DMC-COLLEGE FOUNDATION INC.

STA. FILOMENA, DIPOLOG CITY

COLLEGE OF NURSING

Name: _RAUL T. NOCETE_________ Date: May 24, 2010

Yr/Sec.: _BSN I-Nights_____________ Ratings: _________

HEAD-TO-TOE ASSESSMENT
EQUIPMENT:
 Assessment documentation form  Platform scale with height
 Coin or key attachment
 Cotton ball  Reflex hammer
 Cover card (for eye assessment)  Ruler with centimeter makings
 Gloves  Skinfold calibers, flexible tape
 Goniometer measure
 Gown for client  Small cup of water for client to
 Lubricating jelly drink
 Magnifying glass  Snellen chart
 Marking pencil  Stethoscope and
 Mini-Mental Status Examination sphygmomanometer
(MMSE) form  Substance for testing smell (eg,
 Newspaper print or Rosenbaum soap, coffee)
 Pocket screener  Supplies for collecting vaginal
 Notepad and pencil specimen (slides, spatula, cotton-
tip application)
 Ophthalmoscope
 Thermometer
 Otoscope
 Tongue depressor
 Paper clip
 Tuning fork
 Pen light
 Vaginal speculum
 Pillows (two small pillows)
 Watch

1
 PROCEDURE
PREPARING THE CLIENT:
 Discuss the purpose of the physical assessment with
your client
 Ask permission to perform the various examination
 Provide privacy and confidentiality
 Respect client’s right to refuse any part of the
assessment
 Ask him/her to change gown for examination
GENERAL SURVEY:
 Observe appearance including:
 Overall physical and sexual development
 Apparent age (compare with stated age)
 Overall skin coloring
 Dress, grooming, and hygiene ‘body build, as
well mass and fat distribution
 Behavior (compare with development stage)
 Assess the client’s vital signs:
 Temperature
 Pulse
 Perspiration
 Blood pressure
 Pain
 Take body measurements:
 Height
 Weight
 Waist and hip circumference; mid-arm
circumference
 Triceps skinfold thickness
 Calculate ideal body weight, BMI, waist-to-
hip ratio, and mid-arm muscle area and
circumference.
 Take vision using the Snellen chart.
MENTAL STATUS EXAMINATION:
 In addition to data collected about the client’s
appearance during the general survey, observe:
 Level of consciousness
 Posture and body movements
 Facial expressions
 Speech
 Mood, feelings, and expression
 Thought processes and perceptions
 Assess the client’s cognitive abilities (MMSE may be
use):
 Orientation to person, time, and place
 Concentration, ability to focus and follow
directions
 Recent memory of happenings today
 Remote memory of the past
 Recall of unrelated information in 5-, 10-, and
30-minutes periods
 Abstract reasoning
RATIONALE DONE NOT
DONE
* To help allay anxiety and prepare the
client for the procedures to follow
* To get client’s consent & cooperation
* Preserving the client’s dignity
* The client has the inherent right to
dictate things concerning his health.
* To ensure a smooth procedure and for
the client’s comfort while examination
is done
* Pinpointing a general idea of the
client’s lifestyle by appearance such as
body weight, and posture compared to
actual age.
Detecting signs of distress and anxiety
from behavior such as facial expression
and general demeanor.
* Vital signs provide data that reflect the
status of several body system e.g,
cardiovascular, neurological, peripheral
vascular and respiratory systems. This
will determine whether the client is
within normal body functions
* Taking baseline data of the client’s
body measurement will allow the
examiner to make various assessment
calculations to determine whether the
client is within the acceptable or normal
level or not. This also serves as a basis
in deriving potential complications due
to the client’s body measurements.
* Snellen chart will test for the client’s
distant and near visual acuity and to
have a general idea if the client has
existing visual impairment.
* To be able to determine the client’s
cognitive functions, thoughts processes
and moods. This will allow the
examiner to assess whether the client is
in a normal state of mental being or not.
* The Mini-Mental State Examination
will show the clients current cognitive
functions, able to comprehend, able to
calculate and able to recall short-term
and long-term memories, and the ability
to construct what he has perceived or
shown.
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  Judgment
 Visual perceptual and constructional ability
 Ask the client to empty the bladder
(give the client a specimen cup if a
urine sample is needed) and change
into a gown.
SKIN
 As you to perform each part of the head-to-toe
assessment, assess skin color variations, texture,
temperature, turgor, edema, and lesions.
 Teach the client skin self-examination
HEAD AND FACE
 Inspect and palpate the head for the size, shape, and
configuration.
 Note consistency, distribution, and color of hair.
 Observe face for symmetry, facial features,
expressions, and skin condition.
 Check function of cranial nerves (CN) VII: Have the
client smile, frown, show teeth, blow out cheeks, raise
and chin.
 Palpate the temporal arteries for elasticity and
tenderness
 As the client opens and closes the mouth, palpate the
temporomandibular joint for tenderness, swelling, and
crepitation.
EYES
 Determine the function:
 Test visual fields.
 Assess corneal light reflex
 Perform cover and position tests.
 Inspect external eye:
 Position and alignment of the eyeball in eye
socket
 Bulbar conjunctiva and sclera
 Palpebral conjunctiva
 Lacrimal apparatus
 Cornea, lens, iris, and pupil
 Test pupillary reaction to light.
 Test accommodation of pupils
 Assess corneal reflex (CNVII-facial)
 Use the ophthalmoscope to inspect:
 Optic disk for shape, color, size, and
physiologic cup
 Retinal vessels for color and diameter and
arteriovenous(AV) crossings
 Retinal background for color and lesions
 Fovea centralis
 Anterior chambers for clarity
EARS AND NOSE
 Inspect the auricle, tragus, and lobule for shape,
position, lesions, discolorations, and discharge.
 Palpate the auricle and mastoid process for tenderness.
 Use otoscope to inspect:
 External auditory canal for color and cerumen
(ear wax)
 Tympanic membrane for color, shape,
consistency, and landmarks.
 Test hearing
* The skin plays a vital role in a human
being, being our first line of defense, it
is assessed to determine abnormalities
that affects its function.
*Increasing the client’s awareness on
skin care will enhance his wellbeing.
*To check for any deformities and
irregular shape and protrusions of the
head, any underlying cause that makes
the hair uneven.
*Check for facial symmetry and color
will determine if the cranial nerves
(CN)VII are functioning well.
* To determine any blockage or
accumulation in the temporal arteries.
* To test motor function of the CN V
(trigeminal)
* To pinpoint the functioning level of
each of the client’s eyes. Determining
the normal alignment or deviation of the
or strength of the eye by corneal light
reflex test and cover/position test.
*To determine if client eye is positioned
normally or is suffering from any
alignment deviation or impairments of
the eye and the vicinity therein that
might affect his sight. To ensure that the
pupils respond to stimulus and that it
constrict and dilate accordingly. Also to
test the motor function of CN VII-facial,
whether the client can close his eye as a
reflex or voluntarily and open them.
* Checking for tenderness will show
existing ear problems, and malaligned
ears with corner of the eye will suggest
genetourinary disorders and
chromosomal defects.
*Checking the auditory canal to
determine any blockage within.
*Also noting any deviation on the
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  Whisper test
 Weber’s test for diminished hearing in one ear
 Rinne test to compare bone and air
condition(turning fork on mastoid; the front of
air)
 Inspect the external nose for color, shape, and
consistency. Palpate the external nose for tenderness
 Check patency of airflow through nostrils (occlude one
nostril at a time and ask the client to sniff.)
 Test CN I: ask the client to close his/her eyes and smell
for soap, coffee, or vanilla.(occlude nostril.)
 Use an otoscope with a short wide tip to inspect
internal nose for color and integrity of nasal mucosa,
nasal septum, and inferior and middle turbinates.
 Trans illuminate maxillary sinuses with a
penlight to check for fluid or pus.
MOUTH AND THROAT
Put on gloves. Use a tongue depressor and penlight as needed.
 Inspect lips consistency, color, and lesions.
 Inspect the teeth for number and condition.
 Check the gums and buccal mucosa for color,
consistency, or lesions.
 Inspect the hard (anterior) and soft (posterior) palates
for color and integrity.
 Ask the client to say “aah” and observe the rise of
uvula.
 Test CN X: Touch the soft palate to assess the gag
reflex.
 Inspect the tonsils for color, size, lesion, and exudates.
 Inspect the tongue for color, moisture, size, and texture.
Inspect the ventral surface of the tongue for frenulum,
color, lesion, and Wharton ducts.
 Palpate the tongue for lesions.
 Test CN IX and CN X: Assess tongue strength by
asking the client to press the tongue against to tongue
blade
 Assess CN VII and CN IX: Have the client close his or
her eyes. Check use taste by placing salt, sugar, and
lemon on the tongue.
NECK
 Inspect the neck for appearance of lesions, masses,
swelling, and symmetry.
 Test range of motion (ROM)
 Palpate the preauricular, postauricular, occipital,
tonsilllar, submandibular, and sub-mental nodes.
 Palpate the trachea.
 Palpate the thyroid gland for the size, irregularity, or
masses.
 Auscultate an enlarged thyroid for bruits.
Palpate carotid arteries and auscultate for bruits.
Continue..
ARMS, HANDS, AND FINGERS
 Inspect the upper extremities for overall skin color,
texture, moisture, masses, and lesions.
 Test the function of CN XI (spinal) by shoulder shrug
and turning the head against resistance.
 Palpate arms for tenderness, swelling, and temperature.
 Assess epitrochlear lymph nodes.
 Test ROM of the elbows.
 Palpate the brachial pulse.
 Test ROM of the waist.
 Inspect palms and hands and palpate for temperature.
 Test ROM of the fingers.
 Use the reflex hammer to test biceps, triceps, and
normal color of the tympanic membrane
which is pearly grey, and if it is
functioning well by performing the
different ear test.
* To determine any deformities and
tenderness that might suggest local
infection.
*Check patency of airflow to determine
any sign of swelling within or rhinitis or
chronic allergies. And also to test the
sensory function of CN I-olfactory.
* To check for accumulation of polyps
and/or swelling within.
*Trans illumination will determine any
blockage in the sinuses
*Putting on gloves as a standard
precaution to protect the health of both
client and examiner.
*Any lips discoloration might suggest
anemia(pallor), cyanotic(hypoxia) ,
reddish(ketoacidosis, COPD, CO
poisoning), or swelling(allergies).
*Checking for number of teeth and
discoloration will show some of clients
lifestyle that affect his health.
*To check for midline elevation of uvula
and symmetric elevation of soft palate.
*To determine any inflammation on the
tonsils and tongue.
*Palpating the tongue will reveal any
nodules that might suggest cancer, and
to determine the strength of the tongue
against resistance to assess its
swallowing function.
*Testing the taste or sensory function of
the tongue.
*To determine any asymmetry in the
neck which may indicate enlarged
thyroid gland or inflamed lymph nodes
*To check for muscle spasm or cervical
arthritis that might limit ROM of neck
*To check for deviation of the trachea
*To determine presence of masses and
inflammation in the thyroid
*Auscultation will allow the examiner to
check for any blockage in the thyroid
and carotid arteries.
*To pinpoint abnormalities affecting the
hands, wrists and fingers like
osteoarthritis, or deformities or pain.
*To assess swelling of lymph nodes
*To identify any limitation on the ROM
of the elbows.
*Palpate the brachial pulse to discover
any arterial insufficiency.
*To identify any abnormalities that
limits ROM of the waist.
* To identify situations like
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 brachioradialis reflexes.
 Test rapid alternating movements of the hands.
 Ask the client to close the eyes; test sensation:
 Ask light touch, pain, and temperature
sensation in scattered locations over hands and
arms.
 Evaluate sensitivity of position of fingers.
 Place a quarter or key in the client’s hands to
test stereogenosis.
 Assess graphesthesia by writing a number in
the palm of the client’s hand.
 Assess two-point discrimination in the
fingertips, forearm, and dorsal hands.
 Ask client to continue sitting with
arms at sides and stand behind client.
Untie gown to expose posterior chest.
POSTERIOR AND LATERAL CHEST
 Inspect configuration and shape of scapulae and chest
wall.
 Note use of accessory muscles when breathing and
posture.
 Palpate the tenderness, sensation, crepitus, masses,
lesions, and fremitus.
 Evaluate chest expansion at level T9 or T10.
 Percuss for tone at posterior intercostal spaces
(comparing bilaterally).
 Determine diaphragmatic excursion.
 Auscultate for breath sounds, adventitious sounds, and
voice sounds (bronchophony, egophony, and whispered
pectoriloquy).
 Test for two-point discrimination on the client’s back.
 Ask the client to lean forward and exhale; use bell of
stethoscope to listen over the apex and left sternal
border of the heart.
 Move to front of client and expose anterior
chest. Allow client to maintain modesty.
ANTERIOR CHEST
 Inspect anteroposterior diameter of chest, slope of the
ribs, and color of chest.
 Note quality and pattern of respiration (rate, rhythm,
and depth)
 Observe intercostal spaces for bulging or retractions
and use of accessory muscles.
 Palpate for tenderness, sensation, masses, lesions,
fremitus, and anterior chest expansion.
 Percuss for tone at apices above clavicles, then at
intercostal spaces (comparing bilaterally).
 Auscultate for anterior breath sounds, adventitious
sounds, and voice sounds.
 Pinch the skin over sternum to assess mobility (ease to
pinch) and turgor (return to original shape).
 Ask the client to fold gown to waist and sit
with arms banging freely.
BREAST
Female Breasts
 Inspect size, symmetry, color, texture, superficial
venous pattern, areola, and nipples of both breasts.
 Inspect for retractions and dimpling of nipples. Have
the client raise her arms overhead, press her hands on
her hips, press her hands together in front of her, and
lean forward.
osteoarthritis, rheumatoid arthritis, or
deformities that limits ROM of fingers
*Reflex hammer will test Spinal Cord
levels C-5, C6 for biceps, C-6,C-7,C-8
for ticeps and C-3,C-6 for brachia-
radiales. And coordination thereof.
*Inability to do rapid alternating
movements of hands indicates cerebellar
disease, upper motor neuron weakness,
or extrapyramidal disease.
* To test sensory functions of the hands
and arms, and to further identify if the
client has lesion of the sensory cortex
which will hinder him to correctly
identify objects drawn o held by the
hand.
* To inspect symmetry and no abnormal
protrusion. Common deviations are
scoliosis and kyphosis.
*Trapezius muscles are used to facilitate
inspiration in cases of COPD.
*Tenderness may indicate inflammation,
No crepitus should be noted, increase
fremitus may indicate consolidation.
*Uneven chest expansion may be assign
of atelectasis, pneumonia or trauma.
*Limitation of diaphragmatic descent
may indicated atelectasis or pneumonia
* Diminished breath sounds may
indicate obstruction or abnormalities of
the pleural space.
*To allow maximum chest expansion
when auscultating, and check for
adventitious breath sounds that may
indicate consolidation.
* Important to note that anteroposterior
diameter is less than the transverse, a 1:2
ratio is normal
*To note abnormal breathing pattern that
may indicate, tachypnea, bradypnea,
hyperventilation and hypoventilation.
*Retraction of the ICSs indicates an
increased inspiratory effort e.g. COPD.
* Check for adventitious breath sounds
that may indicate consolidation.
* Pinching the skin to assess for
tenderness and skin integrity.
*Normal breast are symmetrical and free
from any discoloration, tenderness and
protrusion besides the nipples.
*Retraction and dimpling is an
indication of cancer.
* Palpating axilla for any lesions and
5
  Palpate axillae for rashes, infection, and anterior,
central, and posterior lymph nodes.
Male Breasts
 Inspect for swelling, nodules, and ulcerations.
 Palpate the breast tissue and axillae.
 Assist client to supine position with head
elevated to 30 to 45. Stand on client’s right
side.
NECK
Observe and evaluate jugular venous pressure.
 Assist client to supine position (lower examination
table).
Complete examination of female breasts:
 Palpate breasts for masses and the nipples for
discharge.
Teach breast self-examination
HEART
 Inspect and palpate for apical impulse.
 Palpate the apex, left sternal border, and base the heart
for any abdominal pulsations.
 Auscultate over aortic area, pulmonic area, Erb’s point,
tricuspid area, and mitral area (apex) for:
 Heart rate and rhythm (with diaphragm of
stethoscope). If irregular, auscultate for a
pulse rate deficit.
 S1 and S2 (with diaphragm of stethoscope).
 Extra heart sounds S3 and S4. (with
diaphragm and bell of the stethoscope)
 Murmurs (using bell and diaphragm of
stethoscope).
 Ask the client to lie on left sides; use
bell of stethoscope to listen the apex
of the heart
 Cover chest with gown and arrange
draping to expose abdomen.
ABDOMEN
 Inspect for:
 Overall skin color
 Vascularity, striae, lesions, and rashes
 Location, contour, and color of umbilicus
 Symmetry and contour of abdomen
 Aortic pulsations or peristaltic waves
 Auscultate for:
 Bowel sounds (intensity, pitch, and
frequency)
 Vascular sounds and frictions rubs (over
spleen, liver, aorta, iliac artery, umbilicus,
and femoral artery)
 Percuss for:
 one over four quadrants
 Liver location, size, and span
 Spleen location and size
 Lightly palpate:
 Abdominal reflex
 Four quadrants to identify tenderness and
swelling of the lymph nodes an
indication of possible cancer.
*Normal breast are symmetrical and free
from any discoloration, tenderness and
protrusion besides the nipples.
* Palpating axilla for any lesions and
swelling of the lymph nodes, an
indication of possible cancer.
*Observation of distention, bulging or
protrusion may indicate right-sided heart
failure.
* Supine position is the best position for
jugular venous pressure and breast self-
examination.
* Presence of masses may indicate
possible cancer of breast.
*To impart knowledge about BSE and
early detection of cancer.
.
*Apical pulse serves as the Point of
Maximal Impulse(PMI) and check for
possible cardiac enlargement.
*To detect irregularities of the heart,
including irregular rhythm that may
predispose the client to decreased
cardiac output
*To assess the heart rhythm, and listen
for accentuated, diminished, varying or
split S which are all abnormalities.
*An S3 or S4 heart sound and murmurs
of mitral stenosis that was not detected
on supine position maybe revealed when
the client assumes the left lateral
position.
*To look for presence of rashes,
discoloration (Grey Turner’s sign),
redness (inflammation), Dilated veins
(liver cirrhosis)or dilated surfaces
arterioles & capillaries (hypertension)
*Look for deviated umbilicus indicates
presence of mass or enlarged organs.
*A protuberant abdomen may indicate
obesity, fluid accumulation or tumor.
*To check for bowel motility
*To listen for friction-rub which may be
associated with hepatic abscess or
metastases. If heard at the anterior
axillary line, is an indication of splenic
infarction, abscess, infection or tumor.
*To check strength of the stomach and
identify any abnormalities within such
as masses or protrusions
6
 muscular resistance
 Deeply palpate:
 Four quadrants for masses
 Aorta
 Liver, spleen, and kidney for enlargement or
irregularities
 Replace gown and position draping
so lower extremities are exposed.
LEGS, FEET, AND TOES
 Inspect the lower extremities for overall skin
coloration, texture, moisture, masses, lesions, and
varicosities.
 Observe the muscle of the legs and feet.
 Note hair distribution.
 Palpate joints of hips and test ROM. Palpate the
femoral pulse.
 Palpate for:
 Edema, skin temperature
 Muscle size and tone of legs and feet
 Palpate knees including poplitial pulse.
 Palpate the ankles; assess dorsalispedis and posterior
tibial pulses. Test ROM.
 Assess capillary refill.
 Test:
 Sensation to dull and sharp sensations
 Two-point discriminations (on thighs)
 Patellar reflex, Achilles reflex, and plantar
reflex
 Position senses
 Vibratory sensation in bony surface of big toe
 Perform heel-to-shin test.
 As warranted, perform special tests.
 Position change for arterial insufficiency
 Manual compression test
 Trendelenburg test
 Bulge knee test
 Ballottement test
 McMurray’s test
 Secure gown and assist client to
standing position.
MUSCULOSKELETAL AND NEUROLOGIC
EXAMINATION
Note: Parts of these systems have already been assessed
throughout the physical examination.
 Posture.
 Observe the client:
 Check for spinal curvatures and scoliosis.
 Observe gait including base of support, weight-bearing
stability, foot position, stride, arm swing, and post.
Walks heel to toe (tandem walk)
 Hops on one leg, then the other
 Performs Romberg’s test
 Performs finger-to-nose test
 Perform the female and male
genitalia examination last, moving
from the less private to more private
examination for client comport.
GENITALIA
*To check for abnormalities in all
quadrants of the abdomen
*Checking the abdominal aorta for any
sign of aneurysm.
*To identify tenderness on liver, spleen
and kidney areas. Abnormalities may
indicate cancer, CVA or acute hepatitis.
* To assess for indication of peripheral
arterial and venous insufficiencies and
may show possible risk of diabetes or
hypertension.
*To note that loss of hair in the legs due
to arterial insufficiencies.
*The femoral pulse is strong and equal
bilaterally, any weakness or absence
indicates partial or complete arterial
occlusion.
*Edema is a sign of venous
insufficiency, loss of muscle tone may
indicate atrophy.
*To check for symmetry of the knees
and any indication of arthritis or
inflammation. Also the limitation of the
knees Range-Of-Motion.
*Assessing capillary refill to determine
any venous insufficiencies.
*To test for the senses of the periphery,
discrepancies may indicate insufficient
arterial flow.
*Deviation of heel to either side is an
indication of cerebellar disease.
*The following tests are designed to
determine any arterial and/or venous
insufficiency.
*The bulge and ballottement test are
done to check for fluid presence.
*McMurray’s test is performed to assess
a torn meniscus of the knee.
*To check for any indication of
kyphosis or scoliosis, and to check for
balance that may suggest any neurologic
discrepancies.
*Tandem walking will unsteadiness not
noted with normal walking.
*Hopping will show any muscle
weakness or cerebellum disorder.
*Romberg’s test is to detect disease of
the posterior columns, vestibular
dysfunction and cerebellar disorders
*To test for coordination and positional
sense, inability notes cerebellar disease
*To preserve the client’s dignity and
privacy.
7
Female Genitalia
Have the client assume the lithotomy position. Apply gloves.
Apply lubricant as appropriate.
 Inspect:
 Distribution of pubic hair
 Mons pubis, labia majora, and perineum for
lesions, swelling, and excoriations
 Labia minora, clitoris, urethral meatus, vaginal
opening for lesions, swelling, or discharge
 Palpate:
 Bartholin glands, urethra, and Skene glands
 Size of vaginal opening and vaginal
musculature
 Insert speculum and inspect:
 Cervix for lesions and discharge.
 Vagina for color, consistency, and discharge
 Obtain cytologic smears and cultures.
 Perform bimanual examination; palpate:
 Cervix for contour, consistency, mobility, and
tenderness
 Uterus for size, position, shape and
consistency
 Ovaries for size and shape
 Discard gloves and apply clean
gloves and lubricants.
Perform the rectovaginal examination; palpate rectovaginal
septum for tenderness, consistency, and mobility.
Male Genitalia and Septum
Sit on a stool. Have the client stand and face you with gown
raised. Apply gloves.
 Inspect the penis, including:
 Base of penis and pubic hair for excoriation,
erythema, and infestation
 Skin and shaft of penis for rashes, lesions,
lumps, or hardened or tender areas
 Color, location, and integrity of foreskin in
uncircumcised men
 Glans for size, shape, lesions, or redness and
location of urinary meatus
 Palpate for urethral discharge by gently squeezing
glans.
 Inspect scrotum, including:
 Size, shape, and position
 Scrotal skin for color, integrity, lesions, or
rashes
 Posterior skin (by lifting scrotal sac)
 Palpate both testis and epididymis between thumb and
first two fingers for size, shape, nodules, and
tenderness. Palpate spermatic cord and vas deferens.
 Transilluminate scrotal contents for red glows, swelling
or masses. If a mass is found during inspection and
palpation, have the client lie down and inspect and
palpate for scrotal henia.
 As clients bears down, inspect for bulges in inguinal
and femoral sites and palpate for femoral hernias.
 While client shifts weight to each corresponding side,
palpate for inguinal hernia.
 Teach testicular self-examination.
 Ask client to remain standing and bend over
the exam table. Change gloves.
*Lithotomy position, is the best position
in examining the female genitalia.
Gloves are required as standard
precaution since contact with body fluid
is imminent.
*To check for infestation or pediculosis
pubis, an indication of sexually
transmitted disease.
*To note for lesions indicative of herpes
or syphilis and asymmetric labia may
indicate abcess.
*To check for any discharge, swelling or
pain indicative of infection, Neisseiria
Gonorrhoeae or Chlamydia Trachomatis,
*To check abnormalities in the cervix,
(bluish-cyanosis, pale cervix-anemia,
redness-inflammation).
*Vaginal discharges, swelling and red-
ness is indicative of infection.
*Bimanual exam of cervix is to check
for tenderness and hard-immobile cervix
may indicate cancer. For the uterus,
enlargement is indicative of myomas
(fibroid tumors) or endometriosis. For
ovaries, enlargement, masses and
tenderness are abnormal.
*To assess for thickened structures,
immobility and tenderness, which are
abnormalities.
*Standing position is the most
convenient position when examining the
male genitalia.
*To check for any indication of sexually
transmitted diseases (STD), infestion of
the pubis and tenderness/redness.
*Hardness along the ventral surface of
the shaft indicates cancer o urethral
stricture, and inflammation.
*Discoloration of skin is indicative of
scarring or inflammation.
*Chancers from syphilis, venereal warts
and herpes are sometime detected in the
glans.
*Urethral discharge when yellow is
associated with gonorrhea and clear or
white discharge indicates urethritis
*To check for any indication of
hydrocele, hematocele, hernia or tumor.
To check for any inflammation (STD)
*To determine any abnormalities in the
scrotal contents.
*To check for masses in the scrotum
*To note for enlarged or tender nodes
indicative of inflammation or lesions in
the genitalia.
*To check for bulges or thin ligaments
for possible complications like hernia.
*Teaching the client will enhance his
knowledge about the importance of early
detection and treatment testicular
disorders.
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 Inspect:
 Perinial area for lumps, ulcers, lesions, rashes,
redness, fissures, or thickening of epithelium
 Sacrococcygeal area for swelling, redness,
dimpling, or hair
 While client bears down or performs Vasalva
maneuver, inspect for bulges or lesions.
 Apply lubrication and use finger to palpate:
 Anus
 External sphincter for tenderness, nodules, and
hardness
 Peritoneal cavity
 Prostate for size, shape, tenderness, and
consistency
 Inspect stool for color and test feces for occult blood.
*To check for any indication of disorder
involving the perineal area and the
sacrococcygeal area that may be a
possible risk for cancer, tumors or hernia
*To check for rectal prolapsed or
hemorrhoids.
*To check for any abnormalities within
the rectum, such as nodules and polyps
which are indicative of cancer, and
tenderness that maybe caused by
hemorrhoids and fissure.
*To check for any abnormalities in the
prostate, such as benign prostatic
hypertrophy, acute prostatitis or mass
characteristic of prostate cancer.

*To check color of stool indicative of

presence of bile when grey, specks of
red with internal hemmorhoids or black
stool indicative of gastrointestinal
bleeding.

Total Score:

_____________________

DATE

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SIGNATURE CLINICAL INSTRUCTOR

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 DMC-COLLEGE FOUNDATION INC.
STA. FILOMENA, DIPOLOG CITY
COLLEGE OF NURSING

HEALTH
ASSESSMENT

Checklist

RAUL T. NOCETE
BSN 1 NIGHTSB

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