ASSESSMENT paranasal sinuses.

To test deep sensation, use alternating blunt

and sharp ends of a safety pin over same area.
ASSESSING THE NEUROLOGICAL SYSTEM Cranial Nerve VI—Abducens
1. Assemble equipment: - Assess directions of gaze.
- Sugar, salt, lemon juice, quinine flavors Cranial Nerve VII—Facial
- Percussion hammer - Ask the client to smile, raise the eyebrows, frown, puff out cheeks,
- Tongue depressors (one broken diagonally, for testing pain sensation) and close eyes tightly. Ask the client to identify various tastes
- Wisps of cotton, to assess light touch sensation placed on the tip and sides of tongue—sugar, salt—and to identify
- Test tubes of hot and cold water, for skin temperature assessment areas of taste.
(optional) Cranial Nerve VIII—Auditory
- Pins or needles for tactile discrimination - Assess the client’s ability to hear the spoken word and the
vibrations of a tuning fork.
4. Inquire if the client has any history of the following:
- Presence of pain in the head, back, or extremities, as well as Cranial Nerve IX—Glossopharyngeal
onset and aggravating and alleviating factors - Apply tastes on the posterior tongue for identification. Ask the
- Disorientation to time, place, or person client to move tongue from side to side and up and down.
- Speech disorders
- Any history of loss of consciousness, fainting, convulsions, Cranial Nerve X—Vagus
trauma, tingling or numbness, tremors or tics, limping, paralysis, - Assessed with CN IX; assess the client’s speech for hoarseness.
uncontrolled muscle movements, loss of memory, or mood swings
- Problems with smell, vision, taste, touch, or hearing Cranial Nerve XI—Accessory
- Ask the client to shrug shoulders against resistance from your
Language hands and to turn head to the side against resistance from your
5. If the client displays difficulty speaking: hand. Repeat for the other side.
- Point to common objects, and ask the client to name them.
- Ask the client to read some words and to match the printed and Cranial Nerve XII—Hypoglossal
written words with pictures. - Ask the client to protrude tongue at midline, then move it side to
- Ask the client to respond to simple verbal and written commands side.
—e.g., “Point to your toes” or “Raise your left arm.”
Reflexes
Orientation 11. Test reflexes using a percussion hammer, comparing one side of
6. Determine the client’s orientation to time, place, and person by the body with the other to evaluate the symmetry of response.
tactful questioning.
- Ask the client the city and state of residence, time of day, date, Biceps Reflex
day of the week, duration of illness, and names of family - The biceps reflex tests the spinal cord level C-5, C-6.
members. - Partially flex the client’s arm at the elbow, and rest the forearm
- More direct questioning might be necessary for some people- over the thighs, placing the palm of the hand down.
e.g., “where are you now?” “What day is it today?” - Place the thumb of your nondominant hand horizontally over the
biceps tendon.
Memory - Deliver a blow (slight downward thrust) with the percussion
7. Listen for lapses in memory. hammer to your thumb.
- Observe the normal slight flexion of the elbow, and feel the
Ask the client about difficulty with memory. If problems are apparent, biceps’s contraction through your thumb.
three categories of memory are tested: immediate recall, recent
memory, and remote memory. Triceps Reflex
The triceps reflex tests the spinal cord level C-7, C-8.
To assess immediate recall: - Flex the client’s arm at the elbow, and support it in the palm of
- Ask the client to repeat a series of three digits—e.g., 7–4–3— your nondominant hand.
spoken slowly. - Palpate the triceps tendon about 2–5 cm (1–2 inches) above the
- Gradually increase the number of digits—e.g., 7–4–3–5, 7–4–3– elbow.
5–6, and 7–4–3–5–6–7–2—until the client fails to repeat the - Deliver a blow with the percussion hammer directly to the tendon.
series correctly. - Observe for the normal slight extension of the elbow.
- Start again with a series of three digits, but this time ask the client
to repeat them backward. Brachioradialis Reflex
- The average person can repeat a series of 5–8 digits in The brachioradialis reflex tests the spinal cord level C-3, C-6.
sequence, and 4–6 digits in reverse order.
- Rest the client’s arm in a relaxed position on your forearm or on
the client’s own leg.
To assess recent memory: - Deliver a blow with the percussion hammer directly on the radius
2–5 cm (1–2 inches) above the wrist or the styloid process, the
- Ask the client to recall the recent events of the day, such as how bony prominence on the thumb side of the wrist.
he got to the clinic. This information must be validated, however. - Observe the normal flexion and supination of the forearm. The
- Ask the client to recall information given early in the interview— fingers of the hand might also extend slightly.
e.g., the name of a doctor.
- Provide the client with three facts to recall—e.g., a color, an Patellar Reflex
object, an address, or a three-digit number—and ask the client to The patellar reflex tests the spinal cord level L-2. L-3, L-4.
repeat all three. Later in the interview, ask the client to recall all
three items. - Ask the client to sit on the edge of the examining table so that
- To assess remote memory: legs hang freely.
- Ask the client to describe a previous illness or surgery. - Locate the patellar tendon directly below the patella.
- Deliver a blow with the percussion hammer directly to the tendon
Attention Span and Calculation - Observe the normal extension or kicking out of the leg as the
quadriceps muscle contracts. If no response occurs, and you
8. Test the ability to concentrate or attention span by asking the client suspect the client is not relaxed, ask the client to interlock fingers
to recite the alphabet or to count backward from 100. and pull.

Test the ability to calculate by asking the client to subtract 7 or 3 Achilles Reflex
progressively from 100—i.e., 100, 93, 86, 79, or 100, 97, 94. The Achilles reflex tests the spinal cord level S-1, S-2.
- With the client in the same position as for the patellar reflex test,
Level of Consciousness slightly dorsiflex the client’s ankle by supporting the foot lightly in
9. Apply the Glasgow Coma Scale: Eye response, motor response your hand.
and verbal response - Deliver a blow with the percussion hammer directly to the Achilles
tendon just above the heel.
Cranial Nerves - Observe and feel the normal plantar flexion (downward jerk) of
10. Test the cranial nerves. the foot.

Cranial Nerve I—Olfactory Plantar (Babinski’s) Reflex

- Ask client to close eyes and identify different mild aromas, such The plantar or Babinski’s reflex is superficial. It might be absent in
as coffee and vanilla. adults without pathology, or overridden by voluntary control.
Cranial Nerve II—Optic - Use a moderately sharp object, such as the handle of the
- Ask the client to read Snellen’s chart; check visual fields by percussion hammer, a key, or the dull end of a pin or applicator
confrontation, and conduct an ophthalmoscopic examination. stick.
Cranial Nerve III—Oculomotor - Stroke the lateral border of the sole of the client’s foot, starting at
- Assess six ocular movements and pupil reaction. the heel, continuing to the ball of the foot, and then proceeding
Cranial Nerve IV—Trochlear across the ball of the foot toward the big toe.
- Assess six ocular movements. - Observe the response. Normally, all five toes bend downward; this
Cranial Nerve V—Trigeminal reaction is negative Babinski’s. In an abnormal Babinski
- While client looks upward, lightly touch the lateral sclera of the response, the toes spread outward and the big toe moves
eye to elicit the blink reflex. To test light sensation, have the client upward.
close eyes, and wipe a wisp of cotton over client’s forehead and
 - 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
Motor Function finger or toe suddenly to rest in one of the three positions.
12. Gross Motor and Balance Test

Walking Gait Tactile Discrimination

Ask the client to walk across the room and back, and assess the For all tests, the client’s eyes need to be closed:
client’s gait. One- and Two-Point Discrimination
- Alternately stimulate the skin with two pins simultaneously and
Romberg’s Test then with one pin. Ask whether the client feels one or two
Ask the client to stand with feet together and arms resting at the sides, pinpricks.
first with eyes open, then closed.
Stereognosis
Standing On One Foot With Eyes Closed - Place familiar objects—such as a key, paper clip, or coin—in the
- Ask the client to close eyes and stand on one foot, then the other. client’s hand, and ask the client to identify them.
Stand close to the client during this test.
- If the client has a motor impairment of the hand and is unable to
Heel–Toe Walking manipulate an object, write a number or letter on the client’s palm,
- Ask the client to walk a straight line, placing the heel of one foot using a blunt instrument, and ask the client to identify it.
directly in front of the toes of the other foot.
Extinction Phenomenon
Toe or Heel Walking - Simultaneously stimulate two symmetric areas of the body, such
- Ask the client to walk several steps on the toes and then on the as the thighs, the cheeks, or the hands.
heels.
Document findings in the client record.
Fine Motor Tests for the Upper Extremities
Finger-to-Nose Test
- Ask the client to abduct and extend arms at shoulder height and
rapidly touch nose alternately with one index finger and then the ASSESSING THE MOUTH AND OROPHARYNX
other. Have the client repeat the test with eyes closed if the test is
performed easily. PREPARATION
1. Assemble equipment and supplies:
Alternating Supination and Pronation of Hands on Knees ∙ Clean gloves
- Ask the client to pat both knees with the palms of both hands and ∙ Tongue depressor
then with the backs of hands, alternately, at an ever-increasing ∙ 2 x 2 gauze pads
rate. ∙ Penlight
Finger to Nose and to the Nurse’s Finger
- Ask the client to touch nose and then your index finger, held at a PROCEDURE
distance at about 45 cm (18 inches), at a rapid and increasing 4. Inquire if client has any history of the following:
rate. - Routine pattern of dental care
- Last visit to dentist
Fingers to Fingers - Length of time ulcers or other lesions have been present
- Ask the client to spread arms broadly at shoulder height and then - Any denture discomfort
bring fingers together at the midline, first with eyes open and then - Any medications the client is receiving
closed, first slowly and then rapidly.
5. Position the client comfortably—seated, if possible
Fingers to Thumb (Same Hand)
- Ask the client to touch each finger of one hand to the thumb of the Assessment
same hand as rapidly as possible. Lips and Buccal Mucosa

Fine Motor Tests for the Lower Extremities 6. Inspect the outer lips for symmetry of contour, color, and texture.
- Ask the client to lie supine and to perform these tests: Ask the client to purse lips as if to whistle
7. Inspect and palpate the inner lips and buccal mucosa for color,
Heel Down Opposite Shin moisture, texture, and the presence of lesions.
- Ask the client to place the heel of one foot just below the opposite
knee and run the heel down the shin to foot. Repeat with the other Teeth and Gums
foot. The client may also use a sitting position for this test. 8. Inspect the teeth and gums while examining the inner lips and
Toe or Ball of Foot to the Nurse’s Finger buccal mucosa.
- Ask the client to touch your finger with the large toe of each foot. 9. Inspect the dentures. Ask the client to remove complete or partial
dentures. Inspect their condition, noting in particular broken or worn
Light-Touch Sensation areas.
- Compare the light-touch sensation of symmetric areas of the
body. Tongue/Floor of the Mouth
- Ask the client to close eyes and to respond by saying “yes” or 10. Inspect the surface of the tongue for position, color, and texture.
“now” whenever the client feels the cotton wisp touching skin. Ask the client to protrude the tongue and move it from side to side.
- With a wisp of cotton, lightly touch one specific spot and then the
same spot on the other side of the body. 11. Inspect tongue movement. Ask the client to roll the tongue upward
- Test areas on the forehead, cheek, hand, lower arm, abdomen, and move it from side to side.
foot, and lower leg. Check a distal area of the limb first. 12. Inspect the base of the tongue, the mouth floor, and the frenulum.
- Ask the client to point to the spot where the touch was felt. Ask the client to place the tip of his tongue against the roof of the
- If areas of sensory dysfunction are found, determine the mouth.
boundaries of sensation by testing responses approximately 13. Palpate the tongue and floor of the mouth for any nodules, lumps,
every 2.5 cm (1 inch) in the area. Make a sketch of the sensory or excoriated areas.
loss area for recording purposes. Use a piece of gauze to grasp the tip of the tongue and, with the index
finger of your other hand, palpate the back of the tongue, its borders,
Pain Sensation and its base.
Assess pain sensation as follows:
- Ask the client to close his eyes and to say “sharp,” “dull,” or “don’t Salivary Glands
know” when the sharp or dull end of the broken tongue depressor 14. Inspect salivary duct openings for any swelling or redness.
is felt.
- Alternately, use the sharp and dull end of the sterile pin or needle Palates and Uvula
to lightly prick designated anatomic areas at random. The face is 15. Inspect the hard and soft palate for color, shape, texture, and the
not tested in this manner. presence of bony prominences.
- Allow at least two seconds between each test. Ask the client to open mouth wide and tilt head backward. Then,
depress tongue with a tongue blade as necessary, and use a penlight
Temperature Sensation for appropriate visualization.
- Touch skin areas with test tubes filled with hot or cold water.
- Have the client respond say saying “hot,” “cold,” or “don’t know.” 16. Inspect the uvula for position and mobility while examining the
palates. To observe the uvula, ask the client to say “ah” so that the soft
Position or Kinesthetic Sensation palate rises.
- Commonly, the middle fingers and the large toes are tested for the
kinesthetic sensation. Oropharynx and Tonsils
- To test the fingers, support the client’s arm with one hand and 17. Inspect the oropharynx for color and texture.
hold the client’s palm in the other. To test the toes, place the Inspect one side at a time to avoid eliciting the gag reflex. To expose
client’s heels on the examining table. one side of the oropharynx, press a tongue blade against the tongue
- Ask the client to close eyes. on the same side about halfway back while the client tilts head back
- Grasp a middle finger or a big toe firmly between your thumb and and opens mouth wide. Use a penlight for illumination, if needed.
index finger, and exert the same pressure on both sides of the
finger or toe while moving it. 18. Inspect the tonsils for color, discharge, and size.
19. Elicit the gag reflex by pressing the posterior tongue with a tongue - Inspect all skin surfaces by spreading the rugated surface skin and
blade. lifting the scrotum as needed to observe posterior surfaces.
20. Document findings in the client record. 11. Palpate the scrotum to assess the status of underlying testes,
epididymis, and spermatic cord.
- Palpate both testes simultaneously for comparative purposes.

Inguinal Area
12. Inspect both inguinal areas for bulges while the client is standing, if
possible.
ASSESSING THE FEMALE GENITALS AND INGUINAL AREA - First, have the client remain at rest.
- Next, have the client hold his breath and strain or bear down, as
PREPARATION though having a bowel movement.
1. Assemble equipment: 13. Palpate hernias.
- Clean gloves 14. Document findings in the client record.
- Drape
- Supplemental lighting, if needed
ASSESSING THE PERIPHERAL VASCULAR SYSTEM
PROCEDURE PROCEDURE
3. Provide for client privacy. Request the presence of another woman,
if desired, required by agency policy, or requested by client. 4. Inquire if the client has any history of the following:
4. Determine the client’s history of the following: - Heart disorders, varicosities, arterial disease, and hypertension
Age at onset of menstruation - Lifestyle patterns, specifically exercise patterns, activity patterns, and
- Last menstrual period (LMP) tolerance
- Regularity of cycle, duration, amount of daily flow, and whether - Smoking and use of alcohol
menstruation is painful
- Incidence of pain during intercourse Assessment
- Vaginal discharge Peripheral Pulses
- Number of pregnancies 1. Palpate the peripheral pulses on both sides of the client’s body
- Number of live births individually, simultaneously (except the carotid pulse), and
- Labor or delivery complications systematically to determine the symmetry of pulse volume. If you
- Urgency and frequency of urination at night have difficulty palpating some of the peripheral pulses, use a
- Blood in urine Doppler ultrasound probe.
- Painful urination
- Incontinence Peripheral Veins
- History of sexually transmitted disease, past and present 6. Inspect the peripheral veins in the arms and legs for the presence
and/ or appearance of superficial veins when limbs are dependent and
5. Cover the pelvic area with a sheet, or drape at all times when not when limbs are elevated.
actually being examined. Position the client supine, with feet 7. Assess the peripheral leg veins for signs of phlebitis.
elevated on the stirrups of an examination table. Alternately, assist - Inspect calves for redness and swelling over vein sites.
the client into the dorsal recumbent position with knees flexed and - Palpate the calves for firmness or tension of the muscles, edema over
thighs externally rotated. the dorsum of the foot, and areas of localized warmth.
- Push the calves from side to side.
6. Inspect the distribution, amount, and characteristics of the pubic hair. - Firmly dorsiflex the client’s foot while supporting entire leg in
7. Inspect the skin of the pubic area for parasites, inflammation, extension, or have the person stand or walk
swelling, and lesions. To assess pubic skin adequately, separate the
labia majora and labia minora. Peripheral Perfusion
8. Inspect the clitoris, urethral orifice, and vaginal orifice when 8. Inspect the skin of the hands and feet for color, temperature, edema,
separating the labia minora. and skin changes.
9. Palpate the inguinal lymph nodes. 9. Assess the adequacy of arterial flow if arterial insufficiency is
10. Document findings in the client record. suspected.
10. Document findings in the client record.

ASSESSING THE MALE GENITALS AND INGUINAL AREA

PREPARATION ASSESSING THE HEART AND CENTRAL VESSELS

1. Assemble equipment: PREPARATION

- Clean gloves 1. Assemble equipment:
- Stethoscope
PROCEDURE - Centimeter ruler
1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how he can PROCEDURE
cooperate. 4. Inquire if the client has any history of the following:
2. Perform hand hygiene, apply gloves, and observe other appropriate - Family history of incidence and age of heart disease, high
infection control procedures. cholesterol levels, high blood pressure, stroke, obesity, congenital
3. Provide for client privacy. Request the presence of another person if heart disease, arterial disease, hypertension, and rheumatic fever
desired, required by agency policy, or requested by client. - Client’s past history of rheumatic fever, heart murmur, heart
4. Inquire if the client has any history of the following: attack, varicosities, or heart failure
- Usual voiding patterns and any changes, bladder control, urinary - Present symptoms indicative of heart disease
incontinence, frequency, or urgency - Presence of diseases that affect heart
- Abdominal pain - Lifestyle habits that are risk factors for cardiac disease
- Symptoms of sexually transmitted disease
- Swellings that could indicate the presence of a hernia Assessment
- Family history of nephritis, malignancy of the prostate, or malignancy 5. Simultaneously inspect and palpate the precordium for the
of the kidney presence of abnormal pulsations, lifts, or heaves.
- Inspect and palpate the aortic and pulmonic areas, observing
5. Cover the pelvic area with a sheet, or drape at all times when not them at an angle and to the side, to note the presence or absence
actually being examined. of pulsations.
- Inspect and palpate the tricuspid area for pulsations and heaves
Assessment or lifts.
- Inspect and palpate the apical area for pulsation, noting its
Pubic Hair specific location (it may be displaced laterally or lower) and
6. Inspect the distribution, amount, and characteristics of pubic hair. diameter. If displaced laterally, record the distance between the
apex and the MCL in centimeters.
Penis - Inspect and palpate the epigastric area at the base of the
7. Inspect the penile shaft and glans penis for lesions, nodules, sternum for abdominal aortic pulsations.
swellings, and inflammation.
8. Inspect the urethral meatus for swelling, inflammation, and 6. Auscultate the heart in all four anatomic sites: aortic, pulmonic,
discharge. tricuspid, and apical (mitral).
Compress or ask the client to compress the glans slightly to open the
urethral meatus to inspect it for discharge. Carotid Arteries
- If the client has reported a discharge, instruct the client to strip the 7. Palpate the carotid artery. Use extreme caution.
penis from the base to the urethra. 8. Auscultate the carotid artery.
9. Palpate the penis for tenderness, thickening, and nodules. Use your
thumb and first two fingers. Jugular Veins
9. Inspect the jugular veins for distention. The client is placed in a
Scrotum semi-Fowler’s position, with head supported on a small pillow.
10. Inspect the scrotum for appearance, general size, and symmetry. 10. If jugular distention is present, assess the jugular venous
- To facilitate inspection of the scrotum during a physical examination, pressure (JVP).
ask the client to hold the penis out of the way. - Locate the highest visible point of distention of the internal jugular
vein.
- Measure the vertical height of this point in centimeters from the
sternal angle, the point at which the clavicles meet. 13. Auscultate normal breath sounds
- Repeat the steps above on the other side. - Tracheal or bronchial
11. Document findings in the client record. - Bronchovesicular
- Vesicular

Auscultate voice resonce

- Bronchophny
- Whispered pictoriloquy
- Egophony
ASSESSING THE THORAX AND LUNGS
1. Assemble equipment:
- Stethoscope ANTERIOR THORAX
- Skin marker/pencil 14. Inspect breathing pattern, shape, symmetry of anterior chest
- Centimeter ruler 15. Inspect the jugular notch and the costal angle (Costal angle -45-
- Tape measure 90 degrees –normal)
- Hospital gown (optional) 16. Palpate the anterior chest. Use Palpation pattern
- Clean gloves - Feel the temperature and moisture of the skin
17. Palpate the anterior chest for respiratory excursion.
PROCEDURE - Place the palms of your both hands on the 5th ribs , with your
6. Introduce yourself and verify the client’s identity. Explain to the fingers spread laterally at the rib cage and your thumbs at the
client what you are going to do, why it is necessary, and how the portion of the body of the sternum
client can cooperate. - Ask the client to take a deep breath while you observe the
7. Inquire if client has any history of the following: movement of the thumb of your hands, should move apart about
- Family history of illness, including cancer 3-5 cm and equal for a symmetrical chest.
- Allergies
- Tuberculosis 18. Palpate tactile fremitus in the same manner as for the posterior
- Lifestyle habits, such as smoking, and occupational hazards chest using palpation pattern
- Any medications being taken - (If the breasts are large and cannot be retracted adequately for
- Current problems such as swellings, coughs, wheezing, pain palpation, this part of the examination usually is omitted.)

4. Provide privacy …Hospital gown…Drape… 19. Percuss the anterior chest systematically using the percussion
5. Perform hand hygiene and observe other appropriate infection pattern, listen to percussion notes…resonance, dull, flat
control procedures. Wear gloves as needed - Begin above the clavicles in the supraclavicular space, and
proceed downward to the diaphragm.
Assessment - Compare one side of the lung to the other
Posterior Thorax - Displace female breasts for proper examination.
5. Inspect the shape and symmetry of the thorax from posterior and
lateral views. Compare the anteroposterior diameter to the 20. Auscultate the trachea.
transverse diameter. Measure… 21. Auscultate the anterior chest.
- Use the sequence same pattern as in percussion, beginning over
7. Inspect the spinal alignment for deformities. the trachea at the side of the neck between the sternum and up to
- Have the client stand. From a lateral position, observe the three the level of the diaphragm.
normal curvatures: cervical, thoracic, and lumbar.
- To assess for lateral deviation of the spine (scoliosis), observe the Auscultate normal breath sounds
standing client from the rear. Have the client bend forward at the waist - Tracheal/Bronchial
and observe from behind. - Bronchovesicular
- Vesicular
8. Palpate the posterior thorax. Auscultate adventitious breath sounds
- For clients who have no respiratory complaints, rapidly assess the a. Wheeze
temperature and integrity of all chest skin. b. Stridor
- For clients who do have respiratory complaints, palpate all chest c. Rhonchi
areas for bulges, tenderness, or abnormal movements. Avoid deep d. Crackles or rales
palpation for painful areas, especially if a fractured rib is suspected. e. Pleural friction rub

22. Document findings in the client record.

9. Palpate the posterior chest for respiratory excursion. a. Mental status- conscious, GCS- 15
- Place the palms of your both hands over the 7th vertebrae, with your Color –not pale, no cyanosis
thumbs adjacent to the spine and your fingers spread laterally. Ask the Eyes – no abnormal findings
client to take a deep breath while you observe the movement of the Lips- no circum-oral cyanosis, no pursed lip breathing
thumbs of your hands to approximately 3-5 cms. With no lag in the Nose- not flaring, no polyps, no redness, no discharges
movement is considered symmetrical. Mouth-no swelling at the base of the tongue
Throat – no redness, no swelling
10. Palpate the chest for vocal (tactile) fremitus. Neck –no tracheal deviation
- Place the surfaces of your fingertips or the base of palm of your (Inspection)No scars, no previous chest surgery or injury no chest
hand or closed fist on the posterior chest, follow pattern for chest /spinal deformities, eupnea – 16 BPM
palpation (Palpation) Respiratory excursion – 4cm. tactile fremitus- negative
- Ask the client to say the words as “blue moon” or “one, two, three.” (Percussion) Diaphragmatic excursion -4cm. Both sides
Repeatedly as you move your hands downward following the pattern. (Auscultation) Breath/Lung sounds – normal in all sites, no
- Compare the fremitus on both lungs and between the apex and the adventitious sound, and voice resonance – negative
base of each lung, either 1) using one hand and moving it from one Clients, response / reactions:
side of the client to the corresponding area on the other side or 2) Cooperative, but a bit shy
using two hands that are placed simultaneously on the corresponding
areas of each side of the chest. b) Date and time performed; the primary care provider’s name and
signature
11. Percuss the thorax. Follow pattern for posterior chest
12. Percuss for diaphragmatic excursion.
a. Start at the apex right side , tap the posterior chest downwards as ASSESSING THE SKULL AND FACE
you hear the resonance sound (normal lung) note as it change to dull , PROCEDURE
put a mark (you are now at the level of the diaphragm .) Ask the client 1. Introduce yourself and verify the client’s identity. Explain to the client
to inhale deeply while percussing downward, mark where the dull what you are going to do, why it is necessary, and how the client can
sound stops. Ask the client now to exhale while percussing upward and cooperate.
mark where the dull sound stops. Measure the upper mark and the 2. Perform hand hygiene and observe other appropriate infection
lower mark. The distance is approx... 3-5 cms. Means normal control procedures.
diaphragm movement. Repeat to the left side. 3. Provide for client privacy.
4. Inquire if the client has any history of the following:
12. Auscultate the chest using the (flat-disc) diaphragm of the - Lumps or bumps, itching, scaling, or dandruff
stethoscope. - Loss of consciousness, dizziness, seizures, headache, facial pain, or
- Use the systematic Percussion pattern procedure. injury
- Ask the client to take slow, deep breaths through the nose. Listen
at each point to the breath sounds during a complete inspiration If so, ascertain the following:
and expiration. - When and how any lumps occurred
- Compare findings at each point with the corresponding point on - Length of time any other problem existed
the opposite side of the chest. - Any known cause of any problem
- Associated symptoms, treatment, and recurrences Ask the client to:
- Move chin to the chest. (Determines function of the
Assessment sternocleidomastoid muscle.)
5. Inspect the skull for size, shape, and symmetry. - Move head back so that the chin points upward. (Determines
6. Palpate the skull for nodules or masses and depressions. function of the trapezius muscle.)
- Use a gentle rotating motion with the fingertips. Begin at the front and - Move head so that the ear is moved toward the shoulder on each
palpate down the midline, then palpate each side of the head. side. (Determines function of the sternocleidomastoid muscle.)
6. Inspect the facial features. - Turn head to the right and to the left. (Determines function of the
7. Inspect the eyes for edema and hollowness. sternocleidomastoid muscle.)
8. Note symmetry of facial movements. 7. Assess muscle strength.
- Ask the client to elevate the eyebrows, frown, or lower the Ask the client to:
eyebrows, close the eyes tightly, puff the cheeks, and smile and - Turn head to one side against the resistance of your hand.
show teeth. Repeat with the other side.
9. Document findings in the client record. - Shrug shoulders against the resistance of your hands.

Lymph Nodes
ASSESSING THE NOSE AND SINUSES 1. Palpate the entire neck for enlarged lymph nodes.
PREPARATION
1. Assemble equipment: Trachea
- Nasal speculum 2. Palpate the trachea for lateral deviation.
- Flashlight/penlight\ - Place your fingertip or thumb on the trachea in the suprasternal
notch, then move your finger laterally to the left and the right in
PROCEDURE spaces bordered by the clavicle, the anterior aspect of the
sternocleidomastoid muscle, and the trachea.
1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how the client can
Thyroid Gland
cooperate. 3. Inspect the thyroid gland.
2. Perform hand hygiene and observe other appropriate infection - Stand in front of the client.
control procedures. - Observe the lower half of the neck overlying the thyroid gland for
3. Provide for client privacy. symmetry and visible masses.
4. Inquire if the client has any history of the following: - Ask the client to hyperextend head and swallow. If necessary,
- Allergies offer a glass of water to make it easier for the client to swallow.
- Difficulty breathing through the nose 4. Palpate the thyroid gland for smoothness.
- Sinus infections - Note any areas of enlargement, masses, or nodules.
- Injuries to nose or face
- Nosebleeds 12. If enlargement of the gland is suspected:
- Any medications taken - Auscultate over the thyroid area for a bruit.
- Use the bell-shaped diaphragm of the stethoscope.
- Any changes in sense of smell
13. Document findings in the client record.
5. Position the client comfortably—seated, if possible.
ASSESSING THE SKIN
Assessment
Nose PREPARATION
6. Inspect the external nose for any deviations in shape, size, or color 1. Assemble equipment:
and flaring, or discharge from the nares. - Millimeter ruler
7. Lightly palpate the external nose to determine any areas of - Examination gloves
tenderness, masses, or displacements of bone and cartilage. - Magnifying glass
8. Determine patency of both nasal cavities.
- Ask the client to close the mouth, exert pressure on one naris, and PROCEDURE
breathe through the opposite naris. Repeat the procedure to assess 4. Inquire if client has any history of the following:
patency of the opposite naris. - Pain or itching
- Presence and spread of any lesions, bruises, abrasions, or
9. Inspect the nasal cavities using a flashlight or a nasal speculum. pigmented spots
- Hold the speculum in your right hand and inspect the client’s left - Skin problems
nostril, and in your left hand to inspect the client’s right nostril. - Associated clinical signs
- Tip the client’s head back. - Problems in other family members
- Facing the client, insert the tip of the closed speculum about 1 cm, or - Related systemic conditions
up to the point at which the blade widens. Care must be taken to avoid - Use of medications, lotions, or home remedies
pressure on the sensitive nasal septum. - Excessively dry or moist feel to the skin
- Stabilize the speculum with your index finger against the side of the - Tendency to bruise easily
nose. Use the other hand to position the head and then to hold the - Any association of the problem to a season of the year
light.
- Open the speculum as much as possible and inspect the floor of the Assessment
nose, the anterior portion of the septum, the middle meatus, and the 9. Inspect skin color.
middle turbinate’s. The posterior turbinate rarely is visualized because 10. Inspect uniformity of skin color.
of its position. 11. Assess edema, if present.
- Inspect the lining of the nares and the integrity and the position of the 12. Inspect, palpate, and describe skin lesions. Apply gloves if lesions
nasal septum. are open or draining.
- Describe lesions according to location, distribution, color,
10. Observe for the presence of redness, swelling, growths, and configuration, size, shape, type, or structure.
discharge. 13. Observe and palpate skin moisture.
11. Inspect the nasal septum between the nasal chambers. 14. Palpate skin temperature.
- Compare the two feet and the two hands, using the backs of your
Facial Sinuses fingers.
12. Palpate the maxillary and frontal sinuses for tenderness. 15. Note skin turgor by lifting and pinching the skin on an extremity.
13. Document findings in the client record. 16. Document findings in the client record. Draw the location of skin
lesions on body surface diagrams.

ASSESSING THE NECK

8. Inquire if the client has any history of the following: ASSESSING THE NAILS
- Any problems with neck lumps PROCEDURE
- Neck pain or stiffness 4. Inquire if the client has any history of the following:
- When and how any lumps occurred - Diabetes mellitus
- Any diagnoses of thyroid problems - Peripheral circulatory disease
- Any treatments such as surgery or radiation - Previous injury
- Severe illness
Assessment
Neck Muscles Assessment
5. Inspect the neck muscles (sternocleidomastoid and trapezius) for 5. Inspect fingernail plate shape to determine its curvature and
abnormal swellings or masses. Ask the client to hold head erect. angle.
6. Observe head movement. 6. Inspect fingernail and toenail texture.
 7. Inspect fingernail and toenail bed color. - Stay with the client until all medications have been swallowed
8. Inspect tissues surrounding nails. - Dispose of all supplies appropriately.
9. Perform blanch test of capillary refill
- Press two or more nails between your thumb and index finger; Finally,
look for blanching and return of pink color to nail bed. - Document each medication given
10. Document findings in the client record. - Evaluate the effects of the medication.

ASSESSING BODY TEMPERATURE

Assess:
- Clinical signs of fever.
ASSESSING THE HAIR - Clinical signs of hypothermia.
PREPARATION - Site most appropriate for measurement.
1. Assemble equipment: - Factors that might alter core body temperature.
- Clean gloves Assemble equipment:
- Thermometer
PROCEDURE - Thermometer sheath or cover
4. Inquire if client has any history of the following: - Water-soluble lubricant for a rectal temperature
- Recent use of hair dyes, rinses, or curling or straightening - Disposable gloves
preparations - Towel for axillary temperature or tissues/wipes
- Recent chemotherapy
- Presence of disease
PROCEDURE
Assessment
1. Introduce yourself and verify the client’s identity. Explain to the
5. Inspect the evenness of growth over the scalp.
client what you are going to do, why it is necessary, and how the
6. Inspect hair thickness or thinness.
7. Inspect hair texture and oiliness. client can cooperate.
8. Note presence of infections or infestations by parting the hair in 2. Perform hand hygiene and observe other appropriate infection
several areas and checking behind the ears and along the hairline control procedures.
at the neck. 3. Provide for client privacy.
9. Inspect the amount of body hair. 4. Place the client in the appropriate position.
10. Document findings in the client record. 5. Place the thermometer.
- Apply a protective sheath or probe cover, if appropriate.
- Lubricate a rectal thermometer.
ADMINISTERING ORAL MEDICATIONS 6. Wait the appropriate amount of time.
Assess for: - Electronic and tympanic thermometers will indicate that the
- Allergies to medications reading is complete via a light or tone.
- Client’s ability to swallow the medication - Check package instructions for length of time to wait prior to
- Presence of vomiting or diarrhea that would interfere with the reading chemical dot or tape thermometers.
ability to absorb the medication 7. Remove the thermometer and discard the cover, or wipe with a
- Specific drug action, side effects, interactions, and adverse tissue, if necessary.
reactions 8. Read the temperature.
- Client’s knowledge of and learning needs about the medication - If the temperature is obviously too high, too low, or inconsistent
Then, with the client’s condition, recheck it with a thermometer known to
- Perform appropriate assessments specific to the medication and be functioning properly.
- Determine if the assessment date influences the administration of
9. Wash the thermometer, if necessary, and return it to the storage
the medication location.

Assemble equipment and supplies: 10. Document the temperature in the client record.
- Medication administration record (MAR)
- Disposable medication cups: plastic cups for tablets and capsules
- Plastic calibrated medication cups for liquids
ASSESSING RESPIRATIONS
- Drinking glass and water
Assess:
For the procedure
1. Check the MAR - Skin and mucous membrane color.
2. Verify the client’s ability to take medications orally - Position assumed for breathing.
3. Organize the supplies - Signs of cerebral anoxia.
4. Perform hand hygiene - Chest movements.
- Activity tolerance.
5. Compare the label of the medication container with the order
- Chest pain.
on the MAR
- Dyspnea.
6. Check the expiration date of the medication
- Medications affecting respiratory rate.
7. Prepare the medication
8. Provide for client privacy Assemble equipment:

When preparing tablets or capsules for administration Watch with a second hand or indicator
- Place packaged unit–dose capsules or tablets directly into the
PROCEDURE
medicine cup.
- If using a stock container, pour the required number into the bottle 1. Identify yourself and verify the client’s identity. Explain to the client
cap, then transfer the medication to the disposable cup without what you are going to do, why it is necessary, and how the client can
touching the tablets. cooperate.

When preparing liquid medications 2. Perform hand hygiene and observe other appropriate infection
- Thoroughly mix the medication before pouring. control procedures.
- Remove the cap and place it upside down on the countertop.
3. Provide for client privacy.
- Hold the bottle so the label is next to your palm, and pour the
medication away from the label. 4. Observe or palpate and count the respiratory rate.
- Place the medication cup at eye level and fill it to the desired
level, using the bottom of the meniscus to align with the container - If you anticipate the client’s awareness of respiratory assessment,
scale. place a hand against the client’s chest to feel the chest movements
- Before capping the bottle, wipe the lip with a paper towel. with breathing, or place the client’s arm across the chest and observe
the chest movements while supposedly taking the radial pulse.
Place the prepared medications and MAR together and prepare
the client: - Count the respiratory rate for 30 seconds if the respirations are
- Check the client’s identification band. regular. Count for 60 seconds if they are irregular. An inhalation and an
- Assist client to a sitting position. exhalation count as one respiration.

Explain the purpose of the medication and how it will help, using 5. Observe the depth, rhythm, and character of respirations.
language that the client can understand. Include relevant
- Observe the respirations for depth by watching the movement of the
information about effects. Then,
chest.
- Administer the medication at the correct time.
- Give the client sufficient water to swallow the medication - Observe the respirations for regular or irregular rhythm.
- Observe the character of respirations—the sound they produce and - Apical, at the apex of the heart. In an adult this is located on the
the effort they require. left side of the chest, about 8 cm (3 in) to the left of the sternum
(breastbone) and at the fourth, fifth, or sixth intercostal space.
6. Document the respiratory rate, depth, rhythm, and character on the Apical pulse is used routinely for infants and children up to 3
appropriate record. years of age, used to determine discrepancies with radial pulse,
and used in conjuction with some medications.)

1. Assess:
- Clinical signs of cardiovascular alterations.
- Factors that might alter pulse rate.
- Site most appropriate for assessment.

2. Assemble equipment:
ASSESSING AN APICAL PULSE - Watch with a second hand or indicator
- Disposable gloves
Assess:

- Clinical signs of cardiovascular alterations. PROCEDURE

- Factors that might alter pulse rate.
1. Introduce yourself and verify the client’s identity. Explain to the client
Assemble equipment: what you are going to do, why it is necessary, and how the client can
cooperate.
- Watch with a second hand or indicator
- Stethoscope 2. Perform hand hygiene and observe other appropriate infection
- Antiseptic wipe control procedures. Don gloves.

If using Doppler Ultrasound (DUS), assemble the transducer probe, the 3. Provide for client privacy.
stethoscope headset, transmission gel, and tissues/wipes.
4. Select the pulse point. Pulse points can be found in the groin or
PROCEDURE femoral area, popliteal or back of the knee, posterior tibialis or ankle
and dorsalis pedis or foot.
1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how the client can 5. Assist the client to a comfortable resting position.
cooperate.
6. Palpate and count the pulse. Place two or three middle fingertips
2. Perform hand hygiene and observe other appropriate infection lightly and squarely over the pulse point.
control procedures.
7. Assess the pulse rhythm and volume.
3. Provide for client privacy.
- Count the pulse for 60 seconds
4. Position the client appropriately in a comfortable supine position or
assist to a sitting position. Expose the area of the chest over the apex - Remove and dispose gloves
of the heart.
8. Document the pulse rate, rhythm, and volume, and your actions in
5. Locate the apical impulse. the client record.

- Palpate the angle of Louis, just below the suprasternal notch and felt
as a prominence.
ASSESSING BLOOD PRESSURE
- Slide your index finger just to the left of the client’s sternum and
Assess:
palpate the second intercostal space.
- Signs and symptoms of hypertension.
- Place your middle or next finger in the third intercostal space and
- Signs and symptoms of hypotension.
continue palpating downward until you locate the fifth intercostal space.
- Factors affecting blood pressure.
- Move your index finger laterally along the fifth intercostal space - Client for allergy to latex cuff.
towards the MCL. Normally, the apical impulse is palpable at or just - Assemble equipment:
medial to the MCL. - Stethoscope or DUS
- Blood pressure cuff of the appropriate size
6. Auscultate and count heartbeats. - Sphygmomanometer

- Use antiseptic wipes to clean the earpieces and diaphragm of the PROCEDURE
stethoscope.
1. Identify yourself and verify the client’s identity. Explain to the client
- Warm the diaphragm of the stethoscope by holding it in the palm of what you are going to do, why it is necessary, and how the client can
your hand for a moment. cooperate.

- Insert the earpieces of the stethoscope into your ears in the direction 2. Perform hand hygiene and observe other appropriate infection
of the ear canals, or slightly forward, to facilitate hearing. control procedures.

- Tap your finger lightly on the diaphragm to be sure it is the active side 3. Provide for client privacy.
of the head.
4. Position the client appropriately.
- Place the diaphragm of the stethoscope over the apical impulse and
listen for the normal S1 and S2 heart sounds. - The adult client should be sitting unless otherwise specified. Both
feet should be flat on the floor.
- If you have difficulty hearing the apical pulse, ask the supine client to
roll onto left side, or the sitting client to lean slightly forward. - The elbow should be slightly flexed, with the palm of the hand facing
up and the forearm supported at heart level.
- If the rhythm is regular, count the heartbeats for 30 seconds and
multiply by 2. If the rhythm is irregular, count the beats for 60 seconds. - Expose the upper arm.

7. Assess the rhythm and the strength of the heartbeat. 5. Wrap the deflated cuff evenly around the upper arm. Locate the
brachial artery. Apply the center of the bladder directly over the artery.
- Assess the rhythm of the heartbeat by noting the pattern of intervals
between the beats. - For an adult, place the lower border of the cuff approximately 2.5 cm
(1 inch) above the antecubital space.
- Assess the strength (volume) of the heartbeat.
6. If this is the client’s initial examination, perform a preliminary
palpatory determination of systolic pressure.

7. Palpate the brachial artery with the fingertips.

ASSESSING A PERIPHERAL PULSE 8. Close the valve on the bulb.
- The pulse is a wave of blood created by contraction of the left 9. Pump up the cuff until you no longer feel the brachial pulse. Note the
ventricle of the heart. Generally the pulse wave represents the pressure on the sphygmomanometer at which pulse is no longer felt.
stroke volume output or the amount of blood that enters the
arteries with each ventricular contraction. 10. Release the pressure completely in the cuff and wait 1–2 minutes
before taking further measurements.
11. Position the stethoscope appropriately. 1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how the client can
12. Cleanse the earpieces with antiseptic wipe. cooperate.
2. Perform hand hygiene and observe other appropriate infection
13. Insert the ear attachments of the stethoscope in your ears so that control procedures.
they tilt slightly forward. 3. Provide for client privacy.
4. Inquire if the client has any history of the following:
- Ensure that the stethoscope hangs freely from the ears to the
- Family history of diabetes, hypertension, or blood dyscrasia
diaphragm.
- Eye disease, injury, or surgery
14. Place the bell side of the amplifier of the stethoscope over the - Last visit to an ophthalmologist
brachial pulse. Place stethoscope directly on skin, not on clothing over - Current use of eye medications
the site. Hold the diaphragm with the thumb and index finger. - Use of contact lenses or eyeglasses
- Hygienic practices for corrective lenses
15. Auscultate the client’s blood pressure. - Current symptoms of eye problems

16. Pump up the cuff until the sphygmomanometer is 30 mm Hg above Assessment

the point where the brachial pulse disappeared.
External Eye Structures
17. Release the valve on the cuff carefully so that the pressure
decreases at the rate of 2–3 mm Hg per second. 5. Inspect the eyebrows for hair distribution and alignment, and for skin
quality and movement.
- As the pressure falls, identify the manometer reading at Korotkoff
phases I, IV, and V. 6. Inspect the eyelashes for evenness of distribution and direction of
curl.
18. Deflate the cuff rapidly and completely.
7. Inspect the eyelids for surface characteristics, position in relation to
- Wait 1–2 minutes before making further determinations. the cornea, ability to blink, and frequency of blinking. Inspect the lower
eyelids while the client’s eyes are closed.
- Repeat the above steps once or twice as necessary to confirm the
accuracy of the reading. 8. Inspect the bulbar conjunctiva for color, texture, and the presence of
lesions.
19. If this is the client’s initial examination, repeat the procedure on the
client’s other arm. 9. Inspect the palpebral conjunctiva by everting the lids.

10. Evert the upper lids if a problem is suspected.

Variation: Obtaining a Blood Pressure by the Palpation Method - Ask the client to look down while keeping the eyelids slightly open.

Procedure - Gently grasp the client’s eyelashes with thumb and forefinger. Pull
lashes gently downwards.
- Palpate the radial or brachial pulse site as the cuff pressure is
released. The manometer reading at the point where the pulse - Place a cotton-tipped applicator stick about 1cm above the lid margin
reappears represents a value between auscultated systolic and and push it gently downward while holding the eyelashes.
diastolic values.
- Hold the margin of the everted lid or eyelashes against the ridge of
Variation: Taking a Thigh Blood Pressure the upper bony orbit with the applicator stick or your thumb.

Procedure - Inspect the conjunctiva for color, texture lesions, and foreign bodies.

- Help the client to assume a prone position. If the client cannot 11. Inspect and palpate the lacrimal gland.
assume this position, measure the blood pressure while the client
is in a supine position with the knee slightly flexed. Slight flexing - Using the tip of your index finger, palpate the lacrimal gland.
of the knee will facilitate placing the stethoscope on the popliteal
space. - Observe for edema between the lower lid and the nose.
- Expose the thigh, taking care not to expose the client unduly.
12. Inspect and palpate the lacrimal sac and nasolacrimal duct.
- Locate the popliteal artery.
- Wrap the cuff evenly around the midthigh with the compression - Observe for evidence of increased tearing.
bladder over the posterior aspect of the thigh and the bottom
edge above the knee. - Using the tip of your index finger, palpate inside the lower orbital rim
near the inner canthus.
If this is the client’s initial examination, perform a preliminary palpatory
determination of systolic pressure by palpating the popliteal artery. 13. Inspect the cornea for clarity and texture. Ask the client to look
straight ahead. Hold a penlight at an oblique angle to the eye and
In adults, the systolic pressure in the popliteal artery is usually 20–30 move the light slowly across the corneal surface.
mm Hg higher than that in the brachial artery because of use of a
larger bladder; the diastolic pressure usually is the same. 14. Perform the corneal sensitivity (reflex) test to determine the
function of the fifth (trigeminal) cranial nerve. Ask the client to keep
both eyes open and look straight ahead. Approach from behind and
Variation: Using an Electronic Indirect Blood Pressure Monitoring beside the client, and lightly touch the cornea with a corner of the
Device gauze.
Procedure 15. Inspect the anterior chamber for transparency and depth. Use the
same oblique lighting used when testing the cornea.
- Place the blood pressure cuff on the extremity according to the
manufacturer’s guidelines. 16. Inspect the pupils for color, shape, and symmetry of size.
- Turn on the blood pressure switch.
- If appropriate, set the device for the desired number of minutes 17. Assess each pupil’s direct and consensual reaction to light.
between blood pressure determinations.
- When the device has determined the blood pressure reading, - Partially darken a room.
note the digital results.
- Remove the cuff. - Ask the client to look straight ahead.
- Wipe the cuff with an approved disinfectant.
- Document and report pertinent assessment data according to - Using a penlight and approaching from the side, shine a light on the
agency policy. pupil.

- Observe the response. The pupil should constrict (direct response).

ASSESSING THE EYE STRUCTURES AND VISUAL ACUITY
- Shine the light on the pupil again and observe the response of the
1. Assemble equipment and supplies: other pupil. It should also constrict (consensual response).
- Cotton-tipped applicator
18. Assess each pupil’s reaction to accommodation.
- Examination gloves
- Millimeter ruler - Hold an object about 10 cm from the client’s nose.
- Penlight
- Snellen’s or E chart - Ask the client to look first at the top of the object and then at a distant
- Opaque card object behind the penlight. Alternate the gaze between the near and far
PROCEDURE objects.
- Observe the pupil response. Pupils should constrict when looking at 3. Provide for client privacy.
the near object and dilate when looking at the far object.
4. Inquire if the client has any history of the following:
- Next, move the penlight or pencil toward the client’s nose. The pupils - Family history of hearing problems or loss
should converge. To record normal assessment of the pupils, use the - Presence of any ear problems or pain
abbreviation PERRLA. - Medication history, especially if there are complaints of ringing in ears
- 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
Visual Fields obtained
5. Position the client comfortably—seated, if possible.
1. Assess peripheral visual fields.
- Have the client sit directly facing you at a distance of 60–90 cm. Assessment
- Ask the client to cover right eye with the card and look directly at
your nose. Auricles
- Cover or close your eye directly opposite the client’s covered eye
and look directly at the client’s nose. 6. Inspect the auricles for color, symmetry of size, and position. To
- Hold an object in your fingers, extend your arm, and move the inspect position, note the level at which the superior aspect of the
object into the visual field from various points in the periphery. auricle attaches to the head with relation to the eye.
The object should be at an equal distance from the client and
yourself. Ask the client to tell you when the moving object is first 7. Palpate the auricles for texture, elasticity, and areas of tenderness.
spotted.
- Gently pull the auricle upward, downward, and backward.
 To test the temporal field of the left eye, extend and move
your right arm in from the client’s right periphery. Temporally, - Fold the pinna forward. (It should recoil.)
peripheral objects can be seen at right angles to the central
point of vision. - Push in on the tragus.
 To test the upward field of the left eye, extend and move the
right arm down from the upward periphery. The upward field - Apply pressure to the mastoid process.
of vision is normally 50 degrees because the orbital edge is
in the way. External Ear Canal and Tympanic Membrane
 To test the downward field of the left eye, extend and move
8. Using an otoscope, inspect the external ear canal for cerumen, skin
the right arm up from the lower periphery. The downward
lesions, pus, and blood.
field of vision is normally 70 degrees because the cheekbone
is in the way. - Attach a speculum to the otoscope.
 To test the nasal field of the left eye, extend and move your
left arm in from the periphery. The nasal field of vision is - Tip the client’s head away from you and straighten the ear canal.
normally 50 degrees away from the central point because
the nose is in the way. - Hold the otoscope either right side up, with your fingers between the
otoscope handle and the client’s head, or upside down, with your
Repeat the above steps for the right eye. fingers and the ulnar surface of your hand against the client’s head.

- Gently insert the tip of the otoscope into the ear canal, avoiding
pressure by the speculum against either side of the ear canal.
Extraocular Muscle Tests
9. Inspect the tympanic membrane for color and gloss.
2. Assess six ocular movements to determine eye alignment and
coordination.
- Stand directly in front of client and hold the penlight at a Gross Hearing Acuity Tests
comfortable distance, such as 30 cm in front of the client’s eyes.
- Ask the client to hold head in a fixed position facing you and 10. Assess the client’s response to normal voice tones. If the client has
follow the movements of the penlight with the eyes only. difficulty hearing the normal voice, proceed with the following tests.
- Move the penlight in a slow, orderly manner through the six
cardinal fields of gaze. Perform the watch tick test.
- Stop the movement s of the penlight periodically so that the
- Have the client occlude one ear. Out of the client’s sight, place a
nystagmus can be detected.
ticking watch 2–3 cm (1–2 inches) from the unoccluded ear.
21. Assess for location of light reflex by shining a penlight on the pupil - Ask what the client can hear. Repeat with the other ear.
in corneal surface (Hirschberg Test).
Tuning Fork Tests
22. Have the client fixate on a near or far object. Cover one eye and
Perform Weber test.
observe for movement in the uncovered eye (cover test).
- Hold the tuning fork at its base. Activate it by tapping the fork
gently against the back of your hand near the knuckles or by
Visual Acuity stroking the fork between your thumb and index finger
- Place the base of the vibrating fork on top of the client’s head and
23. Assess near vision by providing adequate lighting and asking the ask whether the client hears the noise.
client to read from a magazine or newspaper.
Conduct Rinne test.
24. Assess distance vision by asking the client to wear corrective
lenses unless they are used for reading only. - Ask the client to block the hearing in one ear intermittently by
moving a fingertip in and out of the ear canal.
- Ask the client to sit or stand 6 meters (20 ft) from Snellen’s chart, - Hold the handle of the activated tuning fork on the mastoid
cover the eye not being tested, and identify the letters or characters. process of one ear until the client states that the vibration no
longer can be heard.
- Take three readings: right eye, left eye, and both eyes. - Immediately hold still the vibrating fork prongs in front of the
client’s ear canal. If necessary, push aside the client’s hair. Ask
25. Perform functional vision tests if the client is unable to see the top whether the client now hears the sound.
line (20/200) of Snellen’s chart. 1. Document findings in the client record.
26. Document findings in the client record.
ASSESSING THE BREAST AND AXILLA

1. Assemble equipment:
ASSESSING THE EARS AND HEARING
- Centimeter ruler
1. Assemble equipment:
PROCEDURE
- Otoscope with several sizes or ear specula
1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how she can
PROCEDURE cooperate.

1. Introduce yourself and verify the client’s identity. Explain to the client 2. Perform hand hygiene and observe other appropriate infection
what you are going to do, why it is necessary, and how the client can control procedures.
cooperate.
3. Provide for client privacy.
2. Perform hand hygiene and observe other appropriate infection
4. Inquire if the client has any history of the following:
control procedures.
- Breast masses, and what was done about them 2. Perform hand hygiene and observe other appropriate infection
control procedures.
- Any pain or tenderness in the breasts and relation to the woman’s
menstrual cycle 3. Provide for client privacy.

- Any discharge from the nipple 4. Determine the client’s history of the following:
- Incidence of abdominal pain: its location, onset, sequence, and
- Medication history chronology; its quality (description); its frequency; associated
symptoms
- Estrogen replacement therapy - Bowel habits
- Incidence of constipation or diarrhea
- Mother, sister, aunt with breast cancer
- Change in appetite
- Alcohol consumption - Food intolerances
- Foods ingested in last 24 hours
- High-fat diet - Specific signs and symptoms
- Previous problems and treatment
- Obesity 5. Assist the client to a supine position, with the arms placed
comfortably at the sides.
- Use of oral contraceptive
- Place small pillows beneath the knees and the head to reduce
- Menarche before age 12 tension in the abdominal muscles. Expose only the client’s abdomen
from chest line to the pubic area to avoid chilling and shivering, which
- Menopause after age 55
can tense the abdominal muscles.
- Pregnancy after age 30
Assessment
- Breast self-examination; technique used and when performed in
Inspection of the Abdomen
relation to the menstrual cycle
6. Inspect the abdomen for skin integrity.
Assessment 7. Inspect the abdomen for contour and symmetry.
- Observe the abdominal contour while standing at the client’s side
5. Inspect the breasts for size, symmetry, and contour or shape while when the client is supine.
the client is in a sitting position. - Ask the client to take a deep breath and to hold it.
- Assess the symmetry of contour while standing at the foot of the bed.
6. Inspect the skin of the breast for localized discolorations or - If distention is present, measure the abdominal girth by placing a tape
hyperpigmentation, retraction or dimpling, localized hyper vascular around the abdomen at the level of the umbilicus.
areas, swelling, or edema. 8. Observe abdominal movements associated with respiration,
peristalsis, or aortic pulsations.
7. Emphasize any retraction by having the client: 9. Observe the vascular pattern.
- Raise arms above head;
- Push the hands together, with elbows flexed; and Auscultation of the Abdomen
- Press hands down on hips. 9. Auscultate the abdomen for bowel sounds, vascular sounds, and
peritoneal friction rubs.
8. Inspect the areola area for size, shape, symmetry, color, surface
characteristics, and any masses or lesions. Percussion of the Abdomen
10. Percuss several areas in each of the four quadrants to determine
presence of tympany and dullness.
9. Inspect the nipples for size, shape, position, color, discharge, and
- Use a systematic pattern: Begin in the lower left quadrant, then
lesions.
proceed to the lower right quadrant, the upper right quadrant, and
10. Palpate the axillary, subclavicular, and supraclavicular lymph the upper left quadrant.
nodes.
Percussion of the Liver
- The client is seated with her arms abducted and supported on the 11. Percuss the liver to determine its size.
nurse’s forearm.

- Use the flat surfaces of all fingertips to palpate the four areas of the Palpation of the Abdomen
axilla: 12. Perform light palpation first to detect areas of tenderness and/or
muscle guarding.
The edge of the greater pectoral muscle along the anterior axillary line - Systematically explore all four quadrants.
13. Perform deep palpation over all four quadrants
- The thoracic wall in the midaxillary area
- The upper part of the humerus
- The anterior edge of the latissimus dorsi muscle along the Palpation of the Liver
posterior axillary line 14. Palpate the liver to detect enlargement and tenderness.

11. Palpate the breast for masses, tenderness, and any discharge from Palpation of the Bladder
the nipples. 1. Palpate the area above the pubic symphysis if the client’s history
indicates possible urinary retention.
12. Palpate the areola and the nipples for masses. 2. Document findings in the client record.
ASSESSING THE MUSCULOSKELETAL SYSTEM
- Compress each nipple to determine the presence of any discharge. If 1. Assemble equipment:
discharge is present, milk the breast along its radius to identify the - Goniometer
discharge-producing lobe.

- Assess any discharge for amount, color, consistency, and odor. PROCEDURE

- Note any tenderness on palpation. 1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how the client can
13. Teach the client the technique for breast self-examination cooperate.

14. Document findings in the client record. 2. Perform hand hygiene and observe other appropriate infection
control procedures.

ASSESSING THE ABDOMEN 3. Provide for client privacy.

1. Assemble equipment: 4. Inquire if client has any history of the following:

- Examining light
- Tape measure (metal or unstretchable cloth) - Muscle pain: onset, location, character, associated phenomena,
- Water-soluble skin-marking pencil and aggravating and alleviating factors
- Stethoscope - Any limitations to movement or inability to perform activities of
daily living
PROCEDURE - Previous sports injuries
- Any loss of function without pain
1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do, why it is necessary, and how the client can
cooperate.
ASSESSMENT
Muscles
5. Inspect the muscles for size.
- Compare each muscle on one side of the body to the same
muscle on the other side. For any apparent discrepancies,
measure the muscles with a tape.

6. Inspect the muscles and tendons for contractures.

7. Inspect the muscles for tremors.

- Inspect any tremors of the hands and arms by having the client
hold arms out in front of body.
8. Palpate muscles at rest to determine muscle tonicity.
9. Palpate muscles while the client is active and passive for flaccidity,
spasticity, and smoothness of movement.

10. Test muscle strength. Compare the right side with left side.

Bones
11. Inspect the skeleton for normal structure and deformities.

12. Palpate the bones to locate any areas of edema or tenderness.

Joints
13. Inspect the joint for swelling.
- Palpate each joint for tenderness, smoothness of movement,
swelling, crepitation, and presence of nodules.
14. Assess joint range of motion.
- Ask the client to move selected body parts. If available, use a
goniometer to measure the angle of the joint in degrees.
15. Document findings in the client record.