Nursing Physical Assessment

personal Assessment Lab 120-103 1. General Survey Level? Awake & alert a. Orientation to person, short letter, meter? b. Ability to Communicate in adequate sentences with clear speech? c. Posture unspoilt and erect, shoulders level and symmetrical? d. Personal Hygiene Clean & neat, no odor, dresses appropriately for the weather. 2. Integumentary System a. food colour Uniform color pink, tan, brown, olive. S lightly darker on exposed areas. There are normally no areas of bleeding, ecchymosis, or increased vascularity. No skin lesions should be present except for freckles, birthmarks, or moles, which may be unconditional or elevated. . Temperature Warm and dry bilaterally. Hands and feet may be slightly cooler than the rest of the tree trunk. contend surfaces should be non tender. (use back of both hands on patients forearms) c. Textures Skin should feel docile/fine or bold/thick. d. Turgor When the skin is released, it should instantly recoil, no tenting. scoop up place to assess Ant. ? knocker or abdomen. **Verbalize I will integrate the integumentary frame throughout the rest of the trial run through checking and observing. 3. Head, Face, Neck a. Cranium The headroom should be normocephalic, midline, and symmetrical.? . Scalp The scalp should be w sume to light brown, shiny, intact, and without lesions or masses, flaking, or pidiculi (lice)? c. Hair Pale blonde to black, thick or thin, curly or straight, coarse or fine, shiny or faint.? d. Frontal Maxillary Sinuses Should be non palp satisfactory and non tender (must ask did that suffer? ) e. Cervical Lymph Nodes Should be non palpable and non tender, non microscopic or inflamed. (Preauricular, postauricular, occipital, submental, submandibular, tonsillar, anterior cervical chain, posterior cervical chain, supraclavicular. e. Best place to assess Ant. titty or abdomen. **Verbalize I will integrate the integumentary system throughout the rest of the testing through checking and observing. Physical Assessment Lab 120-103 f. Carotid Artery Has visible pulsation (should be in front of the sternocleidomastoid muscle), palpable bilaterally (not at the same time ), no bruits (soft blowing or wooshing sound from constriction of plaque) g. Temporal Artery Should be palpable and equal bilaterally h. TMJ G palpebraes smoothly, no clicking or crepitus. i. Trachea Midline, Thyroid non palpable, non tender (ask) j.Neck ROM & Muscle Strength Stand arse the patient, touch the chin to the chest, anticipate up at the ? ceiling, move each ear to shoulder (without elevating the shoulder), call on head to each side to look at the shoulder. The Cervical spines alignment is straight, the head is held erect. Normal muscle strength allows for secure, complete, voluntary joint ROM against both gravity and moderate to extensive resistance. Muscle strength is equal bilaterally. There is no observed involuntary muscle movement. Say full active ROM with no restrictions k.Thyroid Palpation take a leak the patient lower the chin slightly in order to relax neck muscles. Place your thumbs on the back of the patients neck and become the other fingers around the neck anteriorly to rest their tips over the trachea on the lower destiny of the neck. Move the finger pads over the tracheal rings. Gently move trachea over to the side, then have patient swallow. Feel for any consistency, nodularity, or tenderness. 4. Eyes? a. Eyelids Palpebral Fissure are symmetrical, no ptosis or lid lag.? b. Lacrimal Glands Pale pink, patent, no excessive tearing, dryness, drainage, or edema.? . Eyelashes Evenly distributed no ectropion no entropion.? d. Eyebrows Even and every bit bilateral? e. Conjunctiva clear, pink, moist, without lesions? f. Sclera white & intact? g. Cornea Surface should be moist and shiny and without discharge, cloudiness, opacity, and irregularity.? h. Iris round, symmetrical, and dingy green, blue, brown, hazel, violet, honey, etc.? i. Pupils PERRLA (Pupils are Equ al, Round, Reactive to clear and Accommodation) Check pupil reflexes. check twice each eye, postulate/consensual, then bring penlight toward nose to assess for accommodation. . Ears? a. Pinna Non tender, symmetrical bilaterally, without lesions or masses, ( acme of pinna should always be equal to outer canthus) palpate simultaneously? b. Tragus non tender, without lesions? c. Mastoid Process (piece of turn out inferior posterior ear) non tender, no swelling, equal bilaterally (if one is different, ask for how long)? d. Tympanic Membrane Pearly gray, shiny, intact (sometimes will go to some white-cottage cheese looking bumps = scarring) MAKE SURE TO CHANGE SPECULUM BTWN EARS FOR PRACTICUM Adult pull back and up, look anterior.Child pull start) **know how to use equiptment Instructors/proctors look for this *** e. Umbo (Part of the Stapes) Make sure this is present, Protruding = dehydrated, Not present = eloquent behind eardrum. f. Cone of Light Tiny triangle anterior inferior on tympanic membrane = healthy. 500 on the right ear, 700 on the left ear. Physical Assessment Lab 120-103 6. nest? a. Nares patent, have patient occlude one nostril and gently blow out air on back of hand to test patency. Mucosa pink, moist, without lesions, edema, drainage? b. Septum without deviation.Best was to assess is to push tip of nose up shows if deviation is present. ***If nares are pink = allergies. If nares are bright red = cold. Saline shortens cold as it washes it down to stomach, where stomach kills the virus. 7. Mouth/Lips? a. Lips pink, moist, intact, without lesions? b. Teeth 32 including 4 wisdom. White with good repair, without caries? c. Tongue pink, moist, papillae intact, midline, full mobility (ask pt to stick tongue out move left, right, up, down), without lesions? d. Oral Mucosa pink, moist, without lesions (use tongue depressor & penlight) no red, no swelling? . Gingiva pink, moist, intact, no bleeding? f. Uvula Midline, rises symmetrically with soft palate when patient says Ahhh If vanish patient will be sensitive to gagging. If long may be a sign of cat sleep apnea? g. Tonsils Pink, symmetrical. They are graded from absent +4) +1 = peeking, +4 = kissing h. Hard/ finespun Palate pink, intact. Soft palate is pinker than hard Write What you would expect to see If not, must state what you see. Are the eyelids covering the top of the iris? Always compare OD to OS. First begin assessment with visual acuity.?Corneal Light involuntary Shine penlight 12-15 away toward eyes (at midline) Should get right reflex in same daub in each eye. If asymmetric they have strabismus (weak eye muscle) Ears Use tuning fork? weber Test work stoppage on palm Hold at tip head (hairline) Should be able to hear equally in each ear. Rinne Test hearing acuity. Hit prongs on palmar, put it on mastoid process until cant hear it any longer, then move it to obtaining it in front of the ear canal. ***Air conduction should be twice as long as bone conducti on*** Semicircular Canals control balance and equilibriumVertigo can be caused by a foreign body which has been dislodged and landed in semicircular canals. Native Americans and Asians can have Torus Palantitis looks like mountain ranges on palate this is a benign condition. 8. Sensory Neuro (answer to most cranial nerve testing is intact) *verbage Physical Assessment Lab 120-103 a. Sensation light touch, astute/dull, intact? a. Upper Extremities use cotton ball, & sharp & dull sides of broken tongue depressor use 3 spots finger, back of hand, arm. * b. Abdominal Reflex * Positive or not present * . Lower Extremities use cotton ball & sharp & dull sides of broken tongue depressor use 3 spots toe, top of foot, and shin.? b. Deep Tendon Reflexes (smack cryptic tendons using flat side of power hammer) *These are graded 0-4 What you would expect to find +2/4) ? a. Biceps place thumb at patients elbow (antecubital) to hold their arm. Hit own thumb with the hammer. ?b. Tricep s hold patients muscle so patients arm can swing freely. Hit hammer above funny bone. ?c. Brachial Radialis Hold pts hand then hit hammer midway btwn wrist & antecubital. d.Patellar Find tendon right above patellar bone, hit hammer on tendon? e. Achilles About 2 above heel, support foot, relax leg. Will have plantar flexion.? f. Plantar or Babinski = severe brain damage abduction. So we say Positive plantar ? flexion, no abduction we only expect to find in babies. How to test use metal side of hammer and identify the outer margin of the foot and across top, under toes. ?babinski or f. Best place to assess Ant. ?Chest or abdomen. **Verbalize I will integrate the integumentary system throughout the rest of the exam through checking and observing.