Physical Assessment

Definition:

- Physical Assessment is an evaluation of the body and its function using IPPA
(Inspection, Palpation, Percussion, and Auscultation) and involves the detailed
examination of the body from head to toe.

Purposes:

1. To obtain baseline data about the client’s functional abilities.

2. To supplement, confirm, and refute data obtained in the nursing history.
3. To obtain data that will help establish nursing diagnosis and plans of care.
4. To evaluate the physiologic outcomes of health care and thus the progress of a client’s
health problems.
5. To make clinical judgments about a client’s health status.
6. To identify areas for health promotion and disease prevention.

Principles:

1. In performing Physical Assessment, always provide client’s privacy.

2. Always explain the procedure/assessment to the client.
3. Wash your hands before and after the procedure.

Equipment:

1. Height Chart 8. Nasal speculum 14. Cotton applicators

2. Weighing Scale 9. Opthalmoscope 15. Gloves
3. Sphygmomanometer 10. Otoscope 16. Lubricants
4. Stethoscope 11. Percussion (reflex) 17. Tongue blades
5. Digital Thermometer hammer (depressors)
6. Skinfold’s caliper 12. Tuning fork 18. Snellen’s chart
7. Flashlight or penlight 13. Vaginal Speculum

Rationales:

1. To promote organization and prevents the nurse from leaving the client to search for a
piece of equipment.
2. To save time and effort.
3. To prevent the spread of microorganisms.
4. To gain patient’s cooperation and to reduce anxiety.

Normal and Abnormal Findings

GENERAL SURVEY

NORMAL FINDINGS ABNORMAL FINDINGS

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 Negative, hostile, withdrawn.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 Negative, hostile, withdrawn.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

SKIN

NORMAL FINDINGS ABNORMAL FINDINGS

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

SCALP AND HAIR

NORMAL FINDINGS ABNORMAL FINDINGS

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

NAILS

NORMAL FINDINGS ABNORMAL FINDINGS

1. Convex curvature; angle of nail plate about Spoon nail; clubbing (180° or greater).
160°.
2. Smooth texture. Excessive thickness or thinness or presence
of grooves or furrows; Beau’s lines;
discoloured or detached nail - often due to
fungus.
3. Highly vascular and pink in light-skinned Bluish or purplish pint (may reflect cyanosis);
clients; dark-skinned clients may have brown pallor (may reflect poor arterial circulation).
or black pigmentation in longitudinal streaks.
4. Intact epidermis. Hang nails; paronychia (inflammation).
5. Prompt return of pink or usual color Delayed return of pink or usual color (may
(generally less than 4 seconds). indicate circulatory impairment).

HEAD AND FACE

NORMAL FINDINGS ABNORMAL FINDINGS

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

EYES AND VISION

NORMAL FINDINGS ABNORMAL FINDINGS

1. Hair evenly distributed; skin intact. Loss of hair; scaling and flakiness of skin.
Eyebrows symmetrically aligned; equal Unequal alignment and movement of
movement. eyebrows.

2. Equally distributed; curled slightly outward Turned inward

3. Skin intact; no discharge; no discoloration. Redness, swelling, flaking, crusting, plaques,

Lids close symmetrically. Approximately 15 to discharge, nodules, lesions. Lids close
20 involuntary blinks per minute; bilateral asymmetrically, incompletely, or painfully.
blinking. Rapid, monocular, absent, or infrequent
blinking. Ptosis, or entropion; rim of sclera
visible between lid and iris.

4. Transparent; capillaries sometimes evident; Jaundiced sclera (e.g., in liver disease);

sclera appears white (darker or yellowish and excessively pale sclera (e.g., in anemia);
with small brown macules in dark-skinned reddened sclera; lesions or nodules (may
clients) indicate damage by mechanical, chemical,
allergenic, or bacterial agents).

5. Shiny, smooth, and pink or red Extremely pale (possible anemia); extremely
red (inflammation); nodules or other lesions

RATIONALE

6.a. Closing the eyelids contracts the orbicular muscle, which prevents lid eversion.

6.b. Upward or outward pulling on the eyelashes causes muscle contraction

6.c. These actions evert the lid, that is, flip the lower part of the lid over on top of itself

6.d. This is to detect sensitivity of the eyelids

6.e. Pinkish conjunctiva, moist in texture, no Reddish conjunctiva (may indicate
lesions and no foreign bodies. inflammation); dry in texture, with lesions and
foreign bodies

7. No edema or tenderness over lacrimal Swelling or tenderness over lacrimal gland

gland

8. No edema or tearing Evidence of increased tearing; regurgitation of

fluid on palpation of lacrimal sac

9. Transparent, shiny and smooth; details of Opaque; surface not smooth (may be the result
the iris are visible. In older people, a thin, of trauma or abrasion). Arcus senilis in clients
grayish white ring around the margin, called under age 40.
arcus senilis, may be evident.

10. Client blinks when the cornea is touched, One or both eyelids fail to respond.
indicating that the trigeminal nerve is intact.

11. Transparent. No shadows of light on iris. Cloudy. Crescent-shaped shadows on far side
Depth of about 3 mm. of iris. Shallow chamber (possible glaucoma)

12. Black in color; equal in size; normally 3 to Cloudiness, mydriasis, miosis, anisocoria;
7 mm in diameter; round smooth border, iris bulging of iris toward cornea
flat and round.

13. Illuminated pupil constricts (direct Neither pupil constricts. Unequal responses.
response). Non-illuminated pupils constricts Absent responses.
(consensual response).

14. Pupils constrict when looking at near One or both pupils fail to constrict, dilate, or
objects; pupils dilate when looking at far converge.
objects; pupils converged when near object
is moved toward nose.

15. When looking straight ahead, client can Visual field smaller than normal (possible
see objects in the periphery glaucoma); one-half vision in one or both eyes
(possible nerve damage).

16. Both eyes coordinated, move in unison, Eye movements not coordinated or parallel; one
with parallel alignment or both eyes fail to follow a penlight in specific
directions, e.g., strabismus (cross-eyes)

Nystagmus (rapid involuntary rhythmic eye

movement) other than at end point may indicate
neurologic impairment

17. Light falls symmetrically on both pupils Light falls off center on one eye (indicates
(e.g., at “6 o’clock” on both pupils) misalignment)

18. Uncovered eyes do not move If misalignment is present, when dominant eyes
is covered, the uncovered eye will move to focus
on object.

19. Able to read newsprint Difficulty reading newsprint unless due to aging
process

20. 20/20 vision on Snellen-type chart Denominator of 40 or more on Snellen-type

chart with corrective lens

21. Normal Signs of glaucoma, heart disease, etc.

EARS AND HEARING

NORMAL FINDINGS ABNORMAL FINDINGS

1. Color same as facial skin. Bluish color of earlobe (e.g., cyanosis); pallor
(e.g., frostbite); excessive redness
(inflammation or fever)

2. Mobile, firm, and not tender; pinna recoils Lesions (e.g., cysts); flaky, scaly skin (e.g.,
after it is folded. soborrhea); tenderness when moved or
pressed (may indicate inflammation or
infection of external ear)

3. Distal third contains hair follicles and glands Redness and discharge

4. Pearly gray color, semitransparent Pink to red, some opacity.

Yellow-amber

White

Blue or deep red

Dull surface

5. Normal voice tones audible Normal voice tones not audible (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)

A.
Unable to hear ticking in one or both ears
 Able to hear ticking in both ears

B.

 Sound is heard in both ears or is localized Sound is heard better in impaired ear,
indicating a bone-conductive hearing loss; or
at the center of the head
sound is heard better in ear without a problem,
indicating a sensorineural disturbance (Weber
positive)

Bone conduction time is equal to or longer

 Air-conducted (AC) hearing is greater than than the air condition time i.e., BC > AC or BC
bone-conducted (BC) hearing, i.e., AC > = AC (negative Rinne; indicates a conductive
BC (positive Rinne) hearing loss)

NOSE AND SINUSES

NORMAL FINDINGS ABNORMAL FINDINGS

1. Symmetric and straight Asymmetric

No discharge or flaring Discharge from nares

Uniform color Localized areas of redness or presence of skin
lesions

2. Not tender; no lesions Tenderness on palpation, presence of lesions

3. Air moves freely as the client breathes Air movement is restricted in one or both nares
through the nares

4.Patent, presence of clear watery discharge Not patent

5. Mucosa pink Mucosa red, edematous

Clear, watery discharge Abnormal discharge (e.g., pus)

No lesions Presence of lesions (e.g., polyps)

6. Nasal septum intact and in midline Septum deviated to the right or to the left

7. Not tender Tenderness in one or more sinuses

8. Not tender Tenderness occur

9. There is no presence of inflammed sinus or Presence of inflammed sinus or sinuses

sinuses

MOUTH AND OROPHARYNX

NORMAL FINDINGS ABNORMAL FINDINGS

1. Uniform pink color (darker, e.g., bluish hue, Pallor; cyanosis

in Mediterranean groupa and dark skinned
clients) Blisters; generalized or localized sweeling;
fissures, crusts, or scales (may result from
Soft, moist, smooth texture excessive moisture, nutritional deficiency or
fluid deficit)
Symmetry of contour
Inability to pursed lips
Ability to pursed lips

2. Uniform pink color (freckled brown Pallor, leukoplakia (white patches), red,
pigmentation in dark-skinned clients) bleeding)

Moist, smooth, soft, glistering, and elastic Excessive dryness

texture (drier oral mucosa in elderly due to
decreased salivation) Mucosal cysts; irritation from dentures;
abrasions; ulcerations; nodules

3. 32 adult teeth Missing teeth; ill-fitting dentures

Smooth, white, shiny tooth enamel Brown or black discoloration of the enamel
(may indicate staining or the presence of
Pink gums (bluish or brown patches in dark caries)
skinned-clients)
Excessively red gums
Moist, firm texture to gums
Spongy texture; bleeding; tenderness (may
No retraction of gums (pulling away from the indicate periodontal disease)
teeth)
Receding, atrophied gums; swelling that
 partially covers the teeth)

4. Smooth, intact dentures Ill-fitting dentures; irritated and excoriated area

under dentures

5. Central position Deviated from center (may indicate damage to

hypoglossal [twelfth cranial] nerve); excessive
Pink color (some brown pigmentation on trembling
tongue borders in dark-skinned clients); moist,
slightly rough; thin whitish coating Smooth red tongue (may indicate iron, vitamin
B12, or vitamin B3 deficiency)
Smooth, lateral margins; no lesions
Dry, furry tongue (associated with fluid deficit
Raised papillae (taste buds) (white coating (may be oral yeast infection)

Nodes, ulcerations, discoloration (white or red

areas); areas of tenderness

6. Moves freely; no tenderness Restricted mobility

7. Smooth tongue base with prominent veins Swelling, ulceration

8. Smooth with no palpable nodules Swelling, nodules

9. Same as color of buccal mucosa and floor Inflammation (redness and swelling)
of mouth

10. Light pink, smooth, soft palate Discoloration (e.g., jaundice or pallor)

Lighter pink hard palate, more irregular texture Palates the same color

Irritations

Exostoses (bony growths) growing from the

hard palate

11. Gag reflex present Absent gag reflex - may indicate problems with
glossopharyngeal (ninth cranial) or vagus
(tenth cranial) nerve

12. Positioned in midline of soft palate Deviation to one side from tumor or trauma;
immobility (may indicate damage to trigeminal
[fifth cranial] nerve or vagus [tenth cranial]
nerve)

13. Pink and smooth posterior wall Redenned or edematous; presence of lesion,
plaques, or discharge

14. Pink and smooth Inflamed

No discharge Presence of discharge

Of normal size or not visible Swollen

 Grade 1 (normal): The tonsils are behind  Grade 2: The tonsils are between the
the tonsillar pillars (the soft structures pillars and the uvula
supporting the soft palate
 Grade 3: The tonsils touch the uvula

 Grade 4: One or both tonsils extend to the

midline of the oropharynx
15. Gag reflex present Absent gag reflex - may indicate problems with
glossopharyngeal (ninth cranial) or vagus
(tenth cranial) nerve

16. Can distinguish taste Cannot distinguish taste

NECK

NORMAL FINDINGS ABNORMAL FINDINGS

1. Muscles equal in size; head centered Unilateral neck swellings; head tilted to one
side (indicates presence of masses, injury,
muscle weakness, shortening of
sternocleidomastoid muscle, scars)

2. Coordinated, smooth movements with no Muscle tremor, spasms, or stiffness

discomfort
a.Limited range of motion; painful movements;
a) Head flexes 45° involuntary movements (e.g., up-and-down
nodding movements associated with
b) Head hyperextends 60° Parkinson’s disease
c) Head laterally flexes 40° b.Head hyperextends less than 50°
d) Head laterally rotates 70° c.Head laterally flexes less than 40°

d.Head laterally rotates less than 70°

3.

a) Equal strength a. Unequal strength

b) Equal strength b. Unequal strength

4. Not palpable Enlarged, palpable, possibly tender

(associated with infection and tumors)

5. Central placement in midline of neck; Deviation to one side, indicating possible neck
spaces are equal on both sides tumor; thyroid enlargement; enlarged lymph
nodes

6. Not visible on inspection Visible diffuseness or local enlargement

Glands ascends during swallowing but is not Gland is not fully movable when swallowing
visible

7. Lobes may not be palpated Solitary nodules

If palpated, lobes are small, smooth, centrally

located, painless, and rise freely with
swallowing

8. Absent of bruit Presence of bruit

POSTERIOR AND LATERAL THORAX

NORMAL FINDINGS ABNORMAL FINDINGS

1. Anteroposterior to transverse diameter in Barrel chest; increased anteroposterior to

ration of 1:2 transverse diameter

Chest symmetric Chest asymmetric

2. Spine vertically aligned Exagerrated spinal curvatures (kyphosis,

lordosis)
Spinal column is straight, right and left
shoulders and hips are at same height Spinal column deviated from one side, often
accentuated when bending over. Shoulders or
hips not even.

3.

a. Skin intact; uniform temperature a. Skin lesions; areas of hyperthermia

b. Chest wall intact; no tenderness; no masses b. Lumps, bulges; depressions; areas of

tenderness; movable structures (e.g., rib)

4. Full and symmetric chest expansion (i.e., Asymmetric and/or decreased chest
when a client takes a deep breath, your expansion
thumbs should move apart an equal distance
and at the same time; normally the thumbs
separate 3 to 5 cm [1 1/2 to 2 inches] during
deep inspiration)

5. Bilateral symmetry of vocal fremitus Decreased or absent fremitus (associated with

pneumothorax)
Fremitus is heard most clearly at the apex of
the lungs Increased fremitus (associated with
consolidated lung tissue, as in pneumonia)
 Low-pitched voices of males are more
readily palpated than higher pitched
voices of females

6. Percussion notes resonate, except over Asymmetry in percussion

scapula
Areas of dullness or flatness over lung tissue
Lowest point of resonance is at the diaphragm (associated with consolidation of lung tissue or
(i.e., at the level of the eighth to tenth rib a mass)
posteriorly

Note: Percussion on rib normally elicits

dullness

7. Excursion is 3 to 5 cm (11/2 to 2 inches) Restricted excursion (associated with lung

bilaterally in women and 5 to 6 cm (2 to 3 disorder)
inches) in men

Diaphragm is usually slightly higher on the

right side

8. Vesicular and bronchovesicular breath Adventitious breath sounds (e.g., crackles,

sounds
 gurgles, wheeze, friction rub)

Absence of breath sounds

ANTERIOR THORAX

NORMAL FINDINGS ABNORMAL FINDINGS

9. Quiet, rhythmic, and effortless respirations Altered breathing patterns

10. Costal angle is less than 90°, and the ribs Costal angle is widened (associated with
insert into the spine at approximately a 45° chronic obstructive pulmonary disease)
angle

11.

c. Skin intact; uniform temperature c. Skin lesions; areas of hyperthermia

d. Chest wall intact; no tenderness; no masses d. Lumps, bulges; depressions; areas of

tenderness; movable structures (e.g., rib)

12. Full symmetric excursion; thumbs normally Asymmetric and/or decreased respiratory
separate 3 to 5 cm (11/2 to 2 inches) excursion

13. Same as posterior vocal fremitus; fremitus Same as posterior fremitus

is normally decreased over heart and breast
tissue

14. Percussion notes resonate down to the Asymmetry in percussion notes

sixth rib at the level of the diaphragm but are
flat over areas of heavy muscle and bone, dull Areas of dullness or flatness over lung tissue
on areas over the heart and the liver, and
tympanic over the underlying stomach

15. Bronchial and tubular breath sounds Adventitious breath sounds

16. Bronchovesicular and vesicular breath Adventitious breath sounds

sounds

HEART AND CENTRAL VESSELS

NORMAL FINDINGS ABNORMAL FINDINGS

1. No pulsations Pulsations

 No pulsations  Pulsations

 No lift or heave  Diffuse lift or heave, indicating enlarged or

overactive right ventricle
 Pulsations visible in 50% of adults and
palpable in most PMI in fifth LICS at or  PMI displaced laterally or lower (indicates
medial to MCL enlarged heart)

 Diameter of 1 to 2 cm (1/3 to 1/2 cm)  Diameter over 2 cm (indicates enlarged

heart or aneurysm)
 No lift or heave
 Diffuse lift or heave lateral to apex
(indicates enlargement or overactivity of
 Aortic pulsations left ventricle)

 Bounding abdominal pulsations (e.g.,

aortic aneurysm)

2. S1: Usually heard at all times Increased or decreased intensity

Usually louder at apical pulse Varying intensity with different beats

S2: Usually heard at all times Increased intensity at aortic area

Usually louder at base of heart Increased intensity at pulmonic area

Systole: silent interval; slightly shorter duration Sharp-sounding ejection clicks

than diastole at normal heart rate (60 to 90
beats/min.) S3: in older adults

Diastole: silent interval; slightly longer duration S4: may be a sign of hypertension
than systole at normal heart rates

S3: in children and young adults

S4: in many older adults

3. Symmetric pulse volume Asymmetric volumes (possible stenosis or

thrombosis
Full pulsations, thrusting quality
Decreased pulsations (may indicate impaired
Quality remains same when client breathes, left cardiac output)
turns head, and changes from sitting to supine
position Increased pulsations

Elastic arterial wall Thickening, hard, rigid, beaded, inelastic walls

(indicate arteriosclerosis)

4. No sound heard on auscultation Presence of bruit in one or both arteries

(suggests occlusive artery disease)

5. Veins not visible (indicating right side of Veins visibly distended (indicating advanced
heart is functioning normally) cardiopulmonary disease)

Bilateral measurements above 3 to 4 cm are

considered elevated (may indicate right-sided
failure)

Unilateral distention (may be caused by local

obstruction)

6. Veins not visible (indicating right side of Veins visibly distended (indicating advanced
heart is functioning normally) cardiopulmonary disease)

Bilateral measurements above 3 to 4 cm are

considered elevated (may indicate right-sided
failure)

Unilateral distention (may be caused by local

obstruction)

PERIPHERAL VASCULAR SYSTEM

NORMAL FINDINGS ABNORMAL FINDINGS

1. Symmetric pulse volumes Asymmetric volumes (indicate impaired

circulation)
Full pulsations
Absence of pulsation (indicates arterial
 spasms or occlusion)

Decreased, weak, thready pulsations (indicate

impaired cardiac output)

Increased pulse volume (may indicate

hypertension, high cardiac output, or
circulatory overload)

2. In dependent positions, presence of Distended veins in the thigh and/or lower leg
distention and nodular bulges at calves or on posterolateral part of calf from knee to
ankle
When limbs elevated, veins collapse (veins
may appear tortuos or distended in older
people)

3. Limbs not tender Tenderness on palpation

Symmetric in size Pain in calf muscles with forceful dorsiflexion

of the foot (positive Homan’s test)

Warmth and redness over vein

Swelling of one calf or leg

BREAST AND AXILLA

NORMAL FINDINGS ABNORMAL FINDINGS

1. Females: Rounded shape; slightly unequal Recent change in breast size; swellings;
in size; generally symmetric marked asymmetry

Males: Breasts even with the chest wall; if

obese, may be similar in shape to female
breasts

2. Skin uniform in color (same in appearance Localized discolorations or hyperpigmentation

as skin of abdomen or back)
Retraction or dimpling (result of scar tissue or
Skin smooth and intact an invasive tumor)

Diffuse symmetric horizontal or vertical Unilateral, localized hypervascular areas

vascular pattern in light-skinned people (associated with increased blood flow

Striae (stretch marks); moles and nevi Swelling or edema appearing as pig skin or
orange peel due to exaggeration of the pores

3. No lesions Presence of lesions

4. Round or oval and bilaterally the same Any asymmetry, mass, or lesions

Color varies widely, from light pink to dark

brown

Irregular placement of sebaceous glands on

the surface of the areola (Montgomery’s
tubercles)

5. Round, everted, and equal in size; similar in Asymmetrical size and color
color; soft and smooth; both nipples point in
the same direction (out in young women and Presence of discharge, crust, or cracks
men, downward in older women)
Recent inversion of one or both nipples
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 Tenderness, masses, nodules

7. No tenderness, masses, nodules, or nipple Tenderness, masses, nodules, or nipple

discharge discharge

8. No tenderness, masses, nodules, or nipple Tenderness, masses, nodules, or nipple

discharge discharge

9. This examination will help detect any abnormalities in the breast

ABDOMEN

NORMAL FINDINGS ABNORMAL FINDINGS

1. Unblemished skin Presence of rash or other lesions

Uniform color Tense, glistening skin (may indicate ascites,

edema)
Silver-white striae (stretch marks) or surgical
scars Purple striae (associated with Cushing’s
disease or rapid weight gain and loss)

2.

a) Flat, rounded (convex), or scaphoid a) Distended

(concave)
b) Evidence of enlargement of liver or spleen
b) No evidence of enlargement of liver or
spleen c) Asymmetric contour, e.g., localized
protrusions around umbilicus, inguinal
c) Symmetric contour ligaments, or scars (possible hernia or tumor)

3. Symmetric movements caused by Limited movement due to pain or disease

respirations process

Visible peristalsis in very lean people Visible peristalsis in non-lean clients (possible
bowel obstruction)
Aortic pulsations in thin persons at epigastric
area Marked aortic pulsations

4. No visible vascular pattern Visible venous patterns (dilated veins) is

associated with liver disease, ascites, and
venocaval obstruction

5. Audible bowel sounds Hypoactive, i.e., extremely soft and infrequent

(e.g., one per minute). Hypoactive sounds
Absence of arterial bruits indicate decreased motility and are usually
associated with manipulation of the bowel
Absence of friction rub during surgery, inflammation, paralytic ileus, or
late bowel obstruction

Hyperactive sounds indicate increased

intestinal motility and are usually associated
with diarrhea, an early bowel obstruction, or
the use of laxatives

True absence of sounds (none heard in 3 to 5

minutes) indicates a cessation of intestinal
motility.
6. Tympany over the stomach and gas-filled Large dull areas (associated with presence of
bowels; dullness, especially over the liver and fluid or a tumor)
spleen, or a full bladder

7. 6 to 12 cm (2 1/2 to 3 1/2 inches) in the Enlarged size (associated with liver disease)
midclavicular line; 4 to 8 cm (1 1/2 to 3 inches)
at the midsternal line

8. No tenderness; relaxed abdomen with Tenderness and hypersensitivity

smooth, consistent tension
Superficial masses

Localized areas of increased tension

9. Tenderness may be present near xiphoid Generalized or localized areas of tenderness

process, over cecum, and over sigmoid colon
Mobile or fixed masses

10. May not be palpable Enlarged (abnormal finding, even if liver is

smooth and not tender)
Border feels smooth
Smooth but tender; nodular or hard

11. Not palpable Distended and palpable as smooth, round,

tense mass (indicates urinary retention)

MUSCULOSKELETAL SYSTEM

NORMAL FINDINGS ABNORMAL FINDINGS

1. Equal size on both sides of body Atrophy (a decreased in size) or hypertrophy

(an increased in size), asymmetry

2. No contractures Malposition of body part e.g., foot drop (foot

flexed downward)

3. No tremors Presence of tremors

4. Normally firm Atonic (lacking tone)

5. Smooth coordinated muscles Flaccidity (weakness or laxness) or spasticity

(sudden involuntary muscle contraction)

6. Equal strength on each side 25% or less normal strength

7. No deformities Bones misaligned

8. No tenderness or swelling Presence of tenderness or swelling (may

indicate fracture, neoplasms, or osteoporosis)

9. No swelling One or more swollen joints

No tenderness, swelling, crepitation, or Presence of tenderness, swelling, crepitation,

nodules or nodules

Joints move smoothly

10. Varies to some degree in accordance with Limited range of motion in one or more joints
person’s genetic makeup and dgree of
physical activity

NEUROLOGICAL SYSTEM
NORMAL FINDINGS ABNORMAL FINDINGS

1. Test for cranial nerves

Cranial Nerve I - Olfactory (Sensory)

- Can identify smell. Has the sense of smell - Loss of sense of smell (anosmia)

Cranial Nerve II - Optic (Sensory)

- Able to read clearly (20/20) on both eyes. - Visual field defects (hemianopias) and
Visual fields are clear. decreased visual acuity or blindness

Cranial Nerve III - Oculomotor (Motor)

- Sphincter of pupil moves; ciliary muscles of - Dysconjugate gaze; gaze weakness or

lens moves paralysis; double vision; dilated pupil, with or
without impaired pupillary reaction to light;
inability to open the affected eyelid

Cranial Nerve IV - Trochlear (Motor)

- Moves eyeball downward and laterally - Dysconjugate gaze, gaze weakness or

paralysis, double vision
Cranial Nerve V - Trigeminal (Sensory)
- Impaired or absent corneal reflex, facial
- Presence of corneal reflex, can detect numbness, jaw weakness
sensitivity to superficial pain.

Cranial Nerve VI - Abducens (Motor)

- Dysconjugate gaze, gaze weakness or
- Lateral eye movement; conjugate movement; paralysis, double vision
sensation of skin and face

Cranial Nerve VII - Facial (Motor and

Sensory)

- Client can smile, whistle, elevates eyebrow, - Facial weakness, inability to completely close
frown, tightly close eyelids against resistance the eyelid, and impaired taste
Cranial Nerve VIII - Auditory (Sensory)

- Client has the equilibrium and sense of - Decreased hearing or deafness and impaired
hearing normally balance
Cranial Nerve IX - Glossopharyngeal (Motor
and Sensory)

- Client can swallow normally, can discriminate

between salt and sugar on posterior third of - Difficulty in swallowing (dysphagia) and
the tongue impaired taste

Cranial Nerve X - Vagus (Motor and

Sensory)

- Gag reflex is present. Sensation in the

pharynx and larynx, no difficulty in swallowing, - Weak or absent gag reflex, difficulty
vocal cords moves swallowing, aspiration, hoarseness, and
slurred speech (dysarthria)

Cranial Nerve XI - Accessory

- Weak or absent shoulder shrug and inability
- Can move head without difficulty, can shrug to turn the head to the side
shoulder

Cranial Nerve XII - Hypoglossal

- Can protrude tongue, moves tongue up and

down and side to side - Cannot protrude tongue, cannot move
tongue up and down and side to side

2. Test reflexes

Biceps Reflex

- Flexion at the elbow and contraction of the - No flexion at the elbow and no contraction of
biceps the biceps

Triceps Reflex

- Contraction of the triceps muscle and - No contraction of the triceps muscle and no
extension of the elbow extension of the elbow

Brachioradialis Reflex

- Flexion and supination of the forearm - No flexion and supination of the forearm

Patellar Reflex

- Contraction of the quadriceps and knee - No contraction of the quadriceps and no

extension knee extension

Achilles Reflex

- Produces a plantar flexion - No plantar flexion

Plantar (Babinski’s) Reflex

- All five toes bend downward; this reaction is - The toes spread outward and the big toe
negative Babinski’s response moves upward; a sign of abnormal Babinski’s
response

3. Gross Motor and Balance Tests

Walking Gait

- Has upright posture and steady gait with - Has poor posture and unsteady; irregular,
opposing arm swing; walks unaided; staggering gait with wide stance; bends legs
maintaining balance only from hips; has rigid or no arm movements

Romberg Test

Negative Romberg: may sway slightly but is Positive Romberg: cannot maintain foot
able to maintain upright posture and foot stance; moves the feet apart to maintain
stance stance

If client cannot maintain balance with the eyes

shut, client may have sensory ataxia (lack of
coordination of the voluntary muscles)

If balance cannot maintained whether the eyes

are open or shut , client may have cerebellar
ataxia
Standing on One Foot with Eyes Closed

- Maintains stance for at least 5 seconds - Cannot maintain stance for 5 seconds
Heel-Toe Walking

- Maintains heel-toe walking along a straight - Assumes a wider foot gait to stay upright
line

Toe or Heel Walking

- Cannot maintain balance on toes and heels
- Able to walk several steps on toes or heels
4. Fine Motor Tests for Upper Extremities

Finger-To-Nose Test

- Can repeatedly and rhythmically touches the - Misses the nose or gives slow response
nose

Alternating Supination and Pronation of

Hands on Knees

- Can alternately supinate and pronate hands - Performs with slow, clumsy movements and
at rapid pace irregular timing; has difficulty alternating from
supination to pronation
Finger To Nose and to the Nurse’s Finger
- Misses the finger and moves slowly
- Performs with coordination and rapidity

Fingers to Fingers
- Moves slowly and is unable to touch fingers
- Performs with accuracy and rapidity consistently

Fingers to Thumb (Same Hand)

- Rapidly touches each finger to thumb with - Cannot coordinate this fine discrete
each hand movement with either one or both hands

5. Fine Motor Tests for Lower Extremities

Heel Down Opposite Shin

- Demonstrates bilateral equal coordination - Has tremors or is awkward; heel moves off
shin
Toe or Ball Foot to the Nurse’s Finger
- Misses your finger; cannot coordinate
- Moves smoothly, with coordination movement

6. Light-Touch Sensation

- Light tickling or touch sensation - Anesthesia, hyperesthesia hypoesthesia, or

paresthesia

7. Pain Sensation

- Able to discriminate “sharp” and “dull” - Areas of reduced, heightened, or absent

sensations sensation (map them out for recording
purposes)

8. Temperature Sensation

- Able to discriminate between “hot” and “cold” - Areas of dulled or lost sensation (when
sensation sensations of pain are dulled, temperature
sense is usually also impaired because
distribution of these nerves over the body is
similar)

9. Position or Kinesthetic Sensation

- Can readily determine the position of fingers - Unable to determine the position of one or
and toes more fingers
10. Tactile Discrimination

One -and-Two-Point Discrimination

- Perception varies widely in adults over - Unable to sense whether one or two ares of
different parts of the body. Normally, a person the skin are being stimulated by pressure
can distinguish between a one-and-two-point
stimulus within the following minimum
distances:

Fingertips: 2.8 mm

Palms of Hands: 8-12 mm

Chest, forearm: 40 mm

Back: 50-70 mm

Upper arm, thigh: 75 mm

Toes: 3-8 mm

Stereognosis (Ability to Recognize Objects

by Touching Them)

- Recognizes common objects - Unable to recognize common objects

Extinction Phenomenon

- Both points of stimulus are felt - Failure to perceive to touch on one side of
the body when two symmetric ares of the body
are touched simultaneously (frequently noted
in clients with lesions of the sensory cortex)

FEMALE GENITALIA AND INGUINAL

Normal Findings Abnormal Findings

1. There are wide variations; generally kinky in Scant pubic hair (may indicate hormonal
the menstruating adult, thinner and straighter problem)
after menopause
Hair growth should not extend to the abdomen
Distributed in the shape of an inverse triangle

2. Pubic skin intact, no lesions Lice, lesions, scars, fissures, swelling,

erythema, excoriations, varicosities, or
Skin of vulva area slightly darker than the rest leukoplakia
of the body

Labia round, full, and relatively symmetric in

adult females

3. Clitoris does not exceed 1 cm in width and 2 Presence of lesions

cm in length
Presence of inflammation, swelling, or
Urethral orifice appears as a small slit and is discharge
the same color as surrounding tissues

No inflammation, swelling or discharge

4. No enlargement or tenderness Enlargement and tenderness

MALE GENITALIA AND INGUINAL

Normal Findings Abnormal Findings

1. Triangular distribution, often spreading up Scant amount or absence of hair

the abdomen

2. Penile skin is intact Presence of lesions, nodules, swellings, or

inflammation
Appears slightly wrinkled and varies in color as
widely as other body skin

Foreskin easily retractable from the glans

penis

Small amount of thick white smegma between

the glans and foreskin

3. Pink and slitlike appearance Inflammation; discharge

Positioned at the tip of the penis Variation in meatal locations (e.g.,

hypospadias, on the underside of the penile
shaft, and epispadias, on the upper side of the
penile shaft)

4. Smooth and semifiirm Presence of tenderness, thickening, or

nodules
Is slightly movable over the underlying
structures Immobility

5. Scrotal skin is darker in color than that of Discolorations; any tightening of the skin (may
the rest of the body and is loose indicate edema or mass)

Size varies with temperature changes (the Marked asymmetry in size

dartos muscles contract when the area is cold
and relax when the area is warm)

Scrotum appears asymmetric (left testis is

usually lower than the right testis

6. Testicles are rubbery, smooth, and free of Testicles are enlarged, with uneven surface
nodules and masses (possible tumor)

Testis is about 2 x 4 cm (0.7 x 1.5 in.) Epididymis is non-resilient and painful

Epididymis is resilient, normally tender, and

softer than the spermatic cord

Spermatic cord is firm

7. No swelling or bulges Swelling or bulge (possible inguinal or femoral

hernia

8. No hernias Presence of hernias

RECTUM AND ANUS

Normal Findings Abnormal Findings

1. Intact perianal skin; usually slightly more Presence of fissures (cracks), ulcers,
pigmented than the skin of the buttocks exconations, inflammations, abscesses,
protruding hemorrhoids (dilated veins seen as
Anal skin is normally more pigmented, reddened protrusions of the skin), lumps or
coarser, and moister than perianal skin and is tumors, fistula openings, or rectal prolapse
usually hairless (varying degrees of protrusion of the rectal
mucous membrane through the anus)
 2. Anal sphincter has good tone Hypertonicity of the anal sphincter (may occur
in the presence of an anal fissure or other
lesions that causes contraction)

Hypotonicity of anal sphincter (may occur after

rectal surgery or result from a neurologic
deficiency

Rectal wall is smooth and not tender Rectal wall is tender and nodular

3. Brown color Presence of mucus, blood, or black tarry stool

REFERENCE:

Kozier, Barbara et al. Fundamentals of Nursing: Concepts, Process, and Practice, Eighth
Edition, Volume 1, Pearson Education South Asia Pte Ltd., 23-25 First Lok Yang Road, Jurong,
Singapore 629733, Pages 564 - 662