Health Assessment

1. GENERAL HEALTH ASSESSMENT AND
HISTORY TAKING
Princy Francis M
Ist Yr MSc (N)
JMCON

2. DEFINTIONS AND TERMINOLOGIES
• HEALTH
“Health is a state of complete physical mental and social well –being and not
merely the absence of disease or infirmity”
- World Health Organization
• “Assessment is a systematic ,dynamic process by which the nurse through
interaction with client, significant others and health care provides, collect
and analyze data about client”
– American Nurses Association

3. • HEALTH HISTORY
Health history is a collection of subjective data that includes information on
both the client’s past and present health status.
• PHYSICAL EXAMINATION
Physical examination provides objective data for identifying problems and
making diagnosis.

4. Assessment: It is a systematic and deliberate process of gathering the
information regarding client’s health.
Inspection: It is one method of physical examination which involves the visual
examination of the body.
Palpation: it is the use of tactile sensation foe identifying the characteristics
of skin and superficial tissues.
Percussion: It is method of physical examination by tapping with the fingers
on the body to determine the quality of sound.
Auscultation: It is a method of physical examination that involves listening
the sounds within body either by ears or stethoscope.

5. PURPOSES OF HEALTH ASSESSMENT
• To obtain baseline data about the client’s functional abilities.
• To supplement, confirm, or refute data obtained in the nursing history.
• To obtain data that will help establish nursing diagnoses and plans of care.
• To evaluate the physiological outcomes of health care and thus the
progress of a client’s health problem.
• To make clinical judgements about a client’s health status.
• To identify areas for health promotion and disease prevention.

6. TYPES OF ASSESSMENT
• Comprehensive health assessment. It includes complete physical examination
and health history.
• Ongoing partial assessment: is one that is conducted at regular intervals during
care of the patient.
• Focused assessment : Examination of a body area
• Emergency assessment: is a type of rapid assessment conducted to identify the
potentially fatal conditions.

7. PREPARING THE CLIENT

8. PREPARING THE ENVIRONMENT

9. CULTURAL SENSITIVITY
A client’s health beliefs, use of alternative therapies, nutritional habits,
relationship with family and comfort with the nurses physical closeness
during an examination and history taking must be considered.

10. COMPONENTS OF A NURSING HEALTH
HISTORY
• Biographic data.
• Reason for seeking health care/ chief complaint.
• History of present Illness
• Past health history
• Family history
• Review of systems
• Lifestyle
• Socio-cultural History
• Psychological History
• Occupational and environment History

11. Biographic data
Personal data including name, address, age and date of
birth, gender, religion, race/ethnic origin, bed number, ward,
medical diagnosis, Surgery (if performed), occupation,
education and type of health plan/insurance

12. Reason for seeking health care/ chief
complaint.
• It should be written in client’s statement.
• In case of multiple problems, ask client to indicate the
priority of complaint.
• Avoid using medical terminology.
• Write problems in chronological order

13. History of present Illness
Expansion of chief complaints.
Chronological order
Location, quality, quantity, chronology, setting, exaggerating
and relieving factors, associated symptoms, effect on
sleep, daily activities.

14. Past health History
• Allergies
• Medical disease such as Hypertension, Diabetes, TB,
Anemia, Seizures, Arthritis, Heart Disease, Glaucoma etc.
• Trauma, Injury: Fracture, abdominal trauma, burns,
blunt/penetrating injury, altered consciousness level.
• Hospitalization
• Childhood disease and immunization
• Obstetric History
• Drug history

15. Family history
Family composition
Sl.
No
Name of
the
family
members
Age/
sex
Relationship
with client
Marital
status
Education
al status
Occupatio
nal status
Health
status

16. FAMILY HISTORY - Family Health
history
The family history should include: causes and age of death
of parents, details about the health of siblings and children
and information about heart disease, hypertension,
diabetes, asthma, allergies & ethnic origin.

17. Review of systems
The review of systems (ROS) is a brief account from the
client of any recent signs or symptoms associated with any
of the body systems.

18. Respiratory History
• Presenting Problem/Complaint : Cough, Sputum,
Hemoptysis, Wheeze, Chest Pain, Shortness of breath,
Systematic symptoms,
• Drug History: Allergies, inhalers, nebulizer, home oxygen
• Social History : Smoking history-measured in pack years
Contact with animals/pets Presence of stairs in or leading
into flat/house Hobbies.
• Family history : e.g. asthma/hay fever

19. Cardiovascular History
• 4 main cardiovascular symptoms: Chest pain, Shortness of
breath, Presence and extent of edema, Palpitations
• Main risk factors for Ischemic Heart Disease: Smoking,
Hypertension, Diabetes mellitus, Hyperlipidemia, Family
history
• Past Medical History : e.g. angina, myocardial infarction,
bypass operation, rheumatic fever, stroke, intermittent
claudication
• Social History: Smoking alcohol, stairs
• Family History
• Drug History: Allergies

20. LOCOMOTOR HISTORY
• Evolution of condition - Acute or chronic, Associated events and
Response to treatment
• Current symptoms - Pain, Stiffness, Swelling. Pattern of joint
involvement
• Involvement of other symptoms - Skin, lung, eye or kidney
symptoms, Malaise, weight loss, fevers or night sweats
• Impact of lifestyle- Patient’s needs/ aspirations, Ability to adapt with
functional loss
• Pain History S -site, O -onset, C -character, R -radiation, A –
associations, T -timing, E -exacerbating & relieving factors , S -
severity (mnemonic ‘SOCRATES’)
• Use of medication for pain relief

21. Personal data/Life style
• Habit
• Diet
• Elimination pattern
• Sleep and rest pattern
• Activity and exercise pattern

22. Obstetric History
• Menstrual Pattern-regular/ irregular
• History of pregnancy, labor, puerperium and
complications if any

23. Socio cultural history
Home environment, family situation, and client’s role in the
family

24. Psychosocial History
Psychosocial history refers to assessment of dimensions
such as self-concept and self-esteem as well as usual
sources of stress and the client’s ability to cope.
Sources of support for clients in crisis, such as family,
significant others, religion, or support groups, should be
explored

25. Occupational and Environmental history
It includes collecting data regarding client’s occupation, life
style in job, working environment etc.
Collecting information includes designation, location of
work, exposure to hazardous material, residing near mines,
farms, factories or shipyard. Congestion, overcrowding,
may spread communicable diseases.

26. PHYSICAL EXAMINATION
PURPOSE
•To make direct observations of any deviations
from normal
•To validate subjective data gathered through the
interview Baseline measurements are obtained,
•Physical examination techniques are used to
gather objective data

27. COMPONENTS OF
PHYSICAL EXAMINATION
General physical examination
• General observations and examinations of head , scalp, skin
and hair, eyes, mouth and pharynx, ear , noise and throat,
neck, breasts and axillae and extremities.
Specific examinations
• Examination of chest for cardiovascular and respiratory
system.
• Examination of abdomen for GI tract , biliary system and
urogenital system.
• Other systematic examinations eg: CNS , locomotor , and
neurological system.

28. PREPATION FOR HEALTH ASSESSMENT
• Preparing the environment:-
• Preparing the equipment:-
• Preparing the client
a)Physical preparations
B) psychological preparations

29. GENERAL PHYSICAL EXAMINATION
METHODS OF ASSESSMENT
Five primary techniques
• Inspection (look –inspect)
• Palpation ( feel with hand)
• Percussion ( tap with hand)
• Auscultation ( listen)
• Olfaction (Smell / odours)

30. GENERAL OBSERVATIONS:
Observe Note the finding/abnormalities
 Facial Expression Puffiness ,smiling , gloomy/depressed ,
blank (mass – like), apathetic, etc
 Position/posture Stopped or erect , supine or prone , rigid or
flaccid
 Complexion Normal or flushed, dark or fair
 Body size and built Obese/overweight , thin , emaciated ,
asthenic , hypoasthenic.
 Mental status Confused , comatosed(unconscious)

31. Observe Note the finding/abnormalities
 Gait and
abnormal
movements
Involuntary movements (tremors ,
chorea, athetosis, twitching), gait
abnormalities (short shuffling,
hemiplegic, waddling , high – stepping,
scissor shaped)
 Sound/vocal
speech
Aphasia , dysphasia , stridor, hoarseness
, wheezing.
 Smell /Odour Bad (lung abscess), fishy (hepatic
coma), urine like (uraemia),sweety
(diabetic ketoacidosis)

32. GENERAL EXAMINATION
• Consciousness: Conscious / Semi – conscious / Unconscious
• Orientation: Oriented to time / place /peers
• Nourishment : Well nourished / moderate nourished / malnourished
• Health: Healthy / Unhealthy
• Body built: Thin/moderate / obese
• Activity : Active /dull
• Look: Pleasant/ happy/alert / sad /depressed/ fearful / anxious / tired /
drowsy
• Hygiene: Good / Bad
• Speech : Clear / slurring / stammering / not clear / maintains eye contact
• Height , Weight, BMI
• Vital signs – Temperature , Pulse, Respiration, B.P

33. Integumentary System (Skin)
• Color : Fair / brown / dark in complexion
• Texture : Normal / dry
• Skin turgor: Normal / decreased
• Hydration: Good / moderate / dehydrated
• Discoloration : Absent / yellowish / cyanosis / vitiligo /
pallor / increased pigmentation.

34. Erythema/ Jaundice/ tan- brown
Subjective symptoms: No complaints /
pain / feeling of cold/ warmth tingling /
numbness

35. Lesions/Masses : Absent / macule / papule/
nodule/ vesicle/ pustule

36. On Observation : Intact / onycholysis /
peeling or cracking / paronychia
Nail beds : Pinks / cyanosed /pale

37. Nail plate : Absent /flat / clubbing /
whitening/ Beau’s lines/Koilonychia(Spoon
nail)/Splinter haemorrhage
Scharmroth’s window test: Normal /abnormal

38. Color : Black / brown / red / grey / dyed
Texture : Normal / dry
Grooming : Not groomed / well groomed
Distribution: Normal / scanty / bald / alopecia

39. Shape : Normocephalic / micro / macro / hydrocephalic
Scalp : Clean / pediculosis / presence of dandruff / any scar
Face : Puffiness / moon face / Bell’s palsy / no complaints

40. Eye brows : Symmetrical / equally distributed /
asymmetrical / scanty
Eye lashes : Absent / equally distributed / presence
of dandruff
Eye lids : Normal / oedematous / ptosis
Pupillary reflex : Reacting to light / unequal
reaction (specify which eye)

41. Pupil size : Pin pointed / 2mm / 3mm /
dilated
Sclera : White / reddish / yellowish
Conjunctiva : Normal / pale / yellowish /
conjunctivitis
Vision : Normal / abnormal (specify including use
of spectacles)

42. Pinna : Normally placed / anotia /
microtia / melotia
Cerumen: Absent / packed with
Ottorhoea: Absent / purulent / serous
/bloody /sangiunous
Hearing: Normal / decreased (specify)

43. Nasal septum: Midline / deviated
Nasal pathway : Patent / obstructed / nasal polyp
Smell : Normal / absent
Rhinorrhoea: Absent / watery / purulent / mucoid /
epistaxis
Frontal & maxillary sinuses : Painful / tender / sinusitis /
no complaints

44. Lips: Dry / cracks ; symmetrical / asymmetrical
Color : Pink / pale / dark
Gums : Color – pink / pale dark ; bleeding / pus/
leukoplakia
Tongue : Moist / dry / coating / lesions / ankyloglossia
Position : Midline / deviated
Mobility : Voluntary / not possible
Color : Pink / pale / reddish /dark

45. Size and symmetry: A symmetrical because of mass
edema.
Range of motion: Lateral head back, side to side.
Position of Trachea
Place index finger in the suprasternal notch and slide it
to right and then left of trachea to note the space on
either side. Normally, space between trachea and
sternocleidomastoid muscle is same in both sides.
Thyroid gland

46. Pulsation in neck region
Jugular vein distension
Tracheal rings, cricoid cartilage and thyroid
cartilage.
Abnormal findings: Tenderness, non-midline
position.

47. Lymph Nodes: Inspect the superficial lymph nodes
for – Edema, Erythema, Red streaks
Palpate. Nodes for size, consistency, mobility
border, tenderness and warmth.
Large, warm, tender, firm, free movable lymph
node – Head or throat infection.
Unilateral, hard, asymmetric, fixed, non-tender
node – Malignancy
Palpation of Lymph Nodes

48. CHEST – RESPIRATORY SYSTEM
Inspection
• Breathing: With efforts, normal without efforts
• Chest wall symmetry: Anterior – Posterior angle (AP angle): anteriorly
should be less than 90o.
• Breathing rate: Normal, tachypnea, bradypnea, apnea.
• Breathing pattern
• Chest expansion
• Apical impulse: Can be seen in hyperthyroidism.
• Chest configuration: Barrel Chest/Funnel Chest (pectus excavatum)/ pigeon
chest (pectus carinatum)/ Kyphoscoliosis

50. Palpation
• Chest wall: Crepitus, pleural friction rub
• Symmetry: Normal, Asymmetry reflects
atelectasis, pneumonia, fail chest,
pneumothorax
• Thoracic expansion/ respiratory excursion
• Tactile fremitus
• Curvature: Scoliosis or Kyphosis.
• Vocal(Tactile) Fremitus: Bilaterally equal.

51. Abnormal findings
• Increased Fremitus: Consolidation, lobar pneumonia
• Decreased Fremitus: Obstruction to transmit vibrations, emphysema,
pleural thickening, pulmonary edema. Pleural effusion, bronchial
obstruction.
• Rhonchi, Fremitus: Bronchial secretions are thick.
• Pleural friction fremitus: Inflammation of parietal or visceral Pleural,
causing decrease in normal lubrication.
• Presence of masses/ tenderness

52. Percussion of Thorax
• Tone: Resonance, hyperresonance, hypo resonance.
• Intensity: Loud, soft, Medium.
• Pitch: Very Low, Low, high pitch.

54. Auscultation for breath sounds
• Bronchial, vesicular, broncho vesicular, adventitious sounds, vocal sounds
Abnormal breath sounds
• Crepts (fine short interrupted sound)
• Rhonchi (Low pitched continuous musical sound)
• Wheeze (High pitched continuous musical sound)
• Pleural friction rub (grating type of sound)

55. Breast and Axilla
Inspection
• Breast size, shape and symmetry
• Skin of Breast: Appearance of colour, pigmentation,
vascularity surface characteristics.
• Other signs/symptoms: None / if any________________
Areola: Color, surface characteristics.
Nipples: Position, symmetry, intactness, discharge, bleeding,
lesions, scaling.
Axillae: Rashes, lesions, masses

56. Palpation
• Breast and axillae
surface characteristics, nodules and tenderness.
• Nipples
Surface characteristics, discharge.

57. HEART (Cardiovascular system)
• Inspection: bulging or pulsation at aortic and pulmonic areas, chest
abnormalities
• Palpation: Thrill / Pulsation. Thrill indicates cardiac murmur. In mitral
area palpate for apical beat.
• Percussion: cardiac dullness is located in the third to fifth intercoastal
space

58. Auscultation
• S1 (apex of heart {left 5th intercoastal space midclavicular line})
• S2 (Aortic area of heart {Right 2nd intercoastal space})
• S3 ventricular gallop (mitral area{left 5th intercoastal space})
• S4 atrial gallop (mitral area in left lateral position)

59. Heart murmur
Heart murmur (harsh, rumbling, blowing sound caused by blood
flow across a defective valve or shunting through an abnormal
passage).
Grading:
Grade I : very faint
Grade II : Quiet but audible
Grade III: moderately loud
Grade IV: Loud
Grade V: very Loud
Grade VI : Very loud without stethoscope.

60. EXAMINATION OF THE ABDOMEN (GastroIntestinal)
Inspection
• Initially look for general signs such as weight loss.
• Shape/symmetry, Abdominal distension ( 5Fs – flatus, faeces,
foetus, fat, fluid), Scars and striae, Prominent veins, Hernia,
Visible peristalsis

62. Auscultation
Bowel sounds
• Place the diaphragm of your stethoscope on the mid-abdomen and
listen for gurgling sounds.
• Normally occur every 5-10seconds
• Absent bowel sounds indicate intestinal ileus. Increased bowel sounds
indicate bowel obstruction.
Arterial bruits
• Place diaphragm of stethoscope over aorta and apply moderate
pressure.
• If a systolic murmur is heard this indicates turbulent flow caused by
atherosclerosis or an aneurysm.
• Listen for renal bruits 2.5cm above and lateral to the umbilicus.

63. Percussion
Liver
Begin by establishing lower liver edge. Place hands parallel to
the right costal margin starting at the same point of palpation.
Repeat in a stepwise manner moving the fingers closer to the
costal margin until the note becomes duller. This is the position
of the lower liver edge. Next find the upper margin of the liver. It
can be located by detecting a change in note from the dullness
of liver to resonance of lungs.

64. Spleen
Begin by percussing the ninth intercostal space anterior to the anterior
axillary line (Traub’s space).
If the spleen is not enlarged the sound will be tympanic.
If it is dull continue to percuss in a stepwise manner moving hands
towards right iliac fossa.

65. Ascites
If fluid is suspected percuss across patients abdomen (from
midline to right flank) until the percussion note changes from
tympanic to dull. Mark that spot and then ask your patient to
turn onto their right side (if you are standing on left of
patient). After 30seconds repeat percussing from the midline
towards the right flank. If fluid is present it will have
redistributed secondary to gravity and therefore the area
previously marked as sounding dull to percussion will now be
tympanic.

66. Bladder
If the bladder is distended the suprapubic area will be dull rather than
tympanic. Percuss from the level of the umbilicus, parallel to the pubic
bone

67. Palpation
• Light palpation of the nine segments
• Observe patient’s face throughout palpation to ensure that you are
not causing pain.
• Light palpation is used to assess tenderness and guarding (a sign of
irritation of the peritoneum).
• Deep palpation is used to assess for masses.
• If appropriate, test for rebound tenderness (a sign of intra-abdominal
pathology)

68. Palpation of organs
Liver
 A normal liver extends from 5th intercostals space to costal margin.
It may be palpable in normal individuals. Position your hand in the
right iliac fossa with fingers in an upward position facing the liver
edge (alternatively you can use the radial aspect of your index
finger). Press your fingertips inward and upward and hold this
position while your patient takes a deep breath. As the liver moves
downward with inspiration the liver edge will be felt under
fingertips. If no edge is felt repeat the procedure closer and closer
to the costal margin until either the liver is felt or the rib is reached.

69. Spleen
• The normal spleen cannot be felt and
only becomes palpable
• It enlarges from under the left costal margin towards the
right iliac fossa. The fingertips of right hand are then
positioned obliquely across the abdomen pointing to the left
costal margin towards the axilla. Press your fingertips inward
and upward and hold this position while your patient takes a
deep breath. As the spleen moves with inspiration the edge
may be felt under your fingertips. If no edge is felt repeat the
procedure closer and closer to the left lower rib cage until the
costal margin is reached

70. Kidneys
• To examine left kidney, place the palmar aspect of left hand
posteriorly under left flank. Position the middle three fingers of
right hand below the left costal margin, lateral to the rectus
muscle (opposite position of left hand). Ask patient to take deep
breath and press both fingers firmly together. If the kidney is
palpable it will be felt slipping between both fingers.

71. Aorta
• In thin patients or those with a dilated aorta, the aorta
can be palpated by placing both hands on either side of
the midline at a point half way between the
xiphisternum and the umbilicus. Press your fingers
posteriorly and slightly medially and the pulsation
should be present against your fingertips.

72. MUSCULOSKELETAL SYSTEM
• Postural curves: Normal / kyphosis / lordosis / scoliosis
• Muscle tone: Normal / hypertonia / hypotonia / flaccid / spastic / rigid
• Muscle strength: Normal / weaker than normal / hyperactive

73. Upper Extremities
• Symmetry: Symmetrical / asymmetrical
• Finger nails: Capillary refill _______ seconds
• Range of motion: Possible / if impossible
(specify)_________
• Peripheral pulses: Radial – rate, rhythm, volume (normal
/abnormal)
• Brachial: Rate, rhythm, volume – (normal / abnormal)
• Reflexes: Biceps - normal / abnormal

74. • Triceps: Normal / abnormal
• Edema/ swelling: Absent / if present (specify area)
____________
• Cyanosis: Absent / if present (specify area) ____________
• Joints: No complaints / swollen /stiff / tender
/crepitus__________
• Deformity: Absent / if present (specify)________________

75. Lower Extremities
• Peripheral pulses: Dorsalis pedis – rate, rhythm volume (normal / abnormal), if
abnormal (specify)__________
• Posterior tibial: Rate, rhythm, volume (normal/ abnormal), if abnormal
(specify)_______
• Popliteal: Rate, rhythm, volume (normal / abnormal) if abnormal
(specify)_________
• Reflexes: Patellar – normal / abnormal
• Plantar: Normal / abnormal

76. GALS Screen
• Check changes in appearance (swelling, deformity, abnormal posture) and movement
(restricted, pain).
Gait: - Ask the patient to walk a few steps, turn and walk back. Observe gait for
symmetry, smoothness and ability to turn quickly.
• Stand patient. Inspect from behind, from side and in front. Look for bulk and
symmetry of shoulder, gluteal, quadriceps and calf muscles; limb alignment,
alignment of spine; level iliac crests; ability to fully extend elbows and knees;
popliteal swelling; abnormalities of feet.

77. Arms: - Ask patient to put their hands behind their head. Assess shoulder
abduction and external rotation and elbow flexion. With patient’s hands
held out, palms down, fingers outstretched, observe the back of the hands
for joint swelling and deformity.
• Ask patient to turn their hands over. Look for muscle bulk and
deformities.
• Ask patient to make a fist. Visually assess power grip, hand and wrist
function and range of movement in fingers.
• Ask patient to bring each finger in turn to meet the thumb. Gently
squeeze MCP joints for tenderness (ask about pain first).
• Pronator Drift test: Ask the patient to stretch out their arms (palms UP)
and close their eyes. Look for any drifting down of the arms, especially
unequal drifts-suggests pyramidal lesion in brain such as stroke-a good
screening test to do at the start of an exam.

78. Legs: - While standing inspect from the front, side and behind
paying special attention to the popliteal fossa. Lie patient on couch.
Assess full flexion and extension of both knees, feeling for crepitus.
With hip flexed to 90 degrees, holding the knee and ankle, assess
internal rotation of each hip in flexion.
Muscle power Grading
0 No movement
1 Flicker of movement
2 Movement with gravity eliminated
3 Movement against gravity
4 Movement against resistance but incomplete
5 Normal power

79. Reflexes
• Biceps (C5, C6): Ask the patient to flex their elbow to 90° and
rest their forearm on their abdomen. Locate the biceps tendon
and rest your finger on it. Strike your finger and watch the
biceps muscle for contraction.
• Triceps (C7): Ask patient to resume the position as above.
Strike the triceps tendon directly, just above the olecranon
process and watch the triceps muscle for contraction.
• Supinator (C5, C6): Ask the patient to maintain the position
described above, making sure their hand is in the mid prone
position. Rest your finger on the lower radius on the extensor
aspect of the arm and strike it with the tendon hammer.
Observe the movement in the brachioradialis muscle.

80. Reflex grading
0 Absent
+/- Present with reinforcement
+ Just present
++ Brisk normal
+++ Exaggerated response

81. GENITO – URINARY SYSTEM
Inspects for:
• Lesions/scar , Discharge/infection, Voiding by self,
Continent, Incontinent / Catheterized, Colour of urine
Male
• Inspect penis and scrotum for swelling
• Palpate: any mass, inguinal hernia, enlargement of prostate
gland.
Female
Discharge, swelling, redness
• Pelvic mass.

82. RECTUM & ANUS
Perianal skin integrity: Intact / excoriation / rashes /
lesions / haemorrhoids / bleeding
Bowel elimination pattern: Normal / constipation / loose
stools / diarrhoea
Subjective symptoms: Pain before or while passing stools /
blood or mucus in stools / rectal mass

83. NEUROLOGICAL SYSTEM
Coordination
Ask patient to slide the heel of one foot in a straight line down the shin
of the other leg.When the heel has reached the bottom of the shin,
ask the patient to flex the leg then bring the heel back down on to the
shin just below the knee. In a person who does not have any problems
with co-ordination these steps are completed in smooth manner-
Gait
Romberg’s test: - Ask the patient whether they can stand with both
feet close together, then put a hand behind & in front to prevent the
patient from falling. Instruct them to close their eyes

85.  Ask to stand on tip-toes (with your hands lightly supporting their
shoulders) for a true test of ankle plantar flexion power.
 Ask the patient to stand back on their heels and lift their toes to
test for foot drop.
Sensory Assessment
Five modalities of the sensory system- light touch, pain,
temperature, proprioception and vibration.

86. Proprioception
This is examined by testing the joint position sense in the
big toe. First isolate the joint by holding it apart from the
other toes. Hold the distal phalanx of the patient’s large
toe at the sides to avoid giving information from pressure.
Demonstrate the movements of ‘up’ and ‘down’ to the
patient. Ask the patient to close their eyes and to say
whether the movement is up or down.
Proprioception can also be assessed by Romberg’s test: ask
the patient to stand with feet together with both eyes open
(be in a position in which to catch patient if required-ie
hand behind & in front of the patient). Then ask the
patient to close their eyes. If they are more unsteady with
their eyes closed this is a sign of difficulty with
proprioception. Remember that proprioception (and
vibrational sense) is conveyed by the dorsal column/medial
lemniscal pathway.

87. Use a 128 Hz tuning fork. Demonstrate the sensation on
the sternum. To ensure that you are testing vibration
rather than sensation ask the patient first ‘if they feel
buzzing sensation’. If they answer yes; ask them to tell you
when ‘it stops’. Vibration is tested on bony prominences,
initially on the medial aspect of the big toe. If vibration is
absent here then the tuning fork should be moved
proximally to establish the level at which it can be
appreciated. Start at a bony part of the toes, the medial or
lateral malleolus, then the upper part of the tibia, then the
iliac crests.

88. GLASGOW COMA SCALE
Action Response Score
Eye response Spontaneously
To speech
To pain
None
4
3
2
1
Best Verbal Response Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1

89. GLASGOW COMA SCALE
Minor Brain injury : 13- 15, moderate brain injury : 9-12, Severe brain injury : 3- 8
Action Response Score
Best Motor Response Obeys commands
Localized pain
Flexion withdrawal
Abnormal flexion
Abnormal extension
Flaccid
6
5
4
3
2
1
Total score Best Response
Comatose patient
Totally unresponsive
15
8 or less
3

90. Cranial Nerve Examination
I - Olfactory nerve: Test the sense of smell in each nostril with coffee
or some other distinct smell
II -Optic nerve: Perform visual field assessment comparing your
visual fields to the patient’s o It is important to test all four
quadrants. Examine the pupils for pupillary light responses. Look
for asymmetry; reactivity to direct & indirect light; and to
accommodation.

91. III/IV/VI- Oculomotor, Trochlear & Abducens nerves
Near and light reaction– the efferent pathways of the
accommodation reaction pass through the oculomotor nerve.
IIIrd nerve palsy (gross ptosis and eye down and out) or
myasthenia (variable ptosis which is worse on prolonged looking
up) Ask the patient to follow your finger with their eyes and
assess eye movements. Hold the finger at the extremes and
observe for the presence of nystagmus

92. V- Trigeminal nerve There are three components:
Sensory – using cotton wool touch each of the 3 divisions
(ophthalmic, maxillary and mandibular) comparing side to side
Motor – examine muscles of mastication – temporalis and
masseter. Ask the patient to open their mouth against
resistance (lateral pterygoids) and note jaw deviation towards
the side of the lesion.
Reflexes - The afferent part of the jaw jerk is formed by the
motor root of the trigeminal nerve. In the corneal reflex the
afferent limb is contained in the ophthalmic division

93. VII -Facial: - Examine the muscles of facial expression (including
buccinator). The upper half of the face is innervated by both
cerebral hemispheres: thus, in upper motor neuron lesions
there is sparing of the frontalis muscle and unilateral, lower
facial weakness. Examine (or ask about) taste- note this is only
for anterior 2/3 of tongue.
VIII-Vestibulocochlear: - Examine hearing by rubbing fingers
together or whispering numbers

94. Rinne’s test-Place a 256 or a 512Hz fork on the mastoid process
and then move it in front of the pinna. A patient with no
hearing problems should hear sounds transmitted via air
conduction louder than those via bone. In a conductive hearing
loss, bone conduction will be louder than through air.
Weber’s test-Place a 256 or a 512Hz tuning fork on top of head
and ask which ear the buzzing is loudest. Normally both are
same. If different it should be heard loudest in the ear affected
by conductive deafness and quieter in the ear affected by
perceptive deafness.

95. IX/X-Glossopharyngeal and Vagus: - Test the gag reflex. To do it,
place a round tongue depresser lightly on the soft palate on each
side. IX is the sensory and X is the motor component.
For vagus, assess movement of soft palate and NOT the uvula (it can
go anyway it likes) (ask the patient to say ‘aahh’). The palate will not
lift up on the side of the lesion

96. XI- Accessory: - Examine the sternomastoid and upper fibres of
the trapezius by asking the patient to shrug their shoulders and
to turn their head against resistance (feel for the strength in the
contralateral sternocleidomastoid).
XII-Hypoglossal: - Examine the tongue for wasting and
fasciculations Assess tongue movements and note any
deviation. The tongue deviates to the side of the lesion

97. AFTERCARE OF ARTICLES AND
DOCUMENTATION
Be sure the patient is safe and comfortable.
Article should be sent for sterilization.
Disposable articles should be disposed off immediately and replacement of all other
articles should be done and to be stored in an area specified.
Document the time of examination, name of examiner, specimens collected and
observations made that may contribute to plan nursing care.

98. JOURNAL ABSTRACT
Teaching physical assessment skill to international students in New
Zealand
In New Zealand physical assessment skills are routinely taught as a
of the UG bachelor programme. Due to changes made by the
council of New Zealand in 2012, a group of internationally qualified
nurses, predominantly GNM diploma nurses from India, who were
studying in the New Zealand, were required to complete a degree
paper in simulated Physical assessment. For each presenting problem
the student used the acronym “OLDCART” to ask questions about the
problem. O - Onset, L – Location, D- Duration, C – Characteristic, A-
Aggravating Factors, R – Relieving Factors, T – Treatment. The
assessment skill enhances nurse’s self confidence and may improve
patient health outcomes and patient experience.

99. DEVELOPMENT OF NURSING ASSESSMENT
TOOL : AN APPLICATION OF ROY’S
ADAPTATION THEORY
• The study aims to examine the Roy adaptation theory
as a basis for development of nursing assessment tool
for the assessment of cardiac patients. Author found a
congruence between concepts old cardiac nursing
and Roy adaptation theory after in-depth review. This
assessment tool was developed based on Roy’s
adaptation theory, in which the health problems of
patients in all four modes and the relevant stimuli can
be identified.

100. • The nursing assessment tool is divided into 3 sections.
• First section covers the baseline information include
biodata, history, diagnosis, information regarding lifestyle,
lab investigation / examination and medications.
• Second section of nursing assessment tool covers the first
level assessment of patient in all four modes:
physiological , self-concept, role function,
interdependence mode and identifying nursing problems.
• Third section covers the assessment of environmental
stimuli i.e, Focal, contextual and residual stimuli related to
the problems identified.

101. IMPORTANCE OF THOROUGH PHYSICAL
EXAMINATION: A LOST ART
- ASIF ET AL
• Several recent studies have described a deterioration
in physical examination skills among modern
physicians. Reasons hypothesized for this change are
improvements in technology and time constraints.
Poor physical exam skills are a noteworthy threat to
patient safety as they can lead to incorrect as well as
missed diagnoses, causing delays in timely
implementation of life-saving treatments.

102. • Here, they present a case of extensive acute embolic
strokes secondary to infective endocarditis. The
patient was initially misdiagnosed as having Bell’s
palsy due to incorrect physical examination. Through
this case, they highlight the importance of
management guided by a thorough history and
physical examination to minimize diagnostic errors.

103. WHY THE HISTORY AND PHYSICAL
EXAMINATION STILL MATTER
• The history and physical examination (H/PE) have been
the foundation of medical diagnosis for centuries.
However, as laboratory tests and diagnostic imaging has
expanded, physical examination skills have been
deemphasized in medical education, and clinicians have
become more reliant on tests and imaging. This article
describes the historical contributions of the H/PE and its
resurgence in a refined form to improve diagnosis.

104. ASSIGNMENT
• Write an assignment on history and physical
examination of a patient with Cirrhosis of Liver.

105. BIBLIOGRAPHY
• https://www.gcu.ac.uk/media/gcalwebv2/hls/content/History%20
Taking.pdf
• Potter AP, Perry GA. Basic nursing essentials for practice. 6th
edition. India: Mosby Elsevier; 2007
• Taylor C, Lillis C, Lemone P. Fundamentals of nursing art and
science of nursing care . fifth edition. India: Wolter Kluwer; 2006.
• Smeltzer CS, Bare GB, Hinkle LJ, Cheever HK. Brunner &
Suddarth’s textbook of Medical-surgical nursing. Volume I.
Twelvth edition. NewDelhi:Wolters Kluwer (India) ; 2011.