PHYSICAL EXAMINATION

DEFINITION

➢ Conducted from head to toe (cephalo-caudal technique).

➢ Determine the mental status and level of consciousness (LOC) at the beginning of
examination.

PURPOSES

• Gather baseline data about the client’s health

• Supplement, confirm or refute data obtained in the midwifery history

• Confirm & identify midwifery diagnosis

• Make clinical judgments about a client's changing health status and management

• Evaluate the physiological outcomes of care

PREPARATION GUIDELINES

1. Explain the procedure

2. Inform the client the need to assume a special position
3. Tell the client that appropriate draping will be provided.
4. Control room temperature, and provide warm blanket.
5. Ask the client to empty the bladder.
6. Encourage the client to defecate.
7. Use a relaxed voice tone and facial expressions to put the client at ease.
8. Encourage the client to ask questions and report discomfort felt during the examination.
9. Have a family member or a third person of the client’s gender in the room during assessment
of genitalia
10. At the conclusion of the assessment, ask the client if he or she has any concerns or questions

POSITIONS:

Sitting

➢ Use this position for the assessment of head, neck, back, posterior thorax, and
lungs, breasts, axillae, heart, vital signs, and upper extremities

➢ It provides full expansion of lungs, and provides better visualization of symmetry

of upper body part.
Supine

➢ back lying position with legs extended, without small pillow under the head

➢ for the assessment of head, and neck, anterior thorax and lungs, breasts, axillae,
heart, abdomen, extremities, pulses, vital signs, vagina

➢ Most normally relaxed position. It provides easy access to pulse sites.

Dorsal recumbent

➢ back lying position with knees flexed and hips externally rotated, with small pillow
under the head.

➢ Head, neck, anterior thorax and lungs, breasts, axillae, heart and abdomen,
extremities, peripheral pulses, vital signs and vagina.

➢ Position is used for abdominal assessment because it promotes relaxation of

abdominal muscles.
Lithotomy

➢ back lying position with feet supported in stirrups; hips should be in line with the
edge of the table

➢ for the assessment of female genitalia, rectum and female reproductive tract

➢ Provides maximal exposure of genitalia and facilitates insertion of vaginal

speculum

Sim’s

➢ side-lying position with lowermost arm behind the body and uppermost leg flexed.

➢ For the assessment of rectum and vagina

➢ Flexion of knee and hip improves exposure of rectal area

Prone

➢ face-lying position with or without a small pillow

➢ assessment of posterior thorax, hip movement

Knee-chest (Genu-pectoral)

➢ kneeling position with torso at a chest.

➢ Assessment of rectum

➢ Provides maximal exposure to rectal area

Fowler’s

➢ Semi-fowler’s – head of bed elevated at 15-45 degree angle.

➢ High Fowler’s – head of bed raised at 80-90 degree angle.

 EQUIPMENTS USED FOR PHYSICAL EXAMINATION

EQUIPMENT USE

Cotton balls or wisps Test the sense of touch

Cotton-tipped applicators Obtain specimens

Culture media Obtain cultures of body fluids and drainage

Dental mirror Visualize mouth and throat structures

Doppler ultrasonic stethoscope Obtain readings of blood pressure, pulse, and

fetal heart rate

Flashlight Provide a direct source of light to view parts of

the body

Gauze squares Obtain specimens; collect drainage

Gloves Protect the nurse and client from

contamination

Goggles Protect the nurse’s eyes from contamination

by body fluids

Lubricant Provide lubrication for vaginal or rectal

examinations
Nasal speculum Dilate nares for inspection of the nose

Ophthalmoscope Inspect the interior structures of the eye

Otoscope Inspect the tympanic membrane and external

ear canal

Penlight Provide a direct light source and test pupillary

reaction

Reflex hammer Test deep tendon reflexes

Ruler, marked in centimeters Measure organs, masses, growths, and lesions

Skin-marking pen Outline masses or enlarged organs

Slides Make smears of body fluids or drainage

Specimen containers Collect specimens of body fluids, drainage, or

tissue

Sphygmomanometer Measure systolic and diastolic blood pressure

Sterile safety pin Test for sensory stimulation

Stethoscope Auscultate body sounds

Tape measure Measure the circumference of the head,

abdomen, and extremities in centimeters

Test tubes Collect specimens

Thermometer Measure body temperature

Tongue blade Depress tongue during assessment of the mouth

and throat

Tuning fork Test auditory function and vibratory sensation

Vaginal speculum Dilate the vaginal canal for inspection of the

cervix

Vision chart Test near and far vision

Watch with second hand Time heart rates, fetal pulse, or bowel sounds
when counting
 TECHNIQUES OF PHYSICAL ASSESSMENT

1. INSPECTION

➢ visual examination
-Should be deliberate, purposeful, and systematic
-is concentrated watching
-it is close, careful scrutiny, first of the individual and as a whole and on each body
system

➢ begins the moment you first meet your client

➢ inspection always comes first

➢ the health care worker inspects with the naked eye and with a lighted instrument

➢ in addition to visual observations, olfactory and auditory cues are noted

➢ inspection is used to assess moisture, color, and texture if body surfaces as well as
shape , position ,size, symmetry of the body

➢ requires good lighting, adequate exposure, and occasional use of certain

instruments to enlarge your view.

Guidelines:

• Make sure the room has a comfortable temperature.

• Use good lighting, preferably sunlight.

• Look & observe before touching.

• Compare appearance of symmetric body parts or both sides of any individual

body part.

2. AUSCULTATION

➢ requires the use of stethoscope

Guidelines:
• Eliminate distracting noises
• Expose the body part you are going to auscultate
• Press the diaphragm firmly
3. PALPATION

Factors/ characteristics to assess are:

1. Texture

2. Temperature of skin area

3. Location/position, size, consistency, mobility of organs or masses

4. Distention

5. Pulsation

6. Presence of pain upon pressure

7. Presence of lumps

Different parts of the hands are best suited for assessing different factors:

1. finger pads

2. grasping action of the fingers and thumb

3. dorsal

4. ulnar or palmar
Types Of Palpation:

1. Light Palpation

➢ place dominant hand lightly on the surface of the structure

➢ there should be very little or no depression

➢ feel the surface using circular motion

➢ use this technique to feel for pulse, tenderness, surface, texture, temperature &
moisture

2. Moderate Palpation
➢ depress the skin surface 1-2 cm (.5-.75 in) with your dominant hand
➢ use circular motion to feel for easily palpable body organs and masses
➢ note for size, consistency and mobility of structures you palpate

3. Deep Palpation

➢ place your dominant hand on the skin surface and your non dominant hand on top
of your dominant hand to apply pressure

➢ surface depression should be 2.5 cm and 5 cm (1-2 in)

➢ allows you to feel very deep organs or structures that are covered by thick muscle

a. Bimanual Palpation

➢ use two hands, placing one on each side of the body part being palpated
➢ use one hand to apply pressure and the other hand to feel the structure
➢ note the size, shape, consistency and mobility of the structures you palpate
4. PERCUSSION

➢ involves tapping body parts to produce sound waves that enable the examiner to
assess underlying structures

Uses:

• Eliciting pain: percussion helps detect inflamed underlying structures.

• Determining location, size and shape

• Determining density
• Detecting abnormal masses
• Eliciting reflexes

Types:
1. Direct Percussion
2. Indirect or mediate Percussion

Procedure:

a. place middle finger of non-dominant hand on body part you are going to
percuss
b. use pad of middle finger of the other hand to strike the middle finger of non-
dominant hand that is placed on the body part
c. withdraw finger immediately
d. deliver 2 quick taps and listen carefully
e. use quick, sharp taps by flexing wrist

Sounds Elicited by Percussion:

1. Resonance
- intensity: LOUD
- pitch: LOW
- length: LONG
- quality: HOLLOW
- origin: NORMAL LUNG

2. Hyper-resonance
- intensity:VERY,LOUD
- pitch:LOW
- length:LONG
- quality:BOOMING
- LUNG W/ EMPHYSEMA

3. Tympany
- intensity: LOUD
- pitch: HIGH
- length: MODERATE
- quality: DRUMLIKE
- PUFFED-OUT CHEEKS

4. Dullness
- intensity: MEDIUM
- pitch: MEDIUM
- length: MODERATE
- quality: THUDLIKE
- DIAPHRAGM, PLEURAL EFFUSION, LIVER

5. Flatness
- intensity: SOFT
- pitch: HIGH
- length: SHORT
- quality: FLAT
- MUSCLE, BONE

Special Considerations:
1. The sequence of methods for physical examination of the abdomen is as
follows: Inspection, Auscultation, Percussion and Palpation (IAPePa). No
abdominal palpation among clients with tumor of the liver or the kidneys.
2. During physical examination of the abdomen, it is important to flex the
knees to relax the abdominal muscles , thereby facilitating the examination of
abdominal organs.
3. The sequence of examining the abdomen is as follows: right lower quadrant,
right upper quadrant, left upper quadrant and left lower quadrant (RLQ, RUQ,
LUQ, LLQ).
4. The best position when examining the chest is sitting/upright position. This
permits the examination of both the anterior and posterior chest.
5. The best position when examining the back is standing position. This enables
the examiner to assess the posture, and the gait of the client.
6. If instrumental vaginal examination is done, pour warm water over the
vaginal speculum before use. To ensure comfort.
7. Is a female client is examined by a male doctor, a female staff must be
in attendance. This ensures that the procedure is done in ethical manner.

Organization of The Examination

1. History taking precedes physical examination.

2. The commonly used system is “head to toe” (cephalocaudal).
3. The extent of the examination depends on the purpose.
••A client returning from surgery for repair of a fractured leg will require
assessment of the circulatory and musculoskeletal function rather than a breast
assessment or examination.
4. If client becomes fatigued, offer rest periods between assessments.
5. Record results of the examination in scientific terms so that any health
professional can interpret the findings.

The Examination

General Survey - The preliminary examination which includes the following:

A. Height and Weight

B. Vital Signs

1. Temperature
- Taken at what route.
2. Pulse
- Rhythm, volume and tension.
3. Respiration
- Rate, rhythm, symmetry, depth, character, color of the client
4. Blood Pressure

C. General Appearance and Behavior

1. Sex and Race
- A person’s sex affects the type of examination performed.
- Different physical features are related to sex and race.
2. Signs of Distress
- There maybe signs or symptoms indicating a problem such as pain, difficulty of
breathing, and anxiety.
3. Body Type
- The body type can reflect the level of health, age and lifestyle
- The HCP observes if the client appears trim, muscular, obese, or excessively
thin.
4. Posture
- Normal standing posture is an upright stance with parallel alignment of his
shoulders.
- Normal sitting posture involves some degree of rounding of the shoulders. --
Observe if the client has an erect, slumped, or a bent posture. Posture may
reflect mood or presence of pain. Many elderly persons assumed a stooped
position.
5. Gait
- The manner of walking. Note if the movements are coordinated or
uncoordinated.
6. Body Movements
- Note for involuntary movements of body
7. Age
- It influences the normal features or physical characteristics of an individual.
The ability to participate n some parts of the examination will also be influenced
by age.
8. Hygiene and Grooming
- Note the client’s level of cleanliness by observing the appearance of the hair,
skin, or the fingernails.
9. Dress
- Note if the type of clothing worn is appropriate for the temperature and
weather condition.
10. Body Odor
- Assess is it from physical exercise, poor hygiene, or poor oral hygiene.
11. Mood and Affect/ Facial Expression
- At rest and in interaction with others.
12. Speech
- It includes the pace of speech, its pitch and clarity.
13. Level of Consciousness
- Including the speed of response to questions and apparent comprehension.

CULTURAL CONSIDERATIONS OF PHYSICAL ASSESSMENT

What you need to Why you need to know it

know
Ethnicity and • This information can be an indicator of the client’s culture,
country of birth traditions, customs, health beliefs and preferred languages.

Remember that:

Ethnicity may be more significant than country of birth. For

example, clients may have been born in a country where their
parents lived briefly.
Literacy • May affect the client’s capacity to respond to written
information provided during the assessment.

• May indicate the client’s social status and education level in

their previous country of residence or origin.

Remember that:

• Clients may rely on family members to read and explain

 written information.

• Clients and their families may not be literate in the

language they prefer to speak.
Interpreter • Identifying an appropriate interpreter, and ensuring that the
preferences client is comfortable using an interpreter, is essential for clear
and appropriate communication.

Remember that:

• The client may not be familiar with using an interpreter:

you may need to explain the process.

• Clients may have concerns about the confidentiality of

interpreters.

• There is a small chance that the client may know the

interpreter, which may raise privacy concerns.

• Consider client preferences regarding the gender and

ethnicity of the interpreter, and whether an on-site or
telephone interpreter is preferred.

• Only qualified interpreters should be used: the client’s

family members should not be used as interpreters.
Migration status and • Stress and trauma resulting from pre-migration, migration or
experience post-migration experiences can greatly affect a client’s health
and wellbeing.

• Visa status can affect access to subsidised health services.

Beliefs about health • Clients’ beliefs and past experience affect the way they view
and illness health, causes of illness and treatment.

• Understanding and acknowledging the client’s health beliefs

and practices is an important step in creating a mutually
acceptable care plan.
Understanding of the • Clients may not be familiar with the structure of the health
health system service system or how to access various services.

• Clients may not be familiar with health system processes (eg

waiting lists for hospitals, Medicare support, etc)
Dietary practices • There may be religious restrictions on food consumption

• Some foods may have cultural meanings for clients (eg the
belief that certain foods are beneficial or harmful to health)
Family and social • The responsibility for care may not lie only with the client:
support other people, including extended family, may assume
responsibility for care
 Remember that:

• In some cultures, ‘family’ may include non-related

individuals.

• A client’s social support networks may be limited.

• A client may be able to access support through community

organizations.
Religious practices • Clients may wish to access spiritual or religious leaders

• Particular times for prayer may be important

• Religious practices may occasionally conflict with treatment

plans.

• Particular customs may need to be followed during birth,

illness and death and dying

VITAL SIGNS TAKING(CARDINAL SIGNS)

*Reflect the body’s physiologic status and provide information critical to evaluating
homeostatic balance
INCLUDES:
1. Temperature
2. Pulse rate
3. Respiratory rate
4. Blood pressure

TEMPERATURE

Body temperature – the balance between the heat produced by the body
and the heat lost from the body.

Types of Body Temperature:

Core temperature – the temperature of the deep tissues of the body.

Measured by taking oral and rectal temperature.

*Temperature of the internal organs and it remains constant most of the

time(37c) with the range of 36.5-37.5c

Measure w/ a thermometer.
 Surface temperature – the temperature of the skin, subcutaneous tissue
and fat. Measured by taking axillary temperature.

*(Ranges bn 20-40c.

Factors affecting the body’s heat production:

Ø Basal Metabolic Rate(BMR) – the younger the person, the higher the
BMR; the older the person, the lower the BMR. Therefore, the older
persons, have lower body temperature than the younger persons.

Ø Muscle Activity – exercise increases body heat production.

Ø Thyroxine Output – increases cellular metabolic rate. Hyperthyroidism

is characterized by increased body temperature.

Ø Epinephrine, norepinephrine, and sympathetic stimulation – increase

the rate of cellular metabolism. These in turn increase body temperature.

Ø Fever – increases the rate of cellular metabolism.

Processes Involved in Heat Loss:

a. Radiation-transfer of heat from the surface of one object to surface of
another without contact between two objects.
b. Conduction-transfer of heat from one molecule to a molecule of lower
temperature.
c. Convection- dispersion of heat by air currents.
d. Evaporation- continuous vaporization of moisture from the respiratory
tract and from the mucosa of the mouth and from the skin.

Factors affecting Body Temperature

1. Age – infant’s body temperature is greatly affected by the

temperature of the environment. Elder people are at risk of
hypothermia due to decreased thermoregulatory controls, decrease
subcutaneous fat, inadequate diet, and sedentary activity.
2. Diurnal Variations(Circadian Rhythms) – highest temperature is
usually reached between 8PM-12MN; and the lowest temperature is
reached between 4-6 AM.
3. Exercise – strenuous increases BMR thus, the body temperature.
4. Hormones – e.g. progesterone, thyroxine, epinephrine and
norepinephrine increase body temperature; estrogen decreases
body temperature.
 5. Stress – sympathetic nervous system stimulation increases the
production of epinephrine and norepinephrine, thereby increasing
the metabolic rate and heat production.

Alterations in Body Temperature

*Normal body temperature is 37c or 98.6 F.

*Range 36-38c(96.8-100F)

Fever=High Temperature

Hypothermia=Low Temperature

1. Pyrexia/hyperthermia/fever – temperature above normal range.(38-

41c)(100.4-105.8).

2. Hyper pyrexia – very high fever, 41>42c degrees celcius (105.8 deg.
Fahrenheit) and above, will lead to death.

3. Hypothermia – subnormal core body temperature. This may be caused

by excessive heat loss, inadequate heat production or impaired
hypothalamic function.

Temperature is between 34-35c, <34c is death.

Types of Fever:

1. Intermittent Fever-the body temperature alternates at regular intervals

between periods of fever and periods of normal or subnormal
temperatures.

2. Remittent Fever-a wide range of temperature fluctuations (more than

2C) occurs over the 24-hour period, all of which are above normal.

3. Relapsing Fever-short febrile periods of a few days are interspersed

with periods of 1 or 2 days of normal temperature.

4. Constant Fever-the body temperature fluctuates minimally but always

remains above normal.

Clinical Signs of Fever

1. Onset
– Increased heart rate
– Increased respiratory rate and depth
– Shivering
– Pallor, cold skin
– Complaints of feeling cold
– Cyanotic nail beds
– “gooseflesh” appearance of the skin
– Cessation of sweating

2. Course
– Absence of Chills
– Glassy-eyed appearance
– Increased pulse and respiratory rate
– Increased thirst
– Mild to severe dehydration
– Drowsiness, restlessness, delirium or convulsions
– Herpetic lesions of the mouth
– Loss of appetite
– Malaise, weakness and aching muscles

3. Defervescence(fever abatement)
– Skin that appears flushed and feels warm
– Sweating
– Decreased shivering
– Possible dehydration

Interventions for Clients with Fever

1. Monitor vital signs.

2. Assess skin color and temperature.

3. Monitor WBC, hematocrit value, and other pertinent laboratory reports

4. Remove excess blankets when the client feels warm, but provide
extra warmth when the clients feels chilled.

5. Provide adequate nutrition and fluids

6. Measure I and O

7. Reduce physical activity

8. Provide oral hygiene

9. Provide a tepid sponge bath

10. Provide dry clothing and bed linens.

11. Administer antipyretics

Methods of Temperature Taking:

1. Oral – most accessible and convenient method.

Ø Allow 15 minutes to elapse between a client’s

§ intake of hot or cold food or smoking and the
§ measurement of oral temperature.

Ø Place thermometer under the tongue, directed towards the side.

Ø Wash the thermometer before use, from bulb to the stem.

Ø Wash the thermometer after use, from the stem to the bulb.

§ This practice ensures medical asepsis.

Ø Contraindications:
a. Oral lesion or surgery
b. Cough
c. Nausea and vomiting
d. Very young children
e. Restless, disoriented
f. Seizure prone

2. Rectal – the most accurate method/reliable

Ø Procedure:
a. Provide privacy.
b. Position - Sim’s
c. Apply disposable gloves.
d. Squeeze liberal portion of lubricant.
e. With non-dominant hand, separate client’s
buttocks to expose the anus.
f. Ask client to breathe slowly and relax.
g. Gently insert thermometer into anus.
h. If resistance is felt during insertion, withdraw
thermometer immediately.
i. Once positioned, leave thermometer in place
j. Remove thermometer from anus.
k. Wipe with antiseptic solution.
l. Return thermometer to storage
m. Wipe client’s anal area with soft tissue to remove lubricant or feces
and discard tissue
n. Remove gloves and dispose.

Ø Contraindications:
a. Anal or rectal conditions or surgeries [hemorrhoids,
hemorrhoidectomy]
b. Diarrhea

3. Axillary – safest and most non-invasive method of temperature

taking.

Ø Procedure:
a. Pat dry the axilla
b. Place the thermometer on the client’s axilla
c. Place the arm tightly across the chest to
d. keep the thermometer in place
e. Remove from axilla.
f. Return thermometer to storage.
g. Perform hand hygiene

Normal Body Temperature: Axillary: 36.5 to 37.5 degrees celcius

4. Temporal Artery – safe and non-invasive; very fast

- requires electronic equipment that may be expensive or unavailable.

PULSE

1. Wave of blood created by contraction of the left ventricle of the heart.

2. Stroke volume and the compliance of arterial wall are the two important
factors influencing pulse rate.

3. Pulse rate is regulated by autonomic nervous system.

Pulse sites:
1. Temporal - over the temporal bone of the head ; superior and lateral
to the eye
2. Carotid - at the lateral aspect of the neck
3. Apical(Central Pulse) - at the left midclavicular line 5th intercostal
space
4. Brachial - at the inner aspect of the upper arm (biceps muscles) or
medially at the antecubital space
5. Radial - on the thumb side of the inner aspect of the wrist.
6. Femoral - along side of the inguinal ligament
7. Posterior tibial- at the middle aspect of the ankle, behind the medial
malleolus.
8. Pedal(dorsalis pedis)- at the dorsum of the foot.
9. Popliteal- at the back of the knee.

10. Peripheral Pulse-Is a pulse located in the periphery of the body e.g in
the foot, and or neck
Assessment of Pulse

Procedure:

1. Perform hand hygiene

2. Assess
3. Position
4. Place tips of first two fingers of hand over groove along radial or
thumb side of client’s inner wrist
5. Lightly compress
6. Determine strength of pulse .
7. After pulse can be palpated regularly, look at the watch’s second
hand and begin to count

Rate- The normal PR per min are as follows:

Ø Newborn to 1 mo.: 120-160 beats/min

Ø 1yr: 80- 140 bpm

Ø 2yrs: 80-130 bpm

Ø 6yrs: 75-120 bpm

Ø 10 yrs: 50-90 bpm

Ø Adult: 60-100 bpm

Tachycardia – Pulse rate above 100 beats per minute (adult)

Bradycardia – Pulse rate below 60 beats per minute (adult)

Rhythm – pattern and intervals of beats

Ø DYSRHYTHMIA – irregular rhythm

Volume (amplitude) – strength of pulse

Ø Normal – moderate pressure

Ø Full or bounding pulse – can be obliterated only by great pressure

Ø Thready pulse (weak, feeble)– it can easily be obliterated

Factors Affecting Pulse Rate

1. Age – younger persons have higher pulse rate than older persons.

Infants range=100-160 BPM

Adult range=60-100 BPM

2. Sex/gender – after puberty, female have higher PR than the males.

3. Exercise – increases BMR, thereby increasing the pulse rate.
4. Fever – increases BMR, therefor the PR increases.
5. Medications – digitalis, beta blockers, decrease PR; epinephrine
atropine sulfate increase pulse rate.
6. Hemorrhage – increases pulse rate as compensatory mechanism for
blood loss.
7. Stress – sympathetic nervous stimulation increases the activity of
the heart.
8. Position changes – In sitting or standing position, there is decrease
venous return to the heart , decrease BP, therefore, increase in the
heart rate.
9. Heat: Increase PR as a compensatory mechanism.

RESPIRATION – act of breathing

3 Processes

1. Ventilation - movement of gases in and out of the lung

2. Diffusion - exchange of gases from an area of higher pressure to an

area of lower pressure

3. Perfusion - the availability and movement of blood for transport of

gases, nutrients and metabolic waste products.

Two Types Of Breathing:

1. Costal (thoracic) – involves movement of the chest.

2. Diaphragmatic (Abdominal) – involves movement

Respiratory Centers:

Medulla Oblongata – primary center

- Pneumotaxic center – responsible for the rhythmic quality of

breathing.

- Apneustic Center – responsible for deep, prolonged inspiration

Assessing respiration

Ø Procedure
1. Position client.
2. Place client’s arm in relaxed position across abdomen or lower chest,
or place hand directly over client’s upper abdomen
3. Observe complete respiratory cycle.
4. After cycle is observed, look at watch’s hand and begin to count

Ø Rate – normal:16-20 cycles/min (adult); 30-60 cycles per

min (newborn)

– If BP is elevated – the RR becomes slow

– If BP is decreased – RR becomes rapid

Ø Depth – observe the movement of the chest

- may be normal, deep or shallow

Ø Rhythm – observe for regularity of exhalations and inhalations

Ø Quality or character – refers to respiratory effort and sound of

breathing

Major Factors Affecting RR:

a. Exercise – increases RR
b. Stress – increases RR
c. Environment – increase temp. – decreases RR
decreased temperature – increases RR
Increased altitude – increases RR
Eupnea- normal respiration that is quiet, rhythmic, effortless

Tachypnea- rapid respiration marked by quick, shallow breaths.

Bradypnea -slow breathing

Hyperventilation- prolonged and deep breaths . carbon dioxide is

excessively exhaled.

Hypoventilation- slow shallow respiration.

Dyspnea- difficult and labored breathing.

Orthopnea- ability to breath only in upright position.

BLOOD PRESSURE

Ø is a measure of the pressure exerted by the blood as it

pulsates through the arteries.

 Systolic pressure – pressure of blood as a result of contraction of

the ventricles
 Diastolic pressure- the pressure when the ventricles are at rest
(60-90 mmHg)
 Pulse pressure – the difference between systolic and diastolic
pressure (normal: 30-40 mmHg)

Factors affecting BP:

• Age – older people have higher BP due to decreased elasticity of

blood vessels.

• Exercise – increases cardiac output, hence the BP.

• Stress – Sympathetic nervous system

• Race – hypertension is one of the 10 leading causes of death

among Filipinos.

• Obesity – BP is generally elevated among overweight and obese

people.

• Sex/Gender

• Medications – some medications can increase or decrease BP.

• Diurnal variations – BP is lowest in the morning and highest in the
late afternoon or early evening.

• Disease Process – DM, renal failure, hyperthyroidism cause

increase in BP.

Assessing BP

Procedure:

1. Ensure the client is rested

2. Allow 30 minutes to pass if the client had smoked or ingested caffeine

before taking the BP

3. Use appropriate size of BP cuff

4. Position the patient in sitting or supine position

5. Apply BP cuff snugly, 1 inch (2.5 cm) above the antecubital space

6. Use the bell shaped diaphragm of the stethoscope since the BP is a

low-frequency sound

7. Inflate deflate the cuff slowly, 2-3 mmHg at a time

8. Wait 1-2 mins before making further determinations

9. Document readings.

Classification of blood pressure for adults

Blood Pressure SBP DBP

Classification mmHg mmHg
Hypotension <90 <60
Normal 90- 120 Less than 80
Elevated 120–129 Less than 80
Stage 1 130-139 80-89
Hypertension
Stage 2 ≥140 ≥90
Hypertension
 Hypertensive Crisis >180 >120
Recommended by American Heart Association

General

➢ Weight loss?
➢ Weight gain?
➢ Fatigue?
➢ Difficulty sleeping?
➢ Feeling well (or poorly) in general?
➢ Recent medical evaluations or treatments?
➢ Chronic pain?
➢ Fevers, chills, sweats, weight loss?

Vision

➢ Chronic or past eye disorders?

➢ Decrease/change in vision or blurriness? With or without pain?
➢ Double vision?
➢ Eye discharge (D/C)?
➢ Change in color of structures?

Head and Neck (H&N)

➢ Chronic or past head and neck disorders?

➢ Pain?
➢ Sores or non-healing ulcers in/around mouth?
➢ Masses or growths?
➢ Change in hearing acuity?
➢ Ear pain or discharge?
➢ Nasal discharge, post nasal drip?
➢ Change in voice/hoarseness?
➢ Tooth pain or problems

Pulmonary

➢ Chronic or past pulmonary disorders?

➢ Shortness of breath - @ rest or w/exertion?
➢ Chest pain?
➢ Cough?
➢ Hemoptysis (coughing up blood)?
➢ Wheezing?
➢ Snoring or stop breathing

Cardiovascular (C/V)

➢ Chronic cardiovascular disorders?

➢ Chest pain (CP) or pressure?

➢ Shortness of breath - @ rest or w/exertion?

➢ Orthopnea (short of breath lying down)?

➢ Paroxysmal Nocturnal Dyspnea (PND)? - sudden shortness of breath that awakens

pt from sleep

➢ Lower extremity edema?

➢ Sudden loss of consciousness (syncope)?

➢ Sense of rapid or irregular heart beat, palpitations?

➢ Calf/leg pain/cramps w/ambulation?

➢ Wounds/ulcers in feet? Difficult/slow to heal?

Gastrointestinal

➢ Chronic or past GI disorders?

➢ Heart burn/sub-sternal burning?
➢ Abdominal pain?
➢ Difficulty swallowing?
➢ Pain upon swallowing?
➢ Nausea or Vomiting?
➢ Abdominal swelling or distention?
➢ Jaundice (yellowish coloration of skin)?
➢ Vomiting blood (hematemasis)?
➢ Black/tarry stools?
➢ Bloody stools?
➢ Constipation?
➢ Diarrhea or other change in bowel habits?

Genito-Urinary

➢ Chronic or past GU disorders?

➢ Blood in urine?
➢ Burning with urination?
➢ Urination at night?
➢ Incontinence (unintentional loss of urine)?
➢ Urgency?
➢ Frequency?
➢ Incomplete emptying? Hesitancy? Decreased force of stream? Need to void soon
after urinating?

Hematology/Oncology

➢ Chronic or past Heme/Onco disease?

➢ Fevers, chills, sweats, weight loss?
➢ Abnormal bleeding/bruising?
➢ New/growing lumps or bumps?
➢ Hypercoagulability?

Ob/Gyn/Breast

➢ Chronic or past disease?

➢ Menstrual Hx?
➢ Sweats?
➢ Past pregnancies?
➢ Vaginal Discharge?
➢ # Sexual partners & type of sexual activity?
➢ Breast mass, pain or discharge?
➢ Therapeutic or spontaneous abortions?
➢ Hx of STIs?

Neurological

➢ Known disease?
➢ Sudden loss of neurological function?
➢ Abrupt loss/change in level of consciousness?
➢ Witnessed seizure activity?
➢ Numbness?
➢ Weakness?
➢ Dizziness?
➢ Balance problems?
➢ Headache?
➢ Tremor?

Endocrine

➢ Known Endocrine disorder?

➢ Polyuria, polydypsia, polyphagia?
➢ Fatigue?
➢ Weight loss?
➢ Weight gain?

Infectious Diseases
➢ Known disease?
➢ Fevers, Chills, Sweats?

Musculoskeletal

➢ Known disease?
➢ Joint pain?
➢ Muscle ache?
➢ Joint swelling?
➢ Joint redness?
➢ Low back pain?

Mental Health

➢ Known mental health disorder?

➢ Do you feel sad or depressed much of the time?
➢ Alcohol, other substance abuse?
➢ Anxious much of the time?
➢ Memory problems?
➢ Confusion?

Skin and Hair

➢ Hair Loss
➢ Known disease?
➢ Skin eruptions/rashes?
➢ Growths?
➢ Sores that grow and/or don't heal?
➢ Lesions changing in size, shape, or color?
➢ Itching
 INTEGUMENTARY SYSTEM

· Skin: The client’s skin is uniform in color, unblemished and no presence of any foul
odor. He has a good skin turgor and skin’s temperature is within normal limit.

· Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable
amount of body hair. There are also no signs of infection and infestation observed.

· Nails: The client has a light brown nails and has the shape of convex curve. It is smooth
and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the
nails return to usual color in less than 4 seconds.

Body Part Technique Findings

Inspection » When skin is pinched it goes to previous state
immediately (2 seconds).
Palpation
Skin
» With fair complexion.

» With dry skin

Inspection » Black, evenly distributed and covers the whole
scalp, thick, shiny, free from split ends.
Inspect for the
color, distribution, » Coarse or fine.
thickness,
lubrication and *Note:
appearance.
Terminal Hair
Hair
- Its is the long, thick, and coarse hair of the body
Palpation which is easily visible on the scalp, axilla, and the
pubic area.
Palpate for texture.
Vellus Hair

- It is the soft, small, tiny hair that covers the

whole body except for the palms and the soles.
Inspection » Smooth and has intact epidermis
With short and clean fingernails and toenails.
Nails
Convex and with good capillary refill time of 2
seconds.
1. WHEN ASSESSING SKIN, YOU SHOULD INSPECT EVERY INCH OF THE
PATIENT’S SKIN
a. Remove/lift gown
b. Remove socks
c. Look under dressings – unless contraindicated or have an order not to remove
dressing

Nursing Points

General

1. Integumentary assessments are often done simultaneously with other body systems
a. More efficient
b. Can observe/inspect skin while inspecting other aspects of that are
2. Supplies needed
a. Wound measurement tape/supplies
b. Dressing supplies as needed
Assessment

1. Inspect
a. Color
i. Should be consistent with ethnicity
ii. Jaundice, cyanosis, pallor, erythema – may indicate a disease process
iii. In darker-skinned patients, look at sclera, lips, and nail beds for color changes

b. Moisture
i. Diaphoresis may indicate fever, hypoglycemia, anxiety, or other disease process

c. Wounds/lesions

i. Color
ii. Drainage
iii. Size
1. Length
2. Width
3. Depth
iv. Tunneling or undermining
v. Location
vi. Raised
vii. Texture
viii. ABCDE mnemonic to assess moles

d. Pressure areas
i. Back of head
ii. Hips
iii. Sacrum
iv. Heels
v. Shoulders
vi. Other bony prominences
 e. Edema
i. If present, assess for pitting
ii. Note location and severity
iii. Can take circumference measurements

f. Hair growth
i. Present where it should be?
ii. Absent where it shouldn’t?

g. Nails
i. Color
ii. Shape
iii. Texture

2. Palpate
a. Edema – fluid accumulation under the skin
i. Press finger or thumb into edema to assess for pitting
b. Temperature – use the back of your hand to feel the skin
i. Should be warm to touch, but not hot
ii. Cool or cold skin may indicate perfusion issues

c. Turgor
i. Pinch skin over clavicle – it should rebound almost immediately
ii. Tight?
1. Can barely pinch
iii. Tenting?
1. Skin tents for >3 seconds

d. Moisture
e. Tenderness

3. Abnormal findings
a. Color changes
i. Hyperpigmentation
1. Addison’s disease
ii. Hypopigmentation
1. Vitiligo
iii. Erythema – redness
1. Inflammation
iv. Cyanosis – bluish color
1. Oxygenation issues
v. Pallor – whitish color
1. Perfusion issues
vi. Jaundice – yellowing of skin or eyes
1. Liver failure

b. Edema
i. Pitting edema scale
1. 1+ mild pitting (2mm, rebounds quickly)
2. 2+ moderate pitting (4mm, rebounds in 3-4 seconds)
3. 3+ severe (6mm, 10-15 seconds to rebound) – usually generalized
throughout extremity
4. 4+ extreme (8mm+, >20 seconds to rebound – sometimes minutes,
generalized throughout extremity, may have perfusion issues)
 ii. Dependent
1. Found only on the lowest aspect (closest to the ground) of the body
part
iii. Generalized (anasarca)
1. Edema throughout body, usually non-pitting

c. Absence of hair growth

i. May indicate chronic venous insufficiency

d. Lesions
i. Macule
1. A flat area of hyperpigmentation, usually less than 10mm.
ii. Patch
1. A larger macule (>10mm)
iii. Papule
1. A well-defined raised area with no visible fluid, usually less than 10
mm.
iv. Plaque
1. A large papule or group of them, usually greater than 10 mm, or a
large raised plateau-like lesion.
v. Nodules
1. Similar to a papule – raised area with no fluid – but is much deeper in
the dermis
vi. Vesicles
1. A small, well-defined raised area filled with fluid, usually <10mm.
2. Also known as a blister
vii. Bulla
1. A large vesicle, usually >10mm.
2. Also known as a blister
viii. Ulcers
1. Involve loss of the epidermis and some or all of the dermis
ix. Fissures
1. A crack in the skin that is usually narrow but deep.
x. Erosions
1. Involve full loss of the epidermis in a defined area.

e. Nail abnormalities
i. Clubbing
1. Hypoxia or hypoxemia
ii. Scoop-like nails
1. Anemia
iii. Pale nail beds
1. Perfusion issues

f. Turgor
i. Tight – may have swelling, edema, or venous insufficiency
ii. Tenting – dehydration
 TYPES OF SKIN LESIONS

LESION DERCRIPTION
bulla raised, fluid-filled lesion larger than a vesicle (plural: bullae)
fissure crack or break in the skin
macule flat, colored spot
nodule solid, raised lesion larger than a papule; often indicative of systemic disease
papule small, circular, raised lesion at the surface of the skin
plaque superficial, flat, or slightly raised differentiated patch more than 1 cm in
diameter
pustule raised lesion containing pus; often hair follicle or sweat pore
ulcer lesion resulting from destruction of the skin and perhaps subcutaneous tissue
vesicle small, fluid-filled, raised lesion; a blister or bleb
wheal smooth, rounded, slightly raised area often associated with itching; seen in
ulticaria (hives), such as that resulting from allergy
 B. HEAD AND NECK ASSESSMENT

Overview

1. Head and neck abnormalities are rare, but could indicate significant disease processes

Nursing Points

General

1. Small, barely noticeable asymmetry is normal

a. One ear may be ever-so-slightly higher than the other
2. Significant asymmetry or weakness on one side is considered abnormal

Assessment

1. Head
a. Inspect
i. General symmetry
1. Have patient make various faces to assess for asymmetry or one-sided
weakness
ii. Size
1. Abnormally large may indicate hydrocephalus, especially in children
iii. Shape
iv. Facial symmetry
1. Eyebrows
2. Nose
3. Mouth
4. Ears
v. Make note of any abnormal features or movements
1. i.e. twitching

b. Palpate
i. Scalp
1. Symmetrical
2. Mostly smooth
a. Small bumps are normal
3. Nontender
ii. Facial stability
1. If trauma is suspected, assess for fractures by gently pressing on the cheeks

2. Neck
a. Inspect
i. Symmetry
ii. Visible swelling or masses
1. Goiter – thyroid issues
iii. Trachea should be midline
 iv. Range of Motion
1. Left to right
2. Chin up and down
3. Ears to shoulders
4. Should all be smooth and well-controlled without pain

b. Palpate
i. TMJ – have patient open and close jaw
1. Movement should be smooth with no clicking or tenderness
ii. Lymph nodes
1. Preauricular – in front of ear
2. Submandibular – below jaw
3. Supraclavicular – above clavicle
a. Almost always indicates malignancy
iii. Thyroid gland
1. Should be midline, not swollen, nontender

1. Head

· Head: The head of the client is rounded; normocephalic and symmetrical.

· Skull: There are no nodules or masses and depressions when palpated.
· Face: The face of the client appeared smooth and has uniform consistency and with no
presence of nodules or masses.

• Eyes and Vision

· Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned
and showed equal movement when asked to raise and lower eyebrows.
· Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
· Eyelids: There were no presence of discharges, no discoloration and lids close
symmetrically with involuntary blinks approximately 15-20 times per minute.
· Eyes

o The Bulbar conjunctiva appeared transparent with few capillaries evident.

o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are visible. The
client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and round.
PERRLA (pupils equally round respond to light accommodation), illuminated and non-
illuminated pupils constricts. Pupils constrict when looking at near object and dilate at
far object. Pupils converge when object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in the periphery
when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client coordinately moved
in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14 inches.

• Ears and Hearing

· Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles
are aligned with the outer canthus of eye. When palpating for the texture, the auricles are
mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch
tick test, the client was able to hear ticking in both ears.

• Nose and Sinus

· Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness and
lesions
· Mouth:
o The lips of the client are uniformly pink; moist, symmetric and have a smooth
texture. The client was able to purse his lips when asked to whistle.
o Teeth and Gums: There are no discoloration of the enamels, no retraction of gums,
pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening
and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist and slightly
rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has a more
irregular texture.
o The uvula of the client is positioned in the midline of the soft palate.

2. Neck
o The neck muscles are equal in size. The client showed coordinated, smooth head
movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend during
swallowing but are not visible.

THE HEAD TO TOE EXAMINATION (Head to Neck)

BODY PART TECHNIQUE NORMAL FINDINGS

A. HEAD » Proportional to the size of the body,
round, with prominences in the frontal
Palpation area anteriorly and the occipital area
posteriorly, symmetrical in all planes &
Skull gently curved
Scalp Inspection » White, clean, free from masses,
lumps, scars, nits, dandruff, and lesions.
Separate the hair strands
carefully to reveal the scalp.

Inspect for color, appearance,

presence of masses, lice, nits and
dandruff
 Palpation

Palpate for areas of tenderness.

Face
» Oblong or oval or square or heart
shaped, symmetrical, facial expression
Inspection
that is dependent on the mood or true
feelings, smooth and free from
Observe for the symmetry, shape, wrinkles, no involuntary muscle
facial expression, movement, and movements.
appearance.
Eyes Inspection

Instruct the client to look straight » Parallel and evenly placed,

and refrain from turning the head symmetrical, non-protruding, with
in different directions. Observe scanty amount of secretions, both eyes
for placement, symmetry, black and clear.
protrusion, clarity, and
lacrimation.
1. Eyebrows Inspection

Observe for the color, symmetry,

quantity of hair, movement,
distribution and placement or
parallelism.
» Black, symmetrical, thick can raise
lower eyebrows symmetrically and
without difficulty, evenly distributed
and parallel with each other.
*Note: To check for movement,
let the client raise and lower the
eyebrows at the same time at the
cue of your command or request.
2. Eyelashes Inspection
» Black, evenly distributed and turned
Observe for the color,
outward
distribution, and direction of
eyelashes
3. Eyelids » Upper lids cover a small portion of
the iris, cornea and the sclera (limbus)
Inspection
when the eyes are open.
Observe for position, symmetry,
» When the eyes are closed, the lids
and color.
meet completely.
Palpation. With the client’s eyes
Symmetrical, color is the same as the
closed, palpate for the lacrimal
surrounding skin.
gland if it’s palpable
» No palpable mass
4. Lid Margins Inspection
» Clear, without scalings or secretions,
lacrimal duct openings (puncta) are
Observe for scaling, secretions,
evident at the nasal ends of the upper
erythema, and the lacrimal duct
and lower lids.
openings (appearance)
5. Palpebral Inspection
Fissures
Inspect for the symmetry (the » Appear equal when the eyes are open.
longitudinal opening between the
eyelids)
6. Lower Inspection
» Salmon pink, shiny, moist and
palpebral
transparent
conjunctiva Observe for color and appearance
7. Sclera Inspection
» White and clear
Observe for color and
appearance.
8. Iris Inspection
» Proportional to the size of the eye,
Note for size, shape, color, round, black/brown, and symmetrical
symmetry
9. Pupils Inspection

Note size, shape, symmetry,

reaction to light and
accommodation (PERRLA).

***To check for the eye’s

reaction to light, there is a need
to control the amount of light that
gets into the eyes.

Therefore, there is need to use

the penlight and while doing so,
the side of the eye opposite the » From pinpoint to almost the size of
direction of the penlight should the iris, round, symmetrical, constrict
be shielded by the examiner’s with increasing light and
hand. Note the degree of accommodation.
constriction of the pupils if they
are symmetrical.

***Accommodation is the ability

of the lens to adjust to objects of
varying distances. To check for
accommodation, the examiner
instructs the client to look
straight into a photo shield
placed in different distances from
the eyes. Note the reaction of the
pupils as the photo is near and
when it is held far.
10. Eye Inspection
Movement
Ask client to refrain from » Able to move eyes in full range of
moving his head while he motion or able to move in all direction.
follows the direction of the
examiner’s fingers with his eyes.
11. Visual Acuity Inspection

Let client read the letters of the

Snellen’s chart at a distance of 20
feet.

Note: If the client has his glasses,

he should wear them, but not if » 20- distance from the chart
the glasses are intended only for
reading. Test each eye separately. » 20- distance at which a normal eye
Determine the smallest line of can read.
print from which he is able to
identify correctly more than half
the figures. Record the visual
acuity designated at the side of
this line.
12. Field of Inspection
Vision
Let the client look
» Able to see 60 degrees superiorly, 90
straightforward without moving
degrees temporally, and 70 degrees
his eyes. By placing your fingers
inferiorly.
in different specific directions,
ask the client if he could still see
your moving fingers.
Ears Inspection

Observe for parallelism, » Parallel, symmetrical, proportional to

symmetry, size, shape, position, the size of the head, bean-shaped, helix
color, and appearance. is in the line with the outer canthus of
the eye, skin is the same color as the
Palpation. Palpate for the surrounding area, clean.
firmness of the cartilage of the
auricles.
1. Ear Canal Inspection

By using a penlight, examine by

pulling up and back for adults, » Pinkish, clean, with scant amount of
down and back for children. cerumen and a few cilia.
Inspect for color, appearance,
presence of cerumen, foreign
bodies, and cilia.
2. Hearing Acuity Inspection

Whisper from the client’s ear at a

distance of 2 feet (one ear at a
time) and then at the back of the
client for both ears.
» Able to hear whisper spoken 2 feet
Note: Instruct the client not to away.
move his head and to repeat the
words that you will say. One
direction at a time.
Nose Inspection » Midline, symmetrical, and patent
 Observe for placement,
symmetry, patency.

Note: Ask client to close one

nostril at a time and ask if he has
any difficulty in breathing while
one nostril is covered.
1. Internal nares Inspection
» Clean, pinkish, with few cilia
Appearance, color of mucus
membrane, presence of cilia.
2. Septum Inspection
» Straight
Note for appearance.
Mouth Inspection
» Pinkish, symmetrical, lip margin well
1. Lips Observe for color, shape,
defined, smooth and moist
symmetry, lip margin,
appearance.
2. Gums Inspection
» Pinkish, smooth, moist, no swelling,
Observe for color, appearance,
no retraction, no discharge
discharge, and swelling or
retraction.
3. Teeth Inspection
» 32 permanent teeth, well-aligned, free
Number, color, alignment, from caries or filling, no halitosis
general condition, breath.
4. Tongue Inspection
» Large, medium, red or pink, slightly
rough on top, smooth along the lateral
Inspect for size, color, surface,
margins, moist, and freely movable.
appearance, and movement.
5. Frenulum Inspection
» Midline, straight, and thin.
Note for position and appearance.
6. Cheeks Inspection
» Pinkish, moist, and smooth
(Buccal Mucosa) Note color and appearance
7. Palate
Inspection
Soft Palate » Pinkish, smooth and moist
Inspect for color and
appearance.
Hard Palate » Slightly pinkish
8. Uvula
Inspection
» At the center, symmetrical, and freely
Note for position, color, size, movable
symmetry, and mobility.
9.Tonsils Inspection » Pinkish, non-inflamed, no exudates
 Note for color, size,
inflammation, exudates
10. Voice Inspection
» No hoarseness and well-modulated.
Detect if there is hoarseness of
voice

B. NECK Inspection » Proportional to the size of the body

and head, symmetrical, and straight
Note for size, symmetry, and
position

Palpation » No palpable lumps, masses, or areas

of tenderness
Palpate for lump, masses, or
areas of tenderness. » Adam’s apple palpable.

Palpate the Adam’s apple.

Range of Motion. » Freely movable without difficulty.

Chin to chest and ear to shoulder.

Muscular Strength » Symmetrical and able to resist applied

force (both muscles)
Symmetry and strength of the
sternocleidomastoid muscle and » Able to resist applied force.
the force and strength of the Symmetrical in structure of size and
trapezius muscles muscular strength.

COMMON EXAMINATIONS BEING USED DURING ASSESSMENT OF HEAD and

NECK

A. Snellen’s Chart for Visual Acuity

A Snellen chart is an eye chart that can be used to measure visual acuity. Snellen charts
are named after the Dutch ophthalmologist Herman Snellen, who developed the chart in
1862.

The normal Snellen chart is printed with eleven lines of block letters. The first line consists of
one very large letter, which may be one of several letters, for example E, H, or N. Subsequent
rows have increasing numbers of letters that decrease in size. A person taking the test covers
one eye from 6 metres or 20 feet away, and reads aloud the letters of each row, beginning at
the top. The smallest row that can be read accurately indicates the visual acuity in that
specific eye. The symbols on an acuity chart are formally known as "optotypes".

In the case of the traditional Snellen chart, the optotypes have the appearance of block
letters, and are intended to be seen and read as letters. They are not, however, letters
from any ordinary typographer's font. They have a particular, simple geometry in
which:
• the thickness of the lines equals the thickness of the white spaces between lines and the
thickness of the gap in the letter "C"
• the height and width of the optotype (letter) is five times the thickness of the line.

Only the nine letters C, D, E, F, L, O, P, T, Z are used in the common Snellen chart. The
perception of five out of six letters (or similar ratio) is judged to be the Snellen fraction. Wall-
mounted Snellen charts are inexpensive and are sometimes used for approximate assessment
of vision, e.g. in a primary-care physician's office. Whenever acuity must be assessed
carefully (as in an eye doctor's examination), or where there is a possibility that the examinee
might attempt to deceive the examiner (as in a motor vehicle license office), equipment is
used that can present the letters in a variety of randomized patterns.

B. Tuning Fork for Hearing Acuity/ Hearing Test (Rinne’s and Weber’s tests)
Background to the tuning fork tests
  The tuning fork tests provide a reliable clinical method for assessing hearing loss

 They are most useful in patients with unilateral hearing loss which is purely
conductive or purely sensorineural

 Patients with bilateral loss or mixed losses are better assessed with formal pure tone
audiometry

 These tests should be carried out with a full examination of the cranial
nerves or the ear

 The Rinne and Weber tests help distinguish between a conductive hearing loss
(CHL) and sensorineural Hearing Loss (SHL)

 Other tuning fork tests include the Schwabach and Bing tests, though these are not
used in routine practice

A. Introduction (WIIPPPE)
· Wash your hands
· Introduce yourself (name and position)
· Identity of patient (confirm name and date of birth)
· Permission (consent and explain examination: “I’m going to examine your hearing
using this tuning fork now, is that OK?”)
· Pain (especially over the mastoid)
· Position (sitting comfortably)
· Exposure

B. Equipment

 A 512 Hz tuning fork

 Note you should ideally be in a completely silent room for Rinne and Weber tests

C. How to do Weber’s Test

 To perform Weber’s test strike the fork against your knee or elbow, then place the
base of the fork in the midline, high on the patient’s forehead

o It is important to steady the patient’s head with your other hand so that reasonably
firm pressure can be applied

 Then ask the patient: “Do you hear the sound louder in one ear than the other?”

o If so, in which ear is it louder?

o If the patient is unclear, you may ask if they hear it “everywhere.” Be careful not to
ask the question in a leading manner
D. Interpretation of Weber’s test

 Weber’s test will ‘lateralise’, i.e. move to one side, with a relatively small amount of
hearing loss (5dB)
 If a patient has a unilateral conductive hearing loss, the tuning fork sound will be
heard louder in the deaf ear
 If a patient has a unilateral sensorineural hearing loss, the tuning fork sound will be
heard louder in the normal ear
 In bilateral and symmetrical hearing loss of either type Weber’s test will be normal
 The various outcomes of Rinne and Weber tests are shown below

E. Interpretation of Rinne’s and Weber’s tests

Test Normal Conductive Hearing Loss Sensorineural Hearing Loss

Rinne's Air louder than Bone Bone louder than Air Air louder than Bone
(Rinne’s Positive) (Rinne’s Negative) (Rinne’s false positive)
Weber's Sound heard in midline Sound heard in bad ear Sound heard in good ear

F. How to do Rinne’s Test

 This test aims compare air conduction with bone conduction

o Rinne’s test has a high sensitivity (0.84) though this varies with the skill of
the examiner
o Rinne’s test can only detect a conductive hearing loss of at least 30dB

 Explain the test first:

o “I’m going to put this vibrating tuning fork in two positions, one touching the
bone near you ear, one a short distance from the ear. I want you to tell me
which position you hear the tuning fork loudest in”

 Begin by striking the tuning fork against your knee or elbow

 Hold the tuning fork in one hand and place the base against the patient’s mastoid
process

o Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity
of the sound

 Then promptly lift the fork off the mastoid process and place the vibrating tips
about 1cm from their external auditory meatus

o Leave it there again for a few seconds before taking the tuning fork away
from their ear

 Ask the patient in which of the positions they were able to hear the note the loudest in

G. What is a positive and negative Rinne’s Test?

 A patient who hears the tuning fork loudest when held 1cm from the external
auditory meatus has a positive Rinne’s test
  A patient who hears the fork loudest when it is held against the mastoid process has
a negative Rinne’s test

H. Interpretations of Rinne’s Test

 In a normal ear sound is conducted to the cochlear most efficiently via air
conduction. Sound can also be transmitted to the cochlea, less efficiently, via bone
 So…

o 1) If a patient can hear best when the tuning fork is in the air (positive
Rinne’s) then air conduction is better than bone conduction so there is no
significant conductive hearing loss

 Therefore in sensorineural hearing loss on the right, for example,

Rinne’s test should be positive on the right

o 2) If the patient can hear best when the tuning fork is on the mastoid
(negative Rinne’s) bone conduction is better than than air conduction,
demonstrating a conductive hearing loss

I. False negative Rinne’s Test

 The difficulty in interpreting Rinne’s test is in total unilateral sensorineural hearing

loss (i.e. a ‘dead’ ear)
 For example, imagine the right ear is ‘dead’. On testing bone conduction on the right
the sound travels to the good left (i.e. untested) ear and sounds louder than when the
fork is held next to the external auditory meatus on the side being tested
 The patient reports that bone conduction is better than air conduction giving a false
negative Rinne’s test