Physical Assessment Health Assessment An integral part of nursing care and is the basis of the nursing process Is used

to plan, implement, and evaluate teaching and care in order to promote an optimal level of health to prevent illness, restore health, and facilitate coping with disabilities Purposes:

1.

Comprehensive With a health history and complete physical examination Done when patient enters a health care setting

2.

Ongoing Partial Conducted at regular intervals during care of patient Focuses on the identified health problems

Obtain physical data about the client s functional abilities 3. Supplement, confirm, or refute data obtained in the client s health history Obtain data that will help the nurse establish diagnoses and plan the client s care. Focused

Used to assess specific problem

4. Emergency Rapid focused assessment Determines potentially fatal situations

Evaluate the physiologic outcomes of health care and thus the progress of a patient s health problem To make clinical judgments about a client s health status To identify areas for health promotion and disease prevention Components of Health Assessment Health history - focused on interviewing skills Physical assessment - head-to-toe sequence, system sequence Factors to Assess During a Health History Biographic Data Chief Complaint History of Present Illness Past medical history Family History Lifestyle Types of Assessment

Preparing the Client Consider client s physiologic and psychological needs Explain the procedure to the client to lower the anxiety Ask relevant questions (health concerns, health habits, lifestyle) Answer client s questions directly and honestly Provide comfort and privacy to the client Ask client to empty bladder Ask client to change gown; help in undressing if necessary Positions Used in Physical Assessment Sitting - used to take vital signs Supine - allows relaxation of abdominal muscles Dorsal recumbent - used for patients having difficulty maintaining supine position Sim s - assessment of rectum and vagina 1 PE

Prone - assessment of hip joint and posterior thorax Lithotomy - assessment of female rectum and vagina; used for brief period only Knee-chest - assessment of rectal area; used for brief period only Standing - assessment of posture, gait and balance Preparing the Environment Agree on the time for assessment Schedule should not interfere with meals and daily routines of the client Client should be as free of pain as possible If possible, choose a quiet, well-lit, warm, and private room Make sure that the equipment are complete and in good condition For Your Information: Make sure to complete the health history of the client before proceeding with the physical assessment Physical assessment is being done to validate the subjective data gathered during the health interview In doing physical assessment, ensure client s safety, privacy, and comfort (eg. Expose only the area being examined) Compare findings on one side of the body to the other side Equipment Needed: Stethoscope Sphygmomanometer Thermometer Weighing scale Stadiometer / tape measure Wrist watch Snellen chart / Newspaper

Penlight Gloves Cardboard Tongue depressor Tuning fork Cotton balls Gauze pad Cotton applicator Alcohol Glass of water Ophthalmoscope / Otoscope Receptacle Paper and pen Techniques in Physical Assessment: Inspection Process of performing deliberate, purposeful observations in a systematic manner Use of different senses such as sight, hearing, and smell Begins with the initial contact and continues all throughout the assessment Assess color, size, shape, position and symmetry Palpation Assessment technique that uses the sense of touch Assess temperature, turgor, texture, moisture, vibrations and shape Dorsum surface: gross measure of temperature Palmar surface: texture, shape, fluid, size, consistency, and pulsation Nurse s hand should be warm; fingernails must be short Types of Palpation 2 PE

Light Palpation Hand should be parallel to the area being palpated 1-2 cm To check muscle tone and assess for tenderness Deep Palpation Hand should be at a 60 degree angle to the area being palpated 4 cm To identify abdominal organs and abdominal masses NOTE: should be done with EXTREME CAUTION Characteristics of Masses Determined by Palpation Shape Size Consistency Surface Mobility Tenderness Pulsatile Percussion Act of striking one object against another to produce sound Used to assess the location, shape, size, and density of tissue Types of Percussion Direct Percussion Primarily used to assess sinuses in the adult Indirect Percussion Two hands are used (plexor and pleximeter) Types of Sounds Heard When Using Percussion

Flatness - soft, high-pitched, and short in duration (e.g. muscle, bone) Dullness - medium in intensity and pitch, moderate duration (e.g. liver, heart) Resonance - loud, low-pitched, and long in duration (e.g. normal lung) Hyperresonance - very loud, very low-pitched, and very long in duration (e.g. emphysematous lung) Tympany - musical; loud, high-pitched, and moderate in duration (e.g. stomach filled with gas) Auscultation Act of listening with a stethoscope to sounds produced within the body Bell side: low-pitched sound (BELL-ow) Ex: heart sounds Diaphragm: high-pitched sound Ex: bowel sounds

Characteristics of Sound Heard When Using Auscultation Pitch - ranging from high to low Loudness - ranging from soft to loud Quality - e.g. gurgling or swishing Duration - short, medium, or long Order of Physical Assessment Cephalocaudal (head-to-toe) Least Invasive to Most invasive Inspection, Palpation, Percussion, Auscultation (except for abdomen) Components of Physical Assessment: General Survey Appearance 3 PE

1.

Body build, posture, and gait (proportion of height to weight, erect or slumped posture, coordination of movements, pattern of gait) Hygiene, grooming (cleanliness, body odors) Signs of illness

Dirty, unkempt Body and Breath Odor Normal Findings: No body odor or minor body odor relative to work or exercise No breath odor Deviations from Normal: Foul body odor, ammonia odor, acetone breath odor, foul breath Signs of distress in posture and facial expression Normal Findings: No distress noted Deviation from Normal: Bending over because of abdominal pain, wincing, or labored breathing Obvious signs of health or illness Normal Findings: Healthy Appearance Deviation from Normal: Pallor, weakness, obvious illness Attitude Normal Findings: Cooperative Deviations from Normal: Negative, hostile, withdrawn Mood and Affect Normal Findings: Appropriate to situation Deviations from Normal: Inappropriate to situation 4 PE

2. 3.

4. Affect, attitude, mood (speech, facial expressions, ability to relax, eye contact, behavior) 5. Cognitive processes (speech content and patterns, orientation, appropriate verbal response)

Body built, height, and weight in relation to age, lifestyle and health Normal Findings: Proportionate, varies with lifestyle Deviations from Normal: Excessively thin or obese Posture and gait, standing, sitting and walking Normal Findings: Relaxed, Erect posture, coordinated movement Deviations from Normal: Tense, slouched, bent, uncoordinated movement, tremors Overall Hygiene and Grooming Normal Findings: Clean, neat Deviations from Normal:

Quantity, Quality, and Organization of Speech Normal Findings: Understandable, moderate pace, exhibits thought association Deviations from Normal:

Begins with an overall inspection of the skin s condition Can be assessed during other body system assessments Skin: Inspect for skin color Assessment Findings

Rapid or slow pace, uses generalizations, lacks association; exhibits confabulation Relevance and Organization of Thoughts Normal Findings:

Normal Findings: varies from light to deep brown; Ruddy pink to light pink; Yellow overtones to olive

Logical sequence, makes sense, has sense of reality Deviations from Normal: Deviations from Normal: Pallor (paleness of the skin) Illogical sequence, flight of ideas, confusion Jaundice (yellow color of the skin) Measurement of Vital Signs (Temperature, Pulse Rate, Respiratory Rate, Blood Pressure) Measurement of Height and Weight Cyanosis (bluish or grayish discoloration of the skin) Erythema (redness of the skin) Illustration: Skin Color Abnormalities Skin: Inspect Uniformity of Color Normal Findings: Generally uniform except in areas exposed to the sun; Areas of lighter pigmentation (palms, lips, nail beds) in dark-skinned people Deviations from Normal: C= (DBW) * .10 N Range= DBW-C (Lower Limit) = DBW+C (Upper Limit) BMI= wt. in kg/ ht. in (m)2 Assessment of the Integument Skin: Inspect skin vascularity Integumentary structures assessed are the skin, nails, hair, and scalp Assessed by observation and palpation Normal Findings: - Absence of bruising/ bleeding on the skin Deviations from Normal: 5 PE areas of either hyperpigmentation or hypopigmentation (eg. Vitiligo, albinism, edema) Illustration: Abnormalities in Skin Uniformity hypopigmentation hyperpigmentation

(Refer to Height and Weight Table) NOTE: Given: DBW= A- B where, A= ht. in cm -100 B= (A) * .10

Ecchymosis Petechiae NOTE: If present, assess location, color, and size Illustration: Abnormalities on Skin Vascularity Ecchymosis (collection of blood in the subcutaneous tissues causing purplish discoloration) Petechiae (small hemorrhagic spots caused by capillary bleeding) Skin: Inspect skin lesions Normal Findings: Freckles, some birthmarks, some flat and raised nevi (moles); No abrasions and other lesions; Deviations from Normal: Various interruptions in skin integrity (eg. Macule, papule, pustule, nodule, wheal, tumor, vesicle, etc.) Illustration: Common Skin lesions

corneum Crust is dried exudate (ie. blood, serum, pus) on the skin surface Excoriation is a loss of skin due to scratching or picking Lichenification is an increase in skin lines & creases from chronic rubbing A fissure is a linear crack in the skin; often very painful A wheal or hive describes a short lived (< 24 hours), edematous, well circumscribed papule or plaque seen in urticaria Petechiae or purpura or ecchymosis describes red blood cells that are outside the vessel walls & areas are nonblanchable Skin Temperature Normal Findings: Uniform; Within normal range

Macule A macule is a small spot that is not palpable & that is < 1 cm

Deviations from Normal: Generalized hyperthermia (eg. Fever); Generalized hypothermia (eg. In shock); Localized hyperthermia (eg. In infection);

A papule is a small superficial bump that is elevated & that is < 1 cm A vesicle is a small fluid-filled bubble that is usually superficial & that is < 0.5 cm A bulla is a large fluid-filled bubble that is superficial or deep & that is > 0.5 cm A pustule is pus containing bubble often categorized according to whether or not they are related to hair follicles A cyst is a sac containing fluid or semisolid material Scale is typically present where there is epidermal inflammation, ie. psoriasis, tinea, eczema. Scale is the accumulation or excess shedding of the stratum

Localized hypothermia (eg. In arteriosclerosis) Skin Moisture Normal Findings: Moisture in skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity) Deviations from Normal: Excessive moisture (eg. In hyperthermia) Excessive dryness (eg. In dehydration) Skin Turgor (Fullness or elasticity of the skin) 6 PE

Normal Findings: When pinched: skin springs back to previous state

Dark- skinned client may have brown or black pigmentation in longitudinal streaks Deviations from Normal:

(good skin turgor) Bluish or purplish tint (my reflect cyanosis); Deviations from Normal: Pallor (may reflect poor arterial circulation) Skin stays pinched or tented or moves back slowly (eg. In dehydration) In edema, there would be difficulty in lifting the skin fold. If there is pitting edema, an indention may remain after the pressure is released Illustrations: Abnormalities in Skin Elasticity Nails: Inspect Nail plate shape (Curvature and Angle) Normal Findings: Convex curvature; Angle between nail and nail bed of about 160 degrees Deviations from Normal: Spoon nail; Clubbing (180 degrees or >) Nails: Inspect Nail Texture Normal Findings: Smooth texture Deviations from Normal: Excessive thickness; excessive thinness or presence of grooves or furrows; Beau s line Deviations from Normal: Illustrations: Abnormalities in Nail Shape and Texture Cont.. Hair and Scalp: Inspect hair thickness or thinness Nails: Inspect Nail Bed Color Normal Findings: Normal Findings: Thick hair Highly vascular and pink in light-skinned clients; Deviations from Normal: 7 PE Patches of hair loss (eg. Alopecia) Hair and Scalp: Inspect the evenness of growth over the scalp Normal Findings: Evenly distributed hair Illustration: Abnormalities in Nail Bed Color Nails: Inspect Tissues Surrounding Nails Normal Findings: Intact epidermis Deviations from Normal: Hangnails; Paronychia (inflammation) Nails: Perform Blanch Test for Capillary Refill Nails: Capillary Refill Normal Findings: Prompt return of pink or usual color Deviations from Normal: Delayed return of pink or usual color (may indicate circulatory impairment) Hair and Scalp: Inspect the evenness of growth over the scalp

Very thin hair (eg. In hypothyroidism) Hair and Scalp: Inspect hair texture and oiliness Normal Findings: Silky, resilient hair Deviations from Normal: Brittle hair (eg. In hypothyroidism); Excessively oily or dry hair Hair and Scalp: Note presence of infection or infestations Normal Findings: No infection or infestation Deviations from Normal: Flaking, sores, lice, nits (louse eggs), ring worm Hair and Scalp: Inspect amount of body hair Normal Findings: Variable Deviations from Normal: Hirsutism (excessive hairiness in women and children) Assessment of the Head and Neck - includes the skull, face, face, eyes, ears, nose, sinuses, mouth and pharynx, trachea, thyroid gland, and lymph nodes Skull and Face: Inspect the skull for size, shape, and symmetry Normal Findings:

Increased skull size with more prominent nose and forehead; Longer mandible (may indicate excessive growth hormone or increased bone thickness) Illustration: Abnormality in Skull Size, Shape, and Symmetry Skull and Face: Palpate the skull for nodules or masses and depressions Normal Findings: Smooth, uniform consistency; Absence of nodules or masses Deviations from Normal: Sebaceous cysts; Local deformities from trauma Skull and Face: Inspect the facial features (eg. Symmetry of structures and of the distribution of hair) Normal Findings: Symmetric or slightly asymmetric facial features; Palpebral fissures equal in size; Symmetric nasolabial folds Deviations from Normal: Increased facial hair; Thinning of eyebrows; Asymmetric features; Exophthalmus; Myxedema facies;

Rounded (Normocephalic and symmetric, with frontal, parietal, and occipital prominences) Smooth skull contour Deviations from Normal: Lack of symmetry;

Moon face Illustrations: Abnormalities in facial features Skull and Face: Inspect the eyes for edema and hollowness Normal Findings: 8 PE

Absence of edema Deviations from Normal: Periorbital edema; Sunken eyes Skull and Face: Note symmetry of facial movements - ask the client to elevate the eyebrows, frown, or lower the eyebrows, close the eyes tightly, puff the cheeks, and smile and show the teeth Normal Findings: Symmetric facial movements Deviations from Normal: Asymmetric facial movements (eg. Eye on affected side cannot close completely); Drooping of lower eyelid and mouth; Involuntary facial movements (eg. Tics or tremors) Assessment of the Eyes Eyes: Inspect the eyebrows for hair distribution and alignment and skin quality and movement Normal Findings: Hair evenly distributed; skin intact; Eyebrows symmetrically aligned; equal movement Deviation from Normal: Loss of hair; scaling and flakiness of skin; Unequal alignment and movement of eyebrows; Eyes: Inspect the eyelashes for evenness of distribution and direction of curl Normal Findings: Equally distributed; Curled slightly outward Deviations from Normal: Turned inward

Eyes: Inspect the eyelids for surface characteristics (eg. Skin quality and texture, position in relation to the cornea, ability to blink, and frequency of blinking) Normal Findings: Skin intact; no discharge; no discoloration; Lids close symmetrically; Approximately 15-20 involuntary blinks/ min.; bilateral blinking; When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered Deviations from Normal: Redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions; Lids close asymmetrically, incompletely, or painfully; Rapid, monocular, absent, or infrequent blinking; Ptosis, ectropion, entropion; rim of sclera visible between lid and iris Illustrations: Abnormalities of the Eyelids Eyes: Inspect the bulbar conjunctiva (lying over the sclera) for color, texture, and presence of lesions Normal Findings: Transparent; Capillaries sometimes evident; Sclera appears white (yellowish in dark-skinned clients) Deviations from Normal: Jaundiced sclera; Excessively pale sclera; Reddened sclera; Lesions or nodules Illustrations: Abnormalities of Conjuctiva 9 PE

Eyes: Inspect the palpebral conjuctiva (lining the eyelids) by everting the lids Eyes: Inspect the palpebral conjuctiva (lining the eyelids) by everting the lids. Note color, texture, and the presence of lesions. Normal Findings: Shiny, smooth, and pink or red Deviations from Normal: Extremely pale (possible anemia);

Opaque; surface not smooth (may be the result of trauma or abrasion); Arcus senilis in clients under age 40 is abnormal Eyes: Perform the corneal sensitivity (reflex) test to determine the function of the 5th (Trigeminal) Cranial Nerve Normal Findings: Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact Deviations from Normal:

Extremely red (inflammation); One or both eyelids fail to respond Nodules or other lesions Inspection of Sclera Conjunctiva Inspection of Eyes: Inspect the anterior chamber for transparency and depth Normal Findings: Eyes: Inspect and palpate the lacrimal gland No shadows of light on iris Normal Findings: Depth of about 3mm No edema or tenderness over lacrimal glands Deviations from Normal: Deviations from Normal: Cloudy; Swelling or tenderness over lacrimal glands Crescent-shaped shadows on far side of iris; Eyes: Inspect and palpate the lacrimal sac and nasolacrimal sac Normal Findings: No edema or tearing Normal Findings: Deviations from Normal: Black in color; Evidenced of increased tearing; Equal in size; 3-7 mm diameter; Regurgitation of fluid on palpation of lacrimal sac Round, smooth border, iris flat and round Eyes: Inspect the cornea for clarity and texture Deviations from Normal: Normal Findings: Transparent, shiny and smooth; details of the iris are visible; In older people, a thin, grayish white ring around the margin, called arcus senilis, maybe evident Deviations from Normal: Cloudiness, mydriasis (dilation of the pupil), myosis (constriction of pupils) , anisocoria; Bulging of iris toward cornea Illustrations: Normal and Abnormal Pupils Eyes: Assess each pupil s direct and consensual reaction to light 10 PE Shallow chamber Eyes: Inspect the pupils for color, shape, and symmetry of size.

Normal Findings: Illuminated pupil constricts (direct response) Non-illuminated pupil constricts (consensual response) Deviations from Normal: Neither pupil constricts Unequal responses

Visual fields Cont.. Eyes: Assess six ocular movements to determine eye alignment and coordination Normal Findings: Both eyes coordinated, move in unison, with parallel alignment Deviation from Normal:

Absent responses Eye movements not coordinated or parallel; Illustrations: Normal Pupil reaction to Light Illustrations: Abnormal Reaction of Pupil to Light Eyes: Assess each pupil s reaction to accommodation and convergence Normal Findings: Cont.. Pupils constrict when looking at near object Pupils dilate when looking at far objects Pupils converge when near object is moved towards nose Deviations from Normal: One or both pupils fail to constrict, dilate, or converge Accommodation Convergence Eyes: Assess peripheral visual fields Eyes: Assess peripheral visual fields Normal Findings: When looking straight ahead, client can see objects in the periphery Deviations from Normal: Visual fields smaller than normal (possible glaucoma); One half vision in one or both eyes (indicates nerve damage) Uncovered eye does not move from fixed point when the other eye is covered Newly uncovered eye, if well aligned, does not move when index card is removed. Deviations from Normal Uncovered eye moves to focus on fixed point, indicating it is not well aligned before other was covered; it is shifting from lateral to central gaze. Newly uncovered eye moves to focus on fixed point, indicating it was not well aligned when covered Eyes: Perform the corneal light reflex test to determine eye alignment Normal Findings: Light reflection appears at symmetric spots in both eyes Deviations from Normal: 11 PE Illustrations: Abnormalities Eyes: Perform the cover-uncover patch test to determine eye alignment. Normal Findings: One or both eyes fail to follow a penlight in specific directions, such as strabismus (cross-eye or squint) Extraocular Movements Cont..

Light reflection appears at different spots in each eye (asymmetric) Eyes: Assess visual acuity (near vision) Normal Findings: Able to read newsprint at a distance of 36 cm (14 in) Deviations from Normal: Difficult reading newsprint unless due to aging process Eyes: Assess visual acuity (distance vision) Normal Findings: 20/20 vision on Snellen chart Interpretation: Client can read the letters/objects in 20 ft which a normal sighted person can read at 20 ft Deviations from Normal: Denominator of 40 or more on Snellen chart with corrective lenses Note: The higher the denominator, the poorer the vision Test for visual acuity Charts used to assess visual acuity PERRLA Pupils Equally Round and Reactive to Light and Accommodation Assessment of the Ears Ears: Inspect the auricles for color, symmetry of size, and position Normal Findings: Color same as facial skin Symmetric position. Line drawn from lateral angle of the eye to point where top part of auricle joins head is horizontal Deviations from Normal:

Bluish color of earlobes (eg. Cyanosis); Pallor (eg. Frostbite); Excessive redness (inflammation or fever) Low-set ears associated with congenital anomaly, such as Down syndrome) Illustrations: Abnormalities in Auricles Ears: Palpate the auricles for texture, elasticity, and areas of tenderness - Pull the auricle upward and backward (>3 y.o.); downward and backward (<3 y.o.) - Pull the pinna forward (it should be recoil) - Push in on the tragus - Apply pressure to the mastoid process Normal Findings: Mobile, firm, and not tender Pinna recoils after it is folded Deviations from Normal: Lesions (eg. Cyst) Flaky, scaly skin Tenderness when moved or pressed (may indicate inflammation or infection of external ear) Ears: Using otoscope, inspect the external canal Ears: Using an otoscope, inspect the external ear canal for cerumen, skin lesions, pus and blood and the tympanic membrane for color Normal Findings: Distal third contains hair follicles and glands Dry cerumen, grayish-tan color; or sticky, wet cerumen in various shades of brown Deviations from Normal: Redness and discharge Scaling Excessive cerumen obstructing canal Ears: Inspect the tympanic membrane for color and gloss 12 PE

Normal findings: Pearly gray color, semitransparent Deviations from Normal: Pink to red, some opacity Yellow amber White Blue or deep red Dull surface

Able to hear ticking in both ears Deviations from Normal: Unable to hear ticking in one or both ears Ears: Perform Weber s Test Ears: Perform Weber s test Normal Findings: Sound is heard in both ears or is localized at the center of the head (Weber negative) Deviations from Normal:

Ears: Assess gross hearing acuity tests Ears: Assess client s response to normal voice tones Normal Findings: Normal voice tones audible Deviations from Normal: Normal voice tones not audible (eg. Requests nurse to repeat words or statement, leans toward the speaker, turn the head, cups the ears, or speaks in loud tone of voice) Ears: Assess client s response to whispered voice - Stand 30 to 60 cm (1-2 ft) from the client in a position where the client cannot read your lips. Ask the client to occlude one ear by putting a finger in it. - Whisper some nonconsecutive numbers and have the client tell you what was heard. Increase the loudness of the whisper until the client can identify at least 50% of the numbers. Repeat with the other ear. Normal Findings: Able to repeat nonconsecutive numbers Deviations from Normal: Unable to repeat 50% of numbers whispered Ears: Perform the watch tick test - Place ticking watch 2 to 3 cm (1-2 in) from the unoccluded ear Normal Findings: Assessment of the Nose 13 PE Sound is heard better in impaired ear, indicating a bone-conductive hearing loss (eg. Due to obstruction), or sound is heard better in ear without a problem, indicating a sensorineural disturbance Note findings as Weber positive and indicate whether right or left ear Ears: Conduct the Rinne test Ears: Conduct the Rinne test to compare air conduction to bone conduction Normal Findings: Air-conducted (AC) hearing is greater than boneconducted (BC) hearing, that is, AC>BC (positive Rinne) Deviations from Normal: Bone conduction time is equal to or longer than the air conduction time, that is, BC>AC or BC=AC (negative Rinne; indicates a conductive hearing loss) Types of Hearing Loss: Conduction hearing loss - the result of interrupted transmission of sound waves through the outer and middle ear structures Sensorineural hearing loss - result of damage to the inner ear, the auditory nerve, or the hearing center in the brain Mixed hearing loss - combination of conduction and sensorineural loss

Nose: Inspect the external nose for any deviations in shape, size, or color and flaring or discharge from the nares Normal Findings: Symmetric and straight No discharge or flaring Uniform color Deviations from Normal: Asymmetric Discharge from nares Localized areas of redness or presence of skin lesions Nose: Lightly palpate the external nose Nose: Lightly palpate the external nose to determine any areas of tenderness, masses, and displacements Normal Findings: No tenderness No lesions Deviations from Normal: Tenderness on palpation Presence of lesion Nose: Determine patency of both nasal cavities - Ask the client to close the mouth, exert pressure on one naris, and breathe through the opposite naris. Repeat on the opposite naris. Normal Findings: Air moves freely as the client breathes through the nares Deviations from Normal: Air movement is restricted in one or both nares Nose: Inspect the nasal cavities Nose: Inspect the nasal cavities

Normal Findings: Mucosa pink Clear, watery discharge No lesions Nasal septum intact and in midline Deviations from Normal: Mucosa red, edematous Abnormal discharge (eg. Purulent_ Presence of lesions (eg. Polyps) Septum deviated Nose: Palpate facial sinuses Palpating the sinuses Nose: Palpate the maxillary and frontal sinuses for tenderness Normal Findings: Not tender Deviations from Normal: Tenderness in one or more sinuses Nose: Transilluminate the frontal sinuses - Place penlight against the inner aspect of the supraorbital ridge of the frontal bone - best done in a darkened room Normal Findings: Sinuses are well-outlined, contain air, and light up equally Deviations from Normal: Fluid in sinuses appears darker on transillumination Nose: Transilluminate the maxillary sinuses - Place a penlight in the mouth and shine it to the left and to the right Normal Findings: As above 14 PE

Deviations from Normal: As above Assessment of the Mouth and Pharynx Mouth and Pharynx: Inspect the outer lips for symmetry of contour, color, and texture Normal Findings: Uniform pink color (darker, eg. Bluish hue, in Mediterranean groups and dark-skinned clients) Soft, moist, smooth texture

Mouth and Pharynx: Inspect teeth and gums - can be done while examining the inner lips and buccal mucosa Normal Findings: 32 adult teeth Smooth, white, shiny tooth enamel Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums No retraction of gums (pulling away from the teeth)

Symmetry of contour Deviations from Normal: Ability to purse lips Missing teeth Deviations from Normal: Ill-fitting dentures Pallor; cyanosis Blisters; generalized or localized swelling; fissures, crusts, or scales (may result from excessive moisture, nutritional deficiency, or fluid deficit) Inability to purse lips (indicative of facial nerve damage) Mouth and Pharynx: Inspect and palpate the inner lips and buccal mucosa Mouth and Pharynx: Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture, and the presence of lesions Normal Findings: Uniform pink color (freckled brown pigmentation in dark-skinned clients) Moist, smooth, soft, glistening, and elastic texture (drier oral mucosa in elderly due to decreased salivation) Deviations from normal: Irritated and excoriated area under dentures Pallor; white patches (leukoplakia) Excessive dryness Mucosal cysts; irritations from dentures; abrasions, ulcerations; nodules Mouth and Pharynx: Inspect the surface of the tongue Mouth and Pharynx: Inspect the surface of the tongue for position, color, and texture 15 PE Brown or black discoloration of the enamel (may indicate staining or the presence of caries) Excessively red gums Spongy texture; bleeding; tenderness (may indicate periodontal disease) Receding atrophied gums; swelling that partially covers the teeth Mouth and Pharynx: Inspect the dentures - Ask client to remove complete or partial dentures - Inspect their condition, noting broken or worn areas Normal Findings: Smooth, intact dentures Deviations from Normal Ill-fitting dentures

Normal Findings: Central position Pink color (some brown pigmentation on tongue borders in dark-skinned clients); moist; slightly rough; thin whitish coating Smooth, lateral margins; no lesions Deviations from Normal: Deviated from center (may indicate damage to hypoglossal or 12th cranial nerve) Smooth red tongue (may indicate iron, Vit B12, or Vit B3 deficiency) Dry, furry tongue (associated with fluid deficit) Nodes, ulcerations, discolorations (white or red areas); areas of tenderness Mouth and Pharynx: Inspect tongue movement Normal Findings: Moves freely No tenderness Deviations from Normal: Restricted mobility Mouth and Pharynx: Inspect the base of the tongue, the mouth floor, and the frenulum - ask the client to place the tip of the tongue against the roof of the mouth Normal Findings: Smooth tongue base with prominent veins Varicosities (tiny bluish-black or purple swollen areas) in elderly people Deviations from normal: Swelling Ulcerations Mouth and Pharynx: Palpate the tongue and floor of the mouth for any nodule, lumps, or exoriated areas. - use gauze to grasp tip of the tongue

Normal Findings: Smooth with no palpable nodules Deviations from Normal: Swelling, nodules Illustration: Abnormality of the Tongue Mouth and Pharynx: Inspect salivary duct openings for any swelling or redness Normal Findings: Same as color of buccal mucosa and floor of mouth Deviations from Normal: Inflammation (redness and swelling) Mouth and Pharynx: Inspect the hard and soft palate for color, shape, texture, and the presence of bony prominences Normal Findings: Light pink, smooth, soft palate Lighter pink hard palate, more irregular texture Deviations from Normal: Discoloration (eg. Jaundice or pallor) Plated the same color Irritations Bony growths (exostoses) growing from the hard palate Mouth and Pharynx: Inspect the uvula for position and mobility while examining the palates Normal Findings: Positioned in midline of soft palate Deviations from Normal: Deviation to one side from tumor or trauma; Immobility (may indicate damage to trigeminal or 5th or vagus or 10th cranial nerve

16 PE

Mouth and Pharynx: Inspect the oropharynx for color and texture Normal Findings:

Neck: Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal swellings or masses Normal Findings:

Pink and smooth posterior wall Muscles equal in size Deviations from Normal: Head centered Reddened or edematous; presence of lesions, plaques, or exudate Mouth and Pharynx: Inspect the tonsils for color, discharge, and size Normal Findings: Pink and smooth No discharge Of normal size Deviations from Normal: Inflamed Presence of discharge Swollen Illustrations: Inspecting tonsils for tonsillitis Grading System for Tonsilitis Deviations from Normal: Grade 1 (Normal) The tonsils are behind the tonsillar pillars Grade 2 between the pillars and the uvula Grade 3 tonsils touch the uvula Grade 4 one or both tonsils extend to the midline of the oropharynx Mouth and Pharynx: Elicit gag reflex Normal Findings: Present Deviations from Normal: Absent (may indicate problems with glossopharyngeal or vagus nerves) Assessment of the Neck 17 PE Muscle tremor, spasm, or stiffness Limited range of motion; painful movements; involuntary movements (eg. Up-and-down nodding movements associated with Parkison s disease) Neck: Assess muscle strength - Turn the head to one side against the resistance of your hand - Shrug the shoulders against the resistance of your hands Normal Findings: Equal strength Deviations from Normal: Unequal strength Neck: Observe head movement ask client to: move the chin to the chest move the head back so that the chin points upward move the head so that the ear is moved toward the shoulder on each side turn the head to the right and to the left Normal Findings: Coordinated, smooth movements with no discomfort Deviations from Normal: Unilateral neck swelling Head tilted to one side (indicates presence of masses, injury, muscle weakness, shortening of sternocleidomastoid muscle, scars)

Neck: Palpate the entire neck for enlarged lymph nodes 1. 2. 3. Submental

Not visible on infection Deviations from Normal: Visible diffuseness or local enlargement

Submaxillary / Submandibular Neck: Palpate the thyroid gland for smoothness Parotid (not a lymph node) 1. Posterior Approach Anterior Approach 2.

4. Preauricular 5. Postauricular

Neck: Palpate the thyroid gland for smoothness Normal Findings: Lobes may not be palpated If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing Deviations from Normal:

6. Occipital 7. Tonsillar / Superficial anterior cervical

8. Supraclavicular 9. Posterior Cervical 10. Anterior or deep cervical chain

Solitary nodules Neck: Palpate the entire neck for enlarged lymph nodes Normal Findings: Not palpable Deviations from Normal: Enlarged, palpable, possibly tender (associated with infection and tumors) Neck: Palpate the trachea for lateral deviation Neck: Palpate the trachea for lateral deviation Normal Findings: Central placement in midline of neck Spaces are equal on both sides Deviations from Normal: Deviation to one side, indicating possible neck tumor; thyroid enlargement; enlarged lymph nodes Neck: Inspect the thyroid gland Normal Findings: Neck: If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit bruit - a soft rushing sound created by turbulent blood flow; use bell side of stethoscope Normal Findings: Absence of bruit Deviations from Normal: Presence if bruit Illustrations: Abnormalities of the Thyroid and Parotid Glands POSTERIOR THORAX 1. Inspect the shape and symmetry of the thorax from posterior and lateral view. NORMAL FINDINGS Anteroposterior to transverse diameter is 1:2 ratio Chest symmetric DEVIATIONS 18 PE Neck: If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit

Barrel chest (1:1) APL ratio Chest asymmetric BARREL CHEST 2. Inspect spinal alignment for deformities Have the client stand in a lateral position, observe the 3 normal curvatures: cervical, thoracic and lumbar To assess the lateral deviation of spine . observe the standing client from the rear. Have the client bend forward and observe from NORMAL FINDINGS Spine vertically aligned. Spinal column straight, R and L shoulders and hips at same height DEVIATIONS Lordosis forward curvature of lumbar spine Kyphosis- hunchback; angular curvature of thoracic spine Scoliosis lateral curvature of spine; shoulders/ hips not even LORDOSIS KYPHOSIS SCOLIOSIS 3. Palpate the posterior thorax

Uniform temperature Skin intact Chest wall intact No lumps, masses areas of tenderness DEVIATIONS Areas of hyperthermia (+)lesions Lumps, bulges, depressions, tenderness, movable structures (eg ribs) Asymmetric/decreased chest expansion 4. Palpate the posterior chest for respiratory excursion (thoracic expansion). Place the palms of both your hands over the lower thorax with your thumbs adjacent to the spine and your fingers stretched laterally. Ask the client to take a deep breath while you observe the movement of your hands and any lag in movement CHEST EXCURSION /CHEST EXPANSION NORMAL FINDINGS Symmetrical chest expansion 3-5 cm or (1.5 to 2 inches) thumb separation @ inspiration DEVIATIONS Asymmetric/decreased chest expansion 5. Palpate vocal tactile fremitus (a thrill felt by the hand on the chest wall while the client is speaking) a . Place hands on the posterior chest starting near the apex of the lungs. palmar surface of your fingertips aspect of your hand or closed fist - ulnar

a. For clients who have no respiratory symptoms, rapidly assess the temperature and integrity of all chest skin. b. For clients who have respiratory complaints, palpate all chest area for bulges, tenderness or abnormal movement. c. Avoid deep palpation for painful areas (ie fractured rib) NORMAL FINDINGS

b. Ask ct to repeat words blue moon , 1, 2, 3 . c. Repeat the two steps moving your hands sequentially to the base of the lungs. 19 PE

(+) dullness / flatness over diapghram lung tissue d. Compare the fremitus on both lungs and b/w the apex and the base of each lung, either using one hand and moving it from one side of the client to the corresponding area on the other side or using 2 hands simultaneously on corresponding areas of each side of chest. NORMAL FINDINGS Bilateral symmetry of vocal fremitus Fremitus is heard most clearly at the apex of the lungs. DEVIATIONS fremitus (pneumothorax) fremitus (pneumonia) SEQUENCE IN GETTING THE VOCAL FREMITUS 6. Percuss the thorax to determine whether underlying lung tissue is air-, water- or solidmaterial filled; to determine positions and boundaries of certain organs. a. Ask ct to bend and fold arms across chest, to separate scapula and expose more lung tissue b. Percuss in intercostals spaces at 5cm (2in) intervals in systematic sequence. Compare both sides of the lungs. Percuss lateral thorax every few inches from axilla th down to 8 rib. SEQUENCE OF POSTERIOR LUNG PERCUSSION a. NORMAL FINDINGS Resonance except over Lowest resonance (consolidation of posterior rib) Dullness over ribs corresponding point on the opposite side DEVIATIONS of the chest. Asymmetry on percussion NORMAL FINDINGS 20 PE 8-10th Use systematic zigzag procedure used in percussion. lung tissue/mass 7. Percuss for diaphragmatic excursion (movement of diaphragm @ maximal inspiration & expiration) a. Ask ct to take deep breath and hold it while you percuss downward along scapular line until to point of dullness @ diaphragm level. Mark this point and repeat on other side. b. Ask ct to take few normal breaths then expel last breath completely and hold it while percussing upward from marked point to assess/mark diaphragmatic excursion @ deep expiration on both sides. c. Measure distance b/w 2 marks DIAPHRAGMATIC PERCUSSION SEQUENCE NORMAL FINDINGS Females: 3-5 cm (1.5 - 2 in) Males: 6 cm (2 - 3 in) *bilaterally usually slightly higher on R side DEVIATIONS Restricted excursion (r/t lung disorder) 8. Auscultate chest using flat disc diaphragm of the stethoscope- best for transmitting high pitched sounds.

b. Ask ct to take a slow deep breath thru the mouth. Listen at each point to the breath sounds during complete inspiration and expiration. c. Compare each point with the

Adventitious sounds (crackles, rhonchi, wheeze, friction rub)

a. Place the palms of both hands on lower thorax with fingers laterally along lower rib cage and thumbs along costal margin. b. Ask ct to take a deep breath while you observe the movement of your hands NORMAL FINDINGS

Absent breath sounds (lung collapse or surgical lung lobe removal) ANTERIOR THORAX

Full and symmetric 1. Inspect breathing patterns (RR, rate). 3 - 5 inches bilateral thumb separation Normal findings : Quiet, rhythmic and DEVIATIONS effortless respiration. Asymmetric or excursion Deviations : Abnormal RR, patterns, rate, ANTERIOR VOCAL FREMITUS characteristics, depth, 5. Palpate tactile fremitus in the same manner as for the posterior chest. 2. Inspect the costal angle (angle formed by intersection of costal margins) and the angle at which the ribs enter the spine. NORMAL FINDINGS Bilateral symmetry of vocal fremitus. Costal angle is < 90 Ribs insert into spine at 45 angle DEVIATIONS Widened costal angle (r/t COPD) 3.Palpate the anterior chest. (same with post. chest) Normal Findings : Uniform temperature Skin intact Chest wall intact No lumps, masses areas of tenderness Deviations: Areas of hyperthermia (+)lesions, Lumps, bulges, depressions, tenderness, movable structures (eg ribs) 4. Palpate anterior chest for respiratory excursion. Fremitus is heard most clearly at the apex of the lungs. fremitus over heart and breast tissue. DEVIATIONS fremitus (pneumothorax) fremitus (pneumonia) 6. Percuss anterior chest systematically. a. Begin above the clavicles in the supraclavicular space, and proceed downward to the diaphragm. b. Compare one side of the lung to the other. c. Displace female breast for proper examination NORMAL FINDINGS 21 PE * Omit this procedure if the breasts are large and cannot be retracted adequately for palpation NORMAL FINDINGS

Resonance down to 6 rib @ diaphragm level Flat over heavy muscles and bone Dull over the heart and the liver Tympanic over underlying stomach. DEVIATIONS Asymmetry (+) dull/flat over lung tissue SEQUENCE ANTERIOR LUNG PERCUSSION 7. Auscultate the trachea. Normal Findings: Bronchial/tubular breath sounds Deviations : Adventitious breath sounds 8. Auscultate the anterior chest Use the sequence used in percussion beginning over the bronchi between the sternum and the clavicles. Normal Findings: Bronchovesicular and vesicular breath sounds. Deviations: Adventitious breath sounds Sequence of Modalities: IAPPa - Auscultation done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can bowel motility and thus bowel sounds, creating false results. 2 common methods in subdividing the abdomen (imagine 2 lines: A vertical line from the xiphoid process to the pubic symphysis and a horizontal line across the umbilicus - 9 Regions (imagine 2 vertical lines that extend superiorly from the midpoints of the inguinal ligaments, and two horizontal lines, one at the edge of the lower ribs and the other at the level of the iliac crests 22 PE Normal Findings Unblemished skin, uniform color (no lesion) Silver-white striae(stretch marks) or surgical scars Abnormal Findings (+) rash and other lesions tense, glistening skin (ascites, edema) purple striae (Cushing s stretchmarks ascites stretchmarks Thank You! 2. Inspect abdomen for skin integrity. Pigmentation, lesions, striae, scars, veins and umbilicus 1. Assist ct to a supine position, with arms placed comfortably at the sides a. Place small pillows beneath the knees and the head to tension in the abdominal muscles. b. Expose only the ct s abdomen from chest line to the pubic area to avoid chilling and shivering, which can tense the abdominal muscles.

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