PHYSICAL ASSESSMENT: ABDOMEN AND MUSCULOSKELETAL
Purpose:
To obtain baseline data of the client’s functional abilities
To assess the general health status of the client
To obtain data that will enable the nurse to establish nursing diagnoses and plan client care
Equipments / Materials:
Pen Light
Neurologic Hammer / Reflex Hammer
Stethoscope
Examination Gloves
PROCEDURE NORMAL ANORMAL ACTUAL
Assessment:
1. Identify the client.
2. Explain the procedure
and discuss how she or
he can cooperate.
Planning:
3. Perform hand hygiene.
4. Provide privacy.
5. Position the client
comfortably allowing
for easy access to the
body part being
assessed.
Implementation:
ABDOMEN
Name:
Bday:
Age:
Health history:
Present condition:
6. Inspect the abdomen Unblemished skin ; Uniform Presence of rash or other
for skin integrity. color; Silver-white striae or lesions ; Tense, glistening
surgical scars skin (may indicate ascites,
edema) ; Purple striae
(associated with Cushing’s
disease)
7. Inspect abdomen for Flat, rounded (convex), or Distended; Evidence of
contour and scaphoid (concave); No enlargement of liver or
symmetry. evidence of enlargement of spleen; Asymmetric contour,
liver or spleen; Symmetric such as localized protrusions
contour; No appearance of around umbilicus, inguinal
bulges or marked ridges ligaments, or scars (possible
hernia or tumor); Bulges or
masses appear
8. Inspect the abdominal Symmetric movements Limited movement due to
movements associated caused by respiration; pain or disease process ;
with respirations, Visible peristalsis in very Visible peristalsis in nonlean
peristalsis or aortic lean people; Aortic clients (with bowel
pulsations in thin persons at obstruction); Marked aortic
pulsations.
epigastric area pulsations
9. Inspect for presence of No visible vascular pattern Visible venous pattern
vascular pattern. (dilated veins) is associated
with liver disease, ascites
and venocaval obstruction
10. Auscultate the Audible; absence of arterial Absent; hypoactive or
abdomen for bowel bruits (swishing) and fiction hyperactive; loud bruit
sounds, vascular rub. over aortic area; bruit
sounds and peritoneal over renal or iliac arteries;
friction rubs. and fiction rub.
(Last ate? After eating
sounds are louder. Per
quadrant. Noise occur 5-
20s.)
11. Perform light No tenderness noted ; With Tenderness and
palpation first then smooth and consistent hypersensitivity; Superficial
deep palpation in all tension; No muscle masses; Localized areas of
four quadrants. guarding; Tenderness may increased tension; Mobile or
be present near xiphoid fixed masses
process, over cecum, and
over sigmoid colon
12. Palpate for an enlarge May not be palpable ; Enlarged ;
liver and spleen. Border feels smooth Smooth but tender
13. Palpate the area Not palpable. Distended and palpable as
above the pubic smooth, round, and tense
symphysis if the mass.
client’s history
indicates possible
urinary retention.
14. Percuss several areas Tympany over the stomach Large dull areas (associated
in each of the four and gas-filled bowels; with presence of fluid or
quadrants for dullness specially over the tumor)
presence of tympany liver and spleen, or a full
bladder
and dullness
MUSCULOSKELETAL
Muscles
15. Inspect muscles for Equal size on both sides of Atrophy (a decrease in size)
size, presence of body hypertrophy (an increased in
contractures, and No contractures size); Malposition of body
tremors No fasciculation or tremors part (foot drop or foot flexed
forward); Presence of
(Compare each muscle on
fasciculation or tremors
one side to the same on the
other side. Use measuring
tape if available.)
16. Palpate muscles at Normally firm Atonic (lack tone)
rest to determine
tonicity.
17. Palpate muscles while Smooth coordinated Flaccidity (weakness or
client is active and movements laxness); Spasticity (sudden
passive for flaccidity, involuntary muscle
spasticity and contraction)
fasciculation or tremors
smoothness of
movement.
18. Test Muscle Strength Equal strength. 25% less muscle strength.
(right and left).
Bones
19. Inspect the skeleton No deformities. Bones misaligned.
for normal structure
and deformities.
20. Palpate the bones for No tenderness or swelling. Presence of tenderness or
edema or tenderness. swelling.
Joint
21. Inspect for the No swelling One or more swollen
location, color and joints
swelling or masses
22. Palpate for any No tenderness, swelling, Presence of tenderness,
tenderness crepitation crepitation (crackling or swelling, crepitation, or
and presence of grating), or nodules. nodules.
nodules
23. Assess joint Range of Varies to some degree in Limited range of motion in
Motion (ROM). accordance with person’s one or more joints
genetic makeup and degree
of physical activity
Cervical, Thoracic and Lumbar Spine
24. Observe for symmetry, Symmetrical, no tenderness, Tenderness
tenderness and no nodules, no presence of Nodule
presence of pain. pain Pain
25. Perform ROM of the Varies to some degree in Limited range of motion in
cervical spine (neck) accordance with person’s one or more joints
(flexion, genetic makeup and degree
hyperextension, of physical activity
lateral bending and
rotation).
26. Perform ROM of the Varies to some degree in Limited range of motion in
thoracic and lumbar accordance with person’s one or more joints
spine (flexion, genetic makeup and degree
hyperextension, of physical activity
lateral bending and
rotation).
Shoulders, Arms and Elbows
27. Observe the shoulders Symmetrical, uniform in Tenderness
and arms for the color, no swelling or masses; Nodules
symmetry, swelling, uniform in size & shape, no Swelling
color and masses. deformities Pain
28. Perform ROM of the Varies to some degree in Limited range of motion in
shoulder (Adduction, accordance with person’s one or more joints
aduction, external and genetic makeup and degree
internal rotation). of physical activity
29. Observe for the Symmetrical, uniform in Tenderness
elbow’s size, shape, color, no swelling or masses; Nodules
deformities, redness uniform in elbow size & Swelling
or swelling. shape, no deformities Pain
30. Palpate for the Not palpable and no Tenderness
olecranon process and tenderness or effusion Nodules
epicondyles in relaxed (fluid). Swelling
and flexed position. Pain
31. Perform ROM of Varies to some degree in Limited range of motion in
elbows. accordance with person’s one or more joints
genetic makeup and degree
of physical activity
Wrist
32. Inspect and palpate Symmetrical, no tenderness, Tenderness
for size, shape, no nodules, no presence of Nodules
symmetry, color and pain Swelling
swelling. Then palpate Pain
for snuffbox for
tenderness ad
nodules.
33. Perform ROM of the Varies to some degree in Limited range of motion in
wrist. (Flexion, accordance with person’s one or more joints
hyperextension, radial genetic makeup and degree
and ulnar deviation) of physical activity
Hands and Fingers
34. Inspect for size, shape, Symmetrical, uniform in Redness
symmetry, color and color, no swelling or masses; Swelling
swelling of hands, uniform in size & shape, no
fingers and deformities
metacarpophalangeal
joint.
35. Palpate for No tenderness; no Tenderness
tenderness, swelling of crepitation; no nodule Nodules
bony prominences, Pain
nodules or crepitus of
each interphalangeal
joint.
36. Perform ROM of hands Varies to some degree in Limited range of motion in
and fingers accordance with person’s one or more joints
(abduction, adduction, genetic makeup and degree
flexion and of physical activity
hyperextension,
thumb away from
fingers, thumb
touching base of small
finger).
Hips
37. Inspect and palpate Symmetrical, uniform in Tenderness
for shape, symmetry, color, no swelling or masses; Nodules
stability, tenderness uniform in size & shape, no Swelling
and crepitus. deformities Pain
38. Perform ROM of the Varies to some degree in Limited range of motion in
hips (hip flexion with accordance with person’s one or more joints
extended knee genetic makeup and degree
straight, hip flexion of physical activity
with knee bent
abduction, adduction,
internal and external
rotation,
hyperextension).
Knees
39. Inspect the knees for Symmetrical, uniform in Redness
the size, shape, color, no swelling or masses; Swelling
symmetry, swelling, uniform in size & shape, no
deformities and deformities
alignment.
40. Palpate for No tenderness; no Tenderness
tenderness, warmth, crepitation; no nodule Nodules
consistency and Pain
nodules.
41. Perform ROM of the Varies to some degree in Limited range of motion in
knees (flexion, accordance with person’s one or more joints
extension, genetic makeup and degree
hyperextension, ask of physical activity
the patient to walk).
Ankles and Feet
42. Perform ROM of the Varies to some degree in Limited range of motion in
ankles and feet accordance with person’s one or more joints
.(dorsiflexion, plantar genetic makeup and degree
flexion, eversion, of physical activity
inversion, abduction,
adduction, flexion and
extension)
Evaluation:
43. Evaluate if findings
from the physical
assessment is within
normal limits.
Documentation:
44. Document and report
significant findings.
