11.02 Head to Toe Nursing Assessment (Physical Exam)
Begin your assessment of the skin by looking at the general color or pigmentation of the patient.
The patient’s color should be consistent with the genetic makeup of the patient, ranging from pink to dark brown. Darker-skinned people may have areas of lighter pigmentation.
Assess for freckles and birthmarks and use the ABCDE framework to determine abnormality of these markers.
Assess the patient’s skin color for any changes in color, also known as pallor, cyanosis, jaundice. Darker-skinned people may be more complicated to find these skin changes in them. The best place to look for these would be nail beds and lips.
Palpate the skin and assess the temperature. Hypothermia versus hyperthermia. As you feel the skin you should also assess for moisture or diaphoresis.
Assess the mucous membranes and for dehydration. The general texture of the skin should also be smooth and firm, thickness of the skin should be uniform throughout the body. The heels and palms may be a little bit thicker.
Assess the skin as well for edema, which would be fluid accumulation. You can assess for this by palpating on the skin and seeing if there’s an imprint left after you lift your hand up. This is known as pitting edema. It could be graded from a scale of +1 to + 4, with +4 being more severe. Edema can mask other more serious signs and symptoms.
Assess the mobility and turgor of the skin. This can be done by pinching the skin up in a fold, upon releasing the fold it should return back to its normal state.
Assess the skin for vascularity and for bruising or lesions. Document their size, color, elevation, general makeup, as well as the location, and make note of any exudate or odor coming from the lesion.
Inspection and Palpation
Inspect and palpate the scalp and hair. Assess for the color of the hair and scalp
Inspect and palpate the nails. Assess the shape of the nail as well as the color of the nail beds. They should be smooth, clean and round. Assess the surface of the nail to ensure that it is consistent throughout and that the thickness of the nails are uniform.
Lastly, assess for capillary refill. Press on the nail for a second or two upon removing pressure color should return to the nail bed within 1 to 2 seconds. That would be normal capillary refill.
Inspection and Palpation
When assessing the head, start with inspecting and palpating. Inspect the head for general symmetry and appropriate size for the body. The skull should fill symmetrical and smooth. There should be no tenderness on palpation.
Inspection and Palpation
Inspect the neck for symmetry and ensure that the neck is midline. Assess for neck range of motion, if the patient is able to point the chin down, lift the chin up, and turn from left to right, as well as the shoulders to the ear and extend the head backward. The motions should be smooth and well-controlled.
Palpate the temporal mandibular joint.
Palpate the lymph nodes. Use a gentle, circular motion to palpate the lymph nodes in front of the ear and within the neck.
Palpate the thyroid gland.
The eye is a sensory organ involved with sight. The eye is protected from external offenses like light or dust by the upper and lower eyelid. The small open space between eyelids is known as the palpebral fissure.
The outermost part of the eye is called the conjunctiva. It lines the inside of the eyelids and the sclera and merges with the cornea which is the outermost covering of the iris and pupil. Behind the cornea is the lens.
A part of the interior of the eye can be visualized with a ophthalmoscope. This area is called the ocular fundus. In this area the optic disc and macula can be seen.
The eye has three lays: sclera just under the conjunctiva, the choroid in the middle, and the retina on the inside. The retina is where light waves are converted into nerve impulses.
When assessing the eyes, inspect the pupils to insure they are equal, round, and reactive to light.
Test for visual acuity with the Snellen chart by having the patient stand 20 feet from the chart. Remove glasses or contact lenses and cover the untested eye.
You should test the visual field. Have the patient look in all directions as you move a pencil in those directions. Eye movement should be fluid and well-controlled.
Inspect extraocular muscle function with the 6 cardinal positions. Move your finger in the 6 positions and have the patient move their eyes in those 6 positions.
Use the confrontation test to assess visual field. Stand 2 feet away from the patient with a pencil in each hand on either side of the patient. While moving the pencils toward midline have the patient state when they are able to see them.
Assess eyebrows for symmetrical movement bilaterally.
Assess eyelids and lashes, notice any redness, swelling or discharge or lesions.
Assess the general shape of the eye. Inspect the eyeballs for any protrusion or sunken appearance.
Inspect the conjunctiva and the sclera. Ask the patient to look up and while using your thumbs to inspect the conjunctiva and sclera of the patient.
Inspect the interior eyeball structures. Shine a light from side to side and check for smoothness and clarity of the eye.
Inspect the iris and the pupils that the pupils are able to accommodate to light. You should determine that both pupils are equal bilaterally. If the patient has 2 different-sized pupils, this is known as anisocoria.
Inspect the ocular fundus by darkening the room and having the patient remove their glasses. Have the patient look at a specific mark with the eyes fixed while the examiner looks into the eyes to inspect the structures of the ocular fundus, specifically the optic disc retinal vessels, and general background of the macula.
Inspect the color, shape, and margins of the optic disk.
Assess the retinal vessels, the number, the color, caliber.
The ears are sensory organs involved with hearing and balance/equilibrium. The ear is divided into three sections: external ear, middle ear, and inner ear.
The external ear is also known as the pinna or auricle. Sound travels into the external auditory canal and reaches the ear drum or tympanic membrane. This thin membrane separates the external and middle ear.
The eardrum vibrates in response to sound and the vibrations travel through the middle ear. The middle ear contains three small bones called ossicles: incus, malleus, and stapes.
The inner ear contains the bony labyrinth which is an opening in the temporal bone that contains the sensory organs for hearing and equilibrium.
The bony labyrinth has three parts: semicircular canals, vestibule, and cochlea. The cochlea is responsibly from turning the pressure from sound into impulses to communicate to the brain. The vestibular system is responsible for balance.
Inspect the general size and shape of the outer ear. They should be equal bilaterally with no obviously swelling or thickening. Assess skin condition, looking for lumps, lesions or tenderness. Palpating the patient’s ear and mastoid process should be painless.
Inspect the external auditory meatus, there should be no swelling or redness. Most patients will have some cerumen, but excessive cerumen would be abnormal.
Inspection of the interior of the ear is called the otoscopic examination. Choose the largest speculum that fits inside the patient’s ear comfortably. For adults, pull the pinna up and back. This helps straighten out the ear canal.
Hold the otoscope upside down with the dorsum of your hand along the person’s cheek. Inspect the external canal, notice any redness, swelling, discharge, or any foreign bodies within the ear canal.
Assess the tympanic membrane by assessing the color and characteristics. It should be translucent with a pearly grey color. The ear drums should be flat and slightly pulled in at the center. The tympanic membrane should be completely intact.
Asses hearing acuity by beginning with the whisper voice test. Stand about 2 feet away and whisper 2 syllable words into the patient’s ear while asking them repeat the words they hear.
Assess air and bone conduction with tuning forks. The Webber test involves striking a tuning fork and placing it midline on the patient’s skull. The patient should hear the sound equally bilaterally.
The Rinne test compares air conduction versus bone conduction. Place the tuning fork midline on the patient’s skull and ask them to state when they stop hearing the sound.
Begin your assessment of the nose, mouth, and throat by inspecting and palpating the nose. Inspect the nose. It should be symmetric and midline on the face. There should be no deformities or inflammation or skin lesions. Test the patency of the nostrils to reveal any obstruction in the nasal cavity.
Inspect the nasal cavity using an otoscope and a wide-tip speculum. Inspect the nasal mucosa noting its normal color and assess for any swelling or discharge.
Inspect the two turbinates, the bony ridges coming down the lateral walls of the nose and also note any polyps or benign growths within the nose.
Palpate the sinus area. You should palpate the frontal sinus, which is directly below the eyebrows and the maxillary sinus right below the cheek bones. The patient will feel pressure but they should not feel pain.
Inspect the mouth. Inspect the lips for their color, moisture, notice any lesions or discoloration.
Inspect the teeth. The teeth should be straight and evenly spaced. There should not be any absent or loose teeth or abnormally positioned teeth. Ask the patient to bite and note the alignment of the jaw.
Inspect the gums. The gums should look pink. Check for swelling or any gingival margins, any bleeding or discoloration.
Inspect the tongue. The tongue is pink. It should be even. Some patients may have a thin, white coating on their tongue. To inspect the area beneath the tongue, have the patient touch the roof of their mouth with their tongue. Make note of any ulcerations or nodules.
Inspect the buccal mucosa, which should be soft and pink and smooth. The Stensen’s duct is the opening of the parotid salivary gland.
Inspect the palate. The anterior palate is hard with rugae. The posterior palate is soft. Ask the patient to say “ah” which will cause the soft palate and the uvula to rise which aids in testing cranial nerve X, the vagus nerve.
Inspect the throat. Inspect the tonsils by having the patient open their mouth. Tonsils are graded on their size with one plus being visible, two plus halfway between the tonsillar pillars and uvula, three plus touching the uvula, and four plus touching each other. Many patients will have one plus or two plus as a normal finding.
2+: Halfway between tonsillar pillars and uvula
3+: Touching the uvula
4+: Touching each other
Inspect the posterior throat for exudate or lesions. Use a tongue blade to elicit a gag reflex. Testing the gag reflex helps with assessing cranial nerves IX and X . Assess cranial nerve XII, the hypoglossal nerve, by asking the patient to stick their tongue out. The tongue should protrude midline with no deviation from side-to-side.
Inspect the posterior chest, the spine, spinal process which straight and midline. The thorax should be symmetric. The neck and trapezius muscles should be developed normally for the age and lifestyle of the patient. The patient’s skin color should be consistent with the patient’s background with no abnormal coloring or lesions.
Palpate the posterior chest. Confirm symmetric chest expansion. Place your hands on the posterior chest wall between level T9 and T10. Ask the patient take a deep breath while watching your hands, they should move apart symmetrically.
Palpate for fremitus, which is a palpable vibration. This is done by placing the ball of the fingers on the patients while having them repeat the “ninety-nine”. Assess areas of the chest noting that vibration is equal corresponding areas. Fremitus will decrease as you move down.
Palpate the chest wall. Notice any areas of tenderness or decreased temperature or moisture or lesions.
Percuss of posterior chest. This is done by starting at the apex and percussing down in the intercostal spaces. Avoid bony processes like the scapula and ribs. Resonance should be heard in healthy lung tissue.
Assess diaphragmatic excursion, which is the movement of the thoracic diaphragm during breathing. This is done by percussing to map out the lower lung border during inspiration and expiration. Normal diaphragmatic excursion should be three to five centimeters.
Auscultate the posterior chest. Begin at the apex, around C7 and proceed to the bases around T10. Begin at C7 and move horizontally across the posterior chest. Three types of normal breast sounds whill be heard, bronchial, bronchovesicular, and vesicular. Bronchial breath sounds are high pitched and inspiration is shorter than expiration. Bronchovesicular is moderately pitched and inspiration is equal to expiration. Vesicular breath sounds are low pitched and inspiration is longer than expiration. While auscultating breath sounds, be cautious to note any adventitious breath sounds which are abnormal breath sounds.
Inspect the shape and configuration of the anterior chest noting that the ribs slope downward and are symmetric, and intercostal spaces are symmetric as well. The patients abdominal muscles should be appropriately developed for the age and activity level. The patient’s face should be relaxed and they should not be showing any signs of tension.
Assess the patient’s skin color and condition and assess the quality of respirations. Normal breathing should be relaxed, regular, and effortless, and should produce no noise. Assess the patient’s respiratory rate and insure that it is within normal limits.
Percuss the anterior chest by beginning at the apex and percussing the intercostal spaces from one side to the other in a descending motion. Dullness is heard over the heart tissue near the fifth intercostal space. In the right midclavicular line, dullness will be heard over the liver. Tympani will be evident over the gastric space.
Auscultate the anterior chest. This is done by beginning at the apex in the supraclavicular areas and moving down from side-to-side noting the three types of breath sounds as mentioned earlier, bronchial, bronchovesicular, and vesicular. Listen to one full respiration in each location.
Palpate the carotid artery. Palpate one artery at a time to avoid compressing blood flow to the brain. Palpate for pulse strength and equality bilaterally.
Auscultate the carotid artery. This is especially indicated in older individuals and those who demonstrate signs of cardiovascular disease. Auscultate for bruit. Listen with the bell of the stethoscope and apply over one carotid artery at a time being cautious not to apply any direct pressure to avoid creating an artificial bruit.
Inspect the jugular venous pulse. This is done by laying the patient at an angle from 30 to 45 degrees to avoid flexing the neck. Ask the patient to turn their head away from the examiner while shining a bright light on the neck. This will highlight the pulsation and shadows of the jugular venous pulse. As a person is raised to the sitting position, the jugular should flatten and disappear usually around 45 degrees.
Inspect the anterior chest for a visible apical impulse. This is also known as point of maximum impulse. If visible, this should be over the fifth intercostal space.
Palpate the apical pulse. This can be done with just one finger pad. Note the location, which should be over the fifth intercostal space, the size, amplitude, and duration.The apical pulse may not be palpable with many patients.
Palpate across the precordium. With the palms of four fingers palpate gently across the precordium assessing for any other pulsations.
Auscultate the heart sounds. Auscultate the four valve areas. These auscultation areas are not over the anatomical structures, but rather over the areas where sounds are most pronounced and most easily heard. The mnemonic APE To Man is useful in recalling the order of auscultation. APE would stand for aortic, pulmonic, and Erb’s point; To Man, tricuspid and mitral.
The aortic valve should be located over the second right intercostal space. The pulmonic valve auscultation area should be located over the second left intercostal space. The tricuspid valve area would be over the left lower sternal border and the mitral valve can be heard over the fifth intercostal space around the left midclavicular line. Actual locations of heart sounds may vary from patient to patient.
Auscultate with the bell for murmurs. Auscultate for any S3 and S4 murmur sounds. Note the rhythm of the heart and the rate. Listen to S1 and S2 separately and listen for any sorts of splitting or murmurs. Murmurs are classified by their timing, loudness which is graded from grade one through six. The pitch and the pattern, the quality, location, radiation, posture.
The peripheral vascular system is the transport system in the body. Vessels in the body contain fluids which can carry a variety of substances throughout the body. The heart pumps blood to the lungs where blood picks up oxygen and returns the heart.
The heart then deliveries the oxygenated blood and nutrients to the body via arteries. Once oxygen has been picked up by cells in the body blood and waste travels back the heart via veins.
Inspect and palpate the arms. Note the color of the skin and the nail beds, the temperature, texture, turgor of the skin and assess for any lesions and edema.
Assess capillary refill. This is done by depressing the nail beds and assessing how long it takes for the color to return. This should happen within one to two seconds.
The arms should be symmetric in size. Assess pulses in all extremities. Palpate radial pulses and dorsalis pedis pulses. Normal would be plus two pulse and they are graded from zero, one plus, two plus, and three plus.
Inspect and palpate the legs. Inspect color, hair growth, venous pattern, any swelling or lesions. Inspect the hair to see if hair growth is even throughout the legs.
Legs should be symmetric in size without new swelling or atrophy. Assess calf circumference and measure the widest part in exactly the same on either side.
Palpate to assess the temperature. Palpate the inguinal lymph nodes and note for any unusual size and make sure that they are non-tender.
Palpate peripheral arteries in both legs. The femoral pulse is found just below the inguinal ligament halfway between the pubis and the anterior-superior iliac spine. Palpate popliteal pulses. This is done with the person’s leg extended and relaxed with the examineers fingers just underneath. Posterior tibial pulses are found along the medial malleolus. The dorsalis pedis pulse is lateral and parallel to the big toe. Doppler may to assess these pulses if they are not easily palpated.
Assess for peripheral edema. Edema is graded from one plus, two plus, three plus, and four plus.
1+: being mild pitting and no swelling of the leg
2+: moderate: both feet plus lower legs, hands or lower arms
3+: severe: generalized bilateral pitting edema, both feet legs, arms, and face
4+: very deep pitting and indentation lasts a long time and the leg appears to be very swollen
Inspect the contour of the abdomen. This is done by stooping to view across the abdomen to determine if it is flat to slightly rounded. Assess the symmetry of the abdomen by shining a light across and assessing for any bulging or visible masses, or asymmetry.
Assess the umbilicus, and notice any discoloration, inflammation or hernia. There should be none.
Assess the skin texture and color. There should be no lesions or scars. If scars are present note the length and general nature.
Assess for any pulsations or movement in the abdominal area. In some individuals, it may be possible to see pulsations of the aorta. Respiratory movements may also be seen in patients.
Auscultation comes after inspection in the abdomen so that palpation does not disrupt bowel sounds and change your assessment.
Begin in the right lower quadrant, and use the diaphragm of the stethoscope pressed lightly against the skin. Note bowel sound characteristics and frequency. They should be anywhere from five to 30 times per minute.
It is not necessary to count bowel sounds, but note if they are hypoactive, hyperactive or normal. Listen for one full minute in each abdominal quadrant to determine activity.
Auscultate vascular sounds within the abdomen. You should listen for any bruits, and you’re going to be listening to the aorta, the left renal artery, the iliac artery and the femoral artery. You may need to use firmer pressure to listen for these sounds.
Percuss for tympany. Percuss to determine the location and size of the liver and the spleen. Percuss in all four quadrants. Tympanny will be heard due to air in the intestines. A duller sound would indicate a mass, or distended bladder, or adipose tissue.
To measure the size of the liver, begin g in the right midclavicular line. Percuss down the right midclavicular line, listening for when lung resonance stops, the sound will change to a dull sound. Mark that spot, which should be around the fifth intercostal space. Continue percussion until tympany is heard once again. This indicates the lower border of the liver.
Measure the distance between the two marks. This indicates the size of the liver. It should range from 6 to 12 centimeters in healthy adults.
To assess the spleen begin by percussing a dull tone over the ninth to eleventh intercostal space, on the left midaxillary line.
Percussion of the kidneys aids in assess for pain and tenderness. This is done by placing the nondominant hand over the costovertebral angle. The nondominant hand is struck with the ulnar surface of the dominate hand made into a fist. Repeat over both kidneys.
Begin palpation by working from light to deep palpation. You begin with light palpation with the forefingers close together, and you should make a small circular motion. Lift the fingers between the quadrants. As you’re moving around the patient, you should assess for any guarding and notice if the patient is feeling pain.
Upon completion of light palpation move on to deep palpation. To do this place two hands, one on top of the other, the top hand pushes the bottom hand. As this is done take note of the location size and consistency of the abdomen, as well as any tenderness.
Assess for the colon, there may be some tenderness over the colon which is a normal finding. If a mass is felt note the location, size, consistency, and any tenderness.
Assess the location of the liver, via palpation. Place your left hand under the person’s back, and lift up to support the abdominal contents. You should then place your right hand on the right upper quadrant, and push deeply down and under the right costal margin. The person should take a deep breath, and with this you should be able to feel the edge of the liver. The liver may not be palpable.
The spleen generally is not palpable. If it is palpable, it may be due to being enlarged. Reach your left hand over the abdomen, and behind the left side of the eleventh and twelfth ribs. You should then place your right hand on the left upper quadrant, with the right fingers pointing towards the left axilla. Push your hand deeply down under the left costal margin. Ask the person to take a deep breath.
When assessing the kidneys place your hands together and position them at the person’s right flank, and then press firmly and deeply, and ask the person to take a deep breath. You should feel no change. You may feel the lower portion of the kidney. Do the same thing on the left side, with the left kidney sitting about one centimeter higher than the right kidney. It should not normally be palpable.
Palpate the aorta, use your thumbs to palpate the aortic pulsation in the upper abdomen. Assess for costovertebral angle tenderness. Place one hand at the costovertebral angle, and the person should feel no pain.
Assess for rebound tenderness to identify peritoneal irritation. To do this hold your hand perpendicular to the abdomen, and push down gently, slowly and deeply, then lift up quickly. If the patient feels rebound tenderness, this is a sign of peritoneal inflammation. Ask where the pain is most intense.
If the patient has a distended abdomen, testing for a fluid wave will help to distinguish between dilated loops of bowel, fat, and free fluid. Have the patient place the ulnar edge of their hand in the umbilical area, mid-line abdomen. You should then place your left hand on the person’s right flank, and with your right hand reach across the abdomen and give the left flank a firm shake. If ascites is present, this will generate a fluid wave through the abdomen. A distinct tap on your opposite hand if ascites is present.
When assessing the musculoskeletal system, begin with inspection. Inspect corresponding joints, structure, and function of each joint to determine full range of motion is present. Note the size of each joint, color, swelling, and any masses or deformity on the joint. Palpate the joint and skin to note temperature, as well as musculoskelatal or muscular deformations or swelling at the joints.
Assess range of motion of the joints by asking the patient to do active range of motion in the joint corresponding to the type of joint that it is, whether it should be flexion, extension, abduction, adduction, pronation, supination, circumduction, elevation, depression, rotation, protraction, retraction, eversion, and inversion. Have the patient try to attempt these movements in each of their joints.
If the patient is unable to do so, attempt passive range of motion. Assist the patient with passive range of motion. If they are unable to complete passive range of motion exercises, do not force any movements. You can use a goniometer to measure the angles at which the patient is able to move. Joint motion should not cause pain or tenderness, or crepitation.
Assess the cervical spine. Inspect the spine first to see that it is aligned with the head and neck, and that it is centered. Palpate the spine and spinal processes. They should feel firm with no spasms or tenderness.
Ask the patient to touch chin to chest, lift their chin toward the ceiling, touch each ear toward the corresponding shoulder without lifting the shoulder, and turn the chin toward each shoulder. The patient should be able to do these movements equally bilaterally, without any sort of pain.
Assess the upper extremities. Inspect both shoulders, posterior and anteriorly check for the size, and check for any atrophy, deformity or swelling. Palpate the shoulders and assess that there are no spasms, tenderness, swelling or heat.
To test range of motion in the upper extremities ask patient stand with arms at sides and elbows extended. Have the patient move each arm forward in upward arcs and vertical arcs. They should then rotate the arms internally, behind the back, and place back of hands as high as possible.
Test the strength of the shoulder by asking the person to shrug the shoulders up and place a slight amount of resistance.
Inspect the elbow, inspect the size and contour, notice any sorts of deformity, or swelling, or lesions. Test range of motion by asking the person to bend and straighten the elbow.
Inspect the wrist and hand, noting position, contour and shape. The fingers should lie straight along the same axis as the forearm. There should be no swelling, redness or deformity. The skin should be smooth, the muscle should be full. You should palpate each joint in the wrists and hands.
There should be no bogginess. The surfaces should be smooth. Test range of motion on the wrists and hands by having the patient bend the hand up at the wrist, bend the hand down, and bend the fingers up and down. The patient should be able to have their palms flat, and turn them inward and outward, spread the fingers apart and make a fist, and touch the thumb to each finger on the hand.
Assess the lower extremities. Begin by assessing the hip and the hip joint. Assess that there is symmetry at the level of the iliac crest, and that the patient has a smooth gait.
Lay the patient in a supine position and palpate the hip joints to test for range of motion in the hip. Have the patient raise each leg, with knee extended, bend each knee up to the chest while keeping the other leg straight. The patient should be able to swing the leg laterally then medially with the knee straight. The patient should be able to, in a standing position, swing a straight leg back behind the body.
Next, inspect the knee. Inspect the lower ligament, and inspect the knee shape and contour. There should be no swelling within the knee. Check the quadricep muscle and anterior thigh for any atrophy. Assess range of motion by asking the patient to bend each knee, extend each knee. Have the patient walk, and assess ambulation as well as range of motion during ambulation.
Assess strength by asking the person to keep the knee flexed while applying a slight amount of pressure.
Inspect the ankle and foot. Compare both feet, the positions of toes and characteristics. Assess for any abnormalities.
Assess the spine. The person should be standing. Place yourself far enough back so that you can see the entire back. Note if the spine is straight by following an imaginary vertical line from head, through the spinous processes and down to the gluteal cleft.
The person’s knees should be aligned with the trunk and should be pointing forward. From the side, you should note a normal convex thoracic curve and a concave lumbar curve. You should assess range of motion of the spine by asking the person to bend forward and touch the toes. They should be able to do this in a smooth fashion.
Assess for Homans sign to identify DVT.
The central nervous system is composed of the brain and spinal column. The brain is encased by the skull and the spinal column by the vertebrae. The primary cell of the CNS is the neuron which has unique capabilities. The brain consists of a right and left hemisphere connected by a group of nerves called the corpus callosum. Each hemisphere contains a frontal lobe, temporal lobe, parietal lobe, and occipital lobe.
In the middle of the brain is the thalamus. It relays sensory signals to the cerebral cortex. It is also involved in sleep wake cycles.
The hypothalamus located just below the thalamus plays a role in hunger, thirst, sleep, emotions, temperature, and stimulation of the pituitary.
Posterior to the hypothalamus is the midbrain and below that is the pons. They are involved in motor and sensory functions.
The cerebellum is associated with balance and equilibrium, coordination, muscle tone. The medulla helps regulate respiratory, gastrointestinal and heart functions.
There are 12 pairs of cranial nerves and 31 pairs of spinal nerves. The cranial nerves originate in the brain while the spinal nerves originate from different sections of the spinal cord. The spinal nerves are further classified based on location: sacral spinal nerves, thoracic spinal nerves etc.
Neurons are the primary cell found in the central nervous system. They have a unique shape that allows them to be quick and efficient communicators. This allows us to instantly sense pain in our hand from a hot stove.
Neurons are capable of transmitting electric impulse as well as communicating chemically via neurotransmitters.
When conducting the neurological system assessment, begin by assessing level of consciousness. Is the person alert, awake and aware of the stimulus in their environment? Are they oriented to person, time, situation and place? What’s their facial expression? What is the quality of their speech? What is their general mood and affect?
Assess the appearance of the patient, the position and posture as well as dress and grooming.
Assess cognitive function. Is the person oriented to time, place and person? Assess attention span. Are they able to focus on the interview? Are they able to focus on you and what is being done at the moment? What is their recent memory? Are they able to recall why they’re in the hospital, what happened, what brought them there?
Assess remote memory, past events, birth dates? What is their judgment? Assess thought processes. Is the person making sense? Are they able to make sense of what is happening? Assess their perceptions, ask them questions about their perception of the world.
Screen them for suicidal thoughts. Ask if they have any thoughts of hurting themselves.
Further assess neurological status. Are they alert? Meaning, are they awake and readily aroused? Are they fully aware of what’s happening? Are they lethargic or somnolent, not fully alert, and drift into sleep, and require stimulation? Are they obtunded, sleeping most of the time, very difficult to arouse? Are they in a stupor, they respond only to vigorous shaking?
Or are they in a coma, completely unconscious? Each institution might have different definitions and states for level of consciousness, so it is important to understand how your hospital and your organization determines level of consciousness.
Test cranial nerves. Test cranial nerve II the optic nerve by testing visual acuity. Assess cranial nerves II, IV, and VI, ocular motor, trochlear and abducens nerves. Assess pupil size, the regularity, equality, reaction to light. Are they equal round and reactive to light? This is known as PERRLA. Assess for extra ocular movements by assessing for the six cardinal positions.
Assess cranial nerve V, the trigeminal nerve, by assessing motor function. Palpate the temporal masseter muscles as the person clenches their teeth. With the person’s eyes closed, test light touch sensation by touching the forehead, cheeks and chin, and having the person state when they feel that they’re being touched.
Test the facial nerve, cranial nerve VII, by motor function. By noting facial symmetry as the person responds, as they smile, frown, close eyes tightly, and lift eyebrows, to show teeth. Assess for symmetry on each side.
Inspect and palpate the motor system. Assess cerebellar function by assessing gait and balance. Is the person able to walk in a smooth gait, is it rhythmic, effortless, and coordinated? Use the Romberg test by asking the person to stand up with their feet together. Have the person stand with their feet together and close their eyes, are thry able to stand in a completely balanced and coordinated fashion for 20 seconds.
Assess the sensory system. The person needs to be alert, comfortable and cooperative in order to do this. Assess for superficial pain by using something sharp and something dull to touch the patient, determine is the patient is able to distinguish between sharp and dull.
Assess stereognosis by placing different objects in the patient’s hand with their eyes closed, and determine if they can distinguish between items like paperclips, keys, and coins.
Assess reflexes. Reflexes are graded from zero to four: zero, no response, to four plus, very brisk, hyperactive.
0: no response
2+: average or normal
3+: brisker than average
4+: very brisk, hyperactive, clonus, indicative of disease.
Assess the bicep reflex, which will test C5 and C6. Assess the tricep reflex, which would be C7 and C8. Assess patellar reflex, L2 to L4. The achilles reflex tests L5 to S2.
Assess the plantar reflex, which would be L4 to S2, with the end of the reflex hammer.
Assess for Babinski reflex by drawing a light stroke from the person’s heel to the person’s toes in the shape of a J. The normal response is the plantar flexion of the toes, which would be bringing the toes forward toward the stimulus. A positive Babinski reflex would indicate when there’s upper motor neuron disease.
Inspect and palpate the scrotum. Scrotal size will vary depending on patient and room temperature. Asymmetry is normal with the left scrotal half lower than the right. There should be no lesions or cysts.
Palpate each half between your thumb and first two fingers. Testis should feel oval. They should be freely movable and slightly tender. There should be no other scrotal content
Inspect and palpate for hernia by inspecting the inguinal region for bulge. Palpate the inguinal canal while the patient strains down. Inspect here for inguinal lymph nodes by palpate along the vertical chain within the upper inner thigh.
Instruct the patient to conduct a testicular self-examination once a month, the best time for this being after a warm shower.
Palpate the prostate gland by pressing into the gland to note the size. The size should be about two-and-a-half centimeters long, about four centimeters wide and should not protrude more than one centimeter into the rectum. Its shape should be heart shape and the surface should be smooth. It should be elastic, and rubbery, and slightly movable. There should be no tenderness on palpation. As the examination finger is withdrawn assess any signs of bright blood or mucous on the glove. At this time test stool for occult blood.
When conducting the assessment of the female genital urinary system, you should note skin color, hair distribution.
The labia majora should be symmetrical and well-formed. There should be no lesions or cysts. With a gloved hands, separate the labia majora to inspect the clitoris. The labia minora should be dark pink,moist and symmetric. The perineum should be smooth, the anus has coarse skin with increase pigmentation.
Palpate the clitoral glans. Assess the urethra and Skenes glan. Insert your finger into the vagina and apply pressure up and out. There should be no pain upon doing this.
Assess the Bartholin’s gland by palpating the posterior part of the labia majora.
Inspect the genitalia by using a speculum for examination. With the speculum inserted, inspect the cervix. The color should be pink and even within a female who is not pregnant. The position should be midline. The size is about two-and-a-half centimeters. The os is small and round in women who have never been pregnant, in parous woman it is a horizontal, irregular slit. It should be smooth.
If there are secretions depending on menstrual cycle, they should be odorless.
Obtain cervical cultures or this is called Pap smear (Papanicolaou) to screen for cervical cancer.
With the woman in a lithotomy position, one hand will be placed on the abdomen, with the other hand insert two fingers into the vagina. Palpate the vaginal wall. It should be smooth with no areas of induration or tenderness. It should feel consistent throughout, be evenly rounded, with the cervix able to move from side-to-side.
With the abdominal hand push the pelvic organs closer to your intervaginal fingers to palpate. Palpate the uterine wall. It normally feels firm and smooth. The uterus should be moved freely and non tender.
Conduct a recto-vaginal examination to assess the recto-vaginal septum, posterior uterine wall, cul-de-sac, and rectum. This may feel uncomfortable to the woman and feel as though she were having a bowel movement. With one hand, insert one finger into the anus and one into the vagina, and with the other hand will use to apply pressure to the abdomen.
Inspect the breast. Note asymmetry and size. There may be a slight amount of asymmetry in the size of the breast which is normal. The skin should be smooth. There should be no lesions, or dimpling, or redness. There should be no edema.
There should be no bulging, discoloration or edema in lymphatic draining areas. The nipples should be symmetrically located and should usually protrude although some may be flat or inverted. If an inverted nipple is noted, question the patient if that is new occurrence or preexisting.
Assess for retraction by asking the woman to lift both arms above her head, both breasts should move up symmetrically. Ask the patient to place her hands on her hips and push her two palms together. There will be slight lifting of both breasts.
Inspect and palpate the axilla. Inspect the skin for any rash or infection. Lift the patients arm and support it yourself so that her muscles relaxed. Reach your fingers into the axilla and move them firmly down in each direction. The lymph nodes are generally not palpable and there should be no tenderness when you palpate in there.
Palpate the breast. Ask the patient to lay in a supine position with a small pad under the side to be palpated. Use the pads of your first three fingers and make a gentle rotation movement on the breast. Palpate from the nipple and move outward, feeling for any nodules. Make note of any discharge.
Note the location, size, shape, consistency, skin color and tenderness of any lumps or masses.
Instruct the patient to conduct a breast self-examination or BSE. The best time for this is right after the menstrual period or the fourth through seventh day of the menstrual cycle.
The lymphatic system is a transport system like the peripheral vascular system, however the vessels are separate. The lymph system is composed of lymph vessels, lymph nodes, lymph ducts, and lymph nodules.
When blood is transported throughout the body plasma from the blood flows into interstitial spaces. To prevent excess build up the lymph system is there to drain excess fluid and plasma protein.
Lymph is collected in vessels and drains into different lymph nodes in the body where it is filtered and microbes can be killed. Lymph is then sent to lymph ducts which deposit lymph into veins into the body to become part of the plasma in the blood supply.
Lymph is very similar to plasma in the blood. The head and neck drain into the cervical lymph nodes. The breast and upper arm are drained by the axillary lymph nodes. The hand and lower arm drain into the epitrochlear lymph node, and the lower extremity drains into the inguinal nodes. Lymph nodules like the thymus and spleen do not connect directly with rest of the lymph system and help protect the body from external pathogens.
Please view the cheatsheet section of this course to learn more about vital sign assessment.
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
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