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nursing chapter 28 Health assessment


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Identify the aspects of the physical health examiniation
1.The nursing health history
2 the physical examination
A physical examination can be of what type
1 complete assesment
2 examination of the body system
3 examination of the body area
what is the purpose of physical examination
1 to obtain baseline data about the clients fucntional abilities
2 to supplement, confirm refute data obtained in the nursing history
3 to obtain data that will help establish nursing diagnosis and plan of care
4 to evaluate the physiologic outcomes of health care an thus the progress of a clients health problem
5 to make clinical judgements about a clients health status
6 to identify areas for health promotion and disease prevention
what should you do before starting an assignment
prepare the environment, positioning, draping and intrumentation with client
4 methods of examining
1 inspection=visual examiniation, assessing by using the sense of sight
2 palapation-is the examiniation of the body using the sense of touch, pads of the fingers are used because their concentration of nerve endings, make them highly sensitive to tactile discrimination
3 percussion-is the act of striking the body surfaces to elicit sounds that can be heard or vibrations than can be felt, percussion is used to determine the size and shape of internal organs by establisihing their borders(direct and indirect
4 ausculation=the process of listening to sounds produced within the body
what are the two types of palpation
light and Deep
light-should always precede deep paplaption, becasue heavy pressures on the fingertips can dull the sense of touch
deep paplation-done with two or one hand
what are the two types of percussion
indirect and direct
indirect is the striking of an object held against the body are to be examined(finger)
direct=the nurse strikes the the area directly with the pads of 2, 3 or 4 fingers pads or with the pads of middle finger
what are the 5 sounds elicited from percussing
Flatness-extremely dull soundproduced by very dense tissue, such as muscle or bone
Dullness-thudlike sound produced by dense tissue such as the liver, spleen or heart
Resonance-hollow sound such as that prodyced by lungs filled with air
Hyperresonnance- not produced in the normal body,it is described as booming and can be heard over an emphysematous lung
Tympany=musical or drumlike sound produced from an air filled stomach
Ausculating sounds are described according to what 4 sounds
Pitch-the frequency of the vibrations(# of vibrations per second)
Intensity=(amplitude)refers to the loudness or softness of a sound
Duration=length(long or short)
Quality-is a subjective description of sound, ie whisteling, gurgling or snapping
How are health assessments done or conducted
Health assessments start with a general survey that involves observation of the clients general appearance and mental status, and measurements of vital signs, height,& weight
what does the integument include
skin, hair and nails
what does assessment of skin include
it involves inspection and palpation
pallor-is the result of inadequate circulation blood or hemoglobin and subsequent reduction in tissue oxygenation
cyanosis-(bluish tinge) is most evident to the nail beds, lips and buccal mucosa
jaundice-(yellowish) first evident in sclera of eyes and in mucous membranes of skin
erythema-redness associated with a variety of rashes
vitiligo-seen as pathces of hypopigmented skin, caused by destruction of melanocytes
edema-presence of excess interstitial fluid
describe different types of primary skin lesions
Macule, patch-unelevated changes in color(freckles, measles, petechia, flat moles.
Nodule(tumor)=elevated solid hard mass that extends deeper into the dermis than a papule
cyst=fluid filled or semisolid in dermis or subquataneous tissues
papule=circumscribed, solid, elevation of skin, ie warts, acne, pimples elevated moles
pustule=vesicle or bulla filled with pus. ie acne, vulgaris impetigo
plaque=larger than 1cm psoriasis, rubeola
wheal-reddened, localized collection of edema fluid, irregular in shape
Describe secondary skin lesions
atrophy-translucent dry paperlike sometimes wrinkled skin (ie stria,stretch marks, aged skin)
erosion=wearing away of the superficial epidermis causing moist shallow depression( ie scratch marks, ruptured vesciles)
ulcer=deep irreguraly shaped area of the skin, may bleed(ie decubitus ulcers, chancres)
fissure-linear crack with sharp edges extending into the dermis(cracks at corner of mouth and hands)
scar=flat irregular shaped are of connective tissue left after a lesion or wound ghas healed (healed surgical wounds, healed acne)
describe the scale for detecting edema
1+ barely detectable 2mm
2+ indentation of 2-4 mm
3+ indentation of 5-7mm
4+ indentation of more than 7mm
ways of describing skin lesions
Type or structure-primary or secondary
size shape & texture=size in mm, round or irregular or depressed solid soft or hard
color-may be no discoloration
distribution-described accourding to the location of the lesions in the body and symetry or asymetry of findings in relative to other body areas
configuration-araingments of lesions in relation to each other
Describe the nails
the nail is normally colorless and conves curve and the angle between the nail bed is normally 160 degrees , the nail bed is highly vascular a characteristic that accounts for its pink color in white people, blue tints reflect cyanosi and pallor may reflect poor arterial circulation
what is clubbing

What is a blanche test
condition in which the angle between the nail and the nail bed is 180 degrees or greater, clubbing may be caused my long term lack of oxygen
Blanche test-can be carried out to test the capillary refill, peripheral circulation, normal nail bed capillaries blanche when pressed but quickly turn pink or their usual color when pressure is released
what does the nurse do during normal assessments of the head
what is normocephalic=
the nurse should inspect, palpate, simutaneoulsy and also ausculate
normacephalic is the normal head size
eyes and vision
examiniation fo the eyes include s assessment of visual acuity-teh degree of detail an eye can discern in an image, ocular movement
visual fields-the area an individual can see when looking straight ahead, and external structures
what is conjuctivitis
inflammation of the bulbar and palpebral conjuctivca(may result from foreign bodies, chemicals, allergins , agents, bacteria, or viruses
what is cataracts-
tend to occur in those over 65 this opacity of the lens or its capsule which block light rays is frequently moved removed and replaced by a lens implant
what is glaucoma
disturbance of the circulation of aqueous fluid which can increase in intracoular pressure, most frequent cause of blindness in people over 40
assessing the eye structures Direct and consensual reaction to light
*partially darken the roon
*ask client tolook straight ahead
*use pen light or flashlight, approaching from the side
*observe the response of the illuminated pupil, it should constrict
*shine light on the pupil again and observe the respone of the other pupil it should also contrict
assessing the eyes, reaction to accomodation
*hold an object about 10cm front he bridge of the nose
*ask the client to look first at the top of the object and then at the distant object behind the penlight
*observe pupil response, pupils should constrict when looking at the near object and dilat when looking at the far object
*next move the penlight toward the clients nose the pupils should converge to record normal assessments of pupils us the abbreviation
PERRLA (Pupils equally round and react to light)
assessing the 6 ocular movements
stand directly in front of client ask the client to hold head in a fixed position and follow movements of pen, in the 6 cardinal fields of gaze
describe assessment of the ear
includes direct inspection and palpation of the external ear,
the ear is divided into three parts
external, middle and inner ear
external ear=auricle or pinna the external auditory canal, and tympanic membrane
lobule-landmarks of the auricle(earlobe)
tragus-cartilaginous protrusion at the entrance to the ear canal
how do we hear
Sound transmission and hearing are complex processes. in brief, sound can be transmitted by air conduction or bone conduction
1 a sound stimulates the external canal and reaches the tympanic memebrane
2 the sound waves vibrate the tympanic membrane and reache the ossicles
3 the sound waves travels fromt eh ossicles to the opening in the inner ear
4 the cochlea recieves the sound ibrations
5 the stimulus travels to othe auditory nerve(8th cranial nerve and the cerebral cortex

Bone conducted sund transmission occurs when skull bones transport the sound directly to the auditory nerve
thorax and lungs
assessing the thorax ans lungs in frequently critical to assessing th clients aeratin status
what are the imaginery lines on the chest
these lines help the nurse identify the position of underlying organs and to record abnormal assessments
Midsternal linevertical line running through the the center pf the sternum
Midclavicular line-vertical lines running midpoint of the clavicle
Anterior axillary line-vertical lines anterior axillary folds
what is the angle of lois
it is the starting point for locating the ribs anteriorly, the junction b/w the body of the sternum and the manubrium
what is the normal adult chest size
in adults the thorax is oval, its anteroposterior diameter is half it's transverse diameter
what are abnormal breath sounds
adventitious breath sounds, ocurs when air passes throuogh narrowed airways or airways filled with fluid or mucous, or when the pleural linings are inflammed
4 types of adventitious breath sounds
Crackling, (rales or crepitations like putting yor hair in b/w fingers and rubbing)
gurgles,-continuous low pitched caorse gurgling harsh loud sounds
pleural friction rubs-superficial grating or creaking sounds heard during inspiration and expiration wheezes-continous high pitched squeaky musical sounds
what are normal breath sounds
Vesicular=soft intesnsity, low pitched, gentle sighing, created by sounds moving through smaller airways(bronchioles and alveoli
Broncho-vesicular=moderate intensity and moderate pitched blowing sounds created by air moving through larger airway(bronchi)
Bronchial(tubular)=high pitched loud harsh sounds created by air moving through the trachea
what are 3 chest deformities
Pigeon chest=a permanent deformity amy be caused by rickets
Funnel chest=a congenital defect opposite of pigeon chest, in that the sternum is depressed, abnormal pressur on the heart may result in altered function
barrel chest=excessive convex curvature of the thoracic spine
describe the normal sounds of the heart
the normal first 2 sounds are produced by closure of the valves of the heart
S1-occurs when the atrioventricualr(av) valves close (lub) these valves close when the ventricles hae been sufficiently filled , after the ventricles close empty their blood into the aorta and pulmonary arteries the semilunar valves close producing the second heart sound
S2=Dub has a higher pitch than s1 and is also shorter these 2 sound occur within a second or less depending on the heart rate
associated with the heart sounds are systole and diastole
systole=is the period in which the ventricles contract begins with S1 and ends at S2 systole is nornally shorter than diastole
Diastole=period in which the ventricles relax is starts with S2 and ends at the subsequent
where are the heart sounds best heard at
the heart sounds are audible anywhere but are best heard over the aortic, pulmonic tricuspid and apical areas
describe the juglar vein
it drains blood from the head and neck directly into the superior vena cava and right side of heart
describe neck veins
normally external neck veins are sitended and visible when a person lies down, they are flat and not as visible when a person stands up because gravity encourages venouse drainage
what organs are in the upper right quadrant
liver gallbladder, right adrenal glands head of pancreas
what organs are in teh right lower quadrant
cecum, appendix, right ovary, part of uterus, right ureter, lower lobe of right kidney
what organs are in the left upper quadrant
stomach left lobe of liver, stomach, spleen, pancreas, left adrenal gland
what organs are in the left lower quadrant
lower lobe of left kidney, sigmoid coln, section of descending colon, left ovary, left fallopian tube, left ureter, part of ureter
what are the major assesments in assessing mental
language, orientation, memory, attenmtion span and calculation
what is aphaisia
any defects in or loss
of the power to express onself by speech, writing, or signs or to comprehend spoken or written language due to disease due to disease or injury of the cerebral cortex
what is a reflex
an automatic response of the bodyto a stimulus, it is not voluntarily learned or conscoius
what is the plantars reflex
the planter reflex, also teh Babinski reflex is superficial, it may be absent in adults without pathology or overriden in voluntary control, use a moderatley sharp objuect, strock the laterla border of the sole of the clients foot, starting at the hell , observe the response
what is the Glascow coma scale
It is a test to tst levels consciusness, the faculties that are measured are eye opening, motor response and verbal response
what is the sims position
it is a side lying position with lowering arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
what is the supine positon
back lying postion with legs extended with or without pillow under the head
what is a prone position
lies on abdomen with head turned to the side, with or without a small pillow
what are the environmental issues that you should consider when prparing to physically examine the client
positioning-important to consider clients ability to assume a position
Draping=drapes should be arrainged so that the area to be assessed is exposed and other body areas are covered
instrumentataion=-all equipoment will be in clean in good working order and readily accessible
what are the aspects of general survey
General survey that involves observation of the clients general appearance and mental status and measurement of vital signs, height, and weight, many components of the general survey are assessed while taking the clients health history, such as the clients body build, posture, hygiene and mental status
assessing the ears
assessment of the ears includes direct inspection and plapation of th external ear, inspection of the remaining parts of teh ear by an OTOSCOPE and determination og auditory acuity
what is conduction hearing loss
result of interrupted transmission of sound waves through the outer and middle ear structures
what is sensorineural hearing loss
reslut of damage to teh inner ear, the auditory nerve or the hearing center in teh brain
what is mixed hearing loss
combination of conduction and sesorineural loss
describe steps when assessing a client abdomen
* ask client to urinate, to empty bladder
*Inspect the abdomen for skin integrity
*inspect the abdomen for contour and symetry
*observe ab movements asscoiated with respiration, peristalis, or aortic pressure
*observe the vascular pattern
ausculate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs
*percuss several areas in each quadrants to determine presence of tymphany and dullness
*percuss liver to determine size
*perform ligh palpations to detect areas of tenderness
*perform deep palpations over quadrants, liver and bladder
what does the examination of the neurological system include
*mental status
*level of consciousness
*cranial nerves
*motor function
*sensory function
in what position is the examination of prostate usually conducted
in teh sims position
what does the musculoskeletal system encompass
the muscles, bones and joints
what is a fasciculation
an abnormal contraction(shortening) of a bundle of muscle fibers
what is a tremor
involuntary trembling of a limb or body part
tremors may invlove large groups or small bundles of muscle fibers
Intention tremor=becomes more apparent when a person attempts a voluntary movement, like holding a cup of coffee
restin tremor=more apparent when person at rest and diminishes with activity
what type pf adventitious breath can be cleared with a cough
gurgles can be altered when coughing all over adventitious sounds may not be cleared with a cough cracles, wheezing, and friction rub

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