HEALTH ASSESSMENT EXAM 1

(CHAPTER 1-5) WEEK 1

SUBJECTIVE: CHAPTER 2 (KATIE)

Discuss the purpose for each of the three phases of a client interview.
1. Preintroductory Phase: Review client’s record before meeting them. Knowing
documented biographical information may assist in conducting the interview.

2. Introductory Phase: Introduce self and explain to clients the purpose of the interview,
discusses the types of question that will be asked, explain reasons for taking notes, and assure
client everything is confidential.

3. Working Phase: The nurse then listens, observes cues, and uses critical thinking skills to
interpret and validate information received from the client. The nurse and client collaborate to
identify the client’s problems and goals

4. Summary/Closing Phase: The nurse summarizes information obtained during the

working phase and validates problems and goals with the client (see Chapter 4). She also
identifies and discusses possible plans to resolve the problem (nursing diagnoses and
collaborative problems) with the client

Describe effective verbal and nonverbal communication techniques to collect subjective client
data.

1. Non-verbal

a. Appearance: Ensure look is professional of a healthcare professional. Hair pulled back,

nails trimmed short and neat. Jewelry should be minimal.

b. Demeanor: Act professional, don’t come into the room loudly and talking/yelling with
other co-workers. Greet client calmly by name not by honey, sweetie, or sugar. Focus on client
and do not be too touchy. Maintain professional distance.

c. Facial Expression: Monitor your facial expression and keep expression neutral and friendly.
If you cannot hide your emotions (anger/anxiety) explain to client, why you’re feeling that way.

d. Attitude: Nonjudgmental attitude. All clients should be accepted, regardless of beliefs,

ethnicity, lifestyle, and health care practices. Do not act as though you feel superior to the client
or appear shocked, disgusted, or surprised at what you are told.

e. Silence: Another nonverbal technique to use during the interview process is silence.
Periods of silence allow you and the client to reflect and organize thoughts, which facilitate
more accurate reporting and data collection
HEALTH ASSESSMENT EXAM 1

f. Listening: To listen effectively, you need to maintain good eye contact, smile or display an
open, appropriate facial expression, and maintain an open body position (open arms and hands,
and lean forward). Avoid preconceived ideas or biases about your client. To listen effectively,
you must keep an open mind. Avoid crossing your arms, sitting back, tilting your head away
from the client, thinking about other things, and looking blank or inattentive, or engaging with
an electronic device instead of the client

2. Verbal
a. Open-Ended Question: elicit the clients feelings and perceptions. Begin with the words
“HOW” and “WHAT”. These types of questions are important because they require more than a
one-word response from the client and, therefore, encourage description. Asking open-ended
questions may help to reveal significant data about the client’s health status.

b. Closed-Ended Questions: use to obtain facts and to focus on specific information. Client
can respond with one or two words. Begin with “WHEN” and “DID”. Closed-ended questions are
useful in keeping the interview on course. They can also be used to clarify or obtain more
accurate information about issues disclosed in response to open-ended questions.

c. Laundry list: ask questions that provide the client with a list of words to choose from in
describing symptoms, conditions, or feelings.

d. Rephrasing: Rephrasing information the client has provided is an effective way to

communicate during the interview. This technique helps you to clarify information the client has
stated; it also enables you and the client to reflect on what was said.

e. Well-places phrases: if the client is in the middle of explaining a symptom or feeling and
believes that you are not paying attention, you may fail to get all the necessary information.
Listen closely to the client during his or her description and use phrases such as “uh-huh,” “yes,”
or “I agree” to encourage the client to continue.

f. Inferring: Inferring information from what the client tells you and what you observe in the
client’s behavior may elicit more data or verify existing data. Ex. Pt said she has pain holding her
hand on the right side of her lower abdomen. So, you say it seems you are having pain with the
right side of your stomach.

g. Providing Information: Another important thing to do throughout the interview is to

provide the client with information as questions and concerns arise. Make sure that you answer
every question as thoroughly as you can. If you do not know the answer, explain that you will
find out.
Explain types of communication to avoid in the client interview.

NON-VERBAL
HEALTH ASSESSMENT EXAM 1

a. Excessive or Insufficient Eye Contact: Avoid extremes in eye contact. It is best to use a
moderate amount of eye contact.

b. Distraction and Distance: Avoid being occupied with something else while you are
asking questions during the interview. Avoid appearing mentally distant and avoid
physical distance exceeding 2-3 f

c. Standing: Avoid standing while the client is seated. Standing puts you and client at
different level. You may be perceived as the superior and client inferior.
VERBAL
a. Biased or leading questions: Avoid using biased or leading question this cause clients
to provide answers that may not be true.

b. Rushing through the interview: This cause clients not to hear questions clearly so
they provide incorrect answers and leaving important information out.

c. Reading the questions: This deflects attention from the clients and results in an
impersonal interview process. As a result, the client may feel ill at ease opening up to
formatted questions

Discuss the appropriate ways to communicate with clients with the following emotional states
Anxious client
 Provide the client with simple, organized information in a structured format.
 Explain who you are, along with your role and purpose.
 Ask simple, concise questions.
 Avoid becoming anxious like the client.
 Do not hurry and decrease any external stimuli.

Angry client
 Approach this client in a calm, reassuring, in-control manner.
 Allow him to ventilate feelings. However, if the client is out of control, do not
argue with or touch the client.
 Obtain help from other health care professionals as needed
 Avoid arguing and facilitate personal space so that the client does not feel
threatened or cornered.
 Never allow the client to position him or herself between you and the door.

Depressed client
 Express interest in and understanding of the client and respond in a neutral manner.
HEALTH ASSESSMENT EXAM 1

 Do not try to communicate in an upbeat, encouraging manner. This will not help the
depressed client.

Manipulative client
 Provide structure and set limits.
 Differentiate between manipulation and a reasonable request.
 If you are not sure whether you are being manipulated, obtain an objective opinion
from other nursing colleagues.

Seductive client
 Set firm limits on overt sexual client behavior and avoid responding to subtle seductive
behaviors.
 Encourage client to use more appropriate methods of coping in relating to others.
 If the overt sexuality continues, do not interact without a witness.
 Report inappropriate behavior to a supervisor.

Discussing sensitive issues

 First, be aware of your own thoughts and feelings regarding dying, spirituality, and
sexuality; then recognize that these factors may affect the client’s health and may need
to be discussed with someone.
 Ask simple questions in a nonjudgmental manner.
 Allow time for ventilation of client’s feelings as needed.
 If you do not feel comfortable or competent discussing personal, sensitive topics, you
may make referrals as appropriate, for example, to a pastoral counselor for spiritual
concerns or other specialists as needed.

Identify the major categories of a complete client health history.

Biographical data:
- Information that identifies the patient such as name, address, phone number, gender,
social security number, health insurance info, culture, ethnicity, religious,
primary/secondary language, and significant other

Reasons for seeking health care:

- Chief complaints. Major health issue or problem at this time. Why are you here?

History of present health concern:

- Encourage the client to explain the health problem or symptom in as much detail as
possible by focusing on the onset, progression, and duration of the problem; signs and
symptoms and related problems; and what the client perceives as causing the problem.
HEALTH ASSESSMENT EXAM 1

Personal health history:

- This portion of the health history focuses on questions related to the client’s personal
history, from the earliest beginnings to the present. Immunization to date, any surgeries
or accidents, and etc.…

Family health history:

- Increasing number of health problems that seem to run in families and that are
genetically based, the family health history assumes greater importance. In addition to
genetic predisposition, it is also helpful to be aware of other health problems that may
have affected the client by virtue of having grown up in the family and being exposed to
these problems

ROS for current health problems:

- Each body system is addressed, and the client is asked specific questions to elicit further
details of current health problems or problems from the recent past that may still affect
the client or that are recurring. Care must be taken in this section to include only the
client’s subjective information and not the examiner’s observations.

Lifestyle and health practices profile:

- Deals with the client’s human responses, which include nutritional habits, activity and
exercise patterns, sleep and rest patterns, self-concept and self-care activities, social and
community activities, relationships, values and beliefs system, education and work,
stress level and coping style, and environment.

Developmental level:
- Young adult: intimacy versus isolation
- Middle adult: generativity versus stagnation
- Older adult: ego integrity versus despair

Explain how a nurse would use the “COLDSPA” mnemonic to analyze a client symptom.
C: Character: Describe the sign or symptoms
O: Onset: When did it begin? Start?
L: Location: where is it? Does it radiate? Does it occur anywhere else?
D: Duration: How long does it last? Does it recur?
S: Severity: How bad is it? How much does it bother you?
P: Pattern: What makes it better? Worse?
A: Associated factors/ how does it affects the client: What other symptoms occur with it? How
does it affect your daily life activity?
OBJECTIVE (CHAPTER 3) (JOHN)
Explain how to prepare oneself, the physical environment and the client for a physical examination.
Physical Examination Preparation:
HEALTH ASSESSMENT EXAM 1

• Comfortable, warm temperature – provide a warm blanket if the room temp cannot be adjusted
• Private area free of interruption – close the door or pull the curtains if possible
• Quiet area – turn off radio, television or other noisy equipment.
• Adequate lighting – best to use sunlight (when available). But, good overhead lighting is
sufficient. A portable lamp is helpful for illuminating the skin and for viewing shadows or
contours.
• Firm examination table or bed – a roll up stool may be useful when it is necessary for the
examiner to sit for parts of the exam.
• Beside table/tray to hold equipment needed for the examination.
Explain the general principles that the nurse should keep in mind while conducting a physical
examination.

Summarize the ways that the nurse can prepare the client for a physical examination
Client Approach and Preparation:
• Establish nurse-client relationship.
• Explain the procedure and the physical assessment that will follow, describing the steps of the
examination.
• Respect client’s requests and desires about the physical examination.

• Explain the importance of the examination and the risk of missing important information.

• Leave room while client changes clothes.

• Provide necessary container in case of need for sample, such as urine sample, needs to be
collected form the client
• Begin exam with less-intrusive procedures such as measuring temperature, pulse, and blood
pressure.
• Explain procedure being performed and the reason why it is being performed
• Explain to client why position changes are necessary during examination.

Discuss the standard precautions that the nurse should take during the physical examination of a client
Standard Precautions:
*observe what is outside the door! Check if there are airborne, contact, droplet, etc precautions

• Hand hygiene
• Gloves
HEALTH ASSESSMENT EXAM 1

• Mask, eye protection, face shield

• Gown
• Patient care equipment; patient placement
• Linen; occupational health and blood-borne pathogens

Survey the various pieces of equipment used to perform a physical examination.

***Thermometer, watch with second hand, sphygmomanometer, pulse oximeter, tape measure, rulers,
pen light, tongue depressor

List the different pieces of equipment needed for physical examination and state their purpose

TABLE 3-1 Equipment Needed for Physical Examination, p. 32

Examination Equipment Purpose

All examinations Gloves and gown Protect examiner in any part of the
examination when the examiner may have
contact with blood, body fluids, secretions,
excretions, and contaminated items, or when
disease-causing agents could be transmitted
to or from the client

Vital signs Sphygmomanometer Measure diastolic and systolic blood

pressure. Stethoscope to auscultate blood
sounds when measuring blood pressure

Thermometer (oral, Measure body temperature

rectal, tympanic) Take heart rate, pulse rate
Watch with second hand Determine perceived pain level
Pain rating scale

Nutritional status Skinfold calipers Measure skinfold thickness of subcutaneous

examination tissue

Flexible tape measure Measure mid-arm circumference

Skin-marking pen Mark measurements

Platform scale with height Measure height and weight

attachment

Skin, hair, and nail Examination light, Provide adequate lighting

examination penlight
HEALTH ASSESSMENT EXAM 1

Mirror Client’s self-examination of the skin

Metric ruler Measure size of skin lesions

Magnifying glass Enlarge visibility of lesion

Wood’s light Test for fungus

Braden Scale for Predict one’s risk to develop pressure sore

predicting Pressure sore Determine the degree of healing of a
risk pressure ulcer
Pressure Ulcer Scale for
Healing (PUSH)

Head and neck Stethoscope Auscultate the thyroid

examination

Small cup of water Help client swallow during examination of

the thyroid gland

Eye examination Penlight Test pupillary constriction

Snellen E chart Test distant vision

Newspaper Test near vision

Opaque card Test for strabismus

Ophthalmoscope View the red reflex and to examine the

retina of the eye

Ear examination Tuning fork Test for bone and air conduction of sound
Otoscope View the ear canal and tympanic membrane

Mouth, throat, Penlight Provide light to view the mouth and the
nose, and sinus throat and to transilluminate the sinuses
examination

4 × 4-in small gauze pad Grasp tongue to examine mouth

Tongue depressor Depress tongue to view throat, check

looseness of teeth, view cheeks, and check
strength of tongue

Otoscope with wide-tip View the internal nose

attachment
HEALTH ASSESSMENT EXAM 1

Thoracic and lung Stethoscope (diaphragm) Auscultate breath sounds

examination Metric ruler and skin- Measure diaphragmatic excursion
marking pen

Heart and neck Stethoscope (bell and Auscultate heart sounds

vessel examination diaphragm) Measure jugular venous pressure
Two metric rulers

Peripheral vascular Sphygmomanometer and Measure blood pressure and auscultate

examination stethoscope vascular sounds

Flexible metric measuring Measure size of extremities for edema

tape

Tuning fork Detect vibratory sensation

Doppler ultrasound Detect pressure and weak pulses not easily
device and conductivity heard with a stethoscope
gel

Abdominal Stethoscope Detect bowel sounds

examination Flexible metric measuring Measure size and mark the area of
tape and skin-marking percussion of organs
pen Place under knees and head to promote
Two small pillows relaxation of abdomen

Musculoskeletal Flexible metric measuring Measure size of extremities

examination tape Measure degree of flexion and extension of
Goniometer joints
HEALTH ASSESSMENT EXAM 1

Neurologic Cotton-tipped applicators Test taste smell perception

examination and substances to smell
and taste
Same equipment as for
eye examination (see
above)
Objects to feel, such as a
coin or key
Reflex (percussion)
hammer
Cotton ball and paper clip
Test vision and extraocular movements and
papillary response
Test for stereognosis (ability to recognize
objects by touch)
Test deep tendon reflexes
Test for light, sharp, and dull touch and two-
point discrimination
Test for rise of uvula and gag reflex
Test for vibratory sensation

Tongue depressor
Tuning fork

Male genitalia and Gloves and water-soluble Promote comfort for client
rectum lubricant Scrotal illumination
examination Penlight Detect occult blood
Specimen card

Female genitalia Vaginal speculum and Inspect cervix through dilatation of the
and rectum water-soluble lubricant vaginal canal
examination Bifid spatula, endocervical Obtain endocervical swab and cervical
broom scrape and vaginal pool sample
Vaginal examination
Large swabs Pap smear
Liquid Pap medium Detect occult blood
Specimen card

Describe various client positions used for different parts of the physical examination.
• Sitting position: sitting upright on the side of the bed, chair or examination table
HEALTH ASSESSMENT EXAM 1

• Supine position: lays on back in bed with legs together.

• Dorsal recumbent position: lies down on the examination table or bed with the knees bent, the
legs separated, and the feet flat on the table or the bed.
• Sim’s position: lays on right or lef side with lower arm placed behind the body and the upper
arm flexed at the shoulder and the elbow. Lower leg slightly flexed at the knee while the upper
leg is flexed at a sharper angle and pulled forward
• Standing position: stands still in a normal, comfortable resting posture.
• Prone position: lies down on the abdomen, head to the side.
• Knee-chest position: kneels on bed with weight of the body supported by the chest and knees.
90 degrees at the hip.
• Lithotomy position: lies on the back with hips at the bottom edge of examination table and the
feet supported by stirrups.

Demonstrate correct inspection, palpation, percussion, and auscultation examination techniques.

Inspection:
 Make sure the room is a comfortable temperature. A too cold or too hot room can alter the
normal behavior of the client and the appearance of the client’s skin.

 Use good lighting—preferably sunlight. Fluorescent lights can alter the true color of the skin. In
addition, abnormalities may be overlooked with dim lighting.

 Look and observe before touching. Touch can alter appearance and distract you from a
complete, focused observation.

 Completely expose the body part you are inspecting while draping the rest of the client as
appropriate.

 Note the following characteristics while inspecting the client: color, patterns, size, location,
consistency, symmetry, movement, behavior, odors, or sounds.

 Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or both sides
of any individual body part.

Palpation:
HEALTH ASSESSMENT EXAM 1

• Light palpation: place dominant hand lightly on the surface of the structure. There should be
very little or no depression (less than 1 cm).
• Moderate palpation: Depress the skin surface 1 to 2 cm (0.5 to 0.75 in) with your dominant
hand, and use a circular motion to feel for easily palpable body organs and masses. Note the
size, consistency, and mobility of structures you palpate.

• Deep palpation: place your dominant hand on the skin surface and your non-dominant hand on
top of your dominant hand to apply pressure. This should result in a surface depression between
2.5 and 5 cm (1 and 2 in). This allows you to feel very deep organs or structures that are covered
by thick muscle.

• Bimanual palpation: use two hands, placing one on each side of the body part (e.g., uterus,
breasts, spleen) being palpated. Use one hand to apply pressure and the other hand to feel the
structure. Note the size, shape, consistency, and mobility of the structures you palpate.

Palpation consists of using parts of the hand to touch and feel for the following characteristics:
• Texture (rough/smooth)
• Temperature (warm/cold) ***Do with dorsal side of the hand
• Moisture (dry/wet)
• Mobility (fixed/movable/still/vibrating)
• Consistency (sof/hard/fluid filled)
• Strength of pulses (strong/weak/thready/bounding)
• Size (small/medium/large)
• Shape (well defined/irregular)
• Degree of tenderness

Percussion:
 Eliciting pain - Percussion helps detect inflamed underlying structures. If an inflamed area is
percussed, the client’s physical response may indicate or the client will report that the area feels
tender, sore, or painful.

• Determining location, size, and shape - Percussion note changes between borders of an organ
and its neighboring organ can elicit information about location, size, and shape.
• Determining density - helps determine whether an underlying structure is filled with air or fluid
or is a solid structure.
• Detecting abnormal masses - can detect superficial abnormal structures or masses. Percussion
vibrations penetrate approximately 5 cm deep. Deep masses do not produce any change in the
normal percussion vibrations.
• Eliciting reflexes - Deep tendon reflexes are elicited using the percussion hammer
• Look for resonance - lungs
Percussion Types:
HEALTH ASSESSMENT EXAM 1

• Direct - tapping of a body part with one or two fingertips to elicit possible tenderness (e.g.,
tenderness over the sinuses).
• Blunt - placing one hand flat on the body surface and using the fist of the other hand to
strike the back of the hand flat on the body surface. Detects tenderness over organs (e.g.,
kidneys)
• Indirect or mediate - most commonly used method of percussion. The tapping done with
this type of percussion produces a sound or tone that varies with the density of underlying
structures. As density increases, the sound of the tone becomes quieter.
• Sounds elicited by percussion - produces a sof tone, fluid produces a louder tone, and air
produces an even louder tone. These tones are referred to as percussion notes and are
classified according to origin, quality, intensity, and pitch

Auscultation

• Eliminate distracting noise.

• Expose the body part being auscultated.
• Diaphragm, high-pitched sounds; bell, low-pitched sounds
• Place earpieces into outer ear canal.
• Angle binaurals down toward nose.

Discuss the purpose of the bell and the diaphragm of the stethoscope

The diaphragm side of the stethoscope is used to auscultate lower frequency sounds.
The bell side of the stethoscope allows auscultation with an emphasis on higher frequency noises.

Discuss the purpose of a stethoscope during a physical examination. Explain the correct use of the
stethoscope and the purpose of the bell and diaphragm
• Warm diaphragm and bell before use.
• Explain what you are listening to and answer any questions.
• Avoid listening through clothes.
VALIDATING DOCUMENTATION (CHAPTER 4) (KIERSAULA)
HEALTH ASSESSMENT EXAM 1

Describe the significance and process for validation of client data.

 Significance: Failure to validate data may result in premature closure of the assessment or
collection of inaccurate data. Errors during assessment cause the nurse’s judgments to be made
on unreliable data, which results in diagnostic errors during the second part of the nursing
process—analysis of data. This is why validating during assessing (first step of the nursing
process) is the most crucial.

 Process of validation:
1. Deciding whether the data requires validation.
2. Determining ways to validate the data.
3. Identifying areas for which data are missing

** what data actually needs validation:

 Discrepancies between subject and objective data:
- Pt states he is happy but just found out his illness is terminal

 Discrepancies between what a pt said one time versus the other:

- Pt states no family history of diabetes but later states her mom has type II

 Findings that are abnormal with other findings:

- Pt’s temp is 105 but seems comfortable and does not complain of any fever.

^ all these situations need validation by either re-asking your pt, checking assessing your data for
mistakes, consulting another healthcare provider, or asking that pt what they consider their “baseline”

Explain what is meant by validation of client data and discuss its purpose and Discuss the following
ways for validating data using examples
If there is ever a discrepancy of data, you may validate using one of these methods:

1. Recheck your own data by reassessing.

EX: if you measure abnormally high BP but pt seems fine, recheck their BP

2. Clarify data by asking the pt additional questions.

EX: pt may squint and may appear as if he cannot see but maybe he is photosensitive and is
suffering from a migraine. Always ask and clarify, “sir, are you having trouble seeing?”

3. Verify data with another healthcare provider:

EX: if your BP reading keeps coming back abnormally high but all other vital signs are normal, ask
a more experienced nurse to take the BP again.

4. Compare objective to subjective findings:

HEALTH ASSESSMENT EXAM 1

EX: If pt states he has absolutely no pain, but still clenches his stomach when he moves, clarify
with that pt about what he thinks is painful.

** the purpose of validating data is to ensure there are no discrepancies between subjective and
objective data, failure to do this could lead to diagnostic errors.

Describe the multiple purposes of accurate and timely documentation of client data.

1. Provides a chronological order of assessment findings that outline the pts overall course of care.

2. Provides a way for all healthcare providers for that pt to communicate efficiently by making all
information about that pt accessible-- if any provider has a question they can simply look at the
pts chart without having to consult with another provider.

3. Provides a way to prove or disprove diagnoses.

4. Provides a way to determine where the pt or family needs more educating-- pts blood sugar is
still high, maybe pt is uneducated on how to maintain a healthy blood sugar level.

5. Provides a way to prove or supply reimbursement to the pt-- by having an accurate record it is
easier to prove to an insurance company why a pt may need more extensive treatment.
6. Acts as a legal record of what did or did not happen to the client.

7. Helps the hospital determine how much staff or what kind is needed on each unit by assigning
levels of acute care. This is called, “Forms a component of client acuity system or client
classification systems.
8. Provides access to significant epidemiologic data for future investigations and research and
educational endeavors.
9. Promotes compliance with legal, accreditation, reimbursement, and professional standard
requirements.

CHAPTER 19 (VERONICA)
HEALTH ASSESSMENT EXAM 1

Describe the function and structure of the thorax and lungs.

- Chest (thorax) and lungs allow for respiration

- Respiration keeps body supplied with O2
- Respiration involves: movement of air from outside to the alveoli
- Gas exchange across alveolar pulmonary capillaries
- Circulatory system transports oxygen to and carbon dioxide from the peripheral tissues.

THORAX
The chest and lung allow for respiration
Purpose of respiration is to keep the body adequately supplied with oxygen and protected from excess
accumulation of carbon dioxide
Respiration involves:
Movement of air back and forth from the alveoli to the outside environment
Gas exchange across the alveolar-pulmonary capillary membranes
Circulatory system transport of oxygen to, and carbon dioxide from, the peripheral tissue.

a. consists of the sternum

b. 12 pairs of ribs, 12 thoracic vertebrae, muscles, and cartilage.
c. It provides protection and support for organs and the lower respiratory system.
d. the thoracic cavity consists of the mediastinum and the lungs.
e. Mediastinum is the central area of the thoracic cavity that contains the trachea, bronchi,
esophagus, heart, great vessels.
LUNGS
a. two-coned shaped elastic structures that suspend within the thoracic cavity
b. The apex of the lungs extends slightly above the clavicle.
c. The base of the lungs is at the level of the diaphragm.

Identify the thoracic landmarks in relation to the underlying thoracic structures.

HEALTH ASSESSMENT EXAM 1

Anterior chest- midsternal, right and lef midclavicular lines

Posterior thorax- vertebral line, right and lef scapular lines

Lateral thorax- midaxillary line, anterior and posterior axillary lines

Mediastinum-central area in the thoracic cavity

Lungs- two cone-shaped elastic structures

Pleura- thin, double layered serous membrane that lines the thoracic cavity.

Thoracic cage = sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, cartilage

HEALTH ASSESSMENT EXAM 1

Landmarks Anterior thoracic cage: pg. 382

- Suprasternal Notch: hollow U shaped depression above sternum in between clavicle
- Sternum: 3 parts; manubrium, body, and xiphoid process
- Manubriosternal angle aka Angle of Louis: articulation of manubrium and body of
sternum

Costal Angle: angle between right and lef costal margins meeting at the level of the xiphoid process.
Normally less than 90 degrees.
- Imaginary landmarks: pg.383
- Right Midclavicular line -Midsternal line –Left midclavicular line

Landmarks Posterior Thoracic cage:

- Vertebrae prominens-7th cervical vertebra (C7): Bony process when neck is flexed
- Spinous processes
- Inferior border of scalpula (lower tip): at the 7th or 8th rib when patient’s arms are at their side.
- 12th rib “floating rib” 11th and 12th ribs are called “floating ribs”.

Imaginary Landmarks: pg.383

-Lef Scapular Line –Vertebral Line –Right Scapular Line
HEALTH ASSESSMENT EXAM 1

Discuss the risk factors for lung cancer across the cultures and ways to reduce one’s risks.
Cultural and age:
- Lung cancer = leading cause of death in U.S. & Europe
• More blacks than whites are affected, especially black males. pg. 390
• Age is a major factor; 82% of those with lung cancer were 60 years or older.

Risk factors:
- Cigarette smoking/second hand smoke
- Genetic predisposition
- Exposure to toxins
- History of previous lung cancer
- Gender
- Asbestos, radon and environmental exposure
- Workplace pollutants
- History of Hodgkin disease
- Diet (research; evidence of smokers who take beta carotene supplements at greater risk)
- Personal or family history of radiation exposure
- Personal or family history of lung cancer, genetics

Ways to reduces risk pg. 391:

• Avoid smoking cigarettes, stop smoking, or join a cessation program if you do smoke
• Avoid secondhand smoke
• Avoid exposure to asbestos or radon, check your home if its old.
• Avoid environmental substances at home or work; arsenic, diesel exhaust, silica, chromium that
irritate the lungs. Use protective gear to avoid them.
• If you do smoke, avoid taking beta-carotene supplements
• Seek medical assessment for respiratory symptoms such as prolonged cough or pain in the chest
area.

Interview a client for an accurate nursing history of the thorax and lungs.
Difficulty Breathing
HEALTH ASSESSMENT EXAM 1

-Do you ever experience difficulty breathing or a loss of breath? If the client answers yes, use
COLDSPA to explore the symptom.
-Character: Describe the difficulty breathing
-Onset: When did it begin?
-Location: Non-applicable
-Duration: How long did the dyspnea last?
-Severity: How did it affect your ability to carry on your usual activities?
-Palliative/aggravating factors:
What aggravates or relieves the dyspnea?
Do any specific activities cause the difficulty in breathing?
Do you have difficulty breathing when you are resting?
Do you have difficulty breathing when you sleep?
Do you use more than one pillow or elevate the head of the bed when you sleep?
Do you snore when you sleep? Have you been told that you stop breathing at night
when you snore?
Associated Factors:
Do you experience any other symptoms when you have difficulty breathing?
Chest Pain
-Do you have chest pain? Is the pain associated with a cold, fever, or deep breathing?
Cough
-Do you have a cough? When and how ofen does it occur?
-Do you produce any sputum when you cough? If so, what color is the sputum?
How much sputum do you cough up? Has this amount increased or decreased recently? Does
the sputum have an odor?
Gastrointestinal symptoms
-Do you have any gastrointestinal symptoms such as heartburn, frequent hiccups, or chronic
cough?
-Do you wheeze when you cough or when you are active?
Personal Health History
-Have you had prior respiratory problems?
-Have you ever had any thoracic surgery, biopsy, or trauma?
-Have you been tested for or diagnosed with allergies?
-Are you currently taking medications for breathing problems or other medications (prescription
or over the counter [OTC]) that affect your breathing? Do you use any other treatments at home
for your respiratory problems?
-Have you ever had a chest x-ray, tuberculosis (TB) skin test, or influenza immunization? -Have
you had any other pulmonary studies in the past?
-Have you recently traveled outside of the United States?
HEALTH ASSESSMENT EXAM 1

Family History
-Is there a history of lung disease in your family?
-Did any family members in your home smoke when you were growing up?
-Is there a history of other pulmonary illnesses/disorders in the family, e.g., asthma?
Lifestyle and Health Practice
-Describe your usual dietary intake.
-Have you ever smoked cigarettes or other tobacco products? Do you currently smoke? At what
age did you start? How much do you smoke and how much have you smoked in the past? What
activities do you usually associate with smoking? Have you ever tried to quit? Have you been
assessed using the 5 A’s of smoking cessation (Ask, Advise, Assess, Assist, Arrange) by a health
professional?
-Are you exposed to any environmental conditions that affect your breathing? Where do you
work? Are you around smokers?
-Do you have difficulty performing your usual daily activities? Describe any difficulties.
-What kind of stress are you experiencing at this time? How does it affect your breathing?
-Have you used any herbal medicines or alternative therapies to manage colds or other
respiratory problems?

Perform a physical assessment of the thorax and lungs using the correct techniques of inspection,
auscultation, palpation, and percussion. Pg. 393
HEALTH ASSESSMENT EXAM 1

Explain procedure to client

Have the client remove all the clothing from the waist up
Ask the client to sit in the upright position
Examination gown and drape
Gloves
Light source
Mask; skin marker and metric ruler

Inspection
Position of scapular and the shape and configuration of the chest wall:
Scoliosis
Spinal configurations- respiratory implications
Trapezius, muscles, facilitate inspiration

Palpation
Tenderness and sensation
Crepitus: crackling sensation
Surface characteristics
Palpate for fremitus: vibrations of air in the bronchial tubes transmitted to the chest wall
Assess chest expansion

Percussion
Tone-resonance
Diaphragmatic excursion

Auscultate
Auscultate for breath sounds

General Routine Screening Pg. 392 shortened version

 Observe color of face, lips, and chest.
 Inspect color and shape of nails.
 Inspect configuration of anterior and posterior thorax.
 Observe use of accessory muscles and intercostal spaces.
 Inspect the client’s positioning.
 Palpate anterior and posterior thorax for tenderness, sensation, and surface masses.
 Palpate anterior and posterior thorax for fremitus, crepitus, and surface characteristics.
 Assess anterior and posterior thorax expansion.
 Percuss for tone.
 Auscultate normal lung sounds and adventitious breath sounds.

Explain the process of inspection of the client’s chest for shape and configuration of the chest wall and
position of the scapulae
While the client sits with arms at the sides, stand behind the client and observe the position of
scapulae and the shape and configuration of the chest wall
Normal:
HEALTH ASSESSMENT EXAM 1

Scapulae are symmetric and nonprotruding. Shoulders and scapulae are at equal horizontal positions.
The ratio of anteroposterior to transverse diameter is 1:2
 Spinous processes appear straight, and thorax appears symmetric, with ribs sloping downward
at approximately a 45-degree angle in relation to the spine.

Abnormal:
Spinous processes that deviate laterally in the thoracic area may indicate scoliosis.
 Ribs appearing horizontal at an angle greater than 45 degrees with the spinal column are
frequently the result of an increased (1 to 1) ratio between the anteroposterior and transverse
diameter (barrel chest).

Explain the assessment of client’s use of accessory muscles during respiration

Tripod position in COPD - Client leans forward, uses arms to support weight, lifs chest to increase
breathing capacity
If the patient is using additional muscles to conduct inhalation and expiration, it is indication that
their breathing capacity is diminished and ofen uses other muscles to assist in breathing.
Normal:
The client does not use accessory (trapezius/shoulder) muscles to assist breathing. The diaphragm is the
major muscle at work. This is evidenced by expansion of the lower chest during inspiration.
Abnormal:
Client leans forward and uses arms to support weight and lif chest to increase breathing capacity,
referred to as the tripod position

Explain the importance of assessing the client’s position during respiration

- Note the client’s posture and ability to support weight while breathing comfortably.
 By assessing the patient’s position, you can determine if they can easily breathe in an erect
posture using abdominal muscles versus breathing in a sloped position in pain. A change in
posture may indicate the patient is in pain or discomfort.

Differentiate between breath sounds, adventitious sounds, and voice sound

Breath Sounds Pg. 397 & 402
- 3 types (Think!---> goes trachea and branches out to peripherals (vesicular). goes from bigger to
smaller descriptive characteristics. Tree to roots analogy. the breeze from tree is louder than
roots absorbing water :) )
• Bronchial: High pitch; harsh or hallow quality; loud amplitude; short duration in during
inspiration, long in inspiration. Located in the trachea and thorax
 HEALTH ASSESSMENT EXAM 1

• Bronchovesicula: Moderate pitch; mixed quality; moderate amplitude; same duration in both
inhalation and inspiration. Located over the major bronchi; posterior side, between scapulae;
anterior side, upper sternum in 1st & 2nd intercostal spaces
• Vesicular: Low pitch; breezy quality, sof amplitude, long duration in inspiration, short in
expiration. Located in peripheral lung fields

TABLE 19-1 Normal Breath Sounds

Type Pitch Qualit Amplitu Duration Location Illustrati
y de on

Bronchial High Harsh or Loud Short during Trachea and thorax

hollow inspiration,
long in
expiration

Bronchovesicu Moderat Mixed Moderate Same during Over the major bronchi—
lar e inspiration posterior: between the
and scapulae; anterior: around the
expiration upper sternum in the first and
second intercostal spaces

Vesicular Low Breezy Soft Long in Peripheral lung fields

inspiration,
short in
expiration

Adventitious Sounds pg. 398 & 402

-sounds added or superimposed over normal breath sounds and heard during auscultation.

Abnormal Characteristics Source Associated Conditions

Sound

Discontinuo High-pitched, short, popping
us Sounds sounds heard during
inspiration and not cleared
Crackles
with coughing; sounds are
(fine) discontinuous and can be
simulated by rolling a strand
of hair between your fingers
Inhaled air suddenly Crackles occurring late in inspiration are
opens the small, associated with restrictive diseases
deflated air such as pneumonia and congestive
passages that are heart failure. Crackles occurring early in
coated and sticky inspiration are associated with
with exudate. obstructive disorders such as bronchitis,
 HEALTH ASSESSMENT EXAM 1

near your ear. asthma, or emphysema.

Crackles Low-pitched, bubbling, moist
sounds that may persist from
(coarse)
early inspiration to early
expiration; also described as
softly separating Velcro.
Inhaled air comes May indicate pneumonia, pulmonary
into contact with edema, and pulmonary fibrosis. “Velcro
secretions in the rales” of pulmonary fibrosis are heard
large bronchi and louder and closer to stethoscope,
trachea. usually do not change location, and are
more common in clients with long-term
COPD.

Continuous Low-pitched, dry, grating Sound is the result of Pleuritis

Sounds sound; sound is much like rubbing of two
Pleural crackles, only more inflamed pleural
friction superficial and occurring surfaces.
rub during both inspiration and
expiration.

Wheeze High-pitched, musical sounds Air passes through Sibilant wheezes are often heard in cases
(sibilant) heard primarily during constricted of acute asthma or chronic emphysema.
expiration but may also be passages (caused
heard on inspiration. by swelling,
secretions, or
tumor).

Wheeze Low-pitched snoring or Same as sibilant Sonorous wheezes are often heard in
(sonorous) moaning sounds heard wheeze. The pitch cases of bronchitis or single
primarily during expiration of the wheeze obstructions and snoring before an
but may be heard throughout cannot be episode of sleep apnea. Stridor is a
the respiratory cycle. These correlated to the harsh, honking wheeze with severe
wheezes may clear with size of the broncholaryngospasm, such as occurs
coughing. passageway that with croup.
generates it.

Voice sounds Pg. 398

3 types
I. Bronchophony
HEALTH ASSESSMENT EXAM 1

- Patient repeating “99” while auscultating the chest wall:

Normal: soft, muffled, & indistinct. voice may be heard

but phrase cannot be distinguished (ex:talking underwater)
Abnormal: words easily understood-->pneumonia, atelectasis, or tumor.
II. Egophony
- Patient repeating letter “E” while listening to chest wall
Normal: soft, muffled, but E should be distinguishable.
Abnormal: areas of compression, sound is louder and sounds like “A”
III. Whispered Pectoriloquy
- Patient whispers “1-2-3” while listening to chest wall
Normal: sound is very faint and muffled. May be inaudible.
Abnormal: sound is transmitted clearly and distinctly.

Describe the findings frequently seen when assessing the older client’s thorax and lungs.
***Older adult considerations pop ups
- Kyphosis: increased curve of thoracic spine—common in adults pg 394
- Because of calcification of costal cartilage and loss of accessory muscles, older pt thoracic
expansion may be decreased but should still be symmetric pg 396
- Deep breathing may be difficult; may fatigue easily. offer rest when needed. pg 397
- Tenderness or pain at costochondral junction of ribs seen with fractures, especially in older
adults with osteoporosis. pg. 399
- Chest pain related to pleuritis may be absent in older adults due to their age-related alterations
of pain perception pg. 387
- Ability to cough effectively maybe be decreases in older patient because of weaker muscles &
increased rigidity of thoracic wall.
- The sternum and ribs may be more prominent in the older client because of loss of
subcutaneous fat

VITAL SIGNS (CHAPTER 8) (MELISSA)

Prepare the client for a survey of general health status and vital signs.
HEALTH ASSESSMENT EXAM 1

Hands-on physical examination begin with vital signs

Provide date that reflect

 Structure and function to observe carried over from chapter 3 objective data

 Physical development and body build

 Gender and sexual development

 Apparent age as compared to reported age

 Skin color and condition

 Dress and hygiene posture and gait

 LOC

 Behaviors and body movements and affect

 Facial expression

 Speech

 Vital signs

***From Nill’s PP:

- State that the general survey is the first step in a head-to-toe assessment of a client.
- Assess accurate vital signs.
- Provide data that reflect status of several body systems
Order of vital signs: T P R B/P SPO2 RM air O2

Temperature:

 Core body temperature 36.5C - 37.7C (96.0F-99.9F) (orally)

 Several factors will influence temperature (exercise, eating/drinking, ovulation,
stress, -raise body temperature)
 Body temp is Lowest in the morning (4-6am) Highest (8pm-midnight)
 Hypothermia <36.5C (96.0F)
 Hyperthermia >38.0C (100.0F)(infections, malignancies, trauma, and blood,
endocrine and immune disorders)
HEALTH ASSESSMENT EXAM 1

 Considerations for older adults- they run higher temps (95-97F) therefore they
may not have an obviously elevated temperature with an infection or be
considered hypothermic <96F
 Locations- Oral, temporal, tympanic, axillary, rectal
Pulse ox:

Document SPO2 on room air OR O2 and what supplemental O2 they are receiving

Pulse: (arterial or peripheral pulse)----Amplitude

(If you find abnormalities perform further assessment on apical pulse 1 min)

AMPLITUDE CAN BE QUANTIFIED AS FOLLOWS:

0: Absent
1+: Weak, diminished (easy to obliterate)
2+: Normal (obliterate with moderate pressure)
3+: Bounding (unable to obliterate or requires firm pressure)

WE HAVE ALSO SEEN IT WRITTEN AS FOLLOWS:

0 ABSENT 1+ BARELY PALPABLE

2+ EASILY PALPABLE (NORMAL PULSE)
3+ FULL OR INCREASED STRENGTH
4+ BOUNDING

 Tachycardia >100 Beats/min - Bradycardia < 60 Beats/min

 Pulse should be equal unilaterally
 Bounding and weak pulse in abnormal
 Artery should be “springy, straight, resilient” not Rigid

PULSES can be found at:

o Temporal
o Carotid
o Brachial
o Radial
o Femoral
o Popliteal
o Dorsalis Pedis
o Posterior Tibialis

Respirations:
HEALTH ASSESSMENT EXAM 1

 Observe respirations without alerting client by watching chest movement while

assessing other vitals.
 Notable characteristics of respiration are- Rate, Rhythm, Depth - 1 minute
 Respirations between 12-20 breaths/min = normal
 Bradypnea < 12 breaths/min - Tachypnea >20 breaths/min
 Rhythm should be smooth and should exhibit bilateral chest expansion

Blood pressure:

 The pressure extended on the walls of the arteries this pressure will vary due to
(Cardiac Output, Distensibility of arteries, Blood Volume, Blood Viscosity, Blood
Velocity)
 Blood pressure fluctuates throughout the day due to external influences- (time
of day, caffeine, nicotine, exercise, emotions, pain, temperature)
 The difference between systolic and diastolic is Pulse Pressure - Determine Pulse
Pressure afer measuring Blood Pressure because it reflects-Stroke Volume
(volume of blood ejected per beat)
 Blood pressure can vary due to site and position (BP standing is ofen higher to
account for gravity)(BP reclining ofen lower due to less resistance)
 < 120/80 mmHg- Normal BP
 12-139/80-89 mmHg Prehypertension
 140-159/90-99 Stage I Hypertension
 > 160/100 mmHg Stage II Hypertension
 Isolated Systolic Hypertension (systolic is elevated >140 but diastolic is <90)
 Measure dominant arm first (primary reading=both arms)
 If pt. takes antihypertensives or has a history of dizziness or fainting assess for
Orthostatic Hypotension (drop of > 20mmHg is consistent with OH)
HEALTH ASSESSMENT EXAM 1

Systolic blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles

are contracted.

Diastolic blood pressure is a measurement of the pressure of the blood in the arteries when the

ventricles are relaxed

Differentiate between normal and abnormal findings in the general survey and vital signs

Discuss the assessment of pain as a fifh vital sign.

 Observe comfort level and use COLDSPA for assessing

Assess accurate vital signs. (TEMPERATURE ORAL, RECTAL, TYMPANIC, AXILLARY-ADD 1 POINT)
HEALTH ASSESSMENT EXAM 1

CHAPTER 21 & 22 (WEEK 3) (ELIZABETH)

Describe the structure and function of the heart and neck vessels.
Heart- located in mediastinum
- Located between lef second and lef fifh intercostal, horizontally extends from
right sternum to lef midclavicular line.
- 4 chambers, right and lef atria on top, right and lef ventricle on bottom, the right and lef sides
are separated by the septum, atria receive blood, ventricles pump blood out.

Blood flow route:

Superior and inferior Vena cava--Right atria -- Right AV Valve (tricuspid)-- Right ventricle--Pulmonary
valve (semilunar)-- Pulmonary artery--lungs for gas exchange--pulmonary veins(oxygenated)--Lef atria--
Lef AV valve (mitral)--Lef ventricle-- aortic valve (semilunar)--ascending aorta
Blue= Pulmonary circulation
Red= Systemic circulation
Layers of heart wall:
1. Pericardium- sac that attaches great vessels and surrounds the heart
2. Parietal pericardium- secretes fluid to prevent friction in heart movement
3. Epicardium- serous membrane on surface of heart
4. Myocardium- cardiac muscle cells
5. Endocardium- innermost layer of heart
Great Vessels- large veins and arteries moving directly to and away from the heart
1. Superior vena cava- returns blood to the right atrium from upper torso
2. Inferior vena cava- returns blood to the right atrium from lower torso
3. Pulmonary artery- exits right ventricle, bifurcates, carries blood to lungs
4. Pulmonary veins- send oxygenated blood to lef atrium
5. Aorta- carries oxygenated blood from lef ventricle to body
List the various components of the electrical system of the heart
Cardiac cycle - spontaneous production of electrical impulse and conduction by specialized parts of
myocardium that conduct the filling and emptying of the chambers of the heart.
- SA node- generates electrical impulse that results in both lef and right atria contracting.
Impulse then travels to rest of cardiac conduction circuit.
- AV node- delays impulse from atria and sends impulse to AV bundle
- AV bundle- electrical impulse travels down right and lef branches to purkinje fibers
HEALTH ASSESSMENT EXAM 1

- Purkinje fibers- in myocardium of both ventricles, impulse in these fibers causes both ventricles
to contract simultaneously.
Describe the diastolic and systolic phases of the cardiac cycle
Systole: contraction of the ventricle
Systole- contraction of the ventricles, from isometric contraction to isometric relaxation, pressure in
ventricles cause AV valves to close (S1 which signifies beginning of systole), pressure drops afer blood
exits and Semilunar valves close (S2).
Diastole: relaxation of the ventricles
Diastole- relaxation of the ventricles, from isometric relaxation to presystole, AV valves open

Perform a physical assessment of the heart and neck vessels using the correct techniques of inspection,
auscultation, palpation, and percussion.
1. Auscultate for bruits in carotids, ensure patient is holding breathe
2. Palpate carotids
3. Inspect arms
4. Palpate arms and check temp
5. Inspect hand, check for clubbing
6. Check radial, ulnar, and brachial pulse
7. Check epitrochlear lymphs
8. Inspect chest for visible pulsations while patient looks to lef
9. Check for external jugular distention
10. Look for heaves and lifs
11. Palpate apical pulse
12. Auscultate heart sounds for rate and rhythm using diaphragm and bell
13. Inspect legs
14. Palpate skin temp, inguinal lymph nodes
15. Palpate and auscultate femoral artery
16. palpate popliteal, dorsalis pedis, and posterior tibialis.
-------------------------------------------------------------------------------------

PERIPHERAL (CHAPTER 22) JEKA

HEALTH ASSESSMENT EXAM 1

GREEN HIGHLIGHT = IMPORTANT FOR EXAM

Explain the ways to reduce the risk factors associated with peripheral vascular disease
• Quit smoking if you're a smoker.
• If you have diabetes, keep your blood sugar under control.
• Exercise regularly. Aim for 30 minutes at least three times a week afer you've gotten your
doctor's OK.
• Lower your cholesterol and blood pressure levels, if necessary.
• Eat foods that are low in saturated fat.
• Maintain a healthy weight.
• Ask your health care provider about screening with an ankle-brachial index (ABI) measurement
once you reach 50 years of age.

Interview a client for an accurate nursing history of the peripheral vascular system.

Describe the technique of inspection of the client’s legs for color, hair distribution, lesions or ulcers, and
edema
Legs: Inspection
• Skin color - Observe skin color while inspecting both legs from the toes to the groin.
NORMAL FINDINGS:
Pink color for lighter-skinned clients and pink or red tones visible under darker-pigmented skin.
There should be no changes in pigmentation.

ABNORMAL FINDINGS:
Pallor, especially when elevated, and rubor, when dependent, suggests arterial insufficiency.
Dark-colored toes and blisters are seen with arterial insufficiency and gangrene. Gangrene is
evident with ulcerations that are slow to heal, dry and shriveled skin that changes color from
blue to black and eventually sloughs off, cold and numb skin; pain may or may not be present.
Cyanosis when dependent suggests venous insufficiency. A rusty, ruddy, or brownish
pigmentation (rubor) around the ankles indicates venous insufficiency

• Distribution of hair: Inspect distribution of hair on legs.

NORMAL FINDINGS:
Hair covers the skin on the legs and appears on the dorsal surface of the toes.
ABNORMAL FINDINGS:
Loss of hair on the legs suggests arterial insufficiency. Ofen thin, shiny skin is noted as well.

*Older Adult Considerations: Hair loss on the lower extremities occurs with aging and is,
therefore, not an absolute sign of arterial insufficiency in the older client*
HEALTH ASSESSMENT EXAM 1

• Lesions or ulcers: Inspect for lesions or ulcers.

NORMAL FINDINGS:
Legs are free of lesions or ulcerations.
ABNORMAL FINDINGS:
Ulcers with smooth, even margins that occur at pressure areas, such as the toes and lateral
ankle, result from arterial insufficiency. Ulcers with irregular edges, bleeding, and possible
bacterial infection that occur on the medial ankle result from venous insufficiency

• Edema: Inspect the legs for unilateral or bilateral edema. Note veins, tendons, and bony
prominences. If the legs appear asymmetric, use a centimeter tape to measure in four different
areas: circumference at mid-thigh, largest circumference at the calf, smallest circumference
above the ankle, and across the forefoot. Compare both extremities at the same locations

NORMAL FINDINGS:
Identical size and shape bilaterally; no swelling or atrophy.
ABNORMAL FINDINGS:
Bilateral edema may be detected by the absence of visible veins, tendons, or bony prominences.
Bilateral edema usually indicates a systemic problem, such as heart failure, or a local problem,
such as lymphedema, but lymphedema is always unilateral unless elephantiasis is diagnosed
(abnormal or blocked lymph vessels) or prolonged standing or sitting (orthostatic edema).

Unilateral edema is characterized by a 1-cm difference in measurement at the ankles or a 2-cm

difference at the calf, and a swollen extremity. It is usually caused by venous stasis due to
insufficiency or an obstruction. It may also be caused by lymphedema. A difference in
measurement between legs may also be due to muscular atrophy. Muscular atrophy usually
results from disuse due to stroke or from being in a cast for a prolonged time.

• Inspect for varicosities and thrombophlebitis: Ask the client to stand because varicose veins
may not be visible when the client is supine and not as pronounced when the client is sitting. As
the client is standing, inspect for superficial vein thrombophlebitis. To fully assess for a
suspected phlebitis, lightly palpate for tenderness. If superficial vein thrombophlebitis is
present, note redness or discoloration on the skin surface over the vein.

NORMAL FINDINGS:
Veins are flat and barely seen under the surface of the skin.
ABNORMAL FINDINGS:
Varicose veins may appear as distended, nodular, bulging, and tortuous, depending on severity.
Varicosities are common in the anterior lateral thigh and lower leg, the posterior lateral calf, or
anus (known as hemorrhoids).

Legs: Palpation
HEALTH ASSESSMENT EXAM 1

• Temperature: Palpate bilaterally for temperature of the feet and legs. Use the backs of your
fingers. Compare your findings in the same areas bilaterally. Note location of any changes in
temperature.
NORMAL FINDINGS: Toes, feet, and legs are equally warm bilaterally.
• Superficial inguinal lymph nodes: First, expose the client’s inguinal area, keeping the genitals
draped. Feel over the upper medial thigh for the vertical and horizontal groups of superficial
inguinal lymph nodes. If detected, determine size, mobility, or tenderness. Repeat palpation on
the opposite thigh.
NORMAL FINDINGS: Nontender, movable lymph nodes up to 1 or even 2 cm are commonly
palpated.
• Femoral pulse, listening for bruits: Ask the client to bend the knee and move it out to the side.
Press deeply and slowly below and medial to the inguinal ligament. Use two hands if necessary.
Release pressure until you feel the pulse. Repeat palpation on the opposite leg. Compare
amplitude bilaterally
NORMAL FINDINGS: Femoral pulses strong and equal bilaterally.

• Popliteal, dorsalis pedis, posterior tibial pulses

Describe the technique of palpation of the client’s fingers, hands, and arms, and note the temperature
Arms: Inspection
• Size, presence of edema, venous patterning: Observe arm size and venous pattern; also look for
edema. If there is an observable difference, measure bilaterally the circumference of the arms at
the same locations with each remeasurement and record findings in centimeters.
NORMAL FINDINGS: Arms are bilaterally symmetric with minimal variation in size and shape. No
edema or prominent venous patterning.
ABNORMAL FINDINGS: Lymphedema results from blocked lymphatic circulation, which may be
caused by breast surgery. It usually affects one extremity, causing induration and nonpitting
edema. Prominent venous patterning with edema may indicate venous obstruction

• Skin color: Observe coloration of the hands and arms

NORMAL FINDINGS: Color varies depending on the client’s skin tone, although color should be
the same bilaterally
ABNORMAL FINDINGS: Raynaud disorder. It is a vascular disorder caused by vasoconstriction or
vasospasm of the fingers or toes, characterized by rapid changes of color (pallor, cyanosis, and
redness), swelling, pain, numbness, tingling, burning, throbbing, and coldness.
• Fingertips for clubbing

Arms: Palpation
• Palpate fingers, hands, and arms and note for temperature
HEALTH ASSESSMENT EXAM 1

NORMAL FINDINGS: Skin is warm to the touch bilaterally from fingertips to upper arms.
ABNORMAL FINDINGS: A cool extremity may be a sign of arterial insufficiency. Cold fingers and
hands, for example, are common findings with Raynaud’s.

• Capillary refill time: Compress the nailbed until it blanches. Release the pressure and calculate
the time it takes for color to return. This test indicates peripheral perfusion and reflects cardiac
output.
NORMAL FINDINGS: Capillary beds refill (and, therefore, color returns) in 2 seconds or less.
ABNORMAL FINDINGS: Capillary refill time exceeding 2 seconds may indicate vasoconstriction,
decreased cardiac output, shock, arterial occlusion, or hypothermia.

• Radial pulse: Gently press the radial artery against the radius. Note elasticity and strength.
NORMAL FINDINGS: Radial pulses are bilaterally strong (2+). Artery walls have a resilient quality
(bounce).
ABNORMAL FINDINGS: Increased radial pulse volume indicates a hyperkinetic state (3+ or
bounding pulse). Diminished (1+) or absent (0) pulse suggests partial or complete arterial
occlusion (which is more common in the legs than the arms). The pulse could also be decreased
from Buerger disease or scleroderma.

Ulnar pulse: Apply pressure with your first three fingertips to the medial aspects of the inner
wrists. The ulnar pulses are not routinely assessed because they are located deeper than the
radial pulses and are difficult to detect. Palpate the ulnar arteries if you suspect arterial
insufficiency.

NORMAL FINDINGS: The ulnar pulses may not be detectable.

ABNORMAL FINDINGS: Obliteration of the pulse may result from compression by external
sources, as in compartment syndrome. Lack of resilience or inelasticity of the artery wall may
indicate arteriosclerosis.

Brachial Pulse: You can also palpate the brachial pulses if you suspect arterial insufficiency.
Do this by placing the first three fingertips of each hand at the client’s right and lef medial
antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps
and triceps.

NORMAL FINDINGS: Brachial pulses have equal strength bilaterally.

ABNORMAL FINDINGS: Brachial pulses are increased, diminished, or absent.

• Epitrochlear lymph nodes: Take the client’s lef hand in your right hand as if you were shaking
hands. Flex the client’s elbow about 90 degrees. Use your lef hand to palpate behind the elbow
in the groove between the biceps and triceps muscles (Fig. 22-12). If nodes are detected,
evaluate for size, tenderness, and consistency. Repeat palpation on the opposite arm.
NORMAL FINDINGS: Normally, epitrochlear lymph nodes are not palpable.
HEALTH ASSESSMENT EXAM 1

ABNORMAL FINDINGS: Enlarged epitrochlear lymph nodes may indicate an infection in the hand
or forearm, or they may occur with generalized lymphadenopathy. Enlarged lymph nodes may
also occur because of a lesion in the area.

• Allen’s test: The Allen test evaluates patency of the radial or ulnar arteries. An Allen test is
essential before arterial sampling (arterial blood gas) or arterial line insertion/placement. It is
implemented when patency is questionable or before such procedures as a radial artery
puncture. The test begins by assessing ulnar patency.
1. Have the client rest the hand palm side up on the examination table and make a fist.
Then use your thumbs to occlude the radial and ulnar arteries
2. Continue pressure to keep both arteries occluded and have the client release the fist
3. Note that the palm remains pale. Release the pressure on the ulnar artery and watch for
color to return to the hand. To assess radial patency, repeat the procedure as before, but
at the last step, release pressure on the radial artery

NORMAL FINDINGS: Pink coloration returns to the palms within 3–5 seconds if the ulnar artery is
patent. Pink coloration returns within 3–5 seconds if the radial artery is patent.
ABNORMAL FINDINGS: With arterial insufficiency or occlusion of the ulnar artery, pallor persists.
With arterial insufficiency or occlusion of the radial artery, pallor persists.