Xavier University

COLLEGE OF NURSING
Ateneo de Cagayan
NCM 101 – HEALTH ASSESSMENT

PERFORMANCE RATING SCALE

PERFORMING PHYSICAL ASSESSMENT

NAME: ______________________________________________ ____ DATE: __________________

BLOCK: ___________ CI: __________________________________ SCORE: _________________

PROCEDURE NORMAL FINDINGS ABNORMAL

FINDINGS
1. Wash your hands. Prevents illnesses and Causes transferring
spread of infections to of microorganisms
others. and causes infection

Handwashing with soap Contamination may

removes germs occur
from hands

2. Prepare all required equipments. To perform the Unable to perform

assessment directly, the assessment
properly and quickly
3. Identify the client. To know if the this is Wrong client and
the right patient you failure to deliver the
are assessing proper assessment

4. Explain the purpose and the procedure to Awareness of the Patient will be
the client. procedures of the doubtful about the
assessment assessment and
there is a possibility
Check for possible in where the patient
diseases so they can be will not cooperate
treated early

Identify any issues that

may become medical
concerns in the future
5. Close doors and/or use a screen. Client feels secure and Client is
comfortable uncomfortable
6. Assist the client to a comfortable Client is comfortable Client is restless and
position. does not feel at ease
NOSE & SINUSES Color of the nose Nasal tenderness on
7. Inspect and palpate the external nose. should be the same palpation
Note nasal color, shape, consistency and with the rest of the accompanies a local
tenderness. face. Nasal structure is infection
smooth and symmetric,
client reports no
tenderness
8. Check the patency of air flow through the Client is able to sniff Client cannot sniff
nostrils by occluding one nostril at a time through each nostril through nostril that is
and asking client to sniff or exhale. while other is occluded not occluded, nor can
he or she sniff or
blow through the
nostrils. This may be
a sign of swelling,
rhinitis, or a foreign
object obstructing
the nostrils. A line
across the tip f the
 nose just above the
fleshy tip is common
in clients with
chronic allergies
9. With nasal speculum, examine:  Nasal mucosa is  Nasal
 Nasal septum dark pink, mucosa is
 Discharges moist and free swollen, pale
 Obstructions of exudate. pink or
 Mucous membrane color  Nasal septum is blueish gray
 Turbinates for color and swelling intact and free in clients
of ulcers or with
 Hold the nasal speculum in your right hand perforations allergies.
and inspect the client’s left nostril, and in  Turbinates are  Nasal
your left hand to inspect the client’s right dark pink mucosa is
nostril. (redder than red and
 Tip the client’s head back. oral mucosa), swollen with
 Facing the client, insert the tip of the closed moist and free upper
speculum about 1 cm or up to the point at of lesions respiratory
which the blade widens. Care must be taken  Superior infection.
to avoid pressure on the sensitive nasal turbinate is not  Exudate is
speculum. visible common
 Stabilize the speculum with your index finger Deviated septum may with
against the side of the nose. Use the other appear to be an infection and
hand to position the head and then to hold overgrowth of tissues may range
the light. (normal finding as long from large
 Inspect the lining of the nares and the coarse as breathing is not amounts of
hairs that filters the air. Observe for the obstructed ) watery
presence of redness, swelling, growth and discharge to
discharges. thick yellow-
green,
purulent
discharge.
Purulent
nasal
discharge is
seen with
acute
bacterial
rhinosinusitis
 Bleeding
(epistais) or
crusting may
be noted on
the on the
lower
anterior part
of the nasal
septum with
local
irritation
 Ulcers of the
nasal mucosa
or a
perforated
septum may
be seen with
use of
cocaine,
trauma,
chronic
infection r
chronic nose
picking.
 Small, pale round,
firm overgrowths or
masses on mucosa
are seen in clients
with client with
chronic allergies

10. Palpate sinuses for tenderness:  Frontal and  Frontal or

 Frontal maxillary sinuses maxillary
 Ethmoid are nontender to sinuses are
 Sphenoid palpation, and no tender to
Maxillary crepitus is evident palpation in
The sinuses are not tender clients with
on percussion allergies or
acute
bacterial
rhinosinusitis
.
 If client has a
large amount
of exudate,
you may feel
crepitus
upon
palpation
vert h
maxillary
sinuses. This
may also be
present with
a viral upper
respiratory
infection
(URI)
The frontal and
maxillary sinuses are
tender upon
percussion in clients
with allergies or
sinus infection
MOUTH Lips are smooth and moist -Pallor around the
If the client wears dentures, offer a piece without lesions or swelling. lips (circumolar
of paper towel and ask to remove it so pallor) is seen in
that you can see the mucosa underneath. anemia and shock
11. Inspect the lips of color, moisture,
pigment, masses, ulceration and -Bluish (cyanotic) lips
fissures. may result from cold
 Ask the patient to purse the lips as if to or hypoxia
whistle. -Reddish lips are
seen in clients with
ketoacidosis, carbon
monoxide poisoning ,
and chronic
obstructive
pulmonary disease
(COPD) with
polycythemia
 Swelling of the lips
(edema) is commo in
local or systemic
allergic o
anaphylactic
reactions
12. Using the tongue depressor and -32 pearly whitish teeth -Clients who
penlight, examine the: with smooth surfaces smoke, drink
 Teeth and edges large quantities
 Gums of coffee or tea,
 Buccal mucosa -Upper molars should or have an
 Pharynx rest directly on the excessive intake
 Ask the client to open the mouth and say lower molars and the of fluoride may
“ah”. This actions help to see the pharynx front upper incisors have yellow or
well. should slightly override brownish teeth.
 Tongue the lower incisors
 Salivary glands -Tooth decay
 Uvula -Some clients normally may appear as
 Tonsils have only 28 teeth if the brown dots or
 Odor of the breath four wisdom teeth do cover more
not erupt extensive areas
 Voice
of chewing
-No decayed areas; no surfaces.
missing teeth
-Missing teeth
-Client may have can affect
appliances on the teeth. chewing as well
Client may have as self image.
evidence of repair work -A chalky white
done on teeth area in the tooth
-Jaws are aligned with surface is a cavity
no deviation seen with that will turn
biting down. darker with time.
-Malocclusion of
-Color and consistency teeth is seen
of tissues along cheeks when upper or
and gums are even lower incisors
protrude
-tissue is smooth and -Poor occlusion
moist without lesions. of teeth, speech,
and self-image.
-Stenson’s ducts are -Brown or yellow
visible with flow of stains or white
saliva and with no spots on teeth
redness, swelling, may result from
pain, or moistness antibiotic
in area. therapy or tooth
traum
-Fordyce spots or -Receeding gums
granules, yellowish-
whitish raised spots, -Red, swollen
are normal ectopic gums that bleed
sebaceous glands. easily are seen in
Gingivitis, scurvy,
-Tongue should be pink, and Leukemia
moist, a moderate size
with papillae present -Receeding red
gums with loss of
-Common variation is a teeth are seen in
fissure, topographic- periodontitis
map-like tongue, which
is not unusual in older -Enlarged reddened
clients gums that may cover
some of the normally
 -No lesions are present exposed teeth may
be seen in
-The tongue’s ventral pregnancy, puberty,
surface is smooth shiny, leukemia, and with
pink, or slightly pale, use of some
with visible veins and medications]A bluish
no lesions black or gray-white
 Frenulum is midline; line along the gum
Wharton ducts are line is seen in lead
visible, with salivary poisoning
flow or moistness in
the area. -Leukoplakia may
 Client has no be seen in
swelling, redness or chronic irritation,
pain heavy smoking,
-No lesions, ulcers, or and alcohol use.
nodules are apparent There are
precancerous
-Tongue offers strong lesions and
resistance should be
referred to the
-Client can distinguish client’s primary
between sweet and salty health care
provide for
-Hard palate is pale or further
whitish with firm, assessment
transverse rugae -Whitish, curd-
like patches that
-Palatine tissues are intact; scrape off over
the soft palate should be reddened
pinkish, movable, spongy mucosa and
and smooth bleed easil
-No unusual or foul indicate “thrush”
odor is noted
-Koplik spots are
-The uvula is a fleshy, an early signs of
solid structure that measles
hangs freely in the -Canker sores
midline. No redness of may be seen
or exudate from uvula
or soft palate. Midline -Dry; nodules,
elevation of uvula and ulcers present;
symmetric elevation of papillae or
the soft palate fissures absent;
assymetrical.
-tonsils may be present Deep
or absent, They are pink longitudinal
and symmetric and may fissure are seen
be enlarged in dehydration
-No exudate, swelling or -Black hairy
lesions should be tongue seen with
present conditions
Throat is normally pink, causing
without exudate or lesions hyposalivation,
heavy smoking,
alcohol intake, se
of antibiotic that
inhibit normal
bacteria leading
to fungus, use of
mouthwashes;
also seen with
bismuth intake
-Raised whitish
feathery areas on
sides of tongue that
cannot be scraped
off suggest hairy
leukoplaskias see in
HIV infection and
AIDS

-Smooth, reddish,
shiny tongue without
papillae is indicative
of niacin or vitamin
B12 deficiencies,
certain anemias,
antineosplastic
therapy

-Enlarged tongue
suggests
hypothyroidism,
acromegaly, down
syndrome, and
angioneurotic edema
of anaphylaxis

-Very small tongue

suggests
malnutrition

-Atrophied tongue or
fasciculations point
to cranial nerve
damage

-Leukoplakia,
persistent lesions,
ulcers or nodules
may indicate cancer
ad should be
referred

-Induration increases
the likelihood of
cancer

-Abnormal findings
include lesions,
ulcers nodules or
hypertrophied duct
openings on either
side of frenulum

-Canker sores may be

seen on the sides of
the tongue in clients
receiving certain
kinds chemotherapy

-Leukoplakia,
persistent lesions,
ulcers, or nodules
may indicate cancer
and should be
further evaluated
medically

-Decreased tongue
strength may occur
with a defect of the
twelfth cranial nerve-
hypoglossal-or with a
shortened frenulum
that limits motion

-Loss of taste
discrimination occurs
with trauma, viral
infection, sinusitis,
and polyposis,
increasing age,
neurologic illnesses
such as Parkinson’s
an Alzheimer’s and
zinc deficiency, or
use of certain
medication that
affect smell
threshold

-Candidal infection
may appear as thick,
white plaques on the
hard palate. Deep
purple, raised, or flat
lesions may indicate
a Kaposi sarcoma

-Yellow tint to the

hard palate may
indicate jaundice
because bilirubin
adheres to elastic
tissue

-Fruity or acetone
breath is associated
with diabetic
ketoacidosis.
-An ammonia odor
often associated with
kidney disease

-Foul odors may

indicate an oral or
respiratory infection,
or tooth decay

-Alcohol or tobacco
use may be identified
by breath odor
-Fecal breath odor
occurs in bowel
obstruction; sulfur
odor occurs in end-
stage liver disese
 -Asymmetric
movement or loss of
movement may
occur after a
cerebrovascular
accident

-Palate fails to rise

and uvula deviates to
normal side with
cranial nerve X

-Tonsils are red,

enlarged, and
covered with
exudate in tonsillitis.
May be indurated
with patches of
white or yellow
exudate

-Bright red throat

with white or yellow
exudat indicates
pharyngitis

-Yellowish mucus on
throat may be seen,
with postnasal sinus
drainage
NECK No neck vein distention Neck vein distention.
13. Inspect for symmetry, masses, Altered cardiac
unusual swelling, pulsations. No unexplained function that could
hypertrophy of neck be reflected with
Range of Motion (ROM) accessory muscles
 Move the chin to the chest cyanosis of skin.
 Move the head back so that the chin No palpable or visible Hypertrophy of neck
points upward cervical nodes
 Move the head so that the shoulder on muscles. Normal in a
each side Thyroid not palpable person who lifts
 Turn the head to the right and to the left weights. Otherwise,
suggest chronic
pulmonary disease,
with potential for
cyanosis or ruddy
skin.

Palpable/visible
nodes

Palpable thyroid

14. Test the strength of cervical muscle Equal strength Unequal

and trapezius muscle
 Cervical muscle
 Turn the head to one side against the
resistance of your hand. Repeat with the
other side.
 Trapezius muscle
 Shrug the shoulders against the
resistance of your hands.
15. Examine the external jugular veins. The jugular venous pulse is Fully distended
not normally visible with jugular veins with the
 Client is in Semi-Fowler’s position with the client sitting upright. client’s torso
the head supposed with a pillow. This position fully distends elevated more than
the vein, and pulsations 45 degrees indicate
increased central
may or may not be
venous pressure that
discernible. may be the result of
right ventricular
failure, pulmonary
hypertension,
pulmonary emboli,
or cardiac
tamponade.
16. Palpate the:
 Salivary glands
- Parotid gland
- Sublingual gland
- Maxillary gland
17. Central placement in Deviation to one
 Trachea midline of neck; Spaces are side, indicating
Place your fingers or thumb on the equal on both sides possible neck tumor;
trachea in the suprasternal notch, then thyroid enlargement;
move your finger laterally to the left and enlarged lymph
right in spaces bordered by the clavicle, nodes
the anterior aspect of the
sternocleidomastoid muscle, and the
trachea.
18. Not visible on inspection. Visible diffuseness or
 Thyroid gland local enlargement.
 Stand in front of the client. Gland ascend during
 Observe the lower half of the neck swallowing, but it is not Gland is not fully
overlying the thyroid gland for symmetry visible. movable with
and visible masses. swallowing.
 Ask the client to hyperextend head and
swallow. If necessary, offer a glass of
water to make it easier for the client to
swallow.
19. Arteries are elastic and no Loss of elasticity may
 Carotid arteries thrills are noted. indicate
 Palpate only one carotid artery at a time. arteriosclerosis.
This ensures adequate cerebral flow Auscultation and palpation: Thrills may indicate a
through the other and thus prevents
No blowing or swishing or narrowing of the
possible ischemia.
 Avoid exerting too much pressure and other sounds are heard. artery.
massaging the area. Pressure can
precipitate bradycardia. Pulses are equally strong; a Auscultation and
 Ask the client to turn the head slightly 2+ or normal with no palpation: A bruit, a
toward the side being examined. This variation in strength from blowing or swishing
makes the carotid artery more beat to beat. Contour is sound caused by
accessible. normally smooth and rapid turbulent blood flow
on the upstroke and slower through a narrowed
and less abrupt on the vessel, is indicative
downstroke. of occlusive arterial
disease
20. LYMPH NODES No swelling, no tenderness, Swelling, tenderness,
 Palpate the lymph nodes by using the no hardness is present. hardness, immobility
pads of your index and middle fingers. are abnormal.
 Move the underlying tissues in each area.
 Examine both sides at once. Enlargement and
 Feel in sequence for the following nodes: tenderness are
 Cervical
abnormal.
 Supra and Infraclavicular nodes
 Axillary nodes
 Inguinal nodes
 Epithroclear node
THORAX & LUNGS Scapulae are symmetric and
 Posterior Thorax nonprotruding
21. Inspect configuration.
While the client sits with arms at the Shoulders and scapulae are
sides, stand behind the client and ate equal horizontal
observe the position of scapulae and the positions
shape and configuration of the chest
wall. Ratio of anterior to
transverse diameter is 1;2
Spinous processes appear
STRAIGHT and thorax
appears symmetric, ribs
slopping downwards
22. Observe use of accessory muscles. The client does not use
Watch as the client breathes and note accessory (trapezius/
use of muscles. shoulder) muscles to assist
breathing . diaphragm is the
major muscles at work. This
evidence by expansion of
the lower chest during
inspiration
Spinous proccess
that deviate laterally
in the thoracic are
may mean taht
patient has
SCOLIOSIS
a medical condition
in which a person's
spine has a sideways
curve. The curve is
usually "S"- or "C"-
shaped
Client leans forward
and uses arm s to
support weight and
lift chest to increase
breathing capacity,
referred to as the
tripod position.

23. Inspect the client’s positioning. Client should be sitting up Tender or painful
Note the client’s posture and ability to and relaxed, breathing areas may indicate
support weight while breathing easily with arms at sides or Inflamed fibrous
comfortably. in lap. connective tissue.
Pain over the
intercostal spaces
may be from
inflamed pleurae.
Pain over the ribs,
especially at the
costal chondral
junctions, is a
symptom of a
fractured ribs .
24. Palpate for tenderness and Client reports no Muscle soreness
sensation. tenderness pain, or unusual from exercise or the
Palpation may be performed with one or sensations. Temperature excessive work of
both hands. Use your fingers to palpate should be equal bilaterally. breathing(as in
for tenderness, warmth, pain or other COPD) may be
sensations. Start toward the midline at palpated as
the level of the left scapula (over the tenderness.
apex of the left lung) and move your
hand left to right, comparing findings Increased warmth
bilaterally. Move systematically may be related to
downward and out to cover the lateral local infection.
portions of the lungs at the bases.
25. Palpate for crepitus. The examiner finds no Crepitus can be
Follow the sequence above. palpable crepitus. palpated if air
escapes from the
lung or other
airwways into the
subcutaneous tissue,
as occurs after an
open thoracic injury,
around a chest tube,
or tracheostomy. It
also maybe palpated
in areas of extreme
congestion or
consolidation. In
such a situations,
 mark margins and
monitor to note any
decrease or increase
in the -crepitant
area.
26. Palpate surface characteristics. Skin and subcutaneous A physician or other
Put on gloves and use your fingers to tissue are free of lesions appropriate
palpate any lesions that you noticed and masses. professional should
during inspection. Feel for any unusual evaluate any unusual
masses. palpable mass.
27. Palpate for fremitus. Fremitus is symmetric and Unequal fremitus is
Following the sequence described easily identified in the usually the result of
previously, use the ball or ulnar edge of upper regions of the lungs. consolidation (which
one hand to assess for fremitus. As you If fremitus is not palpable increases fremitus)
move your hand to each area, ask the on either side, the client or bronchial
client to say “ninety-nine”. Assess all may need to speak louder. obstruction air
areas for symmetry and intensity of A decrease in the intensity trapping in
vibration. of fremitus is normal as the emphysema, pleural
examiner moves towards effusion,
the base of the lungs. pneumothorax(whic
However, fremitus should h all decrease
remain symmetric for fremitus). diminished
bilateral positions. fremitus even with a
loud spoken voice
may indicate an
obstruction of the
tracheobronchial
tree.
28. Assess chest expansion. When the client takes a Unequal chest
Place your hands n the posterior chest deep breath, the examiner’s expansion can occur
wall with your thumbs at the level of T9 thumbs should move 5 to with severe
or T10 and pressing together a small skin 10cm apart symmetrically. atelectasis( collapse
fold. As the client takes a deep breath, or incomplete
observe the movement of your thumbs. expansion),
pneumonia, chest
trauma, or
pneumothora( air in
the pleural space.)
29. 1Percuss for tone. Resonance is the percussion Hyperresonance is
Start at the apices of the scapulae and tone elicited over normal elicited in cases of
percuss across the tops of both lung tissue(Fig 19-14) trapped air such as in
shoulders. Then percuss the intercostals percussion elicits flat tones emphysema or
spaces across and down, comparing over the scapula pneumothorax.
sides. Percuss to the lateral aspects at
the bases of the lungs, comparing sides.

30. Percuss for diaphragmatic excursion. Excursion should be Dullness ias present
equal bilaterally and when fluid or solid
WALA NA HUMAN measure 3-5 cm in tissue replace air in
adults the lung or occupies
the pleural space,
such as in lobar
pneumonia, pleural
effusion, or tumor.
31. Auscultate for breath sounds. Three types of Diminished or
normal breath absent breath
sounds may be sounds often
ausculated - indicated that little
bronchial, or no air is moving in
bronchovesicular, or out of the lung
area being
 and vesicular (table ausculated. This
19-1) may indicate
obstruction within
the lungs as the
result of secretion ,
mucus plug, or a
foreign object.
32. Auscultate voice sounds.
 Bronchophony: Ask the client to repeat the Bronchophony Voice The words are easily
phrase “ninety-nine” while you auscultate the transmission is soft, understood and
chest wall. muffled and louder over areas of
indistinct. The sound increased density.
 Egophony: Ask the client to repeat the letter of the voice may be This may indicate
“E” while you listen over the chest wall. heard but the actual consolidation from
phrase cannot be pneumonia,
 Whispered pectoriloquy: ask the client to distuinguished. atelectasis, or
whisper the phrase “one-two-three” while tumor.
you auscultate the chest wall. Egophony voice
transmission will be Over areas of
soft and muffle but consolidation or
the letter “E” should compression the
be distinguishable. sound is louder and
sounds like “A”.
Whispered
pectoriloquy
Transmission of Over areas of
sound is very faint consolidation or
and muffled. It may compression, the
be inaudible. sound is transmitted
clearly and
distinctly. In such
areas, it sounds as if
the client is
whispering directly
into the
stethoscope.
 Anterior Thorax

33. Inspect for shape and configuration. The anteroposterior

Anteroposterior
Have the client sit with arms at the sides. Stand in diameter is less than
equals transverse
front of the client and assess shape and the transverse
diameter, resulting
configuration. diamter. The ratio of
in a barrel chest
anteroposterior (abnormal Findings
diameter is 1:2 19-1) this is often
seen in emphysema
because of
hyperinflation of
the lungs.
34. Inspect position of the sternum. Stermnum is Pectus excavatum is
Observe the sternum from an anterior and lateral positioned at midline markedly sunken
viewpoint. and straight. sternum and
adjacent cartilages
(often referred to as
funnel chest.) it is a
congenital
malformation that
seldom causes
symptoms other
than self-
consciousness.
35. Watch for sternal retractions. Retraction not Sternal retraction
observed. are noted, with
severely labored
breathing.
36. Inspect slope of the ribs. Ribs slope downward Barrel-chest
with symmetric configuration
intercostal spaces. results in a more
Costal angle is within horizontal position
90 degrees. of the ribs and
costal angle of more
than 90 degrees.
This often results
from long-standing
emphysema.
37. Observe quality and pattern of respiration.
38. Inspect intercostal spaces. No retractions or Retraction of the
bulging of intercostal intercostal spaces
spaces are noted indicates an
increased
inspiratory effort.
This may be the
result of an
obstruction of the
respiratory tract or
atelectasis
39. Observe for use of accessory muscles. Use of accessory Neck muscles
muscles (sternomastoid,
(sternomastoid and scalene, and
rectus abdominis)is trapezius) are used
not seen with normal to facilitate
respiratory effort. inspiration in cases
of acute or chronic
airway obstruction
or atelectsis.
40. Palpate for tenderness, sensation and surface Palpation does not Tenderness or pain
masses. elicit tenderness. at the
costochondral
junction of the ribs
is seen with
fractures, especially
in older client with
osteoporosis .
41. Palpate for tenderness at costochondral Palpation does not Tenderness or pain
junctions of ribs. elicit tenderness. at the
costochondral
junction of the ribs
is seen with
fractures, especially
in older clients with
osteoporosis.

42. Palpate for crepitus as you would on the No crepitus is In areas of extreme
posterior thorax. palpated. congestion or
consolidation,
crepitus may be
palpated,
particularly in
clients with lung
disease.

43. Palpate for any surface masses or lesions. No unusual surface Surface masses or
masses or lesions are lesions may indicate
palpated. cysts or tumors.
44. Palpate for fremitus. Fremitus is Diminished
Palpate for femitus using the same technique as symmetric and easily vibrations, even
for the posterior thorax. identified in the with a loud spoken
upper regions of the voice, may indicate
lungs. A decreased an obstruction of
intensity of fremitus the
is expected toward tracheobronchial
the base of the tree. Clients with
lungs. However, emphysema may
fremitus should be have considerably
symmetric decreased fremitus
bilaterally. as a result of air
trapping.

45. Palpate anterior chest expansion. Thumbs move Unequal chest

outward in a expansion can occur
symmetric fashion with severe
from the midline. atelectasis,
pneumonia, chest
trauma, pleural
effusion, or
pneumothorax.
Decreased chest
excursion at the
bases of the lungs is
seen with COPD.
46. Percuss for tone. Resonance is the Hyperresonance is
Percuss the apices above the clavicles. Then percussion tone elicited in cases of
percuss the intercostals spaces across and down, elicited over normal trapped air such as
comparing sides.
lung tissue. in emphysema or
pneumothorax.
Percussion elicits Dullness may
dullness over breast characterize areas
tissue, the heart, and of increased density
the liver. Tympany is such as
detected over the consolidation,
stomach, and pleural effusion, or
flatness is detected tumor.
over the muscles and
bones.

47. Auscultate for anterior breath sounds, Bronchial (loud, Bronchial sounds
adventitious sounds and voice sounds. tubular) breath herd over lung
Place the diaphragm of the stethoscope firmly and sounds heard over periphery.
directly on the anterior chest wall.
trachea; expiration
longer than Bronchovesicular
inspiration; short breath sounds
silence between heard over lung
inspiration and periphery.
expiration. Decreased breath
Bronchovesicular sounds with
breath sounds heard obstruction, pleural
over mainstream thickening, pleural
effusion, or
bronchi: below
clavicles and pneumothorax
between scapulae
 (inspiratory phase
equal to expiratory
phase)

Vesicular (low, soft,

breezy) breath
sounds heard over
lung periphery
(inspiration longer
than expiration)

BREAST (USE BREAST DUMMY/MODEL) Size and symmetry : Recent increase of

48. Inspect the areola and nipples for position, breast may indicate
pigmentation, inversion, discharge, crusting Breast has a variety inflammation or
and masses. of sizes and are abnormal growth
round and
pendulous. One
breast may be large
than the other

Older clients has

more saggy boobs

COLOR AND
TEXTURE: -redness is
Color depends on the inflammation
clients skin tone, -a pigskin or orange
texture is smooth skin called peau d
with no edema, orange results from
stretch marks are edema (breast
normal disease) edema is
caused by blocked
lymphatic drainage
INSPECTION OF
AREOLAS
-dark pink to dark Nipple recently
brown retracted nipple
-round size that was previously
-small montgomery evrted suggest
tubercles are present malignancy
Any spontaneous
NIPPLE POSITION discharge
Equally bilateral and
same position
May be everted and
inverted or flat

Supernumerary
nipples my appear in
MILK LINE
No discharge
 49. Examine the breast tissue for size, shape, Breast should rise Dimpling is usually
color, symmetry, surface, contour, skin symmetrically with caused by a
characteristics, level of retraction or dimpling. no sign of dimpling or malignant tumor
retraction that has fibrous
Accentuate retraction by having the client: strands attcahed to
 Raise the arms above the head the breast tissue
 Press the hands down on the hips and the fascia of the
muscle

As muscle contracts
it draws the breast
tissue and skin with
it causing dimpling
50. Position the patient with pillows under the Temperature: warm Erythema; heat
scapulae with arms raise. Palpate the breast. indicates
Start with the asymptomatic side. Elasticity: elastic inflammation if
Tenderness: client is not
Three ways in palpating the breast:
lactating or has not
 Hands of the clock nontender; slightly
 Concentric circle tender (tenderness just given birth.
 Vertical strips and fullness may
Lumpy; painful.
occur before
menses) Masses or nodules.
Malignant tumors
Masses (note size, are most often
shape, mobility, found in upper
consistency, and outer quadrant of
location according to breast and are
quadrant): bilateral usually unilateral
firm inframammary with irregular,
transverse ridge at poorly delineated
base of breasts borders; hard;
nontender; and
fixed to underlying
tissues.
Fibroadenomas
(benign) are usually
1-5 cm, round or
oval, mobile firm,
solid, elastic,
nontender, and
single or multiple in
one or both breasts.
Fibrocystic disease
consists of bilateral,
multiple, firm,
regular, rubbery,
mobile nodules with
well-demarcated
borders.
51. Palpate one breast at a time using the palmar Breast has firm Presence
surface in rotating motion compressing the elasticity in young. tenderness, masses,
breast tissue against the chest wall. Glandular tissue may modules, or nipple
feel lobulated, discharge
granular, irregular
("tapioca").

Slight tenderness
and fullness can be
anticipated in
premenstrual period.
 In older women,
breasts feel stringy

52. Note the skin texture, moisture, temperature Skin surface: smooth Retraction,
and masses. dimpling, enlarged
Temperature: warm pores, “peau
Masses (note size, d’orange” (seen in
shape, mobility, metastatic breast
consistency, and disease due to
location according to edema from
quadrant): bilateral blocked lymphatic
firm inframammary
drainage). Edema,
transverse ridge at
lumps, lesions,
base of breasts
rashes, ulcers.

Erythema; heat
indicates
inflammation if
client is not
lactating or has not
just given birth.

Masses or nodules.
Malignant tumors
are most often
found in upper
outer quadrant of
breast and are
usually unilateral
with irregular,
poorly delineated
borders; hard;
nontender; and
fixed to underlying
tissues.
Fibroadenomas
(benign) are usually
1-5 cm, round or
oval, mobile firm,
solid, elastic,
nontender, and
single or multiple in
one or both breasts.
Fibrocystic disease
consists of bilateral,
multiple, firm,
regular, rubbery,
mobile nodules with
well-demarcated
borders.
53. Gently squeeze the nipple and note No discharges Common causes of
discharges. nipple discharge is
pregnancy,hypothyr
oidism,pituitary
adenoma, oral
contraceptives

Colors of discharge:
Red/bloody ;
pailloma in the duct
 Greenish: drainage
breast cyst
Clear: cancer unless
fro the both nipples
54. Repeat the examination of the opposite
breast and compare the findings.

TOTAL SCORE: ______________

A (92 – 100)
A- (84 – 91.99)
B (76 – 83.99)
B- (68 – 75.99)
C (60 – 67.99)
F (<60)

STUDENT’S SIGNATURE: ___________________________

CI’s SIGNATURE: ___________________________