Physical examination, Fundamentals of Nursing

detailed physical examination notes and format

1. Physical Examination Prepared by: Pooja Koirala Lecturer NMCTH

2. Physical examination Physical examination is an important tool in assessing the patient’s health status. About 15% of the information used in the assessment comes from the physical examination. It is performed to collect objective data and to correlate it with subjective data.

3. It is a systematic data collection method that uses the senses of sight, hearing, smell and touch to detect health problems The physical examination, thoughtfully performed, should yield 20% of the data necessary for the patient diagnosis and management.

4. Purposes of physical examination To obtain baseline data about the client’s functional abilities To obtain data that will help the nurse establish nursing diagnosis and plan the care To evaluate the physiologic outcomes of health care and thus the progress of a client’s health problem

5. Purposes of physical examination cont… To make clinical judgments on a client’s health status To determine the client’s eligibility (suitable fitness) for health insurance, military service

6. General guidelines / principles for physical examination Mnemonics: WIPER W: wash the hands I: Introduce yourself to the patient P: permission, P: Pain Expose: expose the necessary parts of the patient. Ensure adequate privacy R: Reposition the patient. In this examination the patient should be lying flat with one pillow under the head.

7. General guidelines / principles for physical examination It should proceed in an orderly fashion with a minimum of required position shifts by the patient. Generally cephalocaudal approach is used. In case of infant and child, examination of heart and lungs function should be done before the examination of other body parts, because as the infant starts crying, his / her respiratory and heart rate may change.

8. Anatomica l area Patient Examiner Vital signs, general inspection Sitting or reclining (lie down) Standing before patient or at right bed side Head and neck Sitting Standing before patient Anterior torso (trunk) Sitting Standing before patient initially, later behind the patient Posterior torso Sitting At patient’s side Anterior chest and abdomen Supine Before the patient Male genitalia Standing Before the patient Gait, station, coordination Variable positions Behind the patient Female genitalia Reclinining on examining table, draped, knees flexed, legs adducted, feet in stirrups Sitting on chair at times or standing

9. Equipment required for physical examination A tray containing: Paper bag with cotton Sphygmomanometer Flashlight Stethoscope Lubricating jelly Thermometer tape measure Oto – opthamlmoscope

10. Equipment required cont… Weighing machine Tongue depressors Pocket eye chart Tuning fork (128Hs) Gloves (for rectal examination) Reflex hammer

11. Methods of physical examination A systematic approach should be used while doing physical examination Generally cephalo caudal approach e.g. head to toe approach is used But the flexibility may be used as per the need of the patient. The procedure can vary according to the age of the individual, severity of the illness. The preferences often nurse, location of the examination and the agency’s priorities and procedures

12. In children examination of heart and lung’s function may be done before the examination of other body parts.

13. Steps of physical examination Inspection Palpation Percussion Auscultation

14. Inspection It is the visual examination, which by assessing the sense of sight to discover some signs of illness. The nurse inspects with the naked eyes and with a lighted instrument such as an otoscope . Visual inspection helps to assess moisture, color, texture of the body surfaces as well as shape, size, symmetry of the body Inspection reveal more information than other method

15. Palpation Palpation follows inspection It is the examination of the body using the sense of touch Different parts of the hands are used for different sensations such as temperature, texture of skin, vibration, tenderness etc Finger tips are used for fine tactile details, the back of fingers for temperature and the flat of the palm and fingers for vibrations such as cardiac thrill All the assessable parts of the body should be palpated

16. Palpation cont… Palpation may be either light or deep and is controlled by the amount of pressure applied to the fingers or hand Light palpation is done with the hand parallel to the floor with the fingers together as in palpation of the abdomen The palm lies lightly on the pat and the fingers depress the part about ½ on 1 cm deep. Light palpation of structure such as abdomen determines the area of tenderness.

17. Palpation cont… Deep palpation is performed by pressing the distal half of the palmer surface of the fingers into the abdominal wall. It is used to examine the condition of organs It also helps to obtain specific information about he mass detected by light palpation.

18. Palpation cont… Palpation is used to determine Texture e.g. the hair Vibration e.g. of a joint Position e.g. size, consistency and mobility of organs or masses Distention e.g. of the urinary bladder Pulsation The presence of pain upon pressure

19. Principles of palpation You should have short fingernails You should warm your hands prior to placing them on the patient Encourage the patient to continue to breathe normally throughout the palpation If pain is experienced during the palpation discontinue the palpation immediately Inform the patient where, when and how the touch will occur, especially when the patient cannot see what you are doing

20. Percussion It is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt when they are tapped with the fingers. They are of two types Direct percussion Indirect percussion

21. Process of indirect percussion Put the middle finger of her left hand against the body part to be percussed Tap the end joint of this finger with the middle finger of the right hand. Move the right hand from the wrist to tap the left middle finger Give two or three taps at each area to be percussed Compare the sound produced at different areas.

22. Types of sound produced in percussion Tympanic: it is a musical or drum like sound produced from an air filled stomach Resonance: it is a hollow sound such as that produced by lungs filled with air (normal lungs sound) Hyper resonance: it is not produced in the normal body. It is described as booming and can be heard over the emphysematous lungs

23. Dullness: it is the thud like sound produced b dense tissue such as the liver, spleen, heart etc Flatness: it is an extremely dull sound produced by very dense tissue, such as muscle or bone

24. Auscultation Auscultation means listening to the sounds transmitted by a stethoscope. The stethoscope is used to listen to the heart, lungs and bowel sounds Auscultation may be direct and indirect. The stethoscope should be always be placed on naked skin because clothing obscures sounds.

25. Steps of doing physical examination Take clinical measurements like height, weight and vital signs Prepare the patient for physical examination Explaining the purposes and procedure for physical examination Telling the patient how long the examination will take Asking him/ her to urinate Arranging for a quiet, private area for assessment

26. Steps of doing physical examination cont… Asking the patient to remove his clothes and giving him a drape to cover Inspect the patient’s general appearance Assess the physical status of the patient in a systematic way by using various methods of physical examination After completing the physical examination, allow the patient to put on his clothes Explain the findings to the patient Record the relevant findings of the physical examination on the patient’s assessment form.

27. Physical examination: General appearance Use Inspection Examination Normal data Abnormal data Gait If patient is in bed, assess posture Walks straight (Assess while standing) Limps General state of health Cheerful, active and appears healthy Sad, tired, weak appearance Stature: note the general bodily proportions and look for any deformities Very short stature in Turner syndrome, renal disease, hypopituitarism (dwarfism), long limbs in marfan’s syndrome

28. Examination Normal data Abnormal data Nutritional status Appears well nourished Obese or thin. Generalized fat in simple obesity Truncal fat with relatively thin limbs in Cushing syndrome BMI:

29. Examination Normal data Abnormal data Behavior Appropriate reaction to the situation Unusual behavior, unexpected shaking movement, gestures, restlessness Cleanliness Good hygiene, clean clothing, well groomed Dirty clothes, poorly groomed Speech (listen for the pace of speech and its pitch, clarity and spontaneity Fast speech may be due to hyperthyroidism, lack of spontaneity in depression, asthma. Slow, thick, hoarse voice of myxedema

30. Skin: use inspection and palpation. Start from head then proceed down Examination Normal data Abnormal data Inspect the skin for a. The color: note the color changes all over the body or in a localized area. Color varying from the black, brown or fair depending upon the genetic factor Uniform color all over the body No pallor, cyanosis, redness or yellowness Pallor due to anemia Peripheral cyanosis (seen on hand, feet) include anxiety, cold exposure and venous obstruction Central cyanosis (seen on lips and tongue) include lung disease, congenital heart disease Vitiligo , albinism, yellow color , scar marks

31. Albinism

32. Inspection of skin Examination Normal data Abnormal data b. Any patches or lesions or any evidence of itching as shown by scratching Skin fee of lesions or abrasion Skin patches, lesions or itching present c. Edema No edema Edema d. Excessive sweating or dehydration No excessive moisture or dryness - Dryness in hypothyroidism, oiliness in acne

33. Skin cont… Examination Normal data Abnormal data e. Evidence of injury No bleeding, bruising or laceration of skin Bleeding, bruising or laceration of skin Palpate the skin for a. temperature: feel it with the back of fingers Warm skin, even temperature Generalized warmth in fever, hyperthyroidism and coolness in hypothyroidism, local warmth in inflammation

34. Palpate the skin for cont… Examination Normal data Abnormal data b. texture: feel the skin for smoothness Smooth, soft skin Roughness in hypothyroidism c. edema: presses the skin with the index and middle finger and then leave and watch the depression Quickly depression recovers Depression recovers slowly Dehydration: dehydrated skin loses its elasticity. Check the elasticity of skin by pinching the skin just below the clavicle in adults and the abdominal skin in children, between the thumb and index finger, pulling it and quickly releasing it Elastic skin: the skin quickly comes back to its previous state Comes back to its previous state slowly

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36. Head Examination Normal data Abnormal data Inspection Scalp : scaliness , lumps or other lesions No scaliness , lumps or other lesions Redness and scaling in seborrheic dermatitis, psoraisis Skull: general size and contour of the skull. Note any deformities, lumps or tenderness Enlarges skull in hydrocephalus Hair: Hair distribution, color, cleanliness clean, smooth and dry hair color of hair varying from black brown and white depending upon genetic factor, no color change in the hair Loss of hair, dirty hair, changes in hair, e.g. fine hair in hyperthyroidism, coarse hair in hypothyroidism

37. Examination of Head Examination Normal data Abnormal data Palpation: swelling, tenderness and depression Hair texture No swelling, tenderness and depression Silky, clean Swelling, tenderness and depression Dry, oily, greasy

38. Examination of face Examination Normal data Abnormal data Face: involuntary movements, edema and masses Uniform movement of the sides of face, no edema and masses One side of the face moves different from the other side indicating one sided facial paralysis

39. Sinus examination

40. Sinuses Examination Normal data Abnormal data Use inspection and palpation Palpate the sinuses: palpate the frontal sinuses for tenderness by pressing up from under the bony brow on each side. Avoid pressure on the eyes. Then press upon each maxillary sinus No tenderness in frontal and maxillary sinuses Local tenderness, together with symptoms such as pain, fever and nasal discharge, suggests acute sinusitits involving the frontal or maillary sinuses Trans illumination of the sinuses It is not done routinely The room should be darkened. Using a strong, narrow light source, place the light snugly deep under each brow, close to the nose. Shield the light with your hand .

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43. Examination Normal data Abnormal data Look for a dim red glow as light is transmitted through the air filled frontal sinus to the forehead Ask the patient to open the mouth wide and tilt he head back. (an upper denture should first be removed.) Shine the light downward from just below the inner aspect of each eye or front of maxillary sinus Look through the open mouth at the hard palate. A reddish glow indicates a normal air filled maxillary sinus Absence of glow on one or both sides suggests a thickened mucosa or secretions in the frontal sinus, but it may also result from developmental absence of one or both sinuses.

44. EYE Examination Normal data Abnormal data Use inspection and palpation Inspection: eye brows: distribution Equal distribution in both sides Absent or abnormally distribution Eye lashes No infection, sty Present infection, sty, dandruff Eye lids No swelling, redness , lesions Present swelling, redness or lesions , ptosis The eye for bulges ( proptosis ) No bulges Bulging, staring or sunken eye Conjunctiva for any redness, paleness, discharge, foreign body, dryness or tear flowing Dark pink in color, no redness, paleness, discharge, foreign body, dryness or tear flowing; it is just moist Pale palpebral conjunctiva indicate anemia and redness indicates conjunctivitis

45. EYE cont… Examination Normal data Abnormal data The sclera for any color change, injury and dilated blood vessels White in color with few small blood vessels Yellow sclera indicates jaundice The cornea for color, abrasions or white spots Transparent , no abrasions or white spots Cloudy appearance , abrasions or white spots The pupils for size and shape Pupils are round and uniform in size and shape Irregular size or shape of the pupil The pupils reaction to light. Light a torch from the side of the eye and remove it. Observe how pupil reacts As the torch approaches the ye, pupils constricts and as the torch is removed the pupils dilate Pupils remain constricted even after the torch is removed

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47. Examination of extraoccular muscles Hold the finger vertically at least 50 cm away from the patient Cover the patient’s one eye Examination of extraoccular movements: ask the patient to follow the examiner’s finger or pencil as the examiner sweep through the six cardinal directions of gaze without moving the patients head . Making a wide H in the air lead the patient’s gaze. Extreme right To the right and upward Down a right To the extreme left To the left and upward Down on the left

48. The inability of the eye to gaze in any of the six direction is an indication of weakness of extra occular muscles A patient whose diplopia is maximal on looking down and to the right has either a weak right inferior rectus or a weak left superior oblique muscle.

49. Cover test (squint test) Cover one eye and ask the patient to look at the light of your pen torch Closely observe the uncovered eye for any movements If it moves to take up fixation, that eye was squinting Repeat the sequence for the other eye

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51. Convergence test (Accommodation) Ask the patient to follow the finger or pencil as you move it in toward the bridge of the nose. Poor convergence in hyperthyroidism

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54. Visual acuity test Snellen chart is used to test vision. Position the patient 20 feet (6 meter) from the chart. Patient who uses glass other than reading glasses should wear them Ask the patient to cover one eye and ask to read the smallest line of the print possible

55. Sequence of examination Use a Snellen chart positioned at 6 meters (20 ft) and dim the room lighting Cover one eye and ask the patient to read the chart from the top down until they cannot read any further. Repeat for the other eye. Snellen visual acuity is expressed as 6 (the distance at which the chart is read)over the number corresponding to the lowest line read

56. Snellen chart cont… If the patient cannot see the largest font, reduce the test distance to 3 meters, then to 1 meter if necessary. If they still cannot see the largest font, document instead whether they can count fingers, see hand movement or just perceive the difference between light and dark

57. Peripheral vision test Sit at about 1 meter away Ask the patient to cover one eye ask to look at the examiners eye directly opposite Close your other eye Slowly bring a pencil or other small test being object from the periphery into the field of vision from the 8 direction and ask the patient to say” now” “ dekhiyo ” as soon as it appears Keep the test object equidistant between your eye and patient’s so that you can compare the patient’s visual field your own. Repeat with the other eye

58. Nystagmus Hold the finger an arm length from the patient. Then ask the patient to look at your finger and follow it with his eyes without moving the head. Move your finger steadily to each side and up and down making a shape of "H". Watch the patient's eyes carefully for jerky movements on the direction of gaze. Normal : there is no abnormal movement (jerking) of the eyeball when at extremes of lateral gauze normal eyeball may also show some jerks. Abnormal : jerking of the eyeball on the direction of gaze

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60. EAR Examination Normal data Abnormal data Use inspection and palpation Inspection: a. Location The top of the pinna meets or crosses the eye: occiput line imaginary line drawn from the outer canthus of the eye to the occipital protuberance The top of the pinna does not meet or cross the eye – occiput line b. Pinna : The pinna for any lump or lesions No lumps or lesion, smooth rounded contour lump or lesions c. External auditory canals for any ear discharge, redness, mass, foreign body or cerumen (A waxy substance produced by ceruminous gland in the outer portion of the canal) No discharge, redness, mass or foreign body, slight cerumen present Clear blood or yellow discharge, redness, mass, foreign body, excessive cerumen present

61. Ear cont.. Examination Normal data Abnormal data d. (Pull ear up and back for adults) Tympanic membrane: use otoscope No perforations, lesions, bulging Perforations, lesions, bulging Palpate the ears by a. Pulling the upper portion of the pinna a little for tenderness b. Pressing the mastoid area for any tenderness No tenderness No tenderness Tenderness present Tenderness behind the ear may be present in the otitis media

62. Rinne test Place the base of the lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ascertain whether the sound can be heard again. Here “U” of the fork should face forward which maximize the sound Normally the sound is heard longer through air than through bone (AC>BC)

63. Abnormal findings: If the sound is louder on the mastoid process, bone conduction is better than air conduction. Record this as BC > AC. This may be due to conductive hearing loss

64. Weber test Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head or on the mid forehead Ask where the patient hears it: one or both sides Normally the sound is heard in the midline or equally in both ears If nothing is heard, try again, pressing the fork more firmly on the head

65. Abnormal finding: The noise is louder in an ear with conductive deafness In unilateral sensorineural hearing loss, the sound is better heard in the normal ear.

66. Weber Test Principles The inner ear is more sensitive to sound via air conduction than bone conduction (in other words, air conduction is better than bone conduction). In the presence of a purely unilateral conductive hearing loss, there is a relative improvement in the ability to hear a bone-conducted sound. This can be explained by the following: Masking effect:  The sound heard via the affected ear has less environmental noise reaching the cochlea via air conduction (for example, the environmental noise is masked) as compared to the unaffected ear which receives sounds from both bone conduction and air conduction. Therefore, the affected ear is more sensitive to bone-conducted sound.

67. Occlusion effect:  Most of the sound transmitted via bone conduction travels through to the cochlea. However, some of the low-frequency sounds dissipate out of the canal. A conductive hearing loss (in other words, when an occlusion is present) will, therefore, prevent external dissipation of these frequencies and lead to increased cochlear stimulation and increased loudness in the affected ear.

68. Nose Examination Normal data Abnormal data Inspection a. Location of nose Centrally located Deviated in location b. The nostrils for their size and flaring Nostrils are uniform in size and do not flare Asymmetrical in size or flaring nostril c. The nasal septum for any polyps (growths) using light No polyp or deviation Presence of polyps or deviation d. Assess the nasal canals with a torch for redness, discharge, foreign bodies etc Dark pink mucous membrane, no discharge or foreign bodies Red swollen mucosa of acute rhinitis; pale mucosa of allergic rhinitis

69. Mouth and throat: inspection and palpation Examination Normal data Abnormal data Inspection: a. The lip for color, moisture, lumps, cracks or ulcers Pink, moist and intact skin, no bluish discoloration, cracks and ulcers Lips bluish in color cracks or ulcers present b. The mucous membrane of the mouth for the color, ulcer, nodules and amount of saliva pink, moist mucous membrane, no ulcer, nodules Inflammation, swelling, redness or bleeding present c. The gums for inflammation, swelling, redness or bleeding Pink, no inflammation, swelling, redness or bleeding Inflammation, swelling, redness or bleeding present

70. Examination Normal data Abnormal data d. The teeth for the color, caries and missing tooth White teeth, no caries and missing teeth Brown teeth, presence of caries or missing teeth e. The tongue for symmetry, color and papillae Symmetry, pink, moist, papillae and midline fissure present Asymmetrical, red, pale, dry papillae or fissure absent f. The throat and note the color and size of the tonsils Pink throat and a small tonsils Red swollen and yellow discharge on the tonsils g. The swallowing difficulty by asking the patient to swallow No difficulty in swallowing Difficulty in swallowing

71. Examination Normal data Abnormal data Palpate: a. The gums on both sides with fore fingers of the right hand and check for swelling and tenderness (use gloves if available) No swelling, no tenderness Swelling and tenderness present b. The teeth by moving them with the fore fingers of the right hand for any pain or loose teeth No toothache, no loose tooth Toothache or loose teeth present Smell: The patient’s breath and note any foul odor or alcohol smell in the breath No foul odor nor smell of alcohol Breath odor of alcohol, acetone in diabetes mellitus, pulmonary infection, uremia etc

72. Lymph nodes Examination Normal data Abnormal data Use inspection and palpation Inspection: Redness or enlargement of lymph nodes Lymph nodes not visible, no redness Enlargement and redness of lymph nodes Palpation: enlargement and tenderness Lymph nodes are not palpable and tenderness Hard, fixed nodes suggest malignancy, enlargement of a supraclavicular lymph node especially on the left, suggests possible metastasis from a thoracic or abdominal malignancy

73. Neck: use inspection and palpation Examination Normal data Abnormal data Inspect The neck by asking the patient to sit straight. Note the position often head and neck Observe masses and scars of the neck No tilting of the head No masses, scars Tilting of the head A scar of past thyroid surgery may be the clue to the unsuspected hypothyroidism Enlargement of the thyroid gland Thyroid gland not visible and enlarged Enlarged thyroid gland For the ability to move neck up and down and from side to side. Note any stiffness or tenderness Full and smooth range of movement, no stiffness or tenderness No swelling or lump Swelling, tenderness and decreased range of motion suggests arthritis Swelling or lump present

74. Examination Normal data Abnormal data Palpation The back of the neck along the spine and back of the head. Check for the muscle tightening, tenderness, lump etc Palpate thyroid gland No tightness of the neck muscles No tenderness along the spine Thyroid gland is palpable in 50 % and 25% of men normally Muscle tightening, tenderness along the spine, lump along the spine Nodules, irregular mass present

75. Chest and lungs: use I,P,P,A Examination Normal data Abnormal data Inspect a. the chest for Size and shape: note the anterioposterior and lateral diameters of the chest Lateral diameter (side to side) is wider than anterioposterior (front to back) diameter Barrel shaped chest (increase antero posterior diameter) due to pulmonary emphysema Funnel shaped chest: characterized by a depression in the lower portion of the sternum Pigeon shaped chest: sternum is displaced anteriorly and increasing anterioposterior diameter b. The symmetry: note the location of sternum Symmetrical shape, sternum is located at the midline Sternum is displaced

76. Examination Normal data Abnormal data c. The intercostal spaces whether they move in (retract) when the patient breathes in No intercostals retraction Retraction at the intercostal spaces d. The cough: if the patient has cough, ask him to cough up the sputum and check the amount and color of sputum No cough, no sputum Brownish grey, yellow, grey, bloody or frothy sputum Palpation Check for tenderness, lumps, depression along the ribs No tenderness, lump or depression along the ribs Tenderness of the chest, lump or depression along the ribs present

77. Assessment of tracheal deviation: With the patient directly looking forwards, look for any deviation of the trachea Gently place the tip of you right index finger into the suprasternal notch and palpate the trachea. Slight displacement to the right is common in healthy people. Measure the distance between suprasternal notch and cricoid cartilage, normally 3 – 4 finger breadths, any less suggests lung hyperinflation.

78. Abnormal findings: Shift of the upper mediastinum causes tracheal deviation

79. Chest expansion Stand behind the patient and assess expansion of the upper lobes by watching the clavicles during tidal breathing Assess expansion of the lower lobes by placing your hands firmly on the chest wall. Your thumbs should almost meet in the midline and place just over the chest so they can move freely with respiration Ask the patient to take deep breath. Your thumbs should move symmetrically apart by at least 5 cm

80. Normal finding: Both sides of the thorax should expand equally during normal breathing and maximal inspiration Abnormal findings: Reduced expansion on one side indicates abnormality on that side For e.g. pleural effusion, lung or lobar collapse, pneumothorax

81. Examination Normal data Abnormal data Tactile fremitus

82. Percussion Put the middle finger of your non-dominant hand firmly to an intercostal space, parallel to the ribs, and drum (strike) the middle phalanx with the flexed tip of your dominant index or middle finger. Percuss in sequence (L shaped), comparing areas on the right with corresponding areas on the left before moving to the next level

83. Percussion technique cont…

84. Percussion Posteriorly , the scapular and spinal muscles obstruct percussion, so position the patient sitting forwards with their arms folded in front to move the scapulae laterally. Compare positions the same distance from the midline on right and left

85. Sites of percussion

86. Lung percussion sound Percussion sound Remark Resonant Normal lung Hyper resonant Pneumothorax Dull Pulmonary consolidation Severe pulmonary fibrosis Pleural effusion Hemothorx

87. Examination Normal data Abnormal data Auscultation Auscultation of breath sound To compare the duration of inspiration and expiration Check for any abnormal sounds like rales , (fine crackling sounds.) Ronchi (loud bubbly sounds) and wheezing Inspiration longer than expiration No rales , ronchi and wheezing sounds Prolonged expiration Rales , ronchi , wheezing sounds, pleural rub, crepitations present

88. Auscultation Ask the patient to be relaxed and breath deeply through the mouth Do not ask the patient to breath deeply for prolonged periods. This may cause giddiness and tetany Auscultate each side alternately, comparing findings over a large number of equivalent positions to ensure that you do not miss localized abnormalities

89. Auscultation cont… Listen Anteriorly from above the clavicle down to the sixth rib Laterally from the axilla to the eight rib Posteriorly down to the level of 11 th rib Assess the quality and amplitude of breath sounds Identify the inspiration and expiration time

90. Normal findings

91. Auscultate breath sound: Bronchial sound heard over the trachea are high pitched, harsh sounds with expirations longer than inspiration (E>I) Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest where inspiration equal to expiration Vesicular sounds are soft, low pitched and heard best in the base of lungs during inspiration longer than expiration

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94. Heart Examination Normal data Abnormal data Inspection Enlargement of neck (jugular) vein No enlargement Enlargement Scar marks History of surgery

95. Palpation Apex beat at 5 th intercoastal spaces or just below the nipple Palpate for thrill at the apex and both sides of the sternum using the flat of your fingers

96. Auscultation of heart sounds Aortic area: 2 nd intercoastal space just to the right of the sternum Pulmonic area: 2 nd intercoastal space just to the left of the sternum Tricuspid area: 4 th intercoastal space just to the left of the sternum Mitral area: 5 th intercoastal space at the mid clavicular line

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98. Auscultation of heart rate: Count the heart rate, compare the radial pulse to detect skipped beat by using stethoscope

99. Normal findings: Clear and regular, heart rate between 60 – 80 b/m. No murmur sound present First (S1) heart sound ( lub ) is caused by the closure of mitral and tricuspid valves at the onset of ventricular systole Second (S2) heart sound (dub) is caused by the closure of the pulmonary and aortic valves at the end of ventricular systole.

100. Abnormal finding: Decreased or inaudible heart sounds irregular or missed heart beats Heart rate less than 60 or more than 80 b/m. Murmur sound present

101. Female breast Examination Normal data Abnormal data Inspection Size and shape of the breast. Observe nipples point to the same direction Look for any swelling and dimpling or retraction of breast The nipple for cracks and discharge Breast and nipples are uniform in size and shape and nipples point to the same direction It is the normal for one beast to be slightly larger than the other No swelling, dimpling and retraction of breast No enlargement of veins No cracks, milky discharge in pregnant or breastfeeding women Irregular in shapes, redness over the breast, swelling and retraction Dimpling breast suggests an underlying cancer Cracks, yellow or bloody discharge

102. Examination Normal data Abnormal data Palpate both the breasts in a circular motion and check for any mass, swelling and tenderness Soft, non tender and often ridge of tissue felt at the bottom of breast Hard, irregular, poorly circumscribed suggest cancer Male breast A firm disc of glandular enlargement in a male is called gynecomastia

103. Abdomen Examination Normal data Abnormal data Inspection For the shape, scars, swelling and distended blood vessels Rounded or flat and uniform shape, no scar, swelling and visible blood vessels in abdomen Irregular in shape Abdominal scars present indicating previous injury or surgery. Swelling of abdomen and distended blood vessles

104. Examination Normal data Abnormal data Auscultation For bowel sounds, listen carefully in all areas using sthestethoscope . The stethoscope should be warm as the cold may contract the abdominal muscles. note whether the bowel sounds are increased, decreased or absent Listen in all quadrant for 5 min Bowel sound present in all areas (bowel sounds are produced in every 5 – 15 seconds) Clicks and gurgling sounds High pitched tinkling sounds, absence of bowel sound (no bowel sound heard for 5 minutes) Loud rushing sound

105. Examination Normal data Abnormal data Percussion Keep the patient in supine position. Note the areas where dull or tympanic sounds are produced (tympanic sound is heard over gas filled viscera and dull sound over fluid filled viscera, fecal organs or masses). Shifting dullness: Then turn the patient on his side and pause for 10 seconds. Again percuss all the Side areas. Note if there is shifting dullness when the patient is moved. Shifting dullness is a sign of fluid in abdomen. Sacttered area of tympany and dullness Absence of tympany

106. Fluid thrill I f the abdomen is tensely distended and you cannot certain whether ascites is present, feel for a fluid thrill. Place the palm of your left hand flat against the left side of the patient's abdomen and ask the assistant or patient to place the edge of his hand on the midline of the abdomen. This prevents transmission of impulse via the skin rather than through the ascites.

107. Fluid Thrill cont.… Then flick a finger of your right hand against the right side of the abdomen and feel a ripple (thrill of fluid). Normal: thrill of fluid is absent. Abnormal: fluid thrill is present.

108. Examination Normal data Abnormal data Palpation Place the patient in the supine position and ask him to relax his abdomen Palpate the abdomen in all four quadrants fell for any masses or tenderness Ask the patient to breath in deeply and gently palpate The liver : place the left hand on the back beneath the patients 11 th and 12 th rib and apply upward pressure to push the liver forward towards the examining right hand . Place the palmer surface of the right hand parallel to the coastal margin.

109. Examination Normal data Abnormal data Ask the patient to take a deep breath and as the liver sliding over the fingers. Note any enlargement or tenderness. If enlarged, estimate the amount of enlargement beyond the right coastal margin. Express it in centimeters No abdominal mass and tenderness Liver is not usually palpable but in thin people it may be palpable immediately below he coastal margin as a smooth structure wit ha regular contour and a firm, sharp edge Liver palpable as soft or hard edge or irregular in contour

110. Examination Normal data Abnormal data The spleen Keep the patient in right lateral position. Place the left hand on the patient’s back under the left rib cage. Apply upward pressure in the pressure in the left upper quadrant with the right hand fingers moving towards the anterior axillary line and beneath the coastal margin. Feel for the enlargement or tenderness of the spleen Spleen is not palpable. No enlargement and tenderness on palpation Spleen enlarge and tender

111. Examination Normal data Abnormal data Kidneys: Keep the patient in the supine position. Place the left hand on the patient’s back between the lowest rib Ask the patient to take deep breaths. Press firmly with the right hand and try to feel the kidney. Feel on the left side too. Note the enlargement or tenderness on kidneys Kidneys are not palpable and tender Kidneys enlarged and tender

112. Anus Examination Normal data Abnormal data Use inspection The anus for any irritation, crack, fissures or enlarged vessels No irritation, fissure, cracks or enlarged blood vessels in the anus Presence of anal irritation, anal fissure and enlarged anal blood vessels Male genitals Use inspection, palpation Inspection The penis for any sores or lumps The scrotum for any redness, swelling or any lesions No sore, lump No swelling, redness or lesions Presence of sore or lumps Swelling, redness or lesions of scrotum

113. Examination Normal data Abnormal data Palpation Palpate testes for Enlargement or tenderness of scrotum No enlargement, tenderness or scrotum. Testes are equal in size, no tenderness Enlargement or tenderness of scrotum, one testis is larger than the other

114. Examination Normal data Abnormal data Female Genitals Inspection The labia for color and look for redness or swelling of the labia. Check the urethral orifice for redness or discharge Look for any discharge or bleeding from the vagina Labia are of same color and size. No redness or swelling of the labia No redness or discharge at the urethra No unusual discharge from the vagina, no bleeding from the vagina (except during menstruation) Red or swollen labia Redness or discharge at urethra Unusual discharge and bleeding (except during menstruation)

115. Musculoskeletal system Examination Normal data Abnormal data Use inspection and palpation and movement Inspection: The muscles and joints: Ask the patient to stand. Inspect his neck, shoulder, arms, hands, hips, knees, legs, ankle and feet. Note any bone or joint deformity, joint redness, swelling or muscle wasting No bone or joint deformity, no redness, swelling of joints, no muscle wasting Presence of bone deformity, joint deformity, joint redness or swelling, muscle wasting

116. Examination Normal data Abnormal data Palpation The musculoskeletal system: e.g. the patient’s neck, shoulder, elbows, writ, fingers, hips, knees, ankles, toes one by one and feel for swelling, tenderness and temperature No joint swelling or tenderness Normal temperature Joints swelling suggests rheumatoid arthritis Increased temperature over a joint

117. Examination Normal data Abnormal data The joint movement. Ask the patient to move his neck, shoulder, elbows, wrists Compare one side with the other side. Able to move joints freely. No sign of pain while moving joints Limited movement of the joint. Signs of pain when moving the joint.

118. Examination Normal data Abnormal data Ask the patient to move his Fingers, hip, knees ankles and toes one by one in all possible directions Able to move joints freely. No sign of pain while moving joints Conditions that impair range of motion include arthritis, inflammation of the tendon sheaths and fibrosis in palmer fascia .

119. Examination Normal data Abnormal data Make a fist with each hand, thumb across the knuckles and then extend and spread the fingers Inspect the patient’s spine. Note its placement and curvature A person able to make tight fists and extend and spread the fingers smoothly and easily Spine is in the midline. Spine slightly curved out form the neck and gradually curving inward at the waist Lateral deviation of spine, increased curvature of spine. Increased curvature of spine or flattening of curves of the spine. Decreased spinal mobility in osteoarthritis.

120. Examination Normal data Abnormal data Range of motion at knees and hips.

121. Stretch test: Sciatic nerve(L4-5,S1-3)

122. Examination Normal data Abnormal data Assess the orientation: By asking the patient about the current time, place and pointing out to a person and asking “ who is he/ she?” Patient says the correct current time, place of stay and the person pointed at Patient cannot say the correct current time, place of stay and the person pointed at

123. Nervous system Examination Normal data Abnormal data Muscle strength: Equal strength in both hands and feet. No muscular weakness Muscular weakness in one or both hands and feet Sensation: ask the patient to close his eyes. Brush the skin of his face, arms, hands, thighs and legs with a piece of cotton and instruct the patient to signal when he feels light brush of the cotton Feels light brush of the cotton equally on both sides of his body Loss of sensation to light brush Coordination of movement: ask the patient to button his shirt or to tie his shoes Coordinated movements Uncoordinated movement

124. Assessment of power Score Remarks No muscle contraction visible 1 Flicker of contraction but no movement 2 Joint movement when the effect of gravity eliminated 3 Movement against the gravity but not against examiners resistance 4 Movement against resistance but weaker than normal 5 Normal power

125. Reflex In a normal person, when a muscle tendon is tapped briskly, the muscle immediately contracts due to nerves that innervates the muscle. 

126. Babinski reflex (planter reflex) Run a blunt object along the lateral border of the sole of the foot towards the toe (from heel of the feet to the ball of the foot towards the big toe) Observe the response Normally all the five toes bend downwards This reaction is negative babinski . In an abnormal (positive) babinski response the toes spread outward and the big toe moves upward

127. Biceps reflex The forearm should be supported, either resting on the patient's thighs or resting on the forearm of the examiner. The arm is midway between flexion and extension. Place your thumb firmly over the biceps tendon, with your fingers curling around the elbow, and tap briskly. The forearm will flex at the elbow or the muscle just above the bicep tendon contracts .

128. Triceps reflex Support the patient's forearm by cradling it with yours or by placing it on the thigh, with the arm midway between flexion and extension. Identify the triceps tendon at its insertion on the olecranon , and tap just above the insertion. There is extension of the forearm or contraction of the muscle just above the triceps tendon .

129. Knee Let the knees swing free by the side of the bed, and place one hand on the quadriceps so you can feel its contraction. If the patient is in bed, slightly flex the knee by placing your forearm under both knees There is contraction of the quadriceps along with extension of the lower leg

130. Achilles tendon The ankle reflex is elicited by holding the relaxed foot with one hand and striking the achilles tendon with the hammer and noting plantar flexion. Compare to the other foot

131. ..\videos\y2mate.com - deep_tendon_reflex_examination_for_nursing_head_to_toe_assessment_of_neuro_system_eqOpNQH09pA_1080p.mp4

132. Thank you