1 - NSG 102.2 Health Assessment Laboratory Manual

I.
ASSESSING VITAL SIGNS
PROCEDURES:
➢ Assessing Body Temperature
Oral Temperature
Rectal Temperature
Axillary Temperature
Tympanic Temperature
➢ Assessing A Pulse
Assessing The Radial Pulse
Assessing The Apical Pulse
Assessing The Brachial Pulse
Assessing The Carotid Pulse
Assessing The Dorsalis Pedis Pulse
Assessing The Femoral Pulse
Assessing The Posterior Tibial Pulse
Assessing The Popliteal Pulse
Assessing The Temporal Pulse
Assessing Pulse Deficit
➢ Assessing Respiratory Rate
➢ Assessing Blood Pressure
Taking Bp By Palpatory Method
Taking Bp By Auscultation Method
Taking Bp Using An Automatic Blood Pressure Monitor
Measuring Orthostatic Blood Pressure
GENERAL OBJECTIVE:
➢ To measure and document patient’s temperature, pulse and respiration (TPR) accurately and
safely, recognizing deviations from the norm.
LEARNING OUTCOMES
The student will be able to:
➢ Assess the patient to determine which method to use for temperature measurement and
which pulses should be checked.
➢ Assess the patient to determine readiness for the temperature, pulse and respiration (TPR).
➢ Analyze the assessment data to determine specific concerns that must be addressed prior to
taking the TPR or palpating peripheral pulses.
➢ Choose the appropriate equipment.
➢ Position the patient appropriately for the procedure, maintaining principles of body
mechanics.
➢ Measure the temperature, pulse and respirations accurately.
➢ Evaluate the effectiveness of the process and accuracy of the results
➢ Document the results in the patient record
1 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

NAME: _________________________________________________________________ DATE: _________________________
ASSESSING BODY TEMPERATURE
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

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THINGS TO DOCUMENT AFTER THE PROCEDURE:

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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
Review medical record for baseline
data factors that influence vital signs.
1.
Identify the client and explain the
procedure. Provide for privacy.
Gather the necessary equipment
(Electronic thermometer or digital
thermometer with disposable
2. protective sheathing, two pairs of non-
sterile gloves, alcohol wipes or cotton
ball with alcohol, and tissues) and bring
to the bedside.
Perform hand hygiene/wash hands,
3.
and apply gloves when appropriate

Assist the client to a comfortable
4.
position either sitting or lying down.
USING THE VARIOUS THERMOMETERS THROUGH DIFFERENT ROUTES
A. Using a digital thermometer orally
Ask the client if he or she has taken hot
or cold liquids or if she/he smoked.
9. Then if yes, wait for 20-30 minutes
after smoking, eating or drinking hot /
cold liquids before taking oral readings.
Carefully place it as far back under the
tongue as possible. Place tip of
thermometer under the client’s tongue
10.
and along the gum line to the posterior
sublingual pocket lateral to center of
the lower jaw.
Instruct client to close lips around the
thermometer and to keep mouth closed
around thermometer until it beeps and
11.
gives a reading. It may take a few
minutes, so tell the client to breathe
through the nose while waiting
B. Using a digital thermometer axillary
Remove client’s arm and shoulder from
13. one sleeve of gown or clothes. Avoid
exposing chest.
Make sure axillary skin is dry; if
14.
necessary, pat dry.
After putting a probe cover on the tip of
the digital thermometer, place probe
into center of axilla (pointing upwards
15. toward the head). Fold the client’s
upper arm straight down, and place
arm across the client’s chest so the
body heat is trapped.
Wait at least a few minutes or until the
16.
thermometer beeps with a reading.
Wait at least one hour after heavy
17. exercise or a hot bath before taking
body temperature from the axilla.
For better accuracy, take readings from
18. both armpits and then average the two
temperatures together.
C. Using a digital thermometer rectally
Provide privacy and place patient in a
19.
side-lying position.
20. Don on gloves.

Before inserting a digital thermometer
into the anus, make sure to lubricate it
with some water-soluble jelly first (KY
21.
jelly). Lubrication is typically placed
over the probe cover to allow for easier
insertion and increased comfort.
Spread the buttocks and insert the tip
of the thermometer no more than 1/2
an inch into the rectum and never force
22.
it if resistance is encountered. Hold
thermometer in place for two to three
minutes
Wait a minute or more for the
23. thermometer to beep, then slowly
remove it.
D. Using a tympanic thermometer
Before sticking the tympanic
24. thermometer into the ear canal,
make sure it's free of wax and dry.
After turning the ear (tympanic)
thermometer on and placing a
sterile cover on the tip, hold the
25. head still and pull back on the top
part of the ear to straighten out the
canal and make it easier for
insertion.
Insert the tympanic thermometer in
26.
to ear canal for 1 second while an
infrared sensor records the body
heat radiated by the eardrum.
Ensure that the probe of the
thermometer is properly inserted
into the ear to allow an optimal
27. reading. There is no need to touch
the eardrum with the tip because
the thermometer is designed to take
a remote reading.
After creating a seal around the
thermometer by pressing it against
28. the canal, wait for it to take a
reading and beep. The reading then
appears on the unit's screen.
For ear thermometer, a new ear-
29.
probe jacket should be used for
different person; the ear canal must
be pulled straight when measuring.
37. Inform client of temperature reading
Remove gloves and perform hand
38.
hygiene.

Record reading according to institution
39.
policies
40. Ability to answer questions

NAME: _________________________________________________________________ DATE: _________________________
ASSESSING PULSE RATE

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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Initial Preparation
1. Identify the client and explain the procedure to the
client to obtain informed consent.
2. Gather the necessary equipment and then bring to
the bedside.
3. Adhere to local infection control policies and
ensure proper hand hygiene (hand washing)
4. Place client in a comfortable position either in a
sitting or supine position.
5. Provide privacy
A. ASSESSING THE RADIAL PULSE
To check the radial pulse, position the client's arm
along the side of the body or across the upper
6.
abdomen with the client's wrist relaxed and palms
either facing upward or downward.

Apply light pressure with the pads of the fingers
(your forefinger and index finger) in the groove
7. along the radial or thumb side of the client's inner
wrist. Be careful not to apply too much pressure,
as this can impair blood flow.
Identify the pulse, feeling for the characteristic
8.
wave-like sensation.
Looking at a clock or watch with a second hand,
9.
count the number of beats over 60 seconds.
10. Assess bilaterally
During or after counting the rate, assess for pulse
11.
rate, rhythm, quality and amplitude.
B. ASSESSING THE APICAL PULSE
Clean the earpieces and diaphragm of the
12. stethoscope with alcohol wipes or cotton balls
with alcohol. Discard wipes or cotton balls
properly.
13. With the client supine or sitting, expose the left
side of the chest but only as much as necessary.
Palpate the 5th intercostal space at the
midclavicular line by:
a. Sliding your finger down from the sternal
notch to the angle of Louis (the bump where
the manubrium and sternum meet).
b. Slide your finger over to the left sternal border
to the 2nd intercostal space
14. c. Now place your index or ring finger in the 2 nd
intercostal space, and count down to the 5th
intercostal space by placing a finger in each of
the spaces.
d. Slide over to the midclavicular line, keeping
your fingers in the 5th intercostal space. The
palpated apical pulse is also called the point of
maximal impulse (PMI)
Warm the stethoscope in your hand for 10
15. seconds then place the diaphragm over the PMI
and listen to the normal S1 and S2 heart sounds
(lub dub)
16. Count the beats for a full minute using a watch
with a second hand.
17. Place back patient’s clothing and place
comfortably in bed.
18. During or after counting the rate, assess for pulse
C. ASSESSING THE BRACHIAL PULSE
Using firm pressure with the pads of your
forefinger and index fingers, press in the inner
19.
aspect of the antecubital fossa until you palpate
the brachial artery.
If you have difficulty palpating the brachial pulse,
20. ask the client to pronate the forearm (turning the
palm of the hand downward).
21. Identify the pulse, feeling for the characteristic
22. Count the beats for a full minute using a watch
with a second hand.


D. ASSESSING THE CAROTID PULSE
To check the carotid pulse, place your fingers on
25. the client’s trachea and slide them to the side into
the groove between the trachea and the
sternocleidomastiod muscle.
Palpate the carotid artery lightly. Pressure on the
26. carotid (especially in older adults) can stimulate
the vagus nerve causing the pulse and BP to drop
suddenly.
Do not palpate the carotid pulse except during
28. cardiopulmonary resuscitation (CPR) in an adult
and in certain situations to assess for circulation
to the head.
E. ASSESSING THE DORSALIS PEDIS PULSE
Palpate the dorsalispedis pulse by running the
30. pads of your fingers up to the groove between the
great and first toes to the top of the foot.
31. Palpate very lightly because dorsalispedis pulse is
easily obliterated

F. ASSESSING THE FEMORAL PULSE
Palpate the femoral pulse by pressing deeply in
35. the groin midway between the anterosupeior iliac
spine and the symphysis pubis
The femoral artery lies very deep and requires
36. significant pressure to palpate. You may need to
use both hands to feel the femoral pulse on an
adult.
38. Looking at a clock or watch with a second hand,
G. ASSESSING THE POSTERIOR TIBIAL PULSE
Palpate the posterior tibial pulse by pressing on
40. the inner (medial) side of the ankle below the
medial malleolus
41. Press down moderately and then increase the
pressure until you feel the pulse


H. ASSESSING THE POPLITEAL PULSE
46. Palpate the popliteal pulse by pressing behind the
knees in the middle of the popliteal fossa
47. Press down moderately and then increase the
pressure until you feel the pulse

I. ASSESSING THE TEMPORAL PULSE
52. Palpate the temporal pulse by pressing lightly
lateral (outside area) and superior (above) the eye
J. ASSESSING PULSE DEFICIT
To assess for a pulse deficit, you will need another
healthcare worker. One person assesses the radial
55.
pulse rate while the other person assesses the
apical pulse ratesimultaneously.
Position the patient either in a supine or a sitting
56. position and expose the patient's sternum and the
left side of the chest.
Using the appropriate anatomical landmarks,
57.
locate the radial and the apical pulses.
Both person will start counting on command and
58. they count the pulse rates simultaneously for 1 full
minute.
59. Both person will stop counting on command.
To calculate the pulse deficit, subtract the radial
60.
pulse rate from the apical pulse rate.
If you find a pulse deficit, assess the patient for
other signs and symptoms of decreased cardiac
61.
output, such as dyspnea, fatigue, chest pain, and
palpitations
K. Evaluation and Documentation
Document the reading and rhythm or amplitude
62. irregularities on the observation chart
immediately
Compare this figure with previous pulse readings,
63. taking into consideration the patient’s clinical
condition

NAME: _________________________________________________________________ DATE: _________________________
ASSESSING RESPIRATORY RATE

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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1. Make the client's position comfortable,
preferably sitting or lying with the head of
the elevated 45 to 60 degrees.
2. After taking the pulse rate, with your
fingers still in place from taking the radial
pulse, or with the stethoscope still in place
from taking the apical pulse; look at the
patient’s chest and observe patient’s
respirations. Observe the rise and fall of
the client’s (one inspiration and one
expiration) 
3. Count the number of respirations for 1
minute using a watch with a second hand.
4. Note the rise and fall of the client’s chest
with each respiration.
5. Remove your hand from the patient and
place patient comfortably on bed.

6. Document the rate, rhythm,
characteristics of respirations, and length
of any periods of apnea.

NAME: _________________________________________________________________ DATE: _________________________
ASSESSING BLOOD PRESSURE

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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Identify the patient and explain the
1.
procedure.
Gather the necessary equipment and
2.
then bring to the bedside.
3. Do hand washing.
Place patient in a comfortable position
(lying or sitting) and position the arm
at the level of the heart with the palm of
4.
hand facing up. Select appropriate arm
for BP taking. (preferably use left arm
because it is nearer the heart)
Roll the patient’s sleeve and expose the
5.
brachial artery.
A. TAKING BP BY PALPATORY METHOD

Center the bladder of the cuff over the
brachial artery, about midway on the
arm, so that lower edge of the cuff is
about 2.5 cm (1 to 2 inches) above the
6.
inner aspect of the elbow. Wrap the cuff
around the arm smoothly and snugly.
Place the gauge safely and where it can
easily be read.
Wrap the cuff around the arm smoothly

and snugly. (not to loose, not too tight)
7.
Check that the needle on the aneroid
gauge is at zero.
Palpate brachial pulse distal to the cuff

8.
with fingertips of non-dominant hand.
Inflate the cuff while still checking the
pulse with other hand. Observe the
9.
point where pulse is no longer
palpable.
Inflate cuff to pressure 20-30 mmHg
10.
above point at which pulse disappears.
Open the screw clamp, deflate the cuff
11.
fully and wait 30 seconds
B. TAKING BP BY AUSCULTATION METHOD
Position the stethoscope’s earpieces
comfortably in your ears (turn tips
12.
slightly forward). Be sure sounds are
clear, not muffled.
Place the diaphragm over the client’s

13. brachial artery. Do not allow chest
piece to touch cuff or clothing
Close the screw clamp on the bulb and

inflate the cuff to a pressure 30 mmHg
14.
above the point where the pulse had
disappeared.
Open the clamp and allow the aneroid
15. dial to fall at rate of 2 to 3 mmHg per
second.
Slowly deflate the cuff. Note the point
on the gauge wherein the first faint but
16.
clear sound is heard that slowly
increases in intensity.

Continue deflating the cuff and note the
point where the sound disappears.
17. Listen for 10 to 20 mmHg after the last
sound. Do not re-inflate the cuff once
air is released.
Release any remaining air quickly in
18.
the cuff and remove it.
Repeat any suspicious reading. But
wait for a minute before BP takings.
19.
Deflate the cuff completely between BP
takings.
20. Repeat at the same arm.
Remove stethoscope earpieces from
21. your ears. Remove cuff from the
patient’s arm.
Assist the client to a comfortable
22. position. Advise the client of the
reading.
Clean and store equipment used
23.
properly
24. Wash your hands.
Record blood pressure taken. Report
25.
any abnormal findings to the physician.
C. TAKING BP USING AN AUTOMATIC BLOOD PRESSURE MONITOR
Assist client in a comfortable place to
sit with good back support at a table or
26. desk and allow client to rest quietly for
three to five minutes before taking the
BP.
Instruct client to place his feet flat on
the floor and rest his arm on a tabletop
27.
even with the heart and to lean against
the back of the chair.
Instruct client to stretch out his arm,
palm upward. Place the cuff on the
28.
client’s bare upper arm one inch above
the bend of his elbow.
Make sure the tubing falls over the
29. front center of the client’s arm so that
the sensor is correctly placed.
Pull the end of the cuff so that it's
evenly tight around the client’s arm.
You should place it tight enough so that
30. you can only slip two fingertips under
the top edge of the cuff. Make sure the
client’s skin doesn't pinch when the
cuff inflates

Once the cuff is in place, switch on the
automated device and press start to
31. record the blood pressure
measurement, following the
manufacturer’s recommendations.
Instruct client to remain still and quiet
32.
as the machine begins measuring.
The cuff will inflate, then slowly deflate
33. so that the machine can take the client’s
measurement.
When the reading is complete, the
34. monitor displays the client’s blood
pressure and pulse on the digital panel.
If the monitor doesn't record a reading,
35.
reposition the cuff and try again
Let the client rest quietly and wait
36. about one to two minutes before taking
another measurement
Switch off the automated device and
remove the cuff. Ensure the device is
correctly and safely stored; if necessary
37.
recharge the battery following the
manufacturer’s recommendations and
institution policy.
Record blood pressure taken. Report
38.
any abnormal findings to the physician.
D. MEASURING ORTHOSTATIC BLOOD PRESSURE
39. Have the client lie down for 5 minutes.
Measure the client’s blood pressure
40.
and pulse rate
41. Have the patient stand
Repeat blood pressure and pulse rate
42. measurements twice (after standing 1
minute and then at 3 minutes)
A drop in BP of ≥20 mm Hg, or in
diastolic BP of ≥10 mm Hg, or
43.
experiencing light-headedness or
dizziness is considered abnormal
Clean and store equipment used
44.
properly
Record blood pressure and pulse rates
45. taken. Report any abnormal findings to
the physician.

II. NURSING PHYSICAL ASSESSMENT
OVERALL OBJECTIVE:
➢ To gain understanding of the components of a complete nursing assessment,

which includes developing skills for collecting data via a health history and
physical examination, performing beginning-level assessment of individual
patients using effective techniques for organizing data and accurately stating
nursing diagnoses based on the data collected.
LEARNING OUTCOMES
The student will be able to:
➢ Assess generally to obtain brief baseline history or complaint from the patient to
determine what types of data, methods, and further assessment techniques are
needed.
➢ Assess the patient’s readiness for the physical assessment.
➢ Analyze the initial data to determine specific concerns that must be addressed
prior to completing the physical assessment using both objective and subjective
data.
➢ Plan appropriate equipment that will aid the assessment process, and organize
the process, so it flows efficiently.
➢ Position the patient appropriately for the physical assessment while maintaining
principles of body mechanics and privacy for the patient.
➢ Implement the data collection and physical assessment processes that are
appropriate to the situation: comprehensive physical assessment, routine shift
assessment, or mini head-to-toe assessment.
➢ Evaluate the effectiveness of the process and the accuracy of the results
obtained.
➢ Begin to formulate nursing diagnoses based on the data collected.
➢ Document the results in the patient’s record or other facility documentation
form as required.

GUIDE TO PHYSICAL ASSESSMENT TECHNIQUES
Head-to-Toe Framework
• General survey • Chest and back
• Vital signs ✓ Skin
• Head
✓ Thorax shape and size
✓ Hair, scalp, face
✓ Eyes and vision ✓ Lungs
✓ Ears and hearing ✓ Heart
✓ Nose ✓ Spinal column
✓ Mouth and oropharynx ✓ Breasts and axillae
• Neck
• Abdomen
✓ Muscles
✓ Lymph nodes ✓ Skin
✓ Trachea ✓ Abdominal sounds
✓ Thyroid gland ✓ Femoral pulses
✓ Carotid arteries • External genitals
✓ Neck veins
• Upper extremities
• Anus
✓ Skin and nails • Lower extremities
✓ Muscle strength and tone ✓ Skin and toenails
✓ Joint range of motion ✓ Gait and balance
✓ Brachial and radial pulses ✓ Joint range of motion
✓ Sensation
✓ Popliteal, posterior tibial, and
dorsalis pedis pulses
Nursing Assessments Addressing Selected Client Situations

Situation Physical Assessment
Inspect, auscultate, percuss, and palpate the abdomen;
Client complains of abdominal pain.
assess vital signs.
Assess level of consciousness using Glasgow Coma Scale;
Client is admitted with a head injury. assess pupils for reaction to light and accommodation; assess
vital signs.
The nurse prepares to administer a cardiotonic drug to
Assess apical pulse and compare with baseline data.
a client.
Assess peripheral perfusion of toes, capillary blanch test,
The client has just had a cast applied to the lower leg.
pedal pulse if able, and vital signs.
The client’s fluid intake is minimal. Assess tissue turgor, fluid intake and output, and vital signs.
PROCEDURE RATIONALE
INSPECTION- It is the visual examination using the sense of sight.
1. Lighting must be sufficient, either natural or artificial

light.
2. Inspect with the naked eye and with a lighted
instrument such as an otoscope.
3. Use visual inspection to assess moisture, color, and
texture of body surfaces.
4. It is also used to assess shape, position, size, color, and
symmetry of the body.

5. Olfactory and auditory cues are also noted.
6. It is important to have a quiet environment for

accurate hearing when using auditory senses during
inspection.
PALPATION- It is the examination of the body using the sense of touch.

7. Pads of fingers are used.
8. The examiner’s hands should be clean and warm, and

the fingernails short.
9. It is used to determine:
a. Texture (e.g. hair)
b. Temperature (e.g. skin area)
c. Vibration (e.g. joint)
d. Position, size, consistency, and mobility of
organs and masses.
e. Distention (e.g. urinary bladder).
f. Pulsation
g. Tenderness or pain
10. Two types:

a. Light (superficial) palpation
b. Deep palpation
Light palpation should always precede deep palpation.
11. Light palpation:

- The nurse extends the dominant hand’s
fingers parallel to the skin surface.
- Presses gently while having the hand in circle.
- Skin is lightly depressed.
- The nurse presses lightly several times rather
than holding the pressure.
12. The dorsum of the hand and fingers are best use to test
skin temperature.
13. Palm of the hand is used to test for vibration.
14. Areas of tenderness should be palpated last.
PERCUSSION- It is the act of striking the body surface to elicit sounds that can be heard or vibrations that
can be felt, used to determine the size and shape of internal organs by establishing their borders.
15. Two types:

a. Direct percussion
b. Indirect percussion
16. Direct percussion:
a. Strike area to be percussed directly with the pads
of two, three, or four fingers or the pad of the
middle finger.
b. Strikes are rapid.
c. Movement is from the wrist.
17. Indirect percussion:

a. Striking of an object (eg., a finger) held against the
body area to be examined.
b. Middle finger of nondominant hand (referred to
as pleximeter) is placed firmly on the client’s skin.
c. Only distal phalanx and joint of this finger should
be in contact with the skin.
d. Using the tip of the flexed middle finger of the
other hand (plexor) the nurse strikes the
pleximeter.
e. Striking motion comes from the wrist; forearm
remains stationary.
f. The angle between the plexor and the pleximeter
should be 900.
g. Blows must be firm, rapid, and short.
AUSCULTATION - It the process of listening to sounds produced within the body.
18. Direct auscultation:

a. Performed using the unaided ear (eg., to listen
to a respiratory wheeze)
19. Indirect auscultation:

a. Performed using a stethoscope.
b. Auscultated sounds are described according to
their pitch, intensity, duration, and quality.

NAME: ________________________________________ DATE: ________________
ASSESSING THE HAIR AND SCALP, SKULL AND FACE

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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ASSESSING THE HAIR AND SCALP
1. Assess both scalp hair and body hair.

2. Note color and length of hair.
3. Inspect the evenness of growth over
the scalp and body.
4. Note distribution of hair.
5. Inspect hair thickness or thinness.

6. Inspect hair texture and oiliness.
7. Note presence of infections or
infestations by parting the hair in
several areas, checking behind the
ears and along the hairline at the neck.
ASSESSING THE HEAD C X N R
8. Inspect skull for size, shape, and

symmetry.
9. Inspect facial features (e.g. symmetry
of structures and of the distribution of
hair).
10. Palpate the head for masses,
tenderness, and depressions.
11. Note symmetry of facial movements.
12. Ask the client to elevate the eyebrows,
frown, or lower the eyebrows, close
the eyes tightly, puff cheeks, and smile
and show the teeth.

NAME: _______________________________________________________________ DATE: ________________
ASSESSING THE EYES

DEFINITION:
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PURPOSE:
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EQUIPMENT:
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EXTERNAL EYE STRUCTURES

1. Inspect the eyebrows: hair
distribution, alignment, skin quality,
and movement.
2. Inspect the symmetry and
distribution of the eyelashes, and
direction of curl.
3. Inspect the eyelids and note for any
lesions, edema, its position in
relation to the cornea, ability to
blink, and frequency of blinking.

4. Gently retract the client’s eyelids
with your thumb and index finger,
and ask the client to look up and
down, and from side to side.
5. Inspect the conjunctiva’s color,
texture, and presence of lesions.
6. Using the tip of your index finger,
palpate the lacrimal gland. Check for
edema and drainage.
7. Inspect the sclera. Note the color and
presence of lesions.
8. Inspect the cornea and lens with a
penlight. Ask the client to look
straight ahead.
9. Hold a penlight at the side of the
client’s eye. Note the color, clarity,
texture, and any presence of lesions.
10. Test the corneal reflex with a cotton
wisp. Ask the client to keep both eyes
open and look straight ahead. With a
wisp of cotton lightly touch the
cornea.
11. Inspect the color, size, shape, and
symmetry of the iris and pupils. Use
the pupil size chart for the size of
the pupils.
12. Inspect pupils for color, shape, and
symmetry of size.
DIRECT AND CONSENSUAL REACTION
13. Assess the pupils direct and
consensual reaction to light using a
penlight.
14. Dim the lights.
15. Ask the client to look straight ahead.
16. With a penlight, approach from the
side and shine a light on the pupil.
17. Observe for pupil reaction to light.
Constriction of pupil should be
noted.
18. Shine the light on the pupil again, and
observe the response of the other

pupil. Constriction of pupil should be
noted.
19. Repeat procedure on the other pupil.
20. Compare reaction and size on both
pupils.
ACCOMMODATION
21. Assess the pupil’s reaction to
accommodation.
22. Hold an object (a pencil or penlight)
about 10cm or 4in. from the bridge of
the client’s nose.
23. Ask the client to look first at the top
of the penlight and then at a distant
object (ex. the far wall) behind he
penlight.
24. Alternate the gaze from the near to
the far object. Observe the response
of the pupils.
25. Ask the client to look at the near
object and then move the object
toward the client’s nose and. Observe
the response of the pupils.
VISUAL FIELDS
26. Assess peripheral visual fields.
27. Have the client sit directly facing you
and position yourself at eye level and
about 2-3 feet away from the patient.
28. Have the client cover one eye (i.e. left
eye) and look directly ahead.
29. Cover or close your eye (i.e. left eye)
directly opposite the client’s covered
eye and look directly at the client’s
nose.
30. Hold an object (penlight or pencil) in
your fingers, extend your arm, and
move the object into the visual fields
from various points in the periphery.
31. The object should be at an equal
distance from the client and yourself.
32. Ask the client to tell you when the
moving object is first spotted.

33. Extend and move your right arm in
from the client’s right periphery.
34. Extend and move the right arm down
from the upward periphery.
35. Extend and move the right arm up
from the lower periphery.
36. Extend and move your left arm in
from the periphery.
37.
Repeat procedure on the right eye.
EXTRAOCULAR MUSCLE TESTS

38. Assess the six ocular movements.
39. Stand directly in front of the client
and hold a penlight about 1 foot from
the client’s eyes.
40. Instruct the client to focus on the top
of the penlight and to follow the
movement of the penlight with his
eyes only.
41. Move the penlight in a slow, orderly
manner through the six cardinal
fields of gaze.
42. Stop moving the penlight for a few
seconds.
43. Perform the cover-uncover patch
test.
44. Instruct client to stare at the top of
the penlight, held about 6 inches in
front of the client’s eyes.
45. With small index card, cover a
client’s eye and observe the
uncovered eye.
46. Remove the index card and observe
the eye movement of the newly
uncovered eye.
47. Repeat procedure on the other eye.
48. Test each eye several times.
49. Perform the corneal light reflex test.
50. Dim the lights.
51. Shine a penlight on the bridge of the
client’s nose.

52. Observe the light reflection in both
corneas.
VISUAL ACUITY
53. Assess distance vision using the
Snellen eye chart.
54. Position the client (stand or sit)
exactly 20 feet from the chart.
55. If patient wears corrective lenses,
conduct the test with them on.
56. Instruct patient to cover one eye.
57. Instruct patient to read the smallest
line possible.
58. Repeat for opposite eye.
59. Take three readings: right eye, left
eye, both eyes.
60. If the client is unable to see even the
top line (20/200) of the Snellen-type
chart, perform selected vision tests.
61. Test near vision by measuring the
ability to read newsprint at a
distance of 14 inches.
62. If the client normally wears glasses
or contact lenses, these should be
worn during the test.
63. Have patient hold and read from
newsprint at a comfortable distance.
64. Document the readings of each eye
and both eyes.
LIGHT PERCEPTION
65. Shine a light on the side of the head
of the client.
66. Then turn off the light.
67. Ask the client to tell you when the
.
light is either on or off.

NAME: __________________________________________________________ DATE: ________________
ASSESSING THE EARS
DEFINITION:
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__________________________________________________________________________________________________________________
PURPOSE:
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__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
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_________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
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A. AURICLES
1. Inspect the auricles for position, size,
shape, symmetry, and color. Note for
lesions or drainage.
2. Palpate the auricles for condition of
skin and any areas of tenderness.
3. Pull the auricle upward, downward,
and backward.
4. Fold the pinna forward and push in on
the tragus.

5. Apply light pressure on the mastoid
process.
B. EXTERNAL EAR AND TYMPANIC MEMBRANE
6. Inspect the external ear canal for
cerumen, skin lesions, pus, and blood.
7. Using an otoscope, inspect the
tympanic membrane.
8. Attach a speculum to the otoscope
with a diameter that will fit the ear
canal without causing discomfort.
9. Have the client tilt his head to the side
not being examined. Inspect for any
foreign object in the ear canal before
inserting the otoscope.
10. ADULT: pull pinna up then backward
PEDIA: pull pinna down then backward
11. Insert the speculum slowly, about 1/3
into the ear canal.
12. Inspect the tympanic membrane for
color and gloss.
C. GROSS HEARING ACUITY TESTS
13. Assess client’s response to normal
voice tones.
14. If the client has difficulty hearing the
normal voice, proceed with the
following tests: Whisper test, tuning
fork tests.
15. Perform the whisper test.
16. Have the client occlude one ear.
17. Out of the client’s sight, at a distance of
1 to 2 ft., whisper a simple phrase such
as “The weather is hot today.”
18. Ask the client to repeat the phrase.
19. Repeat with the other ear using a
different phrase.
D. TUNING FORK TESTS
20. Hold the tuning fork at its base and
strike it on a table.
21. WEBER TEST

Place the base of the vibrating fork on
top of the client’s head.
22. Ask the client where he hears the
noise.
23. RINNE TEST
Strike the tuning fork on the table.
While it’s still vibrating place it on the
client’s mastoid process.
24. Measure the time in seconds that the
client hears the vibration.
25. Strike the tuning fork again and place
it about 1 inch away from the client’s
ear. Measure the time until the client
can no longer hear the vibration.
26. Repeat it on the other ear.

NAME: _____________________________________________________________ DATE: _______________________________
ASSESSING THE NOSE AND SINUSES

DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
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__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
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__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
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PROCEDURE RATIONALE 5 4 3 2
NOSE
1. Inspect the external nose. Note size,
shape, color and flaring or
discharges from the nares.
2. Lightly palpate the external nose.
3. Instruct the client to close his mouth,
occlude one naris, and breathe
through the opposite naris.
4. Repeat the procedure with the other
naris.

NASAL CAVITIES
5. Use a nasal speculum and a penlight
to inspect the nasal cavities.
6. Hold the speculum in your right
hand to inspect the left nostril, and
hold it in your left hand to inspect
the right nostril.
7. Ask the client to tip his head back.
Brace your index finger against the
client’s nose and gently insert the
nasal speculum about 1 cm into the
naris, open as much as possible.
8. With the penlight, shine a light into
the naris.
9. Inspect the nasal septum for
position, deviation, and intactness.
10. Gently remove the nasal speculum,
wipe it dry with a tissue paper or
gauze.
11. Repeat on the other naris.
FACIAL SINUSES
12. Palpate the maxillary and frontal
sinuses.
13. FRONTAL SINUSES
Shine a penlight against the inner
aspect of the supraorbital ridge of
the frontal bone.
14. MAXILLARY SINUSES
Instruct the client to open his mouth
and shine the penlight to the left and
the right.

NAME: ________________________________________ DATE: ________________
ASSESSING THE MOUTH AND OROPHARYNX
DEFINITION:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
PURPOSE:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
EQUIPMENT:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________
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______________________________________________________________________________________________________________________________
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1. Inspect the outer and inner surface of
the lips noting symmetry of contour,
color, texture and lesions. Ask the
client to purse his lips.
2. Inspect and palpate the inner lips and
buccal mucosa for color, moisture,
texture, and any presence of lesions.
3. Ask client to open his mouth.
4. Remove dentures if any. If able you
may ask the patient to this her/himself
Inspect condition and fit.
5. Inspect teeth and gums for
discoloration and diseased or missing
teeth.

6. Inspect the roof of the mouth for color
and structure.
7. Inspect all surfaces of the tongue and
the floor of the mouth.
8. Ask the client to protrude his tongue.
Inspect the upper surface for color,
texture and position.
9. Have the client place the tip of his
tongue on the roof of his mouth. Use a
penlight and inspect the underside of
the tongue, frenulum, floor of the
mouth, and submaxillary glands.
10. Ask the client to roll his tongue
upward, downward, and from side to
side, to check tongue movement.
10. Wear gloves and palpate the tongue
and the floor of the mouth.
11. With the use of a piece of a gauze, pull
the tongue to the left and examine it, .
then do the same to the other side,
12. Ask the client to tilt his head back and
open mouth as wide as possible.
13. Use a tongue depressor and shine a
penlight into the oropharynx.
14. Inspect the hard and soft palate, and
tonsils. Note the color, shape, texture,
and condition.
15. To inspect the uvula, ask the client to
say “Ahhh” and watch the uvula as the
soft palate rises. Inspect its position
and mobility.
16. Inspect tonsils for color, ulcerations,
exudate, and enlargement.
17. Test the gag reflex by touching the
back of the soft palate with a tongue
depressor.

NAME: _____________________________________________________ DATE: ___________________________________
ASSESSING THE INTEGUMENT

DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
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__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
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1. Fully expose area to be examined.

2. Assess under strong, direct light.
3. Note general color as well as local
variations. Inspect uniformity of skin
color.
4. Inspect, palpate, and describe skin
lesions.
5. Describe skin lesions SIZE, SHAPE,
COLOR, DISTRIBUTION,
CONFIGURATION, and if there’s any
DRAINAGE, TENDERNESS or PAIN.

6. Palpate skin temperature with the
dorsal aspect of your hand.
7. Palpate skin texture, moisture and
hydration.
8. Palpate skin turgor by gently pulling
the skin and noting its return.
9. Assess for presence of edema by
firmly pressing over bony area of
tibia or ankle.
10. Note location, color, temperature,
shape, type and degree to which the
skin remains indented or pitted
when pressed by finger.
11. Measuring circumference of
extremity with a millimeter tape may
be useful.
12. Inspect the nail plate shape, texture,
nail bed color, and the tissues
surrounding the nails.
13. Assess capillary refill by pressing on
the nail and releasing.
14. Take note how many seconds did the
color return to its usual color.
15. Examine all the nails on both hands
and feet.
16. Note consistency—smoothness,
thickness, adherence to nail bed.
17. Note shape and contour.

NAME: ______________________________________________________ DATE: ________________
ASSESSMENT OF THE NECK
DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________
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Inspect the neck muscles and condition of the
1 skin. Note for any scars, abnormal swellings,
and masses.
Place the palm of your hand against the client’s
right cheek and tell him move his head against
2
the resistance of your hand. Repeat on the
other side.
Instruct the client to move his head through the
entire range of motion and shrug his shoulders
3
against your arms while he is sitting.
Locate the lymph nodes for size, shape,

4
symmetry, mobility, and tenderness, and

palpate them with your finger pads while
moving in a gentle rotating motion.
Palpate the trachea by placing one finger along

one side of the trachea, and check for symmetry
5
or deviation between its two sides
Palpate the thyroid by standing behind the

patient and put your hands around his neck
with the fingers of both hands over the lower
trachea.
POSTERIOR APPROACH
Stand behind the client and ask him to bend

his head slightly forward and to the left.
Place your hands around the client’s neck,

with the fingertips on the lower half of the neck
over the trachea.
Ask the client to swallow a sip of water, and

feel the thyroid NOTCH as it rises up.
6 Repeat it on the left side by asking the client to
slightly move his head to the right side.
ANTERIOR APPROACH
Stand in front of the client and ask the client

to slightly flex his neck to the left.
Place hands on the neck and apply gentle

pressure on the exposed side of the trachea,
while palpating the other side as the client
swallows a sip of water.
Ask the client to slightly flex his neck to the

right and repeat the procedure on the left side
If the thyroid gland is enlarged or there’s a

mass, auscultate with the bell of the
7 stethoscope over the carotid arteries and the
thyroid area for a bruit.

NAME: _______________________________________________________________ DATE: ________________
ASSESSMENT OF THE CHEST AND LUNGS
DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________
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Inspect the client’s wall for asymmetry,
abnormal respiratory rate and pattern,
1 accessory muscle use, masses or scars, or
paradoxical movement
Inspect for related structures like the spinal

2 cord, skin, tongue, mouth, fingers, and nail
bed
Place the palms of both your hands on the
anterior and posterior chest with your
thumbs about 2 inches apart and fingers
3
spread apart. Run them trough the entire
thorax

4. Percuss the thorax over intercoastal
spaces and not over bones by following this
sequence:
ANTERIOR
5. Percuss diaphragmatic excursion. Ask

the client to take a deep breath and hold it
while you percuss downward along the
5 scapular line until; dullness is produced at
the level of the diaphragm. Mark this point
and repeat on the other side
Ask the client to take slow, deep breaths

through the mouth. Listen at each site
through one full respiratory cycle. Then,
6 auscultate the chest using the same pattern
as for percussion with the diaphragm of a
stethoscope.
Identify the sounds heard upon

7 auscultation of both lung fields

NAME: ____________________________________________________ DATE: ________________
ASSESSING CARDIAC AND PERIPHERAL VESSELS
DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
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CENTRAL VESSELS
To palpate the carotid artery, lightly
1 place your fingers just medial to the
trachea and below the angle of jaw.
Auscultate for vascular sounds over the

2 carotid arteries.
Inspect the internal and external

3 jugular vein and determine for the type
of pulsation it produces.
4. Inspect and palpate the aortic and
4 pulmonic areas, note for any
pulsations.

Inspect and palpate the epigastric area
5 at the base of the sternum for
abdominal aortic pulsations.
Place the client in a semi-Fowler’s
position. Auscultate the AORTIC,
6 PULMONIC, TRICUSPID, and APICAL
area. Use both the bell and diaphragm
of the stethoscope
B. PERIPHERAL SYSTEM
Inspect the peripheral veins in the arms
7
and legs. Note color, temperature and
any presence of edema.
Palpate the peripheral pulses:
TEMPORAL, RADIAL, BRACHIAL,
INGUINAL, FEMORAL, POPLITEAL,
8 DORSALIS PEDIS, and POSTERIOR
TIBIAL. Palpate the pulses on both sides
of the body, and systematically.
Palpate or auscultate for the apical

9
pulse
Assess the pulse for rate, rhythm,
equality, amplitude and elasticity.
Describe pulse amplitude on a scale of 0
to 4:
10 0 = absent, not palpable
1 = diminished, barely palpable
2 = normal
3 = full, increased
4 = bounding
Assess the peripheral leg veins for any
signs of edema, varicosities, and
11
phlebitis. Grade for pitting edema as 1+,
2+, 3+, 4+ according to its depth.
Assess for Arterial and venous
12
insufficiency.

NAME: _______________________________________________________ DATE: ____________
ASSESSING THE BREASTS AND AXILLAE
DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
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__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
__________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________
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1. Explain the procedure and provide
privacy.
2. Inspect the breasts for skin condition,
size, symmetry, and contour or shape.
3. Inspect the nipples and areola for size,
shape, symmetry, color, surface
characteristics and any masses, lesions
or discharges.
4. Ask the client to raise her arms over her
head and place it behind her back.
5. Inspect the axillae for skin condition and
hair distribution.

6. Inspect the client in these positions:
a. Sitting with arms at the sides
b. Sitting with arms raised overhead
c. Sitting with hands pressed on the
hips
d. Sitting and leaning forward
e. Supine with a pillow under the
shoulder of the breast being
examined.
7. Palpate the client’s breasts using the
finger pads index, middle and ring
fingers. Palpate using the vertical strip
method, pie wedge or concentric circles.
8. Palpate the nipples and areola.
9. Squeeze the nipple gently between the
thumb and index finger.
10. Palpate the axillae and clavicular lymph
nodes
11. If a mass is detected record the location
using quadrant or clock method,
position, size in cm, mobility,
consistency, degree of tenderness and
shape.

NAME: ________________________________________ DATE: ________________
ASSESSING THE ABDOMEN

DEFINITION:
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__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
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EQUIPMENT:
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1. Place the client in a supine position with
the head and knees supported with small
pillow or folded sheets with drapes
positioned accordingly
2. Examine the abdomen in this order:
inspection, auscultation, percussion and
palpation.
3. Inspect the abdomen for size, symmetry,
and contour. Observe the condition of the
skin and skin color, hair distribution; and
any presence of lesions, scars, striae, and
superficial veins.

4. Note the position, contour, and color of
the umbilicus.
5. Ask the client to raise his head without
using the arms for support
6. If distention is present, measure the girth
at the umbilicus with a tape measure.
7. Auscultate the abdomen for bowel
sounds, using the diaphragm of the
stethoscope, it should be applied on the
abdominal wall with firm but gentle
pressure. Listen for bowel sounds for 3 to
5 minutes.
8. Place the warm diaphragm in each of the
four quadrant of the abdomen
9. Use the bell of the stethoscope over the
aorta, renal, and iliac arteries to listen for
bruits.
10. Percuss several areas in each of the four
quadrants
11. Use a systematic pattern: Begin in the
lower right quadrant, proceed to the
upper right quadrant, the upper left
quadrant, and the lower left quadrant.
12. Palpate the abdomen over all four

quadrants. Begin with light palpation
then do deep palpation to palpate organs
or any masses.
13. For light palpation, press your palm
down only about 1-2 cm in a rotating
motion. Note areas of slight tenderness or
superficial pain, large masses, and muscle
guarding.
14. For deep palpation, use the bimanual
method. Depress the abdominal wall
about 4 to 5 cm (1.5 to 2 in.)

15. Palpate the liver. Place your right hand at
the midclavicular line under the 11th or
12th rib. Place your left hand under the
client’s back at the lower ribs and press
upward.
16. Ask the client to inhale and exhale deeply
while pressing in and up.
17. Document the procedure done and
findings.

NAME: _________________________________________________ DATE: ________________
ASSESSING THE FEMALE GENITOURINARY SYSTEM
DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
__________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________
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1. Introduce self and verify the client’s
identity. Explain the procedure to the
client. Provide privacy.
2. Ask the client to empty her bladder
before the examination begins
3. Perform hand hygiene, apply gloves
and observe appropriate infection
control.
4. Ask the client to remove her
underwear. Place her in a lithotomy
position and drape.
5. Do perineal care.

6. Normal findings:
• Wide variations; generally
kinky in the menstruating
adult, thinner and straighter
after menopause.
• Distributed in the shape of an
Inspect the distribution, amount, and inverse triangle.
characteristics of pubic hair.
Abnormal findings:
• Scant pubic hair (may indicate
hormonal problem)
• Hair growth should not extend
over the abdomen.
7. Normal findings:
• Pubic skin intact, no lesions.
• Skin of vulva area slightly
darker than the rest of the
body.
• Labia round, full and relatively
Inspect the skin of the pubic area for symmetric in adult females.
any presence of parasites,
inflammation, swelling, or lesions.
Abnormal findings:
• Lice, lesions, scars, fissures,
swelling, erythema,
excoriations, varicosities, or
leukoplakia.
8. Normal findings:
• Clitoris does not exceed 1cm in
width and 2cm in length.
• Urethral orifice appears as a
With your thumb and index finger small slit and is the same color
separate the labia, and inspect the as surrounding tissues.
clitoris, urethral orifice, and vaginal • No inflammation, swelling, or
orifice. Note position, color, size, and discharge.
presence of drainage or lesions.
Abnormal findings:
• Presence of lesions
• Presence of inflammation,
swelling, or discharge.
9. Palpate the inguinal lymph nodes in
the groin area and the vertical chain
at the inner aspect of the thigh. Not
for any enlargement or tenderness. Normal findings:
• No enlargement or tenderness

(lymph nodes of the groin
area)
Abnormal findings:
• Enlargement and tenderness
10. Document findings in the client record

using forms or checklist
supplemented by narrative notes
when appropriate.

NAME: ________________________________________ DATE: ________________
ASSESSING THE MALE GENITOURINARY SYSTEM

DEFINITION:
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PURPOSE:
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__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
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__________________________________________________________________________________________________________________
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3. Perform hand hygiene, apply gloves
and observe appropriate infection
control.
4. Don on clean gloves
5. Ask the client to remove his
underwear. Place him in a supine
position with legs slightly apart, and
drape.
6. Do perineal care.

7. Normal findings:
Pubic Hair • Triangular distribution, often
spreading up the abdomen
Inspect the distribution, amount, and
Abnormal findings:
characteristics of pubic hair.
• Scant amount or absence of
hair
8. Normal findings:
• Penile skin intact appears
slightly wrinkled and varies in
color as widely as other body
skin.
• Foreskin easily retractable
from the glans penis
• Small amount of thick white
smegma between the glans
Penis and foreskin
• Pink and slitlike appearance
Inspect the penile shaft and glans • Positioned at the tip of the
penis and note the skin condition, penis
presence or absence of foreskin,
position of the urethral meatus, and Abnormal findings:
any lesions, swelling, inflammation or • Presence of lesions, nodules,
discharges. swellings, or inflammation
• Foreskin not retractable
• Large amount, discolored, or
malodorous substance
• Inflammation; discharge
• Variation in meatal locations
(e.g.,hypospadias,on the
underside of thepenileshaft,
and epispadias, on the upper
side of the penile shaft)
9. Normal findings:
• Scrotal skin is darker in color
than that of the rest of the body
and is loose. Size varies with
Scrotum temperature changes (the
dartos muscles contract when
Inspect the scrotum for skin condition, the area is cold and relax when
size, position, and symmetry. the area is warm)
• Inspect all skin surfaces by • Scrotum appears asymmetric
spreading the rugated surface (left testis is usually lower
skin and lifting the scrotum as than right testis)
needed to observe posterior
surfaces. Abnormal findings:
• Discolorations; any tightening
of skin (may
• indicate edema or mass)
• Marked asymmetry in size
10. Inguinal Area Normal findings:
• No swelling or bulges
Inspect both inguinal areas for bulges

while the client is standing, if possible Abnormal findings:
• First, have the client remain at • Swelling or bulge (possible
rest. inguinal or femoral hernia)
• Next, have the client hold his
breath and strain or bear
down as though having a
bowel movement. Bearing
down may make the hernia
more visible.
11. Remove and discard gloves. Perform
hand hygiene.
using printed or electronic forms or
checklists supplemented by narrative
notes when appropriate.

NAME: ________________________________________ DATE: ________________
ASSESSING THE ANUS AND RECTUM

DEFINITION:
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PURPOSE:
__________________________________________________________________________________________________________________
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EQUIPMENT:
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__________________________________________________________________________________________________________________
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1. Introduce self and verify the
client’s identity. Explain the
procedure to the client. Provide
privacy.
3. Perform hand hygiene, apply
gloves and observe appropriate
infection control.
4. Position the client:
• In adults, a left lateral or
Sims’ position with the
upper leg acutely flexed is
required for the
examination.

• A dorsal recumbent
position with hips
externally rotated and
knees flexed or a lithotomy
position may be used.
• For males, a standing
position while the client
bends over the examining
table may also be used.
5. Normal findings:
• Intact perianal skin; usually
slightly more pigmented than the
Inspect the anus and its skin of the buttocks Anal skin is
surrounding tissue for color, skin normally more pigmented,
integrity, and presence of lesions. coarser, and moister than
Then, ask the client to bear down perianal skin and is usually
as though defecating. Bearing hairless.
down creates slight pressure on
the skin that may accentuate rectal Abnormal findings:
fissures, rectal prolapse, polyps, or • Presence of fissures (cracks),
internal hemorrhoids. Describe the ulcers, excoriations,
location of all abnormal findings in inflammations, abscesses,
terms of a clock, with the 12 o’clock protruding hemorrhoids (dilated
position toward the pubic veins seen as reddened
symphysis.. protrusions of the skin), lumps or
tumors, fistula openings, or rectal
prolapse (varying degrees of
protrusion of the rectal mucous
membrane through the anus).
6. Remove and discard gloves.
Perform hand hygiene.
7. Document findings in the client
record using printed or electronic
forms or checklists supplemented
by narrative notes when
appropriate.

NAME: ________________________________________________________________ DATE: _____________________________
ASSESSING THE MUSCULOSKELETAL SYSTEM
DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2. Perform hand hygiene and observe
appropriate infection control.
3. Compare bilaterally during assessment.
A. Symmetry, contraction and strength
4. Muscle Normal findings:
• Equal size on both sides of body
Inspect the muscles for size.
Comparethe muscles on one side of the
body (e.g., of the arm, thigh, and calf) to Abnormal findings:
the same muscle on the other side. For • Atrophy (a decrease in size) or
any discrepancies, measure the muscles hypertrophy (an increase in size),
with a tape. asymmetry.

5. Normal findings:
• No contractures
Inspect the muscles and tendons for
Contractures (shortening). Abnormal findings:
• Malposition of body part, e.g., foot
drop(foot flexed downward)
6. Normal findings:
Inspect the muscles for tremors, for • No tremors
Example by having the client hold the
arms out in front of the body. Abnormal findings:
• Presence of tremor
7. Test muscle strength. Compare the right
side with the left side.
• Sternocleidomastoid: Client
turns the head to one side
against the resistance of your
hand. Repeat with the other
side.
• Trapezius:Client shrugs the Normal findings:
shoulders against the
• Equal strength on each body side
resistance of your hands.
• Deltoid: Client holds arm up and
resists while you try to push it Grading Muscle Strength:
down.
• Biceps:Client fully extends each Rating Indication
arm and tries to flex it while 0% of normal strength;
0
you attempt to hold arm in complete paralysis
extension. 10% of normal strength; no
• Triceps:Client flexes each arm movement, contraction of
1
and then tries to extend it muscle is palpable or visible
against your attempt to keep
arm in flexion. 25% of normal strength; full
• Wrist and finger muscles:Client muscle movement against
2
spreads the fingers and resists gravity, with support
as you attempt to push the
fingers together. 50% of normal strength;
• Grip strength:Client grasps your normal movement against
3
index and middle fingers while gravity
you try to pull the fingers out.
• Hip muscles:Client is supine, 75% of normal strength;
both legs extended; client normal full movement
raises one leg at a time while 4 against gravity and against
you attempt to hold it down. minimal resistance
• Hip abduction:Client is supine,
both legs extended. Place your 100% of normal strength;
hands on the lateral surface of normal full movement
5
each knee; client spreads the against gravity and against
legs apart against your full resistance
resistance.
• Hip adduction:Client is in same
position as for hip abduction.
Place your hands between the
knees; client brings the legs
together against your
resistance.
• Hamstrings:Client is supine,
both knees bent. Client resists

while you attempt to straighten
the legs.
• Quadriceps: Client is supine,
knee partially extended; client
resists while you attempt to flex
the knee.
• Muscles of the ankles and
feet:Client resists while you
attempt to dorsiflex the foot
and again resists while you
attempt to flex the foot.
B. RANGE OF MOTION
8.
Test active ROM by asking client to do
joint movements from head to toe.
9.
NECK
Ask client to move head down towards
the chin and up, move head from side
to side, to bend laterally, and rotate
head.
10. ARMS& SHOULDERS
Ask client to move his arm up and
down, to raise his arms forward, to
bring his arms as far back as possible,
and to bring his arms towards and
away from his body, and to rotate his
arms
11.
ELBOWS
Ask client to bend his elbows forward
and downward, and to move his elbows
from side to side.
12.
WRISTS
Ask the client to move his wrist up and
down, and from side to side.
13.
HANDS AND FINGERS

Ask the client to make a fist and to close
and open it, to spread his fingers out,
and to bend each finger individually.

14.
TRUNK
Ask the client to bend towards his toes
and to bend backwards, to bend from
side to side, and to turn from side to
side.
15.
HIP& KNEES
Ask the client to move each leg forward
and backward, to move leg from side to
side, and to rotate each leg. Ask client
to bend each knee.
16.
ANKLES AND FEET
Ask the client to point his toes up and
down, to move his feet from side to
side, and to spread the toes of each foot
apart.
C. DEEP TENDON REFLEXES

17. Have the client relax. Provide support
To provide client’s comfort
for the extremity to be tested.
18. BICEPS
Place your right thumb on the client’s
right biceps tendon (located in the
antecubital fossa) with the client’s arm
slightly flexed.
Strike your thumb with the pointed end Test reflexes using a percussion hammer,
of the hammer head. Strike with the comparing one side of the body with the
least amount of pressure. other to evaluate the symmetry of response.
19. TRICEPS TENDON
Have the client hang his arm freely;
0 – No reflex response
support the arm with your non-
+1 – Minimal activity (hypoactive)
dominant hand.With the elbow flexed,
+2 – Normal response
strike the elbow directly with the
+3 – More active than normal
pointed end of the hammer.
+4 – Maximal activity (hyperactive)
20. BRACHIORADIALIS TENDON
Strike the forearm with the hammer
about 1” above the wrist over the
radius.
21. QUADRICEPS REFLEX

Have the client sit with his legs hanging
over the edge of the table.Strike the
tendon just below the patella.
22. ACHILLES REFLEX
Support the foot in dorsiflexed position.
Tap the Achilles tendon with the
hammer.
23. PLANTAR REFLEX Normally, all five toes bend downward; this
reaction is negative Babinski. In an abnormal
Stroke the sole of the client’s foot with a
(positive) Babinski response, the toes spread
flat object. (Babinski, reflex is
outward and the big toe moves upward.
superficial.
It may be absent in adults without
pathology or overridden by voluntary
control.)

using forms or checklist supplemented
by narrative notes when appropriate.
25. Report deviations from expected or
normal findings to the primary care
provider.

NAME: ________________________________________ DATE: ________________
ASSESSING THE SENSORY-NEUROLOGICAL SYSTEM
DEFINITION:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PURPOSE:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EQUIPMENT:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
A. SENSORY FUNCTION TEST
2. Perform hand hygiene and observe
appropriate infection control.
3. The client’s eyes should be closed
whenever possible. Testing should
always be bilateral.
4. LIGHT-TOUCH SENSATION • Sensitivity to touch varies
• Ask the client to close his among different skin areas (1).
eyes. Let him respond “yes” or • This demonstrates whether the
“now” when he feels the client is able to determine tactile
cotton wisp touching his location (point localization) (2).

skin.With a cotton wisp,
lightly touch one specific spot
and then the same spot on the
other side of the body (1).
• Ask the client to point the
spot where the touch was felt
(2).
Normal findings:
• Light tickling or touch sensation
Abnormal findings:
• Anesthesia, hyperesthesia,
hypoesthesia or paresthesia
5. PAIN SENSATION
• Ask the client to close his
eyes.Let him respond “sharp”,
“dull”, or “don’t know” when Normal findings:
he feels the sharp or dull end
of the safety pin or needle is • Able to discriminate “sharp” and
felt. “dull” sensations
• Alternately use the sharp and
dull end of the sterile pin or Abnormal findings:
needle to lightly prick the • Areas of reduced, heightened, or
hand, forearm, abdomen, absentsensation (map them out
lower leg and foot.Do NOT for recordingpurposes)
test the face.
• Allow at least 2 seconds
between each test.
6. KINESTHETIC SENSATION Normal findings:
Ask the client to close his eyes. • Can readily determine the
Grasp the client’s middle finger or big position of fingers and toes
toe by the sides and move it up and
down. Abnormal findings:
Have the client tell you the • Unable to determine the position
orientation of the middle finger or big of one ormore fingers or toes
toe.
B. CRANIAL NERVE ASSESSMENT

7. OLFACTORY (Cranial Nerve I)
Test sense of smell on each nostril
separately. Have the client occlude a

nostril and use various scents. Repeat
with the other nostril.
8. OPTIC (Cranial Nerve II)
Check the client’s visual acuity using
the Snellen Chart. If the client uses
eye glasses or contact lens let him
wear it.
Test visual fields. Let the client follow
your finger coming into the visual
field from all directions.
9. OPTIC and OCCULOMOTOR (Cranial
Nerve II and III)
Check papillary reaction to light in
both eyes.
10. OCCULOMOTOR, TROCHLEAR, and
ABDUCENS (Cranial Nerve III, IV, and
VI)
Ask the client to follow your finger as
you trace an “H” in mid air.
11. TRIGEMINAL (Cranial Nerve V)
Ask client to clench his jaw, feel for
strength and bulk of the temporalis
and masseter muscles.
12. TRIGEMINAL and FACIAL (Cranial
Nerve V and VII)
Check the corneal reflex by lightly
touching the cornea with a wisp of
cotton.
13. FACIAL (Cranial Nerve VII)
Ask the client to raise his eyebrows,
to close eyes tightly, puff of cheeks,
smile, frown, and show teeth.
14. VESTIBULOCOCHLEAR (Cranial
Nerve VIII)
Test hearingby whispering a word or
holding a ticking wrist watch into
each ear. Do the Rinne and Weber
test as well.
15. GLOSSOPHARYNGEAL and VAGUS
(Cranial Nerve IX and X)
Assess and listen to the client’s voice.
Have the client drink a glass of water.
Check if the uvula is midline.
Have the client say “ahh”; observe if
the soft palate rises evenly. Check the
gag reflex.
16. ACCESSORY (Cranial Nerve XI)

Have the client turn his head against
a resistance, and to shrug his
shoulders against a resistance.
17. HYPOGLOSSAL (Cranial Nerve XII)
Observe the client’s tongue for any
atrophy or fasciculation.
Have the client stick out his tongue
and check if it protrudes midline.
Have the client press his tongue on
the insides of his cheeks.
18. Document findings in the client
record using forms or checklist
supplemented by narrative notes
when appropriate.
19. Report deviations from expected or
normal findings to the primary care
provider.

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I.

ASSESSING VITAL SIGNS

1 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

ASSESSING BODY TEMPERATURE

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

2 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

3 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

4 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

5 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

ASSESSING PULSE RATE

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

6 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

7 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

24. During or after counting the rate, assess for pulse

34. During or after counting the rate, assess for pulse

8 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

45. During or after counting the rate, assess for pulse

51. During or after counting the rate, assess for pulse

9 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

ASSESSING RESPIRATORY RATE

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

10 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

11 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

ASSESSING BLOOD PRESSURE

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE:

12 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

Wrap the cuff around the arm smoothly

Palpate brachial pulse distal to the cuff

Place the diaphragm over the client’s

Close the screw clamp on the bulb and

13 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

14 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

15 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

➢ To gain understanding of the components of a complete nursing assessment,

16 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

Nursing Assessments Addressing Selected Client Situations

INSPECTION- It is the visual examination using the sense of sight.

1. Lighting must be sufficient, either natural or artificial

17 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

6. It is important to have a quiet environment for

PALPATION- It is the examination of the body using the sense of touch.

8. The examiner’s hands should be clean and warm, and

10. Two types:

11. Light palpation:

14. Areas of tenderness should be palpated last.

15. Two types:

17. Indirect percussion:

18 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

18. Direct auscultation:

19. Indirect auscultation:

19 | NSG 102.2 │HEALTH ASSESSMENT LABORATORY MANUAL

ASSESSING THE HAIR AND SCALP, SKULL AND FACE

CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:

THINGS TO DOCUMENT AFTER THE PROCEDURE: