Chp 15: Health & Physical Assessment of the Adult Client

Scoring Deep Tendon Reflex Activity

0 = No response 1 + = Sluggish or diminished 2 + = Active or expected response 3 + = Slightly hyperactive, more brisk than normal; not necessarily pathological 4 + = Brisk, hyperactive with intermittent clonus associated with disease

Head, Neck, & Lymph Nodes Exam

1. Ask the client about headaches; episodes of dizziness (lightheadedness) or vertigo (spinning sensation); history of head injury; loss of consciousness; seizures; episodes of neck pain; limitations of range of motion; numbness or tingling in the shoulders, arms, or hands; lumps or swelling in the neck; difficulty swallowing; medications being taken; and history of surgery in the head and neck region. 2. Head a. Inspect and palpate: Size, shape, masses or tenderness, and symmetry of the skull b. Palpate temporal arteries, located above the cheekbone between the eye and the top of the ear. c. Temporomandibular joint: Ask the client to open his or her mouth; note any crepitation, tenderness, or limited range of motion. d. Face: Inspect facial structures for shape, symmetry, involuntary movements, or swelling, such as periorbital edema (swelling around the eyes). 3. Neck a. Inspect for symmetry of accessory neck muscles. b. Assess range of motion. c. Test cranial nerve XI (spinal accessory nerve) to assess muscle strength: Ask the client to push against resistance applied to the side of the chin (tests sternocleidomastoid muscle); also ask the client to shrug the shoulders against resistance (tests trapezius muscle). d. Palpate the trachea: It should be midline, without any deviations. e. Thyroid gland: Inspect the neck as the client takes a sip of water and swallows (thyroid tissue moves up with a swallow); palpate using an anterior-posterior approach (usually the normal adult thyroid cannot be palpated); if it is enlarged, auscultate for a bruit. 4. Lymph nodes a. Palpate using a gentle pressure and a circular motion of the finger pads. b. Begin with the preauricular lymph nodes (in front of the ear); move to the posterior auricular lymph nodes and then downward toward the supraclavicular lymph nodes. c. Palpate with both hands, comparing the 2 sides for symmetry. d. If nodes are palpated, note their size, shape, location, mobility, consistency, and tenderness. 5. Client teaching: Instruct the client to notify the health care provider (HCP) if persistent headache, dizziness, or neck pain occurs; if swelling or lumps are noted in the head and neck region; or if a neck or head injury occurs.

Nose, mouth, and throat

1. Subjective data a. Nose: Ask about discharge or nosebleed (epistaxis), facial or sinus pain, history of frequent colds, altered sense of smell, allergies, medications being taken, history of nose trauma or surgery. b. Mouth and throat: Ask about the presence of sores or lesions; bleeding from the gums or elsewhere; altered sense of taste; toothaches; use of dentures or other appliances; tooth and mouth care hygiene habits; at-risk behaviors (e.g., smoking, alcohol consumption); and history of infection, trauma, or surgery. 2. Objective data a. External nose should be midline and in proportion to other facial features. b. Patency of the nostrils can be tested by pushing each nasal cavity closed and asking the client to sniff inward through the other nostril. c. A nasal speculum and penlight or a short, wide-tipped speculum attached to an otoscope head is used to inspect for redness, swelling, discharge, bleeding, or foreign bodies; the nasal septum is assessed for deviation. d. The nurse presses the frontal sinuses (located below the eyebrows) and over the maxillary sinuses (located below the cheekbones); the client should feel firm pressure but no pain. e. The external and inner surfaces of the lips are assessed for color, moisture, cracking, or lesions. f. The teeth are inspected for condition and number (should be white, spaced evenly, straight, and clean, free of debris and decay). g. The alignment of the upper and lower jaw is assessed by having the client bite down. h. The gums are inspected for swelling, bleeding, discoloration, and retraction of gingival margins (gums normally appear pink). i. The tongue is inspected for color, surface characteristics, moisture, white patches, nodules, and ulcerations (dorsal surface is normally rough; ventral surface is smooth and glistening, with visible veins). j. The nurse retracts the cheek with a tongue depressor to check the buccal mucosa for color and the presence of nodules or lesions; normal mucosa is glistening, pink, soft, moist, and smooth. k. Using a penlight and tongue depressor, the nurse inspects the hard and soft palates for color, shape, texture, and defects; the hard palate (roof of the mouth), which is located anteriorly, should be white and dome-shaped, and the soft palate, which extends posteriorly, should be light pink and smooth. l. The uvula is inspected for midline location; the nurse asks the client to say "ahhh" and watches for the soft palate and uvula to rise in the midline (this tests 1 function of cranial nerve X, the vagus nerve). m. Using a penlight and tongue depressor, the nurse inspects the throat for color, presence of tonsils, and the presence of exudate or lesions; 1 technique to test cranial nerve XII (the hypoglossal nerve) is asking the client to stick out the tongue (should protrude in the midline). n. To test the gag reflex, touch the posterior pharynx with the end of a tongue blade; the client should gag momentarily (this tests the function of cranial nerve IX, the glossopharyngeal nerve). 3. Client teaching a. Emphasize the importance of hygiene and tooth care, as well as regular dental examinations and the use of fluoridated water or fluoride supplements. b. Encourage the client to avoid at-risk behaviors (e.g., smoking, alcohol consumption). c. Stress the importance of reporting pain or abnormal occurrence (e.g., nodules, lesions, signs of infection).

Ears Exam

1. Subjective data: Difficulty hearing, earaches, drainage from the ears, dizziness, ringing in the ears, exposure to environmental noise, use of a hearing aid, medications being taken, history of ear problems or infections 2. Objective data a. Inspect and palpate the external ear, noting size, shape, symmetry, skin color, and the presence of pain. b. Inspect the external auditory meatus for size, swelling, redness, discharge, and foreign bodies; some cerumen (earwax) may be present. 3. Auditory assessment a. Sound is transmitted by air conduction and bone conduction. b. Air conduction takes 2 or 3 times longer than bone conduction. c. Hearing loss is categorized as conductive, sensorineural, or mixed conductive and sensorineural. d. Conductive hearing loss is caused by any physical obstruction to the transmission of sound waves. e. Sensorineural hearing loss is caused by a defect in the cochlea, eighth cranial nerve, or the brain itself. f. A mixed hearing loss is a combination of a conductive and sensorineural hearing loss; it results from problems in both the inner ear and the outer ear or middle ear. 4. Voice (Whisper) test a. Used to determine whether hearing loss has occurred b. One ear is tested at a time (the ear not being tested is occluded by the client). c. The nurse stands 1 to 2 feet (30 to 60 centimeters) from the client, covers his or her mouth so that the client cannot read the lips, exhales fully, and softly whispers 2-syllable words in the direction of the unoccluded ear; the client points a finger up during the test when the nurse's voice is heard (a ticking watch may also be used to test hearing acuity). d. Failure to hear the sounds could indicate possible fluid collection and/or consolidation, requiring further assessment. 5. Watch test a. A ticking watch is used to test for high-frequency sounds. b. The examiner holds a ticking watch about 5 inches (12.5 centimeters) from each ear and asks the client if the ticking is heard. 6. Tuning fork tests a. Used to measure hearing on the basis of air conduction or bone conduction; includes the Weber and Rinne tests b. To activate the tuning fork, the nurse holds the base and lightly taps the tines against the other hand, setting the fork in vibration. 7. Weber test a. Determines whether the client has a conductive or sensorineural hearing loss b. Stem of the vibrating tuning fork is placed in the midline of the client's skull and the client is asked if the tone sounds the same in both ears or better in 1 ear. c. The client hears the tone by bone conduction and the sound should be heard equally in both ears. d. In conductive loss, the sound travels toward the impaired ear. e. In sensorineural loss, the sound travels toward the good ear. 8. Rinne test a. Stem of the vibrating tuning fork is placed on the client's mastoid process. b. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should still hear a sound. c. Normally the sound is heard twice as long by way of air conduction (AC) (near the ear canal) than by way of bone conduction (BC) (at the mastoid process); AC > BC. d. In sensorineural hearing loss, air conduction is heard longer than bone conduction, but it is not heard to be twice as long. e. In conductive hearing loss, the bone conduction sound is longer than or equal to the air conduction sound. 9. Vestibular assessment -see Quizlet underneath 10. Otoscopic exam a. The client's head is tilted slightly away and the otoscope is held upside down as if it were a large pen; this permits the examiner's hand to lay against the client's head for support. b. In an adult, pull the pinna up and back to straighten the external canal. c. Visualize the external canal while slowly inserting the speculum. d. The normal external canal is pink and intact, without lesions and with varying amounts of cerumen and fine little hairs. e. Assess the tympanic membrane for intactness; the normal tympanic membrane is intact, without perforations, and should be free from lesions. f. The tympanic membrane is transparent, opaque, pearly gray, and slightly concave. g. A fluid line or the presence of air bubbles is not normally visible. h. If the tympanic membrane is bulging or retracting, the edges of the light reflex will be fuzzy (diffuse) and may spread over the tympanic membrane. 12. Client teaching a. Instruct the client to notify the HCP if an alteration in hearing or ear pain or ringing in the ears occurs, or if redness, swelling, or drainage from the ear is noted. b. Instruct the client in the proper method of cleaning the ear canal. c. The client should cleanse the ear canal with the corner of a moistened washcloth and should never insert sharp objects or cotton-tipped applicators into the ear canal.

Eye Exam

1. Subjective data: Difficulty with vision (e.g., decreased acuity, double vision, blurring, blind spots); pain, redness, swelling, watery or other discharge from the eye; use of glasses or contact lenses; medications being taken; history of eye problems 2. Objective data a. Inspect the external eye structures, including eyebrows, for symmetry; eyelashes for even distribution; eyelids for ptosis (drooping); eyeballs for exophthalmos (protrusion) or enophthalmos (recession into the orbit; sunken eye). b. Inspect the conjunctiva (should be clear), sclera (should be white), and lacrimal apparatus (check for excessive tearing, redness, tenderness, or swelling); cornea and lens (should be smooth and clear); iris (should be flat, with a round regular shape and even coloration); eyelids; and pupils 3. Snellen eye chart a. The Snellen eye chart is a simple tool used to measure distance vision. b. Position the client in a well-lit spot 20 feet (6 meters) from the chart, with the chart at eye level, and ask the client to read the smallest line that he or she can discern. c. Instruct the client to leave on glasses or leave in contact lenses; if the glasses are for reading only, they are removed because they blur distance vision. d. Test 1 eye at a time. e. Record the result using the fraction at the end of the last line successfully read on the chart. f. Normal visual acuity is 20/20 (distance in feet at which the client is standing from the chart/distance in feet at which a normal eye could have read that particular line). 4. Near vision a. Use a hand-held vision screener (held about 14 inches [35.5 centimeters] from the eye) that contains various sizes of print or ask the client to read from a magazine. b. Test each eye separately with the client's glasses on or contact lenses in. c. Normal result is 14/14 (distance in inches at which the subject holds the card from the eye/distance in inches at which a normal eye could have read that particular line). 5. Confrontation test a. A crude but rapid test used to measure peripheral vision and compare the client's peripheral vision with the nurse's (assuming that the nurse's peripheral vision is normal) b. The client covers 1 eye and looks straight ahead; the nurse, positioned 2 feet away (60 centimeters), covers his or her eye opposite the client's covered eye. c. The nurse advances a finger or other small object from the periphery from several directions; the client should see the object at the same time the nurse does. 6. Corneal light reflex a. Used to assess for parallel alignment of the axes of the eyes b. Client is asked to gaze straight ahead as the nurse holds a light about 12 inches (30 centimeters) from the client. c. The nurse looks for reflection of the light on the corneas in exactly the same spot in each eye. 7. Cover test a. Used to check for slight degrees of deviated alignment b. Each eye is tested separately. c. The nurse asks the client to gaze straight ahead and cover 1 eye. d. The nurse examines the uncovered eye, expecting to note a steady, fixed gaze. 8. Extraocular muscle function (6 cardinal positions of gaze) a. The 6 muscles that attach the eyeball to its orbit and serve to direct the eye to points of interest are tested. b. Client holds head still and is asked to move his or her eyes and follow a small object. c. The examiner notes any parallel movements of the eye or nystagmus, an involuntary, rhythmic, rapid twitching of the eyeballs. 9. Color vision a. Tests for color vision involve picking numbers or letters out of a complex and colorful picture. b. The Ishihara chart is used for testing and consists of numbers composed of colored dots located within a circle of colored dots. c. The client is asked to read the numbers on the chart. d. Each eye is tested separately. e. Reading the numbers correctly indicates normal color vision. f. The test is sensitive for the diagnosis of red-green blindness but cannot detect discrimination of blue. 10. Pupils a. The pupils are round and of equal size. b. Increasing light causes pupillary constriction. c. Decreasing light causes pupillary dilation. d. Constriction of both pupils is a normal response to direct light. 11. Sclera and cornea a. Normal sclera color is white. b. A yellow color to the sclera may indicate jaundice or systemic problems. c. In a dark-skinned person, the sclera may normally appear yellow; pigmented dots may be present. d. The cornea is transparent, smooth, shiny, and bright. e. Cloudy areas or specks on the cornea may be the result of an accident or eye injury. 12. Ophthalmoscopy a. The ophthalmoscope is an instrument used to examine the external structures and the interior of the eye. b. The room is darkened so that the pupil will dilate. c. The instrument is held with the right hand when examining the right eye and with the left hand when examining the left eye. d. The client is asked to look straight ahead at an object on the wall. e. The examiner should approach the client's eye from about 12 to 15 inches (30.5 to 38 centimeters) away and 15 degrees lateral to the client's line of vision. f. As the instrument is directed at the pupil, a red glare (red reflex) is seen in the pupil. g. The red reflex is the reflection of light on the vascular retina. h. Absence of the red reflex may indicate opacity of the lens. i. The retina, optic disc, optic vessels, fundus, and macula can be examined. 14. Client teaching a. Instruct the client to notify the HCP if alterations in vision occur or any redness, swelling, or drainage from the eye is noted. b. Inform the client of the importance of regular eye examinations. The first slide on the Ishihara chart is one that everyone can discriminate; failure to identify numbers on this slide suggests a problem with performing the test, not a problem with color vision.

Breasts

1. Subjective data: Pain or tenderness, lumps or thickening, swollen axillary lymph nodes, nipple discharge, rash or swelling, medications being taken, personal or family history of breast disease, trauma or injury to the breasts, previous surgery on the breasts, breast self-examination (BSE) compliance, mammograms as prescribed 2. Objective data: Inspection and palpation 3. Inspection a. Performed with the client's arms raised above the head, the hands pressed against the hips, and the arms extended straight ahead while the client sits and leans forward b. Assess size and symmetry (1 breast is often larger than the other); masses, flattening, retraction, or dimpling; color and venous pattern; size, color, shape, and discharge in the nipple and areola; and the direction in which nipples point. 4. Palpation a. Client lies supine, with the arm on the side being examined behind the head and a small pillow under the shoulder. b. The nurse uses the pads of the first 3 fingers to compress the breast tissue gently against the chest wall, noting tissue consistency. c. Palpation is performed systematically, ensuring that the entire breast and tail are palpated. d. The nurse notes the consistency of the breast tissue, which normally feels dense, firm, and elastic. e. The nurse gently palpates the nipple and areola and compresses the nipple, noting any discharge. 5. Axillary lymph nodes a. The nurse faces the client and stands on the side being examined, supporting the client's arm in a slightly flexed position, and abducts the arm away from the chest wall. b. The nurse places the free hand against the client's chest wall and high in the axillary hollow, then, with the fingertips, gently presses down, rolling soft tissue over the surface of the ribs and muscles. c. Lymph nodes are normally not palpable. 6. Client teaching a. Encourage and teach the client to perform BSE (refer to Chapter 48 for information on performing BSE). b. Client should report lumps or masses to the HCP immediately. c. Regular physical examinations and mammograms should be obtained as prescribed.

Auscultatory sounds

A, Anterior thorax B, Posterior thorax

Landmarks for chest auscultation and percussion

A, Posterior view. B, Anterior view. C, Lateral views.

Health History

A. General state of health: Body features and physical characteristics, body movements, body posture, level of consciousness, nutritional status, speech B. Chief complaint and history of present illness (document direct client quotes) that leads the client to seek care C. Family history: The health status of direct blood relatives as well as the client's spouse D. Social history 1. Data about the client's lifestyle, with a focus on factors that may affect health 2. Information about alcohol, drug, and tobacco use; sexual practices; tattoos; body piercing; travel history; and work setting to identify occupational hazards E. Domestic violence screening 1. Done to determine whether the client is experiencing any form of domestic violence 2. Conducted during a 1-to-1 interview with the client while obtaining the health history

Voice Sounds

Bronchophony 1. Ask the client to repeat the words "ninety-nine." 2. Normal voice transmission is soft, muffled, and indistinct. Egophony 1. Ask the client to repeat a long "ee-ee-ee" sound. 2. Normally the nurse would hear the "ee-ee-ee" sound. Whispered Pectoriloquy 1. Ask the client to whisper the word "ninety-nine." 2. Normal voice transmission is faint, muffled, and almost inaudible. a. Performed when a pathological lung condition is suspected b. Auscultate over the chest wall; the client is asked to vocalize words or a phrase while the nurse listens to the chest. c. Normal voice transmission is soft and muffled; the nurse can hear the sound but is unable to distinguish exactly what is being said.

Common Postural Abnormalities

Lordosis (Swayback): Increased lumbar curvature Kyphosis (Hunchback): Exaggeration of the posterior curvature of the thoracic spine Scoliosis: Lateral spinal curvature

Vestibular Assessment

Test for Falling 1. The examiner asks the client to stand with the feet together, arms hanging loosely at the sides, and eyes closed. 2. The client normally remains erect, with only slight swaying. 3. A significant sway is a positive Romberg sign. Test for Past Pointing 1. The client sits in front of the examiner. 2. The client closes the eyes and extends the arms in front, pointing both index fingers at the examiner. 3. The examiner holds and touches his or her own extended index fingers under the client's extended index fingers to give the client a point of reference. 4. The client is instructed to raise both arms and then lower them, attempting to return to the examiner's extended index fingers. 5. The normal test response is that the client can easily return to the point of reference. 6. The client with a vestibular function problem lacks a normal sense of position and cannot return the extended fingers to the point of reference; instead, the fingers deviate to the right or left of the reference point. Gaze Nystagmus Evaluation 1. The client's eyes are examined as the client looks straight ahead, 30 degrees to each side, upward and downward. 2. Any spontaneous nystagmus—an involuntary, rhythmic, rapid twitching of the eyeballs—represents a problem with the vestibular system. Dix-Hallpike Maneuver 1. The client starts in a sitting position; the examiner lowers the client to the exam table and rather quickly turns the client's head to the 45-degree position. 2. If after about 30 seconds there is no nystagmus, the client is returned to a sitting position and the test is repeated on the other side.

Testing for meningeal irritation

a. A positive Brudzinski's sign or Kernig's sign indicates meningeal irritation. b. Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest) and there should be no reports of pain or resistance to the neck flexion; a positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. c. Kernig's sign is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended.

what are priority concepts for health & physical assessment of the adult client?

clinical judgment & health promotion

Abdomen

1. Subjective data: Changes in appetite or weight, difficulty swallowing, dietary intake, intolerance to certain foods, nausea or vomiting, pain, bowel habits, medications currently being taken, history of abdominal problems or abdominal surgery 2. Objective data a. Ask the client to empty the bladder. b. Be sure to warm the hands and the endpiece of the stethoscope. c. Examine painful areas last. 3. Inspection a. Contour: Look down at the abdomen and then across the abdomen from the rib margin to the pubic bone; describe as flat, rounded, concave, or protuberant. b. Symmetry: Note any bulging or masses. c. Umbilicus: Should be midline and inverted d. Skin surface: Should be smooth and even e. Pulsations from the aorta may be noted in the epigastric area, and peristaltic waves may be noted across the abdomen. 4. Auscultation a. Performed before percussion and palpation, which can increase peristalsis. b. Hold the stethoscope lightly against the skin and listen for bowel sounds in all 4 quadrants; begin in the right lower quadrant (bowel sounds are normally heard here). c. Note the character and frequency of normal bowel sounds: high-pitched gurgling sounds occurring irregularly from 5 to 30 times a minute. d. Identify as normal, hypoactive, or hyperactive (borborygmus). e. Absent sounds: Auscultate for 5 minutes before determining that sounds are absent. f. Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular sounds or bruits. 5. Percussion a. All 4 quadrants are percussed lightly. b. Borders of the liver and spleen are percussed. c. Tympany should predominate over the abdomen, with dullness over the liver and spleen. d. Percussion over the kidney at the 12th rib (costovertebral angle) should produce no pain. 6. Palpation a. Begin with light palpation of all 4 quadrants, using the fingers to depress the skin about 1 cm; next perform deep palpation, depressing 5 to 8 cm. b. Palpate the liver and spleen (spleen may not be palpable). c. Palpate the aortic pulsation in the upper abdomen slightly to the left of midline; normally it pulsates in a forward direction (pulsation expands laterally if an aneurysm is present). 8. Client teaching a. Encourage the client to consume a balanced diet; obesity needs to be prevented. b. Substances that can cause gastric irritation should be avoided. c. The regular use of laxatives is discouraged. d. Lifestyle behaviors that can cause gastric irritation (e.g., spicy foods) should be modified. e. Regular physical examinations are important. f. The client should report gastrointestinal problems to the HCP. When performing an abdominal assessment, the specific order for assessment techniques is inspection, auscultation, percussion, and palpation.

Heart and peripheral vascular system

1. Subjective data: Chest pain, dyspnea, cough, fatigue, edema, nocturia, leg pain or cramps (claudication), changes in skin color, obesity, medications being taken, cardiovascular risk factors, family history of cardiac or vascular problems, personal history of cardiac or vascular problems 2. Objective data: May include inspection, palpation, percussion, and auscultation 3. Inspection: Inspect the anterior chest for pulsations (apical impulse) created as the left ventricle rotates against the chest wall during systole; not always visible. 4. Palpation a. Palpate the apical impulse at the fourth or fifth interspace, or medial to the midclavicular line (not palpable in obese clients or clients with thick chest walls). b. Palpate the apex, left sternal border, and base for pulsations; normally none are present. 5. Percussion: May be performed to outline the heart's borders and to check for cardiac enlargement (denoted by resonance over the lung and dull notes over the heart). Peripheral vascular system a. Assess adequacy of blood flow to the extremities by palpating arterial pulses for equality and symmetry and checking the condition of the skin and nails. b. Check for pretibial edema and measure calf circumference c. Measure blood pressure. d. Palpate superficial inguinal nodes (using firm but gentle pressure), beginning in the inguinal area and moving down toward the inner thigh. e. An ultrasonic stethoscope may be needed to amplify the sounds of a pulse wave if the pulse cannot be palpated. f. Carotid artery: Located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle g. Palpate 1 carotid artery at a time to avoid compromising blood flow to the brain. h. Auscultate each carotid artery for the presence of a bruit (a blowing, swishing, or buzzing, humming sound), which indicates blood flow turbulence; normally a bruit is not present. i. Palpate the arteries in the extremities

Lungs

1. Subjective data: Cough; expectoration of sputum; shortness of breath or dyspnea; chest pain on breathing; smoking history; environmental exposure to pollution or chemicals; medications being taken; history of respiratory disease or infection; last tuberculosis test, chest radiograph, pneumonia, and any influenza immunizations. Record the smoking history in pack-years (the number of packs per day times the number of years smoked). For example, a client who has smoked one-half pack a day for 20 years has a 10-pack-year smoking history. 2. Objective data: Includes inspection, palpation, percussion, and auscultation 3. Inspection of the anterior and posterior chest: Note skin color and condition and the rate and quality of respirations, look for lumps or lesions, note the shape and configuration of the chest wall, and note the position the client takes to breathe. 4. Palpation: Palpate the entire chest wall, noting skin temperature and moisture and looking for areas of tenderness and lumps, lesions, or masses; assess chest excursion and tactile or vocal fremitus b. Determine the predominant note; resonance is noted in healthy lung tissue. c. Hyperresonance is noted when excessive air is present and a dull note indicates lung density.

Neurological system

1. Subjective data: Headaches, dizziness or vertigo, tremors, weakness, incoordination, numbness or tingling in any area of the body, difficulty speaking or swallowing, medications being taken, history of seizures, history of head injury or surgery, exposure to environmental or occupational hazards (e.g., chemicals, alcohol, drugs) 2. Objective data: Assessment of cranial nerves, level of consciousness, pupils, motor function, cerebellar function, coordination, sensory function, and reflexes 3. Note mental and emotional status, behavior and appearance, language ability, and intellectual functioning, including memory, knowledge, abstract thinking, association, and judgment. 4. Vital signs: Check temperature, pulse, respirations, and blood pressure; monitor for blood pressure or pulse changes, which may indicate increased intracranial pressure

Musculoskeletal system

1. Subjective data: Joint pain or stiffness; redness, swelling, or warm joints; limited motion of joints; muscle pain, cramps, or weakness; bone pain; limitations in activities of daily living; exercise patterns; exposure to occupational hazards (e.g., heavy lifting, prolonged standing or sitting); medications being taken; history of joint, muscle, or bone injuries; history of surgery of the joints, muscles, or bones 2. Objective data: Inspection and palpation 3. Inspection: Inspect gait and posture, and for cervical, thoracic, and lumbar curves 4. Palpation: Palpate all bones, joints, and surrounding muscles. 5. Range of motion a. Perform active and passive range-of-motion exercises of each major joint. b. Check for pain, limited mobility, spastic movement, joint instability, stiffness, and contractures. c. Normally joints are nontender, without swelling, and move freely. 6. Muscle tone and strength a. Assess during measurement of range of motion. b. Ask client to flex the muscle to be examined and then to resist while applying opposing force against the flexion. c. Assess for increased tone (hypertonicity) or little tone (hypotonicity). 9. Client teaching a. The client should consume a balanced diet, including foods containing calcium and vitamin D. b. Activities that cause muscle strain or stress to the joints should be avoided. c. Encourage the client to maintain a normal weight. d. Participation in a regular exercise program is beneficial. e. The client should contact the HCP if joint or muscle pain or problems occur or if limitations in range of motion or muscle strength develop.

Mental Status Exam

A. The mental status can be assessed while obtaining subjective data from the client during the health history interview. B. Appearance 1. Note appearance, including posture, body movements, dress, and hygiene and grooming. 2. An inappropriate appearance and poor hygiene may be indicative of depression, manic disorder, dementia, organic brain disease, or another disorder. C. Behavior 1. Level of consciousness: Assess alertness and awareness and the client's ability to interact appropriately with the environment. 2. Facial expression and body language: Check for appropriate eye contact and determine whether facial expression and body language are appropriate to the situation; this assessment also provides information regarding the client's mood and affect. 3. Speech: Assess speech pattern for articulation and appropriateness of conversation. D. Cognitive level of functioning -see below Quizlet

Arterial Pulse Points and Grading the Force of Pulses

Arteries in the Arms and Hands Radial Pulse: Located at the radial side of the forearm at the wrist Ulnar Pulse: Located on the opposite side of the location of the radial pulse at the wrist Brachial Pulse: Located above the elbow at the antecubital fossa, between the biceps and triceps muscles Arteries in the Legs Femoral Pulse: Located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine Popliteal Pulse: Located behind the knee Dorsalis Pedis Pulse: Located at the top of the foot, in line with the groove between the extensor tendons of the great and first toes Posterior Tibial Pulse: Located on the inside of the ankle, behind and below the medial malleolus (ankle bone) Grading the Force 4 + = Strong and bounding 3 + = Full pulse, increased 2 + = Normal, easily palpable 1 + = Weak, barely palpable

Palpation of the Chest

Chest Excursion Posterior: The nurse places the thumbs along the spinal processes at the 10th rib, with the palms in light contact with the posterolateral surfaces. The nurse's thumbs should be about 2 inches (5 centimeters) apart, pointing toward the spine, with the fingers pointing laterally. Anterior: The nurse places the hands on the anterolateral wall with the thumbs along the costal margins, pointing toward the xiphoid process. The nurse instructs the client to take a deep breath after exhaling. The nurse should note movement of the thumbs and chest excursion should be symmetrical, separating the thumbs approximately 2 inches (5 centimeters). Tactile or Vocal Fremitus The nurse places the ball or lower palm of the hand over the chest, starting at the lung apices and palpating from side to side. The nurse asks the client to repeat the words "ninety-nine." Symmetrical palpable vibration should be felt by the nurse.

Types of Health and Physical Assessments

Complete Assessment: Includes a complete health history and physical examination and forms a baseline database. Focused Assessment: Focuses on a limited or short-term problem, such as the client's complaint. Episodic/Follow-up Assessment: Focuses on evaluating a client's progress. Emergency Assessment: Involves the rapid collection of data, often during the provision of life-saving measures.

Assessment of the Cranial Nerves

Cranial Nerve I: Olfactory ▪ Sensory ▪ Controls the sense of smell ▪ Have the client close the eyes and occlude 1 nostril with a finger ▪ Ask the client to identify nonirritating and familiar odors (e.g., coffee, tea, cloves, soap, chewing gum, peppermint) ▪ Repeat the test on the other nostril Cranial Nerve II: Optic ▪ Sensory ▪ Controls vision ▪ Assess visual acuity with a Snellen chart and perform an ophthalmoscopic exam ▪ Check peripheral vision by confrontation ▪ Check color vision Cranial Nerve III: Oculomotor ▪ Motor ▪ Controls pupillary constriction, upper-eyelid elevation, and most eye movement ▪ The motor functions of cranial nerves III, IV, and VI overlap; therefore, they should be tested together ▪ Inspect the eyelids for ptosis (drooping); then assess ocular movements and note any eye deviation ▪ Test accommodation and direct and consensual light reflexes Cranial Nerve IV: Trochlear ▪ Motor ▪ Controls downward and inward eye movement Cranial Nerve VI: Abducens ▪ Motor ▪ Controls lateral eye movement Cranial Nerve V: Trigeminal ▪ Sensory and motor ▪ Controls sensation in the cornea, nasal and oral mucosa, and facial skin, as well as mastication ▪ To test motor function, ask the client to clench the teeth and assess the muscles of mastication; then try to open the client's jaws after asking the client to keep them tightly closed ▪ The corneal reflex may be tested by the health care provider; this is done by lightly touching the client's cornea with a cotton wisp (this test may be omitted if the client is alert and blinking normally) ▪ Check sensory function by asking the client to close the eyes; lightly touch forehead, cheeks, and chin, noting whether the touch is felt equally on the 2 sides Cranial Nerve VII: Facial ▪ Sensory and motor ▪ Controls movement of the face and taste sensation ▪ Test taste perception on the anterior two thirds of the tongue; the client should be able to taste salty and sweet tastes ▪ Have the client smile, frown, and show the teeth ▪ Ask the client to puff out the cheeks ▪ Attempt to close the client's eyes against resistance Cranial Nerve VIII: Acoustic or Vestibulocochlear ▪ Sensory ▪ Controls hearing and vestibular function ▪ Assessing the client's ability to hear tests the cochlear portion ▪ Assessing the client's sense of equilibrium tests the vestibular portion ▪ Check the client's hearing, using acuity tests ▪ Observe the client's balance and watch for swaying when he or she is walking or standing ▪ Assessment of sensorineural hearing loss may be done with the Weber or Rinne test Cranial Nerve IX: Glossopharyngeal ▪ Sensory and motor ▪ Controls swallowing ability, sensation in the pharyngeal soft palate and tonsillar mucosa, taste perception on the posterior third of the tongue, and salivation ▪ Usually cranial nerves IX and X are tested together ▪ Test taste perception on the posterior one third of the tongue or pharynx; the client should be able to taste bitter and sour tastes ▪ Inspect the soft palate and watch for symmetrical elevation when the client says "aaah" ▪ Touch the posterior pharyngeal wall with a tongue depressor to elicit the gag reflex Cranial Nerve X: Vagus ▪ Sensory and motor ▪ Controls swallowing and phonation, sensation in the exterior ear's posterior wall, and sensation behind the ear ▪ Controls sensation in the thoracic and abdominal viscera Cranial Nerve XI: Spinal Accessory ▪ Motor ▪ Controls strength of neck and shoulder muscles ▪ The nurse palpates and inspects the sternocleidomastoid muscle as the client pushes the chin against the nurse's hand ▪ The nurse palpates and inspects the trapezius muscle as the client shrugs the shoulders against the nurse's resistance Cranial Nerve XII: Hypoglossal ▪ Motor ▪ Controls tongue movements involved in swallowing and speech ▪ Observe the tongue for asymmetry, atrophy, deviation to 1 side, and fasciculations (uncontrollable twitching); ask the client to stick out the tongue (tongue should be midline) ▪ Ask the client to push the tongue against a tongue depressor, and then have the client move the tongue rapidly in and out and from side to side

Characteristics of Adventitious Sounds

Fine crackles -High-pitched crackling and popping noises (discontinuous sounds) heard during the end of inspiration. Not cleared by cough -May be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases Medium crackles -Medium-pitched, moist sound heard about halfway through inspiration. Not cleared by cough -Same as above, but condition is worse Coarse crackles -Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration -Same as above, but condition is worse or may be heard in terminally ill clients with diminished gag reflex. Also heard in pulmonary edema and pulmonary fibrosis Wheeze (also called sibilant wheeze) -High-pitched, musical sound similar to a squeak. Heard more commonly during expiration, but may also be heard during inspiration. Occurs in small airways -Heard in narrowed airway diseases such as asthma Rhonchi (also called sonorous wheeze) -Low-pitched, coarse, loud, low snoring or moaning tone. Actually sounds like snoring. Heard primarily during expiration, but may also be heard during inspiration. Coughing may clear -Heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis Pleural friction rub -A superficial, low-pitched, coarse rubbing or grating sound. Sounds like 2 surfaces rubbing together. Heard throughout inspiration and expiration. Loudest over the lower anterolateral surface. Not cleared by cough -Heard in individuals with pleurisy (inflammation of the pleural surfaces)

The Mental Status Examination: Cognitive Level of Functioning

Orientation: Assess client's orientation to person, place, and time. Attention Span: Assess client's ability to concentrate. Recent Memory: Assessed by asking the client to recall a recent occurrence (e.g., the means of transportation used to get to the health care agency for the physical assessment). Remote Memory: Assessed by asking the client about a verifiable past event (e.g., a vacation). New Learning: Used to assess the client's ability to recall unrelated words identified by the nurse; the nurse selects 4 words and asks the client to recall the words 5, 10, and 30 minutes later. Judgment: Determine whether the client's actions or decisions regarding discussions during the interview are realistic. Thought Processes and Perceptions: The way the client thinks and what the client says should be logical, coherent, and relevant; the client should be consistently aware of reality.

Assessing and Documenting Pupillary Responses

Pupillary Light Reflex 1. Darken the room (to dilate the client's pupils) and ask the client to look forward. 2. Test each eye. 3. Advance a light in from the side to note constriction of the same-side pupil (direct light reflex) and simultaneous constriction of the other pupil (consensual light reflex). Accommodation 1. Ask the client to focus on a distant object (dilates the pupil). 2. Ask the client to shift gaze to a near object held about 3 inches (7.5 centimeters) from the nose. 3. Normal response includes pupillary constriction and convergence of the axes of the eyes. Documenting Normal Findings: PERRLA P = pupils E = equal R = round RL = reactive to light A = reactive to accommodation

Deep tendon reflexes

a. Includes testing the following reflexes: biceps, triceps, brachioradialis, patella, Achilles b. Limb should be relaxed. c. The tendon is tapped quickly with a reflex hammer, which should cause contraction of muscle.

Cerebellar function

a. Monitor gait as the client walks in a straight line, heel to toe (tandem walking). b. Romberg test: Client is asked to stand with the feet together and the arms at the sides and to close the eyes and hold the position; normally the client can maintain posture and balance. c. If appropriate, ask the client to perform a shallow knee bend or to hop in place on 1 leg and then the other.

how do you perform a physical assessment?

inspection, palpation, percussion, and auscultation