Head to Toe Assessment
Transcript of Head to Toe Assessment
Head-To-Toe
Assessment
Group Members:
Binay, Rizalyn
Busa, Ana Marie
Cabiltes, Claitte
Diano, Christine
Nasayao, jannin
Ramos, Sunny
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Head-To-Toe Assessment
After 3 hours of classroom Discussion and Demonstration the
Level I students will be able to:
I. Define the FF. terms:
a. Nursing Assessment
b. Physical Assessment
c. Anthropometric Measurement
d. Health History
e. Health
f. Reflexes
g. Visual Activity
h. Interview
i. Signs
j. Symptoms
II.
a. Importance of Physical Assessment
b. Purpose of Physical Assessment
c. Four basic techniques in Physical Assessment
d. Principles involved in Physical Assessment
e. Nursing responsibilities before, during and after
Physical Assessment
f. Materials and Equipment used in Physical Assessment
III.
Demonstrate Beginning Skills in Physical Assessment.
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Head to Toe Assessment
Define the Following terms:
A. Nursing Assessment
- Is a major component of nursing care.
- Is a process which includes both physical and
psychological aspect to evaluate client’s condition.
- Enables the nurse to make a judgment about the
client’s health status , ability to manage his/her health
care and need for nursing.
B. Physical Assessment
- Is a process by which a nurse obtains a data that
describes a person’s responses to actual or potential
health problems shich is analyzed to form pertinent
diagnosis.
- Is a head to toe review of each body system that offers
objective information about the client and allows the
nurse to make clinical judgment.
C. Anthropometric Measurement
- Comparative measurements of the body.
Anthropometric measurements are used in nutritional
assessments. Those that are used to assess growth and
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development in infants, children, and adolescents
include length, height, weight, weight-for-length, and
head circumference (length is used in infants and
toddlers, rather than height, because they are unable to
stand). Individual measurements are usually compared
to reference standards on a growth chart. Measurement
of size weight and proportion of the body.
- Most commonly used anthropometric measured are
height, weight, triceps, skinfold thickness, elbow
breadth and arm and head circumference.
D. Health
- State of being physically fit, mentally stable and
socially comfortable.
- It encompasses more than the state of being free of
disease.
E. Health History
- defined as the systematic collection of subjective data
(stated by the client) and objective data (observed by
the nurse) used to determine a client’s functional
health pattern status.
F. Reflexes
- Bent, turned or directed back; or produced by a reflex
without intervention of consciousness.
- Is an involuntary and nearly instantaneous movement
in response to a stimulus.
G. Visual Acuity
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- The degree of detail the eye can discern an image.
- Is a quantitative measure of the ability to identify black
symbols on a white background at a standardized
distance as the size of the symbols is varied.
- Is acuteness or clearness of vision, especially form
vision, which is dependent on the sharpness of the
retinal focus within the eye and the sensitivity of the
interpretative faculty of the brain.
H. Interview
- An interview is a conversation between two or more
people (the interviewer and the interviewee) where
questions are asked by the interviewer to obtain
information from the interviewee. "Interview" word is
derived from french word "entirevior" it means
"glimpse" to each other.
- Therapeutic interaction that has a purpose.
I. Signs
- A sign is the physical manifestation of an illness, injury
or other bodily disorder. A sign is objective and can be
observed
- Signs can be felt, heard, seen, and measured by the diagnostician or
nurse. These include pulse, respirations, blood pressure, and physical
evidence such as bleeding, broken skin, bruising etc.
J. Symptoms
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- Subjective evidence of a disease of physical
disturbance observed by the patient.
- Is a departure from normal function or feeling which is
noticed by a patient, indicating the presence of disease
or abnormality. A symptom is subjective, observed by
the patient, and not measured.
Importance of Physical Assessment:
To early detect and treat diseases and disorders.
To identify actual and potential health problems.
To establish a data based from which the subsequent phases
of the nursing evolve.
To assess the client’s impact of activity and exercise on the
client’s overall level of health.
To assess the client’s routine exercise pattern and observe
how the client’s body system response to activity and
exercise.
To establish the client-nurse relationship
To obtain information about the client’s health including,
physiologic, psychologic, sociocultural, cognitive,
developmental and spiritual aspects.
To identify the client’s strength and weaknesses.
Purpose of Physical Assessment
To supplement, confirm or refute data obtained in the
nursing history.
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To confirm and identify nursing diagnosis.
To make clinical judgments about a client’s changing health
status and management.
To evaluate the physiological outcome of care.
To obtain and gather data about the client’s health basis of
data for future assessment.
An excellent way to evaluate an individual’s current health
status.
Four Basic Techniques in Physical Assessment
I. Inspection
It is the use of ones senses of vision and smell to
consciously observe the patient. It is also known as concentrated
watching. It is a close, careful scrutiny; first of the individual as a
whole and then of each body system. Inspection begins the
moment you first meet the individual and develop a “general
survey”. Then as you proceed through the examination, start the
assessment of each body system with inspection.
II. Palpation
It is the act of touching a patient in a therapeutic
manner to elicit specific information. It follows and often confirms
points you noted during inspection. Palpation applies your sense
of touch to assess these factors: texture, temperature, moisture,
organ location and size, as well as any swelling, vibration or
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pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses and presence of tenderness or pain.
Two distinct types of palpation: Light and deep palpation
Light palpation
It is superficial, delicate and gentle. In light palpation,
the finger pads are used to gain information of the patient’s skin
surface to a depth of approximately ½ - 1 inch below the surface.
Light palpation reveals information on skin texture and moisture;
overt large or superficial masses; and fluid, muscle guarding and
superficial tenderness.
Deep palpation
It can reveal information about the position of organs
and masses, as well as their size, shape, mobility, consistency,
and areas of discomfort. Deep palpation uses the hands to
explore the body’s internal structure to a depth of 1 to 2 inches or
more. This technique is most often used for the abdominal and
male and female reproductive assessments. Variations in this
technique are single handed and bimanual palpations.
III. Percussion
It is the technique of striking or tapping the person’s
skin with short, sharp strokes to assess underlying structures. The
strokes yield a palpable vibration and a characteristic sound that
depicts the location, size and density of the underlying organ.
These sounds also are diagnostic of normal and abnormal
findings. Any part of the body can be percussed, but only limited
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information can be obtained in specific areas such as heart. The
thorax and abdomen are the most frequently percussed location.
Four types of percussion techniques: Immediate or direct,
mediate or indirect, direct fist and indirect fist percussion
A. Immediate or Direct Percussion
The striking hand directly contacts the body wall. This produces a
sound and is used in percussing the infant’s thorax or the adult’s
sinus areas.
B. Mediate or Indirect Percussion
It is used more often and involves both hands. The striking
hand contacts the stationary hand fixed on the person’s skin. This
yields a sound and a subtle vibration.
C. Direct Fist Percussion
It is used to assess the presence of tenderness in internal
organs, such as the liver or the kidneys. The presence of pain in
conjunction with direct fist percussion indicated inflammation of
that organ or a strike of too high in intensity.
D. Indirect Fist Percussion
Its purpose is the same as direct fist percussion. In fact, the
indirect method is preferred over the direct method. It is because
in this methods. The non dominant hand absorbs some of the
force of the striking hand. The resulting intensity should be
sufficient force to produce pain in the patient if organ
inflammation is present
Percussion elicits five types of sounds:
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1) Flatness (dull) – bone and muscle
2) Dullness (thudlike) – liver, spleen, heart
3) Resonance (hollow) – air-filled lung/ normal lung
4) Hyperresonance – emphysematous lung
5) Tympany – stomach filled with gas (air)
IV. Auscultation
It is the act of active listening to the body organs to gather
information on patient’s clinical status. Auscultation includes
listening to sounds that are voluntarily and involuntarily
produced by the body such as the heart and blood vessels
and the lungs and abdomen. Auscultated sounds should be
analyzed in relation to their relative intensity, pitch, duration,
quality, and location.
Two types of auscultation: Indirect and direct auscultation:
1) Direct of Immediate auscultation
It is the process of listening with the unaided ear. This
can include listening to the patient from some distance
away or placing the ear directly on the patient’s skin
surface. And example is the wheezing that is audible to
the unassisted ear in a person having a severe
asthmatic attack.
2) Indirect or Mediate auscultation
It is the use of stethoscope, which transmits the sounds
to the nurse’s ear.
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Principles involved in physical assessment:
Anatomy & Physiology
One has to know the different parts and functions of the
body in order to do a thorough and detailed assessment.
Psychology
Through Psychology, we are able to make good assessments
because we can differentiate a normal mental state and an
abnormal one.
Privacy must be ensured during the Physical Assessment to
avoid the client from being anxious or uncomfortable.
Microbiology
Do medical handwashing before and after the procedure.
Instrument should be sterile.
Time and energy
Starts from lesser to the most sensitive part
Body mechanics
Nurse and patient should maintain proper body mechanics.
Nursing responsibilities before, during and after Physical
assessment
Before
Always dress in clean professional manner, make sure you
have your name pin or workplace identification.
Remove al bracelets, necklaces, or earrings that can
interfere during the physical assessment.
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Be sure your hair will not fall forward and obstruct your
vision or touch to the patient.
Ensure that all necessary equipment is ready for use and
within reach.
Introduce yourself to the patient. Enlist the patient’s
cooperation by explaining what you are about to do, where it
will be done, and how it may feel.
Explain to the patient why you may be spending a long time
performing one particular skill.
Do medical hand washing
Position the patient as dictated by the body system being
assessed.
Warm all instruments prior to their use
During
Conduct the assessment in a systematic fashion every time.
While performing each step in the physical assessment
process you may need to inform the patient of what to
expect, where to expect it, and how it should feel.
Avoid making crude or negative remarks, be cognizant of
your facial expression when dealing with malodorous and
dirty patients or with disturbing findings.
Proceed from the least invasive to the most invasive
procedure for each body system.
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If the patient complains of fatigue, continue the assessment
later.
After
Provide recognition to the patient when the physical
assessment concluded; inform the patient what will happen
next.
Place patient in a comfortable position.
Do after care.
Do medical hand washing.
Document assessment findings in the appropriate section of
the patient record.
Materials and Instruments of Physical Treatment
Supplies Purpose
Flashlight or
penlight
To assist in viewing of the pharynx and
cervix or to determine the reaction of
the pupils of the eye.
Laryngeal or dental
mirror
To observe the pharynx and oral cavity.
Nasal septum To permit visualization of the lover and
middle turbinates; usually a penlight is
used for illumination.
Ophthalmoscope A lighted instrument to visualize the
interior of the eye.
Otoscope A lighted instrument to visualize the
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eardrum and external auditory canal (a
nasal speculum may be attached to the
Otoscope to inspect nasal cavities).
Percussion (reflex)
hammer
An instrument with a rubber head to
test reflexes.
Tuning Fork A two-prolonged metal instrument used
to test hearing acuity and vibratory
sense.
Cotton applicators To obtain specimens.
Gloves To protect the nurse
Lubricant To ease the insertion of instruments
(ex.Vaginal Speculum)
Tongue blades
(depressors)
To depress the tongue during
assessment of the mouth and pharynx.
Various positioning of the patient
Dorsal recumbent
Back-lying position with knees flexed and hips externally
rotated; small pillow under the head; soles of feet on the surface.
Supine (horizontal recumbent)
Back-lying position with legs extended; with or without pillow
under the head
Sitting
A seated position. The back is unsupported and legs hanging
freely.
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Lithotomy
Back-lying position with feet supported in stirrups; the hips
should be in line with the edge of the table.
Sims
Side-lying position with the lowermost leg flexed at the hip
and knee, upper arm flexed at the shoulder and elbow.
Prone
Lies on the abdomen with head turned to the side, with or
without a small pillow.
Body Parts
Assessment of Body PartsHead & NeckHeadInspection:For size, shape & symmetry
Palpation:For contour, masses, depressions.
HairInspection:For color, evenness of growth over the scalp, presence of parasites, amount of body hair.
Palpation:Thickness or thinness texture and oiliness.
Scalp
Normal Findings
The head should be round (normocephalic) and symmetrical.
The normal skull is smooth, and without masses or depressions, non tender.
Can be black, brown or burgundy depending on the race, evenly distributed covers the whole scalp (no evidences of Alopecia), no parasites, and the amount is variable.
Maybe thick or thin, coarse or smooth neither brittle nor dry.
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Inspection:For Color, oiliness, presence of scars, lice and dandruff.
Palpation:For lesions or masses tenderness.
ForeheadInspection:For symmetry, skin appearance, presence of rushes, scars or pimples.
Palpation:For masses, lumps and tenderness
FaceInspection:For shape and symmetry, presence of scars, pimples or acne
Palpation:For any swelling, masses, lumps, and the four sinuses (sphenoidal sinuses, frontal sinuses, ethmoid sinuses and maxillary sinuses).
EyesInspection:For symmetry.
EyebrowsInspection:For hair distribution and alignment and skin quality and movement, presence of pimples, dandruff and color of the hair.
Lighter in color than the complexion, can be moist or oily, no scars noted, free from lice, nits and dandruff.
NO lesions should be noted, neither tenderness nor masses.
Symmetrical, light to dark brown, no rushes, scars and pimples.
Non-tender, no lumps and absence of masses.
The shape of the face can be oval, round, or slightly square, the face is symmetrical, absence of scars, pimples or acne. There should be no edema, disproportionate structures, or involuntary movements.
No lumps and swelling of the face, absence of masses and there is no pain felt during palpation of face
Symmetrical or evenly placed and inline with each other. Non protruding and equal palpebral fissure.
Hair evenly distributed; skin intact. Eyebrows symmetrically aligned; equal movement, absence of pimples and dandruff,
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Palpation:For the presence of lumps, pain and nodules.
EyelashesInspection:For evenness of distribution and direction of curl and color
ScleraInspection:For color, moisture, texture and the presence of lesions.
ConjunctivaeInspection:For lesions, swelling, color and moisture.
Palpation:Presence of pain
CorneaInspection:For clarity, texture and moisture
IrisInspection:For appearance, coloration and shape.
PupilInspection:For color size, shape and equality of the pupils
maybe black brown or blond depending on race.
No lumps, no nodules and no pain felt during palpation
Equally distributed; curled sightly outward and black in color.
The sclera appears white, although blacks occasionally have a gray-blue or “muddy” color to sclera. It should be moist and without lesions
Both conjunctivae are shiny, smooth, and pink or red, absence of swelling, no lesions and it should be moist.
There should be no pain felt during palpation.
The corneal surface should be moist, shiny and transparent, with no discharges and cloudiness.
The iris is normally appears flat, with a regular shape and even coloration.
Black in color; appears round, regular, smooth border and of equal size in both eyes, normally
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Muscle functionCorneal Light Reflex or the Hirschberg Test(Observe the location of reflected light on the cornea)
Cover TestThis test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps two eyes parallel. (Observe the cover eye for movement)
Diagnostic Position testLeading the eye through the six cardinal positions of gaze will elicit any muscle weakness during movement. (Observe for convergence of gaze).
Muscle balanceTest for pupilary light reflex(Cardinal Fields of Gaze)
Test for Accommodation
3-7 mm in diameter.
The reflected light (light reflexes) should be seen symmetrically in the centers of the cornea.
If the eyes are in alignment, there will be no movement of the either eye.
A normal response is parallel tracking of the object with both eyes. Both eyes should move smoothly and symmetrically in each of the six fields gaze and convergence on the held object as it moves toward the nose.
Normally you will see:-Constriction of the same-sided pupil (a direct light reflex).-Simultaneously (a consensual light reflex).
A normal response includes:-Papillary constriction.-Convergence of the axes of the eye.Record the normal response to all these maneuver as:P - PupilsE - EqualR - RoundR - React toL - Light andA - Accommodation
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Visual AcuitySnellen eye ChartThe Snellen eye chart is the most commonly used and accurate measure of visual acuity.
Peripheral VisionTest Visual FieldsConfrontation Test
NoseExternal Inspection:Inspect the nose nothing any bleeding, inflammation, or lesions, masses, swelling, and symmetry, discharges and color, sense of smell.
External Palpation:For tenderness and presence of pain.
Internal Inspection:Inspect for nasal septum for deviation, perforation, lesions and bleeding.
Frontal SinusesInspection:
Normal Visual is 20/20The Top number (numerator) indicates the distance the person is standing from the chart, while the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/20 means you can read that 20 ft. with the normal eye could have read at 20 ft.
The patient is able to see the stimulus at about 90 degrees temporally, 60 degrees nasally, 50 degrees superiorly, and 70 degrees inferiorly.
The shape of the external nose can vary greatly among individual. Normally, it is located symmetrically on the midline of the face that is without swelling, bleeding, lesions, or masses. No discharge or flaring and uniform color, there is a sense of smell.
Non-tender; absence of pain
The nasal mucosa should be pink or dull red without swelling. The septum is at the midline and without perforation, lesions or bleeding, the small amount of watery discharge is normal.
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For any swelling around the eyes
Palpation:Presence of pain and tenderness
Percussion:Note any sound
Maxillary SinusesInspection:For any swelling around the eyesPalpation:Presence of pain and tenderness
Percussion:Note any sound
Transillumination of the sinusesYou may use this technique in the frontal and maxillary sinuses when you suspect sinus inflammation, although it is of limited usefulness.
MouthLipsInspection:For color, texture, cracking, symmetry, lesions and hydration
Palpation:For any presence of pain, lumps and tenderness.
GumsInspection:For color, texture, swelling, bleeding, retraction form the teeth
Palpation:
There is no evidence of swelling around the eyes.
The patient should not feel pain during palpation and no tenderness felt.
The sound should be flat or dull.
There is no evidence of swelling around the nose and eyes.The patient should not feel any pain and tenderness during palpation.
The sound should be flat or dull.
The glow on each side is equal, indication air-filled frontal and maxillary sinuses.
The lips should be pink, soft moist, smooth texture with no evidence of lesions or inflammation. Not crack and symmetrical.
There is no presence of lumps and pain. It is tender.
The gums should be pink, moist, firm texture, no retraction, no swelling or bleeding. The gum margins at the teeth are tight and well-defined.
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For the presence of pain, tenderness and lumps.
TeethInspection:For discoloration, numbers of tooth and texture.
TongueInspection:For color, texture, surface characteristics, symmetry, presence of lesions, and sense of taste.
Palpation:For any nodules, lumps and presence of pain
FrenulumInspection:For the color, texture.
Sublingual AreaInspection:For color, moisture and presence of lesion.
Hard palateInspection:For color, shape, texture, presence of lesions and malformation.
Soft PalateInspection:
There should be no pain felt during palpation, no lumps and non-tender.
The adult normally has 32 teeth, which should be white, straight and smooth edges in proper alignment or evenly placed, clean and free of debris or decay.
The tongue is in the midline of the mouth, the dorsal surface should be pink, moist, rough and without lesions. The tongue is symmetrical and moves freely. The strength of the tongue is symmetrical and strong.The ventral surface of the tongue ahs prominent blood vessels and should be moist without lesions, looks smooth and glistening. There is a sense of taste.
There should be no presence of nodules, lumps and pain.
It should be attached to the tongue, pinkish in color and moist.
It should be pink in color, moist and no presence of lesions.
The hard palate is concave and lighter in pink in color, it has many ridges and it is moist, without any lesion or malformation.
The soft palate is also concave
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For color, shape, texture, presence of lesions, malformation
UvulaInspection: For position, mobility and color.
TonsilsInspection: For color, shape, size and discharge.
Palpation:Presence of pain
EarsExternal earInspection: For position, color, size, shape, any deformities, inflammation, or lesions
Palpation: Presence of pain, tenderness, and lumps.
Auditory AcuityVoice-Whisper test
and light pink in color, it is smooth and no lesions or malformations noted.
It normally looks like a flesh pendant hanging in the midline of soft palate. Tonsils are present and pink in color.
It is pink in color and smooth. Oval in shape. No discharge. Of normal size or not visible, no inflammation, and not swollen.
There should be no pain felt during palpation.
The ear matches the flesh color of the rest of the patient’s skin and should be positioned centrally and in proportion to the head. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye to the occiput with no swelling or thickening. Cerumen should be moist and not obscure the lympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules or lesions.
They should feel firm (not tender) and movement produce pain.
The patient should be able to repeat words whispered from a
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Tuning fork test
Weber’s Test
Rinne’s Test
NeckInspection: For symmetry of the sternocleidomastoid muscles anteriorly, and the trapezius posteriorly.
Palpation: For the presence of masses and tenderness.
Lymph NodesInspection: For any enlargement or inflammation.
Palpation:For size, shape, dellimination,
distance of 2 feet.
Measures hearing by air conduction (AC) or by bone conduction (BC), in which the sound vibrates through the cranial bones to the inner ear.
The patient should perceive the sound equally in both ears or “in the middle”. No lateralization of sound is known as negative Webster test. Air conduction is heard twice as long a bone conduction when the patient hears the sound through the external auditory canal ( air ) after it is no longer heard at the mastoid process ( bone ). This is denoted as AC>BC.
The muscles of the neck are symmetrical with the head at a central position. The patient is able to move head through a full range of motion without complaint of discomfort or noticeable limitation. The patient may be breathing through a stoma or tracheostomy.
The muscles are symmetrical without palpable masses or spasm.
Lymph nodes should not be visible or inflamed.
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mobility, consistency, and tenderness
TracheaPalpation:
Thyroid GlandInspection:For symmetry and visible masses.
Palpation:For nodules or enlargement and tenderness.
ThoraxChest AnteriorInspection: For the breathing patterns, rate, depth, the coastal angle, shape of patient’s chest, and color.
Palpation:For respiratory excursion. Tenderness, masses and temperature.
Normally, lymph nodes should not be palpable in the healthy adult patient; however, small, discrete, movable nodes are sometimes present but are of no significance.
Space should be systemic on both sides or on central placement in midline of neck; spaces are equal on both sides.
Thyroid tissue moves up with swallowing but often the movement is so small it is not visible on inspection. In males, the thyroid cartilage, or Dm’s apple, is more prominent than in females.
No enlargement, masses, or tenderness should be noted on palpation.
Quiet, rhythmic, and effortless respirations. Breathing pattern should be smooth. Costal angle is less than 90°, and the ribs insert into the spine at approximately a 45° angle. Normal rate of breathing in adult is 46/16 per min. red patches present, ribs sloping downward with symmetric interspaces. Colors should be even and consistent with the color of the patients face. Shoulder should be at the same height. shape of thorax – elliptical shape
It should be full symmetric excursion; thumbs normally separate to 3-5 cm (1 ½ to 2
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Percussion: For its different sound
Auscultation:For full two breaths and sounds
LungsInspection:For breath sounds over the following:Trachea
Alveolar Tube (large-stem bronchi)
Lung Field (lung periphery)
HeartPalpation:
Auscultation: For murmurs and sound
Chest PosteriorInspection:For shape and symmetry, spinal alignment for deformities, color,
in). Equal expansion, no tenderness, no masses, skin should be warm and dry, no pulsation should be present. Fremitus is normally decreased over heart and breast tissue.
Normal lung tissue-resonant sound, rib flat sound.
Air brushing through the respiratory tract during inspiration expiration generates different breath sounds.
Bronchial (loud, tubular) breath sounds heard over trachea; expiration longer than inspiration; short silence between inspiration and expiration.
Bronchovesicular breath sound heard over main stem bronchi: below clavicles and between scapulae (inspiratory phase equal to expiatory phase).
Vesicular (low, soft, breezy) breath sounds heard over lung periphery(inspiration longer than expiration).
No pulsation palpable over aortic and pulmonic areas.
Apical has the loudest sound; it should be 60-80 beats/min. No murmurs should be heard.
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abnormal inspiratory.
Palpation:For clients who have no respiratory complaints, temperature.For clients who have respiratory complaints.For respiratory excursion
For vocal and tactile fremitus
Percussion:For sounds
For diaphragm excursion
Auscultation: For sounds
Abdomen
Anteroposterior to transverse diameter in ratio of 1.2; chest symmetric; spine column vertically aligned. No patches, no abnormal inspiratory retraction of interspaces.
The skin should be intact; uniform temperature.
The chest wall intact; uniform temperature. Full and symmetric chest expansion. [Ex. When the client takes a deep breath, your thumbs should be move apart an equal distance and at the same time; normally the thumbs separate 3 to 5 cm (1½ to 2 in.) during deep palpation].
Bilateral symmetry of vocal fremitus. Fremitus is heard most clearly at the apex of the lungs. Low-pitched voices of males are more readily palpated than higher pitched voices of females.
Percussion notes resonate except over scapula.
Lowest point of resonance is at the diaphragm. (Note: percussion on a rib normally elicits dullness)
Excursion is 3-5 cm (1½ to 2 in.) bilaterally in women and 5-6 (2 to 3 in.) in men. Diaphragm is usually slightly higher on the right side. Vesicular and bronchovesicular breathe sounds.
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Inspection:-Color
-Scars
-Striae
-Dilated Veins
-Rashes and lesions-Umbilicus
-The contour of the abdomen
-Hair distribution
-Symmetry-Respiratory movement
Auscultation:Auscultate the four quadrants for basic sounds.Auscultate over the aorta, renal, iliac and femoral arteries. (Vascular sounds)
Percussion: Percuss the four quadrants to as tympany and dullness.
Right Upper Quadrant:- liver- gallbladder- duodenum- head of pancreas- right kidney and adrenal
-Surface is uniform in color and in pigmentation.-Flawless no scars is present. If scars are present draw its location in the person’s record indicating the length in cm.-No striae / stretch marks are present.-A few small veins may be visible normally.-No rashes or lesions are present.-Is normally in the midline and inverted with no sign of inflammation, discoloration or hernia.-Normally range from flat to rounded.-Diamond shape in adult males, inverted triangular shape in adult female.-Symmetric bilaterally and smooth.-The abdomen rises with inspiration and falls with expiration.
High pitched, irregular gurgles (5-35 times/ min) present equally in all four quadrants. No bruits, no venous hums, no friction.
Tympany is usually predominating because of air in the stomach and intestines. Dull sounds are heard over solid masses such as liver, spleen, and kidneys.
Left Upper Quadrant:- stomach- spleen- left lobe of liver
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- hepatic flexure of colon- Part of ascending and transverse colon
Right Lower Quadrant:-Cecum-Appendix-Right ovary and tube-Right ureter-Right spermatic cord
Midline:-Aorta-Uterus(if enlarged)-bladder(if enlarged)
Palpation:Perform palpation to judge the size, location and consistency of certain organs and to screen for an abnormal mass or tenderness.
Light Palpation (1/2 - 1 inch) on all areas of abdomen moving clockwise and in rotary motion.
Deep Palpation (2-3 inches) on all areas on the abdomen moving clockwise and in rotary motion.
Liver Palpation:Located in the RUQ (Right Upper Quadrant).Place your left hand under the person’s back parallel to the 11th and 12th ribs and lift up to support the abdominal contents. Place your right hand on the RUQ with fingers parallel to the midline. Push deeply down and under the right costal margin then ask the person to take a deep breath.
Hooking TechniqueAn alternative method of palpating the liver. Stand up at
- body of pancreas- left kidney and adrenal- spleen flexure of colon- part of transverse & descending colon
Left Lower Quadrant:-Part of descending colon-Sigmoid colon-Left ovary and tube-Left ureter-Left spermatic cord
Normally there is no pain, tenderness, rigidity and muscle guarding
Normally there is no pain, tenderness, rigidity and muscle guarding
It feels like a firm rectangular ridge. Often the liver is not palpable and you feel nothing firm.
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the persons’ shoulder and swivel your body to the right so that you face the person’s feet. Hook your fingers over the costal margin from above. Ask the person to take a deep breath then try to fell the liver edge bump from your fingertips.
Spleen Palpation:Search spleen by reaching your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift for support. Place your hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. Push your hand deeply down and under the left costal margin and ask the person to take a deep breath.
KidneyPercussion:Indirect fist percussion causes the tissues to vibrate instead of producing a sound. Locate kidney by placing hand over the 12th rib at the costoverbral angle on the back. Thump that hand with the ulnar edge of your other fist.
Palpation:locate kidney by placing your hand together in a duck-bill position at the person;s right flank. Press your two hands together firmly (you need deeper palpation than that used to liver and spleen) then ask the person to take a deep breath.
Palpation:Light palpation in all 4 quadrantsDeep palpation in all 4 quadrants
Normally you should feel nothing firm. When enlarged the spleen extends into the lower quadrants.
A person normally feels a thud but no pain.Sharp pain occurs with inflammation of kidneys or paranephric area.
Lower pole of the kidney is round, smooth mass slide in between your fingers.
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ExtremitiesUpper and LowerInspection:-Observe for size, color, contour, symmetry and involuntary movement
-Look for deformities, edema, and presence of lesions.
- Always compare both extremities
Palpation:-Feel evenness of temperature. Normally it should be even for all the extremities.
- Perform range of motion
-Test for muscle strength
Both extremities are equal in size
Have the same contour with prominences of joints.
No involuntary movements. No edema. Color is even.
Temperature is warm and even. Has equal contraction.
Can perform complete range of motion
Can counter act gravity and resistance in ROM
Balance Test
Gait
Observe as the person walk 10-20 feet, turns and
returns to the starting point. Normally, the person moves with a
sense of freedom. The gait is smooth, rhythmic, and effortless,
the opposing arm swing is coordinated, and the turns are smooth.
Romberg’s Test
Ask the person to stand up with feet together and arms
at the side. Once in a stable position, ask the person to close the
eyes and to hold the position. Wait about 20 seconds. Normally, a
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person can maintain posture and balance even with the visual
orienting information blocked, although slight swaying may occur.
(Stand close to catch the person in case he or she falls)
Tandem Walking
Ask the person to walk straight line in a heel-to-toe fashion. This
decrease the base of support and will accentuate any problem
with coordination. Normally, the person can walk straight and stay
balance.
Coordination and Skilled Movements
Rapid Altering Movements (RAM)
Ask the person to pat the knees with both hands, lift up, turn
hands over, and pat the knees with the backs of the hands. Then
ask the person to do this faster. Normally, this is done with equal
turning and a quick rhythmic pace.
Finger-to-nose Test
Ask the person to close the eyes and to stretch out the arms. Ask
the person to touch the tip of his nose or her nose with each index
finger, alternating hands and increasing speed. Normally, this is
done with equal turning & a quick rhythmic pace.
Heel-to-shin Test
Test lower extremity coordination by asking the person who is in
a supine position, to place the heel on the opposite knee, and run
it down the shin from to the ankle. Normally, the person moves
the heel in a straight line down the skin.
Reflex
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It is an automatic response of the body to a stimulus. It is not
voluntarily learned or conscious.
Reflexes are tested using a percussion hammer. The response is
described from 0 to 4. Experience is necessary to determine
appropriate scoring of an individual. Several reflexes are normally
tested during the physical examination: a) the biceps reflex, b)
the triceps reflex, c) the brachioradialis reflex, d) the patellar
reflex, e) Achilles reflex, f) the plantar reflex.
Test the Reflex
The reflex response is guided on a 4 point scale:
4+ very brisk, hyperactive
3+ brisker than average, may indicate disease
2+ average, normal
1+ diminished, low normal
0 no response
Upper Extremity
Biceps Reflex (Flexion)
Support the person’s forearm on yours; this position relaxes, as
well as partially flexes, the person’s arm. Place your thumb on the
biceps tendon and strike a blow on your thumb. You can feel as
well as see the normal response, which are contraction of the
biceps muscle and the flexion of the forearm.
Triceps Reflex (Extension)
Tell the person to let the arm “just go dead” as you suspend it by
holding the upper arm. Strike the triceps tendon directly just
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above the elbow. The normal response is extension of the
forearm.
Brachioradialis Reflex (Flexion and Supination of the arm)
Hold the person’s thumbs to suspend the forearm in relaxation.
Strike the forearm directly, about 2 to 3 cm above the radial
styloid process. The normal response is flexion and supination of
the arm.
Lower Extremity
Quadriceps Reflex (patellar or knee jerk reflex)
Let the lower legs dangle freely to flex the knee and stretch the
tendons. Strike the tendon directly just below the patella.
Extension of the lower legs is the expected response.
Achilles Reflex
Position the person with the knee flexed and the hip externally
rotated. Hold the foot in dorsiflexion, and strike the Achilles
tendon directly. Feel the normal response as the foot plantar
flexes against your hand.
Plantar Reflex
Position the thigh in slight external rotation. With the reflex
hammer, draw a light stroke up the lateral side of the sole of the
foot and inward across the ball of the foot, like an upside-down J.
The normal response is plantar flexion if all the toes and inversion
and flexion of the forefoot.
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Appendices
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Equipment and supplies used for a Health Examination
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Flashlight or Penlight Otoscope
Dental MirrorOpthalmoscope
Tuning ForkCotton Applicators
Tongue DepressorsGloves
Lubricant Percussion HammerNasal Speculum
Various Positioning of the Client
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Dorsal RecumbentLithotomy
SimsHorizontal Recumbent or Supine
Sitting or High FowlersProne
Basic Techniques used in Physical Assessment
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Direct PercussionIndirect Percussion
Deep Palpation
Parts of the Eye
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Light Palpation
Snellen Eye Chart
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Sinus’ Locations
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Side View
Structures of the Mouth
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Front View
Structures of the Ear
Lymph Nodes of the Head and Neck
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External & Internal Lymphatic Drainage
Areas to Auscultate and Palpate on Chest
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Palpation of Thoracic Expansion
Intercostal Landmarks for Percussion & Auscultation of Thorax
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PosteriorAnterior
Posterior Normal Percussive Notes (Posterior)
Respiration Patterns
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AnteriorNormal Percussive Notes (Anterior)
Type Description Pattern Clinical IndicationNormal 12 to 20/min &
regularNormal Breathing Pattern
Tachypnea >24/min & shallow
May be normal response to fever, anxiety or
exercise; can occur with respiratory insufficiency, alkalosis, pneumonia or
pleurisyBradypnea <10/min &
regularMay be normal in well
conditioned athletes; Can occur with medication induced depression of
the respiratory system, diabetic, coma,
neurological damage.Hyperventila
tionIncreased rate &
depthUsually occurs with
extreme exercise, fear or anxiety
Kussmauls’ respiration is a type of hyperventilation associated with diabetic
ketoacidosis.Other causes of
Hyperventilation include disorders of the central
nervous system, an overdose of drug
salicylate or severe anxiety
Hypoventilation
Decreased rate & depth, irregular
pattern
Usually associated with overdose of narcotics of
anestheticsCheyne-Stokes
Respiration
Regular pattern characterized by
alternating periods of deep rapid breathing
followed by periods of apnea
May result from severe congestive heart failure, drug overdose, increased intracranial pressure or
renal failure. May be noted in elderly positions during sleep not related to any disease process.
Biot’s Respiration
Irregular pattern characterized by
varying depth and
May be seen with meningitis or severe
brain damage
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rate of respirations followed by
periods of apnea
Adventitious SoundsSound Site
AuscultatedCause Character
Crackles Are most commonly heard in
dependent lobes; right
and left lung bases.
Random, sudden
reinflation of groups of alveoli;
disruptive passage of
air
Fine crackles are high-pitched fine short
interrupted crackling sounds heard during end of
inspiration, usually not cleared with coughing.
Moist crackles are lover, more moist sounds heard
during the middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds
heard during inspiration not cleared with coughing
Ronchi(sonorous wheeze)
Are primarily
heard over trachea and bronchi; if
loud enough, can be
heard over most lung
fields
Muscular spasm, fluid or mucus in
larger airways, cause
turbulence.
Are loud low – pitched, rumbling coarse sounds heard most often during
inspiration and expiration; may be cleared by
coughing.
Wheezes(sibilant wheeze)
Can be heard all over lung
fields
High – velocity airflow through severely narrowed bronchus
Are high-pitched continuous musical sounds
like a squeak heard continuously during
inspiration, or expiration; usually louder on expiration
Pleural Friction Rub Is heard over
anterior
Inflamed pleura, parietal
Has dry, grating quality heard best during
inspiration; does not clear
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lateral lung field (if
patient is sitting
upright)
pleura rubbing against visceral pleura
with coughing, heard loudest over lower lateral
anterior surface.
Palpation of the Heart
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Locate the apical pulse with the palmar surface.
Palpate the apical pulse with the fingerpad.
Abdominal Viscera and Vascular Structures
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Abdominal Viscera and Vascular Structures
Abdominal Quadrants
Vascular sounds and friction rubs can best be heard over these areas
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Palpation of the liver Spleen Palpation
Kidney Palpation
Common Tests for CoordinationFinger-to-nose test
Heel-to-sheen test
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Testing rapid alternating movements of palms
Common Tests for Reflexes
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Briceps ReflexBrachioradialis Reflex
Triceps Reflex
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Testing for ankle clonus
Plantar Reflex
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Expected Auscultation Sounds (Anterior)
Sites for Auscultating the Abdomen
Sites for Auscultating the Abdomen
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Tactile Fremitus (Posterior) Expected Auscultation Sounds (Posterior)
Percussion Sites for all Quadtrants
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Diaphragmatic Excursion