Health History and Physical Assessment PDF - Nursing Notes

HEALTH HISTORY AND PHYSICAL Melissa Albright MSN, RN ASSESSMENT Created by Melissa Albright June 2022 using P&P ed. 11 chapter 30 SL# 5 content of a patients chart – white board SL# 10 show & tell bring stethoscope & pocket physical asse...

HEALTH HISTORY AND PHYSICAL Melissa Albright MSN, RN ASSESSMENT Created by Melissa Albright June 2022 using P&P ed. 11 chapter 30 SL# 5 content of a patients chart – white board SL# 10 show & tell bring stethoscope & pocket physical assessment handbook (old & new) SL# 17 PERRLA – white board SL# 20 set-up web links/lung sounds Have students get out Head-To-Toe Form to refer to during lecture Encourage ques ons Get familiar with this from Use NA if appropriate Physical assessment skills used during patient’s examination to make clinical judgments. A complete health assessment involves: a health history, as well as a behavioral and physical examination. The patient’s condition and response affect the extent of your examination. The accuracy of your assessment will: influence the choice of therapies a pa ent receives and the evaluation of response to those therapies.  Determine current health status Distinguish variations from norms Recognize improvements or deteriorations in condition Nurse needs to be aware that culture influences patient's behavior Information gained helps the nurse to: 1. Develop a nursing diagnosis and care plan 2. Manage patient problems 3. Evaluate nursing care PURPOSE OF PHYSICAL ASSESSMENT Physical examination is used to: To gather baseline data Identify nursing diagnoses, collaborative problems, and wellness diagnoses To monitor the status of a previously identified problem To screen for health problems add to what we currently know change what we thought was going on with a patient Remember our bodies are constantly changing and adapting Gathering a health history requires good communication skills; the use of therapeutic communication; ask open ended questions (get more information, not YES/NO Qs) ** refer to article posted in Canvas – The Art of Effective Communication With the information we gather we will: confirm and identify nursing diagnoses make clinical judgments and evaluate outcomes of care We manage patient problems with the information gained from assessing our patients Nurses can revise the care plan to ensure that the patient’s problems are addressed. be careful how you approach your patient Build trust: sit close/lean in slightly, be attentive, eye contact, smile, moderate rate of speech and tone, avoid  displays of impatience (tapping pen/foot, looking at watch) be aware of any special needs they may have that are culturally based Avoid stereotyping! Avoid talking down to patients Elderly Patients: makes sure to speak clearly, slowly and loud enough for the to hear, organize exam to reduce the number of times they need to change position Avoid treating them like a child…ex. “we need to this….”NOT we…..”They need to do this/that”…..  PREPARATION FOR THE EXAMINATION  Infection Control  Environment  Equipment (Box 30.1, p.551)  Preparation of the Patient Physical (Positions for Examination table 30.2 p. 519) psychological Special considerations for different age groups Getting ready for a physical exam: infection control start with good hand hygiene environment must provide privacy, good lighting, and climate control. equipment and supplies needed for physical assessment Box 30.1, p.551 Equipment should be properly cleaned or sterilized and in good working order batteries, bulbs, power cords, or calibration tools may need to get an ophthalmoscope for MD make sure it works !! Patients need to be comfortable during the examination. Let them know what you will be doing Sheet or bath blanket cover body as necessary Have patient void prior to exam full bladder can interfere with assessment of abdomen, genitalia, rectal area; AFTER health Hx & BEFORE physical exam ?? Talk to your patient as you examine them puts them more at ease Encourage the patient to ask questions great time to educate them: self breast exam, colon screening, Flu shots etc. At times, if the patient and nurse are of opposite gender a third person in the room Proper positioning; Table 30.2 p.552 lists preferred positions for examination. Standing: upright posture with both feet flat on the floor Use to examine musculoskeletal and neurological system, gait and cerebellar function If client is week or has poor balance may not be able to use this position Sitting: upright at side of bed or exam table Use to assess vital signs, head and neck, chest, cardiovascular system and breasts If client is week may need assistance to maintain this position Supine: lying flat on back with arms and legs fully extended  Including Fowler’s (head is elevated 60 ) and Semi-Fowler’s (head is elevated 30 -45 ) Used to assess the abdomen, breasts, extremities, and pulses If your client is SOB raise the head of the bead Dorsal Recumbent: Supine with knees flexed Used for abdominal assessment if the client has abdominal or pelvic pain Flexing the knees promotes relaxation of the abdominal muscles Lithotomy: Dorsal recumbent position at end of table with feet in stirrups, legs flexed, and widely open Used for female pelvic exam Older patients may need support to assume this position Use a drape to provide privacy Sims: Flexion of the hip and knees in a side-lying position Use to examine the rectal area Can be used for female pelvic exam if patient is unable to assume lithotomy position Do not use if patient has had a total hip replacement Prone: Lying on stomach Use to examine the musculoskeletal system, especially hip extension If patient is having respiratory problems may be difficult to assume Lateral Recumbent: Lying on the side in a straight line Used to evaluate heart murmur during a thorough cardiovascular assessment Knee-Chest: On hands and knees with head down and buttocks elevated This position is not used frequently but can be used to examine the rectal area. Modification for various age groups Infants Use assessment to teach parent about normal growth and development Allow parent to hold the infant during the exam If patient is on an exam table, make sure to take precautions to prevent falls Toddlers Include parents, allow child to stay close to the parent Perform invasive procedures last Give the child choices (i.e. should we listen to your chest first or look in your ears) Allow the child to show you his developmental skills. (allow child to remove clothing etc.) Use praise freely Preschoolers Combat fears by demonstrating procedures on a doll Allow child to sit in a parent’s lap if they want (by around 5 will be usually be able to lie on an exam table) Let the child help with the exam Give reassurance Always compliment the child on her cooperation School-Age Children Develop rapport Support independence Demonstrate your equipment Allow time for teaching Adolescents Provide privacy Be certain to discuss the normal physiological changes Adolescent behavior may be strongly affected by peers Emphasize lifestyle habits that promote wellness Discuss STI and cancer Prepare the adolescent if necessary for pelvic examination and breast examination Screen for depression and suicide risk.  Young/middle adults Modifications may be required I patient has acute or chronic illnesses Older adults Assess the client’s support system and ability to perform ADL’s Limit position changes May have difficulty assuming positions Adapt your techniques especially if have impaired vision or hearing SPICES (will discuss further in a later unit) S= sleep disorder P= Problems with eating or feeding I= Incontinence C= Confusion E= Evidence of falls S= Skin breakdown  Health History Assessment of each body system Follows a systematic routine. Head to toe approach Integrate examination during: This Photo by Unknown author is licensed under CC BY-NC-ND. Vital Signs Bathing Range of motion ORGANIZATION OF THE Activities of Daily living EXAMINATION Tips to help you with your examination: Be organized Compare both sides for symmetry (a degree of asymmetry is occasionally normal) If the patient is seriously ill, assess the body system most at risk first (you will need to use critical thinking skills) If the patient fatigues easily allow a rest period; especially important with elderly Perform painful procedures near the end of the exam. Physical Assessment will take longer for an older adult, more health hx. to talk about Keep patient’s comfort in mind >> organize to minimize position changes Document findings in approved documentation records *** Look at the Head-To-Toe assessment form:*** Note it is systematic (Head & Neck, skin, musculoskeletal, GU, GI, Resp., cardio., neuro, pain, ADL) Your assessment should flow from a head-to-toe approach SimChart has similar content areas General Survey Integumentary: Skin, hair, nails Head: HEENT, head, eyes, ears, nose and throat Neck: Lymph nodes, thyroid gland Breasts and Axillae (will not practice in class) Chest and lungs Cardiovascular system: Heart and blood vessels Abdomen Musculoskeletal system: bones, muscles and joints Neurological System: comprehensive exam is usually only done on patients with a neurological problem. We will fucus on LOC and GCS Genitourinary system (will not practice in class) Anus, rectum, and prostate (will not practice in class) Integration of physical assessment with your nursing care is a learned skill (Goal by practicum will be to complete a head-to-toe assessment in 30 minutes or less) As you practice and gain experience in the clinical setting you will learn how to mange your time effectively and combine care and assessment From the 1st moment you see your patient you will begin to assess them making note of overall appearance, balance, etc.  Comprehensive Focused THREE TYPES OF ASSESSMENT Shift The type of assessment done is designed for patient’s needs, Comprehensive or complete (admission) Involves obtaining health history and performing a physical examination. 1. Demographic Information a. Name, address, contact information b. Birth date, age c. Gender d. Race, ethnicity e. Relationship status f. Occupation, employment status g. Insurance h. Emergency contact information i. Family, others living at home j. Advance directives 2. Source of History a. Client, family members or close friends, other medical records, other providers b. Reliability of the historian 3. Chief Concern a. Brief statement in the client's own words of the reason for seeking care 4. History of Present Illness a. A detailed, chronological description of why the client seeks care b. Details about the manifestations, location quality quantity, setting, timing precipitating factors, alleviating or aggravating factors 5. Past health history and current health status  a. Previous hospitalizations; previous surgeries; normal diet; normal bowel pattern b. Current immunization status, dates and results of any screening tests c. Allergies to medication, environment, food d. Current medications e. Substance use f. Habits and lifestyle patterns 6. Family History a. Health information of grandparents, parents, siblings, children etc. b. Current age or age at death, any acute or chronic disorders of family members 7. Psychosocial History a. Relationships b. Family, friends, coworkers; c. current living situation d. psychological – intellect, self-concept, emotions, behavior; try to pick up on these e. spiritual – belief in higher being; religious preference f. attitudes toward moral decisions & personal conduct 8. Health promotion behaviors a. Exercise/activity b. Diet: Cultural (special foods or other considerations we need to be aware of and observe) c. Stress prevention d. Adequate sleep patterns e. Positive coping measures f. Prevention of exposure to substances, harmful environment etc. g. tobacco use; alcohol use; recreational drug use; General Survey Overall impression of the patient If you discover abnormalities in the general survey need to explore further during focused assessment of the body system Once complete general survey will move on to focused assessment of each body system Focused (or partial) With acutely ill patient focus is on symptoms & assess only the involved body systems More comprehensive assessment is delayed until patient more stable or less acute. focused on urgent need at the moment Ex = chest pain, dyspnea, irregular pulse Shift – focused general health assessment == with special attention to the patient’s acute problem(s) This course looking at normal to be able to recognize abnormal  SOURCES OF INFORMATION Subjective (not visible) Objective (visible)  Information provided by  Directly observed patient, family and Doctors  Directly measured Health History  Vital Signs  Symptoms  Physical. Exam Findings  Feelings, perceptions, and  Diagnostic and Lab Results concerns  Chief complaint (C/C)  Appearance  Nausea  Hygiene  Pain  Wounds,  Dressings  Skin discoloration Primary Source (patient) vs Secondary Source (family, MD etc) Admit Dx vs Chief Complaint (C/C) Keep in mind; are you doing a comprehensive, detailed, initial admitting assessment or are you doing a more focused shift assessment “patient's chart” is set-up Admit Sheet H&P Progress Notes Consults Nurses Notes Lab/DX Test Rehab/PT/OT Surgery Other *** paper and electronic charts will both have these areas ****  INSPECTION LOOK LISTEN SMELL During a physical exam you will use four different types of skills inspection is the first one we’ll talk about. Inspection uses vision and hearing and smell Use these principles when performing inspection (listed in your text as well) Ensure there is adequate lighting Position and expose body parts Inspect area for size, shape, color, symmetry, position, and abnormalities Compare each part to the other (we talked about this a little bit in the vital signs unit with pulses) Use additional light if needed Pay attention to detail take the time you need for this inspection is detail oriented and needs to be done thoroughly and may be time-consuming Best done with patient supine for the abd. Inspection for the contour normal? Abnormal? Odors can help you to identify potential patient problems. Table 30.4, p.555 describes how to assess characteristic odors. Not on this table is the odor of frank blood in the stool once you smell that you will never forget it  Use of touch to gather information Use different parts of hands to palpate different parts of the body (fig 30.1, p. 523 Hands should be warm; fingernails should be short. Start with light palpation, end with deep PALPATION palpation. Palpation uses touch to assess various areas of the body. Fingertips: use for fine tactile discrimination, skin texture, swelling specific locations of pulsations and masses Dorsum of hand: determination of temperature Palmar Surface of hand: locating general area of pulsations Grasping with fingers and thumb: position, shape and consistency of a mass Table 30.5, p.556 presents examples of characteristics measured by palpation for major organ boundaries You will always tell the patient what you are doing. Place the patient in a comfortable position. Encourage the patient to relax. Palpate sensitive areas last Skin Temperature Moisture Turgor and elasticity Texture/Thickness (elderly tend to have thin papery skin) Organs Size Shape Tenderness Absence of masses Glands Swelling Symmetry  PERCUSSION * Tapping the skin with fingertips to produce vibration * Sound determines locations, size and density of structures. Percussion involves tapping the body with the fingers to produce vibrations in the body tissue Similar to palpation The denser the tissue the quieter the sound Generally used when assessing abdomen and lungs You need to know the various densities of structures in order to: Abnormal size or sound suggests mass or air or fluid within an organ or cavity. Developing the skill of percussion requires practice. Usually not done at the RN level done more by advanced practice nurses and physician at a more in-depth level of assessment  AUSCULTATION  Listening to sounds the body makes  Learn normal sounds before being able to identify abnormal variations  Requires a good stethoscope  Requires concentration and practice. This Photo by Unknown author is licensed under CC BY-NC. Auscultation is listening to sounds Some sounds you can hear without assistance; other sounds will require the use of a stethoscope. Becoming proficient in auscultation: requires that you recognize the sounds produced by body parts and the best location to hear sounds. The bell of the stethoscope is used to hear low-pitched sounds The diaphragm used for high-pitched sounds You will auscultate the heart, lungs, and bowel sounds. Frequency indicate the number of sound wave cycles generated per second. The higher the frequency the higher the pitch of sound Loudness refers to the amplitude of the sound wave Quality refers to sounds of similar frequency and loudness from different sources (blowing or gurgling) Duration means the length of time that sound vibrations last (short, medium, long) Need to know what expected sounds will be heard in certain body parts. BOX 30.2 pg 557 Use and Care of the Stethoscope  GENERAL SURVEY  Assess Appearance and Behavior  Assess Vital Signs  Assesses Height and Weight (Table. 30.6, p. 561 Nursing History for Assessment of Weight)  Clinical Indicators of abuse (Box 30.3, p. 559)  Behaviors of substance abuse (Box 30.4, p. 560) General survey is like an overview or a review of your patient’s problems; why are they here? “reason” in their “own words” // ex. an Admission Assessment Gender and Race: Affects the type of exam Associated with different physical features Certain illnesses are gender and race related Age: Influences normal physical characteristics Signs of Distress: Set. Priorities and examine related physical areas first Body Type: Body type reflects the level of health, age and lifestyle Posture: Changes in older-adult physiology often result in a. stooped, forward-bent posture, with hips and knees flexed and arms ben at elbows Gait: note if movements are coordinated or uncoordinated Body: observe if movements are purposeful, are their tremors Hygiene and Grooming: observe appearance of hair, skin and fingernails Dress: Assess. Whether the clothing is appropriate for the temperature, weather conditions, or setting Body Odor: Validate any odors that might indicate a health problem Mental State, Affect and Mood: Determine if verbal expressions match nonverbal behavior and whether the mood is appropriate for the situation Speech: Does the patient speak in a normal tone with clear inflection of words Inappropriate or illogical responses Difficulty speaking or changes in voice quality Rapid speech (anxiety, hyperactivity or overuse of stimulants) Hoarseness (inflammation, infection, overuse foreign body, tumor or obstructive material)  Slow speech (depression, sedation form medications or neurological disorders) Vocabulary and sentence structure Foreign accent or sparse verbalization (may be signal for language barrier and need for an interpreter) Signs of Patient Abuse: Box 30.3 p. 559 Clinical indicators of abuse = can be picked up on during the general survey how???? Numerous cuts, bruises at various stages of healing; trouble sleeping, appears anxious Most states mandate reporting suspected abuse Florida requires it and RN renewal includes regular CEU training Substance abuse Box 30.4 p. 560 Vital signs for that base line comparison Height and weight will reflect a person’s overall level of health Some patients on Daily Weight indicator of fluid status 1 kg (2.2 lbs) wt gain/loss 1 liter fluid gain/loss Increase of weight over 24 hours period indicated potential fluid retention Important for patients with heart failure or dehydration Weight same time same scale same clothing after voiding obtain a diet history for your patient Table 30.6, p.561 presents assessing weight  Begin with health history questions (Table 30.7, p. 563) Color Texture Turgor Vascularity Edema Types of Primary Skin Lessions (Box 30.6, p. 532) SKIN Skin Malignancies (Box 30.7, p. 533) Begin with Health History (table 30.7 p. 562) Inspect all visible skin surfaces Assess less visible areas when examining other body systems Can indicate patients health status r/t oxygenation, circulation, nutrition, local tissue damage and hydration Table 30.8, p.563 presents skin color variations: Color Cyanosis blue/gray/slate/dark purple in the lips, tongue and mucous membranes nail beds, conjunctivae and palms Central Cyanosis Seen in lips, tongue, mucous membranes, facial features Associated with hypoxia Acrocyanosis Bluish discoloration of palms and soles Normal in newborns Causes are heart and lung disease , cold environment (lips may be blue but tongue is not affected, may also be seen in extremities after exposure to extreme cold) Pallor decrease in color, (loss of pink or yellow tones) Causes are anemia (low hemoglobin) and shock (poor circulation) in dark skinned patients; normal brown= is yellow-brown; normal black=ashen gray; Best sites to assess are oral mucous membranes, conjunctiva, nailbeds, palms and soles of feet. OR assess lips or buccal mucous membrane if pallor present areas will be ashen gray Erythema  Reddening Caused by dilation of blood vessels leading to increased blood flow Associated with rashes, skin infections, prolonged pressure on the skin or application of heat and cold Flushing Generalized redness of the face and body Causes: fever, excessive room temperature, sunburn, polycythemia, vigorous exercise, rosacea Petechiae Hemorrhagic spots Non-blanching, pinpoint, red or purple spots on skin Most have no known cause, but can be indicator of blood-clotting disorders, drug reactions and liver disease Ecchymosis Bruised, blue-green-yellow area Color will vary based on age of injury May indicate physical abuse, internal bleeding, side effect of medication, or bleeding disorder Jaundice Yellow-orange discoloration Increased deposits of bilirubin in tissues Causes: Liver disease and destruction of red blood cells Best place to assess is sclera (1st to show), mucous membranes, hard plate of mouth, palms, and soles of feet Texture Appearance of the surface of the skin Normal should be smooth, soft, even and flexible Usually not uniform throughout Exposure: exposed areas tend to be drier and coarser in texture, also elbows and knees Age: infants and young children tend to have very smooth skin d/t lack of exposure to environment Hyperthyroidism: skin can make skin coarse, thick and dry. Impaired Circulation: peripheral arterial insufficiency=smooth, thin , shiny skin w/little or no hair. Venous insufficiency=thick, rough skin, hyperpigmented. Temperature Depends on amount of blood circulating through the dermis Increase or decrease in temp indicates change in circulation Remember that room temp will also affect skin temp Use dorsum (back of hand) to assess Moisture Excessive moisture : hyperthermia, thyroid hyperactivity, anxiety, hyperhidrosis (excessive sweating) Dry skin: dehydration, chronic renal failure, hypothyroidism, excessive exposure, overzealous hygiene Turgor Skin elasticity Grasp fold of skin on forearm or sternum It should lift and fall immediately back in place. If turgor is poor, it will remain “tented” Poor skin turgor leads to increase in risk of skin breakdown and dehydration not the back of the hand skin is loose already Edema excessive amount of fluid in the tissue and is an abnormal finding common with CHF, Kidney disease, PVD or low albumin levels Not actually a condition of the skin, however, is often assessed when with skin Assess for skin lesions or skin cancer (use ABCD) == take the opportunity to educate the patient. A = is for asymmetry – look for uneven shape  B = is for Border – look for edges that re blurred, notched, ragged C = is for color – pigmentation is not uniform; blue, black, brown, …. D = diameter E = elevation Normal Lesions Milia: white raised areas on the nose, chin, and forehead of newborns Nevi (moles),freckles, birthmarks Skin tags: tiny tags or buds of skin, usually found in middle and older adults Striae: “stretch marks Box 30.6, p.565 Types of Primary Skin Lesions Box 30.7, p.566 Skin Malignancies  EDEMA Skin becomes swollen or edematous from buildup of fluid in tissues Note Location, color and shape Appears stretched and shiny When pressure from finger leaves indentation this is called pitting edema Grading edema. See Slide Note location on Head-To-Toe assessment form to see where this is documented Pitting edema: extra-cellular fluid Non-pitting edema: intra-cellular fluid; Ex. Balloon, returns to original shape  HAIR AND SCALP Assess for type of hair Color Distribution Quantity Thickness Texture Lubrication Nursing History for Hair and Scalp Assessment (Table 31.10, p.550) Remember differences will be gender specific and race specific and age-related Alopecia: Hair loss Diffuse alopecia can be caused by chemotherapy, nutritional deficiencies or endocrine disorders Thinning har can also occur in perimenopausal period Patchy hair loss can be caused by fungal infection Alopecia areata: benign autoimmune disorder Hirsutism Excess facial or trunk hair Causes endocrine disorders or steroid use Scalp Normally smooth, firm, symmetrical, nontender and without lesions Pediculosis Head lice Tiny, very mobile and difficult to see Table 30.10, p.566 Nursing history for hair and scalp assessment gives some questions to ask your patient and the rational to help you assess hair and scalp Hairpieces or wigs may be d/t recent chemotherapy Nutrition can influence the condition of the hair (thin and dry) if this condition is noted check thyroid level (TSH) alterations can lead to thin/brittle hair Genetic influence ex. Thinning of hair in some women & men Infection Control consideration wear gloves to exam the hair  Condition of nails reflects:  General Health State of Nutrition o Nursing History for Nail Assessment (Table 30.11, p.535) o Abnormalities of the Nail Bed NAILS (Box 30.9, p.535) Use inspection and palpation to asses nails Table 30.11, p.568 gives questions to ask your patient to help you assess their nail history Box 30.10 p.568 abnormalities of the nail bed Nail Color: Pink nails with rapid capillary refill indicate circulation to the extremities Half and Half nails: low albumin levels or renal disease Mees’ lines: transverse white lines in the nailbed, severe illnesses or nutritional deficiencies Splinter hemorrhage: small hemorrhages under the nailbed, bacterial endocarditis or trauma. Nail Shape Clubbing (angle > 180 degrees), Chronic lack of oxygen; seen with heart or pulmonary disease like COPD (chronic obstructive pulmonary disease)  Trauma, cirrhosis, diabetes, and hypertension can all affect nail shape  Assess for the presence of fungus (thick, yellow, separated from nail bed)  Aging nails become harder and thicker and growth slows  Decreased Calcium can result in brittle, dull, opaque yellow nails  EYES, EARS, NOSE AND MOUTH  Includes assessment of the head, eyes, ears, nose, mouth, pharynx, neck, lymph nodes, carotid arteries, thyroid gland, and trachea.  Use inspection, palpation, and auscultation. Assessment of the Head HEENT: Head, eyes, ears, nose and throat Will use inspection, palpation, percussion, and auscultation During the health history screen for previous or present injuries Skull and Face Acromegaly: enlarged head in adolescent or adult associated with excess growth hormone Microcephaly: abnormally small head size, can be seen in patients with certain types of mental disorders Asymmetry: May be a result of trauma, sx, neuromuscular disorder, paralysis or congenital deformity In infants may be a result of trauma during birth or placement of baby in same position for several hours a day Hydrocephalus: accumulation of excessive cerebrospinal fluid Eyes, assess size, shape, structure, visual acuity, visual fields, conjunctiva, sclera, cornea, pupil, and iris. Table 30.13 pg 570 Nursing History for Eye Assessment Box 30.12 Common eye and vision problems Visual Acuity Use Snellen chart with patient positioned 20 ft away from chart The numerator is distance form the chart (20) denominator is the distance at which the normal eye can read the chart Normal distance vision is 20/20  Myopia: diminished distance vision, 20/40 indicates the patient standing 20 ft can read the line that a person with normal vision can read at 40 ft away. Normal near vision is ability to read newsprint from 14” without hesitation with either eye and with both eyes Color vision is the ability to detect color. Ishihara cards are specialized cards that are for testing color blindness. Extraocular Movements Nurse faces the patient at 2 ft away and holds finger at a comfortable distance 6”-12” form the patient’s eyes. Peripheral vision describes the boundaries of the visual field while the eye is in a fixed position. Nurse directs the patient to follow the. movement of their finger while holding their head still. Nurse moves finger from right to left, diagonally and up and down. Nystagmus: involuntary rhythmical oscillation of the eyes d/t local injury to eye muscles/ supporting structures or damage to cranial nerves. External structures Eyelids and Lashes Ptosis: drooping of the lid, seen in stroke and Bell’s palsy Ectropion: everted eyelid seen in older adults can lead to eye dryness Entropion: inverted eyelid, can lead to corneal damage Lacrimal Apparatus Lacrimal duct is responsible for production of tears Conjunctivae and Sclerae Sclarea can become yellow or green with liver disease Redness of conjunctiva can indicate allergies or conjunctivitis (if present make sure to use clean gloves and change after inspection) Bright red Blood can indicate subconjunctival hemorrhage Lens and Cornea Should be transparent, smooth, and moist Roughness or irregularity is seen with trauma or corneal abrasion Pupils and Irises Should be uniform in color, equal in size, and round PERRLA Pupils, equal, round, reactive, to light and accommodation Using pen light shine light through the pupil and onto the retina tests the third cranial nerve causing muscles of iris to constrict. Measure the diameter of dilation in “mm” (see slide) Shine light across pupil from the side assess direct & consensual reactions Consensual when you constrict one eye does the other eye also constrict, are the two eyes consensual (together?) Accommodation: focus on distant object then close; pupils will converge and will constrict (or accommodate) **only important if defect in pupillary response to light** Sluggish accommodation may be caused by anticholinergic drugs or advanced age Failure of one or both pupils to accommodate may be d/t cranial nerve III  or exophthalmos (associated w/hyperthyroidism) Cloudy cataracts Mydriasis: dilated: glaucoma, trauma, neurological disorders Miosis: constricted pupils: inflammation of the iris or use of drugs Anisocoria: unequal pupils seen in stroke, head trauma, cranial nerve injuries, can also be normal in certain individuals Pinpoint sign of opioid intoxication Internal Structures of Eyes Advanced practice technique Ears External ear Inspect an palpate external ear structures Collects and conveys sound waves to middle ear Protects the middle ear from environmental factors Figure 30.17 anatomical structures of auricle Middle ear Contains the tympanic membrane, Eustachian tube and the ossicles Middle ear conducts sound waves to the inner ear. Inner ear Responsible for hearing and equilibrium Examination of external and middle ear Inspection: ears should be of equal size and similar appearance Palpation: smooth, nontender, pliable and without nodules Pain in outer structures may indicate otitis externa Tenderness behind the ear may indicate otitis media Table 30.14 nursing history for ear assessment When using and otoscope to assess the internal ear the auricle should be pulled up and back, insert the speculum slightly down and forward following the natural shape of the ear canal, make sure the speculum does not touch the ear canal, use the light to visualize the tympanic membrane as a cone shape, should be pearly gray, shiny and translucent Assessing Hearing Whisper test: use numbers (more clearly heard when whispered), cover mouth, do one ear at a time, have patient occlude ear not being tested Weber test: place tuning fork on the center of the client’s head, should sense the vibrations equally in both ears. Positive if vibrations are louder in one ear. If positive need to perform the Rinne test Rinne test Uses a tuning fork to compare air conduction and bone conduction Romberg test: Assesses equilibrium Also done with neuro exam Stand with feet together with arms at side if sway when eyes are closed test is positive. Indicates vestibular or cerebellar disorder Nose  Table 30.16 Nursing History for Nose and Sinus Assessment Observe for shape, size, sin color, presence of deformity or inflammation Inspect mucosa for color, lesions, discharge, swelling and evidence of bleeding. Use palpation to examine sinuses Mouth (technically part of GI tract) Includes lips, tongue, teeth, gingiva (gums), uvula, hard and soft palate, and salivary glands and ducts. Table 30.17 Nursing History for Mouth and Pharyngeal Assessment Use tongue blade and flashlight Uses to detects signs of overall health. Inspect lips for color, texture, hydration, contour and lesions (should be pink, moist, symmetrical and smooth) Inspect teeth to determine dental hygiene Inspect tongue on all side and floor of the mouth. Have patient stick tongue out halfway look for deviation, tremor or limitation of movement. Observe Palate for color, shape, texture and defects. Normal Pharyngeal tissue is pink, smooth and well hydrate, yellow or green exudate indicates infection.  NECK/LYMPH NODES Neck First inspect the area where lymph nodes are distributed and compare both sides. With the patient’s chin raised and head tilted slightly This position stretches the skin slightly over any possible enlarged nodes. Inspect visible nodes for edema, erythema, or red streaks. Nodes are not normally visible. Palpate lymph nodes (normal lymph nodes are less than 1cm, mobile, soft, nontender and are not palpable) Figure 30.28 Palpable lymph nodes in head and neck Occipital nodes: Base of skull Postauricular nodes: over the mastoid Preauricular nodes: In front of the ear Tonsillar (retropharyngeal) nodes: Angle of the mandible Submandibular nodes: along the base of the mandible Submental nodes: midline under the chin Anterior Cervical nodes: along the sternocleidomastoid muscle Posterior cervical nodes: Posterior to the sternocleidomastoid muscle Supraclavicular nodes: above the clavicle Face the patient Use a methodical approach Inspect and palpate both sides of neck for comparison Tenderness almost always indicates inflammation  Observe & palpate carotid arteries (one side at a time) Thyroid gland palpate with pads of the fingers and have patient swallow also helps you to assess the trachea; visual appearance/abnormal shape (Normal is smooth, firm, nontender and often not palpable Assess neck muscles by having pt turn head form side to side, flex neck and hyperextend neck  Assess anterior, posterior, and lateral (Figure 30.34, p.552 Systematic Pattern (for listening) Identify anatomical landmarks (Figure 30.31 & 30.32, p.550 Anatomical Landmarks) Use inspection, percussion, and THORAX AND LUNGS auscultation. Assess anterior (front) and posterior (back):  Figure 30.31 and 30.32, p.584 Anatomical Chest Wall Landmarks, Position of lung lobes in relation to anatomical landmarks Midsternal line: through the center of the sternum Midclavicular line: through the midpoint of the clavicle Anterior axillary line: through the anterior axillary folds Midaxillary line: through the apex of the axillae Posterior axillary line: through the posterior axillary fold Right and left scapular lines: Through the inferior angle of the scapula Vertebral line: along the center of the spine  Box 30.19 p.585 Nursing history for lung assessment  Figure 30.34 pg. 586 Systematic Pattern for palpation and auscultation Unclothed chest (distorts sound); listen under gown Diaphragm of stethoscope (warm) @ ICS Sitting position is best Inspection symmetry of chest wall barrel-shaped (aging or chronic lung disease) postural influences that may interfere with breathing, ex. Kyphosis, lordosis Observe the effort required to breathe, note use of accessory muscles or sternal and intercostal retractions (seen in hypoxia or respiratory distress) Palpate press thumbs toward spine, small skin fold between, have patient take a deep breath, look for symmetrical movement of thumbs Observe for tenderness, masses or crepitus (crackling skin caused by air in the subcutaneous tissue) can occur d/t wounds, central lines, chest tubes or tracheostomy. Check for fremitus: palmar part of finders/hands, begin at top & move down the back, have patient say “ninety-nine” or “one-one-one”, note vocal vibrations, will be stronger at top by trachea, only gross changes ↑ fremitus, ↓ fremitus = lung problem like pneumothorax (collapsed lung) Auscultate Breathe through mouth (1 cycle); Compare right/left sides ladder concept (10 front, 16 back know all locations for practicum will listen to 8 on front and 6 on back )  Don’t hyperventilate your pt!!! Critical thinking: position patient so lungs can equally expand; supine position, not side lying may need HOB elevated is breathing problems Listen for abnormal voice sounds if there is evidence of lung congestions Bronchophony: assess by having client say “1,2,3” as you listen over lung sounds, words are heard clearly over the lung fields Egophony: assess by having patient say “eee” as you listen over lung sounds will be herd as “ay” Whispered pectoriloquy: have patient whisper ”1,2,3” as you listen to lung fields, present if you hear words clerarly  Most common sounds heard: Normal - Vesicular, bronchovesicular, bronchial Table 30.20, p.553 https://www.youtube.com/watch?v=xnubmmeDWrw Adventitious - Crackles, rhonchi, wheezes, pleural friction rub Table 30.21, p.553 https://www.youtube.com/watch?v=dfHMbFQw-p4 Fremitus http://www.youtube.com/watch?v=dx4_M0GEZrg&NR=1 THORAX AND LUNGS You will need to learn normal sounds before you can identify the abnormal Table 30.20, p. 587 Normal Breath Sounds Vesicular: Heard over the lung periphery soft and breezy, low pitched Inspiratory is 3X longer, louder and higher pitched than expiratory Bronchovesicular Heard over the 1st and 2nd ICS anteriorly and over the scapula posteriorly Blowing sounds that are medium pitch and intensity Inspiratory = expiratory and similar in pitch Bronchial Heard over the trachea Blowing , hollow sounds Loud and high pitched Expiratory is longer than inspiratory (3:2 ratio) Table 30.21, p.587 Adventitious Breath Sounds Crackles Air bubbling through moisture in alveoli Bubbling, crackling, popping Soft, high pitched, and very brief sounds, usually heard during inspiration.  Most common in right and left ling bases Indicate pneumonia, heart failure or chronic lung disease Can be fine, medium or coarse Rhonchi Mucous secretions in the large airways Coarse, snoring, continuous low-pitched sounds heard during inspiration and expiration May clear with cough Primarily heard over trachea and bronchi Indicate muscular spasm, fluid or mucus in large areas Wheezes Heard over all lung fields Narrowing of small airways by spasm, inflammation, mucus or tumor. Common in asthma and bronchitis High-pithed, continuous musical sqeuaking sounds, continuous during inspiration or expiration, usually louder on expiration *** Go to web site for adventitious sounds ***  HEART * Compare assessment of heart functions with vascular findings. * Assess PMI. * Use inspection and auscultation. * Locate anatomical landmarks. * Identify S1 and S2. Refer to anatomy and physiology books to review cardiac structure, function, and blood flow Corresponds to vascular assessment as changes in either system can manifest as changes in the other Figure 30.39, p.589 anatomical sites for assessment of cardiac function Table 30.22 p. 588 Nursing history for heart assessment PMI/ Apical pulse = point of maximal impulse  Where the apex of the heart touches the anterior chest wall, 4th to 5th ICS at the left MCL  If you can not locate with patient in supine position have patient roll on left side  Age will affect anatomical positions  Older adults are deeper front to back  Infants heart is positioned more horizontally by age of 7 PMI is in same position as adults  Muscular body type or overweight heart lies to the left and horizontally Cardiac Cycle: Two phases Systole: Ventricles contract and eject blood from the left ventricle into the aorta and from the right ventricle into the pulmonary artery Ventricular pressure rises and closes the mitral and tricuspid valves causing 1st heart sound S1/Lub Diastole: Ventricles relax and the atria contract to move blood into the ventricles and fill the coronary arteries. Ventricular pressure falls and Mitral and pulmonic valves close causing 2nd heart sound S2/Dub Abnormal Heart sounds S3 When heart attempts to fill and already distended ventricle occurs in Heart failure Abnormal in adults over 31, can be normal in children and young adults as well as women in late stages of pregnancy S4 Occurs when atria contract to enhance ventricular filling Can be heard in healthy older adults, children and athletes Not normal in adults so need to notify provider Inspection and Palpation Begin with patient in the supine position or with body elevated at 45 degrees Look for visible pulsations and exaggerated lifts. Palpate for apical pulse Asses for thrills (vibration) Review 6 anatomical landmarks Auscultation Follow a systematic approach Listen for a complete cycle at each location (Aunt Polly Takes Meds) Aortic valve- 2nd ics right sternal border Pulmonic valve- 2nd ICS left sternal border Tricuspid valve-4th ICS left sternal border Mitral valve-5th ICS MCL ERB’s point-3rd ICS left sternal border (auscultation of heart murmurs) Auscultate for rate and rhythm Each complete cycle S1, S2 (lub, dub) = 1 heartbeat Dysrhythmia: failure of the heart to beat at regular successive intervals Ventricular Gallop: occurs after S2 cause by a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension Murmur: sustained swishing or blowing sounds, can be asymptomatic or a sign of heart disease Thrill: continuous palpable sensation sounds like purring of a cat.  VASCULAR SYSTEM  Measurement of blood pressure  Assess integrity of the peripheral vascular system Anatomical positions of pulses (Figure 30.47 and 30.48, p. 560-561) Use inspection, palpation and auscultation. Areas for Assessment:  Radial pulse: thumb side of wrist  Ulnar pulse: little finger side of wrist  Brachial pulse: inside of elbow  Femoral artery: finger tips may require deep palpation  Popliteal artery: finger tips behind knee  Posterior tibial artery: finger tips inner side of each ankle  Dorsalis pedis artery: finger tips top of foot between great toe and first toe. Table 30.23: Nursing history for vascular assessment Measure the blood pressure and assess peripheral vascular system. Perform vascular assessment during other body system assessments (i.e. carotid pulse during neck assessment) Assess skin for s/s of arterial and venous insufficiency Blood Pressure Reading in arms may vary by 10 mm Hg Tends to be higher in right arm Repeat if systolic reading differ by 15 mm Hg Carotid Arteries Have patient lie supine inspect carotid and jugular venous system for pulsations Carotid pulsation is easily visable Do not palpate or massage the carotid arteries vigorously or at the same time (can cause syncope or circulatory arrest especially in older adults) As a general rule only palpate during CPR Bruit: blowing sound d/t a narrowing in a vessel causing disturbance to blood flow (assess using the bell of the stethoscope over the carotid artery) Jugular Veins Return blood from the brain to the superior vena cava Best to examine the right internal jugular vein  Reflects pressure in right atrium Elevate head of bed to 30 45 An absent pulse wave indicates arterial occlusion or stenosis Peripheral Arteries Assess using the distal pads of second and third fingers Apply firm pressure without occluding a pulse Assessment of vital signs includes assessment of the rate, rhythm of radial pulse for 30 seconds or a full minute depending on character of pulse Always count irregular pulse for 60 seconds Carotid artery and femoral artery are used most frequently in medical emergencies Grade pulses from 0 to 4 (p.594) 0 = absent 1= diminished, barely palpable 2 = expected 3 = full, increased 4 = Bounding, aneurysmal FIG 30.49 Ultrasound (Doppler) stethoscope used to assess pulses when difficult to palpate Tissue Perfusion Assess skin, mucosa and nail beds Vascular disease leg cramps, numbness or tingling, cold hands/feet, pain in legs, swelling, cyanosis, edema Assess 5 Ps: Pain, pallor, pulselessness, paresthesia and paralysis Figure 30.48, p.595 Anatomical position of femoral, popliteal, dorsalis pedis arteries / pulses, posterior tibial pulse Table 30.25, p.595 signs of venous and arterial insufficiency Important to know this information Review nursing interventions R/T TED hose, R/T positioning Peripheral Veins Have patient assume sitting and standing positions Inspect and palpate for varicosities, peripheral edema and phlebitis Varicosities are normal for older adults Dependent edema can indicate venous insufficiency or right-side heart failure Phlebitis: assess for localized redness, tenderness and swelling Other diagnostic tests should be used to determine DVT no longer use Homans sign.  ABDOMEN Complex due to the number of organs located within or near the abdominal cavity 9 regions 4 quadrants Use inspection, auscultation, and then palpation Table 30.7 p. 601 Nursing history for abdominal assessment Assess: liver, stomach, uterus, ovaries, kidneys, and bladder. Before you assess, explain what you will be doing, properly drape the patient, place the patient in a position of comfort flat/supine control environment, and use proper lighting. Most important reinforce that the patient should be comfortable and not tense the abdomen Divide abdomen into four imaginary quadrants When examining the abdomen ==look for symmetry, masses, or pulsations 1st Inspection of abdomen: is it flat vs rounded vs concave (note any masses, bulging or distention) Inspect skin for colors, scars, venous patterns, lesions and striae (stretch marks) Scars reflect evidence of past trauma or sx Bruising: accidental injury, physical abuse or bleeding disorder Color changes can indicate jaundice (yellow) or cyanosis (blue) Shiny and taut indicates ascites 2nd Auscultation of the abdomen: Peristalsis is the movement of contents through the intestines hear air and fluid passing through the small and large intestine Hyperactive vs hypoactive, Normal = 5-35 x’s/min; Absent must listen x 5 min r/t bowel obstruction, paralytic ileus or peritonitis  Borborygmi: hyperactive loud “growling” sounds Always turn off any suction devices (from NG tubes or drains) Also listen for vascular bruits not normal report to provider 3 Palpation is performed last (with all other areas usually you will: inspect, palpate, percussion, rd then Auscultate) alter frequency and intensity of bowel sounds if done first Palpation detects tenderness, distention, or masses will use either light or deep palpation Palpate painful areas last Questions to ask: BM When was last BM? What is normal? What do they do for constipation? Urination any burning, itching, color, odor? Nausea? Vomiting?  Inspection: Assess gait, postural abnormalities  Palpation: Assess joints, bones MUSCULOSKELETAL and muscles SYSTEM  Muscle tone and strength  Range of motion (Normal ROM positions, table 30.32 p. 579) At times, you will assess the musculoskeletal system and the neurological system together. Table 30.31 Nursing History for Musculoskeletal Assessment Ask patients if they have had previous problems Falls, fractures, trauma, or neurological deficit. Inspect Gait Osteoporosis: Systemic skeletal condition includes decreased bone mass and deterioration of bone tissue Bones fragile and risk for fracture 80% are women Posture Lordosis: swayback (increased lumbar curvature Kyphosis: Hunchback (exaggeration of posterior curvature in thoracic spine) normal in older adults Scoliosis: Lateral spinal curvature Palpation: joints, bones and surrounding muscles  Note any heat, tenderness, edema or resistance to pressure Patient should not feel any discomfort Muscles should be firm Hypertonicity: increased tone, considerable resistance Hypotonicity: feels flabby, extremity will hang loosely in a position determined by gravity Atrophied: reduced in size, feels soft and boggy Assess for ROM; any limited ROM = make a note of that Table 30.32, p.613 presents terminology for normal range of motion positions  NEUROLOGICAL SYSTEM  Mental and emotional status  Alert & oriented X3 … what does this mean?  Intellectual function  Cranial nerve function  Sensory function  Motor function  Reflexes  Balance  Romberg Test  Table 30.36, p.582 Glasgow Coma Scale This Photo by Unknown Author is licensed under CC BY-NC-ND Compete neurological examination takes time and can be complicated, requires special equipment. Table 30.35 Nursing history for Neurological Assessment Mental and emotional status : Mini-Mental State Examination (MMSE) used to assess orientation and cognitive function Box 30.31 on page 615 shows the questions that can be used. You probably will not administer this test, but you do need to be aware of it Alert and oriented X3 Person, place, time: now X4 situation Standard to do this!! Look at Head-To-Toe = these are the more common areas to assess for all patients Level of Consciousness (LOC): Glasgow Coma Scale (GCS), referred to in Table 30.36, p.616: used to evaluate the patient’s neurological status scale ranges from 15 (highest function) to 3 (no function) Mostly used on neuro units, if specifically ordered by MD, ICU areas, your judgement Language: Assess the patient's voice inflection, tone and manner of speech Aphasia: omission or addition of letters, words, misuse of words or hesitation, caused by injury to the cerebral cortex. Can be sensory (receptive) or motor (Expressive) Intellectual Function Memory is assessed for both recent and past recall  Knowledge: ask about how much they know about their illness Helps determine the patients ability to learn Abstract thinking: Have patient explain common phrases such as “Don’t count your chickens before they hatch Association Finding similarities or associations between concepts Judgment Attempt to measure patients ability to make logical decisions Stereognosis Identifying a familiar object in the hand with eyes closed 12 cranial nerves requires practice and equipment. Table 30.37 p.615reviews cranial nerves, their function, and how to assess them. Used in the recovery room area for return of sensation after a spinal block Will learn in AH2 Sensory function Table. 30.38 Assessment of Sensory Nerve Function p. 619 responses to pain, temperature, light touch, vibration, position, and two-point discrimination. Motor function is examined for any dysfunction do they use a cane? Walker? Coordination: demonstrate maneuver and then have patient repeat it (finger to nose etc) Balance: Romberg Test for balance feet together, arms at side, eyes closed; expect “slight” sway; positive Romberg if client falls to side; be prepared to catch for patient safety Reflexes are graded 1+ to 4+ (text on p. 586) ***advanced practice area of assessment*** Table 30.39, p. 620 Assessment of common reflexes Again, usually not done, but you do need to know about them  FEMALE Includes assessment of internal & external organs GENITALIA AND Cultural sensitivity. Identify changes across the lifespan. REPRODUCTIVE Use inspection and palpation. TRACT This Photo by Unknown Author is licensed under CC BY-SA Assessment may be embarrassing to the patient practice cultural sensitivity Ask about: onset of menarche, history of problems with periods, LMP, if still menstruating STDs Take opportunity to discuss: PAP exams, birth control issues, protection against STDs and spread of AIDS. When examining make sure to tell the patient what you are about to do ensure proper positioning: Lithotomy environmental control, good lighting Actual exam is usually not done unless health problem calls for it Extent of exam depends on condition; Tell patient ‘I’m going to touch you now.” You may need to prep your patient for their provider to examine Breasts: Examine both females and males Use inspection & palpation  Breast size and shape will vary across the lifespan. Look for symmetry. Men who have a mother or sister with breast cancer are at risk for breast cancer Patient teach to examine their breasts.  Assess integrity of external genitalia, inguinal ring, and canal. MALE GENITALIA Use inspection and palpation. Use good communication techniques Take the opportunity to discuss: STDs, use of condoms, and sexual history and self testicular exam == men at highest risk for testicular cancer are ages 15-35 Male genitalia == will change across the lifespan When examining: use good communication, properly drape patient, properly position patient, control the environment, and use good lighting  RECTUM AND ANUS Perform after genital examination. Explain all steps to the patient. Provide privacy. Use inspection and palpation Rectum and Anus: assessment may be uncomfortable and embarrassing to the patient Inspect and palpate ………. Usually done only if health situation warrants it Take the opportunity to discuss; history of polyps, cancer, inflammatory bowel disease. Emphasize the need for self-screening habits and colonoscopy after the age of 50 or earlier if familial history exists. AFTER THE ASSESSMENT Record findings. Give the patient time to dress; assist if needed. If findings are serious, consult health care provider before informing the patient. Delegate cleaning of examination area. Record complete assessment; review for accuracy and thoroughness. Communicate significant findings. This Photo by Unknown Author is licensed under CC BY-NC-ND  Join: vevox.app ID: 113-313-108 POLL OPEN WHICH ARE PARTS OF THE ASSESSMENT OF THE HEAD? SELECT ALL THAT APPLY Vote for up to 3 choices 1. Eyes 88.24% 2. Ears 88.24% 3. Hair 70.59% 4. Mouth 35.29% 5. Throat 11.76% (% = Percentage of Voters) 30 Inspection of the head includes eyes, ears nose, and throat. Hair is part of the integumentary system Mouth is part of the gastrointestinal and mucous membrane assessment  Join: vevox.app ID: 113-313-108 POLL OPEN A CLIENT IS EXPERIENCING A SORE THROAT, FEVER, AND COUGH. WHICH FOCUSED ASSESSMENT SHOULD BE PERFORMED? 1. Ausculation of heart sounds 4.76% 2. Palpation of lymph nodes 95.24% 3. Inspection of the eye 0% 4. Perucssion of the lungs 0% 30 Lymph nodes enlarge in the presence of infection or inflammation. The lymph nodes in the neck should be palpated. Auscultation of heart sounds is part of a complete physical examination, but it is not indicated based on symptoms Eyes may water in the presence of inflammation, but this is not the most relevant assessment. Lung percussion is not the most relevant assessment. Lungs should be auscultated, and the breathing pattern assessed.  Join: vevox.app ID: 113-313-108 POLL OPEN A NURSE IS ADMITTING A CLIENT WHO HAS A 3-DAY HISTORY OF VOMITING AND DIARRHEA. ON INITIAL ASSESSMENT, THE NURSE NOTICES THAT THE CLIENT HAS DECREASED SKIN TURGOR. WHICH IS THIS A LIKELY INDICATION OF? 1. Infection 4.76% 2. Fever 0% 3. Malnutrition 0% 4. Dehydration 95.24% 30 Dehydration: A 3-day history of vomiting and diarrhea would likely result in decreased fluid volume, or poor skin turgor Poor skin turgor is not an indication of infection Fever does not affect the elasticity of skin, or skin turgor Malnutrition , over a long period of time, can affect the turgor, or elasticity of the skin. Given the client’s 3-day history of symptoms, this is not the likely cause