Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY

The Premier University in Zamboanga del Norte
Main Campus, Dapitan City

College of Nursing and Allied Health Sciences

GUIDELINES ON PHYSICAL ASSESSMENT

Note: The physical assessment (PA) format should be used for case presentations and case reports. The review of
systems is a simplified form of the PA format in which the system/s affected will be the focus of the assessment. The
bedside nurse may subscribe to this format for purposes of complying with the requirement under this section.

General Preparation & Procedures:

1. Assemble equipment and supplies.
2. Explain to the client what you are going to do, why it is necessary, and how she can cooperate.
3. Wash hands and observe other appropriate infection control procedures.
4. Provide for client privacy.

THIS DOES NOT INCLUDE THE ASSESSMENT OF THE NEUROLOGICAL SYSTEM.

PLEASE SEE ASSESSMENT TOOL IN THE REFERENCE BOOK USED IN YOUR HEALTH ASSESSMENT SUBJECT.

SYSTEM/ AUSCULTATE/
HISTORY INSPECT PALPATE PERCUSS
POSITION OTHER TESTS
Body build, height, Body & breath odor
weight,
Attitude
Posture & gait,
standing, sitting, Appropriateness of
walking affect/mood
General
Exam/Mental
Quantity, quality &
Status Signs of distress in organization of
posture or facial speech
expression
Thought relevance &
Obvious signs of organization
health or illness
History: Pain, Inspect: color & Palpate: lesions,
itching, presence & uniformity of color, moisture,
spread of lesions, edema, lesions temperature (feet &
bruises, abrasions, hands), turgor
and pigmented
spots, skin Draw location of
Skin problems, systemic lesions if present
conditions, use of
medications/home
remedies, dry/moist
feel, tendency to
bruise easily

History: Inspect: growth

dye/chemical use, evenness, thickness,
chemotherapy, texture, infections
Hair
disease (part hair, behind
ears, along neck
hairline)
History: DM, Inspect: shape
circulatory disease, (curve & angle), nail
past injury, severe & nailbed color,
Nails
illness blanch test (capillary
refill), tissue around
nails
History: lumps, Inspect: size, shape,
bumps, itching symmetry, facial
features, eye edema
& hollowness,
symmetry of
Skull & Face
movements (frown,
elevate/lower brows,
close eyes tightly,
puff cheeks, smile,
show teeth
History: DM, HPN, Inspect: distribution Peripheral visual
Eyes & Visual
blood dyscrasias, & alignment of fields
Acuity eye disease, injury, eyebrows and
 surgery, last visit, eyelashes, eyelids Six ocular
eye meds, assistive for position and movements for eye
devices & care, eye blinking ability, alignment &
problem symptoms conjunctiva, lacrimal coordination
glands, lacrimal sac
& nasolacrimal duct, Near vision, distant
cornea for clarity & vision, Snellen’s
texture, corneal chart (if unable to
reflex, anterior see top line)
chamber for
transparency &
depth, papillary
color, shape &
symmetry, PERRLA
History: genetic & Inspect: auricles for Hearing acuity:
existing hearing color, symmetry & Watch tick test (1-2”
problems or loss, position from ear), Tuning
medication history Palpate: auricles for fork tests (Weber,
(if with tinnitus), texture, elasticity & Rinne)
hearing difficulties, tenderness
use of assistive
Ears & Hearing
devices Otoscope: external
ear canal for
cerumen, lesions,
pus, blood, color &
gloss of tympanic
membrane

History: allergies, Inspect: external Palpate: external

DOB thru nose, nose for shape, size, nose for tenderness,
sinusitis, nasal or color, flaring or masses,
facial injuries, discharges; use displacements of
nosebleeds, flashlight or nasal bone & cartilage;
Nose & Sinuses medications, speculum; redness check patency of
changes in sense of swelling, growths & nasal cavities
smell discharge; nasal (alternate closure);
septum maxillary & frontal
sinuses for
tenderness
History: routine Inspect: Lips for Palpate: inner lips & Elicit: gag reflex
dental care pattern, symmetry, contour, buccal mucosa for (press on posterior
last visit to dentist, & color (pout as if to texture, moisture & tongue w/ tongue
presence of ulcers, whistle), inner lips & lesions, tongue & depressor
denture discomfort, buccal mucosa for floor for nodules,
medications color, moisture, lumps, or excoriated
texture, and areas
presence of lesions,
teeth & gums while
examining inner lips
& buccal mucosa,
dentures
(complete/partial,
condition), surface
of tongue for
position, color, &
Mouth &
texture, tongue
Oropharynx movement (up, side
to side), base of the
tongue, mouth floor,
frenulum, salivary
duct openings for
swelling & redness,
hard & soft palate
for color, shape,
texture & bony
prominences, uvula
for position &
mobility (say “ah”),
oropharynx for color
& texture, tonsils for
color, discharge, &
size
Fingernails,
clubbing, finger
Hands, Arms, nodules, finger
and Shoulders joints deformity,
rashes, pain and
stiffness in the
 elbow and shoulder,
ROM, reflexes,
pulses, presence of
lesions
History: neck lumps, Inspect: neck Palpate: entire neck Auscultate: ONLY if
neck pain/stiffness, muscles (SCM & for enlarged lymph thyroid gland is
previous thyroid trapezius) for nodes, trachea for enlarged; use the
problems, swelling & masses, lateral deviation, BELL
treatments such as head movements thyroid gland for
Neck surgery & radiation (chin-to-chest, head smoothness Muscle strength:
side-to-side, lateral turn head to side
rotation – SCM, chin and shrug shoulders
upwards – against resistance of
trapezius) your hand, thyroid
gland
History: Illness Inspect: shape & Palpate: posterior
including cancer, symmetry of thorax thorax, posterior
allergies, TB, from posterior & chest for respiratory
smoking & lateral views, spinal excursion (thumbs
occupational alignment for adjacent to spine &
Thorax and hazards, meds being deformities (3 fingers stretched
Lungs taken, current normal curvatures – laterally, ask client
problems (cough, cervical, thoracic, to take a deep
swelling, wheezing, lumbar) breath, observe for
pain) lag in movement),
chest for vocal
(tactile) fremitus
History: family for Inspect: jugular Palpate: carotid Auscultate: heart in
incidence & age of veins for distention artery CAUTIOUSLY all four anatomic
heart disease, high (Semi-Fowler’s w/ sites (aortic,
cholesterol, high BP, head supported on a pulmonic, tricuspid,
stroke, obesity, small pillow; if w/ apical/mitral);
congenital heart distention, locate carotid artery for
disease, arterial highest visible point bruit
disease, HPN, & of distention &
RHF; client for RHF, measure vertical
heart murmur, heart height in
attack, varicosities, centimeters from
or HF; present sternal angle)
symptoms indicative
of heart disease; Inspect & Palpate:
presence of diseases precordium for
that affect heart; presence of
lifestyle habits that abnormal pulsations,
 risk for heart lifts, or heaves
Heart & Central disease (aortic & pulmonic
Vessels areas first at an
angle and to the
side, note absence
or presence of
pulsations; tricuspid
area for pulsations,
heaves, or lifts;
apical area for
pulsations, note
specific location &
diameter, if
displaced laterally,
record distance
between apex &
MCL in centimeters;
epigastric area at
base of sternum for
abdominal aorta
pulsations)
History: heart Inspect: peripheral Palpate: peripheral
disorders, veins in arms & legs pulses (except
varicosities, arterial for superficial veins carotid pulse) on
disease, in dependent & both sides of the
hypertension; elevated positions; body individually,
Peripheral lifestyle patterns peripheral leg veins simultaneously, &
Vascular (exercise, activity, for signs of systematically to
System tolerance); smoking phlebitis; skin of determine symmetry
habits & use of hands & feet for of pulse volume
alcohol color, temperature,
edema, & skin
changes; assess
adequacy of arterial
 flow if arterial
insufficiency is
suspected
History: BSE Inspect: breast for Palpate: axillary, Teach: BSE
(technique, when size, symmetry, subclavicular, technique
performed in contour, or shape supraclavicular
relation to mens while in a sitting lymph nodes (seated
cycle); breast position; skin of w/ arms abducted &
masses; pain or breast for localized supported on
tenderness in the discolorations/hyper nurse’s forearm, use
breasts in relation to pigmentation, flat surfaces of
mens cycle; retraction, or fingertips to palpate
discharges from dimplimping, four areas – edge of
nipple; med history; localized greater pectoral
estrogen HRT; hypervascular areas, muscle along
alcohol swelling, or edema; anterior axillary line,
consumption; high- emphasize retraction thoracic wall in
Breast & Axillae fat diet; obesity; use (raise arms above midaxillary area,
of oral head, push hands upper part of
contraceptives; together w/ flexed humerus, anterior
menarche before 12, elbows, press down edge of latissimus
menopause after on hips; areola for dorsi muscle along
age 55, pregnancy size, shape, the posterior axillary
after 30 symmetry, color, line; breast for
surface masses, tenderness,
characteristics, & & nipple discharges;
masses/lesions; areola & nipples for
nipples for size, masses (compress
shape, position, each nipple, if
color, discharge, & present, milk along
lesions its radius); note
tenderness
Abdomen History: abdominal STEP 1. Inspect: STEP 4. Palpate: STEP 3. STEP 2.
pain – location, abdomen for skin abdomen, light Percuss: Auscultate: bowel
Position: supine onset, sequence, integrity, contour, & palpation to detect abdomen, follow sounds (Normal 1:5-
w/ arms placed chronology, quality, symmetry (hold areas of tenderness LLQ, LRQ, URQ, 20 seconds,
comfortably at frequency, & breath, watch from & guarding in all 4 ULQ pattern; Hyperactive 5-6:30
the sides w/ associated side & from foot quadrants, then liver to seconds, hypoactive
small pillows symptoms; bowel part; measure girth deep palpation; liver determine size 1-2:2 minutes,
beneath knees & habits; constipation by placing tape to detect absent 0:3-5
head to reduce or diarrhea; change around abdomen AT enlargement & minutes), vascular
tension in the in appetite; food LEVEL of umbilicus); tenderness; bladder sounds, peritoneal
abdominal intolerances; foods abdominal above the pubic friction rubs
muscles; expose ingested in last 24 movements symphysis if history
only client’s hours; specific signs associated w/ indicates retention
abdomen from & symptoms; respiration; vascular
chest line to previous problems & pattern
pubic area (avoid treatment
chilling &
shivering)
History: age at Inspect: pubic hair Palpate: inguinal
menarche, LMP, for distribution, lymph nodes
regularity of cycle, amount, &
duration, amount of characteristics; skin
Female Genitals daily flow, & if mens of pubic area for
& Inguinal Area is painful; pain parasites,
during intercourse; inflammation,
Position: supine vaginal discharge; swelling, & lesions
w/ feet elevated number of (separate labia
on stirrups of an pregnancies; majora & minora);
examination number of live clitoris, urethral
table; Alternative births; labor or orifice, & vaginal
– dorsal delivery orifice when
recumbent w/ complications; separating labia
knees flexed & urgency & frequency minora
thighs externally of urination at night;
rotated blood in urine;
painful urination;
incontinence; history
of past & present
STD

History: usual Inspect: pubic hair Palpate: penis for

voiding patterns & for distribution, tenderness,
Male Genitals &
any changes, amount, & thickening, &
Inguinal Area bladder control, characteristics of nodules (use thumb
urinary pubic hair; penile + two fingers);
 incontinence, shaft & glans penis scrotum to assess
frequency, or for lesions, nodules, status of underlying
urgency; abdominal swellings, & testes epididymis, &
pain; any symptoms inflammation, spermatic cord
of STD; any urethral meatus for (palpate both testes
swellings that could swelling,, simultaneously);
indicate hernia; inflammation, & hernias
family history of discharge (compress
nephritis, glans to open
malignancy of meatus; if w/
prostate or kidneys discharge, strip
penis from base to
urethra); scrotum
for appearance,
general size, &
symmetry (hold
penis out of the
way, spread rugated
skin surface & lift
scrotum PRN); both
inguinal areas for
bulges while client is
standing (hold
breath & bear down)

History: muscle pain Inspect: muscles for Palpate: muscles at

onset, location, size (compare each rest to determine
character, muscle on one side tonicity; muscles at
associated to the other side, active & passive
phenomena, measure w/ tape if movement for
aggravating, & w/ discrepancies); flaccidity, spasticity,
alleviating factors; muscles & tendons & smoothness of
limitation to for contractures, movement; bones to
movement or fasciculations & locate any areas of
inability to perform tremors (hold arms edema or
Musculoskeletal ADLs; previous out in front of the tenderness; joints
System sports injuries; any body); skeleton for for tenderness,
loss of function w/o normal structure & smoothness of
pain deformities; joint for movement, swelling,
swelling; joint ROM crepitation, &
(move selected body presence of nodules;
parts, measure muscle strength
angle of joint in
degrees using
goniometer, if
available)

Rectum and History: bright blood Inspect: anus & Palpate: rectum for
Anus in stools, tarry black surrounding tissue anal sphincter
stools, diarrhea, for color, integrity, & tonicity, nodules,
Position: left constipation, skin lesions (while masses, tenderness;
latera/Sims’ abdominal pain, bearing down, observe for feces
position w/ upper excessive gas, describe location in upon withdrawal of
leg acutely hemorrhoids, or clock pattern) gloved finger
flexed; rectal pain; family
Alternatives – history of colorectal
lithotomy/dorsal cancer, last FOBT &
recumbent w/ results, any signs or
hips externally symptoms of
rotated prostate
(females), enlargement
standing position
while bending
over the table
(males)

Prepared by:

ROQUEE HOSPICIO H. PARAGOSO, BSN, RN

BSN IV Clinical Instructor

Reference:
Kozier, Barbara, et al. 2004. Fundamentals of Nursing Checklist Seventh Edition. Pearson Education, Inc: New Jersey