1

Head-To-Toe
Assessment

Group Members:
Binay, Rizalyn
Busa, Ana Marie
Cabiltes, Claitte
Diano, Christine
Nasayao, jannin
Ramos, Sunny
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Head-To-Toe Assessment
After 3 hours of classroom Discussion and Demonstration the
Level I students will be able to:
I. Define the FF. terms:
a. Nursing Assessment
b. Physical Assessment
c. Anthropometric Measurement
d. Health History
e. Health
f. Reflexes
g. Visual Activity
h. Interview
i. Signs
j. Symptoms
II.
a. Importance of Physical Assessment
b. Purpose of Physical Assessment
c. Four basic techniques in Physical Assessment
d. Principles involved in Physical Assessment
e. Nursing responsibilities before, during and after
Physical Assessment
f. Materials and Equipment used in Physical Assessment
III.
Demonstrate Beginning Skills in Physical Assessment.
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Head to Toe Assessment

Define the Following terms:

A. Nursing Assessment
- Is a major component of nursing care.
- Is a process which includes both physical and
psychological aspect to evaluate client’s condition.
- Enables the nurse to make a judgment about the
client’s health status , ability to manage his/her health
care and need for nursing.
B. Physical Assessment
- Is a process by which a nurse obtains a data that
describes a person’s responses to actual or potential
health problems shich is analyzed to form pertinent
diagnosis.
- Is a head to toe review of each body system that offers
objective information about the client and allows the
nurse to make clinical judgment.
C. Anthropometric Measurement
- Comparative measurements of the body.
Anthropometric measurements are used in nutritional
assessments. Those that are used to assess growth and
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development in infants, children, and adolescents

include length, height, weight, weight-for-length, and
head circumference (length is used in infants and
toddlers, rather than height, because they are unable to
stand). Individual measurements are usually compared
to reference standards on a growth chart. Measurement
of size weight and proportion of the body.
- Most commonly used anthropometric measured are
height, weight, triceps, skinfold thickness, elbow
breadth and arm and head circumference.
D. Health
- State of being physically fit, mentally stable and
socially comfortable.
- It encompasses more than the state of being free of
disease.
E. Health History
- defined as the systematic collection of subjective data
(stated by the client) and objective data (observed by
the nurse) used to determine a client’s functional
health pattern status.
F. Reflexes
- Bent, turned or directed back; or produced by a reflex
without intervention of consciousness.
- Is an involuntary and nearly instantaneous movement
in response to a stimulus.
G. Visual Acuity
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- The degree of detail the eye can discern an image.

- Is a quantitative measure of the ability to identify black
symbols on a white background at a standardized
distance as the size of the symbols is varied.
- Is acuteness or clearness of vision, especially form
vision, which is dependent on the sharpness of the
retinal focus within the eye and the sensitivity of the
interpretative faculty of the brain.
H. Interview
- An interview is a conversation between two or more
people (the interviewer and the interviewee) where
questions are asked by the interviewer to obtain
information from the interviewee. "Interview" word is
derived from french word "entirevior" it means
"glimpse" to each other.
- Therapeutic interaction that has a purpose.
I. Signs
- A sign is the physical manifestation of an illness, injury
or other bodily disorder. A sign is objective and can be
observed
- Signs can be felt, heard, seen, and measured by the diagnostician or
nurse. These include pulse, respirations, blood pressure, and physical
evidence such as bleeding, broken skin, bruising etc.
J. Symptoms
- Subjective evidence of a disease of physical
disturbance observed by the patient.
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- Is a departure from normal function or feeling which is

noticed by a patient, indicating the presence of disease
or abnormality. A symptom is subjective, observed by
the patient, and not measured.

Importance of Physical Assessment:

• To early detect and treat diseases and disorders.
• To identify actual and potential health problems.
• To establish a data based from which the subsequent phases
of the nursing evolve.
• To assess the client’s impact of activity and exercise on the
client’s overall level of health.
• To assess the client’s routine exercise pattern and observe
how the client’s body system response to activity and
exercise.
• To establish the client-nurse relationship
• To obtain information about the client’s health including,
physiologic, psychologic, sociocultural, cognitive,
developmental and spiritual aspects.
• To identify the client’s strength and weaknesses.

Purpose of Physical Assessment

• To supplement, confirm or refute data obtained in the
nursing history.
• To confirm and identify nursing diagnosis.
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• To make clinical judgments about a client’s changing health

status and management.
• To evaluate the physiological outcome of care.
• To obtain and gather data about the client’s health basis of
data for future assessment.
• An excellent way to evaluate an individual’s current health
status.

Four Basic Techniques in Physical Assessment

I. Inspection
It is the use of ones senses of vision and smell to
consciously observe the patient. It is also known as concentrated
watching. It is a close, careful scrutiny; first of the individual as a
whole and then of each body system. Inspection begins the
moment you first meet the individual and develop a “general
survey”. Then as you proceed through the examination, start the
assessment of each body system with inspection.

II. Palpation
It is the act of touching a patient in a therapeutic
manner to elicit specific information. It follows and often confirms
points you noted during inspection. Palpation applies your sense
of touch to assess these factors: texture, temperature, moisture,
organ location and size, as well as any swelling, vibration or
pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses and presence of tenderness or pain.
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Two distinct types of palpation: Light and deep palpation

• Light palpation
It is superficial, delicate and gentle. In light palpation,
the finger pads are used to gain information of the patient’s skin
surface to a depth of approximately ½ - 1 inch below the surface.
Light palpation reveals information on skin texture and moisture;
overt large or superficial masses; and fluid, muscle guarding and
superficial tenderness.
• Deep palpation
It can reveal information about the position of organs
and masses, as well as their size, shape, mobility, consistency,
and areas of discomfort. Deep palpation uses the hands to
explore the body’s internal structure to a depth of 1 to 2 inches or
more. This technique is most often used for the abdominal and
male and female reproductive assessments. Variations in this
technique are single handed and bimanual palpations.
III. Percussion
It is the technique of striking or tapping the person’s
skin with short, sharp strokes to assess underlying structures. The
strokes yield a palpable vibration and a characteristic sound that
depicts the location, size and density of the underlying organ.
These sounds also are diagnostic of normal and abnormal
findings. Any part of the body can be percussed, but only limited
information can be obtained in specific areas such as heart. The
thorax and abdomen are the most frequently percussed location.
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Four types of percussion techniques: Immediate or direct, mediate

or indirect, direct fist and indirect fist percussion

A. Immediate or Direct Percussion

The striking hand directly contacts the body wall. This produces a
sound and is used in percussing the infant’s thorax or the adult’s
sinus areas.
B. Mediate or Indirect Percussion
It is used more often and involves both hands. The striking
hand contacts the stationary hand fixed on the person’s skin. This
yields a sound and a subtle vibration.
C. Direct Fist Percussion
It is used to assess the presence of tenderness in internal
organs, such as the liver or the kidneys. The presence of pain in
conjunction with direct fist percussion indicated inflammation of
that organ or a strike of too high in intensity.
D. Indirect Fist Percussion
Its purpose is the same as direct fist percussion. In fact, the
indirect method is preferred over the direct method. It is because
in this methods. The non dominant hand absorbs some of the
force of the striking hand. The resulting intensity should be
sufficient force to produce pain in the patient if organ
inflammation is present
Percussion elicits five types of sounds:
1) Flatness (dull) – bone and muscle
2) Dullness (thudlike) – liver, spleen, heart
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3) Resonance (hollow) – air-filled lung/ normal lung

4) Hyperresonance – emphysematous lung
5) Tympany – stomach filled with gas (air)

IV. Auscultation
It is the act of active listening to the body organs to gather
information on patient’s clinical status. Auscultation includes
listening to sounds that are voluntarily and involuntarily
produced by the body such as the heart and blood vessels
and the lungs and abdomen. Auscultated sounds should be
analyzed in relation to their relative intensity, pitch, duration,
quality, and location.
Two types of auscultation: Indirect and direct auscultation:
1) Direct of Immediate auscultation
It is the process of listening with the unaided ear. This
can include listening to the patient from some distance
away or placing the ear directly on the patient’s skin
surface. And example is the wheezing that is audible to
the unassisted ear in a person having a severe
asthmatic attack.
2) Indirect or Mediate auscultation
It is the use of stethoscope, which transmits the sounds
to the nurse’s ear.

Principles involved in physical assessment:

Anatomy & Physiology
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One has to know the different parts and functions of the

body in order to do a thorough and detailed assessment.
Psychology
Through Psychology, we are able to make good assessments
because we can differentiate a normal mental state and an
abnormal one.
Privacy must be ensured during the Physical Assessment to
avoid the client from being anxious or uncomfortable.
Microbiology
Do medical handwashing before and after the procedure.
Instrument should be sterile.
Time and energy
Starts from lesser to the most sensitive part
Body mechanics
Nurse and patient should maintain proper body mechanics.

Nursing responsibilities before, during and after Physical

assessment

Before
• Always dress in clean professional manner, make sure you
have your name pin or workplace identification.
• Remove al bracelets, necklaces, or earrings that can
interfere during the physical assessment.
• Be sure your hair will not fall forward and obstruct your
vision or touch to the patient.
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• Ensure that all necessary equipment is ready for use and

within reach.
• Introduce yourself to the patient. Enlist the patient’s
cooperation by explaining what you are about to do, where it
will be done, and how it may feel.
• Explain to the patient why you may be spending a long time
performing one particular skill.
• Do medical hand washing
• Position the patient as dictated by the body system being
assessed.
• Warm all instruments prior to their use

During

• Conduct the assessment in a systematic fashion every time.

• While performing each step in the physical assessment
process you may need to inform the patient of what to
expect, where to expect it, and how it should feel.
• Avoid making crude or negative remarks, be cognizant of
your facial expression when dealing with malodorous and
dirty patients or with disturbing findings.
• Proceed from the least invasive to the most invasive
procedure for each body system.
• If the patient complains of fatigue, continue the assessment
later.
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After
• Provide recognition to the patient when the physical
assessment concluded; inform the patient what will happen
next.
• Place patient in a comfortable position.
• Do after care.
• Do medical hand washing.
• Document assessment findings in the appropriate section of
the patient record.

Materials and Instruments of Physical Treatment

Supplies Purpose
Flashlight or To assist in viewing of the pharynx and
penlight cervix or to determine the reaction of
the pupils of the eye.
Laryngeal or dental To observe the pharynx and oral cavity.
mirror
Nasal septum To permit visualization of the lover and
middle turbinates; usually a penlight is
used for illumination.
Ophthalmoscope A lighted instrument to visualize the
interior of the eye.
Otoscope A lighted instrument to visualize the
eardrum and external auditory canal (a
nasal speculum may be attached to the
Otoscope to inspect nasal cavities).
Percussion (reflex) An instrument with a rubber head to
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hammer test reflexes.

Tuning Fork A two-prolonged metal instrument used
to test hearing acuity and vibratory
sense.
Cotton applicators To obtain specimens.
Gloves To protect the nurse
Lubricant To ease the insertion of instruments
(ex.Vaginal Speculum)
Tongue blades To depress the tongue during
(depressors) assessment of the mouth and pharynx.

Various positioning of the patient

Dorsal recumbent
Back-lying position with knees flexed and hips externally
rotated; small pillow under the head; soles of feet on the surface.
Supine (horizontal recumbent)
Back-lying position with legs extended; with or without pillow
under the head
Sitting
A seated position. The back is unsupported and legs hanging
freely.
Lithotomy
Back-lying position with feet supported in stirrups; the hips
should be in line with the edge of the table.
Sims
Side-lying position with the lowermost leg flexed at the hip
and knee, upper arm flexed at the shoulder and elbow.
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Prone
Lies on the abdomen with head turned to the side, with or
without a small pillow.

Body Parts
Assessment of Body Parts Normal Findings
Head & Neck
Head
Inspection:
For size, shape & symmetry The head should be round
(normocephalic) and symmetrical.
Palpation:
For contour, masses, depressions. The normal skull is smooth, and
without masses or depressions,
non tender.
Hair
Inspection:
For color, evenness of growth over Can be black, brown or burgundy
the scalp, presence of parasites, depending on the race, evenly
amount of body hair. distributed covers the whole scalp
(no evidences of Alopecia), no
parasites, and the amount is
variable.

Palpation:
Thickness or thinness texture and Maybe thick or thin, coarse or
oiliness. smooth neither brittle nor dry.

Scalp
Inspection:
For Color, oiliness, presence of Lighter in color than the
scars, lice and dandruff. complexion, can be moist or oily,
no scars noted, free from lice, nits
and dandruff.
Palpation:
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For lesions or masses tenderness. NO lesions should be noted, neither

tenderness nor masses.

Forehead
Inspection:
For symmetry, skin appearance, Symmetrical, light to dark brown,
presence of rushes, scars or no rushes, scars and pimples.
pimples.

Palpation:
For masses, lumps and tenderness Non-tender, no lumps and absence
of masses.
Face
Inspection:
For shape and symmetry, presence The shape of the face can be oval,
of scars, pimples or acne round, or slightly square, the face
is symmetrical, absence of scars,
pimples or acne. There should be
no edema, disproportionate
structures, or involuntary
movements.

Palpation:
For any swelling, masses, lumps,
and the four sinuses (sphenoidal
sinuses, frontal sinuses, ethmoid
sinuses and maxillary sinuses).
No lumps and swelling of the face,
absence of masses and there is no
pain felt during palpation of face

Eyes
Inspection: Symmetrical or evenly placed and
For symmetry. inline with each other. Non
protruding and equal palpebral
fissure.

Eyebrows
Inspection:
For hair distribution and alignment Hair evenly distributed; skin intact.
and skin quality and movement, Eyebrows symmetrically aligned;
presence of pimples, dandruff and equal movement, absence of
color of the hair. pimples and dandruff, maybe black
brown or blond depending on race.
Palpation:
For the presence of lumps, pain No lumps, no nodules and no pain
and nodules. felt during palpation
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Eyelashes
Inspection:
For evenness of distribution and Equally distributed; curled sightly
direction of curl and color outward and black in color.

Sclera
Inspection:
For color, moisture, texture and the The sclera appears white, although
presence of lesions. blacks occasionally have a gray-
blue or “muddy” color to sclera. It
should be moist and without
lesions

Conjunctivae
Inspection: Both conjunctivae are shiny,
For lesions, swelling, color and smooth, and pink or red, absence
moisture. of swelling, no lesions and it should
be moist.

Palpation: There should be no pain felt during

Presence of pain palpation.

Cornea
Inspection:
For clarity, texture and moisture The corneal surface should be
moist, shiny and transparent, with
no discharges and cloudiness.
Iris
Inspection:
For appearance, coloration and The iris is normally appears flat,
shape. with a regular shape and even
coloration.

Pupil
Inspection:
For color size, shape and equality Black in color; appears round,
of the pupils regular, smooth border and of
equal size in both eyes, normally 3-
7 mm in diameter.

Muscle function
Corneal Light Reflex or the
Hirschberg Test

(Observe the location of reflected
light on the cornea)
Cover Test
This test detects small degrees of
deviated alignment by interrupting
the fusion reflex that normally
keeps two eyes parallel. (Observe
the cover eye for movement)
Diagnostic Position test
Leading the eye through the six
cardinal positions of gaze will elicit
any muscle weakness during
movement. (Observe for
convergence of gaze).
Muscle balance
Test for pupilary light
reflex(Cardinal Fields of Gaze)
Test for Accommodation
Visual Acuity
Snellen eye Chart
The Snellen eye chart is the most
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The reflected light (light reflexes)
should be seen symmetrically in
the centers of the cornea.
If the eyes are in alignment, there
will be no movement of the either
eye.
A normal response is parallel
tracking of the object with both
eyes. Both eyes should move
smoothly and symmetrically in
each of the six fields gaze and
convergence on the held object as it
moves toward the nose.
Normally you will see:
-Constriction of the same-sided
pupil (a direct light reflex).
-Simultaneously (a consensual light
reflex).
A normal response includes:
-Papillary constriction.
-Convergence of the axes of the eye.
Record the normal response to all
these maneuver as:
P - Pupils
E - Equal
R - Round
R - React to
L - Light and
A - Accommodation
Normal Visual is 20/20

commonly used and accurate
measure of visual acuity.
Peripheral Vision
Test Visual Fields
Confrontation Test
Nose
External Inspection:
Inspect the nose nothing any
bleeding, inflammation, or lesions,
masses, swelling, and symmetry,
discharges and color, sense of
smell.
External Palpation:
For tenderness and presence of
pain.
Internal Inspection:
Inspect for nasal septum for
deviation, perforation, lesions and
bleeding.
Frontal Sinuses
Inspection:
For any swelling around the eyes
Palpation:
19
The Top number (numerator)
indicates the distance the person is
standing from the chart, while the
denominator gives the distance at
which a normal eye could have
read that particular line. Thus
20/20 means you can read that 20
ft. with the normal eye could have
read at 20 ft.
The patient is able to see the
stimulus at about 90 degrees
temporally, 60 degrees nasally, 50
degrees superiorly, and 70 degrees
inferiorly.
The shape of the external nose can
vary greatly among individual.
Normally, it is located
symmetrically on the midline of the
face that is without swelling,
bleeding, lesions, or masses. No
discharge or flaring and uniform
color, there is a sense of smell.
Non-tender; absence of pain
The nasal mucosa should be pink
or dull red without swelling. The
septum is at the midline and
without perforation, lesions or
bleeding, the small amount of
watery discharge is normal.
There is no evidence of swelling
around the eyes.
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Presence of pain and tenderness The patient should not feel pain
during palpation and no tenderness
felt.
Percussion:
Note any sound The sound should be flat or dull.

Maxillary Sinuses
Inspection: There is no evidence of swelling
For any swelling around the eyes around the nose and eyes.
Palpation: The patient should not feel any
Presence of pain and tenderness pain and tenderness during
palpation.

Percussion:
Note any sound The sound should be flat or dull.

Transillumination of the sinuses

You may use this technique in the The glow on each side is equal,
frontal and maxillary sinuses when indication air-filled frontal and
you suspect sinus inflammation, maxillary sinuses.
although it is of limited usefulness.

Mouth
Lips
Inspection:
For color, texture, cracking, The lips should be pink, soft moist,
symmetry, lesions and hydration smooth texture with no evidence of
lesions or inflammation. Not crack
and symmetrical.
Palpation:
For any presence of pain, lumps There is no presence of lumps and
and tenderness. pain. It is tender.

Gums
Inspection:
For color, texture, swelling,
bleeding, retraction form the teeth
Palpation:
For the presence of pain,
tenderness and lumps.
The gums should be pink, moist,
firm texture, no retraction, no
swelling or bleeding. The gum
margins at the teeth are tight and
well-defined.
There should be no pain felt during
palpation, no lumps and non-
tender.
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Teeth
Inspection: The adult normally has 32 teeth,
For discoloration, numbers of tooth which should be white, straight
and texture. and smooth edges in proper
alignment or evenly placed, clean
and free of debris or decay.

Tongue The tongue is in the midline of the

Inspection:
For color, texture, surface
characteristics, symmetry,
presence of lesions, and sense of
taste.
Palpation:
For any nodules, lumps and
presence of pain
mouth, the dorsal surface should
be pink, moist, rough and without
lesions. The tongue is symmetrical
and moves freely. The strength of
the tongue is symmetrical and
strong.
The ventral surface of the tongue
ahs prominent blood vessels and
should be moist without lesions,
looks smooth and glistening. There
is a sense of taste.
There should be no presence of
nodules, lumps and pain.

Frenulum
Inspection:
For the color, texture. It should be attached to the tongue,
pinkish in color and moist.
Sublingual Area
Inspection:
For color, moisture and presence of It should be pink in color, moist
lesion. and no presence of lesions.

Hard palate
Inspection:
For color, shape, texture, presence The hard palate is concave and
of lesions and malformation. lighter in pink in color, it has many
ridges and it is moist, without any
lesion or malformation.
Soft Palate
Inspection:
For color, shape, texture, presence The soft palate is also concave and
of lesions, malformation light pink in color, it is smooth and
no lesions or malformations noted.
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Uvula
Inspection:
For position, mobility and color. It normally looks like a flesh
pendant hanging in the midline of
soft palate. Tonsils are present and
pink in color.

Tonsils It is pink in color and smooth. Oval

Inspection: in shape. No discharge. Of normal
For color, shape, size and size or not visible, no inflammation,
discharge. and not swollen.

Palpation: There should be no pain felt during

Presence of pain palpation.

Ears
External ear
Inspection:
For position, color, size, shape, any The ear matches the flesh color of
deformities, inflammation, or the rest of the patient’s skin and
lesions should be positioned centrally and
in proportion to the head. The top
of the ear should cross an
imaginary line drawn from the
outer canthus of the eye to the
occiput with no swelling or
thickening. Cerumen should be
moist and not obscure the
lympanic membrane. There should
be no foreign bodies, redness,
drainage, deformities, nodules or
lesions.

Palpation:
Presence of pain, tenderness, and They should feel firm (not tender)
lumps. and movement produce pain.

Auditory Acuity
Voice-Whisper test The patient should be able to
repeat words whispered from a
distance of 2 feet.
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Tuning fork test Measures hearing by air

conduction (AC) or by bone
conduction (BC), in which the
sound vibrates through the cranial
bones to the inner ear.

Weber’s Test The patient should perceive the

sound equally in both ears or “in
the middle”. No lateralization of
sound is known as negative
Webster test.

Rinne’s Test Air conduction is heard twice as

long a bone conduction when the
patient hears the sound through
the external auditory canal ( air )
after it is no longer heard at the
mastoid process ( bone ). This is
denoted as AC>BC.

Neck
Inspection:
For symmetry of the The muscles of the neck are
sternocleidomastoid muscles symmetrical with the head at a
anteriorly, and the trapezius central position. The patient is able
posteriorly. to move head through a full range
of motion without complaint of
discomfort or noticeable limitation.
The patient may be breathing
through a stoma or tracheostomy.

Palpation:
For the presence of masses and The muscles are symmetrical
tenderness. without palpable masses or spasm.

Lymph Nodes
Inspection:
For any enlargement or Lymph nodes should not be visible
inflammation. or inflamed.

Palpation:
For size, shape, dellimination, Normally, lymph nodes should not
mobility, consistency, and be palpable in the healthy adult
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tenderness patient; however, small, discrete,

movable nodes are sometimes
present but are of no significance.

Trachea
Palpation: Space should be systemic on both
sides or on central placement in
midline of neck; spaces are equal
on both sides.
Thyroid Gland
Inspection:
For symmetry and visible masses. Thyroid tissue moves up with
swallowing but often the movement
is so small it is not visible on
inspection. In males, the thyroid
cartilage, or Dm’s apple, is more
prominent than in females.
Palpation:
For nodules or enlargement and No enlargement, masses, or
tenderness. tenderness should be noted on
palpation.
Thorax
Chest Anterior
Inspection: For the breathing Quiet, rhythmic, and effortless
patterns, rate, depth, the coastal respirations. Breathing pattern
angle, shape of patient’s chest, and should be smooth. Costal angle is
color. less than 90°, and the ribs insert
into the spine at approximately a
45° angle. Normal rate of breathing
in adult is 46/16 per min. red
patches present, ribs sloping
downward with symmetric
interspaces. Colors should be even
and consistent with the color of the
patients face. Shoulder should be
at the same height. shape of thorax
– elliptical shape

Palpation:
For respiratory excursion. It should be full symmetric
Tenderness, masses and excursion; thumbs normally
temperature. separate to 3-5 cm (1 ½ to 2
in). Equal expansion, no
tenderness, no masses, skin should
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be warm and dry, no pulsation

should be present. Fremitus is
normally decreased over heart and
breast tissue.

Percussion:
For its different sound Normal lung tissue-resonant
sound, rib flat sound.

Auscultation: Air brushing through the

For full two breaths and sounds respiratory tract during inspiration
expiration generates different
breath sounds.

Lungs
Inspection:
For breath sounds over the Bronchial (loud, tubular) breath
following: sounds heard over trachea;
Trachea expiration longer than inspiration;
short silence between inspiration
and expiration.


Alveolar Tube (large-stem bronchi) Bronchovesicular breath sound
heard over main stem bronchi:
below clavicles and between
scapulae (inspiratory phase equal
to expiatory phase).

 Lung Field (lung periphery) Vesicular (low, soft, breezy) breath

sounds heard over lung periphery
(inspiration longer than expiration).

Heart
Palpation: No pulsation palpable over aortic
and pulmonic areas.

Auscultation: Apical has the loudest sound; it

For murmurs and sound should be 60-80 beats/min. No
murmurs should be heard.

Chest Posterior
Inspection:
For shape and symmetry, spinal Anteroposterior to transverse
alignment for deformities, color, diameter in ratio of 1.2; chest
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abnormal inspiratory. symmetric; spine column vertically

aligned. No patches, no abnormal
inspiratory retraction of
interspaces.

Palpation:
For clients who have no respiratory
complaints, temperature.
For clients who have respiratory
complaints.
For respiratory excursion
The skin should be intact; uniform
temperature.
The chest wall intact; uniform
temperature.
Full and symmetric chest
expansion. [Ex. When the client
takes a deep breath, your thumbs
should be move apart an equal
distance and at the same time;
normally the thumbs separate 3 to
5 cm (1½ to 2 in.) during deep
palpation].

For vocal and tactile fremitus Bilateral symmetry of vocal

fremitus. Fremitus is heard most
clearly at the apex of the lungs.
Low-pitched voices of males are
more readily palpated than higher
pitched voices of females.

Percussion:
For sounds Percussion notes resonate except
over scapula.

For diaphragm excursion Lowest point of resonance is at the

diaphragm. (Note: percussion on a
rib normally elicits dullness)

Auscultation:
For sounds Excursion is 3-5 cm (1½ to 2 in.)
bilaterally in women and 5-6 (2 to 3
in.) in men. Diaphragm is usually
slightly higher on the right side.
Vesicular and bronchovesicular
breathe sounds.

Abdomen
 27

Inspection:
-Color -Surface is uniform in color and in
pigmentation.
-Scars -Flawless no scars is present. If
scars are present draw its location
in the person’s record indicating
the length in cm.
-Striae -No striae / stretch marks are
present.
-Dilated Veins -A few small veins may be visible
normally.
-Rashes and lesions -No rashes or lesions are present.
-Umbilicus -Is normally in the midline and
inverted with no sign of
inflammation, discoloration or
hernia.
-The contour of the abdomen -Normally range from flat to
rounded.
-Hair distribution -Diamond shape in adult males,
inverted triangular shape in adult
female.
-Symmetry -Symmetric bilaterally and smooth.
-Respiratory movement -The abdomen rises with
inspiration and falls with
expiration.

Auscultation:
Auscultate the four quadrants for
basic sounds.
Auscultate over the aorta, renal,
iliac and femoral arteries. (Vascular
sounds)
High pitched, irregular gurgles (5-
35 times/ min) present equally in
all four quadrants. No bruits, no
venous hums, no friction.

Percussion:
Percuss the four quadrants to as
tympany and dullness.
Tympany is usually predominating
because of air in the stomach and
intestines. Dull sounds are heard
over solid masses such as liver,
spleen, and kidneys.

Right Upper Quadrant: Left Upper Quadrant:

- liver - stomach
- gallbladder - spleen
- duodenum - left lobe of liver
- head of pancreas - body of pancreas
 28

- right kidney and adrenal - left kidney and adrenal

- hepatic flexure of colon - spleen flexure of colon
- Part of ascending and transverse - part of transverse & descending
colon colon

Right Lower Quadrant: Left Lower Quadrant:

-Cecum -Part of descending colon
-Appendix -Sigmoid colon
-Right ovary and tube -Left ovary and tube
-Right ureter -Left ureter
-Right spermatic cord -Left spermatic cord

Midline:
-Aorta
-Uterus(if enlarged)
-bladder(if enlarged)

Palpation:
Perform palpation to judge the size,
location and consistency of certain
organs and to screen for an
abnormal mass or tenderness.

Light Palpation (1/2 - 1 inch) on all Normally there is no pain,

areas of abdomen moving clockwise tenderness, rigidity and muscle
and in rotary motion. guarding

Deep Palpation (2-3 inches) on all

areas on the abdomen moving Normally there is no pain,
clockwise and in rotary motion. tenderness, rigidity and muscle
guarding
Liver Palpation:
Located in the RUQ (Right Upper It feels like a firm rectangular ridge.
Quadrant).Place your left hand Often the liver is not palpable and
under the person’s back parallel to you feel nothing firm.
the 11th and 12th ribs and lift up
to support the abdominal contents.
Place your right hand on the RUQ
with fingers parallel to the midline.
Push deeply down and under the
right costal margin then ask the
person to take a deep breath.

Hooking Technique
An alternative method of palpating Normally you should feel nothing
 29

the liver. Stand up at the persons’ firm. When enlarged the spleen
shoulder and swivel your body to extends into the lower quadrants.
the right so that you face the
person’s feet. Hook your fingers
over the costal margin from above.
Ask the person to take a deep
breath then try to fell the liver edge
bump from your fingertips.

Spleen Palpation:
Search spleen by reaching your left A person normally feels a thud but
hand over the abdomen and behind no pain.
the left side at the 11th and 12th Sharp pain occurs with
ribs. Lift for support. Place your inflammation of kidneys or
hand obliquely on the LUQ with the paranephric area.
fingers pointing toward the left
axilla and just inferior to the rib
margin. Push your hand deeply
down and under the left costal
margin and ask the person to take
a deep breath.

Kidney
Percussion:
Indirect fist percussion causes the Lower pole of the kidney is round,
tissues to vibrate instead of smooth mass slide in between your
producing a sound. Locate kidney fingers.
by placing hand over the 12th rib
at the costoverbral angle on the
back. Thump that hand with the
ulnar edge of your other fist.

Palpation:
locate kidney by placing your hand
together in a duck-bill position at
the person;s right flank. Press your
two hands together firmly (you
need deeper palpation than that
used to liver and spleen) then ask
the person to take a deep breath.

Palpation:
Light palpation in all 4 quadrants
Deep palpation in all 4 quadrants
 30

Extremities
Upper and Lower
Inspection:
-Observe for size, color, contour, Both extremities are equal in size
symmetry and involuntary
movement

-Look for deformities, edema, and Have the same contour with
presence of lesions. prominences of joints.

- Always compare both extremities No involuntary movements. No

Palpation:
-Feel evenness of temperature.
Normally it should be even for all
the extremities.
edema. Color is even.
Temperature is warm and even.
Has equal contraction.

- Perform range of motion Can perform complete range of

motion

-Test for muscle strength Can counter act gravity and

resistance in ROM

Balance Test
Gait
Observe as the person walk 10-20 feet, turns and
returns to the starting point. Normally, the person moves with a
sense of freedom. The gait is smooth, rhythmic, and effortless,
the opposing arm swing is coordinated, and the turns are smooth.
Romberg’s Test
Ask the person to stand up with feet together and arms
at the side. Once in a stable position, ask the person to close the
eyes and to hold the position. Wait about 20 seconds. Normally, a
 31

person can maintain posture and balance even with the visual
orienting information blocked, although slight swaying may occur.
(Stand close to catch the person in case he or she falls)
Tandem Walking
Ask the person to walk straight line in a heel-to-toe fashion. This
decrease the base of support and will accentuate any problem
with coordination. Normally, the person can walk straight and stay
balance.
Coordination and Skilled Movements
Rapid Altering Movements (RAM)
Ask the person to pat the knees with both hands, lift up, turn
hands over, and pat the knees with the backs of the hands. Then
ask the person to do this faster. Normally, this is done with equal
turning and a quick rhythmic pace.
Finger-to-nose Test
Ask the person to close the eyes and to stretch out the arms. Ask
the person to touch the tip of his nose or her nose with each index
finger, alternating hands and increasing speed. Normally, this is
done with equal turning & a quick rhythmic pace.
Heel-to-shin Test
Test lower extremity coordination by asking the person who is in a
supine position, to place the heel on the opposite knee, and run it
down the shin from to the ankle. Normally, the person moves the
heel in a straight line down the skin.
Reflex
 32

It is an automatic response of the body to a stimulus. It is not

voluntarily learned or conscious.
Reflexes are tested using a percussion hammer. The response is
described from 0 to 4. Experience is necessary to determine
appropriate scoring of an individual. Several reflexes are normally
tested during the physical examination: a) the biceps reflex, b)
the triceps reflex, c) the brachioradialis reflex, d) the patellar
reflex, e) Achilles reflex, f) the plantar reflex.
Test the Reflex
The reflex response is guided on a 4 point scale:
4+ very brisk, hyperactive
3+ brisker than average, may indicate disease
2+ average, normal
1+ diminished, low normal
0 no response

Upper Extremity
Biceps Reflex (Flexion)
Support the person’s forearm on yours; this position relaxes, as
well as partially flexes, the person’s arm. Place your thumb on the
biceps tendon and strike a blow on your thumb. You can feel as
well as see the normal response, which are contraction of the
biceps muscle and the flexion of the forearm.
Triceps Reflex (Extension)
Tell the person to let the arm “just go dead” as you suspend it by
holding the upper arm. Strike the triceps tendon directly just
 33

above the elbow. The normal response is extension of the

forearm.
Brachioradialis Reflex (Flexion and Supination of the arm)
Hold the person’s thumbs to suspend the forearm in relaxation.
Strike the forearm directly, about 2 to 3 cm above the radial
styloid process. The normal response is flexion and supination of
the arm.

Lower Extremity
Quadriceps Reflex (patellar or knee jerk reflex)
Let the lower legs dangle freely to flex the knee and stretch the
tendons. Strike the tendon directly just below the patella.
Extension of the lower legs is the expected response.
Achilles Reflex
Position the person with the knee flexed and the hip externally
rotated. Hold the foot in dorsiflexion, and strike the Achilles
tendon directly. Feel the normal response as the foot plantar
flexes against your hand.
Plantar Reflex
Position the thigh in slight external rotation. With the reflex
hammer, draw a light stroke up the lateral side of the sole of the
foot and inward across the ball of the foot, like an upside-down J.
The normal response is plantar flexion if all the toes and inversion
and flexion of the forefoot.
 34

Appendices
 35

Equipment and supplies used for a Health Examination

Flashlight or Penlight Otoscope

Dental Mirror Opthalmoscope

Tuning Fork
Cotton Applicators

Tongue Depressors Gloves

Lubricant Nasal Speculum Percussion Hammer
 36

Various Positioning of the Client

Dorsal Recumbent Lithotomy

Sims Horizontal Recumbent or Supine

Prone
Sitting or High Fowlers
 37

Basic Techniques used in Physical Assessment

Indirect Percussion
Direct Percussion

Deep Palpation
 38

Light Palpation

Parts of the Eye

 39

Snellen Eye Chart

 40

Sinus’ Locations

Side View
 41

Front View
Structures of the Mouth
 42

Structures of the Ear

Lymph Nodes of the Head and Neck

 43

External & Internal Lymphatic Drainage

Areas to Auscultate and Palpate on Chest

 44

Palpation of Thoracic Expansion

Posterior Anterior

Intercostal Landmarks for Percussion & Auscultation of Thorax

Posterior Normal Percussive Notes (Posterior)

 45

Normal Percussive Notes (Anterior)

Anterior

Respiration Patterns
 46

Type Description Pattern Clinical Indication

Normal 12 to 20/min & Normal Breathing Pattern
regular

Tachypnea >24/min & May be normal response

shallow to fever, anxiety or
exercise; can occur with
respiratory insufficiency,
alkalosis, pneumonia or
pleurisy
Bradypnea <10/min & May be normal in well
regular conditioned athletes; Can
occur with medication
induced depression of the
respiratory system,
diabetic, coma,
neurological damage.
Hyperventila Increased rate & Usually occurs with
tion depth extreme exercise, fear or
anxiety
Kussmauls’ respiration is
a type of hyperventilation
associated with diabetic
ketoacidosis.
Other causes of
Hyperventilation include
disorders of the central
nervous system, an
overdose of drug
salicylate or severe
anxiety
Hypoventilati Decreased rate & Usually associated with
on depth, irregular overdose of narcotics of
pattern anesthetics
Cheyne- Regular pattern May result from severe
Stokes characterized by congestive heart failure,
Respiration alternating drug overdose, increased
periods of deep intracranial pressure or
rapid breathing renal failure. May be
followed by noted in elderly positions
periods of apnea during sleep not related
to any disease process.
Biot’s Irregular pattern May be seen with
Respiration characterized by meningitis or severe
varying depth and brain damage
 47

rate of
respirations
followed by
periods of apnea

Adventitious Sounds
Sound Site Cause Character
Auscultated
Crackles Are most Random, Fine crackles are high-
commonly sudden pitched fine short
heard in reinflation of interrupted crackling
dependent groups of sounds heard during end of
lobes; right alveoli; inspiration, usually not
and left disruptive cleared with coughing.
lung bases. passage of Moist crackles are lover,
air more moist sounds heard
during the middle of
inspiration; not cleared with
coughing. Coarse crackles
are loud, bubbly sounds
heard during inspiration not
cleared with coughing
Ronchi Are Muscular Are loud low – pitched,
(sonorous wheeze) primarily spasm, fluid rumbling coarse sounds
heard over or mucus in heard most often during
trachea and larger inspiration and expiration;
bronchi; if airways, may be cleared by
loud cause coughing.
enough, turbulence.
can be
heard over
most lung
fields
Wheezes Can be High – Are high-pitched continuous
(sibilant wheeze) heard all velocity musical sounds like a
over lung airflow squeak heard continuously
fields through during inspiration, or
severely expiration; usually louder
narrowed on expiration
bronchus

Pleural Friction Rub Is heard Inflamed Has dry, grating quality

over pleura, heard best during
anterior parietal inspiration; does not clear
 48

lateral lung pleura with coughing, heard

field (if rubbing loudest over lower lateral
patient is against anterior surface.
sitting visceral
upright) pleura

Palpation of the Heart

Locate the apical pulse with the palmar surface.

Palpate the apical pulse with the fingerpad.

 49

Abdominal Viscera and Vascular Structures

Abdominal Quadrants
Abdominal Viscera and Vascular
Structures

Vascular sounds and friction rubs can best be heard over these areas
 50

Palpation of the liver Spleen Palpation

Kidney Palpation
 51

Common Tests for Coordination

Finger-to-nose test

Heel-to-sheen test
 52

Testing rapid alternating movements of palms

Common Tests for Reflexes

Briceps Reflex Brachioradialis Reflex

Triceps Reflex
 53

Testing for ankle clonus

Plantar Reflex
 54

Expected Auscultation Sounds (Anterior) Sites for Auscultating the Abdomen

Sites for Auscultating the Abdomen

 55

Percussion Sites for all Quadtrants

Tactile Fremitus (Posterior) Expected Auscultation Sounds (Posterior)

 56

Diaphragmatic Excursion