Physical Assessment Handouts 546f2t

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

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

Is the use of hand to touch for the purpose of determining temperature, moisture, size, shape, position, texture, consistency, and movement.

TYPES OF PALPATION Light Palpation  To check muscle tone and assess for tenderness Techniques: Place the hand with fingers together parallel to the area being palpated. Press down 1 to 2 cm. Repeat in ever-widening circles until the area to be examined is covered.

NURSING SKILLS Physical Assessment

Lecturer: Mark Fredderick R. Abejo R.N, M.A.N

PHYSICAL ASSESSMENT Objectives:  Obtain physical data about the client’s functional abilities  Supplement, confirm, or refuse data obtained in the nursing history  Obtain data that will help the nurse data establish nursing diagnoses and plan the client’s care.  Evaluate the physiologic outcomes of health care and thus the progress of a patient’s health problem  Screen presence of cancer

Deep Palpation  To identify abdominal organs and abdominal masses. Techniques: With fingers together, approach the area to be examined at a 60 degree angle and use the pads and tips of the fingers of one hand to press in 4 cm. Two – handed Deep Palpation place the fingers of one hand on top of those of the other.

CEPHALOCAUDAL ORDER OF EXAMINATION AREAS  HEENT  NECK  UPPER EXTREMITIES  CHEST AND BACK  BREAST AND AXILLAE  ABDOMEN  GENITALS  ANUS AND RECTUM  LOWER EXTREMITIES Note: SKIN IS CHECK THROUGHTOUT ASSESSMENT

THE

General Concepts: Approach the client calmly and confidently. Provide privacy. Make sure that all needed instruments are available before starting the physical assessment Several positions are frequently required during the assessment. Consider the client’s ability to assume a position. Be systematic and organized when assessing the client. (Inspection, Palpation, Percussion, Auscultation If a client is seriously ill, assess the systems of the body that are more at risk Perform painful procedures at the end of the examination METHODS OF EXAMINING    

INSPECTION PALPATION PERCUSSION AUSCULTATION

INSPECTION  Visual examination of the patient done in a methodical and deliberate manner. PALPATION Foundations of Nursing Physical Assessment

PERCUSSION  Striking of the body surface with short, sharp strokes in order to produce palpable vibrations and characteristic sound.  It is used to determine the location, size, shape, and density of underlying structures; to detect the presence of air or fluid in a body space; and to elicit tenderness. TYPES OF PERCUSSION Direct Percussion  Percussion in which one hand is used and the striking finger (plexor) of the examiner touches the surface being percussed. Techniques: Using sharp rapid movements from the wrist, strike the body surface to be percussed with the pads of two, three, or four fingers or with the pad of the middle finger alone. Primarily used to assess sinuses in the adult. Indirect Percussion  Percussion in which two hands are used and the plexor strikes the finger of the examiner’s other hand, which is in with the body surface being percussed (pleximeter). Techniques: Strike at a right angle to the pleximeter using quick, sharp but relaxed wrist motion. Withdraw the plexor immediately after the strike to avoid damping the vibration. Strike each are twice and then move to a new area Blunt  Ulnar surface of the hand or fist is used in place of the fingers to strike the body surface, either directly or indirectly. Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

PERCUSSION SOUNDS RESONANCE – Hollow sound. Ex. normal lung. HYPERRESONANCE – Booming sound. Ex. Emphysematous lung 3. TYMPANY – musical or drum sound. Ex. Stomach and intestines 4. DULLNESS – Thud sound. Ex. Enlarged spleen, full bladder, liver. 5. FLATNESS – extremely dull sound. Ex. Muscle or bone AUSCULTATION  Listening to sounds produced inside the body 1. 2.

EQUIPMENTS FOR PHYSICAL EXAMINATION             

Sphygmomanometer and stethoscope Thermometer Nasal Speculum Ophthalmoscope Otoscope Vaginal Speculum Tongue depressor/blade Penlight Cotton Applicators Tuning fork Reflex hammer Clean gloves Lubricant

GENERAL SURVEY VITAL SIGNS GENERAL SURVEY 1. Physical Appearance 2. Level of Conciousness/ awareness  Alertness– Patient is awake and aware of self and environment.  Lethargy – When spoken to in a loud voice, patient appears drowsy but opens eye, and look at you, responds to questions, then falls asleep.  Obtundation – When shaken gently, patient opens eye and looks at you but responds slowly and is somewhat confused.  Stupor – Patient arouses from sleep only after painful stimuli.  Coma – Despite repeated painful stimuli, patient remains unarousable with eyes closed. 3. Apperance in relation to chronological age 4. Signs of distress 5. Nutritional status 6. Body structure 7. Obvious physical deformities 8. Mobility 9. Behavior 10. Odors of body and breath 11. Facial Expression 12. Mood & affect 13. Speech

SYSTEMS ASSESSMENT INTEGUMENTARY SYSTEM Functions of the Skin:  Protection  Absorption  Regulation  Synthesis  Sensory Foundations of Nursing Physical Assessment

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Procedure: 1. Inspects skin surfaces 2. Palpates with fingertips for edema and skin turgor 3. Palpates skin temperature contra-laterally using back of hands Assessment: Health History  Presenting problem  Changes in the color and texture of the skin, hair and nails.  Pruritus  Infections  Tumors and other lesions  Dermatitis  Ecchymoses  Dryness  Lifestyle practices  Hygienic practices  Skin exposure  Nutrition / diet  Intake of vitamins and essential nutrients  Water and Food allergies  Use of medications  Steroids  Antibiotics  Vitamins  Hormones  Chemotherapeutic drugs  Past medical history  Renal and hepatic disease  Collagen and other connective tissue diseases  Trauma or previous surgery  Food, drug or allergies  Family medical history  Diabetes mellitus  Allergic disorders  Blood dyscrasias  Specific dermatologic problems  Cancer Physical Examination  Color  Areas of uniform color  Pigmentation  Redness  Jaundice  Cyanosis  Vascular changes  Purpuric lesions  Ecchymoses  Petechiae  Vascular lesions  Angiomas  Hemangiomas  Venous stars  Lesions  Color  Type  Size  Distribution  Location  Consistency  Grouping  Annular  Linear  Circular  Clustered     

Edema (pitting or non-pitting) Moisture content Temperature (increased or decreased; distribution of temperature changes) Texture Mobility / Turgor Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Effects of Aging in the Skin  Skin vascularity and the number of sweat and sebaceous glands decrease, affecting thermoregulation.  Inflammatory response and pain perception diminish.  Thinning epidermis and prolonged wound healing make elderly more prone to injury and skin infections.  Skin cancer more common.

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Hypertrophic scar on the other hand does not overgrow the wound boundaries. Fibrosis or sclerosis describes dermal scarring/thickening reactions. Milium is a small superficial cyst containing keratin (usually <1-2 mm in size Vascular Skin Lesions Petechiae is a round or purple macule, associated with bleeding tendencies or emboli to skin Ecchymosis a round or irregular macular lesion larger than petechiae, color varies and changes from black, yellow and green hues. Associated with trauma and bleeding tendencies. Cherry Angioma, popular and round, red or purple, may blanch with pressure and a normal age-related skin alteration. Spider Angioma is a red, arteriole lesion, central body with radiating branches. Commonly seen on face,neck,arms and trunk. Associated with liver disease, pregnancy and vitB deficiency. Telangiectasia , shaped varies: spider-like or linear, bluish in color or sometimes red. Does not blanch when pressure applied. Secondary to superficial dilation of venous vessels and capillaries.

Primary Lesions of the Skin Macule is a small spot that is not palpable and is less than 1 cm in diameter Patch is a large spot that is not palpable & that is > 1 cm. Papule is a small superficial bump that is elevated & that is < 1 cm. Plaque is a large superficial bump that is elevated & > 1 cm. Nodule is a small bump with a significant deep component & is < 1 cm. Tumor is a large bump with a significant deep component & is > 1 cm. Cyst is a sac containing fluid or semisolid material, ie. cell or cell products. Vesicle is a small fluid-filled bubble that is usually superficial & that is < 0.5 cm. Bulla is a large fluid-filled bubble that is superficial or deep & that is > 0.5 cm. Pustule is pus containing bubble often categorized according to whether or not they are related to hair follicles:  follicular - generally indicative of local infection  folliculitis - superficial, generally multiple  furuncle - deeper form of folliculitis  carbuncle - deeper, multiple follicles coalescing

Edema - the presence of large amounts of fluid in the interstitial spaces. Usually due to fluid collecting in the subcutaneous tissue. Edema may be localized or generalized. A.

B.

Secondary lesions of the Skin Scale is the accumulation or excess shedding of the stratum corneum.  Scale is very important in the differential diagnosis since its presence indicates that the epidermis is involved.  Scale is typically present where there is epidermal inflammation, ie. psoriasis, tinea, eczema 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. Maceration is raw, wet tissue. Fissure is a linear crack in the skin; often very painful. Erosion is a superficial open wound with loss of epidermis or mucosa only Ulcer is a deep open wound with partial or complete loss of the dermis or submucosa Distinct Lesions of the Skin Wheal or hive describes a short lived (< 24 hours), edematous, well circumscribed papule or plaque seen in urticaria. Burrow is a small threadlike curvilinear papule that is virtually pathognomonic of scabies. Comedone is a small, pinpoint lesion, typically referred to as “whiteheads” or “blackheads.” Atrophy is a thinning of the epidermal and/or dermal tissue. Keloid overgrows the original wound boundaries and is chronic in nature. Foundations of Nursing Physical Assessment

C. D.

Rating 1+ 2+ 3+ 4+

Some causes are lymphatic obstruction, increased vascular permeability, decreased oncotic pressure due to low levels of plasma proteins (especially albumin), or renal or cardiac disease. Collections of edema are named according to the site: 1. Anasarca - massive generalized edema 2. Ankle 3. Ascites - peritoneal cavity 4. Hydrothorax - thoracic cavity 5. Periorbital - around the eyes 6. Sacral - lower back Edema occurs in dependent areas first. Edema is graded on a scale considering the depth of the indentation and the length of time to return to normal. Assessment: Press firmly with finger for 5 seconds. Assessment 5mm depth, recovers immediately 8-10 mm, duration 10-15 sec. 11-20 mm, duration 15-30 sec. >20 mm, duration >30 sec.

HEAD Procedure: 1. 2.

3.

4. 5. 6.

Observe the size, shape and contour of the skull. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions. Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about tenderness upon doing so. (wear gloves if necessary) Observe and feel the hair condition. Test Cranial Nerve VII Test Cranial Nerve V

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Normal Findings: 1.

2.

3.

Skull · Generally round, with prominences in the frontal and occipital area. (Normocephalic). · No tenderness noted upon palpation. Scalp · Lighter in color than the complexion. · Can be moist or oily. · No scars noted. · Free from lice, nits and dandruff. · No lesions should be noted. · No tenderness nor masses on palpation. Hair · Can be black, brown or burgundy depending on the race. · Evenly distributed covers the whole scalp (No evidences of Alopecia) · Maybe thick or thin, coarse or smooth. · Neither brittle nor dry.

FACE 1. Observe the face for shape. 2. Inspect for Symmetry. a. b.

c.

Inspect for the palpebral fissure (distance between the eye lids); should be equal in both eyes. Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending from the angle of the corner of the mouth). Slight asymmetry in the fold is normal. If both are met, then the Face is symmetrical

3. Test the functioning of Cranial Nerves that innervates the facial structures CN V (Trigeminal)

1. Sensory Function · Ask the client to close the eyes. · Run cotton wisp over the fore head, check and jaw on both sides of the face. · Ask the client if he/she feel it, and where she feels it. · Check for corneal reflex using cotton wisp. · The normal response in blinking. 2. Motor function · Ask the client to chew or clench the jaw. · The client should be able to clench or chew with strength and force. CN VII (Facial)

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1. Sensory function (This nerve innervate the anterior 2/3 of the tongue). · Place a sweet, sour, salty, or bitter substance near the tip of the tongue. · Normally, the client can identify the taste. 2. Motor function · Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the cheeks. Normal Findings: · Shape maybe oval or rounded. · Face is symmetrical. · No involuntary muscle movements. · Can move facial muscles at will. · Intact cranial nerve V and VII. EYE / EYEBROW / EYELASHES Normal findings: Eyebrows · Symmetrical and in line with each other. · Maybe black, brown or blond depending on race. · Evenly distributed. Eyes · Evenly placed and inline with each other. · Non protruding. · Equal palpebral fissure. Eyelashes · Color dependent on race. · Evenly distributed. · Turned outward EYELIDS / LACRIMAL APPARATUS 1. Inspect the eyelids for position and symmetry. 2. Palpate the eyelids for the lacrimal glands. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the client’s upper orbital rim. Inquire for any pain or tenderness. 3. Palpate for the nasolacrimal duct to check for obstruction. To assess the nasolacrimal duct, the examiner presses with the index finger against the client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE. In the presence of blockage, this will cause regurgitation of fluid in the puncta Normal Findings: Eyelids · Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open. · No PTOSIS noted. (drooping of upper eyelids). · Meets completely when eyes are closed. · Symmetrical. Lacrimal Apparatus · Lacrimal gland is normally non palpable. · No tenderness on palpation. · No regurgitation from the nasolacrimal duct. CONJUNCTIVAE The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the client look up, down and to each side. When separating the lids, the examiner should exert no NO PRESSURE against the eyeball; rather, the

Foundations of Nursing Physical Assessment

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

examiner should hold the lids against the ridges of the bony orbit surrounding the eye. In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow: 1. Ask the client to look down but keep his eyes slightly open. This relaxes the levator muscles, whereas closing the eyes contracts the orbicularis muscle, preventing lid eversion. 2. Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes outward or upward; this, too, causes muscles contraction. 3. Place a cotton tip application about I can above the lid margin and push gently downward with the applicator while still holding the lashes. This everts the lid. 4. Hold the lashes of the everted lid against the upper ridge of the bony orbit, just beneath the eyebrow, never pushing against the eyebrow. 5. Examine the lid for swelling, infection, and presence of foreign objects. 6. To return the lid to its normal position, move the lid slightly forward and ask the client to look up and to blink. The lid returns easily to its normal position.

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Normal findings: · There should be no irregularities on the surface. · Looks smooth. · The cornea is clear or transparent. The features of the iris should be fully visible through the cornea. · There is a positive corneal reflex. ANTERIOR CHAMBER / IRIS The anterior chamber and the iris are easily inspected in conjunction with the cornea. The technique of oblique illumination is also useful in assessing the anterior chamber. Normal Findings: · The anterior chamber is transparent. · No noted any visible materials. · Color of the iris depends on the person’s race (black, blue, brown or green). · From the side view, the iris should appear flat and should not be bulging forward. There should be NO crescent shadow casted on the other side when illuminated from one side. PUPIL Examination of the pupils involves several inspections, including assessment of the size, shape reaction to light is directed is observed for direct response of constriction. Simultaneously, the other eye is observed for consensual response of constriction. The test for papillary accommodation is the examination for the change in papillary size as the is switched from a distant to a near object.

Normal Findings: · · · · ·

Both conjunctivae are pinkish or red in color. With presence of many minutes capillaries. Moist No ulcers No foreign objects

1. Ask the client to stare at the objects across room. 2. Then ask the client to fix his gaze on the examiner’s index fingers, which is placed 5 – 5 inches from the client’s nose. 3. Visualization of distant objects normally causes papillary dilation and visualization of nearer objects causes papillary constriction and convergence of the eye. Normal Findings:

SCLERAE The sclerae is easily inspected during the assessment of the conjunctivae.

· Pupillary size ranges from 3 – 7 mm, and are equal in size. · Equally round. · Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual. · Pupils dilate when looking at distant objects, and constrict when looking at nearer objects. If all of which are met, we document the findings using the notation PERRLA, pupils equally round, reactive to light, and accommodate

Normal Findings: · · · ·

Sclerae is white in color (anicteric sclera) No yellowish discoloration (icteric sclera). Some capillaries maybe visible. Some people may have pigmented positions.

CORNEA The cornea is best inspected by directing penlight obliquely from several positions. Foundations of Nursing Physical Assessment

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

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The assessment of visual acuity is indicative of the functioning of the macular area, the area of central vision. However, it does not test the sensitivity of the other areas of the retina which perceive the more peripheral stimuli. The Visual field confrontation test, provide a rather gross measurement of peripheral vision. The performance of this test assumes that the examiner has normal visual fields, since that client’s visual fields are to be compared with the examiners. Follow the steps on conducting the test:

CRANIAL NERVE II ( OPTIC NERVE ) The optic nerve is assessed by testing for visual acuity and peripheral vision. Visual acuity is tested using a snellen chart, for those who are illiterate and unfamiliar with the western alphabet, the illiterate E chart, in which the letter E faces in different directions, maybe used. The chart has a standardized number at the end of each line of letters; these numbers indicates the degree of visual acuity when measured at a distance of 20 feet. The numerator 20 is the distance in feet between the chart and the client, or the standard testing distance. The denominator 20 is the distance from which the normal eye can read the lettering, which correspond to the number at the end of each letter line; therefore the larger the denominator the poorer the version.

1. The examiner and the client sit or stand opposite each other, with the eyes at the same, horizontal level with the distance of 1.5 – 2 feet apart. 2. The client covers the eye with opaque card, and the examiner covers the eye that is opposite to the client covered eye. 3. Instruct the client to stare directly at the examiner’s eye, while the examiner stares at the client’s open eye. Neither looks out at the object approaching from the periphery. 4. The examiner hold an object such as pencil or penlight, in his hand and gradually moves it in from the periphery of both directions horizontally and from above and below. 5. Normally the client should see the same time the examiners sees it. The normal visual field is 180 degress CRANIAL NERVE III, IV & VI ( Oculomotor,Trochlear,Abducens ) All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular Movement (EOM) or the six cardinal position of gaze.

Measurement of 20/20 vision is an indication of either refractive error or some other optic disorder.

Follow the given steps:

In testing for visual acuity you may refer to the following: 1. The room used for this test should be well lighted. 2. A person who wears corrective lenses should be tested with and without them to check fro the adequacy of correction. 3. Only one eye should be tested at a time; the other eye should be covered by an opaque card or eye cover, not with client’s finger. 4. Make the client read the chart by pointing at a letter randomly at each line; maybe started from largest to smallest or vice versa. 5. A person who can read the largest letter on the chart (20/200) should be checked if they can perceive hand movement about 12 inches from their eyes, or if they can perceive the light of the penlight directed to their yes.

1. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the client’s eyes. 2. Instruct the client to follow the direction the object hold by the examiner by eye movements only; that is with out moving the neck. 3. The nurse moves the object in a clockwise direction hexagonally. 4. Instruct the client to fix his gaze momentarily on the extreme position in each of the six cardinal gazes. 5. The examiner should watch for any jerky movements of the eye (nystagmus). 6. Normally the client can hold the position and there should be no nystagmus.

Peripheral Vision or visual fields

Foundations of Nursing Physical Assessment

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

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This test is useful in determining whether the client has a conductive hearing loss (problem of external or middle ear) or a perceptive hearing loss (sensorineural). There are 2 types of tuning fork test being conducted: Test for Accomodation EAR

1. Weber’s test – assesses bone conduction, this is a test of sound lateralization; vibrating tuning fork is placed on the middle of the fore head or top of the skull.

1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when manipulating the auricles and the mastoid process. 3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodies. a. For adult pull the pinna upward and backward to straighten the canal. b. For children pull the pinna downward and backward to straighten the canal 4. Perform otoscopic examination of the tympanic membrane, noting the color and landmarks.

Normal: hear sounds equally in both ears (No Lateralization of sound) Conduction loss – Sound lateralizes to defective ear (Heard louder on defective ear) as few extraneous sounds are carried through the external and middle ear. Sensorineural loss – Sound lateralizes on better ear.

Normal Findings: 2. Rinne Test – Compares bone conduction with air condition. · The ear lobes are bean shaped, parallel, and symmetrical. · The upper connection of the ear lobe is parallel with the outer canthus of the eye. · Skin is same in color as in the complexion. · No lesions noted on inspection. · The auricles are has a firm cartilage on palpation. · The pinna recoils when folded. · There is no pain or tenderness on the palpation of the auricles and mastoid process. · The ear canal has normally some cerumen of inspection. · No discharges or lesions noted at the ear canal. · On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color.

a. Vibrating tuning fork placed on the mastoid process b. Instruction client to inform the examiner when he no longer hears the tuning fork sounding. c. Position in the tuning fork in front of the client’s ear canal when he no longer hears it.

VESTIBULOCHOCLEAR NERVE ( CRANIAL NERVE VII ) Examination of the cranial nerve VIII involves testing for hearing acuity and balance. Hearing Acuity A.

Voice test

1. The examiner stands 2 ft. on the side of the ear to be tested. 2. Instruct the client to occlude the ear canal of the other ear. 3. The examiner then covers the mouth, and using a soft spoken voice, whispers non-sequential number (e.g. 3 5 7 ) for the client to repeat. 4. Normally the client will be able to hear and repeat the number. 5. Repeat the procedure at the other ear. B.

Watcher test

1. Ask the client to close the eyes. 2. Place a mechanical watch 1 – 2 inches away the client’s ear. 3. Ask the client if he hears anything 4. If the client says yes, the examiner should validate by asking at what are you hearing and at what side. 5. Repeat the procedure on the other ear. 6. Normally the client can identify the sound and at what side it was heard.

Normal: Sound should be heard when tuning fork is placed in front of the ear canal as air conduction< bone conduction by 2:1 (positive rinne test) Conduction loss: Sound is heard longer by bone conduction than by air conduction. Sensorineural loss: Sound is heard longer by air conduction than by bone conduction NOSE AND PARANASAL SINUSES The external portion of the nose is inspected for the following: 1. Placement and symmetry. 2. Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in breathing) 3. Flaring of alaenasi 4. Discharge The external nares are palpated for: 1. 2.

Displacement of bone and cartilage. For tenderness and masses

Turning Fork Test Foundations of Nursing Physical Assessment

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

The internal nares are inspected by heperextending the neck of the client, the ulnar aspect of the examiner’s hard over the fore head of the client, and using the thumb to push the tip of the nose upward while shining a light into the naris.

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3. No flaring alae nasi. 4. Both nares are patent. 5. No bone and cartilage deviation noted on palpation. 6. No tenderness noted on palpation. 7. Nasal septum in the mid line and not perforated. 8. The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy). 9. No tenderness noted on palpation of the paranasal sinuses. OLFACTORY NERVE To test the adequacy of function of the olfactory nerve: 1. 2. 3. 4.

The client is asked to close his eyes and occlude. The examiner places aromatic and easily distinguish nose. (e.g. coffee). Ask the client to identify the odor. Each side is tested separately, ideally with two different substances.

Inspect for the following: MOUTH 1. Position of the septum. 2. Check septum for perforation. (can also be checked by directing the lighted penlight on the side of the nose, illumination at the other side suggests perforation). 3. The nasal mucosa (turbinates) for swelling, exudates and change in color.

Paranasal Sinuses

Mouth and Oropharynx Lips are inspected for: 1. 2. 3.

Symmetry and surface abnormalities. Color Edema

Normal Findings: 1. 2. 3. 4.

With visible margin Symmetrical in appearance and movement Pinkish in color No edema

Palpate the temporomandibular while the mouth is opened wide and then closed for: 1. 2. 3.

Crepitous Deviations Tenderness

Normal Findings: Examination of the paranasal sinuses is indirectly. Information about their condition is gained by inspection and palpation of the overlying tissues. Only frontal and maxillary sinuses are accessible for examination. By palpating both cheeks simultaneously, one can determine tenderness of the maxillary sinusitis, and pressing the thumb just below the eyebrows, we can determine tenderness of the frontal sinuses.

1. 2. 3.

Moves smoothly no crepitous. No deviations noted No pain or tenderness on palpation and jaw movement.

Gums are inspected for: 1. 2. 3.

Color Bleeding Retraction of gums.

Normal Findings: 1. 2. 3.

Pinkish in color No gum bleeding No receding gums

Teeth are inspected for:

Normal Findings:

1. 2. 3. 4. 5.

1. 2.

6. 7.

Nose in the midline No Discharges.

Foundations of Nursing Physical Assessment

Number Color Dental carries Dental fillings Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth). Tooth loss Breath should also be assessed during the process. Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Normal Findings: 1. 2. 3. 4. 5.

28 for children and 32 for adults. White to yellowish in color With or without dental carries and/or dental fillings. With or without malocclusions. No halitosis.

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Normal Findings: 1. 2.

The trachea is palpable. It is positioned in the line and straight.

Tongue is palpated for: Texture Normal Findings: 1. 2. 3. 4. 5. 6. 7.

Pinkish with white taste buds on the surface. No lesions noted. No varicosities on ventral surface. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue. Gag reflex is present. Able to move the tongue freely and with strength. Surface of the tongue is rough.

Uvula is inspected for: 1. 2. 3.

mph nodes are palpated using palmar tips of the fingers via systemic circular movements. Describe lymph nodes in of size, regularity, consistency, tenderness and fixation to surrounding tissues.

Position Color Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the uvula will move upward and forward.

Normal Findings: 1. 2. 3. 4.

Positioned in the mid line. Pinkish to red in color. No swelling or lesion noted. Moves upward and backwards when asked to say “ah”

Tonsils are inspected for: 1. 2.

Inflammation Size

A Grading system used to describe the size of the tonsils can be used. Normal Findings: Grade 1 – Tonsils behind the pillar. Grade 2 – Between pillar and uvula. Grade 3 – Touching the uvula Grade 4 – In the midline. NECK

1. 2. 3. 4. 5. 6.

The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension.

May not be palpable. Maybe normally palpable in thin clients. Non tender if palpable. Firm with smooth rounded surface. Slightly movable. About less than 1 cm in size. The thyroid is initially observed by standing in front of the client and asking the client to swallow. Palpation of the thyroid can be done either by posterior or anterior approach.

Normal Findings: Indication of Lymph Nodes 1. 2. 3. 4.

The neck is straight. No visible mass or lumps. Symmetrical No jugular venous distension (suggestive of cardiac congestion).

The neck is palpated just above the suprasternal note using the thumb and the index finger. The neck is palpated just above the suprasternal note using the thumb and the index finger.

    

Posterior Approach: 1. 2.

Foundations of Nursing Physical Assessment

Occipital: Head infection Submental: Dental Carriections, Oral inf SubMandibular: Infection SCM Upper: Lymphoma Supraclavicular: Cancer

Let the client sit on a chair while the examiner stands behind him. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is the isthmus. Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

3. 4.

5. 6.

7.

Ask the client to swallow while feeling for any enlargement of the thyroid isthmus. To facilitate examination of each lobe, the client is asked to turn his head slightly toward the side to be examined to displace the sternocleidomastoid, while the other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid lobe to be examined. Ask the patient to swallow as the procedure is being done. The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the sternocleidomastoid muscle, while the index and middle fingers are placed deep to and in front of the muscle. Then the procedure is repeated on the other side.

Anterior approach: 1.

2. 3.

4. 5.

The examiner stands in front of the client and with the palmar surface of the middle and index fingers palpates below the cricoid cartilage. Ask the client to swallow while palpation is being done. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach. The client is asked to turn his head slightly to one side and then the other of the lobe to be examined. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be examined. Again, the examiner palpates the area and hooks thumb and fingers around the sternocleidomastoid muscle.

Normal Findings: 1. 2. 3.

Normally the thyroid is non palpable. Isthmus maybe visible in a thin neck. No nodules are palpable.

Auscultation of the Thyroid is necessary when there is thyroid enlargement. The examiner may hear bruits, as a result of increased and turbulence in blood flow in an enlarged thyroid. Check the Range of Movement of the neck.

THORAX Lung borders In the anterior thorax, the apices of the lungs extend for approximately 3 – 4 cm above the clavicles. The inferior borders of the lungs cross the sixth rib at the midclavigular line.

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then continues ant medially to end at the 6th rib at the midclavicular line. The right horizontally fissure extends from the 5th rib slightly posterior to the right midaxillary line and runs horizontally to thee area of the 4th rib at the right sternal border. The left oblique (diagonal) fissure extend from the spinous process of the 3rd thoracic vertebra laterally and downward to the left mid axillary line at the 5th rib and continues anteriorly and medially until it terminates at the 6th rib in the midclavicular line. Borders of the Diaphragm. Anteriorly, on expiration, the right dome of the diaphragm is located at the level of the 5th rib at the midclavicular line and he left dome is at the level of the 6th rib. Posteriorly, on expiration, the diaphragm is at the level of the spinous process of T10; laterally it is at the 8th rib at the midaxillary line. On inspiration the diaphragm moves approximately 1.5 cm downward. Inspection of the Thorax For adequate inspection of the thorax, the client should be sitting upright without and uncovered to the waist. The examiner should observe: 1. 2. 3. 4. 5. 6.

Shape of the thorax and its symmetry. Thoracic configuration. Retractions at the ICS on inspiration. (suprasternal, costal, substernal) Bulging structures at the ICS during expiration. position of the spine. pattern of respiration.

Normal Findings: The shape of the thorax in a normal adult is elliptical; the anteroposterior diameter is less than the transverse diameter at approximately a ratio of 1:2. Moves symmetrically on breathing with no obvious masses. No fail chest which is suggestive of rib fracture. No chest retractions must be noted as this may suggest difficulty in breathing. No bulging at the ICS must be noted as this may obstruction on expiration, abnormal masses, or cardiomegaly. The spine should be straight, with slightly curvature in the thoracic area. There should be no scoliosis, kyphosis, or lordosis. Breathing maybe diaphragmatically of costally. Expiration is usually longer the inspiration. Palpation of the Thorax

In the posterior thorax, the apices extend of T10 on expiration to the spinous process of T12 on inspiration. In the Lateral Thorax, the lungs extend from the apex of the axilla to the 8th rib of the midaxillary line. Lung Fissures The right oblique (diagonal) fissure extend from the area of the spinous process of the 3rd thoracic vertebra, laterally and downward unit it crosses the 5th rib at the midaxillary line. It Foundations of Nursing Physical Assessment

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

1.

2.

General palpation – The examiner should specifically palpate any areas of abnormality. The temperature and turgor of the skin should be assessed. Palpate for lumps, masses and areas of tenderness. Palpate for thoracic expansion or lung excursion. A.

B. C.

D.

1.

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Anteriorly, the examiner’s hands are placed over the anterolateral chest with the thumbs extended along the costal margin, pointing to the xyphoid process. Posteriorly, the thumbs are placed at the level of the 10th rib and the palms are placed on the posterolateral chest. Instruct the client to exhale first, then to inhale deeply. The examiner the amount of thoracic expansion during quiet and deep inspiration and observe for divergence of the thumbs on expiration. Normally, symmetry of respiration between the left and right hemithoraces should be felt as the thumbs are separated are separated approximately 3 – 5 cm (1 – 2 inches) during deep inspiration.

Palpate for the tactile fremitus. A.

B. C. D.

E.

Place the palm or the ulnar aspect of the hands bilaterally symmetrical on the chest wall starting from the top, then at then medial thoracic wall, and at the anterolateral Each time the hands move down, ask the client to say ninety-nine. Repeat the procedure at the posterior thoracic wall. Normally, tactile fremitus should be bilaterally symmetrical. Most intense in the 2nd ICS at the sternal border, near the area of bronchial bifurcation. Low pitched voices of males are more readily palpated than higher pitched voices of females. Basic abnormalities like increased tactile fremitus maybe suggestive of consolidation; decreased tactile fremitus may be suggestive of obstructions, thickening of pleura, or collapse of lungs.

Whispered Pectorioquy – Ask the client top whisper “1-2-3” Over normal lung tissue it would almost be indistinguishable, over consolidated lung it would be loud and clear

Percuss the diaphragmatic excursion

Auscultation of the Thorax

Percussion of the Thorax

Anterior thorax: A. B.

C.

Patient maybe placed on a supine position. Percuss systematically at about 5 cm intervals from the upper to lower chest, moving left to right to left. (Percuss over the ICS, avoiding the ribs. Use indirect percussion starting at the apices of the lungs. The examiner notes the sound produced during each percussion.

Foundations of Nursing Physical Assessment

Normal Breath Sound Vesicular Broncho-vesicular

Soft, low pitch Medium pitch

Bronchial

Loud, high pitch

Lung periphery Larger airway blowing Trachea

Abnormal Breath Sound Crackles

Dependent lobes

Rhonchi

Trachea, bronchi

Random, sudden reinflation of alveoli fluids Fluids, mucus Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Wheezes

All lung fields

Pleural Friction Rub

Lateral lung field

Severely narrowed bronchus Inflamed Pleura

Elderly: Physical Changes of Thorax and Breathing Patterns         

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1. 2. 3. 4.

5. Kyphosis Anteroposterior diameter of the chest widens Breathing rate and rhythm are unchanged at rest Inspiratory muscles become less powerful, and inspiration reserve volume decreases. Expiration may require the use of accessory muscles Deflation of the lung is incomplete Small airways lose their cartilaginous and elastic recoil Elastic tissue of the alveoli loses its stretchability and changes to fibrous tissue. Exertional capacity also decreases. Cilia in the airways decrease in number and are less effective in removing mucus, therefore they are at greater risk for pulmonary infections.

6.

Palpation of the Heart The entire precordium is palpated methodically using the palms and the fingers, beginning at the apex, moving to the left sternal border, and then to the base of the heart. Normal Findings: 1. 2. 3.

CARDIOVASCULAR SYSTEM

Position the patient supine with the head of the table slightly elevated. Always examine from the patient's right side. Inspect for precordial movement. Tangential lighting will make movements more visible. Palpate for precordial activity in general. You may feel "extras" such as thrills or exaggerated ventricular impulses. Palpate for the point of maximal impulse (PMI or apical pulse). It is normally located in the 4th or 5th intercostal space just medial to the midclavicular line and is less than the size of a quarter. Note the location, size, and quality of the impulse.

No, palpable pulsation over the aortic, pulmonic, and mitral valves. Apical pulsation can be felt on palpation. There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders of cardiac dullness. Auscultation of the Heart :

Inspection of the Heart The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsation and heaves or lifts Normal Findings: 1. 2.

Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size). There should be no lift or heaves.

Jugular Venous Pressure 1. 2. 3.

4. 5.

6.

Position the patient supine with the head of the table elevated 30 degrees. Use tangential, side lighting to observe for venous pulsations in the neck. Look for a rapid, double (sometimes triple) wave with each heart beat. Use light pressure just above the sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin. Adjust the angle of table elevation to bring out the venous pulsation. Identify the highest point of pulsation. Using a horizontal line from this point, measure vertically from the sternal angle. This measurement should be less than 4 cm in a normal healthy adult.

Precordial Movement Foundations of Nursing Physical Assessment

Anatomic areas for auscultation of the heart Aortic valve – Right 2nd ICS sternal border. Pulmonic Valve – Left 2nd ICS sternal border. Tricuspid Valve – – Left 5th ICS sternal border. Mitral Valve – Left 5th ICS midclavicular line

Positioning the client for auscultation: If the heart sounds are faint or undetectable, try listening to them with the patient seated and learning forward, or lying on his left side, which brings the heart closer to the surface of the chest. Having the client seated and learning forward s best suited for hearing high-pitched sounds related to semilunar valves problem.

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

The left lateral recumbent position is best suited lowpitched sounds, such as mitral valve problems and extra heart sounds.

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BREAST

Auscultating the heart 1. 2.

3. 4.

Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound is best heard over the mitral valve; S2 is best heard over the aortric valve. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs. Count heart rate at the apical pulse for one full minute.

Normal Findings: 1. 2. 3.

S1 & S2 can be heard at all anatomic site. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4). Cardiac rate ranges from 60 – 100 bpm.

Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. Every client should be examined in each position.

PERIPHERAL CIRCULATION

1. 2.

Inspect:

3.

    

Color Edema Stasis ulcers/lesions Varicosities Hair/nail changes

4.

While the client is performing these maneuvers, the breasts are carefully observed for symmetry, bulging, retraction, and fixation. An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through invasion of the suspensory ligaments, to fix, preventing them from upward movement in position 2 and 4. Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory ligament

Palpate:    

The client is seated with her arms on her side. The client is seated with her arms abducted over the head. The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction of the pectoral muscles. The client is seated and is learning over while the examiner assists in ing and balancing her.

Temperature Edema Tenderness Symmetry of pulses

Chronic Venous Insufficiency Chronic Arterial Insufficiency Pain

None to aching pain on dependency

Pulse

Normal

Color

Normal to cyanotic; petechiae or brown pigmentation

Temperature Edema Skin Changes

Pain

Intermittent claudication

Pulse

Decreased

Color

Pale

Warm

Temperature

Cool

Present

Edema

Absent or mild

Dermatitis skin pigmentation

Skin Changes

Thin, shiny atrophic skin, hair loss, thickened nails

Ulceration

Toes/points of trauma

Gangrene

May develop

Ulceration

Medial side of ankle

Gangrene

Does not develop Normal Findings: 1.

Foundations of Nursing Physical Assessment

The overlying the breast should be even. Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

2. 3.

4. 5. 6. 7. 8. 9.

May or may not be completely symmetrical at rest. The areola is rounded or oval, with same color, (Color va,ies form light pink to dark brown depending on race). Nipples are rounded, everted, same size and equal in color. No “orange peel” skin is noted which is present in edema. The veins maybe visible but not engorge and prominent. No obvious mass noted. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward. No retractions or dimpling.

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Auscultation of the Abdomen This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion. The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the abdominal muscles. Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are relatively high-pitched, the bell may be used in exploring arterial murmurs and venous hum. Peristaltic sounds

Palpation of the Breast Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from the periphery to the center going to the nipples. Be sure that the breast is adequately surveyed. Breast examination is best done 1 week post menses. Each areolar areas are carefully palpated to determine the presence of underlying masses. Each nipple is gently compressed to assess for the presence of masses or discharge.

These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel. Normal Findings: No lumps or masses are palpable. No tenderness upon palpation. No discharges from the nipples. NOTE: The male breasts are observed by adapting the techniques used for female clients. However, the various sitting position used for woman is unnecessary.

Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:  



ABDOMEN In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles.



Divide the abdomen in four quadrants. Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures that we follow the direction of bowel movement. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 minutes, especially at the periumbilical area, before concluding that no bowel sounds are present. The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds. It is suggested that the number of bowel sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.

Inspection of the abdomen Some factors that affect bowel sound: Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). Contour (flat, rounded, scapold) Distension Respiratory movement. Visible peristalsis. Pulsations Normal Findings:

1. 2. 3. 4. 5. 6. 7.

Presence of food in the GI tract. State of digestion. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis). Bowel surgery Constipation or Diarrhea. Electrolyte imbalances. Bowel obstruction.

Percussion of the abdomen Skin color is uniform, no lesions. Some clients may have striae or scar. No venous engorgement. Contour may be flat, rounded or scapoid Thin clients may have visible peristalsis. Aortic pulsation maybe visible on thin clients.

Foundations of Nursing Physical Assessment

Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and masses, and in assessing solid structures within the abdomen. The direction of abdominal percussion follows the auscultation site at each abdominal guardant. The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness. Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

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6th or 9th rib just posterior to or at the mid axillary line on the left side. Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be felt with this method. In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the sigmoid colon, and the aorta.

Percussion of the liver The palms of the left hand is placed over the region of liver dullness. 1. 2. 3.

The area is strucked lightly with a fisted right hand. Normally tenderness should not be elicited by this method. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion 1. 2. 3.

Can be done by either indirect or direct method. Percussion is done over the costovertebral junction. Tenderness elicited by such method suggests renal inflammation.

Liver palpation: There are two types of bi manual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand over the left hand. 1. 2. 3.

Ask the patient to take 3 normal breaths. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation. Press hand deeply over the RUQ

The second methods: 1. 2. Palpation of the Abdomen

3.

Light palpation It is a gentle exploration performed while the client is in supine position. With the examiner’s hands parallel to the floor. The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but gently palpating with slow circular motion. This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding.

4. 5.

Normal Findings: The liver usually can not be palpated in a normal adult. However, in extremely thin but otherwise well individuals, it may be felt a the costal margins. When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-tender.

Tensing of abdominal musculature may occur because of: 1. 2. 3.

The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen. The client is ticklish or guards involuntarily. Presence of subjacent pathologic condition.

Normal Findings: 1. 2. 3.

No tenderness noted. With smooth and consistent tension. No muscles guarding.

The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs. Place the examiner’s right hands parallel to the costal margin or the RUQ. An upward pressure is placed beneath the client to push the liver towards the examining right hand, while the right hand is pressing into the abdominal wall. Ask the client to breath deeply. As the client inspires, the liver maybe felt to slip beneath the examining fingers.

MUSCULOSKELETAL 1. 2. 3. 4. 5. 6. 7. 8.

Assess the patient’s posture, stance, and gait Prepare the patient for the examination Inspect for any gross abnormalities. Inspect and palpate the temporomaddibular t and jaw. Inspect and palpate the neck and spine Assess the ROM of the neck Assess the ROM of the spine Inspect and palpate the upper and lower extremities, assessing each t and muscle.

Deep Palpation It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall. The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined. Foundations of Nursing Physical Assessment

RANGE OF MOTION

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

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TEMPORAL MADIBULAR T AND JAW

RANGE OF MOTION: ELBOW

RANGE OF MOTION: NECK RANGE OF MOTION:SHOUDLERS

RANGE OF MOTION:WRISTS

RANGE OF MOTION:ANKLES

RANGE OF MOTION: FINGERS

Foundations of Nursing Physical Assessment

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

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Always compare one side to the other. Grade strength on a scale from 0 to 5 "out of five": Grading Motor Strength RANGE OF MOTION:KNEES

Grade

Description

0/5

No muscle movement

1/5

Visible muscle movement, but no movement at the t

2/5

Movement at the t, but not against gravity

3/5

Movement against gravity, but not against added resistance

4/5

Movement against resistance, but less than normal

5/5

Normal strength

Test the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Flexion at the elbow (C5, C6, biceps) Extension at the elbow (C6, C7, C8, triceps) Extension at the wrist (C6, C7, C8, radial nerve) Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1) Finger abduction (C8, T1, ulnar nerve) Oppostion of the thumb (C8, T1, median nerve) Flexion at the hip (L2, L3, L4, iliopsoas) Adduction at the hips (L2, L3, L4, adductors) Abduction at the hips (L4, L5, S1, gluteus medius and minimus) Extension at the hips (S1, gluteus maximus) Extension at the knee (L2, L3, L4, quadriceps) Flexion at the knee (L4, L5, S1, S2, hamstrings) Dorsiflexion at the ankle (L4, L5) Plantar flexion (S1)

RANGE OF MOTION:HIPS

Neurological Assessment

Pronator Drift 1. 2.

EXTREMITIES

3.

Observation  Involuntary Movements  Muscle Symmetry   Left to Right   Proximal vs. Distal  Atrophy  Pay particular attention to the hands, shoulders, and thighs.  Gait

Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed. Instruct the patient to keep the arms still while you tap them briskly downward. The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motor neuron disease.

C. Coordination and Gait Rapid Alternating Movements 1.

2. 3.

Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible. Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible. Ask the patient to tap your hand with the ball of each foot as fast as possible.

A. Muscle Tone 1. 2. 3. 4. 5.

Ask the patient to relax. Flex and extend the patient's fingers, wrist, and elbow. Flex and extend patient's ankle and knee. There is normally a small, continuous resistance to ive movement. Observe for decreased (flaccid) or increased (rigid/spastic) tone.

B. Muscle Strength

Point-to-Point Movements 1.

2.

Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed.

Test strength by having the patient move against your resistance. Foundations of Nursing Physical Assessment

Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

3.

Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed.

3.

1.

Have the patient rest the forearm on the abdomen or lap. Strike the radius about 1-2 inches above the wrist. Watch for flexion and supination of the forearm.

2. 3.

Romberg 1. 2.

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Be prepared to catch the patient if they are unstable. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without . The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).

Abdominal (T8, T9, T10, T11, T12) 1. 2.

Use a blunt object such as a key or tongue blade. Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12). Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.

3. Gait Ask the patient to: 1. 2. 3. 4. 5. 6. 7.

Knee (L2, L3, L4)

Walk across the room, turn and come back Walk heel-to-toe in a straight line Walk on their toes in a straight line Walk on their heels in a straight line Hop in place on each foot Do a shallow knee bend Rise from a sitting position

1. 2. 3.

Have the patient sit or lie down with the knee flexed. Strike the patellar tendon just below the patella. Note contraction of the quadraceps and extension of the knee.

Ankle (S1, S2) 1. 2. 3.

D. Reflexes

Dorsiflex the foot at the ankle. Strike the Achilles tendon. Watch and feel for plantar flexion at the ankle.

Deep Tendon Reflexes    

The patient must be relaxed and positioned properly before starting. Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response. Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth). Reflexes should be graded on a 0 to 4 "plus" scale:

Clonus If the reflexes seem hyperactive, test for ankle clonus: 1. 2. 3.

the knee in a partly flexed position. With the patient relaxed, quickly dorsiflex the foot. Observe for rhythmic oscillations.

Tendon Reflex Grading Scale Grade

Plantar Response (Babinski)

Description

0

Absent

1+ or +

Hypoactive

2+ or ++

"Normal"

3+ or +++

Hyperactive without clonus

1.

2. 3.

4+ or ++++ Hyperactive with clonus

Biceps (C5, C6) 1. 2. 3. 4.

The patient's arm should be partially flexed at the elbow with the palm down. Place your thumb or finger firmly on the biceps tendon. Strike your finger with the reflex hammer. You should feel the response even if you can't see it.

E. Sensory General    

Triceps (C6, C7) 1. 2. 3.

the upper arm and let the patient's forearm hang free. Strike the triceps tendon above the elbow with the broad side of the hammer. If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest.



Foundations of Nursing Physical Assessment

Explain each test before you do it. Unless otherwise specified, the patient's eyes should be closed during the actual testing. Compare symmetrical areas on the two sides of the body. Also compare distal and proximal areas of the extremities. When you detect an area of sensory loss map out its boundaries in detail.

1. Vibration Use a low pitched tuning fork (128Hz). 1.

Brachioradialis (C5, C6)

Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key. Note movement of the toes, normally flexion (withdrawal). Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.

Test with a non-vibrating tuning fork first to ensure that the patient is responding to the correct stimulus. Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

2.

3.

Place the stem of the fork over the distal interphalangeal t of the patient's index fingers and big toes. Ask the patient to tell you if they feel the vibration.

If vibration sense is impaired proceed proximally: ++ 1. 2. 3. 4. 5. 6. 7.

Wrists Elbows Medial malleoli Patellas Anterior superior iliac spines Spinous processes Clavicles

2. Subjective Light Touch Use your fingers to touch the skin lightly on both sides simultaneously. Test several areas on both the upper and lower extremities. Ask the patient to tell you if there is difference from side to side or other "strange" sensations. 3. Position Sense 1. 2. 3. 4. 5. 6.

Grasp the patient's big toe and hold it away from the other toes to avoid friction. Show the patient "up" and "down." With the patient's eyes closed ask the patient to identify the direction you move the toe. If position sense is impaired move proximally to test the ankle t. Test the fingers in a similar fashion. If indicated move proximally to the metacarpophalangeal ts, wrists, and elbows.

19

5. 6.

Medial and lateral aspect of both calves (L4 and L5) Little toes (S1)

6. Light Touch Use a fine whisp of cotton or your fingers to touch the skin lightly. Ask the patient to respond whenever a touch is felt. Test the following areas: 1. 2. 3. 4. 5. 6.

Shoulders (C4) Inner and outer aspects of the forearms (C6 and T1) Thumbs and little fingers (C6 and C8) Front of both thighs (L2) Medial and lateral aspect of both calves (L4 and L5) Little toes (S1)

7. Discrimination Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal. Graphesthesia 1. 2.

Stereognosis 1. 2. 3.

4. Dermatomal Testing If vibration, position sense, and subjective light touch are normal in the fingers and toes you may assume the rest of this exam will be normal.

Use a suitable sharp object to test "sharp" or "dull" sensation. Test the following areas: 1. 2. 3. 4. 5. 6.

Shoulders (C4) Inner and outer aspects of the forearms (C6 and T1) Thumbs and little fingers (C6 and C8) Front of both thighs (L2) Medial and lateral aspect of both calves (L4 and L5) Little toes (S1)

5. Temperature Often omitted if pain sensation is normal. Use a tuning fork heated or cooled by water and ask the patient to identify "hot" or "cold."

Test the following areas: 1. 2. 3. 4.

Shoulders (C4) Inner and outer aspects of the forearms (C6 and T1) Thumbs and little fingers (C6 and C8) Front of both thighs (L2)

Foundations of Nursing Physical Assessment

Use as an alternative to graphesthesia. ++ Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.). Ask the patient to tell you what it is.

Two Point Discrimination 1.

2. 5. Pain

With the blunt end of a pen or pencil, draw a large number in the patient's palm. Ask the patient to identify the number.

3. 4. 5.

Use in situations where more quantitative data are needed, such as following the progression of a cortical lesion. ++ Use an opened paper clip to touch the patient's finger pads in two places simultaneously. Alternate irregularly with one point touch. Ask the patient to identify "one" or "two." Find the minimal distance at which the patient can discriminate.

SAMPLE CHARTING Ms. X is a young, healthy-appearing woman, well-groomed, fit, and in good spirits. Height is 5’4”, weight 135 lbs, BP 120/80, HR 72 and regular, RR 16, temperature 37.50C. SKIN: Color good. Skin warm and moist. Nails without clubbing or cyanosis. EENT: Head – skull is normocephalic/atraumatic(NC/AT). Hair with average texture. Eyes – visual acuity 20/20 bilaterally. Sclera white; conjunctiva pink. Pupils constrcit 4 mm to 2 mm, equally round and reactive to light and accommodations. Ears – acuity good. Weber midline. Nose – nasal mucosa pink, septum midline, no sinus tenderness. Throat(mouth) – oral mucosa pink; dentition good; pharynx without exudates. Neck – trachea midline. Neck supple; thyroid isthmus palpable, lobe not felt. Lymph nodes – no cervical adenopathy. THORAX AND LUNGS: Abejo

Nursing Skills Physical Assessment Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

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INSPECTION A-P diameter not increased Lips, nailbeds pink Thorax slightly asymmetrical Full expansion equal bilaterally PALPATION No tenderness No enlargement of lymph nodes Fremitus equal bilaterally PERCUSSION Lung field resonant Diaphragmatic excursion – 4cm bilaterally AUSCULTATION Breath sounds clear No rales, rhonchi, or rubs BREAST AND AXILLAE: Breast symmetric and without masses. Nipples without discharge. No axillary adenopathy CARDIOVASCULAR EXAM: PMI is tapping, 2 cm lateral to the midsternal line in the 5th ICS. Good S1 and S2 No murmurs or extra sounds ABDOMEN: Abdomen is protuberant with active bowel sounds. It is soft and non-tender; no masses or hepatosplenomegaly. Liver span is 7cm; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. MUSCULOSKELETAL SYSTEM: Good range of motion in all ts. No evidence of swelling or deformity. Mental status: alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Cranial nerves: I – XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar: RAM, intact. Gait with normal base. Romberg – maintains balance with eyes closed. No pronator drift. Sensory: Pinprick, light touch, position intact. Reflexes: 2+ and symmetric

Foundations of Nursing Physical Assessment

Abejo