Health Assessment

BACHELOR OF SCIENCE IN NURSING – MIDTERMS REVIEWER

WEEK 7: DOCUMENTATION  Records client’s understanding

PURPOSE OF DOCUMENTATION
1 Promote effective communication among
multidisciplinary health team members to facilitate safe
and efficient client care
2 Helps identify health problems, formulate nursing
diagnoses and plan immediate and ongoing
interventions
3 Computer-based documentation system
 database that can link to other documents and
health care department
 eliminate repetition of similar data
 Avoid recording the word “normal”
 Record complete information and details
 Include additional assessment content
 Support objective data with specific observations
ASSESSMENT FORMS USED FOR DOCUMENTATION
1. Initial Assessment form Nursing admission
2. Gordon Functional By Marjory Gordon
Assessment

PURPOSE OF CLIENT’S RECORD

1. Communication
2. Planning patient care
3. Auditing health
agencies
4. Research
5. Education
6. Reimbursement
7. Legal documentation
8. Health care analysis
 vehicle by which different
health professionals who
interact with a client
communicate with each
other
 prevents fragmentation,
repetition, and delays
professional uses data from the
client’s record to plan care for
the client
review of client records for
quality assurance purposes
information in the client’s
record can be a valuable
source of data for research
use data in client records as
educational tool
receive reimbursement from
the federal government
(Philhealth)
client’s record is usually
admissible in court as evidence
assist health care planners to
identify agency needs

TWO KEY ELEMENTS IN DOCUMENTATION 3. Frequent or On-going  flow charts

1. Nursing history Subjective data
Assessment  help record and
2. Physical assessment Objective data retrieve data for
Has 4 techniques: frequent reassessment
 inspection  ex: vital sign sheet or
 palpation progress notes
 percussion 4. Focused or Specialty focused on one major area
 auscultation Area Assessment Form of body for client with
particular problem
WRITTEN NOTES AND ELECTRONIC DOCUMENTATION
METHODS ENSURING CONFIDENTIALITY AND SECURITY OF
 Keep confidential
COMPUTERIZED RECORDS
 Personal password is required to enter and sign off
 Document legibly, print neatly in nonerasable ink
computer files
 Use correct grammar and spelling
 Never leave a computer terminal unattended
 Avoid wordiness
 Do not leave client information displayed on the monitor
 Use phrases instead of sentences
 Shred all unneeded computer-generated worksheets
 Record data findings not how they were obtained
 Know the facility’s policy and procedure for correcting
 Write entries objectively without making premature
an entry error
judgments

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 Follow agency procedures for documenting sensitive
material
 Information Technology (IT) personnel must install a
firewall to protect the server from unauthorized access
ETHICS
 Greece: “ethos”
 Belief that guide life
 Accepted standards of conducts
 Nurse must understand his/her own values
ETHICAL PRINCIPLES
1. Informed consent healthcare provider educates
patient about risks, benefits, and
alternatives of a given procedure or
intervention
2. Confidentiality  respect privacy of patient
 right of the patient to decide
when, how and to what extent
others may have access to
health information
 DATA can be shared with those
who provide medical care
3. Autonomy  respect patient’s freedoms,
preferences, and rights
 patient autonomy allow health
care provider to educate
patient but doesn’t allow them
to make decision for patient
4. Beneficence  “to do good for patients”
 make sound decisions that
serve patient’s best interests
5. Normalifecence  “prevent harm to patients”
 subset of beneficence
6. Justice  “to be fair, treat people equally
and give patients the service
they need”
 foundation: belief that patients
are entitled to services based
on need, regardless of the
ability to pay
7. Fidelity “to respect our words and duty to
clients”
8. Veracity  “truthfulness”
 central to all nurse-patient
interaction because the quality
of relationship depends on
TRUST AND INTEGRITY
 nurses must not withhold the
whole truth from clients even
when it may lead to patient
distress
PATIENT’S RIGHTS
basic rule of conduct between patients and medical
caregivers as well as the institutions and people that support
them
PATIENT
anyone who has requested to be evaluated by or who is
being evaluated
DATA PRIVACY ACT OF 2012
 Republic act no. 10173
 act protecting individual personal information in
information and communications systems in the
government and private sector
 Consent of the data subject refers to any freely given,
specific, informed indication of will, whereby the data
subject agrees to the collection and processing of
personal information about and/or relating to him or her
 Consent shall be evidenced by written, electronic or
recorded means.
RIGHTS OF PATIENTS
1. Right to  right to health and medical care
appropriate without discrimination and
medical care and within the limit of resources,
manpower and competence
humane
 right to care of good quality
treatment
 dignity, convictions, integrity,
needs and culture shall be
respected
 if cannot be immediately given
treatment: direct to wait for care
or be referred or sent for
treatment elsewhere
 if patient must wait, they shall
be informed of the reason of
delay
 patient in emergency shall
receive treatment without any
deposit, pledge, mortgage or
any advance payment
2. Right to  right to clear, truthful and
substantial explanation of
informed consent
procedure
 provider must provide name
and credentials to patient,
possibility of death and serious
side effects
 patient is not subjected to any
procedure without written
informed consent, except:
a) In emergency, physician
can perform diagnostic or
treatment procedure
without consent
b) When health of population
is dependent on adoption
of mass health to control
epidemic
c) When law makes it
compulsory
d) When patient is minor,
third party are required:
- spouse
- son or daughter of legal
age
- either parent
- brother or sister of legal
age
- guardian
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 e) When material
information to patient will
jeopardize success of
treatment
f) When patient waives his
rights
3. Right to privacy  privacy must be assured at all
and confidentiality stages of treatment
 patient must be free from
unwarranted public exposure
except:
a.) mental or physical condition
is in controversy
b.) public health and safety so
demand
c.) patient waives this right
- patient has right to demand
all information, communication
and records to be treated as
confidential
- people involved is not
authorized to divulge any
information to any third party
4. Right to  right to be informed of results
information and extent of disease
 right to examine and be given
itemized bill of hospital
regardless of manner and
source of payment
 right to be informed by
physician about continuing
health care requirement
 patient is entitled to brief,
written summary of illness that
includes history, examinations,
diagnosis, medications, surgical
procedures, ancillary and
laboratory procedure
 if not able to settle payment,
patient is entitled to
reproduction
 patient also has right to not be
informed, by request
5. Right to choose  right to choose provider to serve
health care him as well as the facility
provider and  right to discuss his condition
with consultant specialist
facility
6. Right to self- right to avail any recommended
determination diagnostic and treatment procedures
must be informed of medical
consequences of his choice
releases those involved in care from
any obligation relative to the
consequences
decision will not prejudice public
health and safety
7. Right to religious right to refuse treatment or
belief procedure that’s contrary with
his/her religious belief
8. Right to medical patient is entitled to a summary of
records his medical history and condition
- right to view content of medical
records
- health institution shall issue
medical certificate to patient upon
request
9. Right to leave right to leave hospital or other health
institution regardless of physical
condition
- no patient shall be detained
against his/her will
- only be allowed to leave provided
appropriate arrangements such as
to settle unpaid bills
10. Right to refuse right to be advised if provider plants
participation in to involve him in medical research
medical research
11. Right to right to communicate with relatives
correspondence and to receive visitors subject to
and to receive reasonable limit
visitors
12. Right to express right to express complaints and
grievances grievance about care and services
without fear of discrimination
13. Right to be
informed of his
rights and
obligations as
patient
SOCIETAL RIGHTS OF PATIENTS
1 Right to health
2 Right to access to quality public health care
3 Right to healthy and safe workplace
4 Right to prevention and education program
5 Right to participate in policy decisions
WEEK 8A: ASSESSING THE INTEGUMENTARY
SKIN
 largest organ of the body
 physical barrier that protects underlying tissues and
organs from microorganism, physical trauma, UV
radiation and dehydration
 plays vital role in temperature maintenance, fluid and
electrolyte balance, absorption, excretion, sensation,
immunity, and vitamin D synthesis
 individual’s identity
MELANIN
Major determinant of skin pigment or color
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 2. Apocrine  with hair
gland follicles in
axillae,
perineum and
areolae of
breast
 small non-
functioning
glands until
puberty
 secrete milky
sweat

3. Subcutaneous  also called hypodermis

layer  loose connective tissue
3 MAIN LAYERS OF THE SKIN  contains fat cells, blood vessels,
1. Epidermis  Outer layer nerves and remaining portion of
 Consist of dead, keratinized cells sweat glands and hair follicle
that render the skin waterproof  stores fat as energy reserve
 Completely replaced every 3-4  provides insulation
weeks  serves as cushion to protect bones
and internal organs
Keratin – scleroprotein that is insoluble  contains vascular pathway for
in water supply of nutrients and removal of
2. Dermis  Inner layer waste products
 Connects to epidermis via dermal
papillae
 Create unique pattern of friction
ridges (fingerprint)
 well-vascularized, connective
tissue layer
 contains collagen and elastic
fibers, nerve endings and lymph
vessels
o collagen – most abundant
protein in body that
provides skin with structure
and strengthen skin,
elasticity and hydration
o nerve ending – why we feel
pain
o lymph vessels – why DISTINCT LAYERS OF EPIDERMIS
there’s blood 1. Stratum corneum  Superficial
- origin of sebaceous  consist of dead keratinized
glands, sweat glands and cell that render the skin
hair follicle waterproof
 origin of sebaceous gland, sweat 2. Stratum lucidum  thin, lighter appearing
glands and hair follicles layer
o Sebaceous gland – present  present on palm and soles
over most of body of feet
- secrete oily substance 3. Stratum granulosum  granular layer
called sebum  skin cells that containing
component that contribute
2 TYPES OF SWEAT GLANDS on outer layer
1. Eccrine  located over
4. Stratum spinosum  between granulosum &
gland entire skin
basale
 secrete sweat
 contains keratinized cell
and
 needed for keratin to
thermoregulation
mature
through
evaporation of
5. Stratum basale  called stratum
germinativum
sweat
 undergoes cell division

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  contains melanin (skin 4. Cuticle non-living tissue, dead skin cells
pigment) 5. Hyponychium skin under the free edge of nail just
 contains keratin forming beyond of distal end of nail bed
cell 6. Phalanx provide bony support for nail bed

HAIR SUBJECTIVE DATAS

 Consist layer of keratinized cells
 Found over the body except lips, nipples, soles of feet
and palm SUBJECTIVE FOR SKIN
 provides thermoregulation by wicking sweat away 1 FOR PATHOLOGIC SKIN CONDITION
 protects scalp, provides insulation and allow self-  Are you experiencing any current skin problems?
expression (rashes, lesions, dryness, oiliness, drainage,
bruising, swelling, or changes in skin color)
 What aggravates the problem? What relieves it?
2 FOR ESTABLISHING NORMAL BASELINE DATA
AND TO DETECT VARIATIONS IN APPEARANCE,
SYMMETRY, COLOR VARIATIONS, SIZE,
ELEVATION:
 Do you have any birthmarks or moles or tattoos?
Describe them
 Have any of them changed color, size, or shape?
3 FOR VASCULAR OR NEUROLOGIC PROBLEMS
STRUCTURE OF THE HAIR (CHANGES IN SENSATION):
1. Hair follicle sheath of epidermal cells
- may put client at risk for developing pressure
2. Hair shaft visible above skin
ulcer, impaired skin integrity and skin infections
3. Arrector Pili Muscle  contract in response of cold
 Have you noticed any change in your ability to feel
or fright
pain, pressure, light touch, or temperature
 decrease skin surface area
changes? Are you experiencing any pain, itching,
and cause hair to stand
tingling, or numbness?
erect
 attached in hair follicle
4 PHOTOSENSITIVITY REACTION AFTER SUN
EXPOSURE:
4. Hair bulb forms base of hair follicle, living
cells divide and grow to build hair  Are you taking any medications (prescribed or
shaft OTC), ointments or creams, herbal or nutritional
supplement?
5. Hair papilla  at base of hair follicle
 contains blood supply of  How long have you been taking these?
hair 5 ABNORMALITY WITH SWEAT GLANDS OR
ENDOCRINE PROBLEMS:
NAILS - uncontrolled body odor
 located on distal phalanges of fingers and toes - excessive or insufficient perspiration
 hard, transparent plates of keratinized epidermal cell - perspiration decrease along with aging
that grow from cuticle - poor hygiene practices
 protects distal ends of fingers and toes - Asians & native American: mild to no odor
- Caucasians & African American: strong body odor
 Do you have trouble controlling body odor? How
much do you perspire?

SUBJECTIVE FOR HAIR

1 PATHY HAIR LOSS
- may accompany infections, stress, hairstyle that put
root to stress, chemotherapy, radiation
- due to various systemic illness such as
Hypothyroidism
STRUCTURE OF THE NAILS - occur with aging
1. Nail body extends over entire nail bed  Have you had any hair loss or change in the
has pink tinge because of blood vessel condition of your hair? Describe.
2. Lunula crescent shape area located at base of
nail
SUBJECT FOR NAILS
3. Eponychium living tissue that’s attached to nail
1 MALNUTRITION AND IRON-DEFICIENCY ANEMIA
plate
 Have you had any changes in the condition or
protects nail and epidermis
appearance of your nails?

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 SUBJECTIVE FOR PAST HEALTH HISTORY o Ensure diet is
1 CURRENT PROBLEMS DUE TO RECURRENCES adequate with
- visible scars due to previous problem/treatment vitamin B3
 Describe any previous problems with skin, hair, or (niacin)
nails, including any treatment or surgery and its o Use ABCDE
effectiveness mnemonic when
2 VARIOUS TYPES OF ALLERGIES CAN examining:
PRECIPITATE VARIETY OF SKIN ERUPTIONS (Asymmetry,
- skin rashes or lesions may be related to viruses or Border, Color,
bacteria Diameter,
 Have you ever had any allergic skin reactions to Evolution)
food, medications, plants, or other environmental
substances? 3 SUN EXPOSURE
 Have you had a recent viral or bacterial illness? - cause premature aging of skin
3 HORMONAL BALANCE - increase risk of skin cancer
 For female clients: Are you pregnant? Are your  Do you sun bathe?
menstrual periods regular?  How much sun or tanning-booth exposure do
you get?
4 DERMATOLOGIV DISORDERS
 What type of protection do you use?
 Do you have history of anxiety, depression, or any
psychiatric problems?
SUBJECTIVE FOR LIFESTLYE & HEALTH PRACTICES
SUBJECTIVE FOR FAMILY HISTORY 1 IF CLIENT DOESN’T KNOW HOW TO INSPECT
1 ACNE AND ATOPIC DERMATITIS SKIN, TEACH THEM HOW TO RECOGNIZE
 Has anyone in your family had a recent illness, SUSPICIOUS LESIONS
rash, or other skin problem or allergy? Describe  Do you perform skin self-examination once a
2 SKIN CANCER month?
- abnormal growth of skin cells 2 SUBSTANCES THAT HAVE POTENTIAL TO
- most often developed on skin exposed to sun IRRITATE OR DAMAGE SKIN, HAIR, NAILS AND
- Asians are less susceptible RISKS FOR SKIN CANCER
- African American, Asians, Hispanic: susceptible to  In your daily activities, are you regularly exposed
melanoma to chemicals that may harm the skin?
- Asian Americans and African Americans: present 3 IMPAIRED SKIN INTEGRITY AND PRESSURE
with more advanced disease at diagnosis ULCER (OLD, DISABLED OR IMMOBILE CLIENT)
 Do you spend long periods of time sitting or lying
3 MAJOR TYPES:
1 Basal cell carcinoma in one position?
2 Squamous cell carcinoma 4 TEMPERATURE EXTREMES
3 Melanoma - affect blood supply and damage skin layers
- ex: frostbite and burns
 Has anyone in your family had skin cancer?  Have you had any exposure to extreme
RISK FACTORS temperatures?
o Fair skin o A family history of 5 PIERCING NEEDLE
o History of sunburns skin cancer - can cause skin infection
o Excessive sun o A personal history  Do you have any body piercings?
exposure of skin cancer 6 TATTOOS
o Sunny or high- o Weak immune - risk for skin infection
altitude climates system - removal can cause scarring allergic reaction,
o Moles o Exposure to formation of granulomas, keloid and swelling
o Precancerous skin radiation  Do you have any tattoos?
lesions o Exposure to 7 REGULAR HABITS PROVIDE INFORMATION
carcinogens - product may cause abnormality (dryness)
- improper nail-cutting may lead to ingrown or
PREVENTION infection
o Avoid sun during the o Be aware of sun - aging
middle of the day. sensitizing  What is your daily routine for skin, hair, and nail
o Wear sunscreen medications care?
o Wear protective o Check skin  What products do you use for skin, hair, and
clothing regularly and nails?
o Avoid tanning beds report unusual 8 BALANCED DIET
changes to your - healthy skin, hair and nails
doctor - adequate fluid intake maintain skin elasticity
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  What kind of foods do you consume in a typical ABNORMAL FINDINGS ON SKIN
day? 1. Pallor  loss of color
 How much fluid do you drink each day?  seen in arterial insufficiency,
9 CERTAIN ACTIVITIES THAT MAY EXPOSE YOU decreased blood supply, and anemia
TO ALLERGENS 2. Cyanosis  white skin appears blue, especially in
- exposure to sun may aggravate condition of perioral, nail bed and conjunctival
patients with scleroderma areas
 Do skin problems limit any of your normal
2 TYPES:
activities? 1. Central cardiopulmonary problem
10 SKIN, HAIR, NAIL PROBLEMS CAUSE INABILITY cyanosis
TO INTERACT COMFORTABLY 2. local problem due to
 Describe the skin disorder that prevents you from Peripheral vasoconstriction
enjoying your relationships? cyanosis
11 STRESS
- cause skin abnormalities 3. Jaundice  yellow skin tone
 How much stress do you have in your life?  pale to pumpkin
Describe  sclera, oral mucosa, soles, palms
4. Acanthosis roughening or darkening of skin in
nigricans localized area
OBJECTIVE DATAS strong odor of perspiration or foul odor
may indicate disorder of sweat glands
CLIENT PREPARATION 5. Rashes “butterfly rash”
 Ask the client to remove all clothing and jewelry and put bridge of nose and cheek indicate Discoid
on examination gown Lupus Erythematosus (DLE)
 Remove nail enamel, artificial nails and wigs 6. Albinism loss of pigmentation
 Have the client sit comfortably?
7. Erythema skin redness and warmth
 Ensure privacy by exposing only the body part being
seen in inflammation, allergic reaction or
examined. Close the door or curtain
trauma
 Maintain comfortable room temperature
8. Primary and Secondary Lesion
MATERIALS
o Gloves o Centimeter ruler
o Penlight o Wood light
o Mirror o Examination gown or
o Magnifying glass drape
o Assessment tool

BRADEN SCALE
Assessment tool used for predicting pressure sore risk and to
assess the skin’s integrity.

SKIN ASSESSMENT: INSPECTION

 note any distinctive odor
 generalized color variation
 skin breakdown
 primary, secondary and vascular lesions

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9. Vascular skin lesions
SKIN ASSESSMENT: PALPATION
lesions, texture, temperature and moisture, thickness,
mobility and turgor, edema
ABNORMAL FINDINGS ON SKIN
1. Rough, flaky, dry patients with hypothyroidism
skin
2. Very thin skin  patients with arterial
insufficiency
 those under steroid therapy
3. Increased moisture  profuse sweating
 occur in fever or
or diaphoresis
hyperthyroidism
4. Decreased  seen on dehydrated clients
moisture  clients with hypothyroidism
5. Clammy skin typical in shock or hypotension
6. Cold skin shock or hypotension
7. Cool skin arterial disease
8. Very warm skin febrile state or hyperthyroidism
9. Decreased mobility seen on clients with edema
10. Decreased turgor  slow return of skin to its
normal state (30 seconds)
 seen in dehydration
11. Indentation on skin  to check edema
 vary from slight to great and
may be in one area or all
over the body
12. Pressure ulcers
HAIR ASSESSMENT: INSPECTION AND PALPATION
 general color and condition, cleanliness, dryness or
oiliness, parasites, lesions
 amount and distribution of scalp, body, axillae and
pubic hair
ABNORMAL FINDINGS ON SCALP AND HAIR
1. Patchy gray hair nutritional deficiencies
2. Copper-red hair severe malnutrition in African-
color American children
3. Excessive indicate dermatitis
scaliness
4. Raised lesions indicate infection or tumor growth
5. Dull, dry hair seen in hypothyroidism and
malnutrition
6. Poor hygiene requires health teaching
7. Excessive occur with infection, nutritional
deficiencies, hormonal disorders,
generalized hair
loss thyroid or liver disease, drug toxicity,
hepatic or renal failure
result of chemotherapy or radiation
therapy
8. Patchy hair loss infection of scalp, discoid/systemic
lupus erythematosus (SLE) or some
type of chemotherapy
9. Hirsutism facial hair on female
characteristic of Cushing’s disease
result of imbalance of adrenal
hormones or it may be a side effect
of steroids
NAIL ASSESSMENT: INSPECTION AND PALPATION
 inspection – nail grooming, cleanliness, nail color
and marking, shape of nails
 palpation – assess texture and consistency,
capillary refill
ABNORMAL FINDINGS ON NAILS
1. Dirty, broken or poor hygiene
jagged fingernails
2. Pale or cyanotic indicate hypoxia or anemia
nails
3. Beau’s lines occur after acute illness and
gradually grow out
4. Nail pitting Common in psoriasis
5. Early clubbing 180o angle with spongy sensation
6. Late clubbing greater than 180o occur in hypoxia
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7. Spoon nails thin nails, may be present on Iron NECK
deficiency Anemia (IDA) hyoid bone, several major blood vessels, larynx, trachea,
8. Koilonychia thyroid gland

9. Thickened nails  Toenails

 cause by decreased circulation
 result of sudden or repeated
trauma or injury
10. Paronychia indicates local infection
11. Onycholysis detachment of nail plate from
nailbed, seen on infections or
trauma
12. Slow capillary  greater than 2 seconds
nailbed refill  hypoxia associated with
respiratory or cardiovascular
diseases

WEEK 8B: ASSESSING HEAD AND NECK

MAJOR BLOOD VESSELS IN THE NECK

2 SUBSECTIONS OF SKULL
1. Cranium Houses and protect brain and major CERVICAL VERTEBRAE
sensory organs
2. Face Give shape to face

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 LYMPH NODES
NORMOCEPHALIC
Normal size of the head
SUBJECTIVE DATAS
SUBJECTIVE FOR CURRENT HEALTH PROBLEM
1 NECK PAIN
- muscular problems or cervical spinal cord problems
- stress and tension may increase this
 Do you experience neck pain? Use COLDSPA to
further explore neck pain
2 PRECISE DESCRIPTION
- help determine possible causes of discomfort
 Do you experience headaches?
 Do you have facial pain?
SUBJECTIVE FOR PAST HEALTH HISTORY
1 PREVIOUS HEAD AND NECK TRAUMA
- cause chronic pain and limitation of movement
 Describe any previous head or neck problems like
trauma, injury, falls you had?
 How were they treated and what are the results?
SUBJECTIVE FOR FAMILY HISTORY
1 GENETIC PREDISPOSITION
- risk factor for head and neck cancers
- migraine have familial association
 Is there a history of head or neck cancer and
migraine headaches in your family?
SUBJECTIVE FOR LIFESTYLE & HEALTH PRACTICES
1 CONTACT OR AGGRESSIVE SPORTS
- increase risk of head and neck injury
 In what kind of recreational activity do you
participate? Describe
2 POOR POSTURE OR BODY ALIGNMENT
- lead to head and neck discomfort
 What is your typical posture when relaxing, during
sleep, and when working?
OBJECTIVE DATAS
MATERIALS
o Gloves o Small glass of water
o Penlight o Stethoscope
HEAD ASSESSMENT
INSPECTION OF SIZE, SHAPE, CONFIGURATION AND
INVOLUNTARY MOVEMENT
 Finding – head size and shape vary
- head is usually symmetric, round erect and in midline
 Head should be held still and upright
PALPATION OF HEAD FOR CONSISTENCY
 Findings – head is normally hard or smooth without
lesions
 Wear gloves to protect yourself from possible drainage
FACE ASSESSMENT
INSPECTION OF FACE FOR SYMMETRY, FEATURES,
MOVEMENTS, EXPRESSION AND SKIN CONDITION
 Findings – face is symmetric with round, oval,
elongated, square appearance
- no abnormal movements
 Drooping, weakness or paralysis may result to stroke
BELL’S PALSY STROKE
PALPATION OF TEMPORAL ARTERY FOR TENDERNESS
AND ELASTICITY
Findings – temporal artery is elastic and non-tender
- hard, thick, tender and inflamed temporal may lead to
blindness
PALPATION OF TEMPOROMANDIBULAR JOINT (TMJ)
 range of motion, swelling, tenderness, crepitation
 Findings – no swelling, tenderness or crepitation with
movement
NECK ASSESSMENT
INSPECTION OF CLIENT’S SLIGHTLY EXTENDED NECK
FOR POSITION, SYMMETRY AND LUMPS OR MASSES
Findings – neck is symmetric without lumps or masses
swelling, enlarged masses or nodule indicate an enlarged
thyroid gland
INSPECTION OF MOVEMENT OF NECK STRUCTURE
 ask to swallow a sip of water
 Findings – thyroid and cricoid cartilage move
upward symmetrically as client swallows
INSPECTION OF CERVICAL VERTIBRAE
ask client to flex neck (chin to chest)
INSPECTION OF RANGE OF MOTION
 ask client to turn head to left and right
 ask client to touch each ear to shoulder
 Findings – c7 palpable and visible
- neck movement should be smooth and
controlled:
a) 45o flexion
b) 55o extension
c) 40o lateral abduction
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 d) 70o rotation
PALPATION OF TRACHEA
PALPATION OF THYROID GLAND
 locate landmarks with index and thumb
 Findings - Trachea and landmarks are positioned
midline
 if thin with long neck: thyroid gland is usually not
palpable
 Older adult thyroid may feel more nodular or
irregular because of fibrotic changes that occur
with aging INTERNAL STRUCTURE
o Sclera, cornea, iris, ciliary body
o Pupil, lens, choroid, retina, optic disc
o Anterior and Posterior chamber

SUBJECTIVE DATAS

SUBJECTIVE FOR CURRENT HEALTH

1 SUDDEN CHANGES IN VISION
- associated with acute problems (head trauma,
increase intracranial pressure)
 Describe any recent visual difficulties or changes in
your vision that you have experienced. Were they
sudden or gradual?
2 SPOTS/FLOATERS
- common among clients with myopia or client age
over 40
 Do you see spots or floaters in front of eyes, blind
AUSCULTATE THYROID spots, halos around lights, trouble seeing at night
and double vision?
if you find enlarged thyroid gland during inspection
3 SCOTOMA
and palpation
- blind spot
PALPATION OF LYMPH NODES OF HEAD AND NECK - either normal or slightly diminished peripheral vision
Findings – no swelling or enlargement, no tenderness - seeing halos around light is associated with narrow
or hardness angle glaucoma
- night blindness may indicate optic atrophy
WEEK 8C: ASSESSING THE EYES - double vision (diplopia) indicate increase intracranial
pressure due to injury or trauma
4 BURNING AND ITCHING PAIN
- associated with allergies or irritation
- excessive tearing – caused by exposure irritants
- eye discharges – suggest bacterial or viral infection
 Do you have any eye pain, redness or swelling,
excessive watering or eye discharge?

SUBJECTIVE FOR PERSONAL HISTORY

HISTORY OF EYE PROBLEM PROVIDE CLUES TO
CURRENT HEALTH OF EYE
- ocular side effect of drugs are often unrecognized or
overlooked
 Have you ever had problems with your eyes or vision
and eye surgery?

SUBJECTIVE FOR FAMILY HISTORY

EXTERNAL STRUCTURE 1 GLAUCOMA, REFRACTION ERRORS AND
o Eyelid o Eyelash, conjunctiva MACULAR DEGENERATION
o Lateral (outer) o Lacrimal apparatus  Is there a history of eye problems or vision in the
o Medial (inner) canthus o Extraocular muscle family?

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 SUBJECTIVE FOR LIFESTYLE AND HEALTH PRACTICES  done by using cotton swab where you twist it upward,
1 EXPOSURE TO UV RADIATIONS the client must look downward
- puts client at risk for cataract  Findings - lower and upper palpebral conjunctivae are
- Assistive adaptive visual devices improves client clear and free of swelling, free of foreign bodies or
activities of daily living trauma
 Do you wear sunglasses during exposure to sun? INSPECT AND PALPATE LACRIMAL APPARATUS
 What visual aids do you use to assist you with your Findings – no swelling or redness in lacrimal gland
visual loss? - no drainage from puncta when palpating the
nasolacrimal duct
OBJECTIVE DATAS INSPECT CORNEA, LENS, IRIS AND PUPIL
Findings – cornea: transparent with no opacity
MATERIALS - lens: free from opacities
o Snellen or E-chart o Opaque cards - iris: round, flat and evenly colored
o Penlight o Ophthalmoscope - pupil: equal size (3-5mm)
TEST PUPILLARY REACTION TO LIGHT
EYE/VISION ASSESSMENT  assess consensual response
TEST DISTANT VISUAL ACUITY  Findings - normal direct and consensual pupillary
response is constriction
 position client 20ft from Snellen chart
 ask client to read each line until client can’t decipher the TEST ACCOMMODATION OF PUPILS
letters Findings - normal pupillary response is constriction of the
 note client’s behaviors (leaning forward, head tilting) pupils and convergence of the eyes when focusing on a near
 Findings – normal visual acuity is 20/20 WITH or object
WITHOUT corrective lenses
PERFORM CONFRONTATION TEST OPHTHALMOSCOPE DO’S
Findings – with normal peripheral vision 1 Begin about 10 to 15 in from the client at a 15-degree
- client should see examiner’s finger the same time angle to the client’s side
examiner sees it 2 Pretend that the ophthalmoscope is an extension of your
PERFORM CORNEAL LIGHT REFLEX eye
Findings - reflection of light on corneas should be exact 3 Stay focused on red reflex then rotate diopter setting to
same spot of each eye see optic disc
PERFORM COVER TEST
 detects deviation in alignment or strength and sight OPHTHALMOSCOPE DON’TS
deviation in eye movement 1 Do not use your right eye to examine the client’s left eye
 Findings - uncovered eye should remain fixed straight (vice versa)
ahead 2 Do not move the ophthalmoscope around. Ask the client
- covered eye should remain fixed straight ahead after to look into the light to view the fovea and macula
being uncovered 3 Do not get frustrated
PERFORM CARDIAL FIELDS OF GAZE TEST
 Also called position test
EXTRAOCULAR MUSCLE DYSFUNCTION
 assesses muscle strength and cranial nerve function
1. Corneal light reflex Pseudo strabismus, strabismus
 done by observing eye movement
test abnormalities (or tropia)
 Findings - eye movement should be smooth and
symmetric throughout all directions 2. Test abnormalities Phoria (mild weakness)
INSPECT EYELID AND EYELASHES 3. Positions test Paralytic strabismus, 6th, 4th, 3rd
 assess ability of eyelid to close nerve paralysis
abnormalities
 observe redness, swelling, discharge
 Findings - upper lid margin should be between the
upper margin of the iris and the upper margin of the
pupil
ABNORMALITIES OF EXTERNAL EYE
o Ptosis o Blepharitis
- lower lid margin rests on the lower border of the iris
o Exophthalmos o Conjunctivitis
o Entropion o Hordeolum
OBSERVE POSITION AND ALIGNMENT OF EYEBALL IN o Ectropion o Diffuse episcleritis
EYESOCKET o Chalazion
 protruding eyeball (exophthalmos) is a characteristic
of Graves disease VISUAL FIELD DEFECTS
 Findings - eyeballs are symmetrically aligned in sockets o Unilateral blindness o Lesion in optic nerve
without protruding o Bitemporal hemianopia o Lesion of optic chiasm
INSPECT PALPEBRAL CONJUNCTIVA o Left superior quadrant o Partial lesion of
 evert upper eyelid anopia temporal loop

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o Right visual field loss o Lesion in right optic 3. Malleus  has distinct landmark that
tract or lesion in include handle and short
temporal loop process
 umbo, cone of light, pars
ABNORMALITIES OF CORNEA AND LENS flaccida, pars tensa
1. Corneal  corneal scar 4. Round and oval windows
 pterygium 5. Auditory ossicles a) Malleus
2. Lens  nucleus cataract b) The incus
 peripheral cataract c) The stapes
6. Eustachian tube connect middle ear to nasopharynx
ABNORMALITIES OF IRIS AND PUPIL
o Irregularly shaped iris o Anisocoria STRUCTURE OF THE INNER EAR (LABYRINTH)
o Miosis o Mydriasis 1 Fluid filled and made up of bony and inner membranous
labyrinth
ABNORMALITIES OF OPTIC DISC 2 Bony labyrinth has THREE PARTS:
o Papilledema a) Cochlea
o Glaucoma b) Vestibule
o Optic atrophy c) Semicircular canals
3 Corti
WEEK 8C.2: ASSESSING THE EARS – sensory organ for hearing
- spiral organ that inner cochlear duct contains
4 Vestibular nerve connects with and cochlear nerve forms
Eight Cranial Nerve (Acoustic Nerve)

TYPES OF HEARING LOSS

1. Conductive hearing  dysfunction of the external or
loss middle ear
 when something blocks or
impairs the passage of
vibrations from getting to the
inner ear
 impacted earwax, otitis
media, foreign object,
perforated eardrum,
drainage in middle ear
STRUCTURE OF THE EXTERNAL EAR 2. Sensorineural or  dysfunction of the inner ear
1. Auricle (Pinna)  portion visible without any Perceptive hearing  corti, cranial nerve VIII,
tools loss temporal lobe
 shaped with hollows,
furrows, and ridges that
form an irregular funnel to
conduct sound waves into
the external auditory canal HEARING CONDUCTIVE PHASES
2. External  S-shaped in adult
auditory canal  outer part curves up and
back
 inner part curves down and
forward
 Modified sweat glands in the
external ear canal secrete
cerumen

STRUCTURE OF THE MIDDLE EAR

1. Tympanic cavity small, air-filled chamber in the
temporal bone
2. Tympanic also called eardrum
membrane

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 RISK FACTORS FOR HEARING LOSS devices to improve outbreak of ear
1. Aging – many years of 10. Genetic and family hearing. infections.
exposure to sound susceptibility 7. Immunize children 16. Teach child to avoid
damage inner ear cells 11. Premature birth 8. Be immunized against putting foreign bodies
2. Heredity - genetics that 12. Hypoxia during birth rubella before pregnancy in ears.
are related to 13. Rubella, syphilis, other if a woman of child- 17. Avoid use of
susceptibility to ear infection in pregnant bearing age. instruments to remove
damage mother 9. If pregnant, get screening wax from ears due to
3. Occupational – loud 14. Inappropriate use of for syphilis and other chance of impacting it
noises in the ototoxic drug during STIs, adequate antenatal further
environment pregnancy and prenatal care, and
4. Recreational noises - 15. Neonatal jaundice diagnosis and treatment
exposure to explosive 16. Infectious disease for baby born with
noises (meningitis, measles, jaundice.
5. Ototoxic medications mumps, chronic ear
6. Illnesses infection)
7. Noise exposure 17. Head injury or Ear
SUBJECTIVE DATAS
8. Smoking injury
9. Cardiovascular risk 18. Wax or foreign body SUBJECTIVE FOR NURSING HISTORY OF EARS & HEARING
factors blocking ear canal 1 SUDDEN DECREASE IN ABILITY TO HEAR
- may be associated with otitis media or cerumen
OTITIS MEDIA impaction
 inflammation or infection of middle ear - sudden deafness can be medical emergency
 common in Early Childhood  Describe any recent changes in hearing
 chronic otitis media result to hearing loss 2 DRAINAGE AND EARACHES
- indicates infection
RISK FACTORS FOR OTITIS MEDIA - tinnitus or ringing may be associated with different
1. Age –common in children 7. Cleft palate condition and vertigo
2. Babies fed from a bottle, 8. Down syndrome - vertigo – spinning motion
especially lying down 9. Ethnicity – native  Do you have ear drainage, ear pain, ringing in the
3. Seasons of fall and American ears or feel like you are spinning, or the room is
winter, due to exposure 10. Enlarged adenoids spinning?
to colds, flu, and 11. Wax or foreign body 3 AGE-RELATED HEARING LOSS
increased allergens blocking ear canal - tends to run in the family
4. Poor air quality  Is there a history of hearing loss in your family?
(especially irritants in the 4 CONTINUOUS LOUD NOISES
air, e.g., cigarette smoke) - can cause hearing loss unless protected with ear
5. Family history guards
6. Cardiovascular risk - otitis media are often referred to as “swimmer’s ear”
factors where water stays in the ear canal for a long time
 Do you work or live in area with frequent or
RISK REDUCTION TO PRESERVE HEARING continuous loud noise?
1. Avoid sound exposure 10. Avoid the use of  Do you spend a lot of time swimming?
louder than a washing ototoxic drugs unless
machine prescribed
OBJECTIVE DATAS
2. Avoid recreational risks 11. If you have a newborn,
that involve loud sounds avoid feeding from
or risks of head or ear bottle while infant is MATERIALS
injury. lying on back. o Watch with second hand – Romberg Test
3. Avoid listening to 12. Have newborn infant o Tuning fork (512 or 1024hz)
extremely loud music screened for hearing. o Otoscope
4. Wear hearing protectors 13. Get treatment for ear
and take breaks from the infections as soon as EAR ASSESSMENT
noise in loud noise they are noticed INSPECT AURICLE, TRAGUS, LOBULE
environments. 14. Get treatment for tonsil  for size, shape, position, lesions/discoloration, discharge
5. Have hearing checked and adenoid infections  Findings - Ears are equal in size bilaterally
periodically, especially and inflammation. - auricles align with the corner of each eye
after age 50. 15. Keep child home from PALPATE AURICLE AND MASTOID
6. If hearing loss is day care if possible  for tenderness
detected, obtain and use when there is an  Findings - Ears are equal in size bilaterally
- auricles align with the corner of each eye

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 INSPECT EXTERNAL AUDITORY CANAL WEEK 8D: ASSESSING MOUTH, THROAT, NOSE
 note discharge, color and consistency of cerumen AND SINUSES
 Findings – small amount of odorless cerumen
INSPECT TYMPANIC MEMBRANE (EARDRUM)
 note color, shape, consistency and landmarks
 Findings – eardrum should be pearly gray, shiny,
translucent with no bulges or retraction

GENERAL OBSERVATION OF HEARING AND EQUILIBRIUM

TEST
PERFORM WHISPER TEST
Findings – client should be able to correctly repeat the two-
syllable word whispered
PERFORM WEBER TEST
 help to evaluate the conduction of sound waves through
bone to help distinguish between conductive hearing
and sensorineural hearing
 Findings – vibrations are heard equally in both ears
PERFORM RINNE TEST
 use tuning fork and place the base on the client’s
mastoid process
 when the client no longer hears the sound, note the time
interval
 move the tuning fork in front of the external ear STRUCTURE OF THE MOUTH
 Findings - air conduction sound is normally heard longer 1 Mouth
than bone conduction sound – known as oral cavity
PERFORM ROMBERG TEST 2 Formed by lips, cheeks, hard and soft palate, uvula,
 test the equilibrium tongue and its muscle
 ask client to stand with feet together, arms at sides and 3 Oral cavity
eyes open, then with the eyes closed - contains tongue, teeth, gums, opening of
 Findings - client maintains position for 20 seconds salivary glands
without swaying or with minimal swaying

EXPECTED CHANGES WITH AGING OF EAR

o Presbycusis common o Harder cerumen builds
after 50 years of age as cilia in ear canal
o Negative self-image with become more rigid
hearing aid o Coarse, thick wire-like
o Elongated earlobes with hair may grow at ear
linear wrinkles canal entrance
o Eardrum appears
cloudy
STRUCTURE OF THE MOUTH
ABNORMALITIES OF EXTERNAL EAR AND EAR CANAL 1 Throat – known as pharynx
 Malignant lesions 2 Located behind the mouth and nose
 Otitis externa 3 Serves as a muscular passage for food and air
 Build-up of cerumen (earwax) 4 nasopharynx – upper part
 Exostosis - develop from prolonged irritation of the 5 oropharynx – below nasopharynx
external auditory canal 6 laryngopharynx – below oropharynx
- repeated cold seawater exposure
7 Masses of lymphoid tissue:
- exposure stimulates new bone formation at the a) palatine tonsils
tympanic ring within the external auditory canal b) lingual tonsils
c) Pharyngeal tonsils (adenoids)
ABNORMALITIES OF EXTERNAL EAR AND EAR CANAL
 Acute otitis media
 Serous otitis media
 Blue/dark red tympanic membrane
 Scarred tympanic membrane
 Perforated tympanic membrane
 Retracted tympanic membrane
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STRUCTURE OF THE NOSE
1 External portion covered with skin and internal cavity
2 External: bridge, tip, two oval opening called nares
3 Internal: nasal cavity, nasal septum, Kiesselbach area,
turbinates (superior, middle, inferior)
STRUCTURE OF THE SINUS
1 Have FOUR PAIRS of paranasal sinuses:
a) Frontal
b) Maxillary
c) Ethmoidal
d) Sphenoidal
2 Sinuses decrease the weight of the skull
3 Acts as resonance chambers during speech
NOTES
 Most cases of oral cancer occur in people who are heavy
users of tobacco and alcohol
 Excessive caffeine intake is not linked to oral cancer
 Men are more prone to oral cancer than women
 Vitamin D deficiency may lead to oral cancer
RISK REDUCTION TIPS FOR ORAL CANCER
 Stop smoking
 Limit alcohol consumption
 Balanced diet
 Precautionary measures at workplace
 Practice regular oral hygiene
 Avoid excessive exposure to ultraviolet light
 Avoid sources of oral irritation
SUBJECTIVE DATAS
SUBJECTIVE FOR TONGUE AND MOUTH
PROVIDE DATA & CHECK GUMS
- data to determine if lesions are related to medications,
stress, infection, trauma or malignancy
- Red swollen gums that bleed easily occur in early gum
disease (gingivitis)
 Do you experience tongue or mouth sores or lesions,
swelling and bleeding gums or mouth?
SUBJECTIVE FOR NOSE AND SINUSES
PAIN, SWELLING, TENDERNESS AND PRESSURE
AROUND EYES, CHEEKS, NOSE AND FOREHEAD
- seen in acute sinusitis/infection of the sinuses
- Epistaxis can be local or systemic cause
 Do you have pain over sinuses?
 Do you experience nosebleeds? Describe.
THIN, WATERY NASAL DISCHARGE
- indicate chronic allergy
- yellow mucus drainage is typical of a cold
- Inability to breathe through both nostrils may indicate
sinus congestion, obstruction, or deviated septum
 Do you experience frequent clear or mucous drainage
from your nose?
 Can you breathe through both of the nostrils?
SUBJECTIVE FOR THROAT
DYSPHAGIA AND ODYNOPHAGIA
- seen with tumors of the pharynx, esophagus, or
surrounding structures, narrowing of esophagus, GERD,
anxiety, poorly fitting dentures or neuromuscular disorders
- Sore throat are commonly seen with viral infections
 Do you have difficulty or painful swallowing?
 Do you have sore throat or experience hoarseness?
SUBJECTIVE FOR PERSONAL HEALTH HISTORY
PAST PROBLEMS OR SURGERY
- pollens cause seasonal rhinitis, dust may cause rhinitis
year round
 Have you ever had any oral, nasal, or sinus surgery,
sinus infection?
 Do you have history of seasonal environment allergies?
SUBJECTIVE FOR FAMILY HISTORY
GENETIC RISK FACTOR FOR MOUTH, THROAT, NOSE,
SINUS CANCER
 Is there a history of mouth, throat, nose, or sinus
cancer in the family?
SUBJECTIVE FOR LIFESTYLE AND HEALTH PRACTICES
SMOKING AND EXCESSIVE USE OF ALCOHOL
- increase a person’s risk for oral cancer
- Brushing teeth twice a day with soft bristle toothbrush,
flossing and oral hygiene prevent dental caries and gum
disease
 Do you smoke? Do you drink alcohol?
 Describe how you care for your teeth or dentures?
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 OBJECTIVE DATAS  Findings - Nasal mucosa is dark pink, moist, and free of
exudate
- Nasal septum is intact, no ulcers or perforations
MATERIALS
- Turbinates are dark pink, moist and free of lesions
o Gloves o Nasal speculum
o Cotton gauze pad attached to otoscope
 Deviated septum – may appear to be overgrowth of
tissue
o Penlight o Tongue depressor
- normal finding as long as breathing is not obstructed

MOUTH ASSESSMENT
INSPECT LIPS, TEETH AND GUMS
SINUSES ASSESSMENT
PALPATE SINUSES
 Findings - Lips are smooth, moist and no swelling or
 if infection is suspected, palpation & percussion can be
lesions
use
 32 pearly white teeth with smooth surfaces and edges.
 Findings - Frontal and maxillary sinuses are non-tender
No decayed area or missing teeth
to palpation and percussion and no crepitus is evident
INSPECT THE BUCCAL MUCOSA & INSPECT AND
PALPATE THE TONGUE
 Findings - Buccal mucosa should appear pink in light
CULTURAL VARIATIONS
1. Pink lips  light-skinned: normal
skinned clients, in all clients is smooth and moist without
 dark-skinned: bluish or
lesions
freckled lips
 Tongue should be pink, moist, a moderate size with
papillae present and no lesions
2. Talon cusps on Asian, pacific islander, native
incisors and circular Americans
INSPECT WHARTON DUCTS AND SIDE OF TONGUE
 Findings - Frenulum is midline cusps on molars
 Wharton ducts are visible, with salivary flow or 3. Torus palatinus  bony growth in roof of mouth
moistness in the area  female eskimos, native
 No lesions, ulcers or nodules present Americans, Asians
CHECK STRENGTH OF MOUTH AND THE ANTERIOR 4. Bifid uvula  cleft uvula or split into two
 Native American and Asians
TONGUE’S ABILITY TO TASTE
Findings - tongue offers strong resistance and can
distinguish between sweet and salty
AGE-RELATED CHANCES IN MOUTH, NOSE, THROAT, SINUS
 Gums recede, ischemic,  Oral mucosa drier and
INSPECT HARD AND SOFT PALATE AND UVULA and undergo fibrotic more fragile
 note odor while mouth is open changes  Varicose veins in ventral
 Findings - Hard palate is pale or whitish with firm  Tooth surfaces worn surface of tongue
wrinkle –folds down
- Soft palate should be pinkish, spongy, and smooth.  Decreased ability to
No odor smell and taste
- Uvula hangs freely in the midline. No redness
exudate
INSPECT TONSIL AND POSTERIOR PHARYNGEAL WALL WEEK 8E: ASSESSING THORAX AND LUNGS
Findings - Tonsils may be present or absent, normally pink
and symmetric and may be enlarged to 1+ in healthy clients.
- No exudate, swelling, or lesions. Throat is normally pink,
without exudate or lesions

EXTERNAL NOSE ASSESSMENT

INSPECT AND PALPATE EXTERNAL NOSE & CHECK
PATENCY OF AIR THROUGH NOSETRILS
 note nasal color, shape, consistency and tenderness
 occlude one nostril at a time by asking client to sniff or
exhale
 Findings - Color is the same as the face, structure is
symmetric, no tenderness
- client is able to sniff

INTERNAL NOSE ASSESSMENT

INSPECT INTERNAL USING OTOSCOPE WITH SHORT THORAX
WIDE-TIP ATTACHMENT OR PENLIGHT  portion of the body extending from the base of the neck
superiorly to the level of the diaphragm inferiorly
 lung, distal portion of trachea, bronchi

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STERNUM
breastbone lies in center of chest
THREE PARTS OF STERNUM
1. Manubrium connects laterally with
clavicles and first 2 pairs of
ribs
2. Suprasternal notch important landmark, U-
shaped indentation on the
superior border of manubrium
3. Sternal angle  known as Angle of Louis
 location of 2nd pair of ribs
and reference point for
counting ribs and
intercostal spaces
RIBS AND THORACIC VERTEBRAE
 12 pairs of ribs constitute the main structure of the
thoracic cage
 Each pair of ribs has corresponding pair of intercostal
spaces located immediately inferior to it
 11th and 12th pairs of ribs are called “floating” ribs
because they do not connect to either the sternum or
another pair of ribs anteriorly
VERTICAL REFERENCE LINES
1. Anterior vertical  uses imaginary lines, running
lines vertically on the chest wall
 midsternal, right and left
midclavicular lines
2. Lateral vertical midaxillary line, anterior and
lines posterior axillary lines
3. Posterior vertical vertebral line, right and left
lines scapular lines
THORACIC CAVITY
 consist of mediastinum (central area that contains the
trachea, bronchi, esophagus, heart and great vessels)
 consist of lungs
 lined by pleural membrane
STRUCTURE OF THORAX AND LUNGS
1 Mediastinum – central area in thoracic cavity
2 Lungs – two cone-shaped, elastic
3 Pleura - thin, double-layered serous membrane that
lines the thoracic cavity
4 Trachea
- flexible structure that lies anterior to the esophagus
- begins at the level of the cricoid cartilage in the neck
- 10-12cm long in an adult
5 Bronchi
- right main bronchus is shorter and more vertical
- making aspirated objects more likely to enter the
right lung than the left lung
6 Lungs
- not completely symmetric
- right lung: 3 LOBES
- left lung: 2 LOBES
7 Pleural membrane – has 2 TYPES:
1. Parietal pleura – lines with chest cavity
2. Visceral pleura – covers external surface of lungs
8 Pleural space – between two pleural layers
MECHANICS OF BREATHING
purpose of respiration: maintain adequate oxygen level in
blood to support cellular life
INSPIRATION
 Inhalation
 diaphragm contracts and pulls downward,
enlargement of chest cavity
EXPIRATION
 Exhalation
 occurs with relaxation of the intercostal muscles and
diaphragm
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 SUBJECTIVE DATA
SUBJECTIVE FOR DIFFICULTY OF BREATHING/COUGH
DYSPENA
- indicate number of health problems
- continuous cough associated with acute infections
 Do you ever experience DOB or loss of breath?
COLDSPA
 Do you have a cough?
SPUTUM COLOR
- varies and may have many causes:
a) Common cold, viral infection and bronchitis – white
or mucoid sputum
b) Bacterial infection – yellow or green
c) Tuberculosis or pneumococcal pneumonia – rust
d) Pulmonary edema – pink, frothy
 Do you produce sputum when you cough? Describe.
HISTORY OF RESPIRATORY DISEASES INCREASE RISK OF
RECURRENCE
- surgeries may alter appearance of thorax
- allergic responses
 Have you had prior respiratory problems, thoracic
surgery, biopsy, trauma and allergies?
SUBJECTIVE FOR FAMILY HISTORY
HISTORY OF LUNG DISEASE
- second hand smoke put client at risk for COPD or lung
cancer
 Is there a history of lung disease in your family?
 Did any family members in your home smoke when
you were growing up?
 Findings - Nasal flaring should not be present
- Face, lips, and chest has evenly colored skin tone,
and nail beds has pink tones and has 160-degree angle
between the nail base and the skin
POSTERIOR THORAX ASSESSMENT (INSPECTION)
INSPECT CONFIGURATION
 client sit arms at side, stand behind and observe
position of scapulae
 Findings – ratio of anteroposterior to transverse
diameter is 1:2
OBSERVE USE OF ACCESSORY MUSCLE
 watch client breathes and note use of muscle
 Findings - client does not use accessory
(trapezius/shoulder) muscles to assist breathing.
- Diaphragm is the major muscle at work.
POSITION ASSESSMENT (INSPECTION)
INSPECT CLIENT’S POSITIONING
 note ability to support weight
 Findings - Client should be sitting up and relaxed
 Abnormal finding – tripod position:
- Client leans forwards
- Arms support weight
- Lists chest to increase breathing

SUBJECTIVE FOR LIFESTYLE AND HEALTH PRACTICES

SMOKING
- number of respiratory conditions
 Have you ever smoked cigarettes or other tobacco
products?
 Do you currently smoke? At what age did you start?
 Are you exposed to any environmental conditions that POSTERIOR THORAX ASSESSMENT (PALPATION)
affect your breathing? FOLLOW SEQUENCE FOR TENDERNESS, SENSATION,
CREPITUS AND SURFACE CHARACTERISTIC
Findings - No tenderness, pain, unusual sensations, no
OBJECTIVE DATA palpable crepitus and skin and subcutaneous tissue are free
of lesions and masses
PREPARATION PALPATE FOR FREMITUS
 Explain procedure  use ball or ulnar edge of one hand to assess
 Have client remove clothing from waist up  ask client to say “99”
 Ask client to sit upright  Findings - Fremitus is symmetric and easily identified in
the upper regions of the lungs
MATERIALS ASSESS CHEST EXPANSION
o Examination gown/drape o Light source/penlight - Place hands on posterior chest wall with thumbs at the
o Gloves o Mask level of T9 OR T10
o Stethoscope o Skin marker/metric - pressing together a small skin fold
ruler - Observe movement of thumb as the client takes a deep
breath
GENERAL INSPECTION  Findings - Examiner’s thumb should move 5-10 cm
INSPECT NASAL FLARING AND PURSED LIP BREATHING apart symmetrically when the client takes a deep
breath.
- observe color of face, lips and chest
- inspect color of nails

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 POSTERIOR THORAX ASSESSMENT (PERCUSSION)
PERCUSS FOR TONE
PERCUSS FOR DIAPHRAGMATIC EXCURSIVE
- ask to exhale forcefully and hold breath
- begin at scapular line (T7)
 Findings - Resonance is the percussion tone
elicited over normal lung tissue.
- Excursion should be equal bilaterally and
measure 3-5 cm in adults.
POSTERIOR THORAX ASSESSMENT (AUSCULTATION)
AUSCULTATE FOR BREATH SOUNDS
Findings – have THREE TYPES:
a) Bronchial - tubular and hollow sound loud and high-
pitched with a short pause between inspiration and
expiration
b) Bronchovesicular - softer than bronchial sounds
equal during inspiration and expiration
c) Vesicular - soft, blowing or rustling sounds normally
heard throughout most of the lung fields.
AUSCULTATE ADVENTITIOUS SOUNDS
Findings - No adventitious sounds such as crackles (discreet
and discontinuous sounds) or wheezes (musical and
continuous)
AUSCULTATE VOICE SCOUNDS
a) Bronchopony - repeat phrase “ninety-nine”
b) Egophony - repeat the letter “E”
c) Whispered pectoriloquy - whisper the phrase “one-
two-three”
 Findings – of the following:
a) soft, muffled, and indistinct. Voice can be heard
but actual phrase cannot be distinguished.
b) soft and muffled but letter “E” should be
distinguishable.
c) very faint and muffled and may be inaudible.
ANTERIOR THORAX ASSESSMENT (INSPECTION)
INSPECT SHAPE AND POSITION OF STERNUM
 watch for sternal retractions
 Findings - Anteroposterior diameter is less than the
transverse diameter (Ratio 1:2)
- sternum is positioned at midline and straight and no
retractions
INSPECT SLOPE OF RIBS
 observe quality and pattern of respiration
 Findings - Ribs slope downward with symmetric
intercostal spaces.
- Costal angle is within 90 degrees
- Respirations are relaxed, effortless, and quiet
INSPECT INTERCOSTAL SPACES AND OBSERVE USE OF
ACCESSORY MUSCLE
Findings - No retractions or bulging of intercostal spaces
- accessory muscles is not seen with normal respiratory
effort
ANTERIOR THORAX ASSESSMENT (PALPATION)
PALPATE FOR TENDERNESS, SENSATION, LESIONS,
SURFACE MASSES
PALPATE FOR CREPITUS AND FREMITUS
ASSES ANTERIOR CHEST EXPANSION
Findings - No tenderness or pain palpated. No crepitus and
no unusual masses or lesions
- Fremitus is symmetric and easily identified
- Thumbs move outward in a symmetric fashion from the
midline.
ANTERIOR THORAX ASSESSMENT (PERCUSSION)
PERCUSS FOR TONE
Findings - Resonance is the percussion tone elicited over
normal lung tissue
- Percussion elicits dullness over breast tissue, heart, and
the liver.
- Tympany is detected over the stomach, and flatness is
detected over the muscles and bones
ANTERIOR THORAX ASSESSMENT (AUSCULTATION)
AUSCULTATE ANTERIOR BREATH SOUND,
ADVENTITIOUS SOUND, VOICE SOUND
 place diaphragm firmly and directly on anterior chest
wall
 Findings - No adventitious sounds such as crackles
(discreet and discontinuous sounds) or wheezes
(musical and continuous)
- soft, muffled, and indistinct. Voice can be heard but
actual phrase cannot be distinguished
- soft and muffled but letter “E” should be
distinguishable
- very faint and muffled and may be inaudible
NOTES
 Bronchial, bronchovesicular, and vesicular sounds are
normal breath sounds
 Adventitious sounds are sounds added or superimposed
over normal breath sounds and heard during
auscultation
THORACIC DEFORMITIES AND CONFIGURATION
 Barrel chest
 Pectus excavatum (funnel chest) – sunken
 Scoliosis
 Kyphosis – kuba
 Lordosis – exaggerated lumbar curve
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 OLDER ADULT CONSIDERATION
1. Tenderness or pain at the costochondral junction of the
ribs is seen with fractures, especially in older clients with
osteoporosis.
2. Older adults may experience dyspnea related to aging
changes of the lungs (loss of elasticity, fewer functional
capillaries, and loss of lung resiliency).
3. Chest pain related to pleuritis may be absent
4. The ability to cough effectively may be decreased in the
older client because of weaker muscles and increased
rigidity of the thoracic wall.
5. Deep breathing may be especially difficult for the older EXTERNAL BREAST STRUCTURE
client, who may fatigue easily. 1. Nipple located at the center
6. Kyphosis is common in older adults. contains tiny openings of the
7. Because of calcification of the costal cartilages and loss lactiferous ducts (where milk
of the accessory musculature, the older client’s thoracic pass through)
expansion may be decreased, although it should still be 2. Areola surrounds the nipple
symmetric. contains Montgomery glands (
8. The sternum and ribs may be more prominent in the elevated sebaceous glands) that
older client because of loss of subcutaneous fat. secrete a protective lipid
substance during lactation
ANALYSIS OF DATA
 Selected nursing diagnoses
- health promotion
- risk
- actual
 Selected collaborative problems

DOCUMENTATION
 Report significant findings: subjective and Objective
data
 Documents and records findings in the patient’s medical
record.

WEEK 9A: ASSESSING BREAST AND LYMPHATIC INTERNAL BREAST STRUCTURE (3 TYPES OF TISSUES)
SYSTEM 1 Glandular
2 Fibrous
3 Fatty (adipose)

BREAST AND LYMPHATIC SYSTEM FUNCTION

BREAST
 Paired mammary glands that lie over the muscles of the
anterior chest wall, anterior to the pectoralis major and
serratus anterior muscles
 Produce and store milk
 Aid in sexual stimulation LYMPH NODES THAT DRAIN IMPURITIES FROM BREAST
 “tail of spence”-most breast tumors occur in this (MAJOR AXILLARY LYMPH NODES)
quadrant 1 Anterior (pectoral)
2 Posterior (subscapular)
3 Lateral (brachial)
4 Central (midaxillary)

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 MALE BREAST ANATOMY
0
SUBJECTIVE DATA
SUBJECTIVE FOR COLDSPA, PAST HEALTH HISTORY,
FAMILY HISTORY, LIFESTLYE AND HEALTH PRACTICES
SIGNS OF BREAST CANCER
- Changes in size, color, presence of lumps, swelling,
dimpling, warmth, pain
- recent increase in size of one breast may indicate
inflammation, pregnancy, lactation or abnormal growth
 Have you noticed any lumps or swelling, redness,
warmth or dimpling, size, pain in your breast?
RISK OF RECURRENCE OF BREAST CANCER
- Greater for women who have given birth and had their
first child after age of 30
 Have you had any breast disease or breast surgery?
 Have you given birth? At what age did you have your
first child?
HISTORY OF BREAST CANCER IN FAMILY
 Is there a history of breast cancer in your family?
BREAST ENGORGEMENT IN WOMEN
- Can be caused by hormones and some antipsychotic
agent
- Exposure to environmental hazards can increase risk
- High fat diet may increase this risk
 Are you taking any hormones, contraceptives, or
antipsychotic agents?
 Do you work or live in an area where you have
excessive exposure to radiation or carcinogens?
 What is your typical daily diet?
OBJECTIVE DATA
PREPARATION OF CLIENT
 Client sitting in an upright position
 Explain the importance of exposing both breasts
 Inspection, palpation
MATERIALS
o Centimeter ruler o Specimen slide
o Small pillow o Client handout on breast self-
o Gloves examination
WRINKLES
INSPECTION
 Ask client to disrobe and sit with arms hanging freely.
 Explain what you are observing
 Inspect the following:
a) Size, shape, symmetry, color and texture
b) Superficial venous patterns
c) Retraction and dimpling
d) Bilaterally, color, size, shape, and texture of
areolas
e) Bilaterally, note size and directions of nipples
 Findings – breast varies in size (round and pendulous)
- one may be normally large than the other
- color varies depending on skin tone
- smooth, no edema, linear stretch (pregnancy)
- veins are more prominent (pregnancy)
- areolas depends on client’s skin tone (dark pink to
dark brown)
- nipples are nearly equal bilaterally, usually everted
- nipples may be inverted or flat
- breast should rise symmetrically
 Dimpling or retraction – caused by malignant tumor
 Pigskin-like or orange-peel results from edema that’s
seen in breast disease (peau d’orange)
PALPATION
 Texture and elasticity
 Tenderness and temperature
 Masses: location, size in centimeters, shape, mobility,
consistency, tenderness
 Milky discharge normal only during pregnancy and
lactation
 Mastectomy or lumpectomy site
 Findings – palpation reveals smooth, firm, elastic tissue
- generalized increase in nodularity and tenderness
may be normal (menstruation or hormonal
medications)
- should have normal temperature, no masses
- nipples may be erect; areola may pucker
- scar from mastectomy should be whitish
THE MALE BREAST
 Inspect and palpate the breasts, areolas, nipples, and
axillae
 No swelling, nodules, or ulceration should be detected
 Gynecomastia- enlargement or swelling of breast tissue
in males. commonly caused by male estrogen levels that
are too high or are out of balance with testosterone.
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 EXPECTED CHANGES IN AGING FEMALE BREAST
 Decrease in size
 Decrease in firmness
 Glandular tissue decreases, whereas fatty tissue
increases

WEEK 9B: ASSESSING HEART AND NECK VESSELS

INSPECTION AND PALPATION: AXILLAE

 Inspect and palpate the axillae:
 FINDINGS - No rash or infection
- No palpable nodes or one to two small, discrete, non-
tender, movable nodes in the central area

ABNORMALITIES ON INSPECTION
1. Peau d’orange texture & appearance similar to an STRUCTURE AND FUNCTION OF THE HEART
“orange peel (breast cancer) HEART  Hollow, muscular organ
 Location: middle of thoracic cavity
2. Paget’s disease chronic bone disorder, excessive
breakdown and regrowth of bone between lungs in the space
Bones are bigger & softer (mediastinum)
 Size of a clenched fist
3. Retracted nipple-nipple turn inward
FOUR CHAMBERS
4. Dimpling ATRIUM
5. Retracted breast tissue 1. Left
6. Mastitis inflammation of breast tissue 2. Right
VENTRICLE
7. Mastectomy surgical removal of one or both
breast 3. Left
4. Right
ABNORMALITIES ON INSPECTION
1. Cancerous tumors  Has Two
atrioventricular
2. Fibroadenomas common type of benign breast
tumor valves
 Has Two
6. Benign breast  both women and men can
semilunar valves
disease develop
 noncancerous breast lumps THREE LAYERS
 increase risk for developing 1. Epicardium –
breast cancer outer layer
2. Myocardium –
middle layer
3. Endocardium –
inner layer
Pericardium – mechanical
protection for heart and big vessels
- lubrication to reduce friction
between heart and surrounding
structures
HEART CHAMBERS, VALVES, DIRECTION OF
CIRCULATORY FLOW

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 ELECTRICAL CONDUCTION OF THE HEART
1. Cardiac cycle
2. Sinoatrial node  Location: posterior wall of
Right atrium near junction of
superior and inferior vena
cava
 Pacemaker of heart
3. AV node  Location: lower interatrial
septum
 Slightly delays incoming
electrical impulses from
atria
 Relays impulse to the AV
bundle
4. AV bundle (bundle  Atrioventricular bundle
of HIS)  Continuation of specialized
tissue of AV node
 Serves to transmit electrical
impulse from AV nodes to
Purkinje fibers of ventricles
5. Purkinje fibers  Network of specialized
muscle cells
 Carry cardiac impulses to
ventricles of heart
 Cause them to contract
AUSCULTATION
ELECTROCARDIOGRAM
 Electrical activity of heart measured by
electrocardiography (ECG)
 Phases of ECG: P, Q, R, S, T
 Records depolarization and repolarization
CARDIAC CYCLE
 Filling and emptying of the heart’s chamber
 TWO PHASES:
1. Diastole - relaxation of the ventricles known as filling
2. Systole - contraction of the ventricles known as
emptying
HEART SOUNDS
- Are produced by valve closure
 Normal heart sounds: “lubdubb” (S1 and S2)
 Extra heart sounds: diastolic filling sound (S3 and S4)
 Murmurs: turbulent blood flow
- swooshing or blowing sound
HEART MURMURS
 Turbulent blood flow (swooshing or blowing)
 Conditions that contribute to heart murmurs
– Increased blood velocity
– Structural valve defects
– Valve malfunction
– Abnormal chamber openings
SUBJECTIVE DATA
SUBJECTIVE FOR HISTORY OF PRESENT CONCERN
CHEST PAIN
- Angina
- Discomfort caused when heart muscle doesn’t get
enough oxygen-rich blood
- Feels like pressure or squeezing in chest
 Do you experience chest pain? (COLDSPA)
TACHYCARDIA AND PALPITATION
- Tachycardia is seen with weak heart muscle
- Palpitation occurs with abnormality of heart’s
conduction system
- Fatigue – result from compromised cardiac output
- Dyspnea – result from CHF
 Do you experience faster heartbeat, skip beats or
extra heartbeat?
 Do you experience easy fatigability, dyspnea or SOB?
SUBJECTIVE FOR PERSONAL HISTORY
HEART DEFECTS AND DISEASES
- Affects heart’s ability to pump
- Previous heart surgery change heart sound
- prior ECG allows health care team to evaluate any
changes in cardiac conduction
- Elevated cholesterol levels have been linked to CAD
- Sometimes caused by medication prescribed not taken
regularly
 Have you been diagnosed with a heart defect or
murmur, had rheumatic heart fever and heart surgery?
 Have you ever had ECG, blood test (lipid profile)?
 Do you take medications for heart disease?
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 SUBJECTIVE FOR FAMILY HISTORY
GENETIC PREDISPOSITION
- Increase chances for developing heart disease
 Is there hypertension, MI, coronary heart disease(CHD),
elevated cholesterol levels, or diabetes mellitus(DM) in
your family?
SUBJECTIVE FOR HISTORY OF PRESENT CONCERN
CIGARETTE SMOKING
- Increase risk of heart disease
- Stress is a possible risk factor
 Do you smoke? How many packs of cigarettes per day?
For how many years now?
 What type of stress do you have in your life?
ELEVATED CHOLESTEROL LEVEL
- Increase chance of fatty plaque formation in coronary
vessel
- Sedentary lifestyle is a risk factor for heart disease
 Describe what you usually eat in a day? Do you
exercise?
OBJECTIVE DATA
PREPARATION OF CLIENT
 Explain the procedure and describe step
 Client must assume different position
KEYPOINT:
o Understand anatomy and function of the heart to
identify and interpret findings between normal and
abnormal
o Know normal variations of the cardiovascular system
in older adult clients
MATERIALS
o Stethoscope with a bell o Watch with second
and diaphragm hand
o Small pillow o Centimeter rulers
o Penlight or movable
examination light
NECK VESSELS ASSESSMENT (INSPECTION)
JUGULAR VENOUS PULSE
- not normally visible with the client sitting upright
- fully distends the vein and pulsations may or may not be
visible
- observe by standing on the right side of client with torso
elevated 30-45o
- ask client to turn head slightly to left
- Shine a tangential light source onto the neck to better
visualize pulsations and shadows
- Inspect suprasternal notch
JUGULAR VENOUS PRESSURE
- Normal center of right atrium: 5cm below sternal angle
then add + 5 cm to above measurement to obtain right
atrial pressure
- Measure the vertical distance (in cm) between the
horizontal lines drawn from the upper level of venous
pulsation and the sternal angle
- Use 2 rulers:
o 1 in horizontal to upper level of pulsation
o 2 in vertical distance from sternal angle
NECK VESSELS ASSESSMENT (AUSCULTATION AND
PALPATION)
BLOWING OR SWISHING SOUND
- Bruit or swooshing sound is indicative of occlusive
arterial disease
- Auscultate carotid arteries
- Place bell of the stethoscope over carotid artery and ask
client to hold his/her breath for few seconds so that
breath sounds do not conceal vascular sounds
PULSE
- Are equally strong
- +2 in normal with no variation in strength from beat to
beat
- Palpate carotid arteries by placing the pads of your
index and middle fingers.
- PULSE AMPLITUDE SCALE:
o 0 - absent
o 1+ - weak, diminished
o 2+ - normal
o 3+ - bounding
ANTERIOR CHEST ASSESSMENT (INSPECTION)
APICAL IMPULSE
- Palpated in mitral area (PMI – Point of Maximal
Impulse)
- Amplitude – small (like gentle tap) duration
- No pulsations or vibrations are palpated in the areas of
the apex, left sternal border or base
- Inspect and palpate apical impulse. Palpate for
abnormal pulsations
ANTERIOR CHEST ASSESSMENT (AUSCULTATION)
HEART RATE
- Should be 60-100 beats per minute with regular rhythm
- Bradycardia and Tachycardia
- Auscultate heart rate (HR) and rhythm
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 RADIAL PULSE AND APICAL PULSE WEEK 9C: ASSESSING PERIPHERAL VASCULAR
SYSTEM

ARTERIES

- Should be identical
- PULSE RATE DEFICIT - done by palpating the radial
pulse while you auscultate the apical pulse
- done by 2 person, count 1 full minute
HEART SOUNDS
 Carry oxygenated, nutrient-rich blood from heart to
the capillaries
MAJOR ARTERIES OF ARM
1. Brachial

 Supplies the arm

2. Radial

 Supplies blood to the hand

 Palpated on the lateral aspect of the
- Auscultate 5 AREAS of the heart wrist
- “lub” – S1 ; “dubb” – S2 3. Ulnar
- S1 and S2 – make up the cardiac cycle of systole and
diastole
- S1 – loudest at apex of heart
- S2 – loudest at base of heart
HEART MURMURS  Supplies blood to the hand located on
- No sound = No murmurs medial aspect of the wrist
- Auscultate for extra heart sounds and murmurs  Not easily palpated
MAJOR ARTERIES OF LEG
PHYSIOLOGIC MURMURS 1. Femoral
- caused by a temporary increase in blood flow
- OCCUR WITH:
o Anemia
o Pregnancy
o Fever
 Major supplier of blood to the legs
o Hyperthyroidism
 Palpated under inguinal ligament
2. Popliteal
OLDER CLIENT
 Be cautious with older clients because atherosclerosis
may have caused obstruction, and compression may
easily block circulation.
 In older clients, the apical impulse may be difficult to
palpate because of increased anteroposterior chest
 Palpated behind the knee
diameter.

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3. Dorsalis pedis  Continues
across thigh to
medial aspect
of groin
 Joins femoral
vein
 Anterior branch descends down 2. Small  Begins at
the top of foot saphenous veins lateral dorsal
4. Posterior aspect of foot
tibial  Travels up
behind lateral
malleolus on
the back of leg
 Joins popliteal
 Posterior branch vein
 Palpated behind medial malleolus
of ankle
3. Perforator Connect superficial veins with deep veins
vein
VEINS
CAPILLARIES AND FLUID EXCHANGE
Capillaries

 carry deoxygenated, nutrient-depleted, waste-laden

blood from the tissues back to the heart  small blood vessels that form the
 contains 70% of body’s blood volume connection between the arterioles and
 Blood here is carried under much lower pressure than in venules
arteries  allow circulatory system to maintain the
 Vein walls are much thinner vital equilibrium between the vascular
 Larger in diameter compared to arteries and interstitial spaces
 Can expand if blood volume increases Fluid
THREE TYPES OF VEINS exchange

Arterial  delivers oxygen, water and nutrients in

vessels interstitial fluid to microscopic capillaries
Interstitial  releases oxygen, water and nutrient
fluid  pick-up waste product, CO2 and by-
1. Deep veins  Account for 90% venous return product of cellular metabolism
from lower extremities Lymphatic Remove excess fluid left behind in interstitial
TWO DEEP VEINS capillaries spaces
1. Femoral vein Upper thigh
2. Popliteal vein Behind the knee
LYMPHATIC SYSTEM
2. Superficial TWO SUPERFICIAL VEINS  COMPOSED OF:
veins 1. Great  Longest of all o Lymphatic capillaries
saphenous vein veins o Lymphatic vessels
 Extends from o Lymph nodes
medial dorsal  PRIMARY FUNCTION – drain excess fluid and plasma
aspect of foot protein from bodily tissues and return them to venous
 Crosses over system
medial  Lymph nodes – filter where microorganism, foreign
malleolus materials, dead blood cells, and abnormal cells are
trapped and destroyed

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 SECOND FUNCTION – major part of immune system
- defend body against microorganism
 THIRD FUNCTION – absorb fats (lipids) from small
intestine to bloodstream
DEEP VEIN THROMBOSIS
 Smoking
 Diabetes
RISK FACTORS OF VENOUS STASIS
 Long periods of standing still, sitting, or lying down
 Lack of muscular activity causes blood to pool in the
legs, which, in turn, increases pressure in the veins
 Varicose (tortuous and dilated) veins – increase venous
pressure

REDUCE RISK FACTOR OF PAD #1

 Quit smoking
 Keep blood sugar under control (if with diabetes)
 Exercise regularly – 30 mins/3 times a week
 Lower cholesterol and blood pressure
 Eat food that’s low in saturated fat
 Maintain healthy weight
 Ask about screening with ankle-brachial index (ABI)
 Serious condition that occurs when a blood clot forms in measurement once you reached 50
a vein located deep inside your body
 Blood clot – clump of blood that’s turned to solid state
 Deep vein blood clot – formed in thigh or lower leg SUBJECTIVE DATA
- can also develop in other areas of body
RISK FACTORS SUBJECTIVE FOR HISTORY OF PRESENT CONCERN
o Reduced mobility o Increased viscosity of the blood ARTERIAL INSUFFICIENCY
o Dehydration o Venous stasis-pooling of blood
in the veins

PERIPHERAL ARTERY DISEASE (PAD)

- Cold, pale, clammy skin on extremities especially in

lower leg
 Have you noticed any color, temperature, or texture
changes in your skin?
 Do you experience leg pain and cramping, heaviness
aggravated by standing or sitting for long periods, leg
edema and varicosities?
 Also known as peripheral arterial disease or SYMPTOMS OF PAD
peripheral vascular disease
 Includes both arteries and veins
 diseases of the blood vessels located outside the
heart and brain
 most often caused by a buildup of fatty deposits in
the arteries

RISK FACTORS OF LOWER EXTREMITY PAD

 Ages younger than 50
with diabetes and 1 risk
factor
 Ages 50 to 64 with
history of smoking and
diabetes
 Ages 65 and older
 Leg symptoms with
exertion or ischemic rest
pain
 Atherosclerotic
coronary, carotid, or
renal artery disease
 Obesity
 High blood pressure
 High cholesterol
 Family history of
PAD. Heart disease
SUBJECTIVE FOR PERSONAL HEALTHY HISTORY
or stroke
RECURRANCE AND PAST SURGERIES
 Excess levels of
- Previous history problems in circulation
homocysteine
 African American - Past surgeries alter appearance of the skin and
underlying tissues surrounding blood vessel
 Describe any problems in circulation in your arms and
legs in the past, history of heart or blood vessels
surgery.

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 SUBJECTIVE FOR FAMILY HISTORY
DISORDERS AND ABNORMALITIES
- Tend to be hereditary
- Cause damage to blood vessels
 Do you have a family history of DVT, diabetes,
hypertension, coronary heart disease, hyperlipidemia?

SUBJECTIVE FOR LIFESYLE AND HEALTH PRACTICES

SMOKING
- Increase risk to chronic arterial insufficiency
- Oral contraceptives pills are contraindicated after age
35 if smoking
- increase risk to thrombophlebitis, Raynaud disease, Allen test - pink coloration returns to the palms within 3-5
hypertension and edema seconds if the ulnar artery is patent and the same with radial
artery
- Regular exercise improves peripheral vascular
circulation
 Do you smoke? For how long and how many packs per NOTE
day? Enlarged epitrochlear lymph nodes may suggest an infection
 Do you exercise regularly? in the hand or forearm, or they may occur with generalized
 Do you use oral or transdermal patch contraceptives? lymphadenopathy
(for female clients)
LEG ASSESSMENT
OBJECTIVE DATA INSPECTION
- Observe skin color while inspecting both legs from toes
PREPARING CLIENT to groin
o Explain procedure to client. - Inspect distribution of hair on legs, lesions, ulcers, edema
o Ask client to put on a gown.  Findings - Pink color for lighter-skinned clients and pink
or red tones visible for darker pigmented skin
MATERIALS - hair covers skin of leg
o Gloves o Tourniquet - legs free from lesions, ulcers and no edema
o Centimeter tape o Gauze PALPATION
o Stethoscope o Waterproof pen - Palpate edema
o Doppler ultrasound probe o Blood pressure cuff - Palpate bilaterally from temperature of feet and legs
- Palpate superficial inguinal lymph nodes
ARM ASSESSMENT  Findings – no edema
INSPECTION - Pitting edema - associated with systemic problems,
- Observe arm size, presence of edema and venous such as heart failure or hepatic cirrhosis and local
pattern causes such as venous stasis due to insufficiency or
- Observe skin color of hand and arms obstruction or prolonged standing or sitting(orthostatic
 Findings - Arms are bilaterally symmetric with minimal edema)
variations in size and shape
- no edema or clubbing - Palpate femoral pulse, listen for bruits
- color varies depending on skin tone - Auscultate femoral pulse
PALPATION - Palpate popliteal, dorsalis pedis, posterior tibial pulses
- Palpate fingers, hands and arms for temperature  Findings - Femoral pulses strong and equal bilaterally
- Palpate to assess capillary refill time - no sounds over femoral arteries when auscultated
- Palpate radial, ulnar and brachial pulses - Popliteal pulse detected, dorsalis pedis pulse and
 Findings – skin is warm to touch bilaterally from posterior tibial pulse are both bilaterally strong
fingertips to upper arms
- capillary bed refill in 2 seconds or less - Inspect for varicosities and thrombophlebitis by asking
client to stand
- Palpate epitrochlear lymph node - Do manual compression test
- Perform Allen test - Homans sign – “calf pain” on dorsiflexion of the foot with
 Findings - Normally epitrochlear lymph nodes are not knee straight
palpable  Findings - Veins are flat and barely seen under the
surface of the skin
- Varicosities are common in older adults

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 ELICITING HOMANS’ SIGN ABDOMINAL QUADRANTS

ARTERIAL INSUFFICIENCY - has FOUR QUADRANTS:

Pain intermittent claudication to sharp, o right upper quadrant (RUQ)
unrelenting, constant o right lower quadrant (RLQ)
Pulses Diminished or absent o left upper quadrant (LUQ)
Skin characteristics o left lower quadrant (LLQ)
- has TWO IMMAGINARY LINES:
o vertical – midline
o horizontal - lateral
ABDOMINAL STRUCTURE BY QUADRANTS
Dependent rubor - erythematous
discoloration of the limb in
dependent position due to the effect
of gravity

ARTERIAL INSUFFICIENCY
Pain aching, cramping
Pulses present, but may be difficult to
palpate through edema

OLDER ADULT FINDINGS

 Hair loss on the lower extremities occurs with aging ABDOMINAL REGIONS
- not an absolute sign of arterial insufficiency
 lymphatic tissue is lost, resulting in smaller and fewer
lymph nodes
 Varicosities are common

WEEK 9D: ASSESSING ABDOMEN

ABDOMEN
Regions that are COMMONLY USED:
o Epigastric
o Umbilical
o Hypogastric
o Suprapubic
ABDOMINAL WALL MUSCLES

 bordered superiorly by the costal margins

 bordered inferiorly by the symphysis pubis and inguinal
canals
 bordered laterally by the flanks
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 THREE MUSCLE LAYERS NOTE
1. External abdominal oblique Outermost layer small intestine is not normally palpated during a physical
2. Internal abdominal oblique Middle layer assessment
3. Transverse abdominis Innermost layer
- Protect internal organs SUBJECTIVE DATA
- Allow normal compression of internal organs during
functional activities (such as childbirth) SUBJECTIVE FOR PRESENT HEALTH CONCERN
PAIN AND INDIGESTION
- Quality and character of pain may suggest its origin
- Indigestion may be an indication of acute or chronic
gastric disorder (like Nausea)
 Are you experiencing abdominal pain? (COLDSPA)
 Do you experience indigestion (COLDSPA)?
 Do you experience nausea and vomiting, increase or
decrease appetite?
CHANGE IN BOWEL PATTERN
- Must be compared with usual pattern
- Normal frequency: 2 – 3x a day or 3x per day

Constipation – decrease in frequency of bowel movement or

INTERNAL ANATOMY OF ABDOMEN passage of hard stools
PERITONEUM Diarrhea – frequency of bowel movement producing
- thin, shiny serous unformed or liquid stools
membranes line the
abdominal cavity  Describe your bowel elimination. Have you
(parietal peritoneum) experienced changes?
- provides a protective  Do you have constipation or experienced diarrhea?
covering for most of the
internal abdominal SUBJECTIVE FOR FAMILY HISTORY
organs (visceral - Increase client’s risk
peritoneum)  Has anyone in your family had any type of stomach,
PERITONEAL CAVITY colon, liver cancer or other GI disorders?
- structures of several different body systems:
o Gastrointestinal system SUBJECTIVE FOR LIFESTYLE AND HEALTH PROBLEMS
o Reproductive system (female) ALCOHOL INGESTION
o Lymphatic system - Can affect GI tract through immediate and long-term
o Urinary system effect (stomach, pancreas, liver)
VISCERA - Baseline dietary helps to determine nutritional and fluid
- Palpation depends on location, structural consistency, adequacy
size - Regular exercise promotes peristalsis and regular bowel
- Normally not palpable: movements
o Pancreas  Do you drink alcohol and how much and how often?
o Spleen  What types of foods do you consume each day? How
o Stomach much fluid do you take?
o Gallbladder  Do you exercise? How often?
o Small intestine
Solid viscera liver, pancreas, spleen, adrenal OBJECTIVE DATAS
glands, kidneys, ovaries, uterus
Hollow viscera stomach, gallbladder, small PREPARING THE CLIENT
intestine, colon, bladder
 Empty the bladder.
VASCULAR STRUCTURES  Remove clothes and put on a gown.
- abdominal organs are  Lie supine with the arms folded across the chest or
supplied with arterial resting by the sides.
blood by the abdominal  Drape the client.
aorta and its branches  Breathe through the mouth; take slow, deep breaths.
- Right and left iliac
arteries – pulsations felt
in RLQ and LLQ

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 MATERIALS
o Small pillow or rolled o Stethoscope (warm the
blanket diaphragm and bell)
o Centimeter ruler o Marking pen

INSPECTION
- Observe coloration of skin
AUSCULTATION SOUNDS
- Note vascularity of abdominal skin 1. Abdominal sound normal, hypoactive, or
- Note striae and inspect for scars hyperactive or absent
- Assess lesions and rashes 2. Hypoactive, or often indicate
 Findings - Abdominal skin may be paler reduced, bowel that intestinal activity has slowed
- Scattered fine veins may be visible sounds down
- New striae are pink or bluish in color 3. Hyperactive bowel louder sounds related to
- Old striae are silverly, white. Linear, and uneven sounds increased intestinal activity that
stretch marks from past pregnancies or weight gain can be heard by others
- Pale, smooth minimally raised old scars may be seen
- free from lesions or rashes - Auscultate vascular sounds
- use bell of stethoscope to listen for bruits (low-
pitched murmur sound) over the abdominal aorta and
renal, iliac, and femoral arteries
- Listen for venous hum using bell of stethoscope
 Findings - Bruits are not normally heard over abdominal
aorta or renal, iliac, or femoral arteries
- Venous hum is not normally heard over epigastric
and umbilical; areas

- Inspect umbilicus (color, location, contour)

- Inspect abdominal contours, symmetry, and abdominal
movement when client breathes
- Observe aortic pulsations
- Observe peristaltic wave.
 Findings - Umbilical skin tones are similar to surrounding
abdominal skin tones or even pinkish
- midline at lateral line and is recessed(inverted) or - Auscultate for friction rub over liver and spleen
protruding no more than 0.5cm and is round or conical - Listen over right and left lower rib cage with the
- Abdomen is flat, rounded, or scaphoid. diaphragm of the stethoscope
- Abdomen is symmetric, does not bulge when client  Findings - No friction rub over liver or spleen is present.
raises head
- Abdominal respiratory movement may be seen
PERCUSSION
especially in male. A slight pulsation of the abdominal
aorta which is visible in the epigastrium.
- peristaltic waves are not seen although may be
visible in very thin people.

AUSCULTATION
- Auscultate for bowel sounds
 Findings - Series of intermittent, soft clicks and gurgles
are heard at a rate of 5-30 per minute
- Hyperactive bowel sounds (“borborygmus”) may
also be heard - loud, prolonged gurgles (“stomach
growling)
 Bowel sounds normally occur every 5-15 seconds - For tone
- Light and systematically percuss all quadrants
 Findings - Generalized tympany predominates over the
abdomen because air in the stomach and intestines.
Dullness is heard over the liver and spleen.

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 - Palpate umbilicus and surrounding areas
- Percuss span or height of liver by determining lower and - for swellings, bulges, or masses
upper borders - Palpate aorta
 Findings - lower border of liver dullness is located at the
 Findings - Umbilicus and surrounding area are free of
costal margin to 1-2 cm below
swellings, bulges, or masses
- deep inspiration, the lower border of liver dullness,
- aorta is approximately 2.5-3.0 cm wide with a
may descend from 1 to 4cm. Below the costal margin
moderately strong and regular pulse (mild tenderness)
- normal liver span at MCL is 6-12 cm. and 4-8cm. At
the MSL

- Palpate liver
- note consistency and tenderness
 Findings - usually not palpable although it may be felt in
- Percuss spleen
some thin clients
 Findings - spleen is an oval area of dullness
- If the lower edge is felt, it should be firm, smooth,
approximately 7 cm. wide near left tenth rib and slightly
and even. Mild tenderness may be normal
posterior to MAL
- Splenomegaly is characterized by an area of dullness
greater than 7 cm. wide

- Blunt percussion on the kidneys at Costovertebral

Angles (CVA) over twelfth rib
 Finding - no tenderness or pain is elicited or reported by
the client (examiner senses a dull thud)

PALPATION - Palpate spleen

 Findings - spleen is seldom palpable at the left costal
margin
- edge should be soft and nontender

TEST FOR ASCITES

- Perform light palpation
- identify areas of tenderness and muscular resistance
- use your fingertips and compress to a depth of 1 cm.
in a dipping motion
 Findings – nontender and soft, no guarding

- Perform deep palpation - Test for Shifting dullness

- all quadrants to delineate abdominal organs and
detect subtle masses
- use palmar surface of fingers, compress to
maximum depth of 5-6 cm
- Perform bimanual palpation
- if there’s resistance
- to assess deeper structure
 Findings - Normal(mild) tenderness is possible over the
xiphoid, aorta, cecum, sigmoid colon and ovaries with
deep palpation. No palpable masses are present.
- note change from dullness to tympany and mark the
point
- help client to turn
- percuss abdomen from bed upward, mark level
 Findings - borders between tympany and dullness
remain relatively constant throughout position changes
- Perform fluid wave
 Findings – no fluid wave is transmitted
- Movement of a fluid wave against the resting hand
suggests large amounts of fluid are present. (ascites)

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 MURPHY SIGN
- Used to test for acute cholecystitis
TESTS FOR APPENDICITIS SIGN
PSOAS AND
OBTURATOR SIGN
- To test for
appendicitis
MCBURNEY’S POINT PAIN
Deep tenderness at McBurney's
point, known as McBurney's sign, is a
sign of acute appendicitis.
TYPES FOR ABDOMINAL PAIN
1. Visceral pain  hollow abdominal organs such as
intestines become distended or
contract forcefully
 capsules of solid organs such as
liver and spleen are stretched
 localized and intermittent
 localized and intermittent
2. Parietal pain  parietal peritoneum becomes
inflamed as in appendicitis or
peritonitis
 localized
 more severe and steady pain
3. Referred pain  occurs at distant sites that are
innervated at approximately the
same levels as the disrupted
abdominal organ
 pain travels
 from the primary site and becomes
highly localized at the distant site
ABDOMINAL DISTENTION
o Pregnancy (normal) o Fibroids and other
o Fat masses
o Feces o Flatus
o Ascitic fluid
MECHANISM AND SOURCES OF ABDOMINAL PAIN
ABDOMINAL BULGES
o Umbilical hernia o Diastasis recti
o Epigastric hernia o Incisional hernia
OLDER CLIENT
 Dilated superficial capillaries without pattern may be
seen
- more visible in sunlight
 Assess carefully for acute abdominal conditions
- sensitive to pain may diminish with aging
WEEK 11: GA MENTAL
GENERAL SURVEY
 Observation of the client’s general appearance, level of
comfort, and mental status.
 APPEARANCE AND MENTAL STATUS – general
appearance
- must be assessed in relationship to culture,
educational level, socioeconomic status, and current
circumstances
 Information that provides clues about the overall health
of the client
 Uses senses for inspection
INCLUSION
OVERALL IMPRESSION OF THE CLIENT
 requires your objective observation skills to assess the
client’s appearance, mobility, and body build
 the first time you meet a client, remember certain
obvious characteristics
 observe the client and environment quickly before
interacting with the client
MENTAL STATUS EXAM
 an exam that helps you to determine the client’s
emotional and cognitive functional statuses
 provides information about the cerebral cortex function
 provides information about the cerebral cortex function
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 NOTE
Cerebral abnormalities disturb the client’s intellectual
ability, communication ability, or emotional behaviors

WORKING PHASE
VITAL SIGNS
 includes the following:
o Pulse rate (PR) – 60/100 normal
o Respiration rate (RR) – 12-20 cycle per minute
o Blood Pressure (BP)
o Temperature (Temp) POSTURE AND GAIT
o Pain  Observe
 Posture – erect and comfortable for age
 Pain does not involve the use of fancy instruments, yet
 Gait – rhythmic and coordinated with arms swinging at
an early predictor of impending disability
side
 Ask client if he or she has any pain
- GAIT ABNORMALITIES
 If none, no subjective report of pain
SIGNS OF DISTRESS AND PAIN
Includes the following:
o Posture
o Facial grimace
o Sad expression
o DOB
o Skin color

APPEARANCE IN RELATION TO AGE

Compare client’s stated age with his or her apparent age
and developmental stage  Observe for any curvatures of spine

BODY STRUCTURE
 Observe physical development of body:
o Malnourished children – short, thin, bloated
o Overweight & obesity – abnormal or excessive fat
- Apple-shaped – Central obesity
- abdomen part
- Pear-shaped – or gynoid obesity
- common in female
 Observe for physical deformities such as congenital
 Observe body proportion malformation, birthmarks, webbed digits or extra digits
- note symmetry of body parts o Polydactyly – hand has extra digit (as well as
o Length of limbs – distance from middle fingertip of toes)
left hand to the middle fingertip of right hand (1:1) - TYPES OF POLYDACTYLY:
HEIGHT AND WEIGHT
 Measure and observe variation
 Is the height and weight appropriate to body
structure?
 Calculate BMI
- Body Mass Index (BMI) - inexpensive and easy
screening method for weight category—
underweight, healthy weight, overweight, and o Syndactyly – two or more digits are fused together
obesity - TYPES OF SYNDACTYLY:

𝑤𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)
BMI =
ℎ𝑒𝑖𝑔ℎ𝑡 (𝑚2)

NRM | HA REVIEWER
 HYGIENE AND GROOMING 4. Document and record data and findings gathered in the
 Observe overall hygiene and grooming of your client client’s chart in a factual manner using appropriate
 Is the client neat and unkempt? terminologies
 client is clean and groomed appropriately for occasion
 may depend on the client’s lifestyle and culture
 Are the client clothes appropriate to age group, weather,
culture, and occasion?
 Are there any signs of self-care deficit in relation to
personal hygiene and clothing
BODY ODOR AND BREATH
 Take note
o Halitosis – bad breath
o Keto Breath – fruity scent as nail polish remover
- abnormally high ketones
FACIAL FEATURES AND EXPRESSION
 Note for symmetrical movement of face and size of
facial features
 Observe facial expression during general survey process
 Facial features – symmetric with movement
 Client establishes good eye contact when conversing
with others. Smiles and frowns appropriately
o Facial drooping – loss of facial movement
- damage of nerve (Bell’s palsy or stroke)
o Ptosis – drooping of upper eyelid result from
damage to the nerve that controls muscle of eyelid
AFFECT AND MOOD
 Observe behavioral, body movements and affect.
- Client is cooperative and purposeful in his or her
interaction with others
- mild to moderate anxiety
 Ask client for current feelings and observe
appropriateness of responses
 Observe client’s level of consciousness
- client is alert and oriented to person, time, place and
events
- client responds and interacts appropriately
 Observe mood, feeling and expression
- “How are you feeling today?”
SPEECH
 Listen to speech
 Note tone, clarity, style and pattern
 Speech is in moderate tone, clear, moderately paced
and culturally appropriate
 Adult’s responses may be slowed but speech is clear
and moderately paced
 If with difficulty: perform additional tests

Slurred speech - symptom characterized by poor

pronunciation of words, mumbling, or a change in speed or
rhythm during talking. (dysarthria)

POST IMPLEMENTATION
1. Validate data gathered for accuracy, reliability, and
completeness.
2. Discard PPE appropriately and perform hand hygiene
3. Report significant findings and needs that requires
immediate intervention to nurse supervisor or the
physician.

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