NURS 112 Exam 2 HA and PE

Purpose of the Physical Examination

• Gather baseline data about a patient's health status

• Supplement, confirm, or refute subjective data obtained

• Identify and confirm nursing diagnoses

• Make clinical decisions about a patient's changing health status and management

• Evaluate the outcomes of care

Cultural Sensitivity

• Respect cultural differences

• Be culturally aware and avoid stereotyping

Health History

• Past medical history

• Surgical History

• Current medications (including OTC)

• Family history

• Psychosocial history

• Spiritual Review of systems

Preparation for the Examination

• Infection control

• Environment

• Equipment

• Physical preparation of the patient

• Psychological preparation of the patient

• Assessment of age-groups

Positions for Examination

• Sitting

• Supine

• Dorsal recumbent

• Lithotomy

• Prone

• Lateral recumbent

• Knee-chest

Sitting

• Area Assessed—Head and neck, back, posterior thorax and lungs, anterior thorax and lungs, breast, axillae, heart, vital signs, and upper extremities

• Rationale—Sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts

• Limitations—Physically weakened patient sometimes is unable to sit. Use supine position with head of bed elevated instead

Supine

• Area Assessed—Head and neck, anterior thorax and lungs, breast, axillae, heart, abdomen, extremities, pulses

• Rationale—This is normally a relaxed position. It provides easy access to the pulse sites

• Limitations—If the patient becomes short of breath easily, raise head of bed

Dorsal Recumbent

• Area Assessed—Head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen

• Rationale—Position is for abdominal assessment because it promotes relaxation of abdominal muscles

• Limitations—Patients with painful disorders are more comfortable with knees flexed

Lithotomy

• Area Assessed—Female genitalia and genital tract

• Rationale—Position with knees abducted provides maximal exposure of female genitalia and facilitates insertion of vaginal speculum

• Limitations—Position is embarrassing and uncomfortable; thus, examiner minimizes time that patient spends in it. Keep patient well draped

Prone

• Area Assessed—Musculoskeletal system

• Rationale—Position is only for assessing extension of hip joint, skin, and buttocks

• Limitations—Patient with respiratory difficulties do not tolerate this position well

Lateral Recumbent

• Area Assessed—Heart, rectum and vagina

• Rationale—Side lying position aids in detecting murmurs. Flexion of the hip and knee improves exposure of rectal and perineal area

• Limitations—Patients with respiratory difficulties do not tolerate this position well. Joint deformities hinder patient's ability to bend hip and knee

Knee Chest

• Area Assessed—Rectum

• Rationale—Position provides maximal exposure of rectal area

• Limitations—This position is embarrassing and uncomfortable

Organization of the Examination

• Compare sides for symmetry

• If the patient is seriously ill, 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

Inspection

Carefully look, listen and smell to distinguish normal from abnormal findings

Palpation

Use touch to gather information

Percussion

Tapping the skin with the fingertips to vibrate underlying tissues and organs

Auscultation

Listening to the sounds the body makes to detect variations from normal

Gender and Race

A person's gender affects the type of examination performed and the order of the assessments. Different physical features are related to gender and race. Certain illnesses are more likely to affect a specific gender or race

Age

Influence normal age characteristics and a person's ability to participate in some parts of the examination

Signs of Distress

Sometimes obvious signs or symptoms indicate pain, difficulty breathing, or anxiety. Set priorities and examine the related physical areas first

Body Type

Observe whether the patient appears trim and muscular, obese, or excessively thin. Body type reflects the level of health, age, and lifestyle

Posture

Normal standing posture shows an upright stance with parallel alignment of the hips and shoulders. Normal sitting posture involves some degree of rounding at the shoulders. Observe whether the patient has slumped, erect, or bent posture, which reflects mood or pain. Changes in older-adult physiology often result in stooped, forward-bent posture, with the hips and knees somewhat flexed and the arms bent at the elbows

Gait

Observe as the patient walks into the room or stands at the bedside. Note whether movements are coordinated or uncoordinated. A person normally walks smoothly, with the arms swinging freely at the sides, each leg moving through with heel or toe placement, and the head and face leading the body. Note if the feet touch the floor correctly or is there any dragging of foot

Body Movements

Observe whether movements are purposeful, noting any tremors involving the extremities. Determine whether any body parts are immobile

Hygiene and Grooming

Note a patient's level of cleanliness by observing the appearance of the hair, skin, and fingernails. Determine whether clothes are clean. Grooming depends on the patient's cognitive and social function, daily or social activities, financial resources, and occupation. Observe for excessive use of cosmetics or cologne that could indicate a change in self-perception

Dress

Culture, lifestyle, socioeconomic, and personal preference affect the selection and wearing of clothing. However, you assess whether the clothing is appropriate for the temperature, weather conditions, or setting. People who are depressed or mentally ill may not be able to select proper clothing, and an older adult might tend to wear extra clothing because of sensitivity to cold

Body Odor

An unpleasant body odor can result from physical exercise, poor hygiene, or certain disease states. Validate any odor that might indicate a health problem

Affect and Mood

Affect is how a person appears to others. Patients express mood or emotional state verbally or nonverbally. Determine whether verbal expressions match nonverbal behavior and whether the mood is appropriate for the situation. By maintaining eye contact you can observe facial expression while asking questions

Speech

Normal speech is understandable and moderately paced and shows an association with the person's thoughts. However, emotion or neurological impairment sometimes causes rapid or slowed speech. Observe whether the patient speaks in a normal tone with clear inflection of words

Signs of Patient Abuse

During examination observe whether the patient tears a spouse or partner, a caregiver, a parent, or an adult child. Consider any obvious physical injury or neglect as a sign of possible abuse. Abuse comes in many forms: physical, mental, emotional, sexual, social, and financial or economic. Observe the behavior of the individual for any signs of frustration, explanations that do not fit the physical presentation, or sign of injury. It is difficult to detect abuse because victims often do not report that they are in abusive situations. If you suspect abuse, find a way to interview the patient in private; patients are more likely to reveal any problems when the suspected abuser is absent from the room

Substance Abuse

Unusual or inconsistent behavior may be an indicator of substance abuse, which can affect all socioeconomic groups. Investigate unusual behaviors further with a well-focused history and physical examination. Always approach the patient in a caring and nonjudgmental way; substance abuse involves both emotional and lifestyle issues

Cyanosis

• Condition—Increased amount of deoxygenated hemoglobin (associated with hypoxia)

• Causes—Heart or lung disease, cold environment

• Assessment Location—Nail beds, lips, mouth, skin

Pallor

• Condition—Reduced amount of oxyhemoglobin; Reduced visibility of oxyhemoglobin resulting from decreased blood flow

• Causes—Anemia; shock

• Assessment Location—Face, conjunctivae, nail beds, palms of hands; Skin, nail beds, conjunctivae, lips

Loss of Pigmentation in Skin

• Condition—Vitiligo

• Causes—Congenital or autoimmune condition causing lack of pigments

• Assessment Location—Patchy areas on skin over face, hands, arms

Erythema

• Condition—Increased visibility of oxyhemoglobin caused by dilation or increased blood flow

• Causes—Fever, direct trauma, sacrum, shoulders, other common sites for pressure injuries

• Assessment Location—Face, area of trauma, sacrum, shoulders, other common sites for pressure injuries

Tan Brown Skin

• Condition—Increased among of melanin

• Causes—Suntan, pregnancy

• Assessment Location—Areas exposed to sun: face, arms, areolas, nipples

Skin Color

• Normal skin pigmentation ranges in tone from ivory or light pink to ruddy pink in light skin from light to deep brown or olive in dark skin

• The assessment of skin involves areas of the skin not exposed to the sun

• Usually color hues are most evident in palms, soles of feet, lips, tongue, and nail beds

Hyperpigmentation

Areas of increased color

Hypopigmentation

Areas of decreased color

Skin Moisture

• Hydration of the skin and mucous membranes help to reveal body fluid imbalances, changes in the environment of the skin, and regulation of body temperature

• Skin is normally smooth and dry

• Excessive moisture may cause maceration of the skin or softening of tissues, resulting in an increased risk of breakdown

Skin Temperature

• Depends on the amount of blood circulating through the dermis

• Increased temperature often accompanies localized erythema or redness of the skin

• Reduction in skin temperature often accompanies pallor and reflects a decrease in blood flow

Skin Texture

• Refers to the appearance of the surface of the skin and how the deeper layers feel

• The skin is normally smooth, soft, even, and flexible in children and adults

Skin Turgor

• Refers to the elasticity of the skin

• Normally the skin loses its elasticity with age, but fluid balance can also affect skin turgor

• Normally the skin lifts easily and falls immediately back to its resting position

• When turgor is poor, it stays pinched and shows tenting

Skin Vascularity

• Circulation of the skin affects color in localized areas and leads to the appearance of superficial blood vessels

• Appears reddened, pink, or pale

Skin Edema

• Present when areas of the skin become swollen or edematous from a buildup of fluid in the tissues

• Formation of it separates the surface of the skin from the pigmented and vascular layers, masking skin color

• Also appears shiny and stretched

Skin Lesions

• Any unusual finding on the skin surface

• Collect standard information about its color, location, texture, size, shape, type, grouping, and distribution

Pitting Edema Rating

• 1+ edema equals a 2 mm depth

• 2+ edema equals a 4 mm depth

• 3+ edema equals a 6 mm depth

• 4+ edema equals a 8 mm depth

ABCDE Carcinoma Assessment

• Asymmetry—Look for uneven shape. One half of mole does not match the other half

• Border Irregularity—Look for edges that are blurred, notched, or ragged

• Color—Look for pigmentation that is not uniform; variegated areas of blue, back, and brown and areas of pink, white, gray, blue, or red are abnormal

• Diameter—Look for areas of greater than 6 mm

• Evolution—A change in appearance over time

Macule

• Flat, nonpalpable change in skin color, smaller than 1 cm

• 0.4 inch; e.g., freckle, petechiae

Papule

• Palpable, circumscribed, solid elevation in skin; smaller than 1 cm

• 0.4 inch; e.g., elevated nervus

Nodule

• Elevated solid mass, deeper and firmer than papule; 1-2 cm

• 0.4 - 0.7 inch; e.g., wart

Tumor

• Solid mass that extends deep through subcutaneous tissue; larger than 1 - 2 cm

• 0.4 - 0.7 inch; e.g., epithelioma

Wheal

• Irregularly shaped, elevated area or superficial localized edema; varies in size

• E.g., hive, mosquito bite

Vesicle

• Circumscribed elevation of skin filled with serous fluid, smaller than 1 cm

• 0.4 inch; e.g., herpes simplex, chickenpox

Pustule

• Circumscribed elevation of skin similar to vesicle but filled with pus; varies in size

• E.g., acne, staphylococcal infection

Ulcer

• Deep loss of skin surface that extends to dermis and frequently bleeds and scars varies in size

• E.g., venous stasis ulcer

Atrophy

• Thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size

• E.g., atrial insufficiency

Basal Cell Carcinoma

• 0.5 to 1 cm crusted lesion that is flat or raised and has a rolled, somewhat scaly border

• Frequent appearance of underlying, widely dilated blood vessels with the lesion

Squamous Cell Carcinoma

• Occurs more often on mucosal surfaces and nonexposed areas of skin than basal cell

• 0.5 to 1.5 cm scaly lesion sometimes ulcerated or crusted; appears frequently and grows more rapidly than basal cell

Melanoma

• 0.5 to 1 cm brown, flat lesion; appears on sun-exposed or nonexposed skin; variegated pigmentation, irregular borders, and indistinct margins

• Ulceration, recent growth, and recent changes in long-standing mole are ominous signs

Cradle Cap

Comes from excessive oil production of the baby. Clears on its own in a few months

Head lice

Pediculus Humanus Capitis

Body lice

Pediculus Humanus Corporis

Crab lice

Pediculus Pubis

Normal Nail

Approximately 160 degree angle between nail plate and nail

Clubbing

• Change in angle between nail and nail base (eventually larger than 180 degrees); nail bed softening with flattening; often enlargement of fingertips.

• Causes—Lack of oxygen; heart or pulmonary disease

Beau Lines

• Transverse depressions in nails indicating temporary disturbance of nail growth (nail grows out of several months)

• Causes—Systemic illness such as severe infection; nail injury

Koilonychia

• Concave curves

• Causes—Iron deficiency anemia, syphilis, use of strong detergents

Splinter Hemorrhages

• Red or brown linear streaks in nail bed

• Causes—Minor trauma, subacute bacterial endocarditis, trichinosis

Paronychia

• Inflammation of skin at base of nail

• Causes—Local infection, trauma

Hyperopia

• Farsightedness, a refractive error in which rays of light enter the eye and focus behind the retina

• People can clearly see distant objects but not close objects

Myopia

• Nearsightedness, a refractive error in which rays of light enter and focus in front of the retina

• People can clearly see close objects but not distant objects

Presbyopia

Impaired near vision in middle-age and older adults caused by loss of elasticity of the lens and associated with the aging process

Retinopathy

• Noninflammatory eye disorder resulting from changes in retinal blood vessels

• Leading cause of blindness

Strabismus

• A congenital condition in which both eyes do not focus on an abject simultaneously; these eyes appear crossed

• Impairment of the extraocular muscles or their nerve supply

Cataracts

• An increased opacity of the lens, which blocks light rays from entering the eye

• Sometimes develop slowly and progressively after age 35 or suddenly after trauma

• They are one of the most common eye disorders -Most older adults have some evidence of visual impairment

Glaucoma

• Intraocular structural damage resulting from elevated intraocular pressure

• Obstruction of the outflow of aqueous humor causes this

• Without treatment the disorder leads to blindness

Macular Degeneration

Associated with aging and results in severe loss of a patient's central vision. It is the leading cause of blindness and low vision in the US in those 65 years of age and older. There is no cute, but there are injection and laser treatments that may slow progression

Muscle Strength

• Grade 0: No evidence of contractility

• Grade 1: Slight contractility, no movement

• Grade 2: Full range of motion, gravity eliminated

• Grade 3: Full range of motion with gravity

• Grade 4: Full range of motion against gravity, some resistance

• Grade 5: Full range of motion against gravity, full resistance

Vesicular Breath Sounds

• Are soft, breezy, and low pitched. Inspiratory phase is 3 times longer than expiratory phase

• Location—Best heard over periphery of lung (except of scapula)

• Origin—Created by air moving through smaller airways

Bronchovesicular Breath Sounds

• Blowing sounds that are medium pitched and of medium intensity. Inspiratory phase is equal to expiratory phase

• Location—Best heard posteriorly between scapulae and anteriorly over bronchioles later to sternum at first and second intercostal spaces

• Origin—Created by air moving through large airways

Bronchial Breath Sounds

• Sounds are loud and high pitched with hallow quality. Expiratory lasts longer than inspiratory (3:2 ratio)

• Location—Heard only over trachea

• Origin—Created close to chest wall

Crackles

• Site Auscultated—Most common in dependent lobes: right and left lung bases

• Causes—Random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways. Can result from pneumonia, heart failure, chronic lung disease

• Character—Fine Crackles, Medium Crackles, Course Crackles

Fine Crackles

High-pitched fine, short, interrupted cracking sounds heard during end of inspiration; usually not cleared with coughing

Medium Crackles

Lower, moister sounds heard during middle inspiration; not cleared with coughing

Course Crackles

Loud, bubbly sounds heard during inspiration, not cleared with coughing

Rhonchi

• Site Auscultated—Primarily heard over trachea and bronchi; if loud enough, able to be heard over most lung fields

• Causes—Muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence

• Character—Loud, low-pitched, rumbling, course sounds are heard either during inspiration or expiration, sometimes cleared by coughing

Wheezes

• Site Auscultated—Heard over all lung fields

• Causes—High-velocity airflow through severely narrowed or obstructed airways. Common in asthma and bronchitis

• Character—High-pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration usually louder on expiration

Pleural Friction Rub

• Site Auscultated—Heard over anterior lateral lung field (if patient is sitting upright)

• Causes—Inflamed pleura, parietal pleura rubbing against visceral pleura. Common in viral infections

• Character—Dry, rubbing, or grating quality is heard during inspiration or expiration; does not clear with coughing; loudest over lower later anterior surface

S3 Heart Sound

When the heart attempts to fill an already distended ventricle, an additional heart sound can be heard, as with heart failure. Is considered abnormal in adults over 31 years of age but can often be heard normally in children and young adults

S4 Heart Sound

Can be heard when the atria contracts to enhance ventricular filling. Is heard in health older adults, children, and athletes, but is not normal in adults

Ascites

Abnormal accumulation of fluid in the abdomen

Peristalsis

Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system.

Borborygmi

Loud, gurgling bowel sounds signaling increased motility or hyperperistalsis; occurs with early bowel obstruction, gastroenteritis, diarrhea

Bruits

Abnormal "swishing" sounds heard over organs, glands, and arteries

Olfactory

• Cranial Nerve 1

• Assessment—Patient is asked to identify odors

• Expected Findings—Patient is able to describe odor

• Dysfunction—Patient is unable to identify odors

Optic

• Cranial Nerve 2

• Assessment—Visual acuity is tested using a Snellen chart for distance vision or a handheld chart for near vision; each eye is assessed individually, with the other eye covered

• Expected Findings—Patient has 20/20 near and far vision

• Dysfunction—Patient has decreased visual acuity and visual fields

Oculomotor

• Cranial Nerve 3

• Assessment—Reaction to light, reaction to accommodation

• Expected Findings—PERLA

• Dysfunction—Patient has different sized pupils bilaterally

Trochlear

• Cranial Nerve 4

• Assessment—have patient follow pen light with eyes only

• Expected Findings—Both eyes move in the direction indicated as they follow the examiner's penlight

• Dysfunction—Patient has inability to look up, down, inward, outward, or diagonally.

Trigeminal

• Cranial Nerve 5

• Assessment—Test sensation and corneal reflex

• Expected Findings—Patient feels touch on forehead, maxillary, and mandibular areas of face and chews without difficulty

• Dysfunction—Patient has weakened muscles responsible for chewing; absent corneal reflex; and decreased sensation of forehead and maxillary, or mandibular area