ObjectivesBy the end of the topic students should be able to: Show
Physical assessment
Principles of inspection
Principles of palpation
Preparation for physical exam
General survey
Vital signs
Skull, Scalp & Hair
Skull
Scalp
Hair
Face
1. Sensory Function
2. Motor function
1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
2. Motor function
Eyebrows, Eyes and Eyelashes
Eyebrows
Eyes
Eyelashes
Eyelids and Lacrimal Apparatus1. Inspect the eyelids for position and symmetry. 2. Palpate the eyelids for the lacrimal glands.
3. Palpate for the nasolacrimal duct to check for obstruction.
Eyelids
Lacrimal Apparatus
Conjunctivae
In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow:
Sclerae
Cornea
Anterior Chamber and Iris
Pupils
The test for papillary accommodation is the examination for the change in papillary size as it is switched from a distant to a near object.
If all of which are met, we document the findings using the notation PERRLA, pupils equally round, reactive to light, and accommodate Cranial Nerve II (optic nerve)
In testing for visual acuity you may refer to the following:
Follow the steps on conducting the test:
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
Follow the given steps:
Ears
Nose and Paranasal SinusesThe external portion of the nose is inspected for the following:
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 push the tip of the nose upward while shining a light into the nares. Inspect for the following:
Cranial Nerve I (Olfactory Nerve)To test the adequacy of function of the olfactory nerve:
Inspected for:
Normal Findings:
Palpate while the mouth is opened wide and then closed for:
Normal Findings:
Inspected for:
Normal Findings:
Inspected for:
Normal Findings:
Palpated for:
Normal Findings:
Inspected for:
Normal Findings:
Inspected for:
A Grading system used to describe the size of the tonsils can be used.
Neck
The neck is palpated just above the suprasternal note using the thumb and the index finger. Normal Findings:
Auscultation of the Thyroid is necessary when there is thyroid enlargement. The examiner may hear bruits, as a result of increased and turbulence in blood flow in an enlarged thyroid.
Thorax (Cardiovascular System)Inspection of the Heart
Anatomic areas for auscultation of the heart:
Positioning the client for auscultation:
Auscultating the heart:
Normal Findings:
BreastInspection of the BreastThere are 4 major sitting position of the client used for clinical breast examination. Every client should be examined in each position.
NOTE: The male breasts are observed by adapting the techniques used for female clients. However, the various sitting position used for woman is unnecessary. Abdomen
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:
Some factors that affect bowel sound:
The palms of the left hand are placed over the region of liver dullness.
Light palpation
Tensing of abdominal musculature may occur because of:
Normal Findings:
Deep Palpation
There are two types of bi manual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand over the left hand.
The second methods:
Normal Findings:
ExtremitiesInspection
Table showing the Lovett scale for grading for muscle strength and functional level
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What should the nurse use to assess skin temperature?Temperature is best evaluated by palpating the skin with the dorsum or back of the hand. Using the palm of the hand on the child's back or fingertips on the child's forehead or neck will not get an accurate sense of the child's temperature.
What is the best technique to use to assess the patient's skin temperature?Skin palpation is used to determine skin texture, temperature, sweating differences, keratosis, pain, and induration [4]. Clinicians and lay individuals routinely palpate the skin to assess the presence of temperature changes.
When palpating a client's body to detect warmth The nurse should use which part of the hand?See Figure 1.8. Temperature refers to the degree of heat or cold an object holds. Use the dorsal surface of your own hands (i.e., the back of the hands), to assess the temperature of a surface (e.g., skin). For example, findings may include “warm skin temperature on arms, equal bilaterally.”
Which should be assessed during palpation of the skin?This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present.
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