GENERAL SURVEY
- Observe body built, height and weight in relation to
Physical Assessment – a systematic, comprehensive,
continuous collection, validation and communication of
client’s data using a variety of methods
General Considerations:
- Physical assessment is correlated with the health
history of the patient
o History of present illness
o Past medical history
o Family History
- Examiner must follow certain sequence in doing
physical assessment: i.e. Cephalocaudal, IPPA
- Include only the findings with medical significance
- Findings should not only focus on the symptoms that
are present but should also include pertinent
negatives
- Result should be objective, one does not have an
examiner variance
- Neurological exam is always part of the physical exam
- If examining a patient of the same sex, always have a
companion of the same sex as the patient
- Always maintain the patient’s privacy
- Patient always has the right to refuse examination,
although considered to be an essential part
- Physical findings may change from time to time
- It is recommended that PA is conducted at the
patient’s right side, moving to the opposite side or
foot of the bed as needed. This is the standard
position for PA and has several advantages: Right
jugular venous pressure is more reliable than the left,
right kidney is more palpable than the left
Physical Assessment (Patient Approach During PA)
- When possible, begin with patient in a sitting position,
so front and back and be examined.
- Completely expose the part to be examined but drape
the rest of the body appropriately
- Conduct exam cephalocaudal
- Compare findings on both sides
- Explain all procedures to avoid alarming and
encourage cooperation
- Make the patient as comfortable as possible
Assessing Appearance and Mental Status
- Explain the procedure to the patient.
- Do handwashing.
- Provide privacy.
→ when the patient enters greet the patient with
handshake to convey that you care but it will also allow
you to assess muscle strength, hydration skin
temperature and texture
Assessment
the client’s age, lifestyle and health. Height should be
proportionate to arm span
- Abnormalities:
o Marfan’s syndrome – hereditary disorder that
affects the body’s connective tissues, long limbs
in proportion to the trunk of the patient
o Achondroplastic dwarfism- common type of
dwarfism, disproportion short limbs, large head,
depressed nasal bridge, small face
o Turner’s syndrome –chromosomal anomaly in
female births
o Gigantism- excessive size and stature d/t
hypersecretion of growth hormone
o osteoporosis and vertebral compression fractures
will lead to height loss
o weight – truncal fat with relatively thin limbs in
Cushing’s syndrome
o causes of weight loss include malignancy,
diabetes mellitus, hyperthyroidism, chronic
infection depression diuresis and successful
dieting
o Weight and height are taken for the purpose of
correcting dehydration or fluid overload, fluid
intake and output measurement
o Weight is used to calculate medication doses
- Sthenic → average height, well-developed
musculature, wide shoulders, flat abdomen, oval face
- Hypersthenic → Short, stocky, may be obese; shorter,
broader chest; thicker abdominal wall, rectangular-
shaped face
- Hyposthenic → tall willowy, musculature poorly
developed; long, flat chest; abdomen may sag, long
neck, triangular face
- Asthenic → exaggeration of hyposthenic body type
- Cachectic → profound and marked malnutrition;
wasting; ill health
- Debilitated → , feeble, lack of strength (with
weakness and loss of energy)
- Failure to thrive → Physical and developmental delay
or retardation in infants and children; seen in children
 with illness but more often in children with
psychosocial or maternal deprivation
Weight
- Endomorph (stocky person: somebody whose body
has a stocky build and a prominent abdomen)
- Ectomorph (tall thin person: somebody who belongs
to a physiological type that is tall with long lean
limbs.)
- Mesomorph (muscular person: a husky muscular
body, or somebody who has such a body)
Body Mass Index (BMI)
- Ratio of wt. In kg. And ht. in meters
- Formula = weight / ht in m2
- 2.2 lbs=1 kg; 1 in=2.54 cm; 100 cm = 1 meter
- Result: BMI of
- <18.5 – underweight
- 18.5 – 24.9 – normal
- 25 – 29.9 – overweight
- 30 – 34.9 – obese I
- 35.0 – 39.9 – obese II
- > or = 40 – extreme obesity
Determine waist circumference
- Normal
o (Female) equal or less than 88cm or 35 inches
o (Male) equal or less than 102cm or 40 inches
- Abnormal
o more than the given range
o Android obesity – large visceral fat is stored
mainly around the waist (at risk for DM2, High
cholesterol and triglycerides level, HPN and heart
diseases
o Gynoid obesity – fats are located in the hips and
thighs
o Cushing’s syndrome – truncal fat with relatively
thin limbs
o Unexplained weight loss – Cancer, DM,
hyperthyroidism, depression, diuresis
Posture and Gait (Standing, Sitting, and Walking)
- Let pt. stand against wall, shoulders should lie flat
- Let him sit on a chair with backrest
- Let him walk towards you
- NOTE:
o Patient’s balance or equilibrium
o gait is rhythmic and coordinates with arms
swinging at sides
o posture- may give opportunity to observe for
musculoskeletal abnormalities such as abnormal
curvatures of the spine kyphosis, lordosis and
scoliosis
- Normal:
o Evenly distributed weight client is able to stand
on heels and toes.
o Toes point straight ahead, &equal on both sides.
o Posture erect, movements coordinated and
rhythmic, arms swing in opposition, stride length
appropriate (Swing inn opposition means
stepping with right foot with left arms swinging
forward)
- Abnormal:
o There is limping/discomfort, shuffles, wide base
gait, fear of falling, loss of balance or any
 movement disorder (eg. Cerebral Palsy,
Parkinson’s disease, Polio)
o Scoliosis – ‘S’ formation
o Lordosis – exaggerated lumbar concavity
o Kyphosis – increased forward curvature
o COPD clients – leans forward and brace
themselves with arms
o Slumped– depression
o Tensed/ anxious – elevated and stiff shoulders
o Spastic- seen in stroke patient causing poor
control of flexor muscles during swing phase.
Affected arm is flexed immobile and held close to
the side with elbow and wrist and interphalangeal
joints flexed. Affected leg spastic. ankle plantar
flexed and inverted. Circle leg stiffly.
o Scissors gait seen in spinal cord disease gait is
stiff. Patient advance each leg slowly and the
thigh tend to cross forward on each other on each
step.
o Steppage gait seen in foot drop. Patient either
drag the feet or lift them high with knees flexed
and bring them down with a slap on the floor.
They cannot walk on their heels. Tibialis anterior
and extensor muscles are weak.
o Propulsive gait or Parkinsonian gait-posture is
stooped with flexion of the head, arms and hips
and knees. Patient are slow getting started. Steps
are short and arms swing less and patient turn
around in one piece.
Overall Hygiene and Grooming (r/t previous activities)
- How is he dressed?
- appropriate to temp., weather?
- Clean, properly buttoned etc., appropriate to age and
social group?
- Excess clothing – cold intolerance, hide track marks or
rash or personal preference
- Very light even in cold weather – heat intolerance
- Unkept/ disheveled, dirty, unshaven with foul body
odor – depression /dementia (cognitive
/developmental deterioration) or drug abuse, poor
status
- Extremely loose held up by pins and belts – sudden
weight loss
Body and Breath Odor
- Breath odors:
o Alcohol breath
o Acetone breath (DM)
o Halitosis
Signs of Distress in Posture or Facial Expression
- Observe at rest, during conversation, watch for eye
contact (natural, sustained and unblinking / averted)
- Smiles and frowns appropriately
- Stare of hyperthyroidism (Exophthalmos)
- Immobile face/expressionless (parkinsonism)
- Flat/sad; poor eye contact (depression)
- Decreased eye contact (anxiety/fear)
- Drooping or gross asymmetry occurs with neurologic
disorder/ injury (eg. Bell’s palsy; CVA)
o Bell’s palsy – unilateral paralysis of the facial
nerve results from trauma to the nerve
o Parkinsonism – there is decreased facial mobility
blunts expression. A masklike face results in
decreased blinking and a characteristic stare, neck
and upper trunk tends to flex forward. Facial skin
becomes oily and drooling may occur
Obvious Signs of Health and Illness
- Normal: Generally Healthy
- Abnormal: Poor Nutritional Status
o Listlessness/ apathy
o Poor muscle tone
 o Hair thin/ sparse
o Cheilosis (fissures at mouth angles)
o Glossitis (inflammation of tongue)
o Acutely/chronically ill
o Frail/Feeble
Client’s Attitude
- Cooperative / willing
- Unresponsive / unwilling
- Anxious
Affect/mood; appropriate responses
- Facial features are symmetric, good eye contact,
smiles and frowns appropriately
- Facial expression appropriate to question being
answered
- Appropriate response (who, what, when, and where)
Listen to Quality, Quantity, and Organization of Speech
- Normal: Able to answer in organized manner,
appropriate words
- Abnormal:
o disorganized speech
o consistent (Non-stop) speech
o long periods of silence – mental illness or
neurologic disorder (speech defect)
Relevance and Organization of Thoughts
- Evident in the answer to question
- Abnormal: disorganized speech, word salad
Document
- Document any abnormal findings
Lifespan Consideration
- INFANTS
o Observation of children’s behavior can provide
important data for the general survey, including
physical development, neuromuscular function,
and social and interactional skills
o It may be helpful to have parents hold older
infants and very young children for part of the
assessment
o Measure height of children under age 2 in the
supine position with knees fully extended
o Weigh without clothing
o Include measurement of head circumference until
age 2. Standardized growth charts include head
circumference up to age 3.
- CHILDREN
o Anxiety in preschool-age children can be
decreased by letting them handle and become
familiar with examination equipment
o School-age children may be very modest and shy
about exposing parts of the body
o Adolescents should be examined without parent’s
presence
o Weigh children without shoes and with as little
clothing as possible
- ELDERS
o Allow extra time for clients to answer questions
o Adapt questioning techniques as appropriate for
clients with hearing or visual limitations
o Elders with osteoporosis can lose several inches in
ht. Be sure to document height and ask if they are
aware of becoming shorter in height
o When asking about weight loss, be specific about
amount and time frame
▪ E.g. “have you lost more than 5 lbs in the last
2 months?”
---- E N D ---
SKIN, HAIR, AND SCALP
Skin
Inspect for uniformity of skin color.
- Pallor – decreased redness like in anemia (fingernails,
lips, mucosa)
o lack of the oxyhemoglobin pigment - bright red
pigment which predominates in arteries and
capillaries
- Cyanosis – bluish discoloration (nailbeds, conjunctival
area)
o as blood passes to the capillary bed
oxyhemoglobin loses its O2 to the tissues and
changes to deoxyhemoglobin, a darker and bluish
pigment
o Central cyanosis – bluish tinge like in COPD,
congenital heart disease (lips, oral mucosa,
tongue)
o Peripheral cyanosis – venous obstruction
- Jaundice – yellow color found in sclera, palpebral
conjunctiva, skin etc. (liver disease or excess
Hemolysis of RBCs)
- Jaundice in Newborn
o Pathologic Jaundice – appears within 24 hours
o Physiologic Jaundice – appears 2-3 days after
birth
- Carotenemia – yellow color d/t diet rich in carotene.
Found in palms, soles and face
- Acanthosis nigricans – roughening and darkening of
the skin in localized areas (posterior neck, axilla,
groin; common in obese individuals)
- Albinism – generalized loss of pigmentation, lack of
melanin pigment in the body
- Erythema – skin redness and warmth (inflammation,
allergic reactions and trauma)
Assess Edema if Present
- Let patient sit with legs dangling
- Palpate the skin over the tibia by pressing the skin
between thumb and index finger for 30 sec. to 1 min.
- Run finger pads over area pressed and note
indentation
o Dependent edema- appears in the lowest body
part, the feet and lower legs when sitting or the
sacrum when bedridden. Causes may be cardiac
(heart failure) nutritional (hypoalbuminuria) or
positional.
o If (+): repeat moving up the extremities and note
point at which swelling is not present anymore
o Pitting vs. non-pitting edema. Edema occurs
when fluid that accumulates in tissues leads to
swelling. When pressure is applied to a swollen
area, it may leave a pit, in the skin. In non-pitting
edema, the skin will return to its swollen shape
once the pressure has been removed.
- Scale of edema:
o 1+ barely detectable (2mm)
o 2+ indentation (2-4mm)
o 3+ (5 – 7 mm)
o 4+ (more than 7mm)
Inspect, palpate and describe skin lesions. Use gloves
as needed.
- A skin lesion is a part of the skin that has an abnormal
growth or appearance compared to the skin around it.
o Primary skin lesions are abnormal skin conditions
present at birth or acquired over a person's
lifetime.
o Secondary skin lesions are the result of irritated
or manipulated primary skin lesions
- Primary Skin Lesions
o Macules – flat, variable size and shape, different
from surrounding area, <1cm (eg. Freckles,
petechiae in Dengue → Tourniquet Test: A blood
pressure cuff is applied and inflated to the
midpoint between the systolic and diastolic blood
pressures for five minutes. The test is positive if
there are more than 10 to 20 petechiae per
square inch.)
o Patches – very large macules, coalescence of
macules >1cm (eg. Vitiligo, Pityriasis Rosea)
o Papules – small, solid, elevated, and <1cm (eg.
Chickenpox, Psoriasis)
o Plaque – Broad-based papule, occupies large
surface area, >1cm (eg. Psoriasis, ringworm)
o Nodules – a growth of abnormal tissue; palpable,
firmer and deeper than papule, round to spheroid
shape (marble-like), center may be at dermis or
subcutaneous tissue
o Cyst – Irregular, transient, superficial, localized
edema, flat-topped papule (eg. Mosquito bite,
skin test)
o Wheals – epithelial cell-lined sac, contains liquid
or semi-solid material (fluid, cells, and cell
products) eg. Sebaceous cyst, ganglion cyst
o Vesicles – filled with serous fluid, elevated, <1 cm
(eg. Shingles)
o Bullae – larger than vesicle >1 cm (eg. 2nd degree
burn)
o Pustules – elevated and filled with pus (exudate)
eg. Acne and psoriasis
- Secondary Skin Lesions
o Scales – Thin flake of exfoliated dermis (eg.
Dandruff, psoriasis)
o Crusts (Scab) – Dried residue containing Serum,
pus, and blood; maybe mixed with epithelial and
bacterial debris (eg. Impetigo)
o Excoriations – superficial excavations of epidermis
▪ Linear
▪ Punctuate
o Fissures – linear crack on the skin (eg. Athlete’s
foot, fissure-in-ano)
o Erosions – loss of superficial epidermis, surface is
moist but does not bleed
o Ulcers – Deep loss of epidermis and dermis, may
bleed and scar (eg. Pressure ulcer)
o Scars – New connective tissue (fibrous) that has
replaced lost substance (in the dermis or deeper),
results from injury or disease, and part of normal
reparative process
▪ Hypertrophic
▪ Keloid
Skin Condition
- Skin Moisture
o Dryness – Consider hypothyroidism or
dehydration
o Oiliness – prone to acne
 o Sweating – Consider hyperthermia or
hyperthyroidism
▪ If the sweating can be attributed to an
underlying medical condition, it's called
secondary hyperhidrosis
▪ Diaphoresis is a medical term for perspiration
or sweating. The term usually refers to
unusually heavy perspiration.
▪ Hyperhidrosis pertains to sweating
excessively and unpredictably, usually as a
result of overactive sweat glands
- Skin Integrity
o Assess skin over pressure point areas (sacrum,
hips, and elbows) → prone to decubitus
ulcers/bed sores
o Normal: Intact and no redness
o Abnormal: (+) skin breakdown, redness, warmer
than other body parts
o Note any rough, flaky, or dry skin
(hypothyroidism)
o Obese clients may report dry, or itchy skin
- Skin Thickness
o Note for presence/absence of calluses
▪ Rough, thickened sections of epidermis
▪ Commonly seen in parts exposed to constant
pressure
o Normal: Thin skin without calluses
o Abnormal: very thin skin (arterial
insufficiency/steroids therapy)
- Skin Temperature
o Compare hands and feet bilaterally using dorsal
part of the hand
o Normal: uniform and within normal range
o Abnormal: generalized hyperthermia (fever);
generalized hypothermia (shock); localized
hyperthermia (infection); localized hypothermia
(arteriosclerosis)
- Skin Turgor
o Refers to the skin’s elasticity and how quickly it
returns to its original shape after being pinched
o Refers to skin mobility and how easily the skin can
be pinched
o Assessed by lifting fold of skin and note its ease
with which it lifts up
o Where:
▪ Child/Adult → forehead, chest, abdomen, and
extremities
▪ Elderly → chest and abdomen only
o Normal Findings: Pinched easily and immediately
returns to its original position; Older patients →
decreased elasticity and collagen fibers
(sagging/wrinkled skin in the face, breasts, and
scrotal area)
o Decreased mobility → edema
o Decreased turgor (or >30 seconds) → dehydration
Documentation for Skin Findings
- Draw the location, size, and describe skin lesions on
the body surface diagram
Life Span Considerations
- Newborns/Neonates
o Physiologic jaundice may manifest at 2-3 days
after birth (usually lasts 1 week)
o Pathologic jaundice appears within 24 hours
(usually lasts more than 8 days)
o Note for presence of:
▪ Milia (whiteheads)
▪ Small nodules over the nose and face
▪ Vernix caseosa (white, cheesy, and greasy
material)
▪ If premature: Lanugo (fine, downy hair over
the shoulders and back)
▪ If dark-skinned: may have areas of
hyperpigmentation on the back (sacral area)
→ Mongolian Spots (It normally disappears
three to five years after birth and almost
always by puberty)
- Infants
▪ Diaper rash (diaper dermatitis)
▪ Inquire about details of immunization history
▪ Also assess skin turgor (abdomen)
- Children
o Usually have minor skin lesions (bruising or
abrasions) on arms and legs
o Lesions on other parts of the body may be signs of
disease or abuse (take thorough history, e.g.
glove/stocking injury, cigarette burns)
o Secondary skin lesions may occur frequently as
children scratch or expose a primary lesion to
microbes (staph. spp)
o Oil glands may become more productive and
consequently develop acne (puberty)
- Elderly
o Changes in fairer skin occur earlier than darker-
skinned individuals
 o Wrinkles first appear on skin of face and neck ▪ Diffuse
(abundant in collagen and elastic fibers) ▪ Patchy
o Skin appears thin and translucent due to loss of ▪ Total
dermis and subcutaneous tissue - Alopecia Areata
o Skin may be dry and flaky (less active sebaceous o Clearly demarcated round or oval patches of hair
and sweat glands) loss
o Decreased skin turgor o Usually affects children and young adults
▪ Assess for hydration instead over sternum or o No visible scarring or inflammation
clavicle
o Senile lentigines (melanotic freckles)
▪ Flat, tan-brown, macules appear on areas
exposed to the sun (apparent on back of hand
and other skin areas)
▪ May be as large as 1-2 cm
---- E N D ----
ASSESSMENT OF THE HAIR AND SCALP
- Assess for:
o Growth - Trichotillomania
o Texture o Hair loss due to pulling, plucking, or twisting hair
o Oiliness o Hair shafts are broken at varying lengths
o Infection o More common in children (in settings of family or
o Infestation psychosocial stress)
1. Wear Gloves ▪ Occasionally may lead to hair being consumed
2. Inspect hair (natural color) - Infection
3. Inspect evenness of growth over the scalp o Ringworm → Tinea capitis
4. Inspect hair texture and oiliness - Nutritional Deficiencies
5. Note presence of infections of infestation (part the o Kwashiorkor
hair in several areas and check behind the ears, along - Cancer Treatment
the hairline, and neck) o Radiotherapy
6. Inspect amount of body hair o Chemotherapy
7. Note presence of infection/infestation by parting the - Adrenal imbalance (Hirsutism)
hair o Hirsutism can be caused by: Polycystic ovary
o Normal: scalp free from flaking and no signs of syndrome. This most common cause of
nits or lice hirsutism is caused by an imbalance of sex
o Abnormal: excessive scaliness and raised lesions hormones that can result in irregular periods,
tumor/inflammation) obesity, infertility and sometimes multiple cysts
8. Inspect amount of body hair on your ovaries
o Normal: characteristic hair distribution on body
(biologic sex and physiologic function)
o Abnormal: Excessive hairiness in females (may be
due to imbalance in adrenals)
o Note that excessive hair loss may be caused by:
▪ Infection
▪ Nutritional deficiency
▪ Hormonal disorder
▪ Thyroid or liver disease
▪ Drug toxicity
▪ Hepatic or renal failure - Thyroid disorders
▪ Radiation or chemotherapy o Hyperthyroidism – Fine, silky hair
Hair Conditions o Hypothyroidism – Sparse hair
- Alopecia
o Male pattern hair loss
o Loss of hair which may be:
Lifespan Considerations - blue or cyanotic - peripheral disease or hypoxia
- Neonates/Newborns (and Infants) - Distal band of reddish pink brown covering may be
o Normal to have very little or a great deal of body due to renal disease or hypoalbuminemia.
and scalp hair - White nails (leukonychia) - may be due to trauma,
- Children cardiovascular liver or renal disease
o Axillary and pubic hair begin to appear as puberty - black nails - trauma
approaches - Inspect grooming, color, markings and shape
o Measured by Tanner scale/staging - N: clean, manicured
- AbN: dirty, jagged or broken (poor hygiene or due to
client’s job)
- N: pink w/ some longitudinal ridging; dark-skinned –
freckles or pigmented
- AbN: pale or cyanotic (hypoxia or anemia)
- Splinter hemorrhages – d/t trauma
- Yellow discoloration – fungal infection, psoriasis
- Inspect fingernail plate shape using Schamroth’s
technique
Stage I Stage II Stage III Stage IV Stag V - Put ring fingernails together, locate diamond shaped
No sexual Pubic hair Coarsening Coarse hair Coarse hair
hair appears of pubic across across
space in between the fingernails (Normal)
hair pubis, pubis and
Flat Testicular sparring medial
appearing enlargement Increase thigh thigh
chest with Penis
raised Breast bud size/length Penis Penis and
nipples forms width/glans testis
Breast increases enlarge to
Pre- 8-11.5 years enlarges, adult size
pubertal mound Breast
forms enlarges, Adult
raised breast
11-15 years areola, contour,
mound on areola
mound flattens

13-15 years >15 years

- Elderly
o Possible loss of scalp, pubic, and axillary hair
o Hair on eyebrows, ears, and nostrils may become
bristle-like, and coarse
---- E N D ----
NAIL ASSESSMENT
Equipment Needed
- Acetone
- Cotton Ball
Nails
- Nails are assessed through inspection and palpation.
Condition of the nails often provides important clues
about the patient’s overall health status. Inspect the
color and shape of the nails. Color beneath the nails
should be similar to the overall skin coloring, although
somewhat rosier. There should be no hemorrhage. - No diamond shaped space – indicate clubbing of
Nail texture should uniform and not brittle. Note any fingers (hypoxia)
grooves or lines in the nails. - N: 160 degree angle between the nail base and skin
- normal skin varies from light pink in light skinned - Early clubbing 180 deg. Angle w/ spongy sensation
patient and light brown in dark skinned patients color - Late clubbing >180 deg. Angle
change may indicate local or systemic problem
- Yellow nails - may be due also to smoking
Texture of fingernails/toenails, color, lesions and
obvious deformities
- N: Nails are present and smooth; in elderly =
thickened and yellow d/t decease circulation
- AbN: clubbing: excessive thickness d/t hypoxia
o An increase in hypoxia may activate local
vasodilators, consequently increasing blood flow
to the distal portion of the digits; however, in
most cases, hypoxia is absent in the presence
of clubbing, and many diseases with noted
hypoxia are not associated with clubbing
- Beau’s lines: transverse depression associated with
acute, severe illness
o serious illness that causes nail growth to slow or
halt
o It is believed that there is a temporary cessation
of cell division in the nail matrix
- Koilonychia – spoon shaped nails
o Spooning or concave nail - severe iron deficiency
anemia thyroid and circulatory disease or in
response to some disease and local trauma
- Mee’s lines: transverse lines with curves similar to the
lunula, occur following an acute or severe illness
o arising from the disrupted matrix of the proximal
nail they vary in width and move distally as the
nail grows out. Seen in arsenic poisoning heart
failure chemotherapy leprosy and carbon
monoxide poisoning.
- Leukonychia: white spots that grow slowly out with
the nail following trauma to the nails
o Typical od vigorous and repeated manicuring
- Onycholysis: painless separation of the nail plate from
the nailbed
o Starts distally and progress proximally enlarging
the free edge of the nail. May be due to trauma
from manicuring, psoriasis fungal infection and
allergic reactions to nail cosmetics. Systemic
causes include diabetes, anemia hyperthyroidism
peripheral ischemia and syphilis.
- Paronychia – indicates local inflammation
o superficial infection of the proximal and lateral
nail folds adjacent to the nail plate usually from
staphylococcus aureus or streptococcus.
- Inspect surrounding tissue
- N: intact epidermis
- AbN: presence of hangnails
o Dry skin is a major cause of hang nails. Other
reasons include frequent nail biting, cutting a
cuticle too closely or from previous injury to the
nail. Therefore, in order to prevent hang nails,
depending on your situation, it is important to
address the cause.
 d. Puff cheeks
e. Smile
f. Show teeth
5. Palpate the skull for nodules, masses, or depression
a. Include the fontanels for pediatric patients
Skull Assessment
- Assess for the size, shape, and symmetry of the skull
- Perform blanch or capillary refill test
- Normal: rounded and smooth (normocephalic)
- N: 2-3 seconds Capillary Refill Test (CRT)
- Abnormal: enlarged (hydrocephalus)
o Capillary refill test- gently press on nail and note
o hydrocephalus can be inherited genetically or
blanching then release and note speed of refill
may be associated with developmental disorders,
return of color → poor refill indicates
including spina bifida (congenital defect of the
cardiopulmonary problems or anemia. Note that
spine) and encephalocele (hernia of the brain)
positive capillary refill may be affected by cold
- Abnormal: Lack symmetry
temperatures.
o increased size with prominent nose and forehead
- Document findings
Lifespan Considerations
- INFANTS
o Newborns nails grow very quickly, are extremely
thin, and tear easily
- CHILDREN
o Bent, bruised or ingrown toenails may indicate
shoes that are too tight
o Nail biting should be discussed with a family
member.
- ELDERS
o The nails grow more slowly and thickened
o Longitudinal bands commonly develop, and the
nails tends to split
o Bands across the nails may indicate protein
deficiency; white spots; zinc deficiency; and
spoon-shaped nails; iron deficiency
o Toenail fungus is more common and difficult to
eliminate (although not dangerous to health)
Procedure: Assessing the Nails
- Equipment: acetone and cotton ball
1. Inspect the fingernail plate shape to determine its Assessing Facial Features
curvature and angle - Normal
2. Inspect the fingernail and toenail textures o Symmetrical facial features (round, oval, square,
3. Inspect fingernail and toenail color, lesions and elongated)
obvious deformities o Palpebral fissures equal
4. Inspect surrounding nails o Symmetric nasolabial folds
5. Perform blanch test or capillary refill test (CRT)
6. Document findings in the chart
---- E N D ----

ASSESSMENT OF THE SKULL AND FACE

1. Inspect skull for shape and symmetry
2. Inspect facial features
3. Inspect eyes for edema and hollowness
4. Inspect facial symmetry and movements
a. Elevate eyebrows
b. Frown/lower eyebrows
c. Close eyes tightly
- Abnormal 1. Elevate eyebrows
o Asymmetrical facial features 2. Frown
o Prominent facial hair (hypertrichosis or werewolf 3. Lower eyebrows
syndrome) 4. Close lids tightly
o Exopthalmia 5. Puff the cheeks
▪ Proptosis - In the case of thyroid eye 6. Smile
disease, the immune system 7. Show teeth
attacks the muscles and fatty tissues around
and behind the eye, causing them to become Other Assessments of the Face
inflamed (swollen). - Palpate for any nodules, masses, or depressions
o Facies (a distinctive facial expression associated - Normal: Smooth, uniform, no nodules/masses noted
with a clinical condition) - Abnormal: Indicate which area has abnormalities such
as a depression from local trauma (Le Fort Fractures)

Lifespan Considerations
- Neonates/Newborns
o Shape of the head can be different
▪ Depends on the type of delivery (vaginal vs
caesarian section)
▪ Vaginal delivery: Can sometimes lead to
elongated, molded heads
▪ normal shape of the head becomes more
rounded after 1-2 weeks (molding)
▪ Cesarean Section: Tend to have smooth,
rounded heads
Fontanel Shape Size Time of
Eyes Assessment Closure
- Inspect the eyes for edema and hollowness Anterior Diamond 2-3cm 18 months
- Normally, there should be none Posterior Triangle 1 cm 8 weeks
- Abnormal ▪ Head movement: Can slightly lift their heads
o Periorbital edema and move side to side; Voluntary control is
o Eye bags established at approximately 4-6 months
▪ Lack of sleep increases venous congestion; ---- E N D ----
fluid build-up leads to pooled blood in those
superficial blood vessels, making dark circles ASSESSMENT OF THE EYES
look even darker when you’re tired. Eye structures/visual acuity
o Hollow Eyes or Sunken Eyes - Eyebrows: hair distribution and alignment and for skin
▪ Aging quality and movement
▪ Dramatic Weight Loss o Let pt. raise and lower eyebrow
▪ Lack of Sleep o N: symmetrical, equal eyebrow movement and
▪ Dehydration hair distribution
Facial Symmetry Assessment
- Ask patient to:
 o AbN: scaling (seborrheic dermatitis), lateral
sparseness (hypothyroidism), and asymmetrical
eyebrow movement or distribution
- Eyelashes: evenness and curl direction
o N: evenly distributed and turned outward
o No crusting and infestations
o Absence of eyelashes- alopecia universalis
o Inflammation → called BLEPHARITIS
▪ inflammation at the edge of the eyelids
involving hair follicles and meibomian glands
of the eyelids
o inverted eyelashes - entropion can scratch the
cornea
o Everted eyelashes - ectropion can lead to
excessive drying of the eyes
- Eyelids for surface characteristics etc.
o Elevate brows with thumb and index and let pt.
close eyes
o N: skin intact, no discharge /discoloration
o 15-20 blinks/min; bilateral
o N: palpebral fissures should be equal in size when
eyes are open
- Eye Lids
o upper lid: covers small portion of the iris and
cornea
o lower lid: margin just below the junction of the
cornea and sclera
o lid margins: are clear, lacrimal duct openings
(puncta) evident at nasal ends of upper and lower
lids
o AbN: rapid, monocular, infrequent or absent
blinking
o Ptosis: drooping of upper eyelid may be d/t
myasthenia gravis, damage to oculomotor, senile
ptosis
▪ Ptosis can be due to damage of cranial nerve
3 or stroke if both eyelids affected-
myasthenia gravis
o entropion : more in elderly : inward turning of the
lid margin
- ectropion: margin of lower lid is turned outward,
exposing palpebral conjunctiva, puncta of lower lid
turns outward, tearing occurs
- Conjunctiva (Palpebral and Bulbar)
Palpebral Conjunctiva
Bulbar Conjunctiva
- Bulbar Conjunctiva
o Lower palpebral: ask patient to look up, depress
lower lids with thumbs
o Bulbar: rest thumb and finger on the bones of the
cheek and brow and spread the lids, let patient
look to each side and down
▪ clear with few underlying blood vessels and
white sclera visible
▪ N: transparent and with red blood vessels
▪ AbN: red blood vessels are dilated (bloodshot
eyes)
- Palpebral Conjunctiva
o Upper palpebral: ask pt. to look down, relax the
eyes, raise upper lid slightly so eyelashes
protrude, grasp upper eyelashes pull gently
forward and down
o Place small stick (applicator/tongue blade) 1 cm
above the lid margin, push down the stick as you
raise the edge of the lid then evert
▪ Note for the color and foreign objects.
Palpebral conjunctiva is smooth glistening
pinkish peach color with minimal blood
vessels visible
o Secure upper lashes against the eyebrow with
your thumb and inspect the palpebral conjunctiva
o After: grasp upper lashes and pull forward gently,
ask patient to look up, lid will return to normal
position
o Normal: should be pink and clear
o AbN: Conjunctivitis → inflamed conjunctival
surface
- Lacrimal Ducts and Glands
- Pupils (color, shape, symmetry etc…)
o Use tip of index finger to palpate the lacrimal duct
o (inner canthus) and the gland (outer canthus)
o N: evident at nasal ends of upper and lower lid,
no edema/tenderness noted
o AbN: Dacryocystitis: inflammation of the duct d/t
obstruction
- Cornea
o To see transparency of the cornea
▪ Shine a light on the cornea from an oblique
angle (sides) note clarity and abrasions
o N: shiny, smooth
o AbN: opaque, not smooth
o arcus senilis – (below 40 y.o.), thin gray ring
around the margin
o corneal reflex - to test corneal reflex, take a wisp
of rolled cotton and gently touch the cornea or
take a needleless syringe filled with air and shoot
a puff of air over the cornea note blinking and
tearing
o blink reflex → brush your index fingers across
patient’s eyelashes and note blinking
o PERRLA – pupils equally round, reactive to light
and accommodation
▪ Note for pupil size and equality
▪ test pupillary reaction to light → have patient
look straight ahead while you bring light in
from the side over the eyes and note for the
reaction and speed in both eyes. Direct
reaction eye receiving stimulus constricts
▪ pupils constrict in response to looking at a
near object so shine light from temporal side
not directly in front of patient’s line of vision.
This ensures that pupil constriction you
observe is a result of pupillary light reflex and
not focusing on a near object
▪ Miosis refers to constriction of the pupil and
mydriasis is dilation
o N: constrict with light; round; isocoric (pupils are
the same size)
o AbN: anisocoric (unequal pupils)
o Direct and consensual reaction to light
▪ Darken room and tell client look straight
ahead
▪ penlight should enter field of vision from the
temporal side
▪ Direct reaction to light: pupillary constriction
in same eye
▪ Consensual reaction to light: pupil
constriction in opposite eye
▪ pupil should be round and equal bilaterally
size is larger in children smaller in older
adults’ normal range is 3-5 mm in adults
(usually 3 mm)
o Accommodation
▪ hold object (pencil) about 10 cm (4 in) from
bridge of the nose
▪ Ask patient to look at top of object then
distant object behind penlight
▪ Alternate gaze from near to far
▪ N: pupil response: near (constrict), far (dilate)
- Visual fields ▪ Normal: converging eyes follow object within
o Nurse and patient stand 2 ft away from each 5-8 cm of the nose
other (Facing each other) ▪ Abnormal: eye movement not
o Nurse will hold an object and tests peripheral coordinated/parallel; rapid, lateral, horizontal
vision movement of the eyes (nystagmus)
o Temporal field – 90 degrees to central point ASSESSMENT OF VISUAL ACUITY
o Upward field – 50 degrees d/t orbital ridge - Visual Acuity
o Downward – 70 degrees d/t cheekbone o Degree to which details and contours of objects
o Nasal – Left arm periphery – 50 degrees are perceived
o AbN: Homonymous Hemianopia o Usually defined by shortest distance two (2) lines
▪ Homonymous hemianopsia (or homonymous can be separated and still be perceived as two (2)
hemianopia) is hemianopic visual field loss on lines
the same side of both eyes. - Testing Visual Acuity
o Individual is placed 20 feet (6 meters) away from
a Snellen letter chart
o He reads aloud the smallest line distinguishable to
him

ASSESSMENT OF THE EXTRAOCULAR MUSCLES

- Assess in patients at least 6 months old

o Stand directly in front of patient
o Hold penlight at 60 cm (2 feet)
o Ask to hold head in fixed position and follow
penlight using eyes only
o Normal: movement of eyes in conjugate (refers to
motor coordination of the eyes that allows for
bilateral fixation on a single object) fashion o Equipment: Snellen’s chart
(except when converging on object moving closer) o Child must have 20/20 vision by 6 years old
o Convergence → ability of eyes to turn inward and - Testing Near Vision
focus on very close object o If with glasses, must be used during test
o Reading material should be positioned at least 14
inches away from patient
o Normal: able to read fine print
o Equipment: Rosenbaum Pocket Vision Screener

▪ Ask patient to follow finger or pencil as it is

moved toward the bridge of the nose

- Functional Vision
- Lifespan Considerations
- Testing Distance Vision
o Equipment: Snellen Chart
o Let patient sit/stand 6 meters (20 feet) from the
chart (cover the eye not being tested)
o Take three (3) readings (both eyes)
o Record readings: Smallest line where the patient
was able to read at least half of all the letters
o Top line of the chart is 20/200
▪ Numerator
• always 20 (distance of the patient from
the chart)
▪ Denominator
• greatest distance a person with normal
vision can read the smallest line
o Visual Acuity Test Result
▪ 20/40 – 2 cc (CC refers to "with correction"
while SC refers to "without correction.")
• Means 2 letters were misread by the
patient wearing corrective lenses
- Must know terms in vision testing
o Emmetropia – Normal vision
o Ametropia – Abnormal vision
o Presbyopia – Age-related vision (reading a
newspaper at arm’s length) → farsightedness
caused by loss of elasticity of the lens of the
eye, occurring typically in middle and old age
o Myopia – near vision
o Hyperopia – far vision
o Counting fingers
▪ Result: C/F @ 1 foot (12 inches)
o Hand Movement
▪ Hold hand @ 30 cm (1ft) from client’s face
▪ Move slowly back and forth, stop periodically
▪ Ask client to tell when hand stop moving
o Light perception
▪ Penlight shone from lateral position and turn
light off
▪ Ask client to tell you when light is on/off
▪ Result: “LP”
o INFANTS
▪ Infants 4 weeks of age should gaze at and
follow objects
▪ Ability to focus with both eyes should be
present by 6 months of age
▪ Infants do not have tears until about 3
months of age
▪ A cover test and corneal light reflex
(Hirschberg) test should be conducted on
infants to detect misalignment early and
prevent amblyopia (lazy eye)
▪ Visual acuity is about 20/300 at 4 months and
progressively improves.
▪ Occasionally, normal infants may have
episodes of abnormal eye movements,
including nystagmus or tonic gaze deviations,
during the first 1-2 months of life.
o CHILDREN
▪ The Epicanthal folds, common in persons of
Asian cultures, may cover the medial canthus
and cause eyes to appear misaligned.
Epicanthal folds may also be seen in young
children of any race before the bridge of the
nose begins to elevate.
 ▪ Preschool children’s acuity can be checked
with picture cards or the E chart. Acuity
should approach 20/20 by 6 years of age.
▪ A cover test and corneal light reflex
(Hirschberg) test should be conducted on
young children to detect misalignment early
to prevent amblyopia.
▪ Always perform the acuity test with glasses
on if a child has a prescription to wear lenses.
o ELDERS (VISUAL ACUITY)
▪ Visual acuity decreases as the lens of the eye
ages and becomes opaquer and loses
elasticity.
▪ The ability of the iris to accommodate
darkness and dim light diminishes.
▪ Peripheral vision diminishes
▪ The adaptation to light (glare) and dark
decreases
▪ Accommodation to far objects often
improves, but accommodation to near objects
decreases
▪ Color vision declines; older people are less
able to perceive purple colors and to
discriminate pastel colors.
▪ Many elders wear corrective lenses; they are
most likely to have hyperopia. Visual changes
are due to loss of elasticity (presbyopia) and
transparency of the lens.
▪ EXTERNAL EYE STRUCTURES
• The skin around the orbit of the eye may
darken
• The eyeball may appear sunken because
of the decrease in orbital fat
• Skin folds of the upper lids may seem
more prominent, and the lower lid may
sag
• The eyes may appear dry and lusterless
because of the decrease in tear
production from the lacrimal glands.
• A thin, grayish white arc or ring (Arcus
Senilis) appears around part or all of the
cornea. It results from accumulation of a
lipid substance on the cornea. The cornea
tends to cloud with age.
• The iris may appear pale with brown
discolorations as a result of pigmentation
degeneration
• The conjunctiva of the eye may appear
paler that that of younger adults and may
take on a slightly yellow appearance
because of fat deposits.
• Pupil reaction to light accommodation is
normally symmetrically equal but may be
less brisk.
• The pupils can appear smaller in size,
unequal, and irregular in shape because
of sclerotic changes in the iris.
---- E N D ----
ASSESSING EARS AND HEARING
- 2 main functions of the ears
1. Hearing
2. Equilibrium
- In performing general survey, note overall
appearance. Is the person guarding her or his ear? Or
is the patient tugging his ear? → sign of infection
- Is the patient attentive or responding appropriately?
o Inappropriate responses or inattentiveness may
result from hearing deficits
- Is the patient speaking loudly?
o People with hearing deficits tend to speak louder.
- do you notice any problems with the patient’s ability
to maintain balance?
o Balance problems are associated with inner ear
problem
- pattern is, inspect and palpate then view inner ear
with otoscope then do hearing acuity test
- normal results
o level → helix of the ear is aligned with the outer
canthus
o AbN: low set ear associated with mental
retardation
Assessment of Ears
o Inspect auricles for color, symmetry of size and
position
▪ Note level of superior aspect of auricle in
relation to the eye
▪ Cyanosis (earlobes), pallor, redness
(inflammation/fever)
▪ color same as facial skin
o Palpate auricles for texture, elasticity and areas of
tenderness
▪ Fold pinna forward
▪ N: mobile, firm, pinna recoils
▪ AbN: lesions, tenderness
(inflammation/infection of external ear)
o Inspect external canal of ear
▪ Distal 3rd with hair follicles and glands
▪ Wet/dry cerumen
o Tympanic membrane
▪ Inspect tympanic membrane with the use of
an otoscope
▪ Use shortest and largest speculum that will
accommodate ear canal
 ▪ Hold otoscope with handle up. Have patient
tilt head opposite direction of the ear being
examined. Pull helix up and back to straighten
ear anal for adult and children under 2 years
old pull pinna down and back.
▪ N: pearly gray and semitransparent
▪ AbN: pink, red, yellow, white, blue, dull
surface
• Yellow → serous otitis media
• Dark → tympanic membrane perforation
• blue to black → trauma
• reddish → otitis media
- Gross Hearing Acuity
o Assess using normal tone of voice, if there is
difficulty, then proceed with other tests
o Watch Tick Test
▪ Checking high tone frequency
▪ have patient cover opposite ear being tested
hold ticking watch within 5 inches from ear
▪ Slowly move the watch away from the ear
▪ note ability to hear sound
▪ result = patient should hear tick of a watch in
each ear at a distance of 5 inches
• ≥20 inches (normal)
• <10 inches (hearing loss)
▪ Abnormal result is considered high tone
frequency loss
o Whisper Test
▪ Checking low pitch
▪ have patient cover opposite ear being tested
▪ Stand 1-2 feet behind patient and whisper
• Whisper non-consecutive number, or
whisper two words (different words
should be whispered on the other ear)
▪ Note patient’s ability to hear sound
• Let client repeat the mentioned numbers
or words
▪ N: patient repeats most words whispered in
each ear at a distance of 1 to 2 feet
▪ AbN: inability to repeat words so there is low
tone frequency loss
o Weber Test
▪ Test for lateralization of vibration.
▪ Hold tuning fork by stem.
▪ Tap prongs on palm of hand.
▪ place vibrating tuning fork in the middle of
forehead or on top of the patient’s head.
▪ Ask patient to state on which side is louder:
left, right, or midline (equal)
▪ Note patient’s ability to hear sound and note
for lateralization of sound.
▪ N: Vibration should be heard equally on both
ears; localized at center of head (negative
Weber)
▪ Abnormal
• conductive loss: shifting of sounds to
poorer hearing ear (heard better in
impaired ear) due to obstruction of
ossicles
• sensorineural loss: shifting of sounds to
better ear due to nerve or inner ear
damage
Remember
If the sound is heard equally on both ears: Person may
have normal hearing or equal degrees of hearing loss in
both ears
o Rinne Test
▪ Compares air and bone conduction
▪ Place the vibrating tuning fork on the mastoid
process
▪ let patient tell you when it stops or could no
longer hear the tuning fork
▪ immediately bring vibrating tuning fork in
front of the ear and ask if patient can hear it
▪ Continue to note length of time until patient
no longer hears sound
▪ N: air conduction should be heard twice as
long as bone conducted sound after bone
conduction stops (classify as “positive”)
• Rationale: Air Conduction > Bone
Conduction
▪ Ratio of air conduction and bone conduction
is similar in both ears
 ▪ AbN: air conduction is less than twice bone
conduction. Consider hearing loss caused by
ear wax, otitis media, serous otitis or damage
to ear ossicles
• Patients with conductive hearing loss will
perceive the sound as louder on the
mastoid
• Classify as “negative”
- Lifespan Considerations
o INFANTS
▪ To assess gross hearing, ring a bell from
behind the infant or have the parent call the
child’s name to check for a response.
Newborns will quiet to the sound and may
open their eyes wider.
▪ By 3 to 4 months of age, the child will turn
head and eyes toward the sound.
▪ All newborns should be assessed for hearing
using auditory brain response testing prior to
discharge from the hospital.
o CHILDREN
▪ To inspect the external canal and tympanic
membrane in children less than 3 years old,
pull the pinna down and back. insert the
speculum only ¼ to ½ inch.
▪ Hearing loss is becoming more common in
adolescents and young adults; probably as a
result of exposure to loud music and
prolonged use of headsets at loud volumes.
o ELDERS
▪ The skin of the ear may appear dry and be
less resilient because of the loss of connective
tissue
▪ Increased coarse and wire-like hair growth
occurs along the helix, antihelix and tragus
▪ The pinna increases in both width and length,
and the earlobe elongates.
▪ Earwax is drier
▪ The tympanic membrane is more translucent
and less flexible. The intensity of the light
reflex may diminish slightly
▪ Sensorineural hearing loss occurs
▪ Generalized hearing loss (presbycusis) occurs
in all frequencies, although the first symptom
is the loss of high-frequency sounds: the f, s,
sh and ph sounds. To such persons,
conversation can be distorted and result in
what appears to be inappropriate or confused
behavior.
---- E N D ----
ASSESSING NOSE AND SINUSES
- Nose
o Inspect external nose for any deviations in shape,
size, color, flaring, or discharge from nares.
o Lightly palpate external nose to identify any areas
of tenderness, masses, and displacements of
bone and cartilage.
o Determine patency of both nasal cavities.
▪ Ask patient to close mouth, exert pressure on
one naris, and breathe through the opposite
naris. Repeat on other side.
o N: uniform color, symmetrical, no discharges, no
nasal flaring, nasal septum straight and not
perforated
o N: non tender, no lesions noted
o N: air moves freely as client breathes through the
nares
o Tip head back, speculum is held in non-dominant
hand, little finger at side of nose to stabilize.
▪ Dominant hand – position head/hold light
▪ observe for redness, swelling, growths and
discharges
• N: mucosa pink, clear watery discharges
noted, no lesions or growths noted
- Nasal Septum
o N: intact & midline
o AbN: deviated septum noted
- Maxillary and Frontal Sinuses

o Palpate using both thumbs
▪ Frontal: direct manual pressure upward
toward wall of sinus
▪ Maxillary: pressure upward over lower edge
of maxillary bones
o Percuss with direct or immediate percussion
▪ N: no tenderness and resonant tone (air filled)
▪ Abnormal:
• tenderness → sinusitis
• Dull tone → thickening or fulness of sinus
cavity associated with chronic sinusitis
o N: no tenderness of sinuses noted
o AbN: tenderness of frontal/maxillary sinuses
noted
▪ tenderness indicates infectious or allergic
rhinitis
- Lifespan Considerations
o INFANTS
▪ A speculum is usually not necessary to
examine the septum, turbinates and
vestibules.
▪ Instead, push the tip of the nose upward with
the thumb and shine a light into the nares.
▪ Ethmoid and maxillary sinuses are present at
birth; frontal sinuses begin to develop by 1 to
2 years of age; and sphenoid sinuses develop
later in childhood. Infants and young children
have fewer sinus problems than older
children and adolescents.
o CHILDREN
▪ A speculum is usually not necessary to
examine the septum, turbinates and
vestibule. It might cause the child to be
apprehensive. Instead, push the tip of the
nose upward with the thumb and shine a light
into the nares.
▪ Ethmoid sinuses fully develop by 6 years of
age. Sinus problem in children under this age
are rare. Cough and runny nose are the most
common signs of sinusitis in preadolescent
children
o Adolescents
▪ may have headaches, face tenderness, and
swelling similar to the signs seen in adults
o ELDERS
▪ The sense of smell markedly diminishes
because of decrease number of olfactory
nerve fibers and atrophy of the remaining
fibers. Elders are less able to identify and
discriminate odors.
▪ Nosebleeds (epistaxis) may result from
hypertensive disease or other arterial vessel
changes.
---- E N D ----
ASSESSMENT OF MOUTH AND OROPHARYNX
- Lips/Buccal Mucosa
o Inspect outer lips for symmetry of contour, color
and texture
o Ask to purse lips as if to whistle
o N: uniform pink color, soft, moist and smooth
o AbN: chapped, dry, pale lips noted (facial nerve
damage)
- Inner Lips/Buccal Mucosa
o Wear Gloves
o Check for color, moisture, presence of lesions
o Let client relax the mouth
o Grasp lip on each side between thumb and index
finger
o Pull lip outward away from teeth
o Palpate for lesions, check front teeth and gums
▪ Inspect teeth, gums while examining the inner
lips and mucosa include dentures if any (ask
to remove dentures and check condition)
 o N: entire oral cavity should be pink w/o ulcers ▪ Sublingual/submaxillary (Bartholin’s duct)
o AbN: deep red color, lesions, palpable masses or → open underneath the tongue
swelling
- Tongue
o Inspect tongue surface for position, color and
texture by asking client to protrude tongue
▪ N: pink, moist, slightly rough, thin whitish
coating
▪ AbN: red tongue (Fe, Vit. B12, B3 deficiency)
o Inspect tongue movement
o Roll tongue upward and move side to side
▪ N: no tenderness, able to move freely
▪ AbN: restricted mobility of tongue noted
o Inspect base of tongue, mouth floor and frenulum
by asking patient to place tongue tip to roof of
mouth
▪ N: smooth tongue base with prominent veins
▪ AbN: swelling, ulceration noted
o Palpate tongue and floor of mouth for nodules,
lumps or excoriated areas
o Use piece of gauze to grasp tongue tip and with
index finger of other hand, palpate back of o N: same color as buccal mucosa
tongue, borders and base - Palates
▪ N: smooth, no palpable nodules/lesions o Soft Palate
▪ AbN: deviation/tremor (CN XII) ▪ N: light, pink, and smooth
- Salivary Glands o Hard Palate
o Inspect duct openings ▪ N: Lighter in color
▪ Parotid glands (Stensen’s duct) – level of o AbN: exostosis → bony growth from hard palate
upper teeth halfway back - Uvula
→ Beside the crown of the second upper o N: Midline of soft palate and immobile
molar o Abnormal
▪ Deviation to 1 side (damage to CN V and X)

Parotid papilla
with opening
of parotid duct

▪ Tumor/Trauma
▪ Swelling (Uvulitis)
- Lifespan Considerations
o INFANTS
▪ inspect the palate and uvula for cleft. A bifid
(forked) uvula may indicate an unsuspected
cleft palate (i.e. a cleft in the cartilage that is
covered by skin)
 ▪ Newborns may have a pearly white nodule on
their gums, which resolves without treatment
▪ The first teeth erupt at about 6 to 7 months
of age. Assess for dental hygiene, parents
should cleanse the infant’s teeth daily with a
soft cloth or soft toothbrush
▪ Fluoride supplements should be given by 6
months if the child’s drinking water contains
less than 0.3 parts per million (ppm) fluoride.
o CHILDREN
▪ Tooth development should be appropriate for
age.
▪ White spots on the teeth may indicate
fluoride ingestion.
▪ Drooling is common up to 2 years of age
▪ The tonsils are normally larger in children
than in adults and commonly extend beyond
the palatine arch until the age of 11 or 12
years.
o ELDERS
▪ The oral mucosa may be drier than that of
younger persons because of decreased
salivary gland activity.
▪ Decreased salivation occurs in elderly people
taking prescribed medications such as
antidepressants, antihistamines,
decongestants, diuretics, antihypertensives,
tranquilizers, antispasmodics and
antineoplastics.
▪ Extreme dryness is associated with
dehydration.
▪ Some receding of the gums occurs, giving an
appearance of increased toothiness.
▪ Taste sensations diminish. Sweet and salty
tastes are lost first. Elderly persons may add
more salt and sugar to food than they did
when they were younger. Diminished taste
sensation is due to atrophy of the taste buds
and a decreased sense of smell. It indicates
diminished function of fifth and seventh
cranial nerves.
▪ Tiny purple or bluish black swollen areas
(varicosities) under the tongue, known as
caviar spots are not uncommon.
▪ The teeth may show signs of staining, erosion,
chipping, and abrasions due to loss of dentin.
▪ Tooth loss occurs as a result of dental disease
but preventable with good dental hygiene.
▪ The gag reflex may be slightly sluggish.
▪ Elders who are homebound or are in long
term care facilities often have teeth or
dentures in need of repair, due to the
difficulty of obtaining dental care in these
situations. Do a thorough assessment of
missing teeth and those in need of repair,
whether they are natural teeth or dentures.
- Teeth/Mucosa Terminologies
o Caries – decay and crumbling of a tooth or bone
o Plaque – invisible soft film of enamel which may
be bacteria, saliva, epithelial cells
o Tartar – unchecked plaque, dental calculus forms
▪ visible, hard deposit of plaque and dead
bacteria at gum line
o Gingivitis – red, swollen gingiva
o Glossitis – inflammation of tongue
o Stomatitis – inflammation of oral mucosa
o Parotitis – inflammation of parotid salivary gland
o Sordes – accumulation of foul matter like food,
microorganism and epithelial cells in mouth
---- E N D ----
ASSESSING THE NECK
- Inspect the neck muscle (sternocleidomastoid and
trapezius) for abnormal swellings or masses. Ask the
client to hold the head erect.
o N: Muscles equal in size; head centered
o AbN: Unilateral neck swelling, head tilted to one
side (indicates presence of masses, injury, muscle
weakness, shortening of sternocleidomastoid
muscle, scar)
- Observe for head movement (determines function of
the sternocleidomastoid muscle).
o N: Coordinated, smooth movements with no
discomfort
o Abn: Muscle tremors, spasm or stiffness
- Ask the client to:
o Move chin to the chest.
▪ N: head flexes 45 degrees
▪ Abnormal
• Limited range of motion, painful
movements, involuntary movements (e.g.
up and down nodding movements
associated with Parkinson’s disease)
• Brudzinski’s Sign indicative of Meningitis
o Move her head back so that the chin points
upward.
▪ N: head hyperextends 60 degrees
▪ AbN: Head hyperextends less than 60 degrees
o Move head so that the ear is moved toward the
shoulder on each side.
▪ N: Head laterally flexes 40 degrees
▪ Abn: Head laterally flexes less than 40
degrees
o Turn head to the right and to the left
▪ N: Head laterally rotates 70 degrees
 ▪ Abn: Head laterally rotates less than 70 ▪ Observe the lower half of the neck overlying
degrees the thyroid gland for symmetry and visible
- Assess muscle strength masses.
o Ask the client to turn the head to one side against ▪ Ask the client to hyperextend her neck and
the resistance of your hand. Repeat with the swallow. If necessary, offer a glass of water
other side. for the client to swallow.
▪ N: equal strength o Palpate the thyroid gland for smoothness. Note
▪ Abn: unequal strength any areas of enlargement, masses or nodules.
o Ask the client to shrug the shoulders against o If enlargement of the gland is suspected:
resistance of your hands ▪ Auscultate over the thyroid area for a bruit.
▪ N: Equal strength o Document pertinent findings in the chart.
▪ Abn: Unequal strength ---- E N D ----
- Assess the Lymph Nodes of the Neck

o Palpate the entire neck for enlarged lymph nodes

o Sequence:
▪ Anterior cervical nodes at the
sternocleidomastoid muscle
▪ Posterior cervical nodes along the anterior
border of the trapezius muscle
▪ Posterior cervical nodes deep to the
sternocleidomastoid muscle
▪ Supraclavicular nodes pressing deeply in the
angle formed by the clavicle and
sternocleidomastoid muscle
- Trachea
o Palpate the trachea for lateral deviation.
o Place your fingertip or thumb on the trachea in
the suprasternal notch.
o Move your finger laterally to the left and the right
in spaces bordered by the clavicle, the anterior
aspect of the sternocleidomastoid muscle and
trachea.
- Thyroid Gland
o Inspect the thyroid gland