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) .

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

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 . 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 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 . p r o v i d e s p ri va cy . 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 . 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 . s u c h a s m ov em en t o r pu ls es . 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 . R em em be r R a m o n a L e w i s . m o b i l i t y . D ur in g p os it io ni ng . p h y s i c a l c o n d i t i o n . c l o t h . va ri at io ns ar e no t e d i n t h e di sc us si on of s pe ci f i c b od y a re as la t e r i n t h e c h a p t e r . T 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. a nd pr iv ac y. 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 . 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. P o si t i on s t h at ma y be u se d d ur in g a p hy si ca l a ss es sm en t a r e i l l u s t r a t e d a n d d e s c r i b e d i n B o x 2 5 . t he 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 . h ea lt h s t a t u s . 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.3. 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 . 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. 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 .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 . O nc e vi br at in g.Vaginal Speculum A v ag in al sp e c u l u m i s a t w o . 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 . 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 . 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 . 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. 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 . 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 . i t is i mp or t a nt t o co ns id er t h e pa t i en t ' s a ge . t h e as se ss me nt f i nd in gs o f o ne l eg a re c om pa re d w i t h t h o s e o f t h e o t h e r l e g . 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. o r b e d l i n e n s . e n er gy le ve l. t ha t i s. T he q ui ck . 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 . Tuning Fork A t un in g f or k i s a t w o .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 . 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 . 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. f o r ex am pl e. W h e n c on du ct in g a n as se ss me nt . 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. 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 . D ra pe s m ay b e p a p e r . I n sp ec t i on be gi ns wi t h t he i ni t i al . 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.

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

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

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

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 . 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 . 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 . w hi ch i s pa rt o f t h e n eu ro lo gi ca l s ys t e m) . . d iz zy . ( 3 ) q u a l i t y ( e g . t ak in g vi t a l s ig ns . I ns pe ct t he pa t i en t ' s b od y bu il d. Guidelines for Performing Health Assessment A lt ho ug h t he r e a r e v a r i o u s o r g a n i z i n g s t r u c t u r e s f o r co nd uc t i ng a ph ys ic al as se ss me nt . a nd me as ur i n g h e i g h t a n d w e i g h t . 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 . General Survey T he g en er al s u r v e y i s t h e f i r s t c o m p o n e n t o f t h e p hy si ca l a ss es sm en t .6 B) . 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 . 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 . p r o v i d in g i ns ig ht i nt o nu t r it io na l s t a t u s. T 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. a nd ga it . 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 ). or l on g) . 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 .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 n d g a i t ( w h i l e w a l k i n g u p ri gh t ) . 2 5 . Auscultation A u s cu l t at i o n i s t h e a c t o f l i s t e n i n g w i t h a s t e t h o s c op e t o so un ds pr od uc ed wi t h in t he b od y. A 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.( s e e F i g. 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 . wh il e a s s e s s i n g t h e h e a d a n d n e c k t h e y a l s o as se ss t he cr an ia l ne rv es . 6 08 P . o r pr on e t o f a ll . 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 . a nd ( 4) d ur at io n ( sh or t . I t i s us ed t o a ss es s po st u r e . W h en a us cu lt at in g. 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 . g u r g l i n g o r s w i s h in g) .t o . a nd ( if p os si bl e) li st en i n a q ui et e nv ir on me nt . b a l a n c e . 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 . po st ur e. 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. T he a cc om p a n y i n g h e a d . A s se ss in g P . 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. 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. 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 . 6 07 P . ( 2) lo ud ne ss ( ra ng in g f r o m so f t t o l o u d ) . de sc ri be d i n T ab le 25 -3 .

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

k ne es f le xe d. 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 . a nt er io r t ho r a x . 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. B ot h kn ee s a r e f l e x e d . b r e a s t s . 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. . l u n g s . w i t h t h e u p p e r l e g m o r e a c ut el y f l ex ed .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 . n ec k. 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 . I t is u se d t o a ss es s t he r ec t u m or v ag in a. I t i s us ed t o as se ss t h e he ad . a nd pe ri ph er al pu ls es . h e a r t . an d so le s o f t h e f e et o n t he b ed . 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 . e x t r e m i t i e s . I t sh ou ld n ot be u se d f o r a bd om in al a s s e s s m e n t b e c a u s e i t c a u s e s c o n t r a c t i on of t he a bd om in al mu sc le s.

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

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

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

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 . 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 . b r u i s e s . p l a n t s . T ab le 2 5 . 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. h ai r. 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 ) . 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 .7) a n d pa l p a t e f o r t e m p e r a t u r e . I f t he p at ie nt ca nn ot st an d er ec t . P . an d t e xt ur e.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 . s i z e . 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 . 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 . 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 . 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 . I f t h e p a t i e n t h a s l e si on s. 2 5 .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 . 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 . 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. 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 . m oi st ur e. c h a n g e i n c o l o r . a n d n a i l s a r e a s s e s s e d b y i n s p e c t i on an d pa lp at io n. I ns pe ct t he s ki n f or c ol or . l e s i o n s . y o u m a y as se ss t h e sk in o n t he a bd om en wh il e pe rf or mi ng ot he r a bd om in al a ss es sm en t s ) . o r b ur ns ) C ha n g e i n t h e c o l o r . va sc ul ar it y. t ur go r.4 p r o v i d e s a h e i g h t a n d w e i g h t t a b le f or u se as a s t a nd ar d r ef er en ce . f oo ds .1 ). an d sc al p. an d n ut ri t i on . 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 . 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 . 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 . we ar g lo ve s du ri ng pa lp at io n. a b r a si on 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 . an d n ut ri t i on . Skin T he s ki n i s a g e n e r a l i n d i c a t o r o f t h e p a t i e n t 's h e a l t h s t a t u s a nd p ro vi de s i nf or ma t i on t h at m ig ht i nd ic at e a n un de rl yi ng d i s ea se . hy gi en e. 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 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 . 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. n a i l s . h yd ra t i on st at us . an d l es io ns (F ig . 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 . I t a ls o p ro vi de s d at a a b o u t s e l f . BOX 25-4: Geriatric Depression Scale (GDS) . 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 . 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. h ai r.

5. 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. no . no 3. no 4. 14.Instructions: 1. rather than going out and doing things? yes no 2. yes no 7. 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. yes yes no no 6. yes yes no no 10. no 12. Circle the answer that best describes how you felt over the past week. no 13. 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. 9.

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

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

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 he t ex t u re is d r y . A n e xc es si ve am ou nt o f pe rs pi ra t i on . Weights in pounds are according to frame (in indoor clothing weighing 3 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 . shoes with 1-inch heels). 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 . Weights in pounds are according to frame (in indoor clothing weighing 5 lb. 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 . Texture. Palpating Skin Temperature. l o o s e a n d w r i n k l e d a n d t h e m u c o u s m em br an es a re cr ac ke d an d d ry . Moisture. 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 . † Weights at ages 25 to 59 yr are based on lowest mortality.

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

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

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

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

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

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

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

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

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

Ears A ss es s t h e e x t e r n a l e a r . The eye and surrounding structures. 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 . . 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. 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 . t he p oo re r t he v is io n. No rm al ly b ot h e ye s m ov e t o ge t h e r . 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 . a r e c o o r d i n a t e d . B ri ng t h e p e n l i g h t f r o m t h e s i d e o f t h e p a t i en t ' s f ac e an d b ri ef ly s hi ne t h e li gh t on t h e pu pi l (F ig ur e A ). Guidelines for Nursing Care 25-2 Measuring Pupillary Reaction.2 0/ 20 ) c an r e a d t h e l e t t e r s .4 ) . 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 . Accommodation. T he p at ie nt re ma in s s ea t e d wh il e t he n ur se a ss es se s t h e s t r u c t u r e o f t h e e a r s b y i n s p e c t i o n a nd pa lp at io n. 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 ) .14 ). 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 . an d l es io ns . a nd le si on s. 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 . Figure 25-11. 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 ). a n d t h e i n ne r ea r (F ig . 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 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 .1 5 ) f o r s h a p e . 2 5 . 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 . 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 . a nd t he s ha pe a n d s i z e o f t h e e a r s s h o u l d b e s y m m e t r i c an d pr op or t i on al P . 25 . t h e m i d d l e e a r . 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 . un ev en co lo r. i t t o o n or ma ll y wi ll c on st ri ct (c on se ns ua l r ef le x) . 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” ). s i z e . 6 20 t o t h e h ea d.

a p e n c i l . Assessing accommodation. . 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 . Pupillary gauge measures pupils (dilation or constriction) in millimeters (mm). t h en ba ck t o t h e o bj ec t be in g h el d.e y e d a p p e a r a n c e) . 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 . Assessing pupillary reaction. o r o t h e r s t r a i g ht o bj ec t a bo ut 10 t o 15 c m (4 ″ t o 6 ″ ) f ro m t h e b ri dg e of t h e pa t i en t ' s n os e ( F i g u r e C) . Figure C. Figure B. Accommodation • • H ol d t h e f o r e f i n g e r . t he n at a d is t a nt ob je ct . 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) . A sk t h e p a t i e n t t o f i r s t l o o k a t t h e o b j e c t .Figure A. T 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 .

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 ). Examination of the internal structures of the eye. a n d g r a y ( F i g . 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 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) . 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 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 ) . 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) . 6 21 . s h i n y . 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 . wi t h t he o pp os it e e ar c ov er ed . s en so ri ne ur al (f ro m in ne r e ar d am ag e) . I ns er t t h e o t o sc op e s pe cu lu m as t he pa t i en t ' s h ea d i s sl ig h t l y t i l t e d a w a y f r o m t h e e x a m i n e r . A t t a ch t h e la rg es t s pe cu lu m t h a t w i l l f i t c o m f o r t a b l y i n t o t h e p a t i e n t 's ea r t o t h e ot os co pe .Figure D. 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 . 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 ). 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 25-12. 2 5. t r a n s l u c e n t . I n c h i l d r e n y ou ng er t h an 3 ye ar s of a ge . s t r ai gh t e n t he e ar ca na l of t he ad ul t by g en t l y p ul li n g t h e p i n n a u p a n d b a c k . ma st oi d t e nd er ne ss (f ro m in f e ct io n) . 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. 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 . 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 ). e d e m a .1 6) . (Photo by B. A s se s s t h e p a t i e n t f o r b o t h b o ne c on du ct io n P . E x a mi ne f or w ax . d is ch ar ge . an d f or ei gn bo di es . T h er e s ho ul d be no r ed ne ss or d is ch ar ge . T o a ch ie ve be t t er v is ua li za t i on . o r p re se nc e o f le si on s. a c om bi na t i on o f b o t h . 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 . 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 . Assessing convergence.

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

19 ). 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 . or g ro wt hs . N o r m al ly . f a ci ng y ou a t e ye l ev el . 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 . 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 . di ag on al ly up a nd do wn t o t he r ig ht ( se e F ig ur 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. 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.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. l e f t a n d r i g h t . Palpating the Sinuses P al pa t e t h e f r o n t a l a n d m a x i l l a r y s i n u s e s f o r p a i n an d ed em a. 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 . ex ud at e. 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 . 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 . 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 . 2 5 . 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 . 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 ) . 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) . Guidelines for Nursing Care 25-4 Assessing Extraocular Movements and Peripheral Vision Extraocular Movements • • • A sk t h e p a t i e n t t o s i t o r s t a n d a b o u t 2 f e e t a wa y. A 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 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 ) . 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 . 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 . 25 . 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 . 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 . 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 . 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.2 0) . 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 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) . . 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 . 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. 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 . 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. 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 . N o r m al ly . t h e s in us es a re no t pa in f u l w he n pa lp at ed .

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

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. m o b i l i t y . 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 . 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 . Palpating the Trachea and Lymph Nodes T he t ra ch ea . t e nd er ne ss . m ob il e. an d n on t e nd er . 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. is p al pa t e d f or a li gn me nt an d p os it io n. a ut oi mm un e d is or de rs . 2 5 . I f pa lp ab le . w it h f u ll ra ng e of m ot io n. a nd s id e t o si de t o as se ss r an ge of m o t i o n . as seen through an otoscope. Figure 25-16. Normal tympanic membrane. t h e y s h o u l d b e sm al l. s i z e. 2 5 . c on si s t e n c y . 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 .A ss es s t h e n e c k (F i g . sm oo t h . Figure 25-15. 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 . 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. a nd mo bi li t y . a n d t e n d e r n e s s . i f p a l p a b l e . n o r m a l l y m i d l i n e a t t h e s u p r a s t e r n a l n ot ch . a ss es s lo ca t i on .2 2 ) w i t h t h e p a t i e n t s i t t i n g. f or wa rd . T h e n e c k s h o u l d b e s y m m e t r i c . A 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 . P al pa t e t h e l y m p h n o d e s ( F i g . External structures of the ear. o r me t a st as is o f ca nc er . E n l a r ge d l ym ph P . T h e ne ck s ho ul d b e hy pe re xt en de d sl ig ht ly .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 . 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 .

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 . 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. t en de rn es s. 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.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 . 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 . 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. T he pa t i en t is s it t i ng .6) . I f p al pa bl e. so f t a nt er io r f o nt an el at a bo ut 18 m on t h s o f ag e Figure 25-18. 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. o r no du le s ( wh ic h ma y i nd ic at e t h yr oi d g la nd d is ea se . s ym me t r y. sh ap e. m as se s. Palpating the Thyroid Gland T he t hy ro id g l a n d i s a s s e s s e d b y p a l p a t i o n . Cross-section of the nasal cavity. t h e n o r m a l e a r w i l l d o s o . o r c a n c e r ) . Location of the frontal and maxillary sinuses. i nf ec t i on o f t h e t hy ro i d .• • • • S t r ik e t h e t u n i n g f o r k a s f o r W e b e r 's t e s t . . I mm e d i a t e l y p l a c e t h e s t i l l . P al pa t e f or s iz e. t h e t h yr oi d g la nd sh ou ld f ee l s of t bu t el as t i c. 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 .

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

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. 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 . 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 . an d du ll ne ss . lo ud . an d in t e ns it y o f t he s ou nd s. 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 . 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 . 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. N ot e t h e i nt en si t y . 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 . o r s o l i d s w i t h i n t h e l un gs . h ea rd ov er f lu id o r a s ol id m as s. pi t c h. pi t c h. 2 5 . du ra t i on . R ep e a t f o r t h e o t h e r s i d e . Anterior Approach • • • S t a n d i n g f a c i n g t h e p a t i e n t . A sk t h e p a t i e n t t o s w a l l o w . Auscultating Breath Sounds A us cu lt at io n i s u s e d t o d e t e c t a i r f l o w w i t h i n t h e r e sp ir at or y t ra ct . a n d 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. L is t e n f or t he d ur at io n.2 6) . P al p a t e e a c h l o b e o f t h e t h y r o i d b y h a v i n g t h e pa t i en t t ur n t h e he ad sl ig ht ly t ow ar d t he s id e t o be e xa mi ne d. l i q u i d s . l ow i n pi t c h. a n d p a l p a t e f o r en la rg em en t . t h 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 . 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. t h e s o un d i s ho ll ow . (Photos by B. an d q ua li t y o f s ou nd s pr od uc ed . 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. A sk t h e p a t i e n t t o s w a l l o w . W he n a n or m a l a i r . Proud.) 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 . R ep e a t f o r t h e o t h e r s i d e . . an d of l on g d ur at io n. (B) Using an anterior approach. 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 ). 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.2 6 ) . 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 . 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 .f i l l e d l u n g i s p e r c u s s e d . No rm al ly . 2 5. 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 .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 .

. (B) Posterior. S t r id or is a h ar sh . hi gh .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 . No rm al b re at h s ou nd s (T a bl e 2 5. i f p r e s e n t . 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 . Figure 25-25. s t r e n u o u s r e s p i r a t i o n s . V e s i c u l a r b r e at h so u n d s a re s of t . b ro nc hi . 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 . a nd t r a c h e a . 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.p it ch ed .9) . o r t u mo rs . w h i c h i s l o n g e r t h a n e x pi ra t i on . 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 . s we ll in g.pi t c he d so un ds . 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 . 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 . 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. 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 . S t er t o ro us br ea t h in g i s a ge ne ra l t er m us ed t o r e f e r t o n o i s y .8) v ar y ov er di f f er en t p ar t s o f t he l u n g s . Profile and anteroposterior diameter of normal adult chest and barrel chest. A d v en ti ti o u s b re at h so u n d s a re n ot no rm al ly h ea rd in t he l un gs bu t .Figure 25-24. 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. O rd in ar il y. 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 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.p it ch ed s o u n d s . lo w. h ar sh s ou nd s. wi t h e xp i r at io n b ei ng l on ge r t ha n i ns pi ra t i o n . 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. s u c h a s t h e l a r y nx or t ra ch ea . 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 . 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. Thoracic landmarks (A) Anterior. 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.

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

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

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 . a nd a ny li f t s or h ea ve s. 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 . t r i c u s p i d . f o r c e . a n d l o c a t i o n i n r e l a t i o n sh ip t o t he mi dc la vi cu la r li ne . hollow sounds. 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 . an d E rb 's p oi nt . a n d m i t ra l ar ea s a nd E rb 's po in t . and higher-pitched than inspiration Bronchovesicular . 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 . 25 . 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. p u l mo ni c. 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. ex ce pt t h e ap ic al i mp ul se . d u r a t i o n .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 . a nd a pi ca l a re as .31 ). p al pa b l 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 . 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. and Location Bronchial or Tubular Ratio of Inspiration to Expiration Blowing. auscultated over the trachea Expiration is longer. w hi ch ar e f i n 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 . 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. 25 . p u l m o n i c . I de nt if y an y pr ec or di al t h ri ll 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 . F ig . t ri cu sp id .30 ) f o r v i s ib le p ul sa t i o n s . Table 25-8 Normal Breath Sounds Type.2 9 f o r a v i e w o f t h e he ar 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. 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. lower. N ot e si ze . R e f e r t o F i g u r e 2 5 . 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. 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 . 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 . wi t h a ss es sm en t o f sp ec if ic c ar di ac P . 6 31 l an dm ar ks — t h e a o r t i c . 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. I n s p ec t t h e e pi ga st ri c ar ea at t he t ip of t he s t e rn um f o r pu ls at io n o f t h e a bd om in al a o r t a .

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

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

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

wi t h a rm s at si de s or r ai se d o ve rh ea d. c a l l e d S 1 . 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 ). m en al so a re a t r is k f o r br ea st d i s ea se . T he s ou nd . W h e n s i t t i n g . 2 5.t o . 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 . i f as se ss ed . T he pa t i en t is i n t h e s it t i ng o r s up in e p os it i o n . 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 o . b e n z e n 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 . 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 . i n c l u d in g r el at io ns hi p t o me ns t r ua l pe ri od H is t o r y o f l u m p s o r s w e l l i n g . o r a l c o n t r a c e p t i v e s .e x a m in at io n ( se e Ch ap . e s p e c i a l l y i n f em al es . 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 . 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 . r e d n e s s . T h e he al t h hi st or y el ic it s r i s k f a ct or s f o r c a n c e r o f t h e b r e a s t .du b. 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 . b i o p s y . is h ea rd as t he “ lu b” of “ lu b.• • • • 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 . 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 . t h e p a t i e n t s h o u l d s it e re ct .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 . 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. t h e f i r s t h e a r t s o u n d .3 2) . 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 . l ow -p it ch ed . W h en s up in e. c h a n ge in s iz e.

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

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 . N or ma ll y. 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 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 ) . 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 . 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. a n d v e i n s f i l l i n 1 5 se co nd s. w hi c h a r e a b n o r m a l s o u n d s . c ol or r e t u r n s i n 1 0 s e c o n d s . 6 34 P . 6 35 . R el ea se t he p re ss u r e . O bs e r v e t h e t i m e i t t a k e s f o r t h e o r i g i n a l c ol or o f t h e pa t i en t ' s s ki n t o re t u rn a nd f o r t h e ve in s t o f i ll . No rm al ly . 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 .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 . 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 . 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 . 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 . o b s e r v e t h e t i m e f o r r e t u r n o f c o l or . t 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 . c a u s in g b lo od t o s wi rl . t h e a b d o mi na l a or t a . A ss e s s c a p i l l a r y r e f i l l i n c h i l d r e n b y p r e s s i ng t h e sk in l ig ht ly o ve r t he f or eh ea d o r t o p o f t h e ha nd . P . 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 .

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

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

• • • • • • 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 . p e r c u s s i o n . T he p a t i e n t s h o u l d h a v e a n e m p t y b l a d d e r . 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 . 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. s u c h a s i nf ec t i on s. s u c h as p ep t i c ul ce r d is ea se . 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 . r i g h t l o w e r . a n d l e f t l o w e r (F ig . 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 . 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 . wh ic h m ak es p al pa t i on di f f ic ul t .36 ). . a s we ll a s t h e p o s i t i o n . 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 ). 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 ). o r ve rt ic al s t r ip t ec hn iq ue . e it he r t h e c ir cu la r. T he p at ie nt sh ou l d b e s u p i n e w i t h a s m a l l p i l l o w o r t o w e l b en ea t h he r ba ck . 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 . ga ll bl ad de r di se as e. Figure A. l iv er d is ea s e . 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 . U se t h e p a d s o f t h e f i r s t t h r e e f i n g e r s t o g e n t l y co mp re ss t h e br ea st t i ss ue a ga in st t h e ch es t wa ll . a n d p a l p a t i on . 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 . bo we l d is ea se . 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 d e q u a t e l i g h t i n g . Circular technique. T h es e me as ur es . 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. 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 . 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 k t h e p at ie nt t o b re at he sl ow ly a nd d ee pl y t hr ou gh t h e mo ut h d ur in g t h e e xa mi na t i on t o p r o m o t e r e l a x a t i o n . t h 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 . a u s c u l t a t i o n .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 . 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 . 25 . 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 . 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 . ki dn ey s t o ne s.t h e . w ed ge .

a nd no t e t he ir f r eq ue nc y an d c ha ra ct er . ro un de d. Us in g t h e be ll of t he s t e t h os co pe . 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 . 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 . or c on ca ve . 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 . an d ma ss es . 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 . p er is t a ls is . T he y ar e h ea rd as c li c k s a n d g u r g l e s a n d u s u a l l y o c c u r e v e r y 5 t o 20 s ec on ds . a u s c u l t a t e o v e r t h e a o r t a . T h e s t e t h o s c op e i s wa rm ed . 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. 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. r e n a l a r t e r ie s. T h e a bd om en sh o u l d b e e v e n l y r o u n d e d o r s y m m e t r i c . p ul sa t i on 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 . I n t hi n p eo pl e. c o n t o u r . a nd il ia c ar t e ri es f or b ru it s. s ym me t r y. 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 . 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 .Figure B. wi t h ou t vi si bl e p er is t a ls is . 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 . 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. Figure C. 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 . Wedge technique. 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 . . Vertical strip technique. 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 . i n c l u d i n g t h e u m b i l i c u s . Inspecting the Abdomen S it a t t h e s i d e o f t h e p a t i e n t : a t a n g e n t i a l v i e w e n h a nc es sh ad ow s a nd co nt ou rs . 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.

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

. 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 . 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 . 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. n o d u l a r i t y ( f o u n d wi t h t um or . a nd c ir rh os is of t he l iv er ). m as se s. he pa t i t i s. va gi na l v es t i bu le . 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 . 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 . Figure 25-36.T o pa lp at e b y h o o k i n g . v es t i bu la r g l a nd s. 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 ) . c li t o ri s. e nl ar ge me nt ma y re su lt f ro m h ep at it is . 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 .b e l l y ” ( u n d e r 5 y e a r s o f a g e ) V is ib l e p e r i s t a l t i c w a v e s E as il y p a l p a t e d l i v e r a n d s p l e e n Older Adult C om mo n a b d o m i n a l v a r i a t i o n s i n o l d e r a d u l t s i n c l u d e: • • • D ec r e a s e d b o w e l s o u n d s D ec r e a s e d a b d o m i n a l t o n e L iv er b o r d e r p a l p a t e d m o r e e a s i l y Assessing Female Genitalia T he e xt er na l f e m a l e g e n i t a l i a c o n s i s t o f t h e m o n s p ub is . I nf or ma t i on co ll ec t e d d ur in g t h e h ea lt h hi st or y i s es pe ci al ly h el pf ul in i d e n t i f y i n g r i s k f a c t o r s f o r c a n c e r a n d h e a lt h. 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 . an d v as cu la r e ng o r g e m e n t . la bi a m aj or a an d m in or a. c ir rh os is . a n d m a y n o r m a l ly be m il dl y t e nd er . 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 . 25 . 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 . 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 . v a g i n a l o r i f i c e . or a bs ce ss ). 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. Diagram of abdominal quadrants and outline of underlying organs. li ve r t u mo rs . 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 .37 ). m et as t a t i c ca nc er . s t a n d o n t h e p a t i e n t ' s r i g h t si de a nd h oo k ( cu rl ) t h e f i ng er s o f bo t h ha nd s ov er t h e ed ge of t he r i g ht c os t a l m a r g i n . a n d u r e t h r a l o p e n i n g (F i g . d is ch ar ge . a nd pa in ( f r om v as cu l a r e n g o r g e m e n t a s i n c o n g e s t i v e h e a r t f ai lu re .

A 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 . 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. 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 . A s pa rt o f t h e f oc us ed a ss es sm en t . 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. t he c o l l e g e s t u d e n t w h o r e p or t e d t ha t s he w as r ap ed . a n d d i s c h a r g e . 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 . t y pe o f f lo w. I n ch il dr en . 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 . a n d di sc ha rg e. o r p a i n o n ur in at io n H is t o r y o f s m o k i n g F am i l y h i s t o r y o f r e p r o d u c t i v e o r g e n i t a l c a nc er R ec a l l Ra mo n a L e w i s . . 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 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 . 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 ) . 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 . I n m a n y i n s t a nc es . s iz e of t he la bi a ma jo ra an d va gi na l o pe ni ng . 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 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. a n d ha vi ng v ag in al de li ve ry . 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 . wi t h ou t le si on s o r sw el li ng . 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 ). s e x u a l h i s t o r y . External female genitalia. i t c h i n g . W om en f r om s om e cu lt ur es (I sl am . 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 . 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 . pe ni s. T h e wo ma n i s pl ac ed i n t he l it ho t o my p os it io n o n t h e e xa mi na t i on t ab le . o r f or ei gn o bj ec t s ). 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 . T h i s i s a n a d v a n c e d a s s e s s m e n t t e c h n iq ue . a 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 . 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 .Figure 25-37. a g o o d l i g ht s ou rc e. T h e v ag in al o ri f i ce va ri es i n si ze . T h e v u l v a n o r m a l ly h as m or e p ig me nt at io n t ha n ot he r s ki n ar ea s. T he re ma y b e a s m a l l a m o u n t o f c l e a r o r w h i t i s h v a gi na l d is ch ar ge (t hi s is n or ma l) . l es i o n s . T h e s k i n a n d m uc os a sh ou ld be s mo ot h. d ep en di ng o n t h e w o m a n ' s a g e . 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 . 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 . w it h t h e l e g s i n s t i r r u p s . l en gt h o f f l ow . a nd di sp os ab le gl ov es . p a i n .

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

an d di sc ha rg e. O bt a i n s p e c i m e n s i f n e e d e d . 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 ). 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 . 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 . c o n t o u r . le si on s. a p p e a r a n c e o f t h e s k i n . o b s e r v i n g t h e va gi na l wa ll s. s ha pe . Health History I de nt if y r is k f a c t o r s f o r a l t e r e d m a l e h e a l t h d u r i n g t he he al t h h is t o ry by a sk in g ab ou t t he f ol lo wi ng : • • • • • • • • • F re q u e n c y o f d i g it a l r e c t a l e x a m i n a t i o n s F re q u e n c y o f t e s t i c u l a r s e l f . T h e s iz e. W it h d r a w t h e b l a d e s s l o w l y . 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 . 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 . 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.• • • • • • 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. P . re le as e t he s cr ew so t ha t t h e bl ad es cl os e. f r e q u e n cy . 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 . I f t he pa t i en t is u nc ir cu mc is ed . G l o v e s a r e w or n du ri ng t h is a ss es sm en t . I n sp ec t t h e s cr ot um f or s ym me t r y. 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 . s h ap e. ed em a. N or ma l f i nd in gs in cl ud e s ki n t h at i s f r ee o f l es io ns . t 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 . N or ma ll y. t h e in gu in al ar ea i s . 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. 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 . an d di sc ha rg e. 6 42 Physical Assessment Inspecting and Palpating the Genitalia T he p at ie nt m a y b e s t a n d i n g o r s u p i n e . 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 . p l a ce me nt .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 . u n i f o r m i n c o l o r . r e d n e ss . an d ea si ly re t r ac t e d. Organs of the male urogenital system. 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 . A s s e s s t he lo ca t i on o f t h e u ri na ry m ea t u s. c o l o r . f ar mi ng . 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. 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 .

e d e m a . 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 . u s i n g a w e l l . ) A bn or ma l f in d i n g s a r e l e s i o n s . g lo ve d i nd ex f i ng er . t e st es . 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 .ch es t .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 ) . o r h e m o r r h o i ds at t he a na l s ph in ct er .l u b r i c a t e d. 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 ) . if n ec es sa ry . G l o v e s a r e w o r n . 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 .c ol or ed o r da rk . T h e p at ie nt ma y be i n t h e S im 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 . 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 . p a in . E d em a.f r e e of bu lg e s . k ne e. ( S e e C h a p s . i n c l u d i n g a n y c o n s t i p a t i o n . p ai n. 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 . 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 . ) 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. di ar rh ea .bl ac k) s t o ol s. n o d u l e s . 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 . 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 . ( 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 . in gu in al ly mp h no de s. 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) . 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 . 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 . r e d n e s 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 . an d f e mo ra l h er ni a a re u su al ly p er f o rm ed b y a ph ys ic i a n o r n u r s e w i t h a d v a n c e d e d u c a t i o n a nd s ki ll s. P 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 . ( 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. 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. s k i n c r a c k s . c o l o n o r r e c t a l c a n ce r. or p ro st at e c an ce r H is t o r y o f h e m o r r h o i d s Physical Assessment T ec hn iq ue s u s e d t o a s s e s s t h e r e c t u m a n d a n u s i nc lu de i ns pe ct io n a nd pa lp at io n. B ot h me n a n d w o m e n s h o u l d h a v e r e g u l a r D R E t o a ss es s f o r ca nc er . 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 . re dn es s. a n d h a r d o r a b n o r m a l l y c o l o r e d (s uc h as c la y. f l ui d. ) 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 . 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 . . d is ch ar ge . di sc ha rg e.

si t t in g. T he m us cl es . i n c l u d i n g s t a nd in g. 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. 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 . a nd m us cl e s t r en gt h. 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. li ga me nt 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 . an d jo in t s . A b n o r m a l f i n d i n g s i n c l u d e d e f o r m it y. b o n e s . an d l im it ed R O M ( in di ca t i ng in ju ry . t h e jo in t s a re of e qu al b i l at er al si ze . 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 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 ) . t h e g la nd i s no rm al ly sm oo t h . 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. 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. 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 . 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 ). 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 . no du le s. a nd mo ve t hr ou gh f u ll R O M . an d ab il it y t o mo ve . t e n d on s. s uc h a s pa in . a nd s up in e. T h e p ro st at e gl an d i n me n ca n b e as se s s ed f o r si ze . a n d j o i n t s a r e a s s e s s e d . 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 . f i rm . G u i d e l i n e s 2 5 .1 0 de sc ri be s t es t i ng mu sc le s. a r t h r i t i s . N or ma ll y. A s s e s s m u s c l e s t r e n g t h . 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 . st if f n es 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 c e r v i x i n w om en m ay be f el t as a s ma ll . 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 .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 . t he y ar e s ym me t r ic a nd n on t e nd er . r ou nd m as s wh en pa lp at in g t he a nt er io r r ec t a l wa ll . j o i n t r a n g e o f m o t i o n (R O M ). m us cl es . . 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 . b on e s i z e a n d s t r u c t u r e . cr ep it us . pa in . a r e f r e e o f s w e l l i n g. g ai t . s h a p e a n d c o l o r . s ha pe . Health History I de nt if y r is k f a c t o r s f o r a l t e r e d 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 . 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 . an d a bo ut 1¾ ″ (4 c m) i n si ze . N or ma ll y.

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

. 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 ).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 . 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 . Figure B. Figure C. Figure 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 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 ). Mu sc le s t r en gt h s ho ul d be bi la t e ra ll y eq ua l. Elbow Extension and Flexion • • T he p a t i e n t f i r s t e x t e n d s t h e e l b o w a g a i n s t re si st an ce by t he e xa mi ne r ( F i gu re B ) .

Figure F. 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 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 E. . 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) . Hip Flexion T he p at ie nt a t t e m p t s t o r a i s e h i s t h i g h a g a i n s t e x a m in er 's re si st an ce (F ig ur e F ). Knee Flexion and Extension • • W it h t h e p a t i e n t ' s k n e e b e n t a n d f o o t o n t h e ex am in in g t ab le . Figure D. T o t e s t e x t e n s i o n .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 ).

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) . T he n . .Figure G. Figure H. Figure I.

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

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

S c or es a re g iv en in e ac h ca t e go ry . h as n o sp on t a ne ou s mo ve me nt .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. 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. Assessing Memory A ss es s me m o r y b y a s k i n g q u e s t i o n s t h a t c a l l f o r a n sw er s de mo ns t r at in g i mm ed ia t e re ca ll a nd re ca ll f or p as t e ve nt s. a p at ie nt ma y b e c o n s c i o u s b u t n o t o r i e n t e d . T h is is n ot t he s a m e a s or ie nt at io n. Y ou m ig ht a ls o a sk . A sc or e of 7 o r l es s de f i ne s c om a. c a n m a k e v e r b a l r e s p o n s e s . “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 . an d t im e. 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 ) . 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 . as k. 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. T o a ss es s im me d i a t e m e m o r y . 9) .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 . 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 . 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 . o r i e n t e d t o p e rs on . 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 . 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 . p la ce . “ 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 . a nd v er ba l r es po ns e. r es po nd s t o al l st im ul i. 3 . m o t o r r e s p on se . i f n o r e f l e x e s p r e s e n t . mu st be s ha ke n o r sh ou t e d a t t o a ro u s e . a nd a t ot al s co re i s r e c o r d e d . w i t h h i g h e r s c o r e s i n d i c a t i ng a mo re n or ma l l ev el o f f u nc t i on in g. e v e n w i t h u se of p ai nf ul s t i mu li . 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 . 6 . r es po nd s t o pa in f u l s t i mu li w it h p ur p o s e f u l m o v e m e n t s • C om a t o s e : c a n n ot b e a r o u s e d . b u t t h e se ar e le ss l ik el y t o b e a pp ro pr ia t e .

w hi ch i s a d is or de r of l an gu ag e ab il it y. wo rd s.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. 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. 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) . pu pi ll ar y r es po ns e du ri ng as se ss me nt of t he f ac e) . Table 25-11 Summary of Cranial Nerves . Cranial Nerve Function T he f un ct io n o f t h e 1 2 c r a n i a l n e r v e s i s a s s e s s e d p ri ma ri ly d ur in g t he n eu ro lo gi c a ss es sm en t . t o re ad a sh or t se nt en ce al ou d. b ed . 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. B e su re t h at t he p hr as e i s no t cu lt ur e s pe ci f i c. I n j u r y t o t h e c o r t e x c a n c a u s e a ph as ia . wi t h t h e i r f u n c t i o n a n d a s s e s s m e n t m e t h o d s . a re o ut li ne d i n T a bl e 2 5. 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 . p a j a m a s ) . 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. 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 . T h es e a ph as ia s m ay a ls o be c om bi ne d. 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 . go w n . ” I f i nt el le ct ua l a bi li t y i s i m pa ir ed . 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 ”) . T he c ra ni al n er ve s. 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 .11 . f l o we rs .

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

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 . Us e t h e re f l ex h am me r P . ask strength of the tongue patient to push tongue against cheek. 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 . 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 . f e et . 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. a n d a r m a n d l e g m o v e m e n t s . 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 . g a i t . 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. Ask the patient to protrude tongue. a nd a bs en ce of v ib ra t o ry se ns at io n. a nd h ee l t o t o e. a r e i l l u s t r at ed in T ab le 25 -1 2. se ns or y. A b no rm al f in di ng s i nc lu de lo ss o f ba la nc e. l ig ht t ou ch . a nd co or di na t i on . T he a ss es sm en t p r o c e e d s f r o m d i s t a l ( h a n d s . a nd 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 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. a nd ab n o r m a l p a t t e r n s o f g a i t . Assessing Motor Function and Coordination E va lu at e m o t o r f u n c t i o n a n d c o o r d i n a t i o n b y h a v i n g t h e p at ie nt r ap id ly t o uc h ea ch f i ng er w it h t h e t hu mb . t h e m o v e m e n t s a r e c oo rd in at ed . 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 .Hypoglossal (XII) Motor Movement of the tongue. 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. N o r m a l l y . wi de -b as ed g ai t . ve st ib ul ar . 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: . or l eg s) t o p ro xi ma l (t he t r un k) . O bs er ve p os t u re . 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. o n t he h ee ls . 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 . i f t h e p at ie nt i s su pi ne ).1 3 . a r m s . 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 . T h e po st ur e s ho ul d be er ec t . S el ec t e d re f l ex es . b al a n c e . w it h sl ig ht sw ay in g in t he st an di ng p os it io n. a n d v i b r a t i o n s . a nd c er eb el la r s y s t e m s . T h e s e f i n d i n g s m ay i nd ic at e d is or de rs of t he m ot or . sh uf f l i n g. Re pe at t h e se qu en ce on t he o pp os it e l i m b . it m ay i nd ic at e d is e a s e o f t h e u p p e r m o t o r n e u r o n s o r c e re be ll um . T h e p a t i e nt ma y be e it he r s it t i ng o r su pi ne . l i g h t t o u c h . 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 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. P . a s l i s t e d in T a b l e 2 5 . 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 . 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 . ra pi dl y p at t he h an d o n t h e t h i g h .

m a k e n u r s i n g d i a g n o s e s . N u r s e p r a c t i t i o n e r s a n d p h y s i c i a n s m ak e de ci si on s c on ce rn in g w hi ch d ia gn os t i c t es t s t o s ch ed ul e wh en p ro bl em s a r e n o t e d d u r i n g t h e h e a l t h h i s t o r y o r p h y si ca l as se ss me nt or b ec au se of a p ro bl em st at ed by t he p at ie nt .6. H ow ev er . 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 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 . 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 .14 pr es e n t s a n o v e r v i e w o f d i f f e r e n t t y p e s o f d i ag no st ic pr oc ed ur es . T 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 . p l a n a p p r o p r i a t e ca re . 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 . w i t h e a c h s ys t e m re co rd ed in di vi du al ly . 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 a st e. I n a d d i t i o n . 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 . s ch ed ul in g t he t e st . The Nurse's Role in Diagnostic Procedures N ur se s as si s t b e f o r e . a nd t r an sp or t i ng sp ec im en s. 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 . t r u n k. d u r 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. 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 . D o c u m e n t t h e d a t a . a he al t h h i s t o ry o f a w o m a n d i a g n o s e d w i t h m u l t i p l e s c l e r o s is ( a n eu ro lo gi c d is or de r) i nc lu de s d at a ab ou t f at ig ue an d in cr ea se d w ea k n es s a n d m u s c l e s p a s m s i n t h e l e g s . T hi nk b ac k t o T a m m y B r o w n i n g . 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 .• • • 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 . 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 . F o r ex am pl e. s u c h a s w i t n e s s i n g t h e p a t i e n t 's co ns en t . 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 . di sp os in g of us ed e qu ip me nt . Table 25-12 Normal Responses of Commonly Tested Reflexes . 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 . 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 . a n d a f t e r d i a g n o s t i c t e st s. s me ll . T ab le 2 5. 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. n e c k . or ga ni ze a ll as se ss me nt d at a t o id en t i f y a ct ua l a nd p ot en t i al he al t h p ro bl em s. s i g h t . t em pe ra t u re . 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 .

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

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

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

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

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