HEALTH ASSESSMENT NOTES

TYPE OF ASSESSMENT
• Initial comprehensive assessment-Baseline
data( rst met)
• Ongoing or Partial Assessment(taking vs
every 15 min)
• Focused or Problem-Oriented Assessment
• Emergency Assessment-performed during
life threatening situation. Do assessment
fast. Do not do head-to- toe assessment.
-FOCUS ON ABC
ELDERLY
• HEARING
• Speak slowly
• May be interpreted as mental slowness
• Face client
• Do not yell
• Position- on the side with better hearing
• Speak clearly
• Simple terms
• No slang

INSPECTION
Involves using the senses of vision, smell
any Precedes palpation, percussion and
auscultation
Use of senses - body senses require special
equipment
-Look and observe before touching.
GUIDELINES
-Make sure the room is a comfortable
temperature. A too-cold or too-hot room
can alter the normal bEhavior of the client
and the appearance of the client's skin.
-Use good lighting, preferably sunlight.
overlooked with dim lighting.
fi
 uses:
1. Eliciting pain
2. Determining location, size and shape
3. Determining density

Auscultation
Requires the use of a stethoscope to listen
classi ed
according to:
1. Intensity
2. Pitch
3. Duration
Quality
• loud-soft
• high-low
• length
• musical, crackling, raspy

Physical Examination of the Skin:

Procedure
1. Inspect the skin to evaluate color and
pigmentation
• Normal ndings:
-lighter-pigmented races versus darker-
pigmented races.
-Hyperpigmentation is a common nding to
light-skinned people

-Crepitus- grating, crackling popping sound • Deviations from normal:

and sensation experienced under the joint suggest compromises in metabolism,
skin circulation, or oxygenation
Pallor.
-Fremitus- palpable vibration
2. Inspect and palpate the skin to evaluate
-examiner’s ngernails should be short and moisture
the hands should be a comtortable - Normal ndings:
temperature • dry, moisture in skin folds, slightly warm.
• Anxiety may cause sweaty palms and
STANDARD PRECAUTION- if applicable perspirations in the axillae, and on the
forehead and scalp
Light palpation (safest) and the most - Deviations from normal:
comfortable to moderate palpation to • dryness, sweating, or oiliness (not clinically
deep palpation signi cant)
• Diaphoresis
DEEP PALPATION • Cold and clammy
Place your dominant hand on the skin • Abnormally dry skin.
surface and vour non-dominant hand on
top of your dominant hand to apply 3. Palpate the skin to determine temperature
pressure - Normal ndings:
Result in surface depression between 2.5. warm, some people have cool skin due to skin
5 cm dryness
Allows you to feel very deep organics or
structures that are covered by thick -Deviations from normal:
muscles extreme: warm skin local or systemic, or cold
skin
Percussion
-Involves tapping the body parts to produce
sound waves
-These sound waves or vibrations enable the
examiner to assess underlying structures
fi
fi
fi
fi
fi
fi
fi
 -Remove wig, hat, ornaments, pins, rubber
4. Inspect and palpate the skin to evaluate bands, jewelry and head or neck scarves
texture and -Ask client to sit in an upright position with the
thickness back and shoulders held back and
- Normal ndings: straight
smooth (unexposed areas), rough (exposed), Explain the importance of tagätio? Stildwiof
layers of skin most of the inspection and
varies
-Deviations from normal: Assessment of the Head & Face
• rough skin, friable and easily broken or -Examination of the Head
disrupted in integrity -Inspect and palpate the cranium
(common in very thin skin) size, shape and symmetry, con guration,
tenderness
5. Evaluate skin turgor by lifting a fold of skin -Palpate and auscultate temporal
between your thumb and fore nger arteries
- Normal ndings: thickening, tenderness, bruit
elastic, and rapidly returns to original shape -Inspect and palpate the face
when grasp between thumb and fore nger • symmetry, movements, tenderness,
nodules, saruses, tremors, twitching,
Deviations from normal: paralysis
poor skin turgor - slow to resume its original • Facial features, expressions
shape when pinched.
Loss of turgor (dehydration or as a normal -Head size and shape vary, especially in
aging process) accord with ethnicity.
Usually the head is symmetric, round, erect,
6. Inspect/Survey general hygiene of skin and in midline and
• Normal ndings: appropriately related to body size
clean skin (consider cultural and social (normocephalic). No lesions are
practices) visible.
7. Examine the skin for the presence of edema -An abnormally small head is called
microcephaly. The skull and
Skin- Inspect & palpate facial bones are larger and thicker in
• Lesions (if present) acromegaly
• Color -Acorn-shaped, enlarged skull bones are seen
• Elevation in Paget's disease of
• Pattern or shape the bone
• Size -Head should be held still and upright.
• Location & distribution -Neurologic disorders may cause a horizontal
• on body jerking movement. An involuntary nodding
• Exudate movement may be seen in patients with aortic
insu ciency. Head tilted to one side may
Example of primary skin lesions indicate unilateral vision
-These lesions are original lesions arising or hearing de ciency or shortening of the
from previously normal skin sternomastoid muscle.
-Palpate the head. The head is normally hard
and smooth, without lesions.
HEAD ASSESSMENT -Lesions or lumps on the head may indicate
recent trauma or a sign of cancer
SUBJECTIVE -inspect the face. Inspect for symmetry,
Overlap several body systems - nursing features, movement,
history is needed to detect the cause expression, and skin condition.
underlying problems -The face is symmetric with a round, oval,
elongated, or square appearance. No
EX: abnormal movements noted.
dizziness -Drooping, weakness, or paralysis on one side
lightheadedness of the face may result from a stroke
loss of consciousness (cerebrovascular accident, CVA) and usually is
seen with paralysis or weakness of other parts
Objective
ffi
fi
fi
fi
fi
fi
fi
fi
 -As the client opens and closes her mouth,
palpate the temporomandibular joint for Deviations from normal:
tenderness, swelling, and crepitation. • Flakiness
• sores
Mask Like Expression: • infestations
people with PD have a mask-like expression,
their face has less facial movements and ASSESSMENT OF NOSE AND SINUSES
appears less animated scienti c term for this Inspect the external nose
is Hypomimia, which means a reduction in • Note shape and con guration
the expressiveness of the face. • Observe nares during ventilation
• If nasal discharge is present, note character
ASSESSMENT OF HAIR (watery, purulent, mucoid),
• color, amount, and whether it is unilateral or
Physical Examination of the Hair: bilateral
Procedure Normal Finding:
• Shape of the nose varies among people
• color is the same as the rest of the face: the
1. Inspect the hair to evaluate color and nasal structure is smooth
pigmentation • and symmetric; the client reports no
- Normal ndings: tenderness
• hair color in uenced by genetic makeup. Deviations from normal:
Pigment distribution is • Deviations in the shape or con guration of
uniform in hair shaft. the external nose
Gray hair represents normal aging • Signi cant if (+) tenderness and/or
secondary to trauma
Deviations from normal: • Flaring of the nares
-alteration in color pigmentation may indicate • Nasal discharges (rhinitis) secondary to:
nutrition alterations common cold, allergy, CSF, rhinnorrhea,
-Transverse depigmentation of the hair sinusitis, foreign body
indicating nutrient
de ciency, especially copper and protein Evaluate nasal patency
• Occlude one naris, ask the person to
2. Inspect the quantity of hair. Pull gently a breathe in and out with the mouth close
few strands whether it comes out easily. • Repeat with other naris
Normal ndings: Normal nding:
-hair quantity varies amp gg healthy persons • Quiet nasal breathing indicated patency
on both sexes. Deviations from normal:
-Male balding occurs as anterior regression is • Masses or foreign particles may interfere
considered normal (genetics) with airway patency
Inspect the internal nose
Deviations from normal: • Tip the person's head back and look
-easy pluckability and sparse hair may through the nares to view vestibule,septum,
indicate protein de ciency. and turbinates. Use a penlight to enhance
-Alopecia may occur with anemia, heavy visualization
metal poisoning, • Note the color and condition of the nasal
and hypopituitarism mucosa, appearance of turbinates and nasal
septum
3. Move a few strands of hair between your • The nasal mucosa is dark pink, moist, and
thumb and fore nger to evaluate texture free of exudate. The nasal septum is intact
Normal ndings: and free of ulcers or perforations. Turbinates
-coarse or silky (varies in race) are dark pink (redder than oral mucosal,
Deviations from normal: moist, and free of lesions.
-very coarse hair - hypothyroidism
-Very ne hair - hyperthyroidism Normal ndings and deviations from normal
(Inspection):
4. Survey general hygiene of the hair and
scalp (also, inspect the back of the head
and neck) Nasal septum: deviated septum is common,
Normal ndings: free of lice infestations and and may interfere patency, septum should not
nits be perforated
fi
fi
fi
fi
fi
fi
fi
fi
fi
fl
fi
fi
fi
fi
fi
 thumb and the fore nger to
Nares: masses or foreign particles may determine capillary re ll time
interfere patency Normal ndings:
• Capillary re ll < 3 sec
Mucous membranes: color (pink or dull red), Deviations from normal:
small amount of clear watery discharge is • Capillary re ll > 3 sec indicates poor tissue
considered normal perfusion

Turbinates: normal (nonedematous, no 4. Examine the nails for presence of

masses, pink or dull red) lesions or other abnormalities
• Nasal polyps • Nail Abnormalities
• Epistaxis • Onycholysis
• Beau's Lines
Palpate the sinuses • Splinter hemorrhages
-Frontal sinuses: press upwards from the • Jarvis p. 269
eyebrows with your thumbs. Pay attention
with the eye orbits EXAMINATION OF JAW AND ORAL CAVITY
-Maxillary sinuses: press upward under
zygomatic process (cheekbones) with your General Approach:
nger or thumbs • Technique: Inspection and Palpation
• Use gloves when palpating oral cavity
Deviations from normal: • Interview the client to elicit further
(+) tenderness on palpation information
Equipment:
Transluminates the sinuses (done if + • tongue blades, gauze pads (4x 4), gloves,
tenderness on palpation
penlight or
- darken the room
- Frontal sinus • ashlight
Examination and documentation focus:
PHYSICAL EXAMINATION OF NAILS • Mucous membranes
1. Observe the shape and con guration of the • Structural integrity
nail • Functional ability
Normal ndings:
• Dorsal nail surface: slightly Inspect and palpate the
• Nail thickness: 0.3-0.65 mm outer structures of the oral
• Angle at nail base: 160 degrees (skin-nail cavity
interface) -Assess for malocclussion
Deviations from normal: -Palpate temporomandibular
• Abnormal shape may indicate malnutrition joint
• Spooning: concave nail plates;asso. With -inspect and palpate skin
iron de ciency anemia over the parotid gland
• clubbing -Inspect and palpate lips

Nails are hard and basically immobile. Normal ndings

-Thickened nails (especially toenails )may be -Upper and lower teeth
caused by decreased circulation, and is also should align when jaw is
seen in onychomycosis clenched
-Nails are smooth and rm; nail -Full-range of voluntary
plate should be rmly attached motion
to nail bed. -Parotid gland enlargement,
unilateral or bilateral
2. Note the color of the mails -Lips are symmetric
Normal ndings: Deviations
• Pinkish -Missing teeth, deviate from
• Bluish hue in dark-skinned people alignment
Deviations from normal:
• Nail lesions may alter the color of nail plate
• Cyanosis

3. Squeeze the nail between the

fi
fl
fi
fi
fi
fi
fi
fi
fi
fi
fi
fi
fi
fi
 Examine the dorsal surface of the tongue and use adequate lighting to enhance
-Ask the client to extend visualization
tongue and say “ah” Examination and documentation focus
- Note symmetry of the tongue and uvula • Size
when the tongue is protruded • Shape
-Observe the motion of the • Consistency
soft palate when the client Tenderness
says “ah" occurrence of vascular sounds (bruit)

Examine the oropharynx, Inspect the area of the anterior neck

posterior tongue, and containing the TG
uvula -Ask client to tilt head back slightly and
-Gently press tongue with swallow, note the movement of the trachea
tongue blade (if required) and other cartilage
Inspect the uvula
-Elicit a gag re ex by Normal nding:
touching he posterior wall -TG usually too small to be observed
of the pharynx with the
tongue blade Deviations from normal
-Goiter
- Examine the lip and cheek buccal) oral
mucosa Palpation of TG (Anterior and Posterior
• Examine the underside of the lips and Approach)
anterior surface Normal ndings:
of the gums • Size and shape
• Examine the inner cheek by using a tongue • Rubbery texture
blade or Deviatiöns from normal
gloved nger • Goiter
-Deviations from normal • Firm nodule: usually painless (malignant)
• Abnormal color changes • Pain on palpation may be associated with
• erythema, cyanosis in ammation, which often radiates to ears
• Stomatitis
• Xerostomia Head and Neck Lymphatic System
excessive dryness of oral mucosa
Assessment Findings
Normal ndings:
Examine the lateral and ventral tongue
• Super cial nodes not palpable, and not
surfaces
tender on palpation
-Inspect the mucosa by displacing the tongue
laterally Deviations from normal:
-Ask the person to touch the hard palate with • Greater 1 cm in adults
tongue tip, and examine the ventral • Presence of infection (nodes are
surface enlarged, warm and
-Palpate oral mucosa of the mouth oor with • tender)
glove nger • Sore throat infections
• Otitis media
The Trachea
• Normally it is midline
• Palpate for tracheal shift ASSESSMENT OF EYES
• Place your index nger in the sternal notch Objective Data:
and slip it o to each side Inspect Anterior Eyeball Structures
-The space should be symmetrical on each
side 4 Inspect External Ocular Structures
• General
Physical Examination: Thyroid Gland -Gross visual ability
• General approach/Technique: -Facial expression
• Inspection, palpation, and auscultation Eyebrows
• Ask client to swallow from a glass of water -Present bilaterally & move
during exam, symmetrically
-No scaling or lesions
fl
fi
fi
fi
fi
fi
fi
ff
fl
fi
fl
 Normal: 20/20 both eyes
• Numerator - distance from chart
Eyelids & lashes Denominator - distance normal eye could
• Upper lids overlap superior iris have read chart
• Approximate completely when closed • Jaeger Card: Near vision (> 40 y/o or
• Intact; no redness, discharge, swelling or problems reading)
lesions
14 inches
• Palpebral ssures horizontal
• Test eyes separately with glasses on
• Asians upward slant
• Lashes evenly distributed & curve outward Normal: Jaeger 14/14 in each eye
If no card, use newsprint or magazine
• Eyeballs
Aligned, not protruding or sunken Corneal Light Re ex
Blacks: Slight protrusion normal Assess parallel alignment of eyes
• Conjunctiva & sclera 1. Hold penlight approximately 12 in. from
• Client looks up the client's face
Slide lower lids down with thumbs 2. Shine light toward the bridge of the
Do not push eyeball nose while the client stares ahead
Eyeball should be moist, glossy, small Note re ection of light on corneas
blood vessels visible but otherwise Normal: Symmetric
conjunctivae clear The re ection of light on the corneas
Palpebral conjunctiva pir should d be in the exact same spot on each
Sclera china white eye
Dark-skin: Gray-blue or muddy, freckles,
yellow fat deposits under lids Use the ophthalmoscope to inspect
Abnormal: Jaundice - scleral icterus * Optic disc for shape, color, size, and
physiologic cup
• Cornea & Lens • Retinal vessels for color and diameter
• Shine light from side and AV crossings
• Check smoothness, clarity • Retinal background for color and lesions
• Arcus senilis normal in elderlv • Fovea centralis (sharpest area of vision
• Iris & Pupil and macula
• Iris at, round. even color • Anterior chamber for clarity
Note pupil size, shape, equality
• 5% people have anisocoria EXAMININATION OF EARS

• Pupillary Light Re ex -Preparation

• Darken room, client gazes into distance • Seated comfortably
• Advance light from side • Explain
• Note direct & consensual response NOTE: does the client appean to hear well?
Can gauge in mm (Normal 3-5mm) does it seems she is straming to catch
R3/1=3/11 everything you say?
• Test Accommodation & Convergence does the client respond?
• Client focuses on distant obiect -Equipment
Shift gaze to object 3 inches from eyes • Otoscope with bright light
Normal: Pupils constrict & converge • Tuning fork
Document: PERRLA
• Ears are equal in size bilaterally (normally
Test Central Visual Acuity 4-10 cm).
• Snellen eye chart: Distance vision • The auricle aligns with the corner of each
• 20 feet eye and within
Use an opaque card a 10-degree angle of the vertical position.
Leave on glasses or contacts • Earlobes may be free, attached, or
Remove reading glasses soldered (tightly
Ask to read smallest line of print possible attached to adjacent skin with no apparent
Encourage to read next line also lobe).
fl
fl
fl
fi
fl
fl
 Abnormal Findings: • Place one nger on the tragus & rapidly
• Ears are smaller than 4 cm or larger than push it in & out of the auditory
10 cm. meatus
• Malaligned or low-set ears may be seen Shield lips; position 1-2 ft away from ear
with • Whisper 2 syllable words, e.g., Tuesday,
genitourinary disorders or chromosomal baseball
defects
SENSORINEURAL hearing loss:
EARS - damage is in the inner ear
Auricle align with the eye CONDUCTIVE hearing loss:
- genitourinary disorde - something blocks or impairs the passage
- chromosomal defect of vibrations
- Size
Earlobes: Test Hearing Acuity
- color • Tuning Fork Tests
- cerumen • Activate fork by holding stem & striking
gently on back of
• External Canal hand
Note redness, lesions, or discharge (color & • Weber test
odor) - Distinguish conductive hearing loss or
Tympanic membrane sensorineural
Shin, translucent, pearly graf - Vibrations are heard equally well in both
Cone-shaped light re ex ears. No
5 o'clock right drum; 7 o'clock left drum lateralization of sound to either ear.
Visualize umbo, manubrium & short • Conductive hearing loss- client hears
process sound on the poor ear
Note position - Sensorineural hearing loss- hear the
• Flat, bulging, retracted? sound on the
Check integrity of membrane una ected ear

• The skin is smooth, with no lesions, RINNE TEST

lumps, or nodules. Color compare air and bone conduction
is consistent with facial color Normal: air conduction is normally heard
Abnormal Findings: longer than bone conduction sound
Enlarged preauricular and postauricular
lymph nodes- Conductive hearing loss- bone conduction
infection sound is heard longer than air conduction
• Tophi (nontender, hard, cream-colored sound
nodules on the helix Sensorineural hearing loss- air conduction
or antihelif, containing uric acid crystals) -- is heard longer than bone
gout conduction sound
• Blocked sebaceous glands-postauricular
cysts ASSESSMNET OF BREAST
• Ulcerated, crusted nodules that bleed- Preparation
skin cancer (most Inspection in sitting position, client
often seen on the helix due to skin disrobed to waist, facing
exposure) examiner
• Redness, swelling, scaling, or itching-- • Can use a short gown
otitis externa • Opening at back & lift to shaulders during
• Pale blue ear color-frostbite exam
• Opening in front, keep closed while
Objective Data: waiting, & open during exam
Test Hearing Acuity • During palpation, use supine position &
• Voice (Whisper) Test expose one breast at a
• Test one ear at a time time
ff
fi
fl
 • Use a sensitive but matter-of-fact -Inframammary ridge: Normal, noticeable in
approach large
• Warm hands breasts in lower quadrants
-Large, pendulous breasts: May use
Objective Data bimanual technique
Inspect Breasts in sitting position, leaning forward.
- General appearance
• Symmetry, shape
Slight asymmetry normal (o en L > R) THORACICS ANG LUNG ASSESSMENT
Skin
Smooth, even color • Scapulae are symmetric and non
Note redness, bulging, dimpling, lesions, or protruding.
focal vascular pattern • Shoulders and scapulae are at equal
ne blue vascular network normal during horizontal positions.
pregnancy • The ratio of anteroposterior to transverse
Pale loear striae mav occur after reancv diameter is 1:2.
Edema should not be present • Spinous processes appear straight, and
LOok for orange Decl appearance thorax appears symmetric,
with ribs sloping downward at
approximately a 45-degree angle in
• Inspect Breasts relation to the spine
- Nipple
• Symmetry, protrusion Reference Lines
- Most protrude, some at or inverted • Anterior axillary line
• Note recent retraction or inversion • Posterior axillary line
Normal nipple inversion usually not xed • Midaxillary line
• Note dry scaling, ssures, ulcerations,
bleeding, discharge • The client does not use accessory
• Supernumerary nipple along embryonic (trapezius/ shoulder) muscles to assist
milk line breathing. The diaphragm is the major
- Usuallv 5 to 6 cm below breast near muscle at work. This is evidenced by
midline & no associated expansion of the l&wer chest during
glandular tissue inspiration
• Client should be sitting up and relaxed,
Inspect for Retraction: Position 1 breathing easily with arms at sides or in
• Lift arms slowly over lap
head Normal Findings (palpaton.:
• Both breasts should Sternum, costal cartilages, ribs, ICS,
move up and spine: (-) tenderness
symmetrically Muscles: rm, smooth, and
symmetrical
Inspect for Retraction: Position 3 Tactile fremitus: should be felt on
• If large pendulous chest wall; decreased or absent over
breasts, lean over & the precordium
support forearms Note: compare and contrast R and I.
• Symmetric, free chest
forward movement
Deviations from normal
Objective Data (palpation):
• Palpate the Breast Palpable masses
-Nulliparous: Firm, smooth, elastic tissue • (+) crepitus, or crepitation: a crackling
-After pregnancy: Softer, looser tissue sound (produced by air in the
-Premenstrual: Engorgement, tenderness, subcutaneous tissue)
generalized Increased tactile fremitus: pneumonia
nodularity (with cons Jidation), atelectasis, lung
tumors, etc.
fi
fi
fi
fl
fl
fi
 Decreased tactile fremitus: pleural
e usions, pneumothorax, tumors or Then ask client to "take a deep breath &
masses in the pleural space, hold it"
emphysema, etc • Percuss down from 1st mark to where
sound changes from resonant to dull &
3. Palpate for chest expansion mark
Anterior approach Measure the di erence between the lines
Posterior approach Normal: 3 to 5 cm (well-conditioned people
Normal nding: 7 to 8 cm)
Slide thumbs medially to pinch up small
fold of skin between thumbs Normal ndings (auscultation):
Ask the client to take a deep breath Normal breath sounds:
NORMAL: the thumbs move apart Bronchovesicular breath sounds (soft,
symetrically breezy
Deviations from normal: quality and are lower-pitched than
Lag in thoracic movement: underlying bronchial
lung or pleural disease sounds, but higher pitched than vesicular
sounds)
4. Percuss the Posterior Chest Heard over rainstem bronchi area, anterior:
Lung Fields 1st and 2nd ICS, posterior: between
Start at apices, normally resonant scapulae
Across tops of both shoulders Inspiratory and expiratory phases are equal
Percuss interspaces at 5cm intervals Voice transmission:
making side-to-side Mu ed sounds
comparisons
Avoid scapulae & ribs Crackles or rales (soft, high pitched,
Resonance- percussion tone elicited over discontinuous
normal popping sounds eccurring during
lung tissue inspiration)
Fluid in the air ys or alveoli
4. Normal ndings (Percussion): Restrictive pulmonary disease (crackles on
Resonant sound is emitted late inspiration)
Diaphragm should be slightly higher on the Obstructive pulmonary disease (crackles
right side on early inspiration)
3 to 6 cm: normal diaphragmatic excursion Fine crackles (early inspiration), caused by
Deviations from normal: small airway closure
Hyperresonant or tympanic: Coarse crackles (early inspiration), caused
sound produced when air accumulates in by bronchitis or
the lungs or plural cavity (e.g. emphysema, pneumonia
pneumothorax)
Dullness or at: pieces of leather being rubbed together)
sound produced by vibrations from solid Heard during inspiration alone or during
masses or uid in the lungs (e.g. inspiration and
pneumonia expiration
atelectasis, pleural e usion, lung tumor, Sound disappear when the breath is held
etc) Caused by in ammation and loss of
lubricating pleural uid
Diaphragmatic Excursion Stridor (high pitched crowing sound)
• Diaphragmatic Excursion Originates in larynx or trachea A
• Ask client to "exhale & hold it" brie y May be life threatening
while you percuss down scapular
line
Until sound changes from resonant to dull Auscultate for voice transmission
on each side & mark Ask person to say "99" while
(R) may be slightly higher than (L) due to auscultating lung elds
liver (bronchophony)
ff
ffl
fi
fi
fi
fl
fl
fl
ff
fi
fl
ff
fl
 Ask person to say "ee-ee-ee" to • Abdomen is at, rounded, or scaphoid.
assess (egophony) Abdomen should be evenly
Ask person to whisper "1-2-3" rounded
(whispered pectoriloquy)
AUSCULTATE BOWEL DOUNDS
• Bronchophony (loud distinct voice -bowel Sounds
transmission) Note character & frequency
Whispered pectoriloquy (clear Normal
transmission of whisphered high pitched, gurgling,
sounds) cascading
• Egophony (/e/ to /a/ change in occur irregularly (5-30h>
sound: normally heard over large times/min).
airways (bronchi) Do not count them.
Assess: normal, hypoactive, or
EXAMINATION OF ABDOMEN nyperactive
Hypoactive - or absent
• Inspect the Abdomen Hyperactive - loud, high
Contour pitched rushing sounds
• Assess at eye level Must listen for 5 min before
• Protuberant, distension deciding BS are completely
Determine pro le from rib margin to pubic ansent
bone Borborygmus
Symmetry hyperperistalsis when
• Note localized bulging, visible mass, or you are hungry
asymmetry
• hernia Auscultate Vascular Sounds
Use light if available Note presence of vascular
• Assess from ® side & foot sounds or bruits
Umbilicus • Especially in people
• Normally midline & inverted, no with HTN
discoloration, Location, pitch and
in ammation, discharge, or hernia timing
• May be everted during pregnancy Use bell endpiece with
• Sunken in rm pressure to form a seal & check over
the:
• Abdominal skin may be paler than the • Aorta
general skin tone because • Renal arteries
this skin is so seldom exposed to the • Iliac arteries
natural elements • Femoral arteries
• Scattered ine wains nos be visil Placed
shoveinslocated Percussion
located below the umbilicus ows toward Percuss the Abdomen
the lower body General tympany
• New striae are pink or bluish in color; old 1* percuss lightly in all 4 quadrants
striae are silvery, white, • Tympany should be
linear, and uneven stretch marks from past predominant
pregnancies c weight Air in intestines rises when
gain supine
dullness
• Abdomen is free of lesions or rashes. Flat • bladder distention
or raised brown moles, adipose tissue
however, are normal and may be apparent. uid/mass
• Umbilicus is midline at lateral line.
• It is recessed (inverted) or protruding no
more than 0.5 cm, and is
round or conical.
fl
fi
fl
fl
fi
fl
ASSESSMENT OF HEART

• S1 "lub" closing of MV and TV

• S2 "dub" closing of PV and AV
• Abnormal heart sound:
• Murmurs
• Extra sounds S3, S4

• Aortic area- 2nd RICS

• Pulmonic- 2nd LICS
• Erb's point- 3rd-4th
LICS