Chapter 21 Physical Assessment

Comprehensive physical examination

(also called physical assessment) includes a health history interview and a complete head-to-toe examination of all body systems. For example, you would perform a comprehensive physical exam at an outpatient appointment for an annual physical, a client's admission to an inpatient setting, and at the initial home health visit.

focused physical assessment

(or examination) pertains to a particular topic, body part, or functional ability rather than overall health status, and it adds to the database created by the comprehensive assessment. For example, in an emergency situation, your assessment will be rapid and focused on the presenting problem

Preparing for a Physical Examination

A head-to-toe approach starts at the head and neck and progresses down the body, examining the feet last. A body systems approach examines each system in a predetermined order (e.g., musculoskeletal, cardiovascular, neurological). Whatever the approach, prepare yourself, the environment, and the client before you begin. Prepare Yourself

Older Adults

Allow extra time to interview and examine older adults. They are adjusting to changes in physical abilities and health. As part of a comprehensive exam: Assess the client's support system and ability to perform activities of daily living. Observe your client's energy level during the physical examination and provide rest periods if needed. If the client tires easily, arrange the exam sequence to limit position changes. Be aware that stiff muscles and arthritic joints may make it impossible for the client to assume certain positions. Adapt your techniques when examining older adults with impaired vision or hearing. Obtain feedback to be sure the patient is seeing and hearing you adequately. The acronym SPICES will help you to remember common problems of older adults that require nursing intervention (Fulmer, 1991, 2007) and to focus your assessment as you perform a comprehensive physical examination: S—Sleep disorders P—Problems with eating or feeding I—Incontinence C—Confusion E—Evidence of falls S—Skin breakdown

General Survey

Appearance and Behavior Refer to Procedure 21-1, Performing the general survey, steps 1, 2, and 3, for details about assessing appearance and behavior. Body Type and Posture Posture is a clue about overall health status. Focused assessments in the remainder of the general survey will help to reveal the exact meaning of such cues. Speech As you speak with the client and ask health-related questions, look for clues offered by his speech. Inappropriate or illogical responses may be associated with psychiatric disorders. Difficulty speaking or changes in voice quality may indicate a neurological problem. Rapid speech may be a sign of anxiety, hyperactivity, or use of stimulants. Hoarseness could indicate inflammation in the throat from infection, overuse, a foreign body, or perhaps a tumor or other obstructive material. Slow speech may be due to depression, sedation from medications, or neurological disorders. Vocabulary and sentence structure provide information about the client's educational level and comfort with the language. A foreign accent with hesitancy and/or sparse verbalization may signal a language barrier and a need for an interpreter. Mental State Mental state includes level of consciousness and capacity to interact. If the client has an altered mental status, ask a family member about the onset of the change. Keep in mind that many medications, especially in older adults, may contribute to confusion or other changes in mental status. Dress, Grooming, and Hygiene A client's ability to dress and perform personal hygiene is affected by physical and emotional well-being. It is often a cue to mental or physical self-care deficits. Vital Signs You should assess vital signs as a part of the general survey and with subsequent assessments. Analyze for trends. See Chapter 19 for a complete discussion of vital signs, if needed. Height and Weight Height and weight provide valuable information about your client's growth and development, nutritional status, overall general health, and risk for various diseases such as diabetes and heart disease (Fig. 21-1). These data are important for proper dosing of medication. When possible, the client should wear minimal clothing (gown) and no shoes. Because children have frequent changes in growth, their measurements are documented on growth charts for easy monitoring and comparison to age- and gender-related standards. Body mass index (BMI) evaluates the relationship between height and weight. You can calculate the BMI for adults using a BMI calculator or table (see Procedure 21-1, step 10). KEY POINT: Because the proportion of fat to muscle affects BMI calculation, the BMI is not useful for the following: Athletes (who have a larger proportion of muscle, which is denser than fat mass) Pregnant and lactating women (who have a larger blood and tissue volume) Growing children Frail and sedentary older adults

Skin Lesions

Any lesion, variation in pigment, or break in continuous tissue requires assessment. Normal Lesions Lesions considered to be normal variations and not harmful include: Milia. White raised areas on the nose, chin, and forehead of newborns. These lesions, which resemble "whiteheads," are due to retention of sebum in the maturing sebaceous glands. They disappear during infancy. Nevi (moles), freckles, birthmarks Skin tags. Tiny tags or fleshy buds of skin usually around skin creases in middle-aged and older adults Striae. Silver-to-pink "stretch marks" in pregnant women, women who have had children, and anyone who has experienced significant weight fluctuations. Abnormal Lesions Abnormal lesions are classified as primary or secondary. Primary skin lesions develop as a result of disease or irritation. The pustules of acne are an example. Secondary skin lesions develop from primary lesions as a result of continued illness, exposure, injury, or infection, such as the crusts that form from ruptured pustules. Evaluate all skin lesions for the possibility of malignancy, especially those located in a site exposed to chronic rubbing or other trauma. You can remember the warning signs of malignant lesions by thinking of the letters ABCDE (Asymmetry, Border irregularity, Color variation, Diameter greater than 0.5 cm, and Elevation above skin surface). To help you categorize and describe lesions, see the table Describing Skin Lesions at the end of Procedure 21-2.

Skin Characteristics

As does color, the temperature, texture, and turgor of the skin offer clues to the client's health status. Although it is not technically a skin characteristic, you should also check for edema while you are assessing the skin. Skin Temperature The skin should feel warm, but keep in mind that the temperature should be consistent with the room temperature and the patient's activity level. Skin Moisture Excessive moisture may result from hyperthermia, thyroid hyperactivity, anxiety, or hyperhidrosis (excessive sweating). Dry skin may result from dehydration, chronic renal failure, hypothyroidism, excessive exposure, or overzealous hygiene. Skin Texture The following factors affect skin texture: Exposure. Exposed areas tend to be drier and coarser in texture, as do the elbows and knees. Age. The skin of infants and young children is very smooth because of lack of exposure to the environment. Hyperthyroidism and other endocrine disorders. These may cause the skin to become coarse, thick, and dry. Impaired circulation. Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little to no hair. In contrast, venous insufficiency leads to thick, rough skin that is often hyperpigmented. Skin Turgor refers to the elasticity of the skin, which provides data about hydration status. Edema, which is an excessive amount of fluid in the tissues, is an abnormal finding. It is common in clients with congestive heart failure, kidney disease, peripheral vascular disease, or low albumin levels. A client with edema may tell you his skin feels "tight" or say, "My shoes don't fit anymore." Swollen tissue may feel tender to touch. Edema is not actually a condition of the skin, but it is convenient to assess for it while assessing the skin.

Documenting Cerebral Function

Document LOC by describing the client's response or using the Glasgow Coma Scale (GCS) to grade eye, motor, and verbal responses. The GCS evaluates eye opening, motor responses, and verbal responses. Its limitations are that it relies heavily on vision and verbal interaction, and does not evaluate brainstem reflexes. A systematic review of evidence suggests that best practice should include use of the GCS plus other evaluation of brainstem reflexes, eye examination, vital signs, and respiratory assessment. A new tool, the Full Outline of UnResponsiveness (FOUR), provides additional information beyond that of the GCS. Both scales are included at the end of Procedure 21-16. If you are not using the GCS, use the following terms to describe arousal: Alert—Follows commands in a timely fashion. Lethargic—Appears drowsy; easily drifts off to sleep. Stuporous—Requires vigorous stimulation before responding. Comatose—Does not respond to verbal or painful stimuli. Although these terms are widely used, a thorough description is preferable. Look at the following two chart entries: Example 1: Pt. lethargic. Example 2: Pt. responds to repeated tactile and verbal stimulation. Quickly drifts off to sleep if stimulation is discontinued. As you can see, the second charting entry provides significantly more information than the first.

The Anus, Rectum, and Prostate

Examining the rectum and anus is the last aspect of a comprehensive examination. For the female client, this exam is usually performed at the end of a bimanual pelvic examination while the client is still in the lithotomy position. For a male client you will usually perform the exam after completing your examination of the genitals. For a step-by-step procedure, see Procedure 21-19. Inspect the anus and rectum for skin condition and hemorrhoids and palpate for muscle tone, masses, and tenderness. Skin irritation and erythema are common in clients who have diarrhea and in infants and toddlers who wear diapers. Hemorrhoids (dilated, usually painful, anal vessels) may be seen in clients with a history of constipation. Many women develop hemorrhoids with pregnancy and childbirth. A comprehensive examination for a man should include a digital rectal examination to assess for prostate enlargement. An enlarged prostate may indicate benign enlargement of the prostate, which is common in men older than age 50, or it may indicate prostatitis. A hard nodule or multiple nodules may indicate prostate cancer.

Prepare the Client

In most clinical settings, you must examine a client often to evaluate a changing status, and timing will be decided by the client's condition rather than by convenience. However, when possible, select a time when the client is comfortable and receptive to the exam. Avoid conducting the exam when the client is in pain or is hungry, tired, anxious, or unwilling to cooperate in the assessment. iCare Take the time to establish rapport with the client; this will help him relax and cooperate fully in the assessment. Introduce yourself, ask the client how he wishes to be addressed, and explain what you will be doing. Ask the client to void before the examination; this promotes relaxation and also makes it easier to palpate the abdomen. Always alert the client before touching him. For example, before you start to palpate the neck for lymph nodes, say, "I'm going to feel your neck now." Proper positioning during the exam also promotes comfort (see the following section). Pay attention to the pace of your exam, being careful not to prolong it and tire the client.

THE GENITOURINARY SYSTEM

In most practice settings, nurses assess only the patient's external genitalia and inguinal lymph nodes. Nurse practitioners and physicians perform comprehensive examinations of the female and male reproductive and urinary systems, as do nurses working in specialty areas. However, even as a novice nurse you may assist with exams or just be present as a witness or to provide emotional support to the client. iCare The genitourinary system includes both the reproductive system and the urinary system. Because a genitourinary (GU) assessment focuses on sexual and reproductive function, it might be embarrassing or uncomfortable for many people. A competent, professional approach is needed. Your confidence and ease with these topics will help the client to feel more relaxed. The Male Genitourinary System A complete examination includes assessment of the external genitalia, evaluation for hernias, and a rectal exam for prostate screening. The penis and scrotum are examined by inspection and palpation. You will assess some of the urinary system organs when examining the back (kidneys, ureters) and the abdomen (bladder); the prostate gland is palpated during the exam of the rectum and anus (discussed later in this chapter). For illustrations and steps to follow in examining the male genitourinary system, see Procedure 21-17. As a result of the scarcity of clear, scientific evidence, the American Academy of Pediatrics (2012) no longer recommends circumcision (excision of the foreskin of the penis) as a routine practice. Nevertheless, they do acknowledge the benefits of infant circumcision (Baskin, Lockwood, Bartlett, et al., 2015). Also, circumcision is tied to some religious and cultural beliefs (e.g., among Jews and Muslims), so it is still common. A hernia is a protrusion of the intestine (or other organ) through the wall that contains it. A hernia may be a small protrusion or it may cause pain and distention. In men, a hernia is most likely to be a protrusion of the intestine either through the abdominal wall (direct hernia) or into the inguinal canal and possibly into the scrotum (indirect hernia). An umbilical hernia (fairly common in infants) is an outward bulging due to delayed closure around a small muscle around the umbilicus (belly button). For an illustration of an umbilical hernia, see Procedure 21-14. The Female Genitourinary System You may be called upon to assist with a comprehensive examination. For a procedure for inspecting external female genitalia and palpating inguinal lymph nodes, see Procedure 21-18. External Examination For adolescents and young women who are not sexually active, an external GU examination includes the inspection of the amount and distribution of pubic hair, the skin of the pubic area, and the external genitalia and palpation of the inguinal lymph nodes. Internal Examination Women who have abnormal findings on external examination; who have abdominal, pelvic, or genitourinary complaints; or who are on hormone therapy require an internal genital examination (Qaseem, Humphrey, Harris., et al., 2014). The exam includes the following: Palpation of Bartholin's glands and Skene's ducts (see Procedure 21-18) Assessment of vaginal muscle tone and pelvic musculature Speculum examination Bimanual examination, wherein the examiner palpates the cervix, uterus, and adnexal tissues with the use of one or two fingers within the vagina and the other hand on the outside to help bring the inner structures toward the two hands Pap Smear Recent changes to major guidelines recommend, in general, less frequent routine Papanicolaou tests (Pap smears) to screen for cervical and uterine cancer. They recommend the following for women: Younger than age 21: Not screened, regardless of whether they are sexually active or have other risk-taking behaviors. Ages 21 through 29: Screen every 3 years. Ages 30 to 65: Screen every 3 to 5 years (and follow the advice of their provider). Older than age 65: Do not routinely screen unless they are at high risk. However, a recent study states that the cancer incidence rates used for guidelines do not account for the high rates of hysterectomy in the United States. This has the largest impact on older black women. Authors recommend that the risk and screening guidelines be reconsidered (Rositch, Nowak, & Gravitt, 2014). Those with certain vulnerabilities (e.g., weakened immune system, HIV positive) should have a Pap test every year (American Cancer Society, n.d.b, revised 2015; National Guideline Clearinghouse, 2005, revised 2016). KEY POINT: National screening guidelines vary and they change frequently. Additional cultures or screens may be done if there is unusual discharge or risk of sexually transmitted infection. A speculum examination is performed to collect specimens and assess the cervix. To learn about assisting with a speculum exam, see Clinical Insight 21-3.

Toddlers

Include parents. Toddlers are interested in exploring the environment, but they also like to stay close to a parent, often in the parent's lap. Perform invasive procedures last. Toddlers may be fearful of invasive procedures, such as examination of the oral cavity or inner ear. If they are upset, it will be more difficult to examine other body areas. Give the child choices. Most toddlers enjoy making choices, so this will promote cooperation. For example, you might say, "Should I listen to your chest first, or should we see how much you weigh?" Allow the child to show you his developmental skills. If he needs assistance to remove clothing, have the parent help and observe how the parent and child interact. Use praise freely. Praise the toddler for his abilities and cooperation. This sets the stage for positive feelings about healthcare.

level of consciousness

Level of consciousness (LOC) includes arousal and orientation. Arousal may range from alert to deeply comatose. Arousal is classified based on the type of stimuli (auditory, tactile, or painful) required to produce a response from the client. An alert client responds to auditory stimuli (e.g., verbal communication or noise). KEY POINT: Remember, if your client does not speak your language he may not respond to questions or commands. Orientation refers to the client's awareness of time, place, and person. Orientation to time includes awareness of the year, date, and time of day. Hospitalized patients are subjected to lights and noise around the clock; are roused in the middle of night for medications or time-sensitive treatments; and are given anesthesia and pain medications that alter their sense of awareness, so they easily become disoriented to time. Orientation to place involves awareness of surroundings. The patient should know that he is, for example, in the hospital and not in church. Patients who have been moved (e.g., from the emergency department to a ward bed) may not recall their room number but are easily reoriented. Orientation to person involves recognition of familiar persons and self-identity. The client should be able to state her name or identify people in photographs at the bedside. Because a client may meet many health professionals during a hospitalization, she may not be able to recall your name unless you have had repeated encounters with her. Mental status and cognitive function include behavior, appearance, response to stimuli, speech, memory, communication, and judgment. By this point in the exam, you would have already interviewed the client and talked with him while performing the exam, so you would have a good deal of information about his mental status and cognitive function. You would have already assessed posture, gait, motor movements, dress, and hygiene through the general survey and the musculoskeletal exam; you would be aware of the client's mood based on his tone of voice, actions, and statements. Many clinicians choose to screen for mental status and cognitive function by working questions into the interaction with the client as they assess other body systems. This type of informal assessment is not only more natural for the client but it is also more accurate. If you choose this method, observe for clarity of thought, appropriate content, concentration, memory, and ability to perform abstract reasoning.

Young and middle adults

Most young and middle adults are able to cooperate during a physical examination and do not require a modified approach. Modifications may be required if the client has acute or chronic illness or cannot understand or follow instructions.

Common skin color variations

Pallor In light-skinned clients: extreme paleness; skin appears white; loss of pink or yellow tones. In dark-skinned clients: a loss of red tones May be related to poor circulation or a low hemoglobin level (anemia). Best sites to assess for pallor include the oral mucous membranes, conjunctiva, nailbeds, palms, and soles of feet. Cyanosis A blue-gray coloration of the skin, often described as ashen If seen in the lips, tongue, mucous membranes, and facial features, it is known as central cyanosis and is associated with hypoxia. Acrocyanosis, which is bluish discoloration of palms and soles in the first few hours to days of life, is normal in newborns. Cold causes the lips to turn blue but the tongue is not affected. Cyanosis may also be seen in the extremities, especially hands and feet, after exposure to extreme cold. Jaundice A yellow-orange cast to the skin Often associated with liver disorders. Best sites to assess for jaundice include the sclera, mucous membranes, hard palate of the mouth, palms, and soles of feet. Jaundice in the newborn is a normal finding in the first few weeks of life unless there is blood incompatibility or a congenital disorder. Flushing A widespread, diffuse area of redness Generalized redness of the face and body may occur as a result of fever, excessive room temperature, sunburn, polycythemia (an abnormal increase in red blood cells), vigorous exercise, or certain skin conditions, such as rosacea. Erythema A reddened area Associated with rashes, skin infections, prolonged pressure on the skin, or application of heat or cold. Ecchymosis Bruised (blue-green-yellow) area May be seen anywhere on the body. The color will vary based on the age of the injury. May indicate physical abuse, internal bleeding, side effect to medication, or bleeding disorder. Refer to Chapter 9 to review assessing for abuse. Petechiae Tiny, pinpoint red or reddish-purple spots Visible in the skin due to extravasation (leakage from vessels) of blood into the skin. May be associated with a variety of disorders and medications. Mottling Bluish marbling Occurs in light-skinned clients, especially when cold. In newborns mottling indicates overstimulation of the autonomic nervous system.

Preschoolers

Preschool children are developing initiative and, as a result, usually cooperate with an examination. However, children of this age have fantasies and fears that may arise during the examination. For example, they may object to a noninvasive procedure because they believe it will cause pain or injury, or they may refuse to step on the scale because to them it resembles a monster. Combat fears by demonstrating the procedure on a doll or having the parent step on the scale before you approach the child. Allow the preschool child to sit on a parent's lap if she wishes. By age 5, most children will be comfortable enough to lie on the examination table if a parent is present. Let the child help with the exam. For example, have her hold equipment or remember her height and weight. Give reassurance as you go through the examination, for example, "Your lungs sound very healthy." Always compliment the child on her cooperation.

Prepare the Environment

Privacy. KEY POINT: Physical examination requires you to observe and touch the client's body, so privacy is essential. You will need a room with curtains or a door to shield the client from view. For additional privacy, drape your client and uncover only the area you are examining. For convenience you may use bed linens and/or a gown to drape. Disposable paper drapes are also available. Noise. Because you will need to hear the patient and listen to a variety of sounds during the exam, turn off the television, radio, or other media. Lighting. You will need good lighting to observe subtle changes in skin and body contours. Temperature. Adjust the temperature of the room according to patient comfort. Equipment. Determine the instruments and equipment you will need (see Box 21-1). Take everything you need so that you will not have to leave the client to obtain supplies.

Cranial Nerve Function

Reflex Function Deep tendon reflexes (DTRs) are automatic responses that do not require conscious thought from the brain. A reflex produces a rapid, involuntary response that occurs at the level of the spinal cord (see Procedure 21-16, step 24, for an illustration). Because the brain is not involved, muscle response is instantaneous. Intact sensory and motor systems are required for a normal reflex response. Each DTR corresponds to a certain level of the cord and is graded on a 0 to 4+ scale (see Procedure 21-16, step 24). You can elicit superficial reflexes by swiftly and lightly stroking a body part (e.g., with the reflex hammer). Superficial reflexes are graded as positive or negative. Sensory Function To assess sensory function, ask the client to keep his eyes closed as you apply various stimuli. Ask him to indicate when he feels a sensation. Vary your location and approach so that you test sensation, not pattern recognition. If you notice an area of altered sensation, systematically assess the area to define the border of the change. Usually you will limit your testing to the upper and lower extremities and the trunk. If the client has known or suspected deficits, you should test at numerous other sites. For techniques for assessing reflexes and sensory function, see Procedure 21-16. Motor and Cerebellar Function The neurological system coordinates the function of the skeleton and muscles. Motor pathways transmit information between the brain and muscles and the muscles control movement of the skeleton. The cerebellum helps coordinate muscle movement, regulate muscle tone, and maintain posture and equilibrium. The cerebellum is also largely responsible for proprioception, or body positioning. Disorders of motor and cerebellar function result in pain or problems with movement, gait, or posture. Thus, when you assess the musculoskeletal system, you also assess the motor functions of the neurological system.

Skin Color

Skin color variations commonly seen in neonates and infants include the following: Mongolian spots are benign, blue-black birthmarks that occur on the lower back and buttocks of African American, Hispanic, Native American, and Asian babies. They are due to pigmented cells in the deeper areas of skin. Most fade by age 2 but can persist until early adolescence. Capillary hemangiomas, sometimes known as "stork bites," are small, irregular pink-red areas that are often seen around the face and nape of the neck in newborns. They typically disappear in infancy, although they can persist until age 5. Café-au-lait spots are light brown birthmarks that can occur anywhere on the body. The name of these birthmarks is French for "coffee with milk" because of their light-brown color. Most often café-au-lait spots are not associated with medical problems, although they can sometimes signal a genetic disorder. Table 21-2 discusses the significance of other skin color variations that may be seen in clients of any age.

The Skull and Face

Taking individual variation into account, on inspection the skull should be rounded and the face symmetrical in appearance and movement. Head size is familial. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excess growth hormone. Microcephaly, an abnormally small head size, is seen in clients with certain types of mental disorders. Asymmetry may be the result of trauma, surgery, neuromuscular disorder, paralysis, or congenital deformity. In infants and children, a head that is growing disproportionally faster than the body may be a sign of hydrocephalus (an accumulation of excessive cerebrospinal fluid). Facial appearance that is inconsistent with gender, age, or racial/ethnic group may indicate an inherited or chronic disorder, such as Graves' disease, hypothyroidism with myxedema, or Cushing's syndrome.

Adolescents

The adolescent is self-conscious and introspective and may wish to be examined without parents or siblings present, at least during the more personal aspects of the exam. Offer the adolescent this choice. Provide privacy. Adolescents often worry about the "normalcy" of their changing bodies and appreciate respect for their privacy. Be certain to discuss the normal physiological changes that accompany puberty. If you need to review those changes, see the section on adolescence in Chapter 9. Be aware that adolescent behavior is strongly influenced by peer values. Emphasize lifestyle habits that promote wellness, including a healthful diet, adequate rest and exercise, and avoidance of tobacco, alcohol, and other drugs. Discuss sexually transmitted infections and cancer, particularly testicular cancer and human papillomavirus. Prepare the adolescent, if necessary, for a pelvic examination and breast examination, which usually begin in the teen years. Screen for depression and suicide risk. Suicide is the third leading cause of death among adolescents (see Chapter 13 for a review of depression and suicide).

The breast and axillae

The breasts consist of glandular, adipose, and connective tissue; smooth muscle; and nerves. The functions of the female breast are sexual stimulation and milk production for nourishing offspring. Breast size and shape vary among women, and commonly one breast is slightly larger than the other. At puberty, the ovaries produce estrogen and progesterone, which stimulate the breasts to develop. The menstrual cycle, pregnancy, and breastfeeding also enlarge breast tissue. Although breasts are thought of as female organs, men also have breasts. However, because of limited estrogen and progesterone levels, normal male breasts develop only minimally. Breast tissue and lymph drainage for the breast extend up into the axilla. The majority of breast tumors are found in the tail of Spence, in the axilla. A breast exam, therefore, always includes an exam of the axillae. Many women have breast reconstruction, either after breast removal due to cancer or breast augmentation for cosmetic reasons. These women should not omit breast examination, and it is performed in exactly the same way as for natural breasts. Clinical Breast Exam You should perform a breast exam for the woman if she cannot do it herself and demonstrate the procedure as part of client teaching for self-care. Clinical breast exams are not recommended for average-risk women at any age (American Cancer Society, n.d.b, last revised 2015). Breast Self-Exam KEY POINT: Researchers agree that patients who perform a breast self-exam (BSE) should be trained in proper technique in order to avoid falsely negative findings (American Congress of Obstetricians and Gynecologists, 2012, reaffirmed 2014; Smith, Cokkinides, Brooks, et al., 2011; Smith, Duffy, & Tabár, 2012). For a step-by-step guide to examining the breasts and axillae, see Procedure 21-11. Mammography and Thermography The American Cancer Society (n.d.b, last revised 2015) recommends that women with average risk of breast cancer undergo regular screening mammography or breast thermography starting at age 45 years. Women aged 45 to 54 years should be screened; women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually. Women should have the opportunity to begin annual screening between the ages of 40 and 44 years if history warrants and should continue as long as a woman is in good health and is expected to live 10 more years or longer (Oeffinger, Fontham, Etzioni, et al., 2015).

The cardiovascular system

The cardiovascular system consists of the heart and the blood vessels. The heart is a muscle that pumps blood throughout the body. In a healthy adult, it is about the size of a clenched fist. The blood vessels, which make up the vascular system, have two main networks: the pulmonary circulation and the systemic circulation. See Chapter 38 if you need to review the anatomy of the cardiovascular system. Pulmonary circulation. Oxygen-depleted blood circulates from the heart into the lungs, where it is oxygenated, then back to the heart. This system is known as the pulmonary circulation. Systemic circulation. The left ventricle pumps blood from the heart into the systemic circulation via the arterial system. Capillaries. The arteries subdivide many times, becoming smaller and smaller until they separate in the tissues and organs into capillaries. It is at the capillary level that oxygen is delivered to the tissues. The venous system collects the oxygen-depleted blood and returns it to the right atrium of the heart to begin the circuit again. Coronary circulation, which circulates blood through the heart itself, is a part of the systemic circulation. For further discussion on pulmonary circulation and oxygenation, see Chapter 37. For a complete step-by-step procedure for assessing the heart and vascular system, refer to Procedure 21-13. The Heart The heart is positioned at an angle on the left side of the chest in the 3rd, 4th, and 5th intercostal spaces (ICS). To facilitate auscultation of specific heart sounds, perform the cardiac The Cardiac Cycle During a cardiac cycle, the atria and ventricles alternately contract and relax to fill and empty; while the atria are contracting (emptying), the ventricles are relaxing (filling) and vice versa. Systole refers to the contraction, or emptying, of the ventricles. Diastole refers to the relaxation, or filling, phase of the ventricles. Inspecting and Palpating the Heart Begin your assessment of the heart with the client sitting. Observe the precordium, the area of the chest over the heart, for visible pulsations. A small pulsation at the 5th ICS midclavicular line, also known as the point of maximal impulse (PMI), is normal. Also palpate for vibrations. A thrill is a vibration or pulsation palpated in any area except the PMI. A thrill is associated with abnormal blood flow and usually has an accompanying murmur (additional heart sound). Auscultating the Heart Auscultate to establish cardiac rate and rhythm and to identify normal and abnormal heart sounds. A quiet room is essential. You can hear heart sounds from any location on the anterior chest wall. However, the four sites located over the heart valves are the preferred listening areas. Table 21-3 describes these locations; they are also shown in Procedure 21-13, step 8. Auscultate in an orderly fashion. Start at the aortic area and move gradually through each landmark. The following is a mnemonic you may use to recall the order of the heart sound landmarks: Listen carefully at each site to each component of the heart sounds. You will find information about abnormal heart sounds in step 8 of Procedure 21-13. First Heart Sound S1 (or "lub") results from the closure of the valves between the atria and ventricles. "Lub" is a dull, low-pitched sound, loudest over the mitral and tricuspid areas. S1 marks the beginning of systole. Second Heart Sound S2 (or "dub") corresponds to closure of the semilunar valves (between the ventricles and the great arteries exiting the heart). "Dub" is higher in pitch and shorter than the S1 "lub." The S2 is loudest at the aortic and pulmonic areas. S2 marks the beginning of diastole. Normally the mitral and tricuspid valves and the aortic and pulmonic valves close within a fraction of a second from each other. This near-simultaneous closure results in a singular S1 and S2 sound. However, a split sound may occur, at either S1 or S2, if there is a delay in closure of one of the valves. Third Heart Sound A third heart sound (S3), heard immediately after S2, has a gallop cadence that follows the rhythm of the word "KenTUCKy." It is best heard at the apical site with the client lying on his left side. Fourth Heart Sound A fourth heart sound (S4), heard immediately before S1, has a rhythm that follows the word "FLOrida." S4 is best heard at the apical site, using the bell of the stethoscope, with the client lying on his left side. Murmurs Murmurs are additional sounds produced by turbulent flow through the heart. Some murmurs are "innocent," but others represent pathology such as alteration in valve structure. Identifying and classifying a murmur are advanced skills that require practice. To learn more about assessing murmurs, see Procedure 21-13.

The chest and lungs

The chest, or thorax, is the bony cage that protects the heart, lungs, and great vessels. The ribs, sternum, and vertebrae form the chest. KEY POINT: Be systematic in your assessment: Always assess the areas of the chest and lungs in the same order. To learn how to assess the chest and lungs, see Procedure 21-12. Chest Landmarks Before beginning the thoracic exam, review the following important landmarks that will help you visualize the underlying structures and perform an accurate assessment: Anterior chest—Identify positions vertically on the anterior chest in relation to the ribs. For example, the space between the 5th and 6th ribs is known as the 5th intercostal space (5th ICS). You can easily palpate the ribs and count the spaces if you remember that the 1st rib is tucked up next to the clavicle (Fig. 21-5A). Use a series of imaginary vertical lines (Fig. 21-5B) to further aid in identifying locations on the anterior chest. For instance, the apex of the heart is usually located in the 5th intercostal space at left midclavicular line (5th ICS MCL). Posterior Chest—Identify positions vertically in relation to the vertebra (Fig. 21-6B). The prominent vertebra at the base of the neck is the 7th cervical vertebra (C7). The next one down is T1 (1st thoracic). Counting down to about T9 should be adequate. Lateral and Posterior Chest—Use imaginary lines on the lateral and posterior chest as well. Figure 21-6, parts A and C, illustrates the location of these lines. Notice that the anterior FIGURE 21-5 (A) The anterior thoracic cage and the bony landmarks. (B) A series of imaginary vertical lines is used to describe locations on the chest. axillary line can be used to locate sounds on both the anterior and lateral chest. Chest Shape and Size The chest diameter expands up to 3 in. (7.6 cm) with deep inspiration. The anteroposterior diameter of the chest is half the size of the lateral diameter (written as AP:Lateral = 1:2). Musculoskeletal changes associated with aging result in a gradual increase in the anteroposterior diameter. This change is also seen, regardless of age, in clients who have chronic obstructive pulmonary disease (COPD), a disorder associated with long-term smoking. Figure 21-7 illustrates normal and "barrel" chest shapes. Osteoporosis, a common disorder accompanying aging, is associated with increased porosity of the vertebrae. As a result, vertebrae may compress or collapse, shortening the length of the spine and pushing the ribs forward and downward. Breath Sounds Listen to breath sounds in a quiet room by auscultating one full respiratory cycle at each site. Directly apply the stethoscope to the client's skin. Compare breath sounds bilaterally. See Figure 21-8. Normal Sounds. Three types of normal breath sounds are heard: bronchial, bronchovesicular, and vesicular. To find a description of normal lung sounds, see the table Normal Lung Sounds at the end of Procedure 21-12. FIGURE 21-6 (A) Lateral chest landmarks. (B) The vertebrae are the landmarks on the posterior chest. (C) Landmark lines on the posterior chest. FIGURE 21-7 The normal anteroposterior to lateral ratio is 1:2. The lateral aspect of the chest increases dramatically with COPD, leading to a barrel chest appearance. Abnormal Sounds. Breath sounds that differ from those three are abnormal. To find a description of abnormal breath sounds refer to the table Abnormal Lung Sounds at the end of Procedure 21-12.

The ears

The ears are involved in both hearing and equilibrium. The external ear collects and conveys sound waves to the middle ear. It protects the middle ear from environmental factors such as humidity and temperature and prevents entry of foreign matter. The middle ear contains the tympanic membrane and cavity, the eustachian tube, and the ossicles (the small bones of the middle ear: the malleus, incus, and stapes). The middle ear conducts sound waves to the inner ear. The inner ear is responsible for hearing and equilibrium. Figure 21-4 illustrates the structures of the ear. For procedure steps and guidelines for using the otoscope and tuning fork to examine the ears, see Procedure 21-7. As with the eyes, nurses are usually responsible only for screening and making referrals. However, in some settings nurses perform advanced assessments. Examining the External and Middle Ear On inspection, the ears should be of equal size and similar appearance. Normally the pinna is level with the corner of the eye and within a 10° angle of vertical position (shown in Procedure 21-7). On palpation, the external structure of the ear is smooth, nontender, pliable, and without nodules. A painful auricle or tragus may be associated with otitis externa (an outer ear infection), whereas tenderness behind the ear is seen with otitis media (a middle ear infection). Otoscopic Examination As you begin the otoscopic examination, you may notice that the external auditory canal contains cerumen (wax), which protects the middle ear from excessive drying. However, it should not completely obstruct the ear canal. Cerumen may be black, dark red, yellowish, or brown in color and waxy, flaky, soft, or hard, with no odor; all are normal variations. Be careful as you manipulate the otoscope, because the inner two-thirds of the canal can be tender from the pressure and manipulation of the otoscope head. Normally the tympanic membrane (TM) is pearly gray, shiny, and translucent. Changes in its appearance arise from abnormalities such as otitis media (which causes a red, bulging TM) and the presence of pressure equalization tubes in young clients with chronic ear infections. Assessing Hearing To assess hearing, you will need a quiet room and a tuning fork. Gross hearing ability includes the ability to hear both high- and low-pitched tones. See Procedure 21-7. The Weber and Rinne Tests Hearing involves transmission of sound vibrations and generation of nerve impulses along CN VIII. The Weber test assesses both aspects. When you place a vibrating tuning fork on the center of the client's head, he should be able to sense the vibration equally in both ears. Record a positive Weber test if the vibration is louder in one ear. If the Weber test is positive, you will need to perform the Rinne test to assess the type of hearing problem. The Rinne test also uses a tuning fork to compare air conduction (AC) and bone conduction (BC). Normally AC is twice as long as BC. For step-by-step instructions for performing the Weber, Rinne, and Romberg tests, see Procedure 21-7. The Romberg Test Along with the cerebellum and midbrain, vestibular cells in the ear are responsible for maintaining equilibrium. To assess equilibrium, perform the Romberg test. You may prefer to perform the Romberg test with examination of the neurological system instead of with the ears

The abdomen

The method most commonly used to identify the location of assessment findings is the four-quadrant method, which divides the abdomen into four sections by "drawing" a line vertically from the xiphoid process to the symphysis pubis and a horizontal line at the level of the umbilicus (see Procedure 21-14, step 4). To promote comfort during the assessment, ask the client to empty his bladder before the examination. KEY POINT: When examining the abdomen, inspect and auscultate first, before percussing and palpating. Percussion and palpation stimulate the bowel and may alter bowel sounds; therefore, the examination sequence differs from other body systems. If the client has a painful area, examine that area last to minimize discomfort during the rest of the exam. Inspecting the Abdomen The skin over the abdomen is usually paler than that over other parts of the body. In clients with abdominal distention, the skin will appear taut. Distention may be normal, as with pregnancy, or it may be due to gas or fluid retention or to bowel obstruction. See Figure 21-9 for normal variations in abdominal shape. Auscultating the Abdomen Proceed in an organized manner, listening in several areas in all four quadrants (Procedure 24-14, step 4c). Use the same pattern for every examination so that it becomes a habit. First, Auscultate Bowel Sounds. Bowel sounds are high-pitched, irregular gurgles or clicks lasting one to several seconds and occurring every 5 to 15 seconds (or 5 to 30 times per min) in the average adult. Abnormal bowel sounds are described in Procedure 21-14. Next, Auscultate the Major Arteries. Major arterial vessels lie in the abdomen below the intestines. Listen over the aorta and the renal iliac and femoral arteries for the presence of bruits. Percussing the Abdomen Use indirect percussion to assess for fluid, air, organs, or masses. Some practitioners include percussion of the kidney with the abdominal examination. Palpating the Abdomen Begin with light palpation to put the patient at ease. Palpate for tenderness and guarding in all four quadrants (see Procedure 21-14). Palpation of the liver and spleen is an advanced technique not usually performed by staff nurses, except perhaps in some specialty areas.

School-Age Children

The school-age child has a rapidly expanding vocabulary and usually seeks approval of parents, teachers, and healthcare providers. Develop rapport by asking the child about his favorite school or play activities. Support independence. Allow the child to undress himself and get up on and down from the exam table. Demonstrate your equipment and let the child touch it before you use it. This makes the equipment seem less threatening. Allow time for teaching. The school-age child will be interested in how his body works, so use this opportunity for teaching.

The musculoskeletal system

The musculoskeletal system consists of bones, muscles, and joints. Bone is complex living tissue that responds to nutrition, stress, and illness. The bones include: Long bones, such as the humerus and tibia Flat bones, such as the sternum and ribs Irregular bones, such as the vertebrae and pelvis Tendons, ligaments, and cartilage serve as connecting structures. Bursae, small disc-shaped, fluid-filled sacs, act as cushions to reduce friction between the joint and the tendons that cross over the joint (Fig. 21-10). The musculoskeletal system provides shape and support to the body, allows movement, protects internal organs, produces red blood cells in the bone marrow, and stores calcium and phosphorus. Assessment of the musculoskeletal system includes evaluation of the client's posture, gait, bone structure, muscle function, and joint mobility. See Procedure 21-15. Body Shape and Symmetry To assess bone structure, examine body shape and symmetry. Major deformities in bone structure affect posture and gait. The client should be able to stand upright with the neck and head midline. There are four normal curvatures of the spine (see Procedure 21-15). The cervical and lumbar curves are concave, and the thoracic and sacral are convex. Commonly seen abnormalities include: Kyphosis—accentuated thoracic curve Scoliosis—lateral S deviation of the spine Lordosis—accentuated lumbar curve Balance, Coordination, and Movement Walking is a complex task involving balance, coordination, and movement. Pay attention to the base of support and stride as the client walks. If the client has an altered gait, try to identify the specific portion of the gait that is abnormal. If you need additional information on gait, see Chapter 33 and the illustrations in Procedure 21-15. Tests for balance, movement, and coordination are also explained in Procedure 21-15. iCare As you perform each assessment, pay attention to the client's stability and level of comfort. Do not attempt movements that may produce pain or cause the client to fall. For example, recall that Mr. Nguyen (Meet Your Patient) has bilateral knee pain. Before asking him to perform deep knee bends or hop in place, you would want to assess his pain and its triggers. Joint Mobility and Muscle Function Any joint deformity requires investigation. Color changes in a joint indicate inflammation or infection. If you see erythema or swelling, investigate further by feeling for warmth. Determine any effect the deformity has on function. To assess function, test range of motion (ROM) and muscle strength. Active ROM requires the client to move the joint through its full ROM. Passive ROM is used when the client is unable to exercise each joint independently. Instead, you support the body and move each joint through its ROM.

The neck

The neck has components of the musculoskeletal, neurological, vascular, respiratory, endocrine, and lymphatic systems. The sternocleidomastoid and trapezius muscles form the landmarks of the neck, known as the anterior and posterior triangles. The symmetrical neck muscles center and coordinate movement of the head. The trachea, thyroid gland, anterior cervical nodes, and carotid arteries are positioned in the anterior triangle; the posterior cervical nodes are in the posterior triangle. You will palpate the tracheal rings and the cricoid and thyroid cartilage in the midline of the anterior neck. To see instructions for assessing the neck and illustrations of structures of the neck consult Procedure 21-10. The Cervical Lymph Nodes The cervical lymph nodes occur in three chains (see Procedure 21-10, step 2). The lymph nodes are generally not palpable, although occasionally they can be felt, especially in young children. Normal nodes are small in size (less than 1 cm), mobile, soft, and nontender. The Thyroid Gland Normally the thyroid is smooth, firm, nontender, and often nonpalpable. However, thyroid abnormalities are common. An enlarged thyroid may be associated with either hypothyroidism or hyperthyroidism. Thyroid masses may be malignant but are usually benign.

THE NEUROLOGICAL SYSTEM

The neurological system controls or affects the function of all body systems and allows interaction with the external world. Its work is carried out through the transmission of chemical and electrical signals between the brain and the rest of the body. The basic functions of the nervous system are cognition, emotion, memory, sensation and perception, and regulation of homeostasis. A comprehensive neurological assessment takes hours to complete and is usually reserved for clients with symptoms of neurological problems. As a staff nurse in general practice, you usually perform only portions of a neurological exam. In the next few sections and in Procedure 21-16 we look at the components of a focused neurological exam. Developmental Considerations When interpreting a neurological exam, consider the following developmental changes and modifications: Infants Reflexes present at birth include rooting, sucking, palmar grasp, tonic neck reflex (fencing), and Moro. These reflexes disappear during infancy. With neurological injury, as may occur with stroke or trauma, these reflexes may return, indicating severe problems (see Chapter 9). Young Children Because language skills and motor development are age-dependent, the Denver Developmental Screening Test (Denver II, 1990) is used as a neurological screening test for young children. The Denver II examines motor, language, and coordination skills. It requires specialized training to administer and evaluate. For toddlers and older children, you can usually perform a comprehensive neurological exam with age-appropriate modifications. For example, when testing for smell, use materials that a young child knows, such as bananas or apples. Older Adults With advanced age, changes commonly observed are slower reaction time, a decreased ability for rapid problem-solving, and slower voluntary movement. The number of functioning neurons decreases. However, intelligence, memory, and discrimination do not change with normal aging. Neurological deficits in older adults are usually the result of adverse effects of medications, nutritional deficits, dehydration, cardiovascular changes that alter cerebral blood flow, diabetes, degenerative neurological conditions (e.g., Parkinson's disease or Alzheimer's disease), alcohol or drug use, depression, or abuse. Cerebral Function Cerebral function refers to the client's intellectual and behavioral functioning. It includes level of consciousness, mental status, cognitive function, and communication.

The nose

The nose and sinuses are the organs of smell and are a part of the respiratory system. Vaporized molecules sniffed into the upper nasal cavities trigger receptors that generate impulses along the olfactory nerve (CN I) that travel to olfactory centers in the temporal lobes. To identify the paranasal sinuses and for a procedure for assessing the nose and sinuse

The mouth and oropharynx

The structures of the mouth include the lips, tongue, teeth, gingiva (gums), uvula, hard and soft palate, and salivary glands and ducts. For an illustration of structures of the mouth and for instructions on examining the mouth and oropharynx, see Procedure 21-9. The Lips, Buccal Mucosa, and Gingiva. The lips, buccal mucosa (mucous membrane of the cheeks), and gums should be smooth, moist, and pink in color. Increased pigmentation (e.g., bluish or dark patches) occurs in dark-skinned clients. When inspecting the mouth, be sure to ask your client about use of tobacco, either smoked or chewed. Both forms are associated with increased risk for oral cancer. The Teeth. Tooth decay and periodontal (gum) disease are common. Poor oral hygiene is a major contributing factor for both. As you examine the mouth and teeth, talk to the patient about his oral care. Recommend toothbrushing after each meal, daily flossing, and dental checkups every 6 months. See Chapter 24 for a more complete discussion of oral hygiene and prevention of periodontal disease. The Tongue and Oropharynx. When inspecting the mouth, carefully examine the oropharynx and all aspects of the tongue: dorsal, ventral, and lateral. Procedure 21-9 for illustrations of abnormalities.

The vascular system

The vascular system is a network of arteries and veins that transport oxygen, carbon dioxide, and nutrients to the cells of the body. Arteries carry blood away from the heart. The pulmonary arteries carry oxygen-depleted blood from the right ventricle to the lungs. The systemic arteries carry oxygenated blood from the left ventricle to the body periphery. Veins carry blood toward the heart. The pulmonary veins transport oxygenated blood from the lungs to the left atrium. The systemic veins return oxygen-depleted blood from the periphery to the right atrium of the heart. The Central Vessels The carotid arteries and internal jugular veins run alongside the sternocleidomastoid muscle on both sides of the neck (see Procedure 21-13 for illustrations). These central vessels provide circulation to the brain. The Carotid Arteries Because the carotid arteries are large and close to the heart, you can easily feel a pulse over the carotid artery even when it is difficult to palpate a peripheral pulse. Never palpate both carotid arteries at the same time because bilateral pressure may impair cerebral blood flow. As a general rule, avoid palpating the carotids except during cardiopulmonary resuscitation or when it is necessary to assess them for a specific reason (such as in a comprehensive physical exam or when an underlying pathology makes it necessary to establish that circulation to the head is adequate). Turbulent blood flow through the carotid artery produces a whooshing sound known as a bruit, which you can auscultate using a stethoscope. Bruits are common among older adults. The Jugular Veins return blood from the brain to the superior vena cava. The external jugular veins are superficial; the internal jugular veins are deep. Normally the jugular veins are flat when the client is in an upright position and distend when the client lies flat. Jugular venous distention (JVD) is seen when the right side of the heart is congested because of inadequate pump function. The best position for assessment of JVD is semi-Fowler's (30° to 45° angle). The Peripheral Vessels The peripheral vessels supply blood to all the body cells. The arteries are a high-pressure system with several palpable pulse sites. The veins are a low-pressure system with valves to prevent backflow due to gravity. The veins return blood to the heart via the continuing pressure from the arterial system and pumping action of the adjacent skeletal muscles. You will assess the peripheral vascular system by: Measuring the blood pressure (see Chapter 19). Usually you will measure the blood pressure at the start of the exam as part of the general survey. Palpating the peripheral pulses (see Chapter 19). In a healthy individual, pulses will be regular, strong, and equal bilaterally. Weak, absent, or asymmetrical pulses may indicate partial or complete occlusion of the artery. Other signs of arterial occlusion include pain, pallor, cool temperature, paresthesia, or paralysis. Inspecting and performing tests for adequate perfusion. The data you obtain when inspecting and palpating the integumentary system provide some information about peripheral tissue perfusion. Recall that when an area is not adequately oxygenated, the skin may be pale, cyanotic, cool, and shiny; hair growth may be sparse; and there may be clubbing of the nails. Inadequate tissue oxygenation may be a result of chronic pulmonary problems; however, it can also result from impaired central or peripheral circulation. Refer to Procedure 21-13 for assessment of the peripheral vessels.

Purposes of a Physical Examination

To obtain baseline data. Data about the patient's physical status and functional abilities to serve as a comparison as the patient's health status changes. To identify nursing diagnoses, collaborative problems, and wellness diagnoses. Problem statements form the basis for the plan of care and help you to address the patient's nursing care needs. To monitor the status of a previously identified problem. For example, Mr. Nguyen has already begun treatment for hypertension. Today's examination will be linked to the lab results to further explore the status of his hypertension. To screen for health problems

The Skin

To perform a skin assessment, observe skin color, lesions, and other characteristics. Also notice unusual odors. An unpleasant body odor may be a sign of poor hygiene, the presence of a wound, or underlying disease. Excessive sweating may be related to activity (e.g., if the client has just finished exercising), thyroid problems, or overactive sweat glands. An odor of urine or stool may indicate a nursing diagnosis of Self-Care Deficit or Bowel or Urinary Incontinence.

The nails

Variations in color, shape, or texture of the nails may indicate health problems. For illustrations of nail variations and a step-by-step description of nail assessment, see Procedure 21-4. Nail Color Pink nails with rapid capillary refill indicate circulation to the extremities. Other color abnormalities that you may encounter include the following: Half-and-half nails, in which a distal band of reddish-pink covers 20% to 60% of the nail. These occur in clients with low albumin levels or renal disease. Mees' lines, which are transverse white lines in the nailbed. They are seen in clients who have experienced severe illnesses or nutritional deficiencies. Splinter hemorrhages, small hemorrhages under the nailbed, are associated with bacterial endocarditis or trauma. Nail Shape A change in nail shape may indicate underlying disease. Clubbing, in which the nail plate angle is 180° or more, is associated with long-term hypoxic states, such as occurs with chronic lung disease. Nail Texture Nails and surrounding epidermis are normally smooth. Chronic nail-picking results in callus formation around the nail. Occasionally, the surrounding skin becomes inflamed. This condition, known as paronychia, is painful and may require drainage if infection is present.

The eyes

Visual acuity is a measure of the eye's ability to detect the details of an image. When testing visual acuity, you will assess distant, near, peripheral, and color vision, usually with a Snellen chart. Nurses commonly perform screening tests of visual acuity. Other testing is performed by nurses in advanced or specialty practice or by an optometrist or ophthalmologist as needed. To test visual acuity, see Procedure 21-6. Distance Vision Normal vision is clear vision at 20 feet (20/20) in the right eye, left eye, and both eyes. Myopia, or diminished distant vision, is associated with a smaller fraction. For example, 20/100 vision means that to see text a person with normal vision can read at 100 feet, the client has to stand just 20 feet from the Snellen chart Near Vision A client with normal near vision will be able to read the newsprint from a distance of 35.5 cm (14 in.) without hesitation with either eye and with both eyes. Color Vision Color vision is the ability to detect color. Color blindness may be genetically inherited (usually seen in males), or it may result from macular degeneration or other diseases that affect the cones of the eye. Use the color bars at the base of the Snellen chart to test color vision. Ishihara cards are specialized cards that enable thorough testing for color blindness. They contain embedded figures within a field of color (see Procedure 21-6). Visual Field Visual field is the area the eye is able to observe. It is related to peripheral vision and extraocular muscle (EOM) function. Visual field abnormalities may be caused by problems with cranial nerves III, IV, and VI or with the retina. Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma are other disorders that limit the visual field. Peripheral vision describes the boundaries of the visual field while the eye is in a fixed position. The common phrase "I see you out of the corner of my eye" refers to peripheral vision. The EOMs control the movement of the eye and eyelids and allow you to track movement. Three cranial nerves (CN) innervate the EOM. They are CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). CN III also works together with CN II (optic) to control the pupillary reaction to light. Figure 21-2 illustrates the eye positions affected by the EOM and the corresponding cranial nerves. External Structures of the Eye To review the structure of the external eye, see Figure 21-3. There should be no pallor, dryness, or edema. Eyelids and Lashes The following are common abnormal findings on the eyelids and lashes: A pterygium is a growth or thickening of conjunctiva from the inner canthus toward the iris. Ectropion, an everted eyelid, is commonly seen in older adults secondary to loss of skin tone. It can lead to excessive dryness of the eyes. Entropion, an inverted eyelid, can lead to corneal damage. Ptosis, or drooping of the lid, may be seen in clients who have experienced a stroke (cerebrovascular accident [CVA]) or Bell's palsy (paralysis of the facial nerve, see Procedure 21-5). For ptosis and other eye abnormalities, refer to Procedure 21-6. Visual acuity is a measure of the eye's ability to detect the details of an image. When testing visual acuity, you will assess distant, near, peripheral, and color vision, usually with a Snellen chart. Nurses commonly perform screening tests of visual acuity. Other testing is performed by nurses in advanced or specialty practice or by an optometrist or ophthalmologist as needed. To test visual acuity, see Procedure 21-6. Distance Vision Normal vision is clear vision at 20 feet (20/20) in the right eye, left eye, and both eyes. Myopia, or diminished distant vision, is associated with a smaller fraction. For example, 20/100 vision means that to see text a person with normal vision can read at 100 feet, the client has to stand just 20 feet from the Snellen chart Near Vision A client with normal near vision will be able to read the newsprint from a distance of 35.5 cm (14 in.) without hesitation with either eye and with both eyes. Color Vision Color vision is the ability to detect color. Color blindness may be genetically inherited (usually seen in males), or it may result from macular degeneration or other diseases that affect the cones of the eye. Use the color bars at the base of the Snellen chart to test color vision. Ishihara cards are specialized cards that enable thorough testing for color blindness. They contain embedded figures within a field of color (see Procedure 21-6). Visual Field Visual field is the area the eye is able to observe. It is related to peripheral vision and extraocular muscle (EOM) function. Visual field abnormalities may be caused by problems with cranial nerves III, IV, and VI or with the retina. Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma are other disorders that limit the visual field. Peripheral vision describes the boundaries of the visual field while the eye is in a fixed position. The common phrase "I see you out of the corner of my eye" refers to peripheral vision. The EOMs control the movement of the eye and eyelids and allow you to track movement. Three cranial nerves (CN) innervate the EOM. They are CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). CN III also works together with CN II (optic) to control the pupillary reaction to light. Figure 21-2 illustrates the eye positions affected by the EOM and the corresponding cranial nerves. External Structures of the Eye To review the structure of the external eye, see Figure 21-3. There should be no pallor, dryness, or edema. Eyelids and Lashes The following are common abnormal findings on the eyelids and lashes: A pterygium is a growth or thickening of conjunctiva from the inner canthus toward the iris. Ectropion, an everted eyelid, is commonly seen in older adults secondary to loss of skin tone. It can lead to excessive dryness of the eyes. Entropion, an inverted eyelid, can lead to corneal damage. Ptosis, or drooping of the lid, may be seen in clients who have experienced a stroke (cerebrovascular accident [CVA]) or Bell's palsy (paralysis of the facial nerve, see Procedure 21-5). For ptosis and other eye abnormalities, refer to Procedure 21-6.

The hair

When assessing the hair, use inspection and palpation to obtain data about color, texture, distribution, and condition of the scalp. A client who does not properly groom her hair may need help with other self-care tasks. Color. There is a wide range of naturally occurring hair color. Age-related graying of the hair varies among individuals according to their genetic background. Texture. Normal hair texture varies from fine to coarse. Distribution. Generally, the hair is evenly distributed on the scalp, and fine body hair is present over the body. Alterations in hair distribution may be an indication of disease. Alopecia. Hair loss along the temples and in the center of the scalp is considered a normal balding pattern in men and is largely genetically based. Diffuse alopecia can be caused by chemotherapy for the treatment of cancer, by nutritional deficiencies, or by endocrine disorders. Thinning hair can also occur in the perimenopausal period when hormone levels are fluctuating. Patchy hair loss may be the result of fungal infections of the scalp, hair pulling, constant wearing of caps, or alopecia areata, a benign autoimmune disorder. Hirsutism. Excess facial or trunk hair may be due to endocrine disorders or steroid use. Scalp. Normally the scalp is smooth, firm, symmetrical, nontender, and without lesions. Pediculosis. The hair should be free of pediculosis (head lice infestation). Head lice are tiny, very mobile, and difficult to see. You may find it easier to see the eggs, or nits, that are deposited on the hair shaft close to the scalp.

DOCUMENTING PHYSICAL EXAMINATION FINDINGS (NAM NGUYEN)

Zach Miller has completed his physical examination of Nam Nguyen (Meet Your Patient). What follows is his charting entry. Recall that Zach is an advanced practice nurse and has performed a comprehensive physical exam. Therefore, this examination and charting entry are more extensive than what would be expected of a staff nurse. Keep in mind that you should use only abbreviations that are on your clinical agency's approved list. General Survey 56-year-old moderately obese man presents to the clinic for a physical exam in no apparent distress. Pt. appears stated age; is well dressed and groomed; and alert and oriented to time, place, and person. Speech is clear, response and affect appropriate. Moves all extremities well, gait steady and balanced. Smells of cigarettes. Integumentary Skin even in color, warm & dry, good turgor, no suspicious lesions. Well healed scar in right inguinal area. Hair clean, coarse, evenly distributed. Some graying. Nails pink, brisk capillary refill, no clubbing. Head & Neck Normocephalic, erect, midline. Scalp mobile, no lesions, tenderness, or masses. Facial features symmetrical. Thyroid gland symmetrical and not enlarged; cervical lymph nodes not palpable or tender. Eyes Snellen = right eye 20/100, left eye 20/100, both eyes 20/100. Color vision intact. Difficulty noted with near vision. Visual fields normal by confrontation. Extraocular movements intact. PERRLA at 3 mm by direct and consensual. Eyes clear and bright, + blink, no lid lag or abnormalities. Anterior chamber clear. Cornea & iris intact. Sclera white, conjunctiva clear. Lacrimal glands and ducts nontender. + red reflex bilateral, discs flat with sharp margins, vessels intact, retina & macula even in color. Ears, Nose, & Throat Skin intact, no masses, lesions, or discharge. Position WNL. External ears nontender to palpation. + whisper test. Weber—no lateralization. External canals clear without redness, swelling, lesions, or discharge. Tympanic membranes intact, light reflex and bony landmarks visible; frontal and maxillary sinuses nontender. Nares patent, able to distinguish familiar odors, mucosa pink, no discharge, septum intact with no deviation. Mouth Lips, oral mucosa, gingivae pink with no lesions. All teeth present and in good repair. Pharynx pink, tonsils absent, palate intact. Symmetrical rise of the uvula, + gag and swallow reflex. Tongue smooth, pink, symmetrical, mobile, without lesions, taste intact (correctly identified sweet, salty, and sour). Respiratory Respirations 22 breaths/min and unlabored. Trachea midline, AP less than transverse chest diameter. Chest expansion symmetrical. No tenderness, scars, masses, or lesions. Diaphragmatic excursion 5 cm. Lungs clear to auscultation. Cardiovascular PMI @ MCL at 5th ICS, P 85, regular, no murmurs, gallops, or thrills present; pulses +2, no bruits or thrills, no varicosities; jugular venous pulsation 2 cm at 45°. Carotids without bruits. Breasts Symmetrical. No masses, lymphadenopathy, or discharge. Abdomen Abdomen soft, rounded; no masses or pulsations. Surgical scar right inguinal area. +bowel sounds, +tympany throughout. CLINICALREASONING Musculoskeletal Normal spinal curvature. Joints and muscles symmetrical, no deformity. +Bilateral knee pain (right more than left). Full ROM in upper and lower extremities; +5 muscle strength; moderate crepitus right knee. Neurological Awake; alert; and oriented to time, place, and person. CN I—XII intact. Gait steady and coordinated; negative Romberg; unable to do deep knee bends due to pain. Point-point localization; superficial and deep sensation intact; +2 deep tendon reflexes. Genitourinary Circumcised male; penis nontender, no masses, urethral meatus midline, no discharge; testicles descended bilaterally, nontender, inguinal and femoral canals free of masses, prostate small, smooth, mobile, nontender. Rectal wall smooth, no masses, stool hemoccult negative.

system-specific assessment

a focused assessment limited to one body system (e.g., the lungs, the peripheral circulation). The following are examples of focused and system-specific physical assessments, respectively: Assessing bowel sounds when a client has abdominal pain Listening to breath sounds, counting respirations, and obtaining pulse oximetry readings to assess a patient's respiratory status

Ongoing assessment

is performed as needed after the initial database is completed and, ideally, at every interaction with the patient. For example, on a medical-surgical unit, each nurse who provides care to a client conducts a brief ongoing assessment to determine changes in the client's status. For more details on the types of assessment, see Chapter 3. To learn how to perform a brief bedside assessment, see Procedure 21-20.

Percussion

tapping your fingers on the skin using short strokes. Tapping (percussing) produces vibrations, and the resulting sound allows you to determine location, size, and density of underlying structures. Percussion is especially useful when assessing the abdomen and lungs (Procedures 21-12 and 21-14). A quiet environment allows you to perceive the subtle differences in percussion notes. Percussion takes practice. To learn more about percussion, see Clinical Insight 21-1.

Auscultation

the use of hearing to gather data. Direct auscultation is listening without using an instrument. If you have heard wheezing or chest congestion without the use of a stethoscope, you have already performed direct auscultation. Indirect auscultation is listening with the help of a stethoscope. To improve your skill in indirect auscultation, see Clinical Insight 21-2.

Inspection

the use of sight to gather data. You begin to use inspection the moment you meet the client and continue as you observe the person's gait, personal hygiene, affect, and behavior during the general survey, and as you evaluate each body system. Adequate lighting and proper positioning aid inspection. The otoscope, ophthalmoscope, and penlight also enhance your inspection abilities.

Olfaction

the use of the sense of smell to gather data. Some clinicians may not consider this a formal assessment skill; however, you will certainly use this skill in the clinical setting. Olfaction adds information to the data you collect through the other techniques. Consider these examples: If a client is slurring his words, you will want to look for data that reveal the cause of the problem. Slurred speech might be caused by a stroke or by sedative medications. However, if the client smells of alcohol, you would first investigate recent alcohol use as a probable cause for the slurred words. If an older client smells of urine, you would want to assess for problems with leakage of urine or inability to perform self-care. If the client's breath has a "fruity" or "acetone" odor, you would suspect ketoacidosis, which may accompany diabetes. You would know to assess the urine for ketones and contact the primary care provider if necessary.

Palpation

the use of touch to gather data. Use palpation to assess temperature; skin texture; moisture; anatomical landmarks; and such abnormalities as edema, masses, or areas of tenderness. As you move through the assessment of each body system, always inform the client when you are about to touch him. Use a gentle approach and be certain your hands are warm. Begin with light pressure to detect surface characteristics. Then move to deep palpation to assess the underlying structures. Examine last any areas of discomfort or sensitivity. (Palpation section continues on page 506.) Following is a list of the most common palpation techniques, using different parts of the hand: Fingertips: Use for fine tactile discrimination, including assessment of skin texture, swelling, and specific locations of pulsations and masses. Dorsum of hand: Use for temperature determination. Palmar surface of hand: Use for locating general area of pulsations. Grasping with fingers and thumb: Use to detect the position, shape, and consistency of a mass.