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Nursing Process Abdomen

Assessment  Skin
Diagnosis  Abdominal sounds
Planning  Specific organs
Intervention  Femoral pulses
Evaluation Genitals
 Testicles
4 basic types of assessment  Vagina
Initial comprehensive assessment  urethra
Ongoing or partial assessment Anus and Rectum
Focused or problem-oriented assessment Lower Extremities
Emergency assessment  Skin and toenails
 Gait and balance
Physical Health Assessment
 Joint range of motion
Head-to-toe assessment (Cephalocaudal)
 Popliteal, posterior tibial, and pedal
pulses
General Survey
 Tendon and plantar reflexes
Vital Signs
Head
Preparing the Client
 Hair, scalp, cranium, face
Explanation
 Eyes and vision
 Ears and hearing Preparing the Environment
 Nose and sinuses Well-lighted and equipment organized
 Mouth and oropharynx
 Cranial nerves Positioning
Neck Dorsal Recumbent
 Muscles Supine
 Lymph nodes Sitting
 Trachea Lithotomy
 Thyroid gland Sims
 Carotid arteries Prone
 Neck veins
Upper Extremities Draping
 Skin and nails
 Muscle strength and tone Instrumentation
 Joint range of motion
 Brachial and radial pulses Methods of Examining
 Biceps tendon reflexes Inspection
 Tendon reflexes Palpation
 sensation Percussion
Chest and back Auscultation
 Skin
 Chest shape and size General Survey
Client’s general appearance and mental status
 Lungs
and measurement of vital signs, height and
 Heart
weight.
 Spinal column
 Breasts and axillae
1. Observe body build, height, and weight Palpate skin temperature. Compare two feet
in relation to the client’s age, lifestyle, and the twohands, using the backs of your
and health fingers.

2. Observe client’s posture and gait, Note skin turgor by lifting and pinching the skin
standing, sitting, and walking. on an extremity.

3. Observe client’s overall hygience and Hair


grooming. Relate these to the person’s Inspect the evenness of growth over the scalp
activities prior to the assessment.
Inspect hair thickness or thinness
4. Note body and breath odor in relation
to activity level. Inspect hair texture and oiliness

5. Observe for signs of distress in posture Note presence of infections or infestations by


or facial expression. parting the hair in several areas, chicking
behind the ears and along the hairline at the
6. Note obvious signs of health or illness neck.

7. Assess the client’s attitude. Inspect amount of body hair.

8. Note the client’s affect/mood; assess Nails


the appropriateness of the client’s Inspect fingernail plate shape to determine its
responses. curvature and angle.

9. Listen for quantity of speech, quality, Inspect fingernail and toenail texture.
and organization
Inspect finger nail and toenail bed color.
10. Listen for relevance and organization of
thoughts. Inspect tissues surround nails.

Skin Perform blanch test of capillary refill. Press two


Inspect skin color or more nails between your thumb and index
finger; look for blanching and return of pink
Inspect uniformity of skin color color to nail bed.

Assess edema if present. Skull and Face


Inspect the skull for size, shape and symmetry.
Inspect, palpate, and describe skin lesions.
Palpate lesions to determine shape and texture. Palpate the skull for nodules or masses and
Describe lesions according to location, depressions. Use a gentle rotating motion with
distribution, color, configuration, size, shape, the fingertips. Begin at the front and palpate
type, or structure. down the midline, then palpate each side of the
head.
Observe and palpate skin moisture.
Inspect the facial features

Inspect the eyes for edema and hollowness


 To return the lid to its normal position,
Note symmetry of facial movements. Ask the gently pull the lashes forward, and ask
client to elevate the eyebrows, frown, or lower the client to look up and blink.
the eyebrows, close the eyes tightly, puff the
cheeks, and smile and show teeth. Inspect and palpate the lacrimal gland
Using the tip of your index finger, palpte the
Eyes and Vision lacrimal gland.
External eye structures. Observe for edema between the lower lid and
Inspect the eyebrows for hair distribution and the nose.
alignment and skin quality and movement
Inspect and palpate the lacrimal sac and
Inspect the eyelashes for evenness of nasolacrimal duct.
distribution and direction of curl Observe for evidence of increased tearing.
Using the tip of your index finger, palpate inside
Inspect the eyelids for surface characteristics, the lower orbital rim near the inner canthus.
position in relation to the cornea, ability to
blink, and frequency of blinking. Inspect the cornea for clarity and texture. Ask
the client to look straight ahead. Hold a penlight
Inspect the bulbar conjunctiva for color, at an oblique angle to the eye, and move the
texture, and the presence of lesions. Retract the light slowly across the corneal surface.
eyelids with our thumb and index finger,
exerting pressure over the upper and lower Perform the corneal sensitivity test to
bony orbits, and ask the client to look up, down, determine the function of the fifth cranial
and from side to side. nerve.

Inspect the palpebral conjunctive by everting Inspect the anterior chamber for transparency
the lids. Evert both lower lids, and ask the client and depth. Use the same oblique lighting as
to look up. Then gently retract the lower lids used to test the cornea.
with the index fingers.
Inspect the pupils for color, shape, and
Evert the upper lids if a problem is suspected. symmetry of size.
 Ask the client to look down while
keeping the eyes slightly open. Assess each pupil’s direct and consensual
 Gently grasp the client’s eyelashes with reaction to light to determine the function of
the thumb and index finger. Pull the the third and fourth cranial nerves.
lashes gently downward.
 Place a cotton-tipped applicator stick Assess each pupil’s reaction to accommodation.
about 1 cm above the lid margin, and
push it gently downward while holding Visual Fields
the eyelashes. Assess peripheral visual fields to determine
 Hold the margin of the everted lid or function of the retina and neuronal visual
the eyelashes against the ridge of the pathways to the brain and second optic nerve.
upper bony orbit with the applicator
stick or the thumb. Extraocular muscle tests
 Inspect the conjunctiva for color, Assess six ocular movements to determine eye
texture, lesions, and foreign bodies. alignment and coordination.
Assess for location of light reflex by shining
penlight on pupil in corneal surface. Nose and Sinuses
Inspect the external nose for any deviations in
Have client fixate on a near or far object. Cover shape, size, or color and falring or discharge
one eye and observe for movement in the from the nares
uncovered eye.
Lightly palpate the external nose to determine
Visual Acuity any areas of tenderness, masses, and
Assess near vision by providing adequate displacements of bone and cartilage.
lighting and asking the client to read from a
magazine or newspaper held at a distance of Determine patency of both nasal cavities. Ask
36cm. the client to close the mouth, exert pressure on
one naris, and breathe through the opposite
Assess distance vision by asking the client to naris. Repeat the procedure to assess patency
wear corrective lenses, unless they are used for of the opposite naris.
reading only
Inspect the nasal cavities using a flashlight or a
If the client is unable to see even the top line of nasal speculum.
the Snellen-type chart, perform functional
vision tests. Observe for the presence of redness, swelling,
growths, and discharge.
Ears and Hearing
Auricles Inspect the nasal septum between the nasal
Inspect the auricles for color, symmetry of size, chambers.
and position. To inspect position, note the level
at which the superior aspect of the auricle Facial Sinuses
attaches to the head in relation to the eye. Palpate the maxillary and frontal sinuses for
tenderness.
Palpate the auricles for texture, elasticity, and
areas of tenderness Mouth and Oropharynx
Lips and Buccal Mucosa
External Ear Canal and Tympanic Membrane Inspect the outer lips for symmetry of countour,
Using an otoscope, inspect the external ear color, and texture. Ask the client to purse lips as
canal for cerumen, skin lesions, pus, and blood. if to whistle.

Inspect the tympanic membrane for color and Inspect and palpate the inner lips and buccal
gloss. mucosa for color, moisture, texture, and the
presence of lesions.
Gross Hearing Acuity Tests
Assess client’s response to normal voice tones. Teeth and Gums
If client has difficulty hearing the normal voice, Inspect the teeth and gums while examining the
proceed with the following tests. inner lips and buccal mucosa.

Perform the watch tick test. Inspect the dentures. Ask the client to remove
complete or partial dentures. Inspect their
Tuning fork tests. condition, noting in particular broken or worn
Weber’s test areas.
Rinne test
Tongue/Floor of the mouth
Inspect the surface of the tongue for position,
color, and texture. Ask the client to protrude
the tongue.

Inspect tongue movement. Ask the client to roll


the tongue upward and move it from side to
side.

Inspect the base of the tongue, the mouth floor,


and the frenulum. Ask the client to place the tip
of the tongue against the roof of the mouth.

Palpate the tongue and floor of the mouth for


any nodules, lumps, or excoriated ares. To
palpate the tongue, use a piece of gauze to
grasp its tip, and with the index finger of your
other hand, palpate the back of the tongue, its
orders, and its base.

Salivary glands.
Inspect salivary duct opening for any swelling or
redness.

Palates and uvula


Inspect the ahrd and soft palate for color,
shape, texture, and the presence of bony
prominences. Ask the client to open the mouth
wide and tilt the head backward. Then, depress
tongue with a tongue depressor as necessary,
and use a penlight for appropriate visualization.

Inspect the uvula for position and mobility while


examining the palates.

Oropharynx and tonsils


Inspect the oropharynx for color and texture.
Inspect one side at a time to avoid eliciting gag
reflex.

Inspect tonsils for color, discharge, and size.

Elicit gag reflex by pressing the posterior tongue


with a tongue depressor..