Chapter 2

• Nursing Assessment of Physical Systems
• Physical Assessment


  1. Integumentary (Skin)

  2. Scalp and Hair

  3. Nails

  4. Head and Neck

  5. Eyes

  6. Ear
• Preparing the client for skin, hair, and nail examination

  • Remove all clothing and jewelries and put on an examination gown
  • Remove nail enamel, artificial nails, wigs, hairpieces as appropriate
  • Sit comfortably on the examination table or bed for the beginning of the examination
  • Lie on her side or abdomen to assess the skin on the buttocks and dorsal surfaces
• During the skin examination

  • Ensure privacy by exposing only the body part being examined
  • Make sure that the room is a comfortable temperature
  • Explain what you are going to do, and answer any questions that client may have
  • Wear gloves when palpating because you may be exposed to drainage
  • Consider the client's culture when preparing for assessment
• Equipments


  • Examination light
  • Penlight
  • Magnifying light
  • Centimeter ruler
  • Gloves
  • Wood's light
  • Examination gown or drape
• When preparing to examine the skin, hair, and nails

  • Inspect the skin color, temperature, moisture and texture
  • Check skin integrity (being intact or undamaged)
  • Be alert of skin lesions (may look like bumps or patches, or they may be smooth and they may be a different color or texture compared to nearby skin)
  • Evaluate hair condition, loss or unusual growth
  • Note nail bed condition and capillary refill – normal is less than 2 seconds
• Normal skin


  • Smooth and even
  • Thin, calluses (rough, thick lesions of epidermis) are common on the areas of the body that are exposed to constant pressure
  • Older client's skin may feel dryer
  • Warm temperature
  • Skin pinches easily and immediately returns to its original position
  • Sagging or wrinkled skin appears in the facial, breast and scrotal areas in older client
  • Skin rebounds and does not remain indented when pressure is released
• Abnormal skin findings


  • Pallor (loss of color)
  • Cyanosis (bluish discoloration)
  • Jaundice (yellow skin tones) from pale to pumpkin
  • Acanthosis nigricans (rough and darkening of skin) in localize areas
• Normal scalp and hair


  • Natural hair color varies among clients from pale blond to gray white. The color is determined by the amount of melanin present.
  • Scalp is clean and dry
  • Hair is smooth and firm, somewhat elastic. However as the people age hair feels coarser and drier
  • Varying amount of terminal hair cover the scalp, axillary, body, and pubic areas according to normal gender distribution
  • Fine vellus hair covers the entire body except for the soles, palms, lips, and nipples (These are short, fine hairs that starts to develop in childhood)
• Abnormal scalp and hair findings

  • Patchy gray hair, copper red hair
  • Excessive scaliness, dermatitis, raised lesions, dull dry hair
  • Excessive generalized hair loss, patchy hair loss
• Normal nails


  • There is normally 160 degree angle between the nail base and the skin
  • Nails are hard and basically immobile
  • Older client's nails may appear thickened, yellow, and brittle because of decreased circulation in the extreminities
  • Nails are smooth and firm, nail plate should be firmly attached to nail bed
  • Capillary refill test pink color returns immediately to blanched nail beds when pressure is released
• Abnormal nail findings


  • Dirty, broken, or jagged fingernails maybe seen with poor hygiene
  • Pale or cyanotic nail, splinter hemorrhages, beau's lines, nail pitting, and yellow discoloration
  • Early clubbing (180 degree angle with spongy sensation)
  • Late clubbing (greater than 180 degree angle)
  • Thickened nail especially toenails
  • Paronychia (inflammation), detachment of nailplate from the nailbed (onycholysis)
  • Slow capillary nailbed refill (greater than 2 seconds)
• Head and Neck Assessment

  1. Preparing the client

  2. Inspection and Palpation

  3. Auscultation
• Normal head and neck


  • No abnormal movements noted
  • In older clients, facial wrinkles are prominent
  • The temporal artery is elastic and not tender
  • Temporomandibular normally there is no swelling, tenderness, or crepitation with movement
  • Mouth open and close fully (3 to 6 cm between upper and lower teeth)
  • Lower jaw moves laterally 1 to 2 cm in each direction
  • Neck movement should be smooth and controlled with 45 degree flexion, 40 degree lateral abduction, 70 degree rotation
  • Trachea is midline
  • Thyroid gland is usually not palpable
• Abnormal head and neck findings

  • Swelling, enlarge masses or nodules in the neck
  • Asymmetric movement or generalized enlargement of thyroid gland
• Eyes Assessment


  1. Preparing the client

  2. Evaluating Vision

  3. Testing Extra-ocular Muscle Function

  4. Inspection and Palpation of External Eye Structures

  5. Inspection of Internal Eye Structures
• Abnormal vision findings


  • Myopia (impaired far vision)
  • Hyperopia - Farsightedness
  • Presbyopia (impaired near vision)
  • Visual acuity varies by race
  • A delayed or absent perception of the examiner's finger indicates reduced peripheral vision
  • Asymmetric position of the light reflects indicates deviated alignment of the eyes
  • Phoria is a term used to describe misalignment that occurs only when fusion reflex is blocked
  • Strabismus is a constant malalignment of the eyes
  • Trapia is a specific type of misalignment: estopia an inward turn of the eye, and exotropia an outward turn of the eye
  • Failure of the eyes to follow movement symmetrically is any or all directions
  • Nystagmus an oscillating (shaking) movements of the eye
• Normal external eye structures

  • The upper lid margin should be between the upper margin of the iris and the upper margin of the pupil. The lower lid margin rests on the lower border of the iris. No white sclera is seen above or below the iris
  • The upper and lower lids close easily and meet completely when closed
  • The lower eyelid is upright with no inward or out ward turning. Eyelashes are evenly distributed
  • Skin on both eyelids is without redness, swelling or lesions
  • Eyeballs are symmetrically aligned in sockets without protruding or sinking
  • Bulbar conjunctiva is clear, moist and smooth. Underlying structures are clearly visible. Sclera is white
  • The lower and upper palpebral conjunctivas are clear and free of swelling or lesions
  • No swelling redness should appear over areas of lacrimal gland
  • No drainage should be noted from the puncta when palpating the naso-lacrimal duct
  • Cornea is transparent with no opacities
  • Arcus senilis a white arc around the limbus is a normal condition in older clients
  • The iris is typically round, flat, and evenly colored, is centered in the iris, normally equal in size.
  • The normal direct and consensual pupillary response is constriction
  • The normal papillary response is constriction and convergence of the eyes when focusing on a near object
• Abnormal external eye findings

  • Ptosis drooping of the upper eyelid
  • Failure of lids to close completely
  • An inverted lid
  • Ectropion an everted lower eyelid
  • Redness and crusting along the lid margins
  • Exopthalmos protrusion of the eyeballs accompany by retracted eyelid margins
  • Generalize redness of the conjunctiva
  • Episcleritis non infectious inflammation of the sclera
  • Presence of foreign body or lesions on the upper eyelid
  • Swelling of the lacrimal gland
  • Expressed drainage from the puncta on palpation
  • Areas of roughness or dryness on the cornea
  • Irregular shaped irises, miosis, mydriasis, and anisocoria
  • Monocular blindness detected when light directed to the blind eye result in no response in either pupil
  • Pupils do not react at all to direct and consensual papillary test
  • Pupils do not constrict, eyes do not converge
• Normal internal eye structures

  • The nasal edge may be blurred
  • The physiologic cup, appears on the optic disc as slightly depressed and lighter color than the disc
  • Four sets of arterioles and venules should pass through the optic disc
  • Arterioles are bright red and progressive narrow as they move away from the optic disc
  • General background appears consistent in texture
  • The macula is the darker area
  • The anterior chamber is transparent
• Abnormal internal eye findings

  • Cataracts - appears as block spots against the background of the red light reflex
  • Papilledema - swelling of the optic disc
  • Glaucoma - intraocular pressure interferes blood supply to optic structures
  • Optic atrophy caused by death of optic nerve fibers
  • Constricted arterioles, dilated veins, or absence of major vessels due to changes of blood supply to the retina
  • Excessive clumped pigments appears with detached retinas or retinal injuries
  • Hyperemia occurs when injury causes red blood cells to collect in the lower half of the anterior chamber
  • Hypopyon in which white blood cells accumulate in the anterior chamber and produces cloudiness
• Ear Assessment


  1. Preparing the client

  2. External Ear: Inspection and Palpation

  3. Internal Ear: Otoscopic Examination
• Normal external ear


  • Ears are equal in size bilaterally (normally 4 -10 cm)
  • Auricles aligns with the corner of each eye
  • Earlobes maybe free, attached, or soldered
  • The older client often has elongated earlobes with linear wrinkles
  • The skin is smooth with no lesions, lumps, or nodules. Color is consistent with facial color
  • Normally the auricle, tragus, and mastoid process are not tender
• Abnormal external ear findings


  • Ears are smaller than 4cm or larger than 10 cm
  • Malaligned or low set ear
  • Enlarged preauricular and postauricular lymph nodes
  • Tophi (non tender, hard, cream colored nodules on the helix or anti helix, containing uric acid crystals)
  • Postauricular cyst, blocked sebaceous glands
  • Redness, swelling, scaling, or itching- otitis externa
  • Pale blue ear color – prosbite
  • A painful auricle or tragus is associated with otitis externa or a postauricular cyst
  • Tenderness over the mastoid process (mastoiditis)
  • Tenderness behind the ear (otitis media)
• Normal internal ear


  • A small amount of odorless (earwax) is the only discharge normally present
  • Cerumen may be yellow, orange, red, brown, gray, or black and soft, moist, dry, flaky, or even hard
  • The canal walls should be pink and smooth and without nodules
  • The tympanic membrane should be pearly, gray, shiny, and translucent with no bulging or retraction
• Abnormal internal ear findings

  • Foul smelly, sticky, yellow discharge – otitis externa or impacted foreign body
  • Bloody purulent discharge – otitis media with ruptured tympanic membrane
  • Blood or watery
  • Impacted cerumen blocking the view of external ear canal
  • Reddened, swollen glands – otitis externa
  • Exostosis non-malignant nodular swellings
  • Polyps may block the view of the ear drum
• Otoscopic Examination


  Inspection of the internal ear
• Normal Findings in Otoscopic Examination


  • A small amount of odorless (earwax) is the only discharge normally present
  • Cerumen may be yellow, orange, red, brown, gray, or black and soft, moist, dry, flaky, or even hard
  • The canal walls should be pink and smooth and without nodules
  • The tympanic membrane should be pearly, gray, shiny, and translucent with no bulging or retraction
• Abnormal Findings in Otoscopic Examination

  • Foul smelly, sticky, yellow discharge – otitis externa or impacted foreign body
  • Bloody purulent discharge – otitis media with ruptured tympanic membrane
  • Blood or watery
  • Impacted cerumen blocking the view of external ear canal
• Abnormal Findings in the ear canal

  • Reddened, swollen glands – otitis externa
  • Exostosis non-malignant nodular swellings
  • Polyps may block the view of the ear drum
• Abnormal findings in the tympanic membrane

  • Red, bulging eardrum and distorted diminished or absent light reflex – acute otitis media
  • Yellowish, bulging membrane with bubbles behind – serious otitis media
  • Bluish or dark red color – blood behind the eardrum from skull trauma
  • White spots – scarring from infections
  • Perforations – trauma from infection
  • Prominent landmarks – eardrum retraction from negative ear pressure resulting from an obstructed eustachian tube
  • Obscured or absent landmark – eardrum thickening from chronic otitis media
• Normal Findings in Hearing and Equilibrium Test

  • Weber's Test – with conductive hearing loss, the client reports lateralization of sound to the poor ear, with sensorineural hearing loss, the client reports lateralization of sound to the good ear
  • Rinne Test – With conductive hearing loss, bone conduction is heard longer than or equally as long as air conduction sound. With sensorineural hearing loss, air conduction is heard longer than bone conduction sound
  • Romberg's Test – Clients move feet apart to prevent falls or starts to fall from loss of balance
• Preparing the client for mouth, throat, nose, and sinus assessment
• Equipment for mouth, throat, nose, and sinus assessment
• Normal Findings in Mouth Inspection and Palpation


  • Lips and mouth are moist without lesion or swelling
  • Thirty-two pearly white with smooth surfaces and edges. Upper molar should rest directly on the lower molars and the front upper incisors should slightly override the lower incisors
  • No repaired or decayed areas, no missing teeth or appliances
  • Buccal mucosa should appear pink
  • Stenson's ducts are visible with flow of saliva and with no redness, swelling, pain, or moistness in area
  • Oral mucosa is often drier and more fragile in the older client
  • Tongue should be pink, moist, moderate in size with papillae (little protuberance) presence
  • Tongue's ventral surface is smooth. Shinny, pink or slightly pale with visible veins and no lesions
  • The older client may have varicose veins on the ventral surface of the tongue
  • The frenulum is midline; wharton's ducts are visible with salivary flow or moistness in the area. The client has no swelling, redness, or pain
  • No lesions, ulcers, or nodules are apparent on the tongue
  • The tongue offer strong resistance
  • A person has an ability to taste between the salty and sweet
  • The hard palate is pale or whitish with firm, transverse rugae (wrinkled like folds)
  • A bony protuberance in the midline of the hard palate, called a torus palatines is a normal variations seen more often in females
  • No unusual or foul odor is noted
  • The uvula is fleshy, solid structure that hangs freely in the midline
  • Tonsils may be present or absent. They are normally pink and symmetrical
  • Throat is normally pink without exudates or lesions
• Abnormal Findings in Mouth Inspection and Palpation

  • Pallor around the lips. Swelling of the lips
  • Yellow or brownish color teeth. Presence of tooth decay
  • Missing teeth or malocclusion
  • Lesions, ulcers, nodules, or hypertrophied duct openings on either side of frenulum
  • Presence of chancre sores on the sides of the tongue
  • Decreased tongue strength
  • Loss of taste
  • A thick white plaques on the hard palate
  • Yellow tint to the hard palate
  • Fruity or acetone breath
  • A bifid uvula looks it is split in two or partially severed
  • Tonsils are red, enlarge, and covered with exudates
• Normal Findings in Nose Inspection and Palpation


  • Color is the same as the rest of the face; the nasal structures is smooth and symmetric ; no tenderness
  • Client is able to sniff through each nostril while other is occluded
  • The nasal mucosa is dark pink, moist, and free of exudates
  • The nasal septum is intact and free of ulcers or perforations
  • Turbinates are dark pink redder than oral mucosa, moist and free of lesions
• Abnormal Findings in Nose Inspection and Palpation

  • Nasal tenderness on palpation
  • Cannot sniff through a nostril that is not occluded, nor can blow air through the nostril
  • Nasal mucosa is swollen and pale pink or bluish gray
  • Purulent nasal discharge
  • Bleeding (epistaxis) or crusting
  • Ulcers of the nasal mucosa or perforated septum
• Normal Findings in Sinus Palpation

  • The sinuses are not tender on percussion
  • A red glow transilluminate the frontal and maxillary sinuses. This indicates a normal air filled sinus
• Abnormal Findings in Sinus Palpation

  • Frontal or maxillary sinuses are tender to palpation and percussion in clients with allergies
  • Absence of a red glow usually indicates a sinus filled with fluid, pus or thick mucus