General History taking and physical examinatin

1. General history taking &
physical examination
Presented by
Praseedha.s
1st year msc nursing

2. HEALTH
HISTORY
PHYSICAL
ASSESSMENT

3. HEALTH HISTORY
• A health history is the collection of subjective data
that provides a detailed profile of the patient health
status.
• The nursing health history is data collected about the
client’s current level of wellness, including a review
of body systems, family, and health history,
sociocultural history, spiritual health, and mental
and emotional reactions to illness.
• Therapeutic communication skill and interview
technique used to gather health history.
• It helps to identify actual and potential health
problem.

4. OBJECTIVES
• To identify patterns of health & illness.
• To identify risk factors for physical &
behavioral health problems.
• To identify deviations from normal.
• To identify available resources for adaptation.

5. GUIDELINES
• Establish rapport, put the patient at ease,
encourage honest communication, make eye
contact, and listen carefully to the patient’s
responses to questions about health issues.
• Be aware of his or her own nonverbal
communication, as well as that of the patient.
•Consider patients educational and cultural
background as well as language proficiency.

6. Continues.....
•Phrase questions that is easily
understandable.
•Avoid medical jargon and technical terms.
•Consider the patients disabilities or
impairments (hearing, vision, cognitive, and
physical limitations).
•At the end, summarize and clarify the
information obtained and ask the patient if
he or she has any questions: to correct
misinformation and add facts that may have
been omitted.

7. Physical examination is an integral part of health
examination and it includes head to toe examination
of the patient to rule out any deviation from the
normal.
PHYSICAL EXAMINATION

8. Physical examination
•Physical examination is defined as a
complete assessment of a patient’s
physical and mental status.
•A physical assessment is the systematic
collection of objective information that is
directly observed or is elicited through
examination techniques

9. PURPOSE
•SEE FLASH CARD
•.

10. PREPARATIONS
Comfort
Position,
gowning
Height of
examination
table
Light
sources
Eliminate
distractions
Equipments:
clean & in
working
condition

11. INSTRUMENTS
SUPPLIES PURPOSE
Flash light or
penlight
To assist viewing of the pharynx and
cervix or to determine the reactions
of the pupils of the eye
Nasal speculum to visualization of the lower and
middle turbinates
Opthalmoscope To visualize the interior of the eye
Otoscope To visualized the ear drum and
external auditory canal
Knee hammer To test reflex

12. INSTRUMENTS
SUPPLIES PURPOSE
Tuning fork To test hearing acuity and vibratory sense.
Vaginal speculum To assess cervix and vagina
Cotton applicator To obtain specimens
Gloves To prevent contamination
Lubricant To ease insertion of instruments
Tongue depressors To depress the tongue
Stethoscope To auscultate heart, lung, abdomen and
cardiovascular sound.
Thermometer To check the temperature

16. METHODS OF EXAMINING:
1. Inspection:
A method of systematic observation.
Inspection should begin with general
observation of the patient progressing to
specific body areas.

17. 2. Palpation:
Process of examining patients by application of
the hands.
Used to determine:
• Consistency of tissue.
• Alignment and intactness
of structures.
• Symmetry of body parts.
• Areas of warmth and
tenderness.

18. Parts of hands used for various
palpation:
Part of hand Type of palpation
Finger tips To assess texture, shape,
size, consistency and
palpation
Dorsum of hand and
fingers
To assess temperature
Palm of hand To assess vibration
Pinching of fingers To assess turgor,
consistency and position

19. PRINCIPLES OF PALPATION
•You should have short fingernails.
• You should warm your hands prior to placing them
on the patient.
• Encourage the patient to continue to breathe
normally throughout the palpation.
• If pain is experienced during the palpation.
discontinue the palpation immediately.
• Inform the patient where, when, and how the
touch will occur, especially when the patient cannot
see what you are doing.

20. For light palpation, press the skin gently with the
tips of two or three fingers held close together.

21. DEEP PALPATION

22. 3. Percussion:
Tapping of the body lightly but sharply to
determine consistency of tissues and/or organs
through vibration `& areas of tenderness.

23. PERCUSSION
The sounds may be:
• Resonance: a low pitched and loud sound
heard over the normal lung tissues.
• Hyper resonance: very loud , very low
pitched sound longer than resonance
signifies emphysema.
• Tympany : a drum like sound heard over
the air filled tissues such as gastric air
bubble.
• Dull: A medium pitched sound with a
medium duration without resonance
heard over solid tissues such as heart ,
liver.

24. Percussion sound with examples:
Percussion
sounds
Intensity Pitch Percussion
example
Dullness Medium Moderate Liver
Resonance Loud Low Normal lung
Hyper
resonance
Very loud Lower Emphysematous
lung
Tympany Loud Higher Puffed out cheek
, gastric air
bubble

25. 4. Auscultation:
Process of listening for sounds over body
cavities to determine presence and quality of
heart, lung, and bowel sounds.

26. TYPES OF AUSCULTATION
Direct auscultation: use of
unaided ear
Indirect auscultation:
use of
stethoscope

27. PROCESS OF HEALTH
ASSESSMENT:
I. GENERAL APPEARANCE & BEHAVIOR:
i) Gender and race: Certain illnesses are more likely to
affect the specific gender and race. Eg. Risk of having
skin cancer is 20% higher in whites than in blacks.

28. ii) Age: Age influences the normal physical
characteristics.
iii) Signs of distress: There may be obvious signs
and symptoms indicating pain, difficulty in
breathing or anxiety.

29. iv) Body type: Trim, muscular, obese or
excessively thin.

30. v) Posture: Observe whether the client has a
slumped, erect or bent posture.

31. vi) Gait: Observe the walking pattern of the
client. Not whether the movements are
coordinated or uncoordinated.

32. vii) Body movements: Note for any tremors
involving the extremities.
viii) Hygiene and grooming: Note the appearance
of hair, skin and finger nails. Also observe for the
clothing.
ix) Affect and mood: Affect is a person’s feelings
as they appear to others.
x) Speech: An abnormal pace may be caused by
emotions and neurological impairments.
xi) Substance abuse: Check for the history of
substance abuse.

33. VITALS SIGNS

34. HEIGHT ANDWEIGHT:

35. PHYSICAL EXAMINATION:

36. Look
(Inspection)
Listen
(auscultation)
Feel
(palpation)
Tap
(percussion)
Smell
(olfaction)
SKILLS OF PHYSICAL EXAMINATION

37. HEAD TO TOE ASSESSMENT
A. THE INTEGUMENT:
The integument includes skin, hair and nails. The
examination begins with a generalized inspection using
a good source of lighting.
1. SKIN: Assessment of the skin involves inspection and
palpation.
• Pallor/Jaundice
• Cyanosis
• Erythema
• Edema

38. • Cyanosis
Erythema

39. Jaundice

40. Pallor

41. Inspect skin vascularity
•Ecchymosis

42. Petechiae

43. C Inspect skin lesion

44. Palpate skin temperature, texture,
moisture and turgor

45. EDEMA

46. PITTING EDEMA

47. PITTING EDEMA
• Grades of pitting edema
• Grade 0 : (none)
• Grade +1 :( trace , 2 mm)
• Disappear rapidly
• Grade +2 ( moderate , 4 mm)
• 10-15 sec
• Grade +3 (deep, 6 mm)
• ≥ 1min
• Grade +4 (very deep, 8 mm)
• 2-5min

48. • SENILE KERATOSIS: Thickening of skin.
• CHERRY ANGIOMAS: Ruby red papules.
• MACULE: Flat, non palpable change in skin color smaller than 1cm
• PAPULE: Palpable, circumscribed solid elevation in skin, smaller than 0.5cm
• NODULE: Elevated solid mass, deeper and firmer than papule0.5-0.2cm
• TUMOUR: Solid mass that may extend deep through subcutaneous tissue,
larger than 1-2cm.
• WHEAL: Irregularly shaped elevated area or superficial localized edema;
varies in size.
• VESICLE: Circumscribed elevation of skin(filled with serous fluid, smaller
than 0.5cm
• PUSTULE: Circumscribed elevation of skin similar to vesicle but filled with
pus; varies in size.
• ULCER: Deep loss of skin surface that may extend to dermis and frequently
bleeds and scars; varies in size.
• ATROPHY: Thinning of skin with loss of normal furrow, with skin appearing
shiny and translucent; varies in size.

49. 2. HAIR: Inspect the hairs for colour, alopecia (hair loss) and
the cleanliness of the scalp.
3. NAILS: Nails are inspected for nail plate shape, angle
between the nail and the nail bed, nail texture, nail bed
colour and the intactness of the tissues around the nails.
Clubbing is a condition in which
the angle between the nail and
nail bed is 180 degree or greater.
It may be caused by long term
lack of oxygen.

50. NORMAL NAIL SHAPE
• Technique: view the index finger note the angle of
the nail base it should be above 160 degree.

51. ABNORMAL NAIL SHAPES
Early clubbing
Late clubbing

52. B. HEAD:
a. Eyes: Examine the conjunctiva,
sclera. Test pupils for irregularity,
accommodation, and reaction.
Evaluate visual fields and visual
acuity.

53. Vision
Visual activity(ability to see small
detail): by snellens chart.
Peripheral vision:

54. • HYPEROPIA: Farsightedness,
• MYOPIA: Nearsightedness
• PRESBYOPIA: Impaired near vision in middle age and older adults
• ASTIGMATISM: Parallel light rays do not focus on a single point on the retina.
• RETINOPATHY: Non inflammatory eye disorder resulting from changes in
blood vessels.
• CATARACTS: Increased opacity of the lens,
• GLAUCOMA: Intraocular structural damage
• MACULAR DEGENERATION: Blurred central vision
• NYSTAGMUS: An involuntary, rhythmical oscillation of the eyes.
• EXOPHTHALMUS: Bulging eye balls
• STRABISMUS: Crossing of eyes results from neuromuscular injury or inherited
abnormalities.
• PTOSIS: An abnormal drooping of eyelid over the pupil,
• ECTROPION: Lid margins that turn out
• ENTROPION: Lid margins that turns in.
• CONJUNCTIVITIS: Inflammation of the conjunctiva.
• ARCUS SENILIS: A thin white ring along the margin of the

55. b. Ears: Examine the pinna and peri-auricular
tissues. Test auditory acuity, perform Weber
and Rinne tests.

56. EARS
Examination of ears: Pull the ears backward and
upward.
Instrument used: Auto scope
• External ears: Crusts, discharges, lesions etc.
• Tympanic membrane: Normally it is shiny, translucent,
with a pearl grey color. See for any perforation,
lesions, bulging.
• Hearing: There are 3 ways for testing the hearing.

57. Weber's test
It is used to assess the conductive
hearing loss.
Technique: Place a vibrating tuning
fork in the midline of the persons
skull and ask if he can hear the
sounds same in both the ears or
better in one ear.
Result :
The person should hear the tone
produced by bone conduction
equally in both ears, is the positive
test result

58. Rinne test
This is a test to compare the air conduction and the
bone conduction sounds.
Technique:
Place the stem of the vibrating tuning fork on
persons mastoid process and ask him or her to signal
when the sound disappears note the time in
seconds. Invert the tuning fork so the vibrating end is
near the ear canal he should hear the sound.
Note the time in seconds.
Results : AC : BC = 2 : 1

59. c. Nose: Connect the nasal speculum to the otoscope and
examine the nares, noting the condition of the
mucosa, septum and turbinate's.
d. Mouth: Examine the oral mucosa, the
tongue and teeth. Evaluate the
function of cranial nerves IX, X,
and XII.
e. Face: Evaluation of symmetry, smile, frown, and jaw
movement will provide information about motor
divisions of cranial nerves V and VII.

60. C. Neck:
Palpate the neck with emphasis on the salivary glands,
lymph nodes, and thyroid. Look for tracheal deviation.
Identify the carotid arteries and auscultate for bruits.

61. • Lymph nodes are assessed by palpating with the pad of the
finger for enlargement , tenderness and mobility .
• Normally nodes are not palpable. If palpable they should
be small, mobile, smooth and non tender.
LYMPH NODES

62. Thyroid : palpation for size , symmetry ,
tenderness and nodules.

63. Trachea: Palpation for alignment and position:
unequal space between trachea and sterno-cleido
mastoid muscle on each side is abnormal, indicative
of trachea displacement.

64. CAROTID ARTERY :
Palpate one carotid
artery at a time just
below the upper
border of the thyroid
cartilage.

65. RESPIRATORY ASSESSMENT:

67. Funnel chest (Pectus excavatum
describes an abnormal formation
of the rib cage that gives the chest
a caved-in or sunken appearance.)
Pigeon chest (Pectus carinatum, is
a deformity of the chest
characterized by a protrusion
of the sternum and ribs.)

68. D. CHEST AND LUNGS:
i) Inspection:
• Observe the rate, rhythm, depth, and effort of breathing.
• Listen for abnormal sounds such as wheezes.
• Observe for retractions.
ii) Palpation:
• Identify any areas of tenderness.
• Assess expansion and symmetry
of the chest.
• Check for tactile fremitus, bronchophony, whispered
pectoriloquy, ego phony.

69. iii) Percussion:
Percuss from side to side and top to bottom .
Categorize what you hear as normal, dull, or hyper
resonant.
INTERPRETATION:Percussion Notes and Their Meaning:
Flat or Dull Pleural Effusion or Lobar
Pneumonia
Normal
Healthy Lung or Bronchitis
Hyper resonant Emphysema or
Pneumothorax

71. AUSCULTATE BREATH SOUNDS
• Bronchial sounds heard over the trachea are high –
pitched, harsh sounds with expiration longer than
inspiration .
• Bronchovesicular sounds: heard over the main stem
bronchus and is moderate (blowing) sound with
inspiration equal to expiration.
• Vesicular sounds are soft , low pitched and heard best in
base of lungs during inspiration longer than expiration.

72. iv) Auscultation:
Use the diaphragm of the stethoscope to auscultate
breath sounds. Note the location and quality of the
sounds you hear.

73. Areas of Auscultation
:

74. ABNORMAL BREATH SOUNDS :
Crepts : fine, short interrupted sound heard during
inspiration and expiration. Example : Respiratory distress.
Rhonchi : low pitched continuous musical sound heard
during expiration and clears with coughing. Example :
Pneumonia.
Wheeze : high pitched continuous musical sound heard
during inspiration or expiration and does not clear with
coughing. Example : Pneumonia .
Pleural friction Rub : grating type of sound heard during
inspiration and does not clear with coughing, example :
Empyema .

75. BREASTS,AXILLAE
 INSPECT FOR SIZE&SYMMETRY, CONTOUR OR SHAPE,
NOTE MASSES, RETRACTION.
 PALPATE LYMPH NODES, CONSISTENCY

76. CARDIAC ASSESSMENT:
• Inspection of the Heart
The chest wall and epigastrium is
inspected while the client is in
supine position. Observe for
pulsation and heaves or lifts.
Normal Findings:
• There should be no lift or heaves.

77. PALPATION OF THE HEART
The entire pre-cordium (anterior surface of the body covering
the heart and lower thorax) is palpated methodically using the
palms and the fingers, beginning at the apex, moving to the
left sternal border , and then to the base of the heart.
NORMAL FINDINGS:
• No, palpable pulsation over the
aortic, pulmonary, and mitral valves.
• Apical pulsation can be felt on
palpation.
• There should be no noted abnormal
heaves, and thrills felt over the apex.

78. Percussion of the Heart
• The technique of percussion is of
limited value in cardiac assessment. It
can be used to determine borders of
cardiac dullness.
Auscultation of the Heart
• Aortic valve – Right 2nd intercostal
space (ICS) sternal border.
• Pulmonary Valve – Left 2nd ICS sternal
border.
• Mitral Valve – Left 5th ICS
midclavicular line.
• Tricuspid Valve – Left 5th ICS sternal
border

79. AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonic
and aortic

80. Auscultating the heart
–Auscultate the heart in all anatomic areas aortic,
pulmonic, tricuspid and mitral.
–Listen for the S1 and S2 sounds (S1 closure of AV
valves; S2 closure of semi-lunar valve).
–Listen for abnormal heart sounds e.g. S3, S4, and
Murmurs.
–Count heart rate at the apical pulse for one full
minute.
Normal Findings:
• S1 & S2 can be heard at all anatomic site.
• No abnormal heart sounds is heard (e.g. Murmurs, S3 &
S4).
• Cardiac rate ranges from 60 – 100 beats per min.

81. ABDOMINAL ASSESSMENT

82. E. ABDOMINAL ASSESSMENT:
Abdomen is divided into 4 main quadrants:
• Right Upper Quadrant (RUQ)
• Right Lower Quadrant (RLQ)
• Left Upper Quadrant (LUQ)
• Left Lower Quadrant (LLQ)

84. i) Inspection:
• Look for scars, striae, hernias, vascular changes, lesions, or
rashes, movement associated with peristalsis or pulsations.
• Note the abdominal contour. Is it flat, scaphoid, or
protuberant?
ii) Auscultation:
• Place the diaphragm lightly on the
abdomen, listen for bowel sounds.
• Listen for bruits over the renal
arteries, iliac arteries, and aorta.

85. iii) Percussion:
• Percuss in all four quadrants using proper technique.
• Categorize what you hear as tympanitic or dull.
Tympany is normally present over most of the
abdomen in the supine position. Unusual dullness
may be a clue to an underlying abdominal mass.

86. Liver Span
• Percuss downward from the chest in the right mid-
clavicular line until you detect the top edge of liver
dullness.
• Percuss upward from the abdomen
in the same line until you detect the
bottom edge of liver dullness.
• Measure the liver span between these
two points. This measurement should
be 6-12 cm in a normal adult.

87. Splenic Dullness
• Percuss the lowest costal interspace
in the left anterior axillary line.
This area is normally tympanitic.
• Ask the patient to take a deep
breath and percuss this area again.
Dullness in this area is a sign of
splenic enlargement.

88. vi) Palpation:
Palpation of the Liver
a. Standard Method:
• Place your fingers just below the
right costal margin and press firmly.
• Ask the patient to take a deep breath.
• You may feel the edge of the liver press against your
fingers. Or it may slide under your hand as the patient
exhales. A normal liver is not tender.

89. b. Alternate Method:
• This method is useful when the patient is obese or
when the examiner is small compared to the patient.
• Stand by the patient's chest.
• "Hook" your fingers just below
the costal margin and press
firmly.
• Ask the patient to take a deep breath.
• You may feel the edge of the liver press against your
fingers.

90. •PALPATION OF THE AORTA,SPLEEN
•SPECIAL TESTS: REBOUND TENDERNESS,
COSTOVERTEBRAL TENDERNESS, SHIFTING
DULLNESS, PSOAS SIGN,OBTURATOR SIGN

91. MUSCULOSKELETAL SYSTEM
• Upper and lower Extremities are assessed for size
and symmetry , various patterns , colour and texture
of skin and nail beds , hair distribution on hands ,
lower legs , feet and toes . Observe for pigmentation ,
rashes , scars , ulcers and edema.
• Palpate for tenderness, deformity.
• Range of motion – active & passive
• VASCULAR: pulses, capillary refill, edema, cyanosis,
and clubbing, lymphatic's

92. SPECIALTESTS
• UPPER EXTREMITIES: Snuffbox tenderness, drop
arm test, impingement sign, flexor digitorum
superficialis test, flexor digitorum profundus test.
• Vascular & neurologic: Allen test, phalen’s test,
tinel’s sign
• LOWER EXTREMITIES: Collateral ligament testing,
lachman test, anterior/posterior drawer test,
ballotable patella, milking the knee.
• BACK: Straight leg raising, FABER test

93. HOMAN’S SIGN
• Test for homan’s sign, an indicator of phlebitis in which
pain and soreness are present in the calf area when the
foot is dorsiflexed .The person’s dorsiflexed leg is
supported from calf with your non dominant hand . Note
any pain or soreness in the calf area. If present this would
be a positive homan’s sign ,indicating the possibility of
phlebitis .

94. NEUROLOGICAL SYSTEM

95. MENTAL AND EMOTIONAL
STATUS:

96. CONSCIOUSNESS
Assessment of consciousness begins with noting
whether the client is awake and alert . If the person
has altered the level of consciousness , assess whether
the person is demonstrating stupor or coma . Glasgow
coma scale to be maintained for the patient with
altered sensorium and in that three points are
observed: eye open response, verbal response and
motor response .

97. GLASGOW COMA SCALE
ACTION RESPONSE SCORE
SPONTANEOUSLY 4
EYES OPEN TO SPPECH 3
TO PAIN 2
NONE 1
BEST ORIENTED 5
VERBAL CONFUSED 4
RESPONSE INAPPROPRIATE WORDS 3
INCOMPREHENSIBLE SOUNDS 2
NONE 1
OBEYS COMMANDS 6
LOCALIZED PAIN 5
BEST FLEXION WITHDRAWL 4
MOTOR ABNORMAL FLEXION 3
RESPONSE ABNORMAL EXTENSION 2
FLACCID 1

98. BEHAVIOUR AND APPEARANCE

99. LANGUAGE

100. INTELLECTUAL FUNCTION
•Memory
•Knowledge
•Abstract thinking
•Association
•Judgment

101. CRANIAL NERVE FUNCTION
•Olfactory nerve(1):
•Optic nerve(2)
•Occulomotor(3)
•Trochlear(4)
•Trigeminal(5)
•Abducens(6)

102. CRANIAL NERVE FUNCTION
• Facial(7)
• Auditory(8).
• Glossopharyngeal(9)
• Vagus(10)
• Spinal accessory(11
• Hypoglossal(12)

103. Cranial Nerve I - Olfactory Nerve
Before testing nerve function, ensure patency
of each nostril by occluding in turn and asking
patient to sniff
Once patency is established, ask patient to close
eyes
Occlude one nostril and hold aromatic
substance (coffee) beneath nose
Ask patient to identify substance
Repeat with other nostril

104. Cranial Nerve I - Olfactory
Normal:
■ Patient is able to
identify substance.
(Bear in mind that
some substances may
be unfamiliar,
especially to children)
Abnormal:
■ Anosmia - loss of sense of smell.
• May be inherited and non-
pathological: chronic rhinitis,
sinusitis, heavy smoking, zinc
deficiency, or cocaine use.
• It may also indicate cranial nerve
damage from facial fractures or
head injuries, disorders of base of
frontal lobe such as a tumor, or
atherosclerotic changes.

105. Cranial Nerve II - Optic Nerve
Use the snellen chart to check/test:
- distant vision
- color
Client should be 20 feet distant from the chart
Use an object to occlude one eye
Evaluate the vision one eye at a time

106. Testing eye
movements
Testing pupil
accommodation
Cranial Nerves III, IV and VI
=> Test for ocular rotations,
conjugate movements, nystagmus
** Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis -
using direct & consensual pupillary reaction to light

107. Normal:
■ Able to read without
difficulty
■ Visual acuity intact
20/20, both eyes
Hippus phenomenon:
Brisk constriction of
pupils in reaction to
light, followed by
dilation and
constriction
- may be normal or sign
of early CN III
compression.
Abnormal:
■ CN II deficits
- can occur with stroke or brain
tumor.
■ Changes in pupillary
reactions
- can signal CN III deficits.
■ Increased ICP causes
changes in pupillary reaction
As pressure increases,
response becomes more
sluggish until pupils
finally become fixed and
dilated.

108. CN V - Trigeminal Nerve
a. Testing motor function:
- Ask patient to move jaw from side to side
against resistance and then clench jaw as
you palpate contraction of temporal and
masseter muscles, or to bite down on a
tongue blade.

109. CN V - Trigeminal Nerve
a. Testing motor function:
- Ask patient to move jaw from side to side
against resistance and then clench jaw as
you palpate contraction of temporal and
masseter muscles, or to bite down on a
tongue blade.

110. Testing CNV –
sensory function
CN V - Trigeminal Nerve
b. Testing sensory function:
- Ask patient to close eyes
- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels
sensation on the face.
- Repeat the test using sharp and dull stimuli
(toothpick or tongue blade)
- Instruct to say “Sharp” or “Dull”
(Be random, don’t establish a pattern)

111. Testing corneal reflex
Cranial Nerve V - Trigeminal Nerve
c. Testing corneal reflex:
- Gently touch cornea with cotton wisp.
o Touching cornea can cause abrasions.
oAlternative approach is to:
> puff air across cornea with a needless
syringe, or
> gently touch eyelash
and look for blink reflex

112. Cont. CNV
Normal:
Full range of motion
(ROM) in jaw and 15
strength.
Patient perceives light
touch and superficial
pain bilaterally
Abnormal:
 Weak or absent contraction
unilaterally:
- Lesion of nerve, cervical spine, or
brainstem
 Inability to perceive light touch
and superficial pain
- may indicate peripheral nerve
damage.
■ Trigeminal Neuralgia:
- Neuralgic pain of CN V caused by
the pressure of degeneration of a
nerve
■ Corneal reflex test used in patients
with decreased LOC
- to evaluate integrity of brainstem.

113. Testing CN VII – motor function
Cranial Nerve VII - Facial Nerve
a. Testing motor function:
- Ask patient to perform these movements:
smile, frown, raise eyebrows, show upper teeth,
show lower teeth, puff out cheeks, purse lips,
close eyes tightly while nurse tries to open them.
- Observe face for
flaccid paralysis

114. CN VII - Facial NerveNormal:
• Facial nerve intact
• Able to make faces.
• Taste sensation on
anterior tongue intact.
• (Taste decreased in
older adults.)
Abnormal:
Asymmetrical or impaired
movement:
-Nerve damage, such as that
caused by Bell’s palsy or
stroke.
Impaired taste/loss of
taste:
- Damage to facial nerve,
chemotherapy or radiation
therapy to head and neck.

115. Watch tick test
Cranial Nerve VIII - Acoustic Nerve
a. Perform Weber and Rinne tests for hearing
b. Perform watch-tick test by holding watch close to
patient’s ear.
c. Perform Romberg test for balance
- Nurse at the back or side of the pt.
- Instruct client to stand straight, feet together,
hands at the side and eyes closed.
(Evaluates the balancing function of the CN VIII)

116. Cranial Nerve VIII - Acoustic Nerve
Normal:
Hearing intact.
Negative Romberg
test.
Abnormal:
Hearing loss, nystagmus,
balance disturbance,
dizziness/vertigo:
- Acoustic nerve damage.
■ Nystagmus:
- CN VIII, brainstem, or
cerebellum problem or
phenytoin (Dilantin)
toxicity.

117. Testing CN IX and X
– motor function
Cranial Nerves IX and X
Glossopharyngeal & Vagus Nerves
a. Observe ability to cough, swallow, and talk.
b. Test motor function:
- Ask patient to open mouth and say “ah”
while you depress the tongue with a tongue
blade.
- Observe soft palate and uvula.
- Soft palate and uvula should rise medially.

118. CN IX and X
c. Test sensory function of CN IX and motor function of
CN X by stimulating gag reflex.
Tell patient that you are going to touch interior throat
Then lightly touch tip of tongue blade to posterior
pharyngeal wall.
Observe the pharyngeal movement.
Ask the client to drink a small amount of water
*Note the ease & difficulty of swallowing
*Note quality of the voice or hoarseness when
speaking

119. CN IX and X
Normal:
Swallow and cough
reflex intact.
Speech clear.
Elevation and
constriction of
pharyngeal musculature
and tongue retraction
indicate positive gag
reflex
Abnormal:
 Unilateral movement:
Contra lateral nerve damage.
- Damage to CNs IX and X also
impairs swallowing.
■ Changes in voice quality (e.g.,
hoarseness): CN X damage.
■ Diminished/absent gag reflex:
Nerve damage
- Risk for aspiration
■ Impaired taste on posterior portion
of tongue:
Problem with CN IX

120. CN XI - Spinal Accessory Nerve
a. Test motor function of shoulder and
neck muscles:
=> Ask patient to shrug shoulders upward against
your resistance. (Trapezius muscle)
=> Then ask her or him to turn head from side to
side against your resistance.
(Strenocleidomastoid muscle)
**Observe for symmetry of contraction and muscle
strength.

121. Cranial Nerve XI
Normal:
Movement
symmetrical, with
patient moving
against resistance
without pain.
■ Full ROM of neck
with +5/5 strength.
Abnormal:
Asymmetrical
Diminished
Absent movement
Pain
unilateral or bilateral
weakness: Peripheral
nerve CN XI damage.

122. Testing CN XII –
motor function
CN XII - Hypoglossal Nerve
a. Have patient say “d, l, n, t” or a phrase containing
these letters.
- The ability to say these letters requires use of
the tongue.
b. Ask the patient to protrude the tongue.
Observe any deviation from midline, tumors,
lesions, or atrophy.
c. Now ask the patient to move the
tongue from side to side.

123. Normal:
 Can protrude
tongue medially.
 No atrophy,
tumors, or lesions.
Abnormal:
Asymmetrical/diminished/
absent movement/deviation
from midline/protruded tongue:
- Peripheral nerve CN XII
damage.
■ Tongue paralysis results in
dysarthria.

124. MOTOR SYSTEM:
Inspect the voluntary muscles for atrophy,
fasciculation (uncontrollable twitching)and
involuntary movements. In addition assess gait ,
Romberg's sign for muscle strength and
coordination.
Gait : is a person’s style of walking. To assess gait,
instruct the person to walk across the room, turn and
walk back towards you . Observe the persons balance
and posture . Ataxia is an uncoordinated gait that
result from cerebellar disease or intoxication.

125. Rombergs test : Rombergs test is a test of sensory equilibrium.
Instruct the person to stand with the feet together and eyes
open . Note the persons balance .Then have the person close
the eyes. Normally you will observe only minimal swaying . A
positive test will suggest cerebellar ataxia.

126. •RAPID ALTERNATING MOVEMENTS
•POINT- TO-POINT MOVEMENTS

127. REFLEXES OF MUSCLES:
Tests of muscle strength and
assessment of common reflexes

128. Type Procedure Normal
reflex
Deep
tendon
reflexes
Biceps Flex the client’s arm at elbow with
palms down. Place your thumb in
antecubital fossa at the base of
biceps tendon . Strike the thumb
with the reflex hammer .
Flexion of
arm at
elbow.
Triceps Flex the client’s elbow , holding arm
across the chest , or hold the upper
arm horizontally and allow the
lower arm to go limp. Strike triceps
tendon just above the elbow .
Extension
at elbow.
Patellar Make the client sit with legs hanging
freely over the side of the bed or
chair or have the client lie supine
and support knee in a flexed
position . Briskly tap patellar tendon
Extension
of lower leg
at knee.

129. Procedures Normal
reflex
Achilles Make the client assume the same
position as for patellar reflex. Slightly
dorsiflex the client’s ankle by grasping
toes in the palm of your hand . Strike
achilles tendon just above the heel.
Plantar
flexion of
foot .
Babinsk
i’s
Have the client lie supine with legs
straight and feet relaxed . Take the
handle end of the reflex hammer and
stroke lateral aspect of the sole from
the heel to the ball of the foot , curving
across the ball of the foot toward the
big toe.
Bending of
toe
downwards.

130. Maneuvers to assess muscle strength:
Muscle group Maneuver
Neck Place your hand firmly against the client’s upper jaw .ask the
client to turn head laterally against resistance.
Shoulder Place your hand over the midline of the client’s shoulder ,
exerting firm pressure . Have the client raise shoulder against
resistance.
Elbow,
Biceps,
Triceps.
Pull down the forearm as the client attempts to flex the arm. As
the client’s arm is flexed ,apply pressure against the forearm
.ask the client to straighten his/her arm.
Hip ,
Quadriceps
When the client is sitting apply downward pressure to thigh .
Ask the client to raise his leg up from the table.
The client sits, holding shin of the flexed leg . Ask him to
straighten his leg against the resistance.

131. MUSCLE STRENGTH
To grade or quantify muscle strength, assess the patient as
follow:
Grade Description
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint
2/5 Movement at the joint, but not against gravity
3/5
Movement against gravity, but not against added
resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength

132. SENSORY SYSTEM:
• Light touch/ superficial pain: Using a wisp of cotton
and a safety pin alternatively , touch the distal and
proximal portions of the upper and lower
extremities.
• The temperature test can be done by asking the
patient to touch and identify the hot and cold test
tube filled with hot and cold water respectively.
• Vibration is assessed by tapping a tuning fork and
placing it firmly on a person’s inter-phallengial joint
of the finger and great toe. Ask the patient to
describe the sensation and to identify when the
sensation ends.

133. • Two point discrimination: When assessing two point
discrimination , touch the person alternatively with
one or two safety pins on a particular body part,
such as the finger pads . ask the patient if one or two
sensations are felt.
• Point localization is assessed by touching various
parts of the person’s body with a wisp of cotton. The
person is instructed to open the eyes after having felt
the touch and point to the area.
• GRAPHESTHESIA
• STEREOGNOSIS

135. GENITALIA AND RECTUM:
Providing privacy
Not prolonging the examination
Warming instruments i.e. vaginal speculum
Using lubricants to minimize discomfort
Wear gloves during genital & rectal examination
Empty the bladder before examination

136. Male genitals
• Inspect the skin of glance penis. Observe for any
lesions, color, discharge or inflammation.
• Assess secondary sex characteristics , observe the
penis and testes for size and shape, color, texture of
scrotal skin symmetry and the distribution of pubic
hair , position of meatus and circumcision.
• Palpate the penis using your thumb and first two
fingers. Note any tenderness or nodules. Normally,
testes feel firm and not hard with similar
consistency.

137. Female genitalia
• Female genitalia is examined by inspection and
palpation.
• Inspect the external genitalia. Separate the labia and
inspect the labia minora, clitoris, urethral orifice and
vaginal opening.
• Observe for inflammation, discharge, ulceration,
varicose veins, swelling and nodules.
• In internal inspection, observe cervix for color,
position, bleeding.

138. AFTER CARE:
When the physical examination is over, remove the
drape & help the person to put on cloths. Be sure the
patient is safe and comfortable.
DISMANTLING OF ARTICLES:
Articles should be sent for sterilization. Disposable
articles should be immediately disposed off and
replacement of all the articles should be done to the
area specified.

139. AFTER CARE OF ARTICLES

140. DOCUMENTATION OF DATA

141. AFTER CARE OF THE PATIENT

142. POINTS TO BE REMEMBER:
• Ensure that adequate privacy is provided during the
observation.
• Always take help in case of pediatric /unconscious
patient / uncooperative patient .
• Ensure adequate light.
• Inform the patient / relatives before
and after the physical examination .
• Record all the observations and
preserve in safe custody .
• Inform any abnormal findings
to senior nurse/doctor.

143. BIBLIOGRAPHY
 Barbara kozier (2006), Fundamentals Of Nursing-concepts, process and practice, 2nd edition, New
Delhi, Pearson Education page no: 564-661
 Clement I (2013), Basic Concepts Of Nursing Procedures,2nd edition, New Delhi,Jaypee Publications
page no:18-25
 Helen Hark reader(2009),Fundamentals Of Nursing-Caring & Clinical judgment, 3rd edition,
U.P,Elsevier publications page no:105-110,139-186
 Patricia A Potter, Anne Griffin Perry(2005), Fundamentals Of Nursing, 6th edition, New Delhi, Elsevier
Publications page no:673-769
 Suzanne C. Smeltzer (2009), Brunner &Suddarth’s Textbook Of Medical Surgical nursing,11th edition,
New Delhi , Wolters Kluwer(p)Ltd
Page no: 64-77
 www.com/foundations of history taking and physical examination/chapter 1. Pdf
 downloads.lww.com/wolterskluwer_vitalstream.../sampleChapter1.pdf
 www.uthsc.edu/pediatrics/clerkship/.../OutlineofPhysicalExamination.pdf
 fac.ksu.edu.sa/sites/default/files/bates_guide_to_physical_examination.pdf
 www.ncbi.nlm.nih.gov./pubmed