College of Nursing: 2 Semester (S.Y. 2021-2022)

College of Nursing
2nd Semester (S.Y. 2021-2022)

PA2
Chest and Lungs
General Considerations
Self introduction & Explaining the Hand hygiene and

verification of necessary maintenance of
client’s identity procedure asepsis
Inquiry on client’s
history which likely
Ensuring privacy
affect the results
of assessment
Anatomy of the Thorax
Sternum
• Flat bone
• Divided into three (3)

parts:
– Manubrium
– Body
– Xiphoid process
Sternum
• Manubrium:
– Forms upper part of

sternum
– Articulates with body of

sternum at
manubriosternal joint
Sternum
• Sternal angle (angle of
Louis)
– Formed by articulation
of manubrium with body
of sternum
– Important clinical
landmark (because of its
level)
Sternum
• Important clinical
landmark: Sternal angle
– 2nd costal cartilage
– Intervertebral disc
between 4th and 5th
thoracic vertebrae
– Junction between the

aortic arch and the
ascending and descending
aorta
Sternum
• Important clinical landmark: Sternal Angle
– Bifurcation of the trachea (A: Level of Sternal Angle; P: T4
spinous process)
– Junction of superior and inferior mediastinum
Sternum
• Body of the sternum:
– Articulates with
manubrium (above) and
xiphoid process (below)
– Articulates with 2nd

(lower half) to 7th ribs
Sternum
• Xiphoid process:
– Thin plate of cartilage
– Becomes ossified at its

proximal end during
adult life
– No ribs or costal
cartilages are attached
Ribs
• Twelve (12)
pairs of ribs
• Attached
posteriorly
to the
thoracic
vertebrae
Ribs
• Divided into
three (3)
categories:
– True ribs
– False
– Floating
True Ribs
• Upper seven (7) pairs
• Attached to the
sternum by their costal
cartilages
False Ribs
• Ribs 8th to 10th
• Attached anteriorly to
each other
• Also attached to the 7th

rib by their costal
cartilages and small
synovial joints
Floating Ribs
• Ribs 11th and 12th
• No anterior attachment
Costal Cartilages
• Bars of cartilage
• Connects:
– Upper 7 ribs to lateral edge

of sternum
– 8-10th ribs to cartilage

immediately above them
– Note: 11th-12th ribs end in

abdominal musculature
Anatomic Considerations
Note special landmarks:
● 2nd intercostal space
for needle insertion for
tension pneumothorax.
● 4th intercostal space for
chest tube insertion.
● T4 for the lower margin
of an endotracheal tube on
a chest x-ray.
Neurovascular structures
run along the inferior
margin of each rib, so
needles and tubes should
be placed just at the
superior rib margins.
Learn to number the ribs and ICS
ANTERIOR THORAX
Learn to number the ribs and ICS
POSTERIOR THORAX
Aspiration pneumonia is more common in the right middle and lower lobe
because the right main bronchus is more vertical.
Pleura
Accumulations of pleural fluid, or pleural effusions, may be transudates, seen in heart

failure, cirrhosis, and nephrotic syndrome, or exudates, seen in numerous conditions
ncluding pneumonia, malignancy, pulmonary embolism, tuberculosis, and pancreatitis.
Anatomic Descriptors
Anatomic Descriptors
Breathing is primarily automatic, controlled by
respiratory center (medulla oblongata) in the
brainstem that generate the neuronal drive for the
muscles of respiration.
Pulmonary
Ventilation INSPIRATION - Air MOVES INTO the lungs, when:
Air pressure inside the lungs is LESS THAN

(Breathing) the air pressure in the atmosphere
EXPIRATION - Air MOVES OUT of the lungs, when:
Air pressure inside the lungs is GREATER

THAN the air pressure in the atmosphere
Muscles of Inhalation and Exhalation
Accessory Muscles in the Neck
During exercise and in certain diseases, extra work is required to breathe,

and accessory muscles are recruited; the sternocleidomastoids (SCM) and
the scalenes may become visible
MECHANICS OF RESPIRATION
Normal breathing is quiet and easy—barely
audible near the open mouth as a faint
whish.
Normal When a healthy person lies supine, the

breathing movements of the thorax are
relatively slight. By contrast, the abdominal
Breathing movements are usually easy to see.
In the sitting position, movements of the

thorax become more prominent.
Mechanics of Respiration
• Inspiration and
expiration are
accomplished by:
– Increase and decrease of

thoracic cavity capacity
– Physiologic rate (16-20

breaths per minute)
• Quiet/ Relaxed inspiration versus
Mechanics Forced inspiration
of
• Quiet/ Relaxed expiration versus
Respiration Forced expiration
Quiet/ Relaxed Inspiration
• Increased vertical diameter
of thoracic cavity (due to
contraction and descent of
diaphragm)
• Increased transverse and

anteroposterior diameters
(due to rising of ribs and
thrusting of sternum
forward)
– Through contraction of
intercostal muscles
Quiet/ Relaxed Expiration
• Passive process
(accomplished by):
– Elastic recoil of lungs
– Relaxation of intercostal
muscles and diaphragm
Forced Inspiration
• In addition:
– Scalenus anterior and

medius (raises 1st rib)
– Sternocleidomastoid
(raises sternum)
– Serratus anterior and

pectoralis minor (raise
ribs)
Forced Expiration
• Active process
(accomplished by):
– Contraction of muscles
of abdominal wall
(forces relaxed
diaphragm upward by
raising intraabdominal
pressure)
Forced Expiration
• Active process
(accomplished by):
– Contraction of
quadratus lumborum
(pulls 12th rib downward)
– Contraction of latissimus
dorsi (pulls down lower
ribs)
Labored Breathing
Use of the Accessory Muscles
https://www.youtube.com/watch?v=U5nrX-RN7hQ
Signs of Respiratory Distress
• Tachypnea, RR > 25 breaths/ min
• Cyanosis in the lips, tongue, and oral mucosa
• Audible high-pitched inspiratory whistling, or
stridor
• Use of accessory muscles; intercostal muscle
rib retraction
THE PROCEDURE
Assessing Chest and Lungs
• Remember:
– Explain the procedure to the client.
– Wash your hands.
– Provide privacy.
• Remember:
– History taking: family history (illnesses)

medications
– Current health problems

1. Assemble equipment:
– Stethoscope
– Skin marker/pencil
– Centimeter ruler
The Procedure
1. Inspect shape and
symmetry of the
thorax from posterior
and lateral views.
The Procedure
• Normal:
– adult thorax is oval,

overall shape is
elliptical
– wider than it is deep

The Procedure
2. Inspect spinal alignment
for deformities.
– Have client stand from

lateral position. Observe
client from the rear.
– Have client bend forward

at the waist and observe
from behind. (Adam’s
forward bend test)
The Procedure
• Normal:
– 2 forward curves
(cervical and lumbar
spine)
– 2 backward curves
(thoracic and sacral
area)
– Vertically aligned
The Procedure
3. Palpate posterior thorax.
– For clients who have no respiratory complaints,

rapidly assess the temperature and integrity of
the chest skin.
N: skin intact, uniform temperature

Abn: skin lesions, areas of hyperthermia
The Procedure
3. Palpate posterior thorax.
– For clients with respiratory complaints, palpate

all chest areas for bulges, tenderness, or
abnormal movements.
N: chest wall intact, no masses, no tenderness

AbN: lumps, bulges, depressions, CREPITUS, chest
tenderness, fractures
The Procedure
3. Palpate posterior
thorax.
– Avoid deep
palpation for
painful areas
especially if
fractured ribs are
suspected.
The Procedure
4. Palpate posterior chest for
respiratory excursion.
– Place palms of both hands over

the lower thorax, with your
thumbs adjacent to the spine
and your fingers stretched
laterally.
– Ask client to take a deep breath

while you observe the
movement of your hands and
any lag in movement.
The Procedure
4. Palpate posterior chest for
respiratory excursion
– Normal : full and symmetric

chest expansion; thumbs
separate 3-5 cm (1.5-2 in)
– Abnormal: asymmetric
and/or decreased chest
expansion
Respiratory Excursion
The Procedure
5. Palpate chest for vocal
(tactile) fremitus.
– Ask client to repeat
such words as “blue
moon” or “one, two,
three”
– Repeat the two steps
moving your hand
sequentially to the base
of the lungs.
The Procedure
Compare the fremitus on both lungs and between
the apex and base of each lung. Either:
– Using one hand and moving it from one side of the

client to the corresponding area on the other side
– Using two hands that are placed simultaneously on

the corresponding areas of each side of the chest.
Palpate Tactile Fremitus
The Procedure
Vocal (tactile) fremitus findings:
• Normal:
Bilateral symmetry of vocal fremitus.
Low pitched voices of males are more readily
palpated than higher-pitched voices of female.
• Abnormal:
Decreased/Absent fremitus (as in Pneumothorax)
Increased - associated w/ pneumonia
The Procedure
6. Percuss the thorax.
Technique for
Indirect Chest Percussion
• Use of the striking or plexor
finger, usually the third (middle)
finger, to deliver a rapid tap or
blow against the distal
pleximeter finger, usually the
distal interphalangeal joint of
the third finger of the left hand
laid against the surface of the
chest, to evoke a sound wave
such as resonance or dullness
from the underlying tissue or
organs.
• Note: ONLY the pleximeter finger
should be in contact with the
chest wall to avoid damping out
of the percussion note.
Percussion Techniques
The Procedure
• Normal:
– Resonance except over
scapula
(lowest point of resonance
at the level of 8th – 10th
posterior rib)
• Abnormal: Asymmetry in
percussion
– Areas of dullness or
flatness over lung tissue
Percussion Sounds
Resonance long, loud, low Normal lung
pitched
Flat Short, soft, high Atelectasis
pitched
Dull Medium intensity Lobar Pneumonia
Hyperresonant Very loud COPD,
Pneumothorax
Tympanic Musical Large
Pneumothorax (air
collection
Percussion Sounds
The Procedure
7. Percuss for diaphragmatic excursion.
Percuss for diaphragmatic excursion.
• NORMAL
 bilateral excursion
• Male : 5 to 6 cm
• Female : 3 to 5 cm
 diaphragm is slightly elevated on the right side
• AbN/DEVIATIONS
 abnormally high level of dullness
Diaphragmatic Excursions
The Procedure
8. Auscultate the chest
using the flat disc
diaphragm of the
stethoscope. Warm the
diaphragm. Instruct
client to take a slow,
deep breath.
The Procedure
In auscultating:
a) Use the systematic zigzag
(ladder pattern)
procedure in percussion.
b) Ask client to take slow,

deep breaths through the
mouth. Listen at each
point to the breath
sounds during a complete
inspiration and
expiration.
c) Compare findings at each

point with the
corresponding point on
the opposite side of the
chest.
Auscultation Technique
The Procedure
Auscultation:
• N: vesicular and bronchovesicular breath
sounds
• AbN:
- Adventitious breath sounds
- Absence of breath sounds (associated with
collapsed and surgically removed lung lobes)
The Procedure
9. Inspect breathing patterns (rate, depth,

rhythm)
• Normal – Eupnea
• Abnormal – tachypnea, bradypnea, apnea,
and OTHER ABNORMAL RESPIRATORY
PATTERNS
The Procedure
10. Inspect costal angle
and angle at which
ribs enter the spine.
Normal – angle is
less than 90 degrees
Abnormal – costal
angle is widened
The Procedure
11. Palpate Anterior Chest
12. Palpate anterior chest

for respiratory excursion.
– Place both palms of hands

on the lower thorax with
your fingers laterally along the lower rib cage and
your thumbs along the costal margins.
– Ask client to take a deep breath while you observe

the movement of your hands.
The Procedure
13. Palpate tactile fremitus in
the same manner as for
posterior chest.
– If the breasts are large and

cannot be retracted
adequately for palpation,
this part of the examination
is usually omitted.
The Procedure
14. Percuss the anterior
chest systematically
(displace female breast for
proper examination)
• Normal: Resonate until 6th rib at

the level of diaphragm but are
flat over areas of heavy muscle
and bone, heart, liver, and
tympany over stomach
• Abnormal: Asymmetry in
percussion, notes areas of
dullness or flatness over lung
tissue
The Procedure
15. Auscultate the trachea
– Normal: Bronchial & tubular breath
sounds
– Abnormal: Adventitious breath sounds

The Procedure
16. Auscultate the anterior chest.
(Use the sequence in percussion, beginning over the
bronchi between the sternum and the clavicles)
– Normal: Bronchovesicular and vesicular

– Abnormal: Adventitious breath sounds
17. Document findings in the client’s record.

Examine the Anterior Thorax
NORMAL AND ADVENTITIOUS
BREATH SOUNDS
NORMAL BREATH SOUNDS
Type Description Location Characteristics
Vesicular Soft-intesity, low- Over peripheral lung; Best heard on
pitched, “gentle best heard at the inspiration, about
sighing” sounds base of the lungs 2.5 times longer
created by air than the expiratory
moving through phase ( 5:2 ratio )
smaller airways
Broncho-vesicular Moderate-intensity Between the Equal inspiratory
& moderate- scapula & lateral to and expiratory
pitched , “ blowing” the sternum at the phases ( 1:1 ratio)
sounds created by 1st and 2nd
air moving through intercostal spaces
larger airway
Bronchial ( tubular) High-pitched, loud, Anteriorly over the Louder than
“harsh”sounds trachea; not vesicular sounds;
created by moving normally heard over have a short
through the trachea lung tissue inspiratory phase
and long expiratory
phase (1:2 ratio)
CRACKLES/RALES
• discontinuous sounds resulting from air
bubbling through moisture in the alveoli or
from collapsed alveoli popping open; tend to
occur at the end of inspiration
• Most commonly heard in the bases of the

lower lung lobes
EXPIRATORY WHEEZES/RONCHI
• Continuous sounds caused by the narrowing
of an airway by spasm, inflammation, mucus
secretions, or a solid tumor; high pitched (as
in asthma)
• If low-pitched/gurgling, termed as ronchi

(occurs when fluid partially blocks the large
airways)
FRICTION RUB
• Occurs between pleural layers, not in the lung
• High pitched grating/squeaking sound
• Due to rubbing of layers of the pleural wall

STRIDOR
• Harsh, high pitched, continuous honking
sound resulting from an upper airway
obstruction, a partial obstruction, or a spasm
of the trachea or larynx
• Can be heard even w/o using a stethoscope
• Usually requires immediate intervention due

to acute respiratory distress
• Normal vocal sounds should be muffled
and indistinct through the stethoscope;
otherwise, abnormal.
• Indication: consolidated lung tissue,
pulmonary edema, pulmonary
hemorrhage
Abnormal • Consolidation refers to increased
density of the lung tissue, due to it
Vocal being filled with fluid and/or blood or
mucus.
Sounds
• BRONCHOPHONY – say 99 repeatedly,
• EGOPHONY – from “eee” to “ay”
• WHISPERED PECTORILOQUY – whisper
“1,2,3” (louder and clearer sound to the
area of consolidation)
ABNORMALITIES OF THE THORAX
Deformities of the Chest
• Pigeon chest
• Funnel chest
• Barrel chest
• Pigeon chest (pectus
carinatum):
– Permanent deformity
caused by rickets
(osteomalacia in adults)
• Pigeon chest (pectus
carinatum):
– Narrow transverse
diameter
– Increased
anteroposterior
diameter
– Protruding sternum
• Funnel chest (pectus
excavatum):
– Congenital defect
• Funnel chest (pectus
excavatum):
– Sternum is depressed
– Narrowed
anteroposterior
diameter
• Barrel chest:
– Ratio of anterposterior
to transverse diameter is
1:1
• Barrel chest:
– Seen in clients with

thoracic kyphosis and
emphysema
Deformities of the Spine
Scoliosis
OTHER ABNORMALITIES
Other Abnormalities
• Atelectasis
• Pneumonia
• Chest trauma
• Pleural effusion
• Pneumothorax
• COPD
Atelectasis
• Atelectasis is a complete or partial collapse of the
entire lung or area (lobe) of the lung.
• It occurs when the tiny air sacs (alveoli) within the
lung become deflated or possibly filled with alveolar
fluid.
• Atelectasis is one of the most common breathing
(respiratory) complications after surgery.
PNEUMONIA
• lung inflammation caused by
bacterial or viral infection, in
which the air sacs fill with
pus and may become solid
• Types:
– both lungs ( double
pneumonia )
– one lung ( single pneumonia )
– only certain lobes ( lobar
pneumonia )
CHEST TRAUMA
PLEURAL EFFUSION
• Fluid in the pleural space
• “water in the lungs”
• Decreased excursion, decreased tactile

fremitus, dyspnea, dullness
PNEUMOTHORAX
• occurs when air leaks into
the space between your
lung and chest wall.
• This air pushes on the
outside of your lung and
makes it collapse partially
or totally
• Decreased fremitus
• Hyperresonance
PNEUMOTHORAX
• Tension Pneumothorax
– progressive build-up of air

within the pleural space,
usually due to a lung
laceration which allows air
to escape into the pleural
space but not to return
PNEUMOTHORAX
• Tension Pneumothorax
– Severe respiratory distress,

tachycardia, cyanosis,
tracheal shift away from
affected lung
COPD
• CHRONIC BRONCHITIS • EMPHYSEMA
– “blue bloaters” – “pink puffers”
– Excessive mucus – Permanent enlargement
production with of the alveoli distal to
recurrent, persistent terminal bronchioles
cough during 3mos of a with destruction of
year for 2 consecutive alveolar wall
years
– Hypoxic
THANK YOU.
College of Nursing
The Cardiovascular
Assessment
ANATOMY OF THE
CARDIOVASCULAR SYSTEM
Heart
• Hollow, muscular organ
within the pericardium
• Pyramidal (in shape) about

the size of the fist.
• The heart pumps blood

through the network of
arteries and veins called the
cardiovascular system
Pericardium
• The membrane that surrounds and protects the heart

• It confines the heart to its position in the mediastinum, while
allowing sufficient freedom of movement for vigorous and rapid
contraction.
Pericardium
• Has two (2) main parts:

• Fibrous
• Serous
Pericardium
• Fibrous layer
– Strong, limits unnecessary movement of the heart

(attached to the sternum)
– Fuses above with walls of great blood vessels

(ascending aorta, pulmonary trunk and veins,
superior and inferior vena cavae)
– Firmly attached to central tendon (diaphragm)

Pericardium
• Serous layer (two layers):
– Parietal: lines fibrous pericardium

reflected around roots of the great
vessels
continuous with visceral layer
– Visceral : covers the heart (epicardium)

Pericardium
• Serous layer
– Pericardial cavity (slit-like space between parietal

and visceral layer)
• pericardial fluid (acts as lubricant to facilitate cardiac

movements)
Surfaces of the Heart
• Has Five (5) surfaces:
– Anterior (Sternocostal)
– Posterior (Base)
– Inferior
(Diaphragmatic)
– Right pulmonary (Right

Atrium)
– Left Pulmonary (Left

Atrium)
Chambers of the Heart
• Divided by a vertical
septum into four (4)
chambers
– Right atrium (lies

anterior to left atrium)
– Right ventricle (lies

anterior to left ventricle)
Blood Flow
Conduction System
Electrocardiogram (ECG)
An electrocardiogram (ECG or EKG) records the electrical signal from your

heart to check for different heart conditions. Electrodes are placed on your
chest to record your heart's electrical signals, which cause your heart to beat.
Views of the
Heart
12-Lead ECG Placement
THE HEARTBEAT
Point of Maximal Impulse (PMI)
Palpate → PMI
Auscultate → Apical pulse
PMI Location:
5Th ICS, Left MCL
(7-9 cm from Left MSL)
The PMI is not always

palpable, even in a
healthy patient with
a normal heart.
Detection is affected
by both the patient’s
body habitus and
position during the
examination.
Precordium
Rarely, in situs
inversus and
dextrocardia, the PMI
is located on the right
side of the chest.
Heart Sounds
• Heart makes two (2) sounds:
– Lub (S1)
– (produced by contraction of ventricles and closure
of both atrioventricular valves – tricuspid and
mitral)
– Dub (S2)
– (shorter, produced by sharp closure of aortic and
pulmonary valves)
Normal Heart Sound
Heart Sounds
By Auscultation
Heart Sounds
• Tricuspid valve: - Best heard over right half of

lower end of body of sternum
Heart Sounds
• Mitral valve:
– Best heard over apex beat (level of 5th left intercostal
space, [3.5 inches/ 9 cm from midline])
Heart Sounds
• Pulmonary valve:
– Best heard of medial end of the 2nd left intercostal space
Heart Sounds
• Aortic valve:
– Best heard of medial end of 2nd right intercostal space
Heart Sounds
Erb’s point - located in the third intercostal space close

to the sternum
Heart Murmur – Mitral Stenosis
Blood Vessels
• Arteries
• Veins
• Capillaries
Arteries
• Carry oxygenated blood away from left
portion of the heart and unoxygenated blood
to lungs via pulmonary arteries
• Blood vessels
with 3 coats:
– Tunica Intima
– Tunica Media
– Tunica Adventitia
Veins
• Carry unoxygenated
blood back to the right
portion of the heart,
except for pulmonary
veins w/c carry
oxygenated blood from
lungs to left heart
• Contain the same 3

layers of the arteries
but are thinner with
less elastic and
collagenous tissue and
smooth muscle
Capillaries
• Connect arterial and
venous system for
exchange of gases,
fluids, nutrients, and
wastes
• Single layer of
microscopic endothelial
cells
Types of Bleeding
THE PROCEDURE
THE PROCEDURE
1. Explain to the client
2. Wash hands
3. Provide privacy
4. Inquire client’s family & Health history
5. Simultaneously inspect and palpate the
precordium
THE PROCEDURE
• Inspect and palpate
✓ The aortic & pulmonic area
✓ Tricuspid area for pulsations , heaves or
lifts
✓ Apical area for pulsation
✓ Epigastric area at the base of the sternum
for abdominal aortic pulsation
Palpation
a. Aortic - 2nd ICS right sternal border
b. Pulmonic - 2nd ICS left sternal border
c. Erb’s point - 3rd ICS left sternal border
d. Tricuspid - 5th ICS lower left sternal border
e. Mitral - 5th ICS @ mid clavicular line, PMI38
Inspection and Palpation
THE PROCEDURE
7. Palpate the carotid artery, using extreme caution
• Normal: Symmetric pulse volumes, full
pulsations, thrusting quality, quality remains
same when client breathes, turns head,
elastic arterial wall
THE PROCEDURE
7. Palpate the carotid artery, using extreme caution
• Abnormal: Asymmetric volume, decreased

pulsation, increased pulsations during
activities, thickening, hard rigid and inelastic
walls, thrills
Carotid Artery: Palpate and Auscultate
THE PROCEDURE
• 6. Auscultate the
heart in all four
anatomic sites
Palpation
a. Aortic - 2nd ICS right sternal border
b. Pulmonic - 2nd ICS left sternal border
c. Erb’s point - 3rd ICS left sternal border
d. Tricuspid - 5th ICS lower left sternal border
e. Mitral - 5th ICS @ mid clavicular line, PMI
Heart Sounds - Auscultation
THE PROCEDURE
8. Auscultate Carotid Artery to determine
presence of bruit
a. bruit - blowing or swishing sound,
created by turbulence of blood flow due to narrowed
arterial lumen
b. thrill - vibrating sensation caused by arterial

obstruction
THE PROCEDURE
9. Inspect jugular vein
for distention while
client is in semi-
fowler’s position(If
jugular vein
distention is present,
assess JVP.
11. Document findings
Jugular Vein Distention
• Jugular vein
distention or JVD is
when the increased
pressure of the superior
vena cava causes
the jugular vein to
bulge, making it most
visible on the right side
of a person's neck.
Estimating Jugular Vein Pressure
• JVP is the measurement of the highest
oscillation point “meniscus” of the jugular
pulsation
• Reflects pressure in the right atrium (Central
Venous Pressure)
• Provides information about volume status and
cardiac function
Estimating Jugular Venous Pressure
Estimating Jugular Vein Pressure
• Equipment:
– Ruler (in centimeter)
– Any rectangular object e.g., 3x5 card
• Position the head of bed: 30-degree angle
• Locate and measure the oscillation point of pulsation (top
or uppermost point) in the right internal jugular vein
• Place the 3x5 card horizontally at the meniscus point of
pulsation.
• Place the centimeter ruler vertically at the sternal angle
making a 90-degree angle
• JVP result is the vertical distance in centimeters above
the sternal angle where your card crosses the ruler
JVP Result
• Venous pressure elevated above normal
when:
– 3-4 cm above sternal angle with the head of the
bed elevated at 30°
– Or
– 7-8 cm distance above the atrium

THE PROCEDURE
THE PROCEDURE
1. Explain
2. Wash hands
3. Provide privacy
4. History
THE PROCEDURE
5. Palpate peripheral pulse on both sides of
client’s body to determine the symmetry of
pulse volume.
– Normal: symmetric pulse volumes & full
pulsation
– Abnormal: Asymmetric volumes, absence
of pulsation, decreased, weak,
thready pulsation, increased pulse
volume
Pulse Points
Arterial Pulse Amplitude Grading Scale
0 Absent or unable to palpate
1+ Diminished, weaker than expected
2+ Brisk and expected (normal)
3+ Bounding
Palpating Peripheral Pulses
• RADIAL PULSE
• ULNAR PULSE
• BRACHIAL PULSE
• FEMORAL PULSE
• POPLITEAL PULSE
• DORSALIS PEDIS
• POSTERIOR TIBIALIS
THE PROCEDURE
6. Inspect peripheral veins in the arms and legs for
superficial veins
– normal: In dependent position, presence of distention and
nodular bulges at calves
• When limbs elevated, veins collapse
– Abnormal: distended veins in the thigh and/or lower leg or
on posterolateral part of calf from knee to ankle
THE PROCEDURE
7. Assess the peripheral leg veins for signs of
PHLEBITIS
Normal: limbs not tender, symmetric in size
Abnormal: tenderness on palpation
• ( +) Homan’s sign
• warmth and redness
over vein
• swelling of one calf
or leg
THE PROCEDURE
7. Assess the peripheral leg veins for signs of
PHELBITIS
THE PROCEDURE
8. Inspect the skin of the hands and feet for color,
temp., edema & Skin changes
• Normal: skin color pink, skin temp. not
excessively warm or cold, no edema, skin
texture resilient and moist
• abnormal: Cyanotic, pallor , dusky red color
when limb is lowered, brown pigmentation
around ankles, cool skin edema, skin thin and
shiny or thick, waxy, fragile, with reduced hair
and ulceration
THE PROCEDURE
9. Assess the adequacy of arterial flow if arterial
insufficiency is suspected
normal: BUERGER’S TEST, capillary refill test,
negative ALLEN’S TEST
abnormal: delayed color return or mottling,
delayed venous filling, marked redness
of arms or legs, delayed return of color

Buergers Test
(test for blood supply to the legs)
• Patient in supine
• Raise one leg slowly
– Normal: pink even if raised up to 90°
• Let leg hang on side of the bed after
• Abn:
– <30 °
• ISCHEMIA
– Not pale
• PAD
Buergers Test
(test for blood supply to the legs)
Allen Test
(test for blood flow in the hand)
• Patient to make a fist

• Occlude radial and ulnar arteries
• Patient to open hand (should be pale)
• Release ulnar arterial pressure
• The hand should return to normal color within 5-7
seconds
• N Finding:
– Negative Allen Test
Video on Allen Test
When the heart stops to function!
THANK YOU.
College of Nursing
Examining the Breasts
and Axilla
Review of Anatomy
The Female Breast
• Lies between the 2nd

& 6th ribs between
the sternal edge and
midaxillary line
• 2/3 of breast over

Pectoralis major
• 1/3 is superficial to
the serratus anterior
• Contains the
mammary gland
Structures of the Breast
• Mammary Gland
> Contains 15-20 lobes, each lobe
having 50-75 lobules
• Lactiferous Ducts
• carry milk from glands to
L. sinuses
• Lactiferous Sinuses
• store milk
• Areola
• darker tissue surrounding
nipple
• Contains small glands that
lubricate nipple during
breastfeeding
• Montgomery’s Glands
• Combination of milk and sebaceous
glands
• Nipple
• Circular pigmented skin
• Cooper’s Ligament
• suspensory ligaments attached to
chest wall musculature for breast
support
Mammary Glands
• Milk production is
stimulated largely by the
hormone prolactin from
the anterior pituitary, with
contributions from
progesterone and
estrogens.
• The ejection of milk is
stimulated by oxytocin,
which is released from the
posterior pituitary in
response to the sucking of
an infant on the mother’s
nipple (suckling). Mammary Gland
> Contains 15-20 lobes, each lobe having 50-
75 lobules
• Pectoralis Major and Serratus

Anterior muscles
• Internal Mammary Artery –
blood supply
Anatomy of the Breast
• Conical in shape,
often unequal in size
• Lymph Nodes of the breast
• Anterior (pectoral)
• Central (midaxillary)***
• Posterior (subscapular)
• Internal mammary
• Supraclavicular
• Infraclavicular
Most often palpable***

• Important Levels of Lymph Nodes
in the breast:
• Level I (lateral to pectoralis minor)
• Level II (deep in pectoralis minor)
• Level III (medial to pectoralis minor)
• Note: location is based on its

relationship with the pectoralis
minor (not major)
Physiology of breast
development
Breast Development
• Thelarche is the onset of
secondary breast
• Known as “thelarche” development, which often
represents the beginning
of pubertal development.
• Pre-puberty
• The initial growth of
breasts occurs during fetal
• Puberty development in both males
and females.
• Post-puberty
• Thelarche is the stage at
which male and female
• Pregnancy (and breasts become distinct
Lactation) due to variance in
hormone levels
• Menopause
• Some males have a
condition in which they
develop breasts, a term
called gynecomastia
Breast Development
• Pre-puberty:
• Breast is composed of dense

fibrous stroma and scattered
ducts with epithelium
Breast Development
• Puberty:
• Phase measured by growth of

pubic hair
• Approximately 9-12 years old,

plus (+) menarche [onset of
menstrual cycles]
• Increased deposition of fat,

formation of new ducts by
branching and elongation, and
appearance of lobular units
Breast Development
• Post-puberty:
• “resting” breast contains fat,

stroma, lactiferous ducts, and
lobular units
• Undergoes cyclic stimulation

during menstruation (leads to
hypertrophy and alteration of
breast morphology, but not
hyperplasia)
• Increased accumulation of fluid

and intralobular edema (in
premenstrual phase) → produces
pain and breast engorgement
Breast Development
• Pregnancy (and Lactation):
• Dramatic increase in circulating

hormones (ovarian and placental)
initiates changes in the form and
substance of the breast
• Ductal and lobular epithelium

proliferate, areolar skin darkens,
accessory glands (Montgomery’s
glands) become more prominent
Breast Development
• Pregnancy (and Lactation):
• 1st and 2nd trimester:
• minor ducts branch and develop
• 3rd trimester:
• Fat droplets accumulate in alveolar

epithelium
• Colostrum fills ducts
• Late pregnancy:
• Prolactin stimulates synthesis of fats

and proteins
Breast Development
• Menopause:
• Approximately 40-55 years old
• Involution and increased fat

deposition, decreased connective
tissue, and disappearance of
lobular units
Tanner Scale (Stages)
ABNORMALITIES UPON
ASSESSMENT
Discoloration/ Hyperpigmentation
Dimpling/ Puckering
Inflammation, Swelling, Edema
Inflammation, Swelling, Edema
• Mastitis (inflammation of the mammary gland)

Retracted Nipple
Discharges
Color Possible cause
White, cloudy, yellow, or an infection of the breast
filled with pus or nipple
Green cysts
mammary duct ectasia
Brown or cheese-like
(blocked milk duct)
breast cancer, especially
if only coming from one
Clear
breast
papilloma
papilloma
Bloody
breast cancer
LUMP
• May be seen or felt (inspection, palpation)

LUMP
For Males; Gynecomastia
• Gynecomastia is an enlargement or swelling of breast tissue in

males.
• It is most commonly caused by male estrogen levels that are
too high or are out of balance with testosterone levels
THE PROCEDURE
(abnormalities upon inspection)
• Cracked nipple
THE PROCEDURE
• Signs and Symptoms in Breast Cancer

THE PROCEDURE
• Peau d’Orange
THE PROCEDURE
• Prepubertal gynecomastia:
• Symmetrical enlargement and

projection of the breast bud in a
young girl (before 12 years old)
• Unaccompanied by other changes

in the body
THE PROCEDURE
• Prepubertal gynecomastia:
• May be unilateral
• Not to be confused with

neoplastic growth
• Not an indication for biopsy

THE PROCEDURE
• Supernumerary breasts and

nipples
• Occur when mammary ridges

(begin at 5th-6th week of
embryonic life) do not regress and
persist instead
• May be removed for cosmetic

purposes (especially if milk-
producing)
THE PROCEDURE
Polymastia (extra breasts) Polythelia (extra nipple)

THE PROCEDURE
• Amastia
• No breast (and nipple)

THE PROCEDURE
• Athelia
• No nipples
Key points
Key Points
• Breast Examination:
• Clinical Breast
Examination (CBE)
• Self-breast
Examination (SBE)
Key Points
• Clinical Breast Examination (CBE)
• A clinical breast examination (CBE) is a physical examination of

the breast done by a health professional.
• Clinical breast examinations are used along with mammograms to

check women for breast cancer.
• Clinical breast examinations are also used to check for

other breast problems.
• Must be done every 3 years in women 20-40 years old

Key Points
• Self-breast examination (SBE)
• Not recommended monthly
• Best done when estrogen stimulation is lowest

(5-7 days after onset of menses)
• May be taught in women in their early 20s

Key Points
• Self-breast examination (SBE)
• Note for any discomfort, pain, and lumps
• 50% of women have palpable lumps or nodules
• Premenstrual enlargement and tenderness are

common
Mammogram
BI-RADS
Breast Imaging Reporting and Database System
Breast imaging studies are assigned one of seven assessment categories:
• BI-RADS 0: incomplete
• need additional imaging evaluation (additional mammographic views or ultrasound) and/or for
mammography, obtaining previous images not available at the time of reading
• BI-RADS 1: negative
• symmetrical and no masses, architectural distortion, or suspicious calcifications
• BI-RADS 2: benign
• 0% probability of malignancy
• BI-RADS 3: probably benign
• <2% probability of malignancy
• short interval follow-up suggested
• BI-RADS 4: suspicious for malignancy
• 2-94% probability of malignancy
• for mammography and ultrasound, these can be further divided:
• BI-RADS 4A: low suspicion for malignancy (2-9%)
• BI-RADS 4B: moderate suspicion for malignancy (10-49%)
• BI-RADS 4C: high suspicion for malignancy (50-94%)
• biopsy should be considered
• BI-RADS 5: highly suggestive of malignancy
• >95% probability of malignancy
• appropriate action should be taken
• BI-RADS 6: known biopsy-proven malignancy
The procedure
The Procedure
• Remember:
• Some girls and women may be apprehensive (provide assuring and courteous
approach)
• Before beginning, let patient know you are going to examine her breasts
• Good time to ask if she has noted any lumps or discharges (and if she performs SBE)
• Adequate inspection requires full exposure of the chest (but later, cover one
breast while palpating the other)
THE PROCEDURE
1. Inspect the breasts for size, symmetry, and contour or
shape while the client is in a sitting position
Normal:
> females- rounded shape,
slightly unequal in size;
generally symmetric
> males- breasts even with
the chest wall
Abnormal: recent change in
breast size; swellings; marked
asymmetry
THE PROCEDURE
1. Inspect the breasts for size, symmetry, and contour
or shape while the client is in a sitting position
THE PROCEDURE
2. Inspect the skin of breasts for:
• localized discolorations or hyperpigmentation

• retraction or dimpling
• localized hypervascular areas
• swelling or edema
Normal: skin uniform in color, smooth and intact, diffuse symmetric

horizontal or vascular pattern in light-skinned people, striae, moles
and nevi
THE PROCEDURE
3. Emphasize any retraction
4. Inspect the areola area for size, shape, symmetry, color, surface
characteristics, and any masses or lesions
normal:
• round/oval and bilaterally the same, color
varies widely, from light pink to dark brown
• Irregular placement of sebaceous glands on
the surface of the areola
abnormal: any asymmetry, mass or lesion
THE PROCEDURE
5. Inspect the nipples for size, shape, position, color, discharge, and
lesions
normal: round, everted, and equal in size; similar in color;
soft and smooth; both nipples point in same
direction. no discharge
abnormal: asymmetrical size and color
presence of discharge, crusts or cracks,
recent inversion of one or both nipples
THE PROCEDURE
6. Palpate the axillary, subclavicular,
and supraclavicular lymph nodes
a. Sit or lie down

b. Wear gloves
c. Ask pt to relax her arm and
support it with your non
dominant hand
a. Keep fingers of your dominant hand
together
b. Reach high into apex of the axilla,
directly behind pectoral muscle
toward midclavicle
c. Sweep fingers downward against the
ribs
THE PROCEDURE
7. Palpate the breast for masses, tenderness, and any discharge from
the nipples
normal: no tenderness, masses, nodules, or nipple discharge
abnormal: tenderness, masses, nodules or nipple discharge

THE PROCEDURE
• 7. Palpate the breast for masses, tenderness, and any discharge

from the nipples
THE PROCEDURE
8. Palpate the areola and the nipples

for masses. Assess any discharge for
amount, color, consistency, and
odor. Note also any tenderness on
palpation
Note:
• if a mobile mass becomes fixed when

the arm relaxes (it is attached to ribs
and intercostal muscles)
• If fixed when hand rests on the hip (it

is attached to the pectoral fascia
THE PROCEDURE
9. Teach the client the technique or breast self-examination

▪ Hands-of-the-clock / spokes-on-a-wheel
▪ Concentric circles
▪ Vertical stripes pattern
Best time to do BSE is

a week after your
period, when your
breasts are least likely
tender and swollen
THE PROCEDURE
IF MASS IS DETECTED, note for:
❖Location ❖The skin over the
❖Size lump
❖Shape ❖Nipple appearance
❖Consistency ❖tenderness
❖Mobility

Examining the Breast Video
Examining the Axilla
Thank you.
College of Nursing
Examining the Abdomen
The Abdomen
• Roughly cylindrical
chamber
• Extends from inferior

margin of thorax to the
superior margin of the
pelvis and lower limb
The Abdomen
• Functions:
– Houses major elements

of the gastrointestinal
system (as well as spleen
and parts of the
genitourinary system)
– Aids in breathing
Abdominal Viscera
Peritoneum
Parietal Peritoneum (Red line)

Visceral Peritoneum (Blue line)
Peritoneal Cavity (yellow fill)
Ascites – build up of fluid in the
peritoneal cavity
Symptoms may include increased abdominal size (girth), increased

weight, abdominal discomfort, and shortness of breath.
Paracentesis/ Ascitic Drainage
The Abdomen
• Structures to consider:
– Diaphragm
– Abdominal muscles
The Abdomen
• Under the diaphragm:
• Stomach
• Liver
• Gallbladder
• Spleen
• Parts of the colon
• Superior poles of the kidneys

The Abdomen
• Protected by muscles of the
abdomen:
• Any viscera not under the

diaphragm (intestines, colon,
etc)
The Abdomen
• Breathing:
– Inspiration
– Expiration
The Abdomen
• During Inspiration:
– Diaphragm contracts to
accommodate expansion
of thoracic cavity (and
inferior displacement of
abdominal viscera during
contraction of
diaphragm)
The Abdomen
• During Expiration:
– Diaphragm relaxes to
assist in elevating domes
of diaphragm (thus
reduces thoracic
volume)
The Abdomen
• Additional note:
– Material can be expelled

from airway by forced
expiration using
abdominal muscles
• Coughing
• Sneezing
Foreign Body Airway Obstruction
(Choking)
Heimlich Maneuver or
Abdominal Thrust
The Abdomen
• Contraction of
abdominal walls:
– dramatically increases
intra-abdominal
pressure
– but diaphragm is in fixed

position
The Abdomen
• Contraction of
abdominal walls aids
in:
– voiding contents of
bladder and rectum
– childbirth
The Abdomen
• Contraction of
abdominal walls:
– Air is retained in lungs

(by closing valves in
larynx of the neck)
The Abdomen
• Components:
– Muscular
– Bony
Bony Components of Abdomen
• Five (5) lumbar vertebrae
and their intervertebral
disks (L1-L5)
• Superior parts of the

pelvic bones
• Bony components of
inferior thoracic wall
(costal margins, floating
ribs, and xiphoid process)
Muscular Components of Abdomen
• Lateral to abdominal
wall (similar in
orientation to
transversus abdominis,
internal oblique,
external oblique)
Muscular Components of Abdomen
• Lateral to vertebral
column (quadratus
lumborum, psoas major,
iliacus muscle)
• Anterior (rectus
abdominis)
Palpable Landmarks
• Superior
– Costal margin
• Inferior
– Pubic tubercule
– Anterior superior
iliac spine
– Iliac crest
4 Quadrants of the abdomen
Right upper Left upper
quadrant (RUQ) quadrant (LUQ)
Liver, Spleen, splenic
gallbladder, flexure of colon,
pylorus, stomach, body
duodenum, and tail of
hepatic flexure pancreas, and
of colon, and transverse colon
head of
pancreas
Right lower Left lower

quadrant quadrant (LLQ)
Cecum, Sigmoid colon,
appendix, descending
ascending colon, colon, left ovary
right ovary
9 regions of the abdomen
Another Way to Divide Abdomen
• Value (way to locate
origin of referred pain)
– Epigastric region (pain

from mouth to duodenum)
– Umbilical region (pain from

duodenum to proximal 2/3
of transverse colon)
– Pubic region (pain from 1/3

transverse colon and
below)
Patterns and Mechanisms of
Abdominal Pain
Subjective Assessment
• Difficulty swallowing?
• Do you have nausea or
vomiting?
• Do you have any pain?
• Any appetite and weight
changes?
• Does the patient have
any GI problems?
Constipation, diarrhea,
black tarry stools?
THE PROCEDURE
Sequence:
Inspect → Auscultate → Percuss → Palpate
The Procedure
• Assemble equipment and supplies.
– Examination light
– Tape measure (metal/stretchable cloth)
– Water-soluble skin marking pencil
– Stethoscope
The Procedure
• Explain the steps for
examining the abdomen
to the patient and locate
a good light
• Ask client to urinate. An
empty bladder makes
assessment more
comfortable.
• Pay special attention
when draping to expose
the abdomen
The Procedure
• Assist client to a supine
position with the arms placed
comfortably at the sides.
• Place small pillows beneath

the knees and the head to
reduce tension in the
abdominal muscles.
• Expose only client’s abdomen

from chest line to pubic area
to avoid chilling and shivering,
which can tense the
abdominal muscles.
The Procedure: Inspection
• Inspect abdomen for
skin integrity.
• Normal:
– unblemished skin
skin integrity.
• Abnormal:
– rash, or other lesions
– tense, glistening skin
– purple striae
Cullen’s and Turner’s Sign
Cullen and Grey Turner signs

indicate internal hemorrhage
• Inspect abdomen for contour and
symmetry.
• Observe abdominal contour while

standing at client’s side while
client is supine.
• Ask client to take a deep breath

and hold it.
• Normal:
– flat, rounded, or scaphoid

– no evidence of liver or spleen
enlargement
– symmetric contour
contour and symmetry.
• Abnormal:
– Distended
– Evidence of liver/spleen
enlargement
– asymmetric contour
(measure girth)
• Assess symmetry of
contour while standing
at the foot of the bed.
• If distention is present,
measure abdominal
girth by placing a tape
around the abdomen at
level of the umbilicus.
• Observe abdominal
movements associated
with respiration, visible
peristalsis, and aortic
pulsations.
• Observe the vascular
pattern.
The Procedure: Auscultation
• Auscultate the
abdomen for bowel
sounds, vascular
sounds, and peritoneal
friction rubs.
• Bowel Sounds:
– Occur every 5-20 secs

(active) – listen for at
least 2 min in all
quadrants (6 min total)
– Duration may range from

less than a second to
more than several
seconds
• Normal:
– Audible bowel sounds
– Absence of arterial
bruits
– Absence of friction rub
– NABS – Normoactive
Bowel Sounds
• Abnormal:
– Absent,
hypoactive/hyperactive
bowel sounds
– Loud bruit over aortic

area
– Bruit over renal or iliac

arteries
Gas Forming Foods
• Vascular Sounds:
– Bruit (blowing sound

due to restricted blood
flow through narrowed
vessels)
• Peritoneal friction rubs:
– Rough, grating sounds

(like 2 pieces of leather
rubbed together)
– Caused by inflammation,
infection, and abnormal
growth
• Peritoneal friction rubs
sites:
– Splenic flexure (below

left costal margin)
– Hepatic flexure (below

right costal margin)
The Procedure: Percussion
• Percuss abdomen to
determine tympany and
dullness.
• Normal:
– tympany over stomach

and gas-filled bowels
– dullness over liver,

spleen, or full bladder
• Abnormal:
– large dull areas

• Testing for ascites:
– Percuss outwards
– Confirm thru:
• Shifting dullness
• Fluid wave test

• Shifting Dullness
– Percuss starting at
midline
– Look for point of shift

from tympany to
dullness
– Mark the point using

water-soluble pen
• Shifting Dullness
– Ask patient to turn

towards you
– Percuss at midline again

to check if dullness
shifted beyond marked
point/line
Video on Shifting Dullness
• Fluid Wave Test
– Ask patient to put lateral

aspect of his hand on
midline
– Use further hand to gently

tap on other side of
abdomen
– Use nearer hand to feel for

fluid wave
Fluid Wave Test
• Percuss the liver to
determine its size.
• The purpose of liver

percussion is to
measure the liver size.
Tympany
below
• Normal:
– 6-12 cm at midclavicular line (area of dullness)
– 4-8 cm at midsternal line (area of dullness)
• Abnormal:
– enlarged size
> 6-12 cm at midclavicular

line
> 4-8 cm at midsternal line
The Procedure: Palpation
• Perform light palpation
first to determine areas
of tenderness and/or
muscle guarding.
• Systematically explore
all four quadrants.
• Normal:
– No tenderness
– Relaxed abdomen with

smooth, consistent
tension
• Abnormal:
– Tenderness and
hypersensitivity
– Superficial masses
– Localized areas of
increased tension
• Perform deep palpation
of all four quadrants.
• Normal:
– Tenderness may be
present near or over
xiphoid process, cecum,
and sigmoid colon
• Abnormal:
– Generalized or localized
areas of tenderness
– Mobile or fixed masses

• Palpate the liver to detect enlargement and
tenderness below the right costal margin.
N: may not be palpable

smooth border
Abn: enlarged
smooth but tender
nodular, or hard
• Palpate area above the pubic symphysis if the
client’s history indicates possible urinary
retention.
N: not palpable
Abn: distended and palpable as smooth,
round, tense mass
Remember
• Document findings in the client’s record.
Video on Examining the Abdomen
Video on Examining the Liver
Video on Examining the Kidneys
Video on Examining the Spleen
Video on Examining the Aorta
SPECIAL TESTS
Special Tests
• Peritonitis: • Appendicitis:
– Blumberg Sign – McBurney's Point
• Cholecystitis – Blumberg sign
– Murphy’s sign – Rovsing’s sign
– Psoas sign
– Obturator sign
Blumberg Sign
• A.k.a., rebound tenderness

• Compress abdomen and quickly remove fingers.
• Positive: Tenderness upon withdrawal
Murphy’s Sign
• Hook left thumb or fingers of left and under right costal margin
• Ask patient to take a deep breath
• Positive: Sudden stop in inspiratory effort
McBurney’s Point
McBurney’s Point
Rovsing’s Sign
• Press deeply and evenly on LLQ

• Quickly withdraw fingers
• Positive: Pain in RLQ (despite pressure exerted on other side)
Psoas Sign
• Place hand just above patient’s right knee.

• Ask patient to raise thigh against your hand (with resistance)
• Positive: Increased abdominal pain (psoas muscle tenderness)
Obturator Sign
• Flex patient’s right thigh at hip, with knee bent

• Rotate leg internally at hip
• Positive: Right hypogastric pain
THANK YOU.
College of Nursing
Examining the
Rectum and Anus
ANATOMY OF THE PELVIS (RECTUM
AND ANUS)
The
Pelvis
The Bony Pelvis
• a basin-shaped structure
that supports the spinal
column and protects the
abdominal organs (lower
part of the digestive
tract).
• Composed of four (4)

bones:
– Hip bones (2)
– Sacrum
– Coccyx
The Pelvic Brim
• The pelvic brim is the
edge of the pelvic
inlet.
• It is an approximately
Mickey Mouse head-
shaped line passing
through the
prominence of the
sacrum, the arcuate
and pectineal lines,
and the upper
margin of the pubic
symphysis.
The Pelvis
• Pelvic brim borders:
– Sacral promontory
(posterior)
– Iliopectineal lines
(lateral)
– Symphysis pubis
(anterior)
The Pelvis
• Divided into two (2) regions by the pelvic brim into:
– False (greater pelvis)
– True (lesser pelvis)
The Pelvis
• False (Greater pelvis):
– Considered part of the

abdomen
– Superior region
The Pelvis
• True (Lesser pelvis):
– Related to inferior parts

of the pelvic bones,
sacrum, coccyx
– It has an inlet, an outlet,

and a cavity.
Diameter of the Pelvis (cm)
Types of Pelvis
Pelvimetry
• Pelvimetry assesses the
size of a woman's pelvis CT Pelvimetry Measurements
aiming to predict
whether she will be able
to give birth vaginally or
not.
• This can be done by
clinical examination, or
by conventional X‐rays,
computerized
tomography (CT)
scanning, or magnetic
resonance imaging (MRI).
NSVD or CS?
Childbirth Animation
True Labor VS False Labor
Do not confuse
it or relate it
with true and
false pelvis
The Pelvis
• Joints:
– Sacroiliac (very strong

synovial joints, between
sacrum and iliac bones)
– Symphysis pubis
(cartilaginous joints, between
pubic bones in medial plane)
– Sacrococcygeal (cartilaginous
joint, between sacrum and
coccyx)
The Pelvis
• Pelvic cavity:
– Bowl-shaped
– Enclosed by the true pelvis
– Continuous with
abdominal cavity (contains
parts of GUT, GIT, and
reproductive systems)
The Pelvis
• Consists of:
– Pelvic inlet, Pelvic walls and Pelvic floor
The Pelvic Inlet
• Somewhat heart-
shaped (and completely
ringed by bone)
The Pelvic Inlet
• Borders:
– S1 /sacral promontory
(posterior)
– Prominent rim of pelvic

bone (lateral)
– Symphysis pubis
(anterior)
The Pelvic Outlet
• Somewhat diamond-
shaped
• Limited anteriorly at
midline by the
symphysis pubis
• Formed by bones and

ligaments
The Pelvic Floor
• Separates pelvic cavity
from perineum
• Formed by muscles and

fascia
The Pelvic Floor
• Contains two (2) levator
ani muscles
– Largest components of
pelvic diaphragm
(completed posteriorly
by coccygeus muscles)
The Pelvis
The Pelvis
Key Point
• The pelvis and
perineum are
interrelated regions
• Associated with:
– Pelvic bones
– Vertebral column
(terminal parts)
Functions of Pelvis and Perineum
• Contain and support
bladder, rectum, anal
canal, and reproductive
tracts
• Anchor roots of the

external genitalia
The Perineum
• Inferior to the pelvic
cavity
• Boundaries form pelvic

outlet
The Perineum
• Contains:
– External genitalia
– External openings of the

genitourinary and
gastrointestinal systems
In Both Sexes
• Roots of external genitalia (clitoris or penis)
are firmly anchored to:
– Bony margin of anterior half of pelvic outlet
– Thick, fibrous, perineal membrane (fills the area)

The Colon
Anus and Rectum
ABNORMALITIES OF RECTUM AND
ANUS
Abnormalities of the Rectum and Anus
• Hemorrhoids (internal and external)
• Skin tags
• Anal fissures
• Anal warts (condyloma acuminata)

Bowel Movement Abnormalities
• Diarrhea • Acholic stools
• Constipation • Amebiasis
• Melena • Ascariasis
• Hematochezia • Cholera
Hemorrhoids
• Important in fecal
continence
• Problems arise when

swollen
Hemorrhoids
• Common in pregnancy,
due to:
– Pressure of gravid uterus

on IVC and inferior
mesenteric vein (impairs
venous return)
Hemorrhoids
• Common in pregnancy,
due to:
– Increased progesterone
relaxes smooth muscles
of veins → venous
dilatation
Hemorrhoids (Internal)
• Swollen tributaries of
superior rectal vein
• Painless
Hemorrhoids (External)
• Swollen tributaries of
inferior rectal vein
• painful
Skin Tags
• Small, soft, skin-colored
growths
• Hang on skin (much like

warts)
• harmless
Anal Fissures
• Tears in the lining of the
lower rectum (anal
canal)
• Painful during bowel

movements
• Prone to infection
Anal Warts
• Caused by human
papilloma virus (HPV)
types 6 and 8 (90%)
• Rarely cancerous
• Condyloma acuminata
(another name for
anogenital warts)
Diarrhea
• Reversal of net
absorptive status of
water and electrolytes
into secretion
• Passage of loose stool
• Usually abrupt and at

least three (3) episodes
per day
Constipation
• Symptom (not a disease)
• Characterized by:
– Painful straining
(tenesmus)
– Lumpy or hard stools
– Fewer than three (3) bowel

movements per week
Steatorrhea
• the excretion of
abnormal quantities
of fat with the feces
owing to reduced
absorption of fat by
the intestine.
Melena
• Black, tarry stool
• Usually caused by
internal bleeding-
(upper GI ulcers)
• Requires at least 50-60

mL of blood to turn
stools black
Hematochezia
• Passage of fresh blood
through the anus
(usually accompanied
by stools)
• Suggest lower GI bleed

Acholic Stools
• Due to a problem in the
biliary system
• Lack of bile salts which

should give stools its
characteristically
brownish color
Amebiasis
• Caused by Entamoeba
histolytica
• Stomach pain, loose

feces, and cramping
(amebic dysentery)
• Common in tropical areas

with poor sanitary
conditions (and
congested living spaces)
Amebiasis
• May form a liver
abscess
• Can spread to other

parts of the body (lungs
and brain)
Helminthiasis (Ascariasis)
• Caused by giant
intestinal roundworm
(Ascaris lumbricoides)
• Usually found in
children or adults in
long-term care facilities
– Sign of neglect
Cholera
• Acute intestinal infection
causing profuse watery
diarrhea, vomiting,
circulatory collapse, and
shock
• Cause of death is usually

hypovolemia/dehydration
• Caused by Vibrio cholerae

THE PROCEDURE
The Procedure
1. Explain procedure to client.
2. Wash hands, use gloves, and observe

infection control.
3. Provide privacy.
The Procedure
4. Get patient’s history:
– Bright blood in the stools, tarry black stools,

diarrhea, constipation, abdominal pain, excessive
gas, hemorrhoids, rectal pain, family history of
colorectal cancer, stool examination for occult
blood, signs and symptoms of prostate
enlargement (males)
The Procedure
5. Position the client.
– Adults: left lateral or Sim’s position with the upper

leg accurately flexed is required for the examination.
– Female: dorsal recumbent position with hips

externally located and knees flexed, or lithotomy
position may be used.
– Male: modified standing position while client bends

over examination table may be used.
The Procedure
6. Inspect anus and surrounding tissue for color,
integrity, and skin lesions.
– Ask client to bear down as though defecating.
– Describe location of all abdominal findings in

terms of a clock position toward the symphysis
pubis
The Procedure
7. Palpate rectum for anal sphincter tonicity,
nodules, masses, and tenderness.
8. On withdrawing finger from rectum and

anus, observe for feces
The Procedure
• Normal: • Abnormal:
– brown color – presence of mucus,

blood, or black tarry
stool
Remember.
The
Digital
Rectal
Exam
The Digital Rectal Exam (DRE)
• Normal:
• Intact perianal skin;

slightly more
pigmented than the
skin of the buttocks
• Anal skin is normally

more pigmented,
coarser, and moister
than the perianal
skin and is usually
hairless
The Digital Rectal Exam (DRE)
• Abnormal:
• Presence of
fissures, ulcers,
excoriations,
inflammations,
abscesses,
protruding
hemorrhoids ,
lumps, tumors,
fistula openings or
rectal prolapse
DRE
THANK YOU.
College of Nursing
The Perineum
ANATOMY OF THE PERINEUM
The Perineum
• Lies below the pelvic
diaphragm
• Diamond-shaped
The Perineum
• Borders:
– Anterior - Symphysis pubis
– Lateral - Ischial tuberosities
– Posterior/Inferior - Tip of coccyx
The Perineum
• Divided into two (2)
triangles (by joining the
ischial tuberosities with
an imaginary line):
– Urogenital (Urinary and

Genitalia)
– Anal
Urogenital and Anal Triangles
Male Female
Urogenital Triangle
• Contains urogenital
diaphragm:
– Musculofascial
diaphragm that fills gap
of pubic arch
– Composed of sphincter
urethrae and deep
transverse perineal
muscles
Urogenital Triangle
• Perineal body:
– Small mass of fibrous
tissue attached to center
of posterior margin of
urogenital diaphragm
– Larger in females (than
males)
– Supports posterior
vaginal wall (females)
– Provides attachment for
muscles in the perineum
(both sexes)
Urogenital Triangle
• Contains:
– Male and female
genitalia
Anal Triangle
• Anal canal:
– Approximately 4 cm in
length
– Lies below pelvic

diaphragm
– Passes down and back

from rectal ampulla to
open into surface at the
anus
Anal Triangle
• Anal canal:
– Lateral walls kept in

apposition by levatores
ani muscles and anal
sphincters (except
during defecation)
Male
Genitalia
• Penis
• Scrotum
• Testis
• Epididymis
Male Genitalia
• Penis
– Has free-hanging
cylindrical body and
fixed root
– Expanded distal end is

called glans penis
(covered by prepuce/
foreskin)
Male Genitalia
• Penis
– Encloses the penile urethra (other
parts are prostatic and membranous)
– Distal penile urethra has dilated end
known as fossa terminalis (navicular
fossa)
Male Genitalia
• Scrotum
– Outpouching of lower part

of the anterior abdominal
wall
– Contains:
• Testes
• Epididymis
• Spermatic cords (lower

ends)
Male Genitalia
• Testis
– Paired, ovoid organs
– Produces spermatozoa
and testosterone
– Has outer, fibrous

capsule (tunica
albuginea)
Male Genitalia
• Epididymis
– Lies posterior to each testis
– Has head, body, and tail
– Coiled tube approximately

20 feet in length (6 meters)
– Vas deferens emerges from

its tail
Male Genitalia
• Bulbourethral glands
(Cowper’s glands)
– Paired small glands deep

in perineal pouch within
fibers of sphincter
urethrae muscle
– Their ducts open into

penile urethra
• Semen and sperm are not the same things.
• Sperm is a microscopic cell that is a part of the semen. The job of the sperm is to
fertilize the egg inside a woman's body.
• To get there they are carried by fluids, which are produced by different male sex organs
– Mainly from: Seminal vesicles, prostate gland, and cowper’s glands
• Circumcision is the removal of the foreskin from the human
penis.
• In the most common procedure, the foreskin is opened,
Circumcision adhesions are removed, and the foreskin is separated from
the glans.
• After that, a circumcision device may be placed, and then the
foreskin is cut off
Erection
• A typical erection occurs when men become sexually
aroused. As a result of that arousal, hormones, muscles,
nerves, and blood vessels all work together to create
an erection. It begins when nerve signals in the brain
stimulate penis muscles to relax
Female Genitalia
Female Genitalia
• Collectively known as
the “vulva”
Female Genitalia
• Includes:
– Mons pubis (hair-bearing

skin in front of pubis)
– Labia (majora and minora)
– Clitoris
– Greater vestibular glands

(Bartholin’s Gland)
Female Genitalia
• Labia majora:
– Prominent folds of skin
– Extends from mons

pubis to unite
posteriorly at midline
– Contains fat, and hair

covers outer surfaces
Female Genitalia
• Labia minora:
– Smaller folds of skin
– Devoid of hair
– Lie between the labia

majora
Female Genitalia
• Labia minora:
– Posterior ends unite to

form a sharp fold
(fourchette)
– Splits to enclose the

clitoris (anteriorly)
Female Genitalia
• Vaginal vestibule:
– Space between labia

minora
– Apex (clitoris)
– Floor (openings of
urethra, vagina, and
ducts of greater
vestibular glands)
Female Genitalia
• Clitoris
– Glans is partially hidden

in prepuce
– Composed of three (3)

masses of erectile tissue
(vestibular bulb, right
and left crura of clitoris)
Female Genitalia
• Greater vestibular
glands:
– Pair of mucus-
secreting glands
– Covered by
posterior parts of
vestibular bulb
and labia majora
– Each duct opens

into groove
between hymen
and posterior part
of labia minora
Female Genitalia
• Skene’s glands
– As the Skene's glands
become stimulated,
they secrete mucus-
containing fluids,
which help with
lubrication during
vaginal intercourse.
– Researchers also
believe that fluid
excretions from these
glands may account
for female ejaculation
Female Genitalia
• Female urethra:
– 1.5 inches (3.8 cm) long
– Extends from bladder

neck to external meatus
– Opens onto surface

below clitoris and in
front of vagina
Hymen
• The hymen is a thin
piece of mucosal tissue
that surrounds or partially
covers the external
vaginal opening.
• It forms part of the vulva,
or external genitalia, and
is similar in structure to
the vagina.
• In children, a common
appearance of
the hymen is crescent-
shaped, although many
shapes are possible.
Types of hymen
Menstrual Cycle
Tampons
• A tampon is a menstrual
product designed to absorb
blood and vaginal
secretions by insertion into
the vagina during
menstruation.
• Unlike a pad, it is placed
internally, inside of the
vaginal canal.
• Once inserted correctly, a
tampon is held in place by
the vagina and expands as it
soaks up menstrual blood
THE PROCEDURE (FEMALE)
The Procedure (Female)
1. Explain procedure to the patient
2. Wash hands, apply gloves, and observe

infection control
3. Provide privacy
4. Obtain medical history:
– Amount of daily flow
– Painful menstruation (Dysmenorrhea)
– Pain during intercourse (Dyspareunia)
– Vaginal discharges
The Menstrual History
Menstrual History
• Menarche
• Dysmenorrhea
• Premenstrual syndrome
• Amenorrhea
• Abnormal uterine bleeding
• Menopause
• Postmenopausal bleeding
– Number of pregnancies (Gravida)
– Number of live births (Parity)
– Urgency and frequency of urination
– Blood in urine (Hematuria)

– Dysuria
– Incontinence
– Sexually transmitted infections/diseases (STI/STD)

5. Assemble equipment and supplies:
– Examination gloves
– Drape
– Supplemental lighting
6. Inspect distribution,
amount, and
characteristics of pubic
hair.
• Normal:
– Generally kinky in
menstruating adult
– Thinner and straighter
after menopause
– Inverse triangle
(distribution)
• Abnormal:
– Scant pubic hair
– Should not extend over the abdomen
Tanner Staging
7. Inspect pubic area for
parasites, inflammation,
swelling, and lesions.
• Normal:
– Pubic skin intact, no lesions
– Skin of vulva slightly darker
than rest of the body
– Labia round, full, and
relatively symmetric (adult
females)
• Abnormal:
– Lice, lesions, scars,

fissures, swelling
– Erythema, excoriations,
scars from episiotomies,
varicosities, or
leukoplakia (white or
grayish patches)
8. Inspect clitoris, urethral
orifice, and vaginal
orifice when separating
the labia minora
• Normal:
– Clitoris does not exceed 1
cm in width (and 2 cm in
length)
– Urethral orifice appears as
small slit (same color as
surrounding tissues)
• No inflammation, swelling,
or discharge
• Abnormal:
– Presence of lesions
– Presence of
inflammation, swelling,
or discharge
Genital warts Candidiasis
9. Palpate inguinal
lymph nodes
10.Document findings
in client’s record.
SPECIAL TESTS IN EXAMINATION OF
FEMALE INTERNAL GENITALIA
• Palpate skene’s and bartholin’s glands
• Assessing pelvic musculature
• Inserting vaginal speculum to inspect cervix

and vagina
• Obtaining papanicolaou smear

Palpating Skene’s and Bartholin’s Glands
Assessing Pelvic Musculature
• Rectal squeeze
(DRESS)
• Used to:
– prolapse, a
mass, or
weakened
pelvic floor
muscles
Vaginal Speculum Insertion
Papanicolaou Smear (Pap Smear)
• Nursing Responsibilities:
– Assemble equipment (drapes, gloves, vaginal

speculum, warm water or lubricant, supplies for
cytology, and culture studies)
– Prepare the client
– Support the client during procedure.
– Monitor and assisting client after procedure

THE PROCEDURE (MALE)
The Procedure (Male)
1. Explain procedure to the patient
2. Wash hands, apply gloves, and observe infection

control
3. Provide privacy
4. History: Voiding patterns/ changes, bladder control,

incontinence, frequency, urgency, abdominal pain,
STD, hernia, family history of nephritis, malignancy of
prostate and kidney
5. Assemble equipment
and supplies:
– Examination gloves
6. Inspect distribution,
amount, and
characteristics of pubic
hair
• Normal:
– Triangular distribution
– Spreads up to abdomen
(often)
• Abnormal:
– Scanty amount
– Absence of hair
7. Inspect urethral meatus
for swelling,
inflammation, and
discharge
– Compress or ask client to
compress glans slightly to
open urethral meatus (to
inspect for discharge)
– If client reports
discharge, instruct client
to strip penis from base
to urethra.
7. Inspect the urethral
meatus for swelling,
inflammation, and
discharge
• Normal:
– pink and slit-like

appearance, positioned at
tip of penis
– No discharges (yellowish,
greenish, or bloody)
• Abnormal:
– inflammation, discharge,
variation in meatal
locations
8. Inspect penile shaft
and glans penis for
lesions, nodules,
swellings, and
inflammation
• Inspect the skin
prepuce if
present
• retract the
prepuce or ask
the client to
retract it. This is
essential for
detection of
chancres and
carcinomas
• Normal:
– Penile skin intact, slightly

wrinkled, varies in color as
widely as other body skin
– Foreskin easily retractable

(from glans penis)
– Small amount of thick

white smegma between
glans and foreskin
• Abnormal:
– Presence of lesions,
nodules, swellings, or
inflammation
Abnormal Locations of Urethral Meatus
Epispadias Hypospadias
9. Palpate penis for tenderness, thickening, and
nodules. Use thumb and first two fingers
– Normal: smooth and semi-firm

slightly movable over underlying
structures
– Abn: (+) tenderness, thickening, nodules,

immobility
10. Inspect scrotum for Normal
appearance, generally – Scrotal skin is darker in
size, and symmetry color than that of the rest
of the body and is loose
– Size varies with
– To facilitate inspection of temperature changes
scrotum, ask patient to
hold penis out of the way – Scrotum appears
asymmetric
– Inspect all skin surfaces by
spreading rugated surface Abnormal
of the skin and lifting – Discolorations
scrotum as needed to
observe posterior surfaces. – Tightening of the skin
– Marked asymmetry in size
11. Palpate scrotum to
assess status of
underlying testes,
epididymis, and
spermatic cord.
– Palpate both testes
simultaneously for
comparative purposes
• Normal:
– testicles rubbery, smooth,

no nodules or masses,
– about 2x4 cm
– epididymis resilient,
normally tender, and
softer than spermatic cord,
spermatic cord is firm
• Abnormal:
– testicles enlarged, with

uneven surface
– epididymis non-
resilient and painful
• For any scrotal mass,
describe according to:
– Size, shape, placement,

consistency, tenderness
– Transillumination test
12. Inspect both inguinal areas for bulges while the
client is standing, if possible
– Normal: no swelling or bulges
– Abn: (+) swelling or bulges
13. Palpate hernias

– Normal: no palpable bulge
– Abn: (+) palpable bulge in the area
14. Document findings.

THANK YOU.
College of Nursing
The Musculoskeletal System
ANATOMY AND PHYSIOLOGY OF
THE MUSCLES AND BONES
The Skeletal System
• Axial
– Cranium
– Vertebrae
– Ribs
• Appendicular
– Limbs
– Shoulder
– Hips
The Skeletal System
• Spongy
– forms the interior
– contains red marrow
– can withstand forces in
many directions
• Compact
– outer shell of a bone
– can withstand forces
predominantly in one
direction
– OSTEON – functional
unit of a compact bone
BONE MARROW
• RED BONE MARROW
– produces RBC, WBC, and
platelets
• YELLOW BONE MARROW

– lipids
The Skeletal System
• LONG BONES
– often bears weight
• IRREGULAR BONES
– has unique shape
• FLAT BONES
– protect vital organs and often contain
blood forming cells
• SHORT BONES
– small and bear little or no weight
• SESAMOID
– a small round bone that is imbedded
within a tendon,
The Skeletal System
• Functions
– Support and body

movement
– Protection
– Hematopoiesis
– Storage
The Skeletal System
• Bone Cells
– Osteoprogenitor or
Osteogenic
(stem/parent cell)
– OsteoBLasts - “B”
for building
– Osteocytes –
mature bone cells
– OsteoCLasts - “C”for
crushing
Ligament and Tendon
Sprain = Ligament
Strain = Tendon
JOINTS / ARTICULATIONS
• JOINTS - junctions or spaces
between 2 or more bones and hold
bones together securely but give
the rigid skeleton mobility
• LIGAMENTS hold the bone and

joint in the correct position
• JOINT CAPSULES tough, fibrous

sheath surrounding the articulating
bone; Lined with synovial
membrane which secretes synovial
fluid into the joint capsule
• ARTICULAR CARTILAGE covers the

ends of the bones
Classification of Joints
Structural Functional
• Fibrous joints – generally • Synarthroses – immovable joints
immovable – e.g. sutures, syndesmoses,
gomphoses
– e.g. sutures, syndesmoses,
gomphoses
• Cartilaginous joints – • Amphiarthoses – slightly

immovable or slightly moveable joints
moveable – e.g. pubic symphysis and
intervertebral joints
– e.g. pubic symphysis and
intervertebral joints
• Diarthroses – freely moveable
joints
• Synovial joints – freely
moveable
Types of
Synovial
Joints
Joint Type of Joint
Neck Pivot
Trunk Plane/ Gliding
Shoulder Ball and socket
Elbow Hinge and pivot
Wrist Condyloid
Hand (and fingers) Hinge
Thumb Saddle
Hip Ball and socket
Knee Hinge
Ankle Hinge
Interphalangeal and
Foot (and toes) metatarsophalangeal (hinge)
intertarsal (plane/ gliding)
Types of Body Movements
Types of movements at synovial joints
The Muscles
• Muscular Tissue
– Specialized tissues that
have the ability to shorten
or contract
• Types:
– Cardiac
– Smooth
– Skeletal
Cardiac Muscle
• Branching chains of cells,
uninucleated
• With striations
• With intercalated discs
• Involuntary (has own

pacemaker; also controlled
via nervous system, and
hormones)
• Slow contractions
Smooth Muscle
• Single, fusiform,
uninucleated
• No striations
• Involuntary (via nervous

system, hormones,
chemicals, stretch)
• Very slow contractions

Skeletal Muscle
• Single, very long,
cylindrical,
multinucleated cells
• Obvious striations
• Voluntary (via nervous

system)
• Slow to fast contraction

Skeletal
Muscle
Naming of Skeletal Muscles:

• By location
• By shape
• By size
• By direction
• By origin
• By location to other structure
Properties of Muscles
• Contractility
• Excitability/Irritability
• Elasticity
• Extensibility
• Contractility
– Ability to forcefully shorten
TYPES of MUSCLE CONTRACTION
• Elasticity
– Ability to recoil or bounce back to original length
• Excitability/ Irritability
– Ability to respond to a stimulus (motor neuron or hormone)
• Extensibility
– Ability to be stretched
Functions of Muscles
• Movement
• Posture
• Joint Stability
• Heat Production
• Movement
– Skeletal muscles pull on rigid skeleton (results in different
body movements)
• Posture
– Maintenance of posture
(through constant
contractile force)
– Mostly unconscious
• Joint Stability
– Through resistance of
muscles surrounding the
joints
• Heat Production
– Contraction generates
heat (responsible for
maintenance of
homeostatic
temperature)
• Shiver (when core body

temperature falls)
Principles of Assessment
• Consider function as
well as structure
• Normal ADLs should be

evaluated
Principles of Assessment
• During initial survey,
assess for:
– General appearance
– Bodily proportions
– Ease of movement
History
• Subjective Data • Objective Data
– Do you have pain in joints or
muscles? Any stiffness? – Height (cm) and weight
Weakness? Twitching?
• Rheumatoid Arthritis (kg)
• Osteoarthritis
– Gait; assessing the
– Are you able to care for
yourself? Is your activity patients walking
limited by any physical alignment
factors? Use of cane or
walker? – Spinal curvature
• Checks any mobility issues
– Do you exercise? Participate
in sports? Are you over 50?
Do you take calcium
supplements?
• Screening of osteoporosis
ASSESSMENT OF THE MUSCULAR
SYSTEM
The Procedure
• Prepare equipment:
– Tape measure
– Goniometer
The Procedure
• Inspect muscle size
– Compare both sides
– If there are
discrepancies, measure
using tape
The Procedure
• Normal:
– Equal in size
• Abnormal:
– Atrophy
– Hypertrophy
The Procedure
The Procedure
• Inspect muscle tendons for contractures or shortening
Contracture symptoms include pain and loss of

movement in the joint.
The Procedure
• Normal:
– No contractures
• Abnormal:
– Contractures
– Malposition of body
parts
• Foot fixed in dorsiflexion
The Procedure
• Inspect for: (hand and
arms)
– fasciculations (abnormal
contractions of a bundle of
muscle fibers)
– tremors (involuntary
trembling of limb/body
part)
• Let client hold arms in

front of the body
The Procedure
• Normal:
– No fasciculations
– No tremors
• Abnormal:
– (+) fasciculations
– (+) tremors
The Procedure
Fasciculations (eye) Fasciculations (hand)
The Procedure
• Types of Tremors:
– Intention
– Resting
The Procedure
• Intention Tremor
– More apparent when

individual attempts
voluntary movement
• Resting Tremor:
– Occurs even when client is

at rest
– Diminishes with activity

The Procedure
• Palpate muscles at rest
to determine tonicity
• Normal:
– Normally firm
• Abnormal:
– Atonic (lacks muscle

tone)
The Procedure
• Palpate muscles while
client is active and
passive for:
– Flaccidity
(laxness/weakness)
– Spasticity (sudden
involuntary muscle
contraction)
– Smoothness of movement
The Procedure
• Normal:
– Smooth, coordinated
movements
• Abnormal:
– (+) flaccidity
– (+) spasticity
The Procedure
• Palpate muscle when
client is doing passive
range of motion
• Test muscle strength
• Compare right with left

side
The Procedure
• Normal:
– Equal strength on each

laterality
• Abnormal:
– Unequal strength (25%

of less of normal muscle
strength)
Muscle Strength Grading
Grade Description
Normal full strength; active ROM
5 against gravity and applied
resistance (100%)
Muscle able to move actively
against effect of gravity (up and
4
down movement); with weakness
applied to resistance (75%)
Able to move against the effect of
3
gravity (50%)
Able to move across a surface
2 (side to side movement); can’t
overcome gravity (25%)
Contraction palpable and visible
1
(10%)
No contraction/movement
0
(undetectable)
Abnormalites
Paraplegia
Ambulatory Assistive Devices
Gait training → Cane → Crutches → Walker → Wheelchair

ASSESSMENT OF THE SKELETAL
SYSTEM
The Procedure
• Inspect skeleton for
normal structures and
deformities
• Normal:
– No deformities noted
• Abnormal:
– Bones misaligned,
dislocation? Fracture?
• Check for
clubfoot or
Talipes
which
sometimes
are
acquired:
The Procedure
• Some areas may be
indicative of fractures,
neoplasms, or
osteoporosis
• Palpate along areas of

long bones for areas of:
– Tenderness
– Swelling
The Procedure
• Inspect joints for
swelling:
The Procedure
• Assess joint for range of
motion:
– Gliding (sliding)
– Hinge (flexion/extension)
– Ball and socket (all movements)
– Condyloid (circumduction)
– Saddle
– Pivot (rotation)
The Procedure
• Palpate each joint for:
– Tenderness
– Smoothness of movement
– Swelling
– Crepitation
– Presence of nodules
The Procedure
• Document findings in
the client’s record
THANK YOU.
College of Nursing
Neurologic Assessment
Nervous System
Functions of the nervous system
Sensory input Integration Motor output

Gathering of information To process and interpret A response to stimuli
To monitor and detect sensory input and decide Activates muscles or
changes occurring inside if action is needed glands
and outside of the body
Organization of the Nervous System
- received information will be interpreted and

- E.g. ADULT, HYPERTHERMIA (T 38.5 °C) an appropriate action will be initiated
- Thermoreceptors in the SKIN (SENSE - changes in temperature have the potential to
ORGAN), detects a change in body INTEGRATION cause damage to cells and tissues
temperature
- STIMULI, sensory information
SENSORY INPUT MOTOR OUTPUT
SMOOTH MUSCLE or a GLAND (EFFECTOR ORGAN/ SKELETAL MUSCLE

TISSUE), to do an INVOLUNTARY ACTION. Warm (EFFECTOR ORGAN/
blood directed to the skin, causes TISSUE), to do a
VASODILATATION. voluntary action, e.g.
Sweat glands produce perspiration and to open the windows
through EVAPORATION, aids to the and remove extra
reduction of body heat clothing.
MAINTAIN HOMEOSTASIS
Cranial Nerves
CN FUNCTION
I – ON SOME
II – SAY
OCCASION
III – OUR MARRY
IV – MONEY
TRUSTY
V – TRUCK BUT
VI – ACTS MY
VII – BROTHER
FUNNY
VIII – VERY SAYS
IX – GOOD BIG
X– BRAINS
VEHICLE
XI – ANY MATTER
XII - HOW MORE

Anatomic Placement of Cranial Nerves
Cranial Nerve Location
In front of
I, II brainstem
(supratentorial)
III, IV Midbrain
V, VI, VII, VIII Pons
IX, X, XI, XII Medulla

Spinal Cord Function
• The spinal cord functions
primarily in the
transmission of nerve
signals from the motor
cortex to the body, and
from the afferent fibers of
the sensory neurons to the
sensory cortex.
• It is also a center for

coordinating many reflexes
and contains reflex arcs
that can independently
control reflexes.
Peripheral
Nervous System
Spinal Cord
Neurologic level -
refers to the
lowest level at
which sensory and
motor functions
are normal.
NEUROLOGIC ASSESSMENT
Components
• Cerebral function
• Cranial nerves
• Motor system
• Sensory system
• Reflexes (DTRs, abnormal)

Cerebral Function
• Mental status:
– Level of consciousness
– Orientation to three (3)

spheres (TPP)
– Memory and general

intellectual ability
– Insight
– Judgment and abstraction

Mental Status
• Reveals client’s general
cerebral function
• Functions:
– Intellectual (cognitive)
– Emotional (affective)
– Language
Level of Consciousness
Glasgow Coma Scale (GCS)
Reflexive (non-purposeful response)
Decorticate
rigidity
Caused by interruption in the corticospinal pathways
Decerebrate
rigidity
Caused by dysfunction in the brainstem

Glasgow Coma Scale Practice Scenarios
• A patient fell while rock

climbing in Mt. Apo.
• When you apply a deep

sternal rub, he extends
his arms and legs, and
shows no other
response.
• Patient is pulseless and

apneic.
• A 73-year old man looks

at you when you speak
to him.
• When you ask him the

date, he says “dilawan.”
• You note left-sided

weakness when he grips
your fingers.
Orientation
“If the patient is alert or

awake enough to answer
questions, you can
assess mentation by
asking similar questions
in a conversational and
non-threatening tone to
determine orientation
to person, place, and
time.”
Abnormalities of Language Ability
• Aphasia
– Any defect in or loss of

power to:
• express oneself through

speech, writing, or signs,
• comprehend spoken or
written language
– Due to disease of injury of

the cerebral cortex
Sensory Aphasia
• Loss of ability to
comprehend written or
spoken words
• Types:
– Auditory (symbolic
content through sound)
– Visual (written content

or printed figures)
Motor Aphasia
• Loss of power to
express oneself by:
– Writing
– Making signs
– Speaking
Memory
• Types:
– Immediate (recall of info

presented seconds ago)
– Recent (recall of events

earlier in the day)
– Remote/long term
(recalled knowledge from
months or years ago)
Cranial Nerve Exam
CN NAME FUNCTION DESCRIPTION OF FUNCTION

I Olfactory Sensory ✓ Sense of smell
II Optic Sensory ✓ Vision
III Oculomotor Motor ✓ Eyeball movement
✓ Constriction of pupil
IV Trochlear Motor ✓ Eyeball movement (Superior Oblique)
V Trigeminal Both ✓ Sensation of the upper scalp, upper eyelid, nose, nasal
cavity, cornea, and lacrimal gland
✓ Sensation of the palate, upper teeth, cheek, top lip, lower
eyelid, and scalp
✓ Sensation of the tongue, lower teeth, chin, and temporal
scalp
✓ Chewing
VI Abducens Motor ✓ Lateral movement of eyeball (Lateral Rectus)
Cranial Nerve Exam
CN NAME FUNCTION DESCRIPTION OF FUNCTION
VII Facial Both ✓ Taste
✓ Facial expression, eye lid closing, salivation and
lacrimation
VIII Vestibulocochlear Sensory ✓ Sense of equilibrium (Balance)
(Acoustic)
✓ Sense of hearing
✓ Auditory nerve
IX Glossopharyngeal Both ✓ Swallowing
✓ Gag reflex
✓ Sense of taste
✓ Touch, pressure, and pain from pharynx and posterior
tongue
✓ Receptors to regulate blood pressure
X Vagus Both ✓ Swallowing
✓ Regulation of cardiac rate
✓ Digestion
✓ Sense of taste
XI Accessory Motor ✓ Movement of head and neck
(Spinal Accessory Nerve)
✓ Proprioception
XII Hypoglossal Motor ✓ Movement of tongue for speech and swallowing
MOTOR FUNCTION
Motor Function
• Evaluates
proprioception and
cerebellar function
Motor Function
• Proprioception:
– Sensory nerve terminals
– Give info on body’s

movements and position in
space
– Passes through posterior

column of the spinal cord
– Deficit in function of posterior

column leads to impaired
muscle and position sense
Functions of the Cerebellum
• Helps control posture
• Ensures smooth and

coordinated body
movements (with
cerebral cortex)
• Controls skeletal
muscles (to maintain
equilibrium)
CEREBELLAR FUNCTION TESTS
Walking Gait
• Normal:
– Upright posture
– Arms in opposition
– Walks unaided
– Maintains balance
Walking Gait
• Abnormal:
– Poor posture
– Unsteady, or rigid
– No arm movement
– No balance
Romberg’s Test
• Normal:
– May sway slightly but

able to maintain upright
posture or stance
– (-) Romberg
Romberg’s Test
• Abnormal:
– Can’t maintain foot stance
– Moves feet apart
– Can’t maintain balance

when eyes are shut
(sensory ataxia)
– Can’t maintain balance

with eyes open or closed
(cerebellar ataxia)
Cerebellar Ataxia
Standing on One Foot (Eyes Closed)
• Normal:
– Maintains stance for at

least 5 seconds
• Abnormal:
– Unable to maintain
stance for at least 5
seconds (<5 seconds)
Heel and Toe Walking
• Also known as tandem
walking
Finger to Nose Test
• Normal:
– Able to perform test

rapidly
• Abnormal:
– Misses the nose or lazy

response
Finger to Nose and to Nurse’s Index Finger Test
• Normal:
– Performs with
coordination and rapidly
• Abnormal:
– Misses finger and moves

slowly
Finger to Thumb Test
• Done on same hand
• Normal:
– Rapidly touches finger to

thumb with each hand
• Abnormal:
– Unable to perform with

either one or both hands
Alternating Supination and Pronation
of hands on knees
• Normal:
– Can alternately supinate and

pronate hands at rapid pace
• Abnormal:
– Performs with slow, clumsy

movements
– Irregular timing
– Has difficulty in alternating

positions
Heel to Shin Test
• Client may sit during this
test
• Normal:
– Bilateral, and equal

coordination
• Abnormal:
– Tremors
– Awkward movement
Ball or Toe to Nurse’s Finger Test
• Normal:
– Moves smoothly with
coordination
• Abnormal:
– Misses finger
– No coordination in
movement
Pronator Drift Test
• Normal:
– Able to maintain equal

vertical heights of both
hands
• Abnormal:
– One hand eventually

weakens and lowers down
(suggest weakness or
paralysis)
SENSORY FUNCTION
Sensory Function
• Includes:
– Touch
– Pain
– Temperature
– Position
– Tactile discrimination
Dermatomes - is an area of skin innervated by a single spinal
cord level
DERMATOMAL MAP
Sensory Function
• Abnormalities:
– Loss of sensation (anesthesia)
– More than normal sensation (hyperesthesia)
– Less than normal sensation (hypoesthesia)
– Abnormal sensations [burning pain, electric shock]

(paresthesia)
Tactile Discrimination
• Three (3) types:
– One and two-point discrimination
– Stereognosis
– Extinction
• One and Two-point
discrimination:
– Ability to sense whether

one or two areas of skin
are stimulated by
pressure
One and Two-Point Discrimination
• Normal:
– Able to distinguish from 1 and 2

points with the following minimum
distances (difference between 2
points):
• Fingertips (2.8 mm)

• Palms (8-12 mm)
• Chest/Forearm (40 mm)
• Back (50-70 mm)
• Upper arm/Thigh (75 mm)
• Toes (3-8 mm)
• Abnormal
– Not able to sense whether 1 or 2
point
• Stereognosis:
– Recognizing objects by
touching or
manipulating them
– Without use of vision

Stereognosis
• Normal:
– Able to recognize
specific objects
• Abnormal:
– Unable to recognize
specific objects
• Extinction:
– Failure to perceive touch

on one side of the body
• When 2 symmetrical
areas are touched
simultaneously
Extinction Phenomenon
• Normal:
– Both points of
stimulation are felt and
identified
• Abnormal:
– Fails to perceive touch

(may be due to lesions in
the cerebral cortex)
Light Touch Sensation
• Normal:
– Light tickling or touch

sensation
• Abnormal:
– Anesthesia
– Paresthesia
– Hypoesthesia
– Hyperesthesia
Pain Sensation Test
• Normal:
– Able to discriminate between

sharp and dull sensations
• Abnormal:
– Areas of reduced,
heightened, or absent
sensation
– Note areas for

documentation
Temperature Sensation
• Normal:
– Able to discriminate
between hot and cold
sensation
• Abnormal:
– Areas of dulled or lost
sensation
Position Sense
• Kinesthetic sensation
• Normal:
– Able to readily determine

position of fingers/toes
• Abnormal:
– Unable to determine
position of fingers/toes
The Reflexes
ANATOMY AND PHYSIOLOGY OF A
REFLEX
The Reflex Arc
• Basic unit of integrated
reflex activity
The Nervous Pathway (Reflex Arc)
2. Sensory neuron transmits
impulses
3. Intermediate from the organ to the spinal cord
neuron
1. Receptor
(sensory nerve)
in the skin
4. Synapse 5. Motor neuron
transmits impulses
from the Spinal cord to 6. Effector muscle
the muscles or glands
Monosynaptic Reflex
Polysynaptic Reflex
Bell-Magendie States that:
• Dorsal roots are sensory
Law • Ventral roots are motor
Charles Bell Francois Magendie

The Stretch Reflex
• When a skeletal muscle
with an intact nerve
supply is stretched, it
contracts.
• Typified by the knee

jerk reflex
The Withdrawal Reflex
• Typical response to a
painful stimulation of
the skin or
subcutaneous tissues
and muscles
• Prepotent (pre-empts
other reflex activities
taking place at the
moment)
– Similar to an override
– Increases chance of
survival (or getting away
from nociceptive stimuli)
• Characterized by:
– Contraction (flexor
muscles)
– Inhibition (extensor
muscles)
– Extension of opposite
limb (crossed extensor
response)
MEASURING REFLEXES (DEGREE OF
ACTIVITY)
Use of Reflex Hammer
• Encourage the patient to
relax, then position the
limbs properly and
symmetrically.
• Hold the reflex hammer
loosely between your
thumb and index finger so
that it swings freely in an
arc within the limits set
by your palm and other
fingers (Fig. 17-45).
Grading the Reflex
Meas
Description
ure
+5 Sustained contraction (Clonus)
+4 Maximum activity (hyperactive)
+3 More active than normal
+2 Normal response
+1 Minimal activity (hypoactive)
0 No reflex response (areflexia)

Abnormalities in Reflexes
• Hyperactive
– Suggests CNS disease
– Sustained clonus
confirms it
Abnormalities in Reflexes
• Diminished or Absent
– Relevant spinal segment

damage
– Peripheral nerve damage
– Muscle disease
– Neuromuscular junction
problems
The Deep Tendon Reflexes
• Principles:
– Use just enough force

needed to provoke a
definite response
– Differences between sides

are usually easier to assess
than symmetric changes
– Symmetrically diminished
or absence of reflexes may
be found in normal
individuals
• Use of reinforcement
may be needed if:
– Reflexes are diminished

(or absent)
– Isometric contractions of
other muscles may
increase reflex activity
• Example of
Reinforcement:
– Have patient gently

contract muscle being
tested by raising the
limb very slightly (up to
10 sec)
Reinforcement
• Testing Arms:
– Clench teeth
– Squeeze one thigh with

opposite hand
• Testing Legs:
– Lock fingers (pulling one

hand against the other)
THE REFLEXES (ADULT)
Reflex Main Spinal Roots Involved
Biceps C5, C6
Brachioradialis C5, C6
Triceps C7, C8
Abdominal T8 –T12
(above umbilicus [T8-T10],
below umbilicus [T10-
T12])
Patellar L2, L3, L4
Achilles Tendon
(Ankle) S1
Plantar response
L5, S1
Biceps Reflex
• C5, C6
• Arm should be partially flexed at the elbow with palm down
• Strike aimed directly through your digit toward the biceps tendon
Biceps Reflex
• Observe for flexion at
the elbow
• Watch and feel for the

contraction of biceps
muscle
Triceps Reflex
• C7, C8
• Flex arm at the elbow, with palm towards the body
• Pull it slightly across the chest
Triceps Reflex
• If with difficulty getting
patient relax, try
supporting the arm
• Triceps muscle,
extension at the elbow
Supinator (Brachioradialis) Reflex
• C5, C6
• Hand should rest on the

abdomen or the lap
• With the forearm partly

pronated
Supinator (Brachioradialis) Reflex
• Strike radius about 1 to
2 inches above the wrist
• Watch for flexion and

supination of the
forearm
Abdominal
• T8, T9, T10, T11, T12
• Elicit reflex by lightly

but briskly stroking
each side of the
abdomen above and
below the umbilicus
• Use key, wooden end of

cotton applicator,
tongue blade twisted
and split longitudinally
Abdominal
• Above the umbilicus (T8,
T9, T10)
• Below the umbilicus

(T10, T11, T12)
Abdominal
• Note contraction of the
abdominal muscle and
deviation of umbilicus
towards the stimulus
• Obesity may mask an

abdominal reflex
Knee (Patellar) Reflex
• L2, L3, L4
• Patient may be either sitting or lying down as long as the knee
is flexed.
• Briskly tap the patellar tendon
• A hand on the patient’s anterior thigh lets you feel
this reflex
• Note contraction of the
quadriceps with
extension at the knee
Ankle Reflex
• Primarily S1
• If patient is sitting,
dorsiflex the foot at the
ankle
• If the patient is lying

down, flex one leg at
both hip and knee and
rotate it externally so
that the lower leg rests
across the opposite shin.
Ankle Reflex
• Strike the Achilles tendon
• Watch and feel for plantar

flexion at the ankle
• Note speed of relaxation
• Slowed relaxation phase

of reflexes in
hypothyroidism is often
easily seen and felt in the
ankle reflex.
Plantar Response
• L5, S1
• Elicit reflex by stroking
the lateral aspect of the
sole
Plantar Response
• From heel to the ball of
the foot, curving
medially across the ball
• Use pointed object in

stroking
• Inverted “J” stroke

FURTHER TESTING
Further Testing
• If reflexes are hyperactive, test for ankle clonus
• Testing for clonus:
– Support knee in
partially flexed position
– Dorsiflex and
plantarflex foot
alternately a few times
(using your other hand)
– Then sharply dorsiflex

foot and maintain it
Clonus
• Look and feel for rhythmic
oscillations between
dorsiflexion and plantar
flexion.
• In most normal people, ankle

does not react to this stimulus.
– A few clonic beats may be seen

and felt, especially when the
patient is tense or has exercised.
• Sustained clonus indicate CNS

disease.
THE NEWBORN REFLEXES
The Newborn Reflexes
• Sucking reflex • Stepping (or Walking/
Dancing) reflex
• Rooting reflex
• Babinski reflex
• Moro (or Startle) reflex
• Blinking reflex
• Palmar Grasp reflex
• Neck Righting reflex
• Plantar reflex
• Landau reflex
• Tonic Neck (or Fencing)
reflex • Parachute reflex
Sucking Reflex
• A feeding reflex that
occurs when the
infant’s lips are
touched.
• Persists throughout
infancy.
Rooting Reflex
• A feeding reflex elicited
by touching the baby’s
cheek causing the
baby’s head to turn to
the side that was
touched.
• Disappears after 4
months.
Moro (Startle) Reflex
• Often assessed to
estimate the maturity
of the CNS.
• A loud noise, a sudden

change in position, an
abrupt jarring of the
crib elicits this reflex.
Moro (Startle) Reflex
• The infant reacts by
extending both arms
and legs outward with
the fingers spread, then
suddenly retracting the
limbs.
• Often the infant cries at

the same time.
• Disappears after 4 mos.

Palmar Grasp Reflex
• Occurs when a small
object is placed against
the palm of the hand,
causing the fingers to
curl around it.

Plantar Reflex
• Similar to the palmar
grasp reflex, an object
placed just beneath the
toes causes them to
curl around it.

Tonic Neck (Fencing) Reflex
• A postural reflex.
• When a baby who is lying

on its back turns its head
to the right side, for
example, the left side of
the body shows a flexing
of the left arm and the
left leg.

Stepping (Walking/Dancing) Reflex
• Hold the baby upright
so that the feet touch a
flat surface.
• The legs then move up

and down as if the baby
were walking.

Babinski Reflex
• Sole of the foot is
stroked, the big toe
rises and the other toes
fan out.
• (+) Babinski.
Babinski Reflex
• After age 1, the infant
exhibits a (-) Babinski,
– toes curl downward.
• (+) Babinski after age 1

indicates brain damage.
Blinking Reflex
• Occurs in the presence
of light or loud noise
Neck Righting Reflex
• Head turned to side
where body is rotated
Landau Reflex
• Suspend horizontally
against trunk and neck
flexed, leg will flex and
be drawn up to the
trunk.
Parachute Reflex
• Baby is held prone and
lowered quickly
towards a surface
• Arms and legs will

extend
Meningism
Definition: the triad of
• Nuchal rigidity (stiff neck): inability to flex the neck forward
• Headache
• Photophobia
Examination
• Kernig sign: In a supine patient, extension of the knee when the
thigh is flexed at the hip causes pain (knee at a 90° angle).
• Brudzinski sign: In a supine patient, passive flexion of the neck
provokes involuntary lifting of both legs.
• Etiology: due to inflammatory (bacterial/viral meningitis) or

noninflammatory (e.g., subarachnoid hemorrhage) causes
Kernig's Sign
Brudzinski sign
THANK YOU.

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College of Nursing

2nd Semester (S.Y. 2021-2022)

Self introduction & Explaining the Hand hygiene and

• Divided into three (3)

– Forms upper part of

– Articulates with body of

– 2nd costal cartilage

– Junction between the

– Articulates with 2nd

– Thin plate of cartilage

– Becomes ossified at its

• Also attached to the 7th

– Upper 7 ribs to lateral edge

– 8-10th ribs to cartilage

– Note: 11th-12th ribs end in

Accumulations of pleural fluid, or pleural effusions, may be transudates, seen in heart

Air pressure inside the lungs is LESS THAN

EXPIRATION - Air MOVES OUT of the lungs, when:

Air pressure inside the lungs is GREATER

During exercise and in certain diseases, extra work is required to breathe,

Normal When a healthy person lies supine, the

In the sitting position, movements of the

– Increase and decrease of

– Physiologic rate (16-20

• Increased transverse and

– Elastic recoil of lungs

– Scalenus anterior and

– Serratus anterior and

– Explain the procedure to the client.

– Wash your hands.

– History taking: family history (illnesses)

– Current health problems

– adult thorax is oval,

– wider than it is deep

– Have client stand from

– Have client bend forward

– For clients who have no respiratory complaints,

N: skin intact, uniform temperature

– For clients with respiratory complaints, palpate

N: chest wall intact, no masses, no tenderness

– Place palms of both hands over

– Ask client to take a deep breath

– Normal : full and symmetric

– Using one hand and moving it from one side of the

– Using two hands that are placed simultaneously on

 diaphragm is slightly elevated on the right side

b) Ask client to take slow,

c) Compare findings at each

9. Inspect breathing patterns (rate, depth,

12. Palpate anterior chest

– Place both palms of hands

– Ask client to take a deep breath while you observe

– If the breasts are large and

• Normal: Resonate until 6th rib at

– Abnormal: Adventitious breath sounds

– Normal: Bronchovesicular and vesicular

17. Document findings in the client’s record.

• Most commonly heard in the bases of the

• If low-pitched/gurgling, termed as ronchi

• High pitched grating/squeaking sound

• Due to rubbing of layers of the pleural wall

• Can be heard even w/o using a stethoscope