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HEAD-TO-TOE ASSESSMENT FUND

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A. HEAD (Skull, Scalp and Hair)

1. Observe the size, shape and contour of the skull.


2. Observe scalp in several areas by separating the hair at various locations; inquire
about any injuries. Note presence of lice, nits, dandruff or lesions.
3. Palpate the head by running the pads of the fingers over the entire surface of
skull; inquire about tenderness upon doing so. (wear gloves if necessary)
4. Observe and feel the hair condition.

Normal Findings:

Skull
· Generally round, with prominences in the frontal and occipital area.
(Normocephalic).
· No tenderness noted upon palpation.

Scalp
· Lighter in color than the complexion.
· Can be moist or oily.
· No scars noted.
· Free from lice, nits and dandruff.
· No lesions should be noted.
· No tenderness nor masses on palpation.

Hair
· Can be black, brown or burgundy depending on the race.
· Evenly distributed covers the whole scalp (No evidences of Alopecia)
· Maybe thick or thin, coarse or smooth.
· Neither brittle nor dry.

B. FACE

1. Observe the face for shape.


2. Inspect for Symmetry.
a. Inspect for the palpebral fissure (distance between the eye lids); should
be equal in both eyes.
b. Ask the patient to smile, There should be bilateral Nasolabial fold
(creases extending from the angle of the corner of the mouth). Slight
asymmetry in the fold is normal.
c. If both are met, then the Face is symmetrical
3. Test the functioning of Cranial Nerves that innervates the facial structures

a. CN V (Trigeminal)
1. Sensory Function
· Ask the client to close the eyes.
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· Run cotton wisp over the fore head, check and jaw on both sides of the face.
· Ask the client if he/she feel it, and where she feels it.
· Check for corneal reflex using cotton wisp.
· The normal response in blinking.

2. Motor function
· Ask the client to chew or clench the jaw.
· The client should be able to clench or chew with strength and force.

b. CN VII (Facial)
1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
· Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
· Normally, the client can identify the taste.
2. Motor function
· Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the
cheeks.

Normal Findings:
· Shape maybe oval or rounded.
· Face is symmetrical.
· No involuntary muscle movements.
· Can move facial muscles at will.
· Intact cranial nerve V and VII.

C. EYEBROWS, EYES and EYELASHES

All three structures are assessed using the modality of inspection.


Normal findings:

Eyebrows
· Symmetrical and in line with each other.
· Maybe black, brown or blond depending on race.
· Evenly distributed.

Eyes
· Evenly placed and inline with each other.
· Non protruding.
· Equal palpebral fissure.

Eyelashes
· Color dependent on race.
· Evenly distributed.
· Turned outward.
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D. EYE LIDS and LACRIMAL APPARATUS

1. Inspect the eyelids for position and symmetry.


2. Palpate the eyelids for the lacrimal glands.
a. To examine the lacrimal gland, the examiner, lightly slide the pad of the
index finger against the client’s upper orbital rim.
b. Inquire for any pain or tenderness.

3. Palpate for the nasolacrimal duct to check for obstruction.

a. To assess the nasolacrimal duct, the examiner presses with the index
finger against the client’s lower inner orbital rim, at the lacrimal sac, NOT
AGAINST THE NOSE.
b. In the presence of blockage, this will cause regurgitation of fluid in the
puncta

Normal Findings:

Eyelids
· Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are
open.
· No PTOSIS noted. (drooping of upper eyelids).
· Meets completely when eyes are closed.
· Symmetrical.

Lacrimal Apparatus
· Lacrimal gland is normally non palpable.
· No tenderness on palpation.
· No regurgitation from the nasolacrimal duct.

E. CONJUNCTIVA

The bulbar and palpebral conjunctivae are examined by separating the eyelids
widely and having the client look up, down and to each side. When separating the
lids, the examiner should exert no NO PRESSURE against the eyeball; rather, the
examiner should hold the lids against the ridges of the bony orbit surrounding the
eye.

In examining the palpebral conjunctiva, everting the upper eyelid in necessary and
is done as follow:

1. Ask the client to look down but keep his eyes slightly open. This relaxes the
levatormuscles, whereas closing the eyes contracts the orbicularis muscle,
preventing lid eversion.
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2. Gently grasp the upper eyelashes and pull gently downward. Do not pull the
lashes outward or upward; this, too, causes muscles contraction.

3. Place a cotton tip application about I can above the lid margin and push gently
downward with the applicator while still holding the lashes. This everts the lid.

4. Hold the lashes of the everted lid against the upper ridge of the bony orbit, just
beneath the eyebrow, never pushing against the eyebrow.

5. Examine the lid for swelling, infection, and presence of foreign objects.

6. To return the lid to its normal position, move the lid slightly forward and ask the
client to look up and to blink. The lid returns easily to its normal position.

Normal Findings:
· Both conjunctivae are pinkish or red in color.
· With presence of many minutes capillaries.
· Moist
· No ulcers
· No foreign objects

F. SCLERAE

The sclerae is easily inspected during the assessment of the conjunctivae.

Normal Findings:
· Sclerae is white in color (anicteric sclera)
· No yellowish discoloration (icteric sclera).
· Some capillaries maybe visible.
· Some people may have pigmented positions.

G. CORNEA

The cornea is best inspected by directing penlight obliquely from several positions.

Normal findings:
· There should be no irregularities on the surface.
· Looks smooth.
· The cornea is clear or transparent. The features of the iris should be fully visible
through the cornea.
· There is a positive corneal reflex.

H. ANTERIOR CHAMBER AND IRIS


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The anterior chamber and the iris are easily inspected in conjunction with the
cornea. The technique of oblique illumination is also useful in assessing the anterior
chamber.

Normal Findings:
· The anterior chamber is transparent.
· No noted any visible materials.
· Color of the iris depends on the person’s race (black, blue, brown or green).
· From the side view, the iris should appear flat and should not be bulging forward.
There should be

NO crescent shadow casted on the other side when illuminated from one side.

I. PUPILS

Examination of the pupils involves several inspections, including assessment of the


size, shape reaction to light is directed is observed for direct response of
constriction. Simultaneously, the other eye is observed for consensual response of
constriction.

The test for papillary accommodation is the examination for the change in papillary
size as the is switched from a distant to a near object.

1. Ask the client to stare at the objects across room.


2. Then ask the client to fix his gaze on the examiner’s index fingers, which is
placed 5 – 5 inches from the client’s nose.
3. Visualization of distant objects normally causes papillary dilation
and visualization of nearer objects causes papillary constriction and convergence of
the eye.

Normal Findings:
· Pupillary size ranges from 3 – 7 mm, and are equal in size.
· Equally round.
· Constrict briskly/sluggishly when light is directed to the eye, both directly and
consensual.
· Pupils dilate when looking at distant objects, and constrict when looking at
nearer objects.

If all of which are met, we document the findings using the notation PERRLA, pupils
equally round, reactive to light, and accommodate

J. CN II (OPTIC NERVE)
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The optic nerve is assessed by testing for visual acuity and peripheral vision.

Visual acuity is tested using a snellen chart, for those who are illiterate and
unfamiliar with the western alphabet, the illiterate E chart, in which the letter E
faces in different directions, maybe used. The chart has a standardized number at
the end of each line of letters; these numbers indicates the degree of visual acuity
when measured at a distance of 20 feet.

The numerator 20 is the distance in feet between the chart and the client, or the
standard testing distance. The denominator 20 is the distance from which the
normal eye can read the lettering, which correspond to the number at the end of
each letter line; therefore the larger the denominator the poorer the version.

Measurement of 20/20 vision is an indication of either refractive error or some other


optic disorder.
In testing for visual acuity you may refer to the following:

1. The room used for this test should be well lighted.


2. A person who wears corrective lenses should be tested with and without them
to check fro the adequacy of correction.
3. Only one eye should be tested at a time; the other eye should be covered by an
opaque card or eye cover, not with client’s finger.
4. Make the client read the chart by pointing at a letter randomly at each line;
maybe started from largest to smallest or vice versa.
5. A person who can read the largest letter on the chart (20/200) should be
checked if they can perceive hand movement about 12 inches from their eyes, or if
they can perceive the light of the penlight directed to their yes.

Peripheral Vision or visual fields

The assessment of visual acuity is indicative of the functioning of the macular area,
the area of central vision. However, it does not test the sensitivity of the other areas
of the retina which perceive the more peripheral stimuli. The Visual field
confrontation test, provide a rather grossmeasurement of peripheral vision.

The performance of this test assumes that the examiner has normal visual fields,
since thatclient’s visual fields are to be compared with the examiners.

Follow the steps on conducting the test:


1. The examiner and the client sit or stand opposite each other, with the eyes at
the same,horizontal level with the distance of 1.5 – 2 feet apart.
2. The client covers the eye with opaque card, and the examiner covers the eye
that is opposite to the client covered eye.
3. Instruct the client to stare directly at the examiner’s eye, while the examiner
stares at theclient’s open eye. Neither looks out at the object approaching from the
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periphery.
4. The examiner hold an object such as pencil or penlight, in his hand and
gradually moves it in from the periphery of both directions horizontally and from
above and below.
5. Normally the client should see the same time the examiners sees it. The normal
visual field is 180 degress.

K. CN III,IV,VI (OCCULOMOTOR, TROCHLEAR and ABDUCENS)

All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular
Movement (EOM) or the six cardinal position of gaze.

Follow the given steps:


1. Stand directly in front of the client and hold a finger or a penlight about 1 ft
from the client’s eyes.
2. Instruct the client to follow the direction the object hold by the examiner by eye
movements only; that is with out moving the neck.
3. The nurse moves the object in a clockwise direction hexagonally.
4. Instruct the client to fix his gaze momentarily on the extreme position in each
of the sixcardinal gazes.
5. The examiner should watch for any jerky movements of the eye (nystagmus).
6. Normally the client can hold the position and there should be no nystagmus.

L. EARS

1. Inspect the auricles of the ears for parallelism, size position, appearance and skin
color.
2. Palpate the auricles and the mastoid process for firmness of the cartilage of the
auricles, tenderness when manipulating the auricles and the mastoid process.
3. Inspect the auditory meatus or the ear canal for color, presence of cerumen,
discharges, and foreign bodies.
a. For adult pull the pinna upward and backward to straighten the canal.
b. For children pull the pinna downward and backward to straighten the canal
4. Perform otoscopic examination of the tympanic membrane, noting the color and
landmarks.

Normal Findings:
· The ear lobes are bean shaped, parallel, and symmetrical.
· The upper connection of the ear lobe is parallel with the outer canthus of the eye.
· Skin is same in color as in the complexion.
· No lesions noted on inspection.
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· The auricles are has a firm cartilage on palpation.
· The pinna recoils when folded.
· There is no pain or tenderness on the palpation of the auricles and mastoid
process.
· The ear canal has normally some cerumen of inspection.
· No discharges or lesions noted at the ear canal.
· On otoscopic examination the tympanic membrane appears flat, translucent and
pearly gray in color.

Vestibulochoclear Nerve (cranial nerve VIII)


Examination of the cranial nerve VIII involves testing for hearing acuity and balance.

Hearing Acuity
A. Voice test

1. The examiner stands 2 ft. on the side of the ear to be tested.


2. Instruct the client to occlude the ear canal of the other ear.
3. The examiner then covers the mouth, and using a soft spoken voice, whispers
non-sequential number (e.g. 3 5 7 ) for the client to repeat.
4. Normally the client will be able to hear and repeat the number.
5. Repeat the procedure at the other ear.

B. Watcher test
1. Ask the client to close the eyes.
2. Place a mechanical watch 1 – 2 inches away the client’s ear.
3. Ask the client if he hears anything
4. If the client says yes, the examiner should validate by asking at what are you
hearing and at what side.
5. Repeat the procedure on the other ear.
6. Normally the client can identify the sound and at what side it was heard.

Turning Fork Test


This test is useful in determining whether the client has a conductive hearing
loss (problem of external or middle ear) or a perceptive hearing loss (sensorineural).
There are 2 types of tuning fork test being conducted:

1. Weber’s test – assesses bone conduction, this is a test of sound lateralization;


vibrating tuning fork is placed on the middle of the fore head or top of the skull.
Normal: hear sounds equally in both ears (No Lateralization of sound)

Conduction loss – Sound lateralizes to defective ear (Heard louder on


defective ear) as few extraneous sounds are carried through the external and
middle ear.
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Sensorineural loss – Sound lateralizes on better ear.

2. Rinne Test – Compares bone conduction with air condition.


a. Vibrating tuning fork placed on the mastoid process
b. Instruction client to inform the examiner when he no longer hears the tuning
fork sounding.
c. Position in the tuning fork in front of the client’s ear canal when he no longer
hears it.

Normal: Sound should be heard when tuning fork is placed in front of the ear
canal as air conduction< bone conduction by 2:1 (positive rinne test)
Conduction loss: Sound is heard longer by bone conduction than by air
conduction.
Sensorineural loss: Sound is heard longer by air conduction than by bone
conduction

M. NOSE and PARANASAL SINUSES

The external portion of the nose is inspected for the following:


1. Placement and symmetry.
2. Patency of nares (done by occluding nosetril one at a time, and noting for
difficulty in breathing)
3. Flaring of alaenasi
4. Discharge

The external nares are palpated for:


1. Displacement of bone and cartilage.
2. For tenderness and masses

The internal nares are inspected by heperextending the neck of the client, the ulnar
aspect of the examiner’s hard over the fore head of the client, and using the thumb
to push the tip of the nose upward while shining a light into the naris.

Inspect for the following:


1. Position of the septum.
2. Check septum for perforation. (can also be checked by directing the lighted
penlight on the side of the nose, illumination at the other side suggests perforation).
3. The nasal mucosa (turbinates) for swelling, exudates and change in color.
Paranasal Sinuses
Examination of the paranasal sinuses is indirectly. Information about their condition
is gained by inspection and palpation of the overlying tissues. Only frontal and
maxillary sinuses are accessible for examination.
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By palpating both cheeks simultaneously, one can determine tenderness of the
maxillarysinusitis, and pressing the thumb just below the eyebrows, we can
determine tenderness of the frontal sinuses.

Normal Findings:
1. Nose in the midline
2. No Discharges.
3. No flaring alae nasi.
4. Both nares are patent.
5. No bone and cartilage deviation noted on palpation.
6. No tenderness noted on palpation.
7. Nasal septum in the mid line and not perforated.
8. The nasal mucosa is pinkish to red in color. (Increased redness turbinates are
typical ofallergy).
9. No tenderness noted on palpation of the paranasal sinuses.

N. CN I (OLFACTORY)

To test the adequacy of function of the olfactory nerve:


1. The client is asked to close his eyes and occlude.
2. The examiner places aromatic and easily distinguish nose. (e.g. coffee).
3. Ask the client to identify the odor.
4. Each side is tested separately, ideally with two different substances.

Mouth and OropharynxLips are inspected for:


1. Symmetry and surface abnormalities.
2. Color
3. Edema

Normal Findings:
1. With visible margin
2. Symmetrical in appearance and movement
3. Pinkish in color
4. No edema

Palpate the temporomandibular while the mouth is opened wide and then closed
for:
1. Crepitous
2. Deviations
3. Tenderness

Normal Findings:
1. Moves smoothly no crepitous.
2. No deviations noted
3. No pain or tenderness on palpation and jaw movement.
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Gums are inspected for:


1. Color
2. Bleeding
3. Retraction of gums.

Normal Findings:
1. Pinkish in color
2. No gum bleeding
3. No receding gums

Teeth are inspected for:


1. Number
2. Color
3. Dental carries
4. Dental fillings
5. Alignment and malocclusions (2 teeth in the space for 1, or overlapping
teeth).
6. Tooth loss
7. Breath should also be assessed during the process.

Normal Findings:
1. 28 for children and 32 for adults.
2. White to yellowish in color
3. With or without dental carries and/or dental fillings.
4. With or without malocclusions.
5. No halitosis.

Tongue is palpated for:


1. Texture

Normal Findings:
1. Pinkish with white taste buds on the surface.
2. No lesions noted.
3. No varicosities on ventral surface.
4. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the
tongue.
5. Gag reflex is present.
6. Able to move the tongue freely and with strength.
7. Surface of the tongue is rough.

Uvula is inspected for:


1. Position
2. Color
3. Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note
that the uvula will move upward and forward.
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Normal Findings:
1. Positioned in the mid line.
2. Pinkish to red in color.
3. No swelling or lesion noted.
4. Moves upward and backwards when asked to say “ah”

Tonsils are inspected for:


1. Inflammation
2. Size

A Grading system used to describe the size of the tonsils can be used.
 Grade 1 – Tonsils behind the pillar.
 Grade 2 – Between pillar and uvula.
 Grade 3 – Touching the uvula
 Grade 4 – In the midline.

N. NECK

The neck is inspected for position symmetry and obvious lumps visibility of
the thyroid gland and Jugular Venous Distension.

Normal Findings:
1. The neck is straight.
2. No visible mass or lumps.
3. Symmetrical
4. No jugular venous distension (suggestive of cardiac congestion).

The neck is palpated just above the suprasternal note using the thumb and the
index finger.
The neck is palpated just above the suprasternal note using the thumb and the
index finger.

Normal Findings:
1. The trachea is palpable.
2. It is positioned in the line and straight.
 Lymph nodes are palpated using palmar tips of the fingers via systemic
circular movements.
 Describe lymph nodes in termsof size, regularity, consistency, tenderness
and fixation to surrounding tissues.

Normal Findings:
1. May not be palpable. Maybe normally palpable in thin clients.
2. Non tender if palpable.
3. Firm with smooth rounded surface.
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4. Slightly movable.
5. About less than 1 cm in size.
6. The thyroid is initially observed by standing in front of the client and asking
the client to swallow. Palpation of the thyroid can be done either by posterior or
anterior approach.

A. Posterior Approach:
1. Let the client sit on a chair while the examiner stands behind him.
2. In examining the isthmus of the thyroid, locate the cricoid cartilage and
directly below that is the isthmus.
3. Ask the client to swallow while feeling for any enlargement of
the thyroid isthmus.
4. To facilitate examination of each lobe, the client is asked to turn his head
slightly toward the side to be examined to displace the
sternocleidomastoid, while the other hand of the examiner pushes
the thyroid cartilage towards the side of the thyroid lobe to be examined.
5. Ask the patient to swallow as the procedure is being done.
6. The examiner may also palate for thyroid enlargement by placing the
thumb deep to and behind the sternocleidomastoid muscle, while the
index and middle fingers are placed deep to and in front of the muscle.
7. Then the procedure is repeated on the other side.

A. Anterior approach:
1. The examiner stands in front of the client and with the palmar surface of
the middle and index fingers palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation is being done.
3. In palpating the lobes of the thyroid, similar procedure is done as in
posterior approach. The client is asked to turn his head slightly to one side
and then the other of the lobe to be examined.
4. Again the examiner displaces the thyroid cartilage towards the side of the
lobe to be examined.
5. Again, the examiner palpates the area and hooks thumb and fingers
around thesternocleidomastoid muscle.

Normal Findings:
1. Normally the thyroid is non palpable.
2. Isthmus maybe visible in a thin neck.
3. No nodules are palpable.

Auscultation of the Thyroid is necessary when there is thyroid enlargement. The


examiner may hear bruits, as a result of increased and turbulence in blood flow in
an enlarged thyroid.
 Check the Range of Movement of the neck.

Lung borders
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In the anterior thorax, the apices of the lungs extend for approximately 3 – 4 cm
above the clavicles. The inferior borders of the lungs cross the sixth rib at the
midclavigular line.
In the posterior thorax, the apices extend of T10 on expiration to the spinous
process of T12 on inspiration.
In the Lateral Thorax, the lungs extend from the apex of the axilla to the 8th rib of
the midaxillary line.

Lung Fissures
The right oblique (diagonal) fissure extend from the area of the spinous process of
the 3rdthoracic vertebra, laterally and downward unit it crosses the 5th rib at the
midaxillary line. It then continues ant medially to end at the 6th rib at the
midclavicular line.
The right horizontally fissure extends from the 5th rib slightly posterior to the right
midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal
border.
The left oblique (diagonal) fissure extend from the spinous process of the
3rd thoracic vertebra laterally and downward to the left mid axillary line at the 5th rib
and continues anteriorly and medially until it terminates at the 6th rib in the
midclavicular line.

Borders of the Diaphragm.


Anteriorly, on expiration, the right dome of the diaphragm is located at the level of
the 5th rib at the midclavicular line and he left dome is at the level of the 6th rib.
Posteriorly, on expiration, the diaphragm is at the level of the spinous process of
T10; laterally it is at the 8th rib at the midaxillary line. On inspiration the diaphragm
moves approximately 1.5 cm downward.

Inspection of the Thorax


For adequate inspection of the thorax, the client should be sitting upright without
support and uncovered to the waist.
The examiner should observe:
A.
1. Shape of the thorax and its symmetry.
2. Thoracic configuration.
3. Retractions at the ICS on inspiration. (suprasternal, costal, substernal)
4. Bulging structures at the ICS during expiration.
5. position of the spine.
6. pattern of respiration.

Normal Findings:
 The shape of the thorax in a normal adult is elliptical; the anteroposterior
diameter is less than the transverse diameter at approximately a ratio of 1:2.
 Moves symmetrically on breathing with no obvious masses.
 No fail chest which is suggestive of rib fracture.
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 No chest retractions must be noted as this may suggest difficulty in
breathing.
 No bulging at the ICS must be noted as this may obstruction on expiration,
abnormal masses, or cardiomegaly.
 The spine should be straight, with slightly curvature in the thoracic area.
 There should be no scoliosis, kyphosis, or lordosis.
 Breathing maybe diaphragmatically of costally.
 Expiration is usually longer the inspiration.

Palpation of the Thorax


1. General palpation – The examiner should specifically palpate any areas of
abnormality. The temperature and turgor of the skin should be assessed. Palpate
for lumps, masses and areas of tenderness.
2. Palpate for thoracic expansion or lung excursion.
A. Anteriorly, the examiner’s hands are placed over the anterolateral chest
with the thumbs extended along the costal margin, pointing to the
xyphoid process. Posteriorly, the thumbs are placed at the level of the
10th rib and the palms are placed on the posterolateral chest.
B. Instruct the client to exhale first, then to inhale deeply.
C. The examiner the amount of thoracic expansion during quiet and deep
inspiration and observe for divergence of the thumbs on expiration.
D. Normally, symmetry of respiration between the left and right hemithoraces
should be felt as the thumbs are separated are separated approximately 3
– 5 cm (1 – 2 inches) during deep inspiration.
3. Palpate for the tactile fremitus.
A. Place the palm or the ulnar aspect of the hands bilaterally symmetrical on
the chest wall starting from the top, then at then medial thoracic wall, and
at the anterolateral
B. Each time the hands move down, ask the client to say ninety-nine.
C. Repeat the procedure at the posterior thoracic wall.
D. Normally, tactile fremitus should be bilaterally symmetrical. Most intense
in the 2ndICS at the sternal border, near the area of bronchial bifurcation.
Low pitched voices of males are more readily palpated than higher
pitched voices of females.
E. Basic abnormalities like increased tactile fremitus maybe suggestive of
consolidation; decreased tactile fremitus may be suggestive of
obstructions, thickening of pleura, or collapse of lungs.

Percussion of the Thorax


Anterior thorax:
1. Patient maybe placed on a supine position.
2. Percuss systematically at about 5 cm intervals from the upper to lower
chest, moving left to right to left. (Percuss over the ICS, avoiding the ribs.
Use indirect percussion starting at the apices of the lungs.
3. The examiner notes the sound produced during each percussion.
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Whispered Pectorioquy – Ask the client top whisper “1-2-3” Over normal lung tissue
it would almost be indistinguishable, over consolidated lung it would be loud and
clear.

P. THORAX (Cardiovascular system)

Inspection of the Heart


The chest wall and epigastrum is inspected while the client is in supine position.
Observe for pulsation and heaves or lifts
Normal Findings:
1. Pulsation of the apical impulse maybe visible. (this can give us some
indication of the cardiac size).
2. There should be no lift or heaves.
Palpation of the Heart
The entire precordium is palpated methodically using the palms and the fingers,
beginning at the apex, moving to the left sternal border, and then to the base of the
heart.
Normal Findings:
1. No, palpable pulsation over the aortic, pulmonic, and mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart


The technique of percussion is of limited value in cardiac assessment. It can be used
to determine borders of cardiac dullness.

Auscultation of the Heart


Anatomic areas for auscultation of the heart:
Aortic valve – Right 2nd ICS sternal border.
Pulmonic Valve – Left 2nd ICS sternal border.
Tricuspid Valve – – Left 5th ICS sternal border.
Mitral Valve – Left 5th ICS midclavicular line

Positioning the client for auscultation:


 If the heart sounds are faint or undetectable, try listening to them with the
patient seated and learning forward, or lying on his left side, which brings the
heart closer to the surface of the chest.
 Having the client seated and learning forward s best suited for hearing high-
pitched soundsrelated to semilunar valves problem.
 The left lateral recumbent position is best suited low-pitched sounds, such as
mitral valve problems and extra heart sounds.

Auscultating the heart


A.
1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid
and mitral
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2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of
semilunar valve). S1 sound is best heard over the mitral valve; S2 is
best heard over the aortric valve.
3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
4. Count heart rate at the apical pulse for one full minute.

Normal Findings:
1. S1 & S2 can be heard at all anatomic site.
2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
3. Cardiac rate ranges from 60 – 100 bpm.

Q. BREAST

Inspection of the Breast


There are 4 major sitting position of the client used for clinical breast examination.
Every client should be examined in each position.
1. The client is seated with her arms on her side.
2. The client is seated with her arms abducted over the head.
3. The client is seated and is pushing her hands into her hips, simultaneously
eliciting contraction of the pectoral muscles.
4. The client is seated and is learning over while the examiner assists in
supporting and balancing her.
 While the client is performing these maneuvers, the breasts are carefully
observed for symmetry, bulging, retraction, and fixation.
 An abnormality may not be apparent in the breasts at rest a mass may cause
the breasts, through invasion of the suspensory ligaments, to
fix, preventing them from upward movement in position 2 and 4.
 Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and
shortened suspensory ligaments.

Normal Findings:
1. The overlying the breast should be even.
2. May or may not be completely symmetrical at rest.
3. The areola is rounded or oval, with same color, (Color va,ies form light pink to
dark brown depending on race).
4. Nipples are rounded, everted, same size and equal in color.
5. No “orange peel” skin is noted which is present in edema.
6. The veins maybe visible but not engorge and prominent.
7. No obvious mass noted.
8. Not fixated and moves bilaterally when hands are abducted over the head, or
is learning forward.
9. No retractions or dimpling.

Palpation of the Breast


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 Palpate the breast along imaginary concentric circles, following a clockwise
rotary motion, from the periphery to the center going to the nipples. Be sure
that the breast is adequately surveyed. Breast examination is best done 1
week post menses.
 Each areolar areas are carefully palpated to determine the presence of
underlying masses.
 Each nipple is gently compressed to assess for the presence of masses or
discharge.

Normal Findings:
 No lumps or masses are palpable.
 No tenderness upon palpation.
 No discharges from the nipples.

NOTE: The male breasts are observed by adapting the techniques used for female
clients. However, the various sitting position used for woman is unnecessary.

R. ABDOMEN

In abdominal assessment, be sure that the client has emptied the bladder for
comfort. Place the client in a supine position with the knees slightly flexed to relax
abdominal muscles.

Inspection of the abdomen


 Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and
umbilicus).
 Contour (flat, rounded, scapold)
 Distension
 Respiratory movement.
 Visible peristalsis.
 Pulsations

Normal Findings:
 Skin color is uniform, no lesions.
 Some clients may have striae or scar.
 No venous engorgement.
 Contour may be flat, rounded or scapoid
 Thin clients may have visible peristalsis.
 Aortic pulsation maybe visible on thin clients.

Auscultation of the Abdomen


 This method precedes percussion because bowel motility, and thus bowel
sounds, may be increased by palpation or percussion.
 The stethoscope and the hands should be warmed; if they are cold, they may
initiate contraction of the abdominal muscles.
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 Light pressure on the stethoscope is sufficient to detect bowel sounds and
bruits. Intestinal sounds are relatively high-pitched, the bell may be used in
exploring arterial murmurs and venous hum.

Peristaltic sounds
These sounds are produced by the movements of air and fluids through the
gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility
of bowel.
Listening to the bowel sounds (borborygmi) can be facilitated by following these
steps:
1. Divide the abdomen in four quadrants.
2. Listen over all auscultation sites, starting at the right lower quadrants, following
the cross pattern of the imaginary lines in creating the abdominal quadrants. This
direction ensures that we follow the direction of bowel movement.
3. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner
listen for at least 5 minutes, especially at the periumbilical area, before concluding
that no bowel sounds are present.
4. The normal bowel sounds are high-pitched, gurgling noises that occur
approximately every 5 – 15 seconds. It is suggested that the number of bowel sound
may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for
each breath sound.
Some factors that affect bowel sound:
1. Presence of food in the GI tract.
2. State of digestion.
3. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus,
peritonitis).
4. Bowel surgery
5. Constipation or Diarrhea.
6. Electrolyte imbalances.
7. Bowel obstruction.

Percussion of the abdomen


 Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites),
gaseous distension, and masses, and in assessing solid structures within the
abdomen.
 The direction of abdominal percussion follows the auscultation site at each
abdominal guardant.
 The entire abdomen should be percussed lightly or a general picture of the
areas of tympany and dullness.
 Tympany will predominate because of the presence of gas in the small and
large bowel. Solid masses will percuss as dull, such as liver in the RUQ,
spleen at the 6th or 9th rib just posterior to or at the mid axillary line on the
left side.
 Percussion in the abdomen can also be used in assessing the liver span and
size of the spleen.
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Percussion of the liver
The palms of the left hand is placed over the region of liver dullness.
1. The area is strucked lightly with a fisted right hand.
2. Normally tenderness should not be elicited by this method.
3. Tenderness elicited by this method is usually a result of hepatitis or
cholecystitis.

Renal Percussion
1. Can be done by either indirect or direct method.
2. Percussion is done over the costovertebral junction.
3. Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen


Light palpation
 It is a gentle exploration performed while the client is in supine position. With
the examiner’s hands parallel to the floor.
 The fingers depress the abdominal wall, at each quadrant, by approximately
1 cm without digging, but gently palpating with slow circular motion.
 This method is used for eliciting slight tenderness, large masses,
and muscles, and muscle guarding.

Tensing of abdominal musculature may occur because of:


1. The examiner’s hands are too cold or are pressed to vigorously or deep into
the abdomen.
2. The client is ticklish or guards involuntarily.
3. Presence of subjacent pathologic condition.

Normal Findings:
1. No tenderness noted.
2. With smooth and consistent tension.
3. No muscles guarding.

Deep Palpation
 It is the indentation of the abdomen performed by pressing the distal half of
the palmar surfaces of the fingers into the abdominal wall.
 The abdominal wall may slide back and forth while the fingers move back and
forth over the organ being examined.
 Deeper structures, like the liver, and retro peritoneal organs, like the kidneys,
or masses may be felt with this method.
 In the absence of disease, pressure produced by deep palpation may produce
tenderness over the cecum, the sigmoid colon, and the aorta.

Liver palpation:
There are two types of bi manual palpation recommended for palpation of the liver.
The first one is the superimposition of the right hand over the left hand.
1. Ask the patient to take 3 normal breaths.
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2. Then ask the client to breath deeply and hold. This would push the liver down
to facilitate palpation.
3. Press hand deeply over the RUQ

The second methods:


1. The examiner’s left hand is placed beneath the client at the level of the right
11th and 12thribs.
2. Place the examiner’s right hands parallel to the costal margin or the RUQ.
3. An upward pressure is placed beneath the client to push the liver towards the
examining right hand, while the right hand is pressing into the abdominal
wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip beneath the examining
fingers.

Normal Findings:
 The liver usually can not be palpated in a normal adult. However, in
extremely thin but otherwise well individuals, it may be felt a the costal
margins.
 When the normal liver margin is palpated, it must be smooth, regular in
contour, firm and non-tender.

S. EXTREMITIES

Inspection
1. Observe for size, contour, bilateral symmetry, and involuntary movement.
2. Look for gross deformities, edema, presence of trauma such as ecchymosis or
other discoloration.
3. Always compare both extremities.

Palpation
1. Feel for evenness of temperature. Normally it should be even for all
the extremities.
2. Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s
fingers and noting for equality of contraction).
3. Perform range of motion.
4. Test for muscle strength. (performed against gravity and against resistance)

Table showing the Lovett scale for grading for muscle strength and functional level
Functional level Lovett Scale Grade Percentage of
normal
No evidence of Zero (Z) 0 0
contractility
Evidence of slight Trace (T) 1 10
contractility
Complete ROM Poor (P) 2 25
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without gravity
Complete ROM Fair (F) 3 50
with gravity
Complete range of Good (G) 4 75
motion against
gravity with some
resistance
Complete range of Normal (N) 5 100
motion against
gravity with full
resistance

Normal Findings:
 Both extremities are equal in size.
 Have the same contour with prominences of joints.
 No involuntary movements.
 No edema
 Color is even.
 Temperature is warm and even.
 Has equal contraction and even.
 Can perform complete range of motion.
 No crepitus must be noted on joints.
 Can counter act gravity and resistance on ROM.

ANNEX I (VITAL SIGNS)


 Provide excellent clues to the physiological functioning of the body.
 Alteration in body fxn are reflected in the body temp, pulse, respirations and
blood pressure.
 These data provide part of the baseline info from which plan of care is
developed.
 Any change from normal is considered to be an indication of the person’s
state of health.
 Also called Cardinal Signs.

Heat – producing & Heat – losing Mechanisms


 Heat production: most body heat is produced by the oxidation of foods,
the rate at which it is produced is called METABOLIC RATE.

Heat Loss:
 Radiation  transfer of heat, no contact
 Conduction  transfer of heat with contact from 2 different surface
temperatures(e.g. wipe)
 Convection – dissipation of heat by air current
 Evaporation – vaporization of body fluids
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Pre – optic area of the HYPOTHALAMUS


 Temperature regulator; thermostat
 Receives input from temp receptors in the skin & mucous membranes
(peripheral thermoreceptors) & internal structures (central thermoreceptors)
* if blood temp increases, neurons of the pre – optic area fire nerve if it
decreases.

Heat Promoting Centers


 VASOCONSTRICTION
= Less blood flow from the internal organs to the skin = less heat
transfer from the internal organs to the skin = increases internal body temp
 SYMPATHETIC STIMULATION
= stimulation of sympathetic nerves leading to the adrenal medulla =
secretes epinephrine & norepinephrine = Increases cellular metabolism =
increases heat production
 SKELETAL MUSCLES
= stimulation of part of the brain that increases muscle tone (stretch reflex +
contraction of muscles = SHIVERING) = heat production
 THYROXINE = increases metabolism = increase in body temp

Body Temperature Abnormalities


 FEVER/hyperthermia/hyperpyrexia
- An abnormally high temp mainly results from infection from bacteria (& their
toxins) & viruses. (stimulates prostaglandin secretion)
Other causes: heart attacks, tumors, tissue destruction by x – ray, surgery or
trauma & rxns to vaccines.
 HEAT CRAMPS AND HEAT EXHAUSTION
- Due to fluid & electrolyte loss
 HEAT STROKE
 HYPOTHERMIA

The THERMOMETER
 A glass clinical thermometer is most commonly used to measure body
temperature.

It has 2 parts:
BULB – contains mercury which expands when exposed to heat & rise in the
stem
STEM – is calibrated in degrees of Celcius or Fahrenheit

Sites for Obtaining Body Temperature


 ORAL – most common site (3 or 7 to 10minutes)  36.5 – 37.5 C
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C.I. : unconscious, irrational, seizure – prone patients and infants & young
children, those who breath through their mouth or for those with
diseases/sugery of their mouth or nose.
 RECTAL – most accurate, used when obtaining an oral temp is
contraindicated (2 to 3 minutes)  37.0 – 38.1 C
C.I. : rectal surgery, diarrhea, other diseases of the rectum, certain heart
diseases.
 AXILLARY – used when both oral & rectal are not accessible. Commonly used
site (10minutes or more)  35.8 – 37.5 C
 TYMPANIC  most accurate (36.8 – 37.9 C)

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