Head to Toe Examination

Physical Health Assessment

A complete health assessment may be conducted starting at the head and proceeding in a systematic manner downward (head to toe assessment).

Purposes of physical examination: 1. to obtain baseline data about the clients’ functional abilities 2. to supplement, confirm, or refute data obtained in the nursing history 3. to obtain data that will help establish nursing diagnoses and plan of care 4. to evaluate to physiologic outcomes of health care and thus the progress of the clients’ health problem

Head to Toe Framework

 General Survey  Vital Signs  Head  Neck  Upper extremities  Chest and Back  Abdomen  Genitals  Lower extremities  Neurologic Assessment

Four primary techniques used in physical examination 1. Inspection – is the visual examination; that is, assessing by using the sense of sight - the nurse inspects with the naked eye and with a lighted instrument - nurses frequently use visual inspection to assess moisture, color and texture of body surfaces as well as shape, position, size, color and symmetry of the body 2. Palpation – is the examination of the body using the sense of touch - used to determine texture, temperature, vibration, position size consistency and mobility of organs, distention, pulsation, and presence of pain upon pressure

Two types:  Light palpation – skin is slightly depressed  Deep palpation – is done with two hands or one hand

3. Percussion – is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt Two types:  Direct – the nurse strikes the area to be percussed directly with the pads of two, three or four fingers or with the pad of the middle finger  Indirect – is striking of an object held against the body area to be examined

Five percussion sounds:  Flat sound – elicited by percussing over solid masses, such as bone or muscle  Dull sound – is elicited when high density structures such as the liver are percussed  Resonance – is a hollow sound heard; for example, by percussing the lung  Hyperresonance – is an abnormal sound with a pitch between resonance and tympany and may indicate an emphysematous lung or pneumothorax  Tympany – is a drum-like sound heard over air-filled body parts; such as, the bowel or stomach

4. Auscultation – process of listening to sounds produced within the body, usually the last technique used during examination

Types: . Direct – the use of the unaided ear . Indirect – use of the stethoscope which transmits the sounds to the nurses’ ears

I. General Survey Assessment Normal Findings Deviations from normal 1. Observe body build, Proportionate, varies with Excessively thin or obese height and weight in lifestyle relation to client’s lifestyle and health

2. Observe the client’s Relaxed erect posture; Tense, slouched, bent posture and gait coordinated movements posture; uncoordinated movements; tremors

3. Observe the client’s Clean, neat Dirty, unkempt overall hygiene and grooming. Relate these to the person’s activities prior to the assessment. 4. Note body and breath No body odor or minor Foul body odor; ammonia odor in relation to body odor relative to work odor; acetone breath odor; activity level. or exercise; no breath odor foul breath

5. Observe for signs of No distress noted Bending over because of distress in posture or abdominal pain; wincing or facial expression labored breathing

6. Assess the client’s Cooperative Negative; hostile; attitude withdrawn

7. Note the client’s Appropriate to situation Inappropriate to situation affect/mood: assess the appropriateness of the client’s responses

8. Listen for quantity of Understandable, moderate Rapid or slow pace; uses speech, quality and pace; exhibits thought generalization; exhibits organization (coherence association confabulation; lacks of thought, over association generalization, vagueness)

II. Vital Signs Assessment Normal Findings Deviations from normal

1. Obtain blood pressure, BP = 100/70 – 130/90 Hypotension/hypertension pulse rate, respiratory rate, mmHg and body temperature PR = (female) – 60-100 Tachycardia bpm Bradycardia (male) – 55-95 bpm RR = 15-20 cpm Tachypnea = rapid rate Bradypnea = slow rate dyspnea = difficulty of breathing

Temp. = 35.9 – 37 °C Hyperthermia Hypothermia III. Head Assessment Normal Findings Deviations from normal Skull and Face 1. Inspect the scalp for size Rounded (normocephalic Lack of symmetry; and shape and symmetry and symmetrical with increased skull size with frontal parietal and occipital more prominent nose and prominences); smooth skull forehead; longer mandible contour (may indicate excessive growth hormone or increased bone thickness)

2. Palpate the skull for Smooth, uniform Sebaceous cysts; local nodules or masses and consistency; absence of deformities from trauma depressions. Use a gentle nodules or masses rotating motion with the fingertips. Begin at the front and palpate down the midline; then, palpate each side of the head

3. Inspect the facial features Symmetric or slightly Increased facial hair; (e.g. symmetry of structures asymmetric facial features; thinning of eyebrows; and of the distribution of palpebral fissures equal in asymmetric features; hair) size; symmetric nasolabial exopthalmos; myxedema folds facies; moonface

4. Inspect the eyes for Periorbital edema; sunken edema and hollowness eyes

5. Note symmetry of facial Symmetrical facial Asymmetric facial movements. Ask the client movements movements (e.g. eye on to elevate the eyebrows, affected side cannot close from, or lower the completely); drooping of eyebrows, close the eyes lower eyelid and mouth; tightly, puff the cheeks, and involuntary facial smile and show the teeth movements (i.e. ticks or tremors) Eye structure and Visual Acuity 1. Inspect the eyebrows for Hair evenly distributed; Loss of hair, scaling and hair distribution and skin intact; eyebrows flakiness of skin; unequal alignment and skin quality symmetrically aligned; alignment and movement of and movement (ask client to equal movement. eyebrows raise and lower the eyebrows) 2. Inspect the eyelashes for Equally distributed; curled Turned inward evenness of distribution and slightly outward direction of curl

3. Inspect the eyelids for Skin intact; no discharge; Redness, swelling, flaking, surface characteristics no discoloration crusting, plaques, discharge, position in relation to the Lids close symmetrically nodules, lesions. cornea, ability to blink, and Approximately 15-20 Lids close asymmetrically, frequency of blinking. For involuntary blinks/min; incompletely or painfully. proper visual examination bilateral blinking Rapid, monocular, absent, of the eyelids, elevate the When lids open, no visible or infrequent blinking. eyebrows with your thumb sclera above corneas and Ptosis, ectropion, or and index finger and have upper and lower borders of entropion; rim of sclera the client close the eyes. cornea are slightly covered visible between lid and iris Inspect the lower eyelids where the clients eyes are closed.

4. Inspect the bulbar Transparent; capillary Jaundiced sclera; conjunctiva for color, sometimes evident; sclera excessively pale sclera; texture, and the presence of appears white reddened sclera; lesions or lesions. Retract the eyelids nodules. with your thumb and index finger, exerting pressure over the upper and lower bony orbits and ask the client to look up, down, and from side to side.

5. Inspect the palpebral Shiny, smooth, and pink or Extremely pale; extremely conjunctiva by everting the red red; nodules or other lids. Note color, texture, lesions. and presence of lesions. Evert both lower lids and ask the client to look up, then gently retract the lower lids with the index finger

6. Inspect and palpate the No edema or tenderness Swelling or tenderness over lacrimal gland over lacrimal gland lacrimal gland

7. Inspect and palpate the No edema or tearing Evidence of increased lacrimal sac and tearing; regurgitation of nasolacrimal duct fluid on palpation of lacrimal sac 8. Inspect the pupil for Black in color; equal in Cloudiness, mydriasis, color, shape, and symmetry size; normally 3-7 mm in miosis, anisocoria; bulging of size diameter; round, smooth of iris toward cornea border, iris flat and round

9. Assess each pupil’s direct Illuminated pupil constricts Neither pupil constrict and consensual reaction to (direct response) Unequal responses light Non-illuminated pupil Absent reponses constricts (consensual response)

10. Assess each pupil’s Pupils constrict when One or both pupils fail to reaction to accommodation looking at near object; constrict, dilate, or converge pupils dilate when looking at far object; pupils converge when near object is moved toward nose.

Visual fields Visual fields smaller than 11. Assess peripheral visual When looking straight normal; one-half vision in fields ahead, client can see object one or both eyes. in the periphery

Extraocular muscle tests Eye movements not 12. Assess six ocular Both eyes coordinated, coordinated or parallel; one movements to determine move in unison, with or both eyes fail to follow a eye alignment and parallel alignment penlight in specific coordination directions (e.g. strabismus)

Visual Acuity Difficulty reading newsprint 13. Assess near vision by Able to read newsprint unless due to aging process asking the client to read from a newspaper held at a distance of 36 centimeters or 14 inches. If the client normally wears corrective lenses, the glasses/lenses should be worn during the test Denominator of 40 or more 14. Assess distance vision 20/20 vision on Snellen on Snellen Chart Chart Ears and Hearing Bluish color of earlobes; 1. Inspect the auricles for Color same as facial skin pallor; excessive redness color, symmetry of size and Asymmetry position. To inspect Symmetrical position, note the level at Low set ears (associated which the superior aspect of Auricle aligned with outer woth a congenital the auricle attaches to the canthus of eye above 10 abnormality, such as Down head in relation to the eye degrees from vertical Syndrome

2. Palpate the auricles for texture, elasticity and areas of tenderness Lesions; flaky, scaly skin;  Gently pull the auricle Mobile, firm and not tender tenderness when moved or upward and backward pressed  Fold the pinna Pinna recoils after it is forward (it should folded recoil)  Push in on the tragus  Apply pressure to the mastoid process Redness and discharge 3. Inspect the external ear Dry cerumen, grayish tan Scaling canal for cerumen, skin color; or sticky, wet Excessive cerumen lesions, pus, and blood cerumen in various shades obstructing canal of brown Pink to red, some opacity 4. Inspect the tympanic Pearly gray color, semi- Yellow amber membrane for color and transparent White gloss Blue or deep red Dull surface

Gross hearing acuity test Normal voice tones not 5. Assess client’s response Normal voice tones audible audible (e.g. requests nurse to normal voice tones. If to repeat words or client has difficulty hearing statements, leans toward the the normal voice, proceed speaker, turns the head, with the following tests. cups the ears, or speaks in loud tone of voice)

5A. Perform the watch tick Unable to hear ticking in test. The ticking of a watch Able to hear ticking in both one or both ears has a higher pitch than the ears human voice.  Have the client occlude one ear. Out of the client’s sight, place a ticking watch 2 to 3cm from the unoccluded ear.  Ask what the client can hear. Repeat with the other ear.

5B. Tuning Fork Tests Sound is heard better in Perform Weber’s test to Sound is heard in both ears impaired ear, indicating a assess bone conduction. or is localized at the center bone-conductive hearing of the head (Weber loss or sound is heard better negative) in ear without a problem, indicating a sensorineural disturbance (Weber positive)

Bone conduction time is Conduct the Rhinne test to Air-conducted (AC) hearing equal to or longer than the compare air conduction to is greater than the bone- air conduction time. bone conduction. conducted (BC) hearing, i.e., AC > BC (positive Rhinne)

Nose and Sinuses Assymetric 1. Inspect the external nose Symmetric and straight Discharge from nares for any deviations in shape, No discharge or flaring Localized areas of redness size or color and flaring or Uniform color or presence of skin lesions discharge from the nares. Tenderness on palpation; 2. Lightly palpate the Non-tender presence of lesions external nose. No lesions Air movement is restricted 3. Determine patency of Air moves freely as the in one or both nares both nasal cavities. Ask the client breathes though the client to close the mouth, nares exert pressure on one nares and breath through the opposite nares. Mucosa red, edematous 4. Observe for the presence Mucosa pink Abnormal discharge (e.g. of redness, swelling, Clear watery discharge purulent) growths, and discharge No lesions Presence of lesions (e.g. polyps)

Septum deviated to the right 5. Inspect the nasal septum Nasal septum intact and in or to the left between the nasal chambers midline Tenderness in one or more 6. Palpate the maxillary and Not tender sinuses. frontal sinuses

Mouth Pallor; cyanosis 1. Inspect the outer lips for Uniform pink color Blisters; swelling; fissures, symmetry of contour, color Soft, moist, smooth texture crust or scales. and texture. Ask the client Symmetry of contour Inability to purse lips to purse the lips as if to Ability to purse lips whistle. Pallor; white patches 2. Inspect and palpate the Uniform pink color Excessive dryness inner lips and buccal Moist, smooth, soft, Mucosal cysts; irritations mucosa for color, moisture, glistening, and elastic from dentures; abrasions, texture, and the presence of texture ulcerations; nodules. lesions. Missing teeth; ill-fitting 3. Inspect the teeth and 32 adult teeth dentures gums while examining the Smooth, white, shiny tooth Brown or black inner lips and buccal enamel discoloration of the enamel mucosa. Pink gums Excessively red gums Moist, firm texture to gums Spongy texture; bleeding; No retraction of gums tenderness Receding, atrophied gums; swelling that partially covers the teeth.

Tongue Deviated from center (may 4. Inspect the surface of the Central position indicate damage to tongue for position, color, hypoglossal) ; excessive and texture. Ask the client trembling to protrude the tongue. Smooth red tongue Pink color; moist; slightly rough; thin whitish coating. Dry furry tongue Smooth lateral margins; no lesions. Nodes, ulcerations, Raised papillae (taste buds) discoloration; areas of tenderness. Palates and uvula Discoloration 5. Inspect the hard and soft Light pink, smooth, soft Palates the same color palate for color, shape, palate Irritations texture and the presence of Bony growths growing from bony prominences. Ask the Lighter pink hard palate, the hard palate. client to open the mouth mote irregular texture wide and tilt the head backward. Deviation to one side from 6. Inspect the uvula for Positioned in midline of soft tumor or trauma; position and mobility while palate. immobility examining the palates. To observe the uvula, ask the client to say “ah” so that the soft palate rises. Inflamed 7. Inspect the tonsils for Pink and smooth Presence of discharge color, discharge and size. No discharge Swollen

Absent 8.Elicit gag reflex by Present pressing the posterior tongue with a tongue depressor.

IV. Neck

Assessment Normal Findings Deviations from Normal Neck muscles 1. Inspect the neck muscles Muscles equal in size; head Unilateral neck swelling; (sternocleidomastoid and centered head tilted to one side. trapezius) for abnormal swellings or masses. Ask the client to hold the head erect.

2. Observe head movement. Coordinated, smooth Muscle tremor, spasm, or movements with no stiffness discomfort Limited range of motion; painful movements; involuntary movements.

3. Palpate the entire neck Not palpable Enlarged, palpable, possibly for enlarged lymph nodes. tender

4. Palpate the trachea for Central placement in Deviation to one side, lateral deviation. Place your midline of neck; space are indicating possible neck fingertip or thumb on the equal on both sides. tumor; thyroid enlargement; trachea in the suprasternal enlarged lymph nodes. notch and then move your finger laterally to the left and the right in spaces bordered by the clavicle, the anterior aspect of the sternocleidomastoid muscle, and the trachea.

5. Inspect the thyroid gland.  Stand in front of the client. Not visible Visible diffuseness or local  Observe the lower half enlargement. of the neck overlying the thyroid gland for symmetry and visible masses. Gland ascends during Gland is not fully movable  Ask the client to swallowing but it is not with swallowing. hyperextend the head visible and swallow. If necessary, offer a glass of water to make it easier for the client to swallow. This action determines how the thyroid and cricoid cartilages move and whether swallowing causes a bulging of the gland. Lobes may not be palpated Solitary nodules. 6. Palpate the thyroid gland If palpated, lobes are small, for smoothness. Note any smooth, centrally located, areas of enlargement, painless, and rise freely masses, or nodules. with swallowing.

Absence of bruit Presence of bruit 7. If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit (a soft rushing sound created by turbulent blood flow). Use the bell of the stethoscope.

V. Chest and Back

Assessment Normal findings Deviations from normal Posterior thorax 1. Inspect the shape and Anteroposterior to Barrel chest;increased symmetry of the thorax transverse diameter in ratio anteroposterior to transverse from posterior and lateral of 1:2 diameter views. Compare the anteroposterior diameter to Chest symmetric Chest asymmetric the transverse diameter.

2. Inspect the pinal Spine vertically aligned Exaggerated spinal alignment for deformities. curvatures (kyphosis, Have the client stand. From lordosis) a lateral position, observe the three normal curvatures: cervical, thoracic, and lumbar.  To assess for lateral Spinal column is straight, Spinal column deviates to deviation of spine right and left shoulders and one side, often accentuated (scoliosis), observe the hips are at the same height. when bending over. standing client from the Shoulders or hips not even. rear. Have the client bend forward at the waist and observe from behind.

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

4. Palpate the chest for Bilateral symmetry of vocal Decreased or absent vocal (tactile) fremitus, the fremitus fremitus (associated with faintly perceptible vibration pneumothorax) felt through the chest wall Fremitus is heard most Increased fremitus when the client speaks. clearly at the apex of the (associated with lungs. pneumonia)

5. Percuss the thorax. Percussion notes resonate, Asymmetry in percussion except over scapula Areas of dullness or flatness Lowest point of resonance over lung tissue is at the diaphragm Note: percussion on a rib normally elicits dullness.

6. Auscultate the chest Vesicular (soft-intensity, Absence of breath using the diaphragm of the low-pitched, “gentle sounds(associated with lung stethoscope. sighing” sounds) and collapse)  Use the systematic bronchovesicular Adventitious breath sounds zigzag procedure used (moderate-intensity and a) Crackles: fine, short, in percussion moderate-pitched interrupted crackling  Ask the client to take “blowing” sounds) sounds slow, deep breaths b) Rhonchi: continuous, through the mouth. low-pitched, coarse, Listen at each point to gurgling, harsh, louder the breath sounds during sounds with a moaning a complete inspiration or snoring quality. and expiration. c) Friction rub: superficial  Compare findings at grating or creaking each point with the sounds heard during corresponding point n inspiration and the opposite side of the expiration. chest. d) Wheeze: continuous, high-pitched, squeaky musical sounds.

Anterior thorax 7. Inspect breathing patterns Quiet, rhythmic, and Abnormal breathing effortless respirations patterns a.) Tachypnea: quick, shallow breaths b.) Bradypnea: abnormally slow breathing c.) Apnea: cessation of breathing d.) Dyspnea: difficult and labored breathing e.) Orthopnea: ability to breathe only in upright sitting or standing positions.

8. Palpate the anterior chest for respiratory excursion. Full symmetric excursion; Asymmetric and/or  Place the palms of both thumbs normally separate 3 decreased respiratory your hands on the lower t0 5 cm. excursion. thorax , with your fingers laterally along the lower rib cage and your thumbs along the costal margins.  Ask the client to take a deep breath while you observe the movement of your hands.

9. Percuss the anterior chest Percussion notes resonate Asymmetry in percussion systematically. down to the sixth rib at the notes. Areas of dullness or level of the diaphragm but flatness over lung tissue. are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach.

10. Auscultate the trachea. Bronchial breath sounds: Adventitious breath sounds high-pitched, loud, “harsh” sounds.

11. Auscultate the anterior Bronchovesicular and Adventitious breath sounds chest. vesicular breath sounds

12. Auscultate the heart in S1: Usually heard at all Increased or decreased all four anatomic sites: sites. Usually louder at intensity. aortic, pulmonic, tricuspid, apical area. Varying intensity with and apical. S2: Usually heard at all different beats. sites. Usually louder at base Increased intensity at of heart. pulmonic area. S3: in children and young Sharp-sounding ejection adults clicks S4: in many older adults S3 in older adults S4 may be a sign of hypertension Breasts and Axillae 1. Inspect the breasts for Females: Rounded shape; Recent change in breast size, symmetry, and contour slightly unequal in size; size; swellings; marked or shape. generally symmetric. asymmetry. Males: Breasts even with the chest wall. 2. Inspect the skin of the Skin uniform in color Localized discolorations or breast for localized hyperpigmentation discolorations or Skin smooth and intact hyperpigmentation, Retraction or dimpling retraction or dimpling, Striae (stretch marks) and localized hypervascular moles. Swelling or edema areas, swelling or edema. appearing as pig skin or orange peel due to exaggeration of the pores.

3. Inspect the areola area for Round or oval and Any asymmetry, mass, or size, shape, symmetry, bilaterally the same lesion. color, surface characteristics, and any From light pink to dark masses or lesions. brown in color

4. Inspect the nipples for Round, everted, and equal Asymmetrical size and size, shape, position, color, in size; similar in color; soft color discharge, and lesions. and smooth.

No discharge, except from Presence of discharge, pregnant or breast-feeding crusts, or cracks females

Inversion of the nipples that Recent inversion of one or is present from puberty. both nipples

5. Palpate the axillary, No tenderness, masses, or Tenderness, masses or subclavicular, and nodules nodules supraclavicular lymph nodes

6. Palpate the breast and No tenderness, masses, Tenderness, masses, areola for masses, nodules or nipple discharge. nodules or nipple discharge. tenderness, and any discharge from the nipples.

VI. Abdomen

Assessment Normal findings Deviations from normal Inspection of the abdomen 1. Inspect the abdomen for Unblemished skin Presence of rash or other skin integrity. Uniform color lesions Silver white straie or Tense, glistening skin surgical scars Purple striae

2. Inspect the abdomen for contour and symmetry:  Observe the abdominal Flat, rounded, or scaphoid Distended contour (rib margin to (concave) pubic bone) while standing at the client is supine.  Ask the client to take a No evidence of enlargement Evidence of enlargement of deep breath and to hold of liver or spleen liver or spleen it (makes an enlarged liver or spleen more obvious).  Assess the symmetry of Symmetric contour Asymmetric contour contour  If distention is present, measure the abdominal girth.

Auscultation of the abdomen 3. Auscultate for bowel Audible bowel sounds Absent (none heard in 3 – 5 sounds. minutes) Hypoactive (1 per minute) Percussion of the Hyperactive (every 3 sec.) abdomen 4. Percuss several areas in Tympany over the stomach Large dull areas each of the four quadrants and gas-filled bowels; to determine presence of dullness, especially over the tympany and dullness. liver and spleen, or a full Begin in the lower left bladder. quadrant, proceed to the lower right quadrant, the upper right quadrant, and the upper left quadrant.

Palpation of the abdomen 5. Perform light palpation No tenderness; relaxed Tenderness and first to detect areas of abdomen with smooth, hypersensitivity. tenderness and/ or muscle consistent tension. Superficial masses guarding. Localized area of increased tension.

6. Perform deep palpation Tenderness may be present Generalized or localized over all the quadrants. near xiphoid process, over areas of tenderness cecum, and over sigmoid Mobilized or fixed masses colon

VII. Genito-Urinary

Assessment Normal Findings Deviations from normal Female There are wide variations; Scant pubic hair (may indicate 1. Observe for the generally kinky in the hormonal problem) distribution, amount and menstruating adult, thinner characteristic of pubic hair. and straighter after menopause. Distributed in the shape of an inverse triangle Hair growth should not extend over the abdomen 2. Inspect the skin of the pubic Lice, lesions, scars, fissures, area for parasites (e.g. lice), Pubic skin intact, no leasions swelling, erythema, or inflammation, swelling, and Skin of vulva area slightly leukoplakia. lesions(e.g. fissures, darker than the rest of the excoriations, scars from body episiotomies, varicosities, leukoplakia).

3. Palpate inguinal lymph Enlargement and tenderness nodes No enlargement or tenderness

Male Scant amount or absence of 1. Inspect the distribution and Triangular distribution, often hair characteristics of pubic hair spreading up the abdomen Presence of lesions, nodules, 2. Inspect the penile shaft and Penile skin intact swellings, or inflammation glans penis for lesions, Appears slightly wrinkled and nodules, swellings and varies in color as widely as inflammation. other body skin Inflammation; discharge 3.Inspect the urethral meatus Pink and slitlike appearance Variation in meatal locations for swelling, inflammation, Positioned at the tip of the (e.g., hypospadias, on the and discharge. penis underside of the penile shaft, and epispadias, on the upper side of the penile shaft)

Swelling or bulge (possible 4. Inspect both inguinal areas No swelling inguinal or femoral hernia) for bulges while the client is standing, if possible. Palpable bulge in the area. 5. Palpate hernias No palpable bulge

VIII. Musculoskeletal System / Extremities

Assessment Normal Findings Deviations from normal 1. Inspect for muscle size. Equal size on both sides of Atrophy (a decrease in size) or Compare the muscles on one body hypertrophy (an increase in side of the body (e.g. of the size) arm, thigh, and calf) to the same muscle on the other side. For any discrepancies, measure the muscles with a tape.

2.Inspect the muscles and No contractures Malposition of body part (e.g. tendons for contractures foot fixed in dorsiflexion) (shortening).

3. Inspect the muscles for No fasciculations or tremors Presence of fasciculation or fasciculations and tremors. tremor Inspect any tremors of the hands and arms by having the client hold the arms out in front of the body.

4. Palpate muscles at rest to Normally firm Atonic (lacking tone) determine muscle tonicity (the normal condition of tension, or tone, of a muscle at rest).

5. Palpate muscles while the Smooth coordinated Flaccidity (weakness or client is active and passive for movements laxness) or spasticity (sudden flaccidity, spasticity, and involuntary muscle smoothness of movement. contraction)

6. Test Muscle Strength Equal strength on each body Unequal strength or extreme side weakness on either side.

7. Palpate bones to locate any No tenderness or swelling Presence of tenderness or areas of edema or tenderness swelling (may indicate fractures, neoplasms, or osteoporosis).

8. Inspect the joints for No swelling One or more swollen joints swelling

10. Palpate each joint for No tenderness, swelling, Presence of tenderness, tenderness , smoothness of crepitation, or nodules swelling, crepitation, or movement, swelling, Joints move smoothly nodules crepitation, presence of nodules.

11. Assess joint range of Varies to some degree in Limited range of motion in motion accordance with person’s one or more joints. genetic makeup and degree of physical activity

Upper Extremities No lesions, deformities and Deformities, atrophy and 1. Inspect for lesions atrophy lesions deformity, atrophy and Symmetrical Asymmetrical symmetry of shoulder and arms and elbow No signs of swelling, tremors, Swelling, deformities, redness, 2. Observe for swelling, deformities, redness, pallor or atrophy, pallor and clubbing tremors, deformed and atrophy of fingers (sign of poor clubbing of fingers, redness, oxygenation) pallor or atrophy of hands and fingers.

Lower Exremities No signs of swelling and Swelling of the knee may be a 1. Note the presence of lesions result of meniscal cyst swelling and lesions in the legs and knees. No deformities Clubfoot, flatfoot 2. Inspect for deformities on both feet Pinkish Cyanotic 3. Observe for the color and Convex curvature Spoon nail curvature of toenails

X. Neurological Assessment

Levels of Consciousness: Glasgow Coma Scale Faculty Measure Response Score Eye Opening Spontaneous 4 To verbal command 3 To pain 2 No response 1 Motor response To verbal command 6 Localizes pain 5 Flexes and withdraws 4 Assumes decorticate 3 posture Assumes decerebrate 2 posture No response 1 Verbal response Oriented, converses 5 Disoriented, converses 4 Uses inappropriate words 3 Makes incomprehensible 2 sounds No response 1 Cranial Nerve Functions and Assessment Methods Cranial Name Type Function Assessment Nerve Method I Olfactory Sensory Smell Ask the client to close eyes and identify different mild aromas, such as coffee, tobacco, etc. II Optic Sensory Vision and visual Ask client to fields read Snellen chart, check visual fields by confrontation; and conduct an ophthalmoscopic examination. III Oculomotor Motor Extraocular eye Assess six movement (EOM); ocular movement of movements and ciliary muscles of pupil reaction lens IV Trochlear Motor EOM, specifically Assess six moves eyeball ocular downward and movements laterally V Trigeminal Motor and Sensation of While the client . Opthalmic Sensory cornea, skin of looks upward, . Maxillary face, nasal lightly touch . Mandibular mucosa; Sensation lateral sclera of of skin of face and eye to elicit anterior oral cavity blink reflex; to (tongue and teeth); test light Movement of sensation, have muscles of client close eyes, mastication and wipe a wisp of sensation of skin cotton over of face client’s forehead and paranasal sinuses; to test deep sensation, use alternating blunt and sharp ends of a safety pin over some areas.

Ask client to clench teeth. VI Abducens Motor EOM; moves Assess eyeball laterally directions of gaze VII Facial Motor and Facial expression; Ask client to Sensory taste (anterior two- smile, raise the thirds of tongue) eyebrows, frown, puff out cheeks , close eyes VIII Auditory Sensory Assess methods . Vestibular Equilibrium; are discussed . Cochlear Hearing with cerebeller functions; Asses client’s function ability to hear spoken word and vibrations of tuning fork. IX Glossopharyngeal Motor and Swallowing ability Use tongue Sensory and gag reflex, blade on tongue movement, posterior tongue taste (posterior for tongue) identification; ask client to move tongue from side to side and up and down X Vagus Motor and Sensation of Assessed with Sensory pharynx and cranial nerve IX; larynx; assess client’s swallowing; vocal speech for cord movement hoarseness. XI Accessory Motor Head movement; Ask client to shrugging of shrug shoulders shoulders against resistance from your hands and turn head toside against resistance from your hand (repeat for other side). XII Hypoglossal Motor Protrusion of Ask client to tongue protrude tongue at midline , then to move it side to side.

Reflexes:

1. Biceps reflex – This reflex tests the spinal cord level C-5, C-6 - Partially flex the client’s arm at the elbow, and rest the forearm over the thighs, placing the palm of the hand down - Place the thumb of your nondominant hand horizontally over the biceps tendon - With other hand, hold the percussion hammer between thumb and index finger. - Deliver a blow (slight downward thrust) with the percussion hammer to your thumb). - Observe the normal slight flexion of the elbow, and feel the bicep’s contraction through your thumb

2. Patellar reflex – This reflex tests the spinal cord level L-2, L-3, L-4. - Ask the client to sit on the edge of the examining table so that the legs hang freely. - Locate the patellar tendon directly below the patella (kneecap). - Deliver a blow with the percussion hammer directly to the tendon. - Observe the normal extension or kicking out of the leg as the quadriceps muscle contracts. - If no response occurs and you suspect the client is not relaxed, ask the client to interlock fingers and pull. This action often enhances relaxation so that a more accurate response is obtained.

3. Plantar (Babinski) Reflex – This plantar, or Babinksi reflex is superficial. It may be absent in adults without pathology or overridden by voluntary control. - Use a moderately sharp object, such as the handle of percussion hammer, a key, or the dull end of a pin or applicator stick. - Stroke the lateral border of the sole of the client’s foot, starting at the heel, continuing to the ball of the foot, and then proceeding across the ball of the foot toward the big toe. - Observe the response. Normally, all five toes bend downward; this reaction is negative Babinksi. In an abnormal Babinksi response the toes spread outward and the big toe moves upward. Positive Babinksi is abnormal after the child ambulates.

Motor and Sensory Function Assessment Normal Findings Deviations from normal Motor Function 1. Walking gait. Ask the Has upright posture and Has poor posture and client to walk across the steady gait with opposing unsteady, irregular staggering room and back, and assess arm swing; walks unaided, gait with wide stance; bends the client’s gait. maintaining balance. legs only from hips; has rigid or no arm movements.

2. Romberg Test. Ask the Romberg’s sing: Cannot client to stand with feet Negative Romberg’s: May maintain foot stance; moves together and arms resting at swa slightly but is able to the feet apart to maintain the sides, first with eyes maintain upright posture and stance open, then closed. Stand foor stance. If client cannot maintain close during this tests to balance with the eyes shut, prevent the client from client may have sensory falling. ataxia. If balance cannot be maintained whether the eyes are open or shut, client may have cerebellar ataxia.

Assumes a wider foot gait to 3. Heel-Toe Walking. Ask the Maintains heel-toe walking say upright. client to walk a straight line, along straight line placing the heel of one foot directly in front of the toes of the other foot.

Anesthesia, hyperesthesia, Sensory Function Light tickling or touch hypoesthesia and paresthesia 1. Light-Touch Sensation. sensation Compare the light-touch sensation of symmetric areas of the body Areas of reduced, heightened, Able toi discriminate “sharp” or absentsensation (map them 2.Pain Sensation. Asses pain and “dull sensations out for recording purposes) sensation.

Unable to determine the Can readily determine the position of one or more 3. Position or Kinesthetic position of fingers and toes fingers or toes. Sensation. Commonly, the middle fingers and the large toes are tested for the kinesthetic sensation (sense of position).

Bibliography:

Bickley, Lynn; Szilagyi, Peter. Bates’ Guide to Physical Examination & History Taking (9th Edition). Philadelphia, Pennsylvania: Lippincott Williams and Wilking. 2007.

Fuller, Jill and Schallar-Ayers, Jennifer. Health Assessment: A Nursing Approach. Philadelphia, Pennsylvania: J.B. Lippincott Company. 1990

Kozier, Barbara, et.al. Fundamentals of Nursing: Concepts, Process, and Practice (5th Edition). Singapore: Pearson Education Asia Pte. Ltd. 2002

McCann, Judith, et.al. Assessment: A 2-in-1 Reference for Nurses. Ambler, Pennsylvania: Lippincott Williams and Wilkins. 2005.

Malasanos, Lois, et.al. Health Assessment. St. Louis, Missouri: C.V. Mosby Company. 1990