Physical Assessment: General Survey to Examination of the Nose - Nursing

Unit IVA PHYSICAL EXAMINATION (General Survey to Examination of the Nose) General Survey Assessment begins when the nurse first meet the client. The nurse determines the reason the client is seeking health care. The examina...

Unit IVA PHYSICAL EXAMINATION (General Survey to Examination of the Nose) General Survey Assessment begins when the nurse first meet the client. The nurse determines the reason the client is seeking health care. The examination begins with a general survey and the taking of vital signs, height and weight measurements. Components of a general survey 1. Physical appearance Sex/Gender Age Skin color  Symmetric with movement No signs of acute distress are present Facial features Level of consciousness 2. Body structure A. Stature Height appears normal for age & genetic heritage B. Nutrition Weight appears normal for height and body build; fat distribution is even. Ectomorph. A light build with small joints and Slim, obese or lean muscle. excessively...  Endomorph gains fat very Mesomorph a easily, are solid but large bone and generally soft, shorter build muscle structure with thick arms and legs C. Symmetry Body parts look equal bilaterally and are in relative proportion. C.1 Posture/Position/Contour Stands comfortably erect and appropriate for age C.2 Facial 3. Mobility A. Gait https://www.youtube.com/watch?v=nmSEtrn_T5A Abnormal Gaits Walk is smooth, even, and well-balanced. B. Range of Motion Full mobility for each joint Movement is deliberate, accurate, smooth, and coordinated No involuntary movement 4. Behavior A. Facial expressions Maintains eye contact B. Mood and Affect Person is comfortable and cooperative during nurse-patient interaction Appropriateness of response. Interacts pleasantly. C. Speech Articulation is clear & understandable Conveys ideas clearly and communicates easily D. Dress clothing is appropriate to climate culture, and age group Clothing looks clean & fits appropriately E. Personal hygiene Appears clean and well-groomed for age, occupation, and socio-economic group Sample General Survey: Received a client on her mid- forties, and appears to be in her stated chronologic age. Client is wearing a violet duster and is clean or groomed appropriately for the weather. Stains on hands and dirty nails are evident since during her attack she was rushed from work to the ER for treatment. Client is alert and oriented to what is happening at the time of the interview and physical assessment. Client responds to questions and interacts appropriately. Facial features are symmetric with movement. Client establishes good eye contact when conversing with others. Smiles and frowns appropriately.  Examination of the Skin Classification of skin lesions (CEPSBDE) Color/pigmentation Border and margin Pattern or shape Distribution Size Exudate (color/odor) Description of the Skin Macule a flat, distinct, discolored area of skin less than 1 centimeter (cm) wide. Vitiligo Freckles Papule, a circumscribed, solid elevation of skin with no visible fluid Contact dermatitis Warts Plaque, a circumscribed, elevated, palpable lesion more than 1 cm in diameter. * Psoriasis (thick, silvery-white scales) Nodules, tender, red swollen bumps. * Leprosy Tumor (neoplasm), abnormal mass of tissue that may be solid or fluid-filled. Vesicle a small fluid-filled sac within the body Bulla, large blister containing serous fluid. Pustule, papules with yellowish, liquid pus. Scale, thin piece of the outermost layer of skin resembling a fish scale. * Dermatitis Crusts, dried exudate (ie. blood, serum, pus) on the skin surface. Lichenification, an increase in skin lines & creases from frequent rubbing Scar, mark remaining (as on the skin) after injured tissue has healed. Excoriation is a loss of skin due to scratching or picking. Fissure, is a linear crack in the skin; often very painful Ulceration, deep open wound with partial or complete loss of the dermis or submucosa Erosion, superficial open wound with loss of epidermis or mucosa only Petechiae or purpura or ecchymosis are RBC that are outside the vessel walls & are nonblanchable (skin rash that does not fade when pressed with) Telangiectasis dilated superficial dermal vessels Annular “annulus lesion,” ringed, circular or ovoid macules or patches Serpiginous lesions signifies it as slowly progressive or "creeping“. Flat-Topped lesions, evenly elevated rash or lesions Domed shaped lesion-rounded Digitate lesion-horny with finger-like shape. Pedunculated lesion – connected by a stalk. “Skin tags” Cerebriform lesion - resembling the convolutions of the Causes: sun damage especially brain surface. for those with fairer skin, immunosuppressive treatments, such as those used in cancer, Proteus syndrome is an overgrowth of the bones, skin, and other tissues. Sessile lesion – attached by a broad base as opposed to pedunculated Punctate keratoderma, abnormal thickening of the palms and soles. Rolled border lesion – curled or rounded edge  Assessment Procedure Normal Findings INSPECTION. Inspect Reveals evenly colored the general skin color. skin without unusual discoloration. Normal Findings Acanthosis nigricans a brown black, hyperpigmentation of the skin, usually found in body folds in the neck, armpits, groin etc. Abnormal Findings Xerosis cutis is the medical term for abnormally dry skin. It is a common condition in elderly. Abnormal Findings Cyanosis (bluish discoloration of the nailbeds) in cardiopulmonary insufficiency Presence of jaundice or yellowish skin discoloration is indicative of liver problem. Abnormal Findings Pallor in arterial insufficiency or anemia  Assessment Procedure Normal Findings INSPECTION. Inspect for Some clients may have skin color variations. freckles or white spots. This discoloration is a normal phenomena from its genetic predisposition Abnormal Findings Rashes such as reddish or darkened rash indicative of lupus erythematosus Erythema in inflammation or allergic reactions Abnormal Findings Client with albinism have very pale to white skin, hair and eyes which is indicative of inability to produce melanin. Client with patches of white discoloration is significant in client with vitiligo.  Assessment Procedure Normal Findings INSPECTION. Check skin Skin is intact and there integrity and any skin are no reddened areas or disruptions or injury. skin irritation Abnormal Findings Avulsion of the tip of left little finger where skin droops down which is indicative of traumatic injury. Abnormal Findings A serous and painful ulcers indicative of trauma or untreated infected wound. Gaping postoperative wound indicative of infection  Assessment Procedure Normal Findings INSPECTION. Inspect for Skin is smooth and lesions. Note color, size without lesions. Striae, and shape of lesions. scars, freckles or moles are not noted. Note the location, Normal lesions include distribution / freckles, moles, configuration. Measure birthmarks. They maybe lesion in centimeters. scattered in no particular area. Abnormal Findings Lesions indicate irritation, aging, pregnancy, or presence of cancer.  Assessment Procedure Normal Findings PALPATION. Assess skin Skin is normally moist, texture. Use palmar smooth, thin but calluses surface of the three are common on areas middle fingers. If lesions exposed to constant are noted when pressure. assessing skin thickness, put on gloves. Abnormal Findings Rough, flaky, dry skin in hypothyroidism. Obese clients may reveal dry, itchy skin Abnormal Findings Peripheral vascular disease is a circulatory disorder that affects blood vessels away from the heart. If a person have a poor blood flow, he is at risk of developing ulcers and thinning of skin. Abnormal Findings Skin redness r/t steroid withdrawal Stopping suddenly the steroids can cause the adrenal gland, to stop working. This is known as adrenal insufficiency.  Assessment Procedure Normal Findings PALPATION. Assess Skin surfaces vary from moisture. Check under moist to dry depending skin folds and in on the area assessed unexposed areas Abnormal Findings Decreased moisture in dehydration or hypothyroidism,  Assessment Procedure Normal Findings PALPATION. Assess Has a good balance of moisture if it is wet, oily moisture & tone with no or dry, or has the right discoloration. skin moisture. Skin is normally warm. Any body odor and the extent of perspiration.  Abnormal Findings Oily, dry, sensitive or combination skin, moisture indicative of abnormal sweat glands unless related to environmental factors.  Abnormal Findings Cold skin in shock or hypotension, arterial disease. Very warm skin in febrile state or hyperthyroidism.  Assessment Procedure Normal Findings PALPATION. Assess Skin pinches easily mobility and turgor. Ask returns to its original the client to lie down. position. Using two fingers, gently pinch the skin on the sternum or under clavicle. Skin turgor Test: When you pinch the skin, it should spring back into place with a second or two. Mobility refers to how easily the skin can be pinched. Older client’s skin loses its turgor because of a decrease in elasticity and collagen fibers. Turgor refers to the skin elasticity and how quickly the skin returns to its shape. Abnormal Findings Decreased mobility is seen in edema. Edema results from increased movement of fluid from the intravascular to the interstitial space.  Assessment Procedure Normal Findings PALPATION. If edema is Skin pinches easily present. Perform Grade returns to its original pitting edema test: Apply position. pressure in the edematous area for 5 sec, then release the Grading pitting edema pressure. Classify if (next slide) unilateral or bilateral. Abnormal Findings Skin spots that are purple, red or brown and can A scaly, leathery patches appear flat or raised lesions called eczema is associated with AIDS Dry, scaly and rough skin of a (Kaposi's sarcoma) client with hypothyroidism Cherry-red skin of client poisoned with carbon monoxide Examination of the Nails  Assessment Procedure Normal Findings INSPECTION. Inspect Nails are clean or well nail grooming. trimmed.  Abnormal Findings Dirty, broken, or jagged fingernails in poor hygiene, maybe related to occupation or circulatory issues.  Assessment Procedure Normal Findings INSPECTION. Note nail Normal. Pink tones with color and markings. longitudinal ridging. Healthy nails should generally be a pink color - with the healthy nail plate being pink, and the nail being white in color as it grows off the nail bed. Abnormal Findings Beau’s lines are horizontal or transverse depressions in the nails. This is a sign of malnourishment and chemotherapy. Abnormal Findings Clubbing is when the nails thicken and curve around the fingertips. This can be the result of low oxygen in the blood and is associated with CVD. Abnormal Findings Koilonychia (spooning), due to heart disease, iron deficiency anemia, hemochromatosis, a liver disorder that causes too much iron to be absorbed from food. Abnormal Findings Leukonychia (white spots), due to a minor trauma, nutritional deficit, infectious, metabolic, or systemic diseases as well as certain drugs. Abnormal Findings Onycholysis. Separation of the nail plate from the nail bed, causing white discoloration. This can be due to infection, trauma, or products used on the nails. Abnormal Findings Nail pitting, small depressions or little nail pits. Common in people who have psoriasis. Yellow nail syndrome due to fungal infections. Abnormal Findings Nails grow very thick and turn white or yellow is indicative of tinea. Nails of older persons with ridges Abnormal Findings Terry's nails, white with a "ground glass" appearance without any lunula. Common in liver failure, DM, CHF, hyperthyroidism, or malnutrition.  Assessment Procedure Normal and Abnormal Findings Test capillary refill in Brisk capillary refill is nailbeds. when blood returns to an area quickly after pressure has been applied. It is used to monitor dehydration and the amount of blood flow to tissue. If the return of color takes longer than 2-3 sec that that means that the person’s capillary refill and circulation is impaired.  Sample Skin and Nail Assessment Upon inspection and palpation, client’s skin is warm, smooth and moist. Lesions and rashes are not noted. Facial as well as body deviation are not observed. Gait is properly executed without discomfort. Nails are well-trimmed, unpolished, with normal pinkish in color which is an indication that client is well – hydrated. Capillary refill reveal a “well hydrated client” since after pressing the index finger the color is pinkish after a second. Examination of the Head Assessment Procedure Normal Findings INSPECTION AND Head is symmetric, round PALPATION. Inspect for and erect size, shape or (normocephalic). It configuration. supports the face and is maintained by the skull, which itself encloses the brain. Assessment Procedure Normal Findings External Occipital Protuberance (EOP) is a normal anatomical structure located on the posterior surface of the occipital bone, at the level of the superior nuchal line. Abnormal Findings Acromegaly, growth of the hands, feet, and face, caused by overproduction of growth hormone by the pituitary gland.  Abnormal Findings Paget’s Disease is a condition involving cellular remodeling and deformity of one or more bones. Acorn-shaped, enlarged skull Abnormal Findings Hydrocephalus accumulation of CSF occurs within the brain. Premature babies may have bleeding in the brain, which can block the flow of CSF.  Abnormal Findings Microcephaly is a condition where the head (circumference) is smaller than normal. Microcephaly may be due to genetic alterations, drugs, alcohol, viruses, toxins that the fetus are being exposed during pregnancy.  Abnormal Findings Basilar skull fracture, Cephalohematoma is collection of blood in break of a bone in the the periosteum but does not cross suture base of the skull. lines. Caput succedaneum swelling of the scalp, with subcutaneous fluid collection.  Abnormal Findings Meningitis Glass Test in Meningitis  Assessment Procedure Normal Findings INSPECTION AND Head should be held still PALPATION. Inspect for and upright. involuntary movements.  Abnormal Findings Dystonia is an involuntarily repetitive / twisting movement disorder caused by damage or degeneration of the brain (e.g. brain injury or stroke). Nodding is caused by the systolic pulse is being felt by the client due to increased pulse pressure resulting from the aortic insufficiency. Abnormal Findings Head tilted to one side in shortening of sternomastoid muscle. A condition of the nervous system causing “tics” (sudden twitches, movements, or sounds that people do repeatedly). Abnormal Findings Head movement evident in Huntington’s disease or PD or Alzheimer's disease.. A condition of the nervous system causing “tics” (sudden twitches, movements, or sounds that people do repeatedly).  Assessment Procedure Normal Findings INSPECTION AND The head is normally hard PALPATION. Palpate for and smooth without consistency. Do not lesions. forget to wear gloves.  Abnormal Findings Head trauma and lesions Examination of the Scalp and Hairs Assessment Procedure Normal/Abnormal Findings INSPECTION AND Natural hair color varies PALPATION. Ask client among clients. Scalp is to remove clips, pins or clean and dry. Sparse wigs. With gloved dandruff may be visible. hands, inspect hairs Hair is smooth and firm. from the scalp for dryness, parasites and lesions. Abnormal Findings Seborrheic dermatitis or Vitamin D deficiency Scaliness in dermatitis Abnormal Findings Folliculitis Abnormal Findings Scalp lesions & deviations Abnormal Findings Alopecia areata Abnormal Findings Tinea capitis (ringworm) Abnormal Findings Head Lice  Assessment Procedure Normal Findings INSPECTION AND Varying amounts of PALPATION. terminal hair cover the Note hair amount and scalp, axilla, body and distribution of scalp, pubic areas. Fine vellus body, axillae and pubic hair covers the entire hairs. Look for unusual body except for soles, growth elsewhere on the palms, lips and nipples. body. Normal male baldness is symmetrical. Assessment Procedure Normal Findings Older clients have thinner hair due to decrease in hair follicles. Pubic, axilla, and body hair decrease in aging.  Abnormal Findings Excessive hair loss in infection, nutritional deficiency, hormonal disorders, liver disease, Hyperthyroidism Liver Problems Chemotherapy  Abnormal Findings Hairs in Cushing Syndrome Androgenic Alopecia Abnormal Findings Herpes zoster Abnormal Findings Abnormal Findings  Sample Head Assessment Head is normocephalic and is structurally symmetrical. Lesions are not noted upon inspection of the scalp. Hair is black, coarse and thick at shoulder length. Upon palpation, few parasites are present which is indicative that client needs health teachings on proper personal hygiene. Examination of the Face Assessment Procedure Normal Findings INSPECTION AND Face is symmetrical that PALPATION. Inspect the is, round, oval, elongated face for symmetry, or square in appearance. features, movements, expressions and skin conditions. The nasolabial folds and palpebral fissures are the ideal places to check facial features for symmetry.  Abnormal Findings Asymmetry can be noted in facial paralysis, mumps or presence of tumor. Facial paralysis (Bell’s palsy)  Abnormal Findings Asymmetry can be noted in facial paralysis, mumps or presence of tumor.  Abnormal Findings Tumors that deviates the face  Abnormal Findings “Masklike” face in Parkinson’s A “sunken” face with depressed Disease” eyes and hollow cheeks in cachexia.  Abnormal Findings Basal cell carcinoma a skin cancer that A “sunken” face with depressed most often develops on areas of skin eyes and hollow cheeks in cachexia. exposed to the sun, such as the face  Assessment Procedure Normal Findings INSPECTION AND The temporal artery is PALPATION. Palpate the pulsating though its temporal arteries strength. This is to note immediately in front of the presence of giant cell the tragus of the ear and arteritis. up along the temple.  Abnormal Findings TA is hard, thick and tender with inflammation seen in temporal arteritis leading to blindness.  Assessment Procedure Normal Findings INSPECTION AND No swelling or crepitation PALPATION. Palpate the with movement. temporomandibular joint.  Abnormal Findings Limitation of movement in TMJ syndrome  Abnormal Findings Hirsutism or facial Hypertrichosis hair in women (Werewolf Syndrome)  Sample Face Assessment Nasolabial folds and palpebral fissures are symmetrical. Facial hairs are present, a normal findings since this is an inherited characteristics. Upon palpation, mastication and sensory function test is negative. No indication of abnormal sound heard when client was asked to open mouth to test its mobility. On palpating the TMJ there are no swelling or crepitation with moving. Examination of the Neck Assessment Procedure Normal Findings INSPECTION. Observe Neck is symmetric with the client’s slightly head centered and extended neck for without bulging mass. symmetry, and presence The thyroid cartilage, of lumps/mass. cricoid cartilage and thyroid gland move upward symmetrically.  Assessment Procedure Normal Findings Inspect movement of the neck structures. Ask client to swallow a sip of water. Observe the movement of the thyroid gland. Abnormal Findings Asymmetric movement or generalized enlargement of the thyroid gland is considered abnormal. Swelling, enlarged mass or nodules may indicate thyroid gland enlargement. Hyperthyroidism happens when the thyroid gland makes too much thyroid hormone (overactive thyroid). That can cause many symptoms, such as weight loss, rapid or irregular heartbeat and hand tremors.  Graves' disease is an Hashimoto's immune system thyroiditis is an disorder characterized immune disorder by the presence of where lymphocytic circulating infiltration and autoantibodies that thyrocyte damage stimulate the TSH which can progress to receptor inducing hypothyroidism. hyperthyroidism and goiter.  Goiter, enlargement or uneven growth of the thyroid gland irrespective of its Thyroiditis is a type of pathology. hyperthyroidism triggered by a viral This is more common in infection which females than males, causes inflammation especially after the age of the thyroid gland. of 40 years, i.e., after menopause.  Assessment Procedure Normal Findings INSPECTION. Inspect the C7 is usually palpable. cervical vertebrae. Ask client to flex the neck(chin-chest, ear- shoulder, twist left to right and right to left, backward and forward.  Abnormal Findings Prominence or swelling of the C7 vertebrae and other vertebrae may be abnormal.  Assessment Procedure Normal Findings TEST OF ROM: Ask client Normal client will able to to turn the head to the comply without right and to the left, discomfort touch ear to shoulder, touch chin to chest, and lift chin towards the ceiling. https://www.youtube.com/watch?v=FG-kfybQBWI Chin Tuck Maneuver  Abnormal Findings Muscle spasms, inflammation, or cervical arthritis may cause stiffness and limited movement. Abnormal Findings  Assessment Procedure Normal Findings PALPATION. Palpate Landmarks are thyroid gland and locate positioned midline. key landmarks. Assessment Procedure Normal Findings  Abnormal Findings Trachea may be pulled or pushed to one side in cases of tumors and thyroid gland enlargement. and aortic aneurysm.  Assessment Procedure Normal Findings PALPATION. Palpate the No swelling, enlargement lymph nodes on the head and no tenderness and neck area. present.  Abnormal Findings Enlarged nodes are abnormal. Swollen superficial Swollen supraclavicular cervical lymph nodes lymph nodes Assessment Procedure Normal Findings AUSCULTATION. No bruits (soft, blowing, swishing sound) heard upon auscultation. Assessment Procedure Normal/Abnormal Findings AUSCULTATION. NORMAL: No bruits (soft, blowing, swishing sound) heard upon auscultation.  Abnormal Findings Bruits over the thyroid lobes can be heard in hyperthyroidism due to increase blood flow through the arteries. https://www.youtube.com/watch?v=Ed2WE7heOdU Examination of the Thyroid Gland (Anterior Neck)  Sample Neck Assessment Upon inspection, neck is symmetrical. A deviation was observed to his left lateral area. This is an indication that a growing mass is present on her right pushing the thyroid to his left. The thyroid cartilage, cricoid cartilage and thyroid gland move upward symmetrically especially during interaction. Client can move his head as directed with slight discomfort maybe related to the growing mass. Upon auscultation a soft, blowing, swishing sound is heard which is indicative of the growing mass on his neck. Examination of the Nose Assessment Procedure Normal Findings INSPECTION AND Color is the same as the PALPATION. Inspect the rest of the face; the nasal nose for color and shape. structure is smooth and Palpate for consistency symmetrical; the client and tenderness. reports no tenderness and discomfort.  Abnormal Findings Red, swollen and tender nose is indicative of infection from the internal nasal structures.  Assessment Procedure Normal Findings INSPECTION AND Client is able to sniff PALPATION. Check through each nostril patency of airflow while other is occluded through the nostrils.  Abnormal Findings Dyspnea is significant of a client with rhinitis or presence of foreign object.  Assessment Procedure Normal Findings INSPECTION AND The nasal mucosa is PALPATION. Check the dark, moist and free of internal nose, use exudate. Septum is intact otoscope or lift the tip of and free of lesions. the nose to expose the Turbinates’ are pink. internal nose.  Abnormal Findings Infections/abnormalities of the septum Perforation is a hole that develops through the wall of a body organ  Abnormal Findings Infections/abnormalities of the septum Perforation is a hole that develops through the wall of a body organ  Abnormal Findings Infections of the turbinates’ Abnormal Findings Inborn Abnormality https://www.youtube.com/watch?v=ByBDECwFA6E Examination of the Nose  Assessment Procedure Normal Findings INSPECTION AND Sinuses are not tender PALPATION. Palpate the and no crepitus heard. sinuses. Crepitus is a crackling or popping sound that occurs as a result of tissues rubbing together abnormally. Assessment Procedure Normal Findings No tenderness upon palpation  Abnormal Findings Frontal or maxillary sinuses are tender is significant with allergies / bacterial rhinosinusitis. If the client has a large amount of exudate, the nurse may feel crepitus over maxillary sinuses.  Assessment Procedure Normal Findings PERCUSSION. Percuss The sinuses are not the frontal sinuses and tender on percussion over the maxillary sinuses for tenderness.  Abnormal Findings The frontal and maxillary sinuses are tender upon percussion in clients with allergies or sinus infection. Abnormal Findings  Assessment Procedure Normal Findings TEST FOR CLIENT’S If the client can smell SENSE OF SMELL. Test and identify the odor 8-12 the client’s sense of inches away around the smell. Allow client to chest level, then client smell “coffee, alcohol or has normal smell. or liniment” and client to should identify the odor. Abnormal Findings Anosmia, a condition that causes a person to partially or completely lose his or her sense of smell.  Assessment Procedure Normal Findings TRANSILLUMINATION TEST. Absence of red glow is significant with fluid or pus-filled.  Sample Nose and Sinuses Assessment Upon inspection, external nose is symmetrical with no discoloration, swelling or malformations. Nasal mucosa is pinkish red with no discharge/bleeding, swelling, malformations or foreign bodies. Bright red nasal mucosa with purulent discharge. Palpation and percussion revealed no tenderness along with the four sinuses. Client can move his head as directed, with no tenderness and discomfort. Able to identify the vinegar, when sense of smell was tested. Transillumination test presented a red glow meaning there’s no abnormal pus or discharge in the supraorbital rim.