03Rhoads(F)-04 5/3/07 1:51 PM Page 96

96 C h a p t e r 4 Physical Assessment

KEY POINTS FOR REPORTING AND RECORDING

●A history of any condition reported in the interview (subjec-
tive data) such as chest pain, irregular heartbeats, hyperten-
sion, diabetes, rheumatic fever, stroke, or smoking. Also
include a history of pain in the calves, feet, buttocks, or legs,
including the type of pain, what aggravates the pain, and what
relieves the pain. Note a history of coldness, cyanosis, edema,
varicosities, parethesis, or tingling in the extremities.
Heart
● Assessment findings (objective data) to include
• Anatomic location of apical impulse.
• Heart rate, rhythm, and symmetry of apical pulse and pulse
in extremities.
• Palpation findings: pulsations, thrills.
• Auscultation findings: characteristics of S1 and S2 (location,
intensity, pitch, timing, systole, and diastole).
• Presence of murmurs, clicks, S3 or S4 (description by tim-
ing, location, radiation, intensity, pitch, quality, variation with
respiration).
Blood Vessels
● Assessment findings (objective data) to include
• Amplitude, symmetry of pulses in extremities.
• Jugular vein pulsations and distention, pressure measure-
ment.
• Presence of bruits over carotid, renal, iliac, femoral arteries,
and aorta.
• Temperature, color nail beds of lower extremities.
• Presence of edema, swelling, vein distention, varicosities,
Homan’s sign, tenderness of lower extremities.

PROCEDURE 4.8
Assessing the Musculoskeletal System
OVERVIEW
● The assessment of the musculoskeletal function focuses on deter-
mining range of motion, muscle strength and tone, and joint and
muscle condition.
03Rhoads(F)-04 5/3/07 1:51 PM Page 97

P r o c e d u r e 4 . 8 Assessing the Musculoskeletal System 97

P R E PA R AT I O N
● Depending on the muscle or joint group assessed, the patient may
be standing, sitting, supine, or prone.
● Joints vary in degrees of movement.

Special Considerations
• When assessing range of motion, do not force a joint into a painful
position. It is good practice to know the joint’s normal range and the
extent to which it can be moved.
Elderly Patient
• Note: in older adults, a loss of muscle mass may cause bilateral
weakness.

R E L E VA N T N U R S I N G D I A G N O S E S
● Risk for injury due to immobility
● Self-care deficit due to injury

EXPECTED OUTCOMES
● Assessment completed while maintaining patient’s privacy and
comfort
● Awareness of cultural and traditional health practices

EQUIPMENT/SUPPLIES
Marking pen or pencil
Goniometer
Tape measure
Reflex hammer

I M P L E M E N TAT I O N
➧ Wash hands.
Reduces transmission of microorganisms.

➧ Explain each procedure to patient.

Careful explanation reduces the patient’s anxiety.

➧ Fully expose area and be able to freely move body parts.

Adequate exposure is necessary for a thorough examination.

General Inspection
➧ General inspection.
The nurse inspects patient’s body and observes physical features and gait
and posture.
03Rhoads(F)-04 5/3/07 1:51 PM Page 98

98 C h a p t e r 4 Physical Assessment

● Observe gait and posture as the patient walks into the room. Note
any foot dragging, limping, shuffling, and note the position of the
trunk in relation to the legs.
The patient is unaware of your assessment and is likely to walk
naturally.
● Note standing posture. Note the normal cervical, thoracic, and
lumbar curves.
Normal standing posture is upright with parallel alignment of the hips and
shoulders, and the head is erect. Abnormalities include:
Kyphosis—hunchback
Lordosis—swayback
Scoliosis—lateral spinal curvature
Osteoporosis—height loss occurring in trunk
● Note symmetry of joints, muscles, and extremity length, and look
for obvious deformities.
Asymmetric joints, muscles, and extremity lengths are abnormal and should
be reported.

Palpation
➧ Palpation.
The nurse uses the hands and sense of touch to gather data. Palpation is
used to detect tenderness, temperature, texture, pulsations, and masses, and
other changes in structural integrity.
● Palpate all muscles, joints, bones while noting any tenderness,
swelling, crepitus, and resistance to pressure.
Provides information regarding any abnormalities in joints, muscles, and
bones.

Range of Motion
➧ Range of joint motion.
Assessment of patient mobility and range of joint motion allows the nurse
to determine the amount of work or exercise tolerance a person is able to
perform.

➧ Measure the precise degree of motion in a joint with the goniometer.

This is usually done only when you suspect a reduction in joint movement.
● Ask the patient to put each joint through its full range of motion
while you gently support the extremity.
The same body parts are compared for equality in movement.
If patient is weak or ill, nurse may do passive ROM by gently supporting and
moving the extremities through their range of movement.
03Rhoads(F)-04 5/3/07 1:51 PM Page 99

P r o c e d u r e 4 . 8 Assessing the Musculoskeletal System 99

Note:
Swelling
Stiffness
Instability
Deformity
Tenderness
Crepitus (a crackling sensation and noise caused by rubbing of bone frag-
ments)
Normal joints are nontender and move freely; in the elderly you may see
stiffness with reduced ROM.

Muscle Tone and Strength

➧ Muscle tone and strength.
The muscle tone and strength are assessed bilaterally to compare to oppo-
site muscle. Differences in bilateral muscle tone or strength may indicate a
pathologic diagnosis.
● The nurse may assess muscle strength and tone during range of
motion. Note: tone is the muscular resistance felt.
● You must know each joint’s normal range.

● Do not force a joint into a painful position.

Hypertonicity and movement will be met with resistance.

Hypotonicity feels flabby and may hang loosely in a position determined by
gravity.
● Apply gradual increase in pressure to a muscle group, and have the
patient resist the pressure to measure strength of the muscle.
● Neck: Place hand firmly against patient’s upper jaw and ask patient

to turn head laterally against resistance.

● Shoulder: Place hand over midline of patient’s shoulder, exerting

pressure. Have patient raise shoulders against resistance.

● Elbow: Pull down on forearm as patient attempts to flex arm, as

patient’s arm is flexed, apply pressure against forearm. Ask patient

to straighten arm.
● Hip: With patient in sitting position, apply downward pressure to

thigh. Ask patient to raise leg up from table.

● Gastrocnemius: With patient sitting, hold shin of flexed leg. Ask

patient to straighten leg against resistance.

If weakness is identified, the muscle size is compared to opposite muscle with
a measuring tape.
03Rhoads(F)-04 5/3/07 1:51 PM Page 100

100 C h a p t e r 4 Physical Assessment

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to the normal
● Pursue more specific tests and assessments regarding abnormal
findings if warranted

KEY POINTS FOR REPORTING AND RECORDING

● Gait and posture and symmetry of joints, muscles, and extrem-
ity length.
● Note the joint’s range of motion and the extent to which it
can be moved. Record and report any abnormalities found.
● Note in the patient’s record the muscle tone and strength
that were observed and report any abnormalities found.

PROCEDURE 4.9
Assessing the Abdomen
OVERVIEW
● The abdominal assessment is routine in a physical examination and
is performed on patients of all ages.
● The abdominal cavity contains several of the body’s vital organs and

can provide valuable clues as to the patient’s diagnosis and condition.

P R E PA R AT I O N
● Landmarks help the nurse map out the abdominal region.
● Assessment involves examination of organs and tissues anteriorly
and posteriorly.
● Patients must be relaxed, warm, and provided privacy for the exami-

nation.
● Adequate light is essential for inspection and visualization during

examination.
● Nurse must begin with inspection then follow with auscultation.

Special Considerations
• The nurse must begin with inspection and then follow with
auscultation.