NCM 120 Procedural Checklist

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FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Tel. Number 085-3421830 local 4853
Nursing Program
Name: _______________________________________________ Section: ________
Health Assessment
NURSING LECTURE RETURN GRADE
DEMONSTRATION DEMONSTRATION
PROCEDURES DATE CI’s SIGNATURE DATE CI’s SIGNATURE
Assessing the:
Appearance and Mental Status;
Skin, Hair and Nails
Skull and Face; Eye Structure;
Visual Acuity; Ears and
Hearing; Nose and Sinuses;
Mouth and Oropharynx; Neck
Thorax and Lungs; Heart and
Central Vessels; and the
Peripheral Vascular System
Abdomen
Musculoskeletal System
Neurologic System
Remarks:
Checked by: ____________________________________________ Date: _________
FOR LABORATORY USE ONLY

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Name: _______________________________________________ Section: ________

Supervising Clinical Instructor: ___________________________ Date of Lecture Demo: _____
Assessing the Appearance and Mental Status; Skin, Hair and Nails
Basic Concept:
Assessing the appearance and mental status is an evaluation of the client’s look and mental
state in relation to his/ her culture, socioeconomic status and current circumstances.
Assessing the skin, hair and nails is an overall inspection of the condition of the
integumentary system that provides clues to client’s general health condition. The disease and
disorder of the integumentary system may be local or caused by underlying systemic condition.
Objectives:
Assessing the appearance and mental status
1. To determine client’s current mental state.
2. To determine reliability of the client’s responses throughout the rest of the examination
3. To acquire information regarding client’s level of cognition and emotional stability.
Assessing the skin, hair and nails

1. To obtain information about the nutritional and hydration status and overall health of
the patient.
2. To obtain information associated with certain systemic diseases, infection, immobility,
excessive sun exposure, and allergic reactions.
Preparation:
1. Introduce yourself, and verify the client’s identity. Explain to the client what you are
going to do, why it is necessary, and how the client can cooperate.
2. Perform hand hygiene, and observe appropriate infection control procedures.
3. Provide for client privacy.
Assessing the Appearance and Mental Status
PROCEDURE RATIONALE
1. Observe body build, height, and weight in

relation to the client’s age, lifestyle, and
health.
2. Observe the client’s posture and gait,
standing, sitting, and walking.
3. Observe the client’s overall hygiene and
grooming. Relate these to the person’s
activities prior to the assessment.
4. Note body and breathe odor in relation to
activity level.
5. Observe for signs of distress in posture or
facial expression.
6. Note obvious signs of health or illness.
7. Assess the client’s attitude.
8. Note the client’s affect/mood; assess the
appropriateness of the client’s responses.
9. Listen for quantity, quality and organization
of speech.
10. Listen for relevance and organization
of thoughts.
11. Document findings in the client
record.
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Assessing the Skin
Materials/ Equipment:
Millimeter ruler
Examination gloves/ clean gloves
Magnifying glass
Preparation:
1. Assemble equipment.
PROCEDURE RATIONALE
1. Inquire if client has any history of the

following:
• Pain or itching
• Presence and spread of any lesions,
bruises, abrasions, or pigmented spots
• Skin problems
• Associated clinical signs
• Problems in other family members
• Related systemic conditions
• Use of medications, lotions, or home
remedies
• Excessively dry or moist feel to the
skin
• Tendency to bruise easily
• Any association of the problem to a
season of the year
2. Inspect the skin color.
3. Inspect uniformity of skin color.
4. Assess edema, if present.
5. Inspect, palpate, and describe skin
lesions.
-Apply gloves if lesions are open or
draining.
-Describe lesions according to
location, distribution, color,
configuration, size, shape, type, or
structure.
6. Observe and palpate skin moisture.
7. Palpate skin temperature.
-Compare the two feet and the two
hands using the backs of your fingers.
8. Note skin turgor by lifting and
pinching the skin on an extremity.
9. Documents findings in the client
record.
-Draw the location of skin lesions on
body surface diagrams.
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Assessing the Hair
Material:
Clean gloves
PROCEDURE RATIONALE
1. Inquire if client has any history of

the following:
Recent use of hair dyes, rinses, or
curling or straightening
preparations
Recent chemotherapy
Presence of disease
2. Inspect the evenness of growth
over the scalp.
3. Inspect hair thickness or thinness.
4. Inspect hair texture and oiliness.
5. Note presence of infection or
infestation by parting the hair in
several areas and checking behind
the ears and along the hairline at
the neck.
6. Inspect the amount of body hair.
record.
Assessing the Nails
PROCEDURE RATIONALE
1. Inquire if the client has any history of

the following:
Diabetes mellitus
Peripheral circulatory disease
Previous injury
Severe illness
2. Inspect fingernail plate shape to
determine its curvature and angle.
3. Inspect fingernail and toenail texture.
4. Inspect fingernail and toenail bed
color.
5. Inspect tissues surrounding nails.
6. Perform blanch test of capillary refill.
- Press two or more nails between
your thumb and index fingers; look for
blanching and return of pink color to
nail bed.
record.
Adopted from Kozier and Erb’s Fundamentals of Nursing (2015).
Berman, Audrey, et.al. (2015). Kozier and Erb’s Fundamentals of Nursing: Concept, Process and Practice, 10 th ed.
Weber, Janet R., et.al. (2014). Health Assessment in Nursing, 5th ed.
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PERFORMANCE CHECKLIST
Name: __________________________________________ Date of Return Demo: __________
Assessing the Appearance and Mental Status; Skin, Hair and Nails
Criteria for evaluation or rating the student’s performance:
1 - Performs the step or procedure independently, correctly and appropriately. Shows excellent
attitude and gives the correct rationale of the step/ procedure to be performed. Answers the
question/s correctly and analyzes the situation on or before performing the procedure.
2 – Performs more independently with increasing dependability but occasionally needing
assistance. Shows very satisfactory attitude and gives the correct rationale of the step/ procedure
to be performed but occasionally needing follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and
explanations. Has knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance and
direction to be able to perform the step/ procedure correctly and appropriately. There is a need to
improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/
procedure to be performed; cannot answer the question raised by the supervising clinical instructor
based on the step or procedure to be performed; unable to grasp understanding of the topic or
procedure; unable to perform the required step and state the rationale after being instructed, guided
or directed. Student’s behavior is inappropriate and potentially harmful to the client.
1 2 3 4 5
ASSESSMENT
1. Verifies the client’s identity.
PLANNING
1. Reviews previously learned concepts and principles.
2. Explains the procedure to the client and how the client can cooperate.
3. Prepares and assembles all equipment.
IMPLEMENTATION
1. Introduces self.
2. Performs hand hygiene.
3. Provides client privacy.
Assessing appearance and mental status:
4. Observes body build, height, and weight in relation to the client’s age,
lifestyle, and health.
5. Observes the client’s posture and gait, standing, sitting, and walking.
6. Observes the client’s overall hygiene and grooming.
7. Relates observation on overall hygiene and grooming to the person’s
activities prior to the assessment.
8. Notes body and breathe odor in relation to activity level.
9. Observes for signs of distress in posture or facial expression.
10. Notes obvious signs of health or illness.
11. Assesses the client’s attitude.
12. Notes the client’s affect/mood.
13. Assesses the appropriateness of the client’s responses to your
question and to affect/ mood.
14. Listens for quantity, quality and organization of speech.
15. Listens for relevance and organization of thoughts.
Assessing the Skin:
16. Inquires if client has any history of the following:
a. Pain or itching
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b. Presence and spread of any lesions, bruises, abrasions, or pigmented

spots
c. Skin problems
d. Associated clinical signs
e. Problems in other family members
f. Related systemic conditions
g. Use of medications, lotions, or home remedies
h. Excessively dry or moist feel to the skin
i. Tendency to bruise easily
j. Any association of the problem to a season of the year
17. Inspects the skin color.
18. Inspects uniformity of skin color.
19. Assesses edema, if present.
20. Inspects, palpates, and describes skin lesions.
a. Applies gloves (if lesions are open or draining).
b. Describes lesions according to:
b1. location,
b2. distribution,
b3. color,
b4. configuration,
b5. size,
b6. shape,
b7.type, or
b8. structure.
21. Observes and palpates skin moisture.
22. Palpates skin temperature.
a. Compares the two feet and the two hands using the backs of your
fingers.
23. Notes skin turgor by lifting and pinching the skin on an extremity.
Assessing Hair:
a. Recent use of hair dyes, rinses, or curling or straightening preparations
b. Recent chemotherapy
c. Presence of disease
25. Inspects the evenness of growth over the scalp.
26. Inspects hair thickness or thinness.
27. Inspects hair texture and oiliness.
28a. Notes presence of infection or infestation by parting the hair in
several areas and;
b. checks behind the ears and along the hairline at the neck.
29. Inspects the amount of body hair.
Assessing nails:
30. Inquires if the client has any history of the following:
a. Diabetes mellitus
b. Peripheral circulatory disease
c. Previous injury
d. Severe illness
31. Inspects fingernail plate shape to determine its curvature and angle.
32. Inspects fingernail and toenail texture.
33. Inspects fingernail and toenail bed color.
34. Inspects tissues surrounding nails.
35. Performs blanch test of capillary refill.
a. Presses two or more nails between your thumb and index fingers.
b. Looks for blanching and return of pink color to nail bed.
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37. Documents findings in the client record.

38. For skin assessment, draws the location of skin lesions on body
surface diagrams.
EVALUATION
1. Observes appropriate infection control measures throughout the
performance of the procedure.
2. Applies related and relevant principles / concepts.
3. Distinguishes what is normal findings and deviation to normal
findings,
4. Relates findings or assessment to client’s culture, socioeconomic
status and current circumstances, certain condition or disorder.
5. Shows understanding of the terms, description or findings stated.
6. Performs the procedure with mastery and confidence.
7. Shows a positive and caring attitude towards the client.
Comments and Suggestions:
Rating: ______
Signature of Supervising Clinical Instructor: _______________________
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Assessing the Skull and Face; Eye Structures and Visual Acuity; Ears and Hearing; Nose
and Sinuses; Mouth and Oropharynx; and Neck
Basic Concept:
Assessing the skull and face is an inspection and palpation of the skull and face; and also
measuring the skull circumference, in which the presence of deviation and changes of facial
shape may indicate a disorder or certain condition.
Assessing the eye structures and visual acuity is an examination of the eye that includes
the external eye structure, visual perception, ocular movement and visual fields. Assessment of
vision provides important information about client’s ability to interact with the environment and
perform activities of daily living (Weber, et.al. 2014).
Assessing the ears and hearing is an examination of the ear structure and determination of
the client’s hearing acuity which consists of direct inspection, palpation of the ear and techniques
to assess auditory acuity and sound conduction.
Assessing the nose and sinuses is an inspection and palpation of the external nose
structure and sinuses; and inspection of patency of the nasal cavities.
Assessing the mouth and oropharynx is an inspection of the structures associated with
eating and taste which is composed of the lips, oral mucosa, tongue, floor of the mouth, teeth,
gums, hard and soft palate, uvula, salivary glands, tonsillar pillars and tonsils (Berman, et.al.
2015).
Assessing the neck is an examination of the neck muscles, lymph nodes, trachea, thyroid
gland, carotid arteries and jugular veins (Berman, et.al. 2015).
Objective:
1. To check for any deviations of the skull and face; eye structures and visual acuity; ears and
hearing; nose and sinuses; mouth and oropharynx and neck.
2. To acquire information and accurate nursing history of the eyes and vision; ears and hearing;
nasal, oral and neck of the client.
3. To be able to formulate nursing diagnosis, collaborative problem and referral.
Preparation:
1. Introduce yourself, and verify the client’s identity. Explain to the client what you are going to
do, why it is necessary, and how the client can cooperate.
2. Perform hand hygiene, and observe appropriate infection control procedures.
PROCEDURE RATIONALE

the following:
- Lumps or bumps, itching, scaling, or
dandruff
- Loss of consciousness, dizziness,
seizures, headache, facial pain, or
injury
2. If so, ascertain the following:
-When and how any lumps occurred
-Length of time any other problem
existed
-Any known cause of any problem
-Associated symptoms, treatment, and
recurrences
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3. Inspect the skull for size, shape, and

symmetry.
4. Palpate the skull for nodules or masses
and depressions.
-Use a gentle rotating motion with the
fingertips.
-Begin at the front and palpate down
the midline, then palpate each side of
the head.
5. Inspect the facial features.
6. Inspect the eyes for edema and
hollowness.
7. Note symmetry of facial movements.
-Ask the client to elevate the
eyebrows, frown, or lower the
eyebrows, close the eyes tightly, puff
the cheeks, and smile and show teeth.
record.
Assessing the Eye Structures and Visual Acuity
Preparation:
1. Assemble equipment and supplies:

Cotton-tipped applicator
Examination gloves
Millimeter ruler
Penlight
Snellen’s or E chart
Opaque card
PROCEDURE RATIONALE

the following:
• Family history of diabetes,
hypertension, or blood dyscrasia
• Eye disease, injury, or surgery
• Last visit to an ophthalmologist
• Current use of eye medications
• Use of contact lenses or eyeglasses
• Hygienic practices for corrective
lenses
• Current symptoms of eye problems
Assessing external eye structures:

2. Inspect the eyebrows for hair
distribution and alignment, and for
Note: Italicize step/s is excluded in the return
skin quality and movement.
demonstration routine; however, the student
3. Inspect the eyelashes for evenness of
distribution and direction of curl. is required to state or mention the step.
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4. Inspect the eyelids for surface

characteristics, position in relation to
the cornea, ability to blink, and
frequency of blinking. Inspect the
lower eyelids while the client’s eyes
are closed.
5. Inspect the bulbar conjunctiva for
color, texture, and the presence of
lesions.
6. Inspect the palpebral conjunctiva by
everting the lids.
7. Evert the upper lids if a problem is
suspected.
-Ask the client to look down while
keeping the eyelids slightly open.
-Gently grasp the client’s eyeglass
with thumb and forefinger.
-Pull lashes gently downward while
holding the eyelashes.
-Hold the margin of the everted lid or
eyelashes against the ridge of the
upper bony orbit with the applicator
stick or your thumb.
-Inspect the conjunctiva for color,
texture, lesions and foreign bodies.
8. Inspect and palpate the lacrimal gland.
-Using the tip of your index finger,
palpate the lacrimal gland.
-Observe for edema between the lower
lid and the nose.
9. Inspect and palpate the lacrimal sac
and nasolacrimal duct.
-Observe for evidence of increased
tearing.
-Using the tip of your index finger,
palpate inside the lower orbital rim
near the inner canthus.
10. Inspect the cornea for clarity and
texture.
-Ask the client to look straight ahead. -
--Hold a penlight at an oblique angle
to the eye, and move the light slowly
across the corneal surface.
11. Perform the corneal sensitivity (reflex)
test to determine the function of the
fifth (trigeminal) cranial nerve.
- Ask the client to keep both eyes open
and look straight ahead.
-Approach from behind and beside the
client, and lightly touch the cornea
with a corner of the gauze.
12. Inspect the anterior chamber for
transparency and depth.
-Use the same oblique lighting used
when testing the cornea.
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13. Inspect the pupils for color, shape, and

symmetry of size.
14. Assess each pupil’s direct and
consensual reaction to light in a
partially darken room.
-Ask the client to look straight ahead.
-Using a penlight and approaching
from the side, shine a light on the
pupil.
-Observe the response.
-Shine the light on the pupil again, and
observe the response of the other
pupil.
15. Assess each pupil’s reaction to
accommodation.
-Hold an object about 10cm from the
client’s nose.
-Ask the client to look first at the top
of the object and then at a distant
object behind the penlight.
-Alternate the gaze between the near
and far objects.
-Observe the pupil response.
-Next, move the penlight or pencil
toward the client’s nose. The pupils
should converge.
-To record normal assessment of the
pupil’s use the abbreviation PERRLA.
Assessing visual fields:
16. Assess peripheral visual fields.
-Have the client sit directly facing you
at a distance of 60-90cm.
-Ask the client to cover right eye with
the card and look directly at your nose.
-Cover or close your eye directly
opposite the client’s covered eye, and
look directly at the client’s nose.
-Hold an object in your fingers, extend
your arm, and move the object into the
visual field from various points in the
periphery.
-Ask the client to tell you when the
moving object is first spotted.
-To test the temporal field of the left
eye, extend and move your right arm
in from the client’s right periphery.
-To test the upward field of the left
eye, extend and move the right arm
down from the upward periphery.
-To test the downward field of the left
eye, extend and move the right arm up
from the lower periphery.
-To test the nasal field of the left eye,
extend and move your left arm in from
the periphery.
-Repeat the above steps for the right
eye.
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Extraocular muscle tests:

17. Assess six ocular movements to
determine eye alignment and
coordination.
-Stand directly in front of client, and
hold the penlight at a comfortable
distance such as 30 cm in front of the
client’s eyes.
-Ask the client to hold the head in a
fixed position facing you and follow
the movements of the penlight with
the eyes only.
-Move the penlight in a slow, orderly
manner through the six cardinal fields
of gaze.
-Stop the movement of the penlight
periodically so that nystagmus can be
detected.
18. Assess for location of light reflex by
shinning a penlight on the pupil in
corneal surface (Hirschberg Test).
19. Have the client fixate on a near or far
object. Cover one eye, and observe for
movement in the uncovered eye (cover
test).
Assessing visual acuity:
20. Assess near vision by providing
adequate lighting and asking the client
to read from a magazine or newspaper.
21. Assess distance vision by asking the
client to wear corrective lenses unless
they are used for reading only.
-Ask the client to sit or stand 6 meters
(20ft) from Snellen’s chart, cover the
eye not being tested, and identify the
letters or characters.
-Take three readings: right eye, left
eye, and both eyes.
22. Perform functional vision tests if the
client is unable to see the top line
(20/200) of Snellen’s chart.
record.
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Assessing the Ears and Hearing
Preparation:
1. Assemble equipment:
• Otoscope with several sizes or ear specula
PROCEDURE RATIONALE

the following:
• Family history of hearing problems or
loss
• Presence of any ear problems or pain
• Medication history, especially if there
are complaints of ringing in ears
• Any hearing difficulty: its onset,
factors contributing to it, and how it
interferes with activities of daily living
• Use of a corrective hearing device:
when and from it was obtained
2. Position the client comfortably-seated,
if possible.
Auricles
3. Inspect the auricles for color,
symmetry of size, and position.
- To inspect position, note the level at
which the superior aspect of the
auricle attaches to the head with
relation to the eye.
4. Palpate the auricle for texture,
elasticity, and areas of tenderness.
- Gently pull the auricle upward,
downward, and backward.
- Fold the pinna forward. (It should
recoil)
- Push in on the tragus.
- Apply pressure to the mastoid
process.
External ear canal and tympanic membrane:
5. Using an otoscope, inspect the
external ear canal for cerumen, skin
lesions, pus and blood.
- Attach a speculum to the otoscope.
- Tip the client’s head away from you
and straighten the ear canal.
- Hold the otoscope either right side
up, with your fingers between the
otoscope handle and the client’s head,
or upside down, with your fingers and
the ulnar surface of your hand against
the client’s head.
- Gently insert the tip of the otoscope
into the ear canal, avoiding pressure
by the speculum against either side of
the ear canal.
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6. Inspect the tympanic membrane for

color and gloss.
Gross hearing acuity test:
7. Assess the client’s response to normal
voice tones.
- If the client has difficulty hearing the
normal voice, proceed with the
following tests.
a. Perform the watch tick test.
-Have the client occlude one ear.
-Out of the client’s sight, place a
ticking watch 2-3cm (1-2 inches) from
the unoccluded ear.
-Ask what the client can hear. Repeat
with the other ear.
b. Tuning fork test
b.1. Perform Weber test.
- Hold the tuning fork at its base.
- Activate it by tapping the fork gently
against the back of your hand near the
knuckles or by stroking the fork between your
thumb and index fingers.
- Place the base of the vibrating fork on
the top of the client’s head, and ask whether
the client hears the noise.
b.2. Conducting Rinne test.
- Ask the client to block the hearing in
one ear intermittently by moving a fingertip in
and out of the ear canal.
- Hold the handle of the activated tuning
fork on the mastoid process of one ear until
the client states that the vibration can no
longer be heard.
- Immediately hold still the vibrating
fork prongs in front of the client’s ear canal.
- If necessary, push aside the client’s
hair.
- Ask whether the client now hears the
sound.
record.
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Assessing the Nose and Sinuses
Preparation:
• Nasal speculum
• Flashlight/penlight
PROCEDURE RATIONALE

following:
• Allergies
• Difficulty breathing through the nose
• Sinus infections
• Injuries to nose or face
• Nosebleeds
• Any medications taken
• Any changes in sense of smell
2. Position the client comfortably-seated,
if possible.
Nose:
3. Inspect the external nose for any
deviations in shape, size or color and
flaring, or discharge from the nares.
4. Lightly palpate the external nose to
determine any areas of tenderness,
masses, or displacements of bone and
cartilage.
5. Determine patency of both nasal
cavities.
- Ask the client to close the mouth,
exert pressure on one naris, and
breathe through the opposite naris.
- Repeat the procedure to assess
patency of the opposite naris.
6. Inspect the nasal cavities using a
flashlight or a nasal speculum.
-Hold the speculum in your right hand
and inspect the client’s left nostril, and
in your left hand to inspect the client’s
right nostril.
-Tip the client’s head back.
-Facing the client, insert the tip of the
closed speculum about 1cm or up to
the point at which the blade widens.
-Care must be taken to avoid pressure
on the sensitive nasal septum.
-Stabilize the speculum with your
index finger against the side of the
nose.
-Use the other hand to position the
head and then to hold the light.
-Open the speculum as much as
possible and inspect the floor of the
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nose, the anterior portion of the

septum, the middle meatus, and the
middle turbinates.
-Inspect the lining of the nares and the
integrity and the position of the nasal
septum.
7. Observe for the presence of redness,
swelling, growths, and discharge.
8. Inspect the nasal septum between the
nasal chambers.
Facial Sinuses
9. Palpate the maxillary and frontal
sinuses for tenderness.
record.
Assessing the Mouth and Oropharynx
Preparation:
1. Assemble equipment and supplies:

Clean gloves
Tongue depressor
2 x 2 gauze pads
Penlight
PROCEDURE RATIONALE
following:
• Routine pattern on dental care
• Last visit to the dentist
• Length of time ulcers or other lesions
have been present
• Any denture discomfort
• Any medications the client is receiving
2. Position the client comfortably-seated, if
possible.
Lips and buccal mucosa:
3. Inspect the outer lips for symmetry of
contour, color and texture.
- Ask the client to purse lips as if to
whistle.
4. Inspect and palpate the inner lips and
buccal mucosa for color, moisture,
texture, and the presence of lesions.
Teeth and gums:
5. Inspect the teeth and gums while
examining the inner lips and buccal
mucosa.
6. Inspect the dentures.
- Ask the client to remove complete or
partial dentures. Inspect their condition,
nothing in particular broken or worn
areas.
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Tongue/ floor of the mouth:

7. Inspect the surface of the tongue for
position, color, and texture.
- Ask the client to protrude the tongue and
to move it from side to side.
8. Inspect tongue movement.
-Ask the client to roll the tongue upward
and to move it from side to side.
9. Inspect the base of the tongue, the mouth
floor, and the frenulum.
-Ask the client to place the tip of his/her
tongue against the roof of the mouth.
10. Palpate the tongue and floor of the mouth
for any nodules, lumps, or excoriated
areas.
-Use a piece of gauze to grasp the tip of
the tongue and, with the index finger of
your other hand, palpate the back of the
tongue, its borders, and its base.
Salivary glands:
11. Inspect salivary duct openings for any
swelling or redness.
Palates and Uvula:
12. Inspect the hard and soft palate for color,
shape, texture, and the presence of bony
prominences.
-Ask the client to open mouth wide and
tilt head backward.
-Then, depress tongue with a tongue blade
as necessary, and use a penlight for
appropriate visualization.
13. Inspect the uvula for position and mobility
while examining the palates.
-To observe the uvula, ask the client to
say “ah” so that the soft palate rises.
Oropharynx and tonsils:
14. Inspect the oropharynx for color and
texture.
-Inspect one side at a time to avoid
eliciting the gag reflex.
-To expose one side of the oropharynx,
press a tongue blade against the tongue on
the same side about halfway back while
the client tilts head back and opens mouth
wide.
-Use a penlight for illumination, if
needed.
15. Inspect the tonsils for color, discharge,
and size.
16. Elicit the gag reflex by pressing the
posterior tongue with a tongue blade.
17. Document findings in the client record.
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Assessing the Neck
PROCEDURE RATIONALE
the following:
• Any problems with neck lumps
• Neck pain or stiffness
• When and how any lumps occurred
• Any diagnoses of thyroid problems
• Any treatments such as surgery or
radiation
Neck muscles:
2. Inspect the neck muscles
(sternocleidomastoid and trapezius) for
abnormal swellings or masses.
- Ask the client to hold head erect.
3. Observe head movement.
-Ask the client to:
Move chin to the chest.
Move head back so that the chin points

upward.
Move head so that the ear is moved
toward the shoulder on each side.
Turn head to the right and to the left.
4. Assess muscle strength.

Ask the client to:
- Turn head to one side against the
resistance of your hand. Repeat with
the other side.
- Shrug shoulders against the
resistance of your hands.
Lymph nodes:
5. Palpate the entire neck for enlarged
lymph nodes.
Trachea:
6. Palpate the trachea for lateral
deviation.
- Place your fingertip or thumb on the
trachea in the suprasternal notch, then
move your finger laterally to the left
and the right in spaces bordered by the
clavicle, the anterior aspect of the
sternocleidomastoid muscle, and the
trachea.
Thyroid gland:
7. Inspect the thyroid gland.
- Stand in front of the client.
- Observe the lower half of the neck
overlying the thyroid gland for
symmetry and visible masses.
- Ask the client to hyperextend head
and swallow.
19
- If necessary, offer a glass of water to

make it easier for the client to
swallow.
8. Palpate the thyroid gland to
smoothness.
-Note any areas of enlargement,
masses, or nodules.
9. If enlargement of the gland is
suspected:
-Auscultate over the thyroid area for a
bruit.
-Use the bell-shaped diaphragm of the
stethoscope.
record.
Berman, Audrey, et.al. (2015). Kozier and Erb’s Fundamentals of Nursing: Concept, Process and Practice, 10th ed.
Lynn, P.(2008). Taylor’s Clinical Nursing Skills, 2nd ed.
20
Assessing the Skull and Face; Eye Structures and Visual Acuity; Ears and Hearing; Nose
and Sinuses; Mouth and Oropharynx; and Neck
1 2 3 4 5
ASSESSMENT
PLANNING
IMPLEMENTATION
2. Introduces self.
Assessing the skull and face:
a. Lumps or bumps, itching, scaling, or dandruff
b. Loss of consciousness, dizziness, seizures, headache, facial pain, or
injury
5. If so, ascertains the following:
a. When and how any lumps occurred
b. Length of time any other problem existed
c. Any known cause of any problem
d. Associated symptoms, treatment, and recurrences
6. Inspects the skull for size, shape, and symmetry.
7. Palpates the skull for nodules or masses and depressions.
a. Uses a gentle rotating motion with the fingertips.
b. Begins at the front and palpate down the midline, then palpate each
side of the head.
8. Inspects the facial features.
9. Inspects the eyes for edema and hollowness.
21
10. Notes symmetry of facial movements.

a. Asks the client to elevate the eyebrows, frown, or lower the eyebrows,
close the eyes tightly, puff the cheeks, and smile and show teeth.
Assessing the eye structures and visual acuity:
a. Family history of diabetes, hypertension, or blood dyscrasia
b. Eye disease, injury, or surgery
c. Last visit to an ophthalmologist
d. Current use of eye medications
e. Use of contact lenses or eyeglasses
f. Hygienic practices for corrective lenses
g. Current symptoms of eye problems
Assessing external eye structures:
12. Inspects the eyebrows for hair distribution and alignment, and for
skin quality and movement.
13. Inspects the eyelashes for evenness of distribution and direction of
curl.
14. Inspects the eyelids for surface characteristics, position in relation to
the cornea, ability to blink, and frequency of blinking.
15. Inspects the lower eyelids while the client’s eyes are closed.
16. Inspects the bulbar conjunctiva for color, texture, and the presence
of lesions.
17. Inspects the palpebral conjunctiva by everting the lids.
18. Evert the upper lids if a problem is suspected.
a. Ask the client to look down while keeping the eyelids slightly open.
b. Gently grasp the client’s eyeglass with thumb and forefinger.
c. Pull lashes gently downward while holding the eyelashes.
d. Hold the margin of the everted lid or eyelashes against the ridge of the
upper bony orbit with the applicator stick or your thumb.
e. Inspect the conjunctiva for color, texture, lesions and foreign bodies.
19. Inspects and palpate the lacrimal gland.
a. Uses the tip of index finger, palpates the lacrimal gland.
b. Observes for edema between the lower lid and the nose.
20. Inspects and palpate the lacrimal sac and nasolacrimal duct.
a. Observes for evidence of increased tearing.
b. Uses the tip of his/ her index finger, palpates inside the lower orbital
rim near the inner canthus.
21. Inspects the cornea for clarity and texture.
a. Asks the client to look straight ahead.
b. Holds a penlight at an oblique angle to the eye, and moves the light
slowly across the corneal surface.
22. Performs the corneal sensitivity (reflex) test to determine the function
of the fifth (trigeminal) cranial nerve.
a. Asks the client to keep both eyes open and look straight ahead.
b. Approaches from behind and beside the client, and lightly touches the
cornea with a corner of the gauze.
23. Inspects the anterior chamber for transparency and depth.
a. Uses the same oblique lighting used when testing the cornea.
24. Inspects the pupils for color, shape, and symmetry of size.
25. Assesses each pupil’s direct and consensual reaction to light in a
partially darken room.
a. Asks the client to look straight ahead.
b. Uses a penlight and approaching from the side, shines a light on the
pupil.
c. Observes the response.
22
d. Shines the light on the pupil again, and observes the response of the
other pupil.
26. Assesses each pupil’s reaction to accommodation.
a. Holds an object about 10cm from the client’s nose.
b. Asks the client to look first at the top of the object and then at a distant
object behind the penlight.
c. Alternates the gaze between the near and far objects.
d. Observes the pupil response.
e. Moves the penlight or pencil toward the client’s nose.
f. Records normal assessment of the pupil using the abbreviation
PERRLA.
Assessing visual fields:
27. Assesses peripheral visual fields.
a. Have the client sits directly facing you at a distance of 60-90cm.
b. Asks the client to cover right eye with the card and look directly at
your nose.
c. Covers or closes your eye directly opposite the client’s covered eye,
and look directly at the client’s nose.
d. Holds an object in your fingers, extend your arm, and moves the
object into the visual field from various points in the periphery.
e. Asks the client to tell you when the moving object is first spotted.
f. Extends and moves right arm in from the client’s right periphery.
g. Extends and moves the right arm down from the upward periphery.
h. Extends and moves the right arm up from the lower periphery.
i. Extends and moves left arm in from the periphery.
j. Repeats the above steps for the right eye.
Extraocular muscle tests:
28. Assesses six ocular movements to determine eye alignment and
coordination.
a. Stands directly in front of client, and holds the penlight at a
comfortable distance such as 30 cm in front of the client’s eyes.
b. Asks the client to hold the head in a fixed position and follows the
movements of the penlight with the eyes only.
c. Moves the penlight in a slow, orderly manner through the six cardinal
fields of gaze.
d. Stops the movement of the penlight periodically so that nystagmus can
be detected.
29. Assesses for location of light reflex by shinning a penlight on the
pupil in corneal surface (Hirschberg Test).
30. Have the client fixate on a near or far object. Covers one eye, and
observes for movement in the uncovered eye (cover test).
Assessing visual acuity:
31. Assesses near vision by providing adequate lighting and asks the
client to read from a magazine or newspaper.
32. Assesses distance vision by asking the client to wear corrective
lenses unless they are used for reading only.
a. Asks the client to sit or stand 6 meters (20ft) from Snellen’s chart,
cover the eye not being tested, and identify the letters or characters.
b. Takes three readings: right eye, left eye, and both eyes.
33. Performs functional vision tests if the client is unable to see the top
line (20/200) of Snellen’s chart.
a. Family history of hearing problems or loss
b. Presence of any ear problems or pain
c. Medication history, especially if there are complaints of ringing in ears
23
d. Any hearing difficulty: its onset, factors contributing to it, and how it
interferes with activities of daily living
e. Use of a corrective hearing device: when and from it was obtained
35. Positions the client comfortably-seated, if possible
Auricles
36. Inspects the auricles for color, symmetry of size, and position.
a. To inspect position, notes the level at which the superior aspect of the
auricle attaches to the head with relation to the eye.
37. Palpates the auricle for texture, elasticity, and areas of tenderness.
a. Gently pulls the auricle upward, downward, and backward.
b. Folds the pinna forward. (It should recoil)
c. Pushes in on the tragus.
d. Applies pressure to the mastoid process.
External ear canal and tympanic membrane:
38. Uses an otoscope, inspects the external ear canal for cerumen, skin
lesions, pus and blood.
a. Attaches a speculum to the otoscope.
b. Tips the client’s head away and straightens the ear canal.
c. Holds the otoscope either right side up, with fingers between the
otoscope handle and the client’s head, or upside down, with fingers and
the ulnar surface of hand against the client’s head.
d. Gently inserts the tip of the otoscope into the ear canal, avoiding
pressure by the speculum against either side of the ear canal.
39. Inspects the tympanic membrane for color and gloss.
Gross hearing acuity test:
40. Assesses the client’s response to normal voice tones.
a. If the client has difficulty hearing the normal voice, proceeds with the
following tests.
A. Performs the watch tick test:
a. Have the client occlude one ear.
b. Out of the client’s sight, places a ticking watch 2-3cm (1-2 inches)
from the unoccluded ear.
c. Asks what the client can hear. Repeat with the other ear.
B. The tuning fork tests:
Performs Weber test.
a. Holds the tuning fork at its base.
b. Activates it by tapping the fork gently against the back of hand near
the knuckles or by stroking the fork between your thumb and index
fingers.
c. Place the base of the vibrating fork on the top of the client’s head, and
ask whether the client hears the noise.
Conducting Rinne’s test:
a. Asks the client to block the hearing in one ear intermittently by
moving a fingertip in and out of the ear canal.
b. Holds the handle of the activated tuning fork on the mastoid process of
one ear until the client states that the vibration can no longer be heard.
c. Immediately holds still the vibrating fork prongs in front of the client’s
ear canal.
d. If necessary, pushes aside the client’s hair.
e. Asks whether the client now hears the sound.
Assessing the nose and sinuses:
a. Allergies
b. Difficulty breathing through the nose
c. Sinus infections
d. Injuries to nose or face
24
e. Nosebleeds
f. Any medications taken
g. Any changes in sense of smell
42. Positions the client comfortably-seated, if possible.
Nose:
43. Inspects the external nose for any deviations in shape, size or color
and flaring, or discharge from the nares.
44. Lightly palpates the external nose to determine any areas of
tenderness, masses, or displacements of bone and cartilage.
45. Determines patency of both nasal cavities.
a. Asks the client to close the mouth, exert pressure on one naris, and
breathe through the opposite naris.
b. Repeats the procedure to assess patency of the opposite naris.
46. Inspects the nasal cavities using a flashlight or a nasal speculum.
a. Holds the speculum in your right hand, and inspect the client’s left
nostril, and in left hand to inspect the client’s right nostril.
b. Tips the client’s head back.
c. Facing the client, inserts the tip of the closed speculum about 1cm or
up to the point at which the blade widens.
d. Care is taken to avoid pressure on the sensitive nasal septum.
e. Stabilizes the speculum with index finger against the side of the nose.
f. Uses the other hand to position the head and then to hold the light.
g. Opens the speculum as much as possible and inspect the floor of the
nose, the anterior portion of the septum, the middle meatus, and the
middle turbinates.
h. Inspects the lining of the nares and the integrity and the position of the
nasal septum.
47. Observes for the presence of redness, swelling, growths, and
discharge.
48. Inspects the nasal septum between the nasal chambers.
Facial sinuses:
49. Palpates the maxillary and frontal sinuses for tenderness.
Assessing the mouth and oropharynx:
a. Routine pattern on dental care
b. Last visit to the dentist
c. Length of time ulcers or other lesions have been present
d. Any denture discomfort
e. Any medications the client is receiving
51. Positions the client comfortably-seated, if possible.
Lips and buccal mucosa:
52. Inspects the outer lips for symmetry of contour, color and texture.
a. Asks the client to purse lips as if to whistle.
53. Inspects and palpates the inner lips and buccal mucosa for color,
moisture, texture, and the presence of lesions.
Teeth and gums:
54. Inspects the teeth and gums while examining the inner lips and
buccal mucosa.
55. Inspects the dentures.
a. Asks the client to remove complete or partial dentures. Inspects their
condition, noting in particular broken or worn areas.
Tongue/ floor of the mouth:
56. Inspects the surface of the tongue for position, color, and texture.
a. Asks the client to protrude the tongue and to move it from side to side.
57. Inspects tongue movement.
25
a. Asks the client to roll the tongue upward and moves it from side to
side.
58. Inspects the base of the tongue, the mouth floor, and the frenulum.
a. Asks the client to place the tip of his/her tongue against the roof of the
mouth.
59. Palpates the tongue and floor of the mouth for any nodules, lumps, or
excoriated areas.
a. Uses a piece of gauze to grasp the tip of the tongue and, with the index
finger of other hand, palpates the back of the tongue, its borders, and its
base.
Salivary glands:
60. Inspects salivary duct openings for any swelling or redness.
Palates and Uvula:
61. Inspects the hard and soft palate for color, shape, texture, and the
presence of bony prominences.
a. Asks the client to open mouth wide and tilt head backward.
b. Then, depresses tongue with a tongue blade as necessary, and uses a
penlight for appropriate visualization.
62. Inspects the uvula for position and mobility while examining the
palates.
a. To observe the uvula, asks the client to say “ah” so that the soft palate
rises.
Oropharynx and tonsils
63. Inspects the oropharynx for color and texture.
a. Inspects one side at a time to avoid eliciting the gag reflex.
b. To expose one side of the oropharynx, presses a tongue blade against
the tongue on the same side about halfway back while the client tilts
head back and opens mouth wide.
c. Uses a penlight for illumination, if needed.
64. Inspects the tonsils for color, discharge, and size.
65. Elicits the gag reflex by pressing the posterior tongue with a tongue
blade.
Assessing the neck:
a. Any problems with neck lumps
b. Neck pain or stiffness
c. When and how any lumps occurred
d. Any diagnoses of thyroid problems
e. Any treatments such as surgery or radiation
Neck muscles:
67. Inspects the neck muscles (sternocleidomastoid and trapezius) for
abnormal swellings or masses.
a. Asks the client to hold head erect.
68. Observes head movement.
a. Asks the client to:
Move chin to the chest.
b. Moves head back so that the chin points upward.
c. Moves head so that the ear is moved toward the shoulder on each side.
d. Turns head to the right and to the left.
69. Assesses muscle strength.
Ask the client to:
a. Turns head to one side against the resistance of hand. Repeats with the
other side.
b. Shrugs shoulders against the resistance of hands.
Lymph nodes:
70. Palpates the entire neck for enlarged lymph nodes.
26
Trachea:
71. Palpates the trachea for lateral deviation.
a. Places fingertip or thumb on the trachea in the suprasternal notch, then
moves finger laterally to the left and the right in spaces bordered by the
clavicle, the anterior aspect of the sternocleidomastoid muscle, and the
trachea.
Thyroid gland:
72. Inspects the thyroid gland.
a. Stands in front of the client.
b. Observes the lower half of the neck overlying the thyroid gland for
symmetry and visible masses.
c. Asks the client to hyperextend head and swallow.
d. If necessary, offers a glass of water to make it easier for the client to
swallow.
73. Palpates the thyroid gland to smoothness.
a. Notes any areas of enlargement, masses, or nodules.
b. If enlargement of the gland is suspected:
Auscultates over the thyroid area for a bruit.
c. Uses the bell-shaped diaphragm of the stethoscope.
EVALUATION
findings,
Rating: ______
Signature of Supervising Clinical Instructor: _______________________
27
Name: _________________________________________ Date of Lecture Demo: ________
Assessing the Thorax and Lungs; Heart and Central Vessels; and the Peripheral Vascular
System
Basic Concept: Assessing the thorax and lungs is a thorough examination of the respiratory
system. The thorax comprises the lungs, rib cages, cartilages and intercostal muscles, wherein all
the four assessment/ examination techniques will be used. This nursing skill also recognizes and
identifies normal and abnormal breath sounds, a crucial component of the lung assessment (Lynn,
P. 2008).
Assessing the heart and central vessels is one of the most complex and important
aspect of physical examination. This nursing skill utilizes the palpation, inspection and
auscultation techniques for the assessment of the heart, pulmonary, coronary and neck arteries.
Assessing the peripheral vascular system includes measuring the blood pressure,
palpating peripheral pulses and inspecting skin and tissues to determine perfusion to the
extremities (Berman, et.al. 2015).
Objectives:
1. To check for any deviations of the thorax and lungs and breath sounds; heart and central
vessels; and the peripheral vascular system.
2. To acquire information and accurate nursing history of the lungs or respiratory, cardiovascular
and peripheral vascular systems of the client.
Preparation:
Stethoscope
Skin marker/pencil
Centimeter ruler
2. Introduce yourself, and verify the client’s identity. Explain to the client what you are going
to do, why is it necessary, and how the client can cooperate.
3. Perform hand hygiene, and observe other appropriate infection control procedures.
PROCEDURE RATIONALE
following:
Family history of illness, including cancer
Allergies
Tuberculosis
Lifestyle habit such as smoking, and
occupational hazards
Any medications being taken
Current problems such as swellings, coughs,
wheezing, pain.
Posterior thorax:
2. Inspect the shape and symmetry of the thorax
from posterior and lateral views. - Compare
the anteroposterior diameter to the transverse
diameter.
3. Inspect the spinal alignment for deformities.
-Have the client stand.
28
- From a lateral position, observe the three

normal curvatures: cervical, thoracic, and
lumbar.
- To assess for lateral deviation of the spine
(scoliosis), observe the standing client from
the rear.
- Have the client bend forward at the waist,
and observe from behind.
4. Palpate the posterior thorax.
- For clients who have no respiratory
complaints, rapidly assess the temperature
and integrity of all chest skin.
- For clients who do not have respiratory
complaints, palpate all chest areas for bulges,
tenderness, or abnormal movements.
- Avoid deep palpation for painful areas,
especially if a fractured rib is suspected.
5. Palpate the posterior chest for respiratory
excursion.
- Place the palms of both your hands over the
lower thorax, with your thumbs adjacent to
the spine and your fingers stretched laterally.
- Ask the client to take deep breath while you
observe the movement of your hands and any
lag in movement.
6. Palpate the chest for vocal (tactile) fremitus.
- Place the palmar surfaces of your fingertips
or the ulnar aspect of your hand or closed fist
on the posterior chest, starting near the apex
of the lungs.
- Ask the client to repeat such words as “blue
moon” or “one, two, three”.
- Repeat the two steps, moving your hands
sequentially to the base of the lungs.
- Compare the fremitus on both lungs and
between the apex and the base of each lung,
either:
1) using one hand and moving it from one
side of the client to the corresponding area
on the other side or 2) using two hands that
are placed simultaneously on the
corresponding areas of each side of the chest.
7. Percuss the thorax.
8. Percuss for diaphragmatic excursion.
9. Auscultate the chest using the flat-disc
diaphragm of the stethoscope.
- Use the systematic zigzag procedure used
in percussion.
- Ask the client to take slow, deep breaths
through the mouth.
- Listen at each point to the breath sounds
during a complete inspiration and expiration.
- Compare findings at each point with the
corresponding point on the opposite side of
the chest.
Anterior thorax:
10. Inspect breathing patterns.
29
11. Inspect the costal angle and the angle at

which the ribs enter the spine.
12. Palpate the anterior chest.
13. Palpate the anterior chest for respiratory
excursion.
- Place the palms of both your hands on the
lower thorax, with your fingers laterally
along the lower rib cage and your thumbs
along the costal margins.
- Ask the client to take a deep breath while
you observe the movement of your hands.
14. Palpate tactile fremitus in the same manner
as for the posterior chest.
- If the breast is large and cannot be retracted
adequately for palpation, this part of the
examination usually is omitted.
15. Percuss the anterior chest systematically.
- Begin above the clavicles in the
supraclavicular space, and proceed
downward to the diaphragm.
- Compare one side of the lung to the other.
- Displace female breasts for proper
examination.
16. Auscultate the anterior trachea.
17. Auscultate the anterior chest.
- Use the sequence used in percussion,
beginning over the bronchi between the
sternum and the clavicles.
18. Perform hand hygiene.
Assessing the Heart and Central Vessels
Preparation:
Stethoscope
Centimeter ruler
PROCEDURE RATIONALE
1. Inquire if the client has any history of the Note: Italicize step/s is excluded in the
following: return demonstration routine;
Family history of incidence and age of heart however, the student is required to
disease, high cholesterol levels, high blood state or mention the step.
pressure, stroke, obesity, congenital heart
disease, arterial disease, hypertension, and
rheumatic fever.
Client’s past history of rheumatic fever, heart
murmur, heart attack, varicosities, or heart
failure
Present symptoms indicative of heart disease
Presence of diseases that affect the heart
Lifestyle habits that are risk factors for
cardiac disease
30
2. Simultaneously inspect and palpate the

precordium for the presence of abnormal
pulsations, lifts, or heaves.
- Inspect and palpate the aortic and pulmonic
areas, observing them at an angle and to the
side, to note the presence or absence of
pulsations.
- Inspect and palpate the tricuspid area for
pulsations and heaves or lifts.
Inspect and palpate the apical area for
pulsation, noting its specific location (it may
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
base of the sternum for abdominal aortic
pulsations.
3. Auscultate the heart in all four anatomic sites:
aortic, pulmonic, tricuspid, and apical
(mitral).
Carotid Arteries
4. Palpate the carotid artery. Use extreme
caution.
5. Auscultate the carotid artery.
Jugular Veins
6. Inspect the jugular veins for distension.
- The client is placed in a semi-Fowler’s
position, with the head supported on a small
pillow.
7. If jugular distention is present, assess the
jugular venous pressure (JVP).
- Locate the highest visible point of distension
of the intern jugular vein.
- Measure the vertical height of this portion in
centimeters from the sterna angle, the point at
which the clavicles meet.
- Repeat the steps above on the other side.
31
Assessing the Peripheral Vascular System
PROCEDURE RATIONALE
1. Inquire if the client has any history of the
following:
Heart disorders, varicosities, arterial disease,
and hypertension
Lifestyle patterns, specifically exercise
patterns, activity patterns, and tolerance.
Smoking and use of alcohol
Peripheral pulses:
2. Palpate the peripheral pulses on both sides of
the client’s body individually, simultaneously
(except the carotid pulse), and systematically
to determine the symmetry of pulse volume.
- If you have difficulty palpating some of the
peripheral pulses, use a Doppler ultrasound
probe.
Peripheral veins:
3. Inspect the peripheral veins in the arms and
legs for the presence and/or appearance of
superficial veins when limbs are dependent
and when limbs are elevated.
4. Assess the peripheral leg veins for signs of
phlebitis.
- Inspect calves for redness and swelling over
vein sites.
- Palpate the calves for firmness or tension of
the muscles, edema over the dorsum of the
foot, and areas of localized warmth.
- Push the calves from side to side.
- Firmly dorsiflex the client’s foot while
supporting entire leg in extension, or have the
person stand or walk.
Peripheral perfusion:
5. Inspect the skin of the hands and feet for
color, temperature, edema, and skin changes.
6. Assess the adequacy of arterial flow if arterial
insufficiency is suspected.
Lynn, P.(2008). Taylor’s Clinical Nursing Skills , 2 nd ed.
32
Assessing the Thorax and Lungs; Heart and Central Vessels; and the Peripheral Vascular
System
1 2 3 4 5
ASSESSMENT
PLANNING
2. Introduces self.
IMPLEMENTATION
1. Introduces self.
Family history of illness, including cancer
Allergies
Tuberculosis
Lifestyle habit such as smoking, and occupational hazards
Any medications being taken.
Current problems such as swellings, coughs, wheezing, pain.
Posterior thorax:
4.a. Inspect the shape and symmetry of the thorax from posterior and
lateral views.
b. Compares the anteroposterior diameter to the transverse diameter.
5. Inspects the spinal alignment for deformities.
a. Have the client stand.
b. From a lateral position, observes the three normal curvatures: cervical,
thoracic, and lumbar.
c. To assess for lateral deviation of the spine (scoliosis), observes the
standing client from the rear.
d. Asks the client bend forward at the waist, and observes from behind.
33
6. Palpates the posterior thorax.

a. For clients who have no respiratory complaints, rapidly assesses the
temperature and integrity of all chest skin.
b. For clients who do not have respiratory complaints, palpates all chest
areas for bulges, tenderness, or abnormal movements.
c. Avoids deep palpation for painful areas, especially if a fractured rib is
suspected.
7. Palpates the posterior chest for respiratory excursion.
a. Places the palms of both your hands over the lower thorax, thumbs
adjacent to the spine and fingers stretched laterally.
b. Asks the client to take deep breath while observing the movement of
hands and any lag in movement.
8. Palpates the chest for vocal (tactile) fremitus.
a. Places the palmar surfaces of fingertips or the ulnar aspect of hand or
closed fist on the posterior chest, starting near the apex of the lungs.
b. Asks the client to repeat such words as “blue moon” or “one, two,
three”.
c. Repeats the two steps, moving hands sequentially to the base of the
lungs.
d. Compares the fremitus on both lungs and between the apex and the
base of each lung, either:
d.1. Using one hand and moving it from one side of the client to the
corresponding area on the other side or
d.2. Using two hands that are placed simultaneously on the
corresponding areas of each side of the chest.
9. Percusses the thorax.
10. Percusses for diaphragmatic excursion.
11. Auscultates the chest using the flat-disc diaphragm of the
stethoscope.
a. Uses the systematic zigzag procedure used in percussion.
b. Asks the client to take slow, deep breaths through the mouth.
c. Listens at each point to the breath sounds during a complete
inspiration and expiration.
d. Compares findings at each point with the corresponding point on the
opposite side of the chest.
Anterior thorax:
12. Inspects breathing patterns.
13. Inspects the costal angle and the angle at which the ribs enter the
spine.
14. Palpates the anterior chest.
15. Palpates the anterior chest for respiratory excursion.
a. Places the palms of both hands on the lower thorax, with fingers
laterally along the lower rib cage and thumbs along the costal margins.
b. Asks the client to take a deep breath while observing the movement of
hands.
16. Palpates tactile fremitus in the same manner as for the posterior
chest.
a. If the breast is large and cannot be retracted adequately for palpation,
this part of the examination usually is omitted.
17. Percusses the anterior chest systematically.
a. Begins above the clavicles in the supraclavicular space, and proceeds
downward to the diaphragm.
b. Compares one side of the lung to the other.
c. Displaces female breasts for proper examination.
18. Auscultates the anterior trachea.
34
19. Auscultates the anterior chest.

a. Uses the sequence used in percussion, beginning over the bronchi
between the sternum and the clavicles.
Assessing the heart and central vessels:
a. Family history of incidence and age of heart disease, high cholesterol
levels, high blood pressure, stroke, obesity, congenital heart disease,
arterial disease, hypertension, and rheumatic fever.
b. Client’s past history of rheumatic fever, heart murmur, heart attack,
varicosities, or heart failure
c. Present symptoms indicative of heart disease
d. Presence of diseases that affect the heart
e. Lifestyle habits that are risk factors for cardiac disease
21. Simultaneously inspects and palpates the precordium for the presence
of abnormal pulsations, lifts, or heaves.
a. Inspects and palpates the aortic and pulmonic areas, observing them at
an angle and to the side, to note the presence or absence of pulsations.
b. Inspects and palpates the tricuspid area for pulsations and heaves or
lifts.
c. Inspects and palpates the apical area for pulsation, noting its specific
location (it may be displaced laterally or lower) and diameter.
d. If displaced laterally, records the distance between the apex and the
MCL in centimeters.
e. Inspects and palpates the epigastric area at the base of the sternum for
abdominal aortic pulsations.
22. Auscultates the heart in all four anatomic sites: aortic, pulmonic,
tricuspid, and apical (mitral).
Carotid Arteries:
23. Palpates the carotid artery.
a. Uses extreme caution.
24. Auscultates the carotid artery.
Jugular Veins:
25. Inspects the jugular veins for distension.
a. The client is placed in a semi-Fowler’s position, with the head
supported on a small pillow.
b. If jugular distention is present, assesses the jugular venous pressure
(JVP).
c. Locates the highest visible point of distension of the internal jugular
vein.
d. Measures the vertical height of this portion in centimeters from the
sterna angle, the point at which the clavicles meet.
e. Repeats the steps above on the other side.
Assessing the peripheral vascular system;
26. Inquire if the client has any history of the following:
a. Heart disorders, varicosities, arterial disease, and hypertension
b. Lifestyle patterns, specifically exercise patterns, activity patterns, and
tolerance.
c. Smoking and use of alcohol
Peripheral pulses:
27. Palpates the peripheral pulses on both sides of the client’s body
individually, simultaneously (except the carotid pulse), and
systematically to determine the symmetry of pulse volume.
a. If there is a difficulty palpating some of the peripheral pulses, uses a
Doppler ultrasound probe.
35
Peripheral veins:
28. Inspects the peripheral veins in the arms and legs for the presence
and/or appearance of superficial veins when limbs are dependent and
when limbs are elevated.
29. Assesses the peripheral leg veins for signs of phlebitis.
a. Inspects calves for redness and swelling over vein sites.
b. Palpates the calves for firmness or tension of the muscles, edema over
the dorsum of the foot, and areas of localized warmth.
c. Pushes the calves from side to side.
d. Firmly dorsiflexes the client’s foot while supporting the entire leg in
extension, or have the person stand or walk.
Peripheral perfusion:
30. Inspects the skin of the hands and feet for color, temperature, edema,
and skin changes.
31. Assesses the adequacy of arterial flow if arterial insufficiency is
suspected.
EVALUATION
1. Observes appropriate infection control measures in the performance of
the procedure.
findings,
Rating: ______
Signature of Supervising Clinical Instructor: ___________________
36
Name: ____________________________________________ Date of Lecture Demo: ________
Assessing the Abdomen
Basic Concept: Abdominal assessment is a valuation of the abdomen, liver and bladder
involving four methods of examination: inspection, auscultation, palpation, and percussion.
Objectives:
1. To obtain an accurate nursing health history of the client’s abdomen and related
functions.
2. To determine for any deviations or abnormalities of the abdomen.
Preparation:
Examining light
Tape measure (metal or non-stretchable cloth)
Water-soluble skin-marking pencil
Stethoscope
to do, why it is necessary, and how the client can cooperate.
PROCEDURE RATIONALE
1. Determine the client’s history of the
following:
Incidence of abdominal pain: its
location, onset, sequence, and
chronology; its quality (description);
its frequency; associated and the
symptoms
Bowel habits
Incidence of constipation or diarrhea
Change in appetite
Food intolerances
Foods ingested in the last 24 hours
Specific signs and symptoms
Previous problems and treatment
2. Assist the client to a supine position,
with the arms placed comfortably at
the sides.
-Place small pillows beneath the knees
and the head.
- Expose only the client’s abdomen
from the chest line to the pubic area.
Inspection of the abdomen
3. Inspect the abdomen for skin integrity.
4. Inspect the abdomen for contour and
symmetry.
- Observe the abdominal contour while
standing at the client’s side when the
client is in supine.
- Ask the client to take a deep breath
and to hold it.
37
- Assess the symmetry of contour

while standing at the foot of the bed.
- If distension is present, measure the
abdominal girth by placing a tape
around the abdomen at the level of the
umbilicus.
5. Observe the abdominal movements
associated with respiration, peristalsis,
or aortic pulsations.
6. Observe the vascular pattern.
Auscultation of the abdomen
7. Auscultate the abdomen for bowel
sounds, vascular sounds, and
peritoneal friction rubs.
Percussion of the Abdomen
8. Percuss several areas in each of the
four quadrants.
- Use a systematic pattern: Begin in
the lower left quadrant, then proceed
to the lower right quadrant, the upper
right quadrant, and the upper left
quadrant.
Percussion of the Liver
9. Percuss the liver.
- Begin percussing the abdomen along
the right midclavicular line, starting
below the level of the umbilicus.
- Move upward until the percussion
notes change from tympany to
dullness, usually at or slightly below
the costal margin.
- Mark the point of change with a felt-
tip pen.
-Percuss downward along the right
midclavicular line, starting above the
nipple. Move downward until
percussion notes change from normal
lung resonance to dullness, usually at
the fifth to seventh intercostal space.
- Again, mark the point of change with
a felt-tip pen.
-Estimate the liver’s size by measuring
the distance between the two marks.
(Health Assessment made Incredibly Easy,2007. LWW)
Palpation of the Abdomen
10. Perform light palpation first.
- Systematically explore all four
quadrants.
- Perform deep palpation over all four
quadrants.
Palpation of the Liver
11. Palpate the liver.
a. Method 1: Standard palpation
-Place the patient in the supine position,
-Stand at the right side of client, place
your left hand under client’s back at the
approximate location of the liver.
38
- Place your right hand slightly below the

mark at the liver’s upper border that you
made during percussion.
-Point the fingers of your right hand
toward the patient’s head just under the
costal margin.
-As the patient inhales, deeply, gently
press in and up on the abdomen until the
liver brushes under your right hand.
- Note any tenderness.
b. Method 2: Hooking the liver
-Stand next to the patient’s right shoulder,
facing his feet.
- Place hands side by side, and hook your
fingertips over the right costal margin,
below the lower mark of dullness.
- Ask the patient to take a deep breath as
you push your fingertips in and up.
(Health Assessment made Incredibly Easy,2007. LWW
Palpation of the Bladder

12. Palpate the area above the pubic
symphysis, if the client’s history
indicates possible urinary retention.
record.
Lynn, P.(2008). Taylor’s Clinical Nursing Skills , 2nd ed.
Health Assessment made Incredibly Easy (2007). Lippincott William and Wilkins
39
Assessing the Abdomen
1 2 3 4 5
ASSESSMENT
PLANNING
IMPLEMENTATION
1. Introduces self.
3. Determines the client’s history of the following:
a. Incidence of abdominal pain: its location, onset, sequence, and
chronology; its quality (description); its frequency; associated and the
symptoms
b. Bowel habits
c. Incidence of constipation or diarrhea
d. Change in appetite
e. Food intolerances
f. Foods ingested in the last 24 hours
g. Specific signs and symptoms
h. Previous problems and treatment
4a. Assists the client to a supine position, with the arms placed
comfortably at the sides.
b. Places small pillows beneath the knees and the head.
c. Exposes only the client’s abdomen from the chest line to the pubic
area.
Inspection of the abdomen
5. Inspects the abdomen for skin integrity.
6a.Inspects the abdomen for contour and symmetry.
b. Observes the abdominal contour while standing at the client’s side
when the client is in supine.
40
c. Asks the client to take a deep breath and to hold it.

d. Assesses the symmetry of contour while standing at the foot of the
bed.
e. If distension is present, measures the abdominal girth by placing a tape
around the abdomen at the level of the umbilicus.
7. Observes the abdominal movements associated with respiration,
peristalsis, or aortic pulsations.
8. Observes the vascular pattern.
Auscultation of the abdomen
9. Auscultates the abdomen for bowel sounds, vascular sounds, and
peritoneal friction rubs.
Percussion of the Abdomen
10a. Percusses several areas in each of the four quadrants.
b. Uses a systematic pattern: Begin in the lower left quadrant, then
proceed to the lower right quadrant, the upper right quadrant, and the
upper left quadrant.
Percussion of the Liver
11. Percusses the liver.
a. Begins percussing the abdomen along the right midclavicular line,
starting below the level of the umbilicus.
b. Moves upward until the percussion notes change from tympany to
dullness.
c. Marks the point of change with a felt-tip pen.
d. Percusses downward along the right midclavicular line, starting above
the nipple.
e. Moves downward until percussion notes change from normal lung
resonance to dullness.
f. Marks the point of change with a felt-tip pen.
g. Estimates the liver’s size by measuring the distance between the two
marks.
Palpation of the Abdomen
12a. Perform light palpation first.
b. Systematically explore all four quadrants.
c. Perform deep palpation over all four quadrants.
Palpation of the Liver
13. Palpates the liver.
Method 1: Standard palpation
a. Places patient in position in supine position.
b. Stands at the right side of client.
c. Places left hand under client’s back at the approximate location of the
liver.
d. Places right hand slightly below the mark at the liver’s upper border.
e. Points the fingers of right hand toward the patient’s head just under the
costal margin.
f. As the patient inhales, deeply, gently presses in and up on the abdomen
until the liver brushes under the right hand.
g. Notes any tenderness.
Method 2: Hooking the liver
a. Stands next to the patient’s right shoulder, facing client’s feet.
b. Places hands side by side.
c. Hooks fingertips over the right costal margin, below the lower mark of
dullness.
d. Asks the patient to take a deep breath.
e. Pushes fingertips in and up while client is taking a deep breath.
41
Palpation of the Bladder

12. Palpates the area above the symphysis pubis, if the client’s history
indicates a possible urinary retention.
15. Documents findings.
EVALUATION
findings,
Rating:_______
Signature of Supervising Clinical Instructor Over-printed Name: _________________________
42
Assessing the Musculoskeletal System
Basic concept: Assessing the musculoskeletal system is the valuation of the strength, tone, size
and symmetry of the muscle development and for presence of tremors.
Objectives:
1. To check for any deviations of the musculoskeletal system.
2. To acquire information and accurate nursing history of the muscles, bones and joints of
the client.
Preparation:
Goniometer
to do, why it is necessary, and how the client can cooperate.
PROCEDURE RATIONALE
following:
Muscle pain: onset, location,
character, associated phenomena, and
aggravating and alleviating factors
Any limitations to movement or
inability to perform activities of daily
living
Previous sports injuries
Any loss of function without pain.
Muscles
2. Inspect the muscles for size.
a. Compare each muscle on one side
of the body to the same muscle on the
other side.
b. For any apparent discrepancies,
measure the muscles with a tape.
3. Inspect the muscles and tendons for
contractures.
4. Inspect the muscles for tremors.
a. Inspect any tremors of the hands
and arms by having the client hold
arms out in front of body.
5. Palpate muscles at rest to determine
muscle tonicity.
6. Palpate muscles while the client is
active and passive for flaccidity,
spasticity, and smoothness of
movement.
7. a. Test muscle strength.
b. Compare the right side with left
side.
43
8. Inspect the skeleton for normal

structure and deformities.
Bones
9. Palpate the bones to locate any areas
of edema or tenderness.
Joints
10. Inspect the joint for swelling.
a. Palpate each joint for tenderness,
smoothness of movement, swelling,
crepitation, and presence of nodules.
11. a. Inspect the joint for swelling.
b. Ask the client to move selected
body parts.
c. If available, use a goniometer to
measure the angle of the joint in
degrees.
record.
13.
44
Assessing the Musculoskeletal System
1 2 3 4 5
ASSESSMENT
PLANNING
IMPLEMENTATION
1. Introduces self.
a. Muscle pain: onset, location, character, associated phenomena, and
aggravating and alleviating factors
b. Any limitations to movement or inability to perform activities of daily
living
c. Previous sports injuries
d. Any loss of function without pain
Muscles
5. Inspects the muscles for size.
a. Compares each muscle on one side of the body to the same muscle on
the other side.
b. For any apparent discrepancies, measures the muscle with a tape.
6. Inspects the muscles and tendons for contractures.
7. Inspects the muscles for tremors.
a. Inspects any tremors of the hands and arms by having the client hold
arms out in front of body.
8. Palpates muscles at rest to determine muscle tonicity.
9. Palpates muscles while the client is active and passive for flaccidity,
spasticity, and smoothness of movement.
10a. Tests muscle strength.
b. Compares the right side with left side.
11. Inspects the skeleton for normal structure and deformities.
45
Bones
12. Palpates the bones to locate any areas of edema or tenderness.
Joints
13. Inspects the joint for swelling.
15. Documents findings.
EVALUATION
findings,
Rating:_______
Signature of Supervising Clinical Instructor Over-printed Name: _________________________
46
Name: __________________________________________ Date of Lecture Demo: _______
Assessing the Neurological System
Basic Concept: It is an examination of the neurologic system which comprises the assessment of
the mental status including the level of consciousness, the cranial nerves, reflexes, motor and
sensory functions. Some parts of the neurologic assessment are performed throughout the health
assessment like mental status assessment, observing the appearance and cranial nerve functions
(Berman, et.al. 2015).
Objectives:
1. To obtain an accurate nursing history of the client’s neurologic system.
2. To determine any deviations or abnormal findings of the client’s nervous system
functioning.
3. To formulate valid nursing diagnoses; collaborative problems and / or referrals.
Preparation:
Sugar, salt, lemon juice, quinine flavors
Percussion hammer
Tongue depressors (one broken diagonally, for testing pain sensation)
Wisps of cotton, to assess light touch sensation
Test tubes of hot and cold water, for skin temperature assessment (optional)
Pins or needles for tactile discrimination
2. Introduce yourself, and verify the client’s identity. Explain to the client what you are
going to do, why it is necessary, and how the client can cooperate.
PROCEDURE RATIONALE
the following:
Presence of pain in the head, back or
extremities, as well as onset and
aggravating and alleviating factors.
Disorientation to time, place, or person
Speech disorders
Any history of loss 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
Language
2. If the client displays difficulty
speaking:
-Point to common objects, and ask the
client to name them.
-Ask the client to read some words and
to match the printed and written words
with pictures.
-Ask the client to respond to simple
verbal and written commands-e.g.
47
“Point to your toes,” or “Raise your

left arm”.
Orientation
3. Determine the client’s orientation to
time, place, and person by tactful
questioning.
-Ask the client the city and state of
residence, time of day, date, day of the
week, duration of illness, and names of
family members.
-More direct questioning might be
necessary for some people-e.g.,
“Where are you now?” What day is it
today?”
Memory
4. Listen for lapses in memory.
- Ask the client about difficulty with
memory.
- If problems are apparent, three
categories of memory are tested:
immediate recall, recent memory, and
remote memory.
To assess immediate recall:
- Ask the client to repeat a series of
three digits-e.g., 7-4-3-spoken slowly.
- Gradually increase the number of
digits-e.g., 7-4-3-5,7-4-3-5-6, and 7-4-
3-5-6-7-2-until the client fails to repeat
the series correctly.
- Start again with a series of three
digits, but this time, then ask the client
to repeat them backward.
To assess recent memory:

- Ask the client to recall the recent
events of the day, such as how he got
to the clinic. This information must be
validated.
- Ask the client to recall information
given early in the interview-e.g., the
name of a doctor.
- Provide the client with three facts to
recall-e.g., a color, an object, an
address, or a three-digit number-and
ask the client to repeat all three. Later
in the interview, ask the client to recall
all three items.
To assess remote memory:

- Ask the client to describe a previous
illness or surgery.
Attention Span and Calculation
5. a. Test the ability to concentrate or
attention span by asking the client to
recite the alphabet or to count
backward from 100.
48
b. Test the ability to calculate by

asking the client to subtract 7 or 3
progressively from 100-i.e., 100, 93,
86, 79, or 100, 97, 94.
Level of Consciousness
6. Apply the Glasgow Coma Scale:
Eye response, motor response, and
verbal response
Cranial Nerves
7. Test the cranial nerves.
Cranial Nerve I-Olfactory
- Ask client to close eyes and identify
different mild aromas such as coffee
and vanilla.
Cranial Nerve II-Optic

- Ask the client to read Snellen’s
chart; check visual fields by
confrontation, and conduct an
ophthalmoscopic examination.
Cranial Nerve III-Oculomotor
- Assess six ocular movements and
pupil reaction.
Cranial Nerve IV-Trochlear

- Assess six ocular movements.
Cranial Nerve V-Trigeminal

- While client looks upward, lightly
touch the lateral sclera of the eye to
elicit the blink reflex.
- To test light sensation, have the
client close eyes, and wipe a 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 the same area.
Cranial Nerve VI-Abducens

- Assess directions of gaze.
Cranial Nerve VII-Facial

- Ask the client to smile, raise the
eyebrows, frown, puff out cheeks, and
close eyes tightly.
- Ask the client to identify various
tastes placed on the tip and sides of
tongue-sugar, salt-and to identify
areas of taste.
Cranial Nerve VIII-Auditory

- Assess the client’s ability to hear the
spoken word and the vibrations of a
tuning fork.
49
Cranial Nerve IX-Glossopharyngeal

Apply tastes on the posterior tongue
for identification. Ask the client to
move tongue from side to side and up
and down.
Cranial Nerve X-Vagus

- Assess with CN IX.
- Assess the client’s speech for
hoarseness.
Cranial Nerve XI-Accessory

- Ask the client to shrug shoulders
against resistance from your hands
and to turn head to the side against
resistance from your hand. Repeat for
the other side.
Cranial Nerve XII-Hypoglossal

- Ask the client to protrude tongue at
midline, then, move it side to side.
Reflexes
8. Test reflexes using a percussion
hammer, comparing one side of the
body with the other to evaluate the
symmetry of response.
Biceps Reflex
- Partially flex the client’s arm at the
elbow, and rest the forearm over the
thighs, placing the palm of the hand
down.
- Place the thumb of your non-
dominant hand horizontally over the
biceps tendon.
- Deliver a blow (slight downward
thrust) with the percussion hammer to
your thumb.
- Observe the normal slight flexion of
the elbow, and feel the bicep’s
contraction through your thumb.
Triceps Reflex
- Flex the client’s arm at the elbow,
and support it in the palm of your non-
dominant hand.
- Palpate the triceps tendon about 2-
5cm (1-2 inches) above the elbow.
- Deliver a blow with the percussion
hammer directly to the tendon.
- Observe for the normal slight
extension of the elbow.
Brachioradialis Reflex
50
- Rest the client’s arm in a relaxed

position on your forearm or on the
client’s own leg.
hammer directly on the radius 2-5 cm
(1-2 inches) above the wrist or the
styloid process, the bony prominence
on the thumb side of the wrist.
- Observe the normal flexion and
supination of the forearm. The fingers
of the hand might also extend slightly.
Patellar Reflex
- Ask the client to sit on the edge of
the examining table so that the legs
hang freely.
- Locate the patellar tendon directly
below the patella.
- Observe the normal extension or
kicking out of the leg as the
quadriceps muscle contracts.
- If no response occurs, and you
suspect the client is not relaxed, ask
the client to interlock fingers and pull.
Achilles Reflex
- With the client in the same position
as for the patellar reflex test, slightly
dorsiflex the client’s ankle by
supporting the foot lightly in your
hand.
- Observe and feel the normal plantar
flexion (downward jerk) of the foot.
Plantar (Babinki’s) Reflex

- Use a moderately sharp object such
as the handle of the percussion
hammer, a key, or the dull end of a pin
or applicator stick.
- Stroke the lateral border of the sole
of the client’s foot, starting at the heel,
continuing to the ball of the foot, and
then proceeding across the ball of the
foot toward the big toe.
- Observe the response.
Motor Function
9. Gross Motor and Balance Tests
Walking Gait
- Ask the client to walk across the
room and back, and assess the client’s
gait.
51
Romberg’s Test
- Ask the client to stand with feet
together and arms resting at the sides,
first with eyes open, then, closed.
Standing On One Foot With Eyes

Closed
- Ask the client to close eyes and stand
on one foot, then the other.
- Stand close to the client during this
test.
Heel-Toe Walking
- Ask the client to walk a straight line,
placing the heel of one foot directly in
front of the toes of the other foot.
Toe or Heel Walking

- Ask the client to walk several steps
on the toes and then on the heels.
10. Fine Motor Tests for the Upper
Extremities
Finger-to-Nose Test
- Ask the client to abduct and extend
arms at shoulder height and rapidly
touch nose alternately with one index
finger and then the other.
- Have the client repeat the test with
eyes closed if the test is performed
easily.
Alternating Supination and

Pronation of Hands on Knees
- Ask the client to pat both knees with
the palms of both hands and then with
the backs of hands, alternately, at an
ever-increasing rate.
Finger to Nose and to the Nurse’s

Finger
- Ask the client to touch nose and then
your index finger, held at a distance at
about 45cm (18 inches), at a rapid and
increasing rate.
Fingers to Fingers
- Ask the client to spread arms broadly
at shoulder height and then bring
fingers together at the midline, first
with eyes open and then closed, first
slowly and then rapidly.
Fingers to Thumb (Same Hand)

Ask the client to touch each finger of
one hand to the thumb of the same
hand as rapidly as possible.
52
11. Fine Motor Tests for the Lower

Extremities
- Ask the client to lie supine and to
perform these tests:
Heel Down Opposite Shin
- Ask the client to place the heel of
one foot just below the opposite knee
and run the heel down the shin to 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
- Ask the client to touch your finger
with the large toe of each foot.
12. Light-Touch Sensation

- Compare the light-touch sensation of
symmetric areas of the body.
- Ask the client to close eyes and to
respond by saying, “yes” or “now”
whenever the client feels the cotton
wisp touching the skin.
- With a wisp of cotton, lightly touch
one specific spot and then the same
spot on the other side of the body.
- Test areas on the forehead, cheek,
hand, lower arm, abdomen, foot, and
lower leg. Check a distal area of the
limb first.
Ask the client to point to the spot
where the touch was felt.
If areas of sensory dysfunction are
found, determine the boundaries of
sensation by testing responses
approximately every 2.5cm (1 inch) in
the area.
- Make a sketch of the sensory loss
area for recording purposes.
13. Pain Sensation

Assess pain sensation as follows:
- Ask the client to close his/her eyes
and to say, “sharp”, “dull”, or “don’t
know” when the sharp or dull end of
the broken tongue depressor it felt.
- Alternately, use the sharp and dull
end of the sterile pin or needle to
lightly prick designated anatomic areas
at random.
- The face is not tested in this manner.
- Allow at least two seconds between
each test.
53
14. Temperature Sensation

- Touch skin areas with test tubes
filled with hot or cold water.
- Have the client respond say saying,
“hot”, “cold,” or don’t know”.
15. Position or Kinesthetic Sensation

- Commonly, the middle fingers and
the large toes are tested for the
kinesthetic sensation.
- To test the fingers, support the
client’s arm with one hand and hold
the client’s palm in the other.
- To test the toes, place the client’s
heels on the examining table.
- Ask the client to close his/her eyes.
- Grasp a middle finger or a big toe
firmly between your thumb and index
finger, and exert the same pressure on
both sides of the finger or toe while
moving it.
- Move the finger or toe until it is up,
down, or straight out, and ask the
client to identify the positions.
16. Tactile Discrimination

For all the tests, the client’s eyes need
to be closed:
One-and Two-Point Discrimination
- Alternately stimulate the skin with
two pins simultaneously and then with
one pin.
- Ask whether the client feels one or
two pinpricks.
Stereognosis
- Place familiar objects-such as a key,
paper clip, or coin-in the client’s hand,
and ask the client to identify them.
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, and ask the client to
identify it.
Extinction Phenomenon
- Simultaneously stimulate two
symmetric areas of the body, such as
the thighs, the cheeks, or the hands.
17. Document findings in the client record
54
Assessing the Neurologic System
1 2 3 4 5
ASSESSMENT
PLANNING
2. Introduces self.
IMPLEMENTATION
a. Presence of pain in the head, back or extremities, as well as onset and
aggravating and alleviating factors.
b. Disorientation to time, place, or person
c. Speech disorders
d. Any history of loss consciousness, fainting, convulsions, trauma,
tingling or numbness, tremors or tics, limping, paralysis, uncontrolled
muscle movements, loss of memory, or mood swings
e. Problems with smell, vision, taste, touch, or hearing
Language
2. If the client displays difficulty speaking:
a. Points to common objects, and ask the client to name them.
b. Asks the client to read some words and to match the printed and
written words with pictures.
c. Asks the client to respond to simple verbal and written commands-e.g.
“Point to your toes,” or “Raise your left arm”.
Orientation
3. Determines the client’s orientation to time, place, and person by
tactful questioning.
a. Asks the client the city and state of residence, time of day, date, day of
the week, duration of illness, and names of family members.
b. Uses a more direct questioning when necessary like -e.g., “Where are
you now?” What day is it today?”
55
Memory
4. Listens for lapses in memory.
a. Asks the client about difficulty with memory.
b. If problems are apparent, tests the three categories of memory:
immediate recall, recent memory, and remote memory.
To assess immediate recall:
a. Asks the client to repeat a series of three digits-e.g., 7-4-3-spoken
slowly.
b. Gradually increases the number of digits-e.g., 7-4-3-5, 7-4-3-5-6, and
7-4-3-5-6-7-2-until the client fails to repeat the series correctly.
c. Starts again with a series of three digits, but this time, asks the client to
repeat them backward.
To assess recent memory:
a. Asks the client to recall the recent events of the day, such as how he
got to the clinic.
b. Validates the information.
c. Asks the client to recall information given early in the interview-e.g.,
the name of a doctor.
d. Provides the client with three facts to recall-e.g., a color, an object, an
address, or a three-digit number-and ask the client to repeat all three.
e. Later in the interview, asks the client to recall all three items.
To assess remote memory:
- Asks the client to describe a previous illness or surgery.
Attention Span and Calculation
5. a. Tests the ability to concentrate or attention span by asking the client
to recite the alphabet or to count backward from 100.
b. Tests the ability to calculate by asking the client to subtract 7 or 3
progressively from 100-i.e., 100, 93, 86, 79, or 100, 97, 94.
Level of Consciousness
6. Applies the Glasgow Coma Scale:
Eye response, motor response, and verbal response
Cranial Nerves
7. Tests the cranial nerves.
Cranial Nerve 1-Olfactory
Asks client to close eyes and identify different mild aromas such as coffee
and vanilla.
Cranial Nerve II – Optic
Asks the client to read Snellen’s chart; check visual fields by
confrontation, and conducts an ophthalmoscopic examination.
Cranial Nerve III-Oculomotor
Assesses six ocular movements and pupil reaction.
Cranial Nerve IV-Trochlear
Assesses six ocular movements.
Cranial Nerve V-Trigeminal
a. While client looks upward, lightly touches the lateral sclera of the eye
to elicit the blink reflex.
b. To test light sensation, asks the client close eyes, and wipes a wisp of
cotton over client’s forehead and paranasal sinuses.
c. To test deep sensation, uses alternating blunt and sharp ends of a
safety pin over the same area.
Cranial Nerve VI-Abducens
Assesses directions of gaze.
Cranial Nerve VII-Facial
a. Asks the client to smile, raise the eyebrows, frown, puff out cheeks,
and close eyes tightly.
56
b. Asks the client to identify various tastes placed on the tip and sides of
tongue-sugar, salt-and to identify areas of taste.
Cranial Nerve VIII-Auditory
Assesses the client’s ability to hear the spoken word and the vibrations of
a tuning fork.
Cranial Nerve IX-Glossopharyngeal
a. Applies tastes on the posterior tongue for identification.
b. Asks the client to move tongue from side to side and up and down.
Cranial Nerve X-Vagus
a. Assesses with CN IX.
b. Assesses the client’s speech for hoarseness.
Cranial Nerve XI-Accessory
Asks the client to shrug shoulders against resistance from your hands
and to turn head to the side against resistance from your hand. Repeat
for the other side.
Cranial Nerve XII-Hypoglossal
Asks the client to protrude tongue at midline, then, move it side to side.
Reflexes
8. Tests reflexes using a percussion hammer, comparing one side of the
body with the other to evaluate the symmetry of response.
Biceps Reflex
a. Partially flexes the client’s arm at the elbow, and rest the forearm over
the thighs, placing the palm of the hand down.
b. Places the thumb of your non-dominant hand horizontally over the
biceps tendon.
c. Delivers a blow (slight downward thrust) with the percussion hammer
to your thumb.
d. Observes the normal slight flexion of the elbow, and feel the bicep’s
contraction through your thumb.
Triceps Reflex
a. Flexes the client’s arm at the elbow, and support it in the palm of your
non-dominant hand.
b. Palpates the triceps tendon about 2-5cm (1-2 inches) above the elbow.
c. Delivers a blow with the percussion hammer directly to the tendon.
d. Observes for the normal slight extension of the elbow.
Brachioradialis Reflex
a. Rests the client’s arm in a relaxed position on forearm or on the
client’s own leg.
b. Delivers a blow with the percussion hammer directly on the radius 2-5
cm (1-2 inches) above the wrist or the styloid process, the bony
prominence on the thumb side of the wrist.
c. Observes the normal flexion and supination of the forearm. The
fingers of the hand might also extend slightly.
Patellar Reflex
a. Asks the client to sit on the edge of the examining table so that the legs
hang freely.
b. Locates the patellar tendon directly below the patella.
c. Delivers a blow with the percussion hammer directly to the tendon.
d. Observes the normal extension or kicking out of the leg as the
quadriceps muscle contracts.
e. If no response occurs, suspects the client is not relaxed, asks the client
to interlock fingers and pull.
Achilles Reflex
57
a. With the client in the same position as for the patellar reflex test,
slightly dorsiflexes the client’s ankle by supporting the foot lightly in
your hand.
b. Delivers a blow with the percussion hammer directly to the tendon.
c. Observes and feels the normal plantar flexion (downward jerk) of the
foot.
Plantar (Babinki’s) Reflex
a. Uses a moderately sharp object such as the handle of the percussion
hammer, a key, or the dull end of a pin or applicator stick.
b. Strokes the lateral border of the sole of the client’s foot, starting at the
heel, continuing to the ball of the foot, and then proceeding across the
ball of the foot toward the big toe.
c. Observes the response.
Motor Function
9. Gross Motor and Balance Tests
Walking Gait
Asks the client to walk across the room and back, and assess the client’s
gait.
Romberg’s Test
Asks the client to stand with feet together and arms resting at the sides,
first with eyes open, then, closed.
Standing On One Foot With Eyes Closed
a. Asks the client to close eyes and stand on one foot, then the other.
b. Stands close to the client during this test.
Heel-Toe Walking
Asks the client to walk a straight line, placing the heel of one foot
directly in front of the toes of the other foot.
Toe or Heel Walking
Asks the client to walk several steps on the toes and then on the heels.
10. Fine Motor Tests for the Upper Extremities
Finger-to-Nose Test
a. Asks the client to abduct and extend arms at shoulder height and
rapidly touch nose alternately with one index finger and then the other.
b. Requires the client repeat the test with eyes closed if the test is
performed easily.
Alternating Supination and Pronation of Hands on Knees
Asks the client to pat both knees with the palms of both hands and then
with the backs of hands, alternately, at an ever-increasing rate.
Finger to Nose and to the Nurse’s Finger
Asks the client to touch nose and then your index finger, held at a
distance at about 45cm (18 inches), at a rapid and increasing rate.
Fingers to Fingers
Asks the client to spread arms broadly at shoulder height and then brings
fingers together at the midline, first with eyes open and then closed, first
slowly and then rapidly.
Fingers to Thumb (Same Hand)
Asks the client to touch each finger of one hand to the thumb of the same
hand as rapidly as possible.
Fine Motor Tests for the Lower Extremities
Asks the client to lie supine and to perform these tests:
Heel Down Opposite Shin
a. Positions client comfortably.
b. Asks the client to place the heel of one foot just below the opposite
knee and run the heel down the shin to foot.
c. Repeats with the other foot.
58
Toe or Ball of Foot to the Nurse’s Finger

Asks the client to touch your finger with the large toe of each foot.
Light-Touch Sensation
a. Compares the light-touch sensation of symmetric areas of the body.
b. Asks the client to close eyes and to respond by saying, “yes” or “now”
whenever the client feels the cotton wisp touching the skin.
c. With a wisp of cotton, lightly touches one specific spot and then the
same spot on the other side of the body.
d. Tests areas on the forehead, cheek, hand, lower arm, abdomen, foot,
and lower leg.
e. Checks a distal area of the limb first.
f. Asks the client to point to the spot where the touch was felt.
g. If areas of sensory dysfunction are found, determines the boundaries
of sensation by testing responses approximately every 2.5cm (1 inch) in
the area.
h. Makes a sketch of the sensory loss area for recording purposes.
11. Pain Sensation
Assesses pain sensation as follows:
a. Asks the client to close his/her eyes and to say, “sharp”, “dull”, or
“don’t know” when the sharp or dull end of the broken tongue depressor
it felt.
b. Alternately, uses the sharp and dull end of the sterile pin or needle to
lightly prick designated anatomic areas at random.
c. Notes that the face is not tested in this manner.
d. Allows at least two seconds between each test.
12. Temperature Sensation
a. Touches skin areas with test tubes filled with hot or cold water.
b. Allows the client respond say saying, “hot”, “cold,” or don’t know”.
13. Position or Kinesthetic Sensation
a. Recognizes that commonly, the middle fingers and the large toes are
tested for the kinesthetic sensation.
b. To test the fingers, supports the client’s arm with one hand and holds
the client’s palm in the other.
c. To test the toes, places the client’s heels on the examining table.
d. Asks the client to close his/her eyes.
e. Grasps the middle finger or big toe firmly between your thumb and
index finger, and exerts the same pressure on both sides of the finger or
toe while moving it.
f. Moves the finger or toe until it is up, down, or straight out, and asks
the client to identify the positions.
14. Tactile Discrimination
For all the tests, the client’s eyes need to be closed:
One-and Two-Point Discrimination
a. Alternately stimulates the skin with two pins simultaneously and then
with one pin.
b. Asks whether the client feels one or two pinpricks.
Stereognosis
a. Places familiar objects-such as a key, paper clip, or coin-in the client’s
hand, and ask the client to identify them.
b. If the client has a motor impairment of the hand and is unable to
manipulate an object, writes a number or letter on the client’s palm,
using a blunt instrument, and ask the client to identify it.
Extinction Phenomenon
Simultaneously stimulates two symmetric areas of the body, such as the
thighs, the cheeks, or the hands.
59

EVALUATION
findings,
Comments:
Rating: ____________
Signature of CI Over-Printed Name: __________________________________
60
BIBLIOGRAPHY
Berman, Audrey; Snyder, Shirlee; Kozier, Barbara,; Erb, Glenora (2008). Kozier and
Erb’s Fundamentals of Nursing Checklist, 8th edition. Pearson Education South Asia Pte Ltd,
Jurong, Singapore
Dillon, Patricia M. (2007). Nursing Health Assessment: Student Application, 2nd edition.
F.A. Davis Company, Philadelphia
Lynn, Pamela (2008). Taylor’s Clinical Nursing Skills: A Nursing Process Approach, 2nd
edition. Lippincott William & Wilkins/ Wolters Kluwer, Philadelphia
McCann, Judith S. et.al. (2007). Health Assessment Made Incredibly Easy. Lippincott
William and Wilkins/ Wolters Kluwer, PA
Potter, Patricia; Perry, Ann Griffin; Stockert, Patricia; Hall, Amy (2017). Fundamentals
of Nursing, 9th edition. Elsevier, Inc. Singapore
Weber, Janet; Kelley, Jane; Sprengel, Ann (2014). Lab Manual for Health Assessment in
Nursing, 5th edition. Wolters Kluwer Health/ Lippincott William & Wilkins, Philadelphia

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1

FATHER SATURNINO URIOS UNIVERSITY

Name: _______________________________________________ Section: ________

Checked by: ____________________________________________ Date: _________

FOR LABORATORY USE ONLY

Name: _______________________________________________ Section: ________

Assessing the skin, hair and nails

Assessing the Appearance and Mental Status

1. Observe body build, height, and weight in

Assessing the Skin

1. Inquire if client has any history of the

Assessing the Hair

1. Inquire if client has any history of

Assessing the Nails

1. Inquire if the client has any history of

Name: __________________________________________ Date of Return Demo: __________

Criteria for evaluation or rating the student’s performance:

b. Presence and spread of any lesions, bruises, abrasions, or pigmented

37. Documents findings in the client record.

Comments and Suggestions:

1. Inquire if the client has any history of

3. Inspect the skull for size, shape, and

Assessing the Eye Structures and Visual Acuity

1. Assemble equipment and supplies:

1. Inquire if the client has any history of

Assessing external eye structures:

4. Inspect the eyelids for surface

13. Inspect the pupils for color, shape, and

Extraocular muscle tests:

Assessing the Ears and Hearing

1. Inquire if the client has any history of

6. Inspect the tympanic membrane for

Assessing the Nose and Sinuses

1. Inquire if client has any history of the

nose, the anterior portion of the

Assessing the Mouth and Oropharynx

1. Assemble equipment and supplies:

Tongue/ floor of the mouth:

Assessing the Neck

Move head back so that the chin points

4. Assess muscle strength.

- If necessary, offer a glass of water to

Name: __________________________________________ Date of Return Demo: __________

Criteria for evaluation or rating the student’s performance:

10. Notes symmetry of facial movements.

Comments and Suggestions:

Name: _________________________________________ Date of Lecture Demo: ________

- From a lateral position, observe the three

11. Inspect the costal angle and the angle at

Assessing the Heart and Central Vessels

2. Simultaneously inspect and palpate the

Assessing the Peripheral Vascular System

Name: __________________________________________ Date of Return Demo: __________

Criteria for evaluation or rating the student’s performance:

6. Palpates the posterior thorax.

19. Auscultates the anterior chest.

Comments and Suggestions:

Name: ____________________________________________ Date of Lecture Demo: ________

Assessing the Abdomen

- Assess the symmetry of contour

Name: _______________________________________ Section:

Checked by: ____________________________________ Date: _

Name: _______________________________________ Section:

Name: ________________________________ Date of Return Demo:

Name: ________________________________ Date of Return Demo:

Name: _________________________________ Date of Lecture Demo:

Name: ________________________________ Date of Return Demo:

Name: ____________________________________ Date of Lecture Demo:

Name: ________________________________ Date of Return Demo:

Name: ________________________________ Date of Return Demo:

Name: ________________________________ Date of Return Demo:

Name: ____________________________________ Date of Lecture Demo: _

Name: ________________________________ Date of Return Demo: