Wednesday, February 20, 2019
Nursing Physical Assessment
Physical appraisal Lab 120-103 1. General Survey take aim? Awake & Alert a. Orientation to person, send off, time? b. Ability to Communicate in full sentences with clear speech? c. Posture upright and erect, shoulders level and interchangeable? d. Personal Hygiene Clean & neat, no odor, dresses appropriately for the weather. 2. Integumentary establishment a. Color Uniform color pinko, tan, brown, olive. Slightly darker on exposed aras. thither are normally no areas of bleeding, ecchymosis, or increased vascularity. No strip lesions should be present except for freckles, birthmarks, or moles, which may be matte or elevated. . Temperature Warm and dry isobilaterally. Hands and feet may be approximately cooler than the rest of the organic structure. Skin surfaces should be non tender. ( routine back of both workforce on perseverings forearms) c. Textures Skin should feel soft/ graceful or coarse/ densely. d. Turgor When the skin is released, it should instantly recoil, no tenting. outstrip assign to valuate Ant. ?Chest or abdomen. **Verbalize I result commix the integumentary system through off the rest of the exam through checking and observing. 3. Head, Face, do it a. Cranium The star should be normocephalic, midline, and symmetrical.? . Scalp The scalp should be gabardine to light brown, brilliant, intact, and without lesions or masses, flaking, or pidiculi (lice)? c. H line Pale blonde to black, thick or thin, curly or straight, coarse or fine, shiny or dull.? d. Frontal Maxillary Sin consumptions Should be non palpable and non tender (moldiness ask did that tolerate? ) e. Cervical Lymph Nodes Should be non palpable and non tender, non visible or inflamed. (Preauricular, postauricular, occipital, submental, submandibular, tonsillar, anterior cervical chain, posterior cervical chain, supraclavicular. e. Best place to assess Ant. Chest or abdomen. **Verbalize I will integrate the integumentary system throughout the rest of the exam thro ugh checking and observing. Physical Assessment Lab 120-103 f. carotid Artery Has visible pulsation (should be in front of the sternocleido mastoideus muscleman), palpable bilaterally (not at the same time ), no bruits (soft blowing or wooshing sound from constriction of plaque) g. Temporal Artery Should be palpable and gibe bilaterally h. TMJ Glides smoothly, no clicking or crepitus. i. Trachea Midline, Thyroid non palpable, non tender (ask) j.Neck read-only storage & muscularity Strength Stand goat the patient, touch the chin to the chest, expect up at the ? ceiling, move each ear to shoulder (without elevating the shoulder), yield head to each look to hang at the shoulder. The Cervical grits alignment is straight, the head is held erect. Normal muscle strength allows for full, complete, conscious joint ROM against both gravity and moderate to full resistance. Muscle strength is equal bilaterally. There is no observed involuntary muscle movement. Say full active ROM wi th no restrictions k.Thyroid Palpation induce the patient lower the chin slightly in order to wind off recognise muscles. Place your thumbs on the back of the patients neck and beat the other fingers around the neck anteriorly to rest their tips oer the trachea on the lower portion of the neck. Move the finger pads all over the tracheal rings. Gently move trachea over to the side, then contribute patient swallow. Feel for any consistency, nodularity, or tenderness. 4. Eyes? a. Eyelids Palpebral Fissure are symmetrical, no ptosis or lid lag.? b. Lacrimal Glands Pale pink, patent, no spendthrift tearing, dryness, drainage, or edema.? . Eyelashes Evenly distributed no ectropion no entropion.? d. Eyebrows Even and equally bilateral? e. Conjunctiva clear, pink, moist, without lesions? f. Sclera white & intact? g. Cornea Surface should be moist and shiny and without discharge, cloudiness, opacity, and irregularity.? h. Iris round, symmetrical, and colored green, blue, brown, hazel, violet, h stary, etc.? i. Pupils PERRLA (Pupils are Equal, Round, Reactive to clear and Accommodation) equip pupil inborn reflexes. check in two ways each eye, direct/consensual, then bring penlight toward nose to assess for accommodation. . Ears? a. Pinna Non tender, symmetrical bilaterally, without lesions or masses, (top of pinna should forever be equal to outer canthus) palpate simultaneously? b. Tragus non tender, without lesions? c. Mastoid subprogram (piece of bone inferior posterior ear) non tender, no swelling, equal bilaterally (if one is different, ask for how big)? d. Tympanic Membrane Pearly gray, shiny, intact (sometimes will settle some white-cottage cheese looking bumps = scarring) MAKE SURE TO CHANGE SPECULUM BTWN EARS FOR PRACTICUM braggy pull back and up, look anterior.Child pull overmatch) **know how to use equiptment Instructors/proctors look for this *** e. Umbo (Part of the Stapes) Make sure this is present, Protruding = dehydrated, Not present = f luid behind eardrum. f. Cone of Light Tiny triangle anterior inferior on tympanic membrane = healthy. 500 on the right ear, 700 on the left ear. Physical Assessment Lab 120-103 6. Nose? a. Nares patent, harbour patient occlude one nostril and gently blow out air on back of baseball glove to test patency. Mucosa pink, moist, without lesions, edema, drainage? b. Septum without deviation.Best was to assess is to push tip of nose up shows if deviation is present. ***If nares are pink = allergies. If nares are bright red = cold. Saline shortens cold as it washes it down to stomach, where stomach kills the virus. 7. Mouth/Lips? a. Lips pink, moist, intact, without lesions? b. Teeth 32 including 4 wisdom. White with unassailable repair, without caries? c. Tongue pink, moist, papillae intact, midline, full mobility (ask pt to stick tongue out move left, right, up, down), without lesions? d. Oral Mucosa pink, moist, without lesions (use tongue depressor & penlight) no red, no swelling? . Gingiva pink, moist, intact, no bleeding? f. Uvula Midline, rises symmetrically with soft palate when patient says Ahhh If absent patient will be sensitive to gagging. If long may be a sign of sleep apnea? g. Tonsils Pink, symmetrical. They are grade from absent +4) +1 = peeking, +4 = kissing h. Hard/Soft palate pink, intact. Soft palate is pinker than hard Write What you would expect to see If not, must state what you see. Are the eyelids covering the top of the iris? Always contrast OD to OS. First begin assessment with visual acuity.?Corneal Light Reflex Shine penlight 12-15 away toward eyes (at midline) Should get right reflex in same position in each eye. If asymmetric they occupy strabismus (weak eye muscle) Ears Use tuning fork? Weber screen out ready on palm Hold at tip head (hairline) Should be able to hear equally in each ear. Rinne hear hearing acuity. Hit prongs on palmar, put it on mastoid action until cant hear it any longer, then move it to memory it in front of the ear canal. ***Air conduction should be twice as long as bone conduction*** Semicircular Canals get over balance and equilibriumVertigo can be caused by a foreign body which has been dislodged and landed in semicircular canals. Native Americans and Asians can have toroid Palantitis looks like mountain ranges on palate this is a benign condition. 8. sensational Neuro (answer to most cranial nerve testing is intact) *verbage Physical Assessment Lab 120-103 a. Sensation light touch, sagacious/dull, intact? a. Upper Extremities use cotton ball, & sharp & dull sides of broken tongue depressor use 3 vagrant finger, back of hand, arm. * b. Abdominal Reflex * Positive or not present * . Lower Extremities use cotton ball & sharp & dull sides of broken tongue depressor use 3 spots toe, top of foot, and shin.? b. Deep Tendon Reflexes (smack deep sinews using flat side of invent) *These are graded 0-4 What you would expect to surface +2/4) ? a. Biceps place thumb at patients elbow (antecubital) to hold their arm. Hit own thumb with the hammer. ?b. Triceps hold patients muscle so patients arm can swing freely. Hit hammer above funny bone. ?c. Brachial Radialis Hold pts hand then hit hammer midway btwn wrist & antecubital. d.Patellar Find muscularity right above patellar bone, hit hammer on tendon? e. Achilles About 2 above heel, support foot, relax leg. Will have plantar flexion.? f. Plantar or Babinski = severe brain damage abduction. So we say Positive plantar ? flexion, no abduction we only expect to find in babies. How to test use metal side of hammer and mark the outer margin of the foot and across top, under toes. ?babinski or f. Best place to assess Ant. ?Chest or abdomen. **Verbalize I will integrate the integumentary system throughout the rest of the exam through checking and observing.