Mouth Anatomy Neck Inspection:
� Chains of lymph nodes extend into face under chin and down the lateral neck and on the posterior neck. � Thyroid Gland is assessed for size, shape, masses, nodules, tenderness, and symmetry. Two handed from behind (bimanual) � Assess vascular system: JVD?( Jugular vein dissention, best seen in fowler�s position, caused by back up fluid from the heart and lungs, SOB), Carotids � Auscultate the carotids ABRUIT- swishing that can be heard in any major vessel that has a narrowing., renal, femoral, carotid arteries. Arterial arteries only.
Thorax and lungs:
� Use inspection, palpation, percussion, and auscultation(use this one mainly) to assess the lungs and thorax. � Stethoscope, measuring tape, good lighting, and warm room are essential. � Best if patient is sitting, make adjustments for bed ridden patient. Opens up for full excursion of breath.
General Inspection of Chest:
� Observe color, shape, contour, and breathing patterns. Regular or irregular, easy, gasping, � Color should be the same as the face. Trauma may change the color. � Shape should be transverse is greater than the anterior/posterior diameter (not breast tissue). Should be double from side to side than back to back unless hard time breathing or heart problems. �Barrel Chest�-transverse and anterior posterior distance is same. � Breathing pattern should be even and 12-20 breaths/minute
Palpation:
� Use a sequential pattern to palpate chest checking for tenderness, temperature, muscle development , and fremitus (air underneath the skin, escape from the lungs into the surrounding tissue, feels like rice krispies under the skin). � Normal findings would be warm skin, well developed muscles, no tenderness, and equal voice vibrations throughout. � Abnormal would be cool or excessively dry or moist skin, muscle assymetry, tenderness, unequal fremitus, abnormal breathing patterns or expansion.
Percussion Areas:Percussion of Posterior Lungs Lung Sounds
� Bronchial sounds: Blowing hollow sounds normally heard over the trachea. Sound more hollow than the base, main bronchi � Bronchovesicular sounds: Medium pitched, medium intensity blowing sounds normally heard over upper chest posteriorly and anteriorly. � Vesicular: Soft low pitched sounds heard over remainder of lung fields. Base of lung Draw a diagram Start high, go side to side following the shape of lungs, Breast tissue lift with back of hand and continue to listen.
Auscultation of Lungs-Anterior
Start high, go side to side following the shape of lungs, Breast tissue lift with back of hand and continue to listen.
Auscultation of Posterior Lungs
Start high, go side to side following the shape of lungs,
Adventitious Breath Sounds:
Clear to auscultation� otherwise adventitious breath sounds � Crackles (or rales) sounds like hair rubbing together, what happens when too much fluid on board. We might see edema, increased HR, JVD (jugular vein distention) cannot be cleared with cough. � fine or coarse � Wheezes- caused by narrowing of airway (asthma, allergies, emphysema, bronchitis, chemical irritation, air irritant) high pitched blowing sound � Gurgles (rhonchi)- rattling in the chest, more coarse than rales, can be heard on one side and not the other. Can be cleared with cough. Lower infections such as pneumonia. � Pleural friction rub-sounds like rusty squeaky gate. Accumulation of fluid and infection in the pleural space, fluid filled from cancer cells, can collapse lung. Thorancentisis
Normal Age Related Variations
Common in newborns and children- you can hear much clearer, Louder breath sounds on auscultation More rapid rate Use of abdominal muscles during respirations
Older Adult
� Increased anterior posterior chest diameter � Increased dorsal spinal curve � Decreased thoracic expansion � Use of accessory muscles to exhale
Cardiovascular Peripheral Vascular System:
� Peripheral System can be evaluated as we progress from head to toe and combined with other systems. � Use Inspection and Palpation for peripheral pulses and perfusion noting strength of pulse and color of extremity ( if left hand is dusky, low pulse, etc, check the right side to compare). � Beginning with carotids in neck work down to feet as you progress in your examination. � Grade pulses 0 through 4: absent through bounding ( each institution may be different)
Inspection and Palpation:
� Inspect and palpate the extremities for color, temperature, venous patterns, edema � Is there paleness or coolness PVD? blockages � Is there darkening, brown discoloration? Constant shrinking and expanding of veins, people with poor cardiac function. � Are they hairless or are toenails thickened? Tissues are not being fed by a blood supply or profusion..Injury would be slow to heal. Pulse would be weak. Use Doppler if you cant find pulse. Compare sides. � Is there pain, swelling, or redness or are they shiny and taut (edema)? This is a vascular compromise. If someone has had hip replacement etc., there is a neurovascular sheet and check pulse and color.
Cardiovascular:
� Inspection � look for visible pulsations � only pulsation that is a normal finding is the PMI (apical area) Palpation � Feel for PMI, located between 4th and 5th ribs on left chest wall. May be slightly different for different people.
Auscultation of Heart-look in webers for diagram pg 133
� Aortic �best hear s2 � Pulmonic �best hear s2 � Tricuspid-best hear s1 � Mitral-best hear s1, apical � Closure of these valves responsible for normal heart soundsHerb�s point is where we can hear extra sounds more clearly. Asynchronis closing of valves cause split sound.
Normal Heart Sounds:
� S1-tricuspid, mitral (bicuspid) � S2-aortic, pulmonic
Abnormal heart sounds:
� S3-gallup � S4-gallup � Murmurs- caused by backflow, a valve may be stiff or floppy, turbulence f blood flow.Look for rate, rhythm (regular or irregular)
Normal Age Related Variations:
Newborns/Children � Visible pulsation if chest wall thin � Irregular heart beat � Presence of S3 � More rapid heart rate (up to age 8) Older Adult � Difficult to palpate apical and peripheral pulses � Increased SBP (systolic) and D (diastolic) BP � More prominent vasculature � Widening pulse pressure-the difference between the systolic and diastolic
Older Adult:
� Difficult to palpate apical and peripheral pulses � Increased SBP (systolic) and D (diastolic) BP � More prominent vasculature � Widening pulse pressure-the difference between the systolic and diastolic
Abdomen:
� Divide abdomen into 4 quadrants
� Initiate assessment using different sequence than rest of the body � Inspection-shape, distended, round, concave, scars, stria (stretch marks) trauma � Auscultation- listen before you palpate so as to not disturb the BS. �growling� caused by peristalsis. Should always be present. Listen in systematic way around the quadrants for about a minute and record sounds as present or not, pitch, Very important to listen to BS, �Did you poop or pee?� Bowel obstruction and immobility and narcotics, sedatives can cause low BS, what to look for-N/V, have you had gas, pee or poop? Appetite? � percussion (only sometimes, maybe an OB nurse) � palpation-side to side, up and down, looking for lumps, pain and distention. Watch face. Do painful area last.
Musculoskeletal System:
� Use inspection and palpation only. � Assess bones, muscles, joints. Head to toe � Observation can be done during much of prior assessment. Ex: if sit up, you can see if they can move extremities well. � Palpate and inspect joints for redness, tenderness, symmetry, and swelling. Compare sides. Soreness or tenderness if you touch.
Muscle strength:
� Shoulder Flexion-shrug � Elbow Extension and Flexion � Wrist Extension-up and down � Hand Grip-shake hand � Hip Flexion-lie on side and do scissor motion � Knee Flexion and Extension � Ankle Plantar Flexion and Dorsiflexion-do while you are checking pedal pulse
Normal Age Related Variations:
Infant/ Child � C shaped spine at birth, cervical spine develops at 3-4 months and lumbar curve develops between 12-18 months � Lordosis (exaggerated lumbar curve)-know this, pregnant women � Genu Varum (bow leg) for 1 year after learning to walk or scurvy � Pronation of feet in toddlers-toes stick out.
Normal Variations:
Older Adult � Loss of muscle mass and strength � Decreased ROM � Kyphosis-doagers hump or increase of thoracic curve � Decreased Height-loss of bone mass � Osteoarthritic changes in joints-enlarged knuckles
Inspecting Spinal Curves-know this vocab:
� While patient stands inspect the spine from the back to back and the side to side. � Kyphosis: Increased thoracic curve, seen in elderly. � Lordosis: Exaggerated lumbar curve seen in pregnancy, obesity, childhood � Scolioisis: Lateral curvature that forms S shape to spine (often school screenings identify) shoulder or hip was higher. Assymetrical muscles; can be corrected by exercise and bracing, or chiropractic.
Orthopedic checks:
� Also called extremity check, vascular check, splint check or neurovascular checks � Checking an extremity that has been compromised � Check temperature, swelling, pulse, sensation, discoloration, pain, drainage and record and if necessary report changes
Neurological System:
� Neurological exam is begun with general observation. A & O to person, place and time, this will be seen immediately. May need to be more specific. � In head to toe assessment we have already done part of the cranial nerves. � We use inspection and touch for this exam. � Muscular exam reveals a lot of neurological information.
� Twelve Cranial Nerves
Neurological System- looking for sensitivity and motor. � 1-olfactory-smell � 2,3,4, and 6-eyes, extraoccular movements � 5-trigeminal-face sensation � 7-facial-facial muscles- puff out cheeks � 8-acoustic-hearing � 9- glossopharyngeal-swallowing and movement of tongue � 10 vagus-speaking, uvula raising, gagging � 11-spinal accessory-shoulder, shrugging against resistance � 12-hypoglossal-tongue
Neurological exam:
Neurological Exam � Reflex Grading Scale: Nurses don�t usually do this, we are testing for normal tone. 0 no tone, +1 low tone, +2 normal, +3 brisker than average but may be normal +4 hyperactive often indicative of disease. � Glasgow Coma Scale : Score of 0 to 15, nurses do use this on stroke, ACE unit, head trauma unit. Three areas-Eye Opening (sternal rub, talking to), Motor Response ( movement when people come in, resistance etc), and Verbal Response
Neurologic Age-Related Variations:
Neurologic Age-Related Variations � Plantar Reflex : Toes curl under for adult (flexion) for infants under age 1 toes flair (dorsiflexion) which is called a positive Babinski. This would be abnormal for an adult. � Motor control develops in head, neck, trunk, and extremities sequence for infant.
Older adult:
� decreased sensory function (can�t smell, taste), slower thought process, slower gait, and may have decreased tendon reflexes.
Diagnostic testing:
� Diagnostic Tests are ordered by physicians or advanced practice nurses. � Nurses are responsible for assisting with obtaining consent, preparation, scheduling, and patient support following procedures. � Diagnostic test results confirm or repute physical assessment findings. Nurses obtain results for the chart.
Documentation:
� A total Health Assessment will include the Health History and the Physical Assessment. � Organize data according to institution policy, be consistent. � Data is usually organized in a body systems format. (Neurological, Gastro-intestinal, etc.)