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involves collecting, validating, and analyzing subjective data (also called symptoms), and objective data (also called signs) to determine the overall lvl of physical, psychological, sociocultural, developmental, and spiritual health of a pt.
symptoms; experienced only by the pt (e.g., pain and nausea), and are gathered by verbal report during the health history.
signs; are directly observed/elicited through physical examination techniques (aka physical assessment)
with a health history and a complete physical examination is usually conducted when a pt first enters a HC setting, with information providing a baseline for comparing later assessments. It compasses the physical, psychological, social, and spiritual dimensions of living.
ongoing partial assessment
one that is conducted at regular intervals (e.g., at the beginning of each home health visit or each hospital shift) during care of the pt. This type of assessment concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions.
is conducted to assess a specific problem
a type of rapid focused assessment conducted to determine potentially fatal situations.
a collection of subjective data that provides a detailed profile of the pt's health status. nurses use therapeutic communication skills and interviewing techniques during the health history to establish an effective nurse-pt relationship and to gather data to identify strength.
components of a health history
- - Biographical data: biographical info is often collected during admission to a HC facility or agency and documented on a specific form. It includes: name, address, gender, marital status, occupation, religious preference, HC financing, and PCP.
- - Reason for seeking HC: the pt's reason for seeking care helps to focus the rest of the assessment. Ask an open-ended question, such as, "tell me why you are here today." Document in the pt's own words.
- - History of present health concern: when taking the pt's history of present health concern, be sure to explore the symptoms thoroughly.
- - Medical history: a pt's medical history may provide insight to causes of current symptoms. It also alerts the nurse to certain risk factors. Includes past illnesses, chronic health problems and treatment, and previous surgeries or hospitalizations.
- - Family history: certain disorders have genetic links
- - Lifestyle: a pt's lifestyle contributes to his/her overall health and well-being.
Risk factors for cancer: American Cancer Society Caution Model
- Change in bowel/bladder habit
- A sore that does not heal
- Unusual bleeding/discharge
- Thickening or lump in the breast or somewhere
- Indigestion or difficulty swallowing
- Obvious change in wart or mole
- Nagging cough or hoarseness
is the systematic collection of objective information. Is usually conducted in a head-to-toe sequence or a system sequence but can be adapted to meet the need of the pt.
used to auscultate the heart, lung, abdomen, and CV sounds. The bell is used to listen to low-pitched sounds (such as heart murmurs). Use gentle pressure against the body part being examined when assessing low-pitched sounds. The diaphragm is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds. Use firm pressure against the body part being examined when assessing high pitched sounds.
is a lighted instrument used to visualize the interior structures of the eye. consists of two parts: a body that contains the light source and a detactable head that contains lenses used to magnify the internal eye structures The head, which is secured in the body, contains a dail, which when depressed and turned, turns on the illumination. The head also contains several lenses arranged on a wheel to control the focus for examining the structures in the eye. Each lens is labeled with a positive (black) or negative (red) number, with units of strength called diopters. Red numbers are used for near-sighed (myopic) pts, black numbers for far-sighted (hyperopic) pts. The zero lens is used when either the examiner or the pt has refractive (visual) errors. (Done by dr., but we need to now where it is and see if it's in working order.)
is a lighted instrument used to examine the external ear canal and the tympanic membrane. A speculum which is attached to the body of the otoscope directs the light in a narrow beam to improve visualization of ear structures. Specula come in various sizes; use the largest speculum that will extend into the pt's ear canal.
used as a screening test for distant vision, consists of characters arranged in 11 lines of different-sized type; the line of largest character is at the top of the chart and the line of smallest characters is at the bottom. Scores ranging from 20/10 (the smallest line of the characters) to 20/200 (the largest line of characters) are shown in the left hand column, and distances are in the right-hand column next to the numbers.
is used to visualize the lower and middle turbinates of the nose. A penlight/flashlight is used for illumination. The blades of the speculum are inserted about 1 cm into each nostril and opened so that they do not press on the septum. Alternatively, the otoscope can be used to visualize the internal nares. The light is provided by the scope and the shortest, widest speculum that will fit into the nostril is used.
is a two-bladed instrument used to examine the vaginal canal and cervix. Is inserted into the vagina and the speculum blades are opened, allowing visulalization and assessment of the vagina and cervix. The speculum must be warmed and lubricated with warm water or a water-soluble agent before insertion.
is a two-pronged metal instrument used to test auditory function and vibratory perception. Is activated to vibrate by holding the base and gently tapping the prongs against the palm of the examiner's hand. Once vibrating, the fork is held at the base to avoid diminishing the vibration.
percussion hammer (reflex hammer)
is an instrument with a triangular -shaped rubber head, used to test deep tendon reflexes. The handle of the hammer is held between the thumb and index finger to direct a brisk tap of the broad end of the head on the selected body area. The quick, firm tap is made with a rapid downward and backward wrist action. The pointed end of the hammer is used for smaller areas.
pt lies flat on the back with legs extended and knees slightly flexed. Facilitates abdominal muscle relaxation and is used to assess v/s and head, neck, anterior thorax, lungs, heart, breasts, abdomen extremities, and peripheral pulses.
pt lies on back with legs separated knees flexed and soles of the feet on the bed. Is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles.
used for lumbar puncture
pt lies on either side with the lower arm below the body and upper arm flexed at the shoulder and elbow. Both knees are flexed, with the upper leg more acutely flexed. Is used to assess the rectum or vagina.
pt lies flat on the abdomen with the head turned to one side. it is used to assess the hip joint and the posterior thorax.
pt is in the dorsal recumbant position with the buttocks at the edge of the examinging table and the heels in the stirrups. Is used to assess female genitalia and rectum.
pt kneels, with the body at a 90-degree angle to the hips, back straight, arms above the head. Is used to assess the anus and rectum.
prevents unnecessary exposure, provides privacy, and keeps the pt warm during the physical assessment. May be paper, cloth, or bed linens. Expose only the body parts to be assessed to maintain the pt's modesty and comfort.
Techniques of physical assessment
- 1. inspection
- 2. palpation
- 3. percussion
- 4. ausculation
- Are most often used in the sequence listed; variations may differ in different body parts, such as the stomach. Bilateral body parts are compared, and are normally symmetric--that is, they have the same size and shape as well as the same characteristics, such as movement/pulses.
- the process of performinmg deliberate, pruposeful observations in a systematic manner. The nurse observes visually but also uses hearing and smell to gather data throughout the assessment. Begins with the initial pt contact and continues through the entire assessment. Adequate natural/artificial lighting is essential for distinguishing the color, texture, and moisture of body surfaces. Quiet environment allows sounds to bed heard.
- Each area of the body is inspected for size, color, shape, position, and symmetry, noting normal findings and any deviations from normal.
- uses the sense of touch. the hands and fingers are sensitive tools and can assess skin temperature, turgor (turgor is determined by various factors, such as the amount of fluids in the body and age), texture, and moisture, as well as vibrations within the body (such as the heart) and shape or structures within the body (e.g., the bones). Specific parts of the hand are more effective at assessing different qualities. The dorsum (back) surfaces of the heand and fingers are used for gross measure of temperature. The palmar (front) surfaces of the fingres and finger pads are used to assess texture, shape, fluid, size, consistency, and pulsation. Vibration is palpated best with the palm of the hand. Nurse's hands should be warm. When conducting palpation, any area of tenderness should be palpated last. Light (gentle), moderate, or deep palpation may be used, controlling the depth by the amount of pressure applied. For light palpation, apply pressure with the fingers together and depressing the skin and underlying structures less than 1 cm. Moderate palpation is 1 to 2 cm. Deep palpation is 2 cm, which carries a risk of internal injury, should be used cautiously and only by experienced practitioners.
- Applying intermittent pressure to a specific area allows assessment of surface characteristics and underlying structures. Two hands are used for bimanual palpation (e.g., palpating breast tissue); one hand applies pressure and the other hand feels the tissue or structure.
characteristics of masses determined by palpation
shape: round, ovoid, tubular, irregular; size: measured in cm; consistency: firm, edematous, spongy, cystic; surface: smooth, nodular, granular; mobility: fixed/nonmobile, mobile; tenderness: amount of tenderness to touch; pulsatile: pulsation can/cannot be felt in the mass
- act of striking one object against another to produce sound. (Sound waves produced by the striking action over body tissues are known as percussion tones.) Is used to assess the location, shape, size, and density of tissues. To detect presence of fluids, solid masses, and sound of air.
- Both hands are used to produce sound waves. Nurse's nondominant hand is placed directly on the area to be percussed, with the fingers slightly separated and the middle finger placed firmly on the body surface. The other hand (dominant hand) provides the striking force, initated by a sharp downward wrist movement with the forearm stationary and wrist relaxed. The tip of the middle finger of the dominant hand strikes the middle finger of the opposite hand. This produces a vibration that allows discrimination among five different tones.
- - tymphany: drum-like; gastric air bubble
- - resonance: hollow; normal lung
- - hyper-resonance: booming; emphysematous lung
- - dullness: thudlike; liver
- - flatness: flat; muscle/bone
- act of listening with a stethoscope to sounds produced within the body. Is performed by placing the stethoscope diaphragm/bell against the body part being assessed. When auscultating, the nurse should expose the part listened to, use the proper part of the stethoscope (bell/diaphraphm) for specific sounds, and listen in a quiet environment.
- Four characteristics of sound are assessed by auscultation: (1) pitch (ranging from high to low), (2) loudness (ranging from soft to loud), (3) quality (e.g., gurgling or swishing), and (4) duration (short, medium, or long).
is the first component of the physical assessment. includes observing the pt's overall appearance and behavior, taking v/s, and measuring height and weight. Provides clues to the pt's overall health.
redness of the skin; is more often seen in the face and the neck. Is associated with sunburn, inflammation, fever, trauma, and allergic reaction.
a bluish/grayish discoloration of the skin in response to inadequate oxygenation. Is assessed as a blue tinge in pts with white skin and as dullness in pts with dark skin. Also called hypoxia. Colors can be blue, purple, and even gray.
a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia, and excessive hemolysis (breakdown of RBCs). Usually develops first in the sclera of the eyes and then in the skin and mucous membranes. In dark-skinned ppl is more difficult to observe on the trunk of the body, but the sclera, oral mucous membranes, palms, and soles appear yellow to yellow-orange.
paleness of the skin, often results from a decrease in the amouint of circulating blood or hemoglobin, causing inadquate oxygenation of the body tissues. Depending on severity, pallor may be visible over the entire skin surface or only in the lips, nailbeds, mucous membranes, and conjunctiva. Pallor in dark-skinned people is seen as an ashen gray or yellow tinge.
collection of blood in the subcutaneous tissues, causing purplish discoloration.
small hemorrhagic spots caused by capillary bleeding. If they are present, assess their location, color, and size.
areas of diseases/injured tissue, such as bruises, scratches, cuts, burns, insect bites, and wounds (breaks in the continuity of the skin). Assess lesions for size, shape, depth, location, and presence of drainage or odor. document body area
those that may arise from previously normal skin.
result from changes in the primary lesions.
healed wounds. document body area
skin eruptions; describe in terms of their type, size, elevation, coloring, and presence of drainage/itching. Document exact body surface areas involved.
excessive amount of perspiration, such as when the entire skin is moist
fullness or elasticity of the skin. usually assessed on the sternum/under the clavicle by lifting a fold of skin with the thumb and first finger. it's normal when it returns to it's normal shape when released. when the pt is dehydrated, the skin's elasticity is decreased, and the skin fold returns slowly. However, this may be a normal finding in older pts. Difficulty in lifting the skin fold may indicate edema.
excess fluid in the tissues; is characterized by swelling, with taut and shiny skin over the edematous area. If the area of edema is palpated with the fingers, an indentation (measured in mm for depth of the indentation) may remain after the pressure is released; if the indentation is very deep, it is called pitting edema. Edema may be graded as 0 (none), +1 (trace, 2mm), +2 (moderate, 4mm), +3 (deep, 6 mm), +4 (very deep, 8mm). Edema may be the result of overhydration, heart failure, kidney failure, trauma, or peripheral vascular disease.
lesion equal/less than 1 cm, circumscribed, flat, nonpalpable change in skin color; ex: freckles/petechiae
lesion greater than 1 cm, circumscribed, flat, nonpalpable change in skin color; ex: vitiligo (patch)
mass less/equal 0.5 cm, palpable, elevated solid mass; ex: mole
mass greater than 0.5 cm, palpable, elevated solid mass; ex: coalesced papules
mass 0.5-2 cm; firmer than a papule, palpable, elevated solid mass; ex: nevus (wart)
mass greater than 2cm, palpable, elevated solid mass; ex: lipoma
irregular, superficial area of localized skin edema; ex: hives, mosquito bites
filled with serious fluid, equal/less than 0.5cm; ex: herpes simplex
filled with serous fluid, greater than 0.5cm; ex: second degree burn, cyst
filled with pus; acne, impetigo
loss of superficial epidermis, moist, nonbleeding surface; ex: moist area after rupture of a vesicle, as in chickenpox
loss of epidermis and dermis, may bleed and scar; ex: stasis ulcer
deep linear crack, extends into dermis; ex: athlete's foot
dried residue of serum, pus, or blood; ex: impetigo
thin flake of exfoliated dermis; ex: dandruff, dry skin
thickened and roughened epidermis, with increased visibility of skin furrows
thinning of the skin, loss of skin furrows, shiny appearance; ex: peripheral vascular disease
scratch of the epidermis
fibrous tissue replaces tissue in the dermis or subcutaneous layer
plugged opening of a sebaceous gland, a hallmark of acne; ex: common blackhead
small, dilated, red or bluish surface vessels; may be part of a basal cell carcinoma or skin injury from radiation
flat to slightly elevated, round, evenly pigmented; ex: common mole
inspect for shape, angle, texture, and color. should be somewhat convex and should follow the natural curve of the finger. the angle should be about 160 degrees. nails should be smooth and the nail base, when palpated, should be firm and nontender.
curved/angulation. Looks like a spoon. From anemia/iron deficiency anemia.
indentations; from acute illness
infection along the nailbed
springy, floating; flattened angle 180 degrees; from long-term lack of oxygenation
swollen, springy, floating; angle greater than 180 degrees; from long-term lack of oxygenation
painless separation of the nail plate from the nailbed due to infection or trauma
is found all over, except the palms of the hands, soles of the feet, and parts of the genitalia. Assess for color, texture, and distribution. Hair is normally resilient, evenly distributed, and neither excessively dry nor oily. Separate the hair to inspect the scalp for color, dryness, scaliness, lumps, lesions, or lice. If any lumps or masses are palpated, note their location, size, tenderness, and mobility.
unusual balding (may be normal or may be the result of chemo, readiation therapy, infection, hormal disorders, or inadequate nutrition. Decreased oxygenation of periperal tissues, esp of the lower extremities, may cause loss of hair)
excessive amounts of hair on face and body (may occur in hormonal disorders)
white eggs of lice (can be differentiated from dandruff or lint because they are attached to the hair shaft)
common skin variations in newborns and children include:
- - jaundice and milia in newborns
- - lanugo for the first 2 wks of life
- - smooth, thin skin at birth
- - pubic hair development at the onset of puberty
raised dark areas
flat brown age spots
small round red spots
common skin variations in the older adult include:
- - wrinkles, dryness, scaling, decreased tugor
- - senile keratosis
- - senile lentigines
- - cherry angioma
- - fine, brittle gray or white hair
- - hair loss
- - coarse facial hair in women, decreased body hair in men and women
- - thick, yellow toenails
drooping of the upper lid, which may be attributable to damage to the oculomotor nerve, myasthenia gravis, or a congenital disorder.
inward turning of the lower lid and lashes
outward turning of the lower lid and lashes
loss of opacity of the lens
complicated disease in which damage to the optic nerve leads to progressive, irreversible vision loss.
dilation of the pupil induced by a drug
constriction of the eye, certain drugs can cause this.
may result from CNS injury/illness
decreased or absent pupillary response indicates blindness/serious brain injury. inability of the eye to accommodate/converge is abnormal
pupils equal, round, react to light, accommodation
reduction of the size of the pupil size in response to light. (usually 3 mm)
hold penlight at 10 to 15 cm away from nose and tell pt to look at object. then draw it closer. the pupils should dilate. this is assessing accommodation.
cross-eyed (abnormal extraocular movements)
eye occilates/jerky involuntary movements (abnormal extraocular movements)
conductive (type of hearing loss)
the result of a problem with the transmission of sound waves through the outer and middle ear
sensorineural (type of hearing loss)
from inner ear damage
is used to assess for bone conduction of sound. With this test, the sound is normally heard in both ears or is localized at the center of the head. Pts with conductive hearing loss hear the sound better in the affected ear. If the sound is heard better in the ear with out a problem, it indicates damage to the inner ear or a nerve disorder.
used to compare bone and air conduction of sound. With this test, hearing of air-conducted sound is normally greater than bone-conducted sound (documented as AC > BC). If the hearing loss is conductive, sound of bone conduction will be the same or greater than air conduction.
checking patency of the nose and inspecting the nose
by occluding one nostril at a time and asking the pt to inhale and exhale through the nose. Inspect each nostril using a penlight/otoscope. Examine the mucous membranes for color and the presence of lesions, exudate, or growths. Also inspect the nasal septum for intactness and deviation. Normally the nasal mucosa is moist and darker red than the oral mucosa. Abnormal findings are swelling of the mucosa, bleeding or discharge (indicting allergies with inflammation/infection), perforation/deviation of the nasal septum (cocaine usage; may be congenital/from trauma), and polyps (often seen with chronic allergies).
located in the frontal bones and are palpated for pain, gently by pressing upward on the bony prominences located above each eye. Normally, the sinuses are not painful when palpated, but if pain is present, this finding may indicate that there is an infection or there is obstruction.
located in the maxillary bones and are palpated for pain with gentle pressure on the bony prominences of the upper cheek. Normally it's not painful, but pain may be a finding if the sinuses are infected or obstructed.
swollen, red, and bleeding gums
from nutritional deficits, inflammation or infection, poorly fitted dentures, or poor oral hygiene
swollen, red tonsils
white coating on tongue
from poor oral hygiene, irritation, or smoking
a fissured tongue
a bright-red tongue
seen in deficiencies of iron, vitamin B12, or niacin
a black hairy tongue
from antibiotic use
enlarged lymph nodes; may indicate infection, autoimmune disorders, or metastasis of cancer.
pupils at the inner folds
impaired near vision
a white ring around the cornea
enlargement, masses, or nodules of the thyroid gland
may indicate thyroid gland disease, infection of the thyroid, or cancer
common head and neck variations in newborns and children
- - closing of posterior fontanel at 8 wks of age; soft anterior fontanel at about 18 months of age.
- - Gazing at and following bright objects by 1 month
- - Focusing with both eyes by 6 months of age
- - pseudostrabismus
- - startle reflex in newborns
common head and neck variations in the older adult
- - presbyopia
- - decreased color vision and peripheral vision
- - decreased adapation to light and dark
- - arcus senilis
- - entropion and ectropion
- - presbycusis
- - impaired conductive hearing
- - elongated ear lobes
- - prominent ear landmarks
- - decreased neck range of motion
- - nodular thyroid gland
- - smaller, more easily palpated lymph nodes
vibrations (as on the chest) felt by the hand placed on the part of the body
normal RR range
12 to 20 breaths/min
normal adult chest
should be symmetric, with the transverse diamter greater than the anteroposterior diameter. Shape or contour should have a downward equal slope at the rib cage. Color should be even and consistent with the color of the pt's face. Inspect for color, shape and contour, breathing patterns, and muscle development too.
an increased anteroposterior diameter, as seen in chronic lung diseases, is described as barrel-chest. Depth=width
exaggerated lumbar curve
increase in dorsal spinal curve
lateral curvature of the spine with a increase convexity on the side that's curved
(Pectus Excavatum) caved in/sunken in appearance of the chest
heard over the trachea are high-pitched, harsh sounds, with expiration being longer than inspiration. Blowing/hollow sounds; auscultated over the trachea. Expiration is longer, lower, and higher-pitched than inspiration.
heard over the mainstem bronchus and are moderate "blowing" sounds, with inspiration equal to expiration. Medium-pitched, medium intensity, blowing sounds; ausculated over the first and second interspaces anteriorly and the scapula posteriorly. Inspiration and expiration have similar pitch and duration. (Over the first and second intercostal spaces.)
vescular breath sounds
soft, low-pitched sounds, heard best over the base of the lungs during inspiration, which is longer than expiration. Soft, low-pitched sounds; auscultated over the lung periphery. Inspiration is longer, louder, and high-pitched than expiration.
adventitious lung sounds
abnormal breath sound heard over the lungs; includes wheezing (sibilant), wheezing (sonorous), crackles, and friction rub.
a general term used to refer to noisy, strenuous respirations.
a harsh, high-pitched sound heard on inspiration when there is a narrowing of the upper airway, such as the larynx or trachea. Infants or young children with croup often manifest stridor when breathing.
- are fine to coarse crackling sounds made as air moves through wet secretions; they are most often heard on inspiration. Crackles are described as "fine" when they are made by air passing through moisture in small air passages and alveoli. And then there's "coarse."
- - bubbling, crackling, popping
- - low-to-high pitched, discontinuous sounds
- - auscultated during inspiration
- - occurs in small air passages, alveoli, bronchioles, bronchi, and trachea
that's how coarse crackles are documented. They're "coarse" when they are made by air passing through moisture in the bronchioles, bronchi, and trachea.
continuous sounds that originate in small air passages that are narrowed by secretions, swelling, or tumors. They may be inspiratory or expiratory and are high-pitched sounds.
pleural friction rub
- a grating sound caused by an inflamed pleura rubbing against the chest wall.
- - rubbing/grating
- - loudest over lower lateral anterior surface
- - auscultated during inspiration and expiration
- - musical/squeaking
- - high-pitched, continuous sounds
- - auscultated during inspiration and expiration
- - occurs in small air passages
- - sonorous/coarse
- - low-pitched, continuous sounds
- - auscultated during inspiration and expiration
- - coughing may clear the sound
common thorax and lung variations in newborns and children
- - louder breath sounds on auscultation
- - more rapid respiratory rate (until 8 to 10 yrs of age)
- - use of abdominal muscles during respiration
common thorax and lung variations in older adults
- - increased anteroposterior chest diameter
- - kypohosis
- - decreased thoracic expansion
- - use of accessory muscles to exhale
the portion of the body over the heart and lower thorax, encompassing the aortic, pulmonic, tricuspid, and apical areas, and Erb's point
inflammation of a vein; of the lower extremity is indicated by pain, redness, and swelling of the affected calf/thigh.
neck vein distention
indicating heart disease/chf
heard at 2nd intercoastal space (2ICS) at the R sternal border (RSB) [(S2) is heard best)]
heard at the 2nd intercoastal space (2ICS) at the L sternal border (LSB)
heard at the 4th or 5th intercoastal space at the L sternal border (LSB)
mitral valve (PMI - point of maximum impulse)
heard at the 5th intercoastal space (5ICS) at the L midclavicular line (LMCL) (S1) loudest = closure of the Mitral Valve and the Tricuspid Valve (MV/TV) [AV valves]
atrioventricular (AV) valves
The atrioventricular valves are the mitral and tricuspid valves, which regulate the blood flow from the left and right atriums to the left and right ventricles.
semilunar (SV) valves
The semilunar valves are the aortic valve and the pulmonic valve, which allow the blood to flow from the left ventricle to the aorta and from the right ventricle to the pulmonary artery.
peripheral vascular disease
resulting in decreased blood flow and oxygenation of tissues, the skin of the lower extremities is typically pale and cool, shiny with brown discolorations, and hairless. The toenails are thickened
palpating peripheral pulses (what are the number of amplitudes and how they are described, and how should they be...)
they should be strong and equal bilaterally. the amplitude of the pulses may be documented as 0 (absent), 1+ (weak), 2+ (normal), 3+ (increased), or 4+ (bounding). Abnormal findings include an absent, weak, thready pulse (which may indicate a decreased cardiac cardiac output), forceful or bounding pulse (seen in HTN and circulatory fluid overload), and an asymmetric pulse (r/t impaired circulation). Other specific assessments to determine arterial blood flow include Allen's test, Buerger's test, and capillary refill.
- - Ask pt to rest his/her hand on the examining table w/ the palm up and to make a fist.
- - Use your thumbs to occlude the radial and ulnar arteries and ask the pt to open his/her hand (the palm will be pale).
- - Release your thumb pressure and observe the return of color to the palm (this should normally take 3 to 5 secs)
- - Ask the pt to assume a supine position and then raise one arm or one leg about 1 ft above the lvl of his/her heart.
- - Ask the pt to briskly move the leg/arm up and down for 1 min, then to sit up and dangle the arm/leg downward.
- - Observe the time it takes for the original color of the pt's skin to return and for the veins to fill. Normally, color returns in 10 secs, and veins fill in 15 secs.
- - Using your thumb and forefinger, squeeze the pt's fingernail/toenail until it appears white.
- - Release the pressure and observe the time it takes for normal color to return. Normally, color returns immediately.
- - Assess it in children by pressing the skin lightly over the forehead or top off the hand. Release the pressure; observe the time for return of color.
Heart murmurs are extra heart sounds caused by some disruption of blood flow through the heart. Characteristics of a murmur depends on the adequacy of valve fx, rate of blood flow, and size of the valve opening.
grade I murmur
a murmur so faint that it can be heard only with great effort
grade II murmur
a faint murmur but one that can be easily detected
grade III murmur
a moderately loud murmur
grade IV murmur
a very loud murmur that is usually associated with a thrill sound
grade V murmur
an extremely loud murmur
grade VI murmur
an exceptionally loud murmur that can be heard while the stethoscope is lifted off the skin
are abnormal sounds, are "swooshing" sounds similar to murmurs and are heard over major blood vessels. The sound indicates a partially blocked artery, causing blood to swirl, rather than flow normally. Bruits are most commonly heard over the carotid arteries, the abdominal aorta, and the femoral arteries. Bruits occur when the artery is partially obstructed/distended, which prevents blood flow from moving straight through the vessel.
s3, known as the third heart sound, is often represented by a "lub-dub-dee" pattern; this sound is best heard with the bell at the mitral area, with the pt lying on the left side. S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.
is the fourth heart sound, represented by "dee-lub-dub." S4 is considered normal in older adults but abnormal in children and adults.
the rate increases w/inspiration and decreases with expiration
common CV and peripheral vascular variations in newborns and children
- - visible cardiac pulsation if the chest wall is thin
- - sinus dysrhythmia/arrhythmia
- - presence of s3 (in about one third of all children)
- - more rapid HR (until about 8 yr of age)
common CV and peripheral vascular variations in the older adult
- - difficult to palpate apical pulse
- - difficult to palpate distal arteries
- - dilated proximal arteries
- - more prominent and tortuous blood vessels; varicosities common
- - increased systolic and diastolic BP
- - Widening pulse pressure
Normal findings include that s1 is louder at the tricuspid and apical/mitral areas (AV), with s2 louder at the aortic and pulmonic areas (SL).
skin depressions of the breast
sebaceous glands on the areolae of the breasts
quadrants of the breast
upper outer quadrant, lower outer quadrant, upper inner quadrant, lower inner quadrant, and tail of spence (near armpit)
breasts are normally tender during the wk of menstration. Palpate axillary area for lymph nodes; lymph nodes are an abnormal finding.
enlargement of the gland tissue of the male breast
common breast and axillae variations in newborns and children
- - breast enlargement and a white discharge from the nipples up to 2wks of age
- - female breast growth beginning at 10/11 yrs of age
- - temporary enlargement of one or both breasts (gynecomastia) in pubescent boys
common breast and axillae variations in older adults
- grandular, pendulous breasts in women
name three ways to palpate the breast
- 1. circular:
- - start at the tail of spence and move in increasing smaller circles
- - use the pads of the first 3 fingers to gently compress the breast tissue against the chest wall
- 2. wedge
- -work in a clockwise direction and palpate from the periphery toward the areola
- - use the pads of the first 3 fingers to gently compress the breast tissue against the chest wall
- 3. vertical strip
- - start at the outer edge of the breast and palpate up and down the breast
- - use the pads of the first three fingers to gently compress the breast tissue against the chest wall
sequence of assessing the abd.
inspection, auscultation (use light pressure to avoid creating BS), percussion, palpation (percussion and palpation are done after because they stimulate BS)
- Start in RLQ, and must listen for 2mins or longer in ea. abd quadrant (usually occur q.5-34sec)
fine white/silver lines, often the result of skin stretching from weight gain/pregnancy
accumulation of fluid in the peritoneal cavity, indicating fluid retention. (swelling of the abd.)
tymphany is heard over abd whille dullness is heard over liver and a full bladder (hyperinflated lung is resonant)
using the bell, auscultate over the abd aorta, femoral arteries, and iliac arteries for bruits (abnormal sounds heard over a blood vessel as blood passes an obstruction). A bruit may be heard if an occlusion/arterial insufficiency is present in an abdominal artery. Suggests an aneurysm/arterial stenosis
palpating the abdomen... abnormal findings
abnormal findings include involuntary rigidity, spasm, and pain (which may indicate trauma, peritonitis, infection, tumors, or enlarged/dzed abd organs).
to palpate liver
palpate bimanually, stand at pt's right side and place your left hand under pt's back at the lvl of the 11th to 12th ribs. With your fingers pointing toward the pt's head, ask the pt to inhale and press up and in w/ your fingertips. Normal liver edge should feel firm and smooth and may be mildly tender. Abnormal findings include a hard, firm liver edge (found in cancer of the liver), nodularity (found w/tumor, metastatic cancer, cirrhosis of the liver), and pain (from vascular engorgement as in CHF, hepatitis, or abscess). If the liver border is more than 1 to 3 cm below the costal margin, it's considered enlarged. Liver enlargement may result from hepatitis, liver tumors, cirrhosis, and vascular engorgement. (liver is dull when percussed)
common abd variations in newborns and children
- - umbilical cord in newborns; dries and falls off within the first few wks of life
- - a "pot belly" (under 5 yrs of age)
- - visible peristaltic waves
- - easily palpated liver and spleen
common abd variations in older adults
- - decreased BS
- - decreased abd tone
- - liver border palpated more easily
ruq of abd
- -right kidney and adrenal gland
- - hepatic flexure of colon
- -head of pancreas
rlq of abd
- -right ovary and fallopian tube (female)
- -right ureter and lower kidney pole
- -right spermatic cord (male)
luq of abd
- -left kidney and adrenal gland
- -splenic flexure of colon
- -body of pancreas
llq of abd
- -sigmoid colon
- -left ovary and fallopian tube (female)
- -left ureter and lower kidney pole
- -left spermatic cord (male)
midline of abd
- -urinary bladder
- -urethra (female)
w/o muscle tone
spastic, rigid muscles
weak, flabby muscles
a grating sound heard/felt on movement (by arthritis)
common musculoskeletal variations in newborns and children
- - c-shaped curve of spine at birth; the anterior cervical curve develops at about 3 to 4 months of age, and the anterior lumbar curve develops between 12 and 18 months of age
- - lordosis
- - pronation of the ft in children between 12 and 30 months of age
- - genu varum (bowleg) for 1 yr after learning to walk
common musculoskeletal variations in older adults
- - loss of muscle mass and strength
- - decreased ROM
- - kyphosis
- - decreased height
- - osteoartritic changes in joints
mental status assessment
includes lvl of awareness, lvl of consciousness, behavior and appearance, memory, abstract reasoning, and language.
lvl of awareness
- by evaluating orientation to time, place, and person.
- The following questions can be asked:
- - Time: What is today's date? What day of the week is it? What season is it? What was the last holiday?
- - Place: Where are you now? What is the name of this city? What state are we in?
- - Person: What is your name? How old are you? Who came to visit you this morn?
degree of wakefulness/the ability of a person to be aroused. This is not the same as orientation: a pt may be conscious but not oriented.
lvl of consciousness
- is described as:
- - awake and alert: fully awake; oriented to person, place and time; responds to all stimuli, including verbal commands
- - lethargic: appears drowsy/asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying pt's name
- - stuporous: unconscious most of the time; has no spontaneous movement; must be shaken/shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements
- - comatose: cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes are present, is in a deep coma
Glasgow Coma Scale
standardized assessment tool that assesses lvl of consciousness. 3 parameters are evaluated: eye opening, motor response, and verbal response. Scores are given in ea. category, and a total score is recorded, with higher scores indicating a more normal lvl of fxing. A score of 7 or less defines coma. More accurate evaluation of mental status over time.
memory is assessed by asking questions that require answers demonstrating immediate recall and recall for past events. To assess immediate memory, ask the pt to repeat a series of number forward and backward. Might also ask what they ate for breakfast. Assess past memory, ask, "when is your b-day?" or "when is your wedding anniversary?"
assessing abstract reasoning
ask the pt to explain a proverb such as "the early bird catches the worm." If intellectual ability is impaired, the pt usually gives a literal explanation or repeats the phrase. Be sure that the phrase is not culture specific.
disorder of language ability; injury to the cortex can cause this. it may be expressive (the individual understand written and spoken words but cannot write or speak to commute effectively) or receptive (the individual cannot understand written word/spoken words). These aphasias may also be combined.
biceps reflex test
to test, the elbow is slightly bent and the palm faces downward. the examiner's thumb is placed on the biceps tendon at the bend of the elbow. The percussion hammer strikes the examiner's thumb.
triceps reflex test
to test, the pt's elbow is sharply bent; the forearm is placed across the chest wall with the palm turned toward the body. the triceps tendon is struck with the percussion hammer just above the elbow.
knee reflex test/knee jerk
to test, the pt is in the sitting position. the patellar tendon is just below the patella is struck with the percussion hammer. if the pt is lying down, the reflex is tested while the examiner's hands are placed under the knees to bend them.
ankle reflex test
to test, the leg is bent at the knee and the foot is supported in a walking position. the Achilles tendon is struck with the percussion hammer.
the lateral aspect of the sole of the foot is stroke with an object, such as a key/thumbnail, from the heel to ball of the foot
toes flare up and back; bend back (normal in child ages 12 and 24 mons)
the toes curl (normal in adults and children older than 24 mons)
grading of reflexes scale
- 4+: very brisk, hyperactive; often indicative of disease; often associated with clonus (rhythmic oscillation between flexion and extension)
- 3+: brisker than average; possibly but not necessarily indicative of disease
- 2+: average; normal
- 1+: somewhat diminished; low normal
- 0: no response
common neurologic variations for newborns and children
- - positive babinski's reflex in children 12 and 24 mon
- - grasp reflex (present at birth)
- - motor control develops in head, neck, trunk, and extremities sequence
common neurologic variations in older adult
- - slower thought processes and verbal resonses
- - decreased sensory ability (hearing, sight, smell, taste, temperature, pain)
- - slower coordination and voluntary movements
- - decreased reflex responses
- - appearance of confusion in unfamiliar surroundings
- - slower gait, with a wider base and flexed hips and knees
- - diminished deep tendon reflexes
studies in which a needle/similar instrument is inserted into a body organ/cavity. fluid/tissue is aspirated, prepared, labeled, and sent to the lab for examination. (e.g., liver biopsy, lumbar puncture, paracentesis, thoracentesis)
electrical impulse procedures
studies that use a machine with electrodes attached to the body to monitor electric activity. Electric impulses are recorded on a graph and displayed on paper or an oscilloscope screen. (e.g., EKG/EEG)
studies that allow for direct visual examination of various body cavities and organs by means of a hollow, lighted tube called an endoscope. the tube may be flexible/rigid. may be used to obtain tissue specimens for biopsy/microscopic examination (e.g., bronchoscopy, colonscopy, gastrocscopy, sigmoidoscopy, and laparoscopy)
studies in which body fluids, secretions, or tissues are sent to the lab for analysis (e.g., blood studies, urine studies, sputum studies, fecal studies, and biopies)
because of the ability of x-rays to penetrate human tissues, x-ray studies provide a pic of body structures that looks like a negative of a photograph (e.g., chest x-ray/dye-enhanced cardiac cathterization)
magnetic-resonance imaging (MRI)
the computer-based procedure provides physiologic info and detailed views of fluid-filled soft tissues (MRI of the brain, spine, extremities, joints, heart, pelvis, and abdomen)
studies that use the administration of a radionuclide and subseequent measurement of radiation from an organ to detect fxal abnormalities (brain, heart, lung, and bone scan)
studies in which a harmless, high-frequency sound wave is emitted that penetrates the organ being studied. the sound waves bounce back to the sensor and are electronically converted into a pic of the organ or the contents of the organ. (ultrasound of the pelvis, abdomen, heart, and uterus)
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