NCM 101

Health
Assessment

Lectured by:
Mr. Bornie Baguio RN, MAN
Week 3 Midterm Coverage
A. Preparations guidelines
B. PE guidelines
C. Continuing assessment
1. Pain
2. Fever
Definition
• A physical examination is the evaluation of a
body to determine its state of health.
• A complete physical examination usually starts at
the head and proceeds all the way to the toes.
However, the exact procedure will vary according
to the needs of the person being examined and
the preferences of the examiner.
 Purpose:
• Comprehensive physical examinations provide opportunities
for health care professionals to obtain baseline information
about individuals that may be useful in the future.
• Allow health care providers to establish relationships before
problems occur.
• Physical examinations are appropriate times to answer
questions and teach good health practices.
• Detecting and addressing problems in their early stages can
have beneficial long-term results.
 General Principles:
• The individual being examined should be
comfortable and treated with respect throughout the
examination.
• The examiner should explain what they are doing
and share any relevant findings.
• Using language appropriate to the person being
examined improves the effectiveness of
communications and ultimately fosters better
relations between examiners and examinees.
 Preparation guidelines
✓ Establish a Positive Nurse/Patient Rapport. This
relationship will decrease the stress the patient may
have in anticipation of what is about to be done to
him.
✓ Explain the Purpose for the Physical Assessment.
The data must be factual, not interpretive.
✓ Obtain an Informed, Verbal Consent for the
Assessment.
✓ Ensure Confidentiality of All Data. If possible, choose
a quiet, well-lit and private place where others cannot
overhear or see the patient.
✓ Provide privacy from unnecessary exposure. Assure
as much privacy as possible by using drapes
appropriately and closing doors.
✓ Communicate special instructions to the patient. As
you proceed with the examination, inform the patient
of what you intend to do and how he can help,
especially when you anticipate possible
embarrassment or discomfort.
 P. E. Guidelines:
• Before visiting a health care professional, individuals
should write down important facts and dates about
their own medical history, as well as those of family
members.
• There should be a complete listing of all medications
and their dosages (over-the-counter preparations,
vitamins, and herbal supplements). Any questions or
concerns about medications should be written down.
 P. E. Guidelines:
• Before the physical examination begins, the bladder
should be emptied. A urine specimen is usually
collected in a small container at this time. The urine is
tested for the presence of glucose (sugar), protein,
and blood cells.
• For some blood tests, individuals may be told ahead of
time not to eat or drink after midnight.
 P. E. Guidelines:
• Individuals being examined usually remove all clothing
and put on a loose-fitting hospital gown. An additional
sheet is provided to keep persons covered and
comfortable during the examination.
• Ensure that the patient feels comfortable and is not
embarrassed. Prior to the examination, tell the patient
what will take place and explain the reason for the
procedure. The patient who knows what to expect will
be more relaxed and cooperative.
P. E. Guidelines:
• Arrange equipment and supplies. Be sure
that you have everything needed. Test all
equipment to make certain that it works
correctly. Ensure proper lighting and
optimum safety.
• Accompany the patient to the examination
room and assist him onto the table.
 P. E. Guidelines:
• Wash your hands and measure the patient's vital
signs (temperature, pulse, respiration, blood
pressure), height, and weight. Wear gloves if the
patient has a draining wound, is bleeding, is vomiting,
or has an infection.
• Have the patient's chart available. Call the physician's
attention to any abnormal lab values. Do this away
from the patient.
 Approach to the Patient
• When possible, begin with the patient in a sitting
position, so that both front and back can be
examined.
• Completely expose the part to be examined but
drape the rest of the body appropriately.
• Conduct the examination systematically from head
to foot so as not to miss observing any system or
body part.
 Approach to the Patient
• While examining each region, consider the underlying
anatomical structures, their function, and possible
abnormalities.
• Since the body is bilaterally symmetrical, for the most
part, compare findings on one side with those on the
other.
• Explain all procedures to the client while the
examination is being conducted to avoid alarming or
worrying the patient and to encourage his cooperation.
 Why is PAIN assessment important?
Assessment of a patient’s experience of pain is a crucial
component in providing effective pain management. A
systematic process of pain assessment, measurement and re-
assessment (re-evaluation), enhances the health care teams’
ability to achieve:
✓ a reduced experience of pain;
✓ increased comfort;
✓ improved physiological, psychological and physical
function;
✓ increased satisfaction with pain management.
• Pain is not a simple sensation that can
be easily assessed and measured.
Nurses should be aware of the many
factors that can influence the patients
overall experience and expression of
pain, and these should be considered
during the assessment process.
 Pain assessment and measurement

The pain assessment involves:

• an overall appraisal of the factors that may
influence a patients experience and expression
of pain (McCaffery and Pasero 1999)
• A comprehensive process of describing pain
and its effect on function;
• an awareness of the barriers that may affect
nurses assessment and management of pain.
 Barriers that may affect nurses’
assessment and management
1. Inadequate skills, knowledge, attitudes and beliefs about pain,
its assessment and management and the nurses experience
(Hall-Lord and Larsson, 2006);
2. Poor documentation of pain, its assessment, management and
re-evaluation;
3. Patients’ age, type and stage of illness (Hall-Lloyd and Larson,
2006) (British Pain Society and British Geriatric Society, 2007);
4. Myths and misconceptions about pain and its management, for
example, fear that patients with acute pain can easily become
addicted to their pain medication (McCaffery et al, 2005).
Measuring pain
L. I. Q. U. I. D
Location
Intensity
Quality
Usual Chronology
Ideal Relief
Duration
Fever
• Fever is one of the most common symptoms of
illness. A person is said to be having fever if his
body temperature rises above the normal range
which is between 36oC to 37.2oC. Since each
individual's temperature range varies, generally,
a reading above 37.2oC measured in the mouth
is considered febrile. In adults, fever is usually
not dangerous unless it measures 39oC or
higher.
• Most fevers are self-limiting and usually go away
in a relatively short time, usually within a few
days. In fact, moderate fever (not higher than
38oC) has beneficial effects as the body adapts
itself through normal physiological mechanism
which strengthen the immune system. Hence,
aggressively treating all fevers can actually
interferes with the body's immune response.
• A person who has fever often has other medical
problems. The caregiver must be able to
consider how the problems interact. The signs
and symptoms often help to identify the
underlying causes. However, if you do not know
why the person is having fever, it is best not to try
to lower his temperature which may only mask
the symptoms and make it harder to determine
the cause.
 Assessment Guidelines for Fever
• Body temperature should be measured on
admission and four hourly with other vital signs,
unless clinically indicated for more frequent
measurements.
• Body temperatures falling outside normal ranges
should be monitored and further managed where
appropriate until normothermia is achieved.
 Assessment Guidelines for Fever
• When assessing body temperatures, it is important to
consider patient-based and environmental-based
factors, including prior administration of antipyretics
and recent environmental exposures.
• Body temperature should always be evaluated in the
context of other vital signs and overall patient
presentation.
Nursing a Person with Fever
A complete nursing intervention of a
person with fever need to focus on 4
areas:
1. Decrease Body Heat Production
2. Promote Body Heat Lost
3. Monitor and Maintain Body Functions
4. Promote Comfort
Decrease Body Heat Production
• Advise the person to take a complete rest to
minimise unnecessary energy expenditure which
may increases body temperature.
• Anticipate the person's needs and keep things
within reach to avoid activity on his part.
• Inform the person of his condition and treatment
to reduce apprehension and anxiety.
 Promote Body Heat Lost:
✓ Dress the person with lightweight clothing.
✓ Keep the person cool by providing a fan or nurse him in air-
conditioner room.
✓ Sponge the person with tepid water.
✓ Take a cool bath if necessary.
✓ Increase fluid intake if the person has no fluid restriction. Fluid can
be in the form of water, iced drinks, ice-blocks, jelly, juices, or
whatever he will drink.
✓ Severe anti-fever medicine (paracetamol eg. Panadol) if the
temperature reaches at least 39oC for adults.
Note: Avoid shivering in the attempt to cool the body because this involves
muscular activity that increases heat production.
 Monitor and Maintain Body Functions:
✓Take temperature readings every 4 to 6 hourly. Pulse,
respirations and blood pressure should also be monitored in
high fever as these vial signs may indicate complications. An
increased temperature is usually accompanied with increased
respiration and heart rates.
✓The person behavioral changes such as confusion, restless,
or disorientation should be noted in high fever.
✓Check the state of hydration since fever tends to be very
debilitating and dehydrating. Learn more about dehydration
in the topic Day-to-Day Care, Observation: Fluid Balance.
Monitor and Maintain Body
Functions:
✓Fluid intake should be increased to replace fluids
lost through insensible water loss and sweating.
The inclusion of soups is recommended because
of their sodium content.
✓Provide measures to stimulate appetite and offer
well-balanced meals to meet increased metabolic
needs. Learn more on how to encourage eating
in the topic Day-to-Day Care, General: Assist in
Meals.
 Promote Comfort:
• Provide oral hygiene to keep the mouth and lips moist.
• If the person is lying on bed, frequent changing of
position and linen help to reduce discomfort.
• Frequent changing of clothes is also necessary because
of increased sweating.
• Severe paracetamol such as Panadol if the person has
headache.
• Use a lightweight blanket if the person feels cold or is
shivering.
 Care During a Chill
• A chill is an attack of shivering and a feeling of coldness, often
accompanied by a rapid rise in body temperature. If the person
experiences a chill at the onset of the fever:
• Offer extra blankets and raise the room temperature to keep the
person warm during chills. Remove blankets when the person
feels warm.
• Provide extra fluids to replace fluid lost through increased
metabolism.
• As soon as the chill is over, reduce covers to prevent loss of body
fluid and sodium by excessive sweating.
• Assess onset and duration of chill. Take temperature immediately
after episode.
• https://www.nursingtimes.net/clinical-archive/pain-management/assessment-
of-pain-18-09-
2008/#:~:text=The%20pain%20assessment%20involves%3A,nurses%20asses
sment%20andmanagement%20of%20pain.
• http://www.healthnetcafe.com/content/day-to-
day_care/home_treatment/fever_intervention.html
 NCM 101 Health
Assessment
Lectured by: Mr. Bornie Baguio RN, MAN
Topic Coverage this week:
Holistic Nursing Assessment
1.General status and vital signs
2.Mental status
• Children and adolescent
• Adult
3.Psychosocial, cognitive and moral development
4.Pain
5.Violence
6.Culture and ethnicity
7.Spiritual and religious practices
8.Nutritional status 2
General status
and vital signs
The General Survey
First encounter-
obvious physical
characteristics
It’s an introduction to
prepare for the
physical assessment
Gives an overall
impression
3
 Level of consciousness
✓ Vigilant – hyperalert, overly sensitive to environmental stimuli, startled very easily
✓ Alertness – awake, aware of self and environment. When spoken to in a normal
voice, patient looks at you and responds fully and appropriately to stimuli
✓ Lethargy – when spoken to in a loud voice, patient appears drowsy but opens
eyes and looks at you, responds to questions, then falls asleep
✓ Obtundation – when shaken gently, patient open eyes and looks at you but
responds slowly and is somewhat confused. Alertness and interest in environment
are decreased.
✓ Stupor – arouses from sleep only after painful stimuli. Verbal responses are slow
or absent. Lapses into unresponsiveness when stimulus stops. Has minimal
awareness of self or environment.
✓ Coma – despite repeated painful stimuli, patient remains unarousable with eyes
closed. No evident response to inner need or external stimuli is shown
4
 Temperature
Pulse

Respiration
Blood pressure 5
Vital signs- Definitions
Temperature, pulse, blood pressure, respiratory rate
Indicate the effectiveness of circulatory, respiratory, neural and endocrine body
functions.

• These measures referred to vital signs because of their importance as

indicators of body’s physiological status.
• Any difference between normal baseline measurement and present may
indicate the need for nursing and medical interventions
• Pain- considered to be the 5th vital sign
(Potter & perry,2010).

6
• Vital signs show an individual is alive.
They include heart beat, breathing rate,
temperature, and blood pressure. These
signs may be watched, measured, and
monitored to check an individual's level
of physical functioning. Normal vital
signs change with age, sex, weight,
exercise tolerance, and condition.

7
8
Guidelines in Taking Vital Signs:
1.The nurse caring for the client measures vital signs.
– Give important information about the client’s health status.
2.Equipment should be functional and appropriate.
– To ensure accurate findings.
3.Know the normal range of vital signs.
– Helps the nurse in detecting abnormalities.
4.Know the client’s normal range of vital signs.
– A nurse can detect a change in condition overtime.
9
5. Know the client’s medical history and any therapies or
medications prescribed.
6. Control or minimize any environmental factors that may affect
the vital signs.
– Temperature of the environment, physical activity and effects of illness
cause vital signs to change.
7. Use an organized, systematic approach when taking vital signs.
– Measure temperature first, and then check the pulse, respirations and
blood pressure.
8. Decide the frequency of vital sign assessment on the basis of
client’s condition.
9. Analyze the results of vital sign measurement.
10.Record or document the results of vital signs measured
10
 Frequency of Vital Signs
Nurses should take a patient’s vital signs:
• Upon admission to a facility
• Before and after any surgical procedure
• Before, during, and after administration of medications that
affect vital signs
• As per the institution’s policy or physician orders
• Any time the patient’s condition changes
• Before and after any procedure affecting vital signs
11
Mental status
• a structured assessment of client’s behavioural and cognitive
functioning—is a vital component of nursing care that assists
with evaluation of mental health conditions.
• The MSE is analogous to the physical examination and is
used to evaluate an individual’s current cogitative, affective
and behavioural functioning (Varcarolis, 2014).
• Specifically, the MSE assesses a client’s current state
including general appearance, mood and affect, speech,
thought process and content, perceptual disturbances,
impulse control, cognition, knowledge, judgment and insight
(Lasiuk, 2015). 12
MSE Elements
The acronym BEST PICK can assist with learning the main elements of
an MSE (Carniaux-Moran, 2008). A brief description of the elements that
are assessed includes:
• Behaviour and general appearance - age, sex, gender, cultural background,
posture, dress/ grooming, manner, alertness, as well as agitation,
hyperactivity, psychomotor retardation, unusual movements, catatonia, etc.
• Emotions: mood and state, emotional state and visible expression (state)
including description and variability.
• Speech—rate, amount, style and tone of speech.
• Thought content and processes—abnormalities, obsessions, delusions and
suicidal and homicidal thoughts and thought process as well as loose
associations, tangential thinking, word salad, and neologisms, circumstantial
thought, and concrete versus abstract thought. 13
MSE Elements
• Perceptual disturbances—illusions and hallucinations.
• Impulse control—ability to delay, modulate or inhibit
expressions or behaviours.
• Cognition—consciousness, orientation, concentration and
memory.
• Knowledge, insights and judgment—the capacity to identify
possible courses of action, anticipate consequences, and
choose appropriate behaviour, and extent of awareness of
illness and maladaptive behaviours.
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A. Children and adolescent
1. Focus on health promotion and illness prevention, particularly for care of well children with
competent parenting and no serious health problems (Hockenberry and Wilson, 2011). Focus on
growth and development, sensory screening, dental examination, and behavioral assessment.
2. Children who are chronically ill, disabled, in foster care, or foreign-born adopted may require
additional assessments because of unique health needs.
3. When obtaining histories of infants and children, gather all or part of the information from parents or
guardians.
4. Children who are chronically ill, disabled, in foster care, or adopted from a foreign country may
require additional assessment because of their unique health risks.
5. Parents may think that the examiner is testing or judging them. Offer support during examination
and do not pass judgment.
6. Call children by their preferred name and address parents as “Mr. and Mrs. Cruz” rather than by
first names.
7. Open-ended questions often allow parents to share more information and describe more of the
child’s problems.
8. Older children and adolescents respond best when treated as adults and individuals and often can
15
provide details about their health history and severity of symptoms.
Psychosocial, cognitive and moral development

16
17
18
19
20
21
• A personal & subjective experience w/ few or no
objective measurements.
• Nursing Definition (McCaffery) – “Whatever the
experiencing person says it is, and existing whenever
the person says it does.”
• Int. Assoc. for study of Pain (IASP)- “Unpleasant,
subjective sensory & emotional experience assoc. with
actual or potential tissue damage, or described in terms
of such damage.”
• Multidimensional phenomenon
• Viewed as an experience, not merely a symptom and not
a disease entity. 22
THEORIES:
1. Specific – Theory (Descartes-17th century) – specialized
pathways for pain transmission exist. Free nerve endings
existed in periphery as pain receptors. g transmitted through
the dorsal horn & substantia gelatinosa g thalamus g upper
level of the cortices.

2. Gate Control Theory – controlled by the dorsal horn of the

spinal cord
– Substantia gelatinosa in the dorasal horn of the SC acts as a
gate mechanism that can close or open.
– Most pain impulses are conducted over small-diameter nerve
fibers (A-delta) 23
PROCESS :
1. Pain transduction – stimulation of the nociceptors
2. Pain transmission – discharged impulse travels as
electric activity to spinal cord gbrain = pain
sensation.
– A-beta – larger and carry other sensory info. such
as touch
– A-delta – transmit pain fast.
- C fibers – transmit pain more slowly / no myelin
sheath.
3. Pain modulation – variation in the way clients 24

perceive similarly painful stimuli.

Pain reception
pathway :

25
Perception of pain :
• Pain Threshold – lowest perceivable intensity
of stimuli that is transmitted as pain.
• Pain Tolerance – amount of pain the client is
willing to endure.
• Past experiences of pain.

26
Physiological Responses to pain:
Sympathetic Stimulation :
1. dilation of bronchial tubes & hresp. rate.
2. hheart rate
3. peripheral vasoconstriction (pallor, hBP)
4. hblood glucose level
5. diaphoresis
6. hmuscle tension
7. dilation of pupils
8. iGI motility
27
Parasympathetic Stimulation :
1. pallor
2. muscle tension
3. iHR & BP
4. rapid, irregular breathing
5. nausea & vomiting
6. weakness or exhaustion

28
Behavioral Response:
• Phases of pain experience:
–Anticipation – allows a person to learn about
pain & its relief.
–Sensation – pain is felt. Gauging tolerance
level of pain.
–Aftermath – pain is reduced or stopped.

29
Behavioral Indicators of Effects of Pain
Vocalizations: moaning / crying / screaming / gasping /
grunting
Facial expressions : grimace / clenched teeth / wrinkled
forehead / tightly closed or widely opened eyes or mouth /
lip biting / tightened jaw
Body movement : Restlessness / immobilization / muscle
tension / hhand & finger movements / pacing activities /
rhythmic or rubbing motions / protective movement of body
parts.
Social Interaction : Avoidance of conversation / focus only on
activities for pain relief / avoidance of social contact /
reduced attention span.
30
Factors Influencing Pain :
a. Age f. Attention
b. Sex g. Anxiety
c. Culture h. Fatigue
d. Meaning of pain
e. Previous experience
f. Coping style
g. Family & social support
31
Assess for :
• Onset / time of occurrence
• Duration – chronic or acute
• Severity or intensity – scale 0 – 10
• Mode of transmission – normal pain pathway vs referred
pain
• Location / source
• Causation
• Causative forces / agent – spontaneous / self-inflicted

32
Pain Scale

33
Types of Pain :
o Acute Pain
o Chronic Pain
o Cutaneous or superficial pain
o Deep somatic pain
o Visceral pain
o Referred pain
o Malignant pain
o Pain of Psychological origin
▪ Pretended pain
▪ Psychogenic pain 34
Nursing Intervention :
Alleviating Anxiety Meditation
Autogenic Training Accupressure
Guided Imagery Rhythmic Breathing
Operant Conditioning Biofeedback
Touch Cutaneous Stimulation
Hypnosis Music
Progressive Relaxation Training

35
Pharmacology
Non-narcotic analgesics
‚ Acetaminophen (Tyenol, Datril)
‚ Acetylsalicylic acid (aspirin)
‚ Choline magnesium trisalicylate (Trilisate)

NSAIDS
‚ Ibuprofen (Motrin, Nuprin)
‚ Naproxen (Naprosyn)
‚ Naproxen sodium (Anaprox)
‚ Indomethacin (Indocin)
‚ Tolmetin (Tolectin)
‚ Piroxicam (Feldene) 36
Narcotic Analgesics
‚ Meperidine (Demerol)
‚ Methylmorphine (Codeine)
‚ Morphine sulfate (Morphine)
‚ Fentanyl (Sublimaze)
‚ Butorphanol (Stadol)
‚ Hydromorphone HCl (Dilaudid)
Adjuvants
‚ Amitriptyline (Elavil)
‚ Hydroxyzine (Vistaril)
‚ Caffeine
‚ Chlorpromazine (Thorazine)
‚ Diazepam (Valium)
37
Violence
• Family violence can be defined as “a situation in which
one family member causes physical or emotional harm
to another family member. At the center of this violence
is the abuser’s need to gain power and control over
the victim” (Violence wheel, 2009).

38
The cycle of violence.
(From Varcarolis, E.,
Carson, V., &
Shoemaker, N. [2010].
Foundations of
psychiatric mental
health nursing [6th ed.].
St. Louis: Saunders.)

39
Description:
1. Violence begins with threats or verbal or physical minor
assaults (tension building), and the victim attempts to comply
with the requests of the abuser.
2. The abuser loses control and becomes destructive and
harmful (acute battering), while the victim attempts to protect
himself or herself.
3. After the battering, the abuser becomes loving and attempts
to make peace (calmness and defusing of tension).
40
4. The abuser justifies that violence is normal and the
victim is responsible for the abuse.
5. Outsiders are usually unaware of what is happening
in the family.
6. Family members are isolated socially and lack
autonomy and trust among each other; caring and
intimacy in the family are absent.
7. Family members expect other members of the family
to meet their needs, but none are able to do so.
8. The abuser threatens to abandon the family.
41
Types of Violence
1. Physical Violence - Infliction of physical pain or
bodily harm
2. Sexual Violence - Any form of sexual contact
without consent
3. Emotional Violence - Infliction of mental anguish
4. Physical Neglect - Failure to provide health care to
prevent or treat physical or emotional illnesses
42
Types of Violence
6. Developmental Neglect - Failure to provide
physical and cognitive stimulation needed to
prevent developmental deficits
7. Educational Neglect - Depriving a child of education
8. Economic Exploitation - Illegal or improper exploitation
of money, funds, or other resources for one’s personal
gain

43
The vulnerable person
1. The vulnerable person is the one in the family unit
against whom violence is perpetrated.
2. The most vulnerable individuals are children and
older adults.
3. The perpetrator of violence and the person targeted
by the violence can be male or female.
4. Battering is a crime.
44
Characteristics of abusers
1. Impaired self-esteem
2. Strong dependency needs
3. Narcissistic and suspicious
4. History of abuse during childhood
5. Perceive victims as their property and believe
that they are entitled to abuse them
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Characteristics of victims
1. Victims feel trapped, dependent, helpless, and
powerless.
2. Victims of abuse may become depressed as they are
trapped in the abusers’ power and control cycle
3. As victims’ self-esteem becomes diminished with
chronic abuse, they may blame themselves for the
violence and be unable to see a way out of the
situation.
46
Interventions
1. Report suspected or actual cases of child abuse or abuse of
an older adult to appropriate authorities (follow state and
agency guidelines).
2. Assess for evidence of physical injuries.
3. Ensure privacy and confidentiality during the assessment and
provide a nonjudgmental and empathetic approach to foster
trust; reassure the victim that he or she has not done anything
wrong.
4. Assist the victim to develop self-protective and other problem-
solving abilities. 47
Interventions
5. Even if the victim is not ready to leave the situation,
encourage the victim to develop a specific safety plan (a fast
escape if the violence returns) and where to obtain help
(hotlines, safe houses, and shelters); an abused person is
usually reluctant to call the police.
6. Assess suicidal potential of the victim.
7. Assess the potential for homicide.
8. Assess for the use of drugs and alcohol.
9. Determine family coping patterns and support systems. 48
Interventions
10. Provide support and assistance in coping with contacting
the legal system.
11. Assist in resolving family dysfunction with prescribed
therapies.
12. Encourage individual therapy for the victim that promotes
coping with the trauma and prevents further
psychological conflict.
13. Encourage individual therapy for the abuser that focuses
on preventing violent behavior and repairing
relationships. 49
Interventions
14. Encourage psychotherapy, counseling, group
therapy, and support groups to assist family members
to develop coping strategies.
15. Assist the family to identify an access to community
and personal resources.
16. Maintain accurate and thorough medical health
records.
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Culture and ethnicity
• Culture - dynamic network of knowledge, beliefs,
patterns of behavior, ideas, attitudes, values, and
norms that are unique to a particular group of people.
• Ethnic group - people within a culture who share
characteristics based on race, religion, color, national
origin, or language.
• Ethnicity - an individual’s identification of self as part
of an ethnic group.
51
Personal Cultural Assessment
Five areas to be examined in assessing one’s
own culture and the influence it may have on
personal beliefs about health care are:
– Influences from own ethnic/racial background.
– Typical verbal and non-communication patterns.
– Cultural values and norms.
– Religious beliefs and practices.
– Health beliefs and practices.
52
Client Cultural Assessment
Six categories of information necessary for a
comprehensive cultural assessment of a client
are:
– Ethnic or racial background.
– Language and communication patterns.
– Cultural values and norms.
– Biocultural factors.
– Religious beliefs and practices.
– Health beliefs and practices. 53
Culturally Appropriate Care
• Respect clients for their different beliefs.
• Be sensitive to behaviors and practices different from your
own.
• Accommodate differences if they are not detrimental to
health.
• Listen for cues in the client’s conversation that relay a
unique ethnic belief about etiology, transmission,
prevention, etc.
• Teach positive health habits if client’s practices are
deleterious to good health.
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Spiritual and religious practices
• A spiritual assessment assists the nurse in
planning holistic nursing care. Whether the
nurse is unclear about the patient's spiritual
belief or the patient has a spiritual belief
unfamiliar to the nurse, acronym models such
as FICA provide the basis for an organized,
open and non-biased assessment.
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FICA model
One popular acronym tool is the FICA model. These are the areas of
assessment and possible questions that could be asked:
• F-Faith or beliefs: What are your spiritual beliefs? Do you consider yourself
spiritual? What things do you believe in that give meaning to life?
• I-Importance and influence: Is faith/spirituality important to you? How has
your illness and/or hospitalization affected your personal practices /beliefs?
• C-Community: Are you connected with a faith center in the community? Does
it provide support/comfort for you during times of stress? Is there a
person/group/leader who supports/assists you in your spirituality?
• A-Address: What can I do for you? What support/guidance can health care
provide to support your spiritual beliefs/practices?
56
Nutritional status

57
58
59
60
61
62
63
64
 References:
• Carniaux-Moran, C. (2008). The Psychiatric Nursing Assessement. In O’Brien, P.G., Kennedy, W.Z.,
Ballard, K.A. Psychiatric mental health nursing: an introduction to theory and practice.,Sudbury, MA: Jones &
Bartlett
• Weber, Janet R., Jane H. Kelley (2014); Health Assessment in Nursing; 5th Ed., Wolters Kluwer Health |
Lippincott Williams & Wilkins.
• Perry, A. G., (2014). Clinical Nursing Skills and Techniques. Mosby, Inc., an affiliate of Elsevier Inc., St.
Louis, Missouri 63043 ISBN 978-0-323-08383-6

65
PHYSICAL EXAMINATION OF THE SKIN
Dermatological examination
• Before you can make a diagnosis of any skin lesion, it's important to
be able to accurately describe the skin lesion.
• A thorough examination of the whole skin is considered best
practice.
•First just look
• Note whether the patient looks ill or well. Note whether there any
clues as to systemic illness.
• Wipe off any creams, make-up or anything else that may obscure the
true nature of the lesions.
• Now focus on the lesion(s)
• Note the position of lesions:
• Consider whether the distribution is symmetrical or asymmetrical.
(Symmetrical distribution suggests an endogenous condition such as
psoriasis, while asymmetry is more typical of an exogenous condition such
as tinea.) Some rashes have a characteristic distribution such as with
shingles.
• Note whether flexor or extensor surfaces are involved.
• Establish whether there are areas of friction or pressure.
• Note whether sweaty regions are involved.
• Note whether exposed regions are involved.
• Consider whether sexual contact is a factor (consider genital lesions but also
the lower abdomen and upper thighs).
•Note the size of the lesion. Measure for accuracy.
•Establish whether it is single or multiple.
•If a rash exists, consider its morphology. Are individual lesions:
•Macular?
•Papular?
•Vesicular?
•Crusty?
•Urticarial?
•Note color, shape, regularity or irregularity.
•Note whether areas of inflammation around it exist.
•Consider whether the edge is clearly demarcated or poorly defined.
Now touch
• Tenderness. Warmth. Site within the skin. Thickness.
• Consistency (hard, soft, firm, fluctuant).
• Note whether firm pressure leads to blanching.
• Note whether it is friable and whether it bleeds easily.
• Scaling - disorders of the epidermis may produce scale, which may be
visible, or gentle scratching of the skin may make it apparent.
• If appropriate, look to see if there is any evidence of infestation - eg,
scabies' burrows.
• Note hair in the local skin and on the head.
• Look at the nails.
• Note whether mucous membranes are involved.
• Examine the genitals where appropriate.
• Note regional lymph nodes. This may be relevant for infectious or
malignant lesions.
Standard examination of the skin
without lesions
Setting up the examination
• Good lighting (daylight or its
equivalent)
• Good exposure (ask patient to
disrobe)
• Universal precaution
• Appropriate PPE
• No make up
Standard examination of the skin without
lesions
• Note basic demographics of the patient: age, sex, occupation,
nationality, country of origin.
• Past medical history.
• Family history.
• Personal and social history.
Standard examination of the skin without
lesions
• Focus on reviewing signs and symptoms related to the skin.
• Describe the skin:
• Color
• Moisture
• Temperature
• Texture
• Mobility and turgor
Describing color
Describing texture
Describing temperature
Describing moisture
Describing mobility and turgor
Sample Report
• No history of pigmentation changes, rashes, pruritus, brusing or
bleeding, changes in size and shape of moles, and previously
diagnosed skin disease.
• Dark brown skin appears smooth and supple, warm to touch, with
quick recoil after pinching. Nailbeds appear pinking and capillary refill
time is less than 2 secs. Moles appear with symmetric edges, regular
borders, no variation in color, all less than 0.5 cm. Tongue and
mucous membranes appear pinking and moist. Palpebral
conjunctivae appear pinkish. Hair is black and coarse, with no signs of
hair loss.
Patient with a skin complaint
Terminologies: Secondary Lesions
• Scale – flakes; accumulation of stratum corneum
• Crust – dried exudates
• Scar – fibrous tissue formed as part of wound healing
• Excoriation – erosion from scratching
• Lichenification – thickening, accentuated skin fold markings
• Depressed
• Atrophy (loss of substance, intract dermis)
• Erosion (epidermis)
• Fissure (linear)
• Ulcer (dermis)
Patient with a skin complaint
History:
• Evolution of lesions
a. Site of onset
b. Manner in which the eruption progressed or spread
c. Duration
d. Periods of resolution or improvement in chronic eruptions
Patient with a skin complaint
History:
• Symptoms associated with the eruption
a. Itching, burning, pain, numbness
b. What, if anything, has relieved symptoms
c. Time of day when symptoms are most severe
Patient with a skin complaint
History:
• Current or recent medications
• Associated systemic symptoms
• Ongoing or previous illnesses
• History of allergies
• Presence of photosensitivity
• Review of systems
• Family history
• Social, sexual, or travel history
Sample History
A 56-year-old diabetic man presented erythematous papules and
pustules on the neck and face who had developed since 3 months. He
had been treated with topical corticosteroids for the same time
period that resulted in progressive exacerbation. He additionally
showed patches of hair loss in the beard area, erythema and scaling
of the ears.
Sample History
A 32-year-old woman had developed moderate swelling, erythema and
papules of the central part of her face for 8 weeks. She started to
apply various topical cosmetic products sold for acne that did not
help. As one of her hobbies was outdoor biking she noticed that sun
exposure aggravated her skin condition, also resulting in burning and
stinging sensations. She consulted her general practitioner who
prescribed prednicarbat cream for topical application on the affected
regions. Whereas she observed a slight improvement of the skin
condition during the first week, she later on suddenly developed a
severe worsening with erythema, papules and many pustules.
Sample History
A 29-year old man presented to a dermatology department because of
inflammatory papules and nodules on both cheeks and the chin. The
forehead was not much affected. He had noticed severe seborrhea
and a progressive increase of large pores with continuous thickening
of the skin for several years. There were no comedones. Some small
erythematous lesions and papules were also found on the chest. He
had been treated for acne for several months without any significant
improvement.
Patient with a skin complaint
Physical Examination:
• the morphology of individual lesions
• the types of primary and secondary lesions
• the arrangement of the lesions.
• the distribution of the eruption
Examination of Hair
• Inspect hair quantity, texture and
distribution
Examination of Nails
•Inspect nail color, shape and
presence of lesions

1. Clubbing of fingers
2. Onycholysis
3. Paronychia
4. Terry’s nails
5. Beau’s lines

Psoriatic nails (“oil spots”,

pitting, onycholysis)
AIDS TO DERMATOLOGIC DIAGNOSIS
The examiner’s eye is the most important
instrument .
• Magnification
• Wood’s lamp
• Diascopy
• Patch testing
• Skin biopsy
Distribution
Distribution
Distribution
Distribution
PHYSICAL EXAMINATION OF
THE THORAX AND LUNGS
JOSHUA D. VARGAS, RN, MD
INITIAL SURVEY OF
RESPIRATION AND
THE THORAX
• Observation and
documentation of the rate,
rhythm, depth, and effort of
breathing is the first step of
the respiratory assessment.
General Survey
• Always inspect the patient for any signs of respiratory difficulty.
• Observe the patient’s facial expression—it should be relaxed and calm.
• Observe level of consciousness.
• Assess the patient’s color for cyanosis, especially the face, mucous membranes, and
nail beds. Recall any relevant findings from earlier parts of your examination, such
as the shape of the fingernails.
• Listen to the patient’s breathing.
• Are there any audible sounds (e.g.,wheezing or stridor)? If so, where do they fall in
the respiratory cycle?
• Inspect the neck.
• During inspiration, is there contraction of the accessory muscles, namely, the
sternomastoid and scalene muscles, or supraclavicular retraction? Is the trachea
midline?
General Survey
• Also observe the shape of the chest.
• The anteroposterior (AP) diameter may increase with aging, compared with
the lateral chest diameter.
• Usually there is a 2:1 ratio of transverse to anteroposterior diameters.
PHYSICAL EXAMINATION
POSTERIOR CHEST
Inspection
• From a midline position behind the patient, note the shape of the
chest and how the chest moves, including:
• Deformities or asymmetry
• Abnormal retraction of the intercostal spaces during inspiration.
• Retraction is most apparent in the lower intercostal spaces.
• Impaired respiratory movement on one or both sides or a unilateral
lag (or delay) in movement
Palpation
• Identify tender areas.
• Carefully palpate any area where pain
has been
• reported or where lesions or bruises are
evident.
• Assess any observed abnormalities
such as masses
• Test chest expansion.
• Feel for tactile fremitus.
Palpation
• Palpate and compare symmetric areas of
the lungs in the pattern shown in the
photograph. Identify and locate any
areas of increased, decreased, or absent
fremitus.

• Fremitus is typically more prominent in

the interscapular area than in the lower
lung fields and is often more prominent
on the right side than on the left. It
disappears below the diaphragm.
Percussion
AUSCULTATION
• Breath Sounds (Lung Sounds).
• Learn to identify patterns of breath sounds by their intensity, their pitch, and the
relative duration of their inspiratory and expiratory phases. Normal breath sounds
are:
• Vesicular, or soft and low pitched.
• They are heard through inspiration, continue without pause through expiration, and
then fade away about one third of the way through expiration.
• Bronchovesicular, with inspiratory and expiratory sounds about equal in
Length, at times separated by a silent interval.
• Detecting differences in pitch and intensity is often easier during expiration.
• Bronchial, or louder and higher in pitch, with a short silence between
inspiratory and expiratory sounds.
• Expiratory sounds last longer than inspiratory sounds.
AUSCULTATION
• Listen to the breath sounds with the diaphragm of a stethoscope
after instructing the patient to breathe deeply through an open
mouth.
• Use the pattern suggested for percussion, moving from one side to
the other and comparing symmetric areas of the lungs.
• If you hear or suspect abnormal sounds, auscultate adjacent areas so that you
can fully describe the extent of any abnormality.
• Listen to at least one full breath in each location.
• Be alert for patient discomfort resulting from hyperventilation (e.g.,
lightheadedness, faintness), and allow the patient to rest as needed
AUSCULTATION
• Note the intensity of the breath sounds.
• Breath sounds are usually louder in the lower posterior lung fields and
may also vary from area to area.
• If the breath sounds seem faint, ask the patient to breathe more deeply.
You may then hear them easily.
• When patients do not breathe deeply enough or have a thick chest wall, as
in obesity, breath sounds may remain diminished.
• Listen for the pitch, intensity, and duration of the expiratory and inspiratory
sounds. Are vesicular breath sounds distributed throughout the chest wall?
Or are there bronchovesicular or bronchial breath sounds in unexpected
places? If so, where are they?
AUSCULTATION
•Adventitious (Extra) Sounds.
• Listen for any extra, or
adventitious, sounds that are
superimposed on the usual
breath sounds.
• Detection of adventitious
sounds—crackles (sometimes
called rales), wheezes, and
rhonchi—is an important part
of your examination, often
leading to diagnosis of cardiac
and pulmonary conditions.
AUSCULTATION
•Adventitious (Extra) Sounds.
• Listen for any extra, or
adventitious, sounds that are
superimposed on the usual
breath sounds.
• Detection of adventitious
sounds—crackles (sometimes
called rales), wheezes, and
rhonchi—is an important part
of your examination, often
leading to diagnosis of cardiac
and pulmonary conditions.
AUSCULTATION
•Transmitted Voice Sounds.
• If you hear abnormally located bronchovesicular or bronchial
breath sounds or adventitious sounds, assess transmitted voice
sounds. With a stethoscope, listen in symmetric areas over the
chest wall as you:
• Ask the patient to say “ninety-nine.” Normally the sounds
transmitted through the chest wall are muffled and indistinct.
• Ask the patient to say “ee.” You will normally hear a muffled long E
sound.
• Ask the patient to whisper “ninety-nine” or “one-two-three.” The
whispered voice is normally heard faintly and indistinctly, if at all.
PHYSICAL EXAMINATION
ANTERIOR CHEST
Inspection
•Observe the shape of the patient’s chest and the movement
of the chest wall.
•Note:
• 1. Deformities or asymmetry
• 2. Work of breathing: abnormal retraction of the lower intercostal
spaces during
• inspiration. Supraclavicular or substernal retraction is often
present.
• 3. Local lag or impairment in respiratory movement
Palpation
1. Identification of tender areas
2. Assessment of observed
abnormalities
3. Further assessment of chest
expansion.
1. Place your thumbs along each costal
margin, your hands along the lateral
rib cage. As you position your hands,
slide them medially a bit to raise
loose skin folds between your
thumbs. Ask the patient to inhale
deeply (as the thorax expands
2. Observe how far your thumbs diverge
and feel for the extent and symmetry
of respiratory movement.
Palpation
Assessment of tactile fremitus.
Compare both sides of the chest,
using the ball or ulnar surface of
your hand. Fremitus is usually
decreased or absent over the
precordium. When examining a
woman, gently displace the breasts
as necessary.
Palpation
Assessment of tactile fremitus.
Compare both sides of the chest,
using the ball or ulnar surface of
your hand. Fremitus is usually
decreased or absent over the
precordium. When examining a
woman, gently displace the breasts
as necessary.
Percussion
• Percuss the anterior and
lateral chest, again comparing
both sides. The heart normally
produces an area of dullness
to the left of the sternum from
the 3rd to the 5th intercostal
spaces. Percuss the left lung
lateral to it.
Percussion
• In a woman, to enhance
percussion, gently displace the
breast with your left hand
while percussing with the
right.
• Alternatively, you may ask the
patient to move her breast for
you.
• Identify and locate any area
with an abnormal percussion
note.
Percussion
• With your pleximeter finger above
and parallel to the expected upper
border of liver dullness, percuss in
progressive steps downward in the
right midclavicular line. Identify the
upper border of liver dullness. Later,
during the abdominal examination,
you will use this method to estimate
the size of the liver.
• As you percuss down the chest on
the left, the resonance of normal
lung usually changes to the tympany
of the gastric air bubble.
Auscultation
1. Listen to the breath sounds,
noting their intensity and
identifying any variations from
normal vesicular breathing.
Breath sounds are usually louder
in the upper anterior lung fields.
Bronchovesicular breath sounds
may be heard over the large
airways, especially on the right.
2. Identify any adventitious sounds,
time them in the respiratory
cycle, and locate them on the
chest wall. Do they clear with
deep breathing?
3. If indicated, listen for transmitted
voice sounds.
PHYSICAL EXAMINATION OF
THE EYE
JOSHUA D. VARGAS, RN, MD
Preparation of the Patient
• Preparation of the patient and the environment is crucial to obtain
correct findings during the eye examination. If the Snellen chart is
located outside the exam room, then the patient should do this
portion of the examination prior to changing into a patient gown if a
complete examination is being performed.
• The area should be well lit and free of distractions.
• The remainder of the examination will be in a quiet, well-lit room with
all necessary equipment in the room.
The components of the eye examination
include:
1. Vision tests: distal, near, and peripheral
2. Inspection of the eye, eyebrows, lids, conjunctiva and sclera,
cornea, lens, iris, and pupils
3. Inspection and palpation of the lacrimal apparatus
4. Extraocular movements: assessment of cardinal fields, convergence,
corneal light test, cover–uncover test
5. Inspection of the fundi including the optic disc and cup, retina, and
retinal vessels
Vision Tests
• Visual Acuity (Distal).
• To test the acuity of central
vision, use a Snellen eye chart,
if possible, and light it well.
• Position the patient 20 feet
from the chart.
• Patients who use glasses or
contacts other than for reading
should wear them for the
examination
Vision Tests
• Visual Acuity (Distal).
• Coaxing to attempt the next line
may improve performance.
• A patient who cannot read the
largest letter should be positioned
closer to the chart; note the
intervening distance.
• Determine the smallest line of
print from which the patient can
identify more than half the letters
• Record the visual acuity
designated at the side of this line,
along with use of glasses or
contacts, if any.
Vision Tests
• Visual Acuity (Distal).
• Visual acuity is expressed as
two numbers (e.g.,20/30).
• The numerator indicates the
distance of the patient from the
chart and this number should
always be 20 unless the patient
moved closer to see, and the
denominator is the distance at
which a normal eye can read
the line of letters.
Vision Tests
• Visual Acuity (Near Vision).
• Rosenbaum chart
• Newspaper
Vision Tests
• Peripheral Vision
• Peripheral Visual Fields by Confrontation
• Screening starts in the temporal fields because most
defects involve these areas. Imagine the patient’s visual
fields projected onto a glass bowl that encircles the front
of the patient’s head.
1. Ask the patient to look with both eyes into your
eyes.
2. While you return the patient’s gaze, place your
hands about 2 feet apart, lateral to the patient’s
ears.
3. Instruct the patient to point to your fingers as
soon as they are seen.
4. Then slowly move the wiggling fingers of both
your hands along the imaginary bowl towards the
line of gaze until the patient points to them.
5. Repeat this pattern in the upper and lower
temporal quadrants. Usually a person sees both
sets of fingers at the same time. If so, fields are
usually normal.
Vision Tests
• Peripheral Vision
• Peripheral Visual Fields by
Confrontation
• FURTHER TESTING. If you find a defect,
try to establish its boundaries. Test one
eye at a time. If you suspect a temporal
defect in the left visual field, for example,
ask the patient to cover the right eye
and, with the left one, to look into your
eye directly opposite.
• Then slowly move your wiggling fingers
from the defective area toward the
better vision, noting where the patient
first responds.
• Repeat this at several levels to define the
border.
External Eye
• Position and Alignment of the Eyes.
• Stand in front of the patient and survey the eyes for position and alignment. If one
or both eyes seem to protrude, assess them from above.
• Eyebrows.
• Inspect the eyebrows, noting their quantity and distribution and any scaliness of the
underlying skin.
• Eyelids.
• Note the position of the lids in relation to the eyeballs.
• Inspect for the following:
• Width of the palpebral fissures—open area between the upper and lower
• eyelids
External Eye
• Eyelids.
• Note the position of the lids in relation to the eyeballs.
• Inspect for the following:
• Width of the palpebral fissures—open area between the upper and lower eyelids Edema
of the lids
• Color of the lids
• Lesions
• Condition and direction of the eyelashes
• Adequacy with which the eyelids close. Look for this especially when the eyes are
unusually prominent, when there is facial paralysis, or when the patient is unconscious.
External Eye
• Conjunctiva and Sclera.
• Ask the patient to look up as you
depress both lower lids with your
thumbs, exposing the sclera and
conjunctiva. Inspect the sclera and
palpebral conjunctiva for color, and
note the vascular pattern against the
white scleral background. Look for any
nodules or swelling.
External Eye
• Cornea and Lens.
• With oblique lighting, inspect the cornea
of each eye for opacities and note any
opacities in the lens that may be visible
through the pupil.
• Iris.
• At the same time, inspect each iris. The
markings should be clearly defined. With
your light shining directly from the
temporal side, look for a crescentic
shadow on the medial side of the iris.
Because the iris is normally fairly flat and
forms a relatively open angle with the
cornea, this lighting casts no shadow.
External Eye
• Pupils.
• Inspect the size, shape, and symmetry
of the pupils. If the pupils are large ( 5
mm), small ( 3 mm), or unequal,
measure them. A pupil guide with
black circles of varying sizes facilitates
measurement.
External Eye
• Test the pupillary reaction to light.
• Ask the patient to look into the distance, and shine a bright
light obliquely into each pupil in turn. (Both the distant gaze
and the oblique lighting help to prevent a near reaction.) Look
for:
• The direct reaction (pupillary constriction in the same eye)
• The consensual reaction (pupillary constriction in the opposite
eye)
• Always darken the room and use a bright light before
deciding that a light reaction is absent. If the reaction to light
is impaired or questionable, test the near reaction in normal
room light.
• Testing one eye at a time makes it easier to concentrate on
pupillary responses, without the distraction of extraocular
movement.
• Hold your finger or pencil about 10 cm from the patient’s
eye.
• Ask the patient to look alternately at it and into the distance
directly behind it.
• Watch for pupillary constriction with near effort.
Inspection and palpation of the lacrimal
apparatus
• Lacrimal Apparatus.
• Briefly inspect the regions of the lacrimal gland and lacrimal sac for swelling.
• Look for excessive tearing, dryness, or crusting of the eyes. Assessment of
dryness may require special testing by an ophthalmologist.
Extraocular movements
• Assess the extraocular movements, looking for:
• The normal conjugate movements of the eyes in each direction, or any
deviation from normal
• Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus
on extreme lateral gaze are normal. If you see it, bring your finger in to within
the field of binocular vision and look again.
• Lid lag as the eyes move from up to down.
Extraocular movements
• Cardinal fields.
• To test the six extraocular movements (EOMs), ask the
patient to follow your finger or pencil as you sweep
through the six cardinal directions of gaze. Making a wide
H in the air, lead the patient’s gaze:
• (1) to the patient’s extreme right
• (2) to the right and upward
• (3) down on the right
• (4) without pausing in the middle, to the extreme left
• (5) to the left and upward
• (6) down on the left.

• Pause during upward and lateral gaze to detect

nystagmus. Move your finger or pencil at 12”–18” from
the patient. Because middle-aged or older people may
have difficulty focusing on near objects, make this
distance greater for them than for young people. Some
patients move their heads to follow your finger. If
necessary, hold the head in the proper midline position.
Extraocular movements
• Convergence.
• Finally, test for convergence. Ask the
patient to follow your finger or pencil as
you move it in toward the bridge of the
nose. The converging eyes normally follow
the object to within 5 cm to 8 cm of the
nose.
• Corneal light reflex.
• From about 2 feet directly in front of the
patient, shine a light onto the patient’s
eyes and ask the patient to look at it.
Inspect the reflections in the cornea. They
should be visible slightly nasal to the
center of the pupils.
• A cover–uncover test may reveal a slight
or latent muscle imbalance not
otherwise seen
Ophthalmoscopic examination
• The nurse would examine the
patients eyes without dilating
the pupils. The view is
therefore limited to the
posterior structures of the
retina. To see more peripheral
structures, to evaluate the
macula well, or to investigate
unexplained visual loss,
ophthalmologists dilate the
pupils with mydriatic drops
unless this is contraindicated.
PHYSICAL EXAMINATION OF
THE HEAD AND NECK
JOSHUA D. VARGAS, RN, MD
The Hair
•Note its quantity,
distribution,
texture, and
pattern of loss, if
any.
•You may see loose
flakes of dandruff.
The Scalp.

•Part the hair in

several places
and look for
scaliness, lumps,
nevi, or other
lesions.
The Skull.
•Observe the general size and
contour of the skull. Note any
deformities, depressions,
lumps, or tenderness.
•Learn to recognize the
irregularities in a normal skull,
such as those near the suture
lines between the parietal and
occipital bones.
The Face
•Note the patient’s
facial expression and
contours. Observe for
asymmetry, involuntary
movements, edema,
and masses.
The Skin.

•Observe the skin,

noting its color,
pigmentation,
texture, thickness,
hair distribution,
and any lesions.
The Neck.
• Observe the skin, noting its color,
pigmentation, texture, thickness,
hair distribution, and any lesions.
Inspect the neck, noting its
symmetry and any masses or
scars.
• Look for enlargement of the
parotid or submandibular glands,
and note any visible lymph nodes.
The Lymph Nodes.
• Palpate the lymph nodes.
• Using the pads of your index and
middle fingers, move the skin over
the underlying tissues in each area in
a circular motion.
• The patient should be relaxed, with
neck flexed slightly forward and, if
needed, slightly toward the side
being examined. You can usually
examine both sides at once.
 The Lymph Nodes.
Feel in sequence for the following nodes:
1. Preauricular—in front of the ear
2. Posterior auricular—superficial to the mastoid process
3. Occipital—at the base of the skull posteriorly
4. Tonsillar—at the angle of the mandible
5. Submandibular- midway between the angle and the tip of the
mandible. These nodes are usually smaller and smoother than
the lobulated submandibular gland against which they lie.
6. Submental—in the midline a few centimeters behind the tip of
the mandible
7. Superficial cervical—superficial to the sternomastoid
8. Posterior cervical—along the anterior edge of the trapezius
9. Deep cervical chain—deep to the sternomastoid and often
inaccessible to examination. Hook your thumb and fingers
around either side of the sternomastoid muscle to find them.
10. Supraclavicular—deep in the angle formed by the clavicle and
the sternomastoid
The Trachea and the Thyroid Gland.

• To orient yourself to the neck, identify

the thyroid and cricoid cartilages and
the trachea below them.
• Inspect the trachea for any
deviation from its usual midline
position. Then feel for any
deviation. Place your finger along
one side of the trachea and note
the space between it and the
sternomastoid. Compare it with
the other side. The spaces should
be symmetric.
The Trachea and the Thyroid Gland.
• Inspect the neck for the thyroid gland. Tip the patient’s head back a
bit. Using tangential lighting directed downward from the tip of the
patient’s chin, inspect the region below the cricoid cartilage for the
gland. The lower shadowed border of each thyroid gland shown here
is outlined by arrows.
The Carotid Arteries and Jugular Veins.
• Defer a detailed examination of
these vessels until the patient lies
down for the cardiovascular
examination.
• Jugular venous distention,
however, may be visible in the
sitting position and should not be
overlooked.
• You should also be alert to
unusually prominent arterial
pulsations.
Recording your findings
PHYSICAL EXAMINATION OF
THE EARS, NOSE, SINUSES,
MOUTH AND THROAT
JOSHUA D. VARGAS, RN, MD
The Ear
• The Auricle. Inspect the auricle and surrounding tissue for
deformities, lumps, or skin lesions.
• If ear pain, discharge, or inflammation is present, move the auricle
up and down, press the tragus, and press firmly just behind the ear.
Ear Canal and Drum
• To see the ear canal and drum, use an
otoscope with the largest ear speculum that
the canal will accommodate and the
brightest light.
• Position the patient’s head so that you can
see comfortably through the instrument.
• To straighten the ear canal, grasp the auricle
firmly but gently and pull it upward,
backward, and slightly away from the head.
• Caution the patient to remain still.
Ear Canal and Drum
• Insert the speculum gently into the ear canal about a quarter inch,
directing it somewhat down and forward and through the hairs, if
any, toward the eardrum.
• Inspect the ear canal, noting any discharge, foreign bodies, redness of
the skin, or swelling. Cerumen, which varies in color and consistency
from yellow and flaky to brown and sticky or even to dark and hard,
may wholly or partly obscure your view.
• Inspect the eardrum, noting its color and contour. The cone of light—
usually easy to see—helps to orient you.
Ear Canal and Drum
• Identify the handle of
the malleus, noting its
position, and inspect
the short process of
the malleus.
Auditory Acuity
• To estimate hearing, test one ear at a time. Ask the patient to occlude
one ear with a finger, or better still, occlude it yourself.
• When auditory acuity on the two sides is different, move your finger
rapidly, but gently, in the occluded canal.
• Then, standing 1 or 2 feet away, exhale fully (so as to minimize the
intensity of your voice) and whisper softly toward the unoccluded ear
• To make sure the patient does not read your lips, stand behind the
patient, cover your mouth or obstruct the patient’s vision.
Air and Bone Conduction
• If hearing is diminished, try to distinguish conductive from
sensorineural hearing loss.
• You need quiet room and a tuning fork, preferably of 512 Hz or
possibly 1024 Hz.
Air and Bone Conduction
•Weber test
•Test for lateralization
•Place the base of the lightly vibrating
•tuning fork firmly on top of the
patient’s head or on the midforehead
•Ask where the patient hears it: on one
or both sides
•Normally the sound is heard in the
midline or equally in both ears.
Air and Bone Conduction
Rinne test
• Compare air conduction (AC) and bone
conduction (BC)
• Place the base of a lightly vibrating tuning
fork on the mastoid bone, behind the ear
and level with the canal.
• When the patient can no longer hear the
sound, quickly place the fork close to the
ear canal and ascertain whether the sound
can be heard again.
• Normally the sound is heard longer
through air than through bone (AC>BC).
The Nose
The Nose
• Inspect the anterior and inferior surfaces of the nose. Gentle pressure
on the tip of the nose with your thumb usually widens the nostrils
and, with the aid of a penlight or otoscope light, you can get a partial
view of each nasal vestibule. If the tip is tender, be particularly gentle
and manipulate the nose as little as possible.
• Note any asymmetry or deformity of the nose.
• Test for nasal obstruction, if indicated, by pressing on each ala nasi in
turn and asking the patient to breathe in.
The Nose
• Inspect the inside of the nose with an
otoscope and the largest ear speculum
available.
• Tilt the patient’s head back a bit and
insert the speculum gently into the
vestibule of each nostril, avoiding
contact with the sensitive nasal
septum.
• By directing the speculum posteriorly,
then upward in small steps, try to see
the inferior and middle turbinates, the
nasal septum, and the narrow nasal
passage between them. Some
asymmetry of the two sides is normal.
The Nose
• Observe the nasal mucosa, the nasal septum, and any abnormalities.
The nasal mucosa that covers the septum and turbinates.
• Note its color and any swelling, bleeding, or exudate. If exudate is present,
note its character: clear, mucopurulent, or purulent. The nasal mucosa is
normally somewhat redder than the oral mucosa
• The nasal septum
• Note any deviation, inflammation, or perforation of the septum. The lower
anterior portion of the septum (where the patient’s finger can reach) is a
common source of epistaxis (nosebleed).
• Any abnormalities such as ulcers or polyps.
The Nose
• Inspection of the nasal cavity through the anterior naris is usually
limited to the vestibule, the anterior portion of the septum, and the
lower and middle turbinates.
• Examination with a nasopharyngeal mirror is required for detection of
posterior abnormalities. This technique is used by
otorhinolaryngologists (ear, nose, and throat [ENT] specialists).
• Make it a habit to dispose of all nasal and ear specula after use.
The Sinuses
• Palpate for sinus tenderness.
Press up on the frontal sinuses
from under the bony brows,
avoiding pressure on the eyes.
Then press up on the maxillary
sinuses.
The Mouth and Throat
The Mouth and Throat
• Inspect the following:
• The Lips.
• Observe their color and moisture, and
note any lumps, ulcers, cracking, or
scaliness.
• The Oral Mucosa.
• Look into the patient’s mouth and, with a
good light and the help of a tongue
blade, inspect the oral mucosa for color,
ulcers, white patches, and nodules. The
wavy white line on this buccal mucosa
develops where the upper and lower
teeth meet.
• Irritation from sucking or chewing may
cause or intensify it.
The Mouth and Throat
•Inspect the following:
•The Gums and Teeth.
• Note the color of the gums, normally pink. Patchy brownness
may be present, especially but not exclusively in black people.
Inspect the gum margins and the interdental papillae for
swelling or ulceration.
•Inspect the teeth.
• Are any of them missing, discolored, misshapen, or abnormally
positioned? You can check for looseness with your gloved
thumb and index finger. Look for malocclusion of the teeth.
The Mouth and Throat
• Inspect the following:
• The Roof of the Mouth.
• Inspect the color and architecture of
the hard palate.
• The Tongue and the Floor of the
Mouth.
• Ask the patient to put out his or her
tongue. Inspect it for symmetry—a test
of the hypoglossal nerve (cranial nerve
XII).
• Note the color and texture of the
dorsum of the tongue.
The Mouth and Throat
• Inspect the following:
• Inspect the sides and undersurface of the
tongue and the floor of the mouth. These are
the areas where cancer most often develops.
• Note any white or reddened areas, nodules, or
ulcerations. Because cancer of the tongue is
more common in men older than 50 years,
especially in smokers and drinkers of alcohol,
palpation is indicated.
• Explain what you plan to do and put on gloves.
• Ask the patient to protrude his or her tongue.
• With your right hand, grasp the tip of the
tongue with a square of gauze and gently pull it
to the patient’s left.
• Inspect the side of the tongue, and then
palpate it with your gloved left hand, feeling for
any induration (hardness)
• Reverse the procedure for the other side.
The Pharynx
• Now, with the patient’s mouth open but the
tongue not protruded, ask the patient to say
“ah” or yawn. This action may let you see
the pharynx well. If not, press a tongue
blade firmly down upon the midpoint of the
arched tongue—far enough back to get good
visualization of the pharynx but not so far
that you cause gagging.
• Simultaneously, ask for an “ah” or a yawn.
Note the rise of the soft palate and the
uvula—a test of cranial nerve X (the vagal
nerve).
The Pharynx
• Inspect the soft palate, anterior
and posterior pillars, uvula,
tonsils, and pharynx.
• Note their color and symmetry and
look for exudate, swelling,
ulceration, or tonsillar
enlargement. Tonsils are graded
based on size:
• 1: Tonsils are visible
• 2: Tonsils are between the tonsillar
pillars and the uvula.
• 3: Tonsils are touching the uvula.
• 4: Tonsils are touching each other.