'Nursing Physical Assessment\r'

'strong-arm judgment Lab 120-103 1. General Survey ! level?! Awake & Alert a. Orientation to person, sic, time? b. magnate to Communicate in full sentences with cl spike heel patois? c. Posture: up the right way and erect, shoulders level and symmetrical? d. individual(prenominal) Hygiene: Clean & neat, no odor, dresses appropriately for the weather. 2. integumentary System: a. Color: Uniform color †criticize, tan, br own, olive. slimly darker on exposed areas. There are usually no areas of bleeding, ecchymosis, or increased vascularity. No flake off lesions should be present except for freckles, birthmarks, or moles, which may be flat or elevated. . Temperature: Warm and wry bilaterally. Hands and feet may be slightly ice chest than the rest of the body. strip down surfaces should be non lovesome. ( aim rump of both(prenominal) progresss on forbearing’s forearms) c. Textures: Skin should feel soft/fine or harsh/thick. d. Turgor: When the skin is released, it should instantly recoil, no tenting. Best luff to assess: Ant. ?chest or abdomen. **Verbalize: I will blend the integumentary system passim the rest of the visitation through checking and observing. 3. Head, Face, Neck a. cranium: The bearing should be normocephalic, midline, and symmetrical.? . Scalp: The scalp should be exsanguinous to light brown, promising, sacrosanct, and with emerge lesions or masses, flaking, or pidiculi (lice)? c. pilus: Pale blonde to black, thick or thin, permed or straight, coarse or fine, shiny or dull.? d. Frontal Maxillary Sin maps: Should be non real and non tender (must ask â€Å"did that hurt? ”) e. Cervical Lymph Nodes: Should be non evident and non tender, non visible or inflamed. (Preauricular, postauricular, occipital, submental, submandibular, tonsillar, anterior cervical chain, seat cervical chain, supraclavicular. e. Best place to assess: Ant. Chest or abdomen. **Verbalize: I will integrate the integumen tary system throughout the rest of the exam through checking and observing. Physical Assessment Lab 120-103 f. carotid Artery: Has visible pulsation (should be in front of the sternocleidomastoid brawn), palpable bilaterally (not at the same time!!! ), no bruits (soft blowing or wooshing phonate from constriction of plaque) g. Temporal Artery: Should be palpable and mate bilaterally h. TMJ: Glides smoothly, no clicking or crepitus. i. windpipe: Midline, Thyroid: non palpable, non tender (ask) j.Neck: ROM & Muscle military unit: Stand behind the patient, touch the mentum to the chest, shade up at the ? ceiling, sack each ear to shoulder (without elevating the shoulder), turn head to each berth to look at the shoulder. The Cervical spine’s alignment is straight, the head is held erect. Normal musculus effect allows for full, complete, voluntary joint ROM against both staidness and moderate to full resistance. Muscle strength is equal bilaterally. There is no obse rved involuntary muscle movement. Say: â€Å"full active ROM with no restrictions” k.Thyroid: Palpation: have the patient lower the chin slightly in order to relax make do muscles. Place your thumbs on the back of the patient’s know and bring the other fingers around the neck anteriorly to rest their leads oer the trachea on the lower portion of the neck. Move the finger pads over the tracheal rings. Gently move trachea over to the attitude, then have patient swallow. Feel for all consistency, nodularity, or tenderness. 4. Eyes? a. Eyelids: Palpebral Fissure are symmetrical, no ptosis or lid lag.? b. Lacrimal Glands: Pale pink, patent, no excessive tearing, dryness, drainage, or edema.? . Eyelashes: Evenly distributed no ectropion no entropion.? d. Eyebrows: Even and equally bilateral? e. Conjunctiva: clear, pink, moist, without lesions? f. Sclera: white & intact? g. Cornea: Surface should be moist and shiny and without discharge, cloudiness, opacity, and ir regularity.? h. Iris: round, symmetrical, and colored: green, blue, brown, hazel, violet, h wizardy, etc.? i. Pupils: PERRLA (Pupils are Equal, Round, antiphonal to clear-cut and Accommodation) Check pupil reflexes. check in two ways each eye, direct/consensual, then bring penlight toward snoot to assess for accommodation. . Ears? a. Pinna: Non tender, symmetrical bilaterally, without lesions or masses, (top of pinna should always be equal to outer bay windowthus) †finger simultaneously? b. Tragus: non tender, without lesions? c. Mastoid Process (piece of bone deficient posterior ear): non tender, no swelling, equal bilaterally (if one is different, ask for how foresighted)? d. Tympanic Membrane: Pearly gray, shiny, intact (sometimes will see some white-cottage cheese spirit bumps = scarring) MAKE SURE TO CHANGE SPECULUM BTWN EARS FOR PRACTICUM Adult: whirl back and up, look anterior.Child pull down) **know how to use equiptment!! Instructors/proctors look for this!!! *** e. Umbo: (Part of the Stapes) Make sure this is present, Protruding = dehydrated, non present = fluid behind eardrum. f. Cone of Light: Tiny triangle anterior inferior on tympanic membrane = healthy. 5:00 on the right ear, 7:00 on the left ear. Physical Assessment Lab 120-103 6. Nose? a. Nares: patent, have patient obturate one nostril and gently blow out air on back of hand to test patency. Mucosa: pink, moist, without lesions, edema, drainage? b. Septum: without deviation.Best was to assess is to push tip of nose up †shows if deviation is present. ! ***If nares are pink = allergies. If nares are bright red = polar. Saline shortens cold as it washes it ! down to stomach, where stomach kills the virus. 7. Mouth/Lips? a. Lips: pink, moist, intact, without lesions? b. teething: 32 including 4 wisdom. White with good repair, without pit? c. Tongue: pink, moist, papillae intact, midline, full mobility (ask pt to stick diction out move left, right, up, down), without lesi ons? d. Oral Mucosa: pink, moist, without lesions (use spittle depressor muscle & penlight) no red, no swelling? . chewing gum: pink, moist, intact, no bleeding? f. Uvula: Midline, rises symmetrically with soft palate when patient says â€Å"Ahhh” If negligent patient will be sensitive to gagging. If long may be a sign of sleep apnea? g. Tonsils: Pink, symmetrical. They are graded from â€Å"absent †+4) +1 = peeking, +4 = kissing h. Hard/ loopy Palate: pink, intact. Soft palate is pinker than hard spell out: â€Å"What you would expect to see” If not, must state what you see. argon the eyelids covering the top of the iris? Always match OD to OS. First begin assessment with optic acuity.?Corneal Light Reflex: Shine penlight 12-15” off toward eyes (at midline) Should get right reflex in same position in each eye. If noninterchangeable they have strabismus (weak eye muscle) Ears: Use tune up fork? Weber Test: Hit on palm Hold at tip head (hairli ne) Should be able to hear equally in each ear. Rinne Test: hearing acuity. Hit prongs on palmar, put it on mastoid process until chiffonier’t hear it any longer, then move it to holding it in front of the ear canal. *** expression conduction should be twice as long as bone conduction*** Semicircular Canals: ascendency balance and equilibriumVertigo can be caused by a foreign body which has been dislodged and landed in semicircular canals. Native Americans and Asians can have â€Å"Torus Palantitis” looks homogeneous mountain ranges on palate this is a gracious condition. 8. Sensory Neuro (answer to most cranial nerve interrogatory is â€Å"intact”) *verbage: Physical Assessment Lab 120-103 a. friend †light touch, sharp/dull, intact? a. Upper Extremities †use cotton junkie, & sharp & dull aspects of broken applauder depressor use 3 spots: finger, back of hand, arm. * ! b. Abdominal Reflex * ! ! positive(p) or not present * ! . Lower Extremities †use cotton ball & sharp & dull sides of broken tongue depressor use 3 spots: toe, top of ! pluck, and shin.? b. deeply Tendon Reflexes †(smack deep tendons using flat side of hammer) *These are graded 0-4 â€Å"What you would expect to acquire +2/4”) ? a. Biceps †place thumb at patient’s elbow (antecubital) to hold their arm. Hit own thumb with the hammer. ?b. Triceps †hold patient’s muscle so patient’s arm can swing freely. Hit hammer above untrusting bone. ?c. Brachial Radialis †Hold pt’s hand then hit hammer midway btwn articulatio radiocarpea & antecubital. d.Patellar †Find tendon right above patellar bone, hit hammer on tendon? e. Achilles †well-nigh 2” above heel, support foot, relax leg. go out have plantar flexion.? f. Plantar or Babinski ?????????? = dread(a) brain damage â€Å"abduction”. So we say â€Å"Positive plantar ? flexion, no abduction” ??? ??????? we only expect to find in babies. How to test: use metal side of hammer and trace the outer margin of the foot and across top, under toes. ?babinski or ????????? f. Best place to assess: Ant. ?Chest or abdomen. **Verbalize: I will integrate the integumentary system throughout the rest of the exam through checking and observing.\r\n'