Assessment of the Breast

Definition: To obtain a comprehensive health assessment of the breast

Equipment:
If mass detected: Ruler, flashlight with transilluminator, Glass slide for cytologic fixative, Small
pillow or folded towel

Reference: Kozier’s Fundamentals of Nursing p. 568

Procedure Rationale

1. Prior to performing the procedure, To foster client participation and alleviate

introduce self and verify the client’s patient anxiety
identity using agency protocol. Explain
to the client what you are going to do,
why it is necessary, and how he or
she can participate.
2. Inquire whether the client has ever Gathering relevant past and present health
had a clinical breast exam previously. history records can give the nurse a baseline
Discuss how the results will be used data of the client.
in planning further care or treatments.

3. Perform hand hygiene Prevents the spread of pathogens.

4. Provide privacy Preserve the client’s dignity

5. Inquire if the client has any history of

the following:
a. Breast masses and what was
done about them
b. Pain or tenderness in the
breasts and relation to the
woman’s menstrual cycle
c. Discharge from the nipple; Some medications, like oral contraceptives,
medication history steroids, digitalis, and diuretics, may cause
d. Risk factors that may be nipple discharge, and estrogen replacement
associated with the therapy may be associated with the
development of breast cancer development of cysts or cancer
e. Inquire if the client performs
breast self-examination
f. Technique used and when
performed in relation to the
menstrual cycle

INSPECTION

6. Inspect the breasts for size, symmetry,

 and contour or shape while the client
is in a sitting position.
Normal findings:
● Females: rounded shape;
slightly unequal in size;
generally symmetric
● Males: breasts even with the
chest wall; if obese, may be
similar in shape to female
breasts
Abnormal findings:
● Recent change in breast size;
swellings; marked asymmetry
7. Inspect the skin of the breast for Dimpling or retraction and hyperpigmentation
localized discolorations or may be a result of scar tissue or an invasive
hyperpigmentation, retraction or tumor.
dimpling, localized hypervascular Localized hypervascular areas associated
areas, swelling or edema. with increased blood flow
Normal findings: Swelling (pig skin or orange peel) may be due
● Skin uniform in color (similar to to exaggeration of pores
skin of abdomen if not tanned)
Skin smooth and intact
● Striae, moles, and nevi may be
present
8. Emphasize any retraction by having
the client:
a. Raise the arms above the
head. Pushing the hands together to accentuate
b. Push the hands together, with retraction of breast tissue.
elbows flexed.
c. Press the hands down on the Pressing the hands down on the hips to
hips accentuate retraction of breast tissue
9. Inspect the areola area for size,
shape, symmetry, color, surface
characteristics, and any masses or
lesions.
Normal findings:
● Round or 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
(Montgomery’s tubercles)
Abnormal findings:
● Any asymmetry, mass, or
lesion
10. Inspect the nipples for size, shape,
position, color, discharge, and lesions
Normal findings:
 ● Round, everted, and equal in
size; similar in color; soft and
smooth; both nipples point in
same direction
● No discharge, except from
pregnant or breast-feeding
females
● Inversion of one or both
nipples that is present from
puberty

PALPATION

11. Palpate the axillary, subclavicular, and There are numerous lymph nodes located at
supraclavicular lymph nodes (have the lateral breasts: the lateral, central,
the client sit with arms abducted and intraclavicular, anterior, and posterior.
supported on the nurse’s forearm)
Normal findings:
● The edge of the greater
pectoral muscle (musculus
pectoralis major) along the
anterior axillary line
● The thoracic wall in the
midaxillary area
● The upper part of the humerus
● The anterior edge of the
latissimus dorsi muscle along
the posterior axillary line.
12. Palpate the breast for masses,
tenderness, and any discharge from
the nipples. Palpation of the breast is In the supine position, the breasts flatten
generally performed while the client is evenly against the chest wall, facilitating
supine. But for those patients with palpation
past breast diseases, both supine and
sitting positions are recommended.
a. If the client reports a breast To obtain baseline information of the normal
lump, start with the “normal” breast structure
breast
b. To enhance flattening of the
breast, instruct the client to
abduct the arm and place her
hand behind her head. Then
place a small pillow or rolled
towel under the client’s
shoulder.
c. For palpation, use the palmar
surface of the middle three
fingertips
d. Choose one of three patterns
for palpation:
 Hands-of-the-clock or spokes
on-a-wheel
Concentric circles
Vertical strips pattern.
13. Palpate the areolae and the nipples
for masses. Compress each nipple to
determine the presence of any
discharge.

14. If the client wishes, teach the

technique of breast self-examination

15. Document findings in the client record

using printed or electronic forms or
checklists supplemented by narrative
notes when appropriate.

16. Perform a detailed follow-up

examination of other systems based
on findings that deviated from
expected or normal for the client.
Relate findings to previous
assessment data if available.
 Thorax and Lungs Assessment

Definition: To get a comprehensive health assessment of the respiratory system.

Equipment:
● Stethoscope
● Ballpen/Marker
● Drape
● Ruler

Considerations:
1. Infants
- Infants tend to breath using their diaphragm; assess rate and rhythm by watching
the abdomen, rather than the thorax, rise and fall.
- The thorax is rounded, and the diameter from the front to the back is equal to the
transverse diameter until 6 years old.
- Children tend to breathe more abdominally than thoracically up to age 6.

2. Elders
- The thoracic curvature may present kyphosis because of osteoporosis and
changes in cartilage, resulting in collapse of the vertebrae.
- Anteroposterior diameter widens, 1:1 –barrel chest appearance
- Breathing rate and rhythm are unchanged at rest; the rate normally increases
with exercises but may take longer to return into pre exercise state
- Less powerful inspiratory muscles –decrease depth and volume of air.
- Expiration may require use of accessory muscles
- Deflation of the lung is incomplete

Procedure Rationale

1. Introduce yourself to the client.

2. Explain the procedure For easier client participation and to reduce

patient anxiety.

3. Provide privacy by closing the door Preserves the client’s dignity

and shutting off the curtains

4. Ask for the patient’s relevant medical Asking for the medical history can provide the
past and present history. nurse clues on what to assess further.

5. Put the patient in the appropriate Positioning the patient appropriately for the
assessment position. test helps the nurse locate the body’s anatomy
a. Sitting if posterior thorax and physiology.
b. Supine if anterior thorax
The patient’s arms should be folded across This position swings the scapulae laterally and
the chest with hands resting, if possible, on increases the access to the lung fields
the opposite shoulders.

6. Ask if the patient has someone with Ensure the rights of the patient throughout the
him to witness the procedure (Can procedure.
be another nurse if the patient is
alone).

7. Perform medical handwashing Reduce pathogens.

8. Drape the client Expose only the body part to be assessed.

INSPECTION (Anterior chest)

9. Inspect if the thorax is symmetrical.

Note the shape, color, and any
bumps. Could indicate the oxygen distribution to
a. Include the periphery tissues. Cyanosis in the lips, tongue, and oral
mucosa signals hypoxia. Pallor and sweating
Abnormal findings: are common signs of heart failure.
● Pectus Carinatum
● Pectus Excavatum
● Barren Chest
● Clubbing of fingers
● Cyanosis

10. Check/listen to the breathing rate May indicate audible sounds of wheezing and
and rhythm stridor.
Normal findings:
● Clear and easy (Eupnea)
● Regular breathing (14-20
cpm)
Abnormal Findings:
● Tachypnea
● Bachypnea
● Apnea
● Cheyne-stokes breathing
● Obstructive breathing
● Rapid deep breathing
● Ataxic (biot) breathing
Use of accessory muscle signals difficulty
11. Inspect the neck. breathing from COPD.
Lateral displacement of the trachea occurs in
pneumothorax, atelectasis, or pleural effusion.

PALPATION (Anterior chest)

12. Palpate for tenderness, or any

bumps.
 13. Ask the patient to fold his arms This movement shifts the scapulae out of the
across his chest. way.
14. Check for tactile fremitus (have the
client say 99 and feel for vibrations in Check for vibrations created by speech.
the intercostal muscles - 3 times both
sides).
Normal findings:
● Present and symmetrical on
both sides
Abnormal findings:
● More intense on one side
than the other indicate tissue
consolidationon that side.
● Less intense vibrations may
indicate emphysema,
pneumothorax, or pleural
effusion.
● Faint or no vibrations in the
upper posterior thorax may
indicate bronchial obstruction
or a fluid-filled space.

PERCUSSION (Anterior chest)

15. Place your hand lightly against the
surface to be examined.
16. Hyperextend the middle finger and
apply firm pressure.
17. Strike the middle
finger with one or
two fingertips of
the other hand. When percussing down the chest on the left,
18. Percuss for liver the resonance of the normal lung usually
dullness and changes to the tympany of the gastric air
gastric tympany. bubble.
Abnormal Findings:
● Dullness represents airway Pleural fluid usually sinks to the lowest part of
obstruction from the the pleural space.
inflammation or secretions.
● Dullness–Consolidation or
collapse
● Stony dullness –Pleural
effusion
● Hyperresonance - COPD or
Pneumothorax

AUSCULTATION (Anterior chest)

 19. Warm the stethoscope
with the hand For women or those with high adipose
20. Auscultate the trachea. deposits, you can ask the patient to lift their
21. Start above the clavicle breasts.
where lung field starts.
Normal findings:
● Bronchial and tubular breath
sounds
● Very loud and relatively high
pitched sound
● No adventitious sounds

INSPECTION (Posterior chest)

22. Inspect if the thorax is symmetrical.

Note the shape, color, and any
bumps.
23. Compare the anteroposterior
diameter to the transverse diameter.
Normal findings:
● 1:2 ratio (Barrel chest if 1:1)
24. Inspect the spinal alignment for
deformities. Have the client stand.
(From a lateral position, observe the
three normal curvatures of the
cervical, thoracic and lumbar.)
Abnormal findings:
● Kyphosis
● Scoliosis (have the patient
bend and look from the side)
● Lordosis
Normal findings:
● Spinal column is straight,
right, and left shoulders and
hips are at the same height.

Palpation (Posterior chest)

25. For clients who have no respiratory Skip the part with skin lesions to prevent
complaints, rapidly assess the inflicting pain, which can affect the breathing
temperature and integrity of all chest rate. Avoid deep palpation for painful areas,
skin. especially if a fractured rib is suspected.
26. Check for tactile fremitus (have the
client say 99. Apex to the base of the
lungs)
a. Place the palmar surfaces of
your fingertips or the ulnar
aspect of your hand or closed
fist on the posterior chest,
starting near the apex of the
 lungs.
b. Compare the fremitus on both
lungs and between the apex
and the base of each lung.
27. Check for symmetrical lung
expansion (respiratory excursion)
a. Place the palms of both your
hands over the lower thorax
with your thumbs adjacent to
the spine and your fingers
stretched laterally.
b. Ask the client to take a deep
breath while you observe the
movement of your hands and
any lag in movement.
c. Watch the distance between
your thumbs as they move
apart during inspiration, and
feel for the range and
symmetry of the rib cage as it
expands and contracts.
Normal findings:
● The thumb should move 3-5
cm laterally and
symmetrically.

PERCUSSION (Posterior chest)

28. Stand to the side rather than directly This position is easier to place the finger more
at the back of the patient. firmly on the chest, making the strike more
effective by creating a better percussion note.

29. Always compare the both sides at a Percussion sets the chest wall and underlying
symmetrical distance. tissues in motion, producing audible sound
Normal findings: and palpable vibrations. Percussion helps
● Symmetrical establish whether the underlying tissues are
● Resonant air-filled, fluid-filled, or consolidated.

Percussion cannot detect deep lung lesions as

it can only penetrate 5-7 cm below.

30. Percuss one side of Omit the areas over scapulae. The thickness
the chest and then of muscle and bone alters the percussion
other at each level in notes over the lungs.
a ladder like pattern.

31. Measure the diaphragmatic

excursion
a. First, determine the level of
 diaphragmatic dullness during
quiet respiration.
b. Ask the client to take a deep Deep breathing fills the lungs with air, allowing
breath and hold it while you the diaphragm to contract.
percuss downward along the
scapular line until dullness is
produced at the level of the
diaphragm.
c. Mark the point with a marking
pencil, and repeat the
procedure on the other side
of the chest. Deep exhaling can allow the diaphragm to
d. Ask the client to take a few relax.
normal breaths and then
expel the last breath
completely and hold it while
you percuss upward from the
marked point to assess and
mark the diaphragmatic
excursion during deep
expiration on each side.
e. Measure the distance
between two marks.
Normal findings:
● Diaphragm is higher on the
right side
● 3 - 5.5 cm on full inspiration

AUSCULTATION (Posterior)

32. Before beginning auscultation, ask Air movement through a partially obstructed
the patient to cough once or twice to nose or nasopharynx can also introduce
clear mild atelectasis or airway abnormal sounds.
mucus that can produce unimportant
extra sounds.
33. Listen to the breath sounds with the Different inspiratory sounds may be heard
diaphragm of the stethoscope after upon inspiration (e.g. whooping sound of B.
instructing the patient to breathe pertussis)
deeply through an open mouth.
a. Always place the stethoscope Clothing alters the characteristics of the breath
directly on the skin sounds and can introduce friction and added
b. Use the ladder pattern sounds.
suggested for percussion,
moving from one side to the
other and comparing
symmetric areas of the lungs.
c. Listen to at least one full
breath in each location.
d. If you hear or suspect
abnormal sounds, auscultate
 adjacent areas to assess the
extent of any abnormality.
Normal findings:
● Vesicular
● Broncho-vesicular
● Bronchial
Abnormal Findings
● Crackles
● Gurgles
● Friction rub
● Wheeze
● Stridor

34. Perform medical handwashing.

35. Summarize and document the results

36. Inform the client of the findings (base

on patient’s preference).
 Cardiovascular Assessment

Definition: To obtain a comprehensive health assessment of the cardiovascular system

Equipments
● Ruler
● Stethoscope

Procedure Rationale

1. Prior to performing the procedure,

introduce yourself and verify the
client’s identity using agency protocol.
2. Explain to the client what you are
going to do, why it is necessary, and
how he or she can participate.
3. Discuss how the results will be used
to plan further care or treatments.

4. Eliminate all sources of room noise Heart sounds are of low intensity, and other
noise hinders the nurse’s ability to hear them

5. Heart examination is usually

performed while the client is
semireclined. The practitioner usually
stands at the client’s right side and
auscultates and palpates with the right
hand, but this may be reversed if the
nurse is left-handed.

6. Perform hand hygiene and observe

other appropriate infection prevention
procedures.

7. Provide for client privacy

8. Ask if the patient has someone with
him to witness the assessment.

9. Inquire if the client has any of the Obtaining significant past and present
following: family history of incidence medical history will give the nurse baseline
and age of heart disease, high data on the client’s health.
cholesterol levels, high blood
pressure, stroke, obesity, congenital
heart disease, present symptoms
indicative of heart disease and
lifestyle that could cause heart
disease.
INSPECTION

10. Have patient supine, and keep light

source tangential.

11. Simultaneously inspect and palpate

the precordium for the presence of
abnormal pulsations, lifts, or heaves.
Locate the valve areas of the heart
a. Locate the angle of Louis. It is
felt as a prominence on the
sternum.
b. Move your fingertips down The client’s right second intercostal space is
each side of the angle until the aortic area, and the left second intercostal
you can feel the second space is the pulmonic area
intercostal spaces
c. From the pulmonic area, move The left fifth intercostal space close to the
your fingertips down three left sternum is the tricuspid or right ventricular
intercostal spaces along the area.
side of the sternum.
d. From the tricuspid area, move This is the apical or mitral area, or point of
your fingertips laterally 5 to 7 maximal impulse (PMI)
cm (2 to 3 in.) to the left
midclavicular line. If you have
difficulty locating the PMI, have
the client roll onto the left side
to move the apex closer to the
chest wall.
12. Inspect and palpate the epigastric
area at the base of the sternum for
abdominal aortic pulsations.

PERCUSSION

13. Begin by tapping at anterior axillary

line, moving medially along intercostal
spaces toward sternal borders until
tone changes from resonance to
dullness. Mark skin with marking pen.

AUSCULTATION

14. Auscultate the heart in all four

anatomic sites: aortic, pulmonic,
tricuspid, and apical (mitral).
Auscultation need not be limited to
these areas; however, the nurse may
need to move the stethoscope to find
the most audible sounds for each
client
 a. Eliminate sources of room
noise
b. Keep the client in a supine Certain sounds are more audible in certain
position with head elevated positions.
15° to 45°
c. Warm the stethoscope
d. Use both the diaphragm and Cold stethoscope may shock the patient
the bell to listen to all areas,
from base-apex or apex-base
e. In every area of auscultation,
distinguish both S1 and S2
sounds
f. When auscultating, To help determine if there are abnormal heart
concentrate on one particular sounds between the S1 and S2
sound at a time in each area:
the first heart sound, followed
by systole, then the second
heart sound, then diastole.
Systole and diastole are
normally silent interval
15. Assess rate and rhythm
Normal Finding:
a. 60-90 bpm
16. Assess the S1 S1 is the heartbeat in sync with the
a. Ask patient to breathe carotid pulse
comfortably, then hold breath
in expiration
b. Listen for S1 while palpating
for the carotid pulse
17. Assess the S2
a. Ask the patient to breath S2 becomes two components during
comfortably while listening to inspiration called S2 splitting. May be
the S2 (best heart in aortic or undetected or easily heard
pulmonic areas) to become
two components during
inspiration

18. Check for S3 (Ken-tuc-ky) and S4 S3 sound is indicative of a supple ventricle

(Tenn-es-see). S3 is normal for that can undergo normal rapid expansion in
infants. early diastole in infants and often a sign of
disease in adults.
 Assessment of the Central Vessels (cont of cardiovascular assessment0

Procedure Rationale

19. Palpate carotid arteries with extreme This ensures adequate blood flow through the
caution. other artery to the brain.
a. Palpate only one carotid artery Pressure can occlude the artery, and carotid
at a time sinus massage can precipitate bradycardia
b. Avoid exerting too much (The carotid sinus is a small
pressure or massaging the dilation at the beginning of the internal
area carotid artery just above the bifurcation
c. Ask the client to turn the head of the common carotid artery, in the
slightly toward the side being upper third of the neck.)
examined. This makes the
carotid artery more accessible.
20. Auscultate the carotid artery
a. Turn the client’s head slightly This facilitates placement of the stethoscope.
away from the side being
examined
b. Auscultate the carotid artery
on one side and then the
other.
c. Listen for the presence of a
bruit. If you hear a bruit, gently
palpate the artery to determine
the presence of a thrill.

21. Inspect the jugular veins for distention

while the client is placed in the
semiFowler’s position (15° to 45°
angle), with the head supported on a
small pillow.
a. Locate the highest visible point The external jugular vein is more easily
of distention of the internal affected by obstruction or kinking at the base
jugular vein. Although either of the neck
the internal or the external
jugular vein can be used, the
internal jugular vein is more
reliable
b. Measure the vertical height of
this point in centimeters from
the sternal angle, the point at
which the clavicles meet.
c. Repeat the preceding steps on
the other side.
Normal Finding:
● Veins not visible (indicating
right side of heart is
functioning normally)
 22. Document findings in the client record
using printed or electronic forms or
checklists supplemented by narrative
notes when appropriate.

Peripheral Vasculature Assessment

Definition: To obtain a comprehensive health assessment of the peripheral vascular system.

Equipment:
● Tangential light source
● Stethoscope with bell and diaphragm
● Sphygmomanometer
● Centimeter ruler

Procedure Rationale

1. Prior to performing the procedure, To establish rapport

introduce self and verify the client’s
identity using agency protocol.
2. Explain to the client what you are Encourage client participation and reduce
going to do, why it is necessary, and patient anxiety
how he or she can participate.
3. Discuss how the results will be used
in planning further care or treatments

4. Perform hand hygiene and observe Reduce transmission of pathogens

other appropriate infection prevention
procedures.

5. Provide for client privacy Preserve patient’s dignity

6. Inquire if the client has any of the Gathering relevant past and present health
following: past history of heart history records can give the nurse baseline
disorders, varicosities, arterial data of the client.
disease, and hypertension; lifestyle
habits such as exercise patterns,
activity patterns and tolerance,
smoking, and use of alcohol.

INSPECTION

1. Inspect the peripheral veins in the

arms and legs for the presence and/or
appearance of superficial veins when
limbs are dependent and when limbs
are elevated
 Normal Finding:
● In dependent position,
presence of distention and
nodular bulges at calves When
limbs elevated, veins collapse
(veins may appear tortuous or
distended in older people)
2. Assess for venous obstruction and
insufficiency
a. Inspect extremities, with
patient both standing and
supine.
3. Assess the peripheral leg veins for
signs of phlebitis
a. Inspect the calves for redness
and swelling over vein sites.
b. Assess for venous obstruction
and insufficiency
4. Inspect the skin of the hands and feet
for color, temperature, edema, and
skin changes.
5. Assess the adequacy of arterial flow if
arterial insufficiency is suspected, as
manifested by cyanosis.
6. Inspect the fingernails for changes
indicative of circulatory impairment

PALPATION

7. Palpate carotid, brachial, radial,

femoral, popliteal, dorsalis pedis, and
posterior tibial arteries, using distal
pads of second and third fingers,
a. Compare characteristics
bilaterally, as well as between
upper and lower extremities
Normal Finding:
● Femoral pulse as strong as or
stronger than radial pulse.
● Normal rate (60-100 bpm0
● Normal rhythm
● Normal contour - Smooth,
rounded, or dome shaped.
● Normal Amplitude (rate 0-4; 2
being normal0
8. Check the capillary refill time
a. Press at least one nail on each
hand and foot between your
thumb and index finger
 sufficiently to cause blanching
b. Release the pressure, and
observe how quickly normal
color returns
Normal Finding:
● Less than two seconds Detect blood flow at the peripheries
9. Assess the peripheral leg veins for
signs of phlebitis
a. Palpate the calves for firmness
or tension of the muscles, the
presence of edema over the
dorsum of the foot, and areas
of localized warmth.
b. Push the calves from side to
side to test for tenderness.
c. Firmly dorsiflex the client’s foot Homan’s test is used to detect Deep Vein
while supporting the entire leg Thrombosis (DVT) when the patient feels
in extension (Homans’ test), or pain in the calf upon dorsiflexion
have the person stand or walk.
10. Measure blood pressure

AUSCULTATE

11. Auscultate temporal, carotid, and Bell is effective to detect low-frequency

subclavian arteries; abdominal aorta; sounds like bruits.
and renal, iliac, and femoral arteries
for bruits using the bell of the
stethoscope

12. Do medical hadnwashing and

aftercare

13. Document findings in the client record

using printed or electronic forms or
checklists supplemented by narrative
notes when appropriate

14. Perform a detailed follow-up

examination of other systems based
on findings that deviated from
expected or normal for the client.
Relate findings to previous
assessment data if available.
 Assessment of the abdomen

Definition:

Equipments:
● Tape measure
● Skin-marking pen
● Stethoscope

Procedure Rationale

1. Prior to performing the procedure, Ensure client participation.

introduce self and verify the client’s
identity using agency protocol.
2. Ask if the patient has someone with
him/her to act as a witness during the Protect rights of the
procedure.

3. Ask the client to urinate An empty bladder makes the assessment

4. Ensure that the room is warm since more comfortable.
the client will be exposed

5. Perform hand hygiene and observe

other appropriate infection prevention
procedures

6. Provide for client privacy.

7. Inquire if the client has any history of Gathering relevant past and present health
the following: history records can give the nurse baseline
a. incidence of abdominal pain; data of the client.
its location, onset, sequence,
and chronology
b. Its quality (description)
c. Its frequency
d. Associated symptoms
incidence of constipation or
diarrhea

8. Place small pillows beneath the knees Reduce tension in the abdominal muscles.
and the head
9. Expose the client’s abdomen only Avoid chilling and shivering, which can tense
from the chest line to the pubic area the abdominal muscles.

INSPECTION

10. Inspect the abdomen for skin integrity

Normal Findings
 ● Unblemished skin
● Uniform color
● Silver-white striae (stretch
marks)
● surgical scars
Abnormal Findings
● Lesions
● Purple Striae Could indicate Cushing’s syndrome

11. Observe the abdominal contour while Standing at the side enhances shadow and
standing at the client’s side when the contouring
client is supine
a. Ask the client to take a deep This makes an enlarged liver or spleen more
breath and hold it obvious
b. Assess the symmetry of the
contour while standing at the
foot of the bed.
c. If distention is present,
measure the abdominal girth
by placing a tape around the
abdomen at the level of the
umbilicus.

12. Observe abdominal movements

associated with respiration,
peristalsis, or aortic pulsations.
Normal Findings
● Symmetric movements caused
by respiration
● Visible peristalsis in very lean
people
● Aortic pulsations in thin people
at epigastric area
13. No visible vascular pattern
Normal Findings
● No visible vascular pattern

Auscultation

14. Warm the hands and the stethoscope
diaphragm
15. Auscultate the abdomen for bowel
sounds, vascular sounds, and
peritoneal friction rubs. Use the
flat-disk diaphragm
Normal Findings
● Audible vowel sounds (5-35)
16. Ask when the client last ate
17. Place the diaphragm of the
stethoscope in each of the four
Cold hands and a cold stethoscope may
cause the client to contract the abdominal
muscles, and these contractions may be
heard during auscultation.
Shortly after or long after eating, bowel
sounds may normally increase. They are
loudest when a meal is long overdue
 quadrants of the abdomen.

18. Listen with

stethoscope bell in
epigastric region,
over aorta, and
over renal, iliac,
and femoral
arteries.
Normal Findings
● Absence of arterial bruits
● Absence of friction rubs

PERCUSSION

19. Percuss several areas in each of the

four quadrants to determine the
presence of tympany.
a. Begin in the lower right Begin at the right lower quadrant since it is
quadrant, proceed to the upper where the ileocecal valve is located. It allows
right quadrant, the upper left contents from the small intestine to move to
quadrant, and the lower left the large intestine.
quadrant
Normal Findings
● Tympany over the stomach
and gas-filled bowels
● Dullness, especially over the
liver and spleen, or a full
bladder
Abnormal Findings
● Large dull areas (associated
with the presence of fluid or a
tumor)
b. To determine lower liver
border, percuss upward at
right midclavicular line, and
mark with a pen where
tympany changes to dullness.
To determine upper liver
border, percuss downward at
right midclavicular line from an
area of resonance, and mark
change to dullness. Measure
the distance between marks to
estimate vertical span.
c. To percuss the spleen,
percuss just posterior to
midaxillary line on left,
beginning at areas of lung
resonance and moving in
 several directions. Percuss
lowest intercostal space in left
anterior axillary line before and
after patient takes deep
breath.
d. To percuss the abdomen,
percuss in area of left lower
anterior rib cage and left
epigastric region

PALPATION

20. Stand at patient’s right side.

a. Warm the hands Cold hands can elicit muscle tension and thus
b. Ensure patient position is impede palpatory evaluation.
appropriate for muscle
relaxation
c. Systematically palpate all Avoid problem spots that could elicit pain as it
quadrants, avoiding areas could cause abdominal tension.
previously identified as
problem spots.
d. Perform light palpation. With
palmar surface of fingers,
depress abdominal wall up to
1 cm with light, even circular
motion.
e. If the client is excessively Helps patients predict the movement of the
ticklish, begin by pressing your examiner's hand as it applies pressure to the
hand on top of the client’s skin
hand while pressing lightly.
Then slide your hand off the
client’s and onto the abdomen
to continue the examination
21. Palpate with moderate pressure.
Using same hand position as above,
palpate all quadrants again, this time
with moderate pressure.
22. Palpate deeply. With same hand
position as above, repeat palpation in
all quadrants, pressing deeply and
evenly into abdominal wall. Move
fingers back and forth over abdominal
contents.
a. Use bimanual technique -
exerting pressure with top
hand and concentrating on
sensation with bottom hand if
obesity or muscular resistance
makes deep palpation difficult
b. To help determine whether
 masses are superficial or
intraabdominal, have patient
lift head from examining table
to contract abdominal muscles
and obscure intraabdominal
masses.
23. Palpate umbilical ring and around
umbilicus. Note whether ring is
incomplete or soft in center.
Normal Findings
● Umbilical ring circular and free
of irregularities.
● Umbilicus either slightly
inverted or everted.
24. Palpate the liver
a. Place left hand under patient
at eleventh and twelfth ribs,
lifting to elevate liver toward
abdominal wall
b. Place right hand parallel to
right costal margin
c. Press right hand gently but
deeply in and up.
d. Ask patient to breathe
comfortably a few times and
then take a deep breath.
25. Palpate the gallbladder.
a. Palpate below liver margin at
lateral border of rectus
abdominis muscle.
26. Palpate the spleen
a. Reach across patient with left
hand, place it beneath patient
over left costovertebral angle,
and lift spleen anteriorly
toward abdominal wall.
b. Gently press fingertips inward
toward spleen while asking
patient to take a deep breath.
27. Palpate the kidney
a. Standing on patient’s right,
Tenderness. reach across with
left hand, and place over left
flank
b. Then place right hand at
patient’s left costal margin. Ask
patient to inhale deeply, while
you elevate left flank and
palpate deeply with right hand.
c. Repeat the same process on
 the other side
28. Palpate the aorta
a. Palpate deeply slightly to left
of midline, and feel for aortic
pulsation.
b. As an alternative technique,
place palmar surface of hands
with fingers extended on
midline
29. Palpate the bladder.
a. Palpate the area above the
pubic symphysis if the client’s
history indicates possible
urinary retention.

30. Do the Iliopsoas muscle test to check

for suspected appendicitis.
a. With patient supine, place
hand over right lower thigh.
Ask patient to raise leg, flexing
at hip, while you push
downward
31. Do the Obturator muscle test.
a. With patient supine, ask
patient to flex right leg at hip
and bend knee to 90 degrees.
Hold leg just above knee,
grasp ankle, and rotate leg
laterally and medially,
Abnormal Findings
● Pain in the hypogastric region

32. Do medical handwashing and

aftercare.

33. Document findings in the client record

using printed or electronic forms or
checklists supplemented by narrative
notes when appropriate.

34. Perform a detailed follow-up

examination of other systems based
on findings that deviated from
expected or normal for the client.
Relate findings to previous
assessment data if available.
 Assessment of the Nervous System

Definition:

Equipments:
● Percussion hammer
● Wisps of cotton to assess light-touch sensation
● Sterile safety pin for tactile discrimination

Reference: Koizer’s Fundamentals of Nursing p. 580

Procedure Rationale

1. Prior to performing the procedure, Ensure client participation.

introduce self and verify the client’s
identity using agency protocol. Explain
to the client what you are going to do,
why it is necessary, and how he or
she can participate
2. Discuss how the results will be used
in planning further care treatments

3. Perform hand hygiene and observe Reduces spread of pathogens

other appropriate infection prevention
procedures

4. Provide for client privacy Preserves client dignity

5. Inquire if the client has any history of

the following:
a. Pain in the head, back, or
extremities, and its onset and
aggravating and alleviating
factors
b. Disorientation to time, place,
or person
c. Speech disorder
d. Loss of consciousness,
fainting, convulsions, trauma,
tingling or numbness, limping,
paralysis, uncontrolled muscle
movements, loss of memory,
mood swings
e. Problems with smell, vision,
taste, touch, or hearing

Language
 6. If the client displays difficulty in
speaking:
a. Point to common objects, and
ask the client to name them
b. Ask the client to read some
words and to match the printed
and written words with pictures
c. Ask the client to respond to
simple verbal and written
commands (e.g., “point to your
toes” or “raise your left arm”)

Orientation

7. Determine the client’s orientation to

time, place, and person by tactful
questioning.
a. Ask the client the time of day,
date, day of the week, duration
of illness, city and state of
residence, and names of
family members
b. Ask the client why he or she is “Why” questions may elicit a more accurate
seeing a health care provider clinical picture of the client’s orientation status
than questions directed to time, place, and
person. To evaluate the response, nurse must
know the correct answer.

c. Direct questioning may be

necessary for some people
(e.g., “Where are you now?”
“What day is it today?”)

Memory

8. Listen for lapses in memory.

a. Ask the client about difficulty
with memory.

9. If memory problems are apparent,

three categories are tested:
10. Assess immediate Recall
a. Ask the client to repeat a
series of three digits (e.g.,
7-4-3), spoken slowly
b. Gradually increase the number
of digits until the client fails to
repeat the series correctly
(e.g., 7-4-3-5 -> 7-4-3-5-6 ->
7-4-3-5-6-1)
 c. Start again with a series of The average person can repeat a series of
three digits but ask the client five to eight digits in sequence and 4-6 in
to repeat them backward reverse order
11. Assess Recent Memory
a. Ask the client to recall the This information must be validated
recent events of the day (e.g.,
how the client got to the clinic)
b. Ask the client to recall
information given early in the
interview (e.g., doctor’s name)
c. Provide the client with three
facts to recall or a three-digit
number. Ask the client to
repeat all three. Later in the
interview, ask the client to
recall the three items
12. Assess Remote Memory
a. Ask the client to describe a
previous illness or surgery, or
a birthday or anniversary

Attention Span and Calculation

13. Test the ability to concentrate or

maintain attention span by asking the
client to recite the alphabet or to count
backward from 100.

14. Serial Sevens or Serial Threes:
a. Test the ability to calculate by
asking the client to subtract 7
or 3 progressively from 100
(i.e., 100, 93, 86, 79, or 100,
97, 94, 91),
Normally, an adult can complete the serial
sevens test in about 90 seconds with three or
fewer errors.
The test may be inappropriate for some
people because of educational level,
language, or cultural differences affecting
calculating ability

Level of Consciousness

15. Apply the Glasgow Coma Scale: eye An assessment totaling 15 points indicates
response, motor response, and verbal the client is alert and completely oriented. A
response. comatose client scores 7 or less.
Cranial Nerves

16. Olfactory
a. Ask client to close eyes and To assess the client’s sense of smell
identify different mild aromas,
such as coffee, vanilla, peanut
butter, orange/lemon,
chocolate.

17. Optic
a. Ask client to read Snellen-type To assess the client’s vision and visual fields
chart; check visual fields by
confrontation; and conduct an
ophthalmoscopic examination

18. Oculomotor
a. Assess six ocular movements To assess extraocular eye movement (EOM);
and pupil reaction movement of sphincter of pupil; movement of
ciliary muscles of lens

19. Trochlear
a. Assess six ocular movements To assess EOM; specifically, moves eyeball
downward and laterally

20. Trigeminal Ophthalmic Branch,

Maxillary, Mandibular Branch
a. While client looks upward,
lightly touch the lateral sclera
of the eye with sterile gauze to
elicit blink reflex. To test light
sensation, have client close
eyes, wipe a wisp of cotton
over client’s forehead and
To assess sensation of cornea, skin of face,
and nasal mucosa, sensation of skin of face
and anterior oral cavity (tongue and teeth),
and muscles of mastication; sensation of skin
of face
 paranasal sinuses. To test
deep sensation, use
alternating blunt and sharp
ends of a safety pin over same
areas.
b. Assess skin sensation as for
ophthalmic branch above.
c. Ask client to clench teeth

21. Abducens
a. Assess directions of gaze To assess EOM; moves eyeball laterally

22. Facial
a. Ask client to smile, raise the To assess facial expression; taste (anterior
eyebrows, frown, puff out two thirds of the tongue)
cheeks, close eyes tightly. Ask
client to identify various tastes
placed on tip and sides of
tongue: sugar (sweet), salt,
lemon juice (sour), and quinine
(bitter); identify areas of taste.

23. Auditory, Vestibular Branch, Cochlear

Branch
a. Assess client’s ability to hear To assess the equilibrium and hearing
spoken word and vibrations of
tuning fork.

24. Glossopharyngeal
a. Apply tastes on posterior To assess swallowing ability, tongue
tongue for identification. Ask movement, and taste
client to move tongue from
side to side and up and down.

25. Vagus
a. Assess client’s speech for To assess sensation of pharynx and larynx,
hoarseness. swallowing, and vocal cord movement

26. Accessory
a. Ask client to shrug shoulders To assess head movement and shrugging of
against resistance from your shoulders
hands and turn head to side
against resistance from your
hand (repeat for other side).

27. Hypoglossal
a. Ask client to protrude tongue To assess the protrusion of tongue, moves
at midline, then move it side to tongue up and down and side to side
side.

Reflexes
 28. Test reflexes using a percussion This is to evaluate the symmetry of response
hammer, comparing one side of the
body with the other.

29. Plantar (Babinski) Reflex

a. Use a moderately sharp
object, such as the handle of
the percussion hammer, a key,
or an applicator stick
b. Stroke the lateral border of the
sole of the client’s foot, starting
at the heel, continuing to the
ball of the foot, and then
proceeding across the ball of
the foot toward the big toe
c. Observe the response. Negative Babinski is when all five toes bend
downward. Positive Babinski response is
when the toes spread outward and the big toe
moves upward

Motor Function

30. Walking Gait

a. Ask the client to walk across
the room and back, and
assess the client’s gait.
Normal Findings:
● Has upright posture and
steady gait with opposing arm
swing; walks unaided,
maintaining balance
Deviations:
● Has poor posture and
unsteady, irregular, staggering
gait with wide stance; bends
legs only from hips; has rigid
or no arm movements

31. Romberg Test

a. Ask the client to stand with This prevents the client from falling
feet together and arms resting
at the sides, first with eyes
open, then closed. Stand close
during this test.
Normal Findings:
● May sway slightly but is able to
maintain upright posture and
foot stance
Deviations:
● cannot maintain foot stance;
 moves the feet apart to
maintain stance
● If client cannot maintain
balance with the eyes shut,
client may have sensory ataxia
(lack of coordination of the
voluntary muscles)
● If balance cannot be
maintained whether the eyes
are open or shut, client may
have cerebellar ataxia

32. Standing on One Foot with Eyes

Closed
a. Ask the client to close the eyes
and stand on one foot. Repeat
on the other foot. Stand close
to the client during this test.
Normal Findings:
● Maintains stance for at least 5
seconds
Deviations:
● Cannot maintain stance for 5
seconds

33. Heel-Toe Walking

a. Ask the client to walk a straight
line, placing the heel of one
foot directly in front of the toes
of the other foot
Normal Findings:
● Maintains heel-toe walking
along a straight line
Deviations:
● Assumes a wider foot gait to
stay upright

34. Toe or Heel Walking

a. Ask the client to walk several
steps on the toes and then on
the heels.
Normal Findings:
● Able to walk several steps on
toes or heels
Deviations:
● Cannot maintain balance on
toes and heels
 35. Finger-to-Nose Test
a. Ask the client to abduct and
extend the arms at shoulder
height and then rapidly touch
the nose alternately with one
index finger and then the
other. The client repeats the
test with the eyes closed if the
test is performed easily.
Normal Findings:
● Repeatedly and rhythmically
touches the nose
Deviations:
● Misses the nose or gives slow
response

36. Alternating Supination and Pronation

of Hands on Knees
a. Ask the client to pat both
knees with the palms of both
hands and then with the backs
of the hands alternately at an
ever-increasing rate.
Normal Findings:
● Can alternately supinate and
pronate hands at rapid pace
Deviations:
● Performs with slow, clumsy
movements and irregular
timing; has difficulty
alternating from supination to
pronation

37. Fingers-to-Nose and to the Nurse;s

FInger
a. Ask the client to touch the
nose and then your index
finger, held at a distance of
about 45 cm (18 in.), at a rapid
and increasing rate.
Normal Findings:
● Performs with coordination
and rapidity
Deviations:
● Misses the finger and moves
slowly

38. Fingers-to-fingers
a. Ask the client to spread the
arms broadly at shoulder
 height and then bring the
fingers to- gether at the
midline, first with the eyes
open and then closed, first
slowly and then rapidly.
Normal Findings:
● Performs with accuracy and
rapidity
Deviations:
● Moves slowly and is unable to
touch fingers consistently

39. Fingers-to-thumb (Same Hand)

a. Ask the client to touch each
finger of one hand to the
thumb of the same hand as
rapidly as possible.
Normal Findings:
● Rapidly touches each finger to
thumb with each hand

Deviations:
● Cannot coordinate this fine
discrete move- ment with
either one or both hands

40. Heel Down Opposite Shin

a. Ask the client to place the
heel of one foot just below
the opposite knee and run
the heel down the shin to the
foot. Repeat with the other
foot. The client may also use
a sitting position for this test.
Normal Findings:
● Demonstrates bilateral equal
coordination
Deviations:
● Has tremors or is awkward;
heel moves off shin

41. Toe or Ball of Foot to the Nurse’s

Finger
a. Ask the client to touch your
finger with the large toe of
each foot.
Normal Findings:
 ● Moves smoothly with
coordination
Deviations:
● Misses your finger; cannot
coordinate movement

42. Light-Touch Sensation

a. Compare the light-touch Sensitivity to touch varies among different
sensation of symmetric areas skin areas.
of the body.
b. Ask the client to close the
eyes and to respond by
saying “yes” or “now,”
whenever the client feels the
cotton wisp touching the skin
c. With a wisp of cotton, lightly
touch one specific spot and
then the same spot on the
other side of the body
d. Test areas on the forehead, The sensory nerve may be assumed to be
cheek, hand, lower arm, intact if sensation is felt at its most distal
abdomen, foot, and lower leg. part
Check a distal area of the
limb first.
e. If areas of sensory
dysfunction are found,
determine the boundaries of
the sensation by testing
responses about every 2.5
cm (1 in.) in the area. Make a
sketch of the sensory loss
area for recording purposes
Normal Findings:
● Light tickling or touch
sensation
Deviations:
● Anesthesia, hyperesthesia,
hypoesthesia, or paresthesia

43. Pain Sensation

a. Ask the client to close the
eyes and to say “sharp,”
“dull,” or “don’t know” when
the sharp or dull end of a
safety pin is felt.
b. Alternately, use the sharp
 and dull end to lightly prick
designated anatomic areas at
random (e.g., hand, forearm,
foot, lower leg, abdomen).
c. Allow at least 2 seconds
between each test to prevent
summation effects of stimuli
(i.e., several successive
stimuli perceived as one
stimulus).
Normal Findings:
● Able to discriminate “sharp”
and “dull” sensations
Deviations:
● Areas of reduced,
heightened, or absent
sensation

44. Position or Kinesthetic Sensation

a. To test the fingers, support
the client’s arm and hand
with one hand. To test the
toes, place the client’s heels
on the examining table.
b. Ask the client to close the
eyes.
c. Grasp a middle finger or a big
toe firmly between your
thumb and index finger, and
exert the same pressure on
both sides of the finger or toe
while moving it.
d. Move the finger or toe until it
is up, down, or straight out,
and ask the client to identify
the position.
e. Use a series of brisk, gentle
up-and- down movements
before bringing the finger or
toe suddenly to rest in one of
the three positions.
Normal Findings:
● Can readily determine the
position of the fingers and toes
Deviations:
● Unable to determine the
position of one or more
 fingers or toeslco

45. Document findings in the client

record using printed or electronic
forms or checklists supplemented by
narrative notes when appropriate.
Describe any abnormal findings in
objective terms.