NCM 101 – HEALTH ASSESSMENT RLE

PERFORMING PHYSICAL ASSESSMENT

PART 3

ASSIGNMENT

NAME: Kyra Bianca R. Famacion DATE: December 29, 2020

BLOCK: NB CI: Sir Jethro Daños SCORE:_______________

PROCEDURE Normal Findings Abnormal Findings

1. Assemble equipment
2. Introduce yourself and
verify the client’s identity.
Explain to the client what
your are going to do, why it
is necessary and how the
client can cooperate.
3. Perform hand hygiene
and observe other
appropriate infection
control procedures.
4. Provide for client privacy.
5. Determine the client’s
history of the following:
 Incidence of
abdominal pain: its
location, onset,
sequence and
chronology; its
quality; its
frequency;
associated and the
symptoms
 Bowel habits
 Incidence of
constipation or
diarrhea
 Change in appetite
 Food in appetite
 Food intolerances
 Food ingested in the
last 24 hours
 Specific signs and
symptoms
 Previous problems
and treatment
6. Assist the client to a
supine position, with the
arms placed comfortably at
the sides.
 Place small pillows
beneath the knees
and the head to
reduce tension in the
abdominal muscles.
 Expose only the
client’s abdomen
from the chest line to
the pubic area to
avoid chilling and
shivering, which can
tense the abdominal
muscles.
ASSESSING THE The surface is smooth and Redness with localized
ABDOMEN even, with homogenous Inflammation. Jaundice.
7. Inspect the abdomen for color. Old silver striae orSkin glistening, taut, and
skin integrity. stretch marks is normal striae in ascites. Pink-
after pregnancy or gained purple striae with Cushing’s
excessive weight. Recent syndrome. Prominent,
striae are pink or blue. dilated veins of hepatic
Good turgor. cirrhosis or of inferior vena
caval obstruction. Lesions,
rashes. Poor turgor occurs
with dehydration.
8. Inspect the abdomen for Abdomen is flat, rounded, A generalized protuberant
contour and symmetry. or scaphoid (usually seen in or distended abdomen may
 Observe the adults). Abdomen should be be due to obesity, air (gas),
abdominal contour evenly rounded. or fluid accumulation.
while standing at the Distention below the
client’s side when umbilicus may be due to a
the client is in full bladder, uterine
supine. enlargement, or an ovarian
 Ask the client to take tumor or cyst. Distention of
a deep breath and to the upper abdomen may be
hold it. seen with masses of the
 Assess the pancreas or gastric dilation.
symmetry of contour A scaphoid (sunken)
while standing at the abdomen may be seen with
foot of the bed. severe weight loss or
 If distention is cachexia related to
present, measure starvation or terminal
the abdominal girth illness.
by placing a tape
around the abdomen Abdomen is symmetric. Asymmetry may be seen
at the level of the with organ enlargement,
umbilicus. large masses, hernia,
diastasis recti, or bowel
obstruction.
9. Observe abdominal Abdominal respiratory Diminished abdominal
movements associated with movement may be seen, respiration or change to
respiration, peristalsis, or especially in male clients. thoracic breathing in male
aortic pulsations. clients may reflect
peritoneal irritation.

Normally, peristaltic waves Peristaltic waves are

are not seen, although they increased and progress in
may be visible in very thin ripple-like fashion from the
people as slight ripples on LUQ to the RLQ with
the abdominal wall. intestinal obstruction
(especially small intestine).
In addition, abdominal
distention typically is
present with intestinal wall
 A slight pulsation of the obstruction.
abdominal aorta extends full
length in thin people. Vigorous, wide,
exaggerated pulsations
may be seen with
abdominal aortic aneurysm.
10. Observe the vascular Scatttered fine veins may Dilated veins may be seen
pattern. be visible. Blood in the with cirrhosis of the liver,
veins located above the obstruction of the inferior
umbilicus flows toward the vena cava, portal
head; blood in the veins hypertension, or ascites.
located below the umbilicus
flows toward the lower
body.
11. Auscultate the Normal bowel sounds Two distinct patterns of
abdomen for bowel sounds, consist of clicks and abnormal bowel sounds
vascular sounds and gurgles, occurring at occur: Hyperactive sounds
peritoneal friction rubs. estimated frequency of 5 to (loud, highpitched, rushing,
30 (-34 ) times per minute. tinkling sounds that signal
increased motility),
Hypoactive or absent
sounds (abdominal surgery
or with inflammation of the
peritoneum, paralytic ileus).

Usually no vascular sounds A systolic bruit (a pulsatile

is present. blowing sound) occurs with
stenosis or occlusion of an
artery.

No friction rub over liver or Friction rubs in liver tumor

spleen is present. or abscess, gonococcal
infection around liver,
splenic infection.
12. Percuss several areas Tympany should A protuberant abdomen
in each of the four predominate because of that is tympanitic
quadrants to determine gas in gastrointestinal tract. throughout suggests
presence of tympany and Scattered area of dullness intestinal obstruction. Large
dullness. from fluid and feces. Normal dullness in pregnant uterus,
 Use a systematic dullness in the liver and ovarian tumor, distended.
pattern: begin in the spleen. Dullness may also Bladder, large liver or
left lower quadrant, be elicited over a non- spleen. Dullness in both
then proceed to the evacuated descending flanks indicates further
right lower quadrant, colon. assessment for ascites.
the right upper Absence of tympany.
quadrant and the left
upper quadrant.
13. Percuss the liver to The lower border of liver
determine its size. dullness is located at the
costal margin to 1-2 cm
below. On deep inspiration,
the lower border of liver
dullness may descend from
1 to 4 cm below the costal
margin.

The upper border of liver The upper border of liver

dullness is located between dullness may be difficult to
 the left fifth and seventh estimate if obscured by
intercostal spaces. pleural fluid of lung
consolidation.

The normal liver span at the Hepatomegaly, a liver span

MCL is 6-12 cm (greater in
men and taller clients, less
in shorter clients).
that exceeds normal limits
(enlarged), is characteristic
of liver tumors, cirrhosis,
abscess, and vascular
engorgement. Atrophy of
the liver Is indicated by a
decreased span.

A liver in a lower position

than normal may be
caused by emphysema,
whereas a liver in a higher
position than normal may
be caused by an abdominal
mass, ascites, or a
paralyzed diaphragm. A
liver in a lower or higher
position should have a
normal span, but an
enlarged liver may be
higher, lower, or both.
14. Perform light palpation No abdominal mass. No Presence of muscle
first to detect areas of tenderness. guarding, mass,
tenderness and/or muscle tenderness. Involuntary
guarding. rigidity indicates acute
 Systematically peritoneal inflammation.
explore all four
quadrants.
15. Perform deep palpation Normally palpable structure: Tenderness occurs with
over all four quadrants. xiphoid process, normal local inflammation, with
liver edge, right kidney, inflammation of the
pulsatile aorta, rectus peritoneum or underlying
muscles, sacral promontory, organ, and with an
cecum ascending colon, enlarged organ whose
sigmoid colon, uterus, full capsule is stretched.
bladder. Mild tenderness is
normally present when
palpating the sigmoid colon.
16. Palpate the liver to Liver is not usually Liver palpable as soft
detect enlargement and palpable. People may be hedge or irregular contour.
tenderness. palpable the edge of the Except with a depressed
liver bump immediately diaphragm, a liver palpated
below the costal margin as more than 1 to 2 cm below
the diaphragm pushes it the right costal margin is
down during inhalation: a enlarged. If enlarged,
smooth structure with a estimate the amount of
regular contour, firm and enlargement beyond the
sharp edge. right costal margin.
Express it in centimeters
with its consistency and
tenderness.
17. Palpate the area above An empty bladder is neither A distended bladder
the pubic symphysis if the palpable nor tender. palpated as a smooth,
client’s history indicates round, and somewhat firm
possible urinary retention. mass extending as far as
the umbilicus.
ASSESSING THE
MUSCULOSKELETAL
SYSTEM
18. Inquire if client has any
history of the following:
 Muscle pain: onset,
location, character,
associated
phenomena and
aggravating and
alleviating factors
 Any limitations to
movement or
inability to perform
activities of daily
living
 Previous sports
injuries
 Any loss of function
without pain
19. Inspect the muscles for The muscles should be Atrophy (a decrease in
size. relatively symmetric size); hypertrophy (an
 Compare each bilaterally. In some, increase in size);
muscle on one side muscles may be slightly fasciculations; irregular
of the body to the larger on the dominant side. posture; asymmetry;
same muscle on the misalignment, etc.
other side. For any
apparent
discrepancies,
measure the
muscles with a tape.
20. Inspect the muscles No contractures. Malposition of body part
and tendons for (ex. Foot drop).
contactures.
21. Inspect the muscles for No tremors. Involuntary shaking of
tremors. hands (tremor) present.
 Inspect any tremors
of the hands and
arms by having the
client hold arms out
in front of body.
22. Palpate muscles at rest Passive movement of the Increased tone due to:
to determine muscle limbs should be neither Spasticity (lesions of
tonicity. floppy nor stiff. pyramidal tract (upper
motor neuron)) or Rigidity
(lesions of extrapyramidal
tract); Reduced tone due
to flaccidity (lower motor
neuron lesions).
23. Palpate muscles while Smooth coordinated Flaccidity (weakness or
the client is active and movement. laxness) or spasticity
passive flaccidity, spasticity (sudden involuntary muscle
and smoothness of contraction).
movement.
24. Test muscle strength. Normal strength for the Muscle weakness; muscle
Compare the right side with muscle tested; bilaterally cramping / contracture.
left side. symmetric; full resistance to
opposition.
25. Inspect the skeleton for Symmetrical; correct Asymmetry; misalignment;
normal structure and alignment; no deformities. deformities.
deformities.
26. Palpate the bones to Bones should be non- Presence of tenderness or
locate any areas of edema tender and no edema. edema.
or tenderness.
27. Inspect the joint for Smooth movement. There Restricted or unstable
swelling. should be no tenderness, movement due to
 Palpate each joint crepitus, swelling; nodules. contracture, weakness, etc.
for tenderness, Presence of pain; swelling;
smoothness of crepitation; nodules.
movement, swelling,
crepitation, and
presence of nodules.
28. Assess joint range of ROM of the shoulders Rotator cuff tear (painful
motion. - Extent of forward and limited abduction
 Ask the client to flexion should be 180 accompanied with muscle
move selected body degrees; weakness and atrophy);
parts. hyperextension, 50 Rotator cuff tendinitis
degrees; adduction, (sharp catches of pain
50 degrees; and when bring hands
abduction 180 overhead); Calcified
degrees. tendinitis (chronic pain and
severe limitation of all
shoulder motions).
ROM of the elbows
- 160 degrees of Decreased ROM against
flexion, 180 degrees resistance is seen with joint
of extension, 90 or muscle disease or injury.
degrees of pronation,
and 90 degrees of
supination. Some
clients may lack 5-10
degrees or have
hyper extension. The
client should have
full ROM against
resistance.
ROM of the wrists
- 90 degrees of Rheumatoid arthritis (Ulnar
flexion, 70 degrees deviation of the wrist and
of hyperextension, fingers with limited ROM);
55 degrees of ulnar Epicondylitis of the lateral
deviation, and 20 side of the elbow
degrees of radial (increased pain with
deviation. Client extension of the wrist
should have full against resistance).
ROM against
resistance.
ROM of hands and fingers
- 20 degrees of Dupuytren contracture
abduction, full (inability to extend the ring
adduction of fingers and little fingers)
(touching), 90
 degrees of flexion,
and 30 degrees of
hyperextension. The
thumb should easily
move away from
other fingers and 50
degrees of thumb
flexion is normal. The
client has full ROM
against resistance.
ASSESSING THE
FEMALE GENITALIA,
INGUINAL AREA &
RECTUM
29. Perform hand hygiene,
apply gloves and observe
other appropriate infection
control procedures.
30. Provide for client
privacy. Request the
presence of another
woman if desired, required
by agency policy or
requested by client.
31. Determine the client’s
history of the following
(whichever is applicable to
your client):
 Age of onset of
menstruation
 Last menstrual
period (LMP)
 Regularity of cycle,
duration, amount of
daily flow and
whether
menstruation is
painful
 Incidence of pain
during intercourse
 Vaginal discharge
 Number of
pregnancies
 Number of live births
 Labor and delivery
complications
 Urgency and
frequency of
urination at night
 Blood in urine
 Painful urination
 Incontinence
 History of sexually
transmitted disease,
past and present
32. Place the client in a
lithotomy position. Cover
the pelvic area with a
sheet, or drape at all times
when not actually being
examined.
33. Inspect the distribution, Pubic hair is distributed in Lice or nits (eggs) at the
amount, and characteristics an inverted triangular base of the pubic hairs
of the pubic hair. pattern and there are no indicate infestation with
signs of infestation. Some pediculosis pubis. This
clients may have piercing of condition, commonly
the genital area. referred to as “crabs,” is
most often transmitted by
sexual contact.
34. Inspect the skin of the No parasites, inflammation, Lesions may be from an
pubic area for parasites, swelling and lesions. infectious disease, such as
inflammation, swelling and herpes or syphilis.
lesions. To assess, pubic Excoriation and swelling
skin adequately, separate may be from scratching or
the labia majora and labia self-treatment of the
minora. lesions.
35. Inspect the clitoris, The clitoris is a small Lesions, swelling, bulging
urethral orifice and vaginal mound of erectile tissue, in the vaginal opening, and
orifice when separating the sensitive to touch. The discharge are abnormal
labia minora. normal size of the clitoris findings. Excoriation may
varies. The urethral meatus result from the client
is small and slit-like. The scratching or self-treating a
vaginal orifice is positioned perineal irritation.
below the urethral meatus.
Its size depends on sexual
activity or vaginal delivery.
A hymen may cover the
vaginal opening partially or
completely.
36. Palpate the inguinal No enlargement or swelling Enlarged inguinal nodes
lymph nodes. of the lymph nodes. may indicate a vaginal
infection or may be the
result of irritation from hair
removal.
37. Position the client to a
left lateral or Sim’s position
with the upper leg acutely
flexed. Change gloves.
38. Inspect the anus and The skin around the anal Lesions may indicate STIs,
surrounding tissue for opening is coarser and cancer, or haemorrhoids. A
color, integrity and skin more darkly pigmented. The thrombosed external
lesions. surrounding perianal area hemorrhoid appears
should be free of redness, swollen. It is itchy, painful,
lumps, ulcers, lesions, and and bleeds when the client
rashes. passes stool. A previously
thrombosed hemorrhoid
appears as a skin tag that
protrudes from the anus.

A painful mass that s

hardened and reddened
suggests a perianal
abscess. A swollen skin
tag on the anal canal.
Redness and excoriation
 may be from scratching an
area infected by fungi or
pinworms.

A small opening in the skin

that surrounds the anal
opening may be anorectal
fistula. Thickening of the
epithelium suggests
repeated trauma from anal
intercourse.
39. Palpate the rectum for Client’s sphincter relaxes, Sphincter tightens, making
anal sphincter tonicity, permitting entry. further examination
nodules, masses, and Examination finger enters unrealistic. Examination
tenderness. anus. finger cannot enter the
anus.

The client can normally Poor sphincter tone may be

close the sphincter around the result of a spinal cord
the gloved finger. injury, previous surgery,
trauma, or a prolapsed
rectum. Tightened
sphincter tone may indicate
anxiety, scarring, or
inflammation.

The anus is normally Tenderness may indicate

smooth, nontender, and haemorrhoids, fistula, or
free of nodules and fissure. Nodules may
hardness. indicate polyps or cancer.
Hardness may indicate
scarring or cancer.

The rectal mucosa is Hardness and irregularities

normally soft, smooth, may be from scaring or
nontender, and free of cancer. Nodules may
nodules. indicate polyps or cancer.
ASSESSING THE MALE
GENITALIA, INGUINAL
AREA & RECTUM
40. Perform hand hygiene,
apply gloves and observe
other appropriate infection
control procedures.
41. Provide for client
privacy. Request the
presence of another person
if desired, required by
agency policy or requested
by client.
42. Inquire if the client has
any history of the following
(whichever is applicable to
your client):
 Usual voiding
patterns and any
changes, bladder
control, urinary
 incontinence,
frequency, or
urgency.
 Abdominal pain
 Symptoms of
sexually transmitted
disease
 Swellings that could
indicate the
presence of hernia
 Family history of
nephritis,
malignancy of the
prostrate or
malignancy of the
kidney
43. In positioning the male
client for a genital
examination, the examiner
sits and the client stands.
44. Inspect the distribution, Pubic hair is coarser than Absence or scarcity of
amount and characteristics scalp hair. The normal pubic hair may be seen in
of pubic hair. pubic hair pattern in adults clients receiving
is hair covering the entire chemotherapy. Lice or nit
groin area, extending to the (eggs) infestation at the
medial thighs and up the base of the penis or pubic
abdomen toward the hair is known as
umbilicus. pediculosis pubis,
commonly referred to as
“crabs.”
45. Inspect the penile shaft The skin of the penis is Rashes, lesions, or lumps
and glans penis for lesions, wrinkled and hairless and is may indicate STI or cancer.
nodules, swellings and normally free of rashes, Drainage around piercing
inflammation. lesions, or lumps. Genital indicates infection.
piercing is becoming more
common.

The glans size and shape Chancres (red, oval

vary, appearing rounded, ulcerations) from syphilis,
broad, or even pointed. The genital warts, and pimple-
surface of the glans is like lesions from herpes are
normally smooth, free of sometimes detected on the
lesions and redness. glans.
46. Inspect the urethral The urinary meatus is Presence of swelling,
meatus for swelling, normally free of swelling, inflammation, discharge. A
inflammation and inflammation, and yellow discharge is usually
discharge. discharge. associated with
gonorrhoea. A clear or
white discharge is usually
associated with urethritis.
47. Palpate the penis for The penis in a nonerect Tenderness may indicate
tenderness, thickening and state is usually soft, flaccid, inflammation or infection.
nodules. Use your thumb and nontender. Nodule or induration,
and first two fingers. tenderness on the penis
.
48. Inspect the scrotum for The scrotum varies in size An enlarged scrotal sac
appearance, general size, (according to temperature) may result from fluid
and symmetry. and shape. The scrotal sac (hydrocele), blood
hangs below or at the level (hematocele), bowel

49. Palpate the scrotum to
assess the status of
underlying testes,
epididymis and spermatic
cord. Palpate both testes
simultaneously for
comparative purposes.
of the penis. The left side of (hernia), or tumor (cancer).
the scrotal sac usually A varicocele is an
hangs lower than the right enlargement of the veins
side. within the scrotum.
Testes are ovoid, Absence of a testis
approximately 3.5 to 5 cm suggests cryptorchidism
long, 2.5 cm wide, and 2.5 (an undescended testicle).
cm deep, and equal Painless nodules may
bilaterally in size and indicate cancer.
shape. They are smooth, Tenderness and swelling
firm, rubbery, mobile, free of may indicate acute orchitis,
nodules, and rather tender torsion of the spermatic
to pressure. The epididymis cord, a strangulated hernia,
is nontender, smooth, and or epididymis. If the client
softer than the testes. has epididymitis, passive
elevation of the testes may
relieve the scrotal pain
(Prehn sign).

The spermatic cord and vas

Palpable, tortuous veins
deferens should feel
suggest varicocele. A
uniform on both sides. The
beaded or thickened cord
cord is smooth, nontender,
indicates infection or cysts.
and rope-like. A cyst suggests hydrocele
of the spermatic cord.
50. Inspect both inguinal The inguinal and femoral Bulges that appear at the
areas for bulges while the areas are normally free external inguinal ring or at
client is standing, if
from bulges. the femoral canal when the
possible. client bears down may
 First, have the client signal a hernia.
remain at rest.
 Next, have the client
hold his breath and
strain or bear down,
as though having a
bowel movement.
51. Palpate hernias. Bulging or masses are not A bulge or mass may
normally palpated. indicate a hernia.
52. Ask the client to remain
standing and to bend over
the examination table.
Change gloves.
53. Inspect the anus and The anal opening should Lesions may indicate STIs,
surrounding tissue for appear hairless, moist, and
cancer, or haemorrhoids. A
color, integrity and skin tightly closed. The skin thrombosed external
lesions. around the anal opening is
hemorrhoid appears
coarser and more darkly swollen. It is itchy, painful,
pigmented. The surrounding
and bleeds when the client
perianal area should be free
passes stool. A previously
of redness, lumps, ulcers,
thrombosed hemorrhoid
lesions, and rashes. appears as a skin tag the
protrudes from the anus.
54. Palpate the rectum for Client’s sphincter relaxes, Sphincter tightens, making
anal sphincter tonicity, permitting entry. further examination
nodules, masses, and Examination finger enters unrealistic. Examination
tenderness. anus. finger cannot enter the
anus.
 The client can normally Poor sphincter tone may
close the sphincter around bethe result of a spinal cord
the gloved finger. injury, previous surgery,
trauma, or a prolapsed
rectum. Tightened
sphincter tone may indicate
anxiety, scarring, or
inflammation.

The anus is normally Tenderness may indicate

smooth, nontender, and
free of nodules and
hardness.
haemorrhoids, fistula, or
fissure. Nodules may
indicate polyps or cancer.
Hardness may indicate
scarring or cancer.

The rectal mucosa is Hardness and irregularities

normally soft, smooth, may be from scarring or
nontender, and free of cancer. Nodules may
nodules. indicate polyps or cancer.
55. Document all findings in
the client record.

References

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