VITALS SIGNS NORMAL BODY TEMPERATURE

• vital signs include temperature, pulse, respirations, and blood SITE NORMAL RANGE
pressure Oral 37°C (98.6°F) 36.4°C to 37.6°C (97.6°F to 99.6°F)
• must be measured, reported, and recorded accurately Rectal 37.6° C (99.6°F) 37°C to 37.8°C (98.6°F to 100.6°F)
Axillary 36.4°C (97.6°F) 35.9°C to 37°C (96.6°F to 98.6°F)
• vital signs are taken:
Tympanic 37°C (98.6°F) 37°C (98.6°F)
o when a person is admitted to a health care facility
Temporal 37°C (98.6°F) 37°C (98.6°F)
o several times a day for hospitalized patients
o before and after surgery
TYPES OF THERMOMETERS
o after some nursing procedures
• glass thermometer – small, hollow glass tube that contains
o before medications are given that affect the respiratory or
mercury or a mercury-free substance in a bulb at one end
circulatory system
o when heated, the mercury rises in the tube
o whenever a person complains of pain shortness of breath,
rapid heart rate, or not feeling well
o with the person at rest in a lying or sitting position
• report the vital signs to the nurse if:
o any vital sign is changed from a previous measurement
o vital signs are above the normal range
o vital signs are below the normal range

FACTORS THAT AFFECT VITAL SIGNS

• a change in one vital sign will cause a change in the others

illness environment – weather

emotions – anger, fear, anxiety, pain food and fluid intake
o reading a glass thermometer
exercise and activity medications
age and sex noise
▪ the scale is marked from 94° to 108°
time of day – ↓ in the morning, ↑ in the afternoon or evening ▪ the long lines represent one degree
▪ the short lines represent two tengths of a degree
▪ only every other degree is marked with a number
REPORTING AND RECORDING VITAL SIGNS
• a change in one vital sign will cause a change in the others
• abbreviations for vital signs:
o temperature – T
o pulse – P
o respirations – R
o blood pressure – BP • electronic thermometer
o battery operated
BODY TEMPERATURE o have an oral probe and a rectal probe
• body temperature is the amount if heat in the body o disposable probe cover is placed on the probe
• a balance between the amount of heat produced and the amount o the temperature registers in about 30 seconds
of heat lost
• for the body to function at a cellular level, a core body temperature
between 36.5°C and 37.7°C (96.0°F and 99.9°F orally) must be
maintained
• body temperature is lowest early in the morning (4AM-6AM) and
the highest late in the evening (8PM to midnight)
• heat is produced by:
o contraction of muscles during exercise
o breakdown of food during digestion
o environmental temperature
• heat is lost through:
o urine, feces, respirations, perspiration
• digital thermometer – use a disposable sheath
HYPOTHERMIA HYPERTHERMIA
<36.5°C or 96.0°F >38.0°C or 100°F
may be seen in prolonged may be seen in viral or bacterial
eposure ti cold, hypoglycemia, infections, malignancies,
hypothyroidism, or starvation trauma, and various disorders

TEMPERATURE MEASUREMENT SITES

• body temperature is measured in one of five areas of the body

mouth oral most temperatures are taken

rectum rectal most accurate
axilla (underarm) axillary least accurate
ear tympanic
temporal site forehead
• disposable oral thermometer
• tympanic thermometer – measures the temperature in the
tympanic membrane (eardrum)
o fast and accurate – 1 to 3 seconds
o infants – pull the ear straight back
o adults and children over one year – pull the ear up and back
TAKING TEMPERATURES
Taking an Oral Temperature
1. rinse with cold water
2. check the thermometer for breaks and chips
3. shake down the thermometer so the mercury is below the lines and
numbers
4. place a disposable cover or sheath on the temperature
5. place the thermometer in place for 2-3 minutes
6. if the person has been eating, drinking, or smoking, waith 15
minutes before taking temperature
• Guidelines for Taking an Oral Temperature – do not take an oral
temperature on:
o an infant or young child (under age 6)
o an unconscious patient
o a patient that has had oral surgery or an injury to the face,
neck, nose, or mouth
o a person receiving oxygen
o a patient with a nasogastric tube in place
o a patient who is confused or restless
o a patient who is paralyzed on one side of the body
o has a history of seizures
o a patient who breathes through the mouth
Taking a Rectal temperature
1. lubricate the thermometer before inserting into the rectum
2. place the person in a side-lying position
3. insert the thermometer 1 inch into the rectum
4. hold the thermometer in place for 2 minutes
5. remove the disposable cover and read the thermometer
• Guidelines for Taking A Rectal Temperature – do not take a
rectal temperature on:
o a person who has had rectal surgery or rectal injury
o if the person has diarrhea
o if the person is confused or agitated
o if the person has heart disease (stimulates the vagus nerve
which slows the heart rate)
Taking an Axillary Temperature
• taken only when no other site can be used
• make sure the underarm is clean and dry
• the arm is held close to the body
• hold the thermometer in place while the temperature is being taken
• the thermometer is left in place for 10 minutes
PULSE
• the pulse is the beat of the heart felt at an artery as a wave of blood
passess through the artery
o produced when the heart contracts and forcefully pumps
blood out of the ventricles into the aorta
• a pulse is felt every time the heart beats
• more easily felt in arteries that come close to the skin and can be
gently pressed against a bone
• the pulse should be the same in all pulse sites on the body
• the pulse is an indication of how the cardiovascular system is
meeting the body’s needs
• the pulse rate is affected by many factors – age, fever, exercise,
fear, anger, anxiety, excitement, heat, position, and pain
• medications can be taken that either increase or decrease a
person’s pulse rate
PULSE SITES (ARTERIAL OR PERIPHERAL PULSE SITES)
COUNTING A PULSE
• (usually) count a pulse for 30 seconds and multiply the number
times 2 to get the pulse rate for 1 minute
• note the rhythm (pattern) of the heart beat
o if the heart beat is irregular, count the pulse for a full minute
• observe the force (strength) of the heartbeat
o does the pulse feel: strong full, bounding, weakthready, feeble
• narrowed pulse pressure – less than 20
• widened/normal pulse pressure – more than 60
USING A STETHOSCOPE
• always clean the earpieces of the stethoscope with alcohol before
and after use
• warm the diaphragm in your hand before placing it on the person
• hold the diaphragm in place over the artery
• do not let the tubing strike against anything while the stethoscope
is being used
RADIAL PULSE
• most common site for taking a pulse
• can be taken without disturbing or exposing the person
• characteristics that should be assessed when measuring the
radial pulse: rate, rythym, amplitude and contour, and elasticity
o amplitude can be quantified as follows:
▪ 0 absent
▪ 1+ weak, dimished (easy to obliterate)
▪ 2+ normal (obliterate with moderate pressure)
▪ 3+ bounding (unable to obliterate or require firm
pressure)
• place the first 2 or 3 fingers of one hand against the radial artery
• the radial artery is on the thumb side of the wrist
o do not use your thumb to take a person’s pulse
o use gentle pressure
o count the pulse for 30 seconds and multiply by two
APICAL PULSE
• taken with a stethoscope ABNORMAL BLOOD PRESSURE
• counted by placing the stethoscope over the heart • hypertension – measurements above the normal systolic or
• counted for one full minute diastolic pressures
• the heart beat normally sounds like a lub-dub • hypotension – measurements below the normal systolic or
o each lub-dub is counted as one heartbeat diastolic pressures
o do not count the lub as one heartbeat and the dub as another
• taken on patients who have heart disease, an irregular pulse rate, FACTORS CONTRIBUTING TO BLOOD PRESSURE
or take medications that can affect the heart cardiac output the more blood the heart pumps, the greater pressure
in the blood vessels
peripheral vascular increase in resistance in peripheral vascular
APICAL-RADIAL PULSE
resistance systems, increase blood pressure
• the apical and radial pulse circulating blood increase in blood volume, increases blood pressure
rates should be equal volume sudden drop in blood pressure may indicate blood
• sometimes the heart beat is loss or int. bleeding
not strong enough to create a viscosity when blood becomes thicker or more viscous,
pulse in the radial artery pressure in blood vessels will increase
o this would cause the elasticit of vessel increase in stiffness of the vessel walls will increase
walls blood pressure
radial pulse to be less
than the apical pulse
FACTORS THAT AFFECT BLOOD PRESSURE
• one person counts the
age blood pressure increases as a person grows older
• apical while the other person counts the radial
gender women usually have lower blood pressure than men
• pulse deficit – difference in pulses blood volume severe bleeding lowers the blood pressure
stress heart rate and blood pressure increase as part of the body’s
PULSE RANGES FOR DIFFERENT AGES response to stress
AGE PULSE RATES PER MINUTE pain increases blood pressure
Birth to 4 weeks 80 - 180 exercise increases heart rate and blood pressure
4 weeks to 1 year 80 - 160 weight blood pressure is higher in overweight persons
1 to 2 years 80 – 130 race black persons generally have higher blood pressure than
2 to 6 years 80 – 120 white persons do
6 to 12 years 70 – 110 diet a high-sodium diet increases the fluid volume in the body
12 years and older 80 - 100 which increases blood pressure
• normal adult pulse rate – 60 to 100 beats per minute medications can be taken to raise or lower blood pressure
• tachycardia – heart rate is over 100 position blood pressure is lower when lying down

• bradychardia – heart rate below 60

TYPES OF BLOOD PRESSURE CUFFS
RESPIRATIONS • sphymomanometer – proper name for a blood pressure cuff
• one respiration consists of one inspiration and one expiration
• the chest rises during inspiration (breathing in) and falls during
expiration (breathing out)
• count each time the chest rises
• count for 30 seconds and multiply by 2
• do not let the person know you are cunting their respirations
• count after taking the pulse – keep your fingers in the pulse site
• normal respiratory rate for adults – 12-20 breaths per minute

ABNORMAL RESPIRATIONS
tachypnea respiratory rate over 20
bradypnea respiratory rate below 12
dyspnea shortness of breath, difficulty in breathing
apnea no breathing; absence for >10 seconds
hyperventilation fast and deep respirations
hypoventilation slow and shallow respirations

BLOOD PRESSURE
• amount of force the blood exerts against the artery walls
• systolic pressure – pressure exerted when the heart muscle is
contracting
• diastolic pressure – pressure exerted when the heart muscle is
relaxing between beats
• blood pressure is recorded as a fracyion with the systolic pressure
on top and the diastolic pressure on the bottom
o systolic/diastolic – 120/80
• BP is measured in MM (milimeters) of Hg (mercury)
• affected by several factors: cardiac output, elasticity of arteries,
blood volume, blood velocity (heart rate), and blood viscosity

NORMAL BLOOD PRESSURE

• average adult systolic range – 100 to 140
• average adult diastolic range – 60 to 90
GUIDELINES FOR MEASURING BLOOD PRESSURE MEASURING WEIGHT AND HEIGHT
• do not take a blood pressure on an arm with an IV, cast, or a • standing, chair, and lift scales are used
dialysis shunt • the person only wears a gown or pajamas
• do not take a blood pressure on the side that a person has had • the person voids before being wighed
breast surgery on • weigh the person at the same time of day
• measure blood pressure with the person sitting or lying • use the same scale
• apply the cuff to the bare upper arm; do not apply the cuff over • balance the scale at zero before weighing the person
clothing
• make sure the cuff is snug DEVIATIONS RELATED TO PHYSICAL DEVELOPMENT, BODY
• use a large cuff if necessary BUILD, AND FAT DISTRIBUTION
• make sure the room is quiet DEVIATIONS DEFINITION
• if you do not hear the blood pressure, wait 30 to 60 seconds and dwarfism decreased height and skeletal malformations
very short stature of 4 feet 10 inches or less
try again; if you still can not hear it or are unsure of your readings,
gigantism due to high levels of growth hormone (GH) which
have the nurse check your measurements
causes an abnormal increase in height
also called pediatric acromegaly or pituitary gigantism
PROCEDURE FOR MEASURING BLOOD PRESSURE
acromegaly overgrowth of bones in the face, head, and hands
1. clean the stethoscope earpieces and diaphragm with alcohol anorexia nervosa emaciated appearance that follows self-starvation and
2. locate the brachial pulse (where the stethoscope will be plced) accompanying extreme weight loss
3. wrap the cuff above the elbow with the arrow pointing to the obesity having an excessive amount of body fat, increasing the
brachial artery, fasten the cuff so it fits snugly risk of diseases and help problems
4. place the diaphragm of the stethoscope flat on the pulse site, marfan syndrome elongated fingers
holding it in place with the index and middle fingers of one hand cushing syndrome centralized weight gain
5. locate the radial puse
6. close the valve on the BP cuff by turning it to the right (clockwise) PAIN
7. inflate the cuff until you can no longer feel the radial pulse, then • pain means to ache, hurt, or be sore
inflate the cuff 30mmHg beyond this point • pain is a warning from the body
8. deflate the cuff slowly by opening the valve slightly and turning it • pain is personal
counterclockwise (to the left) with your thumb and index finger; • when pain is present, identify its location, intensity, quality, duration,
allow the air to excape slowly while listening for a pulse sound and any alleviating or aggravating factors
9. note the reading at which you hear the first clear, regular pulse • pain intensity measurement tools such as 1 to 10 Likert scale
sound (systolic pressure) may be used
10. continue listening until the sound disappears (diastolic pressure)
11. open the valve completely to deflate the cuff, remove the cuff from TYPES OF PAIN
the patient acute pain felt suddenly from an injury, disease, trauma, or surgery
chronic pain lasts longer than 6 months
IDENTIFYING KOROTKOFF SOUNDS can be constant or occur on and off
PHASE DESCRIPTION radiating pain felt at the site of tissue damage and in nearby areas
I Phase I is characterized by the first appearance of faint, clear, phantom pain fet in a body part that is no longer there
repetitive tapping sounds that gradually intensify for at least two
consecutive beats; the number on the pressure gauge at which you
SIGN AND SYMPTOMS
hear the first tapping sound is the systolic pressure
location where is the pain?
II Phase II is characterized as muffled or swishing; the loss of sound
onset and duration when did the pain start?
during the latter part of phase I and during phase II is called the
intensity rate the pain on a scale of 1 to 10, with 10 as the most
“auscultory gap” which may cover a range of as much as 40mmHg
severe
III Phase III is characterized by a return of distinct, crisp, and louder
description can you use words to describe the pain?
sounds as the blood flows relatively freely through an increasinly
factors causing pain what were you doing when the pain started
open artery
vital signs take person’s vital signs when the complain of pain
IV Phase IV is characterized by sounds that are muffled, less distinct,
and softer (with a blowing quality) body responses ↑vital signs, nausea, pale skin, sweating, vomiting
V Phase V is characterized by all sounds disappearing completely; behaviors crying, groaning, holding affected body part, irritabilty
the last sound heard before this period of continuous silence is the and restlessness
onset of phase V and the pressure commonly considered as the
diastolic measurement PAIN ASSESSMENT (COLDSPA)
MNEMONIC QUESTION
Character Describe the sign or symptom (feeling,
CHANGES IN BLOOD PRESSURE CLASSIFICATION appearance, sound, smell, or taster if applicable)
CLASSIFICATION GUIDELINES Onset When did it begin?
Normal <120/80 mmHg Location Where is it? Does it radiate? Does it occur
Elevated sysolic between 120 and 129 mmHg and diastolic anywhere else?
between <80 mmHg Duration How long does it last? Does it recur?
Stage I systolic between 130 and 139 mmHg or diastolic Severity How bad is it? How much does it bother you?
between 80 and 89 mmHg Pattern What makes it better or worse?
Stage II systolic at least 140 or diastolic at least 90 mmHg Associated factors What other symptoms occur with it? How does it
Hypertensive crisis systolic over 180 mmHg and/or diastolic over 120 affect you?
mmHg; with patients needing prompt changes

INTERDISCIPLINARY VERBAL COMMUNICATON OF

ASSESSMENT FINDINGS USING SBAR
• Situation
• Background
• Assessment
• Recommendation
 NURSE’S ROLE IN HEALTH ASSESSMENT TYPES OF HEALTH ASSESSMENT
• professional nursing assessment determine nursing clinical Initial Comprehensive • collection of subjective data as well
judgements that will result in client care interventions that either Assessment as objective data
positively or negatively influence their health care and status • needed when the client first enters a
health care system and periodically
ASSESSMENT: STEP 1 OF THE NURSING PROCESS thereafter to establish baseline data
• assessment – first and most critical phase of the nursing process against which future health status
o if data collection is inadequate or inaccurate, incorrect clinical changes can be measured and
judgements may be made that adversely affect the remaining compared
phases of the process
• frequency: depend’s on client’s age,
• assessment os an ongoing and continuous throughout all phases risk factors, health status, health
of the nursing process promotion practices, and lifestyle
• analyzing and synthesizing those data, making judgements about Ongoing or Partial • consists of data collection that occurs
the effectiveness of nursing interventions, and evaluating care Assessment after the comprehensive database is
outcomes
established
• mini overview of the client’s body
systems and holistic health patterns
as a follow-up on health status
• a brief assessment of the client’s
body systems and holistic health
patterns is performed to detect any
new problem
• frequency: determined by the acuity
of the client
Focused or Problem- • does not replace the comprehensive
oriented Assessment health assessment
• performed when a comprehensice
database exists for a client who
comes to the health care agency with
a specific health concern
• thorough assessment of a particular
client problem and does not address
areas not related to the problem
PHASE TITLE DESCRIPTION
Emergency • very rapid assessment performed in
I Assessment Collecting subjective & objective data
Assessment life-threatening situations
II Diagnosis Analyzing subjective & objective data
• immediate assessment is needed to
to make and prioritize professional
proide prompt treatment
clinical judgements
• determine the status of the client’s life
III Planning Generating solutions, developing a
sustaining physical functions
plan, and determining which outcome
should be prioritized
STEPS OF HEALTH ASSESSMENT
IV Implementation Take action, prioritize and implement
planned interventions • Preparing for the Assessment
o nurses should review the client’s medical record, if available
V Evaluation Assess whether the outcomes have
o medical record – provides information about chronic
been met and revising the plan if
diseases, medications, allergies, and so on and give clues to
interventions did not make a difference
how present illness may impact the client’s ADLs
▪ an awareness of the client's previous and current health
FOCUS OF HEALTH ASSESSMENT IN NURSING status provides valuable information to guide your
• comprehensive health assessment – consists of both a healthy interactions with the client
history and physical examination o validate information with the client and be prepared to collect
• purpose of nursing health assessment – collect holistic additional data
subjective and objective data to determine a client’s overall level of 1. Collection of Subjective Data
functioning in order to make a professional clinical judgement o sensations or symptoms, feelings, perceptions, desires,
o nurse performs holistic data collection preferences, beliefs, ideas, values, and personal information
o can be elicited and verified only by the client
FRAMEWORK FOR HEALTH ASSESSMENT IN NURSING o major areas of subjective data:
• nursing framework – helps to organize information and promotes ▪ biographical information
the collection of holistic data ▪ history of present health concern
o provides clues that help to determine human responses ▪ personal health history
• collected data – based on client’s answers to the questions asked ▪ family history
in the nursing history ▪ health and lifestyle practices
• objective data – gathered during the physical assessment, enable ▪ review of systems
the nurse to make informed clinical judgements 2. Collection of Objective Data
• end result of a nursing assessment – identification of client o obtained by general observation and y using the four
problems that require nursing care, interdisciplinary care, physical examination techniques
immediate referral, or client teaching for health promotion ▪ inspection, palpation, percussion, and auscultation
o objective data includes:
▪ physical characteristics, body functions, appearance,
behavior, measurements, & results of laboratory testing
3. Validation of Data
o often occurs along with collection of subjective and objective
data
o ensure that the assessment process is not ended before all
relevant data have been collected and helps to prevent
documentation of inaccurate data
4. Documentation of Data
o forms the database for the entire nursing process and
provides data for all other members of the health care team
ANALYZING CUES TO IDENTIFY CLIENT CONCERNS: STEP 2
OF THE NURSING PROCESS
• requires the nurse to use clinical judgement
• recognize, analyze, and synthesize cues to determine whether the
cues reveal a client concern, collaborative concern, or a concern
that needs to be referred to medicine or another discipline
Client Concern problem of a client who may be an individual,
family, group, or community
identified and prioritized by nurses to plan
nursing interventions to treat and evaluate
the client concern
Collaborative certain “physiological complications that
Problems nurses monitor to detect their onset changes
in status”
• health history – provides the foundation for clinical judgements in
implementing both physician and nurse-
prescribed interventions to reduce further
complications
Referrals nurses assess the “whole” client, often
identifying problems that require the
assistance of other health care professionals
EIGHT SECTIONS OF HEALTH HISTORY
PROCESS OF DATA ANALYSIS
• require diagnostic reasoning skills (critical thinking)
• six major steps of data analysis:
o identify abnormal cues and supportive cues
o cluster cues
o draw inferences and identify and prioritize client concerns
o propose possible collaborative problems to notify primary
care provider
o document conclusions
SUBJECTIVE DATA: THE INTERVIEW AND HEALTH HISTORY
• subjective data includes: sensations or symptoms, feelings,
perceptions, desires, preferences, beliefs, ideas, values, and
personal information
• can be elicited and verified only by the client
• provide clues to possible physiological, psychological, and
sociologic problems
• provide the nurse with information that may reveal a client’s risk for
a problem as well as areas of strengths for the client
INTERVIEWING
• communication process has two focuses:
o establishing rapport and a trusting relationship
o gathering information
PHASES OF THE INTERVIEW
Preintroductory Phase reviews medical record before meeting
with the client
reveal the client’s past health history and
reason for seeking health care
in the instance that the medical record is
not available, the nurse will need to rely on
interviewing skills to elicit valid and reliable
data from the client and their family
Introductory Phase nurse explains the purpose of the
interview, discusses the types of questions
that will be asked, explains the reason for
taking notes, and assures the client that
confidential information will remain
confidential
developing rapport depends heavily on
verbal and nonverbal communication on
the part of the nurse
Working Phase nurse elicits the client’s comments about
major biographical data, reasons for
seeking care, history of present health
concern, past health history, family history,
review of body systems (ROS) for current
health problems, lifestyles, and health
practices, and developmental level
nurse and client collaborate to identify the
client’s problems and goals
Summary and Closing nurse summarizes information obtained
Phase during the working phase and validates
problems and goals with the client
identifies and discusses possible plans to
resolve the problem with the client
ask if anything else concerns the client
and if there are any further questions
COMPLETE HEALTH HISTORY
identifying nursing problems, where to focus, and areas where a
more detailed physical examination may be needed
o provides nurse with specific cues to health problems that are
most apparent to the client
o complete health history is modified or shortened when
necessary
Biographical • include information that identifies the client
Data o when students are collecting
information and sharing it with
instructors, addresses and phone
numbers should be deleted and
initials used to protect privacy
• the client is considered the primary source
and all others are secondary sources
• client’s culture, ethnicity, and subculture
helps the nurse to examine special needs
and beliefs that may affect the client or
family’s health care
• client’s educational level, occupation,
and working status assists the examiner
in tailoring questions to the client’s level of
understanding and help identify possible
client strengths and limitations affecting
health status
• asking who lives with the client and
identifying significant others indicate the
availability of potential caregivers and
support people for the client
o absence of support people would alert
the examiner to the (possible) need for
finding external sources of support
Reason(s) for • primary care providers call this the client’s
Seeking Health chief complaint (CC)
Care • a more holistic approach for phrasing the
question may draw out concerns that reach
beyond a physical complaint and may
address stress or lifestyle changes
History of • takes into account several aspects of the
Present Health health problem and asks questions whose
Concern answers can provide a detailed description
of the concern
 • encourage the client to explain the health
problem or symptom in as much detail as
possible by focusing on COLDSPA
• client’s answer to the questions provide the
nurse with a great deal of information about
the client’s problem and especially how it
affects lifestly and activities of daily living
(ADLs)
Personal Health • focuses on questions related to the client’s
History personal history, from the earliest
beginnings to the present
• childhood illnesses and immunizations to
date, adult illnesses, past surgeries or
accidents, prolonged episodes of pain or
pain patterns they had experienced, PREPARING FOR THE EXAMINATION
allergies, and use of prescription and OTC • how well a nurse prepare the physical setting, themselves, and the
medications client can affect the quality of the data the nurse can elicit and what
• elicit data about the client’s health history supports the clinical judgements
related to their strengths and weaknesses
PREPARING THE PHYSICAL SETTING
• assists the nurse in identifying risk factors
• may take place in a variety of settings
that stem from previous health problems
• comfortable, room temperature
Family Health • due to the increasing number of health
o provide a warm blanket or adjust room temperature
History problems that seem to run in families and
• private area free of interuptions from others
that are genetically based
o close the door or pull the curtains if possible
• should include as many genetic relatives as
• quiet area free of distractions
the client can recall
o turn off the radio, television, or other noisy equipment
• drawing a genogram helps to organize and
• adequate lighting
illustrate the client’s family history
o it is best use sunlight; good overhead lighting is sufficient
Review of • each body system is addressed and the
• firm examination table or bed at a height that prevents stooping
Systems for client is asked specific questions to elicit
o a roll-up stool may be useful when it is necessary for the
Current Health further details of current health problems or
examiner to sit for parts of the assessment
Problems problems from recent past that may still
• a bedside table/tray to hold the equipment needed for the
affect the client or that are recurring
examination
• document the client’s descriptions of their
health status for each body system and PREPARING ONESELF
note the client’s denial of signs, symptoms, • it is helpful to assess your own feelings and anxieties before
diseases, or problems examining the client
Lifestyle and • include nutritional habits, activity and o may easily be conveyed to the patient, making them feel
Health Practices exercise patterns, sleep and rest patterns, uneasy or comfortable
Profile self-concept, and self-care activities, social • wash hands before beginning the examination, immediately after
and community activities, relationships, accidental direct contact with blood or other body fluids, and after
values and beliefs, system, education and completing the physical examination or after removing gloves
work, stress level and coping style, and • always wear gloves; change gloves when moving from a
environment contaminated to a clean body site, and between clients
• clients describe how they are managing • if a pin or other sharp object is used to assess sensory perception,
their lives, their awareness of healthy discard the pin and use a new one for your next client
versus toxic living patterns, and the
• wear a mask and protective eye goggles if you are performing an
strengths and supports they have or use examination in which you are likely to be splashed with blood or
other body fluid droplets
OBJECTIVE DATA: PHYSICAL EXAMINATION
• objective data – information about the client that time the nurse APPROACHING AND PREPARING THE CLIENT
directly observes during interaction with the client and information • establish the nurse-client relationship during the client interview
elicited through physical examination techniques before the physical examination takes place
o helps alleviate any tension or anxiety that the client is
EQUIPMENT experiencing
• each part of the physical examination requires specific pieces of
• at the end of the interview, explain to the client that the physical
equipment
assessment will follow and describe what the examination is
• prior to the examination, collect the necessary equipment and
• respect the client’s desire and requests related to the physical
place it in the area where the examination will be performed
examination
o promotes organization and prevents the nurse from leaving
o explain to the client the importance of the examination and the
the client to searcch for a piece of equipment
risk of missing important information if any part of the
examination is omitted
• begin the examination with the less intrusive procedures
o allows the client to feel more comfortable and help ease the
client’s anxiety about the examination
• approach the client from the right-hand side of the examination
table or bed because most examination are performed with the
examiner’s right hand
 POSITIONING THE CLIENT
Sitting Position the client should sit upright
on the side of the
examination table or on the
edge of a chair or bed
good for evaluating the head,
neck, lungs, back, breasts,
axilae, heart,vital signs, and
upper extremities
permits full expansion of the
lungs and allows examiner to
assess symmetry of upper
body parts
ask the client to lie down with
legs together on the
examination table
Supine Position
a small pillow may be placed
under the head for comfort; if
the client has trouble
breathing, the head of the
bed need to be raised
allows the abdominal
muscles to relax and provide
easy access to peripheral
pulse sites
client lies down on the
examination table or bed with
the knees bent, the legs
Dorsal Recumbent Position separated, and the feet flat
on the examination table or
the bed
may be more comfortable
than the supine position for
clients with pain in the back
or abdomen
abdomen should not be
assessed because the
abdominal muscles are
contracted in this position
client lies on the right or left
side with the lower arm
Sims Position placed behind the body and
the upper arm flexed at the
shoulder and elbow; the
lower leg is slightly flexed at
the knee, while the upper leg
is flexd at a sharper angle
and pulled forward
this position is usefyl for
assessing the rectal and
vaginal areas
Standing Position client stands still in a normal,
comfortable, resting posture
allows the examiner to
assess posture, balance,
and gait
used for examining male
genitalia
Prone Position client lies down on the
abdomen with the head to
the side
used primarily to assess the
hip joint
client kneels on the
examination table with the
weight of the body supported
by the chest and the knees
Knee-Chest Position
a 90-degree angle shoul
exist between the body and
the hips
the arms are placed above
the head, with the head
turned to one side
useful for examining the
rectum
client lies on the back with
Lithotomy Position the hips at the edge of the
examination table and the
feet supported by stirrups
used to examine the female
genitalia, reproductive tracts,
and the rectum
keep the client well draped
during the examination
PHYSICAL EXAMINATION TECHNIQUES
INSPECTION
• involves using the senses to observe and detect any normal or
abnormal findings
• used from the moment the nurse meets the patient and continues
throughout the examination
• preceds palpation, percussion, and auscultation
o these techniques can potentially alter the appearance of what
is being inspected
PALPATION
• consists of using parts of the hand to touch and feel the
following characteristics:
o texture: rough / smooth
o temperature: warm / cold
o moisture: dry / wet
o mobility: fixed / movable / still / vibrating
o consistency: soft / hard/ fluid filled
o strength of pulses: strong / weak / thready / bounding
o size: small / medium / large
o shape: well defined / irregular
o degree of tenderness
• three different parts of the hand are used during the palpation
o fingerpads – fine discrimations: pulses, texture, size,
consistency, shape, crepitus
o ulnar/palmar surface – vibrations, thrills, fremitus
o dorsal surface – temperature
 FOUR TYPES OF PALPATION Dullness intensity: medium
Light Place dominant hand lightly on the surface of the heard over more pitch: medium
Palpation structure. There should be very little or no solid tissue length: moderate
depression (less than 1cm). Feel the surface quality: thud-like
structure using circular motion. example of origin:
Use this technique for pulses, tenderness, surface skin diaphragm, pleural effusion, liver
texture, temperature, and moisture. Flatness intensity: soft
Moderate Depress the skin surface 1cm to 2cm (0.5 to 0.75 heard over very pitch: high
Palpation inch) with your dominant hand. Use a circular motion dense tissue length: short
for easily palpable body organs and masses. Note quality: flat
the size, consistency, and mobility of the structures you example of origin:
palpate. muscle, bone, sternum, thigh
Deep Place your dominant hand on the skin surface and your
Palpation nondominant hand on top of your dominant hand to
apply pressure. This should result in a surface AUSCULTATION
depression between 2.5cm and 5cm (1 to 2 inches) • requires the use of a stethoscope tp listen for heart sounds,
movement of blood through the cardiovascular system, movement
This allows you to feel very deep organs or of the bowel, and movement of air through the respiratory tract
structures that are covered by thick muscle. • stethoscope – used to hear the body sounds that are not audible
Bimanual Use two hands, placing one on each side of the body to the human ear
Palpation part being palpated. Use one hand to apply pressure • the sounds detected using auscultation are identified according to:
and the other hand to feel the structure. Note the size, o intensity: loud / soft
shape, consistency, and mobility of the structures as o pitch: high / low
you palpate. o duration: length
o quality: musical / crackling / raspy

PERCUSSION
• involves tapping body parts to produce sound waves which
enables the examiner to assess underlying structures
• several different assessment used
o eliciting pain – detect inflamed underlying structures
▪ area feels tender, sore, painful
o deterining location, shape, and size
o determining density – determine whether an underlying
structure is filled with air or fluid or is a solid structure
o detecting abnormal masses – can detect superficial abnormal
structures or masses
▪ percussion vibrations usually penetrate approximately
5cm deep, deep masses do not produce any change in
the normal percussion vibrations
o eliciting reflexes – elicited using percussion hammer

THREE TYPES OF PERCUSSION

Direct Percussion direct tapping of a body part with one or
two fingertips to elicit possible tenderness
Blunt Percussion detect tenderness over organs by placing
one hand flat on the body surface and
using the fist of the other hand to strike the
back of the hand flat on the body surface
Indirecr or mediare tapping produces a sound or tone that
percussion varies with the density of underlying
structures

SOUNDS ELICITED BY PERCUSSION

Resonance intensity: loud
heard over part air pitch: low
and part solid length: long
quality: hollow
example of origin: normal lung
Hyperresonance intensity: very loud
heard over mostly pitch: low
air length: long
quality: booming
example of origin: lung with emphysema
Tympany intensity: loud
heard over air pitch: high
length: moderate
quality: drumlike
example of origin: puffed-out cheek
 ASSESSING MUSCULOSKELETAL SYSTEM JOINTS
• the musculoskeletal system provide structure and movement for • joint – where two or more bones meet
the body parts o provide a variety of ranges of motion (ROMs) for the body

BONES CLASSIFICATION OF JOINTD

• provide structure and protection, fibrous joined by fibrous connective tissue and are
serve as levers, store calcium, and immovable (e.g. sutures between skull bones)
produce blood cells cartilaganous joined by cartilage (e.g. joints between vertebrae)
• 206 bones synovial contain a space between the bones that is filled
o axial skeleton with synovial fluid (e.g. shoulders, wrists, hips,
▪ head and trunk knees, and ankles)
o appendicular skeleton contains a space between the bones that is filled
▪ extremeties, shoulders, with synovial fluid – lubricant that promotes a
and hips sliding movement of the ends of the bones
• bones is divided into two: joined by ligaments – joins synovial joints
o compact bone – hard and articular cartilage – smooths and protects the
dense; makes up the shaft bones that articulate with each other
o spongy bone – numerous bursae – small sacs filled with synovial fluid that
spaces and makes up the serve to cushion the joint
ends and centers of the bones
• osteoblasts – active cells that form
the bone tissue; osteoclasts – degrades the bone tissue
• periosteum – covers the bones
o contains osteoblasts and blood vessels that promote
nourishment and formation of new bone tissue

SKELETAL MUSCLES
• made up of 650 skeletal (voluntary) muscles
o under conscious control
o made up of long muscle fibers (fasciculi) arranged together
in bundles and joined by connective tissue
• tendons – attach skeletal muscles to bones
o assist with posture, produce body heat, and allow body
movement

MOVEMENT OF SKELETAL MUSCLES

abduction moving away from midline of the body
adduction moving toward midline of the body
circumduction circular motion
TEMPOROMANDIBULAR JOINT
inversion moving inward
eversion moving outward
extensions straigthening the extremity at the joint and
increasing the angle of the joint
hyperextensions joint bends greather than 180 degrees
flexion bending the extremity at the joint and decreasing
the angle of the joint
dorsiflexion toes draw upward to ankle
plantar flexion toes point away from ankle
pronation turning or facing downward
supination turning or facing upward
protraction moving forward
retraction moving backward
rotation turning of a bone on its long axis
internal rotation turning of a bone toward the center of the body
external rotation turning of s bone away from the body’s center
articulation between the • opens and closes mouth
temporal bone and mandible • projects and retracts jaw
• moves jaw from side to side
STERNOCLAVICULAR JOINT
junction between the manubrium
of the sternum and the clavicle
ELBOW JOINT
articulation between the ulna
and radius of the lower arm and
the humerus of the upper arm
contains a synovial membrane
and several bursae
SHOULDER JOINT
articulation of the head of the
humerus in the glenoid cavity of
the scapula
acromioclavicular joint – •
includes clavicle and acromion
process; contains subacromial
and subscapular process
WRIST, FINGERS, AND THUMB JOINT
• no obvious movements articulation between the distal • wrists: flexion, extension,
radius, ulnar bone, carpalsm and hyperextension, adduction,
metacarpals radial, and ulnar deviation
contains ligaments and is lined • fingers: flexion, extnsion,
with a synovial membrane hyperextension, abduction,
and circumduction
• thumb: flexion, extension,
and opposition
VERTEBRAE JOINT
• flexion and extension of the
forearm
• supination and pronation of
the forearm
33 bones: 7 cervical (C), 12 • flexion
thoracic (T), 5 lumbar (L), 5 • hyperextension
sacral (S), and 3-4 coccygeal • lateral bending
cushioned by elastic • rotation
fibrocartillaginos plates that
provide flexibility and posture to
the spine
• flexion and extension paravertebral muscles are
• abduction and adduction positioned on both sides of
• circumduction vertebrae
rotation (external and
internal)
HIP JOINT HEALTH ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM
• collect subjective data: Nursing Health History
o Present Health History (COLDSPA)
▪ determine for any weight gain
▪ ask for difficulty in chewing or any associated tenderness
or pain
▪ determine any joint, muscle or bone pain
o Personal Health History
o Family Health History
o Lifestyle & Health Practices

PRESENT HEALTH HISTORY (COLDSPA)

articulation between the head of
the femur and the acetablum
contains a fibrous capsule
KNEE JOINT
• determine for any weight gain
• ask for difficulty in chewing or any associated tenderness or pain
• determine any joint, muscle, or bone pain
• flexion with knee flexed and
with knee extended PERSONAL HEALTH HISTORY (COLDSPA)
• extension and • any past problems or injuries on joints, muscles, or bones
hyoerextension
• last tetanus and polio immunizations
• circumduction
• determine if patient was diagnosed with diabetes mellitus, sickle
• rotation (internal and cell anemia, systemic lupus erythematosus (SLE), or osteoporosis
external)
• for middle-aged women: determine if menopause started or taking
• abduction any estrogen or hormone replacement theory
• adduction
FAMILY HISTORY
• determine if there’s history of rheumatoid arthritis, gout, or
osteoporosis

LIFESTYLE AND HEALTH PRACTICES

articulation of the femur, tibia,
and patella
ccontains fibrocartilaganous
disks (medial and lateral
menisci) and many bursae
ANKLE AND FOOT JOINT
• any physical activities (indoor & outdoor)
• medications (including supplements)
• tobacco & cigarette smoking
• alcohol & caffeinated drinks
• description of a typical 24-hour dietary intake
• occupation & line of work
o posture at work and at leisure
o types of shoes used
o any assistive devices
• difficulty in performing ADLs
• any interference in social and sexual activities
• personal views (before and after the MS problems)
• flexion • stress
• extension • bone density screening
PHYSICAL EXAMINATION OF MUSCULOSKELETAL SYSTEM
• observe posture and gait
• inspect joints, muscles, and extremities
• palpate joints, muscles, and extremities
• test musce strength and ROM of joints
• compare bilateral findings of joints and muscles
• perform specia tests for CTS
• perform the “bulge”, “ballottement”, and McMurray knee tests

articulation between rhe talus,
tibia, and fibula
talus also articulates with the
navicular bones
the heelis connected to the tibia
and fibula by ligaments
• ankle: plantar flexion and
dorsiflexion
• foot: inversion and eversion
• toes: flexion, extension,
abduction, and adduction
ASSESSING JOINTS
• inspect size, shape, color, and symmetry
o note any masses, deformities, or
muscle atrophy
• palpate for edema, heat, tenderness, pain,
nodules, or crepitus
• test each joint’s ROM
o demonstrate how to move each joint
through its normal ROM, then ask
client to actively move each joint through the same motions
→ if you identify a limitation in ROM, measure ROM with a
goniometer – device that measures movement in degrees
✓ describe the limited motion of the joint in degrees
✓ example: elbow flexes from 45 degrees to 90 degrees
ASSESSING MUSCLES THE GAIT CYCLE
• test muscle strength by asking the client to move each extremity
through its full ROM against resistance
• document muscle strength by using standard scale
✓ if client cannot move against resistanceask client to move the
part against gravity
✓ attempt to move the part passively through its full ROM
✓ inspect and feel for a palpable contraction of the muscle while
client attempts to move it
• rate muscle strength in accordance to the Rating Scale for Muscle
Strength

Rating Explanation Strength Classification

5 active motion against full normal
resistance
4 active motion against some slight weakness
resistance
3 active motion against gravity average weakness
2 passive ROM (gravity removed poor ROM
and assisted by examiner)
1 slight flicker of contraction severe weakness
0 no muscular contraction paralysis
PHASE DESCRIPTION
Initial Contact or the moment the foot touches the grounf and
GENERAL ROUTINE SCREENING VERSUS FOCUSED SPECIALTY Heel Strike begins the first phase of double support
ASSESSMENT FOR THE MUSCULOSKELETAL SYSTEM establish contact with the ground surface
and initiate weight acceptance
General Routine Focused Specialty Assessment
Loading Response begins with initial contact and continues until
Screening
or Foot Flat the contralateral foot leaves the the ground
• Observe posture & • Measuring of ROM using the foot continues to accept weight and
gait goniometer absorb shock by rolling into pronation
• Inspection for • Palpate the anatomic snuffbox Midstance begins when the contralateral foot leaves the
symmetry, color, and • Test for carpal tunnel syndrome ground and continues until ipsilateral heel
mobility • Test for thumb weakness lifts off the ground
• Palpate tenderness, • Observe for flick signal body is supported by a single leg and begins
heat, swelling, or • Squeeze test to move from force absorption at impact to
tenderness • Measure leg length force propulsion forward
• Perform bulge test, ballottement Terminal Stance or begins when the neel leaves the floor and
test, and Lasegue test Heel Off continues until the contralateral foot contacts
the ground
serves to propel the body forward
ASSESSING POSTURE AND GAIT Pre-Swing or Toe Off begins when the contralateral foot contacts
• notes on gait: the ground and continues until the ipsilateral
• base of support • weight-bearing stability foot leaves the ground
• foot position • arm swing provides the final burst of propulsion as the
• stride, length, and • posture toes leave the ground
cadence of stride Early Swing begins when the foot leaves the ground until
it is aligned with the contralateral ankle
advance the limb and shorten the limb for
ABNORMAL SPINAL CURVATURES foot clearance
Mid-Swing begins from the ankle and foot alignment
and continues until the swing leg tibia is
vertical
functions to advance the limb and shorten
the limb for foot clearance
Late Swing or begins when the swing leg tibia is vertical
Deceleration and ends with the initial contact
limb advancement slows in preparation

flattening of the lumbar may be seen with a herniated disc or

curvature ankylosing spondylitus
lumbar hyperlordosis hip flexion contracture and extensor
weakness drive the lumbar spine into
increasing lordosis for balance
kyphosis a rounded thoracic convexity
scoliosis a lateral curvature of the psine with an
increase in convexity on the side
ankylosing spondylitis spinal column fused by ossification
GAIT ABNORMALITIES
Wide Base Gait
person stand and walk with their
feet spaced widely apart
Hyperkinetic/Choreiform Gait
patient displays irregular, jerky,
involuntary movements in all
extremities; seen with certain
basal ganglia disorders
(Sydenham’s, Huntington’s,
athetosis, or dystonia)
Cerebellar/Ataxic Gait
widened base, unsteadiness,
and irregularity of steps, and
lateral veering; reduced step
frequency with prolonged
stance and double limb support
duration
Trendelenburg Gait
trunk shift over the affected hip
during the stance phase and
away during the swing phase
Shuffling/Propulsive Gait
stooped, stiff posture with the
head and neck bent forward that
can be caused by Parkinson’s
disease
Spastic Gait (Hemiplegic)
stiff, foot-dragging walk caused
by a long muscle contraction on
one side
Circumduction Gait
patients abducts thigh and
swings leg in a semi-circle to
attain adequate clearance
Waddling Gait
patient sways from side to side
and hip drops with each step
Antalgic Gait
stance phase is shortened
relative to swing phase; occurs
when patient walks with a limp
because of pain
ASSESSING TEMPOROMANDIBULAR JOINT (TMJ)
• put the middle and index finger on the front of the ear
• ask the client to open their mouth
• ask the client to move their jaw laterally
→ test the ROM of patient’s jaw; test the integrity of cranial nerve V
(trigeminal nerve)
✓ a grating sound may be heard in a client with TMJ dysfunction
ASSESSING CERVICAL, THORACIC, AND LUMBAR SPINE
• observe the cervical, thoracic, and lumbar curves
• palpate the spinous processes and the paravertebral proces
• test ROM of the cervical spine
o flexion and hyperflexion: touch chin and look up the ceiling
(normal findings: 45° each)
o lateral bending (normal findings: 40° to left and to right)
o rotation (normal findings: 70° rotation)
o repeat cervical ROM movements against resistance
▪ full ROM against resistance, stenght 5/5
• test ROM of lumbar spine
o flexion: bend forward and touch toes (normal findings: 75°-90°)
▪ observe symmetry of shoulders, scapula, and hips
o lateral bending: bend sideways (normal findings: 35°)
o hyperextension: bend backwards (normal findings: 30°)
o rotation: twist shoulders one way then the other (normal
findings: 30°)
• test for back and leg pain: straight leg test
o client lies flat and raise each relaxed leg independently to the
point of pain; dorsiflex the foot at the point of pain
• measure leg length
o client lies down with legs extended
o measure distance between anterior superior iliac spine and
the medial malleolus, crossing the measuring tape on the
medial side of the knee (normal findings: equal or within 1cm)

ASSESSING SHOULDERS, ARMS, AND ELBOWS
• inspect shoulders and arms for symmetry, color, swelling, and
masses then palpate for tenderness, swelling, and heat
o anterior: palpate clavicle, acromioclavicular joint, subacromial
area, and biceps
o posterior: glenohumeral joint, coracoid area, trapezius muscle,
and scapular area
• test ROM
o flexion: move arms forward (normal findings: 180°)
o hyperextension: move arms backward with elbows straight
(normal findings: 50°)
o adduction and abduction: client bring both hands together
overhead, elbows straight, followed by moving both hands in
front of the body past the midline with elbows straight (normal
findings: adduction – 50° abduction – 180°)
o external and internal rotation: client bring the hands together
behind the head with elbows flexed and behind the back
(normal findings: 90°)
o repeat maneuvers against resistance
▪ client can flex, extend, adduct, abduct, rotate, and shrug
shoulders against resistance
• inspect elbows in both flexed and extended positions for size,
shape, deformities, redness, or swelling
• palpate the olecranon process and epicondlyes while elbow is
relaxed and flexed at about 70°
• test ROM
o flexion and extension:
flex elbow and bring
hand to forehead then
straighten elbow
(normal findings:
flexion – 160°
extension – 180°)
o pronation and supination:
hold arm out, turn palm
down, and turn palm up
(normal findings: 90° each)
o repeat movements against resistance
▪ client should have full ROM against resistance
• inspect wrist for size, shape, symmetry, color, and swelling
• palpate for tenderness and nodules
• palpate anatomic snuffbox
• test ROM
o flexion and hyperextension: client bend wrist down and back
(normal findings: flexion – 90° hyperextension – 70°)
o ulnar and radial deviation: move hand outward and inward
(normal findings: ulnar – 55° radial – 20°)
o repeat maneuvers against resistance
▪ client should have full ROM against resistance
• test for carpal tunnel syndrome
o Phalen’s test: rest elbows on a table and place the backs of
both hands against each other while flexing the wrists 90
degrees with fingers pointed downward and wrists dangling,
hold for 60 seconds
o Tinel’s test: percuss lightly over the median nerve
• inspect size, shape, symmetry, swelling, and color of fingers
• palpate the fingers for tenderness, swelling, bony prominences,
nodules, or crepitus
• test ROM
o abduction: spread fingers apart (normal findings: 20°)
o adduction: make a fist (normal findings: full adduction)
o flexion: bend fingers down (normal findings: 90°)
o hyperextension: bend fingers up (normal findings: 30°)
o thumb flexion: move thum away from other fingers and touch
thumb to the base of small finger (normal findings: 50°)
o repeat maneuvers against resistance
▪ client has full ROM against resistance
ASSESSING HIPS
• while client is standing, inspect symmetry and shape of hips
• palpate for stability, tenderness, and crepitus
• while the client is supine:
o raise extended leg then flex knee up to chest while keeping
other leg extended
o abduction and adduction: as far as possible, move exteded
leg away from the midline of body and then toward midline of
the body (normal findings: adduction – 20°-30° abduction –
45°-50°)
o rotation: bend knee and turn leg inward and then outward
(normal findings: internal rotation – 40° external rotation – 45°)
o hyper extension: client lie prone and lift extended leg off table
or askclient to stand and swing extended leg backward
(normal findings: 15°)
o repeat maneuvers against resistance
▪ full ROM against resistance
 • squeeze the foot from each side
with your thumb and fingers
• palpate each metatarsal and
plantar area for swelling or
tenderness
• test ROM:
o dorsiflexion: point toes upward
(normal findings: 20°)
o plantarflexion: point toes downward (normal findings: 45°)
o eversion: turn soles outward (normal findings: 20°)
o inversion: turn soles inward (normal findings: 30°)
o abduction: rotate foot outward (normal findings: 10°)
o adduction: rotate foot inward (normal findings: 20°)
o flexion: turn toes under foot (normal findings: 40°)
o extension: turn toes upward (normal findings: 40°)
o repeat maneuvers against resistance
▪ client should have full ROM against resistance

ASSESSING KNEES, ANKLES, AND FEET

• inspect for size, shape, symmtery, swlling, deformities, and
alignment then observe for quadriceps muscle atrophy
• palpate 10cm above the patella for tenderness, warmth,
consistency, and nodules ABNORMALITIES ON MUSCULOSKELETAL SYSTEM
• bulge test: test for swelling by using the ball of your hand firmly to
stroke the medial side of the knee upward, three to four times, to lumbar lordosis exaggerated lumbar curve
displace any accumulated fluid then press on the lateral side of the scoliosis lateral curvature of the spine with an increase in
knee and look for a bulge on the medial side of the knee convexity on the side
acute tender, painful, swollen, stiff joints
rheumatoid
atrhtritis

chronic chronic swelling and thickening of the

rheumatoid metacarpophalangeal and proximal
arthritis interphalangeal joints; deviation toward ulnar
side

• ballottement test: to help detect

large amounts of fluid in the knee
o firmly press your non-
dominant thumb and index
finger on each side of the
patella then with your boutonniere & buotonniere deformity – flexion of the proximal
dominant fingers, push the swan-neck interphalangeal joint and hyper extension of the
patella down on the femur; feel for a fluid wave or click deformities distal interphalangeal joint
• test ROM swan-neck deformity – hyperextension of the
o flexion: bend each knee up toward buttocks or back (normal proximal interphalangeal joint with flexion of the
findings: 120°-130°) distal interphalangeal joint
o (hyper)extension: straighten the knee (normal findings: 0°-15°)
o repeat these maneuvers against resistance
▪ client should have full ROM against resistance
• McMurray’s test:
perform if client
ganglion nontender, round, enlarged, swollen, fluid-filled
complains of a
cyst at the dorsum of the wrist
“giving in” or
“locking” of the knee
tenosynovitis painful extension of a finger

thenar atrophy atrophy of the thenar prominence due to

pressure on the median nerve is seen in carpal
tunnel syndrome

acute gouty metatarsophalangeal joint of the great toe is

arthritis tender, painful, reddened, hot, and swollen

flat feet no arch and may cause pain and swelling of the
foot surface

callus nonpainful, thickened skin at pressure points

hallux valgus great toe is deviated laterally and may overlap

the second toe

corn painful thickenings of the skin that occur over

bony prominences and at pressure points

hammer hyperextension at the metatarsophalangeal joint

with flexion at the proximal interphalangeal joint

plantar wart painful warts that often occur under a callus,

appearing as tiny dark spots
 ASSESSING NEUROLOGIC SYSTEM SPINAL CORD
• the neurologic system is responsible for coordinating and • extends from the medulla oblongata to
regulating all body functions the first lumbar vertebra
• conducts sensory impulses up ascending
CENTRAL NERVOUS SYSTEM tracts to the brain, conducts motor
• encompasses the brain and spinal cord impulses down descending tracts to neurons
• covered in meninges – three layers of connective tissue that that stimulate glands and muscles
protect and nourish the CNS throughout the body, and is responsible for
• subarachnoid space – surrounds the brain and spinal cord simple reflex activity
o filled with cerebrospinal fluid (CSF)
o cushions the brain and spinal cords, nourishes the CNS, and NEURAL PATHWAYS
removes waste materials • spinothalamic tract – sensations of pain,
temperature, and crude and light touch
BRAIN • posterior columns - sensations of position,
Cerebrum • divided into the right and left cerebral vibration, and fine touch
hemispheres – joined by the corpus • pyramidal (corticospinal) tract and extra-
callosum pyramidal tract – motor impulses are
• gray matter - mediates higher level functions conducted to the muscles
such as memory, perception, communication,
and initiation of voluntary movements
Diencephalon • consists of thalamus and hypothalamus
• thalamus – responsible for screening and
directing the impulses to specific areas in the
cerebral cortex
• hypothalamus – responsible for regulating
many body functions
Brain Stem • midbrain – relay center for ear and eye
reflexes, and relays impulses between the
higher cerebral centers and the lower pons,
medulla, cerebellum, and spinal cord
• pons – links the cerebellum to the cerebrum
and the midbrain to the medulla
• medulla oblongata – contains the nuclei for
cranial nerves; has centers that control and
regulate respiratory function, heart rate and
force, and blood pressure
Cerebellum • coordination and smoothing og voluntary
movements, maintenance of equilibrium, and
maintenance of muscle tone

PERIPHERAL NERVOUS SYSTEM

• 12 pairs of cranial nerves and 31 pairs of spinal nerves
• somatic fibers – carry CNS impulses to voluntary skeletal muscles
o somatic nervous system – conscious or voluntary activities
• autonomic fibers – carry CNS impulses to smooth, involuntary
muscles
o autonomic nervous system – unconscious or involuntary
activities
CRANIAL NERVES SPINAL NERVES
• 8 cervical, 12 thoracic, 5 lumbar, and 1 coccygeal nerve

AUTONOMIC NERVOUS SYSTEM

• carried by both cranial and spinal nerves
• maintains homeostasis of the body
• sympathetic nervous system – activated during stress and elicits
responses
o arise from thoracolumbar lever (T1 to L2)
• parasympathetic nervous system – restore and maintain normal
body functions
o arise from the craniosacral regions (S1 to S4 and cranial
nerves III, VI, IX, and X)

PHYSICAL EXAMINATION OF MUSCULOSKELETAL SYSTEM

CRANIAL NERVE IMPULSE FUNCTION
I – Olfactory Sensory smell impulses CONSIDERATIONS BEFORE CONDUCTING PHYSICAL
II – Optic Sensory visual impulses EXAMINATION
III – Oculomotor Motor contract eye muscles, • ask client to remove all clothing and jewelry and put on an
constricts pupils, and elevates examination gown
eyelids; interior lateral, medial, • explain to client that several different position changes are
and superior eye movements necessary throughout parts of the examination
IV – Trochlear Motor contract one eye muscle; • examination will take a considerable amount of time to perform and
inferomedial eye movement that rest periods will be provided
V – Trigeminal Both (S) – face sensation
(M) – influences clenching and NEUROLOGICAL EXAMINATION
lateral jaw movements (chew Language • client displays difficulty in speaking
and bite) Orientation • determine client’s orientation to time, place,
VI – Abducens Motor lateral eye movements and person by tactful questioning
VII – Facial Both (S) – anterior two-thirds of the Memory • listen for lapses in memory
tongue; simulates secretions of o three categories of memory are
submaxillary and sublingual tested:
salivary glands; tears from ▪ immediate recall – ask patient to
lacrimal glands repeat 6 digits forward and
(M) – facial expressions backward
VIII – Acoustic, Sensory hearing and balance ▪ recent memory – ask what the
Vestibulocochlear client had for breakfast or dinner
IX – Both (S) – posterior two-thirds of the the previous evening
Glossopharyngeal tongue; gag reflex ▪ remote memory – ask client for
(M) – swallowing movements information from childhood that
X – Vagus Both (S) – throat, larynx, heart, can be later verified
lungs, GI tract, and abdominal o attention span and calculation
viscera sensations ▪ attention span – ask client to
(M) – swallowing, talking, and recite alphabet or to count
digestive juice production backward from 100
XI – Accessory Motor neck muscles ▪ ability to calculate – ask client
(sternocleidomastoid and to subtract 7 or 3 progressively
trapezius); movement of head from 100 (100, 93, 86 or 100, 97,
and shoulder 94)
XII – Hypoglossal Motor tongue muscles; movement of Levels of • apply Glasgow Coma Scale
food and tal Consciousness o eye response, motor response, and
verbal response
CN CRANIAL NERVE INJURY ASSOCIATED DEFICIT
I Anosmia
II Visual field deficit; blindness
III Pupillary abnormalities, diplopia (double vision), ptosis
(drooping of upper eyelid)
IV diplopia secondary to superior oblique muscle paralysis
V facial numbness, loss or corneal reflex, weakness of
muscles of mastication (temporal & masseter muscles)
VI diplopia secondary to lateral rectus muscle paralysis
VII paralysis of muscles of facial expression
VIII vestibular dysfunction, hearing loss
IX & X loss of gag reflex, dysphagia (difficulty swallowing), vocal
cord paralysis, tachycardia
XI paralysis of trapexius and sternocleidomastoid muscles,
shoulder dysfunction
XII tongue deviation toward side of injury, tongue atrophy
CRANIAL NERVE ASSESSMENT
CRANIAL NERVE I – OLFACTORY
• ask client to remove any mucus and then close eyes
• occlude one nostril and identify a scented object through the non-
occluded nostril
• anosmia – inability to smell or identify correct scent
CRANIAL NERVE II – OPTIC
• use Snellen’s chart to assess vision in each eye
o ask client to sit or stand 6 meters (20ft) from Snellen’s chart
o cover the eye not being tested
o identify the letters or characters
o take three readings: right eye, left eye, and both eyes
o normal: 20/20 vision OD (right eye) and OS (left eye)
• ask client to read a newspaper or to assess near vision
o reads print at 14 inches
• check visual fields by confrontation
o ask patient to look with both eyes into your eyes or nose
o while you return the patient’s gaze, place hands about 2 feet
apart lateral to patient’s ear
o instruct the patient to point to your fingers as soon as they are
seen
o move slowly the wiggling fingers of both hands along the
imaginary bowl and toward the line of gaze until the patient
identifies them
o repeat in this pattern un upper and lower temporal quadrants
o conduct an opthalmoscopic examination
CRANIAL NERVE II & III – OPTIC AND OCULOMOTOR
• inspect the pupils for color, shape, and symmetry of size
• assess each pupil’s direct and consensual reaction to light
o partially darken a room
o ask client to look straight ahead
o using a penlight and approaching from the side, shine a light
on the pupil
o observe the response
▪ pupils should constrict (direct response)
o shine the light on the pupil again, and observe response of
other pupil
▪ pupil should constrict (consensual response)
• assess each pupil’s reaction to accomodation (ability of the lens
of the eye to change shape)
o hold an object about 10cm from the client’s nose
o ask the client to look firt at the top of the object and then at a
distant ibject behind the penlight
o alternate gaze between the near and far objects
CRANIAL NERVE III, IV, AND VI – OCULOMOTOR, TROCHLEAR,
AND ABDUCENS
• inspect margins of the eyelids; eyelids should cover 2mm of the iris
• assess six ocular movements (trochlear)
• asess directions of gaze (abducens)
o stand directly in front of client
and hold the penlight at a
comfortable distance (30cm infront
of the client’s eyes)
o ask the client to hold head in a fixed position facing you and
follow the movements of the penlight with the eyes only
o move the penlight in a slow, orderly manner through the six
cardinal fiels of gaze
o six ocular movements
– up/right, right, down/right, up/left, left, and down/left
o stop the movement of the penlight periodically so that
nystagmus can be detected
▪ nystagmus – rythmic oscillation of the eyes
CRANIAL NERVE V - TRIGEMINAL
• corneal reflex
o ask client to keep both eyes open and look straight ahead
o lightly touch the cornea with a fine wisp of cotton
• facial sensation
o ask the client to close her/his eyes
o ask the patient to report whether it is “sharp” or dull
▪ allow atleast two seconds between each test
o alternately test for sharp and blunt object in the forehead,
cheeks, and jaw
• light touch
o using a fine wisp of cotton
o ask the patient to respond whenever you touch the skin
• temperature sensation
o ask the patient to identify hot and cold
o touch the skin with test tubes filled with hot and ice-cold water
• jaw movement
o ask the patient to clench his or her teeth
o palpate the temporal and masseter for muscle strength
o muscles should contract bilaterally
CRANIAL NERVE VII - FACIAL
• inspect the face, both at rest and during conversation with the
patient; note for any asymmetry
• observe for tics and any other abnormal movement
• ask the client to: smile, frown and wrinkle forehead, show teeth,
puff out cheeks, purse lips, raise eyebrows, and close eyes tightly
against resistance
o Bell’s palsy – paralysis on the affected side
o stroke - paralysis on the opposite side
• ask client to identify various tastes placed on the tip and sides of
the tongue (anterior two-thirds of tongue)
CRANIAL NERVE VIII – VESTIBULOCOCHLEAR
• whisper test
o ask the patient to occlude one ear and repeat your words
o stand 1-2 feet away (behind the patient)
o exhale fully as to minimize the intensity of your voice
o whisper softly toward the unoccluded ear
o repeat to the other ear
• watch tick test MOTOR ASSESSMENT
o have the client occlude one ear heel-toe walking Romberg’s standing and
o out of the client’s sight, place a ticking watch 2-3 cm (1-2 hopping on foot
inches) from the unoccluded ear
o ask what the client can hear
o repeat to the other ear
• Weber Test
o hold the tuning for at its base
o activate by tapping the fork gently against the back of your
hand near the knuckles or by stroking the fork between thumb
and index finger
o place the base of the vibrating fork on top of the client’s head
and ask whether the client hears the noise equally
• Rinne Test finger to nose alternating fingers to fingers
o ask the client to block the hearing in one ear intermittently by supination and
pressing on the tragus with two fingers pronation
o hold the handle of the activated tuning fork on the mastoid
process of one ear until the client states that the vibration can
no longer be heard
o immediately hold still the vibrating fork prongs in front of the
client’s ear canal; ask whether the client now hears the sound
• Romberg Test
o ask the client to stand with feet together and arms resting at
sides with eyes open; stand close to the patient (behind)
o repeat but ask the client to close their eyes finger to thumb heel to shin graphestisia

CRANIAL NERVE IX & X – GLOSSOPHARYNGEAL AND VAGUS

• apply tastes on the posterior tongue for identification
• ask the client to move tongue from side to side and up and down

• listen for patient’s voice; note for quality and hoarseness

kinesthetic or two-point tactile stereognosis
• ask the patient to say “ah” or to yawn as you watch the movements
position discrimination
of the soft palate and the pharynx
• test for gag reflex
o stimulate the back of throat lightly and repeat on the other side
• check the client’s ability to swallow by giving them a drink of water

CRANIAL NERVE XI – SPINAL ACCESSORY

• look for atrophy or fasciculations in the trapezius muscles and
compare one side with the other
• ask the client to shrug shoulders against resistance
• ask the client to turn head to the side against resistance the repeat
on the other side

CRANIAL NERVE XII – HYPOGLOSSAL

• ask client to protrude tongue at midline then move it side to side
• repeat with resistance (using tongue depressor)

RELEXES ASSESSMENT
biceps triceps brachioradialis

GERIATRIC CONSIDERATIONS
• sense of smell and taste may be decreased
• clients may have reduced muscle mass from degeneration of
muscle fibers
• hand or head tremors or dyskinesia (repetitive movements of lips,
patellar achilles tendon Babinski’s (plantar) jaw, and tongue) may be normal
• some may have slow and uncertain gait; gait assessment may be
very difficult
• rapid alternating movements are difficult due to decreased reaction
time and flexiblity
• light touch and pain sensations may be decreased
• Achilles reflex and flexion of toes may be absent or difficult to elicit
 ASSESSING HEAD, NECK, BREASTS, & LYMPHATIC SYSTEM • sternocleidomastoid (SCM) muscle
– rotates and flexes head
• trapezius muscle – extends the head
HEAD and moves the shoulders
• skull is composed of 22 bones
• cranial nerve XI (spinal accessory)
o divided into two parts: (1) cranium – 8; (2) face – 14
– responsible for muscle movement
of SCM and trapezius
• carotid artery – main blood supply
of the head and brain

NOTE: avoid bilaterally compressing the carotid arteries when

assessing the neck as bilateral compression can reduce the blood
supply to the brain

NECK TRIANGLES
• anterior of SCM (green)
o submandibular triangle
o submental triangle
o carotid triangle
o muscular triangle
CRANIUM – CRANIAL BONES • posterior of SCM (blue)
• houses and protects the brain and the major sensory organs o occipital triangle
• bones in the skull are flat bones o supraclavicular triangle
• the 8 cranial bones that provide protection and structure are:
o 1 frontal o 1 occipital THYROID GLAND
o 2 parietal o 1 ethmoid • largest endocrine gland in the body
o 2 temporal o 1 sphenoid • produces thyroid hormones
• joined by immovable sutures o increase metabolic rate of the body
o sagittal – separates the right and left halves of the skull o hormones: FT3 and FT4 – regulate all metabolic activities
o coronal – between the frontal and parietal bones • has 2 lobes connected by an isthmus
o squamosal – between the parietal and temporal bones • contains 4 parathyroid glands posteriorly
o lambdoid – connect the occipital bone to parietal bones • thyroid cartilage – Adam’s apple; located below the hyoid bone,
posterior to the thyroid gland
FACE – FACIAL BONES • cricoid cartilage – located below the thyroid cartilage
• produce facial movements and expressions
• the 14 facial bones are: LYMPH NODES OF THE HEAD AND NECK
o 2 maxilla o 2 nasal bones
o 2 palatine bones o 1 vomer
o 2 zygomatic bones o 2 inferior nasal conchae
o 2 lacrimal bones o 1 mandible
• all of the facial bones are immovable except for the mandible
o has free movement (up, down, and sideways) at the
temporomandibular joint

OTHERS:
• hyoid bone – “floating bone”
• cervical vertebrae – 7 cervical vertebrae (C1 to C7)
o C1 – “atlas”
o C2 – “axis”
o C7 – vertebral prominens; most prominent

NECK • elastic and has rubbery texture

• contains muscles, hyoid bone, carotid arteries, jugular veins, larynx,
• filters lymph – clear substance composed of excess tissue fluid
trachea, and thyroid gland
o flow of the lymph: subclavian artery (major BV) > drained
• serves as the connection between head and body down or goes back to the venous arc
• produce lymphocytes and antibodies
• if nodes become overwhelmed (mononucleosis – an infection),
they well and become painful
• if cancer metastasizes, nodes may enlarge but are not painful
• most common head and neck lymph nodes
o pre-auricular o submental
o post auricular o superficial cervical
o tonsillar o posterior cervical
o occipital o deep cervical
o submandibular o supraclavicular
• lymphadenopathy – enlargement of lymph nodes above 1cm
 PHYSICAL EXAMINATION
CONSIDERATIONS BEFORE CONDUCTING PHYSICAL
EXAMINATION
• instruct the patient to remove any wig, hat, hair ornaments, pins,
rubber bands, jewelries, and head or neck scarves
• consider cultural norms for touch when assessing the head
• ask the patient to sit upright, back and shoulders held back and
straight
• keep in mind that normal facial structures and features tend to vary
widely among individuals and cultures
• wear gloves (and other PPEs) and prepare stethoscope
INSPECTION: HEAD & NECK
HEAD – size, shape, configuration
normocephalic normal findings: symmetric,
round, erect, in midline, no visible
lesions
microcephaly abnormal small head for age;
usual for babies
macrocephaly abnormal large head for age;
hydrocephalic
acromegaly skull and facial bones are larger
and thicker; close epiphyseal
plate in adulthood; excessive
growth hormone (GH) due to
endocrine problem (anterior
pituitary gland)
Paget’s disease acorn-shaped, enlarged skull;
abnormal or excessive bone
growths (not part of the body)
head bobbing involuntary movement of head;
might indicate aortic insufficiency
(high pressure of the heart)
FACE – symmetry, features (dimples, pimples, freckles, etc.),
movement, expression, and condition of the skin (normal color, pale,
redness, etc.)
stroke facial asymmetry, drooping of
eyelid or nasolabial folds, & one-
sided body weakness
problem in the brain (obstruction
in patient’s cerebral vessels or
arteries or one of the cerebral
artery has ruptured)
Bell’s palsy drooping, weakness, or paralysis
on one side of the face due to
neurologic condition (CN VII or
facial nerve)
NECK – position, symmetry, lumps, or masses; notes for any
palpable lymph nodes or thyroid gland; ask the patient to swallow to
observe for the movement of thyroid cartilage, ask patient to flex the
neck to inspect C7 (vertebral prominens); assess the neck’s ROM
PALPATION: HEAD AND NECK
• note for consistency of the head and face; palpate in circular motion
o hard and smooth without lesions
• palpate the temporal artery
• palpate the temporomandibular joint (TMJ)
• palpate the trachea (two fingers above sternal notch)
• palpate the thyroid gland
o stand behind the patient and use two fingers from both sides
then palpate from chin down
• palpate the lymph nodes of head and neck
o preauricular → postauricular → occipital → tonsillar →
submandibular → submental → superficial cervical →
posterior cervical → deep cervical → supraclavicular nodes
AUSCULTATION: THYROID
• only auscultate if you find an enlarged thyroid gland during
inspection and palpation
• place the bell of the stethoscope over the lateral lobes of the ear
• ask the client to hold his/her breath
o hyperthyroidism – there are bruits
▪ soft, blowing, swishing sounds heard over the lobes
▪ indicate increased blood flow through the thyroid arteries
▪ audible vascular sound associated with turbulent blood
flow
GERIATRIC CONSIDERATIONS
• facial wrinkles are prominent
o subcutaneous fat decreases
• lower face may shrink and the mouth may be drawn inward
o result of resorption of mandibular bone
• cervical curvature may increase because of kyphosis, and fat may
accumulate around the cervical vertebrae (Dowager’s hump)
• thyroid may feel more nodular or irregular because of fibrotic
changes
BREASTS & LYMPHATIC SYSTEM
• paired mammary glands that lie over the anterior chest wall,
anterior to the pectoralis major and serratus anterior muscles
o extend vertically from the second to the sixth rib
o extend horizontally from the sternum to midaxillary line
• enlarges in response to estrogen and progesterone
• functions:
o produce and store milk that provides nourishment
o aid in sexual stimulations
• lymph nodes – drain lymph from the breasts to filter out
microorganisms and return water and protein to the blood
EXTERNAL BREAST ANATOMY
• innervated by the anterior and lateral cutaneous branches of the
4th to 6th intercostal nerves
• breast – smooth and varies in color depending on the client’s skin
tone
• nipple – center of the breast
o contains tiny openings of the lactiferous ducts through which
milk passes
o cold – contract ; hot – relaxed
▪ decreases surface area exposed = decreased amount of
heat lost
• areola – surrounds the nipple • oxytocin – hormone responsible for milk
o contains elevated sebaceous glands (Montogomery’s release or let down
glands) that secrete protective liquid substance during o simulated by nipple sucking
lactation o posterior pituitary gland – where
o more erect during stimulation oxytocin is released
• nipple and areola typically have darker pigment than the breast • lactiferous sinus – slight enlargement in
o amount of pigmentation increases with pregnancy, then each duct; where milk can be stored
decreases after lactation fibrous tissue • provide support for the glandular tissue
• during embryonic development, a milk line or ridge extends from by suspensory ligaments of Cooper
each axilla to the groin area • connective tissue stroma – supporting
o gradually atrophies and disappears as the person grows and structures which surrounds mammary
develops glands
• pectoral fascia – separate the breast
from the pectoralis major muscle and the
breast tissue; attachment point for
suspensory ligaments
fatty tissue • where glandular tissue is embedded
• determines the size and shape of the
breast
• dubcataneous and retromammary fat

LYMPH NODES
• major axillary lymph nodes
• anterior (pectoral) nodes – drain anterior chest wall and breasts
o posterior (subscapular) nodes – drain posterior chest wall
and part of the arms
o lateral (brachial) nodes – drain most of the arms
o central (midaxillary) nodes – receive drainage from the
anterior, posterior, and lateral lymph nodes

INTERNAL BREAST ANATOMY

• vasculature – internal thoracic artery or internal mammary gland

BREAST SELF-EXAMINATION
o branch of subclavian artery
1. inspect breasts standing in front of the mirror and raising your arms
o lateral part of the breast
over your head; observe size, shape, and color
o receive part from the branches of axillary and anterior
• note any swelling, discolorations, dimpling, or nipple
intercostal arteries
drainage by gently squeezing each nipple
• lympathics – receive lymph from the breast
2. repeat step #1 standing in front of the mirror, except place hands
o axillary nodes: 75%
on your hipds
o parasternal nodes: 20%
3. lie down with a small pollow under your head; use hand’s finger
o posterior intercostal nodes: 5%
pads to feel your breasts
• three types of tissue
• using mild, then moderate, then firm pressure down to
glandular tissue • functional part of the breast
your ribcage
• milk production
• cover all breast in a vertical, circular, or wedge pattern
• mammary ducts – converge into a single 4. repeat feeling entire breasts as in step #3 while standing; feel under
lactiferous duct that leaves each lobe and your armpit with elbow slightly bent to make skin less taut
conveys milk to the nipple
• lobe – where milk is produced
• prolactin – hormone that creates milk
 PHYSICAL EXAMINATION GERIATRIC CONSIDERATIONS
• the older client may notice a decrease in the size and firmness of
CONSIDERATIONS BEFORE CONDUCTING PHYSICAL the breasts as she ages because of a decrease in estrogen levels
EXAMINATION o glandular tissue decreases whereas fatty tissue increases
• explain in detail what is happening throughout the assessment and • older client often has more pendulous, less firm, and saggy breasts
answer any questions the client may have • the older client’s breasts may feel more granular, and the
• provide privacy (using a blanket or drape) inframammary ridge may be more easily palpated as it thickens
• have patient sit upright
• explain that it will be necessary to expose both breasts to compare CLINICAL CORRELATION
for symmetry during inspection; one breast may be draped while
the other breast is palpated

INSPECTION
• observe and inspect breast skin, areolas, and nipples for size, color,
shape, rashes, dimpling, swelling, discoloration, retraction,
asymmetry, and other unusual findings

peau d’ orange • orange-peel texture of breast

supernumerary nipples • ‘milk line’
gynecomastia • enlargement of breasts tissues
may be due to puberty (males),
hormonal imbalance (increased
estrogen levels), drug abuse,
cirrhosis, leukemia, and
thyrotoxicosis
• term is only used for males
fibrocystic • benign cyst lesion
Paget’s disease • redness, mild scaling, and flaking
breast disease • round, elastic, defined, tender and mobile
of the nipple
• common to age 30 to menopause
retracted nipple • suggests malignancy
fibroadenoma • benign tumor
• lesions are lobular, ovoid, or round
• firm, well-defined, singular, and mobile
• occur commonly between puberty and
menopause
breast cancer • malignant tumors (near axillary tail of
Spence)
• usually unilateral with irregular, poorly
delineated borders
• hard and nontender, and fixed to underlying
tissues
PALPATION
• mastectomy – removal of breasts
• palpate breasts and axillary lymph nodes for swelling, lumps,
masses, warmth or inflammation, tenderness, and other
abnormalities BREAST CANCER SIGNS AND SYMPTOMS
• ask the client to lie down and to place overhead the arm on the
same side as the breast being palpates; place a small pillow or
rolled towel under the breast being palpated
• use the flat pads of three fingers to palpate the client’s breasts

EARLY DETECTION OF BREAST CANCER

WOMAN’S AGE ACS RECOMMENDATION
40-44 have the option to start annual mammograms
• bimanual technique – for patient’s 45-44 should have annual mammogram
with pendulous breasts to double 55+ can either have mammogram every other year
check for presence of breast mass or continue with annual screening
o nondominant hand under the
breast and dominant hand to • if there is history of breast cancer in the family, be sure to start at
palpate over the top of the breast; the age of 35
palpate in circular motion • breast ultrasound is recommended for young adults rather than
mammogram because they have dense breasts
 ASSESSING NOSE, SINUSES, LUNGS, & THORAX PHYSICAL EXAMINATION

CONSIDERATIONS BEFORE CONDUCTING PHYSICAL

NOSE AND SINUSES EXAMINATION
• ask the client to sit upright with head erect, it is best if the client’s
NOSE head is at nurse’s eye level
• consists of an external portion covered with skin and an internal • explain the specific structures you will be examining
nasal cavity
• dim the room light during transillumination
• external nose – consists of a bridge (upper portion), tip, and two
oval openings called nares
• nasal cavity – located between the roof of the mouth and cranium INSPECTION AND PALPATION OF NOSE
• Kiesselbach area – front of the nasal septum contains a rich
supply of blood vessels
• conchae – superior, middle, and inferior turbinates
o increases the surface area that is exposed to incoming air
• as the person inspires air, nasal hairs (vibrissae) filter large
particles from the air
o rich blood supply of the nose warms the inspired air as it is
moistened by the mucous membrane

SINUSES
• four pair of paranasal sinuses are located in the skull
o frontal – above the eyes
o maxillary – in the upper jaw
o ethmoidal, and sphenoidal – smaller, located deeper in the
skull; not accessible to examination by the nurse
• decrease the weight of the skull and act as resonance chambers
during speech
• often a primary site of infection because they can easily beccome
blocked
• inspect and palpate the external nose for nasal color, shape,
consistency, and tenderness
• check patency of air flow through the nostrils by occluding one
nostril at a time and asking client to sniff or exhale
• inspect internal nose using an otoscope (with short wide-tip
attachment) or a nasal speculum and penlight
o use nondominant hand to stabilize and gently tilt the client’s
head back
o insert the tip of the otoscope into the client’s nostril without
touching the nasal septum and slowly direct the otoscope
back and up; inspect the nasal mucosa, nasal septum, the
inferior and middle turbinates, and nasal passage
▪ position the otoscope’s handle to the side to improve the
view of the structures
o use a penlight and hold the tip of the nose slightly up
• nasal mucosa is dark pink, moist, and free of excudate; nasal
septum is intact and turbinates are dark, pink, and free of lesions
• deviated septum may appear to be an overgrowth of tissue –
normal finding as long as breathing is not obstructed
upper respiratory tract • nasal mucosa is red and swollen
infection (URI)
purulent nasal discharge • seen with acute bacterial
rhinosinusitis
bleeding (epistaxis) • on the lower part of the nasal
septum with local irritation
ulcers of nasal mucosa • seen with the use of cocaine,
or perforated septum trauma, chronic infection, or
chronic nose picking
INSPECTION – TRANSILLUMINATION OF SINUSES
• frontal sinus – place the light just below the brow and cup head
over the light; look for a warm red glow in frontal area
• maxillary sinus – ask the patient to tilt head back and open mouth;
place light against cheek bone below the eye; a reddish glow on
the hard palate indicates normal air-filled sinus
PALPATION OF SINUSES
• palpate frontal sinuses by using the thumbs to press up on the
brown on each side of the nose
• palpate maxillary sinuses by pressing with thumbs up on the
maxillary sinuses
PERCUSSION OF SINUSES
• percuss frontal sinus by lightly tapping over the brow bone and ask
client if they feel any discomfort
• percuss maxillary sinus by identifying cheekbone, go beneath it,
and tap lightly and ask client if they feel any discomfort
LUNGS AND THORAX
STRUCTURE AND FUNCTION
• thorax – extends from the base of the neck superiorly to the level
of the diaphragm inferiorly
• lower respiratory system – constituted by the lungs, distal portion
of the trachea, and the bronchi are located in the thorax
• thoracic cage – outer structure of the thorax
• thoracic cavity – contains respiratory components
THORACIC CAGE
• constructed of the sternum, 12 pairs of ribs, 12 thoracic vertebrae,
muscles, and cartilage
• provides support and protection for many important organs
STERNUM AND CLAVICLES
• sternum – lies in the center of the chest anteriorly
o manubrium – connects laterally with the clavicles and the first
two pairs of ribs
o clavicles – extend from the manubrium to the acromion of the
scapula
o xiphoid process
• suprasternal notch – U-shaped indentation located on the
superior border of the manubrium
• sternal angle (angle of Louis) – location of the second pair of ribs
o where the manubrium articulates with the body of the sternum
RIBS AND THORACIC VERTEBRAE
• the 12 pairs of ribs constitute the main structure of the thoracic
cage
• first seven pairs – articulate with the sternum by way of costal
cartilage
o second ribs and intercostal spaces – easily located
adjacent to the sternal angle
• seven through ten – connect to the cartilages of the pair lying
superior to them rather than the sternum
o costal angle – between the left and right costal margins,
meeting at the level of the xiphoid process
• 11th and 12th pairs – “floating ribs”; do not connect to either the
sternum or another pair of ribs anteriorly
• vertebra prominens – spinous process of the seventh cervical
vertebra (C7)
o the lower tip of each scapula is at the level of the seventh or
eight rib when the arms are at the client’s side
VERTICAL REFERENCE LINES
THORACIC CAVITY
• consist of the mediastinum and the lungs and is lined by the pleural
membranes; lungs lie on each side of the mediastinum
• mediastinum – central area in the thoracic cavity that contains the
trachea, bronchi, esophagus heart, and great vessels

TRACHEA AND BRONCHI

• trachea – approximately 10 to 12 cm long in an adult; C-shaped
rings of hyaline cartilage compose the trachea (help to maintain its
shape and prevent the trachea from collapsing during respiration)
• right main bronchus is shorter and more vertical than the left
main bronchus, making aspirated objects more likely to enter the
right lung than the left

LUNGS
• right lung is made up of three lobes
• left lung contains only two lobes
• fissures – separates the lobes
o oblique fissures – begins from the upper part of the hilum on
the mediastinal surface and cuts the vertebral border at the
fourth or fifth level of the thoracic spine
▪ extend from T3 to the sixth rib at the midclavicular line
o horizontal fissure – separates the right upper lobe from the
middle lobe; extends from the fifth rib in the right midaxillary PHYSICAL EXAMINATION
line to the third intercostal space or fourth rib at the right
sternal angle CONSIDERATIONS BEFORE CONDUCTING PHYSICAL
▪ only present in the right lung EXAMINATION
• during deep inspiration, the lungs extend down to about the eight • observe any obvious difficulty in breathing
intercostal space anteriorly and the twelfth intercostal space • have the client remove all clothing from the waist up and put on an
posteriorly examination gown or drape
• during expiration, the lungs rise to the fifth or sixth intercostal • explain that exposure of the entire chest is necessary during some
space anteriorly and tenth posteriorly parts of the examination, specially for female clients
• ask client to sit in an upright position with arms relaxed at the sides

INSPECTION
• inspect for nasal flaring, pursed lip breathing, color and shape of
nails, and observe color of face, lips, and chest
o normal: 160-degree angle between the nail base and the skin
o pale or cyanotic nails indicate hypoxia
• stand behind the client and observe the position of scapulae and
the shape and configuration of the chest wall
o ratio of AP to transverse diameter is 1:2
• observe the use of accessory muscles (trapezius) and inspect the
client’s position
o leaning forward enhances the use of accessory muscles to
aid breathing

PALPATION
• palpate for tenderness and sensation
using your fingers starting toward the
midline at the level of the left scapula,
PLEURAL MEMBRANES moving hand left toward right
• parietal pleura – lines the chest cavity • palpate for crepitus (subcataneous
• visceral pleura – covers the external surface of the lungs emphysema) – crackling sensation
• palpate for fremitus – vibrations of air
MECHANICS OF BREATHING in the broncial tubes transmitted to the
• maintain adequate oxygen level in the blood to support cellular life chest wall; ask the client to say ninety-nine or tres-tres while you
• respiration assists in the rapid compensation for metabolic acid- move your hand to each area and assess all areas for symmetry
base defects and intensity of vibrations
• external respiration or ventilation – mechanical act of breathing • assess chest expansion by placing
and is accompanied by expansion of the chest, both vertically and hands on the posterior chest wall with
horizontally thumbs at the level of T9 or T10 and
• breathing patterns – change according to cellular demands pressing together a small skin fold
o thumbs should move 5-10cm
inspiration inflow of air into the lungs apart symmetrically
expiration relaxation of the intercostal muscles and diaphragm o atelectasis – collapse or
incomplete expansion
hypercapnia increase in carbon dioxide level in the blood
o pneumothorax – air in the pleural
rise of carbon dioxide levels, increases respiration
space
hypoxemia decrease in oxygen
PALPATION
• percuss for tone at the apices of the scapulae and percuss across
the tops of both shoulders then percuss the intercostal spaces
across and down, comparing sides
o resonance – tone elicited over the normal lung tissue
• percuss for diaphragmatic excursion
o ask the client to exhale forcefully and hold breath
o begin at scapular line (T7)
o percuss downward until resonance changes to dullness
o ask the client to inhale deeply and hold it
o percuss downward until resonance changes to dullness
o level of diaphragm ma be higher on the right because of the
position of liver and excursion can measure up to 7 or 8 cm

AUSCULTATION
• place the diaphragm of the stethoscope firmly and directly on the
posterior chest wall at the apex of the lung at C7
o ask the client to breathe deeply through the mouth for each RESPIRATION PATTERNS
area of auscultation
o ask client to put arm over the chest then slightly bend forward
• auscultate for adventitious sounds
DISCONTINUOUS SOUNDS
fine crackles high-pitched, short, popping sounds
during inspiration
coarse crackles low-pitched, bubbling, moist sounds
early inspiration to early expiration
CONTINUOUS SOUNDS
pleural friction rub low-pitched, dry, grating sound
during both inspiration and expiration
sibilant wheeze high-pitched, musical sounds
during expiration but may also be heard on
inspiration
sonorous wheeze low-pitched snoring or moaning sound
primarily during expiration but may be heard
throughout the respiratory cycle
• auscultate voice sounds
broncophony ninety-nine
normal: soft, muffled, indistinct; phrase cannot
be distinguished
abnormal: wods are easily understood and NSL&T DEFORMITIES AND CONFIGURATIONS
louder over areas of increased density dyspnea difficulty in breathing
egophony letter “E” orthopnea difficulty breathing when lying supine
normal: soft and muffled; letter “E” should be paroxysmal severe dyspnea that awakens the person
distinguished and heard as “eeeee” nocturnal dyspnea from sleep
abnormal: sounds like a bleating “aaaa” sound sleep apnea periods of breathing cessation during sleep
whispered one-two-three pleurisy caused by inflammation of parietal pleura
pectoriloquy normal: very faint and muffled; inaudible cardiac ischema medical emergency requiring immediate
abnormal: very clear and distinct assessment and intervention
chronic obstructive chronic inflammatory lung disease that
pulmonary disease causes obstructed airflow from the lungs
NORMAL BREATH SOUNDS normal chest elliptical in shape with ratio of 1:2
BRONCHIAL BRONCHIO- VESICULAR configuration
VESICULAR
barrel chest round shape with ratio of 1:1
pitch high moderate low
quality harsh/hollow mixed breezy pectus excavatum markedly sunken sternum and adjacent
amplitude loud moderate soft cartilages; funnel chest
duration longer in same during longer in pectus carinatum forward protrusion of the sternum causing the
expiration inspiration and inspiration adjacent ribs to slope backward; pigeon chest
(i < e) expiration (i > e)
(i = e) GERIATRIC CONSIDERATIONS
location trachea and between the peripheral lung
• the ability of smell and taste decreases with age
thorax scapulae, around fields; all parts
upper sternum • older adults may experience dyspnea with certain activities
illustration • ability to cough effectively may be decreased due to weaker
muscles and increased rigidity of thoracic wall
• kyphosis is normal in older adults
• thoracic expansion may be decreased but should still be symmetric