Saunders Book Health Assessment

Testing CNVIII

Assessing the client's ability to hear tests the cochlear portion ▪ Assessing the client's sense of equilibrium tests the vestibular portion ▪ Check the client's hearing, using acuity tests ▪ Observe the client's balance and watch for swaying when he or she is walking or standing ▪ Assessment of sensorineural hearing loss may be done with the Weber or Rinne test

Auscultation of the heart

Auscultate heart rate and rhythm; check for a pulse deficit (auscultate the apical heartbeat while palpating an artery) if an irregularity is noted. Assess S1 ("lub") and S2 ("dub") sounds, and listen for extra heart sounds, as well as the presence of murmurs (blowing or swooshing noise that can be faint or loud with a high, medium, or low pitch).

Brudzinski's sign testing

Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest) and there should be no reports of pain or resistance to the neck flexion; a positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

Testing light touch

Brush a piece of cotton over the client's skin at various locations in a random order and ask the client to say when the touch is felt.

CNII test

Assess visual acuity with a Snellen chart and perform an ophthalmoscopic exam Check peripheral vision by confrontation Check color vision

Judgment

Determine whether the client's actions or decisions regarding discussions during the interview are realistic

recent vs remote memory

Assessed by asking the client to recall a recent occurrence (e.g., the means of transportation used to get to the health care agency for the physical assessment) Assessed by asking the client about a verifiable past event (e.g., a vacation).

Babinski's sign

Dorsiflexion of the great toe and fanning of the other toes (Babinski's sign) is abnormal in anyone older than 2 years and indicates the presence of central nervous system disease indicating an upper motor neuron lesion.

DTRs

Includes testing the following reflexes: biceps, triceps, brachioradialis, patella, Achilles

Lordosis (Swayback)

Increased lumbar curvature

Alopecia

hair loss

The alignment of the upper and lower jaw is assessed by

having the client bite down

hypertonicity vs hypotonicity

increased tone (hypertonicity) or little tone (hypotonicity)

Inspection and palpation of the ear

Inspect and palpate the external ear, noting size, shape, symmetry, skin color, and the presence of pain. Inspect the external auditory meatus for size, swelling, redness, discharge, and foreign bodies; some cerumen (earwax) may be present.

Ptosis, exophthalmos, enophthalmos

inspect eyelids for ptosis (drooping); eyeballs for exophthalmos (protrusion) or enophthalmos (recession into the orbit; sunken eye)

When performing an abdominal assessment, the specific order for assessment techniques is

inspection, auscultation, percussion, and palpation

Order of assessment steps

inspection, palpation, percussion, and auscultation (EXCEPT GI)

normal capillary refill time

less than 3 seconds

Start with _____ palpation to detect surface characteristics, and then perform ______ palpation

light, deeper

Position for female genitalia exam

lithotomy

A positive Brudzinski's sign or Kernig's sign indicates

meningeal irritation.

CNII

optic sensory controls vision

Testing for accommodation

Ask person to focus on distant object, which should dilate the pupils. Then have the person shift their gaze to a near object such of your finger held about 3 inches away from their nose. Normal response includes 1) pupillary constriction and 2) convergence of the axes of the eyes

Percussion

. Involves tapping the client's skin to assess underlying structures and to determine the presence of vibrations and sounds and, if present, their intensity, duration, pitch, quality, and location Provides information related to the presence of air, fluid, or solid masses as well as organ size, shape, and position

Scoring DTRs

0 ¼No response 1+¼Sluggish or diminished 2+¼Active or expected response 3+¼Slightly hyperactive, more brisk than normal; not necessarily pathological 4 +¼Brisk, hyperactive with intermittent clonus associated with disease

Pitting edema scale

1+ A barely perceptible pit, 2mm 2+ A deeper pit, rebounds in a few seconds, 4mm 3+ A deep pit, rebounds in 10-20 seconds, 6mm 4+ A deeper pit, rebounds in >30 seconds, 8mm

Egophony

1. Ask the client to repeat a long "ee-ee-ee" sound. 2. Normally the nurse would hear the "ee-ee-ee" sound.

Bronchophony

1. Ask the client to repeat the words "ninety-nine." 2. Normal voice transmission is soft, muffled, and indistinct.

Whispered Pectoriloquy

1. Ask the client to whisper the word "ninety-nine." 2. Normal voice transmission is faint, muffled, and almost inaudible.

Testing pupillary light reflex

1. Darken the room (to dilate the client's pupils) and ask the client to look forward. 2. Test each eye. 3. Advance a light in from the side to note constriction of the same-side pupil (direct light reflex) and simultaneous constriction of the other pupil (consensual light reflex).

Testing for pain

Assess by applying an object with a sharp point and one with a dull point to the client's body in random order; ask the client to identify the sharp and dull feelings

Attention span

Assess client's ability to concentrate.

Orientation

Assess client's orientation to person, place, and time.

Test for past pointing

1. The client sits in front of the examiner. 2. The client closes the eyes and extends the arms in front, pointing both index fingers at the examiner. 3. The examiner holds and touches his or her own extended index fingers under the client's extended index fingers to give the client a point of reference. 4. The client is instructed to raise both arms and then lower them, attempting to return to the examiner's extended index fingers. 5. The normal test response is that the client can easily return to the point of reference. 6. The client with a vestibular function problem lacks a normal sense of position and cannot return the extended fingers to the point of reference; instead, the fingers deviate to the right or left of the reference point.

Dix-Hallpike Maneuver

1. The client starts in a sitting position; the examiner lowers the client to the exam table and rather quickly turns the client's head to the 45-degree position. 2. If after about 30 seconds there is no nystagmus, the client is returned to a sitting position and the test is repeated on the other side.

Gaze Nystagmus Evaluation

1. The client's eyes are examined as the client looks straight ahead, 30 degrees to each side, upward and downward. 2. Any spontaneous nystagmus—an involuntary, rhythmic, rapid twitching of the eyeballs—represents a problem with the vestibular system.

Test for falling

1. The examiner asks the client to stand with the feet together, arms hanging loosely at the sides, and eyes closed. 2. The client normally remains erect, with only slight swaying. 3. A significant sway is a positive Romberg sign.

Normal visual acuity is:

20/20 (distance in feet at which the client is standing from the chart/ distance in feet at which a normal eye could have read that particular line)

Grading the force of the pulse

4 +¼Strong and bounding 3+¼Full pulse, increased 2+¼Normal, easily palpable 1+¼Weak, barely palpable

Extraocular muscle function test

6 cardinal positions of gaze, indicates the functioning of cranial nerves III, IV, and VI. a. The 6 muscles that attach the eyeball to its orbit and serve to direct the eye to points of interest are tested. b. Client holds head still and is asked to move his or her eyes and follow a small object. c. The examiner notes any parallel movements of the eye or nystagmus, an involuntary, rhythmic, rapid twitching of the eyeballs.

Other things to assess during palpation

Assess texture, temperature, and moisture of the skin, as well as organ location and size and symmetry if appropriate. Assess for swelling, vibration or pulsation, rigidity or spasticity, and crepitation. Assess for the presence of lumps or masses, as well as the presence of tenderness or pain.

Papanicolaou (Pap) smear (test)

A painless screening test for cervical cancer is done; the specimen is obtained during the speculum examination, and the nurse helps to prepare the specimen for laboratory analysis.

Pleural friction rub

A superficial, low-pitched, coarse rubbing or grating sound. Sounds like 2 surfaces rubbing together. Heard throughout inspiration and expiration. Loudest over the lower anterolateral surface. Not cleared by cough Heard in individuals with pleurisy (inflammation of the pleural surfaces)

CNVIII

Acoustic or Vestibulocochlear ▪ Sensory ▪ Controls hearing and vestibular function

Inspection of the eye normal findings

Inspect the conjunctiva (should be clear), sclera (should be white), and lacrimal apparatus (check for excessive tearing, redness, tenderness, or swelling); cornea and lens (should be smooth and clear); iris (should be flat, with a round regular shape and even coloration); eyelids; and pupils

Auscultation

Involves listening to sounds produced by the body for presence and quality, such as heart, lung, or bowel sounds

Checking for inflammation in dark skinned clients

Check for warmth or a shiny or taut and pitting skin area, and compare with the unaffected side.

Checking for cyanosis in dark skinned clients

Check lips and tongue for a gray color; nail beds, palms, and soles for a blue color; and conjunctivae for pallor

Checking for jaundice in dark skinned clients

Check oral mucous membranes for a yellow color; check the sclera nearest to the iris for a yellow color.

Types of Health and Physical Assessments

Complete assessment, focused assessment, episodic/follow-up assessment, emergenct assessment

Emergency Assessment

Involves the rapid collection of data, often during the provision of life-saving measures

Inspection of the breasts

Performed with the client's arms raised above the head, the hands pressed against the hips, and the arms extended straight ahead while the client sits and leans forward retraction, or dimpling; color and venous pattern; size, color, shape, and discharge in the nipple and areola; and the direction in which nipples point.

CN III, IV, and VI

Cranial Nerve III: Oculomotor ▪ Motor ▪ Controls pupillary constriction, uppereyelid elevation, and most eye movement Cranial Nerve IV: Trochlear ▪ Motor ▪ Controls downward and inward eye movement Cranial Nerve VI: Abducens ▪ Motor ▪ Controls lateral eye movement

CNIX and X

Cranial Nerve IX: Glossopharyngeal ▪ Sensory and motor ▪ Controls swallowing ability, sensation in the pharyngeal soft palate and tonsillar mucosa, taste perception on the posterior third of the tongue, and salivation Cranial Nerve X: Vagus ▪ Sensory and motor ▪ Controls swallowing and phonation, sensation in the exterior ear's posterior wall, and sensation behind the ear ▪ Controls sensation in the thoracic and abdominal viscera

cyanosis erythema pallor jaundice

Cyanosis: Mottled bluish coloration Erythema: Redness Pallor: Pale, whitish coloration Jaundice: Yellow coloration

Kyphosis (Hunchback)

Exaggeration of the posterior curvature of the thoracic spine

CNVII

Facial ▪ Sensory and motor ▪ Controls movement of the face and taste sensation

Arteries in the Legs

Femoral Pulse: Located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine Popliteal Pulse: Located behind the knee Dorsalis Pedis Pulse: Located at the top of the foot, in line with the groove between the extensor tendons of the great and first toes Posterior Tibial Pulse: Located on the inside of the ankle, behind and below the medial malleolus (ankle bone)

Focused Assessment

Focuses on a limited or short-term problem, such as the client's complaint

Episodic/ Follow-up Assessment

Focuses on evaluating a client's progress.

Testing CN1

Have the client close the eyes and occlude 1 nostril with a finger Ask the client to identify nonirritating and familiar odors (e.g., coffee, tea, cloves, soap, chewing gum, peppermint) Repeat the test on the other nostril

Fine crackles

High-pitched crackling and popping noises (discontinuous sounds) heard during the end of inspiration. Not cleared by cough Maybe heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases

Wheeze (or sibilant wheeze)

High-pitched, musical sound similar to a squeak. Heard more commonly during expiration, but may also be heard during inspiration. Occurs in small airways Heard in narrowed airway diseases such as asthma

CNXII

Hypoglossal ▪ Motor ▪ Controls tongue movements involved in swallowing and speech

Complete Assessment

Includes a complete health history and physical examination and forms a baseline database

Scoliosis

Lateral spinal curvature

Doing light vs deep palpation

Light palpation is done with 1 hand by pressing the skin gentlywith the tips of2 or 3 fingers held closetogether;deep palpation isdonebyplacing 1 hand on top of the other and pressing down with the fingertips of both hands.

Carotid artery assessment

Located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle Palpate 1 carotid artery at a time to avoid compromising blood flow to the brain. Auscultate each carotid artery for the presence of a bruit (a blowing, swishing, or buzzing, humming sound), which indicates blood flow turbulence; normally a bruit is not present

Checking for bleeding in dark skinned clients

Look for skin swelling and darkening and compare the affected side with the unaffected side

Coarse crackles

Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration Maybe heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases, condition is worse or may be heard in terminally ill clients with diminished gag reflex. Also heard in pulmonary edema and pulmonary fibrosis

Rhonchi (sonorous wheeze)

Low-pitched, coarse, loud, low snoring or moaning tone. Actually sounds like snoring. Heard primarily during expiration, but may also be heard during inspiration. Coughing may clear Heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis

Percussion of the heart

May be performed to outline the heart's borders and to check for cardiac enlargement (denoted by resonance over the lung and dull notes over the heart).

Medium crackles

Medium-pitched, moist sound heard about halfway through inspiration. Not cleared by cough Maybe heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases, but condition is worse

Testing position sense (kinesthesia)

Move the client's finger or toe up or down and ask the client which way it has been moved; this tests the client's ability to perceive passive movement.

When should neck movements not be performed?

Neck movements are never performed if the client has sustained a neck injury or if a neck injury is suspected.

The nurse is performing a cardiovascular assessment and notes the presence of a blowing, swishing sound over the carotid artery. What should the nurse do?

Normally a bruit is not present, so this finding necessitates the need for follow-up. Both carotid arteries should be auscultated. The nurse should notify the health care provider if a bruit is detected. The nurse should also document the findings

Testing CNXII

Observe the tongue for asymmetry, atrophy, deviation to 1 side, and fasciculations (uncontrollable twitching); ask the client to stick out the tongue (tongue should be midline) ▪ Ask the client to push the tongue against a tongue depressor, and then have the client move the tongue rapidly in and out and from side to side

Cranial Nerve I

Olfactory Sensory Controls the sense of smell

Arteries in the arms and hands

Radial Pulse: Located at the radial side of the forearm at the wrist Ulnar Pulse: Located on the opposite side of the location of the radial pulse at the wrist Brachial Pulse: Located above the elbow at the antecubital fossa, between the biceps and triceps muscles

Romberg test

Romberg test: Client is asked to stand with the feet together and the arms at the sides and to close the eyes and hold the position; normally the client can maintain posture and balance.

CNXI

Spinal Accessory ▪ Motor ▪ Controls strength of neck and shoulder muscles

Testing CNVII

Test taste perception on the anterior two thirds of the tongue; the client should be able to taste salty and sweet tastes ▪ Have the client smile, frown, and show the teeth ▪ Ask the client to puff out the cheeks ▪ Attempt to close the client's eyes against resistance

Two-point discrimination:

Tests the client's ability to discriminate 2 simultaneous pinpricks on the skin

Graphesthesia:

Tests the client's ability to identifya number traced on the client's hand

Stereognosis:

Tests the client's ability to recognize objects placed in his or her hand

Snellen eye chart

The Snellen eye chart is a simple tool used to measure distance vision. Position the client in a well-lit spot 20 feet (6 meters) from the chart, with the chart at eye level, and ask the client to read the smallest line that he or she can discern. keep glasses on (except if reading glasses) test 1 eye at a time Record the result using the fraction at the end of the last line successfully read on the chart.

Inspection

The first assessment technique, which uses vision and smell senses while observing the client Requires good lighting, adequate body exposure, and possibly the use of certain instruments such as an otoscope or ophthalmoscope

The first slide on the Ishihara chart

The first slide on the Ishihara chart is one that everyone can discriminate; failure to identify numbers on this slide suggests a problem with performing the test, not a problem with color vision.

Inspecting hard and soft palates

Using a penlight and tongue depressor, the nurse inspects the hard and soft palates for color, shape, texture, and defects; the hard palate (roof of the mouth), which is located anteriorly, should be white and domeshaped, and the soft palate, which extends posteriorly, should be light pink and smooth.

Testing CN III, IV, VI

The motor functions of cranial nerves III, IV, and VI overlap; therefore, they should be tested together Inspect the eyelids for ptosis (drooping); then assess ocular movements and note any eye deviation Test accommodation and direct and consensual light reflexes

Inspecting buccal mucosa

The nurse retracts the cheek with a tongue depressor to check the buccal mucosa for color and the presence of nodules or lesions; normal mucosa is glistening, pink, soft, moist, and smooth.

Inspecting uvula

The uvula is inspected for midline location; the nurse asks the client to say "ahhh" and watches for the soft palate and uvula to rise in the midline (this tests 1 function of cranial nerve X, the vagus nerve)

Thought Processes and Perceptions

The way the client thinks and what the client says should be logical, coherent, and relevant; the client should be consistently aware of reality

Testing gag reflex

To test the gag reflex, touch the posterior pharynx with the end of a tongue blade; the client should gag momentarily (this tests the function of cranial nerve IX, the glossopharyngeal nerve)

CNV

Trigeminal ▪ Sensory and motor ▪ Controls sensation in the cornea, nasal and oral mucosa, and facial skin, as well as mastication

Percussion of the abdoment

Tympany should predominate over the abdomen, with dullness over the liver and spleen. Percussion over the kidney at the 12th rib (costovertebral angle) should produce no pain.

Testing vibration

Use a tuning fork to test the client's ability to feel vibrations over bony prominences; ask the client to announce when the vibration starts and stops.

New learning

Used to assess the client's abilityto recall unrelated words identified by the nurse; the nurse selects 4 words and asks the client to recall the words 5, 10, and 30 minutes later

Palpation

Uses the sense of touch; warm the hands before touching the client

Inspecting throat

Using a penlight and tongue depressor, the nurse inspects the throat for color, presence of tonsils, and the presence of exudate or lesions; 1 technique to test cranial nerve XII (the hypoglossal nerve) is asking the client to stick out the tongue (should protrude in the midline)

A mixed hearing loss is a combination of

a conductive and sensorineural hearing loss; it results from problems in both the inner ear and the outer ear or middle ear.

Testicular self exam

a day of the month is selected and the exam is performed on the same day each month after a shower or bath when the hands are warm and soapy and the scrotum is warm

Sensorineural hearing loss is caused by

a defect in the cochlea, eighth cranial nerve, or the brain itself

avoid percussion and auscultation over female breast tissue because:

a dull sound will be produced

Voice sounds are performed when

a pathological lung condition is suspected Auscultate over the chest wall; the client is asked to vocalize words or a phrase while the nurse listens to the chest. Normal voice transmission is soft and muffled; the nurse can hear the sound but is unable to distinguish exactly what is being said.

Plantar reflex

a. A cutaneous (superficial) reflex is tested with a pointed but not sharp object. b. The sole of the client's foot is stroked from the heel, up the lateral side, and then across the ball of the foot to the medial side. c. The normal response is plantar flexion of all toes.

Watch test

a. A ticking watch is used to test for highfrequency sounds. b. The examiner holds a ticking watch about 5 inches (12.5 centimeters) from each ear and asks the client if the ticking is heard.

Confrontation test

a. Acrude but rapid test used to measure peripheral vision and compare the client's peripheral vision with the nurse's (assuming that the nurse's peripheral vision is normal) b. The client covers 1 eye and looks straight ahead; the nurse, positioned 2 feet away (60 centimeters), covers his or her eye opposite the client's covered eye. c. The nurse advances a finger or other small object from the periphery from several directions; the client should see the object at the same time the nurse does.

Coordination tests

a. Assess by asking the client to perform rapid alternating movements of the hands (e.g., turning the hands over and patting the knees continuously). b. The nurse asks the client to touch the nurse's finger, then his or her own nose; the client keeps the eyes open and the nurse moves the finger to different spots to ensure that the client's movements are smooth and accurate. c. Heel-to-shin test: Assist the client into a supine position, then ask the client to place the heel on the opposite knee and run it down the shin; normally the client moves the heel down the shin in a straight line.

Palpation of the abdomen

a. Begin with light palpation of all 4 quadrants, using the fingers to depress the skin about 1 cm; next perform deep palpation, depressing 5 to 8 cm. b. Palpate the liver and spleen (spleen may not be palpable). c. Palpate the aortic pulsation in the upper abdomen slightly to the left of midline; normally it pulsates in a forward direction (pulsation expands laterally if an aneurysm is present).

Weber test

a. Determines whether the client has a conductive or sensorineural hearing loss b. Stem of the vibrating tuning fork is placed in the midline of the client's skull and the client is asked if the tone sounds the same in both ears or better in 1 ear. c. The client hears the tone by bone conduction and the sound should be heard equally in both ears. d. In conductive loss, the sound travels toward the impaired ear. e. In sensorineural loss, the sound travels toward the good ear.

Otoscope exam

a. The client's head is tilted slightly away and the otoscope is held upside down as if it were a large pen; this permits the examiner's hand to lay against the client's head for support. b. In an adult, pull the pinna up and back to straighten the external canal. c. Visualize the external canal while slowly inserting the speculum. d. The normal external canal is pink and intact, without lesions and with varying amounts of cerumen and fine little hairs. e. Assess the tympanic membrane for intactness; the normal tympanic membrane is intact, without perforations, and should be free from lesions. f. The tympanic membrane is transparent, opaque, pearly gray, and slightly concave. g. A fluid line or the presence of air bubbles is not normally visible. h. If the tympanic membrane is bulging or retracting, the edges of the light reflex will be fuzzy (diffuse) and may spread over the tympanic membrane.

Assessing the rectum and anus

a. Examination can detect colorectal cancer in its early stages; in men, the rectal examination can also detect prostate tumors. b. Women may be examined in the lithotomy position after examination of the genitalia. c. A man is best examined by having the client bend forward with his hips flexed and upper body resting over the examination table. d. A nonambulatory client may be examined in the left lateral (Sims') position. e. The external anus is inspected for lumps or lesions, rashes, inflammation or excoriation, scars, or hemorrhoids. f. Digital examination will most likely be performed by the HCP or nurse practitioner. g. Digital examination is performed to assess sphincter tone; to check for tenderness, irregularities, polyps, masses, or nodules in the rectal wall; and to assess the prostate gland. h. The prostate gland is normally firm, without bogginess, tenderness, or nodules (hardness or nodules may indicate the presence of a cancerous lesion).

Assessing male genitalia

a. Includes assessment (inspection and palpation) of the external genitalia and inguinal ring and canal b. Client may stand or lie down for this examination. c. Genitalia are manipulated gently to avoid causing erection or discomfort. d. Sexual maturity is assessed by noting the size and shape of the penis and testes, the color and texture of the scrotal skin, and the character and distribution of pubic hair. e. The penis is checked for the presence of lesions or discharge; a culture is obtained if a discharge is present. f. The scrotum is inspected for size, shape, and symmetry (normally the left testicle hangs lower than the right) and is palpated for the presence of lumps. g. Inguinal ringand canal;inspection (askingthe client to bear down) and palpation are performed to assess for the presence of a hernia

Inspection and palpation of the neck

a. Inspect and palpate: Size, shape, masses or tenderness, and symmetry of the skull b. Palpate temporal arteries, located above the cheekbone between the eye and the top of the ear. c. Temporomandibular joint: Ask the client to open his or her mouth; note any crepitation, tenderness, or limited range of motion. d. Face: Inspect facial structures for shape, symmetry, involuntary movements, or swelling, such as periorbital edema (swelling around the eyes).

Inspection and palpation of the neck

a. Inspect for symmetry of accessory neck muscles. b. Assess range of motion. c. Test cranial nerve XI (spinal accessory nerve) to assess muscle strength: Ask the client to push against resistance applied to the side of the chin (tests sternocleidomastoid muscle); also ask the client to shrug the shoulders against resistance (tests trapezius muscle). d. Palpate the trachea: It should be midline, without any deviations. e. Thyroid gland: Inspect the neck as the client takes a sip of water and swallows (thyroid tissue moves up with a swallow); palpate using an anterior-posterior approach (usually the normal adult thyroid cannot be palpated); if it is enlarged, auscultate for a bruit.

Normal and abnormal findings for sclera and cornea

a. Normal sclera color is white. b. A yellow color to the sclera may indicate jaundice or systemic problems. c. In a dark-skinned person, the sclera may normally appear yellow; pigmented dots may be present. d. The cornea is transparent, smooth, shiny, and bright. e. Cloudy areas or specks on the cornea may be the result of an accident or eye injury.

Palpating the heart

a. Palpate the apical impulse at the fourth or fifth interspace, or medial to the midclavicular line (not palpable in obese clients or clients with thick chest walls). b. Palpate the apex, left sternal border, and base for pulsations; normally none are present

Palpating the lymph nodes

a. Palpate using a gentle pressure and a circular motion of the finger pads. b. Begin with the preauricular lymph nodes (in front of the ear); move to the posterior auricular lymph nodes and then downward toward the supraclavicular lymph nodes. c. Palpate with both hands, comparing the 2 sides for symmetry. d. If nodes are palpated, note their size, shape, location, mobility, consistency, and tenderness.

Auscultation of abdoment

a. Performed before percussion and palpation, which can increase peristalsis. b. Hold the stethoscope lightly against the skin and listen for bowel sounds in all 4 quadrants; begin in the right lower quadrant (bowel sounds are normally heard here). c. Note the character and frequency of normal bowel sounds: high-pitched gurgling sounds occurring irregularly from 5 to 30 times a minute. d. Identify as normal, hypoactive, or hyperactive (borborygmus). e. Absent sounds: Auscultate for 5 minutes before determining that sounds are absent. f. Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular sounds or bruits.

External female genitalia inspection

a. Quantity and distribution of hair b. Characteristics of labia majora and minora (make note of any inflammation, edema, lesions, or lacerations) c. Urethral orifice is observed for color and position. d. Vaginal orifice (introitus) is inspected for inflammation, edema, discoloration, discharge, and lesions. e. The examiner may check Skene's and Bartholin's glands for tenderness or discharge (if discharge is present, color, odor, and consistency are noted and a culture of the discharge is obtained). f. The client is assessed for the presence of a cystocele (in which a portion of the vaginal wall and bladder prolapse, or fall, into the orifice anteriorly) or a rectocele (bulging of the posterior wall of the vagina caused by prolapse of the rectum).

Rinne test

a. Stem of the vibrating tuning fork is placed on the client's mastoid process. b. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should still hear a sound. c. Normally the sound is heard twice as long by way of air conduction (AC) (near the ear canal) than by way of bone conduction (BC) (at the mastoid process); AC> BC. d. In sensorineural hearing loss, air conduction is heard longer than bone conduction, but it is not heard to be twice as long. e. In conductive hearing loss, the bone conduction sound is longer than or equal to the air conduction sound.

Color vision test

a. Tests for color vision involve picking numbers or letters out of a complex and colorful picture. b. The Ishihara chart is used for testing and consists of numbers composed of colored dots located within a circle of colored dots. c. The client is asked to read the numbers on the chart. d. Each eye is tested separately. e. Reading the numbers correctly indicates normal color vision. f. The test is sensitive for the diagnosis of redgreen blindness but cannot detect discrimination of blue.

Normal pupil findings

a. The pupils are round and of equal size. b. Increasing light causes pupillary constriction. c. Decreasing light causes pupillary dilation. d. Constriction of both pupils is a normal response to direct light.

Testing near vision

a. Use a hand-held vision screener (held about 14 inches [35.5 centimeters] from the eye) that contains various sizes of print or ask the client to read from a magazine. b. Test each eye separately with the client's glasses on or contact lenses in. c. Normal result is 14/14 (distance in inches at which the subject holds the card from the eye/distance in inches at which a normal eye could have read that particular line)

Corneal light reflex

a. Used to assess for parallel alignment of the axes of the eyes b. Client is asked to gaze straight ahead as the nurse holds a light about 12 inches (30 centimeters) from the client. c. The nurse looks for reflection of the light on the corneas in exactly the same spot in each eye.

Cover test

a. Used to check for slight degrees of deviated alignment b. Each eye is tested separately. c. The nurse asks the client to gaze straight ahead and cover 1 eye. d. The nurse examines the uncovered eye, expecting to note a steady, fixed gaze.

Voice (whisper) test

a. Used to determine whether hearing loss has occurred b. One ear is tested at a time (the ear not being tested is occluded by the client). c. The nurse stands 1 to 2 feet (30 to 60 centimeters) from the client, covers his or her mouth so that the client cannot read the lips, exhales fully, and softly whispers 2-syllable words in the direction of the unoccluded ear; the client points a finger up during the test when the nurse's voice is heard (a ticking watch may also be used to test hearing acuity). d. Failure to hear the sounds could indicate possible fluid collection and/or consolidation, requiring further assessment.

Tuning fork tests

a. Used to measure hearing on the basis of air conduction or bone conduction; includes the Weber and Rinne tests b. To activate the tuning fork, the nurse holds the base and lightly taps the tines against the other hand, setting the fork in vibration.

Sound is transmitted by 2 types of conduction:

air conduction and bone conduction Air conduction takes 2 or 3 times longer than bone conduction

ophthalmoscope

an instrument used to examine the external structures and the interior of the eye.

Conductive hearing loss is caused by

any physical obstruction to the transmission of sound waves.

Using an Ophthalmoscope

b. The room is darkened so that the pupil will dilate. c. The instrument is held with the right hand when examining the right eye and with the left hand when examining the left eye. d. The client is asked to look straight ahead at an object on the wall. e. The examiner should approach the client's eye from about 12 to 15 inches (30.5 to 38 centimeters) away and 15 degrees lateral to the client's line of vision. f. As the instrument is directed at the pupil, a red glare (red reflex) is seen in the pupil. g. The red reflex is the reflection of light on the vascular retina. h. Absence of the red reflex may indicate opacity of the lens. i. The retina, optic disc, optic vessels, fundus, and macula can be examined.

Before performing an otoscopic exam and inserting the speculum:

check the auditory canal for foreign bodies. Instruct the client not to move the head during the examination to avoid damage to the canal and tympanic membrane The otoscope is never introduced blindly into the external canal because of the risk of perforating the tympanic membrane.

The tongue is inspected for

color, surface characteristics, moisture, white patches, nodules, and ulcerations (dorsal surface is normally rough; ventral surface is smooth and glistening, with visible veins).

Hearing loss is categorized as:

conductive, sensorineural, or mixed conductive and sensorineural.

An inappropriate appearance and poor hygiene may be indicative of:

depression, manic disorder, dementia, organic brain disease, or another disorder

PERRLA

pupils equal, round, reactive to light and accommodation

Testing patency of the nostrils

pushing each nasal cavity closed and asking the client to sniff inward through the other nostril.

resonance vs hyperresonance

resonance is noted in healthy lung tissue. Hyperresonance is noted when excessive air is present and a dull note indicates lung density

The gums are inspected for

swelling, bleeding, discoloration, and retraction of gingival margins (gums normally appear pink).

What areas should be palpated last?

tender areas- identify tender areas and palpate them last

Vestibular assessment tests

test for falling, past pointing, gaze nystagmus evaluation, dix-hallpike maneuver

Kernig's sign is positive when:

the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended

When auscultating breath sounds, instruct the client to breathe:

through the mouth and monitor the client for dizziness.

Wood's light

ultraviolet light used for diagnosing skin conditions

Three types of breath sounds are considered normal in certain parts of the thorax:

vesicular, bronchovesicular, and bronchial

Testing CNXI

▪ The nurse palpates and inspects the sternocleidomastoid muscle as the client pushes the chin against the nurse's hand ▪ The nurse palpates and inspects the trapezius muscle as the client shrugs the shoulders against the nurse's resistance

Testing CNV

▪ To test motor function, ask the client to clench the teeth and assess the muscles of mastication; then try to open the client's jaws after asking the client to keep them tightly closed ▪ The corneal reflex may be tested by the health care provider; this is done by lightly touching the client's cornea with a cotton wisp (this test may be omitted if the client is alert and blinking normally) ▪ Check sensory function by asking the client to close the eyes; lightly touch forehead, cheeks, and chin, noting whether the touch is felt equally on the 2 sides

Testing CNIX and X

▪ Usually cranial nerves IX and X are tested together ▪ Test taste perception on the posterior one third of the tongue or pharynx; the client should be able to taste bitter and sour tastes ▪ Inspect the soft palate and watch for symmetrical elevation when the client says "aaah" ▪ Touch the posterior pharyngeal wall with a tongue depressor to elicit the gag reflex