Republic of the Philippines

Bulacan State University

City of Malolos

NCM 107B RLE

Care of the Mother, Child and Adolescent

UNIT 3: PHYSICAL ASSESSMENT

Prepared by:

MART JUARESA C. YAMBAO, MAN, RN

EDWIN MENDOZA, MAN, RN

JOSEPH RAINIER ARRIOLA, RN

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 Table of Contents

Unit 3: Level 1 Competencies: Physical Assessment .................................................. 2

Lesson 1: General Survey ....................................................................................................... 5
Lesson 2: Integumentary Assessment .................................................................................. 9
Lesson 3: Head, Eyes, Ears, and Nose Assessment ....................................................... 13
Lesson 4: Mouth, Neck Thorax Assessment...................................................................... 22
Lesson 5: Cardiovascular, Breast and Axillae Assessment ............................................. 33
Lesson 6: Abdomen and Musculoskeletal Assessment ................................................... 38
Lesson 7: The Performance Checklist ............................................................................... 46
Answer Key............................................................................................................................. 52

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Unit 3: Level 1 Competencies: Physical Assessment
Introduction

This is the last module to complete last semester’s topics for Health
Assessment (NCM101). Unit 3 will discuss procedures on how to do a head to toe
physical assessment. Physical assessment is an important tool in obtaining
baseline client health status. It is an integral part of nursing care and is the basis of
the nursing process. It gives pertinent data so nurses can to plan, implement, and
evaluate teaching and care.

This is comprised of seven lessons. Concept and techniques will be given to

better help you in learning the said nursing skill. This will serve as your guide to
promote an optimal level of client health, prevent illness, restore health, and facilitate
coping with disabilities.

To review, there are four methods of physical examination. Inspection means

looking at the client carefully to discover any signs of illness. Palpation uses the
hands to touch and feel different sensations such as temperature, texture, vibration,
and tenderness. Percussion determines the density of various parts of the body from
the sound it produces when these are tapped with fingers. And lastly, auscultation
listens to the sounds of the heart, lungs and bowel sounds transmitted by a
stethoscope.

This particular module is divided into 7 lessons:

● Lesson 1 General survey

● Lesson 2 Integumentary assessment
● Lesson 3 Head, eyes, ears and nose assessment
● Lesson 4 Mouth, neck and thorax assessment
● Lesson 5 Cardiovascular, breast and axillae assessment
● Lesson 6 Abdomen and musculoskeletal assessment
● Lesson 7 The Performance Checklist

Objectives/Competencies

Upon completion of this module, you are expected to:

1. Proficiently demonstrate health assessment skills

2. Compare normal from above normal parameters.
3. Perform documentation of obtained findings.

Pre-test

Encircle your chosen answer:

1. Aspects of assessing a client’s health status depends on the following:

a. Nursing health history
b. Physical examination
c. All of the above
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 d. None of the above

2. Which is not a type of physical examination?

a. Complete assessment
b. By body system
c. By specialty
d. By body area

3. Which is not a purpose of nursing physical assessment?

a. to obtain baseline data
b. to refute data in nursing history
c. to establish medical diagnosis
d. for health promotion and disease prevention

4. Which is not a primary technique used in physical assessment?

a. Inspection
b. Palpate
c. Temperature
d. Auscultation

5. It is part of Physical Assessment which involves using the sense of sight.

a. Palpation
b. Percussion
c. Inspection
d. Auscultation

6. It is part of Physical Assessment which involves using the sense of touch.

a. Percussion
b. Inspection
c. Palpation
d. Auscultation

7. It is part of Physical Assessment which involves striking to elicit sounds.

a. Palpation
b. Inspection
c. Percussion
d. Auscultation

8. It is part of Physical Assessment which involves listening to sounds produces

by the body.
a. Palpation
b. Inspection
c. Auscultation
d. Percussion

9. It is the usual sound produced in an air-filled stomach.

a. Flatness
b. Dullness
c. Tympany
d. Resonance
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10. This is the usual sequence of methods / technique in Physical Assessment
except for abdomen.
a. Inspection, Percussion, Palpation and Auscultation
b. Percussion, Inspection, Palpation and Auscultation
c. Inspection, Palpation, Percussion and Auscultation
d. Percussion, Palpation, Auscultation and Inspection

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Lesson 1: General Survey
Duration: 2 hours

General survey includes assessing the client’s level of consciousness,

language and communication, physical deformities and signs of illness, behavioral
status, body build, height and weight, and posture, symmetry and gait.

Procedure Normal Findings Abnormal Findings

1. Level of Consciousness (LOC) and orientation. LOC is the degree of

awareness of environmental stimuli. It varies from full wakefulness and
alertness to coma.
 Alert. Client is awake, readily aroused, fully aware of the internal and
external environment and conducts meaningful interpersonal
conversation
 Lethargic. Client drifts off to sleep when not stimulated, aroused when
name is called but looks drowsy and responds to question but thinking
seems to be slow
 Obtunded. Patient sleeps most of the time, difficult to arouse, needs a
loud shout or vigorous shake and speech is mumbled
 Stupor or Semi Coma. Client is spontaneously unconscious, responds
only to spontaneous vigorous shake, can only groan, mumble or move
restlessly but reflex activity still persists
 Coma. Patient is completely unconscious, no response to pain, has
some reflex activity but no purposeful activity

 Assess the client’s level  The client is fully  Client has lowered
of consciousness awake and alert: LOC and shows
eyes are open and irritability, short
follow people or attention span, or
objects. The client is dulled perceptions.
attentive to questions  At a lowered LOC,
and responds he/she may respond
promptly and to physical stimuli
accurately to only. The lowest
commands. extreme is coma,
 If sleeping, responds when the eyes are
readily to verbal or closed and the client
physical stimuli and fails to respond to
demonstrates verbal or physical
wakefulness and stimuli, when no
alertness. voluntary movement.
 If LOC is between
full awareness and
coma, objectively
note the client’s eye
movement:
voluntary,
withdrawal to stimuli
or withdrawal to
noxious stimuli
(pain) only.

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  Assess client’s  The client is aware of  He/she is unable to
orientation. Ask the client who he/she is follow simple
to state his/her own (orientation to commands or
name, current location, person), where answer simple
and approximate day, he/she is (orientation questions.
month, or year to place), and when it
is (orientation to
time).

2. Language and communication. Observe the client’s ability to respond to

verbal commands, processing of information, and communication.

 Assess appropriateness  The client responds  The client is

of client’s responses. appropriately to confused, has
commands, repeats inappropriate
and remembers responses
information. Uses
appropriate native
language

 Describe quantity of  Has smooth, normal  Dysphasia

speech (amount and paced manner of  Dysarthria
pace) speaking.  Memory loss
 Hallucinations

 Listen for the relevance  Exhibits relevance  Not clear/ not

and organization of and organization of smooth/
thoughts. thoughts inappropriate
contents

3. Physical deformities and signs of illness

 Observe for obvious  No signs of illness  The client shows

signs of health or illness.  No physical labored breathing,
deformities wheezing, coughing,
wincing, sweating,
guarding of body
part (suggests pain),
anxious facial
expression, fidgety
movements.

4. Behavioral Status

 Describe client’s affect  Eyes are alert and in  Eyes are closed or
and mood contact with you. averted, no eye
 The client is relaxed, contact
smiles or frowns  The client is
appropriately frowning or
grimacing.

 Assess the client’s  Comfortable,  Does not cooperate,

attitude. cooperative and has and does not answer
a calm demeanor. questions

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  Describe over-all  Clothing reflects  Wears unusual
hygiene and grooming gender, age, climate clothing for gender,
and is appropriate age, climate and
for the occasion. occasion

 Hair, skin, and  Hair is poor

clothing are clean, groomed, lack of
well-groomed cleanliness
 Excessive oil on the
skin.
 Body odor is
present.

5. Physical appearance, body built, height, weight and BMI

Body Built
 Endomorph. A pear shaped body, rounded head, wide hips and
shoulders, wider front to back rather than side to side and a lot of fat on
the body, upper arms and thighs
 Mesomorph. A wedge shaped body, cubical head, wide broad
shoulders, muscled arms and legs, narrow hips, narrow from front to
back rather than side to side and has minimum amount of fat
 Ectomorph. A high forehead, receding chin, narrow shoulders and
hips, narrow chest and abdomen, thin arms and legs and has little
muscle and fat
Body Mass Index (BMI) is used to assess the status of nutrition using weight
and height.

Formula for BMI = weight(kg)/height(m)2

Table 6. Body Mass Index

 Describe physical  The person appears  The person does not

appearance his or her stated age appears his or her
stated age
 Describe body built  Proportionate
(Ectomorph,  Extremities not
Mesomorph, proportionate to the
Endomorph); torso

 Measure height  The height appears

a. Ask the client to within normal range  Excessively tall or
remove shoes and for age, genetic short.
stand with his/her back heritage  Dwarfism
and heels touching the  Gigantism
wall.
b. Place a pencil flat on
his/her head so that it
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 makes a mark on the
wall.
c. Measured with cm tape
from the floor to the
mark on the wall (or if
available, measure the
height with a
measuring scale)

 Measure weight. Weigh

client without shoes and  The weight appears
much clothing. within normal range  Uneven fat
for height and body distribution
build; body fat
distribution is even

 Determine BMI  Male 20.7 – 26.4

 Female 19.1 – 25.8  See Table 6.

6. Posture, symmetry and gait

 Describe posture and  Posture is upright,  Rigid spine and

gait. Observe client while stands comfortably neck; moves as one
standing, sitting and erect as appropriate unit.
walking for age.  Stiff and tense,
ready to spring from
chair, fidgety
movements.
 Scoliosis
 Kyphosis
 Lordosis

 Body parts look  Unilateral atrophy of

equal bilaterally and hypertrophy.
are relative in  Asymmetric location
proportion to each of body part.
other

 Base is wide as  Walks with a limp

shoulder width; foot  Waddles
placement accurate;  Drags foot
walk is smooth,  Limb movements
even, and well are uneven or
balanced; (+) of unilateral.
symmetric arm
swing.

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Lesson 2: Integumentary Assessment
Duration: 2 hours

This procedure includes assessment of the integumentary structures like the

skin, nails, hair, and scalp. These are assessed by observation and palpation. It
begins with an overall inspection of the skin’s condition. This can also be assessed
during other body system assessments.

Self Check 15

To review the structures of the skin learned in Anatomy and Physiology,

please answer this self-check. Identify the different structures of the skin.

1. ______________________

2. ______________________

3. ______________________

4. ______________________

5. ______________________

6. ______________________

7. ______________________

8. ______________________

9. ______________________

Procedure Normal Findings Abnormal Findings

1. Skin

Skin Color Variations

 Pallor. Pale, white color caused by decrease of blood flow
(vasoconstriction) or decrease in hemoglobin, shock, or anemia
 Erythema. Redness due to increased blood flow (vasodilation) like in
fever, inflammatory process, emotions, CO poisoning
 Cyanosis. Bluish, purplish hue due to decreased perfusion of tissues
maybe due to hypoxemia due to heart failure, shock or chronic
bronchitis
 Jaundice. Yellow, orange hue due to jaundice (increased bilirubin in
blood) maybe due to liver problems such as hepatitis, cirrhosis

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 Primary Skin Lesions are variations in color or texture that may be
present at birth, or that may be acquired during a person's lifetime, such as
those associated with infectious diseases, allergic reactions, or environmental
agents.
 Macule. A color change less than 1 cm, may be to darker or lighter like
freckles, flat nevi, hypopigmentation, petechiae
 Patch. A color change greater than 1cm like Mongolian spots, vitiligo,
chloasma
 Papule. An elevated lesion less than 1cm in diameter like wart,
elevated nevus
 Plaque. An elevation greater than 1cm in diameter like psoriasis
 Nodule. An elevated solid greater than 1cm extending deeper into
dermis
 Tumor. Greater than few cm in diameter and may be firm or soft
 Wheal. Superficial, raised, transient, and erythematous lesion like a
mosquito bite or an allergic reaction
 Cyst. An encapsulated fluid filled cavity in dermis or subcutaneous
layer
 Vesicle. An elevated cavity containing free fluid, clear and less than
1cm diameter like those in herpes simplex, varicella zoster
 Bulla. Larger than 1cm in diameter and superficial in epidermis, thin
walled like those on blisters, burns
 Pustule. Presence of pus in a cavity like that in impetigo and acne

Secondary Skin Lesions are changes in the skin that result from primary
skin lesions, either as a natural progression or as a result of a person
manipulating a primary lesion.
 Crust. A thick, dry exudate after rupture or drying up of vesicle or
pustule like in impetigo or a scab following abrasion
 Scale. A dry or greasy flakes of skin resulting from shedding of excess
keratin cells like in psoriasis, eczema, seborrheic dermatitis
 Fissure. Linear cracks extending into dermis
 Ulcer. A deep depression extending into dermis which my bleed and
eventually leave a deep scar.
 Excoriation. Self-inflicted abrasion often from scratching
 Lichenification. This are Tightly packed papules from prolonged
intense scratching
 Keloid. A hypertrophic scar which cannot be removed surgically and
are more common in black people

 Inspect for skin color  Varies from light to  Pallor

uniformity deep brown;  Jaundice
 Ruddy pink to light  Cyanosis
pink;  Erythema
 Yellow overtones to
olive

 Generally uniform  Areas of either

pigmentation except hyperpigmentation
in areas exposed to or hypopigmentation
the sun; (Vitiligo, Albinism)
 Areas of lighter
pigmentation (palms,
lips, nail beds) in
dark-skinned people
 Absence of bruising/  Ecchymosis
bleeding on the skin (collection of blood
in the subcutaneous
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 tissues causing
purplish
discoloration)
 Petechiae (small
hemorrhagic spots
caused by capillary
bleeding)

 Freckles, some
 Inspect for lesions birthmarks, some flat  Primary and
according to locations, and raised nevi secondary skin
distribution, color,  No abrasions and lesions
configuration, size, other lesions;
shape, type or structure

 Moisture in skin
 Palpate skin moisture folds and the axillae  Excessive moisture
and temperature that varies with like in hyperthermia
environmental  Excessive dryness
temperature and like in dehydration
humidity, body
temperature, and
activity

 Uniform skin
temperature, within  Skin is warm or cold
normal range when to touch
taken with  Generalized
thermometer hyperthermia like in
Fever
 Generalized
hypothermia like in
shock
 Localized
hyperthermia like in
infection
 Localized
hypothermia like in
arteriosclerosis
 Palpate for turgor by  When pinched: skin  Skin stays pinched
lifting and pinching the springs back to or tented or moves
skin previous state back slowly like in
dehydration

 Note for presence of  No edema  In edema, there

edema. would be difficulty in
lifting the skin fold.
 If there is pitting
edema, an indention
may remain after the
pressure is released
 Periorbital edema
 Anasarca
 Pedal edema

2. Hair

 Inspect the evenness of  Evenly distributed  Patches of hair loss

growth over the scalp. hair like in Alopecia

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  Inspect hair for volume.  Thick hair  Very thin hair like in
hypothyroidism

 Inspect for texture and  Silky, resilient hair  Brittle hair like in
oiliness over the scalp hypothyroidism
 Excessively oily or
dry hair

 Note for presence of  No infection or  Flaking, sores, lice,

infection and infestations infestation nits (louse eggs),
ring worm
 Folliculitis
(Superficial infection
of hair follicles)
 Multiple pustules

 Inspect amount of body  Variable  Hirsutism (excessive

hair. hairiness in women
and children)

3. Nails

Figure 8. Nail Variations

 Inspect fingernail plate  Convex curvature;  Spoon nail (see B on

shape to determine its  Angle between nail figure 8)
curvature and angle and nail bed of  Clubbing (See C and
about 160 degrees D on figure 8)
See A on figure 8)

 Inspect and palpate  Smooth texture  Excessive thickness;

fingernail and toenail excessive thinness
texture or presence of
grooves or furrows;
 Beau’s line (see E
on figure 8)
 Inspect tissues  Intact epidermis  Hangnails;
surrounding nails  Paronychia
(inflammation)

 Inspect Nail Bed Color  Highly vascular and  Bluish or purplish tint
pink in light-skinned (my reflect
clients; cyanosis);
 Dark- skinned client  Pallor (may reflect
may have brown or poor arterial
black pigmentation circulation)
in longitudinal
streaks

 Perform blanch test of  Prompt return of  Delayed return of

capillary refill pink or usual color pink or usual color
(may indicate
circulatory
impairment)

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Lesson 3: Head, Eyes, Ears, and Nose Assessment
Duration: 2 hours

This section deals with the assessment of the structures found in the head.
This includes the skull, face, face, eyes, ears, nose and sinuses.

Self Check 16

To review the structures of the head learned in Anatomy and Physiology,

please answer this self-check. Identify the different parts of the eyes, ears, location
of lymph nodes and sinuses.

1
8 9

2 4

11
12
10
6
7

1. ______________________ 7. ______________________

2. ______________________ 8. ______________________

3. ______________________ 9. ______________________

4. ______________________ 10. ______________________

5. ______________________ 11. ______________________

6. ______________________ 12. ______________________

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 Procedure Normal Findings Abnormal Findings

1. Head (Skull and Face)

 Inspect the skull for the  Rounded  Lack of symmetry;

size, shape and (Normocephalic and  Increased skull
symmetry. symmetric, with size with more
frontal, parietal, and prominent nose
occipital and forehead;
prominences)  Longer mandible
 Smooth skull (may indicate
contour excessive growth
hormone or
increased bone
thickness)

 Palpate for modules,  Absence of nodules  Sebaceous cysts;

masses and or masses  Local deformities
depressions. from trauma

 Inspect the facial  Smooth, uniform  Increased facial

features, symmetry of consistency; hair;
structures, distribution  Symmetric or slightly  Thinning of
of hair and facial asymmetric facial eyebrows;
movements. features;  Asymmetric
Ask the client to features;
elevate the eyebrows,  Drooping of lower
frown, or lower the eyelid and mouth;
eyebrows, close the  Involuntary facial
eyes tightly, puff the movements like
cheeks, and smile and tics or tremors
show the teeth.
 Inspect the eyes for  Absence of edema  Exophthalmus;
edema and  Myxedema facies;
hollowness.  Moon face
 Periorbital edema
 Sunken eye

2. Eyes

Eyebrows
 Inspect for the  Hair evenly  Loss of hair;
evenness of hair distributed; skin scaling and
distribution and intact; flakiness of skin;
alignment / symmetry,  Eyebrows  Unequal alignment
skin quality and symmetrically and movement of
movement of the aligned; equal eyebrows;
eyebrows movement

Eyelashes
 Inspect for the  Equally distributed;  Turned inward
evenness of hair  Curled slightly
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 distribution and outward
direction of curl of the
eyelashes

Eyelids
 Inspect for the surface  Skin intact; no  Redness, swelling,
characteristics, position discharge; no flaking, crusting,
in relation to the discoloration; plaques,
cornea, ability to blink  Lids close discharge,
and frequency of symmetrically; nodules, lesions;
blinking  Approximately 15-20  Lids close
involuntary blinks/ asymmetrically,
min.; bilateral incompletely, or
blinking; painfully;
 When lids open, no  Rapid, monocular,
visible sclera above absent, or
corneas, and upper infrequent blinking;
and lower borders of  Ptosis, ectropion,
cornea are slightly entropion; rim of
covered sclera visible
between lid and
iris

 Inspect the bulbar  Transparent;  Jaundice

conjunctiva (lying over  Capillaries  Pallor
the sclera) for color, sometimes evident;  Erythema
texture and presence  Sclera appears  Presence of
of lesions. white (yellowish in lesions or nodules
dark-skinned clients)

 Inspect the palpebral  Shiny, smooth, and  Extremely pale

conjunctiva (lining the pink or red (possible anemia);
eye lids) for color,  Extremely red
texture and presence (inflammation);
of lesions by everting  Nodules or other
the eyelids. lesions

 Inspect and palpate the  No edema or  Swelling or

lacrimal gland tenderness over tenderness over
lacrimal gland lacrimal glands

 Inspect and palpate  No edema or tearing  Evidenced of

lacrimal sac and increased tearing;
nasolacrimal duct.  Regurgitation of
fluid on palpation
of lacrimal sac

Cornea
 Inspect the cornea for  Transparent, shiny  Opaque; surface
the clarity and texture. and smooth; details not smooth (may
of the iris are visible; be the result of
trauma or
abrasion);
 In older people, a  Arcus senilis in
thin, grayish white clients under age
ring around the 40 is abnormal
margin, called arcus
senilis, maybe
evident
15
 Perform corneal  Client blinks when  One or both
sensitivity to test the the cornea is eyelids fail to
function of the 5th touched, indicating respond
(Trigeminal) Cranial that the trigeminal
Nerve nerve is intact

 Inspect the anterior  No shadows of light  Cloudy;

chamber for on iris  Crescent-shaped
transparency and  Depth of about 3mm shadows on far
depth. side of iris;
 Shallow chamber

Pupils
 Inspect pupils for the  Black in color;  Cloudiness,
color, shape symmetry  Equal in size; 3-7  Mydriasis (dilation
of size. mm diameter; of the pupil),
 Round, smooth  Myosis
border, iris flat and (constriction of
round pupils) ,
 Anisocoria;
 Bulging of iris
toward cornea

 Assess each pupil for

light reaction and  Illuminated pupil  Neither pupil
accommodation. constricts (direct constricts
Shine light into response)  Unequal
pupil for 1 second with  Non-illuminated responses
opposite eye covered. pupil constricts  Absent responses
Observe for pupil (consensual
restriction and dilation. response)
Repeated on opposite
eye

Extra-ocular Muscles
 Assess six ocular  Both eyes  Eye movements
movements to coordinated, move in not coordinated or
determine alignment unison, with parallel parallel;
and coordination. alignment  One or both eyes
Hold a pen at a fail to follow a
distance from the client penlight in specific
and ask to keep head directions, such as
still and follow the pen strabismus
with the eyes only (cross-eye or
Move the pen squint)
towards the right and
left eye, then towards
the ceiling and floor.
Repeat on the other
side

 Perform eye cover test.  Uncovered eye does  Uncovered eye

not move from fixed move to focus on
point when the other fixed point,
eye is covered indicating it is not
well aligned before
16
 other was covered;
it is shifting from
lateral to central
gaze.

 Newly uncovered  Newly uncovered

eye, if well aligned, eye moves to
does not move when focus on fixed
index card is point, indicating it
removed. was not well
aligned when
covered

Visual Acuity
 Test for near and  Able to read  Difficult reading
distant vision.
Ask client to read newsprint at a newsprint unless
newsprint. distance of 36 cm due to aging
(14 in) process

Cranial Nerve II  20/20 vision on  Denominator of 40

Assessment. Snellen chart. Client or more on Snellen
Allow the patient to can read the chart with corrective
use their glasses or letters/objects in 20 lenses. The higher
contact lens if
available. ft which a normal the denominator,
Position the patient sighted person can the poorer the
20 feet in front of the read at 20 ft vision
Snellen eye chart
Have the patient
cover one eye at a time
with an opaque card.
Ask the patient to
read progressively
smaller letters until
they can go no further.
Record the smallest
line the patient read
successfully (20/20,
20/30, etc.)
Repeat with the
other eye.

Visual Fields  When looking  Visual fields

 Assess Peripheral smaller than
visual fields. straight ahead, client normal (possible
can see objects in glaucoma);
the periphery  One half vision in
one or both eyes
(indicates nerve
damage)

3. Ears
Types of Hearing Loss
 Conduction hearing loss is the result of interrupted transmission of

17
 sound waves through the outer and middle ear structures
 Sensorineural hearing loss is a result of damage to the inner ear,
the auditory nerve, or the hearing center in the brain
 Mixed hearing loss is a combination of conduction and sensorineural
loss

Auricles
 Inspect for color,  Color same as facial  Bluish color of
symmetry of size and skin earlobes (eg.
position. Cyanosis); Pallor
(eg. Frostbite);
Excessive redness
(inflammation or
fever)
 Symmetric position.  Low-set ears
Line drawn from associated with
lateral angle of the congenital
eye to point where anomaly, such as
top part of auricle Down syndrome)
joins head is
horizontal

 Palpate for the texture,  Mobile, firm, and not  Lesions (eg. Cyst)
elasticity and areas of tender  Flaky, scaly skin
tenderness.  Pinna recoils after it
Pull the auricle is folded  Tenderness when
upward and backward moved or pressed
(>3 y.o.); downward (may indicate
and backward (<3 y.o.) inflammation or
Pull the pinna
forward (it should be infection of
recoil) external ear)
Push in on the
tragus
Apply pressure to
the mastoid process

Ear Canal
 Inspect cerumen, skin  Distal third contains  Redness and
lesions, pus and blood hair follicles and discharge
with an otoscope, glands  Scaling
 Dry cerumen,  Excessive
grayish-tan color; or cerumen
sticky, wet cerumen obstructing canal
in various shades of
brown

Hearing Acuity Tests

 Assess client’s  Normal voice tones  Normal voice tones
response to normal audible not audible (eg.
voice tones Requests nurse to
repeat words or
statement, leans
toward the speaker,
turn the head, cups
the ears, or speaks
in loud tone of

18
 voice)

 Assess client’s
response to whispered  Able to repeat  Unable to repeat
voice. nonconsecutive 50% of numbers
Stand 30 to 60 cm numbers whispered
(1-2 ft) from the client
in a position where the
client cannot read your
lips. Ask the client to
occlude one ear by
putting a finger in it.
Whisper some
nonconsecutive
numbers and have the
client tell you what was
heard. Increase the
loudness of the
whisper until the client
can identify at least
50% of the numbers.
Repeat with the other
ear.

 Perform the watch tick  Able to hear ticking  Unable to hear

test. in both ears ticking in one or
Place ticking watch both ears
2 to 3 cm (1-2 in) from
the unoccluded ear

 Perform the Weber’s

Test to assess bone  Sound is heard in  Sound is heard
conduction both ears or is better in impaired
Place the activated localized at the ear, indicating a
tuning fork on the center of the head bone-conductive
client’s skull. Note (Weber negative) hearing loss (eg.
findings as Weber Due to obstruction),
positive and indicate or sound is heard
whether right or left ear better in ear without
a problem,
indicating a
sensorineural
disturbance

 Perform the Rinne’s  Air-conducted (AC)  Bone conduction

Test to compare air hearing is greater time is equal to or
conduction to bone than bone- longer than the air
conduction conducted (BC) conduction time,
Place the still hearing, that is, that is, BC>AC or
ringing tuning fork at AC>BC (positive BC=AC (negative
the mastoid process Rinne) Rinne; indicates a
until no sound is heard conductive hearing
and then place the loss)
prongs of the tuning
fork in front of the
client’s ear canal.

19
4. Nose

External Nose
 Inspect external nose  Symmetric and  Asymmetric
for any deviations in straight  Discharge from
shape, size or color  No discharge or nares
and flaring or flaring  Localized areas of
discharge from the  Uniform color redness or
nares. presence of skin
lesions

 Inspect the nasal

cavities for redness,  Mucosa pink  Mucosa red,
swelling, growths and  Clear, watery edematous
discharge using discharge  Abnormal discharge
penlight.  No lesions (eg. Purulent)
 Presence of lesions
(eg. Polyps)

 Inspect the nasal

septum between the  Nasal septum intact  Septum deviated
nasal chambers noting and in midline
its position.

 Test patency of both

nasal cavities  Air moves freely as  Air movement is
Ask the client to the client breathes restricted in one or
close the mouth, exert through the nares both nares
pressure on one naris,
and breathe through
the opposite naris.
Repeat on the opposite
naris.

 Palpate for any

tenderness, masses  No tenderness  Tenderness on
and displacements of  No lesions palpation
bone and cartilage.  Presence of lesion
Press up on the
frontal sinuses from
under the bony brows,
avoiding pressure on
the eyes.
Press upon the
maxillary sinuses

Sinuses
 Locate / palpate /  Not tender  Tenderness in one
identify sinuses and or more sinuses
note for any
tenderness

20
Figure 9. Palpating frontal
sinus.

Figure 10. Palpating

maxillary sinus.

21
Lesson 4: Mouth, Neck Thorax Assessment
Duration: 2 hours

Assessment of the mouth, neck and thorax is little more complex than the
previous lessons. This involves assessing for the condition of the mouth, pharynx,
neck, lymph nodes, trachea, thyroid gland, anterior and posterior thorax.

Self Check 3

Before we start with the procedure, let us have a short review on the different
locations of your lymph nodes in the neck. Identify the lymph nodes found in the
illustration below.
1. ______________________

2. ______________________

3. ______________________

4. ______________________

5. ______________________

6. ______________________

7. ______________________

8. ______________________

10. ______________________

11. ______________________

12. ______________________

13. ______________________

Procedure Normal Findings Abnormal Findings

1. Mouth

Lips and buccal musosa

 Inspect for symmetry of  Uniform pink color  Pallor; cyanosis
contour, color and (darker, eg. Bluish  Blisters;
texture. hue, in generalized or
Mediterranean localized swelling;
groups and dark- fissures, crusts, or
skinned clients) scales (may result
 Soft, moist, smooth from excessive
texture moisture,
 Symmetry of nutritional
22
 contour deficiency, or fluid
 Ability to purse lip deficit)
 Inability to purse
lips (indicative of
facial nerve
damage)

 Inspect and palpate the  Uniform pink color  Pallor; white

inner lips and buccal (freckled brown patches
mucosa for color, pigmentation in (leukoplakia)
moisture, texture and dark-skinned  Excessive dryness
the presence of lesions. clients)  Mucosal cysts;
 Moist, smooth, soft, irritations from
glistening, and dentures;
elastic texture abrasions,
(drier oral mucosa ulcerations;
in elderly due to nodules
decreased
salivation)

Teeth
 Inspect for the color,  32 adult teeth  Missing teeth
number and condition.  Smooth, white,  Brown or black
shiny tooth enamel discoloration of the
enamel (may
indicate staining or
the presence of
caries)
 Note and inspect
dentures.
Ask client to  Smooth, intact  Ill-fitting dentures
remove complete or dentures  Irritated and
partial dentures excoriated area
Inspect their under dentures
condition, noting broken
or worn areas

Gums
 Inspect for the color  Pink gums (bluish  Excessively red
and condition. or dark patches in gums
dark-skinned  Spongy texture;
clients) bleeding;
 Moist, firm texture tenderness (may
to gums indicate
 No retraction of periodontal
gums (pulling away disease)
from the teeth)  Receding
atrophied gums;
swelling that
partially covers the
teeth

23
Tongue / Floor of the
Mouth
 Inspect and palpate  Central position  Deviated from
surface of the tongue  Pink color (some center (may
for the position, color, brown pigmentation indicate damage
texture on tongue borders to hypoglossal or
in dark-skinned 12th cranial nerve)
clients); moist;  Smooth red
slightly rough; thin tongue (may
whitish coating indicate iron, Vit
 Smooth, lateral B12, or Vit B3
margins; no lesions deficiency)
 Dry, furry tongue
(associated with
fluid deficit)
 Nodes,
ulcerations,
discolorations
(white or red
areas); areas of
tenderness

 Inspect tongue  Moves freely  Restricted mobility

movement  No tenderness

 Inspect the base of the  Smooth tongue  Swelling

tongue, the mouth floor, base with  Ulcerations
and the frenulum. prominent veins

 Palpate for any  Varicosities (tiny  Swelling, nodules

nodules, lumps or bluish-black or
excoriated areas. purple swollen
Use gauze to grasp tip areas) in elderly
of the tongue people
 Smooth with no
palpable nodules

Palates and Uvula

 Inspect and palpate for  Light pink, smooth,  Discoloration (eg.
the color, shape, soft palate Jaundice or pallor)
texture and presence of  Plated the same
bony prominences. color
 Irritations
 Bony growths
(exostoses)
growing from the
hard palate

 Inspect uvula for  Lighter pink hard  Deviation to one

position and mobility palate, more side from tumor or
while examining the irregular texture trauma;
palates. Positioned in  Immobility (may
midline of soft indicate damage
palate to trigeminal or 5th
or vagus or 10th
cranial nerve

24
 Oropharynx and Tonsils
 Inspect and palpate  Pink and smooth  Reddened or
oropharynx for color, posterior wall edematous;
shape, texture and presence of
presence of bony lesions, plaques,
prominences or exudate

 Inspect size of tonsils,  Pink and smooth  Inflamed

its color, size and  No discharge  Presence of
presence of discharge  Of normal size discharge
 Swollen
 Elicit gag reflex
 Present  Absent (may
indicate problems
with
glossopharyngeal
or vagus nerves)

2. Neck

Neck Muscles
 Inspect  Muscles equal in  Unilateral neck
sternocleidomastoid size swelling
and trapezius muscles  Head centered  Head tilted to one
of the neck for side (indicates
abnormal swelling or presence of
masses. masses, injury,
muscle weakness,
shortening of
sternocleidomastoid
muscle, scars)

 Observe head  Coordinated,  Muscle tremor,

movement. smooth movements spasm, or stiffness
Ask client to: with no discomfort  Limited range of
Move the chin to motion; painful
the chest movements;
Move the head involuntary
back so that the chin movements (eg.
points upward Up-and-down
Move the head so nodding
that the ear is moved movements
toward the shoulder on associated with
each side Parkison’s
Turn the head to disease)
the right and to the left

 Assess muscle  Equal strength  Unequal strength

strength.
Ask client to:
Turn the head to
one side against the
resistance of your hand
Shrug the
shoulders against the
resistance of your
hands
25
 Lymph Nodes
 Locate / palpate/  Not palpable  Enlarged,
identify lymph nodes palpable, possibly
and note for tenderness tender (associated
and enlargement. with infection and
tumors)

Trachea
 Inspect and palpate for  Central placement  Deviation to one
placement. in midline of neck side, indicating
 Spaces are equal possible neck
on both sides tumor;
 thyroid
enlargement;
 enlarged lymph
nodes

Thyroid Gland
 Inspect for symmetry  Not visible on  Visible diffuseness
and masses. infection or local
enlargement

 Palpate for smoothness  Lobes may not be  Visible diffuseness

and areas of palpated or local
enlargement, masses  If palpated, lobes enlargement
and nodules. are small, smooth,  Solitary nodules
centrally located,
painless, and rise
freely with
swallowing

 If enlargement of the  Absence of bruit  Presence if bruit

gland is suspected,
auscultate over the
thyroid area for a bruit
(a soft rushing sound
created by turbulent
blood flow; use bell side
of stethoscope)

3. Thorax
Normal breath sounds
 Vesicular. Soft-intensity, low-pitched, “gentle sighing” sounds created
by air moving through smaller airways (bronchioles and alveoli).
Located over peripheral lung; best heard at the base of lungs. Best
heard on inspiration, which is about 2.5 times longer than the
respiratory phase (5:2 ratio)
 Bronchovesicular. Moderate-intensity and moderate-pitched “blowing”
sounds created by air moving through larger airways (bronchi). Located
between the scapulae and lateral to the sternum at the first and second
intercostal spaces. Equal inspiratory and expiratory phases (1:1 ratio)
26
  Bronchial (tubular). High-pitched, loud, “harsh” sounds created by air
moving through the trachea. Located anteriorly over the trachea; not
normally heard over lung tissue. Louder than vesicular sounds; have
short inspiratory phase and long expiratory phase (1:2 ratio)
Adventitious breath sounds
 Crackles (rales). Fine, short, interrupted crackling sounds; alveolar
rales are high-pitched; bronchial rales are lower-pitched. Sound can be
simulated by rolling a lock of hair near the ear. Best heard on
inspiration but can be heard on both inspiration and expiration. May not
be cleared by coughing. These are causes by air passing through fluid
or mucus in any air passage. Located most commonly heard in the
bases of the lower lung lobes
 Rhonchi. Continuous, low-pitched, coarse, gurgling, harsh, louder
sounds with a moaning or snoring quality. Best heard on expiration but
can be heard on both inspiration and expiration. May be altered by
coughing. These are caused by air passing through narrowed air
passages as a result of secretion, swelling, tumors. Loud sounds can
be heard over most lung areas but predominate over the trachea and
bronchi
 Friction rub. Superficial grating or creaking sounds heard during
inspiration and expiration which is not relieved by coughing. These are
cause by rubbing together of inflamed pleural surfaces. Heard most
often in areas of greatest thoracic expansion (e.g., lower anterior and
lateral chest)
 Wheeze. Continuous, high-pitched, squeaky musical sounds. Best
heard on expiration and are not usually altered by coughing. These are
caused by air passing through constricted bronchi as a result of
secretions, swelling, and tumors. Heard over all lung fields

Posterior Thorax
 Inspect for the shape,  Antero-posterior to  Barrel chest
symmetry and compare transverse  Increased
the diameter of antero- diameter in ratio of anteroposterior to
posterior thorax to 1:2 lateral diameter
transverse diameter  Chest symmetric  Chest asymmetric

Figure 11 . Cross section of

the thorax

 Inspect the spinal

alignment  Spine vertically  Exaggerated
Have the client aligned spinal curvatures
stand. From a lateral (kyphosis,
position, observe the lordosis)
three normal  Lateral deviation
curvatures: cervical, of spine (scoliosis)
thoracic, and lumbar.
27
 To assess for
lateral deviation of the
spine (scoliosis),
observe the standing
client from the rear.
Have the client bend
forward at the waist and
observe from behind.

 Palpate for  Skin intact  Skin lesions

temperature,  Uniform  Areas of
tenderness and temperature hyperthermia
masses.  Chest wall intact  Presence of
 No tenderness lumps, bulges,
Figure 12. Sequence for  No masses depressions
Palpating the posterior  Areas of
thorax tenderness
 Movable
structures (e.g.,
rib)

 Assess for respiratory  Full and symmetric  Asymmetric and/or

excursion. chest expansion decreased chest
Place the palms of (when the client expansion
both your hands over takes a deep
the lower thorax, with breath, the thumbs
your thumbs adjacent should move apart
to the spine and your an equal distance
fingers stretched and at the same
laterally. Ask the client time; thumbs
to take a deep breath normally separate
while you observe the 3 to 5 cm during
movement of your inspiration)
hands and any lag in
movement.

Figure 13. Palpating the

posterior thorax excursion

28
  Palpate for vocal
fremitus.  Bilateral symmetry  Decreased or
Place the palmar of vocal fremitus absent fremitus
surfaces of your  Fremitus is heard (associated with
fingertips on the most clearly at the pneumothorax)
posterior chest, starting apex of the lungs  Increased fremitus
near the apex of the  Low-pitched voices (associated with
lungs. of males are more consolidated lung
Ask the client to readily palpated tissue, as in
repeat such words as than higher-pitched pneumonia)
“blue moon” or “one, voices of males
two, three.”
Repeat the two
steps, moving your
hands sequentially to
the base of the lungs.
Compare the
fremitus on both lungs
and between the apex
and the base of each
lung, either 1) using
one hand and moving it
from one side of the
client to the
corresponding area on
the other side or 2)
using two hands that
are placed
simultaneously on the
corresponding areas of
each side of the chest.

Figure 14. Palpation of the

Posterior Thorax for Vocal
or Tactile Fremitus

 Percuss the posterior

thorax.  Percussion notes  Asymmetry in
Ask the patient to resonate, except percussion
bend the head and fold over scapula  Areas of dullness
the arms forward  Lowest point of or flatness over
across the chest to resonance is at the lung tissue
separate the scapula diaphragm (i.e., at (associated with
and expose more lung the level of the consolidation of
tissue eighth to tenth rib lung tissue or a
Percuss in the posteriorly) mass)
ICS at about 5 cm (2
in) intervals in a
systematic sequence
Compare one
side of the lung with
the other
Percuss the
29
 lateral thorax every
few inches, starting at
the axilla and working
down to the eighth rib

 Auscultate the posterior

thorax.  Vesicular and  Adventitious
Use flat-disc bronchovesicular breath sounds
diaphragm (best for breath sounds (e.g., crackles,
transmitting high- rhonchi, wheeze,
pitched breath sounds) friction rub)
Use systematic  Absence of breath
zigzag procedure sounds
Ask the patient to (associated with
take slow, deep breaths collapsed and
through the mouth surgically removed
Compare findings lung lobes)
at each point with the
corresponding point on
the opposite side

Figure 15. Percussing and

Auscultating Posterior
Thorax

Anterior Thorax
 Inspect breathing  Rate: Eupnea (12  Rate: Bradypnea;
patterns and costal to 20 breaths/min) Tachypnea
angle formed by the  Depth: Normal  Depth: Deep;
intersection of the  Rhythm: Regular Shallow
costal margins and the  Quality: silent,  Rhythm: Irregular
angle at which the ribs effortless breathing  Quality: noticeable
enter the spine. effort

 Palpate for  Skin intact  Skin lesions

temperature,  Uniform  Areas of
tenderness and temperature hyperthermia
masses.  Chest wall intact  Presence of lumps,
 No tenderness bulges,
 No masses depressions
 Areas of
tenderness
 Movable structures
30
 (e.g., rib)
Figure 16. Sequence for
Palpating the anterior thorax

 Assess respiratory  Full symmetric  Asymmetric and/or

excursion. excursion decreased
Place the palms of  Thumbs normally respiratory
both hands on the separate 3 to 5 cm excursion
lower thorax with (1 ½ to 2 in)
fingers laterally along
the lower rib cage and
thumbs along the costal
margins
Ask the client to
take a deep breath
while observe the
movement of your
hands

 Palpate for tactile  same as posterior  same as posterior

fremitus. fremitus fremitus
Palpated in the
same manner as for the
posterior chest, using
the same sequence
If the breasts are
large and cannot be
retracted adequately for
palpation, this part of
examination is usually
omitted

 Percuss the anterior  Percussion notes  Asymmetry in

thorax. resonate down to percussion notes
Begin above the the 6th rib at the  Areas of dullness
clavicles in the level of the or flatness over
supraclavicular space, diaphragm but are lung tissue
and proceed downward flat over areas of
to the diaphragm. heavy muscle and
Compare one side bone, dull on areas
of the lung to the other. over the heart and
Displace female the liver, and
breasts for proper tympanic over the
examination. underlying stomach

31
Figure 17. Percussing and
Auscultating the Anterior
Thorax

 Auscultate the trachea.  Bronchial (tubular)  Adventitious breath

breath sounds sounds (e.g.,
crackles, rhonchi,
friction rub,
wheeze)

 Auscultate the anterior  Bronchovesicular  Adventitious breath

thorax. and vesicular sounds
breath sounds

32
Lesson 5: Cardiovascular, Breast and Axillae Assessment
Duration: 2 hours

This lesson deals with the different techniques for assessing the
cardiovascular system, breast and axillae.

Procedure Normal Findings Abnormal Findings

1. Cardiovascular Assessment
Locate the Aortic, Pulmonic, Tricuspid, and Apical Areas of the Precordium
 Locate the angle of Louis (the point of tracheal bifurcation). It is felt
as a prominence on the sternum
 Move fingertips down each side of the angle until 2nd ICS is felt. The
client’s (R) 2nd ICS is where the aortic area, and the (L) 2nd ICS is
pulmonic area
 From the pulmonic area, move fingertips down three (L) ICS along the
side of the sternum. The (L) 5th ICS close to the sternum is the
tricuspid or right ventricular area
 From the tricuspid area, move fingertips laterally to 5 to 7 cm (2 to 3
in) to left midclavicular line (LMCL). This is the apical or mitral area,
or point of maximal impulse (PMI). To help locate the PMI, have the
client roll onto the (L) side to move the apex closer to the chest wall.

Figure 18. Anatomical sites of the precordium.

 Simultaneously inspect
and palpate the aortic  No pulsations  Pulsations
and pulmonic areas.
To note the
presence or absence of
pulsations, observe
them at an angle and to
the side

 Inspect and palpate the  No pulsations  Pulsations

33
 tricuspid area for  No lifts to heaves  Diffuse lifts or
pulsations and heaves or heaves, indicating
lifts enlarged or
overactive right
ventricle

 Inspect and palpate the  Pulsations visible in  PMI displaced

apical area 50% of adults and laterally or lower
palpable in most (indicates enlarged
 PMI in 5th LICS or heart)
medial to MCL  Diameter over 2
 Diameter of 1 to 2 cm (indicates
cm enlarged heart or
 No lift or heave aneurysm)
 Diffuse lift or
heave lateral to
apex (indicates
enlargement or
overactivity of L
ventricle)

 Inspect and palpate the  Aortic pulsations  Bounding

epigastric area at the abdominal
base of the sternum for pulsations
abdominal aortic
pulsations.

 Auscultate the heart in all  Systole: Silent  Increased or

four anatomical areas: interval; Slightly decreased
aortic, pulmonic, tricuspid shorter duration intensity in any
and apical (mitral) than diastole at area
Eliminate sources of normal heart rate  Varying intensity
room noise. Heart (60 to 90 beats/min) with different beats
sounds are of low  Diastole: Silent  Sharp-sounding
intensity. interval; Slightly ejection clicks
Keep the client in a longer duration than  S3 in older adults
supine position with head systole at normal  S4 may be a sign
elevated at 30 to 40 heart rates of hypertension
degrees.  S1: Usually heard
Use the bell disc to at all sites; usually
listen to all areas. louder at apical
Concentrate on one area
particular sound at a time  S2: Usually heard
in each area at all sites; usually
Reexamine the heart louder at base of
while the client is in the heart
upright sitting position.  S3 in children and
Heart sounds are more young adults
audible in certain  S4 in many older
positions. adults

Carotid Artery  Symmetric pulse  Assymetric

 Palpate carotid artery volumes; volumes;
with extreme caution  Full pulsations,  Decreased
thrusting quality; pulsations;
 Quality remains  Increased
same when client pulsations;
34
 breathes, turns
head, and changes
from sitting to
supine position;

 Auscultate the carotid  No sound heard on  Presence of bruit

arteries auscultation in one or both
arteries

Jugular Veins
 Inspect for the jugular  Veins not visible  Veins visibly
vein distension. (indicating right side distended
Ask the client to sit of heart is
on a semi-Fowler’s functioning
position, with head normally)
supported on a small
pillow.

Peripheral Pulse
 Palpate peripheral  Rate ranges  Tachycardia
pulses and note for rate normally from 60 -  Bradycardia
and rhythm. 100beats/minute  Irregular rhythm
 The rhythm should
be regular

Peripheral Veins
 Palpate peripheral veins  No signs of  Tenderness
in the arms and legs for infection  Swelling
presence of superficial  Redness
veins and any sign of
phlebitis.

2. Breast and Axillae

 Inspect the breast for

size, symmetry and  Females: Rounded  Recent changes in
contour or shape while shape; slightly breast size
the client in sitting unequal in size;  Swelling
position. generally symmetric  Marked asymmetry
 Males: Breasts
even with chest
wall; if obese, may
be similar in shape
to female breasts

 Inspect the skin of the  Skin uniform in  Localized

breast for localized color (same in discolorations or
discolorations or appearance as skin hyperpigmentation
hyperpigmentation of abdomen or  Retraction or
retraction or dimpling, back) dimpling (result of
swelling or edema.  Skin smooth and scar tissue or an
intact invasive tumor)
35
  Diffuse symmetric  Unilateral,
horizontal or localized
vertical pattern in hypervascular
light-skinned people areas (associated
with increased
blood flow)
 Swelling or edema
appearing as pig
skin or orange peel
due to
exaggeration of
the pores

 Inspect areola for size,  Round or oval and  An asymmetry

shape, symmetry, color, bilaterally the same  Presence of mass
masses or lesions.  Color varies from or lesions
light pink to dark
brown
 Irregular placement
of sebaceous
glands on the
suface of the areola
(Montgomery’s
tubercles)

 Inspect the nipples for  Round, everted,  Asymmetrical size

size, shape, color, and equal in size; and color
discharge, lesions similar in color; soft  Presence of
and smooth; both discharge, crusts,
nipples point the or cracks
same direction  Recent inversion
 No discharge of one or both
except for nipples
colostrum in  Tenderness,
pregnant females masses, or nodule
 Inversion of one or
both nipples

 Palpate the areola,

nipples and breast for  No tenderness,  Presence of
masses. masses, nodules, tenderness,
Compress each or nipple discharge masses, nodules,
nipple to determine the or nipple discharge
presence of any
discharge. If discharge
is present, milk the
breast along its radius
to identify the
discharge-producing
lobe.

36
Figure 19. Techniques for
palpating the breast

 Palpate the axillary,

subclavicular and  Not palpable  Enlarged,
supraclavicular lymph palpable, possibly
nodes. tender (associated
Place the client’s with infection and
arms in abduction and tumors)
supported on the
nurse’s forearm
Use the palmar
surfaces of all fingertips
to palpate the four
areas of axilla:
o The edge of the
greater pectoral
muscle (musculus
pectoralis major)
along the anterior
axillary line
o The thoracic wall
in the midaxillary
area
o The upper part of
the humerus
o The anterior edge
of the latissimus
dorsi muscle along
the posterior
axillary line

37
Lesson 6: Abdomen and Musculoskeletal Assessment
Duration: 2 hours

This lesson deals with assessing the abdomen and the musculoskeletal
system. This involves assessing the condition of the different organs found in the
abdominal area. This will also discuss different techniques to assess the client’s
range of motion.

Self Check 17
Before we proceed with the techniques in assessing the abdomen, let us first
have a review on the different organs found in the four (4) quadrants of the
abdomen. Choose the organs inside the box and write it on its appropriate quadrant.

Stomach Gall bladder

Right ovary and fallopian tube Head of pancreas
Right centre and lower kidney Hepatic flexure of colon
Sigmoid colon Left kidney and adrenal gland
Left ovary and fallopian tube Duodenum
Body of the pancreas Right kidney and adrenal gland
Splenic flexure of colon Cecum
Liver Appendix
Spleen Left centre and lower kidney

RUQ LUQ

RLQ LLQ

38
 Procedure Normal Findings Abnormal Findings

1. Abdomen
Abdominal assessment follows the Inspection, Auscultation, Percussion
and Palpation order (IAPP). Auscultation is done before palpation and
percussion to prevent altering the frequency of bowel sound.

 Inspect the abdomen for  Unblemished skin  Presence of rash or

skin integrity.  Uniform color other lesions
 Silver-white striae or  Tense, glistening
surgical scars skin (may indicate
ascites, edema)
 Purple striae
(associated with
Cushing’s disease)

 Inspect abdomen for  Distended

 Flat, rounded
contour and symmetry.  Evidence of
(convex), or
scaphoid (concave) enlargement of
 No evidence of liver or spleen
enlargement of liver  Asymmetric
or spleen contour, such as
 Symmetric contour localized
 No appearance of protrusions around
bulges or marked umbilicus, inguinal
ridges ligaments, or scars
(possible hernia or
tumor)
 Bulges or masses
appear

 Symmetric  Limited movement

 Inspect the abdominal
movements caused due to pain or
movements associated
by respiration disease process
with respirations,
 Visible peristalsis in  Visible peristalsis
peristalsis or aortic
very lean people in nonlean clients
pulsations.
 Aortic pulsations in (with bowel
thin persons at obstruction)
epigastric area  Marked aortic
pulsations

 Inspect for presence of  No visible vascular  Visible venous

vascular pattern. pattern pattern (dilated
veins) is
associated with
liver disease,
ascites and
venocaval
39
 obstruction

 Auscultate the abdomen  Audible bowel  Absent or

for bowel sounds, sounds hypoactive bowel
vascular sounds and  Absence of arterial sounds
peritoneal friction rubs. bruits  Hyperactive bowel
For bowel sounds,  Absence of friction sounds
use flat-disc diaphragm. rub  Loud bruit over
Intestinal sounds are aortic area
relatively high-pitched. (aneurysm)
Light pressure with the  Bruit over renal or
stethoscope is iliac arteries
adequate to detect  Friction rub
sounds
Ask when the client
last ate. The frequency
of sounds relates to the
state of digestion or the
presence of food in the
GIT. Shortly or long
after eating, bowel
sounds may normally
increase. They are
loudest when a meal is
overdue
Place the flat-disc
diaphragm of the
stethoscope in each of
the four quadrants of
the abdomen over all
the auscultation sites
Listen for active
bowel sounds – high
pitched, irregular
gurgling noises
occurring every 5 to 20
seconds. The duration
of a single sound may
range from less than a
second to more than
several seconds
Normal bowel
sounds are described
as audible. Alterations
in sounds are described
as absent, hypoactive,
or hyperactive

 Perform light palpation  No tenderness noted  Tenderness and

first then deep palpation  With smooth and hypersensitivity;
in all four quadrants. consistent tension  Superficial
 No muscle guarding masses;
40
  Tenderness may be  Localized areas of
present near xiphoid increased tension
process, over  Mobile or fixed
cecum, and over masses
sigmoid colon

 Palpate for an enlarge  May not be palpable  Enlarged

liver and spleen.  Border feels smooth  Smooth but tender

 Palpate the area above  Not palpable  Distended and

the pubic symphysis if palpable as
the client’s history smooth, round,
indicates possible tense mass
urinary retention.

 Percuss several areas in  Tympany over the  Large dull areas

each of the four stomach and gas- (associated with
quadrants for presence filled bowels; presence of fluid or
of tympany and dullness dullness specially tumor)
Use a systematic over the liver and
pattern: Begin in the spleen, or a full
lower left quadrant, then bladder
proceed to the lower
right quadrant, the upper
right quadrant, and the
upper left quadrant

2. Musculoskeletal
Grading Muscle Strength
 Grade 5 - 100% of normal muscle strength; normal full movement
against gravity and against full resistance.
 Grade 4 - 75% of normal strength; normal full movement against gravity
and against minimal resistance.
 Grade 3 - 50% of normal strength; normal movement against gravity.
 Grade 2 - 25% of normal strength; full muscle movement against
gravity, with support.
 Grade 1 - 10% of normal strength; no movement, contraction of muscle
is palpable or visible.
 Grade 0 - 0% of normal strength; complete paralysis

Muscles
 Inspect muscles for size,  Equal size on both  Atrophy (a
presence of sides of body decrease in size)
contractures, and  hypertrophy (an
tremors increased in size)
Compare each
muscle on one side of  No contractures  Malposition of
the body to the same body part (foot
muscle on the other side. drop or foot flexed
For any apparent forward)
discrepancies, measure
41
 the muscles with a tape.  No fasciculation or  Presence of
tremors fasciculation or
tremors

 Palpate muscles at rest  Normally firm  Atonic ( lacking

to determine tonicity. tone)

 Palpate muscles while  Smooth coordinated  Flaccidity

client is active and movements (weakness or
passive for flaccidity, laxness)
spasticity and  Spasticity (sudden
smoothness of involuntary muscle
movement. contraction)

 Test Muscle Strength.

Compare the right  Equal strength on  25% or less
side with left side. each body side muscle strength

Bones
 Inspect the skeleton for  No deformities  Bones misaligned
normal structure and
deformities.

 Palpate the bones for  No tenderness or  Presence

edema or tenderness. swelling tenderness of
swelling

Joint
 Inspect for the location,  No swelling  One or more
color and swelling or swollen joints
masses

 Palpate for any  No tenderness,  Presence of

tenderness crepitation swelling, crepitation, tenderness,
and presence of nodules or nodules swelling,
crepitation, or
nodules

 Assess joint Range of

Motion (ROM).  Varies to some  Limited range of
Ask the client to degree in motion in one or
move selected body accordance with more joints
parts. If available, use a person’s genetic 
goniometer to measure makeup and degree
the angle of the joint in of physical activity
degrees.

Cervical, Thoracic and

Lumbar Spine
 Observe for symmetry,  Symmetrical, no  Tenderness
tenderness and tenderness, no  Nodule
presence of pain. nodules, no  Pain
42
 presence of pain

 Perform ROM of the  Varies to some  Limited range of

cervical spine (flexion, degree in motion in one or
hyperextension, lateral accordance with more joints
bending and rotation). person’s genetic
makeup and degree
of physical activity

 Varies to some
 Perform ROM of the degree in  Limited range of
thoracic and lumbar accordance with motion in one or
spine (flexion, person’s genetic more joints
hyperextension, lateral makeup and degree
bending and rotation). of physical activity

Shoulders, Arms and Elbows

 Observe the shoulders  Symmetrical,  Tenderness
and arms for the uniform in color, no  Nodules
symmetry, swelling, color swelling or masses;  Swelling
and masses. uniform in elbow  Pain
size & shape, no
deformities

 Perform ROM of the  Varies to some  Limited range of

shoulder (Adduction, degree in motion in one or
abduction, external and accordance with more joints
internal rotation). person’s genetic
makeup and degree
of physical activity

 Observe for the elbow’s  Symmetrical,  Tenderness

size, shape, deformities, uniform in color, no  Nodules
redness or swelling. swelling or masses;  Swelling
uniform in elbow  Pain
size & shape, no
deformities

 Palpate for the olecranon  Not palpable  Tenderness

process and epicondyles  No tenderness or  Nodules
in relaxed and flexed effusion  Swelling
position.  Pain

 Perform ROM of elbows.  Varies to some  Limited range of

degree in motion in one or
accordance with more joints
person’s genetic
makeup and degree
of physical activity

Wrist
 Inspect and palpate for  Symmetrical, no  Tenderness
size, shape, symmetry, tenderness, no  Nodules
color and swelling. Then nodules, no  Swelling
palpate for snuffbox for presence of pain; no  Pain
tenderness ad nodules. deformities

 Perform ROM of the  Varies to some  Limited range of

43
 wrist. (Flexion, degree in motion in one or
hyperextension, radial accordance with more joints
and ulnar deviation) person’s genetic
makeup and degree
of physical activity

Hands and Fingers

 Inspect for size, shape,  Symmetrical uniform  Redness
symmetry, color and in color, no swelling  Swelling
swelling of hands, or masses;
fingers and
metacarpophalangeal
joint.

 Palpate for tenderness,  No tenderness, no  Tenderness

swelling of bony crepitation or nodule  Nodules
prominences, nodules or  Pain
crepitus of each
interphalangeal joint.

 Perform ROM of hands  Varies to some  Limited range of

and fingers (abduction, degree in motion in one or
adduction, flexion and accordance with more joints
hyperextension, thumb person’s genetic
away from fingers, makeup and degree
thumb touching base of of physical activity
small finger).

Hips
 Inspect and palpate for  Symmetrical uniform  Tenderness
shape, symmetry, in color, no swelling  Nodules
stability, tenderness and or masses; No  Swelling
crepitus. tenderness, no  Pain
crepitation or
nodules

 Perform ROM of the hips  Varies to some  Limited range of

(hip flexion with degree in motion in one or
extended knee straight, accordance with more joints
hip flexion with knee person’s genetic
bent abduction, makeup and degree
adduction, internal and of physical activity
external rotation,
hyperextension).

Knees
 Inspect the knees for the  Symmetrical uniform  Redness
size, shape, symmetry, in color, no swelling  Swelling
swelling, deformities and or masses;
alignment.
 Palpate for tenderness,  No tenderness, no  Tenderness
warmth, consistency and crepitation or nodule  Nodules
nodules.  Pain
44
  Perform ROM of the  Varies to some  Limited range of
knees (flexion, degree in motion in one or
extension, accordance with more joints
hyperextension, ask the person’s genetic
patient to walk). makeup and degree
of physical activity

Ankles and Feet

 Perform ROM of the  Varies to some  Limited range of
ankles and feet degree in motion in one or
(dorsiflexion, plantar accordance with more joints
flexion, eversion, person’s genetic
inversion, abduction, makeup and degree
adduction, flexion and of physical activity
extension)

45
Lesson 7: The Performance Checklist
Duration: 8 hours

The first six hours of this lesson is attributed to practicing the skill through
online and offline method. Presented below is performance checklist for the skills
discussed in the previous lessons. Take time to review the procedure, watch the
initial demonstration on our Google Classroom and practice the skill on your own at
home. Initial return demonstration schedule will be on next meeting. To perform
grand return demonstration of the skills, see Final Requirement part of this module.

Performing Head to Toe Physical Assessment

Materials Needed:
 Weighing Scale  Thermometer
 Height Chart  Tuning Fork
 Pen Light  Tongue Depressor
 Neurologic Hammer / Reflex  Cotton Applicator
Hammer  Examination Gloves
 Sphygmomanometer and cuff  Notepad and pen
 Stethoscope

Procedures Done Not Remarks

done
ASSESMENT
1. Identify the client.
2. Explain the procedure and discuss how she or
he can cooperate.
PLANNING
1. Perform hand hygiene.
2. Provide privacy.
3. Position the client comfortably allowing for easy
access to the body part being assessed.
IMPLEMENTATION
GENERAL SURVEY
1. Assess the client’s level of consciousness
2. Assess client’s orientation.
3. Assess appropriateness of client’s responses.
4. Describe quantity of speech (amount and pace)
5. Listen for the relevance and organization of
thoughts.
6. Observe for physical deformities and obvious
signs of health or illness.
7. Describe client’s affect / mood.
8. Assess the client’s attitude.
9. Describe client’s affect / mood.
10. Describe over-all hygiene and grooming
11. Describe physical appearance
46
 12. Describe body built
13. Measure height
14. Measure weight
15. Determine body mass index (BMI)
16. Describe posture and gait.
INTEGUMENTARY
Skin
1. Inspect for skin color uniformity,
2. Inspect for lesions according to locations,
distribution, color, configuration, size, shape,
type or structure
3. Palpate skin moisture and temperature
4. Palpate for skin turgor by lifting and pinching
the skin
5. Note for presence of edema.
Hair
6. Inspect the evenness of growth over the scalp.
7. Inspect hair for volume.
8. Inspect for texture and oiliness over the scalp
9. Note for presence of infection and infestations
10. Inspect amount of body hair.
Nails
11. Inspect fingernail plate shape to determine its
curvature and angle
12. Inspect and palpate fingernail and toenail
texture
13. Inspect tissues surrounding nails
14. Inspect Nail Bed Color
15. Perform blanch test of capillary refill
HEAD
Skull and Face
1. Inspect the skull for the size, shape and
symmetry.
2. Palpate for modules, masses and depressions.
3. Inspect the facial features, symmetry of
structures, distribution of hair and facial
movements.
4. Inspect the eyes for edema and hollowness.
EYES
Eyebrows
1. Inspect for the evenness of hair distribution
and alignment / symmetry, skin quality and
movement.
Eye Lashes
2. Inspect for the evenness of hair distribution and
 direction of curl.
Eye lids
3. Inspect for the surface characteristics, position
in relation to the cornea, ability to blink and
frequency of blinking
4. Inspect the bulbar conjunctiva (lying over the
sclera) for color, texture and presence of
lesions.
5. Inspect the palpebral conjunctiva (lining the eye
lids) for color, texture and presence of lesions
by everting the eyelids.
6. Inspect and palpate the lacrimal gland
7. Inspect and palpate lacrimal sac and
nasolacrimal duct.
Cornea
8. Inspect the cornea for the clarity and texture.
9. Perform corneal sensitivity test.
10. Inspect the anterior chamber for transparency
and depth.
Pupils
11. Inspect pupils for the color, shape symmetry of
size.
12. Assess each pupil for light reaction and
accommodation.
Extraocular Muscles
13. Assess six ocular movements to determine
alignment and coordination.
14. Perform eye cover test.
Visual Acuity
15. Test for near and distant vision.
Visual Fields
16. Assess Peripheral visual fields.
EARS
Auricles
1. Inspect for color, symmetry of size and position.
2. Palpate for the texture, elasticity and areas of
tenderness.
Ear Canal
3. Inspect cerumen, skin lesions, pus and blood
Hearing Acuity Tests
4. Assess client’s response to normal voice tones
5. Assess client’s response to whispered voice.
6. Perform the watch tick test.
7. Perform the Weber’s Test to assess bone
conduction by placing the activated tuning fork
 on the client’s skull.
8. Perform the Rinne’s Test to compare air
conduction to bone conduction by placing the
ringing tuning fork at the mastoid process until
no sound is heard and then place the prongs of
the tuning fork in front of the client’s ear canal.
NOSE
External Nose
1. Inspect external nose for any deviations in
shape, size or color and flaring or discharge
from the nares.
2. Inspect the nasal cavities for redness, swelling,
growths and discharge using penlight.
3. Inspect the nasal septum between the nasal
chambers noting its position.
4. Test patency of both nasal cavities
5. Palpate for any tenderness, masses and
displacements of bone and cartilage.
Sinuses
6. Locate / palpate / identify sinuses and note for
any tenderness.
MOUTH
Lips and buccal musosa
7. Inspect for symmetry of contour, color and
texture.
8. Inspect and palpate the inner lips and buccal
mucosa for color, moisture, texture and the
presence of lesions.
Teeth
9. Inspect for the color, number and condition.
Inspect dentures if present.
Gums
10. Inspect for the color and condition.
Tongue / Floor of the Mouth
11. Inspect and palpate surface of the tongue for
the position, color, texture
12. Inspect tongue movement
13. Inspect the base of the tongue, the mouth floor,
and the frenulum.
14. Palpate for any nodules, lumps or excoriated
areas.
Palates and Uvula
15. Inspect and palpate for the color, shape, texture
and presence of bony prominences.
16. Inspect uvula for position and mobility while
 examining the palates.
Oropharynx and Tonsils
17. Inspect and palpate oropharynx for color,
shape, texture and presence of bony
prominences
18. Inspect size of tonsils, its color, size and
presence of discharge
19. Elicit gag reflex
NECK
Neck Muscles
1. Inspect sternocleidomastoid and trapezius
muscles of the neck for abnormal swelling or
masses.
2. Observe head movement.
3. Assess muscle strength.
Lymph Nodes
4. Locate / palpate/ identify lymph nodes and note
for tenderness and enlargement.
Trachea
5. Inspect and palpate for placement.
Thyroid Gland
6. Inspect for symmetry and masses.
7. Palpate for smoothness and areas of
enlargement, masses and nodules.
THORAX
Posterior Thorax
1. Inspect for the shape, symmetry and compare
the diameter of anteroposterior thorax to
transverse diameter
2. Inspect the spinal alignment
3. Palpate for temperature, tenderness and
masses.
4. Assess for respiratory excursion.
5. Palpate for vocal fremitus.
6. Percuss the posterior thorax.
7. Auscultate the posterior thorax.
Anterior Thorax
8. Inspect breathing patterns and costal angle
formed by the intersection of the costal margins
and the angle at which the ribs enter the spine.
9. Palpate for temperature, tenderness and
masses.
10. Assess respiratory excursion.
11. Palpate for tactile fremitus.
12. Percuss the anterior thorax.
 13. Auscultate the trachea.
14. Auscultate the anterior thorax.
CARDIOVASCULAR
1. Simultaneously inspect and palpate the aortic
and pulmonic areas.
2. Inspect and palpate the tricuspid area for
pulsations and heaves or lifts
3. Inspect and palpate the apical area
4. Inspect and palpate the epigastric area at the
base of the sternum for abdominal aortic
pulsations.
5. Auscultate the heart in all four anatomical
areas: aortic, pulmonic, tricuspid and apical
(mitral)
Carotid Artery
6. Palpate carotid artery with extreme caution
7. Auscultate the carotid arteries
Jugular Veins
8. Inspect for the jugular vein distension.
Peripheral Pulses
9. Palpate peripheral pulses and note for rate and
rhythm.
Peripheral Veins
10. Palpate peripheral veins in the arms and legs
for presence of superficial veins and any sign of
phlebitis.
BREAST AND AXILLAE
1. Inspect the breast for size, symmetry and
contour or shape while the client in sitting
position.
2. Inspect the skin of the breast for localized
discolorations or hyperpigmentation retraction
or dimpling, swelling or edema.
3. Inspect areola for size, shape, symmetry, color,
masses or lesions.
4. Inspect for the nipple size, shape, position,
color, discharge and lesions.
5. Palpate the areola, nipples and breast for
masses.
6. Palpate the axillary, subclavicular and
supraclavicular lymph nodes.
ABDOMEN
1. Inspect the abdomen for skin integrity.
2. Inspect abdomen for contour and symmetry.
 3. Inspect the abdominal movements associated
with respirations, peristalsis or aortic pulsations.
4. Inspect for presence of vascular pattern.
5. Auscultate the abdomen for bowel sounds,
vascular sounds and peritoneal friction rubs.
6. Perform light palpation first then deep palpation
in all four quadrants.
7. Palpate for an enlarge liver and spleen.
8. Palpate the area above the pubic symphysis if
the client’s history indicates possible urinary
retention.
9. Percuss several areas in each of the four
quadrants for presence of tympany and
dullness
MUSCULOSKELETAL
Muscles
1. Inspect muscles for size, presence of
contractures, and tremors
2. Palpate muscles at rest to determine tonicity.
3. Palpate muscles while client is active and
passive for flaccidity, spasticity and
smoothness of movement.
4. Test Muscle Strength.
Bones
5. Inspect the skeleton for normal structure and
deformities.
6. Palpate the bones for edema or tenderness.
Joint
7. Inspect for the location, color and swelling or
masses
8. Palpate for any tenderness crepitation and
presence of nodules
9. Assess joint Range of Motion (ROM).
Cervical, Thoracic and Lumbar Spine
10. Observe for symmetry, tenderness and
presence of pain.
11. Perform ROM of the cervical spine (flexion,
hyperextension, lateral bending and rotation).
12. Perform ROM of the thoracic and lumbar spine
(flexion, hyperextension, lateral bending and
rotation).
Shoulders, Arms and Elbows
13. Observe the shoulders and arms for the
symmetry, swelling, color and masses.
14. Perform ROM of the shoulder (Adduction,
 aduction, external and internal rotation).
15. Observe for the elbow’s size, shape,
deformities, redness or swelling.
16. Palpate for the olecranon process and
epicondyles in relaxed and flexed position.
17. Perform ROM of elbows.
Wrist
18. Inspect and palpate for size, shape, symmetry,
color and swelling. Then palpate for snuffbox
for tenderness ad nodules.
19. Perform ROM of the wrist. (Flexion,
hyperextension, radial and ulnar deviation)
Hands and Fingers
20. Inspect for size, shape, symmetry, color and
swelling of hands, fingers and
metacarpophalangeal joint.
21. Palpate for tenderness, swelling of bony
prominences, nodules or crepitus of each
interphalangeal joint.
22. Perform ROM of hands and fingers (abduction,
adduction, flexion and hyperextension, thumb
away from fingers, thumb touching base of
small finger).
Hips
23. Inspect and palpate for shape, symmetry,
stability, tenderness and crepitus.
24. Perform ROM of the hips (hip flexion with
extended knee straight, hip flexion with knee
bent abduction, adduction, internal and external
rotation, hyperextension).
Knees
25. Inspect the knees for the size, shape,
symmetry, swelling, deformities and alignment.
26. Palpate for tenderness, warmth, consistency
and nodules.
27. Perform ROM of the knees (flexion, extension,
hyperextension, ask the patient to walk).
Ankles and Feet
28. Perform ROM of the ankles and feet
(dorsiflexion, plantar flexion, eversion,
inversion, abduction, adduction, flexion and
extension)
EVALUATION
1. Evaluate if findings from the physical
assessment is within normal limits.
 DOCUMENTATION
1. Document and report significant findings.

_____________________ ________________________ _____________

Student's Signature Clinical Instructor’s Date
Printed Name & Signature

Self Check 18

Practice the procedure at home after watching the initial demonstration. Your
clinical instructor will schedule a practice return demonstration online. For remote
learning, your clinical instructor will contact you personally for a practice return
demonstration of the procedure.

Post-test

Encircle your chosen answer:

1. What sequence for checking does the abdomen follows?

a. IPPA
b. IPAP
c. IAPP
d. PPIA

2. Which is not a normal breath sound?

a. Vesicular
b. Bronchovesicular
c. Rales
b. Bronchial

3. What equipment or material checks visual acuity?

a. Reflex hammer
b. Tuning fork
c. Snellen chart
d. Penlight

4. What is the normal color of the tympanic membrane?

a. red
b. pinkish
c. pearl gray
d. light brown

5. Sinuses are checked during which assessment?

a. eyes assessment
 b. ear assessment
c. nose assessment
d. mouth assessment

6. Which is not a normal finding/s of the skull and face?

a. Palpebral Fissures are equal
b. Uniform Consistency
c. Moon Face
d. Absence of Nodules / Lesions / Mass

7. Which is a normal finding in skin assessment?

a. petechiae
b. ecchymosis
c. moles
d. vesicle

8. Which is not a normal finding in mouth and pharynx assessment?

a. ability to purse lips
b. 32 adult teeth
c. absent gag reflex
d. no retraction of gums

9. In what quadrant of the abdomen does the liver resides?

a. Right lower quadrant
b. Left lower quadrant
c. Right upper quadrant
d. Left upper quadrant

10. Deep palpation is usually done in what body assessment?

a. Chest
b. Head
c. Abdomen
d. Extremities

Final Requirement

1. Select any adult family member as your client and obtain consent for the
procedure. Prepare a short video of yourself performing return demonstration
of the procedures:
a. General Survey
b. Integumentary assessment
c. Head, Eyes, Ears, and Nose Assessment
d. Mouth, Neck Thorax Assessment
e. Cardiovascular and Breast and Axillae Assessment
f. Abdomen and Musculoskeletal Assessment
2. Quiz via Google Forms on Google Classroom
Suggested Readings and Websites

1. Berman A, Snyder S, Frandsen G. (2016). Unit 7 Assessing Health. Kozier &

Erb's Fundamentals of Nursing. 10th Edition. (pages 519-580). United States
of America. Pearson Education, Inc.
2. Youtube.com. (2017). Head-to-Toe Assessment Nursing | Nursing Physical
Health Assessment Exam Skills
- https://www.youtube.com/watch?v=gG8kh8MfnGY

References

Berman A, Snyder S, Frandsen G. (2016). Kozier & Erb's Fundamentals of

Nursing. 10th Edition. United States of America. Pearson Education, Inc
.

Answer Key

Pre-Test Post-Test
1. C 1. C
2. C 2. C
3. C 3. C
4. C 4. C
5. C 5. C
6. C 6. C
7. C 7. C
8. C 8. C
9. C 9. C
10. C 10. C