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 :

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

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

• • • •

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

yes yes no no 6. 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. rather than going out and doing things? yes no 2. no 12. no 13. 5.Instructions: 1. no 4. yes no 7. Circle the answer that best describes how you felt over the past week. 9. Are you basically satisfied with yes your life? Have you dropped many of your yes activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home. yes 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 . no 3. yes yes no no 10. 14.

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

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

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 . Texture. Weights in pounds are according to frame (in indoor clothing weighing 5 lb. shoes with 1-inch heels). 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 . † Weights at ages 25 to 59 yr are based on lowest mortality. A n e xc es si ve am ou nt o f pe rs pi ra t i on . 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 . t he t ex t u re is d r y . i s c a l l e d d i a ph or es is . 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 .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. 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 . I n t he d eh yd ra t e d p at ie nt . Palpating Skin Temperature. . Moisture. shoes with 1-inch heels). Weights in pounds are according to frame (in indoor clothing weighing 3 lb.

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 .) 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 . mucous membranes.Figure 25-7. hands and feet. 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 . alcohol intake. particularly the ears. 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 . vascularity. + 3 ( d e e p . Table 25-5 Skin Color Assessment Color Variations Redness (erythema. 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 . k i d ne y f ai lu r e . T he n ai ls s ho ul d b e sm o o t h . and sclera Exposed areas. W he n t h e p at ie nt i s d eh yd ra t e d. 8 mm ). p ai nl es s s ep ar at io n o f t h e n ai l pl at e f r om t h e na il be d ( on yc ho ly si s) f r o m in f e ct io n o r t r a u m a . nailbeds disease (decreased oxygenation) Overall skin areas. t h i s i s c a l l e d p i t t i n g e de ma . an d c l u bb in g ( f r o m l o n g . E d em a is c ha ra ct er iz ed by s we ll in g. Proud. lips. i n f e c t i o n . 2 5 . 2 mm ). 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 . conjunctivae. 6 m m ) . t e x t u r e . a n d t h e n a i l b a s e . 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 . infection Exposed areas. The skin is inspected for color. localized area of skin on the body Blushing. injury trauma. and lesions. he ar t f a il ur 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 . t r a u m a . o r + 4 ( v e r y d ee p. + 1 ( t r ac e. a n d t he s ki n f o ld re t u rn s t o n or ma l s lo wl y.t e r m l a c k o f o x y g e n a t i o n ) . w h e n p a l p a t e d. F i g ur e 2 5. particularly the face and lips. (Photo © B. h ow ev er . 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 . E de ma ma y be g ra de d a s 0 (n on e) . D if f i cu lt y in l i f t i n g a s k i n f o l d m a y i n d i c a t e e d e m a ( ex ce ss f lu id in t he t is su es ). cardiac or respiratory of the mouth. 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 ) . + 2 ( mo de ra t e .9 il lu st ra t e s n ai l ab no rm al it ie s. E de ma m ay b e t he r es ul t of ov er hy dr at io n. flushing) Bluish (cyanosis) Assessment Areas Possible Causes Facial area. a n g l e . A b no rm al f i nd in gs in cl ud e i nd en t a t i on s P . 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 ). an d co lo r. 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 . fever. sh ou ld b e f ir m an d no nt en de r. 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 .8 ) . and mucous membranes Liver disease (increase in bilirubin levels) Yellowish (jaundice) Paleness (pallor) Anemia (decreased hemoglobin) Shock (decreased blood volume) . inside Cold environment. 4 m m ) . an in de nt at io n m ay r em ai n a f t er t he pr e s s u r e i s r e l e a s e d .

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

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

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

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

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

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

di ab et es me ll it us . Face I ns pe ct t h e f a c e f o r c o l o r . I f a bn or ma li t i e s a r e n o t e d . 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 . E d em a o f t h e f a ce . s u c h a s h y p e r t e ns io n. 6 17 Eyes . a nd t r em or s) a re a bn or ma l f in di ng s. A b n o rm al f i nd in gs i nc lu de la ck o f sy mm et ry o r u nu su al s iz e o r co nt ou r of t he s ku ll (e i t h e r m a y b e t h e r e s u l t o f t r a u m a o r d i s ea se s a f f ec t i ng t he gr ow t h o f bo ne ) a nd t e nd er ne ss . P . t i cs . d o c u m e n t t h e i r l o c a t i o n . s y m m e t r y . 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 . 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 . 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 . Examples of nail abnormalities. 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 . Figure 25-9. 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 . c h e w i n g t o b a c c o . a mo un t . 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 ) . 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. an d t i mi ng . m ea su re t he ci rc um f e re nc 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 . f a sc ic ul at io ns . 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 . Skull I ns pe ct an d p a l p a t e t h e s k u l l f o r s i z e a n d s h a p e . a n d d i s t r i b u t i o n o f f a ci al ha ir .

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

No rm al ly b ot h e ye s m ov e t o ge t h e r . 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 ) . 25 . s i z e . Guidelines for Nursing Care 25-2 Measuring Pupillary Reaction. 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.1 5 ) f o r s h a p e . a nd le si on s. un ev en co lo r. 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. 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. O bs e r v e t h e p u p i l ' s r e a c t i o n . 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” ). 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 . 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 . 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) . Ears A ss es s t h e e x t e r n a l e a r . 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 . an d l es io ns . 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 . Figure 25-11. 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 . 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 .14 ). The eye and surrounding structures. 2 5 . 6 20 t o t h e h ea d. a n d t h e i n ne r ea r (F ig . 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 . 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 ).2 0/ 20 ) c an r e a d t h e l e t t e r s . R ep e a t t h e p r o c e d u r e a n d o b s e r v e t h e o t h e r ey e.4 ) . 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 . 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 ). . t he p oo re r t he v is io n. T h e l a r g e r t h e d e n o m i na t o r. 6 19 P . a r e c o o r d i n a t e d . 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 .

a p e n c i l . 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) . 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 . 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) . Figure C. Assessing accommodation. Figure B. 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 . Accommodation • • H ol d t h e f o r e f i n g e r . .Figure A. t he n at a d is t a nt ob je ct . Assessing pupillary reaction. t h en ba ck t o t h e o bj ec t be in g h el d. T h e pa t i en t ' s e ye s s ho ul d no rm al ly c on v e r g e ( a s s u m e a c r o s s . Convergence • • H ol d y o u r f i n g e r a b o u t 6 ″ t o 8 ″ f r o m t h e b r i d ge of t he p at ie nt 's no se .

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 . an d f or ei gn bo di es . a c om bi na t i on o f b o t h . Assessing Hearing and Sound Conduction A ss es s he ar i n g o n e e a r a t a t i m e b y d e t e r m i n i n g w he t h er t he pa t i en t ca n h ea r a wh is pe re d v oi ce o r a t ic ki ng w at ch f ro m a d i s t a nc e o f 1 t o 2 f e e t . a 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) . 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 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 ) . A s s e s s h e a r i n g a c u i t y o u t o f t he p at ie nt 's li ne o f vi si on (t o pr ev en t l ip -r ea di ng ). A 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 ).1 6) . s h i n y . Examination of the internal structures of the eye. E x a mi ne f or w ax . using an ophthalmoscope. T h e t ym pa ni c me mb ra ne s ho ul d b e in t a c t .Figure D. 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 ) . s en so ri ne ur al (f ro m in ne r e ar d am ag e) . 2 5. I n c h i l d r e n y ou ng er t h an 3 ye ar s of a ge . (Photo by B. 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 . e d e m a . o r p re se nc e o f le si on s. wi t h t he o pp os it e e ar c ov er ed . I ns er t t h e o t o sc op e s pe cu lu m as t he pa t i en t ' s h ea d i s sl ig h t l y t i l t e d a w a y f r o m t h e e x a m i n e r . T o a ch ie ve be t t er v is ua li za t i on . 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 . d is ch ar ge . ma st oi d t e nd er ne ss (f ro m in f e ct io n) . 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 . 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) . t r a n s l u c e n t . Figure 25-12. Assessing convergence. 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. 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 h er e s ho ul d be no r ed ne ss or d is ch ar ge . a n d g r a y ( F i g . o r mi xe d. 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 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 . 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 .

an d a re a of r ef le ct ed li gh t (f ov ea ce nt ra li s) . a nd ce nt ra l a re a ( p h y s i o l o g i c c u p ) . 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 . i n t h e R i n n e t e s t . 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) . a i r .1 7) . 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 . c h a r a c t e ri st ic s.co nd uc t e d h ea ri ng (d oc um en t e d a s A C > B C) . Figure 25-13.1 8) . 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 . an d pa t t er n. D ar k e n t h e r o o m a n d h a v e t h e p a t i e n t r e m ov e g la ss es . 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 . 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 . ma rg in s. N or ma ll y.c o n d u c t e d h e a r i n g is g re at er t ha n b on e. S 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 . a n d f r o m s id e t o si de . as se ss in g t he c ha ra ct er is t i cs of t he r et in a. si ze . 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 he n ar es . 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 . F oc u s i n g o n t h e r e d r e f l e x . n ot e c ol or . I f t he h ea ri ng l o s s i s c o n d u c t i v e . sh ap e. R ot a t e t h e l e n s w h e e l u n t i l i n t e r n a l e y e s t r uc t u re s a re s ha rp a nd cl ea r. t he o ss ic le s) t ra ns mi t s t h e s ou nd di re ct l y t o t h e e a r . T h e 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 . 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 . 2 5. 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 .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 . 2 5. 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. N or ma ll y. b o n e c o n d u c t i o n w i l l be t he sa me o r gr ea t e r t ha n ai r co nd uc t i on . 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 . si ze . T h e p at ie nt s ho u l d b e s i t t i n g . A sk t h e p a t i e n t t o l o o k u p . The normal fundus as seen through an ophthalmoscope. an d t he t ur bi na t e s (F i g. Inspecting the Nose . 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. 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. i n t h e W e b e r 's t e s t . 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 . 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. d o w n . as se ss in g co lo r. 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. 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 . 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 . 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 .

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 . 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 . 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 ) . 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 . p er f o ra t i on o r d e v i a t i o n o f t h e n a s a l s e p t u m ( c o c a i ne u se ma y ca us e pe rf or at io n. A sk t h e p a t i e n t t o 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 .2 0) . 25 . 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 . or g ro wt hs . 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. 2 5 . di ag on al ly up a nd do wn t o t he r ig ht ( se e F ig ur e ). P ai n ma y b e a f i nd in g i f t h e si nu se s a r e i n f e c t e d o r o b s t r u c t e d . 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. . f a ci ng y ou a t e ye l ev el . 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 . 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 . 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 .19 ). 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 . 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. 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 ) . 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. 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. H ol d o n e a r m o u t s t r e t c h e d t o o n e s i d e ( r i g ht o r l ef t ) e qu id is t a nt f r om y ou a nd t h e pa t i en t .T 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. 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 . 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 . 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. 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 . l e f t a n d r i g h t . ex ud at e. 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 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 . 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. 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 . 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 . 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 . t h e s in us es a re no t pa in f u l w he n pa lp at ed . 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) . 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 .

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

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

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

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

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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

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 . 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. . o r s o l i d s w i t h i n t h e l un gs . pi t c h. 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 . (Photos by B. 2 5. 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. 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 ) . A sk t h e p a t i e n t t o s w a l l o w . lo ud .f i l l e d l u n g i s p e r c u s s e d . an d q ua li t y o f s ou nd s pr od uc ed . R ep e a t f o r t h e o t h e r s i d e . 2 5 . pi t c h. 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 . W he n a n or m a l a i r . A b no rm al p er cu ss io n s ou nd s a re h yp er re s o n a n c e . an d of l on g d ur at io n. 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 . R ep e a t f o r t h e o t h e r s i d e . 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. 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 . N ot e t h e i nt en si t y . p l a c e y o u r h a n ds a ro un d t he p at ie nt 's ne ck .2 6) . 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.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 . a n d p a l p a t e f o r en la rg em en t . 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 ). 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 . 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 . 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 . Palpating the thyroid (A) using a posterior approach. (B) Using an anterior approach. 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. No rm al ly . an d du ll ne ss . L is t e n f or t he d ur at io n. t h e s o un d i s ho ll ow . Proud. an d in t e ns it y o f t he s ou nd s. h ea rd ov er f lu id o r a s ol id m as s. 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 ) . du ra t i on . l i q u i d s . A sk t h e p a t i e n t t o s w a l l o w . l ow i n pi t c h.) 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 . 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 .

9) . 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 . O rd in ar il y. 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 .pi t c he d so un ds .p it ch ed s o u n d s . S t r id or is a h ar sh . s u c h a s t h e l a r y nx or t ra ch ea . 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.p it ch ed . 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. b ro nc hi . 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. Figure 25-25. 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 .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 . w h i c h i s l o n g e r t h a n e x pi ra t i on . lo w.Figure 25-24. s we ll in g. . 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. 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 .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. 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 . 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 ar sh s ou nd s. Profile and anteroposterior diameter of normal adult chest and barrel chest. hi gh . 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 nd t r a c h e a . s t r e n u o u s r e s p i r a t i o n s . o r t u mo rs . 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. 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 . 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. 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) Posterior. i f p r e s e n t . V e s i c u l a r b r e at h so u n d s a re s of t . 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. 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 . 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 .

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 . and auscultation of the chest.Figure 25-26. Figure 25-27. n ot in g a ny e vi de nc e o f w h e e z i n g . 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 .y e a r . t h e 9 . 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 . 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 . Posterior (A) and anterior (B) chest—landmarks and systematic sequence of assessment. 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 l d w h o w a s st un g by a be e. 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 . Palpation of the posterior thorax for vocal or tactile fremitus. T hi nk b ac k t o B i l l y C o l l i n s . s t r i d o r . an d a mo un t . The examiner uses the palms of the hands to detect vibrations transmitted through the lungs to the chest wall. 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. 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 . c on si st en cy . t h e n u r s e w o u l d i n s p e c t B i l l y ' s c he st f or a cc es so ry mu sc le u se a nd au sc ul t a t e hi s lu ng s.

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

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. N ot e si ze . p al pa b l e . 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 . A d e q u a t e l i gh t i ng i s es se nt ia l f or i ns pe ct io n o f co lo r an d p ul sa t i on s. No rm al f in di ng s i nc lu de n o p ul sa t i on p al pa bl e o ve r t he a or t i c a nd pu lm on i c a r e a s . lower.31 ). f o r c e . 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 . 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 . 25 . a nd a ny li f t s or h ea ve s. and higher-pitched than inspiration Bronchovesicular . an d E rb 's p oi nt . Description. 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. a n d m i t ra l ar ea s a nd E rb 's po in t . hollow sounds. wi t h a ss es sm en t o f sp ec if ic c ar di ac P .30 ) f o r v i s ib le p ul sa t i o n s .w it h t h e h ea d r a i s e d a b o u t 3 0 d e g r e e s . w 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. 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 . 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 nd a pi ca l a re as . ex ce pt t h e ap ic al i mp ul se . 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 .2 9 f o r a v i e w o f t h e he ar t . 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. 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 . and Location Bronchial or Tubular Ratio of Inspiration to Expiration Blowing. 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 . F ig . 6 31 l an dm ar ks — t h e a o r t i c . R e f e r t o F i g u r e 2 5 . w hi ch ar e f i n e. t ri cu sp id . 25 . Table 25-8 Normal Breath Sounds Type. Palpating the Precordium U si ng t he pa l m a r s u r f a c e w i t h t h e f o u r f i n g e r s h e l d t og et he r. I de nt if y an y pr ec or di al t h ri ll s. p u l m o n i c . 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 . 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 . auscultated over the trachea Expiration is longer. 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 . t r i c u s p i d . p u l mo ni c. 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.

pi t c he d so un ds . blowing sounds. C on s i de r T a m m y B r o w n i n g . 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.Medium-pitched.p it ch ed s o u n d s . continuous sounds Auscultated during inspiration and expiration Occurs in small air passages . low-pitched sounds. 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 . 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. b eg in ni ng at t h e a o r t i c a r e a . Us e sy st em at ic a us cu lt at io n. m o v i n g t o t h e p u l m o n i c ar ea . t he n t o E rb 's po in t . 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. a nd f i na ll y t o t he m it ra l a r e a (F i g . Table 25-9 Abnormal Breath Sounds Type and Characteristics Wheeze (Sibilant) • • • • Illustration Musical or squeaking High-pitched.5 ) . auscultated over the lung periphery Inspiration is longer. medium intensity. 2 5 . 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. 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. louder.3 0 ) . 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 . 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. auscultated over the first and second interspaces anteriorly and the scapula posteriorly Vesicular Inspiration and expiration have similar pitch and duration Soft.

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

3 + ( i n c r e a s e d ) . 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 . a nd ha ir le ss . 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. t e m p e ra t u re . va ri co si t i es . Figure 25-31. 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 . 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 ) . c on t i nu it y. o r 4+ ( bo un di ng ). f e mo ra l. on e a t a t i m e an d w it h c a u t i o n . 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 ) .3 i n Ch ap .) 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 : . 1+ ( w e a k ) . B u e r g e r ' s t e s t . u lc er s. 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) . a n d e d e m a . (Photos © Ken Kasper. and (C) apical (mitral) and tricuspid area. v e n o u s p a t t e r n s . Palpating areas of the precordium: (A) aortic area. p op li t e al . 2 4. w e a k . 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. T h e r e ar e n or ma ll y no ve no us p at t e rn s. r a d i a l . 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 . 2 + ( n o r m a l ) .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 . 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 ). d or sa li s pe di s. sh in y wi t h br ow n di sc ol or at io ns . t h e c a r o t i d b r a c h i a l . 2 4) . (B) pulmonic area. 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 . ra sh es . 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 po st er io r t ib ia l pu ls es (s ee F ig . re dn es s. 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 ).7) . 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. an d t he t oe na il s a re t hi ck en e d . P al pa t e . 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. a nd sw el li ng o f t he a f f ec t e d c al f or t hi gh .

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 . 2 5. 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. 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 .du b. t h e p at ie nt 's ha n d o n t h e s i d e b e i n g e x a m i n e d i s p l a c ed un de r t he h ea d. t h e p a t i e n t s h o u l d s it e re ct .• • • • 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 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 h e f i r s t h e a r t s o u n d . i f as se ss ed . b e n z e n e . W h e n s i t t i n g . is h ea rd as t he “ lu b” of “ lu b. 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 . 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 . 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 .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 . o r a l c o n t r a c e p t i v e s . o r a nt id ep re ss an t s E xp o s u r e t o r a d i a t i o n . W h en s up in e. l ow -p it ch ed . wi t h a rm s at si de s or r ai se d o ve rh ea d. m en al so a re a t r is k f o r br ea st d i s ea se .t o . 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 . 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 .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 . 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. ” 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 ). 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 . c h a n ge in s iz e. r e d n e s s .t o .e x a m in at io n ( se e Ch ap . c a l l e d S 1 . e s p e c i a l l y i n f em al es . T he s ou nd .3 2) . b i o p s y . 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 . 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 .

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. k no wn a s t h e t h i r d h e a r t s o u n d . 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 t w o s ou nd s oc cu r w it hi n 1 se co nd or l es 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 . an d h ea d t r au ma . T h e s e c on d he ar t s ou nd . e n d o c r i n e d i s o r d e r s . ra t e of b lo od f lo w.ag ed an d o ld er a du lt s. ” 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 .du b. 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 . w it h t h e pa t i en t l yi ng o n t he l ef t si de . 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 .a nd du ll . S 4 . 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 . 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 . 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 . ” 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 . S 4 is t he f ou r t h h e a r t s o u n d . o r br ui t 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 . 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. Heart sounds in relation to the cardiac cycle and an electrocardiogram.l ub -d ub . E xt ra h ea rt so un ds m ay b e S 3 . 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 2 . d eh yd ra t i on or o ve rh yd ra t i o n . 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 . T he “ du b” o f “ lu b. r e p r e s e n t e d b y “ d e e . 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 . 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. r e s p i r a t o r y d i s or de rs . m ur mu rs . 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 . d ep en di ng o n t h e h e a r t r a t 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 ). an d si ze o f t h e v al ve o pe ni ng . S 3 and S 4 S 3 .

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 . 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. w hi c h a r e a b n o r m a l s o u n d s . 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 . N or ma ll y. 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 . 6 34 P . 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 . 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 . t h e a b d o mi na l a or t a . Buerger's Test • • • A sk t h e p a t i e n t t o a s s u m e a s u p i n e p o s i t i o n an d t he n ra is e o ne a rm o r on e l eg a bo ut 1 f o ot ( 30 cm ) ab ov e t h e l ev el o f h i s o r h e r h e a r t . 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 . co lo r re t u rn s i mm ed ia t e ly . R el ea se t he p re ss u r e . c ol or r e t u r n s i n 1 0 s e c o n d s . Capillary Refill • • • U si n g y o u r t h u m b a n d f o r e f i n g e r . R el e a s e y o u r t h u m b p r e s s u r e a n d o b s e r v e t h e r et ur n of c ol or t o t he p al m ( t h is s ho ul d no rm al ly t a ke 3 t o 5 s ec o n d s ) . a n d v e i n s f i l l i n 1 5 se co nd s. ra t h er t ha n f lo w no rm al ly . 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 . 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 . 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 . c a u s in g b lo od t o s wi rl . a nd t he f e mo ra l ar t e ri es . 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 ) . 6 35 . P .VI An exceptionally loud murmur that can be heard while the stethoscope is lifted off the skin Bruits B ru i t s . 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 . No rm al ly .

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 . 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 . 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 ). c o l or .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 . 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 . 6 36 n od es (F ig . a nd sk in l es io ns . r o u n d o r o v a l . s ha pe . t h e u p p e r i n n e r q u a d r a n t . 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 . l u m p s . s y m m e t r y . 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. 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 . a nd t h e lo we r i nn er q ua dr an t (F i g. d i mp li ng . T h e n ip pl es a re no rm al ly e ve rt ed . G u id el in es f o r Nu rs in g C ar e 2 5. s iz e. l e s i o n s . a nd in ve rs io n. T h e s i z e va ri es am on g in di vi du al s. 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 . D i s c h a r g e .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 . Lateral view of the female breast. a n d m o b i l i t y . t e n d e r n e s s .3 3) . 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) . s h a p e . . co ns is t e nc y. I f a m as s is d et e c t e d . s ha pe . 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 . 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 . w it h a gr an ul ar co ns is t e nc y. a ss es s t h ei r lo ca t i on . 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 . 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 . I f an y n od es a re pa lp ab le . Figure 25-32. 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 . l e s i o n s . 2 5. 2 5 . t h e l ow er o ut er q u a d r a n t . 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 . c on s i s t e n c y . t e xt ur e. 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 . T he b re as t s s ho ul d b e re la t i ve ly s ym me t r ic . T 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. c ru st in g.3 4 ) . T h e b r e a s t t i ss ue sh ou ld b e s mo ot h an d f ir m. an d t en de rn es s. T he co lo r sh ou ld be c on si st en t w it h t he r es t o f t h e s k i n . s i z e. as ym me t r y. P a lp at e t h e n ip pl e an d a re ol a a nd g en t l y c om pr es s t h e ni pp le be t w ee n t he t hu mb a n d f o r e f i n g e r t o a s s e s s f o r d i s c h a r g e . 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 .

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 . 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 . t he p an cr ea s . t h e s p l e e n . 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 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 . t h e sm al l in t e st in e. 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 . f l u i d a n d n ut ri t i on al in t a ke . di sc us se d i n t h e f o ll ow in g s ec t i on . in cl ud in g a bd om in al pa in an d na us ea . 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 .3 5 ) c o n t a i n s t h e s t o m ac h.Figure 25-33. t h e ga ll bl ad de r. Health History I de nt if y r is k f a c t o r s f o r a l t e r e d h e a l t h d u r i n g t h e h e al t h hi st or y by as ki ng a bo ut t h e f o ll ow in g: • • • • • H is t o r y o f 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 . 2 5 . t h e la rg e i nt es t i ne . 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. No t al l o f t h es e or ga ns ca n be as se ss ed . t h e k i d n e y s . P hy si ca l ex am in at io n i s co nd uc t e d t o f ur t h er as se s s p r o b l e m s w i t h p a i n a n d t o i d e n t i f y a n y a bd om in al ma ss es . n a u s e a o r v o m i t i n g . 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 . so i t is n ot i nc lu de d i n t h i s d is cu s s i o n . a nd l if es t y le . 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) . 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 . Location of assessment findings of the breast are identified by quadrant. 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 . t h e l iv er . a n d t h e u r i n ar y bl ad de r.

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

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

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

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 ) . m as se s. c li t o ri s. 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 .b e l l y ” ( u n d e r 5 y e a r s o f a g e ) V is ib l e p e r i s t a l t i c w a v e s E as il y p a l p a t e d l i v e r a n d s p l e e n Older Adult C om mo n a b d o m i n a l v a r i a t i o n s i n o l d e r a d u l t s i n c l u d e: • • • D ec r e a s e d b o w e l s o u n d s D ec r e a s e d a b d o m i n a l t o n e L iv er b o r d e r p a l p a t e d m o r e e a s i l y Assessing Female Genitalia T he e xt er na l f e m a l e g e n i t a l i a c o n s i s t o f t h e m o n s p ub is . t h e in t e rn al pe lv ic e xa mi na t i on is a sk il l mo st o f t en p er f o rm ed by P .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. . or a bs ce ss ). li ve r t u mo rs . c ir rh os is . 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 . an d v as cu la r e ng o r g e m e n t . v es t i bu la r g l a nd 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 . va gi na l v es t i bu le . n o d u l a r i t y ( f o u n d wi t h t um or . la bi a m aj or a an d m in or a. 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 . 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 . 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 . d is ch ar ge .T o pa lp at e b y h o o k i n g . v a g i n a l o r i f i c e . 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 . m et as t a t i c ca nc er . 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. 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 .37 ). 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 . 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 . e nl ar ge me nt ma y re su lt f ro m h ep at it is . 25 . 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 n d m a y n o r m a l ly be m il dl y t e nd er . a nd c ir rh os is of t he l iv er ). 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. he pa t i t i s. 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. Figure 25-36.

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. 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 . W om en f r om s om e cu lt ur es (I sl am . 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 . s e x u a l h i s t o r y . a n d di sc ha rg e. 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 . p a i n . t h e n ur se wo ul d n e e d t o o b t a i n a r e p r o d u c t i v e h e a l t h hi st or y t o pr ov id e a b as el in e f or t he p at ie nt 's pl an of c ar e. i t c h i n g . a n d ha vi ng v ag in al de li ve ry . wi t h ou t le si on s o r sw el li ng . d ep en di ng o n t h e w o m a n ' s a g e . 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 . A s pa rt o f t h e f oc us ed a ss es sm en t . w it h t h e l e g s i n s t i r r u p s . I n s p e c t t he e xt er na l g en it al ia f or co lo r. 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. s iz e of t he la bi a ma jo ra an d va gi na l o pe ni ng . o r f or ei gn o bj ec t s ). 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 . I n m a n y i n s t a nc es . a n d d i s c h a r g e .Figure 25-37. 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 . 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 . ma le he al t h ca re pr ov id er s wi ll a sk t ha t a f em al e be pr es en t in t he r oo m a s a c h a p e r o n e d u r i n g t h e e x a m i n a t i o n . E 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 . 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 . E qu ip me nt re qu ir ed in cl ud es a v ag in al s pe cu lu m ( f o r t h e f e m a l e e x a m i n a t i o n ) . I n ch il dr en . 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 . a g o o d l i g ht s ou rc 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 . t y pe o f f lo w. 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 en gt h o f f l ow . 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 . 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 . a nd di sp os ab le gl ov es . 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 . External female genitalia. 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 . 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) . 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 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 . l es i o n s . 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. 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 . T h e s k i n a n d m uc os a sh ou ld be s mo ot h. T h e v ag in al o ri f i ce va ri es i n si ze . pe ni s.

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 . P . 2 5 . wh ic h m ay i nd ic at e i nf ec t i on . 6 41 I nf or ma t i on f r o m t h e h e a l t h h i s t o r y i s h e l p f u l i n i d e n t i f y in g s el f . an a bs ce ss . 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 . a nd pa in . 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 . di sc ha rg e. 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 . pr os t a t e gl an d.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 . le si on s.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 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 . T hi nk b ac k t o R a m o n a L e w i s . 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. s cr ot um . o r c a n c e r . if c yt ol og ic sp ec im en s ar e t o be t ak en .so lu bl e lu br ic an t m ay b e us ed . 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 . 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 .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 . G ui de li ne s f or N ur si ng Ca re 2 5. a p o l y p .3 8 ) i n c l u d e t h e p e n i s . 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 . 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 . . 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 . s w e l l i n g o f g l a nd s. 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 . 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 . 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. a nd se mi na l ve si cl es . 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 . 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 . ep id id ym is . 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 . D on g l o v e s . 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. t es t i cl es .

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

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

st if f n es s. T h e pa t i en t ' s u su al e xe rc is e p at t e r n s a r e h e l p f u l i n t e a c h i n g h e a l t h y b eh av io rs . Older Adult C om mo n v a r i a t i o n s i n o l d e r a d u l t s i n c l u d e : • • A nu s i s d a r k e r i n c o l o r H em o r r h o i d s a r e o f t e n p r e s e n t Assessing the Musculoskeletal System T he p ri ma ry s t r u c t u r e s o f t h e m u s c u l o s k e l e t a l s y s t em a re t he bo ne s. t e n d on s. t he y ar e s ym me t r ic a nd n on t e nd er . 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. 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 . 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 nd mo ve t hr ou gh f u ll R O M . t h e g la nd i s no rm al ly sm oo t h . s h a p e a n d c o l o r . a n d j o i n t s a r e a s s e s s e d . N or ma ll y. an d ab il it y t o mo ve . 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 . 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 . f i rm . i n c l u d i n g s t a nd in g. 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 . 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 . g ai t . a n d m u s c l e p ai n an d/ or we ak ne ss c au se d b y in ju ry or d is ea se ). N or ma ll y. 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. c ar t i la ge . or c re pi t u s ( gr at in g so un ds on m ov em en t ) . a r e f r e e o f s w e l l i n g. A s s e s s m u s c l e s t r e n g t h . b o n e s . an d jo in t s . 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 . G u i d e l i n e s 2 5 . T he m us cl es . . a nd m us cl e s t r en gt h. cr ep it us . an d a bo ut 1¾ ″ (4 c m) i n si ze . 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 . m us cl es . b on e s i z e a n d s t r u c t u r e . 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. 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. no du le s. pa in . a r t h r i t i s . t h e jo in t s a re of e qu al b i l at er al si ze . si t t in g. 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 . 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 .1 0 de sc ri be s t es t i ng mu sc le s. 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 ) . li ga me nt 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 . j o i n t r a n g e o f m o t i o n (R O M ). a nd s up in e. s ha pe . 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 . an d l im it ed R O M ( in di ca t i ng in ju ry . 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 . s uc h a s pa in .

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

Assessing the Muscles A ss es s mu s c l e s t r e n g t h b y a s k i n g t h e p a t i e n t t o m o ve a ga in st re si st an ce . Figure C. Figure B. 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. 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 . . 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 ) . 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 ). 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 ). 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.

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

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

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

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

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

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

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

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

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

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

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

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

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