NURS 110 Exam 2 Head to Toe Assessment

Male Genital Self-Examination

-15 and older should inspect monthly -perform the examination after a warm bath or shower when the scrotal skin is less thick -stand naked in front of mirror, hold penis in hand and examine head (pull back foreskin if needed) -inspect and palpate head in a clock wise motion looking for bumps, sores, and blisters

crackles

-Air flowing by liquid causes crackles (rales) -can be fine, medium, or coarse\ -Fine crackles are high-pitched crackling or popping sounds -Coarse crackles are low pitched gurgling sounds -usually heard during inspiration -create a dry sound when heard higher in the bronchial tree -create a wet sound when heard lower in the bronchial tree

Rhonchi

-Air flowing over six secretions causes rhonchi -creates a low pitched sound -usually continuous and prolonged -sibilant or high pitched rhonchi are heard over the smaller bronchi -sonorous or low pitched rhonchi are heard over the larger bronchi -sometimes hard to distinguish b/t crackles and rhonchi >>> have the patient cough>>>> if it disappears it is usually rhonchi

wheezes

-Air flowing through constricted airways causes wheezes -have a high pitch musical sound -High pitched wheezes are sibilant -Low pitch wheezes are sonorous. -heard on inspiration and expiration -continuous -usually bilateral -Wheezes that are unbilateral are usually due to an obstruction by a foreign object

vesicle

circumscribed elevation of the skin filled with serous fluid, smaller than 1 cm (herpes simplex, chicken pox)

pustule

circumscribed elevation of the skin similar to a vesicle but is containing pus, varies in size (acne, staph infection)

varicosities

superficial veins that have been dilated -seen in legs -common in older adults

thyroid gland

swallow and feel -midline -no bulging

lordosis

swayback

murmors

swishing/blowing sounds heard at the beginning, middle, or end of the systolic or diastolic process

Osteoporosis

systemic skeletal condition that is noted to have both decreased bone mass and deterioration of bone tissue, making bones fragile and at risk for fracture

weber test

test for sensorineural hearing loss -hit fork -tuning fork applied to middle of fore head (look at power point for better explanation)

tuning fork test

test of ear conduction using a vibration source -Weber and Rinne

visual acuity

the ability to see small details -test central vision

peripheral arteries

assess each peripheral artery for elasticity of the vessel wall, strength, and equality -can use ultrasound stethoscopes

language

assess for aphasia -sensory (receptive) -Motor (expressive)

accommodation

the process by which the eye's lens changes shape to focus near or far objects on the retina -look at far away object (wall) then look at a close object (pen in your hand)

atrophy

thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent, varies in size (Arterial insufficiency)

S3

third heart sound -when the heart attempts to fill an already distended ventricle -occurs after S2 -sounds like "kentucky" -congestive heart failure -abnormal for adults over 31

signs of venous insufficiency

color: normal or cyanotic temp: normal pulse: normal edema: often (marked) skin changes: Brown pigmentation around the ankles

Signs of arterial insufficiency

color: pale, worsened by elevation temp: cool (blood flow blocked to extremity) pulse: decreased or absent edema: absent or mild skin changes: thin, shinny skin, decreased hair growth, thickened nails

screening exams

community setting or in dr office

heart

compare assessment of heart functions with vascular findings -assess point of maximal impulse (PMI) (apical heart rate >>> 1 full min) -locate anatomical landmarks

strabismus

congenital- both eyes do not focus on an object simultaneously -cross eyed

abnormal breath sounds

crackles, wheezes, rhonchi, friction rub

radial pulse

thumb side of wrist

atrophy

to waste away from lack of use -muscle that has reduced its size

where is the apex of the lungs located?

top, above the clavicle

hair and scalp

hair: color, distribution, quantity, thickness, texture, and lubrication scalp: lesions, lumps, dandruff, lice

color of skin

means something....... -pallor -cyanosis -jaundice -erythema -brown or red discolorations

Neurological System

mental and emotional status -is the patient alert and aware or not? -Mini mental state examination (MMSE) -delirium -level of consciousness (Glasgow Coma Scale) -orientation status -behavior and appearance -language

delirium

mental disorder marked by confusion; uncontrolled excitement; delirious -occurs in hospitalized patients -elderly -occurs more at night

PMI (point of maximal impulse)

most accurate heart beat -lay on left side to hear better -Apical/Mitral heart rate -5th intercostal space

Peristalsis

movement of contents through the intestines (normal function of small and large intestines) -normally takes 5-20 seconds to hear a bowel sound however it takes 5 min of continuous listening before determining that bowel sounds are absent

erythema

redness of the skin -indicate circulatory changes

carotid artieries

reflect heart function better than peripheral arteries -commonly auscultated -use the bell (lightly)

secondary lesions

result from later formation of trauma to primary lesion such as a pressure ulcer

daily height and weight

same scale same clothes same time of day

S2

second heart sound -aortic and pulmonary valves closing -"dub" -end of systole/beginning of diastole (best heart at aortic region)

aortic area

second intercostal space to the right of the sternum

orientation status

self, time, place, situation

female breast inspection

size and symmetry -normal for one breast to be smaller than the other contour and shape color nipple and areola (split into 4 quadrants + axillary tail of spence)

abdomen inspection

skin, umbilicus, contour and symmetry, enlarged organs or masses, movements or pulsations (abdominal aneurism??>>> do NOT palpate if see pulsations)

tumor

solid mass that extends deep through subcutaneous tissue, larger than 1-2 cm (epithelioma)

after examination

-Record/document findings -give patient time to dress (assist if needed) -if findings are serious consult w health care provider before informing the patient -delegate cleaning of examination area -record complete assessment and review for accuracy -communicate significant findings

bruit

abnormal blowing or swishing sound detected in carotid arteries -use bell (thrills: humming sounds, also sometimes found)

focused/ problem centered

-actue illness -more detailed in the involved system -will ALWAYS include assessment of heart and lungs (focus on the problem the patient is having at that time)

pupillary response

-as little light in room as possible -shine light into patients eye 1 at a time -check pupils for size (3-7mm) shape (round) and reaction time (briskly reactive)

musculoskeletal system

-assess for lordosis, kyphosis, or scoliosis -range of joint motion -muscle tone and stength

capillary refill

-assessing the circulation to periphery -apply firm pressure to nail bed -release>>>the color should return within 3 seconds if normal -document as: "cap refil < 3 secs"

Ear Assessment

-auricles -outer ear -middle ear -inner ear

inspection

-can begin as soon as you see the patient -done at anytime -use adequate lighting -use direct lighting to inspect body cavities -inspect each are for size, symmetry, position, and abnormality -position and expose body parts as needed so all surfaces can be viewed but privacy can be maintained -validate findings w patient

when inspecting a lesion collect information about its.....

-color -location -texture -size -shape -type grouping (clustered or linear) -distribution (localized or general)

abnormal respirations

-cough, is it productive? (cough something up) if so note the color and consistency -labored, below 12 and over 25 -use of accessory muscles

tactile fremitus

-created by vocal cords -transmitted through the lungs to the chest wall -palpation -have patient say "99" >>>> if you don't feel anything >>>NOT normal>>> to much mucous

dull or thud like sound

-dense areas: liver, heart -or when fluid or solid tissue replaces air containing lungs

preparation of exam for older adults

-do not stereotype -might be confused -assess level of consciousness -problem with ADLs (activities of daily living)

What contains latex?

-equipment such as: gloves, BP cuff, stethoscope tubing etc -house hold items such as: rubber bands, erasers, motor cycle hand grips, swimming goggles, balloons, condoms, carpeting, bananas, advocados etc. *don't forget to ask about allergies

Lower extrimities pulses

-femoral pulse -popliteal pulse (back of knee) -dorsalis pedis pulse (top of foot) -posterior tibial pulse (inside on ankle)

general survey

-general appearance & behavior -gender, race, age, signs of distress, posture, gait, movements, mood, hygiene etc -signs of abuse (REPORT!!!!) -signs of alcohol abuse -check vital signs -height & weight -pain (where is it??)

condition of nails reflect

-general health -state of nutrition -occupation -level of self care

how to test visual acuity

-have patient stand 20ft away from snellen chart -have patient read the chart -make sure the patient wears his or hear contacts or glasses

Diaphragm

-high pitch sounds -press firmly -heart sounds -lung sounds -bowel sounds

Head assessment

-includes the head, eyes, ears, nose, mouth, pharynx, neck, lymph nodes, carotid arteries, thyroid gland, and trachea -start by inspecting patient head and noting the position, size, shape, and contour -palpate the temporomandibular joint (TMJ) space bilaterally (Jaw bone)

friction rubs

-inflammation of the pleural space causes friction rubs -not produced inside the airways -dry, rubbing, crackling, sound -usually caused by inflammation or loss of pleural fluid -hear during inspiration and expiration

dysrythmia

abnormal heart beats

neurological system functions

-intellectual function -cranial nerve function (12) -sensory function -motor function -coordination/function

auscultation

-involves listening to sounds -learn normal sounds first before identifying abnormal or variations -use bell and diaphragm of stethoscope

system investigation

-location, quality, quanity, chronology, setting, aggravating, or alleviating factors, associated manifestations, meaning of symptom to patient -ask patient to show you where -this could have bearing on symptomology whether the location is specific or diffuse

testicular self-examination

-look for swelling or lumps in skin of scrotum while looking in the mirror -use both hands placing index and middle fingers under testicles and thumb on top -gently roll testicle feeling for anything sore or abnormal -find the epididymis >>> feel for small lumps (call health care provider for abnormal findings)

hyperresonant sound

-louder, lower pitched than resonant -children chest or pneumothorax

bell

-low pitch sounds -lightly press -unexpected heart sounds -bruits

resonant sounds

-low pitch, hollow, heard over normal lung tissue

annual exams

-more comprehensive than health maintenance or focused -often incorporates health promotion EX: mammograms, PSA testing, scheduling for colonoscopies

neck

-neck muscles (ROM range of motion) ~anterior triangle ~posterior triangle -lymph nodes -thyroid gland -carotid and jugular vein (covered under vascular) -trachea (should be straight)

normal respirations

-no intercostal or accessory muscle retractions or nasal flaring -rate b/t 12-20, regular pattern, unlabored, quiet -trachea midline -no cough

lymph nodes

-nonpalpable -nontender -shouldn't be hard -shouldn't feel them but may be tender w allergies

rectum and anus

-perform after genital examination -explain all steps to the patient -PROVIDE PRIVACY -use inspection and digital palpation

Abdominal palpation

-perform last -detects tenderness, distension, or masses -may be light or deep as appropriate -aortic pulsation>>> if you see pulsations do NOT palpate (report it)

Mouth assessment

-pink -ask if they've had a sore throat -don't want any colored patches on tongue -any teeth missing? -make sure mouth is not blue -no bleeding -gag reflex intact -tonsils not visible

preparation of exam for children

-play therapy -demonstrate on parent -gain child's trust -open-ended questions -call child by first name

completing a health history

-provides subjective data -includes past health history, surgeries, medications, childhood illnesses, family history, psychosocial history, review of systems

blood pressure

-readings tend to be higher in the right arm -always record the higher reading

Female and Male Genitalia ask if there is any.......

-redness -itching -discharge -swelling -burning -STDs

types of percussion sounds

-resonant -flat or extremely dull -dull or thud like -hyperresonant -tympanic

Scoliosis

abnormal/ lateral spinal curvature

auricles

-size -shape -symmetry -landmarks -position -color (red?) -discharge -pain?

whisper test

-stand 12-14 in to the side of the patient -whisper numbers, words, or questions -have the patient repeat numbers or words or answer questions

Visual fields test

-stand in front of your patient -have them cover 1 eye -you as the nurse cover the opposite eye -move your finger outside you and the patients view -slowly bring finger towards your field of vision -patient reports when he/she can view the finger -you should see it at the same time -if you see the finger before the patient, part of the patient's visual field is reduced

percussion

-tap body w fingertips to produce a vibration -sound determines location, size, and density of structures

jugular veins

-the most accessible veins for examination -best to examine the right internal jugular vein bc it follows a more direct anatomical path to the right atrium of the heart -do NOT have a pulse -visible while in supine position (laying down) -if you sit up and see jugular veins>>>>abnormal -assess pressure

strategies for interviewing

-use a mixture of open and closed ending questions -ask patient to clarify (open ended: get more info) -reduce noise (ex: tv or music) -use simple terms and make sure the patient understands etc.

Braden Scale for Skin Risk Assessment

-used to predict patients at risk for skin breakdown -assess nutrition, mobility sensory, activity, moisture, and friction -score ranges from 6-23, lower the score the greater the risk

palpation

-uses touch to gather info -before touching patient>>>tell/explain patient what you are doing>>>ask permission -use diff parts of hands to detect diff characteristics -hands should be warm, fingernails short -start w light palpation (1cm 1/2 in) & end with deep palpation (4cm 2in) -palpate the tender/painful area last

peripheral veins

-varicosities -peripheral edema (pitting edema) -phlebitis (inflammation of veins)

how do you test coordination and balance?

-walk heel to toe -close eyes (do they sway?)

what is the diagnosis equipment used for examination of thorax and lungs?

-x ray films -MRI -CT scans

rating pulses

0: absent, not palpable 1: pulse diminished, barely palpable 2: expected 3: full, increased 4: bounding, aneurysmal

grade reflexes

0: no response 1+: sluggish/diminished 2+: active/expected response 3+: more brisk than expected, slightly hyperactive 4+: brisk and hyperactive w the intermittent or transient clonus

Abdomen assessment order

1 inspection 2 auscultation 3 percussion 4 palpation -the abdomen is cut into 4 quadrants

techniques for physical exam

1. Inspection 2. palpation 3. percussion (Not done much anymore) 4. auscultation

what are the 6 different points to listen to the heart?

1. aortic 2. pulmonic 3. second pulmonic area 4. tricuspid 5. mitral/apical 6. epigastric

pulmonic area

2nd intercostal space to the left of the sternum

MMSE scale

30-24 none 23-19 intermediate 18-10 moderate 9-0 severe

when is the best time for a self breast exam?

4-7 days in menstrual cycle or right after the cycle ends

tricuspid area

4th intercostal space, along the sternum

Where is the apex of the heart located?

5th intercostal space, left midclavicular line -apical/mitral area -PMI -bottom

apical/mitral area

5th intercostal space, left of sternum, left midclavicular line

motor (expressive) aphasia

A person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate

objective data

AKA signs -what you as the nurse assess -the physical assessment and the diagnostic test provide

subjective data

AKA symptoms -what the patient says -what the health history provides

determining LOC

AWAKE -patient is awake VERBAL -patient responds to a verbal stimulus PAIN -patient responds to a pain stimulus UNRESPONSIVE -patient is unresponsive to stimulus

edema

Abnormal accumulation of fluid in interstitial spaces of tissues -finger print indication does not go away after pressing into skin (pitting edema) -may be discolored, tender -compare side to side

nystagmus

An involuntary, rhythmic oscillation of the eyeballs

clubbing

COPD>>>>thick nails (irregular) -a bulging of tissues at the nail base which causes abnormal curvature of the nails -clubbing suggest a chronic problem such as emphysema and congenital heart disease

skin turgor

Measure of hydration, which tests how quickly the skin returns to its normal position after being pinched -go back to normal in less than 3 seconds

opthalmoscope

Instrument used to examine the eyes

Second pulmonic area

Left third intercostal space

Normal heart sounds

S1 and S2 (lub dub) -use the diaphragm

abnormal heart sounds

S3, S4, murmur -use the bell

T/F anytime you see respiratory difficulty, immediately obtain an O2 sat and get a complete set of VS. If not on O2, apply O2. No resolution call rapid response

TRUE!!!!!!!!!

T/F a nurse should assess a patients skin regularly and try to prevent skin ulcers by turning patients

True

T/F a nurse should turn a patient every 2 hours, elevate arms/legs, and use foam protectors to prevent skin ulcers/injuries

True

T/F a person's eyes dilate when looking at far objects and constrict when looking at close objects

True

T/F assess the posterior thorax first, the lateral thorax second, and the anterior thorax last

True

T/F the right lung has 3 lobes and the left lung has 2 lobes

True

thrill

a continuous palpable sensation that resembles the purring of a cat -grade 1-6 -grade 1: barely audible in a quiet room >>>> grade 6: very loud, audible w stethoscope not in contact w chest, thrill palpable and visible

cyanosis

bluish discoloration of the skin -lips, nail beds, palms, palpebral conjunctivae

Abdomen Auscultation

bowel motility -peristalsis -borborygmi (growling) vascular sounds -bruits kidney tenderness -percussion

middle ear

canal clear, exudate, draining, redness, swelling -use otoscope to inspect

macular degeneration

damaging sharp and central vision. wet and dry. -wet blood vessels grow under the macula -dry occurs when the macula thins causing blurring and eventually blindness

pallor

decrease in coloration -paleness -more evident in the face, mouth (inside cheeks), conjunctiva, nail beds

hypotonicity

decrease in muscle tone, feels flabby

Bronchovesicular

description: -blowing sounds that are medium pitched and intensity -inspiratory phase is equal to expiratory phase location: -best heard posteriorly b/t scapulae and anteriorly over bronchioles lateral to sternum and first and second ICS origin: -created by air moving through large airways

bronchial

description: -loud and high pitched w hollow quality -expiration last longer than inspiration location: -heard over trachea origin: -created by air moving through trachea close to chest wall

vesicular

description: -soft, breezy and low pitched -inspiratory phase is 3x longer than expiratory phase location: -best heard over periphery of lung (except over scapula) origin: -created by air moving through smaller smaller airways

nodule

elevated solid mass, deeper and firmer than papule 1-2cm (wart)

extraocular movements

eye movements controlled by several pairs of eye muscles

hyperopia

farsightedness -difficultly seeing close objects -can see distant objects

T/F it is normal is testicles are different sizes

fasle -testicles should be the same size

S1

first heart sound -valve closing -"lub" -beginning of systole

macule

flat, non-palpable, change in skin color, smaller than 1 cm -freckle, petechiae

health maintenance

follow up for previously treated condition, or chronic illness

S4

fourth heart sound -atria contact to enhance ventricular filling -occurs after S1 -sounds like "tennessee" -often heard in healthy older adults, children, and athletes, but not normal in adults

How to test for extraoccular movement

have patient follow your finger or pen w their eyes w/o them moving there head as you move your finger or pen in 6 different positions -look for nystagmus

Rinne test

hearing test using a tuning fork; checks for differences in bone conduction and air conduction AC > BC = normal BC > AC = conductive loss (look at power point for better explanation)

tympanic sound

hollow, drum like, over stomach -indicates excessive air

kyphosis

hunchback

presbyopia

impaired near vision at middle age and older adults caused by loss of elasticity of the lens (40 or older)

sensory/receptive aphasia

inability to understand written or verbal speech

Hypertonicity

increased muscle tone

Cataracts

increased opacity of the lens (thick glossy color)

Bruits

indicate narrowing of the major blood vessels and disrupts blood flow -presence of bruits can reveal aneurysms or stenotic vessels -use the bell to hear

brachial pulse

inside of elbow

otoscope

instrument used for visual examination of the ear -there are different size probes -change probes b/t each patient

Goniometer

instrument w two flexible arms and a 180 protractor in the center used to measure angels -often used to measure the precise degree of motion in a joint

outer ear

intact, any bruising swelling, scaling -use inspection and palpation

glaucoma

intraocular structural damage from elevated intraocular pressure -leads to blindness (puff of air in eye)

wheal

irregularly shaped, elevated area or superficial localized edema, varies in size (hive, mosquito bite)

ulnar pulse

little finger side of wrist

myopia

nearsightedness -difficulty seeing distant objects -can see close objects

Nose assessment

normal: -midline, nares patent -septum midline, intact -mucosa dark pink, moist no drainage -smell intact abnormal: -nasal flaring -pressure over sinus cavity

primary lesions

occur as an initial sign of pathological process such as with an insect bite

determining orientation status

orientation to...... -person x1 -person and place x2 -person place and time x3 -person place time and situation x4

Flat or extremely dull sounds

over bone

papule

palpable, circumscribed, solid elevated mass, smaller than 1 cm (elevated nevus)

assessment of common reflexes

patella/knee (extension of lower leg) and achilles/armafter (plantar flexion of foot)

T/F asking questions is an example of subjective information

true

T/F it is normal if the left testicle is lower than the right

true

T/F it is not uncommon to not be able to hear bowel sounds after a patient first comes back from surgery

true

T/F to check a patients liver, you can ask the patient to take a deep breath and hold it

true

how do you inspect children's ears?

use otoscope -pull ears back and down

how do you inspect adult ears?

use otoscope -pull ears back and up

female breast palpation

use systematic approach: -vertical -circular -radial wedge technique

Systole

ventricles contract and eject blood from left ventricle into the aorta and from right ventricle into the pulmonary artery

diastole

ventricles relax and the atria contract to move blood into the ventricles and fill the coronary arteries

normal breath sounds

vesicular, bronchovesicular, bronchial

inner ear

view tympanic membrane Normal: pearly gray, no redness, protrusion, drainage; intact membrane w visible light reflex -test patients hearing acuity -note any abnormal drainage and should not be red

Clinical Manifestations

when you understand the clinical disorder, you can guide your data collection more efficiently

who should get a mammogram every year?

women 40 and older and/ or have a family history of breast cancer

Juandice

yellowing of the skin -best revealed by a patients sclera