HA LEC Midterms PDF

HEALTH ASSESSMENT (LECTURE) - Midterms
BS NURSING - 1B 2nd Sem – 2023 I Prof. Marcelo

Variation in Skin with Age
ASSESSMENT OF THE SKIN
Adolescence
Variation in Skin with Age - Apocrine glands enlarge and become more
Infants / Young Children active
- Skin smoother-lack of exposure to elements - Sebaceous glands increase production
- Less subcutaneous fat layer, poorer causing oily skin and predisposition to acne
temperature control - Terminal hair appears in axillae and pubic area
- Eccrine sweat glands secrete after 1 month for both sexes and on face in males
Common Variations in Newborns Terminal Hair and Acne

Acrocyanosis
- is persistent blue or cyanotic discoloration of
the extremities, most commonly occurring in
the hands, although it also occurs in the feet
and distal parts of face.
Transient Mottling Skin Variation with Age

- Is the appearance of uneven
Pregnancy Increased:
spots
- Blood flow to skin to balance heat production
Erythema Toxicum from increased BMR (Basal Metabolic Rate)
- characterized by blotchy red spots - Eccrine sweat gland activity
on the skin with overlying white or - Sebaceous gland activity
yellow papules or pustules. - Fat deposits
- Common rash in neonates.
- Pigmentation of face, nipples, areolae, axillary,
and vulva
Harlequin Sign
- Is unilateral flushing and
sweating of the face and neck Variation in Skin with Age
usually after exposure to heat or Older Adults Decreased:
strenuous exertion - Blood flow to skin
- Eccrine sweat gland activity
Mongolian Spots
- Sebaceous gland activity
- also known as "Mongolian blue
spot", "congenital dermal - Fat deposits
melanocytosis", and "dermal - Pigmentation of skin and hair, first in Whites,
melanocytosis“ later in Blacks and Asians
- is a benign, flat, congenital - Hair production and increased coarseness
birthmark with wavy borders
and irregular shape
Variation in Skin by Race
Telangiectatic Nevi (Stork Bite) Asians, Latinos, Blacks
- appears as a pink or tanned, flat, - Varying intensity of pigmentation
irregularly shaped mark on the - Mucous membranes pink to light brown
knee, back of the neck, and/or the - Sclera white, gray, light brown, often with
forehead, eyelids and, sometimes, pigmented spots
the top lip
- Mongolian markings common in children
Jaundice - Visible difference in pigmentation of ventral
- Yellowish discoloration and dorsal surfaces of extremities
Hair
Milia - Vellus body hair
- also called a milk spot or an oil - Scalp hair varies in texture
seed Skin texture
- is a keratin-filled cyst that can
- Limited apocrine glands (less sweat)
appear just under the
epidermis or on the roof of the - Limited sebaceous glands (less body oils)
mouth. - Frequent washing causes increased dryness
- Milia are commonly associated with newborn
babies but can appear on people of all ages.
P a g e 1 | 37 PANGILINAN, SOFIAH NICOLE

Skin conditions - Nodule <1-2cm/ Tumor >2cm: deeper
- Fine colored lesions harder to see
- Pigmentary changes due to lesions may persist
for months or years
- Licenification common with eczema
- Hypertrophic scars and keloids common
- Vesicle <1cm/ Bulla >1cm: bubble
Whites
- Less variation in intensity of pigmentation
- Mucous membranes pink
- Sclera white
Hair
- Terminal hair on body common - Pustule: purulent vesicle
- Texture and color vary
Skin texture
- Increased apocrine glands result in increased
body sweat
- Increased sebaceous glands lubricates skin
- Wheal: hive
and scalp
- Requires frequent washing
Assessment of the Skin, Hair, Nails

- Inspection
- Palpation
SECONDARY LESIONS:
Assessment of the Skin
Change in primary lesion due to external trauma
Inspect for:
➢ Scale - Scaling skin is the loss of the outer layer
• Lesions
of the epidermis in large
• Skin color
➢ Scar - are areas of fibrous tissue (fibrosis) that
• Areas of pain or itching
replace normal skin after injury
Palpate for:
➢ Crust, Scab - the dried crusty surface of a
• Moisture
healing skin wound or sore
• Temperature
➢ Keloid - is a growth of extra scar tissue where
• Texture
the skin has healed after an injury
• Turgor
➢ Fissures - a cutaneous condition in which
• Mobility
there is a linear-like cleavage of skin,
• Capillary filling
sometimes defined as extending into the
• Elevation or depression
dermis
➢ Lichenification - hardening of the skin, usually
PRIMARY LESIONS:
caused by chronic irritation
Initial appearance of pathological process
➢ Erosion - is a loss of some or all of the
- Macule <1cm/ Patch >1cm: flat lesion
epidermis (the outer layer) leaving a denuded
surface.
➢ Atrophy - is a condition in which the upper
layers of skin get thin
➢ Excoriation (scratch) – the act of abrading or
- Papule 1cm/ Plaque >1cm: elevated wearing off the skin
➢ Ulcer - is a sore on the skin or a mucous
membrane, accompanied by the
disintegration of tissue

Lesion Descriptors
➢ Shape (con’t):
• Geographic
• Lacy
• Serpiginous (snake-like)
• Umbilicated (middle indentation)
Lesion descriptors
• Target, iris (bullseye)
➢ Shape:
• Linear
Normal Tongue
• Round
Geographic pattern of white and
• Annular (round with central clearing)
dark pink mucous membranes on
• Oval
ventral surface of tongue.
• Polycyclic (interlocking circles)
• Morbilliform (confluent, measle-like)
Erythema Infectiosum (Slapped-cheek)
• Zosteriform (dermatomal)
Human Parvovirus B 19 (Fifth Disease)
Intense confluent redness of both cheeks
preceded lacy erythematous macular papular
lesion over trunk and extremities. Mild fever
associated with onset of lesions.
Hemangioma
Round papule measuring 1 cm.
situated superior to outer canthus
of R eye. Uniform deep red color.
Scabies
Serpigenous elevated burrow
Birthmark
measuring 6 cm at base of 3rd-5th
Hyperpigmented linear macules
toes R foot. Client reports lesion is
measuring 1cm by 4.5 cm inferior
itchy.
to right nipple. No indication of
inflammation or irritation.
Molluscum Contagiosum
Small discrete circular papules with
Poison Ivy
umbilicated centers on inner
Linear vesicles on ventral surface
aspect of R elbow.
of forearm. Client reports lesions
are intensely itchy.
Target (bullseye)
lesion
Measles
Erythematous macular papular
lesions over entire body. Infant
observed scratching. Lesions
Lesion Descriptors
associated with fever and mild
➢ Color:
URI symptoms.
• Erythematous
• Pink, red
Herpes Zoster
• Purple
Grouped vesicles on an
• Ecchymotic (black & blue)
erythematous base scattered
• Mottled
along R thoracic dermatome.
• Silver / White
Client reports pain associated
with lesion.

Viral Exanthem unknown Etiology (Pityriasis rosea) Assessment of the Skin
Scattered discrete erythematous papular lesions Lesion Descriptors
on trunk. No lesions present on sun exposed areas. ➢ Distribution:
Client denies itching, fever, or URI symptoms with • Localized (identify where)
rash. vs. generalized
• Symmetrical or
Erythema Nodosum asymmetrical
Abrupt onset of tender • Scattered, grouped
erythematous nodules on extensor • Flexural or extensor surfaces
surfaces of extremities. Lesions • Intertriginous (between skin folds)
evolved into bruises with color • Sun exposed or covered
changes to purple then yellow- • Contact areas for clothing, jewelry,
brown. chemicals
Psoriasis Vulgaris Atopic Dermatitis (Eczema)

Erythematous plaque with silver-white Symmetrical dry excoriated red
scale on extensor surface of legs. plaques on flexor surfaces of knees
and elbows. Child reports intense
Ecchymotic Mottled itching (pruritis) and history of
asthma.
Keloids
Three discrete hairless hyperpigmented
nodules measuring 4x2cm, 4x1.5cm, &
3x1cm at sites of previous mole
removal.
Lesion Descriptors
➢ Color (con’t): Erythema Toxicum (Neonatal Acne)
• Blue Scattered papules and pustules on
• Black erythematous bases of varying
• Yellow diameters. Lesions noted to change
• Hyperpigmented location within hours. No fever
• Hypopigmented, depigmented associated with lesions
• Amelanotic
Herpes Simplex Virus (Herpes Keratitis)
Café-au-lait Spot Grouped vesicles on an erythematous
Hyperpigmented patch with irregular base located below R eye. Conjunctiva
borders measuring 8 cm by 3 cm intact without inflammation.
over L scapula. Client reports area
seems to fade in summer. Happy Lip-Licker
Dry rough erythematous to brown
Vitiligo skin circumscribing lips. Child
Depigmented patches of skin reports licking his lips frequently.
with distinct borders on ventral No other lesions noted on body.
surface of R hand. Hair within the
affected area is also Candidiasis (Yeast)
hypopigmented. No other symptoms reported. Dry macular papular
erythematous confluent lesions
Sunburn with Vitiligo Amelanotic with additional satellite lesions
found on intertriginous skin of L
breast. Client reports mild itching.

Contact Dermatitis Warts
Small white confluent papules Three hard dry verrucous
extending across forehead onto (warty) papules on middle
scalp with a band width of 5 cm. finger of R hand.
(From head band worn during
exercise.) Lichenification (Secondary to Eczema)
Dry thickened skin with
Assessment of the Skin horizontal fissures. Symmetrical
Lesion Descriptors pattern of lesions on flexor
➢ Border / Margins: surfaces of knees and elbows.
• Sharply / poorly marginated (demarcated, Client reports intense itching.
defined) Acanthosis Nigricans
• Irregular Dry thickened hyperpigmented
• Scalloped skin with linear fissures across
• Raised / elevated or flat border posterior neck. Also found
• Active border under arms. Child has BMI
• Lesion variation between border and (Body Mass Index) of 30.
center
Impetigo (Staph or Strep)
Nevus Flammeus (Port-Wine Stain) Vesicles turning to honey-colored
Dark red patch with distinct crusts on erythematous base,
borders extending from R ear below R nares and on bridge of
across lower cheek and chin. Has nose.
been present since birth. Lesion
does not appear to itch and child Primary Gingivostomatitis
has no other symptoms. Moist vesicles on an
erythematous base encircling
Diaper Dermatitis (Contact) the mouth, covering the lips
Confluent dry dark red patch with and extending onto the
well demarcated borders outlining mucous membranes of the mouth. Child has a
diaper area. Some sparing of fever, is irritable and reports pain when
intertrigenous skin folds. No attempting to eat or drink.
satellite lesions.
Bullous Impetigo (Staph or Strep)
Diaper Dermatitis (Candidiasis) 20 by 10 cm bullae with shallow
Confluent dark red slightly moist erosion and moist center mid
patch on perineum and lower abdomen superior to umbilicus.
abdomen with satellite papules Smaller similar lesion superior to
extending upward on abdomen large lesion medial to L nipple.
and onto thighs.
Urticaria (Hives)
Assessment of the Skin Blotchy red irregularly shaped
Lesion Descriptors papules and plaques with
➢ Surface and Texture: prominent elevated borders in
• Soft irregular pattern over entire
• Boggy body. Some lesions with central
• Hard, firm clearing. Noted to fade and reappear within
• Thickened minutes. Child is scratching lesions.
• Verrucous, warty
• Moist, oozing, weeping Tinea Corporis (Ringworm)
Multiple oval plaques with active
(red and scaly) prominent borders
and partial central clearing.
Client reports mild itching.
Lesion Descriptors
➢ Associated Symptoms:
• Pruritic
• Burning, stinging
• Painful, tender
• Swelling
• Asymptomatic
Assessment of the Hair

Inspection and palpation of hair:
• Color
• Texture (vellus or terminal, smooth or brittle,
dry or moist)
• Distribution
• Quantity
• Indications of hair loss
• Infestations
A*B*C*D Rule of Melanoma
• Scalp condition
➢ A - Asymmetry of borders
➢ B - Border, irregular
Pediculosis (Head Lice)
➢ C - Color blue-black or variegated
White ovoid firm 1 mm bodies attached to hair
➢ D - Diameter greater than .6 cm
shafts. Child reports scalp itches intensely.
Tinea Capitus (Ringworm)

Dry crusted circular lesion with
erythematous base on scalp without
evidence of hair follicles. Palpable
lymph nodes present.
Traction Alopecia
Areas of sparse hair growth lateral
to braided hair with evidence of
broken hairs. No signs of infection
or infestation.
Assessment of the Nails Malignant Melanoma

Inspection and palpation
• Color, length, symmetry, and cleanliness
• Ridges, depressions, pitting
• Nail base angle, evidence of clubbing
• Firmness, thickness, separation
• Capillary refill ✓ The Skin Is The Window To The Body
Examine It Carefully
ASSESSMENT OF THE HEAD, FACE AND NECK
HEAD
- The framework of the head is the Skull, which
can be divided into two subsections: the
Cranium and the Face
- Cranium houses and protects the brain and
major sensory organs. It consists of 8 bones:

• Frontal (1) • Parietal (2) • Temporal (2) • - The Sternomastoid Muscle rotates and flexes
Occipital (1) • Ethmoid (1) • Sphenoid (1). the head, whereas the Trapezius Muscle
In the adult client, the cranial bones are extends the head and moves the shoulders.
joined together by immovable sutures: the - The eleventh cranial nerve is responsible for
Sagittal, Coronal, Squamosal, And Lambdoid muscle movement that permits shrugging of
Sutures. the shoulders by the trapezius muscles and
- Facial bones give shape to the Face. The face turning the head against resistance by the
consists of 14 bones: • Maxilla (2) • Zygomatic sternomastoid muscles.
(cheek) (2) • Inferior conchae (2) • Nasal (2) • - Two major muscles that form two triangles that
Lacrimal (2) • Palatine (2) • Vomer (1) • serves as a landmark for assessment. The
Mandible (jaw) (1) Anterior Triangle is located under the
mandible, anterior to the sternomastoid
muscle. The Posterior Triangle is located
between the trapezius and sternomastoid
muscles.
IMPORTANT CONCEPTS
• All the facial bones are immovable except for
the mandible, which has free movement (up, - The Cervical Vertebrae (C1 through C7) are in
down, and sideways) at the the posterior neck and support the cranium .
temporomandibular joint. The Vertebra Prominent is C7, which can easily
• The face also consists of many muscles that be palpated when the neck is flexed. Using
produce facial movement and expressions. C7 as a landmark will help you to locate other
The temporal artery, a major artery, is located vertebrae.
between the eye and the top of the ear.
• Two other important structures located in the BLOOD VESSELS
facial region are the Parotid and - The internal jugular veins and carotid arteries
Submandibular Salivary Glands. are located bilaterally, parallel and anterior to
• The Parotid Glands are located on each side the sternomastoid muscles. The external
of the face, anterior and inferior to the ears jugular vein lies diagonally over the surface of
and behind the mandible. The Submandibular these muscles.
Glands are located inferior to the mandible, - You need to know the location of the carotid
underneath the base of the tongue. arteries when assessing the neck to avoid
bilateral compression of the vessels, which
THE NECK can reduce the blood supply to the brain.
- The structure of the
neck is composed THYROID GLAND
of muscles, Thyroid Gland is the largest
ligaments, and the endocrine gland in the
cervical vertebrae. body. It produces thyroid
- Contained within the neck are the hyoid hormones that increase the
bone, several major blood vessels, the larynx, metabolic rate of most
trachea, and the thyroid gland, which is in the body cells. The thyroid
anterior triangle of the neck. gland is surrounded by
several structures that are important to palpate
MUSCLES AND CERVICAL VERTEBRAE for accurate location of the thyroid gland.
- The sternomastoid (sternocleidomastoid) and
trapezius muscles are two of the paired
muscles that allow movement and provide
support to the head and neck.

COLLECTING SUBJECTIVE DATA: anywhere else? right shoulder with
THE NURSING HEALTH HISTORY How long does it movement."
last? Does it
Pain Rationale
recur?
Do you Neck pain may accompany
Duration How bad is it? "It is OK if I just sit
experience muscular problems or cervical
How much does still, but it hurts
neck pain? spinal cord problems. Stress and
it bother you? more if I turn."
tension may increase neck pain.
Sudden head and neck pain Severity What makes it "It is difficult to
seen with elevated temperature better or worse? drive because I
and neck stiffness may be a sign can't see over my
of meningeal inflammation. shoulder to
Older clients who have arthritis change lanes."
or osteoporosis may experience Pattern What other "Ibuprofen and a
neck pain and a decreased symptoms occur heating pad or
range of motion. with it? How warm shower
Do you A precise description of the does it affect helps a little."
experience symptoms can help to you?
headaches? determine possible causes of the Associated Describe the sign "I can't do my
Describe. discomfort. Temporomandibular factors/ or symptom work on the
joint syndrome is a major cause how it (feeling, computer without
of chronic headaches. See Affects the appearance, being irritated
Table 14-1 for a discussion of client sound, smell, or with it."
typical findings for migraine, taste if
tension, cluster, and tumor- applicable).
related headaches.
Do you have Trigeminal neuralgia (tic KINDS AND CHARACTERISTICS OF HEADACHES
any facial douloureux) is manifested by MIGRAINE
pain? sharp, shooting, piercing facial Character - accompanied by nausea, vomiting,
Describe. pains that last from seconds to and sensitivity to noise or light
min-utes. Pain occurs over the
Onset and Precipitating Factors
divisions of the Fifth Trigeminal
- may have prodromal stage (visual
Cranial Nerve (the ophthalmic,
maxillary, and mandibular disturbances, vertigo, tinnitus, numbness or
areas). tingling of fingers or toes)
Do you have Diseases and disorders involving - precipitated by emotional disturbances,
any difficulty head and neck muscles may anxiety, or ingestion of alcohol, cheese.
moving your limit mobility and affect daily chocolate, or other foods and substances to
head or neck? functioning.
which client is sensitive
Location - located around eyes, temples, cheeks,
COLDSPA Example
or forchead
Use the COLDSPA mnemonic as a guideline to
Duration - lasts up to 3 days
collect needed information for each symptom
Severity - throbbing, severe, recurring
the client shares. In addition, the following
Pattern - rest may bring relief
questions help elicit important information.
Associated Factors - migraines occur more often
in women
Mnemonic Question Client Response
Character Describe the sign "I have trouble
or symptom turning my head CLUSTER
(feeling, to the right." Character - may be accompanied by tearing,
appearance, eyelid drooping, reddened eye, or runny nose
sound, smell, or Onset and Precipitating Factors
taste if - sudden onset
applicable).
- may be precipitated by ingesting alcohol
Onset When did it "Two days ago
Location - localized in the eye and orbit and
begin? when I woke up in
the morning, and radiating to the facial and temporal regions
it is getting worse. Duration - typically occurs in the late *evening or
Location Where is it? Does "In the back of my night
it radiate? Does neck and it Severity - intense and stabbing
it occur radiates to my

Pattern - movement or walking back and forth Have you Problems with the neck
may relieve the discomfort experienced any vessels (such as carotid
Associated Factors - cluster headaches occur dizziness, artery occlu-sion),
lightheadedness, neurologic system, such as
more in young males
spinning sensation, or inner ear disease,
loss of consciousness? cardiovascular system
TENSION Describe. (heart block) may cause
Character - symptoms of anxiety, tension, and these symptoms. These
depression may be present symptoms imply a risk for
Onset and Precipitating Factors injury.
- no prodromal stage Have you noticed a Alterations in thyroid
change in the texture function are manifested in
- may occur with stress, anxiety, or depression
of your skin, hair, or several ways. An increase
Location - usually located in the frontal, temporal,
nails? in thyroid hormone
or occipital region Have you noticed production
Duration - lasts days, months, or years changes in your (hyperthyroidism) can
Severity - dull, aching, tight, diffuse energy level, sleep result in insomnia, thinning
Pattern - symptomatic relief may be obtained by habits, or emotional hair, palpitations, and
local heat, massage, analgesics, anti-depressants, stability? weight loss. A decrease in
Have you thyroid hormone
and muscle relaxants
experienced any production (hypothy-
Associated Factors - tension headaches affect roidism) can result in
palpitations, blurred
worden nore often than men vision or changes in insomnia and will have the
bowel habits? opposite effects of
TUMOR RELATED thickening skin and nails,
Character - neurologic and mental symptoms and decreased energy levels,
nausea and vomiting may develop and constipation.
Onset and Precipitating Factors
Past Health History
- no prodromal stage
- may be aggravated by coughing, sneezing, Question Rationale
Describe any previous Previous head and
or sudden movements of the head
head or neck problems neck trauma may
Location - varies with location of tumor
(trauma, injury. falls) you cause chronic pain and
Duration - commonly occurs in the morning and have had. How were limitation of movement.
lasts for several hours. they treated (surgery, This may affect
Severity - aching, steady, variable in intensity medica-tion, physical functioning. Radiation
Pattern - headache asually subsides later in the therapy)? What were the therapy has been linked
day. results? to the development of
thyroid cancer.
Have you ever Radiation to the neck
undergone radiation area may also cause
therapy for a problem in esophageal strictures
your neck region? leading to difficulty with
swallowing.
Family History
Question Rationale
Is there a history of head Genetic predisposition is
or neck cancer in your a risk factor for head
COLLECTING SUBJECTIVE DATA: family? and neck cancers.
THE NURSING HEALTH HISTORY Is there a history of Migraine headaches
migraine headaches in commonly have a
Other Symptoms
your family? familial association.
Have you noticed any Lumps and lesions that do
lumps or lesions on not heal or disappear may
your head or neck indicate cancer.
that do not heal or Lifestyle and Health Practice
disappear? Describe Question Rationale
their appearance and Do you smoke or chew Tobacco use increases
location. tobacco? If yes, how the risk of head and
much? neck cancer.

Do you wear a helmet Failure to nse safety • However, explain she will be requested to
when riding a horse, precantions increases move and bend the neck for examination of
bicycle, motorcy-cle, or the risk for head and muscles and for palpation of the thyroid gland.
other open sports neck injury (see Promote Be aware that some clients may be anxious as
vehicle (e.g., four- Health Traumatic Brain
you palpate the neck for lymph nodes,
wheeler, go-cart)? Do Injury for more
you wear a hard hat for information). especially if they have a history of cancer that
hazardous occupations? caused lymph node enlargement.
What is your typical Poor posture or body • Tell the client what you are doing and share
posture when relaxing, alignment can lead to your assessment findings
during sleep, and when or exacerbate head • Equipments: Gloves, small cup of water,
working? and neck discomfort. stethoscope
In what kinds of Contact or aggressive
recreational activity do sports may increase the
you participate? risk for a head or neck
Describe the activity. injury.
Have any problems with Head and neck pain
your head or neck may interfere with
interfered with your relationships or prevent
relationships with others clients from completing
or the role you occupy their usual activities of
at home or at work? daily living.
COLLECTING OBJECTIVE DATA:

PHYSICAL EXAMINATION
• This examination can detect head and facial
shape abnormalities, asymmetry, structural
changes, or tenderness.
• Assessment of both the head and neck assists
the nurse to detect enlarged or tender lymph
nodes.
• Thyroid enlargement, nodules, masses, or
tenderness may be detected by palpating the
thyroid gland. Palpation may also detect
abnormalities of the neck and facial muscles.
PREPARING THE CLIENT

• Prepare the client for the head and neck
examination by instructing him or her to
remove any wig, hat, hair ornaments, pins,
rubber bands, jewelry, and head or neck
scarves.
• Take care to consider cultural norms for touch
when assessing the head. Some cultures
prohibit touching the head or touching the feet
before touching the head (Purnell & Paulanka,
2003).
• Another important thing to keep in mind as you
examine the head and neck is that normal
facial structures and features tend to vary
widely among individuals and cultures.
• Ask the client to sit in an upright position with
the back and shoulders held back and straight.
Explain the importance of remaining still during
most of the inspection and palpation of the
head and neck.


ASSESSMENT OF THE EYES
History
Chief complaint / Present Illness
• Visual difficulties, injury, squinting, strabismus,
diplopia, redness, swelling, itching, watering,
discharge, glaucoma, cataracts
Past Medical History
• Surgeries / trauma
• Medications
• Allergies
• Vision testing / results / glasses
• Chronic conditions such as diabetes,
hypertension
• Prematurity
Family History
• Color blindness, cataracts, glaucoma,
allergies, macular degeneration, allergies
Personal / Social
• Employment exposure to gasses, machinery,
foreign bodies
• Competitive sports, use of protective gear
• Glasses, contact lens
• Premature birth, birth without medical care
ASSESSMENT OF THE EYE

• Observation of external structures
• Visual acuity testing
• Examination of eye
o Eye movements, alignment
▪ EOMs (Extra Ocular Muscles)
▪ Cover test
o Pupil reaction
o Red reflex
▪ Corneal light reflex
o Internal inspection of the eye
• External structures
o Symmetry
▪ Orbit
▪ Eyebrows

▪ Movement VISUAL ACUITY
o Clarity / color Newborn 20/400
▪ Sclera • Brief fixation
▪ Iris • Limited binocular vision
▪ Conjunctiva 6 Months
▪ Lens • 20/100
• Symmetry of eyes, lids, • Binocular vision
eyebrows • Color vision near adult
• Placement of eyes in 4 Years
relation to ears • 20/50
• Inspect • Need large print books for near vision
▪ Orbit 7 Years
▪ Conjunctiva • 20/20
▪ Sclera
Newborns Color vision deficit should be
- Sclera is bluish / white tested before school entry
• Jaundice with hyperbilirubinemia • 8% Caucasian males
• Sclera hemorrhage due to birth • 4% African American males
pressure • 0.4%-1% females ISHIHARA TEST
- Iris is usually dusky blue
• Changes between 3 and 6 months Alignment
- Congenital cataracts, glaucoma, infection • Esotropia - Eye turning inward
possible • Exotropia - Eye turning outward
- Inspect for position, color, condition of the • Hypertropia - one eye is deviated upwards
surface, condition and direction of eyelashes, • Hypotropia - one eye is deviated downwards
and the client’s ability to open, close and
blink.
- Margin, and are usually associated with
aging, edema from drug allergy or systemic
disease (kidney disease), congenital lid
muscle dysfunction, neuromuscular disease
(myasthenia gravis), and the third cranial
nerve impairment. NORMAL PUPILS
• Equal, round and about one fourth the size of
ECTROPION – eversion, an out-turning of the eyelid
the iris using normal room light
ENTROPION – inversion, an in-turning of the eyelid
• The normal pupil size in adults varies from 2.5
PTOSIS ECTROPION ENTROPION
to 6 mm in diameter in bright light to 4 to 8
mm in the dark.
• They constrict to direct illumination (direct
response) and to illumination of the opposite
eye (consensual response).
Eye movements (Extra Ocular Eye Movements • The pupil dilates in the dark. Both pupils
{EOM} constrict when the eye is focused on a near
• With the head still, can the eyes follow your object (accommodative response).
penlight or fingers? Do the eyes move • The pupil is abnormal if it fails to dilate to the
together and equally in all directions? dark or fails to constrict to light or
• Do the eyes twitch (nystagmus) when they accommodation.
move?
PUPILLARY REACTION: PERRLA
• Pupils
• Equally
• Round
• Reactive to

• Light and Opthalmoscope
• Accommodation • Used to check red reflex
• Used to see retina
GRADING PUPIL
Normal equal bright red reflexes
• Color pale yellow in newborn
• May be pale yellow in people
with dark skin pigmentssmen
t of the HEAD,ECK
EARS
Examination of ears: Pull the ears backward and
upward.
Instrument used: Otoscope
PUPILLARY REACTION ASSESSMENT • External ears: Crusts, discharges, lesions etc.
Have baseline assessment findings for comparison:
• Tympanic membrane: Normally it is shiny,
• Patient received medications that will either
translucent, with a pearl grey color. See for
constrict or dilate the pupils (Atropine/ valium)
any perforation, lesions, bulging.
• Patient’s previous eye surgery (cataract
removal)
WEBER'S TEST
• Patient may have normal unequal pupils or
• Hearing loss.
result from certain drugs (atropine)
Technique:
1. Strike the tuning fork lightly against your hand
MIOSIS – may indicate an inflammation of the iris or
2. Place a vibrating tuning fork in the midline of
result from such drugs as morphine or pilocarpine.
the persons skull and ask if he can hear the
Also an age-related change in older adults.
sounds same in both the ears or better in one
ANISOCORIA – unequal pupils may result from a
ear.
central nervous system disorder, however slight
Result : The person should hear the tone produced
variations may be normal.
by bone conduction equally in both ears, is the
positive test result
TO TEST FOR ACCOMMODATION
• Place your finger about 4”
(10cm) from the bridge of the
patient’s nose.
• Request to look at fixed object
at the distance and then look
at your finger.
• The patient’s eye should converge and pupils
should constrict RINNE TEST
• This is a test to compare the air conduction
ASSESSMENT OF THE EYE and the bone conduction sounds.
Red Reflex • Perform after Weber’s test
• Light shown into pupil at an angle reflects color 1. Strike the tuning fork lightly against your hand
of retina 2. Place the stem of the vibrating tuning fork on
• Abnormal lens (cataract), cornea (glaucoma), persons mastoid process and ask him or her to
or retina (retinoblastoma) will change red signal when the sound disappears note the
reflex time seconds.
3. Invert the tuning fork so the vibrating end is
near the ear canal he should hear the sound.
Note the time in seconds.
Results : AC : BC =2:1

ASSESSMENT OF THE EYES
EYE EXAMINATION
• Assessment of eye function through specific
vision tests
• Inspection of the external eye
Condition of the mucosa, septum and turbinate's. • Inspection of the internal eye
• Mouth: Examine the oral mucosa, the tongue
and teeth. PREPARING THE CLIENT
• Face: Evaluation of symmetry, smile, frown, and • Explain each vision test thoroughly to
jaw movement will provide information about guarantee accurate results.
motor divisions of cranial nerves V and VII. • For the eye examination, position the client so
she is seated comfortably.
• During examination of the internal eye with
the ophthalmoscope, you will move very close
to the client’s face to view the retina and
internal structures.
NECK: SPEND
• Explain in detail what will be done and answer
S – swelling questions of the client to relieve anxiety.
P – pulsations
E – enlargement- thyroid, lymph nodes EQUIPMENT NEEDED
N – neck masses • Snellen chart
D – distention • Hand - held card or near vision screener
• Penlight
NECK • Opaque cards
Palpate the neck with • Ophthalmoscope
emphasis on the salivary • Disposable gloves
glands, lymph nodes, and
thyroid. Look for tracheal VISUAL ACUITY
deviation. Identify the carotid ➢ DISTANCE VISION
arteries and auscultate for bruits. Normal Findings: Visual acuity of 20/20
Abnormal Findings:
LYMPH NODES - Myopia (near-sightedness)
Lymph nodes are assessed by - Amblyopia - permanent loss of
palpating with the pad of the finger visual acuity resulting from
for enlargement, tenderness and strabismus
mobility.
Normally nodes are not palpable. If ➢ NEAR VISION
palpable they should be small, Normal Findings: Normal near visual acuity is 14/14
mobile, smooth and non tender. (with or without corrective lenses).
Abnormal Findings:
Thyroid: palpation for size, - Presbyopia (impaired near vision) is indicated
symmetry tenderness and when the client moves the chart away
nodules. - Hyperopia difficulty seeing up close
Trachea: Palpation for alignment ➢ COLOR VISION

and position: unequal space Normal Findings: identify all six screening color
between trachea and plates correctly has normal color vision.
sternocleidomastoid muscle on Abnormal Findings: The color vision defect is
each side is abnormal, indicative designated as red/green, blue/yellow or complete
of trachea displacement. when the patient sees only shades of gray.
Palpate one carotid artery at a time just below

the upper border of the thyroid cartilage.

VISUAL FIELDS NYSTAGMUS
➢ CRANIAL NERVE II - involuntary movement and returning to the
Normal Findings: The patient who is able to see the center after each field is tested.
stimulus at about 90 degrees temporally, 60 Abnormal Findings: Abnormal eye movements
degrees nasally, 50 degrees superiorly and 70 consist of failure of an eye to move outward
degrees inferiorly. (CNVI), inability of the eye to move downward
when deviated inward (CNIV) or other defects in
EXTRAOCULAR MUSCLE FUNCTION movement (CNIII)
➢ CORNEAL LIGHT REFLEX (HIRSCHBERG
TEST)
Normal Findings: The reflected light (light reflex)
should be seen symmetrically in the center of each
cornea.
Abnormal Findings: Light reflections noted on
different areas on both eyes
PSEUDO STRABISMUS EXTERNAL EYE STRUCTURE

Normal in young children, the pupils will appear at ➢ EYELIDS & EYELASHES
the inner canthus. Normal Findings:
- Symmetrical with no drooping, infections or
tumors of the lids.
- When the eyes are focused in a normal frontal
gaze, the lids should cover the upper portion of
EXTRAOCULAR MUSCLE FUNCTION the iris.
➢ COVER – UNCOVER TEST (FOR ABNORMAL - Can raise both eyelids symmetrically (CNIII)
EYE MOVEMENT) - When the eye is closed, no portion of the
Normal Findings: cornea should be exposed.
- Uncovered eye does not move as opposite - Normal lid margins are smooth with the lashes
eye is covered evenly distributed and sweeping upward from
- Covered eye does not move as cover is the upper lids and downward from the lower
removed lids.
- Eyebrows are present bilaterally and are
symmetrical and without lesions or scaling
➢ EYELIDS
Abnormal Findings:
Abnormal Findings: 1. Ptosis drooping of the upper lid
- Phoria - misalignment
that occurs only when
fusion reflex is blocked
- Strabismus - constant 2. Lagophthalmos inability to close the eyelids
misalignment of the completely
eyes.
- Esotropia – eye turns inward
- Exotropia – eyes turns outward
3. Exophthalmos protrusion of the eyeballs
➢ Cardinal Fields of Gaze (Extraocular accompanied by retracted eyelid margins
Muscle Movements)
Normal Findings: Both eyes should
move smoothly an symmetrically in
each of the six fields of gaze and 4. Entropion – inverted lower lid
convergence on the held object as
it moves toward the nose.

5. Ectropion everted lower eyelid - There should be no excessive tearing or
discharge from the punctum. (palpation)
➢ CORNEA AND LENS

Normal Findings:
6. Hordeolum a hair follicle infection - Cornea and lens are transparent with no
opacities. The oblique view shows a smooth
and overall moist surface; lens is free of
opacities
- Arcus senilis among elderly clients - white arc
7. Chalazion an infection of around the limbus.
the meibomian gland,
Abnormal Findings:
Abnormal Findings: - Areas of roughness or dryness on the cornea
Color changes : are often associated with injury or allergic
• Redness – redness in the nasal half may responses.
indicate frontal sinusitis - Opacities of the lens are seen with cataracts.
• Bluish – cyanosis can result from orbital vein
thrombosis, tumor or aneurysm ➢ IRIS
• Black and Blue – ecchymosis is caused by Normal Findings:
bleeding into the surrounding tissue following - The color is evenly distributed over the iris,
trauma (black eye) although there can be a mosaic variant
- It is normally smooth and without
➢ CONJUNCTIVA apparent vascularity.
Normal Findings: The bulbar conjunctiva is Abnormal Findings: There is a heavily
transparent with small blood vessels visible in it. No pigmented, slightly elevated area
swelling, injection, exudates, foreign bodies or visible in the iris.
lesions are noted.
Abnormal Findings: ANTERIOR SEGMENT STRUCTURES
- Episcleritis - local non-infectious inflammation ➢ PUPIL
of the sclera Normal Findings:
- The palpebral conjunctiva - Pupil, round with a regular border, is centered
should appear pink and in the iris.
moist. It is without swelling , - Pupils are normally equal in size (3 to 5 mm).
lesions, injection, exudates or - PERRLA
foreign bodies. • Anisocoria
➢ SCLERA
Normal Findings:
- In light skinned individuals, the sclera should be ABNORMAL FINDINGS:
white with some small, superficial vessels and Mydriasis Miosis
without exudates, lesions or foreign bodies.
- In dark-skinned individuals, the sclera may
have tiny brown patches of melanin or grayish
blue or “muddy” color.
Abnormal Findings: Uniformly yellow- jaundice.
INTERNAL EYE STRUCTURE
➢ LACRIMAL APPARATUS ➢ RETINAL STRUCTURES
Normal Findings: Normal Findings:
- There should be no - Red reflex is present
enlargement, swelling or - The optic disc is pinkish in color.
redness, no large amount of Abnormal Findings: The optic disc is pale, due to
exudates and minimal tearing. optic atrophy caused by increased ICP
(inspection)

➢ MACULA
Normal Findings: The macula is a darker,
avascular area with a pinpoint reflective center
(fovea centralis)
Abnormal Findings: The retina is pale with the
macular region appearing as a cherry-red spot
(Tay-Sach’s disease)
SAMPLE OBJECTIVE DATA

• Acuity tested by snellen chart: O.D. 20/20, O.S.
20/20.
• Visual fields full by confrontation.
• Corneal light reflex shows equal position of
reflection.
• Eyes remain fixed throughout the cover test.
• Extraocular movements smooth and symmetric
with no nystagmus.
• Eyelids in normal position with no abnormal
widening 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. Cholesteatoma
Actual Diagnoses Abnormal skin growth or epithelial
- Ineffective Health Maintenance related to lack cyst in middle ear that usually
of knowledge of necessity for eye results from repeated ear infections
examinations.
- Acute Pain related to injury from eye trauma, Perforation
abrasion, or exposure to chemical irritant. Hole in tympanic membrane
caused by chronic negative
middle ear pressure,
ASSESSMENT OF THE EARS
inflammation, or trauma
Physical Assessment of the Ear Return Demo

Checklist
Introduction
1. Appropriate introduction including name and
role
2. Obtain verbal consent. Briefly explain to the
client what the examination involves.
3. Wash hands or use alcohol gel
Earache 4. Position and adequately expose patient
Earches usually result from disorders of the external 5. Ask for any deafness? If so -Manage
and middle ear and are associated with infection, Communication
hearing loss, and otorrhea.
History taking
Hearing Loss 1. History taking, enquire about pain, hearing loss
Several factors can interfere with the ear’s ability to and dizziness before proceeding
conduct sound waves. Cerumen, a foreign body, The following issues should be included:
or a polyp may obstruct the ear canal. Otitis media • Classic symptoms of ear disease: deafness,
may thicken the fluid in the middle ear, which tinnitus, discharge (otorrhoea), pain (otalgia)
interferes with the vibrations that transmit sound. and vertigo.
Otosclerosis, a hardening of the bones in the • Previous ear surgery, or head injury.
middle ear, also interferes with the transmission of • Family history of deafness.
sound vibrations. Trauma can disrupt the middle • Systemic disease (eg, stroke, multiple sclerosis,
ear’s bony chain. cardiovascular disease).
• Ototoxic drugs (antibiotics (eg, gentamicin),
Otitis Media diuretics, cytotoxics).
Inflammation of the middle ear, results from • Exposure to noise (eg, pneumatic drill or
disruption of eustachian tube patency. It can be shooting). History of atopy and allergy in
suppurative or secretory, acute (as shown at the children.
picture) or chronic
External Ear Structures
• Inspect the auricle, tragus, and lobule for size
and shape, position, lesions/ discoloration,
and discharge.
• Palpate the auricle and mastoid process for
tenderness.
Otitis media with effusion

• Characterized by fluid in
middle ear that may not
cause symptoms
• May be acute, subacute, or
chronic

Examination of the Ear
Step 4: Examine the Tympanic Membrane

• Inspect the tympanic membrane, using the
otoscope for color and shape, consistency,
and landmarks
• Have client perform the Valsalva maneuver
Otoscopic Examination and observe the center of the tympanic
Step 1: Have the patient sit down membrane for a flutter. (Do not do this
• Have the patient sit down (May be best for the procedure on the older client, as it may
patient to sit on the desk so the ear is in a interfere with equilibrium and cause dizziness).
convenient position for the nurse)
• Have the patient slightly tilt his head away from Step 5: Examine parts of Middle Ear
the nurse • Look for the Malleus or the handle of the
• Start with the “good” ear – one without Malleus*, and note any abnormalities
problems or infections (if any) • May be obscured by debris or ear wax
Step 2: Holding the otoscope Hearing and Equilibrium Tests

• Hold the otoscope in one hand and turn on the - Perform the whisper test by having the
light client place a finger on the tragus of one
• Gently insert the speculum into the ear ear. Whisper a two syllable word 1 to 2 feet
• With the other free hand, gently pull up, out, behind the client. Repeat on the other ear.
and/or forward on patient’s ear to straighten - Perform the Weber test by using a tuning
out the ear canal for easy viewing fork placed on the center of the head or
• The examiner holds the otoscope in one hand forehead and asking whether the client
and uses his or her free hand to pull the outer hears the sound better in one ear or the
ear gently up and back. This straightens the ear same in both ears.
canal and helps the nurse see inside the ear. Normal Response: If hearing is normal, the patient
• Hold the otoscope with 3 fingers and your will hear the sound equally on each side.
thumb and keep it parallel to the ground. This Abnormal Response:
will help prevent you from wrenching the - If the patient has a sensorineural hearing loss
instrument side to side, which could injure your (SNHL) in one ear, the sound will lateralize to the
patient. side of better hearing.
• In babies younger than 12 months, the - If the patient has a conductive hearing loss
examiner will gently pull the outer ear down (CHL) in one ear, the sound will lateralize to the
and back. side with the hearing loss.
• Use full brightness. - Perform the Rinne test by using a tuning fork
• Wait until the otoscope is fully inserted before and placing the base on the client's mastoid
looking through the instrument process. When the client no longer hears the
sound, note the time interval, and move it in
Step 3: Examine the External Canal front of the external ear. When the client no
• Examine the external ear canal and note any longer hears a sound, note the time interval.
abnormalities –discharge, color and Repeat the procedure with the other ear.
consistency of cerumen, color and consistency Normal Response: If the patient has normal
of canal walls, and nodules. hearing, s/he will hear it louder in front of the
external ear. (Air conduction of sound is louder
through air than bone. In the normal patient, the
external and middle ear system are unimpaired so

s/he will hear the sound better though air (glossopharyngeal), and XII (hypoglossal) assist
conduction.) with some of these functions.
Abnormal Response: ➢ The NOSE AND PARANASAL SINUSES constitute
- If the patient has a sensorineural hearing loss the first part of the respiratory system and are
(SNHL), s/he will hear the sound better in front responsible for receiving, filtering, warming,
of the ear canal just as in the normal response. and moistening air to be transported to the
Since the hearing loss is because the inner ear lungs.
or cochlear nerve is less able to transmit
impulses regardless of how the vibrations reach MOUTH
the cochlea, the normal pattern prevails - air ➢ The MOUTH OR ORAL CAVITY is formed by the
conduction is still louder. lips, cheeks, hard and soft palates, uvula, and
- If the patient has a conductive hearing loss the tongue and its muscles.
(CHL), s/he will hear the sound louder on the ➢ The MOUTH is the beginning of the digestive
mastoid process. Pathways of normal air tract and serves as an airway for the respiratory
conduction through the external and middle tract.The upper and lower lips form the
ear are blocked. Vibrations through bone entrance to the mouth and serve as a
bypass the obstruction to reach the cochlea protective gateway to the digestive and
and are perceived as louder respiratory tracts.
ABNORMAL WEBER RINNE ➢ Contained within the mouth are the tongue,
Conductive Louder on side Louder on teeth, gums, and the openings of the salivary
hearing loss with hearing bone glands (parotid, submandibular, and
loss sublingual).
Sensorineural Louder on Louder in front
hearing loss opposite side (as a normal
THROAT
response)
➢ The THROAT (PHARYNX), located behind the
mouth and nose, serves as a muscular passage
HEARING AND EQUILIBRIUM TEST for food and air.
➢ The upper part of the throat is the
NASOPHARYNX. Below the nasopharynx lies the
OROPHARYNX, and below the oropharynx lies
the LARYNGOPHARYNX.
➢ The soft palate, anterior and posterior pillars,
and uvula connect behind the tongue to form
arches. Masses of lymphoid tissue referred to as
the palatine tonsils are located on both sides of
Perform the Romberg test to evaluate equilibrium. the oropharynx at the end of the soft palate
With feet together and arms at the side, close eyes between the anterior and posterior pillars
for 20 seconds. Observe for swaying. ➢ The lingual tonsils lie at the base of the tongue.
Pharyngeal tonsils or adenoids are found high
ANALYSIS OF DATA in the nasopharynx. Because tonsils are masses
- Formulate nursing diagnoses (wellness, risk, of lymphoid tissue, they help protect against
actual) infection.
- Formulate collaborative problems.
- Make necessary referrals.
ASSESSMENT OF THE MOUTH AND THROAT
MOUTH AND THROAT STRUCTURE AND FUNCTION

➢ The MOUTH AND THROAT make up the first part
of the digestive system and are responsible for
receiving food (ingestion), taste, preparing
food for digestion, and aiding in speech.
Cranial nerves V (trigeminal),VII (facial), IX
COLLECTING SUBJECTIVE DATA:
THE NURSING HEALTH HISTORY

IMPORTANCE
• Examination of the mouth and throat can help
the nurse to detect abnormalities of the lips,
gums, teeth, oral mucosa, tonsils, and uvula.
• This examination also allows for early detection
of oral cancer. Examination of the nose and
sinuses assists the nurse with detection of a
deviated septum, patency of the nose and
nasopharynx, and detection of sinus infection.
• In addition, assessment of the mouth, throat,
nose, and sinuses provides the nurse with clues
to the client’s nutritional and respiratory status.
• Detection of impaired oral mucous
membranes or a poor dental condition may
require a change in the client’s diet.
• Additional mouth care may be needed to
facilitate ingestion of food or to prevent
infection of the gums (gingivitis).
• Detection of nasal septal deviation may help
the nurse to determine which nostril to use to
insert a nasogastric tube or how to suction a
client.
• In addition, assessing for nasal obstruction may
explain the reason for mouth breathing.
PREPARING THE CLIENT

➢ Ask the client to assume a sitting position with
the head erect. It is best if the client’s head is
at your eye level.
➢ Explain the specific structures you will be
examining, and tell the client who wears
dentures, a retainer, or rubber bands on braces
that they will need to be removed for an
adequate oral examination.The client wearing
dentures may feel embarrassed and
concerned about his or her appearance and
over the possibility of breath odor on removing
the dentures. A gentle, yet confident and
matter-of-fact approach may help the client
to feel more at ease.

EQUIPMENT
• Gloves (wear gloves when examining any
mucous membrane)
• 4x4-inch gauze pad
• Penlight
• Short, wide-tipped speculum attached to the
head of an otoscope
• Tongue depressor
• Nasal speculum
ABNORMALITIES
PHYSICAL ASSESSMENT • Red, swollen gums that bleed easily are seen in
When preparing to examine the gingivitis, scurvy (vitamin C deficiency), and
nose and mouth, leukemia.
➢ Be able to identify and • Receding red gums with loss of teeth are seen
understand the relationship in periodontitis.
among the structures of the • Enlarged reddened gums (hyperplasia) that
mouth and throat, nose, and sinuses. may cover some of the normally exposed teeth
➢ Know age-related changes of the oral cavity may be seen in pregnancy, puberty, leukemia,
and nasal and sinus structures. and use of some medications, such as
➢ Be aware of ethnocultural phenomena related phenytoin.
to oral and nasal health. • A bluish-black or grey-white line along the gum
➢ Refine examination techniques line is seen in lead poisoning
LEUKOPLAKIA KOPLIK’S SPOTS
HERPES SIMPLEX TYPE I
CHEILOSIS OF LIPS
CARCINOMA OF LIP

ASSESSMENT OF THE NOSE AND SINUSES
STRUCTURES AND FUNCTIONS

The NOSE AND PARANASAL SINUSES constitute the
first part of the respiratory system and are
responsible for receiving, filtering, warming, and
moistening air to be transported to the lungs.
NOSE
➢ The nose consists of an external portion
covered with skin and an internal nasal cavity.
It is composed of bone and cartilage and is
lined with mucous membrane.
➢ The external nose consists of a bridge (upper
portion), tip, and two oval openings called
nares.
➢ The nasal cavity is located between the roof of
the mouth and the cranium. It extends from the
anterior nares (nostrils) to the posterior nares,
which open into the nasopharynx.
➢ The nasal septum separates the cavity into two
halves. The front of the nasal septum contains
a rich supply of blood vessels and is known as
Kiesselbach’s area. This is a common site for
nasal bleeding.
SINUSES
➢ Four pairs of paranasal
sinuses (FRONTAL,
MAXILLARY,
ETHMOIDAL, AND
SPHENOIDAL) are
located in the skull. These air-filled cavities
decrease the weight of the skull and act as
resonance chambers during speech.

➢ The PARANASAL SINUSES are also lined with ASSESSMENT
ciliated mucous membrane that traps debris INSPECTING THE NOSE
and propels it toward the outside. 1. Observe the patient’s nose for position,
➢ The sinuses are often a primary site of infection symmetry, and color. Note variations, such as
because they can easily become blocked. discoloration, swelling, or deformity. Variations
➢ The FRONTAL SINUSES (ABOVE THE EYES) AND in size and shape are largely caused by
THE MAXILLARY SINUSES (IN THE UPPERJAW) are differences in cartilage and in the amount of
accessible to examination by the nurse. fibroadipose tissue.
➢ The ETHMOIDAL AND SPHENOIDAL SINUSES are 2. Observe for nasal discharge or flaring. If
smaller, located deeper in the skull, and are discharge is present, note the color, quantity,
not accessible for examination. and consistency. If you notice flaring, observe
for other signs of respiratory distress.
COLLECTING SUBJECTIVE DATA: 3. Then inspect the nasal cavity. Check patency
THE NURSING HEALTH HISTORY by occluding one nostril and asking the
patient to breathe in through the other nostril.
Repeat on the other side.
4. Examine the nostrils by direct inspection using
a nasal speculum, a penlight or small
flashlight, or an otoscope with a short, wide-tip
attachment.
INSPECTING THE NASAL CAVITY

• To inspect the nose, ask the patient to tilt his
head back slightly, and then push up the tip
of the nose and gently insert the otoscope.
• Use the light from the otoscope to illuminate
the nasal cavities. Check for severe deviation
or perforation of the nasal septum. Examine
the vestibule and turbinate for redness,
softness, swelling, and discharge.
INSPECTING THE NOSTRILS

• Have the patient sit in front of you with his
head tilted back. Put on gloves and insert the
tip of the closed nasal speculum into one
nostril to the point where the blade widens.
Slowly open the speculum as wide as possible
without causing discomfort, as shown. Shine
the flashlight in the nostril to illuminate the
area.
’
• Observe the color and patency of the nostril,
and check for exudate. The mucosa should
be moist, pink to light red, and free from
IMPORTANCE
lesions and polyps. After inspecting one nostril,
• Full nose examinations assess the function,
close the speculum, remove it, and inspect
airway resistance and occasionally sense of
the other nostril.
smell.
• Common symptoms of nasal disease include:
PALPATING THE NOSE
➢ Airway obstruction.
Palpate the patient’s nose with your thumb and
➢ Rhinorrhea (runny nose).
forefinger, assessing for pain, tenderness, swelling,
➢ Sneezing.
and deformity.
➢ Loss of smell (anosmia).
➢ Facial pain caused by sinusitis.
➢ Snoring (associated with nasal obstruction)

EXAMINING THE SINUSES
ASSESSMENT OF THE THORACIC AND LUNG
• Begin by checking for swelling around the
eyes, especially over the sinus area. Then Complete examination consists of inspection,
palpate the sinuses, checking for tenderness. palpation, percussion, and auscultation of the
• If the patient complains of tenderness during posterior and anterior thorax
sinus palpation, transilluminate the sinuses to
see if they’re filled with fluid or pus. ➢ Have the client remove all clothing from the
Transillumination can also help reveal tumors waist up and put on an examination gown or
and obstructions. drape.
• To perform transillumination, darken the room ➢ Explain the procedure before initiating the
and have the patient close his eyes. Place a examination
penlight under the eyebrow and direct the ➢ The patient must sit in an upright position with
light upward to illuminate the frontal sinuses. arm relaxed at the sides.
Place the penlight on the patient’s ➢ Make sure that the room temperature is
cheekbone just below the eye and ask the comfortable for the client.
patient to open his mouth. A red glow inside
the oral cavity indicates normal maxillary Equipments needed
sinuses. Examination gown and drapes
Stethoscope Light source
Mask Skin marker
PALPATING THE MAXILLARY SINUSES
Metric ruler Gloves
• To palpate the maxillary sinuses, gently press
your thumbs on each side of the nose just • Provide privacy for the client
below the cheekbones. • Keep your hands warm
• Remember, only the frontal and maxillary • Remain nonjudgmental about client’s habits
sinuses are accessible; you won’t be able to and lifestyle
palpate the ethmoidal and sphenoidal
sinuses. Inspect:
• For nasal flaring and pursed lip breathing
FUNCTIONAL EXAMINATION OF NOSE • Color and shape of nails
• PATENCY OF NOSE: • Observe color of face, lips, and chest
- Spatula test: By placing a cold tongue depressor
below the nostril to look for the area of mist Inspect for shape and configuration, position of
formation. Compare the two sides always. sternum, slope of ribs, intercostal spaces
- Cotton wool wisp test: Fluff of cotton is held Normal:
against each nostril and its movements are • The ratio of anteroposterior diameter to the
noticed when patient inhales and exhales. transverse diameter is 1:2
• SENSE OF SMELL: Ask the patient to identify the • Sternum is positioned at midline and straight
smell of the solutions held before the nostril • Retractions not observed
while keeping the eyes closed. Each nostril is • Ribs slope downward with symmetric
tested separately. Common substances used: intercostal spaces. Costal angle is within 90°
Clove oil, peppermint, coffee and essence of • No retractions or bulging of intercostal spaces
rose.
Observe quality and pattern of respiration, use of
NOSE ABNORMALITIES accessory muscles
Normal:
• Respirations are relaxed, effortless and quiet.
• 10-20 cycle per min in adult.
• Use of accessory muscles is not seen with
normal respiratory effort.
• After strenuous exercise or activity, individuals
with normal respiratory status may use neck
muscles for a short time to enhance breathing

Palpate for fremitus; anterior chest expansion • Listen at each site for at
Normal: Fremitus is symmetrical and easily least one complete
identified in the upper regions of the lungs. A respiratory cycle.
decrease intensity of fremitus is expected toward
the base of the lungs; • B = bronchial sounds
• V = vesicular sounds
Palpate for tenderness, sensation • BV = bronchovesicular
Normal: No tenderness or pain is palpated over sounds
the lung area
• Inspect the scapulae and chest wall
Palpate the surface masses configuration
Normal: No unusual surface masses or lesions are • Observe for use of accessory muscles and
palpated assess chest expansion
• Inspect client’s positioning
Assess for crepitus as you would on the posterior o While the patient sits with her arms at the
thorax side, stand behind her
Normal: No crepitus is palpated o Note the client’s posture and his ability to
support weight while breathing
PERCUSS FOR TONE comfortably
Normal: Resonant, dull, flat, and typanitic in
appropriate areas Palpate for tenderness and sensation.
Normal: Client reports no tenderness,
NORMAL PERCUSSION TONES pain, or unusual sensations.
Temperature should be equal
bilaterally
Palpate for Crepitus.

Palpate surface characteristics.
Normal: Skin and subcutaneous tissue are free of
lesions and masses
Fremitus is symmetric and easily identified

It is not palpable on either side, the client may
need to speak louder.
Auscultate for anterior breath sounds, adventitious A decrease in the intensity of fremitus is normal as
sounds, and voice sounds the examiner moves toward the base of the lungs.
• Place the diaphragm of the stethoscope firmly
and directly on the anterior chest wall. Assess chest expansion.
• Auscultate from the apices of the lung slightly Normal: When the client
above the clavicles to the bases of the lungs takes a deep
at the 6th rib. breath, the examiner’s
• Ask the client to breathe deeply through his thumbs should move 5-10
mouth in an effort to avoid transmission of cm apart symmetrically
sounds that may occur with nasal breathing.
• Be alert of the client’s comfort and offer times Percuss for tone.
to rest and normal breathing if fatigue is Normal: Resonant and Flat tones in appropriate
becoming a problem particularly for the older areas
clients.

Percuss for diaphragmatic excursion. Bronchophony: ask the client to repeat
Normal: Excursion should be equal bilaterally and the phrase “99” while you auscultate the
measure 3- 5cm in adults chest wall
o The level of the diaphragm Normal: Voice transmission is soft, muffled and
may be higher on the right indistinct. The sound of the voice may heard but
o In well-conditioned clients, the actual phrase cannot be distinguished
excursion can measure up
to 7-8 cm Egophony: ask the client to repeat the
letter “E” while you listen over the chest
Auscultate for breath sounds, adventitious sounds wall
Normal: Normal: Voice transmission will be soft and
o Breath sounds are muffled but the letter “E” should be
considered distinguishable
o normal only in the area
specified. Whispered Pectoriloquy: ask the client to whisper
o Heard elsewhere, they are the phrase “1-2-3” while auscultating the chest
considered abnormal sounds wall
o Sometimes breath sounds may be hard to Normal: Transmission of sound is very faint and
hear with obese or heavily muscled clients muffled. It may be inaudible
Normal: No adventitious sounds, such as crackles

or wheezes
ABNORMAL CHARACTERISTICS SOURCE ASSOCIATED CONDITION

SOUNDS
Discontinous High pitched, short popping Inhaled air suddenly Crackles occurring late in
Sounds: sound heard during inspiration opens the small inspiration are associated with
a. Fine and not cleared with coughing; deflated air passages restrictive disease such as
Crackles sounds are discontinuous and that are coated and pneumonia and CHF. Crackles
can be stimulated by rolling a sticky with exudates occurring early in inspiration are
strand of hair between your associated with obstructive
fingers near your ear. disorders such as bronchitis,
asthma, or emphysema
b. Coarse Low-pitched bubbling, moist Inhaled air comes into May indicate pneumonia,
Crackles sounds that may persist from contact with pulmonary edema and
early inspiration to early secretions in the large pulmonary fibrosis, also in COPD
expiration; also described as bronchi and trachea
softly separating velcro
Continous Low pitched, dry, grating Sound is the result of Pleuritis
Sounds: sound; sound is much like rubbing of two
a. Pleural crackles, only more superficial inflamed pleural
Friction and occurring during both surfaces
Rub inspiration and expiration
b. Wheeze High pitched, musical sounds Air passes through Sibilant wheezes are often
(Sibilant) heard primarily during constricted passages heard in cases of acute asthma
expiration but may also be (caused by swelling or chronic emphysema
heard on inspiration secretions, or tumor)
c. Wheezes Low pitched snoring or Same as sibilant Sonorous wheezes are often
(Sonorous) moaning sounds heard primarily wheezes. The pitch of heard in cases of bronchitis or
during expiration but may be the wheezes cannot single obstructions and snoring
heard throughout the be correlated to the before an episode of sleep
respiratory cycle. These size of the passage apnea.
wheezes may clear with way that generates it. Stridor is a harsh honking
coughing wheeze
with severe
broncholaryngospasm,
such as occurs with croup

RESPIRATION PATTERN • Vesicular breath sounds auscultated over lung
TYPE DESCRIPTION CLINICAL fields
INDICATION • No adventitious sounds present
Normal 12-20/min and Normal breathing
regular pattern
Wellness Diagnoses
Tachypnea >24/min and Normal breathing
shallow pattern • Readiness for enhance breathing pattern
Bradypnea <10/min May be a normal • Health-seeking behaviour: requests
and regular response to fever, information on TB skin testing, how to quit
anxiety or exercise
Can occur with smoking, or on exercise to improve respiratory
respiratory status
insufficiency, alkalosis,
pneumonia or pleurisy
Risk Diagnoses
Hyper Increase May be normal in well
ventilation rate and conditioned athletes • Risk for respiratory infection related to
increased depth Can occur with exposure to environmental pollutants and lack
medication induced of knowledge of precautionary measures
depression of the
• Risk for activity intolerance related to
respiratory center,
diabetic coma, imbalance between oxygen supply and
neurologic damage demands
Hypo Decrease rate, Usually occurs in • Risk for imbalanced nutrition: less than body
ventilation decreased extreme exercise, fear
depth, irregular or anxiety
requirements related to fatigue secondary to
pattern Kausmaul’s respiration dyspnea
are a type of • Risk for ineffective health maintenance
hyperventilation related to lack of knowledge of condition,
associated with
diabetic infection transmission, and prevention of
ketoacidosis. recurrence
Disorders of the CNS, • Risk for impaired oral mucous membranes
overdose of ASA,
related to mouth breathing
severe
anxiety Actual Diagnoses
Chyne- Regular pattern May result from severe • Anxiety related to dyspnea and fear of
Strokes characterized by CHF, drug suffocation
respiration alternating overdosage, inc. ICP,
periods of deep, RF
• Activity intolerance related to fatigue
rapid breathing May be noted in secondary to inadequate oxygenation
followed by elderly persons during • Ineffective airway clearance related to
periods of apnea sleep, not inability to clear thick, mucous secretions
related to any disease
process secondary to pain and fatigue
Biot’s Irregular pattern May be seen with • Impaired gas exchange related to chronic
respiration characterized by meningitis or severe lung tissue damage secondary to chronic
varying depth brain
smoking
and rate of damage
respirations • Ineffective airway clearance related to
followed by bronchospasm and increased pulmonary
periods of secretions
apnea
• Ineffective breathing pattern: hyperventilation
related hypoxia and lack of knowledge of
Objective Datas
controlled breathing techniques
• Respitrations 18 cpm, relaxed and even
• Disturbed sleep pattern related to excessive
• Antero posterior less than transverse diameter
coughing
• Chest expansion symmetric
• Impaired gas exchange related to poor
• No retracting or bulging of intercostals spaces
muscle tone and decreased ability to remove
• No tenderness noted on palpation
secretions secondary to the aging process
• Tactile fremitus symmetric. Percussion tones
resonant over all lung fields
• Diaphragmatic excursion 4cm and equal
bilaterally

• Occupational exposure
ASSESSMENT OF THE THORAX AND LUNGS
• Allergens & environmental pollutants
RESPIRATORY SYSTEM CARDIOVASCULAR SYSTEM • Activities
Exchange of gases Transport of gases • Age-related changes
GENERAL CONSIDERATIONS DYSPNEA

• Obtain a consent for assessment. - Difficult or
• The patient must be properly undressed and labored breathing
gowned for this examination. - Shortness of
• Ideally the patient should be sitting on the end breath (SOB)
of an exam table.
• The examination room must be quiet to TYPES OF DYSPNEA
perform adequate percussion and 1. Exertional Dyspnea
auscultation. - most common
• The nurse usually examine the posterior thorax - occurs with physical exertion and relieved by
first followed by anterior thorax. rest
• For POSTERIOR THORAX client is uncovered to - occurs when the body uses more oxygen and
the waist and in SITTING POSITION. makes more carbon dioxide – during exercise
• For ANTERIOR THORAX client is either on or physical acitvity
SITTING or LYING POSITION. 2. Sudden Dyspnea
• In examining the thorax, there are two - pneumothorax, airway obstruction, arf, ards,
important factors the nurse should know or pulmunary embolism
3. Orthopnea
A. The nurse should know how to locate the - SOB when in reclining/lying position
CHEST LANDMARKS. - relieved by sitting up
B. The nurse should know how to locate the - heart disease or COPD (chronic obstructive
INTERCOSTAL SPACES pulmonary disease)
CHEST LANDMARKS INTERCOSTAL SPACES 4. Dyspnea with Wheezes
- asthma or COPD
- due to bronchoconstriction
5. PND (Paroxysmal Nocturnal Dyspnea)
- SOB (shortness of breath) with sudden onset
- occurs during sleep or at night
- awakens patient with feeling of suffocation
General Nursing Assessment
- relieved by sitting up
1. Health History
- heart failure
2. Physical Assessment
3. Laboratory / Diagnostic Examinations
• Visible sternocleidomastoid
4. Medications
contractions
• Hyperexpansion of the
Health History
chest (Increased AP
Reasons for seeking health care
diameter)
1. Dyspnea
• Anxious appearance
2. Cough
• Circumoral cyanosis
3. Sputum Production
• Suprasternal retractions
4. Chest Pain
• Intercostal retractions
5. Wheezing
• Sitting posture with body slightly bent forward
6. Hemoptysis
7. Cyanosis
What to assess….
8. Clubbing of fingers
• Acute or chronic
Risk Factors • Progressive, recurrent or paroxysmal
• Associated with cough, fever, chills or night
• Smoking
sweats
• Personal / Family History

• At rest or with exertion • Salty taste, burning or bubbling sensation
• Sudden or gradual before bleeding
• Relieved by any intervention • Associated with certain circumstances or
• Worse when upset activities
• Any changes in body weight • History of chest trauma
• Related to activities Sudden, intermittent or continuous
Cough Cyanosis
• Dry, hacking or wheezy • Due to inadequate amount of oxygen in the
• Productive? – color, consistency, odor & blood
amount • Appears when Hgb level = 5 g/dl
• Particular time/event • Central or Peripheral
• Smoking history/ past medical illness
• Recent or gradual ASSESSMENT OF CHEST AND LUNGS
• Strong or weak C - Chest wall asymmetry and chest lag
R - Respiratory rate and pattern
Sputum Production A - Accessory muscle use and retractions
• Increased production M - Mottling
- profuse or small in amount M - Masses or scars
• Purulent, rusty, bloody, frothy or mucoid Thick P - Paradoxical movement
(tenacious) or thin I - Inspecting related structures
• Offensive odor/ foul-smelling S - Spinal alignment
➢ Profuse Purulent Thick (yellowish, greenish or CHEST-WALL ABNORMALITIES

rusty-colored) – Bacterial Infection NORMAL
➢ Profuse, frothy, pink – Pulmonary Edema • Thorax is oval
➢ Thin, mucoid – Viral Bronchitis • Anteroposterior diameter = 1/2 of transverse
➢ Pink-tinged mucoid – Lung Tumor diameter
➢ Foul- smelling – Lung Abscess or Bronchiectasis ABNORMAL
• Pigeon chest (pectus carinatum)
Chest Pain - Permanent deformity, may be caused
• Intermittent or persistent by rickets (Vit. D deficiency)
• Localized or radiating • Funnel chest (pectus excavatum)
• intensity - Congenital defect, sternum is
• Sharp, dull, tabbing or aching depressed
• Relieved by any interventions • Barrel chest
• Smoking history & environmental exposure - anteroposterior diameter = transverse
• Effects on respiration diameter (1:1)
• Past medical history - indicates chronic breathing problem
• Kyphosis - excessive convex curvature of the
Wheezing thoracic spine
• Scoliosis - lateral deviation of the spine
• High-pitched, musical sound heard mainly on
expiration
Palpation
• Common in patient with bronchoconstriction
• Painful areas or masses
or airway narrowing
• Chest & Diaphragmatic Excursion
• Loud or soft
• Tactile fremitus
• Expiratory or inspiratory
• Symmetrical chest excursion
• Abnormal: decreased in chronic fibrotic (lung
Hemoptysis
tissue) disease; asymmetrical in pleurisy
• Bright red or frothy
(inflamed pleura), chest trauma, bronchial
• URT, GIT or LRT
obstruction
• Amount
• Fremitus: normally louder near the large
bronchi
• Abnormal: absent (emphysema); increased - If the patient has abundant chest hair MAT it
(pneumonia) DOWN with a DAMPWASHCLOTH
- Listen to full inspiration and expiration.
Percussion Remember to compare the sound variations
• Percussion Sounds/Notes from one side to another
1. Resonance
2. Dullness Pitch (P) – high or low
3. Flatness Amplitude (A) – soft or low
4. Hyperresonance Duration (D) – length of time
• Resonance in normal lungs & simple chronic Quality (Q) – description
bronchitis Location (L) – place heard
• Flatness: Pleural effusion (water in the lungs) Timing (T) – early, late middle inspiration or
• Dullness: Lobar pneumonia expiration
• Tympany: Pneumothorax (collapsed lung) Intensity (I) – loud or soft
• Hyperresonance: Emphysema (damaged Density – profuse or scanty
alveoli)
NORMAL BREATH SOUNDS
Percussion reveals the BOUNDARIES of the lungs TRACHEAL
and helps to determines whether the lungs are P – relatively high
filled with AIR or FLUID or SOLID MATERIAL Q – harsh
SOUND DESCRIPTION CLINICAL D – inspiration and expiration are
SIGNIFICANCE about equal
FLAT Short, soft, dull, and Consolidation
(I:E – I<E)
high pitched as found
over the THIGH L - above the supraclavicular
DULL Medium in pitch and Lobar notch
intensity and thudlike pneumonia
as found over the
BRONCHIAL
LIVER
RESONANT Long, loud and low Normal lung P - high
pitched tissue or Bronchitis Q - loud
D – shorter on inspiration,
HYPER Very loud and lower Emphysema or
longer on expiration
RESONANT pitched as found over Pneumothorax
the STOMACH (I:E - I<E)
TYMPANIC Musical and drumlike Pneumothorax L - above the clavicles, each
as found over PUFFED- side of the sternum, over the
OUT CHEEK manubrium
BRONCHOVESICULAR
P – moderate
Q – moderate
D – similar on both inspiration
and expiration
(I:E- I=E)
L – 1st and 2nd interspaces
anteriorly and next to sternum
between the scapulae
Auscultating the Chest
Auscultation VESICULAR
- Have the patient breathe through his mouth, P - low
NOSE BREATHER ALTERS THE PITCH OF BREATH Q – soft
SOUNDS D – longer on inspiration,
- Use the DIAPHRAGM of the STETHOSCOPE in shorter on expiration
auscultation (I:E - I>E)
L – over most of the lungs,
peripheral lung fields

ADVENTITIOUS BREATH SOUNDS RESPIRATORY RATE AND PATTERN
TYPES Respiration should be NON- LABORED and
1. Discontinuous NOISELESS (EUPNEA)
Fine crackles – beginning congestion ABNORMAL RESPIRATORY PATTERNS
Coarse crackles- consolidation (LRTI) 1. Tachypnea – abnormally rapid breathing
2. Continuous 2. Bradypnea - abnormally slow breathing
Wheezes- COPD 3. Apnea – temporary cessation of breathing
Rhonchi- consolidation (URTI) 4. Hyperventilation or Hyperpnea – increased
3. Friction rub - both LRTI and URTI depth & rate of breathing
SOUNDS CHARACTERISTICS 5. Kussmaul’s Respirations – deep & labored
Fine Crackles Non musical, high pitched breathing
HEARD DURING INSPIRATION 6. Cheyne-Stokes Respirations – fast breathing,
CRACKING and POPPING then decreases, then temporary stops
SOUNDS
7. Biot’s Respiration – quick, shallow inspirations,
Coarse Non musical, low pitched
Crackles HEARD AT EARLY INSPIRATION and followed by periods of apnea
POSSIBLY EXPIRATION
BUBBLING and GURGLING Abnormalities of Chest and Lungs
SOUNDS
Wheezes Musical , high pitched
E>I
WHISTLING SOUNDS
Rhonchi Musical, low pitched
E>I
SNORING and MOANING SOUNDS
Friction Rub RUBBING and GRATING SOUNDS
I and E
VOCAL FREMITUS ACCESSORY MUSCLE USE AND RETRACTIONS

1. BRONCHOPHONY- “NINETY-NINE” Normal individual use MAJOR GROUP of muscle
- Ask the patient to say "ninety-nine" several for respiration
times in a normal voice. (intercostal muscle and diaphragm)
- Auscultate several symmetrical areas over A. Accessory muscles
each lung. - scalene
- The sounds you hear should be muffled and - sternocleidomastoid muscle
indistinct. B. Retraction, pursed lip breathing and nasal
- Louder, clearer sounds are called flaring
bronchophony. - Supraclavicular
- Suprasternal
2. WHISPERED PECTORILOQUY- “1,2,3” - Intercostal
- Ask the patient to whisper "ninety-nine" several
times. ACCESSORY MUSCLES FOR RESPIRATION
- Auscultate several symmetrical areas over
each lung.
- You should hear only faint sounds or nothing
at all. If you hear the sounds clearly this is
referred to as whispered pectoriloquy.
3. EGOPHONY- “E”
- Ask the patient to say "ee" continuously. MOTTLING , MASSES AND SCARS
- Auscultate several symmetrical areas over • Mottling - alternating white to blue tinge color
each lung. of the thorax, can be an indication of tissue
- You should hear a muffled "ee" sound. If you hypoxia
hear an "ay" sound this is referred to as "E -> A" • Common in patient with ARDS (Acute
or egophony. Respiratory distress syndrome) and respiratory
***vocal fremitus indicates consolidation arrest

Interventions: Common S/Sx Associated with PVDs (Peripheral
1. Check the oxygen saturation (direct and Vascular Disease)
indirect) measurements • Intermittent claudication
2. If de-saturation is present hyperventilate the • Skin changes: pallor, rubor & cyanosis
patient • Reduce, obliterate or bsence of peripheral
pulse
Masses and Scars • Alopecia, brittle nails, ry skin, atrophy,
Mass/tumor ulcerations & gangrene stabbing pressure
➢ Benign - slightly movable mass and regular in
shape Common Types of Chest Pain and their underlying
➢ Malignant/beginning malignancy - non- causes due to decreased coronary tissue
movable mass or tumor with tenderness and perfusion or compression & irritation of nerve
irregular in shape endings
Gold standard of diagnosis - FNAB (Fine needle Chest Pain: burning, constricting, stabbing, heavy
aspiration biopsy) pressure
Scars - maybe due to accident
ASSESSMENT OF CHEST PAIN
PARADOXICAL CHEST MOVEMENT P - PROVOCATIVE/PALLIATIVE
Paradoxical Chest Movement - uneven Q - QUALITY
movement of chest wall, can be caused by R - RADIATION
multiple rib fractures, chest lag secondary to S - SEVERITY
pleural effusion and accumulation of blood, air or T - TIMING
water to the thoracic cavity.
1. Pneumothorax - Air in the thoracic cavity. Fatigue
2. Hydrothorax – Water in the thoracic cavity. • as a consequence of INADEQUATE CARDIAC
3. Hemothorax – Blood in the thoracic cavity. OUTPUT
Palpitations
Related Structures • unpleasant awareness of the heartbeat
Inspect for signs of CENTRAL and PERIPHERAL • described as POUNDING, RACING or SKIPPING
CYANOSIS • Occur during mild exertion
Color • May indicate heart failure, anemia or
• Cyanosis is a late sign of respiratory distress hyrotoxicosis (excess thyroid hormone)
• Clubbing of fingers is a sign of prolonged Dizziness or Syncope
oxygen deficit • Characterized generalized body weakness
Interventions: with an inability to stand upright, followed by
1. Give supplemental oxygen support loss of consciousness
2. Check for oxygen saturation (direct and • Due to decreased cerebral tissue perfusion
indirect) Edema
• Due to increased hydrostatic pressure in the
The CARDIOVASCULAR System venous system resulting to fluid shift from IVF
1. Heart - pumps blood (Intravascular Fluid) to ISF (Interstitial Fluid)
2. Blood Vessels
3. Blood Past Medical History
1. Childhood and Infectious Diseases
Health History 2. Previous Illnesses & Hospitalizations
Common S/Sx 3. Medications
• Chest pain
• Shortness of Breath Physical Assessment
• Fatigue 1. General Appearance - LOC
• Palpitations 2. Skin - color
• Dizziness or Syncope 3. Vital Signs – BP, RR, PR
• Diaphoresis 4. Jugular Veins – distention, CVP
• Edema / Weight Gain 5. Carotid Arteries – pulsations, bruits
6. Chest – heart sounds

7. Extremities – peripheral edema, capillary refill • However, they sometimes result from harmless
time, clubbing flow characteristics of no clinical significance.
8. Lungs – breath sounds, cough
9. Abdomen – liver, bladder problems PERIPHERAL VASCULAR SYSTEM
• Includes measuring BP, palpating peripheral
Assessing for Jugular Vein distention pulses, & inspecting the skin & tissue to
determine PERFUSION (blood supply to an
area) of the extremities.
PERIPHERAL PULSES
- palpate peripheral pulses. May use DOPPLER
ultrasound probe if you have difficulty
palpating on both side of the body.
NORMAL FINDINGS: symmetric pulse volume & full
pulsations.
ABNORMAL FINDINGS:
• asymmetric volume (impaired circulation)
HEART SOUNDS
• absence of pulsation (arterial spasm or
HEART SOUNDS DESCRIPTION
occlusion)
S1 (SYSTOLE) Closure of MITRAL and TRICUSPID
“LUB” – LOW VALVES • decreased, weak, thready pulsations
PITCHED (impaired
S2 (DIASTOLE) Closure of the AORTIC and • cardiac output)
“DUB”- PULMONIC • increased pulse volume (HPN, high cardiac
HIGH PITCHED VALVES output or circulatory overload)
S3 RAPID VENTRICULAR FILLING.
VENTRICULLAR Indicates CHF (Congestive Heart
GRADING PULSES
GALLOP Failure).
“KEN---TUCKY” S3 is a NORMAL finding for 4+ Bounding
CHILDREN, 3+ Increased
YOUNG ADULTS and ATHELETES. 2+ Normal
It maybe a CARDINAL SIGN of 1+ Weak
HEART 0 Absent
FAILURE.
S4 ATRIAL Can be heard over the TRICUSPID Inspect the peripheral veins in the arms & legs for
GALLOP or MITRAL signs of phlebitis (inflammation of a vein)
“TEN--NESSEE” areas when patient is on LEFT SIDE. NORMAL FINDINGS: in dependent position,
You may presence of distention & nodular bulges at calves.
hear S4 in elderly patients or those
(+) tortuous veins in adult when elevated, limbs
with aortic
stenosis, hypertension and history not tender, symmetric in size
of MI ABNORMAL FINDINGS: distended veins in the thigh
(Myocardial Infarction/ Heart & lower leg or on posterolateral part of the calf
Attack). from knee to ankle, tenderness on palpation, (+)
Homan’s sign, warm, redness over vein, swelling of
MURMURS one calf/leg
• is an abnormal whooshing sounds, an
indication of CARDIAC PROBLEM, normal in ABNORMAL PULSES
infants up to 3 months. 1. WEAK PULSE - due to increase vascular
• are abnormal heart sounds that are produced resistance, as occurs in elders, digoxin toxicity,
as a result of turbulent blood flow which is cold weather and severe heart failure
sufficient to produce audible noise. 2. BOUNDING PULSE - hypertension and increase
• This most commonly results from narrowing or stroke volume
leaking of valves or the presence of abnormal 3. PULSUS ALTERANS - due to LEFT SIDED HEART
passages through which blood flows in or near FAILURE
the heart. 4. PULSUS BIGEMINUS - due to PVC (Premature
Ventricular Contractions)

5. PULSUS PARADOXUS - due to cardiac HA LEC – April 19
tamponade (fluid in the pericardial space) Sensorineural - pag inner
and constrictive pericarditis EARACHE & LOSS
1. Hammer - Malleus
Inspect skin of the hands & feet for color, 2. Anvil - incus
temperature, edema & skin changes. 3. Stirrup - stapes
NORMAL FINDINGS: skin color is pink, temp is not Otitis Media – milk napupunta sa ears sa mga
excessively warm or cold, no edema, texture is babies; fluid in middle ear
moist and resilient. Perforation – occurs to swimmers
ABNORMAL FINDINGS: cyanotic, pallor, dusky red Tinnitus – ringing of the ear
when limb is lowered (arterial insufficiency), brown Discharge – otorrhea
pigmentation around ankles (arterial or venous Pain – otalgia
insufficiency), edema, skin is thin, shiny or thick, Ototoxic Drugs - sensorineural hearing chuchu
waxy, with reduced hair & ulceration 12 months – downwards pull ng ear
Valsalva Maneuver - 15 secs; check if may saket
Assess adequacy of arterial flow if arterial sa puso; irreg heart rhythm.. for ears can help
insufficiency is suspected. relieve pressure that is blocking the Eustachian
NORMAL FINDINGS: Buerger’s Test – patient in tube in the inner ear. During the maneuver,
supine position, lift the leg up to 90 degrees and clogged ears can be unblocked by forcing air
note if there will be a color change. through the sinuses and Eustachian tube.
- original color returns in 10 secs, veins in feet or
hands fill in about 15 secs, immediate return of Weber Test - equal sounds both ears for normal.
color in capillary refill test. Rinne Test – air conduction and bone conduction
ABNORMAL FINDINGS: delayed color return or Romberg Test - positive kapag hindi kaya mag
mottled appearance, delayed venous filling, balance.
marked redness of arms & legs, delayed return of
color in capillary refill (arterial insufficiency) Diabetic Retinopathy is an eye condition that can
cause vision loss and blindness in people who
ARTERIAL INSUFFICIENCY & VENOUS INSUFFICIENCY have diabetes.
Distention for heart failure
SCURVY- DEF VITAMIN C
RICKETS – DEF VITAMIN D
Halitosis (Bad Breath)
Epistaxis – nose bleed; cuz of coagulation, bp
high, trauma. To stop a nosebleed: sit down at a
table, lean forward and firmly pinch the soft part
POOR CARDIAC OUTPUT AND TISSUE PERFUSION
of your nose, just above your nostrils, for at least 10
to 15 minutes. lean forward and breathe through
your mouth – spit out any blood that collects in
your throat or mouth into a bowl; do not swallow
any blood
Melanoma, the most serious type of skin cancer
Tension Headache- caused by stress
Migraine – ayaw sa maliwanag and maingay
PITTING EDEMA AND NON PITTING EDEMA Lordosis, Kyphosis, Scoliosis

Lordosis is an exaggerated inward curve of the
spine that typically affects the lower back
Kyphosis is a spinal disorder in which an excessive
curve of the spine results in an abnormal rounding
of the upper backScoliosis is an abnormal lateral
curvature of the spine. It is most often diagnosed
in childhood or early adolescence.

Hemoptysis refers to coughing up blood from Stork bite / telangiectatic nevi – common birth
some part of the lungs (respiratory tract). Blood mark; pink/red violet
coming from elsewhere, such as your stomach, High bilirubin leads to jaundice, a yellow cast to
can appear to be from the lungs. your skin and the whites of your eyes.
Exertional Dyspnea - exerted effort Vellus hair is thin, fine hair that grows on most of
Nasal flaring, pursed lip – hirap magbreathing your body. Vellus hair is usually shorter and lighter
Crepitus - sounds produced from friction between than terminal hair. Terminal hair is usually longer
bone and cartilage and darker. Also, terminal hair extends deeper
Fremitus refers to vibratory tremors that can be felt into your skin than vellus hair sa pilik mata and
through the chest by palpation. To assess for eyebrows.
tactile fremitus, ask the patient to say “99” or Capillary refill time assesses blood circulation in
“blue moon”. While the patient is speaking, your arms and legs (peripheral perfusion). Pinch
palpate the chest from one side to the other. tumb.. or any nail bed.
Respiratory System- main responsible for air circ Sunken fontanel, depress- depression for baby
Upper- air papasok and palabas ng baga kasi un nalng meron.. til 18 months cuz it will close.
Lower Respi tract w/ lungs – gas exchange (bunbunan)
between lungs and cells Pustule may nana – sa mga pigsa
Blood - medium that transport o2 Wheal- hive.. e.g. insect bites then nag swell..
Sudden Dyspnea - air collection outside the lungs; Mydriasis refers to a dilated pupil or a wider pupil.
ARF acute renal failure? Acute respirratory distress Miosis refers to a constricted pupil or a narrower
syndrom pupil.
Pulmonary- may blood clot from legs ”Emmetropia is the refractive state in a healthy
Embolism- stuck lang eye in which, any individual achieves the perfect
Thrombocys – travel??? visual function.”
Heimlich Maneuver – press ung gitna ; used to Presbyopia is a refractive error that makes it hard
treat upper airway obstructions caused by foreign for middle-aged and older adults to see things up
bodies. This maneuver is commonly taught during close.
basic life support and advanced cardiac life Cataracts- cloudy
support classes but is not given as much attention Glucauma- eye drainage problem, increase
as chest compressions. intraocular pressure. Normal intraocular pressure
Productive – may plema ; non productive then is 10-21 mm Hg, but it can drop as low as 0 mm
dry Hg in hypotony and can exceed 70 mm Hg in
some glaucomas.
Pitting Edema – when pressure is applied to a Cornea, eggshape or football shape.
swollen area, it may leave a pit or indentation in What is astigmatism? Astigmatism is a common
the skin eye problem that can make your vision blurry or
HA LEC – April 12 distorted. It happens when your cornea (the clear
Infants – smooth, not fat, poor temperature front layer of your eye) or lens (an inner part of
control; Eccrine after 1 month your eye that helps the eye focus) has a different
Acrocyanosis – sa extremities; low temp for shape than normal.
babies; emotional distress pag matanda na Epistaxis - nosebleed
Transient mottling – uneven spots; disruption of Hemoptysis - blood in the cough
flow sa vessels. Red to purple. TEMPORARY Hematuria - blood in the urine
Erythema toxicum- papules may pop; pustules Haematemesis - blood in vomiting
may nana; Acne papules are solid, inflamed COPD - Chronic Obstructive Pulmonary Disease
bumps in your skin that don't have a white or kyphotic curve - convex curvature of thoracic
yellow pus-filled tip. Pustules have a white or spine
yellow pus-filled tip. Kyphosis - roundback or — in the case of a severe
Papules can develop into pustules. Common rash curve — as hunchback.
– weeks Sinusitis/Allergic rhinitis - inflammation of the nose
Harlequin sign – uni lateral; 1half red and pale; Orchitis – inflammation of testicles
exporsure to heat or strenuous exposure
Mongolian spots- hyperpigmented patch

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HEALTH ASSESSMENT (LECTURE) - Midterms

BS NURSING - 1B 2nd Sem – 2023 I Prof. Marcelo

Common Variations in Newborns Terminal Hair and Acne

Transient Mottling Skin Variation with Age

P a g e 1 | 37 PANGILINAN, SOFIAH NICOLE

Assessment of the Skin, Hair, Nails

P a g e 2 | 37 PANGILINAN, SOFIAH NICOLE

P a g e 3 | 37 PANGILINAN, SOFIAH NICOLE

Psoriasis Vulgaris Atopic Dermatitis (Eczema)

P a g e 4 | 37 PANGILINAN, SOFIAH NICOLE

Assessment of the Hair

Tinea Capitus (Ringworm)

Assessment of the Nails Malignant Melanoma

ASSESSMENT OF THE HEAD, FACE AND NECK

P a g e 6 | 37 PANGILINAN, SOFIAH NICOLE

P a g e 7 | 37 PANGILINAN, SOFIAH NICOLE

P a g e 8 | 37 PANGILINAN, SOFIAH NICOLE

P a g e 9 | 37 PANGILINAN, SOFIAH NICOLE

COLLECTING OBJECTIVE DATA:

PREPARING THE CLIENT

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P a g e 11 | 37 PANGILINAN, SOFIAH NICOLE

ASSESSMENT OF THE EYES

ASSESSMENT OF THE EYE

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P a g e 13 | 37 PANGILINAN, SOFIAH NICOLE

P a g e 14 | 37 PANGILINAN, SOFIAH NICOLE

ASSESSMENT OF THE EYES

Trachea: Palpation for alignment ➢ COLOR VISION

Palpate one carotid artery at a time just below

P a g e 15 | 37 PANGILINAN, SOFIAH NICOLE

PSEUDO STRABISMUS EXTERNAL EYE STRUCTURE

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➢ CORNEA AND LENS

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SAMPLE OBJECTIVE DATA

APPROPRIATE NURSING DIAGNOSES

P a g e 18 | 37 PANGILINAN, SOFIAH NICOLE

Physical Assessment of the Ear Return Demo

Otitis media with effusion

P a g e 19 | 37 PANGILINAN, SOFIAH NICOLE

Step 4: Examine the Tympanic Membrane

Step 2: Holding the otoscope Hearing and Equilibrium Tests

P a g e 20 | 37 PANGILINAN, SOFIAH NICOLE

ASSESSMENT OF THE MOUTH AND THROAT

MOUTH AND THROAT STRUCTURE AND FUNCTION

COLLECTING OBJECTIVE DATA:

PREPARING THE CLIENT

P a g e 22 | 37 PANGILINAN, SOFIAH NICOLE

LEUKOPLAKIA KOPLIK’S SPOTS

HERPES SIMPLEX TYPE I

P a g e 23 | 37 PANGILINAN, SOFIAH NICOLE

ASSESSMENT OF THE NOSE AND SINUSES

STRUCTURES AND FUNCTIONS

P a g e 24 | 37 PANGILINAN, SOFIAH NICOLE

INSPECTING THE NASAL CAVITY

INSPECTING THE NOSTRILS

P a g e 25 | 37 PANGILINAN, SOFIAH NICOLE

P a g e 26 | 37 PANGILINAN, SOFIAH NICOLE