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:

• • • • • • • •

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 :

• • • •

“ 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 :

• • • •

“ 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 :

• • • •

“ 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:

• • • • •

“ 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) .

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 .y e a r . c le an o r st er il e. 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 . e ne rg y l ev el . 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. t u rn s o n t h e il lu mi na t i on . w he n de pr es se d a nd t u rn ed . 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 . 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 . Snellen Chart T he S ne ll en c h a r t . 2 5 . a nd bo we l so un ds . 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 . 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. a nd t h e s h o r t e s t . 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. 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. l u n g s . 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.s i g h t e d ( h y p e r o p i c ) p at ie nt s.si ze d t y pe . 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 . 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 . 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 . 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 . 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 . 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 . a n d c a r d i ov as cu la r s ys t e m. 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 nd di st an ce s a r e i n t h e r i g h t . T he s pe cu la co me i n va ri ou s s iz es .ha nd co lu mn .t o .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. A l t e r n a t i v e l y . 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 . 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 . T h e d i a l o n t h e h e ad . su c h a s n o r m a l h e a r t s o u n d s .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 . p o s i t i o n 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. T h e li gh t is p ro vi de d b y t h e s co pe . 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 . 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. 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 . W he n us in g t he s t e t h os co pe . Du ri ng he al t h a ss es sm en t . 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. 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 .h a n d c o l u m n n e x t t o t h e nu mb er s. 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. su ch a s a t on gu e b la de a nd pe nl ig ht .2) . a b d o m e n .o l d w h o w a s s t u ng b y a b ee . 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 . 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 . E v e n wh en mo di f i ed .1. 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 . T he h ea d i s s e c u r e d i n t h e b o d y . 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. 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 . 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. b r e a t h s o u n d s. Re d nu mb er s a re u se d f or n ea r. 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 .pi t c he d s ou nd s. in p ro pe r wo rk in g o rd er . 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. bl a c k n u m b e r s f o r f a r .si gh t e d ( my op ic ) p at ie nt s. S om e eq ui pm en t . t h e 9 . s uc h a s ab no rm al c ar di ov as cu l a r s o u n d s . 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 . a nd ph ys ic a l s t a t e . 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 . C on s i de r B il l y C o l l i n s . a s w e l l a s t i m e c o n s t r a i n t s . 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 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.

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 . 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 . R em em be r R a m o n a L e w i s . 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 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. p r o v i d e s p ri va cy . I n sp ec t i on be gi ns wi t h t he i ni t i al .3. Tuning Fork A t un in g f or k i s a t w o . O nc e vi br at in g. 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 . 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 . s u c h a s m ov em en t o r pu ls es . D ur in g p os it io ni ng . W h e n c on du ct in g a n as se ss me nt . p h y s i c a l c o n d i t i o n . 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. 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 . 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. e n er gy le ve l. 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 . 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 . 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 . h ea lt h s t a t u s . 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 . o r b e d l i n e n s .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 . m o b i l i t y . 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 . f o r ex am pl e. a nd pr iv ac y. c l o t h . 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 .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 ha t i s. 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 . D ra pe s m ay b e p a p e r . 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. 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 . 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 . 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 . 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. T he q ui ck . 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 . 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 . 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. 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.Vaginal Speculum A v ag in al sp e c u l u m i s a t w o . 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 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 . 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 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. 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 .

P . as d et er mi ne d b y pa lp at io n. shape. texture. and infestations. 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 . t e x t u r e . thought processes. a n d m o i s t u r e o f b o dy s ur f a ce s.4) . an d sh ap e. Skin: Inspect for color and lesions. an d sy mm et ry . 5 ″ t o 0 . 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 . 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 . 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 . inspect for discharge. • Integument • Gloves • • • Head and neck • • • • • Gloves Snellen chart Ophthalmoscope Otoscope Tongue depressor • • • • . 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 . Li gh t .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 . s h a p e . ar e d es cr ib ed i n T ab le 25 -2 . extraocular movements. F or l ig ht pa lp at io n. 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 . mo de ra t e . f l ui d. 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 . 6 05 P . Take vital signs. and internal structures. A n y ar ea of t en de rn es s i s pa lp at ed la st . 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 . C h a r a c t e r i s t i c s o f m a ss es . or d ee p p al pa t i o n m a y b e u s e d . w hi ch c ar ri es a r is k of in t e rn al i nj ur y. palpate for temperature. 2 5 . Skull and face: Inspect for shape and symmetry. p re ss i nw ar d a bo u t 2 c m ( 1 ″ ) ( s e e F i g .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. Hair: Inspect for texture. Evaluate height and weight. D e e p p a l pa t i on . t u r g o r . posture. t e x t u r e . m o i s t u r 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 . 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 . 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 . 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 . 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 . s iz e. gait. 2 5 . p a lp at in g b re as t t is su e) . w it h in sp ec t i on pr ec ed in g p al pa t i on . and moisture. 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 . 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 . consistency. sh ap e. hygiene. loss. 5 ″ ) ( se e F i g. 2 5. Nails: Inspect for color and condition. a n d p u l s a t i o n . p os it io n. 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 . alignment. Lymph nodes: Palpate for size. Eyes: Test visual acuity. and tenderness.5 A) . 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 . and peripheral vision. 7 5″ ). v i b r a t i on s. speech patterns. 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 . Neck: Palpate trachea and thyroid gland. A qu ie t en vi ro nm en t a ll ow s so un ds t o b e h ea rd . unusual growth. F or d ee p p al pa t i on . c on si st en cy . c o l o r .

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

Anus: Inspect and palpate for hemorrhoids. see. color. hygiene. 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 . amount). swelling. shrug shoulders against resistance. shape. pat knees with palms and backs of hands. Mental status: Assess level of awareness. mobility. Reflexes: Assess degree of response. a nd d en si t y of t i s s u e s . Joints: Test range of motion. Fine motor movement: Test ability to repeatedly touch nose with hand. level of consciousness. Sensory: Test ability to distinguish between sharp and dull touch. Joints and muscles: Inspect for size. lesions. lumps. P er cu ss io n i s us ed t o as se ss t h e lo ca t i on . and edema. palpate for nodules. si ze . feel touch. Uterus: Palpate for size.Female genitalia • • • • • • Gloves Speculum Lubricant Applicators Culture tubes Pap test supplies • • External genitalia: Inspect for inflammation. consistency. 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 . move eyes. 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. fissures. and bulging out of vagina. dress. Please consult an assessment textbook for additional information.6A ). odor. and strength. • Anus. Ovaries: Palpate for size. discharge (color. rectum. Cranial nerves: Test ability to smell. Stool: Inspect for color. shape. and tenderness. 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 . 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. crepitus. and tenderness. 25 . Prostate: Palpate for size. symmetry. and protrude tongue. Gait: Inspect gait and posture. thought processes. and memory and abstract reasoning. position. 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 consistency. test for occult blood. 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 . ulcers. 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 . have facial expressions. 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. s ha pe . speech. swallow. infestations. hear. clench teeth. rashes. and run heel down opposite shin. grooming. taste. masses.

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. 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 . t ak in g vi t a l s ig ns . or l on g) .6 B) . g u r g l i n g o r s w i s h in g) . 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 . a n d g a i t ( w h i l e w a l k i n g u p ri gh 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 . 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 . I t i s us ed t o a ss es s po st u r e . 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 . 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 .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 . ( 3 ) q u a l i t y ( e g . 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 . m ed iu m. a nd ( if p os si bl e) li st en i n a q ui et e nv ir on me nt . 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 . 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 ). A s se ss in g P . 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. 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. 6 08 P . o r pr on e t o f a ll . 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. a nd ( 4) d ur at io n ( sh or t . 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 . de sc ri be d i n T ab le 25 -3 . 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. w hi ch i s pa rt o f t h e n eu ro lo gi ca l s ys t e m) . b a l a n c e . 2 5 .( s e e F i g. 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 . W h en a us cu lt at in g. ( 2) lo ud ne ss ( ra ng in g f r o m so f t t o l o u d ) . a nd ga it . d iz zy . 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 . 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. T he a cc om p a n y i n g h e a d . 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. 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 nd me as ur i n g h e i g h t a n d w e i g h t . I ns pe ct t he pa t i en t ' s b od y bu il d. 6 07 P .t o . . 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. 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 .

f a c i l i t a t e s f u ll lu ng e xp an si on . n ec k. ex t r em it ie s. a nt er io r t ho ra x. h ea rt . br ea st s. h e a r t . l un gs . 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 nd up pe r ex t r em it ie s. 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 . b r ea st s. 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 . or r em ai n in b ed wi t h t he h ea d e le va t e d.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. a nd p er ip he ra l p u l s e s . a nt er i o r a n d p o s t e r i o r t h o r a x . n e c k. 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 . ab do me n. l u n g s . Supine Dorsal Recumbent .

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 i s us ed t o as se ss t h e he ad . 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 . an d so le s o f t h e f e et o n t he b ed . n ec k. B ot h kn ee s a r e f l e x 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. 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. 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 . 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. k ne es f le xe d. 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 . 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 . e x t r e m i t i e s . h e a r t . a nd pe ri ph er al pu ls es . l u n g s . 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 . .

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

) 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 .Figure 25-5. (Photos by B. Degrees of palpation. The skin and underlying structures are depressed about 1 inch (2 cm). light pressure is applied by placing the fingers together and depressing the skin and underlying structures about ½ inch (1 cm). (A) In light palpation. Proud. (B) Deep palpation is used with caution.

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. and density of tissues.) 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 . 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 . Proud. 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 . a nx ie t y . 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 .4 pr es en t s t h e G e ri at ri c De pr es si on S c al e. b o d y o do rs ). shape. (Photos by B. ab il it y t o re la x. size. I f y o u s u s p e c t d e p r e s s i on . 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 . and the middle finger is placed firmly on the body surface. an d a pp ro pr ia t e ve rb al r es po ns es ). Percussion is used to access the location. B o x 2 5 . 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 .Figure 25-6. 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. . 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. T h es e ma y in di ca t e ot he r pr ob le ms . 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 . e ye c on t a ct . N ot e si gn s o f i l l n e s s . No t e a ny d ef ic it s. an d re sp ir at io ns . a t t i t u d e . 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. 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 . s ki n c ol or . T hi nk b ac k t o T a m m y B r o w n i n g . S p e e c h . a n d m o o d . n on ve rb al co mm un ic at io n o f pa in or d i s t r es s. F or e xa mp le . 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 . a nd s h o r t a t t e n t i o n s p a n . (A The nondominant had is placed directly on the area to be percussed. 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 . s u c h a s c h a n g e s i n p o s t u r e . (B) The tip of the middle finger of the dominant hand strikes the joint of the middle finger of the opposite hand. A ss es s af f e c t . f a c i a l ex pr es si on s. or ie nt at io n. o r ot he r me nt al he al t h di so rd er s.

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 . BOX 25-4: Geriatric Depression Scale (GDS) . ha i r . 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 . I ns pe ct t he s ki n f or c ol or . 2 5 . we ar g lo ve s du ri ng pa lp at io n. m oi st ur e. an d l es io ns (F ig . 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 . 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. an d n ut ri t i on .1 ). f oo ds . I t a ls o p ro vi de s d at a a b o u t s e l f . an d sc al p. 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 . 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 . 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.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 . s i z e . I f t h e p a t i e n t h a s l e si on s. 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 . 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 . 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 . 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 ) . hy gi en e. va sc ul ar it y. 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 . n a i l s .7) a n d pa l p a t e f o r t e m p e r a t u r e . 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 ) . I f t he p at ie nt ca nn ot st an d er ec t .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 . c h a n g e i n c o l o r . l e s i o n s . o r b ur ns ) C ha n g e i n t h e c o l o r . 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 . 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 . 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 . an d t e xt ur e. t ur go r. h ai r. h yd ra t i on st at us . P . 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 . h ai r. p l a n t s . an d n ut ri t i on . 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. 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 . 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 . 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 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. b r u i s e s . a b r a si on s. 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 . 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 . T ab le 2 5 . 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. 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 .

yes yes no no 10. yes no 8. 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. 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. 9. yes no 7. yes yes no no 6. 5. 14.Instructions: 1. no 4. no 13. Circle the answer that best describes how you felt over the past week. no . no 12. rather than going out and doing things? yes no 2. 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.

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 . I t i s a ss oc ia t e d w i t h s u n b u r n . 6 11 p at ie nt s w it h d a r k s k i n . a nd pa ll or ( T a bl e 2 5.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 . 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 . Obtaining Weight • • • • • • • B al a n c e t h e s c a l e o n z e r o . 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 . 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.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 . 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. 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 . P a l l o r . a nd c on ju nc t i va . so me t yp es of a ne mi a. i n f l a m m a t i o n . 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 . ja un di ce . 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 . an d h e m o l y s i s . R ai s e L . 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 . L ow e r t h e L . 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 . pe op le of M ed it er ra ne an d es ce nt . 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 . 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) . f e v e r . Hi sp an ic s. . 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. 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 .5) . 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 u c h a s t h e f a c e a nd h an ds . 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 y a n o s i 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 .s k i n n e d p a t i e n t s . 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 . 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 . 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 . or p al en es s o f t h e s ki n. 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 r a l m uc ou s m em br an es . T hi nk b ac k t o B i l l y C o l l i n s . 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 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 . 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 . t h e c h i l d w h o w a s s t u n g b y a be e. S om e bo dy ar ea s of da rk -s ki nn ed pe op le . bu t t he s cl er a. 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. 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 . 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 . t r a u ma . Na t i ve A me ri ca ns .o ra ng e. mu co us m em br an es . 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. 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 . p a l m 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 . n ai lb ed s.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.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 . J au nd ic e i n d a r k . 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 . a nd a ll er gi c r ea ct io ns . P a l l o r i n d a r k . 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 .s k i n n e d p e o p l e . a n d u s i ng t h e sa me s ca le . 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. De pe nd in g o n se ve ri t y .

) S ca rs a re he al ed w ou nd s. h em at ol og ic . as se ss t he ir l oc at io 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 . (W ou nd s a re d is cu ss ed in C ha p. Proud. co lo r. 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. Table 25-4 Height and Weight Table . a n d p r e s e n c e o f d r a i n ag e o r od or . co lo ri ng . sc ra t c he s. 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 . c ut s. o r b r u i s i n g. 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. b l e e d i n g . l o c a t i o n . 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.6 an d 2 5. R em em be r R a m o n a L e w i s . N ot e br ui se 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. in se ct b it es . d e p t h . 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 . 38 . el ev at io n. De s c r i b e P . I f t h ey ar e pr es en t . a nd si ze . Inspecting Skin Lesions I ns pe ct t h e s k i n f o r l e s i o n s .7 ). w hi ch m ay a ri se f r om p re vi ou sl y no rm al sk in . 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 . an d s ec on da ry . 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 . 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 . 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 . 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 . 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 . 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 .© B. s i z e . c au si ng pu rp li sh d is co lo ra t i on . an d p re se nc e o f dr ai na ge or i t c hi ng . o r li ve r d ys f u nc t i on . s ha pe .

i s c a l l e d d i a ph or es is . Moisture. Palpating Skin Temperature. 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 . † Weights at ages 25 to 59 yr are based on lowest mortality. . Texture. 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). 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 . 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 . Weights in pounds are according to frame (in indoor clothing weighing 3 lb. Weights in pounds are according to frame (in indoor clothing weighing 5 lb. 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 . A n e xc es si ve am ou nt o f pe rs pi ra t i on . t he t ex t u re is d r y .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.

o r + 4 ( v e r y d ee p.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 he n ai ls s ho ul d b e sm o o t h . t h i s i s c a l l e d p i t t i n g e de ma . (Photo © B. i n f e c t i o n . 6 m m ) . 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 . mucous membranes. 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 . 4 m m ) . and sclera Exposed areas. particularly the face and lips. Proud. The skin is inspected for color. particularly the ears. w h e n p a l p a t e d. 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 ) . 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 . h ow ev er . an d co lo r. 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 . injury trauma. 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 .) 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 . lips. 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. and lesions. hands and feet. 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. W he n t h e p at ie nt i s d eh yd ra t e d. 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 . a n d t h e n a i l b a s e . 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 . an d c l u bb in g ( f r o m l o n g . 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 ). E de ma m ay b e t he r es ul t of ov er hy dr at io n. 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 . k i d ne y f ai lu r e . 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 . alcohol intake. 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 e x t u r e . and mucous membranes Liver disease (increase in bilirubin levels) Yellowish (jaundice) Paleness (pallor) Anemia (decreased hemoglobin) Shock (decreased blood volume) . 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 . 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 ). F i g ur e 2 5. infection Exposed areas. 8 mm ). E d em a is c ha ra ct er iz ed by s we ll in g. sh ou ld b e f ir m an d no nt en de r. fever. vascularity.t e r m l a c k o f o x y g e n a t i o n ) . + 3 ( d e e p . 2 mm ). conjunctivae. E de ma ma y be g ra de d a s 0 (n on e) . t r a u m a . + 2 ( mo de ra t e . he ar t f a il ur e. 2 5 .8 ) . flushing) Bluish (cyanosis) Assessment Areas Possible Causes Facial area. inside Cold environment. A b no rm al f i nd in gs in cl ud e i nd en t a t i on s P . Table 25-5 Skin Color Assessment Color Variations Redness (erythema. + 1 ( t r ac e. cardiac or respiratory of the mouth. localized area of skin on the body Blushing. a n g l e .

i nf ec t i on . To assess skin turgor. s i z e . Difficulty in lifting a skin fold may indicate presence of edema. no t e t h e i r l o c a t i o n . l es io ns . wh ic h ar e t h e w hi t e e gg s o f li ce . 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 . (Photo © B. o r in ad eq ua t e n ut ri t i on . nailbeds.) 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 . s c a l i n g . d r yn es s. Figure 25-8.Vitiligo (whitish patchy areas on the skin) Tanned or brown Overall skin areas. A ss es s t h e h ai r f o r co lo r. I f a ny l um ps or m as se s ar e p al pa t e d. t e n d e r n e s s . ho rm on e d is or de rs . Ni t 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 . 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. t h e s o l e s o f t h e f e e t . a n d mo bi li t y . lips. a nd p ar t s of t he g en it al ia . a small fold of skin is picked up and then released to return to its normal shape. 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 . l um ps . or l ic e. Proud. 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. conjunctivae Depigmentation (congenital or autoimmune conditions) Sun-exposed areas Overexposure (increased melanin production). d r y n e s s . 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 . ra di at io n t he ra py . d e c r e a s e d t u r g o r . 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) . 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 . e v e n l y d i s t r i b u t e d . ma y ca us e l os s of h ai r. 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 . a nd d i s t r ib ut io n. a n d n ei t h er e xc es si ve ly dr y no r oi ly . t ex t u re .

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 . 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 . no se a nd si nu se s. m ou t h an d ph ar yn x. t hy ro id gl an d . e ye s. 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. a nd sm el l) . 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 . na sa l an d o ra l st ru ct ur es . Table 25-6 Primary Skin Lesions Lesion Name Description Example Illustration Circumscribed. f ac e.• • • • • • • 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 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 . e ar s. t r ac he a. h e a r i n g . 6 16 b on es . 6 15 P . I f t h e p a t i e n t s m o ke s. t a st e. D u r i n g t h e h e a l t h h is t o ry . 6 14 P . Flat. Nonpalpable Change in Skin Color Macule Lesion ≤1 cm Petechiae. 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. freckle . 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 . 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 . s uc h as he a d a c h e s o r d i z z i n e s 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 . a n d l y m p h n o d e s .

5 cm Mole Plaque Mass >0. Elevated Solid Masses Papule Mass >0.5 cm Coalesced papules .Patch Lesion >1 cm Vitiligo Palpable.

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

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

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

P . 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 . 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 . 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 . m ea su re t he ci rc um f e re nc e. 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 ) . a mo un t . 6 17 Eyes . s u c h a s h y p e r t e ns io n. 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 . I f a bn or ma li t i e s a r e n o t e d . di ab et es me ll it us . 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 .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 n d d i s t r i b u t i o n o f f a ci al ha ir . 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 . f a sc ic ul at io ns . c h e w i n g t o b a c c o . E d em a o f t h e f a ce . an d t i mi ng . Examples of nail abnormalities. 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 . Figure 25-9. t i cs . 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 . a nd t r em or s) a re a bn or ma l f in di ng s. s y m m e t r y . 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 . 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. Face I ns pe ct t h e f a c e f o r c o l o r .

in cl ud in g t h e r et in a.r e d a r t er ie s an d d ar k. 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 ) . i n f l a m m a t io n.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 . Extraocular Movements. 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 . 25 . 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. gl au co ma . m ac ul a . t r a u m a . o r a c on ge ni t a l d i s or de r. v is ua l ac ui t y . o r h ai r f ol li cl 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) . 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 n u m e r a t o r i s 2 0 . e y e l i d s . 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 . a nd t he e ye la sh es sh ou ld cu rl o ut wa rd . ye ll ow o pt ic n er ve d i s c . 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 . 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 . a n d eq ua l co ve ra ge of t he ey eb al l. o pt ic ne rv e d i s c. 2 5. 2 5 . 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 d e m a . 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 ) . e y e b r o w 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 ) . 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 . 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. 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 . e xt ra oc ul ar m o v e m e n t s . an d sm oo t h . 6 18 Assessing Visual Acuity. 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 . 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 . 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 . l a cr im al gl an ds . Inspecting External Eye Structures I ns pe ct t h e e y e 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 ).re d ve in s. f o v e a c e n t r a l i s . pu pi ls .12 ) t o a ss es s t he f un du 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 . 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. 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 . 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 . or a d et ac he d r et in a) . 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 . 5 t i me s as l ar ge as t he a rt er ie s ( F i g .1 1) . an d a n ey e c ha rt . 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 . c o n j u n c t i v a e . 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 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 h e e y e b r o ws sh ou ld ha ve e qu al di st ri bu t i on . I n j u r y t o t h e e ye . 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 . a n d r e t i n a l v e s s e l s . 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 . e y e l a s h e s . 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) . e q u a l i n s i z e . a n d l i g h t . t h e ve in s be in g a bo ut 1. T he p up il s a r e n o r m a l l y b l a c k . A cross-section of the eye. h y p e r t e n s i o n .1 3) . m ya st he ni a g ra vi s. P . an o ph t h al mo sc op e. Us in g t h e o ph t h al mo sc op e t ak es pr ac t i ce . a nd i ri s f o r po si t i on an d a li gn me nt (F i g. a n d p e r i p h e r a l v i s i o n . Figure 25-10. a r e d d i s h r e t i n a . a c le ar . 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 . No rm al f in di ng s a re a un if or m re d re f l ex .

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 ). 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 . 25 . an d l es io ns . No rm al ly b ot h e ye s m ov e t o ge t h e r . 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 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 . 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 . 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 . Accommodation. 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. 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 ). . 6 20 t o t h e h ea d. 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 ex t e rn al su rf ac es of t he e ar s ho ul d b e sm oo t h . t he p oo re r t he v is io n. 6 19 P . 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 .14 ). 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 ) .4 ) . s i z e . 2 5 . 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 w i t h t h e o t h e r e y e . Figure 25-11. a r e c o o r d i n a t e d . 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 . a n d t h e i n ne r ea r (F ig . 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 . Guidelines for Nursing Care 25-2 Measuring Pupillary Reaction. The eye and surrounding structures. 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 h e l a r g e r t h e d e n o m i na t o 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. 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 . t h e m i d d l e e a r . 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) .1 5 ) f o r s h a p e . O bs e r v e t h e p u p i l ' s r e a c t i o n .

Pupillary gauge measures pupils (dilation or constriction) in millimeters (mm). 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) . Assessing accommodation. 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 . 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 . Figure B. 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) .e y e d a p p e a r a n c e) . Accommodation • • H ol d t h e f o r e f i n g e r .Figure A. Assessing pupillary reaction. Figure C. . t h en ba ck t o t h e o bj ec t be in g h el d. 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 . 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 . a p e n c i l . t he n at a d is t a nt ob je ct .

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 . 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 . o r mi xe d. e d e m a . 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 . d is ch ar ge . Assessing convergence. 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 . T o a ch ie ve be t t er v is ua li za t i on . ma st oi d t e nd er ne ss (f ro m in f e ct io n) . 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 . o r p re se nc e o f le si on s. 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 .Figure D. I n c h i l d r e n y ou ng er t h an 3 ye ar s of a ge . 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 . 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 ). wi t h t he o pp os it e e ar c ov er ed . an d f or ei gn bo di es . 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 ). 2 5. a n d g r a y ( F i g . s en so ri ne ur al (f ro m in ne r e ar d am ag e) .1 6) . s h i n y . 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) . 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 . Figure 25-12. t r a n s l u c e n t . 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 ) . 6 21 . 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. (Photo by B. 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 . 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) . using an ophthalmoscope. 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 ) . 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 ). 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 . Examination of the internal structures of the eye. T h e t ym pa ni c me mb ra ne s ho ul d b e in t a c t . a c om bi na t i on o f b o t h . E x a mi ne f or w ax . T h er e s ho ul d be no r ed ne ss or d is ch ar ge .

an d t he t ur bi na t e s (F i g.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. 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 . Inspecting the Nose . 2 5. 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. I f t he h ea ri ng l o s s i s c o n d u c t i v e .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 . si ze . 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 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 . N or ma ll y.1 7) . 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 . 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 . 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. a n d f r o m s id e t o si de . t he n ar es . 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 . 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 . 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. A sk t h e p a t i e n t t o l o o k u p . N or ma ll y. 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 . 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) . 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 . T h e p at ie nt s ho u l d b e s i t t i n g . 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.co nd uc t e d h ea ri ng (d oc um en t e d a s A C > B C) . 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 . 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 . 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 o t e c o l o r . i n t h e R i n n e t e s t . F oc u s i n g o n t h e r e d r e f l e x . a nd ce nt ra l a re a ( p h y s i o l o g i c c u p ) . i n t h e W e b e r 's t e s t . sh ap e. 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 . 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. Figure 25-13. 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 . d o w n . a i 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 .1 8) . ma rg in s. The normal fundus as seen through an ophthalmoscope. an d pa t t er n. 2 5. an d a re a of r ef le ct ed li gh t (f ov ea ce nt ra li s) . 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 . 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 . as se ss in g t he c ha ra ct er is t i cs of t he r et in a. 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. 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 . c h a r a c t e ri st ic s. as se ss in g co lo r. 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 . si ze .

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 . 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. 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 . N o r m al ly . di ag on al ly up a nd do wn t o t he r ig ht ( se e F ig ur e ). 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 .19 ). 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 . t h e s in us es a re no t pa in f u l w he n pa lp at ed . 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 . l e f t a n d r i g h t .2 0) . 2 5 . 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 .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. 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 . 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 . 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 . 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. 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. 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. 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 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 ) . 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 . ex ud at e. 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 . 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 . 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 . N o r m al ly . 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. 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. 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 . 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) . f a ci ng y ou a t e ye l ev el . 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 . 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. 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 . 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 . or g ro wt hs . 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. 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 ) . 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 .

a n d s m o o t h . 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 . s wo ll en . 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 . 6 23 i n de f i ci en ci e s o f i r o n .2 1) . p h a r y n x . o r a b la ck . A bn or ma l f in d i n g s a r e p a l l o r . Neck Inspecting the Neck . s al iv ar y gl an d. 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 . 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 ) . pi nk . a t o ng ue bl ad e. a nd h ar d a nd s of t p al at es . an d f re e of s we ll in g o r l e s i o n s . or c ar io us t e et h. a nd gl ov es . 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 . t o ng ue . p o o r l y f i t t e d d e n t u r e s .re d t on gu e ( se en P . 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 . an d t on si ls ( F i g. m o i s t . a f i ss ur ed t o ng ue ( f r om de hy dr at io n) . t ee t h . 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 . s w o ll en . 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. T he l ip s s ho u l d b e p i n k . i r r i t a t i o n .Testing extraocular movement of the eye. a nd s ym me t r ic i n si ze . a n d ne ck i nc lu de s a p en li gh t . 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. re d. Figure 25-14. g um s an d t ee t h . a 4″ × 4″ g au ze s po ng e. m is si ng . h ar d an d s of t pa la t e . 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 . v i t a m i n B 1 2 . a re s ma ll . o r p o o r o r a l h y g i e n e) . t o n g u e . p oo rl y a li gn ed . i f p r e s e nt . t o ns il la r pi ll ar s. Internal structures of the ear. 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 . 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 . le si on s o f t h e mu co sa an d l i p s. 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 . 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. 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 . a b ri gh t . m oi st . o r n i a c i n ) . i nf la mm at io n o r i nf ec t i on . ha ir y t on gu e ( f r om a nt ib io t i c us e) . 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. o r s m o k i ng ). T h e t o n s i l s . an d bl ee di ng gu ms (f ro m nu t r it io na l d ef ic it s. 2 5 . 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 . g um s. c y a n o s i s .

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 . I f pa lp ab le . E n l a r ge d l ym ph P . m o b i l i t y . 2 5 . s i z e. t h e y s h o u l d b e sm al l. c on si s t e n c y . Rinne's Test to Compare Air Conduction With Bone Conduction of Sound .A ss es s t h e n e c k (F i g . t e nd er ne ss . 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 . External structures of the ear. is p al pa t e d f or a li gn me nt an d p os it io n. 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. Palpating the Trachea and Lymph Nodes T he t ra ch ea . a nd s id e t o si de t o as se ss r an ge of m o t i o n .2 2 ) w i t h t h e p a t i e n t s i t t i n g. i f p a l p a b l e . 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.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 . a nd mo bi li t y . m ob il e. P al pa t e t h e l y m p h n o d e s ( F i g . 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 . a ut oi mm un e d is or de rs . Figure 25-16. T h e n e c k s h o u l d b e s y m m e t r i c . 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 . an d n on t e nd er . as seen through an otoscope. a n d t e n d e r n e s s . T h e ne ck s ho ul d b e hy pe re xt en de d sl ig ht ly . 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. 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 . Normal tympanic membrane. o r me t a st as is o f ca nc er . f or wa rd . w it h f u ll ra ng e of m ot io n. Figure 25-15. sm oo t h . 2 5 . 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 . 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 . a ss es s lo ca t i on .

I mm e d i a t e l y p l a c e t h e s t i l l . i nf ec t i on o f t h e t hy ro i d . 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 . . 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. 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. o r c a n c e r ) .6) . 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 . 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 . Cross-section of the nasal cavity. Location of the frontal and maxillary sinuses. T he pa t i en t is s it t i ng . 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 . m as se s. Figure 25-17. I f p al pa bl e.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 . sh ap e. t h e n o r m a l e a r w i l l d o s o . 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 . t en de rn es s. 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. 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 . s ym me t r y.• • • • 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 . 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. P al pa t e f or s iz e. 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.

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

• • • • • •

P.625

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

f i l l e d l u n g i s p e r c u s s e d . 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 ). 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. an d du ll ne ss . 2 5 . an d in t e ns it y o f t he s ou nd s. 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. R ep e a t f o r t h e o t h e r s i d e . L is t e n f or t he d ur at io n. 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 . an d q ua li t y o f s ou nd s pr od uc ed . 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 ) .) 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 .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 . A sk t h e p a t i e n t t o s w a l l o w . (Photos by B. 2 5. A sk t h e p a t i e n t t o s w a l l o w . Proud. an d of l on g d ur at io n. du ra t i on . 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 . l ow i n pi t c h. a n d p a l p a t e f o r en la rg em en t . 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 . 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.2 6) . 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 . 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 . A sk t h e p a t i e n t t o s w a l l o w . lo ud . t h e s o un d i s ho ll ow . R ep e a t f o r t h e o t h e r s i d e . 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 . l i q u i d s . pi t c h. pi t c h. No rm al ly . (B) Using an anterior approach. 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. W he n a n or m a l a i r . Palpating the thyroid (A) using a posterior approach. o r s o l i d s w i t h i n t h e l un gs . h ea rd ov er f lu id o r a s ol id m as s. 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 . 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 . 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 . 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. 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 .2 6 ) . 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. . 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 . N ot e t h e i nt en si t y .

S t r id or is a h ar sh . 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 . 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 . Profile and anteroposterior diameter of normal adult chest and barrel chest. 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 . 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. o r t u mo rs . 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. lo w.p it ch ed s o u n d s . 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. O rd in ar il y. s t r e n u o u s r e s p i r a t i o n s . hi gh . V e s i c u l a r b r e at h so u n d s a re s of t .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 . Thoracic landmarks (A) Anterior. a nd t r a c h e a . 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 . b ro nc hi . i f p r e s e n t . 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 . s u c h a s t h e l a r y nx or t ra ch ea .9) .Figure 25-24. 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 . 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. . s we ll in g.p it ch ed . 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. No rm al b re at h s ou nd s (T a bl e 2 5.pi t c he d so un ds . Figure 25-25. 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 . 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. 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 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. 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 .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 . h ar sh s ou nd s. 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 . 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 . (B) Posterior. w h i c h i s l o n g e r t h a n e x pi ra t i on .

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. Figure 25-27. 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 .Figure 25-26.o l d w h o w a s st un g by a be e. T hi nk b ac k t o B i l l y C o l l i n s . 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 . percussion. c on si st en cy . and auscultation of the chest. The pattern is used for palpation. 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 . 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 . n ot in g a ny e vi de nc e o f w h e e z i n g . s t r i d o r .y e a r . 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 . 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 . The examiner uses the palms of the hands to detect vibrations transmitted through the lungs to the chest wall. t h e 9 . 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 . Palpation of the posterior thorax for vocal or tactile fremitus. Posterior (A) and anterior (B) chest—landmarks and systematic sequence of assessment. an d a mo un t . 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.

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 . Palpating the posterior thorax excursion. a n d a d i e t h i g h i n c a l o r i e s . 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. 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) . 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. Proud. I f t he se r is ks P . l ac k of e xe rc i s e . w it h t h e p at ie nt s it t i ng or s up in e.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. i nc lu di ng sm ok in g. 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 . ch es t pa in . o r dy sp ne a o n ex er t i on . p a l p i t a t i o n s . a nd sa lt . c or on ar y a rt er y di se as e. f a t s . 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 . pa lp at 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 . 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 . 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 . As the patient inhales. 6 30 a re i de nt if ie d . m yo ca rd ia l in f a rc t i on (h ea rt at t a ck ). 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. the examiner's hands should move apart symmetrically (B). Figure 25-28. The examiner's hands are placed symmetrically on the patient's back (A). (Photos by B. 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 . 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. r h e u m a t i c f e v e r . an d a us cu lt at io n.) 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 . 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.

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.30 ) f o r v i s ib le p ul sa t i o n s . 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. 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. 25 . a nd a ny li f t s or h ea ve s. auscultated over the trachea Expiration is longer. f o r c e . p u l m o n i c . and higher-pitched than inspiration Bronchovesicular . 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 hi ch ar e f i n e. a n d m i t ra l ar ea s a nd E rb 's po in t . 6 31 l an dm ar ks — t h e a o r t i c . 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. 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 . 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 . and Location Bronchial or Tubular Ratio of Inspiration to Expiration Blowing. an d E rb 's p oi nt . 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. 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 .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 . t r i c u s p i d . 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 . N ot e si ze . t ri cu sp id . 25 . 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 . a nd a pi ca l a re as . 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 . 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. 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 . 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. 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. hollow sounds. 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 . d u r a t i o n .31 ). ex ce pt t h e ap ic al i mp ul se . Table 25-8 Normal Breath Sounds Type. I de nt if y an y pr ec or di al t h ri ll s. Description. 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 al pa b l e . F ig . R e f e r t o F i g u r e 2 5 . 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 . p u l mo ni c. lower.

b eg in ni ng at t h e a o r t i c a r e a . 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 . blowing sounds. Us e sy st em at ic a us cu lt at io n.pi t c he d so un ds . t he n t o E rb 's po in t . C on s i de r T a m m y B r o w n i n g . continuous sounds Auscultated during inspiration and expiration Occurs in small air passages . auscultated over the lung periphery Inspiration is longer. auscultated over the first and second interspaces anteriorly and the scapula posteriorly Vesicular Inspiration and expiration have similar pitch and duration Soft.3 0 ) . low-pitched sounds. a nd f i na ll y t o t he m it ra l a r e a (F i g .p it ch ed s o u n d s . 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.Medium-pitched. A s k t h e p a t i e n t t o b r e at he no rm al ly . t he n t o t h e t r ic us pi d a re a.5 ) . 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 intensity. louder. Table 25-9 Abnormal Breath Sounds Type and Characteristics Wheeze (Sibilant) • • • • Illustration Musical or squeaking High-pitched. 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. 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. 2 5 . 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. 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. m o v i n g t o t h e p u l m o n i c ar ea .

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

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 . 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 ) . sh in y wi t h br ow n di sc ol or at io ns . 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 . (B) pulmonic area. v e n o u s p a t t e r n s . 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 ) . a n d e d e m a . T h e r e ar e n or ma ll y no ve no us p at t e rn s. 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. 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 . w e a k . 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.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 . t e m p e ra t u re . Palpating areas of the precordium: (A) aortic area. o r 4+ ( bo un di ng ). 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 nd sw el li ng o f t he a f f ec t e d c al f or t hi gh . re dn es s. 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 . ra sh es . p op li t e al . and (C) apical (mitral) and tricuspid area.) 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 : . d or sa li s pe di s. 2 + ( n o r m a l ) . u lc er s. t h e c a r o t i d b r a c h i a l . P al pa t e . 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 ). on e a t a t i m e an d w it h c a u t i o n . 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. 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) . 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. an d po st er io r t ib ia l pu ls es (s ee F ig . (Photos © Ken Kasper. a nd ha ir le ss . 2 4.7) . Figure 25-31.3 i n Ch ap . 2 4) . 1+ ( w e a k ) . c on t i nu it y. r a d i a l . f e mo ra l. va ri co si t i es . B u e r g e r ' s t e s t . 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 . an d t he t oe na il s a re t hi ck en e d . 3 + ( i n c r e a s e d ) .

o r a l c o n t r a c e p t i v e s . 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 x a m in at io n ( se e Ch ap . 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 . 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 a l l e d S 1 . m en al so a re a t r is k f o r br ea st d i s ea se . W h e n s i t t i n g . 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.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) . t h e p a t i e n t s h o u l d s it e re ct . ” 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 ). 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 .t o . 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 . b i o p s y . 2 5. l ow -p it ch ed . 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 . 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. c h a n ge in s iz e. t h e f i r s t h e a r t s o u n d . i f as se ss ed .t o . 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 .du b. wi t h a rm s at si de s or r ai se d o ve rh ea d. 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 . W h en s up in e. is h ea rd as t he “ lu b” of “ lu b. e s p e c i a l l y i n f em al es . 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 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 . 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 .• • • • 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 . 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 . T he s ou nd .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 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. b e n z e n e . r e d n e s s .

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. m ur mu rs . ” 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 .l ub -d ub . 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. 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 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 . e n d o c r i n e d i s o r d e r s . an d h ea d t r au ma . 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 .du b. Heart sounds in relation to the cardiac cycle and an electrocardiogram. 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 . 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 . r e p r e s e n t e d b y “ d e e . 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 .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 . 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 3 and S 4 S 3 . k no wn a s t h e t h i r d h e a r t s o u n d . 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 . S 2 . 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 so un ds m ay b e S 3 . 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 . an d si ze o f t h e v al ve o pe ni ng . d ep en di ng o n t h e h e a r t r a t e . S 4 . ra t e of b lo od f lo w. o r br ui t s .a nd du ll . T he “ du b” o f “ lu b. 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 . 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 ). w it h t h e pa t i en t l yi ng o n t he l ef t si de . 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. 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 . ” 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 . 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 .

a nd t he f e mo ra l ar t e ri es . 6 35 . 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 . co lo r re t u rn s i mm ed ia t e ly . 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 ) . 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 . c ol or r e t u r n s i n 1 0 s e c o n d s . 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 . R el ea se t he p re ss u r e . 6 34 P . 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. 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 . 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 ) . 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 . c a u s in g b lo od t o s wi rl . 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 . 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 . 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 . 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 .VI An exceptionally loud murmur that can be heard while the stethoscope is lifted off the skin Bruits B ru i t s . No rm al ly . 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 h e a b d o mi na l a or t a . 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 . 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 . P . ra t h er t ha n f lo w no rm al ly . N or ma ll y. 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 .

s ha pe . as ym me t r y. 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 . a nd sk in l es io ns . 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) . c o l or . l u m p s . T h e s i z e va ri es am on g in di vi du al s. 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 . c on s i s t e n c y . l e s i o n s . 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 . s ha pe . w it h a gr an ul ar co ns is t e nc y. 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 . 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 . 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 . I f an y n od es a re pa lp ab le . 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 . 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 . s i z e. D i s c h a r g e . 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 .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 . 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 . 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. 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 . c ru st in g. 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 . G u id el in es f o r Nu rs in g C ar e 2 5. s y m m e t r y . d i mp li ng .Inspecting the Breasts I ns pe ct t h e b r e a s t s f o r s i z e . wi t h a sm oo t h s ur f a ce . . co ns is t e nc y. I f a m as s is d et e c t e d . 6 36 n od es (F ig . 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 . a n d as ym me t r y. Figure 25-32. 2 5 . 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. s iz e. a nd t h e lo we r i nn er q ua dr an t (F i g. s h a p e . t e xt ur e. 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 . a nd in ve rs io n. t e n d e r n e s s . a n d m o b i l i t 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 . 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 . 2 5. T h e n ip pl es a re no rm al ly e ve rt ed .3 4 ) . an d t en de rn es 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 . 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 ).3 3) . 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 . r o u n d o r o v a l . t h e l ow er o ut er q u a d r a n t . t h e u p p e r i n n e r q u a d r a n t . Lateral view of the female breast. l e s i o n s .

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 . 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 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. 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 . f l u i d a n d n ut ri t i on al in t a ke . 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 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) . 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 . Location of assessment findings of the breast are identified by quadrant. in cl ud in g a bd om in al pa in an d na us ea . 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 . 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 . n a u s e a o r v o m i t i n g .3 5 ) c o n t a i n s t h e s t o m ac h. t h e sm al l in t e st in e. t h e la rg e i nt es t i ne . t he p an cr ea s . 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. t h e k i d n e y s . No t al l o f t h es e or ga ns ca n be as se ss ed . a n d t h e u r i n ar y bl ad de r. 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 . t h e s p l e e n . 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 ga ll bl ad de r. a nd l if es t y le . 2 5 .Figure 25-33. di sc us se d i n t h e f o ll ow in g s ec t i on . 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 . 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 . t h e l iv er .

ki dn ey s t o ne s. 25 . e it he r t h e c ir cu la 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 . 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 . a u s c u l t a t i o n . 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 . 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 . r i g h t l o w e r . 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. p e r c u s s i o n . 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. 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 . 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 ). ga ll bl ad de r di se as e.• • • • • • 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 . 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 . 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 d e q u a t e l i g h t i n g . Figure A. l e f t u p p e r . a n d p a l p a t i on .36 ). T h es e me as ur es . 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 . 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 .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 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 . Circular technique. o r ve rt ic al s t r ip t ec hn iq ue . a n d l e f t l o w e r (F ig . a s we ll a s t h e p o s i t i o n . 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 . 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 . 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 . w ed ge . bo we l d is ea se .t h e . 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 . s u c h a s i nf ec t i on s. wh ic h m ak es p al pa t i on di f f ic ul t . 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 ). 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 . 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 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 . . 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. s u c h as p ep t i c ul ce r d is ea se .

T h e s t e t h o s c op e i s wa rm ed . 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 . 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. 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 . a u s c u l t a t e o v e r t h e a o r t a . 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 . an d ma ss es . 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. 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 . 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 . or c on ca ve . 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 ). 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 . 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. 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 . c o n t o u r . 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 . 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 . I n t hi n p eo pl e. 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 . 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 . P . ro un de d. i n c l u d i n g t h e u m b i l i c u s . Wedge technique. 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 . . 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 . Figure C. p ul sa t i on s. a nd no t e t he ir f r eq ue nc y an d c ha ra ct er . 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 .Figure B. a nd il ia c ar t e ri es f or b ru it s. wi t h ou t vi si bl e p er is t a ls is . 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. Us in g t h e be ll of t he s t e t h os co pe . r e n a l a r t e r ie s. s ym me t r y. Vertical strip technique.

or a ir . o r m a s s e s . Organs of the abdominal cavity. T o p a l p a t e b im an ua ll y. e nl ar ge me n t o f t h e o r g a n s . 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 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) . p os si bl y ca us ed by f lu id o r a ma ss . p e r i t o n i t i s . di pp in g m ot io n. a n d f r e e of t en de rn es s. or en la rg ed or d is ea se d a bd om in al or ga ns ). r e l a x e d . 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 . 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. 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 . 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 . 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. axillary.Figure 25-34. ge nt le . 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. 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 . P . p al pa t e t h e ar ea of p ai n l as t . t e nd er ne ss .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 . 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. B o w e l s o u n d s o f h i g h . No t e t he di st ri bu t i on of s ou nd s. 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. sp as m. 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 . . 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.p i t c h e d t i n k l in g o r ru sh es o f h ig h. 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 . i n f e 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. 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 . 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 . 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. 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 . t u mo rs . m a s se s. 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 . 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 . and mammary lymph nodes. 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 . Re po rt c ha ng es in o r ab se nc e o f bo we l s ou nd s. Figure 25-35. 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) . no t i ng m us cu la r r es is t a nc e. Location of the cervical.

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 . a nd c ir rh os is of t he l iv er ). c ir rh os is . 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 ) . . 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. 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 .37 ). or a bs ce ss ). n o d u l a r i t y ( f o u n d wi t h t um or . c li t o ri s. la bi a m aj or a an d m in or a. 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 . 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 o pa lp at e b y h o o k i n g . m et as t a t i c ca nc er . 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 . 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 . 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 .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 . 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. e nl ar ge me nt ma y re su lt f ro m h ep at it is . Figure 25-36. a n d u r e t h r a l o p e n i n g (F i g . 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 . Diagram of abdominal quadrants and outline of underlying organs. 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 . 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 .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. 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 . li ve r t u mo rs . d is ch ar ge . he pa t i t i s. a n d m a y n o r m a l ly be m il dl y t e nd er . an d v as cu la r e ng o r g e m e n t . m as se 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 . v a g i n a l o r i f i c e . 25 . 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 . va gi na l v es t i bu le . v es t i bu la r g l a nd s.

W om en f r om s om e cu lt ur es (I sl am . I n s p e c t t he e xt er na l g en it al ia f or co lo r. a n d ha vi ng v ag in al de li ve ry . o r f or ei gn o bj ec t s ). 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. . 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 . 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 . 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. s e x u a l h i s t o r y . 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 ) . 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 . a g o o d l i g ht s ou rc e. l en gt h o f f l ow . 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 . 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 . T h e v ag in al o ri f i ce va ri es i n si ze . 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 . 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 . l es i o n s . 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. p a i n . s iz e of t he la bi a ma jo ra an d va gi na l o pe ni ng .Figure 25-37. 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 . w it h t h e l e g s i n s t i r r u p s . 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 . 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. 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 . 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 . A s pa rt o f t h e f oc us ed a ss es sm en t . T h e s k i n a n d m uc os a sh ou ld be s mo ot h. wi t h ou t le si on s o r sw el li ng . pe ni s. 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 . 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 . a n d 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. 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 . 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 y pe o f f lo w. 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 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 nd di sp os ab le gl ov es . I n ch il dr en . External female genitalia. i t c h i n g . 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 . d ep en di ng o n t h e w o m a n ' s a g e . 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 . I n m a n y i n s t a nc es . 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 . 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 .

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 . a w at er . t he w at e r s er ve s a s t h e l ub ri c a n t . 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 . 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 . a nd pa in . G ui de li ne s f or N ur si ng Ca re 2 5. 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. if c yt ol og ic sp ec im en s ar e t o be t ak en . P . 2 5 . o r c a n c e r . pr os t a t e gl an d. s w e l l i n g o f g l a nd s. 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 .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 . a nd se mi na l ve si cl es . T hi nk b ac k t o R a m o n a L e w i s . 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 . s cr ot um . 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. 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 . t es t i cl es . le si on s.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. 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 .3 8 ) i n c l u d e t h e p e n i s . 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 p o l y p . 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 . 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.so lu bl e lu br ic an t m ay b e us ed . s ee C ha pt er s 3 5 a n d 4 3. . i f n o s p e c i m e n s a r e n e e d e d . 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 . 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 . an a bs ce ss . wh ic h m ay i nd ic at e i nf ec t i on . D on g l o v e 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 .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 . ep id id ym is . 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 . 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 .

c o n t o u r . P . p l a ce me nt . 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 in gu in al ar ea i s . f ar mi ng . 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 . 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 . 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 . 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 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 . 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. Organs of the male urogenital system. 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 ). re le as e t he s cr ew so t ha t t h e bl ad es cl os e. ed em a. N or ma ll y. T h e s iz e. 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 . O bt a i n s p e c i m e n s i f n e e d e d . u n i f o r m i n c o l o r . an d ea si ly re t r ac t e d. 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 . an d di sc ha rg e. 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 . o b s e r v i n g t h e va gi na l wa ll s. s h ap e. f r e q u e n cy .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 . 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. 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 . r e d n e ss . c o l o r . W it h d r a w t h e b l a d e s s l o w l y . le si on s. 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 . 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. 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 . s ha pe . 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. 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 . I f t he pa t i en t is u nc ir cu mc is ed . 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 . I n sp ec t t h e s cr ot um f or s ym me t r y. a p p e a r a n c e o f t h e s k i n . 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 .• • • • • • 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. an d di sc ha rg e.

g lo ve d i nd ex f i ng er . in gu in al ly mp h no de s. 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 . 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. 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 .bl ac k) s t o ol 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 . 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 . p a in . 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 . di sc ha rg e. ( 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. o r h e m o r r h o i ds at t he a na l s ph in ct er . s k i n c r a c k 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 . 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 . 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. p ai n. ( 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 . 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 ) .l u b r i c a t e d. 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. 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 . re dn es s. e d e m a . 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 . 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.f r e e of bu lg e s . 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 . i n c l u d i n g a n y c o n s t i p a t i o n . 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 . 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 . u s i n g a w e l l . ) 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 . ( S e e C h a p s . if n ec es sa ry . ) 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. r e d n e s s . d is ch ar ge . 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 . 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 . T h e p at ie nt ma y be i n t h e S im 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 ) . ) A bn or ma l f in d i n g s a r e l e s i o n s .ch es t . f l ui d.c ol or ed o r da rk . 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) . k ne e. t e st es . E d em a. c o l o n o r r e c t a l c a n ce r. . di ar rh ea . 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 . n o d u l e s . G l o v e s a r e w o r n .

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. t h e g la nd i s no rm al ly sm oo t h . a r t h r i t i s . an d l im it ed R O M ( in di ca t i ng in ju ry . G u i d e l i n e s 2 5 . 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 . 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 . st if f n es s. 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 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 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 . A s s e s s m u s c l e s t r e n g t h . b on e s i z e a n d s t r u c t u r e . t he y ar e s ym me t r ic a nd n on t e nd er . 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 . no du le s. f i rm . N or ma ll y. s ha pe . a nd s up in e. 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 . 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 . c ar t i la ge . m us cl es . 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 . 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 . a n d j o i n t s a r e a s s e s s e d . s h a p e a n d c o l o r . 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 ) . a r e f r e e o f s w e l l i n g. an d a bo ut 1¾ ″ (4 c m) i n si ze . t h e jo in t s a re of e qu al b i l at er al si ze . 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.1 0 de sc ri be s t es t i ng mu sc le 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: • • • • • • • H is t o r y o f t r a u m a . b o n e s . . 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 ). pa in . i n c l u d i n g s t a nd in g. 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 . s uc h a s pa in . t e n d on s.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 . a nd mo ve t hr ou gh f u ll R O M . si t t in g. 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 . 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. N or ma ll y. j o i n t r a n g e o f m o t i o n (R O M ). or c re pi t u s ( gr at in g so un ds on m ov em en t ) . li ga me nt s. 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 . g ai t . cr ep it us . an d jo in t 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 . an d ab il it y t o mo ve . 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. T he m us cl es . a nd m us cl e s t r en gt h.

h y p e r e x t e n s i o 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 . c ra ni al n er ve f u nc t i on . s we ll in g. h e a d a c he s. m us cu lo sk e l e t a l d i s e a s e . s we ll in g. a n d r e f l e x e s . a n d c h a n g e s i n c o n t o u r . a n d m o v e s s m o o t h l y . an d p a i n . 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 . e nl ar ge me n t . 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. No rm al ly . 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. 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 . t a st e. 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 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 . u nc oo rd in at ed mo ve me nt s. 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 . Jo in t mo ve me nt s i nc lu de f l ex io n. 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. a nd de t e ct s en sa t i on 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 ) . t re mo rs ( in vo lu nt ar y m ov em en t s ). de ge ne ra t i ve j oi nt d is ea se . i s no nt en de r . de cr ea se d r an ge o f mo t i on .39 . 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 . 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 . no du le s. Guidelines for Nursing Care 25-10 . 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 . m us cl e s t r en gt h a nd co or di na t i o n . t h e p a t i en t i s al er t an d r es po ns iv e. cr an ia l ne rv e f un ct io n. ea ch jo in t ha s f u ll r an ge of m ot io n. A bn or ma l f i nd in gs ma y in di ca t e t r au ma . o r a n e u r o l o g i c d i s e a s e . an d ab il it y t o se e. 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. 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. a d d u c t i o n . a b d u 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. h ea r. a s y m m e t r y . 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 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 ). N o r m a l l y . ce re be ll ar f u nc t i on . e xt en si on . ha s f u ll s en so ry f u nc t i on . 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 . o r a ne ur ol og ic di se as e. m ot or a nd se ns or y f un ct io n. t ra um a. 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 . su pi na t i on . an d f l ac ci di t y (w it ho ut t on e) of m us cl es . an d r e f l e x e s . a nd pr on at io 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. 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 . A b no rm al f in di ng s i nc lu de pa in . 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 .

. 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 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 ). Figure C.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 . 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 ) . 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. Figure A. Mu sc le s t r en gt h s ho ul d be bi la t e ra ll y eq ua l. Figure B.

Figure E. 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 ). Figure D. 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 . T o t e s t e x t e n s i o n . . 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 ). 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) . 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 ) .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 G. 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) . T he n . . Figure I. Figure H. 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 ).

(A) Normal position and spinal curves. 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 . P ho t o s b y K e n C a s p e r . 6 45 P . Figure 25-39. (B) Scoliosis indicators. P . t a s t 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 . s e e . Screening for scoliosis.Figure J. t i n g l i n g . 6 44 P . 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 .

co gn it iv e ab il it ie 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.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 . sa lt o r su ga r) . ge ne ra l be ha vi or . a bs en t m em or y r ec al l. 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. 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 . 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 p en li gh t . T he p at ie nt s h o u l d h a v e a c l e a n . P . 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. i n pa in . an d be ha vi or . v i a l s o f so lu t i on t o t es t t a st e ( eg . 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. 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 . pe pp er mi nt an d va ni ll a) . a nd t i m e. a l a r g e s a f e t y p i n ) . a n d l a n g u a g e . 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 . n e a t a p p e a r a n c e w it h er ec t po st ur e. a sh ar p o bj ec t ( eg . a v is ua l ac ui t y c ha rt .t er m me mo ry ). 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 . 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 . m e mo ry . a nd ba la nc e. a bi li t y t o s pe ak c le ar ly . 6 47 T hi nk b ac k t o T a m m y B r o w n i n g . O b s e r v e t h e p a t i e n t 's ap pe ar an ce . 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. ca nc er . . a lc oh ol or d ru g i nt ox ic at io n. o r a t um or . c e r e b r o va sc ul ar d is or de r. a t un in g f or k. l e a d. o r g a n i c b r a i n d i s e a s e . c o t t o n b a l l s . 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. 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. i na pp ro pr ia t e d re ss . l ev el o f co ns ci ou sn es s. p la ce . 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 . a n d t h e n p e r s o n o r i e n t a t i o n . e pi le ps y. 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. an d t im e. 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 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 .• • • • • • • 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 . O n i n i t i a l c o n t a c t . 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 . 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 . p l a c e . di so ri en t a t i on .t h e . p la ce . a nd t h e da y o r m o n t h o r y e a r ) .t e r m a n d l o n g. A l z h e im er 's d is ea se . em ot io na l s t a t u s. f o ll ow ed by p la ce o ri en t a t i on . wh er e he o r s he i s. 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. a bs t r ac t r ea s o n i n g . sh ou ld be o ri en t e d t o pe rs on . 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 . 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 . 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 . a t on gu e d ep re ss or . 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 . o r in u nf am i l i a r s u r r o u n d i n g s . a r e f l e x h a m m e r . be ha vi or an d ap pe ar an ce . 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 . me mo ry . a nd r es po ns es t o q u e s t i o n s . a n d p e r s o n t o as se ss l ev el of a wa re ne ss .

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 .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 .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. a nd a t ot al s co re i s r e c o r d e d . an d t im e. S c or es a re g iv en in e ac h ca t e go ry . 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 . i f n o r e f l e x e s p r e s e n t . T o a ss es s im me d i a t e m e m o r y . 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 . “ 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 . T h is is n ot t he s a m e a s or ie nt at io n. as k. 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 . 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. 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 . m o t o r r e s p on se . 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 . 9) . 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. Y ou m ig ht a ls o a sk . 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. 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 . 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 . 6 . r es po nd s t o al l st im ul i. 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. a nd v er ba l r es po ns e. 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 . c a n m a k e v e r b a l r e s p o n s e s . A sc or e of 7 o r l es s de f i ne s c om a. p la ce . o r i e n t e d t o p e rs on . 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 ) . e v e n w i t h u se of p ai nf ul s t i mu li . 3 . 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 . h as n o sp on t a ne ou s mo ve me nt . mu st be s ha ke n o r sh ou t e d a t t o a ro u s e . “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 .

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. w hi ch i s a d is or de r of l an gu ag e ab il it y. go w n . T he c ra ni al n er ve s. p a j a m a s ) . T h es e a ph as ia s m ay a ls o be c om bi ne d. wo rd s. 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 ”) . 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 . f l o we rs . 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) . ” I f i nt el le ct ua l a bi li t y i s i m pa ir ed . Table 25-11 Summary of Cranial Nerves . a re o ut li ne d i n T a bl e 2 5. 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 . 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. b ed . 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. 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 . 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. 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 . t o re ad a sh or t se nt en ce al ou d.11 . pu pi ll ar y r es po ns e du ri ng as se ss me nt of t he f ac e) . 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 . 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 .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 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 .

show teeth. Lateral movement of the Test ocular movement in all directions. 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. temperature. puff out cheeks. Test vision for acuity and visual fields. Movement of shoulder muscles Ask the patient to shrug shoulders against your resistance. light neck touch. tongue Sense of hearing Test hearing ability. 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. eyes Muscles of the face Ask the patient to raise eyebrows. smile. Sense of taste on the Test for taste with various agents.Nerve (Number) Olfactory (I) Type Sensory Functions Sense of smell Methods for Examining Nerve Test each nostril for smell reception and interpretation.” and have swallowing patient yawn to observe upward movement of the soft palate. note ability to swallow. note hoarseness. Sensation on the face and Test face and neck for pain sensations. posterior one third of the tongue Swallowing and speaking Ask the patient to swallow and speak. Acoustic (VIII) Glossopharyngeal (IX) Sensory Motor Pharyngeal movement andAsk the patient to say “ah. elicit gag response. Test for downward and inward movement of the eye. Test pupillary reaction to light and ability to open and close eyelids. Sensory Vagus (X) Motor/Sensory Accessory (XI) Motor/Sensory .

o n t he h ee ls . 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 . 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 . N o r m a l l y . 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 . O bs er ve p os t u re . Us e t h e re f l ex h am me r P . P . w it h sl ig ht sw ay in g in t he st an di ng p os it io n. 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 . b al a n c e . sh uf f l i n g. a r m s . a nd v ib ra t i on .1 3 . a n d a r m a n d l e g m o v e m e n t s . 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 . se ns or y. a nd h ee l t o t o e. a r e i l l u s t r at ed in T ab le 25 -1 2. 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. 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 . a nd ab n o r m a l p a t t e r n s o f g a i t . Ask the patient to protrude tongue. i f t h e p at ie nt i s su pi ne ). 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 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. 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 . 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. f e et . ask strength of the tongue patient to push tongue against cheek. ra pi dl y p at t he h an d o n t h e t h i g h . l i g h t t o u c h . 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 . 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 . t h e m o v e m e n t s a r e c oo rd in at ed . A b no rm al f in di ng s i nc lu de lo ss o f ba la nc e. g a i t .Hypoglossal (XII) Motor Movement of the tongue. a nd c er eb el la r s y s t e m s . S el ec t e d re f l ex es . l ig ht t ou ch . a n d v i b r a t i o n s . 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. a nd a bs en ce of v ib ra t o ry se ns at io n. a nd co or di na t i on . 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 . ve st ib ul ar . 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: . Re pe at t h e se qu en ce on t he o pp os it e l i m b . a s l i s t e d in T a b l e 2 5 . 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 . 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 . 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. wi de -b as ed g ai t . 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 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. T h e po st ur e s ho ul d be er ec t . or l eg s) t o p ro xi ma l (t he t r un k) . 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 . 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. W it h t h e pa t i en t ' s e ye s c l o se d.

T hi nk b ac k t o T a m m y B r o w n i n g . The Nurse's Role in Diagnostic Procedures N ur se s as si s t b e f o r e . D o c u m e n t t h e d a t a . 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 .6. s i g h t . F o r ex am pl e. 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 . 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 . Table 25-12 Normal Responses of Commonly Tested Reflexes . 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. d u r i n g . I n a d d i t i o n . 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. 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 . di sp os in g of us ed e qu ip me nt . 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 . 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 . t em pe ra t u re . 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. 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 . 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 . 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. 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 .• • • 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 . t r u n k. a nd t r an sp or t i ng sp ec im en s. T ab le 2 5. s ch ed ul in g t he t e st . 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 . m a k e n u r s i n g d i a g n o s 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 . w i t h e a c h s ys t e m re co rd ed in di vi du al ly . p l a n a p p r o p r i a t e ca re . 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 . t a st e.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 . 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 . 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 . n e c k . 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 . s me ll . a n d a f t e r d i a g n o s t i c t e st s. H ow ev er . 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 . 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 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 .

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

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

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

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 . 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 . A b d o m en : O b e s e .t e r m m e m o r y . 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 . N o p ai n on l ig ht pa lp at io n. T o h av e m am mo gr am a t n ex t vi si t . U m b i l i c u s m i d l i n e . o r b r u i t s h e a r d . S 1 an d S 2 h ea rd at p ul mo ni c. S pe ec h c le ar a nd ap pr op ri at e. 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 . Re sp ir at io ns e ve n a nd u nl ab or ed . B o we l so un ds he ar d in al l f o ur q ua dr an t s . ao rt ic . 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 . m u r m u r s .t e r m a n d s h o r t . t r ic us pi d. an d mi t r al a re as . o r cr ep it at io n. R ec tu m an d a n u s : I n s p e c t e d o n l y . B re as ts an d a x i l l a : S k i n p i n k . r o u n de d . G a it e ve n. N o r m a l s p i n a l c u r ve s. N o ed em a p re se nt . N o m a ss es p a l p a t e d i n b r e a s t s . p l a c e . Lu ng s ou nd s c le ar . S m a l l e x t e r n a l he mo rr ho id s n ot ed . A p i c a l p u l se 84 b ea t s / m in an d re gu la r. A l l cr an ia l ne rv es t e st s we re i nt ac t . 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. . D em on st ra t e s l o n g .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. N o ex t r a h ea rt so un d s . s li gh t l y st ro ng er on t he r ig ht (d om in an t s id e) . 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 . A re ol ae an d ni pp le s d ar k br ow n. N o d i m p l i n g o r r e t r ac t i on n ot ed . p e r s on . M u s cu l o sk e l e t a l : S t a n d s e r e c t . 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 . N o jo in t d ef or mi t i es . F i ne m ot or m ov em en t s in t a ct . 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. P u ls es e qu al in b ot h l eg s. N o b ru it s he ar d o n a u s c u l t a t i o n . T o en ai ls t hi ck an d ye ll ow . t e nd er ne ss . F ac ia l ex pr es si on s a pp ro pr ia t e . no c ru st in g or dr ai na ge . A l l re f l ex es = 2.

Sign up to vote on this title
UsefulNot useful