Comprehensive Guide on Health Assessments

Hello, Professor King here. Today's lecture is going to be on health assessment and physical examination, and it's going to be a broad overview, and I'm going to try and focus a little bit more about the components of our actual head-to-toe assessment that you'll be learning in lab. So physical assessment skills are used during your patient's examination to guide your clinical judgment in making a nursing diagnosis. A complete health assessment involves taking a health history, as well as a behavioral or physical exam and physical examination. And then as we've talked about before, the components of the health history include your biographic data, past health, family history, review of systems, functional assessment, and their perception of their health. The patient's condition and response affects the extent of your examination. So as you find Things you'll have to delve in deeper to find out more information about them. The accuracy of your assessment will influence the choice of therapy a patient receives. And then evaluation of how they respond to those therapies will guide how you proceed with things. So the physical assessment is the art of arranging all of these steps that you will learn in this class. and to complete a head-to-toe assessment. In the beginning, you may have to pause and think about what comes next rather than just gathering the data. But with repeated rehearsals, you will be able to make it smoother and you'll come to a point where your flow is much more natural. And even if you forget a step, you'll be able to gracefully insert it somewhere else into the assessment in a logical place. And you'll find that as you practice, you'll be able to figure out where those places are. Okay, so the purposes of the physical examination is, first of all, you want a triage for emergency care. A physical examination may be done for routine screenings to promote health and wellness. It's used to determine eligibility for health insurance, military service. Sometimes you need a physical exam to get a new job. And then, of course, when a patient is admitted to the hospital or long-term care facility, there's always an admitting physical exam that's done. Additionally, any time There is a transfer within the hospital setting. You'll do a physical examination upon receipt of that patient. And then you'll also want to do a head-to-toe exam during a shift change because you want to know where that patient started at at the beginning of your shift so you'll be able to monitor for changes throughout your shift. Okay, so... Okay. The use of the physical exam is gathering a health history and it requires you to be able to communicate with your patient. And we've talked about communication techniques already. So you want to employ, you know, very open ended questions when you're gathering data. You want to be supportive and non-judgmental. We'll be talking a great deal about the nursing process, which you'll be learning more about in your foundations class with Professor Ray, and the importance of using a nursing diagnosis and a care plan. Physical assessment findings determine the cause of the diagnosis, which enables nurses to individualize a plan of care. You'll be using a lot of your data to develop an individualized plan of care for your patient that you're taking care of. in that moment. So when you're looking at care plans and stuff, don't just take it straight from the book, but think about how it applies to that patient that you're dealing with at that moment. While managing patient problems, you will want to use physical assessment skills to assess the status of your patient's health. So you will be starting out with very basic skills, vital signs, inspection, auscultation. You'll be looking and listening with your stethoscope, all very basic things, and then you will expand on those skills as you progress in your nursing career. In this class, you'll be developing a beginning organized style for your head-to-toe assessments, and you'll hear me say that over and over. You want to have an organized style for completing your head-to-toe assessment. It's important to get a baseline or beginning assessment on your patient so that you can revise your plan of care throughout the day to address any future problems that may come up with your patient. During the evaluation phase, nurses can revise, amend, or even discontinue nursing interventions as their patient achieves their outcomes or their goals. All right, so with culture sensitivity, remember that there's a difference between cultural characteristics and physical characteristics. You want to learn to recognize common characteristics and disorders among members of ethnic populations in your area. In our area, you will be taking care of a lot of Hispanic patients, Muslim patients, Filipino, Vietnamese, and also a lot of geriatric patients. You don't have to know everything about all of these cultures and their differences, but you do have a responsibility as a nurse that when you are caring for these populations to find out what is appropriate and not appropriate behaviors and treatments for these patients. We really want to avoid stereotyping or gender biases. As nurses, we need to be as objective as possible and look at every person as an individual. Okay, so we have some things that need to be done in order to prepare for our head-to-toe assessment. These aspects need attention to ensure that your patient is physically and emotionally ready for the exam. You will need to use good hand hygiene and follow your health care facilities policies. The environment must provide for privacy. You must have good lighting and climate control. The patient must be comfortable in order to proceed. You need to make sure that you have all of your... equipment that it's properly cleaned or sterilized and in good working order. So that means making sure that you test your equipment and if it requires batteries or bulbs, power cords, or calibration that you do all this ahead of time and have all your equipment prepared and accessible before you start the exam. You don't want to have to run out in the middle of the exam and get a piece of equipment that you've forgotten. Patients need to be told what's going on and when it's going to occur. Proper draping is necessary, as with proper positioning. So you only want to uncover what you're looking at and making sure that you maintain patient privacy at all times. You want to encourage your patient to ask questions, and at times, if the patient and the nurse are of opposite gender, you may need to have a third person in the room. You want to make sure that you consider cultural and social norms with this. When assessing various age groups, you may have to vary your techniques and styles. So children require different handling than adolescents, adults, and even the elderly. We will not be talking about or learning about children in this class. But when we are caring for the elderly, we need to make sure that they have their glasses or hearing aids with them if they use them. Without these aids, they may answer inappropriately, which may give the impression that they are confused. And you need to make sure that you allow adequate time for them to respond to your questions. Okay, so organization of the exam. So some tips that will help you with your examination is just remember that this class focuses on the head-to-toe assessment, which literally means we're going to start at the head and we're going to systematically work down to the toes. However, in the hospital setting, if the patient is seriously ill, you want to first assess the body system that's most at risk. This is called a focused examination. Then you want to continue on with your head-to-toe assessment. If the patient fatigues easily, you want to allow rest periods in between assessments. You want to perform painful procedures near the end of the assessment, and you want to use accepted medical terms and abbreviations to keep your notes brief. You want to record quick notes during the exam, and then complete your larger documentation notes at the end. at the end of the examination. When using the head-to-toe approach, you will address all of the body systems and you won't have to worry about missing anything. You want to compare both sides for symmetry. And once again, you want to focus on just keeping your assessment very organized and systematic. And with practice, it'll become like muscle memory. Okay, so there are four techniques that are used with the physical examination, and they are inspection, palpation, percussion, and auscultation. The three that you will use the most are inspection, auscultation, and palpation. Percussion is really reserved for advanced practice, and you really won't be using this technique while you're in nursing school because it is an advanced technique. All right, so with inspection, it's the simplest of the four assessment skills. So you want to inspect, carefully look, you want to use your sensory skills of listening and smell to distinguish normal from abnormal findings. You want to make sure that you can recognize what is normal so that when you hear something or see something different, you can recognize it as abnormal. You want to make sure that you have adequate lighting. Anytime you're looking into any type of an orifice, whether it be the nares or the ears, you want to make sure that you have your pen light available so that you can see in there and note anything that's abnormal. You want to inspect each thing that you're looking at. You always want to look at the size, the shape, color, symmetry, you know, if you're looking at their eyes, are they equal on both sides. You want to look at their body positions and any abnormalities that you may be able to see just visually. You want to position and expose body parts as needed so that all surfaces can be viewed. That means when you're looking at the feet, make sure that you're taking off their socks, so on and so forth. And when possible, You always want to be able to compare one to another to make sure that they are equal in size. So let's think about this for a minute. Why do you think olfaction, smell, would be important as part of your assessment? Well, olfaction helps detect abnormalities that cannot be detected or recognized by any other means. So, for example, a pretty order of the breath. is a sign of ketoacidosis, which may occur in diabetes. It's a potentially life-threatening condition. Breath that smells like feces can occur with prolonged vomiting, especially if there's a bowel obstruction. So as you become a more seasoned practitioner, you'll be able to recognize these different smells and what they could possibly mean. All right, so with palpation. It involves a lot of touch, so you always want to make sure that you are telling your patient what you're about to do. You want to make sure that your patient is in a comfortable position and encourage them to relax as much as possible. You want to palpate sensitive areas last. You want to make sure that you're using proper hand hygiene and changing your gloves as needed as you move from one area to another. And we'll be discussing this as we go along as well. You want to use different parts of the hand to detect different characteristics. So the palmar surface of the hand and the base of your fingers, so essentially where the finger pads are, are more sensitive than the fingertips and should be used to determine position, texture, size, consistency, masses, fluids, and crepitus. The palmar surface of the hands and fingers are much more sensitive to vibration. You want to assess body temperature by using the back of your hand or the dorsal surface because the skin is much thinner on that side of the hand it's much more sensitive to temperature and for measuring a position or shape or consistency you can use a grasping motion between your fingertip and your thumb just to like what we would do for testing out skin turgor. You want to start with light palpation and end with deeper palpation. You want to make sure that your hands are warm, and you always want to keep your fingernails short so that you don't dig into the patient when you're examining them. All right, so with percussion, as I said before, this is an advanced technique, and it's not an expected skill for the new practitioner. We will not be doing this technique. Developing this skill requires a lot of practice. You just need to be aware of the technique and how it's done. So just basic information. Alright so with auscultation you will be listening to heart rates, lung sounds, and bowel sounds. Some sounds you can hear without assistance. So if you ever think about your stomach growling around lunchtime you know how you can audibly hear that without having to have a stethoscope. Other sounds will require the use of a stethoscope. Becoming proficient with auscultation requires that you recognize the sounds that are being produced by body parts and the best locations for hearing these sounds. So this means you need practice, practice, practice, practice. You can listen to your own heart rate. You can listen to your own bowel sounds. You can listen to your own respiratory sounds. Listen to your friends. Listen to your family. You know, anybody that you can listen to, take that opportunity to listen to so that you are good at recognizing what's normal. That way, when you hear something that's different, you can recognize that as being an abnormal sound. The bell of the stethoscope is used to hear low-pitched sounds, and the diaphragm, which is the larger side, is used for higher-pitched sounds. And so let's think about how you can tell the difference between body sounds and extraneous noises. Well, it goes back to practice. By practicing with your stethoscope, you'll become proficient with using it and realize when sounds are clear. And then you'll be able to recognize when you have extraneous sounds present. So extraneous sounds are created by rubbing the tubing. or the chest piece on something and it interferes with the auscultation of the body organ sounds. So by deliberately reproducing these sounds or causing these things to touch, you'll be able to hear what it sounds like and then recognize when you have that interference when you're trying to actually assess a body system. Be sure to place your stethoscope directly on the patient's skin and that will help avoid some of these extraneous sounds like the sound that you would get from rubbing on the patient's gown or a bandage or something like that. You'll want to do a general survey of your patient. You can learn a lot about your patients before you even lay your hands on them. You want to assess their height and weight because it's a reflection of a person's overall level of health. It will be important to obtain a diet history from your patient. So when you're looking at your patient you want to assess whether or not they appear their stated age. What is their level of consciousness? What is their skin coloring? Are they pale, flushed, cyanotic? What is their nutritional status, their personal hygiene? Look at their posture and position. Are they comfortable? Are they sitting erect? Is observed for any physical deformities? How do they move if they're up in their room or if they're walking into your office? Is there a mobility device in their hospital room that would tell you that the patient needs assistance to get up and out of bed? What is their facial expression, their mood, their affect? How are they hearing? How is their speech? Are their articulation the pattern of their speech? Is the content appropriate? What is their native language? Is there an IV in the room? Is the patient on oxygen? Is there a bedside commode in the room? Are they in any signs of distress? You can learn a lot about your patient just by looking at them and surveying their hospital room as you walk in. All right, so for skin. The integumentary system refers to the skin, hair, scalp, and nails. You will be looking and feeling, so inspection and palpating. You want to examine both hands and inspect the nails, comparing one to the other. For the rest of the exam, you'll examine the skin with the corresponding region that you're examining. You want to observe for cyanosis, which is a blue discoloration of the lips, nail beds, conjunctiva, and palms. The best site to inspect for jaundice, which is a yellow-orange discoloration of the patient's skin, is in the patient's sclera. You can see normal reactive hyperania or redness most often in regions exposed to pressure, such as the sacrum. heels, and greater trochanter areas. You want to inspect for any patches or areas of skin color variation. Localized skin changes such as pallor or urethemia, which is a red discoloration, can indicate circulatory changes. Are there any bruised or ecumatic areas? Is there any edema or swelling? Moisture, you want to check to see if the skin is dry. Are they diaphoretic? which is sweaty. Temperature is the skin cool, warm, hot. Texture refers to the character of the surface of the skin and how the deeper layers feel. By palpating lightly with your fingertips, you can determine whether the patient's skin is smooth or rough, thin or thick, tight or supple, and any indurated areas or soft areas. Turgor. checking the elasticity and hydration of the skin. You never want to check skin turgor on the back of the hand because the skin is naturally looser on the back of your hand. You want to check skin turgor on the forearm or the top of the chest or on the patient's back. The skin should briskly return back to normal. If you pinch it up and it stays tented like that, then it's referred to as tenting and may indicate hydration issues. The circulation of the skin affects color in localized areas and leads to the appearance of superficial blood vessels. Vascularity occurs in localized pressure areas when the patient remains in one position. Vascularity appears reddened, pink, or pale. With aging, capillaries become fragile and are more easily injured. Petechiae are non-blanching, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers. Cherry angiomas are very small usually. They're smooth, slightly raised dots on the skin. They commonly appear on the trunk and are a normal part of aging and usually begin to appear after the age of 30. Direct trauma and impairment of the venous return are two common causes for edema. You want to inspect the venous return. endematous areas for location, color, and shape. The formation of edema separates the surface of the skin from pigmented and vascular layers, masking skin color. Edematous skin also appears stretched and shiny. You want to palpate edematous areas to determine mobility, consistency, and tenderness. When pressure from the examiner's fingers leave an indentation in the edematous area, this is called pitting edema. To assess the degree of pitting edema, you want to press the edematous area firmly with the thumb or index finger for several seconds and then release. A depression left in the skin indicates edema. Grading 1 plus through 4 plus characterizes the severity of the edema. The depth of the pitting is recorded in millimeters and it determines the degree of edema. For example, 1 plus edema equals 2 millimeters depth, 2 plus edema equals 4 millimeters depth, 3 plus equals 6 millimeters, and 4 plus equals 8 millimeters. And you have an example of that here in the PowerPoint. Lesions are assessed by using the ABCD mnemonic. It assesses asymmetry, border irregularity, color, and diameter. This is not something that we'll be learning for your head-to-toe assessment. All right, so for the hair and scalp, you want to inspect and palpate the scalp and hair in the cranium. You want to note, is their hair thick, full, thin, dry, oily? You want to carefully inspect the hair follicles on the scalp and pubic areas because it can reveal lice or other parasites. This is something that you will come across as nurses as people are admitted. You want to check for hair loss, which is alopecia, or thinning of the hair, which is usually related to genetic tendencies or endocrine disorders such as diabetes, thyroiditis, and even menopause. And then during this time, you can ask if they've ever had any head injuries or headaches as you're palpating their scalp and looking. So when you're doing it, you really want to just be... feeling do they have any open sores is there any pain or tenderness you want to look at the hair for the color distribution quantity thickness texture and lubrication how will you be assessing nails well you'll be using inspection and palpation The condition of the nails reflect the overall general health of the patient. It can demonstrate the state of nutrition, whether or not they have a vitamin or protein deficiency. Electrolyte changes can cause variation lines or bands to form in the nail beds. Their occupation, are they dirty? Are they well manicured? Are they a mechanic? Are they a surgeon? Do they do a lot of gardening? So on and so forth. The level of self-care, are they clean? Are their toenails trimmed? We see a lot of patients in the hospital that have very long and overgrown toenails because they aren't able to bend over or be flexible enough to trim their own toenails. Age, the nails become more rigid as a person ages. So these are all things that you would want to look at. Palpation, you would gently squeeze the nail bed to assess their circulatory status, whether or not it responds very quickly back to a pink color, and we'll be learning more about that later as well. So with the head and neck, During the health history, you've already previously screened for past and present injuries that they may have. You'll be using inspection, palpation, and auscultation. And the assessment includes the head, eyes, ears, nose, mouth, fair necks, neck, lymph nodes, carotid arteries, thyroid gland, and in the trachea. So you want to inspect the face. You want to look at their expression and you want to note symmetry. Does the left side of their face match the right side of their face? With Bell's palsy, it's a paralysis of the seventh cranial nerve and the patient will not be able to move the upper or lower half of their face. So they won't blink. They won't be, when they smile, that side of their face won't participate in the smile. They may have a little bit of drooling. They can't put their lips together and whistle. And this helps differentiate between Bell's palsy and a stroke because with a stroke patient, this patient will still be able to close their eyes and wrinkle their forehead because it does not affect that nerve. You want to palpate the temporal artery and then the temporal mandibular joint. As the person opens and closes their mouth, you want to assess for pain or tenderness, any clicking sounds. You want to palpate the maxillary sinuses and the frontal sinuses. Is there any pain or tenderness with that? And then this is also a good time to ask about hearing aids and glasses. As you move on to the eyes, you'll be examining the eyes. You'll assess the size. the shape, the structure, visual acuity, visual fields, the conjunctiva, sclera, cornea, pupil, and the iris. The presence of redness in the conjunctiva could indicate they have allergies or it could be an infectious condition that you need to address. A thin white ring along the margin of the iris is called Arcus Sonalis. It's common with aging, but it's abnormal in anyone younger than 40 years old And in the PowerPoint, you have some examples of the eye structure. This is just mainly for your information. It's not something that you're going to be tested on. The photo at the bottom shows the six directions of gaze. Direct the patient to follow your finger movement through each gaze, and we'll be learning more about this in lab. Extracular muscles will tell you about the, excuse me, the extracular muscles. You'll have the corneal light reflex and the six cardinal positions of gaze, and these test out the cranial nerve 3, 4, and 6. In addition to parallel movement, you would want to note any nystagmus, which is an involuntary rhythmic auscultation of the eyes, and it occurs as a result of local injury to the eye muscle and supporting structures, or may follow a disorder of the cranial nerves and nerve. innerviating that muscle. It can also be caused from alcohol intoxication. So that's one of the things that law enforcement uses to test for alcohol intoxication is the sixth cardinal positions of gaze and they're looking for nystagmus. With the external eye structure, you want to check for the position and alignment of the eyes, the eyebrows, eyelids, lacrimal apparatus, conjunctiva and sclera, the corneas, and the pupils and irises. You want to test the pupil size for light and accommodation and this is where you would use the mnemonic PERLA and PERLA stands for pupils equal, round, reactive to light, and accommodate. To check the pupillary reflexes, the nurse holds up a penlight to the side of the patient's face and then gently shines the light into their eye. And the illumination of the pupil causes pupillary constriction. And you will be learning more about Perla in lab. And this is an example of a chart to pick. depicting pupillary sizes in millimeters and understand that this is blown up quite a bit on the powerpoint so that you can see it and i believe that your pen lights that you'll be getting in lab also have this chart on the side of them so that you have something to compare the pupils to when you're assessing them with inspection of the external error you want to palpate the auricles for texture, tenderness, and skin lesions. Auricles are normally smooth and without lesions. The ear color is usually the same as the face without moles, cysts, deformities, or nodules. Redness is a sign of inflammation or fever. Extreme pallor can indicate frostbite. If palpation causes pain, an external ear infection is likely. If the patient has ear pain but palpation does not cause additional pain, infection may be present in the middle ear. A yellow waxy substance called cerumen is common and you may see an increase in cerumen in your older adults. And impacted cerumen can affect their hearing. Yellowish or green foul-smelling discharge indicates infection or a foreign body. When inspecting the external nose, observe for the shape, size, skin color, and the presence of any deformities or inflammation. You want to test the patency of each nostril. If swelling or deformities exist, you want to gently palpate the ridge and soft tissue of the nose by placing one finger on each side of the nasal arch and gently moving the fingers from the nasal bridge to the tip. How can the color of nasal discharge indicate patient condition? So pale mucosa with a clear discharge indicates allergies, which many of you are familiar with, and a mucoid discharge indicates rheumatitis. A sinus infection results in yellow or greenish discharge, and so you'll always want to assess any discharge that comes from the nose. The patient with a nasal gastric tube, you routinely want to check for localized skin breakdown from that of the nares. It's characterized by redness and skin slothing, and it can occur very, very quickly. During the examination, you want to note any polyps, which are tumor-like growths that look like small clusters of grapes, or any purulent drainage. Examination of the sinuses involves palpation, and during this time, you want to continue to inspect facial symmetry. For the lips, you want to assess the color, texture, hydration, contour, and for lesions. Lip color in the dark-skinned person varies from pink to plum. Anemia can cause pallor of the lips. Cyanosis is caused by respiratory or cardiovascular problems, whereas cherry-colored lips can indicate carbon monoxide poisoning. Any lesions should be evaluated for the potential of being an infection. or an irritation or skin cancer. Dry cracked lips can indicate hydration status and once again you want to note the contour and if there's any presence of lesions. With a pen light you want to inspect the mouth. You want to inspect the mucosa for color, hydration, texture, and lesions such as ulcers, abrasions, or cysts. Normally, the mucosa is glistening pink and smooth and moist, and so retraction of the buccal mucosa also allows for clear visualization, and you see that noted in the top left picture. You want to inspect the teeth to determine the quality of dental hygiene. You want to note the color of the teeth and the presence of any dental caries, which are cavities, tartar. and extraction sites, are they missing any teeth? Because that will give you an indication as to how well they can chew their food and which may affect their dietary status. You want to note the mobility of the uvula as the person phonates ah and tests the gag reflex. Cranial nerve 9 and 10 are indicated with this. And you want to note if the tonsils are present. Ask the person to stick out their tongue. And this will help assess cranial nerve number 12. For the neck, you want to test range of motion. This can also be done when you are assessing the ears. So you want to note whether or not they have full range of motion. Do they have any pain with movement? Can they flex forward? Can they hyperextend backwards? and move laterally or sideways. You want to inspect the neck for symmetry, lumps, and pulsations. You want to palpate the cervical lymph nodes. You want to inspect and palpate the carotid pulse, and you want to do this one side at a time. And if indicated, you want to auscultate. You want to listen for carotid bruise. You want to palpate the trachea, as it should be midline, masses in the neck or mediastinum, and pump. Pulmonary abnormalities cause displacement of the trachea laterally. So to determine the position of the trachea, you want to palpate it at the super sternal notch, slipping the thumb and index finger to each side. And you want to note whether the finger and thumb shift laterally. You don't want to apply forceful pressure because this can elicit a coughing reflex. The thyroid gland is fixed to the trachea and you want to inspect the lower neck for the overlying thyroid gland for obvious masses, symmetry, and any subtle fullness at the base of the neck. So your cervical nodes are often palpable in a healthy person but this decreases with age. Normal lymph nodes feel soft, they're movable and non-tender. With the carotid artery and the jugular vein, you may postpone this part of the examination until you do the vascular system assessment. And when you do do it, you want to make sure that you never palpate both carotid arteries simultaneously as you could cause your patient to pass out. And then this slide is just to show you how many lymph nodes that we have in our head and neck. You do not need to memorize this slide, and then there's additional pictures in your textbook of the remaining lymph nodes throughout the body. And we'll go over these more in detail in future lectures. Accurate physical assessment of the thorax and lungs requires review of the ventilatory and respiratory functions of the lungs. If disease is affecting the lungs, it affects other body systems as well. So your examination will include inspection, palpation, auscultation. Diagnostic equipment such as x-ray films, MRIs, and CT scans create little need for the use of percussion as it is an... an accurate assessment measure. Before assessing the thorax or lungs, be familiar with the landmarks of the chest. This slide indicates all the different landmarks that you need to be familiar with. These landmarks help you to identify findings and to use assessment skills correctly. The patient's nipples, angle of Lewis, suprasternal notch, costal angle, Clavicles and vertebrae are key landmarks that provide a series of imagery lines for sign identification. Keep a mental image of the locations of the lobes, the lungs, and the position of each rib. So with the lungs, reduced mental alertness, nasal flaring, somnolence, and cyanosis are examples of assessed signs that can indicate oxygenation problems. You want to inspect the thorax by observing the shape and symmetry of the chest from the patient's front and back. You can have the patient roll over in bed, that way you can assess their skin for breakdown while looking and listening to their lungs. You want to look at their skin characteristics and symmetry of their shoulders and muscles. You want to assess the rate and rhythm of their breathing and you want to observe for the use of accessory muscles during breathing. The accessory muscles move little with normal passive breathing. However, patients who use a great deal of effort to breathe as a result of strenuous exercise or pulmonary diseases such as COPD, chronic obstructive pulmonary disease, rely on the accessory and abdominal muscles to contract thereby leading to inspiration and expiration for them. Auscultation assesses movement of the air through the tracheobronchial tree and detect mucus or obstructed airways. Normally airflow through the airways in a non-obstructed pattern. You want to recognize the sound created by normal airflow. This allows you to detect sounds that are caused by an airway obstruction. When listening, you will follow a systematic approach that we will go over in lab when we cover the lungs. You will assess six to eight places on the anterior side and eight places on the posterior side. You want to note any sounds that deviate from normal. So once again, you want to listen, listen, listen. The more you listen to sounds, the more you'll be accustomed to hearing what is normal. These abnormal sounds are referred to adventitious sounds. and you are at the basic level of assessment, you don't need to know all the different lung sounds yet because that'll come in Med-Surg. For documentation purposes, you can just say adventitious sounds noted bilaterally at the base of the lungs or throughout the lung field bilaterally or wherever they were noted at. But just to kind of give you an idea, crackles are caused by random sudden reinflation of the groups of alveoli or a disruptive passage of air through small airways. This can be described as fine, medium, or coarse sounds. Ronchi are low-pitched continuous sounds caused by muscular spasm, fluid, and mucus in large airways or new growth or external pressure causing turbulence. Wheezes are high-pitched continuous musical sounds. like a squeak heard continuously during inspiration or expiration. They are usually louder on expiration and often heard in patients with asthma. Normally, the breath sounds you hear when auscultating the lateral thorax are vesicular. And during auscultation, you want to note the location and characteristics of the sound and listen for the absence of breath sounds. And once again, we will be learning more about the lung sounds when we cover the respiratory system. All right, with the heart, you want to compare assessment of the heart functions with your vascular findings. You want to assess the point of maximal impulse. It's often referred to as the PMI. And you want to make sure that you can locate the anatomical landmarks. So what is PMI? It is the apical impulse or point of maximal impulse. A section of the left ventricle shapes the left anterior side of the apex. The apex actually touches the anterior chest wall at approximately the fourth to fifth intercostal space, just medial to the left midclavicular line. This is the apical impulse or the point of maximal impulse, PMI. You will need to verbalize these anatomical landmarks every time you're doing an assessment so that the instructor knows that you are lining up with the apical pulse. So when you're doing your head-to-toe checkoff, make sure that you're verbalizing it. And then when you're doing your assessments in the hospital as well, you'll need to verbalize it so that your instructor knows that you know where these landmarks are. So just make sure that you get in the habit of practicing. in lab saying that you're going down to the fourth, between the fourth and fifth intercostal space, just medial to the left mid-clavicular line, and you're going to assess the apical pulse, and you'll do this for a full 60 seconds. Heart sounds occur in relation to physiological events in the cardiac cycle. S1 and S2 refer to the lub dub sound. So lub is S1, dub is S2. And they're your normal heart sounds that occur as valves open and close normally. And the heart chambers fill and empty of blood. These are the sounds that you will be responsible for knowing this semester. S3 and S4 are more complex, and you will learn more about these in MedSurg and in an advanced MedSurg. So you will want to listen to S1 and S2 and you want to note whether they are equal, strong, regular. So once again, to become proficient at this, you'll want to listen to many, many, many different hearts so that you can hear these sounds. With the heart, you'll be using inspection and palpation. The patient should be relaxed and comfortable. and you want to inspect and palpate simultaneously. So why do you think your patient needs to be relaxed and comfortable? So let's talk about this for a minute. An anxious patient or an uncomfortable patient will exhibit a mild form of tachycardia, and this is often associated with white coat syndrome. People get nervous coming into the office. They're nervous about being in the hospital. And so when you say that you're going to do an assessment on them, They sometimes become a little tachycardic with that. And that can lead to inaccurate findings. So you want to try to make them as comfortable and as relaxed as possible. During inspection and palpation, you want to look for visible pulsations and exaggerated lifts. And you want to palpate for the apical impulse and any source of vibrations or thrills. A thrill is a continuous palpable sensation that resembles the purring of a cat. You want to follow an orderly sequence beginning at with the assessment at the base of the heart and moving towards the apex. Auscultation of the heart detects normal heart sounds, extra heart sounds, and murmurs. The apical rate and rhythm, you want to assess the apical rate for a full 60 seconds. It's the most accurate way to assess the rate. And this can also be a good time for you to count respirations without the patient knowing you're assessing their respirations. Because once again, when a patient knows that you are assessing something like their respirations, they may unintentionally change their breathing rate or pattern because they become self-conscious. So if you can kind of do it on the down low a little bit, you'll get a more accurate reading. You want to assess for extra heart sounds at each auscultatory site, and you want to use the Bell of the Stuff scope to listen for low-pitched extra heart sounds, clicks, and rubs. Auscultate over all anatomical areas of the heart. Failure of the heart to beat at irregular successive intervals is a dysrhythmia, and some dysrhythmias are life-threatening. The final portion of the examination of the heart includes assessment for heart murmurs. Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of systolic or diastolic phases. And the intensity is recorded using grades one through six. Murmurs can vary in pitch and quality and sequence of the patient positions for heart auscultations. You will not be responsible for knowing dysrhythmias or murmurs in this class, but you do want to listen to lots and lots of heart sounds in order to recognize normal heart sounds so that when you do hear something that sounds different you will recognize it as being different. When auscultating blood pressure know that the readings between the arms vary. The right arm tends to be higher. You always want to record the higher measurement and we'll go over the correct technique to take a manual blood pressure in lab. To assess the vascular system you will use the skills of inspection, palpation, and auscultation. It involves the, excuse me, it includes the carotid arteries, jugular veins, peripheral arteries, peripheral veins, tissue perfusion, and lymphatic system. You do not want to palpate or massage the carotid arteries vigorously. because the carotid sinus is located at the bifurcation of the common carotid arteries in the upper third of the neck. This sinus sends impulses along the vagus nerve. Its stimulation can cause a reflex drop in heart rate and blood pressure, which can cause syncope or circulatory arrest. An absent carotid pulse wave indicates arterial occlusion, which is a blockage, or stenosis, which is narrowing. And you want to perform portions of the vascular examination during other body system assessments for efficiency. Most of the accessible veins for examination are the internal and external jugular veins in the neck. It is best to examine the right internal jugular vein because it follows a more direct anatomical path to the right atrium of the heart. Normally, when a patient lies in a supine position, the external jugular vein distends and becomes easily visible. For some patients with heart disease, the jugular vein remains distended when sitting. And then you want to assess venous pressure as well. To examine the peripheral vascular system, first assess the adequacy of blood flow. flow to the extremities by measuring arterial pulses and inspecting the condition and color of the skin and nails, which is something that we've previously talked about. Next, you want to assess the integrity of the venous system by feeling the pulses. Assess the arterial pulse in the extremities to determine the sufficiency of the entire arterial circulation. You are assessing if the peripheral pulses are equal and strong. If they are all the same, then you only need to document that peripheral pulses are equal and strong. The peripheral pulses are under the cardiovascular system. So the strength of the pulse is a measurement of force at which the blood is ejected against the arterial wall. Some examiners use a scale reading from 0 to 4 plus to assess the strength of a pulse. So zero is absent or not palpable. One plus is diminished, barely palpable. Plus two is expected or normal. Plus three is full, increased. And four plus is bounding, something that you would have with like vigorous exercise. So assessment of the peripheral veins includes inspection and palpation for varioscites, peripheral edema, and phlebitis. Varioscites are superficial veins that become dilated especially when the legs are in the dependent position. Dependent edema around the area of the feet and ankles is a sign of venous insufficiency or right-sided heart failure. You want to assess for pitting edema and we talked about that earlier. And phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, or prolonged insertion of your IV catheters. So you want to make sure that if your patient does have an IV that you're assessing that regularly to make sure that that vein is still intact. To assess for phlebitis in the leg, you want to inspect the calves for localized redness tenderness and swelling over vein sites Gentle palpation of the calf muscles reveal warmth, tenderness, and firmness of the muscle. Unilateral edema of the affected leg is one of the most reliable findings of phlebitis. Which organs will you assess with an abdominal assessment? So let's think about it. We have the liver, stomach, uterus, ovaries, kidneys, and bladder all located within the abdominal cavity. This is a more complex assessment because of all these organs, and you will cover this more in detail when we get to the abdomen in class. A thorough nursing history helps interpret physical signs. You want to begin this assessment with inspection, just like we do with all our other assessments of the systems, and then you'll follow with auscultation and then with palpation. So just think of look, listen, and feel. This order is very, very important. If you start poking around the intestines before you listen, you may stimulate them to produce sounds that weren't there before. After you inspect, you'll be listening starting at the right lower quadrant. You will follow the ascending colon up to the transverse, then across, then to the descending colon, and then lastly the sigmoid colon. This will cover all four. quadrants of the abdomen. Before you assess the abdomen, explain what you will be doing. Properly drape the patient and place the patient in a position of comfort. You want to control the environment and use proper lighting. Most important, the patient should be comfortable and should not tense the abdomen. When examining the abdomen, you want to look for contour. Is it flat or is it distended? You want to look at the symmetry. is equal on both sides. You want to look at the skin characteristics, the umbilicus, and you want to assess for any pulsations. You want to auscultate bowel sounds. Listen to lots and lots of bowel sounds. You can listen to your own sounds, you can listen to your friends'sounds, family, but listen to as many bowel sounds as you can so that you can recognize normal. Listen to them before you eat, listen to them after you eat. The best time to auscultate is between meals. Peristalsis is the movement of contents through the intestines. It's a normal function of the small and large intestines. Bowel sounds represent the audible passage of air and fluid that peristalsis creates. Absent bowel sounds indicate a lack of peristalsis, possibly as a result of late stage bowel obstruction, a periolytic ileus, or peritonitis. You must listen for a full five minutes if no bowel sounds are heard in order to document that bowel sounds are absent. Hyperactive sounds are loud growling sounds called borbordomy, which indicate increased GI motility. Brewies indicate narrowing of major blood vessels and a disruption of blood flow. The presence of a bruit in the abdominal area can reveal aneurysms or stenotic vessels. For palpation, you want to use light palpation in all quadrants and then go into a deeper palpation of all the quadrants. You're palpating the liver, spleen, kidneys, and aorta. Palpation is performed last. You want to assess aortic pulsations by palpating with the thumb and forefinger of one hand deeply into the abdomen just left of the midline. Normally a pulsation is transmitted forward if the aorta is enlarged because of an aneurysm, which is a local dilation of the vessel wall, the pulsation expands laterally. You never want to palpate a pulsating abdominal mass. When you're done palpating the abdomen, you want to palpate the bladder. This is a good time to ask about frequency of urination and bowel patterns. At times, you will be able to assess the musculoskeletal and neurological systems together. Conduct an assessment of the musculoskeletal function when observing a patient ambulate or participate in other active movements such as range of motion. Ask patients whether they have had previous problems with falls, fractures, trauma, or neurological deficits. Note the muscle strength as a person sits up. Common postural abnormalities include lordosis, kyphosis, and scoliosis, which you will learn more about in Med-Surg. Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine, and this is common in older adults. Lordosis, or swayback, is an increased lumbar curvature, and a lateral spine curvature is referred to as scoliosis. For palpation, you want to apply gentle palpation to all the bones, joints, and surrounding muscles during a complete examination. Note any heat, tenderness, edema, resistance to the pressure. The patient should not feel any discomfort when you palpate. Muscles should be firm. A loss of height is frequently the first clinical sign of osteoporosis in which height loss occurs in the trunk as a result of vertebral. fracture or collapse. Osteoporosis is a systemic skeletal condition that is noted to have both decreased bone mass and deterioration of bone tissue making bones fragile and a risk for fracture. So you want to test the range of motion for both your upper extremities and your lower extremities. muscle strength of the hands, arms, and shoulders. And during this time you want to palpate the epitrochlear nodes. For your lower extremities you want to inspect for symmetry, skin characteristics, hair distribution, varicose veins. You want to palpate pulses including your femoral, your popliteal, posterior tibial, and dorsalis pedis pulse. You want to separate the toes and inspect them. You want to test the range of motion and muscle strength of your hips, knees, ankles, and feet. You want to ask the person to sit up and dangle their legs off the bed or table. And you want to make sure that you keep their gown on and a drape over their lap. Assessing muscle strength and tone during range of muscle, you want to note is it equal. For passive range of motion, ask the patient to allow an extremity to relax or hang limp. This is often difficult, particularly if the patient feels pain. You want to support the extremity and grasp each limb, asking them to move it slowly through the range of motion. If you identify weakness, compare the size of the muscle with its opposite counterpart. part by measuring the circumference of the body muscle body with a tape measure. A muscle that is atrophied which means reduced in size feels soft and boggy when palpated and hypertonicity or hypotonicity are advanced skills for med surge. Muscle strength and muscle tone is what we're looking for and you're just noting are they equal and strong. These are the things that you will need to know for this class. A full assessment of the neurological function requires much time and attention to detail. For efficiency, integrate neurological measurements with other parts of the physical examination. Observe the patient's mental and emotional status when you walk into the room. You want to note their level of consciousness, their physical status, and their chief complaint. A person's level of consciousness exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli. Talk with your patient. Ask questions about events involving his or her concerns about any health problems. A fully conscious patient responds to questions quickly and expresses ideas logically. When evaluating a level of consciousness, you note, do they know their name and date of birth? Do they know where they are at? Do they know what day and year it is? Do they know what brought them into the hospital? What is their level of consciousness? Are they alert or are they drowsy? If they're alert and can answer all the questions, You would say that they are alert and orientated times four. That means that they are alert and orientated to person, place, time, and situation. With lowering of a patient's consciousness, the Glasgow Coma Scale is used. This is used for objective measurement of consciousness on a numerical scale. You will learn more about this later. Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about a patient's mental status. Remain perceptive of patients'mannerisms and actions during the entire physical assessment. Note any nonverbal and verbal behaviors. Normal cerebral function allows a person to understand spoken or written words and express the self through written words and gestures. Assess the patient's voice inflection, tone, and manner of speech. Is their speech clear? When communication is clearly ineffective, assess for aphasia. This is caused by injury to the cerebral cortex. The two types of aphasia are sensory. or receptive and motor or expressive. With receptive aphasia, a person cannot understand written or verbal speech. With expressive aphasia, a person understands written and verbal speech but cannot write or speak appropriately. A patient sometimes suffers from a combination of receptive and expressive aphasia. You will learn more about this in Med-Surg. Intellectual function includes memory, recent, immediate, and past, knowledge, abstract thinking, association, and judgment. Because cultural and educational backgrounds influence the ability to respond to test questions, do not ask questions related to concepts or ideas with which a patient is unfamiliar. To assess cranial nerve function, you may test all 12 cranial nerves, a single nerve, or related groups of nerves. A complete assessment involves testing the 12 cranial nerves in their numerical order. We will cover these in a few weeks when we talk more about neuro. The sensory pathways of the central nervous system conduct sensations of pain, temperature, position, vibration, and crude and finely localized touch. Different nerve pathways relay the sensations. Most patients require only a quick screening of sensory function unless symptoms of a reduced sensation, motor impairment, or paralysis are noted. An examination of motor function includes assessments made during the musculoskeletal examination as well as cerebrular function. The cerebellum coordinates muscular activity, maintains balance and equilibrium, and controls posture. You can check for questions by calling the coordination during your assessment of the musculoskeletal system. So after the examination or at the end of the examination, you want to provide for the patient's comfort and then document a detailed summary of the physical findings. You want to communicate significant findings to your nurse that you're working with in the hospital and or your instructor as appropriate. before you document or discuss anything with the patient. Thank the person for his or her time. Tell the patient that you are finished with the exam and that you will leave the room if you're in the office that you will leave the room while he or she gets dressed. For the hospitalized person return the bed to its lowest position and any room equipment that you moved put it back the way you found it. Make sure that their call light and telephone are within easy reach. You want to record and document in a timely manner to ensure accuracy. You want to use short, clear phrases and avoid redundant phrases. Some key points to remember. Perform a physical exam only after the proper preparation of the environment and equipment and the patient have been made to prepare the patient physically and psychologically. Throughout the exam, keep the patient warm, comfortable, and informed about each step of the process. A competent examiner is systematic while combining simultaneous assessments of different body systems. Information from the history helps to focus on body systems likely to be affected. Baseline assessment findings reflect a patient's functional abilities and serve as the basis for comparison with subsequent assessment findings. You want to integrate patient teaching throughout the exam to help patients learn about health promotion, disease prevention, and skills to help with any current health issues. And that concludes our lecture today on health assessment and physical examination for the head-to-toe assessment. Thank you.

And then as we've talked about before, the components of the health history include your biographic data, past health, family history, review of systems, functional assessment, and their perception of their health. The patient's condition and response affects the extent of your examination. So as you find Things you'll have to delve in deeper to find out more information about them.

The accuracy of your assessment will influence the choice of therapy a patient receives. And then evaluation of how they respond to those therapies will guide how you proceed with things. So the physical assessment is the art of arranging all of these steps that you will learn in this class.

and to complete a head-to-toe assessment. In the beginning, you may have to pause and think about what comes next rather than just gathering the data. But with repeated rehearsals, you will be able to make it smoother and you'll come to a point where your flow is much more natural. And even if you forget a step, you'll be able to gracefully insert it somewhere else into the assessment in a logical place.

And you'll find that as you practice, you'll be able to figure out where those places are. Okay, so the purposes of the physical examination is, first of all, you want a triage for emergency care. A physical examination may be done for routine screenings to promote health and wellness.

It's used to determine eligibility for health insurance, military service. Sometimes you need a physical exam to get a new job. And then, of course, when a patient is admitted to the hospital or long-term care facility, there's always an admitting physical exam that's done.

Additionally, any time There is a transfer within the hospital setting. You'll do a physical examination upon receipt of that patient. And then you'll also want to do a head-to-toe exam during a shift change because you want to know where that patient started at at the beginning of your shift so you'll be able to monitor for changes throughout your shift.

Okay, so... Okay. The use of the physical exam is gathering a health history and it requires you to be able to communicate with your patient.

And we've talked about communication techniques already. So you want to employ, you know, very open ended questions when you're gathering data. You want to be supportive and non-judgmental. We'll be talking a great deal about the nursing process, which you'll be learning more about in your foundations class with Professor Ray, and the importance of using a nursing diagnosis and a care plan.

Physical assessment findings determine the cause of the diagnosis, which enables nurses to individualize a plan of care. You'll be using a lot of your data to develop an individualized plan of care for your patient that you're taking care of. in that moment.

So when you're looking at care plans and stuff, don't just take it straight from the book, but think about how it applies to that patient that you're dealing with at that moment. While managing patient problems, you will want to use physical assessment skills to assess the status of your patient's health. So you will be starting out with very basic skills, vital signs, inspection, auscultation. You'll be looking and listening with your stethoscope, all very basic things, and then you will expand on those skills as you progress in your nursing career.

In this class, you'll be developing a beginning organized style for your head-to-toe assessments, and you'll hear me say that over and over. You want to have an organized style for completing your head-to-toe assessment. It's important to get a baseline or beginning assessment on your patient so that you can revise your plan of care throughout the day to address any future problems that may come up with your patient.

During the evaluation phase, nurses can revise, amend, or even discontinue nursing interventions as their patient achieves their outcomes or their goals. All right, so with culture sensitivity, remember that there's a difference between cultural characteristics and physical characteristics. You want to learn to recognize common characteristics and disorders among members of ethnic populations in your area. In our area, you will be taking care of a lot of Hispanic patients, Muslim patients, Filipino, Vietnamese, and also a lot of geriatric patients.

You don't have to know everything about all of these cultures and their differences, but you do have a responsibility as a nurse that when you are caring for these populations to find out what is appropriate and not appropriate behaviors and treatments for these patients. We really want to avoid stereotyping or gender biases. As nurses, we need to be as objective as possible and look at every person as an individual. Okay, so we have some things that need to be done in order to prepare for our head-to-toe assessment. These aspects need attention to ensure that your patient is physically and emotionally ready for the exam.

You will need to use good hand hygiene and follow your health care facilities policies. The environment must provide for privacy. You must have good lighting and climate control.

The patient must be comfortable in order to proceed. You need to make sure that you have all of your... equipment that it's properly cleaned or sterilized and in good working order.

So that means making sure that you test your equipment and if it requires batteries or bulbs, power cords, or calibration that you do all this ahead of time and have all your equipment prepared and accessible before you start the exam. You don't want to have to run out in the middle of the exam and get a piece of equipment that you've forgotten. Patients need to be told what's going on and when it's going to occur.

Proper draping is necessary, as with proper positioning. So you only want to uncover what you're looking at and making sure that you maintain patient privacy at all times. You want to encourage your patient to ask questions, and at times, if the patient and the nurse are of opposite gender, you may need to have a third person in the room.

You want to make sure that you consider cultural and social norms with this. When assessing various age groups, you may have to vary your techniques and styles. So children require different handling than adolescents, adults, and even the elderly.

We will not be talking about or learning about children in this class. But when we are caring for the elderly, we need to make sure that they have their glasses or hearing aids with them if they use them. Without these aids, they may answer inappropriately, which may give the impression that they are confused. And you need to make sure that you allow adequate time for them to respond to your questions. Okay, so organization of the exam.

So some tips that will help you with your examination is just remember that this class focuses on the head-to-toe assessment, which literally means we're going to start at the head and we're going to systematically work down to the toes. However, in the hospital setting, if the patient is seriously ill, you want to first assess the body system that's most at risk. This is called a focused examination.

Then you want to continue on with your head-to-toe assessment. If the patient fatigues easily, you want to allow rest periods in between assessments. You want to perform painful procedures near the end of the assessment, and you want to use accepted medical terms and abbreviations to keep your notes brief. You want to record quick notes during the exam, and then complete your larger documentation notes at the end. at the end of the examination.

When using the head-to-toe approach, you will address all of the body systems and you won't have to worry about missing anything. You want to compare both sides for symmetry. And once again, you want to focus on just keeping your assessment very organized and systematic. And with practice, it'll become like muscle memory.

Okay, so there are four techniques that are used with the physical examination, and they are inspection, palpation, percussion, and auscultation. The three that you will use the most are inspection, auscultation, and palpation. Percussion is really reserved for advanced practice, and you really won't be using this technique while you're in nursing school because it is an advanced technique.

All right, so with inspection, it's the simplest of the four assessment skills. So you want to inspect, carefully look, you want to use your sensory skills of listening and smell to distinguish normal from abnormal findings. You want to make sure that you can recognize what is normal so that when you hear something or see something different, you can recognize it as abnormal. You want to make sure that you have adequate lighting.

Anytime you're looking into any type of an orifice, whether it be the nares or the ears, you want to make sure that you have your pen light available so that you can see in there and note anything that's abnormal. You want to inspect each thing that you're looking at. You always want to look at the size, the shape, color, symmetry, you know, if you're looking at their eyes, are they equal on both sides. You want to look at their body positions and any abnormalities that you may be able to see just visually. You want to position and expose body parts as needed so that all surfaces can be viewed.

That means when you're looking at the feet, make sure that you're taking off their socks, so on and so forth. And when possible, You always want to be able to compare one to another to make sure that they are equal in size. So let's think about this for a minute. Why do you think olfaction, smell, would be important as part of your assessment? Well, olfaction helps detect abnormalities that cannot be detected or recognized by any other means.

So, for example, a pretty order of the breath. is a sign of ketoacidosis, which may occur in diabetes. It's a potentially life-threatening condition. Breath that smells like feces can occur with prolonged vomiting, especially if there's a bowel obstruction.

So as you become a more seasoned practitioner, you'll be able to recognize these different smells and what they could possibly mean. All right, so with palpation. It involves a lot of touch, so you always want to make sure that you are telling your patient what you're about to do. You want to make sure that your patient is in a comfortable position and encourage them to relax as much as possible. You want to palpate sensitive areas last.

You want to make sure that you're using proper hand hygiene and changing your gloves as needed as you move from one area to another. And we'll be discussing this as we go along as well. You want to use different parts of the hand to detect different characteristics.

So the palmar surface of the hand and the base of your fingers, so essentially where the finger pads are, are more sensitive than the fingertips and should be used to determine position, texture, size, consistency, masses, fluids, and crepitus. The palmar surface of the hands and fingers are much more sensitive to vibration. You want to assess body temperature by using the back of your hand or the dorsal surface because the skin is much thinner on that side of the hand it's much more sensitive to temperature and for measuring a position or shape or consistency you can use a grasping motion between your fingertip and your thumb just to like what we would do for testing out skin turgor. You want to start with light palpation and end with deeper palpation.

You want to make sure that your hands are warm, and you always want to keep your fingernails short so that you don't dig into the patient when you're examining them. All right, so with percussion, as I said before, this is an advanced technique, and it's not an expected skill for the new practitioner. We will not be doing this technique. Developing this skill requires a lot of practice. You just need to be aware of the technique and how it's done.

So just basic information. Alright so with auscultation you will be listening to heart rates, lung sounds, and bowel sounds. Some sounds you can hear without assistance. So if you ever think about your stomach growling around lunchtime you know how you can audibly hear that without having to have a stethoscope. Other sounds will require the use of a stethoscope.

Becoming proficient with auscultation requires that you recognize the sounds that are being produced by body parts and the best locations for hearing these sounds. So this means you need practice, practice, practice, practice. You can listen to your own heart rate.

You can listen to your own bowel sounds. You can listen to your own respiratory sounds. Listen to your friends.

Listen to your family. You know, anybody that you can listen to, take that opportunity to listen to so that you are good at recognizing what's normal. That way, when you hear something that's different, you can recognize that as being an abnormal sound. The bell of the stethoscope is used to hear low-pitched sounds, and the diaphragm, which is the larger side, is used for higher-pitched sounds. And so let's think about how you can tell the difference between body sounds and extraneous noises.

Well, it goes back to practice. By practicing with your stethoscope, you'll become proficient with using it and realize when sounds are clear. And then you'll be able to recognize when you have extraneous sounds present. So extraneous sounds are created by rubbing the tubing. or the chest piece on something and it interferes with the auscultation of the body organ sounds.

So by deliberately reproducing these sounds or causing these things to touch, you'll be able to hear what it sounds like and then recognize when you have that interference when you're trying to actually assess a body system. Be sure to place your stethoscope directly on the patient's skin and that will help avoid some of these extraneous sounds like the sound that you would get from rubbing on the patient's gown or a bandage or something like that. You'll want to do a general survey of your patient.

You can learn a lot about your patients before you even lay your hands on them. You want to assess their height and weight because it's a reflection of a person's overall level of health. It will be important to obtain a diet history from your patient. So when you're looking at your patient you want to assess whether or not they appear their stated age.

What is their level of consciousness? What is their skin coloring? Are they pale, flushed, cyanotic? What is their nutritional status, their personal hygiene? Look at their posture and position.

Are they comfortable? Are they sitting erect? Is observed for any physical deformities? How do they move if they're up in their room or if they're walking into your office?

Is there a mobility device in their hospital room that would tell you that the patient needs assistance to get up and out of bed? What is their facial expression, their mood, their affect? How are they hearing?

How is their speech? Are their articulation the pattern of their speech? Is the content appropriate?

What is their native language? Is there an IV in the room? Is the patient on oxygen?

Is there a bedside commode in the room? Are they in any signs of distress? You can learn a lot about your patient just by looking at them and surveying their hospital room as you walk in. All right, so for skin. The integumentary system refers to the skin, hair, scalp, and nails.

You will be looking and feeling, so inspection and palpating. You want to examine both hands and inspect the nails, comparing one to the other. For the rest of the exam, you'll examine the skin with the corresponding region that you're examining.

You want to observe for cyanosis, which is a blue discoloration of the lips, nail beds, conjunctiva, and palms. The best site to inspect for jaundice, which is a yellow-orange discoloration of the patient's skin, is in the patient's sclera. You can see normal reactive hyperania or redness most often in regions exposed to pressure, such as the sacrum. heels, and greater trochanter areas.

You want to inspect for any patches or areas of skin color variation. Localized skin changes such as pallor or urethemia, which is a red discoloration, can indicate circulatory changes. Are there any bruised or ecumatic areas? Is there any edema or swelling?

Moisture, you want to check to see if the skin is dry. Are they diaphoretic? which is sweaty.

Temperature is the skin cool, warm, hot. Texture refers to the character of the surface of the skin and how the deeper layers feel. By palpating lightly with your fingertips, you can determine whether the patient's skin is smooth or rough, thin or thick, tight or supple, and any indurated areas or soft areas.

Turgor. checking the elasticity and hydration of the skin. You never want to check skin turgor on the back of the hand because the skin is naturally looser on the back of your hand. You want to check skin turgor on the forearm or the top of the chest or on the patient's back.

The skin should briskly return back to normal. If you pinch it up and it stays tented like that, then it's referred to as tenting and may indicate hydration issues. The circulation of the skin affects color in localized areas and leads to the appearance of superficial blood vessels.

Vascularity occurs in localized pressure areas when the patient remains in one position. Vascularity appears reddened, pink, or pale. With aging, capillaries become fragile and are more easily injured.

Petechiae are non-blanching, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers. Cherry angiomas are very small usually. They're smooth, slightly raised dots on the skin.

They commonly appear on the trunk and are a normal part of aging and usually begin to appear after the age of 30. Direct trauma and impairment of the venous return are two common causes for edema. You want to inspect the venous return. endematous areas for location, color, and shape. The formation of edema separates the surface of the skin from pigmented and vascular layers, masking skin color. Edematous skin also appears stretched and shiny.

You want to palpate edematous areas to determine mobility, consistency, and tenderness. When pressure from the examiner's fingers leave an indentation in the edematous area, this is called pitting edema. To assess the degree of pitting edema, you want to press the edematous area firmly with the thumb or index finger for several seconds and then release.

A depression left in the skin indicates edema. Grading 1 plus through 4 plus characterizes the severity of the edema. The depth of the pitting is recorded in millimeters and it determines the degree of edema.

For example, 1 plus edema equals 2 millimeters depth, 2 plus edema equals 4 millimeters depth, 3 plus equals 6 millimeters, and 4 plus equals 8 millimeters. And you have an example of that here in the PowerPoint. Lesions are assessed by using the ABCD mnemonic. It assesses asymmetry, border irregularity, color, and diameter. This is not something that we'll be learning for your head-to-toe assessment.

All right, so for the hair and scalp, you want to inspect and palpate the scalp and hair in the cranium. You want to note, is their hair thick, full, thin, dry, oily? You want to carefully inspect the hair follicles on the scalp and pubic areas because it can reveal lice or other parasites.

This is something that you will come across as nurses as people are admitted. You want to check for hair loss, which is alopecia, or thinning of the hair, which is usually related to genetic tendencies or endocrine disorders such as diabetes, thyroiditis, and even menopause. And then during this time, you can ask if they've ever had any head injuries or headaches as you're palpating their scalp and looking.

So when you're doing it, you really want to just be... feeling do they have any open sores is there any pain or tenderness you want to look at the hair for the color distribution quantity thickness texture and lubrication how will you be assessing nails well you'll be using inspection and palpation The condition of the nails reflect the overall general health of the patient. It can demonstrate the state of nutrition, whether or not they have a vitamin or protein deficiency. Electrolyte changes can cause variation lines or bands to form in the nail beds.

Their occupation, are they dirty? Are they well manicured? Are they a mechanic? Are they a surgeon?

Do they do a lot of gardening? So on and so forth. The level of self-care, are they clean? Are their toenails trimmed? We see a lot of patients in the hospital that have very long and overgrown toenails because they aren't able to bend over or be flexible enough to trim their own toenails.

Age, the nails become more rigid as a person ages. So these are all things that you would want to look at. Palpation, you would gently squeeze the nail bed to assess their circulatory status, whether or not it responds very quickly back to a pink color, and we'll be learning more about that later as well. So with the head and neck, During the health history, you've already previously screened for past and present injuries that they may have.

You'll be using inspection, palpation, and auscultation. And the assessment includes the head, eyes, ears, nose, mouth, fair necks, neck, lymph nodes, carotid arteries, thyroid gland, and in the trachea. So you want to inspect the face. You want to look at their expression and you want to note symmetry. Does the left side of their face match the right side of their face?

With Bell's palsy, it's a paralysis of the seventh cranial nerve and the patient will not be able to move the upper or lower half of their face. So they won't blink. They won't be, when they smile, that side of their face won't participate in the smile.

They may have a little bit of drooling. They can't put their lips together and whistle. And this helps differentiate between Bell's palsy and a stroke because with a stroke patient, this patient will still be able to close their eyes and wrinkle their forehead because it does not affect that nerve.

You want to palpate the temporal artery and then the temporal mandibular joint. As the person opens and closes their mouth, you want to assess for pain or tenderness, any clicking sounds. You want to palpate the maxillary sinuses and the frontal sinuses.

Is there any pain or tenderness with that? And then this is also a good time to ask about hearing aids and glasses. As you move on to the eyes, you'll be examining the eyes. You'll assess the size. the shape, the structure, visual acuity, visual fields, the conjunctiva, sclera, cornea, pupil, and the iris.

The presence of redness in the conjunctiva could indicate they have allergies or it could be an infectious condition that you need to address. A thin white ring along the margin of the iris is called Arcus Sonalis. It's common with aging, but it's abnormal in anyone younger than 40 years old And in the PowerPoint, you have some examples of the eye structure.

This is just mainly for your information. It's not something that you're going to be tested on. The photo at the bottom shows the six directions of gaze. Direct the patient to follow your finger movement through each gaze, and we'll be learning more about this in lab. Extracular muscles will tell you about the, excuse me, the extracular muscles.

You'll have the corneal light reflex and the six cardinal positions of gaze, and these test out the cranial nerve 3, 4, and 6. In addition to parallel movement, you would want to note any nystagmus, which is an involuntary rhythmic auscultation of the eyes, and it occurs as a result of local injury to the eye muscle and supporting structures, or may follow a disorder of the cranial nerves and nerve. innerviating that muscle. It can also be caused from alcohol intoxication.

So that's one of the things that law enforcement uses to test for alcohol intoxication is the sixth cardinal positions of gaze and they're looking for nystagmus. With the external eye structure, you want to check for the position and alignment of the eyes, the eyebrows, eyelids, lacrimal apparatus, conjunctiva and sclera, the corneas, and the pupils and irises. You want to test the pupil size for light and accommodation and this is where you would use the mnemonic PERLA and PERLA stands for pupils equal, round, reactive to light, and accommodate.

To check the pupillary reflexes, the nurse holds up a penlight to the side of the patient's face and then gently shines the light into their eye. And the illumination of the pupil causes pupillary constriction. And you will be learning more about Perla in lab.

And this is an example of a chart to pick. depicting pupillary sizes in millimeters and understand that this is blown up quite a bit on the powerpoint so that you can see it and i believe that your pen lights that you'll be getting in lab also have this chart on the side of them so that you have something to compare the pupils to when you're assessing them with inspection of the external error you want to palpate the auricles for texture, tenderness, and skin lesions. Auricles are normally smooth and without lesions.

The ear color is usually the same as the face without moles, cysts, deformities, or nodules. Redness is a sign of inflammation or fever. Extreme pallor can indicate frostbite.

If palpation causes pain, an external ear infection is likely. If the patient has ear pain but palpation does not cause additional pain, infection may be present in the middle ear. A yellow waxy substance called cerumen is common and you may see an increase in cerumen in your older adults.

And impacted cerumen can affect their hearing. Yellowish or green foul-smelling discharge indicates infection or a foreign body. When inspecting the external nose, observe for the shape, size, skin color, and the presence of any deformities or inflammation. You want to test the patency of each nostril.

If swelling or deformities exist, you want to gently palpate the ridge and soft tissue of the nose by placing one finger on each side of the nasal arch and gently moving the fingers from the nasal bridge to the tip. How can the color of nasal discharge indicate patient condition? So pale mucosa with a clear discharge indicates allergies, which many of you are familiar with, and a mucoid discharge indicates rheumatitis. A sinus infection results in yellow or greenish discharge, and so you'll always want to assess any discharge that comes from the nose. The patient with a nasal gastric tube, you routinely want to check for localized skin breakdown from that of the nares.

It's characterized by redness and skin slothing, and it can occur very, very quickly. During the examination, you want to note any polyps, which are tumor-like growths that look like small clusters of grapes, or any purulent drainage. Examination of the sinuses involves palpation, and during this time, you want to continue to inspect facial symmetry.

For the lips, you want to assess the color, texture, hydration, contour, and for lesions. Lip color in the dark-skinned person varies from pink to plum. Anemia can cause pallor of the lips. Cyanosis is caused by respiratory or cardiovascular problems, whereas cherry-colored lips can indicate carbon monoxide poisoning.

Any lesions should be evaluated for the potential of being an infection. or an irritation or skin cancer. Dry cracked lips can indicate hydration status and once again you want to note the contour and if there's any presence of lesions. With a pen light you want to inspect the mouth. You want to inspect the mucosa for color, hydration, texture, and lesions such as ulcers, abrasions, or cysts.

Normally, the mucosa is glistening pink and smooth and moist, and so retraction of the buccal mucosa also allows for clear visualization, and you see that noted in the top left picture. You want to inspect the teeth to determine the quality of dental hygiene. You want to note the color of the teeth and the presence of any dental caries, which are cavities, tartar. and extraction sites, are they missing any teeth?

Because that will give you an indication as to how well they can chew their food and which may affect their dietary status. You want to note the mobility of the uvula as the person phonates ah and tests the gag reflex. Cranial nerve 9 and 10 are indicated with this.

And you want to note if the tonsils are present. Ask the person to stick out their tongue. And this will help assess cranial nerve number 12. For the neck, you want to test range of motion.

This can also be done when you are assessing the ears. So you want to note whether or not they have full range of motion. Do they have any pain with movement?

Can they flex forward? Can they hyperextend backwards? and move laterally or sideways. You want to inspect the neck for symmetry, lumps, and pulsations.

You want to palpate the cervical lymph nodes. You want to inspect and palpate the carotid pulse, and you want to do this one side at a time. And if indicated, you want to auscultate. You want to listen for carotid bruise.

You want to palpate the trachea, as it should be midline, masses in the neck or mediastinum, and pump. Pulmonary abnormalities cause displacement of the trachea laterally. So to determine the position of the trachea, you want to palpate it at the super sternal notch, slipping the thumb and index finger to each side.

And you want to note whether the finger and thumb shift laterally. You don't want to apply forceful pressure because this can elicit a coughing reflex. The thyroid gland is fixed to the trachea and you want to inspect the lower neck for the overlying thyroid gland for obvious masses, symmetry, and any subtle fullness at the base of the neck. So your cervical nodes are often palpable in a healthy person but this decreases with age.

Normal lymph nodes feel soft, they're movable and non-tender. With the carotid artery and the jugular vein, you may postpone this part of the examination until you do the vascular system assessment. And when you do do it, you want to make sure that you never palpate both carotid arteries simultaneously as you could cause your patient to pass out. And then this slide is just to show you how many lymph nodes that we have in our head and neck. You do not need to memorize this slide, and then there's additional pictures in your textbook of the remaining lymph nodes throughout the body.

And we'll go over these more in detail in future lectures. Accurate physical assessment of the thorax and lungs requires review of the ventilatory and respiratory functions of the lungs. If disease is affecting the lungs, it affects other body systems as well. So your examination will include inspection, palpation, auscultation.

Diagnostic equipment such as x-ray films, MRIs, and CT scans create little need for the use of percussion as it is an... an accurate assessment measure. Before assessing the thorax or lungs, be familiar with the landmarks of the chest.

This slide indicates all the different landmarks that you need to be familiar with. These landmarks help you to identify findings and to use assessment skills correctly. The patient's nipples, angle of Lewis, suprasternal notch, costal angle, Clavicles and vertebrae are key landmarks that provide a series of imagery lines for sign identification.

Keep a mental image of the locations of the lobes, the lungs, and the position of each rib. So with the lungs, reduced mental alertness, nasal flaring, somnolence, and cyanosis are examples of assessed signs that can indicate oxygenation problems. You want to inspect the thorax by observing the shape and symmetry of the chest from the patient's front and back. You can have the patient roll over in bed, that way you can assess their skin for breakdown while looking and listening to their lungs.

You want to look at their skin characteristics and symmetry of their shoulders and muscles. You want to assess the rate and rhythm of their breathing and you want to observe for the use of accessory muscles during breathing. The accessory muscles move little with normal passive breathing. However, patients who use a great deal of effort to breathe as a result of strenuous exercise or pulmonary diseases such as COPD, chronic obstructive pulmonary disease, rely on the accessory and abdominal muscles to contract thereby leading to inspiration and expiration for them.

Auscultation assesses movement of the air through the tracheobronchial tree and detect mucus or obstructed airways. Normally airflow through the airways in a non-obstructed pattern. You want to recognize the sound created by normal airflow. This allows you to detect sounds that are caused by an airway obstruction. When listening, you will follow a systematic approach that we will go over in lab when we cover the lungs.

You will assess six to eight places on the anterior side and eight places on the posterior side. You want to note any sounds that deviate from normal. So once again, you want to listen, listen, listen.

The more you listen to sounds, the more you'll be accustomed to hearing what is normal. These abnormal sounds are referred to adventitious sounds. and you are at the basic level of assessment, you don't need to know all the different lung sounds yet because that'll come in Med-Surg.

For documentation purposes, you can just say adventitious sounds noted bilaterally at the base of the lungs or throughout the lung field bilaterally or wherever they were noted at. But just to kind of give you an idea, crackles are caused by random sudden reinflation of the groups of alveoli or a disruptive passage of air through small airways. This can be described as fine, medium, or coarse sounds.

Ronchi are low-pitched continuous sounds caused by muscular spasm, fluid, and mucus in large airways or new growth or external pressure causing turbulence. Wheezes are high-pitched continuous musical sounds. like a squeak heard continuously during inspiration or expiration.

They are usually louder on expiration and often heard in patients with asthma. Normally, the breath sounds you hear when auscultating the lateral thorax are vesicular. And during auscultation, you want to note the location and characteristics of the sound and listen for the absence of breath sounds.

And once again, we will be learning more about the lung sounds when we cover the respiratory system. All right, with the heart, you want to compare assessment of the heart functions with your vascular findings. You want to assess the point of maximal impulse. It's often referred to as the PMI. And you want to make sure that you can locate the anatomical landmarks.

So what is PMI? It is the apical impulse or point of maximal impulse. A section of the left ventricle shapes the left anterior side of the apex. The apex actually touches the anterior chest wall at approximately the fourth to fifth intercostal space, just medial to the left midclavicular line. This is the apical impulse or the point of maximal impulse, PMI.

You will need to verbalize these anatomical landmarks every time you're doing an assessment so that the instructor knows that you are lining up with the apical pulse. So when you're doing your head-to-toe checkoff, make sure that you're verbalizing it. And then when you're doing your assessments in the hospital as well, you'll need to verbalize it so that your instructor knows that you know where these landmarks are.

So just make sure that you get in the habit of practicing. in lab saying that you're going down to the fourth, between the fourth and fifth intercostal space, just medial to the left mid-clavicular line, and you're going to assess the apical pulse, and you'll do this for a full 60 seconds. Heart sounds occur in relation to physiological events in the cardiac cycle. S1 and S2 refer to the lub dub sound.

So lub is S1, dub is S2. And they're your normal heart sounds that occur as valves open and close normally. And the heart chambers fill and empty of blood. These are the sounds that you will be responsible for knowing this semester.

S3 and S4 are more complex, and you will learn more about these in MedSurg and in an advanced MedSurg. So you will want to listen to S1 and S2 and you want to note whether they are equal, strong, regular. So once again, to become proficient at this, you'll want to listen to many, many, many different hearts so that you can hear these sounds.

With the heart, you'll be using inspection and palpation. The patient should be relaxed and comfortable. and you want to inspect and palpate simultaneously.

So why do you think your patient needs to be relaxed and comfortable? So let's talk about this for a minute. An anxious patient or an uncomfortable patient will exhibit a mild form of tachycardia, and this is often associated with white coat syndrome. People get nervous coming into the office.

They're nervous about being in the hospital. And so when you say that you're going to do an assessment on them, They sometimes become a little tachycardic with that. And that can lead to inaccurate findings. So you want to try to make them as comfortable and as relaxed as possible. During inspection and palpation, you want to look for visible pulsations and exaggerated lifts.

And you want to palpate for the apical impulse and any source of vibrations or thrills. A thrill is a continuous palpable sensation that resembles the purring of a cat. You want to follow an orderly sequence beginning at with the assessment at the base of the heart and moving towards the apex. Auscultation of the heart detects normal heart sounds, extra heart sounds, and murmurs.

The apical rate and rhythm, you want to assess the apical rate for a full 60 seconds. It's the most accurate way to assess the rate. And this can also be a good time for you to count respirations without the patient knowing you're assessing their respirations.

Because once again, when a patient knows that you are assessing something like their respirations, they may unintentionally change their breathing rate or pattern because they become self-conscious. So if you can kind of do it on the down low a little bit, you'll get a more accurate reading. You want to assess for extra heart sounds at each auscultatory site, and you want to use the Bell of the Stuff scope to listen for low-pitched extra heart sounds, clicks, and rubs.

Auscultate over all anatomical areas of the heart. Failure of the heart to beat at irregular successive intervals is a dysrhythmia, and some dysrhythmias are life-threatening. The final portion of the examination of the heart includes assessment for heart murmurs. Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of systolic or diastolic phases.

And the intensity is recorded using grades one through six. Murmurs can vary in pitch and quality and sequence of the patient positions for heart auscultations. You will not be responsible for knowing dysrhythmias or murmurs in this class, but you do want to listen to lots and lots of heart sounds in order to recognize normal heart sounds so that when you do hear something that sounds different you will recognize it as being different. When auscultating blood pressure know that the readings between the arms vary. The right arm tends to be higher.

You always want to record the higher measurement and we'll go over the correct technique to take a manual blood pressure in lab. To assess the vascular system you will use the skills of inspection, palpation, and auscultation. It involves the, excuse me, it includes the carotid arteries, jugular veins, peripheral arteries, peripheral veins, tissue perfusion, and lymphatic system.

You do not want to palpate or massage the carotid arteries vigorously. because the carotid sinus is located at the bifurcation of the common carotid arteries in the upper third of the neck. This sinus sends impulses along the vagus nerve.

Its stimulation can cause a reflex drop in heart rate and blood pressure, which can cause syncope or circulatory arrest. An absent carotid pulse wave indicates arterial occlusion, which is a blockage, or stenosis, which is narrowing. And you want to perform portions of the vascular examination during other body system assessments for efficiency.

Most of the accessible veins for examination are the internal and external jugular veins in the neck. It is best to examine the right internal jugular vein because it follows a more direct anatomical path to the right atrium of the heart. Normally, when a patient lies in a supine position, the external jugular vein distends and becomes easily visible. For some patients with heart disease, the jugular vein remains distended when sitting.

And then you want to assess venous pressure as well. To examine the peripheral vascular system, first assess the adequacy of blood flow. flow to the extremities by measuring arterial pulses and inspecting the condition and color of the skin and nails, which is something that we've previously talked about. Next, you want to assess the integrity of the venous system by feeling the pulses. Assess the arterial pulse in the extremities to determine the sufficiency of the entire arterial circulation.

You are assessing if the peripheral pulses are equal and strong. If they are all the same, then you only need to document that peripheral pulses are equal and strong. The peripheral pulses are under the cardiovascular system.

So the strength of the pulse is a measurement of force at which the blood is ejected against the arterial wall. Some examiners use a scale reading from 0 to 4 plus to assess the strength of a pulse. So zero is absent or not palpable. One plus is diminished, barely palpable. Plus two is expected or normal.

Plus three is full, increased. And four plus is bounding, something that you would have with like vigorous exercise. So assessment of the peripheral veins includes inspection and palpation for varioscites, peripheral edema, and phlebitis. Varioscites are superficial veins that become dilated especially when the legs are in the dependent position. Dependent edema around the area of the feet and ankles is a sign of venous insufficiency or right-sided heart failure.

You want to assess for pitting edema and we talked about that earlier. And phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, or prolonged insertion of your IV catheters. So you want to make sure that if your patient does have an IV that you're assessing that regularly to make sure that that vein is still intact.

To assess for phlebitis in the leg, you want to inspect the calves for localized redness tenderness and swelling over vein sites Gentle palpation of the calf muscles reveal warmth, tenderness, and firmness of the muscle. Unilateral edema of the affected leg is one of the most reliable findings of phlebitis. Which organs will you assess with an abdominal assessment? So let's think about it.

We have the liver, stomach, uterus, ovaries, kidneys, and bladder all located within the abdominal cavity. This is a more complex assessment because of all these organs, and you will cover this more in detail when we get to the abdomen in class. A thorough nursing history helps interpret physical signs. You want to begin this assessment with inspection, just like we do with all our other assessments of the systems, and then you'll follow with auscultation and then with palpation.

So just think of look, listen, and feel. This order is very, very important. If you start poking around the intestines before you listen, you may stimulate them to produce sounds that weren't there before.

After you inspect, you'll be listening starting at the right lower quadrant. You will follow the ascending colon up to the transverse, then across, then to the descending colon, and then lastly the sigmoid colon. This will cover all four. quadrants of the abdomen. Before you assess the abdomen, explain what you will be doing.

Properly drape the patient and place the patient in a position of comfort. You want to control the environment and use proper lighting. Most important, the patient should be comfortable and should not tense the abdomen. When examining the abdomen, you want to look for contour.

Is it flat or is it distended? You want to look at the symmetry. is equal on both sides.

You want to look at the skin characteristics, the umbilicus, and you want to assess for any pulsations. You want to auscultate bowel sounds. Listen to lots and lots of bowel sounds.

You can listen to your own sounds, you can listen to your friends'sounds, family, but listen to as many bowel sounds as you can so that you can recognize normal. Listen to them before you eat, listen to them after you eat. The best time to auscultate is between meals.

Peristalsis is the movement of contents through the intestines. It's a normal function of the small and large intestines. Bowel sounds represent the audible passage of air and fluid that peristalsis creates.

Absent bowel sounds indicate a lack of peristalsis, possibly as a result of late stage bowel obstruction, a periolytic ileus, or peritonitis. You must listen for a full five minutes if no bowel sounds are heard in order to document that bowel sounds are absent. Hyperactive sounds are loud growling sounds called borbordomy, which indicate increased GI motility.

Brewies indicate narrowing of major blood vessels and a disruption of blood flow. The presence of a bruit in the abdominal area can reveal aneurysms or stenotic vessels. For palpation, you want to use light palpation in all quadrants and then go into a deeper palpation of all the quadrants.

You're palpating the liver, spleen, kidneys, and aorta. Palpation is performed last. You want to assess aortic pulsations by palpating with the thumb and forefinger of one hand deeply into the abdomen just left of the midline.

Normally a pulsation is transmitted forward if the aorta is enlarged because of an aneurysm, which is a local dilation of the vessel wall, the pulsation expands laterally. You never want to palpate a pulsating abdominal mass. When you're done palpating the abdomen, you want to palpate the bladder. This is a good time to ask about frequency of urination and bowel patterns. At times, you will be able to assess the musculoskeletal and neurological systems together.

Conduct an assessment of the musculoskeletal function when observing a patient ambulate or participate in other active movements such as range of motion. Ask patients whether they have had previous problems with falls, fractures, trauma, or neurological deficits. Note the muscle strength as a person sits up. Common postural abnormalities include lordosis, kyphosis, and scoliosis, which you will learn more about in Med-Surg. Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine, and this is common in older adults.

Lordosis, or swayback, is an increased lumbar curvature, and a lateral spine curvature is referred to as scoliosis. For palpation, you want to apply gentle palpation to all the bones, joints, and surrounding muscles during a complete examination. Note any heat, tenderness, edema, resistance to the pressure.

The patient should not feel any discomfort when you palpate. Muscles should be firm. A loss of height is frequently the first clinical sign of osteoporosis in which height loss occurs in the trunk as a result of vertebral. fracture or collapse. Osteoporosis is a systemic skeletal condition that is noted to have both decreased bone mass and deterioration of bone tissue making bones fragile and a risk for fracture.

So you want to test the range of motion for both your upper extremities and your lower extremities. muscle strength of the hands, arms, and shoulders. And during this time you want to palpate the epitrochlear nodes. For your lower extremities you want to inspect for symmetry, skin characteristics, hair distribution, varicose veins. You want to palpate pulses including your femoral, your popliteal, posterior tibial, and dorsalis pedis pulse.

You want to separate the toes and inspect them. You want to test the range of motion and muscle strength of your hips, knees, ankles, and feet. You want to ask the person to sit up and dangle their legs off the bed or table. And you want to make sure that you keep their gown on and a drape over their lap. Assessing muscle strength and tone during range of muscle, you want to note is it equal.

For passive range of motion, ask the patient to allow an extremity to relax or hang limp. This is often difficult, particularly if the patient feels pain. You want to support the extremity and grasp each limb, asking them to move it slowly through the range of motion. If you identify weakness, compare the size of the muscle with its opposite counterpart. part by measuring the circumference of the body muscle body with a tape measure.

A muscle that is atrophied which means reduced in size feels soft and boggy when palpated and hypertonicity or hypotonicity are advanced skills for med surge. Muscle strength and muscle tone is what we're looking for and you're just noting are they equal and strong. These are the things that you will need to know for this class.

A full assessment of the neurological function requires much time and attention to detail. For efficiency, integrate neurological measurements with other parts of the physical examination. Observe the patient's mental and emotional status when you walk into the room. You want to note their level of consciousness, their physical status, and their chief complaint. A person's level of consciousness exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli.

Talk with your patient. Ask questions about events involving his or her concerns about any health problems. A fully conscious patient responds to questions quickly and expresses ideas logically.

When evaluating a level of consciousness, you note, do they know their name and date of birth? Do they know where they are at? Do they know what day and year it is?

Do they know what brought them into the hospital? What is their level of consciousness? Are they alert or are they drowsy?

If they're alert and can answer all the questions, You would say that they are alert and orientated times four. That means that they are alert and orientated to person, place, time, and situation. With lowering of a patient's consciousness, the Glasgow Coma Scale is used.

This is used for objective measurement of consciousness on a numerical scale. You will learn more about this later. Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about a patient's mental status. Remain perceptive of patients'mannerisms and actions during the entire physical assessment. Note any nonverbal and verbal behaviors.

Normal cerebral function allows a person to understand spoken or written words and express the self through written words and gestures. Assess the patient's voice inflection, tone, and manner of speech. Is their speech clear? When communication is clearly ineffective, assess for aphasia.

This is caused by injury to the cerebral cortex. The two types of aphasia are sensory. or receptive and motor or expressive.

With receptive aphasia, a person cannot understand written or verbal speech. With expressive aphasia, a person understands written and verbal speech but cannot write or speak appropriately. A patient sometimes suffers from a combination of receptive and expressive aphasia.

You will learn more about this in Med-Surg. Intellectual function includes memory, recent, immediate, and past, knowledge, abstract thinking, association, and judgment. Because cultural and educational backgrounds influence the ability to respond to test questions, do not ask questions related to concepts or ideas with which a patient is unfamiliar. To assess cranial nerve function, you may test all 12 cranial nerves, a single nerve, or related groups of nerves. A complete assessment involves testing the 12 cranial nerves in their numerical order.

We will cover these in a few weeks when we talk more about neuro. The sensory pathways of the central nervous system conduct sensations of pain, temperature, position, vibration, and crude and finely localized touch. Different nerve pathways relay the sensations. Most patients require only a quick screening of sensory function unless symptoms of a reduced sensation, motor impairment, or paralysis are noted. An examination of motor function includes assessments made during the musculoskeletal examination as well as cerebrular function.

The cerebellum coordinates muscular activity, maintains balance and equilibrium, and controls posture. You can check for questions by calling the coordination during your assessment of the musculoskeletal system. So after the examination or at the end of the examination, you want to provide for the patient's comfort and then document a detailed summary of the physical findings.

You want to communicate significant findings to your nurse that you're working with in the hospital and or your instructor as appropriate. before you document or discuss anything with the patient. Thank the person for his or her time. Tell the patient that you are finished with the exam and that you will leave the room if you're in the office that you will leave the room while he or she gets dressed.

For the hospitalized person return the bed to its lowest position and any room equipment that you moved put it back the way you found it. Make sure that their call light and telephone are within easy reach. You want to record and document in a timely manner to ensure accuracy.

You want to use short, clear phrases and avoid redundant phrases. Some key points to remember. Perform a physical exam only after the proper preparation of the environment and equipment and the patient have been made to prepare the patient physically and psychologically.

Throughout the exam, keep the patient warm, comfortable, and informed about each step of the process. A competent examiner is systematic while combining simultaneous assessments of different body systems. Information from the history helps to focus on body systems likely to be affected.

Baseline assessment findings reflect a patient's functional abilities and serve as the basis for comparison with subsequent assessment findings. You want to integrate patient teaching throughout the exam to help patients learn about health promotion, disease prevention, and skills to help with any current health issues. And that concludes our lecture today on health assessment and physical examination for the head-to-toe assessment.

Thank you.

Transcript for:Comprehensive Guide on Health Assessments

Transcript for:
Comprehensive Guide on Health Assessments