Kirsten R.

Galleta
BSN 1-2

Rationale of Assessing of the Hair

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably, seated if Assessing the client in an uncomfortable
possible position might make them wary and would
not cooperate to the procedure.
Inspect the evenness of growth over the It is important to check the evenness of the
scalp. growth of the hair on the scalp because
uneven growth of the hair on the scalp might
indicate a disease or problem in the client’s
health
Inspect hair thickness or thinness The thickness or thinness of the hair can also
indicate healthiness of the hair. Too thick or
too thin hair might indicate a disease.
Inspect hair texture and oiliness. Rough texture of the hair and too much
oiliness might indicate that there is an
infection or infestation on the scalp.
Inspect amount of body hair. Large amount of body hair might indicate that
there is something wrong with the client’s
health.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.
 Rationale of Assessing the Skull and Face
Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably, seated if Assessing the client in an uncomfortable
possible position might make them wary and would
not cooperate to the procedure.
Inspect the skull for size, shape, and Asymmetry of the skull, unusual size and
symmetry. shape might indicate that there is swelling or
infection either on the inside or outside.
Palpate the skull for nodules or masses and Presence of nodules or masses and
Depressions. depressions on the skull might indicate a past
trauma or disease.
Inspect the facial features. Uneven and unusual facial features might
indicate that there is a problem with the
client’s health status
Inspect the eyes for edema and hollowness. Edema and hollowness are normal for elderly
but for ages below it is not normal and might
indicate a disease or infection.
Note symmetry of facial movements. Asymmetric facial movements might indicate
problems on the client’s health
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.
 Rationale of Assessing the Ears and Hearing
Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably, seated if Assessing the client in an uncomfortable
possible position might make them wary and would
not cooperate to the procedure.
Auricles
Inspect the auricles for color, symmetry of This is to determine if there is a problem or
size, and position infection with the auricles of the client.
Palpate the auricles for texture, elasticity, and To check if there are abnormalities in the
areas of tenderness. texture of the auricles of the client. Also, to
check if it is elastic and can return to its
position when folded as well as to check if
there are any tenderness present.
External Ear Canal and Tympanic Membrane
Using an otoscope, inspect the external ear To check if there are any cerumen, skin
canal for cerumen, skin lesions, pus, and lesions, pus, and blood in the external ear
blood. canal that might indicate a health problem.
Inspect the tympanic membrane for color and To check I the tympanic membrane is pearly
gloss gray in color. Difference in color might
indicate a disease or health problems.
Gross Hearing Acuity Tests
Assess client’s response to normal voice To check if the client can proper hear the
tones. If client has difficulty hearing the normal tone of the voice of the examiner. If
normal voice, proceed with the following not, then there might be some problem with
tests. the client’s health.
Perform the watch tick test. To check if the client can hear the ticking of
the watch while the other is occluded. If the
client cannot hear it then there might be a
problem with client’s hearing capability.
Tuning Fork Tests To check the client’s hearing capacity
through the 2 types of tuning fork test.
Perform Weber test. To check if the client can hear the vibration
from the fork that is placed on the client’s
 forehead.
Conduct Rinne test To check if the client’s bone conduction and
air conduction.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale of Assessing the Nose and Sinuses

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably, seated if Assessing the client in an uncomfortable
possible position might make them wary and would
not cooperate to the procedure.
Inspect the external nose for any deviations To check if there are any deviations in shape,
in shape, size, or color and flaring, or size, and color in the external nose. Also, to
discharge from the nares. check if there are any flaring or discharges
from the nares. Able to find one might
indicate a health problem.
Lightly palpate the external nose to determine To check if there is tenderness, masses, and
any areas of tenderness, masses, and displacement of bone and cartilage in the
displacements of bone and cartilage. external nose. Of the client. Presence of it
might indicate a health issue.
Determine patency of both nasal cavities. This is the check if there is any blockage on
the nasal cavities of the client.
Inspect the nasal cavities using a flashlight or This is to check if there are any foreign
a nasal speculum. objects or mucous on the clients’ nasal
cavities.
Observe for the presence of redness, Presence of swelling, redness, growths, and
swelling, growths, and discharge. discharge might show that there is an
infection in the client’s nose.
Inspect the nasal septum between the nasal To check if there are any blockage in the
chambers. nasal septum between the nasal chambers.
Presence of it might block the airflow of the
client and abnormal appearance on the
structure of the nose.
Facial Sinuses
Palpate the maxillary and frontal sinuses for This is to check is the sinuses of the client is
tenderness. not swollen and there is no infection that
might cause the tenderness.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale of Assessing the Mouth and Oropharynx

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably, seated if Assessing the client in an uncomfortable
possible position might make them wary and would
not cooperate to the procedure.
Lips and Buccal Mucosa
Inspect the outer lips for symmetry of To check if the facial muscles around the lips
contour, color, and texture. are fully developed and strong. Also, to check
if the color of the lips and its texture is
normal.
Inspect and palpate the inner lips and buccal To check if the inner lips and the buccal
mucosa for color, moisture, texture, and the mucosa has a normal color, moisture, texture
presence of lesions and if there are a presence of lesion. If the
findings is abnormal, it might indicate a
possible health problem or issue.
Teeth and Gums
Inspect the teeth and gums while examining To check if the teeth is not decaying and
the inner lips and buccal mucosa. healthy. Abnormal findings may indicate
possible health problems.
Inspect the dentures. To check if there are any infections or
swelling around the dentures and the area
where it is attached.
Tongue/Floor of the Mouth
Inspect the surface of the tongue for position, To check if the tongue is properly positioned
color, and texture. in the middle and if the color and texture are
normal.
Inspect tongue movement. To check if the tongue muscles are
functioning properly. Abnormal findings might
indicate a health problem.
Inspect the base of the tongue, the mouth To check if there are no infections, swelling,
floor, and the frenulum. and lesions present at the base of the
tongue, mouth floor, and frenulum.
Palpate the tongue and floor of the mouth for To check if there are any palpable nodules,
any nodules, lumps, or excoriated areas. lumps, and excoriated area at the tongue and
at the floor of the mouth. Presence of this
might indicate a possible health problem.
Salivary Glands
Inspect salivary duct openings for any To check if there are any swelling or redness
swelling or redness. present at the salivary duct openings that
might alter the secretion of saliva in the
mouth.
Palates and Uvula
Inspect the hard and soft palate for color, To check if the soft and hard palate’s color,
shape, texture, and the presence of bony shape, and texture is normal. Also, to check if
prominences. there are presence of bony prominence in
these areas.
Inspect the uvula for position and mobility To check if the uvula is positioned properly
while examining the palates. and mobility. Also, to check if there are any
deformities at the uvula.
Oropharynx and Tonsils
Inspect the oropharynx for color and texture. To check if the color and the texture of the
oropharynx is normal. Abnormal findings may
indicate health problem.
Inspect the tonsils for color, discharge, and To check if the color and size of the tonsils
size. are normal. To check if there are any
discharges at the tonsils. Abnormal findings
may include swelling and white discharges
that indicates possible health problems.
Elicit the gag reflex by pressing the posterior To check if the gag reflex of the client is
tongue with a tongue depressor. contracting normally.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Neck

 Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably, seated if Assessing the client in an uncomfortable
possible position might make them wary and would
not cooperate to the procedure.
Neck Muscles
Inspect the neck muscles To check if there are any abnormal swelling
(sternocleidomastoid and trapezius) for and masses present at the neck muscles of
abnormal swellings or masses. Ask the patient. If there are any, it might indicate
the client to hold her head erect. health problems or issue.
Observe head movement. To check if the client can move her/his head
Ask client to: normally.
Move her chin to the chest It determines function of the
sternocleidomastoid muscle
Move her head back so that the chin points It determines function of the trapezius
upward muscle.
Move her head so that the ear is moved It determines function of the
toward the shoulder on each side sternocleidomastoid muscle.
Turn her head to the right and to the left It determines function of the
sternocleidomastoid muscle.
Assess muscle strength To check if the muscle of around the neck of
the patient is strong and developed.
Weakness in these muscles might indicate
possible health problems.
Lymph Nodes
Palpate the entire neck for enlarged lymph To check if there are any palpable lymph
nodes nodes that might indicates health problems or
issue.
Trachea
Palpate the trachea for lateral deviation To check if there are any deviations at the
trachea that might cause problem to the client
Thyroid Gland
Inspect the thyroid gland. To check if there are any abnormalities at the
client’s thyroid gland.
Palpate the thyroid gland for smoothness. To check if the thyroid is smooth. If hardening
is detected there might be swelling or lumps
within.
If enlargement of the gland is suspected: To check if there are a presence of
enlargement at the thyroid.
Auscultate over the thyroid area for a bruit. To check if there is a bruit sound present
around the mass at the thyroid gland that
might indicate a proliferation of blood supply
towards it.
Use the bell-shaped diaphragm of the This is use to hear the bruits sounds much
stethoscope. clearer rather than the diaphragm part of the
stethoscope.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale of Assessing the Appearance and Mental Status

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Observe body build, height, and weight in To check if the body build, height, and weight
relation to the client’s age, lifestyle, and of the client matches its age, lifestyle, and
health. health.
Observe the client’s posture and gait, To check if the client’s posture and gait is
standing, sitting, and walking. normal. To check if the way of the client to sit,
stand, and walk is normal appropriate to its
age.
Observe the client’s overall hygiene and To check if the hygiene and grooming of the
grooming. Relate these to the person’s patient is normal and if it matches its
activities prior to the assessment. activities before the assessment.
Observe for signs of distress in posture or To check if there are any distress present in
facial expression the client’s posture and facial expression that
may indicate health problem.
Assess the client’s attitude. To check if the client’s attitude toward the
examiner is normal and understandable.
Listen for quantity, quality, and organization To check if there are any speech disorder or
of speech. alterations present
Listen for relevance and organization of To check if the client’s though process and
thoughts. thought content are normal and related to the
topic that the examiner is discussing.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Skin

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Inspect skin color To check if there is any skin discoloration in
the client like cyanosis and jaundice that
might indicate a disease or disorder.
Inspect uniformity of skin color. To check if there are any patches or part of
the skin that differs in color than the rest that
might indicate a disease or disorder.
Assess edema, if present To check if there are any swelling or
inflammation present at the client’s skin.
Inspect, palpate, and describe skin lesions. To determine what type of lesion is present
Apply gloves if lesions are open or draining. and how severe it. This can also indicate
 underlying issues in the health of the client.
Observe and palpate skin moisture This is to check if the skin of the client has
normal amount of moisture. Dry skin or
excessive moisture might indicate a disease.
Palpate skin temperature. This is to check if the temperature of the body
parts of the patient are even and normal.
Uneven and abnormal temperature might
indicate problem on the client’s health
Note skin turgor. This is to check if the patient is well-hydrated
and has a good skin turgor.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Nails

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Inspect fingernail plate shape to determine its To check if the curvature, angle, and shape
curvature and angle. of the fingernail plate is normal. If there is an
increase or decrease in the angle might
indicate a problem in the client’s health.
Inspect fingernail and toenail texture To check if the texture of the fingernail and
the toenail of the client is normal. Abnormal
findings may indicate possible health issues.
Inspect fingernail and toenail bed color. To check if there is any discoloration present
that might indicate an underlying disease or
illness.
Inspect tissues surrounding nails. To check if there are any infections present at
 the tissue around the client’s nails.
Perform blanch test of capillary refill. To check if the capillary refill of the client is
normal and not sluggish. Sluggish capillary
refill might indicate a problem in the client’s
health
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Peripheral Pulses

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Palpate the peripheral pulses (except the To check if the pulse volume of the peripheral
carotid pulse) on both sides of the client’s pulses of the client is symmetry and palpable.
body individually, simultaneously, and Doppler ultrasound probe is used if the
systematically to determine the symmetry of examiner or the nurse is having a hard time
pulse volume. If you have difficulty palpating on palpating the peripheral pulses.
some of the peripheral pulses, use a Doppler
ultrasound probe
Peripheral Veins
Inspect the peripheral veins in the arms and To check if the peripheral veins of the client
legs for the presence and/ or appearance of are present or showing when the limbs are
superficial veins when limbs are dependent elevated and dependent.
and when limbs are elevated.
Assess the peripheral leg veins for signs of To check if there are a presence of phlebitis
phlebitis. at the legs of the patient.
Peripheral Perfusion
Inspect the skin of the hands and feet for To check the color and temperature of the
color, temperature, edema, and skin skin and feet are normal and the same. To
changes. check if there are any swelling present and if
there are any abnormal skin changes.
Assess the adequacy of arterial flow if arterial To check if the arterial flow is normal and if
insufficiency is suspected. there are any insufficiency in it.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Musculoskeletal System

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Muscles
Inspect the muscles for size. To check if the client’s muscle is within the
normal size and matches the client’s age and
appearance.
Inspect the muscles and tendons for To check if there are any contractures or
contractures tightening ate the client’s muscle and
tendons.
Inspect the muscles for fasciculations and To check if there are any uncontrollable and
tremors. sudden movement at the client’s muscles.
Palpate muscles at rest to determine muscle To check if the muscle of the client of the
tonicity. client is abnormally contracting even at rest.
Palpate muscles while the client is active and To check if the muscle of the client during
passive for flaccidity, spasticity, and active and passive has a presence of
smoothness of movement. weakness, stiffening or tightening, and any
abnormalities at the smoothness of the
muscle.
Test muscle strength. Compare the right side To check if there are any weakness at the
with left side. muscle or if the strength of the muscles is
unequal.
Bones
Inspect the skeleton for normal structure and To check if the skeleton of the client has a
deformities. normal structure and there are no deformities
present.
Palpate the bones to locate any areas of To check if there are any swelling or
edema or tenderness. inflammation present at the bones of the
client.
Joints
Inspect for joint swelling To check if there are presence of swelling at
the client’s joint.
Assess joint range of motion To check if the joint range of motion is
normal.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Neurological System

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Language
If the client displays difficulty speaking: To check if the client can identify the common
Point to common objects, and ask the client objects that the examiner is pointing at.
to name them.
Ask the client to read some words and to To check if the client can read the words and
match the printed and written words with able to match it with the written printed
pictures words. This will help to check if the patient
can effectively analyze and identify it.
Ask the client to respond to simple verbal and To check if the client can understand what
written commands, e.g., “point to your toes” the examiner is saying and if the client can
or “raise your left arm.” understand what the examiner has written by
commanding simple actions.
Orientation
Determine the client’s orientation to time, To check if the client is oriented and knows
place, and person by tactful questioning what time is the procedure taking place,
where are they at the moment, who is the
client talking to.
Memory
Listen for lapses in memory. To determine if there is any problem with the
patient’s capability of remembering
information. Immediate recall, recent
memory, and remote memory are checked.
Attention Span and Calculation
Test the ability to concentrate or attention To check if the client can concentrate and
span by asking the client to recite the pay attention to whatever the other person is
alphabet or to count backward from 100. saying.
Test the ability to calculate by asking the To check if the client has the ability to
client to subtract 7 or 3 progressively from calculate and perform it accurately.
100—i.e., 100, 93, 86, 79, or 100, 97, 94.
Level of Consciousness
Apply the Glasgow Coma Scale To check the level of the client’s
consciousness that matches to its state.
Cranial Nerves
Test Cranial nerves To determine if there are any underlying
issues or problems with the client’s cranial
nerves.
Cranial Nerve I—Olfactory To check if the client’s olfactory nerve is
Ask client to close eyes and identify different working properly by identifying the different
mild aromas, such as coffee, vanilla. aromas presented.
Cranial Nerve II—Optic To check if the client’s optic nerve is working
Ask client to read Snellen’s chart, check properly by identifying its score at the Snellen
visual fields by confrontation, and conduct an chart, its visual acuity, and to check is the
ophthalmoscopic examination back of the eye is normal.
Cranial Nerve III—Oculomotor To check if the oculomotor nerve of the client
Assess six ocular movements and pupil is working properly by being able to perform
reaction. the six ocular movement and has a proper
pupil reaction.
Cranial Nerve IV—Trochlear To check if the client’s trochlear nerve is
Assess six ocular movements working properly by also being able to
perform the six-ocular movement.
Cranial Nerve V—Trigeminal To check if the client’s trigeminal nerve is
While client looks upward, lightly touch lateral working properly by being able to elicit blink
sclera of eye to elicit blink reflex. To test light reflex, appropriate light sensation and deep
sensation, have client close eyes, and wipe a sensation.
wisp of cotton over client’s forehead and
paranasal sinuses. To test deep sensation,
use alternating blunt and sharp ends of a
safety pin over same area.
Cranial Nerve VI—Abducens To check if the client’s abducens nerve is
Assess directions of gaze working properly by checking if the clients
gaze is normal.
Cranial Nerve VII—Facial To check if the client’s facial nerve is working
Ask client to smile, raise the eyebrows, frown, properly by being able to follow the
puff out his cheeks, close his eyes tightly. examiners command of random facial actions
Ask client to identify various tastes place on and to be able to identify different types of
tip and sides of tongue—sugar, salt—and taste.
identify areas of taste
Cranial Nerve VIII—Auditory To check if the client’s auditory nerve is
Assess client’s ability to hear spoken word working properly by being able to hear the
and vibrations of tuning fork. spoken word of the examiner and the
vibrations of the tuning fork.
Cranial Nerve IX—Glossopharyngeal To check if the client’s glossopharyngeal
Apply tastes on posterior tongue for nerve is functioning properly by being able to
identification. Ask client to move tongue from identify the various taste and being able to
side to side and up and down. move the tongue sideways and upward and
downward.
Cranial Nerve X—Vagus To check if the client’s vagus nerve is
Assessed with CN IX; assess client’s speech working properly by assessing the
for hoarseness. hoarseness of the client’s speech.
Cranial Nerve XI—Accessory To check if the client’s accessory nerve is
Ask client to shrug shoulders against working properly by being able to shrug the
resistance from your hands and to turn his shoulders and turn the head against the
head to side against resistance from your resistance of the examiner’s hands.
hand. Repeat for the other side.
Cranial Nerve XII—Hypoglossal To check if the client’s hypoglossal nerve is
Ask client to protrude his tongue at midline, working properly by being able to protrude
then move it side to side the tongue at midline and being able to move
it side by side at this position.
Reflexes
Test reflexes using a percussion hammer, To check if the reflex of the client is
comparing one side of the body with the other functioning and if it’s symmetric with the other
to evaluate the symmetry of response. side’s response.
Biceps Reflex To check the action of the spinal cord level C-
5, C-6
Triceps Reflex To check the action of the spinal cord level C-
7, C-8
Brachioradialis Reflex To check the action of the spinal cord level C-
3, C-6
Patellar Reflex To check the action of the spinal cord level L-
2, L-3, L-4
Achilles Reflex To check the action of the spinal cord level S-
1, S-2
Plantar (Babinski’s) Reflex To check if the client is negative in the
Babinski’s test.
Motor Function
Walking Gait To check if the client’s gait is normal.
Ask the client to walk across the room and
back, and assess the client’s gait.
Romberg’s Test To check if the client can balance her/himself
Ask the client to stand with feet together and when eyes closed as well as when the eyes
arms resting at the sides, first with eyes are open.
open, and then closed.
Standing on One Foot with Eyes Closed To check if the client can balance him/herself
Ask the client to close his eyes and stand on while standing at one foot only with eyes
one foot, then the other. Stand close to the closed.
client during this test.
Heel–Toe Walking To check the client’s balance and ability walk
Ask the client to walk a straight line, placing in a straight line.
the heel of one foot directly in front of the
toes of the other foot.
Toe or Heel Walking To check the strength of the toe or heel as
Ask the client to walk several steps on the well as the balance of the client while
toes and then on the heels performing it.
Fine Motor Tests for the Upper Extremities
Finger-to-Nose Test To check if the client can move its arms and
Ask the client to abduct and extend the arms touch its nose alternately with the index
at shoulder height and rapidly touch the nose fingers rapidly.
alternately with one index finger and then the
other. Have the client repeat the test with the
eyes closed if the test is performed easily.
Alternating Supination and Pronation of To check if the client can move the hands
Hands-on Knees back and forth rapidly. This is not possible if
Ask the client to pat both knees with the the client has an underlying disease or injury.
palms of both hands and then with the backs
of the hands alternately at an ever-increasing
rate
Finger to Nose and to the Nurse’s Finger To check if the client can move its shoulder
Ask the client to touch the nose and then and arms by being able to touch the client’s
your index finger, held at a distance at about nose and the examiners fingers. This is not
45 cm (18 in), at a rapid and increasing rate. possible if the client has a health problem or
issue.
Fingers to Fingers To check if the client can move their arms
Ask the client to spread the arms broadly at away and towards with eyes closed and
shoulder height and then bring the fingers open. This is not possible if the client has a
together at the midline, first with the eyes health problem or issue.
open and then closed, first slowly and then
rapidly.
Fingers to Thumb (Same Hand) To check the muscle of the client’s fingers by
Ask the client to touch each finger of one being able to touch its fingers using the same
hand to the thumb of the same hand as hand.
rapidly as possible.
Fine Motor Tests for the Lower Extremities
Heel Down Opposite Shin To check the function of the client’s lower
Ask the client to place the heel of one foot muscle. This is not possible if the client has
just below the opposite knee and run the heel an underlying disease or illness.
down the shin to the foot. Repeat with the
other foot. The client may also use a sitting
position for this test.
Toe or Ball of Foot to the Nurse’s Finger To check if the client can bring its toe up and
Ask the client to touch your finger with the touch the finger of the nose. It is not possible
large toe of each foot. if the client has an underlying disease or
problem.
Light-Touch Sensation. To check if the client is able to feel the light-
touch sensations made by the nurse to the
client’s body. This will determine if there is
any sensory loss in any part of the client’s
body that might indicate a disease or illness.
Pain Sensation To check if the client can perceive pain in the
different parts of the body. This can also
check if the client can differentiate the dull
and sharp object against the client’s skin.
Temperature Sensation To check if the client can differentiate the
different temperature. Unable to do so might
indicate health problems.
Position or Kinesthetic Sensation To check if the client can identify the position
of his/her middle finger or big toe. Unable to
do so might indicate health problems.
Tactile Discrimination
One- and Two-Point Discrimination To check if the client can differentiate the
Alternately stimulate the skin with two pins area of being pricked by the pin. To check
simultaneously and then with one pin. Ask their ability to process information through
whether the client feels one or two pinpricks. sense of touch.
Stereognosis To check if the client can identify the objects
Place familiar objects—such as a key, paper just by touching it with eyes closed.
clip, or coin—in the client’s hand, and ask the
client to identify them.
Extinction Phenomenon Simultaneously To check if the client can feel the sensation at
stimulate two symmetric areas of the body, the same time.
such as the thighs, the cheeks, or the
hands
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale of Assessing the Thorax and Lungs

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Posterior Thorax
Position the client comfortably, seated if Assessing the client in an uncomfortable
possible position might make them wary and would
not cooperate to the procedure.
Inspect the shape and symmetry of the To check if the client’s thorax shape and
thorax from posterior and lateral views. symmetry is normal from posterior and lateral
views.
Inspect the spinal alignment for deformities. To check if there any deformities present at
the spinal alignment of the thorax.
Palpate the posterior thorax. To check if there are any bulges, tenderness
For clients who have no respiratory and abnormal movements at the client’s
complaints, rapidly assess the temperature posterior thorax. To check if the temperature
and integrity of all chest skin. and integrity of the skin around it is within
For clients who do have respiratory normal.
complaints, palpate all chest areas for
bulges, tenderness, or abnormal movements.
Avoid deep palpation for painful areas,
especially if a fractured rib is suspected.
Palpate the posterior chest for respiratory To check if there are any deviations from the
excursion. respiratory pattern of the client.
Palpate the chest for vocal (tactile) fremitus. To check if there any deviations at the client’s
vocal or tactile fremitus.
Percuss the thorax To check if there are no abnormalities at the
client’s thorax
Percuss for diaphragmatic excursion. To check if there are any diaphragmatic
deviations present.
Auscultate the chest using the flat-disc To check if the sounds produce at the check
diaphragm of the stethoscope. are normal and there are no adventitious
sounds present.
Anterior Thorax
Inspect breathing patterns To check if the client’s breathing patterns is
normal and matches the client’s activities and
state.
Inspect the costal angle and the angle at To check if there any abnormalities and
which the ribs enter the spine. deformities at the client’s costal angle and
angle where the ribs enter the spine.
Palpate the anterior chest. To check if there are any abnormalities at the
client’s anterior chest.
Palpate the anterior chest for respiratory To check if there are any deviations of
excursion respiration at the client’s anterior chest
Palpate tactile fremitus in the same manner To check if there are any abnormalities
as for the posterior chest. present at the client’s tactile fremitus at the
anterior chest.
Percuss the anterior chest systematically To check if there are any swelling or
tenderness at the client’s chest.
Auscultate the trachea. To check if client’s trachea produces normal
sound and no adventitious sounds present.
Auscultate the anterior chest. To check if the client’s anterior chest sounds
Use the sequence used in percussion, are normal and there are no adventitious
beginning over the bronchi between the sounds heard.
sternum and the clavicles.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Heart and Central Vessels

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Simultaneously inspect and palpate the To check if there are any abnormal
precordium for the presence of abnormal pulsations, lifts, and heaves at the client’s
pulsations, lifts, or heaves. precordium.
Inspect and palpate the aortic and pulmonic To check if there are a presence or absence
areas, observing them at an angle and to the of pulsations at client’s aortic and pulmonic
side, to note the presence or absence of areas.
pulsations.
Inspect and palpate the tricuspid area for To check if there are any heaves, lifts and
pulsations and heaves or lifts. abnormal pulsations at the client’s tricuspid
area.
Inspect and palpate the apical area for To check if the client’s apical area has a
pulsation, noting its specific location (it may normal pulsation and its location are normal.
be displaced laterally or lower) and diameter.
If displaced laterally, record the distance
between the apex and the MCL in
centimeters.
Inspect and palpate the epigastric area at the To check if the abdominal aortic pulsations at
base of the sternum for abdominal aortic the client’s epigastric area is present.
pulsations
Auscultate the heart in all four anatomic sites: To check if all the four anatomical sites of the
aortic, pulmonic, tricuspid, and apical (mitral). client’s heart have pulsation and is normal
Carotid Arteries
Palpate the carotid artery. Use extreme To check if the carotid artery of the client is
caution. normal and no abnormalities present.
Auscultate the carotid artery To check if there are any bruit that can be
heard at the client’s carotid artery.
Jugular Veins
Inspect the jugular veins for distention. To check if there are any bulge at the client’s
jugular veins.
If jugular distention is present, assess the To check the pressure of the superior vena
jugular venous pressure (JVP). cava that might be the reason of the
distention of the client’s jugular vein.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Breasts and Axillae

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Inspect the breasts for size, symmetry, and To check if the clients breast size is normal,
contour or shape while the client is in a sitting symmetric, and the shape and contour is
position. normal in a sitting position.
Inspect the skin of the breast for localized To check if there are any discoloration or
discolorations or hyperpigmentation, hyperpigmentation present and to check if
retraction or dimpling, localized hyper there are a presence of dimpling, swelling,
vascular areas, swelling, or edema. hypervascularization, and edema at skin of
the breast.
Emphasize any retraction by having the To check the appearance of the breast when
client: the client is retracting it by performing the
Raise the arms above the head different position asked by the examiner.
Push the hands together, with elbows flexed
Press the hands down on the hips
Inspect the areola area for size, shape, To check if there are any abnormalities
symmetry, color, surface characteristics, and present at the areola area of the client.
any masses or lesions.
Inspect the nipples for size, shape, position, To check if there are any abnormalities at the
color, discharge, and lesions. client’s nipples that might indicate a health
problem.
Palpate the axillary, sub clavicular, and To check if there are any palpable lymph
supraclavicular lymph nodes. nodes at the client’s axillary, sub clavicular,
and supraclavicular areas that may indicate
possible health problems.
Palpate the breast for masses, tenderness, To check if there are any masse and
and any discharge from the nipples. tenderness present at the client’s breast and
if there are any discharge at the client’s
nipples.
Palpate the areola and the nipples for To check if there are any masses preset at
masses. the client’s areola and nipples.
Teach the client the technique of breast self- In order for the client to assess her breast at
examination home and able to identify if there are any
masses or lumps present.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Abdomen

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Assist the client to a supine position, with the In order for the client to be comfortable during
arms placed comfortably at the sides. the whole procedure and for the assessment
to be performed accurately.
Place small pillows beneath the knees and To make the client comfortable at its position
the head to reduce tension in the abdominal and to reduce the tension and shivering at
muscles. Expose only the client’s abdomen the client’s abdomen that may alter the
from chest line to the pubic area to avoid findings at the assessment.
chilling and shivering, which can tense the
abdominal muscles.
Inspection of the Abdomen
Inspect the abdomen for skin integrity. To check if the skin integrity of the client’s
abdomen is normal.
Inspect the abdomen for contour and To check the symmetry of abdominal contour
symmetry. of the client’s side at a supine position. Any
abnormal findings can indicate a presence of
disease or illness.
Ask the client to take a deep breath and to To check the symmetry of contour at an
hold it. angle at the foot of the bed and to check if
there is any distention present that might
indicate a disease.
Observe abdominal movements associated To check if the movement of the abdomen
with respiration, peristalsis, or aortic matches the pulsations, respirations, and
pulsations peristalsis. Abnormal movements may
indicate health problems.
Observe the vascular pattern To check if there are n abnormalities present
at client’s vascular pattern.
Auscultation of the Abdomen
Auscultate the abdomen for bowel sounds, To check if the bowel sounds at the abdomen
vascular sounds, and peritoneal friction rubs is present and there are no bruits and other
abnormalities present.
Percussion of the Abdomen
Percuss several areas in each of the four To check if there are any presence of
quadrants to determine presence of tympany tympany and dullness that may indicate a
and dullness. health problem or issue.
Percussion of the Liver
Percuss the liver to determine its size To check if the liver is within the normal span.
If the liver is too small or if enlargement is
present, it might indicate a problem with the
 client’s health
Palpation of the Abdomen
Perform light palpation first to detect areas of To check if there are any tenderness and
tenderness and/or muscle guarding. muscle guarding present. Presence of this
might indicate a problem within the organs in
the abdomen of the client.
Perform deep palpation over all four To check if there are any tenderness and
quadrants. muscle guarding present deep within the
abdomen of the client.
Palpation of the Liver
Palpate the liver to detect enlargement and To check if there are any problems with the
tenderness. liver. If enlargement and tenderness is
present there might be a disease or problem
with the client’s liver.
Palpation of the Bladder
Palpate the area above the pubic symphysis To check if there are any lumps and
if the client’s history indicates possible urinary tenderness in the client’s pubic symphysis. If
retention. there are any it might indicate a problem for
pre-existing disease.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Female Genitals

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client supine with feet elevated This is for the nurse/examiner to have a
on the stirrups of an examination table. better access to the genital of the client and
Alternately, assist the client into the dorsal in order to perform the procedures
recumbent position with knees flexed and accurately.
thighs externally rotated.
Inspect the distribution, amount, and To check if the pubic hair is properly
characteristics of pubic hair. distributed and its amount and characteristics
are normal.
Inspect the abdomen for skin integrity. To check if there are no abnormalities at
client’s skin integrity.
Inspect the skin of the pubic area for To check if there are any parasites,
parasites, inflammation, swelling, and inflammation, swelling, and lesions present at
lesions. To assess pubic skin adequately, the client’s pubic area.
separate the labia majora and labia minora.
Inspect the clitoris, urethral orifice, and To check if there are any abnormalities at the
vaginal orifice when separating the labia client’s clitoris, urethral orifice and vaginal
minora orifice.
Palpate the inguinal lymph nodes. To check if there are any palpable inguinal
lymph nodes that may indicate a health
problems or issue.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Male Genitals

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client comfortably Assessing the client in an uncomfortable
position might make them wary and would
not cooperate to the procedure.
Pubic Hair
Inspect the distribution, amount, and To check if the pubic hair is evenly
characteristics of pubic hair. distributed, there are normal amount and the
characteristics of the pubic hair are normal.
Penis
Inspect the penile shaft and glans penis for To check if there are any swelling, lesions,
lesions, nodules, swellings, and inflammation. inflammations, and palpable nodules that
might indicate a health problem.
Inspect the urethral meatus for swelling, To check if there are any swelling,
inflammation, and discharge. inflammation, and discharge present that may
indicate a disease or issue on the client’s
health.
Palpate the penis for tenderness, thickening, To check if there are any swelling,
and nodules. Use your thumb and first two tenderness and palpable nodules present. If
fingers. there are any, it might indicate a problem in
the client’s health
Scrotum
Inspect the scrotum for appearance, general To check if there are any abnormalities at the
size, and symmetry client’s scrotum appearance, general size,
and appearance.
Palpate the scrotum to assess status of To check if there are any abnormalities,
underlying testes, epididymis, and spermatic welling, inflammation at the client’s testes,
cord. Palpate both testes simultaneously for epididymis and spermatic cord. To check
comparative purposes. also, for the symmetry of the client’s testes.
Inguinal Area
Inspect both inguinal areas for bulges while To check if there are any bulges or swelling
the client is standing, if possible. at client’s inguinal area while the client is
standing.
Palpate hernias To check if there are any hernias present at
the client.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.

Rationale for Assessing the Rectum

Procedure Rationale
Introduce yourself; explain to the client what This will make the client trust you and
you are going to do, why it is necessary, and cooperate to the procedure that you are
how he/she can cooperate about to do.
Wash hands and observe other appropriate It is important to keep the hands clean
infection control procedures. especially when touching the client.
Uncleaned hands might cause infection to the
client.
Provide for client privacy Privacy is important especially when it comes
to the health status of the client aside from
that there might be some procedures that will
require to check the body of the client.
Determine client’s history Determining the client’s history can help to
understand their current health status as past
health problems may contribute to what they
are experiencing now.
Position the client. In order for the examiner to have an access
In adults, a left lateral or Sims’ position with and to perform the procedure accurately.
the upper leg acutely flexed is required for
the examination.
For females: a dorsal recumbent position with In order for the examiner to have a good view
hips externally rotated and knees flexed or a and access at the client’s rectum.
lithotomy position may be used.
For males: a standing position while the client In order for the examiner to have a good view
bends over the examining table may also be and access at the client’s rectum.
used
Inspect the anus and surrounding tissue for This is to check if there are any abnormal
color, integrity, and skin lesions tissue color, integrity, and skin lesions
present. This can also check if the muscle
around the anus is contracting or functioning
properly. Any abnormal findings might
indicate a disease or health problems.
Palpate the rectum for anal sphincter tonicity, To check if there are any abnormalities at the
nodules, masses, and tenderness client’s rectum that might indicate possible
health problems.
On withdrawing the finger from the rectum To check if there are any abnormalities or
and anus, observe it for feces. infections at the feces that is gathered upon
withdrawal of the fingers from the rectum and
anus. Abnormalities might indicate a possible
health problem.
Document findings in the client record. To create a record or proof of authorization
about the assessment that is performed to
the patient as well as the data gathered from
it.