Midterms | Assessment of the Skin, • characterized by the forehead, eyelids and,

Hair, and Nails blotchy red spots on sometimes, the top lip
the skin with overlying
Variation in Skin with Age white or yellow
Infants / Young Children papules or pustules. Jaundice
• Skin smoother-lack of • It is a common rash • Yellowish
exposure to elements in neonates discoloration
• Less subcutaneous fat
layer, poorer temperature Harlequin sign Milia
control • Is unilateral flushing • also called a milk spot or
• Eccrine sweat glands and sweating of the an oil seed
secrete after 1 month face and neck usually • is a keratin-filled cyst that
after exposure to heat can appear just under
Common Variations in Newborns or strenuous exertion the epidermis or on the roof
Acrocyanosis of the mouth.
• is persistent blue Mongolian spots • Milia are commonly
or cyanotic discoloration • also known as "Mongolian associated with
of the extremities, most blue spot", "congenital newborn babies but can
commonly occurring in dermal melanocytosis", appear on people of all
the hands, although it and "dermal ages.
also occurs in the feet melanocytosis“ • is a benign, flat,
and distal parts of face congenital birthmark with Variation in Skin with Age
wavy borders and Adolescence
Transient mottling irregular shape • Apocrine glands enlarge and become more
•Is the active
appearance of Telangiectatic nevi (stork bite) • Sebaceous glands increase production
uneven spots • appears as a pink or causing
tanned, flat, irregularly oily skin and predisposition to acne
shaped mark on the knee, • Terminal hair appears in axillae and pubic
Erythema toxicum back of the neck, and/or area
for both sexes and on face in males pigmented spots Whites
• Mongolian markings common in children • Less variation in
Skin Variation with Age • Visible difference in pigmentation of intensity of
Pregnancy ventral and pigmentation
Increased: dorsal surfaces of extremities • Mucous membranes
• Blood flow to skin to balance heat pink
production from Asians, Latinos, • Sclera white
increased BMR (Basal Metabolic Rate) Blacks
• Eccrine sweat gland activity Hair Hair
• Sebaceous gland activity • Vellus body hair • Terminal hair on body
• Fat deposits • Scalp hair varies common
• Pigmentation of face, nipples, areolae, in texture • Texture and color vary
axillary, and
vulva Skin texture Skin texture
• Limited apocrine • Increased apocrine
Older Adults glands (less sweat) glands result in increased
Decreased: • Limited sebaceous body sweat
• Blood flow to skin glands (less body oils) • Increased sebaceous
• Eccrine sweat gland activity • Frequent washing glands lubricates skin and
• Sebaceous gland activity causes increased scalp
• Fat deposits dryness • Requires frequent
• Pigmentation of skin and hair, first in Asians, Latinos, Blacks washing
Whites, later in Blacks and Asians Skin conditions
• Hair production and increased coarseness • Fine colored lesions harder to see Assessment of the Skin, Hair,
• Pigmentary changes due to lesions may Nails
Variation in Skin by Race persist • Inspection
Asians, Latinos, Blacks for months or years • Palpation
• Varying intensity of pigmentation • Licenification common with eczema
• Mucous membranes pink to light brown • Hypertrophic scars and keloids common Assessment of the Skin
• Sclera white, gray, light brown, often with Inspect for:
• Lesions Scar - are areas of fibrous tissue (fibrosis) Excoriation (scratch) – the act of abrading or
• Skin color that wearing off the skin
• Areas of pain or itching replace normal skin after injury
Ulcer - is a sore on the skin or a mucous
Palpate for: Crust, Scab - the dried crusty surface of a membrane, accompanied by the
• Moisture healing disintegration of
• Temperature skin wound or sore tissue
• Texture
• Turgor Keloid - is a growth of extra scar tissue Lesion descriptors
• Mobility where the Shape:
• Capillary filling skin has healed after an injury • Linear
• Elevation or depression • Round
Fissures - a cutaneous condition in which • Annular (round with central clearing)
Primary Lesions: there is a • Oval
Initial appearance of pathological process linear-like cleavage of skin, sometimes • Polycyclic (interlocking circles)
• Macule <1cm / Patch >1cm: flat lesion defined as • Morbilliform (confluent, measle-like)
• Papule <1cm / Plaque >1cm: elevated extending into the dermis • Zosteriform (dermatomal)
• Nodule <1-2cm / Tumor >2cm: deeper
• Vesicle <1cm / Bulla >1cm: bubble Lichenification - hardening of the skin, Hemangioma
• Pustule: purulent vesicle usually Round papule
• Wheal: hive caused by chronic irritation measuring 1 cm.
situated superior to
Secondary Lesions: Erosion - is a loss of some or all of outer canthus of R eye.
• Change in primary lesion due to external the epidermis (the outer layer) leaving a Uniform deep red color.
trauma denuded
surface. Birthmark
Scale - Scaling skin is the loss of the outer Hyperpigmented linear
layer of Atrophy - is a condition in which the upper macules measuring 1cm
the epidermis in large layers by 4.5 cm inferior to right
of skin get thin nipple. No indication of
inflammation or irritation. • Lacy Small discrete circular
• Serpiginous (snake-like) papules with
• Umbilicated (middle indentation) umbilicated centers on
Poison Ivy • Target, iris (bullseye) inner aspect of R elbow.
Linear vesicles
on ventral surface of Normal Tongue Target (Bullseye) Lesion
forearm. Geographic pattern of
Client reports lesions white and dark pink Lesion Descriptors
are intensely itchy. mucous membranes • Color:
on ventral surface • Erythematous
Measles of tongue • Pink, red
Erythematous • Purple
macular papular lesions Erythema Infectiosum (Slapped-cheek) • Ecchymotic (black & blue)
over entire body. Human Parvovirus B 19 (Fifth Disease) • Mottled
Infant observed scratching. Intense confluent redness of both cheeks • Silver / White
Lesions associated with preceded
fever and mild URI lacy erythematous macular Viral Exanthem unknown
symptoms. papular lesion over trunk Etiology (Pityriasis rosea)
and extremities. Mild fever associated with Scattered discrete
Herpes Zoster onset of lesions. erythematous
Grouped vesicles papular lesions on
on an erythematous Scabies trunk. No lesions
base scattered along Serpigenous elevated present on sun
R thoracic dermatome. burrow measuring exposed areas.
Client reports pain 6 cm at base of Client denies itching,
associated with lesions. 3rd-5th toes R foot. fever, or URI
Client reports lesion is symptoms with rash.
Lesion Descriptors itchy.
• Shape (con’t): Erythema Nodosum
• Geographic Molluscum Contagiosum Abrupt onset of tender
erythematous nodules on over L scapula. Atopic Dermatitis (Eczema)
extensor surfaces of Client reports Symmetrical dry excoriated
extremities. Lesions area seems to fade in summer. red plaques on flexor
evolved surfaces of knees and
into bruises with color Vitiligo elbows.
changes Depigmented patches Child reports intense itching
to purple then yellow-brown. of skin with distinct (pruritis) and history of
borders on ventral asthma.
Psoriasis Vulgaris surface of R hand.
Erythematous plaque Hair within the Keloids
with silver-white scale affected area is also Three discrete hairless
on extensor surface of hypopigmented. No hyperpigmented nodules
legs other symptoms measuring 4x2cm, 4x1.5cm,
reported. & 3x1cm at sites of previous
Ecchymotic mole removal.
Sunburn with Vitiligo Erythema Toxicum
Mottled (Neonatal Acne)
• Lesion Descriptors Amelanotic Scattered papules and pustules on
• Color (con’t): erythematous bases of varying
• Blue Lesion Descriptors diameters.
• Black • Distribution: Lesions noted to change location
• Yellow • Localized (identify where) vs. generalized within hours. No fever associated
• Hyperpigmented • Symmetrical or asymmetrical with lesions.
• Hypopigmented, depigmented • Scattered, grouped
• Amelanotic • Flexural or extensor surfaces Herpes Simplex Virus (Herpes Keratitis)
• Intertriginous (between skin folds) Grouped vesicles
Café-au-lait Spot • Sun exposed or covered on an erythematous
Hyperpigmented • Contact areas for clothing, jewelry, base located below R
patch with irregular borders chemicals eye.
measuring 8 cm by 3 cm Conjunctiva intact
without inflammation • Border / Margins: and lower abdomen with
• Sharply / poorly marginated (demarcated, satellite papules extending
Happy Lip-Licker defined) upward on abdomen
Dry rough erythematous • Irregular and onto thighs
to brown skin circumscribing • Scalloped
lips. • Raised / elevated or flat border Lesion Descriptors
Child reports licking • Active border • Surface and texture:
his lips frequently. • Lesion variation between border and • Soft
No other lesions noted on center • Boggy
body. • Hard, firm
Nevus Flammeus (Port-Wine Stain) • Thickened
Candidiasis (Yeast) Dark red patch with • Verrucous, warty
Dry macular papular distinct borders extending • Moist, oozing, weeping
erythematous confluent from R ear across lower
lesions with additional cheek and chin. Has been Warts
satellite lesions present since birth. Three hard dry
found on intertriginous Lesion does not appear to verrucous (warty)
skin of L breast. Client itch and child has no papules on middle
reports mild itching. other symptoms. finger of R hand.

Contact Dermatitis Diaper Dermatitis (Contact) Lichenification

Small white confluent Confluent dry dark red (Secondary to Eczema)
papules extending patch with well demarcated Dry thickened skin with
across forehead borders outlining diaper area. horizontal fissures.
onto scalp with a band Some sparing of intertrigenous Symmetrical pattern of
width of 5 cm. skin folds. No satellite lesions. lesions on flexor surfaces
(From head band worn of knees and elbows.
during exercise.) Diaper Dermatitis (Candidiasis) Client reports intense
Confluent dark red slightly itching
Lesion Descriptors moist patch on perineum
Acanthosis Nigricans 20 by 10 cm bullae Lesion Descriptors
Dry thickened with shallow erosion • Associated Symptoms:
hyperpigmented skin and moist center • Pruritic
with linear fissures mid abdomen superior • Burning, stinging
across posterior neck. to umbilicus. • Painful, tender
Also found under arms. Smaller similar lesion • Swelling
Child has BMI superior to large • Asymptomatic
(Body Mass Index) of 30. lesion medial to L nipple.
Assessment of the Hair
Impetigo (Staph or Strep) Urticaria (Hives) • Inspection and palpation of hair:
Vesicles turning to Blotchy red irregularly • Color
honey-colored crusts shaped papules and • Texture (vellus or terminal, smooth or
on erythematous plaques with prominent brittle, dry
base, below R nares elevated borders in or moist)
and on bridge of nose. irregular pattern over • Distribution
entire body. Some • Quantity
Primary Gingivostomatitis lesions with central • Indications of hair loss
Moist vesicles on an clearing. • Infestations
erythematous base Noted to fade and • Scalp condition
encircling the mouth, reappear within
covering the lips minutes. Child is Pediculosis (Head Lice)
and extending onto the scratching lesions. White ovoid firm 1
mucous membranes of the mm bodies attached
mouth. Tinea Corporis (Ringworm) to hair shafts. Child
Child has a fever, is Multiple oval plaques with reports scalp itches
irritable and reports pain active (red and scaly) intensely.
when attempting to eat or prominent borders and partial
drink. central clearing. Client reports Tinea Capitus (Ringworm)
mild itching. Dry crusted circular
Bullous Impetigo (Staph or Strep) lesion with erythematous
base on scalp without Midterms | Assessment of the Head
evidence of hair follicles. and Neck, Eyes, Ears
Palpable lymph A*B*C*D Rule of Melanoma
nodes present. A - Asymmetry of borders ASSESSMENT OF THE
B - Border, irregular EYE
Traction Alopecia C - Color blue-black or variegated
Areas of sparse D - Diameter greater than .6 cm HISTORY
hair growth lateral • Chief complaint / present illness
to braided hair with Benign Malignant • Visual difficulties, injury, squinting,
evidence of broken A = Symmetrical Asymmetrical strabismus,
hairs. No signs of B = Even edges Uneven edges diplopia, redness, swelling, itching, watering,
infection or infestation. C = One shade 2 or more shades discharge,
D = Smaller than Larger than glaucoma, cataracts
Assessment of the Nails 1/4in 1/4in • Past medical history
• Inspection and palpation • Surgeries / trauma
• Color, length, symmetry, and cleanliness The Skin Is The • Medications
• Ridges, depressions, pitting Window To The Body • Allergies
• Nail base angle, evidence of clubbing • Vision testing / results / glasses
• Firmness, thickness, separation • Chronic conditions such as diabetes,
• Capillary refill hypertension
• Prematurity
- Bitten Nails
- Pitting of Nails  Family History
- Paronychia ▪Color blindness, cataracts, glaucoma,
- Clubbing of fingers allergies,
- Onycholysis (Psoriasis or Tinea) macular degeneration, allergies
- Nail changes associated with Aging  Personal / Social
- Capillary Refill ▪ Employment exposure to gases,
- Normal Nails Needing a machinery, foreign
Little Care bodies
▪Competitive sports, use of protective gear relation to ears (myasthenia gravis), and the third cranial
▪Glasses, contact lens nerve impairment.
▪Premature birth, birth without medical care Inspect ECTROPION – eversion, an out-turning of the
▪Orbit eyelid
ASSESSMENT OF THE EYE ▪Conjunctiva ENTROPION – inversion, an in-turning of the
 Observation of external structures ▪Sclera eyelid
 Visual acuity testing
 Examination of eye Newborns - Ptosis
▪ Eye movements, alignment Sclera is bluish / white - Entropion
▪ EOMs (Extra Ocular Muscles) •Jaundice with - Ectropion
▪Cover test hyperbilirubinemia
▪Pupil reaction • Sclera hemorrhage due Eye movements (Extra Ocular Eye
▪Red reflex to birth pressure Movements {EOM})
▪Corneal light reflex Iris is usually dusky blue • With the head still, can the eyes follow
▪ Internal inspection of the eye • Changes between 3 and 6 your penlight
months or fingers? Do the eyes move together and
 External structures Congenital cataracts, equally in
▪Symmetry glaucoma, infection all directions?
▪Orbit possible • Do the eyes twitch (nystagmus) when they
▪ Eyebrows move?
▪ Movement Inspect for position, color, condition of the
▪Clarity / color surface, condition and direction of eyelashes, Visual acuity
▪Sclera and the client’s ability to open, close and Newborn 20/400
▪ Iris blink. ▪Brief fixation
▪Conjunctiva ▪ Limited binocular vision
▪ Lens margin, and are usually associated with 6 Months
aging, ▪20/100
Symmetry of eyes, edema from drug allergy or systemic disease ▪Binocular vision
lids, eyebrows (kidney disease), congenital lid muscle ▪Color vision near adult
Placement of eyes in dysfunction, neuromuscular disease
Acuity numbers 20/40:  Equal, round and about one fourth the size
Person sees at 20 feet what a person with of the iris
normal vision can see at 40 feet using normal room light PUPILLARY REACTION
 The normal pupil size in adults varies from ASSESSMENT
4 Years 2.5 to 6 mm Have baseline assessment findings for
• 20/50 in diameter in bright light to 4 to 8 mm in comparison:
• Need large print books for near vision the dark. Patient received medications that will either
7 Years  They constrict to direct illumination (direct constrict or dilate the pupils (Atropine/
• 20/20 response) valium)
and to illumination of the opposite eye Patient’s previous eye surgery (cataract
Color vision deficit (consensual removal)
should be tested response). Patient may have normal unequal pupils
before school entry  The pupil dilates in the dark. Both pupils
- 8% Caucasian males constrict when or result from certain drugs (atropine)
- 4% African American the eye is focused on a near object MIOSIS
males (accommodative – may indicate an inflammation of the iris or
- 0.4%-1% females response). result
 The pupil is abnormal if it fails to dilate to from such drugs as morphine or pilocarpine.
Alignment the dark or Also
• Esotropia: Eye fails to constrict to light or accommodation. an age-related change in older adults.
turning inward ANISOCORIA
• Exotropia: Eye PUPILLARY REACTION: PERRLA – unequal pupils may result from a central
turning outward Pupils nervous
• Hypertropia Equally system disorder, however slight variations
• Hypotropia Round may be
Reactive to normal.
Cover, uncover test Light and
Accommodation
NORMAL PUPILS TO TEST FOR ACCOMMODATION
GRADING PUPIL Place your finger about
4” (10cm) from the people with dark skin WEBER'S TEST
bridge of the patient’s pig Result :
nose. The person should hear the tone produced
Request to look at fixed EAR by
object at the distance S bone conduction equally in both ears, is the
and then look at your Examination of ears: Pull the ears backward positive test result
finger. and
The patient’s eye should upward. Description Results
converge and pupils Instrument used: Otoscope Normal
should constrict External ears: Crusts, discharges, lesions Hears equally well in both ears
etc.
ASSESSMENT OF THE EYE Tympanic membrane: Normally it is shiny, Right/ lateralization
Red reflex translucent, with a pearl grey color. See for Patient hears left tone better in one
• Light shown into pupil at an any ear
angle reflects color of retina perforation, lesions, bulging
• Abnormal lens (cataract), Conductive hearing loss
cornea (glaucoma), or retina Patient loss hearing tone only in his
(retinoblastoma) will change WEBER'S TEST affected ear
red reflex It is used to assess the conductive
hearing loss. Sensorineural hearing
Opthalmoscope Technique: loss
▪Used to check red 1. Strike the tuning fork lightly Patient loss hearing tone only on his
reflex against your hand unaffected ear
▪Used to see retina 2. Place a vibrating tuning
fork in the midline of the RINNE TEST
Normal equal bright red persons This is a test to compare the air conduction
reflexes skull and ask if he can hear the and the bone conduction sounds.
• Color pale yellow in sounds same in both the ears or Perform after Weber’s test
newborn better in one ear.
• May be pale yellow in RINNE TEST
Technique: than the BC tone LYMPH NODES
1. Strike the tuning fork lightly against your Lymph nodes are assessed by palpating with
hand c. Nose: Connect the nasal the
2. Place the stem of the vibrating tuning fork speculum to the otoscope and pad of the finger for enlargement ,
on examine the nares, noting the tenderness and
persons mastoid process and ask him or her condition of the mucosa, mobility .
to septum and turbinate's. Normally nodes are not palpable. If
signal when the sound disappears note the d. Mouth: Examine the oral palpable they
time mucosa, the tongue and should be small, mobile, smooth and non
seconds. teeth. tender.
3. Invert the tuning fork so the vibrating end e. Face: Evaluation of symmetry,
is near smile, frown, and jaw Thyroid : palpation for size, symmetry
the ear canal he should hear the sound. Note movement will provide tenderness and nodules.
the information about motor
time in seconds. divisions of cranial nerves V Trachea: Palpation for alignment and
Results : AC : BC = 2 : 1 and VII. position: unequal space between trachea
and
NECK: SPEND sterno-cleido mastoid muscle on each side is
Results Description S – swelling abnormal, indicative of trachea
Normal P – pulsations displacement.
Hears AC tone twice as E – enlargement- thyroid, lymph nodes
long as the BC tone N – neck masses Palpate one carotid
D - distention artery at a time just
Conductive hearing loss below the upper
Hears the BC tone NECK: border of the
longer than the AC tone Palpate the neck with emphasis on the thyroid cartilage.
salivary glands, lymph nodes, and thyroid.
Sensorineural hearing Look for tracheal deviation. Identify the
loss carotid arteries and auscultate for bruits.
Hears AC tone longer
 Respiration System
- Exchange of gases

Cardiovascular System
- Transport of gases

GENERAL CONSIDERATIONS
▪ Obtain a consent for assessment.
▪ The patient must be properly undressed
and gowned for this examination.
▪ Ideally the patient should be sitting on the
end of an exam table.
▪ The examination room must be quiet to
perform adequate percussion and
auscultation.
The nurse usually examine the posterior
thorax first followed by anterior thorax.
For POSTERIOR THORAX client is uncovered
to the waist and in SITTING
POSITION.
For ANTERIOR THORAX client is either on
SITTING or LYING POSITION.
In examining the thorax, there are two
important factors the nurse should know
A. The nurse should know how to locate the
Midterms | Assessment of CHEST LANDMARKS.
the Thorax and Lungs B. The nurse should know how to locate the
INTERCOSTAL SPACES

Concept of Oxygenation CHEST LANDMARKS

INTERCOSTAL SPACES Increased airway resistance Progressive, recurrent or paroxysmal
Inflamed Airway Relieved by any interventions
General Nursing Brochospasm At rest or with exertion
Assessment Sudden or gradual
1. Health History Types of Dyspnea Associated with cough, fever,chills or night
2. Physical Assessment Exertional Dyspnea sweats
3. Laboratory / Diagnostic Examinations 2. Sudden dyspnea Worse when upset
4. Medications 3. Orthopnea Any changes in body weight
4. Dyspnea associated with wheezes Related to activities
Health History 5. Paroxysmal Nocturnal Dyspnea
Reasons for seeking health care Cough
1. Dyspnea DYSPNEA Productive? – color, consistency, odor &
2. Cough • Difficult or labored amount
3. Sputum Production breathing Dry, hacking or wheezy
4. Chest Pain • Shortness of Strong or weak
5. Wheezing breath (SOB) Smoking history/ past medical illness
6. Hemoptysis Recent or gradual
7. Cyanosis Visible sternocleidomastoid Contractions Particular time/event
8. Clubbing of fingers Hyperexpansion of the chest(Increased AP
diameter) Sputum Production
Risk Factors Anxious appearance Increased production
• Smoking Circumoral cyanosis - profuse or small in amount
• Personal / Family History Suprasternal retractions Purulent, rusty, bloody, frothy or mucoid
• Occupational exposure Intercostal retractions Thick (tenacious) or thin
• Allergens & environmental pollutants Substernal retractions Offensive odor/ foul-smelling
• Activities Sitting posture with body
• Age-related changes slightly bent forward Sputum Production
Profuse Purulent Thick (yellowish,
Dyspnea What to assess…. greenish or rusty-colored) –
Decreased lung compliance Acute or chronic Bacterial infection
Profuse, frothy, pink – pulmonary Clubbing of the Fingers ▪ Anteroposterior diameter
edema =1/2 of transverse diameter
Thin, mucoid – Viral bronchitis Hemoptysis
Pink-tinged mucoid – Lung tumor Bright red or frothy Abnormal
Foul- smelling – lung abscess or URT, GIT or LRT amount Pigeon chest (pectus carinatum)
Bronchiectasis Sudden, intermittent or continuous ▪ Permanent deformity, may be caused by
Salty taste, burning or bubbling sensation rickets (Vit. D deficiency)
Chest Pain before bleeding
Intermittent or persistent History of chest trauma Funnel chest (pectus excavatum)
Localized or radiating Associated with certain circumstances or ▪ Congenital defect, sternum is depressed
intensity activities
Sharp, dull, Barrel chest
stabbing or aching Cyanosis ▪ anteroposterior diameter=
Relieved by any interventions Due to inadequate amount of transverse diameter (1:1)
Smoking history & oxygen in the blood - indicates
environmental • Appears when Hgb level = 5 g/dl chronic breathing
exposure Problem
Effects on respiration Assessment of chest and lungs
Past medical history C - Chest wall asymmetry and chest lag Kyphosis
R - Respiratory rate and pattern ▪ Excessive convex curvature
Wheezing A - Accessory muscle use and retractions of the thoracic spine
High-pitched, musical sound M - Mottling
heard mainly on expiration M - Masses or scars Scoliosis
• Common in patient with P - Paradoxical movement ▪ lateral
bronchoconstriction or airway I - Inspecting related structures deviation of the spine
Narrowing S - Spinal alignment
- LOud or soft Palpation
- Expiratory or inspiratory Chest-wall abnormalities • Painful areas or masses
NORMAL • Chest & Diaphragmatic
Thorax is oval Excursion
• Tactile fremitus whether the lungs are filled with AIR or – Have the patient breathe through his
• Symmetrical chest excursion FLUID or SOLID MATERIAL mouth, NOSE
• AbN: decreased in chronic fibrotic (lung BREATHER ALTERS THE PITCH OF BREATH
tissue) disease; FLAT SOUNDS
asymmetrical in pleurisy (inflamed pleura), - Short, soft, dull, and high pitched – Use the DIAPHRAGM of the STETHOSCOPE
chest trauma, as found over the THIGH in auscultation
bronchial obstruction - Consolidation – If the patient has abundant chest hair MAT
• Fremitus: normally louder near the large it DOWN with a
bronchi DULL DAMPWASHCLOTH
• AbN: absent (emphysema); increased - Medium in pitch and intensity and – Listen to full inspiration and expiration.
(pneumonia) thudlike as found over the LIVER Remember to compare
- Lobar pneumonia the sound variations from one side to
Percussion another
• Percussion Sounds/Notes
1. Resonance RESONANT Pitch (P)– high or low
2. Dullness - Long, loud and low pitched Amplitude (A) – soft or low
3. Flatness - Normal lung tissue or Bronchitis Duration (D) – length of time
4. Hyperresonance Quality (Q) – description
• Resonance in normal lungs & simple HYPERRESONANT Location (L) – place heard
chronic - Very loud and lower pitched as found over Timing (T) – early, late middle
bronchitis the STOMACH inspiration or expiration
• Flatness: Pleural effusion (water in the - Emphysema or Pneumothorax Intensity (I) – loud or soft
lungs) Density – profuse or scanty
• Dullness: Lobar pneumonia TYMPANIC
• Tympany: Pneumothorax (collapsed lung) - Musical and drumlike as found Normal breath sounds
• Hyperresonance: Emphysema (damaged over PUFFED- OUT CHEEK TRACHEAL
alveoli) - Pneumothorax P – relatively high
Q – harsh
Percussion reveals the BOUNDARIES of the Auscultating the chest D – inspiration and expiration
lungs and helps to determines • Auscultation are about equal
(I:E – I<E) shorter on expiration
L - above the supraclavicular (I:E - I>E) Rhonchi
notch L – over most of the lungs, - Musical, low pitched
peripheral lung fields - E>I
BRONCHIAL - SNORING and MOANING SOUNDS
P - high Adventitious breath sounds
Q - loud TYPES Friction rub
D – shorter on inspiration, 1. Discontinuous - RUBBING and GRATING SOUNDS
longer on expiration Fine crackles – beginning congestion - I and E
(I:E - I<E) Coarse crackles- consolidation (LRTI)
L - above the clavicles, each 2. Continuous VOCAL FREMITUS
side of the sternum, over Wheezes- COPD 1. BRONCHOPHONY- “NINETY-NINE”
the manubrium Rhonchi- consolidation (URTI) - Ask the patient to say "ninety-nine" several
3. Friction rub- both LRTI and URTI times in a normal
BRONCHOVESICULAR voice.
P – moderate Fine crackles - Auscultate several symmetrical areas over
Q – moderate - Non musical, high pitched each lung.
D – similar on both inspiration - HEARD DURING INSPIRATION - The sounds you hear should be muffled and
and expiration - CRACKING and POPPING SOUNDS indistinct.
(I:E- I=E) Louder, clearer sounds are called
L–1 Coarse crackles bronchophony
st and 2nd interspaces -- Non musical, low pitched
anteriorly and next to - HEARD AT EARLY INSPIRATION and 2. WHISPERED PECTORILOQUY- “1,2,3”
sternum between the POSSIBLY EXPIRATION - Ask the patient to whisper "ninety-nine"
scapulae - BUBBLING and GURGLING SOUNDS several times.
- Auscultate several symmetrical areas over
VESICULAR Wheezes each lung.
P - low - Musical high pitched - You should hear only faint sounds or
Q – soft - E>I nothing at all. If you hear
D – longer on inspiration, - WHISTLING SOUNDS
the sounds clearly this is referred to as - Irregularly, interspersed periods of apnea in
whispered Abnormalities of Chest and Lungs a disorganized sequence of breaths
pectoriloquy. Normal: Regular and comfortable at a rate of
12-20per minute Atosic
3. EGOPHONY- “E” - Significant disorganization with irregular
- Ask the patient to say "ee" continuously. Bradypnea and varying depths of respiration
- Auscultate several symmetrical areas over - Slower than 12 breaths per minute
each lung. Accessory muscle use and retractions
- You should hear a muffled "ee" sound. If Tachypnea Normal individual use MAJOR GROUP of
you hear an - Faster than 20 breaths per minute muscle for respiration
"ay" sound this is referred to as "E -> A" or (intercostal muscle and diaphragm)
egophony. Hyperventilation [Hyperpnea] A. Accessory muscles
***vocal fremitus indicates consolidation - Faster than 20 breaths per minute, deep - scalene
breathing - sternocleidomastoid muscle
Respiratory rate and pattern B. Retraction, pursed lip breathing and nasal
Respiration should be NON- LABORED and Sighing flaring
NOISELESS (EUPNEA) - Frequently interspersed deeper breath - Supraclavicular
ABNORMAL RESPIRATORY PATTERNS - Suprasternal
1. Tachypnea – abnormally rapid breathing Air trapping - Intercostal
2. Bradypnea - abnormally slow breathing - Increasing difficulty in getting breath out
3. Apnea – temporary cessation of breathing Accessory muscles for respiration
4. Hyperventilation or Hyperpnea – increased Cheyne-Stokes
depth & rate of breathing - Varying periods of increasing depth Mottling , masses and scars
5. Kussmaul’s respirations – deep & labored interspersed with apnea ▪ Mottling - alternating white to blue tinge
breathing color of the thorax, can be an indication
6. Cheyne-stokes respirations – fast Kussmaul of tissue hypoxia
breathing, then decreases, then temporary - rapid, deep, labored ▪ Common in patient with ARDS (Acute
stops Respiratory distress syndrome) and
7. Biot’s respiration – quick, shallow Biot respiratory arrest
inspirations, followed by periods of apnea Interventions:
1. Check the oxygen saturation (direct and Inspect for signs of CENTRAL and • Dizziness or Syncope
indirect) measurements PERIPHERAL • Diaphoresis
2. If de-saturation is present hyperventilate CYANOSIS • Edema / Weight Gain
the patient Color
▪ Cyanosis is a late sign of respiratory - Pressure in the chest
Masses and scars distress - spreading pain
Mass/tumor ▪ Clubbing of fingers is a sign of prolonged - lightheaded, sweating, or nausea
➢ Benign - slightly movable mass and oxygen
regular in shape deficit Common S/Sx Associated with PVDS
➢Malignant/beginning malignancy - non- Interventions: [Peripheral Vascular Disease]
movable mass or tumor with ➢Give supplemental oxygen support • Intermittent claudication
tenderness and irregular in shape ▪ Check for oxygen saturation (direct and • Skin changes: pallor,
Gold standard of diagnosis - FNAB (Fine indirect) rubor & cyanosis
needle aspiration biopsy) • Reduce, obliterate or
Scars - maybe due to accident The absence of peripheral
CARDIOVASCULAR pulse
PARADOXICAL CHEST MOVEMENT System • Alopecia, brittle nails,
Paradoxical Chest Movement - uneven 1.Heart dry skin, atrophy,
movement of chest wall, can be 2.Blood Vessels ulcerations & gangrene
caused by multiple rib fractures, chest lag 3.Blood
secondary to pleural Common Types of Chest Pain and Their
effusion and accumulation of blood, air or Heart Underlying Causes
water to the thoracic cavity. - pumps blood - Due to decreased coronary tissue perfusion
1. Pneumothorax - Air in the thoracic cavity. or
2. Hydrothorax – Water in the thoracic Health History compression & irritation of nerve endings
cavity. Common S/sx
3. Hemothorax – Blood in the thoracic cavity. • Chest pain - Burning
• Shortness of Breath - Stabbing
Related Structures • Fatigue - Heavy Pressure
• Palpitations - Constricting
 • Due to increased hydrostatic pressure in S2 (DIASTOLE) “DUB”-HIGH PITCHED
ASSESSMENT the - Closure of the AORTIC and PULMONIC
OF CHEST PAIN venous system resulting to fluid shift from VALVES
P- PROVOCATIVE/PALLIATIVE IVF
Q- QUALITY (Intravascular Fluid) to ISF (Interstitial Fluid) S3 VENTRICULLAR GALLOP “KEN---TUCKY”
R- RADIATION - RAPID VENTRICULAR FILLING.
S- SEVERITY Past Medical History Indicates CHF (Congestive Heart Failure).
T- TIMING 1. Childhood and Infectious Diseases S3 is a NORMAL finding for CHILDREN,
2. Previous Illnesses & Hospitalizations YOUNG ADULTS and ATHELETES.
Fatigue 3. Medications It maybe a CARDINAL SIGN of HEART
• as a consequence of INADEQUATE FAILURE.
CARDIAC Physical Assessment
OUTPUT 1. General Appearance - LOC S4 ATRIAL GALLOP “TEN---NESSEE”
2. Skin - color - Can be heard over the TRICUSPID or
Palpitations 3. Vital Signs – BP, RR, PR MITRAL
• unpleasant awareness of the heartbeat 4. Jugular Veins – distention, CVP areas when patient is on LEFT SIDE. You may
• described as POUNDING, RACING or 5. Carotid Arteries – pulsations, bruits hear S4 in elderly patients or those with
SKIPPING 6. Chest – heart sounds aortic
• Occur during mild exertion 7. Extremities – peripheral edema, capillary stenosis, hypertension and history of MI
• May indicate heart failure, anemia or refill time, clubbing (Myocardial Infarction/ Heart Attack).
thyrotoxicosis (excess thyroid hormone) 8. Lungs – breath sounds, cough
9. Abdomen – liver, bladder problems MURMURS
Dizziness or Syncope • is an abnormal whooshing sounds, an
• Characterized generalized body weakness Assessing for Jugular Vein distention indication of CARDIAC
with an inability to stand upright, followed by PROBLEM, normal in infants up to 3 months.
loss of consciousness HEART SOUNDS • are abnormal heart sounds that are
• Due to decreased cerebral tissue perfusion S1 (SYSTOLE) “LUB” – LOW PITCHED produced as a result of turbulent
- Closure of MITRAL and TRICUSPID blood flow which is sufficient to produce
Edema VALVES audible noise. • This most commonly results
from narrowing or leaking of valves
or the presence of abnormal passages absence of pulsation (arterial spasm or 2. BOUNDING PULSE- hypertension and
through which blood flows in occlusion) increase stroke volume
or near the heart. • However, they decreased, weak, thready pulsations 3. PULSUS ALTERANS- due to LEFT SIDED
sometimes result from harmless flow (impaired HEART FAILURE
characteristics cardiac output) 4. PULSUS BIGEMINUS- due to PVC
of no clinical significance. increased pulse volume (HPN, high cardiac (Premature Ventricular Contractions)
output 5. PULSUS PARADOXUS- due to cardiac
PERIPHERAL VASCULAR or circulatory overload) tamponade (fluid in the pericardial
SYSTEM space) and constrictive pericarditis
• Includes measuring BP, palpating • Inspect the peripheral veins in the arms &
peripheral pulses, & inspecting the skin & legs for signs of phlebitis • Inspect skin of the hands & feet for color,
tissue (inflammation of a vein) temperature, edema & skin
to determine PERFUSION (blood supply to an NF: in dependent position, presence of changes.
area) of the extremities. distention & nodular bulges at NF: skin color is pink, temp is not excessively
PERIPHERAL PULSES calves. (+) tortuous veins in adult when warm or cold, no edema, texture
- palpate peripheral pulses. May use elevated, limbs not tender, is moist and resilient.
DOPPLER ultrasound probe if you have symmetric in size AF: cyanotic, pallor, dusky red when limb is
difficulty palpating on both side of the body AF: distended veins in the thigh & lower leg lowered (arterial insufficiency),
or on posterolateral part of brown pigmentation around ankles (arterial
GRADING PULSES the calf from knee to ankle, tenderness on or venous insufficiency),
4+ bounding palpation, (+) Homan’s edema, skin is thin, shiny or thick, waxy,
3+ increased sign, warm, redness over vein, swelling of with reduced hair &
2+ normal one calf/leg
1+ weak • Assess adequacy of arterial flow if arterial
0 absent ABNORMAL PULSES insufficiency is suspected.
1. WEAK PULSE- due to increase vascular NF: Buerger’s Test – patient in supine
NF: symmetric pulse volume & full resistance, as occurs in elders, position, lift the leg up to 90 degrees
pulsations. digoxin toxicity, cold weather and severe and note if there will be a color change.
AF: asymmetric volume (impaired heart failure - original color returns in 10 secs, veins in
circulation) feet or hands fill in about 15
secs, immediate return of color in capillary vision screener
refill test.  Penlight
AF: delayed color return or mottled Midterms | ASSESSMENT OF THE  Opaque cards
appearance, delayed venous filling, EYES  Ophthalmosc
marked redness of arms & legs, delayed ope
return of color in capillary refill EYE EXAMINATION  Disposable
(arterial insufficiency) Assessment of eye function Gloves
through specific vision tests
ARTERIAL AND VENOUS Inspection of the external VISUAL ACUITY
INSUFFICIENCY eye • DISTANCE VISION
Inspection n of the internal Normal Findings:
POOR CARDIAC OUTPUT AND TISSUE Eye  Visual acuity of 20/20
PERFUSION Abnormal Findings: 
PREPARING THE CLIENT Myopia(nearsightedness),
PITTING AND NON PITTING Explain each vision test thoroughly to  Amblyopia
EDEMA guarantee accurate results. For the eye permanent loss of
examination, position the client visual acuity resulting
so she is seated comfortably. During from strabismus
examination of the internal eye with
the ophthalmoscope, you will move very • NEAR VISION
close to the client’s face to view the retina Normal Findings:
and internal structures. Explain in detail - Normal near visual acuity
what will be done and is 14/14 (with or without
answer questions of the client to relieve corrective lenses).
anxiety. Abnormal Findings:  Presbyopia (impaired
near
EQUIPMENT NEEDED vision) is indicated when
 Snellen chart the client moves the chart
 Hand-held away
card or near  Hyperopia difficulty
seeing up close • The reflected light (light reflex) should be blocked
seen symmetrically in the center of each Strabismus -
• COLOR VISION cornea. constant
Normal Findings: Abnormal Findings:  Light reflections noted misalignment
- identify all six screening on different areas on both of the eyes.
color plates correctly Eyes Esotropia
has normal color vision. Exotropia
Abnormal Findings: - The color vision PSEUDO STRABISMUS
defect is designated Normal in young children, the pupils will EXTRAOCULAR MUSCLE FUNCTION
as red/green, appear • Cardinal Fields of Gaze
blue/yellow or at the inner canthus (Extraocular Muscle
complete when the Movements)
patient sees only EXTRAOCULAR MUSCLE FUNCTION Normal Findings:
shades of gray. • COVER – UNCOVER TEST (FOR ABNORMAL • Both eyes should move
EYE smoothly an
VISUAL FIELDS MOVEMENT) symmetrically in each of
CRANIAL NERVE II Normal Findings: the six fields of gaze and
Normal Findings: • Uncovered eye does not move as opposite convergence on the
- The patient who is able to eye is held object as it moves
see the stimulus at about 90 covered toward the nose.
degrees temporally, 60 • Covered eye does not move as cover is
degrees nasally, 50 degrees removed NYSTAGMUS
superiorly and 70 degrees • involuntary movement and
inferiorly. Abnormal returning to the center after each
Findings: field is tested.
EXTRAOCULAR MUSCLE Phoria - Abnormal Findings: - Abnormal eye
FUNCTION misalignment movements
• CORNEAL LIGHT REFLEX (HIRSCHBERG that occurs consist of failure of an eye to
TEST) only when move outward (CNVI), inability
Normal Findings: fusion reflex is of the eye to move downward
when deviated inward (CNIV) or eyeballs accompanied by exudates, foreign bodies
other defects in movement retracted eyelid margins or lesions are noted.
(CNIII) Entropion – inverted lower lid Abnormal Findings: - Episcleritis - local
noninfectious inflammation of the
EXTERNAL EYE STRUCTURE • EYELIDS Sclera
• EYELIDS & EYELASHES Abnormal Findings:
Normal Findings: 5. Ectropion everted lower • The palpebral conjunctiva should appear
 Symmetrical with no drooping, eyelid pink and moist. It is without swelling ,
infections or tumors of the lids.  When the 6. Hordeolum a hair follicle lesions,
eyes are focused in a normal infection injection, exudates or foreign bodies.
frontal gaze, the lids should cover the 7. Chalazion an infection of the
upper portion of the iris.  can raise both meibomian gland • SCLERA
eyelids symmetrically Normal Findings:
(CNIII) EYELIDS  In light skinned individuals, the sclera
 When the eye is closed, no portion of Abnormal Findings:  Color changes :  should be white with some small, superficial
the cornea should be exposed.  Normal lid Redness – redness in the nasal half may vessels and without exudates, lesions or
margins are smooth with the indicate frontal sinusitis foreign bodies.
lashes evenly distributed and sweeping  Bluish – cyanosis can result from orbital  In dark-skinned individuals, the sclera may
upward from the upper lids and vein have tiny brown patches of melanin or
downward from the lower lids.  Eyebrows thrombosis, tumor or aneurysm grayish blue or “muddy” color.
are present bilaterally and  Black and Blue – ecchymosis is caused by Abnormal Findings:
are symmetrical and without lesions or bleeding into the surrounding tissue  Uniformly yellow- jaundice.
scaling. following trauma (black eye)
LACRIMAL APPARATUS
• EYELIDS CONJUNCTIVA Normal Findings:
Abnormal Findings: Normal Findings:  There should be no
Ptosis drooping of the upper lid • The bulbar conjunctiva is enlargement, swelling or
Lagophthalmos inability to close transparent with small redness, no large amount
the eyelids completely blood vessels visible in it. of exudates and minimal
Exophthalmos protrusion of the No swelling, injection, tearing. (inspection)  There should be no
excessive tearing or  There is a heavily pigmented, Miosis
discharge from the slightly elevated area visible Mydriasis
punctum. (palpation) in the iris.
INTERNAL EYE STRUCTURE
• CORNEA AND LENS ANTERIOR SEGMENT STRUCTURES • RETINAL STRUCTURES
Normal Findings: • IRIS Normal Findings:
- Cornea and lens are transparent with Normal Findings:  Red reflex is present
no opacities. The oblique view shows a  The color is evenly  The optic disc is pinkish in color.
smooth and overall moist surface; lens distributed over the iris, Abnormal Findings:
is free of opacities although there can be a  The optic disc is pale, due to optic
- Arcus senilis among elderly clients - mosaic variant atrophy caused by increased ICP
white arc around the limbus.  It is normally smooth and
Abnormal Findings: without apparent • MACULA
 Areas of roughness or dryness on the vascularity. Normal Findings:
cornea are Abnormal Findings: - The macula is a darker,
often associated with injury or allergic  There is a heavily pigmented, avascular area with a
responses. slightly elevated area visible pinpoint reflective
 Opacities of the lens are seen with in the iris. center (fovea centralis)
cataracts Abnormal Findings:
• PUPIL  The retina is pale with the
• IRIS Normal Findings: macular region appearing
Normal Findings: • Pupil, round with a regular border, is as a cherry-red spot (TaySach’s disease)
 The color is evenly centered in the
distributed over the iris, iris. Pupils are normally equal in size (3 to 5 Inspection
although there can be a mm). External Structure
mosaic variant • PERRLA Eyebrows
 It is normally smooth and N.F. even hair distribution, even alignment,
without apparent ANISOCORIA equal movement as facial expression
vascularity. changes
Abnormal Findings: ABNORMAL FINDINGS:
A.F. absence of the lateral third of the - Epicanthus - vertical fold of skin that lies Lacrimal Sac and Nasolacrimal Sac
eyebrows [eg myxedema] over the inner canthus N.F. - Puncta mucosa pink, momedematous,
- uneven alignment - Ectropion - margin of the lower eyelid is absence of discharge/tearing/swelling
- unequal or absent movement as facial turned outward between the nose and lower eyelids
expression changes - entropion - margin of the lower eyelid is
- scaliness turned inward A.F. Dacryocysitis - inflammation of the
- blepharitis - inflammation of the eyelids lacriminal sac and nasolacrimal duct
Eyelashes - chalazion - beady, nontender nodule on the characterized by pain, redness, and swelling
N.F. eyelashes present and evenly skin around the eyelid [chronic inflammation between the nose and lower eyelid
distributed along the eyelid margins of the meibomian gland]
- periorbital edema - swelling and puffiness Conjunctiva and sclera
A.F. eyelashes absent or unevenly around the eyelid N.F. bulbar conjunctiva is transparent with
distributed along the eyelid margins - sty [acute hordeolum] - redness, tiny vessels visnle , sclera is blue-white,
tenderness, and swelling around a hair shiny, smooth, moist, palperbral conjunctiva
Eyelids follicle on the eyelid margin is pink, shiny, smooth, moist
N.F. skin intact similar in color to the face, - Xanthelasma - slightlyraised, yellowish,
smooth, and uniform well-circumscribed plaques on the skin A.F. Jaundice - sclera yellow-orange;
- no sclera visible above the cornea and iris around the eyelid herniated fat - bulging of conjunctivities - diffuse, dilated, reddened
when the eyelids are open the lower eyelids, bulging of the inner third bulbar conjunctival vessels that tend to be
- ability to completely close the eyelids of the upper eyelids or both maximal; subconjunctival hemorrhage -
- upper eyelid margins at or near the limbus sharpy demarcated, bright red area that
[the border between the cornea and sclera] Lacrimal Gland and Nasolacrimal Gland fades over days to yellow then disappears
when the eyelids are open N.F - absence of a bulge in the outer third of
- blinking symmetrical, present, at 15-20 the upper eyelids SAMPLE OBJECTIVE
blinks per minute DATA
A.F. - Dacryoadenitis - inflammation of the  Acuity tested by snellen chart: O.D. 20/20,
A.F. Lid lag - rim of sclera visible above the lacrimal gland characterized by pain, O.S. 20/20.
corneas and iris redness, and swelling in the outer third of  Visual fields full by confrontation.
- Ptosis - drooping of the upper eyelid the upper eyelid  Corneal light reflex shows equal position of
reflection.
 Eyes remain fixed throughout the cover Actual Diagnoses
test. Ineffective Health Maintenance
 Extraocular movements smooth and related to lack of knowledge of
symmetric with necessity for eye examinations.
no nystagmus. Acute Pain related to injury from eye
 Eyelids in normal position with no trauma, abrasion, or exposure to
abnormal widening chemical irritant
or ptosis.
 No redness, discharge, or crusting noted
on lid
margins.
 Conjunctiva and sclera appear moist and
smooth.
 Sclera white with no lesions and redness.
 No swelling and redness over lacrimal
gland.
 Puncta is visible without swelling or
redness.

APPROPRIATE NURSING DIAGNOSES

Wellness Diagnoses:
Readiness for enhanced visual integrity
Risk Diagnoses
Risk for Eye injury related to hazardous
work
area or participation in high-level contact
sports.
Risk for Eye Injury related to decreased tear
production secondary to the aging process.
 - Center or umbo is attached to the yip of the - Several factors can interfere with the ear’s
long process of the malleus on the other side ability to conduct sound waves
of the tympanic membrane - Cerumen, a foreign body, or a polyp may
- Eustachian tube - connects middle ear with obstruct the ear canal
the nasopharynx, equalizing air pressure on - Otitis media, may thicken the fluid in the
either side of the tympanic membrane middle ear, which interferes with the
- conducts sound vibrations to the inner ear vibrations that transmit sound.
- Auclitory ossicles; Stapes[Stirrup], Incus - Otosclerosis, hardening of the bones in the
[Anvil], Malleus [Hammer] middle ear, also interferes with the
transmission of sound vibrations
Inner Ear - trauma can disrupt the middle ear’s bony
- consists of closed fluid filled spaced within chain
the temporal bone
Midterms | ASSESSMENT - contains the bony labyrinth, which include
OF THE EARS 3 connected structure vestibule, semicircular  Otitis media,
canals, and cochlea inflammation of the
External ear - receive vibrations from the middle ear that middle ear, results
- flexible external ear consists mainly stimulate nerve impulses, which travels to from disruption of
cartilage. It contains the ear flap, also known the brain, and the cerebral vortex interprets eustachian tube
as the auricle or pinna, and the auditory the sound patency. It can be
canal - Semicircular canals, vestibule, cochlea, suppurative or
- collects and transmits sound to the middle cochlear nerve secretory, acute (as
ear shown at right) or
- Helix, Antihelix, External acoustic meatus, Outside the norm chronic.
lobule of auricle Earache
- usually results from disorders of the Acute otitis media
Middle ear external and middle ear and are associated - infective fluid in middle ear
- Tympanic membrane seperate the external with infection, hearing loss, and otorrhea - rapid onset and short duration
and middle ear
Hearing Loss Otitis media with effusion
- Characterized by fluid in middle ear that 1. History taking, enquire about pain,  Have the patient slightly tilt his head away
may not cause symptoms hearing loss and dizziness before proceeding from the nurse
- may be acute, subacute, or chronic The following issues should be included:  Start with the “good” ear – one without
▪ Classic symptoms of ear disease: problems or infections (if
Cholesteatoma deafness, tinnitus, discharge (otorrhoea), any)
- abnormal skin growth or epithelial cyst in pain (otalgia) and vertigo. Step 2: Holding the otoscope
middle ear that usually results from repeated ▪ Previous ear surgery, or head injury.  Hold the otoscope in one hand and turn on
ear infections ▪ Family history of deafness. the light
▪ Systemic disease (eg, stroke, multiple  Gently insert the speculum into the ear
Perforation sclerosis, cardiovascular disease).  With the other free hand, gently pull up,
- Hole in tympanic membrane caused by ▪ Ototoxic drugs (antibiotics (eg, out, and/or forward on
chronic negative middle ear pressure, gentamicin), diuretics, cytotoxics). patient’s ear to straighten out the ear canal
inflammation, or trauma ▪ Exposure to noise (eg, pneumatic drill or for easy viewing
shooting).History of atopy and allergy in
Physical Assessment of the Ear children.  The examiner holds the otoscope in one
Return Demo Checklist hand and uses his or her free hand to
External Ear Structures pull the outer ear gently up and back. This
Introduction Inspect the auricle, tragus, and lobule for straightens the ear canal and helps
1. Appropriate introduction including name size and shape, position, lesions/ the nurse see inside the ear.
and role discoloration, and discharge. Palpate the  Hold the otoscope with 3 fingers and your
2. Obtain verbal consent. Briefly explain to auricle and mastoid process thumb and keep it parallel to the
the for tenderness. ground. This will help prevent you from
client what the examination involves. wrenching the instrument side to side,
3. Wash hands or use alcohol gel Otoscopic Examination which could injure your patient.
4. Position and adequately expose patient Step 1: Have the patient sit down  In babies younger than 12 months, the
5. Ask for any deafness? If so -Manage  Have the patient sit down (May be best for examiner will gently pull the outer ear
Communication the patient to sit on the down and back.
desk so the ear is in a convenient position  Use full brightness.
History taking for the nurse)  Wait until the otoscope is fully inserted
before looking through the instrument.
 *May be obscured by debris client's mastoid process.
Step 3: Examine the External Canal or ear wax When the client no longer
 Examine the external ear canal and note hears the sound, note the
any Hearing and Equilibrium Tests time interval, and move it
abnormalities –discharge, color and Perform the Weber test in front of the external ear.
consistency of by using a tuning fork When the client no longer
cerumen, color and consistency of canal placed on the center of hears a sound, note the
walls, and the head or forehead time interval. Repeat the
nodules. and asking whether the procedure with the other
client hears the sound ear.
Step 4: Examine the Tympanic Membrane better in one ear or the
 Inspect the tympanic membrane, using the same in both ears. Normal Response:
otoscope If the patient has normal hearing, s/he will
for color and shape, consistency, and Normal Response: hear it louder in front of the external ear. (Air
landmarks  If hearing is normal, the patient will hear conduction of sound is louder through air
the sound equally than
 Have client perform the on each side. bone. In the normal patient, the external and
Valsalva maneuver and observe Abnormal Response: middle ear system are unimpaired so s/he
the center of the tympanic  If the patient has a sensorineural hearing will
membrane for a flutter. loss (SNHL) in one hear the sound better though air
(Do not do this procedure on ear, the sound will lateralize to the side of conduction.)
the older client, as it may better hearing.
interfere with equilibrium and  If the patient has a conductive hearing loss Abnormal Response:
cause dizziness). (CHL) in one ear, 1) If the patient has a sensorineural hearing
the sound will lateralize to the side with the loss (SNHL), s/he will hear
Step 5: Examine parts of hearing loss. the sound better in front of the ear canal just
Middle Ear as in the normal
Look for the Malleus or the  Perform the Rinne test by response. Since the hearing loss is because
handle of the Malleus*, and using a tuning fork and the inner ear or cochlear
note any abnormalities placing the base on the
nerve is less able to transmit impulses Perform the Romberg test
regardless of how the vibrations to evaluate equilibrium.
reach the cochlea, the normal pattern With feet together and
prevails - air conduction is still arms at the side, close
louder. eyes for 20 seconds.
2) If the patient has a conductive hearing Observe for swaying.
loss (CHL), s/he will hear the
sound louder on the mastoid process. ANALYSIS OF DATA
Pathways of normal air Formulate nursing diagnoses (wellness,
conduction through the external and middle risk, actual)
ear are blocked. Vibrations Formulate collaborative problems. Make
through bone bypass the obstruction to necessary referrals.
reach the cochlea and are
perceived as louder

SUMMARY OF RESPONSE
Conductive hearing loss
Weber
A.F. - louder on side with hearing Loss

Rinne
A.F. - louder on bone

Sensorineural Hearing Loss

- Weber - Louder on opposite side

Rinne - Louder infront [as a normal

response]

Hearing and Equilibrium Test

 The nasal septum separates the cavity into COLLECTING SUBJECTIVE DATA:
two halves. The front of the nasal septum THE NURSING HEALTH HISTORY
contains a rich
supply of blood vessels and is known as Do you have pain over your sinuses?
Midterms | ASSESSMENT OF NOSE Kiesselbach’s area. This is a common site for - sinusitis cause pressure and pain over the
AND SINUSES nasal bleeding sinuses

STRUCTURES AND FUNCTIONS SINUSES Do you experience

The NOSE AND PARANASAL Four pairs of paranasal sinuses (FRONTAL,
SINUSES constitute the first part of MAXILLARY, ETHMOIDAL, AND
the respiratory system and are SPHENOIDAL) are located in the skull. These
responsible for receiving, filtering, air-filled cavities decrease the weight of the
warming, and moistening air to be skull and
transported to the lungs act as resonance chambers during speech.
The PARANASAL SINUSES are also lined with
NOSE ciliated mucous membrane that traps debris
The nose consists of an external portion and
covered with skin and an internal nasal propels it toward the outside.
cavity. It is The sinuses are often a primary site of
composed of bone and cartilage and is lined infection because they can easily become
with mucous membrane. blocked.
The external nose consists of a bridge (upper The FRONTAL SINUSES (ABOVE THE EYES)
portion), tip, and two oval openings called AND THE MAXILLARY SINUSES (IN
nares. THE UPPER JAW) are accessible to
The nasal cavity is located between the roof examination by the nurse.
of the mouth and the cranium. It extends The ETHMOIDAL AND SPHENOIDAL SINUSES
from are smaller, located deeper in the skull, and
the anterior nares (nostrils) to the posterior are
nares, which open into the nasopharynx. not accessible for examination.