PHYSICAL ASSESSMENT

 Physical Assessment is conducted from the head to the toes (cephalo-caudal technique): skin, hair, nails,
head, face, ears, eyes, nose, sinuses, mouth, throat, neck, breast, and axillae, thorax/back, heart and
peripheral vessels, upper extremities, abdomen, anus and rectum, genitals, and lower extremities.

Four Fundamental Types of Assessments that Nurses Perform

1. A comprehensive or complete health assessment
a. obtained through health history and physical exam.
b. is usually performed in acute care settings upon admission, once your patient is stable, or when a
new patient presents to an outpatient clinic.
2. An interval or abbreviated assessment
a. performed at subsequent visits in an outpatient setting, at change of shift, when returning from
tests, or upon transfer to your unit from another in-house unit.
3. A problem-focused assessment
a. usually indicated after a comprehensive assessment has identified a potential health problem.
b. is also indicated when an interval or abbreviated assessment shows a change in status from the
most current previous assessment or report you received, when a new symptom emerges, or the
patient develops any distress.
c. advantage is that it directs you to ask about symptoms and move quickly to conducting a focused
physical exam.
4. An assessment for special populations
a. special populations like Pregnant patients, infants, children, elderly.

Purposes of the Physical Examination

1. To obtain baseline data about the client’s functional abilities
2. To supplement, confirm, or refute data obtained in the nursing history
3. To obtain data that will help establish nursing diagnoses and plans of care
4. To evaluate the physiologic outcomes of health care and thus the progress of a client’s health problem
5. To make clinical judgments about a client’s health status
6. To identify areas for health promotion and disease prevention

TECHNIQUES OF PHYSICAL ASSESSMENT

1. INSPECTION
 A purposeful and systematic examination to detect significant signs
that involves senses of sight, smell and hearing.
 It begins with the first encounters with the client and is the most
important of all techniques. It is important that inspection is
conducted systematically to avoid overlooking significant findings and in a
manner which enables a nurse to give full concentration and scrutiny to
observations being made.
 Combined details and focused observations and comparisons with
established norms that therefore entail the ability to see relationships between what is seen and what is
known.
  Use to assess moisture, color, and texture of body surfaces, as well as shape, position, size, color and
symmetry of the body

2.PALPATION
 The process of examining the body by using the sense of
touch to assess the characteristics of the body structures
underlying the skin.
 It requires perception of position, vibration, pulsation,
motion, temperature, consistency and form, texture,
tenderness, crepitation, size and shape.
 All the accessible parts of the body are examined including
the skin, hair, muscles, bones, organs, glands, and blood
vessels.
 Light palpation should always precede deep palpation
because heavy pressure on the fingertips can dull the sense
of touch

PALPATION

 LIGHT PALPATION PROCEDURES:

o Keeping the fingers of your dominant hand together,
place the finger pad lightly on the skin over the area that
is to be palpated. The hand and forearm will be on a
place to the area being assessed.
o Depress the skin 1cm in light, gentle, circular motions
o Keeping the finger pads on the skin, let the depressed
body surface rebound to its natural position
o If the patient is ticklish, lift the hand off the skin before
moving it to another area
o Using a systematic approach, move the fingers to an
adjacent area and repeat the process
o Continue to move the finger pads until the entire area are being examined has been palpated
o If the patient has complained of tenderness in any area, palpate this area last

 DEEP PALPATION PROCEDURES

o Use this technique to feel internal organs and masses for
size, shape, tenderness, symmetry and mobility
o Depress the skin 1 ½ to 2” (4 to 5 cm) with firm, deep
pressure
o Use one hand on top of the other to exert firmer pressure,
if needed

3. PERCUSSION
It involves tapping a particular area of the body with the fingertips or a percussion hammer in order to elicit
the character and density of the sound in the underlying tissue.
By setting the underlying tissue in motion, percussion helps in determining whether the underlying tissue is
air-filled, fluid-filled, or solid. When the examiner strikes the body surface with the finger, vibration and
sound are produced. This vibration is transmitted through the body tissues, and the character of the
sounds depends on the density of the underlying tissue.

TWO METHODS OF PERCUSSION

a. Direct Method
- It involves striking the body surface directly
with the fingers.

PROCEDURE:
1. Spread the index or middle finger of the
dominant hand slightly apart from the rest
of the fingers.
2. Make a light tapping motion with the finger
pad of the index finger against the body
part being percussed
3. Note what sound is produced

PERCUSSION

b. INDIRECT METHOD
- It is performed by placing the middle finger of the non-dominant hand (called the
pleximeter) firmly against the body surface, keeping the palm and the remaining fingers of the
skin. The tip of the middle finger of the dominant hand (called the plexor) strikes the base of the
distal joint of the pleximeter.

PROCEDURE:
1. Place the nondominant hand lightly on the surface to be percussed
2. Extend the middle finger of this hand, known as the pleximeter, and press its distal
phalanx and distal interphalangeal joint firmly on the location where percussion is to
begin. The pleximeter will remain stationary while percussion is performed in this
location.
3. Spread the other finger of the nondominant hand apart and raise them slightly off the
surface. This prevents interference and, thus, dampening of vibrations during the actual
percussion
4. Flex the middle finger of the dominant hand, called the plexor. The fingernail of the
plexor finger should be very short to prevent undue discomfort and injury to the nurse.
The other fingers on this hand should be fanned.
5. Flex the wrist of the dominant hand and place the hand directly over the pleximeter
finger of the nondominant hand
6. With a sharp, crisp, rapid movement from the wrist of the dominant hand, strike the
pleximeter with the plexor. At this point, the plexor should be perpendicular to the
pleximeter. The blow to the pleximeter should be between the distal interphalangeal
joint and the fingernail. Use the finger pad rather than the fingertip of the plexor to
deliver the blow. Concentrate on the movement to create the striking action from the
dominant wrist only.
7. As soon as the plexor strikes the pleximeter, withdraw the plexor to avoid dampening
the resulting vibrations. Do not move the pleximeter finger
8. Note the sound produced from the percussion
9. Repeat the percussion process one or two times in this location to confirm the sound
 10. Move the pleximeter to a second location, preferably the contralateral location from
where the previous percussion was performed. Repeat the percussion process in this
manner until the entire body surface area being assessed has been percussed

. DIRECT FIST
PERCUSSION – is used
to assess the presence of
tenderness and pain in
internal organs, such as
the liver or the kidneys
PROCEDURES:
1. Explain this technique thoroughly so the patient does not think you are hitting him or her
2. Draw the dominant hand up into fist
3. With the ulnar aspect of the closed fist, directly hit area where the organ is located. The
strike should be moderate force, and it may take some practice to achieve the right intensity

4. AUSCULTATION
Listening to the sounds created in various body organs to detect variations. It is a method that
uses the stethoscope to augment the sense of hearing.

DIRECT
AUSCULTATION
(IMMEDIATE
AUSCULTATION) – is
the process of listening
with the unaided ear.

.INDIRECT
AUSCULTATION
(MEDIATE
AUSCULTATION) –
the process of listening
with some amplification
or medical device.
 SOUNDS DESCRIBED DURING AUSCULTATION
 PITCH – the frequency of the vibrations (number of vibrations per second)
o Heart sound have fewer vibrations per second
o Bronchial sound have high-pitched sound
 INTENSITY – (amplitude) refers to the loudness or softness of a sound
 DURATION – length of the sound (long or short)
 QUALITY – a subjective description of a sound

ORGANIZATION OF THE EXAMINATION

1.History taking precedes physical examination.

2.The commonly used system is “head to toe” (cephalocaudal).
3.The extent of the examination depends on the purpose.
- A client returning from surgery for repair of a fractured leg will require assessment of
the circulatory and musculoskeletal function rather than a breast assessment or
examination.
4.If client becomes fatigued, offer rest periods between assessments.
5.Record results of the examination in scientific terms so that any health professional can interpret the
findings.

THE EXAMINATION

General Survey - The preliminary examination which includes the following:

A. Height and Weight

B. Vital Signs
1. Temperature
- Taken at what route.
2. Pulse
- Rhythm, volume and tension.
3. Respiration
- Rate, rhythm, symmetry, depth, character, color of the client
4. Blood Pressure

C. General Appearance and Behavior

1. Sex and Race
- A person’s sex affects the type of examination performed.
- Different physical features are related to sex and race.

2. Signs of Distress
- There maybe signs or symptoms indicating a problem such as pain, difficulty of
breathing, and anxiety.
3. Body Type
- The body type can reflect the level of health, age and lifestyle
- The nurse observes if the client appears trim, muscular, obese, or excessively thin.

4. Posture
- Normal standing posture is an upright stance with parallel alignment of his shoulders.
- Normal sitting posture involves some degree of rounding of the shoulders. Observe if
the client has an erect, slumped, or a bent posture. Posture may reflect mood or
presence of pain. Many elderly persons assumed a stooped position.

5. Gait
- The manner of walking. Note if the movements are coordinated or uncoordinated.

6. Body Movements
- Note for involuntary movements of body

7. Age
- It influences the normal features or physical characteristics of an individual. The ability
to participate n some parts of the examination will also be influenced by age.

8. Hygiene and Grooming

- Note the client’s level of cleanliness by observing the appearance of the hair, skin, or
the fingernails.

9. Dress
- Note if the type of clothing worn is appropriate for the temperature and weather
condition.

10. Body Odor

- Assess is it from physical exercise, poor hygiene, or poor oral hygiene.

11. Mood and Affect/ Facial Expression

- At rest and in interaction with others.

12. Speech
- It includes the pace of speech, its pitch and clarity.

13. Level of Consciousness

- Including the speed of response to questions and apparent comprehension.

 The largest among glands

 Good indicator of person’s health
THE INTEGUMENTARY status
 General pigmentation (evenness,
appropriate for heritage)
 Color of Skin or Mucous Membranes
 Uniform Color/ Ethnic Race, (pink) skin
or mucous membranes
 Assessment of the Skin
 Inspect skin color
 Inspect uniformity of skin color
 Assess edema, if present. Measuring the
circumference of the extremity with a
millimeter tape, may be useful for future
comparison
 Inspect, palpate and describe skin lesions
 Observe and palpate skin moisture
 Palpate skin temperature
 Note skin turgor
 Document findings in the client record
THE HEAD TO NECK EXAMINATION
Normal Finding
 Varies from light to deep brown; from ruddy
pink to light pink; from yellow overtones to
olive
 Generally uniform except in areas exposed to
the sun; areas of lighter pigmentation
 No edema
 Freckles, some birthmarks, some flat and
raised nevi; no abrasions or other lesions
 Moisture in skin folds and axillae
 Uniform; within normal range
 When pinch, skin springs back to previous
state
 SKULL
NORMAL FINDINGS
Proportional to the size of the body, round, with prominences in
the frontal area anteriorly and the occipital area posteriorly,
symmetrical in all planes & gently curved Proportional to the
size of the body, round, with prominences in the frontal area
anteriorly and the occipital area posteriorly, symmetrical in all
planes & gently curved.

SCALP INSPECTION
Separate the hair strands carefully to reveal the scalp.
Inspect for color, appearance, presence of masses,
lice, nits and dandruff
PALPATION
Palpate for areas of tenderness.
NORMAL FINDING
White, clean, free from masses, lumps, scars, nits,
dandruff, and lesions

FACE
INSPECTION
Observe for the symmetry, shape, facial expression, movement,
and appearance.
NORMAL FINDINGS
Oblong or oval or square or heart shaped, symmetrical, facial
expression that is dependent on the mood or true feelings,
smooth and free from wrinkles, no involuntary muscle
movements

LIFESPAN CONSIDERATION: ASSESSING THE SKULL AND FACE

INFANTS:
 Newborns delivered vaginally can have elongated, molded heads, which take on more rounded shapes
after a week or two. Infants born by cesarean section tend to have smooth, rounded heads
 The posterior fontanel (soft spot) is about 1cm in size and usually closes by 8 weeks. The anterior
fontanel is larger, about 2 to 3cm in size. It closes by 18 months
 Newborns can lift their heads slightly and turn them from side to side. Voluntary head control is well
established by 4 to 6 months
 HAIR
INSPECTION
Inspect for the color, distribution, thickness, lubrication and appearance.
PALPATION
Palpate for texture.
NORMAL FINDINGS
Black, evenly distributed and covers the whole scalp, thick, shiny, free from
split ends. Coarse or fine.
*Note:
Terminal Hair
- Its is the long, thick, and coarse hair of the body which is easily
visible on the scalp, axilla, and the pubic area.

Vellus Hair
- It is the soft, small, tiny hair that covers the whole body except for the
palms and the soles.

LIFESPAN CONSIDERATIONS: ASSESSING THE HAIR

INFANTS:
 It is normal for infants to have either very little or a great deal of body and scalp hair

CHILDREN:
 As puberty approaches, axillary and pubic hair will appear

ELDERS
 There may be loss of scalp, pubic and axillary hair
 Hairs of the eyebrows, ears and nostrils become bristle-like and coarse

INSPECTION
Instruct the client to look straight and refrain from turning the
head in different directions. Observe for placement, symmetry,
protrusion, clarity, and lacrimation
NORMAL FINDINGS
Parallel and evenly placed, symmetrical, non-protruding, with
scanty amount of secretions, both eyes black and clear.
 EYES

EYEBROWS INSPECTION
Observe for the color, symmetry, quantity of hair, movement,
distribution and placement or parallelism.
*Note: To check for movement, let the client raise and lower the
eyebrows at the same time at the cue of your command or request
NORMAL FINDINGS
Black, symmetrical, thick can raise lower eyebrows symmetrically and
without difficulty, evenly distributed and parallel with each other.

EYELASHES
INSPECTION
Observe for the color, distribution, and direction of eyelashes

NORMAL FINDINGS
Black, evenly distributed and turned outward

EYELIDS
INSPECTION
Observe for position, symmetry, and color.
PALPATION. With the client’s eyes closed, palpate for the lacrimal
gland if it’s palpable
NORMAL FINDINGS
Upper lids cover a small portion of the iris, cornea and the sclera
(limbus) when the eyes are open.
When the eyes are closed, the lids meet completely.
Symmetrical, color is the same as the surrounding skin.
No palpable mass

LID MARGINS
INSPECTION
Observe for scaling, secretions, erythema, and the lacrimal duct
openings (appearance)
NORMAL FINDINGS:
Clear, without scalings or secretions, lacrimal duct openings
(puncta) are evident at the nasal ends of the upper and lower lids
INSPECTION
. Inspect for the symmetry (the longitudinal opening between the
eyelids
NORMAL FINDINGS
Appear equal when the eyes are open.
PALPEBRAL FISSURE

LOWER PALPEBRAL
CONJUNCTIVA INSPECTION
Observe for color and appearance
NORMAL FINDINGS
Salmon pink, shiny, moist and transparent

SCLERA
INSPECTION
Observe for color and appearance
NORMAL FINDINGS
White and clear

IRIS INSPECTION
Note for size, shape, color, symmetry
NORMAL FINDINGS
Proportional to the size of the eye, round, black/brown, and
symmetrical

PUPILS
INSPECTION
Note size, shape, symmetry, reaction to light and
accommodation (PERRLA)..
NORMAL FINDING
From pinpoint to almost the size of the iris, round,
symmetrical, constrict with increasing light and accommodation

EYE MOVEMENT
INSPECTION
Ask client to refrain from moving his head while he follows
the direction of the examiner’s fingers with his eyes.
NORMAL FINDING
Able to move eyes in full range of motion or able to move in all
direction

VISUAL ACUITY INSPECTION

Let client read the letters of the Snellen’s chart at a distance of 20ft
Note: If the client has his glasses, he should wear them, but not if the
glasses are intended only for reading. Test each eye separately.
Determine the smallest line of print from which he is able to identify
correctly more than half the figures. Record the visual acuity
designated at the side of this line.
NORMAL FINDING
20- distance from the chart
20- distance at which a normal eye can read.
 FIELD OF VISION
INSPECTION
Let the client look straightforward without moving his eyes.
By placing your fingers in different specific directions, ask the
client if he could still see your moving fingers.
NORMAL FINDING
Able to see 60 degrees superiorly, 90 degrees temporally, and 70
degrees inferiorly

EYE ASSESSMENT

DISTANCE VISION
 Have the patient sit or stand 20’ (6.1m) from the chart
 Cover his left eye with an opaque object
 Ask him to read the letters on one line of the chart and then to move downward to increasingly smaller
lines until he can no longer discern all of the letters
 Have him repeat the test covering his right eye
 Have him read the smallest line he can read with both eyes uncovered to test his binocular vision
 If the patient wears corrective lenses, have him repeat the test wearing them
 Record the vision with and without correction

RECORDING RESULTS:
 Visual acuity is recorded as a fraction. The top number (20) is the distance between the patient and the
chart. The bottom number is the distance from which a person with normal vision could read the line.
The larger the bottom number, the poorer the patient’s vision
 In adults and children age 6 and older, normal vision is measured 20/20
 For children age 5, normal vision is 20/30
 For children age 4, normal vision is 20/40
 For children age 3 and younger, normal vision is 20/50

NEAR VISION: To measure near vision

 Cover one of the patient’s eyes with an opaque object
 Hold the Rosenbaum card 14 inches from the eyes
 Have the patient read the line with the smallest letters he can distinguish
 Repeat the test with the other eye
 If the patient wears corrective lenses, have him repeat the test while wearing them
 Record the visual accommodation with and without corrective lense

ASSESSING EYE MUSCLE FUNCTION

 Corneal Light Reflex
 Ask the patient to look straight ahead; then shine a penlight on the bridge of his nose
from 12 inches to 15 inches (30.5 to 38 cm) away. The light should fall at the same spot
on each cornea. If it doesn’t, the eyes aren’t being held in the same plane by the
extraocular muscles. The patient likely lacks muscle coordination, a condition called
strabismus.
 Cardinal Position of Gaze – evaluate the oculomotor, trigeminal, and abducens cranial nerves and
extraocular muscles
 Ask the patient to remain still while you hold a pencil or other small object directly in
front of his nose at a distance of about 18 inches (45cm)
 Ask him to follow the object with his eyes, without moving his head
 Move the object to each of the cardinal positions, returning to the midpoint after each
movement
 Note abnormal findings, such as nystagmus (involuntary, rhythmic oscillation of the
eyeballs) or amblyyopia (failure of one eye to follow an object)

ASSESSING PUPIL REACTIONS

A. Direct and Consensual Reaction to Light

 Partially darken the room
 Ask the client to look straight ahead
 Using a penlight or flashlight and approaching from the side, shine a light on the pupil
 Observe the response of the illuminated pupil. It should constrict (direct response)
 Shine the light on the pupil again, and observe the response of the other pupil. It should also constrict
((consensual response)

B. Reaction to Accommodation
 Hold an object (a penlight or pencil) about 10 cm from the bridge of the client’s nose
 Ask the client to look first at the top of the object and then at a distant object (e.g. the far wall) behind
the penlight. Alternate the gaze from the near to the far object
 Observe the pupil response. The pupils should constrict when looking at the near object and dilate when
looking at the far object
 Next, move the penlight or pencil toward the client’s nose. The pupils should converge. To record
normal assessment of the pupils, use the abbreviation PERRLA (pupils equally round and react to light
and accommodation)

LIFESPAN CONSIDERATION: ASSESSING the EYE and VISION

INFANT
 Infants 4 weeks of age should gaze at and follows objects
 Ability to focus with both eyes should be present by 6 months of age
CHILDREN
 Epicanthal folds, common in Asian cultures, may cover medial canthus and cause eyes to appear
misaligned
 Dark-skinned children’s sclera may be darkerer and have small brown macules
 Preschool children’s acuity can be checked with picture cards or the E-chart. Acuity should approach
20/20 by 6 years of age.
ELDERS

Visual Acuity
 Visual acuity decreases as the lens of the eye ages and becomes opaque and loses elasticity
 The ability of the iris to accommodate to darkness and dim light diminishes
 Peripheral vision diminishes
 The adaptation to light (glare) and dark decreases
 Accommodation to far objects improves, but accommodation to near objects decreases
 Color vision declines; older people are less able to perceive purple colors and to discriminate pastel
colors
 Many elders wear corrective lenses; they are most likely to have hyperopia. Visual changes are due to
loss of elasticity (presbyopia) and transparency of the lens
External Eye Structures
 The skin around the orbit of the eye may darken
 The eyeball may appear sunken because of the decrease in orbital fat
 Skin folds of the upper lids may seem more prominent, and the lower lids may sag
 The eyes may appear dry and lusterless because of the decrease in tear production from the lacrimal
glands
 A thin, grayish white arc or ring (arcus senilis) appears around part or all of the cornea. It results from an
accumulation of a lipid substance on the cornea. The cornea tends to cloud with age
 The iris may appear pale with brown discoloration as a result of pigment degeneration
 The conjunctiva of the eye may appear paler than that of younger adult and may take on a slightly
yellow appearance because of the deposition of fat
 Pupil reaction to light and accommodation is normally symmetrically equal but may be less brisk
 The pupils can appear smaller in size, unequal, and irregular in shape because of sclerotic changes in the
iris
 EAR
INSPECTION
Observe for parallelism, symmetry, size, shape, position, color,
and appearance.
Palpation. Palpate for the firmness of the cartilage of the auricles.
NORMAL FINDING
Parallel, symmetrical, proportional to the size of the head, bean-
shaped, helix is in the line with the outer canthus of the eye, skin
is the same color as the surrounding area, clean.

EAR CANAL

INSPECTION
By using a penlight, examine by pulling up and back for adults,
down and back for children. Inspect for color, appearance,
presence of cerumen, foreign bodies, and cilia.
NORMAL FINDING
Pinkish, clean, with scant amount of cerumen and a few cilia

HEARING ACUITY
INSPECTION
Whisper from the client’s ear at a distance of 2 feet (one ear at
a time) and then at
OTOSCOPIC the back of the client for both ears.
EXAMINATION
Note: Instruct the client not to move his head and to repeat
the words that you will say. One direction at a time.
NORMAL FINDING
Able to hear whisper spoken 2 feet away.

 Ask the patient to sit with his back straight and head tilted away from you and toward the opposite
shoulder. Straighten the ear canal by grasping the auricle and pulling it up and back
 Insert the speculum 1/3 its length gently down and forward into the ear canal. Be careful not to touch
either side of the inner portion of the canal wall because this area is covered by a thin epithelial layer
that’s sensitive to pressure.
 Hold the otoscope handle between your thumb and fingers and brace your hand firmly against the
patient’s head. Doing so keeps you from hitting the canal with the speculum
 Once the otoscope is positioned properly, you should see the tympanic membrane, pars flaccid, and the
bony structure. The tympanic membrane should be pearl gray, glistening, and transparent. Inspect the
membrane for bulging, retraction, bleeding, lesions and perforations
 The light reflex in the righr ear should be between 4 and 6 o’clock; in the left ear should be between 6
and 8 o’clock. Finally, look for the bony landmarks. The malleus will appear as a dense, white streak at
12 o’clock. The umbo is the inferior portion of the malleus

HEARING ACUITY TESTS

WEBER’S TEST – A tuning fork is used to evaluate bone conduction. The tuning fork should be tuned to the
frequency of normal human speech, 512 cycles/second. To perform Weber’s test:

 Strike the tuning fork lightly against your hand

 Place the vibrating fork on the patient’s forehead at the midline or on the top of his head

RESULTS DESCRIPTION
Normal Patient hears tone equally well in both ears

Right or Left Lateralization Patient hears tone better in one ear

Conductive hearing loss Patient hears tone only in his impaired ear

Sensorineural hearing loss Patient hers tone only in his unaffected ear

RINNE TEST – is used to compare air conduction (AC) of sound with bone conduction (BC) of sound. To perform
this test:
 Strike the tuning fork against your hand
 Place the vibrating fork over the patient’s mastoid process
 Ask the patient to tell you when the tone stops; note this time in seconds
 Move the still – vibrating tuning fork to the ear’s opening without touching the ear
 Ask the patient to tell you when the tone stops; note this time in seconds.

RESULTS DESCRIPTION
Normal hearing Patient hears AC tone twice as long as he hears BC tone
(AC>BC)
Conductive hearing loss Patient hears BC tone as long as or longer than he hears
AC tone (BC> AC))
Patient hears AC tone longer than he hears BC tone
Sensorineural hearing loss (AC>BC)

LIFESPAN CONSIDERATIONS: ASSESSING the EARS and HEARING

INFANT
 To assess gross hearing, ring a bell from behind the infant or have the parent call the child’s name to
check for a response. At 3 – 4 months of age, the child will turn head and eyes toward the sound
CHILDREN
 To inspect the external canal and tympanic membrane in children less than 3 years old, pull the pinna
down and back. Insert the speculum only ¼ to ½ inch.
ELDERS
 The skin of the ear may appear dry and be less resilient because of the loss of connective tissue
 The pinna increases in both width and length, and the earlobe elongates
 Earwax is drier
 The tympanic membrane is more translucent and less flexible
 Sensorineural hearing loss occurs
 Generalized hearing loss (presbycusis) occurs in all frequencies, although the first symptom is loss of
high-frequency sounds; the f, s, sh and ph sounds. To such person conversation can be distorted and
result in what appears to be inappropriate or confused behavior.

NOSE INSPECTION
Observe for placement, symmetry, patency.
Note: Ask client to close one nostril at a time and ask if he
has any difficulty in breathing while one nostril is covered
NORMAL FINDING
Midline, symmetrical, and patent

INTERNAL NARES
INSPECTION
Appearance, color of mucus membrane, presence of cilia.
NORMAL FINDING
Clean, pinkish, with few cilia

SEPTUM
INSPECTION
Note for appearance.
NORMAL FINDING
Straight

LIFESPAN CONSIDERATION: ASSESSING The NOSE and SINUSES

INFANTS
 A speculum is usually not necessary to examine the septum, turbinates, and vestibule. Instead push the
tip of the nose upward with the thumb and shine a light into the nares
CHILDREN
 A speculum is usually not necessary to examine the septum, turbinates and vestibule. It may cause the
child to be apprehensive. Instead, push the tip of the nose upward with the thumb and shine a lighr into
the nares
 Ethmoid sinuses develop by age 6. Sinus problems in children under this age are rare
ELDERS
 The sense of smell markedly diminishes because of a decrease in the number of olfactory nerve fibers
and atrophy of the remaining fibers. Elders, are less able to identify and discriminate odors
 Nosebleeds may result from hypertensive disease or other arterial vessel changes

LIPS
INSPECTION
Observe for color, shape, symmetry, lip margin, appearance
NORMAL FINDING
Pinkish, symmetrical, lip margin well defined, smooth and moist

GUMS INSPECTION
Observe for color, appearance, discharge, and swelling or
retraction.
NORMAL FINDING
Pinkish, smooth, moist, no swelling, no retraction, no discharge

TEETH
INSPECTION
Number, color, alignment, general condition, breath.
NORMAL FINDING
32 permanent teeth, well-aligned, free from caries or filling, no
halitosis
TONGUE
INSPECTION
Inspect for size, color, surface, appearance, and movement.
NORMAL FINDING
Large, medium, red or pink, slightly rough on top, smooth along
the lateral margins, moist, and freely movable
FRENULUM
INSPECTION
Note for position and appearance
NORMAL FINDING
Midline, straight, and thin.

BUCCAL MUCOSA
INSPECTION
Note color and appearance
MOUTH ABNORMALITIES
NORMAL FINDING
Pinkish, moist, and smooth
 HERPES SIMPLEX (TYPE 1) – a recurrent viral infection
caused by human herpesvirus. Its transmitted by oral and
respiratory secretions, affects the mucous membranes, and
produces cold sores and fever blisters.

ANGIOEDEMA – commonly associated with urticaria, is

usually caused by a allergic reaction. It presents subcutaneously
or dermally and produces nonpitted swelling of subcutaneous
tissue and deep, large wheals usually on the lipd, hands, feet,
eyelids, or genitalia.

LEUKOPLAKIA – involves painless, white patches that may

appear on the tongue or the mucous membranes of the mouth
`

CANDIDIASIS – cream-colored or white patches on the

tongue, mouth or pharynx.

THROAT ABNORMALITIES
 DSYPHAGIA – refers to difficulty swallowing

TONSILLITIS – commonly begins with a mild to severe sore

throat which produces dysphagia, fever, swelling and tenderness
of the lymph nodes and redness in the throat

PHARYNGITIS – an acute or chronic inflammation of the

pharynx that produces a sore throat and slight difficulty
swallowing.

DIPHTHERIA – an acute highly contagious, toxin – mediated

infection caused by Corynebacterium diphtheria, causes a sore
throat with rasping cough and leads to airway obstruction

THROAT PAIN – refers to discomfort in any part of the

pharynx

LIFESPAN CONSIDERATIONS: ASSESSING the MOUTH and OROPHARYNX

INFANTS
  Inspect the palate for a cleft
CHILDREN
 Tooth development should be appropriate for age
 White spots on the teeth may indicate excessive fluoride ingestion
 Drooling is common up to 2 years of age
 The tonsils are normally larger in children than in adults and commonly extend beyond the palatine arch
until the age of 11 or 12 years
ELDERS
 The oral mucosa may be drier than that of younger persons because of decreased salivary gland activity.
Decreased salivation occurs only in elderly people taking prescribed medication such as antidepressants,
antihistamine, decongestants, antihypertensive, tranquilizers, antispasmodic and antineoplastics.
Extreme dryness is associated with dehydration
 Some receding of the gums occurs, giving appearance of increased toothliness
 There may be a brownish pigmentation to the gums, especially in black persons
 Taste sensations diminish
 Tiny purple or bluish black swollen areas under the tongue, known as caviar spots, are not uncommon\
the teeth may show sign of staining, erosion, chipping and abrasions due to loss of dentin
 Tooth loss occurs as a result of dental disease but is preventable with good dental hygiene
 The gag reflex may be slightly sluggish
 Elders who are homebound or are in long-term care facilities often have teeth or dentures in need of
repair, due to the difficulty of obtaining dental care in these situations.
 ASSESSMENT OF THE NECK

A. Inspection
Observe the patient’s neck. It should be symmetrical and the skin should be intact. Note any scars. No
visible pulsations, masses, swelling, venous distention, or thyroid gland or lymph node enlargement
should be present. Ask the patient to move his neck through the entire range of motion and to shrug his
shoulders.
B. Palpation
Palpate the patient’s neck using the finger pads of both hands. Assess the lymph nodes for size, shape,
mobility, consistency, temperature and tenderness, comparing nodes on one side with those on the
other.
C. Auscultation
Using light pressure on the bell of the stethoscope, listen over the carotid arteries. Ask the patient to
hold his breath while you listen to prevent breath sounds from interfering with the sounds of circulation.
Listen for bruits, which signal turbulent blood flow. If you detect an enlarged thyroid gland during
palpation, also auscultate the thyroid area with the bell. Check for a bruit or soft rushing sound, which
indicates a hypermetabolic state.

NECK ABNORMALITIES

SIMPLE (NONTOXIC GOITER)

Involves thyroid gland enlargement that isn’t caused by
inflammation or a neoplasm. It’s commonly classified as
endemic or sporadic

GRAVE’S DISEASE
A metabolic imbalance that results from thyroid hormone
overproduction

TOXIC MULTINODULAR GOITER

A form of thyrptoxicosis that involves overproduction of thyroid
hormone by one or more autonomously functioning nodules
within diffusely enlarged gland

LIFESPAN CONSIDERATIONS: ASSESSING the NECK

INFANT and CHILDREN

 Examine the neck while the infant or child is lying supine. Lift the head and turn if from side to side to
determine neck mobility
 An infant’s neck is normally short, lengthening by about age 3 years. This means palpation of the trachea
difficult