HEALTH ASSESSMENT the temporal artery to a point directly behind

PRE FINAL - 1 the ear.

 Axillary Temperature
DATA COLLECTION, DOCUMENTATION AND ANALYIS - Place a probe cover over the electronic
COLLECTING OBJECTIVE DATA thermometer and place in the middle of the
axilla.
VITAL SIGNS - Hold the glass or electronic thermometer under
Proper Use of Thermometer, Stethoscope and the axilla firmly by having the client hold down
Sphygmomanometer and across the chest for 10 mins.
PHYSICAL ASSESSMENT Measuring Blood Pressure
Techniques of Physical Assessment 1. Assemble all your equipment
Equipment 2. Remove client’s clothing and palpate the
pulsations
VITAL SIGNS 3. Place blood pressure cuff so that midline of
- Are the body’s indicator of health. (temperature, pulse, bladder is over the arterial pulsation
respirations, blood pressure and pain) 4. Support client’s arm at heart level
- Good idea to begin the “hands-on” physical 5. Put the earpiece, palpate the brachial pulse
examination. place the stethoscope lightly over the area and
- Noninvasive procedure that reflect several status of position mercury gauge on the manometer at
body system. eye level.
6. Adjust the screw above the bulb to tighten the
PROPER USE OF THERMOMETER valve on the air pump, make sure tubing is not
 Oral Thermometers kink or obstructed
- Place a disposable cover over the probe and 7. Inflate the cuff by pumping the bulb to about 30
insert under the tongue. mmHg.
- Ask patient to close both lips and watch for 8. Deflate the cuff slowly by turning the valve in
digital readout the opposite direction while listening for the
- Take about 10 secs. first of Korotkoff sounds.
- Note for hot and cold liquids even smoking to CONDUCTING PHYSICAL EXAMINATION (PE)
prevent alteration of reading. 1. Preparation of the setting, oneself and client for PE
 Rectal Temperatures 2. Positioning of client appropriately
- Select a rectal thermometer (usually red) 3. Types of and operation of equipment needed for a
- Place disposable cover over the probe and particular examination.
lubricate it. 4. Performance of the Four Assessment Technique
- Ask patient to lie on one side with hip flexed Preparation of Physical Setting
and insert the thermometer about 3-4 cm (1.5  Ensure to meet the following:
inches) into the anal canal, in a direction - Comfortable and warm room temperature
pointing to the umbilicus. - Private area, free from interruptions and
 Tympanic Membrane Temperatures distractions
- Increasingly common practice, and is quick and - Adequate lightning
safe, and reliable. - Firm examination table
- External auditory canal is free from cerumen, - Bedside tray for equipment
which lowers temperature reading. - Collect all necessary equipment prior to PE
- Position the probe into the canal wait for 2-3 - Prevent transmission of infectious agents by
secs. following standard precaution
- Measures core body temperature higher than Preparing Oneself
the normal oral temperature by 0.8C (1.4F)  Assess your own feelings and anxieties
 Temporal Arterial Temperature  Achieve self-confidence
- Remove the protective cap from the  Preventing the transmission of infectious
thermometer agents
- Place over the client’s forehead and while General Principles:
pressing the scan button, gently stroke the - Wash your hands before beginning the
thermometer across the client’s forehead over examination
 - Always wear gloves 2. ULNAR OR PALMAR SURFACE – vibrations, thrills,
- If pin or sharp object is used, discard the pin and fremitus.
use new one 3. DORSAL (back) SURFACE - temperature
- Wear a mask and protective eye googles
- Nurse-client relationship should be established FOUR TYPES OF PALPATION
during client interview before PE LIGHT PALPATION
- Describe to the client what the examination will - Place your dominant hand lightly on the surface
involve of the structure
- Respect client’s desires and requests related to - There should be little or no depression (<1cm)
the PE - Circular motion
- Explain to the client the purpose of collecting - Uses for pulses, tenderness, surface skin
specimen (if necessary) texture, temperature and moisture.
- Ensure client’s privacy MODERATE PALPATION
- Begin examination with less intrusive - Depress the skin surface (1-2cm) with your
procedures such as taking the V/S dominant hand
- Approach client from the right side since most - Circular motion to feel for easily body organs
techniques are performed with the examiner’s and masses. Note the size, consistency, and
right hand mobility of structure.
- Depending on the procedure, the client may be DEEP PALPATION
asked to change positions frequently. - Place your dominant hand on the surface and
TECHNIQUES OF PHYSICAL ASSESSMENT your non-dominant hand to apply pressure.
4 BASIC TECHNIQUES - Surface depression (2.5 and 5 cm) to feel deep
1. INSPECTION organs or structures.
2. PALPATION BIMANUAL PALPATION
3. PERCUSSION - Use two hands, placing each side of the body
4. AUSCULTATION part (e.g. uterus, breasts, spleen)
- Use one hand to apply pressure and the other
INSPECTION hand to feel the structure
- Involves using the senses of vision, smell, and hearing. - Note the size, shape, consistency, and mobility
GUIDELINES: GUIDELINES FOR EFFECTIVE PALPATION
- make sure the room is a comfortable temperature. 1. Wash your hand before and after palpation.
- use good lighting 2. Be aware that touching can cause
- look and observe before touching embarrassment and may put patient at ease
- completely expose the body part you are inspecting (explain: what, where, why?
-note the ff: color, patterns, size location, consistency, 3. Make certain hands are warm
symmetry, movement, behavior, odors or sounds 4. Ask the patient to take slow, deep breaths
- compare the appearance of symmetric body parts through mouth to decrease muscle tension
5. Palpate tender areas last, stop if pain occurs
PALPATION 6. Use pads of hands to assess texture, shape, size
Using the parts of hands to touch and feel for the and movement
following: 7. Use back of hand to check for temperature
- texture 8. Use the palmar or ulnar aspect of hand to
- temperature assess vbrations
- moisture PERCUSSION
- mobility  Tapping body parts to produce sound waves or
-consistency vibrations which helps the examiner to assess
- strength of pulses underlying structures
- size PERCUSSION USES:
- shape • Eliciting pain
- degree of tenderness - Detect inflamed underlying structures ( feels
PARTS OF THE HAND TO USE WHEN PALPATING tender, sore or painful)
1. FINGERPADS – pulses, texture, size consistency, • Determining location, size and shape
shape, crepitus.
- Changes between borders of an organ and its 5. 5. FLATNESS – an extremely dull sound that
neighboring organ produce by a very dense structures such as
• Detecting abnormal masses muscle or bone.
- Can detect superficial abnormal structure or Guidelines for Effective Percussion
masses  Ensure a quiet environment.
• Eliciting reflexes  Have the patient void before percussion of the
- Deep tendon reflexes using the percussion lower abdomen
hammer  Recognize that obesity can cause sounds to be
TYPES OF PERCUSSION muffled
• Direct Percussion  Make certain your hands is warm prior to
- Direct tapping of the body part with one or two touching
fingertips to elicit possible tenderness.  Percuss from more resonant body areas to less
- Using sharp rapid movements from the wrist, resonant areas
strike the body surface to be percussed with the  Use equal force in all areas to allow for accurate
pads of two, three or four fingers. comparison
- Used to assess sinuses in the adult.  Avoid percussing over ribs, scapulae or other
• Indirect or Mediate bony structures, otherwise only dull sound may
- Most commonly used method of percussion be heard
- Produces sound or tone that varies with the  Never use blunt percussion over the thorax of
density of underlying structures an elderly patient. (fx of ribs)
- As density increases, sound tone become AUSCULTATION
quieter. Solid tissue produces a soft tone, fluid - requires the use of stethoscope to listen for heart
produces a louder tone, and air produces louder sound, movement of the blood through the
tone. cardiovascular system, movement of the bowel, and
Technique of Indirect Percussion movement of the air through respiratory tract
1. Place the middle finger of your non-dominant - used to detect presence of normal and abnormal
hand on the body part you are going to percuss. sounds and to assess them in terms of loudness, pitch,
2. Keep your other fingers off the body parts. quality, frequency and duration.
3. Use the pad of your middle finger of the other PROPER USE OF STETHOSCOPE
hand to strike the middle finger of your non- Use to listen for (auscultate) body sounds that cannot
dominant hand be originally heard (e.g. lung sounds, bruits, and bowel
4. Withdraw your finger immediately to avoid sound)
damping the tone. 1. Place the earpieces into the ear canal
5. Deliver two quick taps and listen carefully 2. Angle the binaurals down toward your nose.
6. Use quick taps by quickly flexing your wrist, not 3. Use the diaphragm of the stethoscope to detect
your forearm. high-pitched sounds.
TYPES OF PERCUSSION 4. Use the bell of the stethoscope to detect low-
• Blunt Percussion pitched sounds.
- Used to detect tenderness over organs (e.g. Some Do’s and Don’ts
kidneys) by placing one hand flat on the body 1. Warm the diaphragm or the bell of the
surface and using the fist of the other hand to stethoscope before placing it on the client’s
strike the back skin.
Percussion Sound 2. Explain what you are listening for.
1. RESONANCE – hallow sound like that produced 3. Do not apply too much pressure when using the
by the normal lung. bell
2. HYPERRESONANCE – a booming sound like that 4. Avoid listening through clothing
produced by an emphysematous lung. Guidelines of Auscultation
3. TYMPANY – musical or drum like that produced  Eliminate distracting or competing noises from
by the stomach and intestines the environment
4. 4. DULLNESS – thud sound produced by dense  Expose the body part you are going to
structures such as the liver, and enlarged spleen auscultate. Do not auscultate through the
or full bladder client’s clothing or gown and ovoid rubbing
against the clothing
  Use the diaphragm of the stethoscope to listen - Noninvasive procedures do not involve tools that break
for high pitched sounds (normal heart, breath, the skin or physically enter the body. Examples include
bowel sound) x-rays, a standard eye exam, CT scan, MRI, and ECG
 Use the bell of the stethoscope to listen for low- - Noninvasive devices include hearing aids,
pitched sounds (abnormal sounds and bruits) external splints, and casts.
EQUIPMENT AND INSTRUMENTS LABORATORY TESTS
Basic Equipment:  A medical procedure that involves testing a
• Tape measure/ ruler sample of blood, urine, or other substance from
• Sphymomanometer and cuff the body. Laboratory tests can help determine a
• Stethoscope with a bell and diaphragm diagnosis, plan treatment, check to see if
• Thermometer treatment is working, or monitor the disease
• Otoscope over time.
• Flashlight VALIDATION/RATIONALIZATION
• Tongue blade  Process of confirming or verifying that the
• Vision chart, CB subjective and objective data you have collected
Positioning the Client are reliable and accurate.
 SUPINE POSITION  Steps of Validation
 SITTING POSITION • Data require validation
 DORSAL RECUMBENT • Methods of Validation
 SIM’S POSITION • Identification of areas for which are missing
 STANDING POSITION Data Requiring Validation
 PRONE POSITION  Discrepancies or gaps between the subjective
 KNEE-CHEST POSITION data and objective data;
 LITHOMY POSITION  Discrepancies or gaps between what the client
DIAGNOSTIC PROCEDURES says at one time versus another time;
 Methods and techniques performed to diagnose  Findings that are highly abnormal and
disease, disorders, or conditions. Biological inconsistent with other findings.
samples such as blood, urine, or saliva are used Methods of Validation and Identification of Areas
to detect the presence of bacteria, fungi, or  Recheck your own data through a repeat
other markers to diagnose a disease, disorder, assessment
or condition.  Clarify data by asking additional questions
 RATIONALE - Diagnostic procedures that are  Verify data with other health care professionals
accurate and reliable make for a more efficient  Compare your objective and subjective data
health care system by streamlining treatment DOCUMENTING DATA
and recovery, enhancing the quality of patient PURPOSE:
care, and reducing health care costs.  Promote effective communication
- may also be used to help plan treatment, find out how  Provides database that becomes foundation for
well treatment is working, and make a prognosis. care of clients
INVASIVE PROCEDURES  Identify health problems
 A medical procedure that invades (enters) the  Formulate nursing diagnosis
body, usually by cutting or puncturing the skin  Plan immediate and ongoing interventions
or by inserting instruments into the body INFORMATION REQUIRING DOCUMENTATION
 performed by trained healthcare professionals Two key elements:
using instruments, which include, but are not  Nursing History (Subjective Data)
limited to, endoscopes, catheters, scalpels,  Physical Assessment (Objective Data)
scissors, devices and tubes. GUIDELINES
NON INVASIVE PROCEDURES  Keep confidential
- The term noninvasive can refer to diseases,  Document legibly or print neatly
procedures, or devices.  Use correct grammar or spelling
- Noninvasive diseases usually do not spread to or  Avoid words that create redundancy
damage other organs and tissues.  Use phrases instead of sentences
 Record data findings, not how they were
obtained
  Write entries objectively without pre mature DHN
judgment - Temperature maintenance and electrolyte balance,
 Records client’s understanding and perception absorption, excretion sensation and Vit. D synthesis
 Avoid recording the word normal for “normal HAIR - Consists of layers of keratinized cells found all
finding” over much of the body EXCEPT for lips, nipples, soles of
 Record complete information and details for all the feet, palms of the hand, labia minora and penis.
client’s symptoms - Hair on the head protects the scalp, provides insulation
 Include additional assessment and self expression
 Support objective data with specific observation - Nasal hair, auditory canal hair, eyelashes and
ASSESSMENT FORMS USED eyebrows filter dust.
[Link] Assessment Form NAILS - Located on the distal phalanges of the fingers
 Nursing admission or admission database and toes, are hard, transparent plates of keratinized
 Four types: open-ended forms (traditional), epidermal cells that grow from the cuticle.
cued or check list, integrated cued check list, - Protects the distal ends of the fingers and toes,
nursing minimum data set. enhance precise movement of the digits and allow for
2. Frequent or Ongoing Assessment Form precision grip.
 Flowcharts that help staff to record and retrieve CULTURAL CONSIDERATION
data for frequent reassessments.  oral mucosa is best for assessing color changes
 Examples are vital signs sheets and assessment in dark-skinned persons
flow chart  assess the sclera rather than skin in Asians for
3. Focused or Specialty Area Assessment Form jaundice is more accurate
SUMMARY  at risk for skin CA with prolonged sun exposure
 Collecting objective data is essential for  African Americans have thick and kinky hair.
complete nursing assessment. The nurse must  Asians produce less sweat/less body odor
have basic knowledge and skill  dark-skinned clients have lighter colored palms
 Collecting objective data requires great deal of soles, lips and nail beds
practice.  dark-skinned person appears ashen gray if
cyanosis
EQUIPMENT/PREPARATION
HEALTH ASSESSMENT – 2  Adequate lightning
PERSON AS:  Comfortable room temperature
*Biological Being  Gloves
*Psychosocial Being  Penlight
*Spiritual Being  Magnifying glass
 GUIDELINES IN CONDUCTING HA  Transparent ruler/tape measure
 GENERAL SURVEY Collecting Subjective Data
 PHYSICAL ASSESSMENT  Skin, hair, nails may be local or cause by an
GUIDELINES/GENERAL SURVEY underlying systemic condition. It is important to
 PREPARING THE CLIENT collect data about current symptoms. (Areas of
 PREPARING THE EQUIPMENT Health Assessment)
 PREPARING THE ENVIRONMENT  Ask questions in straight forward manner.
 ETHICO LEGAL CONSIDERATIONS  Keep in mind that a nonjudgmental, sensitive
 AFTER CARE approach is needed. (poor hygiene or unhealthy
 DOCUMENTATION behaviors)
 COMPONETS OF GENERAL SURVEY History of Present Health Concern (SD)
 GENERAL APPEARANCE Focus Questions (SKIN):
 MENTAL STATUS  skin rashes, lesions, itching, bruising, swelling
 MOBILITY OF CLIENT or changes in color. (location, onset,
 BEHAVIOR OF CLIENT precipitating factors)
 birthmarks or mole? (change in color, shape,
SKIN - Largest organ of the body size)
- Physical Barrier that protects underlying tissues and  ability to feel pain, pressure, light touch
organs from micro organism, physical trauma, UVR and  pain, itching, tingling or numbness
  taking any medications (prescribe, OTC) Collecting Objective Data
 trouble controlling body odor, excessive  Skin, hair, nails may be local or cause by an
perspiration underlying systemic problems or alterations in a
 consideration: sweat glad activity decrease as client’s self care activities.
we age, thus perspiration decreases  Local irritation, trauma, dse or systemic
 cultural: most Asians and native Americans problems related to impaired circulation,
have mild to no body odor compare to endocrine imbalance, allergic reactions may
Caucasians and African Americans revealed alteration in the skin, hair or nails
Focus Questions (HAIR and NAILS)  Inspect and palpate skin, hair, and nails paying
 hair loss or change in the condition of hair, attention to lesions and growth.
describe Preparing the Client (OD)
 change in the condition or appearance of nails,  Ask client to remove all clothing and jewelry
dese and put on an examination gown (long or robe)
Personal Health History (SD)  Remove nail enamel, artificial nail, wigs, etc. as
Focus Questions: appropriate
 severe sunburn as a child?  Have the client sit comfortably
 previous problem with skin, hair, nails  Observe privacy, expose only the body parts
(surgeries, treatment, effectiveness) that needs to be examine
 allergic skin reaction to food, medication?  Room temperature. Close door. Wear gloves
 recent viral or bacterial illness?  Conservative religious group, assigned same sex
 pregnancy, menstrual period (for girls) (Muslim)
 history of self injury? Equipment and Physical Assessment (OD)
Family History and Life Style (SD)  examination light
Focus Questions:  penlight
 recent illness, rash, or other skin problem,  mirror for clients self-examination of skin
describe  magnifying glass
 skin cancer history  centimeter ruler
 history of keloids  gloves
 do you sunbathe (frequency, duration, sun block  wood light
use)  gown or drape
 perform self skin examination  braden scale for predicting pressure ulcer
 exposed to chemicals, irritants? (coal, arsenic  pressure ulcer scale for healing (tool to
compounds, alcohol, latex, bleach, etc) measure pressure ulcer healing)
 long periods of sitting or lying in one position Key Points (PA)
Lifestyle and Health Practices (SD)  inspect skin color, temperature, moisture
Focus Questions texture
 exposure to extreme temperature  check skin integrity
 body piercing  be alert for skin lesions
 body tattoos SKIN ASSESSMENT: INSPECTION
 Clinical tip: (Types of Tattoos)  INSPECT GENERAL SKIN COLORATION
- Trauma  cultural consideration: fair complexions are at
- Amateur, non-prof (using ink with pin) an increased risk for skin CA
- Professionals (skilled tattoo) N: reveals evenly colored skin tone
- Medical cultural consideration: small amounts of melanin are
- Cosmetic common in pale or light skin. Large amounts of melanin
- daily routine for skin, hair, nails are common in olive and darker
- products you use  older consideration: the older the client skin
- how do you cut nails becomes pale and decrease melanin production
- type of food consumed in a day, fluid you drink AB: PALLOR (loss of color), arterial insufficiency,
- smoking/ drinking alcohol decrease bld. supply and anemia
- skin problems that limit your activities AB: CYANOSIS, may cause white skin to appear blue-
- skin disorder tinged, esp. in nail bed and conjunctival areas. Dark skin
- stress you have in life, describe
may appear blue, dull and lifeless. (two types Central: AB: rough, flaky, dry skin is seen in hypothyroidism.
Cardio-pulmonary. Peripheral, vasoconstriction) Obese pt. report dry, itchy skin.
• Oral mucosa (Central Cyanosis)  PALPATE TO ASSESS THICKNESS
JAUNDICE, yellow skin tone, pale to pumpkin (sclera, N: skin is normally thin but calluses (areas common
oral mucosa, palms and soles) exposed to constant pressure e.g. heels)
AB: ACANTHOSIS NIGRANS AN: thin skin in pt. with arterial insufficiency or those on
Velvety darkening of skin in body folds and creases esp. steroid therapy.
in neck, groin and axilla. *if lesions is noted, put gloves and palpate lesion
 NOTE FOR SKIN COLORATION, NOTE ANY between thumb and index finger. (tender to palpate,
ODORS nonmobile or fixed lesions may be cancer)
N: slight or no odor of perspiration  PALPATE TO ASSESS MOISTURE (skin folds and
AN: strong odor of perspiration or foul odor may unexposed areas)
indicate d/o of sweat gland (poor hygiene, needs client N: vary from moist to dry depending on the area
teaching) assessed
 INSPECT FOR COLOR VARIATIONS  consideration: older client may feel dryer than
N: common variations, suntanned areas, freckles or the your client (sebum production decreases
white patches. A generalized loss of pigmentation is with age).
seen in ALBINISM. Dark skinned clients have lighter AN: increase in moisture or diaphoresis (fever or
colored palms, soles, nail beds and lips hyperthyroidism). Decrease in moisture occurs with
AB: rashes, or darkened butterfly rash (Malar rash) DHN or hypothyroidism. Cold clammy skin is typical in
common in patient with SLE. shock or hypotension
 ASSESS SKIN INTEGRITY  PALPATE TO ASSESS TEMPERATURE (use dorsal
(pay attention for pressure points) surfaces of your hand)
N: skin is intact and no reddened areas N: skin is normally warm temperature
AN: skin breakdown painful pressure ulcers AN: cold skin (shock or hypotension), cool skin (arterial
 STAGES OF PRESSURE ULCER dse), warm skin (fever or hyperthyroidism)
 STAGE I – intact skin, nonblanchable redness.  PALPATE TO ASSESS MOBILITY AND TURGOR
The areas may be painful, firm, soft, warmer or (lie down, using two fingers gently pinch skin
cooler compared with adjacent tissue. over the clavicle
 STAGE II – partial thickness loss of dermis N: skin is mobile and elastic returns to original shape.
presenting a shallow open ulcer with a red-pink Recoil is immediate
wound bed. AB: decrease mobility (edema)
 STAGE III – full thickness tissue loss. • MOBILITY – how skin can be easily pinched.
Subcutaneous fat may be visible but bone, • TURGOR – skin’s elasticity and how the skin
tendon or muscle is not exposed return to its original shape
 STAGE IV – full thickness tissue loss with  consideration: older clients losses it turgor
exposed bone, tendon or muscle. Can extend because of the decrease elasticity of collagen
into muscle or supporting structures. fibers.
 INSPECT FOR LESSIONS  decrease turgor is seen in DHN
 note symmetry, borders and shape, diameter of  Recoils <2 secs mod dhn, >2 secs severe dhn, >3
lesion, change over time secs TENTING (edema)
 for small lesions, use magnifying glass  PALPATE TO DETECT EDEMA (thumb to press
 note its location, distribution and configuration down on skin, ankles, feet or periorbital-fluid
 measure the lesion with a centimeter ruler accumulation)
N: Skin is smooth. Stretch marks, healed scars, freckles, N: skin rebound and does not appear indented
moles or birth marks are common findings. AN: intentions on the skin
AN: lesions may scattered or localized to one area, or in SCALP AND HAIR: INSPECTION AND PALPATION
sun expose areas ( e.g. Vesicle [herpes simplex/zoster,  INSPECT THE SCALP AND HAIR FOR GENERAL
varicella]) COLOR AND CONDITION
SKIN ASSESSMENT: PALPATION N: natural and opposed to chemically colored hair
 PALPATE THE SKIN TO ASSESS TEXTURE – use (varies to blond, black, gray or white)
the palmar surface of 3 middle finger AB: nutritional deficiencies may cause patchy gray hair
N: skin is smooth and even
  1-INCH INTERVAL, SEPARATE THE HAIR FROM  Avoid sunburns
THE SCALP AND INSPECT AND PALPATE FOR  Understand the link between sun exposure and
CLINLINESS, DRYNESS, OR OILINESS, PARASITES skin cancer
AND LESSIONS (use gloves)  Examine skin for suspected lesions
N: clean and dry, sparse dandruff may be visible,  Ensure intake of Vit B3
smooth and firm. Client Education: Examine Own Skin
AB: excessive scaliness (dermatitis), lesions (infxn),  Examine head and face using one or both
fungal infxn (ring worm) mirrors. Use blow dryer to inspect scalp.
SKIN ASSESSMENT: PALPATION  Check hands, including nails in full length
 DISTRIBUTION OF SCALP, BODY, AXILLAE AND mirror, examine elbows, arms, and underarms
PUBIC HAIR (unusual growth)  Focus on neck, chest, torso. Women: check
N: varies amount of terminal hair covering the scalp, under breast.
body and pubic areas according to gender distribution.  With back of the mirror, use hand mirror to
AN: excessive generalized hair loss occurs with inspect back of the neck, shoulders, upper arms,
infection, deficiencies hormonal problem. back buttocks and legs
NAILS: INSPECTION AND PALPATION  Sitting down, check legs and feet including
 INSPECT NAIL GROOMING AND CLEANLINESS soles, heels and nails. Use hand mirrors to
N: clean and manicured examine genitals.
AN: dirty, broken or jagged fingernails (poor hygiene or Client Education: Pressure Ulcer
occupation)  Bathe with mild soap or other agent, limit
 INSPECT NAIL COLOR AND MARKINGS frictions, use warm not hot
N: pink tones, some longitudinal ridging. Pigmented  For dry skin: Use moisturizers, avoid low
streaks or freckles (dark-skinned) humidity and cold air. Avoid vigorous massage
AN: pale or cyanotic nails (hypoxia or anemia). Yellow and over bony prominences
discoloration (psoriasis).  Complete activity as directed
NAILS: INSPECTION AND PALPATION  Nutritional supplements
 INSPECT SHAPE OF NAILS For bed or chair bound pt
N: 160-degree angle between the nail base and the skin  Self reposition every 15 mins
AN: Clubbing of fingers (hypoxia). Spoon nails (iron dif.)  Use repositioning schedule
180-degree angle.  Use pressure mattress
 PALPATE NAILS TO ASSESS TEXTURE  Use lifting devices
N: nails are hard and basically immobile  Avoid elevation beyond 3o-degress for long
 dark-skinned clients may have thicker nails periods
 older clients may appear thickened, yellow and
brittle because of decrease circulation
AN: thickened nails may be cause by decrease HEAD & NECK
circulation seen in onychomycosis (fungal infxn) Anatomy Overview
 PALPATE: TEXTURE AND CONSISTENCY -skull is the framework of the head.
N: nails are smooth/firm. Nail plate should be firmly -structure of the neck is composed of muscles,
attached to nail bed. ligaments, and cervical vertebrae .
AB: paronychia (inflammation) local infxn. Onycholysis -the sternocleidomastoid and trapezius muscles
(detachment of nail plate) dt infxn or trauma. allows movement and provide support to the head and
 CAPILLARY REFILL neck.
N: pink tone returns immediately to blanched nail beds -the thyroid gland is the largest endocrine gland
when pressure is released. in the body.
AN: slow capillary refill greater than 2 seconds -several lymph nodes are located in the head
(resp/cardiovascular dse-hypoxia) and neck
Client Education: Skin Cancer
 Reduce sun exposure; seek shade
 Use sunscreen (SPF 15 or higher)
 Wear long sleeved shirts and wide brimmed
hats
 Wear sunglasses
 Abnormal- pain, swelling, crepitus, restricted
motion, deviation to one side upon opening the mouth.
Skull Inspection and Palpation
Inspect & Palpate the skull for the ff:
o Cranial Nerve VII (motor function)
Ask pt to smile, frown, raise eyebrows, show
upper/lower teeth, keep eyes tightly closed while you
try to open them
Normal- symmetrical strength and movement
of facial muscles
Abnormal- loss of or asymmetrical movement;
muscle weakness suggested loss of nasolabial fold,
drooping of side of face or drooping of lower lid (bell’s
Equipment Needed palsy)
-clean gloves Skull Inspection and Palpation
-small cup of water for client during thyroid Inspect & Palpate the skull for the ff:
exam. o Cranial Nerve V (motor function)
-penlight
Normal- symmetrical jaw movement; equal
-padded tongue depressor
muscle strength of the jaw sufficient enough to prevent
-gauze
examiner from separating jaw
-nasal speculum
Abnormal- asymmetrical jaw movement;
Subjective Data: Focus Question
unilateral or bilateral decreased strength
-lumps (onset, location, size, texture)?
Skull Inspection and Palpation
-Limited movement of neck? Describe
Inspect & Palpate the skull for the ff:
-Facial pain/neck pain/headache
o Cranial Nerve V (sensory function)
-prior neck injury
Normal- sensation of light touch; eyelids blink
-family history of head/neck Ca
when cornea touched w/ cotton.
Risk Factors
Abnormal- absent, decreased or unequal
-for head injury: high-risk sports, lack of
sensation; absent blink
protective devices, violence, falls
Face Inspection
-for thyroid disease: family history, radiation
Inspect face for the ff:
-for lymphatic enlargement:
o Size and symmetry of facial features
immunosuppression, chronic disease
Normal- variable, symmetric
Head Inspection
Abnormal- excessive large or small, asymmetric,
Inspect head for the ff:
distorted, lesions, masses
o Size
o Facial expressions
Normal- variable
Normal- variable, symmetric, centered head
Abnormal- very small and very large
position
o Symmetry
Abnormal- asymmetrical (bell’s palsy, parotitis,
Normal-symmetrical
mask face); distorted features: hirsutism, tightened,
Abnormal- asymmetric
sunken, swollen
o Position
Nose Inspection
Normal-upright
Inspect nose for the ff:
Abnormal- tilted to 1 side
o Position, deformities, septal deviation,
Skull Palpation
discharges, flaring
Palpate the skull for the ff:
Normal- nose midline, symmetrical, no
o Texture
deviation, no flaring.
Normal- hard and smooth
Abnormal- misalignment of nose (previous
Abnormal- lumps, tenderness
trauma, congenital deformity, mass), + nasal flaring.
o Temporomandibular joint
Q:The nurse observes that infant is experiencing
Normal- 3-6 cm vertical range w/ open mouth nasal flaring. This manifestation suggests?
(snapping or popping common) Nose Inspection
Inspect nose for the ff:
 o Color, lesions, discharges Normal- Hard soft/hard palate: pink and intact;
Normal- nasal mucosa pink, moist, no lesions, tonsils: pink, symmetrical, no exudates; uvula:
edema or discharges symmetrical rise
Abnormal-drainage: clear (glucose spinal fluid), Abnormal- hard/soft palate: cleft palate;
bilateral (allergic rhinitis); yellow or green (URTI), tonsils: reddened, enlarged w/ exudates; uvula:
bloody (trauma, HPN) asymmetrical rise
o Olfaction is also tested by asking patient to Test Swallow Reflex (CNs IX & X)
identify common odors as coffee or mint. Normal- (+) swallow and gag reflex
Lips Inspection Abnormal- (-) swallow and gag reflex
Inspect lips for the ff: Q: Absent of gag reflex in stroke pt poses a risk for?
o Color, condition, lesions Neck Inspection
Normal- pink lips, moist, intact, no lesions Inspect the neck for the ff:
Abnormal- asymmetrical: congenital deformity, o Appearance
trauma, pallor, redness, cyanosis, lesion, cheilitis Normal- smooth, symmetrical head position
(dehydration) Abnormal- asymmetrical, swelling
o Assess for breath odor/pursed lip breathing o Movement
Normal- no unusual odor, no PLB Normal- controlled movements, ROM
Abnormal- halitosis (infxn/GI problems) Abnormal- rigid, jerky movements; limited
Oral Mucosa Inspection ROM, pain on movn’t, stiffness, & rigidity
Inspect oral mucosa for the ff: (arthritis/meningitis)
o Color, condition, lesions Trachea, Thyroid, and Lymph Node Palpation
Normal- pink lips, moist, intact, no lesions Palpate 1st the trachea, then the thyroid then palpate
Abnormal- abrasions, painful, inflammation, the cervical lymph nodes.
ulcerations (allergic stomatitis), white patches (oral Tracheal Palpation
thrush) o Position and landmarks
Gums Inspection Normal- midline position, symmetrical,
Inspect gums for the ff: landmarks identifiable
o Color, condition, bleeding, lesions, presence of Abnormal- asymmetrical, deviates from the
dentures midline (tumors, goiter, pneumothorax)
Normal- pink , moist, intact, no lesions, no In pt with severe PNX what abnormality in the trachea
bleeding, no hypertrophy will you observe?
Abnormal- inflamed, bleeding gums (leukemia); Trachea, Thyroid, and Lymph Node Palpation
gingival hyperplasia: (med. SE); pale/gray gums (chronic Palpating the Thyroid
gingivitis) 1. Stand behind the client and position hands w/
Teeth Inspection thumb on client’s nape.
Inspect teeth for the ff: 2. Ask client to put the head back slightly and
o Number, color, condition index fingers just below the thyroid cartilage.
Normal- 32 teeth in adults; 20 in children; 3. Ask client to swallow water and feel for the
white-light yellow; no caries, no missing or loose teeth rise of thyroid and palpate also the lateral lobes.
Abnormal- loose, malalignment, dental caries, Palpate for the ff:
teeth gray (tetracycline) o Position: N: midline A: deviation (mass)
Q: A loose tooth poses a threat of? o Characteristics, landmarks: N: smooth,
ongue Inspection firm, non-tender A: enlarged and tende
Inspect teeth for the ff:
o Color, texture, position, mobility Trachea, Thyroid, and Lymph Node Palpation
Normal- pink, moist, papillae intact, midline w/ Lymph Node Palpation
full mobility o Size and Shape
Abnormal- ulceration, black hairy tongue Normal- usually not palpable (mobile, soft,
(fungal infxn), painful, reddened: (chemical nontender), if palpable should be less than 1 cm and
irritants/meds) round
Hard/Soft, Palate Tonsils, & Uvula Inspection Abnormal- enlarged and tender nodes (acute
Inspect for the ff: infection) and irregular borders and greater than 1 cm,
o Color, condition, lesions, drainage, exudates
mestastatic (hard and fix); HIV infection (enlarged
occipital nodes)