Xavier University

COLLEGE OF NURSING

Ateneo de Cagayan

NCM 101 - HEALTH ASSESSMENT

PERFORMING PHYSICAL EXAMINATION

PROCEDURE:

WEEK 1

ACTION & RATIONALE NORMAL FINDINGS ABNORMAL FINDINGS

1. Explain the purpose and

procedure.

R: Providing information fosters his/her

cooperation and allays anxiety.

2. Close doors and put screen.

R: To provide privacy.

3. Encourage the client to empty

bladder.

R: A full bladder makes him/her

uncomfortable.

4. Perform physical examination.  The client responds  The client confused,

appropriately to disoriented, or
A. General examination
commands inappropriate
Assess overall body appearance and responses
mental status.

Inspection

Observe the client’s ability to respond to

verbal commands.

R: Responses indicate the client’s speech

and cognitive function.
 5. Observe the client’s level of  The client is fully  Client has lowered
consciousness (LOC) and awake and alert: LOC and shows
orientation. Ask the client to eyes are open and irritability, short
state his/her own name, current follow people or attention span, or
location, and approximate day, objects. The client dulled perceptions.
month, or year. is attentive to  He/she is
questions and uncooperative or
R: Responses indicate the client’s brain responds promptly unable to follow
function. LOC is the degree of awareness and accurately to simple commands or
of environmental stimuli. It varies from commands. answer simple
full wakefulness and alertness to coma.  If he/she is questions.
Orientation is a measure of cognitive sleeping, he/she  At a lowered LOC,
function or the ability to think and responds readily to he/she may respond
reason. verbal or physical to physical stimuli
stimuli and only. The lowest
demonstrates extreme is coma,
wakefulness and when the eyes are
alertness. closed and the client
 The client is aware fails to respond to
of who he/she is( verbal or physical
orientation to stimuli, when no
person), where voluntary movement.
he/she is (  If LOC is between full
orientation to awareness and coma,
place), and when it objectively note the
is( orientation to client’s eye
time). movement:
voluntary, withdrawal
to stimuli or
withdrawal to
noxious stimuli (pain)
only.
6. Observe the client’s ability to  The client is able to  Dysphasia
think, remember, process follow commands  Dysarthria
information and communicate. and repeat and  Memory loss
R: These processes indicate cognitive remember  Disorientation
functioning. information.  Hallucinations
 smooth/  not clear/ not
Inspect articulation on speech style and appropriate native smooth/
contents of speaking. language inappropriate
contents
 7. Observe the client’s ability to  The client can hear  The client cannot
see, hear, smell, and distinguish even though the hear low tones and
tactile sensations. speaker turns must look directly at
away. the speaker.
 He/she can identify  He/she cannot read a
objects or reads a clock or distinguish
clock in the room sharp from soft.
and distinguish
between sharp and
soft objects
8. Observe signs of distress.  The client shows
labored breathing,
R: Alert the examiner to immediate
wheezing, coughing,
concerns. If you note distress, the client
wincing, sweating,
may require healthcare interventions
guarding of body part
before you continue the exam.
(suggests pain),
anxious facial
expression, of fidgety
movements

9. Observe facial expression and  Eyes are alert and  Eyes are closed or
mood. in contact with averted. The client is
R: These could be affected by disease or you. frowning or
ill condition.  The client is grimacing.
relaxed, smiles or  He/she is unable to
frowns answer questions
appropriately and
has a calm
demeanour.

10. Observe general appearance:  Posture is upright  Posture is stopped or

posture, gait, and movement.  Gait is smooth and twisted.
R: To identify obvious changes. equal for the  Limbs movements are
client’s age and uneven or unilateral.
development. Limb
movements are
bilateral.
 11. Observe grooming, personal  Clothing reflects  He/she wears
hygiene, and dress. gender, age, unusual clothing for
R: Personal appearance can indicate self- climate. gender, age, or
comfort. Grooming suggests his/her  Hair, skin , and climate.
ability to perform self-care. clothing are clean,  Hair is poor groomed,
well-groomed, and lack of cleanliness.
appropriate for the  Excessive oil is on the
occasion. skin.
 Body odor is present.

12. Measurement >140(or 145)cm in female <140(or 145) cm in female

 Height

1. Ask the client to remove

shoes and stand with
his/her back and heels
touching the wall.

2. Place a pencil flat on

his/her head so that it
makes a mark on the
wall.

3. This shows his/her

height measured with
cm tape from the floor
to the mark on the wall
(or if available, measure
the height with
measuring scale).

13. Body Mass index (;BMI) is used to assess the status of

nutrition using weight and height in the world.
 Weight
Formula: Formula for BMI = weight(kg)/ height (m)2
Weigh him/her without shoes and much
clothing. In Adults Women Men
anorexia
underweight in < 19.1 < 20.7
normal range 19.1-25.8 20.7-26.4
marginally 25.8-27.3 26.4-27.8
overweight 27.3-32.3 27.8-31.1
obese > 32.3 > 31.1
severely obese 35-40
morbidity obese 40-50
super obese 50-60
 14. Take vital signs.  36-37 ℃
o rate/minute in adult 60-80 / min.
 Temperature o regular and steady
o Pulse  Breaths /minute 16-20/ min.
 clear sound of breaths
 Respiration  regular and steady
 hypothermia < 35 ℃
 Blood pressure
 pyrexia 38-40 ℃
R: Vital signs provide baseline data.  hyperpyrexia > 40.1 ℃
o rate/ minute in adult bradycardia tachycardia
o pulse deficit, arrhythmia
 Breaths /minute bradypnea 20/min.
 Biot’s
 Cheyne-Stokes Kussmaul’s
 wheeze, stridor

 Hypotension: In normal adults < 95/60

 Hypertension
Classification SBP(mmHg) DBP(mmHg)
Normal Pre- <120 <80
hypertension 120-139 80-89
Grade 1 140-159 90-99
Grade 2 160-179 >/= 180 100-109
Grade 3 >/= 110
B. Skin Assessment  The color varying  erythema
from black brown
Assess integumentary structures (skin,
or fair depending  loss of pigmentation
hair, nails) and function.
upon the genetic
 cyanosis
SKIN factors
 pallor
Inspection and Palpation  Color variations on
dark pigmented  jaundice
15. Inspect the back and palms of skin may be best
the client’s hands for skin color. seen in the mucous
Compare the right and left sides. membranes, nail
Make a similar inspection of the beds, sclera, or lips
feet and toes, comparing the
right and left sides.

R: Extremities indicate peripheral

cardiovascular function.
 16. Palpate the skin on the back and  slight moist, no  Excessive dryness
palms of the client’s hands for excessive moisture indicates
moisture, texture. or dryness hypothyreidision

 firm, smooth, soft,  Oiliness in acne.

elastic skin
 Roughness in
hypothyroidism
Velvety texture in
hyperthyroidism

 flaking

 perspiration
(diaphoresis)

17. Palpate the skin’s temperature  warmth  Generalized warmth

with the back of your hand. in fever local warmth

 Coolness in
hypothyroidism

18. Pinch and release the skin on the  Pinched skin that  Pinched skin is very
back of the client’s hand. promptly or gently slow to return to
returns to its normal position.
R: This palpation indicates the skin’s
previous state
degree of hydration and
when released
signifies normal
turgor

19. Press suspected edematous  Depression  Depression recovers

areas with the edge of your recovers quickly slowly or remains.
fingers for 10 seconds and  Edema indicates fluid
observe for your depression. retention, a sign of
circulatory disorders.
 20. Inspect the skin for lesions. Note  Skin is intact,  Erythema
the appearance, size, location, without reddened  Eccymosis
presence and appearance of areas but with  Lesions include
drainage. variations in rashes, macules,
pigmentation and papules, vesicles,
R: Locate abnormal cell, growths or
texture, depending wheals, nodules,
trauma that suggests abnormal
on the area’s pustules, tumors, or
physiologic processes.
location and ulcers.
exposure to light  Wounds include
and pressure. incisions, abrasions,
Freckles, moles, lacerations, pressure
warts are normal. ulcers

NAIL  Pink color  Cyanosis and marked

 Longitudinal bands pallor
21. Inspect and palpate the
of pigment may be  Club being nails
fingernails and toenails. Note
seen in the nails of  Koilonychia (spoon
color, shape, and any lesions.
normal people. nail)
 Onycholysis (fungal
infection)
22. Check capillary refill by pressing  Normally color  Cyanosis nail beds or
the nail edge to blanch and then return is instant sluggish color return
release pressure quickly, noting (<3 seconds) consider
and return of color.  Nails should have cardiovascular or
no discoloration, respiratory
ridges, pitting, dysfunction.
thickening, or
separation from
the edge

HAIR AND SCALP  Color may vary  Hair is excessively dry

23. Inspect the hair for color, from pale blonde or oily Excessive hair
texture, growth, distribution. to total black. loss( alopecia) or
 Texture varies fine coarse hair in
to coarse and looks hypothyroidism
straight to curly  fine silky hair in
hyperthyroidism
 pediculosis
 dandruff

24. Inspect the scaly, lumps, nevi or  All area should be  redness and scaling in
other lesions. clean and free of seborrhoea
any lesions, scaly, dermatitis psoriasis
lumps, and nevi.
 C. Head and Neck Assessment

Assess central neurologic function,

vision, hearing, and mouth structures.

SKULL

25. Observe for the size, shape, and

symmetry.  Head is  Enlarged skull in
symmetrical, hydrocephalus,
round, and erect in Paget’s diseases of
the midline. bone.
 Redness after trauma
26. Palpate and note any  No visible  Presence of
deformities, depression, lumps deformities, lumps depression indicates
or tenderness. or tenderness fracture
 Possible tumor if
lumps are found

FACE  relaxed facial  Moon face with red

27. Inspect the client’s facial expression He/she cheeks in Cushing’s
expression, asymmetry, doesn’t have syndrome
involuntary movements, edema involuntary Edematous face
and masses. movement around the eyes (in
the morning ) and
pale in nephritic
syndrome
 Decreased facial
mobility and blunt
expression in
Parkinson’s disease
EYES  No deviation and  Inward and outward
28. Position: abnormal deviation
Stand in front of the client and inspect profusion  Abnormal profusion
both eyes for position and alignment. in disease or ocular
tumors
29. Eyebrows:  Scaliness in
Inspect the eyebrow, noting their seborrheic dermatitis
quantity and distribution and any  Lateral sparseness in
scaliness. hypothyroidism
 30. Eyelids:  Ptosis
 Entropian
Inspect the position, presence of edema,
 Ectropion
lesions, condition and direction of the
 Lid retraction
eyelashes and adequacy with eyelids
 Chalazion
doze.
 Sty
 Dacryocystitis
 Red inflamed lid
margin Inwards
direction
 Failure of the eyelids
to close exposes the
corneas to serious
31. Lacrimal apparatus:  No lumps and  Lumps and swelling
swelling around  Excessive tearing may
 Inspect the region of the the eyes be due to increased
lacrimal gland and production, drainage
lacrimal sac for swelling. of tear and infection (
such as conjunctiva
 Look for excessive inflammation and
tearing or dryness of the corneal irritation)
eye.

32. Conjunctiva and Sclera:  Transparent white  A yellow sclera

 Expose the sclera and color of sclera indicates jaundice
conjunctiva.  Dark pink color of  Paleness in palpebral
 Inspect the color of conjunctiva conjunctiva indicates
palpebral conjunctiva,  No paleness the anaemia.
vascular pattern against  No nodules or  Local redness due to
the white scleral swelling and infection
background and any redness
nodules or swelling.

33. Cornea and Lens:  Transparent, no  Opacities in the lens

With oblique lighting, inspect the cornea abrasions and due to cataract
of each eye for opacities and nite any white spots  A superficial grayish
opacities in the lens. veiled opacity in the
cornea due to old
injury or to
inflammation
 34. Pupils:  Pupils are equal,  Pupils are unequal.
Inspect the size, shape and compare round, and  Miosis refers to
symmetry. symmetry constriction of the
pupils
 Mydriasis to dilation

35. Pupillary response to light:  As the torch  Unresponsive to light

approaches the  Pupil remains dilated
 Ask the client to look eye, the pupil even after torch
into the distance and constricts. And as removed due to
light a penlight from the the torch removed, oculomotor nerve
side of the eye. the pupil dilates. paralysis. Small
irregular pupils seen
 Remove it on the other as central nervous
side to and observe how system syphilis.
pupil reacts.

 Repeat other side with

same procedure.

36. Coordination of eye movements:  Both eyes move  Eyes do not move
together while together when the
 Hold an object at a following the object moves in
distance from the client. objects: paralysis of the
coordination cranial nerve.
 Ask him/her to keep Strabismus(cross-
his/her head still and eyed or wall-eyed)
follow the object with  Client reports
the eyes only. diplopia(double-
vision)
 Move the object towards
his/her right and left
eye, then towards the
ceiling and floor

37. Convergence Test:  Good convergence  Poor convergence in

hypothyroidism
 Ask the client to follow
your finger or a pencil as
you move it in toward
the bridge of the nose.
 38. Snellen Eye Chart Test:  20/20 vision as  Myopia (near-
normal sightedness)
 Use the Snellen Eye  Hyperopia(far-
Chart, which includes sightedness) is
objects, letters or impaired in middle
numbers of different and elder people.
 Legal blindness
sizes in rows, under well-
light.

 Position the client 20

feet from the chart and
ask the client to identify
the items.

 Compare visual acuity of

the client with normal
vision.

EAR & HEARING  No pain while  Pain with movement

moving the pinna occurs with otitis
39. Using otoscope, hold the helix,  No visible externa
gently pull the pinna upward and discharges or  Clear blood of the
backward toward the occiput. cerumen brain hemorrhage
 A sticky yellow
40. Gently insert the otoscope and discharge
examine the ear. accompanies otitis
externa or otitis
media.
 Impacted cerumen is
a common cause of
conductive hearing
loss
41. Inspect the pinna, external canal.  The top of the  The top of the pinnae
Tympanic membrane, landmarks pinnae meet or don’t meet or cross
(lobules, helix, antihelix, tragus, crosses the eye- the eye – occiput line.
triangular fossa, mastoid occiput line  Atresia(:absence or
 Equal size closure of the ear
process).
bilaterally canal)
 No swelling or  Microtia (ears smaller
thickening than 4 cm vertically)
 Unusual size and  Macrotia (ears larger
shape may be than 10 cm vertically)
familial trail  Edema
without clinical  Asymmetry shape
significance due to trauma
42. Palpate the pinna for  No pain while  Visible swelling
tenderness, consistency of the palpating the pinna  Possible
cartilage and swelling. perichondritis
 43. VOICE TEST:  Normally the client  The client is unable to
repeats each word hear
 Test one ear at a time. correctly after you  High tone loss
said it.
 Stay 30-60cm from
client’s ear.

 Whisper slowly some

two syllable words.

44. Do mechanical testing: WEBER

and RINNE Testing.

WEBER TEST: to assess bone conduction  Equal hearing of  Tone louder on other
by testing the lateralization of sounds. both sides of same side means
type conductive loss
 Hold the tuning fork at its
base. Activate it by tapping
the fork gently against the
back of your hand near the
knuckles or by stroking the
fork between the thumb and
the index finger. It should be
made to ring softly.

 Place the base of the

vibrating fork on top of the
client’s head and ask where
the client hears the noise.

RINNE TEST: to compare air conduction  AC > BC  Negative rinne:

to bone conduction. louder on the
mastoid process
 Hold the handle of the  Positive rinne:
activated tuning fork in bilateral sensory
the mastoid process of neural hearing loss
one ear until the client
states that the vibration
can no longer be heard.

 Immediately hold still

vibrating fork prongs in
front of the client’s ear
canal. Ask whether the
client now hears the
sound. Sound conducted
by air is heard more
readily than sound
conducted by bone. The
tuning fork vibrations
conducted air is
normally heard longer