IN PARTIAL FULLFILLMENT FOR THE REQUIREMENTS

IN THE SUBJECT HEALTH ASSESSMENT

Submitted to:
Mr. Jefferson Colon

Submitted by:
Julian, Jana Rio M.
BSN I-IV
1. Performing Hand Hygiene
*Wash your hands for a minimum of 15 to 20 seconds following the correct sequence or areas
to be washed first. Rinse properly and dry off using a clean towel. If possible, try not touching the faucet
or any handle in the washroom.

2. Gather all equipment need

*Be sure to clean the equipment before going to the client. The equipment varies depending on
what area will be assessed.

3. Identify client and explain the procedure

*The rationale of doing this is to make sure that you have the correct client that will be assessed
and giving him/her knowledge on what you are about to do.

4. Instruct client to void before doing the exam

*The rationale of doing this is to make sure that the area involved will be assessed properly and
to make client more comfortable with an empty bladder.

5. Assist client to change into hospital gown and provide privacy

*Wearing a hospital gown is the most convenient attire when assessing a client. Make sure that
you will be giving privacy as to maintain dignity of client.

GENERAL SURVEY

6. Physical Appearance

Normal Abnormal Other Cases:

Age Appears like stated age Appears older or Turner’s Syndrome
younger
Gender Sexual development is Delayed or advanced
appropriate to gender puberty
and age
Level of Consciousness Alert, oriented, Confused, drowsy,
responds appropriately lethargic
Skin Color Skin tone is even, intact Palor, Cyanosis,
with no obvious lesions Jaundice, Erythema
(redness), presence of
lesions
Facial Features Symmetrical with Immobile, mask-like,
movement asymmetric, drooping
Overall No signs of acute Respiratory signs:
distress Shortness of breath,
wheezing
Pain: Grimace,
 holding/guarding body
part, knees drawn up
over the abdomen

7. Body Structure

Normal Abnormal Other Cases

Structure Height appears within Excessively short or tall Gigantism: experienced
normal range, for age, by children
genetic heritage. Aromegaly: experienced
by people 18 >
Simmonds: low growth
hormone
Nutrition Weight appears within Emaciated, Cachectic Cushing’s Syndrome:
normal range for (Tissue wasting), Obese, Thin extremeties, with
height, body build, fat Fat concentration in buffalo hump
distribution. face, neck, trunk, arms,
and legs
Symmetry Body parts look equal Body parts are not Unilateral Atrophy: Loss
bilaterally and are in proportioned of muscle volume
relative proportion to Hypertrophy: Increased
each other. muscle volume
Posture Clients stand Stiff, tense, with fidgety
comfortably erect. movement, shoulders
humped, looks
depressed
Position Client comfortably sits Client is curled up in
on a chair or on the bed fetal position; leaning
with arms relayed at forward with arm
the sides, head turned braced on chair
to the examiner.
Body Build and Contour Slender, medium build, Thin; muscle wasting; *Things to remember:
stocky or muscular. obese 1. Endomorph: fat
2. Mesomorph: normal
3. Ectomorph: thin

8. Mobility

Normal Abnormal Other Cases

Gait Base is wide as the Exceptionally wide 1. Spastic
shoulders; foot base, staggered, 2. Scissor
placement is accurate stumbling, limping with 3. Propulsive
injury 4. Steppage
5. Waddling
Range of Motion Full mobility of each Paralysis; jerky,
joint; movements are uncoordinated
 deliberate and accurate
9. Behaviour
Normal
Facial expression Client maintains eye
contact, expressions are
appropriate to the
situation
Mood and Affect Client is cooperative;
comfortable with
examiner; interacts
pleasantly.
Speech Client speaks clearly;
stream of talking is
fluent, even; word
choice is appropriate
Dress Clothing is appropriate
to the climate and age
group; looks clean and
fits the body;
Personal Hygiene Appears clean and
groomed; appropriate
for age, occupation, and
socio-economic group;
hair is brushed or
groomed.
INTEGUMENTARY SYSTEM
10. Inspect skin for color, pigmentation, and lesions.
Normal Abnormal
Color Whitish pink, or brown Cyanotic (bluish);
color; Depends on Jaundice (yellowish)
race.
movments
Abnormal Other Cases
Flat, depressed, angry,
sad, anxious
Hostile, distrustful,
suspicious, crying
Difficulty in talking;
abnormal pitch or
volume; voice is hoarse
or whispered; slurred
speech; constant talking
Trousers are too large
and held by belt; looks
unclean;
Unkept hair; Absent
makeup
Other Cases
1. Pallor: decreased
visibility of normal
oxyhemoglobin
2. Carotenemia:
excessive carotene
3. Hyperemia:
increased blood
flow
4. Erythema: redness
 of skin
5. Xanthoma Striata:
Yellowish
discoloration of
palmar and digital
creases
6. Addison’s disease:
bronze-like skin
due to deficit in
cortisol
7. Acanthosis
Nigricans:
brownish skin due
to use of steroids
and obesity
8. Albinism:
generalized
whiteness;
9. Vitiligo: absence of
melanin
10. Erythematosus:
“butterfly rash”
11. Cloasma and Linea
nigra: seen in
pregnant women
Temperature Warm and equal Hyperthermia
For Palpation: bilaterally; hands and
Palpate all feet maybe cooler
nonmucosal skin than rest of body.
surfaces using dorsal
surfaces of hands.

11. Inspect hair distribution, texture, moisture all over the body.

Normal Abnormal Other Cases

Distribution Body is covered with Absence of pubic hair 1. Traction Alopecia:
vellus hair; terminal (unless purposely hair loss in linear
hair is found in removed) formation
eyebrows, eyelashes, 2. Hirsotism: excess
scalp and in axilla and facial and body hair
pubic hair areas. 3. Trichotillomania:
areas of broken-off
hair in irregular
patterns
Texture Feels smooth, even, Roughness on exposed
Evaluate texture using and firm except when areas; Hyperkeratosis
finger pads, check there is significant hair and silk-like
abdomen and medial growth.
surfaces of arms first.
Moisture Skin is dry with Excessive dryness; 1. Xerosis
For Palpation: minimum profuse sweating 2. Diaphoresis
Palpate all non- perspiration, moisture
mucous membrane vary from one area to
skin surfaces using another.
dorsal surfaces of
hands and fingers.

12. Inspect nails for characteristic, color, texture, shape and configuration.
*Note for capillary refill.

Color
Abnormalities:
1. Leukonychia: white striations in the nail bed
2. Leukonychia totalis: nail bed is white due to hypercalcemia
3. Melanonychia: brown color of nail plate
4. Cyanotic: bluish nails
5. Splinter hemorrhage: red or brown linear streaks nail bed
6. Lindsey’s Nails: white proximal end and pink distal portion of nailbed
7. Onychomycosis: yellow or white hue
8. Terry’s Nails: whitish band

Shape and Configuration

Abnormalities:
1. Koilonychia: thin spoon nail with cuplike depression
2. Clubbing: Angle of nailbed is 160 degrees
3. Beau’s Line: transverse furrow in the nail plate
4. Oncholysis: separate of nail from nail bed
5. Caronychia: painful red swelling
6. Sublingual hematoma: purpura or ecchymosis under nail plate
7. Onychocryptosis: distal portion of nail plate is embedded in periungal tissue
8. Eggshell nails: curved under nail edge
9. Onychatrophia: nail atrophy or shrinking
10. Onychorrhixis: nail is split in lengthwise
11. Pterygium: abnormal cuticle that overgrows the nail

Texture
*Nailbase must be firm
*Clubbing is due to prolonged hypoxia (chronic bronchitis, emphysema, heart disease)
13. Palpate for temperature, texture and moisture.

Temperature
Palpate all nonmucosal skin
surfaces using dorsal surfaces of
hands.
Moisture
For Palpation:
Palpate all non-mucous
membrane skin surfaces using
dorsal surfaces of hands and
fingers.
Normal Abnormal
Warm and equal bilaterally; Hyperthermia
hands and feet maybe cooler
than rest of body.
Feels smooth, even, and firm Roughness on exposed areas;
except when there is significant Hyperkeratosis and silk-like
hair growth.
Skin is dry with minimum 1. Xerosis
perspiration, moisture vary from 2. Diaphoresis
one area to another.

14. Perform skin turgor/skin pinch and mobility.

Procedure Normal Abnormal

Palpate skin turgor at dorsal Should return to its original Poor skin turgor; Does not go
surface which reflects the skin’s contour rapidly. It takes about 1- back immediately.
state of hydration 2 seconds.

HEAD AND FACE

15. Inspect the skull for shape, size, masses, nodules, and lumps.

Procedure
1. Have patient sit in a comfortably position.
2. Face the patient with client’s head in level
with yours.
3. Inspect for symmetry.
Normal Shape: Normocephalic
Abnormalities
1. Hydrocephalus: enlargement of head
without enlargement of facial structure
2. Acromegaly: abnormal enlargement of
skull with bony facial structure
3. Craniosynostosis: abnormal shape of skull
at right angles
4. Anencephaly: absence of brain and skull
5. Microcephaly: circumference of head is
smaller than average.

Normal Abnormal Other Cases

Face Symmetrical; Palpebral Structures are
fissure should be equal deformed; Asymmetry
*Slight variations are of face
common
Shape No edema; Slanted eyes with inner Hypertelorism:
Disproportionate epicanthal folds; a short abnormally wide
structures flat nose and a thick distance between the
protruding tongue; eyes.
Facial skin is shiny,
contracted and hard;
face is immobile and
expressionless

16. Inspect face for symmetry~ CN5.

17. Perform test for CN7.

Facial Motor Exam Abnormalities

*Forehead and Upper lid Innervation 1. Unless bilateral lesion, does not affect
forehead
1. Eyebrow elevation 2. Mouth paralysis is overcome by
2. Forehead wrinkling emotional expression
3. Frowning 3. Ipsilateral forehead and lower face
4. Tight Closing of the eyes paralysis

*Lower Face innervation

1. Showing teeth
2. Whistling
3. Puffing cheeks
4. Natural smile
5. Test or inquire about Taste
Sensation

18. Inspect and palpate scalp, hair, and cranium.

Normal Abnormal Other Cases

Scalp Scalp should be pale Infestation, dandruff Head lice (Pediculosis
white to pink in light- Capitis)
skinned people and
light brown in dark-
skinned people.
Hair Dark to pale blonde Patches of gray hair
 that are isolated or
occur in conjunction
with scar

19. Palpate temporal artery – CN5 Motor

20. Palpate frontal and maxillary sinuses for tenderness.
21. Percuss frontal and maxillary sinuses for tenderness.
22. Auscultate temporal artery for bruits.

EYES

23. Inspect eyebrows and eyelashes for hair distribution and alignment.

Normal Abnormal
Eyelashes Symmetrical; evenly distributed; Absence of eyelashes; infection
Eybrows bilateral near areas

24. Inspect lids for skin characteristics, color, and position.

Normal Abnormal Other Cases

Eyelids Symmetrical; client can Drooping; infections; 1. Lagophthalmos:
move both eyelids; tumors; excessive inability to bring
normal lid margins are blinking; swelling about complete lid
smooth with lashes closure
evenly distributed 2. Eyophthalmos:
disparity of
palpebral fissure
3. Enophthalmos:
disparity in size of
globe
4. Entropion:
inversion of lower
lid
5. Ectropion: eversion
of lower lid
6. Hordeolum: acute
inflammation
7. Chalazion: chronic
inflammation
8. Belpharitis:
bilateral
inflammation
25. Inspect bulbar and palpebral conjunctiva, note for color sclera and iris.
Normal Abnormal
1. Gently pull down Increased lacrimation; reddish
eyelashes and place a bulbar conjunctiva
sterile cotton-tipped Pinguecula: yellow nodule on the
applicator above the lid nasal side of bulbar conjunctiva
margin. Pterygium: unilateral/bilateral
2. Gently exert downward triangle shaped encroachment
pressure.
3. Inspect Palpebral
Conjunctiva for infection
and swelling
4. Return eyelid to its
normal position.
Sclera White sclera; small blood Jaundice; bluish sclera
vessels; tiny brown patches (Osteogenesis Imperfecta)

26. Inspect and palpate the lacrimal gland, asses for color, swelling and exudates.
Normal Abnormal Other Cases
Lacrimal apparatus No enlargement, Mucopurulent 1. Dacroadenitis:
swelling, redness, discharge; overflowing acute
exudates; minimal tears (Epiphora) inflammation
tearing 2. Dacrocystisis:
inflammation and
painful swelling
beside nose and
near inner
canthus

27. Test for corneal reflex (Blinking and tearing)

Procedure
1. Instruct the client to look straight ahead.
2. Focus a penlight on the corneas from a distance of 12 to 15 inches away from
midline.
3. Observe location of reflected light on the cornea.

Normal Abnormal
Reflected light should be seen in the center of 1. Strabismus: deviation of one eye
each cornea 2. Esotropia: inward turning of the eye
3. Exotropia: Outward evading of eye
28. Inspect pupils for size, shape and symmetry.

Normal Abnormal
Pupils Black pupils, round, and of equal 1. Miotic Pupils (<2mm
diameter, ranging from 2-6mm; constriction)
brisk constriction to direct light; 2. Mydriatic Pupils (>6mm
dilation)
Pupils with irregular shape

Asses Client’s

29. Direct and consensual reaction to light and accommodation.

30. Visual fields by confrontation (CN II).
31. Six cardinal gaze (EOM).
Normal Abnormal
Procedure: Both eyes should move smoothly Lack of symmetrical mov’t;
1. Place client in sitting and symmetrically in each of the abnormal eye mov’t;
position, facing you. six fields of gaze
2. Place non-dominant 1. Opthalmoplegia:
hand just under the paralysis of one/more
client’s chin as a optic muscles
reminder to keep the 2. Vertical gaze: paralysis
head still. of upward gaze
3. Ask client to follow an 3. Paralysis of horizontal
object with eyes. gaze
4. Move object through the
six fileds of gaze in a
smooth and steady
manner.
5. Note client’s ability to
move eyes in each
direction.
6. Move the object forward
5 inches away from face.
7. Observe for convergence
of gaze

32. Asses visual acuity (Snellen’s)

Procedure
1. Ask client to remove corrective lenses if he/she wears them.
2. Cover one eye.
3. Ask him to read letters on one line going downward until he can no longer discern the letters.

EARS
33. Inspect and palpate auricle/pinna for color, symmetry, position, and palpate for tenderness.
Normal Abnormal Other Cases
External Ear Same color; pain Pale, cyanotic; 1. Microtia:
tenderness; edema abnormally large
ears
2. Auricular
hematoma:
damaged/mutilat
ed ear.
3. Perichondritis:
edematous,
painful ear.
4. Carcinoma: tumor
on external ear
5. Battle’s sign:
hematoma behind
ear over mastoid
bone

34. Inspect external auditory canal for color, patency. Note color and gloss and state characteristics of
tympanic membrane.

35. Assess client’s hearing acuity (Voice whisper).

Normal Abnormal
Client is able to repeat 2 syllable word Client is unable to hear the word

36. Perform Weber’s Test.

Normal Abnormal
Client should perceive the sound equally in both Sound localizes on unaffected ear
ears; No lateralization of sound is known as a
negative Weber’s Test.

37. Perform Rinne’s test.

Normal Abnormal
Air conduction is heard twice as long as bone Client hears the sound longer through the bone
conduction when client hears through the external conduction.
auditory canal is no longer heard.

NOSE
38. Inspect external nose for color, shape, size, flaring and discharges, deviations.

Normal Abnormal
Air can move through nostrils Air cannot move through nostrils

39. Inspect the nasal cavities for color, swelling, edema, discharges, growth with the use of nasal
speculum.

Normal Abnormal
Nasal Mucosa should be pink/dull; without Red mucosa; swollen width copeus; clear water
swellings or polyps discharge; edematous

40. Palpate for tenderness or mass.

Normal
Client should experience no discomfort during
palpation; sinuses should be air filled, therefore
resonant to percussion
Abnormal
Nasal Polyps: Smoot, round masses that are pale
and shiny and are noted protruding from middle
meatus
Nasal Septal Perforation: nasal mucosa is inflamed.

41. Check for patency of both nostrils.

42. Check for CN 1 (Smell Test).

MOUTH AND THROAT

43. Inspect the outer lips for color symmetry, and texture. Palpate for lesions.

Normal Abnormal
Lips should be pink and moist with no lesions or Lips are pale; inflamed
inflammation
1. Herpes Simplex
2. Chancre
3. Wart
4. Nodule

44. Examine oral mucosa, gums, teeth, using the tongue blade and penlight.
Normal Abnormal Other Cases
Oral Mucosa Color may vary Inflamed; lesions 1. Leukoplakia:
according to race; leathery,
should be moist, painless, white,
smooth and free of pointed-looking
lesions palates
2. Apthous ulcer:
 small, round
white ulcers.
3. Stomatitis:
reddish mucosa
4. Xerostoma:
excessive
dryness of
mucosa
Gums Lightly colored; gum Inflamed Gingivitis: red,
margins should be well tender, swollen
defined with no pockets and bleeding
existing between gums gingiva
and teeth
Teeth Presence of 32< teeth Absence/loss of teeth 1. Dental Carries:
white/black
patches on the
surface of the
tooth
2. Dead tooth:
darker in color
and insensitive
to cold
3. Hutchinson’s
Incissors: teeth
with serrated
edges

45. Inspect the outer lips for color, moisture, size, and position. Inspect the hard and soft palates.

Normal Abnormal Other Cases

Palate Hard and soft palates Infection 1. Torus Platinus:
are concave and pink; bony ridge in
hard palate has many the middle of
ridges, soft palate is hard palate
smooth 2. Palatine
Perforation:
hole in hard
palate

46. Inspects the uvula for position, Oropharynx for color.

47. Inspect the tonsils for color, discharge, and size.
48. Perform taste test (CN7- Sensory).
49. Palpates tongue for nodules and lumps.

Normal Abnormal Other Cases

Tongue is in midline of mouth,
dorsum of tongue is pink, moist,
ruoght.
Tongue is enlarged, red, smooth,
w/ absent papillae
1. Glossitis: reddish tongue
with absent papillae.
2. Candidiasis: thick, white,
crudlike coating on
tongue.

50. Note tongue movement and strength (CN 12).

51. Elicits the gag reflex (CN IX and X)

NECK
52. Inspect neck muscles and assesses head movement and strength (CN11)
Normal
Muscles of neck are symmetrical with head in a central position. Patient is able t move the head,
through a full range of motion.

53. Inspect and palpates for location of trachea.

54. Palpates thyroid gland to identify enlargement, nodule and tenderness.
Procedure:
1. Stand behind patient.
2. Have the patient lower the chin slightly.
3. Place your thumb at back of patient’s neck.
4. Move finger pads over tracheal ring.
5. Instruct patient to swallow- palpate for nodules or enlargement.
55. Palpate and identify lymph nodes.
56. Observes for carotid artery pulsation and jugular vein distention.

THORAX AND LUNGS

57. Inspects the size, shape and symmetry of the thorax and note for spinal deformities.

Normal Abnormal Other Cases

Chest Elliptical in shape with AP is larger than lateral 1. Barrel Chest:
lateral diameter that is diameter the AP diameter
larger than the AP is equal to the
diameter. lateral diameter
2. Funnel Chest
(Pectus
Excavatum):
depression of
the sternum
3. Pigeon Chest
(Pectus
Carinatum):
forward
displacement of
the sternum
4. Scoliosis: lateral
curvature and
rotation of
thoracic and
lumbar spine
5. Kyphosis:
exaggerated
posterior
curvature of
thoracic spine

58. Palpate the posterior chest (Spinous process) for tenderness and spacing.

Normal
Posterior Chest Muscle mass should be firm; no
lesions; non tender; movement
and pressure of chest against
your hands should feel smooth.
Abnormal
Tender; lesions; delay in
expansion may indicate
fibrotic/obstructive lung disease.

59. Assess for tactile fremitus.

Normal Abnormal
Symmetrical vibration a. Decreased/Absent fremitus: soft voice,
thick chest wall, COPD, pleural effusion
b. Increased fremitus: fluid in lungs or
infection

60. Note for diaphragmatic excursion (Posterior).

*Abnormal: Dull sounds

61. Percuss the posterior thorax.

Normal Abnormal
3-5 cm distance between marks and even on each Shortened excursion (lungs are not fully
side. Right side maybe 1-2cm higher because of expanding).
the location of the liver.

62. Performs respiratory excursion (Anterior).

63. Auscultate the chest using the systematic zigzag method (both anerior and posterior chest and
identifies the location and type of the normal breath sounds).

Normal Abnormal
Muffled sounds Sound is loud and more distinct

HEART

64. Simultaneously inspect and palpates the precordium for abnormal pulsations heaves/lifts ( using Z
technique)

Normal Abnormal
No visible pulsations, except at the PMI (Point of Neck distention and or visible pulsations in the
Maximal Impulse) or where the apical pulse is precordial area except @ the PMI.
located, visible as a pulsation or thrust.

65. Auscultates the aortic, pulmonic, tricuspid and mitral areas at proper locations for heart sounds
noting for S1 and S2 sounds; PMI.

Normal Abnormal Other Cases

S1- first heart sound (LUB);
S2-2nd heart sound (DUB)
S3-normally present under 34
years and below
S4-may occur on young people
with thin chest wall
Chest pain indicates inadequate 1. Dyspnea:
myocardial tissue oxygenation; labored/difficulty in
pulse deficit breathing
2. Orthopnea:
breathlessness that
prevents client from
 lying down
3. Fatigue: worse at night
due to decreased cardiac
output
4. Cyanosis/Pallor: due t
decreased CO that
results to decreased
tissue perfusion
5. Dependent Edema:
indicates heart failure
6. Jugular Vein Distention:
indicates heart failure

BREAST AND AXILLA

66. Inspect each breast and axilla while client’s hands are resting on her side, placed on hips, above the
head. Note for contour, size, symmetry, discolorations, and dimpling.

Normal Abnormal Other Cases

Smooth; w/o lesions; dense Increased vascularity of breast; Gynecomstia: breast
breast tissue; nipple usually nipple discharge; scaling around enlargement for males.
everted out in the same nipple
direction; no discharge

67. Performs breast-self examination, palpates the breast in a systematic manner and notes for masses,
tenderness and texture.

Normal Abnormal Other Cases

Nodular and granular Lumps; unilateral granulation; Peau d’ orange:
consistency; inferior aspect of mass; itching; swelling; thickening/edema of breast
breast is firm; non-tender tenderness tissue/nipple with enlarged skin
pores.

68. Assess for lymph nodes. (Axillary)

Normal Abnormal
Non-tender; less than 1cm in diameter Fixed; more than 1cm; painful; enlarged; matted
together

ABDOMEN
69. Observe for the contour and inspect the symmetry of abdomen.

Normal Abnormal
Contour: Flat, rounded/scaphoid Protruberant abdomen (normal in pregnant
women)
Contours:
1. Flat *Ascites: accumulation of fluid in abdominal
2. Rounded/Convex cavity.
3. Scaphoid/Concave
4. Protruberant
Symmetry: Without bulging/masses Assymetrical

70. Check umbilicus for contour or hernia, observe skin characteristics.

Normal Abnormal
Located at the center; inverted or protruding; Displaced umbilicus; For non preggo’s: indicates an
clean and free of inflammation or drainage abdominal mass/distended urinary bladder
Hernia: for children

71. Note for pulsations, visible peristalsis, and movement.

72. Auscultate for bowel sounds in the four quadrants. Note the character and frequency.

Normal Abnormal
5-30/min or 10/sec (Borborygmi); no vascular Hypoactive: 1/15 sec
sounds/friction rubs; irregular, gurgling and high Hyperactive: 1/sec
pitched bowel sounds

73. Percuss the abdomen.

Normal Abnormal
a. Tympany: stomach Dullness: distended urinary bladder or ascites
b. Dullness: liver and spleen
Liver: approximately 5-10cm (2-4 in)
Size at midsternal line: 4-9 cm (1.5-3 inc)
Spleen: tympanic sound Dull sound

74. Palpate surface and deep areas, assess size, location, consistency of abdominal organs, screen mass
or tenderness-light/deep.

Normal Abnormal
Stomach: Soft, smooth, non-tender, pain free Masses; tumors; or obstructions during palpation
Liver: Non-palpable; lower border of the liver is Pain; nodules occur with cirrhosis
smooth, firm and non-tender
Spleen: Non palbable Splenomegaly
75. Perform special procedure (rebound tenderness, Murphy’s sign, Iliopsoas muscle, Obturator test)

MUSKULO-SKELETAL- UPPER EXTREMITIES

76. Inspects nail beds for color, shape, texture and surrounding tissues.
77. Performs the capillary test/blanch test.
Normal Abnormal
Nail bed should regain usual color in 1-2 seconds. Nail bed regains own color after more than 2
seconds

78. Inspect muscles for size, notes for symmetry, palpates for muscle tone while client is active and then
passive, palpate joints.

Normal Abnormal
Symmetrical hands and arms; absence of muscle Assymetry or deformity of fingers in rheumatoid
wasting; no edema; no tenderness, redness or arthritis
increased heat

79. Test for muscle strength bilaterally.

Normal
Fingers: Equal strength on both hands
Wrist joint: No enlargement or discomfort or pain;
symmetrical muscle strength
Abnormal
Enlargement along joints or discomfort/pain;
Unequal strength which may indicate weakness on
either side
*Stereognosis: able to identify an object

80. Check for ROM asking client to move selected body parts and names exercises done.

Normal Abnormal
Full, without difficulty Presence of pain

81. Elicits reflexes (Biceps, Triceps, Brachioradialis)

 Normal
Biceps Reflex 2+
Contraction of biceps muscles with flexion of the
elbow
Triceps Reflex 2+
Contraction of triceps muscle with extension of
forearm
Brachio-radialis or supinator Reflex 2+
Flexion and supination of forearm

82. Conducts fine motor test.

83. Conducts light touch sensation and notes for pain and temperature sensation.

Normal Abnormal
Light Touch Sensation: Client is able to feel the Decreased/absent sensation
touch as light or soft on either side
Pain Sensation: Client is able to tell the sensation Client has difficulty feeling sensation
as sharp or dull

Conducts tactile discrimination

84. One and two point

Normal Abnormal
Acceptable standard of distance that a client can Increased distance between the 2 points felt
no longer feel the distance bet/ two points or suggests lesions in sensory cortex
object is 5 millimeters

85. Stereognosis

Normal
Client is able to identify the given object correctly.

86. Extinction phenomenon

Normal Abnormal
Client is able to feel both touches and is able to Feels only one stimulus suggests lesions of the
directly point the correct location of touch sensory cortex

87. Graphestesia
Normal Abnormal
Able to identify number Inability to identify the number written which may
indicate a lesion on the sensory cortex

LOWER EXTREMITIES

88. Inspect legs together, note skin color, distribution, venous pattern, size, lesions.
89. Measure calf circumference along legs down to the feet.

Normal
Symmetrical and equal circumference, size, and length.

90. Palpate skin temperature along legs down to the feet.

Normal
No inflammations or enlargement or pain

91. Assess for Romberg, tandem walking, heel to shin.

Normal
Able to do this in a straight line without losing balance

92. Assess for Homan’s sign.

93. Check for pretibial edema.
94. Check for reflexes.

Reflex Normal
Quadriceps reflex/Patellar reflex Quadriceps contract, lower leg extends
Achilles reflex Plantar flexion
Plantar/Babniski reflexes Plantar flexion without toe fanning or great toe
dorsiflexion

95. Check for muscle strength.

Normal
Toes Good muscle strength
Both legs No limitation of movement