Prepared by:

Haydee Soriano Bacani RN RM MAN (c)

TOP 1 JULY 2021 PNLE
This is a form of obtaining objective data that
involves the use of one’s sense to obtain
information about the structure and function
of an area being observed or manipulated.
I-nspection
P-alpation
P-ercussion
A-uscultation
Inspection!
• Visual examination (sense of sight)
• with the naked eye and with a lighted instrument.
• Other senses may be considered but Vision is the
most valuable tool.
Focuses on:
• overall appearance of health and illness
• signs of distress
• facial expression and mood
• body size, grooming and personal hygiene
PALPATION
Palpation!

• Examination of the body using the

sense of touch.
• Fingertips – Texture and Consistency
• Dorsum – Temperature
• Palm – Vibration
2 Types of Palpation
2. Deep

1. Light
(superficial) Bimanual
dominant hand dominant hand as light One-hand
fingers palpation then finger finger pads of
pads of nondominant dominant hand press
presses gently
hand on the dorsal over the area to be
downward surfaces of the distal palpated then the
while moving interphalangeal joint other hand supports
the hand in a of the middle 3 the mass or organ
circular fingers of dominant from
hand.
fashion.
PERCUSSION
Percussion!

• The body surface is struck to elicit

sounds that can be heard or vibrations
that can be felt.
• Used to determine whether a structure is
air-filled, fluid-filled or solid.
2 Types of Percussion
Indirect middle finger
of nondominant hand
(pleximeter) is place on
Direct – strikes client’s skin. Using the
directly with the tip of flexed middle
pads of 2, 3 or 4 finger of other hand
fingers or with the (plexor), strike the
pad of middle finger. pleximeter at the distal
rapid and movement interphalangeal joint or
is from the wrist. between the joints.
PERCUSSION SOUND AND TONE
• Listening for sounds produced within the body.
• Stethoscope – amplifies the sound and conveys them
to the HCP’s ears.
• 4 Properties:
1. Frequency – measure of vibration which is heard as
pitch
2. Intensity – loudness of sound
3. Duration – length of sound
4. Quality – reflects musical characteristic
• Positioning
• Draping
 Assessment Normal Deviations
Body built, height, Proportionate Excessively thin or
and weight obese

Posture and gait Relaxed, erect Tense, slouched,

(standing, sitting posture, coordinated bent posture,
and walking) movement uncoordinated
movement, tremors
Overall hygiene Clean and neat Dirty, unkempt
and grooming
 Assessment Normal Deviations
Body and breath No body odor or Foul body odor,
odor minor relative to work ammonia odor,
and exercise, no acetone breath odor,
breath odor foul breath odor

Signs of distress in No distress noted Bending over

posture or facial because of
expression abdominal pain,
wincing, or labored
breathing
Signs of health or Healthy appearance Pallor, weakness,
illness obvious illness
 Assessment Normal Deviations
Level of Responds to Impaired, comatose
Consciousness stimuli

Orientation x3 x2, x1, not oriented

Attitude Cooperative Negative, hostile,
withdrawn
 Assessment Normal Deviation
Affect/ Mood Appropriate Inappropriate
Quantity of Understandable, Rapid or slow
speech, quality moderate pace, pace. Lacks
and organization thought association,
association exhibits
confabulation
Relevance and Logical sequence, Illogical
organization of makes sense, sense sequence, flight
thoughts of reality of ideas,
confusion
Level of Consciousness – awareness and
responsiveness to surrounding
environment
Glasgow Coma Scale - for high-risk
patients
Orientation –
X 1 – person (name)
X 2 – person and place (location)
X 3 – person, place and time
(time, day or date)
• Scalp
• Thickness or Thinness
• Texture and Oiliness
• Presence of Infections or
Infestations
• Body hair
Shape:
1. Normal
2. Barrel-shaped
3. Kyphosis
4. Scoliosis
5. kyphoscoliosis
• Normal - ________________
• Too fast - ________________
• Too slow - ________________
• Too shallow - ________________
• Too deep - ________________
• Irregular - ________________
Normal
• silent and effortless
Abnormal
• Nasal flaring
• Facial straining
• Pursed lip breathing
 eupnea – normal tachypnea – too fast
Bradypnea – too slow hypoventilation – too
shallow
hyperventilation – too deep
Cheyne- Stokes – irregular
Breathing Effort
normal – silent and effortless
Nasal flaring, facial straining and pursed lip
breathing indicate abnormal respiratory effort.
Chest Expansion – symmetric, indicating equal
- Inhale deeply,
exhale passively
• VESICULAR
• Soft-intensity, low-pitched
• BRONCHO – VESICULAR
• Moderate-intensity and moderate pitched
• BRONCHIAL
• High-pitched, loud
• CRACKLES (RALES)
• Fine, short, interrupted crackling sounds
• GURGLES (RHONCHI)
• Continuous, low-pitched, coarse, gurgling, harsh, louder sounds
with a moaning or snoring quality.
• FRICTION RUB
• Superficial grating or creaking sounds.
• WHEEZE
• Continuous, high-pitched, squeaky musical sounds.
• The thorax is rounded
• Tactile fremitus
• Infants tend to breathe
using their diaphragm
• Right bronchial branch
1.Appearance

2.Skin

3.Nipple
 Palpation of
Lymph Nodes
and Breast
Hands-of-the-clock
or
spokes-on-a-wheel
pattern
Cardiovascular
Assessment
ABDOMINAL
ASSESSMENT
• Inspection
• Auscultation
• Percussion
• Palpation
• Normal bowel sounds
are tinkling, gurgling
noises that occur
every 5 to 20
seconds.
• Borborygmi – bowel
sounds of increased
frequency and
loudness or
hyperactive bowel
sounds
NEUROLOGIC
SYSTEM
Female Genitalia
• Examine labia minora, labia majora, clitoris
and vaginal opening. The color should be
pink with some brown pigmentations.
• Normal vaginal secretions are white,
colorless and odorless.
• Foul-smelling, purulent drainage is
abnormal.
 Stages of Pubic Hair
Development for Female
• Stage 1. Preadolescence. No pubic hair except for
fine body hair.
• Stage 2. Usually occurs at ages 11 and 12. Sparse,
long, slightly pigmented curly hair develops along
the labia.
• Stage 3. Usually occurs at ages 12 and 13. Hair
becomes darker in color and curlier and develops
over the pubic symphysis.
• Stage 4 Usually occurs between ages 13 and 14.
Hair assumes the texture and curl of the adult but is
not as thick and does not appear on the thighs.
• Stage 5 Sexual maturity. Hair assumes adult
appearance and appears on the inner aspect of
the upper thighs
Male Genitalia
• A man may be circumcised or uncircumcised. If un
circumcised, gently retract foreskin during
examination and return to original position after
inspection.
• Smegma is a normal white discharge that may
collect around the glans especially in uncircumcised.
• Scrotal sac is wrinkled with left scrotal sac usually
hanging lower than the right.
Tanner Stages of
Male Pubic Hair
and External
Genital
Development
(12 to 16 Years)
Muscle Strength
Grading Scale:
0 – no detectable muscle contraction
1 – barely detectable contraction
2 – complete ROM with gravity eliminated
3 – complete ROM against gravity
4 – complete ROM against gravity and some
resistance
5 – complete ROM against gravity and full resistance
Presence of Tremors
Tremor - involuntary trembling of a limb or
body part
Intentional Tremor – more apparent when client
attempts a voluntary movement
Resting Tremor – more apparent when resting
Sensory Assessment
• Evaluate sensory perception by observing
client’s response to:
1. light touch – touch various body
areas with a wisp of cotton
2. vibration – with a tuning fork
3. pain – with a toothpick
*Note any inability to sense stimuli and affected
location of the body.
 Arterial Pulses
• Grading Scale for Pulses:
0 – absent
1 – diminished; thready; easily
obliterated
2 – normal
3 – increased; full volume
4 – bounding hyperkinetic
Deep Tendon Reflex
• Grading Reflect Response :
0 – no reflex
+ 1 – minimal activity
+ 2 – normal response
+ 3 – more activity than normal
+ 4 – hyperactive response
* Common reflexes being tested:
biceps, triceps, patellar and
achilles
Capillary Refill
• It is a simple test of circulatory status that uses
nailbeds. Press down on the nailbed until it
turns white then note how quickly the color
returns after you release the pressure.
• Normal refill time is 3 seconds or less; a
prolonged capillary refill time indicates poor
circulation.
1. Which is a normal finding on
auscultation of the lungs?
A.Tympany over the right upper lobe
B.Resonance over the left upper lobe
C.Hyperresonance over the left lower
lobe
D.Dullness above the left 10th
intercostal spac
2. You position the client sitting upright
during palpation of which area
A.Abdomen
B.Genitals
C.Breast
D.Head and neck
3. After auscultating the abdomen, You
should report which finding to the primary
care provider?
A.Bruit over the aorta
B. Absence of bowel sounds for 60 seconds
C.Continuous bowel sounds over the
ileocecal valve
D.A completely irregular pattern of bowel
sounds
4. If unable to locate the client’s popliteal
pulse during a routine examination, what
should the nurse perform next?
A.Check for a pedal pulse.
B. Check for a femoral pulse.
C.Take the client’s blood pressure on that
thigh.
D.Ask another nurse to try to locate the
pulse.
5. Which of the following is an expected
finding during assessment of the older
adult?
A.Facial hair becomes finer and softer
B. Decreased peripheral, color, and night
vision
C.Increased sensitivity to odors
D.Respiratory rate and rhythm are
irregular at rest
6. If the client reports loss of short-term memory, You
would assess this using which one of the following?
A. Have the client repeat a series of three numbers,
increasing to eight if possible.
B. Have the client describe his or her childhood illnesses.
C.Ask the client to describe how he or she arrived at
this location.
D.Ask the client to count backwards from 100
subtracting seven each time.