1. Health Assessment and Physical Exam Chapter 31

2. Purpose of the Physical Examination

3. Quick Quiz  When meeting a patient for the first time, it is important to establish a baseline assessment that will enable a nurse to refer back to:  A. Physiological outcomes of care  B. The normal range of physical findings  C. A pattern of findings identified when the patient is first assessed.  D. Clinical judgments made about a patient’s changing health status.  When meeting a patient for the first time, it is important to establish a baseline assessment that will enable a nurse to refer back to:  A. Physiological outcomes of care  B. The normal range of physical findings  C. A pattern of findings identified when the patient is first assessed.  D. Clinical judgments made about a patient’s changing health status.

4. Cultural Sensitivity

5. Case Study  Mr. Neal is being admitted to the surgery floor for bowel surgery. He is 76 years old and has a history of rectal bleeding and bowel changes. He smokes 2 packs of cigarettes a day and says he has no family of colon cancer. His wife is with him.  Jane is a nursing student assigned to care for Mr. Neal. She begins her assessment with a review of Mr. Neal’s chart and the health care provider’s orders.  Mr. Neal is being admitted to the surgery floor for bowel surgery. He is 76 years old and has a history of rectal bleeding and bowel changes. He smokes 2 packs of cigarettes a day and says he has no family of colon cancer. His wife is with him.  Jane is a nursing student assigned to care for Mr. Neal. She begins her assessment with a review of Mr. Neal’s chart and the health care provider’s orders.

6. Preparation for Examination  Infection control  Environment  Equipment  Physical preparation of patient Positioning  Psychological preparation of patient  Assessment of age groups  Infection control  Environment  Equipment  Physical preparation of patient Positioning  Psychological preparation of patient  Assessment of age groups

7. Organization of the Examination  Assessment of each body system  Systematic and organized  Head-to-toe approach  Compare sides for symmetry  Assess body systems more at risk for abnormalities  Offer rest periods as needed  Perform painful procedures LAST  Be specific when recording assessments  Record quick brief notes during the examination  Complete larger notes at the end of the examination  Assessment of each body system  Systematic and organized  Head-to-toe approach  Compare sides for symmetry  Assess body systems more at risk for abnormalities  Offer rest periods as needed  Perform painful procedures LAST  Be specific when recording assessments  Record quick brief notes during the examination  Complete larger notes at the end of the examination

8. Techniques of Physical Assessment  Inspection  Palpation  Percussion  Auscultation  Inspection  Palpation  Percussion  Auscultation

9. Inspection  Adequate lighting  Use direct lighting to inspect body cavities  Inspect each area for size, shape, color, symmetry, position, and abnormality  Position and exposed body parts as needed so all surfaces can be viewed but privacy can be maintained  Validate findings with the patient  Adequate lighting  Use direct lighting to inspect body cavities  Inspect each area for size, shape, color, symmetry, position, and abnormality  Position and exposed body parts as needed so all surfaces can be viewed but privacy can be maintained  Validate findings with the patient

10. Palpation  Uses touch to gather information  Use different parts of hands  Hand should be warm and nails short  Start with light then deep palpation  Uses touch to gather information  Use different parts of hands  Hand should be warm and nails short  Start with light then deep palpation

11. Percussion  Tap body with fingertips to produce a vibration  Sound determines location, size, and density of structures.  Tap body with fingertips to produce a vibration  Sound determines location, size, and density of structures.

12. Auscultation  Requires  Good hearing  Stethoscope  Knowledge  Concentration and practice  Sound characteristics  Frequency  Loudness  Quality  Duration

13. Inspection General appearance and behavior  Gender and race  Age  Signs of distress  Body type  Posture  Gait  Body movement  Gender and race  Age  Signs of distress  Body type  Posture  Gait  Body movement  Hygiene and grooming  Dress  Body odor  Affect and mood  Speech  Signs of patient abuse  Substance abuse  Hygiene and grooming  Dress  Body odor  Affect and mood  Speech  Signs of patient abuse  Substance abuse

14. General Survey  Vital Signs  Height & Weight

15. Skin, Hair, and Nails  Skin  Color  Pigmentation  Cyanosis  Jaundice  Erythema  Moisture  Temperature  Texture  Turgor  Skin  Color  Pigmentation  Cyanosis  Jaundice  Erythema  Moisture  Temperature  Texture  Turgor

16. Skin, Hair, and Nails (continued)  Skin  Vascularity  Edema  Lesions  ABCD  Asymmetry  Border irregularity  Color  Diameter

17. Quick Quiz  A patient complains of thirst and headache. The patient appears emaciated. Upon initial examination, you find that the skin does not return to normal shape. The finding is consistent with:  A. Pallor  B. Edema  C. Erythema  D. Poor skin turgor

18. Skin, Hair, and Nails (Continued)  Hair  Color  Distribution  Quantity  Thickness  Texture  Lubrication  Hair  Color  Distribution  Quantity  Thickness  Texture  Lubrication

19. Skin, Hair, and Nails (Continued)  Nails  Color  Length  Symmetry  Cleanliness  Configuration  Nails  Color  Length  Symmetry  Cleanliness  Configuration

20. Head and Neck  Inspection and palpation  Inspect the patient’s head, noting the position, size, shape, and contour.  Examine the size, shape, and contour of the skull.  Palpate the temporomandibular joint (TMJ) space bilaterally.  Inspection and palpation  Inspect the patient’s head, noting the position, size, shape, and contour.  Examine the size, shape, and contour of the skull.  Palpate the temporomandibular joint (TMJ) space bilaterally.

21. Eyes  Visual acuity  Extraocular movements  Nystagmus  Visual fields  Visual acuity  Extraocular movements  Nystagmus  Visual fields

22. Eyes (Continued)  External eye structures  Position & alignment  Eyebrows  Eyelids  Lacrimal apparatus  Conjunctivae & slerae  Corneas

23. Eyes (Continued)  External eye structure  Pupils and irises  PERRLA  Pupils  Equal  Round  Reactive to light and  Accommodation  External eye structure  Pupils and irises  PERRLA  Pupils  Equal  Round  Reactive to light and  Accommodation

24. Eyes (Continued)  Internal eye structures  Retina  Choroid  Macula  Optic Nerve disc  Fovea centralis  Retinal vessels  Internal eye structures  Retina  Choroid  Macula  Optic Nerve disc  Fovea centralis  Retinal vessels

25. Ears  Auricles  Size  Shape  Symmetry  Landmarks  Osiiton  Color  Discharge  Auricles  Size  Shape  Symmetry  Landmarks  Osiiton  Color  Discharge

26. Ears (Continued)  Ear canals & eardrums  Color  Discharge  Scaling  Lesions  Foreign Bodies  Cerumen  Ear canals & eardrums  Color  Discharge  Scaling  Lesions  Foreign Bodies  Cerumen

27. Ears (Continued)  Hearing acuity  3 types of hearing loss  Conduction  Sensorineural  Mixed  Ototoxicity  If a hearing loss is present, test the hearing using a tuning fork  Hearing acuity  3 types of hearing loss  Conduction  Sensorineural  Mixed  Ototoxicity  If a hearing loss is present, test the hearing using a tuning fork

28. Tuning Fork Tests  Weber’s test  Hold fork at base and tap it lightly against heel of palm  Place base of vibrating fork on midline vertex of patient’s head or middle of forehead  Ask patient if she or she hears the sound equally in both ears or better in one ear (lateralization).  Weber’s test  Hold fork at base and tap it lightly against heel of palm  Place base of vibrating fork on midline vertex of patient’s head or middle of forehead  Ask patient if she or she hears the sound equally in both ears or better in one ear (lateralization).

29. Tuning Fork Tests (Continued)  Rinne Test  Place stem of vibrating tuning fork against patient’s mastoid process.  Begin counting the interval using watch.  Ask patient to tell you when she no longer hears the sound; note number of seconds.

30. Tuning Fork Tests (Continued)  Rinne Test  Quickly place still vibrating tines ½ - 2” from ear canal, ask patient to tell you when they no longer hear the sound.  Continue counting time the sound is heard by air conduction  Rinne Test  Quickly place still vibrating tines ½ - 2” from ear canal, ask patient to tell you when they no longer hear the sound.  Continue counting time the sound is heard by air conduction

31. Nose and Sinuses  Nose  Excoriation  Polyps  Sinuses  Nose  Excoriation  Polyps  Sinuses

32. OMG! Need a BREAK

33. Mouth and Pharynx  Lips  Color  Texture  Hydration  Contour  Lesions  Lips  Color  Texture  Hydration  Contour  Lesions

34. Mouth and Pharynx (Continued)  Buccal mucosa  Gums  Teeth  Tongue  Floor of mouth  Buccal mucosa  Gums  Teeth  Tongue  Floor of mouth

35. Mouth and Pharynx (Continued)  Palate  Hard  Soft  Pharynx  Palate  Hard  Soft  Pharynx

36. Neck  Neck muscles  Anterior triangle  Posterior triangle

37. Neck (Continued)  Lymph nodes  Inspection  Lymph nodes  Inspection

38. Neck (Continued)  Lymph nodes  Palpation  Face the patient  Use a methodical approach  Inspect and palpate both sides of the neck for comparison  Tenderness almost always indicates inflammation  Lymph nodes  Palpation  Face the patient  Use a methodical approach  Inspect and palpate both sides of the neck for comparison  Tenderness almost always indicates inflammation

39. Neck (Continued)  Thyroid gland  Carotid artery and jugular neck vein  Trachea

40. Thorax and Lungs  Examination

41. Thorax and Lungs (Continued)  Identify anatomical landmarks

42. Thorax and Lungs (Continued)  Posterior thorax

43. Thorax and Lungs (Continued)  Tactile fremitus  Created by vocal cords  Transmitted through lungs to chest wall  Palpation  Tactile fremitus  Created by vocal cords  Transmitted through lungs to chest wall  Palpation

44. Thorax and Lungs (Continued)  Auscultation  Normal breath sounds  Abnormal or adventitious sounds  Crackles  Rhonchi  Wheezes  Pleural friction rub  Auscultation  Normal breath sounds  Abnormal or adventitious sounds  Crackles  Rhonchi  Wheezes  Pleural friction rub

45. Quick Quiz  A patient is admitted with pneumonia. When auscultation the patient’s chest, you hear low-pitched, continuous sounds over the bronchi. These sounds are labeled as:  A. Crackles  B. Rhonchi  C. Wheezes  D. Pleural rub  A patient is admitted with pneumonia. When auscultation the patient’s chest, you hear low-pitched, continuous sounds over the bronchi. These sounds are labeled as:  A. Crackles  B. Rhonchi  C. Wheezes  D. Pleural rub

46. Thorax and Lungs (Continued)  Lateral thorax  Vesicular sounds  Anterior thorax  Observe accessory muscles  Palpate muscles and skeleton  Assess tactile fremitus  Compare right and left sides  Auscultate for bronchial sounds

47. Case Study (Continued)  During her lung assessment, Jane recognizes that there is a patient-teaching opportunity with Mr. Neal.  What issue does Jane need to address?  During her lung assessment, Jane recognizes that there is a patient-teaching opportunity with Mr. Neal.  What issue does Jane need to address?

48. Heart  Compare assessment of heart functions with vascular findings  Assess point of maximal impulse (PMI)  Locate anatomical landmarks  Compare assessment of heart functions with vascular findings  Assess point of maximal impulse (PMI)  Locate anatomical landmarks

49. Heart (Continued)  Heart sounds  S 1  S 2  S 3  S 4

50. Heart (Continued)  Inspection and palpation  Patient must be relaxed and comfortable  Inspect and palpate simultaneously  PMI  Inspection and palpation  Patient must be relaxed and comfortable  Inspect and palpate simultaneously  PMI

51. Heart (Continued)  Auscultation  Normal heart sounds Dysrhythmia  Extra heart sounds  Murmurs Grade Pitch Quality

52. Vascular System  Blood pressure Readings tend to be higher in the right arm. Always record the highest reading.  Carotid arteries Reflect heart function better than peripheral arteries Commonly auscultated  Blood pressure Readings tend to be higher in the right arm. Always record the highest reading.  Carotid arteries Reflect heart function better than peripheral arteries Commonly auscultated

53. Vascular System (Continued)  Carotid bruit  Narrowed blood vessel creates turbulence, causes blowing/swishing sound  Pronounced “brew-ee”  Carotid bruit  Narrowed blood vessel creates turbulence, causes blowing/swishing sound  Pronounced “brew-ee”

54. Vascular System (Continued)  Jugular veins Most accessible Right internal jugular vein follows more direct path to right atrium. Note distention. Assess pressure.  Jugular veins Most accessible Right internal jugular vein follows more direct path to right atrium. Note distention. Assess pressure.

55. Vascular System (Continued)  Peripheral arteries and veins Assess the adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails. Assess the integrity of the venous system. Assess the arterial pulses in the extremities to determine sufficiency of the entire arterial circulation.  Peripheral arteries and veins Assess the adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails. Assess the integrity of the venous system. Assess the arterial pulses in the extremities to determine sufficiency of the entire arterial circulation.

56. Vascular System (Continued)  Peripheral arteries  Assess each peripheral artery for elasticity of the vessel wall, strength, and equality  Pulses:  0: absent  1: pulse diminished, barely palpable  2: expected/normal  3: full pulse, increased  4: bounding pulse  Peripheral arteries  Assess each peripheral artery for elasticity of the vessel wall, strength, and equality  Pulses:  0: absent  1: pulse diminished, barely palpable  2: expected/normal  3: full pulse, increased  4: bounding pulse

57. Vascular System (Continued)  Peripheral arteries  Upper extremities  Brachial artery – channels blood to radial and ulnar arteries of forearm and hand  Peripheral arteries  Upper extremities  Brachial artery – channels blood to radial and ulnar arteries of forearm and hand

58. Vascular System (Continued)  Peripheral arteries (Cont.)  Radial pulse: thumb side of wrist  Ulnar pulse: little finger side of wrist  Brachial pulse: inside of elbow  Peripheral arteries (Cont.)  Radial pulse: thumb side of wrist  Ulnar pulse: little finger side of wrist  Brachial pulse: inside of elbow

59. Vascular System (Continued)  Peripheral arteries  Lower extremities  Femoral artery

60. Vascular System (Continued)  Peripheral arteries (Cont.)  Femoral pulse  Popliteal pulse  Dorsalis pedis pulse  Posterior tibial  Peripheral arteries (Cont.)  Femoral pulse  Popliteal pulse  Dorsalis pedis pulse  Posterior tibial

61. Vascular System (Continued)  Peripheral Arteries (Cont.)  Ultrasound stethoscopes  Tissue perfusion  Peripheral Veins  Varicosities  Peripheral Edema  Phlebitis  Peripheral Arteries (Cont.)  Ultrasound stethoscopes  Tissue perfusion  Peripheral Veins  Varicosities  Peripheral Edema  Phlebitis

62. Lymphatic System  Lower extremities  Assess during examination of vascular system or genital examination  Upper extremities  Palpate the epitrochlear nodes, located on the medial aspect of the arms  Assess proximal portion during breast examination

64. Breasts  Assess in both male and female patients.  Male breast: small amount breast of glandular tissue  Female breast: majority of breast is glandular tissue  Breast cancer is second to lung cancer as the leading cause of death in women with cancer.  Teach patients health behaviors such as breast self- examination (BSE).  Assess in both male and female patients.  Male breast: small amount breast of glandular tissue  Female breast: majority of breast is glandular tissue  Breast cancer is second to lung cancer as the leading cause of death in women with cancer.  Teach patients health behaviors such as breast self- examination (BSE).

65. Female Breasts

66. Breast Self-Examination 1.Examine right breast – Lie down on your back, place right arm behind head 2.With pads of left 3 middle fingers feel for lumps in right breast. 3.Move around the breast in an up and down pattern 4.Repeat BSE on the left breast 5.Observe breasts in mirror with hands pressing firmly on hips 1.Examine right breast – Lie down on your back, place right arm behind head 2.With pads of left 3 middle fingers feel for lumps in right breast. 3.Move around the breast in an up and down pattern 4.Repeat BSE on the left breast 5.Observe breasts in mirror with hands pressing firmly on hips

67. BSE (Continued) 6.Examine each underarm while sitting or standing and with your arm only slightly raised 7.If implants are present, help the patient determine the edges of each implant and how to evaluate each breast 8.Instruct patient to call the health care provider if she finds a lump or other abnormality. 9.Use Teach Back 6.Examine each underarm while sitting or standing and with your arm only slightly raised 7.If implants are present, help the patient determine the edges of each implant and how to evaluate each breast 8.Instruct patient to call the health care provider if she finds a lump or other abnormality. 9.Use Teach Back

68. Female Breasts (Continued)  Inspection  Size and symmetry Common for one breast to be smaller  Contour or shape  Color  Nipple and areola  Inspection  Size and symmetry Common for one breast to be smaller  Contour or shape  Color  Nipple and areola

69. Female Breasts (Continued)  Palpation  Edge of pectoralis major muscle along anterior axillary line  Chest wall in the midaxillary area  Upper part of humerus  Anterior edge of the latissimus dorsi along posterior axillary line  Palpation  Edge of pectoralis major muscle along anterior axillary line  Chest wall in the midaxillary area  Upper part of humerus  Anterior edge of the latissimus dorsi along posterior axillary line

70. Female Breasts (Continued)  Palpation (Cont.)  Lying down with the arm abducted makes the area more accessible  Place pillow or towel under the patient’s shoulder blade to further position breast tissue  Palpate tail of Spence

71. Female Breasts (Continued)  Palpation (Cont.)  Use systematic approach: A) vertical, B) circular, or C) radial/wedge technique  Palpation (Cont.)  Use systematic approach: A) vertical, B) circular, or C) radial/wedge technique

72. Male Breasts  Inspect the nipple and areola for nodules, edema, and ulceration  Breast enlargement An enlarged male breast results from obesity or glandular enlargement Breast enlargement in young males results from steroid use  Men at high risk may be scheduled by their health care provider for routine mammograms  Inspect the nipple and areola for nodules, edema, and ulceration  Breast enlargement An enlarged male breast results from obesity or glandular enlargement Breast enlargement in young males results from steroid use  Men at high risk may be scheduled by their health care provider for routine mammograms

73. Abdomen  Complex assessment because of organs located in abdominal cavity  Begin with inspection and follow with auscultation  Complex assessment because of organs located in abdominal cavity  Begin with inspection and follow with auscultation

74. Abdomen (Continued)  Inspection  Skin  Umbilicus  Contour and symmetry  Enlarged organs or masses  Movements or pulsations  Inspection  Skin  Umbilicus  Contour and symmetry  Enlarged organs or masses  Movements or pulsations

75. Abdomen (Continued)  Inspection  Skin  Umbilicus  Contour and symmetry  Enlarged organs or masses  Movements or pulsations  Inspection  Skin  Umbilicus  Contour and symmetry  Enlarged organs or masses  Movements or pulsations  Auscultation  Bowel motility Peristalsis Borborygmi  Vascular sounds Bruits  Kidney tenderness  Auscultation  Bowel motility Peristalsis Borborygmi  Vascular sounds Bruits  Kidney tenderness

76. Abdomen (Continued)  Palpation  Performed last  Detects tenderness, distention, or masses  May be light or deep, as appropriate  Aortic pulsation  Palpation  Performed last  Detects tenderness, distention, or masses  May be light or deep, as appropriate  Aortic pulsation

77. Quick Quiz  When conducting an abdominal assessment, the first skill a nurse puts to use is:  A. Auscultation  B. Inspection  C. Palpation  D. Percussion

78. Female Genitalia and Reproductive Tract  Assessment includes both internal and external organs.  Understand cultural sensitivity.  Identify changes across the life span.  Use inspection and palpation.  Assessment includes both internal and external organs.  Understand cultural sensitivity.  Identify changes across the life span.  Use inspection and palpation.