Interactive Process

8/6/2019 Interactive Process

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B. ASSESSMENT

A physical examination is the evaluation of a body to determine its state of health. Thetechniques of inspection include palpation (feeling with the hands and/or fingers),

percussion (tapping with the fingers), auscultation (listening), and smell. A complete

health assessment also includes gathering information about a person's medical historyand lifestyle, conducting laboratory tests, and screening for disease. These elements

constitute the data on which a diagnosis is made and a plan of treatment is developed.

1. PURPOSES FOR PERFORMING A PHYSICAL EXAMINATION

The physical examination can be performed by the following health care providers: a physician, nurse practitioner, or physician assistant. The health care provider makes

specific and general observations as he examines the patient from head to toe. The exam

should include the eyes, ears, nose, mouth, throat, neck, chest, breasts, abdomen, and

extremities. A vaginal or rectal examination is performed if indicated. The purposes for

performing a physical examination are:

a. To determine the patient's level of health or physiological function.

b. To arrive at a tentative diagnosis when there is a health problem or disease.

c. To confirm a diagnosis of disease or dysfunction.

d. To evaluate the effectiveness of prescribed medical treatment and therapy.

FUNCTIONS OF THE PRACTICAL NURSE DURING THE EXAMINATION

PROCEDURE

a. Ensure that the patient feels comfortable and is not embarrassed. Prior to the

examination, tell the patient what will take place and explain the reason for theprocedure. The patient who knows what to expect will be more relaxed and cooperative.

b. Ask the patient to void into a urine specimen cup in order to empty the bladder and

save the urine specimen for urinalysis. Have the patient put on a hospital gown so that hisbody is more accessible for examination.

c. Arrange equipment and supplies. Be sure that you have everything needed. Test allequipment to make certain that it works correctly.

d. Accompany the patient to the examination room and assist him onto the table. Yourpresence lends support and reassurance to the patient. If a male is examining a female

patient, or vice versa, stay in the room to protect the patient, the health care provider, and

the hospital or clinic.

e. Wash your hands and measure the patient's vital signs (temperature,pulse, respiration, blood pressure, height, and weight. Wear gloves if thepatient has a draining wound, is bleeding, is vomiting, or has an infection.

f. Have the patient's chart available. The physician needs to know the information that has

already been obtained via the nursing observations and lab reports. Call the physician's

attention to any abnormal lab values. Do this away from the patient.

g. Have all lab slips and x-ray slips ready with the patient's name, rank, social securitynumber, date, and other required information.

h. Assist the patient to assume the proper position for each part of the examination. To

provide continuing privacy, be sure to adjust the drapes each time the patient assumes adifferent position. If the patient is asked to stand erect, place paper towels on the floor or

have the patient put on slippers.


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i. Hand instruments and supplies to the physician. Properly label and care for all

specimens collected.

j. See that the patient is returned safely to his room and is comfortable.

k. Place all instruments in the proper area for disinfection or sterilization and dispose of

all wastes. Wash your hands again. See that the examination room is cleaned.

Decontaminate the room if necessary. Change the cover on the tables. Replace all

equipment.

PURPOSES FOR DRAPING THE PATIENT DURING THE PHYSICAL EXAM

Drapes should be arranged so that the area to be assessed is exposed and other body areasare covered. Exposure of the body is frequently embarrassing to clients. Drapes provide

not only a degree of privacy but also warmth. Drapes are made of paper, cloth or bed

linen.

The patient should be draped:

a. To prevent unnecessary exposure of the patient's body.

b. To help the patient be relaxa patient who is embarrassed will be tense and less

cooperative.

c. To prevent chilling the drapes will provide warmth.

POSITIONING A PATIENT FOR EXAMINATION OR TREATMENT

Patients are put in special positions for examination, for treatment or test, and to obtain

specimens. You should know the positions used, how to assist the patient, and how to

adjust the drapes.

a. Horizontal Recumbent Position. Used for most physical examinations. Patient is on

his back with legs extended. Arms may be above the head, alongside the body or folded

on the chest.

b. Dorsal Recumbent Position. Patient is on his back with knees flexed and soles of feetflat on the bed. Fold sheet once across the chest. Fold a second sheet crosswise over the

thighs and legs so that genital area is easily exposed.

c. Fowler's Position. Used to promote drainage or ease breathing. Head rest is adjustedto desired height and bed is raised slightly under patient's knees

d. Dorsal Lithotomy Position. Used for examination of pelvic organs. Similar to dorsal

recumbent position, except that the patient's legs are well separated and thighs are acutely

flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise overthighs and legs so that genital area is easily exposed. Keep patient covered as much as

possible.

e. Prone Position. Used to examine spine and back. Patient lies on abdomen with headturned to one side for comfort. Arms may be above head or alongside body. Cover with

sheet or bath blanket.

NOTE: An unconscious patient, or one with an abdominal incision or breathing difficulty

usually cannot lie in this position.

f. Sim's Position. Used for rectal examination. Patient is on left side with right knee

flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm

is placed comfortably.

NOTE: Patient with leg injuries or arthritis usually cannot assume this position.


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g. Knee-Chest Position. Used for rectal and vaginal examinations and as treatment to

bring uterus into normal position. Patient is on knees with chest resting on bed and

elbows resting on bed or arms above head. Head is turned to one side. Thighs are straightand lower legs are flat on bed.

NOTE: Do not leave patient alone; he/she may become dizzy, faint, and fall.

INSTRUMENTATION

All equipment required for the health assessment should be clean, in good working order

and readily accessible. Equipment is frequently set up on trays, ready for use.

Equipment and Supplies Used for a Health Examination:

Flashlight or penlight To assist viewing of the pharynx and cervix or to determine the

reactions of the pupils of the eye

Laryngeal or dental mirror To observe the pharynx and oral cavity

Nasal speculum To permit visualization of the lower and middle turbinates; usually, a

penlight is used for illumination

Ophthalmoscope A lighted instrument to visualize the interior of the eye

Otoscope A lighted instrument to visualize the eardrum and external auditory canal (a

nasal speculum may be attached to the otoscope to inspect the nasal cavities)

Percussion (reflex) hammer An instrument with a rubber head to test reflexes

Tuning fork A two-pronged metal instrument used to test hearing acuity and vibratory

sense

Vaginal speculum To assess the cervix and the vagina

Cotton applicators To obtain specimens

Disposable pads To absorb liquid

Gloves To protect the nurse

Lubricant To ease insertion of instruments (e.g., vaginal speculum)

Tongue blades (depressors) To depress the tongue during assessment of the mouth

and pharynx

BASIC TECHNIQUES USED IN PERFORMING A PHYSICAL ASSESSMENT

a. Inspection. Visual examination of a person is called inspection. This is done in anorderly manner, focusing on one area of the body at a time.

b. Palpation. Examination by touch is called palpation. The nurses feel for texture,

temperature, vibration, distention, pulsation, presence of pain and mobility, size,

consistency, and location of body parts.

There are two types of palpation:

Light Palpation the nurse extends the dominant hands fingers parallel to the

skins surface and presses gently while moving the hand in a circle.


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Deep Palpation done with two hands (bimanually) or one hand.

c. Percussion. Examination of the body by tapping it with the fingers is called

percussion. Percussion is a special assessment skill that the practical nurse is not required

to perform. This technique is usually performed by a registered nurse (RN) or aphysician. Percussion is used to determine the size and shape of internal organs by

establishing their borders. Resonance is a hollow sound such as that produced by lungfilled with air. Hyperresonance is not produced in the normal body; it is described as the

booming and can be heard over an emphysematous lung. Tympany is musical or drum-

like sound produced from an air-filled stomach.

There are two types of percussion:

Direct Percussion the nurse strikes the area to be percussed directly with thepads of two, three or four fingers or with the pad of the middle finger.

Indirect Percussion is the striking of an object held against the body area to be

examined.

d. Auscultation. Examination by listening for sounds produced within the body is calledauscultation. The sounds most frequently listened for are those of the abdominal and

thoracic viscera and the movement of blood in the cardiovascular system.

There are two types of auscultation:

Direct Auscultation - using the ear only, is seldom done. Indirect auscultation is

generally carried out with a stethoscope.

Indirect Auscultation is the use of the stethoscope, which transmits the soundsto the nurses ears.

Auscultated sounds are described according to:

Pitch frequency of the vibrations (number of vibrations per second).

Intensity refers to the loudness or softness of the sound (amplitude).

Duration length of sound (long or short).

Quality can be whistling, gurgling or snapping.

COMPONENTS OF A PHYSICAL ASSESSMENT

a. Health History. During this assessment step, you interview the patient to obtain ahistory so that the nursing care plan may be patterned to meet the patient's individual

needs. The history should clearly identify the patient's strengths and weaknesses, healthrisks such as hereditary and environmental factors, and potential and existing health

problems. Both the seating arrangement and the distance from the patient are important in

establishing a relaxed and comfortable environment for data collection. Chairs placed atright angles to each other about 3 feet apart facilitate an easy exchange of information. If

the patient is in bed, be seated in a chair at a 45-degree angle to the bed. If possible,

communicate with the patient at eye level. State your name and status and the purpose ofthe interview. During the introduction, assess the patient's comfort and ability to

participate in the interview. Terminate the interview when you have obtained the data you

need or the patient cannot provide more information. You need the following information

in order to form the subjective database.


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(1) Chief complaint. Record the chief complaint as a brief statement of whatever is

troubling the patient and the duration of time the problem has existed. The chief

complaint is the signs and symptoms causing the patient to seek medical attention.Generally, it is the answer to the question, "What brought you into the hospital (or clinic)

today?" If a well person is seeking a routine physical, there is no actual chief complaint.

Record his reason for the visit and the date of his last contact with a medical treatmentfacility.

(2) Past medical history. This provides background for understanding the patient as a

whole and his present illness. It includes childhood illnesses, immunizations, allergies,hospitalizations and serious illnesses, accidents and injuries, medications, and habits.

(3) Family health history. This enhances your understanding of the environment in

which the patient lives. Obtaining this information identifies genetic problems,

communicable diseases, environmental problems, and interpersonal relationships.Specific inquiry should be made regarding the general state of health of parents,

grandparents, siblings, spouse, and children. Record if the patient is adopted and has no

access to his biological family's history.

b. Vital Signs. The patient's vital signs are part of the objective data that helps to better

define the patient's condition and helps you in planning care. The following vital signs

may be taken at the time the patient's height and weight are obtained.

(1) Blood pressure. Blood pressure may be taken in both arms. Record whether the

patient was lying, sitting, or standing at the time the reading was obtained. The blood

pressure is recorded as two readings; a high systolic pressure, which is the maximal

contraction of the heart, and the lower diastolic or resting pressure. A normal blood pressure would be 120 being the systolic over 80, the diastolic. Usually the blood

pressure is read from the left arm unless there is some damage to the arm. The differencebetween the systolic and diastolic pressure is called thepulse pressure. The measurementof these pressures is now usually done with an aneroid or electronic sphygmomanometer.

The classic measurement device is a mercury sphygmomanometer, using a column of

mercury measured off in millimeters. In the United States and UK, the common form ismillimeters of mercury, whilst elsewhere SI units of pressure are used. There is no natural

'normal' value for blood pressure, but rather a range of values that on increasing are

associated with increased risks. The guideline acceptable reading also takes into accountother co-factors for disease. Therefore, elevated blood pressure (hypertension) is

variously defined when the systolic number is persistently over 140160 mmHg. Low

blood pressure is hypotension. Blood pressures are also taken at other portions of the

extremities. These pressures are called segmental blood pressures and are used toevaluate blockage orarterial occlusion in a limb, normal measure is 98.6.

(2) Temperature. Record the temperature and whether it is an oral, axillary, or rectal

temperature. Temperature recording gives an indication ofcore body temperature whichis normally tightly controlled (thermoregulation) as it affects the rate of chemical

reactions.

Temperature can be recorded in order to establish a baseline for the individual's normal

temperature for the site and measuring conditions. The main reason for checking bodytemperature is to solicit any signs of systemic infection or inflammation in the presence

of a fever(temp > 38.5C or sustained temp > 38C), or elevated significantly above the

individual's normal temperature. Other causes of elevated temperature includehyperthermia.

Temperature depression (hypothermia) also needs to be evaluated. It is also noteworthy

to review the trend of the patient's temperature. A patient with a fever of 38C does not

necessarily indicate an ominous sign if his previous temperature has been higher. Bodytemperature is maintained through a balance of the heat produced by the body and the

heat lost from the body.
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(3) Pulse. Peripheral pulses are graded on a scale of 0-4 by the following system. The

pulse is the physical expansion of the artery. Its rate is usually measured either at thewrist or the ankle and is recorded as beats per minute. The pulse commonly taken is from

the radial artery at the wrist. Sometimes the pulse cannot be taken at the wrist and istaken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse),

behind the knee (popliteal artery), or in the foot dorsalis pedis orposterior tibial arteries.The pulse rate can also be measured by listening directly to the heartbeat using a

stethoscope. The pulse varies with age. A newborn or infant can have a heart rate of

about 130-150 beats per minute. A toddler's heart will beat about 100-120 times perminute, an older child's heartbeat is around 90-110 beats per minute, adolescents around

80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per

minute.

(a) 0 = absent, without a pulse.

(b) +1 = diminished, barely palpable.

(c) +2 = average, slightly weak, but palpable.

(d) +3 = full and brisk, easily palpable.

(e) +4 = bounding pulse, sometimes visible.

(4) Respiratory Rate. Varies with age, but the normal reference range for an adult is 12

20 breaths/minute. The value of respiratory rate as an indicator of potential respiratory

dysfunction has been investigated but findings suggest it is of limited value.

(5) Fifth Sign. The phrase "fifth vital sign" usually refers to pain, as perceived by the

patient on a Pain scale of 010. For example, the Veterans Administration made this their

policy in 1999. However, some doctors have noted that pain is actually a subjective

symptom, not an objective sign, and therefore object to this classification.

Other sources include oxygen saturation as their fifth sign. Some sources considerpupil

size, equality, and reactivity to light to be a vital sign as well. Many EMS agencies in the

USA use Pulse Oximetry and Blood Glucose Level as vital signs in addition to pulse,

respiratory rate, and blood pressure.

3.2 INTEGUMENTARY SYSTEM

The Integumentary System (skin, hair, scalp, and nails) provides the body withexternal protection, regulated temperature, and is a sensory organ for pain, temperature and

touch. The sebaceous and sweat glands are considered appendages of the skin. Nurses should
http://en.wikipedia.org/wiki/Radial_arteryhttp://en.wikipedia.org/wiki/Brachial_arteryhttp://en.wikipedia.org/wiki/Carotid_arteryhttp://en.wikipedia.org/wiki/Carotid_pulsehttp://en.wikipedia.org/wiki/Popliteal_arteryhttp://en.wikipedia.org/wiki/Dorsalis_pedis_arteryhttp://en.wikipedia.org/wiki/Posterior_tibial_arteryhttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Stethoscopehttp://en.wikipedia.org/wiki/Newbornhttp://en.wikipedia.org/wiki/Infanthttp://en.wikipedia.org/wiki/Toddlerhttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Adolescentshttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Pain_scalehttp://en.wikipedia.org/wiki/Veterans_Administrationhttp://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Medical_signhttp://en.wikipedia.org/wiki/Oxygen_saturationhttp://en.wikipedia.org/wiki/Pupilhttp://en.wikipedia.org/wiki/Radial_arteryhttp://en.wikipedia.org/wiki/Brachial_arteryhttp://en.wikipedia.org/wiki/Carotid_arteryhttp://en.wikipedia.org/wiki/Carotid_pulsehttp://en.wikipedia.org/wiki/Popliteal_arteryhttp://en.wikipedia.org/wiki/Dorsalis_pedis_arteryhttp://en.wikipedia.org/wiki/Posterior_tibial_arteryhttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Stethoscopehttp://en.wikipedia.org/wiki/Newbornhttp://en.wikipedia.org/wiki/Infanthttp://en.wikipedia.org/wiki/Toddlerhttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Adolescentshttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Pain_scalehttp://en.wikipedia.org/wiki/Veterans_Administrationhttp://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Medical_signhttp://en.wikipedia.org/wiki/Oxygen_saturationhttp://en.wikipedia.org/wiki/Pupil


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routinely assess the skin of elderly and debilitated clients for primary lesions that can lead to

the development of secondary lesions such as pressure ulcers.

To facilitate the learning and psychomotor proficiency, the Integumentary System is

assessed separately. However, one skills are established, the Integumentary System

assessment can be integrated into the examination of other systems.

Skin

The Skin is the largest organ system of the body, its surface area covering

approximately 20 square feet in the average adult. The skin thickness, influenced by age,varies from 0.2-1.5 mm. Skin assessment provides a noninvasive window to observed the

bodys physiological functions.

Lesions of the skin vary from superficial, involving only the epidermis, to

penetrating the dermis or the subcutaneous layers of the skin.

Hair and Scalp

Hair is distributed over the body except for the palmar and plantar surfaces, lips,

nipples and the glans penis. The amount and texture of hair vary with age, sex, race and body

part.

Vellus: Fine, unpigmented hair that covers most of the body.

Terminal Hair: Coarser, darker hair of scalp, eyebrows and eyelashes; axilliary and

pubic hair becomes terminal with the onset of puberty.

Men have coarser, thicker chest and and facial hair growth than women. The scalp

should be smooth, clean and intact. It should be free of lumps or tender areas.

Nails

The nail plate (translucent tissue that covers the distal portions of the digits and

provides protection).

Assessment of the Integumentary System

Skin: Inspect and Palpate

1. Color: inspect variations in skin color under natural sunlight to ensure accuracy infindings.

2. Lesions: note color, size and anatomical location and distribution: palpate the lesions withfinger pads for mobility, contour (flat, raised or depressed), and consistency (soft or durable).

3. Moisture (wetness and oiliness): note amount and distribution.

4. Temperature: palpate with back (dorsum) of hand, noting uniformity of warmth.

5. Texture (quality, thickness, suppleness): palpate with finger pads in different areas.

6. Mobility and Tugor (elasticity): assessing mobility and tugor measures the elasticity of

skin to determine the degree of hydration.

Hair: Inspect and Palpate

1. Color and distribution of scalp hair, eyebrows. Eyelashes, and on body surface.

2. Texture and oiliness.


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denominator) indicate the degree of visual acuity when the client is able to read that line of

letters at a distance of 20 feet.

Ears

Physical assessment of the ears consist of auditory screening, inspection and palpation

of the external ear, and otoscopic assessment. The nurse should observe the client for signs ofhearing difficulty during the physical examination, such as turning the head, lipreading and

speaking in a loud voice. If the client is wearing a hearing aid, asked if it is turned on, when

the batteries where last charged, and if the device causes any irritation to the ear canal.

Inspect if the ears are of equal sizebilaterally with no swelling or thickening. Ears of unsizeand shape may be a normal familial trait with no clinical significance. If the skin color is

consistent with the persons facial skin color. The skin is intact no lumps or lesion. Inspect

using the Otoscope, inspect the external ear note the size of the auditory meatus. Then choosethe largest speculum that will fit comfortably in the ear canal and attach the otoscope.

Inspecting using Otoscope:

Otoscope

Nose and Sinuses

Assessment is limited to inspection and palpation of the external nose and nasal passages

usinf a penlight. An examination with a nasal speculum to inspect the nasal chambers is

usually performed only by an advanced nurse practitioner because the nasal chambers arelined with respiratory mucosa. Clients with nasal impairments are at risk of developing

respiratory infections. Sinus assessment is limited to palpation of the frontal and maxillary

sinuses. Transillumination of the sinuses is usually limited to advanced practitioners.

Mouth and Pharynx


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Physical assessment of the oral cavity includes the breathe, lips, tongue, buccal mucosa,

gums and teeth, hard and soft palates and pharynx. If the client is wearing dentures or

removable orthodontia, remove theses devices before examination to visualize and palpatethe gums. The oral cavity can yield significant information regarding the clients health,

because systemic disease may manifest initially in the oral cavity.

Neck

Physical examination of the neck includes neck muscles, lymph nodes of the head and neck,thyroid gland and trachea. The lymph odes are normally not easily palpable. If the client has

an enlarged thyroid gland, the blood supply will be increased, causing a fine vibration that

can be auscultated with the diaphragm of the stethoscope. Inspect and Palpate the Neck in

terms of Symmetry, Range of Motion (ROM) and Lymph Nodes.

3.5 ASSESSING THE HEART AND CENTRAL VESSELS

Planning:

Heart examinations are usually performed while the client is in a semi-reclinedposition. The practitioner stands at the clients right side, where palpation of the cardiac

area is facilitated and optimal inspection allowed.

Delegation:

Assessment of the heart and central vessels is not delegated to unlicensed assistive

personnel. However, many aspects of cardiac function are observed during usual care andmay be recorded by persons other than the nurse. Abnormal findings must be validated

and interpreted by the nurse.

Equipment:

Stethoscope

Centimeter Ruler

Implementation:

Performance

1. Explain to the client what you are going to do, why it is necessary, and how he or

she can cooperate. Discuss how the results will be used in planning further care or

treatments.2. Wash hands and observe appropriate infection control procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following: family history of incidenceand age of heart disease, high cholesterol levels, high blood pressure, stroke,

obesity, congenital heart disease, arterial disease, and hypertension, and rheumatic

fever; clients past history of rheumatic fever, heart murmur, etc.

Assessment

5. Simultaneously inspect and palpate the precordium for the presence of abnormal

pulsations, lifts, or heaves.

Inspect and palpate the aortic and pulmonic areas, observing them at an angle and to

the side, to note the presence or absence of pulsations. Observing them at an angleand to the side, to note the presence or absence of pulsations. Observing these areas

at an angle increases the likelihood of seeing pulsations.

Inspect and palpate the tricuspid area for pulsations and heaves or lifts.

Inspect and palpate the apical area for pulsation, noting its specific location (it may

be displaced laterally or lower) and diameter. if displaced laterally, record thedistance between the apex and the MCL in centimeters.


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Inspect and palpate the epigastric area at the base of the sternum for abdominal

aortic pulsations.6. Ausculate the heart in all four anatomic sites: aortic, pulmonic, tricuspid, and apical

(mitral).

Carotid Assessment

7. Palpate the carotid artery, using extreme caution

8. Auscultate the carotid artery to determine the presence of a bruit.

Jugular Veins

9. Inspect the jugular veins for distention while the client is placed in a semi-Fowlers

position, with the head supported on a small pillow.

10. If jugular distention is present, assess the jugular venous pressure (JVP)

Locate the highest visible point of distention of the internal jugular vein. Althougheither the internal or the external jugular vein can be used, the internal jugular vein

is more reliable. The external jugular vein is more easily affected by obstruction orkinking at the base of the neck.

Measure the vertical height of this point in centimeters from the sterna angle, the

point at which the clavicles meet.

Repeat the preceding steps on the other side.

11. Document findings in the client record using forms or checklists supplemented by

narrative notes when appropriate.

Evaluation:

Perform a detailed follow-up examination based on findings that deviated from

expected or normal for the client. Relate findings to previous assessment data if

available.

Report significant deviations from normal to the physician.


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3.6 ASSESSING THE VASCULAR SYSTEM

Planning:

Delegation:Due to the substantial knowledge and skill required, assessment of the peripheral

vascular system is not delegated to unlicensed assistive personnel. However, many

aspects of the vascular system are observed during usual care and may be recorded bypersons other than the nurse. Abnormal findings must be validated and interpreted by

the nurse.

Equipment:

None

Implementation:

Performance

1.Explain to the client what you are going to do, why is it necessary, and how he or

she can cooperate. Discuss how the results will be used in planning further careor treatments.

2.Wash hands and observe appropriate infection control procedures.

3.Provide for client privacy.

4.Inquire if the client has any history of the following: past history of heartdisorders, varicosities, arterial disease, and hypertensions; lifestyle habits such

as exercise patterns, activity patterns and tolerance, smoking, and use of alcohol.

Assessment

Peripheral Pulses

5.Palpate the peripheral pulses on both sides of the clients body individually,

simultaneously, and systematically to determine the symmetry of the pulsevolume. If you have difficulty palpating some of the peripheral pulses, use a

Dopler ultrasound probe.

Peripheral Veins

6.Inspect the peripheral veins in the arms and legs for the presence and/or

appearance of superficial veins when limbs are dependent and when limbs areelevated.

7.Assess the peripheral leg veins for signs of phlebitis.

Peripheral Perfusion

8.Inspect the skin of the hands and feet for color, temperature, edema, and skinchanges.

9.Assess the adequacy of arterial flow if arterial insufficiency is suspected.10. Document findings in the client record using forms or checklists supplemented

by narrative notes when appropriate.

Evaluation:

Perform a detailed follow-up examination of the heart or central vessels,

integument, or other systems based on findings that deviated from expected or

normal for the client. Relate findings to previous assessment data if available.

Report significant deviations from normal to the physician.


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3.10 MUSCULOSKELETAL SYSTEM

Assessing the Musculoskeletal System

The primary structures of the musculoskeletal system are the bones, muscles, cartilage,ligaments, tendons, and joints. The muscles, bones, and joints are assessed.

Health History

Identify risk factors for altered health during the health history by asking about the

following:

History of trauma, arthritis, or neurologic order

History of pain or swelling in the joints

History of pain in the bones, muscles, or joints

Frequency and type of usual exercise

Dietary intake of calcium

History of smoking

History of alcohol intake

Use of hormone replacement therapy in women

Physical Assessment

The patient assumes a variety of positions, including standing, sitting, and supine.

Assessments of the musculoskeletal system can be integrated into the assessment of other

body systems.

Inspect and Palpate the Muscles


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Examine the muscles by inspection and palpation of muscle groups and by testing muscletone and strength. Muscle groups are observed for bilateral symmetry and palpated for

tenderness. Normally, they are symmetric and nontender. Evaluate muscle tone (the

normal condition of a muscle at rest) by putting each joint and extremity through passiverange of motion. Bilateral equal resistance should be present. Assess muscle strength by

asking the patient to move against resistance. Observe muscle contraction and determine

muscle strength exerted. An individuals dominant side is normally stronger than thenondominant side. Muscle strength should be bilaterally equal, with a slight increase on

the dominant side.

Abnormal findings include atrophy (a decrease in size), tremors ( involuntarymovements), and flaccidity (weakness) of muscles. Other abnormal findings are loss of

strength and tone, decreased range of motion, uncoordinated movements, swelling, and

pain. Abnormal findings may indicate a musculoskeletal disease, trauma, or a neurologicdisease.

Common Abnormalities

Ankylosis

Scarring within a joint leading to stiffness or fixation Atrophy

Wasting of the muscle

Decrease in size

Flabby appearance Decreased function and muscle tone

Contracture Resistance to movement of muscle or joint, fibrosis of soft tissue

Crepitus

Crackling sound or grating sensation from friction between two bones

Kyphosis Round back forward bending of spine

Lordosis

Anteriorposterior curvature with concavity in posterior direction Scoliosis

Lateral curvature lf the spine

Diagnostic Studies

X-ray Arthogram

X-ray

Bone Scan CT scan

Arteriogram

MRI

Lab test CBC

Infection ESR

Inflammatory response, Rheumatoid arthritis

Normal less than 20 mm/hr

Calcium Normal 9-11mg/dl

Alka Phos

Normal 29-30 mg/dl UA

Cancer of the bone has increased calcium levels


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Arthrocentesis

Aspirated fluid from the joint

Infection and hemorrhage

EMG Electrical activity of skeletal muscles and ability to response to stimuli

Thermography

Infrared camera detects amount of heat radiating from the soft tissue infection


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Palpate the Bones

Palpate bones for normal contour and prominence as well as for bilateral symmetry.Abnormal findings include pain, enlargement, asymmetry, and changes in contour.

Abnormal findings may indicate trauma, degenerative joint disease, musculoskeletal

disease, or a neurologic disease.

Inspect and Palpate the Joints

Each joint is put through its full range of motion to assess the degree of movement. Joint

movements include flexion, extension hyperextension, abduction, adduction, supination,and pronation. Normally, each joint has full range of motion, is nontender, and moves

smoothly. Palpate joints for the abnormal findings of pain, swelling, nodules, and

crepitation ( a grating sound heard or felt on movement).

Inspect Spinal Curves

With the patient standing. Inspect the spine from the back and from the side. The lumbar

curve may be flattened with a herniated disk. Kyphosis (an increased thoracic spinalcurve) is more often seen in older adults. An exaggerated lumbar curve (lordosis) is often

seen during pregnancy or in obesity. Scoliosis is a lateral curvature of the spine with

increased convexity on the side that is curved. School nurses often first identify scoliosisduring screenings, which are recommended for girls in grades 5 and 7 for boys in grades

8 or 9 (American academy of orthopedic surgeons, 2001).

Normal Age-Related Variations

Infant/Child

Common musculoskeletal variations in newborns and children include:

C-shaped curve of spine at birth: the anterior cervical curve develops at about 3 to 4

months of age, and thr anterior lumbar curve develops between 12 and 18 months of age

Lordosis (an exaggerated lumbar curve)

Pronation of the feet in children between 12 and 30 months of age

Genu varum (bowleg) for 1year after learning to walk

Older Adult

Common musculoskeletal variations seen in older adults include:

Loss of muscle mass and strength

Decreased range of motion

Kyphosis

Decreased height

Osteoarthritic changes in joints

3.11 NEUROLOGICAL SYSTEM


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Neurologic assessment includes cerebral function, cranial nerve function, cerebellar

function, motor and sensory function, and reflexes.

Health History

Identify risk factor for altered health during the health history by asking about the

following:

History of numbness, tingling, or tremors

History of seizures

History of headache

History of dizziness

History of trauma to the head or spine

History of infection of the brain

History of stoke

Changes in the ability to hear, see, taste, or smell

Loss of ability to control bladder and bowel

History of high blood pressure

History of chronic alcohol use

History of diabetes mellitus or heart disease

Use of prescription and over-the-counter medications

Family history of high blood pressure, alzheimers disease, epilepsy, cancer, or

Huntingtons chorea

Frequency of blood cholesterol tests and results

Exposure to environment hazards (eg, lead, insecticides)

Physical Assessment

Assess cerebral function by observing the patients behavior throughout the interview and

physical assessment. Assess the patients mental status, memory emotional status,cognitive abilities, and behavior. Evaluate cerebellar function by assessing fine motor

skills, coordination, and balance. Assess the sensory system by having the patient identify

various sensory stimuli, and evaluate the reflexes by contraction of specific muscles.

Equipment includes vials of aromatic substances (eg, peppermint and

vanilla), a visual acuity chart, a penlight, a sharp object (eg, a large safety pin), cotton

balls, vials of solution to test taste (eg, salt and sugar), a tunning fork, a tongue depressor,a reflex hammer, and familiar objects such as a key or coin. The patient should be sitting,

and the environment should be quiet.

Assess Mental Status

Mental status assessment includes level of awareness, level of conciousness, behavior

and appearance, memory, abstract reasoning, and language. On initial contact, begin to

evaluate the patients orientation to person, place, and time as well as his or her cognitiveabilities and affect (whether the patient knows who he or she is, where he or she is, and

the day or month or year). Observe the patients appearance, general behavior, and

responses to questions. Note any variation in responses. Also assess the patients abilityto speak clearly.


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The patient should have a clean, neat appearance with erect posture: should be oriented to

person, place, and time: should have memory recall (both short-term and long-term

memory): and should be able to demonstrate coherent and logical thought processes.Abnormal findings include poor hygiene, inappropriate dress, disorientation, absent

memory recall, and incoherent or illogical thought processes. These abnormal findings

may indicate a mental health disorder, mental retardation, organic brain disease,cerebrovascular disorser, alcohol or drug intoxication, or a tumor.

The Following discussion of each of the mental status components includes samplequestions or specific assessments to use during the assessment.

Level of Awareness

Evaluate orientation to time, place, and person to assess level of awareness. Thefollowing question may be used:

Time: What is todays date? What day of the week is it? What season of the year is this?What was the last holiday?

Place: Where are you now? What is the name of this city? What state are we in?

Person: What is your name? how old are you? Who came to visit you this morning?

Although exceptions may occur, individuals who have impairedawareness first lose time orientation, followed by place orientation, and then person

orientation. Remember that is often difficult to know the exact date when one is ill, in

pain or in unfamiliar surroundings.

Level of Consciousness

Consciousness is the degree of wakefulness or the ability of a person to be aroused. This

is not the same as orientation: a patient may be conscious but not oriented. Level ofconsciousness is described as follows:

Awake and alert: fully awake: oriented to person, place, and time: responds to allstimuli, including verbal commands

Lethargic: appears drowsy or asleep most of the time but makes spontaneous

movements: can be aroused by gentle shaking and saying patients name

Stuporous: unconscious most of the time: has no spontaneous movements: must be

shaken or shouted at to arouse: can make verbal responses, but these are less likely to beappropriate; responds to painful stimuli with purposeful movements

Comatose: cannot be aroused, even with use of painful stimuli; may have some reflexactivity (such as gag reflex);

The Glasgow coma scale is a standardized assessment tool that assesseslevel of consciousness. Three parameters are evaluated: eye opening, motor response, and

verbal response. Scores are given in each category, and a total score is recorded, with

higher scores indicating a more normal level of functioning. A score of 7 or less definescoma. This is more accurate evaluation of mental status over time.

Glasgow Coma Scale

1 2 3 4 5 6


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EyesDoes notopen eyes

Opens eyes inresponse to

painful stimuli

Opens eyesin response

to voice

Opens eyesspontaneously

N/A N/A

Verba

l

Makes no

sounds

Incomprehensible

sounds

Utters

inappropriate

words

Confused,

disoriented

Oriented,

converses

normally

N/A

MotorMakes no

movements

Extension topainful stimuli

(decerebrate

response

)

Abnormal

flexion topainful

stimuli

(decorticate

response

)

Flexion /

Withdrawal topainful stimuli

(decerebrate

response

)

Localizespainful

stimuli

Obeys

commands

The scale comprises three tests: eye, verbal and motorresponses. The three values

separately as well as their sum are considered. The lowest possible GCS (the sum) is 3

(deep coma ordeath), while the highest is 15 (fully awake person).

Memory

Assess memory by asking questions that call for answers demonstrating immediate recall

and recall for past events. To assess immediate memory, asks the patient to repeat a series

of numbers forward or backward (e.g., 3, 6, 9). Start with three numbers and graduallyincrease the digits until the patient cannot respond correctly. Most adults can repeat a

series of five to eight numbers forward and four to six digits backward. You might alsoask, What did you eat for breakfast this morning? To assess past memory, ask, When

is your birthday? or when is your wedding anniversary?

Abstract Reasoning

Ask the patient to explain a proverb such as the early bird catches the worm. If

intellectual ability is impaired, the patient usually gives a literal explanation or repeats the

phrase. Be sure that the phrase is not culture specific.

Language

The cerebral cortex controls the ability to express self through writing, words, or gesturesand to understand the spoken and written word. Injury to the cortex can cause aphasia,

which is a disorder of language ability. Aphasia may be expressive (the individual

understands written and spoken words but cannot write or speak to communicate

effectively) or receptive (the individual cannot understand written or spoken words).These aphasias may also be combined. Some simple methods of assessing language

capabilities include asking the patient to name items in the room (e.g. bed, flowers, gown,

pajamas), to follow simple commands, such as Point to your head, to read a shortsentence aloud, or to match printed and spoken words with appropriate pictures.

Assess Cranial Nerve Function

The function of the 12 cranial nerves is assessed primarily during the neurologic

assessment, although pars of cranial nerve function are assessed with body systems (e.g.

papillary response). The cranial nerves, with their function and assessment methods, are

outlined in table 25-10. Each nerve has a specific function and is evaluated individually.
http://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decorticatehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decorticatehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Visual_perceptionhttp://en.wikipedia.org/wiki/Speech_communicationhttp://en.wikipedia.org/wiki/Motor_skillhttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Deathhttp://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decorticatehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decorticatehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Abnormal_posturing#Decerebratehttp://en.wikipedia.org/wiki/Visual_perceptionhttp://en.wikipedia.org/wiki/Speech_communicationhttp://en.wikipedia.org/wiki/Motor_skillhttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Death


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Assess Motor and Sensory Function

Evaluate motor ability by assessing balance, gait, and coordination. Assess sensory

function by testing sensory discrimination of pain, light touch, and vibrations.

Balance and Gait

Evaluate balance and gait by having the patient walk across the room on the toes, on the

heels, and heel to toe. Observe posture, balance, and arm and leg movements. Theposture should be erect, with slight swaying in the standing position, and the gait even

with simultaneous arm movements. Abnormal findings include loss of balance, shuffling,

wide-based gait, and abnormal patterns of gait.

Motor Function and Coordination

Evaluate balance and gait by having the patient walk across the room on the toes, on the

heels, and heel to toe. Observe posture, balance, and arm and leg movements. Theposture should be erect, with slight swaying in the standing position, and the gait even

with simultaneous arm movements. Abnormal findings include loss of balance, shuffling,

wide-based gait, and abnormal patterns of gait.

Motor Function and Coordination

Evaluate motor function and coordination by having the patient rapidly touch each fingerwith the thumb, rapidly pat the hand on the thigh, and tap the foot on the floor (or against

your hand, if the patient is supine). Normally, the movements are coordinated.

Sensory Function

Test sensory perception by evaluating the patients response to pain, light touch, and

vibration. With the patients eyes closed, use a sharp object and a soft object randomly to

touch the upper and lower extremities to test sensation. The assessment proceeds from

distal (hands, arms, feet, or legs) to proximal (the trunk). The patient should be able todistinguish between sharp (pain) and soft or dull touch. The same process is repeated by

using the tuning fork to test for vibratory sensation and placing the fork in bony

prominences. Abnormal findings include inability to perceive pain or light touch,inability to identify the location of touch, and absence of vibratory sensation.

Assess Reflex Function

Evaluate the deep tendon reflexes to determine the functional ability of specific spinal

segment levels. Use the reflex hammer to elicit muscle contraction and reflexes. The

patient may be either sitting or supine.

Normal Age-Related Variations

Infant/Child

Common neurologic variations for newborns and children include;

Positive Babinskis reflex (normal in children between 12 and 24months)


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Grasp reflex (present at birth)

Motor control develops in head, neck, trunk, and extremities sequence

Older Adult

Common neurologic variations for older adults include;

Slower thought processes and verbal responses

Decreased sensory ability (hearing, sight, smell, taste, temperature, and pain)

Slower coordination and voluntary movements

Decreased reflex responses

May appear confused in unfamiliar surroundings

Gait may be slower, with a wider base and flexed hips and knees

Decreased deep tendon reflexes


22/23

Pamantasan ng Lungsod ng Maynila(University of the City of Manila)

Intramuros, ManilaCollege of Nursing

Compilation of

Written Reportsin BaCon B

Group 4

MEMBERS: Adam Ron P. Pineda

Marco Baltazar

Ryan John Tresplacios

Aaron David Santos

Xandra Kaye Intal

Nette Dionisio


23/23

Documents

Interactive Process