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 1. Observe body build, height and weight in relation to clients lifestyle and health 2. Observe the clients posture and gait 3. Observe the clients overall hygiene and grooming. Relate these to the persons activities

Normal Findings Proportionate, varies with lifestyle

Deviations from normal Excessively thin or obese

Relaxed erect posture; coordinated movements Clean, neat

Tense, slouched, bent posture; uncoordinated movements; tremors Dirty, unkempt

prior to the assessment. 4. Note body and breath odor in relation to activity level. 5. Observe for signs of distress in posture or facial expression 6. Assess the clients attitude 7. Note the clients affect/mood: assess the appropriateness of the clients responses 8. Listen for quantity of speech, quality and organization (coherence of thought, over generalization, vagueness) No body odor or minor body odor relative to work or exercise; no breath odor No distress noted Foul body odor; ammonia odor; acetone breath odor; foul breath Bending over because of abdominal pain; wincing or labored breathing Negative; hostile; withdrawn Inappropriate to situation

Cooperative Appropriate to situation

Understandable, moderate pace; exhibits thought association

Rapid or slow pace; uses generalization; exhibits confabulation; lacks association

II. Vital Signs Assessment 1. Obtain blood pressure, pulse rate, respiratory rate, and body temperature

Normal Findings BP = 100/70 130/90 mmHg PR = (female) 60-100 bpm (male) 55-95 bpm RR = 15-20 cpm

Deviations from normal Hypotension/hypertension Tachycardia Bradycardia Tachypnea = rapid rate Bradypnea = slow rate dyspnea = difficulty of breathing Hyperthermia Hypothermia

Temp. = 35.9 37 C

III. Head Assessment Skull and Face 1. Inspect the scalp for size and shape and symmetry

Normal Findings Rounded (normocephalic and symmetrical with frontal parietal and occipital prominences); smooth skull contour

Deviations from normal Lack of symmetry; increased skull size with more prominent nose and forehead; longer mandible (may indicate excessive growth hormone or increased bone thickness) Sebaceous cysts; local deformities from trauma

2. Palpate the skull for Smooth, uniform nodules or masses and consistency; absence of 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 (e.g. symmetry of structures and of the distribution of hair) 4. Inspect the eyes for edema and hollowness 5. Note symmetry of facial movements. Ask the client to elevate the eyebrows, from, or lower the eyebrows, close the eyes tightly, puff the cheeks, and smile and show the teeth Eye structure and Visual Acuity 1. Inspect the eyebrows for hair distribution and alignment and skin quality and movement (ask client to raise and lower the Symmetrical facial movements Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

Increased facial hair; thinning of eyebrows; asymmetric features; exopthalmos; myxedema facies; moonface Periorbital edema; sunken eyes Asymmetric facial movements (e.g. eye on affected side cannot close completely); drooping of lower eyelid and mouth; involuntary facial movements (i.e. ticks or tremors) Loss of hair, scaling and flakiness of skin; unequal alignment and movement of eyebrows

Hair evenly distributed; skin intact; eyebrows symmetrically aligned; equal movement.

eyebrows) 2. Inspect the eyelashes for evenness of distribution and direction of curl 3. Inspect the eyelids for surface characteristics position in relation to the cornea, ability to blink, and frequency of blinking. For proper visual examination of the eyelids, elevate the eyebrows with your thumb and index finger and have the client close the eyes. Inspect the lower eyelids where the clients eyes are closed. 4. Inspect the bulbar conjunctiva for color, texture, and the presence of lesions. Retract the eyelids 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 conjunctiva by everting the lids. Note color, texture, 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 lacrimal gland 7. Inspect and palpate the lacrimal sac and nasolacrimal duct Equally distributed; curled slightly outward Skin intact; no discharge; no discoloration Lids close symmetrically Approximately 15-20 involuntary blinks/min; bilateral blinking When lids open, no visible sclera above corneas and upper and lower borders of cornea are slightly covered Turned inward

Redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions. Lids close asymmetrically, incompletely or painfully. Rapid, monocular, absent, or infrequent blinking. Ptosis, ectropion, or entropion; rim of sclera visible between lid and iris

Transparent; capillary sometimes evident; sclera appears white

Jaundiced sclera; excessively pale sclera; reddened sclera; lesions or nodules.

Shiny, smooth, and pink or red

Extremely pale; extremely red; nodules or other lesions.

No edema or tenderness over lacrimal gland No edema or tearing

Swelling or tenderness over lacrimal gland Evidence of increased tearing; regurgitation of fluid on palpation of

lacrimal sac 8. Inspect the pupil for color, shape, and symmetry of size Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border, iris flat and round Cloudiness, mydriasis, miosis, anisocoria; bulging of iris toward cornea Neither pupil constrict Unequal responses Absent reponses

9. Assess each pupils direct Illuminated pupil constricts and consensual reaction to (direct response) light Non-illuminated pupil constricts (consensual response) 10. Assess each pupils reaction to accommodation Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose. When looking straight ahead, client can see object in the periphery Both eyes coordinated, move in unison, with parallel alignment

One or both pupils fail to constrict, dilate, or converge

Visual fields 11. Assess peripheral visual fields Extraocular muscle tests 12. Assess six ocular movements to determine eye alignment and coordination Visual Acuity 13. Assess near vision by 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 14. Assess distance vision

Visual fields smaller than normal; one-half vision in one or both eyes. Eye movements not coordinated or parallel; one or both eyes fail to follow a penlight in specific directions (e.g. strabismus) Difficulty reading newsprint unless due to aging process

Able to read newsprint

20/20 vision on Snellen Chart

Denominator of 40 or more on Snellen Chart

Ears and Hearing 1. Inspect the auricles for color, symmetry of size and position. To inspect position, note the level at which the superior aspect of the auricle attaches to the head in relation to the eye 2. Palpate the auricles for texture, elasticity and areas of tenderness Gently pull the auricle upward and backward Fold the pinna forward (it should recoil) Push in on the tragus Apply pressure to the mastoid process 3. Inspect the external ear canal for cerumen, skin lesions, pus, and blood 4. Inspect the tympanic membrane for color and gloss

Color same as facial skin Symmetrical Auricle aligned with outer canthus of eye above 10 degrees from vertical

Bluish color of earlobes; pallor; excessive redness Asymmetry Low set ears (associated woth a congenital abnormality, such as Down Syndrome

Mobile, firm and not tender Pinna recoils after it is folded

Lesions; flaky, scaly skin; tenderness when moved or pressed

Dry cerumen, grayish tan color; or sticky, wet cerumen in various shades of brown Pearly gray color, semitransparent

Redness and discharge Scaling Excessive cerumen obstructing canal Pink to red, some opacity Yellow amber White Blue or deep red Dull surface Normal voice tones not audible (e.g. requests nurse to repeat words or statements, leans toward the speaker, turns the head, cups the ears, or speaks in loud tone of voice) Unable to hear ticking in one or both ears

Gross hearing acuity test 5. Assess clients response to normal voice tones. If client has difficulty hearing the normal voice, proceed with the following tests.

Normal voice tones audible

5A. Perform the watch tick test. The ticking of a watch

Able to hear ticking in both

has a higher pitch than the human voice. Have the client occlude one ear. Out of the clients 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 Perform Webers test to assess bone conduction.

ears

Sound is heard in both ears or is localized at the center of the head (Weber negative)

Sound is heard better in impaired ear, indicating a bone-conductive hearing loss or sound is heard better in ear without a problem, indicating a sensorineural disturbance (Weber positive)

Conduct the Rhinne test to compare air conduction to bone conduction.

Bone conduction time is Air-conducted (AC) hearing equal to or longer than the is greater than the boneair conduction time. conducted (BC) hearing, i.e., AC > BC (positive Rhinne) Assymetric Discharge from nares Localized areas of redness or presence of skin lesions Tenderness on palpation; presence of lesions Air movement is restricted in one or both nares

Nose and Sinuses 1. Inspect the external nose for any deviations in shape, size or color and flaring or discharge from the nares. 2. Lightly palpate the external nose. 3. Determine patency of both nasal cavities. Ask the client to close the mouth, exert pressure on one nares and breath through the opposite nares. 4. Observe for the presence

Symmetric and straight No discharge or flaring Uniform color Non-tender No lesions Air moves freely as the client breathes though the nares

Mucosa pink

Mucosa red, edematous Abnormal discharge (e.g.

of redness, swelling, growths, and discharge

Clear watery discharge No lesions

purulent) Presence of lesions (e.g. polyps) Septum deviated to the right or to the left Tenderness in one or more sinuses. Pallor; cyanosis Blisters; swelling; fissures, crust or scales. Inability to purse lips Pallor; white patches Excessive dryness Mucosal cysts; irritations from dentures; abrasions, ulcerations; nodules. Missing teeth; ill-fitting dentures Brown or black discoloration of the enamel Excessively red gums Spongy texture; bleeding; tenderness Receding, atrophied gums; swelling that partially covers the teeth. Deviated from center (may indicate damage to hypoglossal) ; excessive trembling Smooth red tongue Dry furry tongue

5. Inspect the nasal septum between the nasal chambers 6. Palpate the maxillary and frontal sinuses Mouth 1. Inspect the outer lips for symmetry of contour, color and texture. Ask the client to purse the lips as if to whistle. 2. Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture, and the presence of lesions. 3. Inspect the teeth and gums while examining the inner lips and buccal mucosa.

Nasal septum intact and in midline Not tender

Uniform pink color Soft, moist, smooth texture Symmetry of contour Ability to purse lips Uniform pink color Moist, smooth, soft, glistening, and elastic texture 32 adult teeth Smooth, white, shiny tooth enamel Pink gums Moist, firm texture to gums No retraction of gums

Tongue 4. Inspect the surface of the tongue for position, color, and texture. Ask the client to protrude the tongue.

Central position

Pink color; moist; slightly rough; thin whitish coating. Smooth lateral margins; no lesions. Raised papillae (taste buds) Nodes, ulcerations, discoloration; areas of tenderness.

Palates and uvula 5. Inspect the hard and soft palate for color, shape, texture and the presence of bony prominences. Ask the client to open the mouth wide and tilt the head backward. 6. Inspect the uvula for position and mobility while examining the palates. To observe the uvula, ask the client to say ah so that the soft palate rises. 7. Inspect the tonsils for color, discharge and size. 8.Elicit gag reflex by pressing the posterior tongue with a tongue depressor. IV. Neck Assessment

Light pink, smooth, soft palate Lighter pink hard palate, mote irregular texture

Discoloration Palates the same color Irritations Bony growths growing from the hard palate.

Deviation to one side from Positioned in midline of soft tumor or trauma; palate. immobility

Pink and smooth No discharge Present

Inflamed Presence of discharge Swollen Absent

Normal Findings

Deviations from Normal

Neck muscles 1. Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal swellings or masses. Ask the client to hold the head erect. 2. Observe head movement.

Muscles equal in size; head centered

Unilateral neck swelling; head tilted to one side.

Coordinated, smooth movements with no discomfort

Muscle tremor, spasm, or stiffness Limited range of motion; painful movements; involuntary movements. Enlarged, palpable, possibly tender Deviation to one side, indicating possible neck tumor; thyroid enlargement; enlarged lymph nodes.

3. Palpate the entire neck for enlarged lymph nodes.

Not palpable

4. Palpate the trachea for Central placement in lateral deviation. Place your midline of neck; space are fingertip or thumb on the equal on both sides. trachea in the suprasternal 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. Observe the lower half of the neck overlying the thyroid gland for symmetry and visible masses. Ask the client to hyperextend the head 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

Not visible

Visible diffuseness or local enlargement.

Gland ascends during swallowing but it is not visible

Gland is not fully movable with swallowing.

V. Chest and Back Assessment Normal findings Deviations from normal

Posterior thorax 1. Inspect the shape and symmetry of the thorax from posterior and lateral views. Compare the anteroposterior diameter to the transverse diameter. 2. Inspect the pinal alignment for deformities. Have the client stand. From a lateral position, observe the three normal curvatures: cervical, thoracic, and lumbar. To assess for lateral deviation of spine (scoliosis), observe the standing client from the rear. Have the client bend forward at the waist and observe from behind. 3. Palpate the posterior chest for respiratory excursion (thoracic expansion). Place the palms of both your hands over the lower thorax with your thumbs adjacent to the spine and your fingers stretched 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 vocal (tactile) fremitus, the faintly perceptible vibration felt through the chest wall when the client speaks. 5. Percuss the thorax.

Anteroposterior to transverse diameter in ratio of 1:2 Chest symmetric Spine vertically aligned

Barrel chest;increased anteroposterior to transverse diameter Chest asymmetric Exaggerated spinal curvatures (kyphosis, lordosis)

Spinal column is straight, right and left shoulders and hips are at the same height.

Spinal column deviates to one side, often accentuated when bending over. Shoulders or hips not even.

Full and symmetric chest expansion (i.e., when the client takes a deep breath, your thumbs should move apart an equal distance and at the same time; normally the thumbs separate 3 to 5 cm during deep inspiration)

Asymmetric and/or decreased chest expansion.

Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs. Percussion notes resonate, except over scapula

Decreased or absent fremitus (associated with pneumothorax) Increased fremitus (associated with pneumonia) Asymmetry in percussion Areas of dullness or flatness

VI. Abdomen Assessment Normal findings Deviations from normal

Inspection of the abdomen 1. Inspect the abdomen for skin integrity.

Unblemished skin Uniform color Silver white straie or surgical scars

Presence of rash or other lesions Tense, glistening skin Purple striae

2. Inspect the abdomen for contour and symmetry: Observe the abdominal contour (rib margin to pubic bone) while standing at the client is supine. Ask the client to take a deep breath and to hold it (makes an enlarged liver or spleen more obvious). Assess the symmetry of contour If distention is present, measure the abdominal girth. Auscultation of the abdomen 3. Auscultate for bowel sounds. Percussion of the abdomen 4. Percuss several areas in each of the four quadrants to determine presence of tympany and dullness. Begin in the lower left quadrant, proceed to the lower right quadrant, the upper right quadrant, and the upper left quadrant. Palpation of the abdomen 5. Perform light palpation first to detect areas of tenderness and/ or muscle guarding.

Flat, rounded, or scaphoid (concave)

Distended

No evidence of enlargement of liver or spleen

Evidence of enlargement of liver or spleen

Symmetric contour

Asymmetric contour

Audible bowel sounds

Absent (none heard in 3 5 minutes) Hypoactive (1 per minute) Hyperactive (every 3 sec.) Large dull areas

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder.

No tenderness; relaxed abdomen with smooth, consistent tension.

Tenderness and hypersensitivity. Superficial masses Localized area of increased tension.

VII. Genito-Urinary Assessment Female 1. Observe for the distribution, amount and characteristic of pubic hair.

Normal Findings

Deviations from normal

There are wide variations; Scant pubic hair (may indicate generally kinky in the hormonal problem) menstruating adult, thinner 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 area for parasites (e.g. lice), inflammation, swelling, and lesions(e.g. fissures, excoriations, scars from episiotomies, varicosities, leukoplakia). 3. Palpate inguinal lymph nodes

Pubic skin intact, no leasions Skin of vulva area slightly darker than the rest of the body

Lice, lesions, scars, fissures, swelling, erythema, or leukoplakia.

Enlargement and tenderness No enlargement or tenderness Scant amount or absence of hair Presence of lesions, nodules, swellings, or inflammation

Male
1. Inspect the distribution and characteristics of pubic hair 2. Inspect the penile shaft and glans penis for lesions, nodules, swellings and inflammation. 3.Inspect the urethral meatus for swelling, inflammation, and discharge. Triangular distribution, often spreading up the abdomen Penile skin intact Appears slightly wrinkled and varies in color as widely as other body skin Pink and slitlike appearance Positioned at the tip of the penis

Inflammation; discharge Variation in meatal locations (e.g., hypospadias, on the underside of the penile shaft, and epispadias, on the upper side of the penile shaft) Swelling or bulge (possible inguinal or femoral hernia)

4. Inspect both inguinal areas

No swelling

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 1. Inspect for muscle size. Compare the muscles on one side of the body (e.g. of the 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 tendons for contractures (shortening). 3. Inspect the muscles for fasciculations and tremors. 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 determine muscle tonicity (the normal condition of tension, or tone, of a muscle at rest). 5. Palpate muscles while the client is active and passive for flaccidity, spasticity, and Normal Findings Equal size on both sides of body Deviations from normal Atrophy (a decrease in size) or hypertrophy (an increase in size)

No contractures

Malposition of body part (e.g. foot fixed in dorsiflexion) Presence of fasciculation or tremor

No fasciculations or tremors

Normally firm

Atonic (lacking tone)

Smooth coordinated movements

Flaccidity (weakness or laxness) or spasticity (sudden involuntary muscle

smoothness of movement. 6. Test Muscle Strength 7. Palpate bones to locate any areas of edema or tenderness Equal strength on each body side No tenderness or swelling

contraction) Unequal strength or extreme weakness on either side. Presence of tenderness or swelling (may indicate fractures, neoplasms, or osteoporosis). One or more swollen joints Presence of tenderness, swelling, crepitation, or nodules

8. Inspect the joints for swelling 10. Palpate each joint for tenderness , smoothness of movement, swelling, crepitation, presence of nodules. 11. Assess joint range of motion

No swelling No tenderness, swelling, crepitation, or nodules Joints move smoothly

Varies to some degree in accordance with persons genetic makeup and degree of physical activity No lesions, deformities and atrophy Symmetrical No signs of swelling, tremors, deformities, redness, pallor or atrophy

Limited range of motion in one or more joints.

Upper Extremities
1. Inspect for lesions deformity, atrophy and symmetry of shoulder and arms and elbow 2. Observe for swelling, tremors, deformed and clubbing of fingers, redness, pallor or atrophy of hands and fingers. Lower Exremities
1.

Deformities, atrophy and lesions Asymmetrical Swelling, deformities, redness, atrophy, pallor and clubbing of fingers (sign of poor oxygenation)

Note the presence of swelling and lesions in the legs and knees. 2. Inspect for deformities on both feet

No signs of swelling and lesions No deformities Pinkish

Swelling of the knee may be a result of meniscal cyst Clubfoot, flatfoot Cyanotic

3. Observe for the color and curvature of toenails

Convex curvature

Spoon nail

X. Neurological Assessment Levels of Consciousness: Glasgow Coma Scale Faculty Measure Eye Opening Response Spontaneous To verbal command To pain No response To verbal command Localizes pain Flexes and withdraws Assumes decorticate posture Assumes decerebrate posture No response Oriented, converses Disoriented, converses Uses inappropriate words Makes incomprehensible sounds No response Score 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1

Motor response

Verbal response

Cranial Nerve Functions and Assessment Methods Cranial Name Type Function Nerve I Olfactory Sensory Smell

II

Optic

Sensory

Vision and visual fields

III

Oculomotor

Motor

IV

Trochlear

Motor

Extraocular eye movement (EOM); movement of ciliary muscles of lens EOM, specifically moves eyeball downward and

Assessment Method Ask the client to close eyes and identify different mild aromas, such as coffee, tobacco, etc. Ask client to read Snellen chart, check visual fields by confrontation; and conduct an ophthalmoscopic examination. Assess six ocular movements and pupil reaction Assess six ocular movements

Trigeminal Opthalmic Maxillary Mandibular

Motor and Sensory

laterally Sensation of cornea, skin of face, nasal mucosa; Sensation of skin of face and anterior oral cavity (tongue and teeth); Movement of muscles of mastication and sensation of skin of face

While the client looks upward, lightly touch lateral sclera of eye to elicit blink reflex; to test light sensation, have client close eyes, wipe a wisp of cotton over clients 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. Assess directions of gaze Ask client to smile, raise the eyebrows, frown, puff out cheeks , close eyes Assess methods are discussed with cerebeller functions; Asses clients function ability to hear spoken word and vibrations of tuning fork. Use tongue blade on posterior tongue for

VI VII

Abducens Facial

Motor Motor and Sensory

EOM; moves eyeball laterally Facial expression; taste (anterior twothirds of tongue)

VIII

Auditory Vestibular Cochlear

Sensory Equilibrium; Hearing

IX

Glossopharyngeal

Motor and Sensory

Swallowing ability and gag reflex, tongue movement, taste (posterior

tongue)

Vagus

Motor and Sensory

XI

Accessory

Motor

Sensation of pharynx and larynx; swallowing; vocal cord movement Head movement; shrugging of shoulders

XII

Hypoglossal

Motor

Protrusion of tongue

identification; ask client to move tongue from side to side and up and down Assessed with cranial nerve IX; assess clients speech for hoarseness. Ask client to shrug shoulders against resistance from your hands and turn head toside against resistance from your hand (repeat for other side). Ask client to 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 clients 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 biceps 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 clients 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 Motor Function 1. Walking gait. Ask the client to walk across the room and back, and assess the clients gait. 2. Romberg Test. Ask the client to stand with feet together and arms resting at the sides, first with eyes open, then closed. Stand close during this tests to prevent the client from falling. Normal Findings Has upright posture and steady gait with opposing arm swing; walks unaided, maintaining balance. Deviations from normal Has poor posture and unsteady, irregular staggering gait with wide stance; bends legs only from hips; has rigid or no arm movements. Rombergs sing: Cannot maintain foot stance; moves the feet apart to maintain stance If client cannot maintain balance with the eyes shut, client may have sensory ataxia. If balance cannot be maintained whether the eyes are open or shut, client may have cerebellar ataxia. Assumes a wider foot gait to say upright.

Negative Rombergs: May swa slightly but is able to maintain upright posture and foor stance.

3. Heel-Toe Walking. Ask the client to walk a straight line,

Maintains heel-toe walking along straight line

placing the heel of one foot directly in front of the toes of the other foot. Anesthesia, hyperesthesia, hypoesthesia and paresthesia

Sensory Function
1. Light-Touch Sensation. Compare the light-touch sensation of symmetric areas of the body 2.Pain Sensation. Asses pain sensation.

Light tickling or touch sensation

Able toi discriminate sharp and dull sensations

Areas of reduced, heightened, or absentsensation (map them out for recording purposes) Unable to determine the position of one or more fingers or toes.

3. Position or Kinesthetic Sensation. Commonly, the middle fingers and the large toes are tested for the kinesthetic sensation (sense of position).

Can readily determine the position of fingers and toes

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