Fundamentals in Nursing (Notes)
Prev Article Next Article
By the end of the topic students should be able to:
Physical assessment
Inspection
Principles of inspection
Palpation
Principles of palpation
Percussion
Auscultation
Preparation for physical exam
General survey
Vital signs
Skull, Scalp & Hair
Normal Findings:Skull
Scalp
Hair
Face
CN V (Trigeminal)1. Sensory Function
2. Motor function
CN VII (Facial)1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
2. Motor function
Normal Findings
Eyebrows, Eyes and Eyelashes
Normal findingsEyebrows
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.
Normal FindingsEyelids
Lacrimal Apparatus
Conjunctivae
In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow:
Normal Findings:
Sclerae
Normal Findings
Cornea
Normal findings
Anterior Chamber and Iris
Normal Findings:
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.
Normal Findings
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:
Peripheral Vision or visual fields
Follow the steps on conducting the test:
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
Follow the given steps:
Ears
Normal Findings
Nose and Paranasal SinusesThe external portion of the nose is inspected for the following:
The external nares are palpated for:
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:
Paranasal Sinuses
Normal Findings
Cranial Nerve I (Olfactory Nerve)To test the adequacy of function of the olfactory nerve:
Mouth and Oropharynx LipsInspected for:
Normal Findings:
TemporomandibularPalpate while the mouth is opened wide and then closed for:
Normal Findings:
GumsInspected for:
Normal Findings:
TeethInspected for:
Normal Findings:
TonguePalpated for: Normal Findings:
UvulaInspected for:
Normal Findings:
TonsilsInspected 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:
Normal Findings:
Posterior Approach:
Anterior approach:
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
Normal Findings:
Palpation of the Heart
Normal Findings:
Percussion of the Heart
Auscultation of the HeartAnatomic 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.
Normal Findings:
Palpation of the Breast
Normal Findings:
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
Inspection of the abdomen
Normal Findings:
Auscultation of the Abdomen
Peristaltic sounds
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:
Some factors that affect bowel sound:
Percussion of the abdomen
Percussion of the liverThe palms of the left hand are placed over the region of liver dullness.
Renal Percussion
Palpation of the AbdomenLight palpation
Tensing of abdominal musculature may occur because of:
Normal Findings:
Deep Palpation
Liver palpationThere 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
Palpation
Table showing the Lovett scale for grading for muscle strength and functional level
Normal Findings
Choose the letter of the correct answer. Good luck!
Congratulations - you have completed Head to Toe Assessment Practice Exam (PM)*.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%% Your answers are highlighted below.
There are 35 questions to complete. Prev Article Next Article |