NCM 101 – HEALTH ASSESSMENT

• 1. Nursing Process KSA – knowledge, skills, attitude

• 2. Health History
• 3. Physical Assessment Subjective data – elicit, verified, clues, information.
• 4. General Survey - Sensation, Feelings, Perceptions, Desires,
• 5. Integumentary Preferences, Beliefs, Ideas, Values, Personal Info
• 6. Head to Neck Assessment
• 7. Chest to Abdomen Assessment Purpose of Health Interview – get info, identify
• 8. Musculoskeletal Assessment problem, evaluate change, teach, provide support,
• 9. Laboratory and Diagnostic Test provide counselling.

1. NURSING PROCESS Types of Interview Approaches

-is a systemic, rational method of planning and providing 1. Directive Interview - highly structured info
individualized nursing care. - Emergency situation
-is cyclical. - Guided question
- Establish purpose
Nursing – protection, promotion, optimization etc. 2. Non-directive Interview - rapport-building
- Diagnosis and treatment of human response based - Allow client to control
on accurate client assessments. Rapport - understanding between two or more people
- The registered nurse collects comprehensive data
pertinent to the patient’s health or situation. Types of Interview Questions
1. Closed Questions – yes/no, short factual
ADPIE - When, where, who, what
Assessing - Collect, Organize, Validate, Document data - Needed quickly, emergency situation.
- Subjective – covert, verbal interview, Health hx, use 2. Open-Ended Questions – elaborated questions
11 Gordon’s Function - What or how
- Objective – overt, observable, measurable, vital - Non-directed interview
signs, Head – Toe Assessment (cephalocaudal) - Thoughts and feelings
- First/most critical - Gives clients freedom
Diagnosing – NANDA, analyze data, identify health 3. Neutral Questions – can answer without direction
problems, risks, strengths. - Open-ended, non-directive
- Formulate diagnostic statement. 4. Leading Questions – less opportunity
Planning – Goals, Short-Long term Objectives, prevent - Usually closed, directive
- Specific, Manageable, Attainable, Realistic, Time-
bound Planning the Interview Setting
Implementing – interventions, carrying out Time - physically comfortable, free of pain, schedule.
- Independent – “I” Place – well lighted, well ventilated, cannot overhear.
- Dependent – Doctor’s Seating Arrangement – client in bed, 45°
- Collaborative – other HC Team Distance – 2-3 feet, neither too close or too far
Evaluating - Goal Met or Goal Unmet Language – communicate, medical terminology
- Compare date, conclusion
- Reassessment if Unmet Stages of Interview
Opening – most important
Medial diagnosis ≠ Nursing diagnosis - Establish rapport - How Long
Nursing Care Plan – Blueprint (ADPIE) - Orientation - Greeting
- Purpose - Don’t overdo
Body – communicate what they think, feel, knows
2. HEALTH HISTORY - Effective development - comfortable
-consist of subjective data collected during interview Closing – terminate, maintaining rapport
-current state of health. Feeling - “Well,” - Thank you
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NCM 101 – HEALTH ASSESSMENT
- Plan for next - Summary 5. Family health history (Genogram)
Organizing Data 6. Review of systems for current health problems
- Uses written/electronic format 7. Lifestyle and practices profile (pattern of living)
- often referred as nursing health history, nursing 8. Developmental level
assessment, nursing database form.
- May be modified 3. PHYSICAL ASSESSMENT
- first step of Health Care Process
Conceptual Models/Frameworks - Inspection, Palpation, Percussion, Auscultation.
1. Gordon’s Functional Health Pattern Framework - thoughtfully integrated
2. Orem’s self-care model - unique situation
3. Roy’s adaptation model - fundamental skill

Marjorie Gordon (1931-2015) – proposed functional Vital Signs – cardinal signs, measurable signs of
health patterns as a guide etc. cardiopulmonary and thermoregulatory health status.
– a systematic and standardized approach to data Temperature – 98℉/37℃ normal
collection. - 36.5℃ hypothermia, 37.7℃ hyperthermia
Pulse Rate – 60-100bpm (Adult), 120-160bpm (Infant)
Gordon’s 11 Functional Health Pattern Respiratory Rate – 15-22cpm, 30-53cpm (Infant)
1. Health Perception and Management – describes Blood Pressure – 120/80mmHg
the client’s perceived health and well-being and Oxygen Saturation – 95-100%
how health is managed. Pain Scale – 0, Wong-Baker, COLDSPA
2. Nutritional and Metabolic – describes food and
fluid consumption relative to metabolic need. Physical Examination – a critical investigation and
3. Elimination – describes pattern of excretory evaluation of client status.
function. Stool and urine. - Obtain physical data
4. Activity and Exercise – describes activity level, - Health history
exercise program, leisure activities. - Establish diagnosis
5. Sleep and Rest – describes pattern of sleep, rest, - Physiological outcome
relaxation. - Clinical judgement
6. Cognitive/Perceptual – ability too understand and
follow directions, retain info, make decision. Five Key Components
senses. - Health Interview
7. Self-perception and Self-concept – describes - Physical Examination
client’s self-worth, comfort, body image, feeling - Laboratory or Diagnostic Examination
state. - Records Review
8. Roles and Relationship – History (subjective
data), family, social groups, work, school. A systematic way of collecting objective data from a
9. Sexuality and Reproduction – sexual client using the four examination techniques, to assess
relationship, contraceptives, Last Menstrual or identify current health status.
Period.
10. Coping and Stress Tolerance – changes in life, Different Approaches:
tense, medication. - Cephalocaudal
11. Patterns and Belief – describes pattern of values, - Proximodistal
beliefs, goals. - Mediolateral
- Outer to Inner
8 Sections of a Complete Health History - External to Internal
1. Biographic data
2. Reason for seeking health care (chief complaint) With children, always proceed from least invasive to
3. History of present health concern more invasive
4. Past health history
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NCM 101 – HEALTH ASSESSMENT

Preparing the Patient for Physical Assessment Types of Sound

- Consider physiological and psychological needs Flat – soft, thigh area
- Explain the process Dull – medium, liver
- Explain the PA will not be painful/free of pain Resonance – loud, normal lung
- Ask to change gown and empty bladder Hyperresonance – very loud, emphysematous lung
- Answer patient questions directly and honestly Tympany – loud, puffed-out cheek

Preparing the Environment for Physical Assessment Auscultation – sound

- Agree upon time - Pitch – high to low
- Time should not interfere meals - Loudness – soft to loud
- Patient should be free of pain - Quality – gurgling or swishing
- Prepare exam table - Duration – short, medium, long
- Provide gown
- Gather supplies and instruments Diaphragm – detect high pitch sound
- Provide curtain or screen Bell – detect low pitch sound

Preparatory Phase 4. GENERAL SURVEY

- Introduce yourself to patient - overall review
- Help put clean gown, offer bedpan - general
- Unsure privacy - head-toe, cephalocaudal, lateral, proximodistal, front to
- Invite relative or SO back
- Provide adequate lighting
- Gather equipment General Survey – observation of client’s general
- Ensure exam table, perform hand hygiene appearance, gait, body fluid, speech, hygiene, vital signs.

Standing = height and weight, posture, gait, balance Assessing Appearance and Mental Status – a general
Sitting = thorax survey may provide information about client’s current
Supine = posterior thorax, spine health state.
Dorsal recumbent = abdominal palpation
Sim’s/Lateral = rectal area, p. thorax General Appearance and Behavior – begins while
Prone = p. thorax nurse prepare client for examination.
Lithotomy = vaginal examination ▪ Gender and Race – gender affects the type of
Knee-chest = rectal area (brief periods) exam performed. Physical features.
▪ Age – influence normal physical characteristics.
Methods of Examination ▪ Signs of Distress – obvious signs of pain,
I.P.P.A. technique difficulty breathing, anxiety.
▪ Body Type – observes if client appears-
Inspection – visual - Excessively thin – Ectomorph
- Moisture, color, texture - Trim and muscular – Mesomorph
- Shape, position, size, color, symmetry - Obese – Endomorph
Palpation – touch ▪ Body Movement – whether movements are
- Palmar: texture, vibration, presence of fluid, size purposeful and note tremors. Determine if a body
- Dorsum: temperature part is immobile.
- Light Palpation – ½ inch, 1 hand ▪ Hygiene and Grooming – level of cleanliness,
- Deep Palpation – 1 inch (2cm), 2 hands hair, skin, and fingernails.
Percussion – striking ▪ Dress – culture, lifestyle, socioeconomic level,
- Direct Percussion: sharp rapid personal appearance. Appropriate for temperature
- Indirect Percussion: two hands and weather conditions.
Pleximeter: middle finger of nondominant hand
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NCM 101 – HEALTH ASSESSMENT
▪ Body Odor – unpleasant body odor from physical Document findings in the client record.
exercise, poor hygiene, certain disease state, poor
oral hygiene. EVALUATION
▪ Affect and Mood – person’s feelings as they Performance
appear to others. Emotional state expressed - Perform a detailed follow-up examination based on
verbally or nonverbally. findings.
▪ Speech – understandable and moderate. Note if - Relate finding to previous assessment.
talks rapidly and slowly. - Report significant deviation.

Equipment – tape measure, height chart, weighing 5. INTEGUMENTARY

scale. - Inspection and Palpation
- may use olfactory sense to detect unusual skin color.
IMPLEMENTATION Skinfolds or axillae
Performance - Pungent body odor relates to poor hygiene,
- Introduce yourself, verify client’s identity. hyperhidrosis (excessive perspiration, pasma),
- Explain the process. bromhidrosis (foul-smelling perspiration)
- Perform hand hygiene.
- Provide privacy. Skin – largest organ
- Physical barrier that protects
Assessing Appearance and Mental Status - Vital role in temperature maintenance, fluid
Observe signs of distress in posture, facial expression. - Provide identity
• No distress
o Bend over cause by abdominal pain, wincing, Assessing the Skin
frowning, labored breathing Inspect Skin Color
Observe body build etc., relates to lifestyle etc. • Light to deep brown, ruddy pink to light pink
• Proportionate, varies with lifestyle o Pallor, Cyanosis, Jaundice, Erythema
o Excessively thin or obese Pallor – decrease in color, lack of oxyhemoglobin,
Observe posture, gait, standing, sitting, walking. anemia, lack arterial perfusion, fingernails, lips,
• Relaxed, coordinated movement oral mucosa, dark skinned in palms/soles
o Tensed, slouched, bent, tremors, dirty, unkept. Cyanosis – bluish, peripheral cyanosis, central
Observe overall hygiene, relate to activities prior. cyanosis
• Clean, neat Jaundice – Icterus, yellowish, sclera, mucous
o Dirt, unkept membranes, excretions
Note body, breath odor and relates to activity level. Erythema – redness due to congestion capillaries
• No odor, minor odor relative to work
o Foul body odor, ammonia odor (dehydration, UTI), Ecchymosis – collection of blood causing purplish
acetone breath odor (ketones, diabetic), foul breath discoloration.
Note signs of health/illness. Petechiae – small hemorrhagic spots caused by
• Healthy appearance capillary bleeding.
o Pallor, weakness, obvious illness Inspect Uniformity of Skin Color
Assess attitude. • Generally uniform
• Cooperative o Hyperpigmentation (Melasma), Hypopigmentation
o Negative, hostile, withdrawn (Vitiligo)
Note affect/mood, appropriate client’s responses Assess Edema (palpate tibia, medial malleolus, dorsum)
• Appropriate to situation • No edema (less than 2 seconds normal)
o Inappropriate to situation o Edema (greater than 2 seconds)
Listen to quantity, quality, and organization speech. Inspect, palpate skin lesions (location, distribution,
• Understandable, moderate, thought association color, configuration, size, shape, type, structure)
o Illogical sequence, flight of ideas, confusion • Freckles, birthmarks, nevi, no abrasion
o Irregular, multicolored, raised nevi
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NCM 101 – HEALTH ASSESSMENT
Primary Skin Lesions Assessing the Hair
Macule, Patch – unelevated change in color. Ex: Hair – consists of layers of keratinized cells, found all
vitiligo, white patches, rubella except lips, nipples, sloes, palms, labia minora, penis.
Papule – circumscribed, solid elevation. Ex: warts, acne, - Develops within a sheath of epidermal cell (hair
pimple, elevated mole follicle).
Plaque – longer than 1cm. Ex: psoriasis - Hair growth at base follicle
Nodule, Tumor – elevated, solid, hard mass, larger than - Hair shaft is visible, hair root surrounds follicle
2cm. Ex: malignant melanoma, hemangioma - Erector pili (goosebump)
Pustule – Vesicle or bulla filled with pus. Ex: Acne - Kwashiorkor (protein deficiency)
Vulgaris, impetigo - Alopecia (hair loss)
Vesicle, Bulla – circumscribed, round or oval, thin - Hirsutism (too much hair)
translucent filled with fluid or blood. Ex: large blister, - Hypotrichosis (less hair)
2nd degree burn, herpes - Hypothyroidism can cause very thin hair
Cyst – 1cm or longer, semisolid. Ex: sebaceous, - Anhidrosis (unable to sweat)
chalazion
Wheal – reddened, localized collection of edema fluid. Skin Turgor – indicative of status of hydration. Done
Ex: hives, mosquito bites by pinching. Sternum, inner thigh, forehead.

Secondary Skin Lesions Inspect the evenness of growth over the scalp
Atrophy – translucent, dry, paper-like from thinning • Evenly distributed hair
skin loss of collagen and elastin. Pregnant. Ex: striae, o Patches of hair loss (alopecia)
aged skin
Erosion – wearing away superficial depression. Ex: Inspect hair thickness or thinness
scratch marks, ruptured vesicles • Thick hair
Lichenification – Rough, thickened, hardened area, o Very thin hair (hypothyroidism)
scratching or rubbing. Ex: chronic dermatitis Inspect hair texture and oiliness
Scales – shedding flakes of greasy keratinized skin. • Silky, resilient hair
White, grey, silver. Fine to thick. Ex: dry skin, dandruff, o Brittle hair, excessively oily or dry hair
psoriasis Note Presence of Infections or Infestations
Crust – dry blood, serum, pus. Ex: eczema, impetigo, • No infection of infestation
herpes, scabs o Flaking, sores, lice, nits, ringworms
Ulcer – bed sore, deep, irregular shaped area. May Inspect the Amount of Body Hair
bleed, leave scar. Ex: pressure and stasis ulcers, chancres • Variable
Fissure – Linear crack, sharp edges. Ex: crack corners, o Hirsutism in women
Athlete’s foot
Scar – flat, irregular area. Ex: injury, healed acne Assessing the Nails
Keloid – elevated, irregular, darkened area. African Nails – located on distal phalanges of fingers and toes,
descent. Ex: keloid from ear piercing, surgery are hard, transparent plates
Excoriation – chemical burns - Nail body extends over entire nail bed
- Lunula crescent-shaped area
Observe and palpate skin moisture - Nails protect the distal ends, enhance movement
• Moisture in skin folds
o Excessive moisture or dryness Inspect the Fingernail Plate Shape
Palpate skin temperature • Convex curvature: angle is 160°
• Within normal range o Less: spoon shaped. More: Clubbing
o Generalized/localized hyperthermia/hypothermia Normal nail - 160°
Note skin turgor by lifting and pinching the skin Spoon-shaped nail – iron deficiency anemia
• Skin springs back to previous state Early clubbing – flattened angle (180°)
o Skin stays pinched Late Clubbing – may caused by long term oxygen lack
Beau’s line – severe injury or illness
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NCM 101 – HEALTH ASSESSMENT
Inspect movement of the neck structures – swallow
Inspect fingernail and toenail Bed Color water
• Highly vascular and pink • move upward symmetrically
o Bluish or purplish, pallor o asymmetric movement
Palpate fingernail and toenail Texture Inspect the cervical vertebrae – flex the neck (chin-
• Smooth texture chest)
o Excessive thickness or thinness, Beau’s line • C7 (vertebrae prominence) usually visible
Inspect Tissues Surrounding nails (C1 atlas, C2 axis)
• Intact epidermis o Prominence or swelling
o Hangnails, paronychia (infection of skin around Inspect range of motion – turn head right to left
nails), koilonychia (soft nails) • 45° flexion, 55° extension, 40° lateral abduction,
Perform Blanch Test of capillary refill – press two 70° rotation.
nails between thumb and index finger, look for o Muscle spasms, inflammation, cervical arthritis
blanching and return of pink color to nail bed Palpate the Trachea – place finger sternal notch, first
• Return or pink or usual color within 2 seconds upper is cricoid cartilage
o Delayed return • Trachea is midline
o Trachea may be pulled side.
6. HEAD TO NECK ASSESSMENT large atelectasis - complete or partial collapse
- cranium, face, thyroid gland, lymph nodes, sensory fibrosis or pleural adhesions – damaged/scarred
glands. aortic aneurism – balloon-like bulge
Palpate the thyroid gland
Head and Face Assessment • Glandular thyroid tissue may be felt rising
Inspect the Head – size, shape, configuration o deviated from midline due to abnormal growths
• Normocephalic (normal) Auscultate the thyroid only of you find enlarged
o microcephaly (small), acromegaly (large), Acorn- thyroid gland
shaped • no bruits
Inspect for involuntary movement o soft, blowing, swishing sound, hyperthyroidism
• still and upright Palpate the lymph nodes
o neurologic disorders, horizontal jerking movement. • no swelling
Nodding. Tremor “Tourette Syndrome” o enlarged nodes
Inspect the face – symmetry, features, movement
• symmetric, no abnormal movements Cushing syndrome – moon-shaped face, reddened
o drooping, weakness, paralysis of one side “Bell’s cheeks, facial hair.
Palsy” Exophthalmos – “ptosis” – “Proptosis”– seen in
Palpate the head – consistency hyperthyroidism, bruit
• normally hard and smooth Goiter – diffuse enlargement of thyroid gland
o lesions and lumps, may indicate trauma/cancer Trachea – check in front
Palpate the temporal artery Thyroid gland – check in back
• elastic and not tender
o hard, thick, inflammation (temporal arteritis) Assessing the Eyes
Palpate the temporomandibular joint (TMJ) Eye – transmit visual stimuli to the brain for
• no swelling. Mouth 3-6cm. Lower Law 1-2cm interpretation.
o limited range of motion, TMJ syndrome Eye orbit – round, bony hallow, has a fat cushion
Lacrimal Apparatus - consists of tear glands and ducts.
Neck Assessment Extraocular muscles – control direction of eye
Inspect the neck – symmetry, lump/masses movement.
• symmetric, head centered Sclera – white
o swelling, enlarged masses/thyroid gland Iris – colored
inflammation of lymph nodes, tumor Pupil – black

6|Shane Kyle
NCM 101 – HEALTH ASSESSMENT
External Eye Structures Assessment
Tamad na ako
Entropion – inverted
Ectropion – everted
Blepharitis – redness and crusting, seborrhea. Caused
by S. aureus.
Hordeolum – stye, hair follicle infection
Chalazion – infection of Meibomian gland
Grave’s disease – a type of hyperthyroidism
Episcleritis – local, noninfectious inflammation of
20 feet – normal/standard sclera.
20/20 – vision
Visual Acuity – needed in Snellen Chart Cyanosis of lower lid suggests heart or lung disorder
Pupil is normally equal size (3-5mm)
Evaluating Vision
Test distant visual acuity – 20 feet from Snellen chart Anisocoria – unequal size of pupil
• 20/20 vision Mydriasis – dilated
o Myopia (impaired far vision). 20/200 legally blind Miosis – constricted
Test near visual acuity – Consensual response – light right eye, check left eye
Rosenbaum Chart(paragraph) Pupillary response – light right eye, check right eye
• 14/14 normal near visual acuity Phoria – mild weakness, noticeable only in cover test.
o Presbyopia (impaired near vision) Paralytic Strabismus – noticeable in positions test.
Test visual fields for gross peripheral vision – 2 feet
away, cover mirrored eye
(Visual fields- confrontation Test)
• Inferior: 70°
Superior: 50°
Temporal: 90°
Nasal: 60°
o Delayed or absent perception
Perform corneal light reflex test – pen light 12 ins
• Parallel alignment
o Asymmetric position
Perform cover test – focus on distant object, opaque
card
• Remain fix straight II, III, VI – eyesight
o Move to establish focus III, IV, VI – eye movement
Perform the positions test – six cardinal positions
-peripheral, eye movement Penlight – pupil gauge
• Smooth and symmetric Drooping – ptosis
o Nystagmus – an oscillating (shaking) movement of Bulging – proptosis
the eye

Pseudostrabismus – duling, inner canthus, normal in Corneal Scar – greyish white, old injury or
young children. inflammation.
Strabismus (Tropia) – constant malalignment of eye Nuclear cataract – appear grey with flashlight, black
axis, may cause amblyopia spot
Esotropia – inward Ear Pterygium – thickening of the bulbar conjunctiva.
Exotropia - outward Peripheral Cataract – grey spokes
Pupillary gauge – measuring pupil size
7|Shane Kyle
NCM 101 – HEALTH ASSESSMENT
Assessing Ears Assessing Nose
Ear – hearing and equilibrium. External ear, middle ear, Nose – first part of respiratory system.
inner ear. Note: color, shape, consistency, tenderness.
- Ear size, 4-10cm normally Receiving, filtering, warming, moistening air.
- Darwin’s tubercle – normal, projection Olfactory (I) – at nose, sense of smell.
Tympanic membrane – eardrum, separates external and Epistaxis – bleeding
middle. Deviated septum
3 Smallest bones Polyp (redness) lesions, ulcers
Malleus – Hammer Potency of air
Incus - Anvil symmetry
Stapes – Stirrup
Frostbite – pale blue ear color
Cerumen – earwax Assessing Mouth
Enlarged preauricular – infection Mouth – receiving food (ingestion), taste, aid speech.
Tophi – gout, nontender, hard, cream-colored, uric acid Trigeminal (V)
Postauricular cysts – blocked sebaceous glands Facial (VII)
Skin cancer – ulcerated, crusted nodules that bleed Glossopharyngeal (IX)
Otitis externa – redness, swelling, scaling, itching Hypoglossal (XII) – tongue strength
- Foul-smelling, yellow discharge Gums, uvula, tongue, tonsil, palate, frenulum
Otitis media – yellow
- Bloody, purulent discharge 32-28 teeth
Skull trauma – blood or watery drainage (cerebrospinal Bluish lips – hypoxia
fluid) refer to physician immediately. Reddish lips – ketoacidosis, carbon monoxide
Conductive hearing loss – impacted cerumen blocking poisoning, COPD.
view, poor area. Polyps may block the view Edema – allergy, anaphylactic reactions.
Sensorineural hearing loss – unaffected Leukoplakia – precancerous lesion
Exostoses – nonmalignant nodular swellings Pepto-Bismol – black, hairy tongue
Acute otitis media – red, bulging eardrum and distorted Canker sores – cancer patients
Serous otitis media – yellowish, bulging membrane, Kaposi’s sarcoma – AIDS
Bluish or dark red – blood behind eardrum Fruity/acetone breath – diabetic ketoacidosis
White spots – scarring from infection Ammonia breath – kidney disease
Perforations – trauma from infection Foul odor – respiratory infection, tooth decay
Prominent landmarks – eardrum retraction Fecal breath odor – bowel obstruction
Obscured/absent landmarks – eardrum thickening Sulfur odor – liver disease
Vagus (X) – uvula
Rene’s Test – AC > BC, compare air bone conduction, Tonsil – 1+ are visible
both lateral. 2+ midway
Romberg Test – 20 seconds 3+ touch uvula
Weber’s test – tuning test – evaluate conduction of ` 4+ touch each other
sound waves. 3/6 words Pharyngitis – bright red throat with white/yellow
3yrs old – pull pin down Tonsillectomy – removal of tonsil

a- absence tachy - fast

itis- inflammation bradi - slow
ectomy- removal
tomy- cut
rrophy- repair/suture
hypo-low
hyper- high

8|Shane Kyle
NCM 101 – HEALTH ASSESSMENT
7. CHEST TO ABDOMEN ASSESSMENT Normal Breath Sounds
Bronchovesicular – moderate
Assessing Thorax and Lungs Vesicular – low

Posterior Thorax Anterior Thorax

- Sitting - Supine

 Inspecting Posterior Thorax  Inspecting Anterior Thorax

Anteroposterior – 1:2 Pectus Excavatum – funnel chest, sunken sternum
Scoliosis – spinous process Pectus Carinatum – pigeon chest, forward protrusion
Barrel chest – 1:1, emphysema Normal – 10-2 bpm
COPD – tripod position Tachypnea – more than 24 bpm
Bradypnea – less than 10 bpm
 Palpating Posterior Thorax Hyperventilation – increased rate and depth, fear
Left Right Kussmaul – rapid, deep, labored
Hypoventilation – decreased rate, overdose
Crepitus – Crackling, subcutaneous emphysema Cheyne-Stokes – alternating periods, heart failure
Fremitus – “Ninety-nine”, vibration of air Biot’s – irregular pattern, meningitis
Diaphragmatic excursion – T9, T10, skin fold, Ataxic – significant disorganization
5-10 cm normal Air trapping – difficulty getting breath out
Resonance – normal lungs
Hyperresonance – emphysema/pneumothorax Accessory muscles – sternomastoid, rectus abdominis
Flat – scapula (bone) Neck muscles – sternomastoid, scalene, trapezius
Pneumothorax – decrease fremitus, air in pleural space
Atelectasis – collapse/incomplete expansion  Palpating Anterior Thorax
Left Right
 Percussing Posterior Thorax
32
1 4
56 Xiphoid process – outward

T7 – intercostal space, 7-8cm  Percussing Anterior Thorax

BV – bronchovesicular sounds Left Right
V – vesicular sound
Percuss the apices for tone
 Auscultating Posterior Thorax Dullness – breast, heart, liver
Left Right Tympany – stomach
Flatness – muscles, bones
Diaphragm in C7
Adventitious Sound – added/superimposed  Auscultating Anterior Thorax
Crackles – rales, discreet, discontinuous sounds Left Right
- Fine – high pitched, short
- Coarse – low pitched, bubbling Normal Breath Sounds
Wheezes – rhonchi, musical, continuous Bronchial – high
- Pleural – dry Bronchovesicular – moderate
- Sibilant – high pitched, musical Vesicular – low
- Sonorous – snoring, moaning
Assessing Breasts and Lymphatic
SBE – after PMS Breast – paired mammary gland
Bronchophony – “Ninety-nine” Female breast – accessory reproductive organ, produce
Egophony – E normal, A deviation milk, store milk, sexual stimulation
Whispered Pectoriloquy – one-two-three
9|Shane Kyle
NCM 101 – HEALTH ASSESSMENT
Tail of Spence – upper outer quadrant, most breast BSE
tumors - Lie down, right arm head
- Three middle finger, circular motion
- Use light, medium, firm pressure
- Up-and-down most effective
- Examine left breast
- In front of a mirror
- Both underarms

Assessing Heart and Neck Vessels

Cardiovascular system – high complex

Jugular veins visible supine

Carotid artery – place bell, hold breath, 2+ normal
Pulse Amplitude Scale
0 = Absent
1+ = Weak
Peau d’orange – pigskin-like, orange-peel, edema 2+ = Normal
Paget’s Disease – redness, scaling, flaking 3+ = Increased
Retracted nipple – malignancy 4+ = Bounding
Dimpling – gone, malignancy
Apical Pulse – nickel (1-2cm), baby (stethoscope)
Assessment for retraction/dimpling 60-100 bpm
a.) Raises hand
b.) Lowers and presses Aortic area – 2nd, based of heart, right
c.) Presses hand together Pulmonic area – 2nd and 3rd, left
Erb’s point – 3rd – 5th, left, usually
Bimanual technique – large breast Tricuspid area – 4th – 5th, boarder, left
Level of Pressure Mitral (Apical) – 5th, apex of heart, left
Light – superficial
Medium – mid level S1 – loudest at apex, lub
Firm – to the ribs S2 – loudest at based, dub
S3 – children, adolescent, young adult
*Circular or clockwise S4 – athletes, 40-50
*Wedge
*Vertical Strip Bruit – blowing, swishing
Hypovolemia – weak pulses
Ropy, lumpy, bumpy – nodular/glandular Atherosclerosis – loss of elasticity
Palpable nodes – less than 1cm Pulsations – heaves or lifts, enlarged ventricle
Lift – right ventricle, hypertrophy
Fibroadenomas – round, oval, mobile Thrill – second and third intercostal space
Milk cysts – sacs filled with milk Stridor – high pitch
Mastitis – infection Accentuated Apical Impulse – pressure overload
Lipomas – fatty tissue Laterally Displaced Apical Impulse – volume overload
Intraductal papilloma – small growth, ages 35-50 Split S2 – wide, fixed, reversed
S4-Ventricular Gallop – ischemic heart
Cancer Tumors – irregular, firm, hard S4-Atrial Gallop – precordium
Benign Breast Disease – fibrocystic breast disease Murmur – swishing sound
Acanthosis Nigricans – dark, velvety Physiologic murmur – increase blood flow, pregnancy
Gynecomastia – movable disc Mitral Stenosis - fast
10 | S h a n e K y l e
NCM 101 – HEALTH ASSESSMENT
Assessing Abdomen 5-30 minute – soft clicks and gurgles
IAPePa Hyperactive bowel sounds – rushing, tinkling
Hypoactive bowel sounds – diminished bowel motility.

Venous sound – no
Friction Rub – hepatic abscess or metastases
Pyelonephritis – kidney infection

12 rib – blunt percussion

Colycestitis –
Blumberg’s Sign – sharp, stabbing pain

8. MUSCULOSKELETAL ASSESSMENT
Grey-Turner – purple, flank
Ascites – significant abdominal swelling, liver failure Tremor – involuntary trembling.
Striae – stretch mark Intention Tremor – attempts voluntary movement,
Dark Bluish-Ink Striae – Cushing’s syndrome holding a cup of coffee.
Spider Angioma – liver disease Resting Tremor – rest and diminish.
Keloid – excess scar tissue Fasciculation – abnormal contraction
Cullen’s sign – purple, umbilical
0.5cm – contour of umbilicus Axial Skeleton – skull, ribs, vertebra
Scaphoid (sunken) – severe weight loss Appendicular Skeleton – limbs
Borborygmus – stomach growling
Bell – bruit artery (Renal Arterial Stenosis) Skeletal Muscle Movements
1-4cm – below costal margin Abduction: Moving away from midline
4-8cm – liver, midsternal Adduction: Moving toward midline
Aorta – 2.5-3cm wide Circumduction: Circular motion
Psoas Sign – RLQ, pain, sideline, leg Inversion: Moving inward
Rovsing’s Sign – RLQ, LLQ, pain, appendicitis Eversion: Moving outward
Obturator Sign – supine, leg Extension: straighten
Hypersensitivity test – cotton Hyperextension: bends greater than 180°
Flexion: bending, decrease
Flatus – gas/air, tympany Dorsiflexion: toes draw upward
Feces – dull Plantar flexion: toes point away
Pregnancy – tympany to dull Pronation: facing downward
Fat – tympany Supination: facing upward
Ascitic fluid – fluid in the abdomen Protraction: moving forward
Fibroids – large ovarian cyst Retraction: moving backward
Umbilical Hernia – weakness, umbilical ring Rotation: axis
Diastasis Recti – separation two rectus abdominis Internal Rotation: bone toward center
Epigastric Hernia – weakness, linea alba External Rotation: bone away center
Incisional Hernia – defect, surgical incision
Hepatomegaly – enlarge liver Understanding Major Joints
Enlarged Kidney – cyst, tumor, hydronephrosis Temporomandibular - Articulation between temporal
Aortic Aneurysm – prominent, laterally pulsating mass and mandible.
- Opens and closes mouth.
Murphy Sign – sharp pain - Projects and retracts jaw.
Spleen – 7cm - Moves jaw from side to side.
Bruit – bounding Sternoclavicular – Junction between the manubrium of
Peristaltic Wave – not seen, LUQ to RLQ sternum, clavicle.
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NCM 101 – HEALTH ASSESSMENT
Elbow – articulation between ulna and radius Grading Muscle Strength
- Flexion and extension of the forearm. 5 – 100%
- Supination and pronation of the forearm. 4 – 75%
Shoulder – articulation of head and humerus. Clavicle, 3 – 50%
acromion, subacromial, subscapular. 2 – 25% with support
- Flexion and extension 1 – 10% no movement
- Abduction and adduction 0 – 0% complete paralysis
- Circumduction
- Rotation (internal and external) Sternocleidomastoid – client turns the head to one side.
Wrist, Fingers, Thumb – articulation between distal Trapezius – client shrugs the shoulders.
radius, ulnar, carpals, metacarpals. Deltoid – client holds arm up.
- Wrists: Flexion, extension, hyperextension, Biceps – client fully extends each arm
adduction, radial/ulnar deviation Triceps – client flexes each arm
- Fingers: Flexion, extension, hyperextension, Wrist and Finger Muscles – client spread fingers
abduction, circumduction Grip Strength – client grasps your index finger
- Thumb: Flexion, extension, opposition Hip Muscles – client is supine, both legs extended,
Vertebrae (lateral view) - 33 bones. Bones are raises one leg.
cushioned by elastic fibrocartilaginous plates. Hip Abduction – client is supine, both legs extended,
7 cervical - flexion spread legs.
12 thoracic - hyperextension Hip Adduction – same as hip abduction, brings legs
5 lumbar - lateral bending together.
5 sacral - rotation Hamstrings – client is supine, both knees bent
3-4 coccygeal Quadriceps – client is supine, knee partly extended
Hip – articulation between head of femur and Muscles of the ankle and feet – dorsiflex and flex the
acetabulum. foot.
- Flexion with knee
- Extension and hyperextension Bones
- Circumduction No tenderness, swelling, misaligned
- Rotation (internal and external)
- Abduction Joints
- Adduction Goniometer – use to measure angle of joint
Knee – articulation of femur, tibia, patella. Contains
fibrocartilaginous discs, many bursae. Neck-Pivot Joint
- Flexion Flexion – chin to chest, 45°
- Extension Extension – upright, 0°
Ankle and Foot – articulation between talus, tibia, and Hyperextension – back, 55°
fibula. Heel (calcaneus bone) is connected to tibia/fibula. Lateral Flexion – laterally, right to left, 40°
- Ankle: plantar flexion and dorsiflexion Rotation – face right to left, 70°
- Foot: inversion and eversion
- Toes: flexion, extension, abduction, adduction Shoulder-Ball-and-Socket Joint
Flexion – each arm upward, 180°
Muscles Extension – resting position
Atrophy – decrease in size. Hyperextension – behind the body, 50°
Hypertrophy – increase in size. Abduction – above head, palm of hand away, 180°
Malposition – foot drop or foot flexed forward. Adduction – anterior, across front, 50°
Atonic – lacking tone Circumduction – full circle
Flaccidity – weakness or laxness External Rotation – move hand upward, 90°
Spasticity – sudden involuntary muscle contraction Internal Rotation – move hand forward then down, 90°

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NCM 101 – HEALTH ASSESSMENT
Elbow-Hinge Joint Trunk-Gliding Joint
Flexion – each lower arm forward and upward, 160° Flexion – bend the trunk
Extension – each lower arm forward and downward, 0° Extension – straighten the trunk
Rotation for Supination – palm facing upward, 90° Hyperflexion – bend trunk backward
Rotation for Pronation – palm facing downward, 90° Lateral Flexion – bend trunk right or left
Rotation – turn upper part of the body side to side
Wrist-Condyloid Joint
Flexion – finger, inner aspect, 90°
Extension – straighten hand, same plane as arm, 0° 9. LABORATORY AND DIAGNOSTIC TEST
Hyperextension – hand back as far as possible, 70° -commonly called laboratory test
Radial Flexion (abduction) – bend wrist, thumb -confirm diagnosis, monitor illness, client’s response to
Ulnar Flexion (adduction) – bend wrist, fifth finger treatment
Flexion – make a fist
Extension – straighten Traditional sites – hospitals, clinics, primary care
Hyperextension – back as far as possible provider’s office.
Abduction – spread fingers Moving to the community – home, workplace,
Adduction – bring fingers together shopping malls, mobile units.
Diagnostic Test Phases – pre-test, intratest, post-test.
Thumb-Saddle Joint
Flexion – thumb across palmar, fifth finger Preparing for Diagnostic Test
Extension – move thumb away from hand • Instruct procedure
Abduction – extend thumb laterally • Explain purpose
Adduction – move thumb back to hand • Instruct activity restrictions
Opposition – touch thumb to top each finger • Instruct reaction may produce
• Provide detailed information
Hip-Ball-and-Socket Joint • Inform time frame
Flexion – each leg forward and upward • Instruct to ask questions
Extension – each leg back inside
Hyperextension – each leg behind the body Blood Test
Abduction – each leg out to the side - Provide valuable information about hematologic
Adduction – each leg back together, beyond front system
Circumduction – circle Venipuncture – puncture of vein for collection of
Internal Rotation – foot and leg inward blood specimen.
External Rotation – foot and leg outward Phlebotomist – person from laboratory, collects blood
Complete Blood Count (CBC)
Knee-Hinge Joint - Includes hemoglobin and hematocrit, erythrocyte
Flexion – bring heel back of thigh count, leukocyte count, RBC indices, differential
Extension – straighten leg white cell count.
- Basic screening test, one of most frequent
Ankle-Hinge Joint
Extension (plantar flexion) – Point toes downward tamad na ako ilagay yung implications bahala na si
Flexion (dorsiflexion) – point toes upward Lorde

Foot-Gliding Serum Electrocytes

Eversion – turn sole laterally - Often routinely ordered, electrocyte and acid-base
Inversion – turn sole medially imbalances.
- Risk in community, diuretic for hypertension or
Toes heart failure.
Flexion – curl the toe - Sodium, potassium, chloride, bicarbonate ions.
Extension – straighten the toes
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NCM 101 – HEALTH ASSESSMENT
Normal Electrocyte Values for Adults Urinary pH – relative acidity or alkalinity. Normal
urine is slightly acidic, average pH of 6
Glucose – diabetes mellitus, pregnancy. Normally
negligible.
Protein – leaky, protein escape. Glomerulonephritis,
dipstick.

Visualization Procedures
Indirect visualization (non-invasive)
Direct visualization (invasive)

Electrocardiography
- Graphic record, heart’s electrical activity
Blood Chemistry - Electrodes places on skin
- Performed on blood serum - Electrocardiogram (ECG) detect dysrhythmias and
- Certain enzymes (LDH, CK, AST, ALT), serum alterations, myocardial damage, enlargement of
glucose, TH, cholesterol, triglycerides heart, drug effects.
- Provide valuable diagnostic cues. Stress Electrocardiography
- Cardiac markers (CPK-MB, myoglobin, troponin T - Uses ECG during exercise
and troponin I) are released into blood during - Coronary artery disease may develop chest pain
myocardial infarction or heart attack. Angiography
- Elevated levels help differentiate MI and chest - Invasive procedure requires informed consent
pain (angina or pleuritic pain). - Radiopaque dye
- Using fluoroscopy and x-rays
sa ppt ko nalang aralin yung Implications pagod na Computed Tomography (CT)
pagod na ako shutangina - CT scanning, computerized tomography,
computerized axial tomography (CAT), painless,
Specimen Collection and Testing noninvasive x-ray, density of tissues.
- Collecting specimens of body fluids - Three-dimensional image
- Clients have at least one laboratory specimen Magnetic Resonance Imaging (MRI)
collected during their stay - Visualization of brain, spine, limbs, joints, heart,
- Urine, blood, stool, sputum, wound drainage blood vessels, abdomen, pelvis.
provides important adjunct information - Lying down on platform, narrow, closed, high-
- Nurses often assume the responsibility magnet scanner, open, low-magnet scanner.
- Client must lie down very still
Stool Specimen - Provide client health condition - Earplugs to reduce discomfort
- Presence of occult(hidden) blood - 60-90mins
- Analyze dietary products
- Presence of ova and parasites
- Presence of bacteria and viruses

Urine Specimen – nurses are responsible for collecting

urine specimens
- Clean voided urine specimens for urine urinalysis
- Clean-catch or midstream for urine culture
- Time urine for specific health problem
- Via straight catheter insertion

Specific Gravity – urine concentration, amount of

solutes. Gravity ranges 1.010 to 1.025
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