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Health Assessment

Nursing Assessment

Health history

Physical exam

Nursing History
Patient profile
Chief complaint
Past history
Family history
Medications
Allergies
Review of systems

Pain
Palliative/provocative
Quality/quantity
Regio/ radiation
Severety
Time

Examination Techniques

Inspection

Palpation

Percussion

Auscultation
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Inspection

Visual assessment of the patient and surroundings

Findings that may be significant:

Patient hygiene
Clothing
Eye gaze
Body language
Body position
Skin color
Odor
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Inspection

If the emergency response was to the


patient's home, make a visual inspection for
Cleanliness
Prescription medicines
Illegal drug paraphernalia
Weapons
Signs of alcohol use

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Palpation

A technique in which the hands and fingers are used to gather


information by touch

Palmar surface of fingers and finger pads are used to palpate for

Texture
Masses
Fluid
Crepitus
And assess skin temperature

Palpation may be either superficial or deep


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Deep Bimanual Palpation

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Percussion

Used to evaluate for


presence of air or
fluid in body tissues

Sound waves heard


as percussion tones
(resonance)

Procedure
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Auscultation

Best performed in a quiet environment

Requires a stethoscope

Body sounds produced by movement of fluids or gases in patient's


organs or tissues

Note:

Intensity
Pitch
Duration
Quality

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Stethoscope

Used to evaluate sounds created by


cardiovascular, respiratory, and
gastrointestinal systems

Stethoscopes
Acoustic
Magnetic
Electronic

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Stethoscope

Position stethoscope
between index and
middle fingers

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Ophthalmoscope

Used to inspect eye


structures:
Retina
Choroid
Optic nerve disc
Macula
Retinal vessels

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Otoscope

Used to examine
deep structures of
the external and
middle ear

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Blood Pressure Cuff

Sphygmomanometer

Measures systolic and


diastolic blood pressure

Manual or electronic
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Comprehensive Physical Examination

Mental status

Chest

General survey

Abdomen

Vital signs

Posterior body

Skin

Extremities

Head, eyes, ears, nose, and


throat (HEENT)

Neurological exam

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Mental Status

First step in patient care encounter


Patients appearance and behavior
Level of consciousness

A healthy patient is expected to be alert, responsive


to touch, verbal instruction, and painful stimuli

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Mental Status

Appearance and behavior


Posture, gait, and motor activity
Dress, grooming, personal hygiene
Breath or body odors
Facial expression
Mood and affect
Speech and language
Thought and perceptions
Memory and attention
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General Survey

Signs of distress

Cardiorespiratory insufficiency

Pain

Labored breathing
Wheezing
Cough
Wincing
Sweating
Protectiveness of a painful body part or area

Anxiety

Restlessness
Anxious expression
Fidgety movement
Cold, moist palms
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General Survey
Apparent state of health
Skin color and obvious lesions
Height and build
Sexual development
Weight

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Skin Color
Varies from person to person
Varies based on ethnicity
May range in tone from pink or ivory to
deep brown, yellow, or olive
Observe for skin not exposed to sun (e.g.,
palms)

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Skin Lesions

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Height and Build

Descriptions include:

Average, tall, short, lanky, muscular

May also be affected by age and lifestyle

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Sexual Development

Determine if age appropriate

Observe for normal changes associated with


age

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Weight

Observe general appearance

Obese to emaciated

Recent changes may be key finding

Recent weight loss or gain

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Vital Signs
Pulse
Blood pressure
Respirations
Skin
Pupils

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Pulse
Rate
Rhythm
Quality
Consider ECG monitoring

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Blood PressureLocations

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Respirations

Adult rate

12-24 breaths per minute

Observe
Feel for chest movement
Auscultate

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Skin
Texture
Turgor
Hair
Fingernails and toenails

Abnormal findings

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Temperature Measurement
Oral temperature
Hold thermometer
firmly under tongue
Tell child to kiss
Caution to avoid biting

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Axillary Temperature
Hold arm down
firmly
Should be
approximately 1 F
less than core temp

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Tympanic Temperature

Accuracy
questionable

Pull ear back

Insert gently
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Rectal Temperature
Risk of perforation
Avoid in
uncooperative, or
immuno-suppressed
patient
Stabilize thermometer

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EyesVisual Acuity

Have patient

Read printed material


Count fingers at a
distance
Demonstrate ability to
tell light from dark
Use eye chart
(e.g., Snellen chart)

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EyesPupils

Findings may indicate neurological issues

Examine response to light (PERRL)

Pupils are equal, round, and react to light

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Anatomical Regions

Skin
Texture
Turgor
Hair
Fingernails and toenails

Head, ears, eyes, nose, throat


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Head and Face


Inspect skull for shape and symmetry
Palpate for swelling, tenderness, lesions,
indentations
Inspect face for symmetry, expression,
edema, involuntary movements

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Sinuses

Return to Head and Neck

Eyes
Determine

if contacts are present


Determine that both eyes can see
Assess visual acuity
Inspect orbital area for edema
Examine eyes for drainage or redness
Determine structural integrity
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EyesVisual
Fields
Six cardinal fields of gaze

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Cardinal Fields of Gaze

Return to Head and Neck

Visual Fields

Ask the patient to look at his or her nose

Test peripheral vision by extending your arms


with elbows at right angles and wiggle both
index fingers simultaneously

Observe eyes for normal position and


alignment
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Ophthalmoscopic Examination

Used to evaluate:

Cornea
Foreign bodies
Lacerations
Abrasions
Infection
Anterior chamber

Hyphema
Hypopyon
Fundus
Optic nerve
Retina
Vitreous
Eyelid

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Cornea and Sclera

Examine conjunctiva
and sclera

Palpate lower orbital


rim

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Ophthalmoscopic Examination

Inspect:
Size, color, and clarity
of the disc
Integrity of vessels
Assess for retinal
lesions and
appearance of the
macula

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Ophthalmoscopic Examination

Normal findings
Clear, yellow optic
nerve disc
Reddish pink
(European-American)
or darkened retina
(African-American)
Light red arteries
Dark red veins
3:2 vein-to-artery ratio

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Otoscopic Examination

Otoscope used to:


Evaluate inner ear for discharge and foreign
bodies
Assess eardrum

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Otoscopic Examination

Select speculum

Turn on otoscope

Insert speculum into ear canal,


slightly down and forward

Look for foreign bodies, lesions,


discharge

Inspect tympanic membrane


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Otoscopic Examination

Normal findings
Cerumen is dry (tan or light yellow) or moist
(dark yellow or brown)
Ear canal

Not inflamed

Tympanic membrane

Translucent or pearly gray

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Nose
Inspect
Palpate
Discharge from the nose

CSF
Epistaxis
Mucous discharge

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Mouth and Pharynx

Lips

Gums

Mouth and tongue

Pharynx
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Oropharynx

Return to Head and Neck

Neck

Inspect

Use spinal precautions


if trauma is suspected

Palpate trachea

Midline position
normal

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Neck

Palpate
Place both thumbs along sides of distal trachea
Systematically move toward head
Do not apply bilateral pressure to carotid
arteries

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Return to Head and Neck Slide

Measuring JVD

Head and Cervical Spine

Temporomandibular joint (TMJ)

Inspect and palpate cervical spine

Range of motion

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Chest

Ribs
Protect thoracic organs
Support respiratory movements of diaphragm
and intercostal muscles
Anatomical landmarks for examination

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Topographical Landmarks

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Thoracic LandmarksAnterior Chest

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Thoracic LandmarksPosterior Chest

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Inspection

General appearance of chest

Chest wall configuration


Inspect for symmetry
Chest wall should be symmetrical

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Chest Wall Abnormalities

Barrel chest

Funnel chest (pectus


excavatum)

Pigeon chest (pectus


carinatum)

Thoracic kyphosis

Scoliosis
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ChestPalpation

Tracheal position

Respiratory excursion

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Breast Exam Techniques

Documenting the Breast Exam

Percussion and Auscultation of Chest

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Respiratory Effort

Assess:
Respiratory rate, rhythm, symmetry, and quality
Patient position
Accessory muscles
Retractions (intercostal, supraclavicular, or
both)
Nasal flaring
Pausing to take a breath

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Respiratory Patterns

Eupnea
Tachypnea
Bradypnea
Hyperpnea
Hyperventilation
Dyspnea
Orthopnea
Paroxysmal nocturnal
dyspnea

Apnea
Cheyne-Stokes respiration
Kussmaul breathing
Biots respirations
Central neurogenic
hyperventilation

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Auscultation
Patient in sitting position (if possible)
Instruct to breathe deeply and slowly
through open mouth
Use diaphragm of stethoscope
Evaluate anterior and posterior lung fields

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Normal Breath Sounds

Classified as:
Vesicular
Bronchovesicular
Bronchial

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Vesicular Breath Sounds

Most of lung fields

Lungs considered "clear" make


normal vesicular breath sounds

Harsh vesicular breath


sounds

Diminished vesicular breath


sounds
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Bronchovesicular Breath Sounds

Major bronchi and upper right


posterior lung field
Louder and harsher than
vesicular breath sounds
Medium pitch
Equal inspiration and
expiration phases
Heard throughout
respiration

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Bronchial Breath Sounds

Only over trachea

Highest in pitch

Coarse, harsh, loud sounds

Short inspiratory phase and


long expiration

Bronchial sound anywhere but


over trachea is abnormal
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Abnormal Breath Sounds

Absent

Diminished

Incorrectly located
bronchial sounds

Adventitious

Discontinuous
Continuous
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Breath Sounds
Fig.
Fig.11-26
11-26

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Discontinuous Breath Sounds

Crackles
Formerly called rales
High-pitched discontinuous sounds
Usually at end of inspiration
Disease of small airways or alveoli
Coarse crackles: wet, low-pitched sounds
Fine crackles: dry, high-pitched sounds

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Continuous Breath Sounds

Wheezes

Rhonchi

Stridor

Pleural friction rub


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Heart

Assessment includes:
Palpation
Auscultation

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Pulse

Assess:
Rate
Rhythm
Intensity

Palpate pulses simultaneously on both sides


of body

Except carotid
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Pulse

Auscultate for:

Frequency (pitch)
Intensity (loudness)
Duration
Timing in cardiac cycle

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Cardiac Circulation

Auscultating Heart Sounds

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Heart Sounds

S1

Instruct patient to breathe normally and then


hold breath in expiration

S2

Instruct patient to breathe normally again and


then hold breath in inspiration
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Pericardial Friction Rub

Inflammation of pericardial sac

Scratching, grating, or squeaking quality

Louder during inspiration

Differs from pleural friction rubs by


continued presence during breath holding
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Heart Murmurs

Prolonged extra sounds

Caused by disruption in flow of blood


through heart
Most caused by valvular defects
Some serious
Others benign

Have no apparent cause


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Bruit
Abnormal sound or
murmur
Heard while
auscultating carotid
artery, organ or gland

May be local
obstruction
Often low pitched
Hard to hear

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Thrills

Vibrations or tremors

May indicate blood flow obstruction


May palpate over aneurysm or on precordium
Serious or benign

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Abdomen

Two imaginary lines


separate abdominal
region into four
quadrants

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AbdomenInspection

Skin

Umbilicus

Contour

Abdominal movement
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Abdomen

Auscultation
Bowel sounds
Bruits

Percussion and palpation

Detect:
Fluid
Air
Solid masses

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Percussion

Evaluate four quadrants of abdomen:

Tympany

Dullness

Air in stomach and intestines


Solid abdominal organs and solid masses

Proceed from tympany to dullness

Change in sound easier to detect


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Palpation of the Liver

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Palpation of the Spleen

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Female Genitalia

If possible, use same-gender paramedics to


examine

Chaperone if possible

Inspect external genitalia for:


Swelling
Discoloration or redness
Bleeding
Trauma
Lesions
Discharge

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Female Genitalia

Normal vaginal discharge

Clear or cloudy with little or no odor

Yellow-green discharge
Frothy, gray-green discharge with foul odor
White, curdlike discharge with no odor
Gray discharge with fishy, foul odor

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Male Genitalia

Inspect for bleeding or trauma

Penis

Urethral opening

Shaft nontender and flaccid


Priapism

Free of blood and discharge

Scrotum

Nontender and slightly asymmetrical


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Male Genitalia

Anus

Exam indicated if:


Rectal bleeding
Trauma to area

Most patients find side-lying position most


comfortable
Protect patients privacy

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Male Genitalia

Inspect sacrococcygeal and perineal areas for:


Lumps
Ulcers
Inflammation
Rashes
Excoriations

Inflamed external hemorrhoids common

Adults and pregnant women


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Musculoskeletal System
Assess function and structure
Patient position

Evaluate head, neck, shoulders, and upper


extremities with patient in a sitting position
Evaluate chest, back, and ilium with patient
standing
Evaluate hips, knees, ankles, feet with patient supine

Observe general appearance, body proportions,


and ease of movement
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General Principles

Examine normal tissues before those


injured, inflamed, or otherwise affected

Inspect and palpate each body part

Then test range of motion and muscle strength

Note differences between right and left


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Extremities

Evaluate:
Skin and tissue over muscles, cartilage, bones
Joints for injury, discoloration, swelling, masses
Circulatory status

Skin color and temperature


Distal pulses

Structural integrity of bones, joints, and tissues


Muscle tone

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Abnormal Findings

Signs of inflammation

Swelling
Tenderness
Increased heat
Redness of overlying
skin
Decreased function

Asymmetry
Crepitus
Deformities
Decreased muscle
strength
Atrophy

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Joints

Bones move freely over one another

Move each joint through full range of


motion

No clicks, crepitation, or pain

Normal if no pain, deformity, limitation, or


instability

Note:
Limited range of motion
Unusually increased joint mobility

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Hands and Wrists

Inspect for swelling, redness,


deformity, nodules, muscular
atrophy
Palpate joint

Note swelling, tenderness,


deformity

Range of motion
Test muscle strength by hand
grip

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Clubbing of Fingernails

Elbows

Inspection

Palpation

Examine in flexed and extended


position
Note deformity, swelling, nodules

Lateral and medial epicondyles of


humerus
Groove on sides of olecranon
process

Range of motion
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Shoulders and Related Structures

Inspect shoulders, shoulder girdle,


scapulae, and related posterior muscles
Symmetry of size and shape
Note swelling, deformity, muscular atrophy

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Shoulders and Related Structures

Palpate for tenderness in:


Sternoclavicular joint
Acromioclavicular joint
Subacromial area
Biceps groove
Note any tenderness or swelling
Range of motion

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Shoulders and Related Structures

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Ankles and Feet

Skin integrity

Nodules

Contour

Swelling

Position

Calluses

Deformities

Corns

Size

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Ankles and Feet

Palpate:
Anterior aspects of each ankle joint
Achilles tendon
Metatarsophalangeal joints

Note tenderness, swelling, deformity

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Ankles and Feet

Range of motion
Dorsiflexion
Plantar flexion
Inversion
Eversion

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Pelvis

Pelvic structural
integrity

Hands on anterior iliac


crests

Press down and out

Heel of hand on
symphysis pubis

Press down
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Hips
Inspect for symmetry
Palpate:

Instability, tenderness, and crepitus

Range of motion (supine patient)


Raises knee to chest, other leg straight
Note flexion at hip and knee

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Knees

Inspection
Patella smooth, firm, nontender, midline
Alignment, swelling, and deformity
Note atrophy of quadriceps

Palpation

Note thickening, swelling, tenderness

Range of motion

Bend, straighten each knee without pain


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Peripheral Vascular System

Arteries, veins,
lymphatic system
and lymph nodes,
fluids exchanged in
capillary bed

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Arms

Inspect fingertips to shoulders, noting:

Size and symmetry


Swelling
Venous pattern
Color of skin and nail beds
Skin texture

Palpate:

Radial pulses bilaterally


Epitrochlear node

If palpable, note its size and consistency


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Legs
Patient supine and appropriately draped
Inspect from groin and buttocks to feet:

Size and symmetry


Swelling
Venous pattern and venous enlargement
Pigmentation
Rashes, scars, ulcers
Color and texture of the skin
Presence or absence of hair growth

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Legs

Palpate superficial inguinal nodes

Swelling and tenderness

Palpate pulses:
Femoral
Popliteal
Dorsalis pedis
Posterior tibial

Temperature of feet and legs


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Legs

Check for pitting edema:

Press firmly but gently with the thumb for at


least 5 seconds
Over dorsum of foot
Behind medial malleolus
Over shins

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Abnormal Findings

Swollen or asymmetrical extremities

Pale or cyanotic skin

Weak or diminished pulses

Skin cold to the touch

Absence of hair growth

Pitting edema
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Spine

Inspection

Cervical, thoracic, and


lumbar curves

Lordosis (swayback)
Kyphosis (hunchback)
Scoliosis (razorback)

Height differences of
shoulders
Height differences of
iliac crest

Cervical Spine

Inspection
Should be in a midline position
Look for deformities and abnormal posture

Palpation

If patient is alert and denies neck pain, palpate


posterior aspect of neck for point tenderness and
swelling
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Cervical Spine

Range of motion

If no suspected injury:

Bend head forward,


chin to chest (flexion)
Bend head backward
(hyperextension)
Move head side-to-side
(lateral bending)

Should be no pain or
discomfort
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Thoracic and Lumbar Spine


Inspect for injury, swelling, discoloration
Palpate from first thoracic vertebra

Move downward to sacrum

Range of motion
Bend forward at waist
Bend backward at waist
Bend to each side
Rotate upper trunk in a circular motion

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Nervous System

Detail of neurological examination varies

Depends on patients complaint

Peripheral nervous system vs. CNS problems

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Neurological Examination
Mental status and speech
Cranial nerves
Motor system
Sensory system
Reflexes

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Mental Status and Speech

Oriented to person, place, and time

Organizes thoughts and converses freely

If no hearing or speech impediments

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Mental Status and Speech

Abnormal findings
Unconsciousness
Confusion
Slurred speech
Aphasia
Dysphonia
Dysarthria

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Cranial Nerve Assessment

Cranial nerve I

Cranial nerve II

Olfactory: Test sense of smell with spirits of ammonia

Optic: Visual acuity

Cranial nerve II and III

Optic and oculomotor

Size and shape of pupils


Pupil response to light
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Cranial Nerve Assessment

Cranial nerves III, IV, VI

Oculomotor, trochlear, abducens


Extraocular movements
Six cardinal directions of gaze

Cranial nerve V

Trigeminal
Ask patient to clench teeth while palpating temporal
and masseter muscles
Test sensation by touching forehead, cheeks, jaw on
each side

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Cranial Nerve Assessment

Cranial nerve VII

Facial
Inspect face: note symmetry, tics, abnormal movements
Raise eyebrows, frown, show both upper and lower
teeth, smile, puff out cheeks
Close eyes tightly so they cannot be opened, gently
attempt to raise eyelids
Observe for weakness or asymmetry

Cranial nerve VIII

Acoustic: Assess hearing acuity

Cranial Nerve Assessment

Cranial nerves IX and X

Glossopharyngeal and vagus


Ability to swallow with ease; to produce saliva;
produce normal voice sounds
Patient holds breath: assess for normal slowing of
heart rate
Testing for gag reflex will test cranial nerves

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Cranial Nerve Assessment

Cranial nerve XI

Spinal Accessory

Raise and lower shoulders, turn head

Cranial nerve XII

Hypoglossal

Stick out tongue and move it in several directions


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Motor System
Observe patient during movement and at rest
Abnormal involuntary movements evaluated
for:

Quality
Rate
Rhythm
Amplitude

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Motor System

Other body movement assessments:


Posture
Level of activity
Fatigue
Emotion
Muscle strength

Bilaterally symmetrical
Resistance to opposition

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Muscle Strength

Patient to move against resistance:


No muscular contraction detected
A barely detectable flicker or trace of contraction
Active movement of body part with gravity eliminated
Active movement against gravity
Active movement against gravity and some resistance
Active movement against full resistance
This is normal muscle tone

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Upper Extremity Evaluation

Patient to extend
elbow and pull it
toward the chest
against resistance

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Lower Extremity Evaluation

Patient pushes soles of


feet against examiners
palms
Patient pulls toes
toward head against
resistance
Should be easily
performed by patient
without fatigue
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Muscle Strength

Other methods can be used to evaluate


muscle strength, including tests for:
Flexion
Extension
Abduction
Upper and lower extremities

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Coordination
Point-to-point movements
Gait
Stance
Romberg test
Pronator drift test

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Romberg Test

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Pronator Drift Test

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Sensory System

Conduct sensations of:


Pain
Temperature
Position
Vibration
Touch

A healthy patient is responsive to these


stimuli
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Sensory System

Patients response to pain and light touch

Response considered in relation to dermatomes

Perform light touch on hands and feet

If patient cannot feel or is unconscious, gently


prick extremities with sharp object that will not
penetrate skin

Head to toe
Compare symmetrical areas

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Approaching the Pediatric Patient


Remain calm, confident
Avoid separating child from parent
Establish rapport with parents and child
Be honest with child and parent
Have one paramedic stay with child

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Approaching the Pediatric Patient

Observe child before physical examination

Begin assessment without touching patient

Note:
Skin color
Level of consciousness
Respiratory rate
Assess behavior

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Approaching the Pediatric Patient

Note area of body that appears painful


Avoid painful area until end of examination
Warn child before you touch painful area(s)

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General Appearance

Assess from a distance:


Level of consciousness
Spontaneous movement
Respiratory effort
Skin color
Body position

Seriously ill or injured child does not


hide or disguise condition
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Birth to 6 Months
Maintain body temperature
Poor head control normal under 3 months of
age
Infants are abdominal breathers

Stomach protrudes and chest wall retracts


during inspiration

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Birth to 6 Months

Assess anterior fontanel:


Present up to 18 months
Bulges during crying
Firm if child is supine

If sunken, may be
dehydration
Bulging fontanel may
mean increased
intracranial pressure

7 Months to 3 Years

Usually cooperative
Minimal speech, unreliable history
May have separation anxiety
If possible, have parent hold child for exam
May see illness or injury as punishment
Approach slowly and speak in reassuring tones
Use simple and direct questions
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4 to 10 Years

May be cooperative
May provide limited history of event
May have separation anxiety and view illness or
injury as punishment
Approach slowly
Speak in quiet, reassuring tones
Allow child to "help"
Reluctant to show "private parts
Advise of any expected pain or discomfort
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Adolescents (11 to 18 years)


Generally calm, mature, helpful
Concerned about modesty, disfigurement,
pain, disability, and death
Reassure when appropriate
Respect patient's need for privacy
If possible, interview privately
Consider alcohol, drug use, pregnancy

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Communicating with the Older Adult

Allow time for effective communication

Stay close to patient during interview

Repetition of questions may be needed

Do not patronize or offend patient


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Patient History

Multiple health problems

Difficult to isolate injury or illness

Decreased sensory function may disguise signs and symptoms

Watch for illness from medication use or misuse

Consider relationship between drug interactions, disease, and


aging process
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Patient History

Functional ability and daily activities

Walking
Getting out of bed
Dressing
Driving a car
Using public transportation
Preparing meals
Taking medications
Sleeping habits
Bathroom habits
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Physical Examination

Try to ensure patient comfort


Offer clear explanations
Answer questions
Be alert to chronic pain
If hospital transport necessary
Attempt to calm patient
Reassure patient he or she will be cared for in
hospital
Record examination findings
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Conclusion
The Nurse must have a wide range of
knowledge and skills to perform a
comprehensive physical examination and to
make effective clinical patient care
decisions.
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Questions?

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