THORAX AND

LUNGS
ASSESSMENT
LORMA COLLEGES
College of Nursing
2021 Edition
1. Gather equipment:
▪gown and drape
▪Gloves
▪Stethoscope
▪exam light
▪Mask
▪skin marker
▪metric ruler
2. Explain procedure
to client.
3. Ask the client to
put on a gown.
1. Inspect for shape and
configuration of the chest
wall and position of
scapulae.
▪NOTE: While the client sits with
arms at the sides, stand behind
him or her and observe the
position of scapulae and the
shape and configuration of the
chest wall.
▪NORMAL:
▪The scapulae are symmetric, and
non-protruding. Shoulders and
scapulae are equal horizontal
positions. The ratio on
anteroposterior diameter is 1:2.
▪Kyphosis, an
increased curve
of the thoracic
spine is
common in
older clients,
results from a
loss of skeletal
muscles. It may
be a normal
finding.
▪ABNORMAL:
▪Spinal process that deviates laterally in the thoracic
area may indicate scoliosis.
▪Ribs appearing horizontal at an angle greater than
45 degrees with the spinal column are frequently
the result of an increased ratio between the
anteroposterior transverse diameter (barrel chest).
This condition is commonly the result of
emphysema due to hyperinflation of the lungs.
2. Inspect for use of
accessary muscles.
▪NORMAL:
▪The client does not use accessory
(Trapezius/ shoulder) muscle to assist
breathing.
▪*The diaphragm is the major muscle at
work. This is evidenced by expansion of the
lower chest during inspiration.
▪ABNORMAL:
▪Trapezius or shoulder muscles are
used to facilitate inspiration in
cases of acute and chronic airway
obstruction or atelectasis.
▪ Trapezius
▪ Scalene
▪ Sternomastoid
▪ Pectoralis major
and minor (not
shown)
▪ Abdominal
muscles (not
shown)
3. Inspect client's positioning
noting posture and ability to
support weight while
breathing comfortably.
▪NORMAL:
▪Client should be sitting up
and relaxed, breathing easily
with arms at sides or in lap.
▪ABNORMAL:
▪Client leans forward and uses arms to
support weight and lift chest to increase
breathing capacity in chronic obstructive
pulmonary disease (COPD). This is
referred to as tripod position.
4. Palpate for tenderness and
sensation with gloved
fingers.
▪NORMAL:
▪No tenderness, pain or unusual
sensations reported by client.
Warmth should be equal
bilaterally.
▪ABNORMAL:
▪Tender or painful areas may indicate inflamed fibrous
connective tissue.
▪Pain over the intercostal spaces may be from inflamed
pleurae.
▪Pain over the ribs , especially at the costochondral junctions
is a symptom of fractured ribs.
▪Also, muscle soreness from exercise or the excessive work
of breathing as in COPD may be palpated as tenderness.
▪Increased warmth may be related to local infection.
5. Palpate for crepitus by using
fingers.
▪NORMAL:
▪No crepitus must be palpated.
▪ABNORMAL:
▪Crepitus over the thorax may
indicate subcutaneous
emphysema or air trapped in
the subcutaneous tissues
6. Palpate for surface
characteristics such as
lesions or masses with
gloved fingers (during
inspiration).
▪NORMAL:
▪Skin and subcutaneous
tissue are free of lesions and
masses.
▪ABNORMAL:
▪Any unusual palpable mass, which
should be evaluated further by a
physician or other appropriate
professional
7. Palpate for fremitus, using
the ball or ulnar edge of one
hand while client says
"ninety nine." Assess for
symmetry and intensity of
vibration.
▪NOTE:
▪Use the ball or ulnar edge of one hand to
assess for fremitus (vibrations of air in
the bronchial tubes transmitted to the
chest wall, felt by the examiner when the
client says “ninety nine.”
▪NOTE:
▪The ball of the hand is best for assessing
the tactile fremitus because the area is
especially sensitive to vibratory sensation.
As you move your hand to each area, ask
the client to say ninety nine. Assess all areas
for symmetry and intensity of vibration.
▪NORMAL:
▪Fremitus is symmetric and easily identified in
the upper regions of the lungs.
▪If fremitus is not palpable on either side, the
client may need to speak louder.
▪A decrease in intensity of fremitus is normal as
the examiner moves toward the base of the
lungs. However, fremitus should remain
symmetric for bilateral positions.
▪ABNORMAL:
▪Unequal fremitus is usually the result of
consolidation that increases fremitus or bronchial
obstruction, air trapping in emphysema, pleural
effusion or pneumothorax that decreases fremitus.
▪Diminished fremitus even with a loud spoken voice
may indicate an obstruction of the
tracheobronchial tree.
8. Assess for chest expansion by
placing hands on the posterior
chest wall with thumbs at the
level of T9 or T10, and observe
movements of the thumbs as
the client takes a deep breath.
▪NORMAL:
▪When the client takes a deep breath, the
examiner ‘s thumbs should move 5 to 10 cm
apart symmetrically.
▪Because of calcification of the costal
cartilages and loss of the accessory
musculature, the older client’s thoracic
expansion may be decreased, although it
should still be symmetric.
▪ABNORMAL:
▪Unequal chest expansion can occur with
severe atelectasis (collapse / incomplete
expansion), pneumonia, chest trauma or
pneumothorax (air in the pleural space).
Decreased chest excursion at the base of
the lungs is characteristic of COPD. This is
due to decreased diaphragmatic function.
9. Percuss for diaphragmatic
excursion by:
i. Asking the client to exhale
forcefully and hold the
breath.
ii. Percussing at the scapular line
(T7) intercostal spaces of the
right posterior chest wall.
iii. Percussing downwards until
the tone changes from
resonance to dullness.
iv. Marking this level and
allows the client to
breathe.
v. Asking the client to inhale
deeply and hold it.
iv. Percussing the intercostal
space from the mark
downward until resonance
changes to dullness.
v. Marking this level and allows
the client to breathe.
vi. Measuring the distance
between the two marks.
vii. Performing on both sides
of the posterior thorax
▪NORMAL:
▪Excursion should be equal bilaterally and
measure 3-5 cm in adults.
▪The level of the diaphragm may be higher
on the right because of the position of the
liver.
▪In well- conditioned clients, excursion can
measure up to 7-8 cm.
▪ABNORMAL:
▪Diaphragmatic descent may be limited by atelectasis
of the lower lobes or by emphysema, in which
diaphragmatic movement and air trapping are
minimal.
▪The diaphragm remains in a low position on
inspiration and expiration.
▪Other possible causes for limited descent can be
pain, or abdominal changes such as extreme ascites,
tumors or pregnancy.
10. Auscultate for breath
sounds (normal, bronchial,
bronchovesicular, and
vesicular), noting location
▪NOTE: Normal Breath Sounds
▪Bronchovesicular breath sounds are heard over major
bronchi. Moderate pitch and loudness. The upper
sternum area is where major bronchi are located.
▪Vesicular breath sounds are heard over the peripheral
lung fields. It is low pitch soft sound.
▪Bronchial (tracheal) breath sounds are heard over the
trachea and larynx. It is high pitched loud and harsh.
▪NORMAL:
▪Three types are normal:
Bronchial, bronchovesicular and
vesicular
▪ABNORMAL:
▪Diminished or absent breath sounds often
indicate that little or no air is moving in or out
of the lung area being auscultated. This may
indicate obstruction within the lungs as a
result of secretions, mucus plug, or foreign
object, abnormalities of pleural space like
pleural effusion, pneumothorax.
▪ABNORMAL:
▪In cases of emphysema, because of
hyperinflated nature of the lungs, together
with the loss of elasticity of lung tissue
may result in diminished inspiratory breath
sounds.
▪ABNORMAL:
▪When you hear an abnormal sound
during auscultation, always have the client
cough then listen again and note any
change.
11. Auscultate for adventitious
sounds (Crackles. Fine or coarse,
pleural friction rub, wheezes,
sibilant or sonorous). Note the
location on the chest wall when
adventitious sounds are heard.
▪NORMAL:
▪No adventitious breath
sound
▪ABNORMAL:
▪Adventitious lung sounds such as
Crackles – Discrete and discontinuous
sounds and wheezes- musical and
continuous are evident.
12. Auscultate for voice sounds
over the chest wall:
i. Bronchophony-ask the client
to repeat the phrase "ninety
nine".
▪NORMAL:
▪Voice transmission is soft, muffled and
distinct. The sound of the voice may be
heard, but the actual phrase cannot be
distinguished.
▪ABNORMAL:
▪The words will be easily understood
and louder over areas of increased
density. This may indicate consolidation
from pneumonia, atelectasis or tumor.
ii. Egophony-ask the
client to repeat the
letter "E“
▪NORMAL:
▪Voice transmission will be
soft and muffled, but the
letter “E” should be
distinguishable.
▪ABNORMAL:
▪Over areas of consolidation or
compression, the sound will be
louder and change to “A”
ii. Whispered pectoriloquy- ask
the client to whisper the
phrase "one-two-three" when
chest wall is auscultated.
▪NORMAL:
▪Transmission of sounds is
very faint and muffled. It may
be inaudible
▪ABNORMAL:
▪Over areas of consolidation or
compression the sound will be
transmitted clearly and distinctly. In such
areas, it will sound as if the client is
whispering directly into the stethoscope.
1. Inspect for shape and
configuration to determine
the ratio of anteroposterior
diameter to transverse
diameter (normally 1:2).
▪NORMAL:
▪The anteroposterior diameter is less
than the transverse diameter. The
ration of anteroposterior diameter to
the transverse diameter is 1:2
▪ABNORMAL:
▪Anteroposterior diameter equals
transverse diameter, resulting in a
barrel chest. This s often seen in
emphysema because of hyperinflation
of the lungs.
2. Inspect for position of
sternum from anterior and
lateral viewpoints. Watch
for sternal retractions.
▪NORMAL:
▪Sternum midline and
straight
▪ABNORMAL:
▪Pectus excavatum is a markedly sunken sternum
and adjacent cartilages- often referred as funnel
chest.
▪Pectus carinatum is a forward protrusion of the
sternum causing the adjacent ribs to slope
backward. However, both of these conditions
may restrict expansion of the lung's capacity.
3. Inspect for slopes of the ribs
from the anterior and
lateral viewpoints. (Costal
angle is within 90⁰)
▪NORMAL:
▪Rib slope downward with
symmetric intercostal spaces.
Costal angle is within 90
degrees.
▪ABNORMAL:
▪Barrel chest configuration results
in more horizontal position and
costal angle of more than 90
degrees. This often results from
long-standing emphysema
4. Inspect for quality and
pattern of respiration.
Note breathing
characteristics, rate,
rhythm, and depth.
▪NORMAL:
▪Respirations are relaxed, effortless
and quiet. Regular rhythm and
normal depth. Tachypnea and
bradypnea may be normal in some
clients.
▪ABNORMAL:
▪Labored and noisy breathing is often
seen with severe asthma or chronic
bronchitis, tachypnea, bradypnea,
hyperventilation, hypoventilation cheyne-
strokes respiration, Biot’s respiration
5. Inspect intercostal spaces
while client breathes
normally and observe the
intercostal spaces.
▪NORMAL:
▪No retractions or bulging of
intercostal spaces noted
6. Inspect for the
use of accessory
muscles.
▪NORMAL:
▪Use of accessory muscles
(sternomastoid and rectus
abdominis) is not seen with
normal respiration
▪ABNORMAL:
▪Neck muscles (sternomastoid , scalene and trapezius)
are used to facilitate inspiration in cases of acute or
chronic airway obstruction or atelectasis. The
abdominal muscles and the internal costal muscles are
used to facilitate in COPD
▪Seen with labored respirations especially in small
children and indicative of hypoxia
7. Palpates for tenderness,
sensation and surface
masses. Uses fingers to
palpalte for tenderness
and sensation.
▪NORMAL:
▪No tenderness or pain palpated
over the lung area with
respirations.
▪ABNORMAL:
▪Tenderness over the thoracic muscles can
result from exercising (push-ups and the like)
especially in previously sedentary client.
▪Tenderness or pain at costochondral junction
of the ribs is seen with fractures, especially in
older clients with osteoporosis.
8. Assess crepitus.
▪NORMAL:
▪No crepitus palpated
▪ABNORMAL:
▪In areas of extreme congestion or
consolidation, crepitus may be
palpated, particularly in clients with
lung disease
9. Palpate surface
characteristics such as
lesions or masses,
using fingers of gloved
hand.
▪NORMAL:
▪No unusual surface
masses or lesions
10. Palpate for
fremitus while
the client says
"ninety-nine."
▪NORMAL:
▪Fremitus symmetric and easily identified
in the upper regions of the lungs. A
decreased intensity of fremitus is expected
toward the base of the lungs, however,
fremitus should be symmetric bilaterally.
▪ABNORMAL:
▪Diminished vibrations, even with a loud
spoken voice may indicate an obstruction of
the tracheobronchial tree
▪Clients with emphysema may have
considerably decreased fremitus as a result of
air trapping.
11. Palpate for chest expansion by
placing hands on anterolateral
wall with the thumbs along the
costal margins and pointing
toward the xiphoid process.
Observe movement of the thumbs
as the client takes a deep breath.
▪NORMAL:
▪Thumbs move outward in a
symmetric fashion from the
midline.
▪ABNORMAL:
▪Unequal chest expansion can occur with
severe atelectasis, pneumonia, chest trauma,
pleural effusion or pneumothorax. Decreased
chest excursion at the bases of the lungs is
seen with COPD
12. Percuss for tone above
the clavicles and then the
intercostal spaces across
and down, comparing
sides.
▪NORMAL:
▪Resonance is the percussion
tone elicited over normal lung
tissue
▪ABNORMAL:
▪Hyperresonance- in cases of trapped air
such as emphysema, pneumothorax.
▪Dullness may be characterizing areas of
increased density such as consolidation,
pleural effusion or tumor.
13. Auscultate for
breath sounds,
adventitious sounds
and voice sounds.
▪NORMAL:
▪Same as posterior thorax
Risk for Respiratory infection r/t exposure to environmental
pollutants and lack ok knowledge of precautionary measures
Risk for Activity intolerance r/t imbalance between oxygen supply
and demand
Risk for imbalance Nutrition: Less than Body Requirements r/t
fatigue secondary to dyspnea
Risk for impaired Oral Mucous Membrane r/t mouth breathing
Anxiety r/t dyspnea and fear of suffocation
Activity intolerance r/t fatigue secondary to inadequate oxygenation
Ineffective Airway Clearance r/t inability to clear thick, mucous
secretions
Ineffective Airway Clearance r/t bronchospasm and increased
pulmonary secretions.
Impaired gas exchange r/t poor muscle tone and decreased ability to
remove secretions
Disturbed sleeping pattern r/t excessive coughing
HEART AND
NECK VESSELS
ASSESSMENT
LORMA COLLEGES
College of Nursing
2021 Edition
1. Gather equipment:
▪stethoscope with bell diaphragm
▪small pillow
▪penlight or movable exam light
▪watch with second hand
▪two centimeter rulers
2. Explain procedure
to client.
3. Assist the client to
put on a gown.
1. Inspect for jugular
venous pulse.
▪NOTE:
▪Inspect the jugular venous pressure pulse by
standing on the right side of the client.
▪The client should be in supine position with the
torso elevated 30-45 degrees.
▪Make sure the head and torso are on the same
plane.
▪Ask the client to turn the head slightly to the left.
▪Shine a tangential light source onto the neck to
increase visualization of pulsations.
▪NOTE:
▪Assessment of jugular venous pulse is
important for determining the
hemodynamics of the right side of the heart.
▪The level of jugular venous pressure reflects
right atrial (central venous) pressure and,
usually right diastolic filling pressure.
▪NORMAL:
▪The jugular venous pulse is not
normally visible with the client sitting
upright. This position fully distends the
vein and pulsations may or may not be
discernible.
▪ABNORMAL:
▪Fully distended jugular veins with client’s
torso elevated more than 45 degrees
indicate increased intracranial pressure.
▪Right sided heart failure raises pressure
thus raising jugular venous pressure
2. Measure jugular
venous pressure.
▪NOTE:
▪Evaluate jugular venous pressure by
watching for distention of the jugular vein. It
is normal for the jugular veins to be visible
when the client is supine s to evaluate
jugular vein distention, position the client in
a supine position with the head of the bed
elevated 30, 45, 60 and 90 degrees.
▪NOTE:
▪At each increase of the elevation,
have the client’s head turned slightly
away from the side being evaluated.
Using a tangential lighting, observe
for distention, protrusion or bulging.
▪NORMAL:
▪The jugular vein should not
be distended, bulging, or
protruding at 45 degrees.
▪ABNORMAL:
▪Distention, bulging, or protrusion at
45, 60 or 90 degrees may indicate right
sided heart failure. Document at which
positions you observe distention (45, 60
or 90 degrees).
3. Auscultate carotid
arteries for bruits.
▪NOTE:
▪Auscultate the carotid arteries if you suspect
cardiovascular disease or if the client is middle
aged or older
▪Place the bell of the stethoscope over the
carotid artery and ask the client to hold his/ her
breath for a moment so breath sounds do not
conceal any vascular sounds.
▪NOTE:
▪Always auscultate the carotid arteries
before palpating.
▪NORMAL:
▪No blowing or swishing or
other sounds heard
▪ABNORMAL:
▪A bruit, a blowing or swishing sound
caused by turbulent blood flow through
a narrowed vessel is indicative of
occlusive arterial disease.
4. Palpate each carotid
artery for amplitude
and contour of the
pulse, elasticity of the
vessels and thrills.
▪NOTE:
▪Palpate each carotid artery by placing
the pads of the index and middle
fingers medial to the
sternocleidomastoid muscle on the
neck.
▪NORMAL:
▪Pulses equally strong
▪A 2+ or normal with no variation from beat to
beat. Arteries are elastic and no thrills are noted.
▪Contour is normally smooth
▪The strength of the pulse is evaluated on a scale
from 0-4
Pulse Amplitude Scale
▪0 Absent
▪1+ Weak
▪2+ Normal
▪3+ Increased
▪4+ Bounding
▪ABNORMAL:
▪Pulse inequality may indicate arterial
constriction or occlusion in one carotid
▪Weak pulse may indicate
hypovolemia, decreased cardiac output
▪ABNORMAL:
▪A bounding firm pulse may
indicate hypervolemia and
increased cardiac output
▪Thrills may indicate narrowing of
artery.
1. Inspect for visible
pulsations with the
client in supine position
with the HOB elevated
between 30⁰ and 45⁰
▪NORMAL:
▪The apical pulse may or may not be visible.
If apparent, it would be in the mitral area,
left midclavicular line , fourth or fifth
intercostal space. The apical impulse is a
result of the left ventricle moving outward
during systole.
▪ABNORMAL:
▪Pulsations which may also be called
heaves or lifts, other than the apical
pulsation are considered abnormal and
should be evaluated.
▪A heave or lift may occur as the result of
an enlarged ventricle from an overload of
work.
2. Palpate apical pulse
for location, size,
strength, and duration
of pulsation.
▪NOTE:
▪The apical pulse was originally called the
point of maximal impulse (PMI). However
the term is not used anymore because a
maximal impulse may occur in other areas of
the precordium as a result of abnormal
conditions.
▪NOTE:
▪If the pulsation cannot be
palpated, have the client assume a
left lateral chest wall and relocates
the apical impulse farther to the
left.
▪NOTE:
▪Remain on the client’s right side and ask the
client to remain supine.
▪Use the palmar surfaces of your hand to
palpate the apical pulse in the mitral area
th th
(4 or 5 ICS at MCL.) After locating the
pulse, use one finger for more accurate
palpation.
▪NORMAL:
▪The apical pulse is palpated in the mitral
area and may be the size of a nickel. 1-2
cm
▪Amplitude is usually small-like a gentle
tap. The duration is brief, lasting through
the first two thirds of systole and often
less.
▪NORMAL:
▪In obese clients the apical pulse may be
un palpable.
▪In older clients, apical pulse may be
difficult to palpate because of the
increased anteroposterior chest diameter.
▪ABNORMAL:
▪The apical impulse may be impossible to
palpate in clients with pulmonary
emphysema. If the apical pulse is larger than
1-2 cm, displaced, more forceful or of longer
duration, suspect cardiac enlargement.
3. Palpate for abnormal
pulsation or vibrations
at apex, left sternal
border, and base.
▪NORMAL:
▪No pulsations/ vibrations palpated
in the areas of apex, left sternal
border or base
▪ABNORMAL:
▪A thrill, which feels similar to a
purring cat or a pulsation is
usually associated with grade IV
or higher murmur.
4. Auscultate heart sounds
for rate and rhythm
(apical and radial pulse,
pulse rate deficit , S1 and
S2) if irregular rhythm is
detected.
▪NOTE:
▪Place the diaphragm of the stethoscope at the
apex and listen closely to the rate and rhythm of
the apical impulse.
▪If you detect an irregular rhythm, auscultate for
a pulse rate deficit. This is done by palpating the
radial pulse while you auscultate the apical
pulse. Count for a full minute.
▪NORMAL:
▪Rate 60-100 bpm with regular rhythm.
▪A regularly irregular rhythm, such as sinus
arrhythmia when the heart increases with
inspiration and decreases with expiration,
may be normal in young adults.
▪NORMAL:
▪Normally the pulse rate in females is 5 to
15 bpm faster than in males. Pulse rate do
not differ by race or age in adults.
▪Apical pulse and radial pulse should be
identical.
▪ABNORMAL:
▪Bradycardia- less than 60 beats/min or tachycardia-
more than 100 beats per minute may result in decreased
cardiac output.
▪Clients with regular irregular rhythm like premature
atrial contraction or premature ventricular contractions
and regular irregular rhythms like atrial fibrillation and
atrial flutter with varying block should be referred for
evaluation. These patterns may result to decreased
Cardiac Output , heart failure or emboli.
▪ABNORMAL:
▪A pulse deficit may indicate (difference
between the apical and peripheral / radial
pulse) may indicate atrial flutter, atrial
fibrillation, premature ventricular
contractions, and varying degrees of heart
block.
5. Auscultate S1 and S2 heart
sounds for location and
strength pattern (louder/
softer at locations and with
respiration, splitting of S2).
▪NOTE:
▪Auscultate the first sound s1 or lub and the
second heart sound s2 or dub.
▪These 2 sounds make up the cardiac cycle
of systole and diastole. S1 starts systole and
s2 starts diastole.
▪NOTE:
▪The space or systolic pause between s1 and
s2vis of short duration thus s1 and s2 occur
very close together.
▪Whereas, the space or diastolic pause,
between s2 and the start of another s1 is of
longer duration.
▪NOTE:
▪Do not ask the client to hold his or her breath.
Breath holding will cause any normal or
abnormal split to subside.
▪If you are having trouble differentiating s1 from
s2 palpate the carotid pulse; the harsh sound
that occurs with the carotid pulse is S1.
▪NORMAL:
▪S1 corresponds with each carotid
pulsation and loudest at the apex of the
heart. S2 immediately follows after s1
and is the loudest at the base of the
heart
▪ABNORMAL:
▪S1: Accentuated, diminished ,
varying or split
▪S2: Any split heard on expiration is
abnormal. This can be one of three
types wide, fixed, or reversed.
6. Auscultate for extra heart
sounds (clicks, rubs), murmurs
(systolic or diastolic, intensity
grade, pitch, quality, shape or
pattern, location,
transmission, effect of
ventilation and position).
▪NOTE:
▪Use the diaphragm first then the bell to
auscultate the entire area. Note the
characteristics like location, timing of any
extra sound heard.
▪Auscultate during the diastolic pause (
space heard between end of S2 and the next
S1
▪NORMAL:
▪Normally no sound are
heard
▪ABNORMAL:
▪Ejection sounds/ clicks like a mild-
systolic click associated with mitral
valve prolapse. A friction rub may
also be heard during the systolic
pause.
NOTE:
▪While auscultating keep in mind that
development of a pathologic S3 may be the
earliest sign of heart failure.
NORMAL:
▪Normally no sounds are heard.
ABNORMAL:
▪Pathologic S3/ ventricular gallop may be
heard with ischemic heart disease, myocardial
disease.
NOTE:
▪Auscultate for murmurs across the entire heart
area.
▪A swishing sound caused by turbulent blood flow
through the heart valves or great vessels.
▪Use the diaphragm and the bell of the stethoscope
in all areas of auscultation because murmurs have a
variety of pitches.
▪Also auscultate in different positions because some
murmurs occur or subside according to client’s
position.
▪NORMAL:
▪Normally no murmurs are heard.

▪ABNORMAL:
▪Pathologic midsystolic, pansystolic and
diastolic murmurs
7. Auscultate with the
client in the left lateral
position and with the
client sitting up, leaning
forwards, and exhaling.
▪NORMAL:
▪S1 and S2 heart sounds are normally
present
▪ABNORMAL:
▪An S3 and S4 heart sounds or a murmur of
mitral stenosis that was not detected with the
client in the supine position may be revealed
when the client assumes the left lateral position.
Opportunity to Enhance Cardiac Output
Health Seeking Behavior: desired information
on exercise and low fat diet
Risk for Ineffective Denial r/t smoking and
obesity
Fatigue r/t decreased cardiac output
Activity Intolerance r/t compromised oxygen
transport secondary to heart failure
Acute Pain: Cardiac r/t inequality between
oxygen supply and demand
Ineffective Tissue Perfusion: Cardiac r/t
impaired circulation
Decreased Cardiac Output
Hypertension
Cerebral Hemorrhage
Angina
Renal Failure
CHF
CVA
BREAST AND AXILLAE

By:
Arnelle L. Balinao, MAN
Jennifer R. Macagba, MSN
Clinical Instructors
OBJECTIVES:

At the end of the lecture –

discussion, the students will be able
to
Define related terms in relation to
the breast and axillae
Identify the purposes of
performing breast and axillae
assessment
Discuss the importance of
preparing clients prior to
examination
Explain two methods of
examining the breast and axillae
Explain the significance of a
selected breast and axillae
findings
Enumerate the steps in
performing breast and axillae
assessment
State diagnostic procedures
being performed
Discuss variations and special
considerations in performing
examination techniques
appropriate for clients of
different age.
Assessment Techniques Used:

Inspection
Palpation
ANATOMY PHYSIOLOGY
• Divided into four quadrants based
on horizontal and vertical lines
crossing at the nipple

• Axillary tail of breast tissue extends

toward the anterior axillary fold

• Findings can be localized as the

time on the face of a clock (e.g.
3o’clock) and the distance in
centimeters from the nipple
After assessing the breast of a female
client, the nurse should explain to the
client that most breast tumors occurs
in the
• The breast is hormonally sensitive
tissue, responsive to the changes
of monthly cycling and aging.

• Glandular tissue: secretory

tubualveolar ducts, lobules –
drains into the nipples or arreola

• Fibrous connective tissue: support

• Adipose tissue: varies with age,

the general state of nutrition,
pregnancy, exogenous hormone,
ad other factor.
iw
Advantages of BSE:
 Women can use BSE to assess their
breast
 When they perform BSE properly and
regularly, they can note any changes
in their breast and seek further
evaluation
 Examinationshould be done every
month and at the end of menses in all
menstruating women.
However, breast self-exams help
you familiarize yourself with the
shape, size, and texture of your
breasts.
 This is important because it can
help you determine if what you
are feeling is normal or abnormal.
Any time you feel an abnormality
in your breast, tell your doctor.
Barriers to BSE

Lack of confidence
Lack of knowledge and
awareness
Assessment skills:
Preparation prior to assessment

1. Gather equipment:
 Centimeter Ruler
 Small pillow
 Gloves
 Clients
handout for Breast Self-
Examination
 Slide for specimen (if there is any)
2. Explain the procedure to the client
- what the steps of the examinations
are and the rationale for them.
Wash your hands
Warm your hand
Provide privacy.
3. Assist client to put on gown.
 Female Breast:
1. Inspect for
a. size and symmetry
b. color and texture
c. superficial venous patterns
d. areolas e. nipples
f. retraction and dimpling
g. bilaterally, note color, shape &
texture of areolas
g. bilaterally, note size &
direction of nipples
2. Palpates for:
a. texture and elasticity.
b. Tenderness and Temperature
(warmth or inflammation)
c. Masses
Note for location, size in
centimeter, shape mobility,
consistency, and tenderness.
Note the condition of skin over
the mass
 3.
Palpates nipples by compressing
nipple gently between thumb and
index finger; observe for discharge
4. Palpates mastectomy or
lumpectomy site, if applicable
Observing the scar, and any
remaining breast or axillary tissue
for redness, lesion, lumps, swelling
or tenderness.
Women who do not menstruate
should choose a certain day to
perform the exam, such as the
first of each month.

You should also keep a journal of

your self-exams. This will help you
track and record any changes
you have noticed in your breasts.
ASSESSMENT PROCEDURE

FEMALE BREAST
1. Inspects breast for

A. SIZE AND SYMMETRY

Have the client disrobe and sit

with arms hanging freely. Explain
what you are observing to help
ease client anxiety.
Normal Findings:
Breasts can be a variety of sizes
and are somewhat round and
pendulous; one breast may be
larger than the other.
The older client often has more
pendulous, less firm and saggy
breasts.
Abnormal
Findings:
 A recent
increase in the
size of one
breast may
indicate
inflammation or
an abnormal
growth.
A pig skin like or orange peel/ peau
d’orange appearance results from
edema, which is seen in metastatic
breast disease. The edema is caused by
blocked lymphatic drainage.
B. COLOR AND TEXTURE

Normal Findings:
 Color varies depending on the client’s
skin tone. Texture is smooth with no
edema.
 Linear stretch marks may be seen
during and after pregnancy or with
significant weight gain or loss
Abnormal Findings:
Redness is associated with
breast inflammation
C. SUPERFICIAL VENOUS
PATTERNS OBSERVE VISIBILITY
AND PATTERNS OF BREAST VEINS.

Normal Findings:
Veins radiate either
horizontally or and toward the
axilla (transverse) or vertically
with a lateral flare
(longitudinal)
Abnormal Findings:
 A prominent venous pattern may
occur as a result of increased
circulation due to a malignancy. An
asymmetrical venous pattern may
be due to malignancy
D. RETRACTION AND DIMPLING
 Askthe client to remain seated while
performing several different maneuvers. Ask
the client to raise her arms overhead, then
press her hands against her hips. Next ask her
to press hands together.
Normal Findings:
 The
client’s breasts should rise
symmetrically with no sign of
dimpling or retraction
Abnormal Findings:
 Dimpling or retractions is usually caused
by malignant tumor that has fibrous
strands attached to the breast tissue
and fascia of the muscles. As muscles
contracts, it draws the breast tissue and
skin with it, causing dimpling and
D. RETRACTION AND DIMPLING
(CONT..)
 Finally,ask
the client to
lean forward
from waist.
This is a good
position to
use in women
who have
large
Normal Findings:
 Breast should hang freely
and symmetrically.
Abnormal Findings:
 Restricted movement of
breast or retraction of the
skin or nipple indicates
fibrosis and fixation of the
underlying tissues. This is
usually due to an
underlying malignant
tumor.
D. Areolas
E. Nipples
F. Retraction and Dimpling
G. BILATERALLY, NOTE
COLOR, SIZE, SHAPE, AND
TEXTURE OF AREOLAS
Normal Findings:
 Areolas vary from dark
pink to dark brown
depending on the client’s
skin tones. They are round
and may vary in size.
Small Montgomery
tubercles are present.
Abnormal Findings:
 Peau d’orange skin, associated with
carcinoma
 Red, scaly crusty areas
H. BILATERALLY, NOTE SIZE AND
DIRECTION OF NIPPLES
Normal Findings:
 Nipples are nearly equal bilaterally
in size and are in the same location
on each breast. Nipples are usually
everted but they may be inverted
or flat. Supernumerary nipples may
appear
 The older client may have smaller,
flatter nipples that are less erectile
on stimulation
Example of Supernumerary Nipple
Abnormal Findings:
A recently retracted nipple
that was previously everted
suggests malignancy.
Discharges should be referred
for cystologic study and further
evaluation
 GUIDELINES FOR PALPATING THE
BREAST
 Askthe client to lie down and to place
overhead the arm on the same side as
the breast being palpated. Place a
small pillow or rolled towel under the
breast being palpated.
◼ Usethe flat pads of three fingers to
palpate the client’s breast.
Palpate the breast using one of
three different patterns.
Circular/ clockwise
Wedge
Vertical strip
 Be sure to palpate
every square inch of
the breast from the
nipple to areola to
the periphery of the
breast tissue and up
into the tail of
Spence. Vary the
levels of pressure as
you palpate
 Light- superficial
 Medium- mid level
tissue
 Firm- to the ribs
2. Palpates breast for

A. TEXTURE AND ELASTICITY

Normal Findings:
 Smooth, firm , elastic tissue

Abnormal Findings:
 Thickening of the tissues may occur
with an underlying malignant tumor.
B. TENDERNESS AND TEMPERATURE

Normal Findings:
A generalized increase in
nodularity and tenderness may
be normal findings associated
with menstrual cycle or
hormonal medications. Breasts
should be a normal body
temperature.
Abnormal Findings:
Painful breast may be indicative
of benign breast disease but can
also occur in malignant tumor
Heat in the breasts of women
who have not just given birth or
who are not lactating indicates
inflammation.
C. MASSES: NOTING LOCATION, SIZE IN
CENTIMETERS, SHAPE, MOBILITY,
CONSISTENCY, AND TENDERNESS.

Normal Findings:
 No masses
Abnormal Findings:

 Malignant tumors are most often found

in the upper outer quadrant of the
breast. They are unilateral, with irregular,
poorly delineated borders. Hard and
non-tender and fixed to underlying tissue
3. PALPATES NIPPLES BY COMPRESSING
NIPPLE GENTLY BETWEEN THUMB AND
INDEX FINGER; OBSERVE FOR DISCHARGE
 Ask client to lie down, raise right arm
and check the right breast, repeat
procedure to the left breast.
 Wear gloves to compress the nipple
gently with your thumb and index finger.
Note any discharge.
 If spontaneous discharge occurs from
the nipples, a specimen must be
applied to a slide and the smear sent to
the laboratory for cytologic evaluation
Normal Findings:
 The nipple may become erect
 A milky discharge is usually present
only during pregnancy and lactation.

Abnormal Findings:
 Discharge may be seen in endocrine
disorders and with certain medications
( anti hypertension, estrogen)
 Cancer of the breast, fibrocystic
disease
4. PALPATES MASTECTOMY SITE /
LUMPECTOMY SITE, IF APPLICABLE,
OBSERVINGTHE SCAR AND ANY
REMAINING BREAST OR AXILLARY
TISSUE FOR REDNESS, LESIONS,
LUMPS, SWELLING, OR TENDERNESS

 Ask client to sit down then

palpate
Normal Findings:
 Scar is whitish with no redness or
swelling. No lesions, lumps or
tenderness noted

Abnormal Findings:
 Redness, inflammation of the scar
may indicate infection
 Any lesions, lumps or tenderness
should be referred for further
evaluation.
MALE BREAST

1. INSPECT THE BREASTS, AREOLAS,

AND NIPPLE FOR SWELLING,
NODULES, OR ULCERATIONS

Normal Findings:
No swelling or ulcerations
Abnormal Findings:

 Soft, fatty enlargement of the breast

tissue is seen in obesity. Gynecomastia,
a smooth firm movable disc of glandular
tissue may be seen in one breast in
males during puberty for a temporary at
a time. Also seen in hormonal
imbalance, drug abuse, leukemia
 Irregularly shaped, hard nodules occur
in the breast
2. PALPATES THE BREAST, AREOLAS,
AND NIPPLES FOR SWELLING,
NODULES, OR ULCERATIONS

Normal Findings:
 No swelling , nodules/ ulceration

Abnormal Findings:
 Hardnodules, swelling, presence of
ulcerations/ lesions
ASSESSMENT PROCEDURE

AXILLAE
1. INSPECT THE AXILLARY SKIN
FOR RASHES AND INFECTION.

Ask the client to sit up.

Normal Findings:
 No rash or infection noted

Abnormal Findings:
 Redness and inflammation may be
seen in infection of the sweat
gland.
 Dark, velvety pigmentation of the
axillae –acanthosis nigricans, may
indicate an underlying malignancy
2. HOLDS THE ELBOW WITH ONE HAND
AND USE THE THREE FINGER PADS OF
YOUR OTHER HAND TO PALPATE FIRMLY
THE AXILLARY LYMPH NODES.
Normal Findings:
 No palpable nodes or one to two small
(less than 1 cm) discrete, non-tender,
movable nodes in the central area.
Abnormal Findings:
 Enlarged greater than 1 cm lymph nodes
may indicate infection of the hand or
arm.
 Large nodes that are hard and well-fixed
to the skin may indicate malignancy
3. Palpates high into the axillae,
moving downward against the
ribs to feel for the central nodes.
Continue down the posterior
axillae to feel for the posterior
nodes.
USE BIMANUAL PALPATION TO FEEL FOR THE
ANTERIOR AXILLARY NODES. Palpate down
The inner aspect of the upper arm.
If the client has large breast, support breast with
your non dominant hand, and use your
dominant hand to palpate.
4. Ask the client to demonstrate
how she performs breast self-
examination (BSE). (This should
be offered as an option and the
client’s choice)
BREAST SELF-EXAMINATION
 Lie
down and place your right arm
behind the head. The exam is done
while lying down, and not standing
up, because when lying down the
breast tissue spreads evenly over
the chest wall as thinly as possible,
making much easier to feel all
breast tissue.
Use the finger pads of the three
middle fingers on your left hand
to feel for lumps in the right
breast.
Use overlapping dime-sized
circular motions of the finger
pads to feel the breast tissue
 Use three different levels of pressure
to feel all the breast tissue. Light
pressure is needed to feel the tissue
closest to the skin; medium pressure
to feel a little deeper; and firm
pressure to feel the tissue closest to
the chest and ribs. A firm ridge in the
lower curve of each breast is
normal. If your not sure how hard to
press, talk with your doctor or nurse.
Use each pressure level to feel the
breast tissue before moving on to
 Move around the breast in an up-and-
down pattern starting at an imaginary line
drawn straight down your side from the
underarm and moving across the breast to
the middle of the chest bone (sternum or
breastbone). Be sure to check the entire
breast area going down until you feel only
ribs and up to the neck or collar bone
(clavicle).
There is some evidence to suggest that
the up-and-down pattern (sometimes
called the vertical pattern) is the most
effective pattern for covering the entire
breast and not missing any breast
tissue.
 Repeat the exam on your left hand.
While standing in front of the mirror with
your hands pressing firmly down on your
hips, look at your breasts for any
changes of size, shape, contour, or
dimpling. (the pressing down on the hips
position contracts the chest wall muscles
and enhances any breasts changes).
 Examine each underarm while sitting up
or standing and with your arm only
slightly raised so you can easily feel in this
area. Raising your arm straight up
tightens the tissue in this area and makes
THANK YOU! ☺
 QUIZ
1. While Student Nurse inspects the breast for size and symmetry, she
observed a pig skin or orange peel appearance of the breast which
is caused by
A. obesity.
B. infection.
C. malignancy.
D. blocked lymphatic drainage.
2.When assessing the Tail of Spence in a client’s breast, the nurse is
palpating

A. in the lower quadrant, close to the ribs.

B. above the nipple at the midclavicular line.
C. in the upper inner quadrant, near the sternum.
D. in the upper outer quadrant, toward the axilla.
3. Nurse Densio asks a 47 year old client to remain seated while
performing several different maneuvers. He asked client to raise his
arms overhead, press hands against her hips and press hand together.
The nurse is inspecting for

A. Size and shape of areolas.

B. Retraction and dimpling.
C. Direction of nipples
D. Texture and elasticity.
4.During the breast exam, the nurse palpates a series of lymph nodes.
Why is this a part of the breast exam?

A. It's not. It's done because the chest area is exposed.

B. To review the integrity of the skin.
C. To assess the deep lymph nodes which drain the mammary lobules.
D. To assess shoulder range of motion.
5. When examining the breast, palpation should be done using one
of the three different patterns except

A. circular/clockwise.
B. wedge.
C. horizontal strip.
D. vertical strip
6. A 58-year-old client says to the nurse, "My saggy breasts embarrass
me!" What can the nurse say to this client in response?

A. Maybe you can have breast augmentation surgery?

B. Wearing a good bra will help.
C. Don't be silly.
D. Breasts sag because of declining estrogen levels.
7. A client comes into the clinic for a routine breast and axilla exam.
Which assessment technique does the nurse use first during this
examination?

A. Inspection
B. Auscultation
C. Palpation
D. Percussion
8. A 32-week-pregnant client is upset and thinks she has breast
disease because she has a yellowish discharge coming from her
breasts. What can the nurse say or do for this client?

A. This is normal toward the end of pregnancy and is called

colostrum.
B. Refer the client for a mammogram.
C. Notify the health care provider.
D. Ask history questions about previous breast infections.
9.The client tells the nurse, "At times I have discharge from my right
breast." What should the nurse do with this information?

A. Write it in the medical record and say nothing to the client.

B. Phone for a mammogram for the client immediately.
C. Explain that this could be benign or it could mean something else.
It needs to be further investigated.
D. Nothing. It doesn't mean a thing
10. During inspection of the
breast, nurse Tanya will assess
the breast for the following
except
A. symmetry of the breast.
B. superficial venous patterns.
C. size and direction of nipple.
D. tenderness and
temperature.
 TRUE/FALSE

11._____________The client’s breasts should rise symmetrically

with no sign of dimpling or retraction
12._____________Discharges should be referred for
cystologic study and further evaluation
13._____________Use bimanual palpation to feel for
the anterior axillary nodes.
14.____________Be sure to palpate every square inch of the
breast from the nipple to areola to the periphery of the breast
tissue and up to four quadrants of the breast only.
15. _________ Breast self examination should be done
7-10 days before menstrual period
16.________The older client may have smaller, flatter nipples
that are less erectile on stimulation
17. __________ A recent increase in the size of one breast may
indicate inflammation or an abnormal growth.
 IDENTIFICATION

18. A smooth firm movable disc of

glandular tissue may be seen in one
breast in males during puberty for a
temporary at a time IS CALLED?
__________________.
19. It is called the dark, velvety
pigmentation of the axillae
which may indicate an
underlying malignancy.
20. This is a screening method used
in an attempt to detect early breast
cancer. The method involves the
woman herself looking at and
feeling each breast for possible
lumps, distortions or swelling.
 QUIZ answers
1. While Student Nurse inspects the breast for size and symmetry, she
observed a pig skin or orange peel appearance of the breast which
is caused by
A. obesity.
B. infection.
C. malignancy.
D. blocked lymphatic drainage.
2.When assessing the Tail of Spence in a client’s breast, the nurse is
palpating

A. in the lower quadrant, close to the ribs.

B. above the nipple at the midclavicular line.
C. in the upper inner quadrant, near the sternum.
D. in the upper outer quadrant, toward the axilla.
3. Nurse Densio asks a 47 year old client to remain seated while
performing several different maneuvers. He asked client to raise his
arms overhead, press hands against her hips and press hand together.
The nurse is inspecting for

A. Size and shape of areolas.

B. Retraction and dimpling.
C. Direction of nipples
D. Texture and elasticity.
4.During the breast exam, the nurse palpates a series of lymph nodes.
Why is this a part of the breast exam?

A. It's not. It's done because the chest area is exposed.

B. To review the integrity of the skin.
C. To assess the deep lymph nodes which drain the mammary lobules.
D. To assess shoulder range of motion.
5. When examining the breast, palpation should be done using one
of the three different patterns except

A. circular/clockwise.
B. wedge.
C. horizontal strip.
D. vertical strip
6. A 58-year-old client says to the nurse, "My saggy breasts embarrass
me!" What can the nurse say to this client in response?

A. Maybe you can have breast augmentation surgery?

B. Wearing a good bra will help.
C. Don't be silly.
D. Breasts sag because of declining estrogen levels.
7. A client comes into the clinic for a routine breast and axilla exam.
Which assessment technique does the nurse use first during this
examination?

A. Inspection
B. Auscultation
C. Palpation
D. Percussion
8. A 32-week-pregnant client is upset and thinks she has breast
disease because she has a yellowish discharge coming from her
breasts. What can the nurse say or do for this client?

A. This is normal toward the end of pregnancy and is called

colostrum.
B. Refer the client for a mammogram.
C. Notify the health care provider.
D. Ask history questions about previous breast infections.
9.The client tells the nurse, "At times I have discharge from my right
breast." What should the nurse do with this information?

A. Write it in the medical record and say nothing to the client.

B. Phone for a mammogram for the client immediately.
C. Explain that this could be benign or it could mean something else.
It needs to be further investigated.
D. Nothing. It doesn't mean a thing
10. During inspection of the
breast, nurse Tanya will assess
the breast for the following
except
A. symmetry of the breast.
B. superficial venous patterns.
C. size and direction of nipple.
D. tenderness and
temperature.
11.After assessing the breast of a
female client, the nurse should
explain to the client that most
breast tumors occurs in the
A. upper inner quadrant
B. lower inner quadrant
C. upper outer quadrant
D. lower outer quadrant
12. A female client tells the nurse that her breasts become lumpy
and sore before menstruation but get better at the end of the
menstrual cycle. The nurse should explain to the client that these
symptoms are often associated with

A. malignant tumors.
B. fibroadenoma.
C. fibrocystic breast disease.
D. increased estrogen production.
 TRUE/FALSE

13._____________The client’s breasts should rise symmetrically

with no sign of dimpling or retraction

Ans: TRUE
14._____________Discharges should be referred for
cystologic study and further evaluation

Ans: TRUE
15._____________Use bimanual palpation to feel for
the anterior axillary nodes.

 Ans: TRUE
16.____________Be sure to palpate every square inch of the
breast from the nipple to areola to the periphery of the breast
tissue and up to four quadrants of the breast only.

Ans: FALSE. Should be until TAIL OF SPENCE

17. _________ Breast self examination should be done
7-10 days before menstrual period.

Ans: FALSE. It should be after

18.________The older client may have smaller, flatter nipples
that are less erectile on stimulation

Ans: TRUE
19. __________ A recent increase in the size of one breast may
indicate inflammation or an abnormal growth.

Ans: TRUE
 IDENTIFICATION

20. A smooth firm movable disc of

glandular tissue may be seen in one
breast in males during puberty for a
temporary at a time IS CALLED?
__________________.
Answer: GYNECOMASTIA
21. Why does gynecomastia occur?

A. deficiency of estrogen.
B. deficiency of aldosterone.
C. deficiency of Follicular
Stimulating Hormone
D. deficiency of testosterone,
changing hormone level.
22. It is called the dark, velvety
pigmentation of the axillae
which may indicate an
underlying malignancy.

Answer: ACANTHOSIS
NIGRICANS
23. This is a screening method used
in an attempt to detect early breast
cancer. The method involves the
woman herself looking at and
feeling each breast for possible
lumps, distortions or swelling.

Answer:
BREAST SELF EXAMINATIONS
24. What breast is larger than the
other?____________
Ans:left larger than right
 What technique should be used
25.

when the client has large breasts?

_____________________________________
Ans: bimanual breasts
 Assessment of
the PERIPHERAL
VASCULAR
System
1.Gather equipment
a. gloves
b. centimetre tape
c. stethoscope
d. doppler ultrasound probe
e. tourniquet
Gloves
Centimetre Tape
Stethoscope
Doppler Ultrasound Probe
Torniquet
2. Explain procedure to client
3. Assist
client to put
on a gown.
ARMS
1. Inspect bilaterally for size, presence
of edema, and venous pattern.
 NORMAL
Arms are bilaterally symmetric with minimal
variation in size and shape.

No edema or prominent venous patterning.

2. Inspect bilaterally for skin color or
observes coloration of the hands and
arms.
 NORMAL
Color varies depending on client’s skin tone.

Color should be the same bilaterally.

3. Inspect fingertips for clubbing
4. Palpate fingers, hands and arms and
notes for temperature using dorsal
surface of your fingers.
 NORMAL
Skin is warm to touch bilaterally from
fingertips to upper arms.
5. Palpate capillary refill time
Compress the nailbed until it blanches.
Release the pressure and calculate the time
it takes for color to return. This test indicates
peripheral perfusion and reflects cardiac
output.
 NORMAL
Capillary beds refill in 1 to 2 seconds or less.

Inaccurate findings may result if the room is

cool. If the client has edema, anemia, or if the
client recently smoked a cigarette.
6. Palpate radial, ulnar, and
brachial pulses.
RADIAL

Gently press the radial artery against the

radius. Note elasticity and strenght.
 NORMAL
Radial pulse have equal strengthe bilaterally
(2+). Artery walls have a resilient quality
(bounce)

For difficult to palpate pulses, use a Doppler

ultrasound device.
ULNAR
Apply pressure with your first three fingertips
to the medial aspects of the inner wrist.
Palpate the ulnar arteries if you suspect
arterial insufficiency.
BRACHIAL
Palpate brachial pulse if you suspect arterial
insufficiency. Do this by placing the first
three fingertips of each hand at the clent’s
right and left medial antecubital creases
Ulnar pulses may not be detectable.

Brachial pulses have equal strength

bilaterally.
7. Palpate epitrochlear lymph nodes behind
the elbow in the groove between the biceps
and triceps muscles. Evaluates the size,
tenderness and consistency.

Epitrochlear nodes are located approxiately

3 cm above the elbow on the inner (medial)
aspect of the arm.
Take the client’s right hand in your right
hand as if you were shaking hands. Flex the
client’s elbow about 90 degrees . Use your
left hand to palpate behind the elbow in the
groove between the biceps and triceps
muscles.

if nodes are detected, evaluate for size,

tenderness, and consistency.

Repeat palpation on the opposite arm.

 NORMAL
Normally, epitrochlear lymph nodes are not
palpable.
8. Perform Allen’s test by occluding
the radial and ulnar arteries and
observing for palm pallor. Then release
the ulnar artery and watch for color to
return to hand.
VIDEO
1. Have the client rest the hand palm side
up on the examination table and make a
fist.
2. Then use your thumbs to occlude the
radial and ulnar arteries.
3. Continue pressure to keep both arteries
occluded and have the client release the
fist. Note that the palm remains pale.
4. Release the pressure on the ulnar artery
and watch the color to return to the hand.
5. To assess radial patency, repeat the
procedure as before, but at the last step,
release pressure on the radial artery.

Opening the hand into exaggerated

extension may cause persistent pallor (false
positive Allen’s test)
 NORMAL
Pink coloration returns to the palms within 3
to 5 seconds if the ulnar artery is patent.

Pink coloration returns within 3 to 5 seconds

if the radial artery is patent.
LEGS
1. Inspect bilaterally for skin color
(client in supine position)

Drape the groin area and place a pillow

under client’s head for comfort.
 NORMAL
1. for lighter- skinned clients- PINK color
2. For dark pigmented skin – PINK or RED

There should be no changes in

pigmentation.
 ABNORMAL
1. pallor- when elevated
2. Rubor- when dependent (arterial
insufficiency)
3. Cyanosis- when dependent (venous
insufficiency)
4. Rusty or brownish pigmentation- (venous
insufficiency)
2. Inspectbilaterally for
distribution of hair.
 NORMAL
Hair covers the skin on the legs and appears
on the dorsal surface of the toes.

Hair loss on the lower extremities occurs

with aging and is, therefore, not an absolute
sign of arterial insufficiency in the older
client.
3. Inspect for lesion and ulcers
( note whether margins are smooth and
even, location such as at pressure points,
size depth, drainage, odor.)
4. Inspect for edema, unilateral or bilateral
( if calves are asymmetric, measure calf
circumference)
 NORMAL
Identical size and shape bilaterally; no
swelling or atrophy.
5. If client has edema, determines whether if
it is pitting or nonpitting. If the client has
pitting edema, rates on a 1+ to 4+ scale.
Press the edematous are with the tips of
your fingers, hold for a few seconds, then
release.

If the depression does not rapidly refill and

the skin remains indented on release,
pitting edema is present
 NORMAL
No edema (pitting or non pitting) present in
the legs.
6. Palpate skin temperature
( cool, warm, hot). Use dorsal surface
of the hand.
Use the backs of your fingers. Compare
your findings in the same areas bilaterally.
Note location of any changes in
temperature.
 NORMAL
Toes, feet and legs are equally warm
bilaterally.
7. Palpate the superficial inguinal lymph
nodes while keeping the genitals draped. If
detected, note size mobility or tenderness.
1. First, expose the client’s inguinal area,
keeping the genitals draped.
2. Feel over the upper medial thigh for the
vertical and horizontal groups of
superficial inguinal lymph nodes
3. If detected, determine size, mobility or
tenderness .
4. Repeat palpation on the opposite thigh.
 NORMAL
Non tender, movable lymph nodes up to 1 or
even 2 cm are commonly palpated.
8. Palpate and auscultate femoral pulses
over artery. Listen for bruits.
FEMORAL PULSE (palpation)
1. Ask the client to bend the knee and move
it out to the side.
2. Press deeply and slowly below and
medial to the inguinal ligament. Use two
hands if necessary.
3. Repeat pulsation on the opposite leg.
4. Compare the amplitude bilaterally.
FEMORAL PULSE (auscultation)
If arterial occlusion is suspected in the
femoral pulse;
1. Position the stethoscope in the femoral
artery and listen to bruits.
2. Repeat for other artery.
 NORMAL
Palpation
femoral pulses strong and equal
bilaterally.

Auscultation
no sounds auscultated over the femoral
arteries
9. Palpate popliteal, dorsalis pedis and
posterior tibial pulses.
POPLITEAL PULSE
1. Ask the client to raise (flex)the knee
partially.
2. Place your thumbs on the knee while
positioning your fingers deep in the bend
of the knee.
3. Apply pressure to locate the pulse
If you cannot detect a pulse, try palpating
with the client in a prone position.

1. Partially raise the leg.

2. Place your fingers deep in the bend of the
knee.
3. Repeat pulsation in opposite leg
 NORMAL
Popliteal pulse

It is not unusual for the popliteal pulse to

be difficult or impossible to detect, and yet
for circulation to be normal.
Dorsalis pedis pulse

Bilaterally strong. This pulse is congenitally

absent in 5 % to 10% of the population
1. Dorsiflex the client’s foot and apply light
pressure lateral to and along the side of
the extensor tendon of the big toe.
2. The pulse of the both feet may be
assessed at the same time to aid in
making comparisons.
3. Assess amplitude bilaterally

It may be difficult to palpate in an

edematous foot. A doppler ultrasound
device may be useful in this situation.
Tibial pulse

should be strong bilaterally. How ever,

in about 15 % of healthy clients, the
posterior tibial pulses are absent
1. Palpate behind and just below the medial
malleolus

2. Palpate both posterior tibial pulses at the

same time aids in making comparisons.

3. Assess amplitude bilaterally.

 Edema in the ankles may make it
difficult or impossible to palpate posterior
tibial pulse. In this case, Doppler ultrasound
may be used to assess the pulse.
10. Inspect for varicosities and
thrombophlebitis by asking client to stand.
1. Ask the client to stand

2. As the client is standing, inspect for

superficial vein thrombophlebitis.

3. To fully assess phlebitis, palpate for

tenderness.

4. If superficial vein thrombophlebitis is

present, note redness or discoloration on
the skin surface over the vein.
 NORMAL
Veins are flat and barely seen under the
surface of the skin.

Varicosities are common in the older client.

11. Assess for arterial or venous insufficiency
by eliciting bilaterally for Homan’s sign by
having client in supine position and
a. flexing knee 5 degrees and places
hands under the client’s calf muscle and
quickly squeezing the muscle against the
tibia.
b. ask the client to report any pain or
tenderness
12. Repeat the procedure on the opposite leg
VIDEO Youtube
 NORMAL
No pain or tenderness elicited with this
maneuvers

Homan’s sign is negative

13. If varicosities present:

a. Performs the manual compression test

by having client stand.
b. Firmly compress the lower portion of the
varicose vein with one hand.
c. Place other hand 6 to 8 inches above
hand.
d. Feel the pulsation in the upper hand.
Manual compression video
 NORMAL
No pulsation is palpated if the client has
competent valves.
14. If varicosities are present:
a. Perform the Trendelenburg test with client
in supine position.
b. Elevate leg 90 degrees for 15 seconds.
With legs elevated, apply a torniquet to
the upper thigh.
c. Assist client to standing position, and
observe for venous filling.
d. Remove the torniquet after 30 seconds,
and watch for sudden filling of the
varicose veins from above.
 NORMAL
Saphenous vein fills from below in 30
seconds. If valves are competent, there will
be no rapid filling of the varicose veins from
above (retrograde filling)after removing of
torniquet.
ANALYSIS OF DATA
1. Formulate nursing dignoses (wellnes, risk
potential)
2. Formulate collaborative problems
3. Make necessary referrals
HEALTH ASSESSMENT RLE
 ABDOMINAL ASSESSMENT
◼ 1. Gather equipment) pillow/towel,
centimetre ruler, stethoscope, marking
pen)
◼ 2. Explain procedure to client.
◼ 3. Ask client to put on a gown.
 ABDOMINAL QUADRANTS
◼ 4 Quadrants- RUQ, RLQ, LLQ, LUQ
◼ Imaginary vertical line- Midline ( From
sternum ( Xiphoid ) through the umbilicus
to symphysis pubis
◼ 9 regions- epigastric, umbilical
hypogastric/ suprapubic, hypochondric,
lumbar, inguinal
 LANDMARKS OF ABDOMEN
◼ Liver- largest solid organ in the body,
located below diaphragm in RUQ.
Composed of 4 lobes that fills most of the
RUQ and extend to the left midclavicular
line. In many people it extends just
below the right costal margin. The liver
functions as an accessory digestive organ
and metabolic and regulatory functions
◼ Pancreas- located mostly behind
the stomach, deep in the upper
abdomen. Normally not palpable.
Extending across the abdomen
from the RUQ to the LUQ.
Accessory organ of digestion and
endocrine gland
◼ Spleen- approximately 7 cm wide and is
located above the kidney, just below the
diaphragm at the level of the ninth, tenth
and eleventh ribs. It is posterior to the
midaxillary line and posterior and lateral to
the stomach. Soft flat structure and
usually not palpable. In some patients the
lower tip can be felt below the left costal
margin
◼ Kidneys- located high and deep under the
diaphragm. Glandular, bean shaped organs
measuring 10X5X2.5 cm are considered
posterior organs and approximately with
the level of T12 to L3 vertebrae. The tops
of both kidneys are protected by posterior
rib cage. Kidney tenderness is best assssed
at the costovertebral angle.
◼ Right kidney is slightly lowered because of
the position of the liver.
◼ Function: Filtration and elimination
of metabolic waste products. Role
in blood pressure control,
maintenance of salt, water and
electrolyte balance. Function as
endocrine glands by secreting
hormones.
◼ The pregnant uterus may be
palpated above the level of
symphysis pubis in the midline.
The ovaries are located in THE
RLQ and LLQ and are normally
palpated only during bimanual
examination of the internal
genitalia.
 HOLLOW VISCERA
◼ The abdominal cavity starts with stomach-
flashlike organ located in LUQ just below
diaphragm and in between the liver and
spleen. It is not usually palpable. Stomach
main function is to store, churn, and digest
◼ Gallbladder- a muscular cas approximately
10 cm long, primarily to concentrate and
store the bile needed to digest fat. It is
located near the posterior surface of the liver
lateral to the midclavicular line.
◼ It is not usually palpated because it is
difficult to distinguish the gallbladder and the
liver.
◼ The Small intestine is the longest portion of
the digestive tract approximately 7 cm long
and diameter of 2.5 cm
◼ For digestion and absorption of nutrients
through millions of mucosal projections lining
its wall.
◼ Lies coiled in all 4 quadrants of the abdomen
is not usually palpable
◼ Colon/ Large intestine has a wider
diameter than small intestine
approximately 6 cm and 1.4 m
long.
◼ It originates in RLQ where it
attaches to the small intestine at
the illeocecal valve.
◼ Composed of 3 major sections:
ascending, transverse and
descending
◼ Ascending colon extends up along the
right side of the abdomen, at the junction
of the liver in the RUQ.
◼ Transverse colon runs across the upper
abdomen. In the LUQ near the spleen, the
colon forms another right angle and then
extends downward along the left side of
the abdomen as the descending colon
◼ Sigmoid colon is often felt as a firm
structure on palpation, the cecum and
ascending colon may feel softer
◼ The colon functions primarily to
secrete large amounts of alkaline
mucus to lubricate the intestine
and neutralize acids formed by the
intestinal bacteria.
◼ Water is also absorbed in the large
intestine, leaving waste products
to be eliminated in stool
◼ Urinary Bladder- a distensible muscular sac
located behind the pubic bone in the
midline of the abdomen as receptacle for
urine.
◼ A bladder filled urine may be palpated in
the abdomen above the symphysis pubis
VASCULAR STRUCTURES
◼ Abdominal aorta- supplies arterial
blood to abdominal organs. And its
major branches.
◼ Pulsations of the aorta are
frequently visible and palpable at
the midline in the upper abdomen.
◼ Pulsations of the Right and Left
iliac arteries may be felt in RLQ
and LLQ
 INSPECTION
◼ 1. Inspect the skin, noting colour,
vascularity, striae, scars, and lesions (wear
gloves to inspect lesions)
Color of the Skin
Normal Findings- Abdominal skin
may be paler than the general skin
tone because this skin is seldom
exposed.
◼ Pale, taut skin may be seen with ascites
(abdominal swelling indicating fluid
accumulation in the abdominal cavity.
◼ Redness may indicate inflammation.
◼ Bruises or areas of local discoloration are
also abnormal.
◼ Purple discoloration at the flanks (Grey
Turner sign) indicates bleeding within the
abdominal wall, possibly from trauma to
the kidneys, pancreas, or duodenum or
from pancreatitis.
◼ The yellow hue of jaundice may be more
apparent on the abdomen.
Grey Turner sign
Scars
◼Ask the source of a scar and use centimeter
ruler to measure the scar’s length. Document
the location by quadrant and reference lines
◼ ex. 3cm vertical scar in RLQ below the
umbilicus
 VASCULARITY
Normal Findings
◼ Scattered fine veins may be visible.
Abnormal Findings
◼ Dilated veins may be seen with
cirrhosis of the liver, portal
hypertension, or ascites.
LIVER CIRRHOSIS
◼ Ascites is a build up of fluid
between the tissue that lines the
abdomen and the peritoneal cavity
(or the abdominal organs).
ASCITES
Striae

Normal Findings
◼Old, silvery, white striae or stretch
marks from past pregnancies or
weight gain are normal.
Striae
◼ Abnormal Findings
◼ Dark bluish-pink striae
◼ Striae may also be caused by ascites,
which stretches the skin. Ascites
usually results from liver failure or liver
disease.
Assess for lesions and rashes.
Normal Findings
◼Abdomen is fee from lesions or
rashes.
◼Flat or raised brown moles,
however, are normal and may be
apparent.
KELOID
◼ Changes in moles including size, color,
and border symmetry. Any bleeding moles or
petechiae (reddish or purple lesions may
also be abnormal.
2. Inspect the umbilicus, noting color,
location and contour.
Umbilical location

◼ Umbilicus is midline at lateral line.

◼ A deviated umbilicus may be
caused by pressure from a mass,
enlarged organs, hernia, fluid, or
scar tissue.
Contour of the umbilicus.
◼ It is recessed (inverted) or
protruding no more than 0.5cm
and is round or conical.
◼ An everted umbilicus is seen with
abdominal distention. An enlarged,
everted umbilicus suggests
umbilical hernia.
3.Inspect the contour of the abdomen.
Look across the abdomen at eye level at
the client’s side.
Observe the general contour of the
abdomen (flat, protuberant, scaphoid, or
concave; local bulges).
Contour
◼ Look the abdomen at eye level
from the client’s side, from behind
the client’s head, and from the
foot of the bed.
◼A generalized protuberant or distended
abdomen may be due to obesity, air (gas),
or fluid accumulation.
◼ Distention below the umbilicus may be
due to a full bladder, uterine enlargement,
or an ovarian tumor or cyst.
◼ Distention of the upper abdomen may be
seen with masses of the pancreas or
gastric dilation.
4. Inspect the symmetry of the abdomen.

Look at the client’s abdomen as he or she

lies in a relaxed supine position.

To further assess the abdomen for

herniation or mass within abdomen, ask
client to raise the head
◼ 5. Inspect abdominal movement,
noting respiratory movement ,
aortic pulsations, and or peristaltic
waves.
Aortic Pulsations
◼ A slight pulsation of the abdominal
aorta, which is visible. In the
epigastrium
◼ Vigorous wide, exaggerated
pulsations may be seen with
abdominal aortic aneurysm.
 Peristaltic Waves
◼ Normally peristaltic waves are not
seen although they may be visible in very
thin people as slight ripples on the
abdominal wall.
◼ Peristaltic waves are increased and
progress in a ripple-like fashion from the LUQ
to the RLQ with intestinal obstruction
(especially small intestine). In addition,
abdominal distention typically is present with
intestinal wall obstruction.
◼ 6. Auscultate for bowel sounds,
noting intensity, pitch and
frequency.
◼ High-pitched, irregular gurgles 5-35
times/min; present equally in all
quadrants
 Auscultation
1. Place the diaphragm of
your stethoscope lightly
on the abdomen.
2. Listen for bowel sounds.
Are they normal,
increased, decreased, or
absent? Borborygmi =
“growling”
3. Listen for bruits over the
renal arteries, iliac
arteries, and aorta.
◼ Use the diaphragm of the stethoscope
and make sure that it is warm before you
place on the client’s abdomen.
Apply light pressure or simply rest the
stethoscope on a tender abdomen.
Begin in the RLQ and proceed clockwise,
covering all quadrants.(bowel sounds
may be more active over the ileocecal
valve in the RLQ).
◼ Confirm bowel sounds in each quadrant.
Listen for up to 5 minutes (minimum of
1min./quadrant) to confirm the absence
of bowel sounds.
◼ bowel sounds normally occur every 5 to
15 seconds / 5-35 times/min
◼ Note the intensity, pitch, and frequency
of the sounds.
◼ Hypoactive bowel sounds indicate
diminished bowel motility. Common causes
include abdominal surgery or late bowel
obstruction.
◼ Hyperactive bowel sounds indicate
increased bowel motility. Common causes
include diarrhea, gastroenteritis, or early
bowel obstruction.
◼ Postoperatively, bowel sounds
resume gradually depending on
the type of surgery. The small
intestine functions normally in the
first few hours postoperatively;
stomach emptying takes 24 to 48
hours to recover; and the colon
requires 3 to 5 days to recover
propulsive activity.
◼ Absent bowel sounds may be associated
with peritonitis or paralytic ileus. High-
pitched tinkling and rushes of high-pitched
sounds with abdominal cramping usually
indicate obstruction.
(the increasing pitch of bowel sounds is
most diagnostic of obstruction because it
signifies intestinal distention)
7. Auscultate for vascular
sounds and friction rubs.
VENUS HUM
◼ Using the bell of the stethoscope,
listen for a venous hum in the
epigastric and umbilical areas.
 BRUIT
◼ Use the bell of the stethoscope to listen
for bruits (low-pitched, murmur-like
sound) over the abdominal aorta and
renal, iliac, and femoral arteries.
 FRICTION RUB
◼ Auscultate friction rub over the liver and
spleen by listening over the right and left
lower rib cage with the diaphragm of the
stethoscope
 PERCUSSION
o 8.Percuss for tone.
o Abdominal percussion sequences
may proceed clockwise or up and
down over the abdomen.
◼ Percuss in all four quadrants (clockwise)
using proper technique: Inspect –
Auscultation – Percuss – Palpate.
◼ Categorize what you hear as tympanic or
dull. Tympany is normally present over
most of the abdomen in the supine
position. Unusual dullness may be a clue
to an underlying abdominal mass or full
bladder.
9. Percuss the liver.
◼Percuss the span or height of the liver by
determining its lower and upper borders.
◼The lower border of liver dullness is located
at the costal margin to 1 to 2 cm below.
◼If you cannot find the lower border of the
liver, keep in mind that the lower border of
liver dullness may be difficult to estimate when
obscured by intestinal gas
◼ To assess the lower border, begin in the
RLQ at the mid clavicular line (MCL) and
percuss upward toward the chest. Note
the change from tympany to dullness.
Mark this point. It is the lower border of
liver dullness.
◼ To assess the descent of the liver, ask the
client to take a deep breath, then repeat
the procedure. To assess the upper
border, percuss over the upper right chest
at the MCL and percuss downward, noting
the change from lung resonance to liver
dullness. Mark this point- it is the upper
border of liver dullness
◼ Measure the distance between the two
marks- this is the span of the liver
◼ 10.Perform the scratch test.
◼ If you cannot accurately percuss the liver
borders, perform the scratch test.
Auscultate over the liver, starting in the
RLQ, scratch lightly over the abdomen,
◼ Progressing upward toward the liver.
◼ The sound produced by scratching
becomes more intense over the liver.
◼ 11.Percuss the spleen.
◼ Begin posterior to the left mid-axillary
line(MAL) and percuss downward, noting
the change from lung resonance to splenic
dullness. ( results of splenic percussion
may be obscured by air in the stomach or
bowel)
◼ The spleen is an oval area of dullness
approximately 7cm wide near the left
tenth rib and slightly posterior to the MAL.
 Splenic Dullness
1. Percuss the lowest costal
interspace in the left
anterior axillary line. This
area is normally tympanic.
2. Ask the patient to take a
deep breath and percuss
this area again. Dullness in
this area is a sign of splenic
enlargement
◼ Splenomegaly is characterized by
an area of dullness greater than
7cm wide. The enlargement may
result from traumatic injury, portal
hypertension
◼ 12.Perform the blunt percussion
on the liver and the kidneys.
◼ To assess for tenderness in difficult-to-
palpate structures. Percuss the liver by
placing your left hand flat against the
lower right rib cage. Use the ulnar side of
your right fist to strike your left hand.
◼ Normally no tenderness or pain is elicited
or reported by the client. The examiner
senses only a dull thud.
◼ Tenderness or sharp pain elicited over
suggests kidney infection, renal calculi
13. Perform light palpation, noting
tenderness, or masses in all
quadrants
 GENERAL PALPATION
◼ 1. Begin with light palpation . At this point
you are mostly looking for areas of
tenderness. The most sensitive indicator of
tenderness is the patient's facial expression
(so watch the patient's face, not your
hands). Voluntary or involuntary guarding
may also be present.
◼ 2. Proceed to deep palpation after surveying
the abdomen lightly. Try to identify
abdominal masses or areas of deep
tenderness.
 Light Palpation
◼ Light palpation is used to identify areas of
tenderness and muscular resistance .
◼ Using the fingertips, begin palpation in a
non tender quadrant, and compress to a
depth of 1cm in a dipping motion.
◼ Then gently lift the fingers and move to
the next area
◼ To minimize the client’s voluntary guarding
(a tensing or rigidity of the abdominal
muscles usually involving the entire
abdomen)
◼ 2. Deeply palpate all quadrants to delineate
abdominal organs and detect subtle
masses.
Using the palmar surface of the fingers,
compress to a maximum depth (5 to
6cm). Perform bimanual palpation if you
encounter resistance or to assess deeper
structures
◼ Palpate for masses. Note their location,
size (cm), shape, consistency,
demarcation, pulsati, tenderness, and
mobility. Do not confuse a mass with a
normally palpated organ or structures.
◼ Normal (mild) tenderness is possible over
the xiphoid, aorta, cecum, sigmoid colon,
and ovaries with deep palpation.
◼ Severe tenderness or pain may be related
to trauma, peritonitis, infection, tumors, or
enlarged diseased organs.
◼ No palpable masses are present.
◼ A mass detected in any quadrant may be
due to a tumor, cyst, abscess, enlarged
organ, or adhesions.
Considerations
◼ 1. Avoid touching tender or painful areas
until last, and reassure the client of your
intentions.
◼ 2. Perform light palpation before deep
palpation to detect tenderness and
superficial masses.
◼ 3. Keep in mind that the normal
abdomen may be tender.
◼ 4. Overcome ticklishness and minimize
voluntary guarding by asking the client to
perform self-palpation.
◼ Place your hands over the client’s abdomen
After a while, let your fingers glide slowly
onto the abdomen while still resting mostly
on the client’s fingers. The same can be
done by using a warm stethoscope as a
palpating instrument, again letting your
fingers drift over the edge of the diaphragm
and palpate without promoting a ticklish
response.
5. Work with the client to promote relaxation
and minimize voluntary guarding. The
following techniques:
◼place a pillow under the client’s knees.
◼ask the client to take slow, deep breaths
through the mouth.
14. Perform deep palpation, noting
tenderness or masses in all
quadrants
15. Palpate the umbilicus and
surrounding area for swellings,
bulges, or masses.
◼ A soft center of the umbilicus can
be a potential for herniation.
Palpation of a hard nodule in or
round the umbilicus may indicate
metastatic nodes from an occult
gastrointestinal cancer.
16. Palpate the aorta.
◼ Use your thumb and first finger or
use two hands and palpate deeply
in the epigastrium. Slightly to the
left midline. Assess the pulsation
of the abdominal aorta.
◼ The normal aorta is approximately 2.5 to
3.0cm wide with a moderately strong and
regular pulse. Possibly mild tenderness
may be elicited.
◼ A wide bounding pulse may be felt with an
abdominal aortic aneurysm. A prominent,
laterally pulsating mass above the
umbilicus with an accompanying audible
bruit strongly suggests an aortic
aneurysm.
◼ Do not palpate pulsating middle mass it
may be a dissecting aneurysm that can
rupture from the pressure of palpation.
17. Palpate the liver, noting consistency
and tenderness.
◼ To palpate bimanually, stand at the
client’s right side and place your left
hand under the client’s back at the level
of the eleventh to twelfth ribs.
◼ Lay your right hand parallel to the right
costal margin (your fingertips
should point toward the client’s head).
Ask the client to inhale then compress
upward and inward with your fingers.
◼ Hooking Technique for liver palpation
◼ Curl (hook) the fingers
of both hands over the
edge of the right costal
margin.
◼ Ask the client to take a
deep breath
◼ gently but firmly pull
inward and upward
with your fingers.
◼ The liver is usually not palpable,
although it may be felt in some thin
clients. If the lower edge is felt, it should
be firm, smooth, and even. Mild
tenderness may be normal.
◼ A liver more than 1 to 3cm below the
costal margin is considered enlarged
(unless pressed down by the diaphragm.
◼ Enlargement may be due to hepatitis,
liver tumors
18. Palpate the spleen , noting consistency
and tenderness
◼ Start at the client’s right side, reach over the
abdomen with your left arm, and place your
hand under the posterior lower ribs.
◼ Pull up gently.
◼ Place your right hand below the left costal
margin with the fingers pointing toward the
client’s head.
◼ Ask the client to inhale and press inward
and upward as you provide support with
your other hand.
◼ Alternatively ask the client to turn onto the
right side may facilitate splenic palpation by
moving the spleen downward and forward.
◼ Document the size of the spleen in cm.
below the left costal margin.
◼ Also note consistency and tenderness.
◼ (be sure to palpate with your fingers below
the costal margin so you do not miss the
lower edge of an enlarged spleen).
◼ A palpable spleen suggests
enlargement (up to 3 times the
normal size), which may result
from trauma, and cancers.
caution: to avoid traumatizing and
possibly rupturing the organ, be
gentle when palpating an enlarged
spleen.
◼ The spleen feels soft with a
rounded edge when it is enlarged
from infection. It feels firm with a
sharp edge when it is enlarged
from chronic disease.
19. Palpate the kidneys.
◼ To palpate the right kidney,
support the right posterior flank
with your left hand and place your
right hand in the RUQ just below
the costal margin at the MCL.
◼ To capture the kidney, ask the
client to inhale. Then compress
your finger deeply during peak
inspiration.
◼ Ask the client to exhale and hold
the breath briefly. Gradually
release the pressure of your right
hand. If you have captured the
kidney, you will feel it slip beneath
your fingers.
◼ To palpate the left kidney, reverse
the procedure
◼ The kidneys are normally not
palpable. Sometimes the lower
pole of the right kidney may be
palpable by the capture method
because of its lower position. If
palpated, it should feel firm,
smooth, and rounded. The kidney
may o may not be slightly tender.
◼ An enlarged kidney may be due to
a cyst, tumor.
◼ 20.Palpate the urinary bladder.
◼ Palpate for a distended bladder when the
client’s history or other findings warrant
(e.g. dull percussion noted over the
symphysis pubis).
◼ Begin at the symphysis pubis and move
upward and outward to estimate bladder
borders.
◼ Normally the bladder is not
palpable.
◼ A distended bladder is palpated as
a smooth, round, and somewhat
firm mass extending as far as the
umbilicus. It may be further
validated by dull percussion tones.
21. Perform the test for shifting dullness.
This is a test for peritoneal fluid (ascites).
If you suspect that the client has ascites
because of a distended abdomen or
bulging flanks, perform this special
percussion technique.
◼ The client should remain supine, percuss
the flanks from the bed upward toward
the umbilicus. Note the change from
dullness to tympany, and mark this
point. Now help the client turn onto his
or her side. Percuss the abdomen from
the bed upward. Mark the level where
dullness changes to tympany.
◼22.Perform the fluid wave test
◼ Fluid wave test or fluid thrill test is a
test for ascites (free fluid in the
abdominal cavity). It is performed by
having the patient (or a colleague) push
their hands down on the midline of the
abdomen.
◼ The client should remain supine. You will
need assistance with this test. Ask the
client or an assistant to place the ulnar side
of the hand at the lateral side of the
forearm firmly along the midline of the
abdomen. Firmly place the palmar surface
of your fingers and hand against one side
of the client’s abdomen . Use your other
hand to tap the opposite side of the
abdominal wall.
◼ The examiner then taps one flank, while
feeling on the other flank for the tap.
The pressure on the midline prevents
vibrations through the abdominal wall
while the fluid allows the tap to be felt
on the other side. The result is
considered positive if tap can be felt on
the other side
◼ However, even with the midline
pressure, transmission through the skin
must be excluded. A positive fluid wave
test indicates that there is a free fluid
(ascites) in the abdomen. When one
side of the abdomen is pressed, the
other side may also be painful due to
the transfer of the fluid in it.
◼23.Perform the ballotment test.
◼ A Technique performed to identify
mass or enlarged organ within an
ascites abdomen. It can be
performed two different ways-
single handed or bi-manually.
Single-Hand Method
◼ Using a tapping or bouncing motion of
the fingerpad over the abdominal wall,
feel for a floating mass.
Bimanual Method
◼ Place one hand under the flank
(receiving/feeling hand),and push the
anterior abdominal wall with the other
hand.
 24. Perform test for
appendicitis.
a. Rebound tenderness/ Blumberg Sign
◼This is a test for peritoneal irritation. Warn
the patient what you are about to do.
◼1. Press deeply on the abdomen with your
hand.
◼2. After a moment, quickly release
pressure.
◼3. If it hurts more when you release, the
patient has rebound tenderness.
◼ b. Rovsing’s sign
◼ If palpation of the left lower quadrant of a
person's abdomen increases the pain felt
in the right lower quadrant, the patient is
said to have a positive Rovsing's sign and
may have appendicitis.
◼ c. Referred rebound tenderness
◼ Palpate deeply in the LLQ and quickly
release pressure
◼ Normal: No rebound pain
◼ Abnormal findings: Pain in RLQ during
pressure in the LLQ
d. Psoas sign
◼1. Place your hand above the patient's
right knee.
◼2. Ask the patient to flex the right hip
against resistance.
◼3. Increased abdominal pain indicates a
positive psoas sign.
e. Obturator Sign
◼1. Raise the patient's right leg with the knee
flexed.
◼2. Rotate the leg internally at the hip.
◼3. Increased abdominal pain indicates a
positive obturator sign.
◼4. Not used as much lately as there is a
question on how well it predicts appendicitis
◼ f. Hypersensitivity test
◼ Stroke the abdomen with a sharp object (
broken cotton applicator/ tongue blade or
grasp a fold of skin with your thumb and
index finger and quickly let go. Do this
several times along the abdominal wall
◼ Normal: client feels no pain/ no
exaggerated sensation
◼ Abnormal findings: Pain/ exaggerated
sensation felt in RLQ is a positive skin
hypersensitivity test and may indicate
appendicitis
◼ 25.Perform test for cholecystitis (Murphy’s
sign)

◼ To assess RLQ pain or tenderness, which

may signal inflammation of the
gallbladder, press your fingertips under the
liver border at the right costal margin and
ask the client to inhale deeply
ABDOMINAL DISTENTION
Ascites
Enlarged abdominal Organs