Head To Toe Assessment

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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 - Subjective evidence of a disease of physical disturbance observed by the patient.

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- 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. • To confirm and identify nursing diagnosis.

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• 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 pulsation, rigidity or spasticity, crepitation, presence of lumps or masses and presence of tenderness or pain.

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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 information can be obtained in specific areas such as heart. The thorax and abdomen are the most frequently percussed location.

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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

inflammation is present Percussion elicits five types of sounds: 1) Flatness (dull) – bone and muscle 2) Dullness (thudlike) – liver, spleen, heart

patient

if

organ

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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. Principles involved in physical assessment: Anatomy & Physiology

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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. • Be sure your hair will not fall forward and obstruct your vision or touch to the patient.

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• 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. • If the patient complains of fatigue, continue the assessment later.

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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 Flashlight or

Purpose To assist in viewing of the pharynx and

penlight

cervix or to determine the reaction of

the pupils of the eye. Laryngeal or dental To observe the pharynx and oral cavity. mirror Nasal septum

To permit visualization of the lover and middle turbinates; usually a penlight is

Ophthalmoscope

used for illumination. A lighted instrument to visualize the

Otoscope

interior of the eye. A lighted instrument to visualize the eardrum and external auditory canal (a nasal speculum may be attached to the

Percussion (reflex)

Otoscope to inspect nasal cavities). An instrument with a rubber head to

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hammer Tuning Fork

test reflexes. A two-prolonged metal instrument used to test hearing acuity and vibratory

Cotton applicators Gloves Lubricant

sense. To obtain specimens. To protect the nurse To ease the insertion of instruments

Tongue blades

(ex.Vaginal Speculum) To depress the tongue during

(depressors)

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. 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.

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Prone Lies on the abdomen with head turned to the side, with or without a small pillow.

Body Parts Assessment of Body Parts Head & Neck Head Inspection: For size, shape & symmetry Palpation: For contour, masses, depressions. Hair Inspection: For color, evenness of growth over the scalp, presence of parasites, amount of body hair.

Palpation: Thickness or thinness texture and oiliness. Scalp Inspection: For Color, oiliness, presence of scars, lice and dandruff. Palpation:

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.

Lighter in color than the complexion, can be moist or oily, no scars noted, free from lice, nits and dandruff.

16 For lesions or masses tenderness. Forehead Inspection: For symmetry, skin appearance, presence of rushes, scars or pimples. Palpation: For masses, lumps and tenderness Face Inspection: 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). Eyes Inspection: For symmetry.

Eyebrows Inspection: For hair distribution and alignment and skin quality and movement, presence of pimples, dandruff and color of the hair. Palpation: For the presence of lumps, pain and nodules.

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, maybe black brown or blond depending on race. No lumps, no nodules and no pain felt during palpation

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Eyelashes Inspection: For evenness of distribution and direction of curl and color

Equally distributed; curled sightly outward and black in color.

Sclera Inspection: For color, moisture, texture and the The sclera appears white, although presence of lesions. blacks occasionally have a grayblue or “muddy” color to sclera. It should be moist and without lesions Conjunctivae Inspection: For lesions, swelling, color and moisture. Palpation: Presence of pain Cornea Inspection: For clarity, texture and moisture Iris Inspection: For appearance, coloration and shape.

Pupil Inspection: For color size, shape and equality of the pupils

Muscle function Corneal Light Reflex or the Hirschberg Test

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 37 mm in diameter.

18 (Observe the location of reflected light on the cornea) Cover Test This 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 test Leading the eye through the six cardinal positions of gaze will elicit any muscle weakness during movement. (Observe for convergence of gaze).

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.

Muscle balance Test for pupilary light reflex(Cardinal Fields of Gaze)

Normally you will see: -Constriction of the same-sided pupil (a direct light reflex). -Simultaneously (a consensual light reflex).

Test for Accommodation

A normal response includes: -Papillary constriction. -Convergence of the axes of the eye. Record the normal response to all these maneuver as: P - Pupils E - Equal R - Round R - React to L - Light and A - Accommodation

Visual Acuity Snellen eye Chart The Snellen eye chart is the most

Normal Visual is 20/20

19 commonly used and accurate measure of visual acuity.

The 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.

Peripheral Vision Test Visual Fields Confrontation Test

The patient is able to see the stimulus at about 90 degrees temporally, 60 degrees nasally, 50 degrees superiorly, and 70 degrees inferiorly.

Nose External 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 Sinuses Inspection: For any swelling around the eyes Palpation:

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.

There is no evidence of swelling around the eyes.

20 Presence of pain and tenderness Percussion: Note any sound Maxillary Sinuses Inspection: For any swelling around the eyes Palpation: Presence of pain and tenderness Percussion: Note any sound Transillumination of the sinuses You may use this technique in the frontal and maxillary sinuses when you suspect sinus inflammation, although it is of limited usefulness. Mouth Lips Inspection: For color, texture, cracking, symmetry, lesions and hydration Palpation: For any presence of pain, lumps and tenderness. Gums Inspection: For color, texture, swelling, bleeding, retraction form the teeth

Palpation: For the presence of pain, tenderness and lumps.

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. There should be no pain felt during palpation, no lumps and nontender.

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Teeth Inspection: For discoloration, numbers of tooth and texture.

Tongue Inspection: For color, texture, surface characteristics, symmetry, presence of lesions, and sense of taste.

Palpation: For any nodules, lumps and presence of pain Frenulum Inspection: For the color, texture. Sublingual Area Inspection: For color, moisture and presence of lesion. Hard palate Inspection: For color, shape, texture, presence of lesions and malformation. Soft Palate Inspection: For color, shape, texture, presence of lesions, malformation

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 and light pink in color, it is smooth and no lesions or malformations noted.

22 Uvula Inspection: For position, mobility and color.

It normally looks like a flesh pendant hanging in the midline of soft palate. Tonsils are present and pink in color.

Tonsils Inspection: For color, shape, size and discharge.

It is pink in color and smooth. Oval in shape. No discharge. Of normal size or not visible, no inflammation, and not swollen.

Palpation: Presence of pain

There should be no pain felt during palpation.

Ears External ear Inspection: For position, color, size, shape, any deformities, inflammation, or lesions

Palpation: Presence of pain, tenderness, and lumps. Auditory Acuity Voice-Whisper test

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 distance of 2 feet.

23 Tuning fork test

Measures hearing by air conduction (AC) or by bone conduction (BC), in which the sound vibrates through the cranial bones to the inner ear.

Weber’s Test

The patient should perceive the sound equally in both ears or “in the middle”. No lateralization of sound is known as negative Webster test.

Rinne’s 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.

Neck Inspection: For symmetry of the sternocleidomastoid muscles anteriorly, and the trapezius posteriorly.

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.

Palpation: For the presence of masses and tenderness.

The muscles are symmetrical without palpable masses or spasm.

Lymph Nodes Inspection: For any enlargement or inflammation.

Lymph nodes should not be visible or inflamed.

Palpation: For size, shape, dellimination, mobility, consistency, and

Normally, lymph nodes should not be palpable in the healthy adult

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Trachea Palpation:

Thyroid Gland Inspection: For symmetry and visible masses.

Palpation: For nodules or enlargement and tenderness. Thorax Chest Anterior Inspection: For the breathing patterns, rate, depth, the coastal angle, shape of patient’s chest, and color.

Palpation: For respiratory excursion. Tenderness, masses and temperature.

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 in). Equal expansion, no tenderness, no masses, skin should

25 be warm and dry, no pulsation should be present. Fremitus is normally decreased over heart and breast tissue. Percussion: For its different sound Auscultation: For full two breaths and sounds

Lungs Inspection: For breath sounds over the following: Trachea

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.

Alveolar  Tube (large-stem bronchi)

Bronchovesicular breath sound heard over main stem bronchi: below clavicles and between scapulae (inspiratory phase equal to expiatory phase).

 Lung Field (lung periphery)

Vesicular (low, soft, breezy) breath sounds heard over lung periphery (inspiration longer than expiration).

Heart Palpation: Auscultation: For murmurs and sound Chest Posterior Inspection: For shape and symmetry, spinal alignment for deformities, color,

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.

Anteroposterior to transverse diameter in ratio of 1.2; chest

26 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

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.

27 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

-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 (535 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 - body of pancreas

28 - right kidney and adrenal - hepatic flexure of colon - Part of ascending and transverse colon

- left kidney and adrenal - spleen flexure of colon - part of transverse & descending colon

Right Lower Quadrant: -Cecum -Appendix -Right ovary and tube -Right ureter -Right spermatic cord

Left Lower Quadrant: -Part of descending colon -Sigmoid colon -Left ovary and tube -Left ureter -Left 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 Normally there is no pain, areas of abdomen moving clockwise tenderness, rigidity and muscle and in rotary motion. guarding 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 Technique An alternative method of palpating

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.

Normally you should feel nothing

29 the liver. Stand up at 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. Kidney Percussion: 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 quadrants Deep palpation in all 4 quadrants

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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Extremities Upper and Lower Inspection: -Observe for size, color, contour, symmetry and involuntary movement

Both extremities are equal in size

-Look for deformities, edema, and presence of lesions.

Have the same contour with prominences of joints.

- Always compare both extremities

No involuntary movements. No edema. Color is even.

Palpation: -Feel evenness of temperature. Normally it should be even for all the extremities.

Temperature is warm and even. Has equal contraction.

- Perform range of motion

Can perform complete range of motion

-Test for muscle strength

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

Flashlight or Penlight

Otoscope

Dental Mirror

Opthalmoscope

Tuning Fork

Cotton Applicators

Gloves

Tongue Depressors Lubricant

Nasal Speculum

Percussion Hammer

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Various Positioning of the Client

Dorsal Recumbent

Lithotomy

Sims

Horizontal Recumbent or Supine

Sitting or High Fowlers

Prone

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Basic Techniques used in Physical Assessment

Direct Percussion

Indirect Percussion

Deep Palpation

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Light Palpation

Parts of the Eye

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Snellen Eye Chart

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Sinus’ Locations

Side View

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Front View

Structures of the Mouth

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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

Posterior

Anterior

Intercostal Landmarks for Percussion & Auscultation of Thorax

Posterior

Normal Percussive Notes (Posterior)

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Anterior

Normal Percussive Notes (Anterior)

Respiration Patterns

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Type

Description

Normal

12 to 20/min & regular

Normal Breathing Pattern

Tachypnea

>24/min & shallow

Bradypnea

<10/min & regular

Hyperventila tion

Increased rate & depth

Hypoventilati on

Decreased rate & depth, irregular pattern Regular pattern characterized by alternating periods of deep rapid breathing followed by periods of apnea

May be normal response to fever, anxiety or exercise; can occur with respiratory insufficiency, alkalosis, pneumonia or pleurisy May be normal in well conditioned athletes; Can occur with medication induced depression of the respiratory system, diabetic, coma, neurological damage. Usually 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 Usually associated with overdose of narcotics of anesthetics 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. May be seen with meningitis or severe brain damage

CheyneStokes Respiration

Biot’s Respiration

Irregular pattern characterized by varying depth and

Pattern

Clinical Indication

47 rate of respirations followed by periods of apnea

Adventitious Sounds Sound Crackles

Ronchi (sonorous wheeze)

Wheezes (sibilant wheeze)

Pleural Friction Rub

Site Auscultated Are most commonly heard in dependent lobes; right and left lung bases.

Cause

Character

Random, sudden reinflation of groups of alveoli; disruptive passage of air

Fine crackles are highpitched 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 Are loud low – pitched, rumbling coarse sounds heard most often during inspiration and expiration; may be cleared by coughing.

Are primarily heard over trachea and bronchi; if loud enough, can be heard over most lung fields Can be heard all over lung fields

Muscular spasm, fluid or mucus in larger airways, cause turbulence.

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

Is heard over anterior

Inflamed pleura, parietal

Has dry, grating quality heard best during inspiration; does not clear

48 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

Locate the apical pulse with the palmar surface.

Palpate the apical pulse with the fingerpad.

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Abdominal Viscera and Vascular Structures

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

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Common Tests for Coordination Finger-to-nose test

Heel-to-sheen test

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Testing rapid alternating movements of palms

Common Tests for Reflexes

Brachioradialis Reflex

Briceps 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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Percussion Sites for all Quadtrants

Tactile Fremitus (Posterior)

Expected Auscultation Sounds (Posterior)

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Diaphragmatic Excursion