eye assessment

eye assessment 

Objectives:

students will be able to:

1. Demonstrate the ability to safely &

accurately complete a comprehensive

examination of the eye.

2. Demonstrate the ability to accurately

document eye assessment data in organized manner.

Equipment Needed

1 . Snellen Chart

2. Near-vision chart

3. Cover card

4. Penlight

5. Opthalmoscope

6. Ruler

Guidelines for using the ophthalmoscope:

1.Red numbers indicate anegative diopter & areused for

near sighted clients.

2.Black numbers indicate apositive diopter & areused for farsighted clients.

3. The zerolensis usedif neitherthe examiner northeclient hasa refractive error.

4. Turn ophthalmoscope on & select the aperture with the largebround beam of white light.

5. Ask the client to remove glasses ,remove your glasses.

Contactlenses canbe left intheeyes ofthe client ortheexaminer.

6.Ask the client to fixgazeonan object thatis straight ahead & slightly upward

7.Darken theroomto allow pupils to dilate.

8.Hold the ophthalmoscope inyour right hand with your index finger onthelens wheel & place the instrument to

your right eye.Examinethe client'sright eye. use your left hand&left eye to examinethe client's left eye.

9.Begin about 10-15 inches from the client at a15degree angel to the client's side.

10. Keep focuses on the redreflex as you move incloser,then rotate the diopter setting to see the opticdisc

Subjectivedata:—

1. Vision difficulty(decrease acuity)

2.Redness ,swelling

3. Glaucoma (blurring, blindspots)

4. Pain

5,Watering, discharge

6. useof glassesor contact lenses

7. Strabismus, diplpia

8. Past history of ocular problems

9. Self-care behaviors

External Eye Structures:

Eye brow for shape,movement , hair distribution :normal finding revealed symmetrical in shape intact skin and evenly hair distribution ,symmetrical movement

Eye lashes: evenlyhair distribution,curl directed outward

Eye lids: inspect for color,lesion and movement :color same as the face nodiscoloration,free of lesion and discharge when lids closedit should be

symmetrical complete ,sclera not visible

Assess bulbar conjunctiva( cover the eye

ball andsclera : transparent ,sclera white

or yellowin skinny person. 

capillary appears free oflesion (retract)

Assess palpebral conjunctiva line the eye

lideverting the eyelid normal finding pink

tored,shiny smooth free of discharge and

lesion By using gauze or cotton touch the client cornea blinking indicate that the trigeminal (5th) nerve is intact

Inspect pupil : 
black in color , equal in size

normally 3-7mm in diameter and round ,iris flat and rounded

Assess pupil for :
Direct reaction to light: pupil constrict ( penlight) 
Reaction to Accommodation :Penlight placed 10cm or 4 in near nose bridge ,normal finding pupil constrict when looking on near object and dilated on far object.

Documentation : PERRLA (pupils equal round reacting to light and accommodation

Assess Lacrimal Gland Sac and Nasolacrimal duct

Inspect and us index to palpate :Free of edema ,no tenderness ,no excessive

tearing Lacrimal gland in outer eye canthus

Lacrimal sac and duct inner canthus of eye

Exteraoccular Muscle Test

Stand direct in front of the client use

penlight within 1ft distance (30 cm) ask

the client to follow the object move

toward 6 cardinal direction . Normal

finding both eye coordinated movement

Abnormal: eye fail to follow the object

squint and strabismus ( cross –eye)

Nystagmus : caused by nerve impairment

How is visual fie ld testing done?

visual field testing is performed one eye at a time, with the opposite eye completely covered to avoid errors. In all testing, the patient must look straight ahead at all times in order to avoid testing the central vision rather than the periphery.

To summarize, for numerous reasons:

* visual field testing is useful screening for glaucoma,

*testing patient with glaucoma for treatment response,

*screening and testing for lid droop or ptosis,particularly for insurance approval of lid lift surgical procedures

* Temporal can detected within 90 degree

central

* Upward detected with 50 because of

orbital ridge

* Downward detected with 70 cheek bone

* Nasal filed within 50 because of nose

Normal : client can see the object

Abnormal: small field glaucoma ,

Visual acuity:

Near vision: within 30-36cm distance ask

the client to read newspaper or magazine

with keeping glass or lenses

Distance vision test within 20 feet or 6

meter by using snellen chart the client

read the chart line from top to bottom .

First number 20 indicate the distance

Between the chart &client

Second number 20 indicate

The distance that normal

Eye can read Glass and lenses keeped

—Distance from the chart

◦D (distant) for the evaluation done at 20 feet (or 6 meters).

◦N (near) for the evaluation done at 14 incheor or 36 cm).—Eye evaluated

◦OD (Latin oculus dexter) for the right eye.

◦OS (Latin oculus sinister) for the left eye.

◦OU (Latin oculi uterque) for both eyes.

◦cc (Latin cum correctore) with correctors.

◦sc: (Latin sine correctore) without correctors

Performing functional vision test

1- light perception: shin penlight from

lateral than off ask client about light if he

recognize documentation : LP+

2- Hand movement within 30 cm 1 feet

move hand back ,front than stop ask

client when it stopped doc: H\M 1ft +

3- Counting finger within 30 cm or 1 ft ask

the client number of finger doc: F\C+

Ophthalmoscope: A lighted instrument,

one of the most important tools for

examining the optic disc . Normal orange

to pink with vessel appearance

Abnormal pale red spot

ear

Physical Examination

Ear, Nose, Mouth and Throat

COMPETENCIES

* Discuss the system-specific history for the ears,nose, mouth, and throat.

*Describe normal findings in the physical

assessment of the ears, nose, mouth, and

throat.

*Describe common abnormalities found in the physical assessment of the ears, nose, mouth,and throat.

* Explain the pathophysiology of common

abnormalities of the ears, nose, mouth, and

throat.

General Approach to Ears, Nose, Mouth, and Throat

1. Greet the patient and explain the assessment techniques

that using.

2. Use a quiet room that will be free from interruptions.

3. Ensured that the light in the room provides sufficient

brightness adequate observation of the patient.

4. Place the patient in an upright sitting position or for patients who cannot tolerated he sitting position assess head so that it can be rotated from side to side

5. Visualize the underlying structures during the assessment allow adequate description of findings.

6. Always compare right and left ears, as well as right and left nose, sinuses, mouth, and throat..

Equipment

Otoscope with earpieces of different

sizes and pneumatic attachment

Nasal speculum

Penlight

Tuning fork (512)Hz

Tongue blade

Watch

Gauze square

Clean gloves

Transilluminator

Cotton-tipped applicator

Sings & Symptoms:

-History of hearing problem

-Family history

-Medication history

-Ringing in ears hearing difficulty ,onset ,factors contributing to it, and how it interferes with living activities of daily , corrective hearing device

-Pain ,discharge , and lesion

AURICLES

Inspect the auricle for colors, symmetry of size and position 'To inspect position . Note the level at which the superior aspect of the auricle attach to the head in relation to the eye

Normal :

-Color same as facial skin

-Symmetrical

-Auricle aligned with outer canthus of eye, about 10" from vertical.

Abnormal:

-Bluish color of earlobes(cyanosis) pallor( cold weather)excessive

redness (inflammation or fever)

-Asymmetry

-Low-set( associate with congenital abnormality as Downs syndrome

Palpate the auricles for texture' lasticity,

and tenderness'

- Gent pull he auricles up-down and back war '

- Fold the Pinna forward (it should recoil).

- apply pressure on the mastoid

Normal

Mobile, firm , and not tender pinna recoils after it is folded

Abnormal

Lesions , scaly skin ,tenderness (infection of external ear)

External Ear Canal :

Using anotoscop inspect the external ear canal for cerumen, skin lesion ,pus or blood

Normal: pink in color , dry , hairy , dry yellow or brow cerumen , free of discharge blood and lesion

Abnormal :Redness , discharge excessive cerumen or lesion

Inspect tympanic membrane :

Color: gray , shinny ,semitransparent

Abnormal :Pink or red ,blue bleeding , yellow infection with dull surface

Hearing acuity :

1- Assess client responses to normal voice :

audible

Abnormal: request for repeat , lean, cups ear

2- Watch tick test : able to hear ticking in both ear

Abnormal: unable to hear

3- Tuning fork test :

Weber’s test

Rinne test

Romberg test

Mouth & Oropharynx

Equipmen t Needed

1. Penlight

2. Tongue blade

3. Small gauze (2*2)

4. Clean gloves

Preparation:

1. Position the client sitting up straight with his \her head

at your eye level.

2. Remove client's dentures if available

Subjective data:

I. Sores & Lesions

2.Sore Throat

3. Bleeding gum.

4. Toothache

5. Hoarseness

6. Dysphagia

7. Altered taste

8. Smoking, Alcohol

consumption

9. Self-care behaviors,

dental care pattern,

dentures or appliances

Inspection & palpationlips

Normal Findings

Color: in white skin Pink , in dark skin: may have bluish hue or freckle like pigmentation.

Movement: symmetrical during smile , open and close . No lesions, swelling, drooping , its moist and smooth Wearing gloves, 
inspect & palpate lips for the following:

The patient's teeth should be clean with no decay, appear white and shiny smooth surfaces and edges. Adults should have a total of 32 teeth with 16 teeth in each arch. Children by the age of 2 1/2 have a total of 20 teeth with 10 in each arch.

Abnormal findings

Missing teeth, loose or broken teeth and misaligned teeth. 

Wearing gloves,
inspect & palpate buccal mucosa for the following:

Color: Pink (increased pigmentation often noted in dark-skinned client

Consistency : Smooth, moist, without lesions

Landmarks : Parotid duct openings are seen small papilla located near upper second molar Retract client's lips to inspect & palpate gums for the following:

Color : pink

Consistency : Moist, free of lesion and ulcer ,pale or yellow defined in gingivitis

Inspect protruded tongue for the following:

Symmetry & texture and color moist; papillae present;

symmetrical appearance; midline fissure present ,pink ,smooth Inspect ventral surface of the tongue & mouth floor for

the following:

Color: pink slightly pale

Landmarks: Submandibular duct openings are located on both sides of the frenulum , tongue is free of lesions or increased redness; frenulum is centered.

Palpate inspected the site of tongue: pink , moist ,free of lesion and ulcer

Inspect hard & soft palate for the following:

Color & consistency : hard palate is pale irregular while soft palate is pink and soft , spongy

Inspect oropharynx for the following:

Color : pink

Landmarks : Tonsillar pillars symmetrical;

tonsils present (unless urgically removed) &

without exudates; uvula at midline & rises on phonation.

Grading of Tonsils :

0 : tonsils not visible

1+ tonsils are visible,

2+ tonsils are between the pillars

and uvula

3+ tonsils are touching the uvula

4 + tonsils extend to the midline of

the oropharynx.

lung assessment

Lung& Thorax Assessment

—Breast self-examination (BSE) is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps,

distortions or swelling.

—BSE was once promoted heavily as a means of finding cancer at a more curable stage

Breast Examination

Equipment Needed : None

The patient must be properly gowned for this examination. All upper

body clothing should be removed.

General Considerations

The patient must be properly gowned for this examination. All upper body clothing should be removed.

Breast tissue changes with age, pregnancy, and menstrual status.

The procedure described here can also be used for self-examination using a mirror for inspection. Give a brief overview of examination to patient Have the patient sit at end of exam table.

Ask the patient to remove gown to her waist, assist only if needed

Inspection

Have the patient relax arms to her side.

Examine visually for following:

Size , symmetry and shape : Female rounded slightly unequal , symmetry in size , while in male breast even with chest wall , if the client obese may be as female breast shape.

Dimpling or retraction of skin: free of scar or retraction because of invisible tumor Color and pigmentation : even to abdominal color without pigmentation . While abnormal localized discoloration and hyper pigmentation Swelling or edema pig skin (Orange peel ) on skin because of exaggeration pores

Observe the movement of breast tissue during the following maneuvers:

- Shrug shoulders with hands on hips

- Slowly raise arms above head

- Pushing the hand together to observed retraction

- Lean forward with hands on knees (large breasts only)

Inspect the areola for :

shape and size : 
Normal finding : rounded or oval

bilaterally symmetry.

Color and surface look for lesion : light pink to dark brown , surface irregular because of sebaceous gland

—Inspect nipple for size and position: 

—Normal: equal ,rounded , similar in color and everted ,both nipple pointed to the same direction free of discharge except pregnant woman and breast feeding female ,inversion present from puberty .

—Abnormal finding : Asymmetrical in size or color , presence of discharge or crusts

Palpation

Have the patient lie supine on the exam table.

Ask the patient to remove the gown from one breast and place her

hand behind her head on that side.

Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers. If open sores or discharge are visible, wear gloves.

Press breast tissue against the chest wall in small circular motions.

Use very light pressure to assess superficial layer, moderate pressure for middle layer and firm pressure for deep layers.

Palpate the breast in overlapping vertical strips. Continue until

you have covered the entire breast including the axillary "tail."

Palpate around the areola and the depression under the nipple.

Press the nipple gently between thumb and index finger and make note of any discharge.

Lower the patient's arm and palpate for axillary lymph nodes.

Have the patient replace the gown and repeat on the other side.

palpation method : palpate for tenderness , mass (lump) , (either

superficial or deeper in tissue) or soreness. There are several common patterns, which are designed to ensure complete coverage.

1- The vertical strip pattern involves moving the fingers up and down over the breast.

2- The pie-wedge pattern starts at the nipple and moves outward.

The circular pattern involves moving the fingers in concentric circles from the nipple outward.

3- Some guidelines suggest mentally dividing the breast into four quadrants and checking each quadrant separately. 
The palpation process covers the entire breast, including the"axillary tail" of each breast that extends toward the axilla .

—Finally, women that are not breastfeeding gently squeeze each

nipple to check for any discharge

Lymph nodes

By asking the client to hold his arm palpate :

Lateral node

Central

Posterior

Infraclavicular lymph node

Lung Examination

Objectives:

At the end of this lab, the students will be able to:

1. Demonstrate the ability to safely &accurately complete thorax & lung assessment.

2. Demonstrate the ability to accurately document thorax &lung assessment data in organized

manner.

Equipment Needed

1. Stethoscope

2. Small ruler, marked in centimeters

3. Marking pen

4. Alcohol swab

Preparation

1. Ask the client to sit upright &the male to disrobe to the waist.

2. For female, leave the gown on &open at the back.

3. When examining the anterior chest, lift up the gown& drape it on her shoulders rather than removing it completely.

4. For farther comfort: a warm room, a warm diaphragm end piece.

5. Private examination time with no interruption.

Subjective data:

Cough

Past history of respiratory infections

Self-care behaviors 

Shortness of breath

Smoking historyü

Chest pain with breathing 

Environmental exposure

Chest Landmarks

Anterior : Right anterior axillary line ,

Right midclavicular line ,

Mid sternum line

left midclavicular line ,

left anterior axillary line

Mid axillary line

Posterior: L . posterior axillary line ,

L.mid scapular line

,mid spinal line , 

R. mid scapular line 

R. posterior

axillary line ,

Inspect anterior, posterior, &lateral thorax for the following:

Color : Pink

Intercostals spaces : Even

Chest symmetry: Equal

Rib slope : Less than 90 degree downward Respiration (rate, depth, rhythm) ,Even, 12-20/min,unlabored Anterior-posterior to lateral diameter 1: 2 ratio Shape &position of sternum : level with ribs Position of trachea Midline

Inspection

Normal chest

Slight retraction of

intercostal spaces

2x as wide as deep

Anterior/ posterior

diameter

1:2

Inspection

Barrel chest

anterior-posterior

diameter

2:2

Inspection

Pigeon chest

Sternum protrudes

outward

anterior-posterior

diameter

h

Inspection

Scoliosis

Lateral curvature of

thoracic spine

Assessment

Shoulders elevated?

Complications

Lung &heart damage

Back problems

Body image

Inspection

Kyphosis—

Abnormal curvature of—

the thoracic spine

Inspection

Lordosis—

Sway-back—

Abnormal curvature of—

the lumbar spine

Inspection

Uniform expansion of

the chest

Pneumonia

Pleural effusion

Pneumothorax

Bulging intercostal

spaces

Obstruction

Emphysema

Palpate thorax at three levels for the following:

Sensation : no pain or tenderness

Vocal fremitus ( tactius) as client says 99Use either the palm base (the ball) of fingers, or the ulnar edge of one hand.

- Touch the client's chest- Ask the client to repeat aresonant phrases that generate strong vibration Like 99.

- Start over the lung apices &palpate from side to another.
- Avoid palpating over the scapulae.

Vibration decreased over periphery of lungs &increased

over major airways .

Palpate chest expansion :

Posterior : placing your warmed hand on the poster lateral chest wall

- The thumbs should be at level of T9 or T10.

- Slide your hands medially to pinch up a small fold between your thumbs.

- Ask the client to take deep breath.

- Your thumb should move with respiration.

Anterior: placing your warmed hand on the anterolateral wall.

- Thumbs should be along the costal margins &pointing toward the xiphoid process. 

- Ask the client to take deep

breath.

- Watch your thumbs move with respiration.

2 to 3-inch symmetrical thoracic expansion.

Symmetrical expansion (thumbsmove apart

equal distance in both directions).

Percussion (Diaphragmatic Excursion)

Posteriorely :

ask the client to exhale &hold it.

- Percuss down the scapular line until the sound changes from resonant to dull each side.

- Mark the level where the sound changed to dull.

- Ask the client to take deep breath &hold it. -Continue percussing from the mark down ward.

- Mark the level the sound changed to dull on deep inspiration.

- Measure the difference.

Normal Finding :

It should be equal bilateraly, &measure about 3-5cm in

adult, although it may be up to 7-8cm.

Auscultation

Purpose

Asses normal and

abnormal air flow

through bronchial

tree by using

Diaphragm of

stethoscope

Compare R to L

Auscultation: normal lung sound

Bronchial : Trachea , high ,

inspiration shorter than

expiration

Bronchovesicular :

Moderate , Between scapulae

Side of sternum intercostals

space , inspiration equal with

expiration

Vesicular : Lung field ,

inspiration longer than

expiration is it soft and low

Auscultation: Results

Adventitious

Crackles—

air à bronchi with —

secretions

Auscultation: Results

Wheezes

Sonorous wheezes

Deep low pitched

Snoring > E

Caused by air à

narrowed passages

R/t h secretions

Sibilant Wheezes

High pitched

Whistle-like I &E

Caused by air à

narrowed passages

R/t constriction

Asthma

Auscultation: Results

Pleural friction rub

R/t inflammation of

pleural space

Grating, creaking I &E

Best heard Anterior,

Lower, lateral area

head assessment

Head Assessment 

Objectives:

At the end of this lab the student will be able to:

I . Demonstrate the ability to safely and

accurately complete a comprehensive

examination of Head, Neck, and Lymph Nodes.

2. Demonstrate the ability to accurately &

comprehensively document assessment data in organized and legible manner.

3. Evaluate assessment data to determine

problems and identify client's concerns.

Preparation

I. Nurse

II. Environment

III. Client

IV. Equipment

Equipment:

V. Stethoscope

VI. Cup of water

Subjective data:

1. Headache

2. Dizziness

3. Lumps or swelling

4. Head injury

5. Neck pain, limitation of motion

6. History of head or neck surgery

Head Assessment

PE:

Inspection:

Symmetry : symmetrical

Shape : Normocephalic

Abnormal :

Hydrocephalic: enlargement of the head without change facial structure .

Acromegaly: enlargement of skull and facial bones cause by excessive secretion of growth hormone laceration S calp should be intact, free of lesion and (wound)

Palpation :

Palpate scalp begin with frontal ,parietal,

temporal and occipital Normal skull should be smooth ,no tenderness and no masses

Assess temporal artery it should be smooth ,non tender pulse is within +1

Abnormal: artery may be tender, hard

consistency because of arteritis

Face Assessment 

Inspection:

1-Color : evenly white ,brown ,free of

pigmentation

Abnormal: Butterfly distributed on cheeks and nose

2-Shape: symmetry ,rounded ,oval or square Hair distribution: evenly distributed on eye brow

3-Movement : ask client to close his eyes,

clench his eye brow and elevate them , smile than puffy his cheeks it should be symmetry

heart

Heart & Neck Vessels Assessment

Objectives:

At the end of this lab, the students will be able to:

1. Demonstrate the abilit y to safely & accurately complete heart & neck vessels assessment. 

2.Demonstrate the abilit y to accurately document heart & neck vessels assessment data in organized manner.

Equipment needed:

I . Marking Pen
2. Small centimeter
3. Stethoscope with diaphragm & bell
4. Alcohol swab
5- Watch with second hand

Preparation
1. To evaluate the carotid arteries, the client can be sitting.
2. To assess the jugular veins & the pericardium, the person should be supine with the head & chest slightly elevated.
3. Stand on the client's right side.
4. The room should be warm.
5. Ensure the female's privacy by keeping her breasts draped.
6. Gently displace the breast upward, or ask the client to hold it out of the way.

Subjective data:
1. Cough
2. Nocturia
3. Dyspnea
4. Fatigue
5. Past cardiac history
6. Orothopnea
7. Cyanosis or pallor
8. Family cardiac history
9. Edema
10.Chest pain
1 1. Personal habits

The Neck Vessels
Palpate the carotid artery
- Palpate each carotid artery medial to the
sternomastoid muscle in the neck.
- Avoid excessive pressure on the carotid sinus area.
- Palpate gently.
- Palpate only one carotid artery at a
time. 
- Feel the contour & amplitude of the pulse.
- Compromise finding to the other side.

Normal finding :
Contour is smooth with rapid upstroke & slower down stroke. Strength is 2+ or moderate.
Findings should be same bilaterally

Auscultation of the carotid artery
- Keep the neck in a neutral position.
- Lightly apply the bell of the
stethoscope over the carotid artery at
three levels:
o Angle of jaw.
o Mid –line area.
o Base of the neck.
- Ask the client to take a breath. Exhale & hold it briefly while you listen. Normally no sound present

Inspect the Jugular Venous Pulse
- Put the client in supine position anywhere from 30-40 degree angle. 
- Remove the pillow to avoid flexing of the neck.
- Turn the client's head slightly away from the examined side.
- Direct strong light onto the neck.
- Note the external jugular veins overlying the stemomastoid muscle.
- Look for pulsation of internal jugular veins in the ¢ area of suprasternal notch Internal jugular vein pulsations 3cm above sternal angel

Palpate the Apical impulse: 
- localize the apical impulse using one finger pad. 
- Ask the client to "exhale & then hold". 
- Role the client midway to the left. Note the following:
Location
Size
Amplitude
Apical impulse occupy only on intercostals space, the 5* , & be at or medial to the M CL. *2cm.

Note: apical impulse is not palpable in obese or in client s with thick chest wall.

Palpate across the precordium
- Using the palm aspect of your four fingers, gently palpate the apex.
- Sear ch for any pulsation : Normally no pulsation

Percussion
- place your stationary finger in the client's 5th ICS over on left side of chest near the anterior axillary line. - Slide your hand toward your self, percussing as you go. - Note the change of sound. .

The left border of cardiac dullness is at the midclavicular line in the 5' interspace, & slopes toward the sternum as youp rogress upward, so that by the 2"dinter space the border of dullness coincides with the left sternal border.

Auscultation
- clean the end pieces with alcohol swab. -
After you place the stethoscope, try
closing your eyes briefly to get out any
distraction.
- Begin with the diaphragm end piece & note the following:
Rate & rhythm
Identify S1 & S2
Listen for murmurs

Normal finding:
Rate range from 60-IOO bpm, &
the rhythm is regular.
Sl is louder than S2 at the apex,
& S2 is louder than S1 at the base.
Should not be heard.

S1 : produced by click of the
ateroventracular valve while S2 :
produced by click of the semiluner valve
After auscultating in supine position, role
the client toward his \ her left side.
- Listen with the bell at the apex. - Ask the
client to sit up, lean forward slightly, &
exhale.
- Listen with the diaphragm firmly pressed
at the base, right, & left side. - Check for
the soft high-pit ched sound.

Where to place your stethoscope
As with palpation of the heart, auscultation should proceed in a logical manner over 5 general areas on the anterior chest, beginning with the patient in the supine position. Examined with diaphragm, including:
1- Aortic region at the 2nd intercostal spaces at the right
2- Pulmonic region at the 3rd intercostal spaces at the left 3- Erb’s point at the 4
th intercostal spaces
4- Tricuspid region at the 5th intercostal spaces at the left border of sturnum
5- Mitral region (near the apex of the heard between the 5th intercostal spaces in the mid-clavicular line) (apex of the heart).

neck assessment

Neck & Cervical Assessment

Inspect neck for the following:

Appearance:

Normal :Symmetrical, centered head position

Movement:

Smooth, controlled movements; range of motion

(ROM) from:

Flexion = 45 degree

Extension = 55 degree

Lateral abduction = 40 degree

Rotation = 70 degree

Abnormal : Asymmetrical , mass benign or

malignant ,client may complains pain with

flexion or rotation ,pain associated muscle

spasm cause by meningitis , generalized

discomfort may related to trauma, inflammation of muscle or vertebral disease

Palpation

Palpate trachea for position

(tracheal rings, cricoid &thyroid cartilage).

Midline position; symmetrical

Palpate thyroid for the following:

Position Characteristics, landmarks

Midline ,Smooth, firm, no tender

Ask the client to drink sips of water normally thyroid move upward . The movement not visible in males the thyroid cartilage large or Adam’s apple is more prominent than in females

Guidelines for palpating thyroid:

- Stand behind client &position hands with thumbs on nape of client's neck.

- Ask client to flex neck forward &to the right, & use fingers of the left hand to displace thyroid to the right.

- Palpate the right lobe using the right fingers while client swallows small sips of water.

- Repeat procedure to examine the left lobe.

(Note: ability to see or palpate the thyroid

varies considerably with client thyroid

size &body build).

Palpate cervical lymph nodes for the

following:

Size &shape : Cervical lymph nodes are usually

not palpable. If palpable, they

should be lcm or less &round.

Delineation:Discrete

Mobility:mobile

Consistency:soft

tenderness :No tender

Lymph Nodes

1- Preaurical

2- Postaurical

3- Occipital

4- Tonsillar

5- Submandibular

6- Submental

7-Anterior cervical chain (deep cervical)

8- Posterior cervical chain

9- Supraclavical

Auscultation

Use bell to assess bruit sound for carotid

artery and thyroid gland

skin integmenutry

Integumentary System

Equipment

Ruler

Lighting

Penlight

Gloves

Magnifying glass

Woods lamp

Nails Assessment

PE Technique :

Inspection

1-Color

Normal : pink

Abnormal: Pale, Bluish

2-Hygiene: Clean, Wally trimmed

Abnormal: Dirty ,

Conside ration : client work ,educat e for cleaning

3-Shape: Convex ,the angle between the nail bad and the nail is 160 degree

Abnormal : spoon shape 180 degree ,

early clubbing More than 180 degree ,

 late clubbing

,Beau’s line

PE Palpation

1-Texture

Normal: smooth & thin

Abnormal: Hard & thick

2-Vascularity

Asse ssed by Blanch te st ( refill)

normal color returned within2 second

Skin Assessment

PE Technique

Inspection

1-Color : Evenly white to light brown

Abnormal: pale, cyanosis , yellowish &

Erythema ( local or general)

2-Marks and pigmentation :

Moles ,naive &birth marks normal

Abnormal : changing of Moles ABCD

Pigmentation :

petechiae : pin point red flat discoloration of skin impalpable

Purpura : hemorrhage into skin caused by decrease platelet ,liver disfunction

Ecchymosis : discoloration of skin called black and blue mark due to trauma

Lesion:

Macule : red ,less than 1cm flat as freckle

Papule :Solid elevated less than 0.5 cm such as warts &nevi

Patch : red flat more than 1cm 1stage pressure ulcer

Nodule s : Solid elevated deep than papule within 0.5-2 cm such as cyst

Vesicle : Accumulation of fluid in skin

elevated , less than 0.5 cm full of serous such as blister

Bullae : as vesicle but great than 0.5 cm

Pustule : such as vesicle less than 0.5 cm put full of pus such as acne

Wheal : local edema irregular elevation may be red or pale as insect bite

Palpation

1-Temperature

2-Texture : smooth evenly firm

Abnormal : roughness ( occupation , weather &chemical products

3-Moisture : dry some perspiration in palm ,axially , folded skin area

Abnormal : diaphoresis clammy

4-Mobility and Elasticity ( turgor)

Mobility

Elasticity