A. Nursing Health History a. Biographic Data b. Chief Complaint c. History of Present Illness d. Past Health History of Illness e.

FUNCTIONAL HEALTH PATTERNS (11 by Gordon) B. Physical Examination

Best done when? Techniques: Head toe (cephalo-caudal) examination Special Considerations: Positioning: a. Neck: nurse behind the client b. Thorax/Lungs: sitting position c. Abdomen: Position sequence of examination (technique and quadrants

Skills of Physical Assessment Palpation: SENSITIVITY OF PARTS OF THE HAND

Hand Part Used Fingertips Palmar / Ulnar surface Dorsal Surface

Type of Sensation Felt Fine discriminations Vibratory sensations (e.g. thrills, fremitus) Temperature

Deep palpation

Light palpation

2 TYPES OF PALPATION: 1. Light palpation - 1 cm dominant hands fingers parallel to skin surface skin is slightly depressed; 2.Deep palpation 4 cm done with one or two hands (bimanually) a. deep bimanual b. deep palpation using one hand

Indirect percussion

Direct percussion

Skills of Physical Assessment 3.Percussion sense of touch and hearing tappi ng a part of body with fingertips to elicit character and density of underlying tissue determine whether underlying tissue a. AIR FILLED b. FLUID FILLED C. SOLID

Skills of Physical Assessment 3.Percussion Two types: a.Direct to elicit tenderness or pain (differentiate) b.Indirect Pleximeter: middle finger of non-dominant hand Plexor: dominant hand * Plexor strikes the distal interphalengeal joint

Skills for Physical Assessment 4. Auscultation process of listening to various sounds (breath, heart, bowel) produced within the body using stethoscope - stethoscope: bell and diaphragm: types of sounds

General Color: a. Normal: pinkish b. Pallor Dark skinned? Ashen gray Brown skinned? Yellowish brown tinge Light skin?
* Face, conjunctiva, nail

 General Color: c. Jaundice yellowish tinge

Evident where?

* Sclera, mucous membranes, skin

Dark skinned: normal yellow pigmentation of sclera: Where to assess for jaundice?

*Hard palate

General Color: d. Cyanotic bluish tinge/discoloration

Best assess where?

* Nail beds, lips, buccal mucosa 1. Central cyanosis

lips, buccal mucosa, tongue

2. Peripheral cyanosis
nails and skin of extremities

 Skin Turgor:
fullness or elasticity How:

* lifting and pinching the skin a. Normal: Good: springs back to previous state b. Poor
For elderly: For children:

Scale for describing edema:

Grade 1+ : 2 mm Grade 2+ : 4 mm Grade 3+ : 6 mm Grade 4+ : 8 mm

* BRAWNY EDEMA

SKIN LESIONS: PRIMARY = APPEARS INITIALLY Macule small flat Patch bigger macule Papule elevated Plaque bigger papule Vesicle with fluid Bulla bigger vesicle Pustule with pus Wheal mosquito bites

SECONDARY : TRAUMATIZED PRIMARY LESION

C = Crust
dried blood, pus or serum

U = Ulcer
deep, irregular wearing away

E = Erosion
wearing away of epidermis

S = Scales
shedding flakes

NAIL PLATE SHAPE : curvature and angle convex curvature

angle between nail and nail bed: 160 degrees

b. Spoon shaped nail: Koilonychia

BLANCH TEST (CAPILLARY REFILL)

a. Normal:

b. Delayed return of pink

EYES AND VISION

Visual Acuity Tests: a. Distance Vision Test b. Near Vision Test PERRLA Pupil size Abnormalities: Unequal pupil: Dilated pupil? Constricted pupil?

II. EYES AND VISION

Abnormalities: a. Myopia b. Hyperopia c. Presbyopia: loss of elasticity of lens d. Astigmatism: uneven curvature of cornea Tests for glaucoma: a. Tonometry measures IOP: Normal: 8- 21mmHg b. Perimetry loss of peripheral vission

EARS AND HEARING

To visualize ear canal: a. AdUlt b. ChilD Tests: a. Rinne Test Normal: AC is greater than BC Conductive problems: BC > AC

b. Weber test bone conduction by testing lateralization of sounds: N: (-) Conductive hearing loss, Bad ear hears better Sensorineural hearing loss, Good ear hears better Interpretations: BAD-CONDUCTION, GOOD-SENSATION

Mouth and Pharynx

Question:

PART WHERE CENTRAL

CYANOSIS IS BEST ASSESSED?

THORAX AND LUNGS

a.APL ratio b.Percussion: Normal: Resonant Dullness: with solid tissue (PNEUMONIA) or fluid (Pleural effusion) Hyperresonance: hyper-inflated lungs (asthma, emphysema)

Thorax and Lungs Chest deformities:

1. Pigeon chest : pectus carinatum Narrow, transverse diameter, increased AP and protruding sternum 2. Funnel chest : pectus excavatum Sternum depressed, narrow AP diameter,

Thorax and Lungs

Chest deformities: 3. Barrel chest : APL is 1:1 4. Kyphosis

Excessive convex curvature

5. Scoliosis

NORMAL BREATH SOUNDS:

a. Bronchial air passing thru trachea in front of trachea. 1:2 ratio (inspiration: expiration) b. Bronchovesicular air moving thru larger bronchi between scapulae, 2nd ICS. 1:1 ratio

NORMAL BREATH SOUNDS: c. Vesicular

air moving through smaller bronchioles and alveoli
peripheral, base of lungs 5:2 ratio

ADVENTITIOUS BREATH SOUNDS:

1. CRACKLES RALES: R = Roll hair A= Air pass mucus L= Low lungs

E= Exaged by inspiration
S= Styles: fine, med, course

ADVENTITIOUS BREATH SOUNDS: 2. FRICTION RUB rubbing, inflamed pleural surfaces. grating sound lower anterior chest

audible: both inspiration and expiration.

ADVENTITIOUS BREATH SOUNDS: 3. GURGLES

air thru narrowed spaces coarse, with snoring quality predominate: bronchi and trachea. best heard on expiration.

ADVENTITIOUS BREATH SOUNDS:

4. WHEEZE
air thru constricted bronchus high pitched, squeaky musicalsound.

over all lung fields

best heard on expiration.

JUGULAR VEIN: semi-fowlers: 30-45during assessment. veins not visible: normal

veins distended: possible right sided heart disease.

Measure JV highest distention from angle of Louis until 4cm only. above 4cm: vein distention

BREAST
a. Upper outer quadrant common site of breast cancer

b. BSE 5-7 after the first menstruation day MONTHLY

c. 20-40 y/o: Clinical breast exam yearly

d. Mammography at 40 yearly

a. Sequence:
By quadrant: RLQ, RUQ, LUQ, LLQ

b. Position: c. Bowel Sounds:

Normoactive Hypoactive Hyperactive Absent:

COMPONENTS OF NEUROLOGICAL ASSESSMENT

1.Mental Status

2.Level of Consciousness
3.Reflexes 4.Motor Functions 5.Sensory Functions 6.Cranial Nerves

A. Language
Aphasia inability to express oneself by speech, writing or comprehend spoken or written language due to disease of cerebral cortex Two Categories:

1.Sensory or receptive aphasia

2.Motor or expressive aphasia

1.Sensory/receptive aphasia
- loss of ability to comprehend written or spoken words

Two types: a.Auditory aphasia unable to understand symbolic content associated with sounds b.Visual aphasia unable to understand printed or written figures

2. Motor/ expressive aphasia loss of power to express oneself by writing, making signs or speaking How to assess language deficits: Point to common objects and name them Read some words and match printed and written words with pictures Respond to verbal/written commands

Speech Patterns:
- pace, clarity, spontaneity Abnormalities: a.Perseveration -repeating the same response as different questions are asked

b.Paraphasia - speech appropriately expressed but contains incorrect words

B. Orientation 3 spheres C. Memory

- Listen for lapses of memory - If problems are present:

Three categories of memory: 1. Immediate recall N:can repeat series of 5 8 digits in sequence and 4 6 digits in reverse order

2. Recent memory -Ask to recall the events of the day -Recall information given early in the interview -Provide 3 facts to recall (color, object, address),then ask later 3. Remote memory -Previous illness or surgery (years ago),birthday, anniversary

D. Attention Span
-Tests the ability to concentrate (alphabet, count backward from 100)

E. Calculation
-Serial seven or serial three test N: can complete serial seven in 90 seconds with 3 or less errors

II. Level of Consciousness Conscious, L O S C Glasgow Coma Scale (GCS) a.Eye opening 4 b.Verbal response 5 c.Motor response 6 Perfect score: 15 (fully alert and oriented) * Score of 7 or less- comatose

III. REFLEXES

-Automatic response of the body to stimulus

-Not voluntary learned or conscious -Deep tendon reflex (DTR) is activated when tendon is stimulated (tapped) and its associated muscle contracts -Reflex response varies among individuals and by age.

Equipment: reflex hammer Scale for Grading Reflex Responses 0: No reflex response +1: minimal activity (hypoactive) +2: normal response

+3: more active than normal

+4: maximum activity (hyperactive)