HEALTH ASSESSMENT

2 Data collected during Assessment (Cues) 1. Subjective symptoms or covert data; verbalized, described & verified only by patient; nurse cant feel nor see; includes feelings, sensations, beliefs, attitudes, & health perception ( I feel weak) Objective Signs & Symptoms / overt data; detectable by nurse thru physical examination & lab exam; can be seen thru senses; measurable (ex. v/s, height & weight, BMI, urine output, skin color)

2.

General State of Health - overall health assessment 1. 2. 3. 4. 5. Loss or Impairment of any special senses Signs of Distress (suffering or pain) State of Awareness Stature / Posture / Motor Activity Skin Color 6. 7. 8. 9. 10. Speech Facial Expression Grooming & Personal Hygiene Attitude of the Patient Vital Signs

Principles of Physical Assessment 1. Bilaterally Symmetrical Draw a line at the center of a person; both sides should be equal left & right; check front, back and sides. Cephalocaudal Cephalo (head); Caudal (tail); Head to toe assessment; Exception: abdomen tender areas last Use of all the Senses instead of sense of taste use common sense. Follow the Plan of Order Inspect, Palpate, Percuss, Auscultate Abdomen: Inspect, Auscultate, Percuss, Palpate (IAPP) a. Uncomfortable b. May induce pain (patient may cry; assessment will took longer; patient may stop assessment) c. May alter bowel sounds Drape the Patient Expose only the areas need to be examined for the integrity, privacy & warmth of patient. Position the Patient properly according to condition Consider patients ability to assume a position, age, physical condition, energy level. Post Op: Position in Supine for 8 hours then in 30 minutes turn sideways and assess Prepare the Environment Time should be convenient for both Nurse & PT Provide a warm & conducive environment ;room must be well - lighted Provide Privacy a. family and friends should be asked to go outside during examination unless the PT asks for someone b. if nurse of a different gender, ask if exam is acceptable to perform OR ask if a nurse of same gender is preferred

2.

3. 4.

5.

6.

7.

Frameworks of Physical Assessment 1. Functional Framework Evaluates the effects of the mind, body, and environment in relation to the PTs capability to perform activities of daily living (ADL) Involves 2 Patterns: Past and Present Ex. Tuberculosis (There is always a disease pattern d/t smoking ask past & present consumption and brand; nutritional status ask foods ingested past & present) Head to toe Assessment Body System Framework or Focused Assessment Most commonly used by Medical Practitioners Ex. Abdominal Pain (assess GIT and V/S)

2. 3.

Proper Positions for Physical Examination

Position Erect OR Normal Standing Position Sitting Position Areas Assessed Posture, Body Alignment, Contours Front, Back, Sides Muscle & Extremities Male Genitalia & F. Breasts Front and Back Upper Body Head, neck, chest, lungs, heart Vital Signs Advantages Greater expansion of lungs Good visualization of Upper Body Popliteal 2 3 in away from the edge of the chair to prevent circulatory stasis. Most relaxing position Easy access to Pulse Sites Disadvantages Tiring for Elders Weak lower extremities Leg Problems Physically weak may be unable to seat (use supine head elevated) Elders Dyspnea (DOB) Cardio and Respiratory Probs (raise head of bed)

Supine

Dorsal Recumbent

Back lying w/ legs extended freely on bed; w/ or w/o pillow under head Chest, lungs, breast, heart, abdomen Extremities Pulse Sites and Vital Signs Supine position with legs separated, knees flexed, & soles of feet flat on the surface Female genitals Rectum Same w/ dorsal but patient is placed on a table & feet supported in stirrups Female Genitals Rectum *Use speculum*

Lithotomy

Prone

Sims / Semi Prone / Left Lateral

Fowlers

Genupectoral / Knee Chest / Dog Style Trendelenburg

PT lies on abdomen, head turned to side, arms in line with head; with or w/o pillow Hip Joint movement Posterior Thorax Side lying with lower arm behind the body, uppermost leg flexed at hip & knee, upper arm flexed at shoulder & elbow Rectum Vagina Back Head of the bed is elevated for 45 90 degree angle High Fowler 90 Semi Fowler 60 to 90 Semi Sitting 20 to 45 Rectum

PTs w/ painful disorders are relaxed when knees are flexed IE of Perineum & Anus Perineal Flushing & Shaving Peri Lighting after NSD Insertion of Meds thru Catheter Labor and Delivery Dilation & Curettage Catheterization Insertion of Vaginal Instruments & Drugs Maximal exposure of Vagina Minimize time for this position and Keep PT well draped Patients with good body alignment Only for short periods of time

DOB Leg Problems Weak Legs

Uncomfortable & Embarrassing DOB Leg Problems (Arthritis, Weak Legs) Elders

DOB Spinal Problem Cervical & Neck Problem Elders Elders Obese Limited Joint Movement (hinders to bend hip & knee)

Cleansing Enema (left side b/c of the direction of colon) Comfortable for Pregnant Unconscious (prevents aspiration) Paralyzed (pressure on sacrum)

DOB NGT Insertion & Feeding Feeding

Spinal Problems Cervical and Neck Prob

Head lower than the rest of the body; legs are elevated 30 45 degree angle w/ feet on pillow or foot board (for venous return)

Prostate Exam Anal Exam Fleet Enema First Aid for Shock Circulatory Stasis

DOB Obese and Elders Leg & Spinal Problems Patient who will vomit (increases pressure to brain)

Physical Examination Technique

Inspection Latin Word Inspectio Act of Beholding Thorough and Unhurried visualization of client that requires the use of sense of sight. Lighting must be adequate (Natural Sunlight during morning if not contraindicated w/ condition) Use appropriate tools for lighting (ex. Otoscope to check ears) 1. 2. 3. 4. 5. 6. Body features & symmetry appearance (symmetrical means balance; asymmetrical means unbalanced) Gait (manner of walking) and Manner of Speaking Skin Color Hair Distribution Nutritional Status or Weight Sounds and Odors of the Client (use sense of hearing and smell)

Gross Deviations 1. 2. 3. 4. Abnormal Contours Visible Masses Discoloration Edema or Swelling Presence of interstitial fluids S/S: swollen, shiny, and taut (rigid or stiff) and tends to blanch skin color or, if accompanied by inflammation, may redden skin. Generalized edema - most often indication of impaired venous circulation; some reflects cardiac dysfunction or venous abnormalities.

Palpation Latin Word Palpatio- Act of touching Technique is using the examiners accurate sense of touch to gather info Examiner will use the most sensitive parts of the hand for each type of palpation.

Approach to Client 1. 2. 3. Warm hands before palpation Palpate tender areas last (ex. Abdomen) Gradually increase pressure from light to deep palpation

Types of Palpation 1. Light Palpation (Superficial) Tool: Finger & Fingertips Procedure: Fingers are closed together & Fingertips are applied to body surface in a gentle manner or dipping motion Advantages or Purpose: a. Elicit muscular resistance b. Tenderness and masses c. Measure and relax the patient

2.

Deep Palpation Tool and Purpose: Palmar surface of fingers for deep pressure to assess deeper body organs When difficult (ex. obese) for muscular resistance, USE TWO HANDS ONE ON TOP OF THE OTHER by either: a. Bi manual hand side by side; superimposition of the hand b. Ballottement apply pressure by tapping or gentle pushing while feeling the impact thru rebound.

Percussion

Latin Word Percussio act of striking Involves Principle of Cause and Effect Relationship Tool: 1. Hands Close Fist Percussion strike with lateral aspect of hand in fisted position Purpose: elicit sensation by the vibration of tissue. a. Stimulate Pain Hepatitis, Gallbladder Disease b. Stimulate Tenderness Kidney Disease 2 Types: a. Direct fist percussion b. Indirect fist percussion 2. Side of the Hand 3. Fingertips a. Hyperextend middle finger of Left Hand (PLEXIMETER). b. Press distal interphalangeal joint on the surface to be percussed. Avoid contact by any part of the body that would damp the vibration. c. Aim at your distal phalangeal joint to transmit vibrations d. Use tip by the PLEXOR and not the finger pads e. Movement is at the wrist, relaxed, brisk, and a bit bouncy. f. Short fingernails are required to avoid self mutilation. Note: a. b. c. Lightest Percussion produces a CLEAR RATE Thick Chest Wall requires heavier percussion In comparing 2 areas thump TWICE then move to another area to compare.

5 PERCUSSION NOTES PERCUSSION NOTE Flatness Dullness Resonance

1. 2. 3.

4.

Hyper resonance

5.

Tympany

DESCRIPTION From very dense matter Flat sound From less dense matter Thud like sound From air filled structure (lung filled with air) Hollow sound Over inflated air filled structure (lungs) Booming sound Air & fluid filled structure in concert with tissue surrounding it Drumlike sound

ANATOMIC REGION Muscle and Bones Thigh Spleen, Liver, Heart Lung (normal)

Emphysematous Lung entrapment of air in the lungs

Air bubble in GIT

Auscultation

Latin Word Auscultate to listen to Process of listening for sounds produced by the human body Act of hearing & listening to differentiate normal to abnormal sound with the use of stethoscope

2 Important Stethoscopes 1. Acoustic Stethoscope a. Bell most effective in LOW frequency sounds (ex. heart sounds - heart murmurs) b. Diaphragm most effective in HIGH frequency sounds (ex. lungs bronchial sounds and heart) Magnetic - Single head w/ only the diaphragm bowed outward when not compressed against body.

2.

Instructions when using Stethoscope 1. 2. 3. 4. 5. Earpiece should occlude meatus to block extra external sounds but not to cause pain. Binaural are angled towards the nose, the natural direction of ear canal. Tubing should not be longer than 12 15 inches Hold stethoscope between index and middle finger Exert enough pressure to ensure solid contact. a. Bell not to flatten skin by pressing bell firmly w/c will inhibit vibrations (stretching) b. Diaphragm applied firmly on skin to move synchronously with body wall; water soluble jelly is applied to skin to improve sound transmission; if client is hairy, dampen hair with a moist cloth. Place diaphragm in between bones & not over them. Create a quiet environment.

6. 7.

SKIN ASSESSMENT
Use indirect natural daylight (preferably) Assessment technique involves INSPECTION and PALPATION. Use also the sense of smell (olfactory) to detect unusual skin odors most evident in skin folds and axillae.

VARIATIONS IN SKIN COLOR

Color
Brown

Process
1. Deposition of Melanin 2.

Selected Causes
Sunlight Pregnancy 1. 2.

Typical Localization
Exposed areas (Melasma) Face (Chloasma) or mask of pregnancy, nipples, areolar, vulva, & linea nigra

Picture

Blue OR Dusky Blue Cyanosis

Deoxyhemoglobin secondary to hypoxia (decreased o2 in cells) 1. Peripheral 2. 3. Central / Arterial Abnormal Hgb

Anxiety or Cold Environment Heart & Lung Disease Congenital or Acquired

Nails and Lips Nails, Lips, Buccal, Tongue

Nails, Lips, Buccal, Tongue Dark skinned clients: check PALPEBRAL CONJUNCTIVA (lining of eyelids), palms, soles

Reddish Blue or Purplish Blue Ecchymosis (Pasa)

1.

2.

Combination & amt of hemoglobin Circulatory Stasis

Polycythemia (RBC)

Face, conjunctiva, mouth, hands, feet Face, upper and lower extremities

Pale or Pallor

Collection of blood in subcutaneous tissue blood flow to superficial skin OR hemoglobin

Yellow Jaundice

Biliburin in blood

Purpura similar to Hematoma / hemorrhage of skin Anemia Leukemia Cancer Hemophilia or Hemophilic - pasain Liver Disease Hepatitis yellow skin, itching d/t bile salts and weak

Face, conjunctiva, mouth, hands, feet

Sclera, Conjunctiva, Mucous Membranes, & Skin Dark skinned client: has a normal yellow pigment in sclera. Check hard palate Palm, soles of feet, face NOT in conjunctiva and mucous membrane

Yellow to Yellow Orange Carotemia (dry and peeling skin) Dark Yellow Orange

Carotene in blood

intake of Carotene rich vegetables & fruits including supplements

Biliburin in tissue d/t death of liver cells

Leptospirosis urine and stool of rat

All portions of the body

Generalized Redness

Physiologic changes, exercise, food, climate Delivery of heat from hypothalamus

Defined areas of Redness

Exercise, spicy food, allergic rxn to drugs, climate Fever, Systemic Infection Local infection Sunburn

Face, neck arms, and legs

3 Kinds of Ecchymosis 1. 2. 3. Petechial capillaries burst, + hermans sign (12 is warning; >20 is +); to check rash perform BP or put tourniquet on the area higher than 1 inch. Purpura or Purpuric purplish Hematoma massive blood clot, blood collection

Erythema Redness of skin associated with rashes Dark skinned clients have areas of lighter pigmentation such as palms, lips, and nail beds. Localized areas of: a. hyperpigmentation increased pigmentation (ex. birthmark) b. hypopigmentation decreased pigmentation (ex. vitiligo patches of hypopigmented skin)

VARIATIONS IN PIGMENTATION CONDITION Diffused Hyper pigmentation Addisons Disease ACTH Producing Tumors Arsenic Poisoning (usually seen in miners) Hemochromatosis (iron metabolism disorder) Scleroderma (thickening of skin d/t thickening of fibrous tissue; common in farmers) Uremia (instead eliminated, urine went to skin) A. B. Lack of Pigmentation Vitiligo (Piebald Skin) Acquired loss of melanin which starts at head Appearance on normal skin Albinism Congenital or Hereditary D/t Tyrosine or Protein abnormality in melanin production CHARACTERISTIC COLOR LOCATION

Bronzing Color OR Tan to Brown Dusky with Pallor Spots Brown to Grayish Brown d/t iron absorption Yellow to Tan May also have depigmentation

Generalized, more on exposed areas, mucous membranes of mouth Trunk, Upper & Lower Extremities Generalized Generalized

Yellow to Brown Retention if urinary chromogens OR Renal Yellow Pigment Circumscribed nd rd Secondary to 2 and 3 degree burn

Generalized but more on exposed areas DOES NOT involve conjunctiva & other mucous membrane

One or two areas which is common in: Face, eyelids, hands, wrist

Partial or Complete lack of melanin

Generalized or Universal Albinism Common Site: Skin, hair, eyes

SKIN TYPE AND MOISTURE 1. 2. 3. 4. 5. 6. Procedure: Wait for an hour prior assessment. Use onion skin paper and place paper on forehead with pressure for 5 seconds then remove; Consider front and back (maybe with pimples) Normal Oily Combination T-zone area is oily yet cheeks are dry; skin feels tight then oily. Dry - tight skin after washing Sensitive itching d/t dust, rosy cheeks when drinking, Sweating or Perspiration - use aluminum chlohydrate in wet areas (Driclor use when glands are relaxed)

SKIN TEMPERATURE Tool: Dorsum of Hand (b/c it is thin) 1. 2. 3. Generalized warmth palmar, hands, and neck Cool Localized Areas maybe with infection or swelling & inflammation

SKIN TEXTURE Tool: Dorsum of Hand (b/c it is thin) 1. 2. 3. Fineness soft & smooth Coarseness present on oily skin Scaly perform scratch test; person may put lotion while skin is still damp

SKIN MOBILITY & TURGOR (SKIN ELASTICITY) Procedure: Lift a skin fold over abdomen & observe how quickly it returns back to its normal shape or state. Poor Turgor: > 7 seconds / Poor Margin: > 3 seconds and up Associated with: a. Aging of Skin b. Dry Skin or Lack of Moisture c. Dehydration d. Thickening of Skin

SKIN LESIONS

Alteration of normal skins appearance

Configuration (Placement or Arrangement) of Lesion on the Skin 1. 2. 3. Single Group or Clustered Herpetiform or Zosteriform multiple groups of vehicles erupting unilaterally a. Herpes Zoster damages the cutaneous nerve d/t zoster virus; similar to chicken pox; painful & firm; directed towards center w/ alternate pattern; unilateral (one sided) not scattered b. Herpes Simplex mouth, lips 4. Linear in line 5. Annular or Circular circles, ring shaped 6. Scattered 7. Polycyclic multiple arrangements; multiple annular 8. Arciforms arc or bow shaped 9. Reticular form of a network 10. Confluent or Coalescent merged together, not discrete (separated) 11. Umbilicated pitlike or depression at the center Determine the ff during closer examination of lesions: 1. 2. Color of Lesion Red, brown, black, gray to blue, white, purple, orange, yellow Circumscribed well defined lesions (defined border) w/ the color changes limited to the border of lesions. Diffused borders of lesions may be undefined w/ the color changes spread over a large area. Change with Diascopy? Use slide to press on lesion and see if theres color change; as ordered Shape of Lesion a. Round b. Oval or Angular

c.

Umbilicated / Depressed / Pitlike

3. 4. 5.

Size of Lesion Use ruler or tape measure; measure in cm or inches Firmness of Lesion (+) or (-) for Pain when Palpated. No. of Lesions a. Single b. Numerous c. Actual Count Morphological Classification of Lesions a. Primary appears initially in response to external and internal environmental changes of skin b. Secondary doesnt appear initially; result from modification such as chronicity, trauma or secondary infection from primary infection (ex. a vesicle or blister (primary) may rupture and cause erosion (secondary) )

6.

Types of Primary Lesions

Type Macule Description Flat, non palpable, circumscribed (ex. freckles, measles, petechiae, flat moles) Image

Patch

Flat, non palpable, irregular in shape, a macule greater than 1 cm (ex. port wine birthmark, vitiligo, rubella) Elevated, palpable, firm, circumscribed and solid (ex. warts, acne, pimples, elevated moles) Elevated, palpable, firm, rough, superficial papule greater than 1 cm (ex. psoriasis, rubeola) Elevated, palpable, firm, circumscribed, deeper in dermis than papule, 1 2 cm (ex. squamous cell carnicoma, fibroma) Elevated, solid, may or may not be demarcated, > 2cm (ex. malignant melanoma, hemangioma)

Papule

Plaque Nodule

Tumor

Vesicle

Elevated, circumscribed, superficial, fluid filled < 1cm Ex. Herpes Simplex, Early Chicken Pox, Small Burn Blister)

Bulla

Elevated, vesicle > 1 cm Ex. Large Blister, Secondary 2 Degree Burn, Herpes Simplex)
nd

Note: < 1 cm macule, papule, nodule, vesicle Macule & Papule flat & non palpable Papule & Plaque elevated & palpable Nodule & Tumor elevated, palpable & deep to dermis Vesicle and Bulla fluid filled

Primary Lesions of Varying Types

Pustule Elevated, vesicle or bulla filled with pus (ex. Acne Vulgaris, Impetigo) Wheal (Pantal) d/t cutaneous edema, irregular shape, elevated, changing, pale (ex. hives, mosquito bites) Telangiectasia Fine, irregular red lines d/t dilation of capillaries; spider veins

Cyst

Elevated, circumscribed, palpable, encapsulated, fluid filled or semi fluid or semi solid material (ex. Sebaceous and epidermoid cysts, chalazion of eyelid)

Secondary Lesions Pictures

Heel Fissure

Pressure Ulcer

Comedo

Keloid
Types of Secondary Lesions Type Scale

Lichenification

Crust Excoriation Erosion

Fissure Scar

Description Loose keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied size, silver in white color (ex. dry skin, dandruff, psoriasis, eczema) Dried surface fluids either blood or pus; large crusts that adhere to skin are called SCABS (ex. Eczema, impetigo, herpes, scabs following abrasion) Scratch mark, loss of epidermis, linear or hollow crusted area, dermis exposed, linear erosion (ex. scratches, some chemical burns) Loss of cell or part of epidermis, doesnt extend to dermis, depressed, moist, glistening, follows rupture of vesicle or bulla, larger than fissure, heal w/o scarring (ex. Scratch marks, ruptured vesicles) Linear crack with sharp edges extending into dermis or break from epidermis to dermis (ex. Cracks at the mouth corners or in hands, foot) First red then pale (silvery or white), smooth wound repair may be flat, depressed, elevated or hypertropic scar like Keloid

Keloid Ulcer

Atrophy Lichenification Comedo

(ex. healed surgical wound or injury, healed acne) Irregular shape, elevated, progressively enlarging scar, grows beyond boundaries of wound d/t excessive collagen formation during healing Loss of tissue from surface caused by destruction of superficial lesion, deep, irregularly shaped of skin extending into dermis or subcutaneous tissue, may bleed, may leave scar (ex. Decubitus ulcer, stasis ulcers, chancres) Thinning or wasting of skin and loss of skin marking d/t loss of collagen and elastin (ex. Striae, aged skin) Thickening & hardening of skin caused by chronic scratching, rubbing or irritation (ex. Chronic dermatitis) Marks the plugged opening of sebaceous gland (ex. blackhead)

Nail Assessment
Type Anonychia Platonychia Koilonychia Spoon Nail Description Complete absence of nail; maybe caused d/t trauma or infection Change in Curvature Flattening of nails; color & thickness not altered; hereditary & forerunner of koilonychias Fingernails are thin and curved inwardly from side to side; generally spoon shape; tip portion is fragile and breaks easily Maybe d/t: 1. Trauma 2. Tumor 3. Infection 4. Malnutrition 5. Eczema 6. Iron Deficiency Anemia Flattened and expanded (usually thumb); considered a sign of secondary syphilis Changes in Nail Adhesion Separation of nail to nail bed; originates at the free edge & progressing proximally Separation of nail at the roof part and progressing to free margin Most common complaint r/t to nails Inflammation of the fold of tissue that surrounds the nails leading to erythema Clinical Manifestation 1. Inflammation & swelling 2. Pain & tenderness 3. Ulceration 4. Death of nail plate 5. Broken nails and destroyed as necrosis Common among 1. Diabetics rd 2. 3 stage syphilis 3. Leprosy 4. Injury or Trauma 5. Allergy Contact Dermatitis 6. Infections caused by: Candida Abicans or Fungus Staphylococci Streptococci Change in Nail Surface Striations (1mm deep and or 0.5 1mm wide running along entire nail Associated with severe Illness such as 1. Diabetes 2. Infection 3. Tuberculosis

Racket Nail Onycholysis Onychomadesis Paronychia

Beaus Line / Beaus Striations / Transverse Crosswise Sulci

Mees Line Psoriatic Nail Pitting

Leukonychia Leukonychia Totalis

Melanonychia Pigment Band

4. Syphilis 5. Anemia 6. Malnutrition Crescent shape transverse line similar in the color of lunula Observed in arsenic poisoning Depression of the nail w/c maybe: Pin point or pin head size Linear Irregular depression & distribution Changes in Nail Color White striations & dots 1 2 mm; progress as growth proceeds Complete White Nails of entire nail plate associated with 1. Hepatic Disease 2. Anemia 3. Leprosy 4. Arsenic Poisoning Presence of brown color in nail plate d/t distribution of melanocytes Single black or brown streak in a nail of a white person.

Hair Assessment
1. Inspect Hair Growth from TOP to BOTTOM a. Scalp b. Eyebrow and eyelashes c. Ears and nose d. Mustache e. Beard f. Chest Include MIDPHALANGEAL are of fingers and toe Assess a. Appearance (Shape, Color, and Texture) b. Growth Characteristics c. Density of Growth d. Distribution e. Hygiene Inspection Technique Procedure: Section hair using a fine tooth comb and look for the ff: a. Presence of Nits (Eggs of lice and lice itself) b. Scaliness of Scalp (dandruff) c. Lumps d. Lesions e. Odor g. h. i. j. k. l. Axilla Arms Hypogastric Thigh & Lower Leg Feet Genital

2.

3.

Morphologic Hair Types 1. 2. 3. 4. 5. Head relatively small root, tapered, many variations in hair conditions Eyebrows and eyelashes curved, smooth, coarse, punctuate tip Beard and mustache relatively longer root than scalped hair, blunt tip, more dense and thick Body coarse, irregular, usually curves but may be spiral or straight Axillary coarse, straighter than pubic, may be spiral tufted in blacks

Ear Assessment
1. Inspect Pinna or Auricle (Right and Left ) a. Inspect each pinna Deformities in shape, size, and position (to check position, use ruler & measure the level at which the tip of pinna attaches to the head in relation to the eye. Pinna should be aligned with other canthus of eye, about 10 degree from vertical; low set ears associated with Down Syndrome) Nodules and Lumps Lesions Procedure 1. Palpate pinna from top to bottom 2. Move pinna up, down, front, and back (to check if theres pain, discharge & inflammation) 3. Fold the pinna it should recoil 4. Press tragus (to check if theres pain, discharge & inflammation) 5. Press back of ear (mastoid bone) from top to bottom

b.

Note 2. If moving pinna and pressing tragus causes pain is Acute Otitis Media Externa not Media Interna Tenderness behind ear is present in Otitis Media (infection of middle ear; red in color) Inspect Eardrum / Ear Canal / External Auditory Meatus For otoscopic exam Tool: Otoscope and Speculum Prior Insertion of the speculum of otoscope: a. Inspect for redness, swelling, presence of foreign body, and discharge. b. Appearance & color c. Position PT in supine or standing, head tipped towards opposite shoulder for easy examination. If non ambulatory, position in side lying if patient can assume. d. Straighten ear canal 3 y/o and below down and back 3y /o and above up and back e. Insert Speculum gently & not too far to cause pain (inner 2/3 of external meatus has a bony skeleton & sensitive to pressure) f. Once inserted, observe the ff: Redness Pain Cerumen waxy substance produced by sebaceous & apocrine glands Variations of Color of Cerumen 1. 2. 3. Dark Skinned brown black Fresh Cerumen is light yellow, light brown, and pink for Caucasians Old Dry Cerumen is darker, yellowish brown with whitish cast.

Testing for Auditory Function 1. Voice Test (test one ear at a time) a. Ask PT to occlude one ear by pressing the tragus b. Stand 1 2 ft away & whisper softly to unconcluded ear Choose numbers or 1 2 simple words (house, ballpen) c. Intensity of voice is increased From medium to loud whisper From soft, medium, to loud voice Using a Tuning Fork in a Quiet Room Determines conductive, sensorineural, and mixed hearing loss a. Conductive Hearing Loss Disorder of External or Middle Ear Due to the ff: a. Impacted Cerumen b. Perforation of Tympanic Membrane c. Pus or Serum in Middle Ear d. Fusion of Ossicles (smallest bones, bones of ear; malleus, stapes and incus) Vibrations are not adequately transmitted to ear; theres partial hearing loss. Sensorineural or Perceptive Hearing Loss Disorder of Inner Ear and Auditory Nerve of Brain Vibrations are transmitted but patient cant translate the message (cochlear nerve damage) Mixed Hearing Loss Combination of conductive & sensorineural hearing loss.

2.

b.

c.

Principles of Tuning Fork 1. 2. Held at the base w/o fingers touching the prongs (vibrations may softened or stopped) Pre activate Tuning Fork a. Gently stroke prongs b. Tap gently on the knuckles of opposite hand. c. It should ring softly and not harshly

Air Conduction Transmission of sound thru ear canal, tympanic, and ossicles to cochlea and auditory nerve Bone Conduction Transmission of sound thru bones of skull to cochlea and auditory nerve. To Check Bone Conduction: Perform Weber Test 1. Place the base of lightly vibrating tuning fork on the either the ff: a. Top of the head b. Midforehead c. Teeth (even if with dentures) Ask if the PT can hear it on one or both sides and which side can hear most. Normally, it is heard both equally on ears or midline If nothing is heard, pre activate fork and press more firmly on the head / midforehead / teeth

2.

To check Air and Bone Conduction: Perform Rinnes Test 1. 2. Place the base of lightly vibrating tuning fork on the mastoid bone (behind ear) and level with ear canal. When PT can no longer hear the sound, quickly place close to ear canal (not too close patient may vomit) and move farther. Ask whether he can hear it. Normally sound is heard AC > BC

Comparison: a. b. Conduction Hearing Loss BC > AC; (-) Rinnes Test Sensorineural Hearing Loss AC > BC; (+) Rinnes Test

Assessment of Nose and Paranasal Sinuses

1. External Part of the Nose a. Size, Shape, and Color b. Discharges along nasal flares c. Displacement of bone Palpate ridge top to bottom then move L & R at the middle of ridge (if pain, bone is intact) Nasal Function a. Check Ability to Smell Ask PT to close eyes and occlude one naris. Place aromatic substance 1- 2 inches away from nasal (ex. coffee, alcohol, coffee bean). And ask to identify odor. Each naris is tested separately b. Check Patency of Nasal Cavities Ask client to close his mouth and occlude one naris with finger Ask to breathe in opposite or unoccluded naris. Repeat procedure to other naris. Examination of Nasal Cavities Tool: Otoscope / Nasal Speculum w/ penlight / Thumb & Penlight (gloves) Ask patient to tilt head backward Retract the nose upward with your left hand and shine with penlight Note the ff: a. Color Mucoid (normal) b. Secretions Watery, crusty, pus, bloody (abnormal)

2.

c.

3.

Check Paranasal Sinuses (indirect) a. Frontal and Maxillary (only accessible) b. Ethmoid and Sphenoid (not accessible) Technique: INSPECT, PALPATE, LIGHT PERCUSSION (to assess if positive pain; normal is no tenderness) a. Frontal Sinus from top to bottom, palpate by finger above eyebrows b. Maxillary palpate maxillary area of cheeks when tenderness may be elicited

Giving Medications for Sinuses: 1. Frontal and Maxillary Parkinsons Position (Mummification); head tilted backwards and turn at the side.; nurse may stand at the back or front Ethmoid or Sphenoid Proets position (Football position)

2.

Assessment of Mouth and Oropharynx

1. Conducted from Anterior to Posterior; Areas of mouth and begins with external areas. Inspect Temporomandibular Joint a. Ask client to open & close mouth to check mobility of mandible and occlusion of teeth b. Palpated while mouth is open wide and then closed for any tenderness or deviation Note: a. b. c. 2. There should be no pain If theres a sound maybe lack of calcium intake If client has a denture, offer a paper towel and ask to remove.

Inspect Lips and Tongue Check the ff from top to bottom: a. b. c. d. e. Color Moisture (check peeling) Crackling (linear cracks) Lumps (wear gloves) Ulcers (canker sores pumuputok)

Systematic Procedure a. b. c. d. Palpate lips from top to bottom with a gloved hand Inspect mucosa of lower anterior area Inspect mucosa of each cheek with the indetification of stensons duet. Open left cheek using tongue depressor *Koplick Spots at buccal area white spots at the center with reddened areola; positive measles *Teeth 32 pearly white teeth (28 d/t lack of wisdom); tooth decay & plaque; check color alterations e. f. Inspect mucosa of upper anterior area Inspect Tongue *Place fingers at the dorsum area of tongue and check for any swelling, variation in size and color, coating, ulceration * Ask client to extend tongue to check deviation and limitation of movement (CN 12 Hypoglossal) 3. Inspect Pharynx Clients head tilted backwards and Put tongue depressor Assess Palates (soft and hard) and Uvula Note any deviations or lack of movement of uvula and rise of soft palate indicates CN 10 Vagus Nerve Damage (mixed nerve, muscles of pharynx and larynx, stimulates heart and lungs and abdomen)

Muscles of Mastification 1. 2. CN 5 Trigeminal CN 7 Facial

Agneusia a. b. c. loss of taste sensations (sweet, sour, salty, bitter) Causes: Zinc Deficiency Medications such as Cancer Drugs or Antineoplastic Drugs Antibiotic Therapies

Check Sense of Taste 1. 2. 3. Use applicator with cotton OR pipette and apply to appropriate region of the lateral aspect of tongue Use different applicator for each taste Let client sip water to avoid mixed taste

Association of Breath Odors to Disease 1. Halitosis, Fetid odor of necrotic tissue (bulok) a. Pyorrhea (gum infection) b. Poor dental hygiene c. Tonsilitis d. Lung Abscess e. PTB Feculent odor of feces a. GIT Obstruction b. Colon Cancer or Bowel Cancer Fetor Hepaticus fishy monsy; sulfur odor a. Leptospirosis b. Liver / Hepatic Failure Acid or Acrid acid odor a. PUD / Ulcer b. Posion Ingestion Uriniferous Ammoniacal odor of urine a. Renal Failure Acetone odor of acetone; smell of rotten apple a. Diabetes Bitter Almonds odor of bitter almond a. Cyanide Poisoning b. Lead Poisoning c. Silicosis

2.

3.

4.

5.

6.

7.

Tongue Abnormalities 1. 2. 3. 4. Large Longtitudinal Fissure Black Tongue (Bismuth Drug) Shiny Tongue Smooth Shiny Tongue and reddish w/o papillae (d/t lack of Vit B3 Niacin and Vit B12 Cobalamin)

5. 6.

Enlarged Tongue (d/t hyperthyroidism, down syndrome, angio edema) Small Tongue (d/t CN 12 Hypoglossal damage)

Topographic Map Fissures normal line; 1 line fissures on tongue Tetracyclines Stains the teeth (dark brown) Cant be given <8 y/o dt the ff: a. Stains the teeth b. Non development of permanent teeth b/c of decalcification of bones and teeth

Occlusion Problem 1. 2. 3. Difficulty to chew Speech Problem Self Image Disturbance

Gums Color: Natural Light Pink Check if theres Gingivitis (decrease Vit C; common in Leukemia and Mouth Cancer)

Check Leukophakia Tongue full of white spots (thick white patches) Common to the ff: a. Chronic Infection b. Irritation c. Smoking d. Poor Hygiene

Check Oral Thrush Fungal infection of mouth with whitish curdlike (cheeselike) Bleeds easily

Check Tonsils and Uvula (Midline) Rank and grade tonsils +1 = visible tonsils +2 = midway between tonsilar pillar and uvula +3 = touches uvula +4 = tonsils and uvula touches together

Check Gag Reflex and Movement of Palatine and Uvula 1. 2. 3. Ask Patient to open mouth and shine with penlight Uvula should rise and fall Ask patient to swallow (+ gag reflex)

Eye Assessment
Terms 1. 2. 3. O.D. (Oculus Dexter) right eye O.S. (Oculus Sinister) left eye O.U. (Oculus Uterque) both eyes; left and right

Assessment 1. Assess EYELIDS a. Check if puffy, protruded, and has dark under eye circles (maybe anemic) b. Check no. of blinks Main Ave: 8 12 involuntary blinks per min Average: 15 20 involuntary blinks per min c. Procedure: Ask PT to open and close the eyes if they close completely (Normal: no pain and closes completely) Ptosis or Lid Lag drooping of eyelid; delayed downward movement of upper eyelid

Expothalmos or Proptosis protrusion of the eyeball; occurs in Hyperthyroidism & Graves Disease.

d.

Check if theres Dirty Sclera (Retract lower eyelid and see if theres brown in color)

Ophthalmic Installations Retract lower eyelid with tissue IF eyedrops middle to outer If ointment inner to outer canthus Close the eyes and dont blink to allow meds to penetrate and dont rub

Abnormal Findings 1. 2. 3. 4. 5. 6. Anopthalmia absence of the eye Ablepharon absence of eyelid Lagopthalmia eyes entirely covered with eyelid Achromatopia color blindness Distichiasis extra eyelashes Ephiphora Excessive tearing; problem with Nasolacrimal duct and lacrimal sac Procedure: Apply pressure along inner eye canthus to check tearing and discharge.

2.

Assessment of Pupil Normal: Equal in size (3 7 mm in diameter) PERLAC - Pupil Equally Round Reactive to Light and Accommodation and Convergence a. Pupils direct and consensual reaction to light st Illuminated pupil should constrict (1 shine direct response) Non illuminated pupil constricts Equal responses on both pupil Procedure: Ask PT to look straight, penlight at the side and shine pupil directly. Opposite eye should also constrict (consensual reflect) Pupils reaction to Accommodation Procedure: Ask PT to look at the object 4 6 inches away and then in line with the bridge of the nose (papalapit) Normal: a. Pupil dilates when looking at far objects b. Pupil constricts when looking at near objects c. Pupil converge when near objects are moved towards the nose (becomes cross eyed)

b.

3.

Assessment of Visual Acuity (Near and Distance Vision)

2 Visual Acuity Charts 1. Snellen Alphabet Chart Most common to test vision Assessing visual acuity in distance vision Procedure: a. Ask PT to stand at 20ft away from the chart and cover his Left Eye with an opaque object. b. Ask to read the letters on one line from top (E) to bottom until patient can no longer read the letters. c. Repeat procedure to right eye. Note: 1. 2. Normal Vision of 0 / 20 on Snellen Chart Visual Acuity is recorded as fraction: 20 Distance between patient & snellen chart 20 Distance from which the patient with normal vision could read the lines at 20 feet away from chart. The higher the denominator, the poorer vision Not usually demonstrated until 5 6 y/o.

3. 4.

Other: Assessing Visual Acuity (Near Vision) if theres no snellen provide reading material Procedure: Ask PT to read newsprint from large to small letters (with corrective lenses if client has one) Normal: PT can read newsprint from large to small letters 2. Snellen E Chart For children and adults who cant read Procedure: a. Cover left eye of PT then point to E. b. Ask where the letter faces c. Repeat to right eye.

Snellen E Chart

Snellen Alphabet Chart

Assess Peripheral Vision Normal: When looking straight ahead, client can see objects at periphery (sides) Procedure: a. Stand or sit directly across patient to have his eyes focus her gaze on your eyes. b. Ask not to move head only her eyes c. Nurse will move hands at SUPERIOR & INFERIOR positions (Hand Movement)

Assess Extraocular Muscles 1. 6 Cardinal Rule of Gaze or 6 Ocular Movements Goal: determine eye alignment and coordination Evaluates the ff: a. CN 3 Oculomotor most eye movement b. CN 5 Trigeminal corneal reflex and protective blink c. CN 6 Abducens lateral eye movement d. Extraocular Muscles Procedure: a. Stand directly in front of PT and Hold penlight at 1 Feet Distance b. Ask to follow the penlight movement and not to move his head c. Move penlight in a slow, orderly manner thru 6 Cardinal Positions of Gaze from center of eye along the lines of arrows (periphery)

2.

Eyes should move in Yolk Fashion Procedure: Ask PT to follow the object w/o moving his head. Move the object using 6 cardinal positions of gaze.

Abnormal Findings 1. 2. 3. Conjugate Movement of eyes or gaze movement of eyes symmetrical and synchronous Dysconjugate or Disjunctive movement of eyes simultaneously movement of eye in opposite direction. Strabismus or Squinting - cross eyed; muscle imbalance d/t improper alignment of visual axes of 2 eyes.

2 Types of Strabismus

1. 2. 3. 4. 5.

Esotropia or Convergent Strabismus One eye focused on the object, the other eye deviates inward (adduction) Exotropia or Divergent Strabismus Unilateral or simultaneous abduction of eyes Diplopia Double vision Myopia Near sightedness (close objects are seen clearly, far objects are blurred) Hyperopia Far sightedness (far objects are seen clearly, near objects are blurred)

3. Finger Counting Test (FC) 4. If patient can identify or count fingers If patient cant identify or hard to identify perform hand movement.

Hand Movement Test (HM) To identify movement of hands in different directions If hand movement is not perceived perform Light perception. Light Perception (Using Penlight) Note: Examiner should move backwards every time the PT is able to respond well to each test.

5.

Abnormal Findings 1. 2. 3. Cataract opacity of lens, halo, cloudy Amaurosis complete absence of light Gaze Palsies paralysis of eye muscles

Assess Cornea (Blinking Test or Corneal Sensitivity Test) Procedure: Use a wisp of cotton and lift upper eyelid then place cotton at lateral surface Normal: client blinks when cornea is touched (CN5 Trigeminal is intact)

Assess Palpebral Conjunctiva and Bulbar Conjunctiva Procedure: retract upper and lower eyelid Normal: a. Palpebral: pink and moist b. Bulbar: capillaries sometimes evident; sclera appears white; yellowish in dark skinned. Conjunctivitis: pink eyes; Blood Injection baka mataas BP To check Convergence 1. Cover PTs eye. If eye converge at center or laterally its abnormal.

Important Questions for Eye Test 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Does Patient wear corrective lenses? Is it for distance or reading? Is it hard or soft lens? Does patient experience blurring of vision? (ex. blind spots, floaters, halos, double vision, photo sensitivity) Problem seeing at night? Any past eye injury or surgery? When and where? Allergies Last eye exam Does patient complain eye pain and head ache Any color blindness Pathologic Diseases (Ex. Diabetic Malabo paningin) Medical History (use of optic drugs) Occupation maybe exposed to fumes, welding, debris, smoke Elders: When did eye problem start? How can you manage ADL? Children: ask mom if NSD or CS (may have eye infection d/t vaginal infection put erythromycin) Does child can identify colors and objects