HEAD TO TOE FOCUSED EXAMINATION

what to assess for external genitalia (males)

*inspect penis, ureteral meatus, scrotum, and pubic hair *palpate the scrotal contents *test the cremasteric reflex

adventitious sounds

Abnormal breath sounds in this category include rales, rhonchi, wheezes, stridor, and pleural friction rubs.

Which element is included in the physical examination component of the functional assessment?

Assessing the skin for signs of decubitus ulcers Assessing the skin for signs of decubitus ulcers is an element of the functional assessment physical examination.

Common problems experienced by older adults:

Nutritional deficiencies and malnutrition Urinary incontinence Memory changes and signs of dementia Depression Medication-induced delirium Prior falls or fear of falling

Which elements are included in the review of systems for the functional assessment?

Nutritional status Assessment of nutritional status is an element of the review of systems for the functional assessment. Memory changes Assessment of memory changes is an element of the review of systems for the functional assessment. Urinary incontinence Assessment of urinary incontinence is an element of the review of systems for the functional assessment. Prior falls or fear of falling Assessment of prior falls or fear of falling is an element of the review of systems for the functional assessment.

Crepitus

a crackling or grating sound usually of bones

during abdominal assessment what can also be tested?

abdominal reflexes -optional- may ask patient to lift head as the abdominal muscles are inspected

Inspect the skin for signs

decubitus or venous stasis ulcers.

Palpate the scrotum for

testes and presence of a hernia or hydrocele

Percussion of lungs

-Percuss the anterior and lateral chest in the ICSs, comparing bilateral findings. -Avoid percussing over bone, which produces a flat tone. normal: Percussing over lung tissue produces resonance. -Percussing over the heart produces dullness from the 3rd-5th ICS to the left of the sternum. abnormal: Dullness percussed over lung tissue indicates consolidation (or solidification, usually from fluid), as in pneumonia.

how to observe balance using Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds used to evaluate cerebellar function and balance

What to consider during a physical assessment?

1) review patients health history for important medical, surgical and family history before the examination starts 2) chief c/o? 3) gather appropriate equipment ex: stethoscope, v/s equipment, penlight and gloves 4) provide privacy 5) record both normal and abnormal findings

for female breasts examinations

pt's arm hanging loosely at the sides, extended over head or flexed behind neck, pushing hands or hips, and leaning forward from the waist. PERFORM: >bimanual digital palpation of breast tissue

Begin the general inspection and look for:

skin color facial expression mobility dress and posture speech and hearing orientation and mental alertness

decubitus ulcer

sore caused by lying down for long periods of time

ask patient to stand and bend forward to assess

spine also patient ROM during flexion , HTN, Lateral bending, and rotation of the trunk

Which elements are included in the assessment of the hips of an adult patient?

test ROM Palpate for stability of motion

what to assess with a patient's neck while patient is sitting?

thyroid symmetry and smoothness inspect patients ROM; test resistance against examiner's hand test shoulder shrug ( CN IX 9) palpate carotid pulses, 1 at a time (and when patient is supine) palpate tracheal position, thyroid and lymph nodes Auscultate carotid arteries and thyroid

Following the inspection of the external genitalia, ask the patient

to lean over the examination table with his arms and chest resting on the table. Then, have the patient point his toes inward to help relax the buttocks and make the examination more comfortable. Inspect the sacrococcygeal and perianal areas. Next, the healthcare provider should perform a rectal examination, palpating sphincter tone as well as circumferentially for any rectal masses.

how to palpate female breast while patient is supine with arm above head

uncover female breast and palpate all areas of breast tissue systematically using light, medium and deep palpation with the pt's arm over her head also *DEPRESS NIPPLES into the areola*

then moving on to the assessment of the abdomen, Inguinal area and external genitalia (males) ---- this comes after the assessment of the chest and heart

abdomen assessment: *inspect skin characteristics, contour, pulsations, and movement *auscultate all quadrants for bowel sounds *auscultate aorta, renal, iliac and femoral arteries for bruits **PERCUSS all quadrants for tone, percuss liver borders and estimate span*** >> lightly palpate all quadrants, deeply palpate all quadrants, palpate midline for aortic pulsations

Then ask patient to walk heel to toe , what does this test?

ask patient to stand on one foot, then the other with eyes closed. Ask the patient to hop in place on one foot then the other **assess for inguinal and femoral hernias***

after collecting supplies needed and greeting the patient what should the nurse do , and in what order?

assess: head ears nose and throat Inspect: back Percuss: posterior chest Auscultate: chest Palpate: breasts

document vital signs

b/p pulse RR temp O2 sats

Pay special attention to the patient's _____ during the neurologic portion of the examination

balance, coordination, and gait

Basic ADLs include:

bathing, dressing, toileting , ambulation, feeding, grooming

instruct patient to do what to prepare for physical exam?

empty bladder remove clothing as much as necessary and put on gown ask for a chaperone to remain with the pt is necessary -consider age, gender and type of exam

begin with the patient sitting down and assess head, face, eyes, nose, mouth, pharynx , neck and upper extremities and THEN

examine eyelids, eyelashes and palpebral folds inspect: iris, sclera, conjunctiva test pupillary response to light and accommodation test extraocular movements (CN III, IV, and VI) and assess VISUAL fields (CNII) perform ophthalmic exam for red reflex; inspect lens, disc, cup margins, vessels and retinal surfaces THEN.... -note structure and position of septum (NOSE) ***determine patency of each nostril (deviated septum?) >>>inspect mucosae, septum and turbinates

unctional Assessment: Physical Assessment

focused on common problems of older adults. Assess the older adult's mental status for cognition, memory, and mood.

Rinne test

hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction **rinne under the pinne***

once patient is supine you should also assess the ?

heart -palpate the chest wall for thrills, heaves and pulsations *auscultate systematically; you can turn the patient slightly to the left side and repeat ascultation*

instrumental ADLs include

housekeeping grocery shopping meal perpetration medication management communication skills money managment

what to assess on the ears

inspect alignment and placement *surface characteristics *palpate auricle *screen hearing with whisper test (CN VIII) -Rinne test (air conduction v bone conduction) -weber testing (on top of the forehead ringing)

for male breasts assessment

inspect breasts and nipples for symmetry, enlargement and surface characteristics

what to assess on upper extremities?

inspect skin and nails inspect symmetry of muscle mass inspect and palpate hands, arms, and shoulders assess joint ROM and muscle strength: fingers, wrists, elbows, and shoulders assess pulses: radial brachial

Which element of the examination would the nurse perform while the adult patient is in a standing position?

inspecting the spine

for female patients requiring examination of the genitalia

once the patient is draped and has legs spread assess: pubic hair, labia, perineum, and anus Palpate: the labia and BArtholin glands Perform a speculum examination to inspect the vagina and cervix. Then stand and perform bimanual palpation to assess the uterus and cervix.

During the respiratory examination, evaluate for

or dyspnea on exertion

Measure blood pressure both in sitting and standing positions to assess for

orthostatic hypotension

inguinal area

palpate for lymph nodes, pulses, and hernias

assessing adult patient n supine position with legs exposed...

palpate hips for stability test ROM and strength of hips **inspect skin characteristics, hair distribution and muscle mass** palpate for temperature, texture, pulses ( dorsalis pedis, posterior tibial, popliteal) TEST ROM and strength of toes ankles knees

How to assess jugular venous pressure

pt supine with HOB elevated 45 degrees use tangential lighting identify the highest point of the IJV pulse and extend a long rectangular object from IJV pulse to area above sternal angle should be <3-4cm above sternal angle

begin with the patient sitting down and assess head, face, eyes, nose, mouth, pharynx , neck and upper extremities FIRST :

*inspect skin *inspect and palpate scalp/hair for texture, distribution and quantity *palpate facial bones and temporomandibular joint while pt opens and closes mouth *INSPECT pt's ability to clench jaw, squeeze eyes tightly shut, wrinkle forehead, smile, puff out cheeks (cranial nerves V and VIII)

SECOND part of physically assessment: >>>> PART ONE: back and posterior chest

*inspect skin and thorax *inspect symmetry of the shoulders and musculoskeletal development *inspect and palpate the scapular and spine *palpate and percuss costovertebral angle if indicated

THIRD: CHEST, LUNGS AND HEART (FRONT SIDE OF BODY)

*inspect skin, musculoskeletal development, and symmetry *ASSESS respirations, posture, respiratory effort >>PALPATE CHEST WALL: crepitation and tenderness >> PALPATE pericardium for thrills, heaves, and pulsations >>PALPATE left side of chest to locate APICAL pulse ***palpate for tactile fermitus **palpate axillary lymph nodes *PERCUSS systematically for RENSONANCE **AUSCULATE systematically for breath sounds, hearts sounds: aortic, pulmonic, second pulmonic, mitral and tricuspid areas

what to assess in the patient mouth

*lips, gums, mouth for color, surface characteristics, and any apparent abnormalities inspect oropharynx inspect teeth for color, #, and surface characteristics inspect tongue for color, characteristics, symmetry, and movement (CNXII(12) ) test GAG reflex and soft palate rising by asking the pt to say "AHHHH" ( CN IX 9 and X 10 )

SECOND part of physically assessment: >>>> PART TWO: LUNGS

*observe for depth, rhythm and pattern *palpate for expansion and tactile fremitus (a tremulous vibration of the chest wall during speaking that is palpable on physical examination) palpate scapular and subscapular nodes percuss posterior chest and lateral walls systematically for RESONANCE Percuss to measure diaphragmatic excursion Auscultate systematically for breath sounds- Note characteristics and adventitious sounds

Functional Assessment: ADLs

Bathing Toileting Dressing Grooming Eating Mobility Communicating and ability to drive a car or prepare own meals INCLUDES: comprehensive Hx physical Exam social assessment detailed list of all medications

Social Assessment

Identify caregivers and probable caregivers. Assess caregivers' abilities and resources. Assess financial resources and health insurance. Ask about the existence of advance directives or a durable power of attorney for health care decisions.

Which element of the examination is best performed while the adult patient is reclining at 45 degrees?

Inspecting jugular venous distention and pulsation Inspecting jugular venous distention and pulsation is best performed while the adult patient is reclining at 45 degrees.

Bimanual Digital Palpation

Place 1 hand's palmar surface facing up under pt's breast With other hand walk across the breast tissue feeling for lumps as you compress the tissue between the fingers of 1 hand & palm of the other

Which components are included in the functional assessment?

SOCIAL ASSESSMENT PHYSICAL EXAM EVALUATION OF ADLS COMPREHENSIVE HX

weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. "weber it's right or left ear" if pt only hears the tuning fork in the right ear that means left ear has Sensorineural loss and vis versa--- tuning fork should be heard in both ears

Which assessment element of the adult head-to-toe examination is best performed with the patient standing?

The Romberg test

Order the elements of the abdominal/genital assessment that should be performed while the male patient is standing.

The order of examination according to the guidelines for assessing the abdominal/genital area is as follows: ask the patient to lean over the examination table, instruct the patient to relax the buttocks, inspect the perianal area, and palpate the sphincter tone.

Order the elements of an abdominal examination of an adult who is supine.

When performing an abdominal examination of an adult who is supine, the nurse should begin with inspection of the skin and contour, and follow with auscultation, percussion, and light and deep palpation, respectively, of all four quadrants. This order of examination follows the guidelines for assessing the abdomen, which include inspection, auscultation, percussion, and light palpation followed by deep palpation.