UNIVERSITY OF CEBU-LAPULAPU AND MANDAUE

COLLEGE OF NURSING

SKILLS LABORATORY
PERFORMANCE CHECKLIST

PHYSICAL ASSESSMENT

Name :_______________________________ YR. & SEC___________ DATE_________GRADE_____

Legend:
Ex- Excellent
VS- Very Satisfactory
G- Good
F- Fair
P- Poor

Possible questions to ask students (Self-directed activities):

1. Definition: Physical Assessment?

2. Purposes of conducting Physical Assessment
3. Questions related to Anatomy and Physiology
4. Anatomical positions/points
5. The 12 Cranial nerves
6. Different heart sounds and abnormal sounds
7. Different lung sounds and abnormal sounds
8. Medical handwashing
9. Principles of sterility
10. Gloving
11. Normal values- Temperature
a. Pulse rate
b. Respiratory rate
12. Patient Positioning
13. Reflexes

PROCEDURE RATIONALE

NOTE: INTEGUMENTARY SYSTEM (skin,

hair, scalp, and nails)
 This is integrated into the examination of other
systems. But it is important to note what to assess
when examining the integumentary system.

Inspect and Palpate

1. Color to inspect the color/abnormalities of the skin.

2. Lesions, and anatomic location and distribution: palpate

the lesions with finger pads for mobility, contour (flat,
raised, or depressed), and consistency (soft or durable.) finger pads are used for discriminatory
sensation

3. Moisture (wetness and oiliness): note amount and

distribution. checking skin can help the nurse determine
skin problems.

4. Temperature: palpate using the back of the hand noting

uniformity of warmth.
the back of the hand gives gives fair and
accurate assessment of the skins
temperature. Thus, the skin is warm.

5. Texture (quality, thickness, suppleness): palpate using

the finger pads in different areas.
to identify normal structure, masses, and
assess for tenderness.

6. Mobility and turgor (elasticity) to know how long the indentation remains
 Palpate dependent areas (sacrum, feet, and ankles) when the fingers are removed.
for mobility by applying pressure with fingers,
noting the degree of indentation. Ig indentation
occurs firmly apply pressure with your thumb for 5

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secs: note the degree of edema based on the depth

of indentation in centimeters
 Pinch a fold of skin in the sternal area using your
thumb and forefinger. Note the speed with which it
returns into place (turgor).

HEAD AND FACE: INSPECT AND PALPATE

1. Inspect head and face for size, shape, contour, and To determine the abnormalities finding that
symmetry in proportion to the body. occurs in development

2. Inspect the scalp for scaliness and scars. To inspect and determine the patient's scalp
through touch/feel if there is a lice/notice
that causes its scars.
3. Palpate scalp To ensure that there are no regions of
bogginess, oedema, or fluid accumulation
since some of the anomalies are fairly
significant.

4. Use tips of middle and index fingers to feel temporal To find out the beat or its palpate of the
arteries ( You may listen for bruits using a stethoscope). temporal arteries.

5. Slide down fingers down slightly and feel the mandibular To access the joint mobility and motor
joins. Palpate while you let the patient open and close his function of the mandibular part of the
mouth. patient.

6. Ask the client to raise and lower the eyebrows, bare his Determine if the client can raise & lower both
feet, smile broadly, puff his cheeks and keep his mouth eyebrows, puff it cheeks.
closed as you try to open it.

7. Assess the patient’s ability to identify simple touch To estimate if the patient's ability can feel
(using a cotton ball or paper clip) have the patient tell you and identify the things that are quiet touch.
“now” when he feels the object touch him. Check on both
sides of the forehead, cheeks, and jaw.

EYES: INSPECT and PALPATE

1. Assess visual acuity. To test the client’s ability to read letters near
 Ask the patient to stand 20 feet from the Snellen and far without wearing corrective lenses.
chart. Ask the patient to identify the letters. If the
patient is wearing corrective lenses, ask him to
remove them first. Instruct client to covers one eye
and read lines starting from top from left to right.
Repeat the procedure with the other eye and then
with corrective lenses. Record results as a fraction
of 20 distance number and the number of letters.

2. Place your fingers 12 inches from the client’s eyes. Ask To test the client’s eyes ability to adjust from
the client to follow the movement of your finger with your near vision to far.
eyes. Move your fingers to the upper right, far right, lower
right, upper left, far left, and lower left.

3. Place your finger 4 inches from the patient’s nose. Ask To test if the client’s eyes are moving inward
him to look at your finger, then to the wall behind you then as they focus on a close object using near
back at your finger again. vision.

4. Perform the cover-uncover test. While the client stares

at the wall behind you, cover one eye with the card. To assess proper alignment of the eyes of the
Observe the uncovered eye client’s eyes.
Uncover the eye and watch the covered eye.

5. Assess the eye and external eye structures. To check the eyelid and brow position and
abnormalities of the external eye structure.
6. Ask the client to close his eyes and gently palpate the Gently palpate the eyes in order to avoid
eyelids for nodules and tenderness. hurting the patient.

7. Ask the patient to look up and evert the lower eyelids to In doing so, you can better visualize the
observe the lower conjunctiva. Continue by having the sclera and palpebral conjunctivae.
client look down and pull his upper eyelid to inspect the
upper conjunctiva and sclera.

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8. Palpate the lacrimal apparatus by gently passing below reveal distention or expression of fluid from
the orbit near the nose. the puncta, thus diagnosing obstruction,
patent canaliculi and blockage proximal to the
lacrimal sac or nasolacrimal duct.
9. Have the patient stares straight ahead while you shine a It should be 12 inches away to ensure the
light at the bridge of his nose 12 inches away. pupillary constriction to light.

10. Inspect the pupil by comparing it with the standard Pupils should be round and bilaterally equal in
sizes on your card as prescribed. size. This, the pupil’s diameter usually ranges
from 2 to 5 mm.
11. Dim the room: shine a light on one pupil approaching Allows the eye to adjust from the amount of
from the periphery. light reaching the retina and protects the
photoreceptors from bright lights.
12. Assess the internal eye structures utilizing the It should be 15 inches away; in order to
ophthalmoscope. Have the patient look straight ahead and avoid accidents. This allows us to inspect the
about 15 inches away shine the light directly on his pupil. macula clearly.
Keep looking to the red reflex as you move towards the
patient. As retinal details become sharper follow the vessels
until they converge at the optic disco on the retina.
Note: Always view the macula last because shining the light
on may cause tearing and papillary constriction.

13. Perform the corneal sensitivity test using the cotton It should elicit a blink response that is
wisp. symmetric between the sides. Failure to blink
may indicate reduced sensory function in the
first division of the trigeminal nerve on the
side of decreased response.

EARS: INSPECT AND PALPATE

1. Examine external ears for placement, symmetry, and To examine the ear ensures that any
color. abnormalities/infection are detected

2. Palpate the ears Examine the tympanic membrane using an

otoscope.
3.Palpate mastoid process The mastoid and tragus should be palpated
for tenderness, To indicating mastoiditis and
otitis externa
4. Test hearing acuity It will be assessed by determining the
intensity at which a tone is just audible.
 Voice Test To test the auditory function of a client/
Occlude the clients and gently wiggle your finger to patient if there’s a detecting hearing
one ear and stand 1-2 feet away from the patient. impairment done accurately in a whispered
Whisper 2- syllable word on the open ear. Ask the voice test.
client to repeat the words you mentioned. Repeat
procedure on the other ear.

 Weber Test To test for evaluating hearing loss and to

Use tuning fork on the mastoid (for bone detect unilateral conductive and sensorineural
conduction/BC) process. Count the number of hearing loss of a client/patient.
seconds until the client can no longer hear the
sound. Immediately place the vibrating fork in the
front midline on the client’s skull. Ask the client to
describe the sound.

 Rinne Test strikes the tuning fork and places it on the

Place stem of tuning fork on the mastoid (for bone patient's mastoid process to measure bone
conduction/BC) process. Count the number of conduction. To differentiates sound
seconds until the client can no longer hear the transmission via air conduction
sound. Immediately place the vibrating fork in front
of his ears and count the seconds again until the
client say he can no longer hear the sound (for air
conduction/AC).

5. Perform otoscopic exam. Penlight may be used to to facilitate in the visualization and
examine the external ear. examination of a client's ear canal and
eardrum
6. Examine the tympanic membrane or eardrum. Note the to evaluate the condition of the ear canal,
malleus, incus, and light reflex. tympanic membrane and the middle ear.

NOSE AND SINUSES: INSPECT,

PALPATE, AND PERCUSS

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1. Inspect for symmetry, deformity, flaring, or To inspect and note abnormalities from the
inflammation and discharges from nares. nares.

2. Test patency of the nostrils. Instruct the client to To determine the patency of both nasal
occulate the nostrils while you let him inhale and exhale. cavities, or if there’s unusual findings in the
Repeat test on opposite nares. nose.

3. If the client compared loss of smell, test the olfactory To check if the nostrils are open enough and
nerve. Have his eyes close and let him identify common if it is not resistant to airflow.
scents.

4. Inspect nasal cavity with the nasal speculum (optional) The penlight allows the nurse to oversee the
or with the use of a penlight. Tilt the client’s head back unusual cavity found in the client’s nose.
slightly, then evert client his nose. (Tilting of head ensures better angle)

5. Observe the nasal septum. To assess if there are no damages in the

nasal septum.
6. Palpate the nasal sinuses by applying gentle, upward To identify certain conditions such as sinusitis
pressure on the frontal and maxillary areas, avoiding involving the frontal or maxillary sinuses.
pressure on the eyes. Percuss area with the middle or index
finger. (If pain is noted then assess the sinus further for
transillumination.

MOUTH: INSPECT AND PALPATE

1. Before observing the mouth, ask the client to remove To overlook the better sight in the mouth
any dentures. without any dentures

2. Stand 12-18 inches in front of the client and smell the In order to detect if there’s any bad smell of
breath. the breathe at 12-18 inches away in front of
the client or if there is a health problem
finding
3. Observe the lips for color, moisture, swelling, lesions To observe these so that it can properly
cracking, or edema. identify if there are any abnormal findings.

4. Palpate the lips using thumbs and index fingers. To dense sensory innervation

5.Ask the client to bite down and bare his teeth to assess To inspect if there’s an unusual findings
his jaw alignment.

6. Inspect the oral mucosa with the use of a tongue blade A penlight is used to inspect the back of the
and penlight. patient's throat, looking for pink, symmetrical
and normal-size tonsils.
7. Inspect teeth, gums, soft and hard palate, uvula, and
tongue.

8. Using the gauze pad, hold tongue to one side. Palpate In order to feel the soft tissue structures in
the floor of the mouth. the floor of the mouth

9. Have the client stick out his tongue To oversee the structure of the internal
mouth.
10. Place a tongue blade at the side of the mouth and ask to give unimpeded views of the throat and
the client to push it away. mouth by depressing the tongue.

11. Depress the tongue with a tongue blade and have the Asking the patient to say "Ah” to inspect any
client say “AH”. tonsilar enlargement, redness, or discharge.

12. While the client says “AH” again, inspect the tonsils and To determine the grade of his/her tonsils
pharynx. Grade the tonsils from +1 (visible) to +4 (touch
each other.)

13. If the client reported a loss of taste during health to identify and examine further the client
history, let him identify different flavors: sweet, sour, salty, through letting him taste in different flavor.
and bitter.

14. As the patient swallow to check for the gag reflex. To know and to determine if the client has a
Lightly touch the back of his tongue with a tongue blade. problem in swallowing and choking.

NECK: INSPECT, PALPATE AND

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 PROCEDURE RATIONALE

AUSCULTATE

1. Inspect the neck for symmetry and musculature.

2. Ask the client to touch his chin to his chest, turn to the To check the pt’s ROM.
right then left, tilt his head towards right shoulder then left
shoulder, and tilt his head backward.

3. Ask the client to shrug his shoulders while you provide Shoulders should be evenly spaced and able
resistance. to handle pressure.

4. Ask the client to turn head to the side and provide To maintain a symmetrical neck and midline
resistance when turning back to the midline. with no swelling or lumps.

5. Palpate lymph nodes using circular motions observing To find out if the patient is having problems
the sequence: preauricular, postauricular, occipital, with their neck now or has had problems with
submental, submandibular, tonsillar, superficial cervical, their neck in the history.
deep cervical chain, and post cervical and supraclavicular
nodes. Note size, shape, mobility and consistency, and
tenderness. If you detect swelling and tenderness, identify
the cause.

6. Ask the client to assume the semi-fowlers position. Have To observe the internal jugular vein from the
his head turn slightly away, inspect the internal jugular semi-point fowler's of view.
vein.

7. Have the client sit up and inspect the trachea by To examine the trachea, taking note of any
identifying the sternal notch. abnormalities especially of sternal notch

8. Using the fingers of the left hand, displace the thyroid To examine the thyroid gland for signs of
gland to the right and then place your right fingers between enlargement.
the trachea and sternocleidomastoid. Have the client
swallow.

9. If thyroid feels enlarged, auscultate to hear for bruits to hear some sounds but no bruits should be
using the bell of the stethoscope. detected.

10. Observe carotid arteries for pulsations. Gently palpate Pulses should be consistent and forceful, but
using the middle and index fingers. Remember to palpate not bounding.
one carotid artery at a time so you don’t block the flow.

11.Have the client take a deep breath while you listen to holding one's breath causes an increase in
the carotid artery with the bell of the stethoscope. arterial carbon dioxide tension.

THORAX: INSPECT , PALPATE, PERCUSS

AND AUSCULTATE

Posterior Thorax

1. Place the client in a sitting position. By this position, you expose more pulmonary
parenchyma to the examiner's hands and
ears.
2. Assess shape and symmetry. Note rate and rhythm and The chest must expand symmetrically
respirations, movement of the chest wall with deep
inspiration and full expiration, and signs of distress.

3. Estimate the anteroposterior diameter in proportion to to ensure that the posterior is a "bucket-
lateral diameter. handle" sign when assessing the thorax.

4. Use finger pads to palpate the spinous process Since the finger can detect the bony
projection off the posterior (back) of each
vertebra.
5.Assess respiratory expansion by placing thumbs at the Look for any unexpected anomalies in the
level of T10. Spread fingers and allow a small fold of skin thumb movement.
between your thumbs. Ask the client to take a deep breath,
slow breath, as he does, watch your thumbs move with
respiration.

6. Instruct the patient to fold his arms across his chest. It may be detected with the stethoscope
Assess tactile fremitus, use the balls of your hand to feel when the patient says "99," which is normally
for vibrations, and have the patient say “99”. Move from barely heard but becomes more audible when
apices to the bases and lower lateral thorax. the lung consolidates.

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 PROCEDURE RATIONALE

7. Percuss posterior thorax in a systematic pattern. to evaluate diaphragm movement.

8. Ask the patient to exhale and hold it. Percuss starting

from the scapula down to where the sound changes from To find out how much air is in your lungs.
resonance to dullness. Mark this spot with a pen then ask
the patient to inhale deeply and hold it while you percuss
down to the area of dullness, then mark this spot. Repeat
the process on the other side. Measure the distance of each
side.

9. Use blunt/ fist percussion over the costovertebral angle No pain or soreness should be provoked.
to assess the kidneys.

10. Auscultate for breath sounds using the diaphragm of to detect of unusual or obnoxious sounds
the stethoscope. Ask the client to fold his arm across his
chest. Let him breathe through the mouth. Instruct client
to inhale and exhale slowly as the stethoscope is felt on the
back. Follow a systematic pattern. Listen at each location
for full respiration. Repeat on the left lung apex.

11. If you suspect abnormalities ask a client to cough and to identify normal respiratory noises
listen again to see if the abnormal sound is cleared. If you from abnormal ones.
still suspect abnormalities, have the patient say “99” and
auscultate again in the same area.

Anterior Thorax
1. Observe the appearance, movement of bones and to observe obvious external markers of
muscles as the client breathes. Instruct client to inhale respiratory function.
deeply and exhale fully. Inspect thorax for symmetry and
depth of movement, rhythm or respirations, the shape of
ribs, and musculoskeletal deformities.

2. Palpate thorax with finger pads from the apices to the To examine signs of pain, perspiration,
bases. abnormalities, lumps, or crepitus.

3. Place hands on the chest along the costal margins with To measure respiratory expansion,
the thumbs pointing towards the xiphoid process. Have the
client take deep breaths.

4. Assess tactile fremitus by asking the client to say “99”. To detect locations of increased or reduced
Move from the apices down to the point below the nipple lung density.
comparing both sides.

5.Percuss using a systematic pattern. In order to assess the similarity or difference

between the tones heard in one place
6. Auscultate using a systematic pattern. Use the In order to listen to the body's interior noises
diaphragm of the stethoscope. of the lungs

7. If you suspect abnormalities, ask the client to cough and to distinguish between normal and abnormal
listen again to see abnormal sound is cleared. If you still breathing sounds or to detect easily the
suspect abnormalities, have the patient say “99” and unusual sound.
auscultate again in the same area.

HEART:INSPECT PALPATE AND

AUSCULTATE
1. Have the client assume a semi-fowlers position. Move to
his right side.

2. Check the apical pulse( PMI). Have the patient exhale To evaluate cardiac function.
and hold his breath. Look at the patient’s 4 th and 5th
intercostal spaces at the midclavicular line. Then palpate it.

3.Inspect precordium area. Note pulsations, heaves, or to examine the properties of the right and left
retractions. ventricular impulses.

4. Inspect and palpate each of the cardiac landmarks:

sternal clavicular area, aortic area, pulmonic area, and left to discover peripheral and systemic effects of
ventricular area. Note pulsations, thrills or heaves, lift, and cardiac illnesses and noncardiac conditions
vibrations.

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that may impact the heart.

5. Auscultate the heart over the aortic pulmonic, mitral to identify heart sounds and murmurs
(PMI) and tricuspid area (4 th ICS) using the diaphragm.
Note the heart rate, rhythm, and normal heart sounds, the
timing of heart sounds. Concerning the cardiac cycle, be
alert for abnormal sounds.

6. Use the bell of the stethoscope and listen for the five The bell is used to detect low-frequency
anatomical areas for extra heart sounds. sounds.

7. In a supine position. Place bell of the stethoscope over The patient should be in the supine posture
visible aortic pulsations and auscultate for 10-15 seconds. for auscultation. This location has produced
typical results.
8. Palpate high in the epigastric region for pulsations. to elicit air movement in the stomach has
been recommended as a routine maneuver
after tracheal intubation even before
auscultating the chest.

BREAST AND AXILLAE: INSPECT AND

PALPATE

1. Inspect the breasts To check for abnormalities in the brest

2. Inspect the nipples Allows the nurse to observe for any sores,
Male: (Supine position) Palpate the nipples, breast tissue, peeling, or change in direction.
and axillae

3. Ask the client to raise arms. Then ask her to press hands The arms should be elevated during palpation
on her hips. Have her lean forward. to distribute the breast tissue over the chest
wall.
4. Instruct the client to place arms at the side. Palpate To determine if there is a unusual occurred
breast in a sweeping manner. found in the breast.

5. Palpate the nipple. Compress between thumb and index to examine the color, consistency, and
finger. quantity of discharge.

6. Instruct the client to assume the supine position.

7. Place the pillow behind the shoulder of the breast being This posture flattens the breast and makes it
examined. Raise the arms on that side. easy to inspect.

8. In palpating the breast, mentally divide the breast into 4 To assess for potential metastases.
quadrants. Palpate also the Tail of Spence, which is
considered as the fifth quadrant as well as the nipple.

9. Palpate also the axillary lymph nodes. reveals the existence or absence of a
malignant or inflammatory condition, and its
localisation or spread.
10. You may also think of the breast as a clock with the Allows the nurse to assess the size, shape,
nipple at the center. Use three methods: hardness, or location of a disease-like
 Using the pads of the fingers, palpate the breast anomaly.
using a circular motion from the center out.
 In and out pattern
 Sweeping manner

MUSCULOSKELETAL: INSPECT AND

PALPATE

Upper Extremities
1. Inspect the patient’s hands. Check for anomalies or abnormalities

2. Check the capillary refill lime (Blanch test). Indication of tissue perfusion and dehydration

3. Palpate brachial pulses. Note its intensity, rate, rhythm, and if any
blood vessel tenderness, tortuosity, or
nodularity
4. Palpate the epithroclear lymph nodes
4.1 Inspect and palpate upper extremities. Note This determines the function of the lymph
arms range of motion (ROM), muscle mass and nodes
strength, vascular system
4.2 Palpate muscle mass at rest and while active

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 PROCEDURE RATIONALE

5. Assess sensory system

 Assess light touch. Randomly touch a cotton wisp Evaluate patient's ability to perceive light
on his arms and have him tell you “now” when he touch in all parts of the body
feels a sensation.

 Assess pain sensation. Use a safety pin randomly Evaluate patient’s ability to distinguish sharp
lightly touch the client’s body with the sharp and and dull.
then blunt end. Be careful not to pierce the skin. A
paper clip may also be used instead of a pin. Ask
the client to identify each sensation as sharp or
dull. Discard the pins after in a biohazard container.

 Test temperature. Prepare two test tubes filled with Evaluate patient’s ability to distinguish hot,
warm and cold water. Touch hot or warm test tube warm, and cold temperatures.
to his check for about one second. Ask the client to
describe the temperature and where he felt it.
Repeat procedure on the opposite cheek, both
arms, and legs.

 Test vibrations. Hold tuning fork from the stem. Psychogenic sensory abnormalities can be
Place it on the client’s elbow. After few seconds, detected by the use of vibration testing.
stop the vibration. Ask the client to tell you when
she feels vibrations and when she feels them, stop.
Repeat the procedure over bony areas.

 Test proprioception. Hold client’s finger. Move it up Examine the patient's ability to control their
and down. With each movement, ask the client to limbs in a coordinated manner.
tell you in which direction you moved his finger.
Repeat this test on the wrist, ankles, and toes.

6. Test fine touch discrimination

-Assess stereognosis (ability to identify an object for its Evaluate the patient’s ability to recognize
size and shape). Ask the client to close his eyes while you objects by touch
place an object in his hand. Use common objects such as a
spoon, paper clip, cup, coin, and key. Then ask him to
identify the object.

-Have the client open his palm up. Use a finger or blunt Evaluate the patient’s ability to recognize
object to draw a large number on her palm. Ask her to letters or numbers drawn on the finger or
identify the number. palm (graphesthesia)
-Two-point discrimination. Use ends of 2 paper clips. Touch Evaluate the patient’s ability to distinguish
a finger pad simultaneously with the ends of the paper clip. between two distinct and sharply contrasting
Alternate this touch using the end of only one paperclip. skin stimuli presented at progressively
Ask the client to identify one or two-point touches. As you decreasing distances
repeat the test, bring the points closer together.

7. Assess for motor system.

-Assess the deep tendon reflexes The muscle contraction should be seen and
a) Biceps reflex felt and compared side-to-side. If reflexes are
b) Triceps reflex diminished or absent, try reinforcing the
c) Brachial radials reflex reflex by distracting the patient or having the
patient contract other muscles
-Assess the cerebellar function Observe for rhythm, steadiness, speed, and
Rapid alternating movements precision of movements
 Ask the client to pat his knees with his palms up
and down gradually increasing the speed.
 Ask the patient to touch his thumb to each finger
on the same hand and reverse the direction.
 Assess point-to-point localization using finger-
finger test by asking the patient to touch his finger
to your finger then his nose.
 Perform the finger-to-nose test.

8. Test and grade muscle strength

 Deltoid
Clients hold their arm up and resist while the nurse Evaluate patient’s weakness and can be
tries to push it down. effective in differentiating true weakness
from imbalance or poor endurance.

 Biceps Observe if the biceps are wek then the

The client fully extends each arm and then tries to patient will pronate the forearm before
flex it while the nurse attempts to hold the arm in flexing the elbow
extension.

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 PROCEDURE RATIONALE

 Triceps Adducted, the triceps muscle functions as a

The client flexes each arm and then tries to extend stabilizing force to keep the humerus' head in
it against the nurse’s attempt to keep the arm in the socket. To avoid humerus displacement,
flexion. perform this action. At the shoulder, the long
head aids with arm extension and adduction.
 Wrist and Fingers When you try to force the fingers together,
The client spreads the fingers and resists as the the client spreads his or hers widely and
nurse attempts to push the fingers together. refuses.

 Grip strength Client grasps your index and middle fingers

The client grasps the nurse’s index and middle while you try to pull the fingers out.
fingers while the nurse tries to put fingers out.

ABDOMEN : INSPECT, AUSCULTATE,

PERCUSS, PALPATE

1. Before examining the abdomen assesses the patient’s Most gastrointestinal and genitourinary
history if abdominal pains have been reported and examine disorders can be diagnosed by an abdominal
the painful area last, Check also patient’s face for signs of exam, as can anomalies in other organ
pain throughout the examination. systems.

2. Stand at the right side of the client. it makes things easier to do while facing the
patient.
3. Inspect the abdomen from the rib margin to symphysis Inspect, auscultate, percussion, and palpation
pubis. should always be done in this order. The
frequency of bowel sounds can be affected
and the results can become less reliable if
these diagnostic approaches are performed in
a different order.
4. Shine a penlight towards you. Include assessing the Observe abdominal movements associated
umbilicus. with respiration, peristalsis, or aortic
pulsations, as well as vascular pattern.
5. Auscultate four abdominal quadrants using diaphragm of A usculation of the abdomen is used to
stethoscope for bowel sounds (high pitched). identify abnormal bowel noises, rubs, or
vascular bruits.
6. Auscultate for vascular sounds using the bell. Aorta, The aorta, renal arteries, iliac arteries, and
Renal artery, Iliac artery, and Femoral Artery. femoral arteries are common places to hear
bruits. Using the stethoscope's bell to detect
bruits is the most effective method.
7. Percuss all four quadrants in systematic fashion (RLQ, The small and large intestines occupy the
RUQ, LUQ, and LLQ). majority of the remaining space in a healthy
abdomen. Play around with different sounds
in each quadrant to get a sense of what is
usual.
8. Assess the liver. Percuss from the right lung area to the
mid-clavicular line until dullness is heard. The purpose of liver percussion is to measure
the liver size.

9. Mark this point which indicates the liver’s upper border.

10. Then percuss from the umbilical level up to the mid- Percussion is done to determine the size and
clavicular line until dullness is perceived. density of the structures and organs inside of
the abdominal cavity, and to detect the
presence of air or fluid.
11. Mark this point which indicates the liver’s lower border. Feel for soreness and mass to get a rough
idea of the liver's size. Be aware that many
liver disease symptoms can be present
outside of the abdomen. The lower boundary
of liver dullness should be much below where
the right hand is placed on the patient's
abdomen when they are lying supine.
12. Measure the distance between the two marks to The liver span is a physical examination
estimate the size of the liver. measurement used to estimate the liver's
size and find signs of hepatomegaly.
13. Assess the stomach. Percuss from the left upper An examiner may be able to explain how the
quadrant. tympanitic percussion notes change from
resonant to dull and finally tympanic as the
percussion moves from the lung to the liver.
14. Have the patient roll on his right side and assess the Observe for evidence of enlargement of the
spleen. Percuss from the 6th rib down to the mid-axillary spleen
line.

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 PROCEDURE RATIONALE

15. Assess the bladder. Start 5 centimeters above the Inquire into the language used to describe
symphysis pubis and percuss downward. the sensations of pain, fullness, and difficulty
in emptying. The patient was able to feel a
swollen bladder in the suprapubic region. If
you get a feeling of fullness in your bladder
or notice a bulge above your pubic
symphysis, this is a sign of urine retention.
16. Perform light palpation first, use finger parts to depress
the abnormal wall 1 cm starting on the RLQ, and move Tenderness in a particular quadrant or area is
clockwise on all four quadrants. Never palpate areas where often detected using this test, which is
bruits are heard. frequently the first one conducted. Palpation
of the abdomen to a depth of 4–5 cm is
considered deep.

17. Then switch to deep palpation depressing up to 5-8 cm

in the same manner. Note the size, location, consistency, Deep palpation is a technique for locating and
and mobility of the abdominal organs. evaluating tenderness in normal tissues and
masses. It is necessary to press 1.5-2.0
inches into the abdomen during deep
palpation. It's possible that the abdominal
organs won't be palpable in an obese patient.

18. Ask the client to relax his abdomen. Palpate the liver by Liver palpation is used to determine the size
sliding your left hand under the client's back approximately and soreness or bulk of the liver, among
at the location of the liver. Place your right hand at the other things. Be aware that many liver
right costal margin. Gently press in and up as the client disease symptoms can be present outside of
inhales. Note any irregularities or tenderness. the abdomen. The lower boundary of liver
dullness should be much below where the
right hand is placed on the patient's abdomen
when they are lying supine.
19. If non-palpable, try “hooking” it. Stand next to the
client’s right shoulder and place your hand's side by side In some patients, the abdominal organs won’t
below the right costal margin. Then press your fingers in be palpable, mostly for obese patients.
and up as you attempt to feel the edge of the liver.

20. Palpate the gallbladder using the same technique with Palpate the gallbladder and check for
liver palpation. enlargement

21. Palpate the spleen. Place your left hand behind his back Several essential clinical diagnoses are
at the 10th or 12th rib and push up. Place your right hand accompanied by an enlarged spleen. The
below the left costal margin. Push right hand in and up spleen can be identified by palpation and
toward the axilla. Then have the patient take a deep percussion of the organ.
breath.

22. Palpate the bladder. Begin placing the index and middle It is possible to identify an enlarged bladder
finger at the midline about 2 ½ cm above the symphysis with gentle probing of the lower abdomen in
pubis. Palpate upward until you feel the edge of the neonates. Detecting tiny masses or kidney
bladder. enlargement by deep palpation is easiest to
achieve shortly after birth when the newborn
is still, quiet, and not yet receiving much
nourishment.
23. Palpate the right kidney by placing the left hand under If a patient has tender or ballotable kidneys,
the waist below the 12th rib and the right hand directly this might reveal a much about the
above it. Bring the hands together as you instruct the underlying cause of their renal disease,
patient to take a deep breath. including whether or not they have polycystic
kidney disease.
24. Palpate the aortic pulsations. Place the thumb and When listening for cardiac murmurs, it's a
index finger to the left of the midline. Estimate the good idea to palpate an artery first. A
pulsations width. murmur's diastolic or systolic nature can be
determined significantly more quickly with
this method. Use any artery in the arm or
hand for this procedure. It's also critical to
ensure that the patient is properly positioned.
25. Check the abdominal superficial reflex. Stroke the As the umbilicus is stroked, an abdominal
handle of a reflex number across the abdomen from the reflex is activated, which is a superficial
side to the midline. neurological response. It can be useful in
assessing the severity of a CNS lesion
26. Raise the patients' gown and palpate the inguinal Palpation of the lymph nodes can reveal
lymph nodes. whether a malignant or inflammatory
condition is present, as well as whether it is
localized or generalized.
27. Assess for hernias. Instruct the patient to bear down as In order to make a hernia more noticeable,
you inspect the inguinal and femoral areas. you'll likely be advised to stand and cough or
strain. An abdominal ultrasound, CT scan, or
MRI may be ordered by your doctor if the

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 PROCEDURE RATIONALE

diagnosis isn't clear.

28. Palpate the inguinal canal for hernias. Place the index In order to diminish the hernia and bring
finger along with the upper scrotal sac and insert your back the contents of any mass identified on
fingertip on the external ring. Have the patient bear down examination of the groin, gentle groin
while gently pushing your finger. pressure should be used. With the patient
lying down on the examination table,
incarcerated hernias can be decreased more
easily.

MUSCULOSKELETAL: INSPECT AND

PALPATE

Lower Extremities
1. Inspect lower extremities throughout the procedure. Why is it important to check the;
Note the legs' range of motion (ROM), muscle mass, and ROM (Range of Motion) - the measurement
strength, vascular system. of movement around a specific joint or body
part.
Muscle Mass- As your muscle mass
increases, the faster your body is able to
burn calories/energy. This leads to an
increase of your basal metabolic rate (BMR),
which helps in losing weight.
A. Vascular System
2. Inspect the legs. Note the skin color, condition, hair Inspecting the legs allows the nurse to note
distribution, and nail integrity. any abnormalities.

3. Using the back of the hands, check the temperature of The back of the hand allows fair and accurate
the legs from the feet upwards measurement of temperature of the legs.

4. Flex the patient’s knee and compress the calf muscles

against the tibia to release the pressure. And dorsiflex the
patient’s foot.

5. Palpate the femoral artery. Palpating the femoral artery allows the nurse
to feel the femoral pulse.

The femoral pulse may be the most

sensitive in assessing for septic shock and is
routinely checked during resuscitation.
6. Assess the popliteal pulse in flexing the patient’s knee. Assessing the popliteal pulse allows the nurse
Place one thumb on the knee and fingers behind it. to check the status of the popliteal artery.

7. Palpate the posterior tibialis pulse, dorsalis pedis pulse. Palpating the posterior tibialis pulse allows
the nurse to check the status of the tibial
artery and dorsalis pedis pulse for dorsalis
pedis pulse.
8. Assess for edema by pressing over the tibia or medial Assessing the edema allows the nurse to note
malleous for 5 seconds and release. for the presence of pitting edema which is a
Note: If the presence of pitting enema is noted, grade from serious health issue.
a scale of 1(mild) to 4(severe)

B. Sensory System
9. Light touch Light touch sensibility is a necessary
component for the discrimination of fine
touch
10. Pain sensation Assessing the pain sensation of the pt allows
the nurse to test his alertness for potential
damage.
11. Temperature Assessing the pt’s body temperature allows
the nurse to observe/ note possible illness
such as fever.
12. Vibration Assessing the pt's ability to feel vibration
allows the nurse to test the vestibulocochlear
nerve.
13. Proprioception Assessing the pt's proprioception allows the
nurse to observe the pt’s motor skills, muscle
strength, and balance.
C. Motor Function
14. Assess the deep tendon reflexes Assessing the DTR helps in noting the
 Quadriceps reflex integrity of the motor system.
 Achilles reflex
 Babinski reflex Importance of Reflex:
- They protect us from danger, they help us
move our body and they help us to see.

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 PROCEDURE RATIONALE

15. Test and grade muscle strength

 Hip muscles
The client is supine with both legs extended.
 Hip abduction
The nurse’s hands are on the lateral surface of each
knee and provide resistance.
 Hip adduction
The nurse’s hands are now placed between the
knees.
 Quadriceps
Knees are partially extended.
D. Cerebellar Function
16. Ask the client to perform a heel to chin test. to test the pt’s measure of coordination .

17. Ask the client to sit upright without support. Evaluate to test the pt's ability to balance and
balance and coordination. coordinate his body without support.
(vestibulocochlear nerve)
18. Ask the client to sit on the side of the bed or examining
the side.

19. Ask the client to stand.

20. Assess the patients gait and gross motor function. Have to check for abnormalities in locomotion.
the client walk 10-15 feet turn and walk back.

21. Perform Romberg test if the client has weakness or gait allows the nurse to test the pt’s sense of
abnormalities. balance

22. Assess tendon walking asks the client to walk heel-to- assessing the achilles tendon allows the nurse
toe, observe her balance. Stand nearby to reassure her to to observe the pt’s ability to observe balance
provide assistance. while tip-toeing

EXTERNAL GENITALIA AND ANUS: INSPECT

AND PALPATE

Female
1. Place the client in a lithotomy position. It gives better access for the nurse to assess
the genetalia and anus.
2. Elevate head for comfort.

3. Drape the client’s torso and thigh to expose external Draping the client’s torso and tight facilitates
genitalia. better access for assessment.

4. Don gloves To facilitate hand hygiene and minimize

spread of microorganisms.
5. Inspect mons pubis and vulva. Observe skin color and Pubic hair should be distributed in an inverted
condition. Separate labia majora. Note color, lesions, or triangular pattern and there are no signs of
trauma. infestation.

6. Inspect the clitoris using the dominant hands thumb and The clitoris is a small
index finger. Separate the labia minora laterally to expose mound of erectile tissue, sensitive to touch.
the prepuce of the clitoris. Note size and condition. The normal size of the clitoris varies.

7. Keeping the labia minora retracted laterally. Inspect the

vaginal introits. Inspect the client to bear down while you
note patency and bulging.

8. Inspect the perineum and anus. Note texture and color The anal opening should appear hairless,
of perineum, color, and shape of the anus. moist, and tightly closed.

9. Palpate the labium between the thumb and index finger Bartholin’s glands are usually soft, non-
of the dominant hand for swelling, indurations, pain, or tender, and drainage free.
discharge from a Bartholin gland.

10. Inspect the perineum and anus. Note the texture and
color of the perineum, color, and shape of the anus.

Male
1.Instruct the client to stand with legs spread slightly. To facilitate the assessment.

2.Don gloves Proper hand hygiene and protection from

microorganisms.

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 PROCEDURE RATIONALE

3. Assess the glans penis, urethral meatus, scrotum, and Retracting the foreskin allows the nurse to
inguinal areas. Instruct uncircumcised client to retract the asses it properly.
foreskin.

4.Inspect the anterior and posterior surfaces by lifting the To observe for abnormalities
penis. Note lesion, swelling, or inflammation (Client can
replace the foreskin).

5.Inspect the urethral meatus. Note location and color, The urinary meatus is normally free of
observe for discharge (culture and discharge). discharge.

6.Inspect the scrotum by placing the penis to one side to

assess the scrotal skin. Lift the posterior side.

7.Palpate the shaft of the penis using one thumb and first
two fingers to assess the entire length of the penis. Note
pulsations, tenderness, swelling, and masses of plaques.
Note lesions, inflammation, and swelling.

8.Palpate the inguinal areas with client standing. Instruct

the client to strain.

9.Examine the anal and rectal area with the client in the to make sure causes of rectal bleeding such
side-lying position. as hemorrhoids are not missed.

10.Spread the buttocks with your non-dominant hand. The anal opening should appear hairless,
Inspect sacrococcygeal and perineal areas. Observe for moist, and tightly closed.
excoriation, rashes, inflammations, and nodes. Palpate any
nodules for tenderness.

11.Lubricate gloves to the index finger of the dominant To facilitate smooth process of examining the
hand. anus.

12.Instruct the client to strain down. Place pad of index Straining down allows the nurse to easily
finger over anus. acess and assess the anus of the pt

13.As the sphincter relaxes, insert a finger pad into the

anal canal pointing toward the umbilicus. Note sphincter
tone, tenderness, or nodules.

14.Insert finger further and palpate as much of rectal wall

as possible in sequence (right lateral, posterior, lateral
surfaces), noting nodules, irregularities, or undue
tenderness.

______________________________________

Signature of Student/Date

_______________________________________

Signature of Supervising Clinical Instructor/Date

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