NCM 101

HA RLE
Group 2

Submitted by:
Jan Elmer L. Labesores
BSN-1B

Submitted to:
Angelito P. Abao, MN, RN
 PHYSICAL ASSESSMENT

AREA NORMAL FINDINGS ABNORMAL FINDINGS

GENERAL SURVEY AND 1. Proportionate, varies with 1. Excessively thin or obese.
MENTAL STATUS lifestyle. 2. Tense, slouched, bent posture,
2. Relaxed, erect posture; uncoordinated movements;
coordinated movement.
tremors.
3. Clean, neat
4. No body odor or minor body 3. Dirty, unkempt
odor relative to work or 4. Foul body odor, ammonia odor,
exercise; no breath odor. acetone breath odor,; foul
5. No distress noted. breath.
6. Healthy appearance. 5. Bending over because of
7. Cooperative, able to follow abdominal pain, wincing,
instructions.
frowning, or labored breath.
8. Appropriate to situation.
9. Healthy appearance 6. Pallor; weakness; lesions
10. Cooperative, able to follow 7. Negative, hostile, withdrawn.
instructions. 8. Inappropriate to situation.
11. Appropriate to situation. 9. Pallor; weakness; lesions
12. Understandable, moderate 10. Negative, hostile, withdrawn.
pace; clear tone and inflection; 11. Inappropriate to situation.
exhibits thought association.
12. Rapid or slow pace; overly loud
13. Logical sequence; make
sense; has sense of reality. or soft; uses generalizations;
14. Can follow and elaborate lacks association.
15. This is to prepare for the 13. Illogical sequence; flight of
examination ideas; confusion; vague.
14. Cannot follow and cannot
elaborate.

SKIN 1. Varies from light to deep 1. Pallor, cyanosis, jaundice,

brown; from ruddy pink to erythema.
light pink; from yellow 2. Areas of either
overtones to olive.
hyperpigmentation or
2. Generally uniform except in
hypopigmentation.
areas exposed to the sun;
areas of lighter pigmentation 3. Has edema (See the scale for
(palms, lips, nail beds) in dark- describing edema)
skin people. 4. Various interruptions in skin
3. No edema integrity; irregular,
4. Freckles, some birthmarks, multicolored, or raised nevi.
some flat and raised nevi; no
5. Excessive moisture (e.g. in
abrasions or other lesions.
5. Moisture in skin folds and hyperthermia), excessive
the axillae (varies with dryness (e.g. in dehydration)
environmental temperature 6. Generalized hyperthermia (e.g.
 and humidity, body in fever); generalized
temperature, and activity.) hypothermia (e.g. in shock);
6. Uniform; with normal range. localized hyperthermia (e.g. in
7. When pinch, skin springs
infection); localized
back to previous state; may be
hypothermia (e.g. in
slower in elders.
arteriosclerosis).
7. Skin stays pinched or tented or
moves back slowly (e.g. in
dehydration)

SCALP AND HAIR 1. Evenly distributed hair. 1. Patches of hair loss (i.e.,
2. Silky, resilient hair. alopecia).
3. No infection or infestation. 2. Brittle hair (e.g.,
4. Variable.
hypothyroidism); excessively
oily or dry hair.
3. Flaking, sores, lice, nits (louse
eggs), and ringworm.
4. Hirsutism (abnormal hairiness)
in women; naturally absent or
sparse leg hair (poor
circulation).

NAILS 1. Convex curvature; angle of 1. Spoon nail; clubbing (180° or

nail plate about 160°. greater).
2. Smooth texture. 2. Excessive thickness or thinness
3. Highly vascular and pink in
or presence of grooves or
light-skinned clients; dark-
furrows; Beau’s lines;
skinned clients may have
brown or black pigmentation discoloured or detached nail -
in longitudinal streaks. often due to fungus.
4. Intact epidermis. 3. Bluish or purplish pint (may
5. Prompt return of pink or reflect cyanosis); pallor (may
usual color (generally less than reflect poor arterial circulation).
4 seconds).
4. Hang nails; paronychia
(inflammation).
5. Delayed return of pink or usual
color (may indicate circulatory
 impairment).

HEAD AND FACE 1. Rounded (normocephalic 1. Lack of symmetry; increased

and symmetric, with frontal, skull size with more prominent
parietal, and occipital nose and forehead; longer
prominences); smooth skull
mandible (may indicate
contour.
2. Smooth, uniform excessive growth hormone or
consistency; absence of increased bone thickness).
nodules or masses. 2. Sebaceous cyst; local
3. Symmetric or slightly deformities from trauma;
asymmetric facial features; masses, nodules.
palpebral facial fissures equal 3. Increased facial hair; thinning of
in size; symmetric nasolabial
eyebrows; asymmetric
folds.
4. Symmetric facial features; exophthalmos;
movements. myxedema faces; moon face.
5. Symmetric sensations 4. Asymmetric facial movements
6. Elastic and tender (e.g. eye on affected side
7. Not tender, no swelling, and cannot close completely);
crepitation drooping of eyelid and mouth;
involuntary facial movements
(i.e. tics or tremors).
5. Asymmetric sensations of
forehead, cheeks, and chin
6. Non-elastic and non-tender
7. Tender, swelling, and with
crepitation

EYES AND VISION 1. Hair evenly distributed; skin 1. Loss of hair; scaling and
intact. Eyebrows symmetrically flakiness of skin. Unequal
aligned; equal movement. alignment and movement of
2. Equally distributed; curled
eyebrows.
slightly outward
2. Turned inward
3. Skin intact; no discharge; no
discoloration. Lids close 3. Redness, swelling, flaking,
symmetrically. Approximately crusting, plaques, discharge,
15 to 20 involuntary blinks per nodules, lesions. Lids close
minute; bilateral blinking. asymmetrically, incompletely,
4. Transparent; capillaries or painfully. Rapid, monocular,
sometimes evident; sclera
absent, or infrequent blinking.
appears white (darker or
yellowish and with small Ptosis, or entropion; rim of
brown macules in dark-skinned sclera visible between lid and
clients) iris.
5. Shiny, smooth, and pink or 4. Jaundiced sclera (e.g., in liver
red
disease); excessively pale sclera
6.e. Pinkish conjunctiva, moist
(e.g., in anemia); reddened
in texture, no lesions and no
foreign bodies. sclera; lesions or nodules (may
7. No edema or tenderness indicate damage by mechanical,
over lacrimal gland chemical, allergenic, or
8. No edema or tearing bacterial agents).
9. Transparent, shiny and 5. Extremely pale (possible
smooth; details of the iris are
anemia); extremely red
visible. In older people, a thin,
grayish white ring around the (inflammation); nodules or
margin, called arcus senilis, other lesions
may be evident. 6. Reddish conjunctiva (may
10. Client blinks when the indicate inflammation); dry in
cornea is touched, indicating texture, with lesions and
that the trigeminal nerve is foreign bodies
intact.
7. Swelling or tenderness over
11. Transparent. No shadows
of light on iris. Depth of about lacrimal gland
3 mm. 8. Evidence of increased tearing;
12. Black in color; equal in size; regurgitation of fluid on
normally 3 to 7 mm in palpation of lacrimal sac
diameter; round smooth 9. Opaque; surface not smooth
border, iris flat and round.
(may be the result of trauma or
13. Illuminated pupil constricts
abrasion). Arcus senilis in
(direct response). Non-
illuminated pupils constricts clients under age 40.
(consensual response). 10. One or both eyelids fail to
14. Pupils constrict when respond.
looking at near objects; pupils 11. Cloudy. Crescent-shaped
dilate when looking at far shadows on far side of iris.
objects; pupils converged
Shallow chamber (possible
when near object is moved
toward nose. glaucoma)
15. When looking straight 12. Cloudiness, mydriasis, miosis,
ahead, client can see objects in anisocoria; bulging of iris
the periphery toward cornea
16. Both eyes coordinated, 13. Neither pupil constricts.
move in unison, with parallel Unequal responses. Absent
alignment
responses.
17. Light falls symmetrically on
both pupils (e.g., at “6 o’clock” 14. One or both pupils fail to
on both pupils) constrict, dilate, or converge.
18. Uncovered eyes do not 15. Visual field smaller than normal
move (possible glaucoma); one-half
 19. Able to read newsprint vision in one or both eyes
20. 20/20 vision on Snellen- (possible nerve damage).
type chart 16. Eye movements not
21. Normal
coordinated or parallel; one or
both eyes fail to follow a
penlight in specific directions,
e.g., strabismus (cross-eyes)
17. Nystagmus (rapid involuntary
rhythmic eye movement) other
than at end point may indicate
neurologic impairment
18. Light falls off center on one eye
(indicates misalignment)
19. If misalignment is present,
when dominant eyes is
covered, the uncovered eye will
move to focus on object.
20. Difficulty reading newsprint
unless due to aging process
21. Denominator of 40 or more on
Snellen-type chart with
corrective lens
22. Signs of glaucoma, heart
disease, etc.

EARS AND HEARING 1. Color same as facial skin. 1. Bluish color of earlobe (e.g.,
2. Mobile, firm, and not cyanosis); pallor (e.g.,
tender; pinna recoils after it is frostbite); excessive redness
folded.
(inflammation or fever)
3. Distal third contains hair
2. Lesions (e.g., cysts); flaky, scaly
follicles and glands
4. Pearly gray color, skin (e.g., soborrhea);
semitransparent tenderness when moved or
5. Normal voice tones audible pressed (may indicate
A. inflammation or infection of
Able to hear ticking in both external ear)
ears
3. Redness and discharge
B.
Sound is heard in both ears or 4. Pink to red, some opacity.
is localized at the center of the 5. Yellow-amber
head 6. White
Air-conducted (AC) hearing is 7. Blue or deep red
 greater than bone-conducted 8. Dull surface
(BC) hearing, i.e., AC > BC 9. Normal voice tones not audible
(positive Rinne) (e.g., request nurse to repeat
words or statements, leans
toward the speaker, turns the
head, cups the ears, or speaks
in loud tone of voice)
10. Unable to hear ticking in one or
both ears
11. Sound is heard better in
impaired ear, indicating a bone-
conductive hearing loss; or
sound is heard better in ear
without a problem, indicating a
sensorineural disturbance
(Weber positive)
12. Bone conduction time is equal
to or longer than the air
condition time i.e., BC > AC or
BC = AC (negative Rinne;
indicates a conductive hearing
loss)

NOSE AND SINUSES 1. Symmetric and straight 1. Asymmetric

No discharge or flaring 2. Discharge from nares
Uniform color 3. Localized areas of redness or
2. Not tender; no lesions
presence of skin lesions
3. Air moves freely as the
client breathes through the 4. Tenderness on palpation,
nares presence of lesions
4.Patent, presence of clear 5. Air movement is restricted in
watery discharge one or both nares
5. Mucosa pink 6. Not patent
Clear, watery discharge 7. Mucosa red, edematous
No lesions
8. Abnormal discharge (e.g., pus)
6. Nasal septum intact and in
midline 9. Presence of lesions (e.g.,
7. Not tender polyps)
8. Not tender 10. Septum deviated to the right or
9. There is no presence of to the left
inflammed sinus or sinuses 11. Tenderness in one or more
sinuses
12. Tenderness occur
13. Presence of inflammed sinus or
 sinuses

MOUTH AND OROPHARYNX 1. Uniform pink color (darker, 1. Pallor; cyanosis

e.g., bluish hue, in 2. Blisters; generalized or localized
Mediterranean groupa and sweeling; fissures, crusts, or
dark skinned clients)
scales (may result from
Soft, moist, smooth texture
excessive moisture, nutritional
Symmetry of contour
Ability to pursed lips deficiency or fluid deficit)
2. Uniform pink color (freckled 3. Inability to pursed lips
brown pigmentation in dark- 4. Pallor, leukoplakia (white
skinned clients) patches), red, bleeding)
Moist, smooth, soft, glistering, 5. Excessive dryness
and elastic texture (drier oral
6. Mucosal cysts; irritation from
mucosa in elderly due to
decreased salivation) dentures; abrasions;
3. 32 adult teeth ulcerations; nodules
Smooth, white, shiny tooth 7. Missing teeth; ill-fitting
enamel dentures
Pink gums (bluish or brown 8. Brown or black discoloration of
patches in dark skinned- the enamel (may indicate
clients)
staining or the presence of
Moist, firm texture to gums
No retraction of gums (pulling caries)
away from the teeth) 9. Excessively red gums
4. Smooth, intact dentures 10. Spongy texture; bleeding;
5. Central position tenderness (may indicate
Pink color (some brown periodontal disease)
pigmentation on tongue
11. Receding, atrophied gums;
borders in dark-skinned
swelling that partially covers
clients); moist, slightly rough;
thin whitish coating the teeth)
Smooth, lateral margins; no 12. Ill-fitting dentures; irritated and
lesions excoriated area under dentures
Raised papillae (taste buds) 13. Deviated from center (may
6. Moves freely; no tenderness indicate damage to hypoglossal
7. Smooth tongue base with
[twelfth cranial] nerve);
prominent veins
8. Smooth with no palpable excessive trembling
nodules 14. Smooth red tongue (may
9. Same as color of buccal indicate iron, vitamin B12, or
mucosa and floor of mouth vitamin B3 deficiency)
10. Light pink, smooth, soft 15. Dry, furry tongue (associated
palate with fluid deficit (white coating
Lighter pink hard palate, more
(may be oral yeast infection)
irregular texture
11. Gag reflex present 16. Nodes, ulcerations,
12. Positioned in midline of discoloration (white or red
soft palate areas); areas of tenderness
13. Pink and smooth posterior
wall 17. Restricted mobility
14. Pink and smooth
18. Swelling, ulceration
No discharge
Of normal size or not visible 19. Swelling, nodules
Grade 1 (normal): The tonsils 20. Inflammation (redness and
are behind the tonsillar pillars swelling)
(the soft structures supporting 21. Discoloration (e.g., jaundice or
the soft palate pallor)
15. Gag reflex present 22. Palates the same color
16. Can distinguish taste
23. Irritations
24. Exostoses (bony growths)
growing from the hard palate
25. Absent gag reflex - may indicate
problems with
glossopharyngeal (ninth cranial)
or vagus (tenth cranial) nerve
26. Deviation to one side from
tumor or trauma; immobility
(may indicate damage to
trigeminal [fifth cranial] nerve
or vagus [tenth cranial] nerve)
27. Redenned or edematous;
presence of lesion, plaques, or
discharge
28. Inflamed
29. Presence of discharge
30. Swollen
31.  Grade 2: The tonsils are
between the pillars and the
uvula
32.  Grade 3: The tonsils
touch the uvula
33.  Grade 4: One or both
tonsils extend to the midline of
the oropharynx
34. Absent gag reflex - may indicate
problems with
glossopharyngeal (ninth cranial)
or vagus (tenth cranial) nerve
35. Cannot distinguish taste
NECK 1. Muscles equal in size; head 1. Unilateral neck swellings; head
centered tilted to one side (indicates
2. Coordinated, smooth presence of masses, injury,
movements with no
muscle weakness, shortening of
discomfort
a) Head flexes 45° sternocleidomastoid muscle,
b) Head hyperextends scars)
60° 2. Muscle tremor, spasms, or
c) Head laterally flexes stiffness
40° 3. a.Limited range of motion;
d) Head laterally rotates painful movements; involuntary
70°
movements (e.g., up-and-down
3.
a) Equal strength nodding movements associated
b) Equal strength with Parkinson’s disease
4. Not palpable 4. b.Head hyperextends less than
5. Central placement in 50°
midline of neck; spaces are 5. c.Head laterally flexes less than
equal on both sides 40°
6. Not visible on inspection
6. d.Head laterally rotates less
Glands ascends during
swallowing but is not visible than 70°
7. Lobes may not be palpated
If palpated, lobes are small, a. Unequal strength
smooth, centrally located, b. Unequal strength
painless, and rise freely with 7. Enlarged, palpable, possibly
swallowing tender (associated with
8. Absent of bruit
infection and tumors)
8. Deviation to one side,
indicating possible neck tumor;
thyroid enlargement; enlarged
lymph nodes
9. Visible diffuseness or local
enlargement
10. Gland is not fully movable
when swallowing
11. Solitary nodules
12. Presence of bruit

POSTERIOR AND LATERAL 1. Anteroposterior to 1. Barrel chest; increased

THORAX transverse diameter in ration anteroposterior to transverse
of 1:2 diameter
Chest symmetric
2. Chest asymmetric
2. Spine vertically aligned
3. Exagerrated spinal curvatures
 Spinal column is straight, right (kyphosis, lordosis)
and left shoulders and hips are 4. Spinal column deviated from
at same height one side, often accentuated
3.
when bending over. Shoulders
a. Skin intact; uniform
or hips not even.
temperature
b. Chest wall intact; no
tenderness; no masses a. Skin lesions; areas of
4. Full and symmetric chest hyperthermia
expansion (i.e., when a client b. Lumps, bulges;
takes a deep breath, your depressions; areas of
thumbs should move apart an tenderness; movable
equal distance and at the same
structures (e.g., rib)
time; normally the thumbs
separate 3 to 5 cm [1 1/2 to 2 5. Asymmetric and/or decreased
inches] during deep chest expansion
inspiration) 6. Decreased or absent fremitus
5. Bilateral symmetry of vocal (associated with
fremitus pneumothorax)
Fremitus is heard most clearly 7. Increased fremitus (associated
at the apex of the lungs
with consolidated lung tissue,
 Low-pitched voices of
males are more readily as in pneumonia)
palpated than higher pitched 8. Asymmetry in percussion
voices of females 9. Areas of dullness or flatness
6. Percussion notes resonate, over lung tissue (associated
except over scapula with consolidation of lung
Lowest point of resonance is at
tissue or a mass)
the diaphragm (i.e., at the
10. Restricted excursion
level of the eighth to tenth rib
posteriorly (associated with lung disorder)
Note: Percussion on rib 11. Adventitious breath sounds
normally elicits dullness (e.g., crackles, gurgles, wheeze,
7. Excursion is 3 to 5 cm (11/2 friction rub)
to 2 inches) bilaterally in 12. Absence of breath sounds
women and 5 to 6 cm (2 to 3
inches) in men
Diaphragm is usually slightly
higher on the right side
8. Vesicular and
bronchovesicular breath
sounds

ANTERIOR THORAX 9. Quiet, rhythmic, and 1. Altered breathing patterns

effortless respirations 2. Costal angle is widened
10. Costal angle is less than (associated with chronic
90°, and the ribs insert into the
obstructive pulmonary disease)
spine at approximately a 45°
 angle a. Skin lesions; areas of
11. hyperthermia
a. Skin intact; uniform b. Lumps, bulges;
temperature
depressions; areas of
b. Chest wall intact; no
tenderness; movable
tenderness; no masses
12. Full symmetric excursion; structures (e.g., rib)
thumbs normally separate 3 to 3. Asymmetric and/or decreased
5 cm (11/2 to 2 inches) respiratory excursion
13. Same as posterior vocal 4. Same as posterior fremitus
fremitus; fremitus is normally 5. Asymmetry in percussion notes
decreased over heart and
6. Areas of dullness or flatness
breast tissue
14. Percussion notes resonate over lung tissue
down to the sixth rib at the 7. Adventitious breath sounds
level of the diaphragm but are 8. Adventitious breath sounds
flat over areas of heavy muscle
and bone, dull on areas over
the heart and the liver, and
tympanic over the underlying
stomach
15. Bronchial and tubular
breath sounds
16. Bronchovesicular and
vesicular breath sounds

HEART AND CENTRAL 1. No pulsations 1. Pulsations

VESSELS  No pulsations 2.  Pulsations
 No lift or heave 3.  Diffuse lift or heave,
 Pulsations visible in
indicating enlarged or
50% of adults and palpable in
overactive right ventricle
most PMI in fifth LICS at or
medial to MCL 4.  PMI displaced laterally
 Diameter of 1 to 2 cm or lower (indicates enlarged
(1/3 to 1/2 cm) heart)
 No lift or heave 5.  Diameter over 2 cm
 Aortic pulsations (indicates enlarged heart or
2. S1: Usually heard at all times
aneurysm)
Usually louder at apical pulse
S2: Usually heard at all times 6.  Diffuse lift or heave
Usually louder at base of heart lateral to apex (indicates
Systole: silent interval; slightly enlargement or overactivity of
shorter duration than diastole left ventricle)
at normal heart rate (60 to 90 7.  Bounding abdominal
beats/min.) pulsations (e.g., aortic
Diastole: silent interval; slightly
aneurysm)
longer duration than systole at
normal heart rates 8. Increased or decreased
S3: in children and young intensity
adults 9. Varying intensity with different
S4: in many older adults beats
3. Symmetric pulse volume
10. Increased intensity at aortic
Full pulsations, thrusting
area
quality
Quality remains same when 11. Increased intensity at pulmonic
client breathes, turns head, area
and changes from sitting to 12. Sharp-sounding ejection clicks
supine position 13. S3: in older adults
Elastic arterial wall 14. S4: may be a sign of
4. No sound heard on
hypertension
auscultation
5. Veins not visible (indicating 15. Asymmetric volumes (possible
right side of heart is stenosis or thrombosis
functioning normally) 16. Decreased pulsations (may
6. Veins not visible (indicating indicate impaired left cardiac
right side of heart is output)
functioning normally) 17. Increased pulsations
18. Thickening, hard, rigid, beaded,
inelastic walls (indicate
arteriosclerosis)
19. Presence of bruit in one or both
arteries (suggests occlusive
artery disease)
20. Veins visibly distended
(indicating advanced
cardiopulmonary disease)
21. Bilateral measurements above
3 to 4 cm are considered
elevated (may indicate right-
sided failure)
22. Unilateral distention (may be
caused by local obstruction)
23. Veins visibly distended
(indicating advanced
cardiopulmonary disease)
24. Bilateral measurements above
3 to 4 cm are considered
elevated (may indicate right-
sided failure)
25. Unilateral distention (may be
caused by local obstruction)
PERIPHERAL VASCULAR 1. Symmetric pulse volumes 1. Asymmetric volumes (indicate
SYSTEM Full pulsations impaired circulation)
2. In dependent positions, 2. Absence of pulsation (indicates
presence of distention and
arterial spasms or occlusion)
nodular bulges at calves
When limbs elevated, veins 3. Decreased, weak, thready
collapse (veins may appear pulsations (indicate impaired
tortuos or distended in older cardiac output)
people) 4. Increased pulse volume (may
3. Limbs not tender indicate hypertension, high
Symmetric in size cardiac output, or circulatory
overload)
5. Distended veins in the thigh
and/or lower leg or on
posterolateral part of calf from
knee to ankle
6. Tenderness on palpation
7. Pain in calf muscles with
forceful dorsiflexion of the foot
(positive Homan’s test)
8. Warmth and redness over vein
9. Swelling of one calf or leg

BREAST AND AXILLA Females: Rounded shape; 1. Recent change in breast size;
slightly unequal in size; swellings; marked asymmetry
generally symmetric 2. Localized discolorations or
Males: Breasts even with the
hyperpigmentation
chest wall; if obese, may be
similar in shape to female 3. Retraction or dimpling (result of
breasts scar tissue or an invasive
Skin uniform in color (same in tumor)
appearance as skin of 4. Unilateral, localized
abdomen or back) hypervascular areas (associated
Skin smooth and intact with increased blood flow
Diffuse symmetric horizontal
5. Swelling or edema appearing as
or vertical vascular pattern in
light-skinned people pig skin or orange peel due to
Striae (stretch marks); moles exaggeration of the pores
and nevi 6. Presence of lesions
3. No lesions 7. Any asymmetry, mass, or
Round or oval and bilaterally lesions
the same 8. Asymmetrical size and color
Color varies widely, from light
9. Presence of discharge, crust, or
pink to dark brown
 Irregular placement of cracks
sebaceous glands on the 10. Recent inversion of one or both
surface of the areola nipples
(Montgomery’s tubercles)
11. Tenderness, masses, nodules
Round, everted, and equal in
12. Tenderness, masses, nodules,
size; similar in color; soft and
smooth; both nipples point in or nipple discharge
the same direction (out in 13. Tenderness, masses, nodules,
young women and men, or nipple discharge
downward in older women)
No discharge, except for
pregnant or breast-feeding
females
Inversion of one or both
nipples that is present from
puberty
6. No tenderness, masses, or
nodules
7. No tenderness, masses,
nodules, or nipple discharge
8. No tenderness, masses,
nodules, or nipple discharge

ABDOMEN 1. Unblemished skin 1. Presence of rash or other

Uniform color lesions
Silver-white striae (stretch 2. Tense, glistening skin (may
marks) or surgical scars
indicate ascites, edema)
2.
3. Purple striae (associated with
a) Flat, rounded (convex),
or scaphoid (concave) Cushing’s disease or rapid
b) No evidence of weight gain and loss)
enlargement of liver or spleen
c) Symmetric contour
3. Symmetric movements a) Distended
caused by respirations b) Evidence of
Visible peristalsis in very lean enlargement of liver or
people spleen
Aortic pulsations in thin c) Asymmetric contour,
persons at epigastric area
e.g., localized
4. No visible vascular pattern
5. Audible bowel sounds protrusions around
Absence of arterial bruits umbilicus, inguinal
Absence of friction rub ligaments, or scars
6. Tympany over the stomach (possible hernia or
and gas-filled bowels; dullness, tumor)
especially over the liver and
4. Limited movement due to pain
spleen, or a full bladder
7. 6 to 12 cm (2 1/2 to 3 1/2 or disease process
inches) in the midclavicular 5. Visible peristalsis in non-lean
line; 4 to 8 cm (1 1/2 to 3 clients (possible bowel
inches) at the midsternal line
obstruction)
8. No tenderness; relaxed
6. Marked aortic pulsations
abdomen with smooth,
consistent tension 7. Visible venous patterns (dilated
9. Tenderness may be present veins) is associated with liver
near xiphoid process, over disease, ascites, and venocaval
cecum, and over sigmoid colon obstruction
10. May not be palpable 8. Hypoactive, i.e., extremely soft
Border feels smooth
and infrequent (e.g., one per
11. Not palpable
minute). Hypoactive sounds
indicate decreased motility and
are usually associated with
manipulation of the bowel
during surgery, inflammation,
paralytic ileus, or late bowel
obstruction
9. Hyperactive sounds indicate
increased intestinal motility and
are usually associated with
diarrhea, an early bowel
obstruction, or the use of
laxatives
10. True absence of sounds (none
heard in 3 to 5 minutes)
indicates a cessation of
intestinal motility.
11. Large dull areas (associated
with presence of fluid or a
tumor)
12. Enlarged size (associated with
liver disease)
13. Tenderness and
hypersensitivity
14. Superficial masses
15. Localized areas of increased
tension
16. Generalized or localized areas
of tenderness
17. Mobile or fixed masses
18. Enlarged (abnormal finding,
 even if liver is smooth and not
tender)
19. Smooth but tender; nodular or
hard
20. Distended and palpable as
smooth, round, tense mass
(indicates urinary retention)

FEMALE GENITALIA AND 1. There are wide variations; 1. Scant pubic hair (may indicate
INGUINAL generally kinky in the hormonal problem)
menstruating adult, thinner 2. Hair growth should not extend
and straighter after
to the abdomen
menopause
3. Lice, lesions, scars, fissures,
Distributed in the shape of an
inverse triangle swelling, erythema,
2. Pubic skin intact, no lesions excoriations, varicosities, or
Skin of vulva area slightly leukoplakia
darker than the rest of the 4. Presence of lesions
body 5. Presence of inflammation,
Labia round, full, and relatively
swelling, or discharge
symmetric in adult females
3. Clitoris does not exceed 1 6. Enlargement and tenderness
cm in width and 2 cm in length
Urethral orifice appears as a
small slit and is the same color
as surrounding tissues
No inflammation, swelling or
discharge
4. No enlargement or
tenderness

MALE GENITALIA AND 1. Triangular distribution, often 1. Scant amount or absence of

INGUINAL spreading up the abdomen hair
2. Penile skin is intact 2. Presence of lesions, nodules,
Appears slightly wrinkled and
swellings, or inflammation
varies in color as widely as
other body skin 3. Inflammation; discharge
Foreskin easily retractable 4. Variation in meatal locations
from the glans penis (e.g., hypospadias, on the
Small amount of thick white underside of the penile shaft,
smegma between the glans and epispadias, on the upper
and foreskin side of the penile shaft)
3. Pink and slitlike appearance
5. Presence of tenderness,
Positioned at the tip of the
penis thickening, or nodules
4. Smooth and semifiirm
 Is slightly movable over the 6. Immobility
underlying structures 7. Discolorations; any tightening
5. Scrotal skin is darker in color of the skin (may indicate edema
than that of the rest of the
or mass)
body and is loose
8. Marked asymmetry in size
Size varies with temperature
changes (the dartos muscles 9. Testicles are enlarged, with
contract when the area is cold uneven surface (possible
and relax when the area is tumor)
warm) 10. Epididymis is non-resilient and
Scrotum appears asymmetric painful
(left testis is usually lower than
11. Swelling or bulge (possible
the right testis
6. Testicles are rubbery, inguinal or femoral hernia
smooth, and free of nodules 12. Presence of hernias
and masses
Testis is about 2 x 4 cm (0.7 x
1.5 in.)
Epididymis is resilient,
normally tender, and softer
than the spermatic cord
Spermatic cord is firm
7. No swelling or bulges
8. No hernias

RECTUM AND ANUS 1. Intact perianal skin; usually 1. Presence of fissures (cracks),
slightly more pigmented than ulcers, exconations,
the skin of the buttocks inflammations, abscesses,
Anal skin is normally more
protruding hemorrhoids
pigmented, coarser, and
moister than perianal skin and (dilated veins seen as reddened
is usually hairless protrusions of the skin), lumps
2. Anal sphincter has good or tumors, fistula openings, or
tone rectal prolapse (varying degrees
Rectal wall is smooth and not of protrusion of the rectal
tender mucous membrane through the
3. Brown color
anus)
2. Hypertonicity of the anal
sphincter (may occur in the
presence of an anal fissure or
other lesions that causes
contraction)
3. Hypotonicity of anal sphincter
(may occur after rectal surgery
or result from a neurologic
 deficiency
4. Rectal wall is tender and
nodular
5. Presence of mucus, blood, or
black tarry stool