With presence of many minutes capillaries. dilation and visualization of nearer objects causes papillary
· Moist constriction and convergence of the eye.
· No ulcers
· No foreign objects
Normal Findings:

SCLERAE
· Pupillary size ranges from 3 – 7 mm, and are equal in size.
· Equally round.
The sclerae is easily inspected during the assessment of the · Constrict briskly/sluggishly when light is directed to the eye,
conjunctivae. 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

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.
Foundations of Nursing Abejo
CRANIAL NERVE II ( OPTIC NERVE ) 3. Instruct the client to stare directly at the examiner’s eye,
while the examiner stares at the client’s open eye. Neither looks
The optic nerve is assessed by testing for visual acuity out at the object approaching from the periphery.
and peripheral vision. 4. The examiner hold an object such as pencil or penlight, in
his hand and gradually moves it in from the periphery of both
Visual acuity is tested using a snellen chart, for those directions horizontally and from above and below.
who are illiterate and unfamiliar with the western alphabet, the 5. Normally the client should see the same time the examiners
illiterate E chart, in which the letter E faces in different sees it. The normal visual field is 180 degress
directions, maybe used. The chart has a standardized number at
the end of each line of letters; these numbers indicates the CRANIAL NERVE III, IV & VI
degree of visual acuity when measured at a distance of 20 feet. ( Oculomotor,Trochlear,Abducens )

The numerator 20 is the distance in feet between the All the 3 Cranial nerves are tested at the same time by
chart and the client, or the standard testing distance. The assessing the Extra Ocular Movement (EOM) or the six cardinal
denominator 20 is the distance from which the normal eye can position of gaze.
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.

Follow the given steps:

1. Stand directly in front of the client and hold a finger or a

penlight about 1 ft from the client’s eyes.
In testing for visual acuity you may refer to the following: 2. Instruct the client to follow the direction the object hold by
the examiner by eye movements only; that is with out moving
the neck.
1. The room used for this test should be well lighted. 3. The nurse moves the object in a clockwise direction
2. A person who wears corrective lenses should be tested with hexagonally.
and without them to check fro the adequacy of correction. 4. Instruct the client to fix his gaze momentarily on the
3. Only one eye should be tested at a time; the other eye extreme position in each of the six cardinal gazes.
should be covered by an opaque card or eye cover, not with 5. The examiner should watch for any jerky movements of the
client’s finger. eye (nystagmus).
4. Make the client read the chart by pointing at a letter 6. Normally the client can hold the position and there should
randomly at each line; maybe started from largest to smallest or be no nystagmus.
vice versa.
5. 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.
Test for Accomodation
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. EAR

1. Inspect the auricles of the ears for parallelism, size position,

Follow the steps on conducting the test:
appearance and skin color.
2. Palpate the auricles and the mastoid process for firmness of
1. The examiner and the client sit or stand opposite each the cartilage of the auricles, tenderness when manipulating the
other, with the eyes at the same, horizontal level with the auricles and the mastoid process.
distance of 1.5 – 2 feet apart. 3. Inspect the auditory meatus or the ear canal for color,
2. The client covers the eye with opaque card, and the presence of cerumen, discharges, and foreign bodies.
examiner covers the eye that is opposite to the client covered
eye.
Foundations of Nursing Abejo
a. For adult pull the pinna upward and backward to straighten Normal: hear sounds equally in both ears (No Lateralization of
the canal. sound)
b. For children pull the pinna downward and backward to
straighten the canal
Conduction loss – Sound lateralizes to defective ear (Heard
louder on defective ear) as few extraneous sounds are carried
4. Perform otoscopic examination of the tympanic membrane, through the external and middle ear.
noting the color and landmarks.
Sensorineural loss – Sound lateralizes on better ear.
Normal Findings:
2. Rinne Test – Compares bone conduction with air condition.
· The ear lobes are bean shaped, parallel, and symmetrical.
· The upper connection of the ear lobe is parallel with the outer
canthus of the eye. a. Vibrating tuning fork placed on the mastoid process
· Skin is same in color as in the complexion. b. Instruction client to inform the examiner when he no longer
· No lesions noted on inspection. hears the tuning fork sounding.
· The auricles are has a firm cartilage on palpation. c. Position in the tuning fork in front of the client’s ear canal
· The pinna recoils when folded. when he no longer hears it.
· 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 pearly gray in color.

VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VII )

Examination of the cranial nerve VIII involves testing for

hearing acuity and balance.
Normal: Sound should be heard when tuning fork is placed in
Hearing Acuity front of the ear canal as air conduction< bone conduction by 2:1
(positive rinne test)
A. Voice test
Conduction loss: Sound is heard longer by bone conduction than
by air conduction.
1. The examiner stands 2 ft. on the side of the ear to be tested.
2. Instruct the client to occlude the ear canal of the other ear.
3. The examiner then covers the mouth, and using a soft Sensorineural loss: Sound is heard longer by air conduction than
spoken voice, whispers non-sequential number (e.g. 3 5 7 ) for by bone conduction
the client to repeat.
4. Normally the client will be able to hear and repeat the NOSE AND PARANASAL SINUSES
number.
5. Repeat the procedure at the other ear. The external portion of the nose is inspected for the following:

B. Watcher test 1. Placement and symmetry.

2. Patency of nares (done by occluding nosetril one at a time,
1. Ask the client to close the eyes. and noting for difficulty in breathing)
2. Place a mechanical watch 1 – 2 inches away the client’s ear. 3. Flaring of alaenasi
3. Ask the client if he hears anything 4. Discharge
4. If the client says yes, the examiner should validate by
asking at what are you hearing and at what side. The external nares are palpated for:
5. Repeat the procedure on the other ear.
6. Normally the client can identify the sound and at what side
it was heard. 1. Displacement of bone and cartilage.
2. For tenderness and masses
Turning Fork Test
The internal nares are inspected by heperextending the neck of
the client, the ulnar aspect of the examiner’s hard over the fore
This test is useful in determining whether the client head of the client, and using the thumb to push the tip of the
has a conductive hearing loss (problem of external or middle nose upward while shining a light into the naris.
ear) or a perceptive hearing loss (sensorineural). There are 2
types of tuning fork test being conducted:

1. Weber’s test – assesses bone conduction, this is a test of

sound lateralization; vibrating tuning fork is placed on the
middle of the fore head or top of the skull.
Inspect for the following: MOUTH

1. Position of the septum. Mouth and Oropharynx Lips are inspected for:
2. 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). 1. Symmetry and surface abnormalities.
3. The nasal mucosa (turbinates) for swelling, exudates and 2. Color
change in color. 3. Edema

Normal Findings:
Paranasal Sinuses
1. With visible margin
2. Symmetrical in appearance and movement
3. Pinkish in color
4. No edema

Palpate the temporomandibular while the mouth is opened

wide and then closed for:

1. Crepitous
2. Deviations
3. Tenderness

Normal Findings:

1. Moves smoothly no crepitous.

Examination of the paranasal sinuses is indirectly. 2. No deviations noted
Information about their condition is gained by inspection and 3. No pain or tenderness on palpation and jaw
palpation of the overlying tissues. Only frontal and maxillary movement.
sinuses are accessible for examination.
Gums are inspected for:
By palpating both cheeks simultaneously, one can
determine tenderness of the maxillary sinusitis, and pressing the 1. Color
thumb just below the eyebrows, we can determine tenderness of 2. Bleeding
the frontal sinuses. 3. Retraction of gums.

Normal Findings:

1. Pinkish in color
2. No gum bleeding
3. No receding gums

Teeth are inspected for:

1. Number
2. Color
3. Dental carries
4. Dental fillings
5. Alignment and malocclusions (2 teeth in the space for
Normal Findings: 1, or overlapping teeth).
6. Tooth loss
7. Breath should also be assessed during the process.
1. Nose in the midline
2. No Discharges.
3. No flaring alae nasi. Normal Findings:
4. Both nares are patent.
5. No bone and cartilage deviation noted on palpation. 1. 28 for children and 32 for adults.
6. No tenderness noted on palpation. 2. White to yellowish in color
7. Nasal septum in the mid line and not perforated. 3. With or without dental carries and/or dental fillings.
8. The nasal mucosa is pinkish to red in color. (Increased 4. With or without malocclusions.
redness turbinates are typical of allergy). 5. No halitosis.
9. No tenderness noted on palpation of the paranasal sinuses.
Tongue is palpated for:
OLFACTORY NERVE
Texture
To test the adequacy of function of the olfactory nerve:
Normal Findings:
1. The client is asked to close his eyes and occlude.
2. The examiner places aromatic and easily distinguish 1. Pinkish with white taste buds on the surface.
nose. (e.g. coffee). 2. No lesions noted.
3. Ask the client to identify the odor. 3. No varicosities on ventral surface.
4. Each side is tested separately, ideally with two 4. Frenulum is thin attaches to the posterior 1/3 of the
different substances. ventral aspect of the tongue.
 5. Gag reflex is present.
6. Able to move the tongue freely and with strength.
7. Surface of the tongue is rough. mph nodes are palpated using palmar tips of the fingers via
systemic circular movements. Describe lymph nodes in termsof
Uvula is inspected for: size, regularity, consistency, tenderness and fixation to
surrounding tissues.
1. Position
2. Color
3. Cranial Nerve X (Vagus nerve) – Tested by asking the
client to say “Ah” note that the uvula will move
upward and forward.

Normal Findings:

1. Positioned in the mid line.

2. Pinkish to red in color.
3. No swelling or lesion noted.
4. Moves upward and backwards when asked to say “ah”

Tonsils are inspected for:

1. Inflammation
2. Size

A Grading system used to describe the size of the tonsils can be

used.
Normal Findings:

Grade 1 – Tonsils behind the pillar.

1. May not be palpable. Maybe normally palpable in thin
Grade 2 – Between pillar and uvula. clients.
Grade 3 – Touching the uvula 2. Non tender if palpable.
Grade 4 – In the midline. 3. Firm with smooth rounded surface.
4. Slightly movable.
NECK 5. About less than 1 cm in size.
6. The thyroid is initially observed by standing in front
of the client and asking the client to swallow.
The neck is inspected for position symmetry and obvious lumps Palpation of the thyroid can be done either by
visibility of the thyroid gland and Jugular Venous Distension. posterior or anterior approach.

Normal Findings: Indication of Lymph Nodes

1. The neck is straight.  Occipital: Head infection

2. No visible mass or lumps.  Submental: Dental Carriections, Oral inf
3. Symmetrical  SubMandibular: Infection
4. No jugular venous distension (suggestive of cardiac
 SCM Upper: Lymphoma
congestion).
 Supraclavicular: Cancer

The neck is palpated just above the suprasternal note using the
Posterior Approach:
thumb and the index finger.

1. Let the client sit on a chair while the examiner stands

The neck is palpated just above the suprasternal note using the
behind him.
thumb and the index finger.
2. In examining the isthmus of the thyroid, locate the
cricoid cartilage and directly below that is the isthmus.
Normal Findings: 3. Ask the client to swallow while feeling for any
enlargement of the thyroid isthmus.
1. The trachea is palpable. 4. To facilitate examination of each lobe, the client is
2. It is positioned in the line and straight. 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.
5. Ask the patient to swallow as the procedure is being
done.
6. 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.
7. Then the procedure is repeated on the other side.
Anterior approach: Inspection of the Thorax

1. The examiner stands in front of the client and with the For adequate inspection of the thorax, the client should be sitting
palmar surface of the middle and index fingers upright without support and uncovered to the waist.
palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation is being The examiner should observe:
done.
3. In palpating the lobes of the thyroid, similar procedure
is done as in posterior approach. The client is asked to 1. Shape of the thorax and its symmetry.
turn his head slightly to one side and then the other of 2. Thoracic configuration.
the lobe to be examined. 3. Retractions at the ICS on inspiration.
4. Again the examiner displaces the thyroid cartilage (suprasternal, costal, substernal)
towards the side of the lobe to be examined. 4. Bulging structures at the ICS during
5. Again, the examiner palpates the area and hooks expiration.
thumb and fingers around the sternocleidomastoid 5. position of the spine.
muscle. 6. pattern of respiration.

Normal Findings: Normal Findings:

1. Normally the thyroid is non palpable. The shape of the thorax in a normal adult is elliptical;
2. Isthmus maybe visible in a thin neck. the anteroposterior diameter is less than the transverse
3. No nodules are palpable. diameter at approximately a ratio of 1:2.
Moves symmetrically on breathing with no obvious
Auscultation of the Thyroid is necessary when there is thyroid masses.
enlargement. The examiner may hear bruits, as a result of No fail chest which is suggestive of rib fracture.
increased and turbulence in blood flow in an enlarged thyroid. No chest retractions must be noted as this may suggest
difficulty in breathing.
No bulging at the ICS must be noted as this may
Check the Range of Movement of the neck.
obstruction on expiration, abnormal masses, or
cardiomegaly.
The spine should be straight, with slightly curvature
in the thoracic area.
THORAX There should be no scoliosis, kyphosis, or lordosis.
Breathing maybe diaphragmatically of costally.
Lung borders Expiration is usually longer the inspiration.
In the anterior thorax, the apices of the lungs extend
for approximately 3 – 4 cm above the clavicles. The inferior Palpation of the Thorax
borders of the lungs cross the sixth rib at the midclavigular line.

In the posterior thorax, the apices extend of T10 on

expiration to the spinous process of T12 on inspiration.

In the Lateral Thorax, the lungs extend from the apex

of the axilla to the 8th rib of the midaxillary line.

Lung Fissures

The right oblique (diagonal) fissure extend from the

area of the spinous process of the 3rd thoracic vertebra, laterally
and downward unit it crosses the 5th rib at the midaxillary line. It 1. General palpation – The examiner should specifically
then continues ant medially to end at the 6th rib at the palpate any areas of abnormality. The temperature and
midclavicular line. turgor of the skin should be assessed. Palpate for
lumps, masses and areas of tenderness.
The right horizontally fissure extends from the 5th rib 2. Palpate for thoracic expansion or lung excursion.
slightly posterior to the right midaxillary line and runs
horizontally to thee area of the 4th rib at the right sternal border.
A. Anteriorly, the examiner’s hands are placed
over the anterolateral chest with the thumbs
The left oblique (diagonal) fissure extend from the extended along the costal margin, pointing
spinous process of the 3rd thoracic vertebra laterally and to the xyphoid process. Posteriorly, the
downward to the left mid axillary line at the 5th rib and thumbs are placed at the level of the 10th rib
continues anteriorly and medially until it terminates at the 6th rib and the palms are placed on the
in the midclavicular line. posterolateral chest.
B. Instruct the client to exhale first, then to
Borders of the Diaphragm. inhale deeply.
C. The examiner the amount of thoracic
expansion during quiet and deep inspiration
Anteriorly, on expiration, the right dome of the and observe for divergence of the thumbs on
diaphragm is located at the level of the 5th rib at the expiration.
midclavicular line and he left dome is at the level of the 6th rib. D. Normally, symmetry of respiration between
Posteriorly, on expiration, the diaphragm is at the level of the the left and right hemithoraces should be felt
spinous process of T10; laterally it is at the 8th rib at the as the thumbs are separated are separated
midaxillary line. On inspiration the diaphragm moves
approximately 1.5 cm downward. approximately 3 – 5 cm (1 – 2 inches)
during deep inspiration.
 1. Palpate for the tactile fremitus. Percuss the diaphragmatic excursion

A. Place the palm or the ulnar aspect of the

hands bilaterally symmetrical on the chest
wall starting from the top, then at then
medial thoracic wall, and at the anterolateral
B. Each time the hands move down, ask the
client to say ninety-nine.
C. Repeat the procedure at the posterior
thoracic wall.
D. Normally, tactile fremitus should be
bilaterally symmetrical. Most intense in the
2nd ICS at the sternal border, near the area of
bronchial bifurcation. Low pitched voices of
males are more readily palpated than higher
pitched voices of females.
E. Basic abnormalities like increased tactile
Auscultation of the Thorax
fremitus maybe suggestive of consolidation;
decreased tactile fremitus may be suggestive
of obstructions, thickening of pleura, or
collapse of lungs.

Percussion of the Thorax

Anterior thorax:
Normal Breath Sound
A. Patient maybe placed on a supine position.
B. Percuss systematically at about 5 cm intervals from Vesicular Soft, low pitch Lung periphery
the upper to lower chest, moving left to right to left. Broncho-vesicular Medium pitch Larger airway
(Percuss over the ICS, avoiding the ribs. Use indirect blowing
percussion starting at the apices of the lungs. Loud, high pitch Trachea
Bronchial
C. The examiner notes the sound produced during each
percussion.
Abnormal Breath Sound

Crackles Dependent lobes Random, sudden

reinflation of alveoli
fluids
Rhonchi Trachea, bronchi Fluids, mucus
Wheezes All lung fields Severely narrowed
bronchus
Pleural Friction Lateral lung field Inflamed Pleura
Rub

Elderly:
Physical Changes of Thorax and Breathing Patterns

 Kyphosis
 Anteroposterior diameter of the chest widens
 Breathing rate and rhythm are unchanged at rest
 Inspiratory muscles become less powerful, and
inspiration reserve volume decreases.
 Expiration may require the use of accessory muscles
 Deflation of the lung is incomplete
 Small airways lose their cartilaginous support and
Whispered Pectorioquy – Ask the client top whisper “1-2-3”
elastic recoil
Over normal lung tissue it would almost be indistinguishable,
 Elastic tissue of the alveoli loses its stretchability and
over consolidated lung it would be loud and clear
changes to fibrous tissue. Exertional capacity also
decreases.
 Cilia in the airways decrease in number and are less
effective in removing mucus, therefore they are at
greater risk for pulmonary infections.
CARDIOVASCULAR SYSTEM 3. 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

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:

1. Pulsation of the apical impulse maybe visible. (this

can give us some indication of the cardiac size).
2. There should be no lift or heaves.

Jugular Venous Pressure

1. Position the patient supine with the head of the table Anatomic areas for auscultation of the heart
elevated 30 degrees.
2. Use tangential, side lighting to observe for venous
pulsations in the neck. Aortic valve – Right 2nd ICS sternal border.
3. Look for a rapid, double (sometimes triple) wave with Pulmonic Valve – Left 2nd ICS sternal border.
Tricuspid Valve – – Left 5th ICS sternal border.
each heart beat. Use light pressure just above the
Mitral Valve – Left 5th ICS midclavicular line
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin.
4. Adjust the angle of table elevation to bring out the Positioning the client for auscultation:
venous pulsation.
5. Identify the highest point of pulsation. Using a
horizontal line from this point, measure vertically If the heart sounds are faint or undetectable, try
from the sternal angle. listening to them with the patient seated and learning
6. This measurement should be less than 4 cm in a forward, or lying on his left side, which brings the
normal healthy adult. 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
Precordial Movement semilunar valves problem.
The left lateral recumbent position is best suited
1. Position the patient supine with the head of the table low- pitched sounds, such as mitral valve problems
slightly elevated. and extra heart sounds.
2. Always examine from the patient's right side.
3. Inspect for precordial movement. Tangential lighting Auscultating the heart
will make movements more visible.
4. Palpate for precordial activity in general. You may
feel "extras" such as thrills or exaggerated ventricular 1. Auscultate the heart in all anatomic areas aortic,
impulses. pulmonic, tricuspid and mitral
5. Palpate for the point of maximal impulse (PMI or 2. Listen for the S1 and S2 sounds (S1 closure of AV
apical pulse). It is normally located in the 4th or 5th valves; S2 closure of semilunar valve). S1 sound is
intercostal space just medial to the midclavicular line best heard over the mitral valve; S2 is best heard over
and is less than the size of a quarter. the aortric valve.
6. Note the location, size, and quality of the impulse. 3. Listen for abnormal heart sounds e.g. S3, S4, and
Murmurs.
4. Count heart rate at the apical pulse for one full minute.
Palpation of the Heart
Normal Findings:
The entire precordium is palpated methodically using the palms
and the fingers, beginning at the apex, moving to the left sternal
1. S1 & S2 can be heard at all anatomic site.
border, and then to the base of the heart. 2. No abnormal heart sounds is heard (e.g. Murmurs, S3
& S4).
Normal Findings: 3. Cardiac rate ranges from 60 – 100 bpm.

1. No, palpable pulsation over the aortic, pulmonic, and

mitral valves.
2. Apical pulsation can be felt on palpation.
PERIPHERAL CIRCULATION 2. The client is seated with her arms abducted over the
head.
Inspect: 3. The client is seated and is pushing her hands into her
hips, simultaneously eliciting contraction of the
 Color pectoral muscles.
 Edema 4. The client is seated and is learning over while the
 Stasis ulcers/lesions examiner assists in supporting and balancing her.
 Varicosities
 Hair/nail changes While the client is performing these maneuvers, the
breasts are carefully observed for symmetry, bulging,
Palpate: retraction, and fixation.
An abnormality may not be apparent in the breasts at
 Temperature rest a mass may cause the breasts, through invasion of
 Edema the suspensory ligaments, to fix, preventing them from
 Tenderness upward movement in position 2 and 4.
 Symmetry of pulses Position 3 specifically assists in eliciting dimpling if
a mass has infiltrated and shortened suspensory
ligament

Chronic Venous Insufficiency

Chronic Arterial Insufficiency

Pain None to aching pain on dependency

Pain Intermittent claudication

Pulse Normal
Pulse Decreased
Normal to cyanotic; petechiae or brown
Color
pigmentation
Color Pale

Temperature Warm
Temperature Cool

Edema Present Ed e m a Absent or mild

Skin Thin, shiny atrophic skin, hair loss,

Skin Changes Dermatitis skin pigmentation Changes thickened nails

Ulceration Toes/points of trauma

Ulceration Medial side of ankle
Gangrene May develop

Gangrene Does not develop

Normal Findings:

BREAST 1. The overlying the breast should be even.

2. May or may not be completely symmetrical at rest.
3. The areola is rounded or oval, with same color, (Color
va,ies form light pink to dark brown depending on
race).
4. Nipples are rounded, everted, same size and equal in
color.
5. No “orange peel” skin is noted which is present in
edema.
6. The veins maybe visible but not engorge and
prominent.
7. No obvious mass noted.
8. Not fixated and moves bilaterally when hands are
abducted over the head, or is learning forward.
9. 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
Inspection of the Breast examination is best done 1 week post menses.
Each areolar areas are carefully palpated to determine
There are 4 major sitting position of the client used for clinical the presence of underlying masses.
breast examination. Every client should be examined in each Each nipple is gently compressed to assess for
position. the presence of masses or discharge.

1. The client is seated with her arms on her side.

Normal Findings:  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
No lumps or masses are palpable.
ensures that we follow the direction of bowel movement.
No tenderness upon palpation.  Peristaltic sounds are quite irregular. Thus it is
No discharges from the nipples. recommended that the examiner listen for at least 5
minutes, especially at the periumbilical area, before
NOTE: The male breasts are observed by adapting the concluding that no bowel sounds are present.
techniques used for female clients. However, the various sitting  The normal bowel sounds are high-pitched, gurgling noises
position used for woman is unnecessary. that occur approximately every 5 – 15 seconds. It is
suggested that the number of bowel sound may be as low as
ABDOMEN 3 to as high as 20 per minute, or roughly, one bowel sound
for each breath sound.

In abdominal assessment, be sure that the client has emptied the

bladder for comfort. Place the client in a supine position with the Some factors that affect bowel sound:
knees slightly flexed to relax abdominal muscles.
1. Presence of food in the GI tract.
Inspection of the abdomen 2. State of digestion.
3. Pathologic conditions of the bowel (inflammation,
Gangrene, paralytic ileus, peritonitis).
Inspect for skin integrity (Pigmentation, lesions, 4. Bowel surgery
striae, scars, veins, and umbilicus). 5. Constipation or Diarrhea.
Contour (flat, rounded, scapold) 6. Electrolyte imbalances.
Distension 7. Bowel obstruction.
Respiratory movement.
Visible peristalsis. Percussion of the abdomen
Pulsations
Abdominal percussion is aimed at detecting fluid
Normal Findings: in the peritoneum (ascites), gaseous distension, and
masses, and in assessing solid structures within the
abdomen.
Skin color is uniform, no lesions.
The direction of abdominal percussion follows
Some clients may have striae or scar. the auscultation site at each abdominal guardant.
No venous engorgement. The entire abdomen should be percussed lightly or a
Contour may be flat, rounded or scapoid Thin general picture of the areas of tympany and dullness.
clients may have visible peristalsis. Aortic Tympany will predominate because of the presence of
pulsation maybe visible on thin clients. 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 is placed over the region of liver
dullness.

1. The area is strucked lightly with a fisted right hand.

Auscultation of the Abdomen 2. Normally tenderness should not be elicited by
this method.
This method precedes percussion because bowel 3. Tenderness elicited by this method is usually a result
motility, and thus bowel sounds, may be increased by of hepatitis or cholecystitis.
palpation or percussion.
The stethoscope and the hands should be warmed; Renal Percussion
if they are cold, they may initiate contraction of the
abdominal muscles.
1. Can be done by either indirect or direct method.
Light pressure on the stethoscope is sufficient to 2. Percussion is done over the costovertebral junction.
detect bowel sounds and bruits. Intestinal sounds are 3. Tenderness elicited by such method suggests renal
relatively high-pitched, the bell may be used in inflammation.
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.

Palpation of the Abdomen 3. An upward pressure is placed beneath the client to
push the liver towards the examining right hand, while
Light palpation the right hand is pressing into the abdominal wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip
It is a gentle exploration performed while the client is beneath the examining fingers.
in supine position. With the examiner’s hands parallel
to the floor.
Normal Findings:
The fingers depress the abdominal wall, at each
quadrant, by approximately 1 cm without digging, but
gently palpating with slow circular motion. The liver usually can not be palpated in a normal
This method is used for eliciting slight adult. However, in extremely thin but otherwise well
tenderness, large masses, and muscles, and muscle individuals, it may be felt a the costal margins.
guarding. When the normal liver margin is palpated, it must
be smooth, regular in contour, firm and non-tender.
Tensing of abdominal musculature may occur because of:
MUSCULOSKELETAL
1. The examiner’s hands are too cold or are pressed to
vigorously or deep into the abdomen. 1. Assess the patient’s posture, stance, and gait
2. The client is ticklish or guards involuntarily. 2. Prepare the patient for the examination
3. Presence of subjacent pathologic condition. 3. Inspect for any gross abnormalities.
4. Inspect and palpate the temporomaddibular joint and
jaw.
Normal Findings:
5. Inspect and palpate the neck and spine
6. Assess the ROM of the neck
1. No tenderness noted. 7. Assess the ROM of the spine
2. With smooth and consistent tension. 8. Inspect and palpate the upper and lower extremities,
3. No muscles guarding. assessing each joint and muscle.

Deep Palpation RANGE OF MOTION

It is the indentation of the abdomen performed by

pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall.
The abdominal wall may slide back and forth while
the fingers move back and forth over the organ being
examined.
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.
TEMPORAL MADIBULAR JOINT AND JAW

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.

1. Ask the patient to take 3 normal breaths.

2. Then ask the client to breath deeply and hold. This
would push the liver down to facilitate palpation.
3. Press hand deeply over the RUQ

The second methods:

1. The examiner’s left hand is placed beneath the client

at the level of the right 11th and 12th ribs. RANGE OF MOTION: NECK
2. Place the examiner’s right hands parallel to the costal
margin or the RUQ.
Nursing Skills
Physical Assessment
Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 16

RANGE OF MOTION:WRISTS

RANGE OF MOTION:ANKLES

RANGE OF MOTION: FINGERS

RANGE OF MOTION:KNEES

RANGE OF MOTION: ELBOW

RANGE OF MOTION:SHOUDLERS
RANGE OF MOTION:HIPS
 Nursing Skills
Physical Assessment
Prepared by: Mark Fredderick R. Abejo R.N, M.A.N 17

Neurological Assessment Pronator Drift

1. Ask the patient to stand for 20-30 seconds with both

arms straight forward, palms up, and eyes closed.
2. Instruct the patient to keep the arms still while you tap
EXTREMITIES them briskly downward.
3. The patient will not be able to maintain extension and
Observation supination (and "drift into pronation) with upper motor
neuron disease.
 Involuntary Movements
 Muscle Symmetry C. Coordination and Gait
 Left to Right
 Proximal vs. Distal
Rapid Alternating Movements
 Atrophy
 Pay particular attention to the hands, shoulders, and
thighs. 1. Ask the patient to strike one hand on the thigh, raise
 Gait the hand, turn it over, and then strike it back down as
fast as possible.
2. Ask the patient to tap the distal thumb with the tip of
the index finger as fast as possible.
3. Ask the patient to tap your hand with the ball of each
A. Muscle Tone foot as fast as possible.

1. Ask the patient to relax.

2. Flex and extend the patient's fingers, wrist, and elbow.
3. Flex and extend patient's ankle and knee. Point-to-Point Movements
4. There is normally a small, continuous resistance to
passive movement.
5. Observe for decreased (flaccid) or increased 1. Ask the patient to touch your index finger and their
(rigid/spastic) tone. nose alternately several times. Move your finger about
as the patient performs this task.
2. Hold your finger still so that the patient can touch it
B. Muscle Strength with one arm and finger outstretched. Ask the patient
to move their arm and return to your finger with their
Test strength by having the patient move against your resistance. eyes closed.
Always compare one side to the other. 3. Ask the patient to place one heel on the opposite knee
Grade strength on a scale from 0 to 5 "out of five": and run it down the shin to the big toe. Repeat with the
patient's eyes closed.
Grading Motor Strength
Romberg
Grade Description
0/5 No muscle movement 1. Be prepared to catch the patient if they are unstable.
1/5 Visible muscle movement, but no movement at the joint 2. Ask the patient to stand with the feet together and eyes
closed for 5-10 seconds without support.
2/5 Movement at the joint, but not against gravity 3. The test is said to be positive if the patient becomes
Movement against gravity, but not against added unstable (indicating a vestibular or proprioceptive
3/5 problem).
resistance
4/5 Movement against resistance, but less than normal
Gait
5/5 Normal strength
Ask the patient to:

Test the following:

1. Walk across the room, turn and come back
2. Walk heel-to-toe in a straight line
1. Flexion at the elbow (C5, C6, biceps) 3. Walk on their toes in a straight line
2. Extension at the elbow (C6, C7, C8, triceps) 4. Walk on their heels in a straight line
3. Extension at the wrist (C6, C7, C8, radial nerve) 5. Hop in place on each foot
4. Squeeze two of your fingers as hard as possible 6. Do a shallow knee bend
("grip," C7, C8, T1) 7. Rise from a sitting position
5. Finger abduction (C8, T1, ulnar nerve)
6. Oppostion of the thumb (C8, T1, median nerve)
7. Flexion at the hip (L2, L3, L4, iliopsoas)
D. Reflexes
8. Adduction at the hips (L2, L3, L4, adductors)
9. Abduction at the hips (L4, L5, S1, gluteus medius and Deep Tendon Reflexes
minimus)
10. Extension at the hips (S1, gluteus maximus)  The patient must be relaxed and positioned properly
11. Extension at the knee (L2, L3, L4, quadriceps) before starting.
12. Flexion at the knee (L4, L5, S1, S2, hamstrings)  Reflex response depends on the force of your
13. Dorsiflexion at the ankle (L4, L5) stimulus. Use no more force than you need to provoke
14. Plantar flexion (S1) a definite response.
 Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles
(clenched teeth).
 Reflexes should be graded on a 0 to 4 "plus" scale:
 Plantar Response (Babinski)
Tendon Reflex Grading Scale
1. Stroke the lateral aspect of the sole of
Grade Description
each foot with the end of a reflex
0 Absent hammer or key.
2. Note movement of the toes, normally
1+ or + Hypoactive
flexion (withdrawal).
2+ or ++ "Normal" 3. Extension of the big toe with fanning of
the other toes is abnormal. This is
3+ or +++ Hyperactive without clonus
referred to as a positive Babinski.
4+ or ++++ Hyperactive with clonus
E. Sensory

Biceps (C5, C6) General

1. The patient's arm should be partially flexed at the  Explain each test before you do it.
elbow with the palm down.  Unless otherwise specified, the patient's eyes
2. Place your thumb or finger firmly on the biceps should be closed during the actual testing.
tendon.  Compare symmetrical areas on the two sides of the
3. Strike your finger with the reflex hammer. body.
4. You should feel the response even if you can't see it.  Also compare distal and proximal areas of the
extremities.
 When you detect an area of sensory loss map out
Triceps (C6, C7) its boundaries in detail.

1. Support the upper arm and let the patient's forearm 1. Vibration
hang free.
2. Strike the triceps tendon above the elbow with the Use a low pitched tuning fork (128Hz).
broad side of the hammer.
3. If the patient is sitting or lying down, flex the patient's
arm at the elbow and hold it close to the chest. 1. Test with a non-vibrating tuning fork first to
ensure that the patient is responding to the correct
stimulus.
Brachioradialis (C5, C6) 2. Place the stem of the fork over the distal
interphalangeal joint of the patient's index fingers
1. Have the patient rest the forearm on the abdomen or and big toes.
lap. 3. Ask the patient to tell you if they feel the vibration.
2. Strike the radius about 1-2 inches above the wrist.
3. Watch for flexion and supination of the forearm. If vibration sense is impaired proceed proximally: ++

Abdominal (T8, T9, T10, T11, T12) 1. Wrists

2. Elbows
1. Use a blunt object such as a key or tongue blade. 3. Medial malleoli
2. Stroke the abdomen lightly on each side in an inward 4. Patellas
and downward direction above (T8, T9, T10) and 5. Anterior superior iliac spines
below the umbilicus (T10, T11, T12). 6. Spinous processes
3. Note the contraction of the abdominal muscles and 7. Clavicles
deviation of the umbilicus towards the stimulus.

Knee (L2, L3, L4) 2. Subjective Light Touch

1. Have the patient sit or lie down with the knee flexed. Use your fingers to touch the skin lightly on both sides
2. Strike the patellar tendon just below the patella. simultaneously.
3. Note contraction of the quadraceps and extension of Test several areas on both the upper and lower
the knee.
extremities.
Ask the patient to tell you if there is difference from
Ankle (S1, S2) side to side or other "strange" sensations.

1. Dorsiflex the foot at the ankle. 3. Position Sense

2. Strike the Achilles tendon.
3. Watch and feel for plantar flexion at the ankle.
1. Grasp the patient's big toe and hold it away from the
other toes to avoid friction.
2. Show the patient "up" and "down."
Clonus 3. With the patient's eyes closed ask the patient to
identify the direction you move the toe.
4. If position sense is impaired move proximally to test
If the reflexes seem hyperactive, test for ankle clonus: the ankle joint.
5. Test the fingers in a similar fashion.
1. Support the knee in a partly flexed position. 6. If indicated move proximally to the
2. With the patient relaxed, quickly dorsiflex the foot. metacarpophalangeal joints, wrists, and elbows.
3. Observe for rhythmic oscillations.
4. Dermatomal Testing Two Point Discrimination

If vibration, position sense, and subjective light touch are 1. Use in situations where more quantitative data are
normal in the fingers and toes you may assume the rest of this needed, such as following the progression of a
exam will be normal. cortical lesion. ++
2. Use an opened paper clip to touch the patient's
5. Pain finger pads in two places simultaneously.
3. Alternate irregularly with one point touch.
4. Ask the patient to identify "one" or "two."
Use a suitable sharp object to test "sharp" or "dull" sensation. 5. Find the minimal distance at which the patient can
Test the following areas: discriminate.

1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1) SAMPLE CHARTING
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2) Ms. X is a young, healthy-appearing woman, well-groomed, fit,
5. Medial and lateral aspect of both calves (L4 and L5) and in good spirits. Height is 5’4”, weight 135 lbs, BP 120/80,
6. Little toes (S1) HR 72 and regular, RR 16, temperature 37.5 0C.

SKIN: Color good. Skin warm and moist. Nails without

clubbing or cyanosis.
5. Temperature EENT:
Head – skull is normocephalic/atraumatic(NC/AT). Hair with
average texture.
Often omitted if pain sensation is normal.
Eyes – visual acuity 20/20 bilaterally. Sclera white; conjunctiva
Use a tuning fork heated or cooled by water and ask pink. Pupils constrcit 4 mm to 2 mm, equally round and reactive
the patient to identify "hot" or "cold." to light and accommodations.
Ears – acuity good. Weber midline. Nose – nasal mucosa pink,
septum midline, no sinus tenderness. Throat(mouth) – oral
Test the following areas: mucosa pink; dentition good; pharynx without exudates.
Neck – trachea midline. Neck supple; thyroid isthmus palpable,
1. Shoulders (C4) lobe not felt.
2. Inner and outer aspects of the forearms (C6 and T1) Lymph nodes – no cervical adenopathy.
3. Thumbs and little fingers (C6 and C8) THORAX AND LUNGS:
4. Front of both thighs (L2) INSPECTION
5. Medial and lateral aspect of both calves (L4 and L5) - A-P diameter not increased
6. Little toes (S1) - Lips, nailbeds pink
- Thorax slightly asymmetrical
- Full expansion equal bilaterally
PALPATION
6. Light Touch - No tenderness
- No enlargement of lymph nodes
Use a fine whisp of cotton or your fingers to touch the - Fremitus equal bilaterally
skin lightly. PERCUSSION
Ask the patient to respond whenever a touch is felt. - Lung field resonant
- Diaphragmatic excursion – 4cm bilaterally
Test the following areas: AUSCULTATION
- Breath sounds clear
- No rales, rhonchi, or rubs
1. Shoulders (C4) - BREAST AND AXILLAE:
2. Inner and outer aspects of the forearms (C6 and T1)
- Breast symmetric and without masses. Nipples
3. Thumbs and little fingers (C6 and C8)
without discharge.
4. Front of both thighs (L2)
- No axillary adenopathy
5. Medial and lateral aspect of both calves (L4 and L5)
CARDIOVASCULAR EXAM:
6. Little toes (S1)
- PMI is tapping, 2 cm lateral to the midsternal line in
the 5th ICS.
- Good S1 and S2
7. Discrimination - No murmurs or extra sounds
ABDOMEN:
- Abdomen is protuberant with active bowel sounds. It
Since these tests are dependent on touch and position sense, they is soft and non-tender; no masses or
cannot be performed when the tests above are clearly abnormal. hepatosplenomegaly. Liver span is 7cm; edge is
smooth and palpable 1 cm below the right costal
Graphesthesia margin. Spleen and kidneys not felt.
MUSCULOSKELETAL SYSTEM:
1. With the blunt end of a pen or pencil, draw a large - Good range of motion in all joints. No evidence of
swelling or deformity.
number in the patient's palm.
2. Ask the patient to identify the number. - Mental status: alert, relaxed, and cooperative. Thought
process coherent. Oriented to person, place, and time.
- Cranial nerves: I – XII intact.
Stereognosis - Motor: Good muscle bulk and tone. Strength 5/5
throughout.
1. Use as an alternative to graphesthesia. ++ - Cerebellar: RAM, intact. Gait with normal base.
2. Place a familiar object in the patient's hand (coin, Romberg – maintains balance with eyes closed. No
paper clip, pencil, etc.). pronator drift.
3. Ask the patient to tell you what it is. - Sensory: Pinprick, light touch, position intact.
- Reflexes: 2+ and symmetric