Advanced Physical Exam Maneuvers for Nurses

William Kelly, MSN, FNP-C

Updated June 2026 · Medically reviewed for nurses

10 min read

Advanced physical exam maneuvers can help you recognize serious conditions at the bedside — findings you can escalate to the provider to improve patient outcomes.

In nursing school we are taught the basics: talk with patients, confirm they are alert and oriented, listen to lungs and heart, check for leg swelling or redness, and watch for significant changes each shift. But many advanced maneuvers are not taught in school, often because they tend to guide diagnosis. Knowing them still strengthens your assessment and helps you catch what matters.

What Are Advanced Physical Exam Techniques?

Advanced physical exam techniques are a set of methods and maneuvers used to gain a more comprehensive understanding of a patient's condition. They often require a higher level of skill, a keen understanding of anatomy and physiology, and the ability to integrate clinical findings with advanced reasoning — from nuanced palpation and auscultation to more revealing use of tools like the otoscope or ophthalmoscope.

While basic exam skills are essential for all nurses, advanced techniques are particularly valuable for those in specialized roles such as nurse practitioners, clinical nurse specialists, and nurses in acute or critical care settings.

Extraocular Muscles (EOMs)

Extraocular muscles (EOMs) are responsible for eye movement and are largely innervated by the third cranial nerve — the oculomotor nerve — as well as the 4th and 6th cranial nerves. Intact EOMs suggest those three cranial nerves are intact, and testing them is important in ruling out a central lesion such as a stroke or a mass — although a more thorough cranial nerve assessment is required.

When looking at the extremes of vision, nystagmus (a fine rhythmic oscillation of the eyes) can occur. A few beats at the lateral gaze extremes can be normal, but excessive nystagmus — especially when the eyes are more centered — can suggest vertigo, seizure activity, Chiari malformation, stroke, or a mass.

Testing EOMs is also useful when evaluating for orbital cellulitis, an infection of the orbital structures and muscles. When the extraocular muscles are infected they are inflamed and painful, so testing the EOMs is often painful, especially in a certain direction. Painful EOMs with swelling or redness of the eye or surrounding area should prompt a CT of the orbits with contrast to rule out orbital cellulitis. Orbital cellulitis often requires IV antibiotics, whereas periorbital cellulitis can usually be discharged home with PO antibiotics and close ophthalmology follow-up.

Test EOMs whenever there is a neurologic complaint (possible stroke, vertigo, seizure) or when you suspect periorbital or orbital cellulitis.

How to Test EOMs

Hold a finger or pen about 2 feet from the patient's eyes. Ask them to follow your finger or object with their eyes only. Move through the six cardinal directions, making a large "H" in the air: right, upper right, lower right, then left, upper left, and lower left.

An abnormal exam is when these movements are painful, cause dizziness, or when one or both eyes cannot gaze in a specific direction. The latter can indicate a brain lesion such as a stroke — a major finding you don't want to miss, and part of the NIH Stroke Scale.

Jugular Vein Distention

Jugular vein distention (JVD) is exactly what it sounds like — bulging or distended jugular veins. Pressure in the jugular veins reflects right atrial pressure, which is helpful when evaluating patients with known or suspected heart failure, volume overload, or pulmonary embolism.

Testing jugular venous pressure isn't easy, and a "gestalt" JVD is often noted by clinicians, usually when patients are in clear volume overload. Check JVD whenever you suspect volume overload or increased right atrial pressures — heart failure, volume overload in renal failure, or pulmonary embolism.

How to Test for JVD

JVD can be "noticed" as a bulging external jugular vein when the patient is between 30 and 45 degrees semi-Fowler's, with the head turned toward the left. Evaluate the right side — it is the most accurate indication of right atrial pressures. The higher the patient is sitting up while still showing distention, the higher the pressure.

To officially measure, elevate the head of the bed to about 30–45 degrees and turn the patient's head to the left. Identify the top of the venous pulsations of the external jugular vein, or preferably the internal jugular vein. You cannot directly visualize the internal jugular vein but should see its pulsations. Use a pen to visualize a horizontal line from the top of the pulsations to above the sternal angle (the notch where the sternum begins).

Now measure how high this line is above the skin, then add 5 cm because the right atrium is about 5 cm deep. The total is the patient's estimated central venous pressure (CVP). Normal CVP is 3–8 cm H₂O; anything higher is abnormal and may indicate increased right atrial pressures.

The hepatojugular reflux (HJR) is an additional maneuver to help determine possible heart failure exacerbation or other conditions that increase venous pressures. It is often performed when JVD is not obvious but clinical suspicion remains.

Position the patient the same as for JVD. Apply gentle pressure over the RUQ or mid-abdomen for 10–60 seconds and watch for increased JVD. Normal patients should have a decrease in JVP (less distention) since this maneuver decreases venous return. Those with fluid overload and heart failure will have an increase greater than 3 cm in measured JVP.

Related article: Interpreting Cardiac Labs

Murphy's Sign

Murphy's sign is a maneuver to assess the possibility of cholecystitis, or inflammation of the gallbladder. It is a useful test to aid in clinical suspicion of acute cholecystitis.

Test Murphy's sign when a patient presents with abdominal symptoms such as abdominal pain, nausea, or vomiting. You can also perform it for a fever of unknown etiology — especially in the elderly or those who may not verbally express pain.

How to Test for Murphy's Sign

Place your fingers firmly in the patient's right upper quadrant underneath the ribs, and ask the patient to take a deep breath. This is deep subcostal palpation; on inspiration, the diaphragm pushes the gallbladder toward your fingers, which is painful if the gallbladder is inflamed.

A positive Murphy's sign is when, during inspiration, the patient has an acute increase in pain that causes them to stop inspiring mid-breath. Murphy's sign has high sensitivity (~97%) for acute cholecystitis but is much less specific (~48%), meaning it could indicate other pathology in the liver or surrounding area.

Costovertebral Angle Tenderness

Costovertebral angle (CVA) tenderness is used when evaluating potential kidney stones or other inflammatory renal pathology. The costovertebral angle is formed by the lower border of the 12th rib and the transverse process of the upper lumbar vertebrae — basically, on the back where the ribs end on each side, approximately where the kidneys lie. If the kidneys or surrounding structures are inflamed and irritable, percussion over this area often causes acute worsening of pain.

Check CVA tenderness whenever you suspect a kidney stone or pyelonephritis — often when the patient presents with flank pain, back pain, or dysuria (painful urination, difficulty going, or hematuria).

How to Test for CVA Tenderness

Place one hand over the costovertebral angle on the back, and percuss with your other fist. Don't be too forceful — if they have a kidney stone, this can be very painful — but also avoid percussing too lightly. Percuss a few times on each side.

Positive CVA tenderness is pain with percussion. In practice this is often very painful for those with acute kidney stones, but plenty of patients with negative CVA tenderness still have acute renal pathology, including stones.

McBurney's Sign

Not to be confused with Murphy's sign, McBurney's sign is a maneuver to help raise suspicion for acute appendicitis.

How to Test for McBurney's Sign

McBurney's point tenderness is when the patient's most tender area is 1.5–2 inches from the anterior superior iliac spine in the direction of the umbilicus. Draw an imaginary line from the anterior superior iliac spine to the navel; about one-third down the line, closest to the iliac spine, is the "sweet spot."

If a patient has abdominal pain with this as their most tender spot, they should undergo further testing to rule out acute appendicitis. McBurney's sign is roughly 50–94% sensitive and 75–86% specific.

Wrapping It Up

These advanced maneuvers should always be used with clinical judgment as part of a full history and physical exam. Nurses are constantly at the bedside, and knowing these techniques can strengthen your physical assessment skills and help you escalate serious findings sooner.

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