Health Assessment

Principles of Health Assessment Purpose of Health Assessment
T he p ur po se o f a h e a l t h a s s e s s m e n t i s t o c o l l e c t s ub je ct iv e a nd ob je ct iv e da t a ab ou t a p at ie nt t o de t e rm in e h is o r h er o ve ra ll le ve l o f p h y s i c a l , p s y c h o l o g i c a l , s o c i o c u l t u ra l, d ev el op me nt al , an d sp ir it ua l h ea lt h. A n ur si ng as se ss me nt di f f er s f r o m ot he r t y p e s o f h e a l t h c a r e a s s e s s m e n t s ( f o r e x am pl e, on e pe rf or me d b y a ph ys ic ia n) in t ha t i t is a h ol is t i c co ll ec t i on o f in f o rm at io n a b o u t f a c t o r s t h a t a f f e c t o r a r e a f f e ct ed by o ne 's le ve l of h ea lt h. He al t h as se ss me nt i s an in t e gr al c om po ne nt o f n u r s i n g c a r e a n d i s t h e f o u n d a t i o n o f t h e n ur si ng p ro ce ss . T he i nf or ma t i on f r om t he he al t h a ss es sm en t i s u se d t o f o rm u l a t e n u r s i n g d i a g n o s e s t h a t r e q u i r e n u rs in g c ar e. A ss es sm en t s ar e us ed t o p la n, i mp le me nt , a nd e va lu at e t ea ch in g a n d c a r e t o p r o m o t e a n o p t i m a l l e v e l o f h e al t h t h ro ug h in t e rv en t i on s t o p re ve nt i ll ne ss , r es t o re h ea lt h, an d f ac il it at e c op i n g w i t h d i s a b i l i t i e s o r d e a t h . T h e i n f o rm at io n i s al so u se d t o id en t i f y he al t h p ro bl em s t ha t re qu ir e i nt er di sc ip li n a r y c a r e o r i m m e d i a t e r e f e r r a l t o o t h e r he al t h ca re pr ov id er s. T h is c ha pt er pr ov id es in f o rm at io n ne ce ss ar y t o i de nt if y r is k s f o r a l t e r a t i o n s i n h e a l t h , p e r f o r m t h e sk il ls o f ph ys ic al ex am in at io n, an d id en t i f y no rm al a ge - re la t e d v ar ia t i on s i n p h y s i c a l s t r u c t u r e s a n d f u n c t i o n s . A d d it io na l i nf or ma t i on ab ou t as se ss me nt is f ou nd in C ha pt er 12 .

Types of Assessment
T he s co pe a n d t y p e o f a s s e s s m e n t c o n d u c t e d v a r y b as ed o n t he s et t i ng , t he h ea lt hc ar e n ee ds of t he p at ie nt , a nd t he a cu it y of t h e h e a l t h p r o b l e m . A h e a l t h a s s e s s m e n t m ay b e co mp re he ns iv e, on go in g p ar t i al , f oc us ed , or em er ge nc y. A c o m p r eh en s i v e a s s e s s m e n t w i t h a h e a l t h h i s t o r y a nd co mp le t e ph ys ic al e xa mi na t i on is u su al ly co nd uc t e d w he n a p at ie nt f i rs t e n t e r s a h e a l t h c a r e s e t t i n g , w i t h i n f o r m at io n p ro vi di ng a ba se li ne f o r co mp ar in g l at er a ss es sm en t . A n o n g o i n g p a r t i a l a s s e s s m e n t i s o n e t h a t i s c o n d u c t e d a t re gu la r i nt er va ls ( eg , a t t h e be gi nn in g o f ea ch ho me h ea lt h v is it o r ea ch ho s p i t a l s h i f t ) d u r i n g c a r e o f t h e p a t i e n t . T hi s t y pe o f as se ss me nt co nc en t r at es on i de nt if ie d h ea lt h p ro bl em s t o m on it or po si t i v e o r n e g a t i v e c h a n g e s a n d e v a l u a t e t he ef f e ct iv en es s of in t e rv en t i on s. A fo cu se d a ss es sm en t i s c on du ct ed t o a s s e s s a s p e c i f i c p r o b l e m . F o r e x a m pl e, if a w om an i s ha vi ng ab do mi na l p ai n, t he nu rs e as ks q ue st io ns a bo ut ur in ar y p r o b l e m s , b o w e l p r o b l e m s , a l l e r g i e s , an d me ns t r ua l h is t o ry d ur in g t he h ea lt h h is t o ry a nd t h en a ss es se s v i t al s ig ns a n d a b d o m i n a l s t r u c t u r e s d u r i n g t h e p h y si ca l as se ss me nt . A n em er g e n c y a ss es sm en t i s a t y pe of r ap id f oc us ed as s e s s m e n t c o n d u c t e d t o d e t e r m i n e p o t e n t ia ll y f at al si t u at io ns . F o r ex am pl e, as se ss in g t he a ir wa y, b re at hi ng , a nd ci rc ul at i o n b e f o r e b e g i n n i n g c a r d i o p u l m o n a r y re su sc it at io n i s pa rt of a n em er ge nc y a ss es sm en t . C on s i de r B il l y C o l l i n s , t h e 9 - y e a r - o l d w h o w a s s t u ng b y a b ee . I n t hi s si t u at io n, t h e nu rs e w ou ld c on du ct an e me rg en cy a ss es sm en t t o d e t e r m i n e t h e i m m e d i a t e e f f e c t s o f t he be e st in g, a ss es si ng f o r in di ca t i on s o f an al le rg ic r ea ct io n. O n ce t hi s em er ge n c y a s s e s s m e n t i s c o m p l e t e d , t h e n u r s e wo ul d p er f o rm a f o cu se d as se ss me nt t o a dd re ss t h e bo y' s h is t o ry o f a l l er gi es .

Health Assessment Preparation Preparing the Patient
C on s i de r a n d r e m a i n s e n s i t i v e t o t h e p a t i e n t 's p h y s io lo gi c n ee ds ( eg , p ai n or d ec re as ed st am in a b ec au se of a ge o r i l l ne ss ) an d p s y c h o l o g i c a l n e e d s ( e g , a n x i e t y r e l a t e d t o ex am in at io n) . E xp la in t h at t he f ir st p ar t o f t h e as se ss me nt wi ll i nv ol ve qu es t i o n s a b o u t t h e p a t i e n t 's h e a l t h c o n c e r ns , h ea lt h ha bi t s , a nd l if es t y le (F ig . 25 - 1) . A f t e r t h e h ea lt h hi st or y i s c om pl et ed , b o d y s t r u c t u r e s w i l l b e e x a m i n e d . T e l l t h e p at ie nt t ha t t he a ss es sm en t s sh ou ld n ot be p ai nf ul . T he p at ie nt m ay b e a nx i o u s f o r v a r i o u s r e a s o n s . E x p l a i n i n g t h e as se ss me nt i n g en er al t er ms ca n he lp d ec re as e t he pa t i en t ' s e mb ar ra ss m e n t , f e a r o f p o s s i b l e a b n o r m a l p h y s i c a l f in di ng s, o r f e ar of “ f a il in g” a t e st . B e s ur e t o t he n e xp la in ea ch a ss es sm en t i n g r e a t e r d e t a i l a s i t i s p e r f o r m e d . E x p la in t h at d ra pe s ( co ve rs ) wi ll b e us ed du ri ng t he ex am in at io n, an d o nl y t h e a re a b e i n g a s s es s e d w i l l b e e x p o s e d . A n s we r t h e pa t i en t ' s q ue st io ns di re ct ly an d ho ne st ly . T hi nk b ac k t o R a m o n a L e w i s , t h e c o l l e g e s t u d e n t w ho r ep or t e d t ha t sh e wa s a v ic t i m of d at e ra pe . T he n ur se wo ul d ne ed t o in co rp or a t e k n o w l e d g e o f t h e e m o t i o n a l a n d p h y si ca l e f f ec t s o f ra pe wh en c om mu ni ca t i ng wi t h M s. L ew is . I n ad di t i on , t he p at ie nt 's a n x i e t y i s l i k e l y t o b e h i g h ; t h u s , u s i n g e mp at hy an d es t a bl is hi ng a t r us t i ng nu rs e– pa t i en t r el at io ns hi p a re k ey .

D ir ec t t h e p a t i e n t t o a p r i v a t e d r e s s i n g a r e a o r t o a c om f o rt ab le ar ea i n t h e h om e an d a sk t he p at ie nt t o c ha ng e i nt o a g ow n. I f n ec e s s a r y , a s s i s t t h e p a t i e n t w i t h u n d r e s s i ng . A sk t he p at ie nt t o e mp t y t he b la dd er be f o re t h e ex am in at io n s o t ha t he or s h e w i l l b e m o r e c o m f o r t a b l e d u r i n g t h e as se ss me nt a nd as se ss me nt of t he a bd om en wi ll b e ea si er

Preparing the Environment
T he e nv ir on m e n t n e e d s t o b e p r e p a r e d b e f o r e t h e he al t h a ss es sm en t i s co nd uc t e d. Cl in ic s, o f f ic es , an d h os pi t a ls ma y h av e a s pe c i a l e x a m i n a t i o n r o o m t h a t p r o v i d e s a q ui et , pr iv at e s pa ce f or a ss es sm en t . I f s uc h a r oo m is a va il ab le , t he e xa mi na t i on t a b l e i s p r e p a r e d , a g o w n a n d d r a p e f or t h e pa t i en t a re p ro vi de d, an d in st ru me nt s a nd s pe ci al su pp li es n ee de d f or t h e a s s e s s m e n t a r e g a t h e r e d . I f t h e a r ea i s op en t o o t h er s, an e nc lo su re wi t h a c ur t a in or s cr ee n is e ss en t i al . T he r oo m s h o u l d b e w a r m e n o u g h t o p r e v e n t c h i l l i n g, a nd t h e ar ea or r oo m sh ou ld be a de qu at el y l ig ht ed , e it he r by s un li gh t o r o v e r h e a d l i g h t i n g .

Maintaining Cultural Sensitivity
E ac h pe rs on i s a u n i q u e i n d i v i d u a l . T h e p a t i e n t ' s c ul t u re do es n ot af f e ct h ow a h ea lt h a ss es sm en t i s co nd uc t e d, bu t it i s a n in t e gr al c o m p o n e n t o f t h e i n t e r a c t i o n s b e t w e e n t he nu rs e an d t he p at ie nt . N ur se s sh ou ld kn ow r is k f a ct or s f o r a l t er at io ns i n h e a l t h t h a t a r e b a s e d o n r a c i a l i n h e r i t a nc e, as w el l as n or ma l v ar ia t i on s t h at oc cu r wi t h in r ac es . N ur se s m us t co ns id e r t h e i r p a t i e n t s w i t h i n t h e c o n t e x t o f f am il y, c ul t u re , a nd c om mu ni t y (W eb er & K el le y, 20 07 ). C ha pt er 3 p ro vi de s i nf o r m a t i o n a b o u t c u l t u r a l d i v e r s i t y a n d t he i mp or t a nc e o f pr ov id in g c ul t u ra ll y se ns it iv e n ur si ng c ar e.

The Health History
A h ea lt h h is t o r y i s a c o l l e c t i o n o f s u b j e c t i v e d a t a t h at pr ov id es a d et ai le d p ro f i le of t he p at ie nt 's he al t h st at us . Nu rs es u se t he ra pe u t i c c o m m u n i c a t i o n s k i l l s a n d i n t e r v i e w in g t ec hn iq ue s d ur in g t h e h ea lt h hi st or y t o es t a bl is h a n ef f e ct iv e n ur se –p at ie n t r e l a t i o n s h i p a n d t o g a t h e r d a t a t o i d en t i f y ac t u al a nd po t e nt ia l h ea lt h pr ob le ms as w el l as so ur ce s of s t r en gt h. E f f e c t i v e i n t e r v i e w i n g s k i l l s a r e d e s c r i b e d in C ha pt er s 1 2 an d 2 1. R ec a l l T a mm y B r o w n i n g , t h e p r e g n a n t w o m a n w i t h a h is t o ry of s ub st an ce ab us e. T he ra pe ut ic co mm un ic at io n s ki ll s wo ul d b e ke y t o es t a b l i s h i n g a t r u s t i n g n u r s e – p a t i e n t r e l at io ns hi p, wh ic h is e ss en t i al f o r ga t h er in g d at a ab ou t t he p at ie nt 's r ec en t d ru g u s e . I nf or ma t i on i s c o l l e c t e d d u r i n g a n i n t e r v i e w w i t h t h e p at ie nt , wh o i s t h e pr im ar y so ur ce of d at a. C om po ne nt s o f t he h ea lt h h i s t o ry , wi t h e x a m p l e s o f q u e s t i o n s t o a s k , a r e o u t l in ed in B ox 2 5- 1 . Nu rs es s ho ul d b e se ns it iv e t o cu lt ur al di f f er en ce s t ha t in f l ue nc e h o w b o t h v e r b a l a n d n o n v e r b a l c o m m un ic at io ns ar e in t e rp re t e d.

BOX 25-1: Components of a Health History Biographical Data
B io gr ap hi ca l i n f o r m a t i o n i s o f t e n c o l l e c t e d d u r i n g ad mi ss io n t o a he al t h ca re f a ci li t y o r ag en cy an d do cu me nt ed on a s pe ci f i c f o rm ; i t h e l p s t o i d e n t i f y t h e p a t i e n t . B i o g r ap hi ca l d at a in cl ud e:

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N am e A dd r e s s G en d e r M ar it a l s t a t u s O cc u p a t i o n R el ig i o u s p r e f e r e n c e H ea l t h c a r e f i n a n c i n g P ri m a r y h e a l t h c a r e p r o v i d e r

Reason for Seeking Health Care
T he p at ie nt 's r e a s o n f o r s e e k i n g c a r e h e l p s t o f o c u s t h e r es t of t he a ss es sm en t . P r es en t an op en -e nd ed qu es t i on , s uc h a s, “ T e ll m e w h y y o u a r e h e r e t o d a y . ” B e s u r e t o d oc um en t i n t h e pa t i en t ' s o wn wo rd s. F or e xa mp le , i f Ni na D un ni ng

c om es i nt o t h e c l i n i c a n d s t a t e s , “ I a m h a v i n g t r o u b le sl ee pi ng . A t n ig ht , I c an 't se em t o st op m y t h ou gh t s . A ll I d o i s w or ry . ” I nc or re ct do c u m e n t a t i o n : P a t i e n t c o m p l a i n s o f i n s o mn ia an d an xi et y. C or re ct d oc u m e n t a t i o n : “ I a m h a v i n g t r o u b l e s l e e p i ng . A t ni gh t , I ca n' t se em t o s t o p my t ho ug ht s. A l l I do i s wo rr y. ”

History of Present Health Concern
W he n t a ki ng t h e p a t i e n t ' s h i s t o r y o f p r e s e n t h e a l t h c on ce rn , b e su re t o e xp lo re t he sy mp t o ms t ho ro ug hl y. S a mp le q ue st io ns in c l u d e :

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“ W h e n d i d y o u f i r s t b e g i n h a v i n g t h i s p r o b l e m? ” “D id it h ap pe n s ud de nl y or sl ow ly ?” “ S h o w m e e x a c t l y w h e r e y o u a r e h a v i n g t h i s p ro bl em . ” “ W h a t o t h e r s y m p t o m s h a v e y o u h a d w i t h t hi s pr ob le m? ” “ Ho w h a v e y o u t r e a t e d t h i s p r o b l e m ? ”

Medical History
A p at ie nt 's m e d i c a l h i s t o r y m a y p r o v i d e i n s i g h t t o c au se s o f cu rr en t s ym pt om s. I t al so a le rt s t he n ur se t o c er t a in r is k f ac t o rs . Me d i c a l h i s t o r y i n c l u d e s p a s t i l l n e s s e s , c h ro ni c he al t h pr ob le ms an d t r ea t m en t , an d pr ev io us su rg er ie s o r h os pi t a li za t i o n s . S a m p l e q u e s t i o n s i n c l u d e :

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“ T e ll m e a b o u t t h e c h i l d h o o d i l l n e s s e s , s u c h a s me as le s o r mu mp s, t ha t y ou h ad . ” “What are you allergic to?” “ De s c r i b e a n y a c c i d e n t s , i n j u r i e s , a n d s u r g e ri es y ou ha ve h ad . ” “ W h a t p r e s c r i b e d o r o v e r - t h e - c o u n t e r m e d i c at io ns d o y ou u se ? D o yo u t a ke a ny he rb al o r d ie t a r y s up pl em en t s ?”

Family History
C er t a in di so r d e r s h a v e g e n e t i c l i n k s . F o r e x a m p l e , a f a mi ly h is t o ry o f ca nc er is a r is k f a ct or f or c an ce r. S a mp le f am il y h i s t o ry q ue s t i o n s i n c l u d e :

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“ Ho w o l d a r e t h e m e m b e r s o f y o u r f a m i l y ? ” “ I f a n y m e m b e r s o f y o u r f a m i l y a r e n o t l i v i n g , w ha t ca us ed t h ei r de at h? ” “ I s t h e r e a n y h i s t o r y o f t h i s h e a l t h p r o b l e m y ou h av e i n ot he r f a mi ly me mb er s? ” “ Do a n y f a m i l y m e m b e r s h a v e c h r o n i c i l l n e ss es ?”

Lifestyle
A p at ie nt 's l i f e s t y l e c o n t r i b u t e s t o h i s o r h e r o v e r a l l h ea lt h an d w el l- be in g. F o r ex am pl e, s mo ki ng is r el at ed t o m an y h ea lt h p ro bl e m s . S a m p l e l i f e s t y l e q u e s t i o n s i n c l u d e:

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“ Do y o u s m o k e , d r i n k , o r u s e d r u g s ? I f s o , f or h ow l on g a nd h ow m uc h? ” “ De s c r i b e t h e f o o d s y o u e a t d u r i n g a t y p i c a l d ay . ” “ T e ll m e a b o u t h o w w e l l y o u s l e e p . ” “ Ho w m u c h e x e r c i s e d o y o u g e t e a c h d a y ? ” “ W h o i n y o u r f a m i l y o r c o m m u n i t y i s a v a i l a b le t o h el p yo u wi t h he al t h p ro bl em s i f yo u ne ed it ?”

T he h ea lt h h i s t o r y h e l p s t h e n u r s e i d e n t i f y r i s k f a c t o rs f o r al t e ra t i on s i n he al t h . Ri sk f ac t o rs of t e n re la t e sp ec if ic al ly t o t he b od y s ys t e m b e i n g a s s e s s e d . T h e r e f o r e , i n t h i s ch ap t e r, q ue st io ns t o a sk r eg ar di ng ri sk f ac t o rs f o r al t e re d h ea lt h ar e p ro vi de d i n t h e h e a l t h h i s t o r y s e c t i o n o f e a c h b o d y s ys t e m. I n ad di t i on , b e s ur e t o s cr ee n c li en t s f or t he r is k f a ct or s f or a nd wa rn in g s i g n s o f c a n c e r ( B o x 2 5 - 2) .

Otoscope A n ot os co pe i s a l i g h t e d i n s t r u m e n t u s e d t o e x a m i n e t he e xt er na l e ar c an al an d t h e t ym pa ni c me mb ra ne . T h e p hy si ca l as se ss me nt is u su al ly c on du ct ed in a h e a d . Snellen Chart T he S ne ll en c h a r t . m ay b e us ed in t h e p h y s i c a l a s s e s s m e n t b u t a r e n o t i n c l ud ed i n t hi s di sc us si on . e xp os e t he b od y p ar t t o be a u s c u l t a t e d a n d t r y t o m i n i m i z e e n v i r o n me nt al no is es . c le an o r st er il e. w i d e s t s p e c u l u m t h a t w i l l f it i nt o t he n os t r il i s us ed . T h e b l a d e s o f t h e s p e c u l u m a r e i n s e r t e d a bo ut ½″ ( 1 cm ) in t o e ac h n os t r il a nd o pe ne d s o t ha t t h ey d o n ot p re ss o n t he s e p t u m . b u t t h e i ns t r um en t s a nd t e ch ni qu es ar e di sc us se d h er e so t he y c an u nd er st an d w h a t i s b e i n g d o n e b y m o r e a d v a n c e d pr ac t i t i on er s. B e gi nn in g s t u de nt s w il l no t co nd uc t a ll e l e me nt s o f a c o m p l e t e p h y s i c a l a s s e s s m e n t . E q ui pm en t t ha t wi ll t ou ch t h e pa t i en t s ho ul d be wa rm ed ( by t he e xa mi ne r' s h a n d s o r w a r m w a t e r ) b e f o r e u s e . I t is o f t en ne ce ss a r y t o m o d i f y t h e s e q u e n c e . t h e o t o s c o p e c an be u se d t o vi su al iz e t h e i nt er na l na re s. A pe nl ig ht or f la sh li gh t i s us ed f or i l l um in at io n.o l d w h o w a s s t u ng b y a b ee . Re d nu mb er s a re u se d f or n ea r. T h e li gh t is p ro vi de d b y t h e s co pe . A l t h ou gh no t a ll t he i ns t r um en t s de sc ri be d b el ow w il l be n ee de d i n e ve ry a ss es sm en t . Ophthalmoscope A n op ht ha lm o s c o p e i s a l i g h t e d i n s t r u m e n t u s e d t o v is ua li ze t he in t e ri or s t r uc t u re s o f t h e ey e. c on si st s o f ch ar ac t e rs i n 1 1 li ne s of d if f e re nt . T h e nu rs e w ou ld m od if y t he h ea lt h a ss es sm en t by f o cu si ng o n t h e i mm e d i a t e p r o b l e m a t h a n d : t h e b e e s t i n g a nd po ss ib le a ll er gi c r ea ct io n. T h e be ll o f t h e s t e t h o s c o p e i s p r e s s e d l i g h t l y a g ai ns t t he b od y p ar t t o l is t e n t o lo w.t o e s e q u e n c e o r a s y s t e m s eq ue nc e b ut c an be a da pt ed t o m ee t t he n ee ds of t he p at ie nt . I t c on si st s of t wo p ar t s : a b od y t ha t co n t a i n s t h e l i g h t s o u r c e a n d a d e t a c h a b le h ea d t h at co nt ai ns l en se s t ha t ma gn if y t he i nt er na l e ye s t r uc t u re s. u s e d a s a s c r e e n i n g t e s t f o r d i s t an t v is io n. p o s i t i o n s . t he l i n e o f la r g e s t c h a r a c t e r s i s a t t h e t o p o f t h e c h ar t a nd t he li ne o f sm al le st c ha ra ct er s i s at t he bo t t om .h a n d c o l u m n n e x t t o t h e nu mb er s. A n at t a ch ed s pe cu lu m d i r e c t s t h e l i g h t i n a n a r r o w b e a m t o i m p ro ve vi su al iz at io n o f ea r st ru ct ur es . T he s pe cu la co me i n va ri ou s s iz es .s i g h t e d ( h y p e r o p i c ) p at ie nt s. T he ze ro l en s is u se d w he n ei t h er t h e ex am in er or t he p at ie nt ha s r e f r a c t i v e e r r o r s .si ze d t y pe . su c h a s n o r m a l h e a r t s o u n d s .1. t h e st et ho sc op e i s us ed t o l is t e n t o so un ds of t h e h e a r t . T he h ea d i s s e c u r e d i n t h e b o d y . t h e h ea lt h as se ss me nt sh ou ld be c on du ct ed in a n o rg an iz ed a n d k n o w l e d g e a b l e m a n n e r . bl a c k n u m b e r s f o r f a r . t u rn s o n t h e il lu mi na t i on . su ch a s a t on gu e b la de a nd pe nl ig ht .pi t c he d s ou nd s. Co mp on en t s of a c om pr eh en si ve ph ys ic al a ss es sm en t a r e p r o v i d e d i n T a b l e 2 5 . E a ch l en s i s la be le d w it h a po si t i ve ( bl ac k) o r n e g a t i v e ( r e d ) n u m b e r . a b d o m e n . w he n de pr es se d a nd t u rn ed . Nasal Speculum A n as al sp ec u l u m i s u s e d t o v i s u a l i z e t h e l o w e r a n d m id dl e t u rb in at es of t he n os e. E v e n wh en mo di f i ed . e ne rg y l ev el . a nd bo we l so un ds .y e a r . l u n g s . 2 5 .t o . a nd di st an ce s a r e i n t h e r i g h t . a n d c a r d i ov as cu la r s ys t e m. a nd ph ys ic a l s t a t e . a nd t h e s h o r t e s t .si gh t e d ( my op ic ) p at ie nt s. Stethoscope T he s t e t h os c o p e i s i l l u s t r a t e d a n d d e s c r i b e d i n C h a pt er 24 . C on s i de r B il l y C o l l i n s . Equipment T he e qu ip m e n t u s e d i n a p h y s i c a l a s s e s s m e n t s h o u ld be r ea di ly ac ce ss ib le . T he b el l a nd d ia ph ra gm ar e i ll us t r at ed i n F i gu re 25 3 .Physical Assessment A p hy si ca l a s s e s s m e n t i s t h e s y s t e m a t i c c o l l e c t i o n o f ob je ct iv e in f o rm at io n. b r e a t h s o u n d s.2) . Du ri ng he al t h a ss es sm en t . T h e d i a p h r a g m o f t h e s t e t h os co pe is p re ss ed f ir ml y ag ai ns t t he b od y p ar t t o l is t e n t o hi gh -p it ch ed s ou nd s. in p ro pe r wo rk in g o rd er . t h e y a r e c o m m o n l y u s e d i n a t o t a l a s se ss me nt . u se t he la rg e s t s p e c u l u m t h a t w i l l e x t e n d i n t o t h e pa t i en t ' s e ar c an al . S c or es r an gi ng f r o m 20 / 1 0 ( t h e s m a l l e s t l i n e o f c h a r a c t e r s ) t o 2 0 / 2 00 (t he l ar ge st li ne o f ch ar ac t e rs ) a re s ho wn in t he l ef t . a s w e l l a s t i m e c o n s t r a i n t s .ha nd co lu mn . T h e d i a l o n t h e h e ad . S om e eq ui pm en t . C on du ct in g a n a c c u r a t e h e a l t h a s s e s s m e n t t a k e s t i me a nd p ra ct ic e. t h e 9 . A l t e r n a t i v e l y . W he n us in g t he s t e t h os co pe . w i t h u n i t s o f s t r e ng t h ca ll ed d io pt er s. an d sp ec if ic as se ss me nt s ba se d o n t h e p at ie nt 's ag e. s uc h a s ab no rm al c ar di ov as cu l a r s o u n d s . . an d o rg an iz ed f o r t h e c o r r e c t s e q u e n c e o f u s e (F i g . S ev er al l en se s a re a r r a n g e d o n a w h e e l t h a t c o n t r o l s t h e f o cu s on st ru ct ur es i n t h e e ye .

i t is i mp or t a nt t o co ns id er t h e pa t i en t ' s a ge . m o b i l i t y . W ar mi ng a nd lu br ic at in g t he s pe cu lu m w ou ld b e ve ry im po rt an t t o p ro vi de pa t i e n t c o m f o r t d u r i n g t h i s e x t r e m e l y u p s e t t in g t im e. a nd pr iv ac y. Tuning Fork A t un in g f or k i s a t w o . R em em be r R a m o n a L e w i s . O nc e vi br at in g. e n er gy le ve l. va ri at io ns ar e no t e d i n t h e di sc us si on of s pe ci f i c b od y a re as la t e r i n t h e c h a p t e r . t h e as se ss me nt f i nd in gs o f o ne l eg a re c om pa re d w i t h t h o s e o f t h e o t h e r l e g . T he q ui ck . B i l a t e r a l b o d y p a r t s a r e al wa ys c om pa re d. f o r ex am pl e.p r o n g e d m e t a l i n s t r u m e n t u s ed t o t es t au di t o ry f u nc t i on a nd vi br at or y pe rc ep t i on . Percussion Hammer A p er cu ss io n h a m m e r ( a l s o c a l l e d a r e f l e x h a m m e r ) is a n i ns t r um en t wi t h a ru bb er h ea d u se d t o t e st d ee p t e nd on r ef le xe s. W h e n c on du ct in g a n as se ss me nt . al lo wi ng vi su al iz at io n an d a ss es sm en t o f t h e va gi na an d ce rv ix . t h e c o l l e g e s t u d e n t w h o re po rt ed t h at s he w as a vi ct im o f da t e r ap e. U n c o m f o rt ab le or e mb ar ra ss in g p os it io ns s ho ul d n ot b e m ai nt ai ne d f or l on g p er io ds . Techniques of Physical Assessment T he f ou r p ri m a r y a s s e s s m e n t t e c h n i q u e s a r e : • • • • I ns p e c t i o n P al p a t i o n P er c u s s i o n A us c u l t a t i o n T he se as se s s m e n t s a r e p r i m a r i l y u s e d i n t h e s e q u en ce li st ed . ho ld t h e f o rk a t t h e b as e t o a vo id di mi ni s h i n g t h e v i b r a t i o n o f t h e p r o n g s . I n sp ec t i on be gi ns wi t h t he i ni t i al . Positioning A v ar ie t y o f p o s i t i o n s a r e u s e d d u r i n g a p h y s i c a l a s se ss me nt . Draping D ra pi ng pr e v e n t s u n n e c e s s a r y e x p o s u r e . B i l a t e r a l b o d y pa rt s ar e n or ma ll y sy mm et ri c. h ea lt h s t a t u s .Vaginal Speculum A v ag in al sp e c u l u m i s a t w o . t he y ha ve t he sa me s iz e an d s ha pe as w e l l a s t h e s a m e c h a r a c t e r i s t i c s . D ra pe s m ay b e p a p e r .3. an d k ee ps t he pa t i en t wa rm d ur in g t he p hy s i ca l a ss es sm en t . t h u s m i n i m i z i n g u n n e e d e d a n d p o s s i b l y t i r in g mo ve me nt s. t ha t i s. T he p oi nt ed en d of t he ha mm er i s us ed f o r s ma ll er a re a s . T he f o rk i s a ct iv at ed t o v i b r a t e b y g e n t l y t a p p i n g i t s p r o n g s a ga in st t he pa lm o f t h e ha nd . P os it io ni ng pa t i en t s wh o ar e we ak or h av e p hy si ca l l im i t a t i o n s m a y r e q u i r e a s s i s t a n c e . A va gi na l ex am in at io n w ou ld be c ru c i a l f o r c o l l e c t i n g d a t a t o c o n f i r m t h e ra pe . T he a s s e s s m e n t s h o u l d b e o r g a n i z e d s o t h at s ev er al bo dy s ys t e ms c an be a ss es se d w it h t h e pa t i en t i n on e p os it io n.b l a d e d i n s t r u m e n t u s ed t o e xa mi ne t h e va gi na l c an al a nd ce rv ix . T h e h a m m e r i s h e l d b e t w e e n t h e t h u m b a n d in de x f in ge r t o d ir ec t a b ri sk t ap o n t he s el ec t e d b od y ar ea . s u c h a s m ov em en t o r pu ls es . p h y s i c a l c o n d i t i o n . p ur po se f u l o bs er va t i on s i n a sy st em at ic ma nn er . o r b e d l i n e n s . f i rm t a p i s m a d e w i t h a r a p i d d o w n w a r d a n d ba ck wa rd wr is t ac t i on . p r o v i d e s p ri va cy . Inspection I n s p e ct i o n i s t h e p r o c e s s o f p e r f o r m i n g d e l i b e r a t e . T h e sp ec ul um is i ns er t e d i nt o t h e v ag i n a a n d t h e s p e c u l u m b l a d e s a r e o p e n e d. e xp os e on ly t h e bo dy p ar t s be in g as se ss ed t o ma in t a in t h e p a t i e n t ' s m o d e s t y a n d c o m f o r t . T h e n ur se o bs er ve s v i s ua ll y bu t a l s o u s e s h ea r i n g a n d s m e l l t o g a t h e r da t a t hr ou gh ou t t he as se ss me nt . D ur in g p os it io ni ng . c l o t h . T h e s pe cu lu m m u s t b e w a r m e d a n d l u b r i c a t e d w i t h w a r m w at er or a w at er -s ol ub le ag en t b ef or e in se rt io n. P o si t i on s t h at ma y be u se d d ur in g a p hy si ca l a ss es sm en t a r e i l l u s t r a t e d a n d d e s c r i b e d i n B o x 2 5 .

consistency. t h e d e p t h b e i n g c o n t r ol le d b y t h e a mo un t of pr es su re a pp li ed . 5 ″ t o 0 . inspect for discharge. t e x t u r e . 6 06 T wo h an ds a r e u s e d f o r b i m a n u a l p a l p a t i o n ( e g . Hair: Inspect for texture. Skin: Inspect for color and lesions. T he n ur se 's h a n d s s h o u l d b e w a r m a n d t h e f i n g e r n a il s s ho rt . and tenderness. Take vital signs. ap pl y li gh t p re ss ur e w it h t h e f i n g e r s t o g e t h e r d e p r e s s i n g t h e s ki n an d u nd er ly in g s t r uc t u re s le ss t ha n 1 c m (0 . 6 05 P . 7 5″ ).p at ie nt co nt a c t a n d c o n t i n u e s t h r o u g h t h e e n t i r e a s se ss me nt . 2 5 . 2 5 . Palpation P al p a ti o n i s a n a s s e s s m e n t t e c h n i q u e t h a t u s e s t he s en se of t ou ch . and peripheral vision. texture. w hi ch c ar ri es a r is k of in t e rn al i nj ur y. 2 5. p a lp at in g b re as t t is su e) . Lymph nodes: Palpate for size. Evaluate height and weight. c on si st en cy . as d et er mi ne d b y pa lp at io n. P . thought processes. A de qu at e n at ur al or a rt if ic ia l li gh t i ng is e ss en t i al f or d i s t i ng ui sh in g t h e c o l o r . Eyes: Test visual acuity. Neck: Palpate trachea and thyroid gland. T h e d o r s u m (b ac k) s ur f a ce s o f t h e ha nd an d f i ng er s a re u se d f or g ro ss m ea su re of t em pe ra t u re . unusual growth. and internal structures. and moisture. F or l ig ht pa lp at io n. Skull and face: Inspect for shape and symmetry. C h a r a c t e r i s t i c s o f m a ss es . s iz e. A n y ar ea of t en de rn es s i s pa lp at ed la st . w it h in sp ec t i on pr ec ed in g p al pa t i on . I ns pe ct ea ch a r e a o f t h e b o d y f o r s i z e . alignment. c o l o r . or d ee p p al pa t i o n m a y b e u s e d . f l ui d. Li gh t .5 A) . m o i s t u r e . A qu ie t en vi ro nm en t a ll ow s so un ds t o b e h ea rd . an d sh ap e. p os it io n. I n s p e c t i o n m a y b e c o m b i n e d w i t h t h e p al pa t i on ph as e o f t h e a ss es sm en t . hygiene. t e x t u r e . Nails: Inspect for color and condition. on e ha nd ap pl ie s p re ss ur e an d t he o t h er ha nd f ee ls t he t i s s u e o r s t r u c t u r e . v i b r a t i on s. an d sy mm et ry . no t i ng no rm al f in di ng s a nd an y de vi at io ns f r o m no rm al . a n d m o i s t u r e o f b o dy s ur f a ce s. A pp ly in g i nt e r m i t t e n t p r es s u r e t o a s p e c i f i c a r e a a l lo ws as se ss me nt o f su rf ac e c ha ra ct er is t i cs an d un de rl yi ng st ru ct ur es . and infestations. t u r g o r . M od er at e p a l p a t i o n i s c o n d u c t e d b y d e p r e s s i n g t h e s ki n s ur f a ce 1 t o 2 c m (0 . s h a p e . • Integument • Gloves • • • Head and neck • • • • • Gloves Snellen chart Ophthalmoscope Otoscope Tongue depressor • • • • . p re ss i nw ar d a bo u t 2 c m ( 1 ″ ) ( s e e F i g . T h e p a l m a r ( f r o n t ) s u r f a c e s o f t h e f i n g er s a nd f in ge r p ad s ar e u se d t o a ss es s t ex t u re .5 B ) . Table 25-1 Summary of a Comprehensive Physical Assessment Component General survey Equipment (as needed) • • • Assessment Parameters • • Scales Sphygmomanometer Stethoscope Observe general appearance. a n d p u l s a t i o n . sh ou ld b e u se d ca ut io us ly a nd on ly a f t e r c o n s i d e r a b l e p r a c t i c e . posture. extraocular movements. Ce rt ai n pa rt s o f t h e ha nd ar e mo re e f f ec t i ve at a ss es si ng d i f f e r e n t t h i n gs (F i g . D e e p p a l pa t i on . mo de ra t e . V i b r a t i o n i s p a l p a t e d b es t wi t h t he pa lm o f t h e ha nd .4) . loss. F or d ee p p al pa t i on . T h e h an ds a nd f i ng er s ar e s en si t i ve t oo ls a nd ca n a ss es s t e mp e r a t u r e . sh ap e. gait. shape. palpate for temperature. 5 ″ ) ( se e F i g. speech patterns. ar e d es cr ib ed i n T ab le 25 -2 .

patency Arms and legs: Inspect for color. shape. rate. character. and lesions. external ear. condition of teeth. inspect position. nipple (discharge). palpate apical impulse. infestations. hair pattern. lesions. color. symmetry. condition of tonsils. distention. Peripheral pulses: Palpate for symmetry. Precordium: Inspect for pulsations. auscultate heart sounds and murmurs. palpate for crepitus and expansion. lesions. exudate. consistency. consistency. auscultation.• Ears: Test hearing acuity. rashes. palpate for tenderness. strength. masses. and pitch. palpate for tenderness. dimpling. frequency. and discharge. palpate pulse strength. Carotid arteries: Auscultate for bruit. Thorax: Inspect posture and respiratory rate. Nose. tympanic membrane. Breasts: Inspect size. Liver: Percuss and palpate for location and consistency/size. auscultate breath sounds. pulsations. throat: Inspect for color. palpate for masses or tenderness. and edema. • . and tenderness. palpate for temperature. and hernia. Scrotum and testes: Inspect for inflammation. Abdomen: Inspect for size. shape. areolas. palpate for tenderness. Axillary lymph nodes: Palpate for size. percuss for tones. veins. edema. palpate for masses. Male genitalia • Gloves • Penis: Inspect for inflammation. percuss for tones. then palpation. shape. and for cerumen. contour. Aorta: bruits. percussion. Bowel sounds: Auscultate for intensity. retraction. Jugular vein: Inspect for pulsations and distention. pulsation • Thorax and lungs • • • Gloves Stethoscope Tape measure • • • Cardiovascular • • Stethoscope Watch with a second hand • • • Peripheral vascular • • Stethoscope Doppler (if needed) • • Abdomen • Stethoscope • • • • Remember: Sequence of techniques is different for the abdomen: inspection. and heart rate and rhythm. lesions. mouth. Palpate for masses.

rectum. a nd d en si t y of t i s s u e s . pat knees with palms and backs of hands. Prostate: Palpate for size. Please consult an assessment textbook for additional information. P er cu ss io n i s us ed t o as se ss t h e lo ca t i on . discharge (color. see. shape. shape. Percussion P er cu ss i o n i s t h e a c t o f s t r i k i n g o n e o b j e c t a g a i n st an ot he r t o pr od uc e s ou nd . and tenderness. crepitus. Stool: Inspect for color. grooming. Joints: Test range of motion. Joints and muscles: Inspect for size. and memory and abstract reasoning. palpate for nodules. thought processes. fissures. shrug shoulders against resistance. rashes. have facial expressions. test for occult blood. hear. s ha pe . si ze . Anus: Inspect and palpate for hemorrhoids. mobility. speech. Reflexes: Assess degree of response. taste. dress. and strength. Ovaries: Palpate for size. and bulging out of vagina. T h e s ou nd w av es pr od uc ed by t he s t r ik in g a ct io n o ve r b o d y t i s s u e s a r e k n o w n a s p e r c u s s i o n t o ne s.Female genitalia • • • • • • Gloves Speculum Lubricant Applicators Culture tubes Pap test supplies • • External genitalia: Inspect for inflammation. i n i t i a t ed by a s ha rp do wn wa rd wr is t mo ve me nt w it h t h e f or ea rm s t a t i on ar y a nd t h e wr is t r e l a x e d . hygiene. symmetry. odor. feel touch. shape. Fine motor movement: Test ability to repeatedly touch nose with hand. consistency. masses. and tenderness. Uterus: Palpate for size. prostate • • • Gloves Lubricant Occult blood test • • • Musculoskeletal None • • • Neurologic • • • Reflex hammer Sharp/dull objects Aromatic scents • • • • • Not all assessments on this table are discussed in the narrative. lumps. T he o t h er ha nd ( do mi na nt h a n d ) p r o v i d e s t h e s t r i k i n g f o r c e . Mental status: Assess level of awareness. move eyes. swallow. infestations. B ot h ha nd s a r e u s e d t o p r o d u c e s o u n d w a v e s . and protrude tongue. and consistency. swelling. Cranial nerves: Test ability to smell. Gait: Inspect gait and posture. wi t h t he f in ge rs s l i g h t l y s e p a r a t e d a n d t h e m i d d l e f i n g e r pl ac ed f i rm ly o n t h e bo dy su rf ac e (F ig . and run heel down opposite shin. clench teeth. Sensory: Test ability to distinguish between sharp and dull touch.6A ). 25 . T h e t i p o f t h e m i d d l e f i n g e r o f t h e do mi na nt ha nd st ri ke s t h e mi dd le f i ng er o f t h e o pp os in g h an d . level of consciousness. lesions. • Anus. and edema. amount). T h e n on do mi na nt h an d is p la ce d d ir ec t l y on t h e ar ea t o b e pe rc us se d. position. ulcers. color.

wh il e a s s e s s i n g t h e h e a d a n d n e c k t h e y a l s o as se ss t he cr an ia l ne rv es . 6 08 P . I n f o rm at io n f r om t h e ge ne ra l s ur ve y pr ov id es cl ue s t o t h e o ve ra l l h e a l t h o f t h e p a t i e n t . o r pr on e t o f a ll . u s e t h e p r o p e r p a r t o f t he b el l f or s pe ci f i c so un ds . I t i n c l u d e s o b s er vi ng t he pa t i en t ' s o ve ra ll a pp ea ra nc e an d be ha vi or . A u sc ul t a t i on is p er f o rm ed b y p l a ci ng t h e s t e t h o s c o p e d i a p h r a g m o r b e l l a g a i n s t t he bo dy p ar t be in g a ss es se d. m ed iu m. t ak in g vi t a l s ig ns . U nc oo rd in at ed or s po nt an eo us mo ve me nt s m ay s ug ge st ne u r o l o g i c p r o b le m s . A l t h o u g h e ac h b o d y s y s t e m i s d i s c u s se d i nd iv id ua ll y h er e. W h en a us cu lt at in g. N o t e c o o r d i n a t i o n o f m o v e m e n t s an d pa t t er n o f ga it . No t e w he t h er t h e pa t i en t h as e re ct o r sl um pe d p o s t u r e . po st ur e. a nd me as ur i n g h e i g h t a n d w e i g h t . Appearance and Behavior I nf or ma t i on a b o u t t h e p a t i e n t 's a p p e a r a n c e a n d b e h av io r i s us ua ll y ga t h er ed wh en t a ki ng t he h ea lt h h is t o ry . F ou r ch ar ac t e r i s t i c s o f s o u n d a r e a s s e s s e d b y a u s c ul t a t i on : ( 1) p it ch (r an gi ng f ro m h ig h t o l ow ).t o .t o e a s s e s s m e n t v i d e o d em on st ra t e s p ro pe r t ec hn iq ue . Auscultation A u s cu l t at i o n i s t h e a c t o f l i s t e n i n g w i t h a s t e t h o s c op e t o so un ds pr od uc ed wi t h in t he b od y. No t e p r o p o r t i o n o f h e i g h t t o w e i g h t . General Survey T he g en er al s u r v e y i s t h e f i r s t c o m p o n e n t o f t h e p hy si ca l a ss es sm en t . 6 07 P . T h i s p o s i t i o n s h o u l d n o t be u se d f or p at ie nt s wh o a re w ea k. T h i s a c t i o n p r o d u c e s a v i b r a t i o n t ha t a ll ow s di sc ri mi na t i on am on g f iv e di f f er en t t o ne s. ( 2) lo ud ne ss ( ra ng in g f r o m so f t t o l o u d ) . t h e nu rs e s ho ul d e xp os e t he p a r t l i s t e n e d t o . on e o f t en u se d p ro ce ed s f ro m h ea d t o t o e.6 B) . d iz zy . w hi ch i s pa rt o f t h e n eu ro lo gi ca l s ys t e m) . g u r g l i n g o r s w i s h in g) . a n d g a i t ( w h i l e w a l k i n g u p ri gh t ) . de sc ri be d i n T ab le 25 -3 . A s se ss in g P . i n re al it y n ur se s us ua ll y c om bi ne s ev er al sy st em s ( eg . a nd ( if p os si bl e) li st en i n a q ui et e nv ir on me nt . b a l a n c e . or l on g) . . I ns pe ct t he pa t i en t ' s b od y bu il d. Guidelines for Performing Health Assessment A lt ho ug h t he r e a r e v a r i o u s o r g a n i z i n g s t r u c t u r e s f o r co nd uc t i ng a ph ys ic al as se ss me nt .( s e e F i g. a nd ( 4) d ur at io n ( sh or t . BOX 25-3: Positions Used in Physical Assessment Standing T he p at ie nt s t a n d s e r e c t . 2 5 . ( 3 ) q u a l i t y ( e g . I t i s us ed t o a ss es s po st u r e . a nd ga it . p r o v i d in g i ns ig ht i nt o nu t r it io na l s t a t u s. T he a cc om p a n y i n g h e a d . 6 09 a pp ea ra nc e p r o v i d e s i n f o r m a t i o n a b o u t v a r i o u s a s p ec t s of t he p at ie nt 's he al t h .

a nd p er ip he ra l p u l s e s . h ea rt . Sitting Supine T he p at ie nt l i e s f l a t o n t h e b a c k w i t h l e g s e x t e n d e d an d kn ee s s li gh t l y f l ex ed . a nd is u se d t o a ss es s v it al s ig ns a nd t h e he ad . I t a l l ow s vi su a l i z a t i o n o f t h e u p p e r b o d y . Supine Dorsal Recumbent . a nt er io r t ho ra x. I t f a ci li t a t e s ab do mi na l m us cl e r el ax at io n a nd is u se d t o a s s e s s v i t a l s i g n s a n d t h e h e a d . a nt er i o r a n d p o s t e r i o r t h o r a x . a nd up pe r ex t r em it ie s. ab do me n. n e c k. l u n g s . br ea st s. ex t r em it ie s. h e a r t . l un gs . b r ea st s. n ec k. or r em ai n in b ed wi t h t he h ea d e le va t e d. f a c i l i t a t e s f u ll lu ng e xp an si on .Standing Sitting T he p at ie nt m a y s i t i n a c h a i r o r o n t h e s i d e o f t h e be d or e xa mi ni ng t a bl e.

k ne es f le xe d. Dorsal Recumbent Sims Position T he p at ie nt l i e s o n e i t h e r s i d e w i t h t h e l o w e r a r m b el ow t h e bo dy an d t h e u pp er a rm f le xe d a t t h e sh ou ld er an d e lb ow . n ec k. Sims Position Prone T he p at ie nt l i e s f l a t o n t h e a b d o m e n w i t h t h e h e a d t u rn ed t o o ne si de . b r e a s t s . an d so le s o f t h e f e et o n t he b ed . I t sh ou ld n ot be u se d f o r a bd om in al a s s e s s m e n t b e c a u s e i t c a u s e s c o n t r a c t i on of t he a bd om in al mu sc le s. e x t r e m i t i e s . Prone Lithotomy T he p at ie nt i s i n t h e d o r s a l r e c u m b e n t p o s i t i o n w i t h t h e bu t t oc ks at t he e dg e o f t h e ex am in in g t ab le an d t h e he el s i n s t i rr up s. I t i s us ed t o as se ss t h e he ad . . a nt er io r t ho r a x .T he p at ie nt l i e s o n t h e b a c k w i t h l e g s s e p a r a t e d . I t i s us ed t o a ss es s t h e hi p j oi nt a nd t he po st er io r t ho ra x. h e a r t . I t is u se d t o a ss es s t he r ec t u m or v ag in a. I t is u s e d t o a s s e s s f e m a l e g e n i t a l i a a n d re ct um . B ot h kn ee s a r e f l e x e d . w i t h t h e u p p e r l e g m o r e a c ut el y f l ex ed . l u n g s . a nd pe ri ph er al pu ls es .

d e g r e e a n gl e t o t h e hi ps . w i t h t h e b o d y a t a 9 0 .Lithotomy Knee-chest T he p at ie nt k n e e l s . vibration. (Right) The dorsum. such as texture. (Left) Palmar surfaces of the examiner's fingertips and finger pads are used for discriminatory sensation. b ac k st ra ig ht . I t is u se d t o a ss es s t h e a n u s a n d r e c t u m . or size and consistency of a mass. is used to assess surface temperature. presence of fluid. Knee-chest Figure 25-4. or back of the hand. . ar ms ab ov e t h e h ea d.

light pressure is applied by placing the fingers together and depressing the skin and underlying structures about ½ inch (1 cm). Proud. (Photos by B. (B) Deep palpation is used with caution.Figure 25-5. (A) In light palpation. The skin and underlying structures are depressed about 1 inch (2 cm). Degrees of palpation.) Table 25-2 Characteristics of Masses Determined by Palpation Quality Shape Characteristics to Determine Round Ovoid Tubular Irregular Measured in centimeters Firm Edematous Spongy Cystic Smooth Nodular Granular Fixed or nonmobile Mobile Amount of tenderness to touch Pulsation can or cannot be felt in the mass Size Consistency Surface Mobility Tenderness Pulsatile .

size. a nd s h o r t a t t e n t i o n s p a n . S p e e c h . w r o ng f or t he se as on ) or w or n o r di rt y cl ot hi ng ma y ha ve d ep re ss io n o r i na de qu at e f i n a n c i a l r e s o u r c e s . t h e p r e g n a n t w o m an wi t h a h is t o ry o f su bs t a nc e a bu se . u se ap pr op ri at e s cr ee ni ng t o o l s a n d r e f e r a s n e c e s s a r y . A s c og ni t i ve p ro ce ss es a r e c o n t r o l l e d b y t h e n e u r o l o g i c a l s y s t e m . and density of tissues. T hi nk b ac k t o T a m m y B r o w n i n g . A ss es s co gn i t i v e p r o c e s s e s ( s p e e c h c o n t e n t a n d p at t e rn s. N ot e si gn s o f i l l n e s s . (Photos by B. t h es e ar e d is cu ss ed f ur t h er un de r t h at se ct io n. T h e q u e s t i o n n a i r e i s g iv en t o p at ie nt s t o c om pl et e. B o x 2 5 . a n d m o o d . shape.) Table 25-3 Percussion Tones Tone Flat Dull Resonance Hyperresonance Tympany Relative Intensity Soft Medium Loud Very loud Loud Sample Location Thigh Liver Normal lung Emphysematous lung Gastric air bubble or puffed-out cheek O bs er ve hy g i e n e a n d g r o o m i n g ( c l e a n l i n e s s . p a t i e n t s w i t h i n a p p r o p r i a t e d r e s s ( e g . n on ve rb al co mm un ic at io n o f pa in or d i s t r es s.4 pr es en t s t h e G e ri at ri c De pr es si on S c al e. T h es e ma y in di ca t e ot he r pr ob le ms . (A The nondominant had is placed directly on the area to be percussed. b o d y o do rs ). a nd b eh av io r a ll p ro vi de cl ue s t o mo od an d m e n t a l h e a l t h . Vital Signs V it al s ig ns a r e m e a s u r e d t o e s t a b l i s h a b a s e l i n e f o r t h e da t a ba se an d t o de t e ct a ct ua l o r po t e nt ia l h ea lt h pr ob le ms . No t e a ny d ef ic it s. F or e xa mp le . an d re sp ir at io ns . an d a pp ro pr ia t e ve rb al r es po ns es ). e ye c on t a ct . (B) The tip of the middle finger of the dominant hand strikes the joint of the middle finger of the opposite hand. T he n ur se wo ul d pe rf or m a g en er al su rv e y o f t h e p a t i e n t t o d e t e r m i n e a n y f i n d in gs s ug ge st iv e o f re ce nt su bs t a nc e u se . a t t i t u d e . s u c h a s c h a n g e s i n p o s t u r e . Proud. V it al s i g ns a re di s c u s s e d i n d e t a i l i n C h a p t e r 2 4. o r ot he r me nt al he al t h di so rd er s.Figure 25-6. a us ef ul t oo l i n sc re en in g o l d er ad ul t s f o r d e p r e s s i o n . and the middle finger is placed firmly on the body surface. s ki n c ol or . . A ss es s af f e c t . Percussion is used to access the location. I f y o u s u s p e c t d e p r e s s i on . ab il it y t o re la x. a nx ie t y . f a c i a l ex pr es si on s. or ie nt at io n.

ha i r . Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • • • • • • H is t o r y o f r a s h e s . a nd c hi ld re n s ho ul d b e we ig he d i n t h ei r un de rw ea r. P ro t e ct t he p at ie nt 's pr iv ac y b y ex po si ng on ly t he b od y p a r t b e i n g e x a m i n e d . I f t he p at ie nt ca nn ot st an d er ec t . h ai r. T h e p a t i e n t 's a c t u a l h e i g h t a nd w ei gh t c an b e c om pa re d wi t h re co mm en de d a ve ra ge we ig ht s on a s t a nd ar di ze d c h a r t a s a g e n e r a l g u i d e l i n e f o r a s s e s si ng nu t r it io na l st at us an d he al t h (s ee t he G u id el in es f o r Nu rs in g C ar e 2 5. h yd ra t i on st at us . I nf an t s sh ou l d b e w e i g h e d w i t h o u t a n y c l o t h i n g . o r s h a p e o f a m o l e R ec e n t c h e m o t h er a p y o r r a d i a t i o n t h e r a p y E xp o s u r e t o c h e m i c a l s t h a t m a y b e h a r m f u l t o t he s ki n.7) a n d pa l p a t e f o r t e m p e r a t u r e .Height and Weight T he r at io of h e i g h t a n d w e i g h t i s a n a s s e s s m e n t o f ov er al l he al t h . as we ll a s cl ue s t o l oc al or s ys t e mi c he al t h pr ob le ms . I t a ls o p ro vi de s d at a a b o u t s e l f . He ig ht an d we ig ht s ho ul d b e m e a s u r e d u s i n g a c c u r a t e s c a l e s a n d m e as ur in g d ev ic es . t ur go r. o r b ur ns ) C ha n g e i n t h e c o l o r . Skin T he s ki n i s a g e n e r a l i n d i c a t o r o f t h e p a t i e n t 's h e a l t h s t a t u s a nd p ro vi de s i nf or ma t i on t h at m ig ht i nd ic at e a n un de rl yi ng d i s ea se . hy gi en e. C hi ld re n t o 2 y e a r s o f a g e s h o u l d h a v e t h e i r h e i g h t m ea su re d i n t h e r ec um be nt p os it io n w it h t h e l eg s f u ll y ex t e nd ed . p l a n t s . a n d n a i l s a r e a s s e s s e d b y i n s p e c t i on an d pa lp at io n. I ns pe ct t he s ki n f or c ol or . an d sc al p. o r it ch in g H is t o r y o f b r u i s i n g o r b l e e d i n g i n t h e s k i n H is t o r y o f a l l e r g i e s t o m e d i c a t i o n s . A s se ss in g f or s ki n ca nc er is e ss en t i al a nd pr ov id e s t h e b a s e f o r t e a c h i n g s k i n c a n c e r p r e v en t i on . n a i l s .1 ). an d n ut ri t i on . b r u i s e s . va sc ul ar it y. an d n ut ri t i on . an d t e xt ur e. T ab le 2 5 . an d l es io ns (F ig . we ar g lo ve s du ri ng pa lp at io n. c h a n g e i n c o l o r . m oi st ur e. h ai r. A s se ss in g t h e in t e gu me nt ar y st ru ct ur es p ro vi de s i nf or ma t i on a b o u t t h e p a t i e n t 's o v e r a l l h e a l t h s t a t u s . or n ai ls D eg r e e o f m o b i l i t y T yp e s o f f o o d e a t e n a n d l i q u i d s c o n s u m e d ea ch d ay Physical Assessment T he s ki n. T h e p a t i e n t r e ma in s in t he si t t in g po si t i on f o r mo st o f t h e e xa mi na t i on bu t wi ll n ee d t o s t a nd or l ie o n t h e s i d e w h e n t h e p o s t e r i o r p a r t o f t he b od y i s ex am in ed . BOX 25-4: Geriatric Depression Scale (GDS) . T h e p at ie nt s ho ul d r em ov e sh oe s a nd h ea vy cl ot hi ng i f t h e me as u r e m e n t s a r e t a k e n b e f o r e u n d r e s s i n g . l e s i o n s . 6 10 T he a ss es sm e n t b e g i n s w i t h a n o v e r a l l i n s p e c t i o n of t he s ki n' s c on di t i on . f oo ds . 2 5 . s i z e . P . a b r a si on s. S p ec if ic ar ea s of t he sk in c an b e a ss es se d d ur in g o t h er b o d y s y s t e m a s s e s s m e n t s ( e g . or o t h er su bs t a nc es E xp o s u r e t o t h e s u n a n d s u n b u r n h i s t o r y P re s e n c e o f l e s i on s ( w o u n d s . y o u m a y as se ss t h e sk in o n t he a bd om en wh il e pe rf or mi ng ot he r a bd om in al a ss es sm en t s ) . I f t h e p a t i e n t h a s l e si on s. w ei gh t c an b e o bt a i ne d u si ng c ha ir s ca le s or be d s c a l e s . A s k t h e p at ie nt t o re mo ve al l cl ot hi ng an d pu t o n an e xa mi na t i on g o w n ( i f a p p r o p r i a t e ) . A d e q u a t e l i g h t i n g i s e s s e n t i a l f o r a cc ur at e a ss es sm en t s .c a r e a c t i v i t i e s t o m a i n t a i n he al t h . Assessing the Integument I nt eg um en t a r y a s s e s s m e n t i n c l u d e s t h e s k i n .4 p r o v i d e s a h e i g h t a n d w e i g h t t a b le f or u se as a s t a nd ar d r ef er en ce .

Instructions: 1. Do you feel that you have more yes problems with memory than most? Do you think it is wonderful to be yes alive now? Do you feel worthless the way you are now? Do you feel full of energy? yes no 11. no 12. yes yes no no 6. 9. yes no no Do you feel that your situation is yes hopeless? Do you think that most people areyes better off than you are? 15. no 3. 5. 14. no . Circle the answer that best describes how you felt over the past week. yes no 8. no 13. yes no 7. Are you basically satisfied with yes your life? Have you dropped many of your yes activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home. yes yes no no 10. rather than going out and doing things? yes no 2. no 4.

s k i n n e d p e o p l e i s m o r e d i f f i c u l t t o ob se rv e on t h e t r un k of t h e bo dy . o r a l m uc ou s m em br an es . 6 11 p at ie nt s w it h d a r k s k i n . R et u r n t h e s c a l e w e i g h t i n d i c a t o r t o z e r o . A sk t h e p a t i e n t t o r e m o v e s h o e s ( a n d c o a t . Obtaining Weight • • • • • • • B al a n c e t h e s c a l e o n z e r o . m ay h av e a s om ew ha t di f f er en t c ol or f ro m a re as t ha t ar e u su al ly co ve r e d b y c l o t h i n g . ja un di ce . s u c h a s A f r i c a n A me ri ca ns . A sk t h e p a t i e n t t o s t e p d o w n f r o m t h e p l a t f o rm . C on s i d e r a t i o n s : D a i l y w e i g h t s s h o u l d b e o b t a in ed at t he s am e t im e ea ch d ay (u su al ly e ar ly mo rn in g) . R ea d t h e h e i g h t i n i n c h e s a n d r e c o r d .s h a p e d s l i d i n g a r m o n t h e m e a s u r i n g d ev ic e at t a ch ed t o t he s ca le so me wh at h ig he r t ha n t he p at ie nt 's a pp r o x i m a t e h e i g h t . Cy an os is i s as se ss ed as a b lu e t in ge i n p a t i e n t s w i t h w h i t e s k i n a n d a s d u l l ne ss in P . t r a u ma . J au nd ic e i n d a r k .5) . c y a n o s i s . n ai lb ed s. S ki n a re as t h at a r e n o r m a l l y e x p o s e d . mu co us m em br an es . A sk t h e p a t i e n t t o s t e p d o w n f r o m t h e p l a t f o rm . p a l m s . T h es e c ol or c ha ng es ar e of t e n e as ie r t o as s e s s i n l i g h t . a n d s o l e s a p p e a r y e l l o w t o y e l lo w. Hi sp an ic s. L ow e r t h e L . A sk t h e p a t i e n t t o s t e p o n t h e p l a t f o r m o f t he s ca le an d st an d e re ct w it h t h e ba ck t o t he m ea su ri ng de vi ce an d t h e h ee ls t o g e t h e r . so me t yp es of a ne mi a. T hi nk b ac k t o B i l l y C o l l i n s . b u t o t h e r w i s e s k i n c o l o r i s re la t i ve ly c on st an t . R ea d t h e w e i g h t i n p o u n d s a n d r e c o r d . C ya n o si s i s a b l u i s h o r g r a y i s h d i s c o l o r a t i o n o f t h e sk in i n re sp on se t o i na de qu at e ox yg en at io n. an d h e m o l y s i s . M ov e t h e s l i d i n g i n d i c a t o r t o t h e l e f t u n t i l t he s ca le ba la nc es . i f ap pr op ri at e) an d s t e p on t o t h e pl at f o rm . n o r m a l l y h a v e l e s s p i g m en t a t i on t h an ot he r bo dy ar ea s. J a u n d i c e i s a y e l l o w c o l o r of t he s ki n r es ul t i ng f ro m li ve r a nd g al lb la dd er di se as e. Guidelines for Nursing Care 25-1 Obtaining Height and Weight With an Upright Balance Scale Obtaining Height • • • • • • A sk t h e p a t i e n t t o r e m o v e s h o e s . pe op le of M ed it er ra ne an d es ce nt . T h e nu rs e w ou ld u se i ns pe ct io n s ki ll s t o o bs er ve f o r e ry t h em a i n t h e a r e a o f t h e s t i n g . o f t en r es ul t s f r om a n i na de qu at e a m o u n t o f c i r c u l a t i n g b l o o d o r h e m o g l o bi n.s k i n n e d p e o p l e . su ch as t he p al ms of t he h an ds a nd t h e so le s o f t h e f e e t . a nd c on ju nc t i va . or p al en es s o f t h e s ki n.s h a p e d s l i d i n g a r m u n t i l i t r e s t s on t op of t he p at ie nt 's he ad . P a l l o r . wi t h t he p at ie n t w e a r i n g t h e s a m e c l o t h i n g .s k i n n e d p a t i e n t s . C ha ng es in s k i n c o l o r i n c l u d e e r y t h e m a . bu t t he s cl er a.o ra ng e. a n d u s i ng t h e sa me s ca le . a nd a ll er gi c r ea ct io ns .Inspecting Skin Color S ki n co lo r v a r i e s a m o n g r a c e s a n d a m o n g i n d i v i d u al s. R ai s e L . s u c h a s t h e f a c e a nd h an ds . p a l l o r m a y b e v i s i b l e o v e r t h e e n t i r e s ki n su rf ac e o r on ly i n t he l ip s. S om e bo dy ar ea s of da rk -s ki nn ed pe op le . ca us in g i na de qu at e o xy ge na t i on of t he bo dy t is su es . S p ec ia l ca re mu st b e t a ke n t o de t e ct c ol or c ha ng es in d a r k . i n f l a m m a t i o n .s k i n n e d p e o p l e i s s e e n as a n as he n g ra y or y el lo w t in ge . E r y t h e m a (r ed ne ss of t he s ki n) i s mo re of t e n se en in t he f ac e a nd t he n ec k. . a nd pa ll or ( T a bl e 2 5. I t u s u a l l y d e v e l o p s f i r s t i n t h e s cl er a of t he e ye s a nd t he n i n t h e sk in a nd mu co us m em br an es . f e v e r . De pe nd in g o n se ve ri t y . t h e c h i l d w h o w a s s t u n g b y a be e. a n d w h i t e s w h o a r e d e e p l y s u n t a n n e d . ra ng in g f ro m a pi nk is h w hi t e t o va ri ou s s ha de s of b ro wn . I t i s a ss oc ia t e d w i t h s u n b u r n . Na t i ve A me ri ca ns . P a l l o r i n d a r k .

c ut s. co lo r. 38 . l o c a t i o n . t h es e si gn s mi gh t r el at e t o a ca rd io va sc ul ar . T he n ur se wo ul d in sp ec t t he p at ie nt f o r si gn s an d s ym pt om s o f t r a u m a . an d p re se nc e o f dr ai na ge or i t c hi ng . sc ra t c he s.7 ). Table 25-4 Height and Weight Table . 6 12 r as he s ( sk in e r u p t i o n s ) i n t e r m s o f t h e i r t y p e . Proud. b l e e d i n g . Inspecting Skin Lesions I ns pe ct t h e s k i n f o r l e s i o n s . R em em be r R a m o n a L e w i s . A ss es s wo un ds (b re ak s in t h e co nt in ui t y of t he s ki n) f or s i z e. (W ou nd s a re d is cu ss ed in C ha p.6 an d 2 5. t h e c o l l e g e s t u d e n t r e p or t i ng a ra pe . s i z e . s ha pe . an d s ec on da ry . d e p t h . c au si ng pu rp li sh d is co lo ra t i on . h em at ol og ic . as se ss t he ir l oc at io n. L e s i o n s a r e c a t e g o r i z e d a s p r i m a r y . in se ct b it es . P et ec h i ae a re s ma ll he m o r r h a g i c s p o t s c a u s e d b y c a p i l l a r y b l ee di ng . i n c l u d i n g a n y b r u i s i n g o r p e t e ch ia e. wh ic h r es ul t f r om c h a n g e s i n p r i m a r y l e s i o n s (T a b l e s 2 5 . co lo ri ng . I f t h ey ar e pr es en t . a nd si ze . a nd wo un ds . Inspecting Skin Vascularity I ns pe ct t h e s k i n f o r v a s c u l a r i t y . N ot e br ui se s. w h i c h a r e a r e a s o f d i s ea se d o r in ju re d t is su e. T h es e f in di ng s wo ul d b e im po rt an t o bj ec t i ve d at a t o he lp s ub st an t i at e t h e r a p e . De s c r i b e P . o r b r u i s i n g.© B. w hi ch m ay a ri se f r om p re vi ou sl y no rm al sk in . D oc um en t t he e xa ct bo d y s u r f a c e a r e a s i n v o l v e d . E c c h y m o s i s i s a c o l l e c t i o n o f b l o o d i n t he s ub cu t a ne ou s t i ss ue s. el ev at io n. ) S ca rs a re he al ed w ou nd s. o r li ve r d ys f u nc t i on . a n d p r e s e n c e o f d r a i n ag e o r od or .

t he t ex t u re is d r y . Moisture. T h e t e x t u r e o f t h e s k i n m a y v a r y f r o m s mo ot h a nd s of t t o r ou gh an d d ry . A n e xc es si ve am ou nt o f pe rs pi ra t i on . i s c a l l e d d i a ph or es is . . l o o s e a n d w r i n k l e d a n d t h e m u c o u s m em br an es a re cr ac ke d an d d ry . I n t he d eh yd ra t e d p at ie nt . and Turgor T he s ki n i s n o r m a l l y w a r m a n d d r y . shoes with 1-inch heels). shoes with 1-inch heels). Texture. † Weights at ages 25 to 59 yr are based on lowest mortality. A n i n c r e a s e i n sk in t em pe ra t u re an d m oi st ur e ca n in di ca t e an e le va t e d b od y t em pe ra t u re .Height 5′ 2″ 5′ 3″ 5′ 4″ 5′ 5″ 5′ 6″ 5′ 7″ 5′ 8″ 5′ 9″ 5′ 10″ 5′ 11″ 6′ 0″ 6′ 1″ 6′ 2″ 6′ 3″ 6′ 4″ Weight (lb) Men* Small Frame Medium Frame Large Frame Height 128–134 130–136 132–138 134–140 136–142 138–145 140–148 142–151 144–154 146–157 149–160 152–164 155–168 158–172 162–176 131–141 133–143 135–145 137–148 139–151 142–154 145–157 148–160 151–163 154–166 157–170 160–174 164–178 167–182 171–187 138–150 140–153 142–156 144–160 146–164 149–168 152–172 155–176 158–180 161–184 164–188 168–192 172–197 176–202 181–207 4′ 10″ 4′ 11″ 5′ 0″ 5′ 1″ 5′ 2″ 5′ 3″ 5′ 4″ 5′ 5″ 5′ 6″ 5′ 7″ 5′ 8″ 5′ 9″ 5′ 10″ 5′ 11″ 6′ 0″ Weight (lb) Women† Small Frame Medium Frame Large Frame 102–111 103–113 104–115 106–118 108–121 111–124 114–127 117–130 120–133 123–136 126–139 129–142 132–145 135–148 138–151 109–121 111–123 113–126 115–129 118–132 121–135 124–138 127–141 130–144 133–147 136–150 139–153 142–156 145–159 148–162 118–131 120–134 122–137 125–140 128–143 131–147 134–151 137–155 140–159 143–163 146–167 149–170 152–173 155–176 158–179 * Weights at ages 25 to 59 yr are based on lowest mortality. Weights in pounds are according to frame (in indoor clothing weighing 5 lb. s uc h as wh e n t h e e n t i r e s k i n i s m o i s t . Palpating Skin Temperature. Weights in pounds are according to frame (in indoor clothing weighing 3 lb.

F i g ur e 2 5. I f t h e a re a of ed em a is p al pa t e d w it h t h e f in ge rs .9 il lu st ra t e s n ai l ab no rm al it ie s. nailbeds disease (decreased oxygenation) Overall skin areas. t h i s i s c a l l e d p i t t i n g e de ma . localized area of skin on the body Blushing. vascularity. + 2 ( mo de ra t e .8 ) . E de ma m ay b e t he r es ul t of ov er hy dr at io n. W he n t h e p at ie nt i s d eh yd ra t e d. E d em a is c ha ra ct er iz ed by s we ll in g. (Photo © B. he ar t f a il ur e. infection Exposed areas. t h e s k i n ' s e l a s t i c i t y i s d e c r e a s e d . T h e a n g l e b e t w e e n t h e na il an d it s ba se in t he f in ge r s ho ul d be ab ou t 16 0 d eg re es . particularly the face and lips. a n d t h e n a i l b a s e . and lesions. t e x t u r e . 2 mm ). k i d ne y f ai lu r e . a n d t he s ki n f o ld re t u rn s t o n or ma l s lo wl y. a n g l e . alcohol intake. + 1 ( t r ac e. D if f i cu lt y in l i f t i n g a s k i n f o l d m a y i n d i c a t e e d e m a ( ex ce ss f lu id in t he t is su es ). o r p e r i p h e r a l v a s c u l a r d i s e a se . T h e na il s sh ou ld be s om ew ha t c on ve x a nd s ho ul d f ol lo w t h e n at ur al cu rv e o f t h e f i n g e r . 6 13 c al le d B ea u ' s l i n e s ( f r o m a c u t e i l l n e s s ) . an d c l u bb in g ( f r o m l o n g . 8 mm ). p ai nl es s s ep ar at io n o f t h e n ai l pl at e f r om t h e na il be d ( on yc ho ly si s) f r o m in f e ct io n o r t r a u m a . o r + 4 ( v e r y d ee p. + 3 ( d e e p . wi t h t au t an d s hi n y s k i n o v e r t h e e d e m a t o u s a r e a .Figure 25-7. w h e n p a l p a t e d. 4 m m ) . i n c r e a s e d b r i t t l e n e s s o r t hi ck ne ss an d an gu la t i on (f ro m a ne mi a or i ro n d ef ic ie nc y an em ia ). 2 5 . Table 25-5 Skin Color Assessment Color Variations Redness (erythema. conjunctivae. i t c a n b e p i c k e d u p i n a f o ld an d re t u rn s t o it s sh ap e w he n re le as ed . Nails T he n ai ls ar e i n s p e c t e d f o r s h a p e . an in de nt at io n m ay r em ai n a f t er t he pr e s s u r e i s r e l e a s e d .t e r m l a c k o f o x y g e n a t i o n ) . A b no rm al f i nd in gs in cl ud e i nd en t a t i on s P . lips. hands and feet. The skin is inspected for color. sh ou ld b e f ir m an d no nt en de r. Proud. an d co lo r. particularly the ears. and mucous membranes Liver disease (increase in bilirubin levels) Yellowish (jaundice) Paleness (pallor) Anemia (decreased hemoglobin) Shock (decreased blood volume) . h ow ev er . i n f e c t i o n . E de ma ma y be g ra de d a s 0 (n on e) . mucous membranes. T he n ai ls s ho ul d b e sm o o t h . fever. No rm al t u rg or r es ul t s i n e l a s t i c i t y o f t h e s k i n . 6 m m ) . injury trauma. flushing) Bluish (cyanosis) Assessment Areas Possible Causes Facial area. t r a u m a . inside Cold environment. t hi s ma y be a no rm al f i n di ng in o l d e r p a t i e n t s ( F i g . cardiac or respiratory of the mouth. and sclera Exposed areas.) T u r g o r is t h e f u l l n e s s o r e l a s t i c i t y o f t h e s k i n a n d i s us ua ll y as se ss ed on t he s t e rn um or u nd er t h e cl av ic le .

ho rm on e d is or de rs . (Photo © B. l um ps . a nd d i s t r ib ut io n. lips. A ss es s t h e h ai r f o r co lo r. Proud. i nf ec t i on .Vitiligo (whitish patchy areas on the skin) Tanned or brown Overall skin areas. wh ic h ar e t h e w hi t e e gg s o f li ce . d r yn es s. o r in ad eq ua t e n ut ri t i on . or l ic e. Difficulty in lifting a skin fold may indicate presence of edema. E xc es si ve h a i r g r o w t h m a y o c c u r i n p e r s o n s w i t h h o rm on e d is or de rs . l es io ns . s i z e . a nd p ar t s of t he g en it al ia . a n d n ei t h er e xc es si ve ly dr y no r oi ly . t h e s o l e s o f t h e f e e t . s c a l i n g . To assess skin turgor. A b n o r m a l f i n d i n g s i n c l u d e u n u s u a l b a l di ng (a lo pe ci a) a nd ex ce ss iv e am ou nt s o f ha ir on t he f ac e a nd b od y ( hi rs ut is m) . d e c r e a s e d t u r g o r . I f a ny l um ps or m as se s ar e p al pa t e d. Figure 25-8. e v e n l y d i s t r i b u t e d . e sp ec ia ll y o f t h e lo we r e xt re mi t i es . sc al in es s. H a i r l o s s m ay b e t h e r e s u l t o f c h e m o t h er ap y.) Normal Age-Related Variations Infant/Child C om mo n s ki n v a r i a t i o n s i n n e w b o r n s a n d c h i l d r e n i nc lu de : • • • • J au n d i c e a n d m i l i a ( w h i t e h e a d s ) i n n e w b o r n s F in e d o w n y h a i r (l a n u g o ) f o r t h e f i r s t 2 w e e ks o f li f e S mo o t h . d r y n e s s . no t e t h e i r l o c a t i o n . conjunctivae Depigmentation (congenital or autoimmune conditions) Sun-exposed areas Overexposure (increased melanin production). D e c r e a s e d o x y g e n a t i o n o f p e r i p h e r a l t i s s ue s. pregnancy (brown spots) Hair and Scalp T he h ai r i s n o r m a l l y r e s i l i e n t . S ep ar at e t h e h a i r t o i n s p e c t t h e s c a l p f o r c o l o r . t e n d e r n e s s . ma y ca us e l os s of h ai r. a small fold of skin is picked up and then released to return to its normal shape. nailbeds. t h i n s k i n a t b i r t h P ub i c h a i r d e v e l op m e n t a t t h e o n s e t o f p u b er t y Older Adult C om mo n s ki n v a r i a t i o n s i n t h e o l d e r a d u l t i n c l u d e : • W ri n k l e s . a n d mo bi li t y . ca n b e d i f f e r e n t i a t e d f r o m d a n d r u f f o r l i n t b e ca us e t h ey ar e at t a ch ed t o t he h ai r s ha f t . t ex t u re . Ha ir is f ou nd o n a ll b od y su rf ac es e xc ep t t he p a l m s o f t h e h a n d s . ra di at io n t he ra py . Ni t s .

b r i t t l e g r a y o r w h i t e h a i r H ai r l o s s C oa r s e f a c i a l h a i r i n w o m e n . na sa l an d o ra l st ru ct ur es . m ou t h an d ph ar yn x. t hy ro id gl an d . h e a r i n g . P h y s i c a l e x a m i n a t i o n o f t h e s t r u c t u r e s o f t he h ea d a nd n ec k pr ov id es da t a ab ou t t h e s ha pe a nd st ru ct ur e of c r a ni al P . 6 14 P . f ac e. s uc h as he a d a c h e s o r d i z z i n e s s . f un ct i o n o f s p e c i a l s e n s e s ( s i g h t . y e l l o w t o e n a i l s Assessing the Head and Neck A ss es sm en t o f t h e h e a d a n d n e c k i n c l u d e s t h e s k u l l.• • • • • • • R ai s e d d a r k a r e a s ( s e n i l e k e r a t o s i s ) F la t b r o w n a g e s p o t s ( s e n i l e l e n t i g i n e s ) S ma l l r o u n d r e d s p o t s ( c h e r r y a n g i o m a ) F in e. a n d l y m p h n o d e s . e ar s. Table 25-6 Primary Skin Lesions Lesion Name Description Example Illustration Circumscribed. t a st e. I f t h e p a t i e n t s m o ke s. freckle . a n d a n y s w e l l i n g o r p a i n i n t h e l y mp h no de s i n t h e n ec k. d e c r e a s e d b o d y ha ir in m en a nd wo me n T hi c k . D u r i n g t h e h e a l t h h is t o ry . t r ac he a. a di sc us si on of w ay s t o s t o p sm ok in g s ho ul d b e in cl ud ed in t he p l a n o f ca re . 6 15 P . no se a nd si nu se s. Nonpalpable Change in Skin Color Macule Lesion ≤1 cm Petechiae. a nd sm el l) . e ye s. t he s iz e an d c on si st en cy o f t he t hy ro id g l a n d . Flat. n ot e an y he al t h pr ob le ms ma ni f e st ed by s ub je ct iv e re po rt . 6 16 b on es .

5 cm Coalesced papules .Patch Lesion >1 cm Vitiligo Palpable.5 cm Mole Plaque Mass >0. Elevated Solid Masses Papule Mass >0.

firmer than a papule Nevus (wart) Tumor Mass >2 cm Lipoma Wheal Irregular. Superficial Skin Elevations Formed by Free Fluid in a Cavity Within the Skin Layers .Nodule Mass 0. mosquito bite Circumscribed.5–2 cm. superficial area of localized skin edema Hives.

impetigo Table 25-7 Secondary and Miscellaneous Skin Lesions .Vesicle Filled with serous fluid. >0. ≤0.5 cm Herpes simplex Bulla Filled with serous fluid.5 cm 2nd-degree burn Pustule Filled with pus Acne.

may bleed and scar Deep linear crack. red or bluish surface vessels. Not Technically Primary or Secondary Comedo Telangiectasia Plugged opening of a sebaceous gland. as in chickenpox Stasis ulcer Athlete's foot Ulcer Fissure Loss of epidermis and dermis. extends into dermis Material on the Skin Surface Crust Scale Dried residue of serum. round. a hallmark of acne Small. may be part of a basal cell carcinoma or skin injury from radiation Flat to slightly elevated. moist. pus. evenly pigmented Common blackhead Nevus Common mole Health History . or blood Thin flake of exfoliated dermis Impetigo Dandruff. shiny appearance Scratch of the epidermis Fibrous tissue replaces tissue in the dermis or subcutaneous layer Hypertrophied scar Peripheral vascular disease Atrophy Excoriation Scar Keloid Other Common Skin Lesions. with increased visibility Atrophic dermatitis of skin furrows Thinning of the skin. dilated. nonbleeding surface Moist area after rupture of a vesicle. loss of skin furrows. dry skin Miscellaneous Lesions Lichenification Thickened and roughened epidermis.Lesion Name Description Example Secondary Lesions Loss of Skin Surface Erosion Loss of superficial epidermis.

a nd t r em or s) a re a bn or ma l f in di ng s. Examples of nail abnormalities.I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • • • • • • • • • C ha n g e s w i t h a g i n g i n v i s i o n o r h e a r i n g H is t o r y o f u s e o f c o r r e c t i v e l e n s e s o r h e a r i n g a id s L os s o f a n e y e ( u s e o f a r t i f i c i a l e y e ) H is t o r y o f a l l e r g i e s H is t o r y o f d i s t u r b a n c e s i n v i s i o n o r h e a r i n g H is t o r y o f c h r o n i c i l l n e s s e s . A b n o rm al f i nd in gs i nc lu de la ck o f sy mm et ry o r u nu su al s iz e o r co nt ou r of t he s ku ll (e i t h e r m a y b e t h e r e s u l t o f t r a u m a o r d i s ea se s a f f ec t i ng t he gr ow t h o f bo ne ) a nd t e nd er ne ss . s u c h a s h y p e r t e ns io n. an d t i mi ng . T he p ar t s of t he h ea d a nd f ac e s ho ul d be in p ro po rt io n t o ea ch o t h er a nd sy mm et r i c . Face I ns pe ct t h e f a c e f o r c o l o r . g en er al ly t h e sh ap e i s ge nt ly c ur ve d w it h p ro mi ne nc es a t t h e f r o n t a l a n d p a r i e t a l b o n e s . d o c u m e n t t h e i r l o c a t i o n . M ea su ri ng he ad ci rc um f e re nc e i s a n or ma l p a r t o f i n f a n t a s s e s s m e n t t o t h e a g e o f 2 ye ar s an d s ho ul d be co nd uc t e d a t ea ch v is it . f a sc ic ul at io ns . a n d d i s t r i b u t i o n o f f a ci al ha ir . Figure 25-9. a n d i n v o l u n t a r y f a c i a l m o v e m e nt s ( eg . m ea su re t he ci rc um f e re nc e. t i cs . di ab et es me ll it us . c h e w i n g t o b a c c o . P . or t hy ro id di se as e E xp o s u r e t o h a r m f u l s u b s t a n c e s o r l o u d n o i se s E xp o s u r e t o u l t r a v i o l e t l i g h t H is t o r y o f s m o k i n g . a mo un t . s y m m e t r y . Skull I ns pe ct an d p a l p a t e t h e s k u l l f o r s i z e a n d s h a p e . A l t h o u g h t h e s h a p e o f t h e n o r m a l s ku ll v ar ie s co ns id er ab ly . o r c o c ai ne us e H is t o r y o f e y e o r e a r i n f e c t i o n s H is t o r y o f h e a d t r a u m a H is t o r y o f p e r s i s t e n t h o a r s e n e s s O ra l a n d d e n t a l ca r e p r a c t i c e s Physical Assessment A ss es s t h e s t r u c t u r e s o f t h e h e a d a n d n e c k w i t h t h e p at ie nt s ea t e d. 6 17 Eyes . E d em a o f t h e f a ce . es pe ci al ly ar ou nd t h e ey e ( pe ri or bi t a l e d e m a ) . I f a bn or ma li t i e s a r e n o t e d . I f t h e sk ul l of a c hi ld o r a n a d u l t a p p e a r s d i s p r o p o r t i o n a t e l y l a r g e or s ma ll .

F i g u re 25 -1 0 il lu st ra t e s s t r uc t u re s of t he ey e. h y p e r t e n s i o n . Inspecting Internal Eye Structures T he i nt er na l e y e i s e x a m i n e d w i t h t h e o p h t h a l m o s co pe (F ig . 25 . pu pi ls . f o v e a c e n t r a l i s . T h e n u m e r a t o r i s 2 0 . w h i c h m a y b e a t t r i b u t a b l e t o d am ag e t o t h e oc ul om ot or ne rv e. a n d r e t i n a l v e s s e l s . Extraocular Movements. A cross-section of the eye. gu id el in es f o r as se ss in g t he i nt er na l e ye a r e l i s t e d i n t h e G u i d e l i n e s f o r N u r s i n g C ar e 25 -3 .A ss es s t h e s t r u c t u r e s a n d f u n c t i o n s o f t h e e y e s u s in g a p en li gh t . A bn or ma l f in d i n g s i n c l u d e c l o u d i n e s s o f t h e l e n s ( f ro m ca t a ra ct s) . r o u n d . e xt ra oc ul ar m o v e m e n t s . A sy mm et ry o f po si t i on an d al ig nm en t m ay b e ca us ed by m us cl e w ea k n es s o r a c o n g e n i t al a b n o r m a l i t y . No t e w he t h er t h e pa t i en t ' s v i s io n is b ei n g t e s t e d w i t h o r w i t h o u t c o r r e c t i v e l e ns es . m ya st he ni a g ra vi s. A ss es s t h e p u p i l s f o r t h e i r r e a c t i o n t o l i g h t a n d a c co mm od at io n a nd f o r co nv er ge nc e ( se e G ui de li ne s f or N ur si ng Ca re 2 52 ). a nd t he e ye la sh es sh ou ld cu rl o ut wa rd . or a d et ac he d r et in a) .1 1) . a nd ce rt ai n me di ca t i on s m ay c au se t h e pu pi l t o di la t e ( my dr ia si s) . T he p up il s m ay b e pa le an d cl ou dy if t he p at ie nt ha s c at ar ac t s (l o s s o f o p a c i t y o f t h e l e n s ) . o pt ic ne rv e d i s c. l a cr im al gl an ds . an d u ne qu al pu pi ls m ay r es ul t f ro m ce nt ra l ne rv ou s s ys t e m i nj ur y or il ln e s s . I n j u r y t o t h e e ye . 2 5 . Inspecting External Eye Structures I ns pe ct t h e e y e s . 2 5. c o n j u n c t i v a e .r e d a r t er ie s an d d ar k. c e r t a i n d r u g s c a n c a u s e c o n s t r i c t i o n ( m io si s) . r e p r e s e n t i n g t h e di st an ce f r om w hi ch a pe rs on w it h no rm al vi si on ( re co rd ed as . v is ua l ac ui t y . e d e m a . an o ph t h al mo sc op e. A s s e s s m e n t s o f t he e ye i nc lu de ex t e rn al an d in t e rn al ey e st ru ct ur es . ou t w ar d t ur ni ng o f t h e l ow er l id ( ec t r op io n) . T h e ey es ar e a ss es se d p r i m a r i l y b y i n s p e c t i o n . e y e l a s h e s . in w a r d t u r n i n g o f t h e l o w e r l i d ( e n t r o p i o n ). t h e ve in s be in g a bo ut 1. a nd re dn es s or d ra in ag e ( f r om i nf ec t i o n o f t h e l i d m a r g i n s .re d ve in s. a n d eq ua l co ve ra ge of t he ey eb al l. Figure 25-10. ch an ge s i n t h e s iz e an d sh ap e o f bl oo d v es se ls ( f r om h yp er t e ns io n o r a r t e r i o s c l e r o s i s ) .1 3) . t r a u m a . a c le ar . in cl ud in g t h e r et in a. o r h ai r f ol li cl es ). m ac ul a . a nd i ri s f o r po si t i on an d a li gn me nt (F i g. A sk t he p at ie nt t o r ea d t he s ma ll es t p o s s i b l e l i n e o f l e t t e r s . e q u a l i n s i z e . A bn or ma l f in di ng s i nc lu de d ro op in g o f t he u pp er li d s ( p t o s i s ) . a n d l i g h t . V i su al ac ui t y i s me as ur ed by s t a nd ar di ze d n um be rs li st ed o n t he s i d e of t h e c h a r t . I ns pe ct a nd pa lp at e t he l ac ri ma l gl an ds f o r ed em a a nd p ai n. a r e d d i s h r e t i n a . gl au co ma . Us in g t h e o ph t h al mo sc op e t ak es pr ac t i ce . e y e l i d s . an d sm oo t h . I ns pe ct t h e e y e s f o r s y m m e t r y a n d p a r a l l e l a l i g n m e nt .12 ) t o a ss es s t he f un du s. D ec re as e d o r a b s e n t p u p i l l a r y r e s p o n s e i n d i c a t es bl in dn es s o r se ri ou s br ai n d am ag e. T he p up il s a r e n o r m a l l y b l a c k . i n f l a m m a t io n. f i r s t w i t h b o t h e ye s an d t he n wi t h o ne ey e at a t i me . a n d c h a n g e s i n c ol or a nd su rf ac e ch ar ac t e ri st ic s ( f r om s uc h he al t h pr ob le ms as d i a be t e s m e l l i t u s . I ns p e c t t h e e y e l i d s f o r c o l o r . P . T h e e y e b r o ws sh ou ld ha ve e qu al di st ri bu t i on . an d a n ey e c ha rt . No rm al f in di ng s a re a un if or m re d re f l ex . e y e b r o w s . a n d p e r i p h e r a l v i s i o n . 5 t i me s as l ar ge as t he a rt er ie s ( F i g . 6 18 Assessing Visual Acuity. I n ab il it y of t he ey es t o a cc om mo da t e o r c o n v e r g e i s a b n o r m a l . o r a c on ge ni t a l d i s or de r. and Peripheral Vision A ss es s vi su a l a c u i t y b y p l a c i n g t h e p a t i e n t 2 0 f e e t f r om t h e S n el le n c ha rt a nd t es t i ng ea ch e ye . ye ll ow o pt ic n er ve d i s c .

T es t s f or p er i p he ra l v is io n ( or v i s ua l f i el ds ) a r e u s e d t o a s s e s s r e t i n a l f u n c t i o n a nd op t i c ne rv e f un ct io n. a t u n i n g f o r k a n d t i c k in g wa t c h a re u se d t o as se ss h ea ri ng ac ui t y . i t n o r m a l l y r a pi dl y co ns t r ic t s (d ir ec t re sp on se ) ( F i gu re B ) . s i z e . un ev en co lo r.2 0/ 20 ) c an r e a d t h e l e t t e r s . R ep e a t t h e p r o c e d u r e w i t h t h e o t h e r e y e . F ul l pe ri ph er al vi si on is n or ma l (s ee G u id el in es f or N ur si ng C a r e 2 5 . T he p at ie nt re ma in s s ea t e d wh il e t he n ur se a ss es se s t h e s t r u c t u r e o f t h e e a r s b y i n s p e c t i o n a nd pa lp at io n. and Convergence Pupillary Reaction • • • • • A sk t h e p a t i e n t t o l o o k s t r a i g h t a h e a d .1 5 ) f o r s h a p e . The eye and surrounding structures. a nd le si on s. a nd t he s ha pe a n d s i z e o f t h e e a r s s h o u l d b e s y m m e t r i c an d pr op or t i on al P . V is ua l a cu it y is r ec or de d a s t h e sm al le st l i n e of le t t er s t h a t c a n b e r e a d a c c u r a t e l y w i t h n o m or e t h an t wo in ac cu ra t e r ea di ng s ( su ch as “ 20 / 3 0– 2 w it h gl as se s” ). T h e l a r g e r t h e d e n o m i na t o r. No rm al ly b ot h e ye s m ov e t o ge t h e r . . 2 5 . Accommodation. t he p oo re r t he v is io n.14 ). A b n o r m a l f i n d i n g s o f t h e e x t e r n a l e a r in cl ud e u ne qu al he ig ht a nd si ze . T es t ex t r ao c u l a r m o v e m e n t s b y a s s e s s i n g t h e c a r d in al f i el ds o f vi si on f or co or di na t i on an d al ig nm en t . an d l es io ns . a n d t h e i n ne r ea r (F ig . Ears A ss es s t h e e x t e r n a l e a r . R ep e a t t h e p r o c e d u r e a n d o b s e r v e t h e o t h e r ey e. i t t o o n or ma ll y wi ll c on st ri ct (c on se ns ua l r ef le x) . Inspecting the External Ear I ns pe ct t h e e x t e r n a l e a r (F i g . Figure 25-11. B ri ng t h e p e n l i g h t f r o m t h e s i d e o f t h e p a t i en t ' s f ac e an d b ri ef ly s hi ne t h e li gh t on t h e pu pi l (F ig ur e A ). Guidelines for Nursing Care 25-2 Measuring Pupillary Reaction. A n o t o sc op e w it h t h e co rr ec t s iz e of e ar s pe cu lu m m ay b e u se d t o in sp e c t t h e e a r c a n a l . T h e ex t e rn al su rf ac es of t he e ar s ho ul d b e sm oo t h . a n d a r e p a r a l l e l ( s ee G u id el in es f o r Nu rs in g C ar e 25 -4 ). 25 . a r e c o o r d i n a t e d . 6 20 t o t h e h ea d. O bs e r v e t h e p u p i l ' s r e a c t i o n .4 ) . 6 19 P . t h e m i d d l e e a r .

. Assessing accommodation. Assessing pupillary reaction. T h e pa t i en t ' s e ye s s ho ul d no rm al ly c on v e r g e ( a s s u m e a c r o s s . Convergence • • H ol d y o u r f i n g e r a b o u t 6 ″ t o 8 ″ f r o m t h e b r i d ge of t he p at ie nt 's no se . Accommodation • • H ol d t h e f o r e f i n g e r . Figure B. t h en ba ck t o t h e o bj ec t be in g h el d.e y e d a p p e a r a n c e) . Pupillary gauge measures pupils (dilation or constriction) in millimeters (mm). A sk t h e p a t i e n t t o f i r s t l o o k a t t h e o b j e c t .Figure A. t he n at a d is t a nt ob je ct . a p e n c i l . T he pu pi l n or m a l l y c o n s t r i c t s w h e n l o o k i n g a t a n e a r o bj ec t an d d il at es w he n l oo ki ng at a d is t a nt o bj ec t . M ov e y o u r f i n g e r t o w a r d t h e p a t i e n t 's n o s e t o a ss es s co nv er ge nc e ( F i gu re D) . o r o t h e r s t r a i g ht o bj ec t a bo ut 10 t o 15 c m (4 ″ t o 6 ″ ) f ro m t h e b ri dg e of t h e pa t i en t ' s n os e ( F i g u r e C) . Figure C.

w a x p l u g s i n t h e e a r c a n a l ( f r o m an a cc um ul at io n o f ce ru me n) . Assessing convergence. Figure 25-12. A s s e s s h e a r i n g a c u i t y o u t o f t he p at ie nt 's li ne o f vi si on (t o pr ev en t l ip -r ea di ng ). a c om bi na t i on o f b o t h . using an ophthalmoscope.1 6) . wi t h t he o pp os it e e ar c ov er ed . I ns er t t h e o t o sc op e s pe cu lu m as t he pa t i en t ' s h ea d i s sl ig h t l y t i l t e d a w a y f r o m t h e e x a m i n e r . A t t a ch t h e la rg es t s pe cu lu m t h a t w i l l f i t c o m f o r t a b l y i n t o t h e p a t i e n t 's ea r t o t h e ot os co pe . a r ed a nd sw o l l e n e a r d r u m ( s y m p t o m s o f a n i n f e c t i o n i n t h e mi dd le ea r) . A bn or ma l f in d i n g s i n c l u d e r e d n e s s o f t h e c a n a l ( f r o m in f l am ma t i on or i nf ec t i on ). a nd d ra in ag e ( f r om a n i nf ec t i on o r f or ei gn bo dy i n t h e e a r c a n a l ) . an d f or ei gn bo di es . I n c h i l d r e n y ou ng er t h an 3 ye ar s of a ge . T h er e s ho ul d be no r ed ne ss or d is ch ar ge . e d e m a . Examination of the internal structures of the eye. Assessing Hearing and Sound Conduction A ss es s he ar i n g o n e e a r a t a t i m e b y d e t e r m i n i n g w he t h er t he pa t i en t ca n h ea r a wh is pe re d v oi ce o r a t ic ki ng w at ch f ro m a d i s t a nc e o f 1 t o 2 f e e t . A s se s s t h e p a t i e n t f o r b o t h b o ne c on du ct io n P . E x a mi ne f or w ax . d is ch ar ge . t r a n s l u c e n t . 2 5. P a in w he n ma ni pu la t i ng t he p in na is a s ym pt om o f an in f e ct i o n o f t h e e x t e r n a l e a r . o r mi xe d. T o a ch ie ve be t t er v is ua li za t i on . a n d g r a y ( F i g . Inspecting the Ear Canal and Tympanic Membrane T he o t o sc op e i s u s e d t o e x a m i n e t h e e a r c a n a l a n d t he t y mp an ic m em br an e w it h t h e pa t i en t s it t i ng . 6 21 . o r p re se nc e o f le si on s. H ea ri ng l os s m ay b e co nd uc t i ve (t he r es ul t o f a pr ob le m w it h t h e t r a ns mi ss io n o f s o u n d w a v e s t h r o u g h t h e o u t e r a n d m id dl e e ar ).Figure D. T h e t ym pa ni c me mb ra ne s ho ul d b e in t a c t . s en so ri ne ur al (f ro m in ne r e ar d am ag e) . s t r ai gh t e n t he e ar c an al by p ul li ng t h e p i n na do wn a n d b a c k . s h i n y . T un in g f or k t e s t s h e l p a s s e s s t h e t y p e o f h e a r i n g l os s. s t r ai gh t e n t he e ar ca na l of t he ad ul t by g en t l y p ul li n g t h e p i n n a u p a n d b a c k . ma st oi d t e nd er ne ss (f ro m in f e ct io n) . a pe rf or at ed ea rd ru m ( f r om a n in f e ct io n c au si ng r up t u re or t r a u m a ) . (Photo by B. Palpating the External Ear P al pa t e t h e e x t e r n a l e a r g e n t l y f o r p a i n . Proud) T he e ar ca n a l s h o u l d b e s m o o t h a n d p i n k i s h .

G u id el in es f o r Nu rs in g C ar e 25 -5 d i s cu ss es ho w t o a s s e s s h e a r i n g w i t h a t u n i n g f o r k . an d y ou r le f t h an d a nd e ye f o r t h e pa t i en t ' s l ef t e ye . as se ss in g t he c ha ra ct er is t i cs of t he r et in a. I f t h e s o u n d i s h e a r d b e t t er i n t h e e ar w it ho ut a pr ob le m. N or ma ll y. N or ma ll y. b o n e c o n d u c t i o n w i l l be t he sa me o r gr ea t e r t ha n ai r co nd uc t i on . 2 5. an d t he t ur bi na t e s (F i g. F ol lo w b l o o d v e s s e l s o u t w a r d t o e a c h o f t h e f o ur qu ad ra nt s. i t in di ca t e s d am ag e t o t h e in ne r e ar o r a n er ve di so r d e r . K ee p b o t h e y e s o p e n w h i l e l o o k i n g t h r o u g h t he o ph t h al mo sc op e vi ew er . a nd ce nt ra l a re a ( p h y s i o l o g i c c u p ) . d o w n . s l o w l y m o v e t h e op ht ha lm os co pe t o wa rd t h e pa t i en t ' s e ye .c o n d u c t e d h e a r i n g is g re at er t ha n b on e. S hi n e t h e l i g h t o n t h e p u p i l a n d o b s e r v e t h e ro un d r ed o r or an ge gl ow ( t h e r ed r ef le x) . Inspecting the Nose . T h e ma xi ll ar y s in us es a re l oc at ed in t h e m a x i l l a r y b o n e . t h e f r o n t a l s i n u s e s i n t he f ro nt al bo ne ( F i g. S it f a c i n g t h e p a t i e n t a n d a s k h i m o r h e r t o l oo k st ra ig ht ah ea d d ur in g t h e e xa mi na t i on . n ot e c ol or . Nose and Sinuses A ss es s t h e n o s e b y e x a m i n i n g t h e e x t e r n a l n o s e . F oc u s i n g o n t h e r e d r e f l e x . as se ss in g co lo r. Figure 25-13.1 8) . i n t h e R i n n e t e s t . si ze . si ze . T h e no se is a ss es se d b y in sp ec t i on an d t he s in us es b y i n s p e c t i o n a n d p a l p a t i o n . c h a r a c t e ri st ic s. t he o ss ic le s) t ra ns mi t s t h e s ou nd di re ct l y t o t h e e a r . T h e p at ie nt s ho u l d b e s i t t i n g . t h e s o u n d i s h e a r d i n bo t h e ar s or is l oc al iz ed a t t h e c en t e r of t he he ad .co nd uc t e d h ea ri ng (d oc um en t e d a s A C > B C) . F ol lo w b l o o d v e s s e l s t o w a r d t h e m i d l i n e t o l oc at e t h e o pt ic d is c. A sk t h e p a t i e n t t o l o o k u p . an d pa t t er n. D ar k e n t h e r o o m a n d h a v e t h e p a t i e n t r e m ov e g la ss es . t he n ar es . L oc a t e t h e m a c u l a b y f i r s t l o c a t i n g t h e o p t i c di sc a nd t h en l oo ki ng t o wa rd t he pa t i en t ' s t em pl e f o r a s ma ll c ir cu la r s t r uc t u r e n e a r t h e d i s c . i n t h e W e b e r 's t e s t .1 7) . 2 5. a n d f r o m s id e t o si de . I f t he h ea ri ng l o s s i s c o n d u c t i v e . R ot a t e t h e l e n s w h e e l u n t i l i n t e r n a l e y e s t r uc t u re s a re s ha rp a nd cl ea r. n o t e c o l o r . A l lo w t i me f o r t h e pa t i en t ' s p up il s t o di la t e . Guidelines for Nursing Care 25-3 Assessing the Internal Eye • • • • • • • • • • • • A ss e m b l e t h e o p h t h a l m o s c o p e . The normal fundus as seen through an ophthalmoscope. a i r . B e g i n w i t h t h e li gh t s et t i ng a t t h e l ar ge w hi t e li gh t an d t h e l en s wh ee l a t 0 se t t in g. U se y o u r r i g h t h a n d a n d e y e t o e x a m i n e t h e pa t i en t ' s r ig ht e ye . an d a re a of r ef le ct ed li gh t (f ov ea ce nt ra li s) . P a t i en t s wi t h c on du ct iv e h e a r i n g l o s s h e a r t h e s o u n d b e t t e r i n t h e af f e ct ed ea r be ca us e b on e ( in t hi s ca se . T h e p a t i e n t si t s w it h t he h ea d s li gh t l y t i lt ed b ac k.o f so un d a n d a i r c o n d u c t i o n o f s o u n d w i t h t h e W e b er 's t e st a nd t he Ri nn e t e st . sh ap e. ma rg in s.

I t i s n o t n e c e s s a r y t o u s e a na sa l sp ec ul um wi t h a c hi ld . T h e f r on t a l s in us es a re p al pa t e d b y g en t l y pr es si ng up wa rd o n t h e b on y p r o m i n e n c e s l o c a t e d a b o v e e a c h e y e . b l e e di ng or d is ch ar ge (i nd ic at in g a ll er gi es wi t h i nf la mm at io n o r in f e ct io n) . 6 22 p ro mi ne nc es o f t h e u p p e r c h e e k ( F i g . 25 . d i a g o n a l l y u p a n d d ow n t o t h e le f t . Peripheral Vision • • • • • • • H av e t h e p a t i e n t s t a n d o r s i t a b o u t 2 f e e t a wa y. R ep e a t t h e p r o c e d u r e f o r t h e o t h e r e y e . P ai n ma y b e a f i nd in g i f t h e si nu se s a r e i n f e c t e d o r o b s t r u c t e d .2 0) . m ov e i t sl ow ly t hr ou gh t h e ca rd in al po si t i on s: u p a nd d o w n . K ee p i n g y o u r f i n g e r o r l i g h t a b o u t 1 f o o t f r om t h e pa t i en t ' s f ac e. A bn or ma l f in d i n g s a r e s w e l l i n g o f t h e m u c o s a . di ag on al ly up a nd do wn t o t he r ig ht ( se e F ig ur e ). p er f o ra t i on o r d e v i a t i o n o f t h e n a s a l s e p t u m ( c o c a i ne u se ma y ca us e pe rf or at io n. A sk t h e p a t i e n t t o t e l l y o u w h e n t h e f i n g e r s a re f ir st s ee n ( bo t h y ou an d t h e p at ie nt s ho ul d s ee t he f i ng er s at t he s am e t i m e ) . Palpating the Sinuses P al pa t e t h e f r o n t a l a n d m a x i l l a r y s i n u s e s f o r p a i n an d ed em a.19 ). A sk t h e p a t i e n t t o c o v e r o n e e y e w i t h a h a nd o r a n in de x ca rd . I ns pe ct t he n as al se pt um f or i nt ac t n es s a n d d e v i a t i o n . f ac in g y ou s it t i ng or s t a nd in g a t ey e le ve l wi t h t h e pa t i en t .T es t t h e n os e f o r p a t e n c y b y o c c l u d i n g o n e n o s t r i l at a t im e an d a sk in g t h e p at ie nt t o in ha le an d e xh al e t h ro ug h t he n os e. Guidelines for Nursing Care 25-4 Assessing Extraocular Movements and Peripheral Vision Extraocular Movements • • • A sk t h e p a t i e n t t o s i t o r s t a n d a b o u t 2 f e e t a wa y. a n d p o l y p s ( o f t e n s e e n w i t h c h r o n i c al le rg ie s) . A sk t h e p a t i e n t t o h o l d t h e h e a d s t i l l a n d f o l lo w t he m ov em en t o f yo ur f or ef in ge r o r a pe nl ig ht wi t h t he ey es . f a ci ng y ou a t e ye l ev el . or g ro wt hs . a de vi at ed se pt um ma y be c on ge ni t a l o r f r o m t r au ma ) . I ns pe ct ea ch n o s t r i l u s i n g a n o t o s c o p e w i t h a s h o r t . C ov e r y o u r o w n e y e o p p o s i t e t h e p a t i e n t ' s c lo se d ey e. . N o r m al ly . ex ud at e. 2 5 . l e f t a n d r i g h t . E xa mi ne t h e m u c o u s m e m b r a n e s f o r c o l o r a n d t h e pr es en ce o f l es io ns . an d mo ve yo ur f in ge rs i nt o t h e v i s u a l f i el d s f r o m v a r i o u s p e r i p h e r a l p oi nt s. A sk t h e p a t i e n t t o l o o k d i r e c t l y a t y o u r n o s e an d f i x hi s o r he r ey es o n t ha t sp ot . t h e s in us es a re no t pa in f u l w he n pa lp at ed . p us h t h e t i p o f t h e no se up wa rd w it h y ou r t h um b a n d s h i n e a li g h t i n t o t h e n a r e s . H ol d o n e a r m o u t s t r e t c h e d t o o n e s i d e ( r i g ht o r l ef t ) e qu id is t a nt f r om y ou a nd t h e pa t i en t . t h e na sa l m uc os a is m oi st a nd re dd er t h an t he o ra l m uc os a. N o r m al ly . wi de t ip o r us in g a n as al sp ec ul um a nd pe nl ig ht (F ig . T he ma xi ll ar y si nu se s a re p al pa t e d b y ge nt le pr es su re o n t he b on y P .

m o i s t . s wo ll en . an d t on si ls ( F i g. o r n i a c i n ) . a w hi t e co at in g on t h e t on gu e ( f r om p o o r o r a l h y g i e n e . 6 23 i n de f i ci en ci e s o f i r o n . m oi st . a b ri gh t . h ar d an d s of t pa la t e . W e a r g l o v e s w h e n a s s e s s i n g a p at ie nt 's mo ut h an d u se 4 ″ × 4 ″ ga uz e t o ho ld t he t o ng ue f o r p al pa t i on . p o o r l y f i t t e d d e n t u r e s . t o ns il la r pi ll ar s. o r p o o r o r a l h y g i e n e) . o r r e d n e s s an d sw el li ng of t he m uc ou s m em br an es .Testing extraocular movement of the eye. an d f re e of s we ll in g o r l e s i o n s . p oo rl y a li gn ed . a nd s ym me t r ic i n si ze . W i t h t h e p a t ie nt 's t o ng ue re la xe d o n t h e f lo or o f t h e mo ut h. c y a n o s i s . T he u vu la is n or ma ll y c en t e re d a n d f r e e l y m o v a b l e . a n d ne ck i nc lu de s a p en li gh t . a nd h ar d a nd s of t p al at es . a f i ss ur ed t o ng ue ( f r om de hy dr at io n) . Mouth and Pharynx T he m ou t h a n d p h a r y n x i n c l u d e t h e l i p s . a t o ng ue bl ad e.2 1) . T he t ee t h s ho ul d b e re gu la r a nd f r ee o f c a v i t i e s o r h a v e d e n t a l r e s t o r a t i o n . A bn or ma l f in d i n g s a r e p a l l o r . T he l ip s s ho u l d b e p i n k . s w o ll en . T h e t o n s i l s . a re s ma ll . t o ng ue . g um s. m is si ng . p h a r y n x . o r s m o k i ng ). Inspecting the Mouth and Pharynx E qu ip me nt u s e d t o a s s e s s t h e m o u t h . A s s e s s t h e m o u t h a n d p h a r y n x b y i n s p ec t i ng t h e l ip s. t h ey ar e re mo ve d f or t he i ns pe ct io n o f t h e g um s an d ro of of t he m ou t h . a 4″ × 4″ g au ze s po ng e. Ha ve t he pa t i en t si t wi t h t he he ad t il t e d b ac kw ar d an d t he m ou t h op en e d w i d e .re d t on gu e ( se en P . s al iv ar y gl an d. I f t h e p a t i e n t w e a r s d e n t u r e s . re d. i f p r e s e nt . le si on s o f t h e mu co sa an d l i p s. an d bl ee di ng gu ms (f ro m nu t r it io na l d ef ic it s. Neck Inspecting the Neck . v i t a m i n B 1 2 . or c ar io us t e et h. T h e t o ng ue an d m uc ou s me mb ra ne s a re n or ma ll y p in k. 2 5 . a nd gl ov es . ex am in e t he m uc ou s m em br an e o f t h e o r o p h a r y n x w h i l e d e p r e s s i n g t h e b as e o f t h e t o ng ue wi t h a t on gu e d ep re ss or . i r r i t a t i o n . pi nk . t ee t h . Figure 25-14. ha ir y t on gu e ( f r om a nt ib io t i c us e) . o r a b la ck . g um s an d t ee t h . r e d t o n s i l s ( i n d i c a t i n g i n f e c t i o n ) . Internal structures of the ear. t o n g u e . a n d s m o o t h . Us e p al pa t i on if a n y a b n o r m a l i t i e s a r e n o t e d d u r i n g i n s pe ct io n. i nf la mm at io n o r i nf ec t i on . T he g um s s h o u l d b e p i n k a n d s m o o t h .

A sk t h e p a t i e n t wh e r e t h e s o u n d i s h e a r d b es t . a n d t e n d e r n e s s . m o b i l i t y . Rinne's Test to Compare Air Conduction With Bone Conduction of Sound . T h e ne ck s ho ul d b e hy pe re xt en de d sl ig ht ly . c on si s t e n c y . Figure 25-16. 2 5 . A s se ss t he ne ck f or r an ge of m o t i o n a n d v e n o u s d i s t e n t i o n . No n ec k ve in di st en t i on (i nd i c at in g he ar t p ro bl em s) sh o u l d b e v i s i b l e . P al pa t e t h e l y m p h n o d e s ( F i g . a nd mo bi li t y .2 2 ) w i t h t h e p a t i e n t s i t t i n g.2 3) w i t h t h e p a d s of t he f i ng er s f o r en la rg em en t . an d n on t e nd er . w it h f u ll ra ng e of m ot io n. i f p a l p a b l e . a nd s id e t o si de t o as se ss r an ge of m o t i o n . o r me t a st as is o f ca nc er . Figure 25-15. sm oo t h . m ob il e. I f pa lp ab le . 6 24 n od es (l ym p h a d e n o p a t h y ) m a y i n d i c a t e i n f e c t i o n . t h e y s h o u l d b e sm al l. Normal tympanic membrane.A ss es s t h e n e c k (F i g . as seen through an otoscope. T h e n od es a re g en er al l y n o t p a l p a b l e . t e nd er ne ss . Palpating the Trachea and Lymph Nodes T he t ra ch ea . A s k t h e p a t i en t t o t i lt t he h ea d b ac kw ar d. a ss es s lo ca t i on . External structures of the ear. A n un e q ua l s pa ce b et we en t h e t r a c h e a a n d t h e s t e r n o c l e i d o m a s t o i d m us cl e o n ea ch s id e i s an a bn or ma l f in di ng in di ca t i ng t ra ch ea l d i s pl ac em en t . E n l a r ge d l ym ph P . a ut oi mm un e d is or de rs . Guidelines for Nursing Care 25-5 Using a Tuning Fork to Assess Hearing Weber's Test for Bone Conduction of Sound • • • H ol d t h e t u n i n g f o r k a t i t s b a s e a n d s t r i k e i t a ga in st yo ur o t h er p al m s o t h at t he f o rk v ib ra t e s. n o r m a l l y m i d l i n e a t t h e s u p r a s t e r n a l n ot ch . f or wa rd . is p al pa t e d f or a li gn me nt an d p os it io n. 2 5 . T h e n e c k s h o u l d b e s y m m e t r i c . P la ce t h e b a s e o f t h e t u n i n g f o r k o n t h e c e n t e r o f t h e t o p o f t h e pa t i en t ' s h ea d. s i z e.

t h e t h yr oi d g la nd sh ou ld f ee l s of t bu t el as t i c. so f t a nt er io r f o nt an el at a bo ut 18 m on t h s o f ag e Figure 25-18. Cross-section of the nasal cavity. I f p al pa bl e. I mm e d i a t e l y p l a c e t h e s t i l l . o r c a n c e r ) . P al pa t e f or s iz e. s ym me t r y. an d p re se nc e o f an y n od u l e s ( s e e G u i d e l i n e s f o r N u r s i n g C a r e 2 5. a l t h o u gh it i s no rm al ly no t pa lp ab le in s om e p at ie nt s. sh ap e. R ep e a t t h e t e s t w i t h t h e o t h e r e a r . w it h t h e e xa m i n e r u s i n g a n a n t e r i o r o r p o s t e r i o r a p pr oa ch . . Palpating the Thyroid Gland T he t hy ro id g l a n d i s a s s e s s e d b y p a l p a t i o n .6) . m as se s.v i b r a t i n g t u n i n g f or k cl os e t o t h e ex t e rn al ea r ca na l an d a sk w he t h er t h e pa t i en t c an h ea r t h e s o u n d . I t sh ou ld b e no nt en de r a n d s h o u l d h a v e n o e n l a r g e m e n t . i nf ec t i on o f t h e t hy ro i d .• • • • S t r ik e t h e t u n i n g f o r k a s f o r W e b e r 's t e s t . H ol d t h e b a s e o f t h e t u n i n g f o r k a g a i n s t t h e ma st oi d pr oc es s o f t h e pa t i en t a nd a sk t he pa t i en t t o t e ll y ou w he n t he s o u n d c a n n o l o n g e r b e h e a r d . t en de rn es s. o r no du le s ( wh ic h ma y i nd ic at e t h yr oi d g la nd d is ea se . t h e n o r m a l e a r w i l l d o s o . T he pa t i en t is s it t i ng . Location of the frontal and maxillary sinuses. Normal Age-Related Variations Infant/Child C om mo n h e a d a n d n e c k v a r i a t i o n s i n n e w b o r n s a n d c hi ld re n i nc lu de : • C lo s i n g o f p o s t e r i o r f o n t a n e l a t 8 w e e k s o f ag e. Figure 25-17.

Figure 25-19. Examination of the nasal passages using an otoscope with a wide speculum. (Photo © B. Proud.)

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G az i n g a t a n d f o l l o w i n g b r i g h t o b j e c t s b y 1 mo nt h o f ag e F oc u s i n g w i t h b o t h e y e s b y 6 m o n t h s o f a g e P up i l s a t t h e i n n e r f o l d s ( p s e u d o s t r a b i s m u s ) S t a rt l e r e f l e x i n n e w b o r n s

Older Adult
C om mo n h e a d a n d n e c k v a r i a t i o n s i n t h e o l d e r a d u l t in cl ud e:

• • • • • • • • • • • •

I mp a i r e d n e a r v i s i o n ( p r e s b y o p i a ) D ec r e a s e d c o l o r v i s i o n a n d p e r i p h e r a l v i s i o n D ec r e a s e d a d a p t a t i o n t o l i g h t a n d d a r k A w h i t e r i n g a r o u n d t h e c o r n e a ( a r c u s s e n i l i s) E nt ro p i o n a n d e c t r o p i o n H ea r i n g l o s s ( p r es b y c u s i s ) I mp a i r e d c o n d u c t i v e h e a r i n g E lo n g a t e d e a r l o b e s P ro m i n e n t e a r l a n d m a r k s D ec r e a s e d n e c k r a n g e o f m o t i o n N od u l a r t h y r o i d g l a n d S ma l l e r , m o r e e a s i l y p a l p a t e d l y m p h g l a n d s

Assessing the Thorax and Lungs
T he t ho ra x ( F i g . 2 5 - 2 4) c o m p r i s e s t h e l u n g s , r i b c a ge , ca rt il ag e, an d in t e rc os t a l m us cl es . Da t a f r om t he h ea lt h h is t o ry m ay e li ci t su b j e c t i v e d a t a i n d i c a t i n g a h e a l t h p r o b l em , s uc h as d ys pn ea or c he st pa in , as w el l a s in f o rm at io n a bo ut s le ep p at t e rn s, co u g h , a n d s p u t u m . A h i s t o r y o f s m o k i n g in di ca t e s t he n ee d t o in cl ud e w ay s t o s t o p s mo ki ng i n t h e p la n of c ar e. E nv ir on me nt a l e x p o s u r e t o c e r t a i n i n h a l a n t s ( s u c h a s se co nd - ha nd s mo ke , p ai nt , ai r po ll ut io n, or a sb es t o s f ib er s) i n t h e h om e o r wo r k p l a c e m a y i n c r e a s e t h e r i s k o f r e s p i r a t o ry d is ea se s a nd ca nc er . P h ys ic al e xa mi na t i on pr ov id es da t a ab ou t t he b on y s t r u c t u r e s o f t h e t h o r a x , r e s p i r a t o r y e f f o r t , c he st ex pa ns io n, an d br ea t h so un ds .

Health History
I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g:

• • • • • • • • •

H is t o r y o f t r a u m a t o t h e r i b s o r l u n g s u r g e r y N um b e r o f p i l l o w s u s e d w h e n s l e e p i n g H is t o r y o f c h e s t p a i n w i t h d e e p b r e a t h i n g H is t o r y o f p e r s i s t e n t c o u g h w i t h o r w i t h o u t pr od uc in g s pu t u m H is t o r y o f a l l e r g i e s E nv ir o n m e n t a l e x p o s u r e t o c h e m i c a l s , a s b es t o s, o r sm ok e H is t o r y o f s m o k i n g H is t o r y o f l u n g d i s e a s e i n f a m i l y m e m b e r s o r s el f H is t o r y o f f r e q u e n t o r c h r o n i c r e s p i r a t o r y i nf ec t i on s

Figure 25-20. (A) The frontal sinuses are palpated by gently pressing upward on the bony prominences above each eye. (B) The maxillary sinuses are palpated by applying gentle pressure on the bony prominences of the upper cheek. (Photos by B. Proud.)

Figure 25-21. Structures of the mouth.

P . 6 26

Physical Assessment
P hy si ca l as s e s s m e n t o f t h e t h o r a x a n d l u n g s r e q u i r es a st et ho sc op e a nd a t a pe m ea su re . T he e nv ir on me nt sh ou ld be w ar m an d a d e q u a t e l y l i t . T h e t e c h n i q u e s f o r t h i s a s se ss me nt i nc lu de in sp ec t i on , p al pa t i on , p er cu ss io n, an d au sc ul t a t i on . T he p at ie nt s i t s d u r i n g t h e a s s e s s m e n t .

Inspecting the Thorax
B eg in in sp e c t i o n b y o b s e r v i n g t h e p a t i e n t ' s c h e s t f or c ol or , s ha pe o r co nt ou r, br ea t h in g p at t e rn s, an d mu sc le d ev el op me n t . T h e c o l o r s h o u l d b e e v e n a n d c o n s i st en t w it h t h e co lo r of t h e pa t i en t ' s f ac e. T he sh ap e or c on t o ur sh ou ld

h av e a d ow n w a r d e q u a l s l o p e a t t h e r i b c a g e . T h e ch es t s ho ul d be sy mm et ri c, w it h t h e t r an sv er se di am et er gr ea t e r t h an t he a nt er op o s t e r i o r d i a m e t e r . A n i n c r e a s e d a n t e r o p os t e ri or d ia me t e r, a s s ee n in c hr on ic lu ng d is ea se s, is d es cr ib ed as b ar re l- c he st ( F i g . 2 5 - 2 5) . R e s p i r a t i o n s s h o u l d b e s mo ot h an d e ve n, r an gi ng f r om 1 2 t o 20 b re at hs / m in .

Figure 25-22. Structures of the neck.

Figure 25-23. Location of the lymph nodes of the neck.

A bn or ma l f in d i n g s i n c l u d e a n i n c r e a s e i n c h e s t s i z e a nd c on t o ur , a bn or ma l b re at hi ng pa t t er ns w it h u se o f ac ce ss or y m us cl es ( sy m p t o m s o f r e s p i r a t o r y d i s e a s e , s u c h a s ch ro ni c ob st ru ct iv e p ul mo na ry di se as e or as t h ma ), u ne qu al ch es t e xp an si on (m a y o c c u r i n c h e s t t r a u m a o r p n e u m o n i a) , a nd a bn or ma l r es pi ra t i on s.

Palpating the Thorax
P al pa t i on is u s e d t o d e t e c t a r e a s o f s e n s i t i v i t y , c h es t ex pa ns io n d ur in g r es pi ra t i on s, an d vi br at io ns (f re mi t u s) . Us e t he p al ma r s ur f a c e o f t h e h a n d s t o p a l p a t e t h e a n t e r i o r a nd po st er io r t h or ac ic la nd ma rk s (F i g. 2 5- 2 6) i n a se qu en t i al pa t t er n f or t em pe ra t u r e , m o i s t u r e , m u s c u l a r d e v e l o p m e n t , a nd an y t e nd er ne ss or m as se s. T h e sk in s ho ul d b e wa rm a nd dr y, w it h m us cu la r d e v e l o p m e n t s y m m e t r i c , a n d t h e r e s h o u l d be n o t e nd er ne ss or m as se s. A b no rm al f in di ng s m ay b e c oo l or e xc es si ve ly d r y o r m o i s t s k i n , m u s c l e a s y m m e t r y , t e nd er ne ss , a nd m as se s. T he s am e s e q u e n c e i s u s e d t o t e s t f o r t a c t i l e ( v o c al ) f r em it us , c om pa ri ng bi la t e ra l si de s ( F i g. 2 5- 2 7) . F r em it us i s a s ym me t r ic v i b r a t i o n o f t h e c h e s t w a l l t h a t o c c u r s w i t h s pe ak in g. No rm al ly , eq ua l b il at er al m il d vi br at io ns ar e pa lp ab le , a nd ar e lo ud e r i n t h e u p p e r r e g i o n o f t h e l u n g s . T o as se ss f re mi t u s, u se t h e ba ll o f t h e h an d t o pa lp at e ov er t h e po st er io r t ho ra x a nd a s k t h e p a t i e n t t o r e p e a t “ n i n e t y - n i n e ” at e ac h a re a. U ne qu al f r em it us m ay in cr ea se f ro m co ns ol id at io n of l un g t i s su e or t r a p p e d a i r i n ch r o n i c o b s t r u c t i v e p u l m o n a ry di se as e or de cr ea se w it h p ne um ot ho ra x ( ai r in t he lu ng s) . C he s t e xp an s i o n i s d e t e r m i n e d b y p l a c i n g t h e h a n d s ov er t h e po st er io r c he st w al l, w it h t h e f in ge rs a t t h e l ev el o f T 9 o r T 10 . A s k t h e p a t i e n t t o t a k e a d e e p b r e a t h , a n d o b s er ve P . 6 27 t he m ov em e n t o f y o u r t h u m b s . T h e t h o r a x s h o u l d e x pa nd s ym me t r ic al ly (F ig . 25 - 28 ).

Guidelines for Nursing Care 25-6 Palpating the Thyroid Gland

Proud. L is t e n f or t he d ur at io n. N ot e t h e i nt en si t y . p l a c e y o u r h a n ds a ro un d t he p at ie nt 's ne ck . h e a r d o v e r e m p h y s e m a t o u s l u ng t i ss ue . A sk t h e p a t i e n t t o s w a l l o w . Anterior Approach • • • S t a n d i n g f a c i n g t h e p a t i e n t . (B) Using an anterior approach. l i q u i d s . R ep e a t f o r t h e o t h e r s i d e . P l a c e t h e w a r m e d d i a p hr ag m o f t h e st et ho sc op e o ve r t h e t ho ra ci c la nd ma rk s a nd a us cu lt at e b re at h s ou n d s P . l ow i n pi t c h. p l a c e t h e f i n g e rs of y ou r le f t h an d a ro un d t he s t e rn om as t o id mu sc le (S ee F ig ur e B ). an d of l on g d ur at io n. Palpating the thyroid (A) using a posterior approach. a n d p a l p a t e f o r en la rg em en t . h ea rd ov er f lu id o r a s ol id m as s. 2 5 .2 6 ) . an d q ua li t y o f s ou nd s pr od uc ed .Posterior Approach • • • • • S t a n d i n g b e h i n d t h e p a t i e n t . P al p a t e e a c h l o b e o f t h e t h y r o i d b y h a v i n g t h e pa t i en t t ur n t h e he ad sl ig ht ly t ow ar d t he s id e t o be e xa mi ne d. A f l a t t o n e i s h e a r d o v er b on y or we ll -d ev el op ed mu sc le t is su e. R ep e a t f o r t h e o t h e r s i d e . A sk t h e p a t i e n t t o s w a l l o w .) Percussing the Thorax A lt ho ug h n o t u s e d f r e q u e n t l y i n a s s e s s i n g t h e l u n g s .2 6) . A b no rm al p er cu ss io n s ou nd s a re h yp er re s o n a n c e . an d du ll ne ss . o r s o l i d s w i t h i n t h e l un gs . W he n a n or m a l a i r . pi t c h. w it h t h e f i ng er t i ps ov e r t he lo we r ha lf o f t he n e c k a n d t r a ch e a ( s e e F i g u r e A ) . Auscultating Breath Sounds A us cu lt at io n i s u s e d t o d e t e c t a i r f l o w w i t h i n t h e r e sp ir at or y t ra ct . a n d f e e l f o r e n l ar ge me nt of t he g la nd as i t ri se s. 2 5. an d in t e ns it y o f t he s ou nd s. T h e se at ed pa t i en t i s as ke d t o b re at he sl ow ly a nd d ee pl y t hr ou g h t h e m o u t h . br ea t h so un ds re su lt f r o m t h e f re e m o v e m e n t o f a i r i n t o a n d o u t o f a l l p a rt s o f t h e br on ch ia l t re e. . T h is p er cu ss io n t on e i s kn ow n a s r e s o n a n c e . (Photos by B. 6 28 i n t h e s am e s e q u e n t i a l p a t t e r n a s u s e d f o r p a l p a t i on an d p er cu ss io n ( se e F i g. pi t c h. No rm al ly . A sk t h e p a t i e n t t o s w a l l o w . t h en g en t l y d i s p l a c e t h e t r a c h e a w i t h o n e h a n d .f i l l e d l u n g i s p e r c u s s e d . a n d p a l p a t e t h e t h yr oi d w it h t h e ot he r h an d. T h e s ho ul de r ar ea an d an t e ri or an d p os t e ri or t ho ra x a re p er cu ss ed in a s y s t e m a t i c p a t t e r n ( s e e F i g . lo ud . t h e s o un d i s ho ll ow . pe rc us si on ma y be us ed t o de t e rm in e l un g p os it io n an d s iz e an d t o d et ec t t he p r e s e n c e o f a i r . du ra t i on .

A p l e u r a l f r i c t i o n r u b i s a g r a t i ng so un d c au se d by an i nf la me d p le ur a ru bb in g a ga in st t h e ch es t w al l. B r o n c h i a l s o u n d s h e a r d o v e r t h e t r ac he a a re h ig h. t h ey a re m os t of t e n h e a r d o n i n s p i r a t i o n .p it ch ed s o u n d s . wi t h e xp i r at io n b ei ng l on ge r t ha n i ns pi ra t i o n . s we ll in g. W h ee ze s ar e c on t i nu ou s s ou nd s t h at or ig in at e in P .p it ch ed . hi gh . h ea rd be st o ve r t h e b as e of t he l un gs du r i n g i n s p i r a t i o n . T he y ma y be i ns pi ra t o ry or e xp ir at or y a nd a re h i g h. b r e a t h s o u n d s a r e n o t a u d i b l e w i t h o u t a us cu lt at io n. C r a c k l e s a r e f i n e t o c o u r s e c ra ck li ng s ou nd s m ad e as a ir mo ve s t h ro ug h w et s ec re t i on s. w it h in sp ir at i o n e q u a l t o e x p i r a t i o n . O rd in ar il y. o r t u mo rs . b ro nc hi . a nd t r a c h e a .pi t c he d s ou nd h ea rd on i ns pi ra t i on wh en t h er e i s a na rr ow i n g o f t h e u p p e r a i r w a y . S t er t o ro us br ea t h in g i s a ge ne ra l t er m us ed t o r e f e r t o n o i s y .8) v ar y ov er di f f er en t p ar t s o f t he l u n g s . w h i c h i s l o n g e r t h a n e x pi ra t i on . S t r id or is a h ar sh . Thoracic landmarks (A) Anterior. B r o n c h o v e s i c u l a r s o u n d s a r e h ea rd ov er t he ma in st em b ro nc hu s a nd ar e mo de ra t e “ b lo wi ng ” so un ds . No rm al b re at h s ou nd s (T a bl e 2 5. s t r e n u o u s r e s p i r a t i o n s . lo w. C oa r s e c r a c k l e s c a n a l s o b e d oc um en t e d a s rh on ch i. i f p r e s e n t . s u c h a s t h e l a r y nx or t ra ch ea .pi t c he d so un ds . V e s i c u l a r b r e at h so u n d s a re s of t . (B) Posterior. .Figure 25-24. h ar sh s ou nd s. 6 29 s ma ll a ir p as s a g e s t h a t a r e n a r r o w e d b y s e c r e t i o n s .9) . Figure 25-25. m a y b e a u s c u l t a t e d a l o n g w i t h no rm al b re at h s ou nd s (T a bl e 2 5. C r a c k l e s a r e d e s c ri be d a s “f in e” wh en t he y ar e m ad e by a ir pa ss in g t h ro ug h m oi st ur e i n s ma ll a ir p as s a g e s a n d a l v e o l i a n d a s “ c o a r s e ” w h e n t he y ar e m ad e by a ir p as si ng t h ro ug h m oi st ur e in t h e br on ch io le s. I nf an t s o r yo un g c hi ld re n w it h cr ou p of t e n m an if es t s t r id or w he n b r e a t h i n g . Profile and anteroposterior diameter of normal adult chest and barrel chest. A d v en ti ti o u s b re at h so u n d s a re n ot no rm al ly h ea rd in t he l un gs bu t .

The pattern is used for palpation. c on si st en cy . t h e n u r s e w o u l d i n s p e c t B i l l y ' s c he st f or a cc es so ry mu sc le u se a nd au sc ul t a t e hi s lu ng s. a n d w h e ez es ca n be he ar d wi t h ou t a mp li f i ca t i on . and auscultation of the chest.Figure 25-26. t h e 9 . T hi nk b ac k t o B i l l y C o l l i n s . Palpation of the posterior thorax for vocal or tactile fremitus. I f a p ro du ct iv e c ou gh o cc ur s d ur in g as se ss me nt of t he t ho ra x a nd l u n g s . I nc or po ra t i ng kn ow le dg e o f t he s ig ns a nd sy mp t o ms o f a n al le rg ic r e a c t i o n . The examiner uses the palms of the hands to detect vibrations transmitted through the lungs to the chest wall. Posterior (A) and anterior (B) chest—landmarks and systematic sequence of assessment. A lt ho ug h s t e r t o r o u s r e s pi r a t i o n s . n ot in g a ny e vi de nc e o f w h e e z i n g .o l d w h o w a s st un g by a be e. s t r i d o r . Figure 25-27. w h i c h i s c o m m o n l y n o t e d w i t h al le rg ic r ea ct io ns . Normal Age-Related Variations Infant/Child C om mo n t ho r a x a n d l u n g v a r i a t i o n s i n n e w b o r n s a nd c hi ld re n i nc lu de : • • • L ou d e r b r e a t h s o u n d s o n a u s c u l t a t i o n M or e r a p i d r e s p i r a t o r y r a t e ( u n t i l 8 t o 1 0 y e a rs o f ag e) U se o f a b d o m i n a l m u s c l e s d u r i n g r e s p i r a t i o n Older Adult C om mo n t ho r a x a n d l u n g v a r i a t i o n s i n o l d e r a d u l t s i nc lu de : • • • • I nc re a s e d a n t e r o p o s t e r i o r c h e s t d i a m e t e r I nc re a s e i n t h e d o r s a l s p i n a l c u r v e ( k y p h o s i s) D ec r e a s e d t h o r a c i c e x p a n s i o n U se o f a c c e s s o r y m u s c l e s t o e x h a l e . c ra ck le s an d pl eu ra l f ri ct io n r ub s ar e u su a l l y h e a r d o n l y b y a u s c u l t a t i o n w i t h a st et ho sc op e. t h e s p u t u m s h o u l d b e a s s e s s e d f or c ol or .y e a r . percussion. an d a mo un t .

an d a us cu lt at io n. i nc lu di ng sm ok in g. f a t s . w it h t h e p at ie nt s it t i ng or s up in e. 6 30 a re i de nt if ie d . h ig h b l o o d c h o l e s t e r o l l e v e l s . I f t he se r is ks P . A ss es sm en t s a r e d o n e b y i n s p e c t i o n a n d p a l p a t i o n . As the patient inhales. o r c he st o r he ar t s ur ge ry F am i l y h i s t o r y o f h y p e r t e n s i o n ( h i g h b l o o d p re ss ur e) . D at a ca n al so be u se d t o i de nt if y a ct i v i t i e s o f d a i l y l i v i n g a n d h e a l t h b e h a v i o rs t h at i nc re as e t he r is k of c ar di ov as cu la r d is ea se .Assessing the Cardiovascular and Peripheral Vascular Systems C ar di ov as cu l a r a n d p e r i p h e r a l v a s c u l a r a s s e s s m e n t i nc lu de s t h e h ea rt a nd t h e ex t r em it ie s. T h e p h y s i c a l e x a m i n a t i o n i s u s ed t o i de nt if y si gn s a nd s ym pt om s of pe ri ph er al va sc ul ar d is ea se an d h ea rt di se as e . m yo ca rd ia l in f a rc t i on (h ea rt at t a ck ). r h e u m a t i c f e v e r .) Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • • • • • • • • • H is t o r y o f c h e s t p a i n . The examiner's hands are placed symmetrically on the patient's back (A). Q u es t i on s in t he he al t h h i s t o ry c an i d e n t i f y s u b j e c t i v e d a t a s u c h a s l e g p a i n. Figure 25-28. p a l p i t a t i o n s . l ac k of e xe rc i s e . (Photos by B. the examiner's hands should move apart symmetrically (B). P er ip he ra l v as cu la r a ss es sm en t s m ay b e c om b i n e d w i t h a s s e s s m e n t o f o t h e r b o d y a r ea s. o r dy sp ne a o n ex er t i on . t h e p l a n o f c a r e s h o u l d i n c l u d e r e f e r ra l f o r a dd it io na l d ia gn os t i c t e st in g a nd t ea ch in g a bo ut he al t h p ro mo t i on a c t i v i t i e s . A st et ho sc op e w it h a b el l an d d ia p h r a g m a n d a s p h y g m o m a n o m e t e r a r e u se d. o r d i a b e t e s m el li t u s H is t o r y o f s m o k i n g H is t o r y o f a l c o h o l u s e T yp e a n d a m o u n t o f e x e r c i s e U su a l f o o d s e a t e n e a c h d a y C ha n g e s i n c o l o r o r t e m p e r a t u r e o f t h e e x t r e mi t i es H is t o r y o f p a i n i n t h e l e g s w h e n s l e e p i n g o r p ai n t ha t is w or se ne d b y wa lk in g H is t o r y o f b l o o d c l o t s o r s o r e s o n t h e l e g s t h at d o no t h ea l Physical Assessment P er ip he ra l v a s c u l a r a s s e s s m e n t i n c l u d e s m e a s u r i n g t he b lo od pr es su re a nd as se ss in g pe ri ph er al pu ls es an d pe rf us io n. T h e pa t i en t m ay b e in a si t t in g po si t i on or i n a su pi ne po si t i on . c or on ar y a rt er y di se as e. a n d a d i e t h i g h i n c a l o r i e s . Proud. Palpating the posterior thorax excursion. T he t ec hn iq u e s u s e d f o r c a r d i o v a s c u l a r a s s e s s m e n t i nc lu de i ns pe ct io n. pa lp at io n. o r d i z z i ne ss S we l l i n g i n t h e a n k l e s a n d f e e t N um b e r o f p i l l o w s u s e d t o s l e e p T yp e a n d a m o u n t o f m e d i c a t i o n s t a k e n d a i l y H is t o r y o f h e a r t d e f e c t . a nd sa lt . ch es t pa in .

30 ) f o r v i s ib le p ul sa t i o n s . A qu ie t e nv ir on me nt i s n e c e s s a r y f o r a c c u r a t e a u s c u l t a t i o n of h ea rt s ou nd s. F i n d i n g s o f n e c k v e i n d i s t e n t i o n ( in di ca t i ng he ar t di se as e) or v is ib le p ul sa t i on s i n pr ec or di al ar ea s o t h er t ha n t he a pi c a l i m p u l s e ( w h i c h m a y r e s u l t f r o m a b n or ma li t i es of t he v en t r ic le ) a re c on si de re d a bn or ma l. wh ic h in vo lv e a r i s e al on g t h e b o r d e r o f t h e s t e r n u m w i t h e a c h h e a r t b ea t . an d E rb 's p oi nt . in cl ud in g t h e h ea rt v al ve s r es po ns ib le f o r he ar t so un ds . Table 25-8 Normal Breath Sounds Type. p al pa b l e . a nd a ny li f t s or h ea ve s. auscultated over the trachea Expiration is longer. N ot e si ze . P a l p a t i o n p ro ce ed s i n a sy st em at ic m an ne r. A d e q u a t e l i gh t i ng i s es se nt ia l f or i ns pe ct io n o f co lo r an d p ul sa t i on s. No rm al f in di ng s i nc lu de n o p ul sa t i on p al pa bl e o ve r t he a or t i c a nd pu lm on i c a r e a s . P al pa t e t h e ap ic al im pu ls e in t he mi t r al a re a. R em em be r t h a t h a n d s s h o u l d b e w a r m . wi t h a ss es sm en t o f sp ec if ic c ar di ac P . Neck and Precordium Inspecting the Neck and Precordium O bs er ve t h e n e c k a n d p r e c o r d i u m ( t h e a o r t i c . lower. p u l mo ni c. Description. and higher-pitched than inspiration Bronchovesicular . and Location Bronchial or Tubular Ratio of Inspiration to Expiration Blowing. f o r c e . r u s h i n g v i b r a t i o n s o v e r t h e r i g h t o r le f t s ec on d i nt er co st al s pa ce . l oc at ed at a bo ut t he f o ur t h o r f i f t h i nt er co st al s p a c e a t t h e l e f t m i d c l a v i c u l a r l i n e .2 9 f o r a v i e w o f t h e he ar t . F ig . 25 . 6 31 l an dm ar ks — t h e a o r t i c . T h e nu rs e i s us ua ll y po si t i on ed at t he ri gh t si de o f t he p at ie nt . p u l m o n i c . a nd a pi ca l a re as . p al pa t e t h e p re co rd iu m ge nt ly f o r pu ls at io ns (F ig .w it h t h e h ea d r a i s e d a b o u t 3 0 d e g r e e s . w hi ch ar e f i n e. a n d l o c a t i o n i n r e l a t i o n sh ip t o t he mi dc la vi cu la r li ne . Palpating the Precordium U si ng t he pa l m a r s u r f a c e w i t h t h e f o u r f i n g e r s h e l d t og et he r. I de nt if y an y pr ec or di al t h ri ll s. t r i c u s p i d . d u r a t i o n . w i t h a p a l p a b l e a p i c a l i m p u l s e. T h e r e a r e u s u a l l y n o v i s i b l e p u l sa t i on s.31 ). 25 . R e f e r t o F i g u r e 2 5 . hollow sounds. I n s p ec t t h e e pi ga st ri c ar ea at t he t ip of t he s t e rn um f o r pu ls at io n o f t h e a bd om in al a o r t a . t ri cu sp id . a n d m i t ra l ar ea s a nd E rb 's po in t . ex ce pt t h e ap ic al i mp ul se .

C on s i de r T a m m y B r o w n i n g . auscultated over the first and second interspaces anteriorly and the scapula posteriorly Vesicular Inspiration and expiration have similar pitch and duration Soft. Us e sy st em at ic a us cu lt at io n. medium intensity. 2 5 .5 ) . t h e p r e g n a n t w o m a n d e sc ri be d i n t h e R ef le ct iv e P r ac t i ce di sp la y. T he s t e t h os co pe di ap hr ag m i s f i rs t us ed t o l is t e n t o h i g h. t he n t o E rb 's po in t . m o v i n g t o t h e p u l m o n i c ar ea . F oc us o n t he o ve ra ll ra t e a nd r hy t h m o f t he h ea rt an d t h e n o r m a l h e a r t s o u n d s (B o x 2 5 .Medium-pitched. low-pitched sounds.3 0 ) . b eg in ni ng at t h e a o r t i c a r e a .p it ch ed s o u n d s . and higher-pitched than expiration Auscultating Heart Sounds A us cu lt at io n i s u s e d t o d e t e r m i n e t h e h e a r t s o u n d s ca us ed by c lo su re o f t h e h ea rt v al ve s. I n ad di t i on t o c om pl et in g a h ea lt h a ss es s m e n t f o r T a m m y .pi t c he d so un ds . Table 25-9 Abnormal Breath Sounds Type and Characteristics Wheeze (Sibilant) • • • • Illustration Musical or squeaking High-pitched. auscultated over the lung periphery Inspiration is longer. t h e n u r s e w o u l d n e e d t o au sc ul t a t e f e t a l he ar t s ou nd s t o a ss es s f et al s t a t u s. continuous sounds Auscultated during inspiration and expiration Occurs in small air passages . blowing sounds. f o l l o w e d b y u s e o f t h e b e l l t o l is t e n t o lo w. a nd f i na ll y t o t he m it ra l a r e a (F i g . t he n t o t h e t r ic us pi d a re a. A s k t h e p a t i e n t t o b r e at he no rm al ly . louder.

Figure 25-30. crackling. bronchi. and trachea Friction Rub • • • Rubbing or grating Loudest over lower lateral anterior surface Auscultated during inspiration and expiration Figure 25-29. P .to high-pitched. 6 32 . popping Low. Traditional cardiac landmarks and areas for auscultation. continuous sounds Auscultated during inspiration and expiration Coughing may clear the sound Crackles • • • • Bubbling.Wheeze (Sonorous) • • • • Sonorous or course Low-pitched. bronchioles. View of the interior of the heart showing the atrioventricular and semilunar valves responsible for normal heart sounds. discontinuous sounds Auscultated during inspiration Occurs in small air passages. alveoli.

r a d i a l . (B) pulmonic area. 2 4. d or sa li s pe di s. a nd ha ir le ss . Figure 25-31.3 i n Ch ap . f e mo ra l. P hl eb it is (i n f l a m m a t i o n o f a v e i n ) o f t h e l o w e r e x t r em it y is i nd ic at ed by p ai n. sh in y wi t h br ow n di sc ol or at io ns . ra sh es . B u e r g e r ' s t e s t . T h e s k i n o f t h e p a t i en t w it h pe ri ph er al va sc ul ar di se as e (r es ul t i ng in d ec re as ed bl oo d f l o w an d o xy g e n a t i o n o f t i s s u e s ) i s t y p i c a l l y p a l e a nd co ol . re dn es s. a nd sw el li ng o f t he a f f ec t e d c al f or t hi gh . t h e c a r o t i d b r a c h i a l . u lc er s. T h e r e ar e n or ma ll y no ve no us p at t e rn s. va ri co si t i es . Palpating areas of the precordium: (A) aortic area. c on t i nu it y. T h e s e s h o u l d b e s t r o n g a n d e q ua l bi la t e ra ll y. 6 33 b l o od f l ow i n c l u d e A l l e n ' s t e s t . o r e de ma on t h e l o w e r e x t r e m i t i e s . P al pa t e . a n d ca pi ll ar y r ef il l (s ee G ui de li ne s f or N ur si ng Ca re 2 5. an d po st er io r t ib ia l pu ls es (s ee F ig . t e m p e ra t u re . 2 4) . a f or ce f u l o r b ou nd in g p u l s e ( s e e n i n h y p e r t e n s i o n a n d c i r c u l a t or y o ve rl oa d) . an d t he t oe na il s a re t hi ck en e d . w e a k . T h e am pl it ud e o f t h e p ul se s ma y be do cu me nt ed as 0 ( ab se nt ). a n d e d e m a . p op li t e al . A bn or ma l f in d i n g s i n c l u d e a n a b s e n t . on e a t a t i m e an d w it h c a u t i o n . Palpating Peripheral Pulses U se t he pa d s o f t h e i n d e x a n d m i d d l e f i n g e r s t o p a l pa t e pe ri ph er al pu ls es f or a mp li t u de an d s ym me t r y. 2 + ( n o r m a l ) .7) . and (C) apical (mitral) and tricuspid area. 3 + ( i n c r e a s e d ) . (Photos © Ken Kasper. l es io ns (a s de sc ri be d p re vi ou sl y f o r a ss es sm en t of t he i nt eg um e n t ) .Peripheral Vascular System Inspecting the Extremities I ns pe ct t h e s k i n o f t h e e x t r e m i t i e s f o r c o l o r . 1+ ( w e a k ) . o r 4+ ( bo un di ng ). t h r e a d y pu ls e ( wh ic h ma y in di ca t e a de cr ea se d c ar di ac o ut pu t ) . v e n o u s p a t t e r n s . an d a n as ym me t r ic pu ls e (r el at ed t o i mp ai re d c i r cu la t i on ). O t h e r s p e c i f i c a s s e s s m e n t s t o d e t e r m i ne ar t e ri al P .) Normal Age-Related Variations Infant/Child C om mo n c a r d i o v a s c u l a r a n d p e r i p h e r a l v a s c u l a r v ar ia t i on s in n ew bo rn s a nd ch il dr en i nc lu de : .

e s p e c i a l l y i n f em al es . W h e n s i t t i n g .p a l p a t e d i s t a l a r t e r i e s D il at e d p r o x i m a l a r t e r i e s M or e p r o m i n e n t a n d t o r t u o u s b l o o d v e s s e l s . t he p at ie nt sh ou l d h a v e f u r t h e r d i a g n o s t i c t e s t s . is h ea rd as t he “ lu b” of “ lu b.p a l p a t e a p i c a l p u l s e D if f i c u l t .3 2) . P h ys ic al as se ss me nt o f t he b re as t s a nd ax il la a re pr im ar il y c on du ct ed t o i d e n t i f y a n y l u m p s i n t h e b r e a s t s a n d / o r e nl ar ge me nt or p ai n i n ax il la ry l ym ph no de s. W h en s up in e. ” T hi s so un d oc cu rs wh en t he mi t r al a nd t r ic us pi d v a l v e s c l o se a n d c o r r e s p o n d s t o t h e o ns et o f ve nt ri cu la r c on t r ac t i on (s ee f ig ur e ). t h e f i r s t h e a r t s o u n d . t h e p at ie nt 's ha n d o n t h e s i d e b e i n g e x a m i n e d i s p l a c ed un de r t he h ea d. t h e p a t i e n t s h o u l d s it e re ct . T he pa t i en t is i n t h e s it t i ng o r s up in e p os it i o n . b e n z e n e . i n c l u d in g r el at io ns hi p t o me ns t r ua l pe ri od H is t o r y o f l u m p s o r s w e l l i n g . o r s u r g e ry M en s t r u a l a n d p r e g n a n c y h i s t o r y U se o f h o r m o n e s . E ac h b r e a s t h a s a l y m p h a t i c n e t w o r k t h a t dr ai ns in t o t he un de rl yi ng ax il la (F i g. BOX 25-5: Heart and Cardiovascular Sounds Normal Heart Sounds D ur in g a us c u l t a t i o n . o r di mp li ng in t he br ea st s H is t o r y o f d i s c h a r g e f r o m t h e b r e a s t F am i l y h i s t o r y o f o v a r i a n o r b r e a s t c a n c e r H is t o r y o f b r e a s t d i s e a s e .• • • • V is ib l e p u l s a t i o n i f t h e c h e s t w a l l i s t h i n S in u s d y s r h y t h m i a ( t h e r a t e i n c r e a s e s w i t h i ns pi ra t i on a nd de cr ea se s w it h ex pi ra t i on ) P re s e n c e o f S 3 ( i n a b o u t o n e t h i r d o f a l l c h il dr en ) M or e r a p i d h e a r t r a t e ( u n t i l a b o u t 8 y e a r s o f ag e) Older Adult C om mo n c a r d i o v a s c u l a r a n d p e r i p h e r a l v a s c u l a r v ar ia t i on s in o ld er ad ul t s i nc lu de : • • • • • • D if f i c u l t . b i o p s y .t o . T h e he al t h hi st or y el ic it s r i s k f a ct or s f o r c a n c e r o f t h e b r e a s t . c h a n ge in s iz e. o r a s b e s t o s U su a l d i e t a r y i n t a k e a n d a l c o h o l c o n s u m p t i on K no w l e d g e a n d p r a c t i c e o f b r e a s t s e l f . o r a l c o n t r a c e p t i v e s . c a l l e d S 1 . r e d n e s s . wi t h a rm s at si de s or r ai se d o ve rh ea d. 3 5) M os t r e c e n t c l i n i c a l b r e a s t e x a m i n a t i o n a n d ma mm og ra m Physical Assessment T he b re as t s a n d a x i l l a a r e a s s e s s e d i n b o t h m e n a nd w om en by i ns pe ct io n a nd p al pa t i on .t o . Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • • • • • • • H is t o r y o f p a i n i n o n e o r b o t h b r e a s t s . o r a nt id ep re ss an t s E xp o s u r e t o r a d i a t i o n . l ow -p it ch ed . i f as se ss ed .du b.e x a m in at io n ( se e Ch ap . v ar ic os it ie s c om mo n I nc re a s e d s y s t o l i c a n d d i a s t o l i c b l o o d p r e s s ur e W id e n i n g p u l s e p r e s s u r e Assessing the Breasts and Axillae A lt ho ug h t he a s s e s s m e n t s a n d d i s o r d e r s d e s c r i b e d he re f oc us on t he f em al e b re as t . 2 5. T he s ou nd . m en al so a re a t r is k f o r br ea st d i s ea se .

Abnormal Heart Sounds A bn or ma l f in d i n g s i n c l u d e e x t r a h e a r t s o u n d s a t a ny o f t h e c ar di ac l an dm ar ks an d ab no rm al ra t e o r r hy t h m. S 3 and S 4 S 3 . r e p r e s e n t e d b y “ d e e .ag ed an d o ld er a du lt s. T h e s e c on d he ar t s ou nd . E xt ra h ea rt so un ds m ay b e S 3 . an d h ea d t r au ma . Heart sounds in relation to the cardiac cycle and an electrocardiogram. T h e c ha ra ct er is t i cs o f a m ur mu r de p e n d o n t h e a d e q u a c y o f v a l v e f u n c t i o n . t hi s so un d i s be st h ea rd wi t h t h e s t e t h o s c o p e b e l l a t t h e m i t r a l a r e a . i s o f t e n r e p r e s e nt ed by a “l ub -d ub -d ee ” p at t e rn (“ de e” b ei ng S 3 ). A wi de v ar ie t y of c on di t i on s m ay a lt er t he no rm al h ea rt ra t e o r r h y t h m . i n c l u d i n g s e r i o u s i n f e c t i o n s . S 4 is t he f ou r t h h e a r t s o u n d . r e s p i r a t o r y d i s or de rs . an d si ze o f t h e v al ve o pe ni ng . ” S 4 i s co ns id er ed no rm al in o ld er a du lt s b ut a bn or ma l i n c hi ld re n a nd a d u l t s .du b.l ub -d ub . d ep en di ng o n t h e h e a r t r a t e . m ur mu rs . ra t e of b lo od f lo w. S 2 . ” it r ep re se nt s t he cl os ur e of t he ao rt ic a nd p ul mo ni c v a l v e s . T h e s o u n d o f S 2 i s h i g h e r p i t c h e d a nd sh or t e r t h an S 1 . o cc ur s at t h e t e rm in at io n o f sy st ol e an d c or re sp on ds t o t h e o n s e t o f v e n t r i c u l a r d i a s t o l e . N or ma l f i nd i n g s i n c l u d e S 1 t h a t i s l o u d e r a t t h e t r i c us pi d an d a pi ca l ar ea s. is h e a r d b e s t a t t h e a p i c a l a r e a . di se as es of t he he ar t mu sc le o r c on du ct in g s ys t e m.a nd du ll . w it h t h e pa t i en t l yi ng o n t he l ef t si de . T h e t w o s ou nd s oc cu r w it hi n 1 se co nd or l es s. wi t h S 2 lo ud er at t he a or t i c a nd p ul mo ni c a re as . S 4 . e n d o c r i n e d i s o r d e r s . G ra di ng of h ea rt m ur mu rs : Grade Description I II III IV V A murmur so faint that it can be heard only with great effort A faint murmur but one that can be easily detected A moderately loud murmur A very loud murmur that is usually associated with a thrill sound An extremely loud murmur . Murmurs H ea rt m ur mu r s a r e e x t r a h e a r t s o u n d s c a u s e d b y s om e d is ru pt io n o f bl oo d f l ow t h ro ug h t h e h ea rt . E xt ra h ea rt s ou nd s a re o f t e n h e a r d w h e n t h e p a t i e n t h a s a n e mi a o r he ar t di se as e. d eh yd ra t i on or o ve rh yd ra t i o n . o r br ui t s . k no wn a s t h e t h i r d h e a r t s o u n d . S 3 i s co ns id er ed no rm al in c hi ld re n a nd y o u n g a d u l t s a n d a b n o r m a l i n m i d d l e . T he “ du b” o f “ lu b.

VI An exceptionally loud murmur that can be heard while the stethoscope is lifted off the skin Bruits B ru i t s . 6 35 . ra t h er t ha n f lo w no rm al ly . No rm al ly . P . o b s e r v e t h e t i m e f o r r e t u r n o f c o l or . t h e a b d o mi na l a or t a . Buerger's Test • • • A sk t h e p a t i e n t t o a s s u m e a s u p i n e p o s i t i o n an d t he n ra is e o ne a rm o r on e l eg a bo ut 1 f o ot ( 30 cm ) ab ov e t h e l ev el o f h i s o r h e r h e a r t . A sk t h e p a t i e n t t o b r i s k l y m o v e t h e l e g o r a rm u p an d d ow n f o r 1 mi nu t e . A ss e s s c a p i l l a r y r e f i l l i n c h i l d r e n b y p r e s s i ng t h e sk in l ig ht ly o ve r t he f or eh ea d o r t o p o f t h e ha nd . Capillary Refill • • • U si n g y o u r t h u m b a n d f o r e f i n g e r . R el e a s e y o u r t h u m b p r e s s u r e a n d o b s e r v e t h e r et ur n of c ol or t o t he p al m ( t h is s ho ul d no rm al ly t a ke 3 t o 5 s ec o n d s ) . N or ma ll y. co lo r re t u rn s i mm ed ia t e ly . a r e “ s w o o s h i n g” s ou nd s s im il ar t o mu rm ur s a nd a re he ar d ov er ma jo r bl oo d v es se ls . U se y o u r t h u m b s t o o c c l u d e t h e r a d i a l a n d ul na r a rt er ie s an d a sk t he p at ie nt t o o pe n h is o r he r ha nd (t he p al m w il l b e pa l e ) . a n d v e i n s f i l l i n 1 5 se co nd s. w hi c h a r e a b n o r m a l s o u n d s . s q u e e z e t he pa t i en t ' s f in ge rn ai l o r t o en ai l un t i l i t ap pe ar s w hi t e . R el e a s e t h e p r e s s u r e a n d o b s e r v e t h e t i m e it t ak es f o r no rm al c ol or t o r et ur n. c a u s in g b lo od t o s wi rl . t he n t o si t up a nd d an gl e t he ar m or l eg d ow n w a r d . a nd t he f e mo ra l ar t e ri es . R el ea se t he p re ss u r e . O bs e r v e t h e t i m e i t t a k e s f o r t h e o r i g i n a l c ol or o f t h e pa t i en t ' s s ki n t o re t u rn a nd f o r t h e ve in s t o f i ll . T he s ou nd i n d i c a t e s a p a r t i a l l y b l o c k e d a r t e r y . 6 34 P . B ru it s ar e mo st c om mo nl y h e a r d o v e r t h e c a r o t i d a r t e r i e s . Guidelines for Nursing Care 25-7 Assessing Peripheral Circulation Allen's Test • • • A sk t h e p a t i e n t t o r e s t h i s o r h e r h a n d o n t he e xa mi ni ng t a bl e w it h t h e pa lm up a nd t o m ak e a f i st . c ol or r e t u r n s i n 1 0 s e c o n d s .

I f a m as s is d et e c t e d . co ns is t e nc y.3 4 ) . T h e b r e a s t t i ss ue sh ou ld b e s mo ot h an d f ir m. I f an y n od es a re pa lp ab le . T he co lo r sh ou ld be c on si st en t w it h t he r es t o f t h e s k i n . s ha pe . D i s c h a r g e . M on t g om er y' s t ub er cl es (s eb ac eo us gl an ds o n t he a re ol ae o f t h e b r e a s t s ) a r e a n o r m a l c o m p o n e nt of t he ar eo la . wi t h a sm oo t h s ur f a ce . c ru st in g. Lateral view of the female breast. A n in cr ea se i n t h e n o d u l a r i t y a n d t e n d e r n e s s o f t h e b re as t s ma y be a ss oc ia t e d w it h t h e m en st ru al p er io d o r ma y in di ca t e f i b ro cy st ic d i s e a s e . c on s i s t e n c y . as ym me t r y. P a l p ab le ly mp h no de s a re a n a bn or ma l f in di ng . T he ar eo la r an d n i p pl e a re as s h o u l d b e eq u a l i n s i z e . s h a p e . 6 36 n od es (F ig .8 p ro vi de s i n s t r u c t i o n s f o r p a l p a t i o n . s y m m e t r y . P a lp at e t h e n ip pl e an d a re ol a a nd g en t l y c om pr es s t h e ni pp le be t w ee n t he t hu mb a n d f o r e f i n g e r t o a s s e s s f o r d i s c h a r g e . s iz e. T h e s i z e va ri es am on g in di vi du al s. . Palpating the Breasts and Axillae P al pa t e t h e b r e a s t t o d e t e c t a n y a b n o r m a l l u m p s . d i mp li ng . t h e u p p e r i n n e r q u a d r a n t . an d t h e r e s h o u l d b e n o s k i n d e p r e s s i o n s ( re t r ac t i on ) o r pu ck er in g ( di mp li ng ). Figure 25-32. G u id el in es f o r Nu rs in g C ar e 2 5. I ns pe ct t h e a r e o l a a n d n i p p l e s f o r s i z e a n d s h a p e a nd t h e ni pp le s f or d is ch ar ge . an d t en de rn es s. a nd t h e lo we r i nn er q ua dr an t (F i g. T h e sh ap e o f t h e b re as t s i s ro un d a nd s mo ot h. a nd sk in l es io ns . c a r e f u l l y a s s e s s i t s l o c a t i o n .Inspecting the Breasts I ns pe ct t h e b r e a s t s f o r s i z e . r o u n d o r o v a l . a ss es s t h ei r lo ca t i on . P a l p a t e t h e a x i l l a r y a r e a s f o r l y m p h P . a l t h o u g h v a r i a t i o n s a r e n o r m a l . l u m p s . a n d t h e t e x t u r e o f t h e s k i n s h o u ld be s of t . a n d m o b i l i t y . an d pa lp ab le ly mp h no de s m ay b e i nd ic at iv e of b re as t c an c e r . D is ch ar ge f r om t he n i p pl es is a n a b n o r m a l f i n d i n g e x c e p t i n p r e g n a n c y (l ea ki ng is n or ma l du ri ng pr eg na nc y a nd br ea st f e ed in g) . l e s i o n s . a nd in ve rs io n. t e xt ur e. T h e n ip pl es a re no rm al ly e ve rt ed .3 3) . w h i c h n o r m a l l y a r e n o n p a l p a b l e a nd n on t e nd er . s i z e. l e s i o n s . T he b re as t s s ho ul d b e re la t i ve ly s ym me t r ic . T he b re as t i s as se ss ed i n f o ur qu ad ra nt s: t h e up pe r o ut er q ua dr an t . O t h er a bn or ma l f in d i n g s i n c l u d e t h e d i m p l i n g . s ha pe . T h e br ea st s ar e n or ma ll y t en de r d ur in g t h e w e e k b e f o r e m e n s t r u a t i o n . a n d as ym me t r y. t e n d e r n e s s . c o l or . 2 5. w it h a gr an ul ar co ns is t e nc y. t h e l ow er o ut er q u a d r a n t . 2 5 .

p e n d u l o u s b r e a s t s i n w o m e n Assessing the Abdomen T he a bd om i n a l c a v i t y (F i g . t h e k i d n e y s . A l t h ou gh t h e l i v er i s no t n o r m a l l y p a l p a b l e . Normal Age-Related Variations Infant/Child C om mo n b re a s t a n d a x i l l a e v a r i a t i o n s i n n e w b o r n s an d ch il dr en in cl ud e: • • • B re a s t e n l a r g e m e n t a n d a w h i t e d i s c h a r g e f ro m t he n ip pl es (u p t o 2 w ee ks of a ge ) F em a l e b r e a s t g r o w t h b e g i n n i n g a t 1 0 o r 1 1 ye ar s of a ge T em p o r a r y e n l a r g e m e n t o f o n e o r b o t h b r e as t s (g yn ec om as t i a) in p ub es ce nt bo ys Older Adult C om mo n b re a s t a n d a x i l l a e v a r i a t i o n s i n o l d e r a d u l t s in cl ud e: • G ra n u l a r . so i t is n ot i nc lu de d i n t h i s d is cu s s i o n . a nd t o c ol le ct d at a a bo ut t h e pa t i e n t ' s e l i m i n a t i o n p a t t e r n s . a n d t h e u r i n ar y bl ad de r. t he p an cr ea s . P hy si ca l ex am in at io n i s co nd uc t e d t o f ur t h er as se s s p r o b l e m s w i t h p a i n a n d t o i d e n t i f y a n y a bd om in al ma ss es . t h e sm al l in t e st in e. Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • H is t o r y o f a b d o m i n a l p a i n H is t o r y o f i n d i g e s t i o n . t h e s p l e e n .Figure 25-33. T he s pl ee n i s ra r e l y p a l p a b l e a n d a s s e s s m e n t r e q u i r e s d ee p p al pa t i on (r eq ui ri ng m or e a dv an ce d s ki ll s) .3 5 ) c o n t a i n s t h e s t o m ac h. No t al l o f t h es e or ga ns ca n be as se ss ed . t h e ga ll bl ad de r. t h e t e c h n i q u e f o r a s s es si ng i t is i nc lu de d b ec au se ab no rm al f i nd in gs a re im po rt an t . a f t e r s u r ge ry ) a nd r et en t i on of u ri ne in t he u ri na ry bl ad de r. 2 5 . in cl ud in g a bd om in al pa in an d na us ea . f l u i d a n d n ut ri t i on al in t a ke . A b do mi na l a ss es sm en t s ar e al so u se d t o as se ss t he r et ur n o f b o w e l s o u n d s ( f o r e x a m p l e . di sc us se d i n t h e f o ll ow in g s ec t i on . H ea lt h h is t o r y q u e s t i o n s a r e u s e d t o i d e n t i f y s u b j e c t i ve da t a . n a u s e a o r v o m i t i n g . T h e a b d o m i n a l c a v i t y a l s o c o n t ai ns t h e f e ma le r ep ro du ct iv e o rg an s. t h e la rg e i nt es t i ne . co ns t i pa t i on or d ia rr he a H is t o r y o f f o o d a l l e r g i e s o r l a c t o s e i n t o l e r a nc e A pp e t i t e a n d u s u a l f o o d a n d f l u i d i n t a k e U su a l b o w e l a n d b l a d d e r e l i m i n a t i o n p a t t e r ns . t h e l iv er . Location of assessment findings of the breast are identified by quadrant. a nd l if es t y le .

ga ll bl ad de r di se as e. T o lo ca t e or g a n s m o r e e a s i l y a n d t o m a k e d o c u m e n t a t i on mo re sp ec if ic . Guidelines for Nursing Care 25-8 Palpating the Breasts P al pa t e ea c h q u a d r a n t o f e a c h b r e a s t i n a s y s t e m a t i c me t h od . a n d w a r m h an ds w it h s ho rt f in ge rn ai ls ar e ne ed ed t o a ss es s t h e a bd om en . Figure A.co un t e r me di ca t i on s u se d A mo u n t a n d t y p e o f a l c o h o l i n g e s t i o n F or w o m e n . a u s c u l t a t i o n . A s k t h e p a t i e n t t o i de nt if y pa in f u l a re as of t he P . a s we ll a s t h e p o s i t i o n . S ma ll pi ll ow s ma y be p la ce d u nd er t h e he ad an d k ne es . t h e ab do me n c an be d iv id ed in t o f ou r qu ad ra nt s: r i g ht u pp er . s u c h as p ep t i c ul ce r d is ea se . . 25 . h e l p p r e v e n t c o n t r a c t i o n o f t h e ab do mi na l m us cl es . w ed ge . Ma ke su re t ha t t h e p at ie nt i s wa rm a nd co mf or t a bl e. or k id ne y d is ea se H is t o r y o f a b d o m i n a l s u r g e r y o r t r a u m a T yp e a n d a m o u n t o f p r e s c r i b e d a n d o v e r . A s k t h e p at ie nt t o b re at he sl ow ly a nd d ee pl y t hr ou gh t h e mo ut h d ur in g t h e e xa mi na t i on t o p r o m o t e r e l a x a t i o n . T h es e me as ur es . Wedge • • W or k i n a c l o c k w i s e d i r e c t i o n a n d p a l p a t e f r om t he p er ip he ry t o wa rd t h e ar eo la (F ig ur e B ). 6 37 a bd om en an d e x p l a i n y o u w i l l a s s e s s t h e s e a t t h e en d of t h e ex am in at io n.• • • • • • H is t o r y o f g a s t r o i n t e s t i n a l d i s o r d e r s . r i g h t l o w e r . m e n s t r u a l h i s t o r y Physical Assessment A w ar m st et h o s c o p e . a n d p a l p a t i on . e it he r t h e c ir cu la r. P er cu ss io n a nd p al pa t i on st im ul at e b ow el s ou nd s a nd t h us a re d on e a f t er a u s c u l t a t i o n o f t h e a b d o m e n . T he s eq ue nc e o f t ec hn iq ue s u se d t o a ss es s t he a bd om en i s in sp ec t i on . p e r c u s s i o n . T he p a t i e n t s h o u l d h a v e a n e m p t y b l a d d e r . T he p at ie nt sh ou l d b e s u p i n e w i t h a s m a l l p i l l o w o r t o w e l b en ea t h he r ba ck . U se t h e p a d s o f t h e f i r s t t h r e e f i n g e r s t o g e n t l y co mp re ss t h e br ea st t i ss ue a ga in st t h e ch es t wa ll . l e f t u p p e r . wh ic h m ak es p al pa t i on di f f ic ul t . bo we l d is ea se . o r a p p e n d i c i t i s H is t o r y o f u r i n a r y t r a c t d i s o r d e r s . l iv er d is ea s e . ki dn ey s t o ne s. s u c h a s i nf ec t i on s. Circular technique. a d e q u a t e l i g h t i n g . Circular • • S t a rt a t t h e t a i l o f S p e n c e a n d m o v e i n i n c r ea si ng sm al le r ci rc le s (F ig ur e A ). U se t h e p a d s o f t h e f i r s t t h r e e f i n g e r s t o g e n t l y co mp re ss t h e br ea st t i ss ue a ga in st t h e ch es t wa ll .t h e . a n d l e f t l o w e r (F ig .36 ). T he p at ie nt li es s u p i n e w i t h t h e h e a d s l i g h t l y e l e v a t e d a nd a rm s a t t h e si de s. o r ve rt ic al s t r ip t ec hn iq ue .

o f t en t h e re su lt o f s ki n st re t c hi ng f r o m we ig ht g a i n o r p r e g n a n c y . Wedge technique. P . Vertical strip technique. p ul sa t i on s. a nd il ia c ar t e ri es f or b ru it s. T he y ar e h ea rd as c li c k s a n d g u r g l e s a n d u s u a l l y o c c u r e v e r y 5 t o 20 s ec on ds . A us cu lt at io n i s pe rf or me d in a sy st em at ic m an ne r. Us in g t h e be ll of t he s t e t h os co pe . an d ma ss es . T h e s t e t h o s c op e i s wa rm ed . . T h e s ki n co lo r ma y be s l i gh t l y li gh t e r t h a n e x p o s e d a r e a s . a s s e ss in g a ll f ou r qu ad ra nt s s ys t e ma t i ca ll y. A b n o r m a l f i n d i n g s i n c l u d e s we ll in g o f t h e ab do me n ( in di ca t i ng f l ui d r et en t i on c al le d a sc it es ) an d a bd om in al m a s s e s o r u n u s u a l p u l s a t i o n s . T h e a bd om en sh o u l d b e e v e n l y r o u n d e d o r s y m m e t r i c . an u pp er mi dl in e pu ls at io n m ay n or ma ll y b e v i s i b l e . an d t he f la t di ap hr ag m i s pl ac ed li gh t l y on t he ab do me n i n on e o f t h e s e l e c t e d q u a d r a n t s . 6 38 M ov e t h e s t e t h o s c o p e i n a c l o c k w i s e m a n n e r . r e n a l a r t e r ie s. U se t h e p a d s o f t h e f i r s t t h r e e f i n g e r s t o g e n t l y co mp re ss t h e br ea st t i ss ue a ga in st t h e ch es t wa ll . s ym me t r y. F i n e w h i t e o r s i lv er l in es ( st ri ae ) ma y b e vi si bl e. p er is t a ls is . or c on ca ve . Inspecting the Abdomen S it a t t h e s i d e o f t h e p a t i e n t : a t a n g e n t i a l v i e w e n h a nc es sh ad ow s a nd co nt ou rs . u si ng t h e f o u r q u a d r a n t s a s a g u i d e . T h e u m b i l i c u s s h o ul d b e ce nt ra ll y l oc at ed a nd ma y be f la t . a nd no t e t he ir f r eq ue nc y an d c ha ra ct er . Vertical Strip • • S t a rt a t t h e o u t e r e d g e o f t h e b r e a s t a n d p a lp at e u p a nd d ow n t he b re as t (F ig ur e C ). L i s t e n c a r e f u l l y f o r bo we l s ou nd s. Auscultating Bowel Sounds and Vascular Sounds A us cu lt at io n i s u s e d t o a s s e s s b o w e l s o u n d s a n d v as cu la r so un ds . ro un de d. c o n t o u r .Figure B. wi t h ou t vi si bl e p er is t a ls is . I n sp ec t s ki n co lo r an d s ur f a ce c ha ra ct er is t i c s . Figure C. a u s c u l t a t e o v e r t h e a o r t a . I n t hi n p eo pl e. i n c l u d i n g t h e u m b i l i c u s .

sp as m.p i t c h e d t i n k l in g o r ru sh es o f h ig h. ge nt le . p e r i t o n i t i s . p al pa t e t h e ar ea of p ai n l as t . c l o c k w i s e m a n n e r t o i d e n t i f y f l u i d . o r ab se nt b ow el so un ds (i nd ic at in g pe ri t o ni t i s o r p ar al yt ic il eu s ) . A b no rm al f i nd in gs in cl ud e in vo lu nt a r y r ig id it y. di pp in g m ot io n. or en la rg ed or d is ea se d a bd om in al or ga ns ). . P a l p a t e e a c h q u a d r a n t i n a sy st em at ic m an ne r. A b n o r m a l f i n d i n g s i n c l u d e d ec re as ed t y mp an y a nd i nc re as ed du ll ne ss . W a t c h t h e pa t i en t ' s f ac e f or n on ve rb al si gn s of p ai n d ur in g p a l p a t i o n . and mammary lymph nodes. T he l ow er e dg e o f t h e li ve r m ay b e pa lp at ed us in g l i g ht p al pa t i o n o r a h o o k i n g t e c h n i q u e . Figure 25-35. no t i ng m us cu la r r es is t a nc e. t u mo rs . as k t he p at ie nt t o i nh al e an d p re ss u p a nd i n wi t h y ou r f in ge rt ip s. Percussing the Abdomen P er cu ss io n i s u s e f u l i n a s s e s s i n g a f u l l b l a d d e r o r ch an ge s i n ab do mi na l c on t e nt s. a nd pa in ( wh i c h m a y i n d i c a t e t r a u m a . p os si bl y ca us ed by f lu id o r a ma ss . W it h yo ur f in g e r t i p s p o i n t i n g t o w a r d t h e p a t i e n t 's h e ad . Palpating the Abdomen U se t he pa d s o f t h e f i n g e r s t o p a l p a t e w i t h a l i g h t .Figure 25-34. N or ma l s ou nd s ar e t ym pa ny ov e r t h e a b d o m e n a n d d u l l n e s s o v e r t h e l i ve r an d a f ul l bl ad de r. B o w e l s o u n d s o f h i g h . Re po rt c ha ng es in o r ab se nc e o f bo we l s ou nd s. Location of the cervical. Organs of the abdominal cavity. T he a bd om en sh o u l d n o r m a l l y b e s o f t . T h e do mi na nt pe rc us si on no t e i n a bd om in al a ss es sm en t i s t y m p a n y . t e nd er ne ss . a n d f r e e of t en de rn es s. or a ir . P . A l l f o ur q ua dr an t s ar e p er cu ss ed in a s ys t e ma t i c. i n f e ct io n. r e l a x e d . o r m a s s e s . d ec re as ed b ow el so un d s ( h e a r d a f t e r a b d o m i n a l s u r g e r y o r l a t e b ow el ob st ru ct io n) . A b ru it m ay be h e a r d i f a n a n e u r y s m o r s t e n o s i s i s p re se nt in a n ab do mi na l a rt er y. I f t h e p a t i e nt co mp la in s o f ab do mi na l p ai n. Palpating the Liver T he l iv er is n o t u s u a l l y p a l p a b l e . b u t i t i s a s s e s s e d f o r a bn or ma li t i es .pi t c he d s ou nd s in di ca t e a bo we l o bs t r uc t i on . m a s se s. T o p a l p a t e b im an ua ll y. axillary. e nl ar ge me n t o f t h e o r g a n s . A bn or ma l f in d i n g s i n c l u d e i n c r e a s e d b o w e l s o u n d s (o f t en he ar d wi t h d ia rr he a o r in ea rl y bo we l ob st ru ct io n) . No t e t he di st ri bu t i on of s ou nd s. 6 39 s t a nd at t he p a t i e n t 's r i g h t s i d e a n d p l a c e y o u r l e f t h an d u nd er t h e pa t i en t ' s b ac k at t he le ve l of t he 11 t h t o 12 t h ri bs .

A bn or ma l f in di ng s in cl ud e a h ar d a nd f ir m li ve r e dg e ( f o un d i n c a n c e r o f t h e l i v e r ) .37 ). Diagram of abdominal quadrants and outline of underlying organs. a n d m a y n o r m a l ly be m il dl y t e nd er . c li t o ri s. I n f o r m at io n a bo ut re ct al e xa mi na t i on is g iv en se pa ra t e ly .r el at ed be ha vi or s t h at ma y le ad t o s ex ua ll y t r an sm it t e d i nf ec t i on s.b e l l y ” ( u n d e r 5 y e a r s o f a g e ) V is ib l e p e r i s t a l t i c w a v e s E as il y p a l p a t e d l i v e r a n d s p l e e n Older Adult C om mo n a b d o m i n a l v a r i a t i o n s i n o l d e r a d u l t s i n c l u d e: • • • D ec r e a s e d b o w e l s o u n d s D ec r e a s e d a b d o m i n a l t o n e L iv er b o r d e r p a l p a t e d m o r e e a s i l y Assessing Female Genitalia T he e xt er na l f e m a l e g e n i t a l i a c o n s i s t o f t h e m o n s p ub is . t h e in t e rn al pe lv ic e xa mi na t i on is a sk il l mo st o f t en p er f o rm ed by P . Figure 25-36. a nd e n l a r g e m e n t o f i n t e r n a l o r g a n s . 25 . n o d u l a r i t y ( f o u n d wi t h t um or . c ir rh os is . va gi na l v es t i bu le . e nl ar ge me nt ma y re su lt f ro m h ep at it is . m as se s. a nd pa in ( f r om v as cu l a r e n g o r g e m e n t a s i n c o n g e s t i v e h e a r t f ai lu re . A s k t h e p a t i e n t t o t a k e a d e e p b re at h an d g en t l y pu ll up a nd i n w it h yo ur f in ge r t ip s. s t a n d o n t h e p a t i e n t ' s r i g h t si de a nd h oo k ( cu rl ) t h e f i ng er s o f bo t h ha nd s ov er t h e ed ge of t he r i g ht c os t a l m a r g i n . a nd c ir rh os is of t he l iv er ).T o pa lp at e b y h o o k i n g . d is ch ar ge . he pa t i t i s. or a bs ce ss ). v a g i n a l o r i f i c e . T he n or ma l l iv er e dg e s ho ul d f e e l f i r m a n d s m o o t h . m et as t a t i c ca nc er . Normal Age-Related Variations Infant/Child C om mo n a b d o m i n a l v a r i a t i o n s i n n e w b o r n s a n d c h i ld re n in cl ud e: • • • • U mb i l i c a l c o r d i n n e w b o r n s . d r i e s a n d f a l l s of f wi t h in t he f i rs t f e w we ek s of l if e A “ po t . an d v as cu la r e ng o r g e m e n t . T h e r ec t u m an d a nu s ma y be as se ss ed d ur in g p ar t of t h is e xa mi na t i on if a t ot al h ea lt h a s s e s s m e n t i s b e i n g p e r f o r m e d . li ve r t u mo rs . v es t i bu la r g l a nd s. I f t he l iv er b or de r i s mo re t ha n 1 t o 3 c m be lo w t h e c o s t a l m a r g i n i t i s c o n s i d e r e d e n l a r g ed . la bi a m aj or a an d m in or a. A lt ho ug h t he e x t e r n a l g e n i t a l i a m a y b e e x a m i n e d . T h e f em al e ge ni t a li a a re a ss es se d f or l es io ns . 6 40 a p hy si ci an o r a n u r s e w i t h a d v a n c e d e d u c a t i o n a n d sk il ls . I nf or ma t i on co ll ec t e d d ur in g t h e h ea lt h hi st or y i s es pe ci al ly h el pf ul in i d e n t i f y i n g r i s k f a c t o r s f o r c a n c e r a n d h e a lt h. . a n d u r e t h r a l o p e n i n g (F i g .

nu mb er of p ar t n er s) N um b e r o f p r e g n a n c i e s a n d l i v e b i r t h s H is t o r y o f s e x u a l l y t r a n s m i t t e d i n f e c t i o n U se o f c o n t r a c e p t i v e s F re q u e n c y o f p e l v i c e x a m i n a t i o n s a n d P a p s me ar s H is t o r y o f v a g i n a l d i s c h a r g e . Inspecting and Palpating the External Genitalia T he b la dd er s h o u l d b e e m p t i e d b e f o r e t h e e x a m i n a t io n. A de sc ri pt io n o f an i nt er na l p el vi c as se ss me nt of w om en i s i nc lu de d i n t h i s c h a p t e r . E x pl ai n t he p ro ce du re t o h er an d he lp h er t o r el ax a s i t i s p e r f o r m e d . s iz e of t he la bi a ma jo ra an d va gi na l o pe ni ng . a nd di sp os ab le gl ov es . T h e s k i n a n d m uc os a sh ou ld be s mo ot h. t he c o l l e g e s t u d e n t w h o r e p or t e d t ha t s he w as r ap ed . a n d d r a p e d s o t h a t on ly t he g en it al ia ar e e xp os ed . T h e v ag in al o ri f i ce va ri es i n si ze . p ai n) S ex u a l h i s t o r y ( a g e a t w h i c h s e x u a l a c t i v i t y b eg an . an d t h e mu co us m em br an es a r e d a r k p i n k a n d m o i s t . l es i o n s . w it h t h e l e g s i n s t i r r u p s . l en gt h o f f l ow . W om en f r om s om e cu lt ur es (I sl am . T h e l ab ia s ho ul d b e sy m m e t r i c w i t h o u t l e s i o n s o r s w e l l i n g . o r p a i n o n ur in at io n H is t o r y o f s m o k i n g F am i l y h i s t o r y o f r e p r o d u c t i v e o r g e n i t a l c a nc er R ec a l l Ra mo n a L e w i s . a n d ha vi ng v ag in al de li ve ry . P a lp at e t h e l ab ia f or m as se s a nd t h e B a rt h o l i n ' s g l a n d s f o r s w e l l i n g . wi t h ou t le si on s o r sw el li ng . t y pe o f f lo w. d ep en di ng o n t h e w o m a n ' s a g e .Figure 25-37. b ut n ur se s o f t en a ss is t in pe rf or mi ng v ag in al ex am in at io ns an d n ee d t o be f a m i l i a r w i t h t h e p r o c e d u r e . o r f or ei gn o bj ec t s ). Health History I de nt if y r is k f a c t o r s f o r a l t e r e d f e m a l e h e a l t h d u r i n g t h e he al t h hi st or y by a sk in g a bo ut t he f o ll ow in g: • • • • • • • • • M en s t r u a l h i s t o r y ( a g e o f f i r s t a n d l a s t p e r i od . I n ch il dr en . f o r ex am pl e) ma y ag re e t o a p hy si ca l e xa m i n a t i o n o f t h e g e n i t a l i a o n l y b y a f e m al e nu rs e o r f e ma le p hy si ci an . I n m a n y i n s t a nc es . A s pa rt o f t h e f oc us ed a ss es sm en t . a l t h o u g h i n d i v i d u a l h e a l t h ag en cy po li ci es va ry o n wh et he r t hi s is i nc lu de d a s pa rt o f t h e h ea lt h a ss es sm en t . T h i s i s a n a d v a n c e d a s s e s s m e n t t e c h n iq ue . a g o o d l i g ht s ou rc e. Physical Assessment T he g en it al i a a r e a s s e s s e d b y i n s p e c t i o n a n d p a l p at io n. t h e n ur se wo ul d n e e d t o o b t a i n a r e p r o d u c t i v e h e a l t h hi st or y t o pr ov id e a b as el in e f or t he p at ie nt 's pl an of c ar e. G l o v e s a r e w o r n d u r in g t hi s as se ss me nt . p a i n . T h e wo ma n i s pl ac ed i n t he l it ho t o my p os it io n o n t h e e xa mi na t i on t ab le . External female genitalia. lo ss of h ym en al t is su e b et we en t he 3 o' cl oc k a n d 9 o 'c l o c k p o s i t i o n i n d i c a t e s t r a u ma ( f r om di gi t s . pe ni s. L es io ns ma y be t he r es ul t o f in f e ct io ns (s uc h as h er pe s o r sy ph il is ). a n d di sc ha rg e. a n d d i s c h a r g e . . ma le he al t h ca re pr ov id er s wi ll a sk t ha t a f em al e be pr es en t in t he r oo m a s a c h a p e r o n e d u r i n g t h e e x a m i n a t i o n . E qu ip me nt re qu ir ed in cl ud es a v ag in al s pe cu lu m ( f o r t h e f e m a l e e x a m i n a t i o n ) . I n s p e c t t he e xt er na l g en it al ia f or co lo r. s e x u a l h i s t o r y . T h e v u l v a n o r m a l ly h as m or e p ig me nt at io n t ha n ot he r s ki n ar ea s. T he re ma y b e a s m a l l a m o u n t o f c l e a r o r w h i t i s h v a gi na l d is ch ar ge (t hi s is n or ma l) . T he e xt er na l g e n i t a l i a a r e i n s p e c t e d f i r s t . i t c h i n g .

3 8 ) i n c l u d e t h e p e n i s . t es t i cl es . D on g l o v e s . s w e l l i n g o f g l a nd s. E x a m i n a t i o n o f h e r e x t e r n a l a n d in t e rn al g en it al ia is r eq ui re d t o co ll ec t e vi de nc e in di ca t i ng ra pe . T hi nk b ac k t o R a m o n a L e w i s . E n su re t ha t n o p u b i c h a i r i s c a u g h t i n t h e s p e c u l u m . G ui de li ne s f or N ur si ng Ca re 2 5. 5 y e a r s a f t e r pu be rt y b eg in s I rr eg u l a r m e n s t r ua l c y c l e f o r f i r s t 2 y e a r s Older Adult C om mo n g e n i t a l i a v a r i a t i o n s i n o l d e r a d u l t s i n c l u d e: • • • • D ec r e a s e d l a b i a s i z e D ec r e a s e d p u b l i c h a i r D ec r e a s e d v a g i n a l s e c r e t i o n s S ho r t e n e d v a g i n a l v a u l t Assessing Male Genitalia T he m al e g e n i t a l i a (F i g . a p o l y p . A bn or ma l f in d i n g s i n c l u d e r e d n e s s . a nd pa in .ca re an d li f e st yl e f a ct or s t ha t in cr ea se t h e ri sk o f i l l ne ss es su c h a s t e s t i c u l a r c a n c e r o r s e x u a l l y t r a n sm it t e d in f e ct io ns . pr os t a t e gl an d. le si on s. t he w at e r s er ve s a s t h e l ub ri c a n t . U si n g t w o f i n g e r s p l a c e d j u s t i n s i d e t h e v a g in a. 6 41 I nf or ma t i on f r o m t h e h e a l t h h i s t o r y i s h e l p f u l i n i d e n t i f y in g s el f . an a bs ce ss .so lu bl e lu br ic an t m ay b e us ed . T ur n t h e s p e c u l u m s o t h a t t h e h a n d l e i s d o wn an d t h e bl ad es ar e in a ho ri zo nt al po si t i on . 2 5 . W ar m t h e s p e c u l u m u n d e r w a r m r u n n i n g w at er . wh ic h m ay i nd ic at e i nf ec t i on . I ns e r t t h e s p e c u l u m b l a d e s v e r t i c a l l y i n t o t he v ag in a. ep id id ym is . if c yt ol og ic sp ec im en s ar e t o be t ak en . F o r r e l a t e d a s s e s s m e n t s o f s ex ua ll y t r an sm it t e d d is ea se s an d t he u ri na ry t r ac t . a w at er . . T he n ur se wo ul d n e e d t o k e e p i n m i n d t h e a g e n c y ' s p o l ic y a nd l oc al a nd st at e le ga l r eq ui re me nt s r el at ed t o c ol le ct io n of r ap e e vi de nc e.Inspecting Internal Genitalia A s pe cu lu m i s u s e d t o e x a m i n e t h e i n t e r n a l g e n i t a l ia . t h e c o l l e g e s t u d e n t w ho a rr iv ed a t t he e me rg en cy de pa rt me nt re po rt in g t ha t sh e wa s a v i c t i m of d a t e r a p e .9 li st s t h e se qu en ce of an i nt er na l v ag in al ex am i n a t i o n . di sc ha rg e. i f n o s p e c i m e n s a r e n e e d e d . t h e po st er io r p or t i on p oi nt ed at a 45 -d eg re e a ng le . P . s cr ot um . a nd se mi na l ve si cl es . s ee C ha pt er s 3 5 a n d 4 3. o r c a n c e r . T he p hy si ca l e xa mi na t i on is f oc us ed on d et ec t i ng a bn or ma l f in d i n g s s o t h a t e a r l y d i a g n o s i s a n d t r e a t me nt c an be i ni t i at ed . Guidelines for Nursing Care 25-9 Vaginal Examination • • • • • • E xp la i n t h e p r o c e d u r e t o t h e p a t i e n t . Normal Age-Related Variations Infant/Child C om mo n g e n i t a l i a v a r i a t i o n s i n n e w b o r n s a n d c h i l d re n in cl ud e: • • • • E nl a r g e d l a b i a a n d c l i t o r i s a t b i r t h P ub l i c h a i r a n d b r e a s t d e v e l o p m e n t o c c u r a t pu be rt y a nd f o ll ow a r eg ul ar se qu en ce of d ev el op me nt M en s t r u a t i o n b e g i n s a b o u t 2 . p re ss do wn g en t l y o n t h e po st er io r v ag in al wa ll .

i t i s no t un us u a l f o r t h e l e f t t e s t i c l e t o l i e l o w e r i n t h e s cr ot al sa c t h an t he ri gh t t e st ic le . f ar mi ng . N or ma ll y. s ha pe . Health History I de nt if y r is k f a c t o r s f o r a l t e r e d m a l e h e a l t h d u r i n g t he he al t h h is t o ry by a sk in g ab ou t t he f ol lo wi ng : • • • • • • • • • F re q u e n c y o f d i g it a l r e c t a l e x a m i n a t i o n s F re q u e n c y o f t e s t i c u l a r s e l f .e x a m i n a t i o n U se o f c o n t r a c e p t i v e s O cc u p a t i o n a l e x p o s u r e t o c h e m i c a l s ( t i r e a nd r ub be r m an uf ac t u ri ng . I f t he pa t i en t is u nc ir cu mc is ed .• • • • • • O pe n t h e b l a d e s a n d c l o s e t h e s c r e w t h a t l oc ks t he bl ad es o pe n. W he n t h e s p e c u l u m b l a d e s a r e c l e a r o f t h e ce rv ix . re le as e t he s cr ew so t ha t t h e bl ad es cl os e. an d di sc ha rg e. an d di sc ha rg e. P . r e d n e ss . N or ma l f i nd in gs in cl ud e s ki n t h at i s f r ee o f l es io ns . T he s cr ot um an d t e st es s ho ul d b e f r ee of m as se s an d n on t e nd er . f r e q u e n cy . r et ra ct t he f or es ki n f or i n s p e c t i o n o f t h e g l a n s p e n i s . T he ur in ar y me at us is n or ma ll y lo ca t e d i n t h e c en t e r o f t h e g l a n s p e n i s a n d i s f r e e o f d i s c h a r g e . u n i f o r m i n c o l o r . le si on s. ed em a. 6 42 Physical Assessment Inspecting and Palpating the Genitalia T he p at ie nt m a y b e s t a n d i n g o r s u p i n e . s h ap e. Organs of the male urogenital system. m ec ha ni cs ) H is t o r y o f s e x u a l l y t r a n s m i t t e d i n f e c t i o n H is t o r y o f d i s c h a r g e f r o m t h e p e n i s D if f i c u l t y w i t h u r i n a t i o n ( h e s i t a n c y . O bt a i n s p e c i m e n s i f n e e d e d . t e s t e s ) s h o u l d b e s i m i l ar b il at er al ly . a nd wi t h dr aw t he s pe c u l u m f r o m t h e v a g i n a . I ns p e c t t h e c e r v i x a n d o s f o r s i z e . I n sp ec t t h e s cr ot um f or s ym me t r y. c o n t o u r . v oi di ng a t n ig ht ) H is t o r y o f i n c o n t i n e n c e H is t o r y o f e r e c t i l e d y s f u n c t i o n Figure 25-38. an d ea si ly re t r ac t e d. G l o v e s a r e w or n du ri ng t h is a ss es sm en t . T h e s iz e. A s s e s s t he lo ca t i on o f t h e u ri na ry m ea t u s. c o l o r . p l a ce me nt . P ro v i d e t h e p a t i e n t w i t h t i s s u e s t o r e m o v e t he l ub ri ca t i ng je ll y (i f us ed ). an d a f or es ki n ( if p r e s e n t ) t h a t i s i n t a c t . a nd c on si st en cy o f t h e s cr ot a l c o n t e n t s ( i e . o b s e r v i n g t h e va gi na l wa ll s. t h e in gu in al ar ea i s . a p p e a r a n c e o f t h e s k i n . I ns pe ct io n o f t h e i n g u i n al a r e a m a y b e d o n e a t t h i s t im e by as ki ng t he p at ie nt t o b ea r d ow n. W it h d r a w t h e b l a d e s s l o w l y . I n sp ec t t h e e xt er na l g e ni t a li a f or s iz e.

c ol or ed o r da rk . S po n t a n e o u s n o c t u r n a l e m i s s i o n o f s e m i n a l f l ui d o cc ur s at p ub er t y . o r l it ho t o my p os it io n o r ma y be s t a nd in g a nd l e a n i n g o v e r t h e e x a m i n a t i o n t a b l e . S p hi nc t e r t on e at t he an us s ho ul d b e f i rm a nd t he m uc os al l i n i n g s m o o t h .bl ac k) s t o ol s. ( F e c a l s p e c i m e n s m a y be t ak en at t hi s t i me . P al pa t i on i s us ed t o a s s e s s t h e r e c t u m . G l o v e s a r e w o r n . a n d d i s p l a c e m e n t o f t h e u ri na ry m ea t u s o r di f f ic ul t i es w it h v oi di ng . an d pe ni s o cc ur s at p ub er t y an d f ol lo ws a r eg u l a r s e q u e n c e t o a d u l t c o n f i g u r a t i o n . e d e m a . t e st es . re dn es s. c o l o n o r r e c t a l c a n ce r. a n d h a r d o r a b n o r m a l l y c o l o r e d (s uc h as c la y. ( F u r t h e r a s s e s s m e n t f o r i n g u i n a l h er ni a. P hy si ca l ex am in at io n p ro vi de s i nf or ma t i on t o s up po rt t e ac h i n g a b o u t r i s k f o r c o l o n c a n c e r a n d t h e ri sk s of s ex ua ll y t ra ns mi t t ed in f e ct io ns ( in cl ud in g A I D S ) a ss oc ia t e d w it h un pr ot e c t e d a n a l s e x . in gu in al ly mp h no de s. T h e p at ie nt ma y be i n t h e S im s. u s i n g a w e l l . ( S e e C h a p s . Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • B ow e l p a t t e r n s .f i ll ed ma ss es i n t h e sc ro t u m ( sy mp t o ms o f a h yd ro ce le or v a r i c o c e l e ) . 3 5 a n d 4 3 f o r a d d i t i o n a l di sc us si on of s ex ua ll y t ra ns mi t t ed d is ea se s a nd t he ma le u ri na ry t r a ct . or t ro ub le c on t r ol li ng bo we ls H is t o r y o f b l o o d o r m u c u s i n t h e s t o o l F am i l y h i s t o r y o f p o l y p s . n o d u l e s . o r pa in ma y i n d i c a t e a n i n f e c t i o n . di ar rh ea .f r e e of bu lg e s . d is ch ar ge . I n f o rm at io n f ro m t h e h ea lt h h is t o r y p r o v i d e s i n f o r m a t i o n a b o u t n o r m a l p a t t er ns o f b ow el e li mi na t i on an d id en t i f i es ri sk s f o r il ln es s ( su ch a s c ol on ca nc e r ) a n d h e a l t h b e h a v i o r s ( s u c h a s f r e q u en cy o f d ig it al r ec t a l ex am in at io ns [ D RE ] or en ga gi ng in r ec t a l se x) .l u b r i c a t e d. I ns pe ct io n i s u s e d t o a s s e s s t h e a n a l a r e a . ) A b no rm al f i nd in gs i nc lu de re la xe d s ph in ct er t o n e . V o i d i n g d i f f i c u l t i e s m ay r es ul t f r om s ca rr in g c au se d b y in f e ct io ns o r p ro st at e e nl ar ge me n t . g lo ve d i nd ex f i ng er . i n c l u d i n g a n y c o n s t i p a t i o n . p ai n. B ot h me n a n d w o m e n s h o u l d h a v e r e g u l a r D R E t o a ss es s f o r ca nc er .ch es t . or p ro st at e c an ce r H is t o r y o f h e m o r r h o i d s Physical Assessment T ec hn iq ue s u s e d t o a s s e s s t h e r e c t u m a n d a n u s i nc lu de i ns pe ct io n a nd pa lp at io n. . p a in . di sc ha rg e. r e d n e s s . k ne e. o r h e m o r r h o i ds at t he a na l s ph in ct er . an d f e mo ra l h er ni a a re u su al ly p er f o rm ed b y a ph ys ic i a n o r n u r s e w i t h a d v a n c e d e d u c a t i o n a nd s ki ll s. w h i c h n or ma ll y ha s in cr ea se d p ig me nt at io n a nd so me h ai r g ro wt h. bl ee di ng (w hi ch ma y in di ca t e h em or rh oi ds or c ol or ec t a l c a n c e r ) . ) Normal Age-Related Variations Infant/Child C om mo n g e n i t a l i a v a r i a t i o n s i n n e w b o r n s a n d c h i l d re n in cl ud e: • • D ev e l o p m e n t o f p u b i c h a i r a n d e n l a r g e m e n t o f t h e sc ro t u m. Ne ce ss ar y eq ui pm en t i nc lu de s l ub ri ca nt an d g o o d l i g h t i n g . f l ui d. ) A bn or ma l f in d i n g s a r e l e s i o n s . E d em a. Older Adult C om mo n g e n i t a l i a v a r i a t i o n s i n o l d e r a d u l t s i n c l u d e: • • • D ec r e a s e d p e n i s s i z e D ec r e a s e d p u b i c h a i r D ec r e a s e d s i z e o f t e s t e s Assessing the Rectum and Anus T he r ec t u m a n d a n u s a r e n o t a s s e s s e d i n a l l p a t i e n t s bu t t h is is a p ar t of a t ot al he al t h a ss es sm en t . if n ec es sa ry . s k i n c r a c k s .

a r t h r i t i s . t h e c e r v i x i n w om en m ay be f el t as a s ma ll . li ga me nt s. an d jo in t s . Inspecting and Palpating the Muscles E xa mi ne t h e m u s c l e s b y i n s p e c t i o n a n d p a l p a t i o n o f mu sc le g ro up s a nd b y t es t i ng m us cl e t o ne an d st re ng t h . t h e g la nd i s no rm al ly sm oo t h . no du le s. an d l im it ed R O M ( in di ca t i ng in ju ry . m us cl es . A b n o r m a l f i n d i n g s i n c l u d e e n l a r g e m e n t or c ha ng es in c on si st en cy ( wh ic h o cc ur i n be ni gn pr os t a t i c e nl ar ge me n t o r c a n c e r ) . H e a lt h h is t o ry i nf or ma t i on is u se d t o ev al ua t e t he pa t i en t ' s a bi li t y t o ca rr y o ut P . N or ma ll y. b o n e s . T h e p ro st at e gl an d i n me n ca n b e as se s s ed f o r si ze . or c re pi t u s ( gr at in g so un ds on m ov em en t ) . 6 43 a ct iv it ie s of d a i l y l i v i n g a n d t o c o l l e c t s u b j e c t i v e d at a. A b n o r m a l f i n d i n g s i n c l u d e c h a n g e s i n c on si st en cy . N or ma ll y. a n d j o i n t s a r e a s s e s s e d . G u i d e l i n e s 2 5 . A s se ss me nt s o f t h e mu sc ul os ke le t a l s ys t e m ca n b e i n t e g r a t e d i n t o t h e a s s e s s m e n t o f o t he r b od y sy st em s. st if f n es s. s h a p e a n d c o l o r . Normal Age-Related Variations Infant/Child N ot e: N or ma l l y p h y s i c a l e x a m i n a t i o n o f t h e r e c t u m an d a nu s is n ot p er f o rm ed in y ou ng ch il dr en or a do le sc en t s . . si t t in g. an d a bo ut 1¾ ″ (4 c m) i n si ze . Older Adult C om mo n v a r i a t i o n s i n o l d e r a d u l t s i n c l u d e : • • A nu s i s d a r k e r i n c o l o r H em o r r h o i d s a r e o f t e n p r e s e n t Assessing the Musculoskeletal System T he p ri ma ry s t r u c t u r e s o f t h e m u s c u l o s k e l e t a l s y s t em a re t he bo ne s. T he m us cl es . pa in . s ha pe . t e n d on s. A s s e s s m u s c l e s t r e n g t h . a nd c o n s i s t e n c y b y p a l p a t i o n t h r o u g h t h e a nt er io r r ec t a l wa ll . b on e s i z e a n d s t r u c t u r e . g ai t . a n d m u s c l e p ai n an d/ or we ak ne ss c au se d b y in ju ry or d is ea se ). E va lu at e m u s c l e t o n e ( t h e n o r m a l c o n d i t i o n o f a m us cl e at r es t ) b y pu t t in g e ac h j oi nt a nd e xt re mi t y t h ro ug h p as si ve r an ge o f mo t i on . M us cl e g ro up s a re o b s e r v e d f o r b i l a t e r a l s y m m e t r y a n d p a l pa t e d f or t e nd er ne ss .I f a re ct al a s s e s s m e n t i s c o n d u c t e d . o r n e u r o l o g i c d i s or de r H is t o r y o f p a i n o r s w e l l i n g i n t h e j o i n t s H is t o r y o f p a i n i n t h e m u s c l e s o r j o i n t s F re q u e n c y a n d t y p e o f u s u a l e x e r c i s e D ie t a r y i n t a k e o f c a l c i u m H is t o r y o f s m o k i n g H is t o r y o f a l c o h o l i n t a k e Physical Assessment T he p at ie nt a s s u m e s a v a r i e t y o f p o s i t i o n s . f i rm . t h e jo in t s a re of e qu al b i l at er al si ze . a nd m us cl e s t r en gt h. c ar t i la ge . cr ep it us . i n c l u d i n g s t a nd in g. a nd s up in e. t he y ar e s ym me t r ic a nd n on t e nd er . r ou nd m as s wh en pa lp at in g t he a nt er io r r ec t a l wa ll . an d ab il it y t o mo ve .1 0 de sc ri be s t es t i ng mu sc le s. T h e pa t i en t ' s u su al e xe rc is e p at t e r n s a r e h e l p f u l i n t e a c h i n g h e a l t h y b eh av io rs . A b n o r m a l f i n d i n g s i n c l u d e d e f o r m it y. a r e f r e e o f s w e l l i n g. Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • • • H is t o r y o f t r a u m a . j o i n t r a n g e o f m o t i o n (R O M ). P hy si ca l ex am in at io n p ro vi de s i nf or ma t i on ab ou t po st ur e. s uc h a s pa in . a nd mo ve t hr ou gh f u ll R O M . in f l am ma t i on an d/ or a rt hr it is o f t h e a f f e c t e d j o i n t s o r b o n e s .

A bn or ma l f in d i n g s i n c l u d e a t r o p h y ( a d e c r e a s e i n si ze ). a nd pr on at io n. a n d m o v e s s m o o t h l y . m us cu lo sk e l e t a l d i s e a s e . K y p h o s i s ( a n i n c r e a s e d t h o r a c i c s p in al cu rv e) i s mo re of t e n se en in o ld er a du lt s. h ea r. h e a d a c he s. e nl ar ge me n t . c ra ni al n er ve f u nc t i on . ce re be ll ar f u nc t i on . Palpating the Bones P al pa t e bo n e s f o r n o r m a l c o n t o u r a n d p r o m i n e n c e a s we ll as f or b il at er al sy mm et ry . t h e a n t e r i or c er vi ca l c ur ve d ev el op s a t ab ou t 3 t o 4 mo nt hs of a ge . A b no rm al f in di ng s i nc lu de pa in . an d f l ac ci di t y (w it ho ut t on e) of m us cl es . Normal Age-Related Variations Infant/Child C om mo n m u s c u l o s k e l e t al v a r i a t i o n s i n n e w b o r n s a n d c hi ld re n in cl ud e: • • • • C -s h a p e d c u r v e o f s p i n e a t b i r t h . t re mo rs ( in vo lu nt ar y m ov em en t s ). l o s s o f s e n s a t i o n . A n e xa gg er at ed lu mb ar c ur ve ( lo rd o s i s ) i s o f t e n s e e n d u r i n g p r e g n a n c y o r in o be si t y . o r a ne ur ol og ic di se as e. Guidelines for Nursing Care 25-10 . m us cl e s t r en gt h a nd co or di na t i o n . t ra um a. S c ol io si s i s a la t e ra l cu rv at ur e o f t h e s pi ne w it h in cr ea se d c on ve xi t y on t h e s i d e t h a t i s c u r v e d . No rm al ly . Jo in t mo ve me nt s i nc lu de f l ex io n. Inspecting Spinal Curves W it h t h e pa t i e n t s t a n d i n g . an d a ll m us cl e g ro up s a re b i l a t e r a l l y s t ro n g . a s y m m e t r y . F i nd in gs i nd ic at in g s co li os is a re il lu st ra t e d in F i g ur e 2 5. t h e p a t i en t i s al er t an d r es po ns iv e. a b d u c t i o n . cr an ia l ne rv e f un ct io n. su pi na t i on .39 . no du le s. a nd de t e ct s en sa t i on s. ea ch jo in t ha s f u ll r an ge of m ot io n. t a st e. an d ab il it y t o se e. de ge ne ra t i ve j oi nt d is ea se . a d d u c t i o n . an d p a i n . u nc oo rd in at ed mo ve me nt s. i n s p e c t t h e s p i n e f r o m t h e b ac k an d f ro m t h e si de . ha s f u ll s en so ry f u nc t i on . s we ll in g. A b n o r m a l f i n d i n g s a r e di sc us se d w it h sp ec if ic p ar t s o f t he e xa mi na t i on t h at f ol lo w. s we ll in g. de cr ea se d r an ge o f mo t i on . A b n o r m a l f i n d i n g s m a y i n d i c a t e a mu sc ul os ke le t a l d is ea se . P a l p a t e j o i n t s f o r t h e ab no rm al f i nd in gs of p ai n. T h e l um ba r cu rv e m ay b e f l at t e ne d w it h a h er ni at ed di s k . a n d r e f l e x e s . i s no nt en de r . o r a n e u r o l o g i c d i s e a s e . an d r e f l e x e s . an d cr ep it at io n ( a g ra t i ng so un d h e a r d o r f e l t o n m o v e m e n t ) . e xt en si on . m ot or a nd se ns or y f un ct io n. Inspecting and Palpating the Joints E ac h jo in t i s p u t t h r o u g h i t s f u l l r a n g e o f m o t i o n t o a ss es s t h e de gr ee of m ov em en t . a n d c h a n g e s i n c o n t o u r . an d t he a nt er i o r l u m b a r c u r v e d e v e l o p s b e t w e e n 1 2 a nd 1 8 mo nt hs of a ge L or d o s i s ( a n e x a g g e r a t e d l u m b a r c u r v e ) P ro n a t i o n o f t h e f e e t i n c h i l d r e n b e t w e e n 1 2 an d 30 mo nt hs o f ag e G en u v a r u m ( b o w l e g ) f o r 1 y e a r a f t e r l e a r n i n g t o wa lk Older Adult C om mo n m u s c u l o s k e l e t al v a r i a t i o n s s e e n i n o l d e r ad ul t s in cl ud e: • • • • • L os s o f m u s c l e m a s s a n d s t r e n g t h D ec r e a s e d r a n g e o f m o t i o n K yp h o s i s D ec r e a s e d h e i g h t O st e o a r t h r i t i c c h a n g e s i n j o i n t s Assessing the Neurologic System N eu ro lo gi c a s s e s s m e n t i n c l u d e s c e r e b r a l f u n c t i o n . P h ys ic al e xa mi na t i on i s c o n d u c t e d t o i d e n t i f y m e n t a l s t a t u s an d le ve l of co ns ci ou sn es s. w hi ch ar e r ec om me nd e d f o r g i r l s i n g r a d e s 5 a n d 7 a n d f o r b oy s in g ra de s 8 o r 9. su ch a s d i z z i n e s s . T h e h e a l t h h i s t o r y i s u s e f u l in o bt ai ni ng in f o rm at io n a bo ut a ct iv it ie s o f da il y li vi ng a nd su bj ec t i ve d at a. N o r m a l l y . h y p e r e x t e n s i o n . O t h e r a b n o r m a l f i n d i n g s a r e l o s s o f s t r e n gt h a nd t on e. S e e C h a pt er 39 f or f ur t h er di sc us si on a nd il lu st ra t i on of j oi n t m ob il it y. A bn or ma l f i nd in gs ma y in di ca t e t r au ma . S c h o o l n u r s e s of t e n f ir st i de nt if y sc ol io si s d ur in g sc re en in gs .

T he n h e f l e x e s t he e l b o w a g a i n s t r e s i s t a n c e (F ig ur e C ). . wi t h a s l i gh t in cr ea s e o n t h e d o m i n a n t s i d e . T ec hn iq ue s f o r a s s e s s i n g t h e m u s c l e s i n c l u d e : Shoulder Flexion T he p at ie nt f l e x e s s h o u l d e r m u s c l e a g a i n s t r e s i s t a nc e o f t h e ex am in er 's ha nd (F ig ur e A ). Elbow Extension and Flexion • • T he p a t i e n t f i r s t e x t e n d s t h e e l b o w a g a i n s t re si st an ce by t he e xa mi ne r ( F i gu re B ) . Figure A. Figure C. Figure B. Mu sc le s t r en gt h s ho ul d be bi la t e ra ll y eq ua l. B il at er al e qu al re si st an ce sh ou ld b e p re se nt O bs er ve mu s c l e c o n t r a c t i o n a n d d e t e r m i n e m u s c l e st re ng t h ex er t e d.Assessing the Muscles A ss es s mu s c l e s t r e n g t h b y a s k i n g t h e p a t i e n t t o m o ve a ga in st re si st an ce .

Figure E. Hip Flexion T he p at ie nt a t t e m p t s t o r a i s e h i s t h i g h a g a i n s t e x a m in er 's re si st an ce (F ig ur e F ). Knee Flexion and Extension • • W it h t h e p a t i e n t ' s k n e e b e n t a n d f o o t o n t h e ex am in in g t ab le . Figure F. t h e e x a m i n e r s u p p o r t s t h e p at ie nt 's kn ee an d t h e p at ie nt a t t em pt s t o st ra ig ht en hi s le g ag ai ns t r es is t a n c e a t t h e a n k l e ( F i g u r e H) . .Wrist Extension T he p at ie nt m a k e s a f i s t a n d r e s i s t s e x a m i n e r 's a t t e mp t s t o p ul l do wn wr is t (F ig ur e D ). Figure D. t h e p at ie nt a t t em pt s t o ke ep f oo t d ow n wh il e t he e xa m i n e r a t t e m p t s t o s t r a i g h t e n t h e p a t i e n t ' s l eg t o t e st f le xi on (F ig ur e G ). T o t e s t e x t e n s i o n . Grip T he p at ie nt s q u e e z e s t h e e x a m i n e r 's i n d e x a n d m i d dl e f in ge rs ( F i gu re E ) .

Ankle Plantar Flexion and Dorsiflexion • • T he p a t i e n t f i r s t p u s h e s t h e b a l l s o f t h e f e e t a ga in st re si st an ce of t he e xa mi ne r' s h an ds (F ig ur e I ). t h e p a t i e n t a t t e m p t s t o p u l l a g a i n s t e xa mi ne r' s r es is t a nc e ( F i gu re J) . Figure I. Figure H. . T he n .Figure G.

(A) Normal position and spinal curves. t a s t e . s e e . 6 44 P . o r t r e m o r s H is t o r y o f s e i z u r e s H is t o r y o f h e a d a c h e s H is t o r y o f d i z z i n e s s H is t o r y o f t r a u m a t o t h e h e a d o r s p i n e H is t o r y o f i n f e c t i o n s o f t h e b r a i n H is t o r y o f s t r o k e C ha n g e s i n t h e a b i l i t y t o h e a r . Figure 25-39. P .Figure J. P ho t o s b y K e n C a s p e r . Screening for scoliosis. t i n g l i n g . o r s me ll L os s o f a b i l i t y t o c o n t r o l b l a d d e r a n d b o w e l H is t o r y o f h i g h b l o o d p r e s s u r e . 6 46 Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • • • • • • H is t o r y o f n u m b n e s s . (B) Scoliosis indicators. 6 45 P .

O b s e r v e t h e p a t i e n t 's ap pe ar an ce . a nd r es po ns es t o q u e s t i o n s . a t on gu e d ep re ss or . a nd sh ou ld be a bl e t o de mo ns t r at e c oh er en t an d l og ic al t h ou g h t p r o c e s s e s . a v is ua l ac ui t y c ha rt . O n i n i t i a l c o n t a c t . sh ou ld be o ri en t e d t o pe rs on . a l a r g e s a f e t y p i n ) . A s se ss t he s en so ry sy st e m b y ha vi ng t h e p at ie nt id en t i f y v a r i o u s se n s o r y s t i m u l i . A b n o r m a l f i n d i n g s i n c l u de po or hy gi en e. R e m e m b e r t h at it i s of t e n di f f ic ul t t o kn ow t he e xa ct da t e w he n o ne i s il l. co gn it iv e ab il it ie s. n e a t a p p e a r a n c e w it h er ec t po st ur e. i na pp ro pr ia t e d re ss .t h e . a bi li t y t o s pe ak c le ar ly .c o u n t e r m ed ic at io ns F am i l y h i s t o r y o f h i g h b l o o d p r e s s u r e . p l a c e . a n d t h e n p e r s o n o r i e n t a t i o n . a n d p e r s o n t o as se ss l ev el of a wa re ne ss .• • • • • • • H is t o r y o f s m o k i n g H is t o r y o f c h r o n i c a l c o h o l u s e H is t o r y o f d i a b e t e s m e l l i t u s o r h e a r t d i s e a s e U se o f p r e s c r i p t i o n a n d o v e r . f o ll ow ed by p la ce o ri en t a t i on . T h e pa t i en t s ho ul d be si t t in g an d t h e e nv ir on me nt s ho ul d b e qu i e t . be ha vi or an d ap pe ar an ce . ge ne ra l be ha vi or . pe pp er mi nt an d va ni ll a) . v i a l s o f so lu t i on t o t es t t a st e ( eg . p la ce . N o t e a n y v a r i a t i o n i n r e s p on se s. e pi le ps y.t er m me mo ry ). a bs t r ac t r ea s o n i n g . a sh ar p o bj ec t ( eg . T he n ur se wo ul d as se ss t h e p at ie nt 's me n t a l s t a t u s f o r c l u e s s u g g e s t i n g r e c e n t d ru g us e. a bs en t m em or y r ec al l. l e a d. me mo ry . . T h es e a bn or ma l f i nd in gs ma y in di ca t e a me nt al he al t h d is or de r. in se ct ic id es ) Physical Assessment A ss es s ce re b r a l f u n c t i o n b y o b s e r v i n g t h e p a t i e n t ' s b eh av io r t hr ou gh ou t t he h ea lt h h is t o ry i nt er vi ew an d ph ys ic al a ss es sm en t . a t un in g f or k. 6 47 T hi nk b ac k t o T a m m y B r o w n i n g .t e r m a n d l o n g. E va lu at e c er eb el la r f u n c t i o n b y a s s e s s i n g f i n e m o t o r s k i l l s . a n d l a n g u a g e . m en t a l r et ar d a t i o n . t h e p r e g n a n t w o m an wi t h a h is t o ry o f su bs t a nc e a bu se . l ev el o f co ns ci ou sn es s. an d be ha vi or . c o t t o n b a l l s . T he f ol lo wi n g d i s c u s s i o n o f e a c h o f t h e m e n t a l s t a t u s c om po ne nt s i nc lu de s sa mp le qu es t i on s o r sp ec if ic a ss es sm en t s t o u se d ur in g t h e a s s e s s m e n t . b eg in t o e va lu at e t he p at ie nt 's or ie nt at io n t o pe rs on . T he f ol lo wi ng qu es t i on s ma y b e us ed : • • • T im e : W h a t i s t o d a y 's d a t e ? W h a t d a y o f t h e we ek i s it ? W h at se as on o f t h e y ea r is t hi s? W ha t w as t he l as t h ol id a y ? P la ce : W h e r e a r e y o u n o w ? W h a t i s t h e n a m e o f t h is c it y? W ha t s t a t e a re w e in ? P er s o n : W h a t i s y o u r n a m e ? H o w o l d a r e y ou ? W h o ca me t o v is it y ou t hi s mo rn in g? A lt ho ug h e x c e p t i o n s m a y o c c u r . p la ce . an d t im e. s ho ul d h av e m e m o r y r e c a l l ( b o t h s h o r t . o r in u nf am i l i a r s u r r o u n d i n g s . a n d e v a l u a t e t h e re f l ex es by c on t r ac t i on of s pe ci f i c mu sc le s. i n d i v i d u a l s w h o h av e i mp ai re d a wa re ne ss f ir st l os e t im e or ie nt at io n. Mental Status M en t a l s t a t u s a s s e s s m e n t i n c l u d e s l e v e l o f a w a r e n e ss . T he p at ie nt s h o u l d h a v e a c l e a n . in co rp or at in g k no wl ed ge of a bn or ma l f in di ng s i nt o t h e a ss es sm en t . a nd ba la nc e. a nd i n c o h e r e n t o r i l l o g i c a l t h o u g h t p r o c e s s e s. c e r e b r o va sc ul ar d is or de r. em ot io na l s t a t u s. P . o r a t um or . wh er e he o r s he i s. co or di na t i on . a n d f a m i l i a r o b j e c t s s uc h a s a ke y or c oi n. a nd t h e da y o r m o n t h o r y e a r ) . E qu ip me nt i n c l u d e s v i a l s o f a r o m a t i c s u b s t a n c e s ( e g. i n pa in . o r g a n i c b r a i n d i s e a s e . di so ri en t a t i on . or H un t i ng t o n' s ch or ea F re q u e n c y o f b l o o d c h o l e s t e r o l t e s t s a n d r es ul t s E xp o s u r e t o e n v i r o n m e n t a l h a z a r d s ( e g . A s s e s s t h e p a t i e n t 's m e n t a l s t a t u s . Assessing Level of Awareness E va lu at e o ri e n t a t i o n t o t im e . a nd t i m e. sa lt o r su ga r) . a p en li gh t . A l z h e im er 's d is ea se . a lc oh ol or d ru g i nt ox ic at io n. a s we l l a s h i s o r h e r c o g n i t i v e a b i l i t i e s a n d a f f e ct ( wh et he r t he p at ie nt kn ow s wh o h e or s he is . m e mo ry . a r e f l e x h a m m e r . ca nc er .

c an be a ro us ed by g en t l e s h a k i n g a n d s a y i n g p a t i e n t 's n a m e S t u p o r o u s : u n c o n s c i o u s m o s t o f t h e t i m e . mu st be s ha ke n o r sh ou t e d a t t o a ro u s e . 9) .1 0) i s a s t a n d a rd iz ed as se ss me nt t o ol t ha t a ss es se s le ve l o f co ns ci ou sn es s. w i t h h i g h e r s c o r e s i n d i c a t i ng a mo re n or ma l l ev el o f f u nc t i on in g. e v e n w i t h u se of p ai nf ul s t i mu li . h as n o sp on t a ne ou s mo ve me nt . a nd a t ot al s co re i s r e c o r d e d . o r i e n t e d t o p e rs on . “ W h en i s yo ur bi rt hd ay ?” or “ W h en i s yo ur w ed di ng an ni ve rs ar y? ” Table 25-10 Glasgow Coma Scale Component Eye opening Response Spontaneous To verbal command To pain No response Motor response To verbal command To localized pain Flexes/withdraws Flexes abnormally Extends abnormally Score 4 3 2 1 6 5 4 3 2 . 6 . i s i n a d e e p co ma T he G la sg ow C o m a S c a l e (T a b l e 2 5 . T hi s i s a m o r e a c c u r a t e e v a l u a t i o n o f m e n t a l s t a t u s o ve r t i me . c a n m a k e v e r b a l r e s p o n s e s . an d t im e. as k. T o a ss es s im me d i a t e m e m o r y .Assessing Level of Consciousness C on s c io us ne s s i s t h e d e g r e e o f w a k e f u l n e s s o r t h e a bi li t y o f a pe rs on t o b e a ro us ed . “W ha t di d yo u e at f or b re ak f a st t h i s m o r n i n g ? ” T o a s s e s s p a s t m e m o r y . T h is is n ot t he s a m e a s or ie nt at io n. a p at ie nt ma y b e c o n s c i o u s b u t n o t o r i e n t e d . Mo st a du lt s c an r ep ea t a s er ie s of f i v e t o e i g h t n u m b e r s f o r w a r d a n d f o u r t o s ix d ig it s ba ck wa rd . A sc or e of 7 o r l es s de f i ne s c om a. Y ou m ig ht a ls o a sk . T h re e p ar am et er s a r e e v a l u a t e d : e y e o p e n i n g . m o t o r r e s p on se . Assessing Memory A ss es s me m o r y b y a s k i n g q u e s t i o n s t h a t c a l l f o r a n sw er s de mo ns t r at in g i mm ed ia t e re ca ll a nd re ca ll f or p as t e ve nt s. L e v e l of c on sc io us ne ss is d es cr ib ed as f ol lo ws : • • • A wa k e a n d a l e r t : f u l l y a w a k e . p la ce . 3 . i nc lu di ng ve rb al c om m a n d s L et ha r g i c : a p p e a r s d r o w s y o r a s l e e p m o s t o f t h e t im e bu t ma ke s sp on t a ne ou s mo ve me nt s. S t ar t wi t h t hr ee nu mb e r s a n d g r a d u a l l y i n c r e a s e t h e d i g i t s u nt il t he pa t i en t ca nn ot re sp on d c or re ct ly . a s k t h e p a t i e n t t o r e p e at a se ri es o f nu mb er s f or wa rd o r ba ck wa rd (e g. a nd v er ba l r es po ns e. i f n o r e f l e x e s p r e s e n t . m ay h av e so me re f l ex a ct iv it y (s uc h as ga g r ef le x ) . S c or es a re g iv en in e ac h ca t e go ry . r es po nd s t o pa in f u l s t i mu li w it h p ur p o s e f u l m o v e m e n t s • C om a t o s e : c a n n ot b e a r o u s e d . b u t t h e se ar e le ss l ik el y t o b e a pp ro pr ia t e . r es po nd s t o al l st im ul i.

o r ge st ur es an d t o u nd er st an d t h e sp ok en a nd wr it t e n w o r d . pu pi ll ar y r es po ns e du ri ng as se ss me nt of t he f ac e) . ” I f i nt el le ct ua l a bi li t y i s i m pa ir ed .No response Verbal response Oriented/talks Disoriented/talks Inappropriate words Incomprehensible sounds No response Assessing Abstract Reasoning 1 5 4 3 2 1 A sk t he p at i e n t t o e x p l a i n a p r o v e r b s u c h a s “ t h e e ar ly b ir d ca t c he s t he w or m. T he c ra ni al n er ve s. T h es e a ph as ia s m ay a ls o be c om bi ne d. or t o m at ch p ri nt e d a n d s p o k e n w o r d s w i t h a p p r o p r i a t e p ic t u re s. f l o we rs . Assessing Language T he c er eb ra l c o r t e x c o n t r o l s t h e a b i l i t y t o e x p r e s s se lf t hr ou gh wr it in g. t he p at ie nt us ua l l y g i v e s a l i t e r a l e x p l a n a t i o n o r r e p e a t s t h e ph ra se . w hi ch i s a d is or de r of l an gu ag e ab il it y. b ed .11 . A ph as ia ma y be e xp re ss iv e ( t h e i n d i v i d u a l u n d e r s t a n d s w r i t t e n a n d sp ok en wo rd s bu t ca nn ot wr it e or s pe ak t o c om mu ni ca t e ef f e ct iv el y) o r r ec ep t i ve (t h e i n d i v i d u a l c a n n o t u n d e r s t a n d w r i t t e n o r sp ok en wo rd s) . E a ch n er ve ha s a sp ec if ic f u nc t i on a nd i s ev al ua t e d i n d i v i d u a l l y . Table 25-11 Summary of Cranial Nerves . p a j a m a s ) . I n j u r y t o t h e c o r t e x c a n c a u s e a ph as ia . al t h ou gh pa rt s of c ra ni al n er ve f u nc t i o n a r e a s s e s s e d w i t h o t h e r b o d y s y s t e m s ( eg . Cranial Nerve Function T he f un ct io n o f t h e 1 2 c r a n i a l n e r v e s i s a s s e s s e d p ri ma ri ly d ur in g t he n eu ro lo gi c a ss es sm en t . t o re ad a sh or t se nt en ce al ou d. B e su re t h at t he p hr as e i s no t cu lt ur e s pe ci f i c. go w n . t o f o l l o w s i m p l e c o m m a n d s ( su ch a s “ P o in t t o y ou r he ad ”) . wo rd s. S o me s i m pl e me t h o d s o f a s s e s s i n g l a n g u a g e c a p a b i l i t i e s i nc lu de as ki ng t he p at ie nt t o n am e i t e ms i n t h e ro om (e g. wi t h t h e i r f u n c t i o n a n d a s s e s s m e n t m e t h o d s . a re o ut li ne d i n T a bl e 2 5.

Sense of taste on the Test for taste with various agents. posterior one third of the tongue Swallowing and speaking Ask the patient to swallow and speak. smile. Sensory Vagus (X) Motor/Sensory Accessory (XI) Motor/Sensory . tongue Sense of hearing Test hearing ability. Test pupillary reaction to light and ability to open and close eyelids. note ability to swallow. Movement of shoulder muscles Ask the patient to shrug shoulders against your resistance. light neck touch. Sensory Abducens (VI) Motor Facial (VII) Motor Sensory Sense of taste on the Test for the taste sensation with various anterior two thirds of the agents.” and have swallowing patient yawn to observe upward movement of the soft palate. eyes Muscles of the face Ask the patient to raise eyebrows. Optic (II) Oculomotor (III) Sensory Motor Sense of vision Pupil constriction Raise eyelids Downward inward eye movement Trochlear (IV) Motor/Proprioceptor Trigeminal (V) Motor Jaw movements— Ask patient to open and clench jaws while chewing and mastication you palpate the jaw muscles.Nerve (Number) Olfactory (I) Type Sensory Functions Sense of smell Methods for Examining Nerve Test each nostril for smell reception and interpretation. elicit gag response. Lateral movement of the Test ocular movement in all directions. Test for downward and inward movement of the eye. show teeth. Test vision for acuity and visual fields. Acoustic (VIII) Glossopharyngeal (IX) Sensory Motor Pharyngeal movement andAsk the patient to say “ah. note hoarseness. puff out cheeks. Sensation on the face and Test face and neck for pain sensations. temperature.

l ig ht t ou ch . a nd c er eb el la r s y s t e m s . Inspecting Balance and Gait E va lu at e b a l a n c e a n d g a i t b y h a v i n g t h e p a t i e n t w al k ac ro ss t h e ro om o n t he t oe s. t h e m o v e m e n t s a r e c oo rd in at ed . A g r a d e o f 2 i s c o n s i d e r e d a n or ma l o r ac t i ve r es po ns e. T h e pa t i en t s ho ul d b e ab le t o d i s t i ng ui sh b e t w e e n s h a r p ( p a i n f u l ) a n d s o f t o r d u l l t o uc h. T he y ar e u su al ly g ra de d o n a s ca le o f 0 t o 4 . a n d a r m a n d l e g m o v e m e n t s . us e a s h a r p o b j e c t a n d a s o f t o b j e c t r a n d o ml y t o t o uc h t he u pp er an d lo we r e xt re mi t i es t o t e st s en sa t i on . g a i t . A b no rm al f i nd in gs i nc lu de in ab il it y t o pe rc ei ve p ai n o r l i g ht t ou ch . ask strength of the tongue patient to push tongue against cheek. f e et . a n d t a p t h e f o o t o n t h e f l o o r ( o r a ga in st y ou r h an d. a nd v ib ra t i on . a r e i l l u s t r at ed in T ab le 25 -1 2. a nd a bs en ce of v ib ra t o ry se ns at io n. W it h t h e pa t i en t ' s e ye s c l o se d. T h e sa me p ro ce ss is r ep ea t e d b y us in g t h e t un in g f o rk t o t es t f or v ib ra t o ry s e n s a t i o n a n d p l a c i n g t h e f o r k o n b o n y pr om in en ce s. a r m s . a nd ab n o r m a l p a t t e r n s o f g a i t . ra pi dl y p at t he h an d o n t h e t h i g h . Re pe at t h e se qu en ce on t he o pp os it e l i m b . w it h no rm al r es po ns es a n d m e t h o d s o f a s s e s s m e n t .Hypoglossal (XII) Motor Movement of the tongue.1 3 . Normal Age-Related Variations Infant/Child C om mo n n e u r o l o g i c v a r i a t i o n s f o r n e w b o r n s a n d c hi ld re n in cl ud e: . A b no rm al f in di ng s i nc lu de lo ss o f ba la nc e. Us e t h e re f l ex h am me r P . a nd t h e ga it e v e n w i t h s i m u l t a n e o u s a r m m o v e m e n t s. 6 49 t o el i c it m us c l e c o n t r a c t i o n a n d r e f l e x e s . w it h sl ig ht sw ay in g in t he st an di ng p os it io n. i n a b i l i t y t o i d e n t i f y t h e l o c a t i o n o f t o u c h . T h e p a t i e nt ma y be e it he r s it t i ng o r su pi ne . A ss es s se ns or y f un ct io n by t e st in g se ns or y d i s cr im in at io n o f p a i n . a nd co or di na t i on . Reflex Function E va lu at e t he d e e p t e n d o n r e f l e x e s t o d e t e r m i n e t h e f u nc t i on al ab il it y o f sp ec if ic s pi na l s eg me nt l ev el s. S el ec t e d re f l ex es . P . Assessing Sensory Function T es t se ns or y p e r c e p t i o n b y e v a l u a t i n g t h e p a t i e n t ' s r es po ns e t o pa in . it m ay i nd ic at e d is e a s e o f t h e u p p e r m o t o r n e u r o n s o r c e re be ll um . i f t h e p at ie nt i s su pi ne ). a n d v i b r a t i o n s . a nd h ee l t o t o e. O bs er ve p os t u re . b al a n c e . l i g h t t o u c h . wi de -b as ed g ai t . ve st ib ul ar . a s l i s t e d in T a b l e 2 5 . T he a ss es sm en t p r o c e e d s f r o m d i s t a l ( h a n d s . T h e s e f i n d i n g s m ay i nd ic at e d is or de rs of t he m ot or . N o r m a l l y . I f t h e p at ie nt i s un ab le t o p er f o rm t h es e mo ve me nt s. sh uf f l i n g. se ns or y. 6 48 Motor and Sensory Function E va lu at e m o t o r a b i l i t y b y a s s e s s i n g b a l a n c e . Assessing Motor Function and Coordination E va lu at e m o t o r f u n c t i o n a n d c o o r d i n a t i o n b y h a v i n g t h e p at ie nt r ap id ly t o uc h ea ch f i ng er w it h t h e t hu mb . Ask the patient to protrude tongue. o n t he h ee ls . or l eg s) t o p ro xi ma l (t he t r un k) . T h e po st ur e s ho ul d be er ec t .

or ga ni ze a ll as se ss me nt d at a t o id en t i f y a ct ua l a nd p ot en t i al he al t h p ro bl em s. s i g h t . t h e p r e g n a n t w o m an wi t h a h is t o ry o f su bs t a nc e a bu se . a nd e va lu at e t he p at ie nt 's re sp on se s t o t r ea t m en t . a nd ex t r em it ie s se qu en ce Older Adult C om mo n n e u r o l o g i c v a r i a t i o n s f o r o l d e r a d u l t s i n c l ud e: • • • • • • • S lo w e r t h o u g h t p r o c e s s e s a n d v e r b a l r e s p o n se s D ec r e a s e d s e n s o r y a b i l i t y ( h e a r i n g . F o r ex am pl e. s u c h a s w i t n e s s i n g t h e p a t i e n t 's co ns en t . w i t h a w i d e r b a s e a n d f l e x e d h i ps a nd kn ee s D ec r e a s e d d e e p t e n d o n r e f l e x e s Documenting the Data A f t er c om pl e t i n g t h e n u r s i n g h i s t o r y a n d a s s e s s m e n t .6. a nd t r an sp or t i ng sp ec im en s. T he n ur se is a ls o re sp on si bl e f or o t h er ac t i vi t i es a ss oc ia t e d w it h d i a gn os t i c t e s t s . Table 25-12 Normal Responses of Commonly Tested Reflexes . a nd pa in ) S lo w e r c o o r d i n a t i o n a n d v o l u n t a r y m o v e m e nt s D ec r e a s e d r e f l e x r e s p o n s e s A pp e a r a n c e o f c o n f u s i o n i n u n f a m i l i a r s u r r ou nd in gs S lo w e r g a i t .• • • P os it i v e B a b i n s k i 's r e f l e x ( n o r m a l i n c h i l d r e n b et we en 12 a nd 24 m on t h s) G ra s p r e f l e x ( p r e s e n t a t b i r t h ) M ot o r c o n t r o l d e v e l o p s i n h e a d . H ow ev er . p l a n a p p r o p r i a t e ca re . a n d a f t e r d i a g n o s t i c t e st s. di sp os in g of us ed e qu ip me nt . p r o v i d i n g c a r e a f t e r t h e t e s t . t h e s p e c i m en w as t o b e us ed f o r dr ug t es t i ng wi t h ou t t h e p at ie nt 's kn ow le dg e. t he n ur se wo ul d ne ed t o k no w t h e a ge nc y' s p o l i c y a n d l e g a l s t a t u t e s o f t h e a r e a r e g a rd in g c on se nt f o r dr ug t es t i ng be f o re o bt ai ni ng t h e s pe ci me n. I n a d d i t i o n . pr ep ar in g t he p at ie nt ph ys ic al ly a nd e mo t i on al ly f o r t h e t e s t . T h e s e d a t a a r e u s e d t o s u p p o r t t h e n u r si ng d ia gn os is of A ct iv it y I n t o le ra nc e r el at ed t o f at ig ue an d lo we r e xt re mi t y w e a k n e s s . A pa t t er n i s o f t en es t a bl i s h e d t h a t b e g i n s d u r i n g t h e h i s t o r y a n d is c on f i rm ed du ri ng t h e ph ys ic al as se ss me nt . w i t h e a c h s ys t e m re co rd ed in di vi du al ly . n e c k . T yp ic al ly a s i g n e d c o n s e n t f o r m i s n o t n e c e s s a r y f or u ri ne sp ec im en s. t em pe ra t u re . N u r s e p r a c t i t i o n e r s a n d p h y s i c i a n s m ak e de ci si on s c on ce rn in g w hi ch d ia gn os t i c t es t s t o s ch ed ul e wh en p ro bl em s a r e n o t e d d u r i n g t h e h e a l t h h i s t o r y o r p h y si ca l as se ss me nt or b ec au se of a p ro bl em st at ed by t he p at ie nt . D ia gn os t i c t e s t s p r o v i d e c r u c i a l i n f o r m a t i o n a b o u t a pa t i en t ' s h ea lt h. D o c u m e n t t h e d a t a . a he al t h h i s t o ry o f a w o m a n d i a g n o s e d w i t h m u l t i p l e s c l e r o s is ( a n eu ro lo gi c d is or de r) i nc lu de s d at a ab ou t f at ig ue an d in cr ea se d w ea k n es s a n d m u s c l e s p a s m s i n t h e l e g s . T ab le 2 5. A d oc um en t a t i on ex am pl e i s il lu st ra t e d i n B o x 25 .14 pr es e n t s a n o v e r v i e w o f d i f f e r e n t t y p e s o f d i ag no st ic pr oc ed ur es . t a st e. P h y s i c a l e xa mi na t i on f i nd in gs in cl ud e de cr ea se d m us cl e s t r en gt h in t h e lo we r e xt re mi t i es . s me ll . s ch ed ul in g t he t e st . The Nurse's Role in Diagnostic Procedures N ur se s as si s t b e f o r e . m a k e n u r s i n g d i a g n o s e s . d u r i n g . A u ri ne s pe ci me n w as t o be o bt ai ne d f or r o u t i n e t e s t in g . t r u n k. T hi nk b ac k t o T a m m y B r o w n i n g . a nd t h ei r re su lt s be co me a pa rt of t he t ot al h ea lt h a ss es sm en t .

The percussion hammer strikes the examiner's thumb. the forearm is placed across the chest wall with the palm turned toward the body. . To test the triceps reflex. If the patient is lying down. and the palm faces downward. To test the knee reflex. The patellar tendon just below the patella is struck with the percussion hammer. Knee The contraction of the quadriceps causes the knee to extend. the patient is in the sitting position. To test the biceps reflex. The triceps tendon is struck with the percussion hammer just above the elbow. The examiner's thumb is placed on the biceps tendon at the bend in the elbow.How to Test Reflex Biceps Normal Response The contraction of the biceps can be seen and felt. Triceps The contraction of the triceps can be seen as the elbow extends. the reflex is tested while the examiner's hands are placed under the knees to bend them. the elbow is slightly bent. the patient's elbow is sharply bent.

Ankle The foot jerks and moves downward. from the heel to the ball of the foot. The lateral aspect of the sole of the foot is stroked with an object. Abdominal The contraction of abdominal musculature can be seen. with the patient lying on the back. each side of the abdomen is stroked from the sides toward the center with a tongue blade or key. the leg is bent at the knee and the foot is supported in a walking position. To test the ankle reflex. The Achilles tendon is struck with the percussion hammer. Table 25-13 Grading of Reflexes on a 0 to 4+ Scale . Babinski The toes bend or curl. such as a key or a thumbnail. To test the abdominal reflex.

” S he s ay s sh e ha s a bo ut t wo mi xe d dr in ks a w ee k a nd d oe s n ot s mo ke .Grade Description 4+ Very brisk. p uf f o ut c he ek s. d i e d o f h e a r t p r o b l e m s a t 7 7 ye ar s o f ag e M at er na l g ra n d m o t h e r . d i e d o f u n k n o w n c a u s e s a t 5 6 ye ar s o f ag e S is t e r.si gh t e dn es s.c o u nt er m ed ic at io ns f o r co ns t i pa t i on an d c ol ds . R = 16 br ea t h s / m i n . H ea ri ng t e st ed b y us e o f a cl oc k. sm il e. V is io n wi t h g l a s s e s 2 0 / 3 0 . De mo ns t r at es ac co mm od at io n. h ad an a pp en de ct om y a t 2 2 ye ar s of a ge . s h i n y . M rs . H er f am il y h i s t o r y o f i l l n e s s i s a s f o l l o w s : M at er na l g ra n d f a t h e r . P u p il s eq ua l a nd r ea ct t o l ig ht . O r a l m u c o u s m e m b ra ne s pi nk . L e n s c l e a r . cl os e ey es . R i g h t n o s t r i l c l e a r . 4 9 y e a r s o f a g e . . possibly but not necessarily indicative of disease Average. 4 i n c h e s t a l l . E xt er na l e ar s s y m m e t r i c . low normal No response 3+ 2+ 1+ 0 Box 25-6: Documenting a Health Assessment M rs . T on si ls a bs en t . E x t e r n a l e y e s t r u c t u r e s s y m m e t r i c . S c l e r a w hi t e . H a i r d a r k b r o w n .t h e . t h yr oi d no np al pa bl e. d i e d o f d i a b e t e s c o m p l i c a t i o ns at 6 9 y ea rs o f ag e P at er na l g ra n d f a t h e r . S he sa ys . a nd i s al le rg ic t o p en ic il li n ( c a us es ra s h a n d d i f f i c u lt y b r e a t h i n g ) . T ee t h i n go od re pa i r w i t h s i x f i l l i n g s . h ad h e r t o n s i l s r e m o v e d a t 5 y e a r s o f a g e . P = 8 2 b e a t s / m i n . i s a 5 2 . RL Q (a pp en de ct om y) . d ie d a t 2 2 y e a r s o f a g e i n a c a r a c c i d e n t Physical Assessment V it al s ig ns : T = 9 8 . B P = 1 5 0 / 8 8 m m H g H ei gh t / we ig h t : 5 f e e t . D. n or ma l d is t r ib ut io n. D . S h e g ra du at ed f r o m h i g h s c h o o l a n d i s e m p l o y e d a s a s ec re t a ry f o r a lo ca l in su ra nc e a ge nc y. a nd or ie nt ed . C a n a l s s m o o t h a n d p i n k wi t h ou t ex ce ss ce ru me n. c on ve rg en ce . “I j us t st ar t e d h av in g a l ot o f g a s a n d w a s s i c k t o m y s t o m a c h a f t er e at in g f ri ed f oo ds . ” T h e nu rs e i n ch ar ge o f t he a ge nc y m ak es t he f ol lo wi ng as s e s s m e n t s . often indicative of disease. w hi ch s he he ar d cl ea rl y a t 2 f e et . Health History M rs . al er t . c on ju nc t i va pi nk . O ld sc ar . L ef t ma xi ll ar y s in us s li gh t l y t e nd er on p al pa t i on . a n d p e r i p h e r a l v i s i o n . normal Somewhat diminished. d i e d o f s t r o k e a t 8 2 y e a r s o f a ge P at er na l g ra n d m o t h e r . F a c i al f ea t u re s s ym me t r ic .gr oo me d. H ea d an d n e c k : S k u l l s i z e a n d s h a p e n o r m a l . W e ar s gl as se s t o co rr ec t ne ar . S h e h a s h a d a ll h er i mm un iz at io ns . S h e t a ke s a p re sc ri pt io n m ed ic at io n t w i c e a d a y f o r “ h i g h b l o o d p r e s s u r e . S he h as ha d f i v e p r e g n a n c i e s . b ut he r la st t et an us sh ot w as 1 0 y ea rs a go . hyperactive. D. n o r m a l t u r g o r .2 o n S n e l l e n ' s c h a r t .ol d h us ba nd on a f ar m in a ru ra l mi dw es t e rn ar ea . 8 ° F ( o r a l l y ) . often associated with clonus (rhythmic oscillations between flexion and extension) Brisker than average. 1 7 8 p o u n d s I n t eg u m en t : S k i n w a r m a n d d r y . N ai ls c on ve x a n d s m o o t h . S h e o c c a s i o n a l l y t a k e s o v e r . N o l y m ph n od es p a l p a b l e . N um er ou s f re ck le s ov er f ac e a nd a rm s. is w el l. l e f t n o s t r i l o c c l u d e d w it h mu cu s. D. c om e s t o a l o c a l c o m m u n i t y o u t p a t i e n t a g e n cy f or h er in t o le ra nc e o f ea t i ng f a t t y f o od s. Ca n r ai se e ye br ow s. T ym pa ni c m em br an es in t a ct w it ho ut re dn es s o r dr ai na ge .o l d w o m a n w h o l i v e s w i t h h e r 54 -y ea r. Mr s. h e a l t h y B ro t h er . r e s u l t i n g i n f i v e l i v i n g ch il dr en . T r ac he a mi dl in e.y e a r .

A re ol ae an d ni pp le s d ar k br ow n. F i ne m ot or m ov em en t s in t a ct . N o ex t r a h ea rt so un d s . F u ll a ct iv e r an ge o f mo t i on in a l l j o i n t s . t e nd er ne ss . M u s c l e s t r e n g t h e q u a l b i l a t e r al ly . S pe ec h c le ar a nd ap pr op ri at e. N o m a ss es p a l p a t e d i n b r e a s t s . M u s cu l o sk e l e t a l : S t a n d s e r e c t . ao rt ic . P e rc e i v e s p a i n o r l i g h t t o u c h a p p r o p r i a t e l y . B o we l so un ds he ar d in al l f o ur q ua dr an t s . F ac ia l ex pr es si on s a pp ro pr ia t e . S m a l l e x t e r n a l he mo rr ho id s n ot ed . D em on st ra t e s l o n g . Re sp ir at io ns e ve n a nd u nl ab or ed . N o p ai n on l ig ht pa lp at io n. r o u n de d .t e r m a n d s h o r t . T o en ai ls t hi ck an d ye ll ow . Lu ng s ou nd s c le ar . an d mi t r al a re as . N eu ro l o g i c: A l e r t a n d o r i e n t e d t o t i m e . U m b i l i c u s m i d l i n e . N o r m a l s p i n a l c u r ve s. A l l re f l ex es = 2. s li gh t l y st ro ng er on t he r ig ht (d om in an t s id e) . S u pe rf i c ia l v ar ic os e v ei ns p re se nt on b o t h l o w e r e x t r e m i t i e s b e t w e e n a n k l e a nd k ne e. B re as ts an d a x i l l a : S k i n p i n k . no c ru st in g or dr ai na ge . t r ic us pi d. m u r m u r s . A p i c a l p u l se 84 b ea t s / m in an d re gu la r.T h o ra x/ l u n g s / h e a r t : T h o r a x s y m m e t r i c w i t h e q u a l ex pa ns io n. o r cr ep it at io n. A b d o m en : O b e s e . G a it e ve n. T o h av e m am mo gr am a t n ex t vi si t . P er i p h e ra l v a s c u l a r : P ul s e s e q u a l i n b o t h a r m s . A l l cr an ia l ne rv es t e st s we re i nt ac t . A x i l l a r y l y m p h n o d e s ar e n ot p al pa bl e. N o b ru it s he ar d o n a u s c u l t a t i o n . p l a c e . N o jo in t d ef or mi t i es . S 1 an d S 2 h ea rd at p ul mo ni c. No v i s ib le p ul sa t i o n s n o t e d i n n e c k o r p r e c o r d i u m . N o d i m p l i n g o r r e t r ac t i on n ot ed . o r b r u i t s h e a r d . N o ed em a p re se nt . G en i t al i a : W i l l b e a s s e s s e d a t n e x t v i s i t w i t h p e l v i c an d P a pa ni co la ou 's s me ar . p e r s on . P u ls es e qu al in b ot h l eg s.t e r m m e m o r y . R ec tu m an d a n u s : I n s p e c t e d o n l y . .

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