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