Nursing Health History and Physical Examination

Assessments Overview

• Nursing Health History (interview) and Physical Examination comprise assessments.
• Physical examinations include complete examination, body system examination, and body area examination (e.g., lungs with DOB).

Nursing Health History (HX)

• Involves obtaining biographic data.
• Gathering medical history.
• Collecting psychosocial history.
• Ascertaining the chief complaint.
• Taking a family history.
• Inquiring about activities of daily living.

Physical Examination

• Uses four primary techniques: inspection, palpation, percussion, and auscultation.

Inspection

• It is the visual examination, relying on sight.
• Olfactory (smell) and auditory (hearing) cues are noted.
• Can be performed with the naked eye or with lighted instruments such as an otoscope.

Percussion

• It involves striking the body surface to produce sound.
• Direct percussion: middle finger strikes rapidly, movement from the wrist.
• Indirect percussion: requires two hands, utilizing a plexor and pleximeter at a 90° angle.

Palpation

• Examination of the body using the sense of touch.
• Fingerpads are used to determine hair texture and small masses on the chest.
• Light palpation: one hand presses gently at less than 1 inch depth.
• Deep palpation: pressure extends greater than 1 inch.

Sounds

• Tympany: drum-like sound.
• Resonance: hollow sound.
• Hyperresonance: booming sound.
• Flat: extremely dull sound.
• Dull: thud-like sound.

Sound Location

• Tympany sound is typically found in the stomach when filled with air.
• Normal lungs produce resonant sounds.
• Hyperresonant sounds may indicate lungs with emphysema.
• Muscles and bones produce flat sounds.
• Organs, such as the liver, produce dull sounds.

Auscultation

• Involves listening to sounds produced by the body.
• Direct auscultation: listening with the unaided ear.
• Indirect auscultation: uses a stethoscope for bowel sounds and blood pressure monitoring.

Auscultated Sounds

• Pitch is the number of vibrations per second.
• Low-pitched sounds include heart sounds.
• High-pitched sounds include bronchial sounds.
• Duration is the length of a sound: long or short.
• Quality is a subjective description, like whistling and gurgling.
• Intensity is the loudness or softness.
• Loud sounds are bronchial sounds in the trachea.
• Soft sounds may indicate normal breath sounds.

Positions for Assessment

• Supine: assessed areas include head, axillae, breast, abdomen, extremities, and vital signs.
• Prone: assessment focuses on the posterior thorax and hip joint movement.
• Dorsal recumbent: used for examining the genitals, rectum, and female reproductive tract.
• Lithotomy: position for rectum and vagina exams.
• Sims: position used for rectum examination.
• Trendelenburg and Reverse Trendelenburg positions.
• Sitting: examines the head, anterior/posterior thorax, lungs and heart, breast and axillae, extremities, and vital signs.

Physical Assessment - Integumentary

• Pallor: reduced tissue oxygenation due to decreased circulating blood; check conjunctiva.
• Dark-skinned individuals: absence of underlying red tones; buccal mucosa is observed.
• Brown skinned: yellowish-brown tinged.
• Black skinned: ashen gray
• Cyanosis: deoxygenated hemoglobin.
• Children with Tetralogy of Fallot: exhibit bluish skin during crying or feeding episodes.
• Dark skinned persons: inspect palpebral conjunctiva (lining of eyelids) and palms.
• Jaundice: yellowish tinge; first evident in the sclera; inspect the posterior part of the hard palate.
• Erythema (redness): associated with a variety of rashes.
• Hyperpigmentation: birthmarks.
• Hypopigmentation: vitiligo.
• Edema: excess interstitial fluid; appears swollen and shiny.
• Skin lesions: if client agrees, photograph the lesion for the client record.

Primary Skin Lesions

• Macule: flat, unelevated change in color, 1 mm to 1 cm (e.g., measles, flat moles).
• Patch: larger than 1 cm (e.g., vitiligo white patches).
• Papule: palpable, solid mass, less than 1 cm (e.g., warts, pimples).
• Plaque: larger than 1 cm (e.g., psoriasis).
• Nodule: extends deeper into the dermis, 0.5 to 2 cm (e.g., squamous cell carcinoma).
• Tumor: larger than 2 cm (e.g., malignant melanoma).
• Vesicle: filled with serous fluid, less than 0.5 cm (e.g., chickenpox).
• Pustule: filled with pus (e.g., acne vulgaris).
• Bulla: less than 0.5 cm (e.g., large blisters, 2nd-degree burn).
• Cyst: encapsulated fluid-filled (subcutaneous tissues or dermis; e.g., epidermoid cyst).
• Wheal: reddened, edema fluid, irregular shape (e.g., hives, mosquito bites).

Secondary Skin Lesions

• Atrophy: dry, paper-like, wrinkled skin due to loss of collagen (e.g., striae, aged skin).
• Erosion: wearing away of the epidermis; shallow depression (e.g., stretch marks).
• Lichenification: thickened, hardened skin due to scratching/rubbing (e.g., chronic dermatitis).
• Scales: shedding flakes of greasy, keratinized tissue (e.g., dry skin, dandruff, psoriasis).
• Crust: dried blood, serum/pus when vesicles burst (e.g., eczema, scab following abrasion).
• Ulcer: skin loss, may bleed, may leave a scar (e.g., decubitus ulcers/pressure sores).
• Fissure: linear crack (e.g., cracks at the corner of the mouth, athlete's foot).
• Scar: flat, irregular tissue left after a wound (e.g., healed wound, healed acne).
• Keloid: elevated, darkened area extending beyond the site of injury (e.g., keloid from surgery).
• Excoriation: linear erosion (e.g., scratches).

Hair

• Normal: resilient, evenly distributed.
• Normal hair is thick with silky resilient texture, has no infection/infestation and variable count of hair.
• Kwashiorkor: hair color is faded, coarse, and dry due to protein deficiency.
• Marasmus: severe undernutrition with deficiency in carbohydrates, proteins, and fats.
• Abnormal Hair: patches of hair loss (alopecia), thin, brittle hair with oily or dry texture, and flaking, lice, or sores; hirsutism (abnormal hair in women).

Nails

• Colorless nails with a convex curve of 160° and smooth texture are normal.
• Conducting a blanch test of capillary refill by pressing two or more nails between thumb and index finger: normal return of pink or usual color in less than 3 seconds.
• Thin nails with grooves and furrows may indicate iron deficiency anemia.
• Clubbed finger indicates long-term lack of oxygen.
• Koilonychia has a spoon shape and may be seen in those with iron deficiency anemia.
• Beau's line is a horizontal depression due to injury or severe illness.
• Onychomycosis indicates nail fungus.
• Paronychia is inflammation of the tissue surrounding the nails (ingrown).
• Thick nails indicate fungal infection.

Head / Skull / Face

• Assess: inspect skull, palpate for nodules, inspect facial features, and inspect eyes.
• Normal Skull: normocephalic, smooth with (-) nodules.
• Abnormal skull: lock of symmetry, increased skull size, and prominent nose.
• Normal Facial Features: symmetrical with (-) edema noted in eyes.
• Abnormal: presence of masses, nodules (+), increased facial hair, exophthalmos, moon face, or periorbital edema with sunken eyes.

Eyes

• Check for PERRLA (Pupils Equal Round Reactive to Light and Accommodation)
• Cataract: cloudy pupils.
• Mydriasis: enlarged pupils.
• Miosis: constricted pupils.
• Anisocoria: unequal pupils.

Visual Acuity

• Near vision: read magazine/newspaper, which is at 14 inches.
• If a client wears contact lenses/glasses, they should be worn during the test.
• Distance vision: stand or sit at 20 feet.
• Take 3 readings: right, left, and both eyes.
• Use Snellen E chart for adults; use preschool children's chart for kids.
• Hyperopia: farsightedness.
• Myopia: nearsightedness.
• Presbyopia: loss of elasticity of the lens and ability to see close objects.
• Astigmatism: uneven curvature of the cornea.

Visual Field

• Client should sit facing the nurse two to three feet away.
• Have the client cover the right eye and look directly at the nurse's nose.
• Cover the nurse's eye opposite of the client's covered eye (left eye).
• Hold an object and extend your arms.

Ear Assessment

• Temporal field: objects can be seen at 90°.
• Downward field: 70°.
• Upward field: 50°.
• Auricles: aligned with outer canthus, eye at 10°, color the same as facial skin.
• Tympanic membrane: pearly gray color and semi-transparent.
• Watch Tick Test: occlude one ear and place a ticking watch 1 to 2 inches out of the client's sight: ask the client what they can hear; normal: hear ticking in both ears; abnormal: unable to hear in one or both ears.

Tuning Fork Test

• Weber's test: a conduction test; normal: sound heard in both ears/localized at the center of the head; abnormal: sound heard in ear.
• Rinne's test: normal: air > bone conduction; abnormal: conductive hearing loss.

Hearing Loss Tests

• Rinne's Test for Normal Hearing: AC > BC.
• Weber's Test for midline heard In Normal Hearing.
• Rinne's Test for Conductive Hearing Loss: BC > AC.
• Weber's Test heard in the bad ear with Conductive Hearing Loss.
• Rinne's Test for Sensorineural Hearing Loss: AC > BC (false positive).
• Weber's Test in good ear with Sensorineural Hearing Loss.

Nose

• Examine the nasal cavity using a flashlight or nasal speculum.
• Normal nasal septum: intact and midline pink, clear discharge, and no lesions.
• Abnormal findings: septum deviation (R/L), pus, and/or polyps.
• To use the speculum: hold the speculum with the right hand to examine the left nostril; use the left hand to examine the right nostril.

Lungs

• Broncho-vesicular: blowing sound heard between the scapula and sternum.
• Bronchial (tubular): harsh sound heard over the trachea.
• Vesicular: gentle sighing sound heard over the base of the lungs.

Adventitious Breath Sounds

• Crackles (Rales): crackling sound.
• Gurgles (Rhonchi) : gurgling, harsh sound.
• Friction rub: grating/creaking sound.
• Wheeze: high-pitched, squeaky sound.

Heart Assessment

• Assessed by inspection, palpation, and auscultation in a semi-reclined position.
• Carotid Arteries: palpate one artery at a time to avoid too much pressure, Auscultate with no sound heard normally.
• Bruits are considered abnormal, and indicate occlusive artery disease.
• Jugular Veins: check for distension, which should be at 30 to 45°.

Peripheral Vascular System

• Buerger's Test is performed on a supine patient.
• Raise one leg/spine (1 feet) ABOVE the heart.
• Move it up and DOWN for 1 minute and then sit up and DANGLE LEGS.
• Normally, color returns in 10-15 seconds; abnormal findings include delayed color return and mottled appearance.

Breast and Axillae

• Perform inspection for size and symmetry while sitting.
• Check for retractions and size, shape, and discharge from the nipples.
• Palpate the axillae & Palpate breast while Supine
• Use the hands of clock/spokes on a wheel, concentric circles, or vertical string pattern techniques during palpation.

Abdomen

• Divide into four quadrants or nine regions for assessment purposes.
• Sequence in assessment: Inspection, auscultation, percussion, and palpation.
• Normal Inspection: Flat abdomen or a silver to white striae (stretch marks).
• Abnormal: Distended abdomen and/or purple striae; indication of Enlargement of Liver.

Bowel Sounds

• During auscultation, use the flat disc diaphragm for bowel sounds and the bell for vascular sounds (aorta, renal artery).
• Auscultation should be after client mentions when they last ate, listen for active bowel sounds, which typically occur about 5-20 sec.
• Shortly after and long after eating = bowel sound will increase
• Normal Sounds: Tympany over the stomach and dullness over the liver. Full Bladder.
• Abnormal Sounds: large dullness.areas indicated fluid/tumor.
• Abdominal Palpation using light and deep palpation.
• Look for abnormalities in bowels, palpate sensitivity areas in last.
• Perform rebound test to see if bowel push back to the touch.

Cranial Nerves Overview

• I. Olfactory: identify different mild aromas (e.g., coffee, vanilla, orange).
• II. Optic: Snellen Chart, Visual Filled.
• III. Oculomotor: pupil reaction, 6 ocular movements.
• IV. Trochlear: 6 Ocular Movement.
• V. Trigeminal: blink reflex, wisp clench teeth.
• VI. Abducens: assesses directions at gaze.
• VII. Facial: smile, raise eyebrow, taste: sweet, sour.
• VIII. Vestibulocochlear: Romberg test, hear spoken word, tuning fork fest.
• IX. Glossopharyngeal: taste-posterior, move tongue.
• X. Vagus: listen to voice "AH".
• XI. Accessory: shrug shoulders.
• XII. Hypoglossal: protrude the tongue.

Nursing Considerations

• No abdominal palpation is done if there is a tumor of the liver or kidneys.
• FLEX KNEES during physical examination of the abdomen to relax abdominal muscle.
• When examining the chest, sit patient upright; or standing when assessing back problems.

Altered Urine Productions

• All about emptying of bladder (Micjutition, voiding, urination)
• Normal, Straw/Amber, transparent urine contains no Microorganisms, with a Specific Gravity of 1.010- 1.025, PH 4.5-8 and Oder, a faint Aroma
• Polyuria = voiding excess urine .
• Oliguria = less voiding urine.
• Anuria = almost on voiding urine.
• Nocturia = when waking up at night to excessively void.
• Frequency = voiding excess urine a day.
• Enuresis = involentarily have no control passing urine.
• Pollakiuria = passing some urine in small amounts.

Urinary Incontinence

• Total incontinence is where there is inconsistent volting
• If <45 m urine during the the test = STRESS
• If client reaches bladder volume and the suddenly voids with out any will = REFLEX.

Inserting a Catheter

• Sterile procedure inserting catheter in urinary bladder.
• It is the most common thing that happens to elderly that causes HAP.

Catheterisation Info

• Catheters inserted to collect urine, as well to help promote good healing to the urinary tract.
• A CBI-3 will be for a folley catheter, whereas a -2 is retention for
• Key step is to tell client to Breath deeply and not push on the catheter, as well as not inflate catheter when inside the patient.

Caths Tips

• Before inserting you must lubricated tip to help slide catheter it.
• When cath slips inside pt vagina (women) or rectum, do not remove and replace it a cath.
• To know how much to inflate you must read, the size on cath.
• As well as position pt in trendel and lift leg for easier access to insert catheter.
• As well as do frequent clamping that is 2-4 hour intervals to try to help bladder and pt acclimate and adjust urination on own.
• Make sure to be slow when preforming cath procedure and tell client it will be bit uncomfotable

Defection & Stool

• Expulsion of fees from retum
• small passage is considered constipation
• Liquid feces is considered diarrhea

Stool Info

• ACHOLIC STOOL Gray and palor clay clored
• hematochezia is Bright red stool
• Melena is black, Tarry stool
• steatorrhea is bulky, foul smelling

Enema

• This a form a solution to clean or treat and or push bowel movement through intestines.

Solutions

• Must follow all medical and or doctor orders, as nurses can not adminsters unless authorized
• Must assess clients abilities and or knowledge before having them self a adminsters enema a nurses will assist the ptc if there is needed .

• If preforming yourself, must follow a 5-10 minute intervals max.

• -> And use warm water for the area.

Nasogastrio Tube

• Measure the area from clients nose
• Ascertain placement by XRA
• Inject ML of Air
• Check Intact flash light