Use physical examination to do the following
• Gather baseline data about the patient’s health status.
• Support or refute subjective data obtained in the nursing
history.
• Identify and confirm nursing diagnoses.
• Make clinical decisions about a patient’s changing health
status and management.
• Evaluate the outcomes of care.
Two types of allergic responses
appear with NRL. Latex
The most immediate is an immunological reaction
type 1 response, for which the body develops antibodies
known as immunoglobulin E that can lead to an anaphylactic
response.
The
second is the allergic contact dermatitis type 4 response, which
causes a delayed reaction that appears 12 to 48 hours after exposure
sitting position
Head and neck, back, posterior thorax and lungs, anterior thorax and lungs, breasts, axillae, heart, vital signs, and upper extremities
Sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts. Physically weakened patient is sometimes unable to sit. Use supine position with head of bed elevated instead
supine Head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses
This is most normally relaxed
position. It provides easy
access to pulse sites.
If patient becomes short of breath
easily, raise the head of bed
Dorsal recumbent
Head and neck, anterior thorax
and lungs, breasts, axillae,
heart, abdomen`
Position is for abdominal
assessment because it
promotes relaxation of
abdominal muscles.
Patients with painful disorders are
more comfortable with knees
flexed.
prone
musculoskeltal system
Position is only for assessing
extension of hip joint, skin,
buttocks.
Patients with respiratory
difficulties do not tolerate this
position well
lateral recumbent
heart
Position aids in detecting
murmurs.
Patients with respiratory
difficulties do not tolerate this
position well.
knee-chest
rectum
Position provides maximal
exposure of rectal area.
This position is embarrassing and
uncomfortable.
lithotomy
Female genitalia and genital
tract
Position provides maximal
exposure of female genitalia
and facilitates insertion of
vaginal speculum
Lithotomy position is embarrassing and uncomfortable; thus examiner minimizes time that patient spends in it. Keep patient well draped.
Olfaction helps to detect
abnormalities that cannot be
recognized by any other means. For example, when a patient’s
breath has a sweet, fruity odor, assess for signs of diabetes
Describe any sound you hear using the following
characteristics:
Frequency indicates the number of sound wave cycles generated
per second by a vibrating object. The higher the
frequency, the higher the pitch of a sound and vice versa.
• Loudness refers to the amplitude of a sound wave. Auscultated
sounds range from soft to loud.
• Quality refers to sounds of similar frequency and loudness
from different sources. Terms such as blowing or gurgling
describe the quality of sound.
• Duration means the length of time that sound vibrations
last. The duration of sound is short, medium, or long. Layers
of soft tissue dampen the duration of sounds from deep
internal organs.
CAGE is an acronym for the
following:
• Have you ever felt the need to Cut down on your drinking
or drug use?
• Have people Annoyed you by criticizing your drinking or
drug use?
• Have you ever felt bad or Guilty about your drinking or
drug use?
• Have you ever used or had a drink first thing in the
morning as an Eye-opener to steady your nerves or feel
normal?
history of any substantial weight gain or loss
A weight gain of 5 pounds (2.3 kg) in 1 day indicates fluid-retention
problems. A weight loss is considered significant if the patient has
lost more than 5% of body weight in a month or 10% in 6 months.
Observe for cyanosis
(bluish discoloration)
in the lips, nail beds, palpebral conjunctivae, and palms
Inspect sites where abnormalities are more easily identified
For
example, pallor is more evident in the face, buccal (mouth) mucosa,
conjunctiva, and nail beds.
The best site to inspect for jaundice
(yellow-orange discoloration)
is on the patient’s sclera.
edema
Areas of the skin become swollen or edematous from
a buildup of fluid in the tissues. Direct trauma and impairment of
venous return are two common causes of edema.
The
depth of pitting, recorded in millimeters, determines the degree of
edema
For example, 1+ edema equals a 2-mm
depth, 2+ edema equals a 4-mm depth, 3+ equals 6 mm, and 4+
equals 8 mm
primary lesions
maculues and nodules
seconday lesions
such as ulcers occur as
alterations in primary lesions.
Use the ABCD mnemonic to assess the skin for any type of carcinoma
• Asymmetry—look for an uneven shape
• Border irregularity—look for edges that are blurred, notched,
or ragged
• Color—look for pigmentation that is not uniform; variegated
areas of blue, black, and brown and areas of pink,
white, gray, blue, or red are abnormal
• Diameter—look for areas greater than the size of a typical
pencil eraser
Nystagmus,
an involuntary, rhythmical oscillation of the
eyes, occurs as a result of local injury to eye muscles and supporting
structures or a disorder of the cranial nerves innervating the muscles
PERRLA
(pupils equal, round, reactive to light, and
accommodation)
Cherry-colored lips indicate
carbon monoxide poisoning
Varicosities
(swollen, tortuous veins)
comon on the tongues of older adults,
Assessment of the neck includes
assessing the neck muscles, lymph
nodes of the head and neck, carotid arteries, jugular veins, thyroid
gland, and trachea
Check each node methodically
in the following sequence:
occipital nodes at the base of the skull,
postauricular nodes over the mastoid, preauricular nodes just in
front of the ear, retropharyngeal nodes at the angle of the mandiblesubmandibular nodes, and submental nodes in the midline behind
the mandibular tip.
Vesicular sounds are soft, breezy, and low pitched. Inspiratory phase is 3 times longer than expiratory phase.
Best heard over periphery of lung (except over scapula) Created by air moving through smaller airways
Bronchovesicular sounds are blowing sounds that are medium pitched and of medium intensity. Inspiratory phase is equal to expiratory phase.
Best heard posteriorly between scapulae and anteriorly over bronchioles lateral to sternum at first and second intercostal spaces
Created by air
moving
through large
airways
Bronchial sounds are loud and high pitched with hollow quality. Expiration lasts longer than inspiration (3 : 2 ratio).
Heard only over trachea
Created by air moving through trachea close to chest wall
Crackles
Random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways right and left lung bases
Fine crackles are high-pitched fine, short;
interrupted crackling sounds heard during end of
inspiration; usually not cleared with coughing.
Medium crackles are lower; moister sounds heard
during middle of inspiration; not cleared with
coughing.
Coarse crackles are loud, bubbly sounds heard
during inspiration; not cleared with coughing.
Rhonchi (sonorous wheeze)Muscular spasm, fluid, or mucus
in larger airways; new growth
or external pressure causing
turbulence
Loud, low-pitched, rumbling coarse sounds are
heard either during inspiration or expiration;
sometimes cleared by coughing
Wheezes (sibilant wheeze)
High-velocity airflow through
severely narrowed or
obstructed airway
High-pitched, continuous musical sounds are like
a squeak heard continuously during inspiration
or expiration; usually louder on expiration
Pleural friction rub
Inflamed pleura; parietal pleura
rubbing against visceral
pleura
Dry, rubbing, or grating quality is heard during
inspiration or expiration; does not clear with
coughing; heard loudest over lower lateral
anterior surface.
apical impulse or point of maximal impulse (PMI).
The apex actually touches the anterior chest wall at
approximately the fourth to fifth intercostal space just medial to
the left midclavicular line.
In tall, slender persons the heart hangs
more vertically and is positioned more centrally. In shorter or
stockier individuals the heart tends to lie more to the left and horizontally
An infant’s heart is positioned more horizontally. The apex of
the heart is at the third or fourth intercostal space, just to the left
of the midclavicular line. By the age of 7 a child’s PMI is in the
same location as the adult’s.
During systole
the ventricles contract and eject blood from the left
ventricle into the aorta and from the right ventricle into the pulmonary
artery.
During diastole
the ventricles relax, and the atria
contract to move blood into the ventricles and fill the coronary
arteries.
a third heart sound (S3) can be heard, as with
heart failure
When the heart attempts to fill an already distended
ventricle
S4 also indicates an abnormal condition
A fourth heart sound (S4) occurs when the atria contract
to enhance ventricular filling. An S4 is often heard in healthy
older adults, children, and athletes; but it is not normal in adults
S3 ventricular gallop
It is caused
by a premature rush of blood into a ventricle that is stiff or dilated
as a result of heart failure and hypertension. The combination of
S1, S2, and S3 sounds like “Ken-tuck’-y.”
S4, or an atrial gallop
occurs just before S1 or ventricular systole.
The sound of an S4 is similar to that of “Ten’-es-see.”
Pain caused by vascular condition
tends to increase with activity.
Musculoskeletal pain usually is
not relieved when exercise ends.
Raised venous pressure
reflects right-sided heart failure.
Systemic diseases (e.g.,
arteriosclerosis, atherosclerosis,
diabetes).
Diseases result in changes in
integrity of walls of arteries and
smaller blood vessels.
Coagulation disorders (e.g., thrombosis, embolus).
Blood clot causes mechanical
obstruction to blood flow.
Local trauma or surgery (e.g.,
contusion, fracture, vascular
surgery).
Direct manipulation of vessels or
localized edema impairs blood
flow.
Application of constricting devices
(e.g., casts, dressings, elastic
bandages, restraints).
Constriction causes tourniquet
effect, impairing blood flow to
areas below site of constriction
examiners use a scale
rating from 0 to 4+ for the strength of a pulse
0: Absent, not palpable 1+: Pulse diminished, barely palpable 2+: Expected/normal 3+: Full pulse, increased 4+: Bounding pulse
The five Ps—pain, pallor, pulselessness,
paresthesias, and paralysis—
..
Varicosities
Varicosities in the anterior or medial part of the
thigh and the posterolateral part of the calf are abnormal
are superficial veins that become
dilated, especially when the legs are in a dependent position
The best time for a BSE
is the fourth through seventh day of
the menstrual cycle or right after the menstrual cycle ends, when
the breast is no longer swollen or tender from hormone elevations
theophyllines.
brochodialator
consistency of breast tissue
normally
feels dense, firm, and elastic.
Cancerous lesions are
hard, fixed, nontender, irregular in shape,
and usually unilateral.
abdominal region
The xiphoid process
(tip of the sternum) is the upper boundary of the anterior abdominal
region. The symphysis pubis marks the lower boundary
Bruising indicates
accidental injury, physical
abuse, or a type of bleeding disorder
Hernias
(protrusion of abdominal organs through the
muscle wall) cause upward protrusion of the umbilicus.
Absent sounds indicate
a lack of peristalsis, possibly the result of late-stage bowel obstruction;
paralytic ileus; or peritonitis
Bruits indicate
narrowing of the major
blood vessels and disruption of blood flow
Normally there are no vascular sounds
over the aorta (midline through the abdomen) or femoral arteries (lower quadrants)
to assess aortic pulsation
Palpate with the thumb and forefinger of
one hand deeply into the upper abdomen just left of the midline
