Health Assessment and Physical Lecture Notes 1

Health Assessment and Physical Lecture Notes

a) When were talking about the physical assessment, we are looking at a systematic way for collecting data and collecting your nursing assessment on a pt. b) Nurses automatically do a very comprehensive assessment on a pt when theyre first admitted into the hospital. c) We often do assessments anytime there is a change in a pts condition. d) We are also responsible for doing assessments when we take over responsibility and care of a pt. i) We dont do complete assessments every time we go in and see the pt, at a minimum, when were taking over the care and responsibility of a pt, our goal would be looking at our generalized survey. This is the bare minimum assessment that well do on the pt when we take over responsibility for them: (1) Assess the pts orientation (2) There LOC (3) Listen to their heart (4) Listen to their lungs (5) Then, we focus more deeply on the particular problem that the pt is having ii) Before starting an assessment, you need to make sure that the environment is set up. It needs to be: (1) Well or adequate lighting (a) We may need to look at the skins color and appearance. (2) Room is warm b/c we may need to expose body parts (a) If the pt has low or subnormal temperature and when you expose them, they may start shivering and getting cold which will affect our results. (3) Equipment is warm (4) Hands are warm (5) Make sure the environment is quiet (a) Turn off the TVs (b) Ask the pts family to step outside (6) Maintain the pts modesty (a) Make sure the door is closed (b) Make sure the curtains are closed (c) Only expose the body part youre assessing one at a time and leave everything else covered. Make sure to cover the exposed area before moving to another area to assess. (7) Make sure to have all of the equipment needed for the assessment (8) Be organized (9) Be systematic with the assessment. (a) The assessment tends to go head to toe. Go from the clean areas to the dirtiest areas.

Health Assessment and Physical Lecture Notes 2 (10)For pts who are elderly or really sick, you may need to break the assessment up into a couple of different levels or increments b/c they may not have the physical energy to be changing positions and moving constantly so they can tolerate doing the assessment. (a) Always give the elderly more time b/c it takes them longer to respond to questions and change positions. 2) Initial Observations a) You get a ton of information just by walking into the pts room and looking at them. b) Clients physical status i) posture, appearance, odors, body positioning ii) Questions that you need to ask yourself and answer: (1) What does my pt look like? (2) How are they groomed? (3) Are they clean or are they dirty? (a) You can sometimes smell their body odors such as incontinent urine or stool or halitosis (which means bad breath). (4) How are they positioned in the bed? (5) Are they holding or guarding a body area or extremity? (a) You can anticipate if theyre having some type of pain or somethings going on with that body part or area. (b) If your pt is slumped or leaning over a bedside table, it could mean theyre having difficulty with breathing b/c its a classic sign. Its called Tripod positioning b/c it gives the pts lungs a lot of room for expansion. iii) Youre looking at body positioning for evidence of pain, breathing problems, or guarding behaviors b/c theyre hurting. c) Mood and behavior i) Questions that you need to ask yourself and answer: (1) What kind of facial expression does my pt have? (a) It gives you an idea of their emotional status which should be appropriate. (2) Are they exhibiting symptoms of anxiety or nervousness? (a) Nail biting (b) Pacing (c) Breathless (d) Picking at their clothing (3) How are they speaking to me? What is their speech pattern? (a) If they pt is talking really fast or making wide leaps in their conversation and its not making much sense gives the nurse an idea of their mood and behavior. (b) Another sign is a flat tone with no emotion or reflection in their voice. Their voice doesnt go up or modulate, then its a very flat tone. ii) Anxiety and nervousness usually happens within a couple of seconds with the nurse walking in the door. d) Signs and symptoms of distress i) Questions that you need to ask yourself and answer: (1) Are they exhibiting signs of distress?

Health Assessment and Physical Lecture Notes 3 (a) How hard are they working to breathe (b) Are they using their shoulders and neck muscles to help them to breathe (2) Is their RR fast or slow? (a) Shallow (b) Panting (c) Deep (3) Are they maintaining eye contact? (a) When the nurse walks into the room, you should anticipate that they will look up at the nurse. If they dont, it could be signs of: (i) Hearing loss and didnt recognize that someone has entered their room (ii) Not awake or lethargic (iii) Cultural 1. Some cultures think its a sign of disrespect to maintain eye contact. (4) How is the color in their face? (a) Blue lips are a symptom of distress. (b) If they are hugely saturated w/ sweat (or diaphoresis) then they are exhibiting symptoms of distress. (c) Face is bright red, thats another symptom of distress. ii) You are usually able to see symptoms and signs of distress very quickly upon entering a pts room. e) Vital Signs i) They are usually done by a NA prior to being assessed by the nurse. ii) If a pt is in distress, then the nurse may choose to get another set of VS to confirm what the NA got and also to look and see if there have been changes from previous results. iii) May not be a part of the standard assessment but it may need to be something you add in if its appropriate due to the change in your pts condition. f) Height and weight i) A pts weight is one of the best indicators of fluid volume. (1) If a pt is having difficulty with retaining excess fluid or have a deficiency such as dehydration and dont have enough body fluid, then we are going to monitor their weight on a daily basis b/c its going to give you a really good idea of that fluid status. ii) Rules for doing daily weight on a pt: (1) Same bed (2) Same scale (3) Same amt of clothing or blankets (4) Same time of day iii) Accurate weight is also important when it comes to drug dosages. A lot of times we base drug dosages on an infants or an elderly persons weight. We need to know their accurate weight so we can give the appropriate amt of medication. 3) Physical Exam or Physical Assessment

Health Assessment and Physical Lecture Notes 4 a) It always goes in a routine order: i) Inspect (1) When youre inspecting, youre looking for any abnormalities or changes. ii) Palpation (1) Youre touching for temperature, inflammation, or any abnormalities. iii) Percussion (1) A method of tapping body parts with fingers, hands, or small instruments as part of a physical examination. (2) There is nothing on the skin that nurses need to percuss. iv) Auscultation (1) Involves the use of a stethoscope to amplify the sounds from within the body, like a heartbeat. (2) There is nothing on the skin that nurses will need to auscultate. 4) Skin a) Skin assessment is done as we go from head to toe. b) As were doing the skin assessment, need to make sure that were: i) Wearing gloves b/c the pt may have open sores or open wounds c) Color (the inspection part of the physical assessment and is the first step) i) Normal skin color ranges anywhere from light pink, to yellow with more olive undertones for certain ethnic groups, to dark brown. The skin color needs to be consistent and uniform throughout the entire body. ii) When looking at the pts skin, youre also going to look at their lips and mucous membranes (inside the mouth and eyes). (1) Pallor (pale) (a) It could mean that the pt is: (i) Anemic (b) If the pt has dark skin, its very hard to see pallor. You will more likely see ashy grey coloration. (i) The best place to look for pale or pallor on a dark skin individual is by looking at their mucous membranes by looking inside their mouth or looking at the inside lining of their eyes (conjunctiva).

Health Assessment and Physical Lecture Notes 5 (c) If they have brown or olive toned skin, they will have a more yellowish brown coloration when they are pale or have pallor. (2) Erythema (increased redness) (a) When you see erythema of the skin, it usually reflects: (i) Inflammation (ii) Infection (b) When you see a flushed face, it usually indicates or reflects: (i) Fever (ii) Severe dehydration (c) Since you cant see redness on a dark skin individual, you can palpate an area that you suspect is inflamed for warmth. (i) When palpating for warmth, ALWAYS use the back of your hand (ii) DO NOT use your fingertips b/c they less sensitive b/c they have more calluses and things (3) Melanin (a) The color of our skin is related to melanin. It is the naturally bound brown pigment in our skin that gives it its color. (i) Here is a more general definition: a dark brown to black pigment occurring in the hair, skin, and iris of the eye in people and animals. It is responsible for tanning of skin exposed to sunlight. (b) Certain places on our bodies tend to have more melanin due to pressure, like: (i) Elbows (ii) Nipples (iii) Creases in our palms (c) Pts who have problems w/ melanin: (i) Pts who have Addisons disease. 1. They have issues w/ their adrenal glands b/c it doesnt produce enough of their hormones. 2. They will start laying down lots and lots of melanin, knuckles and knees will have more than normal melanin deposited which could be an indication that somethings going wrong with that. (4) Cyanosis (bluish discoloration) (a) Its usually a result of less oxygen being carried on the Hgb, so decreased oxygenation. You can see it on: (i) The lips (ii) Mucous membranes (iii) Nail beds (b) You often see it with pts who: (i) Have circulatory problems (ii) Are freezing cold (c) Since its hard to see cyanosis on dark skin individuals, the best places to look for it are on the:

Health Assessment and Physical Lecture Notes 6 (i) Conjunctiva (ii) Palms (iii) Soles of the feet (iv) Oral mucosa (5) Jaundice (yellowish discoloration) (a) It usually reflects: (i) Liver disease (ii) Sometimes gallbladder disease that backs up into the liver that cause jaundice (b) Youll see a yellowish discoloration on: (i) The skin (ii) The sclera (white of the eye) (c) The best places to look for jaundice in dark skinned individuals are: (i) On the hard palate (roof of their mouth) (ii) In the mucous membranes of their mouth (d) In dark skinned individuals, it may be normal for the sclera of their eye to be a bit more yellow in coloration. Its normal and does not reflect jaundice in a dark skinned individual. (6) Carotenemia (yellowish discoloration of the palms, soles, face and have increased betacarotene levels in the blood) (a) This usually results from a diet high in carotene such as carrots, squash, and sweet potatoes. (b) However, you can see this in pts who have certain endocrine disorders, like: (i) Diabetes (ii) Hypothyroidism d) Moisture (the palpation part of the physical assessment) i) The moisture of the skin is a reflection of the wetness or the oiliness of the skin. ii) Moisture of the skin is a good reflection of the pts fluid balance. (1) If the pt is severely dehydrated, their skin will be dry. (2) If the pt has a fever, it will cause them to perspire which will cause their skin to be more wet. (3) Infection will cause the pt to perspire. (4) Anxiety, or nervousness, will cause the pt to perspire. (5) Pts going through menopause often sweat profusely. (6) Hyperthyroidism (a) When the pts thyroid is working really hard, they are usually really anxious and their HR is up and they are heat intolerant and sweat like crazy. (7) As pts age, their skin will dry out and be drier. e) Temperature (the palpation part of the physical assessment) i) When feeling for temperature, you are feeling w/ the dorsum (back) of your hand. ii) Temperature is a reflection of the pts blood circulation to the skin. (1) If youre concerned about circulation to an extremity, you are always going to compare one side to the other. Example: you would feel the right arm the same time youre

Health Assessment and Physical Lecture Notes 7 feeling the left arm so you could compare the temperature which should be the same. If one arm feels cooler than the other than that could be a good indication that there may be some circulation problems going on. iii) If you see erythema, youre going to feel for warmth. (1) Often times w/ inflammation and infection, youre going to feel increased warmth. iv) If a pt is having circulatory problems, some type of peripheral vascular disease, especially to the lower extremities, you will anticipate that one of their limbs will be cool to touch. v) If a restraint, or cast, is on and too tight, that limb will be cool to touch. f) Texture i) It is the suppleness of the skin. (1) If you were to look at the bottom of your foot, the texture of the skin on the heel of your foot is very different than the texture of the skin on the inside of your forearm. (2) The bottom of our feet and our fingertips has thicker and more callus type of skin. (3) You can see alterations in texture from people who go to tanning beds and do excessive tanning, their skin often times look like leather. (4) As we age, the texture of our skin changes. In the elderly, their skin tends to become thinner and more frail and becomes easier to rip and break open. g) Skin turgor i) This talks about elasticity. (1) When testing skin turgor, you are going to pinch up skin usually around the sternum or the clavicle. When the skin is released, it should very quickly return to normal. (a) If a pt is very dehydrated, the skin will stay in that tented position and doesnt quickly return to normal. Its an indication of poor fluid balance. (2) Dont test for skin turgor on the arm of an elderly pt b/c its normal for it to have tenting in that area so the best place to test for it is on the sternum or clavicle. h) Edema i) Its the accumulation of fluid in the intercellular spaces. ii) There are two types of edema: (1) Pitting- When you are assessing for edema, you will press your finger down on the suspected edema area for 5 seconds and when you remove it, your finger would have left an indentation or pit in the skin. (a) When youre pressing down on the edema, its pushing the fluid out of the way to leave the indentation. (i) You can see pitting edema as a result of socks that are too tight. (ii) You can see pitting edema if there is a venous problem. Theres a problem w/ the veins return the blood flow to the heart. (iii) You may see edema w/ pts who have blood clots. They could have edema in an extremity. (iv) Circulatory problems can also cause edemas. 1. Pts who have heart failure. Its a problem w/ too much fluid on board. W/ pts who have heart failure and have excessive amts of fluid, you will see edemas.

Health Assessment and Physical Lecture Notes 8 (b) W/ pitting edema, you want to quantify it by using a scale: (i) 0- no edema (ii) +1- 2 mm indentation, trace and barely detectable, immediate rebound. (iii) +2- 4 mm indentation, moderate, takes a few seconds to rebound. (iv) +3- 6 mm indentation, deep, can take up to 12 seconds to rebound. (v) +4- 8 mm or more indentation, very deep, takes >20 seconds to rebound. (c) Often times w/ edema, the skin looks different as well. Its often: (i) Really tight (ii) Shiny in appearance (d) The nursing process when it comes to edemas: (i) Inspect 1. Compare the extremity w/ the other extremity. Example: right side to the left side. (ii) Palpate 1. Put pressure on it, release it, and wait to see if you see an indentation. 2. If you found some edema, you need to see how far up it goes. You palpate further up until you find where it ends. I may go up to the knee or just stop at the ankle. (iii) If the pt is edematous, you want to measure the circumference of the leg. 1. Since were going to institute something to correct the edema, we need to constantly measure the circumference of the leg as the swelling decreases and we know that our implementations are working and the edema is going away. (iv) Anytime you see unilateral swelling (one sided) and redness in a leg or calf, you need to suspect a DVT (deep vein thrombosis) or blood clot in that pt. 1. For most ppl, both calfs should be pretty close to the same size. So if one calf suddenly looks bigger than the other, you need to suspect a DVT. 2. Anytime your pt has a DVT, youre going to measure the size of the calf that has the DVT and the side that doesnt for comparison purposes. It gives you a rough idea as to what the calf w/ the DVT should get down to eventually. (e) Legs and feet arent the only places that can get edema. Water is going to go to the most dependent location. (i) If a pt is on bed rest w/ their legs lying in front of them, they may get edema on their sacrum. (ii) If a pt has had a stroke and theyre leaning over their side rail or wheelchair and their arm is just hanging, they could get edema in their hand and arm. (2) Non-Pitting- Still have fluid in the interstitial spaces; however, when you palpate and put pressure on the area, it doesnt leave an indentation. You see it in pts who have: (a) Lymphedema (i) Pts who have problems w/ their lymph systems. Most commonly in: 1. Pts who have had mastectomies and had their lymph nodes removed. A lot of times these women will have edema in the affected arm.

Health Assessment and Physical Lecture Notes 9 (ii) Any kind of damage to the lymph system is typically non-pitting edema. (b) Severe hypothyroidism (i) Thyroids arent working. They often get severe non-pitting edema when theyre getting into big time trouble. i) When doing a skin assessment, be sure to take off their gowns, hoses, and dressings in order to see their skin correctly. j) It is important to look at every single pts sacrum and heels b/c those are two very high risk areas for pressure sores or pressure ulcers. What youre looking for is reddened areas. Symptoms of tissue damage: i) Erythema on the heels or sacrum ii) When you put pressure on the reddened areas, they dont blanch (turn white). iii) Non-blanching erythema is the first sign of tissue damage w/ a pressure ulcer. (1) DO NOT rub these areas b/c it will worsen the tissue damage. iv) Afterwards, the tissue starts to break down and they start to develop ulcers after that. k) If you have a pt who is bony w/ no body fat, be sure to look at all of their bony prominences b/c they could have that non-blanching erythema there as well. 5) Skin Lesions a) Cherry Angioma i) A ruby red, sometimes gets a little more brownish w/ age, small spot on the skin. You often find them on the: (1) Trunk (2) Face (3) Extremities ii) They dont mean anything and are nothing bad. iii) They sometimes increase in numbers as we age. iv) Sometimes they may blanch if we put pressure on them. b) Spider Angioma i) They have a central little round part w/ spider like tentacles coming out of the center. They are commonly known as a grouping of small blood vessels at the skin surface. You often find it on the: (1) Upper body (2) Face (3) Trunk (4) Upper extremities ii) Sometimes you see it normally w/ pregnancy, w/ pts who have vitamin B deficiency, in pts on birth control pills, or in people w/ liver disease. (1) You often see it on the abdomen or torso w/ pts who have liver disease. Its a bad thing when you see it w/ liver disease. c) Petechia vs Purpura vs Ecchymosis i) These are black and blues, sometimes purple. ii) The difference is the size. iii) They all reflect bleeding underneath the skin. The bleeding could be from:

Health Assessment and Physical Lecture Notes 10 (1) Trauma (such as bumping into a table) (2) B/c a pt is on aspirin, Coumadin, heparin, or on any anticoagulants or (3) Antibiotics such as Levaquin and Cipro can cause bleeding disorders (4) Pts who have low platelets (5) Pts w/ liver disease b/c the liver makes clotting factors iv) Petechia is teeny teeny tiny spots that measure < 3 mm. v) Purpura is the same thing as petechia, only larger in size measuring from 3 to 10 mm. vi) Ecchymosis is anything > 1 cm in size. Its just a black and blue. d) Macule vs Papule vs Vesicle i) Macule- a freckle (1) A change in skin color that is benign and doesnt mean anything bad. ii) Papule- a solid raised lesion or a solid raised bump. Another definition is its a solid raised area of the skin that is < 1 cm in size. Examples: (1) An elevated mole (2) An elevated birthmark iii) Vesicle- a blister. A fluid-filled nodule. You can see them w/: (1) Burn (2) Sunburn (3) Herpes zoster (shingles) e) Nodule vs Pustule i) Nodule- Just like a papule except its bigger. A solid elevated lesion that tends to go deeper into the subcutaneous tissues of the skin. Its just bigger than the papule. ii) Pustule- Pus-filled nodule. Examples: (1) Acne (2) Boil (3) Carbuncle 6) ABCDE Skin Evaluation a) Mnemonic used for evaluating increased risk for skin cancers. b) Anytime we are looking at a cancerous lesion, it will have some type of abnormality related to the mnemonic. i) A= Asymmetry (1) The two halves of the lesion should match. If you were to cut the lesion in half, they should match up with each other. If they do not match and are asymmetric, it needs to be further investigated. ii) B= Border (1) It should be smooth and not all jaggedy. If you have a jagged irregular border, you need to investigate it further. iii) C= Color (1) Easiest way to remember color is: blue and black is bad. If you see a blue or black lesion, it needs to be further investigated. (2) If you see a change in color or if you see that one part of the lesion is one color and the other part of the lesion is another color, it needs to be investigated.

Health Assessment and Physical Lecture Notes 11 (3) Irregular color throughout the lesion is bad so it needs to get investigated. iv) D= Diameter (1) Anything larger than the size of a pencil eraser needs to be investigated. (2) Questions you need to ask your pt: (a) Has the size changed? (b) Has there been an increase in size? (c) Is it bigger than the size of a pencil eraser? v) E= Elevation (1) Is it flat, at skin level, or is it raised (a) Usually elevated moles w/ uneven surfaces need to be looked at. 7) Nails a) Need to look at both toe nails and fingernails. b) Normal: i) In light skinned individuals, the nail bed is pink. ii) In dark skinned individuals, its normal to see longitudinal streaks of brown or black pigments in the nail bed. iii) For all individuals, when you palpate, the nail bed should be firm, it shouldnt be spongy and soft. iv) From where the skin goes down and the nail goes up, it should be at a 160 degree angle. (1) Capillary Refill (a) When looking at your pts nails, you are going to inspect the color and then youre going to do this. When you do this, you are going to pinch your pts fingernail and squeeze it until it blanches and then Im going to release it. You are looking at how quickly the color returns on that nail bed. The normal is that the blood and color should come back w/in 3 seconds. (b) If it takes longer than 3 seconds for the color and blood to return to the nail bed, its abnormal. Its usually an indication of circulatory problems. (c) If your pt has oxygenation problems, their capillary refill is going to be sluggish b/c it will be greater than 3 seconds. (2) Clubbing (a) Its an angle that is greater than 180 degrees. It usually causes the nail to curve downward. Their fingertips get bulbous later in the stages as a result of chronic hypoxia. Its classically seen in pts who have: (i) Hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply. Hypoxia may be classified as either generalized, affecting the whole body, or local, affecting a region of the body) meaning the pt has oxygenation problems. (ii) Emphysema (iii) Chronic Lung Disease (iv) COPD (b) When you palpate it, it feels very spongy. (3) Koiloncychia (spoon nail) (a) Theres a concave curve to the nail.

Health Assessment and Physical Lecture Notes 12 (b) You often see this w/ pts who have: (i) Iron deficiency anemia (ii) Syphilis (4) Beaus line (a) Transverse lines that go across the nail that eventually grow out. There might be a color change and the line looks more white. Seen in pts who have: (i) Had trauma to the nail/finger (ii) Severe systemic disease (iii) Severe systemic infections (5) Paronychia (a) Inflammation at the nail base or skin around the nail. Its usually swollen, red, and tender like a hang nail. v) You will also be looking at toe nails. Thickened toe nails on an adult means decreased circulation, not enough arterial circulation will cause those toe nails to become very thick. vi) You will also see thick, brittle, peeling nails as a symptom or result of fungal infections in the toes. vii) White spots in your nails are fairly common and could mean vitamin or nutritional deficiencies. 8) Head a) Normally hair should be shiny and kind of resilient which means it has some strength to it. It could be straight or curly. It could also be thick vs thin. i) Hair (1) Color (a) As a result of aging, we start to lose melanin in our hair which makes it turn grey. (2) Distribution (alopecia, hirsutism) (a) Alopecia- Hair loss (i) Its not just hair on our head, its any place that we have hair such as eyebrows, eyelashes, underarms, and genitalia. (ii) It usually results from: 1. Aging (both men and women can lose hair as a result) 2. Chemotherapy 3. Psychiatric condition where pts will pull out their hair 4. Poor nutrition (iii) You want to look at pts legs b/c hair is normal on the legs. If older adults start to lose hair on their lower extremities, often times its a symptom of circulation problems. Its a very sharp delineation of hair growth that usually stops at midcalf. (b) Hirsutism- Excessive hair growth (i) You can develop hirsutism as a result of: 1. Cushings disease which is too much adrenal 2. Taking Dilantin (seizure medication/anticonvulsant) (3) Texture/oiliness

Health Assessment and Physical Lecture Notes 13 (a) You can see dry, dull, and brittle hair w/ pts who have: (i) Poor nutrition or malnutrition (ii) Hypothyroidism b/c their thyroids arent working (iii) Over processing w/ women who do too much stuff to their hair such as too much perms and coloring. (4) Absence of infestation (a) Looking specifically for lice (i) You will see white eggs at the base of the hair shaft (ii) You can see them on the head and in the pubic area ii) Scalp (1) If a pt has had some type of a head injury, you may need to palpate the scalp for symmetry. (2) Normally, the scalp should be shiny and smooth w/o any lumps and bumps. There shouldnt be any lesions or open areas. (3) Some abnormalities you may see would be: (a) Lice (b) Dandruff (dry scaly skin) (c) Seborrhea (red, itchy rash that can cause white flaky scales) (i) It tends to be more adherent; it sticks rather than falls out like dandruff. iii) Skull (1) Youre looking for shape and symmetry. (a) It should be symmetrical on both sides. (2) It should be upright and midline w/ the rest of the body. (3) Some abnormalities w/ the shape of the skull: (a) Acromegaly (excessive amt of growth hormone) (i) They get increased sides of the forehead (ii) The face is much more long and elongated (iii) They usually have a large jaw, large forehead, and large nose. (b) Pagets disease (i) Pts get an enlarged forehead and have an increased size of the skull, specifically around the forehead. iv) Face (1) Youre looking at their expressions. (a) Pts who have Parkinsons disease have a masked face meaning they have a serious facial expression. They dont make a lot of facial expressions and they are kind of bland. (2) If you draw an imaginary line down the center of their face, one side of the face should look just like the other. (3) If the face is not symmetrical on both sides, it could indicate a couple of different things: (a) Stroke (i) They have facial drooping (b) Bells palsy

Health Assessment and Physical Lecture Notes 14 (i) Has a problem w/ cranial nerve 7 which is the facial nerve and its also responsible for taste (ii) As a result of the problem w/ cranial nerve 7, they could have asymmetrical facial drooping on one side of their face (4) When youre looking at a pts face, youre looking for sunken cheeks, sunken temporal areas, and sunken eyes b/c it could mean that your pt is dehydrated or malnourished. (5) Youre also looks for exophthalmos which are big bulging eyes and its classic w/ hyperthyroidism. (6) Youre also going to look at the pts face. Some abnormalities you may see w/ the shape: (a) Moon face (big round face) (i) Classic for Cushings disease which is too much adrenal (ii) Can be b/c the pt is taking steroids like Prednisone (7) To test for cranial nerve 7, youre going to ask the pt to make different expressions like smiling (the corners of their mouth should be at equal places), frowning, raise their eyebrows, and puff out their cheeks. One side should look just like the other side and they should be able to make all of those facial movements. Since its also responsible for taste, you can give the pt something to taste. (8) To test for cranial nerve 5 which deals w/ facial sensation, you dont prompt your pt. Youre going to ask the pt to close their eyes and tell them to tell you when, where, and what they feel. Youre going to use soft, dull, and sharp (break a tongue blade in half) objects. Move them around their face. (9) Since cranial nerve 5 also deals w/ muscle strength and chewing. Youre going to ask them to bite down and clench their jaw. (10)Pts who have problems w/ their cranial nerve 5 develop a syndrome called Trigeminal Neuralgia. W/ these pts, when you ask them to clench their jaw, clench their teeth, chew, or brush their teeth it causes them severe pain. Its an abnormality w/ cranial nerve 5 that you can see in your pts face. 9) Eyes a) The first thing youre going to do is inspect the eyes and the eyelids. What youre looking for are any redness, drainage, masses, and ulcerations b/c none of those should be present. b) If you see red crusty edges to your eyes, thats inflammation. i) Inspect (1) Snellen Chart (tests cranial nerve 2) (a) Its the typical E or letters of the alphabet that is usually posted on the wall that physicians use to test and measure visual acuity. (i) You have your pts stand 20 ft away from the chart. Then they should remove their glasses and/or contacts and they should cover one eye and read the smallest print that they can. Then they repeat this process w/ the opposite eye. You repeat it for the third time w/ their corrective lenses on and making them cover one eye and then the other. 1. 20/20 vision means that when they stand 20 ft away, they can read what a normal person can read standing at 20 ft.

Health Assessment and Physical Lecture Notes 15 2. 20/40 vision means that that when they stand 20 ft, they can read what a normal person can read standing at 40 ft. 3. 20/10 vision means that that when they stand 20 ft, they can read what a normal person can read standing at 10 ft. (ii) In order to get credit for that line, your pt needs to be able to read over half of those letters on that line in order to get credit. If they cant, then you tell them to go to the next biggest line. (iii) For children who cant read letters yet, they do have adaptations to where they show them pictures and they tell them what the picture is of. They may have them tell them where the E is pointing. (2) Eyelids (a) Youre also going to be looking at the positioning of the eyelids. The upper eyelids should only cover the upper edge or portion of the iris. Its abnormal if the eyelids droop excessively. Some abnormalities you may see w/ eyelids: (i) Ptosis which is drooping or falling of the upper eyelid. 1. You see it in pts who have Myasthenia gravis. (ii) Excessive paleness and swelling around the eyes is called Periorbital edema. 1. Its classic for pts who have kidney disease. (3) Conjuntiva and Sclera (a) You want to look at the conjunctiva, which is the inside lining of the lower lid. Normally, it should be pink in coloration and moist. Youre going to very lightly retract or pull down the skin so you can see the inside lining of the lower lid of the pts eyes. You can also ask your pts to look up as you do so. Abnormalities you could see w/ the conjunctiva: (i) Pale coloration 1. Pt could be anemic, not enough oxygenation. You will usually see the paleness near the outer part of the conjunctiva b/c the inside that is by your nose tends to be paler in color anyway. (ii) Bright red coloration 1. Pt could have inflammation or infection going on w/ the eyes. (iii) Cyanotic (blue) coloration 1. It means not enough oxygenation. (iv) Conjunctiva is dry 1. Its dehydration. (b) The sclera is the white of your eye. (i) In light skinned individuals, the sclera is normally white w/ some superficial blood vessels. (ii) In darker skinned individuals, the sclera is more grey blue to a kind of yellowish coloration and you might see some brown patching on the sclera, its normal. (iii) Some abnormalities you might see w/ the sclera: 1. If you see redness, that could mean inflammation. 2. Sometimes you may see broken blood vessels in the sclera. a. Pts who have high BP and hypertension

Health Assessment and Physical Lecture Notes 16 b. Pts who are coughing forcefully c. Giving birth (pushing a baby out) d. Pushing 3. You can see a yellowish discoloration meaning jaundice in the sclera in light skinned individuals. 4. You can see drainage from the conjunctiva w/ infection. a. Pink eye 5. You can see pale or pallor w/ the conjunctiva w/ pts who have anemia. (4) Cornea, Pupil, Iris, Lens (a) The cornea is the outer coating/outer layer of the eye that should be transparent. (i) If you start to see a milky, kind of hazy coloration in the cornea, its called cataracts. (ii) Grey coloration on the cornea could be an ulceration on the cornea of the eye. (b) The iris is the color part of the eye. (c) The pupil is the dark center of the iris. (i) The size of the pupils should be equal on both sides and symmetrical. 1. If pts pupils arent symmetrical, its bad. If one is big and the other is small and they dont react to light equally, its a bad sign and usually means that they have too much pressure in their brain and needs to be reported. (ii) The normal pupil size should be about 3 to 7 mm Hg. (iii) Should be round. 1. If the pupil is not round, the pt could have had cataract surgery. It sometimes changes their pupil shape into a cat slit type of look. (iv) Should be black. (d) Pupils can be abnormally constricted for a couple of different reasons: (i) Morphine will constrict the eyes (ii) Given them eye drops to treat Glaucoma which could constrict their eyes (e) Pupils can be dilated by using eye drops for eye exams. The mydriatic eye drops that they give dilates the pupils so they can see the inside lining of your retina very well. They also give those eye drops to pts who are having eye surgery. (5) PERRLA (tests cranial nerves 3, 4, and 6 and the way you remember it is 3, 4 and 6 make your eyes do tricks) (a) Stands for Pupils Equal Round Reactive to Light and Accommodation. (b) What that means is youre going to test your pts and youre going to take your pin light and shine it into the eye and the pupil should constrict b/c it was exposed to light, and then youre going to take it out of their field of vision. Youre going to take the pin light and shine it back into the eye while looking at the opposite eyes pupil to see if it constricts and take it out of their field of vision. Repeat this same process w/ the opposite eye. (c) Accommodation has to do w/ when the pt looks out into the distance, the pupils should normally dilate. To test for accommodation, you ask your pts to look for something that is far away and then you ask them to focus on an object, like a pen

Health Assessment and Physical Lecture Notes 17 or pen light, and you bring that object closer to their face. Their pupils should then constrict and their eyes should converge (point towards the center). (6) Extraocular eye movements (tests cranial nerves 3, 4, and 6) (a) What youre going to do is youre going to take an object such as a finger or pin light and move it in all of the different visual fields. What youre watching is the eyes should smoothly and evenly follow the direction of the object in a cat whisker type of movement. Make sure the pts head stays still though. Youre watching for nystagmus which is extra eye movements which is like a vibration, tremors, or twitching in the eye. You can see nystagmus w/: (i) Dilantin (seizure medication) toxicity (ii) Neurological problem (iii) Inebriation (7) Visual Fields (tests cranial nerve 2) (a) The pt covers one of their eyes and the examiner covers their eye that is across from them. You will take your hand in your peripheral field and see when the pt can no longer see your hand in their peripheral field. Pts who have problems w/ their peripheral field: (i) Glaucoma, they lose their peripheral vision 10) Ears a) We hear sounds two ways, through bone conduction and through air conduction. i) Auditory screening (tests cranial nerve 8) (1) Pts w/ hearing deficits get really good at reading lips. (2) To do an auditory screening, youre going to ask the pt to cover one of their ears and youre going to stand behind them and whisper something to them and they should be able to repeat it back to you. Do the same thing w/ the other ear. (3) If the pts are putting their good ear out to hear you speak or if they are constantly asking you to repeat yourself, they may be experiencing some hearing loss. (a) If their television is really loud, they may have hearing loss. (b) If the pt has their back turned to you and you enter a room and they dont turn to look at you, they may have some hearing loss as well. ii) Inspection and palpation of external ear (1) When youre inspecting, youre looking at symmetry and where they connect w/ the head which should be at about the same location. Where your ears attach to your head should be in line w/ the corners of your eyes. (a) Pts w/ Down Syndrome, their ears are actually lower than their eye levels (2) You want to look at the inside and the outside of the ear. The ear should be free of redness and there should be no drainage. (a) Yellow or green drainage could mean infection (b) Clear drainage coming from the ear could be cerebral spinal fluid and thats not normal (i) If you see clear drainage, you need to investigate it for a possible cerebral spinal fluid leak.

Health Assessment and Physical Lecture Notes 18 (3) You will see redness of the ear w/ inflammation or fever. (4) You should also look for any ulcerations or open lesions or sores on the ears b/c its a common place for skin cancer since its exposed to the sun. (5) You can look inside their ears for wax (yellowish color) which should be moist. If its really dry, it means that its been in there for a long time. (a) For the elderly they have excessive wax and its dry and builds up and diminishes their hearing. (6) You can palpate their ear, and you shouldnt feel any sort of masses. (a) You could find tophi which are hard little nodules on the ears that you see in pts who have gout. iii) Weber test (tests cranial nerve 8) (1) Tests hearing conduction (2) Youre going to use a tuning fork and strike it against the palm of your hand and hit it hard which creates vibrations. Hold it by the handle and put it on the center of your pts head and ask them where do they hear it. The correct answer is they should hear it equally in both ears. iv) Rinne test (tests cranial nerve 8) (1) Tests hearing conduction (2) Youre going to strike the tuning fork and put it on the mastoid process and tell the pt to tell you when they no longer hear it and time it. W/o striking it again, you place it beside their ear and time it again. When its beside their ear, it should be twice as long as when they heard it when it was placed on their mastoid process. (3) The pts are supposed to hear it twice as long through air conduction as they do w/ bone conduction. (a) If the pt has lots of wax in their ear or have an obstruction in their ear, they wont be able to hear it twice as long through air conduction. (4) Pts you may need to do a more thorough ear exam or ear assessment on : (a) Elderly b/c we lose hearing as we age (b) Pts taking ototoxic drugs (drugs that are toxic to the ear) (i) Lasix (ii) Aminoglycoside antibiotics 1. Gentamicin 2. Vancomycin 11) Nose and Sinuses a) Ability to smell (tests cranial nerve 1) i) Just ask them to close their eyes and youre going to put something w/ a classic odor (such as coffee, cinnamon, or peppermint) underneath their nose. Never use alcohol. Have them test one nare at a time. Your sense of smell is your most acute smell. b) Inspection i) External (1) Youre looking at the external shape and any presence of deformities. (a) If pt has had a broken nose, they may have a bump on it

Health Assessment and Physical Lecture Notes 19 (b) It may point to the wrong direction (c) Appear more flattened (2) Youre also looking for symmetry. One side of the nose should look like the other side of the nose. (3) Evidence for possible trauma. (4) Flaring nares means that theyre having trouble breathing ii) Nare patency (1) Asking the pt to smell something is helping you figure out which nare is more patent, meaning more open. If they were latent, they would be hidden. Normal is you should be able to breathe in and out w/ both nares. iii) Nasal Discharge (1) Clear, thin discharge from the nose could mean that its cerebral spinal fluid (2) Thicker, clear drainage is normal (3) Yellow and green discharge means infection, usually bacterial (4) Bloody discharge could mean trauma, decreased platelets, Coumadin or Heparin which are anticoagulants iv) Noses are also a common place for skin cancer so look for lesions or ulcerations using the ABCDE v) Normal nose should be midline on the face, should be symmetrical w/ no bleeding, no drainage, and no lesions. vi) You can take your pin light and look inside their nose. Just ask the pt to tilt their head back. Youre going to look at the mucous membranes inside of the nose. (1) What youre looking for is color (a) If theyre really pale, they could be anemic (b) If its red, it could be infection or inflammation (c) If its edematous inside, it usually results from allergies and hay fever (2) Looking at the drainage (a) Clear and thick is normal (b) Green and yellow is an bacterial infection vii) If you have clear and thin drainage coming from the nose or ears, test it for glucose. Cerebral spinal fluid will test positive for glucose. Whereas normal nasal drainage wont test positive for glucose. (1) If pt has had a head injury, you want to test nasal and ear drainage. If it does test positive for glucose, you need to notify your physician. c) Palpation i) Youre palpating your pts sinuses. Your frontal sinuses are across your forehead and your maxillary sinuses are at your cheekbones. If pt has a lot of sinus congestion, the palpation will be uncomfortable and painful. d) Percussion i) Youre going to take your non-dominant hand and push down on an area w/ some force, and youre going to take your other hand and tap on your hand where the skin meets the nail, not on the nail itself. Youre going to listen to the sound that it makes. When you

Health Assessment and Physical Lecture Notes 20 percuss over an air sinus, it should sound hollow. If they have tons of drainage in their sinuses, its going to sound dull. e) Transillumination i) Youre going to take your pt into a dark room and press your pin light onto their maxillary sinuses and ask the pt to open their mouth and youre looking for the glow of the pin light on the hard palate. If their sinuses are clear, it will be brighter. If its congested w/ a lot of junk and mucus, its going to be very dull and dim. 12) Mouth and Pharynx a) Breath i) Smell pts breath. Halitosis is bad breath. Halitosis usually results from: (1) Poor dental care (2) Dental caries or cavities (3) Dont brush their teeth (4) Infection ii) Pts that have metabolic acidosis and very high blood sugars sometimes develop diabetic ketoacidosis and those key tones give their breath a fruity odor. iii) Liver disease will sometimes make a pts breath smell like feces. b) Lips i) Youre looking for color, moisture, and swelling. (1) If their lips are pale, it could mean anemia (2) If theyre cyanotic (blue), it could be b/c they arent getting enough oxygen or that they are cold (3) If theyre lips are really dry, it could mean dehydration (4) You should look for swelling and possible signs of angioedema. (a) Angioedema is swelling of the mouth, tongue, throat, and airways. (i) As those places swell, the amt of air that can get through gets smaller and smaller. (ii) It can kill pts. (iii) Its a side effect of ACE inhibitors and allergic reactions. (5) Youre looking for cold sores or fever blisters. Youll see blisters on pts mouth that could be like herpes blisters, but they arent genital herpes. Cold sores are a result from a herpes virus. They are vesicles that eventually get crusty. (6) Its a prime site for skin cancer. (7) Cherry colored lips are a result from carbon monoxide poisoning. c) Oral mucosa and Gums i) If pts have dentures, you may need to ask them to remove their dentures so you can look at their mucosa and hard palate. You may need to use a pin light. You may need to use a tongue depressor to retract the tongue or cheek to look at the oral mucosa and the gums. ii) Normal oral mucosa is pink, moist, and no lesions. iii) Types of abnormal oral mucosa: (1) Pale, they could be anemic (2) Dry, they could be dehydrated

Health Assessment and Physical Lecture Notes 21 (3) If there are ulcers, they may be taking chemotherapy or radiation treatments (4) If there is bleeding, they may be taking anticoagulants like Coumadin or their platelet levels may be low. Scurvy could be a reason why they have bleeding gums, which is a vitamin C deficiency. Periodontal disease could cause bleeding gums when they brush their teeth. (5) You will look for jaundice or cyanosis in dark skin individuals by looking at their oral mucosa. d) Tongue (tests cranial nerve 12) i) The tongue should be midline, smooth around the edges, and rough on top and pink in color. (1) If its pale, theyre anemic (2) If its dark red, its classic for vitamin b12 deficiency which is a type of anemia (3) If its dry, they are dehydrated. There would be a deep central furrow in the center of the tongue. (4) If its enlarged, its inflammation (5) They could develop thrush which is a white coating of the tongue. Pts receiving chemotherapy and who dont have good functioning immune systems develop thrush. Pts who have a super infection after getting antibiotics develop thrush. (a) Sometimes with super infections get a black furry tongue. For women, after taking antibiotics they can get fungal yeast infections in their genitalia, the same kind of infection could occur on the tongue. ii) Ask the pts to stick out their tongue when testing and it should be straight and midline. (1) If the tongue deviates to one side, they could have had a stroke or some type of neuromuscular disorder. e) Teeth (tests cranial nerve 5) i) Have them clench their teeth and look at their tooth alignment, top teeth should match their bottom teeth. ii) Youre looking for: (1) Teeth that are missing (2) Teeth that are black from cavities iii) Drugs that affect teeth: (1) Iron will make them brown (2) Tetracycline will make them green or grey (a) Not given to pregnant moms or to kids w/ teeth development going on b/c itll affect the color of their teeth f) Hard and soft palate i) The hard palate is at the front of the mouth, on the roof of the mouth. It should be hard and has ridges and should be pink and moist. It should not have ulcers. An abnormality would be a cleft palate where the hard palate doesnt fuse together so theres a space. ii) The soft palate is further back and its smooth. Should be pink in coloration and moist. iii) If theyre swollen, it could mean infection. g) Pharynx (testing cranial nerves 9 & 10. Way to remember it is: 9 and 10 are under the chin.)

Health Assessment and Physical Lecture Notes 22 Its in the back of the throat. Ask the pt to open their mouth and say AHHH, and when youre doing that youre testing cranial nerve 10. You should see the uvula rise and it should rise symmetrically and stay midline. If the uvula deviates, it could mean a stroke. ii) The mucous membranes around the pharynx should be pink and moist. (1) If its bright red, it could mean inflammation. (2) If there are sores or lesions, it could mean inflammation as well iii) Look at the tonsils (1) White patches could mean tonsillitis (2) Looking for drainage w/ inflammation as well iv) Last thing youre looking at w/ the pharynx is gag reflex which is testing cranial nerve 9. Youre going to take a tongue blade and touch the posterior third of the tongue and they should gag. If they dont gag, theyre at risk for aspiration b/c the gag reflex is a protective mechanism. If they lack their gag reflex, they arent safe to eat or drink. 13) Neck a) Neck muscles i) One thing youre going to ask your pt to do is tilt their chin to their chest. For pts who have no difficulties w/ their neck, it shouldnt be an issue or a problem. (1) If the pt tilts their chin to their chest and it causes them pain, it could be nuchal rigidity and its classic w/ meningitis. (2) If you have pts that have cervical spine issues, they could have pain and discomfort in the cervical spine area b/c of the compression and spinal issues. They could have muscle spasms there as well. ii) To test cranial nerve 11, youll put your hands on their shoulders and put a little bit of downward pressure and ask them to shrug against your resistance. iii) You will also place your hand against your pts face and ask them to turn their head against your resistance on both sides. (1) Sometimes when we do surgeries on the neck, we can damage cranial nerve 11 and those pts can have weakness and wont be able to lift or turn against resistance. (2) Pts who have had strokes and have one-sided weakness or paralysis wont have strength there as well. b) Lymph nodes of head and neck i) Lymph nodes run from behind and in front of the ears and underneath the jaw and chin. There are lots of lymph nodes in the cervical and clavicular regions. ii) You can palpate your pts lymph nodes by using the pads of your fingers and gently rubbing along those areas feeling for enlarged lymph nodes. Normally, lymph nodes shouldnt be enlarged or palpable. (1) When pts have infection or have malignancies or cancer such as lymphoma, those lymph nodes will be enlarged and palpable. c) Carotid i) You can palpate the pulsations of your pts carotid artery. You can ask your pt to turn their neck slightly to the side and it helps to relax some of those neck muscles and feel the pulsations. i)

Health Assessment and Physical Lecture Notes 23 (1) You CANNOT simultaneously palpate both carotid arteries b/c it could cut off blood supply to your pts brain and thats NOT a good thing. ii) By using your stethoscope, you can listen for bruits. When listening for a bruit, youre going to use the bell of your stethoscope. All you need to do is turn the tubing to the bell side. The bell of the stethoscope is used for listening to more low-pitched sounds. Press the bell very lightly against the skin. (1) Carotid bruits reflect turbulent blood flow which means the lining of that carotid is clogged or has an accumulation of atherosclerosis. (a) Pts who have those blockages or have all of that buildup are at risk for having strokes b/c its going to decrease blood flow to the brain. iii) Youre going to ask your pts to turn their head away from you and ask them to hold their breath while you place the bell of the stethoscope lightly against or along their carotid artery. (1) Normal is not to hear anything. (a) Youre not going to hear pulsations (2) Abnormal is the presence of a bruit and youre going to hear a whooshing sound. That means there is turbulent blood flow. iv) If the pt has a really long neck, you may need to listen to a couple of different locations. v) The stethoscope goes in your ears w/ the ear pieces pointing forward. d) Trachea i) Normally, the trachea should be midline. You can just very lightly take your fingers and palpate along the trachea and feel for it going straight down. (1) If its not normal and there is something wrong, you can see that trachea deviate to one side or the other. (a) The deviated trachea could mean that there is a big mass or some type of tumor that is pressing on it and pushing it out of its normal location. (b) The pt could have pneumothorax meaning their lung has collapsed. If their lung has collapsed then it pushes their trachea out of midline. e) Jugular Venous Distension (JVD) i) Youre going to lay your pt supine w/o a pillow behind their head and youre going to lay them flat. Youre going to get your eyes down to your pts head or neck level and what youll see from the collar bone and up to the neck; you will see your pts jugular vein distend. It is normal for it to distend in the flat position. Then youre going to raise your pts head of the bed to about 45 degrees and you should see that distension in that jugular vein disappear. (1) Disappearing of the distension is normal (2) Its abnormal if the distension does not disappear. (a) It usually reflects that your pt has fluid overload, too much fluid in their body. (b) Heart failure is also too much fluid in your body so b/c your pts heart is not strong enough to pump that fluid out and that fluid is going to back up someplace (i) It could back up into their lungs and they can have too much fluid in their lungs (ii) It could back into the rest of their body and they could have edema 14) Thorax

Health Assessment and Physical Lecture Notes 24 a) Inspect i) Rate, rhythm and symmetry of respirations (1) Youre looking at your pts respiratory rate and rhythm of their respirations. Youre looking at their chest movement to decide if its shallow, deep, or normal. Youre looking at how hard they are breathing, are they working too hard to breathe? Is their breathing labored or are they breathing really easy? Are they using extra muscles to breathe, like their shoulders rising or neck muscles? Are their nares flaring? (a) Youre looking for cyanosis, if they are having respiratory problems then theyre probably having oxygenation problems as well. (2) You want to look at the symmetry of their chest wall movements. If they are breathing and only one half of their chest is moving, then its abnormal. Its normal for both sides of the chest to be rising symmetrically. (a) If you see the ICSs between the ribs bulging and that means your pt is working really hard to breathe. (b) If there is retraction in the ICSs, those pts may have some obstruction going on. When you see your pt breathe in and its retracting, it means there is obstruction. (3) Normal should be that their RR is between 12 and 20 and their chest rise should be symmetrical, un-labored, and quiet. (4) You can look at their symmetry of respirations by looking at chest expansion. Youre going to place your hands at about the 10th ribs about 2 inches apart and push them together and ask your pt to take a deep breath in. In normal pts, when they take that deep breath, you should see symmetrical separation of your hands. (a) If your pt was having uneven expansion on one side, one hand will move and the other wont. (i) It could mean a collapsed lung (ii) It could mean that the alveoli has collapsed (5) Elderly tend not to have big chest expansion and there is less chest wall movement so you wont see that separation quite as much (6) If pts have had chest or abdominal surgeries, they arent going to take big deep breaths and will have very little chest wall movements unless theyve been given pain meds ii) Patients posture (1) Youre also going to be looking at their posture, if they are up right or sitting in that tripod position, it could mean they are having respiratory issues. iii) AP diameter (Anterior/Posterior diameter or ratio) (1) Pts should be twice as wide as they are deep. The normal AP ratio is 1:2 meaning that they are 1 times deep and twice as wide. The most common abnormalities are: (a) Emphysema (b) COPD (2) Pts who have chronic lung problems end up being equally wide front to back as they are side to side and its called a barrel chest. They usually have a 1:1 AP ratio. (3) In the elderly, b/c of some of their skeletal changes, their AP diameter increases as well. (a) As the skeleton changes, their ribs may become more horizontal.

Health Assessment and Physical Lecture Notes 25 b) Palpate i) You can palpate pts chest for lesions, masses, or nodules. ii) You can also palpate for tenderness if your pt has had some type of chest trauma like a blow to the chest and you may palpate for fractured ribs or other injuries as well. (1) Crepitus (a) A medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue. It feels a lot like bubble wrap. (b) Its a sign that air is underneath the tissues. It happens when air has escaped the lungs. (2) Tactile fremitus (a) The vibrations your feel when a pt speaks. (b) A tremulous vibration of the chest wall during speaking that is palpable on physical examination. Tactile fremitus may be decreased or absent when vibrations from the larynx to the chest surface are impeded by chronic obstructive pulmonary disease, obstruction, pleural effusion, or pneumothorax. It is increased in pneumonia. (i) When palpating for the vibrations, youre using the ball of your hand and youre going to place it on your pts back and ask them to say 99. When they say 99, you should feel the vibration in your hand. Its normal to feel more vibrations at the top and it should decrease slightly as you go down your pts lungs. (ii) If your pt has mucus, fluid, or a tumor, those substances are going to block those vibrations so youre going to feel less vibration. (iii) W/ larger pts, if you are trying to feel vibrations through adipose tissues, you may feel less vibrations b/c it has to go through more tissue density. (c) When palpating your pts lungs, you need to go side to side and then going down to side to side. c) Percuss i) Remember that youre putting pressure on your fingers that are against what youre going to percuss just above the fingernail and doing short hard tapping motions. ii) Youre going to choose every other ICS. Youre going to put your fingers nice and hard against that area and youre going to tap. The normal sound you should hear is resonance and its a low-pitched hollow sound. You are going to go side to side when percussing and comparing. (1) If there is lots and lots of excess air in the pts lungs b/c they have emphysema or some type of other lung disease, its going to sound really hollow and like a drum like when you tap your cheek, thats abnormal in your lungs. Its called hyper-resonance. (2) If your pt has a lot of mucus, or a tumor, or has pneumonia, its going to sound really dull b/c youre percussing through more solid material. 15) Thorax and Lungs a) There are 4 places on each lung on the front of the chest youre going to listen to and they start just underneath the clavicle and another one goes down a little bit further, another one goes

Health Assessment and Physical Lecture Notes 26 down a little bit further, and the last one goes out. Youre going to be listening to 8 different locations on the front of your pt w/ your stethoscope. Youre comparing side to side. b) When youre listening for lung sounds, youre going to be using the diaphragm of your stethoscope. c) Youre going to be listening to 5 different sites on your pts back on each lung. You can ask them to cross their arms in the front and it will separate the scapula and it will help you to get more lung space to listen to. d) Dont put your stethoscope over breast tissue or a big muscle mass. It will be much more difficult to listen through lots of mass or tissue. Youre going to listen by comparing each side, youre going side to side. Youre going down and out under the scapula. i) Auscultation of Normal Breath Sounds (1) You have different lung sounds in different areas of your lungs and you need to know where theyre found and what each of them sound like. (a) Bronchial sounds (i) Heard on the trachea. (ii) They are loud, really hollow sounding, and high-pitched. (iii) You hear them longer and louder on expiration. (b) Bronchovesicular sounds (i) You can hear them on your pts back between the scapula and on the front at the 1st and 2nd ICS on either side of the sternum. (ii) They are medium-pitched, kind of blowy sound. (c) Vesicular sounds (i) Heard in the periphery of the lungs. (ii) They are soft, low-pitched sound. (iii) They are heard more on inspiration. (2) The best way to hear these sounds are by having your pt breathe in and out through their mouth using big, deep breaths. (3) Make sure your stethoscope is on your pts skin and not on their gown. You are comparing side to side. ii) Auscultation of Adventitious (Abnormal) Breath Sounds (1) Crackles (Rales) (a) A crackling, popping kind of sound (b) Often described as rubbing your fingers in your hair, rubbing them back and forth (c) It usually represents fluid in the lungs (d) You tend to hear them more on inspiration (2) Rhonchi (a) Has a kind of low-pitched snoring sound

Health Assessment and Physical Lecture Notes 27 (b) Often means mucus or secretions in the lungs (i) When the secretions start to fill up some of the tubules and things in the lungs, so as that air is trying to get through there is creates that snoring sound (3) Wheezes (a) Its a whistling sort of musical noise that is made when air is trying to get through narrowed airways (b) They mean narrowed airways (i) Pts w/ asthma tend to wheeze when their airways are constricted and air is trying to get through those airways to their lungs (4) Stridor (a) Its harsh and high-pitched and often times loud that you can hear it even w/o a stethoscope (b) It means airway obstruction (i) They are usually gasping when trying to get air around the obstruction (5) Pleural Friction Rub (a) It sounds like sand paper, kind of like a dry rubbing grating sound that you can hear. (i) If the pleural linings in the lungs are inflamed, you may hear the grating sound. (ii) Pleural friction rubs are the squeaking or grating sounds of the pleural linings rubbing together and can be described as the sound made by treading on fresh snow. They occur where the pleural layers are inflamed and have lost their lubrication. Pleural rubs are common in pneumonia, pulmonary embolism, and pleurisy (pleuritis). Because these sounds occur whenever the patient's chest wall moves, they appear on inspiration and expiration. (6) If there is an obstruction in one of the lungs, you arent going to hear any breath sounds. (7) If the alveoli have collapsed and they have atelectasis, youre not going to hear as many breath sounds. They are going to be decreased b/c the alveoli arent filling w/ air.

Health Assessment and Physical Lecture Notes 28 16) Heart

a) The base of the heart is at the top, and the apex of the heart is at the bottom. i) The apex is located at the left 5th ICS at the midclavicular line. Its also where we listen to the apical HR. Its also called the PMI (point of maximum impulse). If you put your hand at the 5th ICS at the midclavicular line, you can feel the pulsations of the heart b/c thats where its closest to the skin surface. (1) Heart Sounds (a) S1 (i) Lub sound (ii) Contraction of the ventricles (mitral & tricuspid) (iii) When you feel the carotid artery pulsation, thats the S1 sound. (b) S2 (i) Dub sound (ii) Relaxation of the ventricles (pulmonic & aortic valves close) (2) Inspection (a) Upon inspection, you should not see any pulsations on the chest coming from the heart. You might see some pulsations from your aorta and it might be normal for really skinny ppl.

Health Assessment and Physical Lecture Notes 29 (3) Palpation for thrills and heaves (a) You are going to go to each of those 5 locations looking for thrills and heaves using the ball of your hand and fingertips. (i) Thrill is a vibration that is like a cat purring. When feeling for thrills, you use the ball of your hand. 1. A vibration usually means that there is a murmur. (ii) Heaves are like a thrusting, a big push of the heart that is up against the hand. To feel for heaves, you use your fingertips. 1. Heaves show that the heart has to work really hard to do its job. Increased workload of the heart. (b) You can go up to the suprasternal notch that is high up at the gastric area for pulsations and its normal to feel that and see those pulsations as well. (4) Cardiac Landmarks (a) Aortic- Right 2nd ICS (b) Pulmonic- Left 2nd ICS (c) Erbs Point- Left between 3rd & 4th ICS (d) Tricuspid- Left 5th ICS (e) Mitral/PMI (Point of Maximum Impulse)- Left 5th ICS midclavicular line (i) Where you listen to the apical heart rate (ii) Also where the apex of the heart is located (5) Two Mnemonics: (a) All Pigs Eat Too Much (b) All People Enjoy Time Magazine (6) Auscultation (a) Youre going to put your stethoscope, listening w/ the diaphragm, at each of the 5 cardiac landmarks listening for heart sounds. They will sound slightly different at each of those areas. (i) At Erbs point, youre going to hear both the lub and the dub equally strong. (b) What is normal is that the rhythm is regular, the intervals are 1 beat to the next and has the same amt of time in between and same amt of pause in between 1 beat to the next.

Health Assessment and Physical Lecture Notes 30 (i) If the pt has some abnormalities, you may hear extra sounds either before the lub or after the dub. Those extra sounds may be called S3 or S4. Pericardial Friction Rub (i) It sounds like a grating sandpaper kind of sound. 1. If the pericaridial sac of the heart is inflamed, you may hear the grating sound. If you hear an irregular rhythm, you can go ahead and assess for a pulse deficit. (i) It could mean that the contraction of the ventricles may not be creating enough strength or enough up flow of blood to actually create a pulse on your pt. (ii) Have one nurse count the apical HR and simultaneously you have another nurse count the peripheral pulse and you are going to compare those numbers. After listening to heart sounds w/ the diaphragm of your stethoscope, you can then go on to listen w/ the bell of your stethoscope for murmurs or a low-pitched sound. (i) To help you find those murmurs, you can have your pt turn to their left side or have them sit up and lean slightly forward to bring the heart closer to the chest wall. At a minimum, youre going to listen to the heart w/ the diaphragm of your stethoscope. If you pt has a hx of cardiac problems or has some type of problem where you need to investigate the cardiac status more then you will look for thrills and heaves and listen w/ a bell.

(c)

(d)

(e)

(f)

17) Abdomen a) The order of the assessment for the abdomen is different. i) The reason is if you were to percussing before auscultating, it will affect the bowel sounds. b) The best position to do an abdominal assessment on your pt is supine, lying on their back. You can put a pillow underneath their knees b/c it helps relax the abdominal muscles. (1) Inspection (a) Be sure to expose their stomach before assessing. (i) Symmetry 1. Youre looking at the shape and symmetry of their stomach. One half should look like the other half. If the stomach is bulging, it could be b/c of a: a. Hernia b. Tumor c. Bowel obstruction d. Organs could be enlarged 2. Look at the shape of the stomach. a. If the pt has distension, it is big and is usually firm and hard. It could be b/c of: i. Lots of stools ii. Bowel obstruction iii. Air that is accumulating in the stomach iv. Pancreatitis (ii) Umbilicus

Health Assessment and Physical Lecture Notes 31 (iii) Peristalsis 1. Sometimes on thin pts, you can see visible waves of the intestines moving the food through. But normally on most ppl, you can see that. (iv) Pulsations 1. You want to look at the aorta and look for pulsations. It may be normal to see that w/ thin pts. (v) Scars, striae, masses 1. Look for previous scars and striae (stretch marks). Pts who may have striae: a. Women whove had babies b. Ppl who have gained weight c. Pts who have liver disease 2. Youre also looking for visible masses. If you see bulging at the belly button, it could mean a hernia. 3. If pt has had an abdominal surgery, you want to look at the incision. What youre looking at the incision for are: a. Redness which could mean inflammation b. Yellow or green drainage could mean infection c. You want to make sure the incision edges meet which is called well approximated. d. Warmth b/c it could mean infection or inflammation e. Odor (2) Auscultation (a) Beginning with the RLQ, RUQ, LUQ, LLQ. (i) RLQ- its where the ileocecal valve is located, where the large and small intestines meet, and where youre most likely to hear bowel sounds. Bowel sounds represent peristalsis of the intestines. Youre going to use the diaphragm of your stethoscope and put it over the RLQ and listen for a good amt of time. (ii) You cannot tell if your pt has active bowel sounds until youve listened for 5 minutes b/c pts may have slow bowel sounds. Normal is to hear bowel sounds every 5 to 15 seconds. They sound like gurgling. (iii) When listening to the bowel sounds, you can listen to them w/ the bell of your stethoscope and listen for these sounds: 1. Normal a. You wouldnt hear a sound 2. Tympany a. It sounds like tapping on your cheek. Its a hollow sound. It sounds like a drum. 3. Dullness a. If you hear a dull thud while percussing, it means that there is something abnormal there. It could mean: i. Enlarged organ ii. Tumor

Health Assessment and Physical Lecture Notes 32 iii. Fluid 4. Bruits a. Bruits in the abdominal aorta could mean that the pt has had an aneurysm. You would hear an abnormal whooshing sound. i. Never palpate over a bruit b/c you can cause the aneurysm to rupture. b. You can also listen for bruits in the femoral arteries as well should you need to. 5. Hyperactive or hypoactive sounds a. Hypoactive bowel sounds- you hear 1 or 2 bowel sounds every 2 minutes or so or < 5 to 15 seconds. Pts who may have these bowel sounds: i. Surgical pts, why: ii. Anesthesia slows everything down iii. Pts who are taking pain meds b/c it slows everything down as well b. Hyperactive bowel sounds- sounds like youre hungry i. Pts who are hungry may have these bowel sounds ii. Pts w/ diarrhea b/c they have a lot of peristalsis going on c. Absent bowel sounds where you dont hear any at all i. If you give a pt food when they have absent bowel sounds, it could either sit there or they could throw it up. After a pt has had abdominal surgery, you need to make sure the bowel sounds have resumed before you start giving them food. (3) Percussion (a) When pts are lying in the supine position, it causes air to rise to the surface. Start w/ the RLQ, press your fingers hard against your pts stomach, and tap on it. The normal sound you should hear in your pts stomach is called tympany. In the RUQ, you should anticipate that youll hear a more hollow sound. (4) Palpation (a) Start in the RLQ, you are going to palpate w/ a circular motion and feel for: (i) Tumors or mass (ii) Nodules (iii) Enlarged areas (iv) Areas of tenderness (b) Normally, stomachs are really soft and gushy. If the stomach is really distended, it will feel hard and firm. If the pt has peritonitis (inflammation of the peritoneal cavity) they get a really rigid, hard, and firm stomach and need to notate it b/c its abnormal. (c) If the pt has RLQ pain, you will leave that Q to percuss and palpate for last. (i) The appendix is located in the RLQ, so you need to think that they could potentially have appendicitis. For these pts, you can do a test called rebound tenderness. You take your fingers and kind of push in on their stomach and

Health Assessment and Physical Lecture Notes 33 quickly release it. When you quickly release it, it causes pain. Its not the pressure down; its the quick release that elicits tenderness and pain. (d) If a pt is larger and has a lot of adipose tissue, you may need to palpate using both hands. (e) You can also palpate for costovertebral tenderness which is down at about the 12th rib, you take your hand and put it over their back and you tap on it, it will illicit pain and you see that w/ pts who have kidney problems. It could be an infection w/ their kidneys, kidney stones, or some type of kidney problem that will illicit pain when you tap at the 12th rib. 18) Vascular System a) Inspect i) Youre looking for color. (1) If your pt isnt getting sufficient circulation, you may see pale or pallor or cyanosis. (2) You may also see increased redness or erythema b/c of inflammation (3) Look at pts lower extremities b/c those who have venous disease or venous return often get brown staining on their lower legs. It means poor venous return to the heart. ii) Youre also looking for excessive bruising. It means that theyre bleeding. Pts who have problems w/ bleeding are: (1) Pts on anticoagulants (2) Pts who have low platelets (3) Pts who are taking ASA (4) Pts on Heparin iii) The different types of bruising that you will see: (1) Petechia (2) Purpura (3) Ecchymosis iv) Youre looking for varicose veins which are big, enlarged torturous veins. v) Youre looking for ulcers. Pts who develop ulcers: (1) Pts who dont have enough arterial circulation (2) On their extremities b/c they have poor venous circulation vi) Looking for edema. (1) If your pt has heart failure, their heart cant pump out enough blood, that blood flow causes things to back up and when it backs up, pts get peripheral edema. (a) These pts may have JVD (b) Edema in their legs (c) Edema in their stomach (d) Edema on their sacrum if theyve been bed ridden vii) Youre also looking at hair distribution on the legs. Pts who have circulation problems, such as peripheral vascular disease, will lose hair on their lower extremities. b) Palpate i) Bilateral peripheral pulses: radial, brachial, femoral, posterior popliteal, posterior tibial, and pedal

Health Assessment and Physical Lecture Notes 34 (1) Youre going to simultaneously palpate the right and left radial pulse. Youre not counting at this point, youre comparing. Does the right pulse feel like the left pulse? (a) If you cant find a radial pulse, you can move on up and find the brachial (i) Pts pulses may feel different if they have blockages in those vessels, so youre not having as much blood flow go through or the pts BP is really low, you may not be able to feel peripheral pulses. (2) Youre also going to palpate both pedal pulses at the same time and compare them. (a) If a pt has severe peripheral vascular disease in their legs, you may not be able to find a peripheral pulse. (i) The next step would be to try and palpate the posterior tibialis pulse. (ii) If you cant find a pedal pulse, you are going to go get a Doppler, and use a Doppler to try and find that pulse as well. 1. Sometimes they are a little more difficult to find if your pt has a lot of edema and when you take a Doppler which is going to use sound waves and w/ some transducer gel, you should be able to find and hear the pulse. (b) Youre trying to find the pulses to see if they have good circulation to their peripheral extremities and distal areas. If they dont have good circulation, tissues could start to die. (c) If you use a Doppler to find their pulses, you should take your marker and mark the spot so that the next RN can find it a little bit easier. ii) Skin temperature (1) Youre going to compare the skin temperature of one limb as opposed to the other simultaneously. (a) If your pt has circulatory problems w/ one leg and the other leg is fine, then the one w/ the problems is going to be cooler to touch. iii) Capillary refill (1) Youll also be able to do capillary refill on your pts toes and comparing the left side to the right side. c) Test Sensation i) Youre really combining neuro and vascular together and doing them both at the same time. 19) Musculoskeletal System a) Youre going to compare one side of the body to the other side. i) Inspection and Palpation (1) Joints (a) Youre looking for redness or tenderness. (i) If a pt has periostitis of a joint, it could indicate inflammation or infection. (2) Hand grasps (a) Youre going to ask your pt to grasp your fingers. Youre going to use them to squeeze your fingers w/ both hands at the same time. Youre looking to see that both hands are equally strong w/ the opposite hand. (3) Movement against resistance

Health Assessment and Physical Lecture Notes 35 (a) You can also ask your pt to push against your hands and pull against your hand. These tests are testing for strength. Pts who may have problems w/ strength are: (i) Pts who have had a stroke (ii) Somebody who is in the process of having a TIA where theyve got muscle weakness (iii) Somebody whos had a spinal cord injury will not have motion (iv) Pts who are dehydrated (v) Pts who have an electrolyte disturbances 1. Hypokalemia, low potassium will cause them to be weak and will cause their bowel sounds to be hypoactive (b) They can do these tests with their arms, lower legs, and thighs. (4) Crepitus (a) You can also test joints for the cracking and popping sound that crepitus makes. When you hear or feel crepitus w/ a joint, the joints are rubbing together. The cartilage and things are gone so those tissues are abnormally rubbing together. (b) Pts w/ arthritis, you can hear more crepitus. (c) You may hear crepitus for a couple of different reasons: (i) Sometimes if your pt has some type of infection of the bone or around that joint they may have increased crepitus (ii) If your pt has an unstable bone fracture, it could make that crepitus sound and you dont want to be moving it around (5) Symmetry (a) Looking at your pts back, when theyre standing are their shoulders even, are their gluteal folds even, are their hips even or are they off kilter? Their shoulders, gluteal folds, and hips should be straight across from one another. Scalpula should be straight across. (b) Different skeletal deformities you need to look for: (i) Kyphosis- hunchback 1. Found in elderly (ii) Cushings disease 1. Pts can develop a fatty hump as a result of this disease or lots of steroids such as Prednisone (iii) Lordosis- accentuated lumbar curve, almost duck like 1. Pts who are very obese (iv) Scoliosis- lateral curve to the spine 1. When pts bend over, you can see the curvature

Health Assessment and Physical Lecture Notes 36 ii) Range of Motion (ROM) (1) If its appropriate for your pt. This is testing to see that the joints move in all positions that it should normally move. (a) Can the pts wrist go up and down, side to side, can their elbow go back and forth, can they raise their shoulders b) Normal assessment of the musculoskeletal system is: i) The spine is straight ii) Joints are free of pain and swelling and have full ROM iii) Equal strength on both sides 20) Neurological System a) Neurological and vascular go together. Youre doing this w/ every pt. Mental Status/LOC (level of consciousness)- Orientation X 4 (1) LOC- Is the pt awake? Are they really sleep and lethargic? Are they comatose? (a) If the pt is awake and alert they should be able to respond and recognize when a nurse walks into the room (b) If the pt is sleeping, they should be able to wake up and respond to the nurse vs lethargic is when the pt is having a hard time staying awake and having a hard time interacting w/ the nurse (c) The comatose pt does not wake up (i) You may need to resort to using painful stimuli to see if they will respond. You can either press against a nail bed using a pen or rub on their sternum. (2) Orientation- Does your pt know who, where, and what they are. Determining their orientation uses 4 questions: (a) Can you tell me your name? (b) Can you tell me where you are? (c) Can you tell me the date? (d) Why are you here? (i) Pts usually lose why they are here 1st, then lose date and time, then theyll lose where they are, and theyll lose who they are last. 1. If they can answer all of those questions accurately, they are oriented times 4. If they cant tell you why they are there then they are oriented times 3. If they cant tell you why they are there and the date and time, they are oriented times 2. If they can only tell you their name, they are oriented times 1.

i)

Health Assessment and Physical Lecture Notes 37 (ii) If the pt has been in the hospital for a long period of time, they may not know the date and time so you can ask them who the president is or what year it is. Sensation (1) Sensation in the face tests cranial nerve 5 which is the trigeminal nerve (2) You can do sensation testing on arms, legs, and other parts of the body as well. (3) Use the same procedure you use when testing sensation in the face. (4) Pts you may need to test sensation in: (a) Pts who have had a stroke (b) Pt who has had a spinal cord injury (c) Pt who has diabetes b/c they sometimes lose sensation and feeling in their feet and legs (i) MDs will use a monofilament test where there is a handle w/ a piece of rigid fishing line and they will touch it to the pts foot until it bends and the pt should be able to feel that (5) Ask you pts about paresthesia which is numbness or tingling or any abnormal sensations in the arms, legs, or feet (a) Pts who have diabetes get numbness and tingling in their feet (b) Pts w/ back problems may have numbness and tingling down part of their leg (i) Some pts will have it on the back of their leg where the front will feel fine (c) Pts w/ cervical back issues will complain of numbness and tingling in their arms (6) Anytime youre concerned about blood flow to a certain extremity you should do a neurovascular assessment on them if they have a cast on it and to make sure its not too tight (7) If a pt has a lot of swelling in an extremity, youre going to do a much more thorough assessment to make sure the swelling isnt compromising the blood flow or nerve functioning to the extremity Cranial Nerves Gait (1) Assess how the pt walks (2) Normal is it should be heel to toe and their arms should be swinging by their sides and they should be upright and straight (3) If a pt is limping, its not normal (4) Pts w/ Parkinsons disease tend to shuffle and get out of alignment meaning their head starts getting further and further in front of their toes until they start to go faster and faster and lose their balance and fall Cerebellar Function- Rombergs test (1) Cerebellum is involved w/ balance. (2) Youre going to have your pt stand w/ their feet together w/ you standing in front of them so you can catch them if they were to start and fall and then you ask them to close their eyes. When they do, they should have a little bit of swaying but they should be able to maintain their balance and stay on their feet. They should be able to stand w/

ii)

iii) iv)

v)

Health Assessment and Physical Lecture Notes 38 their eyes closed for 20 seconds w/ maintaining their balance and have minimal swaying. vi) Coordination (1) Ask your pts to take their finger and touch their nose and they should be able to and the nurse sticks her finger out and the pt should be able to touch their nose and then the nurses finger and the nurse just moves her finger. (2) When testing the lower extremities, ask the pt to take their heel and run it down their shin while theyre sitting down. vii) Deep Tendon Reflexes (DTR) (1) You just take a reflex hammer and the deep tendon reflexes are a natural response to stimuli, you dont think about it, it just automatically happens. You just tap the triceps or the patellar, just below where the knee cap is and when you tap it, your pts foot should just automatically swing up. When you tap the biceps, its going to cause the arm to jerk outward. (2) If a pt has had a stroke, spinal cord injury, or electrolyte imbalances (such as low potassium or elevated calcium or calcium deficiencies will cause changes in their DTR) they may not have active DTR viii) Babinski Reflex (1) You start at the heel and go along the outside of the foot and curl up underneath the toes using a pin light or the end of the reflex hammer (a) Normally in an adult, the toes should curl in (b) In an abnormal Babinski, the big toe stands up and the other toes fan out (i) Its a sign of a head injury in an adult (ii) Its normal in children up to the age of 2 21) Cranial Nerves i) Olfactory- sense of smell ii) Optic- visual acuity iii) Oculomotor- muscles that move the eye and lid, pupil constriction iv) Trochlear- muscles that move the eye v) Trigeminal- facial sensation, chewing vi) Abducens- muscles that move the eye vii) Facial- facial expression, taste viii) Auditory- hearing and equilibrium ix) Glossopharyngeal- taste, swallow and gag reflex, x) Vagus- parasympathetic innervations of the thoracic and abdominal organs and muscles of throat and mouth xi) Spinal accessory- sternocleidomastoid and trapezius muscles xii) Hypoglossal- tongue movement Mnemonic to use for remembering the cranial nerves:

Health Assessment and Physical Lecture Notes 39 Cranial nerve 1 is 1 nose Cranial nerve 2 is 2 eyes Cranial nerves 3, 4, and 6 make your eyes do tricks Cranial nerve is 5 is try Cranial nerve is facial Cranial nerve 8 is the shape of the ear Cranial nerves 9 and 10 are under the chin YouTube Links for Heart & Lung Sounds Crackles: http://www.youtube.com/watch?v=9C5RFb1qWT8&NR=1 Wheezes: http://www.youtube.com/watch?v=YG0-ukhU1xE&feature=related Rhonchi: http://www.youtube.com/watch?v=QPBZOohj2a0&NR=1 Bronchial vs. Vesicular Sounds: http://www.youtube.com/watch?v=nhUT5BfAFic&feature=related Normal Breath Sounds: http://www.youtube.com/watch?v=h7BtrWATfg8 Heart sounds: http://www.youtube.com/watch?v=2aO0HKIP3vI Abnormal Heart Sounds: http://www.youtube.com/watch?v=XvtBpnV_lOE&feature=related Online Resources Breathing Patterns: http://www.breathsounds.org/docs/Breathing%20Patterns.pdf Easy Auscultation: http://www.easyauscultation.com/ Practical Clinical Skills: http://www.practicalclinicalskills.com/

Health Assessment and Physical Lecture Notes 40

Nursing Assessment Lecture Notes

22) Types of Data a) Subjective i) From pts point of view ii) What pt or family tells you (1) I am having trouble breathing b) Objective i) Observable and measureable ii) Using standard assessment techniques, lab values, diagnostic tests iii) Resp. rate 24, crackles auscultated in lung bases, O2 sat 90% 23) Assessment a) Obtain baseline of data regarding the patients overall health status and begins to establish the nurse-client relationship & ID nursing problems b) Comprehensive c) Focused d) Ongoing e) Emergency 24) Nursing Health History a) Demographics b) Reason for seeking healthcare c) Previous illness, hospitalizations and surgeries d) Client/ family hx e) Allergies f) Current medications g) Culture & religious beliefs/psychosocial h) ADLs i) Review of systems