30 Health Assessment and Physical Examination

Preparation for Examination: Assessment of age groups; seven variations when examining older adults

A comprehensive health assessment and examination of older adults includes physical data; family relationships; religious and occupation pursuits; and review of the patients cognitive affective and social level asses ability to perform basic ADL's: bathing and grooming and complex ADL's making a phone call remember older pts present subtle or atypical signs and symptoms • Do not stereotype about aging patients' level of cognition. • Recognize that some older adults have sensory or physical limitations that affect how quickly they can be interviewed and examinations can be conducted. It might be necessary to plan for more than one examination session. Sometimes it helps to give patients an initial health questionnaire before they come to a clinic or office. • Perform the examination with adequate space; this is especially important for patients with mobility aids such as a cane or walker. • During the examination use patience, allow for pauses, and observe for details. Recognize normal physiological and behavioral changes that are characteristic of later life. • Giving certain types of health information is stressful for older patients. Some view illness as a threat to independence and a step toward institutionalization. • Be aware of the location of the closest bathroom in case the patient has an urgent need to eliminate. • Be alert to signs of increasing fatigue such as sighing, grimacing, irritability, leaning against objects for support, and drooping head and shoulders.

Thorax and lung Abnormal or adventitious sounds ill sounds

Abnormal sounds result from air passing through moisture, mucus, or narrowed airways due to reinflating or inflammation in the pleural friction rub during auscultation note location, sounds, listen for the absence of breaths sounds normally found in pts with collapsed or surgically removed lungs crackles most common in dependent lobes: right and left lung base cause by random, sudden reinfaltion of groups of alveoli; disruptive passage of air though small airways Character fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing medium crackles are lower, moister sounds heard during middle of inspiration; coarse crackles loud and bubbly sounds heard during inspiration rhonchi (sonorous wheeze) heard over trachea and bronchi; if loud enough, able to be heard over most lung fields Muscular spasms, fluid, or mucus in larger airway; new growth or external pressure causing turbulence loud, low-pitched, rumbling, coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing wheeze (sibilant wheeze) heard over all lung fields high velocity airflow through severely narrowed or obstructed airway high pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration; usually louder on expiration pleural friction rub heard over anterior lateral lung field (if pt is sitting upright) inflamed pleura; parietal pleura rubbing against visceral pleura dry rubbing or grating quality is heard during inspiration or expiration; does not clear with coughing; heard louder over lower lateral anterior surface

Head and Neck: Assessing the nodes of the neck

occipital nodes at the base of the skull postauricular nodes over the mastoid preauricular nodes just in front of the ear retropharyngeal nodes at the angle of the mandible submandibular nodes submental nodes in the midline behind the mandibular rip

Neurologic System: Sensory pathways of CNS

pain have pt vocice when they feel dull or sharp temperature ask pt to identify hot or cold light touch vibration tuning fork position two point discrimination crude and finely localized touch

Supine

Area assessed Head and neck, Anterior thorax and lungs, breast, axillae, heart, abdomen, extremities, pulse Rationale this is normally a relaxed position. provides easy access to pulse sites Limitations if pt is Short of breath raise head of bed

lithotomy

Area assessed female genitalia and genital tract Rationale position provides maximal exposure of female genitalia and facilities insertion of vaginal speculum limitations Lithotomy position is embarrassing and uncomfortable; thus examiner minimizes time that patients spends in it. Keep pt well draped Some patients with arthritis or other joint deformities are unable to assume this position.

Dorsal recumbent

Area assessed head and neck , anterior thorax and lungs, breasts, axillae, heart abdomen Rationale Positions is for abdominal assessment because it promotes relaxation of abdominal muscles Limitations Pts with painful disorders are more comfortable with knees flexed

sims'

Area assessed Rectum and vagina Rationale flexion of hip and knee improves exposure of rectal area Limitation joint deformities hinder patients ability to bend hip and knee

Prone

Area assessed musculoskeletal system Rationale position is only for assessing extension of hip joint, skin and buttocks Limitations Patients with rest difficulties do not tolerate this position well

lateral recumbent

Areas Assessed heart Rationale Position aids in detecting murmurs limitations patients with rest difficulties do not tolerate this position well

Nursing assessment for lung

Ask history of tobacco or marijuana Ask whether pt has persistent cough, sputum w/blood, voice change, chest pain, SOB, orthopnea, dyspnea during exertion or at rest, poor activity tolerance, or recurrent aacks of pneumonia or bronchitis. Determine work environment with pollutants or exposure to radiation review hx ask

Nursing Hx of hair and scalp assessment

Ask pt if they wear a wig if so have pt remove it Determine if pt has noted change in their hair growth loss of hair or change in texture or color identify hair products determine if pt has been on chemo or taken vasodilator for air growthn and changes in diet or appetite

Nursing Hx of Wt assessment

Ask pt of total weight lost or gained and if it was planned. Always compare current weight with weight history. Note: gradual, sudden, desired or undesired. If weight loss desired, ask about eating habits, diet plan followed, food preparation, calorie intake, appetite, exercise pattern, support group participation, weight goal. If weight loss undesired, ask about anorexia; vomiting; diarrhea; thirst; frequent urination; and change in lifestyle, activity, and stress levels. Assess whether patient has noted changes in social aspects of eating: more meals in restaurants, rushing to eat meals, stress at work, or skipping meals. Assess whether patient takes chemotherapy, diuretics, insulin, fluoxetine, prescription and nonprescription appetite suppressants, laxatives, oral hypoglycemics, or herbal supplements (weight loss); steroids, oral contraceptives, antidepressants, insulin (weight gain). Assess for preoccupation with body weight or body shape such as fasting, never feeling thin enough, unusually strict caloric intake or restrictions, laxative abuse, induced vomiting, amenorrhea, excessive exercise, alcohol intake.

Vascular system: Steps the nurse would use to asses venous pressure

place the pt in a semi-fowler position expose the neck and upper thorax lean the pt back into a spin position; the level of venous pulsations begins to rise as the patient reaches a 45 degree angle use two rulers to measure repeat the same measurement on the other side

Organization of the Examination

Assess each body system during a physical examination Patients with focused symptoms or needs require only parts of an examination; thus, when a patient comes to a clinic with symptoms of a severe chest cold, a neurological assessment is not usually required. when admitted to Hospital a complete examination at the time of admission and once each day to maintain and monitor pt's baseline for adults examination begins with assessing the head and neck and progress down the body keep assessment organized • Compare both sides of the body for symmetry. A degree of asymmetry is occasionally normal (e.g., the biceps muscles in the dominant arm are sometimes more developed than the same muscles in the nondominant arm). • If the patient is seriously ill, first assess the systems of the body most at risk for being abnormal. For example, complete a cardiovascular assessment first when caring for a patient with chest pain. • If the patient becomes fatigued, offer rest periods between assessments. • Perform painful procedures near the end of an examination. • Record assessments in specific terms in the electronic or paper record. A standard form allows for recording information in the same sequence that it is gathered. • Use common and accepted medical terms and abbreviations to keep notes accurate, brief, and concise. • Record quick notes during the examination to avoid delays. Complete any larger documentation notes at the end of the examination.

Lymphatic System

Assess the lymphatic drainage of the lower extremities during examination of the vascular system or during the female or male genital examination. superficial and deep nodes drain legs supine to palpate(firm and gentle) superficial inguinal nodes in groin area enlarged hardened, tender nodes reveal potential sites of infection or metastatic disease upper extremities lymph carried collection ducts from the upper extremeities Gently palpate the epitrochlear nodes, located on the medial aspect of the arms near the antecubital fossa

Neurologic System:Language two types of aphasia

Assess the patient's voice inflection, tone, and manner of speech. Normally a patient's voice has inflections, is clear and strong, and increases in volume appropriately. Speech is fluent. Injury to the cerebral cortex results in aphasia. Receptive (sensory)a person can not understand written or verbal speech Expressive (motor) a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate Some simple assessment techniques include the following: • Point to a familiar object and ask the patient to name it. • Ask the patient to respond to simple verbal and wrien commands such as "Stand up" or "Sit down." • Ask the patient to read simple sentences out loud. Intellectual function includes memory (recent, immediate, and past), knowledge, abstract thinking, association, and judgment.

Head and Neck: Inspect external eye

position and alignment eyebrows eyelids lacrimal apparatus conjunctivae sclera corneas pupils and irises

Female Genitalia and Reproductive tract

Chancres are syphilitic lesions, which appear as small, open ulcers that drain serous material Papanicolaou specimen is used to test for cervical and vaginal cancer

Thorax and lungs:

Chest excursion is normally symmetrical, separating thumbs 3 to 5 cm; Reduced chest excursion may be caused by pain, postural deformity or fatigue blocks the vibrations from reaching the chest wall: accumulation of mucus the collapse of lung tissue the presence of one or more lung lesions Palpate: firm light touch

skin

Color Pigmentation Is skin color Normal skin pigmentation ranges in tone from ivory or light pink to ruddy pink in light skin and from light to deep brown or olive in dark skin. older adults, pigmentation increases unevenly, causing discolored skin. be aware that cosmetics or tanning agents sometimes mask normal skin color. The assessment of color first involves areas of the skin not exposed to the sun such as the palms of the hands. Moisture The hydration of skin and mucous membranes helps to reveal body fluid imbalances, changes in the environment of the skin, and regulation of body temperature. Increased perspiration (sweating) can be associated with activity, exposure to warm environments, obesity, anxiety, or excitement. Observe for dullness, dryness, crusting, and flaking that resembles dandruff when the skin surface is lightly rubbed. Other factors causing dry skin include lack of humidity, exposure to sun, smoking, stress, excessive perspiration, and dehydration. Excessive dryness worsens existing skin conditions such as eczema and dermatitis. Temperature depends on the amount of blood circulating through the dermis. Increased or decreased skin temperature indicates an increase or decrease in blood flow. An increase in skin temperature often accompanies localized erythema or redness of the skin. A reduction in skin temperature often accompanies pallor and reflects a decrease in blood flow. assess temperature by palpating the skin with the dorsum or back of the hand Always assess skin temperature for patients at risk of having impaired circulation such as after a cast application or vascular surgery. Texture the appearance of the surface of the skin and how the deeper layers feel. By palpating lightly with the fingertips, you determine whether the patient's skin is smooth or rough, thin or thick, tight or supple, and indurated (hardened) or soft. Older adults will have changes in skin they have decrease in collagen, subcutaneous fat and sweat glands. Skin becomes wrinkled and leathery ask the patient about recent injury to the skin when there is irregularities Deeper palpation sometimes reveals irregularities such as tenderness or localized areas of induration, caused by an injury or repeated injections.

Vascular system: signs of venous and arterial insufficiency

Color Normal or cyanotic (venous) Pale; worsened by elevation of extremity; dusky red when extremity is lowered (arterial) Temp Normal (venous) cool blood flow blocked to extremity (arterial) Pulse normal (venous) decreased or absent (arterial) Edema often marked (venous) absent or mild (arterial) Skin changes brown pigmentation around ankles (venous) thin, shiny skin; decreased hair growth; thickened nails (arterial)

Skin Malignancies

Common Neoplasms Basal cell carcinoma - most common in sun-exposed areas. Rolled, scaly border. Slow-growing. • 0.5- to 1-cm crusted lesion that is flat or raised and has a rolled, somewhat scaly border • Frequent appearance of underlying, widely dilated blood vessels within the lesion Squamous cell carcinoma - more serious than basal cell. Develops more often on mucosal surfaces. Scaly, ulcerated, or crusty. More aggressive than Basal Cell. • Occurs more often on mucosal surfaces and nonexposed areas of skin than basal cell • 0.5- to 1.5-cm scaly lesion sometimes ulcerated or crusted; appears frequently and grows more rapidly than basal cell Melanoma - deadly. Appears on sun-exposed or non exposed skin. Variegated pigmentation, irregular borders, indistinct margins. Mets easily. • 0.5- to 1-cm brown, flat lesion; appears on sun-exposed or nonexposed skin; variegated pigmentation, irregular borders, and indistinct margins • Ulceration, recent growth, or recent changes in long-standing mole are ominous signs report abnormal lesions to the health care provider

Preparation for Examination: to address cultural diversity

Consider the patients health beliefs, use of alternative therapies, nutrition habits, relationships with family and comfort with physical closeness of exam learn to recognize common characteristics and disorders among ethnic populations Recognize variations in physical characteristics among ethnic populations skin and musculoskeletal Recognize your own knowledge deficits Consider how the illness may impact the patient, adaptations that may be needed for the physical assessment, mode of communication, health beliefs and practices, familial relationships and nutritional practices

Condition, Causes and assessment location

Cyanosis increased amount of deoxygenated hemoglobin / heart or lung disease cold environment assess nail beds, lips, mouth, skin Pallor reduced amount of oxyhemoglobin( anemia) assess face, conjunctivae, nail beds, palms of hands; reduced visibility of oxyhemoglobin resulting from decreased blood flow(shock) assess skin, nail beds , conjunctivae, lips Loss of pigmentation vitiligo; congenital or autoimmune condition causing lack of pigment Jaundice increased deposit of bilirubin in tissues ; liver disease, destruction of red blood cells; assess sclera, mucosa membrane, skin Erythema increase visibility of oxyhemoglobin caused by dilation or increased blood flow; Fever, direct trauma, blushing, alcohol intake ; face, area of trauma, sacrum, shoulders, other common sites for pressure injuries Tan-brown increased amount of melanin; suntan, pregnancy; asses areas exposed to sun: face, arms, areolas, nipples

Skin, Hair, and Nails: Indicative of substance abuse

Diaphoresis -Sedative hypnotic (including alcohol) Spider angiomas- Alcohol, stimulants Burns (especially fingers)- Alcohol Needle marks Opioids Contusion, abrasions, cuts, scars- Alcohol, other sedative hypnotics, intravenous (IV) opioids "Homemade" tattoos Cocaine, IV opioids (prevents detection of injection sites) Vasculitis Cocaine Red, dry skin Phencyclidine (PCP)

Head and Neck: Terms related to the nose

Excoriation- is skinbreakdown charactrized by redness and skin sloughing polyps are tumor-like growths

Head and Neck: Three parts of the ear canal and hearing loss, normal tympanic membrane appears, ototoxicity is caused by

External ear (auricle, outer ear canal, and tympanic membrane) middle ear (three bony ossicles) inner ear (cochlea, vestibule, and semicircular) the normal tympanic membrane appears translucent, shiny and pearly gray three types of hearing loss conduction sensorineural mixed Ototoxicity injury to the auditory nerve resulting from high maintenance does of abx

Head and Neck: Terms related to the oral cavity

Leukoplakia are thick white patches that are often precancerous lesions seen in heavy smokers and people with alcoholism Varicosities are swollen, tortuous veins that are common in older adults Exostosis is extra bony growth between the two plates

Musculoskeletal system : ROM

Flexion Movement decreasing angle between two adjoining bones; Bending of limb, Elbows, fingers, knees Extension Movement increasing angle between two adjoining bones Hyperextension movement of body part beyond its normal resting extend position Head Pronation movement of body part so that front or ventral surface faces downward hand and forearm Supination Movement of body part so that front or ventral surface faces upward Hand and forearm Abduction movement of extremity away from the midline of body leg, arm, fingers Adduction movement of extremity toward midline of body legs, arms, fingers Internal Rotation of joint inward knee hip External Rotation of joints out ward knee hip Eversion turning of body part away from midline foot Inversion turning of body part toward midline foot Dorsiflexion flexion of toes and foot upward foot Plantar Flexion bending of toes and foot downward foot

Head and Neck

Head Inspection (noting the position, size, shape and contour) tilt of the head to one side might indicate unilateral hearing or visual loss or muscle weakness in the neck. Tremor can be horizational jerking or bobbing note facial features Palpation skull- for nodules or masses TMJ screens for intracranial injury and local or congenital deformities Eyes examination include: detects visual alterations and determines the general level of assistance that patients require when ambulating or performing self care activities Nursing hx for eye assess Hx of eye disease, eye trauma, diabetes, HTN or eye surgery family hx of eye disorders ask if pt wears glasses of contacts last visit eye doctor meds pt is taking including eyedrops or ointment Visual Acuity- the ability to see small details assess near vision distance testing you would use the snellen chart note the smallest line that the pt can read Extraocular Movements Nystagmus Visual Fields External Eye Structures Position and Alignment Eyebrows Eyelids Lacrimal Apparatus Conjunctivae and Sclerae Corneas Pupils and Irises PERRLA Internal Eye Structures Retina choroid optic nerve disc macula fovea centralis Retinal vessels Ears Auricles Ear Canals and Eardrums Hearing Acuity Nose and Sinuses Excoriation polyps Mouth and Pharynx Lips Buccal Mucosa, Gums, and Teeth Tongue and Floor of Mouth Palate Pharynx Neck Neck Muscles anterior/posterior triangle Lymph Nodes inspections and palpation Thyroid Gland Carotid Artery and Jugular Vein Trachea

Preparation for Examination should include

Head to toe physical assessment is required daily. always perform a head to toe assessment every time a pt's condition changes (improves or worsens) Safety for pts who are confused should be priority never leave a pt who is confused or combative alone during an examination Cultural aspects infection control use standard precautions Open lesions (wear gloves) Wound infections Communicable disease If there is drainage use additional PPE like isolation gown and eyewear Ask pt's if they are allergic to latex 3 types of Natural Rubber Latex Allergies Type 1 response immunological reaction IMgE leads to anaphylactic Type IV delayed response hypersensitivity: Tcell mediated and appears 48 to 96 hrs after exposure Irritant contact dermatitis environment requires privacy; adequate light; eliminate extra noise and take precautions to prevent interruptions. helping pt's on and off to prevent injuries elevated the head of the table about 30 degrees Equipment hand hygiene before touching equipment; arrange any necessary equipment so it is readily available. Ex. warm the diaphragm of the stethoscope; ophthalmoscope(eye viewing equipment) and otoscope (ear equipment) have good batteries. Physical Preparation of the patient with proper dress and draping; Provide the patient privacy and plenty of time to undress to lessen the patient's anxiety; Routinely ask whether he or she is comfortable. Positioning Patients' abilities to assume positions depend on their physical strength, mobility, ease of breathing, age, and degree of wellness. only exposed area that needs to be examine To decrease the number of position changes, organize the examination so that all techniques requiring a sitting position are completed first, followed by those that require a supine position next, and so forth. Use extra care when positioning older adults with disabilities and limitations Psychological preparation of the patient explain the purpose and steps of the exam will let the pt know what to expect

Head and Neck: Common eye and visual abnormalities

Hyperopia is a refractive error causing farsightedness Myopia is a refractive error causing nearsightedness Presbyopia is impaired near vision in middle age and older adults caused by loss of elasticity of the lens Retinopathy is noninflammatory eye disorder resulting from changes in retinal blood vessels Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously Cataract is an increased opacity of the lens that blocks light rays from entering the eye Glaucoma is intraocular structural damage result from increased intraocular pressure Macular Degeneration is blurred central vision , often occurring suddenly, caused by progressive degeneration of the center of the retina

Musculoskeletal system: Muscle tone and strength

Hypertonicity increased muscle tone Hypotonicity feels flabby Atrophied reduced in size Use a grading scale of 0 to 5 to compare symmetrical muscle pairs for strength Muscle function level 0 no evidence if contractility 1/10%/ T (trace) slight contractility, no movement 2/25%/P (poor)Full ROM, gravity eliminated 3/50%/F (fair) Full ROM with gravity 4/75%/ G (good) Full ROM against gravity, some resistnce 5/100%/N (normal) Full ROM against gravity, full resistance

Neurologic System: 12 cranial nerves

I. Olfactory- sensory sense of smell II. Optic- sensory visual acuity use snellen chart or have pt read a printed material III. Oculomotor- Motor extraocular eye movements, pupil constriction and dilation; opening the eye IV. Trochlear-motor downward, inward eye movements V. Trigeminal- sensory and motor sensory nerve to skin of face, motor nerve to muscles of jaw VI. abducens-motor lateral movement of eyeballs VII. Facial- sensory and motor facial expression, taste smile frowns, eyebrows look for asymmetry VIII. Auditory-sensory hearing assess ability to hear spoke words IX. Glossopharyngeal- sensory and motor taste, ability to swallow pt will identify sweet or sour on back of tongue, use tongue blade to elicit gag reflects X. Vagus- sensory and motor sensation of pharynx, movement of vocal cords, parasympathetic innervation to gland and organs XI. spinal accessory- motor movement of head and shoulders ask pt to shrug shoulders and turn head against passive resistance XII. hypoglossal - motor position of tongue ask to stick out tongue and move side to side On old Olympus' towering tops, a Finn and German viewed some hops.

Heart

Inspection and Palpation Auscultation as a nurse you compare assesment of patients heart with findings from the vascular assessment heart problems are signs of life threatening condition requiring immediate attention only asses the problem and when pt is in stable conditions you conduct a more through assessment. asses cardiac system through the anterior thorax heart location for adults is the center of the chest precordium the base of the heart is upper part and the apex is the bottom tip two phase of cardiac cycle: () Systole (ventricles contract/ eject before from the left vent to the aorta and from right vent to pulmonary artery) Diastole (vent relaxes/ atria contract to move blood to the vent to fill coronary arteries) Inspection and Palpation provide relaxed/ comfortable enviroment explain procedure to reduce anxiety If pt is not calmed or relaxed it can cause a mild tachycardia(rapid heart rate) can lead to inaccurate findings supine with upper body elevated 45 degrees pts with heart disease while laying flat experience SOB look for visible pulsation exaggerated lift and palpate the apical impulse and thrills start from the base (top) to apex (bottom) Auscultation normal sounds extra heart sounds murmurs eliminate noise and explain procedure systemic pattern listen for the complete cycle "Lub-dub" bell of the stethoscope Postions during exam Sitting up and leaning foward (all areas and high pitched murmurs) supine (good for all areas) left lateral recumbent(best position for Lowe pitched sounds in diastole)

skin lesions

Macule: flat nonpalpable change in skin color; smaller than 1 cm ( freckle, petechiae) Papule: palpable , circumscribed, solid elevation in skin; smaller than 1 cm (elevated nevus (moles)) Nodule: elevated solid mass, deeper and firmer than papule; 1-2 cm (wart) Tumor: solid mass, that extends deep through subcutaneous tissue; larger than 1-2 cm (epithelioma) Wheal: irregularly shaped, elevated area or superficial localized edema; varies in size (hive, mosquito bite) Vesicle: circumscribed elevation of skin filled with serous fluid, smaller than 1 cm (herpes simplex, chickenpox) Pustule: circumscribed elevation of skin similar to vesicle but filled with pus; varies in size (acne, staph infection) Ulcer: deep loss of skin surface that extends to dermis and frequently bleeds and scars; varies in size (venous stasis ulcer) Atrophy: thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent (arterial insufficiency)

Vascular System

Measure Blood Pressure and integrity of the peripheral vascular system inspection, palpation and auscultation assess the skin for S&S of arterial and venous insufficiency BP: Readings tend to be higher in the right arm 10 mmHg 15 mmHg indicate atherosclerosis or disease of the aorta always record the highest reading Carotid Arteries Reflect heart function better than peripheral arteries commonly auscultated supply oxygenated blood to the head and neck exam carotid: have pt sit or lie supine head of bed 30 one at a time if the arteries are occluded during palpitation pt loses consciousness due to inadequate circulation to the brain Do not palpate or massage the carotid arteries vigorously This sinus sends impulses along the vagus nerve. Stimulating it causes a reflex drop in heart rate and blood pressure, causes syncope (faint) or circulatory arrest. problem for older adult only site to assess the quality of a pulse wave absent pulse is arterial occlusion (blockage) or stenosis (narrowing) ask pt to look straight or turn head normal is localized and strong equal in pulse rate, rhythm, strength and equally elastic abnormal is diminished or unequal pulsations (atherosclerosis or arterial disease) most commonly asculatated pulse it is important in middle age or older adults or pts with suspected CVD narrowed blood vessels disturb blood flow creating turbulence (blowing bruits or swishing sound ) Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle pt is to hold their breath Jugular Veins Internal (deeper along the carotid ) and external(superficia above clavicall) veins in the neck (drain bilaterally head to neck to superior vena cava) Most accessible right internal jugular view follows more direct path to right atrium note distention assess pressure venous pressure (influence by blood volume)right sided reflects heart failure pts with heart disease the veins remain distended when sitting Peripheral Arteries and Veins first assess the adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails. than assess the integrity of venous system assess the arterial pulse in the extremities (arms and legs) to determine sufficiency of the entire arterial circulation Factors: coagulation ( thrombosis, embolus) local trauma or surgery(contusion, fracture, vascular surgery) cast or bandages (casts, dressing, elastic bandages, restraint) systemic disease impaired circulation to extriemited (arteriosclerosis, atherosclerosis, diabetes) Peripheral Arteries examine with distal pads of your second and third fingers count 30 secs normal pulse or 1 min (60 secs) normal or irregular pulse 0: Absent, not palpable 1: Pulse diminished, barely palpable 2: Expected (normal) 3: Full, increased 4: Bounding, aneurysmal abnormal artery is hard, inelastic, or calcified Palpate the ulnar pulse when evaluating arterial insufficiency to the hand. palpate the brachial pulse, find the groove between the biceps and triceps muscle above the elbow at the antecubital fossa Ultrasound Stethoscopes when difficult to palpate use Doppler amplifies the sound of a pulse wave apply gel here for a whooshing sound to indicate arterial blood flow weaken pulse: obesity reduction in the stroke volume of the heart diminished blood volume arterial obstruction Tissue Perfusion skin, lip, mucosa and nail bed determines the status of circulatory blood flow places to look face and extremities (arms and legs) inspect Bluish color of lips or nail beds or decrease in pallor sometimes indicate cyanosis. assess oxygenation saturation clubbing- bulging of the tissues abnormal curvature of the nail indicated chronic problem emphysema and congenital heart disease inspect lower extremities changes in color, temp, and skin. indicate arterial or venous alterations ask pt if they have leg pain if so pt will have pain distal to occlusion characterics of occlusion Five P's Pain Pallor Pulselessness Paresthesias Paralysis lower extremities inspect skin and nail hair distribution legs, feet, toes venous pattern scars pigmentation ulcers no hair my indicate circulatory insufficiency chronic ulcers are serious signs of circulatory insufficiency and need PCP interventions palpate the legs for color, temp and edema capillary refill is used to determine adequacy of peripheral blood flow to the digits Peripheral Veins

Skin, Hair, and Nails: Assessment of Skin Reveals Health status

Oxygenation Circulation Nutrition Local tissue damage Hydration If there is an alteration in integumentary status, then adequate nutrition and hydration may become priority goals of therapy risk for skin impairment in a hospital setting. pressure against the skin when the patient is immobile, reactions to various medications used in treatment, and moisture if the patient is incontinent or has wound drainage. high risk are those who have neurological impairments, chronic illnesses, decreased mental status, poor tissue oxygenation, low cardiac output, or inadequate nutrition or those who have had orthopedic or vascular injurie Adequate lighting is required when assessing the skin. Daylight is the best choice for identifying variations in skin color fluorescent lighting is the next best choice. Room temp is important Warm causes superficial vasodilation resulting in increased redness of the skin. cool environment causes a sensitive patient to develop cyanosis around the lips and nail beds ask nursing history for skin assessment question before inspecting Inspect all skin surfaces, making a point to do so when examining other body systems. Often overlooked, inspection of the feet is absolutely essential for patients with poor circulation or diabetes. When abnormalities are found you palpate the affected area Use disposable gloves for palpation if open, moist, or draining lesions are present. remain alert for skin odors. Ask patient about history of changes in skin: Consider whether patient has the following history: Determine whether patient works or spends excessive time outside. Determine whether patient has noted lesions, rashes, or bruises. Question patient about frequency of bathing

Three types of lice

Pediculosis capitis (head) Pediculosis corposis (body) Pediculosis pubis (pubic or crabs)

General Survey: signs of abuse

Physical injury or neglect are signs of possible abuse (evidence of malnutrition or presence of bruising) watch for fear of the spouse or partner, caregiver or parent Behaviors That Are Suspicious for Substance Abuse Red flags: • The risk of suicide, seizures, and violent behavior is high among substance abusers. • Intoxicated patients, particularly those with phencyclidine (PCP) or methamphetamine intoxication, are at significant risk for becoming agitated and violent, placing themselves and others at risk for injury. Observe for combinations or repetition of these behaviors: • Frequently misses appointments • Frequently requests written excuses for absence from school or work • Drops out of school • Chief complaints of insomnia, "bad nerves," or pain that do not fit a particular pattern • Reports lost prescriptions (e.g., tranquilizers or pain medications) or asks for frequent refills • Frequent emergency department visits • History of changing health care providers or brings in medication bottles prescribed by several different providers • History of gastrointestinal bleeds, peptic ulcers, pancreatitis, cellulitis, or frequent pulmonary infections • Frequent sexually transmitted infections (STIs), complicated pregnancies, multiple abortions, or sexual dysfunction • Complaints of chest pains or palpitations or has a history of admissions to rule out heart attacks • History of activities that place the patient at risk for human immunodeficiency virus (HIV) infection (multiple partners, multiple rapes) • Family history of addiction; history of childhood sexual, physical, or emotional abuse; or social and financial or marital problems • Intimate partner violence older adults, risk factors for development of alcohol-related problems include chronic medical disorders, sleep disorders, social isolation, loneliness, bereavement, and acute or chronic pain. When assessing adolescents use Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) and Screening to Brief Intervention (S2BI)

Heart: terms related to assessment of the heart

Point of maximal impulse(apical impulse): the point of maximal impulse is where the apex of the heart is touching the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line S1: mitral and tricuspid valve closure causes the first hear sound the lub S1 is high pitched, dull in quality, and heard best at the apex. S2: aortic and pulmonic valve closure causes the second heart sound dub S3: when the Heart attempt to fill an already distended ventricle, a third heart sound can be heard; abnormal in adults 31 years +; low-pitched S4: when the atria contract to enhance ventricular filling , a fourth sound is heard; normal in healthy older adults and athletes; not normal in adults Failure of the heart to beat at regular successive intervals is a dysrhythmia. Some dysrhythmias are life threatening. irregular heart beat compare apical (auscultate) and radial (palpate) there can be one examiner or two when there is a deficit radial pulse will be slower than the apical report to PCP asap

After the examination

Record findings from the physical assessment either during the examination or after it has been completed Integrate physical assessment findings into the plan of care. give the patient time to dress. If the findings have revealed serious abnormalities such as a mass or highly irregular heart rate, consult the patient's health care provider before revealing them Delegate the cleanup of the examination area to support staff if needed. infection control practice to remove materials or instruments soiled with potentially infectious wastes bed linen is dry and clean perform hand hygiene Communicate significant findings to appropriate personnel, either verbally or in the patient's wrien care plan.

knee chest

Rectum Rationale Position provides maximal exposure of rectal areas limitations Embarrassing and uncomfortable Some patients with arthritis or other joint deformities are unable to assume this position.

nail bed

The nail reflects a person general health, state of nutrition, occupation, and habits of self care the vascularity of the nail bed creates the color of the nail Lunula whitish semilunar area gather information: ask about recent trauma or changes in nails(splitting, breaking, discoloration, thickening) changes shape and growth Has pt had other symptoms of pain swelling, presence of systemic disease with fever or psychological or physical stress question pt's nail care determine whether pt has risks of nail or foot problems (diabetes, peripheral vascular disease, older adulthood, obesity) Inspection and Palpation color, length, symmetry, cleanliness and configuration gives clues of Pathophysiology problems gather sense of patient hygiene practice nails are transparent, smooth, well rounded and convex¬ Normal - 160 degree angle between nail plate and nail Clubbing - change in angle between nail and nail base, eventually larger than 180 degrees. (Chronic lack of oxygen; heart of pulmonry disease) Beau's lines - transverse depressions in nails (systemic illness or nail trauma) Koilonychia - "spoon nail" Splinter hemorrhages - red or brown linear streaks in nail bed (trauma, sub-acute bacterail endocarditis, trichinosis Paronychia - inflammation of skin at base of nail (local infection, trauma

Neurologic System: Mini-mental state examination

The neurological system is responsible for many functions, including initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought processes, control of speech, and storage of memory. • Reading material • Vials containing aromatic substances (e.g., vanilla extract and coffee) • Opposite tip of coon swab or tongue blade broken in half • Snellen eye chart • Penlight • Vials containing sugar, salt, lemon with applicators • Tongue blade • Two test tubes, one filled with hot water and the other with cold water • Coon balls or coon-tipped applicators • Tuning fork • Reflex hammer The Mini-Mental State Examination (MMSE) measure orientation and cognitive function • Orientation to time"What is the date?" • Registration "Listen carefully. I am going to say three words. Say them back after I stop. Ready? Here they are . . .HOUSE (pause), CAR (pause), LAKE (pause). Now repeat these words back to me."(Repeat up to 5 times but score only the first trial.) • Naming"What is this?" (Point to a pencil or pen.) • Reading "Please read this and do what it says." (Show examinee the words on the stimulus form.) Close Your Eyes

Hair

Two types of hair cover the body: soft, fine, vellus hair, which covers the body; and coarse, long, thick terminal hair, which is easily visible on the scalp, axillae, and pubic areas and in the facial beard on men. inspect the condition and distribution under good light source Color Distribution Thickness Texture Lubrication hair should be shiny, smooth and pliant inspection explain it is necessary to separate parts of the hair to detect abnormalities wear gloves

Thorax and Lungs: Normal breath sounds heard over the posterior Thorax Well

Vesicular sound are soft, breezy, and low pitched sounds that are created by air moving through smaller airways Best heard over periphery of lung (expect over scapula) inspiratory phase is 3 times long than expiratory phase Bronchovesicular sounds are blowing sounds that are medium pitched and of medium intensity that are created by air moving through large airway. Best heard posteriorly between scapulae and anteriorly over bronchioles lateral to sternum at first and second intercostal spaces Bronchial sounds are loud and high pitched with a hollow quality that are created by air moving through the trachea close to the chest wall. heard only over trachea. Expiration lasts longer than inspiration (3:2 ration)

General Survey (appraisal)

When pt walks in observe his or her walk and general appearance and be attentive to his or her behavior and dress. presentation and behavior provides info of illness, function idependently, body image, emotional status, weight change, and developmental status. General Appearance and Behavior Assess Gender and race affects the type of examination (the incidence of skin cancer is more common in whites than in blacks, prostate cancer is higher in black men than in white men, and cancer of the bladder is higher in men than in women) Age influences normal physical characteristics and a person's ability to participate Signs of distress S&S indicate pain (grimacing, splinting painful area), difficulty breathing(SOB, sternal retractions) or anxiety. Set priorities and examine the related physical areas first. Body type Observe whether the patient appears trim and muscular, obese, or excessively thin. reflects the health level, age and lifestyle. Posture Observe whether the patient has a slumped, erect, or bent posture, which reflects mood or pain. Changes in older adult physiology often result in a stooped, forward-bent posture, with the hips and knees somewhat flexed and the arms bent at the elbows Gait Observe as the patient walks into the room or stands at the bedside (if the patient is ambulatory) note movements as coordinated or uncoordinated Body movements Observe whether movements are purposeful, noting any tremors involving the extremities. Determine whether any body parts are immobile. Hygiene and grooming level of cleanliness by observing the appearance of the hair, skin, and fingernails. Determine whether his or her clothes are clean. Dress Culture, lifestyle, socioeconomic level, and personal preference affect the selection and wearing of clothing. assess whether the clothing is appropriate for the temperature, weather conditions, or setting. Body order unpleasant body odor can result from physical exercise, poor hygiene, or certain disease states. Affect and mood Determine whether verbal expressions match nonverbal behavior and whether the mood is appropriate for the situation. By maintaining eye contact you can observe facial expressions while asking questions. Speech is understandable and moderately paced and shows an association with the person's thoughts. Observe whether the patient speaks in a normal tone with clear inflection of words. Signs of patient abuse observe whether the patient fears his or her spouse or partner, a caregiver, a parent, or an adult child. Observe the behavior of the individual for any signs of frustration, explanations that do not fit his or her physical presentation, or signs of injury. Report abuse and make sure patient has safe housing. Substance abuse unusual or inconsistent behavior may be indicator of substance abuse Vital Signs Measurement of vital signs is more accurate if completed before beginning positional changes or movements. Assess for pain, the fifth vital sign, whenever you take a patient's vital signs. Temperature Range Average temperature range: 36° to 38°C (96.8° to 100.4°F) Average oral/tympanic: 37°C (98.6°F) Average rectal: 37.5°C (99.5°F) Axillary: 36.5°C (97.7°F) Pulse 60 to 100 beats/min, strong and regular Pulse Oximetry (SpO2) Normal: SpO2 ≥95% Respirations 12 to 20 breaths/min, deep and regular Blood Pressure Systolic <120 mm Hg Diastolic <80 mm Hg Pulse pressure: 30 to 50 mm Hg Capnography (EtCO2) Normal: 35-45 mm Hg Height and Weight Assess every patient to identify whether he or she is at a healthy weight, underweight, overweight, or obese Wt is measured Routinely Measuring height and weight of older adults, along with obtaining a dietary history shows risk factors for chronic diseases. Assessments screen for abnormal weight changes. weight normally varies daily because of fluid loss or retention. A weight gain of 2 to 3 lb (0.9-1.4 kg) in 1 day indicates fluid-retention problems. A weight loss is considered significant if the patient has lost more than 5% of body weight in a month or 10% in 6 months.

General Survey: Accurate weight measurement of a hospitalized pt

Wt pts at the same time of day On the same scale In the same clothes allows an objective comparison of subsequent weights. Accuracy of weight measurement is important because health care providers base medical and nursing decisions (e.g., drug dosage, medications) on changes. standing scale. Electronic scales Bed and chair scales

Heart: Murmur, six factors to consider when auscultating, sounds grade 1-6

a murmur is a sustained swishing or blowing sound heard at the beginning, middle, or end of the systolic or diastolic phase auscultate all valve areas for placement in the cardia cycle, where best heard, radiation , loudness, pitch, and quality determine if they occur between S1 and S2 (systolic) and S2 and S1 (diastolic) the location is not necessarily over the valves listen over areas besides where the murmur is heard best to assess for radiation (neck and back) feel for a thrust or intermittent palpable sensation at the auscultation site in serious murmurs and rate the intensity 1= barely audible 2= clearly audible but quiet 3=moderately loud 4= loud with associated thrill 5= very loud thrill easily palpable 6= louder; heard without stethoscope syncope: is caused by a drop in heart rate and blood pressure arterial occlusion absent pulse wave (blockage) stenosis narrowing bruit is the blowing sound caused by turbulence in a narrowed section of a blood vessel

Abdomen

abdominal examination is complex assessment include lower GI tract liver, stomach, uterus, ovaries, kidneys and bladder begin with inspection and follow with auscultation inspection skin umbilicus contour and symmetry enlarged organs or masses movement or pulsations ausculation bowel mobility vascular sounds kidneys tenderness Palpation aortic pulsation Striae-are stretch marks due to obesity or pregnancy Hernia-is a protrusion of abdominal organs throughout the muscle wall Distention-is swelling by intestinal gas, tumor, or fluid in the abdominal cavity Peristalsis- is movement of contents through the intestines, which is a normal function of the small and large intestine Borborygmi- are growling sounds, which are hyperactive bowel sounds Rebound tenderness-is the pain a patient may experience when the nurse quickly lifts his or her hand away after pressing it deeply into the involved area Aneurysm-is a localized dilation of a vessel wall

Neurologic System: Delirium and clinical criteria

acute mental disorder is characterized by confusion, disorientation and restlessness there is reduced clarity of awareness of the enviorment ability to focus, sustain, or shift attention is impaired irrelevant stimuli easily distract the person accompanying change in cognition recent memory commonly is affected disorientation usually occurs language disturbance perceptual disturbances

Assessment of characteristic odors

alcohol Oral cavity ingestion of alcohol, diabetes ammonia Urine urinary tract infection, renal failure body odor skin, parts that rub together, underarms and under breast poor hygiene, excess sweat perspiration (hyperhidrosis), foul smelling perspiration (bromhidrosis); wound site wound abscess; vomitus abdominal irritation, contaminated food feces vomitus/ oral cavity (fecal odor) bowel obstruction rectal area fecal incontinence foul-smelling stools in infants stool malabsorption syndrome halitosis oral cavity poor dental and oral hygiene, gum disease sweet, fruity ketones oral cavity diabetic acidosis stale urine skin uremic acidosis sweet, heavy, thick odor draining wound pseudomonas (bacterial) infection musty odor casted body part infection in cast fetid, sweet odor tracheostomy or mucus secretions infection of bronchial tree (pseudomonas bacteria )

Thorax and Lungs: Vocal or Tactile Fremitus

are vibrations that you can palpate externally caused by sound waves

Sitting

areas assessed Head and neck, back, anterior/Posterior thorax and lungs, breast, axillae, heart, vital signs, and upper extremities Rationale sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts Limitations physically weakened unable to sit; use supine position with head of the bed elevated

Neurologic System:Motor functions; Function of the cerebellum

assess the patient's cerebellar function controls muscular activity , maintains balance and equilibrium, and helps to control posture coordination assess fine-motor function, have the patient extend the arms out to the sides and touch each forefinger alternately to the nose (first with eyes open, then with eyes closed). Test lower-extremity coordination with the patient lying supine, legs extended. Test each foot for speed and smoothness. Balance Romberg's test by standing with feet together, arms at the sides, both with eyes open and eyes closed. Protect the patient's safety by standing at the side; observe for swaying. Expect slight swaying of the body in the Romberg's test. A loss of balance (positive Romberg) causes a patient to fall to the side. Another test involves asking the patient to walk a straight line by placing the heel of one foot directly in front of the toes of the other foot.

Lesion

broadly to any unusual finding of the skin surface. Normally the skin is free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. collect standard information about its color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). Next observe for any exudate, odor, amount, and consistency. Measure the size of the lesion in centimeters by using a small, clear, flexible ruler. Measure each lesion for height, width, and depth. For example, a tumor is usually an elevated, solid lesion larger than 2 cm (1 inch). Primary lesions such as macules and nodules come from some stimulus to the skin closely inspect it in good lighting. Palpate gently, covering the entire area of the lesion. If it is moist or draining fluid, wear gloves during palpation and pay attention to whether the patient identifies any areas of tenderness.

Vascularity

circulation of the skin affects color in localized areas and leads to the appearance of superficial blood vessels. Occurs in Localized pressure areas when patients remain in one position. appears reddened, pink, or pale Aging capillaries become fragile and easily injured Petechiae nonblanching, pinpoint-size, red or purple spots on the skin caused by small hemorrhages unknown cause indicate serious blood clotting disorders, drug reactions, or liver disease.

Breasts: Three systemic approaches to palpation of the breast

clockwise or counterclockwise forming small concentric circles vertical technique- up and down each quadrant center of the breast in a radial fashion

Purposes of the Physical Examination (PE)

conduct PE for many reasons: Initial evaluation in triage for emergency Routine screening to promote wellness behaviors/ preventive health care measures Eligibility for health insurance Military service New job Admit a patient to hospital Long term facility • Gather baseline data about a patient's health status. • Supplement, confirm, or refute subjective data obtained. • Identify and confirm nursing diagnoses. • Make clinical decisions about a patient's changing health status and management. • Evaluate the outcomes of care. Cultural Sensitivity influences behavior consider health belief, alternative therapies, nutritional habits, relationships w/ family, personal comfort zone Ex. severe asthma episode, the nurse first focuses on the pulmonary and cardiovascular systems so that treatments can begin immediately. once the pt is no longer at risk the nurse will perform a comprehensive exam of all body systems

Neurologic System: two normal reflexes

deep tendon reflexes (biceps, triceps, patellar, achilles) Cutaneous reflexes (plantar, gluteal, abdominal) Grade reflexes as follows 0: No response 1+: Sluggish or diminished 2+: Active or expected response 3+: More brisk than expected, slightly hyperactive 4+: Brisk and hyperactive with intermient or transient clonus assessing reflexes, have the patient relax as much as possible to avoid voluntary movement or tensing of muscles. Normally the older adult presents with diminished reflexes.

Nursing Hx for head assessment

determine if pt has experienced head trauma if yes assess state of consciousness after injury, duration of unconsciousness and predisposing factors Trauma is major cause for lumps, bumps, cuts, bruises, or deformities of scalp or skull. Loss of consciousness following head injury indicates possible brain injury. ask if pt has a hx of headaches note onset duration character patterns and symptoms Character of headache helps to reveal causative factors such as sinus infection, migraine, or neurological disorders. determine the length of time pt experienced Neurological symptoms review pts occupational hx for use of safety helmets ask if pt participated in contact sports etc.

Thorax measured by palpation

excursion Palmar surface tenderness finger pads/ palmar surface of fingers Fremitus Palmar or ulnar surface of entire hand

Heart: appropriate sites for inspection and palpation

first inspect Angle of Louis Aortic area second intercostal space on the right Pulmonic area left second intercostal space Second Pulmonic area left third intercostal space Tricuspid area fourth or fifth intercostal space alone the sternum Mitral area fifth intercostal space jut to the left of the sternum; left midclavicular line Epigastric area tip of the sternum : Palpate there if you suspect aortic abnormalities

Indurated

hardened

Breasts: prevention screening for early detection of breast cancer

important to exam both genders second to lung cancer as the leading cause of death in women at risk pts need MRI and mammogram yearly Female Breasts Ages: 40-44 should have the choice to start annual breast cancer screening with mammogram 45-54 should get a mammogram every year 55+ should have mammogram every 2 years High risk groups early and more extensive screening for personal history of breast cancer, family history, genetic mutation, previous radiation therapy to the chest before 30 years old

Vascular system: Assess for phlebitis

inspect the calves for localized redness, tenderness, and swelling over vein sites Peripheral Veins sitting and standing positions assess includes inspection and palpation for varicosities (superficial veins are dilated seen in older adults; fibrous, dilate, stretch; also common in people that stand long period of time), peripheral edema , phlebitis (inflammation of the viens caused by trauma to the vessel wall, infection, immobilization and prolonged insertion of IV) phlebitis in legs inspect the calves for localized redness, tenderness, and swelling over vein sites. palpation of calf muscles reveals warmth, tenderness and firmness of the muscle unilateral edema of the affected leg is a finding of phlebitis varicosities in the anterior or medial part of the thigh and posterolateral part of the calf are abnormal

Ptosis

is an abnormal drooping of the eyelid over the pupil

Ectropion

is an eyelid margin that turns out

Entropion

is an eyelid margins that turns in

Exophthalmos

is bulging of the eye

Edema

is present when areas of the skin become swollen or edematous from a buildup of fluid in the tissue common causes of edema direct trauma and impairment of venous return inspect for location, color, and shape Palpate edematous areas to determine mobility, consistency and tenderness indentation in the edematous ares is called pitting edema asses by pressing the edematous area firmly with the thumb several seconds and release record depth of pitting in mm 1+ edema equals a 2-mm depth 2+ edema equals a 4 -mm depth 3+ 6 mm 4+ 8 mm

Conjunctivitis

is the presence of redness, which indicates and allergy or an infection

Thorax and lungs: Key landmarks of the chest to assess correctly

landmarks provide imaginary lines patient's nipples angle of Louis (mandubriosternal junction) suprasternal notch costal angle clavicles vertebrae

Breasts: Palpating abnormal masses note

location in relation to the quadrants diameter shape (round or discoid) consistency (soft, firm, or hard) tenderness mobility discreteness (clear or unclear boundaries)

Techniques of Physical Assessment

look, listen, and smell to distinguish normal from abnormal findings aware of personal visual, hearing, or olfactory deficits. pay attention to details Inspection occurs when interacting with a patient, watching for nonverbal expressions of emotional and mental status and assessing physical movements and structural components. • Make sure that adequate lighting is available, either direct or indirect. • Use a direct lighting source (e.g., a penlight or lamp) to inspect body cavities. • Inspect each area for size, shape, color, symmetry, position, and abnormality. • Position and expose body parts as needed so that all surfaces can be viewed but privacy can be maintained. • When possible, check for side-to-side symmetry by comparing each area with its match on the opposite side of the body. • Validate findings with the patient. Olfaction helps to detect abnormalities (cranial Nerve I) Palpation involves using the sense of touch to gather information. make judgments about expected and unexpected findings of the skin or underlying tissue, muscle, and bones. use for skin temp, moisture, texture, turgor, tenderness, and thickness and the abdomen for tenderness, distention, or masses. Display respect and concern throughout examination warm hand; fingernails short and use gentle approach slowly, gently, and deliberately promote relaxation by having the pt taking slow deep breaths and place both arms along the sides of the body Palpate tender areas last two types light (pressing inward 1cm superficial) and deep ( depressing the area 4 cm to asses the conditions of organs ) used for Physical examination Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs. The vibration travels through body tissues, and the character of the resulting sound reflects the density of the underlying tissue. the denser the quieter the sound abnormal sound indicates mass or substance (air or fluid) note: location, map their edges and determine size Auscultation involves listening to internal sounds the body makes to detect variations from normal. Bell is best used for low-pitched (vascular and heart sounds) Diaphragm is best for listening to high pitched sounds (bowel and lungs) requires concentration and practice. Describe any sound you hear using the following characteristics: • Frequency indicates the number of sound wave cycles generated per second by a vibrating object. The higher the frequency, the higher the pitch of a sound and vice versa. • Loudness refers to the amplitude of a sound wave. Auscultated sounds range from soft to loud. • Quality refers to sounds of similar frequency and loudness from different sources. Terms such as blowing or gurgling describe the quality of sound. • Duration means the length of time that sound vibrations last. The duration of sound is short, medium, or long. Layers of soft tissue dampen the duration of sounds from deep internal organs.

Musculoskeletal system

musculoskeletal assessment can be performed as a separate examination or integrated with other parts of the total physical examination. focuses on determining range of joint motion, muscle strength and tone, and joint and muscle condition. Inspection gait Note how the patient walks, sits, and rises from a siing position. look at the extremities for overall size, gross deformity, bony enlargement, alignment, and symmetry. Normally there is bilateral symmetry in length, circumference, alignment, and position and in the number of skinfolds Kyphosis hunchback (common in older adults) Lordosis swayback scoliosis is a lateral spinal curvature osteoporosis is a metabolic bone disease that cause a decrease in quality and quantity of bone. Loss of height is frequently the first clinical sign goniometer is an instrument that measures the precise degrees of motion in a particular joint Palpation all bones, joints, and surrounding muscles during a complete examination. note heat, tenderness, edema, or resistance to pressure

Head and Neck: assessment of the neck

neck muscles lymph nodes of the head and neck carotid arteries jugular veins thyroid glands trachea

Neurologic System: LOC Glasgow coma scale

provides an objective measurement of consciousness on a numerical scale over time With a lowering of a patient's consciousness, use the Glasgow Coma Scale (GCS) for an objective measurement of consciousness on a numerical scale eyes open Repsonse spontaneously 4 to speech 3 to pain 2 none 1 Best verbal respones oriented 5 confused 4 inappropriate words 3 incomprehensible sounds 2 none 1 Best motor respones obeys commands 6 localized pain 5 flexion withdrawal 4 abnormal flextion 3 abnormal extension 2 flaccid 1 total score 3 to 15 The higher the score, the beer the patient's neurological function. Behavior and Appearance Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about mental status. focus assessment on the appropriateness of clothing for the weather

Blood vessels (carotid and femoral artery) measured by palpation

pulse amplitude, elasticity, rate, rhythm palmar surface/ pads of fingertips

PERRLA

pupils equal, round, reactive to light and accommodation

Turgor

refers to the elasticity of the skin. assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release Edema or dehydration diminishes turgor and makes the skin tauter. the back of the hand is normally loose and thin, turgor is not assessed reliably at that site Poor tugor stays pinched and show tenting Evaluate the skin movement and speed as it returns to its resting point Failure to do so indicates dehydration

Head and Neck: Internal eye structure examine with ophthalmoscope

retina choroids optic nerve disc macula fovea centralis retinal vessels

Thorax and Lungs:

review of the ventilatory and respiratory function lung can affect other body parts like the brain reduce O2 result in changes of LOC and mental alertness use inspection, palpation, and auscultation Diagnostic test include Xray filmes MRI CT risk factors are review at the time of resp assessment Posterior Thorax Left scapular line vertebral line right scapular line indication of oxygenation problems : Reduced mental alertness, nasal flaring, somnolence, and cyanosis inspect by observing shape and symmetry from Both front and back (anteroposterior diameter) shape and posture can impair ventilatory movement barrel shaped chest- characterized by aging and chronic lung disease Look for deformities, position of the spine, slope of the ribs, retraction of the intercostal spaces during inspiration, bulging of the intercostal spaces during expiration Bulging indicates that a pt is using great effort to breathe assess rate and rhythm Palpate: Thoracic muscles and skeleton for lumps, masses, pulsations and unusual movement avoid deep palpate when pt reports pain or tenderness lightly palpate when there is suspicious mass or swollen area to determine the size, shape, and lesions older adults chest movement declines because of costal cartilage calcification and rest Auscultate for normal breath sounds and abnormal or adventitious sounds Bronchovesicular and vesicular heard over the posterior thorax normal sounds Lateral Thorax Posterior axillary line midaxillary line anterior axillary line Have pt raise the arms to improve access use inspections, Palpation, auscultation do not assess excursion you hear vesicular normal sounds Anterior Thorax midsternal line midclavicular line anterior axillary line inspect same features as posterior thorax sits or lies with head elevated accessory muscles of breathing (move little with normal passive breathing) Sternocleidomastoid trapezius abdominal muscles effort to breath results in strenuous exercise or pulmonary disease COPD relay on accessory muscles to contract inhale and exhale pts will have grunting sounds. normal breathing patterns are quit and barely audible most often assess resp rate and rhythm anteriorly man resp are diaphragmatic females resp are costal (ribs) palpate anterior thoracic muscles and skeleton assess tactile fremitus findings differ from posterior finding because of pts of the heart and female breast auscultation follows systematic pattern compare the right and left sider special attention to lower lobs becuase mucus secretions is gather

organs (liver or intestine) measured by Palpation

size, shape, tenderness, absence of masses Entire palmar surface of hand or palmar surface of fingers

glands (thyroid and lymph) measured by palpation

swelling, symmetry and mobility pads of fingertips

Head and Neck: Abnormality of superficial lymph nodes

systemic disease or neoplasm

Skin measure by palpation

temp dorsum of hand/ fingers moisture palmar surface texture palmar surface turgor and elasticity grasping with fingertips thickness palmar surface

Head and Neck: Examination of the Eye includes assessment of five areas

visual acuity that tests central vision with a snellen chart visual fields objects seen in the periphery extraocular movements test is 6 muscles that guide the eye external eye structures internal eye structures

Mnemonic to assess the skin for carcinoma: ABCD

• Asymmetry—Look for an uneven shape. One half of mole does not match the other half. • Border irregularity—Look for edges that are blurred, notched, or ragged. • Color—Look for pigmentation that is not uniform; variegated areas of blue, black, and brown and areas of pink, white, gray, blue, or red are abnormal. • Diameter—Look for areas greater than 6 mm (about the size of a typical pencil eraser).

Use and Care of the Stethoscope

• Ensure that the earpiece follows the contour of the ear canals. • Place the earpieces in your ears with the tips turned toward the face. • Put on the stethoscope and lightly blow into the diaphragm. If the sound is barely audible, lightly blow into the bell. Sound is carried through only one part of the chest piece at a time. • Place the diaphragm over the anterior part of your chest. Ask a friend to speak in a normal conversational tone. Environmental noise seriously detracts from hearing the noise created by body organs. When using a stethoscope, the patient and the examiner need to remain quiet. • Put on the stethoscope and gently tap the tubing. It is often difficult to avoid stretching or moving the stethoscope tubing. The examiner is in a position so that the tubing hangs free. • Care of the stethoscope: Remove earpieces regularly and clean; remove cerumen (earwax). Keep the bell and diaphragm free of dust, lint, and body oils. Keep the tubing away from any body oils. Avoid draping the stethoscope around the neck next to the skin. Clean daily or after soiling by wiping the entire stethoscope (e.g., diaphragm, tubing) with alcohol. Be sure to dry all parts thoroughly. Follow manufacturer recommendations. • Infection control: Harmful bacteria such as gram-positive bacilli, methicillin-resistant Staphylococcus aureus (MRSA), nonaureus Staphylococcus, Enterobacter cloacae, and methicillin-sensitive S. aureus can be transferred from patient to patient when using portable equipment such as stethoscopes. Clean the stethoscope (diaphragm/bell) before reuse on another patient. Using a disinfectant such as isopropyl alcohol (with or without chlorhexidine), benzalkonium, or sodium hypochlorite is effective in reducing the number of bacterial colonies. Hand foam serves this purpose well. Earpieces of stethoscopes are sources of transferable bacteria. When you inadvertently touch your ears and care for the patient, potential pathogens could contaminate the earpieces. Using hand hygiene before and after patient contact decreases the risk of transmitting microorganisms from your ear to your patient. Follow the institution's infection control guidelines, especially Contact Precautions, to decrease this risk

Preparation for Examination: Data collection when examining children

• Gather all or part of the history on infants and children from parents or guardians. Use open-ended questions to allow parents to share more information and describe more of the children's situation. This will allow observation of parent- child interactions. Older children can be interviewed and provide details about their health history and severity of symptoms. • Gain a child's trust before doing any type of an examination. Perform the examination in a nonthreatening area. Talk and play with the child first. Do the visual parts of the examination before touching the child. Start the examination from the periphery and then move to the center (e.g., start with the extremities before moving to the chest). • Because parents sometimes think the examiner is testing them, offer support during the examination and do not pass judgment. • Call children by their first names and address the parents as "Mr., Mrs., or Ms." rather than by their first names unless instructed differently. • Treat adolescents as adults and individuals because they tend to respond best when treated as such. Remember that adolescents have the right to confidentiality. After talking with parents about historical information, speak alone with adolescents.

General Survey: CAGE

• Have you ever felt the need to Cut down on your drinking or drug use? • Have people Annoyed you by criticizing your drinking or drug use? • Have you ever felt bad or Guilty about your drinking or drug use? • Have you ever used or had a drink first thing in the morning as an Eye-opener to steady your nerves or feel normal?