Body system Assessment

1. PHYSICAL ASSESSMENT
Mrs. Shany Thomas
Asst. Professor

2. • A physical health assessment is conducted to
assess the function and integrity of the clients’
body part.
Responsibility of the nurse
1. Preparing the client –
2. Preparing the environment –
3. Positioning
4. Draping
5. Instrumentation –

3. Preparing the patient
– Explanation about the procedure
– When and where it will take place
– Importance
– What will happen during examination & is
painless
– Empty their bladder
– Sequence of assessment differ with children
and adult

4. Preparing the environment
– Depending on the time of
assessment, environment needs to be well
ventilated & lighted.
– Providing privacy

5. Positioning

7. Draping
• Drapes are made up of paper, cloth or
bed linen. Drapes should be arranged so
that the area to be assessed is exposed &
other body areas are covered.

8. Instrumentation
• All equipments required for the health
assessment should be clean, and in good
working condition and readily accessible.

10. Assessment techniques
• Inspection
• Palpation
• Percussion
• Auscultation

11. Inspection
• Close and careful visualization of the person
as a whole and of each body system
• Ensure good lighting
• Perform at every encounter with your client

12. Palpation
Palpation is the examination of the body
using the sense of touch. The pads of the
fingers used because their concentration of
nerve endings makes them highly sensitive to
tactile discrimination.

13. General guidelines for palpation
• Hands clean and warm, fingernails cut and filed
• Areas of tenderness should be palpated last
• Deep palpation should be done after superficial
palpation
• Client should be relaxed – gowning, draping,
comfortable positioning, and warm hands & be
sensitive to client’s verbal & facial expressions
indicating discomfort.

14. Types of palpation
 Light
 Deep
 Bimanual

15. 1. Light palpation (superficial)
• with light palpation extend the dominant hands
fingers parallel to the skin surface & presses
gently while moving in a circle. The skin is
slightly depressed to determine the details of
mass.

16. Deep /Bimanual Palpation
Deep palpation is done with 2 hands/one
hand .
Extend the dominant hand like light
palpation, place the finger pads of the non
dominant hand on the dorsal surface of the distal
interphalangeal joint of the middle 3 fingers of
the dominant hand .
Top hand applies pressure while lower hand
remains relaxed to perceive tactile sensation. It is
done with extreme caution because pressure can
damage internal organs.

17. Location Site on the body, dorsal/ventral surface
size Length and width in centimeters
Shape Oval, round, elongated, irregular
Consistency Soft, firm, hard
surface Smooth, nodular
Mobility Fixed /mobile
pulsatility Present/absent
Tenderness Degree of tenderness to palpation
Characteristics of masses

18. Percussion
• Percussion is the act of striking the body
surface to elicit sounds that can be heard
or vibrations that can be felt.
• It is used to guess the size, borders, and
texture of some chest organs and organs
in the abdomen.

19. There are 2 types of percussion
1.Immediate or direct percussion refers to
tapping (percussion) done by striking the
fingers on the surface of the chest or
abdomen.
2.Indirect, mediate, or finger percussion is
striking a finger of one hand on a finger of the
other hand as it is placed over an organ

20. Direct Percussion Indirect Percussion

22. Sound Intensity Location
Flatness Soft loud Muscle, bone
Dullness Medium Liver, heart
Resonance Loud Normal lung
Hyper
resonance
Very loud Emphysematous
tympany loud Stomach filled
with gas

23. Auscultation
 Listening to sounds produced by the body
 Instrument: stethoscope (to skin)
 Diaphragm –high pitched sounds
Heart
Lungs
Abdomen
 Bell – low pitched sounds
Blood vessels

24. It is of 2 types
• Auscultation may be done with the ear
alone.It is direct auscultation.
• Indirect Auscultation may be done with the
stethoscope.

25. General Survey
• Appearance
– skin color, facial features
– Body Structure - figure, nutrition, posture, symmetry
– Mobility - Gait, ROM
• Behavior
– Facial expression, mood, speech, dress, hygiene
• Cognition
– Level of Consciousness and Orientation

26. • Vital Signs
– Pulse
– Respirations
– Blood Pressure
– Temperature
• Height
• Weight
• Spo2

27. Breathing Patterns

28. Skin , Hair And Nails
Assessment of Integument

29. Skin color variations
locations Description Condition Areas
Bluish
(cyanosis)
Increased amount of
deoxygenated hemoglobin
Heart or lung
disease,
cold environment
Nail beds, lips, mouth & skin
(severe cases)
,
Pallor
(decrease in
color)
(associated with hypoxia)
Reduced amount of
oxyhemoglobin
Reduced visibility of
oxyhemoglobin resulting from
decreased blood flow
Anemia
Shock
Face, conjunctivae, nail
beds, palms of hands Skin,
Loss of
pigmentation
Vitiligo Congenital or
autoimmune
Condition causing
lack of pigment
lips Patchy areas on skin over
face, hands, arms
Yellow-orange
(jaundice)
Increased deposit of bilirubin
in tissues
Liver disease,
destruction of red
blood cells
Sclera, mucous membranes, skin
Red
(erythema)
Increased visibility of
oxyhemoglobin
caused by dilation or
increased blood flow
Fever, direct
trauma,, alcohol
intake
Face, area of trauma, sacrum,
shoulders, other common sites for
pressure ulcers
Tan-brown Increased amount of melanin Suntan, pregnancy Areas exposed to sun: face,
arms; areola, nipples

30. • Moisture: hydration of skin and mucous
membrane.
Observe for dullness, dryness, crusting and flaking.
• Temperature: palpate the skin with dorsum of
hand. Temperature depends on the variation in
blood supply
• Texture: the character of skin surface
Normally smooth and soft
• Turgor: Skins elasticity
To assess skin turgor , a fold of skin on the
back of forearm or sternal area is grasped with
finger tips and released. Normally skin lifts easily
and snaps back immediately. If the skin remains
pinched when turgor is poor.

31. • Vascularity: observe for petechiae
• Edema: Areas of skin become swollen due to
collection of fluid in tissues
• lesion:

32. Hair and scalp
• Hair: note the
color, distribution, quantity, thickness, texture
and lubrication of hair.
• Scalp: check for lesions, lumps or bruises.

33. • Inspect the nail bed for color, cleanliness and length;
thickness and shape of the nail plate, the texture of
the nail; the angle between the nail and the nail bed.
observe for splinter hemorrhage and cyanosis and
clubbing.
• Palpate the nail base: normally smooth , round and
convex.
• Check the capillary refill: grasp the finger and
observe the color of the nail bed. Apply gentle , firm
pressure with the thumb to the nail bed and release
it. As pressure applied nail bed appears white or
blanched. Pink color should return immediately on
release of pressure.
Nails

35. • Calluses and corns are found on the toes or
fingers.
• Callus is flat and painless caused by thickening
of epidermis
• Corns are caused by friction and pressure
from shoes

36. Assessment Normal findings Deviation from
normal
Inspect skull for size,
shape & symmetry
Rounded
(normocephalic &
symmetrical, with
frontal, parietal and
occipital prominences,)
Lack of
symmetry,increased
skull size with more
prominent nose and
forehead
Palpate the skull for
nodules /masses &
depressions with
fingertips with rotating
motion with the finger
tips
Smooth uniform
consistency: absence of
nodules and masses
Sebaceous cyst; local
deformities from trauma
Inspect the facial
features for symmetry of
structure & of the
distribution of hair
Symmetric slightly
asymmetrical facial
features.
↑ Facial hair, thinning of
eyebrows, asymmetric
features, exophthalmos,
moon face.
Head and neck

37. Inspect the eyes for
edema & hollowness
Periorbital edema,
sunkun eyes.
Note symmetry of
facial movement
Elevate the
eyebrow
Close the eyes
tightly
Puff the cheeks
Smile and show the
teeth
Symmetric facial
movement
Eyes cannot be
closed, dropping
eyelid & mouth,
involuntary facial
movements
Document findings

38. Eye
Some of the terminologies
• Myopia – nearsightedness
• Hyperopia – farsightedness
• Presbiopia – loss of elasticity of the lens
hence loss of ability to see close objects
• Conjunctivitis– inflammation of the
conjunctiva
• Cataract – opacity of the lens

39. Assessment Normal findings Deviation from
normal
Inspect the eyebrows
for hair distribution
Evenly distributed Loss of hair, scaling &
flakiness of the skin
Inspect the eyelashes
for evenness of
distribution
Equally distributed Inversion of the
eyelid
Inspect the bulbar
conjunctiva(lying over
the sclera) for color,
texture and presence
of lesions
Transparent;
capillaries evident,
sclera appears white&
yellowish in dark
colored clients.
Jaundiced, excessively
pale, reddened sclera,
lesions or nodules.
General assessment

40. Inspect the palpebral
conjunctiva
Shiny smooth and
pink or red.
Jaundiced, excessively
pale, reddened sclera,
lesions or nodules
Inspect & palpate the
lacrimal gland and
naso lacrimal duct
No edema & tearing Increased tearing
Perform corneal
sensitivity test
Client blinks
(trigeminal intact)
One or both lids fail
to respond
Inspect the pupils for
color, shape &
symmetry of shape.
Black in color, equal
in size, normally 3-
7mm In diameter,
round smooth border
Cloudiness, bulging of
iris towards cornea.

41. Assess for each pupils
direct and consensual
reaction to light
Illuminated pupil
constricts ( direct
response)
Either
constricts/unequal
responses.
Assess each pupils
reaction to
accommodation
Pupils constricts when
looking at near objects
& dilate when looking
at far object.
One/ both pupils fail
to constrict/ dilate.

42. VISUAL ACUITY: the ability to see the small
details
• Assessment of near vision: Ask the patient to
read printed material under good lighting.
• Assessment of distant vision: use of snellen
chart. Ask the patient to sit or stand 20feet from
the chart, cover the eye not being tested and
identify the letters on the chart.

44. Assessing the pupil reaction
• Partially darken the room
• Look straight ahead
• Using penlight from the side, shine a light
on the pupil
• Observe response & do on the other eye
Normally pupil constrict in the presence
of light source and dilates when the light
source is moved away.

45. Extra ocular movements
• Make the patient to sit 2feet away from the
nurse.
• Hold a finger about 30 cm away from the patient.
• The client keeps the head fixed and follows the
movement of the nurse’s finger with only the
eyes.

47. Visual Field
• Patient sits 60cm away from the nurse, facing
the nurse at the eye level.
• Patient covers one eye
• Nurse closes the opposite eye.
• Nurse moves a finger equidistant from the
nurse and the client out side the field of vision
and slowly brings it back to the visual field.
• The patient is asked to say when the finger is
seen.

48. Internal eye structures
Ophthalmoscope is used to
inspect the internal eye
structures.

49. EAR

50. Auricle :
• Inspect the auricle’s size, shape , symmetry,
position and color.
• Palpate the auricle for texture , tenderness, and
skin lesions.
• Inspect the opening of the ear canal for size and
discharges

51. Hearing acuity
• Ask the patient to remove the hearing aids if
any.
• Note the clients response to questions.
• If hearing los is suspected check the clients
response to whispered voices.

52. Tuning fork test
• Weber’s Test
• Rinne Test

53. Weber’s Test : (Lateralization of sound)
Steps
• Hold the tuning fork at the
base and tap it against the
heal of the palm
• Place the base of the fork on
the middle of the clients
forehead.
• Ask the patient weather the
sound is heard equally in both
ears or better in one ear.
Rationale
• Patient with normal hearing
hears sound equally in both
rears. In conduction
deafness sound is heard
best in impaired ear.

54. Rinne Test
Steps
• Place stem of vibrating tuning
fork against mastoid process
• Count the time
• Ask the patient when the
sound is no longer heard.
• Quickly place the fork against
the ear canal. Ask the patient
to say when the sound is no
longer heard
• Compare the time the sound
is heard by bone conduction
versus air conduction
Rationale
• Air conducted sound should
be heard twice as long as
bone conducted sound.

55. Inspecting the ears with otoscope
• Attach the speculum to the otoscope
• Tilt the clients head away from you, & straighten the
ear canal by pulling the pinna up & back
• Hold the otoscope
- either right side up, with your fingers between the
otoscope handle and the client’s head.
- Upside down, with your fingers & the ulnar surface
of 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.

56. Assess the
tympanic
membrane for
color & gloss
Pearly gray color, semi
transparent
Pink to red, some
opacity, yellow-amber,
white, blue or deep red
& dull surface

57. Assessment of Nose

58. Inspect the external
nose for any
deviations in shape,
size /color & flaring /
discharge from the
nares.
Symmetric &
straight
Asymmetric
Light palpate
external nose for
areas of tenderness
Not tender: no
lesions
Tenderness &
presence of lesions

59. Determine
Patency of both
nasal cavity
Air moves freely as
the client breaths
through the nares
Air movement is
restricted
Inspect the nasal cavity with the speculum
Observe the
presence of
redness, swelling,
growths &
discharge.
Pink, clear, watery
discharge
Mucosa red,
edematous,
abnormal
discharge, septum
deviated to right /
Left.

60. Inspect the nasal
septum B/n nasal
chambers
Nasal septum is
intact & in midline
Septum deviation
to R/L
Facial sinuses
Palpate the
maxillary & frontal
sinuses for
tenderness
Not tender Tenderness on
one more sinuses
Document deviations

62. Assessment of Neck

63. Includes:
– the muscles,
-lymph nodes,
-trachea,
-thyroid gland,
-carotid arteries and jugular veins

64. • The areas of the neck are defined by sterno-
cleidomastoid muscles. Which divide the each
side of the neck into two triangles.
The anterior and posterior
• The anterior triangle - Trachea, thyroid
gland, anterior cervical nodes, & carotid artery
• The posterior triangle – posterior lymph nodes

65. Procedure
• Explain the procedure
• Wash hands and observe infection control
procedure
• Provide for client privacy
• Inquire if the client has any h/o following:
- any problems,
-neck pain or stiffness,
-how & when any lumps occurred,
-any previous diagnosis of thyroid
problems,
-any other treatments

66. Inspect the SCM
muscle
Equal in size,
head centered
Unilateral neck
swelling, head
tilted, lumps,
injury shortening
of muscles.
Observe head
movement
Head - chin
Head back
Head – shoulders
Head – right &
left
Co coordinated
smooth
movements
with no
discomfort
Parkinson's
disease

67. Assess muscle strength
• Ask the client to turn the head to one side
against the resistance of your hand - equal
strength
• Abnormality – unequal strength

68. Lymph nodes (how to palpate the neck lymph
node)
• Face the client, bend the client head forward
slightly/towards the side being examined to relax
the soft muscles.
• Move the finger tips in gentle rotating motion
• When palpating the supraclavicular node,
• Bend the head forward hook your index & 3rd
finger over the clavicle lateral to the sternicleido
mastoid muscles.

69. • When palpating the anterior cervical node & post.
Cervical node, move your fingertips slowly in a
forward circular motion against the sternocleido
mastoid muscles respectively

70. Palpate the trachea
for lateral
deviation
Central placement
in midline of the
neck , spaces are
equal on the both
sides.
•Deviation to one
side
• thyroid
enlargement
• enlargement of
nodes.

71. Thyroid gland

72. Palpating the thyroid gland
• 2 approaches
• Posterior approach
• Place hand over the neck , lower half of the neck
over the trachea.
• Ask the client to swallow & feel for any
enlargement of the thyroid
• Examine on the right side & left side lobes

73. • Anterior approach
– Place the tips of index & middle fingers over the
trachea & palpate the thyroid isthmus
– To palpate right thyroid client turns to the chin on
right to feel for right lobe
– To palpate left thyroid client turns to the chin on
left to feel for left lobe
If enlargement of the gland is suspected auscultate
over the thyroid area for a bruit

74. Thorax and lungs

75. Land marks
• Adult thorax is oval
• Mid sternal line- vertical line running through
the centre of the sternum
• Mid clavicular lines
• Anterior axillary lines - axillary fold
• Posterior axillary line
• Mid axillary line – apex of the axilla

76. Anterior axillary
line
Midsternal line

77. Posterior thorax
Inspect the shape
& symmetry of
the thorax from
posterior to
lateral
AP diameter is
half of the
transverse
diameter
Barrel chest,
pigeon chest,
funnel chest
Inspect for the
spinal alignment
Straight, right &
left shoulders are
at same height.
Spinal column
deviations

78. Palpation of post. thorax
Assess for
temperature and
integrity of chest
skin
Intact & uniform
temperature
Skin lesions.
Areas of
hyperthermia
Palpate for
bulges,
tenderness,
masses
No tenderness or
masses
Lumps, bulges,
depressions, areas
of tenderness

79. Palpate for respiratory excursion
• Place hands on lower thorax thumbs adjacent to
spine & fingers stretched laterally
• Ask the client take deep breath
• Full & symmetric expansion
• Normally thumbs separate 3-5cm(11/2 -2in.)

80. Palpate the chest for fremitus
• Fremitus is a faintly perceptible vibration felt through
the chest wall when the client speaks (1,2,3,or 99 or
blue moon etc)
• Fremitus is tested both anteriorly and posteriorly
• Bilaterally symmetric
• Increased – pnemothorax
• Decreased – consolidation, pneumonia etc

82. Steps
• Bend the head &fold the arms forward across
the chest.
• Percuss in the ICS over the symmetrical areas of
the lungs moving side to side.
• Starting posteriorly and then moving laterally
and anteriorly
• Compare one side of the lung with the other.

85. Percussion notes
• Resonance : Air filled lungs
• Dull : Lung mass
• Flat : Scapula, ribs, spine

86. • Detects the movement of air through the
tracheobronchial tree and detect mucus and
obstructed airways.

87. Normal breath sounds
Type Location Description characteristics
Vesicular Over
peripheral lung,
best at base of
the lung
Soft intensity –
air moving
Heard On
inspiration
Broncho -
vesicular
Between the
scapula &lateral
to the sternum
&1st & 2nd ICS
Moderate
intensity
Equal
inspiratory &
expiratory
phases.
Bronchial
(tubular)
Anteriorly over
the trachea
High pitched,
loud, harsh
sound created
by air
Louder than
vesicular
sounds

88. Abnormal (adventitious breath sounds)
Name description Cause Location
Crackles
(rales)
Best heard on
inspiration
Air passing through
fluid or mucus
Base of lower
lung
Gurgles
(rhonchi)
Best heard on
expiration
Air passing through
narrow air passage
due to secretions,
swelling, tumors.
Predominate
over trachea &
bronchi
Friction rub Superficial
grating or
creaking
sounds
Rubbing together
of inflamed pleural
spaces.
Lower anterior
& posterior
chest.

89. Name description Cause Location
wheeze Continuous, high
pitched, squeaky
musical sounds
best heard on
expiration.
Air passing
through
constricted
bronchus as a
result of
secretions,
swellings &
tumors.
Heard over all
lung fields

90. Assessment of CVS

91. Locating landmarks in precordium
Locate the angle of loius
• Right 2nd ICS near sternum- aortic area
• Left 2nd ICS near sternum - pulmonic area
• Left 5th ICS close to sternum- tricuspid area
• Left 5th ICS midclavicular line - apical / mitral
area
• Left 3rd ICS near sternum – Erb’s point

93. Auscultation
• S1 usually heard at all sites & usually louder at
apical area (closure of AV Valves)
• S2 usually heard at all sites & usually louder at
base of the heart (closure of semi lunar valves)

94. Vascular system

95. Carotid arteries
Palpate the carotid
artery
Symmetric pulse ,
volume and
Quality remains
same with all
activity
Assymetric
volume, decreased
pulsations,
Auscultate the
carotid artery for
Bruit
No sound heard Presence of bruit
indicate
obstruction

96. Jugular veins
jugular venous pressure (JVP)
Blood pressure in the jugular vein, which reflects
the blood volume and pressure in the right side of
the heart.

97. Procedure
• Have the client lie supine with the head elevated
30-45 degrees
• Use two rulers. Line up the bottom edge of a
regular ruler with the top of the area of pulsation
in the jugular vein. Take a centimeter ruler and
align it perpendicular to the first ruler at the level
of the sternal angle. Measure in centimeters the
distance between the ruler and the sternal angle.
• Bilateral pressure higher than 2.5cm are
considered elevated.

99. Peripheral vessel
Palpate for the
peripheral pulses
on both sides of
the body
Symmetric pulse
volumes
Full pulsations
Asymmetric,
absence, weak
thready pulse
inspect the
peripheral veins
for phlebitis
Limbs not tender Tenderness on
palpation, pain,
warm & redness.

100. Allen’s test
Done to assess the collateral circulation of the
upper extremities.
The client makes a fist as the ulnar and radial
arteries are compressed simultaneously.
The client then opens the hand and the nurse
releases the ulnar artery. The hand should
quickly turn pink if the ulnar artery is patent.
The test may be repeated by releasing only the
radial artery.

101. Gastrointestinal system

102. Abdominal cavity

103. • The abdomen is roughly divided into four quadrants:
right upper, right lower, left upper and left lower.

104. Inspect-color,
texture &
integrity
Uniform color, silver
white striae / surgical
scars
Tense, glittering
skin,
Inspect for
shape &
symmetry
Flat, round /scaphoid distended
Ask to deep
breath &hold
No evidence of
enlargement of organs
Hepatomegaly/
spleenomegaly
If distension present measure the girth at the level of
umbilicus

105. Observe for
abdominal
movements
associated with
respiration,
peristalsis/aortic
pulsation
-symmetric
movement.
- visible peristalsis
& aortic pulsation
in lean people
Limited
peristalsis, visible
pulsation, dilated
veins, marked
aortic pulsation
etc

106. Auscultation of the abdomen
• Warm hands
Bowel sounds
• Auscultate with diaphragm
• Ask when did they eat
• Place the diaphragm at all 4 quadrants
• Listen for active bowel sounds- irregular gurgling
sounds occurring every 5 to 20 secs.

107. Percussion of the abdomen
Percuss the 4
quadrants to
determine the
presence of
tymphany
Tympany over the
stomach & gas
filled intestine,
dullness over the
liver, spleen & full
bladder
Large dull area
indicate presence
of tumor or fluid
Percuss the liver to
determine its size
6 – 12 cm in the
mid clavicular line
4-8 cm in the
midsternal line
Enlarged size

108. Palpation of the abdomen
Perform light
palpation to determine
areas of tenderness
No tenderness relaxed
abdomen with
smooth, consistent
tension.
Perform deep
palpation
Tenderness may be
present over xiphoid
process, cecum, &
sigmoid colon

109. Assessment of
Reproductive system

110. Female reproductive system
• Assessment of breast
• Assessment of inguinal lymph nodes
• External genitalia

111. PUBIC HAIR
Inspect the distribution,
amount, & characteristics
of pubic hair
Inverse Triangular,
Inspect the pubic area for
parasites, inflammation,
swelling & leisons
Skin of valva is slightly
darker than the body

112. Observe in the mirror for shape and symmetry
Breast examination

114. Vertical strips pattern

115. Concentric circles

116. Hands –of- the -clock

117. Assessment of
Male reproductive
System

118. Organs include
•Penis
•Scrotum & testis
•Prostate gland

119. PUBIC HAIR
Inspect the distribution,
amount, & characteristics of
pubic hair
Triangular, often spreading
up to abdomen
Penis
Inspect the penile shaft &
glans penis for leisons,
nodules, swelling &
inflammation
Penile skin intact, foreskin
easily retractable
- Smegma b/n the glans &
foreskin +
Inspect the urethral meatus
for swelling, inflammation,
& discharge
Pink & slit like appearance,
urethra positioned at tip of
the penis

120. Palpate the penis for
tenderness, thickening
& nodules
Smooth & semi firm
scrotum
Inspect the scroutum
for general size and
symmetry.
Size varies with
temperature, scrotum
generally asymmetric
bilaterally (left is lower)
Inguinal area
Inspect both inguinal
areas for bulges,
while the client is
standing
No swelling/ bulges

121. Palpating a hernia
• Have the client remain at rest
• Have the client hold the breath & bear down as
though having a bowel movement
• Bearing down makes the hernia more visible

122. ASSESSMENT OF
NEUROLOGICAL SYSTEM

123. NEUROLOGICAL SYSTEM
• Takes 2-3 Hrs.
• It includes –
1. Mental status including
consciousness
2. Motor function & sensory function
3. Reflexes
4. The cranial nerves

124. Terminologies
Mental status –
• reveals clients general function
• major areas of mental status include –
language, orientation, memory & attention span &
calculation.

125. Assessment of level of consciousness –Glasgow
coma scale
• Glasgow Coma Scale, a system for describing the
degree of loss of consciousness in the severely ill.
It is also used to predict the length and result of
coma, mostly in patients with head injuries.

126. Withdrawal
Flexed

127. The lower the score is, the more severe
the brain injury.
• Scores below 8 indicate a severe brain
injury
• Scores between 9 and 12 indicate a
moderate brain injury,
• Scores above 13 indicate a minor
brain injury.

128. Cerebellar function
a) Gait
b) Co-ordination
a. Romberg test
Ask the patient to stand, feet together with
eyes closed and arms at sides. Romberg-only
positive if loss of balance occurs.
b. FTN test
Ask the patient to alternately point from his or
her nose to the examiner’s finger. The
examiner will typically move his or her finger
to different locations.

129. c. Heel To Shin test
Ask the patient to run
the heel of one foot
along the shin of the
opposite leg. The
patient then does the
same procedure on the
opposite side

130. Sensory function:
• Superficial Touch: Touch the skin with your
fingertip, Have the patient point to the area
touched.
• Superficial pain: Alternating the point and hub
of a sterile needle, touch the patients skin is an
unpredictable pattern. Ask the patient to identify
the sensation as dull or sharp.
• Vibrations: Place the stem of a vibrating tuning
fork against several bony prominences.

131. • Temperature and deep pressure:
Only when superficial pain is not intact, the
temperature and deep pressure sensation tests
are performed. Roll test tubes of hot and cold
water alternatively in an unpredictable manner
to evaluate the temperature sensation.

132. • Cortical Sensory function: Cortical or
discriminatory sensory functions test the cognitive
ability to interpret sensation associated with co-
coordination abilities.
Stereognosis: Have the patient a familiar object to
identify by touch and manipulation. Inability to
recognize objects by touch suggests a parietal
lesion.
Graphesthesis: abilty to feel writing on the skin

133. Extinction phenomenon:
Simultaneously touch the cheek, hand or other area on
each side of the body with sterile needle. Ask the patient
to tell you how many stimuli there are and where they
are.
Point location - Touch an area on the patients skin and
withdraw the stimulus. Ask the patient to point to the
area touched

134. Reflexes: Superficial and Deep tendon Reflexes
• Superficial Reflexes:
With the patient supine, stroke each quadrant of the
abdomen with the end of a reflex hammer or tongue
blade edge. The upper abdominal reflexes are elicited by
stroking downward and toward the umbilicus and lower
abdominal reflexes are elicited by stroking downward
away from the umbilicus toward each area of stimulation
should be bilaterally equal.

135. • deep tendon reflex (DTR), a quick
contraction of a muscle when its tendon is
sharply tapped by a finger or rubber
hammer. Absence of the reflex may be
caused by damage to the muscle, the
nerve, nerve roots, or the spinal cord. A
violent reflex may be caused by disease of
the nervous system or by overactive
thyroid gland.

136. Deep tendon Reflexes:
1. Biceps reflex
2. Brachioradial reflex
3. Triceps reflex
4. Patellar reflex
6. Achilles reflex
7. Plantar reflex

137. 1. Biceps reflex: Flex the patient's arms up to 45
degrees at elbow. Palpate the biceps tendons in
the antecubital fossa. Place your thumb over the
tendon. Strike your thumb, rather than tendon
directly with reflex hammer. Contraction of biceps
causes palpable flexion of the elbow.

139. Brachioradial reflex: Flex
the patient’s arm up to
45 degrees and rest his
or her forearm on
your arm and hand
slightly pronated.
Strike the
brachioradials tendon
directly with the reflex
hammer. Pronation of
forearm and flexion of
the elbow should
occur.

140. • Triceps reflex: Flex the
patient’s arm at elbow up to
90 degrees and rest the
patient’s hand against side
of the body. Palpate the
triceps tendon strike it
directly visible or palpable
extension of elbow should
occur.

141. • Achilles reflex: With the
patient sitting, flex the knee
and dorsiflex the angle upto 90
degrees holding the heel of the
foot in your hand. Striking the
tendon may cause contraction
of the gastrocnemus muscle
and plantar flexion of the foot.

142. Plantar reflex: Using a
pointed object, stroke the
lateral side of the foot
from heel to the ball, then
curve across the ball of
the foot to medial side.
Observe for plantar
flexion, fannings of the
toes or dorsiflexion of
great toe with or without
fanning of other toes.

143. • Patellar reflex

144. Assessment of cranial nerves

145. Cranial Nerve Function Method
I Olfactory Smell reception and
interpretation
Ask client to close eyes and
identify different mild aromas such
alcohol, powder and vinegar.
II Optic Visual acuity and fields Ask client to read newsprint and
determine objects about 20 ft. away
III Oculomotor Extraocular eye
movements, lid elevation,
papillary constrictions
lens shape
Assess ocular movements and
pupil reaction
IV Trochlear Downward and inward
eye movement
Ask client to move eyeballs
obliquely

146. V Trigeminal Sensation of face, scalp, cornea,
and oral and nasal mucous
membranes. Chewing
movements of the jaw
Elicit blink reflex by lightly touching
lateral sclera; to test sensation, wipe a
wisp of cotton over client’s forehead
for light sensation and use alternating
blunt and sharp ends of safety pin to
test deep sensation
Ask client to clench teeth
VI Abducens Lateral eye movement Ask client to move eyeball laterally
VII Facial Taste on anterior 2/3 of the
tongue
Facial movement, eye closure,
speech
Ask client to do different facial
expressions such as smiling, frowning
and raising of eyebrows; ask client to
identify various tastes placed on the
tip and sides of the mouth: sugar, salt
and coffee
VIII Acoustic Hearing and balance Assess client’s ability to hear loud and
soft spoken words; do the watch tick
test

147. IX Glossopharyngeal Taste on posterior 1/3 of
tongue, gag reflex, sensation
from the eardrum and ear
canal.
Swallowing and phonation
muscles of the pharynx
Apply taste on posterior tongue for
identification (sugar, salt and coffee);
ask client to move tongue from side
to side and up and down; ask client to
swallow and elicit gag reflex through
sticking a clean tongue depressor into
client’s mouth
X Vagus Sensation from pharynx,
viscera, carotid body and
carotid sinus
Ask client to swallow; assess client’s
speech for hoarseness
XI Spinal accessory Trapezius and
sternocledomastoid muscle
movement
Ask client to shrug shoulders and turn
head from side to side against
resistance from nurse’s hands
XII Hypoglossal Tongue movement for
speech, sound articulation
and swallowing
Ask client to protrude tongue at
midline, then move it side to side

148. MUSCULOSKELETAL SYSTEM

149. MUSCLES
1. Inspect the Muscles for size. Compare the muscles on one side of
the body to the same muscle on the other side. For any
discrepancy, measure the muscles with tape.
2. Inspect the muscles and tendons for contractures and shortening
3. Inspect the muscles for tremors.

150. 4. Inspect any tremors of the hands and arms
by having the client hold the arms out in
front of the body
5. Palpate muscles at rest to determine muscle
tonicity (the normal condition of tension, or
tones of a muscle at rest).

151. Muscle strength scale
0- No detection of muscular contraction
1- A barely detectable flicker or trace of contraction with
observation or palpation.
2- Active movement of body part with elimination of
gravity.
3- Active movement against gravity only and not against
resistance
4- Active movement against gravity & some resistance
5- Active movement against full resistance without
evident fatigue (Normal muscle strength)

152. Maneuvers to assess muscle strength
Neck:
Sternocleidomastoid- place hand firmly against
upper jaw. Ask patient to turn head against
resistance
Shoulder:
Trapezius- Exert mild pressure over patient’s
shoulder. Have patient raise shoulders against
resistance

153. Elbow:
Biceps- pull down forearm as patient
attempts to flex arm
Triceps- apply pressure against flexed arm
as patient try to straighten the arm
Hip:
Quadriceps- while sitting apply pressure over the
thigh, ask the patient to lift the leg
Gastrocnemius- Hold shin of flexed leg ,ask
patient to straighten the leg

154. Deviations from Normal
• Atrophy (a decrease in size) or hypertrophy (an
increase in size).
• Malposition of body part, e.g., foot drop (foot
flexed downward).
• Presence of tremor.
• Atonics (lacking tone)
• Flaccidity (weakness and laxness) or spasticity
(sudden involuntary muscle contraction)
• 25% or less of normal strength

155. BONES
• Inspect the skeleton for normal
structure and deformities
• Palpate the bones to locate any areas
of edema or tenderness

156. JOINTS
• Inspect the joint for swelling, Palpate each joint
for tenderness, smoothness of
movement, swelling, crepitation, and presence
of nodules.
• Assess joints for range of motion.
– Ask the client to move selected body parts. The
amount of joint movements can be measured by a
goniometer, a device that measures the angle of
joint in degrees.

158. Specific joints
1. Temporo-mandibular
joints
2. Cervical spine
3. Thoracic & lumbar
spine
4. Shoulders
5. Elbows
6. Hands and wrists
7. Hips
8. Knees
9. Feet & ankles

159. Temporomandibular
joints
• Open & close the
mouth
• Move the lower jaw to
each side (1-2cm)
• Protrude & extract
chin
• Strength of
temporalis muscle
checked by asking to
clench the teeth

160. Cervical spine
• Position, alignment of
head, symmetry of
skin folds & muscles
• Cervical & lumbar
spine should be
concave
• Flexion & extension at
450
• Lateral bending at 40
degrees

161. Thoracic & lumbar spine
• Thoracic spine should be
convex
• Bend forward & try to
touch the toes flexion of
the 75 – 900
• Expect lateral bending of
350
• Swing the waist in a
circular motion

162. Shoulders
• Inspect symmetry & contour
of shoulder
• Palpate the joints & groves
• Examine following ROM
– Raise both arms forward
& straight up
– Stretch both arms behind
back
– Adduction, Internal
rotation, & external
rotation

163. Elbows
• Bend and straighten
the elbows
• Flexion at 1600
• Full extension at 1800

164. Hand & wrist
• Inspect the dorsal & palmer
aspects of the hands
• Identify deviations of fingers
• Examine ROM of Hand &
wrist
- bend the fingers at metacarpals
- touch the thumb to each
fingertips
- bend the hand at wrist up &
down
- with the palm side down, turn
each hand right & left

165. HIPS
• Inspect the symmetry of the
iliac crest
• ROM
– Rise the leg with knee
Extended above the body
– Swing the straightened leg
either standing or prone
– Raise knee to the chest
while keeping other leg
straight
– Rotate inward and
outwardly

166. Knees
• Inspect the Popliteal
area
• Observe the lower
leg alignment
• Bend knees for
flexion1300
• Full extension

167. Feet & ankles
• Dorsiflexion of 200
• Bending the foot at the
ankle
• Rotating the ankle