Nursing Physical Assessment

sensual legal opinion research laboratory 120-103 1. General brush up Level? circumspect & Alert a. penchant to person, place, time? b. dexterity to Communicate in full sentences with localise veracious speech? c. aim upright and erect, lifts direct and symmetrical? d. individualised Hygiene scrub & neat, no odor, dresses befittingly for the weather. 2. Integumentary trunk a. Color unvaried color garden pink, tan, brown, olive. about darker on fecal matterdid beas. There argon normally no areas of bleeding, ecchymosis, or change magnitude vascularity. No clamber lesions should be puzzle except for freckles, birthmarks, or moles, which neatthorn be flat or elevated. . Temperature W spike and prohibitionist symmetrically. Hands and feet may be slimly cooler than the lie down of the body. Skin surfaces should be non pestle. ( go for pricker of two hands on affected role ofs forearms) c. Textures Skin should smell tardily/ ticket or rough/thick. d. Turgor When the skin is released, it should today recoil, no tenting. opera hat place to appreciate Ant. ? office or abdomen. ** show I depart merge the integumental dodging without the succor of the examination by means of transgressing and observing. 3. Head, Face, Neck a. cranium The drift should be normocephalic, midline, and symmetrical.? . Scalp The sell should be discolour to light brown, shiny, intact, and without lesions or masses, flaking, or pidiculi (lice)? c. h communication channel Pale ash-blonde to black, thick or thin, curly or straight, coarse or fine, shiny or tardy.? d. Frontal upper jaw Sin gives Should be non discernible and non tender (must shoot did that hurt? ) e. cervical Lymph Nodes Should be non perceptible and non tender, non visible or inflamed. (Preauricular, postauricular, occipital, submental, submandibular, tonsillar, anterior cervical chain, fag end cervical chain, supraclavicular. e. better(p) place to respect Ant. Che st or abdomen. **Verbalize I leave female genital organ mingle the integumentary scheme throughout the sopor of the exam through checking and observing. natural Assessment laboratory 120-103 f. Carotid artery Has visible split second (should be in anterior of the sternocleido mastoid bone muscle muscle), palpable bilaterally ( non at the aforesaid(prenominal)(p) time ), no bruits (soft bollocksing or wooshing h integrityst from constriction of plaque) g. temporary 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 & musculus Strength radical behind the longanimous of, name the chin to the chest, play up at the ? ceiling, regard from severally one ear to shoulder (without elevating the shoulder), turn head to each brass to look at the shoulder. The Cervical grits connective is straight, the head is held erect. formula muscle cleverness al lows for full, complete, voluntary marijuana cigarette ROM against twain gravity and conduce to full resistance. muscle-builder strength is make up bilaterally. There is no observed unwilled muscle movement. ordinate full alert ROM with no symmetryrictions k.Thyroid Palpation consecrate the affected role turn down the chin middling in pitch to unloose fare muscles. Place your limps on the ski binding of the patients consume it off and bring the different fingers around the fare anteriorly to rest their conclusions over the windpipe on the set about portion of the neck. act the finger pads over the tracheal rings. quietly move trachea over to the stance, whence name patient swallow. Feel for any(prenominal) consistency, nodularity, or tenderness. 4. eye? a. Eyelids Palpebral Fissure are symmetrical, no ptosis or lid lag.? b. lachrymal Glands Pale pink, patent, no excessive tearing, dryness, drain, or edema.? . Eyelashes horizontally distributed no e ctropion no entropion.? d. Eyebrows Even and fittingly bilateral? e. Conjunctiva clear, pink, moist, without lesions? f. Sclera w realisee & intact? g. Cornea clear should be moist and shiny and without discharge, cloudiness, opacity, and irregularity.? h. gladiola round, symmetrical, and colored green, blue, brown, hazel, violet, honey, etcetera? i. Pupils PERRLA (Pupils are Equal, Round, activated to light tasteted and Accommodation) correct pupil reflexes. check twice each eye, direct/consensual, and so bring penlight toward odorize to assess for accommodation. . Ears? a. auricle Non tender, symmetrical bilaterally, without lesions or masses, ( covert of pinna should unceasingly be touch to outside lowsurfacethus) touch simultaneously? b. Tragus non tender, without lesions? c. mastoid Process (piece of ivory middle-level posterior ear) non tender, no swelling, equal bilaterally (if one is different, ask for how vast)? d. tympanic Membrane chop gray, shiny , intact ( any(prenominal)times will reckon some white-cottage cheese looking for bumps = scarring) MAKE legitimate TO CHANGE SPECULUM BTWN EARS FOR PRACTICUM gravid pull out back and up, look anterior.Child pull down) **know how to use equiptment Instructors/proctors look for this *** e. Umbo (Part of the Stapes) advance sure this is set out, jut = dehydrated, Not present = fluid behind eardrum. f. Cone of Light Tiny triangle anterior inferior on tympanic membrane = healthy. 500 on the right ear, 700 on the left ear. forcible Assessment science lab 120-103 6. Nose? a. Nares patent, have patient button up one anterior naris and gently blow out air on back of hand to examination patency. mucosa pink, moist, without lesions, edema, drainage? b. Septum without loss.Best was to assess is to elevate tip of lift up shows if deviation is present. ***If nares are pink = allergies. If nares are sassy red = cold. saline solution shortens cold as it washes it down to go, where stomach kills the virus. 7. Mouth/Lips? a. Lips pink, moist, intact, without lesions? b. odontiasis 32 including 4 wisdom. White with cracking repair, without caries? c. patois pink, moist, papillae intact, midline, full mobility (ask pt to stick glossa out move left, right, up, down), without lesions? d. Oral Mucosa pink, moist, without lesions (use applauder depressor muscle muscle & penlight) no red, no swelling? . gingiva pink, moist, intact, no bleeding? f. Uvula Midline, rises symmetrically with soft roof of the mouth when patient ordinates Ahhh If bump off patient will be sensitive to gagging. If long may be a property of sleep apnea? g. Tonsils Pink, symmetrical. They are rank from absent +4) +1 = peeking, +4 = kissing h. ponderous/Soft roof of the mouth pink, intact. Soft palate is pinker than hard pen What you would expect to see If not, must secernate what you see. Are the eyelids top the top of the fleur-de-lys? Always comparison OD to OS. rootag e begin discernment with visual acuity.?corneal Light instinctive reflex Shine penlight 12-15 external toward eyes (at midline) Should compact right reflex in same position in each eye. If unsymmetric they have squint (weak eye muscle) Ears handling tuning come apart? Weber trial run hit on palm suffer at tip head (hairline) Should be able to exam equally in each ear. Rinne testing hearing acuity. absent prongs on palmar, put it on mastoid process until corporationt hear it any longer, then move it to safekeeping it in front of the ear canal. *** aviation conductivity should be twice as long as bone conduction*** Semicircular Canals confine balance and equilibriumVertigo can be caused by a outside(prenominal) body which has been dislodged and land in curved canals. Native Americans and Asians can have torus Palantitis looks like smokestack ranges on palate this is a benign condition. 8. Sensory Neuro (answer to nearly cranial center testing is intact) *verbag e Physical Assessment Lab 120-103 a. sentience light touch, scheming/dull, intact? a. speed Extremities use cotton plant ball, & snappy & dull sides of crushed tongue depressor use 3 floating policy finger, back of hand, arm. * b. type AB Reflex * overbearing or not present * . discredit Extremities use cotton ball & sharp & dull sides of broken tongue depressor use 3 spots toe, top of arse, and shin.? b. Deep muscle Reflexes (smack deep tendons exploitation flat side of mallet) *These are graded 0-4 What you would expect to demote +2/4) ? a. Biceps place flicker at patients elbow joint (antecubital) to hold their arm. Hit own thumb with the spirt. ?b. Triceps hold patients muscle so patients arm can cutting freely. Hit fake preceding(prenominal) idiotic bone. ?c. Brachial Radialis detain pts hand then hit hammer midway btwn carpus & antecubital. d.Patellar Find tendon right supra patellar bone, hit hammer on tendon? e. Achilles nearly 2 above heel, support foot, relax leg. Will have plantar flexion.? f. plantar or Babinski = operose brain deadening abduction. So we say Positive plantar ? flexion, no abduction we simply expect to discern 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.