EYES

 People under age 40 should have their eyes tested every 3 to

5 years

 After age 40, every 2 years

 Refractive errors
 Myopia- near sightedness
 Hyperopia- farsightedness
 Prresbyopia- loss of elasticity of the lens thus losing its ability to
see close objects
 Begins at about 45 yrs old
 Astigmatism- uneven curvature of the cornea that prevents
horizontal and vertical rays from focusing in the retina
◼ Eyes
◼ Evenly placed and
inline with each
other.
◼ Non protruding.
◼ Equal palpebral
fissure
 Common inflammatory disorders
 Conjunctivitis
 Inflammation of the conjunctiva
 Dacrocystitis
 Inflammation of lacrimal sac
 Hordeolum
 Sty
 Redness, swelling and tenderness of
the hair follicle and glands at the
eyelids
 Iritis
 Inflammation of the iris
 Contusions or hematoma
 Black eye
 Cataract- opacity of the lens
 Glaucoma- increase in intraocular
pressure
 Ptosis – drooping of the eyelids
 Mydriasis
 Dilation of the pupils
 Glaucoma,
atropine, cocaine,
amphetamine use

 Miosis
 Constricted pupils
 Inflammation of the
iris, morphine,
heroine, narcotics,
barbiturates or
pilocarpine use

 Anisocoria
 Unequal pupil size
 Position and Alignment of the
Eyes
 Stand in front of the patient
and

 survey the eyes for position

and alignment. If one or both
eyes seem to protrude,assess
them from above

 Abnormalities:
 Esotropia (inward deviation)
 exotropia (outward
deviation)
 abnormal protrusion in
Graves disease or ocular
tumors
 Eyebrows
 Inspect the eyebrows,
noting their fullness, hair
distribution, and any
scaliness of the underlying
skin.
 Scaliness occurs in
seborrheic dermatitis,
lateral sparseness in
hypothyroidism

 Eyelids
 Note the position of the lids
in relation to the eyeballs
 Inspect form the following:
 Width of the palpebral
fissures
 Edema of the lids
 Color of the lids
 Lesions

 Condition and direction of

the eyelashes:
 Upslanting palpebral
fissures are noted in Down
syndrome.
 Red inflamed lid margins
occur in blepharitis, often
with crusting.
 EYE / EYEBROW /
EYELASHES
Normal findings:
◼ Eyebrows
◼ Symmetrical and in line with
each other.
◼ Maybe black, brown or blond
depending on race.
◼ Evenly distributed.
 EYELIDS / LACRIMAL
APPARATUS

1. Inspect the eyelids for position and

symmetry.
2. Palpate the eyelids for the lacrimal glands.
◼ To examine the lacrimal gland, the
examiner, lightly slide the pad of the
index finger against the client’s upper
orbital rim.
◼ Inquire for any pain or
tenderness.
3. Palpate for the nasolacrimal
duct to check for obstruction.
◼ examiner presses with the

index finger against the

client’s lower inner orbital
rim, at the lacrimal sac, NOT
AGAINST THE NOSE.
◼ 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.
◼ 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.
◼ Eyelashes
◼ Color dependent on race.
◼ Evenly distributed.
◼ Turned outward
 CONJUNCTIVAE
◼ bulbar and palpebral conjunctivae
◼ 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 NO PRESSURE against the eyeball
◼ the examiner should hold the lids against
the ridges of the bony orbit surrounding
the eye.
• 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.
- To return the lid to its normal position,
move the lid slightly forward and ask the
client to look up and to blink
- 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
◼ 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
◼ cornea is best inspected by directing
penlight obliquely from several
positions.
 Cornea and Lens
 With oblique lighting, inspect the
cornea of each eye for
opacities.

 Note any opacities in the lens

that may be visible through the
pupil.

 Iris
 At the same time, inspect
each iris.
 The markings should be
clearly defined.
 With your light shining directly
from the temporal side, look
for a crescentic shadow on
the medial side of the iris
 Because the iris is normally
fairly flat and forms a
relatively open angle with
the cornea, this lighting casts
no shadow.
 ANTERIOR CHAMBER /
IRIS

◼ anterior chamber and

the iris are easily
inspected in
conjunction with the
cornea
◼ technique of oblique
illumination is also
useful in assessing
the anterior chamber.
 Normal Findings:

◼ The anterior chamber is transparent.

◼ No visible materials noted
◼ 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
 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
 Visual field testing
 Have the client sit in front of you at a distance of 2 to 3 feet

 Ask client to cover the right eye with a card and look directly at your
nose

 Cover YOUR eye directly opposite the client’s covered eye and look
directly at the client’s nose

 Hold an object in your fingers, extend your arm and move the object into
the visual field from various points in the periphery
 Instruct the client to follow the direction the object hold by the examiner
by eye movements only
 - without moving the neck.
 The object should be at equal distance from the client and
yourself

 Ask the client to tell you when the moving object is first
spotted

 Peripheral objects can be seen at right angles to the central

vision
Six cardinal positions of gaze
 Used to check for muscle
weakness in the eyes

 The client is asked to hold

the head steady, then follow
movement of an object
through the positions of
gaze.

 The client should follow the

object in a parallel manner
with the two eyes

 Assess for nystagmus, an

oscillating movement of the
eye, best noted around the
iris.
 Visual acuity test
 Ask client to read from a
magazine or newspaper
held at a distance of
14inches

 If wearing glasses, have

the patient wear them

 Cranial nerve II
 Position the client in a well-lit spot 20 feet
from the chart, with the chart at eye level

 ask the client to read the smallest line that

he or she can discern.

 Instruct the client to leave on glasses or

leave in contact lenses
• if the glasses are for reading only, they are
removed because they blur distant vision.

 Test one eye at a time

 Record result using the fraction at the end

of the last line successfully read on the
chart.

 Normal visual acuity is 20/20

• distance in feet at which the client is
standing from the chart/distance in feet at
which a normal eye could have read that
particular line

Snellen eye
chart
 Color vision
 Ishihara chart is a tool used to assess color vision

 it determines the client’s ability to distinguish a pattern of color (a number)

in a series of color plates

 The nurse tests each eye separately and asks the client to identify the
number that he or she sees on the chart

 The ability to read the number correctly depends on the normal

functioning of color vision.
Ears and Hearing
Direct inspection

Palpation External

Parts of the ear Middle

Inner
EAR
 External ear
• Pinna or auricle
• Lobule (earlobe)
• Helix ( posterior curve of upper aspect of the auricle)
• Antihelix (anterior curve of posterior aspect)
• Tragus (cartilagenous protrusion)
• Mastoid (bony prominence)
• Auditory canal
• Ceruminous glands • Ear canal curvature
• Cerumen or earwax • Infant and toddler
• Tympanic membrane or eardrum • Upward curvature
• Age 4 onwards
• Downward curvature
Middle ear
• Tympanic membrane
• Pearly white
• Ossicles
• For sound transmission
• Malleus (hammer)
• Incus (anvil)
• Stapes (stirrups)
• Eustachian tube
• Connects the middle ear to the nasopharynx
• Stabilizes the air pressure between the external
atmosphere and the middle ear
• Preventing rupture of the eardrum
 Inner ear
• Cochlea
• Seashell-shaped structure
• For sound transmission and hearing
• Vestibule and Semi-circular canal
• For equilibrium
Sound transmission
• Sound stimulus enters the ear canal and
reaches the tympanic membrane
• Sound waves vibrate the eardrum and
reach the ossicles
• Sound waves from the ossicles to the
opening in the inner ear
• The cochlea receives the sound
vibrations
• Stimulus travels to the auditory nerve
and the cerebral cortex
 EAR
1.Inspect the auricles of the ears for parallelism, size position,
appearance and skin color.
• superior aspect of the auricle should be aligned with the outer
canthus of the eye
• Low set ears are associated with a congenital anomaly such as
Down’s syndrome
• Palpate the auricles for texture, elasticity, and areas of
tenderness
• Gently pull the auricle upward, downward, and backward
• Fold the pinna forward– should recoil
• Push in on the tragus
• Apply pressure to the mastoid process
• SOULD BE MOBILE, FIRM AND NOT TENDER
• PINNA RECOILS AFTER IT IS FOLDED

• Inspect the external ear canal for cerumen, skin

lesions, pus, and blood
• Distal 3rd contains hair follicles and glands
• Dry cerumen, grayish tan color
• Or sticky wet cerumen in various shade
• Abnormal findings
• Redness, scaling, excessive cerumen blocking the canal
 3. Inspect the auditory meatus or the ear canal for color,
presence of cerumen, discharges, and foreign bodies.

◼ a. For adult pull the pinna

upward and backward to
straighten the canal.
◼ b. For children pull the pinna
downward and backward to
straighten the canal
4. Perform otoscopic examination of the
tympanic membrane, noting the color
and landmarks.
• Hold the otoscope either right side up with fingers
between the otoscope and client’s head or upside
down with fingers and the ulnar surface of your
hand against the client’s head
• Stabilizes the head and protects the eardrum and canal
from injury
• Gently insert the tip of the otoscope into the ear
canal
• To prevent client discomfort
• Inspect the eardrum
• Pearly gray in color, semi-transparent
• Red, yellow, blue, dull color
• infection
 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 has 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 upon
inspection.
◼ No discharges or lesions noted at the ear canal.
◼ On otoscopic examination the tympanic membrane
appears flat, translucent and pearly gray in color.
 VESTIBULOCHOCLEAR NERVE
( CRANIAL NERVE VIII) )
Hearing Acuity
Voice test
1. The examiner stands 2 ft. on the side of the ear to be tested.
2. Instruct the client to occlude the ear canal of the other ear.
3. The examiner then covers the mouth, and using a soft spoken
voice, whispers non-sequential number (e.g. 3 5 7 ) for the client
to repeat.
4. Normally the client will be able to hear and repeat the number
5.Repeat the procedure at the other ear
Tuning Fork Test
◼ useful in determining whether the client
has
◼ conductive hearing loss
◼ problem of external or middle ear
◼ perceptive hearing loss
◼ sensorineural
 Weber’s test
◼ assesses bone conduction, this is a test of sound lateralization
◼ To assess bone conduction by examining the lateralization of sounds (sideward
transmission)
Hold the tuning fork at its base
Activate it by tapping the fork gently against the back of your hand near the knuckles
or by stroking the fork between your thumb and index fingers
Place the base of the vibrating fork on top of the client’s head
ask where the client hears the noise
Sound is heard in both ears or is localized at the center of the head --- Weber
negative (normal)
Sound heard better in impaired ear indicating a bone-conducting hearing loss
If sound is heard better in ear without a problem, indicates a sensorineural
hearing loss
WEBER POSTIVE
Rinne Test
◼ Compares bone conduction with air condition.
◼ Place the handle of the activated tuning fork on the
client’s mastoid process of one ear until the client states
that the vibration can no longer be heard
◼ Immediately hold the still vibrating fork prongs in front of
the client’s ear canal
◼ Sound conducted by air is heard more readily than bone
conduction
◼ Vibrations conducted by air are normally heard longer
◼ AC hearing is greater than BC hearing (POSITIVE RINNE--
NORMAL) AC>BC
◼ BC>AC or BC=AC (negative rinne—conductive hearing
loss)
NOSE AND PARANASAL SINUSES

Inspection:

1. Placement and symmetry.

2. Patency of nares (done by
occluding nostril one at a time,
and noting for difficulty in
breathing)
3. Flaring of alae nasi
4. Discharge
⚫ external nares are palpated for:
⚫ Displacement of bone and
cartilage.
⚫ For tenderness and masses
⚫ internal nares are inspected by:
⚫ hyperextending the neck of the client
⚫ ulnar aspect of the examiner’s hard
over the fore head of the client
⚫ 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. Check nasal mucosa (turbinates) for
swelling, exudates and change in color
paranasal
sinuses
⚫inspection and palpation of the overlying
tissues
⚫ Only frontal and maxillary sinuses are
accessible for examination.
⚫ palpating both cheeks simultaneously
⚫ can determine tenderness of the
maxillary sinusitis
⚫ pressing the thumb just below the eyebrows
⚫ determine tenderness of the frontal
sinuses
 • 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.
Normal Findings
• Nasal septum in the mid line and not
perforated.
• nasal mucosa is pinkish to red in color
• Increased redness turbinates are typical of
allergy
• No tenderness noted on palpation of the
paranasal sinuses
OLFACTORY
NERVE
⚫ client is asked to close his eyes and
occlude the nose, one nostril at a
time
⚫ The examiner places aromatic and
easily distinguish nose
⚫ e.g. coffee
⚫ Ask the client to identify the odor.
⚫ Each side is tested separately, ideally
with two different substances.
 MOUTH

◼ Lips are 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
 Palpate the
temporomandibular while
Crepitous Deviations
the mouth is opened wide
and then closed for:

Normal Findings:
• Moves smoothly no crepitations.
Tenderness • No deviations noted
• No pain or tenderness on
palpation and jaw movement.
Gums are inspected for:
• Color
• Bleeding
• Retraction of gums.
Normal Findings:
• Pinkish in color
• No gum bleeding
• No receding gums
Teeth are 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:

• 28 for children and 32 for adults.

• White to yellowish in color

With or without dental carries and/or

dental fillings.

With or without malocclusions.

• No halitosis.
Tongue
◼-is palpated for:

◼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 is 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
◼ positioned in the midline
◼ pinkish to red in color
◼ no swelling or lesion noted
◼ moves upward and forward when asked to say “ah”
Tonsils are inspected for:
1. Inflammation
2. Size
Grading system
◼ Grade 1 ␣ Tonsils behind the pillar.

◼ Grade 2 ␣ Between pillar and uvula.

◼ Grade 3 ␣ Touching the uvula

◼ Grade 4 ␣ In the midline.

 NECK
◼ position symmetry
◼ obvious lumps
◼ visibility of the thyroid gland
◼ 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 notch Normal Findings:
using the thumb and
the index finger.

It is positioned in the
The trachea is palpable.
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

• ask 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. 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.
4. The client is asked to turn his head slightly to one side and then the
other of the lobe to be examined.
5. Again the examiner displaces the thyroid cartilage towards the side
of the lobe to be examined.
6. 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

◼ a result of increased and turbulence in

blood flow in an enlarged thyroid.
◼ Check the Range of Movement of the neck.
CHEST
AND
LUNGS
REVIEW OF
ANATOMY
 Procedure

▪ Explain the procedure

▪ Wash hands
▪ Provide privacy
Equipment ▪ Stethoscope
Anterior Chest
Chest deformities:
A, pigeon chest
B, funnel chest
C, barrel chest
D, kyphosis
E, scoliosis.

10
 POSTERIOR THORAX

▪ Inspection
• Shape
• Symmetry
• Measure/estimate the anterior vs lateral chest
diameter
• Spinal alignment for deformities
- Let client stand; observe the 3 normal curvatures
- Cervical, thoracic, lumbar
- Assess for scoliosis (lateral deviation of the
spine)
• Standing
• bending
SCOLIOSIS

15
12
KYPHOSIS

14
 ▪Palpation
▪ Palpation
• Assess temperature and
integrity of all chest skin
• Bulges
• Assess for tender areas
• Palpate painful areas last
• Palpate for respiratory
excursion
• Chest expansion
CHEST EXCURSION

▪ Palms of both hands at

lower thorax
▪ Thumbs adjacent to the
spine
▪ Take a deep breath
▪ Observe movement of
hands
▪ Note for lags
Vocal fremitus ▪ Tactile fremitus

▪ Palmar or ulnar surface

▪ Start palpating at the
apex
▪ Ask client to say “ninety-
nine”
▪ “1-2-3”
▪ Move hands sequentially and
compare fremitus on both
lung fields
▪ Percussion
• heart normally produces an area of dullness to the left of
the sternum from the 3rd to the 5th interspaces
• Percuss the left lung lateral to it
Percussion
 Auscultation

▪ patient breathes
with mouth open,
somewhat more
deeply than
normal
▪ Listen to
the breath
sounds
▪ Identify any
adventitious
sounds
Auscultation

▪ Use the diaphragm of the stethoscope

▪ Listen for breath sounds
▪ Compare
▪ https://drive.google.com/file/d/1A4qq-GdFCeXdo1WD-b
31Mff_nKFhfWwO/view?usp=sharing
Bronchophony