Health Assessmenttt
Health Assessmenttt
Health Assessmenttt
May be conducted starting at the head and proceeding in a systematic manner downward (head-totoe assessment)
Procedure can vary acc. to
o
Age
o
Severity of illness
o
Preferences of nurse
o
Location of the examination
o
Agencys priorities and procedures
Conducted in a systemic and efficient manner that results in the fewest position changes for the
client
Purposes
o
To obtain baseline data about pt functional abilities
o
To supplement, confirm, or refute data obtained in nursing history
o
To obtain data that will help establish nursing diagnoses and plans of care
o
To evaluate physiologic outcomes of health care and thus the progress of a clients health
problem
o
To make clinical judgments about a pt health status
o
To identify areas for health promotion and disease prevention
Nurses use national guidelines and evidence-based practice to focus health assessment on specific
conditions
Time for physical assessment should be convenient to both client and nurse
Environment needs to be well lighted
Equipment should be organized for efficient use
Room should be warm enough to be comfortable for client
Providing privacy is important; Most people are embarrassed if their bodies are
exposed or if others can overhear or view them during assessment
Culture, gender and age of both client and nurse influence how comfortable the client
will be and what special arrangements might be needed
Family and friends should not be present unless the client ask for someone
POSITIONING
DRAPING
INSTRUMENTATION
Should be
o
Clean
o
In good working order
o
Readily accessible
Frequently set up on trays and ready for use
Supplies :
o
Flashlight/penlight
o
Nasal speculum
o
Ophthalmoscope
o
Otoscope
o
o
o
o
o
o
o
METHODS OF EXAMINING
Inspection
Palpation
Visual examination
Nurse inspects w/ the naked eye and w/ a lighted instrument
Should be deliberate, purposeful and systematic
Olfactory and Auditory cues are also noted
Used to assess
o Moisture
o Size
o Color
o Symmetry
o Texture
o Shape
o Position
Light must be sufficient for the nurse to see clearly
Observation can be combined w/ the other assessment techniques
2 Types
1. Light palpation
Nurse extends the dominants hands finger parallel to the skin surface and presses gently while moving the hand in a circle
Skin is lightly depressed
2.
Deep palpation
Done w/ two hands (bimanually) or one hand
Usually not done during a routine examination
Requires a significant practitioner skill
Performed w/ extreme caution because pressure can damage internal organs
Usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
Effectiveness depends largely on pts relaxation
Nurse can assist a pt to relax by :
o Gowning the pt appropriately
o Positioning the pt comfortably
o Ensuring that their own hands are warm before beginning
During this, nurse should be sensitive to pt verbal and facial expressions indicating discomfort
Deep bimanual palpation
Nurse extends the dominant hand as for light palpation, then places the finger pads of the nondominant hand on the dorsal surface of
the distal interphalangeal joint of the middle three fingers of the dominant hand
Top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations
Deep palpation using one hand
Finger pads of the dominant hand press over the area to be palpated
Other hand is used to support a mass or organ from below
To Test Skin temperature
It is best to use the dorsum (back) of the hand and fingers , where the examiners skin is thinnest
To Test for vibration
Percussion
Act of striking the body surface to elicit sounds that can be heard or vibrations the can be felt
Used to determine size and shape of internal organs by establishing their borders
Indicates whether tissue is
o Fluid filled
o Air filled
o Solid
2 Types
1. Direct percussion
Nurse strikes the area to be percussed directly w/ the pads of 2, 3 or 4 fingers or w/ the pad of the middle finger
Strikes are rapid and movement is from the wrist
Not generally used to percuss thorax
Useful in percussing adults sinuses
2.
Indirect percussion
Striking of finger held against the body area to be examined
Pleximeter ,middle finger of the nondominant hand is placed firmly on the pts skin
Using the plexor , the tip of the flexed middle finger of the other hand , nurse strikes usually at the distal interphalangeal joint of
the pleximeter
Angle bet. plexor and pleximeter should be 90 degrees
Blows must be firm, rapid and short to obtain a clear sound
Types of Sounds
Describe acc. to its intensity, pitch, duration, and quality
1. Flatness
Extremely dull
Produced by very dense tissue (least amt. of air) such as muscle or bone
2. Dullness
Thudlike sound
Produced by dense tissue such as liver, spleen, heart
3. Resonance
Hollow sound
Produced by a lungs filled w/ air /normal lung
4.
Hyperresonance
Booming sound
Not produced in the normal body
Can be heard over an emphysematous lung
5. Tympany
Musical or drumlike sound
Produced from an air-filled stomach
Auscultation
Stethoscope
o Tubing should be 30 to 35 cm
o W/ an Internal diameter of about 0.3 cm
o Diaphragm best transmits high-pitched sounds such as bronchial sounds
o Bell best transmits low-pitched sounds such as some heart sounds
o Earpieces should fit comfortably into nurses ears , facing forward
o Amplifier is placed firmly but lightly against clients skin
o
o
o
GENERAL SURVEY
> General Appearance
> Mental Status
> Vital Signs
> Height
> Weight
Assessment
Normal findings
Deviations
o
o
Proportionate
Varies w/ lifestyle
o
o
Excessively thin
Excessively obese
o
o
o
Relaxed
Erect posture
Coordinated movement
o
o
o
o
o
Tense
Slouched
Bent posture
Uncoordinated movement
Tremors
o
o
Clean
Neat
o
o
Dirty
Unkempt
o
o
o
No body odor
Minor body odor r/t work or exercise
No breath odor
o
o
o
o
No distress noted
o
o
o
o
Healthy appearance
o
o
o
Pallor
Weakness
Lesions
Attitude
o
o
Cooperative,
Able to follow instructions
o
o
o
Negative
Hostile
Withdrawn
Appropriate to situation
Inappropriate to situation
o
o
o
o
Understandable
Moderate pace
Clear tone and Inflection
Exhibits thought association
o
o
o
o
o
o
o
Logical sequence
Makes sense
Has sense of reality
o
o
o
o
Illogical sequence
Flight of ideas
Confusion
Vague
Affect/Mood
THE INTEGUMENT
> Skin
> Hair
> Nails
SKIN
- Involves inspection and palpation
- Nurse may also use the olfactory sense to detect unusual skin odors w/c are usually most evident in skinfolds or in axillae
- Pungent body odor is frequently r/t :
> Poor hygiene
> Hyperhidrosis (Excessive perspiration)
> Bromhidrosis (Foul-smelling perspiration)
Pallor
Cyanosis
Bluish tinge
Most evident in nail beds, lips and buccal mucosa
Jaundice
Yellow tinge
Evident in
o Sclera of eyes
o Mucous membranes
o Skin
Nurses should take care not to confuse jaundice w/ the normal yellow pigmentation in sclera of a dark-skinned
client
If suspected, posterior part of hard palate should also be inspected for a yellowish color tone
Erythema
Localized Areas of
Hypo/Hyperpigmentation
Hyperpigmentation
Increased pigmentation
Ex : birthmark
Hypopigmentation
Decreased pigmentation
Ex: vitiligo
Vitiligo
Patches of hypopigmented skin
Caused by destruction of melanocytes in the area
Albinism
Complete or partial lack of melanin in skin, hair and eyes
Edema
Generalized edema
Skin lesion
- Alteration in clients normal skin appearance
Appear initially in response to some change in the external or internal environment of the skin
o Macule, Patch
o Papule
o Plaque
o Nodule , Tumor
o Pustule
o Vesicle, Bulla
o Cyst
o Wheal
Atrophy
Erosion
Lichenification
Scales
Crust
Ulcer
Fissure
Scar
Keloid
Excoriation
o
o
Color
Primary
Secondary
Note size in mm
o Circumscribed or Irregular
o Round or Oval
o Flat, Elevated or Depressed
o Solid, Soft or Hard
o Rough or Thickened
o Fluid filled or Has flakes
o
o
o
o
o
No discoloration
One discrete color
Several colors
Circumscribed When color changes are limited to the edges of a lesion
Diffuse When spread over a large area
Distribution
Configuration
o
o
o
o
o
Pain or Itching
Stress
Presence and spread of lesions, bruises, abrasions, pigmented spots
Previous experience w/ skin problems
Occupation
Family history
Medications
Presence of problems in other family members
Recent travel
Related systemic conditions
Housing
Use of medications , lotions, home remedies
Recent contact w/ allergens
Excessively dry or moist feel to the skin
Association of the problem to season of year
Tendency to bruise easily
Assessment
Normal findings
Deviations
Skin color
o
o
o
o
o
o
o
Pallor
Cyanosis
Jaundice
Erythema
Areas of either
hypo/Hyperpigmentation
Edema
No edema
o
o
o
o
+1 (2mm)
+2 (4mm)
+3 (6mm)
+4 (8mm)
Skin lesions
o
o
o
o
Freckles
Some birth marks
Some flat and raised nevi
No abrasions or other lesions
o
o
o
o
Skin moisture
o
o
Skin temperature
o
o
Uniform
Within normal range
o
o
o
o
Skin turgor
o
o
HAIR
- Consideration :
> Developmental changes
> Ethnic differences
> Individuals hair care practices
Kwashiorkor
Alopecia
Hair loss
Hypothyroidism
Assessment
Normal findings
Deviations
Evenly distributed
Thickness or thinness
Thick hair
Texture or Oiliness
o
o
Silky
resilient
o
o
No infection or
infestation
o
o
o
o
o
Flaking
Sores
Lice
Nits
Ringworm
Variable
o
o
Hirsutism in women
Naturally absent or Sparse leg hair
(poor circulation)
NAILS
Nail plate
- Normally colorless
- Has convex curve
- Angle bet. the fingernail and nail bed is normally 160 degrees
Nail bed
- Highly vascular , a characteristic that accounts for its color
- Bluish or purplish tint may reflect cyanosis
- Pallor may reflect poor arterial circulation
Nail Abnormalities :
Spoon shape
Koilonychia
Nail curves upward from the nail bed
May be seen in clients w/ iron deficiency anemia
Early Clubbing
Late Clubbing
Angle bet. the nail and nail bed is greater than 180 degrees
May be caused by long term lack of oxygen
Beaus line
Excessively thick
nails
Can appear in elders in the presence of poor circulation or in relation to a chronic fungal
infection
Excessively thin
nails
Nail fungus
Onychomyocosis
Symptoms :
o Brittleness
o Crumbling of the nail
o Discoloration
o Detaching of the nail
o Thickening
o Distortion of nailshape
Paronychia
Blanch Test
Carried out to test the capillary refill i.e the peripheral circulation
Normal nail bed capillaries blanch when pressed but quickly turn pink or their usual color
when pressure is released
Slow rate of capillary refill may indicate circulatory problems
Presence of DM
Peripheral circulatory disease
Previous injury or severe illness
Assessment
Normal findings
Deviations
o
o
Convex curvature
Angle of nail plate about 160 degrees
o
o
Spoon nail
Clubbing
Nail Texture
Smooth texture
o
o
o
o
o
o
Intact epidermis
o
o
Hangnails
Paronychia
Capillary refill
THE HEAD
> Skull
> Ears
> Face
> Nose
> Eyes
> Sinuses
Frontal
Mandible
Parietal
Maxilla
Occipital
Zygomatic
Mastoid process
Hyperthyroidism
Hypothyroidism/Myxedema
Can cause a dry, puffy face w/ dry skin and coarse features and thinning of scalp hair and eyebrows
Can cause a round face w/ reddened cheeks (moonface) and Excessive hair growth on the upper lips , chin
and sideburn areas
Prolonged illness,
Starvation, Dehydration
Assessment
Normal findings
o
o
Rounded
Smooth skull contour
Deviations
o
o
o
Lack of symmetry
Increased skull size w/ more prominent
nose and forehead
Longer mandible (may indicate excessive
growth hormone or increased bone
thickness)
o
o
o
o
Sebaceous cysts
Local deformities from trauma
Masses
Nodules
o
o
o
o
Symmetric
Slightly asymmetric facial features
Palpebral fissures equal in size
Symmetric Nasolabial folds
o
o
o
o
o
o
o
o
o
o
o
Myopia Nearsightedness
Hyperopia Farsightedness
Presbyopia Loss of elasticity of the lens and thus loss of ability to see close objects
Astigmatism An uneven curvature of the cornea that prevents horizontal and vertical rays
from focusing on the retina ; May be corrected w/ glasses or surgery
Dacrocystitis
Hordeolum (sty)
Manifested by
o Redness
o Swelling
o Tenderness of the hair follicle and glands that
empty at the edge of the eyelids
Iritis
Contusions / Hematomas
Other problems :
Cataracts
Glaucoma
Disturbance in the circulation of aqueous fluid w/c causes an increase in intraocular pressure
Most frequent cause of blindness in people over 40
Can be controlled if diagnosed early
Danger signs :
o Blurred or foggy vision
o Loss of peripheral vision
o Difficulty focusing on close
objects
o Difficulty adjusting to dark
rooms
o Seeing rainbow-colored rings
around lights
Ptosis
Ectropion
Eversion
Outturning of the eyelid
Entropion
Inversion
Inturning of the lid
Mydriasis
Enlarged pupils
May indicate:
o Injury
o Glaucoma
May result from:
o Certain drugs (e.g. atropine)
Miosis
Anisocoria
Constricted pupils
An age related change in older adults
May indicate :
o Inflammation of the iris
May result from :
o Some drugs (e.g. morphine, pilocarpine)
Unequal pupils
May result from :
o CNS disorder
Assessment
Eyebrows hair distribution and
alignment, skin quality and movement
Normal findings
o
o
o
Loss of hair
Scaling and flakiness of skin
Unequal alignment and movement of eyebrows
Turned inward
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Redness
Swelling
Flaking
Crusting
Plaques
Discharge
Nodules
Lesions
Lids close asymmetrically, incompletely or
painfully
Rapid, Monocular, absent or infrequent blinking
Ptosis
Ectropion
Entropion
Rim of sclera visible bet. lids and iris
o
o
o
o
Jaundiced sclera
Excessively pale sclera
Reddened sclera
Lesions or nodules
o
o
Deviations
Equally distributed
Curled slightly outward
o
o
o
Extremely pale
Extremely Red
Nodules or other Lesions
o
o
Ask the client to look down while keeping the eyes slightly
open
Rationale : Closing the eyelids contracts the orbicular muscle
muscle contraction
Lacrimal gland
o
o
o
Opaque
Surface not smooth
Arcus senilis under age 40
o
o
o
o
o
o
o
Cloudy
Crescent-shaped shadows on far side of iris
Cloudiness,
Mydriasis
Miosis
Anisocoria
Bulging of iris toward cornea
o
o
o
II.
Visual Fields
Assessment
Normal findings
To determine function of
o Retina
o Neuronal visual pathways to the brain
o 2nd (optic) cranial nerve
Deviations
o
o
III.
Assessment
Assess Six ocular movements
Normal findings
To determine
o Eye alignment
o Eye coordination
Stand directly in front of the client and hold the penlight at a
comfortable distance such as 30 cm/ 1 ft in front of the clients
eyes
Ask the client to follow the movements of the penlight w/ the
eyes only
Move the penlight in a slow, orderly manner through the 6 cardinal
Deviations
o
o
fields of gaze from the center of the eye along the lines of the
arrows and back to the center
1. Superior rectus (CN III)
(CN IV)
2. Lateral rectus (CN VI)
III)
3. Inferior rectus (CN III)
III)
o
o
4. Superior oblique
5. Medial rectus (CN
6. Inferior oblique (CN
Hirschberg Test
Cover Test
Assessment
Near vision
Normal findings
Distance vision
Deviations
Ask the client to wear corrective lenses unless they are used for
reading only , i.e for distances of only 36 cm /12 to 14 in
Ask the client to stand or sit 6m /20 ft from a Snellen chart
Cover the eye not being tested and identify the letters in the
chart
Take 3 readings :
o
Right eye
o
Left eye
o
Both eyes
If the client is unable to see even the top line (20/200) of the
Snellen type chart
NOSE
Inquire
Assessment
Normal findings
External nose
o
o
o
o
o
Deviations
o
o
o
o
o
Asymmetric
Discharge from nares
Localized areas of redness or presence of
skin lesions
Tenderness on palpation
Presence of lesions
o
o
o
Mucosa pink
Clear, watery discharge
No lesions
o
o
o
o
Mucosa red
Edematous
Abnormal discharge (e.g pus)
Presence of lesions (e.g polyps)
Not tender
- Tongue
- Teeth
- Uvula
-Salivary glands
- Tonsillar pillars
- Tonsils
3 Pairs Salivary glands :
Parotid gland
Largest
Empties through the Stensens duct opposite the second molar
Submandibular gland
Sublingual gland
Invisible soft film that adheres to the enamel surface of the teeth
Consists of :
o Bacteria
o Molecules of saliva
o Remnants of epithelial cells and leukocytes
Tartar
Gingivitis
Glossitis
Stomatitis
Parotitis
Sordes
Accumulation of foul matter (food, microorganisms, and epithelial elements) on teeth and gums
Plaque
Normal findings
Deviations
o
o
o
o
o
o
o
o
Pallor
Cyanosis
Blisters
Generalized or Localized swelling
Fissures
Crusts
Scales
Inability to purse lips (may indicate
facial nerve damage)
o
o
o
o
o
o
o
o
o
o
Pallor
Leukoplakia (white patches)
Red
Bleeding
Excessive dryness
Mucosal cysts
Irritations from dentures
Abrasions
Ulcerations
Nodules
o
o
32 adult teeth
Smooth, white, shiny tooth enamel
o
o
Missing teeth
Brown or black discoloration of the
enamel (may indicate staining or
presence of caries)
o
o
o
o
Pink gums
Bluish in dark-skinned clients
Moist, firm texture
No retractions of gums (pulling away from teeth)
o
o
o
o
o
o
Dentures
Ill-fitting dentures
Irritated and excoriated area under
dentures
o
o
Tongue movement
o
o
o
o
o
o
o
o
o
o
o
o
o
Restricted mobility
o
o
Swelling
Ulceration
o
o
Swelling
Nodules
o
o
o
o
Ask the client to roll the tongue upward and move it from side to
side
o
Moves freely
o
No tenderness
Central position
Pink color
Moist, slightly rough
Thin whitish coating
Smooth
Lateral margins
No lesions
Raised papillae (taste buds)
To palpate the tongue , use a piece of gauze to grasp its tip and
w/ index finger , palpate the back of tongue , its borders and its
base
o
Smooth w/ no palpable nodules
Ask client to open mouth wide and tilt the head backward
Depress tongue w/ a tongue depressor
Use a penlight for app. visualization
o
Light pink, Smooth ,soft palate
o
Lighter pink hard palate , more irregular texture
o
o
o
o
Discoloration
Palates the same color
Irritations
Exostoses (bony growths) growing from the
hard palate
o
o
Reddened
o
o
Gag Reflex
o
o
o
o
Edematous
Presence of lesions, plaques, drainage
o
Inflamed
o
Presence of discharge
o
Swollen
Grade 2 : Tonsils are bet. the pillars and uvula
Grade 3 : Tonsils touch the uvula
Grade 4 : One or both tonsils extend to the midline
of the oropharynx
EARS
Ear is divided into 3 parts :
External ear
Includes :
o Auricle/pinna
o External auditory canal
o Tympanic membrane/ Eardrum
Middle ear
Landmarks of auricle :
o Lobule - Earlobe
o Helix Posterior curve of the auricles upper aspect
o Antihelix Anterior curve of the auricles upper aspect
o Tragus Cartilaginous protrusion at the entrance to the ear canal
o Triangular fossa A depression of the antihelix
o External auditory meatus Entrance to the ear canal
Eustachian tube
Connects the middle ear to the nasopharynx
Stabilizes the air pressure bet. the external atmosphere and middle ear thus preventing rupture of the
tympanic membrane and discomfort produced by marked pressure differences
Inner ear
Contains :
o Cochlea A seashell-shaped structure essential for sound transmission and hearing
o Vestibule
o Semicircular canals Contains the organs of equilibrium
Air conducted
transmission
Occurs by :
o A sound stimulus enters the external canal and reaches the tympanic membrane
o The sound waves vibrate the tympanic membrane and reach the ossicles
o Sound waves travel from the ossicles to the opening in the inner ear (oval window)
o The cochlea receives the sound vibrations
o Stimulus travels to the auditory nerve (eight cranial nerve) and the cerebral cortex
Bone conducted
transmission
Occurs when skull bones transport sound directly to the auditory nerve
Conduction hearing
loss
Result of interrupted transmission of sound waves through the outer and middle ear structures
Possible causes :
o Tear in the tympanic membrane
o Other causes in auditory canal
o Obstruction due to swelling
Sensorineural
hearing loss
Result of damage to the inner ear , auditory nerve, or the hearing center in brain
I. Auricles
Assessment
Normal findings
Deviations
o
o
o
o
o
o
Lesions
Flaky, Scaly skin
Tenderness when moved or pressed
o
o
o
o
Redness
Discharge
Scaling
Excessive cerumen obstructing canal
Tip the clients head away from you and straighten the
ear canal
For an adult, straighten the ear canal by pulling the pinna
up and back
Rationale : Straightening the ear canal facilitates vision of
Gently insert the tip of the otoscope into the ear canal,
avoiding pressure by the speculum against the either side
of the ear canal
Rationale : The inner two-thirds of the ear canal is bony; if
shades of brown
o
o
o
o
o
o
o
If client has difficulty hearing the normal voice , proceed w/ the ff tests :
Webers Test
Rinne Test
THE NECK
- Examination of the neck includes :
> Muscles
> Trachea
Sternocleidomastoid muscles
- Divide each side of the neck into two triangles (posterior and anterior)
- Anterior triangle includes :
> Trachea
Occipital
Postauricular (mastoid)
Location : Behind the auricle of the ear or in front of the mastoid process
Area drained : Parietal region of the head and part of the ear
Preauricular
Submandibular
/submaxillary
Submental
Location : Along the medial border of the mandible, halfway bet. the angle of the jaw and the chin
Area drained : Chin, Upper lip, Cheek, Nose, Teeth, Eyelids, Part of tongue, and of the floor of the mouth
Location : Behind the tip of the mandible in the midline, under the chin
Area drained : Anterior third of the tongue. Gums, and Floor of the mouth
NECK
Superficial anterior
cervical (tonsillar)
Posterior cervical
Deep cervical
Supraclavicular
Location : Above the clavicle, in angle bet. the clavicle and sternocleidomastoid muscle
Area drained : Lateral regions of the neck and lungs
Neck lumps
When and How any lumps occurred
Neck pain
Previous diagnoses of thyroid problems
Stiffness
Other treatments provided
I . Neck Muscles
Assessment
Neck muscles (sternocleidomastoid and
trapezius) for abnormal swellings or
masses
Normal findings
Ask client to hold the head erect
o Muscles equal in size
o Head centered
o
o
Head movement
Coordinated
Smooth movements w/ no discomfort
Deviations
o
o
o
o
o
Muscle tremor
Spasm
Stiffness
o
o
Unequal strength
Unequal strength
muscle
muscle
muscle
Muscle strength
sternocleidomastoid muscle
o
Equal strength
Equal strength
o
o
o
Bend the clients head forward slightly or toward the side being examined
Rationale: This relaxes the soft tissue and muscles
Palpate the nodes using pads of the fingers. Move the fingertips in gently
rotating motion
When palpating the anterior cervical nodes and posterior cervical nodes
o Move your fingertips slowly in a forward circular motion against the
sternocleidomastoid and trapezius muscle
Enlarged
Palpable
Possibly tender
(associated w/ infection
and tumors)
III. Trachea
lateral deviation
o
o
Visible diffuseness
Local enlargement
Solitary nodules
Thyroid gland
Place your hands around the clients neck w/ your fingertips on the
lower half of the neck over the trachea
Ask the client to swallow and feel for any enlargement of the
thyroid isthmus as it rises
Anterior Approach
Place the tips of your index and middle fingers over the trachea
Palpate the thyroid isthmus as the client swallows
Enlargement of gland
Auscultate over the thyroid area for a bruit , a soft rushing sound
created by turbulent blood flow
Use the bell of the stethoscope
Rationale: Bell transmits this low frequency sound better than the diaphragm
does
Absence of bruit
Presence of bruit
ANTERIOR CHEST
Midsternal line
Midclavicular lines
Anterior Axillary
lines
Midaxillary line
Vertebral line
Scapular lines
LATERAL CHEST
POSTERIOR CHEST
DIVISION OF LUNG
Each lung is first divided into upper and lower lobes by an oblique fissure that
runs from the level of the spinous process of the third thoracic vertebra (T-3)
to the level of the sixth rib at the Midclavicular line
Abbreviation :
o Right Upper lobe (RUL)
o Left Upper lobe (LUP)
o Right Lower lobe (RLL)
o Left Lower lobe (LLL)
Right lung is further divided by a minor fissure into right upper lobe and right
middle lobe (RML) . This fissure runs anteriorly from the right midaxillary line
at the level of fifth rib to the level of fourth rib
Angle of Louis
Manubrium
Rib identification
A permanent deformity
May be caused by rickets
Characteristics :
o Narrow transverse diameter
o Increased anteroposterior diameter
o Protruding sternum
A congenital defect
Characteristics :
o Sternum is depressed
o Narrowed anteroposterior diameter
o Because the sternum points posteriorly , abnormal pressure on hear
may result altered function
Barrel chest
Kyphosis
Scoliosis
BREATH SOUNDS
Adventitious breath sounds
- Abnormal breath sounds
- Occur when :
> Air passes through narrowed airways or airways filled w/ fluid or mucus
> Pleural linings are inflamed
Description :
Fine , Short, Interrupted crackling sounds
High-pitched
Can be stimulated by rolling a lock of hair near the ear
Best heard on inspiration but can be heard on both inspiration and expiration
May not be cleared by coughing
Cause :
Air passing through fluid or mucus in any air passage
Location :
Most commonly heard in the bases of the lower lung lobes
Gurgles/ Ronchi
Description :
Continuous
Low-pitched
Coarse
Gurgling
Harsh
Louder sounds w/ a moaning or snoring quality
Best heard on expiration but can be heard on both inspiration and expiration
May be altered by coughing
Cause :
Air passing through narrowed air passages as a result of secretions, swelling, tumors
Location :
Most lung areas but predominate over the trachea and bronchi
Friction rub
Description :
Superficial grating
Creaking sounds
Heard during inspiration and expiration
Not relieved by coughing
Cause :
Rubbing together of inflamed pleural surfaces
Location :
Heard most often in areas of greatest thoracic expansion (e.g lower anterior and lateral chest)
Wheeze
Description :
Continuous
High-pitched
Squeaky musical sound
Best heard on expiration
Not usually altered by coughing
Cause :
Air passing through a constricted bronchus as a result of secretions , swelling, tumors
Location :
Heard over all lung fields
Associated w/ :
Collapsed
Surgically removed lobes
Severe pneumonia
Vesicular
Description :
Soft intensity
Low pitched
Gentle sighing sounds created by air moving through smaller airways (bronchioles and alveoli)
Location :
Over peripheral lung
Best heard at the base of lungs
Characteristics :
Best heard on inspiration w/c is about 2.5 times longer than expiratory phase (5:2ratio)
Broncho-vesicular
Description :
Moderate-intensity
Moderate pitched
Blowing sounds created by air moving through larger airway (bronchi)
Location :
Between the scapulae
Lateral to the sternum at the first and second intercostals spaces
Characteristics :
Equal inspiratory and expiratory phases (1:1 ratio)
Bronchial (tubular)
Description :
High-pitched
Loud
Harsh sounds created by air moving through the trachea
Location :
Anteriorly over the trachea
Not normally heard over lung tissue
Characteristics :
Louder than vesicular sounds
Have a short inspiratory phase and long expiratory phase (1:2 ratio)
Inquire
I. Posterior Thorax
Assessment
Shape and Symmetry of thorax from
posterior and lateral view
Normal findings
Compare the anteroposterior diameter to the transverse diameter
o Anteroposterior to transverse diameter in ratio of 1:2
o Chest symmetric
Deviations
o
o
o
Barrel chest
Increased anteroposterior to
transverse diameter
Chest asymmetric
Place the palms of both your hands over the lower thorax w/ your
thumbs adjacent to the spine and your fingers stretched laterally
Ask client to take a deep breath while you observe the movement
of your hands and any lag in movement
o Full and symmetric chest expansion
To determine
o Whether underlying lung tissue is filled w/ air, liquid, or
o
o
o
o
Skin lesions
Areas of hyperthermia
o
o
o
o
o
Lumps
Bulges
Depressions
Areas of tenderness
Movable structures (e.g rib)
o
o
Asymmetric
Decreased chest expansion
solid material
Positions and boundaries of certain organs
Ask client to bend head and fold the arms forward across the
chest
Rationale: This separates the scapula and exposes more lung tissue to
percussion
Asymmetry in percussion
Areas of dullness or flatness over
lung tissue (associated w/
consolidation of lung tissue or
mass)
o
o
o
o
o
Quiet
Rhythmic
Effortless respirations
Breathing patterns
o
o
Ask client to take a deep breath and hold it while you Percuss
downward along the scapular line until dullness is produced at the
level of diaphragm
Mark this point w/ a marking pen and repeat procedure on the
other side of the chest
Ask client to take a few normal breath and then expel the last
breath completely and hold it while you Percuss upward from the
marked point to assess and mark the diaphragmatic excursion
during deep expiration on each side
Measure the distance bet. the 2 marks
o
o
o
o
o
Asymmetric
Decreased respiratory excursion
o
o
Assessment
Inspect Breast for size, symmetry,
contour or shape
Normal findings
o
o
o
o
Deviations
o
o
o
Localized discoloration or
Hyperpigmentation
Retraction or dimpling (result of scar
tissue or an invasive tumor)
Unilateral, Localized hypervascular areas
(associated w/ increased blood flow)
Swelling or Edema appearing as pig skin
or orange peel due to exaggeration of the
pores
o
o
o
o
o
o
Round or Oval
Bilaterally the same
Color varies widely : from light pink to dark brown
o
o
o
Any asymmetry
Mass
Lesion
o
o
o
o
o
o
o
Round
Everted
Equal in size
Similar in color
Soft, smooth
Both nipples point in same direction
No discharge except from pregnant or breast-feeding
females
Inversion of one or both nipples that is present from
puberty
o
o
o
o
o
o
o
Tenderness
Masses
Nodules
Nipple discharge
o
o
Tenderness
Masses
facilitating palpation
o
o
o
Teach the client the technique of
breast self examination
No masses
No nodules
No nipple discharge
o
o
Nodules
Nipple discharge
THE ABDOMEN
- Methods of subdividing the abdomen :
> Quadrants
> Regions
Quadrants
Regions
Nurse imagines :
o 2 vertical lines that extend superiorly from the midpoints of the inguinal ligaments
o 2 horizontal lines , one at the level of the edge of the lower ribs and the other at the level of the iliac crests
Inspection (first)
Auscultation
Percussion
Palpation
4 ABDOMINAL QUADRANTS
Liver
Gallbladder
Duodenum
Head of pancreas
R adrenal gland
Upper lobe of R kidney
Hepatic flexure of colon
Section of ascending colon
Section of transverse colon
L lobe of liver
Stomach
Spleen
Upper lobe of L kidney
Pancreas
L adrenal gland
Splenic flexure of colon
Section of tranverse colon
Section of descending colon
9 ABDOMINAL REGIONS
RIGHT HYPOCHONDRIAC
EPIGASTRIC
LEFT HYPOCHONDRIAC
R lobe of liver
Gallbladder
Part of duodenum
Hepatic flexure of colon
Upper half of R kidney
Suprarenal gland
Aorta
Pyloric end of stomach
Part of duodenum
Pancreas
Part of liver
Stomach
Spleen
Tail of pancreas
Splenic flexure of colon
Upper half of L kidney
Suprarenal kidney
RIGHT LUMBAR
UMBILICAL
LEFT LUMBAR
Ascending colon
Lower half of R kidney
Part of duodenum and jejunum
Omentum
Mesentery
Lower part of duodenum
Part of jejunum and ileum
Descending colon
Lower half of R kidney
Part of jejunum and ileum
HYPOGASTRIC (PUBIC)
LEFT INGUINAL
RIGHT INGUINAL
Cecum
Appendix
Lower end of ileum
R ureter
R spermatic cord
R ovary
Ileum
Bladder
Uterus
Sigmoid colon
L ureter
L ovary
Inquire
Assessment
Normal findings
Skin Integrity
o
o
o
o
Unblemished skin
Uniform color
Silver-white striae (stretch marks)
Surgical scars
o
o
o
Deviations
o
o
o
o
o
o
o
o
o
Vascular pattern
II.
Distended
Evidence of enlargement of liver or
spleen
Asymmetric contour (e.g localized
protrusions around umbilicus , inguinal
ligaments, or scars [possible hernia or
tumor])
TO AUSCULTATE :
Splenic site
Place the stethoscope over the left lower rib cage in the
anterior Axillary line and ask client to take a deep breath
Deep breath may accentuate the sound of a friction rub area
Liver site
Place the stethoscope over the lower right rib cage
o
o
o
Hypoactive sounds
Extremely soft and infrequent (e.g one
per min.)
- Indicate decreased motility
- Usually associated w/ manipulation of
the bowel during surgery, inflammation,
paralytic ileus, late bowel destruction
Hyperactive sounds
- High pitched, loud, rushing sound
- Occur frequently (e.g every 3 sec)
- Also known as borborygmi
- Indicate increased intestinal motility
- Usually associated w/ diarrhea, an early
bowel obstruction, use of laxatives
o
o
-o
o
o
o
-o
o
palpatory evaluation
o
o
No tenderness
Relaxed abdomen w/ smooth, consistent tension
-o
o
VI. Palpation of the Liver
Palpate the liver to detect
enlargement and tenderness
2. Second Method
Bimanual palpation method in w/c one hand is superimposed on
the other
-o
o
o
o
o
o
o
Distended
Palpable as smooth, round, tense mass
(indicates urinary retention)
I. Muscles
Assessment
Inspect muscle for size
Normal findings
Compare muscles on one side of the body to the same muscle on other
side
For any discrepancies, measure the muscles w/ a tape
o Equal size on both sides of body
Deviations
o
o
o
No contractures
No tremors
Presence of tremor
Normally firm
o
o
Sternocleidomastoid
Client turns the head to one side against the resistance of your
hand
Repeat w/ the other side
Trapezius
Triceps
Client flexes each arm and then tries to extend it against your
attempt to keep arm in flexion
Wrist and finger muscles
Client spreads the fingers and resists as you attempt to push the
fingers together
Grip strength
Client grasps your index and middle fingers while you try to pull
fingers out
Hip muscles
Client is supine, both legs extended
Client raises one leg at a time while you attempt to hold it down
Hip abduction
Client is supine, both legs extended
Place your hands on the lateral surface of each knee
Client spreads the legs apart against your resistance
Hip adduction
Client is in same position as for hip abduction
Place your hands bet. the knees
Client brings the legs together against your resistance
Hamstrings
Client is supine, both knees bent
Client resists while you attempt to straighten the leg
Quadriceps
Client is supine, knee partially extended
Client resists while you attempt to flex the knee
Muscles of the ankles and feet
Client resists while you attempt to dorsiflex the foot and again
resists while you attempt to flex the foot
o
No deformities
Bones misaligned
No tenderness or swelling
o
o
No swelling
No tenderness, crepitation or nodules
o
o
II. Bones
III. Joints
Eye Opening
Motor Response
Verbal Response
RESPONSE
SCORE
Spontaneous
To verbal command
To pain
No response
To verbal command
To localized pain
Flexes abnormally
Extends abnormally
No response
Oriented, converses
Disoriented, converses
No response
CRANIAL NERVE
NAME
TYPE
FUNCTION
ASSESSMENT METHOD
Olfactory
Sensory
Smell
Optic
Sensory
Oculomotor
Motor
II
III
Movement of sphincter of
pupil
Movement of ciliary muscles of
lens
IV
Trochlear
Motor
EOM
Moves eyeball downward &
laterally
V
Trigeminal
Sensory
Ophthalmic branch
Sensory
Sensation of skin of face and
anterior oral cavity (tongue
and teeth)
Muscles of mastication
Sensation of skin of face
EOM
Moves eyeball laterally
Facial expression
Taste (anterior 2/3 of tongue)
Mandibular branch
Motor and Sensory
VI
Abducens
Motor
Facial
VII
Sensory
Equilibrium
- Romberg test
Cochlear branch
Sensory
Hearing
Glossopharyngeal
Swallowing ability
Tongue movement
Taste (posterior tongue)
IX
XI
Accessory
Motor
Head movement
Shrugging of shoulders
Hypoglossal
Motor
Protrusion of tongue
Moves tongue up and down and
side to side
XII
Language
Aphasia
Any defects in or loss of the power to express oneself by speech, writing, or signs or to comprehend spoken or written language
due to disease or injury of the cerebral cortex
Categories :
I. Sensory or receptive aphasia
Loss of the ability to comprehend written or spoken words
2 types :
o Auditory aphasia have lost the ability to understand the symbolic content associated w/ sounds
o Visual aphasia have lost the ability to understand printed or written figures
II. Motor or expressive aphasia
Involves loss of the power to express oneself by writing, making signs or speaking
Pt have lost the ability to combine speech sounds into words
Orientation
Determines the :
Clients ability to recognize other persons
Awareness of when and where they presently are
Awareness of who they , themselves are
Memory
Nurse
LOC
Determines clients ability to focus on a mental task that is expected to be able to be performed by persons of normal
intelligence
REFLEXES
MOTOR FUNCTION
Include
:
Touch
Position
Pain
Tactile disrimination
Temperature
I. Language
II. Orientation
- Determine clients orientation to person, time and place
III. Memory
- Assess immediate recall , recent memory, and remote memory
IV. Attention Span and calculation
V. Level of consciousness
- Apply the Glasgow coma scale
VI. Cranial Nerves
VII. Reflexes
- Test reflexes using a percussion hammer
- Compare one side of the body w/ the other
- Evaluate the symmetry of response :
O No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity
1. Biceps reflex tests the spinal cord level C-5 , C-6
2. Triceps reflex tests the spinal cord level C-7, C-8
3. Brachioradialis reflex tests the spinal cord level C-5, C6
4. Patellar reflex tests the spinal cord level L-2, L-3, L-4
5. Achilles reflex tests the spinal cord level S-1, S-2
6. Plantar (Babinski) reflex is superficial ; may be absent in adults w/o pathology, or overridden by voluntary control
VIII. Motor Function
Walking Gait
Ask the client to walk across the room and back, and assess the
clients gait
o
Has upright posture and steady gait w/ opposing arm swing
o
Walks unaided
o
Maintaining balance
Romberg Test
Ask the client to stand w/ feet together and arms resting at the
sides, first w/ eyes open , then closed
Stand close during this test to prevent the client from falling
o
Negative Romberg : may sway slightly but is able to maintain
upright posture and foot stance
o
o
o
o
-o
--
--
--
Finger-To-Nose Tests
Ask the client to abduct and extend the arms at shoulder height and
then rapidly touch the nose alternately w/ one index finger and then
the other
The client repeats the test w/ eyes closed if the test is performed
easily
o Repeatedly and rhythmically touches the nose
o
Finger to Nose and to the Nurses finger
Ask the client to touch the nose and then your index finger , held at
a distance of about 45 cm at a rapid and increasing rate
o Performs w/ coordination and rapidity
-o
o
o
Fingers to Fingers
Ask the client to spread the arms broadly at shoulder height and
then bring the fingers together at the midline , first w/ eyes open
and then closed, first slowly and then rapidly
-o
--
-o
o
o
o
o
o
Anesthesia
Hyperesthesia
Hypoesthesia
Paresthesia
Pain sensation
Temperature sensation
Tactile discrimination
EXTINCTION PHENOMENON
Simultaneously stimulate two symmetric areas of the body , such as
thighs , the cheeks or the hands
o
Both points of stimulus are felt
--
Inquire
I. Pubic Hair
Assessment
Distribution , Amount , and
Characteristics
Normal findings
Deviations
o
o
Scant amount
Absence of hair
o
o
o
o
Lesions
Nodules
Swelling
Inflammation
o
o
o
o
o
Inflammation
Discharge
Variation in meatal locations (e.g
hypospadias [on the underside of the
penile shaft] and epispadias [on the upper
side of the penile shaft])
o
o
o
Smooth
Semifirm
Slightly movable over the underlying structures
o
o
o
o
Tenderness
Thickening
Nodules
Immobility
II.
Penis
III. Scrotum
o
o
o
o
o
o
o
o
o
Discolorations
Any tightening of skin (may indicate
edema or mass)
Marked asymmetry in size
Testes
During assessment of male adolescents , note the
undescended testes
Epididymis
Located at the top of the testis and extends behind it
Spermatic cord
Found at the top lateral portion of the scrotum and feels
firm
If swelling or irregularities are detected:
Attempt to Transilluminate the lesion
Done by darkening the room and shining a flashlight behind
the scrotum through the mass
Rationale: Serous fluid causes the light to show a red glow ;
o
o
Inquire
regarding the ff :
Age of onset of menstruation
Whether menstruation is painful
Number of live births
Painful urination
LMP
Incidence of pain during intercourse
Labor or delivery complications
Incontinence
Regularity of cycle
Vaginal discharge
Urgency and Frequency of urination at night
Duration and Amount of daily flow
Number of pregnancies
Blood in urine
History of STD
Assessment
Normal findings
Deviations
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Lice
Lesions
Scars
Fissures
Swelling
Erythema
Excoriations
Varicosities
Leukoplakia
o
o
o
o
o
o
Lesions
Inflammation
Swelling
Discharge
No enlargement or tenderness
Digital examination can cause apprehension and embarrassment in pt, help the client relax by encouraging the client to
take a slow , deep breaths because tension can cause spasms of the anal sphincter making the examination
uncomfortable
Inform the client about potential sensations such as feelings of defecation or passing gas
Drape client appropriately
Assessment
Inspect anus and surrounding tissue
for color, integrity, and skin lesions
Normal findings
Deviations
Presence of
o
Fissures
o
Ulcers
o
Excoriations
o
Inflammations
o
Abscesses
o
Protruding hemorrhoids (dilated veins
seen as reddened protrusions of the
skin)
o
Lumps
o
Tumors
o
Fistula openings
o
Rectal prolapse (varying degrees of
protrusion of the rectal mucous
membrane through the anus)
Slowly insert your finger into the anus and rectum in the
direction of the umbilicus
o
The anal canal (distance from the anal opening to the
anorectal junction) is short (less than 3 cm /about 1 inch)
o
The posterior wall of the rectum follows the curve of the
coccyx and sacrum
o
Nurses finger is usually able to palpate a distance of 6 to
10 cm (2 to 4 in)
Never force digital insertion . If lesions are painful or bleeding
occurs, discontinue the examination
o
Ask the client to tighten the anal sphincter around your finger
and note the tone of the anal sphincter
Rotate the pad of index finger along the canal and rectal walls ,
feeling for nodules, masses and tenderness
Note the location of any abnormalities of the rectum
o
Rectal wall is smooth and not tender