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Process of Systematic Assessment Health Assessment 1. Collect data 2. Verify data Chapter 01: Nursing Process 3....

Process of Systematic Assessment Health Assessment 1. Collect data 2. Verify data Chapter 01: Nursing Process 3. Organize data 4. Identify Patterns Definition of Nursing Process: 5. Report & Record data Specific to the nursing profession A framework for critical thinking Comprehensive data collection: It’s purpose is to:“Diagnose and treat human ✓ Begins before you actually see the patient (Nurse responses to actual or potential health problems” report from ER, Chart reviews) Organized framework to guide practice ✓ Continues with admission interview and physical Problem solving method - client focused assessment once you meet patient. Systematic- sequential steps ✓ Other information resources include: family, Goal oriented- outcome criteria significant others, nursing records, old medical records, Dynamic-always changing, flexible diagnostic studies, relevant nursing literature. Involves looking at the whole patient at all ✓ Consider age, growth & development times Types of Data: It provides a "road map" that ensures a) Objective Data – signs; those that can be observed and good nursing care & improves patient measured outcomes. Ex. “I have a headache b) Subjective Data – symptoms; those that described only Critical Thinking- nurses need to use the by the person experiencing it. Nursing process Ex. Vital signs: BP: 130/80, PR: 68, - Always thinking about your thinking, your RR: 19 Temp: 37.0 C actions, and your decisions Sources of Data: Basis in using Critical Thinking: a) Primary – patient/client Deal w/ complex problems on a daily b) Secondary – family members, patient’s record, health basis team members, related literature Work w/ patient that are unique Provide holistic care Interview Technique Advantages of Nursing Process: The interview is a purposeful conversation, generally 1. Provides individualized care in a face-toface meeting. It involves at least two persons; -Client is an active participant the interviewer, the one who seeks information, and the 2. Promotes continuity of care interviewee, the person from whom the information is 3. Provides more effective communication among nurses sought. and healthcare professionals The interviewer is a verbal and nonverbal exchange 4. Develops a clear and efficient plan of care that provides for the beginning and development of a 5. Provides personal satisfaction as you see relationship. It is the second most common method of client achieve goals gathering information next to questionnaire. 6. Professional growth as you evaluate effectiveness of your interventions Categories of Interview: ❖ PHASES OF NURSING PROCESS 1. Standardized/ Structured - The interviewer is not permitted to change the specific A. ASSESSMENT wording of the interview question schedule. He must endeavor to conduct each interview in precisely the same First step of the Nursing Process manner and he cannot adapt questions for a specific systematic, deliberate process by which the nurse situation. collects and analyzes data about the patient 2. Non-Standardized Gather Information/Collect Data through Nursing - The interviewer has complete freedom to develop each Interview (history), Health Assessment -Review of interview in the most appropriate manner for Systems, Physical Exam each situation. He is not held to any specific questions. Entire plan is based on the data you collect, data 3. Semi-Standardized needs to be complete and accurate - The interviewer maybe required asking a number of Make sure information is complete & specific questions, but beyond these, he is free to probe Accurate as he chooses. 4. Focused - The interviewer approaches the respondent with a series 4. Focusing of questions based on previous a. Elicit information relevant to the purpose of the understanding and knowledge of the problem or interview phenomenon being studied. The interviewer is thus b. Have an organized sequence of questions able to direct his questioning so as to discover the kinds c. Follow the respondent’s verbal cues of backgrounds and experiences that have influenced the d. Ask for clarification appropriately subject. e. Make appropriate transitional statements 5. Non-Directive 5. Terminating The Interview - The subject is given the opportunity to express his a. Ask the interviewee if he has any questions feelings without fear of disapproval. There is freedom to b. Summarize what has been said discuss a topic without pressure from the interviewer. c. Thank the respondent and say goodbye appropriately ❖ Interview Instruments Health History 1. Interview Schedule Taking a Patient’s history is arguably the most - A questionnaire is read to the respondent. important aspect of patient assessment, and is 2. Interview Guide increasingly being undertaken by HCPs including - One that provides ideas but allowsthe interviewer midwives. The procedure allows patients to present their freedom to pursue relevant topics in depth. account of the problem and provides essential information for the practitioner. ❖ Types Of Questions 1. Open-Ended Questions Preparing the environment - One aimed at eliciting response that is more than one or The first part of any history-taking process and, two words in length. This type is effective in stimulating indeed, most interactions with patients is preparation of descriptive or comparative responses. the environment 2. Close-Ended Questions HCPs can encounter patients in a variety of - A type of inquiry that requires no more than one or two environments: accident and emergency; general wards; worded answer. This might be an agreement or department areas; primary care centres; health centre disagreement. The responses maybe yes or no and maybe clinics and the patient’s home. answered nonverbally by a nod of the head. Respect for the patient as an individual is an important 3. Biased Or Leading Questions feature of assessment, and this includes - Those that carry a suggestion of the kind of information consideration of beliefs and values and the ability to that should be included in the response. remain non-judgemental and professional 4. Neutral Questions Respect also involves maintenance of privacy and - These are questions wherein a person can answer dignity; the environment should be private, quiet and without direction or pressure. It is often used in non- ideally, there should be no interruptions. directive interviews. Communication Guidelines When Conducting An Interview The HCP should be able to gather information in a 1. Initiation systematic, sensitive and professional manner a. Greet the respondent by name Good communication skills are essential. b. Introduce self Introducing yourself to the patient is the first part of c. Explain the purpose of theinterview this process d. Put the respondent at ease (physical comfort) It is important to let patients tell their story in their 2. Appropriate Use Of Non-Verbal Communication own words while using active listening skills. It is also a. Maintain good eye contact important not to appear rushed, as this may interfere with b. Observe proper body posture the patient’s desire to disclose information c. Use silence appropriately Practitioners should avoid the use of technical terms d. Avoid distractions (chewing lips, gums, playing with or jargon and, whenever possible, use the patient’s own pen) words. 3. Questioning Examples of non-verbal and verbal a. Speak clearly communication skills b. Use simple language Non-Verbal Verbal c. Ask open-ended questions d. Ask one question at a time Eye contact Interested Appropriate language e. Wait for the respondent to answer posture Nodding of Avoid jargon and f. Ask appropriate probing questions head Hand gestures technical terms Pitch g. Control pace of interview Clothing Rate and intonation h. Control direction of the interview Facial gestures Volume i. Do not be judgmental Consent 2. Past Medical History Before any healthcare intervention, Listing of illness unrelated to the present illness, including history taking, informed experienced in the past consent should be gained from the Including childhood diseases patient Serious injuries and surgery not requiring hospitalization State that patients can only provide Mention of each disease with an approximate date, consent if they are able to act under severity, duration, complications and sequel their own free will, have an (consequences) is essential understanding of what they have agreed to and have enough 3. Medication History information on which to base a This is crucially important and should consider not decision only what medication the patient is currently taking but also what he or she might have been taking until recently. ❖ The History Taking Process Because of the availability of so many 1. The Presenting Complaint: medications without prescription, known as over-the- To elicit information about the presenting counter drugs, remember to ask complaint start by using an open question, for example: specifically about any medications that have been bought ‘What is the problem?’ or ‘Tell me about the problem?’ at the pharmacy or supermarket, including homeopathic This should provide a breadth of valuable information and herbal remedies. For each medication ask about: the from the patient, but not necessarily in the order that generic name, if possible; dose; route of you would like. The patient should then be asked more administration; and any recent changes, such as increase specific details about his or her symptoms, starting with or decrease in dose or change in the amount of times the the most important first. It is important to concentrate on patient takes the medication. Finally, ask about any symptoms and not on diagnosis to ensure that no allergies and sensitivities, especially drug allergies, such information is missed. as allergy or sensitivity to penicillin. It is important to find out what the patient experienced, how it presented in When a patient reports symptoms from a specific terms of symptoms, when it occurred and whether it was body system, all of the cardinal symptoms in the system diagnosed. should be explored. For example, if a patient complains of palpitations, then specific questions should be asked 4. Family history about chest pain, breathlessness, ankle swelling and pain Some disorders are considered familial; a family history in the lower legs when walking to ensure that all cardinal can reveal a strong history of, for example, questions relating to the cardiovascular system have been cerebrovascular disease or a history of dementia,that covered. might help to guide the management of the patient. Open questioning followed by closed questioning can be used Each symptom should be explored in more to gather information about any significance in the detail for clarification because this helps to construct a patient’s family history. For example, start with an open more accurate description of the patient’s problems. question such as: ‘Are there any illnesses in the family?’ Direct questions can be used to ask about: Then ask specifically about immediate family – namely Onset – was it sudden, or has it developed gradually? parents and siblings. For each individual ask about Duration – how long does it last, minutes, days or diagnosis and age of onset and, if appropriate, age and weeks? cause of death. Site and radiation – where does it occur? D o e s it occur anywhere else? Aggravating and relieving features – is there anything 5. Social History that makes it better or worse? A patient’s ability to cope with a change Associated symptoms – when this happens, does in health depends on his or her social wellbeing. A level anything else happen with it, such as nausea, vomiting or of daily function should be established throughout the headache? history taking. Fluctuating – is it always the same? The HCP should be mindful of this level Frequency – have you had it before? of function and any transient or permanent change in function as a result of past or current illness. Direct questioning can be used to ask about the Questions about function should include the sequence of events, how things are currently and any ability to work or engage in leisure activities if retired; other symptoms that might be associated with possible perform house holdchores, such as housework and differential diagnoses and risk factors. Negative responses shopping; perform personal requirements, such as are also important, and it is vital to understand how the dressing, bathing and cooking. In particular, with symptoms affect the patient’s day-to-day activities. deteriorating health a patient may have needed to give up club or society memberships, which may lead to a Do you have any allergy? If yes then type sense of isolation or loss. of allergy. HCPs should consider the whole of the family Any surgery in past? What type of when exploring a social history. surgery? Relationships to the patient shoexplored, for Last physical examination & for what example, is the patient married, is his or her spouse purpose. healthy, do they have children and, if so, what age are Are you using any medicine recently? they? The health and residence to the patient should be Do you know about these medicines? known to understand actual and potential support networks. Other support structures include asking about 2. Nutrition and Metabolism Pattern friends and social networks, including any involvement of Assessment is focused on the pattern of food and fluid social services or support from charities. consumption relative tometabolic need. The adequacy of The social history should also include enquiry into local nutrient supplies is evaluated. Actual or potential the type of housing in which the patient lives. This should problems related to fluid balance, tissue integrity, and include if the accommodation is owned, rented or leased, host defenses may be identified as well as problems with what condition it is in and whether there have the gastrointestinal system. been any adaptations. Alcohol In relation to the social history ask Example of Nutrition and Metabolism FHP specifically about alcohol intake. The HCP should ask Assessment Questions: about past and present patterns of drinking alcohol. Ask about their skin, scalp and nails? Smoking It is documented that smoking causes What is your diet menu? early death in the population and no safe maximum or Any food restriction regarding disease minimum limit, unlike alcohol, has been identified. HCPs point of view? should ask questions that identify the history of the Any food restriction regarding religious patient’s smoking. point of view? Traditionally questions surrounding smoking Any food like or dislike? include: ‘What age did you start smoking?’, ‘What kind of Any food allergy? cigarettes do you smoke?’, ‘How many cigarettes a day do you smoke?’, ‘Do you use roll ups or filtered?’ and ‘Are 3. Elimination Pattern they low or high tar content?’. Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as Gordon’s 11 Functional Patterns incontinence, constipation, diarrhea, and urinary Marjorie Gordon was a nursing theorist and professor retention may be identified. who proposed a nursing assessment theory known as Gordon's 11 Functional Health Patterns in 1987. FHP's as Example of Elimination FHP Assessment a guide, used by nurses in the nursing process for Questions: establishing a comprehensive nursing data base as a Color of urine, amount, frequency, odor result of nursing assessment of the patient. Gordon's and any discharge. Functional Health Pattern include 11 categories, which Any urinary problem, dysurea, Anurea, make a systematic and standardized approach to data collection possible, and enable the nurse to determine the Oligourea, , polyuria. following aspects of health and human function: Are you using any laxative? If yes which? 1. Health Perception and Health Management Any problem during passing defecation? Pattern. Data collection is focused on the person's perceived level of health and well-being, and on practices 4. Activity and Exercise Pattern for maintaining health. Habits that may be detrimental to Assessment is focused on the activities of daily living health are also evaluated, including smoking and alcohol requiring energy expenditure, including self-care or drug use. Actual or potential activities, exercise, and leisure activities. The status of problems related to safety and health management may major body systems involved with activity and exercise be identified as well as needs for modifications in the is evaluated, including the respiratory, cardiovascular, home or needs for continued care in the home. and musculo-skeletal systems. Example of Health Perception and Health Example of Activity and Exercise FHP Assessment Management FHP Assessment Questions: Questions: What is your opinion about health? Do you any breathing problem? (In which Are you immunized about seven target apnea, hypoxia, hypoxemia, hypercapnia.) diseases? Do you have cough? (Productive or nonproductive) Last immunization? Any changes in heart beat during exercise? What is your role in family? Do you feel pale during exercise? If you are in hospital then who will What type of exercise you do or any perform your responsibilities? problem during exercise? All the family members are cooperative with you? 5. Cognition and Perception Pattern Who is decision maker in your family? Assessment is focused on the ability to comprehend and use information and onthe sensory functions. Data 9. Sexuality and Reproduction Pattern pertaining to neurologic functions are collected to aid Assessment is focused on the person's satisfaction or this process. Sensory experiences such as pain and dissatisfaction with sexuality patterns and reproductive altered sensory input may be identified and further functions. Concerns with sexuality may he evaluated. identified. Example of Activity and Exercise FHP Assessment Example of Sexuality and Reproduction FHP Questions: Assessment Questions: Orientation about time place and person. When you first notice changes in your Any difficulty in sentence making? menarche (first menses is called menarche) Loss of memory. Do you have any sexual problem? (Loss of libido) 6. Sleep and Rest Pattern Active sex (direct sex with male and Assessment is focused on the person's sleep, rest, and female) relaxation practices. Dysfunctional sleep patterns, fatigue, Passive sex (sex without male and female and responses to sleep deprivation may be identified. partner) Digital sex Example of Activity and Exercise FHP Assessment Reproductive: Infertility Questions: Sleeping hour? 10. Coping and Stress Tolerance Pattern Are you using nap (evening type Assessment is focused on the person's perception of sleeping). stress and on his or her coping strategies Support systems What do you feel after waking? (Fresh, are evaluated, and symptoms of stress are headache, drowsy). noted. The effectiveness of a person's coping strategies Are you using any medication for in terms of stress tolerance may be further evaluated. sleeping? Do you have any exercise or walking at Example of Sexuality and Reproduction FHP night? Assessment Questions: If you have stress then what is your 7. Self-Perception and Self-Concept Pattern coping mechanism towards stress? Assessment is focused on the person's attitudes Crying, angry, violence, (what is your toward self, including identity, body image, and sense of opinion regarding that) self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified. 11. Values and Belief Pattern Assessment is focused on the person's values and Example of Self-Perception and Self-Concept FHP beliefs (including spiritual beliefs), or on the goals that Assessment Questions: guide his or her choices or decisions. What is your self-perception about yourself? Example of Sexuality and Reproduction FHP Are you satisfied with your self-body Assessment Questions: image? What is your religion? Do you like grooming? Do you offer prayer? 8. Roles and Relationships Pattern Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated. Example of Roles and Relationships FHP Assessment Questions:  Formulating a Nursing Diagnosis: 1. Use accepted qualifying terms (Altered, Decreased, Increased, Impaired) 2. Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer) 3. Don’t state 2 separate problems in one diagnosis 4. Refer to NANDA list in a nursing text book ( North American Nursing Diagnosis Association it formally identifies, develops, and classifies nursing diagnoses) Parts of Diagnosis Statement: 1. Problem statement ( Diagnostic Label)- based on your assessment of client (gathered information), a. pick a problem from the NANDA list b. the client’s response to a problem 2. Etiology- what’s causing/contributing to the client’s problem a. determine what the problem is caused by or related to (R/T) 3. Defining Characteristics- what’s the evidence of the problem i. -then state as evidenced by (AEB) the specific facts the problem is based on… Example: Ineffective therapeutic regimen management related to difficulty maintaining lifestyle changes and lack of knowledge as evidenced by B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”. Types Of Nursing Diagnosis: B. DIAGNOSIS 1. Actual- Patient problem & Causes if known Second Step of the Nursing Process - Imbalanced nutrition; less than body requirements RT Provide a basis for selection of nursing interventions chronic diarrhea, nausea, and pain AEB height 5’5” weight so that goals and outcomes can be achieved 105 lbs. Interpret & analyze clustered data 2. Risk- Problem & Risk Factors Identify client’s problems and strengths - patient is at risk for developing this problem Formulate Nursing Diagnosis (NANDA: North -Example: Risk for falls RT altered gait and generalized American Nursing Diagnosis Association)-Statement of weakness how the client is RESPONDING to an actual or 3. Wellness- (NANDA) describes human responses to potential problem that requires nursing intervention levels of wellness in an individual, family, or community Responsible for recognizing health problems, that have a readiness for enhancement anticipating complications, initiating actions to ensure -Example: Family coping: potential for appropriate and timely treatment. growth RT unexpected birth of twins. Apply critical thinking to problem identification Requires knowledge, skill, and Experience Sources Of Diagnostic Error: Nursing Diagnosis Medical Diagnosis 1. Patient response not medical diagnosis Within the scope Within the scope of 2. NANDA diagnostic statement not symptom of nursing practice medical practice 3. Treatable cause or risk factor not a clinical sign or chronic problem that is not treatable Identify Focuses on curing responses to pathology 4. Problem caused by the treatment or diagnostic study not the treatment or study itself health and illness 5. Patient response to equipment not equipment itself Can change from Stays the same as 6. Patient's problems not your problems day to day long as the disease is present  Chapter 02: Physical Examination Dorsal recumbent back lying position with knees PHYSICAL EXAMINATION flexed and Hips externally DEFINITION rotated, with small pillow under Conducted from head to toe (cephalocaudal technique). the head. Determine the mental status and level of consciousness Head, neck, anterior thorax (LOC) at the beginning of examination. and lungs, breasts, axillae, heart PURPOSES and abdomen, extremities, peripheral pulses, vital signs. Gather baseline data about the client’s health and vagina.. Supplement, confirm or refute data obtained in the Position is used for abdominal assessment because it midwifery history promotes relaxation of abdominal. Confirm & identify midwifery diagnosis muscles.. Make clinical judgments about a client's changing health status and management Lithotomy. Evaluate the physiological outcomes of care back lying position with feet supported in stirrups; hips should PREPARATION GUIDELINES be in line with the edge of the 1. Explain the procedure table 2. Inform the client the need to assume a special position for the assessment of female 3. Tell the client that appropriate draping will be provided. genitalia, rectum and female reproductive tract 4. Control room temperature, and provide warm blanket. Provides maximal exposure of genitalia 5. Ask the client to empty the bladder. and facilitates insertion of vaginal speculum 6. Encourage the client to defecate. 7. Use a relaxed voice tone and facial Sim’s expressions to put the client at ease. side-lying position with 8. Encourage the client to ask questions and report lowermost arm behind the body discomfort felt during the examination. and uppermost leg flexed. 9. Have a family member or a third person of the client’s For the assessment of rectum gender in the room during assessment of genitalia and vagina 10. At the conclusion of the assessment, ask the client if Flexion of knee and hip he or she has any concerns or questions improves exposure of rectal area. ❖ POSITIONS: Prone face-lying position with or without a Sitting small Pillow assessment of posterior Use this position for the thorax, hip movement assessment of head, neck, back, posterior Knee-chest (Genu-pectoral) thorax, and lungs, kneeling position with torso at a breasts, axillae, heart, chest. vital signs, and upper Assessment of rectum extremities Provides maximal exposure to It provides full expansion of lungs, and provides better rectal area visualization of symmetry of upper body part. Fowler’s Supine back lying position with legs extended, without small pillow under the head for the assessment of head, and neck, anterior thorax, and lungs, breasts, axillae, heart, abdomen, extremities, Semi-fowler’s – head of bed elevated pulses, vital signs, vagina at 15-45 degree angle. Most normally relaxed position. It provides easy access to pulse sites.  High Fowler’s – head of bed raised at o inspection is used to assess moisture, color, and 80-90 degree angle. texture if body surfaces as well as shape , position ,size, symmetry of the body o requires good lighting, adequate exposure, and occasional use of certain instruments to enlarge your view. Guidelines: Trendelenburg Make sure the room has a comfortable Shock or low blood pressure; Abdominal surgery temperature. Use good lighting, preferably sunlight. Look & observe before touching. Compare appearance of symmetric body parts or both sides of any individual body part. 2. AUSCULTATION requires the use of stethoscope EQUIPMENTS USED FOR PHYSICAL Guidelines: EXAMINATION 1. Eliminate distracting noises 2. Expose the body part you are going to auscultate 3. Press the diaphragm firmly 3. PALPATION Factors/ characteristics to assess are: 1. Texture 2. Temperature of skin area 3. Location/position, size, consistency, mobility of organs or masses 4. Distention 5. Pulsation 6. Presence of pain upon pressure 7. Presence of lumps Different parts of the hands are best suited for assessing different factors: 1. finger pads 2. grasping action of the fingers and thumb 3. dorsal 4. ulnar or palmar Types Of Palpation: 1. Light Palpation TECHNIQUES OF PHYSICAL ASSESSMENT o Place dominant hand 1. INSPECTION lightly on the visual examination o surface of the structure o Should be deliberate, purposeful, and systematic o there should be very little o is concentrated watching or no depression o it is close, careful scrutiny, first of the individual o feel the surface using circular motion and as a whole and on each body system o use this technique to feel for pulse, tenderness, o begins the moment you first meet your client surface, texture, temperature & moisture o inspection always comes first o the health care worker inspects with the naked 2. Moderate Palpation eye and with a lighted instrument o depress the skin surface 1-2 cm o in addition to visual observations, olfactory and (.5-.75 in) with your dominant auditory cues are noted hand o use circular motion to feel for easily  o palpable body organs and masses -quality: HOLLOW o note for size, consistency and mobility of -origin: NORMAL LUNG structures you palpate 3. Deep Palpation 2. Hyper-resonance o -place your dominant hand -intensity: VERY, LOUD on the skin surface and -pitch: LOW your non dominant hand -length: LONG on -quality: BOOMING o top of your dominant hand to apply pressure -LUNG W/ EMPHYSEMA o surface depression should be 2.5 cm and 5 cm (1- 2 in) 3. Tympany o allows you to feel very deep organs or structures -intensity: LOUD that are covered by thick muscle -pitch: HIGH a. Bimanual Palpation -length: MODERATE o use two hands, placing one oneach side of the -quality: DRUMLIKE body part being palpated -PUFFED-OUT CHEEKS o use one hand to apply pressure and the other hand to feel the structure 4. Dullness o note the size, shape, consistency and mobility of -intensity: MEDIUM the structures you palpate -pitch: MEDIUM 4. PERCUSSION -length: MODERATE involves tapping body parts to product sound waves that -quality: THUDLIKE enable the examiner to assess underlying structures -DIAPHRAGM, PLEURAL EFFUSION, LIVER Uses: 5. Flatness -Eliciting pain: percussion helps detect inflamed -intensity: SOFT underlying structures. -pitch: HIGH -Determining location, size and shape -length: SHORT -Determining density -quality: FLAT -Detecting abnormal masses -MUSCLE, BONE -Eliciting reflexes Special Considerations: Types: 1. The sequence of methods for physical 1.Direct Percussion examination of the abdomen is as 2. Indirect or mediate Percussion follows: Inspection, Auscultation, Percussion and Palpation (IAPePa). No Direct Percussion Indirect Percussion abdominal palpation among clients with tumor of the liver or the kidneys. 2. During physical examination of the abdomen, it is important to flex the knees to relax the abdominal muscles , thereby facilitating the examination of abdominal organs. 3. The sequence of examining the abdomen Procedure: is as follows: right lower quadrant, right a. place middle finger of non-dominant hand on body part upper quadrant, left upper quadrant and you are going to percuss. left lower quadrant (RLQ, RUQ, LUQ, b. use pad of middle finger of the other hand to strike the LLQ). middle finger of nondominant hand that is placed on the 4. The best position when examining the body part. chest is sitting/upright position. This anterior and c. withdraw finger immediately. posterior chest. d. deliver 2 quick taps and listen carefully e. use quick, sharp taps by flexing wrist 5. The best position when examining the back is standing position. This enables the examiner to assess the posture, Sounds Elicited by Percussion: and the gait of the client. 1. Resonance 6. If instrumental vaginal examination is done, pour warm -intensity: LOUD water over the vaginal speculum before use. To ensure -pitch: LOW comfort. -length: LONG 7. Is a female client is examined by a male doctor, a 7. Age female staff must be in attendance. This ensures that the - It influences the normal features or physical procedure is done in ethical manner. characteristics of anindividual. The ability to participate And some parts of the examination will also be influenced Organization of The Examination by age. 8. Hygiene and Grooming 1. History taking precedes physical examination. - Note the client’s level of cleanliness by observing the 2. The commonly used system is “head to toe” appearance of the hair, skin, or the fingernails. (cephalocaudal). 9. Dress 3. The extent of the examination depends on the purpose. - Note if the type of clothing worn is appropriate for the i. A client returning from surgery for repair of a temperature and weather condition. fractured leg will require assessment of the 10. Body Odor circulatory and musculoskeletal function - Assess is it from physical exercise, poor hygiene, or poor rather than a breast assessment or examination. oral hygiene. 4. If client becomes fatigued, offer rest periods between 11. Mood and Affect/ Facial Expression assessments. - At rest and in interaction with others. 5. Record results of the examination in scientific terms so 12. Speech that any health professional can interpret the findings. - It includes the pace of speech, its pitch and clarity. 13. Level of Consciousness ❖ The Examination - Including the speed of response to questions and General Survey - The preliminary examination apparent comprehension. which includes the following: A. Height and Weight CULTURAL CONSIDERATIONS OF B. Vital Signs PHYSICAL ASSESSMENT 1. Temperature - Taken at what route. 2. Pulse - Rhythm, volume and tension. 3. Respiration - Rate, rhythm, symmetry, depth, character, color of the client 4. Blood Pressure C. General Appearance and Behavior 1. Sex and Race - A person’s sex affects the type of examination performed. - Different physical features are related to sex and race. 2. Signs of Distress - There maybe signs or symptoms indicating a problem such as pain, difficulty of breathing, and anxiety. 3. Body Type - The body type can reflect the level of health, age and lifestyle - The HCP observes if the client appears trim, muscular, obese, or excessively thin. 4. Posture - Normal standing posture is an upright stance with parallel alignment of his shoulders. - Normal sitting posture involves some degree of rounding of the shoulders. --Observe if the client has an erect, slumped, or a bentposture. Posture may reflect mood or presence of pain. Many elderly persons assumed a stooped position. 5. Gait - The manner of walking. Note if the movements are coordinated or uncoordinated. 6. Body Movements - Note for involuntary movements of body  temperature. c. Convection- dispersion of heat by air currents. d. Evaporation- continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. Factors affecting Body Temperature 1. Age – infant’s body temperature is greatly affected by the temperature of the environment. Elder people are at risk of hypothermia due to decreased thermoregulatory controls, decrease subcutaneous fat, inadequate diet, and sedentary activity. 2. Diurnal Variations(Circadian Rhythms) – highest temperature is usually reached between 8PM-12MN; and the lowest temperature is reached between 4-6 AM. 3. Exercise – strenuous increases BMR thus, the body temperature. 4. Hormones – e.g. progesterone, thyroxine, epinephrine and norepinephrine increase body temperature; estrogen decreases body temperature. 5. Stress – sympathetic nervous system stimulation increases the production of epinephrine and norepinephrine, thereby increasing the metabolic rate and heat production. Alterations in Body Temperature ❖ VITAL SIGNS 1. Pyrexia/hyperthermia/fever – temperature above normal range. TEMPERATURE 2. Hyperpyrexia – very high fever, 41 degrees Celsius 1. Body temperature – the balance between the heat (105.8 deg. Fahrenheit) and above. produced by the body and the heat lost from the body. 3. Hypothermia – subnormal core body temperature. This may be caused by excessive heat loss, inadequate heat Types of Body Temperature: production or impaired hypothalamic function. 1. Core temperature – the temperature of the deep Types of Fever: tissues of the body. Measured by taking oral and rectal 1. Intermittent Fever-the body temperature alternates at temperature. regular intervals between periods of fever and periods of 2. Surface temperature – the temperature of the skin, normal or subnormal temperatures. subcutaneous tissue and fat. Measured by taking axillary 2. Remittent Fever-a wide range of temperature temperature. fluctuations (more than 2C) occurs over the 24-hour period, all of which are above normal. Factors affecting the body’s heat 3. Relapsing Fever-short febrile periods of a few days are production: interspersed with periods of 1 or 2 days of normal Basal Metabolic Rate(BMR) – the younger the person, temperature. the higher the BMR; the older the person, the lower the 4. Constant Fever-the body temperature fluctuates BMR. Therefore, the older persons, have lower minimally but always remains above normal. body temperature than the younger persons. Muscle Activity – exercise increases body heat Clinical Signs of Fever production. 1. Onset Thyroxine Output – increases cellular metabolic rate. – Increased heart rate Hyperthyroidism is characterized by increased body – Increased respiratory rate and depth temperature. – Shivering Epinephrine, norepinephrine, and sympathetic – Pallor, cold skin stimulation – increase the rate of cellular metabolism. – Complaints of feeling cold These in turn increase body temperature. – Cyanotic nail beds Fever – increases the rate of cellular metabolism. – “gooseflesh” appearance of the skin Processes Involved in Heat Loss: – Cessation of sweating a. Radiation-transfer of heat from the surface of one object to surface of another without contact between two 2. Course objects. – Absence of Chills b. Conduction-transfer of heat from one molecule to a – Glassy-eyed appearance molecule of lower – Increased pulse and respiratory rate c. Apply disposable gloves. – Increased thirst d. Squeeze liberal portion of lubricant. – Mild to severe dehydration e. With non-dominant hand, separate client’s buttocks to – Drowsiness, restlessness, delirium orconvulsions expose the anus. – Herpetic lesions of the mouth f. Ask client to breathe slowly and relax. – Loss of appetite g. Gently insert thermometer into anus. – Malaise, weakness and aching muscles h. If resistance is felt during insertion, withdraw thermometer immediately. 4. Defervescence(fever abatement) i. Once positioned, leave thermometer in place – Skin that appears flushed and feelswarm j. Remove thermometer from anus. – Sweating k. Wipe with antiseptic solution. – Decreased shivering l. Return thermometer to storage – Possible dehydration m. Wipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue Interventions for Clients with Fever n. Remove gloves and dispose. Contraindications: a. Anal or rectal conditions or surgeries [hemorrhoids, hemorrhoidectomy] b. Diarrhea 1. Monitor vital signs. 8. Axillary – safest and most non- 2. Assess skin color and temperature. invasive method of temperature 3. Monitor WBC, hematocrit value, and taking other pertinent laboratory reports Procedure: 4. Remove excess blankets when the client 1. Pat dry the axilla feels warm, but provide extra warmth 2. Place the thermometer on the client’s axilla when the clients feels chilled. 3. Place the arm tightly across the chest to 5. Provide adequate nutrition and fluids 4. keep the thermometer in place 6. Measure I and O 5. Remove from axilla. 7. Reduce physical activity 6. Return thermometer to storage. 8. Provide oral hygiene 7. Perform hand hygiene 9. Provide a tepid sponge bath Normal body temperature: Axillary: 36.5- 10. Provide dry clothing and bed linens. 37.5 degrees celcius in all age groups. 11. Administer antipyretics 9. Temporal Artery – safe and noninvasive; Methods of Temperature Taking: very fast 1. Oral – most accessible and convenient method. - requires electronic equipment that may be expensive or Allow 15 minutes to elapse between a client’s intake unavailable. of hot or cold food or smoking and the measurement of oral temperature. PULSE Place thermometer under the tongue, directed Wave of blood created by contraction of the left towards the side. ventricle of the heart. Wash the thermometer before use, from bulb to the stem, after use, from the stem to the bulb. This practice Pulse sites: ensures medical asepsis. 1. Temporal - over the temporal bone of the head; Contraindications superior and lateral to the eye 1. Oral lesion or surgery 2. Carotid - at the lateral aspect of the neck 2. Cough 3. Apical - at the left midclavicular line 5th 3. Nausea and vomiting intercostal space 4. Very young children Assessment of Pulse Procedure 5. Restless, disoriented 1. Temporal - over the temporal bone of the 6. Seizure prone head; superior and lateral to the eye 2. Carotid - at the lateral aspect of the neck 7. Rectal – the most accurate 3. Apical - at the left midclavicular line 5th method/reliable intercostal space 4. Brachial- at the inner aspect of the upper arm (biceps Procedure: muscles) or medially at the antecubital space a. Provide privacy. 5. Radial – on the thumb side of the inner aspect of wrist. b. Position - Sim’s 6. Femoral – alongside pf the inguinal ligament. 1. Age – younger persons have higher pulse rate than 7. Posterior tibial – at the middle aspect of the ankle, older persons. behind the medial malleolus. 2. Sex/gender – after puberty, female have higher PR 8. Pedal (Dorsal Pedis) – at the dorsum of the foot than the males. 9. Popliteal- at the back of the knee 3. Exercise – increases BMR, thereby increasing the pulse rate. 4. Fever – increases BMR, therefor the PR increases. 5. Medications – digitalis, beta blockers, decrease PR; epinephrine atropine sulfate increase pulse rate. 6. Hemorrhage – increases pulse rate as compensatory mechanism for blood loss. 7. Stress – sympathetic nervous stimulation increases the activity of the heart. 8. Position changes – In sitting or standing position, there is decrease venous return to the heart , decrease BP, therefore, increase in the heart rate. ❖ RESPIRATION – act of breathing ❖ 3 Processes 1. Ventilation - movement of gases in and out of the lung 2. Diffusion - exchange of gases from an area of higher pressure to an area of lower pressure Assessment of Pulse 3. Perfusion - the availability and Procedure: movement of blood for transport of 1. Perform hand hygiene gases, nutrients and metabolic waste 2. Assess products. 3. Position 4. Place tips of first two fingers of hand over groove along Two Types Of Breathing: radial or thumb side of client’s inner wrist 1. Costal (thoracic) – involves movement 5. Lightly compress of the chest. 6. Determine strength of pulse. 2. Diaphragmatic (Abdominal) – involves 7. After pulse can be palpated regularly, look at the Movement watch’s second hand and begin to count Respiratory Centers: Rate- The normal PR per min are as follows: Medulla Oblongata – primary center Newborn to 1 mo.: 120-160 beats/min - Pneumotaxic center – responsible for the rhythmic 1yr: 80- 140 bpm quality of breathing. 2yrs: 80-130 bpm - Apneustic Center – responsible for deep, prolonged 6yrs: 75-120 bpm inspiration 10yrs: 50-90 bpm Adult: 60-100 bpm Assessing respiration Procedure Tachycardia – Pulse rate above 100 beats 1. Position client. per minute (adult) 2. Place client’s arm in relaxed position across abdomen Bradycardia – Pulse rate below 60 beats or lower chest, or place hand directly over client’s upper per minute (adult) abdomen Rhythm – pattern and intervals of beats 3. Observe complete respiratory cycle. DYSRHYTHMIA – irregular rhythm 4. After cycle is observed, look at watch’s hand and begin Volume (amplitude) – strength of pulse to count Normal – moderate pressure Rate – normal:16-20 cycles/min (adult); 30-60 cycles Full or bounding pulse – can be obliterated only by per min (newborn) great pressure – If BP is elevated – the RR becomes Thready pulse (weak, feeble)– it can slow easily be obliterated – If BP is decreased – RR becomes rapid Factors Affecting Pulse Rate Depth – observe the movement of the chest - may be normal, deep or shallow 5. Apply BP cuff snugly, 1 inch (2.5 cm) above the Rhythm – observe for regularity of exhalations and antecubital space inhalations 6. Use the bell-shaped diaphragm of the stethoscope Quality or character – refers to= respiratory effort since the BP is a low nfrequency and sound of breathing sound 7. Inflate deflate the cuff slowly, 2-3 mmHg at a time Major Factors Affecting RR: 8. Wait 1-2 mins before making further determinations a. Exercise – increases RR 9. Document readings. b. Stress – increases RR Classification of blood pressure for adults c. Environment – increase temp. – decreases RR decreased temperature – increases RR Increased altitude – increases RR Eupnea- normal respiration that is quiet, rhythmic, effortless Tachypnea- rapid respiration marked by quick, shallow breaths. Bradypnea -slow breathing Hyperventilation- prolonged and deep breaths. carbon dioxide is excessively exhaled. Hypoventilation- slow shallow respiration. Dyspnea- difficult and labored breathing. Orthopnea- ability to breath only in upright position. o BLOOD PRESSURE is a measure of the pressure exerted by the blood as it pulsates through the arteries. Systolic pressure – pressure of blood as a result of contraction of the ventricles Chapter 03: Review System Diastolic pressure- the pressure when the ventricles are at rest (60-90 mmHg) ADULT REVIEW OF SYSTEMS Pulse pressure – the difference Overview between systolic and diastolic pressure The review of systems (or symptoms) is a list of (normal: 30-40 mmHg) questions, arranged by organ system, designed to uncover dysfunction and disease. Factors affecting BP: It can be applied in several ways: Age – older people have higher BP due to decreased elasticity of blood vessels. 1. As a screening tool asked of every patient that the Exercise – increases cardiac output, hence the BP. clinician encounters. Stress – Sympathetic nervous system 2. Asked only of patients who fall into particular risk Race – hypertension is one of the 10 leading causes of categories (e.g. reserving questions designed to uncover death among Filipinos. occult disease of the prostate to men over 50). Obesity – BP is generally elevated among overweight 3. To better define the likely causes of a presenting and obese people. symptom, as described in the HPI section (e.g. patients Sex/Gender w/a chief concern of "chest pain" would be asked detailed Medications – some medications can increase or cardiac and pulmonary ROS). decrease BP. Diurnal variations – BP is lowest in the morning and It's important to realize that historical Q&A is just one highest in the late afternoon or early evening. piece of the clinical puzzle. Patient's responses must be Disease Process – DM, renal failure, hyperthyroidism interpreted within the context of the rest of their profile, cause increase in BP. including: risk factors, past history,and exam findings. For example, a Assessing BP patient whose ROS is positive for chest pain, would then Procedure: be asked to define the dimensions of this symptom 1. Ensure the client is rested including: duration, 2. Allow 30 minutes to pass if the client had smoked or precipitating events, severity, characterization, radiation, ingested caffeine before taking the BP associated symptoms, etc (or 3. Use appropriate size of BP cuff questioning using OLD CARTS mnemonics). In addition, 4. Position the patient in sitting or supine position an assessment of cardiac risk factors and an organized search for exam findings indicative of Ear pain or discharge? vascular disease (e.g. elevated BP, Nasal discharge, post nasal drip? diminished peripheral pulses, audible bruits, etc) would Change in voice/hoarseness? be very relevant. On the basis of the sum of this data, the Tooth pain or problems clinician can come to an informed conclusion about the importance/cause of this patient's chest pain (e.g. angina, Pulmonary heartburn, pulmonary embolism, etc), and use it to guide Chronic or past pulmonary disorders? their subsequent decision making. Shortness of breath - @ rest or w/exertion? Chest pain? There is no ROS gold standard. The breadth of Cough? questions included is somewhat arbitrary, based on the Hemoptysis (coughing up blood)? author's sense of the most commonly occurring illnesses Wheezing? and Snoring or stop breathing their symptoms. There is planned redundancy, as the same symptoms often apply to multiple organ systems. In Cardiovascular (C/V) addition, some subspecialty Chronic cardiovascular disorders? areas use an expanded ROS, specific to the conditions that they evaluate and treat. Chest pain (CP) or pressure? Shortness of breath - @ rest or w/exertion? I would like to highlight several important limitations: Orthopnea (short of breath lying down)? Paroxysmal Nocturnal Dyspnea (PND)? a. The list of possible diagnoses that follows a question is - sudden shortness of breath that awakens pt from sleep not exhaustive. In addition, please realize that no patient Lower extremity edema? responses are pathognomonic. Sudden loss of consciousness (syncope)? b. The symptoms in parentheses represent a partial listing Sense of rapid or irregular heart beat, of those most commonly associated w/a particular palpatations? disorder. They are based on general experience, not Calf/leg pain/cramps w/ambulation? discrete evidence. Wounds/ulcers in feet? Difficult/slow to heal? c. The disease categorizations reflect rough groupings. There are many exceptions. For example, disorders listed Gastrointestinal in the "acute" section may have chronic presentations, Chronic or past GI disorders? those described as "upper abdominal" may present Heart burn/sub-sternal burning? w/thoracic symptoms, etc. Abdominal pain? Difficulty swallowing? General Pain upon swallowing? Weight loss? Nausea or Vomiting? Weight gain? Abdominal swelling or distention? Fatigue? Jaundice (yellowish coloration of skin)? Difficulty sleeping? Vomiting blood (hematemasis)? Feeling well (or poorly) in general? Black/tarry stools? Recent medical evaluations or treatments? Bloody stools? Chronic pain? Constipation? Fevers, chills, sweats, weight loss? Diarrhea or other change in bowel habits? Vision Genito-Urinary Chronic or past eye disorders? Chronic or past GU disorders? Decrease/change in vision or blurriness? With or without Blood in urine? pain? Burning with urination? Double vision? Urination at night? Eye discharge (D/C)? Incontinence (unintentional loss of urine)? Change in color of structures? Urgency? Frequency? Head and Neck (H&N) Incomplete emptying? Hesitancy? Chronic or past head and neck disorders? Decreased force of stream? Need to void soon after Pain? urinating? Sores or non-healing ulcers in/around mouth? Masses or growths? Hematology/Oncology Change in hearing acuity? Chronic or past Heme/Onc disease?  Fevers, chills, sweats, weight loss? Skin eruptions/rashes? Abnormal bleeding/brusing? Growths? New/growing lumps or bumps? Sores that grow and/or don't heal? Hypercoaguability? Lesions changing in size, shape, orcolor? Itching Ob/Gyn/Breast Chronic or past disease? NOTE: Menstrual Hx? A review of systems (ROS), also called a systems Sweats? enquiry or systems review, is a technique used by Past pregnancies? healthcare providers for eliciting a medical history from a Vaginal Discharge? patient. It is often structured as a component of an # Sexual partners & type of sexual activity? admission note covering the organ systems, with a focus Breast mass, pain or discharge? upon the subjective symptoms perceived by the patient Therapeutic or spontaneous abortions? (as opposed to the objective signs perceived by the Hx STIs? clinician). Along with the physical examination, it can be Neurological particularly useful in identifying conditions that do not Known disease? have precise diagnostic tests. Sudden loss of neurological function? Abrupt loss/change in level of consciousness? Chapter 04: Physical Assessment Witnessed seizure activity? Numbness? INTEGUMENTARY SYSTEM Weakness? Dizziness? Skin: The client’s skin is uniform in color, unblemished Balance problems? and no presence of any foul odor. He has a good skin Headache? turgor and skin’s temperature is within normal limit. Tremor? Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There Endocrine are also no signs of infection and infestation observed. Known Endocrine disorder? Nails: The client has a light brown nail and has the Polyuria, polydypsia, polyphagia? shape of convex curve. It is smooth and is intact with the Fatigue? epidermis. When nails pressed between the fingers Weight loss? (Blanch Test), the nails return to usual color in less than Weight gain? 4 seconds. Body Parts Technique Findings Infectious Diseases Skin Inspection When skin is Known disease? Palpation pinched it goes to Fevers, Chills, Sweats? previous state immediately (2 seconds) Musculoskeletal With fair Known disease? complexion Joint pain? With dry skin Muscle ache? Hair Inspection Black, evenly distributed Joint swelling? Inspect for the and covers the whole Joint redness? Color, scalp, thick, shiny, free Low back pain? distribution, from ends. thickness, Course or fine Mental Health lubrication and Known mental health disorder? appearance. Note: Do you feel sad or depressed much of the time? Terminal Hair Alcohol, other substance abuse? Palpation ▪ It is the long, Anxious much of the time? Palpate the thick, and course Memory problems? texture hair of the body Confusion? which is easily visible on the Skin and Hair scalp, axilla, and Hair Loss the pubic hair. Known disease?  Vellous Hair E. Edema ▪ It is the soft, If present, assess for pitting. small, tiny, that Note location and severity. covers the whole Can take circumstances measurement. body except for the palms and the o Palpate soles. A. Edema – Fluids accumulation under the skin Nails Inspection Smooth and has intact Press finger or thumb into edema to assess epidermis with short and pitting clean fingernails and B. Temperature – use the back of your hand to feel toenails Convex and with the skin good capillary refill time of Should be warm to touch, but not too hot 2 seconds Color or cold skin may indicate perfusion issues C. Tugor 1. When assessing skin, you should inspect every Pitch skin over clavicle – it should rebound almost inch of the patient’s skin. immediately Remove gown. Tight – Can barely pinch Remove Socks Tenting – Skin tents for >3 seconds Look under dressing – Unless contraindicated or Moisture have an order to remove dressing. Tenderness Nursing Pints: ABNORMAL FINDING General a. Color Changers 1. Integumentary assessments are often done ▪ Hyperpigmentation simultaneously with other body systems 1. Addison’s disease a. More efficient ▪ Hypopigmentation b. Can Observe/Inspect skin while inspecting other 1. Vitiligo aspects ▪ Erythema – Redness 2. Supplies needed. 1. Inflammation a. Wound measurement tape/supplies ▪ Cyanosis – Bluish Color b. Dressing supplies as needed. 1. Oxygenation issues ▪ Pallor – Whitish Color o Inspect 1. Perfusion issues ▪ Jaundice – Yellowing of the skin or eyes A. Color 1. Liver Fairlure Should be consistent with ethnicity. Jaundice, cyanosis, pallor, erythema – may b. Edema indicate a disease process ▪ Pitting Edema Scale In darker- skinned patients, look for sclera, 1+ Mild pitting (2mm, rebound quickly) lips, and nail beds for color changer 2+ Moderate pitting (4mm, rebound in 3-4 sec) B. Moisture 3+ Severe (6mm, 10-15 seconds to rebound) – Diaphoresis may indicate fever, usually generalized throughout extremity hypoglycemia, anxiety, or other disease 4+ Extreme (8mm+, >20 sec to rebound – process sometimes minutes, generalized throughout C. Wounds extremity, may be prefusion issues) Color ▪ Dependent Drainage 1. Found only on the lowest aspect ( closest to the Size (Length, Width, Depth) ground) of the body part Tunneling or undermining ▪ Generalized Location 1. Edema throughout body, usually non-pitting Raised Texture c. Absence of hair growth D. Pressure Areas ▪ May indicate chronic venous insufficiency. Back of Head Hips d. Lesions Sacrum ▪ Macule Heels 1. A flat area of pigmentation, usually less than Shoulders 10mm Other bony prominences ▪ Patch  1. A larger macule (>10mm) Macule flat, colored spot ▪ Papule Nodule solid, raised lesion larger than a papule; 1. A well-defined raised area with no visible fluid, often indicative of systemic disease usually less than 10mm Papule small, circular, raised lesion at the surface ▪ Plaque of the skin 1. A large papule or group pf them, usually greater Plaque superficial, flat, or slightly raised than 10 mm, or a large, raised plateau- like differentiated patch more than 1 cm in lesion. diameter ▪ Nodules Pustule raised lesion containing pus; often hair 1. Similar to papule – raised area with no fluid – but follicle or sweat pore is much deeper in the dermis. Ulcer lesion resulting from destruction of the ▪ Vesicles skin and perhaps subcutaneous tissue 1. A small, well-defined raised area filled with fluid, Vesicles small, fluid-filled, raised lesion; a blister or usually 10mm ulticaria (hives), such as that resulting 2. Also known as blister from allergy ▪ Ulcers 1. Involves loss of the epidermis and some or all the Head and Neck Assessment dermis Overview: ▪ Fissures ▪ Head and neck abnormalities are rare but could 1. A crack in the skin that is usually narrow but indicate significant disease processes. deep. Nursing Points ▪ Erosions ▪ Small, barely, noticeable asymmetry is normal. 1. Involves full loss of the epidermis in a defined - One ear may be ever-so-slightly higher than the area. other. ▪ Significant asymmetry or weakness on one side is e. Nail Abnormalities considered abnormal. ▪ Clubbing Assessment 1. Hypoxia or Hypoxemia 1. Head ▪ Scoop-like nails ▪ General symmetry 1. Anemia - Have patient make various faces to assess for ▪ Pale nail beds asymmetry or one-sided weakness 1 Perfusion issues ▪ Size - Abnormally large may indicate hydrocephalus, f. Tugor especially in children ▪ Tight – may have swelling, edema, or venous ▪ Shape insufficiency. ▪ Face symmetry ▪ Tenting – dehydration 1. Eyebrows 2. Nose TYPES OF SKIN LESIONS 3. Mouth 4. Ears NOTE: Make note of any abnormal features or movements like twitching o Palpation ▪ Scalp 1. Symmetry 2. Mostly Smooth - Small bumps are normal. 3. Nontender ▪ Facial Stability - IF trauma is suspected, assess for fractures by gently pressing on the cheeks. Shape Lesions Description 2. Neck Bulla raised, fluid-filled lesion larger than a a. INSPECT vesicle (plural: bullae) ▪ Symmetry Fissures crack or break in the skin ▪ Visible swelling or masses  - Goiter – thyroid issues o When testing for the Extraocular Muscle, both eyes ▪ Trachea should be midline. of the client coordinately moved in unison with parallel ▪ Range of Motion alignment. 1. Left to right. o The client was able to read the newsprint held at a 2. Chin up and down distance of 14 inches. 3. Ears to shoulders 4. Should all be smooth and well-controlled Ears and Hearing without pain Ears: The Auricles are symmetrical and has the same b. PALPATE color with his facial skin. The auricles are aligned with the ▪ TMJ – Have patient open and close jaw. outer canthus of eye. When palpating for the - Movements should be smooth with no clicking or texture, the auricles are mobile, firm and not tender. The tenderness. pinna recoils when folded. During the assessment of ▪ Lymph Nodes Watch tick test, the client was able to hear ticking in both 1. Preauricular – in front of ear ears. 2. Submandibular – below jaw Nose and Sinus 3. Supraclavicular – above clavicle Nose: The nose appeared symmetric, straight and - Almost always indicate malignancy. uniform in color. There was no presence of discharge or ▪ Thyroid Gland flaring. When lightly palpated, there were no - Should be midline, not swollen, nontender. tenderness and lesions 1. Head Mouth: The lips of the client are uniformly pink; moist, Head: The head of the client is rounded; normocephalic symmetric and have a smooth texture. The client was able and symmetrical. to purse his lips when asked to whistle. Skull: There are no nodules or masses and depressions Teeth and Gums: There are no discoloration of the when palpated. enamels, no retraction of gums, pinkish in color of gums Face: The face of the client appeared smooth and has The buccal mucosa of the client appeared as uniformly uniform consistency and with no presence of nodules or pink; moist, soft, glistening and with elastic texture. masses. The tongue of the client is centrally positioned. It is pink Eyes and Vision in color, moist and slightly rough. There is a presence of Eyebrows: Hair is evenly distributed. The client’s thin whitish coating. eyebrows are symmetrically aligned and showed equal The smooth palates are light pink and smooth while the movement when asked to raise and lower hard palate has a more irregular texture. eyebrows. The uvula of the client is positioned in the midline of the Eyelashes: Eyelashes appeared to be equally soft palate. distributed and curled slightly outward. Eyelids: There were no presence of discharges, no 2. Neck discoloration and lids close symmetrically with involuntary The neck muscles are equal in size. The client showed blinks approximately 15-20 times per minute. coordinated, smooth head movement with no discomfort. Eyes The lymph nodes of the client are not palpable. o The Bulbar conjunctiva appeared transparent with The trachea is placed in the midline of the neck. few capillaries evident. The thyroid gland is not visible on inspection and the o The sclera appeared white. glands ascend during o The palpebral conjunctiva - swallowing but are not visible. appeared shiny, smooth and pink. o There is no edema or tearing of the lacrimal gland. BODY TECHNIQUE NORMAL FINDINGS o Cornea is transparent, smooth and shiny and the PART details of the iris are visible. The client blinks when the A. HEAD cornea was touched. » Proportional to the size of o The pupils of the eyes are black and equal in size. The the body, round, with prominences in the iris is flat and round. PERRLA (pupils equally round Skull frontal area anteriorly