NURS 190 PHYSICAL ASSESSMENT FINAL EXAM study guide-tutor verified -2024-2025 .docx, Exams of Nursing

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NURS 190 PHYSICAL ASSESSMENT FINAL EXAM

study guide-tutor verified -2024-

Physical Assessment Final Exam Inspection technique (3): ● FIRST technique with general survey ● General survey: ○ Observing mobility / gait, physical appearance, general wellness/health, mood & behavior (facial expressions, interactions), mental status (observing patient’s body language and response when asking questions) ● Do it the SAME WAY every time → less likely to forget something ● Do not rush it, especially with anxious patients ○ Make sure the patient is comfortable ○ Temperature in the room is suitable for the patient ● Make sure that you have everything that you need → so that the patient has confidence in you ● Know normal vs abnormal when surveying appearance & symmetry ○ Compare ANYTHING that has a pair ○ Eyes- level, equal, is there eyelid drooping? ○ Smile- is there a droop? ○ Always compare the two sides to ensure that there is no abnormality between the two sides ● Listen for natural sounds ○ Abnormal sounds : wheezing, labored breathing, crepitus during ROM ● Detect abnormal odors: ○ CDIFF, alcohol on a patient, acetone / sugary breath ● Try not to assume anything! → use critical thinking! ○ Ex: someone with low blood sugar or issues with hypoxia can appear intoxicated ● Know your normal values: ○ Blood pressure, HR, RR, O2 sats, temperature ○ For each age levels ■ Infants: must faster RR than elderly Percussion technique (3) ● Types: ○ Direct percussion- tapping body with fingertips of dominant hand

■ For a small infant → direct percussion on the chest ■ Adult → on the sinuses on the face ○ Blunt percussion- place palm of nondominant hand flat against the surface and strike it with closed-fist dominant hand ■ Used to assess the kidneys → assessing for pain / tenderness

(UTI)

○ Indirect percussion- most commonly used ■ Plexor = hammer or tapping finger ■ Pleximeter = device or surface that accepts the tap ● Sounds: ○ Intensity of amplitude: softness or loudness ○ Pitch or frequency: high or low (vibrations per second) ○ Duration: length of time ○ Quality: recognizable overtones or drumlike sounds ● Tympany- sound heard over stomach or intestines ○ Loud, high-pitched, drum-like tone ● Resonance- normal sound heard over lungs ○ Loud, low-pitched, hollow tone ● Hyperresonance- air trapped in lungs ○ Abnormally loud, low tone of longer duration than resonance ■ COPD, trauma or lung collapse ● Dullness- over solid body organs (liver) ○ High-pitched tone, soft and short ● Flatness- over solid tissue, muscle, or bone ○ High-pitched tone, very soft & shorter than dullness ■ Ex: ribs Skin assessment (5) ● Life span considerations: ○ Infants and children ■ Newborn skin → covered with vernix caseosa ■ Infants have thin, soft, skin and free of hair ■ Milia and stork bites - common, harmless markings in newborns ■ Mongolian spots- gray, blue or purple spots in sacral and buttocks area ● Fade by age 3 ● Try not to confuse it with possibility of abuse → ask the parent “is this something that has been here since birth?” ■ Poor temperature regulation → do not secrete from glands ○ Pregnant female ■ Skin pigmentation increases → in areolae, nipples, vulva, perianal area ● Development of melasma and linea nigra down the abdomen ● Resolve itself after pregnancy ■ Hormonal changes→ cause oil and sweat glands to become hyperactive ● Acne worsens in 1st trimester ■ Hair may fall out during months 1- ○ Older adult ■ Skin elasticity decreases with aging

■ Sebum production decreases → causes dryness ● More prone to skin breakdown ■ Perspiration / sweating decreases ■ Decrease in melanin production → result in gray hair ■ Nails become thicker and more brittle due to decreased amount of circulation ■ Hair thins because of decrease of hair follicles ■ Liver spots, hyperpigmented freckles, increased amount of skin tags ● Psychosocial considerations: ○ Stressed induced illness: ■ Trichotillomania- hair twisting & pulling ■ Nail biting ■ Visible skin disorders in relation to self-esteem / body image ● Cultural and environmental considerations: ○ Socioeconomic status ■ Not able to go to the doctor because of finances ○ Home environment ■ Are they homeless? → if so, could be more likely to develop skin cancer due to outside exposure ○ Means of employment ■ If they work outside → important to know ■ Do not assume bad hygiene!! → could be from work ○ Changes in skin color → may be more difficult to detect in patients with dark skin ○ Dry skin does not necessarily indicate dehydration ○ Skin response to stressors differ from person to person ■ Autoimmune disorders ○ Differences in hair color and texture vary from different cultural groups ○ Prolonged immersion of hands in water can cause paronychia- reddened cuticles causing infection ○ Table 13.2 (variations) 31: ● Focused interview- questions related to: ○ Notice any smells / foul odors ○ Changes in color → oxygenation issues or perfusion ○ Sweating → fever, being in the sun too long, excessive sweating ○ Skin : ■ In general ■ Illness or infection ■ Symptoms, pain, behaviors ■ Age ■ External environment ○ Hair : ■ In general ■ Infants and children

○ Nails : ■ In general ■ Infants and children ■ Pregnant females ■ Older adult ● Color variations in light and dark skin ○ Pallor- loss of color in skin due to absence of oxygenated hemoglobin ■ Light skin: ● White skin loses rosy tones ● Yellow tone appears more yellow ■ Dark skin: ● Black skin loses its red undertones and appears ash-gray ● Brown skin becomes yellow-tinged ○ Absence of color- loss of pigment ■ Albinism- white/pale blond hair and pink irises ■ Vitiligo- very noticeable as patchy milk-white areas ■ Tinea- appears patchy areas paler than surrounding skin ○ Cyanosis- blue color in skin due to inadequate tissue perfusion ■ Light skin: ● Skin, lips, mucous membranes look blue-tinged; nail beds are blue ■ Dark skin: ● May appear a shade darker ● May be undetectable except for lips, tongue, oral mucous membranes, nail beds, and conjunctivae ○ Reddish blue tone- ruddy tone due to increased hemoglobin and stasis of blood ■ Light skin: reddish purple hue ■ Dark skin: difficult to detect; normal skin may appear darker in some patients ○ Erythema- redness of the skin due to increased visibility of normal oxyhemoglobin ■ Light skin: local inflammation and redness ■ Dark skin: hard to detect; inflammation appear purple or darker than surrounding skin ○ Jaundice- yellow undertone due to increased bilirubin ■ Generalized; visible in sclera, oral mucosa, hard palate, fingernails, palms of hands, and soles of the feet Skin lesions (5) ● Primary lesions: ○ Macule and patch- flat, nonpalpable change in the skin color ■ Macule : Smaller than 1 cm ■ Patch : larger than 1 cm ○ Papule and plaque- elevated, solid palpable masses with a circumscribed

border ■ Papule : smaller than 0.5 cm ■ Plaques : groups of papules that form lesions larger 0.5 cm ○ Nodule and tumor- elevated, solid, hard or soft palpable mass extending deeper into the dermis ■ Nodules : smaller than 2 cm ■ Tumors : may have irregular borders and are larger than 2 cm ○ Vesicle and bulla: elevated, fluid-filled, round or oval-shaped, palpable masses with thin, translucent walls and circumscribed borders ■ Vesicles : smaller than 0.5 cm ■ Bullae : larger than 0.5 cm ○ Pustule- elevated, pus-filled vesicle or bulla with a circumscribed border ■ Size varies ○ Wheal- an elevated, often reddish area with an irregular border caused by diffuse fluid in tissues ■ Size varies ○ Cyst- elevated, encapsulated, fluid-filled or semisolid mass originating in subcutaneous tissue or dermis ■ Usually 1 cm or larger ● Vascular lesions: ○ Ecchymosis- flat, irregular shaped lesion of varying size with no pulsation; does not blanch with pressure → BRUISE ■ In light skin : bluish, purple mark that changes yellow ■ Brown skin : varies from blue to deep purple ■ Black : darkened area ○ Hemangioma- bright, red raised lesion about 2-10 cm in diameter that does not blanch with pressure; present at birth or within few months of birth and typically disappears by age 10 ■ Cluster of immature capillaries ○ Cullen sign- periumbilical; could indicate internal bleeding in abdomen ○ Grey turner sign- flank area; could indicate bleeding into peritoneum, pancreatitis, etc. ○ Hematoma- raised, irregularly shaped lesion similar to ecchymosis except that it is elevated and looks like swelling ■ Caused by leakage of blood into the skin and subcutaneous tissue ○ Petechiae- flat, red or purple rounded “freckles”; approximately 1-3 mm in diameter; pinpoint lesions ■ Difficult to detect in dark skin and do not blanch ○ Purpura- flat, reddish-blue, irregularly shaped extensive patches of varying size ○ Port-wine stain- flat, irregular shaped lesion ranging from pale red to deep purple-red ■ Color deepens with exertion, emotional response, or exposure to extreme temperatures ■ Present at birth and typically does not fade

○ Spider angioma- flat, bright red dot with tiny radiating blood vessels ranging in size from a pinpoint to 2 cm; blanches with pressure ○ Venous lake- soft, compressible, slightly elevated vascular lesion; color typically ranges from dark blue to purple ● Infectious lesions: ○ Tinea- fungal infection affecting the body, scalp, or feet ■ Body = tinea corporis ■ Scalp = tinea capitis ■ Feet = tinea pedis (athlete’s foot) ○ Measles (Rubeola)- highly contagious viral disease that causes a rash of red to purple macules or papules that begins on face, then progresses over the neck, trunk, arms, and legs ■ Lesions do not blanch ■ Oral mucosa may demonstrate tiny, white spots that look like grains of salt ○ Varicella (chicken pox)- mild infections disease caused by primary infection with the varicella zoster virus; small, red, fluid-filled vesicles usually on the trunk from which the rash progresses to the face, arms, and legs ■ Erupt over several days forming pustules, then crusts ■ Cause intense itching ○ Rubella- highly contagious disease caused by rubella virus; typically begins as pink, papular rash that is similar to measles but paler ■ Skin lesions begin on the face and then spread over the body ○ Herpes simplex → cold sores ○ Herpes zoster → shingles ■ Clusters of small vesicles that form on the skin along the route of sensory nerves ○ Impetigo- contagious, bacterial skin infection that usually appears on the skin around the nose and mouth ■ Lesions may begin as barely perceptible patch of blisters that break, exposing red, weeping area beneath ■ Tan crust forms over the area ■ Common in children Nail abnormalities (2) ● Caused by: genetic factors, infectious disease processes, traumatic injuries ● May also provide clues to presence of underlying disease process involving other body systems ● Spoon nails / koilonychia- can be a sign of anemia, especially iron-deficiency anemia ● Paronychia- soft tissue infection around a fingernail at the cuticle causing inflammation ● Beau lines- occur after illness, injury to the nail, eczema around the nail, during chemotherapy for cancer

● Splinter hemorrhage- can be a manifestation of connective tissue condition such as lupus or scleroderma; appear as reddish-brown spots in the nail ● Onycholysis- painless separation of the nail from the nail bed; fungal infection causing the nails to thicken and lift off nail bed ● Clubbing- nails appear convex and wide; angle is greater than 160 degrees ○ Poor oxygenation Subjective data (3) Equipment (2) ● Various instruments that help in visualizing, hearing, and measuring data ○ Stethoscope, otoscope, penlight, doppler ultrasound, ophthalmoscope, reflex hammer, BP machine (table 9.1) ○ Before physical assessment: ■ Gather all equipment! ■ Organize it ■ Place within easy reach for availability ○ Stethoscope- auscultates body sounds such as BP, heart sounds, respirations, bowel sounds ■ Used on exposed skin!! ■ Components : ● Binaurals- pointed toward face ● Flexible tubing ● End piece ○ Bell- low-pitched sounds (murmurs) ○ Diaphragm- best for high-pitched sounds (lung sounds, bowel sounds, normal heart sounds) ■ Does not “amplify” sound!! → just isolates them ○ Doppler ultrasonic stethoscope- detect sounds that are difficult to hear with regular stethoscope ■ Fetal heart sounds, peripheral pulses ■ Use gel → isolates sound waves better ○ Ophthalmoscope- inspects internal eye structures ■ Components: ● Handle & head ● Used to see anterior structure of the eye: ○ Large aperture: dilated pupils ○ Small aperture: constricted pupils ○ Red-free filter: help to see optic disc ○ Grid: if there is any lesions → help to locate size of lesions ○ Slit

○ Otoscope- examines external ear structures ■ Need to make sure you’re using the right size! ● Too large or too small can prevent you from seeing anything ■ Components : ● Handle, light, lens, specula of various sizes ■ Normal appearance of tympanic membrane: clear, pearl colored; no purulent fluid ○ Wood lamp → used for fungal infection General survey (2) ● Observing mobility / gait, physical appearance ● General wellness/health ● Mood & behavior (facial expressions, interactions) ● Mental status (observing patient’s body language and response when asking questions) ● Open-ended- intentionally general and encourage the patient to provide additional information ○ Can be during actual assessment ○ H & P ○ What kind of changes have you noticed that have occurred with your skin? ○ “Tell me more about that…” ● Close-ended- quick and simple, yes or no question ○ Do you have allergies? Are you taking any medication? Neck assessment (1) ● Inspection of skin ● Testing range of motion ● Observation of carotid arteries and jugular veins ● Palpation of trachea ● Inspection, palpation, and auscultation of thyroid gland Eye assessment (5) ○ General : “Describe your vision today…” ○ Consider expectations based on: ■ Age ■ Race ■ Environment ■ Health practices ■ Past & current problems / therapies ○ Ask about any infections, surgeries, or injuries ○ Consider patient’s ability to participate → based on any problems stated that are significant ○ Symptoms, pain and behaviors ○ “When was your last eye exam?” → especially in an older client, diabetic

patients ● Lifespan considerations: ○ Infants and children: ■ Did the mother have a vaginal infection? ■ Was the child full term or premature? If premature, how early? ● Could have been over oxygenated in NICU causing visual problems ○ Pregnant female: ■ Any changes in vision? ■ Reassure mother that it is temporary → will return by 6 months ○ Older adult: ■ Do you have any dryness? ● If the individual OVER USES eye drops → the lacrimal glands are less likely to continue to produce tears ■ Any problems with night vision? → may affect their daily living ○ Internal environment: ■ Ask whether or not the patient is taking any medications that could affect vision ■ Is there a family history of eye problems? ● Glaucoma IS inherited ● Cataracts are not genetic ○ External environment: ■ Have they been exposed to any eye irritants? ■ Do they work in an environment that can cause eye irritants? ■ Are they using safety equipment to protect eye? ● Eye assessment (5) ○ Inspection : ■ What does the sclera look like? ● Is it a normal white color? ● Is there jaundice? → can indicate liver problems ■ Looking for redness, drainage ○ Tests : ■ Snellen Tests (distance)- tests for visual acuity ● Tests for cranial nerve II ● Stand 20 feet away and cover one eye ○ Read the smallest line they can possibly read ○ If patient reads half or more of the line wrong → move up to the next highest level ● First number → 20 feet away from Snellen ○ NEVER CHANGES ● Second number → how far away someone with normal vision will see what you see ● Ex: 20/40 : you’re standing at 20 feet and seeing what a person

with normal vision could see at 40 feet ■ Jaeger / Rosenbaum- near vision ● 12-14 inches away ■ Confrontation test- peripheral vision ● Your eye AND the patient eye are covered on the opposite sides (same eye when facing each other) ● Something is coming into view → if the patient sees it at the same time that you do, they have normal vision ■ Cardinal fields of gaze- extraocular muscles ● Cranial nerves 3, 4, 6 ● Assessing for any deviation in vision ■ Cover / uncover: ● Normal = no deviation ● Could have a slight deviation → but will not see it until you cover / uncover the eye ■ PERRLA- pupils are equal, round, and reactive to light and accommodation ● Pupil size are equal: between 3 and 6 ● Reactive to light : constriction when light is shined at them ● Accommodation: eyes converge and pupils constrict when looking at something close up ■ Consensual constriction - pupil constricts when a light is shone in the eye ○ Palpation: ■ Warmth, tenderness, edema, etc ○ Ophthalmoscope- looking at the internal parts of the eye (pupils) ■ Looking at the fundus, macula ■ Want to see a red reflex → light reflection from the retina ■ Looking for normal blood vessels: ● Are the constricted or enlarged? ■ Are there any lesions? ■ White spots on the macula? ■ Pale conjunctiva → can indicate types of anemia ■ Parts: ● Small aperture - constricted pupils ● Large aperture - pupils that are dilated ● Grid aperture - to detect a presence of any kind of lesion Eye abnormalities (5) ● Abnormalities of the eyelids: ○ Blepharitis- general inflammation / redness of the eyelids ■ Staphylococcal infection leads to red, scaly, and crusted lids

■ The eye burns, itches, and tears ○ Basal cell carcinoma- usually seen on the lower lid and medial canthus ■ Papular appearance ○ Chalazion- firm, nontender nodule on the eyelid arising from infection of the meibomian gland ■ Not painful unless inflamed ○ Hordeolum- also called a stye ■ Result of staphylococcal infection of hair follicles on the margin of the lids ■ Affected eye is swollen, red, and painful ○ Entropion- inversion of the eyelid and lashes caused by muscle spasm of the eyelid ■ Friction from lashes can cause corneal irritation ○ Ectropion- eversion of the lower eyelid caused by muscle weakness exposing the palpebral conjunctiva ○ Ptosis- drooping of the eyelid ■ Occurs with cranial nerve damage or systemic neuromuscular weakness ○ Periorbital edema- swollen, puffy eyelids ■ Occurs with crying, infection, trauma, systemic problems (kidney failure, heart failure, allergies) ○ Exophthalmos- abnormal protrusion of one or both eyeballs ■ Usually occurs secondary to Grave’s disease ● Lipids are being deposited in the back of the eye and pushes it out ■ Can also be caused by infectious disease, certain forms of cancer and other disorders ● Abnormalities of the eye: ○ Conjunctivitis- infection of the conjunctiva usually due to bacteria or virus ■ Pink eye ○ Iritis- serious disorder characterized by redness around the iris and cornea ■ Decreased vision and deep, aching pain ■ Pupil is often irregular ○ Subconjunctival hemorrhage- results from ruptured blood vessel that leads to blood accumulation in the subconjunctival space ■ Caused by trauma, anticoagulant therapy, hypertension, elevated venous pressure ○ Pterygium- non-cancerous growth that develops from the conjunctiva and extends onto the sclera ■ May also extend to the cornea ■ Can cause problems with vision ○ Hyphema- collection of blood in the anterior chamber of the eye that is most often caused by blunt trauma to the eye ■ Can also be caused by eye surgery, blood vessel abnormalities, medical problems ○ Acute glaucoma- result of sudden increase in intraocular pressure resulting from

blocked flow of fluid from the anterior chamber ■ Pupil is oval shaped and dilated ■ Cornea appears cloudy with circumcorneal redness ■ Pain onset → sudden and accompanied by decrease in vision and halos around lights ■ Requires immediate intervention !! ○ Cataract- opacity in the lens; occurs in aging ■ Can be surgically removed ○ Pinguecula- yellowish nodules that are thickened areas of the bulbar conjunctiva ■ Caused by prolonged exposure to sun, wind, and dust ● Abnormalities of the fundus (eye) ○ Diabetic retinopathy- changes that occur in the retina and its vasculature ■ Microaneurysms, hemorrhages, macular edema, retinal exudates ○ Hypertensive retinopathy- changes in the retina and its vasculature in response to high blood pressure ■ Flame hemorrhages, nicking of vessels, and “cotton wool” spots that arise from nerve fiber infarction ○ Age-related macular degeneration (ARMD)- degenerative condition of the macula, the central retina ■ Causing gradual loss of central vision while peripheral vision remains intact ■ Eyes are affected at different rates ■ Two types: ● Dry and wet ● Wet → hemorrhaging occurs in eyeball ■ Risk factors : hypertension and cigarette smoking ● Smoking → causes vasoconstriction & decreases amount of perfusion and speed up macular degeneration ○ Anisocoria- unequal pupil size; can be just a benign condition ■ If not benign → cranial nerve condition or CNS condition ○ Cranial nerve III damage- ptosis; unilaterally dilated ○ Mydriasis- very dilated pupils ■ Caused by dim light, anxiousness (sympathetic nervous system activation), medication for glaucoma ○ Miosis- excessive constricted pupils ■ Caused by narcotics, glaucoma, parasympathetic nervous system stimulation ● Abnormal findings: ○ Myopia- nearsighted; rays in FRONT of retina ○ Hyperopia- farsighted; rays BEHIND retina ○ Astigmatism- refraction of light spreads over a wide area rather than a distinct point on the retina ■ Produces an unclear picture ■ Familial / hereditary condition

○ Presbyopia- age-related vision loss ○ Cardinal fields of gaze: strabismus (cross eyed) → deviations in gaze ■ Esophoria- deviation inwards / medially ■ Exophoria- deviation outwards / laterally Ear assessment (3) ● Observe patient and listen to cues ○ Are they having trouble hearing you? ○ May turn their head to hear you or appear to be reading your lips ● Consider in relation to normative parameters and expectations of function as well as other factors ● Follow-up questions may be necessary ○ Do they have hearing aids / hearing deficits? ○ Have they had any surgeries? ● Questions: ○ General ○ Illness or infection ○ Symptoms, pain, behaviors ○ Environment ■ Internal & external ■ Do they work in an environment that can pose a risk to their hearing? ■ Are they wearing / using the proper equipment to protect them? ● Hearing aids, ear plugs, ear muffs ○ Age ■ Infants and children ● Increased risk of ear infections due to shorter eustachian tube ■ Pregnant female ■ Older adult ○ Specific to nose and sinuses ○ Specific to mouth and throat ● Inspection of external ear ■ Looking for redness, drainage, skin breakdown ○ Palpation of auricle and tragus ■ Should not feel lumps, bumps, or edema ○ Palpation of mastoid process ■ Looking for any increase / swollen lymph nodes ■ Is there any tenderness? ■ Signs of infection? ○ Inspection of auditory canal using otoscope ■ Adult: Pull the pinna OUT and UP ■ Child: Pull the pinna OUT and DOWN ■ Inserting: ● Handle up or down ● Straightening ear canal

○ Examination of tympanic membrane using otoscope ■ Want to see: pearly, shiny, gray membrane ■ Abnormal: ● Bulging, purulent drainage, redness → infection ● Retraction / sucking in of the tympanic membrane → indicates a blocked eustachian tube ○ Whisper test ■ Stand 1-2 feet behind the patient ■ Whisper something to see if the patient can hear you ■ Can have them cover one ear → testing for deficits in a single ear ■ Cover mouth to make sure patient is not reading your lips ○ Rhine and Weber tests using the tuning fork ■ Weber: (unicorn) ● Tuning fork is placed above the forehead ● Patient will be able to feel vibrations on both sides & hear EQUAL in both ears ● If there is any hearing loss / conductive → you will hear it louder on the impaired / affected ear ● If it’s a sensory issue → the good side will hear it louder ■ Rinne: ● Tuning fork is placed behind the ear (mastoid process) ● Testing the bone conduction! ○ Vibrations should last only half the time of air conduction ● If air conduction is 30 sec → bone conduction should be 15 seconds ● If they do not hear the vibrations, an abnormality may be present (bone conduction is longer than air conduction) ○ Romberg test for equilibrium / balance ■ Cranial nerve 8 ■ Abnormal : Positive → equilibrium problem or vertigo ■ Normal : want minimal amount of swaying Ear abnormalities (3) ● Keloid- scar tissue that forms following a tissue injury ■ Can caused by ear piercing ■ Tissue may be pink, red, or flesh-colored ○ Otitis externa- infection of the outer ear ■ Causes redness and swelling of the auricle and ear canal and scanty drainage

■ May be accompanied by itching, fever, and enlarged lymph nodes ■ Swimmer’s ear ○ Tophi- small white nodule on the helix or antihelix of the ear that contain uric acid crystals ■ Indication / sign of gout → arthritis that is caused by a build-up of uric acid in the joints ■ Can occur in the olecranon process (elbow), knee joint, palm, and Achilles tendon ○ Otitis media- infection of the middle ear producing a red, bulging eardrum ■ Causes fever and hearing loss ■ Otoscopic examination reveals absent light reflex ○ Perforation of the tympanic membrane- rupturing of the eardrum due to trauma or infection ■ During otoscopic inspection, may be seen as a dark spot on the eardrum ■ Symptom that you might notice: ABSENCE of pain after having an ear infection → pressure is gone due to rupture ○ Scarred tympanic membrane- eardrum has white patches of scar tissue due to repeated ear infections ■ Chronic irritation of the tympanic membrane without infection also causes scarring ■ Does not typically cause hearing loss Throat abnormalities (1) ● Tonsillitis- inflammation of the tonsils ○ Throat is red and tonsils are swollen covered by white or yellow patches ○ May include high fever and enlarged cervical chain lymph nodes Sinus assessment (1) ● Palpation of sinuses → any tenderness? ● Percussion of sinuses → presence of dullness? ○ DIRECT PERCUSSION- with fingertips ● Transillumination of sinuses ○ Normal: sinus appears hollow and light shines through giving a reddish glow ○ Abnormal: inflamed and blocked with secretions or mucus → light fails to shrine through and the sinus appears opaque ○ Light source in the mouth = maxillary ○ Light source on the cheek pointing towards the forehead OR underneath the eyebrow = frontal Respiratory assessment (2) ○ Focused interview: ■ Consider patient’s ability to participate → could be experiencing: ● Dyspnea, cyanosis, difficulty with speech or anxiety

● Patient is having a hard time speaking, trying to catch breath ■ Provide privacy and provide a warm area ■ General questions: ● Are they a nose breather? → if not, could have a problem with the nose (allergies, edema, inflammation) ● Does the patient have shortness of breath when lying down? ■ Illness or infection ● Any respiratory treatment, surgeries, illness, etc ■ Symptoms, pain, behaviors ● How long have you had the cough? ● Is is a production? ● Is there a particular odor or color? → can be indicative of cancer ● Is there muscle pain during cough? ● Are you on any medications? ○ Some medications can mask respiratory difficulties ● Feelings of dizziness or lightheadedness ○ Could be hypoxia ■ Nutritional intake / dietary habits ● Could be anemic ■ Age ● Infants & children: ○ Watch children putting things in their mouth → risk of aspiration ○ Solid foods TOO early can cause aspiration in children ● Older adults having kyphosis can affect breathing ○ Individual leans forward making it difficult to breath ■ Environment ● Work environment (chemicals, pollutants, etc) ● Are you often around smoke or smog often? ■ Do they smoke and/or participate in marijuana use or hookah use? ■ Include patient education ● Discuss immunization and stress importance ● Infants should be placed on back when sleeping ○ Firm mattress / bedding → not too soft ○ Should not be a lot of bedding, pillow, stuffed animals around ● Stress hand hygiene → especially with children! ○ Coughing into elbow ○ Using a tissue when sneezing ● Regular exercise → increase efficiency of respiratory system ○ Also decreases weight and increases lung expansion ● Explore triggers for asthmatic patients → discuss how to avoid them ■ Decrease asthma complications ● Identify triggers for asthma prevention: ○ Air pollution, allergies, cold air, a cold or flu virus, sinusitis, smoke,

fragrances ● Green zone: ○ 80- 100% of “normal” peak flow rate signals all clear ● Yellow zone: ○ 50 - 80% of “normal” peak flow rate signals caution ● Red zone: ○ <50% of “normal” peak flow rate signals a Medical Alert. Take your rescue medications right away ○ Inspection: front and back of thoracic cavity ■ Observation of skin color ■ Inspection of anterior and posterior thorax ● Symmetry ● Configuration 2: ● Respiratory rate and rhythm ○ 12- ■ Observe chest rise and fall ■ Observe for retractions / are they using their accessory muscles? ■ Is the patient using pursed lip breathing? ■ Infants → COUNT FOR FULL MINUTE ● They do have irregular respiratory rate ■ Obese client may have rapid, shallow respiration due to excess weight ○ Palpation of posterior thorax: ■ Feeling for any air trapped underneath the skin → feels like bubble wrap ■ Ribs, intercostal spaces, respiratory expansion ■ Tactile fremitus - feeling the vibration on the chest wall when the patient speaks ● Consolidation (pneumonia) → increased fremitus ● Effusion (pleural effusion) → decreased fremitus or absent ■ Unequal chest expansion occurs with atelectasis, pneumonia, pleural effusion, trauma, or pneumothorax ○ Percussion of posterior thorax: ■ Lungs, diaphragmatic excursion ○ Auscultation of the lungs → vesicular; what you would normally hear it ■ On bare skin ○ Normal breath sounds: Tracheal ● Location : over trachea ● I < E ● Quality : harsh, high pitched Bronchial- near the tracheal sounds ● Location : next to trachea , superior to each clavicle and in the first intercostal space ● E > I ● Quality : loud, high pitched

Bronchovesicular

• along sternal border ● Location : over major bronchi in the second and third intercostal spaces; Along sternal border ● I = E ● Quality : medium loudness, medium pitch Vesicular ● Location : remainder of lungs ● I > E ● Quality : soft, low pitched ○ Adventitious / abnormal breath sounds: Rales/ Crackles Fine- occurs at end of inspiration, do not clear with cough ● Quality : high pitched, short crackling ● Causes : collapsed or fluid-filled alveoli open Coarse- occurs at end of inspiration, do not clear with cough ● Quality : loud, moist, low pitched bubbling ● Causes : collapsed or fluid-filled alveoli open Rhonchi Wheezes (sibilant)- occurs at expiration / inspiration when severe ● Quality : high pitched, continuous ● Causes : blocked airflow as in asthma, infection, foreign body obstruction Rhonchi (sonorous)- occurs at expiration / inspiration; change / disappear with cough ● Quality : low pitch, continuous, snoring, rattling ● Causes : fluid-blocked airways Stridor- occurs at inspiration ● Quality : loud, high-pitched crowing heard without stethoscope ● Causes : obstructed upper airway Friction rub- occurs at inhalation / exhalation ● Quality : low-pitched grating, rubbing ● Causes : pleural inflammation ● Auscultation of voice sounds: ○ Bronchophony- have patient say “99” ■ Should not be able to hear it well when auscultation ■ If you DO hear it → could be pneumonia ○ Egophony- have patient say “E” ■ If you hear “A” → could indicate some kind of lung consolidation or pneumonia ○ Whispered pectoriloquy

● Palpation of the anterior thorax: ○ Sternum, ribs, intercostal spaces ○ Assessing for: ■ Muscle mass ■ Growths, nodules, masses ■ Tenderness ■ Crepitus- air underneath the skin ○ Decreased fremitus → with obstruction, pleural effusion, pneumothorax, and emphysema ○ Increased fremitus → pneumonia ● Percussion: ○ If you’re getting dullness instead of resonance → might be fluid in that area ○ Hyperresonance → excess amount of air trapped in the lungs OR pneumothorax ■ Large pocket of air due to lung collapse ● Normal respiratory rates and patterns ○ Eupnea: even depth, regular pattern ■ Inspiration = expiration ■ Occasional sigh ● Normal configuration ○ Adult: elliptical in shape with a lateral diameter that is larger than the anteroposterior diameter in a 2:1 ratio ○ Child: becomes of adult proportion by age 6 ○ Infant: rounded in shape with equal lateral and anteroposterior diameters Respiratory abnormalities (8) ● Tachypnea: rapid, shallow respirations ○ Rate > 24 ○ Precipitating factors: fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, pneumonia ● Bradypnea: slow, regular respirations ○ Rate < 10 ○ Precipitating factors: diabetic coma, drug-induced respiratory depression, increased intracranial pressure ● Hyperventilation: rapid, deep respirations ○ Rate > 24 ○ Precipitating factors : extreme exertion, fear, diabetic ketoacidosis (Kussmaul’s), hypoxia, salicylate overdose, hypoglycemia ● Hypoventilation: irregular, shallow respirations ○ Rate < 10 ○ Precipitating factors : narcotic overdose, anesthetics, prolonged bed rest, chest splinting ● Cheyne-Stokes: periods of deep breathing alternating with periods of apnea ○ REGULAR pattern

○ Precipitating factors: normal children and aging, heart failure, uremia, brain damage, drug-induced respiratory depression ● Biot’s (Ataxic) respirations: shallow, deep respirations with periods of apnea ○ IRREGULAR pattern ○ Precipitating factors: respiratory depression, brain damage ● Sighing: frequent sighs ○ Precipitating factors: hyperventilation syndrome, nervousness ○ Caused by: dyspnea, dizziness ● Obstructive breathing: prolonged expiration ○ Precipitating factors: COPD, asthma, chronic bronchitis ● Orthopnea: shortness of breath / dyspnea that occurs while lying down from COPD ● Abnormal configuration ○ Barrel chest- anteroposterior diameter is equal to the lateral diameter with ribs horizontal ■ Occurs normally with aging and accompanies COPD ○ Pectus excavatum (funnel chest)- congenital deformity characterized by depression of the sternum and adjacent costal cartilage ■ Sternum displays INWARD ■ If severe → can interfere with respiration, murmurs can be present ○ Pectus carinatum (pigeon chest)- congenital deformity characterized by FORWARD displacement of the sternum with depression of the adjacent costal cartilage ■ No treatment is required generally ○ Scoliosis- LATERAL curvature and rotation of the thoracic and lumbar spine ■ Occurs most frequently in females ■ May result in elevation of the shoulder and pelvis ■ Deviation > 45° → may cause distortion of the lung, decreased lung volume ○ Kyphosis- exaggerated posterior curvature of the thoracic spine ■ “Hunchback” ■ Associated with aging ■ Severe kyphosis → may decreased lung expansion and increased cardiac problems ● Abnormal breath sounds: ○ Rales: clicking, bubbling, or rattling sounds; occurs when air opens closed air spaces ○ Crackles: cellophane being rubbed together; fluid in airways ○ Rhonchi: snoring; occurs when air is blocked or air flow becomes rough through lung airways ○ Stridor: wheeze-like sounds; due to a blockage of airflow in trachea ○ Wheezing: high-pitched, musical sounds through narrowed airways; can be audible ● Respiratory disorders:

○ Asthma- chronic hyperactive condition ■ Wheezing heard during inspiration (stridor) → indicates a more severe narrowing of the airways ○ Atelectasis- obstruction of airflow ■ Inspection : ● Cough ● Delayed chest expansion on affected side ● Increased RR and HR ● Possible cyanosis ■ Palpitation : ● Chest expansion decreased on affected side ● Tactile fremitus decreased ■ Percussion : ● Dull ■ Auscultation : ● Breath sounds decreased ● Possible crackles ○ Bronchitis- inflammation of tracheobronchial tree ■ Cough with mucus on most days → for at least 3 months ■ Wheezing (especially with asthmatic or rhonchi) ○ Emphysema- obstruction of alveoli ■ Results in air trapping and hyperinflation ● Air trapping results in barrel chest ■ Hypercarbia- increased CO2 ■ Percussion : hyperresonance ○ Pneumonia- infection of the alveoli ■ Dull percussion ■ Coarse crackles ■ Tactile fremitus would be louder ○ Pleural effusion- fluid in the pleural space ■ May not hear breath sounds ○ Pneumothorax- collapse of lung ■ Percussion : hyperresonance ■ Auscultation : absent sounds ■ Tracheal deviation towards the good lung → medical emergency ● Will have severe respiratory distress ● Can cause tension pneumothorax ○ Congestive heart failure- edema around the alveoli ○ Valley fever- fungal infection ○ COPD: ■ Barrel chest → same configuration ■ Skin color, possible cyanosis ■ Clubbing due to poor oxygenation ■ Puffy cheeks, pursed lip breathing

■ Retractions ■ Increased RR ■ Percussion: hyperresonance ■ Auscultation: decreased breath sounds Breast assessment (1) ● Make sure to consider information related to norms and expectations of individual’s breasts & lymphatic function ● Mastalgia- breast pain most often associated with menstrual cycle ● Rule out: cardiac, pulmonary, & GI causes ● Breast pain: ○ OLDCART: ■ Onset ■ Location ■ Duration ■ Characteristic ■ Aggravating factors ■ Relieving factors ■ Therapies tried ○ ICE: ■ Impact on ADL’s ■ Coping strategies ■ Emotional response ● Questions: ○ General ■ Has there been any change in your breast tissue? ■ Has there been any discharge? ■ Are you doing any hormonal replacement therapy or on birth control? ○ Presence of illness or infection ○ Symptoms or behaviors due to age ■ Preadolescent, pregnant female, older adult ○ Environmental ■ Internal, external ● Inspection: ○ Size, symmetry ○ Color, venous patterns, moles or other marking ■ Is there an orange peel appearance? → indication of increased risk of cancer ■ Inflamed skin, red and warm → might be from blocked lymph nodes ■ Unilateral venous pattern in one than the other ● Can indicate increased blood flow to a tumor ○ Observation of shape, surface characteristics and suspensory ligaments ○ Retraction or inversion of nipple → indicates malignancy

○ Inspect axilla → enlargement of lymph nodes! ● Palpation: ○ Skin turgor and breast tissue ○ Palpation of nipple and areolae, including compression ○ Palpate axillae ○ Vertical strip method, concentric circle pattern Special considerations assessment techniques (2) ● Lifespan considerations: infant & children, pregnant women, older adults ● Psychosocial considerations ● Environmental and cultural considerations Cardiac assessment (3) ● Landmarks for cardiac assessment: ○ Sternum ○ Clavicles ○ Ribs ○ 2nd through 5th intercostal spaces ■ Aortic: 2nd ICS, RSB ■ Pulmonic: 2nd ICS, LSB ■ Erbs: 3rd ICS ■ Tricuspid: 4th ICS, L ■ Mitral: 5th ICS, midclavicular ● Inspection: ○ Face, lips, ears, scalp ○ Jugular veins ■ Assess for JVD (jugular vein distention) → indication of fluid overload, congestive heart failure, any right side heart conditions ○ Carotid arteries ○ Hands and fingers ■ Splinter hemorrhage- most common cause in a single nail is trauma, but can be endocartditis if in more than a few nails ○ Chest, abdomen, legs, and skeletal structure ● Palpation of the chest: ○ Precordium at right and left intercostal spaces ○ Left 3rd intercostal space ○ Left 4th intercostal space ○ Left 5th intercostal space at midclavicular line ● Palpation of the carotid pulses ● Percussion of chest for cardiac border ● Auscultation of chest using diaphragm and bell in various positions: ○ Aortic : at right 2nd intercostal space ■ S1 < S2

○ Pulmonic : at left 2nd intercostal space ■ S1 < S2 ○ Erb’s point: at left 3rd intercostal space ■ S1 = S2 ■ Use the bell of the stethoscope! ○ Tricuspid : at left 4th intercostal space ■ S1 > S2 ○ Mitral / apex: at left 5th intercostal space; midclavicular line ■ S1 > S2 ○ If patient is obese → have the patient lay left lateral ● Auscultation of the carotid arteries using the bell ○ Have patient hold their breath when listening ● Compare the apical pulse to carotid pulse Cardiac abnormalities (5) ● Myocardial ischemia ● Myocardial infarction (MI) ● Congestive heart disease ● Ventricular hypertrophy ● Valvular heart disease ● Septal defects- openings between right and left atria or right and left ventricles ● Congenital heart disease ○ Coarctation of aorta- aorta is severely narrowed in the region inferior to the left subclavian artery ■ Narrowing RESTRICTS blood flow from the left ventricle into the aorta and out into systemic circulation ■ CHF in newborn ○ Patent ductus arteriosus- occurs when the ductus arteriosus fails to close between 24 - 48 hours after delivery ○ Tetralogy of Fallot- four cardiac defects: ■ Dextroposition of the aorta ■ Pulmonary stenosis ■ Right ventricular hypertrophy ■ Ventricular septal defect ■ LIFE THREATENING FOR NEWBORN ● Classifications of heart murmurs: Mitral stenosis- narrowing of the left mitral valve ● Etiology : rheumatic fever or cardiac infection ● Finding : murmur heard at the apical area with the patient in the left lateral position ● Quality : rumbling ● Pitch : low and best heard with bell ● Radiation : rare ● Changes with respirations : inspiration may intensify