Download Nursing Care Evaluation: Physical Assessment with Inspection, Palpation, and Respiration and more Study Guides, Projects, Research Nursing in PDF only on Docsity!
Page 1 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
Nursing Assessment
- Part of Nursing Process
- Nurses use physical assessment skills to: a) Obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve b) To identify and manage a variety of patient problems (actual and potential) c) Evaluate the effectiveness of nursing care d) Enhance the nurse-patient relationship e) Make clinical judgments
Gathering Data
Subjective data - Said by the client (S) Objective data - Observed by the nurse (O ) Document: SOAPIER
Assessment Techniques:
The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the abdomen which is Inspect – Auscultation – Percuss – Palpate. A. Inspection – critical observation always first
- Take time to “observe” with eyes, ears, nose (all senses)
- Use good lighting
- Look at color, shape, symmetry, position
- Observe for odors from skin, breath, wound
- Develop and use nursing instincts
- Inspection is done alone and in combination with other assessment techniques B. Palpation – light and deep touch
- Back of hand (dorsal aspect) to assess skin temperature
- Fingers to assess texture, moisture, areas of tenderness
- Assess size, shape, and consistency of lesions and organs
- Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep C. Percussion – sounds produced by striking body surface
- Produces different notes depending on underlying mass (dull, resonant, flat, tympanic)
- Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air-filled, fluid-filled, or solid
- Action is performed in the wrist. D. Auscultation – listening to sounds produced by the body
- Direct auscultation – sounds are audible without stethoscope
- Indirect auscultation – uses stethoscope
- Know how to use stethoscope properly [practice skill]
- Fine-tune your ears to pick up subtle changes [practice skill]
- Describe sound characteristics (frequency, pitch intensity, duration, quality) [practice skill]
- Flat diaphragm picks up high-pitched respiratory sounds best.
- Bell picks up low pitched sounds such as heart murmurs.
- Practice using BOTH diaphragms
Page 2 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
General Assessment
A general survey is an overall review or first impression a nurse has of a person’s well being. This is done head to toe, or cephalo-caudal, lateral to lateral, proximal to distal, and front to back. General surveying is visual observation and encompasses the following. Appearance appears to be reported age; sexual development appropriate; alert & oriented; facial features symmetric; no signs of acute distress Body structure/mobility (^) weight and height within normal range (refer to Center for Disease Control and Prevention (CDC) Body Mass Index (BMI) [adult] or BMI-for-age and gender forms [children]); body parts equal bilaterally; stands erect, sits comfortably; gait is coordinated; walk is smooth and well balanced; full mobility of joints Behavior maintains eye contact with appropriate expressions; comfortable and cooperative; speech clear; clothing appropriate to climate; looks clean and fit; appears clean and well-groomed Deviations from what would generally be considered to be normal or expected should be documented and may require further evaluation or action, including a report and/or referral. Standardized and routine screening such as audiometric screening, scoliosis and vision screening using the Snellen Test are usually discussed in General Survey areas.
Health History
A patient history should be done as indicated by the age specific prevention guidelines, usually set forth by Center for Disease Control and Prevention (CDC), American Medical Association, American Association of Pediatrics, and National Association of Pediatric Nurse Practitioners. The Healthy People website (www.healthypeople.gov) provides an excellent source to determine benchmarks for healthy living across the life span. A comprehensive history, including chief complaint or reason for the visit, a complete review of systems, and a complete past family and/or social history should be obtained on the first encounter with a patient, regardless of setting and by a registered nurse. The history should be age and sex appropriate and include all the necessary questions to enable an adequate delivery of services according to prevention guidelines, scope of practice, patient need, visit requirement, and/or request. Usually, completing a provider based Health History and Physical Examination Form will assist in the assessment of the patient’s past and current health and behavior risk status. Certain health problems, which may be identified on a health history, are more common in specific age groups and gender.
Page 4 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
How to measure Height:
- Obtain height by measuring the recumbent length of children less than 2 years of age and children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used. a) Lay the child flat against the center of the board. The head should be held against the headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is moved until it is firmly against the child’s heels. Read and record the measurement to the nearest 1/8 inch. b) A modified technique in home settings is to lay the child flat and straight where the head should be held by the parent and the knees held so that the hips and knees are extended, mark the flat surface at the top of the head and tip of the heels. Move child and measure the distance between the marks with a tape measure. Read and record the measurement to the nearest 1/8 inch.
- When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36 months growth chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18 year chart. After plotting measurements for children on age and gender specific growth charts, evaluate, educate and refer according to findings.
- Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The flat surface of the stadiometer is lowered until it touches the crown of the head, compress the hair. A measuring rod attached to a weight scale should not be used.
Measuring weight:
- Balance beam or digital scales should be used to weigh patients of all ages. Spring type scales are not acceptable. CDC recommends that all scales should be zero balanced and calibrated. Scales must be checked for accuracy on an annual basis and calibrated in accordance with manufacturer’s instructions.
- Prior to obtaining weight measurements, make sure the scale is “zeroed”.
- Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal clothing.
- Place the patient in the middle of the scale. Read the measurement and record results immediately. Plot measurements on age and gender specific growth charts and evaluate accordingly
Measuring Body Mass Index.
- The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a weight-related illness.
- Instructions for obtaining the BMI are included within the chart in this section for adults. To calculate BMI for children, see BMI Tables for Children and Adolescents for guidance.
Measuring Head and Chest Circumference.
- Obtain head circumference measurement on children from birth to 36 months of age by extending a non-stretchable measuring tape around the broadest part of the child’s head. For greatest accuracy, the tape is placed three times, with a reading taken at the right side, at the left side, and at the mid-forehead, and the greatest circumference is plotted. The tape should be pulled to adequately compress the hair.
- Head circumference should be measured each visit.
- Chest: This is measured at the nipple line.
- In a newborn, the head circumference will be about 2 cm larger than the chest circumference. As the child ages, the chest circumference becomes larger than the head circumference.
Page 5 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
Vital Signs
Vital signs, generally described as the measurement of temperature, pulse, respirations and blood pressure, give an immediate picture of a person’s current state of health and well being. Normal and abnormal ranges with management guidelines follow for children and adults.
Equipment Needed
- Stethoscope
- Blood Pressure Cuff
- Watch Displaying Seconds
- Thermometer
General Considerations
- The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of the exam.
- Ideally the patient should be sitting with feet on the floor and their back supported. The examination room should be quiet and the patient comfortable.
- History of hypertension, slow or rapid pulse, and current medications should always be obtained.
A. Temperature
- Temperature can be measured is several different ways: a) Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C) b) Axillary with a glass or electronic thermometer (normal 97.6F/36.3C) c) Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C) d) Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)
- Of these, axillary is the least and rectal is the most accurate.
- Use back of hand (dorsal aspect) to assess skin temperature
B. Respiration
- Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations
- Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored?
- Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute.
- In adults, normal resting respiratory rate is between 14-20 breaths/minute.
- Rapid respiration is called tachypnea.
C. Pulse – see also Cardiovascular Exam
- Sit or stand facing your patient.
- Grasp the patient's wrist with your free (non-watch bearing) hand (patient's right with your right or patient's left with your left). There is no reason for the patient's arm to be in an awkward position, just imagine you're shaking hands.
- Compress the radial artery with your index and middle fingers.
- Count the pulse for 15 seconds and multiply by 4.
- Always count for a full minute if the pulse is irregular.
- Record the rate and rhythm Note whether the pulse is regular or irregular: Regular - evenly spaced beats, may vary slightly with respiration Regularly Irregular - regular pattern overall with "skipped" beats Irregularly Irregular - chaotic, no real pattern, very difficult to measure rate accurately
Page 7 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November In children, pulse and blood pressure vary with the age. The following table should serve as a rough guide: Average Pulse and Blood Pressure in Normal Children Age Birth 6mo 1yr 2yr 6yr 8yr 10yr Pulse 140 130 115 110 103 100 95 Systolic BP 70 90 90 92 95 100 105 Blood Pressure Classification in Adults Category Systolic Diastolic Normal <130 < High Normal 130- 139 85- 89 Mild Hypertension 140- 159 90- 99 Moderate Hypertension 160- 179 100- 109 Severe Hypertension 180- 209 110- 119 Crisis Hypertension >210 >
Page 8 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
The Physical Exam
A. Skin B. Head and Neck Exam; Lymphatic Exam C. Eye Exam D. Chest and Lung Exam E. Cardiovascular Exam and Peripheral vascular System F. Abdominal Exam G. Musculoskeletal Exam H. Neurologic Exam I. Genito-Urinary
A. Examination of Skin
- Inspect: skin color and uniformity of color, moisture, hair pattern, rashes, lesions, pallor, edema
- Palpate: temperature, turgor, lesions, edema, texture
- Percussion and auscultation: rarely used on skin
- Terminology: pallor, cyanosis, edema, ecchymosis, macule, papule, cyanosis, jaundice, types of edema, vitiligo, hirsutism, alopecia, etc.
- Pale, cool, moist skin can be indicative of heat stroke, shock or other cardiac complications. 6. There are abnormal and normal skin findings (such as nevus)
B. Examination of the Head and Neck
Equipment Needed
- Otoscope
- Tongue blades
- Cotton tipped applicators
- Non-latex exam gloves
General Considerations
The head and neck exam is not a single, fixed sequence. The assessment varies depending on the examiner and the situation.
Head
- Look for scars, lumps, rashes, hair loss, or other lesions.
- Look for facial asymmetry, involuntary movements, or edema.
- Palpate to identify any areas of tenderness or deformity.
Fontanels in a newborn - toddler:
- Posterior fontanel – triangle shaped; closes 1-2 months
- Anterior fontanel – diamond shaped; closes at 9 months – 2 years
Page 10 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
Lymph Nodes
- Systematically palpate with the pads of your index and middle fingers for the various lymph node groups.
- Preauricular - In front of the ear
- Postauricular - Behind the ear
- Occipital - At the base of the skull
- Tonsillar - At the angle of the jaw
- Submandibular - Under the jaw on the side
- Submental - Under the jaw in the midline
- Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle
- Supraclavicular - In the angle of the sternomastoid and the clavicle
- The deep cervical chain of lymph nodes lies below the sternomastoid and cannot be palpated without getting underneath the muscle. Inform the patient that this procedure will cause some discomfort.
- Hook your fingers under the anterior edge of the sternomastoid muscle.
- Ask the patient to bend their neck toward the side you are examining.
- Move the muscle backward and palpate for the deep nodes underneath.
- Note the size and location of any palpable nodes and whether they were soft or hard, non- tender or tender, and mobile or fixed
Thyroid Gland
- Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical. A visibly enlarged thyroid gland is called a goiter.
- One way to look is to have person swallow sip of water; the thyroid gland will move upward with a swallow.
- Move to a position behind the patient. Have the patient tilt head slightly to right.
- Identify the cricoid cartilage with the fingers of both hands.
- Move downward two or three tracheal rings while palpating for the isthmus.
- Move laterally from the midline while palpating for the lobes of the thyroid.
- Note the size, symmetry, and position of the lobes, as well as the presence of any nodules. The normal gland is often not palpable.
Special Tests
A. Facial Tenderness
- Ask the patient to tell you if these maneuvers cause excessive discomfort or pain.
- Press upward under both eyebrows with your thumbs. (frontal sinus)
- Press upward under both maxilla with your thumbs. (maxillary sinus)
- Excessive discomfort on one side or significant pain suggests sinusitis.
B. Sinus Transillumination
- Darken the room as much as possible.
- Place a bright otoscope or other point light source on the maxilla.
- Ask the patient to open their mouth and look for an orange glow on the hard palate.
- A decreased or absent glow suggests that the sinus is filled with something other than air.
- Not always definitive of disease process.
Page 11 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November C. Temporomandibular Joint
- Place the tips of your index fingers directly in front of the tragus of each ear.
- Ask the patient to open and close their mouth.
- Note any decreased range of motion, tenderness, or swelling.
C. Examination of the Eye - see also Cranial Nerve II, III, IV, V
Equipment Needed
- Snellen Eye Chart or Rosenbaum Pocket Vision Card
- Ophthalmoscope
Visual Acuity
In cases of eye pain, injury, or visual loss, always check visual acuity before proceeding with the rest of the exam or putting medications in your patients eyes.
- Allow the patient to use their glasses or contact lens if available. You are interested in the patient's best corrected vision.
- Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance).
- Have the patient cover one eye at a time with an opaque card.
- Ask the patient to read progressively smaller letters until they can go no further.
- Record the smallest line the patient read successfully (20/20, 20/30, etc.)
- Repeat with the other eye. Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.
Inspection
- Observe the patient for ptosis, exophthalmos, lesions, deformities, or asymmetry.
- Ask the patient to look up and pull down both lower eyelids to inspect the conjunctiva and sclera.
- Next spread each eye open with your thumb and index finger. Ask the patient to look to each side and downward to expose the entire bulbar surface.
- Note any discoloration, redness, discharge, or lesions. Note any deformity of the iris or lesion cornea.
- If you suspect the patient has conjunctivitis, be sure to wash your hands immediately. Viral conjunctivitis is very contagious, so protect your self!
Visual Fields - Screen Visual Fields by Confrontation
- Stand two feet in front of the patient and have them look into your eyes.
- Hold your hands to the side half way between you and the patient.
- Wiggle the fingers on one hand.
- Ask the patient to indicate which side they see your fingers move.
- Repeat two or three times to test both temporal fields.
- If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card.
Extraocular Muscles
A. Corneal Reflections
- Shine a light from directly in front of the patient.
- The corneal reflections should be centered over the pupils.
- Asymmetry suggests extraocular muscle pathology.
Page 13 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November Notes
- Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient is from the chart and the second number is the distance from which the "normal" eye can read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance.
- You may, instead of wiggling a finger, raise one or two fingers (unilaterally or bilaterally) and have the patient state how many fingers (total, both sides) they see. To test for neglect , on some trials wiggle your right and left fingers simultaneously. The patient should see movement in both hands.
- Diopters are used to measure the power of a lens. The ophthalmoscope actually has a series of small lens of different strengths on a wheel (positive diopters are labeled in green, negative in red). When you focus on the retina you "dial-in" the correct number of diopters to compensate for both the patient's and your own vision. ***********************************************************************************************
D. Examination of the Chest and Lungs
Equipment Needed
- Stethoscope - Peak Flow Meter
General Considerations
- The patient must be properly undressed and gowned for this examination.
- Ideally the patient should be sitting on the end of an exam table.
- The examination room must be quiet to perform adequate percussion and auscultation.
- Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.).
- Try to visualize the underlying anatomy as you examine the patient.
Inspection
- Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged.
- Listen for obvious abnormal sounds with breathing such as wheezes.
- Observe for retractions and use of accessory muscles (sternomastoids, abdominals).
- Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter.
- Confirm that the trachea is near the midline
- A-P (anterior-posterior) diameter vs. transverse diameter a) A-P should be less than Transverse in adults; 1:2 – 5: b) Elevated A-P size = barrel chest, may be COPD in adult; normal in children
Palpation
- Identify any areas of tenderness or deformity by palpating the ribs and sternum.
- Assess expansion and symmetry of the chest by placing your hands on the patient's back, thumbs together at the midline, and ask them to breathe deeply.
- Check for tactile fremitus. (process page 16)
Page 14 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
Percussion
Proper Technique
- Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest.
- With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger.
- Categorize what you hear as normal, dull, or hyperresonant.
- Practice your technique until you can consistently produce a "normal" percussion note on your (presumably normal) partner before you work with patients.
Diaphragmatic Excursion
- Find the level of the diaphragmatic dullness on both sides.
- Ask the patient to inspire deeply.
- The level of dullness (diaphragmatic excursion) should go down 3-5 m symmetrically. Posterior Chest Anterior Chest
Anterior Chest
- Percuss from side to side and top to bottom using the pattern shown in the illustration.
- Compare one side to the other looking for asymmetry.
- Note the location and quality of the percussion sounds you hear.
Posterior Chest
- Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae.
- Compare one side to the other looking for asymmetry.
- Note the location and quality of the percussion sounds you hear.
- Find the level of the diaphragmatic dullness on both sides.
Interpretation
Percussion Notes and Their Meaning Flat or Dull Pleural Effusion or Lobar Pneumonia Normal Healthy Lung or Bronchitis Hyperresonant Emphysema or Pneumothorax
Page 16 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
B. Voice Transmission Tests
These tests are only used in special situations. This part of the physical exam has largely been replaced by the chest x-ray. All these tests become abnormal when the lungs become filled with fluid (referred to as consolidation ).
C. Tactile Fremitus
- Ask the patient to say "ninety-nine" several times in a normal voice
- Palpate using the ball of your hand.
- You should feel the vibrations transmitted through the airways to the lung.
- Increased tactile fremitus suggests consolidation of the underlying lung tissues.
D. Bronchophony
- Ask the patient to say "ninety-nine" several times in a normal voice.
- Auscultate several symmetrical areas over each lung.
- The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called bronchophony.
E. Whispered Pectoriloquy
- Ask the patient to whisper "ninety-nine" several times.
- Auscultate several symmetrical areas over each lung.
- You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as whispered pectoriloquy.
F. Egophony
- Ask the patient to say "ee" continuously.
- Auscultate several symmetrical areas over each lung.
- You should hear a muffled "ee" sound. If you hear an "ay" sound this is referred to as "E -> A" or egophony.
E. Cardiovascular Examination and Peripheral Vascular System
General Considerations
- The patient must be properly undressed and in a gown for this examination.
- The examination room must be quiet to perform adequate auscultation.
- Observe the patient for general signs of cardiovascular disease (finger clubbing, cyanosis, edema, etc.).
Pulses – see vital signs for radial pulse standards; Apical and others described below
- Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial pulses.
- Check the posterior tibia and dorsalis pedis pulses on both sides. If these pulses are absent or weak, check the popliteal and femoral pulses.
- Location of pulses a) Carotid – neck b) Brachial – upper arm c) Radial – wrist d) Femoral – groin e) Popliteal – behind knee f) Posterior tibial – back of leg near Achilles tendon g) Dorsalis pedis (pedal) – top of foot. Requires light touch
Page 17 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
- Grading force of pulse 0 absent 1+ weak, thready 2+ normal 3+ increased, full, bounding
Blood Pressure – see vital signs (Blood pressure for process and interpretation)
Pulse pressure : difference between the systolic and diastolic blood pressure reading.
Amplitude and Contour (Carotid)
- Observe for carotid pulsations.
- Place your fingers behind the patient's neck and compress the carotid artery on one side with your thumb at or below the level of the cricoid cartilage. Press firmly but not to the point of discomfort.
- Assess the following: a. The amplitude of the pulse. b. The contour of the pulse wave. c. Variations in amplitude from beat to beat or with respiration.
- Repeat on the opposite side.
Auscultation for Bruits (Carotids)
If the patient is late middle aged or older, you should auscultate for bruits. A bruit is often, but not always, a sign of arterial narrowing and risk of a stroke.
- Place the bell of the stethoscope over each carotid artery in turn. You may use the diaphragm if the patient's neck is highly contoured.
- Ask the patient to inhale deep breath then exhale and hold momentarily.
- Listen for a blowing or rushing sound--a bruit. Do not be confused by heart sounds or murmurs transmitted from the chest.
Jugular Venous Pressure
- Position the patient supine with the head of the table elevated 30 degrees.
- Use tangential, side lighting to observe for venous pulsations in the neck.
- Look for a rapid, double (sometimes triple) wave with each heart beat. Use light pressure just above the sternal end of the clavicle to eliminate the pulsations and rule out a carotid origin.
- Adjust the angle of table elevation to bring out the venous pulsation.
- Identify the highest point of pulsation. Using a horizontal line from this point, measure vertically from the sternal angle.
- This measurement should be less than 4 cm in a normal healthy adult.
Precordial Movement
- Position the patient supine with the head of the table slightly elevated.
- Always examine from the patient's right side.
- Inspect for precordial movement. Tangential lighting will make movements more visible.
- Palpate for precordial activity in general. You may feel "extras" such as thrills or exaggerated ventricular impulses.
- Palpate for the point of maximal impulse (PMI or apical pulse). It is normally located in the 4th or 5th intercostal space just medial to the midclavicular line and is less than the size of a quarter.
- Note the location, size, and quality of the impulse.
Page 19 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
Murmurs
- Grade i-ii functional systolic murmurs are common in young children and resolve with age
- Auscultate for blowing, swishing sound.
- Some are ‘innocent” murmurs, but most are indicative of disease.
- Murmurs are graded. A grade “2” murmur would be rated ii/vi. Grade Description i Barely audible. Heard only if room silent and then still hard to hear ii Clearly audible, but faint iii Moderately loud, easy to hear iv Loud, associated with thrill on chest wall v Very loud, can hear with edge of stethoscope off chest vi Loudest, can hear with entire stethoscope off chest wall
Edema, Cyanosis, and Clubbing
- Check for the presence of edema (swelling) of the feet and lower legs.
- Check for the presence of cyanosis (blue color) of the feet or hands.
- Check for the presence of clubbing of the fingers. a) Normal = 160 degrees b) Curved = 160 degrees or less c) Early clubbing = 180 degrees
Pitting edema:
Scale Level of pitting Indentation Swelling of leg 1+ Mild Slight Not noticeable 2+ moderate Subsides rapidly 3+ Deep Remains for short time Leg looks swollen 4+ Very deep Remains for long time Grossly swollen and misshapen
Lymphatics
- Check for the presence of epitrochlear lymph nodes. (antecubital)
- Check for the presence of axillary lymph nodes. (breast and arm)
- Check for the presence of inguinal lymph nodes. (groin)
- PEDIATRICS: to assess lymph nodes in younger children, tilt head slightly to check neck nodes.
Page 20 of 36 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Physical examination & health assessment. (6th^ Ed). Elsevier: St. Louis.MO. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November
F. Examination of the Abdomen
Equipment Needed
Stethoscope
General Considerations
- When assessing start in RLQ over ileocecal valve
- The patient should have an empty bladder.
- The patient should be lying supine on the exam table and appropriately draped.
- The examination room must be quiet to perform adequate auscultation and percussion.
- Watch the patient's face for signs of discomfort during the examination.
- Use the appropriate terminology to locate your findings: a) Right Upper Quadrant (RUQ) b) Right Lower Quadrant (RLQ) c) Left Upper Quadrant (LUQ) d) Left Lower Quadrant (LLQ) e) Midline: Epigastric f) Periumbilical g) Suprapubic
Notes
- Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint.
- Consider the inguinal/rectal examination in males.
- Consider the pelvic/rectal examination in females.
Inspection
- Look for scars, striae, hernias, vascular changes, lesions, or rashes.
- Look for movement associated with peristalsis or pulsations.
- Note the abdominal contour. Is it flat, scaphoid, or protuberant?
- Contour in newborn is normally protuberant and soft
- Contour in child is normally symmetric and slightly rounded Auscultation
- Place the diaphragm of your stethoscope lightly on the abdomen.
- Listen for bowel sounds. Are they normal, increased, decreased, or absent? Borborygmus = “growling”
- Listen for bruits over the renal arteries, iliac arteries, and aorta.
Percussion
- Percuss in all four quadrants (clockwise) using proper technique: Inspect – Auscultation – Percuss – Palpate.
- Categorize what you hear as tympanic or dull. Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may be a clue to an underlying abdominal mass or full bladder.
