) ) ) ) ) ) ) ) ) GROUP VI:

) ) ) ) ) ) ) ) )
Montecino, Mustafa, Nasil,
Orcine, Osabel

Physical
Assessment
) ) ) ) ) ) ) ) ) CONTENTS
) ) ) ) ) ) ) ) )
CONTENTS

1. INTRODUCTION
2. ASSESSING THE ABDOMEN
3. MUSCULOSKELETAL SYSTEM
4. NEUROLOGIC SYSTEM
5. MALE GENITALIA & RECTUM
6. FEMALE GENITALIA & RECTUM
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
INTRODUCTION

) ) ) ) ) ) )
Introduction

Physical Examination

Physical examination is the process

of evaluating objective anatomic
findings through the use of
observation
palpation
percussion
auscultation
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )

01

ASSESSMENT OF THE Chapter 1

ABDOMEN
Reported by: Nasil, Curtis Meryllle B
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PREPARATION

Gather Equipments:

• Stethoscope • Tape Measure

• Water soluble marker •Gown and drapes
• Ruler with centimeter • Gloves
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PROCEDURE

Introduce yourself and verify the

01 03
client's identity. Explain to the Provide for client's
client what you are going to do, privacy. Ask client to wear
why it is necessary, and how the gown.
client can cooperate.

02 04
Perform hand hygiene, and Position the client
observe other appropriate comfortably - seated, if
infection control procedures. possible.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASK CLIENT ANY HISTORY
OF THE FOLLOWING:

Ask the client for any of the following:Incidence of

abdominal pain
Change in appetite and food intolerances
Bowel habits and problems with bowel movement Food
ingested in the last 24 hours.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )

1. ASK CLIENT TO EMPTY

BLADDER

2. POSITION CLIENT SUPINE; KNEES

SLIGHTLY FLEXED TO RELAX THE
ABDOMEN.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
1. INSPECT THE ABDOMEN FOR SIZE, SHAPE,
SYMMETRY, SURFACE CHARACTERISTICS SUCH
AS COLOR, LESIONS, STRIAE.

NORMAL FINDINGS

Size: Abdomen is flat or slightly rounded.

Shape: Symmetrically rounded without protrusions.
Symmetry: Both sides appear symmetrical.
Surface: Consistent color, no abnormal lesions or striae.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
2. INSPECT UMBILICUS FOR POSITION, CONTOUR,
COLOR, AND DISCHARGE. NOTE ANY BULGES (HERNIAS)
BY ASKING THE CLIENT TO RAISE HEAD FROM THE BED.

NORMAL FINDINGS
Umbilicus Position: Located centrally, usually in line with the midline of the
body.
Contour: Normally flat or slightly convex.
Color: Matches surrounding skin tone, without redness or discoloration.
Discharge: Absence of any discharge or unusual odor.
No bulges or hernias observed when the client raises their head from the
bed.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
2. INSPECT UMBILICUS FOR POSITION, CONTOUR,
COLOR, AND DISCHARGE. NOTE ANY BULGES (HERNIAS)
BY ASKING THE CLIENT TO RAISE HEAD FROM THE BED.

Hernia Bulges
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
3. .AUSCULTATE THE ABDOMEN IN ALL FOUR
QUADRANTS FOR AT LEAST 5 MINUTES USING THE
DIAPHRAGM PORTION OF THE STETHOSCOPE.

NORMAL FINDINGS
Bowel sounds are present in all four quadrants.
Sounds are audible at a rate of 5-30 per minute.
Sounds are typically high-pitched and gurgling.
Absence of abnormal sounds such as bruits or vascular murmurs.
No tenderness or discomfort reported by the client during
auscultation.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
3. .AUSCULTATE THE ABDOMEN IN ALL FOUR
QUADRANTS FOR AT LEAST 5 MINUTES USING THE
DIAPHRAGM PORTION OF THE STETHOSCOPE.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
4. USE THE BELL PORTION OF THE STETHOSCOPE TO
LISTEN FOR VASCULAR SOUNDS (BRUITS OR
VENOUS HUMS).

NORMAL FINDINGS
No bruits (abnormal vascular sounds) or venous hums heard
over major vessels.
Absence of abnormal pulsations or thrills during auscultation
with the bell of the stethoscope.
No complaints of pain, discomfort, or unusual sensations
reported by the client during the assessment.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
5. PERCUSS THE ABDOMEN IN ALL FOUR
QUADRANTS; PERCUSS TENDER AREAS LAST. NOTE
AREAS OF DULLNESS AND TYMPANY.

NORMAL FINDINGS
Tympany is predominant in the gastric and intestinal areas.
Dullness may be present over solid organs such as the liver,
spleen, or distended bladder.
No areas of significant tenderness noted during percussion.
The transition between tympanic and dull sounds is clear and
distinct.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
5. PERCUSS THE ABDOMEN IN ALL FOUR
QUADRANTS; PERCUSS TENDER AREAS LAST. NOTE
AREAS OF DULLNESS AND TYMPANY.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
6. LIGHTLY PALPATE EACH QUADRANT; PALPATING PAINFUL AREAS LAST.
NOTE SURFACE CHARACTERISTICS AND AREAS OF TENDERNESS. PERFORM
TEST FOR REBOUND TENDERNESS (MCBURNEY'S POINT) IF CLIENT HAS
COMPLAINT OF ABDOMINAL PAIN.

NORMAL FINDINGS

Soft and non-tender abdomen.

No palpable masses or areas of tenderness.
Smooth surface characteristics.
No distension noted.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
Rebound Tenderness

McBurney's point refers to the point on the lower right quadrant of the
abdomen at which tenderness is maximal in cases of acute appendicitis.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )

7. WASH HANDS AFTER

THE PROCEDURE

8. DOCUMENT
FINDINGS
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
02
CHAPTER 2
ASSESSING THE
MUSKULOSKELETAL
SYSTEM
Reported By: Sarah Montecino
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PREPARATION

Assemble Equipment:
Percussion Hammer
Tape Measure
Goniometer (Optional)
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PROCEDURE

Introduce yourself and verify Provide for client's privacy.

the client's identity. Explain Request the presence of

01 to the client what you are

going to do, why it is
necessary, and how the client
03 another woman/person, if
desired, required by agency
policy or requested by the
can cooperate. client.

Perform hand hygiene, use Inquire client’s medical and

02 gloves, and observe other

appropriate infection control
procedures.
04 family hisotry.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASK CLIENT’S HISTORY OF
THE FOLLOWING:

Sudden weight gain

Muscle, Joint, and Bone Pain
Soreness of Joint or Muscle
Past hospitalizations concerning your musculoskeletal system
Trauma and accidents
Immunizations
Family history of Arthritis, Diabetes, Kidney disease, etc.
) ) ) ) ) ) ) ) ) OBSERVE GAIT FOR BASE, WEIGHT BEARING STABILITY, FEET
) ) ) ) ) ) ) ) )
POSITION, STRIDE, ARM SWING AND POSTURE

Observe gait. Observe the client’s gait as the client

enters and walks around the room.

NORMAL FINDINGS DEVIATION FROM NORMAL

Evenly distributed weight.
Client able to stand on heels and toes.
Uneven weight bearing is evident.
Toes point straight ahead. Equal on both
Client cannot stand on heels or toes.
sides.
Client limps, shuffles, propels forward,
Posture erect, movements coordinated
or has wide-based gait.
and rhythmic, arms swing in opposition,
stride length appropriate.
) ) ) ) ) ) ) ) ) INSPECT AND PALATE CERVICAL THORACIC AND LUMBAR
) ) ) ) ) ) ) ) )
SPINE FOR PAIN AND TENDERNESS

Observe the cervical, thoracic, and lumbar curves from the side, then from behind.
Have the client standing erect with the gown positioned to allow an adequate view
of the spine.
Observe for symmetry, noting differences in height of the shoulders, iliac crests,
and buttock creases.
NORMAL FINDINGS DEVIATION FROM NORMAL

Cervical and lumbar spines are concave; A flattened lumbar curvature may be
seen with a herniated lumbar disc or
thoracic spine is convex.
ankylosing spondylitis.
Spine is straight Lateral curvature of the thoracic spine
(when observed from behind). with an increase in the convexity on the
curved side is seen in scoliosis.
) ) ) ) ) ) ) ) ) INSPECT AND PALATE CERVICAL THORACIC AND LUMBAR
) ) ) ) ) ) ) ) )
SPINE FOR PAIN AND TENDERNESS

Palpate the spinous processes and the paravertebral

muscles on both sides of the spine
for tenderness or pain.

NORMAL FINDINGS DEVIATION FROM NORMAL

Nontender spinous processes; Compression fractures and lumbosacral

well-developed, firm and smooth, muscle strain can cause pain and
tenderness
nontender
of the spinal processes and
paravertebral muscles.
) ) ) ) ) ) ) ) ) TEST ROM (RANGE OF MOTION) OF CERVICAL SPINE
) ) ) ) ) ) ) ) )

Explain to the client that you will be assessing ROM

(consisting of flexion, extension, and lateral flexion).

Flexion - ask the

patient to touch Lateral Flexion -
their chin to ask the patient
their chest to touch their
ears to their
Extension - ask shoulders,
the patient to without raising
look upwards the shoulders
and back
) ) ) ) ) ) ) ) ) TEST ROM OF THORACIC AND LUMBAR SPINE
) ) ) ) ) ) ) ) )

Explain to the client that you will be assessing ROM

(consisting of flexion, extension, lateral flexion, and rotation).

Lateral Flexion - ask

the patient to place a
hand on the outer
thigh and to run the
hand down that side
without bending
forward

Flexion - the patient is asked to touch their Rotation - the patient

toes whilst keeping their knees straight is asked to turn one
side as far as possible
Extension is assessed by asking the patient and then the other
to bend back as far as possible
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE SHOULDERS FOR SYMMETRY, COLOR,
) ) ) ) ) ) ) ) )
SWELLING AND MASSES

Inspect anteriorly and posteriorly for symmetry, color, swelling, and masses.
Palpate for tenderness, swelling, or heat.
Anteriorly palpate the clavicle, acromioclavicular joint, subacromial area, and the biceps.
Posteriorly palpate the glenohumeral joint, coracoid area, trapezius muscle, and the
scapular area.

NORMAL FINDINGS DEVIATION FROM NORMAL

Shoulders are symmetrically round;

Flat, hollow, or less-rounded
no redness, swelling, or deformity or heat.
shoulders are seen with dislocation.
Muscles are fully developed. Muscle atrophy is seen with nerve or
Clavicles and scapulae are even and muscle damage or lack of use.
symmetric. Tenderness, swelling, and heat may
The client reports no tenderness. be noted with shoulder strains,
sprains, and arthritis.
) ) ) ) ) ) ) ) ) TEST ROM OF SHOULDERS
) ) ) ) ) ) ) ) )
Explain to the client that you will be assessing ROM
(consisting of flexion, extension, adduction, and abduction).

Internal Rotation -
involves moving the
flexed forearm
across the front of
the body. The
movement is limited
by the chest wall Flexion - 180 degrees.
Approximately 90 degrees is
External Rotation - attributable to the glenohumeral
the flexed forearm is joint
moved outwards Extension - approximately 65
degrees
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE ELBOWS FOR SIZE, SHAPE,
) ) ) ) ) ) ) ) )
DEFORMITIES, REDNESS OR SWELLING

Inspect for size, shape, deformities, redness, or swelling.

Inspect elbows in both flexed and extended positions.

NORMAL FINDINGS DEVIATION FROM NORMAL

Elbows are symmetric, without Redness, heat, and swelling may be

deformities, redness, or swelling. seen with bursitis of the olecranon
process due to trauma or arthritis.
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE ELBOWS FOR SIZE, SHAPE,
) ) ) ) ) ) ) ) )
DEFORMITIES, REDNESS OR SWELLING

With the elbow relaxed and flexed about 70 degrees, use your thumb and middle
fingers to palpate the olecranon process and epicondyles.

NORMAL FINDINGS DEVIATION FROM NORMAL

Firm, nontender, subcutaneous

Nontender; without nodules. nodules is palpated in rheumatoid
arthritis or rheumatic fever.
Tenderness or pain over the
epicondyles may be palpated in
epicondylitis (tennis elbow) due to
repetitive movements of the
forearm or wrists..
) ) ) ) ) ) ) ) ) TEST ROM OF ELBOWS
) ) ) ) ) ) ) ) )
Test ROM. Ask the client to perform the following movements to test ROM:
flexion, extension, pronation, and supination.

Flexion - flex the

Supination and
elbow and bring
Pronation -
the hand to the
then the hold
forehead
arm out, turn
the palm down,
Extension -
then turn the
straighten the
palm up
elbow.
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE WRIST FOR SIZE, SHAPE,
) ) ) ) ) ) ) ) )
SYMMETRY, COLOR, SWELLING, TENDERNESS AND NODULES

Inspect wrist size, shape, symmetry, color, and swelling.

Then palpate for tenderness and nodules

NORMAL FINDINGS DEVIATION FROM NORMAL

Swelling is seen with rheumatoid

Wrists are symmetric, arthritis.
without redness, or swelling. Tenderness and nodules may be
They are nontender and free of nodules. seen with rheumatoid arthritis.
A nontender, round, enlarged,
swollen, fluid-filled cyst (ganglion)
may be noted on the wrists.
) ) ) ) ) ) ) ) ) TEST ROM OF WRISTS
) ) ) ) ) ) ) ) )
Test ROM. Ask the client to perform the following movements to test ROM:
flexion, extension, radial deviation and ulnar deviation.

Radial
Flexion
Deviation and
and
Ulnar Deviation
Extension
- next. have the
- ask the
client hold the
client to
wrist straight
bend the
and move the
wrist down
hand outward
and back
and inward
) ) ) ) ) ) ) ) ) TEST FOR CARPAL TUNNEL SYNDROME THROUGH
) ) ) ) ) ) ) ) )
PHALEN’S TEST

Perform Phalen’s test.

Ask the client to rest elbows on a table and place the backs of both hands against each
other while flexing the wrists 90 degrees with fingers pointed downward and wrists
dangling.
Have the client hold this position for 60 seconds.

NORMAL FINDINGS DEVIATION FROM NORMAL

If symptoms develop within a

No tingling, numbness, or pain result minute with Phalen’s test, carpel
tunnel syndrome is suspected.
from Phalen’s test
Client may report tingling,
numbness, and pain with carpal
tunnel syndrome.
) ) ) ) ) ) ) ) ) TEST FOR CARPAL TUNNEL SYNDROME THROUGH
) ) ) ) ) ) ) ) )
PHALEN’S TEST

Perform Phalen’s test.

Ask the client to rest elbows on a table and place the backs of both hands against each
other while flexing the wrists 90 degrees with fingers pointed downward and wrists
dangling.
Have the client hold this position for 60 seconds.

PHALEN’S MANUEVER
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE HANDS AND FINGERS FOR SIZE, SHAPE,
) ) ) ) ) ) ) ) )
SYMMETRY, SWELLING, COLOR, TENDERNESS AND NODULES

Inspect size, shape, symmetry, swelling, and color.

Palpate the fingers from the distal end proximally, noting tenderness, swelling, bony
prominences, nodules, or crepitus of each interphalangeal joint.
Assess the metacarpophalangeal joints by squeezing the hand from each side between
your thumb and fingers.
Palpate each metacarpal of the hand, noting tenderness and swelling.

NORMAL FINDINGS DEVIATION FROM NORMAL

Hands and fingers are symmetric,
nontender, and without nodules. Pain, tenderness, swelling,
Fingers lie in straight line. shortened finger,
No swelling or deformities. depressed knuckle and/or inability
Rounded protuberance noted next to to move the finger is seen with
the thumb over the thenar prominence. finger fractures.
Smaller protuberance
seen adjacent to the small finger.
) ) ) ) ) ) ) ) ) TEST ROM OF HANDS AND FINGERS
) ) ) ) ) ) ) ) )
Ask the client to:
(A) spread the fingers apart (abduction) , (B) make a fist (adduction)
(C) bend the fingers down (flexion) and then up (hyperextension),
(D) move the thumb away from other fingers, and then
(E) touch the thumb to the base of the small finger.
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE HIPS
) ) ) ) ) ) ) ) )
FOR SHAPE AND SYMMETRY

With the client standing, inspect symmetry and shape of the hips.
Observe for convex thoracic curve and concave lumbar curve.
Palpate for stability, tenderness, and crepitus.

NORMAL FINDINGS DEVIATION FROM NORMAL

Buttocks are equally sized; iliac Instability, inability to stand, and/or

crests are symmetric in height. a deformed hip area are indicative
Hips are stable, nontender, and of a fractured hip.
without crepitus. Tenderness, edema, decreased
ROM, and crepitus are seen in hip
inflammation and DJD.
) ) ) ) ) ) ) ) ) TEST ROM OF HIPS
) ) ) ) ) ) ) ) )
Ask the client to do:
90 degrees of hip flexion with knee
straight;
120 degree with knee bent
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE KNEES FOR SIZE, SHAPE, SYMMETRY,
) ) ) ) ) ) ) ) )
DEFORMITIES, SWELLING, PAIN AND ALIGNMENT

With the client supine then sitting with knees dangling, inspect for size, shape, symmetry,
swelling, deformities, and alignment.
Observe for quadriceps muscle atrophy.

NORMAL FINDINGS DEVIATION FROM NORMAL

Knees symmetric, hollows present on Knees turn in with knock knees and
both sides of the patella, turn out with bowed legs.
no swelling or deformities. Swelling above or next to the
Lower leg in alignment with the patella may indicate fluid in the
upper leg. knee joint or thickening of the
synovial membrane.
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE KNEES FOR SIZE, SHAPE, SYMMETRY,
) ) ) ) ) ) ) ) )
DEFORMITIES, SWELLING, PAIN AND ALIGNMENT

Palpate for tenderness, warmth, consistency, and nodules.

Begin palpation 10 cm above the patella, using your fingers and
thumb to move downward toward the knee

NORMAL FINDINGS DEVIATION FROM NORMAL

Tenderness and warmth with a

boggy consistency may be
Nontender and cool. Muscles firm.
symptoms of synovitis.
No nodules.
Asymmetric muscular development
in the quadriceps may indicate
atrophy.
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE KNEES FOR SIZE, SHAPE, SYMMETRY,
) ) ) ) ) ) ) ) )
DEFORMITIES, SWELLING, PAIN AND ALIGNMENT

Perform the ballottement test. This test helps to detect large amounts of fluid in the
knee. With the client in a supine position, firmly press your nondominant thumb and
index finger on each side of the patella. This displaces fluid in the suprapatellar bursa,
located between the femur and patella. Then with your dominant fingers, push the patella
down on the femur. Feel for a fluid wave or a click.
BALLOTTEMENT TEST

NORMAL FINDINGS: No movement of

the patella is noted. Patella
rests firmly over the femur.

DEVIATION FROM NORMAL: Fluid

wave or click palpated, with large
amounts of joint effusion.
) ) ) ) ) ) ) ) ) TEST ROM OF KNEES
) ) ) ) ) ) ) ) )

Clients should have full ROM of the knee:

Flexion and Extension

Flexion - the knee is flexed with Extension - the leg is

one hand resting on the patella straightened to its fullest extent
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE ANKLES AND FEET FOR POSITION,
) ) ) ) ) ) ) ) )
ALIGNMENT, SHAPE, TENDERNESS, TEMPERATURE, SWELLING
AND NODULES

With the client sitting, standing, and walking, inspect position, alignment,
shape, and skin.

NORMAL FINDINGS DEVIATION FROM NORMAL

Toes usually point forward and lie flat;. A laterally deviated great toe with
Toes and feet are in alignment with the possible overlapping of the 2nd toe.
lower leg. Painful thickening of the skin over
Skin is smooth and free of corns and bony prominences and at pressure
calluses. Longitudinal arch. points. Nonpainful thickened skin
Most of the weight bearing is on the foot that occurs at pressure points.
midline. Painful warts that often occur
under a callus.
) ) ) ) ) ) ) ) ) INSPECT AND PALPATE ANKLES AND FEET FOR POSITION,
) ) ) ) ) ) ) ) )
ALIGNMENT, SHAPE, TENDERNESS, TEMPERATURE, SWELLING
AND NODULES

Palpate ankles and feet for tenderness, heat, swelling, or nodules.

Note tenderness, swelling, bony, nodules, or crepitus.

NORMAL FINDINGS DEVIATION FROM NORMAL

Tender, painful, reddened, hot, and

swollen metatarsophalangeal joint
No pain, heat, swelling, or nodules are of the great toe is seen in gouty
noted. arthritis.
Nodules of the posterior
ankle may be palpated with
rheumatoidarthritis.
) ) ) ) ) ) ) ) ) TEST ROM OF ANKLES AND TOES
) ) ) ) ) ) ) ) )

Clients should have full ROM of the ankles and toes:

Plantarflexion, Dorsiflexion, Flexion and Extension
) ) ) ) ) ) ) ) ) TEST DEEP TENDON REFLEXES
) ) ) ) ) ) ) ) )

Brachioradialis Reflex
With the patients forearm resting on the lap or across the abdomen, the
brachioradialis reflex is assessed
A gentle strike of the hammer 2.5 to 5 cm above the wrist results in flexion and
supination of the forearm

Achilles Reflex
The ankle jerk reflex, also known as the Achilles reflex
To elicit an achilles reflex, the foot of dorsiflexed at the ankle and the hammer strikes the
stretched achilles tendon. This reflex normally produces flexion
) ) ) ) ) ) ) ) ) TEST DEEP TENDON REFLEXES
) ) ) ) ) ) ) ) )

Triceps reflex
Grasp the patient’s wrist with your left hand and pull his arm across his chest so the elbow
is flexed about 90 degree and the forearm is partially bend down.
Tap the triceps brachial tendon directly above the olecranon process.
The normal response is elbow extension

Patellar reflex
The knee-jerk reflex, also known as the patellar reflex, is a simple reflex that causes the
contraction of the quadriceps muscle when the patellar tendon is stretched.
The patient may be either sitting or lying down as long as the knee flexed.
Briskly tap the patellar tendon just below the patella.
Note contraction of the quadriceps with extension at knee.
A hand on the patient’s anterior thigh let you feel this reflex
) ) ) ) ) ) ) ) ) TEST DEEP TENDON REFLEXES
) ) ) ) ) ) ) ) )

Biceps reflex
Have the patient’s elbow at about a 90 degree angle of flexion with the arm
slightly bent down
Grasp the elbow with your left hand so the fingers are behind the elbow and
your abductee thumb presses the biceps brachial tendons
Strike your thumb a series of blows with the rubber hammer, varying your thumb pressure
with each blow until the most satisfactory response is obtained
Normal reflex is elbow flexion
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )

03

ASSESSING THE
NEUROLOGIC SYSTEM
Chapter 3
Reported by: Ivy Celine Orcine
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PREPARATION

Assemble Equipment:
Percussion Hammer
Tongue Depressors
Wisps of cotton, to assess light touch
sensation
Tuning fork
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PROCEDURE

Introduce yourself and verify Provide for client's privacy.

the client's identity. Explain Request the presence of

01 to the client what you are

going to do, why it is
necessary, and how the client
03 another woman/person, if
desired, required by agency
policy or requested by the
can cooperate. client.

Perform hand hygiene, use Inquire client’s medical and

02 gloves, and observe other

appropriate infection control
procedures.
04 family hisotry.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASK CLIENT’S HISTORY OF
THE FOLLOWING:

Presence of pain in the head, back, or extremities, as well as

onset, aggravating & elevating pain.
Disorientation to time, place, or person.
Speech disorders.
Loss of consciousness, fainting, convulsions, trauma, tingling or
numbness, tremors or tics, limping, paralysis, uncontrolled
muscle movements, loss of memory, or mood swings
Problems with smell, vision, taste, touch, or hearing.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART I. MENTAL STATUS AND
LEVEL OF CONSCIOUSNESS

1. Observe level of consciousness

1.1 Call the client’s name and note the response. If the client does not
respond. Call the name louder.
1.2 Shake the client’s hand gently. If there is no response, apply a painful
stimulus
1.3 Use the Glasgow Coma Scale for clients at high risk for rapid
deterioration of the nervous system.
1.4 Observe posture and body movements.
1.5 Observe dress, grooming and hygiene.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART I. MENTAL STATUS AND
LEVEL OF CONSCIOUSNESS

1.6 observe facial expression.

1.7 Observe speech.
1.8 Observe thought process and perceptions
1.9 Observe cognitive abilities such as orientation;
concentration; recent memory and remote memory; use of
memory to learn new information; abstract reasoning and
judgement.
1.10 Visual perceptual and construction ability.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

2. Assess Cranial Nerve I (Olfactory)

2.1 Have the client sit in a comfortable position at your eye

level.
2.2 Ask the client to clear the nose to remove any mucous
or secretions.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

2.3 Close the eyes, occlude one nostril and

Normal
let the client identify a scented object that Abnormal Findings
the client is holding. Findings

Inability to smell (neurogenic anosmia) or

identify the correct scent may indicate
olfactory tract lesion or tumor or lesion
of the frontal lobe. Loss of smell may also
Client correctly
be congenital or due to other causes such
identifies scent
as nasal or sinus problems. It may also be
presented to
caused by injury of nerve tissue at the top of
each nostril.
the nose or the higher smell pathways in the
brain due to viral upper respiratory infection.
Smoking and use of cocaine may also impair
one’s sense of smell
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

3. Assess Cranial Nerve II (Optic)

3.1 Use a snellen chart to assess vision in each eye

3.2 Ask the client to read a newspaper or magazine to
assess near vision
3.3 Assess visual fields of the eye by confrontation
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Normal
Abnormal Findings
3.2 Ask the client to Findings
read a newspaper
or magazine to Client reads print by holding closer than
assess near vision 14 inches or holds print farther away as in
Client reads print at
presbyopia, which occurs with aging
14 inches without
3.3 Assess visual difficulty
fields of the eye by Loss of visual fields may be seen in retinal
damage or detachment, with lesions of the
confrontation Full visual fields
optic nerve, or with lesions of the parietal
cortex
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

4. Assess Cranial Nerve III (Oculomotor), IV (Trochlear), and VI

(Abducens)

4.1 Inspection of the eyelids of each eye

4.2 Assess extraocular movements
4.3 Assess pupillary response to light (direct and indirect)
) ) ) ) ) ) ) ) ) PART II. CRANIAL NERVE
) ) ) ) ) ) ) ) )
ASSESSMENT

4.1 Inspection Normal Findings Abnormal Findings

of the eyelids
of each eye Ptosis (drooping of the eyelid) is seen with weak eye muscles such as in
Eyelid covers about 2 mm of the myasthenia gravis.
4.2 Assess
iris.
extraocular NYSTAGMUS (rhythmic oscillation of the eyes): cerebellar disorders.
movements Eyes move in a smooth, limited eye movement through the six cardinal fields of gaze: increased
coordinated motion intracranial pressure.
4.3 Assess in all directions (the six cardinal
PARALYTIC STRABISMUS: paralysis of the oculomotor, trochlear, or abducens
pupillary fields).
nerves
response to Bilateral illuminated pupils
Dilated pupil (6-7 mm): oculomotor nerve paralysis.
Argyll Robertson Pupils: CNS syphilis, meningitis, brain tumor, alcoholism.
light (direct constrict simulta-
neously. Pupil opposite the one Constricted, fixed pupils: narcotics abuse or damage to the pons.
and indirect) illuminated Unilaterally dilated pupil unresponsive to light or accommodation.
constricts simultaneously. Constricted pupil unresponsive to light or accommodation.
) ) ) ) ) ) ) ) ) PART II. CRANIAL NERVE
) ) ) ) ) ) ) ) )
ASSESSMENT

Ptosis PARALYTIC
STRABISMUS

Dilated
NYSTAGMUS Pupil
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Assess Cranial Nerve V (Trigeminal)

5.1 Ask the client to clench the teeth while

palpating the temporal and masseter muscle
for contraction.
Test Sensory Function
5.2 Touch the forehead, cheeks, and chin of the
client with a sharp or dull side of the safety pin
or paper clip.
5.3 Ask to close the eyes and tell if he feel a
sharp or dull sensation
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Assess Cranial Nerve V (Trigeminal)

5.4 Repeat test for light with a

wisp of cotton

Test the Corneal Reflex

5.5 Ask the client to look away
and up while gently touching the
cornea with a fine wisp of cotton.
Repeat on other side.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Test Sensory Function Normal Findings Abnormal Findings

5.2 Touch the forehead,
cheeks, and chin of the
client with a sharp or dull
side of the safety pin or
paper clip. The client correctly identifies sharp and Inability to feel and correctly identify
5.3 Ask to close the eyes dull stimuli and light touch to the facial stimuli occurs with lesions of the
and tell if he feel a sharp forehead,cheeks, and chin. trigeminal nerve or lesions in the
or dull sensation spinothalamic tract or
5.4 Repeat test for light posterior columns
with a wisp of cotton
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Test the Corneal Reflex Normal Findings Abnormal Findings

5.5 Ask the client to

look away and up An absent corneal reflex may be
while gently noted with lesions of the
Eyelids blink bilaterally. trigeminal nerve or lesions of
touching the cornea the motor part of cranial nerve VII
with a fine wisp of (facial)
cotton. Repeat on
other side.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

6. Assess Cranial Nerve VII (Facial)

Test Motor Function
6.1 Ask the client to smile;
frown and wrinkle forehead;
show teeth; puff out cheeks,
purse lips; raise eyebrows; and
close eyes tightly against
resistance.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Normal Findings Abnormal Findings

Test Motor Function
6.1 Ask the client to
smile; frown and wrinkle Inability to close eyes, wrinkle forehead, or
raise forehead along with paralysis of the
forehead; show teeth; Client smiles, frowns, wrinkles
lower part of the face on the affected side
forehead,shows teeth, puffs out
puff out cheeks, purse is seen with Bell’s palsy (a peripheral injury
cheeks, purses lips,
lips; raise eyebrows; and raises eyebrows, and closes eyes
to cranial nerve VII [facial]). Paralysis of
the lower part of the face on the opposite
close eyes tightly against resistance. Movements
side affected may be seen with a central
against resistance. are symmetric.
lesion that affects the upper motor
neurons, such as from stroke.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

7. Assess Cranial Nerve VIII (Auditory/Acoustic/Vestibulocochlear)

7.1 Whisper or Watch-tick test

7.2 Ask the client to hum.
7.3 Perform Weber's (Sound Lateralization) and Rinne's (Air &
Bone Conduction) Tests.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Normal Findings Abnormal Findings

7.1 Whisper or Watch-
tick test
7.2 Ask the client to
hum. Client hears whispered words from
Vibratory sound lateralizes to good
7.3 Perform Weber's 1–2 feet.
ear in sensorineural loss. Air
Weber test: Vibration heard equally
(Sound well in both ears.
conduction is longer than bone
conduction, but not twice as long,
Lateralization) and Rinne test: AC > BC (air conduction is
in a sensorineural loss (see
Rinne's (Air & Bone twice as long as bone conduction)

Conduction) Tests.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

8. Assess Cranial Nerve IX (Glossopharyngeal), and X

(Vagus)

8.1 Ask the client to open mouth wide and say "ah"
while using the tongue depressor on a client's tongue.
8.2 Test the gag reflex. Touch the posterior pharynx
with tongue depressor.
8.3 Check the dient's ability to swallow by giving the
client a water to drink. Note also the client's voice
quality (Hoarseness of voice)
) ) ) ) ) ) ) ) ) PART II. CRANIAL NERVE
) ) ) ) ) ) ) ) )
ASSESSMENT

Assess Cranial Nerve IX (Glossopharyngeal), and X (Vagus)

Normal Findings Abnormal Findings

Soft palate does not rise with bilateral lesions of cranial nerve X (vagus).
Unilateral rising of the soft palate and deviation of the uvula to the normal
side are seen with a unilateral lesion of cranial nerve X (vagus)
Uvula and soft palate rise bilaterally and
symmetrically on phonation
An absent gag reflex may be seen with lesions of cranial nerve IX
(glossopharyngeal) or X (vagus)
Gag reflex intact. Some normal clients
may have a reduced or absent gag reflex.
Dysphagia or hoarseness may indicate a lesion of cranial nerve IX
Client swallows without difficulty. No
(glossopharyngeal) or X (vagus) or other neurologic disorder
hoarseness noted.
) ) ) ) ) ) ) ) ) PART II. CRANIAL NERVE
) ) ) ) ) ) ) ) )
ASSESSMENT

9. Assess Cranial Nerve XI (Spinal Accessory)

9.1 Ask the client to shrug the shoulders

against resistance to assess the trapezius
muscle
9.2 Ask the client to turn the head against
resistance, first to the right and to the left
to assess the sternocleidomastoid
muscles.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Assess Cranial Nerve XI (Spinal Accessory)

Normal Findings Abnormal Findings

Asymmetric muscle contraction or

drooping
There is symmetric, strong of the shoulder may be seen with
contraction of the paralysis
trapezius muscles. or muscle weakness due to neck injury
or
torticollis.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

10. Assess Cranial Nerve XII (Hypoglossal)

10.1 Ask the client to protrude the tongue

10.2 Ask the client to move tongue side to side against resistance of
a tongue depressor, then put it back in the mouth.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Assess Cranial Nerve XII (Hypoglossal)

Normal Findings Abnormal Findings

Fasciculations and atrophy of the

Tongue movement is symmetric
tongue may be seen with peripheral
and smooth,
nerve disease. Deviation to the affected
and bilateral strength is apparent
side is seen with a unilateral lesion
) ) ) ) ) ) ) ) ) PART III. MOTOR AND CEREBELLAR SYSTEMS
) ) ) ) ) ) ) ) )
(GROSS MOTOR AND BALANCE TEST)

11. Assess condition and movement of muscles

11.1 Assess the size and symmetry of all
muscles.

12. Assess the strength and tone of all muscle

groups. Note any unusual involuntary
movements such as fasciculations, tics or
tremors.
12.1. Note any unusual involuntary
movements such as fasciculations, tics, or
tremors.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Normal Findings Abnormal Findings

Injury of the central spinal cord is associated with extremity weakness.

Muscles are fully developed and
Loss of motor function, pain and tempera- ture seen in anterior cord
symmetric in size (bilateral sides
syndrome.
may vary 1 cm from each other)
Loss of proprioception seen in posterior cord syndrome A loss of strength,
proprioception, pain and temperature is seen in Brown-Séquard syndrome
Relaxed muscles contract
voluntarily and show mild, smooth
Soft, limp, flaccid muscles are seen with lower motor neuron involvement.
resistance to passive movement.
Spastic muscle tone is noted with involvement of the corticospinal motor
All muscle groups equally strong
tract. Rigid muscles that resist passive movement are seen with abnormalities
against resistance, without
of the extrapyramidal tract
flaccidity, spasticity, or rigidity.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART III. MOTOR AND CEREBELLAR SYSTEMS
(GROSS MOTOR AND BALANCE TEST)

13. Evaluate balance

13.1 To assess gait, ask the client to walk

naturally across the room.
13.2 Note posture, freedom of movement,
symmetry, rhythm and balance.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART II. CRANIAL NERVE
ASSESSMENT

Normal Findings Abnormal Findings

Gait and balance can be affected by disor ders of

the motor, sensory, vestibular, and cerebellar
Gait is steady; opposite arm swings. systems. Therefore, a thorough examination of
all systems is necessary when an uneven or
unsteady gait is noted
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART III. MOTOR AND CEREBELLAR SYSTEMS
(GROSS MOTOR AND BALANCE TEST)

14. Romberg's Test

14.1 Ask the client to stand erect with arms at

side and feet together. Note any unsteadiness
or swaying. Then with the client in the same
body position, ask the client to close the eyes
for 20 seconds. Again note any imbalance or
swaying. Stand close to the client during this
test.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART III. MOTOR AND CEREBELLAR SYSTEMS
(GROSS MOTOR AND BALANCE TEST)

Normal Findings Abnormal Findings

Positive Romberg test: Swaying and moving

Client stands erect with minimal swaying, feet apart to prevent fall is seen with disease
with eyes both open and closed. of the posterior columns, vestibular dysfunc-
tion, or cerebellar disorders.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART III. MOTOR AND CEREBELLAR SYSTEMS
(GROSS MOTOR AND BALANCE TEST)

15. Standing on One Foot with Eyes closed

15.1 Ask the client to close the eyes and stand on one
foot. Repeat on the other foot. Stand close to the client
during this test.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART III. MOTOR AND CEREBELLAR SYSTEMS
(GROSS MOTOR AND BALANCE TEST)

16. Heel-to-toe Walking

16.1 Ask the client to walk a straight line, placing the

heel of one foot directly in front of the toes of the other
foot. Demonstrate the walk first; then stand close by in
case the client loses balance.
16.2 Ask the client to walk several steps on the toes and
then on the heels.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART III. MOTOR AND CEREBELLAR
SYSTEMS (GROSS MOTOR AND
BALANCE TEST)

Normal Findings Abnormal Findings

Bends knee while standing on one Inability to stand or hop on one

foot; hops foot is seen with muscle weakness
on each foot without losing balance or disease of the cerebellum.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART IV. FINE MOTOR TEST

17. Finger-to-Nose Test

17.1 Ask the client to abduct and extend the arms at

shoulder level and then rapidly touch the nose
alternatively with one index finger and then the other.
17.2 The client repeats the test with the eyes closed if
test is performed easily.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART IV. FINE MOTOR TEST

Normal Findings Abnormal Findings

Client touches finger to nose with Uncoordinated, jerky movements and

smooth, accurate movements, with little inability to touch the nose may be seen
hesitation. with cerebellar disease.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART IV. FINE MOTOR TEST

18. Alternate Supination and

Pronation of Hands on Knees

18.1. Ask the client to pat both

knees with the palms of both
hands and then with the backs of
the hands alternatively at an
increasing rate.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART IV. FINE MOTOR TEST

19. Finger to Nose and to the Nurse's Finger

19.1 Ask the client to touch the nose and then your index finger (nurse),
held at a distance of about 45 cm (18 in) at a rapid and increasing rate.
20. Fingers to Fingers
20.1 Ask the client to spread the arms broadly at shoulder height at the
midline, first with the eyes open and then closed, first slowly then
rapidly.
21. Fingers to Thumbs (Same Hand)
21.1 Ask the client to touch each finger of one hand to the thumb of the
same hand as rapidly as possible.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART IV. FINE MOTOR TEST

22. Heel Down Opposite Shin

22.1 Ask the client to place the heel of one foot just below the opposite
knee and run the heel down the shin to the foot.
22.2 Repeat with the other foot. The client may also use a sitting
position for this test.

23. Toe or Ball of Foot to the Nurse's Finger

23.1Ask the client to touch your finger with the large toe of each foot.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART IV. FINE MOTOR TEST

Normal Findings Abnormal Findings

Deviation of heel to one side or the other may be

seen in cerebellar disease.

Client is able to run each heel smoothly Inability to perform rapid alternating move ments
down each shin may be seen with cerebellar disease, upper motor
neuron weakness, or extrapyramidal disease.
Client touches each finger to the thumbrapidly
Uncoordinated movements or tremors are
abnormal findings. They are seen with cer-
ebellar disease (dysdiadochokinesia).
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

24. Light touch Sensation

24.1 Ask the client to close the eyes and to respond by saying "yes" or
"now" whenever the client feels the cotton wisp touching the client's
skin.
24.2 With a wisp of cotton, lightly touch one specific spot and then the
same spot on the other side of the body.
24.3 Test areas on forehead, cheek, hand, lower arm, abdomen, foot and
lower leg. Check a distal area of the limb first (the hand before the arm
and the foot before the leg)
24.4 Ask the client to point to the spot where the touch was felt..
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

Normal Findings Abnormal Findings

Many disorders can alter a person’s ability to

perceive sensations correctly. These include
peripheral neuropathies (due to diabetes
Client correctly identifies light touch
mellitus, folic acid deficiencies, and alcohol-
ism) and lesions of the ascending spinal
Client correctly differentiates between dull
cord, brain stem, cranial nerves, and cerebral
and sharp sensations and hot and cold tem-
cortex.
peratures over various body parts.

Reports: Anesthesia, Hypesthesia, Analgesia, Hypalgesia,

Hyperalgesia
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

25. Pain Sensation

25.1 Ask the client to close the eyes and to say "sharp", "dull" or "don't know"
when the sharp or dull end of the broken tongue depressor is felt.
25.2 Alternately, use the sharp and dull end to lightly prick designated
anatomic areas at random (e.g., hand, forearm, foot, lower leg, and abdomen).
The face is tested in this manner.
25.3 Allow at least 2 seconds between each test to prevent summation effects
of stimuli.
26. Temperature Sensation
26.1 Touch skin areas with test tubes filled with hot or cold water. 26.2 Have the
client respond by saying "hot" or "cold" or "don't know".
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

27. Position or Kinesthetic Sensation

27.1 To test the fingers, support the client's arm and hand with one hand. 27.2
To test the toes, place the client's heels on the examining table
27.3 Ask the client to close the eyes.
27.4 Grasp a middle finger or big toe firmly between your thumb and index
finger.
27.5 Exert the same pressure on both sides of the finger or toe while moving it.
27.6 Move the finger or toe until it is up, down or straight out and ask the client
to identify the position.
27.7 Use a series of brisk up and down movements before bringing the finger or
toe suddenly to rest in one of the three positions.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

Normal Findings Abnormal Findings

Inability to sense vibrations may be seen

Client correctly identifies in posterior column disease or peripheral
sensation. neuropathy (e.g., as seen with diabetes or
chronic alcohol abuse).
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

Normal Findings Abnormal Findings

Inability to identify the directions of the

Client correctly identifies movements may be seen in posterior
directions of column disease or peripheral neuropathy
movements. (e.g., asseen with diabetes or chronic
alcohol abuse)
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

28. Tactile Discrimination (Fine Touch)

-Client's eyes need to be closed in all the tests.

One and Two Point Discrimination

28.1 Alternately stimulate the skin with two pins simultaneously and then with
one pin.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

Normal Findings Abnormal Findings

nability to correctly identify objects (aste-

reognosis), area touched, number written in
Client correctly identifies
hand; to discriminate between two points; or
object.
identify areas simultaneously touched may
be seen in lesions of the sensory cortex.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

29. Stereognosis
29.1 Place familiar objects such as key, paper clip,
coin, in the client's hand and ask the client to
identify them.
29.2 If the client has a motor impairment of the
hand and is unable to manipulate an object, write
a number or letter on the client's palm using a
blunt instrument. Ask the client to identify it.
(Graphestesia)

30. Extinction Phenomenon

30.1 Simultaneously stimulate two symmetric
areas of the body, the thigh, cheeks, and hands.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART V. SENSORY SYSTEM

Normal Findings Abnormal Findings

Correctly identifies points

nability to correctly identify objects (aste-
touched.
reognosis), area touched, number written in
hand; to discriminate between two points; or
Client correctly identifies
identify areas simultaneously touched may
number written. be seen in lesions of the sensory cortex.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART VI. REFLEXES

32. Assess Brachioradialis Reflex (c5,c6)

32.1 Ask the client to flex elbow with palm down and
hand resting on the abdomen or lap.
32.2 Tap the tendon at the radius about 2 inches
above the wrist. 32.3 Repeat on the other side.
33. Assess Triceps Reflex (c6,c7,c8)
33.1 Ask the client to hang his or her arm freely ("limp
like it is hanging from a clothesline to dry") while you
support it with your non- dominant hand.
33.2 With the elbow flexed, tap the tendon above the
olecranon process
33.3 Repeat on the other side.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART VI. REFLEXES

Normal Findings Abnormal Findings

Elbow flexes and contraction of the biceps

muscle is seen or felt. Ranges from 1+ to 3+.
Forearm flexes and supinates. Ranges from
No response or an exaggerated
1+ to 3+
response is
.Elbow extends, triceps contracts. Ranges
abnormal
from 1+ to 3+.
Knee extends, quadriceps muscle contracts.
Ranges from 1+ to 3+.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART VI. REFLEXES

34. Assess Patellar Reflex (12,13.14)

34.1 Ask the client to let both legs hang freely off the side of the examination table
. 34.2 Tap the patellar tendon.
34.3 Repeat on the other side.

35. Assess Achilles Reflex (s1,s2)

35.1 With the client's leg hanging freely, dorsiflex the foot.
35.2 Tap the Achilles tendon with the reflex hammer.
35.3 Repeat on the other side

36. Test ankle clonus when the other reflexes tested have been hyperactive
36.1 Place one hand under the knee to support the leg.
36.2 Briskly dorsiflex the foot towards the client's head
36.3 Repeat on the other side.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART VI. REFLEXES

Patellar Reflex Achilles Tendon Ankle Clonus

Reflex
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART VI. REFLEXES

Normal Findings Abnormal Findings

Normal response is plantarflexion of the

foot. Ranges from 1+ to 3+. No response or an exaggerated response is
abnormal.

In some older clients, the Achilles reflex

Repeated rapid contractions or oscillations
may be absent or difficult to elicit of the ankle and calf muscle are seen with
lesions of the upper motor neurons.
No rapid contractions or oscillations (clonus)
of the ankle are elicited
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART VI. REFLEXES

37. Test Superficial Reflexes (t12,11,12)

37.1 Assess plantar reflex. With the end of the reflex
hammer, stroke the lateral aspect of the sole from the
heel to the ball of the foot curving medially across the
ball.
37.2 Repeat on the other side.

38. Test Abdominal Reflex (Lower-t8,19,t10; Upper-t10,111,112)

38.1 Lightly stroke the abdomen on each side, above and
below the umbilicus.

39. Test Cremasteric Reflex for male patients (t12,11,12)

39.1 Lightly stroke the inner aspect of the upper thigh
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PART VI. REFLEXES

Normal Findings Abnormal Findings

The toes will fan out for abnormal (positive Babinski response).

Except in infancy, extension (dorsiflexion) of the big toe and

Flexion of the toes occurs
fanning of all toes (positive Babinski response) are seen with
lesions of upper motor neurons. Unconscious states resulting
Abdominal muscles contract; the
from drug and alcohol intoxication, brain injury, or subsequent to
umbilicus
an epileptic seizure may also cause it
deviates toward the side being
stimulated
Superficial reflexes may be absent with lower or upper motor
neuron lesions
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
SENSORY REFLEX

Sensory Reflex Normal Abnormal

Findings Findings
Test cremasteric Scrotum Absence of
reflex in male clients. elevates on reflex may
Lightly stroke the stimulated side. indicate motor
inner aspect of the neuron
upper thigh. This disorder.
evaluates the
function of spinal
levels T12, L1, and L2
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
NEUROLOGIC SYSTEM

40. Document your

findings
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )

04

ASSESSING THE MALE GENITALIA AND

RECTUM

Report by: Timothy Allen P. Osabel

Group VI
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PREPARATION

Gather equipment needed for the examination:

Clean gloves
Drape
Supplemental lighting (if needed)
Water-soluble lubricant
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PROCEDURE

Introduce yourself and verify Provide for client's privacy.

the client's identity. Explain Request the presence of

01 to the client what you are

going to do, why it is
necessary, and how the client
03 another woman/person, if
desired, required by agency
policy or requested by the
can cooperate. client.

Perform hand hygiene, use Drape client appropriately or

02 gloves, and observe other

appropriate infection control
procedures.
04 cover the pelvic area with a
drape at all times when not
actually being examined.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA

5. Ask the client any history of the following:

Painful intercourse, urination, or incontinence
Urgency or frequency of urination at night.
History of sexually transmitted diseases, past and present
Hernias and prostate problems
 ASSESSING THE
) ) ) ) ) ) ) ) ) MALE GENITALIA
) ) ) ) ) ) ) ) )

6. Position client in standing

position.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA

7. Cover the pelvic area with a large drape at all

times when not actually being examined
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 8 Normal Findings Deviations from Normal
There are wide
8. Inspect the Scant pubic hair (may
variations; generally
distribution, amount, indicate hormonal
kinky in the
and characteristics of problem)
menstruating adult,
the pubic hair. thinner and straighter
Hair growth should not
after menopause extend over the
Distributed in the shape abdomen
of an inverse triangle
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 9 Normal Findings Deviations from Normal
The skin of the penis is
9. Inspect the penile wrinkled and hairless and is
Rashes, lesions, or
shaft and Glans Penis normally free of rashes, lumps may indicate
for Lesions, Nodules, lesions, or lumps. The glans STI or cancer
Swelling or size and shape vary, Drainage around
appearing rounded, broad, or
inflammation piercings indicates
even pointed. The surface of
infection.
the glans is normally smooth,
free of lesions and redness.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 9 Deviations from Normal
Chancres (red, oval
9. Inspect the penile ulcerations) from syphilis,
shaft and Glans Penis genital warts, and
for Lesions, Nodules, pimple-like lesions from
Swelling or herpes are sometimes
inflammation detected on the glans.
Tenderness may indicate
inflammation or
infection.
 APPEARANCE
NORMAL
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ABNORMAL
APPEARANCE
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 10 Normal Findings Deviations from Normal

10. Inspect the Swelling, Inflammation,

Urethral meatus for or discharge may
The Urethral meatus is
swelling, inflammation indicate STI or cancer
normally free of swelling,
and discharge. inflammation and
discharge
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 11 Normal Findings Deviations from Normal

11. Palpate the penis The penis in a Tenderness and

for tenderness, nonerect state is nodules may indicate
thickening, and usually soft, flaccid, inflammation or
nodules. Use your and nontender; free of infection.
thumb and first two tenderness and
fingers. nodules
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 12 Normal Findings Deviations from Normal
The scrotum varies in size
12. Inspect the scrotum An enlarged scrotal
(according to
for appearance, sac may result from
temperature) and shape.
general size, and
The scrotal sac hangs fluid (hydrocele), blood
symmetry. To facilitate (hematocele), bowel
below or at the level of the
inspection of scrotum, (hernia), or tumor
penis. The left side of the
ask the penis hold his (cancer)
scrotal sac usually hangs
penis out of the way
lower than the right side.
) ) ) ) ) ) ) ) ) ASSESSING THE
) ) ) ) ) ) ) ) )
MALE GENITALIA
Normal Findings
Procedure 12 Scrotal skin is thin and
Deviations from Normal
rugated (crinkled) with little
12. Inspect the scrotum Rashes, lesions, and
hair dispersion. Its color is
for appearance, inflammation are
slightly darker than that of the
general size, and abnormal findings
penis. Lesions and rashes are
symmetry. To facilitate
not normally present. However,
inspection of scrotum, sebaceous cysts (small,
ask the penis hold his yellowish, firm, nontender,
penis out of the way benign nodules) are a normal
finding.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 13 Normal Findings Deviations from Normal
The scrotum varies in size
13. Palpate the scrotum An enlarged scrotal
(according to
to assess the status of sac may result from
temperature) and shape.
underlying testes,
The scrotal sac hangs fluid (hydrocele), blood
epididymis and (hematocele), bowel
below or at the level of the
spermatic cord. (hernia), or tumor
penis. The left side of the
Palpate both testes (cancer)
scrotal sac usually hangs
simultaneously.
lower than the right side.
) ) ) ) ) ) ) ) ) ASSESSING THE
) ) ) ) ) ) ) ) )
MALE GENITALIA
Deviations from Normal
Absence of a testis suggests
cryptorchidism (an undescended
Procedure 13 Normal Findings testicle). Painless nodules may
Testes are ovoid,
indicate cancer. Tenderness and
13. Palpate the scrotum approximately 3.5–5 cm long,
2.5 cm wide, and 2.5 cm deep, swelling may indicate acute
to assess the status of
and equal bilaterally in size orchitis, torsion of the spermatic
underlying testes,
epididymis and and shape. They are smooth, cord, a strangulated hernia, or
spermatic cord. firm, rubbery, mobile, free of epididymitis . If the client has
Palpate both testes nodules, and rather tender to epididymitis, passive elevation of
simultaneously. pressure. The epididymis is the testes may relieve the scrotal
nontender, smooth, and pain (Prehn’s sign).
softer than the testes.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 13 Normal Findings Deviations from Normal

13. Palpate the scrotum Palpable, tortuous veins

to assess the status of The spermatic cord and suggest varicocele. A
underlying testes, vas deferens should feel beaded or thickened
epididymis and uniform on both sides. The cord indicates infection
spermatic cord. cord is smooth, nontender, or cysts. A cyst suggests
Palpate both testes and rope-like hydrocele of the
simultaneously. spermatic cord.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 14 Normal Findings Deviations from Normal

14. inspect both inguinal Bulges that appear at

hernias for bulges while the external inguinal
client is standing.
The inguinal areas are ring or at the femoral
normally free from bulges. canal when the client
bears down may signal
a hernia
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
MALE GENITALIA
Procedure 14 Normal Findings Deviations from Normal

15. Palpate for Hernias

A bulge or mass may

Bulging or masses are not indicate a hernia
normally palpated.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )

05

ASSESSING THE FEMALE GENITALIA

Report by: Khairunnisa A. Mustafa

Group VI
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PREPARATION

Gather equipment needed for the examination:

Clean gloves
Drape
Supplemental lighting (if needed)
Water-soluble lubricant
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PROCEDURE

Introduce yourself and verify Provide for client's privacy.

the client's identity. Explain Request the presence of

01 to the client what you are

going to do, why it is
necessary, and how the client
03 another woman/person, if
desired, required by agency
policy or requested by the
can cooperate. client.

Perform hand hygiene, use Drape client appropriately or

02 gloves, and observe other

appropriate infection control
procedures.
04 cover the pelvic area with a
drape at all times when not
actually being examined.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
FEMALE GENITALIA

5. Ask the client any history of the following:

Menarche, LMP, regularity of menstrual cycle, duration and
amount of daily flow, or presence of pain.
Labor and delivery complications
Painful intercourse, urination, or incontinence
Urgency or frequency of urination at night.
History of sexually transmitted diseases, past and present
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
FEMALE GENITALIA

6. Position client in supine, with feet elevated on

the stirrups of an examination table.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
FEMALE GENITALIA
Procedure 7 Normal Findings Deviations from Normal
There are wide
7. Inspect the Scant pubic hair (may
variations; generally
distribution, amount, indicate hormonal
kinky in the
and characteristics of problem)
menstruating adult,
the pubic hair. thinner and straighter
Hair growth should not
after menopause extend over the
Distributed in the shape abdomen
of an inverse triangle
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
FEMALE GENITALIA
Procedure 8 Normal Findings Deviations from Normal
-Pubic skin intact, no
8. Inspect the skin of the Lice, lesions, scars,
pubic area for parasites, lesions
fissures, swelling,
inflammation, swelling, -Skin of vulva area
erythema, excoriations,
and lesions. To assess slightly darker than the
rest of the body
varicosities,
pubic skin adequately,
-Labia round, full, and or leukoplakia
separate the labia
majora and labia minora. relatively symmetric in
adult females
Abnormal findings
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
FEMALE GENITALIA
Procedure 9 Normal Findings Deviations from Normal
-Clitoris does not exceed 1
9. Inspect the clitoris, Presence of lesions
cm (0.4 in.) in width and 2 cm
urethral orifice, and
(0.8 in.) in length
vaginal orifice when -Urethral orifice appears as
separating the labia a small slit and is the same
minora. color as surrounding tissues
-No inflammation, swelling,
or discharge
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
FEMALE GENITALIA

10. Palpate the inguinal lymph nodes.

-Use the pads of the fingers in a rotary motion,

noting any enlargement or tenderness.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE FEMALE
GENITALIA

) ) ) ) ) ) )
Procedure 10 Lymph nodes of
10. Palpate the inguinal lymph the groin area.
nodes.

-Use the pads of the fingers in a

rotary motion, noting any
enlargement or tenderness.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE
FEMALE GENITALIA
Procedure 10 Normal Findings Deviations from Normal
10. Palpate the inguinal No enlargement or Enlargement and
lymph nodes. tenderness tenderness

-Use the pads of the

fingers in a rotary
motion, noting any
enlargement
or tenderness.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )

05

ASSESSING THE RECTUM OF

AN ADULT FEMALE AND MALE

Report by: Khairunnisa A. Mustafa and Timothy Allen P.

Osabel
Group VI
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
PREPARATION

Gather equipment needed for the examination:

Clean gloves
Drape
Supplemental lighting (if needed)
Water-soluble lubricant
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT FEMALE
AND MALE

Because digital examinations can cause

apprehension and embarrassment in the client, it
is important to help the client relax by
encouraging the client to take deep breaths and
informing the client about potential sensations
such as feelings of defecation or passing gas.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT FEMALE
AND MALE

1. Ask client any history of the following:

Bright blood in stools, tarry black stools,
diarrhea, constipation, abdominal pain,
excessive gas, hemorrhoids, or rectal pain.
Family history of colorectal cancer.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT FEMALE

2. For females: A dorsal recumbent position with

hips externally rotated and knees flexed or a
lithotomy position may be used.
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT MALE

2. For males: A standing position while the client

bends over the examining table or lateral postion
may be used
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT FEMALE
AND MALE
Procedure 3 Normal Findings Deviations from Normal
3. Inspect the anus or -Intact perianal skin; usually Presence of fissures,
surrounding tissue for slightly more ulcers, excoriations,
color, integrity, and skin pigmented than the skin of inflammations,
lesions. the buttocks abscesses, protruding
-Anal skin is normally more
hemorrhoids, lumps or
pigmented, coarser,
tumors, fistula openings,
and moister than perianal
or rectal prolapse
skin and is usually hairless
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT FEMALE
AND MALE
Procedure 4 Normal Findings Deviations from Normal
4. Palpate the rectum -Good sphincter tone Presence of polyps
for anal sphincter -No masses, nodules, (Pedunculated polyps or
tonicity, nodules, tenderness Sessile polyps)
masses, and -Even pressure on finger of
tenderness. the examiner
-Continuous, smooth
surface with minimal
discomfort to client
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT FEMALE
AND MALE

5. On withdrawing the finger from the rectum and

anus, observe it for feces. If ordered, perform a test
for occult blood on the stool (guaiac fecal occult
blood test).
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )
ASSESSING THE RECTUM
OF AN ADULT FEMALE
AND MALE

6. Discard used gloves and perform hand hygiene.

[Link] findings in the client's record.

 Thank You
) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) )