NEO 111 Melanie Jorgenson, RN, BSN

 Inspection: performing deliberate, purposeful observations in a systematic manner  Palpation: using the sense of touch  Percussion: striking one object against another to produce sound  Auscultation: listening with a stethoscope to sounds produced in the body

 Biographical data  Reason for seeking care  History of present health concern  Past medical history  Family history  Lifestyle

 Sitting (to examine head, back, lungs, breast, heart, extremities)  Supine (to examine head, neck, lungs, breast, abdomen, heart, extremities)  Sims (to examine rectum and vagina)  Knee-chest (to examine rectum)  Dorsal recumbent (to examine head, neck, lungs, breast, heart)  Prone (to examine posterior thorax, lungs, hip)  Lithotomy (to examine female genitalia, rectum, genital tract)

 Temperature  Turgor  Texture  Moisture  Pulsations  Vibrations  Shape and masses  Organs

 Location  Shape  Size of organs  Density of other underlying structures or tissues

 Assessments  Blood pressure  Heart sounds  Lung sounds  Bowel sounds  Characteristics of sounds  Pitch  Loudness  Quality

 General survey  Height and weight  Vital signs

 The Head & Neck  The Eyes & Ears  The Nose & Sinuses  The Mouth & Throat  Chest and back  The Posterior and Lateral Thorax  The Anterior Thorax  The Heart

 As important as assessing the client’s vital signs.  Routinely taken on admission to acute care facilities and on visits to physicians’ offices, clinics, and other health care settings.

 Facial structures  Eyes, ears, nose, mouth, and throat  Anterior neck structures  Trachea, esophagus, thyroid glad, arteries, veins, and lymph nodes  Posterior neck areas  Upper portion of the spine

Focuses on:  Cardiovascular status.  Respiratory status.  Wounds, scars, drains, tubes, dressings.  Breasts.

 Bronchial (loud and high-pitched with a hollow quality)  Bronchovesicular (medium-pitched and blowing)  Vesicular (soft, breezy, and low-pitched)

 Adventitious breath sounds (abnormal)  Sibilant wheezes (high-pitched, whistling)  Sonorous wheezes (low-pitched snoring)  Crackles (popping sounds heard on inhalation or exhalation  Pleural friction rub (low-pitched grating sound heard on inhalation or exhalation)  Stridor (high-pitched, harsh sound heard on inspiration while trachea or larynx is obstructed)

 Respiratory system  Recognizing and identifying normal and abnormal breath sounds  Components of the thorax  Lungs, rib cage, cartilage, and intercostal muscles  Assessment techniques  Inspection, palpation, percussion, and auscultation

 Functions of the system  Transports oxygen, nutrients, and other substances to the body tissues  Removes metabolic waste products to the kidneys and lungs  Assessment techniques  Careful auscultation is important to identify heart sounds

 Any symptoms patient is experiencing  Vital signs  Color and temperature of skin; capillary refill of nails  Inspection findings related to carotid arteries, jugular veins, and anterior chest wall  Palpation findings related to sternoclavicular area and anterior chest wall  Auscultation findings, including rate, rhythm, pitch, and location of sounds

NEO 111 Melanie Jorgenson, RN, BSN

 Neurological  Skin  Musculoskeletal  Upper and lower extremities  Abdomen

 Neurologic system  Assesses cognitive function  Evaluates sensation in the body, cranial nerves, and DTR  Musculoskeletal examination  Provides information on muscles and joints  Peripheral vascular system  Identifies condition of arteries and veins in the extremities

Focuses on:  Level of consciousness  Pupil response  Hand grasps  Foot pushes

 Components of the integumentary system  Skin, hair, nails, sweat glands, and sebaceous glands  Findings  Nutrition and hydration  Overall health status  Information associated with certain systemic diseases, infection, immobility, sun exposure, and allergies

 Through observation of client gait and overall range of movement, the nurse is able to obtain some knowledge of the symmetry and strength of muscles

 Focuses on gastrointestinal and genitourinary status  Includes use of inspection, auscultation, percussion, and palpation within the four quadrants of the abdomen to establish bowel function and status

 Components of the abdominal cavity  Men and women: stomach, small and large intestines, liver, gallbladder, pancreas, spleen, kidneys, urinary bladder, adrenal gland, and major blood vessels  Women: uterus, fallopian tubes, and ovaries  Assessment techniques  Order: inspection, auscultation, percussion, and palpation  Not all organs can be assessed

 The nurse must maintain accurate documentation of the amount of drainage, color, or other changes