Health Assessment and Physical Examination

Health Assessment and Physical Examination
Chapter 30 Health Assessment and Physical Examination •Physical assessment skills are used during your patient’s examination to guide clinical judgments. •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.

Purposes of 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 [Table 30-3 (on text p. 492) provides a list of recommended preventive screening procedures.]

Purposes of Physical Examination (cont’d)
Use physical examination to: Gather baseline data about patient’s health Support 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 •Gathering a health history requires that you communicate with the patient. In Chapter 24, we discussed communication techniques. •We have talked a lot about nursing process and the importance of a nursing diagnosis and a nursing care plan. Physical assessment findings determine the cause of the diagnosis, which enables nurses to individualize a plan of care. While managing patient problems, you will use physical assessment skills to assess the status of your patient’s health. Nurses can revise the care plan to ensure that the patient’s problems are addressed. •During the evaluation phase, nurses can revise, amend, or discontinue nursing interventions as patients achieve their outcomes and/or goals.

Cultural Sensitivity Culture influences a patient’s behavior.
Consider health beliefs, use of alternative therapies, nutritional habits, relationships with family, and personal comfort zone. Avoid stereotyping. Avoid gender bias. •In Chapter 9, we discussed culture and ethnicity. •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. [Ask the class: 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.] •Remember that recognition and respect for cultural diversity lead to patient satisfaction and improved clinical outcomes.

Case Study (cont’d) 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 the class: What is the next step in Jane’s assessment of Mr. Neal?]

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. •We will discuss infection control more thoroughly in Chapter 28. However, you will use good hand hygiene and will follow health care facility policies. [Table 30-1 (on text p. 489) provides a short list of products that contain latex and available alternatives.] •The environment must provide privacy, good lighting, and climate control. The patient must be comfortable. [Box 30-1 (on text p. 489) presents a list of equipment and supplies needed for physical assessment. Equipment should be properly cleaned or sterilized and in good working order (batteries, bulbs, power cords, or calibration tools).] •Patients need to be told what is going to occur and when. Proper draping is necessary, as is proper positioning. [Table 30-2 (on text p. 490) lists positions for examination.] •Encourage the patient to ask questions. At times, if the patient and the nurse are of opposite gender, a third person in the room may be indicated. Consider cultural and social norms. •When assessing various age groups, you may have to vary your techniques and styles. Children require different handling than do adolescents, adults, and the elderly.

Organization of the Examination
Assessment of each body system Follows the nursing history Systematic and organized Head-to-toe approach •Some tips will help you with your examination: Compare both sides for symmetry. If the patient is seriously ill, first assess the body system that is most at risk. If the patient fatigues easily, allow a rest period between assessments. Perform painful procedures near the end of the assessment. Use accepted medical terms and abbreviations to keep notes brief. Record quick notes during the examination, and complete larger documentation notes at the end of the examination.

Techniques of Physical Assessment
Inspection Palpation Percussion Auscultation •The four techniques used in a physical examination are inspection, palpation, percussion, and auscultation.

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 symmetry. Validate findings with the patient. •To inspect, carefully look, listen, and smell to distinguish normal from abnormal findings. •Recognize normal and abnormal. •Inspection is the simplest of the five assessment skills. [Ask the class: 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.] [Table 30-4 (on text p. 493) provides a list of characteristic odors and the conditions that they may indicate.]

Palpation Used 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. •Always tell the patient what you are doing. •Place the patient in a comfortable position, and encourage the patient to relax. •Palpate sensitive areas last. •Use different parts of the hand to detect different characteristics. 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. Assess body temperature by using the dorsal surface or back of the hand. The palmar surface of the hand and fingers is more sensitive to vibration. Measure position, consistency, and turgor by lightly grasping the body part with the fingertips. [Table 30-5 (on text p. 494) provides examples of characteristics measured by palpation.] [Images are Figures 30-1 and 30-2 (on text p. 494) and illustrate the use of different parts of the hands, as well as palpation pressure.]

Percussion Tap body with fingertips to produce a vibration.
Sound determines location, size, and density of structures. •You need to know the various densities of structures to locate organs or masses, to map their boundaries, and to determine their size. •An abnormal size suggests a mass or air or fluid within an organ or cavity. •Developing the skill of percussion requires practice.

Auscultation Involves listening to sounds
Learn normal sounds first before identifying abnormal sounds or variations. Requires a good stethoscope Requires concentration and practice •Some sounds you can hear without assistance; other sounds require the use of a stethoscope. •Chapter 29 describes the parts of the stethoscope and its general use. •Becoming proficient in auscultation requires that you recognize the sounds produced by body parts and the best locations for hearing sounds. •The bell of the stethoscope is used to hear low-pitched sounds and the diaphragm for high-pitched sounds. [Box 30-2 (on text p. 495) provides ways to practice using techniques of caring for the stethoscope.] [Ask the class: 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.]

General Survey Assess appearance and behavior. Assess vital signs.
Assess height and weight. •You can learn a lot about your patients before you ever lay hands on them. •By looking at your patient, you will be able to assess: Gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, signs of patient abuse, and signs of substance abuse. Always remember how age, gender, culture, and ethnicity affect your patient. Box 30-3 (on text p. 497) provides clinical indicators of abuse. Box 30-4 (on text p. 498) provides behaviors that are suspicious for substance abuse. Box 30-5 (on text p. 498) provides questions for assessing dietary history for older adults. •We just discussed vital signs in Chapter 29. Remember to incorporate that knowledge. •Height and weight reflect a person’s overall level of health. It will be important to obtain a diet history for your patient. [Table 30-6 (on text p. 499) presents a guideline for weight based on height.] [Table 30-7 (on text p. 499) provides nursing history for weight assessment.] [Image is Figure 30-3 (on text p. 498), Measurement of infant length.]

Skin Integument Color Moisture Temperature Texture Turgor Pigmentation
Cyanosis Jaundice Erythema Moisture Temperature Texture Turgor The integumentary system refers to the skin, hair, scalp, and nails. Observe for cyanosis (bluish discoloration) of the lips, nail beds, palpebral conjunctivae, and palms. The best site to inspect for jaundice (yellow-orange discoloration) is the patient’s sclera. You can see normal reactive hyperemia, or redness, most often in regions exposed to pressure such as the sacrum, heels, and greater trochanter. Inspect for any patches or areas of skin color variation. Localized skin changes such as pallor or erythema (red discoloration) indicate circulatory changes. For example, an area of erythema is caused by localized vasodilation resulting from sunburn, inflammation, or fever. 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. [Ask your students: Why do you need to assess your patient’s skin? Discuss: to assess oxygenation, circulation, nutrition, local tissue damage, and hydration.] [Table 30-8 (on text p. 500) provides nursing history for skin assessment.] [Table 30-9 (on text p. 501) presents skin color variations. You need to remember to consider ethnicity.] [Table (on text p. 501) lists physical findings of the skin indicative of substance abuse.] [Ask your students: What abnormalities should you look for? Discuss: cyanosis, pallor, jaundice, erythema, petechiae] [Images are Figure 30-4 (on text p. 500), A cross-section of the skin reveals three layers: epidermis, dermis, and subcutaneous fatty tissues; and Figure 30-5 (on text p. 502), Assessment of skin turgor.]

Skin (cont’d) 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. With aging, capillaries become fragile and are more easily injured. Petechiae are nonblanching, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers. 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 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, this is called pitting edema. To assess the degree of pitting edema (shown), 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. Assess for skin lesions or skin cancer, and take the opportunity to educate the patient. Use the ABCD mnemonic to assess the skin for any type of carcinoma: 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 [Box 30-6 (on text p. 503) shows types of primary skin lesions.] [Box 30-7 (on text p. 504) shows skin malignancies.] [Box 30-8 (on text p. 505) provides evidence-based practice for skin assessment.] [Image is Figure 30-6 (on text p. 502), Assessing for pitting edema.]

Hair and Scalp Hair: Color Distribution Quantity Thickness Texture
Lubrication •Careful inspection of hair follicles on the scalp and pubic areas can reveal lice or other parasites. •Remember that differences will be gender specific and race specific. •Hair loss (alopecia) or thinning of the hair is usually related to genetic tendencies or endocrine disorders such as diabetes, thyroiditis, and even menopause. •Age-related differences will be seen across the life span. [Ask students: What are the two types of hair? Discuss: vellus and terminal.] [Table (on text p. 504) provides a nursing history for hair and scalp assessment.] [Box 30-9 (on text p. 506) provides patient teaching for hair and scalp assessment.] [Image is Figure 30-7 (on text p. 505), Head lice. Numerous white nits attach to hairs.]

Nails Condition of nails reflects: General health State of nutrition
Occupation Level of self-care Age [Ask students: How do you assess nails? Discuss: inspection and palpation.] •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. [Table (on text p. 506) provides nursing history for nail assessment.] [Box (on text p. 507) illustrates abnormalities of the nail bed.] [Box (on text p. 507) provides patient teaching for nail assessment.] [Image is Figure 30-8 (on text p. 506), Components of nail unit.] [Image is Figure 30-9 (on text p. 507), Pigmented bands in nail of patient with dark skin.]

Head and Neck Includes assessment of the head, eyes, ears, nose, mouth, pharynx, neck, lymph nodes, carotid arteries, thyroid gland, and trachea. Use inspection, palpation, and auscultation. •During the health history, screen for previous or present injuries. •Take an opportunity to enforce helmet use during contact and noncontact activities, such as biking, roller boarding, skating, ice skating, ice hockey, football, rock climbing, and skiing. [Table (on text p. 508) provides nursing history for head assessment.]

Eyes Visual acuity Extraocular movements Visual fields Nystagmus
•When examining the eyes, you will assess size, shape, structure, visual acuity, visual fields, conjunctiva, sclera, cornea, pupil, and iris. •Nystagmus, an involuntary, rhythmical oscillation of the eyes, occurs as a result of local injury to eye muscles and supporting structures, or may follow a disorder of the cranial nerves innervating the muscles. •The presence of redness in the conjunctiva indicates an allergic or infectious conjunctivitis. •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. •The photo at the bottom shows the six directions of gaze. Direct patient to follow finger movement through each gaze. [Table (on text p. 509) provides nursing history for eye assessment.] [Box (on text p. 509) lists common eye and vision problems.] [Box (on text p. 510) provides patient teaching for eye assessment.] [Top image is Figure (on text p. 508), Cross-section of eye.] [Bottom image is Figure (on text p. 510) , Six directions of gaze. Direct patient to follow finger movement through each gaze. CN, Cranial nerve.]

Eyes (cont’d) [Image is Figure (on text p. 511), The lacrimal apparatus secretes and drains tears, which moisten and lubricate eye structures.] The lids are close to the eyeball. An abnormal drooping of the lid over the pupil is called ptosis, which is caused by edema or impairment of the third cranial nerve. In the older adult, ptosis results from loss of elasticity that accompanies aging. The nurse observes for defects in the position of the lid margins. An older adult frequently has lid margins that turn outward (ectropion) or inward (entropion).

Eyes (cont’d) [Image is Figure (on text p. 511), Chart depicting pupillary size in millimeters.]

Eyes (cont’d) External eye structure Position and alignment Eyebrows
Eyelids Lacrimal apparatus Conjunctivae and sclerae Corneas Pupils and irises PERRLA [Ask your students: What does the mnemonic PERRLA stand for? Discuss: pupils equal, round, reactive to light, and accommodation.] [Images are Figure (on text p. 512), 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.]

Eyes (cont’d) Internal eye structure Retina Choroid Optic nerve disc
Macula Fovea Centralis Retinal vessels •Patients in greatest need of an examination are those with diabetes, hypertension, and intracranial disorders. •Examination of internal eye structures through the use of an ophthalmoscope is beyond the scope of practice of new graduate nurses. Advanced nurse practitioners use the ophthalmoscope to inspect the fundus. [Images are Figure (on text p. 512), Fundus of (A) white patient and (B) black patient.]

Ears Auricles Texture Tenderness Lesions Color Pain Cerumen
•Palpate the auricles for texture, tenderness, and skin lesions. •Auricles are normally smooth and without lesions. •Ear color is usually the same as that of the face, without moles, cysts, deformities, or nodules. Redness is a sign of inflammation or fever. Extreme pallor indicates frostbite. •If palpation causes pain, an external ear infection is likely. If the patient has ear pain, but palpation does not cause additional pain, infection may be present in the middle ear. •A yellow, waxy substance called cerumen is common. Yellow or green, foul-smelling discharge indicates infection or a foreign body. [Table (on text p. 513) provides nursing history for ear assessment.] [Box (on text p. 514) provides patient teaching for ear assessment.] [Top image is Figure (on text p. 512), Structures of external, middle, and inner ear.] [Bottom image is Figure (on text p. 513), Anatomical structures of auricle.]

Ears (cont’d) Ear canals and eardrums
•Observe the deeper structures of the external and middle ear with the use of an otoscope. •Insert the scope while pulling the auricle upward and backward in the adult and the older child. This maneuver straightens the ear canal. For infants, the auricle should be pulled downward and backward. [Image is Figure (on text p. 514), Otoscopic examination.]

Ears (cont’d) Hearing acuity Three types of hearing loss Ototoxicity
[Ask students: What are the three types of hearing loss? Discuss: 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. •Older adults are especially at risk for hearing loss caused by ototoxicity (injury to auditory nerve) resulting from high maintenance doses of antibiotics. •Hearing loss among adolescents is increasing, especially among those with high levels of noise exposure, as from loud music. [Image is Figure (on text p. 514), Normal right tympanic membrane.]

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. •Rationale: 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. [Image is from Table (on text p. 515) , Tuning Fork Tests.]

Tuning Fork Tests (cont’d)
Rinne test Place stem of vibrating tuning fork against patient’s mastoid process (see illustration B). Begin counting the interval with your 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 [Image is from Table (on text p. 515) , Tuning Fork Tests.]

Rinne test Quickly place still-vibrating tines 1 to 2 cm (1/2 to 1 inch) from ear canal, and ask patient to tell you when she no longer hears the sound. Continue counting time the sound is heard by air conduction. [Image is from Table (on text p. 515) , Tuning Fork Tests.]

Rinne test 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.

Nose and Sinuses Nose Sinuses Excoriation Polyps
•When inspecting the external nose, observe for shape, size, skin, color, and the presence of deformity or inflammation. •If swelling or deformities exist, gently palpate the ridge and soft tissue of the nose by placing one finger on each side of the nasal arch and gently moving the fingers from the nasal bridge to the tip. [Ask students: How can the color of nasal discharge indicate patient condition? Discuss: Pale mucosa with clear discharge indicates allergy. A mucoid discharge indicates rhinitis. A sinus infection results in yellowish or greenish discharge.] •For the patient with a nasogastric tube, routinely check for local skin breakdown (excoriation) of the naris, characterized by redness and skin sloughing. •During the examination, note any polyps (tumorlike growths) or purulent drainage. •Examination of the sinuses involves palpation. [Table (on text p. 516) provides nursing history for nose and sinus assessment.] [Box (on text p. 517) describes teaching guidelines during nose and sinus assessment.] [Image is Figure (on text p. 516), Palpation of maxillary sinuses.]

Mouth and Pharynx Lips Color Texture Hydration Contour Lesions
•Lip color in the dark-skinned patient varies from pink to plum. •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, an irritation, or skin cancer. [Table (on text p. 517) describes the nursing history for assessment of the mouth and pharynx.] [Image is Figure (on text p. 517), Lips are normally pink, symmetrical, smooth, and moist.]

Mouth and Pharynx (cont’d)
Buccal mucosa Gums Teeth •Ask the patient to clench the teeth and smile to observe tooth occlusion. The upper molars normally rest directly on the lower molars, and the upper incisors slightly override the lower incisors. •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. If lesions are present, palpate them gently with a gloved hand for tenderness, size, and consistency. •Inspect the gums (gingivae) for color, edema, retraction, bleeding, and lesions. •Inspect the teeth to determine the quality of dental hygiene. Note the color of teeth and the presence of dental caries (cavities), tartar, and extraction sites. [Left image is Figure (on text p. 518), Inspection of inner oral mucosa of lower lip.] [Right image is Figure (on text p. 518), Retraction of buccal mucosa allows for clear visualization.]

Tongue Floor of mouth •Using a penlight for illumination, examine the tongue for color, size, position, texture, and coatings or lesions. Inspect for color, swelling, and lesions such as nodules or cysts. [Image is Figure (on text p. 519), The undersurface of the tongue is highly vascular.]

Palate Hard Soft Pharynx •Observe the palates for color, shape, texture, and extra bony prominences or defects. •Perform an examination of pharyngeal structures to rule out infection, inflammation, or lesions. [Box (on text p. 518) provides patient teaching for mouth and pharyngeal assessment.] [Left image is Figure (on text p. 519), The hard palate is located anteriorly in the roof of the mouth.] [Right image is Figure (on text p. 519), A penlight and tongue depressor allow the visualization of the uvula and posterior soft palate.]

Neck Neck muscles Anterior triangle Posterior triangle
•Inspect the neck in the usual anatomical position, flexed forward, hyperextended backward, and moved laterally and sideways to test the sternocleidomastoid and trapezius muscles. •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. [Image is Figure (on text p. 520), 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. ]

Palpable Lymph Nodes •An abnormality of superficial lymph nodes sometimes reveals the presence of an infection or malignancy. [Image is Figure (on text p. 521), Palpable lymph nodes in the head and neck.]

Neck Lymph nodes Carotid artery Jugular vein Malignancy
•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 fingers over the clavicle lateral to the sternocleidomastoid muscle. •You may postpone examination of the jugular veins and carotid arteries until the vascular system assessment is performed. •Never palpate both of the carotid arteries simultaneously. [Table (on text p. 520) reviews the nursing history for the head and neck examination.] [Box (on text p. 521) provides patient teaching for neck assessment.] [Image is Figure (on text p. 521), Supraclavicular lymph node palpation.]

Neck (cont’d) Thyroid gland Trachea
Part of the upper respiratory system •The thyroid gland is fixed to the trachea. •Inspect the lower neck overlying the thyroid gland for obvious masses, symmetry, and any subtle fullness at the base of the neck. Masses in the neck or mediastinum and pulmonary abnormalities cause displacement laterally. •Determine the position of the trachea by palpating at the suprasternal notch, slipping the thumb and index fingers to each side. Note whether the finger and the thumb shift laterally. Do not apply forceful pressure because this elicits coughing. [Image is Figure (on text p. 522), Anatomical position of thyroid gland.]

Thorax and Lungs Examination Inspection Palpation Auscultation
•Diagnostic equipment such as x-ray films, magnetic resonance imaging (MRI), and computed tomography (CT) scans creates little need for the use of percussion as an assessment measure. •Before assessing the thorax and lungs, be familiar with the landmarks of the chest. These landmarks help you to identify findings and to 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. Keep a mental image of the location of the lobes of the lung and the position of each rib. [Image is Figure (on text p. 523), Anatomical chest wall landmarks. A, Posterior chest landmarks. B, Lateral chest landmarks. C, Anterior chest landmarks.]

Thorax and Lungs (cont’d)
Identify anatomical landmarks. •Accurate physical assessment of the thorax and lungs requires review of ventilatory and respiratory functions of the lungs. If disease is affecting the lungs, it affects other body systems as well. •Risk factors for lung disease are reviewed at the time of respiratory assessment. [Box 30-18, on text p. 522, presents patient teaching for lung assessment.] [Table (on text p. 524) reviews the nursing history for lung examination.] [Image is Figure (on text p. 523), Position of lung lobes in relation to anatomical landmarks. A, Anterior position. B, Lateral position. C, Posterior position.]

Posterior thorax Inspect for deformities, position of the spine, slope of the ribs, retraction of the intercostal spaces during inspiration, bulging of the intercostal spaces, and rate and rhythm of breathing. •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. •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. •Assess the rate and rhythm of breathing (see Chapter 29). •Palpation of the posterior thorax provides further information about a patient’s health status. [Images are Figure (on text p. 524), A, Hand position for palpation of posterior thorax excursion. B, As patient inhales, movement of chest excursion separates thumbs.]

Tactile fremitus Created by vocal cords Transmitted through lungs to chest wall Palpation •Sound created by the vocal cords is transmitted through the lung to the chest wall and can be palpated externally. The 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. •Auscultation assesses the movement of air through the tracheobronchial tree and detects mucus or obstructed airways. Recognizing the sounds created by normal airflow allows you to detect sounds caused by airway obstruction. [Image is Figure (on text p. 525), A to C, A systematic pattern (posterior-lateral-anterior) is followed when the thorax is palpated and auscultated.]

Auscultation Adventitious sounds Crackles Rhonchi Wheezes Pleural friction rub •Auscultation assesses 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. When listening, follow the same systematic approach that was used for palpation. •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. •Crackles are caused by random, sudden reinflation of groups of alveoli, or disruptive passage of air through small airways, and can be described as fine, medium, or coarse. •Rhonchi are low-pitched, continuous sounds caused by muscular spasm, fluid, or mucus in larger airways; or new growth or external pressure causing turbulence. •Wheezes are high-pitched continuous musical sounds, like a squeak heard continuously during inspiration or expiration. They usually are louder on expiration and often are heard in asthma. •A pleural friction rub has a dry, rubbing or grating quality and is caused by inflamed pleura: parietal pleura rubbing against visceral pleura. •During auscultation, note the location and characteristics of the sounds, and listen for the absence of breath sounds. [Table (on text p. 525) provides the characteristics of normal breath sounds.] [Table (on text p. 526) provides the characteristics of adventitious breath sounds.] [Image is Figure (on text p. 525), Use the diaphragm of the stethoscope to auscultate breath sounds.]

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. Use inspection, palpation, and auscultation skills to examine the lateral thorax. Normally, the breath sounds you hear when auscultating the lateral thorax are vesicular. •Inspect the anterior thorax for the same features as the posterior thorax. •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.

Case Study (cont’d) During her lung assessment, Jane recognizes that there is a patient teaching opportunity with Mr. Neal. What issue does Jane need to address? [Ask the class: What patient teaching strategies would you use with regard to Mr. Neal’s smoking?] Explain to Mr. Neal the risk factors for chronic lung disease and lung cancer, including cigarette smoking, history of smoking for over 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.

Heart Compare assessment of heart functions with vascular findings.
Assess point of maximal impulse (PMI). Locate anatomical landmarks. [Ask students: What is PMI? Discuss: apical impulse or point of maximal impulse.] •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). [Table (on text p. 527) provides nursing history for heart assessment.] •Age and size affect anatomical position. For instance, an infant’s heart is positioned more horizontally. [Image is Figure (on text p. 527), Anatomical position of the heart.]

Heart (cont’d) Heart sounds S1 S2 S3 S4
•Heart sounds occur in relation to physiological events in the cardiac cycle. S1 and S2 (lub/dub) are normal heart sounds that occur as valves open and close normally, and the heart chambers fill and empty of blood. S3 can be heard when the heart attempts to fill an already distended ventricle, as in congestive heart failure. This sound can be normal in people younger than 30 years of age and in women in the late stages of pregnancy. 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. [Image is Figure (on text p. 528), Cardiac cycle. AVC, Aortic valve closes; AVO, aortic valve opens; ECG, electrocardiogram; MVC, mitral valve closes; MVO, mitral valve opens.]

Heart (cont’d) Inspection and palpation
Patient must be relaxed and comfortable. Inspect and palpate simultaneously. PMI [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.] •During inspection and palpation, look for visible pulsations and exaggerated lifts, and palpate for the apical impulse and any source of vibrations (thrills). A thrill is a continuous palpable sensation that resembles the purring of a cat. •Follow an orderly sequence, beginning with assessment of the base of the heart and moving toward the apex. •Locate the six anatomical landmarks of the heart, and inspect and palpate each area. •Estimate the size of the heart by noting the diameter of the PMI and its position relative to the midclavicular line. [Top image is Figure (on text p. 528), Anatomical sites for assessment of cardiac function.] [Bottom image is Figure (on text p. 529), Palpation of apical pulse.]

Heart (cont’d) Auscultation Dysrhythmia Extra heart sounds
Murmurs (grade, pitch, quality) •Auscultation of the heart detects normal heart sounds, extra heart sounds, and murmurs. •Failure of the heart to beat at regular successive intervals is a dysrhythmia. Some dysrhythmias are life threatening. •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. •S4, or an atrial gallop, occurs just before S1, or ventricular systole. •The final portion of the examination includes assessment for heart murmurs. Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase. Intensity is recorded using grades 1 through 6. Murmurs can vary in pitch and quality. [Box (on text p. 530) provides patient teaching for heart assessment.] [Image is Figure (on text p. 529), Sequence of patient positions for heart auscultation. A, Sitting. B, Supine. C, Left lateral recumbent.]

Vascular System Blood pressure Carotid arteries
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 •To assess the vascular system, you will assess: Carotid arteries, jugular veins, peripheral arteries, peripheral veins, tissue perfusion, lymphatic system •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 measurement. •Do not palpate or massage the carotid arteries vigorously because the carotid sinus is located at the bifurcation of the common carotid arteries in the upper third of the neck. This sinus sends impulses along the vagus nerve. Its stimulation causes a reflex drop in heart rate and blood pressure, which causes syncope or circulatory arrest. •An absent carotid pulse wave indicates arterial occlusion (blockage) or stenosis (narrowing). •Use the skills of inspection, palpation, and auscultation. •Perform portions of the vascular examination during other body system assessments. [Table (on text p. 531) reviews the nursing history data collected before the examination.] [Top image is Figure (on text p. 531), Anatomical position of carotid artery.] [Bottom image is Figure (on text p. 531), Palpation of internal carotid artery along margin of sternocleidomastoid muscle.]

Vascular System (cont’d)
Carotid bruit Narrowed blood vessel creates turbulence, causes blowing/swishing sound. Pronounced “brew-ee” [Left image is Figure (on text p. 532), Occlusion or narrowing of the carotid artery disrupts normal blood flow. The resultant turbulence created a sound (bruit) that is auscultated.] [Right image is Figure (on text p. 532), Auscultation for carotid artery bruit.]

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. •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. •Normally, when a patient lies in the supine position, the external jugular vein distends and becomes easily visible. For some patients with heart disease, the jugular veins remain distended when sitting. •Assess venous pressure. [Top image is Figure (on text p. 533), Position of patient to assess jugular vein distention.] [Bottom image is Figure (on text p. 533), Measuring venous pressure.]

Peripheral arteries and veins Blood flow Condition of skin and nails Integrity of venous system Pulses/sufficiency of 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 the sufficiency of the entire arterial circulation. [Box (on text p. 534) provides patient teaching for vascular assessment.] [Table (on text p. 533) presents indicators for assessing local blood flow.] [Table (on text p. 536) presents signs of venous and arterial insufficiency.] [Left image is Figure (on text p. 534), Anatomical positions of brachial, radial, and ulnar arteries.] [Right image is Figure (on text p. 535), Anatomical position of femoral, popliteal, dorsalis pedis, and posterior tibial arteries.]

Pulses 0: absent, not palpable 1+: pulse diminished, barely palpable 2+: expected/normal 3+: full pulse, increased 4+: bounding pulse •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.

Peripheral Arteries Radial pulse Ulnar pulse Thumb side of wrist
Little finger side of wrist •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. •The ulnar pulse is on the opposite side of the wrist and feels less prominent. •Palpate the ulnar pulse only when evaluating arterial insufficiency to the hand. [Table (on text p. 533) provides indicators for assessing local blood flow.] [Right image is Figure (on text p. 534), Palpation of radial pulse.] [Left image is Figure (on text p. 535), Palpation of ulnar pulse.]

Peripheral Arteries (cont’d)
Brachial pulse Femoral pulse •To palpate the brachial pulse, find the groove between the biceps and triceps muscles above the elbow at the antecubital fossa. 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. •The femoral artery is the primary artery in the leg, delivering blood to the popliteal, posterior tibial, and dorsalis pedis arteries. Find the femoral pulse with the patient lying down with the inguinal area exposed. 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. [Right image is Figure (on text p. 535), Palpation of brachial pulse.] [Left image is Figure (on text p. 535), Palpation of femoral pulse.]

Popliteal pulse Dorsalis pedis pulse •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 and muscles relaxed. Palpate with the fingers of both hands deeply into the popliteal fossa, just lateral to the midline. •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. To find the pulse, place the fingertips between the first and second toes, and slowly move up the dorsum of the foot. [Right image is Figure (on text p. 535), Palpation of the popliteal pulse.] [Left image is Figure (on text p. 536), Palpation of the dorsalis pedis pulse.]

Posterior tibial pulse Ultrasound stethoscopes Tissue perfusion •Find the posterior tibial pulse on the inner side of each ankle. Place the fingers behind and below the medial malleolus (ankle bone). With the foot relaxed and slightly extended, palpate the artery. •If a pulse is difficult to palpate, an ultrasound (Doppler) stethoscope is a useful tool that amplifies the sounds of a pulse wave. •The condition of the skin, mucosa, and nail beds offers useful data about the status of circulatory blood flow/tissue perfusion. Color, clubbing, temperature, texture, venous pattern, hair distribution on the lower leg, scars, ulcers, and capillary refill are all indicators of the effectiveness of the circulation. [Top image is Figure (on text p. 536), Palpation of posterior tibial pulse.] [Bottom image is Figure (on text p. 536), Ultrasound stethoscope in position on brachial artery.]

Peripheral Veins Varicosities Peripheral edema Phlebitis Pitting edema
•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. •Dependent edema around the area of the feet and ankles is a sign of venous insufficiency or right-sided heart failure. •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. (See Slide 16.) •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. [Table (on text p. 536) provides signs of venous and arterial insufficiency.]

Vascular System Lymphatic system Upper and lower extremities
Assess drainage. Palpate. •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 firm but gentle pressure when palpating over each lymphatic chain. •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. [Image is Figure (on text p. 537), A, Lymphatic drainage for the lower extremities. B, Lymphatic drainage for the upper extremities.]

Breasts Examine both females and males. Use inspection and palpation.
Look for symmetry. •Breast size and shape will vary across the life span. •Men who have a mother or a sister with breast cancer are at risk for breast cancer, so they need to examine their breasts regularly. •Men at high risk may be scheduled for routine mammograms. •Take this opportunity to teach both females and males breast self-examination. [Table (on text p. 539) provides nursing history for breast assessment.] [Box (on text p. 539) describes normal changes in the breast during a woman’s life span.] [Box (on text p. 541) provides patient teaching on female breast assessment.] [Image is Figure (on text p. 541), 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.]

Breast Self-Examination
1. Stand before a mirror. Inspect both breasts for anything unusual such as discharge from the nipples, puckering, dimpling, or scaling of the skin. •Patients should perform breast self-examination (BSE) once a month to become familiar with the usual appearance and feel of both breasts. •Familiarity makes it easier to notice any changes in the breast from one month to another. •Early discovery of a change from baseline is the purpose of BSE. •If menstruating, the best time to do BSE is 2 or 3 days after the monthly period ends, when breasts are least likely to be tender or swollen. •If no longer menstruating, pick a day such as the first day of the month as a reminder to do BSE. [Image is from Box (on text p. 538), Breast Self-Examination.]

Breast Self-Examination (cont’d)
2. Watching closely in the mirror, clasp hands behind the head, and swing elbows forward. •The next two steps are designed to emphasize any change in the shape or contour of the breasts. During each step, the patient will feel chest muscles tighten. [Image is from Box (on text p. 538), Breast Self-Examination.]

3. Press hands firmly on hips and bow slightly toward the mirror, while pulling shoulders and elbows forward. [Image is from Box (on text p. 538), Breast Self-Examination.]

4. Raise left arm. Use three or four fingers of right hand to explore left breast firmly, carefully, and thoroughly. Beginning at outer edge, press flat part of fingers in small circles, moving circles slowly around breast. Gradually work toward nipple. Cover entire breast. Pay special attention to area between breast and armpit, including armpit itself. Feel for any unusual lump or mass under the skin. •Some women do the next part of the examination in the shower. Fingers glide over soapy skin, making it easy to appreciate the texture underneath. [Image is from Box (on text p. 538), Breast Self-Examination.]

5. Gently squeeze the nipple and look for discharge. Repeat the examination on the right breast. [Image is from Box (on text p. 538), Breast Self-Examination.]

6. Repeat steps 4 and 5 while lying down. Lie flat on back, right arm over head and pillow/folded towel under right shoulder. This position flattens the breast for easier examination. Use same circular motion described earlier. 7. Repeat on the right breast. [Image is from Box (on text p. 538), Breast Self-Examination.]

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. [Image is Figure (on text p. 540), Quadrants of left breast and axillary tail of Spence.]

Breasts (cont’d) •Palpation assesses the condition of underlying breast tissue and lymph nodes. •Breast tissue consists of glandular tissue, fibrous supportive ligaments, and fat. •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. [Image is Figure (on text p. 540), Anatomical position of axillary and clavicular lymph nodes.]

Breasts (cont’d) •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: 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. [Image is Figure (on text p. 540), Support patient’s arm and palpate axillary lymph nodes.]

Breasts (cont’d) •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. •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 with 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. [Image is Figure (on text p. 541), 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.]

Abdomen Complex assessment because of organs located in the abdominal cavity Inspection Auscultation Palpation [Ask students: Which organs will you assess? Discuss: liver, stomach, uterus, ovaries, kidneys, and bladder.] •A thorough nursing history helps interpret physical signs. Table (on text p. 542) provides nursing history for abdominal assessment. •Begin with assessment and follow with auscultation, then with palpation. [Image is Figure (on text p. 543), A, Anterior view of abdomen divided by quadrants. B, Posterior view of abdominal section.]

Abdomen (cont’d) Inspection Umbilicus Contour and symmetry
Enlarged organs or masses Movements or pulsations •Before you assess, explain what you will be doing, properly drape the patient, place the patient in a position of comfort, control the environment, and use proper lighting. Most important, reinforce that the patient should be comfortable and should not tense the abdomen. •When examining the abdomen, look for symmetry, masses, or pulsations.

Abdomen (cont’d) Auscultation Bowel motility Vascular sounds
Peristalsis Borborygymi Vascular sounds Bruits Kidney tenderness •Peristalsis, or the movement of contents through the intestines, is a normal function of the small and large intestines. Bowel sounds represent the audible passage of air and fluid that peristalsis creates. •The best time to auscultate is between meals. •Bowel sounds generally are described as normal, audible, absent, hyperactive, or hypoactive. •Absent sounds indicate lack of peristalsis, possibly as the result of late-stage bowel obstruction, paralytic ileus, or peritonitis. •Normally, absent sounds may be audible after general anesthesia. •Hyperactive sounds are loud, “growling” sounds called borborygmi, which indicate increased GI motility. •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. •Assess for kidney inflammation with percussion. If the kidneys are inflamed, the patient feels tenderness during percussion. [Box (on text p. 544) provides patient teaching for abdominal assessment.]

Abdomen (cont’d) Palpation Performed last
Detects tenderness, distention, or masses May be light or deep, as appropriate Aortic pulsation •Assess aortic pulsation by palpating with the thumb and forefinger of one hand deeply into the upper abdomen just left of the midline. 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. [Top image is Figure (on text p. 544), Light palpation of the abdomen.] [Bottom image is Figure (on text p. 545), Deep palpation of the abdomen.]

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. •Assessment may be embarrassing to the patient. You will need to practice cultural sensitivity. •Ask about onset of menarche, history of problems with periods, sexually transmitted infections (STIs). •You may take this opportunity to discuss Papanicolaou (Pap) examinations, birth control issues, and protection against STIs and spread of AIDS. •When examining, make sure to tell the patient what you are about to do, and ensure proper positioning, environmental control, and good lighting. [Table (on text p. 546) provides nursing history for female genitalia and reproductive tract assessment.]

Female Genitalia and Reproductive Tract (cont’d)
Preparation of the patient External genitalia Speculum examination of internal genitalia •Make sure that the equipment is ready before the examination begins. •Ask the patient to empty her bladder so the uterus and ovaries are readily palpable. •Assist the patient into position, and drape. •A male examiner must always have a female attendant present. A female examiner may choose to work alone. If requested, an additional female should be present. •Inspect the external and internal genitalia looking for inflammation, irritation, atrophy, or lesions. •Patients who are at risk for contracting an STI need to learn to perform a genital self-examination. [Box (on text p. 547) provides patient teaching for female genitalia and reproductive tract assessment.] •Internal examination involves use of a plastic or metal speculum consisting of two blades and an adjustment device. The examiner assesses the internal genitalia for cancerous lesions and other abnormalities and collects a specimen for a Pap test for cervical and vaginal cancer. The cervix is inspected for color, position, size, surface characteristics, and discharge. [Image is Figure (on text p. 547), Female external genitalia.]

Male Genitalia Assess the integrity of the external genitalia, inguinal ring, and canal. Use inspection and palpation. •Patients may be embarrassed. Use good communication techniques. •Take the opportunity to discuss STIs, use of condoms, and sexual history. •Male genitalia will change across the life span. •When examining, use good communication, properly drape the patient, properly position the patient, control the environment, and use good lighting. [Box (on text p. 548) provides patient teaching for male genitalia assessment.] [Table (on text p. 548) provides nursing history for male genitalia assessment.] [Image is Figure (on text p. 548), External and internal male sex organs.]

Male Genitalia (cont’d)
Sexual maturity Penis Scrotum Inguinal ring and canal •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. •Inspect the genitalia for lice, rashes, excoriations, lesions, or discharge. Obtain a culture if discharge is present. •Tightening of the scrotal skin or loss of wrinkling reveals edema. •Testicular cancer is common in young men aged 18 to 34 years. Explain testicular self-examination while examining the patient. •The external inguinal ring provides the opening for the spermatic cord to pass into the inguinal canal. Examine the inguinal ring for signs of hernia. [Image is Figure (on text p. 549), Appearance of male genitalia. A, Circumcised. B, Uncircumcised.]

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. •All men 15 years and older need to perform this examination monthly, using these steps.

Male Genital Self-Examination (cont’d)
Look for any genital warts. Look at opening (urethral meatus) at end of penis for discharge. Look along entire shaft of penis for same signs. 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. [Image from Box (on text p. 549), Male Genital Self-Examination.]

Male Genital Self-Examination (cont’d)
Be sure to separate pubic hair at base of penis, and carefully examine skin underneath. •Self-examination is a routine part of self-care. [Image from Box (on text p. 549), Male Genital Self-Examination.]

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. [Image from Box (on text p. 549), Male Genital Self-Examination.]

Testicular Self-Examination (cont’d)
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. Testicular cancer is a solid tumor common in young men aged 18 to 34 years. Early detection is critical. Explain testicular self-examination while examining the patient. The testes normally are sensitive but not tender. [See Box (on text p. 549), Male Genital Self-Examination.]

Rectum and Anus Perform after genital examination.
Explain all steps to the patient. Provide privacy. Use inspection and digital palpation. •This assessment may be uncomfortable and embarrassing for the patient. •Take the opportunity to discuss history of polyps, cancer, inflammatory bowel disease. •Emphasize the need for self-screening habits and colonoscopy after the age of 50, or earlier if familial history exists. •Rectal examination detects colorectal cancer in its early stages and is used to detect prostatic tumors in men. •Inspect anal tissue for skin characteristics, lesions, external hemorrhoids (dilated veins that appear as reddened protrusions), ulcers, fissures and fistulas, inflammation, rashes, or excoriation. •Advanced practitioners examine the anal canal and sphincters with digital palpation, and in male patients, the prostate gland is palpated to rule out enlargement. [Table (on text p. 550) provides nursing history for rectal and anal examination.] [Box (on text p. 551) provides patient teaching for rectal and anal assessment.]

Musculoskeletal System
General inspection: Gait Postural abnormalities Age-related changes •At times, you will assess the musculoskeletal system and the neurological system together. •Conduct an assessment of musculoskeletal function when observing a patient ambulate or participate in other active movements. •Ask patients whether they have had previous problems with falls, fractures, trauma, or neurological deficit. [Table (on text p. 552) presents nursing history for musculoskeletal assessment.] [Image is Figure (on text p. 551), Inspection of overall body posture. A, Anterior view. B, Posterior view. C, Lateral view.]

Musculoskeletal System (cont’d)
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. [Box (on text p. 552) provides patient teaching for health promotion to prevent osteoporosis in women.] [Image is Figure (on text p. 551), Common postural abnormalities. A, Lordosis. B, Kyphosis. C, Scoliosis.]

Palpation Joints Bones Muscles •Apply gentle palpation to all bones, joints, and surrounding muscles during a complete examination. •For a focused assessment, examine only 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. •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.

Range of motion Active and passive •Ask the patient to put each major joint through active and passive full range of motion (ROM) (see Chapter 47). •Do no force a joint into a painful position. •Compare the same body parts for equality in movement. •Know the normal range of each joint and the extent to which you can move the patient’s joints. •Ideally, assess the patient’s normal range to determine a baseline for assessing later change. [Table (on p. 553) provides terminology for normal range-of-motion positions.] [Image is Figure (on text p. 553), 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.]

Range of motion Goniometer •A goniometer measures the precise degree of motion in a particular joint and is used 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. •Measure the joint angle before moving the joint. After taking the joint through full ROM, measure the angle again to determine the degree of movement. •Compare the reading with the normal degree of joint movement. [Image is Figure (on text p. 554), The patient flexes the arm; the goniometer measures joint range of motion.]

Muscle tone and strength Hypertonicity Hypotonicity Atrophy •Assess muscle strength and tone during range of motion measurement. •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 range of motion. •If a muscle has increased tone, or hypertonicity, resistance is considerable 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. •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. [Table (on text p. 554) lists maneuvers to assess muscle strength.] [Table (on text p. 554) provides the grading scale for muscle strength.] [Image is Figure (on text p. 554), Assessing muscle tone.]

Case Study (cont’d) 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 the class: What focused systems assessment does Jane need to complete? Describe the key elements of these assessments.] [Discuss: •Focused assessments include cardiovascular and peripheral vascular, respiratory, abdominal (gastrointestinal/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.]

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. •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. For example, test cranial nerve function while assessing the head and neck. •Observe mental and emotional status during the initial interview. •You will need the following items for a complete examination: reading material, vials containing aromatic substances (e.g., vanilla extract, coffee), opposite tip of cotton swab or tongue blade broken in half, Snellen eye chart, penlight, vials containing sugar or salt, tongue blade [Table (on text p. 555) lists the data collected in the nursing history.]

Neurological System (cont’d)
Mental and emotional status Mini-Mental State Examination (MMSE) Cultural considerations Delirium •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. For example, the Mini-Mental State Examination (MMSE) is an instrument that measures orientation and cognitive function. •To ensure an objective assessment, consider a patient’s cultural and educational background, values, beliefs, and previous experiences. •Delirium is an acute mental disorder that occurs among hospitalized patients. It is characterized by confusion, disorientation, and restlessness. [Box (on text p. 556), provides clinical criteria for delirium.]

MMSE Sample Questions Orientation to time Registration
“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.) [Box (on text p. 556), Mini-Mental State Examination Sample Questions.]

MMSE Sample Questions (cont’d)
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.) [Box (on text p. 556), Mini-Mental State Examination Sample Questions.]

Neurological System Level of consciousness Glasgow Coma Scale
•A person’s level of consciousness exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli. •Talk with the patient, asking questions about events involving his or her concerns about any health problems. •A fully conscious patient responds to questions quickly and expresses ideas logically. •With lowering of a patient’s consciousness, use the Glasgow Coma Scale (GCS) for an objective measurement of consciousness on a numerical scale [Table (on text p. 556) shows the Glasgow Coma Scale.]

Behavior and appearance Nonverbal and verbal Language Aphasia •Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about mental status. •Remain perceptive of a patient’s mannerisms and actions during the entire physical assessment. •Note nonverbal and verbal behaviors. •Normal cerebral function allows a person to understand spoken or written words and to express the self through written words or gestures. •Assess the patient’s voice inflection, tone, and manner of speech. •When communication is clearly ineffective, assess for aphasia, which is caused by an injury to the cerebral cortex. •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. •A patient sometimes suffers a combination of receptive and expressive aphasia.

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. •Testing each aspect of function involves a specific technique. •However, 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. •To assess cranial nerve function, you may test all 12 cranial nerves, a single nerve, or related groups of nerves. •A complete assessment involves testing the 12 cranial nerves in their numerical order. [Table (on text p. 558) presents cranial nerve function and assessment.]

Sensory function •The sensory pathways of the central nervous system (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 symptoms of reduced sensation, motor impairment, or paralysis are noted. [Table (on text p. 560) lists assessment of sensory function.] [Image is Figure (on text p. 559), 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.]

Motor function Coordination Higher extremity/fine-motor control Lower extremity •An examination of motor function includes assessments made during the musculoskeletal examination, as well as cerebellar function. •The cerebellum coordinates muscular activity, maintains balance and equilibrium, and controls posture. •To test coordination, demonstrate each maneuver and then have the patient repeat it, observing for smoothness and balance in his or her movements. [Box (on text p. 558) provides patient teaching for neurological assessment.] •To assess fine-motor function, have the patient extend the arms out to the sides and touch each forefinger alternately to the nose (first with eyes open, then with eyes closed). •A second activity involves touching each finger with the thumb of the same hand in rapid sequence. A patient moves from the index finger to the little finger and back, with one hand tested at a time. •Test lower extremity coordination with the patient lying supine, legs extended. Place a hand at the ball of the patient’s foot. The patient taps the hand with the foot as quickly as possible. Test each foot for speed and smoothness.

Motor function Balance Gross-motor function •Test to assess balance and gross-motor function. •Be aware of the risk of falls in older adults; they may need help with this examination •Have the patient perform Romberg’s test by standing with feet together, arms at the sides, with eyes open and with eyes closed. 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.

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. •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. Grade reflexes according the scale on the slide. [Image is Figure (on text p. 560), Pathway of the reflex arc.]

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 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. [Image is Figure (on text p. 561), Position for eliciting patellar tendon reflex. The lower leg normally extends.]

Assessment of Common Reflexes
Deep Tendon Reflexes Biceps Flex patient’s arm up to 45 degrees at elbow with palms down. Place your thumb in antecubital fossa at base of biceps tendon and your fingers over biceps muscle. Strike triceps tendon with reflex hammer. Flexion of arm at elbow Triceps Flex patient’s arm at elbow, holding arm across chest, or hold upper arm horizontally and allow lower arm to go limp. Strike triceps tendon just above elbow. Extension at elbow [Table (on text p. 561) summarizes common deep tendon and cutaneous reflexes.]

Assessment of Common Reflexes (cont’d)
Deep Tendon Reflexes Patella Have patient sit with legs hanging freely over side of table or chair, or have him or her lie supine and support knee in a flexed 90-degree position. Briskly tap patellar tendon just below patella. Extension of lower leg Achilles Have patient assume same position as for patellar reflex. Slightly dorsiflex patient’s ankle by grasping toes in palm of your hand. Strike Achilles tendon just above heel at ankle malleolus. Plantar flexion of foot [Table (on text p. 561) summarizes common deep tendon and cutaneous reflexes.]

Assessment of Common Reflexes (cont’d)
Cutaneous Reflexes Plantar Have patient lie supine with legs straight and feet relaxed. Take handle end of reflex hammer and stroke lateral aspect of sole from heel to ball of foot, curving across ball of foot toward big toe. Plantar flexion of all toes Abdominal Have patient stand or lie supine. Stroke abdominal skin with base of cotton applicator over lateral borders of rectus abdominis muscle toward midline. Repeat test in each abdominal quadrant. Contraction of rectus abdominis muscle with pulling of umbilicus toward stimulated side [Table (on text p. 561) summarizes common deep tendon and cutaneous reflexes.]

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 examination area. Record complete assessment; review for accuracy and thoroughness. Communicate significant findings. At the end of the examination, provide for the patient’s comfort, and then document a detailed summary of physical assessment findings.

Key Points Perform a physical examination only after proper preparation of the environment and equipment and the patient has been prepared physically and psychologically. Throughout the examination, keep the patient warm, comfortable, and informed of each step of the process. A competent examiner is systematic while combining simultaneous assessment of different body systems. Information from the history helps to focus on body systems likely to be affected. Baseline assessment findings reflect a patient’s functional abilities and serve as the basis for comparison with subsequent assessment findings. Integrate patient teaching throughout the examination to help patients learn about health promotion, disease prevention, and skills to help with any current health issue.

Health Assessment and Physical Examination

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