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Physical assessment
A physical assessment is conducted to evaluate the function and integrity of a client's body systems. The nurse is responsible for preparing the client and environment, positioning, draping, and using proper instrumentation. Assessment techniques include inspection, palpation, percussion, and auscultation of various body systems such as skin, head, eyes, ears, nose, neck, heart, lungs and abdomen. The summary provides an overview of the key components and responsibilities involved in performing a thorough physical assessment.
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Physical assessment
- 1. PHYSICAL ASSESSMENT Mrs. ShanyThomas Asst. Professor
- 2. • A physicalhealth assessment is conducted to assess the function and integrity of the clients’ body part. Responsibility of the nurse 1. Preparing the client – 2. Preparing the environment – 3. Positioning 4. Draping 5. Instrumentation –
- 3. Preparing the patient –Explanation about the procedure – When and where it will take place – Importance – What will happen during examination & is painless – Empty their bladder – Sequence of assessment differ with children and adult
- 4. Preparing the environment –Depending on the time of assessment, environment needs to be well ventilated & lighted. – Providing privacy
- 5.
- 7. Draping • Drapes aremade up of paper, cloth or bed linen. Drapes should be arranged so that the area to be assessed is exposed & other body areas are covered.
- 8. Instrumentation • All equipmentsrequired for the health assessment should be clean, and in good working condition and readily accessible.
- 10. Assessment techniques • Inspection •Palpation • Percussion • Auscultation
- 11. Inspection • Close andcareful visualization of the person as a whole and of each body system • Ensure good lighting • Perform at every encounter with your client
- 12. Palpation Palpation is theexamination of the body using the sense of touch. The pads of the fingers used because their concentration of nerve endings makes them highly sensitive to tactile discrimination.
- 13. General guidelines forpalpation • Hands clean and warm, fingernails cut and filed • Areas of tenderness should be palpated last • Deep palpation should be done after superficial palpation • Client should be relaxed – gowning, draping, comfortable positioning, and warm hands & be sensitive to client’s verbal & facial expressions indicating discomfort.
- 14. Types of palpation Light Deep Bimanual
- 15. 1. Light palpation(superficial) • with light palpation extend the dominant hands fingers parallel to the skin surface & presses gently while moving in a circle. The skin is slightly depressed to determine the details of mass.
- 16. Deep /Bimanual Palpation Deeppalpation is done with 2 hands/one hand . Extend the dominant hand like light palpation, place the finger pads of the non dominant hand on the dorsal surface of the distal interphalangeal joint of the middle 3 fingers of the dominant hand . Top hand applies pressure while lower hand remains relaxed to perceive tactile sensation. It is done with extreme caution because pressure can damage internal organs.
- 17. Location Site onthe body, dorsal/ventral surface size Length and width in centimeters Shape Oval, round, elongated, irregular Consistency Soft, firm, hard surface Smooth, nodular Mobility Fixed /mobile pulsatility Present/absent Tenderness Degree of tenderness to palpation Characteristics of masses
- 18. Percussion • Percussion isthe act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. • It is used to guess the size, borders, and texture of some chest organs and organs in the abdomen.
- 19. There are 2types of percussion 1.Immediate or direct percussion refers to tapping (percussion) done by striking the fingers on the surface of the chest or abdomen. 2.Indirect, mediate, or finger percussion is striking a finger of one hand on a finger of the other hand as it is placed over an organ
- 20. Direct Percussion IndirectPercussion
- 22. Sound Intensity Location FlatnessSoft loud Muscle, bone Dullness Medium Liver, heart Resonance Loud Normal lung Hyper resonance Very loud Emphysematous tympany loud Stomach filled with gas
- 23. Auscultation Listening tosounds produced by the body Instrument: stethoscope (to skin) Diaphragm –high pitched sounds Heart Lungs Abdomen Bell – low pitched sounds Blood vessels
- 24. It is of2 types • Auscultation may be done with the ear alone.It is direct auscultation. • Indirect Auscultation may be done with the stethoscope.
- 25. General Survey • Appearance –skin color, facial features – Body Structure - figure, nutrition, posture, symmetry – Mobility - Gait, ROM • Behavior – Facial expression, mood, speech, dress, hygiene • Cognition – Level of Consciousness and Orientation
- 26. • Vital Signs –Pulse – Respirations – Blood Pressure – Temperature • Height • Weight • Spo2
- 27.
- 28. Skin , HairAnd Nails Assessment of Integument
- 29. Skin color variations locationsDescription Condition Areas Bluish (cyanosis) Increased amount of deoxygenated hemoglobin Heart or lung disease, cold environment Nail beds, lips, mouth & skin (severe cases) , Pallor (decrease in color) (associated with hypoxia) Reduced amount of oxyhemoglobin Reduced visibility of oxyhemoglobin resulting from decreased blood flow Anemia Shock Face, conjunctivae, nail beds, palms of hands Skin, Loss of pigmentation Vitiligo Congenital or autoimmune Condition causing lack of pigment lips Patchy areas on skin over face, hands, arms Yellow-orange (jaundice) Increased deposit of bilirubin in tissues Liver disease, destruction of red blood cells Sclera, mucous membranes, skin Red (erythema) Increased visibility of oxyhemoglobin caused by dilation or increased blood flow Fever, direct trauma,, alcohol intake Face, area of trauma, sacrum, shoulders, other common sites for pressure ulcers Tan-brown Increased amount of melanin Suntan, pregnancy Areas exposed to sun: face, arms; areola, nipples
- 30. • Moisture: hydrationof skin and mucous membrane. Observe for dullness, dryness, crusting and flaking. • Temperature: palpate the skin with dorsum of hand. Temperature depends on the variation in blood supply • Texture: the character of skin surface Normally smooth and soft • Turgor: Skins elasticity To assess skin turgor , a fold of skin on the back of forearm or sternal area is grasped with finger tips and released. Normally skin lifts easily and snaps back immediately. If the skin remains pinched when turgor is poor.
- 31. • Vascularity: observefor petechiae • Edema: Areas of skin become swollen due to collection of fluid in tissues • lesion:
- 32. Hair and scalp •Hair: note the color, distribution, quantity, thickness, texture and lubrication of hair. • Scalp: check for lesions, lumps or bruises.
- 33. • Inspect thenail bed for color, cleanliness and length; thickness and shape of the nail plate, the texture of the nail; the angle between the nail and the nail bed. observe for splinter hemorrhage and cyanosis and clubbing. • Palpate the nail base: normally smooth , round and convex. • Check the capillary refill: grasp the finger and observe the color of the nail bed. Apply gentle , firm pressure with the thumb to the nail bed and release it. As pressure applied nail bed appears white or blanched. Pink color should return immediately on release of pressure. Nails
- 35. • Calluses andcorns are found on the toes or fingers. • Callus is flat and painless caused by thickening of epidermis • Corns are caused by friction and pressure from shoes
- 36. Assessment Normal findingsDeviation from normal Inspect skull for size, shape & symmetry Rounded (normocephalic & symmetrical, with frontal, parietal and occipital prominences,) Lack of symmetry,increased skull size with more prominent nose and forehead Palpate the skull for nodules /masses & depressions with fingertips with rotating motion with the finger tips Smooth uniform consistency: absence of nodules and masses Sebaceous cyst; local deformities from trauma Inspect the facial features for symmetry of structure & of the distribution of hair Symmetric slightly asymmetrical facial features. ↑ Facial hair, thinning of eyebrows, asymmetric features, exophthalmos, moon face. Head and neck
- 37. Inspect the eyesfor edema & hollowness Periorbital edema, sunkun eyes. Note symmetry of facial movement Elevate the eyebrow Close the eyes tightly Puff the cheeks Smile and show the teeth Symmetric facial movement Eyes cannot be closed, dropping eyelid & mouth, involuntary facial movements Document findings
- 38. Eye Some of theterminologies • Myopia – nearsightedness • Hyperopia – farsightedness • Presbiopia – loss of elasticity of the lens hence loss of ability to see close objects • Conjunctivitis– inflammation of the conjunctiva • Cataract – opacity of the lens
- 39. Assessment Normal findingsDeviation from normal Inspect the eyebrows for hair distribution Evenly distributed Loss of hair, scaling & flakiness of the skin Inspect the eyelashes for evenness of distribution Equally distributed Inversion of the eyelid Inspect the bulbar conjunctiva(lying over the sclera) for color, texture and presence of lesions Transparent; capillaries evident, sclera appears white& yellowish in dark colored clients. Jaundiced, excessively pale, reddened sclera, lesions or nodules. General assessment
- 40. Inspect the palpebral conjunctiva Shinysmooth and pink or red. Jaundiced, excessively pale, reddened sclera, lesions or nodules Inspect & palpate the lacrimal gland and naso lacrimal duct No edema & tearing Increased tearing Perform corneal sensitivity test Client blinks (trigeminal intact) One or both lids fail to respond Inspect the pupils for color, shape & symmetry of shape. Black in color, equal in size, normally 3- 7mm In diameter, round smooth border Cloudiness, bulging of iris towards cornea.
- 41. Assess for eachpupils direct and consensual reaction to light Illuminated pupil constricts ( direct response) Either constricts/unequal responses. Assess each pupils reaction to accommodation Pupils constricts when looking at near objects & dilate when looking at far object. One/ both pupils fail to constrict/ dilate.
- 42. VISUAL ACUITY: theability to see the small details • Assessment of near vision: Ask the patient to read printed material under good lighting. • Assessment of distant vision: use of snellen chart. Ask the patient to sit or stand 20feet from the chart, cover the eye not being tested and identify the letters on the chart.
- 44. Assessing the pupilreaction • Partially darken the room • Look straight ahead • Using penlight from the side, shine a light on the pupil • Observe response & do on the other eye Normally pupil constrict in the presence of light source and dilates when the light source is moved away.
- 45. Extra ocular movements •Make the patient to sit 2feet away from the nurse. • Hold a finger about 30 cm away from the patient. • The client keeps the head fixed and follows the movement of the nurse’s finger with only the eyes.
- 47. Visual Field • Patientsits 60cm away from the nurse, facing the nurse at the eye level. • Patient covers one eye • Nurse closes the opposite eye. • Nurse moves a finger equidistant from the nurse and the client out side the field of vision and slowly brings it back to the visual field. • The patient is asked to say when the finger is seen.
- 48. Internal eye structures Ophthalmoscopeis used to inspect the internal eye structures.
- 49.
- 50. Auricle : • Inspectthe auricle’s size, shape , symmetry, position and color. • Palpate the auricle for texture , tenderness, and skin lesions. • Inspect the opening of the ear canal for size and discharges
- 51. Hearing acuity • Askthe patient to remove the hearing aids if any. • Note the clients response to questions. • If hearing los is suspected check the clients response to whispered voices.
- 52. Tuning fork test •Weber’s Test • Rinne Test
- 53. Weber’s Test :(Lateralization of sound) Steps • Hold the tuning fork at the base and tap it against the heal of the palm • Place the base of the fork on the middle of the clients forehead. • Ask the patient weather the sound is heard equally in both ears or better in one ear. Rationale • Patient with normal hearing hears sound equally in both rears. In conduction deafness sound is heard best in impaired ear.
- 54. Rinne Test Steps • Placestem of vibrating tuning fork against mastoid process • Count the time • Ask the patient when the sound is no longer heard. • Quickly place the fork against the ear canal. Ask the patient to say when the sound is no longer heard • Compare the time the sound is heard by bone conduction versus air conduction Rationale • Air conducted sound should be heard twice as long as bone conducted sound.
- 55. Inspecting the earswith otoscope • Attach the speculum to the otoscope • Tilt the clients head away from you, & straighten the ear canal by pulling the pinna up & back • Hold the otoscope - either right side up, with your fingers between the otoscope handle and the client’s head. - Upside down, with your fingers & the ulnar surface of hand against the client’s head. • Gently insert the tip of the otoscope into the ear canal, avoiding pressure by the speculum against either side of the ear canal.
- 56. Assess the tympanic membrane for color& gloss Pearly gray color, semi transparent Pink to red, some opacity, yellow-amber, white, blue or deep red & dull surface
- 57.
- 58. Inspect the external nosefor any deviations in shape, size /color & flaring / discharge from the nares. Symmetric & straight Asymmetric Light palpate external nose for areas of tenderness Not tender: no lesions Tenderness & presence of lesions
- 59. Determine Patency of both nasalcavity Air moves freely as the client breaths through the nares Air movement is restricted Inspect the nasal cavity with the speculum Observe the presence of redness, swelling, growths & discharge. Pink, clear, watery discharge Mucosa red, edematous, abnormal discharge, septum deviated to right / Left.
- 60. Inspect the nasal septumB/n nasal chambers Nasal septum is intact & in midline Septum deviation to R/L Facial sinuses Palpate the maxillary & frontal sinuses for tenderness Not tender Tenderness on one more sinuses Document deviations
- 62.
- 63. Includes: – the muscles, -lymphnodes, -trachea, -thyroid gland, -carotid arteries and jugular veins
- 64. • The areasof the neck are defined by sterno- cleidomastoid muscles. Which divide the each side of the neck into two triangles. The anterior and posterior • The anterior triangle - Trachea, thyroid gland, anterior cervical nodes, & carotid artery • The posterior triangle – posterior lymph nodes
- 65. Procedure • Explain theprocedure • Wash hands and observe infection control procedure • Provide for client privacy • Inquire if the client has any h/o following: - any problems, -neck pain or stiffness, -how & when any lumps occurred, -any previous diagnosis of thyroid problems, -any other treatments
- 66. Inspect the SCM muscle Equalin size, head centered Unilateral neck swelling, head tilted, lumps, injury shortening of muscles. Observe head movement Head - chin Head back Head – shoulders Head – right & left Co coordinated smooth movements with no discomfort Parkinson's disease
- 67. Assess muscle strength •Ask the client to turn the head to one side against the resistance of your hand - equal strength • Abnormality – unequal strength
- 68. Lymph nodes (howto palpate the neck lymph node) • Face the client, bend the client head forward slightly/towards the side being examined to relax the soft muscles. • Move the finger tips in gentle rotating motion • When palpating the supraclavicular node, • Bend the head forward hook your index & 3rd finger over the clavicle lateral to the sternicleido mastoid muscles.
- 69. • When palpatingthe anterior cervical node & post. Cervical node, move your fingertips slowly in a forward circular motion against the sternocleido mastoid muscles respectively
- 70. Palpate the trachea forlateral deviation Central placement in midline of the neck , spaces are equal on the both sides. •Deviation to one side • thyroid enlargement • enlargement of nodes.
- 71.
- 72. Palpating the thyroidgland • 2 approaches • Posterior approach • Place hand over the neck , lower half of the neck over the trachea. • Ask the client to swallow & feel for any enlargement of the thyroid • Examine on the right side & left side lobes
- 73. • Anterior approach –Place the tips of index & middle fingers over the trachea & palpate the thyroid isthmus – To palpate right thyroid client turns to the chin on right to feel for right lobe – To palpate left thyroid client turns to the chin on left to feel for left lobe If enlargement of the gland is suspected auscultate over the thyroid area for a bruit
- 74.
- 75. Land marks • Adultthorax is oval • Mid sternal line- vertical line running through the centre of the sternum • Mid clavicular lines • Anterior axillary lines - axillary fold • Posterior axillary line • Mid axillary line – apex of the axilla
- 76.
- 77. Posterior thorax Inspect theshape & symmetry of the thorax from posterior to lateral AP diameter is half of the transverse diameter Barrel chest, pigeon chest, funnel chest Inspect for the spinal alignment Straight, right & left shoulders are at same height. Spinal column deviations
- 78. Palpation of post.thorax Assess for temperature and integrity of chest skin Intact & uniform temperature Skin lesions. Areas of hyperthermia Palpate for bulges, tenderness, masses No tenderness or masses Lumps, bulges, depressions, areas of tenderness
- 79. Palpate for respiratoryexcursion • Place hands on lower thorax thumbs adjacent to spine & fingers stretched laterally • Ask the client take deep breath • Full & symmetric expansion • Normally thumbs separate 3-5cm(11/2 -2in.)
- 80. Palpate the chestfor fremitus • Fremitus is a faintly perceptible vibration felt through the chest wall when the client speaks (1,2,3,or 99 or blue moon etc) • Fremitus is tested both anteriorly and posteriorly • Bilaterally symmetric • Increased – pnemothorax • Decreased – consolidation, pneumonia etc
- 82. Steps • Bend thehead &fold the arms forward across the chest. • Percuss in the ICS over the symmetrical areas of the lungs moving side to side. • Starting posteriorly and then moving laterally and anteriorly • Compare one side of the lung with the other.
- 85. Percussion notes • Resonance: Air filled lungs • Dull : Lung mass • Flat : Scapula, ribs, spine
- 86. • Detects themovement of air through the tracheobronchial tree and detect mucus and obstructed airways.
- 87. Normal breath sounds TypeLocation Description characteristics Vesicular Over peripheral lung, best at base of the lung Soft intensity – air moving Heard On inspiration Broncho - vesicular Between the scapula &lateral to the sternum &1st & 2nd ICS Moderate intensity Equal inspiratory & expiratory phases. Bronchial (tubular) Anteriorly over the trachea High pitched, loud, harsh sound created by air Louder than vesicular sounds
- 88. Abnormal (adventitious breathsounds) Name description Cause Location Crackles (rales) Best heard on inspiration Air passing through fluid or mucus Base of lower lung Gurgles (rhonchi) Best heard on expiration Air passing through narrow air passage due to secretions, swelling, tumors. Predominate over trachea & bronchi Friction rub Superficial grating or creaking sounds Rubbing together of inflamed pleural spaces. Lower anterior & posterior chest.
- 89. Name description CauseLocation wheeze Continuous, high pitched, squeaky musical sounds best heard on expiration. Air passing through constricted bronchus as a result of secretions, swellings & tumors. Heard over all lung fields
- 90.
- 91. Locating landmarks inprecordium Locate the angle of loius • Right 2nd ICS near sternum- aortic area • Left 2nd ICS near sternum - pulmonic area • Left 5th ICS close to sternum- tricuspid area • Left 5th ICS midclavicular line - apical / mitral area • Left 3rd ICS near sternum – Erb’s point
- 93. Auscultation • S1 usuallyheard at all sites & usually louder at apical area (closure of AV Valves) • S2 usually heard at all sites & usually louder at base of the heart (closure of semi lunar valves)
- 94.
- 95. Carotid arteries Palpate thecarotid artery Symmetric pulse , volume and Quality remains same with all activity Assymetric volume, decreased pulsations, Auscultate the carotid artery for Bruit No sound heard Presence of bruit indicate obstruction
- 96. Jugular veins jugular venouspressure (JVP) Blood pressure in the jugular vein, which reflects the blood volume and pressure in the right side of the heart.
- 97. Procedure • Have theclient lie supine with the head elevated 30-45 degrees • Use two rulers. Line up the bottom edge of a regular ruler with the top of the area of pulsation in the jugular vein. Take a centimeter ruler and align it perpendicular to the first ruler at the level of the sternal angle. Measure in centimeters the distance between the ruler and the sternal angle. • Bilateral pressure higher than 2.5cm are considered elevated.
- 99. Peripheral vessel Palpate forthe peripheral pulses on both sides of the body Symmetric pulse volumes Full pulsations Asymmetric, absence, weak thready pulse inspect the peripheral veins for phlebitis Limbs not tender Tenderness on palpation, pain, warm & redness.
- 100. Allen’s test Done toassess the collateral circulation of the upper extremities. The client makes a fist as the ulnar and radial arteries are compressed simultaneously. The client then opens the hand and the nurse releases the ulnar artery. The hand should quickly turn pink if the ulnar artery is patent. The test may be repeated by releasing only the radial artery.
- 101.
- 102.
- 103. • The abdomenis roughly divided into four quadrants: right upper, right lower, left upper and left lower.
- 104. Inspect-color, texture & integrity Uniform color,silver white striae / surgical scars Tense, glittering skin, Inspect for shape & symmetry Flat, round /scaphoid distended Ask to deep breath &hold No evidence of enlargement of organs Hepatomegaly/ spleenomegaly If distension present measure the girth at the level of umbilicus
- 105. Observe for abdominal movements associated with respiration, peristalsis/aortic pulsation -symmetric movement. -visible peristalsis & aortic pulsation in lean people Limited peristalsis, visible pulsation, dilated veins, marked aortic pulsation etc
- 106. Auscultation of theabdomen • Warm hands Bowel sounds • Auscultate with diaphragm • Ask when did they eat • Place the diaphragm at all 4 quadrants • Listen for active bowel sounds- irregular gurgling sounds occurring every 5 to 20 secs.
- 107. Percussion of theabdomen Percuss the 4 quadrants to determine the presence of tymphany Tympany over the stomach & gas filled intestine, dullness over the liver, spleen & full bladder Large dull area indicate presence of tumor or fluid Percuss the liver to determine its size 6 – 12 cm in the mid clavicular line 4-8 cm in the midsternal line Enlarged size
- 108. Palpation of theabdomen Perform light palpation to determine areas of tenderness No tenderness relaxed abdomen with smooth, consistent tension. Perform deep palpation Tenderness may be present over xiphoid process, cecum, & sigmoid colon
- 109.
- 110. Female reproductive system •Assessment of breast • Assessment of inguinal lymph nodes • External genitalia
- 111. PUBIC HAIR Inspect thedistribution, amount, & characteristics of pubic hair Inverse Triangular, Inspect the pubic area for parasites, inflammation, swelling & leisons Skin of valva is slightly darker than the body
- 112. Observe in themirror for shape and symmetry Breast examination
- 114.
- 115.
- 116. Hands –of- the-clock
- 117.
- 118. Organs include •Penis •Scrotum &testis •Prostate gland
- 119. PUBIC HAIR Inspect thedistribution, amount, & characteristics of pubic hair Triangular, often spreading up to abdomen Penis Inspect the penile shaft & glans penis for leisons, nodules, swelling & inflammation Penile skin intact, foreskin easily retractable - Smegma b/n the glans & foreskin + Inspect the urethral meatus for swelling, inflammation, & discharge Pink & slit like appearance, urethra positioned at tip of the penis
- 120. Palpate the penisfor tenderness, thickening & nodules Smooth & semi firm scrotum Inspect the scroutum for general size and symmetry. Size varies with temperature, scrotum generally asymmetric bilaterally (left is lower) Inguinal area Inspect both inguinal areas for bulges, while the client is standing No swelling/ bulges
- 121. Palpating a hernia •Have the client remain at rest • Have the client hold the breath & bear down as though having a bowel movement • Bearing down makes the hernia more visible
- 122.
- 123. NEUROLOGICAL SYSTEM • Takes2-3 Hrs. • It includes – 1. Mental status including consciousness 2. Motor function & sensory function 3. Reflexes 4. The cranial nerves
- 124. Terminologies Mental status – •reveals clients general function • major areas of mental status include – language, orientation, memory & attention span & calculation.
- 125. Assessment of levelof consciousness –Glasgow coma scale • Glasgow Coma Scale, a system for describing the degree of loss of consciousness in the severely ill. It is also used to predict the length and result of coma, mostly in patients with head injuries.
- 126.
- 127. The lower thescore is, the more severe the brain injury. • Scores below 8 indicate a severe brain injury • Scores between 9 and 12 indicate a moderate brain injury, • Scores above 13 indicate a minor brain injury.
- 128. Cerebellar function a) Gait b)Co-ordination a. Romberg test Ask the patient to stand, feet together with eyes closed and arms at sides. Romberg-only positive if loss of balance occurs. b. FTN test Ask the patient to alternately point from his or her nose to the examiner’s finger. The examiner will typically move his or her finger to different locations.
- 129. c. Heel ToShin test Ask the patient to run the heel of one foot along the shin of the opposite leg. The patient then does the same procedure on the opposite side
- 130. Sensory function: • SuperficialTouch: Touch the skin with your fingertip, Have the patient point to the area touched. • Superficial pain: Alternating the point and hub of a sterile needle, touch the patients skin is an unpredictable pattern. Ask the patient to identify the sensation as dull or sharp. • Vibrations: Place the stem of a vibrating tuning fork against several bony prominences.
- 131. • Temperature anddeep pressure: Only when superficial pain is not intact, the temperature and deep pressure sensation tests are performed. Roll test tubes of hot and cold water alternatively in an unpredictable manner to evaluate the temperature sensation.
- 132. • Cortical Sensoryfunction: Cortical or discriminatory sensory functions test the cognitive ability to interpret sensation associated with co- coordination abilities. Stereognosis: Have the patient a familiar object to identify by touch and manipulation. Inability to recognize objects by touch suggests a parietal lesion. Graphesthesis: abilty to feel writing on the skin
- 133. Extinction phenomenon: Simultaneously touchthe cheek, hand or other area on each side of the body with sterile needle. Ask the patient to tell you how many stimuli there are and where they are. Point location - Touch an area on the patients skin and withdraw the stimulus. Ask the patient to point to the area touched
- 134. Reflexes: Superficial andDeep tendon Reflexes • Superficial Reflexes: With the patient supine, stroke each quadrant of the abdomen with the end of a reflex hammer or tongue blade edge. The upper abdominal reflexes are elicited by stroking downward and toward the umbilicus and lower abdominal reflexes are elicited by stroking downward away from the umbilicus toward each area of stimulation should be bilaterally equal.
- 135. • deep tendonreflex (DTR), a quick contraction of a muscle when its tendon is sharply tapped by a finger or rubber hammer. Absence of the reflex may be caused by damage to the muscle, the nerve, nerve roots, or the spinal cord. A violent reflex may be caused by disease of the nervous system or by overactive thyroid gland.
- 136. Deep tendon Reflexes: 1.Biceps reflex 2. Brachioradial reflex 3. Triceps reflex 4. Patellar reflex 6. Achilles reflex 7. Plantar reflex
- 137. 1. Biceps reflex:Flex the patient's arms up to 45 degrees at elbow. Palpate the biceps tendons in the antecubital fossa. Place your thumb over the tendon. Strike your thumb, rather than tendon directly with reflex hammer. Contraction of biceps causes palpable flexion of the elbow.
- 139. Brachioradial reflex: Flex thepatient’s arm up to 45 degrees and rest his or her forearm on your arm and hand slightly pronated. Strike the brachioradials tendon directly with the reflex hammer. Pronation of forearm and flexion of the elbow should occur.
- 140. • Triceps reflex:Flex the patient’s arm at elbow up to 90 degrees and rest the patient’s hand against side of the body. Palpate the triceps tendon strike it directly visible or palpable extension of elbow should occur.
- 141. • Achilles reflex:With the patient sitting, flex the knee and dorsiflex the angle upto 90 degrees holding the heel of the foot in your hand. Striking the tendon may cause contraction of the gastrocnemus muscle and plantar flexion of the foot.
- 142. Plantar reflex: Usinga pointed object, stroke the lateral side of the foot from heel to the ball, then curve across the ball of the foot to medial side. Observe for plantar flexion, fannings of the toes or dorsiflexion of great toe with or without fanning of other toes.
- 143.
- 144. Assessment of cranialnerves
- 145. Cranial Nerve FunctionMethod I Olfactory Smell reception and interpretation Ask client to close eyes and identify different mild aromas such alcohol, powder and vinegar. II Optic Visual acuity and fields Ask client to read newsprint and determine objects about 20 ft. away III Oculomotor Extraocular eye movements, lid elevation, papillary constrictions lens shape Assess ocular movements and pupil reaction IV Trochlear Downward and inward eye movement Ask client to move eyeballs obliquely
- 146. V Trigeminal Sensationof face, scalp, cornea, and oral and nasal mucous membranes. Chewing movements of the jaw Elicit blink reflex by lightly touching lateral sclera; to test sensation, wipe a wisp of cotton over client’s forehead for light sensation and use alternating blunt and sharp ends of safety pin to test deep sensation Ask client to clench teeth VI Abducens Lateral eye movement Ask client to move eyeball laterally VII Facial Taste on anterior 2/3 of the tongue Facial movement, eye closure, speech Ask client to do different facial expressions such as smiling, frowning and raising of eyebrows; ask client to identify various tastes placed on the tip and sides of the mouth: sugar, salt and coffee VIII Acoustic Hearing and balance Assess client’s ability to hear loud and soft spoken words; do the watch tick test
- 147. IX Glossopharyngeal Tasteon posterior 1/3 of tongue, gag reflex, sensation from the eardrum and ear canal. Swallowing and phonation muscles of the pharynx Apply taste on posterior tongue for identification (sugar, salt and coffee); ask client to move tongue from side to side and up and down; ask client to swallow and elicit gag reflex through sticking a clean tongue depressor into client’s mouth X Vagus Sensation from pharynx, viscera, carotid body and carotid sinus Ask client to swallow; assess client’s speech for hoarseness XI Spinal accessory Trapezius and sternocledomastoid muscle movement Ask client to shrug shoulders and turn head from side to side against resistance from nurse’s hands XII Hypoglossal Tongue movement for speech, sound articulation and swallowing Ask client to protrude tongue at midline, then move it side to side
- 148.
- 149. MUSCLES 1. Inspect theMuscles for size. Compare the muscles on one side of the body to the same muscle on the other side. For any discrepancy, measure the muscles with tape. 2. Inspect the muscles and tendons for contractures and shortening 3. Inspect the muscles for tremors.
- 150. 4. Inspect anytremors of the hands and arms by having the client hold the arms out in front of the body 5. Palpate muscles at rest to determine muscle tonicity (the normal condition of tension, or tones of a muscle at rest).
- 151. Muscle strength scale 0-No detection of muscular contraction 1- A barely detectable flicker or trace of contraction with observation or palpation. 2- Active movement of body part with elimination of gravity. 3- Active movement against gravity only and not against resistance 4- Active movement against gravity & some resistance 5- Active movement against full resistance without evident fatigue (Normal muscle strength)
- 152. Maneuvers to assessmuscle strength Neck: Sternocleidomastoid- place hand firmly against upper jaw. Ask patient to turn head against resistance Shoulder: Trapezius- Exert mild pressure over patient’s shoulder. Have patient raise shoulders against resistance
- 153. Elbow: Biceps- pull downforearm as patient attempts to flex arm Triceps- apply pressure against flexed arm as patient try to straighten the arm Hip: Quadriceps- while sitting apply pressure over the thigh, ask the patient to lift the leg Gastrocnemius- Hold shin of flexed leg ,ask patient to straighten the leg
- 154. Deviations from Normal •Atrophy (a decrease in size) or hypertrophy (an increase in size). • Malposition of body part, e.g., foot drop (foot flexed downward). • Presence of tremor. • Atonics (lacking tone) • Flaccidity (weakness and laxness) or spasticity (sudden involuntary muscle contraction) • 25% or less of normal strength
- 155. BONES • Inspect theskeleton for normal structure and deformities • Palpate the bones to locate any areas of edema or tenderness
- 156. JOINTS • Inspect thejoint for swelling, Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence of nodules. • Assess joints for range of motion. – Ask the client to move selected body parts. The amount of joint movements can be measured by a goniometer, a device that measures the angle of joint in degrees.
- 158. Specific joints 1. Temporo-mandibular joints 2.Cervical spine 3. Thoracic & lumbar spine 4. Shoulders 5. Elbows 6. Hands and wrists 7. Hips 8. Knees 9. Feet & ankles
- 159. Temporomandibular joints • Open &close the mouth • Move the lower jaw to each side (1-2cm) • Protrude & extract chin • Strength of temporalis muscle checked by asking to clench the teeth
- 160. Cervical spine • Position,alignment of head, symmetry of skin folds & muscles • Cervical & lumbar spine should be concave • Flexion & extension at 450 • Lateral bending at 40 degrees
- 161. Thoracic & lumbarspine • Thoracic spine should be convex • Bend forward & try to touch the toes flexion of the 75 – 900 • Expect lateral bending of 350 • Swing the waist in a circular motion
- 162. Shoulders • Inspect symmetry& contour of shoulder • Palpate the joints & groves • Examine following ROM – Raise both arms forward & straight up – Stretch both arms behind back – Adduction, Internal rotation, & external rotation
- 163. Elbows • Bend andstraighten the elbows • Flexion at 1600 • Full extension at 1800
- 164. Hand & wrist •Inspect the dorsal & palmer aspects of the hands • Identify deviations of fingers • Examine ROM of Hand & wrist - bend the fingers at metacarpals - touch the thumb to each fingertips - bend the hand at wrist up & down - with the palm side down, turn each hand right & left
- 165. HIPS • Inspect thesymmetry of the iliac crest • ROM – Rise the leg with knee Extended above the body – Swing the straightened leg either standing or prone – Raise knee to the chest while keeping other leg straight – Rotate inward and outwardly
- 166. Knees • Inspect thePopliteal area • Observe the lower leg alignment • Bend knees for flexion1300 • Full extension
- 167. Feet & ankles •Dorsiflexion of 200 • Bending the foot at the ankle • Rotating the ankle