MIDDLE EAST University- Faculty of Nursing

Health Assessment Course/ Theory

1. HISTORY TAKING AND

INTERVIEW SKILLS
 OUTLINE

• Introduction to nursing process

• Components of nursing process
• Assessment process
• History Taking
• Interview Skills
 LEARNING OUTCOMES
 To define process and nursing process appropriately.
 To identify the components on nursing process.

 To recognize the physical examination skills.

 To identify the source of data.

 To differentiate between subjective and objective data.

 To discuss assessment process focusing on history

taking.
 Discuss interview skills.
 INTRODUCTION

* A process: is a series of steps or acts that lead to

accomplishing some goal or purpose.

* Nursing process: is the framework for providing

professional, quality nursing care. It directs nursing
activities for health promotion, health protection, and
disease prevention and is used by nurses in every
practice setting and specialty.

* The purpose of the nursing process: is to provide care

for clients that is individualized, holistic, and
effective.
 COMPONENTS OF NURSING PROCESS

Assessment. Diagnosis. Plan of care. Implementation.

Evaluation.
NURSING PROCESS
 ASSESSMENT
* Assessment: is the first step in the nursing process
includes systematic collection, verification, organization,
interpretation, and documentation of data. The
completeness and correctness of this data relate directly to
the accuracy of the steps that follow.

* Purpose of Assessment:
- Organize a database regarding a client’s physical, psychosocial, and
emotional health to identify actual problems and draw the appropriate
diagnosis and plan of care.
 ASSESSMENT

* Types of Assessment:

1. Comprehensive Assessment: provides baseline client data including a

complete health history and current needs assessment. It is usually
completed upon admission to a health care agency.

2. Focused Assessment: is limited to potential health care risks, a

particular need, or health care concern. Used when short stays are
anticipated (e.g., outpatient surgery centers and emergency departments).

3. Ongoing Assessment: When problems are identified during a

comprehensive or focused assessment, follow-up is required. An ongoing
assessment includes systematic monitoring of specific problems.
 ASSESSMENT
Data collection/ Data base
* Source of Data:
A) The primary source of data:
 The client (the major provider of information about self). As much
information as possible should be gathered from the client, using both
interview techniques and physical examination skills. Assessment
provides information that will form the client database

B) The secondary sources of data:

 Family members, other health care providers, and medical records.
 TYPES OF DATA
A) Subjective data (also called symptoms): are data from the
client’s (sometimes family’s) point of view.
 Examples of subjective information:
 I have a headache”.
 I drink only coffee for breakfast.
 I have had pains in my legs for three days now.

B) Objective data (also called signs): are observable and

measurable data that are obtained through both standard assessment
techniques and the results of laboratory and diagnostic testing.
 Examples of objective information include:
 T 37 °C, P 100 b/m, R 12breahe /m, BP 130/70 mmHg.
 Bowel sounds auscultated in all four quadrants.
 ASSESSMENT

A. Health History
B. Physical Examination
C. Diagnostic tests
 ASSESSMENT
A. Health history
* The health history: Is a review of the client's functional
health patterns prior to the current contact with a health
care agency.

* The nursing health history: Focuses on the client's

functional health patterns, responses to changes in health
status, and alterations in lifestyle.
 HEALTH HISTORY SEQUENCE

1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily
living (ADLs)
 1.BIOGRAPHIC DATA
 Biographic data include name, address, and
phone number; age and birth date; birthplace;
gender; relationship status; race; ethnic origin;
and occupation.
 If illness has caused a change in occupation,
include both the usual occupation and the
present occupation.
 Record the person's primary language. (medical
interpreter)
 2.REASON FOR SEEKING CARE
( CHIEF COMPLAINT)

 This describes the reason for the visit (in the person's own words) .
 It states one (possibly two) symptoms or signs and their duration.
A symptom is a subjective sensation that the person feels
A sign is an objective abnormality that you as the examiner
could detect

Try to record whatever the person

says is the reason for seeking care,
enclose it in quotation marks to
indicate the person's exact words,
and record a time frame.
3. PRESENT HEALTH OR HISTORY
OF PRESENT ILLNESS

“Tell me all about your headache, from the time it started

until the time you came to the hospital”

1. Location. Be specific; ask the person to point to the location.

If the problem is pain, note the precise site. “Head pain” is vague,
whereas descriptions such as “pain behind the eyes,” “jaw pain,”
and “occipital pain” are more precise and diagnostically
significant. Is the pain localized to one site or radiating? Is the
pain superficial or deep?

2. Character or Quality. This calls for specific descriptive terms

such as burning, sharp, dull, aching, gnawing, throbbing,
shooting, viselike when describing pain.
 3.PRESENT HEALTH OR HISTORY OF
PRESENT ILLNESS

3. Quantity or Severity. Attempt to quantify the sign or

symptom such as “profuse bleeding flow soaking five pads per
hour.” Quantify the symptom of pain using the scale shown
on the right. With pain, avoid adjectives, and ask how it
affects daily activities.

4. Timing (Onset, Duration, Frequency). When did the

symptom first appear? “How long did the symptom last
(duration)?” “Was it steady (constant) or did it come and go
(intermittent)?” “Did it resolve completely and reappear days
or weeks later (cycle of remission and exacerbation)?”
 3. PRESENT HEALTH OR HISTORY OF
PRESENT ILLNESS

5. Setting. Where was the person or what was the person

doing when the symptom started? What brings it on?
For example, “Did you notice the chest pain after
shoveling snow, or did the pain start by itself?”

6. Aggravating or Relieving Factors. What makes the

pain worse? Is it aggravated by weather, activity, food,
medication, standing, fatigue, time of day, or season?
What relieves it (e.g., rest, medication, or ice pack)?
What is the effect of any treatment?
 3. PRESENT HEALTH OR HISTORY OF
PRESENT ILLNESS
7. Associated Factors. Is this primary symptom
associated with any others (e.g., urinary frequency and
burning associated with fever and chills)? Review the
body system related to this symptom, review the
person's medication regimen (including alcohol and
tobacco use) because the presenting symptom may be a
side effect or toxic effect of a chemical.

8. Patient's Perception. Find out the meaning of the

symptom by asking how it affects daily activities. This is
crucial because it alerts you to potential anxiety if the
person thinks the symptom may be threatening.
3. PRESENT HEALTH OR HISTORY OF CURRENT
PRESENT ILLNESS

10/24/2024
➢ Another Chart
▪ Onset: When did (does) it start?
▪ Location: Where is it? Does it radiate?
▪ Duration: How long does it last?
▪ Characteristic Symptoms. (Severity)
▪ Associated Manifestations
▪ Relieving/Exacerbating Factors.
▪ Treatment.

20
3.PRESENT HEALTH OR HISTORY OF CURRENT
PRESENT ILLNESS
PQRSTU
 P-Provocative or Palliative

 Q-Quality or Quantity

 R-Region or Radiation

 S-Severity Scale

 T-Timing/ Treatment

 U-Understand Patient’s Perception

 4. PAST HEALTH

 Past health events are important because they may have residual effects on the
current health state.
 The previous experience with illness may also give clues about how the person
responds to illness and the significance of illness for him or her.
 Childhood Illnesses. Measles, mumps, rubella, chickenpox, pertussis. Avoid
recording “usual childhood illnesses. Ask about serious illnesses that may have
effects for the person in later years (e.g., rheumatic fever, scarlet fever,
poliomyelitis).
 Accidents or Injuries. Auto accidents, fractures, penetrating wounds, head injuries
(especially if associated with unconsciousness), and burns.
 Serious or Chronic Illnesses. Asthma, depression, diabetes, hypertension, heart
disease, hepatitis, sickle cell anemia, cancer, and seizure disorder.
 Hospitalizations. Cause, name of hospital, how the condition was treated, how long
the person was hospitalized, and name of the physician.
 4. PAST HEALTH
 Operations. Type of surgery, date, name of the surgeon, name of the
hospital, and how the person recovered.
 Obstetric History.
 Immunizations. Routinely assess vaccination history and urge the
recommended vaccines.
 Last Examination Date. Physical, dental, vision, hearing,
electrocardiogram (ECG), chest x-ray, mammogram, Pap test, stool occult
blood, serum cholesterol.
 Allergies. Note both the allergen (medication, food, or contact agent such
as fabric or environmental agent) and the reaction (rash, itching, runny
nose, watery eyes, difficulty breathing).
 Current Medications.
 Medication reconciliation is a comparison of a list of current medications
with a previous list, which is done at every hospitalization and every clinic
visit. The purpose is to reduce errors and promote patient safety.
 5. MEDICATION RECONCILIATION
 Medication reconciliation is a
comparison of a list of current medications
with a previous list, which is done at
every hospitalization and every clinic
visit. The purpose is to reduce errors and
promote patient safety.
 6. FAMILY HISTORY

 Highlights diseases and conditions for which a particular patient may be at

increased risk.
 A person who learns that he or she may be vulnerable for a certain condition
may seek early screening and periodic surveillance.
 Record the medical condition of each relative and other significant health
data such as age and cause of death, tobacco use, and heavy alcohol use.
 Health of close family members (spouse, children)
 Ask specifically about coronary heart disease, high blood pressure, stroke,
diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle
cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness,
suicide, seizure disorder, kidney disease, and tuberculosis (TB).
➢ Family tree (genogram)
 7.REVIEW OF SYSTEMS

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➢ General overall health state ➢ Respiratory system
➢ Skin ➢ Cardiovascular system
➢ Hair ➢ Peripheral vascular system
➢ Head ➢ Gastrointestinal system
➢ Eyes ➢ Urinary system
➢ Ears ➢ Genital system
➢ Nose and sinuses ➢ Sexual health
➢ Mouth and throat ➢ Musculoskeletal system
➢ Neck ➢ Neurologic system
➢ Breast ➢ Hematologic system
➢ Axilla ➢ Endocrine system

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 8. FUNCTIONAL ASSESSMENT
(INCLUDING ACTIVITIES OF DAILY LIVING)

 Functional assessment measures a person's self-care ability in

the areas of general physical health

 ADLs such as bathing, dressing, toileting, eating, walking;

 Needed for independent living such as housekeeping, shopping,

cooking, doing laundry, using the telephone, managing
finances; social relationships and resources; self-concept and
coping; and home environment.
 FUNCTIONAL ASSESSMENT,
INCLUDING ADLS

10/24/2024
 Self-esteem, self-concept
 Activity/exercise

 Sleep/rest

 Nutrition/elimination

 Interpersonal relationships/resources

 Spiritual resources

 Coping and stress management

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 FUNCTIONAL ASSESSMENT,
INCLUDING ADLS

10/24/2024
 Personal habits
✓ Tobacco
✓ Alcohol
✓ Street drugs
 Environment/hazards
 Occupational health

 Intimate partner violence

31
Thank You
Physical Examination/Techniques

Health Assessment Course/ Theory

 Assessment

A. Health History
B. Physical Examination/Techniques
C. Diagnostic tests
Cultivating Your Senses
The physical examination requires you to develop
technical skills and a knowledge base.

The technical skills are the tools to gather data.

You use your senses (sight, smell, touch, and hearing) to

gather data during the physical examination.
 Physical assessment techniques

Inspection
Palpation
Percussion
Auscultation.

Use these techniques in this sequence except when you perform an

abdominal assessment.
(Auscultation after Inspection)
 It is the most frequently used and reveal
more information than the other
technique.
Type :
a. Direct inspection : It is the use of sight ,
smell , and hearing.
b. Indirect inspection : use of special
Inspection instrument as speculum, ….etc.
For better inspection do the following :
a. Good exposed area.
b. Focus on color, shape, texture , size and
movement.
c. Clean , warm hands , and privacy.
 Inspection
➢ Inspect each body system using vision, smell, and
hearing to assess normal conditions and deviations.
➢ Observe for color, size, location, movement, texture,
symmetry, odors, and sounds as you assess each
body system.
➢ Use good lighting (preferably sunlight)
➢ The room should be comfortable temperature.
➢Perform at every encounter with your client.
 Inspection

➢ Completely expose the body part you are inspecting while

draping the other parts.
➢ Odors from skin, breath, wound.
➢ Compare the appearance of symmetric body parts (eyes, ears,
arms, hands).
➢ Inspection is done alone and in combination with other
assessment techniques.
➢ Special equipment used (ophthalmoscope, otoscope).
Uses of palpation :
Temperature (warm/cold), Texture (rough/smooth), Moisture (dry/wet)
Organ size (small/medium/large)
Mobility (fixed/movable/vibrating)
Consistency (soft/hard/fluid filled)
Strength of pulse (strong and bounding, weak or thready)
Shape (well defined/irregular) and degree of tenderness
Palpation

◼ Finger-pads: Best for fine tactile discrimination, as of skin texture,

swelling, pulsation, and determining presence of lumps.
◼ A grasping action of the fingers and thumb: To detect the position,
shape, and consistency of an organ or mass.
◼ The dorsa (backs) of hands and fingers—Best for determining
temperature.
◼ Base of fingers (metacarpophalangeal joints) or ulnar surface of the
hand—Best for vibration.
Types of palpation
1.Light Palpation
Feel for surface abnormalities.
Depress the skin ½" to ¾" (1.5 to 2
cm) with your finger pads, using the
lightest touch possible.
Assess for texture, tenderness,
temperature, moisture, elasticity,
pulsations, superficial organs, and
masses.
2. Deep Palpation

Feel internal organs and masses for size, shape, tenderness, symmetry,
and mobility.
Depress the skin 1½" to " (4 to 5 cm) with firm, deep pressure. 2
Use one hand on top of the other to exert firmer pressure (Use one
hand to apply pressure and the other to feel the structure) (bimanual
palpation).
 Percussion

 Tapping body parts quickly and sharply to locate organ borders, identify
organ shape and position, and determine if an organ is solid or filled with
fluid or gas.
Direct Percussion
 Reveals tenderness.
 Commonly used to assess an adult patient's sinuses.
 Using one or two fingers, tap directly
on the body part.
Ask the patient to tell you which areas are painful, and
watch his face for signs of discomfort.
Percussion
Indirect Percussion
 Elicits sounds that give clues to the makeup of the
underlying tissue.
▪ Press the distal part of the middle finger of your
non-dominant hand firmly on the body part.
▪ Keep the rest of your hand off the body surface
(not to damp the tone).
▪ Flex the wrist of your dominant hand.
▪ Using the middle finger of your dominant hand,
tap quickly and directly over the point
where your other middle finger
touches the patient's skin.
▪ Listen to the sounds produced.
 Percussion sounds
Sound Intensity Pitch Length Quality Example of
origin
Resonance (heard Loud Low Long Hollow Normal lung
over part air and
part solid
Hyper-resonance Very loud Low Long Booming Lung with
(heard over mostly emphysema
air
Tympany (heard Loud High Moderate Drum like Puffed-out
over air) cheek, gastric
bubble
Dullness (heard Medium Medium Moderate Thud like Diaphragm,
over more solid pleural
tissue effusion
Flatness (heard Soft High short Flat Muscle, Bone,
over very dense Thigh
tissue
Auscultation
Listening to sounds produced by the body
Sound is classified according to intensity (loud/soft), pitch
(high/low), duration, quality (musical/crackling)

Instrument: stethoscope (to skin)

1. Diaphragm –high-pitched sounds
Heart (S1, S2)
Lungs
Abdomen
2. Bell – low-pitched sounds
Blood vessels
abnormal heart sound
Auscultation

➢ Provide a quiet environment.

➢ Make sure the area to be auscultated is exposed. (Auscultating over a
gown or bed linens can interfere with sounds.)
➢ Warm the stethoscope head in your hand.
➢ Close your eyes to help focus your attention.

 The stethoscope does not magnify sound but does block out
extraneous room sounds.
Using the
stethoscope
The room must be quiet, to eliminate any confusing
artifacts
Keep the examination room warm, and warm your
stethoscope.
Clean your stethoscope endpiece with an alcohol
wipe, and warm it by rubbing the endpiece in your
palm.
For a man's hairy chest, wet the hair before
auscultating the area.
Never listen through a gown
Avoid your own “artifact”
Setting
The examination room should be warm and
comfortable, quiet, private, and well lit.
Lighting with natural daylight is best,
Artificial light from two sources suffices and
prevents shadows.
Position the examination table so that both
sides of the person are easily accessible
Limit interruptions
 Equipment
Have all your equipment easily accessible and laid out in an organized fashion

Stethoscope with bell and diaphragm Tongue depressor

Thermometer Pocket vision screener
Pulse oximeter (in hospital setting) Reflex hammer
Flashlight or penlight Cotton balls
Otoscope/ophthalmoscope Clean gloves
Tuning fork Alcohol wipes
Nasal speculum Hand sanitizer
 General consideration

Standard precautions:
Take all steps to avoid any possible transmission of
infection between patients or between patient and
examiner

Single most important step to decrease risk of

microorganism transmission is to wash your hands.

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 General consideration
Continuous explanations of steps.
Take safety precautions to prevent transmission of infection
Use quite, warm and comfortable room.
Avoid unnecessary exposure of body parts.
Consider the person's emotional status.
Avoid distraction and concentrate .
Proper documentation.
Give brief patient teaching if appropriate.
Do not forget to thank the person at the end.

10/24/2024 21
 Assessment

A. Health History
B. Physical Examination/Techniques
C. Diagnostic tests
C. Diagnostic studies and laboratory
investigations

Blood: CBC, KFT, LFT, Urine: analysis and Stool: analysis and
* Laboratory:
RBS, blood culture… culture culture

Sputum: analysis
Swab Sperm ………. * Radiology:
and cx

X-ray ( chest, CT-scan (computed

Mammogram: for Panorama: for
abdomen, tomography) for
breast cancer…. teeth….
bones…….._ brain, abdomen, ….

MRI (Magnetic
resonance imaging)
Nuclear images.
for brain, vessels,
joints…
C. Diagnostic studies and laboratory
investigations
* Other diagnostic tests:
-ECG: (Electrocardiogram).
-Echo
-Ultrasound
-Doppler
The Interview

The Interview
The purpose is to collect Subjective data, while in physical
examination we collect objective data.
The interview is a contract between the patient and the examiner
The interviewer has to consider the following
◦ Time and place
◦ Purpose
◦ Length
◦ Introduction and explanation
◦ Expectations
◦ Presence of others
◦ privacy
The Interview

Process of Communication
1. Sending 4. External factors
◦ Ensure privacy
2. Receiving
◦ Refuse interruptions
3. Internal factors ◦ Physical environment and physical
◦ Liking others (help other) distance
◦ Empathy 0-1.5 feet: intimate
◦ Ability to listen 1.5-4 feet: personal distance
◦ Self Awareness 4-12 feet: social distance
12: public distance
* 4-5 feet is the preferred distance
◦ Dress
◦ Note-taking: using hospital forms
The Interview

Techniques of Communication
Introducing the interview Communication Techniques
◦ Silence
Working phase
◦ Reflection
◦ Open-ended questions
◦ Empathy
◦ Closed or direct questions
◦ Clarification
◦ Confrontation
◦ Interpretation
◦ Explanation
◦ Summary
 Techniques of Communication,
The Interview

cont.
Ten Traps of Interviewing
1. Providing false assurance or reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions
 Techniques of Communication,
The Interview

cont.
Nonverbal skills
◦Physical appearance
◦Posture
◦Gestures
◦Facial expression
◦Eye contact
◦Voice
◦Touch
Closing the interview
The Interview Overcoming
Communication Barriers

Nonverbal cross-cultural communication

◦Vocal cues (and silence)
◦Action cues
◦Object cues
◦Use of personal and territorial space
◦Touch
The Interview Interviewing People
With Special Needs
People under the
Client with
Acutely ill influence of
Hearing-
people street drugs or
impaired or loss
alcohol

Sexually
aggressive Crying Anger
people

Threat of
Anxiety
violence
The Interview

Cross-Cultural Communication
Cultural perspectives on professional
interactions

Etiquette

Space and distance

Cultural considerations on gender and

sexual orientation
Perception of Health
Ask the person questions such as:
How do you define health?
How do you view your situation now?
What are your concerns?
What do you think will happen in the future?
What are your health goals?
What do you expect from us as nurses or
physicians (or other health care providers)?”
Thank You
Middle east University- Faculty of Nursing

Physical Assessment Course/ Theory

2. SKIN, HAIR, AND NAIL

ASSESSMENT
 OUTLINE

• Structure and function of the skin

• Collecting subjective data
• Steps to perform physical assessment
• Nail assessment
• Hair assessment
 LEARNING OUTCOMES

• To discuss the structure and function of skin, nail, and hair.

• To identify the correct the steps to collect subjective data.
• To discuss the process of performing physical assessment to skin, hair ,
and nail.
• To recognize the common abnormalities.
 STRUCTURE AND FUNCTION

Skin – 3 layers Epidermal Appendages

1. Epidermis
1. Hair
• Basal Cell layer
2. Sebaceous Glands
• stratum corneum
Cell layer 3. Sweat Glands

2. Dermis 4. Nails

3. Subcutaneous
Figure 10-1. p. 214.
 EPIDERMIS

• Tough, Thin, Protective Barrier

• New Skin Cells – formed in basal cell layer from tough fibrous
protein / Keratin
• Melanocytes – produce melanin / brown pigment in hair and
skin,
 The amount of melanin produced varies
• stratum corneum cell layer – dead cells being shed
• Avascular- it is nourished by blood vessels in the dermis below
 DERMIS
• Inner supportive layer consisting mostly of connective
tissue, or collagen; which gives the skin strength
and resistance to tearing
• It also contains elastic tissue for flexibility,
nerves, sensory receptors, blood vessels, and
lymphatic vessels. Additionally, hair follicles,
sebaceous glands, and sweat glands extend
from the epidermis into the dermis.
 EPIDERMAL APPENDAGES

1. Hair
Threads of keratin, each follicle function independently,
growth varies
• Arrector Pili – muscular tissue around follicle that
contracts & elevates the hair w/cold and emotion (goose
flesh)
 Vellus Hair – fine, covers most of the body
 Terminal Hair – darker, thicker hair, that covers the
scalp, eyebrows, axillae, pubic area, male chest & face
 EPIDERMAL APPENDAGES
2. Sebaceous Glands
•Sebum – protective liquid secreted through the hair
follicles
•Lubricates the skin & hair, emulsifies w/water to
decrease water loss
•Abundant in scalp, forehead, face, chin, not on the
palms or soles
 EPIDERMAL APPENDAGES

3. Sweat Glands

•Eccrine – produce a dilute saline solution called sweat, open

onto skin surface, mature in 2-month-old infant

•Apocrine – thick milky secretion, opens into hair follicles, react

with bacterial flora on the skin forming “musky” body odor,
mature during puberty.
 EPIDERMAL APPENDAGES
4. Nails

•Hard plates of Keratin

•Nail matrix – where new keratinized
cells are formed.
•Lunula is the white opaque semilunar
area at the proximal end of the nail
•Cuticle – covers & protects the nail
matrix
•The nail folds overlap the posterior
and lateral borders.
 FUNCTIONS OF THE SKIN

• Protection • Communication
• Prevents Penetration • Wound Repair
• Perception • Absorption & Excretion
• Temperature Regulation • Production of Vit. D
• Identification
 SUBJECTIVE DATA

1. Past history of skin disease. Significant familial predisposition:

Any past skin disease or problem? allergies, Hay fever, psoriasis, atopic
• How was this treated? dermatites (eczema), acne.
• Any family history of allergies or
allergic skin problems?
Any known allergies to drugs, plants, Identify offending allergen.
animals?
Any birthmarks, tattoos? At risk for:
Inflammatory
•Hypersensitivity reactions.
•Skin cancers
 SUBJECTIVE DATA

2. Change in pigmentation. Hypopigmentation (loss of color);

Any change in skin color ? hyperpigmentation (increase in
color).
A generalized color change (all over) or Generalized change suggests
localized? systemic illness: pallor, jaundice,
cyanosis.
3. Change in mole. Signs suggest neoplasm in
Any change in a mole: color, size, shape, pigmented nevus.
sudden appearance of tenderness,
bleeding, itching? May be unaware of change in nevus
• Any “sores” that do not heal? on back or buttocks that he or she
cannot see.
4. Excessive dryness or moisture. Seborrhea—Oily.
Any change in the feel of your skin:
temperature, moisture, texture?
Any excess dryness? Xerosis—Dry.
Is it seasonal or constant?
Skin Tone and Pigmentation
 SUBJECTIVE DATA

5. Pruritus. Pruritus is the most common skin symptom;

Any skin itching? Is it mild occurs with dry skin, aging, drug reactions,
or intense (intolerable)? allergy, obstructive jaundice, uremia, lice.
• Does it awaken you from
sleep?
Where is the itching? When Presence or absence of pruritus helps diagnosis.
did it start? Scratching causes excoriation of primary lesion.
6. Excessive bruising. Multiple cuts and bruises, bruises in various
stages of healing, illogical explanation—
Any excess bruising? consider physical abuse.
Where on the body?
• How did this happen? Frequent falls may be caused by dizziness of
• How long have you had it? neurologic or cardiovascular origin. Frequent
minor trauma may be a side effect of alcoholism
or other drug abuse.
 SUBJECTIVE DATA

7. Rash or lesion. Rashes are a common cause of seeking

Any skin rash or lesion? health care.
• Onset. When did you first
notice it?
8. Medications. Drugs, especially antibiotics, may cause
Which medications do you take? allergic skin eruption.
• Prescription and over-the- Some drugs may increase sunlight
counter? sensitivity and give burn response
• Recent change? Some drugs can cause hyperpigmentation:
9. Hair distribution. Alopecia is a significant loss.
Any recent hair loss?
• A gradual or sudden onset?

Any unusual hair growth? Hirsutism is shaggy or excessive hair.

 SUBJECTIVE DATA

10. Change in nails. Any change in

nails: shape, color, brittleness?
Do you tend to bite or chew nails?

11. Environmental or occupational Majority of skin cancers result

hazards. from environmental or
Any environmental or occupational occupational agents.
hazards?
Work with dyes, toxic chemicals,
radiation? sun exposure?
12. Patient-centered care. Assess self-care and influence on
Care for skin, hair, nails? self-concept
Which cosmetics, soaps, chemicals do
you use? Many over-the-counter remedies
• Clip cuticles on nails, use adhesive for are costly and exacerbate skin
false fingernails? problems.
Objective Data/Physical
Examination
 PREPARATION

• Control external variables that may influence the finding.

• Gain baseline knowledge of skin color and pigmentation.
• Begin with assessing the hands to accustom the client to
your touch.
• Assess the outer surface of the skin before assessing the
underlying structures.
• Remove the client's socks to inspect feet, nails, and between
toes.
 SKIN ASSESSMENT
Inspection
• Color & pigmentation
• Normal: pink or appropriate for race
& even pigmentation
• Widespread skin color changes:
• Pallor
• Cyanosis
• Erythema
• Jaundice
• Change in pigmentation:
• Vitiligo, freckles
WIDESPREAD SKIN COLOR CHANGES
Pallor Cyanosis

Erythema

Jaundice
 CAUSES

• Pallor: peripheral vasoconstriction/ sympathetic responses, shock, cold,

smoking, shock anemia.(face, mouth, conjunctiva, and nails).
• Cyanosis: increased deoxygenated blood, cardiac and pulmonary disease ( nails,
lips, oral mucosa, and tongue).
• Erythema: hyperemia, dilatation of blood, local inflammation and allergy,
emotional responses, fever ( generalized or localized ).
• Jaundice: increased bilirubin, biliary obstruction hemolytic disease (generalized
and most apparent in the conjunctiva and mucous membrane).
PIGMENTATION: VITILIGO
 SKIN ASSESSMENT/ PALPATION

Temperature: Palpate the forehead or face using the dorsal surface of your
fingers.
Moisture: Inspect and palpate the face, skin folds
axillae, and palms.
- Diaphoresis indicates hyperthyroidism or
myocardial infarction.
- Dry lips and mucous membranes indicate
dehydration, hypothyroidism, and vascular insufficiency.
- Oily: overproduction of sebum from sebaceous glands.
Mobility and Turgor: The skin’s ability to return to its normal position and
shape.

-This reflects the elasticity of the skin.

-Pinch up a large fold of skin on the anterior chest under the clavicle.

-Decreased elasticity (a slow return of the skin to its normal state taking
longer than 30 seconds) is seen in dehydration.
SKIN MOBILITY AND TURGOR
 EDEMA

• Decreased in skin mobility caused by an accumulation of fluid in the interstitial

spaces

• Four–point scale for grading edema

• +1, 2 mm- lasting up to 8 sec

• +2, 4 mm- (Lasting up to 15 sec)

• +3, 6 mm- (Lasting up to 60 sec)

• +4, 8 mm- (Lasting longer than 60 )

TEXTURE

• Normal findings: Smooth and soft.

• Abnormal findings: Rough and thick
• Skin Tags (Acrochordons): are overgrowths of normal skin.
• Eczema
 ECZEMA

A medical condition in which patches of skin become rough and

inflamed, with blisters that cause itching and bleeding, sometimes
resulting from a reaction to irritation but more typically having no
obvious external cause.
LESIONS
 ABNORMAL CHARACTERISTICS OF A
PIGMENTED LESION
DANGER SIGNS: ABCDE

• Asymmetry

• Border irregularity

• Color variation

• Diameter

• Elevation and Enlargement

 HAIR AND SCALP ASSESSMENT
• Distribution
• Thickness/thinness
• Texture (fine/smooth)
• Infections
• Scalp lesions –use woods lamp
• Note normal changes with aging
ALOPECIA (Hair loss)
SCALP LESIONS
INSPECT AND PALPATE THE HAIR
FOR:
Findings Normal Abnormal

1. Color Appropriate for White: lack of

race melanin

2. Amount and Thick and equally Alopecia

distribution distributed Baldness.

Hirsutism.

3. Palpate hair for Fine to coarse Dry and oiliness.

texture.
Alopecia areata Baldness
 NAIL ASSESSMENT

• Inspect Nail bed color

• Inspect Grooming and cleanliness
• Inspect shape
• Nail angle
• Palpate texture & consistency
• Capillary refill
Findings Normal Abnormal

1.color pink Pale, cyanosis,

2.Shape Round 160 Clubbing

3.texture hard Soft ,cracked

4. Nail beds Smooth , firm and pink. Paronychia :

inflammation of the skin

5. Capillary refill Within 3 second More than 3 seconds.

NORMAL NAIL
NAIL ANGLE
1-CLUBBING: OXYGEN DEFICIENCY
2- SPOON NAIL: IRON DEFICIENCY ANEMIA
Thin red lines or splinter hemorrhages in the nail beds are associated with
infective endocarditis
TRAUMA
FUNGAL INFECTION -
ONYCHOMYCOSIS
NAIL INFECTION (PARONYCHIA)
 CAPILLARY REFILL

• The capillary nail refill test is a quick test performed on the nail beds to
monitor dehydration and the amount of blood flow to tissue.

• If there is good blood flow to the nail bed, a pink color should return in less
than 2 seconds after pressure is removed.

• If time greater than 2 seconds

(Dehydration ,Shock, Peripheral vascular disease and Hypothermia).

Thank you
Head, Face, Neck,
and Regional
Lymphatics
Health Assessment

Presented by: Dr. Yasmeen Abu

Sumaqa
Outlines
o Structure and function of Head, Face, Neck, and Regional Lymphatics

o Subjective data: health history data and physical exam

o Objective data: Physical examination

o Inspect & Palpate Skull.

o Inspect the Face.

o Inspect & Palpate the Neck.

o Inspect & Palpate the Thyroid Gland.

o Abnormal Findings.

o Documentation

o References
LEARNING OBJECTIVES/ THEORETICAL COURSE:

On completion of this chapter, the learner will be able to:

1. Identify the structures and landmarks of the head and
neck (K-PH.I.1).
2. Describe the names and functions of the lymph nodes of
the neck and their locations (K-PH.I.1).
3. Describe the assessment and documentation of an
abnormal lymph node(K-H. P.M.1).
4. Identify appropriate gathering of subjective data of the
head and neck.
5. Demonstrate general techniques of assessment of the head
and neck (S-H. P.M.1).
6. Incorporate health promotion concepts and screenings
when performing an assessment of the head and neck (C-
H. P.M.1).
7. Differentiate between normal and abnormal head, face, and neck
(C-PH.I.1).
8. Describe documentation of subjective and objective data
of the head and neck(K-S.E.E.1).
3
LEARNING OBJECTIVES/ CLINICAL COURSE

On completion of this chapter, the learner will be able

to:
1. Perform a head and neck assessment correctly (S.PH.I.2)
2. Modify assessment techniques to reflect variations across
the life span(S-S.E.E.1.2)
3. Recognize deviations from norms (S.PH.I.3)
4. Document actions and observations (S. G.H.E.2.1)
5. Describe abnormal findings of physical assessment
(K.P.S.I.2.1)
6. Respect patient rights during performing the procedure
(C.P.S.I.2.2)
7. Interpret subjective and objective data appropriately
(C.PH.I.6)
8. Respond to problematic situation that may arise during
physical assessment (S-S.E.E.1.2)
4
 Face
• The human face has many appearances and
expressions that reflect mood.
• The expressions are formed by the facial muscles,
which are mediated by cranial nerve VII, the facial
nerve.
• Facial muscle function is symmetric bilaterally.

• Facial sensations of pain or touch are mediated by

the 3 sensory branches of cranial nerve V.
 Continue

• Facial structures are symmetric; the eyebrows, eyes,

ears, nose, and mouth appear the same on both
sides.

• The palpebral fissures are equal bilaterally. Also, the

nasolabial folds should look symmetric.
 Neck

 From the skull base to the manubrium, clavicle,

1st rib,1st thoracic vertebra below.
 Structures are vessels, muscles, nerves,
lymphatics & viscera of the respiratory and
digestive systems.
 Carotid artery (internal and external), jugular vein
(internal & external).

7
 Muscles

 Sternomastoid (head
rotation & head flexion).

 Trapezius (moves
shoulders & extend & turn
head).

The eleventh cranial nerve (XI)

the spinal accessory,
innervates them.
 Thyroid gland

 In the middle of the neck,

it has 2 lobes, separated
by isthmus, & secrete T3
&T4 hormones (stimulate
metabolism)

9
Cricoid cartilage-upper tracheal ring

The cricoid cartilage is above

the thyroid isthmus, then the
thyroid cartilage above that
(Adam’s apple) in males, and
the highest is the hyoid
bone.
 Lymph nodes
• Lymph nodes are small, oval clusters of lymphatic
tissue that are set at intervals along the lymph
vessels.
• The nodes slowly filter the lymph and engulf
pathogens.
• Nodes are located throughout the body but are
accessible to examination only in four areas: head
and neck, arms, axillae, and inguinal region.
• The greatest supply is in the head and neck.
• The head and neck have a rich supply of 60 to 70
lymph nodes
1. Preauricular: in front of ear
2. Posterior auricular: superficial
to mastoid process
3. Occipital: at the base of the
skull
4. Submental: midline, behind
the tip of the mandible
5. Submandibular: halfway
between the angle & tip of
the mandible.
6. jugulodigastric
(tonsillar): under the angle
of the mandible

7. Superficial cervical:
overlying sternomastoid
muscle

8. Deep cervical: under

sternomastoid muscle

9. Posterior cervical: at the

edge of the trapezius

10. Supraclavicular: above

clavicle, at sternomastoid
 Subjective Data
1. Headache: Severe headache in adult for
 Onset: when did this kind of the first time is a red flag.
headache start? Tension headache is occipital,
 Location: where do you feel frontal, or with band-like
it? Is pain localized on one side tightness, headache of sinusitis
or all over? is frontal.-
Character: throbbing
(shooting) or aching (dull)? Throbbing headache with
 Severity: Is it mild, moderate,
migraine or temporal arteritis
or severe? Severe pain with migraine.
 Duration: what time of day
Migraine occurs twice a month
do the headaches occur: each lasting 1-3 days
morning, evening?
 Subjective Data

1. Headache (CONT’):
•Stress, menstruation, chocolate,
 How long do they last?
coffee, cheese, alcohol,
 Precipitating factors- what precipitate migraine
brings it on? •Nausea, vomiting, visual
 Associated factors- as disturbances with migraine
nausea or vomiting? •Hypothyroidism, fever, and
 Do you have any other hypertension cause headaches.
illness? •Alcohol, oral contraceptives,
 Do you take any
bronchodilators, and carbon
medications? monoxide poisoning cause
headaches.
2. Head injury

 Onset-when? describe exactly what happened?

 Setting- any hazardous conditions, were you
wearing a helmet?
 How about before the head injury? Did you feel
dizzy, light headed, or suddenly lost consciousness
before the fall?
 Any history of illness such as DM?
 Duration: how long were you unconscious?
 Associated symptoms as vision change?
3. Dizziness

 Onset- abrupt or gradual? Associated factors as nausea or

vomiting or tinnitus.
True vertigo: rotational spinning because of neurological
deficit.

4. Neck Pain:
 onset- how did the pain start? Injury, accident…etc
 location- does the pain radiate? to shoulder, arms?
 Associated symptoms, limitations to range of motion

Acute onset of neck stiffness with headache and fever is a

sign of meningeal inflammation
 Precipitating factors, what movements cause pain?
5. Lumps or swelling in the neck

 Any recent infection, tenderness?

 How long have you had it? has it changed in size?

 Any difficulty swallowing?

 Do you smoke?

Smoking increases risks of respiratory and oral cancers

 Ever had a thyroid problem?

6. History of head or neck surgery

 For what condition? when did the surgery occur?

Surgery for head and neck cancers is disfiguring and affects

body image.
Objective Data
Position and Equipments

• Ask the client to sit in an upright position with the

back and shoulders held back and straight.
• Explain to the client, that he will be requested to
move and bend the neck for examination of muscles
and for palpation of the thyroid gland.

• Equipment
Gloves
Small cup of water
Stethoscope
 INSPECT & PALPATE SKULL
 Size & shape: Normocephalic, round symmetric skull, related to
body size.
for shape palpate scalp, no tenderness (symmetric & smooth).

Micro or Macrocephalic.
 Temporal area: palpate temporal artery (with arteritis: painful and
hard)
 Palpate tempo-mandibular joint: just below the temporal artery
and anterior to the tragus as the person opens mouth, no limitation
or tenderness.
 FACE INSPECTION
 Facial structures: Inspect the face, noting the facial
expression and its appropriateness to behavior or
reported mood. Anxiety is common in hospitalized or ill
people.
- Note the symmetry of eyebrows, palpebral fissures,
nasolabial folds, and sides of the mouth. Note any
abnormal facial structures (coarse facial features,
exophthalmos, changes in skin color or pigmentation) or
any abnormal swelling, note any involuntary movements
(tics) in the facial muscles. Normally there are none.
 Tense and rigid muscles: anxiety, pain.
 Flat: depression.
 Marked asymmetry: brain lesion (stroke), or facial nerve
damage (bells palsy).
 NECK: INSPECT & PALPATE

 Symmetry: the accessory neck

muscles should be symmetric, the Head tilt: muscle
head held erect & still spasm.
 ROM: ask the person to touch the Rigid head and neck:
chin to chest, turn head to Rt & Lt, arthritis.
try to touch each ear to the
shoulder, and test muscle strength
(CNXI) by trying to resist the
person’s movements with your
hands as the person shrugs
shoulders & turns the head to each
side.
 Note enlargement of salivary glands Parotid swelling with
& lymph nodes, note pulsations mumps
(carotid artery)
 NECK: cont
 Lymph nodes: using a gentle circular motion of your
fingerpads, palpate lymph nodes, palpate 10 groups in a
routine order in both hands.
 If any nodes are palpable note location, size, shape,
mobility, and tenderness
 Lymph nodes are normally invisible, and smaller nodes are

also non-palpable.
 Use both hands to palpate and compare, except for the
submental node
  For deep cervical chain, tip the persons’ head
toward the side being examined to relax the
muscle to be able to press your hand under the
muscle.
 Search for the supraclavicular node by
having the person hunch the shoulders and
elbows forward.

• Lymphadenpathy: > 1cm, cancer, infection.

 Continue

 Trachea: midline The trachea will be shifted

 Palpate for the shift: to the unaffected side in
place your index on the case of a thoracic aneurysm,
trachea in the sternal
pneumothorax, one-lobe
notch& slip it off to each
side, should be symmetric thyroid enlargement, or
on both sides. mass.

Trachea is pulled toward the

affected side in atelactasis,
adhesion, or fibrosis.
 Thyroid gland
 Inspect neck as person takes a sip & swallow,
thyroid moves up with a swallow.
a. posterior approach:
 Move behind the person
 Ask him to sit up straight & then to bend head
slightly forward & to right
 Use fingers of your Lt hand to push trachea
slightly to Rt.
 Curve your Rt fingers between trachea &
sternomastoid
 Ask him to take a sip of water, thyroid moves
up
 Reverse the procedure for Lt side
 Check for enlargement and symmetry.
in thin people with long neck: may feel isthmus.
Lateral lobes usually not palpable
 Thyroid gland

b. anterior approach:
 Stand facing person

 Ask him to tip head forward & to Rt

 Use your Rt thumb to displace trachea

slightly to the person’s right.
 Hook your Lt thumb & fingers around
the sternomastoid.
 Feel for lobe enlargement as he

swallows.
 Auscultate thyroid: if it was enlarged
auscultate for bruit (a soft pulsatile
blowing sound heard with bell).
 Documentation
- Subjective Data: Denies any unusually frequent or severe
headache; no history of head injury, dizziness, or syncope;
no neck pain, limitation of motion, lumps, or swelling.
- Objective data:
• Head: Normocephalic, no lumps, no lesions, no tenderness,
no trauma.
• Face: Symmetric, no drooping, no weakness, no
involuntary movements.
• Neck: Supple with full ROM, no pain. Symmetric, no
cervical lymphadenopathy or masses.
• Trachea midline, thyroid not palpable, and no bruits.
References
• Jarvis Carolyn. (2020). Physical Examination &
Health Assessment. (8th edition), Saunders, United
State
• Bickley, L.S. (2018). Bates guide to physical
examination and history taking. Philadelphia:
Lippincott Williams
• Cox, C.L. (2019). Physical assessment for nurses.
London: Blackwell Publisher
• Berman, A. Snyder, S., & Frandsen, G. (2022). Kozier
& Erb's Fundamentals of Nursing. 10th Edition
Middle East University- Faculty of
Nursing

Physical Assessment Course/ Theory

4.EYE ASSESSMENT
 OUTLINE

• Structure and function

eyes
• Subjective data
• Objective data
 LEARNING
OUTCOMES
• To identify the structure and function of eyes.
• To identify the subjective data related eyes assessment.
• To recognize the common abnormalities.
• To discuss the correct steps of conducting physical
examination for eyes.
STRUCTURE
AND
FUNCTION
Structureand Function
 SUBJECTIVE DATA

1.Vision difficulty. Any difficulty seeing or Night blindness occurs with optic atrophy,
any blurring? glaucoma, vitamin A deficiency.
Any blind spots? Come on suddenly or progress
slowly? In one eye or both?
Any night blindness?

2. Pain. Photophobia is the inability to tolerate light.

3. Strabismus, diplopia. Strabismus is a deviation in the parallel axes

Any history of crossed eyes? Now or in the of the two eyes.
past? Does this occur with eye fatigue?

4.Redness, swelling. Any redness or swelling

in the eyes?
•Any infections? Now or in the past? When do
these occur? In a particular time of year?
Diplopia.
 SUBJECTIVE DATA

5. Watering, discharge. Any watering or excessive

tearing?

6. History of ocular problems. Any history of injury Allergens (e.g., makeup, contact lens solution) cause
Or surgery to eye? Or any history of allergies? irritation of conjunctiva or cornea.

7.Glaucoma. Ever been tested for glaucoma? Glaucoma is characterized by increased intraocular
Results? pressure.
• Any family history of glaucoma?

8. Use of glasses or contact lenses. Do you wear

glasses or contact lenses? How do they work for you?

Self-care behaviors for eyes and vision.

Patient-centered care. Last vision test? Ever tested for
color vision?
Objective Data/Physical
Examination
 1.TESTING CENTRALVISUAL
ACUITY

• A .Snellen eye chart:

• Position the client exactly 20 feet ( = 6 meters ) from the Snellen chart.
• If the client uses corrective lenses or eyeglasses for distance vision, test first
•with eyeglasses, then without glasses.
• Have the patient cover one eye at a time with a card.
•Normal - Frowning, leaning forward and vision 20/20 (6/6) in each eye.
squinting indicates visual or reading difficulty.
 1.TESTING CENTRAL
VISUAL ACUITY
• A .Snellen Eye chart:

• Only the letters C, D, E, F, H, K, N, P, R, U, V, and Z should be used for the

testing of vision based upon equal legibility of the letters.
• The biggest letter on an eye chart often represents an acuity of 20/200

• (6/60), the value that is considered "legally blind."

• (20/30) numerator ‫ البسط‬indicates the distance the person is
standing from the chart, and the denominator‫ المقام‬gives the
distance at which a normal eye could have read that
particular line.Thus ―20/30 means, ―You can read at 20
feet what the normal eye can see from 30 feet away.
• If the person is unable to see even the largest letters,
shorten the distance to the chart until it is seen, and record
that distance
SNELLEN
CHART
 1.TESTING CENTRAL
VISUAL ACUITY
B. Near vision

* Client is sitting with a chart held at a distance of 12 -14 inches ( 30-35 cm).

⦁ Normal result 14/14 in each eye.

⦁ hyperopia: a condition where people can see distant objects clearly but
objects up close seem blurry. Hyperopia can occur at any age and is often there
after birth.

⦁ Presbyopia: an age-related condition in which the lens of the eye becomes

less flexible.
NEAR
VISION
 2.TESTING VISUAL
FIELDS
* By confrontation:
⦁ Testing peripheral vision.
⦁ It compares the person's peripheral vision with your own, assuming
that yours is normal.
⦁ Client should be sitting 2 to 3 feet ( 0.6 to 0.9 m ) from you at eye
level.
⦁ Repeats in all 4 visual fields, clockwise.
⦁ Looking straight at you, the person covers one eye with an opaque
card (here the right eye) as you cover the opposite eye.
⦁ Hold a wiggling finger as a target midline between you
and the person, and slowly advance it in from the periphery in several
directions. Ask the person to say “now” as the target is first seen; this
should be just as you also see the object.
 3. INSPECT EXTRAOCULAR
MUSCLE FUNCTION
A. Diagnostic Position Test

-Leading the eyes through the six cardinal positions of gaze elicits any muscle weakness
during movement

- Stand about 3-6 feet in front of the client.

- Testing eye movements and the muscles of the eye.

- Use the letter ( H ) method or wagon wheel method to assess the client’s ability to
follow your movements with eyes.
• Report normal findings (smooth eye movement, parallel

alignment, no nystagmus)

• Nystagmus: rapid fluttering of the eyeball due to weakness

in the extra ocular muscles or cranial nerve III (oculomotor)
& IV (trochlear), & VI (Abducens).
 3. INSPECT EXTRAOCULAR
MUSCLE FUNCTION
B.Corneal light reflex (H irschberg Test):

⦁ Shine light into the eyes from a distance of 12 inches (30 cm )

⦁ The reflection of light should appear in the same spot on both

pupils, this appears as a (twinkle ) in the eye.

⦁ If the reflection of light is not symmetrical, there could be a

weakness in the extraocular muscle.
 4. INSPECT EXTRAOCULAR
MUSCLE STRUCTURE
A. General Inspection

- Color and alignment of eyes

- Eyelids : Notes any lesions, edema, or lid lag. Note the eversion of the upper lid.

- Eyelashes: Assess symmetry and distribution

- Eyebrows: Assess symmetry

- Lacrimal ducts and glands: Checks for edema and drainage.

- Conjunctiva: Assess color, moisture, and contour.

- Inspect both palpebrals and bulbar conjunctiva.

 4. INSPECT EXTRAOCULAR
MUSCLE STRUCTURE
• A. General Inspection

- Cornea and sclera constitute the outer covering or coat of the eyeball.

- Sclera: Notes color and presence of lesions.

- Inspects cornea: and lens with penlight Notes color and lesions.
- If indicated, test the corneal reflex with a cotton wisp or puff of air:

• * The client will react by blinking the eyes and may tearing occur, Fail to response (
cranial nerve 5 is sensory for this reflex and cranial nerve 7 is motor ).
5. INSPECT THE ANTERIOR STRUCTURE OF
THE EYE
• Darken the room/ To dilate pupils.
• Stand about 1 foot from the client / For a comfortable position.
• Dial the lens wheel to zero with the index finger/ For better light.
• Hold the ophthalmoscope to own brow/ For comfort
• Ask the client to look straight ahead while shining the light on one pupil/ To
identify the red-light reflex.
• Once the red-light reflex is identified/move in closer to within a few inches
of the eye and observe the internal structures of the eye. Adjust the lens
wheel to focus as needed/For more visualization of the internal eye.

*Use the right eye to examine the client’s right eye, and the left eye to examine
the client’s left eye/ For the comfort of examiner and patient
5. INSPECT THE ANTERIOR STRUCTURE OF
THE EYE

A. Lens opacity:

Cataract:Is a clouding of the normally clear lens of the eye.

5. INSPECT THE ANTERIOR STRUCTURE OF
THE EYE

B. PERRLA (Pupil equal, round, reaction to light and

accommodation)
- Equal: Size: 2-3 mm

- Rounded: Shape

- Reaction to light:

. Shine a bright light obliquely into each pupil in turn.

. Look for both the direct (same eye) and consensual (other eye) reactions.
Both eyes react together.
5. INSPECT THE ANTERIOR STRUCTURE OF
THE EYE
B. PERRLA (Pupil equal, round, reaction to light and
accommodation)
- Accommodation: a response that automatically occurs when you switch focus from an
object that’s faraway to one that’s closer.
. Hold your finger about 10cm from the patient's nose
. Ask them to alternate looking into the distance and at your finger.
. Observe the pupillary response in each eye: Pupils constrict
at a near distance and dilate with a far distance.
• Dilated pupils: indicate glaucoma, trauma, or neurological disorder.
• Constricted pupils: indicate drug abuse or use.
* Failure to consensual reaction indicated problems In the III, IV and VI cranial
nerves.
5. INSPECT THE ANTERIOR STRUCTURE OF
THE EYE
C. Ocular fundus: the fundus of the eye is the interior surface of the eye opposite to
the lens and includes the retina, optic disc, macula.
5. INSPECT THE ANTERIOR STRUCTURE OF
THE EYE
C. Ocular fundus: observe for myopia and hypermyopia.
Optic disc: Note color, size

Retinal vessels: Note arteries and veins

General background: Note color

Macula ( area of central vision): Note color

RED to PINK
• Thank You
 Faculty of Nursing

Physical Assessment Course/ Theory

5. Ear Assessment
 Outline

• Structure and function of ears

• Subjective data
• Objective data
 Learning Outcomes

 To identify the structure and function of ears.

 To collect the subjective data related to ears assessment.
 To recognize common abnormalities.
 To discuss the correct steps of conducting physical examination
for ears.
 External Ear Structure

 The external ear is called the auricle or pinna

 The external auditory canal is 2.5 to 3 cm long in the adult and
terminates at the eardrum {tympanic membrane (TM)}.
 The canal is lined with glands that secrete cerumen, a yellow, waxy
material that lubricates and protects the ear. The wax forms a sticky
barrier that helps keep foreign bodies from entering and reaching the
sensitive tympanic membrane. The canal has a slight S-curve in the
adult.
 Structure and Function of
the Ear
 The ear is the sensory organ for hearing and maintaining equilibrium. It has
three parts:
1. the external ear
2. the middle ear
3. the inner ear
 The tympanic separates the external and middle ear and is
tilted obliquely to the ear canal, facing downward and
somewhat forward. It is translucent with a pearly gray color.
 Cerumen migrates out to the meatus by the movements of
chewing and talking.
 Tympanic membrane

 Separates the external and middle ear

 Is tilted obliquely to the ear canal, facing downward
and forward
 It is translucent with a pearly Gray colour and a
prominent cone of light in the anteroinferior quadrant,
which is the reflection of the otoscope light (at 5
o’clock position in R ear and 7 o’clock position in L
ear)
 The Middle Ear

 It contains tiny ear bones, or auditory ossicles: the malleus, incus, and stapes.

 Its opening to the outer ear is covered by the tympanic membrane.

 The openings to the inner ear are the oval window and the round window.

 Another opening is the eustachian tube, which connects the middle ear with the
nasopharynx and allows passage of air.
 The middle ear has three functions:
1. Conducts sound vibrations from the outer ear to the central
hearing apparatus in the inner ear
2. Protects the inner ear by reducing the amplitude of loud
sounds
3. Its eustachian tube allows equalization of air pressure on
each side of the tympanic membrane so the membrane does
not rupture
 The Inner Ear
 It contains the bony labyrinth, which holds the sensory
organs for equilibrium and hearing.
 Within the bony labyrinth:

 The vestibule
 The semicircular canals
 The cochlea
 Hearing

 The ear transmits sound and converts its vibrations into

electrical impulses, which can be analysed by the brain.
 The sound waves produce vibrations on your tympanic
membrane.
 These vibrations are carried by the middle ear ossicles to your
oval window.
 Then the sound waves travel through your cochlea.
 The electrical impulses are conducted by the auditory portion of
cranial nerve VIII 8(vestibulocochlear ) to the brainstem.
 Hearing Loss
 Anything that obstructs the transmission of sound impairs hearing.

1. Conductive hearing loss involves a mechanical dysfunction of the external or

middle ear.
 It is a partial loss.
 Conductive hearing loss may be caused by impacted cerumen, foreign
bodies, a perforated tympanic membrane, pus or serum in the middle ear,
and a decrease in mobility of the ossicles.
2. Sensorineural (or perceptive) loss signifies pathology of the inner ear, cranial
nerve VIII, or the auditory areas of the cerebral cortex.
 Sensorineural hearing loss may be caused by nerve degeneration that occurs
with aging and by ototoxic drugs.
3. Mixed loss is a combination of conductive and sensorineural types in the same
ear.
 Clues that suggest hearing
loss
1. Person lip-reads or watches your face and lips closely
rather than your eyes
2. Frowns or strains forward to hear
3. Postures head to catch sounds with better ear
4. Misunderstands your questions or frequently asks you to
repeat
5. Acts irritable or shows startle reflex when you raise your
voice (recruitment)
6. Person's speech sounds garbled, possibly vowel sounds
distorted
7. Inappropriately loud voice
8. Flat, monotonous tone of voice
 Subjective Data

1. Earache (PQRST) Referred pain from a problem in

teeth or oropharynx.
Infection
Rupture in tymbanic membrane
2. Infections A history of chronic ear problems
alerts you to possible hearing loss.

3. Discharge Otorrhea (ear drainage)suggests

infected canal or perforated eardrum

4. Hearing loss Gradual vs sudden

A trauma hearing loss is often sudden
 Subjective Data

5. Environmental noise
Exposed to loud sound, Noise
protection
6. Tinnitus Occurs with sensorineural hearing loss,
Ringing, roaring, or buzzing in your ears cerumen impaction, middle ear infection,
and other ear disorders
Ototoxic drugs
7. Vertigo Feeling of spinning of person (subjective
vertigo) or the objects around person
(objective vertigo).
8. Patient-centered care
Clean your ears Frequency of hearing
assessment
 Objective
Data/Physical
Examination
Inspection and Palpation of the External
Ear
 Size and shape :
Equal size bilaterally with no swelling or thickening
 Skin Condition :
-Color consistent with facial skin color
-Intact skin, with no lump or lesions.
 Tenderness:
-move the pinna & push the tragus (should feel firm with no
pain )
 External auditory meatus :
Some cerumen -color varies from gray-yellow to light brown
and black; may be moist and waxy to dry
Inspection of Ears Using Otoscope

➢ Tiltperson’s head slightly away from

you toward the opposite shoulder
➢ Pull the pinna up and back on an
adult
➢ Pull the pinna down and back for a
child < 3 yrs
➢ Hold the otoscope upside down
➢ Insert the speculum slowly and
carefully
➢ Once in place, rotate the otoscope
slightly
The Tympanic
Membrane

 Color: shiny and translucent with a pearl

gray color.
 Cone-shaped light reflex: prominent in the
anteroinferior quadrant
 Position : The eardrum is flat and slightly
pulled in at the center
 Integrity of membrane : intact
 Hearing Acuity ( Assess CN VIII )

 Your screening for a hearing deficit begins

during the history; “Do you have difficulty
hearing now?” If the answer is yes,
perform audiometric testing or refer for
audiometric testing. If the answer is no,
screen using the whispered voice test
described as follows.
Hearing Acuity

 audiometer gives a precise quantitative measure of

hearing by assessing the person's ability to hear
sounds of varying frequency.
 Tell the patient, “You will hear faint tones of
different pitches. Please raise your finger as soon as
you hear the tone; then lower your finger as soon as
you no longer hear the tone.”
 Choose tones of random loudness in decibels on the
audios cope. Each tone is on for 1.5 seconds and off
for 1.5 seconds. Test each ear separately and record
the results.
 Whispered Voice Test

 Stand arm's length (20-30 cm) behind the

person. Test one ear at a time while masking
hearing in the other ear to prevent sound
transmission around the head. This is done by
placing one finger on the tragus and pushing
it in and out of the auditory meatus. Move
your head to 1 to 2 feet from the person's
ear. Exhale fully and whisper slowly a set of 3
random numbers and letters, such as “6. 5,
B, ” Normally the person repeats each
number/letter correctly after you say it. If
the response is not correct, repeat the
whispered test using a different combination
of 3 numbers and letters.
 A passing score is correct repetition of 4 of a possible 6
numbers/letters. Assess the other ear using yet another set of
whispered items “4, K, 2.”
 Tuning Fork Tests

 It is measure hearing by air conduction (AC) or bone

conduction (BC), in which the sound vibrates through the
cranial bones to the inner ear.
 The AC route through the ear canal and middle ear is usually
the more sensitive route. If hearing loss is identified by history
or whispered voice test, tuning fork tests traditionally were
used to distinguish conductive loss from sensorineural loss..
 Be aware that neither test can distinguish normal hearing from
a sensorineural loss in both ears —you should rely on
audiometry.
Type of hearing loss

 A conductive hearing loss happens when sounds cannot

get through the outer and middle ear. It may be hard to
hear soft sounds. Louder sounds may be muffled.

 Sensorineural hearing loss results from damage to the

hair cells within the inner ear, the vestibulocochlear
nerve, or the brain's central processing centers. This
differs from a conductive hearing loss, which results
from the inability of sound waves to reach the inner ear.
Tuning Fork tests: Weber test

 Place TF in the midline of the skull or mid

forehead and ask whether the sounds the
same in both ears or better in one.
 Test of lateralization.

 Normal; should hear BC and the sound is

equally loud in both ears
 Tuning Fork tests: Rinne test

 Place the stem of TF on the mastoid

process and ask the client to signal
when the sound goes away.
 Invert the fork so the ends near the ear
canal.
 Normal; Positive AC:BC 2:1 (Patient still
hearing the sound AC twice as BC).
 Romberg Test
 The Romberg test assesses the ability of the vestibular
apparatus in the inner ear to help maintain standing
balance.
 Ask patient to stand up with feet together and arms
at side. When stable have client close eyes wait about
30 -60 seconds; slight swaying may occur
 proprioception; sensation of position with visual
information is blocked.
 Positive Romberg ’s ; loss of balance that occurs when
closing eyes.
 Thank You
Middle East University- Faculty of Nursing

Physical Assessment Course/ Theory

6. Nose, Sinuses, Throat, and

Mouth
 Outline

• Structures and functions of nose, sinuses, throat, and mouth

• Subjective data
• Objective data
 Learning Outcomes

 To identify the structure and function of nose, sinuses, throat,

and mouth.
 Identify subjective data related to nose, sinuses, throat, and
mouth assessment.
 To recognize common abnormalities.
 To discuss the correct steps of conducting physical examination
for nose, sinuses, throat, and mouth.
Structure and function
Nose and Sinuses
Structure and function
Nose and Sinuses
Structure and function
Nose and Sinuses
 The olfactory receptors (hair cells) lie at the roof of the nasal cavity
and in the upper one-third of the septum.

 These receptors for smell merge into the olfactory nerve, cranial
nerve I, which transmits to the temporal lobe of the brain.
 Structure and function
Nose and Sinuses
- The sinuses: are air-filled pockets. They communicate
with the nasal cavity and are lined with the same type of
ciliated mucous membrane.

-Sinuses lighten the weight of the skull bones; serve as

resonators for sound production; and provide mucus,
which drains into the nasal cavity.

- The sinus openings are narrow and easily occluded,

which may cause inflammation or sinusitis.
Structure and function
Mouth and throat
 Subjective Data
Nose

1. Discharge Rhinorrhea occurs with colds, allergies,

sinus infection, trauma.
2. Frequent colds (upper respiratory
infections)
3. Sinus pain Sinusitis

4. Trauma Trauma may cause deviated septum,

which may cause nares to be obstructed.
5. Epistaxis (nosebleeds) Epistaxis occurs with trauma, vigorous
nose blowing, foreign body.
6. Allergies
Allergic to pollen, dust, pets?
7. Altered smell Sense of smell diminishes with cigarette
smoking, chronic allergies, aging.
 Subjective Data
Mouth and Throat

1. Sores or lesions

2. Sore throat
3. Bleeding gums

4. Toothache

5. Hoarseness Hoarseness of the larynx has many causes: overuse of the voice,
, chronic inflammation, lesions, or a neoplasm
6. Dysphagia

7. Altered taste

8. Smoking, alcohol Chronic tobacco use leads to tooth loss, coronal and root caries,
consumption and periodontal disease in older adults.
 Subjective Data
Mouth and Throat

6. Dysphagia

7. Altered taste

8. Smoking, alcohol consumption

9. Patient-centered care
Dental care pattern
Dentures or appliances
 Objective
Data/Physical
Examination
 1. Nose and Sinuses

A. Inspect and palpate the external nose:

- Inspect size, shape, and position: to check symmetry and
deviation.
- Inspect Skin condition: To identify any abnormalities such as
change in color ,lumps, skin lesion, trauma.
- Note for redness, swelling, and discharge: Rhinorrhea,
epistasis, Rhinitis
- Note the size of the opening: to detect the size of the
speculum.
- Palpate skin condition: for lesions and tenderness.
- Push each nostril with your finger while asking the
person to sniff inward through the other nostril: to check the
patency of nostrils.
 1. Nose and Sinuses
B. Inspect nasal cavity with nasal speculum:
- Gently lift the tip of the nose with your fingers before
Inserting: To facilitate the insertion of the speculum and Otoscope.

- Insert the Otoscope with the speculum attached to it in the nasal vestibule:
To view the nasal cavity.

- Avoid pressure on the nasal septum: To avoid hearting the client’s nasal
septum.

- Examine each nasal cavity first with the person's head erect, then with the
head tilted back to ensure all parts are visualized.
 1. Nose and Sinuses
B. Inspect nasal cavity with nasal speculum:
- Inspect the nasal mucosa: To note the normal red color and smooth,
moisture surface; to identify any swelling, dryness or discharge.

- Observe the nasal cavity: To identify any deviation or perforation of

the septum.
* Deviated septum is common and is not significant unless air flow is
obstructed.

- Inspect the turbinate: For any changes, or presence of polyp. (usually they
are light red color).
* The superior turbinate will not be in your view.
* Nasal polyps: are smooth, pale benign growth found in many clients with
chronic allergies.
 nasal spaculum
Nasal polyps
 1. Nose and Sinuses
C. Palpate the sinus areas:

* Only 2 pairs of sinuses are accessible for palpation ( frontal and

maxillary; the other 2 pairs are deep and small.

- Using your thumbs, press the frontal sinuses by pressing firmly

up and under the eyebrows; and over the maxillary sinuses below
(not over) the cheekbones: To assess for tenderness, normal
patients will feel pressure but not pain.
 1. Nose and Sinuses
D. Transillumination
- Darken the exam room: Important to get correct result.
- Fix a strong narrow light to the end of the Otoscope.
- Hold the Otoscope under the superior orbital ridge against the
location of the frontal sinus; to test the frontal sinuses: A diffuse
red glow is a normal response.
- Ask the person to tilt the head back and open mouth: To inspect
the maxillary sinuses.
- Shine the light on each cheek under the inner corner of
the eye: The light transmit through sinuses; Note a dull glow
inside the mouth on the hard palate. The light transmit through
sinuses.
 2. Mouth and throat
A. Inspect and palpate the lips:
- Inspect the lips for color, moisture, cracking, skin lesion:
To identify any abnormalities ( lesion, dryness, pale,
cyanosis…).

- Retract the lips and note the inner surface: To identify any
abnormalities in the inner surface( lesion, dryness, pale,
cyanosis… ).
 2. Mouth and throat
B. Inspect and palpate gum (gingivae) and teeth:
- Ask the person to open his mouth and inspect the teeth: To identify any
diseased (dental caries), loose or abnormally positioned.

- Compare the number of teeth with the expected number

to age: To identify the number of missing teeth.

- Ask the person to bite as if chewing something: To note the alignment of

the upper and lower jaw
* The upper incisors slightly override the lower incisors.

- Inspect the gum for swelling, retraction of gingival margin, spongy,

bleeding, or discolored gum: To identify if there is gingivitis , gingival
hypertrophy, changing in color may indicate certain types of poisoning.
 2. Mouth and throat
C. Inspect and palpate tongue:
- Inspect the tongue for color, moisture, position and surface
characteristics: To identify any abnormalities.
* Normally: The color is pink and even. The dorsal surface
is normally roughened from the papillae (taste buds). A thin white coating may be
present.
* Enlarged tongue occurs with hypothyroidism; a small tongue accompanies
malnutrition.
* Dry mouth occurs with dehydration.
* Smooth tongue occurs with deficiency of vitamin B and iron.

- Ask the person to touch the tongue to the roof of the mouth: To inspect the
dorsum surface of the tongue.
* Veins and saliva are visible normally.
 2. Mouth and throat
D. Inspect and palpate basal mucosa:
- Use a wooden tongue blade and hold the cheek open to visualize the inner part
of the cheek.

- Inspect the inner part of the cheek for color, moisture, smoothness, nodules,
and lesions: To identify abnormalities.

- Normal: It looks pink, smooth, and moist.

 2. Mouth and throat
E. Inspect and palpate palate:
- Shine a light up to the roof of the mouth: To visualize the palate area.
- Inspect the anterior and posterior palate: To differentiate between the
anterior (hard) and posterior palate(soft)
- Normal: the anterior palate is white with irregular transverse rugae; the
posterior is pink.
 The hard palate appears yellow with jaundice.
- Observe a torus palatinus: A benign growth that develops after puberty; it is
more common in American Indians and Asians and is more prevalent in
females than in males..
- Ask the person to say '' ahhh '' observe the uvula and the soft
palate: To be able to visualize the uvula and the soft palate.
- Inspect the uvula and the soft palate arising in the middle: This test one
function of the cranial nerve X.
Torus palatinus
 2. Mouth and throat
F. Inspect and palpate throat:
- Depress the tongue with a tongue blade: To enlarge your view of the posterior pharyngeal wall.
- Push down halfway back on the tongue: To depress the tongue.
- Press slightly off-center: To avoid eliciting the gag reflex.
- Inspect the posterior wall for color exudates and lesions.
- Inspect tonsils for color, exudates, and grades: To identify abnormalities
 +1 for visible.
 +2 for halfway between tonsillar pillars and uvula.
 +3 for touching uvula.
 +4 touching each other.
 Tonsils are enlarged to +2, +3, or +4 with an acute infection.
 With an acute infection tonsils are bright red and swollen and may have exudate or large white
spots.

- Touch the posterior tongue with the tongue blade which should elicit the gag reflex: This tests
the cranial nerve IX, X.
- Discard the tongue blade in the medical used items: For infection control.
 Clinical features
 Clinical features help but are not sufficient in determining the cause of
pharyngitis:

 Viral pharyngitis: shows erythematous tonsils with no hypertrophy or exudates.

When accompanied by cough, hoarseness, and rhinorrhea, a rapid antigen test
and/or culture may not be needed in low-risk groups.

 Streptococcal pharyngitis: shows with erythematous, enlarged tonsils with

exudates. Four features suggest streptococcal cause: absence of cough; swollen,
tender anterior cervical nodes; fever >100.4° F (38° C); tonsillar exudate.
- With these features and in children 3 to 14 years, rapid antigen testing is warranted.
 Thank You