PHYSICAL ASSESSMENT

BODY PART TECHNIQUE NORMAL ACTUAL ANALYSIS

TO BE FINDINGS FINDINGS
ASSESSED
SKIN
• Note for color INSPECTION Varies from The skin is Pallor is due to
and light to deep pale. It is decreased
uniformity brown; from warm to visibility of the
ruddy pink to touch.. the normal
Best assessed light; from oxyhemoglobin.
under natural yellow over The patient has a
light and on tones to olive. decreased blood
areas not Generally flow.
exposed to sun. uniform expect
in areas
exposed to
sun; area of
lither
pigmentation
(palm, lips,
nail beds in
dark skinned
people)

• Assess INSPECTION/ No edema Presence of The excess

presence of PALPATION edema in the salt causes
edema IV site. the body to
retain water.
This water
then leaks into
the interstitial
tissue spaces,
where it
appears as
edema.

• Assess skin PALPATION Moisture in the The skin folds

moisture. skin folds and and the axillea
Note skin in the axillae, are uniform in
lesions freckles, some moisture. NORMAL
according to birthmarks, No lesions
location, some flat and were noted.
distribution, raised nevi Birthmark was
color, (moles); no noted on the
configuration abrasion or any back. Some
, size, shape, other lesion. moles were
type or seen (flat and
structure raised).
No abrasion or
any other
lesion.

• Note skin Uniform, It is uniform

temperature, within normal within normal NORMAL
compare the range. range.
two feet and
two hands
 using the
backs of your
fingers

• Note skin When pinched, Decreased

turgor skin springs skin turgor Poor skin turgor
(fullness and back to is due to severe
elasticity) previous state weight loss of
the patient.
HAIR

• Note INSPECTION Evenly Hair is black, Thinning of hair

evenness of distributed thin, dry but is a sign of
growth over hair, thick, evenly aging.
the scalp, silky and distributed to
thinness or resilient hair. the scalp.
thickness of
scalp, texture
and oiliness.

• Note No infection or There is a

presence of infestation. little bit of Hair not
infections or dandruff, no properly rinse.
infestations infection and
infestation
(presence of
few lice) was
noted.

• Palpate for PALPATION Fine. Fine NORMAL

texture.
NAILS

• Note finger INSPECTION Convex Convex in NORMAL

nail plate curvature; curvature,
shape to angle of nail 160° angle of
determine its plate about nail plate.
curvature and 160°.
angle.

• Note finger INSPECTION Smooth It is smooth in NORMAL

nail and texture. texture.
toenail
texture.

• Note toenail INSPECTION Highly Pinkish and NORMAL

bed color. vascular and high vascular
pink in light
skinned
clients; dark
skinned clients
may have
brown or black
pigmentation
in longitudinal
streaks
• Note tissue INSPECTION Intact Skin around NORMAL
surrounding epidermis the nails is
nails. intact.

• Perform Prompt return Poor capillary Poor capillary

blanch test of of pink or refill refill due to poor
capillary usual color. cardiac output
refill. (Generally less
than four
seconds.)

Skull

Size and symmetry INSPECTION Normocephalic, Normocephalic NORMAL

and shape symmetrical ,symmetrical

Presence of nodules, PALPATION No presence of No presence of NORMAL

masses and nodules, masses nodules,
depressions and depressions masses and
depressions
was noted.

Scalp

Color, appearance INSPECTION White in color, no White in Scalp was

flakes and color, few not
infestations and flakes and properly
masses, no scars infestations rinse.
(lice) and no
masses, no
scars was
seen.

Tenderness PALPATION No presence of No presence NORMAL

tenderness of tenderness
 BODY PART TO TECHNIQUE NORMAL ACTUAL ANALYSIS
BE ASSESSED
FINDINGS FINDINGS

External eye
structures
1.Inspect the
eyebrows for hair INSPECTION Hair evenly Hair is evenly NORMAL
distribution and distributed; skin distributed; skin
alignment and skin intact intact.
quality movement
Eyebrows Eyebrows
symmetrical aligned; symmetrical aligned;
equal movement equal in movement.

Inspect the eyelashes INSPECTION Equally distributed; It is equally NORMAL

for evenness of curl slightly outward distributed; curl
distribution and slightly outward.
direction of curl

Inspect the eyelids for INSPECTION Skin intact; no Skin is intact; no NORMAL
surface characteristics discharge; no discharge; no
position in relation to discoloration; lids discoloration; lids
cornea, ability to blink close symmetrically; close symmetrically;
and frequency of approximately 15-20 approximately 15-20
blinking involuntary blinks involuntary blinks per
per min.; bilateral min.; bilateral
blinking; when lids blinking; when lids
open no visible open no visible sclera
sclera above cornea above cornea and
and upper and lower upper and lower
border of cornea are border of cornea are
slightly covered slightly covered.
Transparent Transparent
capillaries; capillaries; sometimes
sometimes evident; evident; sclera
sclera appears appears white
white(yellowish in
dark skinned clients)

Inspect bulbar INSPECTION Shiny, smooth, and Pale bulbar Pale is due to
conjunctiva for color, pink or red conjunctiva decreased
texture and the visibility of
presence of lesions the the normal
oxyhemoglobi
n.

It should appear pink The patient’s Pale is due to

INSPECTION and moist. palpebral conjunctiva
Inspect the palpebral decreased
looks slightly wet and visibility of
conjunctiva by
pale in color. the the normal
everting the lids
oxyhemoglobi
n.

It should appear The patient’s upper

Body Parts To Be Technique Normal Actual Analysis
Assessed Findings Findings

Ears and Hearing

Inspect the auricles Inspection Color same as facial Color similar to NORMAL
for color, skin symmetrical, facial skin,
symmetry of size auricle aligned with symmetrical,
and position the outer cantus of auricles aligned
eyes. with the outer
cantus of eyes.

Palpate The Palpation Mobile, firm, and not Movable, firm, and NORMAL
auricles for tender; pinna recoils not tender; pinna
texture, elasticity, after it is folded returns to normal
and areas of shape after it is
tenderness folded

Using an otoscope, Inspection Distal third contains Hair follicles and NORMAL
inspect the external hair follicles and glands can be seen
ear canal for glands in the distal third
cerumen, skin
lesions pus , and Dry Cerumen, The Cerumen is dry
blood Grayish-tan color; or
sticky wet cerumen in
various shades of
brown

Inspect the Inspection Pearl gray color, Pearl gray color, NORMAL
tympanic Semitransparent Translucent
membrane for
color and gloss

Assess client’s Inspection Normal voice Patient can hear normal NORMAL
response to normal tones audible voice tones
voice tones.

Perform the watch Inspection Able to hear The client cannot hear This
tick test ticking of ticking in both Ticking sounds audible indicates a
a watch has a ears in both ears hearing less
higher pitch than in the high
the human voice. frequency
range that
may be
caused by
excessive
exposure to
loud noise

Tuning Fork Test

Perform Weber’s Inspection Sound is heard in Patient cannot hear The patient
test to assess bone both ears or is sound on both ears cannot hear
conduction localized at the sound due to
center of the head ototoxic
drug that
she had
taken.

Conduct the Rinne Inspection Air-conducted Air-Conducted hearing NORMAL

test to compare air hearing is greater was greater than the
conduction to bone than bone bone conducted hearing
conduction conducted
hearing

NOSE &
SINUSES

Inspect the Inspection Symmetric and Symmetric and NORMAL

external nose for straight no straight ,no presence of
any deviations in discharge or flaring discharge or flaring,
shape, size, or uniform color uniform in color
color and flaring
or discharge from
the nares.
Lightly palpate the Palpation Not tender; no Nose is not tender; no NORMAL
external nose to lesions lesions can be seen
determine any
areas of tenderness
masses and
displacements of
bone and cartilage

Determine Patency Inspection Air moves freely as No obstructions are NORMAL

of both nasal the client breathes present,air passes freely
cavities through the nares in the nares when
patient breathes

Inspect the nasal Inspection There should be no No swelling, tenderness NORMAL

cavities using a swelling, redness or or redness is present
flashlight or a any tenderness
nasal speculum

Observe for the Inspection Mucosa pink clear, Mucosa is pale, clear, Pale is due
presence of watery discharge no no discharge ,no lesions to decreased
redness swelling, lesions visibility of
the the
growths, and
normal
discharge. oxyhemoglo
bin.

Inspect the nasal Inspection Nasal septum intact Nasal septum is intact NORMAL
septum between and aligned in the and located at the
the nasal chambers midline midline

Bone and cartilage Palpation There should be no No presence of NORMAL

displacements, displacements,masses
masses and or tenderness
tenderness

Palpate the Inspection There should be no No inflammation or NORMAL

maxillary and and inflammation and tenderness is present
frontal sinuses for Palpation tenderness
tenderness

Mouth and Oropharynx

Inspect the outer Inspection Uniform pink color Uniform color: pale. Pale is due
lips for symmetry Soft, moist, smooth Soft,smooth and moist. to decreased
of contour, color texture symmetry of Lips are symmetrical, visibility of
the the
and texture contour, ability to patient is able to purse
normal
purse lips lips oxyhemoglo
bin.
Inspect and palpate Inspection Uniform pink color, Uniform color: pale. Pale is due
the inner lips and moist, smooth, Moist, smooth and to decreased
buccal mucosa for glistening and glistening. Both are visibility of
the the
color, moisture , elastic texture elastic.
normal
texture, and oxyhemoglo
presence of lesions bin.

Inspect the teeth Inspection 32 adult teeth, The client has 18 adult Pale is due
and gums while smooth, white, teeth. Gums are pale to decreased
examining the shiny tooth enamel, ,firm and shows no visibility of
the the
inner lips and pink gums, moist retraction.
normal
buccal mucosa firm texture to oxyhemoglo
gums, no retraction bin. Teeth
of gums maybe not
properly
brush.

Inspect the Inspection Smooth, intact No Dentures NORMAL

dentures dentures

Inspect the surface Inspection Central position Located at the center NORMAL
of the position
color and texture

Inspect the base of Inspection Smooth tongue base Tongue base is smooth NORMAL
the tongue, the with prominate with prominate veins
mouth floor, and veins
the frenulum
Palpate the tongue Palpation Smooth with no Smooth. Absence of NORMAL
and floor of the palpable nodules nodules and lumps.
mouth for any
nodules, lumps, or
excoriated areas.
To palpate the
tongue use gauze
to grasp its tip.

Inspect salivary Inspection Same as color of Color is similar with NORMAL

duct openings for buccal mucosa and buccal mucosa and floor
any swelling or floor of mouth of mouth
redness

Inspect the hard Inspection Light pink, smooth, Soft palate: light pink, NORMAL
and soft palate for soft palate lighter smooth
color, shape, pink hard palate,
texture, and the more irregular Hard palate: light pink,
presence of bony texture. irregular texture
prominences

Inspect the uvula Inspection Positioned in Uvula located at the NORMAL

for position and midline of soft midline of soft palate
mobility while palate
examining the
palates

Inspect the Inspection Pink and smooth Color of posterior wall NORMAL
oropharynx for posterior wall is pink, texture is
color and texture smooth
inspect one side at
a time to avoid
eliciting the gag
reflex

Inspect the tonsils Inspection Pink and smooth, Tonsils are pink and NORMAL
for color, no discharge of smooth, with no
discharge, and size normal size presence of discharge
and of normal size

Elicit the gag Inspection Present Gag reflex triggered NORMAL

reflex by pressing when posterior tongue
the posterior was pressed with a
tongue with a tongue blade
tongue blade
Neck and Glands

Inspect the neck Palpation Muscles equal size; Muscles are of equal NORMAL
muscles for head centered size; head positioned at
abnormal the center
swellings or
masses.

Observe head Inspection Coordinated, Coordinated, smooth NORMAL

movement. smooth movements movements with no
with no discomfort discomfort or pain

Move the chin to Inspection Head flexes 45 Head flexed at 45 NORMAL

the chest degree degrees

Move the head Inspection Head hyper-extends Head hyper-extended at NORMAL

back so that the 60 degree 60 degrees
chin points upward

Move the head so Inspection Head laterally Head flexed laterally at NORMAL
the ear is moved flexes 40 degree 40 degrees
toward the
shoulder on each
side

Turn the head to Inspection Head laterally Head laterally rotated at NORMAL
the right and to the rotates 70 degree 70 degrees
left

Muscle strength Inspection Equal strength Equal strength was NORMAL

turn the head to demonstrated
one side against
the resistance of
your hand repeat
on the other side

Shrug the Inspection Equal strength Equal strength was NORMAL

shoulders against demonstrated
the resistance of
your hands

Palpate the entire Palpation No lymph nodes No lymph nodes were NORMAL
neck for enlarged should be palpable palpated
lymph nodes,
Palpate the trachea Palpation Central placement Located at midline NORMAL
for lateral in midline of neck
deviation. spaces are equal on Spaces are equal
both sides

Inspect the thyroid Inspection Not visible on Not visible during NORMAL
gland stand in inspection inspection
front of the client,
observe the lower
half of the neck
overlying the
thyroid gland for
symmetry and
visible masses

Hyper extend the Inspection Glands ascends Glands rise while NOMAL
head and swallow during swallowing swallowing
but not visible

Palpate the thyroid Palpation Lobes may not be Glands were not NORMAL
gland for palpated if palpated, palpable, no pain is felt
smoothness lobes are small, during swallowing
smooth centrally
located, painless
and rise freely with
swallowing

If enlargement of Auscultate Absence of bruit No bruit is present NORMAL

the gland is
suspected,
auscultate over the
thyroid area for a
bruit

BODY PART TO TECHNIQUE NORMAL ACTUAL ANALYSIS

BE ASSESSED FINDINGS FINDINGS
POSTERIOR
THORAX
1. Inspect the shape, INSPECTION Anteroposteri Anteroposterior Normal
symmetry of the or to to transverse
thorax from posterior transverse diameter ratio
to lateral views. diameter in is 1:2. Chest is
Compare the ratio of 1:2. symmetrical.
anteroposterior Chest
diameter to the symmetric
transverse diameter.
2. Inspect the spinal INSPECTION Spine Spine of the px Normal
alignment for vertically is aligned
deformities. aligned. vertically.
3. Place the palms of PALPATION Full and Full and Normal
both your hands over symmetric symmetrical
the lower thorax with chest expansion
your thumbs adjacent expansion when the px
to the spine and your (when the performs deep
fingers stretched client takes a inspiration.
laterally. deep breath,
your thumbs
should move
apart an equal
distance and
at the same
time;
normally the
thumbs
separate 3-5
cm (1.5-2
inches) during
deep
inspiration.

4. Palpate the chest PALPATION 1. Bilateral Fremitus is felt Normal

for vocal (tactile) symmetry of most at the
fremitus, the faintly vocal apex of the
perceptible vibration fremitus. lungs.
felt through the chest 2. Fremitus is
wall when the client heard most of
speaks. clearly at the
apex of the
lungs.
3. Low
pitched voices
of males are
more readily
palpated than
higher pitched
voices of
females.

5. Percuss the thorax PERCUSSION Percussion When Normal

notes percussed
• Ask resonate, resonant sounds
the client to except over are heard
bent the scapula. except over the
head and scapula.
fold the
arms
forward
across the
chest. This
separates
the scapula
and
exposes
more lung
 tissue to
percussion.
• Percus
s in the
intercostal
spaces
about 5cm
(2 in)
intervals in
a
systematic
sequence.
• Compare
one side of
the lung
with the
other.
• Percuss the
lateral
thorax
every few
inches,
starting at
the axilla
and
working
down to the
eight rib.
6. Percuss the PERCUSSION Excursion is 3 Bilateral Normal
diaphragmatic to 5 cm excursion of 3-
excursion. bilaterally in 5 cm is present
women and 5
to 6 cm in
men.
7. Auscultate the AUSCULTATE Vesicular and Vesicular and Normal
chest using the flat- bronchovesic bronchovesicul
disc diaphragm of the ular breath ar Are breath
stethoscope. sounds sounds are
heard.

ANTERIOR
THORAX
8. Inspect breathing INSPECTION Quiet, Patients shows Normal
pattern (respiratory rhythmic, and quiet, rhythmic
rate rhythm) effortless and effortless
respirations. respiration.

9. Inspect costal INSPECTION Costal angle The ribs of the Normal

angle and the angle is less than 90 px is insert into
which rib enters the degrees and the spine at
spine. the ribs insert approximately
into the spine a 45 degrees
at angle and
approximately Costal angle is
a 45 degrees less than 90
 angle. degrees

10. Palpate the PALPATION Full and Full and Normal

anterior chest for symmetric symmetrical
respiratory excursion. chest chest expansion
expansion is present when
(then the patient takes a
client takes a deep breath.
deep breath,
your thumb
should move
apart an equal
distance and
at the same
time,
normally the
thumbs
separate 3-5
cm (1.5-2
inches) during
deep
inspiration.
11. Palpate tactile PALPATION Bilateral Fremitus is Normal
fremitus in the same symmetry of heard mostly at
manner as for the vocal the apex of the
posterior chest and fremitus. lungs.
using the sequence. If Fremitus is
the breasts are large heard most of
and cannot be clearly at the
retracted adequately apex of the
for palpation, this lungs:
part of examination is fremitus is
usually omitted. normally
decreased
over heart and
breast tissue.

12. Percuss the PERCUSSION Percussion Upon notes Normal

anterior chest notes resonate resonant sounds
systematically. down to the was noted to
sixth rib at the the 6th rib at the
• Beginning level of the level of the
above the diaphragm diaphragm but
clavicle in the but flat over flat over areas
supraclavicula areas of heavy of heavy
r space, and muscles and muscles and
proceed bone, dull on bone, dull on
downward to areas over the areas over the
diaphragm. heart as the heart as the
• Compare one liver, liver,
side of the thympanic thympanic over
lung to the over the the underlying
other. underlying stomach.
• Displace stomach.
female breast
 for proper
examination.

13. Auscultate the AUSCULTATE Bronchial and Brinchial and Normal

trachea. breath sounds breath sounds
were heard.
14. Auscultate the AUSCULTATE Bronchovesic Bronchovesicul Normal
anterior chest. ular and ar and vesicular
vesicular breath sounds
breath sounds were heard.

Peripheral Vascular System

BODY PART TO TECHNIQUE NORMAL ACTUAL ANALYSIS

BE ASSESSED FINDINGS FINDINGS

Palpate the Palpation Symmetric Symmetric pulse NORMAL

peripheral pulses pulse volume. volume was
on both sides of observed.
the client’s body
individually, Full pulsation was
Full pulsations. observed
simultaneously,
and systematically
to determine the
symmetry of pulse
volume.

Inspect the Inspection In dependent In dependent NORMAL

peripheral veins in position, position, presence
the arms and legs presence of of distension and
for the presence distension and nodular bulges at
and/or appearance nodular bulges calves was noted
of superficial veins at calves.
when limbs are When limbs are
dependent and When limbs elevated, veins
when limbs are elevated, veins collapse
elevated. collapse.

Assess the Inspection Limbs not Limbs are not NORMAL

peripheral legs tender. tender.
veins for signs of
phlebitis Symmetric in Symmetric in size
size. and shape.

Inspect the skin of Inspection Skin color Skin color pink. NORMAL
the hands and feet No presence of
for color, pink. edema, has no skin
temperature, changes and
edema, and skin regular
changes. temperature

Assess the Inspection Buerger’s test: Is positive in NORMAL

adequacy of original color Buerger’s test
arterial flow if returns in 10
arterial secs.; veins in
insufficiency is feet or hands
suspected. fill in about 15
secs.
Poor capillary
Capillary refill Poor capillary refill due to poor
test: immediate refill cardiac output.
return of color.

BODY PARTS TO TECHNIQUE NORMAL ACTUAL ANALYSIS

BE ASSESSED
FINDINGS FINDINGS

Breast

Inspect the breast Inspection slightly unequal generally NORMAL

for size, symmetry in size; generally symmetrical
and contour of symmetric
shape while client is
in sitting position

Skin uniform in
color (same of Skin color is
Inspect the skin of Inspection
appearance as uniform and
the breast for
localized skin of abdomen similar with the
NORMAL
discolorations or or back);Skin skin of back and
hyperpigmentation, smooth and abdomen, smooth,
retraction or with presence of
intact;Diffuse
dimpling,localized striae, and absence
hypervascular areas, symmetric
horizontal or of dimpling and
swelling or edema
vertical vascular hyperpigmentation
pattern in light-
skinned people
Striae (stretch
 marks) moles

Emphasize
retraction by having During inspection,
client no retraction was
Inspection present NORMAL
No presence of
• Race the
retraction
arms above
the head

• Push the
hands
together
with elbows
fixed

• Press the
hands down
on the hips

Round and
NORMAL
bilaterally similar.
Inspect the areola
Round or oval
area for size, shape, Inspection
symmetry, color, and bilaterally
surface same Dark brown in
characteristics, and color. NORMAL
any masses or Color varies
lesions. lightly from light
pink to dark
brown

Placement of NORMAL
sebaceous glands
Irregular
is irregular.
placement of
sebaceous glands
on the surface of
the areola
(Montogomery’s
tubercles)
Nipples are equal
Inspect the nipples in size, same in
NORMAL
for size, shape, Round, everted, color, soft and
position, color, and equal in smooth, and both
Inspection
discharge, and size; similar in nipples point
lesions. color; soft and forward.
smooth; both
nipples point in
the same
No discharge
direction
Palpate the axillary ,
subclavicular, and No discharge, NORMAL
supraclavicular except from present
lymph nodes while pregnant or
breast feeding
the clients sits with
females
the arms abducted
and supported on
the nurse’s forearm

• The edge of
Inversion of one No nipple is NORMAL
greater
or both nipples inverted.
pectoral
that is present
muscle
Palpation from puberty
(musculus
pectoralis
major) along
the anterior
axillary line

No tenderness, No tenderness,
• The thoracic NORMAL
No masses or masses or nodules
wall on the nodules present
midaxillary
area No tenderness
No tenderness No
No masses or
masses or nodules
nodules No NORMAL
• The upper No nipple
nipple discharge
part of the discharge
humerus

No tenderness
No tenderness No
No masses
• The anterior masses or nodules NORMAL
No nodules or
edge of the No nipple
latissimus nipple discharge
discharge
dorsi muscle
along the
posterioraxil
lary line
No tenderness No tenderness,
No masses masses nodules or
Palpate the breast nipple discharge NORMAL
No nodules or
for masses, present.
nipple discharge
tenderness, and any Palpation
discharge from the
nipples

No tenderness No tenderness,
Palpate the areola No masses masses, nodules or NORMAL
and nipples for No nodules or nipple discharge
masses
 Palpation nipple discharge prensent

BODY PART TO TECHNIQUE NORMAL ACTUAL ANALYSIS

BE ASSESSED FINDINGS FINDINGS
Inspect the abdomen Unblemished skin Px is unblemished NORMAL
for skin integrity Inspection Uniform color and uniform in color
Silver-white striae
or surgical scars

Flat rounded Px abdomen is flat NORMAL

Inspect the abdomen Inspection (convex), or rounded and
for contour and scaphoid scaphoid, there is no
symmetry. (concave). evidence of
No evidence of enlargement of the
enlargement of liver or spleen
liver or spleen.
Symmetric contour

Observe abdominal Inspection Symmetric Px abdomen is NORMAL

movements movements caused symmetrical in
associated with by respiration. movement caused by
respirations, Visible peristalsis respiration, presence
peristalsis or aortic in very lean of peristalsis and
pulsations people. aortic pulsation in the
Aortic pulsations px epigastric area.
in thin persons at
epigastric area
Observe the vascular No visible vascular The px has negative NORMAL
pattern. Inspection pattern. presence of vascular
pattern
Auscultate the The px abdomen has NORMAL
abdomen for bowel Auscultation Audible bowel clear bowel sounds.
sounds, vascular sounds There is absence of
sounds, and Absence or atrial atrial bruits and
peritoneal friction bruits friction rubs.
rubs. Absence of friction
rubs
Percuss several areas Tympany over the Atrophy is present in NORMAL
in each of the four Auscultation stomach and gas- the stomach. Gas-
quadrants to filled bowels; filled bowels upon
determine presence dullness, the px’s peristalsis.
of tympany and especially over the
dullness. liver and spleen, or
a full bladder
Percuss the liver to Percussion 6 to 12 cm (2 ½ to Upon measurement NORMAL
determine its size. 3 ½ in) in the mid of liver, there is 6 to
clavicular line; 4 12 cm in the mid
to 8 cm (1 ½ to 3 clavicular line and 4
in) at the to 8 cm at the
midsternal line. midsternal line.
Perform light Percussion No tenderness; Upon performing NORMAL
palpation first to relaxed abdomen light palpation, there
detect areas of with smooth, is no presence of
tenderness and/or or consistent tension tenderness, abdomen
muscle guarding. is relaxed and smooth
Symetrically explore with consistent
all four quadrants. tension detected.
Perform light No tenderness; Performing a light NORMAL
palpation first to Percussion relaxed abdomen palpation, there is no
detect areas of with presence of
tenderness and/or smooth.consistent tenderness, abdomen
muscle guarding tension is relaxed and smooth
with consistent
tension detected.

Perform deep Palpation Tenderness may be Performing deep NORMAL

palpation over all present near palpation over the
four quadrants . xiphoid process, four quadrants,
over cecum, and tenderness is present
over sigmoid colon in the xiphoid process
over cecum and also
in the sigmoid colon.
Palpate the liver to Palpation May not be Upon palpation of the NORMAL
detect enlargement palpable. liver, the border feels
and tenderness. Border feels smooth and
smooth sometimes not
palpable.

Palpate the ares Palpation Distended and It is distended and NORMAL

above the pubic palpable as palpable as smooth,
symphisis if the smooth, round, round.
clients history tense mass
indicates possible (indicates urinary
urinary retention. retention)
BODY PART TO TECHNIQUE NORMAL ACTUAL ANALYSIS
BE ASSESSED FINDINGS FINDINGS
Muscles:

Inspect the muscles Inspection Equal size on both The px’s muscle size NORMAL
for size and compare sides of the body on the left side is
both sides similar to the muscle
size on the right side.

Inspect the muscles Inspection No contractures There is no visible

and tendons shortening of muscle NORMAL
and tendons of the
px.

Inspect the muscles Inspection No fasciculations Upon inspection of NORMAL

for fasciculations muscles there are no
and tremors visible tremors and
fasciculation.

Palpate muscles at Palpation Normally firm Upon palpation of

rest to determine muscle at rest the NORMAL
muscle tonicity muscle tone is
normally firm.

Test muscle strength Inspection Equal strength on The px exhibit equal

each body side muscle strength to NORMAL
each side of the body.

Bones:

Inspect the skeleton Inspection No deformities There are no NORMAL

for structure and deformities in the
deformities px’s skeleton
 structure.
Areas
Palpate thetobones
be to Technique Normal Actual Findings Interpretation/
locateAssessed
edema or Palpation NoFindings
tenderness or There is visible Analysis
NORMAL
1.)
tenderness Language Inspection The client is
swelling able The client is
edema on bone of the NORMAL
a.) Ask client to to understand by able to namepx. the
point to common naming the pointed object
objects and ask the
Joints: pointed object clearly and able
client to name them. clearly and has to respond to
b.) Ask and
Inspect the client
palpateto Inspection/Palp the No swelling, verbal
ability to Upon andinspection and NORMAL
respond
the to simple
joint for ation respond to
tenderness, written
palpation of joints
verbal and written
swelling, tenderness, simple verbal or commands.
crepitation there is no swelling
commandsoflike
smoothness andnodules,
written joints and tenderness, joints
”point
movement, to your toes” commands
move smoothly also moves smoothly.
2.) Orientation
crepitation, and Inspection The client is able The client is NORMAL
Ask the client
presence of nodules the to state the able to verbalize
city or residence, current time, current time,
time
Assess ofjoint
day, range
date ofof Inspection date,
Varies to some date,Upon
year, place, placeinspection
and of NORMAL
day, day of week,
motion his own name,
degree in his/her personal
the px’s joint range it
duration of illness duration of with information.
accordance is according to
and names of illness and name
person’s genetic genetic makeup and
family members. of family
makeup and level of physical
members.
degree of physical activity.
3.) Memory Inspection The average
activity The client is NORMAL
Listen for lapses in person can able to repeat a
memory. Ask the repeat a series of series of five to
client about five to eight eight digits in
difficulty with digits in sequence.
memory. sequence.
a) Assess
immediate recall by
asking the client to
repeat a series of
three digits,
4.) Attention
Span
Test the ability of the Inspection Able to focus on The client can NORMAL
client to concentrate examiner’s count from
by asking the client questions. Able backward from
to recite the alphabet to recite the 50 and able to
or to count backward alphabet or to recite alphabet
from 50. count backward
from 50
5.) Calculation Inspection Able to answer The client can NORMAL
Test the ability to the equation solve the
calculate by asking quickly. equation
the client to solve quickly.
simple equation.
6.) Level of
Consciousness
* Apply Glasgow Inspection An assessment Upon inspection NORMAL
coma scale; eye totaling 15 the patient’s is
response, motor points indicates totaling 15
response, and verbal the client is alert points that
response. and completely indicates
oriented. A alertness and
comatose client very well
scores 7 or less. oriented.
 Cranial Nerves

I. Olfactory Inspection Able to smell The client can NORMAL

distinctive but smell familiar
familiar aromas aromas even
even eyes are eyes are closed.
closed.

Inspection Able to read The client This is due to

II. Optic reading materials cannot read old age
newspaper
without his
eyeglasses.

III. Oculomot
IV. Trochlear,
V. Facial –
Facial
expression

All the 3 Cranial

nerves are tested at
the same time by
assessing the Extra
Ocular Movement
(EOM) or the six
cardinal position of
gaze.

Follow the given

steps:

1. Stand directly Inspection Normally the The client is

in front of the client client can hold able to hold the NORMAL
and hold a finger or the position and position and
a penlight about 1 ft there should be there is no
from the client’s no nystagmus. presence of
eyes. nystagmus.

2. Instruct the Inspection Same as no. 1 The client can

client to follow the hold the NORMAL
direction the object position by
hold by the examiner following the
by eye movements object using
only; that is with out his/her eyes.
moving the neck.
3. The nurse Inspection Same as no. 1 The client can
moves the object in a hold the NORMAL
clockwise direction position by
hexagonally. following the
object using
his/her eyes.

4. Instruct the Inspection Same as no. 1 The client can

client to fix his gaze hold the NORMAL
momentarily on the position and can
extreme position in fix his gaze on
each of the six the extreme
cardinal gazes. position in each
of the six
cardinal gazes.
 Glasgow coma Scale

I. Motor Response
6 - Obeys commands fully
5 - Localizes to noxious stimuli
4 - Withdraws from noxious stimuli
3 - Abnormal flexion, i.e. decorticate posturing
2 - Extensor response, i.e. decerebrate posturing
1 - No response

II. Verbal Response

5 - Alert and Oriented
4 - Confused, yet coherent, speech
3 - Inappropriate words and jumbled phrases consisting of words
2 - Incomprehensible sounds
1 - No sounds

III. Eye Opening

4 - Spontaneous eye opening
3 - Eyes open to speech
2 - Eyes open to pain
1 - No eye opening

The final score is determined by adding the values of I+II+III.

This number helps medical practioners categorize the four possible levels for survival,
with a lower number indicating a more severe injury and a poorer prognosis:

Mild (13-15):

• More in-depth discussion on the Mild TBI Symptoms page.

Moderate Disability (9-12):

• Loss of consciousness greater than 30 minutes

• Physical or cognitive impairments which may or may resolve
• Benefit from Rehabilitation

Severe Disability (3-8):

• Coma: unconscious state. No meaningful response, no voluntary activities

Vegetative State (Less Than 3):

• Sleep wake cycles

• Aruosal, but no interaction with environment
• No localized response to pain

Persistent Vegetative State:

• Vegetative state lasting longer than one month

Brain Death:
 • No brain function
• Specific criteria needed for making this diagnosis
• Scale for Grading reflex responses

Grade Description

0 Absent; No evidence of contraction

1+ Decreased, but still present (hypo-reflexic)

2+ Normal or physiologic

3+ Increased and maybe normal or pathologic

4+ Markedy hyperactive with transient clonus

5+ Markedy hyperactive with sustained clonus

AREA TO BE ASSESS TECHNIQUES

CN1. OLFACTORY
-make sure nostrils are patent.
Have him identify the odor of Smell 2
at least two common
substances, such as coffee, or
cinnamon avoid ammonia or
peppermint which stimulate
trigeminal nerve.

CN2.OPTIC
-test visual acuity quickly and
informally, in reading Vision 1
newspaper, start at large
headlines to small print. 20/20
indicates normal vision

CN3.OCULOMOTOR
CN4.TROCHLEAR
CN6.ABDUCENS

-it is responsible for eyelid

elevation and papillary Eye movement, papillary 2
constriction. Make sure pt. constriction, upper eyelid
pupils constrict when exposed elevation
to light and his eyes
accommodate for seeing
objects

CN5.TRIGEMINAL
-check for ability to feel light
touch on his face,and touch
perception by touching the tip Chewing, corneal reflex, 2
of a safety pin in the forehead, face and scalp sensation
check, and jaws.

CN7.FACIAL
- assess it by observing the pt.
face for symmetry at rest and Expression in forehead, 2
while he smiles frowns and eye, and mouth.
raises his eyebrows and also by
tasting.

CN8.ACOUSTIC
-test hearing by covering the
other ear, stand on opposite Hearing and balance 1
side by whispering

CN9.GLOSSOPHARYNGEAL
CN10.VAGUS
-Tested together assess by
listening to pt. voice, check gag Swallowing salivating and
reflex by touching tip of tongue taste, gag reflex talking 2
blade and ask him to open wide
and say “ah”.

CN11.ACCESSORY
-test the strength of both
muscles bilaterally. Test the
muscles by placing palm -shoulder movement and 3
against pt. and check him to head rotation
turn his head against your
resistance repeat to opposite
side.

CN12.HYPOGLOSSAL
Test tongue strength by asking
the pt. to push his tongue Tongue movement 2
against his cheek as you apply
resistance.