HEALTH-Assessment.docx

HEALTH ASSESSMENT **Thorax and Lungs** The term **THORAX** identifies the portion of the body extending from base of the neck superiorly to the level of the diaphragm inferiorly. **The LUNGS** distal portion of the trachea, and the bronchi, are located in the thorax and constitute the lower respi...

HEALTH ASSESSMENT **Thorax and Lungs** The term **THORAX** identifies the portion of the body extending from base of the neck superiorly to the level of the diaphragm inferiorly. **The LUNGS** distal portion of the trachea, and the bronchi, are located in the thorax and constitute the lower respiratory system. **The THORACIC CAGE** is constructed of the - Sternum - 12 pairs of ribs - 12 thoracic vertebrae - Muscles - Cartilage ***NOTE***: It provide support and protection for many important organs including those of the lower respiratory system. **VERTICAL REFERENCE LINES** - On the anterior chest - **Midsternal line** - **Right and left midclavicular lines** - On the posterior thorax - **Vertebral (or spinal) line** and - **Right and left scapular lines,** which extended through the inferior angle of the scapulae wen the arms are at the clients side. - **The lateral aspect** of the thorax is divided into three parallel lines. - The **midaxillary line** runs from the apex of the axillae to the level of the 12^th^ rib. - **The anterior axillary** line from the anterior axillary fold along the anterolateral aspect of the thorax. - **The posterior axillary line** runs from the posterior axillary fold down the posterolateral aspect of the chest wall. **CHEST SHAPE AND SIZE** - IN ADULTS - **THORAX IS OVAL** - Antero-posterior diameter is a half its transvere diameter is smaller at the top than at the base. **SEVERAL DEFORMITES OF THE CHEST** - ***PECTUS CARINATUM OR PIGEON CHEST*** - Can be caused by rickets and its permanent. - ***PECTUS EXCAVATUM OR FUNNEL CHEST*** - A congenital deformity and the opposite of pigeon chest **SEQUENCE OF PERCUSSION** **BREATH SOUNDS** **SPECIAL TEST** - ***Bronchophony*** 1. Ask the patient to say "ninety nine" several times in a normal voice. 2. Auscultate several symmetrical areas over each lungs. 3. The sounds you hear should be muffled and indistinct, louder, clearer sounds are called bronchophony. - ***Whisper Pectoriloquy*** 1. Ask the patient to whisper "ninety nine" several times. 2. Auscultate several symmetrical areas over lungs. 3. You should you hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as whisper pectoriloquy. - ***Egophony*** 1. Ask the patient to say "ee" continuously. 2. Auscultate several symmetrical areas over each lungs. 3. You should hear a muffled "ee" sound. If you hear an "ay" sound thisa is referred to as " E" \> "A" oe egophony. - **INSPECT FOR MUSCLE SIZE** - Compare the muscle on one side of the body to the same muscle on the other side, measure with tape measure. Note for: - ***Atrophy- decrease in size*** - ***Hyperthropy- increase in size*** **INSPECT THE MUSCLE AND TENDONS FOR CONTRACTURE** - Contracture or shortening of the muscle and tendon can cause malposition of body part like foot drop. **INSPECT THE MUSCLE FASCICULATION AND TREMORS** - Inspect any tremors of the hands and arms by having the client hold the arms out in front of the body. **PALPATE MUSCLE AT REST** - To determine tonicity (the normal condition of tension or tone of a muscle at rest. **PALPATE MUSCLES WILE THE CLIENT IS IN ACTIVE OR PASSIVE MOVEMENT** - This is to determine foe flaccidity, spasticity and smoothness of movement **BREAST ASSESSMENT** **CHARACTERISTIC OF A NORMAL BREAST** - The ***skin of the breast*** is smooth and varies in color depending on the clients skin tones. - The ***nipple***, which is located in the center of the breast, contains the tiny openings of the **lactiferous ducts** through which milk passes. - The **areola**, surronds the **nipple(generally 1 to 2 cmradius) and contains elevated sebaceous gland( Montgomery glands)** that secrete a protective lipid substance during lactation. - **The nipple and areola** typically have darker pigment than the surrondings breast. Their color ranges from dark pink to dark brown, depending on the persons skin color. The amount of pigmentation increases with pregnancy then decreases after lactation. - **Hair follicles** commonly appear around the areola. - Breasts can be a variety of sizes and are somewhat round and pendulous. One breast may normally be larger than the other. **ABNORMAL FINDINS** What are **your instruction to your client**? - To inspect the breasts accurately for retraction and dimpling, ask the client to remain seated while performing several different maneuvers. - Ask the client to: - Raise her arms overhead - Press her hands against her hips - Ask her to press her hands together   **ABDOMINAL ASSESSMENT** **Physical examination** **Keypointers:** - The sequence for assessment of the abdomen differs from the typical order of assessment. Auscultate after you inspect so as not to alter the client\'s pattern of bowel sounds. Percussion then palpation follow auscultation. - Adjust the bed level as necessary throughout the examination and approach the client from the right side. - Use tangential lighting, if available, for optimal visualization of the abdomen. **ΚΕΥΡΟΙΝΤERS** - The nurse needs to understand and anticipate various concerns of the client by listening and observing closely for verbal and nonverbal cues. - Commonly clients feel anxious and modest during the examination, possibly from anticipated discomfort or fear that the examiner will find something seriously wrong. **ΚΕΥΡΟΙΝΤERS** - As a result, the client may tense the abdominal muscles, voluntarily guarding the area. Ease anxiety by explaining each aspect of the examination, answering the client\'s questions, and draping the client\'s genital area and breasts (in women) when these are not being examined. - Another potential factor to deal with is ticklishness. A ticklish client has trouble lying still and relaxing during the hands-on parts of the examination. - Warm hands are essential for the abdominal examination. Cold hands cause the client to tense the abdominal muscles. Rubbing them together or holding them under warm water just before the hands-on examination may be helpful **PREPARE THE CLIENT** - Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination. - Instruct the client to remove clothes and to put on a gown. - Help the client to lie supine with the arms folded across the chest or resting by the sides. **PREPARE THE CLIENT** - A flat pillow may be placed under the client\'s head for comfort. Slightly flex the client\'s legs by placing a pillow or rolled blanket under the client\'s knees to help relax the abdominal muscles - Drape the client with sheets so the abdomen is visible from the lower rib cage to the pubic area **PREPARE THE CLIENT** - Instruct the client to breathe through the mouth and to take slow, deep breaths; this promotes relaxation. - Before touching the abdomen, ask the client about painful or tender areas. These areas should always be assessed at the end of the examination. - Reassure the client that you will forewarn her when you will examine these areas. Approach the client with slow, gentle, and fluid movements. **Auscultate for bowel sounds.** - Confirm bowel sounds in each quadrant. Listen for up to 5 minutes (minimum of 1 minute per quadrant) to confirm the absence of bowel sounds. - Bowel sounds normally occur every 5 to 15 seconds. An easy way to remember is to equate one bowel sound to one breath sound. Note the intensity, pitch, and frequency of the sounds. **Auscultate for bowel sounds.** - A series of intermittent, soft clicks and gurgles are heard at a rate of 5 to 30 per minute. Hyperactive bowel sounds that may be heard normally are the loud, pro- longed gurgles characteristic of stomach growling. These hyperactive bowel sounds are called \"borborygmi. **Auscultate for vascular sounds** - Use the bell of the stethoscope to listen for bruits (low-pitched, murmur-like sound) over the abdominal aorta and renal, iliac, and femoral arteries **Auscultate for a friction rub over the liver and spleen.** Listen over the right and left lower rib cage with the diaphragm of the stethoscope. - No friction rub over liver or spleen is present. - A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases. **Perform light palpation**. - Light palpation is used to identify areas of tenderness and muscular resistance. - Using the fingertips, begin palpation in a nontender quadrant, and compress to a depth of 1 cm in a dipping motion. Then gently lift the fingers and move to the next area **Deeply Palpate (all quadrants to delineate abdominal organs and detect subtle masses.)** - Using the palmar surface of the fingers, compress to a maximum depth (5 to 6 cm) - Perform bimanual palpation if you encounter resistance or to assess deeper structures **Palpate For Masses** - Note their location, size (cm), shape, consistency, demarcation, pulsatility, tenderness, and mobility. - Do not confuse a mass with a normally palpated organ or structure **Palpate the Umbilicus and surrounding area for swellings, bulges, or masses**. - Umbilicus and surrounding area are free of swellings, bulges, or masses. **Palpate the Aorta.** - Use your thumb and first finger or use two hands and palpate deeply in the epigastrium, slightly to the left of midline. - Assess the pulsation of the abdominal aorta. **Palpate the Liver.** - Note consistency and tenderness. - To palpate bimanually, stand at the client\'s right side and place your left hand under the client\'s back at the level of the eleventh to twelfth ribs. Lay your right hand parallel to the right costal margin (your fingertips should point toward the client\'s head). Ask the client to inhale then compress upward and inward with your fingers **Palpate the Spleen** - Stand at the client\'s right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. - Place your right hand below the left costal margin with the fingers pointing toward the client\'s head. - Ask the client to inhale and press inward and upward as you provide support with your other hand **Palpate the Kidneys.** - To palpate the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL. **Palpate the Urinary Bladder.** - Palpate for a distended bladder when the client\'s history or other findings warrant (e.g., dull percussion noted over the symphysis pubis). - Begin at the symphysis pubis and move upward and outward to estimate bladder borders Considerations for Palpating the Abdomen 1. Avoid touching tender or painful areas until last and reassure the client of your intentions. 2. Perform light palpation before deep palpation to detect tenderness and superficial masses. 3. Keep in mind that the normal abdomen may be tender, especially in the areas over the xiphoid process, liver, aorta, lower pole of the kidney, gas-filled cecum, sigmoid colon, and ovaries. 4. Overcome ticklishness and minimize voluntary guarding by asking the client to perform self-palpation. Place your hands over the client\'s. After a while, let your fingers glide slowly onto the abdomen while still resting mostly on the client\'s fingers. The same can be done by using a warm stethoscope as a palpating instrument, again letting your fingers drift over the edge of the diaphragm and palpate without promoting a ticklish response. 5. Work with the client to promote relaxation and minimize voluntary guarding. Use the following techniques: - Place a pillow under the client\'s knees. - Ask the client to take slow, deep breaths through the mouth - Apply light pressure over the client\'s sternum with your left hand while palpating with the right. This encourages the client to relax the abdominal muscles during breathing against sternal resistance. **CARDIO- VASCULAR SYSTEM** **Dyspnea-** Shortness of breath **Nocturia-** Urgeny of urination **Edema**- Swelling all over the body ***PHYSICAL EXAMINATION*** ***NECK VESSELS*** - ***Inspection*** - Observe the jugular venous pulse - Evaluate jugular venous pressure - ***Auscultation and palpation*** - Auscultate the carotid arteries - Palpate the carotid arteries **The Precordium** **Inspection** - Inspect pulsation - With the client in supine position with the head of the bed elevated between 30 and 45 degrees, stand on the clients right side and look for the apical impulse and any abnormal pulsation. - **Palpate the apical impulse** - Remain on the clients right side and ask the client to remain supine. - Use the palmar surfaces of your hand to palpate the apical impulse in the mitral area***(fourth(child)h and fifth(adult) intercostal space at the midclavicular line)*** - After locating the pulse, use one finger pad for more accurate palpation - **Palpate for abnormal pulsation** - Use your palmar surfaces to palpate the apex, left sternal border and base.