HEAD TO TOE ASSESSMENT

Preview
 Head (Skull, Scalp, Hair)
 Face
 Eyebrows, Eyes and Eyelashes
 Eye lids and Lacrimal Apparatus
 Conjunctivae
 Sclerae
 Cornea
 Anterior Chamber and Iris
 Pupils
 Cranial Nerve II (optic nerve)
 Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
 Ears
 Nose and Paranasal Sinuses
 Cranial Nerve I (olfactory Nerve)
 Neck
 Thorax ( Cardiovascular System)
 Breast
 Abdomen
 Extremities
Skull, Scalp & Hair
 Observe the size, shape and contour of the skull.
 Observe scalp in several areas by separating the hair at various locations;
inquire about any injuries. Note presence of lice, nits, dandruff or lesions.
 Palpate the head by running the pads of the fingers over the entire surface of
skull; inquire about tenderness upon doing so. (wear gloves if necessary)
 Observe and feel the hair condition.
Normal Findings:
Skull
 Generally round, with prominences in the frontal and occipital area.
(Normocephalic).
 No tenderness noted upon palpation.
Scalp
 Lighter in color than the complexion.
 Can be moist or oily.
 No scars noted.
 Free from lice, nits and dandruff.
 No lesions should be noted.
 No tenderness or masses on palpation.
 Hair
 Can be black, brown or burgundy depending on the race.
 Evenly distributed covers the whole scalp (No evidences of Alopecia)
 Maybe thick or thin, coarse or smooth.
 Neither brittle nor dry.
 Face
1. Observe the face for shape.
2. Inspect for Symmetry.
 Inspect for the palpebral fissure (distance between the eye lids); should
be equal in both eyes.
 Ask the patient to smile, There should be bilateral Nasolabial fold
(creases extending from the angle of the corner of the mouth). Slight asymmetry in
the fold is normal.
 If both are met, then the Face is symmetrical
3. Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)
1. Sensory Function
 Ask the client to close the eyes.
 Run cotton wisp over the fore head, check and jaw on both sides of the face.
 Ask the client if he/she feel it, and where she feels it.
 Check for corneal reflex using cotton wisp.
 The normal response in blinking.
2. Motor function
 Ask the client to chew or clench the jaw.
 The client should be able to clench or chew with strength and force.
CN VII (Facial)
1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
 Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
 Normally, the client can identify the taste.
2. Motor function
 Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff
the cheeks.
Normal Findings
 Shape maybe oval or rounded.
 Face is symmetrical.
 No involuntary muscle movements.
 Can move facial muscles at will.
 Intact cranial nerve V and VII.
Eyebrows, Eyes and Eyelashes
 All three structures are assessed using the modality of inspection.
Normal findings
Eyebrows
 Symmetrical and in line with each other.
 Maybe black, brown or blond depending on race.
 Evenly distributed.
Eyes
 Evenly placed and inline with each other.
 None protruding.
 Equal palpebral fissure.
Eyelashes
 Color dependent on race.
 Evenly distributed.
 Turned outward.
Eyelids and Lacrimal Apparatus
1. Inspect the eyelids for position and symmetry.

2. Palpate the eyelids for the lacrimal glands.

a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index
finger against the client’s upper orbital rim.
b. Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
a. To assess the nasolacrimal duct, the examiner presses with the index finger
against the client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE
NOSE.
b. In the presence of blockage, this will cause regurgitation of fluid in the puncta
Normal Findings
Eyelids
 Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes
are open.
 No PTOSIS noted. (Drooping of upper eyelids).
 Meets completely when eyes are closed.
 Symmetrical.
Lacrimal Apparatus
 Lacrimal gland is normally non palpable.
 No tenderness on palpation.
 No regurgitation from the nasolacrimal duct.
Conjunctivae
 The bulbar and palpebral conjunctivae are examined by separating the eyelids
widely and having the client look up, down and to each side. When separating the lids,
the examiner should exert NO PRESSURE against the eyeball; rather, the examiner
should hold the lids against the ridges of the bony orbit surrounding the eye.
In examining the palpebral conjunctiva, everting the upper eyelid in necessary
and is done as follow:
1. Ask the client to look down but keep his eyes slightly open. This relaxes the
levator muscles, whereas closing the eyes contracts the orbicularis muscle, preventing
lid eversion.
2. Gently grasp the upper eyelashes and pull gently downward. Do not pull the
lashes outward or upward; this, too, causes muscles contraction.
3. Place a cotton tip application about I can above the lid margin and push gently
downward with the applicator while still holding the lashes. This everts the lid.
4. Hold the lashes of the everted lid against the upper ridge of the bony orbit, just
beneath the eyebrow, never pushing against the eyebrow.
5. Examine the lid for swelling, infection, and presence of foreign objects.
6. To return the lid to its normal position, move the lid slightly forward and ask
the client to look up and to blink. The lid returns easily to its normal position.
Normal Findings:
 Both conjunctivae are pinkish or red in color.
 With presence of many minutes capillaries.
 Moist
 No ulcers
 No foreign objects
Sclerae
 The sclerae is easily inspected during the assessment of the conjunctivae.
Normal Findings
 Sclerae is white in color (anicteric sclera)
 No yellowish discoloration (icteric sclera).
 Some capillaries maybe visible.
 Some people may have pigmented positions.
Cornea
 The cornea is best inspected by directing penlight obliquely from several
positions.
Normal findings
 There should be no irregularities on the surface.
 Looks smooth.
 The cornea is clear or transparent. The features of the iris should be fully
visible through the cornea.
 There is a positive corneal reflex.
Anterior Chamber and Iris
 The anterior chamber and the iris are easily inspected in conjunction with the
cornea. The technique of oblique illumination is also useful in assessing the anterior
chamber.
Normal Findings:
 The anterior chamber is transparent.
 No noted any visible materials.
 Color of the iris depends on the person’s race (black, blue, brown or green).
 From the side view, the iris should appear flat and should not be bulging
forward. There should be NO crescent shadow casted on the other side when
illuminated from one side.
Pupils
 Examination of the pupils involves several inspections, including assessment of
the size, shape reaction to light is directed is observed for direct response of
constriction. Simultaneously, the other eye is observed for consensual response of
constriction.
The test for papillary accommodation is the examination for the change in
papillary size as it is switched from a distant to a near object.
 Ask the client to stare at the objects across room.
 Then ask the client to fix his gaze on the examiner’s index fingers, which is
placed 5 – 5 inches from the client’s nose.
 Visualization of distant objects normally causes papillary dilation and
visualization of nearer objects causes papillary constriction and convergence of the
eye.
Normal Findings
 Pupillary size ranges from 3 – 7 mm, and are equal in size.
 Equally round.
 Constrict briskly/sluggishly when light is directed to the eye, both directly and
consensual.
 Pupils dilate when looking at distant objects, and constrict when looking at
nearer objects.
If all of which are met, we document the findings using the notation PERRLA,
pupils equally round, reactive to light, and accommodate

Cranial Nerve II (optic nerve)

 The optic nerve is assessed by testing for visual acuity and peripheral vision.
 Visual acuity is tested using a snellen chart, for those who are illiterate and
unfamiliar with the western alphabet, the illiterate E chart, in which the letter E faces
in different directions, maybe used.
 The chart has a standardized number at the end of each line of letters; these
numbers indicates the degree of visual acuity when measured at a distance of 20 feet.
 The numerator 20 is the distance in feet between the chart and the client, or the
standard testing distance. The denominator 20 is the distance from which the normal
eye can read the lettering, which correspond to the number at the end of each letter
line; therefore the larger the denominator the poorer the version.
 Measurement of 20/20 vision is an indication of either refractive error or some
other optic disorder.
In testing for visual acuity you may refer to the following:
 The room used for this test should be well lighted.
 A person who wears corrective lenses should be tested with and without them
to check fro the adequacy of correction.
 Only one eye should be tested at a time; the other eye should be covered by an
opaque card or eye cover, not with client’s finger.
 Make the client read the chart by pointing at a letter randomly at each line;
maybe started from largest to smallest or vice versa.
 A person who can read the largest letter on the chart (20/200) should be
checked if they can perceive hand movement about 12 inches from their eyes, or if
they can perceive the light of the penlight directed to their yes.
Peripheral Vision or visual fields
 The assessment of visual acuity is indicative of the functioning of the macular
area, the area of central vision. However, it does not test the sensitivity of the other
areas of the retina which perceive the more peripheral stimuli. The Visual field
confrontation test, provide a rather gross measurement of peripheral vision.
 The performance of this test assumes that the examiner has normal visual
fields, since that client’s visual fields are to be compared with the examiners.
Follow the steps on conducting the test:
1. The examiner and the client sit or stand opposite each other, with the eyes at
the same, horizontal level with the distance of 1.5 – 2 feet apart.
2. The client covers the eye with opaque card, and the examiner covers the eye
that is opposite to the client covered eye.
3. Instruct the client to stare directly at the examiner’s eye, while the examiner
stares at the client’s open eye. Neither looks out at the object approaching from the
periphery.
4. The examiner hold an object such as pencil or penlight, in his hand and
gradually moves it in from the periphery of both directions horizontally and from
above and below.
5. Normally the client should see the same time the examiners sees it. The normal
visual field is 180 degrees.
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
 All the 3 Cranial nerves are tested at the same time by assessing the Extra
Ocular Movement (EOM) or the six cardinal position of gaze.
Follow the given steps:
1. Stand directly in front of the client and hold a finger or a penlight about 1 ft
from the client’s eyes.
2. Instruct the client to follow the direction the object hold by the examiner by eye
movements only; that is with out moving the neck.
3. The nurse moves the object in a clockwise direction hexagonally.
4. Instruct the client to fix his gaze momentarily on the extreme position in each
of the six cardinal gazes.
5. The examiner should watch for any jerky movements of the eye (nystagmus).
6. Normally the client can hold the position and there should be no nystagmus.
Ears
1. Inspect the auricles of the ears for parallelism, size position, appearance and
skin color.
2. Palpate the auricles and the mastoid process for firmness of the cartilage of the
auricles, tenderness when manipulating the auricles and the mastoid process.
3. Inspect the auditory meatus or the ear canal for color, presence of cerumen,
discharges, and foreign bodies.
 For adult pull the pinna upward and backward to straiten the canal.
 For children pull the pinna downward and backward to straiten the canal
4. Perform otoscopic examination of the tympanic membrane, noting the color
and landmarks.
Normal Findings
 The ear lobes are bean shaped, parallel, and symmetrical.
 The upper connection of the ear lobe is parallel with the outer canthus of the
eye.
 Skin is same in color as in the complexion.
 No lesions noted on inspection.
 The auricles are has a firm cartilage on palpation.
 The pinna recoils when folded.
 There is no pain or tenderness on the palpation of the auricles and mastoid
process.
 The ear canal has normally some cerumen of inspection.
 No discharges or lesions noted at the ear canal.
 On otoscopic examination the tympanic membrane appears flat, translucent and
pearly gray in color.
Nose and Paranasal Sinuses
The external portion of the nose is inspected for the following:
1. Placement and symmetry.
2. Patency of nares (done by occluding nosetril one at a time, and noting for
difficulty in breathing)
3. Flaring of alae nasi
4. Discharge
The external nares are palpated for:
1. Displacement of bone and cartilage.
2. For tenderness and masses
The internal nares are inspected by hyper extending the neck of the client, the
ulnar aspect of the examiners hard over the fore head of the client, and using
the thumb to push the tip of the nose upward while shining a light into the
nares.

Inspect for the following:

1. Position of the septum.
2. Check septum for perforation. (Can also be checked by directing the lighted
penlight on the side of the nose, illumination at the other side suggests perforation).
3. The nasal mucosa (turbinates) for swelling, exudates and change in color.
Paranasal Sinuses
 Examination of the paranasal sinuses is indirectly. Information about their
condition is gained by inspection and palpation of the overlying tissues. Only frontal
and maxillary sinuses are accessible for examination.
 By palpating both cheeks simultaneously, one can determine tenderness of the
maxillary sinusitis, and pressing the thumb just below the eyebrows, we can determine
tenderness of the frontal sinuses.
Normal Findings
 Nose in the midline
 No Discharges.
 No flaring alae nasi.
 Both nares are patent.
 No bone and cartilage deviation noted on palpation.
 No tenderness noted on palpation.
 Nasal septum in the mid line and not perforated.
 The nasal mucosa is pinkish to red in color. (Increased redness turbinates are
typical of allergy).
 No tenderness noted on palpation of the paranasal sinuses.
Cranial Nerve I (Olfactory Nerve)
To test the adequacy of function of the olfactory nerve:
1. The client is asked to close his eyes and occlude.
2. The examiner places aromatic and easily distinguish nose. (E.g. coffee).
3. Ask the client to identify the odor.
4. Each side is tested separately, ideally with two different substances.
Mouth and Oropharynx Lips
Inspected for:
1. Symmetry and surface abnormalities.
2. Color
3. Edema
Normal Findings:
1. With visible margin
2. Symmetrical in appearance and movement
3. Pinkish in color
4. No edema
Temporomandibular
Palpate while the mouth is opened wide and then closed for:
1. Crepitous
2. Deviations
3. Tenderness
Normal Findings:
1. Moves smoothly no crepitous.
2. No deviations noted
3. No pain or tenderness on palpation and jaw movement.
Gums
Inspected for:
1. Color
2. Bleeding
3. Retraction of gums.
Normal Findings:
1. Pinkish in color
2. No gum bleeding
3. No receding gums
Teeth
Inspected for:
1. Number
2. Color
3. Dental carries
4. Dental fillings
5. Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).
6. Tooth loss
7. Breath should also be assessed during the process.
Normal Findings:
1. 28 for children and 32 for adults.
2. White to yellowish in color
3. With or without dental carries and/or dental fillings.
4. With or without malocclusions.
5. No halitosis.
Tongue
Palpated for:
1. Texture
Normal Findings:
1. Pinkish with white taste buds on the surface.
2. No lesions noted.
3. No varicosities on ventral surface.
4. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the
tongue.
5. Gag reflex is present.
6. Able to move the tongue freely and with strength.
7. Surface of the tongue is rough.
Uvula
Inspected for:
1. Position
2. Color
3. Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note
that the uvula will move upward and forward.
Normal Findings:
1. Positioned in the mid line.
2. Pinkish to red in color.
3. No swelling or lesion noted.
4. Moves upward and backwards when asked to say “ah”
Tonsils
Inspected for:
1. Inflammation
2. Size
 A Grading system used to describe the size of the tonsils can be used.
 Grade 1 – Tonsils behind the pillar.
 Grade 2 – Between pillar and uvula.
 Grade 3 – Touching the uvula
 Grade 4 – In the midline.
Neck
 The neck is inspected for position symmetry and obvious lumps visibility of the
thyroid gland and Jugular Venous Distension
Normal Findings:
1. The neck is straight.
2. No visible mass or lumps.
3. Symmetrical
4. No jugular venous distension (suggestive of cardiac congestion).
The neck is palpated just above the suprasternal note using the thumb and
the index finger.

Normal Findings:
1. The trachea is palpable.
2. It is positioned in the line and straight.
 Lymph nodes are palpated using palmar tips of the fingers via systemic circular
movements. Describe lymph nodes in terms of size, regularity, consistency,
tenderness and fixation to surrounding tissues.
Normal Findings:
 May not be palpable. Maybe normally palpable in thin clients.
 Non tender if palpable.
 Firm with smooth rounded surface.
 Slightly movable.
 About less than 1 cm in size.
 The thyroid is initially observed by standing in front of the client and asking the
client to swallow. Palpation of the thyroid can be done either by posterior or anterior
approach.
Posterior Approach:
1. Let the client sit on a chair while the examiner stands behind him.
2. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly
below that is the isthmus.
3. Ask the client to swallow while feeling for any enlargement of the thyroid
isthmus.
4. To facilitate examination of each lobe, the client is asked to turn his head
slightly toward the side to be examined to displace the sternocleidomastoid, while the
 other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid
lobe to be examined.
5. Ask the patient to swallow as the procedure is being done.
6. The examiner may also palate for thyroid enlargement by placing the thumb
deep to and behind the sternocleidomastoid muscle, while the index and middle
fingers are placed deep to and in front of the muscle.
7. Then the procedure is repeated on the other side.
Anterior approach:
1. The examiner stands in front of the client and with the palmar surface of the
middle and index fingers palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation is being done.
3. In palpating the lobes of the thyroid, similar procedure is done as in posterior
approach. The client is asked to turn his head slightly to one side and then the other of
the lobe to be examined.
4. Again the examiner displaces the thyroid cartilage towards the side of the lobe
to be examined.
5. Again, the examiner palpates the area and hooks thumb and fingers around the
sternocleidomastoid muscle.
Normal Findings:
1. Normally the thyroid is non palpable.
2. Isthmus maybe visible in a thin neck.
3. No nodules are palpable.
Auscultation of the Thyroid is necessary when there is thyroid enlargement.
The examiner may hear bruits, as a result of increased and turbulence in
blood flow in an enlarged thyroid.
 Check the Range of Movement of the neck.
Thorax (Cardiovascular System)
Inspection of the Heart
 The chest wall and epigastrum is inspected while the client is in supine
position. Observe for pulsation and heaves or lifts
Normal Findings:
1. Pulsation of the apical impulse maybe visible. (this can give us some indication
of the cardiac size).
2. There should be no lift or heaves.
Palpation of the Heart
 The entire precordium is palpated methodically using the palms and the fingers,
beginning at the apex, moving to the left sternal border, and then to the base of the
heart.
 Normal Findings:
1. No, palpable pulsation over the aortic, pulmonic, and mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and thrills felt over the apex.
Percussion of the Heart
 The technique of percussion is of limited value in cardiac assessment. It can be
used to determine borders of cardiac dullness.
Auscultation of the Heart
Anatomic areas for auscultation of the heart:
 Aortic valve – Right 2nd ICS sternal border.
 Pulmonic Valve – Left 2nd ICS sternal border.
 Tricuspid Valve – – Left 5th ICS sternal border.
 Mitral Valve – Left 5th ICS midclavicular line
Positioning the client for auscultation:
 If the heart sounds are faint or undetectable, try listening to them with the
patient seated and learning forward, or lying on his left side, which brings the heart
closer to the surface of the chest.
 Having the client seated and learning forward s best suited for hearing high-
pitched sounds related to semilunar valves problem.
 The left lateral recumbent position is best suited low-pitched sounds, such as
mitral valve problems and extra heart sounds.
Auscultating the heart:
1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of
semilunar valve). S1 sound is best heard over the mitral valve; S2 is best heard over
the aortric valve.
3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
4. Count heart rate at the apical pulse for one full minute.
Normal Findings:
1. S1 & S2 can be heard at all anatomic site.
2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
3. Cardiac rate ranges from 60 – 100 bpm.
Breast
Inspection of the Breast
There are 4 major sitting position of the client used for clinical breast
examination. Every client should be examined in each position.
1. The client is seated with her arms on her side.
2. The client is seated with her arms abducted over the head.
3. The client is seated and is pushing her hands into her hips, simultaneously
eliciting contraction of the pectoral muscles.
4. The client is seated and is learning over while the examiner assists in
supporting and balancing her.
 While the client is performing these maneuvers, the breasts are carefully
observed for symmetry, bulging, retraction, and fixation.
 An abnormality may not be apparent in the breasts at rest a mass may cause the
breasts, through invasion of the suspensory ligaments, to fix, preventing them from
upward movement in position 2 and 4.
 Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and
shortened suspensory ligaments.
Normal Findings:
1. The overlying the breast should be even.
2. May or may not be completely symmetrical at rest.
3. The areola is rounded or oval, with same color, (Color va,ies form light pink to
dark brown depending on race).
4. Nipples are rounded, everted, same size and equal in color.
5. No “orange peel” skin is noted which is present in edema.
6. The veins maybe visible but not engorge and prominent.
7. No obvious mass noted.
8. Not fixated and moves bilaterally when hands are abducted over the head, or is
learning forward.
9. No retractions or dimpling.
Palpation of the Breast
 Palpate the breast along imaginary concentric circles, following a clockwise
rotary motion, from the periphery to the center going to the nipples. Be sure that the
breast is adequately surveyed. Breast examination is best done 1 week post menses.
 Each areolar areas are carefully palpated to determine the presence of
underlying masses.
 Each nipple is gently compressed to assess for the presence of masses or
discharge.
Normal Findings:
 No lumps or masses are palpable.
 No tenderness upon palpation.
 No discharges from the nipples.
NOTE: The male breasts are observed by adapting the techniques used for
female clients. However, the various sitting position used for woman is
unnecessary.

Abdomen
 In abdominal assessment, be sure that the client has emptied the bladder for
comfort. Place the client in a supine position with the knees slightly flexed to relax
abdominal muscles.
Inspection of the abdomen
 Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and
umbilicus).
 Contour (flat, rounded, scapold)
 Distension
 Respiratory movement.
 Visible peristalsis.
 Pulsations
Normal Findings:
 Skin color is uniform, no lesions.
 Some clients may have striae or scar.
 No venous engorgement.
 Contour may be flat, rounded or scapoid
 Thin clients may have visible peristalsis.
 Aortic pulsation maybe visible on thin clients.
Auscultation of the Abdomen
 This method precedes percussion because bowel motility, and thus bowel
sounds, may be increased by palpation or percussion.
 The stethoscope and the hands should be warmed; if they are cold, they may
initiate contraction of the abdominal muscles.
 Light pressure on the stethoscope is sufficient to detect bowel sounds and
bruits. Intestinal sounds are relatively high-pitched, the bell may be used in exploring
arterial murmurs and venous hum.
Peristaltic sounds
 These sounds are produced by the movements of air and fluids through the
gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility
of bowel.
Listening to the bowel sounds (borborygmi) can be facilitated by following these
steps:
1. Divide the abdomen in four quadrants.
2. Listen over all auscultation sites, starting at the right lower quadrants,
following the cross pattern of the imaginary lines in creating the abdominal quadrants.
This direction ensures that we follow the direction of bowel movement.
3. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner
listen for at least 5 minutes, especially at the periumbilical area, before concluding
that no bowel sounds are present.
4. The normal bowel sounds are high-pitched, gurgling noises that occur
approximately every 5 – 15 seconds. It is suggested that the number of bowel sound
may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each
breath sound.
Some factors that affect bowel sound:
1. Presence of food in the GI tract.
2. State of digestion.
3. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus,
peritonitis).
4. Bowel surgery
5. Constipation or Diarrhea.
6. Electrolyte imbalances.
7. Bowel obstruction.
Percussion of the abdomen
 Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites),
gaseous distension, and masses, and in assessing solid structures within the abdomen.
 The direction of abdominal percussion follows the auscultation site at each
abdominal guardant.
 The entire abdomen should be percussed lightly or a general picture of the
areas of tympany and dullness.
 Tympany will predominate because of the presence of gas in the small and
large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the
6th or 9th rib just posterior to or at the mid axillary line on the left side.
 Percussion in the abdomen can also be used in assessing the liver span and size
of the spleen.
Percussion of the liver
The palms of the left hand are placed over the region of liver dullness.
1. The area is strucked lightly with a fisted right hand.
2. Normally tenderness should not be elicited by this method.
3. Tenderness elicited by this method is usually a result of hepatitis or
cholecystitis.
Renal Percussion
1. Can be done by either indirect or direct method.
2. Percussion is done over the costovertebral junction.
3. Tenderness elicited by such method suggests renal inflammation.
Palpation of the Abdomen
Light palpation
 It is a gentle exploration performed while the client is in supine position. With
the examiner’s hands parallel to the floor.
 The fingers depress the abdominal wall, at each quadrant, by approximately 1
cm without digging, but gently palpating with slow circular motion.
 This method is used for eliciting slight tenderness, large masses, and muscles,
and muscle guarding.
Tensing of abdominal musculature may occur because of:
1. The examiner’s hands are too cold or are pressed to vigorously or deep into the
abdomen.
2. The client is ticklish or guards involuntarily.
3. Presence of subjacent pathologic condition.
Normal Findings:
1. No tenderness noted.
2. With smooth and consistent tension.
3. No muscles guarding.
Deep Palpation
 It is the indentation of the abdomen performed by pressing the distal half of the
palmar surfaces of the fingers into the abdominal wall.
 The abdominal wall may slide back and forth while the fingers move back and
forth over the organ being examined.
 Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or
masses may be felt with this method.
 In the absence of disease, pressure produced by deep palpation may produce
tenderness over the cecum, the sigmoid colon, and the aorta.
Liver palpation
There are two types of bi manual palpation recommended for palpation of the
liver. The first one is the superimposition of the right hand over the left hand.
1. Ask the patient to take 3 normal breaths.
2. Then ask the client to breath deeply and hold. This would push the liver down
to facilitate palpation.
3. Press hand deeply over the RUQ
The second methods:
1. The examiner’s left hand is placed beneath the client at the level of the right
11th and 12th ribs.
2. Place the examiner’s right hands parallel to the costal margin or the RUQ.
3. An upward pressure is placed beneath the client to push the liver towards the
examining right hand, while the right hand is pressing into the abdominal wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip beneath the examining
fingers.
Normal Findings:
 The liver usually can not be palpated in a normal adult. However, in extremely
thin but otherwise well individuals, it may be felt the costal margins.
 When the normal liver margin is palpated, it must be smooth, regular in
contour, firm and non-tender.
Extremities
Inspection
1. Observe for size, contour, bilateral symmetry, and involuntary movement.
2. Look for gross deformities, edema, presence of trauma such as ecchymosis or
other discoloration.
3. Always compare both extremities.
Palpation
1. Feel for evenness of temperature. Normally it should be even for all the
extremities.
2. Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s
fingers and noting for equality of contraction).
3. Perform range of motion.
4. Test for muscle strength. (performed against gravity and against resistance)
Table showing the Lovett scale for grading for muscle strength and functional
level

Lovett Grad Percentage of

Functional level Scale e normal
No evidence of contractility Zero (Z) 0 0
Evidence of slight contractility Trace (T) 1 10
Complete ROM without gravity Poor (P) 2 25
Complete ROM with gravity Fair (F) 3 50
Complete range of motion against gravity with
some resistance Good (G) 4 75
Complete  range of motion against gravity with full Normal
resistance (N) 5 100
Normal Findings
 Both extremities are equal in size.
 Have the same contour with prominences of joints.
 No involuntary movements.
 No edema
 Color is even.
 Temperature is warm and even.
 Has equal contraction and even.
 Can perform complete range of motion.
 No crepitus must be noted on joints.
 Can counter act gravity and resistance on ROM.

Cranial Nerves Assessment Form

Assessment
Cranial Nerve Normal Response Client’s Response
Technique

Client is able to
identify different
Ask the client to smell
smell with each
and identify the smell Client was able to
nostril separately
I. Olfactory of cologne with each describe the odor of
and with eyes
nostril separately and the materials used.
closed unless such
with the eyes closed.
condition like colds
is present.

Provide adequate
lighting and ask client The client should be
Client was able to
to read from a reading able to read with
II. Optic read with each eye
material held at a each eye and both
and both eyes.
distance of 36 cm. (14 eyes.
in.).

III. Oculomotor Reaction to PERRLA (pupils

light: Using a penlight equally round and
and approaching from reactive to light and
the side, shine a light accommodation)
on the pupil. Observe Illuminated and non-
the response of the illuminated pupil
illuminated pupil. should constrict.
Shine the light on the
pupil again, and
observe the response
of the other pupil.

Reaction to Pupils constrict

accommodation: As when looking at a
 k client to look at a
near object and then near object, dilate
at a distant object. when looking at a
Alternate the gaze distant object,
from the near to the converge when near
far object. Next, move object is moved
an object towards the towards the nose.
client’s nose.

Hold a penlight 1 ft. in

front of the client’s
eyes. Ask the client to
follow the movements Client’s eyes should Both eyes are able
IV. Trochlear of the penlight with be able to follow the to move as
the eyes only. Move penlight as it moves. necessary.
the penlight upward,
downward, sideward
and diagonally.

While client looks

upward, lightly touch
lateral sclera of eye to
elicit blink reflex.

To test light
sensation, have client
close eyes, wipe a Client should have a
Client was able to
wisp of cotton over (+) corneal reflex,
elicit corneal reflex,
client’s forehead. able to respond to
sensitive
V. Trigeminal light and deep
To test deep to pain stimuli and
sensation and able
sensation, use distinguish hot from
to differentiate hot
alternating blunt and cold.
from cold.
sharp ends of an
object. Determine
sensation to warm
and cold object by
asking client to
identify warmth and
coldness.

Hold a penlight 1 ft. in Both eyes

front of the client’s coordinated, move Both eyes move in
VI. Abducens eyes. Ask the client to in unison with coordination.
follow the movements parallel alignment.
of the penlight with
 the eyes only. Move
the penlight through
the six cardinal fields
of gaze.

Client should be
Ask client to smile,
able to smile, raise
raise the eyebrows, Client performed
eyebrows, and puff
frown, and puff out various facial
out cheeks and
cheeks, close eyes expressions without
VII. Facial close eyes without
tightly. Ask client to any difficulty and
any difficulty. The
identify various tastes able to distinguish
client should also be
placed on tip and varied tastes.
able to distinguish
sides of tongue.
different tastes.

Have the client

occlude one ear. Out
of the client’s sight, Client should be
Client was able to
place a tickling watch able to hear the
hear tickling in both
2 to 3 cm. ask what tickling of the watch
ears.
the client can hear in both ears.
VIII. and repeat with the
Vestibulocochlear other ear.

The client should The client was able

Ask the client to walk
have upright posture to stand and walk in
across the room and
and steady gait and an upright position
back and assess the
able to maintain and able to maintain
client’s gait.
balance. balance.

Ask the client to say

“ah” and have the
patient yawn to
observe upward Client should be
Client was able to
movement of the soft able to elicit gag
IX. elicit gag reflex and
palate. reflex and swallow
Glossopharyngeal able to swallow
without any
without difficulty.
Elicit gag response. difficulty.

Note ability to
swallow.

The client should be Client was able to

Ask the patient to
able to swallow swallow without
X. Vagus swallow and speak
without difficulty and difficulty and speak
(note hoarseness)
speak audibly. audibly.
 Ask client to shrug
shoulders against
Client should be Client was able to
resistance from your
able to shrug shrug his shoulders
hands and turn head
XI. Accessory shoulders and turn and turn his head
to side against
head from side to from one side to the
resistance from your
side. other.
hand (repeat for other
side).

Ask client to protrude The client should be

The client was able
tongue at midline and able to move tongue
XII. Hypoglossal to move tongue in
then move it side to without any
different directions.
side. difficulty.

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