A.

Nursing Health History

a. Biographic Data
b. Chief Complaint
c. History of Present Illness
d. Past Health History of Illness
e. FUNCTIONAL HEALTH PATTERNS
(11 by Gordon)

B. Physical Examination
 Best done when?
 Techniques:
 Head – toe (cephalo-caudal) examination
 Special Considerations: Positioning:
a. Neck: nurse behind the client
b. Thorax/Lungs: sitting position
c. Abdomen:
 Position
 sequence of examination (technique and quadrants)
 Skills of Physical Assessment
Palpation:
SENSITIVITY OF PARTS OF THE HAND

Hand Part Used Type of Sensation

Felt
Fingertips Fine discriminations

Palmar / Ulnar surface Vibratory sensations

(e.g. thrills, fremitus)
Dorsal Surface Temperature
 Deep palpation

Light palpation
2 TYPES OF PALPATION:
1. Light palpation - 1 cm
 dominant hand’s fingers parallel to skin
surface
 skin is slightly depressed;
2. Deep palpation – 4 cm
 done with one or two hands (bimanually)
a. deep bimanual
b. deep palpation using one hand
 Indirect percussion

Direct percussion
 Skills of Physical Assessment
3. Percussion
 sense of touch and hearing
 tapping a part of body with fingertips to elicit
character and density of underlying tissue
 determine whether underlying tissue
a. AIR – FILLED
b. FLUID FILLED
C. SOLID
 Skills of Physical Assessment
3. Percussion
Two types:
a. Direct – to elicit tenderness or pain
(differentiate)
b. Indirect
 Pleximeter: middle finger of non-dominant
hand
 Plexor: dominant hand
* Plexor strikes the distal interphalengeal joint
 Skills for Physical Assessment
4. Auscultation
 process of listening to various sounds (breath,
heart, bowel) produced within the body using
stethoscope
- stethoscope: bell and diaphragm: types of
sounds
General Color:
a. Normal: pinkish

b. Pallor
 Dark – skinned? Ashen gray
 Brown – skinned? Yellowish brown tinge
 Light skin?
* Face, conjunctiva, nails
General Color:
c. Jaundice – yellowish tinge
 Evident where?
* Sclera, mucous membranes, skin
 Dark skinned: normal yellow
pigmentation of sclera:

Where to assess for jaundice?

* Hard palate
General Color:

d. Cyanotic – bluish tinge/discoloration

 Best assess where?
* Nail beds, lips, buccal mucosa
1. Central cyanosis
 lips, buccal mucosa, tongue
2. Peripheral cyanosis
 nails and skin of extremities
Skin Turgor:
 fullness or elasticity
 How:
* lifting and pinching the skin
a. Normal: Good: springs back to previous
state
b. Poor
 For elderly:
 For children:
 Scale
for describing edema:
Grade 1+ : 2 mm
Grade 2+ : 4 mm
Grade 3+ : 6 mm
Grade 4+ : 8 mm

* BRAWNY EDEMA
SKIN LESIONS:
PRIMARY = APPEARS INITIALLY
Macule – small flat Patch – bigger macule
Papule – elevated Plaque – bigger papule
Vesicle – with fluid Bulla– bigger vesicle
Pustule – with pus Wheal – mosquito bites
 SECONDARY :
TRAUMATIZED PRIMARY LESION

C = Crust – dried blood, pus or serum

U = Ulcer – deep, irregular wearing away
E = Erosion – wearing away of epidermis
S = Scales – shedding flakes
NAIL PLATE SHAPE : curvature and angle
▪ convex curvature
▪ angle between nail and nail bed: 160 degrees

b. Spoon – shaped nail: Koilonychia:

(IDA)
NAIL PLATE SHAPE : curvature and
angle

c. Clubbing
Early clubbing: flattened angle
(180)
Late Clubbing > 180
BLANCH TEST (CAPILLARY REFILL)
a. Normal:

b. Delayed return of pink

EYES AND VISION
 Visual Acuity Tests:
a. Distance Vision Test
b. Near Vision Test
 PERRLA
 Pupil size
 Abnormalities:
 Unequal pupil:
 Dilated pupil?
 Constricted pupil?
II. EYES AND VISION
 Abnormalities:
a. Myopia
b. Hyperopia
c. Presbyopia: loss of elasticity of lens
d. Astigmatism: uneven curvature of cornea
 Tests for glaucoma:
a. Tonometry – measures IOP: Normal: 8- 21
mmHg
b. Perimetry – loss of peripheral vision
c. Opthalmoscopy – cupping of the disc
d. Gonioscopy – measures the angle to differentiate closed
and open angle glaucoma
Question:

 What type of lens should be used to

correct myopia?

 Type of lens to be used to correct

hyperopia?
EARS AND HEARING
 To visualize ear canal:
a. AdUlt
b. ChilD
 Tests:
a. Rinne Test
 Normal: AC is greater than BC
 Conductive problems: BC > AC
c. Schwabach Test
b. Weber test
 bone conduction by testing lateralization of sounds: N:
(-)

 Conductivehearing loss,
Bad ear hears better
 Sensorineuralhearing loss,
Good ear hears better
 Interpretations:
BAD-CONDUCTION,
GOOD-SENSATION
Mouth and Pharynx

Question:

PART WHERE
CENTRAL CYANOSIS
IS BEST ASSESSED?
THORAX AND LUNGS

a. APL ratio
b. Percussion:
Normal:
 Resonant
Dullness:
 with solid tissue (PNEUMONIA) or fluid (Pleural
effusion)
Hyperresonance:
 hyper-inflated lungs (asthma, emphysema)
 Thorax and Lungs
Chest deformities:

1. Pigeon chest : pectus carinatum

 Narrow, transverse diameter, increased AP
and protruding sternum

2. Funnel chest : pectus excavatum

 Sternum depressed, narrow AP diameter,
 Thorax and Lungs
Chest deformities:

3. Barrel chest :
 APL is 1:1

4. Kyphosis
 Excessive convex curvature

5. Scoliosis
 NORMAL BREATH SOUNDS:

a. Bronchial
 air passing thru trachea
 in front of trachea.
 1:2 ratio (inspiration: expiration)
 NORMAL BREATH SOUNDS:

b. Bronchovesicular
 air moving thru larger bronchi
 between scapulae, 2nd ICS.
 1:1 ratio
 
 NORMAL BREATH SOUNDS:
c. Vesicular
 air moving through smaller bronchioles and
alveoli
 peripheral, base of lungs
 5:2 ratio
ADVENTITIOUS BREATH SOUNDS:

1. CRACKLES – RALES:
R = Roll hair
A = Air pass mucus
L = Low lungs
E = Exaged by inspiration
S = Styles: fine, med, course
ADVENTITIOUS BREATH SOUNDS:

2. FRICTION RUB
 rubbing, inflamed pleural surfaces.
 grating sound
 lower anterior chest
 audible: both inspiration and expiration.
ADVENTITIOUS BREATH SOUNDS:

3. GURGLES
 air thru narrowed spaces
 coarse, with snoring quality
 predominate: bronchi and trachea.
 best heard on expiration.
ADVENTITIOUS BREATH SOUNDS:

4. WHEEZE
 air thru constricted bronchus
 high pitched, squeaky musical sound.
 over all lung fields
 best heard on expiration.
JUGULAR VEIN:
 semi-fowler’s: 30-45° during
assessment.
 veins not visible: normal
 veins distended: possible right sided heart
disease.
 Measure JV highest distention from angle
of Louis
 until 4cm only.
 above 4cm: vein distention.
a. Point of Maximal Impulse
a. Semilunar and Attrioventricular (AV) valves
P: 2nd ICS left sternal border
A: 2nd ICS right sternal border
M: 5th ICS left MCL
T: 5th ICS left sternal border
BREAST
a. Upper outer quadrant
 common site of breast cancer
b. BSE 5-7 after the first menstruation day
MONTHLY
c. 20-40 y/o: Clinical breast exam
yearly
D. Mammography at 40 yearly
a. Sequence:
 By quadrant: RLQ, RUQ, LUQ, LLQ
b. Position:
c. Bowel Sounds:
 Normoactive
 Hypoactive
 Hyperactive
 Absent:
Abdominal
Test:

Shifting
Dullness
 COMPONENTS OF
NEUROLOGICAL ASSESSMENT
1. Mental Status
2. Level of Consciousness
3. Reflexes
4. Motor Functions
5. Sensory Functions
6. Cranial Nerves
I. Mental Status:
 Reveals cerebral function (intellectual and
affective)
 Major areas of assessment:
a. Language
b. Orientation
c. Memory
d. Attention span
e. Calculation
A. Language
Aphasia – inability to express oneself by
speech, writing or comprehend spoken or
written language due to disease of
cerebral cortex
Two Categories:
1. Sensory or receptive aphasia
2. Motor or expressive aphasia
1. Sensory/receptive aphasia
- loss of ability to comprehend written or
spoken words
Two types:
a. Auditory aphasia – unable to understand
symbolic content associated with sounds
b. Visual aphasia – unable to understand printed
or written figures
2. Motor/ expressive aphasia
- loss of power to express oneself by writing,
making signs or speaking
How to assess language deficits:
 Point to common objects and name them
 Read some words and match printed and
written words with pictures
 Respond to verbal/written commands
Speech Patterns:
- pace, clarity, spontaneity
Abnormalities:
a. Perseveration
- repeating the same response as different
questions are asked
b. Paraphasia
- speech appropriately expressed but contains
incorrect words
B. Orientation – 3 spheres
C. Memory
- Listen for lapses of memory
- If problems are present:
Three categories of memory:
1. Immediate recall
N: can repeat series of 5 – 8 digits in sequence and
4 – 6 digits in reverse order
C. Memory
2. Recent memory
- Ask to recall the events of the day
- Recall information given early in the
interview
- Provide 3 facts to recall (color, object,
address), then ask later
C. Memory
3. Remote memory
- Previous illness or surgery (years ago), birthday,
anniversary
D. Attention Span
- Tests the ability to concentrate
(alphabet, count backward from 100)
E. Calculation
- Serial seven or serial three test
N: can complete serial seven in 90 seconds
with 3 or less errors
II. Level of Consciousness
 Conscious, L O S C
 Glasgow Coma Scale (GCS)
a. Eye opening 4
b. Verbal response 5
c. Motor response 6
Perfect score: 15
(fully alert and oriented)
* Score of 7 or less- comatose
III. REFLEXES
- Automatic response of the body to stimulus
- Not voluntary learned or conscious
- Deep tendon reflex (DTR) is activated when
tendon is stimulated (tapped) and its associated
muscle contracts
- Reflex response varies among individuals and by
age
 Equipment: reflex hammer
Scale for Grading Reflex Responses
0: No reflex response
+1: minimal activity (hypoactive)
+2: normal response
+3: more active than normal
+4: maximum activity (hyperactive)
REFLEXES:
1. Biceps Reflex
- tests the spinal cord C5 & C6
2. Triceps Reflex
- spinal cord C7 and C8
- triceps tendon 1-2 in above elbow
REFLEXES
3. Brachioradialis reflex
- spinal cord C3 and C6
- tap directly on the radius (1-2 in) above
the wrist or the styloid process (bony
prominence on the thumb side of the
wrist)
REFLEXES
4. Patellar reflex
- spinal cord L2, L3, L4
5. Achilles reflex
- spinal cord level S1 and S2
- dorsiflex the ankle
6. Plantar (Babinski) reflex
CEREBELLAR FUNCTION
a. Posture and gait
b. Smooth and coordinated movements
c. Equilibrium
Cerebellar disorders:
Ataxia
 lack of muscle coordination
 tremors
 disturbance of equilibrium, timing of
movements and gait
MOTOR FUNCTION
Gross Motor and Balance Tests
a. Gait
b. Romberg test
c. Standing on one foot with eyes closed (5
seconds)
d. Heel to toe walking
MOTOR FUNCTION
Fine Motor Tests for Upper Extremities
a. Finger to Nose Test
b. Alternating Supination and Pronation of Hands
on Knees
c. Finger to Nose and nurse’s finger ( 18 in)
d. Finger to thumb
V. SENSORY FUNCTION
 include touch, pain, temperature,
position and tactile discrimination
 face, arms, legs, hands, feet are tested
Three types of tactile discrimination:
a. One and two point discrimination
 ability to sense whether one or two areas of skin are
being stimulated by pressure
b. Stereognosis
 act of recognizing objects by touching and
manipulating them
c. Extinction
 failure to perceive touch on one side of the body when
two symmetrical areas of the body touched
simultaneously
AGNOSIA
- Inability to recognize objects by use of senses
 THE CRANIAL NERVES
CN I: Olfactory
CN II: Optic
CN III: Oculomotor
CN IV: Trochlear
CN V: Trigeminal
CN VI: Abducens
CN VII: Facial
CN VIII: Vestibulocochlear/Acoustic
CN IX: Glossopharyngeal
CN X: Vagus
CN XI: Spinal Accessory
CN XII: Hypoglossal
 The intervention that should be included in the
assessment of a patient’s orientation would be:
A. asking the patient to state the time of day
      B. inquiring if the patient remembers the
nurse’s name
      C. ascertaining if the patient can follow simple
directions
      D. determining if the patient follows
movement
with the eyes
 Which of the following indicates a normal
finding on percussion of the lungs?

1. Tympany over the right upper lobe

2. Resonance over the left upper lobe
3. Hyperresonance over the left lower lobe
4. Dullness above the left 10th intercostal
space
1. Tympany would be heard over the
stomach (air filled).
2. Correct. Resonance is a normal
sound over the lung.
3. Hyperresonance is never a normal
finding
4. Dullness would be heard below (not
above) the 10th intercostal space.
 After auscultating the abdomen, the nurse
should report which of the following to the
primary care provider?
1. Bruit over the aorta
2. Absence of bowel sounds for 60 seconds
3. Continuous bowel sounds over the ileocecal
valve
4. A completely irregular pattern of bowel sounds
1. Correct. A bruit suggests abnormal
turbulence in the aorta, and the primary
care provider must be notified.
2. In order for absence of bowel sounds to be
considered abnormal, they must be silent
for 3 to 5 minutes.
3. Continuous bowel sounds are normally
heard over the ileocecal valve following
meals.
4. Bowel sounds are more commonly
irregular than they are regular.
 If unable to locate the client’s popliteal pulse
during a routine examination, the nurse should
perform which of the following next?
1. Check for a pedal pulse.
2. Check for a femoral pulse.
3. Take the client’s blood pressure on that thigh.
4. Ask another nurse to try to locate the pulse.
1. Correct. If a pedal pulse, which is more distal than the
popliteal, is present, then adequate arterial circulation
to the leg is present even though the popliteal artery
has not been located.
2. Presence of a femoral pulse would not provide
confirmation that arterial flow exists below that point.
3. Taking a thigh BP requires locating the popliteal pulse.
4. Since the purpose of finding the popliteal pulse is to
provide information about arterial circulation to the leg,
checking the distal pulse before requesting assistance
from another nurse is appropriate.
 Which of the following is an expected
finding during assessment of the older
adult?
1. Facial hair becomes finer and softer.
2. Decreased peripheral, color, and night
vision.
3. Increased sensitivity to odors.
4. Respiratory rate and rhythm are
irregular at rest.
1. Facial hair is likely to become coarser, not
finer.
2. Correct. Visual acuity often lessens with
age.
3. The sense of smell becomes less, rather
than more acute.
4. The respiratory rate and rhythm is regular
at rest. However, both may change
quickly with activity and be slow to return
to the resting level.
 If the client reports loss of short-term
memory, the nurse would assess this using
which one of the following?
1. Have the client repeat a series of three
numbers, increasing to eight if possible.
2. Have the client describe his or her childhood
illnesses.
3. Ask the client to describe how he or she
arrived at this location.
4. Ask the client to count backwards from 100
subtracting seven each time.
1. Recalling a series of numbers tests
immediate recall.
2. Recalling childhood events tests
remote (long-term) memory.
3. Correct. Recent memory includes
events of the current day.
4. Subtracting backwards from 100 tests
attention span and calculation skills.