Physical Assessment: Body Systems

Describe the pulse amplitude scale:

0 is absent. 1+ is weak. 2+ is normal. 3+ is increased. 4+ is bounding.

A head to toe assessment consists of:

1. level of consciousness. 2. bilateral pulse. 3. sounds and blood pressure. 4. hygiene, also a good time to check genital and perineal. 5. legs and feet.

Time required to complete a focused assessment...

10 minutes

Time required to complete a shift assessment...

10 to 20 minutes, such as initial shift assessment.

Time required to complete an admission assessment...

30 to 90 minutes because it's thorough.

Neurologic System Assessment Scale

4+ hyperactive with clonus (spastic jerky motion), indicates disease 3+ brisker than average 2+ average or normal 1+ diminished, low normal 0 no response

Nodule

A non fluid filled hard area.

Rhonchi

Can be cleared with coughing. Continuous, low pitched, and rattling. Heard during expiration and caused by fluid partially blocking large airways.

To hear normal breath sounds...

Have the client sit up straight.

Subjective data of the neurologic system includes:

Headache, head injury, dizziness or vertigo, seizures, tremors, weakness, incoordination, numbness or tingling, difficulty in swallowing, difficulty speaking, significant past history, and environmental or occupational hazards.

Strabismus

Abnormal alignment of the eyes, having a squint.

First Level Priority Problems

Airway. Breathing. Cardiac or circulation. Signs, vital signs concerns.

In a physical assessment...

Always compare the symmetry, by looking side to side.

Graft is needed for...

An abdominal aortic aneurysm greater than 5 centimeters.

Which valve areas should be auscultated in a heart assessment?

Aortic valve at patient's right 2nd intercostal space. (Hand on chest, thumb is on aortic.) Pulmonic valve at the left 2nd intercostal space. Erb's point at 3rd left intercostal space. Tricuspid valve at left lower sternal border (4th intercostal). Mitral valve at left 5th intercostal space at midclavicular line (at apex).

Anatomy of the Heart

Apex, apical pulse. Base is at the top. Chambers, valves: atrioventricular (tricuspid and mitral valve), and semilunar (pulmonic and aortic).

What is included in subjective data of the abdomen?

Appetite and dysphagia which is the inability to swallow and could be from post CVA stroke. Food intolerance, abdominal pain, nausea and vomiting, and bowel habits. Past abdominal history, nutritional assessment, and medications because certain meds can have negative effects, such as opioids that cause constipation.

When assessing abnormalities...

Assess skin for cancer via ABCDE for basal cell, malignant melanoma, and squamous cell. Assess for pruritis or itching. And determine if abnormality is in linear form, polycystic, or zosteriform (example is singles, follows the path of a nerve).

To palpate the apical impulse of the heart (formerly PMI)...

At 4th or 5th intercostal space at the midclavicualr line. May need to roll client midway to left or have patient sit up. Use ball of hand, then fingertips to locate apical impulse. Note amplitude, size, intensity, location, and duration (do not count the rate at this time).

Third Level Priority Problems

Health problems other than those already covered. Examples are lack of knowledge, activity, rest, and family coping.

What techniques should be used to auscultate the heart during assessment?

Begin with the diaphragm. Listen to 1 sound at a time. Note the rate and rhythm. Identify S1 and S2 and assess S1 and S2 separately. Listen for extra heart sounds. Listen for murmurs with the bell.

Direct or Immediate Auscultation is...

Heard by the unaided ear or without a stethoscope. Examples include expiratory wheeze and nasal congestion.

Exopthalmos

Bulging eyes, related to thyroid.

Crackles/Rales

Cannot be cleared with coughing because crackles are low lung tissues, indicative of fluids. Coarse crackles are frying or popping, moist, and low pitched heard in inspiration and some expiration. Medium crackles are not as loud as coarse, and found in mid inspiration. Fine crackles are non continuous, popping and high pitched, at end of inspiration.

Subjective data of the heart and neck vessels includes:

Chest pain, dyspnea and orthopnea, cough (if left side of the heart has problems, it backs up to the lungs causing fluid, crackles), fatigue, cyanosis or pallor, edema (swelling, right side of theheart has problems so backs up to rest of body), nocturia, past cardiac history, family cardiac history, and personal habits (cardiac risk factors) such as cholesterol, diet, ascites or fluid in belly.

What is heard in the first heart sound, S1 or lub?

Closure of the AV valves. Beginning of systole. Heard loudest at the apex (bottom). *Erb's is in the middle so S1 equals S2.

What is heard in the second heart sound, S2 or dub?

Closure of the semilunar valves. End of systole. Loudest at the base (top of the heart).

In the mouth and throat, look for:

Color (pallor, cyanosis, cherry-red lips associated with CO poisoning), lesions, moistness, exudate or drainage, edema, ulceration, inflammation, and presence of dentures.

What should be assessed for nails?

Color, for example if yellow, thick cracked nails, treat for fungus. Check for clubbing and capillary refill in less than 3 seconds.

For skin, hair, and nails, review:

Color, temperature, moisture, texture, edema (Swelling, pitting or non pitting), turgor (measure of hydration), vascularity (for example, shiny without hair indicates a circulation problem), bruising, and lesions (such as abscesses).

What is heard in the fourth heart sound, S4?

Considered an extra heart sound and sounds more like a gallop. Atrial diastolic gallop. Occurs at end of diastole when ventricle resistant to filling. Heard best at the apex of the heart with patient in supine or left lateral position, use bell. Low pitched sound heard late in diastole just before S1 (Ten - nes - see). Heard in elderly patients or those with previous myocardial infarction.

What is heard in the third heart sound, S3?

Considered an extra heart sound. Ventricular diastolic gallop. Vibrations caused by ventricular filling. Occurs when ventricles are resistant to filling. Heard best at the apex of the heart with patient in supine or left lateral position, use the bell. Dull, low pitched sound heard immediately after S2, Ken S1 - tuck S2 - y S3. Normal in children and young adults. Presence in adults over 30 indicates ventricular failure (CHF).

Wheezes

Continuous and high pitched, heard on inspiration or expiration (more so) or both. Caused by constriction of airway with resultant blockage of air flow.

Subjective data of the lungs and thorax includes:

Cough, chest pain, history or respiratory infections, smoking history (have they and for how long), environmental exposure, and self care behaviors.

For color of the skin, watch for:

Cyanosis meaning blue. Pallor meaning pale. Jaundice meaning yellow, on the sclera or skin indicating liver issues. Erythema meaning redness.

To hear tracheal breath sounds...

Heard over the trachea, they are harsh and high pitched. Inspiration is less than expiration.

Deep Palpation is...

Depresses skin 1.5 to 2 inches (3.8 to 5 cm). Uses firm, deep pressure. May use one hand on top of the other for more pressure. Used to feel internal organs or masses for size, shape, symmetry, mobility, and tenderness. Typically not done by the nurse.

Urinary System

Determine voiding pattern. Inspect the abdomen for bladder distention an the urine for COCA, if cloudy or odorous could indicate UTI. For a foley catheter or suprapubic catheter, provide catheter care.

Vertigo

Dizziness

Percussion is...

Done by tapping the fingers sharply and rapidly against the patient's body, for instance, against the lungs, abdomen, or liver. Helps locate organ borders, shape, and position. Can tell if the organ is solid or filled with fluid or gas. 2 types are direct, on the organ, or indirect, on the finger on the organ.

Different functions for different parts of the hand:

Dorsal surface is used for temperature. Finger tips are used for texture, size, pulse, form, etc. Palmar surface is used for vibration, for example, detecting a thrill or graft where vessels are put together.

Diplopia

Double vision

Upward palpebral slant of the eyes indicates...

Downs Syndrome

Otorrhea

Drainage of the ears

Ptosis

Drooping of the eyes

Vesicle

Elevated and filled with serous fluid, for example, a blister or herpes.

Papules

Elevated and less than 1 centimeter. For example, a mole.

Wheal

Examples include PPD, insect bite, and hives.

Pustule

Examples include a zit or acne, impetigo. They are elevated and filled with pus.

Inspect the female genitalia for:

External genitalia for inflammation, irritation, skin color, hair distribution, lesions, and parasites. Urethral orifice for inflammation or discharge. Vaginal orifice for inflammation or discharge, edema or discoloration, and discharge.

When inspecting the eyes, look at:

Extraocular structures and conjunctiva around the sclera, iris, and pupil.

Macule

Flat and colored. Could be an age spot. Less than 1 centimeter. Examples include freckles or birth marks.

Cyst

Fluid filled, palpable, and encapsulated. Glowing red with a pen light indicates fluid filled. If not glowing red, it is not fluid filled.

When assessing the heart...

Focus on systole, then diastole. Listen first with the diaphragm, then the bell at all sights. Listen for extra sounds such as a midsystolic click or mitral valve prolapse, and during systole for S3 and S4. Also listen for murmurs such as bruits or swishing and turbulence or back flow.

Percuss the muscles of the musculoskeletal system:

For pain or cramps and weakness.

Percuss the bones of the musculoskeletal system:

For pain, deformity, and trauma including fractures, sprains, and dislocations. *Also perform a functional assessment for ADLs and assess for self care behaviors.

Percuss the joints of the musculoskeletal system:

For pain, stiffness, swelling, heat, and redness, and limitation of movement.

How can we interpret and assess tactile fremitus?

Fremitus means vibration. Vibrations will be more intense in areas of tissue consolidation (pneumonia). Less intense vibrations may mean the presence of emphysema, pneumothorax or pleural effusion. If vibrations in upper posterior thorax are faint or absent, there may be bronchial obstruction or a fluid filled pleural space.

Pitch is...

Frequency of sound waves.

What are the characteristics of auscultating heart sounds?

Frequency or pitch, being high or low (diaphragm hears S1 and S2 while bell hears S3 and S4). Intensity or loudness, being loud or soft. Duration and timing during systole or diastole.

General Genitalia Subjective Data

Frequency, urgency, and nocturia. Dysuria. Hesitancy and straining. Urine color, associate REDA and COCA. Past genitourinary history. Penis with pain, lesions, and or discharge. Scrotum with self care behaviors such as lump exams. Sexual activity and contraceptive use. STD contact.

When examining the eyes, always note:

General appearance for symmetry, irritation, discharge, and swelling. Visual acuity check with the Snellen chart, has a big E at the top and measures what patient can see at 20 ft, which is indicated by 20/20. Corneal light reflex is also addressed here.

Use the diaphragm of the stethoscope for...

High-pitched sounds

How to determine elasticity:

If skin pops back into place, patient is well hydrated. If skin illustrates turgor, patient is dehydrated.

What should be inspected and palpated in the arms and legs of the peripheral vascular system?

In the arms: assess pulses, symmetry, and lesions. In the legs: assess symmetry, pulses, temperature, and lesions, measure calf circumference if discrepancy, and palpate teh lymph nodes.

Neurochecks

Indicated after head trauma, cranial surgery, change in LOC, and possibility of brain swelling/compression (IICP). Done at specified intervals. Includes: LOC and orientation, PERRLA, ability to follow commands, ability to move all extremities, and muscle strength.

Flow of Blood through the Heart

Inf. vena cava and sup. vena cava → r. atrium →tricuspid valve →r. ventricle→pul. semilunar valve→pul. arteries→lungs→pul. veins→l. atrium→bicuspid valve→l. ventricle→aortic semilunar valve→aorta→body

What should be assessed on the head and neck?

Inspect for position and size such as hydrocephalus (fluid on the brain) and acromegaly (features keep growing). Inspect for symmetry, presence of nodules, masses, and bulges. Use of neck muscles with breathing. Look for jugular vein distention to check for too much fluid on board and lymphadenopathy by palpating the lymphnodes for enlargement with lymphedema.

Male Genitalia

Inspect the glans penis and urethra for position of the meatus, inflammation or discharge, and edema. Inspect the scrotum for swelling, inflammation, lesions, and ask or teach about the testicular self-exam.

Jugular Veins

Inspect the veins for distention: normally full when the client is in supine position, as the head of the bed is raised slowly to sitting position, jugular vein should flatten and disappear at 45 degree angle. If it doesn't disappear, it's distended and has fluid overload.

Nystagmus

Irregular eye movement related to drugs or congenital issues

Describe edema in the vascular system...

It is swelling in dependent part of the body. Non pitting yields no indentation with pressure. Pitting could be: 1+ or 2mm indicating mild pitting slight indentation and no swelling of the leg, 2+ or 4mm indicates moderate pitting and indentation leaves quickly, 3+ or 6mm indicates deep pitting indentation remains for a while and leg appears swollen, and 4+ or 8mm indicates very deep pitting indentation remains for a long time and leg is very swollen.

Inspect the musculoskeletal system for:

Joint size and contour, joint deformities ex. rheumatoid arthritis, skin color and swelling ex. warmth and tenderness, observe the gait and posture. Note lordosis (larger butt/lumbar), kyphosis (hunchback), or scoliosis (S shape).

What should be inspected for around the umbilicus:

Position and color, a bluish color around the umbilicus occurs with intra-abdominal bleeding indicating Cullen's sign. Inversion, if everted, could indicate ascites associated with the liver, masses, or hernia. Also inspect hair distribution, and marked pulsations or peristalsis.

Subjective data of the peripheral vascular system includes...

Leg pain or cramps. Skin changes on the arms or legs such as shine, graying, or color. Swelling. Lymph node enlargement. Medications.

In the rectum and anus, inspect for:

Lesions, rashes, inflammation and irritation, and hemorrhoids.

Abnormalities of the mouth could include:

Leukoplakia, white patches. Candidiasis, fungus due to good bacteria being killed off. Cancer. Black hairy tongue, related to dry mouth, smoking, diet, meds, etc. Gingivitis, inflammed gingiva.

Assess the neurologic system for:

Level of consciousness (LOC), orientation meaning person, place, and time, and glascow coma scale if unresponsive maybe a head injury. Assess speech if clear or garbled, and if the patient has trouble finding words or expressing thoughts. Assess for memory lapses and deficits, and coordination and balance.

For the mouth and throat, inspect the:

Lips, gingiva (gums), buccal mucosa (cheeks), tongue, and pharynx (throat). Inspecting the mouth is especially important in elders.

Auscultate the abdomen for vascular sounds:

Listen for bruits over the aorta, renal, iliac, and femoral arteries.

Auscultate the abdomen for bowel sound in all 4 quadrants:

Listen for character and frequency, sounds are heard every 5 seconds. 5 to 35 sounds is normal, greater than 35 sounds is hyperactive: loud, high pitched, rushing or tinkling, less than 5 sounds is hypoactive. 0 sounds mean absent, so listen for 5 minutes in each quadrant, common after anesthesia (immobility for surgery).

Auscultation

Listening for breath, heart, and bowel sounds, sometimes pulse sounds too. Performed with or without a stethoscope. Stethoscope should be placed on skin, not clothes. Sounds are described by pitch, intensity, duration, and quality.

To hear bronchovesicular breath sounds...

Located at the lower chest in the secondary bronchus. Heard next to the sternum and between the scapulae. Medium in loudness and in pitch. Inspiration equals expiration.

To hear vesicular breath sounds...

Located outside the center of the chest, and every where else. Heard in the rest of the lung, periphery. Soft and low pitched. Inspiration is greater than expiration.

When looking for pattern and configuration of lesions...

Look for excoriation, scar, atrophic scar, lichenification, port wine stain, and peteciae. Port wine stain (considered a birth mark) and peteciae are both just vascular lesions.

Observe the chest over the thorax and lungs:

Look for shape and symmetry: Barrel chest (emphysema), pectus excavatum (sunken in), pectus carinatum (pronounced), scoliosis (curvature of the spine), and kyphosis (hump in the spine). Also look for swelling, masses, and abnormal skin.

When assessing the abdomen...

Look, listen, and feel, in that order.

In the abdomen, instead of inspecting, palpating, percussing, and auscultating...

Look, listen, and feel.

Intensity is...

Loudness

Use the bell of the stethoscope for...

Low sounds

Primary lesions on the skin include:

Macules, papules, plaques, vesicles, pustules, cysts, nodules, and wheals.

What is percussion of the heart used for?

May help to locate the cardiac borders. Not as useful a tool in cardiac assessment.

Female Genitalia Subjective Data

Menstrual history, obstetric history, menopause, self care behavior, urinary symptoms, vaginal discharge, past history, sexual activity, contraceptive use, STD contact, and STD risk education.

Second Level Priority Problems

Mental status change. Acute pain. Acute urinary elimination problems. Untreated medical problems. Abnormal laboratory values. Risks of infection, safety, or security. *Mothers Always Advise Us to Act Responsibly

What is PERRLA?

Method to check pupils constricting as light comes in. Pupils. Equal. Round. React to. Light. Accommodation (constrict and convert).

When assessing the heart for rate and rhythm...

Normal beats are 60 to 100 per minute. Regular or irregular rhythm. Note the irregularities such as premature beats, irregularly irregular rhythm, and pulse deficit ( a difference between apical pulse and radial pulse).

Observe the breathing pattern of the thorax and lungs:

Normal, tachypnea (fast breathing greater than 20), hyperventilation (quick deep breathing pattern), bradypnea (slow breathing less than 12), hypoventilation (slower, deep breathing pattern), cheyne stokes respirations (breathing in periods of apnea), biot's repsirations, chronic obstructive breathing (COPD), and kussmaul's respirations (deep breathing pattern, diabetic ketoacidosis, trying to blow off CO2).

In relation to the head and neck:

Normocephalic means normal head. Microcephalic means smaller head. Macrocephalic means larger head. Torticollis, neck is in a strange position with the head.

Pleural Friction Rub

Not as long as a crackle. Low pitched, grating, rubbing. Heard on inspiration and expiration. Caused by inflammation of the pleura. May have pain in the area where heard.

Massage is...

Not frequently used anymore, perform per institution policy because it could cause the clot to move more toward the heart and lungs.

What should be inspected under the general appearance of the heart?

Obese or thin, anxious and alert, note skin color, clubbing, check for mucous membranes for pallor if necessary, observe chest for palpations, symmetry, retractions, and heaves (right ventricular at sternal border and left ventricular at apex), and use tangenital light source to locate apical impulse.

When inspecting the ears, inspect for:

Position (low set ears indicate Downs Syndrome), condition of the skin, presence of lesions, and drainage. Watch for hearing impairments and hearing aids.

Carotid Artery

Palpate medial to sternocleidomastoid muscle: avoid excessive pressure, palpate one at a time, note contour and amplitude, and should be same bilaterally. Auscultate for bruits: use the bell, listen for blowing and swishing sound indicating turbulent blood flow, normally no bruits are present.

In a review of systems...

Patient gives a subjective response to a series of body-system related questions. The review is cephalo-caudal meaning head to toe. Sign and symptom related questions. Need to document positive and negative findings. Follow up with positive findings, for example a wet cough.

When inspecting the lungs and thorax, observe signs for respiratory distress:

Patients look anxious because they cannot breathe. Signs could be shortness of breath (SOB), restlessness, decreased mental alertness, cyanosis, pallor, nasal flaring, orthopnea (breathing is easier in a seated position, leaning forward), intercostal retractions (space between the rib cage retracts), use of accessory muscles, and increased heart rate.

Equipment needed for a neurologic exam:

Pen light, tongue blade, cotton swab, cotton ball, tuning fork either 128 Hz or 256 Hz, percussion hammer, and occasionally an aromatic substance.

During a neurologic system assessment:

Perform a mental status exam, and test the cranial nerves by turning the head, blinking, open and closing the mouth, and sticking out tongue. Inspect and palpate the motor system via gait and balance, knee flexion with a hop or shallow knee bend, and rapid alternating movements. Assess cerebellar function with balance tests via gait, tandem walking, romberg test, and shallow knee bend, and also with coordination ad skilled movements such as rapid alternating movements, finger to finger test, finger to nose test, and heel to shin test. Test sensory function via superficial pain and light touch with arms and legs, vibration with arms and legs, and position sense.

Percuss the abdomen for costovertebral angle tenderness (CVA):

Place one hand over the 12th rib at the CVA on back, thump that hand with the ulnar ridge of the other hand. The client should feel a thud but no pain. Sharp pain occurs with kidney inflammation.

To check for normal vibrations and sound:

Place open palms on both sides of the patient's back and ask the patient to say 99 loud enough to hear the vibrations, repeat on the anterior chest.

When palpating the lungs and thorax:

Place palms lightly over the chest and palpate for masses, tenderness, alignment, and retractions of chest or intercostal spaces. Use fingertips to feel for lumps, scars, lesions, and ulcerations, temperature, turgor, moisture, and subcutaneous crepitus (common with chest tubes, air in subcutaneous tissue, a popping sound, related to pneumothorax or air in lungs and emphysema).

When inspecting the nose, inspect for:

Placement, nasal flaring, drainage, naval mucosa, and deviated septum (indicates breathing problems).

Indirect Percussion...

Pressing the distal middle finger (non dominant hand) on the body part, keeping the rest of the hand off of the body surface. Flex wrist of dominant hand and strike point where middle finger of other hand touches the patient's skin. Keep fingers perpendicular. Listen for sounds. Determine if sounds are over air, solid tissue, or dense tissue.

Periorbital Edema

Puffy eyes or swelling around the eyes. *arcus senilis indicates a cholesterol problem

When assessing circulation of the vascular system...

Pulses, use Doppler if unable to palpate. Pain, pallor, and paresthesia which is diabetic nerve pain. Temperature and compare bilateral extremities. *If patient presents with a clot, ambulate to instructor or call 911, do not move the patient so as not to dislodge the clot.

When checking the eyes, check:

Pupil size, pupillary response to light and accommodation. . Check via PERRLA

Plaque

Raised silvery area because the first level of the skin is absent.

Assess the joints of the musculoskeltal system for:

Range of motion and muscle tone and strength. Flexion is bent or flexed, and extension is extended. *Always compare both sides of the body.

Tinnitis

Ringing in the ears

What should be assessed for the hair and scalp?

Should be assessed for lesions, lumps, and bruises. Assess for abnormal hair distribution such as hirsutism (excess hair) and alopecia (loss of hair). Also assess for pediculosis (lice), prevalent with little hygiene care, and sometimes have to where caps for outbreaks.

Palpate the abdomen for:

Size, location, and consistency of organs. For abnormal masses. LASTly, tenderness: voluntary guarding from cold, tickling, or tensity, involuntary guarding from constant board-like hardness, and rebound tenderness from pain on release of pressure, associated with appendicitis.

Inspect the skin of the abdomen for:

Smooth and evenness, color such as jaundice, redness, striae or silvery white jagged lines, moles, petechiae, and cutaneous angioma or spider nevi (spider pattern on belly) which is indicative of portal hypertension and liver disease. If taut and shiny, ascites. Also for lesions and rashes.

Indirect or Mediate Auscultation is...

Sounds heard with a stethoscope.

Abnormal Gaits

Spastic hemiparesis is slow walk. Cerebellar ataxia is chunky walk. Parkinsonian (festinating) is shuffling gait or mask face. Steppage or foot drop is a gait with wide elevated step or foot board for muscle wasting of foot "dropping". Also scissors, waddling, and short leg.

To test for pitting:

Squeeze the body part. It does not hurt the patient to test for pitting.

What is the Glascow Coma Scale (GCS)?

Standardized objective assessment that defines level of consciousness. Gives level of consciousness a numeric value. Determines best: eye opening response, motor response, and verbal response. A fully alert normal person's score is 15.

Borborygmus

Stomach growling or hunger. *Early bowel obstruction sounds extreme, like alien.

Quality is...

Subjective data. For instance, sounds could be rumbling, blowing, or musical.

What should be inspected or looked for on the abdomen:

Symmetry and contour, discomfort, splinting, guarding, lesions and scars, and bruising and discoloration because any bruising on the belly could indicate internal bleeding. Swelling, bulges, distention, for instance, distention with no bowel movement is a problem. Ostomies, drains, and dressings. Ostomies are reroutes ad could be permanent or temporary, for example, an ileostomy would be more liquid while a colostomy would be less liquid.

What are all of the pulses of the body?

Temporal, carotid, brachial, radial, apical, femoral (used for femoral cathaterization), popliteal, posterior tibialis (inside leg), and dorsalis pedis (come down from middle of 2nd and 3rd toe). Assess bilaterally unless you are counting a pulse.

What do the sounds we percuss, determine?

The less dense the tissue (meaning more air) the louder and teh longer the sound. Tympany is heard in the least dense tissue. It's a hollow sound for example, the stomach. Resonance, for example the lung. Hyperresonance, for example, an emphysema patient. Dullness, for example, in the liver or spleen. Flatness, the most dense tissue, for example, the muscle.

To hear bronchial breath sounds...

They are in the upper chest in the primary bronchus, they are heard next to the trachea. They are loud and high pitched. Inspiration is greater than expiration.

Duration is...

Time

Palpation is...

Touching the patient with different parts of your hands, there is deep and light palpation. Palpate tender areas last. Nails should be short and hands should be warm. Wear gloves if in contact with mucous membranes or body fluids.

To palpate across the precordium of the heart...

Use palmar surface of the fingers. Palpate the apex, left sternal border, and base. Note any heaves or thrills, vibrations signaling turbulent blood flow, normally none present. *Also palpate the sternoventricular, aortic, pulmonic, tricuspid, and epigastric areas for abnormal pulsations.

Direct Percussion...

Using 2 fingers to tap directly on a body part. Ask the patient where it is painful. Watch for signs of discomfort. Also used to check the sinuses.

Light Palpation is...

Using finger pads with very light touch. Depress the skin .5 to .75 inches (1.25-2 cm). Assess for texture, tenderness, moisture, elasticity, pulsations, surface organs, and masses.

Subjective data of the anus, rectum, and prostate:

Usual bowel routine, change in bowel habits, rectal bleeding or blood in the stool (dark blood is from upper GI, bright red is from lower GI and could indicate hemorrhoid cancer), medications such as laxatives, stool softeners, and iron, rectal conditions such as pruritis, hemorrhoids, fissure and fistula, family history, and self care behaviors such as diet and recent exams.

Cardiac Cycle: Systole

Ventricles contract, emptying phase. Semilunar valves open.

Cardiac Cycle: Diastole

Ventricles relaxed, filling phase. AV valves open.

Inspection

Visual examination of size, shape, color, symmetry (from side to side), position (deformities), and abnormalities.

Palpate the joints of the musculoskeletal system for:

Warmth, tenderness, swelling, and masses.

Auscultation of the Lungs and Thorax

We auscultate in 6 places on the front and 6 on the back plus 1 on each side. Breath sounds could be normal, decreased or diminished (in bases where fluid builds up 1st), absent, increased, or adventitious (irregular).

Percussion Sounds of the Lungs and Thorax

We percuss in places we auscultate (6 places in front, and 6 in back, down and over). Resonance is heard over normal lung tissue. Dull sounds are heard over the heart. Hyperresonance is heard if there is increased air in the lungs or pleural space. Abnormal dullness is found with areas of decreased air in the lungs.

What is Homan's sign in the vascular system?

With the client in supine position, dorsiflex foot toward the tibia. This should not cause pain. Calf pain may indicate deep vein thrombosis, phlebitis, tendonitis, muscle injury or lumbosacral disorders. A positive Homer's sign occurs in 35% of deep vein thrombosis patients.

Stridor

Worse than a wheeze. Continuous, high pitched, and loud. Heard on inspiration. Caused by imminent obstruction of the airway.