dando head-toe assessment

8/9/2019 Dando Head-Toe Assessment

1/45

Head: Shape and symmetry; condition of hair and scalp

Eyes:

Conjunctiva and sclera, pupils; reactivity to light and ability to follow your finger or a light

Ears: Hearing aids, pain? Speak in a whisper: can he hear you and comprehend? urn away to

make sure he isn!t reading your lips"

Nose: #rainage, congestion, difficulty breathing, sense of smell

Throat and Mouth: $ucous membranes, any lesions, teeth or dentures, odor, swallowing,

trachea, lymph nodes, tongue

%" &evel of Consciousness and 'rientation:

(s he awake and alert? (s he oriented to Person )knows his name*, Place )he can tell

you where he is* andTime )knows the day and date*" + fourth level of orientation

is Purpose )he knows why you are eamining him; or knows the function of something

such as your penlight or stethoscope*"

-" Skin:

+s you eamine all body systems you need to make note of the status of the (ntegumentary

System for any breaks in the skin, scars, lesions, wounds, redness, or irritat." horacicregion:

+ssess lung and cardiac sounds from the front and back" +ssess them for character and

/uality as well as for the presence or absence of appropriate sounds" 0alpate the chest

wall and breasts for any tenderness or lumps"

1" +bdomen:

&isten to bowel sounds throughout the - /uadrants" 0alpate for tenderness or lumps"

0alpate the bladder" +sk about intake and output of bowels and bladder" +sk about

appetite" +sses genitalia for tenderness, lumps or lesions"

2" 3tremities:

+ssess for temperature, capillary fill and 4'$" 0alpate for pulses" 5ote any edema,lesions, lumps or pain"

6" 7eneral 8uestions:

+sk the patient how he feels" Has anything changed recently? +ny pain, burning, S'9,

chest pains, change in bowel or bladder habitsfunction, change in sleep habits, cough,

discharge from any orifice, depression, sadness, or change in appetite? ion" +ssess theturgor, color, temperature and moisture of the skin"

Integument


2/45

• Skin: The client’s skin is uniform in color, unblemished and

no presence of any foul odor. He has a good skin turgor and

skin’s temperature is within normal limit.

• Hair: The hair of the client is thick, silky hair is evenly

distributed and has a variable amount of body hair. There are

also no signs of infection and infestation observed.

• Nails: The client has a light brown nails and has the shape of

convex curve. It is smooth and is intact with the epidermis.

hen nails pressed between the !ngers "#lanch Test$, the

nails return to usual color in less than % seconds.

Head

• Head: The head of the client is rounded& normocephalic and

symmetrical.

• Skull: There are no nodules or masses and depressions

when palpated.

• Face: The face of the client appeared smooth and has

uniform consistency and with no presence of nodules or

masses.

'yes and (ision

• Eyebrows: Hair is evenly distributed. The client’s eyebrows

are symmetrically aligned and showed e)ual movement when

asked to raise and lower eyebrows.

• Eyelashes: 'yelashes appeared to be e)ually distributed

and curled slightly outward.

• Eyelids: There were no presence of discharges, no

discoloration and lids close symmetrically with involuntaryblinks approximately *+- times per minute.

• Eyes


3/45

• The #ulbar con/unctiva appeared transparent with few

capillaries evident.

• The sclera appeared white.

• The palpebral con/unctiva appeared shiny, smooth and

pink.

• There is no edema or tearing of the lacrimal gland.

• 0ornea is transparent, smooth and shiny and the details

of the iris are visible. The client blinks when the cornea was

touched.

• The pupils of the eyes are black and e)ual in si1e. The

iris is 2at and round. 3'4456 "pupils e)ually round respond

to light accommodation$, illuminated and nonilluminated

pupils constricts. 3upils constrict when looking at near

ob/ect and dilate at far ob/ect. 3upils converge when ob/ect

is moved towards the nose.

• hen assessing the peripheral visual !eld, the client

can see ob/ects in the periphery when looking straight

ahead.

• hen testing for the 'xtraocular 7uscle, both eyes of

the client coordinately moved in unison with parallel

alignment.

• The client was able to read the newsprint held at a

distance of *% inches.

'ars and Hearing

• Ears: The 6uricles are symmetrical and has the same color

with his facial skin. The auricles are aligned with the outer

canthus of eye. hen palpating for the texture, the auricles

are mobile, !rm and not tender. The pinna recoils when folded.

8uring the assessment of atch tick test, the client was able

to hear ticking in both ears.


4/45

9ose and inus

• Nose: The nose appeared symmetric, straight and uniform

in color. There was no presence of discharge or 2aring. henlightly palpated, there were no tenderness and lesions

• Mouth:

• The lips of the client are uniformly pink& moist,

symmetric and have a smooth texture. The client was able

to purse his lips when asked to whistle.

• Teeth and Gums: There are no discoloration of the

enamels, no retraction of gums, pinkish in color of gums

• The buccal mucosa of the client appeared as uniformly

pink& moist, soft, glistening and with elastic texture.

• The tongue of the client is centrally positioned. It is pink

in color, moist and slightly rough. There is a presence of

thin whitish coating.

• The smooth palates are light pink and smooth while the

hard palate has a more irregular texture.

• The uvula of the client is positioned in the midline of

the soft palate.

• Neck:

• The neck muscles are e)ual in si1e. The client showed

coordinated, smooth head movement with no discomfort.

• The lymph nodes of the client are not palpable.

• The trachea is placed in the midline of the neck.

• The thyroid gland is not visible on inspection and the

glands ascend during swallowing but are not visible.

Thorax, 5ungs, and 6bdomen

• Lungs / hest: The chest wall is intact with no tenderness

and masses. There’s a full and symmetric expansion and the

thumbs separate -; cm during deep inspiration when


5/45

assessing for the respiratory excursion. The client manifested

)uiet, rhythmic and e


6/45

6ssessment =indings

• kin hen skin is pinched it goes to

previous state immediately "-

seconds$.

ith fair complexion.

ith dry skin

• Hair 'venly distributed hair.

ith short, black and shiny hair.

ith presence of pediculosis

0apitis.

• 9ails mooth and has intact epidermis

ith short and clean !ngernails

and toenails.

0onvex and with good capillary

re!ll time of - seconds.

kull 4ounded, normocephalic and

symmetrical, smooth and has

uniform consistency.6bsence of

nodules or masses.

=ace ymmetrical facial movement,

palpebral !ssures e)ual in si1e,

symmetric nasolabial folds.

'yes and (ision


7/45


8/45

6ssessment =indings

penlight which is held in an

obli)ue angle of the eye and

moving the light slowly across the

eye.

Has >brown? eyes.

• 0orneal sensitivity #links when the cornea is touched

through a cotton wisp from the

back of the client.

3upils #lack, e)ual in si1e with

consensual and direct reaction,

pupils e)ually rounded and

reactive to light and

accommodation, pupils constrict

when looking at near ob/ects,

dilates at far ob/ects, converge

when ob/ect is moved toward the

nose at four inches distance and

by using penlight.

(isual =ields hen looking straight ahead, the

client can see ob/ects at the

periphery which is done by having

the client sit directly facing the

nurse at a distance of -; feet.

The right eye is covered with a

card and asked to look directly at

the student nurse’s nose. Hold


9/45

6ssessment =indings

penlight in the periphery and ask

the client when the moving ob/ect

is spotted.

(isual 6cuity 6ble to identify letter@read in the

newsprints at a distance of

fourteen inches.

3atient was able to read the

newsprint at a distance of A

inches.

'ar and Hearing

• 6uricles 0olor of the auricles is same as

facial skin, symmetrical, auricle is

aligned with the outer canthus of

the eye, mobile, !rm, nontender,

and pinna recoils after it is being

folded.

• 'xternal 'ar 0anal ithout impacted cerumen.

• Hearing 6cuity Test (oice sound audible.

• atch Tick Test6ble to hear ticking on right ear ata distance of one inch and was

able to hear the ticking on the left

ear at the same distance


10/45

6ssessment =indings

9ose and sinuses

• 'xternal 9ose ymmetric and straight, no

2aring, uniform in color, air moves

freely as the clients breathes

through the nares.

• 9asal 0avity 7ucosa is pink, no lesions and

nasal septum intact and in middle

with no tenderness.

7outh and Bropharynx ymmetrical, pale lips, brown

gums and able to purse lips.

• Teeth ith dental caries and decayed

lower molars

• Tongue and 2oor of the

mouth

0entral position, pink but with

whitish coating which is normal,

with veins prominent in the 2oor

of the mouth.

• Tongue movement 7oves when asked to move

without diCculty and without

tenderness upon palpation.

Dvula 3ositioned midline of soft palate.


11/45

6ssessment =indings

Eag 4e2ex 3resent which is elicited through

the use of a tongue depressor.

9eck 3ositioned at the midline without

tenderness and 2exes easily. 9o

masses palpated.

Head movement 0oordinated, smooth movement

with no discomfort, head laterally

2exes, head laterally rotates and

hyperextends.

7uscle strength ith e)ual strength

5ymph 9odes 9onpalpable, non tender

• Thyroid Eland 9ot visible on inspection, glands

ascend but not visible in female

during swallowing and visible in

males.

Thorax and lungs

3osterior thorax 0hest symmetrical

• pinal alignment pine vertically aligned, spinal

column is straight, left and right

shoulders and hips are at the


12/45

6ssessment =indings

same height.

#reath ounds ith normal breath sounds

without dyspnea.

• 6nterior Thorax Fuiet, rhythmic and e


13/45

6ssessment =indings

resistance.

#ones and oints 9o deformities or swelling, /oints

move smoothly.

7ental tatus

5anguage 0an express oneself by speech or

sign.

Brientation Briented to a person, place, date

or time.

6ttention span 6ble to concentrate as evidence

by answering the )uestions

appropriately.

5evel of 0onsciousness 6 total of *+ points indicative of

complete orientation andalertness.

7otor =unction

Eross 7otor and #alance

• alking gait Has upright posture and steady

gait with opposing arm swing


14/45

6ssessment =indings

unaided and maintaining balance.

tanding on one foot with eyes

closed

7aintained stance for at least !ve

"+$ seconds.

Heel toe walking 7aintains a heel toe walking

along a straight line

Toe or heel walking 6ble to walk several steps in

toes@heels.

=ine motor test for Dpper

'xtremities

=inger to nose test 4epeatedly and rhythmically

touches the nose.

6lternating supination and

pronation of hands on knees

0an alternately supinate and

pronate hands at rapid pace.

=inger to nose and to the nurse’s

!nger

3erform with coordinating and

rapidity.

=ingers to !ngers 3erform with accuracy and

rapidity.

=ingers to thumb 4apidly touches each !nger to


15/45

6ssessment =indings

thumb with each hand.

=ine motor test for the 5ower

'xtremities

3ain sensation 6ble to discriminate between

sharp and dull sensation when

touched with needle and cotton.

kull, calp Hair

• Bbserve the si1e, shape and contour of the skull.

• Bbserve scalp in several areas by separating the hair at

various locations& in)uire about any in/uries. 9ote presence of

lice, nits, dandru< or lesions.

• 3alpate the head by running the pads of the !ngers over the

entire surface of skull& in)uire about tenderness upon doing so.

"wear gloves if necessary$

• Bbserve and feel the hair condition.

Normal Findings:

kull

• Eenerally round, with prominences in the frontal and

occipital area. "9ormocephalic$.

• 9o tenderness noted upon palpation.

calp

• 5ighter in color than the complexion.

• 0an be moist or oily.

• 9o scars noted.


16/45


17/45

• The normal response in blinking.

2. Motor function

• 6sk the client to chew or clench the /aw.

• The client should be able to clench or chew with strength

and force.

09 (II "=acial$

1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).

• 3lace a sweet, sour, salty, or bitter substance near the tip of

the tongue.

• 9ormally, the client can identify the taste.

2. Motor function

• 6sk the client to smile, frown, raise eye brow, close eye lids,

whistle, or pu< the cheeks.

Normal Findings

• hape maybe oval or rounded.

• =ace is symmetrical.

• 9o involuntary muscle movements.

• 0an move facial muscles at will.

• Intact cranial nerve ( and (II.

'yebrows, 'yes and 'yelashes

• 6ll three structures are assessed using the modality of

inspection.

Normal fndings

'yebrows

• ymmetrical and in line with each other.


18/45

• 7aybe black, brown or blond depending on race.

• 'venly distributed.

evere exopthalmos

'yes

• 'venly placed and inline with each other.

• 9one protruding.

• ')ual palpebral !ssure.

'yelashes

• 0olor dependent on race.

• 'venly distributed.

• Turned outward.

'yelids and 5acrimal 6pparatus

• Inspect the eyelids for position and symmetry.

• 3alpate the eyelids for the lacrimal glands.

• To examine the lacrimal gland, the examiner, lightly

slide the pad of the index !nger against the client’s upper

orbital rim.

• In)uire for any pain or tenderness.

• 3alpate for the nasolacrimal duct to check for obstruction.

• To assess the nasolacrimal duct, the examiner presses

with the index !nger against the client’s lower inner orbital

rim, at the lacrimal sac,N$T !G!%NST THE N$SE&


19/45

• In the presence of blockage, this will cause

regurgitation of 2uid in the puncta

Normal Findings

'yelids

• Dpper eyelids cover the small portion of the iris, cornea, and

sclera when eyes are open.

• 9o 3TBI noted. "8rooping of upper eyelids$.

•

7eets completely when eyes are closed.• ymmetrical.

5acrimal 6pparatus

• 5acrimal gland is normally non palpable.

• 9o tenderness on palpation.

• 9o regurgitation from the nasolacrimal duct.

0on/unctivae

• The bulbar and palpebral con/unctivae are examined by

separating the eyelids widely and having the client look up,

down and to each side. hen separating the lids, the

examiner should exert 9B 34'D4' against the eyeball&

rather, the examiner should hold the lids against the ridges of

the bony orbit surrounding the eye.

In examining the pape!ra con"unctiva# everting the upper eyei$ in necessary

an$ is $one as foo%&

*. 6sk the client to look down but keep his eyes slightly open.

This relaxes the levator muscles, whereas closing the eyes

contracts the orbicularis muscle, preventing lid eversion.


20/45

-. Eently grasp the upper eyelashes and pull gently downward.

8o not pull the lashes outward or upward& this, too, causes

muscles contraction.

;. 3lace a cotton tip application about I can above the lid

margin and push gently downward with the applicator while

still holding the lashes. This everts the lid.

%. Hold the lashes of the everted lid against the upper ridge of

the bony orbit, /ust beneath the eyebrow, never pushing

against the eyebrow.

+. 'xamine the lid for swelling, infection, and presence of

foreign ob/ects.

J. To return the lid to its normal position, move the lid slightly

forward and ask the client to look up and to blink. The lid

returns easily to its normal position.

Normal Findings

• #oth con/unctiva are pinkish or red in color.

• ith presence of many minutes capillaries.

• 7oist

• 9o ulcers

• 9o foreign ob/ects

clerae

• The sclerae is easily inspected during the assessment of the

con/unctivae.

Normal Findings

• clerae is white in color "anicteric sclera$

• 9o yellowish discoloration "icteric sclera$.

• ome capillaries maybe visible.

• ome people may have pigmented positions.


21/45

0ornea

• The cornea is best inspected by directing penlight obli)uely

from several positions.

Normal fndings

• There should be no irregularities on the surface.

• 5ooks smooth.

• The cornea is clear or transparent. The features of the iris

should be fully visible through the cornea.• There is a positive corneal re2ex.

6nterior 0hamber and Iris

• The anterior chamber and the iris are easily inspected in

con/unction with the cornea. The techni)ue of obli)ue

illumination is also useful in assessing the anterior chamber.

Normal Findings

• The anterior chamber is transparent.

• 9o noted any visible materials.

• 0olor of the iris depends on the person’s race "black, blue,

brown or green$.

• =rom the side view, the iris should appear 2at and should not

be bulging forward. There should be 9B crescent shadow

casted on the other side when illuminated from one side.

3upils

• 'xamination of the pupils involves several inspections,

including assessment of the si1e, shape reaction to light is

directed is observed for direct response of constriction.

imultaneously, the other eye is observed for consensual

response of constriction.


22/45

• The test for papillary accommodation is the examination for

the change in papillary si1e as it is switched from a distant to a

near ob/ect.

• 6sk the client to stare at the ob/ects across room.

• Then ask the client to !x his ga1e on the examiner’s index

!ngers, which is placed + K + inches from the client’s nose.

• (isuali1ation of distant ob/ects normally causes papillary

dilation and visuali1ation of nearer ob/ects causes papillary

constriction and convergence of the eye.

Normal Findings

• 3upillary si1e ranges from ; K L mm, and are e)ual in si1e.

• ')ually round.

• 0onstrict briskly@sluggishly when light is directed to the eye,

both directly and consensual.

• 3upils dilate when looking at distant ob/ects, and constrict

when looking at nearer ob/ects.

• If all of which are met, we document the !ndings using the

notation 3'4456, pupils e)ually round, reactive to light, and

accommodate

6 nellen chart


23/45

0ranial 9erve II "optic nerve$

• The optic nerve is assessed by testing for visual acuity and

peripheral vision.• (isual acuity is tested using a snellen chart, for those who

are illiterate and unfamiliar with the western alphabet, the

illiterate ' chart, in which the letter ' faces in di


24/45

movement about *- inches from their eyes, or if they can

perceive the light of the penlight directed to their yes.

3eripheral vision or visual !elds

• The assessment of visual acuity is indicative of the

functioning of the macular area, the area of central vision.

However, it does not test the sensitivity of the other areas of

the retina which perceive the more peripheral stimuli. The

(isual !eld confrontation test, provide a rather gross

measurement of peripheral vision.

• The performance of this test assumes that the examiner has

normal visual !elds, since that client’s visual !elds are to be

compared with the examiners.

Foo% the steps on con$ucting the test&

• The examiner and the client sit or stand opposite each other,

with the eyes at the same, hori1ontal level with the distance of

*.+ K - feet apart.

• The client covers the eye with opa)ue card, and the

examiner covers the eye that is opposite to the client covered

eye.

• Instruct the client to stare directly at the examiner’s eye,

while the examiner stares at the client’s open eye. 9either

looks out at the ob/ect approaching from the periphery.

• The examiner hold an ob/ect such as pencil or penlight, in his

hand and gradually moves it in from the periphery of both

directions hori1ontally and from above and below.

• 9ormally the client should see the same time the examiners

sees it. The normal visual !eld is *A degrees.

'rania erve III# I * I (+cuomotor# Trochear# ,!$ucens)


25/45

• 6ll the ; 0ranial nerves are tested at the same time by

assessing the 'xtra Bcular 7ovement "'B7$ or the six cardinal

position of ga1e.

Follow the given steps:

• tand directly in front of the client and hold a !nger or a

penlight about * ft from the client’s eyes.

• Instruct the client to follow the direction the ob/ect hold by

the examiner by eye movements only& that is with out moving

the neck.

• The nurse moves the ob/ect in a clockwise direction

hexagonally.

• Instruct the client to !x his ga1e momentarily on the

extreme position in each of the six cardinal ga1es.

• The examiner should watch for any /erky movements of the

eye "nystagmus$.

• 9ormally the client can hold the position and there should be

no nystagmus.

'ars

• Inspect the auricles of the ears for parallelism, si1e position,

appearance and skin color.

• 3alpate the auricles and the mastoid process for !rmness of

the cartilage of the auricles, tenderness when manipulating

the auricles and the mastoid process.

• Inspect the auditory meatus or the ear canal for color,

presence of cerumen, discharges, and foreign bodies.

• =or adult pull the pinna upward and backward to straiten the

canal.

• =or children pull the pinna downward and backward to

straiten the canal


26/45

• 3erform otoscopic examination of the tympanic membrane,

noting the color and landmarks.

Normal Findings

• The ear lobes are bean shaped, parallel, and symmetrical.

• The upper connection of the ear lobe is parallel with the

outer canthus of the eye.

• kin is same in color as in the complexion.

• 9o lesions noted on inspection.

• The auricles are has a !rm cartilage on palpation.

• The pinna recoils when folded.

• There is no pain or tenderness on the palpation of the

auricles and mastoid process.

• The ear canal has normally some cerumen of inspection.

• 9o discharges or lesions noted at the ear canal.

• Bn otoscopic examination the tympanic membrane appears

2at, translucent and pearly gray in color.

9ose and 3aranasal inuses

• The external portion of the nose is inspected for the

following:

• 3lacement and symmetry.

• 3atency of nares "done by occluding nosetril one at a

time, and noting for diCculty in breathing$

• =laring of alae nasi

• 8ischarge

• The external nares are palpated for:

• 8isplacement of bone and cartilage.

• =or tenderness and masses

• The internal nares are inspected by hyper extending the

neck of the client, the ulnar aspect of the examiners hard

over the fore head of the client, and using the thumb to


27/45

push the tip of the nose upward while shining a light into

the nares.

• Inspect for the following:

• 3osition of the septum.

• 0heck septum for perforation. "0an also be checked by

directing the lighted penlight on the side of the nose,

illumination at the other side suggests perforation$.

• The nasal mucosa "turbinates$ for swelling, exudates

and change in color.

3aranasal inuses

• 'xamination of the paranasal sinuses is indirectly.

Information about their condition is gained by inspection and

palpation of the overlying tissues. Bnly frontal and maxillary

sinuses are accessible for examination.

• #y palpating both cheeks simultaneously, one can determine

tenderness of the maxillary sinusitis, and pressing the thumb

/ust below the eyebrows, we can determine tenderness of the

frontal sinuses.

Normal Findings

• 9ose in the midline

• 9o 8ischarges.

• 9o 2aring alae nasi.

• #oth nares are patent.

• 9o bone and cartilage deviation noted on palpation.

• 9o tenderness noted on palpation.

• 9asal septum in the mid line and not perforated.

• The nasal mucosa is pinkish to red in color. "Increased

redness turbinates are typical of allergy$.

• 9o tenderness noted on palpation of the paranasal sinuses.


28/45

0ranial 9erve I "Blfactory 9erve$

• To test the ade)uacy of function of the olfactory nerve:

•

The client is asked to close his eyes and occlude.• The examiner places aromatic and easily distinguish

nose. "'.g. alcohol, vinegar, co


29/45


30/45

-apate$ for&

• Texture

Normal Findings:

• 3inkish with white taste buds on the surface.

• 9o lesions noted.

• 9o varicosities on ventral surface.

• =renulum is thin attaches to the posterior *@; of the ventral

aspect of the tongue.

• Eag re2ex is present.

• 6ble to move the tongue freely and with strength.

• urface of the tongue is rough.

Dvula

Inspecte$ for&

• 3osition

• 0olor

• 0ranial 9erve M "(agus nerve$ K Tested by asking the client

to say N6hO note that the uvula will move upward and forward.

Normal Findings:

• 3ositioned in the mid line.

• 3inkish to red in color.

• 9o swelling or lesion noted.

• 7oves upward and backwards when asked to say NahO

Tonsils

Inspecte$ for&

• In2ammation


31/45

• i1e

• 6 Erading system used to describe the si1e of the tonsils can

be used.

• Erade * K Tonsils behind the pillar.

• Erade - K #etween pillar and uvula.

• Erade ; K Touching the uvula

• Erade % K In the midline.

9eck

• The neck is inspected for position symmetry and obvious

lumps visibility of the thyroid gland and ugular (enous

8istension

• 0heck the 4ange of 7ovement of the neck.

Normal Findings:

• The neck is straight.

• 9o visible mass or lumps.

• ymmetrical

• 9o /ugular venous distension "suggestive of cardiac

congestion$.

• The neck is palpated /ust above the suprasternal note using

the thumb and the index !nger.

Normal Findings:

• The trachea is palpable.

• It is positioned in the line and straight.

• 5ymph nodes are palpated using palmar tips of the !ngers

via systemic circular movements. 8escribe lymph nodes in

terms of si1e, regularity, consistency, tenderness and !xation

to surrounding tissues.

Normal Findings:


32/45

• 7ay not be palpable. 7aybe normally palpable in thin

clients.

• 9on tender if palpable.

• =irm with smooth rounded surface.

• lightly movable.

• 6bout less than * cm in si1e.

• The thyroid is initially observed by standing in front of the

client and asking the client to swallow. 3alpation of the thyroid

can be done either by posterior or anterior approach.

Posterior Approach:

*. 5et the client sit on a chair while the examiner stands behind

him.

-. In examining the isthmus of the thyroid, locate the cricoid

cartilage and directly below that is the isthmus.

;. 6sk the client to swallow while feeling for any enlargement

of the thyroid isthmus.

%. To facilitate examination of each lobe, the client is asked to

turn his head slightly toward the side to be examined to

displace the sternocleidomastoid, while the other hand of the

examiner pushes the thyroid cartilage towards the side of the

thyroid lobe to be examined.

+. 6sk the patient to swallow as the procedure is being done.

J. The examiner may also palate for thyroid enlargement by

placing the thumb deep to and behind the sternocleidomastoid


33/45

muscle, while the index and middle !ngers are placed deep to

and in front of the muscle.

L. Then the procedure is repeated on the other side.

Anterior approach:

*. The examiner stands in front of the client and with the

palmar surface of the middle and index !ngers palpates below

the cricoid cartilage.

-. 6sk the client to swallow while palpation is being done.

;. In palpating the lobes of the thyroid, similar procedure is

done as in posterior approach. The client is asked to turn his

head slightly to one side and then the other of the lobe to be

examined.

%. 6gain the examiner displaces the thyroid cartilage towards

the side of the lobe to be examined.

+. 6gain, the examiner palpates the area and hooks thumb and

!ngers around the sternocleidomastoid muscle.

Normal Findings:

• 9ormally the thyroid is non palpable.

• Isthmus maybe visible in a thin neck.

• 9o nodules are palpable.

• 6uscultation of the Thyroid is necessary when there is

thyroid enlargement. The examiner may hear bruits, as a

result of increased and turbulence in blood 2ow in an enlarged

thyroid.

Thorax "0ardiovascular ystem$

Inspection of the Heart

• The chest wall and epigastrum is inspected while the client is

in supine position. Bbserve for pulsation and heaves or lifts


34/45

Normal Findings:

• 3ulsation of the apical impulse maybe visible. "this can give

us some indication of the cardiac si1e$.

• There should be no lift or heaves.

3alpation of the Heart

• The entire precordium is palpated methodically using the

palms and the !ngers, beginning at the apex, moving to the

left sternal border, and then to the base of the heart.

Normal Findings:

• 9o, palpable pulsation over the aortic, pulmonic, and mitral

valves.

• 6pical pulsation can be felt on palpation.

•

There should be no noted abnormal heaves, and thrills feltover the apex.

3ercussion of the Heart

• The techni)ue of percussion is of limited value in cardiac

assessment. It can be used to determine borders of cardiac

dullness.

6uscultation of the Heart


35/45

• 6natomic areas for auscultation of the heart:

• 6ortic valve K 4ight -nd I0 sternal border.

• 3ulmonic (alve K 5eft -nd I0 sternal border.

• Tricuspid (alve K K 5eft +th I0 sternal border.

• 7itral (alve K 5eft +th I0 midclavicular line

Positioning the client for auscultation:

*. If the heart sounds are faint or undetectable, try listening to

them with the patient seated and learning forward, or lying on

his left side, which brings the heart closer to the surface of the

chest.

-. Having the client seated and learning forward s best suited

for hearing highpitched sounds related to semilunar valves

problem.

;. The left lateral recumbent position is best suited lowpitched

sounds, such as mitral valve problems and extra heart sounds.


36/45

Auscultating the heart:

*. 6uscultate the heart in all anatomic areas aortic, pulmonic,

tricuspid and mitral

-. 5isten for the * and - sounds "* closure of 6( valves& -

closure of semilunar valve$. * sound is best heard over the

mitral valve& - is best heard over the aortric valve.

;. 5isten for abnormal heart sounds e.g. ;, %, and 7urmurs.

%. 0ount heart rate at the apical pulse for one full minute.

6uscultation of Heart ounds

Normal Findings:

• * - can be heard at all anatomic site.

• 9o abnormal heart sounds is heard "e.g. 7urmurs, ; %$.

• 0ardiac rate ranges from J K * bpm.


37/45

#reast

Inspection of the #reast

• There are % ma/or sitting position of the client used for

clinical breast examination. 'very client should be examined in

each position.• The client is seated with her arms on her side.

• The client is seated with her arms abducted over the

head.

• The client is seated and is pushing her hands into her

hips, simultaneously eliciting contraction of the pectoral

muscles.• The client is seated and is learning over while the

examiner assists in supporting and balancing her.

• hile the client is performing these maneuvers, the breasts

are carefully observed for symmetry, bulging, retraction, and

!xation.

• 6n abnormality may not be apparent in the breasts at rest a

mass may cause the breasts, through invasion of the

suspensory ligaments, to !x, preventing them from upward

movement in position - and %.


38/45

• 3osition ; speci!cally assists in eliciting dimpling if a mass

has in!ltrated and shortened suspensory ligaments.

Normal Findings:

• The overlying the breast should be even.

• 7ay or may not be completely symmetrical at rest.

• The areola is rounded or oval, with same color, "0olor va,ies

form light pink to dark brown depending on race$.

• 9ipples are rounded, everted, same si1e and e)ual in color.

• 9o Norange peelO skin is noted which is present in edema.

• The veins maybe visible but not engorge and prominent.

• 9o obvious mass noted.

• 9ot !xated and moves bilaterally when hands are abducted

over the head, or is learning forward.

• 9o retractions or dimpling.

3alpation of the #reast

• 3alpate the breast along imaginary concentric circles,

following a clockwise rotary motion, from the periphery to the

center going to the nipples. #e sure that the breast is

ade)uately surveyed. #reast examination is best done * week

post menses.

• 'ach areolar areas are carefully palpated to determine the

presence of underlying masses.

• 'ach nipple is gently compressed to assess for the presence

of masses or discharge.

Normal Findings:

• 9o lumps or masses are palpable.

• 9o tenderness upon palpation.

• 9o discharges from the nipples.


39/45

• 9BT': The male breasts are observed by adapting the

techni)ues used for female clients. However, the various

sitting position used for woman is unnecessary.

6bdomen• In abdominal assessment, be sure that the client has

emptied the bladder for comfort. 3lace the client in a supine

position with the knees slightly 2exed to relax abdominal

muscles.

Inspection of the abdomen

• Inspect for skin integrity "3igmentation, lesions, striae, scars,

veins, and umbilicus$.

• 0ontour "2at, rounded, scapold$

• 8istension

• 4espiratory movement.

• (isible peristalsis.

• 3ulsations

Normal Findings:

• kin color is uniform, no lesions.

• ome clients may have striae or scar.

• 9o venous engorgement.

• 0ontour may be 2at, rounded or scapoid

• Thin clients may have visible peristalsis.

• 6ortic pulsation maybe visible on thin clients.

6uscultation of the 6bdomen

•

This method precedes percussion because bowel motility,and thus bowel sounds, may be increased by palpation or

percussion.


40/45

• The stethoscope and the hands should be warmed& if they

are cold, they may initiate contraction of the abdominal

muscles.

• 5ight pressure on the stethoscope is suCcient to detect

bowel sounds and bruits. Intestinal sounds are relatively high

pitched, the bell may be used in exploring arterial murmurs

and venous hum.

3eristaltic sounds

• These sounds are produced by the movements of air and

2uids through the gastrointestinal tract. 3eristalsis can provide

diagnostic clues relevant to the motility of bowel.

• 5istening to the bowel sounds "borborygmi$ can be

facilitated by following these steps:

• 8ivide the abdomen in four )uadrants.

• 5isten over all auscultation sites, starting at the right

lower )uadrants, following the cross pattern of the

imaginary lines in creating the abdominal )uadrants. This

direction ensures that we follow the direction of bowel

movement.

• 3eristaltic sounds are )uite irregular. Thus it is

recommended that the examiner listen for at least +

minutes, especially at the periumbilical area, before

concluding that no bowel sounds are present.

• The normal bowel sounds are highpitched, gurgling

noises that occur approximately every + K *+ seconds. It is

suggested that the number of bowel sound may be as low

as ; to as high as - per minute, or roughly, one bowel

sound for each breath sound.

• ome factors that a


41/45

• tate of digestion.

• 3athologic conditions of the bowel "in2ammation,

Eangrene, paralytic ileus, peritonitis$.

• #owel surgery

• 0onstipation or 8iarrhea.

• 'lectrolyte imbalances.

• #owel obstruction.

3ercussion of the abdomen

• 6bdominal percussion is aimed at detecting 2uid in the

peritoneum "ascites$, gaseous distension, and masses, and in

assessing solid structures within the abdomen.

• The direction of abdominal percussion follows the

auscultation site at each abdominal guardant.

• The entire abdomen should be percussed lightly or a general

picture of the areas of tympany and dullness.

• Tympany will predominate because of the presence of gas in

the small and large bowel. olid masses will percuss as dull,

such as liver in the 4DF, spleen at the Jth or Pth rib /ust

posterior to or at the mid axillary line on the left side.

• 3ercussion in the abdomen can also be used in assessing the

liver span and si1e of the spleen.

3ercussion of the liver

• The palms of the left hand are placed over the region of liver

dullness.

• The area is strucked lightly with a !sted right hand.

•

9ormally tenderness should not be elicited by this method.• Tenderness elicited by this method is usually a result of

hepatitis or cholecystitis.

4enal 3ercussion


42/45

• 0an be done by either indirect or direct method.

• 3ercussion is done over the costovertebral /unction.

• Tenderness elicited by such method suggests renal

in2ammation.

3alpation of the 6bdomen

Light palpation

• It is a gentle exploration performed while the client is in

supine position. ith the examiner’s hands parallel to the2oor.

• The !ngers depress the abdominal wall, at each )uadrant, by

approximately * cm without digging, but gently palpating with

slow circular motion.

• This method is used for eliciting slight tenderness, large

masses, and muscles, and muscle guarding.• Tensing of abdominal musculature may occur because of:

• The examiner’s hands are too cold or are pressed to

vigorously or deep into the abdomen.

• The client is ticklish or guards involuntarily.

• 3resence of sub/acent pathologic condition.

Normal Findings:

• 9o tenderness noted.

• ith smooth and consistent tension.

• 9o muscles guarding.

Deep Palpation

• It is the indentation of the abdomen performed by pressing

the distal half of the palmar surfaces of the !ngers into the

abdominal wall.


43/45

• The abdominal wall may slide back and forth while the

!ngers move back and forth over the organ being examined.

• 8eeper structures, like the liver, and retro peritoneal organs,

like the kidneys, or masses may be felt with this method.

• In the absence of disease, pressure produced by deep

palpation may produce tenderness over the cecum, the

sigmoid colon, and the aorta.

5iver palpation

• There are two types of bi manual palpation recommended for

palpation of the liver. The !rst one is the superimposition of

the right hand over the left hand.

• 6sk the patient to take ; normal breaths.

• Then ask the client to breath deeply and hold. This

would push the liver down to facilitate palpation.

• 3ress hand deeply over the 4DF

• The second methods:

• The examiner’s left hand is placed beneath the client at

the level of the right **th and *-th ribs.

• 3lace the examiner’s right hands parallel to the costal

margin or the 4DF.

• 6n upward pressure is placed beneath the client to

push the liver towards the examining right hand, while the

right hand is pressing into the abdominal wall.

• 6sk the client to breath deeply.

• 6s the client inspires, the liver maybe felt to slip

beneath the examining !ngers.

Normal Findings:


44/45

• The liver usually can not be palpated in a normal adult.

However, in extremely thin but otherwise well individuals, it

may be felt the coastal margins.

• hen the normal liver margin is palpated, it must be

smooth, regular in contour, !rm and nontender.

'xtremities

Inspection

• Bbserve for si1e, contour, bilateral symmetry, and

involuntary movement.

• 5ook for gross deformities, edema, presence of trauma such

as ecchymosis or other discoloration.

• 6lways compare both extremities.

3alpation

• =eel for evenness of temperature. 9ormally it should be even

for all the extremities.

• Tonicity of muscle. "0an be measured by asking client to

s)uee1e examiner’s !ngers and noting for e)uality of

contraction$.

• 3erform range of motion.

•

Test for muscle strength. "performed against gravity andagainst resistance$

• Table showing the 5ovett scale for grading for muscle

strength and functional level

=unctional level 5ovett

cale

Erad

e

3ercentage of

normal

9o evidence of contractility Qero "Q$


45/45

'vidence of slight contractility Trace

"T$

* *

0omplete 4B7 without gravity 3oor "3$ - -+

0omplete 4B7 with gravity =air "=$ ; +

0omplete range of motion against

gravity with some resistance

Eood

"E$

% L+

0omplete range of motion against

gravity with full resistance

9ormal

"9$

+ *

Normal Findings

• #oth extremities are e)ual in si1e.

• Have the same contour with prominences of /oints.

• 9o involuntary movements.

• 9o edema

• 0olor is even.

• Temperature is warm and even.

• Has e)ual contraction and even.

• 0an perform complete range of motion.

• 9o crepitus must be noted on /oints.

dando head-toe assessment

Documents