NURSING PROCESS 4 Types of Assessment

Assessing 1. initial (during admission)

2. problem-focused (on-going
 collect data 3. emergency (during crisis)
 organize data 4. time-lapsed (several months after interval)
 validate data
 document data Collecting Data

Diagnosing Database – all information about the client

 analyze data Types of Data

 identify health problems, risks, and strengths
 formulate diagnostic statements A. Subjective/Covert Data (Symptoms)
 apparent, described and verified by the
Planning person/client only
 includes client’s sensation, feelings,
 prioritize problems/diagnoses
attitudes, beliefs and perception
 formulate goals/desired outcomes
B. Objective/Overt Data (Signs)
 select nursing interventions
 can be seen, heard, felt, or smelled
 write nursing interventions
 obtained by observation or physical
Implementing examination

 reassess the client Sources of Data

 determine the nurses’ need for assistance
A. Primary Sources
 implement the nursing interventions
1. Client – the best source of primary data
 supervise delegated care
B. Secondary Sources
 document nursing activities
1. Family and Significant Others
Evaluating  can be primary sources of info about
infants/children, critically ill, mentally
 collect data related to outcomes handicapped, disoriented or
 compare data with outcomes unconscious clients
 relate nursing actions to client goals/outcomes 2. Client Records
 draw conclusions about problem status  medical records of therapies
 continue, modify, or terminate the client’s care  enables the nurse to identify past &
plan present patterns of health & illness –
ASSESSMENT coping behaviors, health practices,
previous illnesses & responses to
Assessing treatment, allergies
 other records such as educational,
 the systematic and continuous collection,
military, and employment records
organization, validation, and documentation of
3. Health Care Professionals/Team Members
data or information
 physicians, nurses, physical therapists,
 continuous process done in all phases of NP
social workers, community health
workers, etc.
 sharing of info ensures continuity of
care and verification of information
 4. Literature perceptions and feelings and what is
 pharmacological, nursing, and important to patients
medical literature about an illness
Types of Questions
 establish standards of therapeutic
process 1. Closed Questions
5. Nurse’s Experience 2. Open-Ended Questions
 a nurse’s ability to make an
assessment will improve from using Interviewing Techniques
past experience , applying relevant
1. Open interview shortly with a courteous greeting
knowledge, and focusing on data
– introduce self.
collection
2. Don’t rush.
Data Collection Methods 3. Allow enough time for the interview.
4. Explain that information from the interview if
1. Observation/Observing confidential.
 gathering data by use of senses 5. Actively listen to what your patient is saying.
 conscious deliberate skill 6. Maintain eye contact.
 two aspects: noticing the data and selecting, 7. Work at the same level with your patient. Pull up
organizing, & interpreting the data a chair and sit next to her or him.
2. Interviewing 8. Don’t invade your patient’s personal space. Two
 is a planned communication or conversation or four feet away is a comfortable distance for
with a purpose most patients.
 interpersonal skill is used in a healing way to 9. Consider your patient’s cultural background
help the patient (therapeutic use of self) 10. Consider your patient’s developmental level.
11. Don’t become preoccupied with writing. You may
Techniques that Enhances Therapeutic Use of Self convey to the patient that the forms you are
1. showing empathy completing are more important than he or she is.
2. giving recognition 12. Be nonjudgmental.
3. demonstrating acceptance (maintaining a neutral, 13. Avoid “why?” questions; they tend to put patients
nonjudgmental position and demonstrating on the defensive.
acceptance of patient’s verbal and nonverbal 14. Nonverbal behavior is more accurate than verbal.
communication) 15. Take a good look at your patient’s nonverbal
behavior. Is it consistent with what he or she is
Types of Interview telling you?
16. Present reality
1. Directive
17. Be honest
 highly structured and elicits specific
18. Provide reassurance and encouragement
information
 used when time is limited; client has limited Planning the Interview and Setting
opportunities to ask questions/discuss
a) Time – when client is physically comfortable;
concerns
interruption is minimal; in client’s home at a time
2. Non-Directive/Rapport-Building
selected by the client
 nurse allows client to control purpose,
b) Place – private, well-lighted, well-ventilated, free
subject matter, and pacing
from distractions
 nurse summarizes and clarifies data; more
c) Seating arrangement – sitting at 45-degree angle
time needed; effective in eliciting patient’s
to the client’s bed, horse-shoe, circular
 d) Distance – about 2-3 feet away 3. Closing – nurse or patient terminates the
e) Language – use of common terms understandable interview (offer to answer questions; conclude;
to the client; observe confidentiality, use of thank; express concern; plan for next meeting;
translators as necessary provide a summary)

PHASES OF AN INTERVIEW C. Examining

Before beginning the interview, gather Physical Examination/Physical Assessment - systematic

preliminary data. Consider the most appropriate data collection method which uses the technique of
method for conducting the interview. Discuss the types inspection, auscultation, palpation, and percussion
of questions that will be asked and the client’s role in
the process. Physical Exam

Introductory Phase  provides the objective data base

 helps you assess the patient’s health status and
 the time to introduce yourself to your patient,
identify actual or potential problems
put him or her at ease, and explain the purpose
 taking of V/S, other measurements, and the
of the interview and the time frame needed to
examination of all body parts using the
complete it
techniques of inspection, palpation, percussion,
 explain that you will be taking notes, but keep
and auscultation (IPPA)
writing to a minimum
 any problem detected during the general survey
 reassure patient that information collected is
should be further evaluated during physical
kept confidential
examination
Working Phase
General Survey
 often where data collection occurs
 structured and also the longest phase  first impression of your patient begins as you
 listen to what she is saying, both verbal and meet him or her
nonverbal  use your senses and observational skills to
 take minimal notes and document data after assess for clues that might signal a problem
rather than during the interview
Components of a General Survey
Termination Phase
1. Signs of Distress
 summarize and restate your findings 2. Facial Characteristics
 provides an opportunity to clarify the data and 3. Body Type
share your findings with the patient 4. Gait
 discuss follow-up plans 5. Posture
 give a clue that the interview is coming to an 6. Speech
end 7. Dress, Grooming, and Hygiene
8. Mental State
Stages of an Interview

1. Opening /Introduction – the most important part;

the purpose is to establish rapport (creating
goodwill and trust) and orient the interviewee)
2. Body – client communicates what he/she thinks,
feels, knows, and perceives in response
 Organizing the Data 7. Self-Perception/Self-Concept Pattern
 individual’s attitudes about self, perception of
Using a written format such as the nursing health abilities, body image, identity, general sense
history, nursing assessment or nursing database form of worth and emotional patterns
 assess descriptions of self, physical
Gordon’s 11 Functional Health Patterns
appearance, effects of illness, major life
1. Health Perception-Health Management accomplishments, and changes
 client’s awareness of personal health & well- 8. Role-Relationship Pattern
being  client’s perception of major roles and
 health practices responsibilities in current life situation
 understanding of how health practices  assess client’s perceptions of key
contribute to health status relationships, observation of interaction with
 to assess this pattern, focus on a general others
survey of the client’s health status and their 9. Sexuality-Reproductive Pattern
usual behaviors  client’s perceived satisfaction/dissatisfaction
2. Nutritional-Metabolic Pattern with sexuality pattern
 patterns of food intake, relationship of intake  reproductive stage and pattern
to metabolic needs  assess client’s appraisal of his/her sexual role
 skin assessment, fluid volume, and sexual health
thermoregulation 10. Coping/Stress Tolerance Pattern
 to assess this pattern, focus on eating habits,  general coping pattern, stress tolerance &
appraisal of appetite, weight loss or gain management, support systems
3. Elimination Pattern  perceived ability to control and manage
 patterns of excretory function situations
 asses usual bowel and bladder elimination  assess current stress level, coping ability to
habits, laxative use, excretory function of skin endure life stressors, physiologic responses to
4. Activity-Exercise Pattern stress
 patterns of exercise, activity, leisure 11. Value-Belief Pattern
recreations, and ADL  values, goals, or beliefs that guide choices or
 factors that interfere with desired or decisions
expected individual pattern  assess identification of values people and
 assess mobility status, exercise routine, possessions, source of support, religious
leisure activities, cardiovascular status practices
5. Sleep-Rest Pattern
COLLECTING SUBJECTIVE DATA
 patterns of sleep and rest-relaxation periods
during 24-hour day Health History
 assess regular sleeping habits and routines
6. Cognitive-Perceptual Pattern  provides the subjective database for your
 adequacy of sensory-perceptual and cognitive assessment
patterns  subjective, allowing you to see your patient
 assess changes in cognitive function, ability to through his or her eyes
hear, see and speak, presence of pain,  provides a holistic, qualitative picture of patient
numbness, or other sensations  consists of what the patient thinks is important
Purposes of the Health History  ask about health status and ages of patient's
family member
 provide the subjective database
 may be recorded in one of two ways: list
 identify the patient’s strengths family members along with their age and
 identify patient’s health problems, both health status or use a genogram (family tree)
actual and potential
 identify supports Another tool in taking family history is an ECOMAP -
 identify teaching needs assessment tool that identifies the needs, patterns, and
 identify discharge needs relationships among family members and the
 identify referral needs environment, such as school, work, church, healthcare
system.
Types of Health History
Characteristics of an ECOMAP include:
 Complete Health History
 Focused Health History  depicts the nature of the relationships with the
external systems
D. Past Health History  identifies both positive and negative relationships
 explores prior illness, injuries, medical with the external systems
interventions  identifies the flow of energy and resources
 obtaining data about the client’s past can help between family members and the environment
the health worker draw probable associations  allows you to see each member within the whole
between the present complaint and what has family unit and the relationship with the
occurred in the past environment
 also explain patient’s response to illness, F. Psychosocial History
healthcare, and healthcare workers  a description of a typical day, nutritional
 be sure to ask for dates physician’s names, assessment, activity and exercise patterns,
names of hospitals, and reasons for recreational activities, sleep/rest patterns,
hospitalizations or surgeries personal habits, occupational risks,
environmental risks, family roles and
Categories of Past Health History
relationships and stress coping mechanism
A. Childhood Illness Psychosocial History includes:
B. Medical History
C. Surgical History  Health Practices and Beliefs
D. Immunization  Nutritional Patterns
E. Allergies  Activity and Exercise
F. Accidents or Injuries  Recreation, Hobbies, Pets
G. Serious/Chronic Illnesses  Sleep/Rest Pattern
H. Ob-Gyne History  Occupational Health Patterns
I. Recent Travels  Socioeconomic Status
J. Medications  Environmental Health Pattern
K. Military Service  Roles, Relationships, Self-Concept & Social
Supports
E. Family History
 Cultural
 provides clues to genetically linked or familial
 Spiritual
diseases that may be risk factors for your
 Sexuality
patient
G. Review of System Barthel Index
 a system by system review of the functions of
the body  a patient scoring 100 BI is continent, feeds himself,
dresses himself, gets up out of bed and chairs,
 begun during the interview with the patient
bathes himself, walks at least a block, and can
and completed during the physical exam as
ascend and descend stairs
physical findings prompt further questions
 this does not mean that he is able to live alone: he
Purposes: may not be able to cook, keep house, and meet
the public, but he is able to get along without
 to ask and identify the problems of each major attendant care
system
 a score of zero is given in all of the above activities
 to make sure that you have not missed any
when the patient cannot meet the criteria as
important symptom especially in areas that you
defined above
have not thoroughly explored
PHYSICAL EXAM
FUNCTIONAL ASSESSMENT
Physical Examination
 It includes ADLS such as eating, bathing, dressing,
transferring, toileting and ambulation PA is a head-to-toe review of each body system
 IADLs (I meaning Instrumental) include taking that offers objective information about the client and
medications, paying bills, using the telephone, and allows the nurse to make clinical judgments.
using public transportation
Purposes of Physical Examination
Gordon's Functional Health Pattern
 to gather baseline data about the client's
 organization of data into 11 functional groups that functional abilities to supplement, confirm, or
contribute to a person's overall health and well- refute (to prove falsity or error) data obtained in
being, quality of life, and attainment of human the nursing history
potential  to obtain data that will help establish nursing
 used not only among older adults diagnosis and plan of care
 to evaluate the physiological outcomes of health
Instrumental Activities of Daily Living (IADL) care and the progress of a client's health problems
 include activities/areas like telephone, travelling,  to identify areas of health promotion and disease
shopping, preparing meals, housework, prevention
medication, money  to make clinical judgments about clients health
status
The Katz Index of ADL
Types of Physical Assessment
 one of the best ways in evaluating the health
status of older adults 1. Complete PA
2. Focused PA
Score Interpretation Include:
Preparation for Examination
 6: indicates full function
Client Preparation:
 4: indicates moderate impairment
 2 or less indicates sever functional impairment a. psychological
b. physical
Preparation for Examination:  if possible, compare each are inspected with
the same area on the opposite side of the
 Instrument/Equipment body
 Environment  use additional light to inspect body cavities
 Ethico-legal considerations (e.g. penlight)
 Documentation  do not hurry; pay attention to detail, so that
 Positioning you will not be missing any significant detail
 Draping
 Infection Control Principles of Inspection

Tips of a Well Organized Exam  Make sure good lighting is available.

 Position and expose body parts so that all
 compare both sides of the body for symmetry surfaces can be viewed.
 if a client is seriously ill, first asses the systems of  Inspect each area for size, shape, color,
the body more at risk symmetry, position, and abnormalities.
 if the client becomes fatigues, offer rest periods B. Palpation
 do not rush, pay attention to client's responses
 perform painful procedures near the end of the The assessment of body parts through the sense of
examination (don't be procedure centered but touch. Delicate and sensitive measurements of specific
client centered) physical signs can be made like texture of the hair,
 record results in specific anatomical and scientific temperature, vibration, the position, size, consistency
terms and mobility or organs and masses, distention (urinary
 use common and acceptable medical bladder), pulsation, and presence of pain upon
abbreviations pressure.
 record quick notes to avoid keeping the client Principles of Palpation
waiting. ask permission if it is okay with them (be
sure that you have asked the client's permission)  Clients appreciate warm, clean hands, short
 something her fingernails and gentle approach
 Tender areas should be palpated last
SKILLS OF PHYSICAL EXAMINATION
 Light palpation always precedes deep palpation
A. Inspection  Client should be relaxed and positioned
 deliberate, purposeful observations comfortably
performed in a systematic manner
Parts of Hands used for Palpation
 HW (health worker) inspects body parts to
detect normal characteristics or significant  palmar surface of the fingers and fingerpads
physical signs  dorsum or back of the hand and fingers
 observations are made using visual, auditory,  palm or the ulnar surface of the hand
and olfactory senses  grasping with the fingertips
 pay attention to the client, watching all
movements and looking carefully at any body Site on the body, dorsal or
Location
part or area being inspected ventral surface
 it helps to know more physical characteristics Length and width in
Size
centimeters
before trying to distinguish abnormal findings
Oval, round, elongated,
 the nurse inspects with the naked eye or with Shape
irregular
the use of a lighted instrument such as an
otoscope, opthalmoscope Consistency Soft, firm, hard
  To auscultate correctly, listen in a quiet
Mobility Fixed, mobile
environment, listening for the presence of
sound and its characteristics
Pulsatility Present or absent

Degree of tenderness on Reminders for Auscultation

Tenderness
palpation
 auscultate on bare skin (clothing obscures
Surface Smooth or nodular sound)
 use the diaphragm or bell of the stethoscope
Plexor - the one tapping sa percussion chever, is the appropriately
dominant  stethoscope tubing should not be longer than
30-35 cm (12-14 in) to minimize sound
Pleximeter - non dominant hand obliteration or because longer tubing may distort
the sound
C. Percussion
 warm steth’s end piece by rubbing it on your
 Involves tapping the body with fingertips to
palm
evaluate the size, borders and consistency of
body organs and to discover body fluid in  if the client is very hairy, dampen the hairs with a
moist so that the hair will lie flat against the skin
body cavities
and not causing scratching sounds
 Involves striking one object against another,
thus producing subsequent sound waves.
P.A. OF THE SKIN
Vibration is transmitted through the body
tissues Inspection of the Skin
 The least used assessment technique because
it requires considerable skills Expected
Characteristics Abnormal
Findings
 An abnormal sound suggests a mass or
 Light skin
substance such as air or fluid within an organ
(ivory, light
or body cavity  Cyanosis
pink to ruddy
 Jaundice
pink)
Two Methods: 1. Color  Erythema
 Dark skin
 Pallor
(dark brown
a. Immediate/Direct  Albinism
to deep
b. Mediate/Indirect
brown)

SOUND INTENSITY PITCH DURATION QUALITY LOCATION Cyanosis – low oxygen levels in the blood causes the
Flatness Soft High Short
Extremely
Muscle, bone lips, fingers, and toes to look blue
dull

Dullness Medium Medium Moderate Thud like Liver, heart Jaundice – condition in which the skin, whites of the
Resonance Loud Low Long Hollow Normal lung
eyes and mucous membranes to turn yellow because of
a high level of bilirubin
Hyper Very Emphysematous
Very loud Very long Booming lung
resonance low
Stomach filled Albinism – is a congenital disorder characterized by the
Tympany Loud High Moderate Musical
with gas
complete or partial absence of pigment in the skin, hair,
and eyes
D. Auscultation
 Listening to sounds produced within the body Vitiligo – a disease in which the pigment cells of the
with the unassisted ear (direct) or with the skin, melanocytes, are destroyed in certain areas
use of a stethoscope (indirect)
Hyperpigmentation – excess of the melanin; patches of G. Pustule – circumscribed elevation of the skin similar
skin become darker in color than the normal to vesicles but filled with pus (e.g. Acne vulgaris,
surrounding skin Folliculitis, impetigo)
H. Ulcer – deeper depression extending into dermis,
Expected irregular shape; may bleed; leaves scars when heals
Characteristic Abnormal
Findings
(e.g. Venous stasis ulcers, pressure ulcer)
 Unusual body
odor Expected
 Odor from Characteristic
Findings
Abnormal
excessive  Dependent
2. Odor  No odor
sweating 4. Edema  No edema edema
 Odors from  Pitting edema
night sweats
 Urine odor Grades:
 If present,
inspect for  1+ or +1 = if indentation if 2mm in depth
color, location,
 2+ or +2 = 4 mm in depth
3. Lesions  No lesions texture, size,
shape, type,  3+ or +4 = 6 mm in depth
grouping, and  4+ or +4 = 8 mm in depth
distribution
Expected
Characteristic Abnormal
Types of Primary Lesions Findings
 Warm, equal  Hot (fever)
1. Temperature
A. Macule – flat, non-palpable change in skin color, bilaterally  Cool
less than 1 cm (e.g. freckles, flat mole, petechiae,  Smooth &
 Dryness
scarlet fever) relatively dry
 Flaking
2. Moisture with minimal
 Nevi – a visible, circumscribed, chronic lesion  Crusting
perspiration
of skin or mucosa  Scaliness
and oiliness
 Freckles – a small patch of light brown color  Smooth, soft,
on the skin  Scars
even and
 Hardening,
B. Papule – something you can feel (solid, elevated, 3. Texture flexible (in
coarse, thick,
circumscribed), less than 1 cm diameter, due to children &
dry
superficial thickening in the epidermis (e.g. Kaporis adults)
Sarcoma, Psoriasis, mole)  Lifts easily &
snaps back
C. Nodule – solid, elevated, hard or soft, larger than 1 4. Mobility &  Poor (skin
immediately
cm, may extend deeper into dermis than papule Turgor stays pinched)
to its resting
(e.g. wart) position
D. Tumor – larger than 2 cm, firm or soft, deeper into
dermis, may be benign or malignant (e.g. lipoma) P.A. OF THE NAILS
E. Wheal – irregularly shaped, elevated area and
Inspection of the Nails
superficial localized edema (e.g. hives, mosquito
bites, allergic reaction) Expected
F. Vesicle – elevated cavity containing free fluid, up to Characteristic Abnormal
Findings
1 cm, clear serum flows if wall is ruptured (e.g.
1. Color
blister, contact dermatitis, herpes simplex, chicken  Pinkish  Splinter
a. nail bed
pox)  Transparent hemorrhages
b. nail body
 Translucent  Leukomychia
c. free edge
white tips
  Ragged,  Pediculosis
5. Presence of
irregular  None capitis (head
lice
 Beau’s line lice)
(deep grooved 6. Presence of
2. Shape &  Well-rounded,  None  Dandruff
lines that run scaliness
contour convex
from side to
side on the Psoriasis – skin condition that speeds up the life cycle of
fingernail or skin cells; a chronic disease
the toenail)
 Clubbing Hirsutism – a condition of unwanted, male-pattern hair
3. Angle  160 degrees
 Koilonychia growth in women
 Normal
 Brittle Tinea capitis – cutaneous fungal infection
 Older adults:
4. Thickness  Dull
thicker & may
 Opaque Types of Alopecia
turn to yellow

Paronychia – nail disease that is an often tender Alopecia areata – hair is lost from the same or all areas
bacterial or fungal infection of the body; spot baldness

Clubbing – deformity of the finger or toe nails Alopecia totalis – complete loss of hair on the scalp

Spoon shaped nails – refers to a concavity in the Alopecia universalis –the complete loss of hair on the
fingernail scalp and body

Palpation of the Nails Types of Hair

Expected 1. Terminal hair – thick, long, and dark coarse hair

Characteristic Abnormal 2. Vellus hair – short, thin, slight-colored, and barely
Findings
 Soft boggy noticeable hair
1. Texture  Firm nails
 Brittle nails Inspection of the Scalp
 Prompt return
of pink or  Greater than 4 Characteristic
Expected
Abnormal
2. Capillary refill Findings
usual color in seconds
2 seconds  Lighter than
1. Color
face
P.A. OF THE HAIR & SCALP 2. Elasticity  Inelastic

Inspection of the Hair 3. Presence of  Dandruff

dandruff or  Tinea capitis
 None
Expected scaliness or  Pediculosis
Characteristic Abnormal lice capitis
Findings
 black, brown,  Smooth,
4. Texture  Rough
1. Color gray, white, coarse
blonde, etc.  Pediculosis
5. Presence of
 Alopecia,  None capitis (head
2. Quantity  Thick or thin lice
Hirsutism lice)
 Alopecia, 6. Presence of
3. Distribution  Equal  None  Dandruff
psoriasis scaliness
 Smooth,
4. Texture  Rough
coarse
Palpation of the Hair & Scalp Palpation of the Face

Expected Expected
Characteristic Abnormal Characteristic Abnormal
Findings Findings
 Seborrheic  Presence of
1. Deformities 1. Masses and
 None dermatitis  None masses and
and lumps tenderness
(cradle cap) tenderness
2. Tenderness  None  Tender
P.A. OF THE EYEBROWS
Hydrocephalus – by excessive accumulation of fluid
Inspection of the Eyebrows
Seborrheic dermatitis – skin condition that affects scalp;
Characteristic Expected Findings
causes scaly patches
 Hair evenly distributed,
P.A. OF THE HEAD & FACE with intact skin
1. Distribution, alignment,  Eyebrows are
Inspection of the Head position/symmetry, symmetrical on
skin quality, presence appearance and
Expected of scaliness and movement
Characteristic Abnormal
Findings movement  Thick or thin
 Microcephaly  No scaliness
1. Size  Normocephalic
 Macrocephaly
2. Shape or
contour of  Round Palpation of the Eyebrows
skull
 Tilting of head Expected
Characteristic Abnormal
to one side Findings
due to 1. Normal  None  Present
 Held upright &
3. Position unilateral
still
hearing or P.A. OF THE EYES
visual loss
 Torticollis Accessory Structures

Inspection of the Face 1. Extra ocular muscles

2. Eyelashes
Expected 3. Eyelids or palpebrae
Characteristic Abnormal
Findings
 Round, oval, Internal Eye Structure
1. Contour
heart, square
 Symmetrical 1. Iris
(but slight 2. Pupil
2. Symmetry
asymmetry is 3. Cornea
normal) 4. Lens
5. Retina
3. Edema  None  Edematous
6. Optic Nerve
 Tic douloureux 7. Conjunctiva
4. Involuntary
 None  Orofacial
Movements
dyskinesia Normal Eye Vision

1. Normal Focus
2. Nearsighted Focus
3. Farsighted focus
Inspection of the Eye Disease Condition of Eyelids

Normal Abnormal 1. Ptosis - drooping of the upper eyelids; lazy eye

2. Peripheral Cranial Nerve 7 (Facial nerve)
 Absence of
eyelashes dysfunction - function of the facial nerve is
 Eyelashes
 Lice or ticks at partially or completely lost
equally
the base of 3. Entropion - eyelids fold inwards
1. Eyelashes distributed
eyelashes 4. Ectropion - eyelids fold outward
 Curled
 Inflammation 5. Hordeolum or sty - infection/inflammation of the
outward
 Inverted eyelids, engulfing hair follicle of the eyelashes
eyelashes
6. Blepharitis -
 Eyelids intact 7. Enophthalmos - displacement of the eyeball
 No discharges, (going inside)
discoloration 8. Exophthalmos - bulging of the eyeball
 Lids close 9. Lid edema - fluid accumulation in the eyelids
symmetrically
 Approximately Test for Visual Acuity (sharpness or clarity of vision)
2. Eyelids 15-20
involuntary 1. Near Vision
 Inspect: blinks/min w/
position, color,
Normal: Able to read without hesitancy and
bilateral without moving the printed material farther away
edema, lesions,
blinking
ability to close 2. Far Vision
and open or  Lids do not
cover the Normal:
blink
pupil, no  O.U. - oculo uterque 20/20
visible sclera  O.D. - oculo dexter (Right eye)
above and  O.S. - oculo sinister (Left eye)
below corneas;
but partially  cc - with corrections (with glasses)
covers the iris  sc - without corrections (without glasses)
when open
When to use Snellen E Chart: If the patient is illiterate
3. Eyeball
Snellen Chart - Developed by Hermann Snellen (a Dutch
 Inspect for  Doesn’t
opthalmologist)
protrusion protrude
beyond
3. Color Vision
 Palpate for frontal bone
firmness and  Globe is firm  Ask the client to identify color bars on Snellen
tenderness and nontender Eye chart
 Expected findings: Correctly identifies colored
4. Lacrimal and bars on the Snellen Eye Chart
Nasolacrimal
Duct Macular Degeneration - irreversible vision loss; retina
 Inspect for  No swelling
and redness degenerates or deteriorates
swelling,
redness  No increased
Glaucoma - group of eye conditions that damage the
 Palpate glands tearing and
optic nerve
and ducts for tenderness
increased
tearing and Cataract - clouding of the lens in the eye
tenderness
 Normal Abnormal aging
Normal Lens
 Palpebral -  No cloudiness
smooth, Normal Iris:
glistening,
 Appears flat and
pinkish-peach,
round even with  Anisocoria
color with
color distribution (condition
minimal blood
Normal Pupil: characterized
vessels visible 8. Iris & Pupils
5. Conjunctiva  3-7 mm in size by unequal
 Bulbar - globes
 Black in color size of the
are clear; with
 Round and equal eyes' pupils)
few underlying
in size in both
blood vessels and
eyes
white sclera
visible
Note: Room should
be dim
 China 9. Pupillary
white/anicteric Light Reflex  Direct light reflex
(not yellowish)  Consensual lights
 Dark skinned reflex
(may normally
appear yellowish
due to fatty Test for Accommodation and Convergence
deposits beneath
6. Sclera  Cataract
the lids) do not Accommodation - the process by which the eye changes
confuse it with
optical power to maintain clear image
yellowish sclera
in jaundice which
Convergence - coordinated movement and focus of our
is called "scleral
icterus" two eyes inward
 With small brown
macules on sclera Normal: PERRLA (pupil equal round reactive to light &
accommodation)
Muddy brown sclera - brownish discoloration of sclera
Extra ocular Movement (Six Direction of Gaze)
Icteric sclera - the yellowing of the white of the eye
 LR - Lateral Rectus (outward movement)
Ptyregium - pinkish tissue growth on the cornea of the  MR - Medial Rectus (inward movement)
eye  SR - Superior Rectus (upward movement)
 IR - Inferior Rectus (downward movement)
Expected Findings Abnormal  SO - Superior Oblique (downward & outward)
Normal Cornea  IO - Inferior Oblique (upward & outward)
 No opacities or
cloudiness  Nurse is two feet away from client
 Transparent,  Pen or object is 12 inches or 1 foot away from the
shiny and bridge of the nose of the client
7. Cornea &
smooth, no  Note for parallel movement of the eye.
Lens
abrasions
 Arcus seniles Nystagmus - involuntary eye movement
(white, grey, or
bluish ring) is Strabismus - one eye is looking at the object while the
expected w/
other is misaligned
Strabismus: 2. Lesions or
 None  Present
nodules
 Esotropia - inward
 Exotropia - outward Palpation of Auricles
 Hypertropia - upward
 Hypotropia - downward Characteristic Normal Abnormal

P.A. OF THE EARS  Soft and  Pain upon

1. Consistency palpation
pliable
Anatomy & Physiology (external
middle ears
Parts: 2. Tenderness  Non tender infection,
mastoiditis)
a. External
 Auricle (cartilage covered by skin) Mastoiditis - complication of the ear infection
 Auditory Canal (Ear canal)
 Tympanic Membrane (Ear drum) Sebaceous cyst – closed sac found under the skin
b. Middle
c. Inner Keloid above the ear – firm, rubbery, fibrous nodules
that form on the ear after minor trauma (e.g. ear
Inspection of the Ears piercing)

Characteristic Expected Findings Abnormal Ear Canal & Eardrums

 Auricles are  Above 3 years old (upward and backward)

level with each
 Below 3 years old (downward and backward)
other whose
1. Angle of
upright point of  Low set ear
attachment Inspection of Ear Canal & Eardrums
attachment is
align with the
lateral canthus Characteristic Normal Abnormal
 Same w/ the  Redness  Canal is
2. Color
face  Extreme pallor uniformly pink  Red ear canal
1. Color
with tiny hair with discharge
3. Size  4 cm < x < 10 cm in its outer
 With little
4. Symmetry  Symmetrical
cerumen,
5. Position  Almost vertical appears dry
(light brown
 Cauliflower
6. Deformities  No deformities 2. Discharges to gray &
ears
flaky) or moist
Low set ear - point of attachment is lower than the (dark yellow
to brown) and
outer corner of the eye; a sign of Down syndrome
sticky
3. Lesions  None  Present
Cauliflower ears - deformity of the ear caused by blunt
trauma or other injury (also referred to as boxer’s ear or Auditory Acuity
wrestler’s ear)
Stand 2 feet away from patient and let him/her hear a
Inspection of the Auricles whispered voice or ticking of watch; cover your mouth;
recite numbers
Characteristic Normal Abnormal
1. Swelling  No swelling
 P.A. OF THE NOSE  Mucoid
discharge
Anatomy & Physiology 2. Exudates  No exudates (rhinitis)
 Yellowish or
Parts: Sinuses:
greenish
 Bridge  Frontal discharge (sinus
 Tip  Maxillary infection)
3. Bleeding  No bleeding  Puffiness and
 Columella
 Naris increase
vascularity
 Ala
(habitual use of
Inspection of the External Structures of the Nose intranasal
4. Exudates  No swelling
cocaine and
Characteristic Normal Abnormal opioid)
 Proportion to
other facial Nasal Septum
1. Size
features and
in the midline Characteristic Normal Abnormal
2. Shape  Normal
1. Bleeding  No bleeding  Present
3. Symmetry  Symmetrical
 A deviated
 Edema and  The septum is
septum can
discoloration 2. Deviation close to the
 Same with the obstruct
4. Color may be an midline
face breathing
effect of
 Perforation of
recent trauma
the septum
 Saddle Nose  Intact, with no
5. Deformity  No deformity can occur after
Deformity 3. Perforation lesions or
repeated use
perforation
of intranasal
Saddle Nose Deformity- characterized by a loss of
cocaine
height of the nose, because of the collapse of the bridge
Inferior and Middle Turbinates
Lepromatous Leprosy- chronic, progressive bacterial
infection caused by the bacterium Mycobacterium
leprae, characterized by multiple skin lesions. Characteristic Normal

1. Color  Pinkish
Palpation of the External Structures of the Nose
2. Swelling  No swelling
Characteristic Normal Abnormal
3. Exudates  No exudates
 Nasal bone is
1. Tenderness  Present 4. Polyps  No polyps
firm and stable
2. Nodules  None  Present
Allergic Rhinitis (hay fever) - inflammation in the nose
Inspection of the Internal Structures of the Nose which occurs when the immune system overreacts to
allergens in the air; swelling of the lining of the nose
Nasal Mucosa
Sinusitis - inflammation of the sinuses
Characteristic Normal Abnormal
Palpation of the Sinuses
 Pale mucosa
 Pink and moist Press sinuses using the thumb in a gentle upward
with clear
1. Color with clear, motion.
discharge
scant, mucus
(allergy)
Normal: No tenderness Abnormal: Sinusitis
 P.A. OF THE MOUTH 2. Lesions  None
Anatomy & Physiology  Glistening,
soft, moist,
Parts: smooth and
3. Condition  Leukoplakia
intact
 Lips  Dry in older
 Buccal mucosa adults
 Gums 4. Masses  No masses  Present
 Teeth
5. Lumps  No lumps
Inspection of the Lips
Leukoplakia - thick, white or grayish patches form
Characteristic Normal Abnormal usually inside your mouth
 Pallor of lips
1. Color  Pink  Cherry-colored Inspection of the Gingiva
lips
 Symmetrical, Characteristic Normal Abnormal
2. Condition skin intact, 1. Color  Pink
moist
2. Edema  No edema  Present
3. Lesions  None  Present
3. Bleeding  No bleeding  Bleeding gums
4. Odor  No odor
4. Retraction  None  Present
Palpation of the Lips
5. Hypertrophy  None
Characteristic Normal Abnormal  Smooth, moist
with a tight
1. Consistency  Soft margin at
 Non tender each tooth
2. Tenderness  Patchy
 Gums are
 Cold Sores pigmented
usually pale in
Type 1 6. Condition gums
3. Nodules  None older adults
 Oral Herpes  Leukoplakia
 African-
Lesions Type 2  Gingivitis
Americans
4. Masses  No masses  Present may have
patchy
5. Lumps  No lumps pigmentation

Cold Sores Type 1- sores around the mouth and lips Gingivitis - inflammation of the gums, usually caused by
(sometimes called fever blisters or cold sores) a bacterial infection

Oral Herpes Lesions Type 2 - infection caused by the Palpation of the Gingiva
herpes simplex virus; causes painful sores on your lips,
gums, tongue, roof of your mouth, and inside your Characteristic Normal Abnormal
cheeks
 Spongy gums
1. Tenderness  Non tender
Inspection of the Oral Mucosa  Swollen gums
2. Lesions  No lesions  Present
Characteristic Normal Abnormal
3. Thickening  None  Present
1. Color  Pink
4. Masses  No masses  Present
 P.A. OF THE TEETH Inspection of the Hard Palate

Anatomy & Physiology Characteristic Normal

Parts: 1. Color  Whitish

 4 incisors 2. Architecture  Dome-shaped

 2 canines 3. Deformities  No deformities
 4 premolars
 6 molars Inspection of the Soft Palate
Teeth Names
Characteristic Normal
1. Color  Pink
2. Architecture  Smooth
3. Deformities  No deformities

Inspection of the Tongue

Characteristic Normal Abnormal

1. Color  Pink
 Slightly rough
on the top
surface and
Inspection of the Teeth 2. Texture
smooth along
the lateral
Characteristic Normal Abnormal margins
 Chalky white 3. Moisture  Moist
discoloration
of enamel  Raised
4. Papillae
 Discolored papillae
 White, smooth,  Centrally
teeth 5. Position
1. Color with shiny located
 Yellowish
tooth enamel  Macroglossia
teeth
 Plaque  Ankyloglossia
6. Size  Medium
 Smoker’s  Tongue
teeth splitting
2. Number  28 or 32 teeth 7. Symmetry  Symmetrical

3. Missing teeth  None Floor of the Mouth and Frenulum

4. Loose teeth  None  Present
Characteristic Normal
5. Extraction  None  Present
1. Color  Pink
6. Caries  None  Present
 Smooth with prominent
7. Filling  None  Present 2. Texture veins between the
frenulum folds
Tartar - plaque that has hardened on your teeth; can
Macroglossia - refers to an enlarged tongue stemming
irritate gum tissues
from various conditions
Ankyloglossia - tongue-tie, is a congenital oral anomaly Inspection of the Neck
that may decrease mobility of the tongue tip and is
caused by an unusually short, thick lingual frenulum, a Characteristic Normal Abnormal
membrane connecting the underside of the tongue to
the floor of the mouth 1. Symmetry  Symmetrical  Torticollis
2. Scars  No scars  Present
Tongue splitting - oral body modification that involves
splitting your tongue in half 3. Growths  None  Present
4. Enlargement
Inspection of the Oropharynx  Parotitis or
of the parotid  None
mumps
gland
Characteristic Normal Abnormal

1. Color  Pink Mumps - viral infection that primarily affects saliva-

producing (salivary) glands that are located near your
2. Symmetry  Symmetrical  Present ears
 Yellow & green
3. Discharges  None Torticollis - flexion, extension, or twisting of muscles of
exudates
the neck beyond their normal position
4. Ulcerations  None  Present
5. Enlargement  Regular in Lymph Nodes
 Tonsillitis
of tonsils size
6. Alignment & Your lymph nodes, also called lymph glands,
 Uvula raises play a vital role in your body's ability to fight off
characteristic  Deviated uvula
centrally infections. They function as filters, trapping viruses,
of uvula
bacteria and other causes of illnesses before they can
Tonsillitis - inflammation of the tonsils infect other parts of your body.

Deviated uvula - if the uvula deviates to one side or the A lymph node is a small, round or bean-shaped
other, it can indicate a weakness in one of the cranial cluster of cells covered by a capsule of connective
nerves, specifically 9 and 10 tissue. The cells are a combination of lymphocytes —
which produce protein particles that capture invaders,
Bifurcated uvula - an abnormal split or division in the such as viruses — and macrophages, which break down
uvula, or tissue that hangs down at the end of the soft the captured material. Lymphocytes and macrophages
palate in the roof of the mouth filter your lymphatic fluid as it travels through your
body and protect you by destroying invaders.
Inflamed uvula (Uvulitis) - severe swelling of your uvula
Lymph nodes are located in groups, and each
P.A. OF THE NECK group drains a specific area of your body. You may be
more likely to notice swelling in certain areas, such as in
Anatomy & Physiology the lymph nodes in your neck, under your chin, in your
armpits and in your groin. The site of the swollen lymph
Parts: nodes may help identify the underlying cause.

 Thyroid cartilage & cricoid cartilage Palpation of the Lymph Nodes

 Thyroid gland
 Trachea Normal Abnormal

Muscles of the Neck:  Enlarged and fixed,

inflamed
 Lymph nodes are not
 Sternocleidomastoid  Non-tender, hard,
easily palpable
 Trapezius discrete nodes
 Presence of node
Sequence of Palpation Position: The client may sit in an upright position; arms
across the chest for maximum expansion.
1. occipital
2. post-auricular For comfort: warm room, warm stethoscope, good
3. pre-auricular lighting, and privacy.
4. tonsillar
5. submaxillary/submandibular Inspection of the Posterior Chest
6. submental
7. anterior cervical Characteristic Normal Abnormal
8. posterior cervical
1. Rate
9. deep cervical
10. supraclavicular 2. Rhythm
11. infraclavicular
3. Depth
P.A. OF THE CHEST  Spine is straight
without lateral  Scoliosis
Anterior Thoracic Landmarks
deviation;  Kyphosis
1. Suprasternal notch Thorax is  Lordosis
2. Sternum 4. Effort and elliptical;  Barrel Chest
3. Angle of Louis Shape Scapula is  Pectus
4. ICS symmetrical; ICS Excavatum
without bulging  Pectus
Posterior Thoracic Landmarks or active Carinatum
movement
1. C7
 Chest  Smokers -
2. Spinous Process
configuration anteroposteri
3. Scapula
(anteroposterior or is no
Reference Lines: 5. Configuration diameter 1/3- longer 1/3-
of Chest Wall 1/2 of the 1/2 of the
Anterior Chest transverse transverse
diameter) diameter, but
1. Midsternal Line 1:1
2. Midclavicular Line
3. Anterior Axillary Line (Left and Right)  Scoliosis - lateral deviation of the spine
Posterior Chest  Kyphosis - backward/posterior curvature of the
spine
1. Vertebral Line (Midspinal)  Lordosis - forward/anterior curvature of the spine
2. Scapular Line (Left and Right)  Barrel Chest - generally refers to a broad, deep
chest
Lateral View  Pectus Excavatum (Funnel Chest) - ribcage has a
depression
1. Anterior Axillary Line
 Pectus Carinatum (Pigeon Breast) - chest is
2. Posterior Axillary Line
protruding forward
3. Midaxillary Line
Palpation of the Posterior Chest
P.A. OF POSTERIOR CHEST

Draping Characteristic Normal Abnormal

 Presence of
 Males - expose posterior chest (disrobe to the 1. Masses  None
masses
waist)
2. Tenderness  Non tender  Tender
 Females - leave the gown open at the back
 Presence of
3. Crepitus  None
crepitus
Crepitus - a coarse crackling sensation palpable over the Auscultation of the Chest
skin surface
Breath Sounds
How to Palpate the Chest:
1. Bronchial (tracheal or tubular)
 high-pitched, loud “harsh” hollow sounds
created by air moving through the trachea
 heard anteriorly over the trachea
 short inspiratory phase and long expiratory
phase (1:2)
2. Bronchovesicular
Anterior Posterior  moderate-intensity and moderate pitched
“blowing” sounds created by air moving
Palpation of the Chest through the large airways or bronchi
 best heard between the scapulae and lateral to
Characteristic Normal Abnormal
the sternum at the 1st and 2nd ICS
 Symmetrical  equal inspiratory and expiratory phase (1:1)
1. Respiratory
movement of  Reduced chest 3. Vesicular
Excursion -
the thumbs (1 excursion;
ability of the
½ - 2 inches in unequal chest  soft, breezy, low-pitched gentle sighing sounds
chest to created by air moving through smaller airways
women, 2-3 expansion
expand
inches in men) (bronchioles and alveoli)
2. Tactile  heard over the peripheral lung
 Equal  Decreased
Fremitus -  best heard at the base of lungs except scapula
bilaterally & fremitus;
detect
diminished Increased  inspiratory phase is 2.5 times longer than
vibrations in
midthorax fremitus expiratory phase (5:2 ratio)
the chest

Tactile Fremitus: Tell the patient to say 99 every time Adventitious Sounds
you touch the patient's back. 1. Crackles/Rales - discrete and non-continuous
Factors Affecting Fremitus sounds (may be stimulated by rolling a lock of hair
between your fingers near your ears)
 location of bronchi to the chest wall 2. Ronchi/Wheezes - musical sounds produced by the
 thickness of the chest wall rapid passage of air through a bronchus that is
 pitch and intensity of the voice narrowed to the point of closure; present in
patients with asthma
Increased Fremitus - denser or inflamed lung tissue 3. Stridor - is a harsh, high-pitched, continuous
Decreased Fremitus - air or fluid in the pleural spaces or honking sound resulting from an upper airway
a decrease in lung tissue density obstruction, a partial obstruction, or a spasm of
the trachea or larynx
Emphysema - lung condition that causes shortness of 4. Grunting - is a larger airway sound heard
breath; air sacs in the lungs (alveoli) are damaged
predominantly on expiration; results from
Pneumothorax - air in the lungs retention of air in the lungs, which prevents
alveolar collapse
Pleural Effusion - presence of fluid in the pleura
5. Friction rub - different from all other adventitious
Consolidation - presence of water in the lungs (e.g. sounds because it occurs between the pleural
Pneumonia) layers, not in the lungs; results from rubbing
together of the parietal and visceral layers of an
 inflamed pleura, which produces a high-pitched Position and Surface Landmarks
grating or squeaking sound
 Precordium
P.A. OF ANTERIOR CHEST  Mediastinal area
 Heart – 2nd to 5th ICS from right sternal border to
Palpation of the Anterior Chest
left MCL
1. Base – top of the heart
Characteristic Normal Abnormal
2. Apex – 4th to 5th ICS left MCL
 Presence of Infant – 3rd to 4th ICS left MCL
1. Masses  None
masses
 Symmetrical Heart Sounds
2. Respiratory
movement of  Reduced chest
Excursion -
the thumbs (1 excursion; 1. S1 – first heart sound, “lub”, closure of AV valves
ability of the
½ - 2 inches in unequal chest 2. S2 – 2nd heart sound, “dub”, closure of semilunar
chest to
women, 2-3 expansion valves
expand
inches in men)
3. Tactile Extra Heart Sounds
 Equal  Decreased
Fremitus -
bilaterally & fremitus;
detect 1. S3 – occurs immediately after S3, “lub-dub-ee”
diminished Increased
vibrations in (Kentu-cky), due to rapid filling of the ventricles
midthorax fremitus
the chest
Normal: Children and young adults
Abnormal: Older adults (sign of HPN)
Auscultate
2. S4 – 4th heart sound which occurs just before S1,
1. Breath Sounds “ee-lub-dub” (Ten-nessee)
 Bronchovesicular and vesicular sounds heard Normal: In many older adults but may be a sign of
above and below the clavicles and along the heart failure (abnormal)
lung periphery 3. Murmur – a sustained swishing or blowing sound
 Bronchial sounds heard over the trachea heard at the beginning, middle, or end of systolic
2. Heart Sounds of diastolic phase

P.A. OF THE HEART The Great Vessels

 Superior and Inferior Vena Cava

 Pulmonary artery
 Pulmonary vein
 Aorta

Heart Valves

1. AV Valves
a. Tricuspid (right A & V)
b. Bicuspid (left A & V)
2. Semilunar Valves
a. Pulmonic valve
b. Aortic valve

Note: No valves are present between vena cava and

right atrium, nor between the pulmonary veins and the
left atrium
Causes of Murmur Quadrants of the Breast

 Velocity of blood increases

 Increase viscosity of blood
 Structural defects of the valves or unusual openings
of the chambers

Assessment

a. Palpate for PMI

b. Locate area where S1 is best heard at 5th ICS LMCL Developmental Conditions
c. Locate area where S2 is best heard at 2nd ICS R & L
Female
sternal border
d. Characterize S1 and S2 according to rate and  Adolescent
rhythm  Adult non-pregnant
e. Note any abnormal heart sounds as necessary  Aging female

Auscultation Male

 Listen to S1 at the mitral area (5th ICS, LMCL)  Gynecomastia - enlargement or swelling of breast
 Listen to S2 at the aortic area (2nd ICS, right sternal tissue in males
border)
Inspection of the Breast
 Note the rate and rhythm

Abnormal: Premature beat, irregularly irregular, atrial Characteristic Normal Abnormal

fibrillation  Hyper
1. Color  Same as skin pigmentation
Responsibility: Get pulse deficit then refer!!!  Redness
 Extends from
P.A. OF THE BREAST 3rd to 6th ribs,
 Sudden
nipples at 4th
Anatomy & Physiology increase in
2. Size ICS
size
 One breast is
Parts  Inflammation
normally larger
than the other
 Tail of Spence
 Retraction,
 Nipple  Convex flattening,
 Areola  Pendulous dimpling,
3. Shape
 Conical and edema
The Tail of Spence (Spence’s Tail, axillary process, Flat  Peau d’
axillary tail) is an extension of the tissue of the breast orange
that extends into the axilla. It is actually an extension of  Symmetrical or
 Change in
the upper lateral quadrant of the breast. 4. Symmetrical slight
symmetry
symmetry
Internal Anatomy  Presence of
erythema,
Breast Composition infection,
5. Lesions  None abscess,
 Glandular (milk) inflammatory
 Fibrous (ligaments, supportive, and scar tissues) carcinoma,
 Adipose tissue breast cancer
6. Discharge  No discharge  1-2 cm in
2. Size
diameter
 Bilaterally the
 Round or oval,
same  Asymmetrical 3. Shape bilaterally
7. Venous  No increase in increased
equal
Pattern venous pattern venous
unless pattern Palpation of the Breast
pregnant
8. Dimpling or
 None  Dimpling
retraction

Dimpling - or puckering, is a sign of abnormal traction

on Cooper’s ligament (connective tissues connect the
breast tissue to the lower layer of the skin and the
breast)
Palpate abnormal masses to determine:
Check for Retraction
1. Location in relation to quadrants
1. Raise arms above the head
2. Size or diameter in centimeters
2. Press hands against the head
3. Shape – round, oval, lobulated, or indistinct
3. Extend arms straight ahead (lean forward)
4. Consistency – soft, firm, or hard
4. Pushing hands together
5. Delimitation/discreteness in relation to
Inspection of the Nipples surrounding tissues – well-circumcised or not
6. Tenderness – painful upon palpation
7. Mobility – freely movable or fixed
Characteristic Normal Abnormal
 Pink to dark  Hyper Note: An alternative method of localizing findings
1. Color
brown pigmentation visualizes the breast as the face of a clock. A lesion or
 Protruded or nodule may be located by the “time” and by the
 Sudden
2. Position everted or distance in centimeters from the nipple.
inversion
inverted
 No lesions, Cancerous lesions – hard, fixed, non-tender, and
3. Lesions rashes,  Present irregular in shape
ulcerations
Bimanual Technique
 Point in
4. Direction symmetrical  Asymmetrical
 Used when palpating for large, pendulous breasts
direction
 Done by supporting the inferior portion of the
 No discharges,
5. Discharges  Present breast with one hand while the other hand palpates
no bleeding
the breast tissue against the supporting hand
Inverted nipple - a condition in which the nipple is
Palpation of the Breast
pulled inward into the breast instead of pointing
outward; can be a congenital condition as a normal
Characteristic Normal Abnormal
variant in some women; may arise as a result of disease
or trauma  Firm and elastic
in
Inspection of the Areola premenopausal
women
 Presence of
Characteristic Normal Abnormal 1. Consistency  Feels stringy and
mass
 Sudden nodular or
 Pink to dark cordlike in
1. Color change in
brown postmenopausal
appearance
women
  Enlarged Fibrocystic disease - benign, breast is lumpy, painful,
2. Lymph nodes  Not palpable
nodes and sometimes with nipple discharges

Palpation of Nipples and Areola Lymph Nodes:

Characteristic Normal Abnormal  Supraclavicular node

1. Elasticity  Elastic  Loss of elasticity  Infraclavicular node
 Central axillary node
2. Tenderness  Non-tender
 Pectoral nodes (anterior)
 Bloody, purulent  Lateral nodes
discharge
 Epitrochlear nodes
 Serous,
serosanguineous,
P.A. OF THE ABDOMEN
3. Discharges  No discharge or bloody
discharge Anatomy & Physiology
 Thick, gray
drainage; fixation Anterior Surface Landmarks:
of nipple
 Xiphoid process
Inspection and Palpation of the Axilla
 Symphysis Pubis

Characteristic Normal Abnormal Posterior Surface Landmarks:

 Redness
 Unusual  Vertebral column
pigmentation  Paravertebral muscles
 No unusual
1. Color (infection or
pigmentation Internal Anatomy
allergy)
 Acanthosis
Solid Viscera Hollow Viscera
nigricans
 Rashes  Liver  Stomach
 Skin intact  Spleen  Gall bladder
 Infection
2. Lesions  No rashes; no
(Hidradenitis  Adrenal glands  S.I.
lesions
suppurativa)  Kidneys  L.I.
 No unusual  Ovaries  Colon
3. Odor
odor
 Uterus  Bladder
 None  Enlarged
 One or more lymph nodes
Anatomical Mapping
soft, small  Large, firm,
4. Nodes
(<1cm), non- hard, matted,
Anatomical Landmarks
tender nodes fixed
are common (malignant)
 Xiphoid process of the sternum
Acanthosis nigricans - a skin condition characterized by  Costal margin
areas of dark, velvety discoloration in body folds and
creases  Midline (down the center of the abdomen)
 Umbilicus
Hidradenitis suppurativa - a painful, long-term skin
condition that causes abscesses and scarring on the skin  Anterior-superior iliac spine
 Inguinal ligament
Rashes - an area of reddening of a person's skin,
sometimes with raised spots, appearing especially as a  Superior margin of the iliac bone
result of allergy or illness
Divisions of the Abdominal Wall Left Lower Quadrant

1. Four Quadrants  Part of descending colon

 Sigmoid colon
 Left ovary & tube
 Left ureter
 Left spermatic cord

Midline: aorta, uterus (gravid), bladder (distended)

2. Nine Regions

Right Upper Quadrant

 Liver
 Gallbladder
 Duodenum
 Head of pancreas
 Right kidney & adrenal
 Hepatic flexure of colon
 Part of ascending and transverse colon
Preparation
Left Upper Quadrant
1. Provide adequate lighting
 Stomach 2. Proper draping (from xiphoid to symphysis)
 Spleen
Equipment
 Left lobe of liver
 Body of pancreas 1. Stethoscope
 Left kidney & adrenal 2. Ruler (cm) or tape measure
 Splenic flexure of the colon 3. Marking pen
 Part of transverse and descending colon 4. Pen light

Right Lower Quadrant Position

 Cecum 1. Relaxed (dorsal recumbent), hands on sides

 Appendix
 Right ovary & tube Measures to enhance abdominal wall relaxation
 Right ureter
1. Empty bladder
 Right spermatic cord
2. Room warm and private
 3. Dorsal recumbent with head on pillow, arms at purple in
the sides Cushing’s
4. Warm stethoscope end piece & hands; fingernails syndrome
short  Use of
 Thoracic in accessory
5. Ask for tender areas
women muscles
6. Learn to use distraction 8. Respirations
 Abdominal in  Shallow
men respirations in
Order of Physical Assessment: men
 Increased
1. Inspection peristaltic
2. Auscultation waves
3. Percussion  Reverse
4. Palpation peristaltic
9. Peristalsis &  May be seen in waves
Inspection of the Abdomen pulsations the clients  Increased/
diffuded
Characteristic Normal Abnormal pulsations
 Marked
 Not enlarged  Enlargement
pulsation of
1. Size  Proportional to  Obese aorta
body abdomen
 Protuberant Spider Angioma - found slightly beneath the skin
2. Shape (nurse  Flat, round, or w/ complaint surface, often containing a central red spot and reddish
is at the right scaphoid of tightness
extensions which radiate outwards like a spider's web
side of the  Moles or  Abdominal
bed) papules distention
Dilated Veins - caused by a weakening in the vessel wall;
(swelling)
 Presence of might appear as clusters of blue or purple veins
3. Symmetry
bulges or
(nurse is at  Symmetrical Cushing’s Syndrome - a metabolic disorder caused by
masses
the foot of bilaterally overproduction of corticosteroid hormones by the
(hernia,
the bed)
tumors) adrenal cortex and often involving obesity and high
 Jaundice blood pressure
 Consistent w/  Redness
pt’s ethnicity  Cyanosis Cullen’s sign - superficial edema and bruising in the
 Same  Cullen’s sign subcutaneous fatty tissue around the umbilicus
4. Skin color & throughout  Grey Turner’s
vascularity abdomen sign Grey Turner’s sign - bruising of the flanks, the part of
 Scattered fine  Bruises the body between the last rib and the top of the hip;
veins may be  Caput medusa appears as a blue discoloration, and is a sign of bleeding
visible  More visible behind the lining of the abdominal cavity
veins
 Equally and
5. Hair  Alopecia Caput Medusa - appearance of distended and engorged
symmetrically
distribution universalis superficial epigastric veins, which are seen radiating
distributed
from the umbilicus across the abdomen
 Skin intact
 Cutaneous
6. Lesions  No lesions,
angioma Cutaneous Angioma - abnormal growth on the skin
rashes, masses
 Linea  Also occurs produced by the dilatation or new formation of blood
7. Striae albicantes or with ascites vessels
stretch marks  Looks pink-
Linea albicantes - white or colorless lines on the Vascular Sounds
abdomen caused by stretching of the skin
Note: Use bell of stethoscope
Inspection of the Umbilicus
Characteristic Normal Abnormal
Characteristic Normal Abnormal  No such sound
 Systolic bruit
1. Vascular over aorta
 Deviated or  Peritoneal
1. Position  Midline Sounds (above
displaced friction rub
umbilicus)
 Everted
(pouched out) Note: If bruit is present, report immediately to physician.
 Inverted (flat  Enlarged and Bruit may indicate fever, anemia, or hyperthyroidism
2. Contour
or concave) everted with
umbilical Percussion of the Abdomen
hernia
 Same as
3. Color surrounding  Cullen’s sign
skin

Umbilical Hernia - abnormal bulge that can be seen or

felt at the umbilicus

Ascites - abnormal buildup of fluid in the abdomen

Hepatomegaly - abnormal enlargement of the liver

Markedly Enlarged Gall Bladder (GB) - inflammation of

the gall bladder; usually occurs when drainage from the
gall bladder becomes blocked Purposes:

Obese Abdomen - presence of excess fat in the  To assess relative density of abdominal contents
abdominal area  To locate organs
 To screen for abdominal fluid or mass
Auscultation of Bowel Sounds and Bruit
 Reveal presence of air in the stomach and intestines
1. Auscultate between meals
2. Avoid talking Note: Percuss lightly on the four quadrants.
3. Use diaphragm end piece
Characteristic Normal Abnormal
4. Warm stethoscope
5. Hold stethoscope lightly against skin  Dullness
 Tympany in all
6. Begin at RLQ 1. Percussion (masses)
quadrants
Sounds of 4  High-pitched
 Dullness
Quadrants tympanic
Bowel Sounds (organs)
sounds
Note: Wait for 3-5 minutes before concluding that bowel
Percussion of the Liver
sounds are absent.
Note: Percuss starting the 4th ICS (mark the point where
Characteristic Normal Abnormal percussion sound changes from resonance to dullness),
 Hypoactive then percuss going upward at MCL from the RLQ (mark
 Audible (5-35x  Hyperactive the point where percussion sound changes from
1. Bowel Sounds
per minute) (Borborygni) tympany to dullness), then measure.
 Absent
 Characteristic Normal Abnormal Characteristic Normal Abnormal
 Dull  Tenderness
 Adult: 6-12 cm (local
1. Percussion of (RMCL) 1. Deep masses  None inflammation)
Liver span or  Overall mean  Hepatomegaly  Enlarged organs
size liver span  Peritonitis
Men: 10.5 cm
Women: 7 cm Note: The purpose is to delineate abdominal organs and
detect less obvious masses.
Note: Stand at the right.
Peritonitis - inflammation of the peritoneum, typically
Palpation of the Abdomen caused by bacterial infection either via the blood or
after rupture of an abdominal organ
Purposes:
If tenderness is found, do rebound tenderness or
 To determine size, location, & consistency of organs Blumberg’s sign (indicative of appendicitis or
 To screen for abnormal masses or tenderness peritonitis).
Measures to enhance complete muscle relaxation: Positive: If pain is elicited with the release of the hand.
1. Bend knees If masses are present note for the:
2. Palpitating hand should be parallel to the surface
3. Fingernails short 1. Location (quadrants)
4. Teach client to breath slowly 2. Size (centimeters)
5. Try “emotive” therapy
3. Shape (round, discoid)
6. If patient is ticklish, keep clients hands under your
own 4. Consistency (soft, firm, hard)
7. Warm hands 5. Surface (smooth, nodular)
6. Mobility (fixed, mobile)
Light Palpation 7. Pulsability
8. Presence of tenderness (if pain is present upon
Note: Palpate tender areas last, light palpation (1 cm),
palpation)
keep palms and forearm horizontal.
Palpation of the Liver Size
Characteristic Normal Abnormal
 Muscle  The purpose is to detect for liver enlargement
 Voluntary  Place non-dominant hand parallel to the 11th and
guarding,
1. Masses or guarding (if 12th rib while applying upward pressure
rigidity, large
tenderness cold, tense, or  Place finger of dominant hand under the right
masses,
ticklish) costal margin (below liver’s border)
tenderness
 Ask client to deep breath and hold inhalation
Note: The objective is not to search for organs but to phase
form an overall impression of the skin surface and  Palpate the end or do the hooking technique
superficial musculature.
Hooking technique - an alternative method of palpating
the liver
Deep Palpation
Normal Abnormal
Note: Deep palpation (2-4 cm) may use one or two
hands (bimanual), may normally cause tenderness in  Liver palpated more
healthy client over cecum, sigmoid colon, and aorta.  Liver is non-palpable than 1-2 cm below the
and non-tender right costal margin
(enlarged)
 P.A. OF THE MUSCULOSKELETAL SYSTEM Moving a body part backward
6. Retraction
and parallel to the ground
Skeletal System
Moving a body part forward
Parts of Appendicular Skeleton: 7. Protraction
and parallel to the ground
 Pectoral girdles Turning the forearm so that the
8. Pronation
 Bones of the upper extremities palm is down
 Pelvic girdles
 Bones of the lower extremities Turning the forearm so that the
9. Supination
palm is up
Joints
Moving the sole of the foot
10. Inversion
inward at the ankle
 The junction of two or more bones
 Stabilizes the bones and allow a specific type of Moving the sole of the foot
11. Eversion
movement outward at the ankle
 The closer the bones fit at the point of contact, the Flexion of the toes and the foot
stronger the joint 12. Dorsiflexion
upward

Structural Classification of Joints Bending of the toes and the

13. Plantar flexion
foot downward
1. Fibrous - “fixed” or “immovable” joints
2. Cartilaginous - allow more movement between 14. Elevation Raising a body part
bones
3. Synovial - most flexible type of joint between 15. Depression Lowering a body part
bones
Moving the head around a
Functional Classification of Joints 16. Rotation
central axis

1. Synarthrosis - an immovably fixed joint between

bones connected by fibrous tissue
2. Amphiarthrosis - slightly moveable joint
3. Diarthrosis - freely moveable joint

Types of Joint Motion

Normal Abnormal

Moving the arm in a circle

1. Circumduction
around the shoulder

2. Flexion Bending a limb at a joint

3. Extension Straightening a limb at a joint

Moving a limb away from the

4. Abduction
midline of the body

Moving a limb toward the

5. Adduction
midline of the body