Assessing the Skull and Face

Assessment Normal and Abnormal Findings

Rationale
 Normal
Inspect the skull for size, Rounded (normocephalic and symmetric, with frontal,
shape, and symmetry. parietal, and occipital prominences); smooth skull contour
 Abnormal
Lack of symmetry, increased skull size with more prominent
nose and forehead; longer mandible (may indicate
excessive growth hormone or increased bone thickness)
 Normal
Palpate the skull for Smooth, uniform consistency; absence of nodules/ masses
nodules or masses and or depression
depressions. Abnormal
 Sebaceous cysts; local deformities from trauma; masses;
nodules
 To indicate an inherited or Normal
Inspect the facial features. chronic disorder with typical Symmetric or slightly asymmetric facial features; palpebral
 facies such as Grave’s fissures equal in size, symmetric nasolabial folds
disease, hyperthyroidism Abnormal
with myxedema, crushing Increased facial hair; low hair line; thinning of eyebrows;
syndrome or acromegaly. asymmetric features; exophthalmos; myxedema facies;
moon face
 Normal
Inspect the eyes for edema No edema
and hollowness. Abnormal
 Peri-orbital edema; sunken eyes
 Normal
Note symmetry of facial Symmetric facial movements
movements. Abnormal
 Asymmetric facial movements (e.g., eye cannot close
completely); dropping of lower eyelid and mouth; involuntary
Ask the client to elevate the facial movements (i.e., tics and tremors)
eyebrows, frown, or lower
the eyebrows, close the
eyes tightly, puff the
cheeks, and smile and
show the teeth.

ASSESSING THE SKIN

Assessment Rationale Normal findings /Abnormal
5. Inspect skin color (best Some medications can cause Normal:
assessed under photosensitivity reactions after being Varies from light to deep brown; from ruddy
natural light and on areas not exposed to the sun. It often appears 24 pink to light pink; from yellow overtones to olive
exposed to hours after taking the medication and Abnormal:
the sun). leaves after discontinuing the medication. Pallor, cyanosis, jaundice, erythema
Some clients may exhibit allergic skin
reaction to specific drugs.

6. Inspect uniformity of skin color. Skin color is the result of reflected and Normal:
absorbed light from unpigmented skin, Generally uniform except in areas exposed
mixed with colors of various constitutive to the sun; areas of lighter pigmentation
pigments, such as melanin’s, (palms, lips, nail beds) in dark-skinned
hemoglobin’s, and carotenes. As light hits People
 the skin's surface, it is either reflected Abnormal:
diffusely back, scattered, or absorbed by Areas of either hyperpigmentation or
particles within the skin. hypopigmentation
7. Assess edema, if present (i.e., Edema occurs when something disrupts Normal:
location, the usual balance of fluids in your cells. No edema
color, temperature, shape, and As a result, an abnormal amount of fluid Abnormal:
the accumulates in your tissues (interstitial See the scale for describing edema.
degree to which the skin remains space). Gravity pulls the fluid down into
indented or pitted when pressed your legs and feet. Peripheral edema is
by a common in older adults and pregnant
finger). Measuring the women, but it can occur at any age
circumference of
the extremity with a millimeter
tape may
be useful for future comparison
8. Inspect, palpate, and describe skin lesion Touching a patient conveys Normal:
skin empathy and reassurance (where Freckles, some birthmarks that have not
lesions. Apply gloves if lesions appropriate) that the patient's rash is not changed since childhood, and some
are open contagious. Palpation, specifically, is an long-standing vascular birthmarks such
or draining. Palpate lesions to important but underestimated as strawberry or port-wine hemangiomas,
determine examination modality. some flat and raised nevi, no abrasions or
shape and texture. Describe For localized lesions, palpation identifies other lesions
lesions tenderness, consistency, induration, Abnormal
according to location, distribution, depth and fixation. Various interruptions in skin integrity; irregular,
color, multicolored, or raised nevi, some pigmented
configuration, size, shape, type, birthmarks such as melanocytic nevi,
or and some vascular birthmarks such as
structure (Box 30–5 on page cavernous hemangiomas. Even these
527). Use deviations from normal may not be
the millimeter ruler to measure dangerous or require treatment.
lesions. If Assessment by an advanced level
gloves were applied, remove and practitioner is required.
discard
gloves. Perform hand hygiene.
9. Observe and palpate skin Normal:
moisture. Moisture in skinfolds and the axillae (varies
with environmental temperature and
humidity, body temperature, and activity)
Abnormal
Excessive moisture (e.g., in hyperthermia);
excessive dryness (e.g., in dehydration)
10. Palpate skin temperature. Changes in sensation or temperature Normal:
Compare the may indicate vascular or neurologic Uniform: within normal range Generalized hyperthermia (e.g., in
two feet and the two hands, using problems such as peripheral neuropathy fever);
the related to diabetes mellitus or arterial Abnormal
backs of your fingers. occlusive disease. Decreased sensation Uniform: within normal range Generalized hyperthermia (e.g., in
may put the client at risk for fever);
developing pressure ulcers.
11. Note skin turgor (fullness or Its refers to the elasticity of your skin. Normal:
elasticity) When you pinch the skin on your arm, for Uniform: within normal range Generalized hyperthermia (e.g., in
by lifting and pinching the skin on example, it should spring back into place fever);
an with a second or two. Having poor skin Abnormal
extremity or on the sternum. turgor means it takes longer for your skin Skin stays pinched or tented or moves back
to return to its usual position. It's often slowly (e.g., in dehydration). Count in seconds
used as a way to check for dehydration. how long the skin remains tented. There is
no widely accepted time span distinguishing
normal from abnormal skin turgor (de Vries
Feyens & de Jager, 2011).

ASSESSING THE HAIR

Assessment Normal Rationale Normal findings / Abnormal

5. Inspect the evenness Evenly distributed hair Scalp should be free Normal:
of growth over the from dandruff, lesion or Evenly distributed hair
scalp. parasites. Abnormal:
Patches of hair loss (i.e., alopecia
6. Inspect hair thickness Thick hair Normal:
or thinness. Thick hair
Abnormal
Very thin hair (e.g., in hypothyroidism)
7. Inspect hair texture Silky, resilient hair Hair should be smoothNormal:
and oiliness. not oily or dry Silky, resilient hair
Abnormal:
Brittle hair (e.g., hypothyroidism); excessively
oily or dry hair
8. Note presence of No infection or infestation Many of these conditions Normal:
infections or infestations show the presence No infection or infestation
by parting the hair in of Staphylococcus Abnormal:
several areas, checking aureus [SA] and NormalFlaking, sores, lice, nits (lice eggs), and
behind the ears and response to antibiotic ringworm
along the hairline at the therapy
neck.
9. Inspect amount of Variable To determine the Normal:
body hair. quantity, quality, and Variable
distribution of hair. Abnormal
Hirsutism (excessive hairiness) in women.
naturally absent or sparse leg hair (poor
circulation)

Normal findings / Abnormal

Assessment Normal Rationale
5. Inspect fingernail Convex curvature; determined by the form of the Normal
plate shape to angle of nail plate underlying bone. A few layers Convex curvature; angle of nail plate about
determine its about of dead, compacted cells make 160° (Figure 30–10A)
curvature and angle. 160° (Figure 30– the nail strong and rigid, yet Abnormal
10A) somewhat flexible. Spoon nail (Figure 30–10B); clubbing (180°
or greater) (Figure 30–10C and D)
6. Inspect fingernail Smooth texture To determine the quality of Normal
and toenail texture. blood circulation Smooth texture
Abnormal
Excessive thickness or thinness or presence of grooves or
furrows; Beau’s lines
(Figure 30–10E); discolored or detached nail
7. Inspect fingernail Highly vascular and Color changes in nails may Normal
and toenail bed pink in light-skinned indicate a local or systemic Highly vascular and pink in light-skinned
color. clients: dark-skinned problem. clients: dark-skinned clients may have
clients may have brown or black pigmentation in longitudinal
brown or black streaks
pigmentation in Abnormal
longitudinal Bluish or purplish tint (may reflect cyanosis);
streaks pallor (may reflect poor arterial circulation
8. Inspect tissues Intact epidermis The paronychium is the Normal
surrounding nails. soft tissue border around Intact epidermis
the nail, and paronychia is an Abnormal
infection in this area. Hangnails; paronychia (inflammation)

9. Perform blanch Prompt return of pink is performed on the nail beds as Normal
test of capillary refill. or usual color an indicator of tissue perfusion Prompt return of pink or usual color
Press the nails (generally, less than (the amount of blood flow to (generally, less than 2 seconds)
between your thumb 2 seconds) tissue) and dehydration
 and Abnormal
index finger: look for Delayed return of pink or usual color
blanching and return (may indicate circulatory impairment)
of pink color to nail
bed. Perform on
at least one nail on
each hand and foot.

NECK

Procedure Rationale Normal Abnormal

Neck Muscles
Muscles equal in Unilateral neck swelling; head tilted to one side (indicates
1. size; head centered presence of masses, injury, muscle weakness, shortening
Inspect the neck muscles of sternocleidomastoid muscle, scars) muscle tremor,
(sternocleidomastoid and spasm, or stiffness.
trapezius) for abnormal
swellings or masses. Ask the
client to hold the head erect.
2.

Observe head movement. Ask

client to:
This determines function Coordinated, smooth Limited range of motion; painful movements; involuntary
of the sternocleidomastoid movements with no movements (e.g., up-and-down nodding movements

muscle. discomfort associated with Parkinson’s disease)
Move chin to chest.
Head flexes 45°

 This determines function Head hyperextends Head hyperextends less than 60°
Move the head back so that of the trapezius muscle. 60°
the chin points upward.

 This determines function Head laterally flexes Head laterally flexes less than 40°
Move the head so that the ear of the sternocleidomastoid 40°
is moved toward the shoulder muscle.
on each side.

 This determines function Head laterally Head laterally rotates less than 70°
Turn the head to the right and of the sternocleidomastoid rotates 70°
to the left. muscle.

1.
Assess muscle strength.
2. This determines the Equal strength Unequal strength
strength of the

sternocleidomastoid
Ask the client to turn the
muscle
head to one side against the
resistance of your hand.
Repeat with the other side.

This determines the Equal strength Unequal strength
Ask the client to shrug the strength of the trapezius
shoulders against the muscles.
resistance of your hands.

Lymph Nodes

1. This relaxes the soft tissue Not palpable Enlarged, palpable, possibly tender (associated with
Palpate the entire neck for and muscles. infection and tumors)
enlarged lymph nodes.
2.

 Face the client, and bend the
client’s head forward slightly
or toward the side being
examined.


Palpate the nodes using the
pads of the fingers. Move the
fingertips in a gentle rotating
motion.

Trachea

1. The trachea is a part of Central placement in Deviation to one side, indicating possible neck tumor;
Palpate the trachea for lateral the upper respiratory midline of neck; thyroid enlargement; enlarged lymph nodes
deviation. Place your fingertip system that you directly spaces are equal on
or thumb on the trachea in the palpate. It is normally both sides
suprasternal notch, and then located in the midline
move your finger laterally to above the suprasternal
the left and the right in spaces notch. Masses in the neck
bordered by the clavicle, the or mediastinum and
anterior aspect of the pulmonary abnormalities
sternocleidomastoid muscle, cause displacement
and the trachea. laterally.
2.
Thyroid Gland

1. Not visible on Visible diffuseness or local enlargement

Inspect the thyroid gland. inspection
2.

Stand in front of the client


Observe the lower half of the
neck overlying the thyroid
gland for symmetry and
visible masses.

 This action determines Gland ascends Gland is not fully movable with swallowing
Ask the client to extend the how the thyroid and during swallowing
head and swallow. If cricoid cartilages move but is not visible
necessary, offer a glass of and whether swallowing
water to make it easier for the causes a bulging of the
client to swallow gland.


Document findings in the

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

EYES

Assessing the Eye Structures and Visual Acuity Rationale Normal and Abnormal Findings

Preparation

Procedure
1.Explain to the client what you are
 going to do, why it is necessary, and how
she can cooperate.
2.Wash hands and observe other
appropriate infection control procedures.
3.Provide for client privacy. To provide comfort.
4.Determine client’s history of the following:

Family history of diabetes, hypertension,
or blood dyscrasias


Eye disease, injury, or surgery


Last visit to an ophthalmologist


Current use of eye medications


Use of contact lenses or eyeglasses


Hygienic practices for corrective lenses


Current symptoms of eye problems

External Eye Structures
5.Inspect the eyebrows for hair distribution Ask client to raise and lower the eyebrows. NORMAL:
and alignment and for skin quality and The hair of the eyebrows are evenly distributed, the
movement. skin is intact and has no signs of scaling and flakiness,
the eyebrows are symmetrically aligned and equal.

ABNORMAL:
Loss of hair; scaling and flakiness of skin
Unequal alignment and movement of eyebrows
6.Inspect the eyelashes for evenness of NORMAL:
distribution and direction of curl. The eyelashes are equally distributed. It is curled
slightly outward.

ABNORMAL:
Turned inward
7.Inspect the eyelids for surface NORMAL:
characteristics, position in relation to the The skin of the eyelids is intact. There is no any
cornea, ability to blink, and frequency of discharge and discoloration. The eyelids also close
blinking. Inspect the lower eyelids while symmetrically. Approximately there are 15 to 20
the client’s eyes are closed. involuntary blinks per minute and the blinking is
bilateral. When lids are open, there is no visible sclera
above the corneas, and upper and lower borders of
cornea are slightly covered.

ABNORMAL:
Redness, swelling flaking, crusting plaques, discharge,
nodules, lesions
Lids close asymmetrically, incompletely, or painfully
Rapid, monocular, absent, or infrequent blinking
Ptosis (drooping or falling of the upper eyelid),
ectropion (lower eyelid turns or sags outward, away
from your eye), or entropion (eyelid is rolled inward
against the eyeball); rim of sclera visible between lid
and iris
8.Inspect the bulbar conjunctiva for color, Retract the eyelids with your thumb and index NORMAL:
texture, and the presence of lesions. finger, exerting pressure over the upper and The bulbar conjunctiva is transparent, the capillaries
lower bony orbits, and ask the client to look up, are sometimes evident and the sclera appears white
do wn, and from side to side. (darker or yellowish and with small brown macules in
dark-skinned clients). There is no presence of any
lesions or nodules.

ABNORMAL:
 Jaundiced sclera (e.g., in liver disease); excessively
pale sclera (e.g., in anemia); reddened sclera; lesions
or nodules (may indicate damage by mechanical,
chemical, allergenic, or bacterial agents)
9.Inspect the palpebral conjunctiva by Evert both lower lids and ask the client to look up. NORMAL:
everting the lids. Then gently retract the lower lids with the index Has a shiny, smooth, and pink or reddish palpebral
fingers. conjunctiva. There is no any lesions or nodules.

ABNORMAL:
Extremely pale (possible anemia); extremely red
(inflammation); nodules or other lesions
Evert the upper lids if a problem is Ask the client to look down while keeping the
suspected. eyes slightly open. Rationale: Closing the eyelids
contracts the orbicular muscle, which prevents lid
eversion.
• Gently grasp the client's eyelashes with the
thumb and index finger. Pull the lashes gently
downward. Rationale: Upward or outward pulling
on the eyelashes causes muscle contraction.
• Place a cotton-tipped applicator stick about 1
cm above the lid margin, and push it gently
downward while holding the eyelashes.
Rationale: These actions evert the lid, that is, flip
the lower part of the lid over on top of itself.
• Hold the margin of the everted lid or the
eyelashes against the ridge of the upper bony
orbit with the applicator stick or the thumb.
• Inspect the conjunctiva for color, texture,
lesions, and foreign bodies.
• To return the lid to its normal position, gently
pull the lashes forward, and ask the client to look
up and blink.

11.Inspect and palpate the lacrimal gland. Using the tip of your index finger, palpate the NORMAL:
lacrimal gland. Observe for edema between the There is no presence of any edema or tenderness
lower lid and the nose. over the lacrimal gland.
ABNORMAL:
Swelling or tenderness over lacrimal gland
12.Inspect and palpate the lacrimal sac and Observe for evidence of increased tearing. Using NORMAL:
nasolacrimal duct. the tip of your index finger, palpate inside the The lacrimal sac and nasolacrimal duct has no edema
lower orbital rim near the inner canthus. or tearing.
ABNORMAL:
Evidence of increased tearing; regurgitation of fluid on
palpation of lacrimal sac
13. Inspect the cornea for clarity and texture. NORMAL:
Ask the client to look straight ahead. Hold Transparent, shiny, and smooth. The details of the iris
a penlight at an oblique angle to the eye, are also visible. In older people, a thin, grayish white
and move the light slowly across the ring around the margin, called arcus senilis, may be
corneal surface. evident

ABNORMAL:
Opaque; surface not smooth (may be the result of
trauma or abrasion); Arcus senilis in clients under age
40
14. Perform the corneal sensitivity (reflex) NORMAL:
test to determine the function of the fifth Blinks when the cornea is touched, indicating that the
(trigeminal) cranial nerve. trigeminal nerve is intact.
Ask the client to keep both eyes open
and look straight ahead. Approach from ABNORMAL:
behind and beside the client, and lightly One or both eyelids fail to respond
touch the cornea with a corner of the
gauze.
15. Inspect the anterior chamber for NORMAL:
transparency and depth. Use the same The anterior chamber is transparent. There are no
oblique lighting used when testing the shadows of light on the iris and has a depth of about 3
cornea. mm.

ABNORMAL: Cloudy; Crescent-shaped shadows on

far side of iris; Shallow chamber (possible glaucoma)

16. Inspect the pupils for color, shape, and NORMAL:

symmetry of size. The pupil is black in color and equal in size. It is
normally 3 to 7 mm in diameter. It is round, has a
 smooth border, and the iris is iris flat and round.

ABNORMAL:
Cloudiness, mydriasis, miosis, anisocoria; bulging of
iris toward cornea
17. Assess each pupil’s direct and • To determine the function of the third NORMAL:
consensual reaction to light. (oculomotor) and fourth (trochlear) cranial nerves. The illuminated pupil constricts (direct response) and
• Partially darken the room. the non-illuminated pupil constricts (consensual
• Ask the client to look straight ahead. response).
• Using a penlight and approaching from the side,
shine a light on the pupil. ABNORMAL:
• Observe the response of the illuminated pupil. It Neither pupil constricts; Unequal responses; Absent
should constrict (direct response). responses
• Shine the light on the pupil again and observe
the response of the other pupil. It should also
constrict. (consensual response).

18. Assess each pupil’s reaction to •Hold an object (a penlight or pencil) about 10 cm NORMAL:
accommodation. (4 in.) from the bridge of the client's nose. The pupils constrict when looking at near object, it also
• Ask the client to look first at the top of the object dilate when looking at far object and it converge when
and then at a distant object (e.g., the far wall) near object is moved toward the nose. The pupils are
behind the penlight. Alternate the gaze from the equally round and react to light and accommodation.
near to the far object.
• Observe the pupil response. The pupils should ABNORMAL:
constrict when looking at the near object and One or both pupils fail to constrict, dilate, or converge
dilate when looking at the far object.
• Next, move the penlight or pencil toward the
client's nose. The pupils should converge. To
record normal assessment of the pupils, use the
abbreviation PERRLA (pupils equally round and
react to light and accommodation).

Visual Fields

19. Assess peripheral visual fields. To determine function of the retina and neuronal NORMAL:
visual pathways to the brain and second (optic) When looking straight ahead, client can see objects in
cranial nerve. the periphery

ABNORMAL:
Visual field smaller than normal (possible glaucoma);
one-half vision in one or both eyes (possible nerve
damage)
Extraocular Muscle Tests

20. Assess six ocular movements to These can be performed on clients over 6 months NORMAL:
determine eye alignment and of age. Both eyes coordinated, move in unison, with parallel
coordination. alignment
Light falls symmetrically on both pupils (e.g., at "6
o'clock" on both pupils) and the uncovered eye does
not move

ABNORMAL:
Eye movements not coordinated or parallel; one or
both eyes fail to follow a penlight in specific directions,
e.g., strabismus (cross-eye)
Nystagmus (rapid involuntary rhythmic eye movement)
other than at end point may indicate neurologic
impairment.
Light falls off center on one eye (indicates
misalignment). If misalignment is present, when
dominant eye is covered, the uncovered eye will move
to focus on object.

Visual Acuity

21. Assess near vision. By providing adequate lighting and asking the NORMAL:
client to read from a magazine or newspaper held The client can able to read newsprint.
at a distance of 36 cm (14 in.) If the client
normally wears corrective lenses, the glasses or ABNORMAL:
 lenses should be worn during the test. Difficulty reading newsprint unless due to aging
process
22. Assess distance vision. By asking the client to wear corrective lenses, NORMAL:
unless they are used for reading only, i.e., for 20/20 vision on Snellen-type chart.
distances of only 36 cm (12 to 14 in.
ABNORMAL:
Denominator of 40 or more on Snellen-type chart with
corrective lenses
23. Perform functional vision tests if the client LIGHT PERCEPTION
is unable to see the top line (20/200) of Shine a penlight into the client's eye from a lateral If the client knows when the light is on or off, the client
Snellen’s chart. position, and then turn the light off. Ask the client has light perception, and the vision is recorded as
to tell you when the light is on or off. "LP."

HAND MOVEMENTS (H/M)

Hold your hand 30 cm (1 ft) from the client's face
and move it slowly back and forth, stopping it If the client knows when your hand stops moving,
periodically. Ask the client to tell you when your record the vision as "H/M 1 ft."
hand stops moving.

COUNTING FINGERS (C/F)

Hold up some of your fingers 30 cm (1 ft) from the
client's face and ask the client to count your If the client can do so, note on the vision record "C/F 1
fingers. ft.

ABNORMAL:
Functional vision only (e.g., light perception, hand
movements, counting fingers at 1 ft)
24. Document findings in the client record.

Assessing the Ears and Hearing

PROCEDURE RATIONALE FINDINGS

Assemble equipment and supplies:


Otoscope with several sizes or ear specula

Procedure.

Explain to the client what you are going to

do, why it is necessary, and how she can
cooperate.

Wash hands and observe other appropriate

infection control procedures.

Provide for client privacy.

Determine client’s history of the

following: 
 Age-related hearing loss tends to run in
Family history of hearing problems or loss families
 


Presence of any ear problems 
Ringing in the ears (tinnitus) may be

associated with excessive earwax build-up,
high blood pressure, or certain ototoxic

medications (such as streptomycin,
Medication history, especially if there are
 complaints of ringing in ears gentamicin, kanamycin, neomycin,
 ethacrynic acid, furosemide, indomethacin,
or aspirin), loud noises, or other causes.


Hearing loss or ear pain may interfere with
the client’s ability to perform usual ADLs.
Clients may not be able to drive, talk on the
telephone, or operate machinery safely
because of decreased hearing acuity. The
ability to perform in occupations that rely
heavily on hearing, such as a receptionist or
telephone operator, may be affected


Any hearing difficulty: its onset, factors
contributing to it, and how it interferes with
activities of daily living



Use of a corrective hearing device: when
and from whom it was obtained


Position the client comfortably, seated if This helps to promote the client’s
possible. participation, which is very important in this
examination. In addition, the test should be
explained thoroughly to guarantee accurate
results. To ease any client anxiety, explain in
detail what you will be doing. Also, answer
any questions the client may have.

Assessment
Auricles
1. . NORMAL: Ears are equal in size bilaterally
Inspect the auricles for color, symmetry of (normally 4–10 cm). The auricle aligns with the
size, and position corner of each eye and within a 10-degree angle
2. of the vertical position. Earlobes may be free,
attached, or soldered (tightly attached to
adjacent skin with no apparent lobe).

ABNORMAL: Ears are smaller than 4 cm or

larger than 10 cm.
Mal-aligned or low-set ears may be seen with
genitourinary disorders or chromosomal defects.

Some abnormal findings suggest various

disorders, including:

Enlarged pre-auricular and post-auricular lymph
nodes—infection


Tophi (non-tender, hard, cream-colored nodules
on the helix or antihelix, containing uric acid
crystals)—gout • Blocked sebaceous glands—
post-auricular cysts
 

Ulcerated, crusted nodules that bleed— skin
cancer (most often seen on the helix due to skin
exposure)


Redness, swelling, scaling, or itching—otitis
externa


Pale blue ear color—frostbite

1. NORMAL: Normally the auricle, tragus, and

Palpate the auricles for texture, elasticity, mastoid process are not tender.
and areas of tenderness.
2. ABNORMAL: A painful auricle or tragus is
associated with otitis externa or a post-auricular
cyst.

Tenderness over the mastoid process suggests

mastoiditis.

Tenderness behind the ear may occur with otitis

media.
External Ear Canal
and Tympanic Membrane
NORMAL: A small amount of odourless cerumen
Using an otoscope, inspect the external ear (earwax) is the only discharge normally present.
canal for cerumen, skin lesions, pus, and Cerumen color may be yellow, orange, red,
blood. brown, gray, or black. Consistency may be soft,
moist, dry, flaky, or even hard.

ABNORMAL: Abnormal findings associated with

specific disorders include:

Foul-smelling, sticky, yellow discharge— otitis
externa or impacted foreign body


Bloody, purulent discharge—otitis media with
ruptured tympanic membrane


Blood or watery drainage (cerebrospinal fluid)—
skull trauma (refer client to physician
immediately)


Impacted cerumen blocking the view of the
external ear canal—conductive hearing loss


NORMAL: The canal walls should be pink and

Observe the color and consistency of the smooth, without nodules.
ear canal walls and inspect the character of
any nodules. ABNORMAL: findings in the ear canal may
include: • Reddened, swollen canals—otitis
externa • Exostoses (non-malignant nodular
swellings) • Polyps may block the view of the
eardrum
NORMAL: The tympanic membrane should be
Inspect the tympanic membrane for color pearly, gray, shiny, and translucent, with no
and gloss. bulging or retraction. It is slightly concave,
smooth, and intact. A cone-shaped reflection of
 the otoscope light is normally seen at 5 o’clock
in the right ear and 7 o’clock in the left ear. The
short process and handle of the malleus and the
umbo are clearly visible.

ABNORMAL: Abnormal findings in the tympanic

membrane may include:

Red, bulging eardrum and distorted, diminished,
or absent light reflex—acute otitis media


Yellowish, bulging membrane with bubbles
behind—serous otitis media


Bluish or dark red color—blood behind the
eardrum from skull trauma


White spots—scarring from infection


Perforations—trauma from infection


Prominent landmarks—eardrum retraction from
negative ear pressure resulting from an
obstructed eustachian tube


Obscured or absent landmarks—eardrum
thickening from chronic otitis media


NORMAL: The healthy membrane flutters when

the bulb is inflated and returns to the resting
position once the air released.
To evaluate the mobility of the tympanic
membrane, perform pneumatic otoscopy ABNORMAL: With otitis media, the membrane
with a bulb insufflator attached by using an does not move or flutter when the bulb is
otoscope with bulb insufflators. Observe the inflated.
position of the tympanic membrane when
the bulb is inflated and again when the air is
released.

Gross Hearing Acuity Tests

NORMAL: Able to correctly repeat the two-
Assess client’s response to normal voice syllable word as whispered.
tones. If client has difficulty hearing the
normal voice, proceed with the following ABNORMAL: Unable to repeat the two-syllable
tests. word after two tries indicates hearing loss and
requires follow-up testing by an audiologist.
Perform the watch tick test.

Have the client occlude one ear. Out of the

client’s sight, place a ticking watch 2–3 cm
(1–2 in) from the unconcluded ear.

Ask what the client can hear. Repeat with

the other ear.
 Tuning Fork Tests
Perform Weber test. NORMAL: Vibrations are heard equally well in
both ears. No lateralization of sound to either
ear.

ABNORMAL: With conductive hearing loss, the

client reports lateralization of sound to the poor
ear—that is, the client “hears” the sounds in the
poor ear. The good ear is distracted by
background noise and conducted air, which the
poor ear has trouble hearing. Thus the poor ear
receives most of the sound conducted by bone
vibration.

With sensorineural hearing loss, the client

reports lateralization of sound to the good ear.
This is because of limited perception of the
sound due to nerve damage in the bad ear,
making sound seem louder in the unaffected ear

With conductive hearing loss, bone conduction

(BC) sound is heard longer than or equally as
long as air conduction (AC) sound (BC ≥ AC).
Conduct Rinne test. NORMAL: Air conduction sound is normally
heard longer than bone conduction sound (AC >
BC).

ABNORMAL: With sensorineural hearing loss,

air conduction sound is heard longer than bone
conduction sound (AC > BC) if anything is heard
at all.

Sensorineural hearing loss occurs with damage

to the inner ear (cochlea), or to the nerve
pathways between the inner ear and brain. This
is the most common type of permanent hearing
loss. It decreases one’s ability to hear faint
sounds.

Even loud speech may be muffled. Causes

include: ototoxic drugs, genetic hearing loss,
aging, head trauma, malformation of the inner
ear, and loud noise exposure (ASHA, 2011c).
Document findings in the client record.
Validate the ear assessment data that you
have collected. This is necessary to verify
that the data are reliable and accurate.
Document the assessment data following the
health care facility or agency policy.

MOUTH AND OROPHARYNX ASSESSMENT

ASSESSMENT NORMAL AND ABNORMAL FINDINGS RATIONALE

Preparation
Assemble equipment and supplies
Procedure
1.
Explain to the client what you are going to
do, why it is necessary, and how she can
cooperate
2.
1.
 Wash hands and observe other appropriate
infection control procedures.
2.
1.
Provide for clients privacy
2.
1.
Determine client’s history of the following
2.
Assessment

LIPS AND BUCCAL MUCOSA Normal

1. Uniform pink color ( darker, e.g., blush hue,
Inspect the outer lips for symmetry of in Mediterranean groups and dark skinned
contour, color and texture. Ask the client to clients)
purse the lips as if to whistle. Soft, moist, smooth texture
2. Symmetry of contour
Ability to purse lips

Abnormal
Pallor; cyanosis
Blisters; generalized or localized swelling:
fissures, crusts, or scales (may result from
excessive moisture, nutritional deficiency, or
fluid deficit
Inability to purse lips (may indicate facial
nerve damage)
 Normal
Inspect and palpate the inner lips and buccal Uniform pink color (freckled brown
mucosa for color, moisture, texture, and the pigmentation in dark skinned clients)
presence of lesions.
 Abnormal
 Pallor; leukoplakia (white patches), red
Apply clean gloves bleeding

Normal
Moist, smooth, soft, glistening, and elastic
texture (drier oral mucosa in older clients
due to decreased salivation)
 Abnormal
Ask the client to relax the mouth, and, for Excessive dryness
better visualization, pull the lip outward and Mucosal cysts; irritations from dentures;
away from the teeth abrasions, ulcerations; nodules


Grasp the lip on each side between the
thumb and index finger

TEETH AND GUMS Normal
1. 32 adult teeth
Inspect the teeth and gums while examining Smooth, white, shiny tooth enamel
the inner lips and buccal mucosa.
Pink gums (bluish or brown patches in dark-
skinned clients)
2. Moist, firm texture to gums

Ask the client to open the mouth. Using a No retraction of gums
tongue depressor, retract the cheek.(View
the surface buccal mucosa from top to Abnormal
bottom and back to front. A flashlight or Missing teeth; ill-fitting dentures
penlight will help illuminate the surface. Brown or black discoloration of the enamel
Repeat the procedure for the other side). (may indicate staining or the presence of
 caries)
Excessively red gums
 Spongy texture; bleeding; tenderness (may
indicate periodontal disease)
Receding, atrophied gums; swelling that
partially covers the teeth


Examine the back teeth. For proper vision of
molars, use the index fingers of both hands
to retract the cheek. (Ask the client to relax Closing the jaw assists in observation of tooth
the lips and first close, then open, the jaw). alignment and loss of teeth; opening the jaw
 assists in observation of dental fillings and
carries. Observe the number of teeth, tooth
color, the state of fillings, dental caries, and
tartar along the base of the teeth. Note the
presence and fit of partial or complete dentures.

Normal
 Smooth, intact dentures
Inspect the gums around the molars.
Observe for bleeding, color, retraction
(pulling away from the teeth), edema and
lesions. Abnormal
 Ill-fitting dentures; irritated and excoriated
area under dentures
TONGUE AND FLOOR OF THE MOUTH

1.
Inspect the surface of the tongue for Normal
position, color, and texture. Ask the client to Central position
protrude the tongue. Pink color (some brown pigmentation on
tongue borders in dark skinned clients);
moist; slightly rough; thin whitish coating
Smooth, lateral margins; no lesions
Raised papillae (taste buds)

Abnormal
Deviated from center (may indicate damage
to hypoglossal [12th cranial] nerve);
excessive trembling
Smooth red tongue (may indicate iron,
vitamin B12, or vitamin B2 deficiency)
Dry, furry tongue (associated with fluid
deficit), white coating (may be oral yeast
infection)
Nodes, ulcerations, discolorations (white or
red areas); areas of tenderness

2.

Normal
Moves freely; no tenderness
Abnormal
Restricted mobility

1. Normal
Inspect tongue movement. Ask the client to Smooth tongue base with prominent veins
roll the tongue upward and move it from side Abnormal
to side. Swelling, ulceration
2.

1.
 Inspect the base of the tongue, the mouth
floor, and the frenulum. Ask the client to
place the tip of the tongue against the roof of
the mouth.
2.
PALATES AND UVULA

1. Normal
Inspect the hard and soft palate for color, Light pink, smooth, soft palate
shape, texture, and the presence of bony Lighter pink hard palate, more irregular
prominences. Ask the client to open the texture
mouth wide and tilt the head backward. Abnormal
Then, depress tongue with a tongue Discoloration (e.g., jaundice or pallor)
depressor as necessary, and use a penlight Palates in the same color
for appropriate visualization. Irritations
2. Exostoses (bony growths) growing from the
hard palate

1.
Inspect the uvula for position and mobility Normal
while examining the palates. To observe the Positioned in midline of soft palate, rises
uvula, ask the client to say “ah” so that the during vocalization
soft palate rises. Abnormal
2. Deviation to one side from tumor or trauma;
immobility (may indicate damage to
trigeminal [5th cranial] nerve or Vagus [10th
cranial] nerve)
OROPHARYNX AND TONSILS

1. Normal
Inspect the oropharynx for color and texture. Pink and smooth posterior wall
Inspect one side at a time to avoid eliciting
the gag response. To expose one side of the Abnormal
oropharynx, press a tongue depressor Reddened or edematous; presence of
against the tongue on the same side about lesions, plaques, or drainage
halfway back while the client tilts the head
back and opens the mouth wide. Use a
penlight for illumination, if needed.
2.

1.
Inspect the tonsils (behind the fauces) for
color, discharge, and size.
2. Normal
Pink and smooth
No discharge
Of normal size or not visible

Grade 1 (normal): The tonsils are behind the
tonsillar pillars (the soft structures
supporting the soft palate)

Abnormal
Inflamed
Presence of discharge
Swollen

Grade 2: The tonsils are between the pillars
and the uvula


 Grade 3: The tonsils touch the uvula


Grade 4: One or both tonsils extend to
midline of the oropharynx


Remove and discard gloves.


Perform hand hygiene


Document findings in the client record.

NOSE
PROCEDURE RATIONALE NORMAL AND ABNORMAL FINDINGS
Inspect and palpate the external nose. Note . 
nasal color, shape, consistency, and Client reports no tenderness Color is the same
tenderness. as the rest of the face; the nasal structure is
smooth and symmetric.


Nasal tenderness on palpation accompanies a
local infection


Check patency of air flow through the 

nostrils by occluding one nostril at a time Client is able to sniff through each nostril while
and asking client to sniff. other is occluded



Client cannot sniff through a nostril that is not
occluded, nor can he or she sniff or blow air
through the nostrils. This may be a sign of
swelling, rhinitis, or a foreign object obstructing
the nostrils. A line across the tip of the nose just
above the fleshy tip is common in clients with
chronic allergies.

Inspect the internal nose. To inspect the 
internal nose, use an otoscope with a short The nasal mucosa is dark pink, moist, and free of
wide-tip attachment or you can also use a exudates. The nasal septum is intact and free of
nasal speculum and penlight ulcers or perforations. Turbinate are dark pink
(redder than oral mucosa), moist, and free of
lesions. The superior turbinate will not be visible
from this point of view



A deviated septum may appear to be an
overgrowth of tissue. This is a normal finding as
long as breathing is not obstructed.


Nasal mucosa is swollen and pale pink or bluish

gray in clients with allergies. Nasal mucosa is red
and swollen with upper respiratory infection.
Exudate is common with infection and may range
 from large amounts of watery discharge to thick
yellow-green, purulent discharge. Purulent nasal
discharge is seen with acute bacterial
rhinosinusitis. Bleeding (epistaxis) or crusting
may be noted on the lower anterior part of the
nasal septum with local irritation. Ulcers of the
nasal mucosa or a perforated septum may be
seen with use of cocaine, trauma, chronic
infection, or chronic nose picking. Small, pale,
round, firm overgrowths or masses on mucosa
(polyps) are seen in clients with chronic allergies.

SINUSES
PROCEDURE RATIONALE NORMAL AND ABNORMAL FINDINGS
Palpate the maxillary and frontal sinuses for Palpate the sinuses. When an infection is
tenderness. suspected, the nurse can examine the Frontal and maxillary sinuses are no tender to
sinuses through palpation, percussion, and palpation, and no crepitus is evident.
transillumination. Palpate the frontal
sinuses by using your thumbs to press up
on the brow on each side of nose
Frontal or maxillary sinuses are tender to
palpation in clients with allergies or acute
bacterial rhinosinusitis. If the client has a large
amount of exudate, you may feel crepitus upon
palpation over the maxillary sinuses.

THORAX AND LUNGS

PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

General
INSPECTION

Inspect for nasal flaring and pursed lip Nasal flaring is not observed. Normally the Nasal flaring is seen with labored respirations
breathing diaphragm and the external intercostal (especially in small children) and is
muscles do most of the work of breathing. indicative of hypoxia.
This is evidenced by outward expansion of
the abdomen and lower ribs on inspiration as Pursed lip breathing may be seen in asthma,
well as return to resting position on emphysema, or CHF as a physiologic response
expiration. to help slow down expiration and keep alveoli
open longer.
Observe color of face, lips, and chest. The client has evenly colored skin tone, Ruddy to purple complexion may be seen in
without unusual or prominent discoloration. clients with COPD or CHF as a result of
polycythemia. Cyanosis may be seen if client is
cold or hypoxia
Inspect color and shape of nails. Pink tones should be seen in the nail beds. Pale or cyanotic nails may indicate hypoxia.
There is normally a 160-degree angle Early clubbing (180-degree angle) and late
between the nail base and the skin. clubbing (greater than a 180-degree angle) can
occur from hypoxia.
Posterior Thorax
INSPECTION

Inspect configuration. While the client sits Scapulae are symmetric and non protruding. Spinous processes that deviate laterally in the
with arms at the sides, stand behind the Shoulders and scapulae are at equal thoracic area may indicate scoliosis. Spinal
client and observe the position of scapulae horizontal positions. The ratio of antero- configurations may have respiratory
and the shape and configuration of the chest posterior to transverse diameter is 1:2. implications. Ribs appearing horizontal at
wall. Spinous processes appear straight, and an angle greater than 45 degrees with the
thorax appears symmetric, with ribs sloping spinal column are frequently the result of an
downward at approximately a 45-degree increased ratio between the antero-posterior–
angle in relation to the spine. transverse diameter (barrel chest). This
 condition is commonly the result of emphysema
due to hyperinflation of the lungs.
Abnormal Findings depicts
various thoracic configurations.
Trapezius, or shoulder, muscles are used to
facilitate inspiration in cases of acute and
chronic airway obstruction or atelectasis.
Observe use of accessory muscles. The client does not use accessory Client leans forward and uses arms to support
(trapezius/shoulder) muscles to assist weight and lift chest to increase breathing
Watch as the client breathes and note use of breathing. The capacity, referred to as the tripod position
muscles. diaphragm is the major muscle at work. This
is evidenced by expansion of the lower chest
during inspiration.
Inspect the client’s positioning. Note the Client should be sitting up and relaxed, Tender or painful areas may indicate inflamed
client’s posture and ability to support weight breathing easily with arms at sides or in lap fibrous connective tissue. Pain over the
while breathing comfortably. intercostal spaces may be from inflamed
pleurae.
Pain over the ribs, especially at the costal
chondral junctions, is a symptom of fractured
ribs.
PALPATION

Palpate for tenderness and sensation. Client reports no tenderness, pain, or Muscle soreness from exercise or the
Palpation may be performed with one or both unusual sensations. Temperature should be excessive work of breathing (as in COPD) may
hands, but the sequence of palpation is equal bilaterally be palpated as tenderness.
established Use your fingers to palpate for
tenderness, warmth, pain, Increased warmth may be related to local
or other sensations. Start toward the midline Infection.s3
at the level of the left scapula (over the apex
of the left lung) and move your hand left to
right, comparing findings bilaterally. Move
systematically downward and out to cover
the lateral portions of the lungs at the bases
Palpate for crepitus. Crepitus, also called The examiner finds no palpable crepitus Crepitus can be palpated if air escapes from
subcutaneous emphysema, is a crackling the lung or other airways into the subcutaneous
sensation (like bones or hairs rubbing against tissue, as occurs after an
each other) that occurs when air passes open thoracic injury, around a chest tube, or
through fluid or exudate. Use your fingers. tracheostomy. It also may be palpated in areas
of extreme congestion or consolidation. In such
situations, mark margins and
monitor to note any decrease or increase in the
crepitant area.
Posterior Thorax (continued)

Palpate surface characteristics. Put on Skin and subcutaneous tissue are free of A physician or other appropriate professional
gloves and use your fingers to palpate any lesions and masses. should evaluate any unusual palpable mass.
lesions that you noticed during inspection.
Feel for any unusual masses.
Palpate for fremitus. Following the sequence Fremitus is symmetric and easily identified in Unequal fremitus is usually the result of
described previously, use the ball or ulnar the upper regions of the lungs. If fremitus consolidation (which increases fremitus) or
edge of one hand to assess for fremitus is not palpable on either side, the client may bronchial obstruction, air trapping in
(vibrations of air in the bronchial tubes need to speak louder. A decrease in the emphysema, pleural effusion, or pneumothorax
transmitted to the chest wall). intensity of fremitus is normal as the (which all decrease fremitus). Diminished
As you move your hand to each area, ask the examiner moves toward the base of the fremitus even with a loud spoken voice may
client to say “ninety-nine.” Assess all areas lungs. However, fremitus should remain indicate an obstruction of the tracheobronchial
for symmetry and intensity of symmetric for bilateral positions. tree.
vibration.
Assess chest expansion. Place your hands When the client takes a deep breath, the Unequal chest expansion can occur with
on the posterior chest wall with your thumbs examiner’s thumbs should move 5 to 10 cm severe atelectasis (collapse or incomplete
at the level of T9 or T10 and pressing apart symmetrically. expansion), pneumonia, chest trauma, or
together a small skin fold. As the client takes pneumothorax (air in the pleural space).
a deep breath, observe the movement of Decreased chest excursion at the base of the
your thumbs lungs is characteristic of COPD. This is due to
decreased diaphragmatic function.
PERCUSSION
Percuss for tone. Start at the apices of the Resonance is the percussion tone elicited Hyperresonance is elicited in cases of trapped
scapulae and percuss across the tops of over normal lung tissue. Percussion elicits air such as in emphysema or pneumothorax.
both shoulders. Then percuss the intercostal flat tones over the scapula.
spaces across and down, comparing sides.
Percuss to the lateral aspects at the bases of
the lungs, comparing sides.
Percuss for diaphragmatic excursion.
Ask the client to exhale forcefully and hold
the breath. Beginning at the scapular line Excursion should be equal bilaterally and Dullness is present when fluid or solid tissue
(T7), percuss the intercostal spaces of the measure 3–5 cm in adults. replaces air in the lung or occupies the pleural
right posterior chest wall. Percuss downward space, such as in lobar pneumonia, pleural
until the tone changes from resonance to The level of the diaphragm may be higher on effusion, or tumor.
dullness. Mark this level and allow the client the right because of the position of the liver.
to Diaphragmatic descent may be limited by
breathe. Next ask the client to inhale deeply In well-conditioned clients, excursion can atelectasis of the lower lobes or by
and hold it. Percuss the intercostal spaces measure up to 7 or 8 cm. emphysema, in which diaphragmatic movement
from the mark downward until resonance and air trapping are minimal.
changes to dullness. Mark the level and allow
the client to breathe. Measure the The diaphragm remains in a low position on
distance between the two marks. inspiration and
Perform this assessment technique on both expiration.
sides of the posterior thorax.
Other possible causes for limited descent can
be pain or abdominal changes such as
extreme ascites, tumors, or pregnancy.
Uneven excursion may be seen with
inflammation from unilateral pneumonia,
damage
to the phrenic nerve, or splenomegaly
AUSCULTATION

Auscultate for breath sounds. To best assess Three types of normal breath sounds may be Diminished or absent breath sounds often
lung sounds, you will need to hear the auscultated—bronchial, Broncho vesicular, indicate that little or no air is moving in or
sounds as directly as possible. Do not and vesicular out of the lung area being auscultated. This
attempt to listen through clothing or a drape, may indicate obstruction within the lungs as a
which may produce additional sound or Sometimes breath sounds may be hard to result of secretions, mucus plug, or a
muffle lung sounds that exist. To begin, place hear with obese or heavily muscled clients foreign object. It may also indicate
the diaphragm of the stethoscope firmly due to increased distance to underlying lung abnormalities of the pleural space such as
and directly on the posterior chest wall at the tissue. pleural
apex of the lung at C7. Ask the client to thickening, pleural effusion, or pneumothorax.
breathe deeply through the mouth for each In cases of emphysema, the hyperinflated
area of auscultation (each placement of the nature of the lungs, together with a loss of
stethoscope) in the auscultation sequence elasticity of lung tissue, may result in
so that you can best hear inspiratory and diminished inspiratory breath sounds.
expiratory sounds. Be alert to the client’s Increased (louder) breath sounds often occur
comfort and offer times for rest and normal when consolidation or compression results in a
breathing if fatigue is becoming a problem. denser lung area that enhances the
transmission of sound.

Auscultate from the apices of the lungs at

C7 to the bases of the lungs at T10 and
laterally from the axilla down to the seventh
or
eighth rib. Listen at each site for at least one
complete respiratory cycle.
Auscultate for adventitious sounds.
Adventitious sounds are sounds added or
superimposed over normal breath sounds No adventitious sounds, such as crackles Adventitious lung sounds, such as crackles
and heard during auscultation. Be careful to (discrete and discontinuous sounds) or (formerly called rales) and wheezes (formerly
note the location on the chest wall were wheezes (musical and continuous), are called rhonchi) are evident.
adventitious sounds are heard as well as the auscultated.
location of such sounds within the respiratory
cycle.
Auscultate voice sounds.
Bronchophony: Ask the client to repeat the Voice transmission is soft, muffled, and The words are easily understood and louder
phrase “ninety-nine” while you auscultate the indistinct. The sound of the voice may be over areas of increased density. This may
chest wall. heard but the actual phrase cannot be indicate consolidation from pneumonia,
distinguished. atelectasis, or tumor.

Over areas of consolidation or compression,

Egophony: Ask the client to repeat the letter Voice transmission will be soft and muffled the sound is louder and sounds like “A.”
“E” while you listen over the chest wall. but the letter “E” should be distinguishable.
Over areas of consolidation or compression,
Whispered pectoriloquy: Ask the client to Transmission of sound is very faint and the sound is transmitted clearly and distinctly.
whisper the phrase “one–two–three” while muffled. It may be inaudible. In such areas, it sounds as if the client is
you auscultate the chest wall. whispering directly into the stethoscope.
Anterior Thorax
INSPECTION

Inspect for shape and configuration.

Have the client sit with arms at the sides.
Stand in front of the client and assess shape The antero-posterior diameter is less than Antero-posterior equals transverse diameter,
and configuration the transverse diameter. The ratio of antero- resulting in a barrel chest. This is often seen in
posterior diameter to the transverse emphysema because of hyperinflation of the
diameter is 1:2. lungs.
Inspect position of the sternum.
Observe the sternum from an anterior and
lateral viewpoint. Sternum is positioned at midline and Pectus excavatum is a markedly sunken
straight. sternum and adjacent cartilages (often referred
to as funnel chest). It is a congenital
malformation that seldom causes symptoms
other than self-consciousness. Pectus
carinatum is a forward protrusion of the
sternum causing the adjacent ribs to slope
backward (often
referred to as pigeon chest; see Abnormal
Findings 19-1 on page 393 for illustrations of
both conditions). Both conditions may restrict
expansion of the lungs and decrease lung
capacity.
Watch for sternal retractions. Retractions not observed. Sternal retractions are noted, with severely
labored breathing
Inspect slope of the ribs.
Assess the ribs from an anterior and lateral Ribs slope downward with symmetric Barrel-chest configuration results in a more
viewpoint. intercostal spaces. Costal angle is within 90 horizontal position of the ribs and costal
degrees. angle of more than 90 degrees. This often
results from long-standing emphysema
Observe quality and pattern of respiration.
Note breathing characteristics as well as
rate, rhythm, and depth. Respirations are relaxed, effortless, and Labored and noisy breathing is often seen with
quiet. They are of a regular rhythm and severe asthma or chronic bronchitis. Abnormal
normal depth at a rate of 10–20 per minute breathing patterns include
in adults. Tachypnea and bradypnea may be tachypnea, bradypnea, hyperventilation,
normal in some clients. hypoventilation, Cheyne-Stokes respiration,
and Biot’s respiration.
Inspect intercostal spaces.
Ask the client to breathe normally and No retractions or bulging of intercostal Retraction of the intercostal spaces indicates
observe the intercostal spaces spaces are noted. an increased inspiratory effort. This may be
the result of an obstruction of the respiratory
tract or atelectasis. Bulging of the intercostal
spaces indicates trapped air such as in
emphysema or asthma.
Observe for use of accessory muscles.
Ask the client to breathe normally and
observe for use of accessory muscles. Use of accessory muscles (sternomastoid Neck muscles (sternomastoid, scalene, and
and rectus abdominis) is not seen with trapezius) are used to facilitate inspiration in
normal respiratory effort. After strenuous cases of acute or chronic airway obstruction or
exercise or activity, clients with normal atelectasis. The abdominal muscles and the
respiratory internal intercostal muscles are used to
status may use neck muscles for a short facilitate expiration in COPD.
time to enhance breathing
PALPATION
Palpate for tenderness, sensation, and
surface masses.
Use your fingers to palpate
for tenderness and sensation. Start with your No tenderness or pain is palpated over the Tenderness over thoracic muscles can result
hand positioned over the left clavicle (over lung area with respirations from exercising (e.g., pushups) especially in a
the apex of the left lung) and move previously sedentary client.
your hand left to right, comparing findings
bilaterally. Move your hand systematically
downward toward the midline at the level of
the breasts and outward at the base to
include the lateral aspect of the lung. The
established sequence for palpating the
anterior thorax
Palpate for tenderness at costochondral Palpation does not elicit tenderness
junctions of ribs.
Palpate for crepitus as you would on the No crepitus is palpated In areas of extreme congestion or
posterior thorax (described previously). consolidation, crepitus may be palpated,
particularly in clients with lung disease.
Palpate for any surface masses or lesions No unusual surface masses or lesions are Surface masses or lesions may indicate cysts
palpated. or tumors
Palpate for fremitus.
Using the sequence for the anterior chest Fremitus is symmetric and easily identified in Diminished vibrations, even with a loud spoken
described previously, palpate for fremitus the upper regions of the lungs. A ecreased voice, may indicate an obstruction of the
using the same technique as for the posterior intensity of fremitus is expected toward the tracheobronchial tree. Clients with emphysema
thorax base of the lungs. However, fremitus should may have considerably decreased
be symmetric bilaterally fremitus as a result of air trapping.
Palpate anterior chest expansion.
Place your hands on the client’s anterolateral
wall with your thumbs along the costal Thumbs move outward in a symmetric Unequal chest expansion can occur with
margins and pointing toward the xiphoid fashion from the midline. severe atelectasis, pneumonia, chest trauma,
process. As the client takes a deep breath, pleural effusion, or pneumothorax.
observe the movement of your thumbs Decreased chest excursion at the bases of the
lungs is seen with COPD
PERCUSSION

Percuss for tone. Resonance is the percussion tone elicited Hyper-resonance is elicited in cases of trapped
Percuss the apices above the clavicles. Then over normal lung tissue. Percussion elicits air such as in emphysema or pneumothorax.
percuss the intercostal spaces across and dullness over breast tissue, the heart, and Dullness may characterize areas
down, comparing side the liver. Tympany is of increased density such as consolidation,
detected over the stomach, and flatness is pleural effusion, or tumor.
detected over the muscles and bones.
Anterior Thorax
AUSCULTATION

Auscultate for anterior breath sounds, Refer to text in the posterior thorax section
adventitious sounds, and voice sounds. for normal voice sounds.
Place the diaphragm of the stethoscope
firmly and directly on the anterior chest wall.
Auscultate from the apices of the lungs
slightly above the clavicles to the bases of
the lungs at the sixth rib. Ask the client to
breathe deeply through the mouth in an effort
to avoid transmission of sounds that may
occur with nasal breathing. Be alert to the
client’s comfort and offer times for rest and
normal breathing if fatigue is becoming a
problem, particularly for the older client.
Listen at each site for at least one complete
respiratory cycle.
Question Rationale
Characteristics: Describe the Difficulty of breathing Dyspnea (difficulty breathing) can indicate a number of health problems including
pulmonary disorders, congestive heart failure (CHF), coronary heart disease (CHD),
myocardial ischemia, and myocardial infarction (MI). Clients who have chronic
obstructive pulmonary disease (COPD) may describe their dyspnea as not being able
to “breathe or take a deep breath. ”Anxious clients may describe their dyspnea as
feeling like they are suffocating or may have tingling in the lips due to a decrease in
carbon dioxide level.

Onset: When did it begin: It may occur during rest, sleep, or with mild, moderate, or extreme exertion.
Gradual onset of dyspnea is usually indicative of lung changes such as emphysema;
sudden onset is associated with viral or bacterial infections.
Location:
Duration: How long did the dyspnea last? They may have continuous coughing (“smoker’s cough”) with lots of sputum,
shortness of breath with everyday activities, and wheezing (American Lung
Association, 2012). Common symptoms of asthma are wheezing, frequent cough with
or without mucous, shortness of breath, and chest tightness (American Lung
Association, 2012)
Severity: Dyspnea with exercise or heavy activities is normal if the dyspnea subsides with
resting from the activity. Dyspnea will occur with typical non-strenuous activities (such
as walking one block or climbing two stairs) of daily living in clients with lung disease.

Palliative/Aggravating factors: What aggravates or OLDER ADULT CONSIDERATIONS

relieves the dyspnea? Do any specific activities cause Older adults may experience dyspnea with certain activities related to aging changes
the difficulty breathing? Do you have difficulty of the lungs (loss of elasticity, fewer functional capillaries, and loss of lung resiliency).
breathing when you are resting? Do you have difficulty Dyspnea can occur with stress and anxiety.
breathing when you sleep? Do you use more than one
pillow or elevate the head of the bed when you sleep?
Do you snore when you sleep? Have you been told
that you stop breathing at night when you snore.
Associated Factors: Do you experience any other Associated symptoms provide clues to the underlying problem. Certain associated
symptoms when you have difficulty breathing? symptoms suggest problems in other body systems. For example, edema or angina
that occurs with dyspnea may indicate a cardiovascular problem. Orthopnea (difficulty
breathing when lying supine) may be associated with heart failure. Paroxysmal
nocturnal dyspnea (severe dyspnea that awakens the person from sleep) also may be
associated with heart failure. Changes in sleep patterns may cause the client to feel
fatigued during the day. Sleep apnea (periods of breathing cessation during sleep)
may be the source of snoring and gasping sounds. In general, sleep apnea diminishes
the quality of sleep, which may account for fatigue or excessive tiredness, depression,
irritability, loss of memory, lack of energy, and a risk for automobile and workplace
accidents
Do you have chest pain? Is the pain associated with a Immediately assess any reports of chest pain further to determine if it is due to cardiac
cold, fever, or deep breathing? ischemia, which is a medical emergency requiring immediate assessment and
intervention. Pain-sensitive nerve endings are located in the parietal pleura, thoracic
 muscles, and tracheobronchial tree, but not in the lungs.
Do you have a cough? When and how often does it Continuous coughs are usually associated with acute infections, whereas those
occur? occurring only early in the morning are often associated with chronic bronchial
inflammation or smoking. Coughs late in the evening may be the result of exposure to
irritants during the day. Coughs occurring at night are often related to postnasal drip or
sinusitis.
Do you produce any sputum when you cough? If so, Nonproductive coughs are often associated with upper respiratory irritations and early
what color is the sputum? How much sputum do you congestive heart failure (CHF). White or mucoid sputum is often seen with common
cough up? Has this amount increased or decreased colds, viral infections, or bronchitis. Yellow or green sputum is often associated with
recently? Does the sputum have an odor? bacterial infections. Blood in the sputum (hemoptysis) is seen with more serious
respiratory conditions. Rust-colored sputum is associated with tuberculosis or
pneumococcal pneumonia. Pink, frothy sputum may be indicative of pulmonary
edema. An increase in the amount of sputum is often seen in an increase in exposure
to irritants, chronic bronchitis, and pulmonary abscess (“Sputum color,” 2006–2011).
Clients with excessive, tenacious secretions may need instruction on controlled
coughing and measures to reduce viscosity of secretions.
Do you wheeze when you cough or when you are Wheezing indicates narrowing of the airways due to spasm or obstruction. Wheezing
active? is associated with CHF, asthma (reactive airway disease), or excessive secretions.
Do you have any gastrointestinal symptoms such as Studies have shown that up to 75% of clients with asthma have gastroesophageal
heartburn, frequent hiccups, or chronic cough reflux disease (GERD) or are more susceptible to GERD (Cleveland Clinic, 2008).
Have you had prior respiratory problems? A history of respiratory disease increases the risk for a recurrence. In addition, some
respiratory diseases may imitate other disorders. For example, asthma symptoms
may mimic symptoms commonly associated with emphysema or heart failure.
Have you ever had any thoracic surgery, biopsy, or Previous surgeries may alter the appearance of the thorax and cause changes in
trauma? respiratory sounds. Trauma to the thorax can result in lung tissue changes.
Have you been tested for or diagnosed with allergies? Many allergic responses are manifested with respiratory symptoms such as dyspnea,
cough, or hoarseness. Clients may need education on controlling the amount of
allergens in their environment.
Are you currently taking medications for breathing Consider all medications when determining if respiratory problems could be attributed
problems or other medications (prescription or over to adverse reactions. Certain medications, for example, beta-adrenergic antagonists
the counter [OTC]) that affect your breathing? Do you (beta blockers) such as atenolol (Tenormin) or metoprolol (Lopressor) and
use any other treatments at home for your respiratory angiotensin-converting enzyme (ACE) inhibitors such as enalapril (Vasotec) or
problems? lisinopril (Zestril), are associated with the side effect of persistent cough (The Asthma
Center, 2011). These medications are contraindicated with some respiratory problems
such as asthma. If the client is using oxygen or other respiratory therapy at home, it is
important to evaluate knowledge of proper use and precautions as well as the client’s
ability to afford the therapy.
Have you ever had a chest x-ray, tuberculosis (TB) Information on previous chest x-rays, TB skin tests, influenza immunizations, and the
skin test, or influenza immunization? Have you had like is useful for comparison with current findings, and provides insight on self-care
any other pulmonary studies in the past? practices and possible teaching needs.
Have you recently traveled outside of the United Travel to high-risk areas such as mainland China; Hong Kong; Hanoi, Vietnam;
States? Singapore; or Toronto, Canada may have exposed the client to SARS (severe acute
respiratory syndrome).
Is there a history of lung disease in your family? The risk for lung cancer is thought to be partially based on genetics. A history of
certain respiratory diseases (asthma, emphysema) in a family may increase the risk
for development of the disease (CDC, 2011). Exposure to viral or bacterial respiratory
infections in the home increases the risk for development of these conditions.
Did any family members in your home smoke when Second-hand smoke puts clients at risk for COPD (including emphysema and chronic
you were growing up? bronchitis) or lung cancer later in life (CDC, 2011).
Is there a history of other pulmonary Some pulmonary disorders, such as asthma, tend to run in families.
illnesses/disorders in the family, e.g., asthma?
Describe your usual dietary intake. Poor nutritional status (both weight loss and obesity) is frequently seen in clients with
COPD and is a predictor of mortality (Kelly, 2007).
Have you ever smoked cigarettes or other tobacco Smoking is linked to a number of respiratory conditions, including lung cancer
products? Do you currently smoke? At what age did (Evidence-Based Practice 19-2, p. 378). The number of years a person has smoked
you start? How much do you smoke and how much and the number of cigarettes per day influence the risk for developing smoking related
have you smoked in the past? What activities do you respiratory problems. Information on smoking behavior and previous efforts to quit
usually associate with smoking? Have you ever tried may be helpful later in identifying measures to assist with smoking cessation
to quit?
Are you exposed to any environmental conditions that Exposure to certain environmental inhalants can result in an increased incidence of
affect your breathing? Where do you work? Are you certain respiratory conditions. Environmental irritants commonly associated with
around smokers? occupations include coal dust, insecticides, paint, pollution, asbestos fibers, and the
like. For example, inhaling dust contaminated with Histoplasma capsulatum may
cause histoplasmosis, a systemic fungal disease. This disease is common in the rural
midwestern United States (Fayyaz, 2011). Second-hand smoke is another
Irritant that can seriously affect a person’s respiratory health.
Do you have difficulty performing your usual daily Respiratory problems can negatively affect a person’s ability to perform the usual
activities? Describe any difficulties. ADLs.
What kind of stress are you experiencing at this time? Shortness of breath can be a manifestation of stress. Client may need education
How does it affect your breathing? about relaxation techniques
Have you used any herbal medicines or alternative Many people use herbal therapies, such as Echinacea, or alternative therapies, such
therapies to manage colds or other respiratory as zinc lozenges, to decrease cold symptoms. Knowing what clients are using enables
problems? you to check for side effects or adverse interactions with prescribed medications.

ASSESSING THE BREAST AND AXILLAE

ASSESSMENT RATIONALE FINDINGS

NORMAL: Breasts can be a variety of sizes and are somewhat round and
Inspect the breast for size, symmetry, pendulous. One breast may normally be larger than the other.
and contour or shape while the client is in
a sitting position. ABNORMAL: A recent increase in the size of one breast may indicate
inflammation or an abnormal growth.

NORMAL: Color varies depending on the client’s skin tone. Texture is

Inspect the skin of the breast for localized smooth, with no edema. Linear stretch marks may be seen during and after
discolorations or hyperpigmentation, pregnancy or with significant weight gain or loss.
retraction or dimpling, localized hyper
vascular areas, swelling, or edema Veins radiate either horizontally and toward the axilla (transverse) or
vertically with a lateral flare (longitudinal). Veins are more prominent during
pregnancy.

ABNORMAL: Redness is associated with breast inflammation.

A pigskin-like or orange-peel appearance results from edema, which is seen
in metastatic breast disease

The edema is caused by blocked lymphatic drainage.


Veins radiate either horizontally and toward the axilla (transverse) or
vertically with a lateral flare (longitudinal). Veins are more prominent during
pregnancy.


A prominent venous pattern may occur because of increased circulation
due to a malignancy.


An asymmetric venous pattern may be due to malignancy.

1. NORMAL: The client’s breasts should rise symmetrically, with no sign of
Emphasize any retraction by having the dimpling or retraction.
client:
2. ABNORMAL: Dimpling or retraction is usually caused by a malignant tumor
that has fibrous strands attached to the breast tissue and the fascia of the
muscles. As the muscle contracts, it draws the breast tissue and skin with it,
causing dimpling or retraction.

NORMAL: Breasts should hang freely and symmetrically

ABNORMAL: 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.


Raise the arms above the head


Push the hands together, with elbows
 flexed


Press the hands down on the hips

1. NORMAL: Areolas vary from dark pink to dark brown, depending on the
Inspect the areola area for size, shape, client’s skin tones. They are round and may vary in size. Small Montgomery
symmetry, color, surface characteristics, tubercles are present.
and any masses or lesions.
2. ABNORMAL: Peau d’orange skin, associated with carcinoma, may be first
seen in the areola. Red, scaly, crusty areas may appear in Paget’s disease.
NORMAL: Nipples are nearly equal bilaterally in size and are in the same
Inspect the nipples for size, shape, location on each breast. Nipples are usually everted, but they may be
position, color, discharge, and lesions. inverted or flat.
ABNORMAL: A recently retracted nipple that was previously everted
suggests malignancy. Any type of spontaneous discharge should be
referred for cytologic study and further evaluation.
NORMAL: Palpation reveals smooth, firm, elastic tissue.
Palpate the axillary, sub clavicular, and
supraclavicular lymph nodes. ABNORMAL: Thickening of the tissues may occur with an underlying
malignant tumor.

NORMAL: No swelling, nodules, or ulceration should be detected.
The client is seated with the arms
abducted and supported on the nurse’s
ABNORMAL: Soft, fatty enlargement of breast tissue is seen in obesity.
forearm.
Gynecomastia, a smooth, firm, movable disc of glandular tissue, may be

seen in one breast in males during puberty, usually temporary (Fig. 20-13).
 However, it may also be seen in hormonal imbalances, drug abuse,
Use the flat surfaces of all fingertips to cirrhosis, leukemia, and thyrotoxicosis. Irregularly shaped, hard nodules
palpate the four areas of the axilla: occur in breast cancer.


The edge of the greater pectoral muscle
along the anterior axillary line


The thoracic wall in the midaxillary area


The upper part of the humerus


The anterior edge of the latissimus dorsi
muscle along the posterior axillary line

1. NORMAL: A generalized increase in nodularity and tenderness may be a
Palpate the breast for masses, normal finding associated with the menstrual cycle or hormonal
tenderness, and any discharge from the medications.
nipples.
2. ABNORMAL: Painful, tender breasts may be indicative of fibrocystic
breasts, especially right before menstruation (Mayo Clinic, 2010b).

However, pain may also occur with a malignant tumor.

1. NORMAL: The nipple may become erect and the areola may pucker in
Palpate the areola and the nipples for response to stimulation. A milky discharge is usually normal only during
masses. pregnancy and lactation. However, some women may normally have a clear
2. discharge.

ABNORMAL: Discharge may be seen in endocrine disorders and with

Compress each nipple to determine the
certain medications (i.e., anti-hypertensives, tricyclic antidepressants, and
presence of any discharge. If discharge is
estrogen).
present, milk the breast along its radius to
identify the discharge-producing lobe.
Discharge from one breast may indicate benign intraductal papilloma,
fibrocystic disease, or cancer of the breast. Sometimes there is only a
watery, pink discharge from the nipple. This should be referred to a primary
Assess any discharge for amount, color, care provider (Medline Plus, 2009).
consistency, and odor.

Note any tenderness on palpation.

Teach the client the technique of breast

self-examination.

Document findings in the client record.

References:

 Al-Idrus, M.M (2003). Education, Health & Medicine, Business

 Bickley, L. S. (2012). Bates’ guide to physical examination and history taking (12th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins.
 Jarvis, C. (2011). Physical examination & health assessment (6th ed.). St. Louis, MO: Elsevier.
 Rhoads, J., & Petersen, S. W. (2011). Advanced health assessment and diagnostic reasoning (2nd ed.). Burlington,
 MA: Jones & Bartlett.
 Kozier and Erb's fundamentals of Nursing 10th Edition.
 Kozier and Erb, 2016. (Kozier and Erb's Fundamentals of Nursing Concepts, Process, Practice 10th Edition)
 Potter and Perry, 2013 (Fundamentals of Nursing 8th Edition)
 Weber and Kelly, 2014 (Health Assessment in Nursing 5th Edition)
 Regan et.al. , 2016. (Seeley's Essentials of Anatomy and Physiology 9th Edition)
 https://www.youtube.com/watch?v=ZNW9kn3NMgA
 https://www.youtube.com/watch?v=pgSj3l9iV6k

ASSESSING ABDOMEN

Assessment Rationale Normal and abnormal findings

INSPECTION OF THE ABDOMEN Normal
6. Inspect the abdomen for skin Unblemished skin, Uniform color
integrity Silver-white striae (stretch marks) or surgical scars

Abnormal
Presence of rash or other lesions Tense, glistening skin (may
indicate ascites, edema)
Purple striae (associated with Cushing’s disease or rapid weight
gain and loss)
7. Inspect the abdomen for contour and
symmetry: Normal
• Observe the abdominal contour Flat, rounded (convex), or scaphoid (concave)
(profile line from the rib margin to the
pubic bone) while standing at the
client’s side when the client is supine. No evidence of enlargement of liver or spleen
o This makes an enlarged liver
Ask the client to take a deep breath and or spleen more obvious. Symmetric contour
to hold it.
o Abnormal
o Distended
Assess the symmetry of contour while
standing at the foot of the bed. Evidence of enlargement of liver or spleen
o
• If distention is present, measure Asymmetric contour, e.g., localized protrusions around umbilicus,
the abdominal girth by placing a inguinal ligaments, or scars (possible hernia or tumor)
 tape around the abdomen at the
level of the umbilicus. If girth
will be measured repeatedly,
use a skin-marking pen to
outline the upper and lower
margins of the tape placement
for consistency of future
measurements.
8. Observe abdominal movements Normal
associated with respiration, peristalsis, Symmetric movements caused by respiration Visible peristalsis in
or aortic pulsations. very lean people Aortic pulsations in thin people at epigastric area
Abnormal
Limited movement due to pain or disease process Visible
peristalsis in nonlean clients (possible bowel obstruction) Marked
aortic pulsations

9. Observe the vascular pattern. Normal

No visible vascular pattern

Abnormal
Visible venous pattern (dilated veins) is associated with liver
disease, ascites, and venocaval obstruction
AUSCULTATION OF THE ABDOMEN
10. Auscultate the abdomen for bowel
sounds, vascular sounds, and Cold hands and a cold Normal
peritoneal friction rubs. Warm the hands stethoscope may cause the Audible bowel sounds
and the stethoscope diaphragms. client to contract the
For Bowel Sounds abdominal muscles, and these Abnormal
o contractions may be heard Hypoactive, i.e., extremely soft and infrequent (e.g., one per
Use the flat-disk diaphragm during auscultation. minute). Hypoactive sounds indicate decreased motility and are
o Intestinal sounds are usually associated with manipulation of the bowel during surgery,
relatively high pitched and inflammation, paralytic ileus, or late bowel obstruction.
best accentuated by the Hyperactive/increased, i.e., high-pitched, loud, rushing sounds that
diaphragm. Light pressure occur frequently (e.g., every 3 seconds) also known as borborygmi.
with the stethoscope is Hyperactive sounds indicate increased intestinal motility and are
 adequate. usually associated with diarrhea, an early bowel obstruction, or the
Ask when the client last ate. Shortly after or long after use of laxatives. True absence of sounds (none heard in 3 to 5
 eating, bowel sounds may minutes) indicates a cessation of intestinal motility
 normally increase. They are
Place diaphragm of the stethoscope in loudest when a meal is long Normal
each of the four quadrants of the overdue. Four to 7 hours after Absence of arterial bruits
abdomen. a meal, bowel sounds may be Abnormal
 heard continuously over the Loud bruit over aortic area (possible aneurysm) Bruit over renal or
ileocecal valve area (right iliac arteries

lower quadrant) while the
Listen for active bowel sounds—
digestive contents from the Normal
irregular gurgling noises occurring about
small intestine empty through Absence of friction rub
every 5 to 20 seconds. The duration of
the valve into the large Abnormal
a single sound may range from less
intestine. Friction rub
than a second to more than several
seconds


For Vascular Sounds

• Use the bell of the stethoscope over
the aorta, renal arteries, iliac arteries,
and femoral arteries.

Peritoneal Friction Rubs

• Peritoneal friction rubs are rough,
grating sounds like two pieces of leather
rubbing together. Friction rubs may be
caused by inflammation, infection, or
abnormal growths.
PERCUSSION OF THE ABDOMEN Normal
 11. Percuss several areas in each of Tympany over the stomach and gas-filled bowels; dullness,
the four quadrants to determine especially over the liver and spleen, or a full bladder
presence of tympany (sound indicating Abnormal
gas in stomach and intestines) and Large dull areas (associated with presence of fluid or a tumor)
dullness (decrease, absence, or
flatness of resonance over solid masses
or fluid). Use a systematic pattern:
Begin in the lower right quadrant,
proceed to the upper right quadrant, the
upper left quadrant, and the lower left
quadrant.
PALPATION OF THE ABDOMEN
1.
Perform light palpation first to detect Cold hands can elicit muscle Normal
areas of tenderness and/or muscle tension and thus impede No tenderness; relaxed abdomen with smooth, consistent tension
guarding. Systematically explore all four palpatory evaluation. Abnormal
quadrants. Ensure that the client’s Tenderness and hypersensitivity Superficial masses Localized
position is appropriate for relaxation of areas of increased tension
the abdominal muscles, and warm the
hands.
2.
Light Palpation

Hold the palm of your hand slightly
above the client’s abdomen, with your
fingers parallel to the abdomen.


Depress the abdominal wall lightly,
about 1 cm or to the depth of the
subcutaneous tissue, with the pads of
your fingers.


Move the finger pads in a slight circular
motion.


Note areas of tenderness or superficial

pain, masses, and muscle guarding. To
determine areas of tenderness, ask the
client to tell you about them and watch
for changes in the client’s facial
expressions.

If the client is excessively ticklish, begin

by pressing your hand on top of the
client’s hand while pressing lightly. Then
slide your hand off the client’s and onto
the abdomen to continue the
examination.

PALPATION OF THE BLADDER

13. Palpate the area above the pubic Normal
symphysis if the client’s history Not palpable
indicates possible urinary retention.
Abnormal
Distended and palpable as smooth, round, tense mass (indicates
urinary retention)
14. Document findings in the client
record using printed or electronic forms
or checklists supplemented by narrative
notes when appropriate.
MUSCULOSKELETAL SYSTEM
ASSESSMENT RATIONALE FINDINGS
Promotes cooperation
Explain to the client what you are going
to do, why it is necessary, and how she
can cooperate.

Reduces/prevents
Wash hands and observe other transmission of
appropriate infection control microorganism
procedures.

Provide for client privacy.

Determine client’s history

Muscles
Normal: Equal size on both sides of body
Inspect the muscles for size.
Deviations from normal: Atrophy (a decrease in size) or hypertrophy
Compare each muscle on one side of (an increase in size), asymmetry
the body to the same muscle on the
other side. For any apparent
discrepancies, measure the muscles
with a tape.
Normal: No contractures
Inspect the muscles and tendons for
contractures (shortening). Deviations from normal: Malposition of body part, e.g., foot drop
(foot flexed downward)
Presence of tremor
Normal: No tremors
Inspect the muscles for fasciculations
and tremors. Deviations from normal: Presence of tremor

Inspect any tremors of the hands and

arms by having the client hold the arms
out in front of the body.

Palpate muscles at rest to determine

muscle tonicity.

Palpate muscles while the client is

active and passive for flaccidity,
spasticity, and smoothness of
movement.

Normal: Equal strength on each body side

Test muscle strength. Compare the right
side with left side. Deviations from normal:
Grading Muscle Strength
Sternocleidomastoid: Client turns the 0: 0% of normal strength; complete paralysis
head to one side against the resistance 1: 10% of normal strength; no movement, contraction of muscle is
of your hand. Repeat with the other palpable or visible
side. 2: 25% of normal strength; full muscle movement against gravity,
with support
Trapezius: Client shrugs the shoulders 3: 50% of normal strength; normal movement against gravity
against the resistance of your hands. 4: 75% of normal strength; normal full movement against gravity
and against minimal
Deltoid: Client holds arm up and resists resistance
while you try to push it down. 5: 100% of normal strength; normal full movement against gravity
and against full resistance
Biceps: Client fully extends each arm
and tries to flex it while you attempt to
hold arm in extension.

Triceps: Client flexes each arm and

then tries to extend it against your
attempt to keep arm in flexion.

Wrist and finger muscles: Client

spreads the fingers and resists as you
attempt to push the fingers together.

Grip strength: Client grasps your index

and middle fingers while you try to pull
the fingers out.

Hip muscles: Client is supine, both legs

extended; client raises one leg at a time
while you attempt to hold it down.

Hip abduction: Client is supine, both

legs extended. Place your hands on the
lateral surface of each knee; client
spreads the legs apart against your
resistance.

Hip adduction: Client is in same position

as for hip abduction. Place your hands
between the knees; client brings the
legs together against your resistance.

Hamstrings: Client is supine, both knees

bent. Client resists while you attempt to
straighten the legs.
Quadriceps: Client is supine, knee
partially extended; client resists while
you attempt to flex the knee.

Muscles of the ankles and feet: Client

resists while you attempt to dorsiflex the
foot and again resists while you attempt
to flex the foot.
Bones
Normal: No deformities
Inspect the skeleton for normal structure
and deformities. Deviations from Normal:
Bones misaligned
Normal: No tenderness or swelling
Palpate the bones to locate any areas
of edema or tenderness. Deviations from normal: Presence of tenderness or swelling (may
indicate fracture, neoplasms, or
osteoporosis)
Joints
Normal: No swelling
Inspect the joint for swelling. No tenderness, swelling, crepitation, or nodules
Joints move smoothly
Palpate each joint for tenderness,
smoothness of movement, swelling, Deviations from normal:
crepitation, and presence of nodules. One or more swollen joints
Presence of tenderness, swelling, crepitation, or nodules
Normal: Varies to some degree in accordance with
Assess joint range of motion. person’s genetic makeup and degree of physical activity

Ask the client to move selected body Deviations from normal:

parts. If available, use a goniometer to Limited range of motion in one or more
measure the angle of the joint in joints
degrees.

Document findings in the client record.

NEUROLOGICAL SYSTEM
Rationale Normal/Abnormal
Findings
Procedure
1. Explain to the client what you are
going to do, why it is necessary,
and how he can cooperate.
2.Wash hands and observe other
appropriate infection control
procedures.
3.Provide for client privacy.
4.Determine client’s history of the
following:
Presence of pain in the head, back,
or extremities, as well as onset and
aggravating and alleviating factors
Disorientation to time, place, or
person
Speech disorders
Any history of loss of
consciousness, fainting,
convulsions, trauma, tingling or
numbness, tremors or tics, limping,
paralysis, uncontrolled muscle
movements, loss of memory, or
mood swings
Alterations in smell, vision, taste,
touch, or hearing
Language
5.If the client displays difficulty Injury to the cerebral cortex Normal: The patient can execute properly the test
speaking: can impair the ability to speak Abnormal:
6.Point to common objects, and ask or under-stand verbal Unable to perform the following task
the client to name them. language.
7.Ask the client to read some words
and to match the printed and written
words with pictures.
8.Ask the client to respond to simple
verbal and written commands, e.g.,
“point to your toes” or “raise your
left arm.”
Orientation
9.Determine the client’s orientation to Normal: The patient can execute properly the test
time, place, and person by tactful Abnormal: Unable to perform the following task.
questioning.
Ask the client the city and state of
residence, time of day, date, day of
the week, duration of illness, and
names of family members.
More direct questioning may be
necessary for some people, e.g.,
“Where are you now?” “What day is
 it today?”
Memory
10Listen for lapses in memory. Normal:
Ask the client about difficulty with The average person can repeat a series of five to eight digits in
memory. If problems are apparent, sequence, and four to six digits in reverse order.
three categories of memory are Abnormal:
tested: immediate recall, recent Unable to perform the following task
memory, and remote memory.
To assess immediate recall:

>Ask the client to repeat a series of

three digits—e.g., 7-4-3—spoken
slowly.

>Gradually increase the number of

digits—e.g., 7-4-3-5, 7-4-3-5-6, and
7-4-3-5-6-7-2—until the client fails
to repeat the series correctly.

>Start again with a series of three

digits, but this time ask the client to
repeat them backward.

To assess recent memory: Normal: The patient can execute properly the test
Abnormal:
>Ask the client to recall the recent Unable to perform the following task
events of the day, such as how he
got to the clinic. This information
must be validated, however.

>Ask the client to recall information

given early in the interview, e.g., the
name of a doctor.

>Provide the client with three facts

to recall—e.g., a color, an object,
an address, or a three-digit number
—and ask the client to repeat all
three. Later in the interview, ask the
client to recall all three items.
To assess remote memory: Normal: The patient can execute properly the test
Abnormal: Unable to perform the following task
>Ask the client to describe a
previous illness or surgery.
Attention Span and Calculation
11.Test the ability to concentrate or Normal: The patient can execute properly the test
attention span by asking the client Abnormal: Unable to perform the following task
to recite the alphabet or to count
backward from 100.
Test the ability to calculate by
asking the client to subtract 7 or 3
progressively from 100—i.e., 100,
93, 86, 79, or 100, 97, 94.
Level of Consciousness
12.Apply the Glasgow Coma Scale. Normal: An assessment totaling 15 points indicates the client is
alert and completely oriented.
Abnormal: A comatose client scores 7 or less.

Cranial Nerves
13.Cranial Nerve I—Olfactory A decrease in the ability to Normal: Client correctly identifies scent presented to each nostril.
Ask client to close eyes and identify smell may be related to a Abnormal: Inability to smell (neurogenic anosmia) or identify the
different mild aromas, such as dysfunction of cranial nerve I correct scent may indicate olfactory tract lesion or tumor or lesion
coffee, vanilla. (olfactory) or a brain tumor. of the frontal lobe. Loss of smell may also be congenital or due to
other causes such as nasal or sinus problems. It may also be
OLDER ADULT caused by injury of nerve tissue at the top of the nose or the
 CONSIDERATION higher smell pathways in the brain due to viral upper respiratory
Decreased taste and scent infection. Smoking and use of cocaine may also impair one’s
sensation occurs normally in sense of smell.
older adults.
14Cranial Nerve II—Optic Changes in vision may occur Normal:
Ask client to read Snellen’s chart, with dysfunction of cranial ●Client has 20/20 vision OD (right eye) and OS (left eye).
check visual fields by confrontation, nerve II (optic), increased ●Full visual fields
and conduct an ophthalmoscopic intracranial pressure, or brain Round red reflex is present, optic disc is 1.5 mm, round or
examination. tumors. Damage to cranial slightly oval, well-defined margins, creamy pink with paler
nerves III (oculomotor), IV physiologic cup. Retina is pink
(trochlear), or VI (abducens) Abnormal:
may cause double or blurred ●include difficulty reading Snellen chart, missing letters, and
vision. Transient blind spots squinting.
may be an early sign of a ●Loss of visual fields may be seen in retinal damage or
cerebrovascular accident detachment, with lesions of the optic nerve, or with lesions of the
(CVA). parietal cortex
OLDER ADULT ●Papilledema (swelling of the optic nerve) results in blurred optic
CONSIDERATION disc margins and dilated, pulsating veins. Papilledema occurs
There is a normal decrease in with increased intracranial pressure from intracranial hemorrhage
the older person’s ability to or a brain tumor. Optic atrophy occurs with brain tumors
see.

15Cranial Nerve III—Oculomotor Normal: Bilateral illuminated pupils constrict simulta-neously.

Assess six ocular movements and Pupil opposite the one illuminated constricts simultaneously.
pupil reaction. Abnormal:
Some abnormalities and their implications follow:
●DILATED PUPILS: oculomotor nerve paralysis.
●ARGYLL ROBERTSON PUPILS : syphilis, meningitis, brain
tumor, alcoholism ●CONSTRICTED, FIXED PUPILS: narcotics
abuse or damage to the pons.
●LATERALLY DILATED
to light or accommodation: damage to cranial nerve III

16Cranial Nerve IV—Trochlear Normal: Temporal and masseter muscles contract bilaterally.
Assess six ocular movements. Abnormal: Decreased contraction in one of both sides.
Asymmetric strength in moving the jaw may be seen with lesion
or injury of the 5th cranial nerve.
17Cranial Nerve V—Trigeminal To avoid transmitting Normal:
While client looks upward, lightly infection, use a new object ●The client correctly identifies sharp and dull stimuli and light
touch lateral sclera of eye to elicit with each client. Avoid touch to the forehead, cheeks, and chin.
blink reflex. To test light sensation, “stabbing” the client with the ●Eyelids blink bilaterally
have client close eyes, and wipe a object’s sharp side. Abnormal:
wisp of cotton over client’s forehead ● Inability to feel and correctly identify facial stimuli occurs with
and paranasal sinuses. To test lesions of the trigeminal nerve or lesions in the spinothalamic
deep sensation, use alternating tract or posterior columns.
blunt and sharp ends of a safety pin ●.An absent corneal reflex may be noted with lesions of the
over same area. trigeminal nerve or lesions of the motor part of cranial nerve VII
(facial).

18Cranial Nerve VI—Abducens Normal:

Assess directions of gaze. Abnormal:
19Cranial Nerve VII—Facial Make sure that the client Normal:
Ask client to smile, raise the leaves the tongue protruded to ●Client smiles, frowns, wrinkles forehead, shows teeth, puffs out
eyebrows, frown, puff out his identify the flavor. Otherwise, cheeks, purses lips, raises eyebrows, and closes eyes against
cheeks, close his eyes tightly. Ask the substance may move to resistance.
client to identify various tastes the posterior third of the ●Movements are symmetric.
place on tip and sides of tongue— tongue (vagus nerve ●Client identifies correct flavor.
sugar, salt—and identify areas of innervation). The posterior Abnormal:
taste. portion is tested similarly to ●Inability to close eyes, wrinkle forehead, or raise forehead
evaluate functioning of cranial along with paralysis of the lower part of the face on the affected
nerves IX and X. The client side is seen with Bell’s palsy (a peripheral injury to cranial nerve
should rinse the mouth with VII [facial]). Paralysis of the lower part of the face on the opposite
water between each taste test. side affected may be seen with a central lesion that affects the
upper motor neurons, such as from stroke.
●Inability to identify correct flavor on anterior two-thirds of the
tongue suggests impairment of cranial nerve VII (facial).
 20Cranial Nerve VIII—Auditory The vestibular component, Normal: Client hears whispered words from 1–2 feet. Weber
Assess client’s ability to hear responsible for equilibrium, is test: Vibration heard equally well in both ears.
spoken word and vibrations of not routinely tested. In Rinne test:
tuning fork. comatose clients, the test is AC > BC (air conduction is twice as long as bone conduction).
used to determine integrity of Abnormal:
the vestibular system. (See a Vibratory sound lateralizes to good ear in sensorineural loss. Air
neurology textbook for detailed conduction is longer than bone conduction, but not twice as
testing procedures.) long, in a sensorineural loss
21Cranial Nerve IX— Normal:
Glossopharyngeal ●Uvula and soft palate rise bilaterally and symmetrically on
Apply tastes on posterior tongue for phonation
identification. Ask client to move ●Soft palate does not rise with bilateral lesions of cranial nerve X
tongue from side to side and up and (vagus).
down. Abnormal:
Unilateral rising of the soft palate and deviation of the uvula to
the normal side are seen with a unilateral lesion of cranial nerve
X (vagus).

22Cranial Nerve X—Vagus Check the client’s ability to Normal: Client swallows without difficulty. No hoarseness noted.
Assessed with CN IX; assess swallow by Abnormal: Dysphagia or hoarseness may indicate a lesion of
client’s speech for hoarseness. giving the client a drink of cranial nerve IX (glossopharyngeal) or X (vagus) or other
water. Also note neurologic disorder.
the client’s voice quality.

23Cranial Nerve XI—Accessory Normal:

Ask client to shrug shoulders There is symmetric, strong contraction of the
against resistance from your hands Trapezius muscles.
and to turn his head to side against Abnormal:
resistance from your hand. Repeat Asymmetric muscle contraction or drooping
for the other side. of the shoulder may be seen with paralysis
or muscle weakness due to neck injury or
torticollis.
24Cranial Nerve XII—Hypoglossal Normal: Tongue movement is symmetric and smooth, and
Ask client to protrude his tongue at bilateral strength is apparent
midline, then move it side to side. Abnormal: Fasciculations and atrophy of the tongue may be seen
with peripheral nerve disease. Deviation to the affected side is
seen with a unilateral lesion.

Reflexes
.Test reflexes using a percussion
hammer, comparing one side of the
body with the other to evaluate the
symmetry of response.
Biceps Reflex
The biceps reflex tests the spinal cord
level C-5, C-6.
25Partially flex the client’s arm at the Normal: Elbow flexes and contraction of the bicepsmuscle is
elbow, and rest the forearm over seen or felt. Ranges from 1+ to 3+.
the thighs, placing the palm of the Forearm flexes and supinates. Ranges from
hand down. 1+ to 3+.
Place the thumb of your Abnormal:
nondominant hand horizontally over No response or an exaggerated response is
the biceps tendon. abnormal.
Deliver a blow (slight downward
thrust) with the percussion hammer
to your thumb.
Observe the normal slight flexion of
the elbow, and feel the biceps’s
contraction through your thumb.
Triceps Reflex
The triceps reflex tests the spinal cord
level C-7, C-8.
26Flex the client’s arm at the elbow, Normal:
and support it in the palm of your Knee extends, quadriceps muscle contracts.
nondominant hand. Ranges from 1+ to 3+.
 Palpate the triceps tendon about 2– Abnormal:
5 cm (1–2 in) above the elbow. No response or exaggerated response.
Deliver a blow with the percussion
hammer directly to the tendon.
Observe for the normal slight
extension of the elbow.
Brachioradialis Reflex
The brachioradialis reflex tests
the spinal cord level C-3, C-6.
27Rest the client’s arm in a relaxed Normal:
position on your forearm or on the Elbow extends, triceps contracts. Ranges
client’s own leg. from 1+ to 3+.
Deliver a blow with the percussion Abnormal:
hammer directly on the radius 2–5 No response or an exaggerated response is
cm (1–2 in) above the wrist or the abnormal
styloid process, the bony
prominence on the thumb side of
the wrist.
Observe the normal flexion and
supination of the forearm. The
fingers of the hand may also extend
slightly.
Patellar Reflex
The patellar reflex tests the spinal cord
level L-2. L-3, L-4.
28Ask the client to sit on the edge of Normal:
the examining table so that his legs Normal response is plantar flexion of the
hang freely. foot. Ranges from 1+ to 3+.
Locate the patellar tendon directly Abnormal:
below the patella. No response or an exaggerated response is
Deliver a blow with the percussion abnormal.
hammer directly to the tendon.
Observe the normal extension or
kicking out of the leg as the
quadriceps muscle contracts.
If no response occurs, and you
suspect the client is not relaxed,
ask the client to interlock the fingers
and pull.
Achilles Reflex
The Achilles reflex tests the spinal cord
level S-1, S-2.
29With the client in the same position OLDER ADULT Normal: Normal response
as for the patellar reflex, slightly CONSIDERATION Ranges from 1+ to 3+.
dorsiflex the client’s ankle by In some older clients, the
supporting the foot lightly in the Achilles reflex Abnormal:
hand. may be absent or difficult to No response or an exaggerated response is
Deliver a blow with the percussion elicit. abnormal.
hammer directly to the Achilles
tendon just above the heel.
Observe and feel the normal plantar
flexion (downward jerk) of the foot.
Plantar (Babinski’s) Reflex
The plantar or Babinski’s reflex is
superficial. It may be absent in adults
without pathology, or overridden by
voluntary control.
30Use a moderately sharp object, Normal: Flexion of the toes occurs (plantar response;
such as the handle of the Abnormal: The toes will fan out for abnormal (positive
percussion hammer, a key, or the Babinski response
dull end of a pin or applicator stick.
Stroke the lateral border of the sole
of the client’s foot, starting at the
heel, continuing to the ball of the
foot, and then proceeding across
the ball of the foot toward the big
 toe.
Observe the response. Normally, all
five toes bend downward; this
reaction is negative Babinski’s. In
an abnormal Babinski response, the
toes spread outward and the big toe
moves upward.
Motor Function
Assessment
Gross Motor and Balance Tests
31Walking Gait Normal:
Ask the client to walk across the Has upright posture and steady gait with opposing arm swing;
room and back, and assess the walks unaided, maintaining balance
client’s gait. Abnormal:
Has poor posture and unsteady, irregular, staggering gait with
wide stance; bends legs only from hips; has rigid or no arm
movements
32Romberg’s Test Let the patient stand beside Normal:
Ask the client to stand with feet the chair. Negative Romberg: may sway slightly but is able to maintain
together and arms resting at the This prevents the client from upright posture and foot stance
sides, first with eyes open, then falling. Abnormal:
closed. Positive Romberg: cannot maintain foot stance; moves the feet
apart to maintain stance If client cannot maintain balance with
the eyes shut, client may have sensory ataxia
33Standing On One Foot With Eyes Normal:
Closed Maintains stance for at least 5 seconds
Ask the client to close his eyes and Abnormal:
stand on one foot, then the other. Cannot maintain stance for 5 seconds
Stand close to the client during this
test.
34Heel–Toe Walking Normal:
Ask the client to walk a straight line, Maintains heel-toe walking along a straight line
placing the heel of one foot directly Abnormal:
in front of the toes of the other foot. Assumes a wider foot gait to stay upright
35Toe or Heel Walking Normal:
Ask the client to walk several steps Able to walk several steps on toes or heels
on the toes and then on the heels. Abnormal:
Cannot maintain balance on toes and heels
Fine Motor Tests for the Upper
Extremities
36Finger-to-Nose Test Normal:
Ask the client to abduct and extend Repeatedly and rhythmically touches the nose
the arms at shoulder height and Abnormal:
rapidly touch the nose alternately Misses the nose or gives slow response
with one index finger and then the
other. Have the client repeat the
test with the eyes closed if the test
is performed easily.
37Alternating Supination and Normal: Client rapidly turns palms up and down
Pronation of Hands on Knees Abnormal: Uncoordinated movements or tremors are abnormal
Ask the client to pat both knees with findings. They are seen with cerebellar
the palms of both hands and then disease (dysdiadochokinesia)
with the backs of the hands
alternately at an ever-increasing
rate.
38Finger to Nose and to the Nurse’s Normal: Performs with coordination and rapidity
Finger Abnormal: Misses the finger and moves slowly
Ask the client to touch the nose and
then your index finger, held at a
distance at about 45 cm (18 in), at a
rapid and increasing rate.
39Fingers to Fingers Normal: Performs with accuracy and rapidity
Ask the client to spread the arms Abnormal: Moves slowly and is unable to touch fingers
broadly at shoulder height and then consistently
bring the fingers together at the
midline, first with the eyes open and
 then closed, first slowly and then
rapidly.
40Fingers to Thumb (Same Hand) OLDER ADULT Normal: Client touches each finger to the thumb
Ask the client to touch each finger CONSIDERATIONS rapidly.
of one hand to the thumb of the For some older clients, rapid Abnormal: Inability to perform rapid alternating movements
same hand as rapidly as possible. alternating may be seen with cerebellar disease,
movements are difficult upper motor neuron weakness, or extrapyramidal
because of disease.
Decreased reaction time and
flexibility.
Fine Motor Tests for the Lower
Extremities
Ask the client to lie supine and to
perform these tests:
41Heel Down Opposite Shin Normal: Client is able to run each heel smoothly
Ask the client to place the heel of down each shin.
one foot just below the opposite Abnormal: Deviation of heel to one side or the other may be seen
knee and run the heel down the in cerebellar disease.
shin to the foot. Repeat with the
other foot. The client may also use
a sitting position for this test.
42Toe or Ball of Foot to the Nurse’s Normal: Performs with coordination and rapidity
Finger Abnormal: Misses the finger and moves slowly
Ask the client to touch your finger
with the large toe of each foot.
43Light-Touch Sensation.
Compare the light-touch sensation Sensitivity to touch varies Normal:
of symmetric areas of the body. among different ●Client correctly identifies light touch.
Ask the client to close the eyes and skin areas. ●Client correctly differentiates between dulland sharp sensations
to respond by saying “yes” or “now” various body parts
whenever the client feels the cotton ●Client correctly identifies sensation.
wisp touching his skin.
With a wisp of cotton, lightly touch Abnormal:
one specific spot and then the ●Many disorders can alter a person’s ability to perceive
same spot on the other side of the sensations correctly.
body. ●These include
Test areas on the forehead, cheek, peripheral neuropathies (due to diabetes mellitus, folic acid
hand, lower arm, abdomen, foot, deficiencies, and alcoholism) and lesions of the ascending spinal
and lower leg. Check a specific cord, brain stem, cranial nerves, and cerebral cortex.
area of the limb first. ●Inability to sense vibrations may be seen
Ask the client to point to the spot in posterior column disease or peripheral
where the touch was felt. neuropathy
If areas of sensory dysfunction are
found, determine the boundaries of
sensation by testing responses
about every 2.5 cm (1 in) in the
area. Make a sketch of the sensory
loss area for recording purposes.
44Pain Sensation
Assess pain sensation as follows: Normal: Able to discriminate “sharp” and “dull” sensations
Ask the client to close his eyes and Abnormal: Areas of reduced, heightened, or absent sensation
to say “sharp,” “dull,” or “don’t (map them out for recording purposes)
know” when the sharp or dull end of
the broken tongue depressor is felt.
Alternately, use the sharp and dull
end of the sterile pin or needle to
lightly prick designated anatomic
areas at random. The face is not
tested in this manner.
Allow at least 2 seconds between
each test.
45Temperature Sensation
Touch skin areas with test tubes Normal: Able to identify hot or cold
filled with hot or cold water. Abnormal: : Areas of reduced, heightened, or absent sensation
Have the client respond say saying (map them out for recording
“hot,” “cold,” or “don’t know.” purposes)
 46Position or Kinesthetic Sensation
Commonly, the middle fingers and Normal: Can readily determine the position of fingers
the large toes are tested for the and toes
kinesthetic sensation. Abnormal: Unable to determine the position of one or
To test the fingers, support the more fingers or toes
client’s arm with one hand and hold
the client’s palm in the other. To
test the toes, place the client’s
heels on the examining table.
Ask the client to close his eyes.
Grasp a middle finger or a big toe
firmly between your thumb and
index finger, and exert the same
pressure on both sides of the finger
or toe while moving it.
Move the finger or toe until it is up,
down, or straight out, and ask the
client to identify the position.
Use a series of brisk up-and-down
movements before bringing the
finger or toe suddenly to rest in one
of the three positions.
47 Tactile Discrimination
For all tests, the client’s eyes need
to be closed:
One- and Two-Point Discrimination Normal:
Alternately stimulate the skin with Identifies two points on:
two pins simultaneously and then ●Fingertips 2-5mm apart
with one pin. Ask whether the client ●Forearm at 40mm apart
feels one or two pinpricks. ●Doral hands at 20-30mm apart
●Back at 40mm apart
●Thigh at 70 mm apart
Abnormal:
Inability to correctly identify objects (astereognosis),
area touched, number written in hand; to discriminate between
two points; or
identify areas simultaneously touched may
be seen in lesions of the sensory cortex.

Stereognosis Normal:
Place familiar objects—such as a Client correctly identifies object.
key, paper clip, or coin—in the Abnormal:
client’s hand, and ask the client to Inability to correctly identify objects (astereognosis),
identify them. area touched, number written in hand; to discriminate between
two points; or
If the client has a motor impairment identify areas simultaneously touched may
of the hand and is unable to be seen in lesions of the sensory cortex.
manipulate an object, write a
number or letter on the client’s
palm, using a blunt instrument, and
ask the client to identify it.
Extinction Phenomenon Normal:
Simultaneously stimulate two Correctly identifies points touched
symmetric areas of the body, such Abnormal:
as the thighs, the cheeks, or the Inability to correctly identify objects (astereognosis),
hands. area touched, number written in hand; to discriminate between
two points; or
identify areas simultaneously touched may
be seen in lesions of the sensory cortex.

48Document findings in the client

record.
RECTUM AND ANUS

Preparation

1.Assemble equipment and supplies:

Examination gloves
Water-soluble lubricant
Procedure Rationale Normal Findings Deviation from Normal
1.Explain to the client what you are going Promotes cooperation
to do, why it is necessary, and how he and establishes
or she can cooperate. rapport.
2.Wash hands and observe other Prevents transmission
appropriate infection control of microorganism.
procedures.
3.Provide for client privacy. Keeps the client safe
and comfortable,
prevent undue
exposure of body
parts.
4.Determine client’s history of the To gather subjective
following: data from the client or
client’s family so that
History of bright blood in stools, tarry the health care plan
black stools, diarrhea, constipation, can easily be created.
abdominal pain, excessive gas,
hemorrhoids, or rectal pain

Family history of colorectal cancer

When last stool specimen for occult

blood was performed, and the results

For males, if not obtained during the

genitourinary examination, any signs or
symptoms of prostate

5.Position the client. To easily assess the

In adults, a left lateral or Sims’ position client while keeping
with the upper leg acutely flexed is them comfortable.
required for the examination.
For females: a dorsal recumbent
position with hips externally rotated
and knees flexed or a lithotomy
position may be used.
For males: a standing position while
the client bends over the examining
table may also be used.
Assessment
6.Inspect the anus and surrounding To initially assess Intact perianal Presence of fissures (cracks), ulcers, excoriations,
tissue for color, integrity, and skin client’s anus for other skin; usually inflammations, abscesses, protruding
lesions. unusual presence that slightly more hemorrhoids (dilated veins seen asreddened
may indicate any pigmented than protrusions of the skin), lumps or tumors, fistula
diseases. the skin of the openings, or rectal prolapse (varying degrees of
Then, ask the client to bear down as Bearing down creates buttocks protrusion of the rectalmucous membrane through the
though defecating. slight pressure on the Analskin is anus).
skin that may normally more
accentuate rectal pigmented,
fissures, rectal coarser,and
prolapse, polyps, moister than
orinternal perianal skin and
hemorrhoids. is
 Describe the location of all abnormal To identify exact usuallyhairless.
findings in terms of a clock, with the 12 location of any unusual
o’clock position toward the pubic findings.
symphysis.
7.Palpate the rectum for anal sphincter To assess the rectum
tonicity, nodules, masses, and for other unusual
tenderness. presence that may
indicate any diseases.
8.On withdrawing the finger from the To identify color of
rectum and anus, observe it for feces. feces or other unusual
discharges.
9.Document findings in the client record. To secure client’s
record and findings.

MALE GENITALIA
 Assessing the Male Genitals and Inguinal Area
Preparation Rationale Findings
1.Assemble equipment and supplies:
Examination gloves
Procedure
1.Explain to the client what you are To establish rapport.
going to do, why it is necessary, and
how he can cooperate.
2.Wash hands and observe other To avoid transfer of
appropriate infection control procedures. infectious microorganisms
3.Provide for client privacy.
4.Determine client’s history of the For baseline data
following:

Usual voiding patterns and any changes,
bladder control, urinary incontinence,
frequency, or urgency


Abdominal pain


Any symptoms of sexually transmitted
disease


Any swellings that could indicate
presence of hernia


Family history of nephritis, malignancy of
the prostate, or malignancy of the
kidney.

Assessment
Pubic Hair
5.Inspect the distribution, amount, and Normal:
characteristics of pubic hair. Pubic hair is coarser than scalp hair. The normal pubic hair
pattern in adults is hair covering the entire groin area, extending
to the medial thighs and up the abdomen toward the umbilicus.
Abnormal:
Absence or scarcity of pubic hair may be seen in clients
receiving chemotherapy. Lice or nit (eggs) infestation at the
base of the penis or pubic hair is known as pediculosis pubis.
This is commonly referred to as “crabs.”

Penis
6.Inspect the penile shaft and glans penis Lesions may be a sign of a Normal:
for lesions, nodules, swellings, and sexually transmitted The skin of the penis is wrinkled and hairless and is normally
inflammation. infection (STI) or cancer. free of rashes, lesions, or lumps. Genital piercing is becoming
more common, and nurses may see male clients with one or
Swelling, or masses found more piercings of the penis.
in the scrotum, genital, or Abnormal:
groin area may indicate Rashes, lesions, or lumps may indicate STI or cancer.
infection, hernia, or cancer.
7.Inspect the urethral meatus for swelling, May indicate infection
inflammation, and discharge.
Compress or ask the client to compress
the glans slightly to open the urethral
meatus to inspect it for discharge.
If the client has reported a discharge,
instruct the client to strip the penis from
the base to the urethra.
8.Palpate the penis for tenderness, To detect localized areas of Normal:
thickening, and nodules. hardness or tenderness. The penis in a nonerect state is usually soft, flaccid, and
Use your thumb and first two fingers. nontender.
Abnormal:
Tenderness may indicate inflammation or infection.
Scrotum
9.Inspect the scrotum for appearance, May indicate edema or Normal:
general size, and symmetry. mass Scrotal skin is darker in color than that of the rest of the body
FEMALE GENITALIA
ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
External Genitalia Pubic hair is distributed in an Lice or nits (eggs) at the base of the pubic hairs indicate
INSPECTION inverted triangular pattern and infestation with pediculosis pubis. This condition, commonly
Inspect the mons pubis. Wash your there are no signs of infestation. referred to as “crabs,” is most often transmitted by sexual contact
hands and put on gloves. As you begin OLDER CLIENT
the examination, note the distribution CONSIDERATION
of pubic hair. Also be alert for signs of Older clients may have gray,
infestation thinning pubic hair
Observe and palpate inguinal lymph Some clients, particularly younger Drainage from the urethra indicates possible urethritis. Any
nodes. ones, shave or pluck the pubic discharge should be cultured. Urethritis may occur with infection
hair. Some clients may have with Neisseria gonorrhoeae or Chlamydia trachomatis
piercing of the mons pubis.
There should be no enlargement
or swelling of the lymph nodes.
Inspect the labia majora and The labia majora are equal in size Lesions may be from an infectious disease, such as herpes or
perineum.Observe the labia majora and free of lesions, swelling, and syphilis Excoriation and swelling may be from scratching or self-
and perineum for lesions, swelling, and excoriation. A healed tear or treatment of the lesions. Evaluate all lesions and refer the client
excoriation. episiotomy scar may be visible on to a primary care provider for treatment.
the perineum if the client has given
birth. The perineum should be
smooth.
Inspect the labia minora, clitoris, The labia minora appear Asymmetric labia may indicate abscess. Lesions, swelling,
urethral meatus, and vaginal opening. symmetric, dark pink, and moist. bulging in the vaginal opening, and discharge are abnormal
Use your gloved hand to separate the The clitoris is a small mound of findings Excoriation may result from the client scratching or self-
labia majora and inspect for lesions, erectile tissue, sensitive to touch. treating a perineal irritation
excoriation, swelling, and/or discharge The normal size of the clitoris
varies. The urethral meatus is
small and slit-like. The vaginal
opening is positioned below the
urethral meatus. Its size depends
on sexual activity or vaginal
delivery. A hymen may cover the
vaginal opening partially or
completely.
PALPATION Bartholin’s glands are usually soft, Swelling, pain, and discharge may result from infection and
Palpate Bartholin’s glands. If the client non tender, and drainage free. abscess If you detect a discharge, obtain a specimen to send to
has labial swelling or a history of it, the laboratory for culture
palpate Bartholin’s glands for swelling,
tenderness, and discharge. Place your
index finger in the vaginal opening and
your thumb on the labia majora. With a
gentle pinching motion, palpate from
the inferior portion of the posterior
labia majora to the anterior portion.
Repeat on the opposite side.

Palpate the urethra. If the client No drainage should be noted from Drainage from the urethra indicates possible urethritis. Any
reports urethral symptoms or urethritis, the urethral meatus. The area is discharge should be cultured. Urethritis may occur with infection
or if you suspect inflammation of normally soft and non tender. with Neisseria gonorrhoeae or Chlamydia trachomatis
Skene’s glands, insert your gloved
index finger into the superior portion of
the vagina and milk the urethra from
the inside, pushing up and out
Internal Genitalia The normal vaginal opening varies A condition in which the vagina becomes thinner and dryer is
Inspect the size of the vaginal opening in size according to the client’s vaginal atrophy. This occurs when the body lacks estrogen.
and the angle of the vagina. Insert age, sexual history, and whether Some causes may include: menopause, breast feeding, surgical
your gloved index finger into the she has given birth vaginally. The removal of the ovaries, and cancer treatments. The risk
vagina, noting the size of the opening vagina is typically tilted posteriorly increases if you smoke or with the absence of vaginal birth
and whether the lining of the vagina is at a 45-degree angle and should (Hormone Health Network, 2011). Any loss of hymenal tissue
thinning or feels dry. Then attempt to feel moist. between the 3 o’clock position and the 9 o’clock position
touch the cervix. This will help you indicates trauma (penetration by digits, penis or foreign objects)
establish the size of the speculum you in children for more information about sexual abuse in children.
need to use for the examination and This finding is not as relevant in adults
the angle at which to insert it.
Next, while maintaining tension, gently
pull the labia majora outward. Note
hymenal configuration and
transections or injury
Inspect the vaginal musculature. Keep The client should be able to Absent or decreased ability to squeeze the examiner’s finger
your index finger inserted in the client’s squeeze around the examiner’s indicates decreased muscle tone. Decreased tone may decrease
vaginal opening. Ask the client to finger. Typically, the nulliparous sexual satisfaction
squeeze around your finger woman can squeeze tighter than Bulging of the anterior wall may indicate a cystocele. Bulging of
the multiparous woman. the posterior wall may indicate a rectocele. If the cervix or uterus
Use your middle and index fingers to protrudes down, the client may have uterine prolapse. If urine
separate the labia minora. Ask the No bulging and no urinary leaks out, the client may have stress incontinence
client to bear down. discharge

Inspect the cervix. Follow the The surface of the cervix is In a nonpregnant woman, a bluish cervix may indicate cyanosis;
guidelines for using a speculum in normally smooth, pink, and even. in a nonmenopausal woman, a pale cervix may indicate anemia.
Assessment With the speculum Normally, it is midline in position Redness may be from inflammation
inserted in position to visualize the and projects 1–3 cm into the
cervix, observe cervical color, size, vagina. In pregnant clients, the
and position. cervix appears blue (Chadwick’s
sign).

Inspect the vagina. Unlock the The vagina should appear pink, Reddened areas, lesions, and colored, malodorous discharge
speculum and slowly rotate and moist, smooth, and free of lesions are abnormal and may indicate vaginal infections, STIs, or
remove it. Inspect the vagina as you and irritation. It should also be free cancer (Abnormal Findings 27-2, p. 639 and Abnormal Findings
remove the speculum. Note the of any colored or malodorous 27-3, p. 641). Altered pH may indicate infection
vaginal color, surface, consistency, discharge.
and any discharge.
Bimanual Examination he vaginal wall should feel Tenderness or lesions may indicate infection
Palpate the vaginal wall. Tell the client smooth, and the client should not
that you are going to do a manual report any tenderness.
examination and explain its purpose.
Apply water soluble lubricant to the
gloved index and middle fingers of
your dominant hand. Then stand and
approach the client at the correct
angle. Placing your nondominant hand
on the client’s lower abdomen, insert
your index and middle fingers into the
vaginal opening. Apply pressure to the
posterior wall, and wait for the vaginal
opening to relax before palpating the
vaginal walls for texture and
tenderness
Palpate the cervix. Advance your The cervix should feel firm and A hard, immobile cervix may indicate cancer.
fingers until they touch the cervix and soft (like the tip of your nose). It is Pain with movement of the cervix may indicate infection
run fingers around the circumference. rounded, and can be moved (Chandelier’s sign).
Palpate for: somewhat from side to side
• Contour without eliciting tenderness.
• Consistency
• Mobility
• Tenderness
Palpate the uterus. Move your fingers The fundus, the large, upper end An enlarged uterus above the level of the pubis is abnormal; an
intravaginally into the opening above of the irregular shape suggests abnormalities such as myomas (fibroid
the cervix and gently press the hand uterus, is normally round, firm, and tumors) or endometriosis.
resting on the abdomen downward, smooth. In most women, it is at the
squeezing the uterus between the two level of the pubis; the cervix is
hands. Note uterine size, position, aimed posteriorly (anteverted
shape, and consistency position). However, several other
positions are considered normal
Palpate the ovaries. Slide your Ovaries are approximately 3 × 2 × Enlarged size, masses, immobility, and extreme tenderness are
intravaginal fingers toward the left 1 cm (or the size of a walnut) and abnormal and should be evaluated
ovary in the left lateral fornix and place almond-shaped.
your abdominal hand on the left lower
abdominal quadrant. Press your
abdominal hand toward your
intravaginal fingers and attempt to
palpate the ovary
Slide your intravaginal fingers to the Ovaries are firm, smooth, mobile, Large amounts of colorful, frothy, or malodorous secretions are
right lateral fornix and attempt to and somewhat tender on palpation abnormal. Ovaries that are palpable 3–5 years after menopause
palpate the right ovary. Note size, are also abnormal
shape, consistency, mobility, and
tenderness.
Withdraw your intravaginal hand and Ovaries are firm, smooth, mobile,
inspect the glove for secretions. and somewhat tender on palpation
CLINICAL TIP
It is normal for the ovaries to be
difficult or impossible to palpate in
obese women, in postmenopausal
women because the ovaries atrophy, A clear, minimal amount of
and in women who are tense during drainage appearing on the glove
the examination. from the vagina is normal.
Rectovaginal Examination The rectovaginal septum is Masses, thickened structures, immobility, and tenderness are
Explain that you are going to perform a normally smooth, thin, movable, abnormal.
rectovaginal examination and explain and firm. The posterior uterine wall
its purpose. Forewarn the client that is normally smooth, firm, round,
she may feel uncomfortable as if she movable, and nontender6
wants to move her bowels but that she
will not. Encourage her to relax.
Change the glove on your dominant
hand and lubricate your index and
middle fingers with a water-soluble
lubricant

Ask the client to bear down to promote The rectovaginal septum is Masses, thickened structures, immobility, and tenderness are
relaxation of the sphincter and insert normally smooth, thin, movable, abnormal
your index finger into the vaginal and firm. The posterior uterine wall
orifice and your middle finger into the is normally smooth, firm, round,
rectum. While pushing down on the movable, and non tender
abdominal wall with your other hand,
palpate the internal reproductive
structures through the anterior rectal
wall. Pay particular attention to the
area behind the cervix, the
rectovaginal septum, the cul-de-sac,
and the posterior uterine wall.
Withdraw your vaginal finger and
continue with the rectal examination
Inspect the perianal area. Spread the The anal opening should appear Lesions may indicate STIs, cancer, or hemorrhoids. A
client’s buttocks and inspect the anal hairless, moist, and tightly closed. thrombosed external hemorrhoid appears swollen. It is itchy,
opening and surrounding area for the The skin around the anal opening painful, and bleeds when the client passes stool. A previously
following: is more coarse and more darkly thrombosed hemorrhoid appears as a skin tag that protrudes
• Lumps pigmented. The surrounding from the anus.
• Ulcers perianal area should be free of
• Lesions redness, lumps, ulcers, lesions, A painful mass that is hardened and reddened suggests a
• Rashes and rashes perianal abscess. A swollen skin tag on the anal margin may
• Redness indicate a fissure in the anal canal. Redness and excoriation may
• Fissures be from scratching an area infected by fungi or pinworms. A
• Thickening of the epithelium small opening in the skin that surrounds the anal opening may
be an anorectal fistula

Ask the client to perform Valsalva’s No bulging and lesions Bulges of red mucous membrane may indicate a rectal prolapse.
maneuver by straining or bearing
down. Inspect the anal opening for any
bulges or lesions.
CLINICAL TIP
Document any abnormalities by noting
position in relation to a face of a clock
Inspect the sacrococcygeal area. Area is normally smooth, and free Hemorrhoids or an anal fissure may also be seen and hair.A
Inspect this area for any signs of of redness and hair reddened, swollen, or dimpled area covered by a small tuft of
swelling, redness, dimpling, or hair. hair located midline on the lower sacrum suggests a pilonidal
cyst
Palpate the anus. Inform the client that Client’s sphincter relaxes, Sphincter tightens, making further examination unrealistic
you are going to perform the internal permitting entry
examination at this point. Explain that
it may feel like her bowels are going to
move but that this will not happen.
Lubricate your gloved index finger; ask
the client to bear down. As the client
bears down, place the pad of your
index finger on the anal opening and
applyslight pressure; this will cause
relaxation of the sphincter.Never use
your fingertip—this causes the
sphincter to tighten and, if forced into
the rectum, may cause pain
If the sphincter does not relax and the Examination for anus Examination finger cannot enter the anus
client reports severe pain, spread the
gluteal folds with your hands in close
approximation to the anus and attempt
to visualize a lesion that may be
causing the pain. If tension is
maintained on the gluteal folds for 60
seconds, the anus will dilate normally.
Ask the client to tighten the external
sphincter; note the tone.
Rotate finger to examine the muscular The client can normally close the Tenderness may indicate hemorrhoids, fistula, or fissure.
anal ring. Palpate for tenderness, sphincter around the gloved finger Nodules may indicate polyps or cancer. Hardness may indicate
nodules, and hardness scarring or cancer

Palpate the rectum. Insert your finger The rectal mucosa is normally soft, Hardness and irregularities may be from scarring or cancer.
further into the rectum as far as smooth, nontender, and free of Nodules may indicate polyps or cancer
possible . Next, turn your hand nodules
clockwise then counterclockwise. This
allows palpation of as much rectal
surface as possible. Note tenderness,
irregularities, nodules, and hardness
Palpate the cervix through the anterior Cervix palpated as small round Bright red blood on gloved finger when removed. Large mass
rectal wall mass. May also palpate tampon or palpated. Do not mistake tampon for mass
retroverted uterus. Should not
have any bright red blood when
gloved finger is removed
Inspect the stool. Withdraw your Stool is normally semi-solid, Black stool may indicate upper gastrointestinal bleeding, gray or
gloved finger. Inspect any fecal matter brown, and free of blood tan stool results from the lack of bile pigment, and yellow stool
on your glove. Assess the color, and suggests steatorrhea (increased fat content). Blood detected in
test the feces for occult blood. Provide the stool may indicate cancer of the rectum or colon. Refer the
the client with a towel to wipe the client for an endoscopic examination of the colon.
anorectal area

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