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NURS2520 Health Assessment II. Head-to-Toe Assessment. Unit One Head-to-toe assessment review. Objective One Demonstrate head to toe assessment of the adult client. Physical Examination Techniques.

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NURS2520 Health Assessment II


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    1. NURS2520Health Assessment II Head-to-Toe Assessment

    2. Unit One Head-to-toe assessment review

    3. Objective OneDemonstrate head to toe assessment of the adult client

    4. Physical Examination Techniques • Inspection = observation of the client (may at times include use of penlight, otoscope, and/or ophthalmoscope) • Palpation = use of touch to assess client • Use light pressure first to assess body surface • Next use deep palpation to assess underlying structures • Assess areas of pain/tenderness/discomfort last • Percussion = tapping fingers on the client’s skin using short strokes to assess underlying structures to determine size/density/location • Auscultation = use of hearing to assess client

    5. Types ofPercussion and Auscultation • Percussion -- • Direct percussion involves tapping lightly with the pads of the fingers directly on the client’s skin • Indirect percussion involves use of both hands; strike the stationary finger like a hammer to produce the best sound • Auscultation -- • Direct auscultation involves listening to the client without using an assistive instrument (i.e. wheezing, chest congestion) • Indirect auscultation involves listening to the client with the use a stethoscope

    6. Assessment of 5 Percussion Notes • Flatness = soft intensity, high pitch, short duration • Heard over solid areas (muscle) • Dullness = medium intensity, medium pitch, medium duration • Heard over fluid-filled areas • Resonance = loud intensity, low pitch, long duration • Normal lung sound • Hyper resonance = very loud intensity, lower pitch, longer duration • Heard over hyperinflated areas (emphysema) • Tympany = loud intensity, high pitch • Heard over air-filled areas (gastric air bubble)

    7. General Survey *Begins at first contact with the client and continues throughout the exam *Provides an overall impression of the client/client system • Appearance and behavior • Appears stated age • Speech/behavior appropriate to developmental stage • Facial expressions • Physical/emotional distress • Skin color • Vision and hearing • Glasses, hearing aid, etc

    8. General Survey (cont’d) • Speech • Appropriate, logical • Tone, speed, and clarity • Vocabulary/grammar • Body type and posture • Body size/build • Mobility, gait, and coordination • Physical deformities • Range of motion • Dress, grooming, and hygiene • Poor hygiene/unkempt • Manner of dress appropriate for climate

    9. General Survey (cont’d) • Mental status • Level of consciousness • Orientation • Mood, affect • Affect is the emotional state as it appears to others. Mood is the emotional state as described by the patient. Observe the patient's facial expression. No part of the body is as expressive as the face. Feelings of joy, sadness, fear, surprise, anger, and disgust are conveyed by facial expression. Facial expressions generally are not consciously controlled. • Interaction • Vital signs • T/P/R and BP • Pain assessment • Allergies • Height and weight • Nutritional status • Unexplained weight loss

    10. Skin Assessment • Skin characteristics • Temperature • Compare upper and lower extremities, and bilaterally • Excessive warmth may indicate fever, whereas excessive coolness may indicate poor circulation, shock, or hypothyroidism • Moisture • Should be warm and dry (but excessively dry skin may indicate dehydration) • Color • Varies per age, culture, ethnicity • Mongolian spots = blue-black areas that are sometimes present on the lower back or buttocks of African American, Native American, and Asian babies • Capillary hemangiomas (‘stork bites’) = small, irregular pink-red areas present around the face/neck of newborns

    11. Skin Assessment (cont’d) • Skin characteristics (cont’d) -- • Texture • Should be smooth and soft • May be affected by exposure, age, endocrine disorder, and impaired circulation • Turgor • Refers to the elasticity of the skin, and indicates hydration status • Skin that takes 3 seconds or longer to return to its original position is termed ‘tenting’, and indicates dehydration • Lesions • Primary = result of disease or irritation • Secondary = develops from primary lesions as a result of continued illness, exposure, injury, or infection • Evaluate for size, shape, pattern, tenderness, pain, etc

    12. Skin • Nodule--a solid mass extending into the dermis. • (2) Tumor--a solid mass larger than a nodule. • (3) Cyst--an encapsulated fluid-filled mass in the dermis or subcutaneous layer. • (4) Wheal--a relatively reddened, flat, localized collection of fluid. An example is hives. • (5) Vesicle--circumscribed elevation containing serous fluid or blood. An example is chickenpox. • (6) Bulla-- large fluid-filled vesicle. An example is a second-degree burn. • (7) Pustule--a vesicle or bulla filled with pus. An example is acne.

    13. Skin characteristics (cont’d) -- • Edema • Excessive amount of fluid in the tissues • Common in congestive heart failure, kidney disease, peripheral vascular disease, or low albumin levels • Pitting edema is graded on a 0 to +4 scale

    14. Assessing the Hair • Assess for color, texture, condition, and distribution • Pediculosis = head lice infestation • Nits (lice eggs) may be found on the hair shaft close to the scalp • Alterations in hair distribution may be the sign of disease • Alopecia = hair loss • Chemotherapy • Nutritional deficiencies • Hirsutism = excess facial or trunk hair • Endocrine disorders • Steroid use • Assess scalp (dandruff, dermatitis, psoriasis, etc)

    15. Vital Signs • Body temperature • Wait for 15-30 minutes after the client smokes or eats/drinks something hot/cold before taking an oral temperature • Respirations • Count unobtrusively for 30 seconds if respirations are regular, and for 60 seconds if they are irregular • Observe rate, rhythm, and depth of respirations • Blood pressure • Client should be seated with both feet on the floor • Client should be inactive for 5 minutes before measuring • Use correct cuff size, and support the client’s arm at the level of his heart

    16. Vital Signs (cont’d) • Assess apical pulse • Palpate 5th intercostal space at the midclavicular line for stethoscope placement • Count for 60 seconds • Note pulse rate, rhythm, and quality, as well as the S1 and S2 heart sounds • Assess radial pulse • Make sure client is resting while assessing the peripheral pulse • Palpate appropriate site, counting for 30 seconds if the pulse is regular, and for 60 seconds if the pulse is irregular • Compare pulses bilaterally

    17. Assessing the Head • Observe symmetry of features, facial expressions • Abnormal facial features may indicate genetic or chronic disorder (i.e. Graves’ disease, hypothyroidism/myxedema, Cushing’s syndrome) • Assess jaw motion for clicking, pain, or crepitus, which may indicate temporomandibular joint syndrome (TMJ) • Measure head circumference if indicated • Acromegaly, a disorder of excessive growth hormone, may result in enlarged head in adolescents and adults • Microcephaly is an abnormally small head size that may accompany mental retardation • Hydrocephalus may present in infants and children, indicating an accumulation of excessive cerebrospinal fluid

    18. Assessing the Eyes • External structures • PERRLA (pupils equal, round, reactive to light and accommodation) • Conjunctiva: smooth, glistening , and ‘peach’ in color • Sclera: smooth, glistening, and blue-white in color • Cornea: transparent, smooth, and moist • Visual acuity • Snellen chart measures distance vision • Myopia = diminished distance vision • Near vision measured by having client read newsprint from a distance of 14 inches • Hyperopia = diminished near vision • Presbyopia = decrease in near vision due to the aging process

    19. Assessing the Ears • Otic structures • External ear = collects and conveys sound waves; protects the middle ear from the external environment • Otitis externa = infection of the outer ear that may result in a painful auricle or tragus • Middle ear = consists of the tympanic membrane, eustachian tube, and the ossicles; conducts sound waves from the external ear to the inner ear • Otitis media = middle ear infection that may present as tenderness behind the ear • Inner ear = hearing and equilibrium • Cerumen (ear wax) should be present, but should not occlude the ear canal • May be black, dark red, gray, or brown in color

    20. Assessing the Nose • Sinus areas should be nontender upon palpation • Nasal passages should be pink and moist, and free from drainage or lesions • Septum should be symmetrical • Assess client’s ability to breathe freely through both sides of the nose • Sense of smell is diminished in older adults due to atrophy of olfactory nerve fibers

    21. Assessing the Mouth and Neck • Buccal mucosa should be smooth, moist, and pink:

    22. Mouth and Neck Assessment (cont’d) • Mouth/lips should be symmetrical • Assess for swelling or drooping • Assess for difficulty swallowing • Assess teeth for dentures, obvious caries, loose teeth • Tongue should be moist, symmetrical, slightly rough, smooth, pink, and freely movable • Abnormal findings include deviation from midline; glossitis (inflammation of the tongue); limited mobility; dry, furry tongue related to dehydration; black, “hairy” tongue associated with fungal infections; swelling, nodules, or ulcers • Palpate neck for tenderness/nodules, thyroid • Inspect for swelling, ROM

    23. Lung Assessment • Alterations in respiratory rate • Bradypnea = slow respirations (<10 breaths/minute) • Tachypnea = fast respirations (>24 breaths/minute) • Alterations in respiratory effort • Dyspnea = labored breathing • Orthopnea = inability to breath in the horizontal position • Abnormal breath sounds • Wheezes = high-pitched, continuous musical sounds • Usually heard on expiration • Caused by narrowing of the airways • Rhonchi = low-pitched, continuous sounds • Caused by secretions in the large airways • Often clears with coughing

    24. Lung Assessment (cont’d) • Abnormal breath sounds (cont’d) -- • Crackles = discontinuous sounds that may be high-pitched, popping sounds (fine crackles), or low-pitched, bubbling sounds (course crackles) • Usually heard on inspiration • Stridor = piercing, high-pitched sound • Primarily heard during inspiration • Indicates respiratory distress • Stertor = labored breathing that produces a snoring sound • Retraction refers to the visible sinking of tissues around and between the ribs, sternum, or clavicles due to respiratory difficulty • Note clubbing, coughing, and signs of hypoxia

    25. Cardiovascular Assessment • Observe the precordium (area of the chest over the heart) for pulsations or heaves • Abnormal anywhere except at the 5th ICS MCL (‘point of maximal impulse’, or PMI) • Associated with an enlarged ventricle • Palpate for ‘thrill’ (vibration or pulsation) over the chest • May indicate abnormal blood flow and/or presence of a heart murmur • Assess circulation • Palpate peripheral pulses • Check capillary refill • Assess Homan’s sign or calf tenderness • Assess extremities for peripheral edema

    26. Cardiovascular Assessment (cont’d) • Blood pressure • Cuff width should cover approximately 2/3 of the length of the upper arm for an adult, and the entire upper arm for a child • Incorrect cuff size can result in measurement error of up to 30mmHg • Using a cuff that is too large is better than using one that is too small • Use the popliteal artery if brachial arteries unavailable • Systolic pressure may be 20-30mmHG higher in the lower extremities, but diastolic pressure should be the same • Auscultate apical rate and rhythm • Listen to apical pulse for full minute • Compare apical pulse to radial pulses

    27. Assessment of the Extremities • Assess for musculoskeletal abnormalities, as major deformities may affect posture and gait • Kyphosis = accentuated thoracic curve • Scoliosis = lateral ‘S’ deviation of the spine • Lordosis = accentuated lumbar curve • Assess balance and movement by having client tandem walking, heel-and-toe walking, deep knee bends, and hopping in place • Assess coordination via finger-thumb opposition and having client run the heel of one foot down the shin of the other • Movements should be smooth and controlled

    28. Extremity Assessment (cont’d) • Joints should be smooth, nontender, warm to the touch, and of similar color to surrounding tissue • Color changes may indicate inflammation or infection • Assess effect on joint function • Active ROM • Passive ROM • Crepitus = clicking or grating at the joint • Assess muscle strength by applying resistance while client is performing active range of motion exercises • Should be strong and equal bilaterally • Test ‘hand grasp’ strength and ‘foot push’ strength • Both should be equal bilaterally

    29. Assessment of the Genitourinary System • The GI system consists of the external genitalia, rectum, urethra, bladder, kidneys, ureters, and prostate in males • Circumcision = excision of the foreskin of the penis • No longer recommended as routine practice • Parental preference remains widespread • Hernia = protrusion of the intestine or other organ • Typically found in the inguinal area in males • May cause pain and distention • Hemmorrhoids = dilated, painful anal vessels • Commonly seen in pregnancy, childbirth, constipation • Assess for problems or changes in voiding

    30. Objective TwoDocument findings by narrative charting

    31. Narrative Charting • Tells the story of the patient’s experience in a chronological format • Goal = track client’s changing health status and progress toward positive outcomes • Especially useful in constructing a timeline of events (i.e. cardiac arrest, etc) • Requires the writing out of the details of the patient’s care in sequence • Be sure to organize your thoughts prior to beginning your documentation, as it can be easy to ramble in narrative charting

    32. Unit Two Physical assessment techniques for the lungs and abdomen

    33. Objective OneDemonstrate the assessment technique of light palpation and percussion to abdomen

    34. Examination of the Abdomen • Inspect and auscultate the abdomen first in order to avoid stimulating/altering bowel sounds through percussion/palpation; bladder should be emptied prior to examination • Auscultate bowel sounds in all 4 quadrants of the abdomen • Discontinue NG suction (or clamp tube) if indicated • Absent bowel sounds = no sound auscultated after listening for 5 minutes • Hypoactive bowel sounds = very soft and infrequent (i.e. 1 sound per minute) • Hyperactive bowel sounds = loud, rushing sounds occurring every 2-3 seconds

    35. Examination of the Abdomen (cont’d) • Palpation of abdomen • Use light palpation (pads of fingertips) to evaluate for tenderness and guarding, superficial masses • Involuntary rigidity of the abdominal muscles may indicate peritoneal inflammation • Use deep palpation to assess organs (this is an advanced technique that is not usually performed by staff nurses) • Liver border should be smooth and free of masses • Should not be able to palpate the spleen • Abdominal percussion should be primarily tympanic • Liver should be dull over right MCL • Stomach should be tympanic at left lower anterior ribcage • Spleen should be dull near left 10th rib posterior to MAL

    36. Objective TwoDemonstrate the assessment technique of percussion of the thorax and abdomen

    37. Examination of the Thorax • Thorax = formed by the ribs, sternum, and vertebrae; protects the heart, lungs, and great vessels • Assess with client in sitting position • Observe sternal angle • Rib slope should be less than 90° • Estimate chest diameter • Anteroposterior diameter should be twice the size of transverse diameter • ‘Barrel chest’ (equal diameters) often seen with COPD • Osteoporosis may shorten length of spine, pushing ribs forward and downward • Light palpation of the lungs (perform both anterior and posterior assessment) • Assess symmetry of respiratory movement by having client inhale deeply while grasping the lateral ribcage with thumbs level to the 10th ribs

    38. Examination of the Thorax (cont’d) • Palpation of the lungs (cont’d) -- • Assess for tactile fremitus by having client repeat the words ‘99’ while using palm of hand to palpate chest and back • Identify areas of increased or decreased fremitus • Fremitus is decreased (or absent) if the bronchus is obstructed or there is fluid in the pleural space • Fremitus is increased near large bronchi and over consolidated lung tissue (i.e. pneumonia) • Percussion of the lungs • Assess if underlying tissues are air-filled, fluid-filled, or solid • Identify level of diaphragmatic dullness bilaterally during respiration per posterior percussive assessment • Have client fold arm across chest and percuss across the top of each shoulder to identify lung apex • Percuss symmetrical areas of lung while moving down client’s back • Percuss areas along the sides beneath the scapulae and down the middle of client’s back

    39. Examination of the Thorax (cont’d) • Percussion of the lungs (cont’d) -- • Systematically move down the chest wall for anterior percussion assessment • Should percuss dullness over the heart (left of the sternum from the 3rd to the 5th interspaces) • Dullness replaces resonance when fluid or solid tissue replaces air • Abnormally high dull sounds indicate pleural effusion or atelectasis • Only a large amount of pleural effusion can be detected per anterior percussion because fluid displaces posteriorly when client is in the supine position • Identify upper border of the liver by percussing dullness to the right of the thorax • Identify tympanic gastric air bubble via percussion to the left of the thorax

    40. Unit Three Physical assessment techniques for the eye, ear, and nose

    41. Objective OneDemonstrate the proper use of the ophthalmoscope

    42. Examination via Ophthalmoscope • Perform examination in a darkened room • Switch on ophthalmoscope light; turn lens disc to 0 • Keep index finger on lens disc to facilitate refocusing during assessment; use right hand when examining client’s right eye, and left hand when examining client’s left eye • Use large round beam (0) for large pupils • Use small round beam for small pupils • Use green/red beam to detect lesions • May use thumb of opposite hand on client’s eyebrow to guide movement, and to gently ‘lift’ upper lid if needed • Have the client look straight ahead at a specific point on the wall; hold scope firmly against your own face with your eye directly behind the sight hole • Hold scope 15 inches away, and about 15˚ lateral to client’s line of vision; shine beam of light on the pupil

    43. Ophthalmoscopic Exam (cont’d) • Identify optic disc • Should be yellowish orange, oval or round • Should note branching of vessels away from the optic disc, and progressive enlargement of vessel size as the vessels approach the disc • Disc outline should be clear • Lens should be transparent • Assess for the ‘red reflex’ (orange glow) • Absence may indicate cataract, detached retina, or artificial eye • Keep light beam focused on the red reflex as you move ophthalmoscope closer to the pupil • Identify arterioles and veins • Arterioles are light red, smaller, with bright light reflex • Veins are dark red, larger, with absent light reflex

    44. Ophthalmoscopic Exam (cont’d) • Adjust lens disc • Use clear glass lens for normal-sighted client • Use lens with longer focus and rotate lens disc counterclockwise (minus diopters, or red numbers) for nearsighted client • Rotate lens disc clockwise (plus diopters, or black numbers) for farsighted client • Rotate progressively to +10 to +12 diopters to focus on the anterior structures of the eye • Observe macular area (which is responsible for central vision) by having client look directly into the beam • Identify retinal abnormalities • Flame-shaped hemorrhages may indicate hypertension • Large, horizontal line may indicate preretinal hemorrhage • Tiny red spots are indicative of diabetic retinopathy

    45. Glaucoma Cataract