NARAYANA NURSING INSTITUTIONS

PHYSICAL EXAMINATION

B.Sc NURSING

GENERAL APPEARANCE:

Consciousness : Consciousness/ Semi Consciousness/ coma

Orientation : Oriented to time , place , and person

Sign of distress :Pain/ dyspnea / fatigue

Body built : Firm / muscular / obese / excessively thin

Posture and gait : Normal/ coordinated / un coordinated

Body movements :Normal/ tremors/ immobility

VITAL SIGNS :

Temperature :

Pulse :

Respiration :

Blood pressure :

MEASUREMENTS:

Height :

Weight :

SKIN AND NAILS

Colour and vascularity : Pink / brown /flushed / pallor/ cyanosed / jaundiced / brown /

pigmentation

Moisture : Moist/ dry/ sweating

Temperature :Warm/ cold / feverish / clammy

Texture : Smooth/ rough/ thin/ thick /coarse/ scaly/ puffy.

Turgor : Normal/ elastic/ wrinkled

Edema : Dependent/ pitting pedal edema / orbital edema /

generalized edema
Integrity : Intact/ lesions/ birth marks / moles/ scars/ rashes

Nails :Clean / smooth / dry/ brittle / splinting / crackling / clubbing /

splinter haemorrhage / parynchyla.

HEAD AND SCALP

Skull size , shape, contour : Normal/ hydrocephalous / acromegaly/ nodules / masses

/lumps

Scalp : Dandruff/ pediculosis/ lesions

Hair : Color/ fine/ thick/ straight/ curly/ shiny/ dry/ brittle/

distribution/ alopecia/ hirsutism

Face : Shape/ symmetry / sensation

EYES

Eye brows : Shape – curved / straight/ thick/ thin/ sparse

Eye lids :Swollen/ infected / ptosis / ectropion/ masses

Eye lashes :Long/ short/ curved/ none/ artificial

Sclera :White/ red/ pink/ discharges

Conjunctiva :Pale/ pink/ red inflamatted

Cornea and pills :Color/ opaque/ intact

Pupils : PERRLA ( pupils equally round reacting to light ,

accommodation )

Eye movement : Normal/ nystagmus / estropia/ exotropia

Lacrimal Gland :Tender/ non- tender/ swollen/ tearing

Visual field :Intact and normal

Vision : Normal 6/6 or 20/20 / myopia/ presbyopia

EARS

Pinnae-size/shape : Large/small/symmetry

Position : Equal to outer canthus of eyes/low set/high set

Ear canal : Clean/discharges/cerumen/nodules/foreign objects

Tympanic membrane : Whitish and intact/redness/bulging/perforated

Hearing : Normal (whisper test, weber and rhinne’s test)

NOSE

Size and shape : long/short/swollen/flaring of nostrils

Septum : Midline/deviated/perforated

Nasal mucosa : Pink/red/discharge/rhinitis/epistaxis/allergies

Patency : Patent/obstructed

Sinuses : Tender/non-tender

MOUTH AND PHARYNX

Lips : Colour (pale, pink, cyanosed)/smooth/dry/crackles/fissures

Teeth : colour/stained/carries/alignment/dentures

Gums : Pink/swollen/bleeding/gingivitis/ulcerated/spongy

Buccal mucosa : Colour/dry/moist/intact/ulcers/chancre/cleft lip and palate

Tongue : Dry/whitecoated/fissures/crackled/bluish/microglossia/

Macroglossia/ glossitis/halitosis

Tonsils :Enlarged/redness/dysphagia/

Uvula-mobile/midline/gag reflex

NECK

Appearance : Long/short/symmetrical/nonsymmetrical/jugular vein

distension /carotid bruits

Thyroid :Palpable/nodules/tenderness

Trachea :Midline/deviated

Lymphnode :Palpable/not palpable/mobile/hard/firm

Movements :ROM possible/not possible

CHEST:

Thoracic configuration: size and shape-symmetrical/pigeon/barrel shape

Respiratory pattern- retractions/ respiratory rate/ visible pulsation

Breast : tenderness and fremitus

Size/shape/symmetry/nipple/discharges/retractions/discharges/nodules/lumps/pain/trauma/
history of breast disease/ surgery

Lung sounds :Crackles//ronchi/wheeze/pleural friction/air entry

Heart sounds :S1, S2, other sounds-murmurs, heart rate.

Abdomen :

Inspection :Flunt rounded/ascites/umbilical bulging/ striace/scars/ rashes

Auscultation :Present/absent/hyper active/hypo active

Palpation Ppresent /absent//dullness or tympany on percussion

Percussion :Palpable spleen, liver/ tenderness/linguinal or femoral hernia

GENITALIA

Female genitalia :Echymosis/haemotoma/pseudo hermaphroditism/foul smelling

dischargescystocele terine prolapsed/ perineum intact

Male genitalia ;phimosis/priapisim/epispadiasis/hypospadiasis/hydrocele/hernia

ANUS/RECTUM

:Hemorrhoids/inflammation/lesions/fissures/skin tags/rectocele/patency

BACK :

Spinal curvature :Kyphosis/ lardosis/ scoliosis

Vertebrae : Intact/ tenderness/ spondilysis/spinal cord defects

Lesions : Rashes/lesions

ROM :Possible/limited

EXTREMITIES :

Size&symmetrical : Normal/symmetrical/non symmetrical/ swollen

edema/defourmities/rashes/ prosthesis / varicose vein

Muscle tone and strength : Firm/muscularflabby/flaccid/spastic/atropy//tremors

 SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

Inspection : respiration- rate/tachypnea/ bradypnea/ apnea/laboured/ shallow gasping

: Shape& symmetry- symmetrical/ barrel, pigeon, funnel shaped

: Rhythm- regular/irregular

: Movement of chest wall –intercostals and accessory muscle relaxation

: A.p &transverse diameter – 1;2

:lesions, cyanosis, scars

Palpation : tenderness, lumps, crepitus, thoracic excursion,tactile fremitus, mass

Percussion : resonance/ dullness flatness

Auscultation : normal lung sounds/ adventitious breath sounds-crackles, wheeze rhonchi

/ pleural friction rub// stridor.

CARDIO VASCULAR SYSTEM:

Inspection : visible pulsation// jugular venous distension// edema(0-4)

Palpation : pulse & heart rate/ thrills/ allen’s test

Auscultation : s1/s2/s3/s4/murmurs, split heart sounds/ BP

GASTRO INTESTINAL SYSTEM:

Inspection : Contor, enlargement, ascitis, umbilicus, movements, visible peristalsis,

Lesions, scar, striae, hair distribution

Auscultation : Bowel sounds-present / absent

Percussion : Fluid collection-thrill/dullness

Palpation : Soft/firm/hard/tenderness/organomegaly/hernia

RENAL SYSTEM

Inspection : redness in flank region/edema

Palpation ; tenderness/palpable

Urine output : amount/frequency/color/turbidity

MUSCULO SKELETAL SYSTEM:

Inspection : size, symmetry, shape, edema. deformity, prosthesis gait, ROM of each

Joint, skin color & characteristics

palpation ; Muscle tone, strength (0-5), bony articulation

reflexes

REPRODUCTIVE SYSTEM:

Female : Discharges/lumps/masses/menstrual abnormalities/ prolapsed

cystocele/rectocele

Male : Phimosis/priapisim/epispadiasis/hypospadiasis/hydrocele/hernia

CENTRAL NERVOUS SYSTEM :

 GCS (0-15)

RESPONSE SCORE
EYE OPENING Spontaneously 4
To command 3
To pain 2
No response 1
MOTOR RESPONSE Obeys commands 6
Localizes pain 5
Flexion withdrawal 4
Flexion 3
Extension 2
No response 1
VERBAL RESPONSE Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
TOTAL 15

COGNITIVE PERCEPTUAL PATTERN :

Mental status : orientation : person, place, time

Level of consciousness : alert,drowsy/lethargic , difficult/unable to arouse , other
Memory : intact , recent memory deficit , remote memory deficit
Thought processes: Answers questions appropriately
Answers unreliably
 Poor historian
Explain
Restraints : indications for use
Restraints alternatives : bed alarm , sitter , frequent observations, side rails ,others ,
Pupils : PERRLA yes /no , explain :
Vision : normal , glasses, contacts , explain:
Hearing : normal , impaired, aid used, explain :

 CRANIAL NERVE ASSESSMENT:

CRA NAME FUNCTION HOW TO TEST
NIAL
NER
VES
1 Olfactary Sense of smell Close the eyes, occlude one nostril and
identify the odour
2 Optic Control visual activity Instruct the patient to cover one eye,
and visual field position a news paper 12 – 18 inches
from patient and ask him to read
3,4,6 Occulomotor, Controls pupilary Ask the patient to follow an object
trochlear, reaction moved systematically in various
abducens directions
5 Trigeminal Control facial sensation Ask the patient to close his eyes then
and jaw movements the various parts of the face is gently
touched using a wisp of cotton.
7 Facial Control the facial Assessed by having the patient wrinkle
muscles her fore head, smile, showing her teeth.
8 Auditory/vestibule Controls hearing and webers test and rinnes test to evaluate
cochlear sense of balance air and bone conduction.
9, 10 Hypoglossal, Controls swallowing, Instruct the patient to pen his mouth
vagus the gag reflex, and say ah. Use the tip of tongue
articulation depressor to stimulate the back of the
pharynx. Swallowing is tested by
asking the patient to drink a clear fluid
11 Spinal accessory Controls the trapezius Instruct the patient to rise both
and sternocleido shoulders and to hold tightly and apply
mastoid muscle resistance to shoulders using both
hands.
12 Glosso pharyngeal Controls tongue Is assessed by having the patient
movement and strength protrude her tongue

MOTOR FUNCTION: MUSCLE STRENGTH AND CO-ORDINATION

MUSCLE POWER GRADING

GRADE DESCRIPTION
5/5 Full range of motion against gravity with extreme resistance
4/5 Full range of motion against gravity with some resistance
3/5 Full range of motion against gravity with no resistance
2/5 Full range of motion with gravity eliminated
 1/5 Slight contraction visible
0/5 No movements

 Sensory examination
 Response to touch
 Response to pain and temperature
 propioception
Reflexes:superficial &deep (abdominal, Achilles, corneal, biceps, triceps, patellar, plantar,
babinski reflex)

ASSESSMENT OF CEREBELLAR FUNCTIONS

 Finger to finger test

 Finger to nose test
 Patting test
 Romberg test
 Tandom walking test