III. HEALTH ASSESSMENT A.

HEALTH HISTORY GUIDELINES Purpose The health history aids both individuals and health care providers by supplying essential information that will assist with diagnosis, treatment decisions, and establishment of trust and rapport between lay persons and medical professionals. The information also helps determine an individual's baseline, or what is normal and expected for that person. Demographics Every person should have a thorough health history recorded as a component of a periodic physical examination. These occur frequently (monthly at first) in infants and gradually reach a frequency of once per year for adolescents and adults. A. INTERVIEW 1. PURPOSE 2. STRUCTURE 3. GUIDELINES OF AN EFFECTIVE INTERVIEW The clinical interview is the most common method for obtaining a health history. When a person or a designated representative can communicate effectively, the clinical interview is a valuable means for obtaining information. The information that comprises the health history may be obtained from a person's previous records, the individual, or, in some cases, significant others or caretakers. The depth and length of the historytaking process is affected by factors such as the purpose of the visit, the urgency of the complaint or condition, the person's willingness or ability to contribute information and the environment in which information is sought. When circumstances allow, a history may be holistic and comprehensive, but at times only a cursory review of the most pertinent facts is possible. In cases where the history-gathering process needs to be abbreviated, the history focuses on a person's medical experiences.

Health histories can be organized in a variety of ways. Often an organization such as a hospital or clinic will provide a form, template, or computer database that serves as a guide and documentation tool for the history. Generally, the first aspect covered by the history is identifying data. Identifying or basic demographic data includes facts such as:

name gender age date of birth occupation family structure or living arrangements source of referral

Once the basic identifying data is collected, the history addresses the reason for the current visit in expanded detail. The reason for the visit is sometimes referred to as the chief complaint or the presenting complaint. Once the reason for the visit is established, additional data is solicited by asking for details that provide a more complete picture of the current clinical situation. For example, in the case of pain, aspects such as location, duration, intensity, precipitating factors, aggravating factors, relieving factors, and associated symptoms should be recorded. The full picture or story that accompanies the chief complaint is often referred to as the history of present illness (HPI). The review of systems is a useful method for gathering medical information in an orderly fashion. This review is a series of questions about the person's current and past medical experiences. It usually proceeds from general to specific information. A thorough record of relevant dates is important in determining relevance of past illnesses or events to the current condition. A review of systems typically follows a head-to-toe order. The names for categories in the review of systems may vary, but generally consists of variations on the following list:

head, eyes, ears, nose, throat (HEENT) cardiovascular respiratory gastrointestinal genitourinary integumentary (skin) musculoskeletal, including joints endocrine

nervous system, including both central and peripheral components mental, including psychiatric issues

Past and current medical history includes details on medicines taken by the person, as well as allergies, illness, hospitalizations, procedures, pregnancies, environmental factors such as exposure to chemicals, toxins, or carcinogens, and health maintenance habits such as breast or testicular self-examination or immunizations. An example of a series of questions might include the following:

How are your ears? Are you having any trouble hearing? Have you ever had any trouble with your ears or with your hearing?

If an individual indicates a history of auditory difficulties, this would prompt further questions about medicines, surgeries, procedures, or associated problems related to the current or past condition. In addition to identifying data, chief complaint, and review of systems, a comprehensive health history also includes factors such as a person's family and social life, family medical history, mental or emotional illnesses or stressors, detrimental or beneficial habits such as smoking or exercise, and aspects of culture, sexuality, and spirituality that are relevant to each individual. The clinicians also tailor their interviewing style to the age, culture, educational level, and attitudes of the persons being interviewed.

A. INTERVIEW 1. PURPOSE 2. STRUCTURE 3. GUIDELINES OF AN EFFECTIVE INTERVIEW III. HEALTH HISTORY A. PERSONAL PROFILE 1. CHIEF COMPLAINT OF PRESENT ILLNESS 2. PAST HEALTH HISTORY 3. CURRENT MEDICATIONS 4. PERSONAL HABITS & PATTERNS OF LIVING 5. PSYCHOSOCIAL HISTORY A. MENTAL STATUS ASSESSMENT CHILDREN AND ADOLESCENT ADULTS B. FUNCTIONAL ASSESSMENT 1. ADULTS 2. PHYSICAL ACTIVITIES OF DAILY LIVING (PADC) 3. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) C. FUNCTIONAL ASSESSMENT TESTS 1. NEWBORNS APGAR SCORING SYSTEM 2. INFANTS & CHILDREN MMDST 3. ADULTS A. KATZ INDEX OF INDEPENDENCE IN ADL B. BARTHEL INDEX D. REVIEW OF SYSTEMS (SYMPTOMS) E. ASSESSMENT IN PREGNANCY (E.G. LMP, EDC) F. PEDIATRIC ADDITIONS TO A. HEALTH HISTORY (E.G. HEAD CIRCUMFERENCE, WEIGHT, HEIGHT, IMMUNIZATION) G. GERIATRIC ADDITIONS TO THE HEALTH HISTORY (E.G. IMMUNIZATION, CURRENT PRESCRIPTION MEDICATIONS, OVER THE COUNTER MEDICATIONS, ADL, SOCIAL SUPPORT, ETC.) III. PHYSICAL EXAMINATION A. PREPARATION GUIDELINES B. PE GUIDELINES C. TECHNIQUES IN PHYSICAL ASSESSMENT 1. INSPECTION 2. AUSCULTATION 3. PERCUSSION 4. PALPATION D. CONTINUING ASSESSMENT 1. PAIN 2. FEVER E. PEDIATRIC ADAPTATION

43 1. GENERAL GUIDELINES 2. SPECIFIC AGE GROUPS F. GERIATRIC ADAPTATIONS 1. GENERAL GUIDELINES 2. MODIFICATIONS G. CULTURAL CONSIDERATIONS 1. SEQUENCE OF PE (ADULT/PEDIA/GERIATRIC ADAPTATIONS) A. OVERVIEW B. INTEGUMENT C. HEAD D. NECK E. BACK F. ANTERIOR TRUCK G. ABDOMEN H. MUSCULOSKELETAL SYSTEM I. NEUROLOGIC SYSTEM J. GENITOURINARY SYSTEM H. CLINICAL ALERT I. DOCUMENTATION OF FINDINGS J. PATIENT & FAMILY EDUCATION & HOME HEALTH TEACHING IV. DIAGNOSTIC TESTS (ROUTINE LABORATORY EXAMS) V. APPROPRIATE NURSING DIAGNOSIS GUIDE FOR RLE PROVIDES OPPORTUNITY TO DEMONSTRATE THE VARIOUS NURSING PROCEDURES LEARNED. PROVIDES OPPORTUNITY TO CARE FOR CLIENTS. LABORATORY SUPPLIES AND EQUIPMENT : ASSESSMENT FORMS PATIENTS CHART OPHTHALMOSCOPE WATCH WITH SECOND HAND OTOSCOPE SPHYGMOMANOMETER FLASHLIGHT OR PENLIGHT STETHOSCOPE TONGUE DEPRESSOR GLOVES AND LUBRICANT RULER & TAPE VAGINAL SPECULUM AND EQUIPMENT FOR CYTOLOGICAL THERMOMETER BACTERIOLOGICAL STUDY TUNING FORK REFLEX HAMMER SAFETY PINS PAPER, PEN AND PENCIL COTTON COURSE NAME
6.2 PHYSICAL ASSESSMENT

Physical assessment is a systematic means of collecting objective assessment data. Equipment Needed: Scale with height measurement bar Sphygmomanometer Watch with second hand Stethoscope Thermometer Patient gown Examining table if necessary Gloves Sheet, bath blanket, or towel, as needed for draping Tape Lighting, including a flashlight Laryngeal mirror Tongue blades Percussion, reflex hammer Otoscope Tuning fork Tape measure Visual acuity chart Ophthalmoscope Test tube of hot and cold water Containers of odorous materials e.g., coffee or chocolates) and substances for taste assessment (sugar, salt, vinegar) Miscellaneous items such as coin, pin, cotton, or paper clip Waterproof pads Water-soluble lubricants Facial tissues Cotton-tip applicator Assessment Complete Health history

Definition The health history is a current collection of organized information unique to an individual. Relevant aspects of the history include biographical, demographic, physical, mental, emotional, sociocultural, sexual, and spiritual data.
Obtain biographical data Patients name Address Telephone number

Contact person Gender Age Birth date Birthplace SSS no. Marital status Education Religion Occupation Race Nationality Cultural background

Hierarchy of needs Assessment of physiological needs Body systems Model Data collection according to tissue and organ functions in the various body systems (e.g. respiratory, cardiovascular, and gastrointestinal) it is called the medical model because it is frequently use by the physicians. 11 FUNCTIONAL HEALTH PATTERNS (Gordon, 1998) Health Perception/health management pattern Expectations of health care Promotive, preventive, and restorative practices (e.g. breast self-examination, seat belt use) What client considers an illness Nutritional/ metabolic pattern Height and weight 24-hour dietary recall, including number of portions and portion sizes Activity /exercise pattern Type and level of activities Sufficiency of energy for completing desired/required activities (home, work, leisure) Exercise program (type and regularity) Cognitive/perceptual pattern Hearing difficulty, use of aids, devices, last time checked Visual problems; use of aids, devices, last time checked Changes on memory Pain discomfort, management done Sleep/rest pattern Circadian rhythms, time, duration of sleep

Use of supportive aids or devices (e.g. warm fluids, milk, sedatives, alcohol Sleep onset problems, dreams, nightmares, early awakenings Generally rested and ready for daily activities after sleep Self-perception/self-concept pattern Description of self Feelings toward self Body image (appearance, limits, inner structure) Changes felt in the body and the desire to do something about them Changes in feelings towards self when illness started Things, persons, situations, that caused anger, fear, anxiety, depression and measures done to alleviate them (self help) Role/relationship pattern Support system/significant others (age, relationship to client) Family form and structure (role, value system, communication pattern, leadership, decision-making structure) Family functions Sufficiency of income Structural characteristics perceptions, feeling, transaction, and degree of association of the family with the neighborhood/community Accessibility and utilization health care and nutritional resources Sexuality/reproductive pattern Sexual preference (frequency, type of sexual activity) Satisfaction with sexual activity Sexual history (past and present) Use of contraceptive methods Menstrual history and puberty history Pregnancies (miscarriages, live births) Coping/stress- tolerance Development Stage: o Psychosocial (Erickson) o Psychosexual (Sigmund Freud) o Cognitive (Piaget) Frequency of feeling tense and anxious; manifestations Coping strategies and stress management methods to alleviate anxieties/fear, crisis situation and their efficacy Persons most helpful in taking things over, availability of such person

Major life changes/events for the last two years, how were these handled and the relative degree of success Value/belief pattern Satisfaction with ones life Things and personal values held as important (specifically health and nutrition) Family/social values that influenced ones life Spiritually; importance of life in religion Religious practices that affect hospitalization and related therapeutic regimen, including food Techniques for Physical assessment Inspection is the systematic visual examination of the client Palpation is the examination of the body through the use of touch Light palpation Deep palpation Percussion is the use of short, sharp strikes to the body surface to produce palpable vibrations and characteristics sounds. Auscultation is the process of listening to sounds generated within the body. Outline of a Head-to-toe physical assessment General survey Height and weight Vital signs Integument Inspection Color of the skin and mucous membranes (complexion, jaundice, cyanosis, Erythema) Pigmentation Lesion and scars (distribution, type, configuration, size), superficial vascularity Moisture Edema Hair distribution Nails Palpation Temperature Texture and consistency, elasticity, turgor, mobility Tenderness Normal findings No lesions Skin warm, slightly moist, smooth, finely textured, with good skin turgor Hair distribution characteristic for gender and age Nails present and smooth Mucous membranes moist and pink

Head Inspection Skull size and shape Symmetry of face Scalp: flaking, lesions, masses, deformities, swelling, tenderness Hair color, distribution, nits on hair shafts Palpation Hair texture Scalp Skull shape: bony overgrowths, symmetry Normal findings Skull normocephalic Face symmetric Scalp clear No alopecia or foreign bodies in hair Eyes and vision Vision testing Test visual acuity with a Snellens chart Test visual peripheral fields Inspection Globes: observe for protrusion Palpebral fissures: assess symmetry and width Lid margins: observe for scaling, secretions, Erythema, position of lashes Conjunctivae: inspect for congestion; note color Sclera and irises: observe color Pupils: note size, shape, symmetry, reaction to light and accommodation Eye movement: assess extraocular movements; note nystagmus or convergence Palpation Evaluate strength of the upper lids by attempting to open the patients closed lids against his or her resistance. Assess tenderness and tension of eyeballs Fundoscopic examination (with opthalmoscope) Locate the red reflex Check the transparency of the anterior and posterior chambers, cornea, and lens Examine the retina (color, pigmentation, hemorrhages, and exudates): optic disk (color, distinction of margins, pigmentation, degree of elevation, cupping); macula(color); and blood vessels (diameter, atriovenous [AV] ratio, origin and course, venous-arterial crossings).

 Normal findings Central vision 20/20 OU (both eyes), visual fields unrestricted No ptosis or lid lag Eyes move in conjugate fashion Anterior and posterior chambers, lens and cornea transparent; sclera and conjunctiva clear Lacrimal system unobstructed Pupils equal, round, and reactive to light and accommodation (PERRLA) Red reflex present bilaterally Bilateral well-marginated discs revealed on Fundoscopic examination C-D ratio 1:4, vessels to all four quadrants AV ratio 2:3 No arterial narrowing, venous engorgement, AV nicking, hemorrhages, or exudates Ears and Hearing Hearing assessment Test gross hearing acuity with whispered words or a watch. With a tuning fork (512 to 1024 Hz), perform the Weber(bone conduction) and Rinne (air conduction to bone conduction ratio) tests. Inspection Pinna: Assess size, shape, placement on head, and color; note any lesions or masses. External canal: With an otoscope, check for discharge, impacted cerumen, inflammation, masses, and foreign bodies Tympanic membrane: With an otoscope inserted inferiorly into the distal portion of the tympanic canal, assess color, luster, shape, position, transparency, and integrity; note any scarring; locate landmarks (cone of light, umbo, handle and short process of malleus, pars flaccida, and pars tensa). Palpation Examine pinna for tenderness, consistency of cartilage, swelling, and pain Normal findings Weber test not referred (or lateralized) Rinne test positive (air conduction greater than bone conduction) External ear appearance normal Canals clear without discharge Tympanic membranes pearly gray and intact, with landmarks visible

Nose and sinuses Inspection Observe position of the nose on the face Note any discharge Assess airway patency; note any nasal obstruction Perform a speculum examination of interior structures: nasal septum (assessing position, noting any bleeding or perforation), mucous membranes (noting hydration and color), and turbinates (assess color, any swelling). Palpation Apply fingertip pressure to the frontal and maxillary sinuses to assess tenderness Normal findings Nose symmetrically placed on face Nasal passages patent with septum in midline Mucous membrane moist and dark pink without perforation or bleeding Sinuses nontender Mouth and oropharynx Inspection (Note: use a penlight and tongue depressor when examining inside the patients mouth) Lips: Observe color, moisture; note abnormal pigmentation, masses, ulcerations, or fissures. Teeth: Note number, arrangement, and general condition. Gingivae: Assess color and texture; note discharge, swelling, retraction, or bleeding. Buccal mucosa: assess for discoloration, vesicles, ulcerations, or masses. Pharynx: Note any inflammation, exudates, or masses. Tongue (both at rest and protruded): Assess size, color, moisture, and symmetry; note any lesions, deviations from midline, fasciculations, or tremors. Salivary glands: assess patency Uvula: Assess position on phonation; should be midline. Soft palate: Observe symmetry on phonation, intactness. Tonsils: Note presence or absence, size, ulcerations, exudates, or inflammation. Note breath odor. Assess voice volume; note any hoarseness. Check the patients ability to swallow. Palpation (Note: wear glove when putting your fingers inside the patients mouth)

Oral cavity: palpate for masses and ulcerations. Tongue: Grasp the tongue with a gauze sponge to retract and palpate it and to inspect its undersurface and the floor of the oral cavity. Gag reflex: Attempt to elicit bilaterally. Normal findings No lesions of lips, gums, tongue, or bucal mucosa Tongue pink, moist, well papillated, and in midline, both at rest and on protrusion Salivary glands: unobstructed Pharynx: not injected Uvula: in midline Tonsils: nononbstructing Palate: elevating symmetrically on phonation Gag reflex: present bilaterally Teeth: present with no carries Gums: clear Neck Inspection All areas of neck anteriorly and posteriorly: Assess muscle symmetry and range of motion; note any masses, unusual swelling, or pulsations. Thyroid: observe for enlargement External jugular veins: note distention Palpation Cervical nodes and salivary glands: Palpate for enlargement, tenderness. Trachea: Note deviation from midline. Thyroid: palpate for nodules, masses, or irregularities. Carotid arteries: note amplitude and symmetry of pulsations Auscultation Listen for bruits over the carotid arteries and the thyroid. Normal findings Neck symmetric with no tenderness or limitation of movement Trachea: in midline Thyroid: nonpalpable No bruits auscultated Lymph nodes Inspection : note observable nodes Palpation Feel for palpable nodes: Assess size, shape, mobility, and consistency; note tenderness or inflammation.

Locations to palpate: cervical, supra, and infraclavicular; Axillary central, lateral, subscapular, and pectoral groups; inguinal (horizontal and vertical); epitrochlear. Normal findings: no palpable or tender nodes Female Breasts Inspection With the patient sitting and her arms at her side, inspect the nipples and areola for position, pigmentation, inversion, discharge, crusting, and masses; note any supernumerary nipples. Observe for the size, shape, color, symmetry, surface contour, skin characteristics, and level of breast; note any retraction or dimpling of skin or nipples, new pigmentation, engorged veins, swelling, or any tendency of a breast to cling to the thorax. Repeat these observations with the patients hands above or behind her head, with her hands pressed firmly on her hips, with the patient leaning forward from the hips, and with the patient supine. Palpation Palpate the breast with the patient in both sitting and supine positions; when the patient is supine, and for a patient with large breast being palpated, and raise the arm on that side over the patients head Palpate one breast at time, using the palmar aspects of your fingers in a rotating motion and moving in concentric circles from the periphery of the breast to the nipple. Assess skin texture, moisture, and temperature; note any masses. Be sure to include the tail of Spence (breast tissue extending into the Axillary region in the upper outer quadrant of the breast). Gently squeeze, milk, and then invert the nipple to check for any expressible discharge and to detect any mass beneath the niiple. Repeat these steps for the other breast, and compare findings on both sides. Conclude by applying lotion for lubrication, then using the palmar surface of the fingers sweeping both breast superiorly to inferiorly, compressing them against the thorax; note any masses. Normal findings Nipples symmetric with no erosion, discharge, or recent inversion Breast symmetric although possibly varying in size Tissue soft, lobular, and homogenous Male Breasts

 Inspection: observe the nipples and areola for ulceration, nodules, swelling or discharge. Palpation: Palpate the areola, noting nodules and tenderness. Normal findings Nipples symmetric with no erosion or discharge No masses, discharge, or tenderness Thorax and Lungs Inspection Posterior chest: With the patient seated, observe spine for mobility and structural deformity; symmetry, posture, mobility of thorax, and intercostals spaces (bulges or retraction) on respiration; anteroposterior diameter in relation to lateral diameter of chest. Anterior chest: With the patient supine, inspect for structural deformities; assess the width of the costal angle; note rate and rhythm of breathing; observe for respiratory abnormalities (e.g. bulging or retraction of ICS, use of accessory muscles), and asymmetry. Palpation Posterior chest: With the patient seated, palpate the ribs and costal margins for symmetry, mobility, and tenderness, and the spine for tenderness and vertebral position. Assess respiratory excursion (note the distance that your thumbs part) and symmetry of motion and fremitus with the patients arms crossed and scapulae separated. Anterior chest: With the patient supine, assess as for the posterior chest, comparing symmetric areas and gently displacing femnale breast if necessary. Percussion Posterior chest: With the patient seated with his or her arms across the chest and the scapulae separated, percuss symmetric areas, comparing sides. Begin across the top of each shoulder and proceed downward between the scapulae and then under the scapulae, both medially and laterally in Axillary lines; note and localize abnormal percussion sounds (Table 1-1). Percuss for diaphragmatic excursion on complete exhalation and inhalation, marking points where resonance changes to dullness; note symmetry levels.
TABLE 1-1 Review of Percussion Notes Flat sounds Dull sounds Soft, high pitched, and short duration (e.g., thigh Medium in intensity, pitch, and duration (e.g., liver)

Resonant sounds Hyperresonant sounds Tympanic sounds

Loud, low pitched, and long duration (e.g. normal lung) Very loud, lower in pitch, and longer in duration (e.g. emphysematous lung) Loud and musical (e.g. gastric air bubble, intestine

Anterior chest: With the patient supine with his or her arms at sides, percuss from just below the clavicles along the midclavicular line (displacing female breast as necessary), then move laterally. Note intercostals spaces where you detected hepatic dullness on the right side and cardiac dullness and gastric air bubble tympany on the left side. Auscultation Posterior chest: With the patient seated as for percussion, ask him or her to breathe somewhat more deeply than normal with mouth open. With a stethoscope, listen over the same areas and in the same pattern as for percussion, comparing from side to side and moving from spices to lung bases. Anterior chest: Auscultate over the same areas and in the same pattern as for percussion, comparing sides and proceeding from lungs apices to bases. Note the distribution of vesicular and Bronchovesicular sounds, both posteriorly and anteriorly.
TABLE 1-2 Review of Vocal Sounds Breath Sounds Vesicular sounds: longer on inspiration than expiration, of low pitch and soft intensity on expiration, and heard over most of the peripheral lung. Bronchovesicular sounds: equal in duration on inspiration and expiration, of medium pitch and intensity on expiration, and heard near the main stem bronchi (anteriorly, below the clavicles at sternal borders to near the level of the second ICS; posteriorly, between the clavicles and between T1 and T4) Brachial (tracheal, tubular) sounds: shorter on inspiration than expiration, of high pitch and loud intensity on expiration, and heard over the trachea. (Note: Bronchial sounds heard over a lung are always abnormal). Adventitious sounds

Crackles: discrete, non continuous sounds most commonly heard on inspiration in dependent right and left lung bases and may clear on coughing (formerly called rales and crepitations) Two types: Fine crackles: (short, soft, high pitched) Coarse crackles (louder, slightly longer, lower pitched) Gurgles: loud gurgling and bubbling sounds heard during both inspiration and expiration, possible produced by secretions in the trachea and large bronchi. Wheezes: continuous musical sounds of greater duration that may be heard during inspiration or expiration Pleural rubs: loud, low pitched, and confined to a relatively small area of the chest wall: produced by inflamed pleura. Altered voice sounds (spoken sounds that change when transmitted through airless lung tissue) Bronchophony: voiced sound99 heard louder and clearer tha usual. Egophony: gives nasal bleating quality to voiced sounds: the patients ee sounds likeay Whispered pectoriloquy: whispered sounds: (e.g. 1,2,3 or 99 Heard louder and clearer than usual.

Normal findings Respiratory rate 12 to 18 breaths per minute Thorax symmetric; costal angle less than 90 degrees; transverse diameter 1:2 to 5:7; expansion 3 to 5 cm, symmetric, free and easy; no bulges or retractions in intercostals spaces. Diaphragm position and excursion 3 to 6 cm Fremitus felt throughout lung fields, diminishing near periphery. Percussion resonant over symmetric areas of lung to expected lung borders (5th ICS) anteriorly, 7th ICS laterally, T10 posteriorly); dullness between the 3rd and 5th left ICS (heart) No adventitious sounds (crackles, gurgles, wheezes, or friction rubs), enhanced voiced sounds (egophony, brochophony, or whispered pectoriloquy) or bronchial breath sounds. Heart Inspection

Precordium: Look for fits, heaves, thrusts, or pulsations. Apical impulse: observe for visible palpations (occurs in about 50% of patients). Palpation Using the palms, palpate all ausculatory areas, noting vibrations or thrills. Locate the apical impulse, and assess the rate and strength of pulsations. Percussion: percuss the hearts borders in the 3rd to 5th left ICS, noting areas of cardiac dullness. Auscultation Listen with the stethoscopes diaphragm (best for highpitched sounds) and bell (best for low-pitched sounds) in each ausculatory area. Identify A1 and S2 (lub-dub). Determine which sound is louder. (Normally, S2 loudest in the aortic and pulmonic areas. S1 is louder than equal or equal to S2 in the tricuspid area, and S1 is loudest in the mitral area.) Listen for physiologic split in S2. Determine systolic phase (between S1 and S2) and diastolic phase (between S2 and S1): diastolic should be longer than systolic at a heart rate of 120 beats per minute or less. Note extra sounds or murmurs. Determine heart rate and rhythm. Normal findings AP rate 60 to 80 beats per minute, regular No thrills, heaves, or abnormal pulsations Apical impulse 5 left ICS at or medial to midclavicular line (palpated within one ICS and no more than 1 to 2 cm wide; 7 to 9 from the sternal border). Left cardiac border dullness 9 to 12 cm from the sternal border S1 and S2 heard in expected locations with expected intensities (S2 split common in supine position on inspiration); no extras sounds or murmurs.

Peripheral circulation Inspection Jugular veins: with the patient supine, observe the neck for internal jugular venous pulsations; if present, note their characteristics and relationship to inspiration. With the patient sitting, observe for distended jugular veins. Carotid arteries: Observe for pulsations (timed with apical impulse)

Extremities (arterial): Observe color, noting pallor or rubor; hair distribution, noting abnormal absence; and skin characteristics, noting shiny or thin skin and any circumscribed lesions on feet and toes. Extremities (venous): Observe color, noting abnormal brown pigmentation; look for skin lesions on the lower legs, varicosities and edema. Palpation Extremities (arterial): Assess the temperature of the skin. Palpate pulses (radial, femoral, posterior tibial, dorsalis pedis), comparing sides. Check capillary refill times in fingernails and toenails. Perform Allens test on radial and ulnar arteries. Extremities (venous): Palpate the skin over the tibia and at the medical malleoli for pitting edema. Compress the calf between your two hands placed anteriorly and posteriorly; note any pain that this maneuver elicits. Auscultation Listen over the carotid, abdominal, and femoral arteries for bruits. Normal findings Jugular veins soft and undulating, decreasing on inspiration when supine; not observable when sitting. Carotid artery pulsations synchronous with apical impulse varicosities, or edema Pulses 2+ bilaterally on a scale of 0 to 3+ Capillary refill immediate; hands pink immediately in response to Allenstest No calf tenderness elicited No bruits auscultated over the carotid, abdominal, or femoral artery Abdomen Inspection Skin: scars, striae, and rashes General contour and symmetry Visible peristalsis, aortic pulsations and hernias(umbilical, inguinal, and incisional) Auscultation: (Note: auscultate the abdomen before percussing and palpating to avoid stimulating intestinal activity and altering bowel sounds.) Bowel sounds: Listen in all quadrants; note frequency, pitch and duration Auscultate for bruits over abdominal aorta and the renal, iliac, and femoral arteries. Percussion Percuss in all quadrants; note areas of tympany or dullness.

Percuss along the right midclavicular line, starting below the umbilicus and moving upward, to locate the liver borders. Percuss in the left upper quadrant for gastric air bubble. With the patient sitting, strike the back at the costovertebral angles; note tenderness or pain. Normal findings: No scars: abdominal wall flat and symmetric; no incisional, umbilical, or inguinal hernias Bowel sounds intermittent (every 5to 35 seconds) and gurgling with no hyperactive or tinkling sounds; rushing sounds over the ileocecal valve (in the right lower quadrant) 4 to 7 hours after eating; no bruits Liver dullness 6 to 12 cm at RMCL; tympany of gastric air bubble over left anterior lower border of thorax; tympany in all quadrants No costovertebral angles tenderness Muscle tone normal; abdomen soft with no masses or tenderness Aorta with 2.5 to 4 cm; soft, pulsatile Pole of right kidney may be palpable

Male genitalia and hernias: (Note: wear gloves during examination) Inspection Pubic hair: Assess distribution; note any nits or lice. Penis: Retract the foreskin, if present. Note any ulcerations, masses, or scarring on the glans penis. Inspect the urethral meatus for location, lesions, and discharge. Scrotum: Inspect anterior and posterior aspects, assessing size, contour, and symmetry; note ulcerations, masses, redness, or swelling. Inguinal areas: Look for bulges, with and without the patient bearing down, or when raising his head off the bed. Palpation Penis: Palpate the shaft for lesions, nodules, or masses; if present, note tenderness, contour, size, and degree of indurations Scrotum: Palpate each testis and epididymis, assessing size, shape, and consistency. Note any masses of unusual tenderness. Also note any nodules or tenderness of the spermatic cord and vas deferens. Inguinal and femoral areas: Assess for hernias. Normal findings Normal male pubic hair distribution with no infestations No penile lesions, masses, or discharge

Testes symmetric without masses or undue tenderness; the left testis may be slightly larger and hang lower than the right testis No inguinal or femoral hernias

Female genitalia (Note: Wear gloves during examination) Inspection and palpation (performed almost simultaneously) Place the patient in lithotomy position; drape properly. Assess pubic hair distribution; note nits or lice. Inspect the labia majora, mons pubis, and perineum; note skin color and integrity. Separate the labia majora, and inspect the clitoris, urethral meatus, and vaginal opening; note abnormal color, ulcerations, swelling, nodules, lesions, and discharge. Rectum (Note: Wear gloves during examination) Inspection With the patient lying in left Sims position and properly draped, spread the buttocks and examine the anus and the perianal and sacral regions. Note any inflammation, nodules, scars, lesions, ulcerations, rashes, bleeding, fissures, or hemorrhoids. Check for bulges when the patient bears down. If necessary, use an alternative position for examination: for a male patient, standing and bent over the table; for a female patient, the lithotomy position. Palpation Ask the patient to bear down; slowly insert your lubricated index of gloved hand through the anal sphincter; assess sphincter tone. Then, gently rotate your index finger to palpate the rectum and rectal walls anteriorly and posteriorly; note any nodules, masses, or tenderness. Palpate for fecal impaction. In a male patient, anteriorly palpate the two lateral lobes of the prostate gland for irregularities, nodules, swelling, or tenderness. Withdraw your finger gently; test any fecal material on the glove for occult blood. Normal findings Sphincter closes around finger Wall of rectum smooth and moist; soft stool may be present No hemorrhoids, fissures, or fistulas Stool guaiac test negative

Male prostate 2.5 to 4 cm in size with a small groove separating the lobes; feels firm, smooth, non-movable, non- tender, and rubbery.

Musculoskeletal system Inspection Observe the patients ability to perform functional tasks of daily living (e.g., grasping objects, performing personal hygiene, bathing, dressing, bending, sitting, rising from sitting to standing, and walking up and downstairs as well as on the level surface). Note any pain the patient experiences while performing functions or being examined. Examine the arms and legs; note size, symmetry, muscle mass, and any deformities. Assess the spine fro range of motion (flexion, extension, lateral flexion, and rotation) and lateral or anteriorposterior curvature. Assess all major joints, noting any limitations to active range of motion, swelling , or redness. Neck: Assess flexion, extension, and rotation Shoulders: Assess flexion, extension, supination, and pronation Elbows: Assess flexion, extension, supination, and pronation Wrists: Assess flexion, extension, and ulnar and radial deviation. Fingers: Assess flexion, extension, abduction, and adduction Hips: Assess flexion, extension, and rotation. Knees: Assess dorsiflexion, plantar flexion, inversion, and eversion Toes: Assess flexion, extension, abduction, and adduction. Palpation Palpate the joints of the neck and upper and lower extremities, noting tenderness, swelling, temperature, limitations to passive range of motion, and crepitation. Palpate muscles to assess size, tone, and any tenderness. Palpate the spine, noting bony deformities and crepitation. Percussion Directly percuss the spine with the ulnar surface of the fist from the cervical to lumbar region; note any pain or tenderness. Normal findings No limitation to function

No gross deformities or abnormal postures Range of joint motion unrestricted in extremities and spine Muscle mass symmetric with no hypertrophy or atrophy; tone normal No joint pain, crepitus, bony overgrowths, or tenderness in extremities or spine.

Neurologic system Components of neurologic examination include: Mental status: observed during history taking, includes: o State of consciousness: alert, somnolent, stuporous, comatose o Orientation to person, place, and time o Memory: immediate, recent, remote o Cognition: calculations, current events, response to proverbs o Judgment and problem solving ability o Emotion: mood, affect, congruence of responses Cranial nerve function o Olfactory (CN I): with the patients eyes closed, present various odors, occluding one nostril at a time. Note the patients ability to identify the odors. o Optic (CN II): test visual acuity and visual fields, and examine the optic disc with an opthalmoscope. o Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI): Assess extraocular motion by evaluating the six cardinal positions of gaze (parallelism, nystagmus), performing the coveruncover test (movement of the eye when uncovered or opposite eye when contralateral eye covered, and corneal light reflex (symmetry of reflection of light on pupil): check size and shape of pupils and papillary reaction to light and accommodation (PERRLA). o Trigeminal (CN V): Motor assess the patients ability to chew, assess strength of bite. Sensory assess the patients ability to distinguish light touch and pain when you lightly stroke his or her face with a cotton wisp and gently prick the skin with a sterile pin on forehead (to assess the ophthalmic branch), cheek (to assess the maxillary branch), and chin (to assess the mandibular branch). o Facial (CN VII):

Motor Assess symmetry of facial movements as the patient smiles, frowns, grimaces, clenches his or her teeth, and so forth. Sensory ask the patient to identify various flavors placed on the anterior two thirds of the tongue. Acoustic (CN VII) Cochlear branch assess hearing acuity. Vestibular branch perform the Romberg test to evaluate equilibrium. Glossopharyngeal (CN IX) Test for the gag reflex by gently touching the posterior pharyngeal wall with a tongue blade. Vagus (CN X) As the patient speaks, check movement of the uvula (noting any deviation from midline) and palate (noting asymmetric elevation). Spinal accessory (CN XI) Assess strength of the sternocleidomatoid (SCM) and upper trapezius muscles by asking the patient to move the head against resistance of your hand. Observe and palpate contraction of SCM muscle on the opposite side; ask the patient to shrug the shoulders against resistance of your hands. Hypoglossal(CN XII) Test strength and articulation of the tongue by having the patient push the tongue to the side of the mouth against resistance applied to the check. Ask the patient to stick out the tongue and then return it to the mouth while you observe for deviation, asymmetry, tremors, and fasciculations.

Cerebellar function (coordination and balance) o Assess posture, gait, and balance; have the patient walk forward and backward in a straight line. o Perform the Romberg test; stand close to the patient to provide support if necessary. o Assess coordination in the upper extremities by having the patient perform the finger-to-nose test.

Assess coordination in the lower extremities by having the patient tap the shoes and slide the heel down the contralateral shin. Motor function o Muscle mass: assess asymmetry and distribution distally and proximally, and circumference of extremities bilaterally. o Tone: Evaluate resistance of muscles in response to passive motion during flexion and extension of extremities. o Strength: assess hand squeeze and evaluate muscle strength in each extremity against resistance during flexion and extension (also abduction and adduction where appropriate), comparing bilaterally. o Observe for involuntary movements (tics, fasciculations, tremors, or twitching) and abnormal postures (e.g. fetal, decerebrate). Sensory function: With the patients ayes closed, assess: o Light touch Have the patient indicate response to cotton wisp lightly stroked on skin at representative dermatomes (i.e., backs of hands, forearms and upper arms, torso, thigh, tibia, and dorsal portion of foot): compare bilaterally and distal to proximal. o Pain: Repeat the pattern of light touch assessment, using a sterile safety pin to elicit sharp sensation; alternate with the pins rounded end to contrast. o Vibration: Place a vibrating low-pitched tuning fork (128 Hz) over the sternum, then quickly on the distal interphalangeal joint of a finger; ask the patient to identify whether vibration sensation in the finger is 100%, 75%, 50%, or 25% of that felt in the sternum, and to indicate when vibration is no longer felt. Repeat this procedure in a great toe. If vibration sense is impaired in the finger or toe, proceed to assessment in more proximal bony prominences (wrist and elbow or medial malleolus, patella, anterior iliac spine, and spinous processes). o Position sense: o

With your fingers placed on the lateral surface of the patients digit (finger, great toe), move it up or down; ask the patient which direction the digit is pointing. o Stereognosis: Ask the patient to identify small objects placed in his or her hand, one hand at a time. o Graphesthesia: Ask the patient to identify a number that you trace in his or her palm with your fingertip. Deep tendon reflexes: Striking with a reflex hammer, compare reflex amplitude bilaterally, grading on scale of: 0 to 4 +(4 + = hyperactive; 2 + or 3 + = average 1 + = diminished 0 = no response o Brachioradialis (C5, C6): Strike the radius tendon about 1 to 2 inches above the wrist; observe for flexion and supination of the forearm. o Biceps (C5, C6): Place your thumb or forefinger at the base of the biceps tendon and strike it; observe for flexion of the arm at the elbow. o Triceps (C7, C8): Strike the triceps tendon, just above the elbow; observe for slight elbow; observe for slight elbow extension. o Patellar or quadriceps (L2, L3, and L4): Sharply strike the patellar tendon; observe for extension of knee. o Achilles or ankle jerk (S1, S2): Support the patients foot in the dorsiflexed position; tap the Achilles tendon, and observe for plantar flexion. Superficial cutaneous reflexes o Abdominal: Stroke the abdomen above (T8, T9,T10) and below (T10, T11, T12) the umbilicus bilaterally; observe for contraction of abdominal muscles and deviation of the umbilicus toward the stimulus. o Cremasteric (L1, L2):

In a male patient, stroke the inner surface of the thigh; observe for prompt elevation of the testis on the ipsilateral side. o Plantar (L4, L5, S1, S2): Extend the patients legs with the feet relaxed; stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball; observe for flexion of toes. Normal findings o Mental status: Alert, quiet, able to follow threestep instructions; oriented to person, place, and time; judgment and intellectual performance within normal limits. o Cranial nerve function: CN 1 through XII grossly normal o Motor: no atrophy, tremors, or weakness o Muscle tone: no flaccidity, rigidity, or spascity o Muscle strength: + 5 (on a scale of 0 to + 5) o Sensory function: light touch, pain, vibration and position sense normal; stereognosis and graphesthesia normal bilaterally o Reflexes: deep tendon reflexes + 2 (on a scale of 0 to + 4) (brachioradialis, biceps, triceps, patella, ankle); superficial reflexes present (abdominal, cremasteric); plantar reflexes normal (toes reflex)

III. LABORATORY STUDIES: the third part of a complete health assessment, laboratory study results fall into three basic categories: Laboratory Studies A. Urinalysis Protein Glucose Specific gravity B. Hematology Hemoglobin (Hgb) Normal Values 0 5 mg/100mL. 0 15 mg/100mL. 0.032 in young adults 1.024 By age 80. Men: 13 18 g/100mL Women: 12 16 g/100mL Elderly men: drops to 1-2 g/100mL Elderly women: no change documented. Men: 45% - 52% Women: 37% - 48% 4,300 10,800/cu mm. in young

Hematocrit (Hct) Leukocytes

 C. BLOOD

Lymphocytes Platelets Prothrombin time CHEMISTRY Albumin

adults 3,100 -9,000/cu mm with aging. T-lymphocytes 500 -2,400/mL B-lymphocytes 50-200/mL 150,000 350,000/cu mm. 11 15 seconds 3.5 5.0 g/100 mL; Before age 65, level tends to be higher in men than in women. After age 65, values equalize and decline at the same rate; 2.3 3.5 g/100 mL. Increases slightly with aging. 6.0 8.4 g/100 mL. 135 145 mEq/L. 3.5 5.5 mEq/L. 24 30 mEq/L. 100 106 mEq/L. Men; 10 -25 mg/100mL Women: 8 -20 mg/100mL. 0.6 -1.5 mg/100mL. 0.6 1.9 mg/100 mL. in elderly 104 125 mL/min. 1 hour, 160 -170 mg/100mL 2 hours, 115 -125 mg/100mL 3 hours, 70 110 mg/100 mL. 40 -150 mg/100 mL 20 -200 mg/100mL in elderly. 120 220 mg/100 mL 80 -310 mg/100 mL 4.5 13.5 mcg/100 mL 90 230 mg/100 mL 0.5 5.0 mcg U/mL 13 39 IU/L Young men: 0.13 -0.63 U/mL Young women: 0.01 0.56 U/mL 0 -40 U/L

Beta globulin Total serum protein Sodium Potassium Carbon dioxide Chloride Blood Urea Nitrogen (BUN) Creatinine Creatinine clearance Glucose tolerance Triglycerides Cholesterol High-density lipoproteins (HDL) Thyroxine (T4) Triiodothyronine (T3) Thyroid-stimulating hormone (TSH) Alkaline phosphatase Acid phosphatase Serum glutamicoxaloacetic transaminase (SGOT) Creatinine kinase (CK)

17 -148 U/L.

Lactase dehydrogenase (LDH)

45 90 U/L.

Positions used in Physical assessment Standing Sitting Dorsal recumbent

Lithotomy

Prone position

Sims position

Knee-chest

Unexpected situations and associated interventions While you are testing a patients visual acuity, the patient tells you he cant see anything without his glasses: Stop the test, instruct the clients to put on his glasses, and then rsum testing.

When assessing patients lungs, you hear short, high-pitched popping sounds on inspiration. Ask the patient to cough and auscultate again. If the sounds remain, suspect fine crackles, which may indicate restrictive disease such as pneumonia or heart failure. Notify the physician.

Special considerations Always warm equipment such as stethoscope