Chapter 31 Health Assessment and Physical Examination

Chapter 31 Health Assessment and Physical Examination
By performing health assessments and physical examinations, you will identify health patterns and evaluate each patient’s response to treatments and therapies. A complete health assessment involves a nursing history, as well as a behavioral and physical examination. The patient’s condition and response affect the extent of your examination. The accuracy of your assessment will influence the choice of therapies a patient receives and evaluation of the response to those therapies. Health Assessment and Physical Examination Copyright © 2017, Elsevier Inc. All Rights Reserved.

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Objectives Perform physical head to toe assessment in an organized manner on an adult client Distinguish normal and abnormal findings Recognize normal signs of the aging process Determine normal findings in various ethnic groups Copyright © 2017, Elsevier Inc. All Rights Reserved.

Purposes of the Physical Examination
Triage for emergency care Routine screening to promote health and wellness To determine eligibility for: Health insurance Military service A new job To admit a patient to a hospital or long-term care facility After considering the patient’s current condition, a nurse selects a focused physical examination on a specific system or area. When the patient is no longer at risk for a bad outcome or injury, the nurse performs a more comprehensive examination of other body systems. For patients who are hospitalized, a nurse integrates the collection of physical assessment data during routine patient care, validating findings with what is known about the patient’s health history. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Purposes of Physical Examination (Cont.)
Use physical examination to: Gather baseline data about the patient’s health status. Supplement, confirm, or refute subjective data obtained in the nursing history. Identify and confirm nursing diagnoses. Make clinical decisions about a patient’s changing health status and management. Evaluate the outcomes of care. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 1.When meeting a patient for the first time, it is important to establish a baseline assessment that will enable a nurse to refer back to: A. physiological outcomes of care. B. the normal range of physical findings. C. a pattern of findings identified when the patient is first assessed. D. clinical judgments made about a patient’s changing health status. Answer: C Rationale: Baseline assessment findings are a pattern of findings identified from the patient is first assessed. Baseline assessment findings reflect a patient’s functional abilities and serve as the basis for comparison with subsequent assessment findings. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Cultural Sensitivity Culture influences a patient’s behavior Consider: Health beliefs Use of alternative therapies Nutritional habits Relationships with family Personal comfort zone Avoid stereotyping There is a difference between cultural characteristics and physical characteristics. Learn to recognize common characteristics and disorders among members of ethnic populations in your area. It is equally important to recognize variations in physical characteristics such as in the skin and musculoskeletal system, which are related to racial variables. [Ask students: Why do you think it’s important to be aware of disorders that are more commonly seen in a particular ethnic group? Discuss: More likely to recognize rare conditions unique to each ethnic group, which will lead to higher-quality care.] Consider the patient’s cultural beliefs as you assess how the person receives, processes, and understands health care information as well as how he or she makes health care decisions. By recognizing cultural diversity, you show respect for each patient’s uniqueness, leading to higher-quality care and improved clinical outcomes Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Mr. Neal is being admitted to the surgery floor for bowel surgery. He is 76 years old and has a history of rectal bleeding and bowel changes. He smokes 2 packs of cigarettes a day and says he has no family history of colon cancer. His wife is with him. Jane is a nursing student assigned to care for Mr. Neal. She begins her assessment with a review of Mr. Neal’s chart and the health care provider’s orders. [Ask students: What is the next step in Jane’s assessment of Mr. Neal? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Integration of Physical Assessment with Nursing Care
Integrate examination during routine nursing care: Vital signs Bathing Range of motion Activities of daily living Copyright © 2017, Elsevier Inc. All Rights Reserved.

Tools for Physical Assessment
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Preparation for Examination
Infection control Environment Equipment Physical preparation of patient Positioning Psychological preparation of patient Assessment of age groups These aspects need attention to ensure that your patient is physically and emotionally ready for an examination. Some patients present with open skin lesions, infected wounds, or other communicable diseases. Use standard precautions throughout an examination. Although most health care agencies make nonlatex gloves available, it is your responsibility to identify latex allergies in patients and use equipment items that are latex free. [Review Table 31-1, Products Containing Latex and Nonlatex Substitutes, with students.] The environment must provide privacy, good lighting, a quiet environment, and climate control. The patient must be comfortable. Prepare equipment and ensure that the equipment functions properly before using it. [Review Box 31-1, Equipment and Supplies For Physical Assessment, with students.] Before starting, ask if the patient needs to use the restroom. Physical preparation also involves making certain that patient privacy is maintained with proper dress and draping. Routinely ask if he or she is comfortable. During the examination ask the patient to assume proper positions so body parts are accessible and he or she stays comfortable. To decrease the number of position changes, organize the examination so all techniques requiring a sitting position are completed first, followed by those that require a supine position next, and so forth. Use extra care when positioning older adults with disabilities and limitations. [Review Table 31-2, Positions for Examination, with students.] A thorough explanation of the purpose and steps of each assessment lets a patient know what to expect and how to cooperate. Adapt explanations to the patient’s level of understanding and encourage him or her to ask questions and comment on any discomfort. Consider cultural or social norms when performing an examination on a person of the opposite gender. When this situation occurs, another person of the patient’s gender or a culturally approved family member needs to be in the room. Vary your techniques and style when assessing various age groups. Children require different handling than do adolescents, adults, and the elderly. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Organization of the Examination
Assessment of each body system Systematic and organized Head-to-toe approach Compare sides for symmetry Assess body systems most at risk for being abnormal Offer rest periods as needed Perform painful procedures at the end Be specific when recording assessments Record quick notes during the examination; complete larger notes at the end of the examination You will conduct a physical examination by assessing each body system. Use judgment to ensure that an examination is relevant and includes the correct assessments. Patients with focused symptoms or needs require only parts of an examination. A head-to-toe approach includes all body systems, and the examiner recalls and performs each step in a predetermined order. A patient in the community seeks screening for specific conditions, often dependent on the patient’s age or health risks. [Review Table 31-3, Recommended Preventive Screenings, with students.] The following tips help keep an examination well organized: Compare both sides of the body for symmetry. A degree of asymmetry is normal (e.g., the biceps muscles in the dominant arm are sometimes more developed than the same muscles in the nondominant arm). If the patient is seriously ill, first assess the systems of the body most at risk for being abnormal. For example, a patient with chest pain first undergoes a cardiovascular assessment. If the patient becomes fatigued, offer rest periods between assessments. Perform painful procedures near the end of an examination. Record assessments in specific terms in the electronic or paper record. A standard form allows for recording information in the same sequence that it is gathered. Use common and accepted medical terms and abbreviations to keep notes accurate, brief, and concise. Record quick notes during the examination to avoid delays. Complete any larger documentation notes at the end of the examination. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Techniques of Physical Assessment
Inspection Palpation Percussion Auscultation The four techniques used in a physical examination are inspection, palpation, percussion, and auscultation. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Inspection Use adequate lighting. Use direct lighting to inspect body cavities. Inspect each area for size, shape, color, symmetry, position, and abnormality. Position and expose body parts as needed so all surfaces can be viewed but privacy can be maintained. When possible, check for side-to-side symmetry. Validate findings with the patient. To inspect, carefully look, listen, and smell to distinguish normal from abnormal findings. [Ask students: Why is olfaction an important part of your assessment? Discuss: Olfaction helps to detect abnormalities that cannot be recognized by any other means. For example, when a patient’s breath has a sweet, fruity odor, assess for signs of diabetes.] [Review Table 31-4, Assessment of Characteristic Odors, with students.] Continue to inspect various parts of the body during the physical examination. Palpation may be used concurrently with inspection, or it may follow in a more deliberate fashion. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Palpation Uses touch to gather information. Use different parts of hands to detect different characteristics. Hands should be warm, fingernails short. Start with light palpation; end with deep palpation. Tender area last Through touch you make judgments about expected and unexpected findings of the skin or underlying tissue, muscle, and bones. For example, you palpate the skin for temperature, moisture, texture, turgor, tenderness, and thickness, and the abdomen for tenderness, distention, or masses. The palmar surface of the hand and finger pads is more sensitive than the fingertips and should be used to determine position, texture, size, consistency, masses, fluid, and crepitus. Measure position, consistency, and turgor by lightly grasping the body part with the fingertips. Assess body temperature by using the dorsal surface or back of the hand. [Review Table 31-5, Examples of Characteristics Measured by Palpation, with students.] Display respect and concern throughout the examination. Before palpating consider the patient’s condition and ability to tolerate the assessment techniques, paying close attention to areas that are painful or tender. In addition, always be conscious of the environment and any threats to the patient’s safety. Palpation proceeds slowly, gently, and deliberately. Two types of palpation are used for physical examination, light and deep. Light palpation is performed by placing the hand on the body part being examined; it also involves pressing inward about 1 cm (½ inch). Light, superficial palpation of structures such as the abdomen gives the patient the chance to identify areas of tenderness. Deep palpation is used to examine the condition of organs such as those in the abdomen. Depress the area under examination approximately 4 cm (2 inches) using one or both hands (bimanually). When using bimanual palpation, relax one hand (sensing hand) and place it lightly over the patient’s skin. The other hand (active hand) helps apply pressure to the sensing hand. The lower hand does not exert pressure directly and thus remains sensitive to detect organ characteristics. For safety deep palpation should be observed by your clinical instructor when you first attempt the procedure. [Shown at top is Figure 31-1: A, Radial pulse is detected with the pads of fingertips, the most sensitive part of the hand. B, Dorsum of the hand detects temperature variations in skin. C, The bony part of the palm at the base of the fingers detects vibrations.] [Shown at bottom is Figure 31-2: A, During light palpation gentle pressure against underlying skin and tissues can detect areas of irregularity and tenderness. B, During deep palpation depress tissue to assess the condition of underlying organs.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Percussion Tap body with fingertips to produce a vibration. Sound determines location, size, and density of structures. Percussion involves tapping the skin with the fingertips to vibrate underlying tissues and organs. The vibration travels through body tissues, and the character of the resulting sound reflects the density of the underlying tissue. The denser the tissue, the quieter the sound. By knowing how various densities influence sound, it is possible to locate organs or masses, map their edges, and determine their size. An abnormal sound suggests a mass or substance such as air or fluid within an organ or body cavity. The skill of percussion is used more often by advanced practice nurses than by nurses in daily practice at the bedside. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Auscultation Requires Good hearing A good stethoscope Knowledge Concentration and practice Sound characteristics Frequency Loudness Quality Duration Some sounds you can hear without assistance; other sounds require the use of a stethoscope. Internal body sounds are created by blood, air, or gastric contents as they move against the body structures. Learn to recognize abnormal sounds after learning normal variations. Becoming more proficient in auscultation occurs by knowing the types of sounds each body structure makes and the location in which the sounds are heard best. To auscultate internal sounds you need to hear well, have a good stethoscope, and know how to use it properly. Nurses with hearing disorders can obtain stethoscopes with extra sound amplification. The bell is best for hearing low-pitched sounds such as vascular and certain heart sounds, and the diaphragm is best for listening to high-pitched sounds such as bowel and lung sounds. [Ask students: How can you tell the difference between body sounds and extraneous noise? Discuss: Practice! By practicing with the stethoscope, you become proficient at using it and realize when sounds are clear and when extraneous sounds are present. Extraneous sounds created by rubbing against the tubing or chest piece interfere with auscultation of body organ sounds. By deliberately producing these sounds, you learn to recognize and disregard them during the actual examination.] [Review Box 31-2, Use and Care of the Stethoscope, with students.] Auscultation requires concentration and practice. While listening, know which sounds are expected in certain parts of the body and what causes the sounds. Expected sounds will be discussed in each body system section of this chapter. After understanding the cause and character of normal auscultated sounds, it becomes easier to recognize abnormal sounds and their origins. Describe any sound you hear using the following characteristics: Frequency indicates the number of sound wave cycles generated per second by a vibrating object. The higher the frequency, the higher the pitch of a sound and vice versa. Loudness refers to the amplitude of a sound wave. Auscultated sounds range from soft to loud. Quality refers to sounds of similar frequency and loudness from different sources. Terms such as blowing or gurgling describe the quality of sound. Duration means the length of time that sound vibrations last. The duration of sound is short, medium, or long. Layers of soft tissue dampen the duration of sounds from deep internal organs. Copyright © 2017, Elsevier Inc. All Rights Reserved.

General Survey General appearance and behavior Gender and race Age Signs of distress Body type Posture Gait Body movement Hygiene and grooming Dress Body odor Affect and mood Speech Signs of patient abuse Substance abuse Assess appearance and behavior while preparing the patient for the examination. [Review Box 31-3, Clinical Indicators of Abuse, with students.] [Review Box 31-4, Behaviors That are Suspicious for Substance Abuse, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

General Survey (Cont.) Vital signs Height and weight After completing the general survey, measure the patient’s vital signs. Measurement of vital signs is more accurate if completed before beginning positional changes or movements. If there is a chance that the vital signs are skewed when first measured, recheck them later during the rest of the examination. Pain, considered the fifth vital sign, should also be assessed. The relationship of height and weight reflect a person’s general health status. Assess every patient to identify if he or she is at a healthy weight, overweight, or obese. Assess trends in weight changes compared with height for signs of poor health. When a patient is hospitalized, daily weight is measured at the same time of day, on the same scale, with approximately the same clothes. This allows an objective comparison of subsequent weights. [Ask students: Why is it important to be accurate when measuring weight? Discuss: Health care providers base medical and nursing decisions (e.g., drug dosage, medications) on weight and weight changes.] [Review Box 31-5, Dietary History for Older Adults, with students.] [Review Table 31-6, Nursing History for Weight Assessment, with students.] Several different scales are available for use including standing scales for patients who can stand, bed and chair scales for patients who cannot stand, and basket or platform scales to weigh infants. Electronic scales automatically display the weight within seconds. They are calibrated automatically each time they are used. Remove shoes when measuring height in weight-bearing and non-weight-bearing patients. Place non-weight-bearing patients supine on a firm surface when measuring them. When measuring an infant, hold his or her head and make sure that his or her legs are straight at the knees. After positioning the infant, use a tape measure to measure length from the head to the bottom of the feet. Record the infant’s length to the nearest 0.5 cm or ¼ inch. [Shown is Figure 31-3: Measurement of infant length. (From Murray SS, McKinney ES: Foundations of maternal-newborn and women’s health nursing, ed 5, St Louis, 2010, Saunders.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Skin, Hair, and Nails Skin Color Pigmentation Cyanosis Jaundice Erythema Moisture Temperature Texture Turgor The integumentary system refers to the skin, hair, scalp, and nails. To assess the integument, you first gather a health history to guide your examination and use the techniques of inspection and palpation. Begin an assessment of the skin by focusing on health history questions. [Review Table 31-7, Nursing History for Skin Assessment, with students.] Assessment of the skin reveals the patient’s health status related to oxygenation, circulation, nutrition, local tissue damage, and hydration. Check the condition of the patient’s integument to determine the need for nursing care. Skin color varies from body part to body part and from person to person. Normal skin pigmentation ranges in tone from ivory or light pink to ruddy pink in light skin and from light to deep brown or olive in dark skin. Observe for cyanosis (bluish discoloration) in the lips, nail beds, palpebral conjunctivae, and palms. Assess the lips, nail beds, and mucous membranes for generalized pallor; if pallor is present, the mucous membranes are ashen gray. Localized skin changes such as pallor or erythema (red discoloration) indicate circulatory changes. The best site to inspect for jaundice (yellow-orange discoloration) is on the patient’s sclera. Be sure to ask if the patient has noticed any changes in skin coloring. [Review Table 31-8, Skin Color Variations, with students.] There is also a pattern of findings associated with patients who are chemically dependent or intravenous (IV) drug abusers. A patient who takes repeated IV injections has edematous, reddened, and warm areas along the arms and legs. This pattern suggests recent injections. Evidence of old injection sites appears as hyperpigmented and shiny or scarred areas. [Review Table 31-9, Physical Findings of the Skin Indicative of Substance Abuse, with students.] The hydration of skin and mucous membranes helps to reveal body fluid imbalances, changes in the environment of the skin, and regulation of body temperature. Use ungloved fingertips to palpate skin surfaces. Observe for dullness, dryness, crusting, and flaking that resembles dandruff when the skin surface is lightly rubbed. Excessive moisture may cause maceration of the skin, or softening of the tissues resulting in an increased risk for breakdown Increased or decreased skin temperature indicates an increase or decrease in blood flow. An increase in skin temperature often accompanies localized erythema or redness of the skin. A reduction in skin temperature often accompanies pallor and reflects a decrease in blood flow. Patient temperature can be influenced by the temperature of the exam room. Accurately assess temperature by palpating the skin with the dorsum or back of the hand. Texture refers to the character of the surface of the skin and how the deeper layers feel. By palpating lightly with the fingertips, you determine whether the patient’s skin is smooth or rough, thin or thick, tight or supple, and indurated (hardened) or soft. Localized skin changes result from trauma, surgical wounds, or lesions. When there are irregularities in texture such as scars or indurations, ask the patient about recent injury to the skin. Deeper palpation sometimes reveals irregularities such as tenderness or localized areas of induration, which can be caused by repeated injections. Turgor refers to the elasticity of the skin. Normally the skin loses its elasticity with age, but fluid balance can also affect skin turgor. Edema or dehydration diminishes turgor. To assess skin turgor, grasp a fold of skin on the back of the forearm or sternal area with the fingertips and release. [Shown at top is Figure 31-4: A cross-section of the skin reveals three layers: epidermis, dermis, and subcutaneous fatty tissues.] [Shown at bottom is Figure 31-5: Assessment for skin turgor. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Skin, Hair, and Nails (Cont.)
Skin (Cont.) Vascularity Edema Lesions ABCD: Asymmetry Border irregularity Color Diameter The circulation of the skin affects color in localized areas and leads to the appearance of superficial blood vessels. Vascularity occurs in localized pressure areas when patients remain in one position. Vascularity appears reddened, pink or pale. Petechiae are nonblanching, pinpoint-size, red or purple spots on the skin caused by small hemorrhages in the skin layers. Petechiae may indicate serious blood-clotting disorders, drug reactions, or liver disease. Areas of the skin become swollen or edematous from a buildup of fluid in the tissues. Direct trauma and impairment of venous return are two common causes of edema. Inspect edematous areas for location, color, and shape. The formation of edema separates the surface of the skin from the pigmented and vascular layers, masking skin color. Edematous skin also appears stretched and shiny. Palpate edematous areas to determine mobility, consistency, and tenderness. When pressure from the examiner’s fingers leaves an indentation in the edematous area, it is called pitting edema. To assess the degree of pitting edema, press the edematous area firmly with the thumb for several seconds and release. The depth of pitting, recorded in millimeters, determines the degree of edema. For example, 1+ edema equals a 2-mm depth, 2+ edema equals a 4-mm depth, 3+ equals 6 mm, and 4+ equals 8 mm. The term lesion refers broadly to any unusual finding of the skin surface. Normally the skin is free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. When you find a lesion, collect standard information about its color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). Next observe for any exudate, odor, amount, and consistency. Measure the size of the lesion in centimeters by using a small, clear, flexible ruler. Measure each lesion for height, width, and depth. Primary lesions such as macules and nodules come from some stimulus to the skin. [Review Box 31-6, Types of Primary Skin Lesions, with students.] Secondary lesions such as ulcers occur as alterations in primary lesions. Cancerous lesions have distinct features and over time undergo changes in color and size. [Review Box 31-7, Skin Malignancies, with students.] Use the ABCD mnemonic to assess the skin for any type of carcinoma (ACS, 2013): Asymmetry—look for an uneven shape Border irregularity—look for edges that are blurred, notched, or ragged Color—look for pigmentation that is not uniform; variegated areas of blue, black, and brown and areas of pink, white, gray, blue, or red are abnormal Diameter—look for areas greater than the size of a typical pencil eraser Report abnormal lesions to the health care provider for further examination. Teach patients how to perform a skin self-examination, using the best-quality teaching materials. [Shown is Figure 31-6: Assessing for pitting edema. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 2. A patient complains of thirst and headache. The patient appears emaciated. Upon initial examination, you find that the skin does not return to normal shape. Which assessment is consistent with this finding? A. Pallor. B. Edema. C. Erythema. D. Poor skin turgor. Answer: D Copyright © 2017, Elsevier Inc. All Rights Reserved.

Color Distribution Quantity Thickness Texture Lubrication Two types of hair cover the body: soft, fine, vellus hair, which covers the body; and coarse, long, thick terminal hair, which is easily visible on the scalp, axillae, and pubic areas and in the beard on men. [Review Table 31-10, Nursing History for Hair and Scalp Assessment, with students.] During inspection explain that it is necessary to separate parts of the hair to detect abnormalities. Wear a pair of clean gloves if open lesions or lice are noted. First inspect the color, distribution, quantity, thickness, texture, and lubrication of body hair. Be aware of the normal distribution of hair growth in a man and a woman. Assess for causes of changes in the thickness, texture, and lubrication of scalp hair. [Ask students: What can changes in hair quality indicate? Discuss: Conditions such as thyroid disease alter the condition of the hair, making it fine and brittle. Hair loss (alopecia) or thinning of the hair is usually related to genetic tendencies or endocrine disorders such as diabetes, thyroiditis, and even menopause. Poor nutrition causes stringy, dull, dry, and thin hair. The oil of sebaceous glands lubricates the hair, but excessively oily hair is associated with androgen hormone stimulation. Dry, brittle hair occurs with aging and excessive use of chemical agents.] The three types of lice are Pediculus humanus capitis (head lice), Pediculus humanus corporis (body lice), and Pediculus pubis (crab lice). Lice spread easily, especially among children who play closely together. Head and crab lice attach their eggs to hair. The tiny eggs look like oval particles of dandruff, although the lice themselves are difficult to see. Head and body lice are very small with grayish-white bodies, whereas crab lice have red legs. Combing with a fine-tooth comb reveals the small oval-shaped lice; discovery of lice requires immediate treatment. Teach the patient to perform best hair and scalp hygiene practices. [Review Box 31-8, Patient Teaching: Hair and Scalp Assessment, with students.] [Shown is Figure 31-7: Head lice infestation. (From Habif TP: Clinical dermatology: A color guide to diagnosis and therapy, ed 4, Philadelphia, 2004, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Color Length Symmetry Cleanliness Configuration The condition of the nails reflects general health, state of nutrition, a person’s occupation, and habits of self-care. Before assessing the nails, gather a brief history. [Review Table 31-11, Nursing History for Nail Assessment, with students.] The most visible portion of the nail is the nail plate, the transparent layer of epithelial cells covering the nail bed. The vascularity of the nail bed creates the underlying color of the nail. The semilunar whitish area at the base of the nail bed is called the lunula, from which the nail plate grows. Inspect the nail bed for color, length, symmetry, cleanliness, and configuration. The shape and condition of the nails can give clues to pathophysiological problems. Assess the thickness and shape of the nail, the texture of the nail, the angle between the nail and the nail bed, and the condition of the lateral and proximal nail folds around the nail. The nails are normally transparent, smooth, well rounded, and convex, with a nail bed angle of about 160 degrees. A larger angle and softening of the nail bed indicate chronic oxygenation problems. [Review Box 31-9, Abnormalities of the Nail Bed , with students.] When palpating, expect to find a firm nail base and check for any abnormalities such as erythema or swelling. To palpate, gently grasp the patient’s finger and observe the color of the nail bed. The nail bed and nails appear pink with white nail tips in white patients. In darker-skinned patients the nail beds are darkly pigmented with a blue or reddish hue. A brown or black pigmentation is normal with longitudinal streaks. Trauma, cirrhosis, diabetes mellitus, and hypertension cause splinter hemorrhages. Vitamin, protein, and electrolyte changes cause various lines or bands to form on the nail beds. With aging the nails of the fingers and toes become harder and thicker. Longitudinal striations develop, and the rate of nail growth slows. Nails become more brittle, dull, and opaque and turn yellow in older adults with insufficient calcium. The cuticle becomes less thick and wide. Calluses and corns are commonly found on the toes or fingers. A callus is flat and painless, resulting from a thickening of the epidermis. Friction and pressure from shoes cause corns, usually over bony prominences. During the examination instruct the patient in proper nail care. [Review Box 31-10, Patient Teaching: Nail Assessment, with students.] [Shown on left is Figure 31-8: Components of nail unit. (From Lewis SL et al: Medical-surgical nursing, ed 9, St Louis, 2014, Mosby.)] [Shown on right is Figure 31-9: Pigmented bands in nail of patient with dark skin. (From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed 5, St Louis, 2010, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Head and Neck Inspection and palpation
Inspect the patient’s head, noting the position, size, shape, and contour. Examine the size, shape, and contour of the skull. Palpate the temporomandibular joint (TMJ) space bilaterally. An examination of the head and neck includes assessment of the head, eyes, ears, nose, mouth, pharynx, and neck (lymph nodes, carotid arteries, thyroid gland, and trachea). During assessment of peripheral arteries also assess the carotid arteries. Assessment of the head and neck uses inspection, palpation, and auscultation, with inspection and palpation often used simultaneously. The nursing history screens for intracranial injury and local or congenital deformities. [Review Table 31-12, Nursing History for Head Assessment, with students.] The head is normally held upright and midline to the trunk. Holding it tilted to one side acts as a behavioral indicator of a potential unilateral hearing or visual loss or is a physical indicator of muscle weakness in the neck. A horizontal jerking or bobbing indicates a tremor. Note the patient’s facial features, looking at the eyelids, eyebrows, nasolabial folds, and mouth for shape and symmetry. It is normal for slight asymmetry to exist. If there is facial asymmetry, note if all features on one side of the face are affected or if only a portion of the face is involved. Various neurological disorders (e.g., facial nerve paralysis) affect different nerves that innervate muscles of the face. The skull is generally round with prominences in the frontal area anteriorly and the occipital area posteriorly. Trauma typically causes local skull deformities. In infants a large head results from congenital anomaly or the buildup of cerebrospinal fluid in the ventricles (hydrocephalus). Some adults have enlarged jaws and facial bones resulting from acromegaly, a disorder caused by excessive secretion of growth hormone. Palpate the skull for nodules or masses. Gently rotate the fingertips down the midline of the scalp and along the sides of the head to identify abnormalities. Palpate the temporomandibular joint (TMJ) space bilaterally. Place the fingertips just anterior to the tragus of each ear. The fingertips should slip into the joint space as the patient’s mouth opens to gently palpate the joint spaces. Normally the movements should be smooth, although it is not unusual to hear or feel a clicking or snapping in the TMJ. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Eyes Visual acuity Extraocular movements Nystagmus Visual fields Examination of the eyes includes assessment of visual acuity, visual fields, extraocular movements, and external and internal eye structures. The eye assessment detects visual alterations and determines the general level of assistance that patients require when ambulating or performing self-care activities. Some patients with visual problems also need special aids for reading educational materials or instructions (e.g., medication labels). [Review Table 31-13, Nursing History for Eye Assessment, with students.] [Review Box 31-11, Common Eye and Vision Problems, with students.] The assessment of visual acuity (i.e., the ability to see small details) tests central vision. The easiest way to assess near vision is to ask patients to read printed material under adequate lighting. If patients wear glasses, make sure that they wear them during the assessment. Assessment of distant vision requires using a Snellen chart (paper chart or projection screen). If a patient is unable to read, use an E chart or one with pictures of familiar objects. Instead of reading letters, patients tell which direction each E is pointing or the name of the object. Assess near vision by asking the patient to read a handheld card containing a vision screening chart. This portion of the examination is a good time to discuss the need for routine eye examinations. [Review Box 31-12, Patient Assessment: Eye Assessment, with students.] Six small muscles guide the movement of each eye. Both eyes move parallel to one another in each of the six directions of gaze. To assess extraocular movements the patient sits or stands, and the nurse faces the patient from 60 cm (2 feet) away. The nurse holds a finger at a comfortable distance (15 to 31 cm [6 to 12 inches]) from the patient’s eyes. While the patient maintains his or her head in a fixed position facing forward, the nurse directs him or her to follow with the eyes only as the nurse’s finger moves to the right, left, and diagonally up and down to the left and right. As the eyes move through each direction of gaze, the upper eyelid covers the iris only slightly. Nystagmus, an involuntary, rhythmical oscillation of the eyes, occurs as a result of local injury to eye muscles and supporting structures or a disorder of the cranial nerves innervating the muscles. To assess visual fields direct the patient to stand or sit 60 cm (2 feet) away at eye level. The patient gently closes or covers one eye (e.g., the left) and looks at your eye directly opposite. You close your opposite eye (in this case the right) so the field of vision is superimposed on that of the patient. Next move a finger equidistant between you and the patient outside the field of vision and slowly bring it back into the visual field. The patient reports when he or she is able to see the finger. If you see the finger before the patient does, a portion of the patient’s visual field is reduced. To test temporal field vision, hold an object or your finger slightly behind the patient. Repeat the procedure for each field of vision for the other eye. Patients with visual field problems are at risk for injury because they cannot see all of the objects in front of them. Older adults commonly have loss of peripheral vision caused by changes in the lens. [Shown at top is Figure 31-10: Cross-section of eye.] [Shown at bottom is Figure 31-11: Six directions of gaze. Direct patient to follow finger movement through each gaze. CN, Cranial nerve.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Eyes (Cont.) External eye structures Position and alignment Eyebrows Eyelids Lacrimal apparatus Conjunctivae and sclerae Corneas To inspect external eye structures, stand directly in front of the patient at eye level and ask him or her to look at your face. Assess the position of the eyes in relation to one another. Normally they are parallel to one another. Bulging eyes (exophthalmos) usually indicate hyperthyroidism. Crossed eyes (strabismus) result from neuromuscular injury or inherited abnormalities. Tumors or inflammation of the orbit often cause abnormal eye protrusion. Inspect the eyebrows for size, extension, texture of hair, alignment, and movement. Inspect the eyelids for position; color; condition of the surface; condition and direction of the eyelashes; and the patient’s ability to open, close, and blink. An abnormal drooping of the lid over the pupil is called ptosis (pronounced “toe-sis”), caused by edema or impairment of the third cranial nerve. An older adult frequently has lid margins that turn out (ectropion) or in (entropion). Entropion sometimes leads to the lashes of the lid irritating the conjunctiva and cornea. An erythematous or yellow lump (hordeolum or sty) on the follicle of an eyelash indicates an acute suppurative inflammation. Tears flow from the lacrimal gland across the surface of the eye to the lacrimal duct, which is in the nasal corner or inner canthus of the eye. The lacrimal gland is sometimes the site of tumors or infections and should be inspected for edema and redness. Observe the sclera under the bulbar conjunctiva; it normally has the color of white porcelain in light-skinned patients and is light yellow in dark-skinned patients. Sclerae become pigmented and appear either yellow or green if liver disease is present. Normally the conjunctivae are free of erythema. The presence of redness indicates an allergic or infectious conjunctivitis. Bright red blood in a localized area surrounded by normal-appearing conjunctiva usually indicates subconjunctival hemorrhage. Conjunctivitis is a highly contagious infection, wear clean gloves and perform proper hand hygiene before and after the examination. The cornea is the transparent, colorless portion of the eye covering the pupil and iris. Any irregularity in the surface indicates an abrasion or tear that requires further examination by a health care provider. In an older adult, the iris becomes faded. A thin, white ring along the margin of the iris, called an arcus senilis, is common with aging, but is abnormal in anyone younger than age 40. [Shown at top is Figure 31-12: The lacrimal apparatus secretes and drains tears, which moisten and lubricate eye structures.] [Shown at bottom is Figure 31-13: Chart depicting pupillary size in millimeters.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Eyes (Cont.) External eye structure (Cont.) Pupils and irises PERRLA: pupils equal, round, reactive to light, and accommodation Observe the pupils for size, shape, equality, accommodation, and reaction to light. They are normally black, round, regular, and equal in size (3 to 7 mm in diameter.) Cloudy pupils indicate cataracts. Dilated pupils result from glaucoma, trauma, neurological disorders, eye medications (e.g., atropine), or withdrawal from opioids. Inflammation of the iris or use of drugs (e.g., pilocarpine, morphine, or cocaine) causes constricted pupils. Pinpoint pupils are a common sign of opioid intoxication. Shining a beam of light through the pupil and onto the retina stimulates the third cranial nerve, causing the muscles of the iris to constrict. Any abnormality along the nerve pathways from the retina to the iris alters the ability of the pupils to react to light. Changes in intracranial pressure, lesions along the nerve pathways, locally applied ophthalmic medications, and direct trauma to the eye alter pupillary reaction. Test pupillary reflexes (to light and accommodation) in a dimly lit room. Instruct the patient to avoid looking directly at the light. While the patient looks straight ahead, bring a penlight from the side of his or her face, directing the light onto the pupil. A directly illuminated pupil constricts, and the opposite pupil constricts consensually. Observe the quickness and equality of the reflex. Repeat the examination for the opposite eye. To test for accommodation, ask the patient to gaze at a distant object (the far wall) and then at a test object (finger or pencil) held approximately 10 cm (4 inches) from the bridge of his or her nose. The pupils normally converge and accommodate by constricting when looking at close objects. The pupillary responses are equal. Testing for accommodation is only important if the patient has a defect in the pupillary response to light (Ball et al., 2015). If assessment of pupillary reaction is normal in all tests, record the abbreviation PERRLA (pupils equal, round, reactive to light, and accommodation). [Shown is Figure 31-14: A, To check pupillary reflexes the nurse first holds the penlight to the side of the patient’s face. B, Illumination of the pupil causes pupillary constriction.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Eyes (Cont.) Internal eye structures Retina Choroid Optic nerve disc Macula Fovea centralis Retinal vessels The examination of the internal eye structures through the use of an ophthalmoscope is beyond the scope of new graduate nurses’ practice. Advanced nurse practitioners use the ophthalmoscope to inspect the fundus, which includes the retina, choroid, optic nerve disc, macula, fovea centralis, and retinal vessels. Patients in greatest need of an examination are those with diabetes, hypertension, and intracranial disorders. [Shown is Figure 31-15: Fundus of white patient (A) and black patient (B). (Courtesy MEDCOM, Cypress, Calif.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Ears Auricles Size Shape Symmetry Landmarks Position Color Discharge The three parts of the ear are the external, middle, and inner ear. Inspect and palpate external ear structures. The middle ear is inspected with an otoscope. Finally, the inner ear is tested by measuring the patient’s hearing acuity. Use nursing history data to identify patients’ risks for hearing disorders. [Review Table 31-14, Nursing History for Ear Assessment, with students.] With the patient sitting comfortably, inspect the size, shape, symmetry, landmarks, position, and color of the auricle. Palpate the auricles for texture, tenderness, and skin lesions. Auricles are normally smooth and without lesions. Inspect the opening of the ear canal for size and presence of discharge. If discharge is present, wear clean gloves. A swollen or occluded meatus is not normal. A yellow, waxy substance called cerumen is common. Yellow or green, foul-smelling discharge indicates infection or a foreign body. [Review Box 31-13, Patient Teaching: Ear Assessment, with students.] [Shown at top is Figure 31-16: Structures of external, middle, and inner ear.] [Shown at bottom is Figure 31-17: Anatomical structures of auricle.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Ears (Cont.) Ear canals and eardrums Color Discharge Scaling Lesions Foreign bodies Cerumen Observe the deeper structures of the external and middle ear with the use of an otoscope. A special ear speculum attaches to the handle of the ophthalmoscope. Before inserting the speculum, check for foreign bodies in the opening of the auditory canal. Make sure that the patient avoids moving the head during the examination to avoid damage to the canal and tympanic membrane. Infants and young children might need to be held securely to prevent movement. Turn on the otoscope by rotating the dial at the top of the handle. To insert the speculum properly, ask the patient to tip the head slightly toward the opposite shoulder. Hold the handle of the otoscope in the space between the thumb and index finger, supported on the middle finger. There are two ways to grip the otoscope: (1) hold the handle along the patient’s face with the fingers against the face or neck; or (2) lightly brace the inverted otoscope against the side of the patient’s head or cheek. This latter grip, used with children, prevents accidental movement of the otoscope deeper into the ear canal. Insert the scope while pulling the auricle upward and backward in the adult and older child. This maneuver straightens the ear canal. For infants the auricle should be pulled down and back. Insert the speculum slightly down and forward 1 to 1.5 cm (½ inch) into the ear canal. The ear canal normally has little cerumen and is uniformly pink with tiny hairs in the outer third of the canal. Observe for color, discharge, scaling, lesions, foreign bodies, and cerumen. Normally cerumen is dry (light brown to gray and flaky) or moist (dark yellow or brown) and sticky. Dry cerumen is common in Asians and Native Americans. A reddened canal with discharge is a sign of inflammation or infection. During the examination ask the patient about methods he or she uses to clean the ear canal. The light from the otoscope allows visualization of the tympanic membrane. Know the common anatomical landmarks and their appearances. A ring of fibrous cartilage surrounds the oval membrane. The umbo is near the center of the membrane, behind which is the attachment of the malleus. The underlying short process of the malleus creates a knoblike structure at the top of the drum. Check carefully to make sure that there are no tears or breaks in the membrane. The normal tympanic membrane is translucent, shiny, and pearly gray. A pink or red bulging membrane indicates inflammation. A white color reveals pus behind it. If cerumen is blocking the tympanic membrane, warm water irrigation safely removes the wax. [Shown at top is Figure 31-18: Otoscopic examination. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] [Shown is Figure 31-19: Normal right tympanic membrane. (Courtesy Dr. Richard A. Buckingham, Abraham Lincoln School of Medicine, University of Illinois, Chicago.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Ears (Cont.) Hearing acuity Three types of hearing loss (conduction, sensorineural, and mixed) Ototoxicity If a hearing loss is present, test the hearing using a tuning fork. A patient with a hearing loss often fails to respond to conversation. The three types of hearing loss are conduction, sensorineural, and mixed. A conduction loss interrupts sound waves as they travel from the outer ear to the cochlea of the inner ear because the sound waves are not transmitted through the outer and middle ear structures. For example, causes of a conduction loss include swelling of the auditory canal and tears in the tympanic membrane. A sensorineural loss involves the inner ear, auditory nerve, or hearing center of the brain. Sound is conducted through the outer and middle ear structures, but the continued transmission of sound becomes interrupted at some point beyond the bony ossicles. A mixed loss involves a combination of conduction and sensorineural loss. Patients working or living around loud noises are at risk for hearing loss. In addition, adolescents are at risk for premature hearing loss from continued exposure to loud music in their car or home or at concert events. Hearing loss among adolescents is increasing, especially among those with high levels of noise exposure such as from loud music. Older adults experience an inability to hear high-frequency sounds and consonants (e.g., S, Z, T, and G). Deterioration of the cochlea and thickening of the tympanic membrane cause older adults to gradually lose hearing acuity. They are especially at risk for hearing loss caused by ototoxicity (injury to auditory nerve) resulting from high maintenance doses of antibiotics (e.g., aminoglycosides). To conduct a hearing assessment, have the patient remove any hearing aid if worn. Note his or her response to questions. Normally he or she responds without excessive requests to have the questions repeated. If a hearing loss is suspected, check the patient’s response to the whispered voice. Test one ear at a time while the patient occludes the other ear with a finger. Ask him or her to gently move the finger up and down during the test in response to the whispered sound. While standing 31 to 60 cm (1 to 2 feet) from the testing ear, speak while covering the mouth so the patient is unable to read lips. After exhaling fully, whisper softly toward the unoccluded ear, reciting random numbers with equally accented syllables such as nine-four-ten. If necessary, gradually increase voice intensity until the patient correctly repeats the numbers. Then test the other ear for comparison. Ball et al. (2015) report that patients normally hear numbers clearly when whispered, responding correctly at least 50% of the time. If a hearing loss is present, test the hearing using a tuning fork. A tuning fork of 256 to 512 hertz (Hz) is most commonly used. The tuning fork allows for comparison of hearing by bone conduction with that of air conduction. Hold the base of the tuning fork with one hand without touching the tines. Tap the fork lightly against the palm of the other hand to set the fork in vibration. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Tuning Fork Tests Weber’s test Hold fork at base and tap it lightly against heel of palm. Place base of vibrating fork on midline vertex of patient’s head or middle of forehead. Ask patient if he or she hears the sound equally in both ears or better in one ear (lateralization). This test is done for lateralization of sound. Patient with normal hearing hears sound equally in both ears. In conduction deafness, sound is heard best in impaired ear. In sensorineural hearing loss, sound is heard better in normal ear. [Review Table 31-15, Tuning Fork Tests, with students.] [Shown is Figure A from Table 31-15: Tuning Fork Tests.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Tuning Fork Tests (Cont.)
Rinne test Place stem of vibrating tuning fork against patient’s mastoid process. Begin counting the interval using watch. Ask patient to tell you when she no longer hears the sound; note number of seconds. This test is done for comparison of air and bone conduction. [Shown is Figure B from Table 31-15: Tuning Fork Tests.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Tuning Fork Tests (Cont.)
Rinne test Quickly place still-vibrating tines 1 to 2 cm (1/2 to 1 inch) from ear canal, and ask patients to tell you when they no longer hear the sound. Continue counting time the sound is heard by air conduction. Compare number of seconds the sound is heard by bone conduction versus air conduction. Patient should hear air-conducted sound twice as long as bone-conducted sound (2:1 ratio). For example, if patient hears bone-conducted sound for 10 seconds, he or she should hear air-conducted sound for an additional 10 seconds. In conduction deafness, patient hears bone conduction longer than air conduction in affected ear. In sensorineural loss, patient hears air conduction longer than bone conduction in affected ear, but at less than a 2:1 ratio. [Shown is Figure C from Table 31-15: Tuning Fork Tests.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nose and Sinuses Nose Excoriation Polyps
Assess by inspection and palpation Observe shape, symmetry, color, deformities, patency, tenderness, deviation, lesions, discharge, swelling, and signs of bleeding Assess the integrity of the nose and sinuses by using inspection and palpation. A more detailed examination requires use of a nasal speculum to inspect the deeper nasal turbinates. Do not use a speculum unless a qualified practitioner such as a nurse educator or an advanced practice nurse is present. [Review Table 31-16, Nursing History for Nose and Sinus Assessment, with students.] When inspecting the external nose, observe for shape, size, skin, color, and the presence of deformity or inflammation. Recent trauma sometimes causes edema and discoloration. Note any tenderness, masses, or underlying deviations. Nasal structures are usually firm and stable. To assess patency of the nares, place a finger on the side of the patient’s nose and occlude one naris. Ask the patient to breathe with the mouth closed. Repeat the procedure for the other naris. While illuminating the anterior nares, inspect the mucosa for color, lesions, discharge, swelling, and evidence of bleeding. If discharge is present, apply gloves. To view the septum and turbinates, have the patient tip the head back slightly to provide a clear view. Illuminate the septum and observe for alignment, perforation, or bleeding. A deviated septum obstructs breathing and interferes with passage of a nasogastric tube. Perforation of the septum often occurs after repeated use of intranasal cocaine. Note any polyps (tumorlike growths) or purulent drainage. Examination of the sinuses involves palpation. In cases of allergies or infection, the interior of the sinuses becomes inflamed and swollen. The most effective way to assess for tenderness is by externally palpating the frontal and maxillary facial areas. Palpate the frontal sinus by exerting pressure with the thumb up and under the patient’s eyebrow. Gentle, upward pressure elicits tenderness easily if sinus irritation is present. Do not apply pressure to the eyes. If sinus tenderness is present, the sinuses may be transilluminated. However this procedure requires advanced experience. [Review Box 31-14, Patient Teaching: Nose and Sinus Assessment, with students.] [Shown is Figure 31-20: Palpation of maxillary sinuses.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Palpation of Maxillary Sinuses
Assess by palpation Assess for tenderness Copyright © 2017, Elsevier Inc. All Rights Reserved.

Mouth and Pharynx Lips Color Texture Hydration Contour Lesions Oral hygiene, lips, buccal mucosa, gums, teeth, tongue, floor of the mouth, and palate Assess the mouth and pharynx to detect signs of overall health; determine oral hygiene needs; and determine therapies needed for patients with dehydration, restricted intake, oral trauma, or oral airway obstruction. To assess the oral cavity use a penlight and tongue depressor or gauze square. Wear clean gloves during the examination. [Review Table 31-17, Nursing History for Mouth and Pharyngeal Assessment, with students.] Inspect the lips for color, texture, hydration, contour, and lesions. With the patient’s mouth closed, view the lips from end to end. Normally they are pink, moist, symmetrical, and smooth. Lip color in the dark-skinned patient varies from pink to plum. Have female patients remove their lipstick before the examination. Anemia causes pallor of the lips, with cyanosis caused by respiratory or cardiovascular problems. Cherry-colored lips indicate carbon monoxide poisoning. Any lesions should be evaluated for the potential of being an infection, irritation, or skin cancer. [Shown is Figure 31-21: Lips are normally pink, symmetrical, smooth, and moist.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Mouth and Pharynx (Cont.)
Buccal mucosa Gums Teeth Ask the patient to clench the teeth and smile to observe teeth occlusion. The upper molars normally rest directly on the lower molars, and the upper incisors slightly override the lower incisors. A symmetrical smile reveals normal facial nerve function. Inspect the teeth to determine the quality of dental hygiene. Note the position and alignment of the teeth. To examine the posterior surface of the teeth, have the patient open the mouth with the lips relaxed. Use a tongue depressor to retract the lips and cheeks, especially when viewing the molars. Note the color of teeth and presence of dental caries (cavities), tartar, and extraction sites. Normal, healthy teeth are smooth, white, and shiny. A chalky white discoloration of the enamel is an early indication of caries formation. Brown or black discolorations indicate the formation of caries. A stained yellow color is from tobacco use; coffee, tea, and colas cause a brown stain. In the older adult loose or missing teeth are common because bone resorption increases. An older adult’s teeth often feel rough when tooth enamel calcifies. Yellow or darkened teeth are also common in the older adult because of the general wear and tear that exposes the darker underlying dentin. [Review Box 31-15, Patient Teaching: Mouth and Pharyngeal Assessment, with students.] To view the mucosa and gums, ask the patient to first remove any dental appliance. View the inner oral mucosa by having the patient open and relax the mouth slightly and then gently retract his or her lower lip away from the teeth. Repeat this process for the upper lip. Inspect the mucosa for color; hydration; texture; and lesions such as ulcers, abrasions, or cysts. Normally the mucosa is glistening, pink, smooth, and moist. Some common small, yellow-white raised lesions on the buccal mucosa and lips are Fordyce spots, or ectopic sebaceous glands (Ball et al., 2015). If lesions are present, palpate them gently with a gloved hand for tenderness, size, and consistency. To inspect the buccal mucosa, ask the patient to open the mouth and then gently retract the cheeks with a tongue depressor. View the surface of the mucosa from right to left and top to bottom. A penlight illuminates the most posterior portion of the mucosa. Normal mucosa is glistening, pink, soft, moist, and smooth. Varying shades of hyperpigmentation are normal in 10% of whites after age 50 and in up to 90% of blacks by the same age. For patients with normal pigmentation, the buccal mucosa is a good site to inspect for jaundice and pallor. In older adults, the mucosa is normally dry because of reduced salivation. Thick white patches (leukoplakia) are often a precancerous lesion seen in heavy smokers and alcoholics. Palpate for any buccal lesions by placing the index finger within the buccal cavity and the thumb on the outer surface of the cheek. Patients who smoke cigarettes, cigars, or pipes, and those who use smokeless tobacco have an increased risk of oral, pharyngeal, laryngeal, and esophageal cancer. These individuals may have leukoplakia or other lesions anywhere in their oral cavity (e.g., lips, gums, or tongue) at an early age. Inspect the gums (gingivae) for color, edema, retraction, bleeding, and lesions while retracting the cheeks. Healthy gums are pink, smooth, and moist and fit tightly around each tooth. Dark-skinned patients often have patchy pigmentation. In older adults, the gums are usually pale. Using clean gloves, palpate the gums to assess for lesions, thickening, or masses. Normally there is no tenderness. Spongy gums that bleed easily indicate periodontal disease and vitamin C deficiency. If the patient has loose or mobile teeth, swollen gums, or pockets containing debris at the tooth margins, a dental referral should be considered to check for periodontal disease or gingivitis. [Shown at top is Figure 31-22: Inspection of inner oral mucosa of lower lip.] [Shown at bottom is Figure 31-23: Retraction of buccal mucosa allows for clear visualization.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Tongue Floor of mouth Carefully inspect the tongue on all sides and the floor of the mouth. Have the patient relax the mouth and stick the tongue out halfway. Note any deviation, tremor, or limitation in movement. This tests hypoglossal nerve function. If the patient protrudes the tongue too far, it elicits the gag reflex. When the tongue protrudes, it lays midline. To test for tongue mobility, ask the patient to raise it up and move it from side to side. It should move freely. Using a penlight for illumination, examine the tongue for color, size, position, texture, and coatings or lesions. A normal tongue is medium or dull red in color, moist, slightly rough on the top surface, and smooth along the lateral margins. The undersurface of the tongue and the floor of the mouth are highly vascular. Take extra care to inspect this area, a common site for oral cancer lesions. The patient lifts the tongue by placing its tip on the palate behind the upper incisors. Inspect for color, swelling, and lesions such as nodules or cysts. The ventral surface of the tongue is pink and smooth, with large veins between the frenulum folds. To palpate the tongue, explain the procedure and ask the patient to protrude it. Grasp the tip with a gauze square and gently pull it to one side. With a gloved hand palpate the full length of the tongue and the base for any areas of hardening or ulceration. Varicosities (swollen, tortuous veins) are common in the older adult and rarely cause problems. [Shown is Figure 31-24: The undersurface of the tongue is highly vascular.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Palate Hard Soft Pharynx Examine to rule out infection, inflammation and lesions Inspect the uvula, soft palate, tonsils, edema, petechiae, and exudate Have the patient extend the head backward, holding the mouth open to inspect the hard and soft palates. The hard palate, or roof of the mouth, is located anteriorly. The whitish hard palate is dome shaped. The soft palate extends posteriorly toward the pharynx. It is normally light pink and smooth. Observe the palates for color, shape, texture, and extra bony prominences or defects. A bony growth, or exostosis, between the two palates is common. Perform an examination of pharyngeal structures to rule out infection, inflammation, or lesions. Have the patient tip the head back slightly, open the mouth wide, and say “ah” while you place the tip of a tongue depressor on the middle third of the tongue. Take care not to press the lower lip against the teeth. By placing the tongue depressor too far anteriorly, the posterior part of the tongue mounds up, obstructing the view. Placing the tongue depressor on the posterior tongue elicits the gag reflex. With a penlight, first inspect the uvula and soft palate. Both structures, which are innervated by the tenth cranial (vagus) nerve, should rise centrally as the patient says “ah.” Examine the anterior and posterior pillars, soft palate, and uvula. View the tonsils in the cavities between the anterior and posterior pillars and note the presence or absence of tissue. The posterior pharynx is behind the pillars. Normally pharyngeal tissues are pink and smooth and well hydrated. Small irregular spots of lymphatic tissue and small blood vessels are normal. Note edema, petechiae (small hemorrhages), lesions, or exudate. The back of the pharynx is a common site for oral cancer (Oral Cancer Foundation, 2014). Patients with chronic sinus problems frequently exhibit a clear exudate that drains along the wall of the posterior pharynx. Yellow or green exudate indicates infection. A patient with a typical sore throat has a red and edematous uvula and tonsillar pillars with possible presence of yellow exudate. [Shown at top is Figure 31-25: The hard palate is located anteriorly in the roof of the mouth.] [Shown at bottom is Figure 31-26: A penlight and tongue depressor allow the visualization of the uvula and posterior soft palate.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Neck Neck muscles Anterior triangle Posterior triangle Assessment of the neck includes assessing the neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid gland, and trachea. You may postpone the examination of the jugular veins and carotid arteries until the vascular system assessment. Inspect and palpate the neck to determine the integrity of its structures and examine the lymphatic system. An abnormality of superficial lymph nodes sometimes reveals the presence of an infection or malignancy. Examine the lymphatic system region by region during the assessment of other body systems (head and neck, breast, genitalia, and extremities). Examination of the thyroid gland and trachea also aids in ruling out malignancies. Perform this examination with the patient sitting. The sternocleidomastoid and trapezius muscles outline the areas of the neck, dividing each side of the neck into two triangles. The anterior triangle contains the trachea, thyroid gland, carotid artery, and anterior cervical lymph nodes. The posterior triangle contains the posterior lymph nodes. [Review Table 31-18, Nursing History for Neck Assessment, with students.] First inspect the neck in the usual anatomical position, with slight hyperextension. Observe for symmetry of the neck muscles. Ask the patient to flex the neck with the chin to the chest, hyperextend the neck backward, and move the head laterally to each side and then sideways with the ear moving toward the shoulder. This tests the sternocleidomastoid and trapezius muscles. The neck normally moves without discomfort. Perform other tests for muscle strength and function during assessment of the musculoskeletal system. [Shown is Figure 31-27: Anatomical position of major neck structures. Note triangles formed by the sternocleidomastoid muscle, lower jaw, and anterior neck anteriorly and the sternocleidomastoid muscle, trapezius muscle, and lower neck posteriorly.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Neck (Cont.) Lymph nodes Inspection An extensive system of lymph nodes collects lymph from the head, ears, nose, cheeks, and lips. The immune system protects the body from foreign antigens, removes damaged cells from the circulation, and provides a partial barrier to growth of malignant cells within the body. Assessing the lymph nodes requires competence when caring for patients with suspected immunoincompetence, which is often linked to allergies, human immunodeficiency virus (HIV) infection, autoimmune disease (e.g., lupus erythematosus), or serious infection. With the patient’s chin raised and head tilted slightly, first inspect the area where lymph nodes are distributed and compare both sides. This position stretches the skin slightly over any possible enlarged nodes. Inspect visible nodes for edema, erythema, or red streaks. Nodes are not normally visible. [Shown is Figure 31-28: Palpable lymph nodes in the head and neck. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Neck Lymph nodes (Cont.) Palpation Face the patient Use a methodical approach Inspect and palpate both sides of neck for comparison Tenderness almost always indicates inflammation. During palpation either face or stand to the side of the patient for easy access to all nodes. Use the pads of the middle three fingers of each hand to gently palpate in a circular motion over the nodes. Check each node methodically in the following sequence: occipital nodes at the base of the skull, postauricular nodes over the mastoid, preauricular nodes just in front of the ear, retropharyngeal nodes at the angle of the mandible, submandibular nodes, and submental nodes in the midline behind the mandibular tip. Try to detect enlargement and note the location, size, shape, surface characteristics, consistency, mobility, tenderness, and warmth of the nodes. If the skin is mobile, move it over the area of the nodes. It is important to press underlying tissue in each area and not simply move the fingers over the skin. However, if you apply excessive pressure, you miss small nodes and destroy palpable nodes. To palpate supraclavicular nodes, ask the patient to bend the head forward and relax the shoulders. Palpate these nodes by hooking the index and third finger over the clavicle lateral to the sternocleidomastoid muscle. Palpate the deep cervical nodes only with the fingers hooked around the sternocleidomastoid muscle. Normally lymph nodes are not easily palpable. However, small, mobile, nontender nodes are common. Lymph nodes that are large, fixed, inflamed, or tender indicate a problem such as local infection, systemic disease, or neoplasm. [Review Box 31-16, Patient Teaching: Neck Assessment, with students.] When you find enlarged nodes, explore the adjacent areas and regions drained by the nodes. A problem involving a lymph node of the head and neck means an abnormality in the mouth, throat, abdomen, breasts, thorax, or arms. These are the areas drained by the head and neck nodes. [Shown is Figure 31-29: Supraclavicular lymph node palpation.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Neck (Cont.) Thyroid gland Carotid artery and jugular vein Trachea The thyroid gland lies in the anterior lower neck, in front of and to both sides of the trachea. The gland is fixed to the trachea, with the isthmus overlying the trachea and connecting the two irregular, cone-shaped lobes. Inspect the lower neck overlying the thyroid gland for obvious masses, symmetry, and any subtle fullness at the base of the neck. Ask the patient to hyperextend the neck, which helps tighten the skin for better visualization. Offer the patient a glass of water, and, while observing the neck, have him or her swallow. This maneuver helps to visualize an abnormally enlarged thyroid. Normally the thyroid cannot be visualized. Advanced practice nurses examine the thyroid by palpating for more subtle masses; this technique is not discussed here. The carotid artery and jugular vein portion of the examination is described under examination of the vascular system (see later section). The trachea is a part of the upper respiratory system that you directly palpate. It is normally located in the midline above the suprasternal notch. Masses in the neck or mediastinum and pulmonary abnormalities cause displacement laterally. Have the patient sit or lie down during palpation. Determine the position of the trachea by palpating at the suprasternal notch, slipping the thumb and index fingers to each side. Note if the finger and thumb shift laterally. Do not apply forceful pressure because this elicits coughing. [Shown is Figure 31-30: Anatomical position of thyroid gland.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Thorax and Lungs Examination Accurate physical assessment of the thorax and lungs requires review of the ventilatory and respiratory functions of the lungs. If disease is affecting the lungs, it affects other body systems as well. For example, reduced oxygenation causes changes in mental alertness because of the sensitivity of the brain to lowered oxygen levels. Use data from all body systems to determine the nature of pulmonary alterations. You will use inspection, palpation, and auscultation to examine the thorax and lungs. Diagnostic equipment such as x-ray films, magnetic resonance imaging (MRI), and computed tomography (CT) scans create little need for the use of percussion as an assessment measure. Risk factors for lung disease are reviewed at the time of respiratory assessment. [Review Box 31-17, Patient Teaching: Lung Assessment, with students.] Before assessing the thorax and lungs, be familiar with the landmarks of the chest. These landmarks help you identify findings and use assessment skills correctly. The patient’s nipples, angle of Louis, suprasternal notch, costal angle, clavicles, and vertebrae are key landmarks that provide a series of imaginary lines for sign identification. [Shown is Figure 31-31: Anatomical chest wall landmarks. A, Posterior chest landmarks. B, Lateral chest landmarks. C, Anterior chest landmarks.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Thorax and Lungs (Cont.)
Identify anatomical landmarks. Keep a mental image of the location of the lobes of the lung and the position of each rib. The proper orientation to anatomical structures ensures a thorough assessment of the anterior, lateral, and posterior thorax. Locating the position of each rib is critical to visualizing the lobe of the lung being assessed. To begin, locate the angle of Louis at the manubriosternal junction. The angle is a visible and palpable angulation of the sternum and is the point at which the second rib articulates with the sternum. Count the ribs and intercostal spaces (between the ribs) from this point. The number of each intercostal space corresponds with that of the rib just above it. The spinous process of the third thoracic vertebra and the fourth, fifth, and sixth ribs help to locate the lobes of the lung laterally. The lower lobes project laterally and anteriorly. Posteriorly the tip or inferior margin of the scapula lies approximately at the level of the seventh rib. After identifying the seventh rib, count upward to locate the third thoracic vertebra and align it with the inner borders of the scapula to locate the posterior lobes. The examination requires the patient to be undressed to the waist, with good lighting. Assess patients at risk for pulmonary problems such as the patient confined to bed rest or with chest pain who cannot fully expand the lungs. The examination begins with the patient sitting for assessment of the posterior and lateral chest. Have him or her sit or lie down for assessment of the anterior chest. [Review Table 31-19, Nursing History for Lung Assessment, with students.] [Shown is Figure 31-32: Position of lung lobes in relation to anatomical landmarks. A, Anterior position. B, Lateral position. C, Posterior position. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Posterior thorax Begin examination of the posterior thorax by observing for any signs or symptoms in other body systems that indicate pulmonary problems. Reduced mental alertness, nasal flaring, somnolence, and cyanosis are examples of assessed signs that indicate oxygenation problems. Inspect the posterior thorax by observing the shape and symmetry of the chest from the patient’s back and front. Note the anteroposterior diameter. Body shape or posture significantly impairs ventilatory movement. Normally the chest contour is symmetrical, with the anteroposterior diameter one-third to one-half of the transverse, or side-to-side, diameter. A barrel-shaped chest (anteroposterior diameter equals transverse diameter) characterizes aging and chronic lung disease. Infants have an almost round shape. Congenital and postural alterations cause abnormal contours. Some patients lean over a table or splint the side of the chest because of a breathing problem. Splinting or holding the chest wall because of pain causes a patient to bend toward the side affected. Such a posture impairs ventilatory movement. Standing at a midline position behind the patient, look for deformities, position of the spine, slope of the ribs, retraction of the intercostal spaces during inspiration, and bulging of the intercostal spaces during expiration. The scapulae are normally symmetrical and closely attached to the thoracic wall. The normal spine is straight without lateral deviation. Posteriorly the ribs tend to slope across and down. The ribs and intercostal spaces are easier to see in a thin person. Normally no bulging or active movement occurs within the intercostal spaces during breathing. Bulging indicates that the patient is using great effort to breathe. Also assess the rate and rhythm of breathing. Observe the thorax as a whole. It normally expands and relaxes regularly with equality of movement bilaterally. In healthy adults, the normal respiratory rates vary from 12 to 20 respirations per minute. Palpation of the posterior thorax provides further information about a patient’s health status. Palpate the thoracic muscles and skeleton for lumps, masses, pulsations, and unusual movement. If the patient voices pain or tenderness, avoid deep palpation. Fractured rib fragments could be displaced against vital organs. Normally the chest wall is not tender. If there is a suspicious mass or swollen area, lightly palpate it for size, shape, and the typical qualities of a lesion. To measure chest excursion or depth of breathing, stand behind the patient and place the thumbs along the spinal processes at the tenth rib, with the palms lightly contacting the posterolateral surfaces. Place thumbs 5 cm (2 inches) apart, pointing toward the spine with fingers pointing laterally. Press the hands toward the spine so a small skinfold appears between the thumbs. Do not slide the hands over the skin. Instruct the patient to exhale and then take a deep breath. Note movement of the thumbs during inhalation. Chest excursion is symmetrical, separating the thumbs 3 to 5 cm (1¼ to 2 inches). Reduced chest excursion may be caused by pain, postural deformity, or fatigue. In older adults chest movement normally declines because of costal cartilage calcification and respiratory muscle atrophy. [Shown is Figure 31-33: A, Hand position for palpation of posterior thorax excursion. B, As patient inhales, movement of chest excursion separates thumbs.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Tactile fremitus Created by vocal cords Transmitted through lungs to chest wall Palpation During speech the sound created by the vocal cords is transmitted through the lung to the chest wall. The sound waves create vibrations that you palpate externally. These vibrations are called vocal or tactile fremitus. The accumulation of mucus, the collapse of lung tissue, or the presence of one or more lung lesions blocks the vibrations from reaching the chest wall. To palpate for tactile fremitus, place the palmar surfaces of the fingers or the ulnar part of the hand over symmetrical intercostal spaces, beginning at the lung apex and using a firm, light touch. Ask the patient to say “ninety-nine” or “one-one-one.” Palpate both sides simultaneously and symmetrically (from top to bottom) for comparison or use one hand, quickly alternating between the two sides (Ball et al., 2015). Normally a faint vibration is present as the patient speaks. If fremitus is faint, ask the patient to speak in a louder or lower tone of voice. Normally fremitus is symmetrical. Vibrations are strongest at the top, near the level of the tracheal bifurcation. Strong vibrations through the chest wall occur in crying infants. Auscultation assesses the movement of air through the tracheobronchial tree and detects mucus or obstructed airways. Normally air flows through the airways in an unobstructed pattern. Recognizing the sounds created by normal airflow allows you to detect sounds caused by airway obstruction. Follow the same systematic approach when listening that was used for palpation. [Shown is Figure 31-34: A to C, A systematic pattern (posterior-lateral-anterior) is followed when palpating and auscultating the thorax.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Auscultation Normal breath sounds Abnormal or adventitious sounds Crackles Rhonchi Wheezes Pleural friction rub Place the diaphragm of the stethoscope firmly on the skin, over the posterior chest wall between the ribs. The patient folds the arms in front of the chest and keeps the head bent forward while taking slow, deep breaths with the mouth slightly open. Listen to an entire inspiration and expiration at each position of the stethoscope. If sounds are faint, as in the obese patient, ask the patient to breathe harder and faster temporarily. Breath sounds are much louder in children because of their thin chest walls. The bell works best in children because of a child’s small chest. Auscultate for normal breath sounds and abnormal or adventitious sounds. Normal breath sounds differ in character, depending on the area you are auscultating. Bronchovesicular and vesicular sounds are normally heard over the posterior thorax. [Review Table 31-20, Normal Breath Sounds, with students.] Abnormal sounds result from air passing through moisture, mucus, or narrowed airways. They also result from alveoli suddenly reinflating or an inflammation between the pleural linings of the lung. Adventitious sounds often occur superimposed over normal sounds. The four types of adventitious sounds are crackles, rhonchi, wheezes, and pleural friction rub. A specific entity causes each sound, and each has typical auditory features. During auscultation note the location and characteristics of the sounds and listen for the absence of breath sounds (found in patients with collapsed or surgically removed lobes). Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Medium crackles are lower, moister sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing. Crackles are caused by random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways. Rhonchi are loud, low-pitched, rumbling coarse sounds heard either during inspiration or expiration; sometimes cleared by coughing. Rhonchi are caused by muscular spasms, fluid, or mucus in larger airways; new growth or external pressure causing turbulence. Wheezes are high-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration; usually louder on expiration. Wheezes are caused by high-velocity airflow through severely narrowed or obstructed airways. Pleural friction rub is a dry, rubbing, or grating quality heard during inspiration or expiration; does not clear with coughing; heard loudest over lower lateral anterior surface. Pleural friction rub is caused by inflamed pleura; parietal pleura rubbing against visceral pleura. [Review Table 31-21, Adventitious Breath Sounds, with students.] If there are abnormalities in tactile fremitus or auscultation, perform the vocal resonance tests (spoken and whispered voice sounds). Place the stethoscope over the same locations used to assess breath sounds and have the patient say “ninety-nine” in a normal voice tone. Normally the sound is muffled. If fluid is compressing the lung, the vibrations from the patient’s voice are transmitted to the chest wall, and the sound becomes clear (bronchophony). Then ask the patient to whisper “ninety-nine.” The whispered voice is usually faint and indistinct. Certain lung abnormalities cause the whispered voice to become clear and distinct (whispered pectoriloquy). [Shown is Figure 31-35: Use the diaphragm of the stethoscope to auscultate breath sounds.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 3. A patient is admitted with pneumonia. When auscultating the patient’s chest, you hear low-pitched, continuous sounds over the bronchi. These sounds are labeled as: A. crackles. B. rhonchi. C. wheezes. D. pleural rub. Answer: B Rationale: Rhonchi are loud, low-pitched, rumbling coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing. Rhonchi are caused by muscular spasms, fluid, or mucus in larger airways; new growth or external pressure causing turbulence. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Lateral thorax Vesicular sounds Anterior thorax Observe accessory muscles. Palpate muscles and skeleton. Assess tactile fremitus. Compare right and left sides. Auscultate for bronchial sounds. Extend the assessment of the posterior thorax to the lateral sides of the chest. The patient sits during examination of the lateral chest. Have the patient raise the arms to improve access to lateral thoracic structures. Use inspection, palpation, and auscultation skills to examine the lateral thorax. Do not assess excursion laterally. Normally the breath sounds you hear are vesicular. Inspect the anterior thorax for the same features as the posterior thorax. The patient sits or lies down with the head elevated. Observe the accessory muscles of breathing: sternocleidomastoid, trapezius, and abdominal muscles. The accessory muscles move little with normal passive breathing. However, patients who use a great deal of effort to breathe as a result of strenuous exercise or pulmonary disease (e.g., chronic obstructive pulmonary disease) rely on the accessory and abdominal muscles to contract, thereby leading to inspiration and expiration. Some patients who require great effort produce a grunting sound. Observe the width of the costal angle. It is usually larger than 90 degrees between the two costal margins. Observe the breathing pattern. Normal breathing is quiet and barely audible near the open mouth. You most often assess respiratory rate and rhythm anteriorly. The male patient’s respirations are usually diaphragmatic, whereas a female’s are more costal. Accurate assessment occurs as the patient breathes passively. Palpate the anterior thoracic muscles and skeleton for lumps, masses, tenderness, or unusual movement. The sternum and xiphoid are relatively inflexible. Place the thumbs parallel approximately along the costal margin 6 cm (2½ inches) apart with the palms touching the anterolateral chest. Push the thumbs toward the midline to create a skinfold. As the patient inhales deeply, the thumbs normally separate approximately 3 to 5 cm (1¼ to 2 inches), with each side expanding equally. Assess tactile fremitus over the anterior chest wall. Anterior findings differ from posterior findings because of the heart and female breast tissue. Fremitus is felt next to the sternum at the second intercostal space, at the level of the bronchial bifurcation. It decreases over the heart, lower thorax, and breast tissue. Auscultation of the anterior thorax follows a systematic pattern comparing right and left sides. This is important so lung sounds in one region on one side of the body can be compared with sounds in the same region on the opposite side of the body. If possible, have the patient sit to maximize chest expansion. Give special attention to the lower lobes, where mucus secretions commonly gather. Listen for bronchovesicular and vesicular sounds above and below the clavicles and along the lung periphery. In addition, auscultate for bronchial sounds, which are loud, high pitched, and hollow sounding, with expiration lasting longer than inspiration (3:2 ratio). This sound is normally heard over the trachea. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) During her lung assessment, Jane recognizes that there is a patient-teaching opportunity with Mr. Neal. What issue does Jane need to address? [Ask students: What patient-teaching strategies would you use with regard to Mr. Neal’s smoking? Discuss: Explain to Mr. Neal the risk factors for chronic lung disease and lung cancer, including cigarette smoking, history of smoking for more than 20 years, exposure to environmental pollution, and radiation exposure from occupational, medical, and environmental sources. Exposure to residential radon and asbestos also increases risk, especially for cigarette smokers. Other risk factors include certain metals (arsenic, cadmium), some organic chemicals, and tuberculosis. Exposure to secondhand cigarette smoke increases risk for nonsmokers. Share brochures on lung cancer from the American Cancer Society with Mr. Neal and family. Mr. Neal could benefit from receiving this information before discharge from the hospital. Discuss with Mr. Neal the warning signs of lung cancer, such as a persistent cough, blood-streaked sputum, chest pains, and recurrent attacks of pneumonia or bronchitis. Counsel Mr. Neal and his wife on the benefits of receiving influenza and pneumonia vaccinations as appropriate because of greater susceptibility to respiratory infection. Instruct patients with chronic obstructive pulmonary disease (COPD) in coughing and pursed-lip breathing exercises. Refer persons at risk for tuberculosis who visit clinics or health care centers for skin testing.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Heart (Cont.) Compare assessment of heart functions with vascular findings. Assess point of maximal impulse (PMI). Locate anatomical landmarks. Compare the assessment of heart function with findings from the vascular assessment (see later section). Alterations in either system sometimes manifest as changes in the other. Some patients with signs or symptoms of heart (cardiac) problems have a life-threatening condition requiring immediate attention. In this case act, quickly and conduct only the portions of the examination that are absolutely necessary. Conduct a more thorough assessment when the patient is more stable. The nursing history provides data to help interpret physical findings. [Review Table 31-22, Nursing History for Heart Assessment, with students.] Assess cardiac function through the anterior thorax. Form a mental image of the exact location of the heart. In the adult, it is located in the center of the chest (precordium), behind and to the left of the sternum, with a small section of the right atrium extending to the right of the sternum. The base of the heart is the upper portion, and the apex is the bottom tip. The surface of the right ventricle composes most of the anterior surface of the heart. A section of the left ventricle shapes the left anterior side of the apex. The apex actually touches the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line. This is the apical impulse or point of maximal impulse (PMI). An infant’s heart is positioned more horizontally. The apex of the heart is at the third or fourth intercostal space, just to the left of the midclavicular line. By the age of 7 years, a child’s PMI is in the same location as the adult’s. In tall, slender persons the heart hangs more vertically and is positioned more centrally. In shorter or stockier individuals the heart tends to lie more to the left and horizontally. [Shown is Figure 31-36: Anatomical position of heart.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Heart (Cont.) Heart sounds S1 S2 S3 S4 To assess heart function, a clear understanding of the cardiac cycle and associated physiological events is of utmost importance. The heart normally pumps blood through its four chambers in a methodical, even sequence. Events on the left side occur just before those on the right. As blood flows through each chamber, the valves open and close, the pressures within chambers rise and fall, and the chambers contract. Each event creates a physiological sign. Both sides of the heart function in a coordinated fashion. There are two phases to the cardiac cycle: systole and diastole. During systole the ventricles contract and eject blood from the left ventricle into the aorta and from the right ventricle into the pulmonary artery. During diastole the ventricles relax, and the atria contract to move blood into the ventricles and fill the coronary arteries. Heart sounds occur in relation to physiological events in the cardiac cycle. As systole begins, ventricular pressure rises and closes the mitral and tricuspid valves. Valve closure causes the first heart sound (S1), often described as “lub.” The ventricles then contract, and blood flows through the aorta and pulmonary circulation. After the ventricles empty, ventricular pressure falls below that in the aorta and pulmonary artery. This allows the aortic and pulmonic valves to close, causing the second heart sound (S2), described as “dub.” As ventricular pressure continues to fall, it drops below that of the atria. The mitral and tricuspid valves reopen to allow ventricular filling. When the heart attempts to fill an already distended ventricle, a third heart sound (S3) can be heard, as with heart failure. An S3 is considered abnormal in adults over 31 years of age but can often be heard normally in children and young adults. It can also be present among women in the late stages of pregnancy. A fourth heart sound (S4) occurs when the atria contract to enhance ventricular filling. An S4 is often heard in healthy older adults, children, and athletes; but it is not normal in adults. Because S4 also indicates an abnormal condition, report it to a health care provider. [Shown is Figure 31-37: Cardiac cycle. AVC, Aortic valve closes; AVO, aortic valve opens; ECG, electrocardiogram; MVC, mitral valve closes; MVO, mitral valve opens.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Heart (Cont.) Inspection and palpation Patient must be relaxed and comfortable Inspect and palpate simultaneously PMI Make the patient relaxed and comfortable before the examination. Explain the procedure to relieve his or her anxiety. [Ask students: Why does your patient need to be relaxed and comfortable? Discuss: An anxious or uncomfortable patient has mild tachycardia, which leads to inaccurate findings.] Use the skills of inspection and palpation simultaneously. Begin the examination with the patient in the supine position or the upper body elevated 45 degrees because patients with heart disease frequently suffer shortness of breath while lying flat. Stand at the patient’s right side. Do not let the patient talk, especially when auscultating heart sounds. Good lighting in the room is essential. Direct your attention to the anatomical sites best suited for assessment of cardiac function. During inspection and palpation look for visible pulsations and exaggerated lifts and palpate for the apical impulse and any source of vibrations (thrills). Follow an orderly sequence, beginning with assessment of the base of the heart and moving toward the apex. First inspect the angle of Louis, which lies between the sternal body and manubrium, and feel the ridge in the sternum approximately 5 cm (2 inches) below the sternal notch. Slip the fingers along the angle on each side of the sternum to feel adjacent ribs. The intercostal spaces are just below each rib. The second intercostal space allows identification of each of the six anatomical landmarks. The second intercostal space on the right is the aortic area, and the left second intercostal space is the pulmonic area. You need to use deeper palpation to feel the spaces in obese or heavily muscled patients. After locating the pulmonic area, move the fingers down the patient’s left sternal border to the third intercostal space, called the second pulmonic area. The tricuspid area is located at the fourth or fifth intercostal space along the sternum. To find the apical or mitral area, locate the fifth intercostal space just to the left of the sternum and move the fingers laterally to the left midclavicular line. Locate the apical area with the palm of the hand or the fingertips. Normally you feel the apical impulse as a light tap in an area 1 to 2 cm (½ to ¾ inch) in diameter at the apex. Another landmark is the epigastric area at the tip of the sternum. Palpate there if you suspect aortic abnormalities. Locate the six anatomical landmarks of the heart and inspect and palpate each area. Look for the appearance of pulsations, viewing each area over the chest at an angle to the side. Normally pulsations are not seen, except perhaps at the PMI in thin patients or at the epigastric area as a result of abdominal aorta pulsation. Use the proximal halves of the four fingers together and alternate this with the ball of the hand to palpate for pulsations. Touch the areas gently to allow movements to lift the hand. Normally no pulsations or vibrations are felt in the second, third, or fourth intercostal spaces. Loud murmurs cause a vibration. Time palpated pulsations or vibrations and their occurrence in relation to systole or diastole by auscultating heart sounds simultaneously. The apical impulse or PMI is easily felt. If you cannot locate it with the patient in a supine position, have him or her roll onto the left side, moving the heart closer to the chest wall. Estimate the size of the heart by noting the diameter of the PMI and its position relative to the midclavicular line. In cases of serious heart disease, the cardiac muscle enlarges, with the PMI found to the left of the midclavicular line. The PMI is sometimes difficult to find in the older adult because the chest deepens in its anteroposterior diameters. It is also difficult to find in muscular or overweight patients. An infant’s PMI is located near the third or fourth intercostal space. It is easy to palpate because of the child’s thin chest wall. [Shown at top is Figure 31-38: Anatomical sites for assessment of cardiac function.] [Shown at bottom is Figure 31-39: Palpation of apical pulse.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Heart (Cont.) Auscultation Normal heart sounds Dysrhythmia Extra heart sounds Murmurs Grade Pitch Quality Auscultation of the heart detects normal heart sounds, extra heart sounds, and murmurs. Concentrate on detecting low-intensity sounds created by valve closures. To begin auscultation eliminate all sources of room noise and explain the procedure to reduce the patient’s anxiety. Follow a systematic pattern, beginning at the aortic area and inching the stethoscope across each of the anatomical sites. Listen for the complete cycle (“lub-dub”) of heart sounds clearly at each location. Repeat the sequence using the bell of the stethoscope. Sometimes you will have a patient assume three different positions during the examination to hear sounds clearly: sitting up and leaning forward (good for all areas and to hear high-pitched murmurs), supine (good for all areas), and left lateral recumbent (good for all areas; best position to hear low-pitched sounds in diastole). Learn to identify the first (S1) and second (S2) heart sounds. At normal rates, S1 occurs after the long diastolic pause and preceding the short systolic pause. S1 is high pitched, dull in quality, and heard best at the apex. S2 follows the short systolic pause and precedes the long diastolic pause; it is best heard at the aortic area. Auscultate for rate and rhythm after hearing both sounds clearly. Each combination of S1 and S2 or “lub-dub” counts as one heartbeat. Count the rate for 1 minute and listen for the interval between S1 and S2 and then the time between S2 and the next S1. A regular rhythm involves regular intervals of time between each sequence of beats. There is a distinct silent pause between S1 and S2. Failure of the heart to beat at regular successive intervals is a dysrhythmia. Some dysrhythmias are life threatening. When assessing an irregular heart rhythm, compare apical and radial pulse rates simultaneously to determine if a pulse deficit exists. Auscultate the apical pulse first and then immediately palpate the radial pulse (one-examiner technique). Assess the apical and radial rates at the same time when two examiners are present. When a patient has a pulse deficit, the radial pulse is slower than the apical pulse because ineffective contractions fail to send pulse waves to the periphery. Report a difference in pulse rates to the health care provider immediately. Assess for extra heart sounds at each auscultatory site. Use the bell of the stethoscope and listen for low-pitched extra heart sounds such as S3 and S4 gallops, clicks, and rubs. Auscultate over all anatomical areas. S3, or a ventricular gallop, occurs after S2. It is caused by a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension. The combination of S1, S2, and S3 sounds like “Ken-TUCK-y” S4, or an atrial gallop, occurs just before S1 or ventricular systole. The sound of an S4 is similar to that of “TEN-nes-see” Physiologically it is caused by an atrial contraction pushing against a ventricle that is not accepting blood because of heart failure or other alterations. Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase. They are caused by increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or heart chamber, or backward flow through a valve that fails to close. A murmur can be asymptomatic or a sign of heart disease. They are common in children. Intensity or loudness is related to the rate of blood flow through the heart or the amount of blood regurgitated. Feel for a thrust or intermittent palpable sensation at the auscultation site in serious murmurs. A thrill is a continuous palpable sensation that resembles the purring of a cat. Intensity is recorded using the following grades: Grade 1: Barely audible in a quiet room Grade 2: Quiet but clearly audible Grade 3: Moderately loud Grade 4: Loud, with associated thrill Grade 5: Very loud, thrill easily palpable Grade 6: Very loud, audible with stethoscope not in contact with chest; thrill palpable and visible A murmur is low, medium, or high in pitch, depending on the velocity of blood flow through the valves. A low-pitched murmur is best heard with the bell of the stethoscope. If the murmur is best heard with the diaphragm, the murmur is high pitched. The quality of a murmur refers to its characteristic pattern and sound. A crescendo murmur starts softly and builds in loudness. A decrescendo murmur starts loudly and becomes less intense. [Review Box 31-18, Patient Teaching: Heart Assessment, with students.] [Shown is Figure 31-40: Sequence of patient positions for heart auscultation. A, Sitting. B, Supine. C, Left lateral recumbent. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Vascular System Blood pressure Readings tend to be higher in the right arm. Always record the highest reading. Carotid arteries Reflect heart function better than peripheral arteries Commonly auscultated Examination of the vascular system includes measuring the blood pressure and assessing the integrity of the peripheral vascular system. Use the skills of inspection, palpation, and auscultation. Perform portions of the vascular examination during other body system assessments. [Review Table 31-23, Nursing History for Vascular Assessment, with students.] When auscultating blood pressure, know that readings between the arms vary by as much as 10 mm Hg and tend to be higher in the right arm. Always record the higher reading. Repeated systolic readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta. When the left ventricle pumps blood into the aorta, the arterial system transmits pressure waves. The carotid arteries reflect heart function better than peripheral arteries because their pressure correlates with that of the aorta. The carotid artery supplies oxygenated blood to the head and neck. Examine one carotid artery at a time. If both arteries are occluded simultaneously during palpation, the patient loses consciousness as a result of inadequate circulation to the brain. Do not palpate or massage the carotid arteries vigorously; syncope could result. Begin inspection of the neck for obvious pulsation of the artery. Have the patient turn the head slightly away from the artery being examined. Sometimes the wave of the pulse is visible. The carotid is the only site for assessing the quality of a pulse wave. An absent pulse wave indicates arterial occlusion (blockage) or stenosis (narrowing). To palpate the pulse ask the patient to look straight ahead or turn the head slightly toward the side you are examining. Turning relaxes the sternocleidomastoid muscle. Slide the tips of the index and middle fingers around the medial edge of the sternocleidomastoid muscle. Gently palpate to avoid occlusion of circulation. The normal carotid pulse is localized and strong rather than diffuse. It has a thrusting quality. As the patient breathes, no change occurs. Rotation of the neck or a shift from a sitting to a supine position does not change the quality of the carotid impulse. Both carotid arteries are normally equal in pulse rate, rhythm, and strength and are equally elastic. Diminished or unequal carotid pulsations indicate atherosclerosis or other forms of arterial disease. [Shown at top is Figure 31-41: Anatomical position of carotid artery.] [Shown at bottom is Figure 31-42: Palpation of internal carotid artery along margin of sternocleidomastoid muscle.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Vascular System (cont’d)
Carotid bruit Narrowed blood vessel creates turbulence, causes blowing/swishing sound Pronounced “brew-ee” The carotid is the most commonly auscultated pulse. Auscultation is especially important for middle-age or older adults or patients suspected of having cerebrovascular disease. When the lumen of a blood vessel is narrowed, it disturbs blood flow. As blood passes through the narrowed section, it creates turbulence, causing a blowing or swishing sound. The blowing sound is called a bruit (pronounced “brew-ee”). Place the bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid muscle. Have the patient turn his or her head slightly away from the side being examined. Ask him or her to hold the breath for a moment so breath sounds do not obscure a bruit. Normally you do not hear any sounds during carotid auscultation. Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit. [Shown at top is Figure 31-43: Occlusion or narrowing of the carotid artery disrupts normal blood flow. The resultant turbulence creates a sound (bruit) that is auscultated.] [Shown at bottom is Figure 31-44: Auscultation for carotid artery bruit. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Vascular System (cont’d)
Jugular veins Most accessible Right internal jugular vein follows more direct path to right atrium. Note distention. Assess pressure. The most accessible veins for examination are the internal and external jugular veins in the neck. Both veins drain bilaterally from the head and neck into the superior vena cava. The external jugular vein lies superficially and is just above the clavicle. The internal jugular vein lies deeper, along the carotid artery. It is best to examine the right internal jugular vein because it follows a more direct anatomical path to the right atrium of the heart. The column of blood inside the internal jugular vein serves as a manometer, reflecting pressure in the right atrium. The higher the column, the greater is the venous pressure. Raised venous pressure reflects right-sided heart failure. Normally, when a patient lies in the supine position, the external jugular vein distends and becomes easily visible. In contrast, the jugular veins normally flatten when the patient changes to a sitting or standing position. However, for some patients with heart disease the jugular veins remain distended when sitting. To measure venous pressure, first inspect the jugular veins. Venous pressure is influenced by blood volume, the capacity of the right atrium to receive blood and send it to the right ventricle and the ability of the right ventricle to contract and force blood into the pulmonary artery. Any factor resulting in greater blood volume within the venous system results in elevated venous pressure. Assess venous pressure by using the following steps: 1. Ask the patient to lie supine with the head elevated 31 to 45 degrees (semi-Fowler’s position). 2. Expose the neck and upper thorax. Use a pillow to align the head. Avoid neck hyperextension or flexion to ensure that the vein is not stretched or kinked. 3. Usually pulsations are not evident with the patient sitting up. As he or she slowly leans back into a supine position, the level of venous pulsations begins to rise above the level of the manubrium as much as 1 or 2 cm (½ to 1 inch) as the patient reaches a 45-degree angle. Measure venous pressure by measuring the vertical distance between the angle of Louis and the highest level of the visible point of the internal jugular vein pulsation. 4. Use two rulers. Line up the bottom edge of a regular ruler with the top of the area of pulsation in the jugular vein. Then take a centimeter ruler and align it perpendicular to the first ruler at the level of the sternal angle. Measure in centimeters the distance between the second ruler and the sternal angle. 5. Repeat the same measurement on the other side. Bilateral pressures higher than 2.5 cm (1 inch) are considered elevated and are a sign of right-sided heart failure. One-sided pressure elevation is caused by obstruction. [Shown at top is Figure 31-45: Position of patient to assess jugular vein distention. (From Thompson JM et al: Mosby’s manual of clinical nursing, ed 5, St Louis, 2001, Mosby.)] [Shown at bottom is Figure 31-46: Measuring jugular venous pressure. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Vascular System (Cont.)
Peripheral arteries and veins Assess the adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails. Assess the integrity of the venous system. Assess the arterial pulses in the extremities to determine sufficiency of the entire arterial circulation. To examine the peripheral vascular system, first assess the adequacy of blood flow to the extremities by measuring arterial pulses and inspecting the condition of the skin and nails. Next, assess the integrity of the venous system. Assess the arterial pulses in the extremities to determine sufficiency of the entire arterial circulation. Factors such as coagulation disorders, local trauma or surgery, constricting casts or bandages, and systemic diseases impair circulation to the extremities. Discuss risk factors and ways to monitor for circulatory problems with the patient. [Review Table 31-24, Indicators for Assessing Local Blood Flow, with students.] [Review Box 31-19, Patient Teaching: Vascular Assessment, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Peripheral arteries Assess each peripheral artery for elasticity of the vessel wall, strength, and equality. Pulses 0: absent, not palpable 1: pulse diminished, barely palpable 2: expected/normal 3: full pulse, increased 4: bounding pulse Examine each peripheral artery using the distal pads of your second and third fingers. The thumb helps anchor the brachial and femoral artery. Apply firm pressure but avoid occluding a pulse. When a pulse is difficult to find, it helps to vary pressure and feel all around the pulse site. Be sure not to palpate your own pulse. Routine vital signs usually include assessment of the rate and rhythm of the radial artery because it is easily accessible. Count the pulse for either 31 seconds or a full minute, depending on the character of the pulse (see Chapter 30). Always count an irregular pulse for 60 seconds. With palpation, normally feel the pulse wave at regular intervals. When an interval is interrupted by an early, a late, or a missed beat, the pulse rhythm is irregular. During cardiac emergencies health care providers usually assess the carotid artery because it is accessible and most useful in evaluating heart activity. To check local circulatory status of tissues (e.g., when a leg cast is in place or following vascular surgery), palpate the peripheral arteries long enough to note that a pulse is present. Assess each peripheral artery for elasticity of the vessel wall, strength, and equality. The arterial wall is normally elastic, making it easily palpable. After depressing the artery, it springs back to shape when the pressure is released. An abnormal artery is hard, inelastic, or calcified. The strength of a pulse is its measurement of the force at which blood is ejected against the arterial wall. Some examiners use a scale rating from 0 to 4 to assess the strength of a pulse. Measure all peripheral pulses for equality and symmetry. Compare the left radial pulse with that of the right and so on. Lack of symmetry indicates impaired circulation such as a localized obstruction or an abnormally positioned artery. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Peripheral arteries (Cont.) Upper extremities Brachial artery channels blood to radial and ulnar arteries of forearm and hand If circulation in this artery becomes blocked, the hands do not receive adequate blood flow. If circulation in the radial or ulnar arteries becomes impaired, the hand still receives adequate perfusion. An interconnection between the radial and ulnar arteries guards against arterial occlusion. [Shown is Figure 31-47: A, A, Anatomical positions of brachial, radial, and ulnar arteries.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Peripheral arteries (Cont.) Radial pulse: thumb side of wrist Ulnar pulse: little finger side of wrist Brachial pulse: inside of elbow To locate pulses in the arm have the patient sit or lie down. Find the radial pulse along the radial side of the forearm at the wrist. Thin individuals have a groove lateral to the flexor tendon of the wrist. Feel the radial pulse with light palpation in the groove (left). The ulnar pulse is on the opposite side of the wrist and feels less prominent (center). Palpate the ulnar pulse only when evaluating arterial insufficiency to the hand. To palpate the brachial pulse, find the groove between the biceps and triceps muscle above the elbow at the antecubital fossa (right). The artery runs along the medial side of the extended arm. Palpate it with the fingertips of the first three fingers in the muscle groove. [Shown is Figure 31-47: B, Palpation of radial pulse. C, Palpation of ulnar pulse. D, Palpation of brachial pulse.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Peripheral arteries (Cont.) Lower extremities Femoral artery The femoral artery is the primary artery in the leg, delivering blood to the popliteal, posterior tibial, and dorsalis pedis arteries. An interconnection between the posterior tibial and dorsalis pedis arteries guards against local arterial occlusion. [Shown is Figure 31-48: A, A, Anatomical position of femoral, popliteal, dorsalis pedis, and posterior tibial arteries.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Peripheral arteries (Cont.) Femoral pulse Popliteal pulse Dorsalis pedis pulse Find the femoral pulse with the patient lying down with the inguinal area exposed (top right). The femoral artery runs below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine. Sometimes deep palpation is necessary to feel the pulse. Bimanual palpation is effective in obese patients. Place the fingertips of both hands on opposite sides of the pulse site. Feel a pulsatile sensation when the arterial pulsation pushes the fingertips apart. The popliteal pulse runs behind the knee. Have the patient slightly flex the knee with the foot resting on the examination table or assume a prone position with the knee slightly flexed (bottom left). Instruct him or her to keep leg muscles relaxed. Palpate with the fingers of both hands deeply into the popliteal fossa, just lateral to the midline. The popliteal pulse is difficult to locate. With the patient’s foot relaxed, locate the dorsalis pedis pulse. The artery runs along the top of the foot in line with the groove between the extensor tendons of the great toe and first toe (bottom center). To find the pulse, place the fingertips between the first and second toes and slowly move up the dorsum of the foot. This pulse is sometimes congenitally absent. Find the posterior tibial pulse on the inner side of each ankle (bottom right). Place the fingers behind and below the medial malleolus (ankle bone). With the foot relaxed and slightly extended, palpate the artery. [Shown is Figure 31-48: B, Palpation of femoral pulse. C, Palpation of popliteal pulse. D, Palpation of dorsalis pedis pulse. E, Palpation of posterior tibial pulse.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Peripheral Arteries (Cont.) Ultrasound stethoscopes Tissue perfusion If a pulse is difficult to palpate, an ultrasound (Doppler) stethoscope is a useful tool that amplifies the sounds of a pulse wave. Factors that weaken a pulse or make palpation difficult include obesity, reduction in the stroke volume of the heart, diminished blood volume, or arterial obstruction. Apply a thin layer of transmission gel to the patient’s skin at the pulse site or directly onto the transducer tip of the probe. Turn on the volume control and place the tip of the transducer at a 45- to 90-degree angle on the skin. Move the transducer until you hear a pulsating “whooshing” sound that indicates that arterial blood flow is present. Tissue Perfusion: The condition of the skin, mucosa, and nail beds offers useful data about the status of circulatory blood flow. Examine the face and upper extremities, looking at the color of the skin, mucosa, and nail beds. The presence of cyanosis requires special attention. Heart disease sometimes causes central cyanosis, which indicates poor arterial oxygenation. Some characteristics of this are a bluish discoloration of the lips, mouth, and conjunctivae. Blue lips, earlobes, and nail beds are signs of peripheral cyanosis, which indicates peripheral vasoconstriction. When cyanosis is present, consult with a health care provider to request laboratory testing of oxygen saturation to determine the severity of the problem. Examination of the nails involves inspection for clubbing, a bulging of the tissues at the nail base. Clubbing is caused by insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease. Inspect the lower extremities for changes in color, temperature, and condition of the skin, indicating either arterial or venous alterations. This is a good time to ask the patient about any history of pain in the legs. If an arterial occlusion is present, the patient has signs resulting from an absence of blood flow. Pain is distal to the occlusion. The five Ps—pain, pallor, pulselessness, paresthesia, and paralysis—characterize an occlusion. Venous congestion causes tissue changes that indicate an inadequate circulatory flow back to the heart. [Review Table 31-25, Signs of Venous and Arterial Insufficiency, with students.] During examination of the lower extremities, also inspect skin and nail texture; hair distribution on the lower legs, feet, and toes; the venous pattern; and scars, pigmentation, or ulcers. Palpate the legs and feet for color and temperature. Capillary refill, traditionally used to determine adequacy of peripheral blood flow to the digits, has limited value. The absence of hair growth over the legs indicates circulatory insufficiency. Remember not to confuse absence of hair on the legs with shaved legs. In addition, men who wear tight-fitting dress socks or jeans may have less hair on their calves. Chronic recurring ulcers of the feet or lower legs are a serious sign of circulatory insufficiency and require a health care provider’s intervention. [Shown is Figure 31-49: Ultrasound stethoscope in position on brachial artery.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Peripheral Veins Varicosities Peripheral edema Pitting edema Phlebitis Assess the status of the peripheral veins by asking the patient to assume sitting and standing positions. Assessment includes inspection and palpation for varicosities, peripheral edema, and phlebitis. Varicosities are superficial veins that become dilated, especially when the legs are in a dependent position. They are common in older adults because the veins normally fibrose, dilate, and stretch. They are also common in people who stand for prolonged periods. Varicosities in the anterior or medial part of the thigh and the posterolateral part of the calf are abnormal. Dependent edema around the area of the feet and ankles is a sign of venous insufficiency or right-sided heart failure. It is common in older adults and people who spend a lot of time standing. To assess for pitting edema, use the index finger to press firmly for several seconds and release over the medial malleolus or the shins. A depression left in the skin indicates edema. Grading 1+ through 4+ characterizes the severity of the edema. Phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, and prolonged insertion of IV catheters. To assess for phlebitis in the leg, inspect the calves for localized redness, tenderness, and swelling over vein sites. Gentle palpation of calf muscles reveals warmth, tenderness, and firmness of the muscle. Unilateral edema of the affected leg is one of the most reliable findings of phlebitis. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Lymphatic System Lymphatic system Lower extremities Assess during examination of vascular system or genital examination Upper extremities Palpate the epitrochlear nodes, located on the medial aspect of the arms Assess proximal portion during breast examination Assess the lymphatic drainage of the lower extremities during examination of the vascular system or during the female or male genital examination. Superficial and deep nodes drain the legs, but only two groups of superficial nodes are palpable. With the patient supine, palpate the area of the superficial inguinal nodes in the groin area. Then move the fingertips toward the inner thigh, feeling for any inferior nodes. Use a firm but gentle pressure when palpating over each lymphatic chain. Multiple nodes are not normally palpable, although a few soft, nontender nodes are not unusual. Enlarged, hardened, tender nodes reveal potential sites of infection or metastatic disease. In the upper extremities lymph is carried by the collecting ducts from the upper extremities to the subclavian lymphatic trunk. To assess this lymph system, gently palpate the epitrochlear nodes, located on the medial aspect of the arms near the antecubital fossa. The proximal portion of the upper-extremity lymph system is located in the axilla and is usually assessed during examination of the breasts. [Shown is Figure 31-50: A, Lymphatic drainage for the lower extremities. B, Lymphatic drainage for upper extremities. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Breasts Assess in both male and female patients. Male breast: small amount breast of glandular tissue Female breast: majority of breast is glandular tissue Breast cancer is second to lung cancer as the leading cause of death in women with cancer. Teach patients health behaviors such as breast self-examination (BSE). It is important to examine the breasts of both female and male patients. Men have a small amount of glandular tissue, a potential site for the growth of cancer cells, in the breast. In contrast, the majority of the female breast is glandular tissue. New cases of invasive breast cancer were predicted to affect an estimated 231,480 women in the United States, with 2,140 new cases expected in men. The disease is second to lung cancer as the leading cause of death in women with cancer. Early detection is the key to cure. A major responsibility for nurses is to teach patients health behaviors such as breast self-examination (BSE). [Review Box 31-20, Evidence-Based Practice: Detection of Breast Cancer, with students.] Encourage both men and women to observe their breasts for changes. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Female Breasts Early breast cancer detection recommendations: Monthly BSE is an option for women in their 20s and 30s. 20 years of age and older: need to report any breast changes to a health care provider immediately 20 to 40: clinical breast examination by a health care provider every 3 years; older than 40: annually. Family history of breast cancer: annual examination by a health care provider. Asymptomatic women: screening mammogram by age 40; women age 40 and older: annually. Women at increased risk: consider additional testing (MRI). Women need to be taught to know how their breasts usually look and feel and report changes to a health care professional. In addition, they need to know about the benefits and limitations of performing a systematic BSE. Once thought essential for early breast cancer detection, BSEs are now considered optional. If the patient already performs BSEs, assess the method she uses and times she does the examination in relation to her menstrual cycle. The best time for a BSE is the fourth through seventh day of the menstrual cycle or right after the menstrual cycle ends, when the breast is no longer swollen or tender from hormone elevations. If the woman is postmenopausal, advise her to check her breasts on the same day each month. The pregnant woman should also check her breasts on a monthly basis. Older women require special attention when reviewing the need for regular BSE. Fixed incomes limit many older women, thus they fail to pursue regular clinical breast examination and mammography. Unfortunately, many older women ignore changes in their breasts, assuming that they are a part of aging. In addition, physiological factors affect the ease with which older women perform a BSE. Musculoskeletal limitations, diminished peripheral sensation, reduced eyesight, and changes in joint range of motion (ROM) limit palpation and inspection abilities. Find resources for older women, including free screening programs. Teach family members to perform the patient’s examination. The American Cancer Society (ACS) recommends the following guidelines for the early detection of breast cancer: Monthly BSE is an option for women in their 20s and 30s. Women 20 years of age and older need to report any breast changes to a health care provider immediately. Women need a clinical breast examination by a health care provider every 3 years from ages 20 to 40 and annually for women older than age 40. Women with a family history of breast cancer need an annual examination by a health care provider. Asymptomatic women need a screening mammogram by age 40; women age 40 and older need to have a mammogram annually. For women at increased risk, the ACS recommends talking with the health care provider for screening options and additional testing, such as magnetic resonance imaging (MRI) (ACS, 2014c). The patient’s history reveals normal developmental changes and signs of breast disease. Because of its glandular structure, the breast undergoes changes during a woman’s life. Knowing these changes allows complete and accurate assessment. [Review Table 31-26, Nursing History for Breast Assessment, with students.] [Review Box 31-22, Normal Changes In The Breast During A Woman’s Life Span, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Breast Self-Examination
Examine right breast Lie down on your back and place your right arm behind your head Use finger pads of 3 middle fingers on left hand to feel for lumps in right breast Examine your right breast. Lie down on your back and place your right arm behind your head. The exam is completed lying down, not standing up, because when you lie down the breast tissue spreads evenly over the chest wall and is as thin as possible, making it much easier to feel all the breast tissue. Use finger pads of the three middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue. Use three different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure, to feel the tissue closes to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast, but you should tell your health care provider if you feel anything else out of the ordinary. If you’re not sure how hard to press, discuss this with your health care provider. Use each pressure level to feel the breast tissue before moving on to the next spot. [Review Box 31-21, Breast Self-Examination, with students.] [Shown is Figure A and Figure B from Box 31-21: Breast Self-Examination.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Breast Self-Examination (Cont.)
Move around the breast in an up-and-down pattern Repeat self-examination in the left breast Observe breasts in mirror with hands pressing firmly on hips Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the under arm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle) (see illustration C). Evidence shows that the up-and-down pattern is the most effective pattern for covering the entire breast. Repeat self-examination in the left breast, putting your left arm behind your head and examining the left breast as noted in Steps 1 to 3. While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts, observing for any changes in size, shape, contour, dimpling, or redness or scaliness of the nipple or breast tissue. Pressing down on your hips contracts the chest wall muscles and enhances any breast changes. [Shown is Figure C from Box 31-21: Breast Self-Examination.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Breast Self-Examination (Cont.)
Examine each underarm while sitting or standing and with your arm only slightly raised If implants are present, help the patient determine the edges of each implant and how to evaluate each breast Instruct patient to call the health care provider if she finds a lump or other abnormality. Use Teach Back Examine each underarm while sitting or standing and with your arm only slightly raised so you can easily feel in this area or any lumps or changes. Raising your arm straight tightens the tissue in this area making it harder to examine. If implants are present, help the patient determine the edges of each implant and how to evaluate each breast. Instruct patient to call the health care provider if she finds a lump or other abnormality. Use Teach Back—State to the patient, “I want to be sure I explained to you how to conduct a Breast Self-Examination. Can you show me how to conduct an exam on both of your breasts?” Document your evaluation of patient learning. Revise your instruction or develop a plan for revised patient teaching to be implemented at an appropriate time if patient is not able to teach back correctly. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Female Breasts (Cont.) Inspection Size and symmetry Common for one breast to be smaller Contour or shape Color Nipple and areola Have the patient remove the top gown or drape to allow simultaneous visualization of both breasts. Have her stand or sit with her arms hanging loosely at her sides. If possible, place a mirror in front of her during inspection so she sees what to look for when performing a BSE. To recognize abnormalities the patient needs to be familiar with the normal appearance of her breasts. Describe observations or findings in relation to imaginary lines that divide the breast into four quadrants and a tail. The lines cross at the center of the nipple. Each tail extends outward from the upper outer quadrant. Inspect the breasts for size and symmetry. Normally they extend from the third to the sixth ribs, with the nipple at the level of the fourth intercostal space. It is common for one breast to be smaller. However, inflammation or a mass causes a difference in size. As a woman becomes older, the ligaments supporting the breast tissue weaken, causing the breasts to sag and the nipples to lower. Observe the contour or shape of the breasts and note masses, flattening, retraction, or dimpling. Breasts vary in shape from convex to pendulous or conical. Retraction or dimpling can result from invasion of underlying ligaments by tumors. The ligaments fibrose and pull the overlying skin inward toward the tumor. Edema also changes the contour of the breasts. To bring out retraction or changes in the shape of breasts, ask the patient to assume three positions: raise arms above the head, press hands against the hips, and extend arms straight ahead while sitting and leaning forward. Each maneuver causes a contraction of the pectoral muscles, which accentuates the presence of any retraction. Carefully inspect the skin for color; venous pattern; and the presence of lesions, edema, or inflammation. Lift each breast when necessary to observe lower and lateral aspects for color and texture changes. The breasts are the color of neighboring skin, and venous patterns are the same bilaterally. Venous patterns are easily visible in thin or pregnant women. Women with large breasts often have redness and excoriation of the undersurfaces caused by rubbing of skin surfaces. Inspect the nipple and areola for size, color, shape, discharge, and the direction in which the nipples point. The normal areolas are round or oval and nearly equal bilaterally. Color ranges from pink to brown. In light-skinned women the areola turns brown during pregnancy and remains dark. In dark-skinned women the areola is brown before pregnancy. Normally the nipples point in symmetrical directions, are everted, and have no drainage. If the nipples are inverted, ask if this has been a lifetime history. A recent inversion or inward turning of the nipple indicates an underlying growth. Rashes or ulcerations are not normal on the breast or nipples. Note any bleeding or discharge from the nipple. Clear yellow discharge 2 days after childbirth is common. While inspecting the breasts, explain the characteristics you see. Teach the patient the significance of abnormal signs or symptoms. [Shown is Figure 31-51: Quadrants of left breast and axillary tail of Spence. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Female Breasts (Cont.) Palpation Edge of pectoralis major muscle along anterior axillary line Chest wall in the midaxillary area Upper part of humerus Anterior edge of the latissimus dorsi along posterior axillary line Palpation assesses the condition of underlying breast tissue and lymph nodes. Breast tissue consists of glandular tissue, fibrous supportive ligaments, and fat. Glandular tissue is organized into lobes that end in ducts that open onto the surface of the nipple. The largest portion of glandular tissue is in the upper outer quadrant and tail of each breast. Suspensory ligaments connect to skin and fascia underlying the breast to support the breast and maintain its upright position. Fatty tissue is located superficially and to the sides of the breast. A large portion of lymph from the breasts drains into axillary lymph nodes. If cancerous lesions metastasize (spread), the nodes commonly become involved. Study the location of supraclavicular, infraclavicular, and axillary nodes. The axillary nodes drain lymph from the chest wall, breasts, arms, and hands. A tumor of one breast sometimes involves nodes on the same and opposite sides. To palpate the lymph nodes have the patient sit with her arms at her sides and muscles relaxed. While facing the patient and standing on the side you are examining, support her arm in a flexed position, and abduct it from the chest wall. Place the free hand against the patient’s chest wall and high in the axillary hollow. With the fingertips press gently down over the surface of the ribs and muscles. Palpate the axillary nodes with the fingertips, gently rolling soft tissue. Palpate four areas of the axilla: at the edge of the pectoralis major muscle along the anterior axillary line, the chest wall in the midaxillary area, the upper part of the humerus, and the anterior edge of the latissimus dorsi muscle along the posterior axillary line. Normally lymph nodes are not palpable. Carefully assess each area and note their number, consistency, mobility, and size. One or two small, soft, nontender palpable nodes are normal. An abnormal palpable node feels like a small mass that is hard, tender, and immobile. Continue to palpate along the upper and lower clavicular ridges. Reverse the procedure for the patient’s other side. [Shown at top is Figure 31-52: Anatomical position of axillary and clavicular lymph nodes..] [Shown at bottom is Figure 31-53: Support patient’s arm and palpate axillary lymph nodes. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Female Breasts (Cont.) Palpation (Cont.) Lying down with the arm abducted makes the area more accessible Place pillow or towel under the patient’s shoulder blade to further position breast tissue Palpate tail of Spence It is sometimes difficult for a patient to learn to palpate for lymph nodes. Lying down with the arm abducted makes the area more accessible. Instruct the patient to use her left hand for the right axillary and clavicular areas. Take the patient’s fingertips and move them in the proper fashion. Then have the patient use her right hand to palpate for nodes on the left side. With the patient lying supine and one arm under the head and neck (alternating with each breast), palpate her breast tissue. The supine position allows the breast tissue to flatten evenly against the chest wall. The position of the arm and hand further stretches and positions breast tissue evenly. Place a small pillow or towel under the patient’s shoulder blade to further position breast tissue. Palpate the tail of Spence. The consistency of normal breast tissue varies widely. The breasts of a young patient are firm and elastic. In an older, patient the tissue sometimes feels stringy and nodular. A patient’s familiarity with the texture of her own breasts is very important. Patients gain familiarity through monthly BSE. [Review Box 31-23, Patient Teaching: Female Breast Assessment, with students.] [Shown is Figure 31-54: A, The patient lies flat with arm abducted and hand under head to help flatten breast tissue evenly over the chest wall. B, Each breast is palpated in a systematic fashion. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Female Breasts (Cont.) Palpation (Cont.) Use systematic approach: vertical, circular, or radial/wedge technique If the patient complains of a mass, examine the opposite breast to ensure an objective comparison of normal and abnormal tissue. Use the pads of the first three fingers to compress breast tissue gently against the chest wall, noting tissue consistency. Perform palpation systematically in one of three ways: (1) using a vertical technique with the fingers moving up and down each quadrant; (2) clockwise or counterclockwise, forming small concentric circles with the fingers along each quadrant and the tail; or (3) palpating from the center of the breast in a radial fashion, returning to the areola to begin each spoke. Whichever approach you use, be sure to cover the entire breast and tail, directing attention to any areas of tenderness. Use a bimanual technique when palpating large, pendulous breasts. Support the inferior portion of the breast in one hand while using the other hand to palpate breast tissue against the supporting hand. During palpation note the consistency of breast tissue. It normally feels dense, firm, and elastic. With menopause breast tissue shrinks and becomes softer. The lobular feel of glandular tissue is normal. The lower edge of each breast sometimes feels firm and hard. This is the normal inframammary ridge and not a tumor. It helps to move the patient’s hand so she can feel normal tissue variations. Palpate abnormal masses to determine location in relation to quadrants, diameter in centimeters, shape (e.g., round or discoid), consistency (soft, firm, or hard), tenderness, mobility, and discreteness (clear or unclear boundaries). Cancerous lesions are hard, fixed, nontender, irregular in shape, and usually unilateral. A common benign condition of the breast is benign (fibrocystic) breast disease. Bilateral lumpy, painful breasts and sometimes nipple discharge characterize this condition. Symptoms are more apparent during the menstrual period. When palpated the cysts (lumps) are soft, well differentiated, and movable. Deep cysts feel hard. Give special attention to palpating the nipple and areola. Palpate the entire surface gently. Use the thumb and index finger to compress the nipple and note any discharge. During the examination of the nipple and areola, the nipple sometimes becomes erect with wrinkling of the areola. These changes are normal. Continue by positioning the patient and examining the other breast. After completing the examination, have the patient demonstrate self-palpation. Observe the patient’s technique and emphasize the importance of a systematic approach. Urge the patient to see her health care provider if she discovers an abnormal mass during routine monthly BSE. She also needs to know all of the signs and symptoms of breast cancer. [Shown is Figure 31-55: Various methods for palpation of breast. A, Palpate from top to bottom in vertical strips. B, Palpate in concentric circles. C, Palpate out from center in wedge sections. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Male Breasts Inspect the nipple and areola for nodules, edema, and ulceration Breast enlargement An enlarged male breast results from obesity or glandular enlargement Breast enlargement in young males results from steroid use Men at high risk may be scheduled by their health care provider for routine mammograms Examination of the male breast is relatively easy. Inspect the nipple and areola for nodules, edema, and ulceration. An enlarged male breast results from obesity or glandular enlargement. Breast enlargement in young males results from steroid use. Fatty tissue feels soft, whereas glandular tissue is firm. Use the same techniques to palpate for masses used in examination of the female breast. Because breast cancer in men is relatively rare, routine self-examinations are unnecessary. However, men who have a first-degree relative (e.g., mother or sister) with breast cancer, are at risk for breast cancer and need to palpate their breasts at regular intervals. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Abdomen Complex assessment because of organs located in abdominal cavity Begin with inspection and follow with auscultation The abdominal examination is complex because of the number of organs located within and near the abdominal cavity. A thorough nursing history helps interpret physical signs. The examination includes an assessment of structures of the lower gastrointestinal (GI) tract in addition to the liver, stomach, uterus, ovaries, kidneys, and bladder. Abdominal pain is one of the most common symptoms that patients report when seeking medical care. An accurate assessment requires matching patient history data with a careful assessment of the location of physical symptoms. [Review Table 31-27, Nursing History for Abdominal Assessment, with students.] Assess the organs anteriorly and posteriorly. A system of landmarks help map out the abdominal region. The xiphoid process (tip of the sternum) is the upper boundary of the anterior abdominal region. The symphysis pubis marks the lower boundary. Divide the abdomen into four imaginary quadrants; refer to assessment findings and record them in relation to each quadrant. Posteriorly the lower ribs and heavy back muscles protect the kidneys, which are located from the T12 to L3 vertebrae. The costovertebral angle formed by the last rib and vertebral column is a landmark used during kidney palpation. During the abdominal examination the patient needs to relax. A tightening of abdominal muscles hinders palpation. Ask the patient to void before beginning. Be sure that the room is warm and drape upper chest and legs. The patient lies supine or in a dorsal recumbent position with the arms at the sides and knees slightly bent. Place small pillows beneath the knees. If the patient places the arms under the head, the abdominal muscles tighten. Proceed calmly and slowly, being sure that there is adequate lighting. Expose the abdomen from just above the xiphoid process down to the symphysis pubis. Warm hands and stethoscope further promote relaxation. Ask the patient to report pain and point out tender areas. Assess tender areas last. The order of an abdominal examination differs slightly from previous assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation there is less chance of altering the frequency and character of bowel sounds. Be sure to have a tape measure and marking pen available during the examination. [Shown is Figure 31-56: A, Anterior view of abdomen divided by quadrants. B, Posterior view of abdominal section.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Abdomen (Cont.) Inspection Skin Umbilicus Contour and symmetry Enlarged organs or masses Movements or pulsations Make it a habit to observe the patient during routine care activities. Note his or her posture and look for evidence of abdominal splinting: lying with the knees drawn up or moving restlessly in bed. A patient free from abdominal pain does not guard or splint the abdomen. To inspect the abdomen for abnormal movement or shadows, stand on the patient’s right side and inspect from above the abdomen. After sitting or stooping down to look across the abdomen, assess abdominal contour. Direct the examination light over the abdomen. Inspect the skin over the abdomen for color, scars, venous patterns, lesions, and striae (stretch marks). Note the umbilicus’s position; shape; color; and signs of inflammation, discharge, or any protruding masses. A normal umbilicus is flat or concave with the color the same as that of the surrounding skin. Underlying masses cause displacement of the umbilicus. Inspect for contour, symmetry, and surface motion of the abdomen, noting any masses, bulging, or distention. A flat abdomen forms a horizontal plane from the xiphoid process to the symphysis pubis. A round abdomen protrudes in a convex sphere from the horizontal plane. A concave abdomen appears to sink into the muscular wall. Each of these findings is normal if the shape of the abdomen is symmetrical. Intestinal gas, a tumor, or fluid in the abdominal cavity causes distention (swelling). When distention is generalized, the entire abdomen protrudes. Observe the contour of the abdomen while asking the patient to take a deep breath and hold it. This maneuver forces the diaphragm downward and reduces the size of the abdominal cavity. Any enlarged organs in the upper abdominal cavity (e.g., liver or spleen) descend below the rib cage to cause a bulge. To evaluate the abdominal musculature have the patient raise the head. This position causes superficial abdominal wall masses, hernias, and muscle separations to become more apparent. Inspect for movement. Normally men breathe abdominally, and women breathe more costally. Closely inspect for peristaltic movement and aortic pulsation by looking across the abdomen from the side. These movements are visible in thin patients; otherwise no movement is present. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Abdomen (Cont.) Auscultation Bowel motility Peristalsis Borborygmi Vascular sounds Bruits Kidney tenderness Auscultate before palpation during the abdominal assessment because manipulation of the abdomen alters the frequency and intensity of bowel sounds. Ask patients not to talk. Patients with gastrointestinal (GI) tubes connected to suction need them temporarily turned off before beginning an examination. Peristalsis, or the movement of contents through the intestines, is a normal function of the small and large intestine. Bowel sounds are the audible passage of air and fluid that peristalsis creates. Place the warmed diaphragm of the stethoscope lightly over each of the four quadrants. Normally air and fluid move through the intestines, creating soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Sounds usually last ½ second to several seconds. It normally takes 5 to 20 seconds to hear a bowel sound. However, it takes 5 minutes of continuous listening before determining that bowel sounds are absent. Auscultate all four quadrants to be sure that you do not miss any sounds. The best time to auscultate is between meals. Sounds are generally described as normal, audible, absent, hyperactive, or hypoactive. Absent sounds indicate a lack of peristalsis, possibly the result of late-stage bowel obstruction; paralytic ileus; or peritonitis. Normally absent or hypoactive bowel sounds occur after surgery following general anesthesia. Hyperactive sounds are loud, “growling” sounds called borborygmi, which indicate increased GI motility. Inflammation of the bowel, anxiety, diarrhea, bleeding, excessive ingestion of laxatives, and reaction of the intestines to certain foods cause increased motility. Teach patients practices to promote normal elimination patterns. [Review Box 31-24, Patient Teaching: Abdominal Assessment, with students.] Bruits indicate narrowing of the major blood vessels and disruption of blood flow. The presence of bruits in the abdominal area can reveal aneurysms or stenotic vessels. Use the bell of the stethoscope to auscultate in the epigastric region and each of the four quadrants. Normally there are no vascular sounds over the aorta (midline through the abdomen) or femoral arteries (lower quadrants). You can hear renal artery bruits by placing the stethoscope over each upper quadrant anteriorly or over the costovertebral angle posteriorly. Report a bruit immediately to a health care provider. With the patient sitting or standing erect, use direct or indirect percussion to assess for kidney inflammation. You might require an advanced practice nurse to help you with this skill. With the ulnar surface of the partially closed fist, percuss posteriorly the costovertebral angle at the scapular line. If the kidneys are inflamed, the patient feels tenderness during percussion. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Abdomen (Cont.) Palpation Performed last Detects tenderness, distention, or masses May be light or deep, as appropriate Aortic pulsation Palpation primarily detects areas of abdominal tenderness, distention, or masses. As your skill base increases, learn to palpate for specific organs by using light and deep palpation. Use light palpation over each abdominal quadrant to detect areas of tenderness. Initially avoid areas previously identified as problem spots. Lay the palm of the hand with fingers extended and approximated lightly on the abdomen. Explain the maneuver to the patient and, with the palmar surface of the fingers, depress approximately 1.3 cm (1/2 inch) in a gentle dipping motion. Avoid quick jabs and use smooth, coordinated movements. If the patient is ticklish, first place his or her hand on the abdomen with your hand on the patient’s; continue this until the patient tolerates palpation. Use a systematic palpation approach for each quadrant and assess for muscular resistance, distention, tenderness, and superficial organs or masses. Observe the patient’s face for signs of discomfort. The abdomen is normally smooth with consistent softness and nontender without masses. In contrast to firm muscles found among young adults, an older adult often lacks abdominal tone. Guarding or muscle tenseness sometimes occurs while palpating a sensitive area. If tightening remains after the patient relaxes, peritonitis, acute cholecystitis, or appendicitis is sometimes the cause. It is easy to detect a distended bladder with light palpation. Normally the bladder lies below the umbilicus and above the symphysis pubis. Routinely check for a distended bladder if the patient has been unable to void (e.g., because of anesthesia or sedation) or has been incontinent or if an indwelling urinary catheter is not draining well. With practice and experience perform deep palpation to delineate abdominal organs and detect less obvious masses. You need short fingernails. It is important for the patient to be relaxed while the hands depress approximately 2.5 to 7.5 cm (1 to 3 inches) into the abdomen. Never use deep palpation over a surgical incision or over extremely tender organs. It is also unwise to use palpation on abnormal masses. Deep pressure causes tenderness in a healthy patient over the cecum, sigmoid colon, aorta, and the midline near the xiphoid process. Survey each quadrant systematically. Palpate masses for size, location, shape, consistency, tenderness, pulsation, and mobility. Test for rebound tenderness by pressing a hand slowly and deeply into the involved area and letting go quickly. The test is positive if the patient feels pain with the release of the hand. Rebound tenderness occurs in patients with peritoneal irritation such as occurs in appendicitis; pancreatitis; or any peritoneal injury causing bile, blood, or enzymes to enter the peritoneal cavity. Palpate with the thumb and forefinger of one hand deeply into the upper abdomen just left of the midline to assess aortic pulsation. Normally a pulsation is transmitted forward. If the aorta is enlarged because of an aneurysm (localized dilation of a vessel wall), the pulsation expands laterally. Do not palpate a pulsating abdominal mass. When enlargement from an aneurysm is present, only lightly palpate this area, referring the finding to the health care provider. In obese patients it is often necessary to palpate with both hands, one on each side of the aorta. [Shown at top is Figure 31-57: Light palpation of abdomen. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] [Shown at bottom is Figure 31-58: Deep palpation of abdomen. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 4. Which technique should the nurse use first when conducting an abdominal assessment? A. Auscultation. B. Inspection. C. Palpation. D. Percussion. Answer: B Rationale: The order of the abdominal assessment is inspection, auscultation, percussion (if used), and palpation. Auscultate before palpation during the abdominal assessment because manipulation of the abdomen alters the frequency and intensity of bowel sounds. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Female Genitalia and Reproductive Tract
Assessment includes both internal and external organs. Understand cultural sensitivity. Identify changes across the life span. Use inspection and palpation. Examination of the female genitalia is embarrassing to a patient unless you use a calm, relaxed approach. The gynecological examination is one of the most difficult experiences for adolescents. A person’s cultural background further adds to apprehension. For example, female Mexican-Americans have a strong social value that women do not expose their bodies to men or even to other women. Similarly, Chinese-Americans believe that the examination of genitalia is offensive. Provide a thorough explanation of the reason for the procedures used in the examination. The lithotomy position assumed during the examination is an added source of embarrassment. A patient is more comfortable when you use correct positioning and draping. Be sure to explain each portion of the examination in advance so patients anticipate necessary actions. Adolescents sometimes choose to have parents present in the examination room. Sometimes a patient requires a complete examination of the female reproductive organs, including assessing the external genitalia and performing a vaginal examination. You can examine external genitalia while performing routing hygiene measures or when preparing to insert a urinary catheter. An internal examination is part of each woman’s preventive health care because ovarian cancer causes more deaths than any other cancer of the female reproductive system (ACS, 2014d). Adolescents and young adults are examined because of the growing incidence of sexually transmitted infections (STIs). The average age of menarche among young girls has declined, and the majority of male and female teenagers are sexually active by age 19 (Hockenberry and Wilson, 2015). It is important to assess a patient’s level of anxiety when obtaining the nursing history. Combine rectal and anal assessments with the pelvic examination since the patient is situated in a lithotomy or dorsal recumbent position. [Review Table 31-28, Nursing History for Female Genitalia and Reproductive Tract Assessment, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Female Genitalia and Reproductive Tract (Cont.)
Preparation of the patient External genitalia Speculum examination of internal genitalia The beginning nurse is often responsible for assisting a patient’s health care provider with the examination. For a complete examination the following equipment is needed: examination table with stirrups, vaginal speculum of correct size, adjustable light source, sink, clean disposable gloves, sterile cotton swabs, glass slides, plastic or wooden spatula, cervical brush or broom device, cytological fixative, and culture plates or media. Assist the patient to the lithotomy position in bed or on an examination table for the external genitalia assessment. Assist her into stirrups for a speculum examination. Some women suffering from pain or deformity of the joints are unable to assume a lithotomy position. In this situation, it is necessary to have the patient abduct only one leg or have another assist in separating the patient’s thighs. In addition, use the side-lying position with the patient on the left side with the right thigh and knee drawn up to her chest. Give a square drape or sheet to the patient. She holds one corner over her sternum, the adjacent corners fall over each knee, and the fourth corner covers the perineum. After the examination begins, lift the drape over the perineum. A male examiner always needs to have a female attendant present during the examination, whereas a female examiner may choose to work alone. An additional female should be present if the patient requests it. Make sure that the perineal area is well illuminated. Follow standard precautions. The perineum is sensitive and tender; do not touch the area suddenly without warning the patient. While sitting at the end of the examination table or bed, inspect the quantity and distribution of hair growth. Inspect surface characteristics of the labia majora. The labia majora are normally without inflammation, edema, lesions, or lacerations. To inspect the remaining external structures, use your nondominant hand and gently place the thumb and index finger inside the labia minora and retract the tissues outwardly. Be sure to have a firm hold to avoid repeated retraction against the sensitive tissues. Use the other hand to palpate the labia minora between the thumb and second finger. On inspection the labia minora are normally thinner than the labia majora, and one side is sometimes larger. The size of the clitoris varies, but it normally does not exceed 2 cm in length and 0.5 cm in width. Look for atrophy, inflammation, or adhesions. The urethral meatus is anterior to the vaginal orifice and is pink. It appears as a small slit or pinhole opening just above the vaginal canal. Note any discharge, polyps, or fistulas. Inspect the vaginal orifice for inflammation, edema, discoloration, discharge, and lesions. Normally the opening is a thin, vertical slit, and the tissue is moist. While inspecting the vaginal orifice, note the condition of the hymen, which is just inside the opening. In the virgin female the hymen restricts the opening of the vagina, but the tissue retracts or disappears after sexual intercourse. Inspect the anus, looking for lesions and hemorrhoids (see rectal examination). After completion of the external examination, dispose of examination gloves and offer the patient soft disposable cloths for perineal hygiene. Patients who are at risk for contracting an STI need to learn to perform a genital examination. The purpose of the examination is to detect any signs or symptoms of an STI. Many persons do not know that they have an STI (e.g., chlamydia), and some STIs (e.g., syphilis) remain undetected for years. [Review Box 31-25, Patient Teaching: Female Genitalia and Reproductive Tract Assessment, with students.] An examination of the internal genitalia requires much skill and practice. Advanced nurse practitioners and primary care providers perform this examination. As a nursing student you observe the procedure or assist the examiner by helping the patient with positioning, handing off specimen supplies, and providing emotional support for the patient. The examination involves use of a plastic or metal speculum consisting of two blades and an adjustment device. The examiner inserts the speculum into the vagina to assess the internal genitalia for cancerous lesions and other abnormalities. During the examination the examiner collects a specimen for a Papanicolaou (Pap) test for cervical and vaginal cancer. The cervix is inspected for color, position, size, surface characteristics, and discharge. [Shown is Figure 31-59: Female external genitalia.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Male Genitalia Assesses the integrity of the external genitalia, inguinal ring, and canal. Use a calm, gentle approach to lessen the patient’s anxiety. An examination of the male genitalia assesses the integrity of the external genitalia, inguinal ring, and canal. Because the incidence of STIs in adolescents and young adults is high, an assessment of the genitalia needs to be a routine part of any health maintenance examination for this age group. The examination begins by having the patient void. Make sure the examination room is warm. Have the patient lie supine with the chest, abdomen, and lower legs draped or stand during the examination. Apply clean gloves. [Review Box 31-26, Patient Teaching: Male Genital Assessment, with students.] Use a calm, gentle approach to lessen the patient’s anxiety. The position and exposure of the body during the examination is embarrassing for some men. To minimize his anxiety, it often helps to offer explanations of the steps of examination so he anticipates all actions. Manipulate the genitalia gently to avoid causing erection or discomfort. Obtain a thorough history before the examination, ensuring that the assessment is complete. [Review Table 31-29, Nursing History for Male Genitalia Assessment, with students.] [Shown is Figure 31-60: External and internal male sex organs.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Male Genitalia (Cont.) Sexual maturity Penis Scrotum Inguinal ring and canal First note the sexual maturity of the patient by observing the size and shape of the penis and testes; the size, color, and texture of the scrotal skin; and the character and distribution of pubic hair. Also inspect the skin covering the genitalia for lice, rashes, excoriations, or lesions. Normally it is clear, without lesions. To inspect penile surfaces, manipulate the genitalia or have the patient assist. Inspect the shaft, corona, prepuce (foreskin), glans, and urethral meatus. The dorsal vein is apparent on inspection. In uncircumcised males, retract the foreskin to reveal the glans and urethral meatus. The foreskin usually retracts easily. A small amount of white, thick smegma sometimes collects under this foreskin. Obtain a culture if abnormal discharge is present. The urethral meatus is slitlike in appearance and positioned on the ventral surface just millimeters from the tip of the glans. In some congenital conditions the meatus is displaced along the penile shaft. Gently compress the glans between the thumb and index finger; this opens the urethral meatus for inspection of lesions, edema, and inflammation. Normally the opening is glistening and pink without discharge. Palpate any lesion gently to note tenderness, size, consistency, and shape. When inspection and palpation of the glans is complete, pull the foreskin down to its original position. Continue by inspecting the entire shaft of the penis, including the undersurface, looking for lesions, scars, or edema. Palpate the shaft between the thumb and first two fingers to detect localized areas of hardness or tenderness. A patient who has lain in bed for a prolonged time sometimes develops dependent edema in the penis shaft. It is important for any male patient to learn to perform a genital self-examination to detect signs or symptoms of STIs, especially men who have had more than one sexual partner or whose partner has had other partners. Men may have an STI but not be aware of it; self-examination is a routine part of self-care. Be particularly cautious while inspecting and palpating the scrotum because the structures lying within the scrotal sac are very sensitive. The scrotum is divided internally into two halves. Each half contains a testicle, epididymis, and the vas deferens, which travels upward into the inguinal ring. Normally the left testicle is lower than the right. Inspect the size, shape, and symmetry of the scrotum while observing for lesions or edema. Gently lift the scrotum to view the posterior surface. The scrotal skin is usually loose, more deeply pigmented than body skin, and the surface is coarse. Tightening of the skin or loss of wrinkling reveals edema. The size of the scrotum normally changes with temperature variations because the dartos muscle contracts in cold and relaxes in warm temperatures. Testicular cancer is a solid tumor common in young men ages 18 to 34 years. Early detection is critical. Explain testicular self-examination while examining the patient. The testes are normally sensitive but not tender. The underlying testicles are normally ovoid and approximately 2 to 4 cm (1 to 1½ inches) in size. Gently palpate the testicles and epididymis between the thumb and first two fingers. Note the size, shape, and consistency of the organs. The most common symptoms of testicular cancer are a painless enlargement of one testis and the appearance of a palpable, small, hard lump, about the size of a pea, on the front or side of the testicle. Continue to palpate the vas deferens separately as it forms the spermatic cord toward the inguinal ring, noting nodules or swelling. It normally feels smooth and discrete. The external inguinal ring provides the opening for the spermatic cord to pass into the inguinal canal. The canal forms a passage through the abdominal wall, a potential site for hernia formation. Have the patient stand during this part of the examination. During inspection ask the patient to strain or bear down. The maneuver helps to make a hernia more visible. Look for obvious bulging in the inguinal area. Complete the examination by palpating for inguinal lymph nodes. Normally small, nontender, mobile horizontal nodes are palpable. Any abnormality indicates local or systemic infection or malignant disease. [Shown is Figure 31-61: Appearance of male genitalia. A, Circumcised. B, Uncircumcised. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Male Genital Self-Examination
Perform the examination after a warm bath or shower, when the scrotal skin is less thick. Stand naked in front of a mirror, hold the penis in your hand, and examine the head. Pull back foreskin if uncircumcised to expose glans. Inspect and palpate head of penis in a clockwise motion, looking carefully for bumps, sores, or blisters. Look for any genital warts. All men 15 years and older need to perform this examination monthly, using these steps. [Review Box 31-27, Male Genital Self-examination, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Male Genital Self-Examination (Cont.)
Look at opening at end of penis for discharge. Look along entire shaft of penis for same signs. Separate pubic hair at base of penis, and carefully examine skin underneath. [Shown is Figure 1 from Box 31-27: Male Genital Self-examination.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Testicular Self-Examination
Look for swelling or lumps in skin of scrotum while looking in mirror. Use both hands, placing index and middle fingers under testicles and thumb on top. Testicular self-examination is important for detecting testicular carcinoma. [Shown is Figure 2 from Box 31-27: Male Genital Self-examination.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Testicular Self-Examination (Cont.)
Gently roll testicle, feeling for lumps, swelling, soreness, or harder consistency. Find the epididymis (cordlike structure on top and back of testicle; it is not a lump). Feel for small, pea-sized lumps on front and side of testicle. Abnormal lumps are usually painless. Call your health care provider for abnormal findings. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Rectum and Anus Perform after genital examination. Explain all steps to the patient. Provide privacy. Use inspection and digital palpation. A good time to perform the rectal examination is after the genital examination. Usually this examination is not performed for young children or adolescents. It detects colorectal cancer in its early stages. The rectal examination also detects prostatic tumors in men. Collect a health history to detect the patient’s risk for bowel or rectal disease (men and women) or prostatic disease (men). Teach the patient about the purpose of the examination. [Review Table 31-30, Nursing History for Rectal and Anal Assessment, with students.] [Review Box 31-28, Patient Teaching: Rectal and Anal Assessment, with students.] The rectal examination is uncomfortable; thus explaining all steps helps a patient relax. Use a calm, slow-paced, gentle approach during the examination. Female patients remain in the dorsal recumbent position following genitalia examination or they assume a side-lying (Sims’) position. The best way to examine men is to have the patient stand and bend over forward with hips flexed and upper body resting across an examination table. Examine a nonambulatory patient in the Sims’ position. Use nonlatex clean gloves. Using the nondominant hand, gently retract the buttocks to view the perianal and sacrococcygeal areas. Perianal skin is smooth, more pigmented, and coarser than skin over the buttocks. Inspect anal tissue for skin characteristics, lesions, external hemorrhoids (dilated veins that appear as reddened protrusions), ulcers, fissures and fistulas, inflammation, rashes, or excoriation. Anal tissues are moist and hairless, and the voluntary external muscle sphincter holds the anus closed. Next ask a patient to bear down as though having a bowel movement. Any internal hemorrhoids or fissures appear at this time. Use clock reference (e.g., 3 o’clock or 8 o’clock) to describe location of findings. Normally there is no protrusion of tissue. Examine the anal canal and sphincters with digital palpation, and in male patients palpate the prostate gland to rule out enlargement. Usually advanced practitioners perform this portion of the examination. This technique is not discussed here. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Musculoskeletal System
General inspection: Gait Posture Standing Sitting The musculoskeletal assessment can be performed as a separate examination or integrated with other parts of the total physical examination. The assessment of musculoskeletal function focuses on determining range of joint motion, muscle strength and tone, and joint and muscle condition. Because muscular disorders are often the result of neurological disease, you may choose to perform a simultaneous neurological assessment. While examining a patient’s musculoskeletal function, visualize the anatomy of bone and muscle placement and joint structure. For a complete examination expose the muscles and joints so they are free to move. Have the patient assume a sitting, supine, prone, or standing position while assessing specific muscle groups. [Review Table 31-31, Nursing History for Musculoskeletal Assessment, with students.] Observe the patient’s gait when entering the examination room. When the patient is unaware of the nature of your observation, gait is more natural. Later, a more formal test has the patient walk in a straight line away from and return to the point of origin. Older adults often walk with smaller steps and a wider base of support. Observe the patient from the side and while facing the patient in a standing position. The normal standing posture is upright with parallel alignment of the hips and shoulders. While observing from the side of the patient, note the normal cervical, thoracic, and lumbar curves. As the patient sits, some degree of rounding of the shoulders is normal. Older adults tend to assume a stooped, forward-bent posture with the hips and knees somewhat flexed and arms bent at the elbows, raising the level of the arms. [Shown is Figure 31-62: Inspection of overall body posture. A, Anterior view. B, Posterior view. C, Lateral view.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Musculoskeletal System (Cont.)
Assess for lordosis, kyphosis, or scoliosis. Common postural abnormalities include lordosis, kyphosis, and scoliosis. Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. This postural abnormality is common in older adults. Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called scoliosis. Loss of height is frequently the first clinical sign of osteoporosis, in which height loss occurs in the trunk as a result of vertebral fracture and collapse. Osteoporosis is a systemic skeletal condition that is noted to have both decreased bone mass and deterioration of bone tissue, making bones fragile and at risk for fracture. Osteopenia, characterized by low bone mass of the hip, puts persons at risk for osteoporosis, fractures, and potential complications later in life. Approximately 80% of people with osteoporosis are women; approximately 20% of the time the disease affects men. It affects any age group, including children. Patients should be taught ways to reduce the chance of developing this disease. [Review Box 31-29, Patient Teaching: Health Promotion to Prevent Osteoporosis in Women, with students.] During general inspection look at the extremities for overall size, gross deformity, bony enlargement, alignment, and symmetry. Normally there is bilateral symmetry in length, circumference, alignment, and position and in the number of skinfolds. A general review pinpoints areas requiring specialized assessment. [Shown is Figure 31-63: Common postural abnormalities. A, Lordosis. B, Kyphosis. C, Scoliosis.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Palpation Range of joint motion Apply gentle palpation to all bones, joints, and surrounding muscles during a complete examination. For a focused assessment only examine the involved area. Note any heat, tenderness, edema, or resistance to pressure. The patient should not feel any discomfort when you palpate. Muscles should be firm. The examination includes comparison of both active and passive range of motion (ROM). Ask the patient to put each major joint through active and passive full ROM. Learn the correct terminology for the movements that the joints are capable of making and teach the patient how to move through each ROM. Demonstrate ROM to the patient when possible. To assess ROM passively, ask the patient to relax and then passively move the extremities through their ROM. Compare the same body parts for equality in movement. [Review Table 31-32, Terminology for Normal Range-of-Motion Positions, with students.] Do not force a joint into a painful position. Know the normal range of each joint and the extent to which you can move the patient’s joints. ROM is equal between contralateral joints. Ideally assess the patient’s normal range to determine a baseline for assessing later change. [Shown is Figure 31-64: Range of motion of hand and wrist. A, Metacarpophalangeal flexion and hyperextension. B, Finger flexion: thumb to each fingertip and to the base of the little finger. C, Finger flexion, fist formation. D, Finger abduction. E, Wrist flexion and hyperextension. F, Wrist radial and ulnar movement. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Range of motion (Cont.) Goniometer Muscle tone and strength Hypertonicity Hypotonicity Atrophy A goniometer, frequently used by physical and occupational therapists, measures the precise degree of motion in a particular joint and is mainly for patients who have a suspected reduction in joint movement. The instrument has two flexible arms with a 180-degree protractor in the center. Position the center of the protractor at the center of the joint you are measuring. The arms extend along the body parts on each side of the protractor. Measure the joint angle before moving the joint. After taking the joint through a full ROM, measure the angle again to determine the degree of movement. Compare the reading with the normal degree of joint movement. Joints are typically free from stiffness, instability, swelling, or inflammation. There should be no discomfort when applying pressure to bones and joints. In older adults, joints often become swollen and stiff, with reduced ROM resulting from cartilage erosion and fibrosis of synovial membranes. If a joint appears swollen and inflamed, palpate it for warmth. Assess muscle strength and tone during ROM measurement. Integrate these findings with those from the neurological assessment. Note muscle tone, the slight muscular resistance felt as you move the relaxed extremity passively through its ROM. Ask the patient to allow an extremity to relax or hang limp. This is often difficult, particularly if the patient feels pain in it. Support the extremity and grasp each limb, moving it through the normal ROM. Normal tone causes a mild, even resistance to movement through the entire range. If a muscle has increased tone, or hypertonicity, there is considerable resistance with any sudden passive movement of a joint. Continued movement eventually causes the muscle to relax. A muscle that has little tone (hypotonicity) feels flabby. The involved extremity hangs loosely in a position determined by gravity. For assessment of muscle strength, have the patient assume a stable position. He or she performs maneuvers demonstrating strength of major muscle groups. [Review Table 31-33, Maneuvers to Assess Muscle Strength, with students.] Use a grading scale of “0 to 5” to compare symmetrical muscle pairs for strength. [Review Table 31-34, Muscle Strength, with students.] Examine each muscle group. Ask the patient to first flex the muscle you are examining and then to resist when you apply an opposing force against that flexion. It is important to not allow the patient to move the joint. Gradually increase pressure to a muscle group (e.g., elbow extension). Have the patient resist the pressure you apply by attempting to move against resistance (e.g., elbow flexion) until instructed to stop. Vary the amount of pressure applied and observe the joint move. If you identify a weakness, compare the size of the muscle with its opposite counterpart by measuring the circumference of the muscle body with a tape measure. A muscle that has atrophied (reduced in size) feels soft and boggy when palpated. [Shown at top is Figure 31-65: The patient flexes the arm; the goniometer measures joint range of motion. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] [Shown at bottom is Figure 31-66: Assessing muscle tone.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Jane continues to care for Mr. Neal. He had a colon resection for cancer 2 days ago. The morning shift has just started, and the night nurse reported that he had an “uneventful” night. Mr. Neal is allowed nothing by mouth (NPO) and has an IV line for parenteral fluids, a nasogastric (NG) tube connected to low intermittent suction, an abdominal dressing, and a urethral (Foley) catheter with gravity drainage. [Ask students: What focused systems assessment does Jane need to complete? Discuss: key elements of these assessments.] Focused assessments include cardiovascular and peripheral vascular, respiratory, abdominal (GI/genitourinary), and integumentary. The key elements of these assessments include: Cardiovascular: blood pressure, heart rate, and auscultation of the heart. Peripheral vascular: inspection and palpation of extremities; peripheral pulses; edema; skin color and temperature; capillary refill of nail beds. Respiratory: inspect, palpate, and auscultate anterior, posterior, and lateral lung fields bilaterally. Abdominal: inspect and auscultate abdomen in all four quadrants; no palpation or percussion due to abdominal surgery; check NG tube functioning (turn off for a moment to assess bowel sounds); assess abdominal dressing for intactness and drainage. Assess Foley catheter function. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Neurological System Responsible for many functions Full assessment requires time and attention to detail. Many variables must be considered during evaluation: level of consciousness (LOC), physical status, chief complaint. Collect all equipment before beginning. The neurological system is responsible for many functions, including initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought processes, control of speech, and storage of memory. A full assessment of neurological function requires much time and attention to detail. For efficiency, integrate neurological measurements with other parts of the physical examination. Consider many variables when deciding the extent of the neurological examination. A patient’s level of consciousness influences his or her ability to follow directions. General physical status influences tolerance to assessment. A patient’s chief complaint also helps determine the need for a thorough neurological assessment. If a patient complains of headache or a recent loss of function in an extremity, he or she needs a complete neurological review. [Review Table 34-35, Nursing History for Neurological Assessment, with students.] You will need the following items for a complete examination: Reading material Vials containing aromatic substances (e.g., vanilla extract and coffee) Opposite tip of cotton swab or tongue blade broken in half Snellen eye chart Penlight Vials containing sugar, salt, lemon with applicators Tongue blade Two test tubes, one filled with hot water and the other with cold water Cotton balls or cotton-tipped applicators Tuning fork Reflex hammer Copyright © 2017, Elsevier Inc. All Rights Reserved.

Neurological System (Cont.)
Mental and emotional status Mini-Mental State Examination (MMSE) Cultural considerations Delirium You learn a great deal about mental capacities and emotional state simply by interacting with a patient. Ask questions during an examination to gather data and observe the appropriateness of emotions and thoughts. Special assessment tools are designed to assess a patient’s mental status. The Mini-Mental State Examination (MMSE) is an instrument developed by Folstein et al. that measures orientation and cognitive function. The maximum score on the MMSE is 31. Patients with scores of 21 or less generally reveal cognitive impairment requiring further evaluation. To ensure an objective assessment, consider a patient’s cultural and educational background, values, beliefs, and previous experiences. Such factors influence response to questions. An alteration in mental or emotional status reflects a disturbance in cerebral functioning. The cerebral cortex controls and integrates intellectual and emotional functioning. Primary brain disorders, medication, and metabolic changes are examples of factors that change cerebral function. Delirium is an acute mental disorder that occurs among hospitalized patients. Obtain a thorough history of a patient’s behavior before delirium develops so as to recognize the condition early. Family members are usually a good resource. Among older adults delirium most often presents within the first 48 to 72 hours of hospital admission. It is an acute mental disorder characterized by confusion, disorientation, and restlessness. It is often a sign of an impending or underlying physical illness in older adults. The acute condition differs from dementia, a more progressive, organic mental disorder such as Alzheimer’s disease. You need to recognize the difference so you can try to learn the underlying cause of delirium. Fortunately, the condition often reverses when it is correctly assessed and the underlying cause is treated (i.e., central nervous system [CNS], metabolic, and cardiopulmonary disorders; systemic illnesses; and sensory deprivation or overload). To avoid misdiagnosis you need to adequately assess mental status. Frequently, patients who develop delirium are labeled with “sundown syndrome” because the delirium frequently worsens at night. Many practitioners mistake this as being common with old age. Be aware that children are vulnerable to delirium from causes such as infection, drugs, serious trauma, autoimmune disorders, general anesthesia, and after transplant. [Review Box 31-31, Clinical Criteria for Delirium, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

MMSE Sample Questions Orientation to time “What is the date?” Registration “Listen carefully. I am going to say three words. Say them back after I stop. Ready? Here they are. . .HOUSE (pause), CAR (pause), LAKE (pause). Now repeat these words back to me.” (Repeat up to 5 times but score only the first trial.) Naming “What is this?” (Point to a pencil or pen.) Reading “Please read this and do what it says.” (Show examinee the words on the stimulus form: CLOSE YOUR EYES.) [Review Box 31-30, Mini-mental State Examination Sample Questions, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Level of consciousness Glasgow Coma Scale Behavior and appearance Nonverbal and verbal Language Aphasia Sensory (receptive) Motor (expressive) A person’s level of consciousness exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli. With a lowering of a patient’s consciousness, use the Glasgow Coma Scale (GCS) for an objective measurement of consciousness on a numerical scale. The GCS allows evaluation of a patient’s neurological status over time. The higher the score, the better the patient’s neurological function. Ask short, simple questions such as “What is your name?” “Where are you?” and “What day is this?” Also ask the patient to follow simple commands such as “Move your toes.” If the patient is not conscious enough to follow commands, try to elicit the pain response. Apply firm pressure with the thumb over the root of the patient’s fingernail. The normal response to the painful stimuli is withdrawal of the body part from the stimulus. A patient with serious neurological impairment exhibits abnormal posturing in response to pain. A flaccid response indicates the absence of muscle tone in the extremities and severe injury to brain tissue. [Review Table 31-36, Glasgow Coma Scale, with students.] Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about mental status. Note nonverbal and verbal behaviors. The patient should behave in a manner expressing concern and interest in the examination. He or she should make eye contact with you and express appropriate feelings that correspond to the situation. Normally the patient shows some degree of personal hygiene. Choice and fit of clothing reflect socioeconomic background or personal taste rather than deficiency in self-concept or self-care. Avoid being judgmental and focus assessment on the appropriateness of clothing for the weather. Older adults sometimes neglect their appearance because of a lack of energy, finances, or reduced vision. Normal cerebral function allows a person to understand spoken or written words and express the self through written words or gestures. Assess the patient’s voice inflection, tone, and manner of speech. Normally a patient’s voice has inflections, is clear and strong, and increases in volume appropriately. Speech is fluent. When communication is clearly ineffective, assess for aphasia. Injury to the cerebral cortex results in aphasia. The two types of aphasia are sensory (or receptive) and motor (or expressive). With receptive aphasia a person cannot understand written or verbal speech. With expressive aphasia a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate. A patient sometimes suffers a combination of receptive and expressive aphasia. Assess language capabilities when it is clear that a patient is communicating ineffectively. Some simple assessment techniques include the following: Point to a familiar object, and ask the patient to name it. Ask the patient to respond to simple verbal and written commands such as “Stand up” or “Sit down.” Ask the patient to read simple sentences out loud. Normally a patient names objects correctly, follows commands, and reads sentences correctly. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Intellectual function Memory Knowledge Abstract thinking Association Judgment Cranial nerve function Intellectual function includes memory (recent, immediate, and past), knowledge, abstract thinking, association, and judgment. Because cultural and educational background influences the ability to respond to test questions, do not ask questions related to concepts or ideas with which a patient is unfamiliar. Assess immediate recall and recent and remote memory. Patients demonstrate immediate recall by repeating a series of numbers (e.g., 7, 4, 1) in the order they are presented or in reverse order. Patients normally recall a series of five to eight digits forward and four to six digits backward. To assess past memory, ask the patient to recall his or her mother’s maiden name, a birthday, or a special date in history. It is best to ask open-ended rather than simple yes/no questions. With older adults do not interpret hearing loss as confusion. Assess knowledge by asking how much the patient knows about his or her illness or the reason for seeking health care. If there is an opportunity to teach, test a patient’s mental status by asking for feedback during a follow-up visit. Interpreting abstract ideas or concepts reflects the capacity for abstract thinking. For an individual to explain common phrases such as “A stitch in time saves nine” or “Don’t count your chickens before they’re hatched” requires a higher level of intellectual function. Note whether a patient’s explanations are relevant and concrete. A patient with altered mental status probably interprets the phrase literally or merely rephrases the words. Another higher level of intellectual functioning involves finding similarities or associations between concepts: a dog is to a beagle as a cat is to a Siamese. Name related concepts and ask the patient to identify their associations. Ask questions that are appropriate to the patient’s level of intelligence, using simple concepts. Judgment requires a comparison and evaluation of facts and ideas to understand their relationships and form appropriate conclusions. Attempt to measure the patient’s ability to make logical decisions with questions such as “Why did you seek health care?” or “What would you do if you became ill at home?” Normally a patient makes logical decisions. To assess cranial nerve function, you may test all 12 cranial nerves, a single nerve, or related group of nerves. A dysfunction in one nerve reflects an alteration at some point along the distribution of the cranial nerve. A complete assessment involves testing the 12 cranial nerves in their numerical order. To remember the order of the nerves, use this simple phrase, “On old Olympus’ towering tops, a Finn and German viewed some hops.” The first letter of each word in the phrase is the same as the first letter of the names of the cranial nerves listed in order. [Review Table 31-37, Cranial Nerve Function and Assessment, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Sensory function The sensory pathways of the CNS conduct sensations of pain, temperature, position, vibration, and crude and finely localized touch. Different nerve pathways relay the sensations. Most patients require only a quick screening of sensory function unless there are symptoms of reduced sensation, motor impairment, or paralysis. The risk of skin breakdown is greater in a patient with impaired sensation. When assessing decreased sensation, complete a skin and tissue assessment of the area affected by the sensory loss. In addition, teach the patient to avoid pressure, thermal, and/or chemical trauma to the area. Normally a patient has sensory responses to all stimuli that are tested. He or she feels sensations equally on both sides of the body in all areas. Assess the major sensory nerves by knowing the sensory dermatome zones. Some areas of the skin are innervated by specific dorsal root cutaneous nerves. For example, if assessment reveals reduced sensation when checking for light touch along an area of the skin (e.g., the lower neck), this determines in general where a neurological lesion exists (e.g., fourth cervical spinal cord segment). Perform all sensory testing with the patient’s eyes closed so he or she is unable to see when or where a stimulus touches the skin. Then touch the patient’s skin in a random, unpredictable order to maintain his or her attention and prevent detection of a predictable pattern. Ask the patient to describe when, what, and where he or she feels each stimulus. Compare symmetrical areas of the body while applying stimuli to the patient’s arms, trunk, and legs. [Review Table 31-38, Assessment of Sensory Nerve Function, with students.] [Shown is Figure 31-67: Dermatomes of body (body surface areas innervated by particular spinal nerves); C1 usually has no cutaneous distribution. A, Anterior view. B, Posterior view. It appears that there is a distinct separation of surface area controlled by each dermatome, but there is almost always overlap between spinal nerves. (From Ball JW et al: Seidel’s guide to physical examination, ed 8, St Louis, 2015, Mosby.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Motor function Coordination Balance Have the patient perform a Romberg’s test by standing with feet together, arms at the sides, both with eyes open and eyes closed. Have the patient close the eyes, with arms held straight at the sides, and stand on one foot and then the other. Another test involves asking the patient to walk a straight line by placing the heel of one foot directly in front of the toes of the other foot. An examination of motor function includes assessments made during the musculoskeletal examination. In addition, the nurse assesses cerebellar function. The cerebellum coordinates muscular activity, maintains balance and equilibrium, and controls posture. To avoid confusion, demonstrate each maneuver and then have the patient repeat it, observing for smoothness and balance in his or her movements. In older adults, normally slow reaction time causes movements to be less rhythmical. [Review Box 31-32, Patient Teaching: Neurological Assessment, with students.] Use one or two of the following tests to assess balance and gross-motor function. When examining the older adult for balance and equilibrium, be aware of the risk for falls. Some older adults need help with this portion of the examination. Have the patient perform a Romberg’s test by standing with feet together, arms at the sides, both with eyes open and eyes closed. Protect the patient’s safety by standing at the side, observe for swaying. Expect slight swaying of the body in the Romberg’s test. A loss of balance (positive Romberg) causes a patient to fall to the side. Normally he or she does not break the stance. Have the patient close the eyes, with arms held straight at the sides, and stand on one foot and then the other. Normally patients are able to maintain balance for 5 seconds with slight swaying. Another test involves asking the patient to walk a straight line by placing the heel of one foot directly in front of the toes of the other foot. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Reflexes: 0: no response 1+: sluggish/diminished 2+: active/expected response 3+: more brisk than expected, slightly hyperactive 4+: brisk and hyperactive with intermittent or transient clonus Eliciting reflex reactions provides data about the integrity of sensory and motor pathways of the reflex arc and specific spinal cord segments. Assessment of reflexes does not determine higher neural center functioning. Each muscle contains a small sensory unit called a muscle spindle, which controls muscle tone and detects changes in the length of muscle fibers. Tapping a tendon with a reflex hammer stretches the muscle and tendon, lengthening the spindle. The spindle sends nerve impulses along afferent nerve pathways to the dorsal horn of the spinal cord segment. Within milliseconds the impulses reach the spinal cord and synapse to travel to the efferent motor neuron in the spinal cord. A motor nerve sends the impulses back to the muscle, causing the reflex response. The two categories of normal reflexes are deep tendon reflexes, elicited by mildly stretching a muscle and tapping a tendon, and cutaneous reflexes, elicited by stimulating the skin superficially: 0: No response 1+: Sluggish or diminished 2+: Active or expected response 3+: More brisk than expected, slightly hyperactive 4+: Brisk and hyperactive with intermittent or transient clonus [Shown is Figure 31-68: Pathway of the reflex arc.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Reflexes Position. Tap tendon briskly. Compare corresponding sides. When assessing reflexes have the patient relax as much as possible to avoid voluntary movement or tensing of muscles. Position the limbs to slightly stretch the muscle being tested. Hold the reflex hammer loosely between the thumb and fingers so it is able to swing freely and tap the tendon briskly. Compare the responses on corresponding sides. Normally the older adult presents with diminished reflexes. Reflexes are hyperactive in patients with alcohol, cocaine, or opioid intoxication. [Review Table 31-39, Assessment of Common Reflexes, with students.] [Shown is Figure 31-69: Position for eliciting patellar tendon reflex. The lower leg normally extends.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

After the Examination Record findings. Give the patient time to dress; assist if needed. If findings are serious, consult health care provider before informing the patient. Delegate cleaning of equipment and examination area. Record complete assessment; review for accuracy and thoroughness. Communicate significant findings. Record findings from the physical assessment either during the examination or when it is completed. Special forms are available to record data. Review all findings before helping the patient dress in case it is necessary to recheck any information or gather additional data. Integrate physical assessment findings into the plan of care. After completing the assessment give the patient time to dress. The hospitalized patient sometimes needs help with hygiene and returning to bed. When the patient is comfortable, it helps to share a summary of the assessment findings. If the findings reveal serious abnormalities such as a mass or highly irregular heart rate, consult the patient’s health care provider before revealing them. It is the health care provider’s responsibility to make definitive medical diagnoses. Explain the type of abnormality found and the need for the health care provider to conduct an additional examination. Delegate cleaning the examination area to support staff if needed. Use infection control practice to remove materials or instruments soiled with potentially infectious wastes. If the patient’s bedside was the examination site, clear away soiled items from the bedside table and make sure that the bed linen is dry and clean. A patient appreciates a clean gown and the opportunity to wash the face and hands. Afterward be sure to perform hand hygiene. Be sure to record a complete assessment. If you delayed entering any items into the assessment form, record them at this time to avoid forgetting any important information. If you made entries periodically during the examination, review them for accuracy and thoroughness. Communicate significant findings to appropriate medical and nursing personnel, either verbally or in the patient’s written care plan. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Summary Remember to gather equipment Only expose client when necessary Perform in an organized manner Prevent changing client’s position frequently Recognize changes due to aging process Be respectful to client Copyright © 2017, Elsevier Inc. All Rights Reserved.

Question What should the nurse instruct the client to do in order to assess cranial nerve 11? A. Smile. B. Frown. C. Shrug shoulder. D. Stick out tongue. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Question While assessing a 82-year-old client’s skin, a nurse discovers nonpainful ruby red papules on the patient’s trunk. What is the nurse’s next action? A. Explain that the client has basal cell carcinoma and should watch for spread. B. Document cherry angiomas as a normal geriatric skin finding. C. Tell the client that he has a benign squamous cell carcinoma. D. Document the presence of edema. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Answer Correct Answer: B The skin is normally free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. Basal cell carcinoma is most common in sun-exposed areas and frequently occurs in a background of sun-damaged skin; it almost never spreads to other parts of the body. Squamous cell carcinoma is more serious than basal cell and develops on the outer layers of sun-exposed skin; these cells may travel to lymph nodes and throughout the body. Report abnormal lesions to the health care provider for further examination. Edema is an area of skin that becomes swollen or edematous from a buildup of fluid in the tissues. This has nothing to do with cherry angiomas. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Chapter 31 Health Assessment and Physical Examination

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