Head-to-Toe Physical Assessment Guide for Nurses

Introduction to Nursing Head-to-Toe Physical Assessment

Assessment, as part of the nursing process, is a key foundational skill needed for the planning and provision of competent client care. Knowledge of and ability to conduct comprehensive and focused physical assessments are critical core competencies required by nurses providing care to complex clients in both acute care and community settings. Thus, it is imperative that student nurses develop strong physical assessment skills in order to provide comprehensive and safe nursing care.

Utilization of the head-to-toe assessment framework allows for a structured organized approach to completing and collecting data in a physical examination. The core head-to-toe physical assessment framework requires the student to perform essential physical assessment skills and to use clinical reasoning to know when to complete a more focused assessment. Focused assessments are a very important part of the nursing process as a nurse asks questions to gather data specifically for an identified concern. Clinical reasoning is an important part of the process as students must use critical thinking to analyze the assessment data and make important clinical judgments about the client’s overall health needs.

Assessment Techniques

Physical assessment is a basic but essential nursing skill. Being able to assess the client’s current condition can help identify early changes. The importance of early recognition of deterioration before overt physiologic signs, such as vital sign changes, cannot be overstated given the link between unrecognized client deterioration and serious adverse events. However, physical assessment as practiced daily in contemporary nursing focuses more on vital signs than physical assessment; this is likely due to time restraints and a reliance on technology to determine the client’s clinical status. Inspection, palpation, percussion, and auscultation (IPPA) are the four basic techniques of physical assessment. They should be sued in a sequence, unless during an abdominal assessment.

• Inspection is performed by observing each body system using vision, smell, and hearing to assess normal conditions and deviations.
• Palpation requires the nurse to touch the client with different parts of the hands, using varying degrees of pressure. The nurse’s fingernails must be kept short and the hands warm. When palpating mucous membranes or areas in contact with body fluids, wearing gloves is a must. Tender areas must be palpated last to avoid compromising the assessment results of surrounding areas. Light palpation is used to feel surface abnormalities, while deep palpation is used to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.
• Direct percussion may reveal tenderness; it is commonly used to assess an adult’s sinuses. Using one or two fingers, the nurse taps directly on the body part. Indirect percussion elicits sounds that give clues to the makeup of the underlying tissue.
• This involves listening for various lung, heart, and bowel sounds with a stethoscope. The diaphragm of the stethoscope is used to pick up high-pitched sounds. The bell is sued to pick up low-pitch sounds.

Types of Assessment Data

According to the American Nurses Association, the assessment includes collecting “pertinent data, including but not limited to, demographics, social determinants of health, health disparities, and physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic, ongoing process with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Client data is considered either subjective or objective, and it can be collected from multiple sources.

• Subjective data
  This data is information obtained from the client and/or family members and offers important cues from their perspectives. When documenting subjective data, it should be in quotation marks. There are two types of subjective information, primary and secondary. Primary data is information provided directly by the client, while information collected from a family member, chart, or other sources is known as secondary data.
• Objective data.
  Objective data is anything that you can observe through your senses of hearing, sight, smell, and touch while assessing the client. Objective data is reproducible, meaning another person can easily obtain the same data.

Types of Assessment

As student nurses embark on their journey to become skilled healthcare professionals, it is important to grasp the fundamentals of nursing assessment. Assessing clients is like uncovering a puzzle- each piece of information helps build a complete picture of the client’s status. There are different types of nursing assessment, each serving a unique purpose.

• Initial assessment. The initial assessment is also referred to as triage. Its purpose is to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages.
• Focused assessment. Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the client. This may include one or more body systems.
• Time-lapsed assessment. The time-lapse assessment is conducted to evaluate how the client reacts to the agreed treatment plan and how their condition is evolving. Depending on the issue, a time-lapse assessment can last from a few hours to a few months. Throughout this time, the client is constantly evaluated and their condition is compared to previously recorded parameters to see if the treatment is effective.
• Emergency assessment. The emergency assessment is performed during emergency situations when it is crucial to evaluate the client’s airway, breathing, and circulation, as well as the exact cause of the problem. Emergency assessments can take place outside typical healthcare settings and in these situations the nurse must also make sure that no other people are negatively affected by the emergency rescue process.

Preparations

Before initiating client interaction and starting the assessment, the nurse should prepare themselves and their clients first. The nurse must perform hand hygiene and utilize personal protective equipment as appropriate, perform introductions, and provide a culturally safe space for the client.

• Hand hygiene. Using hand hygiene is a simple but effective way to prevent infection when performed correctly and at the appropriate times when providing client care. Generally, hand sanitizers are as effective as washing soap and water and are less drying to the skin. However, if the hands are visibly soiled, they should be washed with soap and water. Hand hygiene must be performed at the following times:
  • Immediately before touching a client
  • Before performing an aseptic/clean procedure
  • After direct contact with body fluid
  • After touching a client
  • After touching surfaces around the client
• Personal protective equipment. Additional precautions can be implemented by the healthcare tea, when a client has, or is suspected of having, an infectious disease. These additional precautions are called personal protective equipment (PPE) and are based on how infection is transmitted, such as by contact, droplet, or airborne routes. PPE includes gowns, eyewear, face shields, and face masks.
• Assessment tools and equipment. The nurse must be familiar with the tools and instruments used during physical assessment and how they must be used appropriately. This includes:
  • Otoscope
  • Penlight
  • Stethoscope with a bell and a diaphragm
  • Thermometer
  • Bladder scanner
  • Speculum
  • Eye charts
  • Cardiac and blood pressure monitors
  • Fetal doppler
  • Extremity doppler
  • Sphygmomanometer
  • Percussion hammer
  • Tuning fork
  • Tongue depressor
  • Weighing scale
  • Height wall ruler
  • Soft and sharp sterile objects
• Client identification. Before performing the physical assessment, the client must be properly identified using two identifiers:
  • First identifier. Ask the client to state their name and date of birth. Compare the given information on the client’s hospital wristband or the client’s chart. If the client cannot state their name and date of birth, the nurse may ask their caregiver or family member to identify them, then match the given information with the client’s wristband or chart.
  • Second identifier. To confirm the first identifier, the nurse may scan the client’s wristband or the client’s chart, ask staff to verify the client in a long-term care setting, compare the client’s picture on the medication administration record, or ask a family member or caregiver to identify them, if present.
• Cultural safety. When initiating client interaction, it is important to establish cultural safety. Cultural safety refers to the creation of safe spaces for clients to interact with health professionals without judgment or discrimination. Use an open-ended question if more information is needed about the client’s cultural beliefs to customize their care.

General Survey

A general assessment survey is a component of a client assessment that observes the entire client as a whole. General surveys begin with the initial client contact and continue throughout the helping relationship.

• Chief concerns. Asking about the client’s chief concern recognizes that clients are complex beings with potentially multiple coexisting needs. Aside from the mnemonics PQRSTU and SAMPLE, the nurse may also ask questions regarding the client’s main medical concern, or use open-ended questions to allow the client to explain further to improve the understanding of their health concerns. The nurse may ask the following questions to elicit the client’s chief concern:
  • “Please tell me what brought you in today.”
  • “Can you tell me how long this has been going on?”
  • “Please tell me what your main concerns are today since your admission.”
  • “How is this affecting you?”
  • “Have you noticed any improvements since you were admitted?”
  • “Do you have any symptoms currently?”
• Appearance. A general survey consists of using the senses to observe a client’s general appearance. A client may exhibit signs of distress or pain. The client should be observed if they appear at their stated age. Body type can reflect nutritional status, lifestyle choices, and medical conditions. The client’s overall cleanliness may adobe observed, including their hair, face, nails, and their odor. They may also express their mood through facial expressions, eye contact, or their affect. The client’s body movements, posture, gait, and range of motion should also be observed.
• Vital signs. Vital signs are typically obtained prior to performing a physical assessment. It includes temperature, pulse, respiratory rate, blood pressure, and oxygen saturation.
  • Temperature. Accurate temperature measurements provide information about a client’s health status and guide clinical decisions. Methods of measuring the body temperature may include oral, tympanic, axillary, and rectal routes. It is important to document the route used to obtain a client’s temperature because of normal variations in temperature in different locations of the body. Temperature can be expressed and recorded in Fahrenheit (℉) and Celsius (℃).
    • Oral temperature. The normal oral temperature is 35.8 to 37.3℃ (96.4 to 99.1℉). Oral temperature is reliable when it is obtained close to the sublingual artery, or when the thermometer is placed in the posterior sublingual pocket. The oral temperature should be taken 15 to 25 minutes following the consumption of a hot or cold beverage or food and 5 minutes after chewing gum or smoking to avoid alterations in the results.
    • Tympanic temperature. The tympanic temperature is typically 0.3 to 0.6℃ higher than an oral temperature. It is an accurate measurement because the tympanic membrane shares the same vascular artery that perfuses the hypothalamus. The tympanic thermometer should be turned on before placing the probe just inside the ear canal. The device beeps within a few seconds after the temperature is measured.
    • Axillary temperature. The axillary method is a minimally invasive way to measure temperature and is commonly used in children. It uses the same electronic device as an oral thermometer with blue coloring. The axillary temperature can be as much as 1℃ lower than the oral temperature.
    • Rectal temperature. Measuring the rectal temperature is an invasive method. When measuring infant temperature, this route is considered the gold standard because of its accuracy. The rectal temperature is usually 1℃ higher than the oral temperature. A rectal thermometer has red coloring to distinguish it from an oral/axillary thermometer.
  • Pulse or heart rate. Pulse or heart rate refers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It can be palpated at many points throughout the body. The most common locations include the radial, brachial, carotid, and apical pulse areas. The pulse is measured in beats per minute, and the normal adult pulse rate at rest is 6- to 100 beats per minute. Parameters for assessment of the pulse include its rate, rhythm, volume, amplitude, and rate of increase.
    • Rhythm. The pulse could be regular, irregular, or irregularly irregular. A normal pulse has a regular rhythm, meaning the frequency of the pulsation felt by the fingers is an even tempo with equal intervals between pulsations.
    • Rate. The pulse rate is counted with the first beat felt by the fingers as “one”. It is considered best practice to assess the client’s pulse for a full 60 seconds.
    • Volume. A low-volume pulse could be indicative of inadequate tissue perfusion; this can be a crucial indicator of indirect prediction of the systolic blood pressure of the client.
    • Pulse force or amplitude. The pulse force is the strength of the pulsation felt on palpation. Pulse force can range from absent to bounding. The volume of blood, the heart’s functioning, and the arteries’ elastic properties affect a client’s pulse force.
    • Equality. Pulse equality refers to a comparison of the pulse forces on both sides of the body. The radial and femoral pulse can be checked simultaneously. The carotid pulse, however, should never be palpated at the same time because this can decrease blood flow to the brain.
  • Respiratory rate. A respiratory cycle is one sequence of inspiration and expiration and is counted as one breath while measuring the respiratory rate. Respirations normally have a regular rhythm in children and adults who are awake. Normal respiratory rates vary based on the client’s age. The normal resting respiratory rate for adults is 10 to 20 breaths per minute, whereas infants younger than one-year-old normally have a respiratory rate of 30 to 60 breaths per minute.
  • Oxygen saturation. A client’s oxygen saturation is routinely assessed using pulse oximetry. SpO2 is an estimated oxygen level based on the saturation of hemoglobin measured by the pulse oximeter. The target range for SpO2 for an adult is 94 to 98%.
  • Blood pressure. Blood pressure is an essential vital sign to comprehend the hemodynamic condition of the client. The client should not have taken any caffeinated rink at least one hour before blood pressure testing and should not have smoked any nicotine products at least 15 minutes before. A full bladder also adds 10 mm Hg to the pressure readings. Blood pressure measurements can be obtained using a stethoscope and a sphygmomanometer or a blood pressure cuff. The blood pressure cuff is placed around a client’s extremity, and a stethoscope is placed over an artery for manual blood pressure readings. The blood pressure cuff is inflated at least 30 mm Hg above the point at which the radial pulse is no longer palpable. Normal adult blood pressure is less than 120/80 mm Hg.
• Pain level. Pain is a subjective experience, and self-report of pain is the most reliable indicator of a client’s experience. Determining pain is an important component of a physical assessment, and it is sometimes referred to as the “fifth vital sign”. The mnemonic PQRSTU or LOTTAARP (location, onset, timing, type, associated symptoms, alleviating factors, radiation, precipitating events) can be used to help guide pain assessment. Age-based rating scales can be used, such as visual analogs and the numerical scale. The Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) tool can be used for observational assessment in infants or young children. A body diagram map can be completed to fully assess the location of a client’s pain.
• Height, weight, and Body Mass Index (BMI). the height and weight can be used as a guide to reflect the client’s general health. Weight is routinely assessed during all healthcare visits, as well as height. Height may be documented in centimeters, meters, or feet, and weight may be documented in kilograms or pounds. BMI is a standardized reference range that is used to analyze the client’s weight status and provides a representation of body fat. BMI can be calculated using the formula kg/m² (weight in kilograms divided by height in meters squared).

Client History and Physical Assessment Guide

The client’s health history and physical examination are the starting points of interactions with clients. They lay the groundwork for building trust, understanding their unique needs, and devising individualized care plans. These are a nurse’s opportunity to connect with clients, showing empathy and respect. With practice, a nurse can become skilled in interpreting the signs and symptoms that shape the understanding of a client’s health status.

Comprehensive Health History

To collect detailed information about a client’s human response to illness and life processes, nurses perform a health history. A health history is part of the assessment phase of the nursing process. It consists of using directed, focused interview questions and open-ended questions to obtain symptoms and perceptions from the client about their illnesses, functioning, and life processes. While obtaining a health history, the nurse also simultaneously performs a general survey.

• Demographic data. Demographic and biographic data includes basic characteristics about the client, such as their name, contact information, birth date, age, gender and preferred pronouns, allergies, languages spoken and preferred language, relationship status, occupation, and resuscitation status.
• Present health concern. It is helpful to begin the health history by obtaining the reason why the client is seeking healthcare in their own words.  During a visit to a clinic or the emergency department or on admission to a healthcare agency, the client’s reasons for seeking care are referred to as the chief concerns. After the client has been admitted, the term ‘main health needs’ is used to classify what the client feels is most important at that time. After identifying the reason why the client is seeking healthcare, additional focused questions are used to obtain detailed information about this concern.
  • PQRSTU. This mnemonic is often used to ask the client questions in an organized manner, especially about pain.
    • Provocative/palliative (“What makes your pain worse?” or “What makes your pain feel better?”)
    • Quality (“What does the pain feel like?” e.g. aching, stabbing, burning or “What does the dizziness feel like?”)
    • Region/radiation (“Where exactly do you feel the pain? Does it move around or radiate elsewhere?” or “Where exactly do you feel the itching?”)
    • Severity (“How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain?” or “How would you rate your shortness of breath on a scale of 0 to 10, with 0 being no problem and 10 being the worst breathing issues?”)
    • Timing/treatment (“When did the pain start?” “Is the pain constant or intermittent?” or “How long does the pain last?”)
    • Understanding (“What do you think is causing the pain?” or “What do you think is causing the itching?”)
  • SAMPLE. This mnemonic is used to gather essential client history information to diagnose the client’s concerns and make treatment decisions.
    • Signs and symptoms
    • Allergies
    • Medications
    • Pertinent medical history
    • Last meal or oral intake
    • Events before the acute situation
• Current and past medical history. The client’s current and past medical histories are reviewed to obtain a full understanding of their human response to medical conditions and life processes. Categories included are current health, medications, childhood illnesses, chronic illnesses, acute illnesses, accidents, injuries, and obstetrical health for females. Medication reconciliation is a comparison of a list of current medications with a previous list and is completed at every hospitalization and clinic visit.
• Family health history. It is also important to understand the risk and likelihood of a client developing illnesses based on their family health because many diseases have a genetic component. The client may be asked about the health status, age, and, if applicable, the cause of death of immediate family members.
• Functional health, such as ADLs and IADLs. Functional health assessment collects data related to the client’s functioning and their physical and mental capacity to participate in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
  • ADLs are daily basic tasks that are fundamental to everyday functioning (e.g. hygiene, elimination, dressing, eating, and moving).
  • IADLs are more complex daily tasks that allow clients to function independently such as managing finances, paying bills, purchasing and preparing meals, managing one’s household, taking medications, and facilitating transportation.
• Cultural assessment. The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. This includes ethnic origin, languages spoken, the need for an interpreter, support system, decision-makers, living arrangements, religious practices, emotional responses, special food requirements or dietary considerations, and cultural customs or taboos.

Physical Assessment

The physical examination is typically the first measure performed after taking the client’s health history. It allows for an initial assessment of symptoms and is crucial for determining the diagnosis and interventions. Ideally, a complete physical examination should be performed for every client and must be tailored to specific concerns.

1. Neurological system

Nurses must be skilled in the general assessment of neurologic function and be able to focus on specific areas as needed. Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders.

• Health History
  The nurse may ask about any family history of genetic diseases, such as familial Alzheimer’s disease, Duchenne muscular dystrophy, or epilepsy. The nurse should also inquire about any history of trauma or falls that may have involved the head or spinal cord. The use of alcohol, medications, and illicit drugs is also a relevant component of the health history.
• Common Symptoms
  The symptoms of neurologic disorders are as varied as the disease processes. Symptoms may be subtle or intense, fluctuating or permanent, inconvenient or devastating. Common symptoms that may indicate a neurologic disorder include:
  • Acute or chronic pain
  • Seizures
  • Dizziness and vertigo
  • Visual disturbances
  • Muscle weakness
  • Abnormal sensation
• Assessing Consciousness and Cognition
  The nurse must observe the client’s mental status, intellectual function, thought content, and emotional status. These must be recorded to permit comparison over time.
  • Mental status. An assessment of the mental status begins by observing the client’s appearance and behavior, noting dress, grooming, and personal hygiene.
    • Postures, gestures, movements, and facial expressions often provide important information.
    • Assessing orientation to time, place, and person assists in evaluating mental status. Ask the client what day it is, what year, or the name of their country’s current president.
    • Assessment of immediate and remote memory is also important to determine the capacity for immediate memory and if it is still intact.
  • Intellectual function. Ask the client to count backward from 100 ir to subtract 7 from 100, then 7 from that, and so forth. Questions designed to assess this capacity may include the ability to recognize similarities.
  • Thought content. Preoccupation with death or morbid events, hallucinations, and paranoid ideation are examples of unusual thoughts or perceptions that require further evaluation.
  • Emotional status. Observe the client’s effect, whether it is natural and even, irritable, angry, anxious, flat, apathetic, or euphoric. Record whether nonverbal cues are consistent with verbal communication.
  • Language ability. The client with normal neurologic function can understand and communicate in spoken and written language. A deficiency in language function is called aphasia.
  • Level of consciousness. Consciousness is the client’s wakefulness and ability to respond to the environment. To assess for LOC, the nurse may observe for alertness and ability to follow commands. The nurse may also use the Glasgow-Coma Scale as an assessment tool.
• Cranial Nerve Testing
  An abnormality in the cranial nerve function helps in localizing the lesion to a specific level of the brain or brainstem. Cranial nerves have motor, sensory, and autonomic functions.
  • Cranial nerve I (olfactory nerve). Assess the client’s sense of smell by covering one nostril and letting the client smell and scent, and vice versa.
  • Cranial nerve II (optic nerve). Assessment of the optic nerve function includes a test for visual acuity and visual fields. Each eye is tested separately. The pupillary light reflex can be tested by shining a light directly into the eye. A commonly used abbreviation to describe normal pupils is PERRLA, or pupils equal, round, and reactive to light and accommodation. Visual acuity can be tested using a Snellen eye chart placed 20 feet away from the client. A fundoscopic examination is also done to visualize the optic disk.
  • Cranial nerves III, IV, and VI (oculomotor, trochlear, and abducens nerves). These are nerves for extraocular muscle movements. Draw an “H” in front of the client and ask them to follow with their eyes. The client should follow the target with their eyes, carefully keeping their head still. Any deviation should be noted.
  • Cranial nerve V (trigeminal nerve). Assessment of this nerve involves asking the client to clench their jaw and test for the sensation of the ophthalmic, maxillary, and mandibular branches. The sensory portions can be evaluated by lightly touching a blunt tip needle and a cotton swab or ball to the client’s face with their eyes closed. Have the client indicate whether the sensation is soft or sharp. Evaluate the corneal reflex by touching a cotton swab to the middle or lateral portion of the cornea gently.
  • Cranial nerve VII (facial nerve). Ask the client to move their facial muscles by raising their eyebrows, closing their eyes tightly, smiling, and blowing up their cheeks.
  • Cranial nerve VIII (vestibulocochlear nerve). Gross assessment of function can be done by whispering words behind the client, rubbing fingers or hair together close to the ear, and asking if the client can hear. Doing a Weber and Rinne test can differentiate sensorineural from conductive hearing loss.
  • Cranial nerves IX and X (glossopharyngeal and vagus nerves). Assessment of these nerves includes listening as the client talks and watching out for hoarseness, or nasal speech. The client can be asked to swallow some water and observe for coughing or gurgling speech. Ask the client to open the mouth and say “ah”, and observe the palatal arch asymmetry.
  • Cranial nerve XI (spinal accessory nerve). Assessment involves asking the client to turn their head to the side against resistance and shrug their shoulders.
  • Cranial nerve XII (hypoglossal nerve). Assessment involves inspection of the tongue in the relaxed position inside the mouth. Ask the client to stick out the tongue, the deviation to one side is indicative of a lesion on the same side.
• Motor Exam
  A thorough examination of the motor system includes an assessment of muscle size and tone as well as strength, coordination, and balance.
  • Motor ability. Ask the client to walk across the room, if possible, and observe for gait and posture. Inspect and palpate the muscles for size and symmetry. Muscle tone is evaluated by palpating various muscle groups at rest and during passive movement.
  • Muscle strength. Assessing the client’s ability to flex or extend the extremities against resistance tests muscle strength. The manual muscle testing is scored as:
    • 0 – None; No visible or palpable contraction
    • 1 – Trace; Visible or palpable contraction
    • 2 – Poor; Full ROM with gravity eliminated
    • 3 – Fair; Full ROM against gravity
    • 4 – Good; Full ROM against gravity with moderate resistance
    • 5 – Normal; Full ROM against gravity with maximum resistance
  • Balance and coordination. Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination.
    • Coordination in the hands and upper extremities is tested by having the client perform rapid, alternating movements and point-to-point testing. Ask the client to pat their thigh as fast as possible with each hand separately. Then, the client is instructed to alternately pronate and supinate the hand as rapidly as possible. Lastly, the client is asked to touch each of the fingers with the thumb in consecutive motion.
    • Coordination in the lower extremities is tested by having the client run the heel down the anterior surface of the tibia of the other leg, and then the opposite leg.
    • The Romberg test is a screening test for balance that can be done with the client seated or standing. The client can be seated or stand with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 seconds. The nurse stands close to support the standing client if they begin to fall.
• Sensory Exam
  The sensory system is even more complex than the motor system because sensory modalities are more widespread throughout the central and peripheral nervous systems.
  • Tactile sensation is assessed by lightly touching a cotton wisp or fingertip to corresponding areas on each side of the body.
  • Pain and temperature sensations are transmitted together. Determining the client’s sensitivity to a sharp object can assess superficial pain perception. The client may be asked to differentiate between the sharp and dull ends of a broken wooden cotton swab or tongue depressor.
  • Vibration may be evaluated through the use of a low-frequency tuning fork. The handle of the vibrating fork is placed against a bony prominence, and the client is asked if they feel a sensation and instructed to signal if the sensation ceases.
  • Proprioception may be determined by asking the client to close both eyes and indicate, as the great toe or index finger is alternately moved up and down, in which direction movement has taken place.
  • Assess for integration of sensation in the brain by using two-point discrimination. When the client is touched with two sharp objects simultaneously, are they perceived as two or as one?
• Deep Tendon Reflexes
  A reflex hammer is used to elicit a deep tendon reflex. The extremity is positioned so that the tendon is slightly stretched. The assessment can be done by tapping a specific tendon with the reflex hammer and observing for a reflex muscle contraction.
  • Babinski reflex. This involves stimulation of the lateral plantar aspect of the foot. The presence of an upgoing big toe indicates a positive result.
  • Chaddock reflex. The stimulation of the lateral aspect of the foot.
  • Oppenheim reflex. Stroking the anterior and medial tibia downward.
  • Gordon reflex. Squeezing the calf muscle. The presence of an upgoing big toe indicates a positive response.
  • Hoffman reflex. This can be done by flicking the distal digit of the middle finger with the positive response being the involuntary flexion of the other fingers, including the thumb.
  • Biceps reflex. This is elicited by striking the biceps tendon over a slightly flexed elbow.
  • Triceps reflex. The client’s arm is flexed at the elbow and hanging freely at the side. A direct blow to the tendon normally produces contraction of the triceps muscle and extension of the elbow.
  • Brachioradialis reflex. With the client’s forearm resting on the lap or across the abdomen, the brachioradialis reflex is assessed. A gentle strike of the hammer above the wrist results in flexion and supination of the forearm.
  • Patellar reflex. This is elicited by striking the patellar tendon just below the patella. Contractions of the quadriceps and knee extension are normal responses.
  • Achilles reflex. The foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon. This normally produces plantar flexion.

2. Head, eyes, ears, nose, and throat (HEENT)

Most physical assessments may start with the head, eyes, ears, nose, and throat. The client is positioned sitting upright which then allows the nurse to systematically work down through each of the body systems.

• Health History
  Begin the assessment by asking focused interview questions to determine if the client is currently experiencing any symptoms or has a previous medical history related to head, eyes, ears, neck, and throat issues.
• Inspection
  • Inspecting the Head
    • Inspect the head and face for symmetry.
    • Inspect the hair for color, distribution, and texture.
    • Inspect for flaking, lesions, and deformities.
  • Inspecting the Eyes
    • Note the position and alignment of the eyes and the presence of discharge, irritation, and redness.
    • Observe the eyelids. Check for drooping of the upper eyelids. Check the strength of the upper eyelids by having the client squeeze their eyes shut.
    • Inspect the sclera and conjunctiva of each eye.
    • Inspect each cornea, iris, and lens, checking for transparency.
  • Inspecting the Ears
    • Examine each arousing an otoscope. Gently pull the pinna of the ear up and back to straighten the external canal.
    • Inspect the external canal for color, drainage, cerumen build-up, canal edema, erythema, or masses.
    • Assess the tympanic membrane for color, shape, transparency, integrity, bulging, and scarring.
    • Test auditory acuity in each ear with the whisper test. Stand two feet behind the client and occlude the non-test ear with a finger. Whisper a combination of three words of numbers and letters and ask the client to repeat them back.
  • Inspecting the Nose
    • Inspect the external nose for color, size, shape, symmetry, and presence of drainage, tenderness, and masses.
    • Inspect the nasal passages for patency, nasal mucosa for color, nasal septum for deviation, and turbinates for color and swelling. Use a penlight and nasal speculum or otoscope.
    • Check the patency of each nare by asking the client to occlude one nare and breathe through the other, then vice versa.
  • Inspecting the Throat
    • Inspect the lips for color, moisture, masses, cracks, sores, fissures, and symmetry.
    • Inspect the oral mucosa for color, lesions, dryness/moisture, masses, and swelling.
    • Inspect the tongue for color, thickness, moisture, symmetry of movement from left to right, and deviations from the midline.
    • Inspect the teeth for their general condition and evaluate if any tooth is missing.
    • Inspect the gums for color, texture, swelling, retraction, and bleeding.
    • Inspect the uvula for movement, position, size, symmetry, and color.
    • Inspect the pharynx (hard and soft palate) for color, redness, inflammation, exudate, masses, and lesions.
    • Inspect the tonsils for size, color, inflammation, and exudate.
    • Inspect the salivary glands for patency and signs of inflammation or redness.
    • Check the client’s ability to swallow and their gag reflex.
  • Inspecting the Neck
    • Check neck muscles for symmetry, masses, swelling, and range of motion.
    • Assess the head and neck for a range of motion.
    • Check the trapezius muscle strength by asking the client to shrug their shoulders against the nurse’s hands as resistance is applied.
    • Check cervical muscle strength; ask the client to turn their chin or jaw against the nurse’s hand.
    • Assess the trachea for deviations.
• Palpation
  • Palpate the scalp and skull for tenderness.
  • Palpate the frontal and maxillary sinuses for tenderness and for signs of infection.
  • Palpate cervical lymph nodes for signs of swelling or tenderness. Cervical lymph nodes should not be fixed or palpable. Lymph nodes should be small and freely moving.
  • Evaluate the thyroid gland, noting enlargement or the presence of nodules and masses. It should be smooth.

3. Integumentary system

Assessment of the skin, hair, and nails is part of a routine head-to-toe assessment completed by nurses. During inpatient care, a comprehensive skin assessment on admission establishes a baseline for the condition of a client’s skin and is essential for developing a care plan for the prevention and treatment of skin injuries.

• Health History
  During health history, the nurse asks about the use of hair and skin products, as well as any family and personal history of skin allergies; allergic reactions to food, medications, and chemicals; previous skin conditions; and skin cancer. The client is also asked about nonprescription or herbal preparations that are being used. The names of cosmetics, soaps, shampoos, and other personal hygiene products are obtained if there have been any recent skin conditions noticed with the use of these products.
• Inspection
  • Color. Inspect the color of the client’s skin and compare findings to what is expected for their skin tone. Note a change in skin coloration such as pallor, cyanosis, jaundice, or erythema. Not for ecchymosis or bruising.
  • Scalp. If the client reports itching of the scalp, inspect the scalp for lice and/or nits.
  • Lesions and skin breakdown. Note any lesions, skin breakdowns, or unusual findings, such as rashes, petechiae, unusual moles, or burns.
  • Rash. Point a penlight laterally across the skin to highlight the rash, making it easier to observe. The skin is stretched gently to decrease the reddish tone and make the rash more visible. The client’s mouth and ears are included in the examination.
  • Nails. A brief inspection of the nails includes observation of configuration, color, and consistency. Beau lines, a transverse depression in the nails, may reflect retarded growth of the nail matrix. Ridging, hypertrophy, and other changes may also be visible because of local trauma. Spoon-shaped nails are indicative of severe iron deficiency anemia.
  • Hair. The hair is separated so that the condition of the skin underneath can be easily seen. The nurse notes the color, texture, and distribution of hair shafts.
• Palpation
  • Temperature. Fever decreased perfusion of the extremities, and local inflammation in tissues can cause changes in skin temperature. Instruct the client not to hold anything warm or cold in their hands for several minutes prior to palpation.
  • Moisture. Assess if the skin feels dry or moist and the texture of the skin. Skin that appears or feels sweaty is referred to as being diaphoretic.
  • Capillary refill. Pressure is applied to a fingernail or toenail until it turns white, indicating that the blood has been forced from the tissue under the nail. If there is sufficient blood flow to the area, a pink color should return within two seconds after the pressure is removed.
  • Skin turgor. Gently grasp the skin on the client’s lower arm between two fingers so that it is tented upwards, and then release. Skin with normal skin turgor snaps rapidly to return to its normal position.
  • Edema. If edema is present on inspection, palpate the area to determine if the edema is pitting or nonpitting. Press on the skin for indentation, ideally over a bony structure, such as the tibia.

4. Cardiovascular system

The evaluation of the cardiovascular system includes a thorough medical history and a detailed examination of the heart and the peripheral vascular system. Understanding how to properly assess the cardiovascular system and identifying both normal and abnormal findings will allow the nurse to provide quality and safe care to the client.

• Health History
  During the health history, the nurse determines if the client and involved family members are able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome or heart failure, and seek timely treatment of these symptoms. All too often a client’s new symptoms or those of progressing cardiac dysfunction go unrecognized. This results in prolonged delays in seeking life-saving treatment.
• Common Symptoms
  The signs and symptoms commonly experienced by clients with cardiovascular disorders are related to dysrhythmias and conduction problems.
  • Chest pain or discomfort
  • Pain or discomfort in other areas of the upper body, such as the arms, back, neck, jaw, or stomach
  • Shortness of breath or dyspnea
  • Peripheral edema
  • Weight gain
  • Abdominal distention or ascites
  • Palpitations or tachycardia
  • Unusual fatigue
  • Dizziness, syncope, or changes in the level of consciousness
• Inspection
  • Skin color. Inspect the face, lips, and fingertips for cyanosis or pallor.
  • Jugular vein distention (JVD). inspect the neck for JVD which occurs when the increased pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on the right side of the client’s neck. JVD should not occur in an upright position or when the head of the bed is at 30 to 45 degrees.
  • Precordium. Inspect the chest area over the heart (precordium) for deformities, scars, or any abnormal pulsations produced by the underlying heart chambers and great vessels. An apical impulse is a normal finding observed in young clients and adults who have thin chest walls.
  • Upper extremities. Inspect the fingers, arms, and hands bilaterally noting color, warmth, movement, and sensation.
  • Lower extremities. Inspect the toes, feet, and legs bilaterally noting color, warmth, movement, and sensation, and the presence of peripheral edema, superficial distended veins, and hair distribution.
  • Peripheral edema. Note any presence of edema, such as peripheral edema in the feet, ankles, or legs. Edema can be observed in the sacral area of clients on bed rest.
  • Deep vein thrombosis (DVT). inspect the lower extremities bilaterally for size, color, temperature, and for the presence of pain in the calves. Unilateral warmth, redness, tenderness, swelling in the calf, or sudden onset of intense, sharp muscle pain that increases with dorsiflexion of the foot is an indication of DVT.
  • 6 P’s. Signs and symptoms of acute obstruction of arterial blood flow in the extremities, referred to as the 6 P’s are pain, pallor, pulselessness, paresthesia, poikilothermia, and paralysis. These signs may typically occur during the first few hours after invasive cardiac procedures.
• Palpation
  • Capillary refill. Assess capillary refill by compressing the nail bed until it blanches and record the time taken for the color to return to the nail bed. Normal capillary refill is less than three seconds.
  • Pulses. Compare the rate, rhythm, and quality of arterial pulses bilaterally, including the carotid, radial, brachial, posterior tibialis, and dorsalis pedis pulses. Bilateral comparison for all pulses, except the carotid pulse, is important for determining subtle variations in pulse strength. Carotid pulses should be palpated on one side at a time to avoid decreasing perfusion of the brain. Only light palpation is essential; firm pressure can obliterate the temporal, dorsalis pedis, and posterior tibial pulses.
  • Pulse quality. The quality of the pulse is graded on a scale of 0 to 3, with 0 being absent pulses, 1 being decreased pulses, 2 within normal range, and 3 as increased or bounding pulses. The use of a Doppler ultrasound can determine the presence or absence of a pulse that cannot be palpated.
  • Pitting edema. The nurse may use the thumb to place firm pressure over the dorsum of each foot, behind each medial malleolus, and over the shins or sacral area for five seconds. This helps assess for pitting edema. Pitting edema is graded as absent (0) or as present on a scale from slight (1+ = up to 2 mm) to very marked (4+ = more than 8 mm).
  • Precordium. After inspection of the precordium, it is then palpated. Precordial movements can be palpated at the apex or the mitral area. The nurse uses the palm of the hand to locate the apical impulse initially and the finger pads to assess its size and quality. Palpation of the apical pulse may be facilitated by repositioning the client to the left lateral position, which puts the heart in closer contact with the chest wall.
  • Thrills. A vibration or purring sensation may be felt over areas where abnormal, turbulent blood flow is present. It is best detected by using the palm of the hand. This vibration is called a thrill and is associated with a loud murmur.
• Auscultation     
  • A stethoscope is used to auscultate for heart sounds. It should have both the diaphragm and the bell functions for accurate auscultation of the chest.
  • The client remains supine during the auscultation.
  • The nurse may start at the apical area using the diaphragm of the stethoscope and progress upward along the left sternal border to the pulmonic and aortic areas.
  • Alternatively, the examiner may begin at the aortic and pulmonic areas and progress downward to the apex of the heart.
  • Initially, the intensity and splitting of S1 are identified and evaluated. Then, the intensity and splitting of S2 is noted.
  • After the S1 and S2, the nurse may listen for extra sounds in systole and then in diastole.
  • Normal heart sounds. These are referred to as the S1 and S2 and are produced by the closure of the AV valves and the semilunar valves.
    • S1 (first heart sound). Tricuspid and mitral valve closure create the first heart sound, “lub”, or S1. This is usually heard the loudest in the apical area.
    • S2 (second heart sound). Closure of the pulmonic and aortic valves produces the second heart sound, commonly referred to as the “dub” sound. The aortic component of S2 is heard loudest over the aortic and pulmonic areas; however, the pulmonic component is a softer sound and is heard best over the pulmonic area.
  • Abnormal heart sounds. Abnormal heart sounds develop during systole or diastole when structural or functional heart problems are present. These are called S3 or S4 gallops, opening snaps, systolic clicks, and murmurs.
    • S3 (third heart sound). An S3 (“DUB”) is heard early in diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. It is heard immediately after S2 and is best heard using the bell of the stethoscope. This is a normal finding or a physiologic S3 in children and adults up to 35 or 40 years old. In older adults, an S3 may suggest heart failure.
    • S4 (fourth heart sound). S4 (“LUB”) occurs late in diastole. S4 is heard just before S1 is generated during atrial contraction as blood forcefully enters a noncompliant ventricle. This may be caused by hypertension, coronary artery disease, cardiomyopathies, aortic stenosis, and numerous other conditions.
    • Opening snaps. Opening snaps are abnormal diastolic sounds heard during the opening of an AV valve. This can be caused by mitral stenosis. The unusually high-pitched, snapping quality of the sound differentiates it from an S3. it is best heard using the diaphragm of the stethoscope placed medial to the apical area and along the lower left sternal border.
    • Systolic clicks. A systolic click is created due to stenosis of one of the semilunar valves, producing a short, high-pitched sound in early systole, immediately after S1. These clicks can be caused by mitral or tricuspid valve prolapse and are loudest in the areas directly over the malfunctioning valve.
    • Murmurs. Murmurs are created by the turbulent flow of blood in the heart. The causes may be a critically narrowed valve, a malfunctioning valve that allows regurgitant blood flow, a congenital defect of the ventricular wall, a defect between the aorta and the pulmonary artery, or an increased blood flow through a normal structure. Murmurs produce a rumbling, blowing, whistling, harsh, or musical sound.
    • Friction rub. A harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A pericardial friction rub can be heard best using the diaphragm of the stethoscope, with the client sitting up and leaning forward.

5. Respiratory system

The assessment of the respiratory system includes collecting subjective and objective data through a detailed interview and physical examination of the thorax and lungs. This assessment can offer significant clues related to issues associated with the body’s ability to obtain adequate oxygen to perform daily functions.

• Health History
  The health history initially focuses on the client’s presenting problem and associated symptoms. The nurse should explore the onset, location, duration, character, aggravating and alleviating factors, radiation, and timing of the presenting problem and associated signs and symptoms. The nurse should also explore how these factors impact the client’s activities of daily living, usual work and family activities, and quality of life.
• Common Symptoms
  The major signs and symptoms of respiratory diseases include:
  • Dyspnea
  • Cough
  • Sputum production
  • Chest pain
  • Wheezing
  • Hemoptysis
• Inspection
  • Nose. The nurse inspects the external nose for lesions, asymmetry, or inflammation. Then, the internal structures of the nose are examined, and the nasal mucosa for color, swelling, exudate, or bleeding. The septum is inspected for deviation, perforation, or bleeding. The nurse also inspects the inferior and middle turbinates.
  • Mouth and pharynx. The nurse assesses the mouth and the pharynx, instructing the client to open the mouth wide and take a deep breath. The nurse inspects these structures for color, symmetry, and evidence of exudate, ulceration, or enlargement. A tongue depressor may be used to visualize the pharynx by firmly pressing it beyond the midpoint of the tongue.
  • Thorax. The nurse observes the skin over the thorax for color and turgor and for evidence of loss of subcutaneous tissue. It is important to note asymmetry, if present. In locating the thoracic landmarks, location is defined by lobe.
    • Horizontally, thoracic locations are identified according to their proximity to the rib or the intercostal space under the nurse’s fingers.
    • For vertical reference points, the midsternal line passes through the center of the sternum, the midclavicular line is an imaginary line that descends from the middle of the clavicle, and the point of maximal impulse normally lies along this line on the left thorax.
  • Breathing pattern. Observe the breathing pattern, including the rhythm, effort, and use of accessory muscles. Breathing effort should be non-labored and in a regular rhythm. Observe the depth of respiration and note if the respiration is shallow or deep.
    • Eupnea. This is normal breathing at 14 to 20 breaths per minute.
    • Bradypnea. This is slower than normal breathing (<10 breaths per minute), with normal depth and regular rhythm.
    • Tachypnea. This is rapid, shallow breathing >24 breaths per minute.
    • Hypoventilation. This refers to shallow, irregular breathing.
    • Hyperpnea. This refers to the increased depth of respirations.
    • Hyperventilation. An increased rate and depth of breathing results in decreased PaCO2 level. The inspiration and expiration are nearly equal in duration. It is also called Kussmaul’s respiration if associated with diabetic ketoacidosis or renal origin.
    • Apnea. These are periods of cessation of breathing. The time duration varies; apnea may occur briefly during other breathing disorders.
    • Cheyne-stokes. These are regular cycles where the rate and depth of breathing increase, then decrease until apnea (usually about 20 seconds) occurs.
    • Biot’s respiration. This occurs as normal periods of breathing ( 3 to 4 breaths), followed by a varying period of apnea (usually 10 to 60 seconds). It is also called ataxic breathing and is associated with complete irregularity.
    • Obstructive. This occurs with a prolonged expiratory phase of respiration and is associated with airway narrowing.
  • Pattern of expiration. Clients who experience difficulty expelling air, such as those with emphysema, may have prolonged expiration cycles.
  • Skin coloration. Observe the client’s color in their lips, face, hands, and feet. Clients with light skin tones should be pink in color. For those with darker skin tones, assess for pallor on the palms, conjunctivae, or the inner aspect of the lower lip.
    • Cyanosis. Cyanosis is the bluish coloring of the skin, which is a very late indicator of hypoxia. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin. Peripheral cyanosis results from decreased blood flow to the body’s periphery, as in vasoconstriction from exposure to cold.
    • Pallor. Pallor is the loss of color, or paleness of the skin or mucous membranes and is usually the result of reduced blood flow, oxygenation, or decreased number of red blood cells.
  • Chest configuration. Inspect the chest configuration. Note the location of the ribs, sternum, clavicle, and scapula, as well as the underlying lobes of the lungs. Observe the anterior-posterior diameter of the client’s chest and compare it to the transverse diameter. The expected ratio should be 1:2.
    • Barrel chest. A client with a 1:1 ratio is described as barrel-chested, often seen with chronic obstructive pulmonary diseases (COPD) and emphysema.
    • Funnel chest (pectus excavatum). Funnel chest occurs when there is a depression in the lower portion of the sternum this may occur with rickets or Marfan syndrome.
    • Pigeon chest (pectus carinatum). A pigeon chest occurs as a result of the anterior displacement of the sternum, which also increases the anteroposterior diameter. This may occur with rickets, Marfan syndrome, or severe kyphoscoliosis.
    • Kyphoscoliosis. Kyphosis, an outward curvature of the spine, may be seen in older adults due to changes in their anatomy. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. It may occur with osteoporosis and other skeletal disorders that affect the thorax.
  • Chest symmetry. The trachea should be midline, and the clavicles should be symmetrical. Note the location of the ribs, sternum, clavicle, and scapula, as well as the underlying lobes of the lungs. Chest movement should be symmetrical on inspiration and expiration.
  • Clubbing of fingernails. Inspect the fingers for clubbing if the client has a history of chronic respiratory disease. Clubbing is a bulbous enlargement of the tips of the fingers due to chronic hypoxia.
  • Use of accessory muscles. The nurse should observe the use of accessory muscles, such as the sternocleidomastoid, scalene, and trapezius muscles during inspiration, and the abdominal and internal intercostal muscles during expiration.
• Palpation
  • Sinuses. The nurse may palpate the frontal and maxillary sinuses for tenderness. Using the thumbs, the nurse applies gentle pressure in an upward fashion at the supraorbital ridges (frontal sinuses) and in the cheek area adjacent to the nose (maxillary sinuses).
  • Trachea. The position and mobility of the trachea are noted by direct palpation, this is done by placing the thumb and the index finger of one hand on either side of the trachea just above the sternal notch. The trachea is highly sensitive, and palpating too firmly may trigger a coughing or gagging response.
  • Thorax. The nurse palpates the thorax for tenderness, masses, lesions, respiratory excursion, and vocal fremitus. If the client has reported an area of pain or if lesions are apparent, the nurse performs direct palpation with the fingertips or with the ball of the hand.
    • Respiratory excursion is an estimation of thoracic expansion. The nurse assesses for range and symmetry of excursion. For anterior assessment, the nurse places the thumbs along the costal margin of the chest wall and instructs the client to inhale deeply. The nurse observes the movement of the thumbs during inspiration and expiration, which is usually symmetric. Posterior assessment is done by placing the thumbs adjacent to the spinal column at the level of the 10th rib. Then the client is asked to inhale and exhale fully.
    • Tactile fremitus.  This describes the vibrations of the chest wall that result from speech detected on palpation. Fremitus is more pronounced where the targe bronchi are closest to the chest wall, is more prominent on the right side, and is least palpable over the lower lung fields. The client may be asked to repeat “ninety-nine” or “one, one, one” as the nurse’s hands move down the client’s thorax.
    • Crepitus. This feels like a popping or crackling sensation when the skin is palpated and is a sign of air trapped under the subcutaneous tissues.
• Percussion
  • Thorax. Percussion usually begins with the posterior thorax. The nurse percusses across each shoulder top. Locating the 5-cm width of resonance overlying the lung apices. Then the nurse proceeds down the posterior thorax. To perform percussion, the middle finger of the nondominant hand is firmly placed against the area of the chest wall to be percussed. The distal interphalangeal joint of this finger is struck with the tip of the middle finger of the dominant hand. Percussion occurs in a smooth, dart-like fashion.
  • Diaphragmatic excursion. To assess the position and motion of the diaphragm, the nurse instructs the client to take a deep breath and hold it while the maximal descent of the diaphragm is percussed. The client is then asked to exhale fully and hold it while the nurse again percusses downward to the dullness of the diaphragm.
• Auscultation
  • Thorax. The nurse auscultates for normal breath sounds, adventitious breath sounds, and voice sounds. The nurse places the diaphragm of the stethoscope firmly against the bare skin of the chest wall as the client breathes slowly and deeply through the mouth. Auscultation is done in a systemic fashion from the apices to the bases and along the midaxillary lines.
    • Breath sounds. Normal breath sounds are distinguished by their location over a specific area of the lung and are identified as vesicular, bronchovesicular, and bronchial breath sounds.

• • • • Vesicular. These are soft and relatively low inspiratory sounds that last longer than expiratory ones. They can be heard over the upper sternum and between the scapulae.

• • • • Bronchovesicular. These are intermediate inspiratory and expiratory sounds that are equal in duration. They are often heard in the 1st and 2nd interspaces anteriorly and between the scapulae or over the main bronchus.

• • • • Bronchial. These are loud and relatively high expiratory sounds that last longer than the inspiratory ones and can be found over the manubrium if at all heard.

• • • • Tracheal. These are very loud and relatively high inspiratory and expiratory sounds that are about equal in duration and heard over the trachea in the neck.

• • • Adventitious sounds. An abnormal condition that affects the bronchial tree and alveoli may produce adventitious sounds.

• • • • Crackles (in general). These are soft, high-pitched, discontinuous popping sounds that occur during inspiration.

• • • • Coarse crackles. Discontinuous popping sounds were heard in early inspiration. They are harsh, moist sounds that originate from the large bronchi.

• • • • Fine crackles (rales). These are discontinuous popping sounds heard in late inspiration. They sound like hair rubbing together and originates in the alveoli.

• • • • Wheezes. These are usually heard on expiration but may be heard on inspiration depending on the cause.

• • • • Rhonchi or sonorous wheezes. These are deep, low-pitched rumbling sounds heard primarily during expiration and are caused by air moving through narrowed tracheobronchial passages.

• • • • Sibilant wheezes. Continuous, musical, high-pitched, whistle-like sounds are heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways.

• • • • Stridor. This is heard only on inspiration. It is associated with mechanical obstruction at the level of the trachea or upper airway.

• • • • Pleural friction rub. These are harsh, crackling sounds. Like two pieces of leather being rubbed together. They are heard during inspiration alone or during both inspiration and expiration. They are best heard over the lower lateral anterior surface of the thorax.

• • • Voice sounds. The sounds heard through the stethoscope as the client speaks are known as vocal resonance. The nurse should assess voice sounds when abnormal breath sounds are auscultated. Voice sounds are evaluated by having the client repeat “ninety-nine” or “eee” while the nurse listens with the stethoscope.

• • • • Bronchophony. This describes vocal resonance that is more intense and clearer than normal.

• • • • Egophony. This describes voice sounds that are distorted. It is best appreciated by having the client repeat the letter E.

• • • • Whispered pectoriloquy. This describes the ability to clearly and distinctly hear whispered sounds that should not normally be heard.

6. Abdomen/Gastrointestinal system

A thorough assessment of the abdomen provides valuable information regarding the function of the client’s gastrointestinal system. The GI system is responsible for the ingestion of food and the absorption of nutrients. During assessment, the nurse collects subjective and objective data regarding underlying structures and the normal functioning of the GI system.

• Health History
  A focused GI assessment begins with a complete history. Information about abdominal pain, dyspepsia, gas, nausea, vomiting, diarrhea, constipation, fecal incontinence, jaundice, and previous GI disease is obtained. The nurse may ask about the client’s normal toothbrushing and flossing routine; frequency of dental visits; awareness of any lesions or irritated areas in the mouth, tongue, or throat; recent history of sore throat or bloody sputum; discomfort caused by certain foods; daily food intake; the use of alcohol and tobacco, including smokeless chewing tobacco; and the need to wear dentures or a partial plate.
• Common Symptoms
  • Abnormal pain
  • Dyspepsia or abdominal discomfort
  • Intestinal gas
  • Nausea and vomiting
  • Change in bowel habits and stool characteristics
• Inspection
  • Lips. The examination begins with an inspection of the lips for moisture, hydration, color, texture, symmetry, and the presence of ulcerations or fissures. The client is instructed to open the mouth wide for the assessment of color and lesions in the buccal mucosa.
  • Gums. The gums are inspected for inflammation, bleeding, retraction, and discoloration. The odor of the breath is also noted. The hard palate is examined for color and shape.
  • Tongue. The dorsum or back of the tongue is inspected for texture, color, and lesions. The client is instructed to protrude the tongue and move it laterally so that the nurse can estimate the tongue’s size as well as its symmetry and strength. A tongue blade may be used to depress the tongue for adequate visualization of the pharynx.
  • Abdomen. Inspection of the abdomen may require mapping methods, such as the four-quadrant method which involves the use of an imaginary line drawn vertically and horizontally. Place the client in a supine position with the head and knees supported with small pillows or folded sheets. The client’s arms must be at their side and not folded behind the head as this tenses the abdominal wall. Inspection is performed first, noting skin changes, nodules, lesions, scarring, discolorations, inflammation, bruising, or striae. The contour and symmetry of the abdomen are noted, and any localized bulging, distention, or peristaltic waves are identified.
  • Bowel elimination. Assess the client’s bowel movement and output, noting for unusual stool characteristics if applicable:
    • Diarrhea. An abnormal increase in the frequency and liquidity of the stool or in daily stool weight or volume. This commonly occurs when the contents move so rapidly through the intestines and colon that there is inadequate time for the GI secretions and oral contents to be absorbed.
    • Constipation. A decrease in the frequency of stool, or stools that are hard, dry, and of smaller volume than typical.
    • Melena. If blood is shed in sufficient quantities into the upper GI tract, it produces a tarry-black color.
    • Hematochezia. Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red.
    • Steatorrhea. This refers to pale, bulky, and very offensive-smelling stools. It is often frothy, floats and takes several attempts to be flushed away. This indicates malabsorption of fats.
• Auscultation. Auscultation always precedes percussion and palpation, because they may alter the bowel sounds. Auscultation is used to determine the character, location, and frequency of bowel sounds and to identify vascular sounds. Bowel sounds are assessed using the diaphragm of the stethoscope for soft clicks and gurgling sounds. Borborygmi is heard as a loud prolonged gurgle.
  • Normal bowel sounds. These are heard about every 5 to 20 seconds.
  • Hypoactive bowel sounds. One or two sounds may be heard in two minutes.
  • Hyperactive bowel sounds. Five to six sounds may be heard in less than 30 seconds.
  • Absent bowel sounds. No sounds may be heard in three to five minutes.
• Percussion. Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, solid masses. All quadrants are percussed for overall tympani and dullness. Tympani is the sound that results from the presence of air in the stomach and small intestines; dullness is heard over organs and solid masses.
• Palpation. The use of light palpation is appropriate for identifying areas of tenderness or muscular resistance, and deep palpation is used to identify masses. Testing for rebound tenderness is not performed by many examiners because it can cause severe pain.
  • Guarding. This refers to the voluntary contraction of the abdominal wall musculature, usually the result of fear, anxiety, or the touch of cold hands.
  • Rigidity. This refers to the involuntary contraction of the abdominal musculature in response to peritoneal inflammation.
  • Rebound tenderness. This is another sign of peritoneal inflammation or peritonitis. The nurse maintains pressure over an area of tenderness and then withdraws the hand abruptly.
• Rectal inspection and palpation. The final part of the examination is the evaluation of the terminal portions of the GI tract, the rectum, the perianal region, and the anus.
  • Positions for the rectal examination include knee-chest, left lateral with hips and knees flexed, or standing with hips flexed and upper body supported by the examination table.
  • Gloves, water-soluble lubrication, a penlight, and drapes are necessary tools for the evaluation.
  • The external examination includes inspection for lumps, rashes, inflammation, excoriation, tears, scars, pilonidal dimpling, and tufts of hair at the pilonidal area.
  • Carefully spread the client’s buttocks for visual inspection until the client has relaxed the external sphincter control.
  • Ask the client to bear down to allow the appearance of fistulas, fissures, rectal prolapse, polyps, and internal hemorrhoids.
  • For rectal palpation, an internal examination is done with a gloved, lubricated index finger inserted into the anal canal while the client bears down.
  • Note the tone of the anal sphincter, as well as any nodules or irregularities of the anal ring.

7. Musculoskeletal system

An assessment of the musculoskeletal system includes collecting data regarding the structure and movement of the body, as well as the client’s mobility. The purpose of a routine physical examination of the musculoskeletal system by the nurse is to assess function and screen for abnormalities.

• Health History
  The nursing assessment of a client with musculoskeletal dysfunction includes a health history and physical examination that evaluates the effects of the musculoskeletal disorder on the client. The nurse should address problems associated with immobility and advocate for evidence-based periodic musculoskeletal health screenings. Information during the subjective assessment should be compared to expectations for the client’s age group or the client’s baseline. Any previous history of trauma or injury to the musculoskeletal system or a history of falls should be included as well.
• Common Symptoms
  A client with a musculoskeletal disorder may report the following common signs and symptoms during physical assessment:
  • Pain (bone, muscular, fracture, or joint pain)
  • Tenderness
  • Altered sensations
• Inspection
  • Posture. The normal curvature of the spine is convex through the thoracic portion and concave through the cervical and lumbar portions. Common deformities of the spine include:
    • Kyphosis. This is an increased forward curvature of the thoracic spine that causes a bowing or rounding of the back, leading to a hunchback or slouching posture.
    • Lordosis. Also called swayback, this is an exaggerated curvature of the lumbar spine. Lordosis can affect persons of any age.
    • Scoliosis. This is a lateral curving deviation of the spine. Scoliosis may be congenital, idiopathic, or the result of damage to the paraspinal muscles.
  • Spine. During the inspection of the spine, the entire back, buttocks, and legs are exposed. The nurse inspects the spinal curves and trunk symmetry from posterior and lateral views. The nurse also notes any differences in the height of the shoulders or iliac crests. Shoulder and hip symmetry, as well as the line of the vertebral column, is inspected with the client erect and with the client bending forward.
  • Gait. Gait is assessed by having the client walk away from the nurse for a short distance. Observe the client’s gait for smoothness and rhythm.
    • Antalgic gait. This refers to an abnormal pattern of walking secondary to pain that ultimately causes a limp, whereby the stance phase is shortened relative to the swing phase.
    • Vaulting gait. This is common in children with limb discrepancy.
    • Trendelenburg gait. The pelvis drops to the unaffected side.
    • Steppage gait. The client is unable to strike their heel causing initial contact with toes (foot drop)
    • Waddling gait. This refers to toe walking with a posterior lurch and bilateral Trendelenburg gait.
    • Ataxic gait. The client shows a broad-based, unsteady gait.
    • Hemiparetic gait. Gait is slow, with a broad base, and the knees and hips are extended. During the swing phase, the paretic leg performs a lateral movement.
    • Festinating or shuffling gait. Short-stepped, hurrying gait, with weak arm swing, or naturally very slow arm swing. Some clients may exhibit freezing and slow turning.
    • Paraspastic gait. The gait may appear stiff and insecure, narrow-based, stiff, and toe-scuffing.
  • Bone integrity. The bony skeleton is assessed for deformities and alignment. Symmetric parts of the body, such as the extremities, are compared. If the client has a fracture, the nurse should observe for the following:
    • Assess the overall appearance of the affected and unaffected extremities.
    • Observe if the client can move the affected part if it has a normal sensation, motion, and temperature.
    • Assess the color of the part distal to the affected area (pale, dusky, mottled, or cyanotic).
    • Assess if the capillary refill rapidly occurs.
    • Assess for the presence of a pulse distal to the affected area. Compare with the pulse in the unaffected extremity.
    • Assess for the presence of edema.
    • Note for any constrictive device or clothing causing nerve or vascular compression.
    • Observe for any alteration in the symptoms when the affected part is elevated or its position is modified.
  • Joint function. The articular system is evaluated by noting the range of motion, deformity, stability, tenderness, and nodular formation.
    • Range of motion. Precise measurement of the range of motion can be made by a goniometer. A limited range of motion may be the result of skeletal deformity, joint pathology, or contracture.
    • Effusion. If the joint motion is compromised or the joint is painful, the joint is examined for effusion or excessive fluid within the capsule, swelling, and increased temperature. The most common site for joint effusion is the knee.
    • Deformity. Joint deformity may be caused by contracture, dislocation, subluxation, or disruption of structures surrounding the joint.
• Palpation
  • Joint. Palpation of the joint, while it is moved passively, provides information about the integrity of the joint. Normally, the joint moves smoothly. A snap or crack may indicate that a ligament is slipping over a bony prominence.
  • Nodule formation. The tissues surrounding joints are examined for nodule formation. Rheumatoid arthritis, gout, and osteoarthritis may produce characteristic nodules.
    • Rheumatoid arthritis. The subcutaneous nodules are soft and occur within and along tendons that provide extensor function to the joints.
    • Gout. The nodules of gout are hard and lie within and immediately adjacent to the joint capsule itself.
    • Osteoarthritis. Osteoarthritic nodules are hard and painless and represent a bony overgrowth that has resulted from the destruction of the cartilaginous surface of bone within the joint capsule.
  • Muscle tone. By palpating the muscle while passively moving the relaxed extremity, the nurse can determine muscle tone.
  • Muscle strength. The nurse assesses muscle strength by having the client perform certain maneuvers with and without added resistance. Muscle strength should be assessed bilaterally. The Muscle Strength Scale is a common method of evaluating muscle strength. This method involves testing key muscles from the upper and lower extremities against gravity and the nurse’s resistance and grading the client’s strength on a 0 to 5 scale (0-no muscle contraction, 1-trace muscle contraction, 2-active movement only when gravity is eliminated, 3-active movement against gravity but not against resistance, 4-active movement against gravity and some resistance, and 5-active movement against gravity and the nurse’s full resistance).
    • Upper extremity 

• • • • Assess bilateral hand grip strength by extending the index and second fingers on each hand toward the client and asking them to squeeze as tightly as possible.

• • • • Then, ask the client to extend both arms with their palms up while placing resistance on their forearms, and ask the client to pull their arms toward them.

• • • • Finally, ask the client to place their palms against the nurse’s palms and press while providing resistance.

• • • Lower extremity 

• • • • The client should be seated. The nurse should palace their palms on the client’s thighs and ask them to lift their legs while providing resistance.

• • • • Then, the nurse places their hands behind the client’s calves and asks them to pull their legs backward while providing resistance.

• • • • The nurse places their hands on top of the client’s feet and asks them to pull their feet upward against the resistance.

• • • • The nurse places their hands on the soles of the client’s feet and asks them to press downward while the nurse provides resistance.

• • Muscle size. The nurse measures the girth of an extremity to monitor increased size due to exercise, edema, or bleeding into the muscle. Girth may decrease due to muscle atrophy. The unaffected extremity is also measured for comparison. It is important that the measurements be taken at the same location on the extremity, and with the extremity in the same position, with the muscle at rest.

8. Genitourinary system

A focused genitourinary assessment collects data about the signs and symptoms of GU diseases, including any relevant medical or family history of GU disease, and any current treatment for related issues.

• Health History
  Obtaining a health history for genitourinary concerns requires excellent communication skills because many clients are embarrassed or uncomfortable discussing genitourinary function or symptoms. It is important to review the risk factors, particularly for clients at high risk.  When obtaining the health history, the nurse should inquire about the following:
  • The client’s chief concern or reason for seeking healthcare
  • The location, character, and duration of pain, if present, and its relationship to voiding
  • History of urinary tract infections and their past treatment
  • Previous renal or urinary diagnostic tests, surgeries, or procedures
  • Presence or history of genital lesions or sexually transmitted infections
  • Menstrual history for females, including menarche, length of cycles, duration and amount of flow, presence of cramps or pain, bleeding between periods or after intercourse, or bleeding after menopause
  • Pregnancies (number and outcomes of pregnancies)
  • Exposure to medications such as diethylstilbestrol and immunosuppressive agents
  • Sexual history
  • STIs and methods of treatment
  • Current or previous sexual abuse or physical abuse
  • Past surgery or other procedures on reproductive tract structures
  • The presence or family history of a genetic disorder
• Common Symptoms
  Dysfunction of the genitourinary system can produce a complex array of symptoms throughout the body.
  • Genitourinary pain
  • Changes in voiding
    • Anuria. This refers to a urine output of <50 mL per day.
    • Bacteriuria.  This refers to a bacterial count of >100,000 colonies/mL in the urine.
    • Dysuria. This refers to painful or difficult voiding.
    • Enuresis. This is an involuntary voiding during sleep.
    • Frequency. Refers to frequent voiding of more than every three hours.
    • Hematuria. This refers to the presence of red blood cells in the urine.
    • Hesitancy.  A delay or difficulty in initiating voiding.
    • Incontinence. The involuntary loss of urine.
    • Nocturia. The awakening during the night to urinate.
    • Oliguria. This refers to a urine output of <0.5 mL/kg/hour.
    • Polyuria. Increased volume of the urine voided.
    • Proteinuria. This refers to the protein found in the urine.
    • Urgency. This refers to a strong desire to void.
  • Gastrointestinal symptoms
    • Nausea
    • Vomiting
    • Diarrhea
    • Abdominal discomfort
    • Abdominal distension
  • Reproductive system symptoms
    • Dysmenorrhea. Pain with menses
    • Dyspareunia. Pain with intercourse
    • Symptoms of vaginitis (odor or itching)
  • Unexplained anemia
• Inspection
  • Pelvic, cervical, and vaginal examination. A pelvic examination includes the assessment of the appearance of the vulva, vagina, and cervix, and the size and shape of the uterus and ovaries.
    • Instruct the client to expect to have a feeling of fullness or pressure during the examination, but there is no pain.
    • Inform the client that a narrow, warmed speculum will be inserted to visualize the cervix, and a Papanicolau  (Pap) smear will be obtained.
    • Place the client in a supine lithotomy position.
    • A speculum may be inserted into the posterior portion of the introitus and slowly advanced to the top of the vagina.
    • Inspect the external genitalia by looking at the labia majora and minora, noting the epidermal tissue of the labia majora.
    • Evaluate any type of lesions present (genital warts, pigmented lesions).
    • Ask the client to bear down to assess for cystocele ( a bulge caused by the bladder protruding into the submucosa of the anterior vaginal wall), rectocele, or uterine prolapse.
    • The cervix is inspected for color, position, size, surface characteristics, discharge, and size and shape of the cervical os.
    • The vagina is inspected as the speculum is withdrawn.
• Palpation
  • The left kidney is palpated by reaching over to the client’s left side and placing the right hand beneath the client’s lower left rib. Push the hand on the top forward as the client inhales deeply.
  • It may be possible to palpate the smooth, rounded lower pole of the kidney between the hands.
  • The right kidney is easier to detect because it is somewhat lower than the left one.
  • Palpate for tenderness over the costovertebral angle, which is the angle formed by the lower border of the 12th, or bottom, rib and the spine. This may suggest renal dysfunction.
  • The inguinal area is examined for enlarged nodes, an inguinal or femoral hernia, and a varicocele.
  • In women, the vulva, urethral meatus, and vagina are examined. The urethra is palpated for diverticula, and the vagina is assessed for adequate estrogen effect and any of the five types of herniation:
    • Urethrocele. The bulging of the anterior vaginal wall into the urethra.
    • Cystocele. The herniation of the bladder wall into the vaginal wall into the vaginal vault.
    • Pelvic prolapse. This is the bulging of the cervix into the vaginal vault.
    • Enterocele. The herniation of the bowel into the posterior vaginal wall.
    • Rectocele. The herniation of the rectum into the vaginal wall.
  • Bimanual pelvic palpation. 
    • Inform the woman that she will be examined internally with the examiner’s fingers.
    • The gloved fingers are advanced vertically along the vaginal canal, and the vaginal wall is palpated.
    • The cervix is palpated and assessed for its consistency, mobility, size, and position.
    • The nurse places the opposite hand on the abdominal wall halfway between the umbilicus and the pubis and presses firmly toward the vagina. The uterus should be freely movable.
    • Uterine size, mobility, and contour can be estimated through palpation.
    • The right and left adnexal areas are palpated to evaluate the fallopian tubes and ovaries. The fingers of the hand of the nurse are moved first to one side, then to the other, while the hand palpating the abdominal area is moved correspondingly to either side of the abdomen and downward. The adnexa is palpated for an obvious mass, tenderness, and mobility.
    • Bimanual palpation of the vagina and cul-de-sac is accomplished by placing the index finger in the vagina and the middle finger in the rectum. The examiner should put on new gloves between the examination of the vaginal and rectal orifices to prevent cross-contamination.
• Percussion
  • To check for residual urine, the bladder should be percussed after the client voids.
  • Percussion of the bladder begins at the midline just above the umbilicus and downward. The sound changes from tympanic to dull when percussing over the bladder.
• Auscultation
  • The abdomen is auscultated to assess for bruits (low-pitched murmurs that indicate renal artery stenosis or an aortic aneurysm).

In conclusion, the head-to-toe physical examination stands as a cornerstone of comprehensive healthcare, offering a holistic assessment of an individual’s overall well-being. From the crown of the head to the tips of the toes, this meticulous examination provides invaluable insights into a client’s health status, serving as a fundamental tool for healthcare professionals.

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