ADPIE-

Assessment is to collect subjective and objective data

Diagnosis is to analyze sub and obj data to make a nursing judgment…this is where you do your referrals,
collaborative prob, and make a nursing dx

Planning is to determine the outcome criteria and develop a plan

Implementing is carrying out that plan

Evaluate is did it work or does your plan need advising

The purpose of the health assessment is to collect subj and object data to determine overall functioning
to make a professional clinical judgment

The steps of assessment are as follows; subjective data, objective data, validation, and documentation.

Validation is crucial. Its serves to ensure the assessment process has NOT ended before relevent data
have been collected and it helps prevent inaccurate data

Data analysis is the critical thinking. It has seven steps….Id normal strengths and data, clusters data,
inferences, nursing dx, definining characteristics, confirm and rule out, document (this is what we did
our concept map on)

Culture is learned, shared and associated with adaptation of environment and it’s universal

Review of symptoms are signs and symptoms of a current health problem (aka review body systems) it
draws out current health problems, include only subjective data like a headache, fatigue, cramps.

When preparing for an exam the nurse must assess your own feelings before examine the client. The
patient nurse relationship must also be established during the client interview before the physical exam
can take place.

The general surgery is the first step in the head to toe assessment. It consists of the overall impression,
mental status, and vital signs

Temperature 36.5-37.7

Pulse- 60-100 +1 is weak, +2 is normal +3 is bounding

Respiration is 12-20 breaths/ minute

Blood pressure- <120, and <80

Cold spa

C character- signs and symptoms

Onset- when it began

Location- where and does it radiate

Duration= how long and does it reoccur

Severity- how bad

Pattern- what makes it better or worse?

Associated factors- other symptoms that occur with it like (ROS)

Orthostatic HTN is caused by decreased bar receptors, sensitivity fluid volume, dehydration, medication
like anti hypertensives.

The stages of hypertension are

1. D. 140-159; S.90-99
2. D. 160-179; S. 100-109
3. D. >180, S> 110

The bell on a stethoscope is used to detect murmurs and soft sounds, like bruits.

Pain is an unpleasant sensory and emotional experience associated with tissue damage and is
considered the fifth vital sign. The Must rely on the patients reporting of there pain.

When asking the patient the location of the pain it is important to know that the radiation of the pain
can help ID it’s source. Example chest pain that radiates to arm is a MI

Different scales for pain

Wong baker scale is the faces

NRS 0-10

VAS- Visual and you pick the point where your pain is

VDS mild severe, moderate, worse

To check for patients hydration the nurse must assess for pitting edema, skin tenting, muscle and fat
distribution, neck veins, tongue, lung sounds and venous fillings
The healthy bmi is between 19-24

25-30 is considered over weight

30 or more is obese

How you measure your height and weight on the bmi is for every 5 feet tall you are you you add 5
pounds for one inch of your height. For example I am 5’6 so my Ideal body weight would be about 130
lbs.

Well child development focuses on normal growth and development.

SKIN HAIR AND NAILS

Cyanosis (makes white skin appear blue-tinged, especially in the perioral, nailbed, and conjunctival
areas. Dark skin appears blue, dull and lifeless in the same areas.
Central cyanosis results from a cardiopulmonary problem whereas peripheral cyanosis may be a local
problem resulting from vasoconstriction.
To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa
Jaundace in light- and dark-skinned people is characterized by yellow skin tones, from pale to pumpkin,
particularly in the sclera, oral mucosa, palms, and soles.Acanthosis nigricans (AN), a linear streak-like
pattern in dark-skinned people, suggests diabetes mellitus is roughening and darkening of skin in
localized areas, especially the posterior neck. Pallor (loss of color) is seen in arterial insufficiency,
decreased blood supply, and anemia. Pallid tones vary from pale to ashen without underlying pink.
Clammy skin is typical in shock or hypotension Cold skin may accompany shock or hypotension. Cool skin
may accompany arterial disease. Very warm skin may indicate a febrile state or
hyperthyroidismIncreased moisture or diaphoresis (profuse sweating) may occur in conditions such as
fever or hyperthyroidism. Decreased moisture occurs with dehydration or hypothyroidism

Macule, Patch

 Flat, non-palpable skin color change (skin color may be Freckles

brown, white, tan, purple, red)
 Macule: < 1 cm, circumscribed border  Flat moles
 Patch: > 1cm, may have irregular border  Petechiae
 Rubell
 Vitiligo
 Port wine stains
 Ecchymosis

 Papule. Plaque

 Elevate, palpable, solid mass; circumscribed border

Papules:

 Elevated nevi
 Warts
 L

Nodule, Tumor

 Elevated, solid, palpable mass

 ichen planus
 Lipoma
 Squamous cell carcinoma
 Poorly absorbed injection
 Dermatofibroma

Vesicle, Bulla

 Circumscribed elevated, palpable mass containing serous fluid

Vesicles:

 Herpes simplex/zoster
 Varicella (chickenpox)
 Poison ivy
 Second-degree burn

Pustule
  Pus-filled vesicle or bulla  Acne

Lichenification

 Thickening and roughening of the skin

 Accentuated skin markings
 May be secondary to repeated rubbing, irritation, scratching

Contact dermatitis, often resulting from exposure to aero allergens, chemicals, foods, and emotional
stress

Petechia (Pl. Petechiae)

 Round red or purple macule

 Small: 1–2 mm
 Secondary to blood extravasation
 Associated with bleeding tendencies or emboli to skin

Ecchymosis (Pl. Ecchymoses)

 Round or irregular macular lesion

 Larger than petechia
 Color varies and changes: black, yellow, and green hues
 Secondary to blood extravasation
 Associated with trauma, bleeding tendencies

Cherry Angioma

 Papular and round

 Red or purple
 Noted on trunk, extremities
 May blanch with pressure
 Normal age-related skin alteration
  Usually not clinically significant

When assessing moles follow the code ABCDE

Asymetry , border, color, diameter, and elevation

Head Neck and Lymphatic

Palpate the temporomandibular joint. To assess the temporomandibular joinNormally there is no

swelling, tenderness, or crepitation with movement. Mouth opens and closes fully (3 to 6 cm between
upper and lower teeth). Lower jaw moves laterally 1 to 2 cm in each direction.t (TMJ), place your index
finger over the front of each ear as you ask the client to open her mouth, Limited range of motion,
swelling, tenderness, or crepitation may indicate TMJ syndrome

N or ma ll y ly mp h n od es , wh ic h a re r ou nd an d sm al le r t ha n 1 cm , ar e n ot p al pa bl e. Wh en l ym ph
n od e e nl ar ge me nt ex ce ed s 1 c m, t he c li en t is s ai d t o ha ve l ym ph ad en op at hy , wh ic h ma y b e
c au se d b y ac ut e or ch ro ni c in f e ct io n, an a ut oi mm un e d is or de r, or m et as ta ti c di se as e

Neck pain may accompany muscular problems or cervical spinal cord problems. Stress and tension may
increase neck pain. Sudden head and neck pain seen with elevated temperature and neck stiffness may
be a sign of meningeal inflammation.

Drooping of one side of the face may result from a stroke—or cerebrovascular accident (CVA)—or a
neurologic condition known as Bell's palsy (Fig. 12-6).
A “masklike” face marks Parkinson's disease; a “sunken” face with depressed eyes and hollow cheeks is
typical of cachexia (emaciation or wasting); and a pale, swollen face may result from nephrotic syndro

Palpate the thyroid gland. Locate key landmarks with your index finger and thumb. cases of diffuse
enlargement; such as hyperthyroidism, Graves' disease, or an endemic goiter, the thyroid gland may be
palpated. An enlarged, tender gland may result from thyroiditis. Multiple nodules of the thyroid may be
seen in metabolic processes. However, rapid enlargement of a single nodule suggests a malignancy and
must be evaluated further. soft, blowing, swishing sound auscultated over the thyroid lobes is often
heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries

1. Tonisllar grading Grading Scale

1. Tonsil 0: Tonsils fit within tonsillar fossa
2. Tonsil 1+: Tonsils <25% of space between pillars
3. Tonsil 2+: Tonsils <50% of space between pillars
4. Tonsil 3+: Tonsils <75% of space between pillars
5. Tonsil 4+: Tonsils >75% of space between pillars

EYE
Redness or swelling of the eye is usually related to an inflammatory response caused by allergy, foreign
body, or bacterial or viral infection. Discharge other than tears from one or both eyes suggests a
bacterial or viral infection.

Myopia (impaired far vision) is present when the second number in the test result is larger than the first
(20/40). Presbyopia (impaired near vision) is indicated when the client moves the chart away from the
eyes to focus on the print.Asymmetric position of the light reflex indicates deviated alignment of the
eyes. This may be due to muscle weakness or paralysis

Drooping of the upper lid, called ptosis, may be attributed to oculomotor nerve damage,

An inverted lower lid is a condition called an entropion, which may cause pain and injure the cornea as
the eyelash brushes against the conjunctiva and cornea.
Ectropion, an everted lower eyelid, results in exposure and drying of the conjunctiva

Protrusion of the eyeballs accompanied by retracted eyelid margins is termed exophthalmos

sunken appearance of the eyes may be seen with severe dehydration or chronic wasting illnesses.

Generalized redness of the conjunctiva suggests conjunctivitis (pink eye).

Areas of dryness are associated with allergies or trauma.
Episcleritis is a local, noninfectious inflammation of the sclera. The condition is usually characterized by
either a nodular appearance or by redness with dilated vessels

Test for direct response by darkening the room and asking the client to focus on a distant object. To test
direct pupil reaction, shine a light obliquely into one eye and observe the pupillary reaction. Shining the
light obliquely into the pupil and asking the client to focus on an object in the distance ensures that
pupillary constriction is a reaction to light and not a near reaction.

Hordeolum (stye), a hair follicle infection, causes local redness, swelling, and pain. A chalazion, an
infection of the meibomian gland (located in the eyelid), may produce extreme swelling of the lid,
moderate redness, but minimal pain

corneal scar, which appears grayish white, usually is due to an old injury or inflammation. Chalazion
(infected meibomian gland). Blepharitis (staphylococcal infection of the eyelid). N ot ic ea bl e w it h th e
p os it io ns t e st , pa ra ly t i c st ra bi sm us is u su al ly t he re su lt o f we ak ne ss or p ar al ys is of o ne o r
m or e ex t r ao cu la r m us cl es

EAR Earache (otalgia) can occur with ear infections, cerumen blockage, sinus infections, or teeth and
gum problems.

Mouth nose sinuses

Dysphagia (difficulty swallowing) may be seen in esophageal disorders, anxiety, poorly fitting dentures,
or a neurologic disorder. Dysphagia increases the risk for aspiration, and clients with dysphagia may
require consultation with a speech therapist. Difficulty chewing, swallowing, or moving the tongue or
jaws may be a late sign of oral cancer.uth nose sinuses
leukoplakia (thick white patches of cells). Leukoplakia is a precancerous condition. Leukoplakia is a
precancerous lesion, and the client should be referred for evaluation. Whitish, curdlike patches that
scrape off over reddened mucosa and bleed easily indicate “thrush” (Candida albicans) infection.
Koplik's spots (tiny whitish spots that lie over reddened mucosa) are an early sign of the measles

Clients who smoke, drink large quantities of coffee or tea or have an excessive intake of fluoride may
have yellow or brownish teeth. Among possible abnormalities are deep longitudinal fissures seen in
dehydration; a black tongue indicative of bismuth (PeptoBismol) toxicity: black, hairy tongue; a smooth,
reddish, shiny tongue without papillae indicative of niacin or vitamin B 12 Fruity or acetone breath is
associated with diabetic ketoacidosis. Purulent nasal discharge is seen with acute bacterial
rhinosinusitis.

LUNGS

Wheezing indicates narrowing of the airways due to spasm or obstruction. Wheezing is associated with
congestive heart failure (CHF), asthma (reactive airway disease), or excessive secretions. Studies have
shown that patients with asthma often have GERD (gastroesophageal reflux disease) or are more
susceptible to GERD. Nonproductive coughs are often associated with upper respiratory irritations and
early congestive heart failure.
   White or mucoid sputum is often seen with common colds, viral infections, or bronchitis. Yellow or
green sputum is often associated with bacterial infections. Blood in the sputum (hemoptysis) is seen
with more serious respiratory conditions. Rust-colored sputum is associated with tuberculosis or
pneumococcal pneumonia. Pink, frothy sputum may be indicative of pulmonary edema. An increase in
the amount of sputum is often seen in an increase in exposure to irritants, chronic bronchitis, and
pulmonary abscess. Clients with excessive, tenacious secretions may need instruction on controlled
coughing and measures to reduce viscosity of secretions. Client leans forward and uses arms to support
weight and lift chest to increase breathing capacity, referred to as the tripod position (Fig. 16-10). This is
often seen in chronic obstruc-tive pulmonary disease (COPD). Crepitus, also called subcutaneous
emphysema, is a crackling sensation (like bones or hairs rubbing against each other) that occurs when
air passes through fluid or exudate. Use your fingers and follow the above sequence when palpating.
fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall). Unequal chest expansion
can occur with severe atelectasis (collapse or incomplete expansion), pneumonia, chest trauma, or
pneumothorax (air in the pleural space). Decreased chest excursion at the base of the lungs is
characteristic of chronic obstructive pulmonary disease (COPD). This is due to decreased diaphragmatic
function.

Resonance is the percussion Hyperresonance is elicited in cases of trapped air such as in

tone elicited over normal lung emphysema or pneumothorax. Dullness is present when
tissue (Fig. 16-14). Percussion fluid or solid tissue replaces air in the lung or occupies the
elicits flat tones over the pleural space such as in lobar pneumonia, pleural effusion,
 scapula. or tumor

Adventitious lung sounds, such as crackles (formerly called rales) and wheezes (formerly called rhonchi)
are evident. See Table 16-2 for a complete description of each type of adventitious breath sound.

Labored and noisy breathing is often seen with severe asthma or chronic bronchitis. Abnormal breathing
patterns include tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes respiration,
and Biot's respiration Retraction of the intercostal spaces indicates an increased inspiratory effort. This
may be the result of an obstruction of the respiratory tract or atelectasis. Bulging of the intercostal
spaces indicates trapped air such as in emphysema or asthma. Hyperresonance is elicited in cases of
trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased
density such as consolidation, pleural effusion, or tumor

areas of extreme congestion or consolidation, crepitus may be pal-pated particularly in clients with lung
disease.

Continuous coughs are usually associated with acute infections, whereas those occurring only early in
the morning are often associated with chronic bronchial inflammation or smoking. Coughs late in the
evening may be the result of exposure to irritant during the day. Coughs occurring at night are often
related to postnasal drip or sinusitis. Orthopnea (difficulty breathing when lying supine) may be
associated with heart failure. Paroxysmal nocturnal dyspnea (severe dyspnea that awakens the person
from sleep) also may be associated with heart failure. Changes in sleep patterns may cause the client to
feel fatigued during the day.

HEART

Extra Heart Sounds

S 3 an d S 4 ar e re f e rr ed t o a s di as t o li c f il li ng s ou nd s o r ex tr a he ar t s ou nd s, wh ic h re su lt f ro m
v en t r ic ul ar vi br at io n se co nd ar y t o ra pi d v en tr ic ul ar fi ll in g. I f pr es en t, S 3 c an b e h ea rd e ar ly in
d ia st ol e.
Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. Angina (cardiac chest pain)
is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of
pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Diaphoresis and pain
worsened by activity are usually related to cardiac chest pain.
Pulse Amplitude Scale
0 = Absent
1+ = Weak
2+ = Normal
3+ = Increased
4+ = Bounding
Apical pulse (fourth or fifth intercostal space at the midclavicular line)
A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel, is
indicative of occlusive arterial disease
Mitral valve insuffiency the SI will be dimished
Chestr pain Emegent, mi, aaa, phenmothorax
Non Emergent CHF, phnemonia, anxiety, gerds chronditis
Peripheral vascular
Know whre to assess all pulses, radial, ulner, popliae, femur, dorsal pedis, etc
Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower
legs, are associated with arterial insufficiency. Warm skin and brown pigmentation around the ankles
are associated with venous insufficiency.
Intermittent claudication characterized by cramping pain in the calves, thighs, or buttocks and weakness
that occurs with activity and is relieved with rest may indicate arterial disease (Scherer & Regensteiner,
2004). Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and
is relieved by rest are associated with venous disease. Leg pain that awakens a client from sleep is often
associated with advanced chronic arterial occlusive disease. However, the lack of pain may signal
neuropathy in a diabetic client. Reduced sensation or an absence of pain can result in a failure to
recognize a problem or fully understand the problem's significance

Arterial Insufficiency
P ai n: I nt er mi t t en t c la ud ic at io n t o sh ar p, un re le nt in g, co ns ta nt
P ul se s: D im in is he d o r ab se nt
S ki n Ch ar ac t e ri st ic s: De pe nd en t r ub or

 E le va t i on pa ll or o f f o ot
 D ry , sh in y sk in
 C oo l- t o - co ld t em pe ra t u re
 L os s of ha ir o ve r t o es an d do rs um of f oo t
 N ai ls t hi ck en ed an d r id ge d

U lc er C ha ra ct er is t i cs :

 L oc at io n: T i ps o f t o es , t oe w eb s, h ee l o r ot he r pr es su re ar ea s i f co nf in ed t o b ed
 P ai n: V er y p ai nf ul
  D ep t h of u lc er : De ep , o f t en i nv ol vi ng jo in t sp ac e
 S ha pe : C ir cu la r
 U lc er b as e: P a le b la ck t o d ry a nd g an gr en e
 L eg ed em a: M in im al un le ss e xt re mi ty k ep t i n de pe nd en t p os it io n c on st an tl y t o re li ev e
p ai n

Venous Insufficiency
P ai n: A ch in g, cr am pi ng
P ul se s: P re se nt bu t ma y be di f f ic ul t t o p al pa te th ro ug h e de ma
S ki n Ch ar ac t e ri st ic s:

 P ig me nt at io n i n ga it or ar ea ( ar ea of m ed ia l an d l at er al m al le ol us )
 S ki n t h ic ke ne d a nd t o ug h
 M ay b e r ed di sh -b lu e i n co lo r
 F re qu en t l y a ss oc ia t e d w it h de rm at it is

U lc er C ha ra ct er is t i cs :

 L oc at io n: Me di al m al le ol us or a nt er io r t ib ia l ar ea
 P ai n: I f su pe rf ic ia l, mi ni ma l pa in ; b ut m ay b e v er y pa in fu l
 D ep t h of u lc er : S u pe rf ic ia l
 S ha pe : I rr eg ul ar b or de r
 U lc er b as e: G r an ul at io n t is su e– be ef y r ed t o ye ll ow fi br in ou s in c hr on ic lo ng -t er m u lc er
 L eg ed em a: M od er at e t o se ve re

Right Upper Quadrant (RUQ)

 A sc en di ng an d t r an sv er se co lo n
 D uo de nu m
 G al lb la dd er
 H ep at ic f l ex ur e of c ol on
 L iv er
 P an cr ea s ( he ad )
 P yl or us ( t h e s ma ll b ow el —o r i le um —t ra ve rs es a ll qu ad ra nt s)
 R ig ht a dr en al gl an d
 R ig ht k id ne y ( up pe r p ol e)
 R ig ht u re t e r

Right Lower Quadrant (RLQ)

  A pp en di x
 A sc en di ng co lo n
 C ec um
 R ig ht k id ne y ( lo we r po le )
 R ig ht o va ry an d t u be
 R ig ht u re t e r
 R ig ht s pe rm at ic co rd

Left Upper Quadrant (LUQ)

 L ef t ad re na l g la nd
 L ef t ki dn ey (u pp er po le )
 L ef t ur et er
 P an cr ea s ( bo dy a nd t a il )
 S pl ee n
 S pl en ic f l ex ur e of c ol on
 S t o ma ch
 T ra ns ve rs e d es ce nd in g c ol on

Left Lower Quadrant (LLQ)

 L ef t ki dn ey (l ow er p ol e)
 L ef t ov ar y a nd t ub e
 L ef t ur et er
 L ef t sp er ma t i c c or d
 D es ce nd in g a nd si gm oi d co lo n

Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive
Murphy's sign and is associated with acute cholecystitis. Pain or an exaggerated sensation felt in the RLQ
is a positive skin hypersensitivity test and may indicate appendicitis. Pain in the RLQ indicates irritation
of the obturator muscle due to appendicitis or a perforated appendix. Pain in the RLQ (Psoas sign) is
associated with irritation of the iliopsoas muscle due to an appendicitis (an inflamed appendix). Pain in
the RLQ during pressure in the LLQ (referred rebound tenderness) suggests appendicitis. Pain in the RLQ
during pressure in the LLQ is a positive Rovsing's sign. It suggests acute appendicitis. The client has
rebound tenderness when he or she perceives sharp, stabbing pain as the examiner releases pressure
from the abdomen (Blumberg's sign). It suggests peritoneal irritation (as from appendicitis). If the client
feels pain at an area other than where you were assessing for rebound tenderness, consider that area as
the source of the pain. In the client with ascites, you can feel a freely movable mass moving upward
(floats). It can be felt at the fingertips. A floating mass can be palpated for size. The spleen feels soft with
a rounded edge when it is enlarged from infection. It feels firm with a sharp edge when it is enlarged
from chronic disease.
Tenderness accompanied by peritoneal inflammation or capsular stretching is associated with splenic
enlargement. palpable spleen suggests enlargement (up to three times the normal size), which may
result from trauma, mononucleosis, chronic blood disorders, and cancers. The splenic notch may be felt,
which is an indication of splenic enlargement. hard, firm liver may indicate cancer. Nodularity may occur
with tumors, metastatic cancer, late cirrhosis, or syphilis. Tenderness may be from vascular
engorgement (e.g., congestive heart failure), acute hepatitis, or abscess.
A liver more than 1 to 3 cm below the costal margin is considered enlarged (unless pressed down by the
diaphragm).
Enlargement may be due to hepatitis, liver tumors, cirrhosis, and vascular engorgement. A wide,
bounding pulse may be felt with an abdominal aortic aneurysm. A prominent, laterally pulsating mass
above the umbilicus with an accompanying audible bruit strongly suggests an aortic aneurysm. A mass
detected in any quadrant may be due to a tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.
Involuntary reflex guarding is serious and reflects peritoneal irritation. The abdomen is rigid and the
rectus muscle fails to relax with palpation when the client exhales. It can involve all or part of the
abdomen but is usually seen on the side (i.e., right vs. left rather than upper or lower) because of nerve
tract patterns. Right-sided guarding may be due to cholecystitis. Tenderness elicited over the liver may
be associated with inflammation or infection (e.g., hepatitis or cholecystitis). Friction rubs are rare. If
heard, they have a high-pitched, rough, grating sound produced when the large surface area of the liver
or spleen rubs the peritoneum. They are heard in association with respiration.
A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases.
A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction,
abscess, infection, or tumor. hernia (protrusion of the bowel through the abdominal wall) is seen as a
bulging in the abdominal wall. Diastasis recti appears as a bulging between a vertical midline separation
of the abdominis rectus muscles. This condition is of little significance. An incisional hernia may occur
when a defect develops in the abdominal muscles because of a surgical incision. A mass within the
abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is
obscured. Bluish or purple discoloration around the umbilicus (Cullen's sign) indicates intra-abdominal
bleeding.
Assess for rebound tenderness and
Rovsing's Sign. Abdominal pain and
tenderness may indicate peritoneal
irritation. To assess this possibility,
test for rebound tenderness. Palpate
deeply in the abdomen where the
client has pain then suddenly release
pressure (Fig. 20-31). Listen and
watch for the client's expression of
pain. Ask the client to describe which
hurt more—the pressing in or the
releasing—and where on the abdomen
the pain occurred.
 Test for rebound tenderness
should always be performed at the end
of the examination because a positive
response produces pain and muscle
spasm that can interfere with the
remaining examination.
Figure 20-29 Performing fluid wave test.   Figure 20-30 Performing ballottement with one hand
(A) and bimanually (B).
Palpate deeply in the LLQ.
Test for referred rebound
tenderness. Palpate deeply in the
LLQ and, quickly release pressure.
Assess for Psoas sign. Raise the
client's right leg from the hip and
place your hand on the lower thigh.
Ask the client to try to keep the leg
No rebound The client has rebound tenderness
tenderness when he or she perceives sharp,
is present. stabbing pain as the examiner
releases pressure from the abdomen
(Blumberg's sign). It suggests
peritoneal irritation (as from
appendicitis). If the client feels pain
at an area other than where you were
assessing for rebound tenderness,
consider that area as the source of
the pain (see test for referred
rebound tenderness, below).
No pain is Pain in the RLQ during pressure in
elicited. the LLQ is a positive Rovsing's sign.
It suggests acute appendicitis.
No rebound Pain in the RLQ during pressure in
pain is the LLQ (referred rebound
elicited. tenderness) suggests appendicitis.
 Avoid continued palpation
when test findings are positive for
appendicitis because of the danger
of rupturing the appendix.
No Pain in the RLQ (Psoas sign) is
abdominal associated with irritation of the
pain is iliopsoas muscle due to an
present. appendicitis (an inflamed appendix).
 elevated as you apply pressure
downward against the lower thigh
(Fig. 20-32).

Assess for Obturator sign. Support No Pain in the RLQ indicates irritation
the client's right knee and ankle. Flex abdominal of the obturator muscle due to
the hip and knee and rotate the leg pain in appendicitis or a perforated
internally and externally (Fig. 20-33). present. appendix.

Test for Cholecystitis

Assess RUQ pain or tenderness,
which may signal cholecystitis
(inflammation of the gallbladder).
Press your fingertips under the liver
border at the right costal margin and
ask the client to inhale deeply.
No increase Accentuated sharp pain that causes
in pain is the client to hold his or her breath
present. (inspiratory arrest) is a positive
Murphy's sign and is associated with
acute cholecystitis.

M US CU LO

Test for carpal tunnel syndrome. Perform No tingling, After either test, client
Phalen's test. Ask the client to place the backs numbness, or pain may report tingling,
of both hands against each other while flexing result from numbness, and pain
the wrists 90 degrees downward (Fig. 24- Phalen's test or with carpal tunnel
20A). Have the client hold this position for 60 from Tinel's test. syndrome.
seconds. Median nerve
Optionally test for Tinel's sign. With your entrapped in the carpal
finger, percuss lightly over the median nerve tunnel results in pain,
(located on the inner aspect of the wrist) (Fig. numbness, and
24-20B). impaired function of
the hand and fingers

Test for pain and injury. If the client complains of

a “giving in” or “locking” of the knee, perform
McMurray's test (Fig. 24-29). With the client in
the supine position, ask the client to flex one knee
and hip. Then place your thumb and index finger
of one hand on either side of the knee. Use your
other hand to hold the heel of the foot up. Rotate
 the lower leg and foot laterally. Slowly extend the
knee, noting pain or clicking. Repeat, rotating
lower leg and foot medially. Again note pain or
clicking.

Neurological

Cerebellum i t s p ri ma ry f un ct io ns in cl ud e c oo rd in at io n a nd s mo ot hi ng of v ol un ta ry
m ov em en t s , m ai nt en an ce of e qu il ib ri um , a nd m ai nt en an ce o f mu sc le t on e

Cerebrum me mo ry , pe rc ep t i on , c om mu ni ca ti on , a nd in it ia ti on of v ol un ta ry m ov em en ts .

Frontal Directs voluntary, skeletal actions (left side of lobe controls right side
of body and right side of lobe controls left side of body). Also
influences communication (talking and writing), emotions, intellect,
reasoning ability, judgment, and behavior. Contains Broca's area,
which is responsible for speech.

Parietal Interprets tactile sensations, including touch, pain, temperature, shapes,

and two-point discrimination.

Occipital Influences the ability to read with understanding and is the primary
visual receptor center.

Temporal Receives and interprets impulses from the ear. Contains Wernicke's
area, which is responsible for interpreting auditory stimuli.
I (olfactory) Sensory Carries smell impulses from nasal mucous membrane to
brain

II (optic) Sensory Carries visual impulses from eye to brain

III (oculomotor) Motor Contracts eye muscles to control eye movements

(interior lateral, medial, and superior), constricts pupils,
and elevates eyelids

IV (trochlear) Motor Contracts one eye muscle to control inferomedial eye

movement

V (trigeminal) Sensory Carries sensory impulses of pain, touch, and temperature

from the face to the brain
Motor Influences clenching and lateral jaw movements (biting,
chewing)

VI (abducens) Motor Controls lateral eye movements

VII (facial) Sensory Contains sensory fibers for taste on anterior two thirds of
tongue and stimulates secretions from salivary glands
Motor (submaxillary and sublingual) and tears from lacrimal
glands
Supplies the facial muscles and affects facial expressions
(smiling, frowning, closing eyes)

VIII (acoustic, Sensory Contains sensory fibers for hearing and balance
vestibulocochlear)

IX Sensory Contains sensory fibers for taste on posterior third of

(glossopharyngeal) tongue and sensory fibers of the pharynx that result in
Motor the “gag reflex” when stimulated
Provides secretory fibers to the parotid salivary glands;
promotes swallowing movements

X (vagus) Sensory Carries sensations from the throat, larynx, heart, lungs,
Motor bronchi, gastrointestinal tract, and abdominal viscera
Promotes swallowing, talking, and production of
digestive juices
 XI (spinal accessory) Motor Innervates neck muscles (sternocleidomastoid and
trapezius) that promote movement of the shoulders and
head rotation. Also promotes some movement of the
larynx

XII (hypoglossal) Motor Innervates tongue muscles that promote the movement of
food and talking

Lethargy: Client opens eyes, answers questions, and falls back asleep.
Obtunded: Client opens eyes to loud voice, responds slowly with confusion, seems unaware of
environment.
Stupor: Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep.
Coma: Client remains unresponsive to all stimuli; eyes stay closed. Client with lesions of the
corticospinal tract draws hands up to chest (decorticate or abnormal flexor posture) when
stimulated (Fig. 25-8).
Client with lesions of the diencephalon, midbrain, or pons extends arms and legs, arches neck
and rotates hands and arms internally (decerebrate or abnormal extensor posture) when
stimulated

Use the Glasgow Coma Scale
(GCS) for clients who are at
high risk for rapid
deterioration of the nervous
system (Display 25-2).
GCS score of 14 GCS score of less than 14
indicates an optimal indicates some impairment in the
level of level of consciousness. A score of
consciousness. 3, the lowest possible score,
indicates deep coma.

Test CN I (olfactory). For all assessments of the cranial nerves, have client sit in a comfortable position
at your eye level. Ask the client to clear the nose to remove any mucus then to close eyes, occlude one
nostril, and identify a scented object that you are holding such as soap, coffee, or vanillaAssess CN III
(oculomotor), IV (trochlear), and VI (abducens). Inspect margins of the eyelids of each eye. Assess CN V
(trigeminal).
Test motor function. Ask the client to clench the teeth while you palpate the temporal and masseter
muscles for contractionTest corneal reflex. Ask the client to look away and up while you lightly touch the
cornea with a fine wisp of cottonTest CN VII (facial).
Test motor function. Ask the client to

 Smile
 Frown and wrinkle forehead (Fig. 25-15A)
 Show teeth
Test CN VIII (acoustic/vestibulocochlear). Test the client's hearing ability in each ear and
perform the Weber and Rinne tests to assess the cochlear (auditory) component of cranial nerve
VIIITest CN IX (glossopharyngeal) and X (vagus).
Test motor function. Ask the client to open mouth wide and say “ah” while you use a tongue
depressor on the client's tongueTest CN XI (spinal accessory). Ask the client to shrug the
shoulders against resistance to assess the trapezius muscleTest CN XII (hypoglossal). To assess
strength and mobility of the tongue, ask the client to protrude tongue, move it to each side
against the resistance of a tongue depressor, then put it back

Assess the strength and Relaxed muscles contract voluntarily and show mild, smooth
tone of all muscle groups resistance to passive movement. All muscle groups equally strong
(see Chapter 24). against resistance, without flaccidity, spasticity, or rigidity.

Soft, limp, flaccid muscles are seen with lower motor neuron involvement. Spastic muscle tone
is noted with involvement of the corticospinal motor tract. Rigid muscles that resist passive
movement are seen with abnormalities of the extrapyramidal tract.

Elderly assessmentma jo r t h re at t o t he h ea lt h o f a fr ai l e ld er ly p er so n i s re sp ir at or y in fe ct io n.
P ne um on ia is t he m os t c om mo n ca us e o f in fe ct io n- re la te d d ea th s i n el de rl y cl ie nt s a nd i s
c ha ra ct er iz ed as a “ si le nt ki ll er

D ec re as ed t e ar p ro du ct io n b y t he la cr im al g la nd s o ft en r es ul ts in d ry e ye s. AD LS Ability
to Telephone, shopping, food prep, house keep, laundry,
transportation, meds, financ

occurring with standing up and associated with dizziness may point to orthostatic hypotension
and an adverse reaction to medication. If the client reports tripping or slipping in the absence of
stiffness or weakness and any symptoms, an environmental basis such as shoes or floors with a
slick surface or loose carpeting or rugs may be suspected. It’s pretty basic

Family assessment

The goal of the nurse to assess domestic violence is to Identify, Safety, and Referal.

Components of Family Assessment

 S t r uc t u re F am il y st ru ct ur e h as t hr ee el em en ts : in te rn al st ru ct ur e, e xt er na l s tr uc tu re , a nd
c on te xt . S om e t h eo ri st s f o cu s o n a st ru ct ur al –f un ct io na l fr am ew or k th at , w he n ap pl ie d
t o f a mi ly a ss es sm en t , ex am in es th e in te ra ct io n b et we en th e fa mi ly a nd it s in te rn al a nd
e xt er na l e nv ir on me nt
 D ev el op me nt L ik e in di vi du al s, fa mi li es go t hr ou gh st ag es o f gr ow th an d de ve lo pm en t.
T he se st ag es o f de ve lo pm en t a re as i mp or ta nt to t he h ea lt h a nd w el l- be in g o f th e f am il y
a s t h ey ar e t o t he i nd iv id ua l. I n f ac t, a st at ic f am il y st ru ct ur e i s dy sf un ct io na l
  F un ct io n de f i ne d f iv e ba si c f a mi ly fu nc ti on s: a ff ec ti ve , s oc ia li za ti on an d so ci al
p la ce me nt , r ep ro du ct iv e, ec on om ic , a nd h ea lt h c ar e

T he g en og ra m ( se e F ig . 31 - 1 ) a ct s as a co nt in uo us vi su al r em in de r t o ca re gi ve rs t o “ th in k
f am il y. ” I n a dd it io n, t h e e co ma p (s ee Fi g. 3 1- 3 ) il lu st ra te s t he f am il y' s in te ra ct io ns wi th o ut si de
s ys t e ms composition. Use a genogram and fill in as much information as possible. Ask the
following questions:

 What is the family type (nuclear, three generation, single-parent)?

 Who does the family consider to be family?
 Has anyone recently moved in or out? Has anyone recently died?

Community

Barriers to access to health care are public transportion

Study the history of the The community history The history of some
community. Look for this should include initial communities may include
information at the local development, any specific episodes that have had a
library or ask local residents. ethnic groups that may disruptive influence on the
Use this information to gain have settled there, past people of the community such
insights into the health economic trends, and past as relocation because of
practices and belief systems population trends. repeated flooding, a history of
of community members. racial or ethnic problems, or the
closing of a factory.

Infant assessment

Temperature is 97.5 to 99° F (36.4 to 37.2° C). Rate is 30 to 60 breaths/min. Pulse is regular and
between 120 to 160 breaths/min (rate is 100 breaths/min if the infant is sleeping and 180
breaths/min if the infant is crying). Pulse is regular and between 120 to 160 breaths/min (rate is
100 breaths/min if the infant is sleeping and 180 breaths/min if the infant is crying).

Skin color ranges from pale white with pink, yellow, brown, or olive tones to dark brown or
black. No strong odor should be evident, and the skin should be lesion free.
Skin should be soft, warm, slightly moist with good turgor and without edema or lesions.
Common newborn skin variations include

 Physiologic jaundice
 Birthmarks
 Milia (Fig. 28-15)
 Erythema toxicum (Fig. 28-15)
 Telangiectatic nevi (stork bites) (Fig. 28-15)
Yellow skin may indicate jaundice or passage of meconium in utero secondary to fetal distress.
Jaundice within 24 hours after birth is pathologic and may indicate hemolytic disease of the
newborn. Blue skin suggests cyanosis, pallor suggests anemia, and redness suggests fever,
irritation.

Head is normocephalic and symmetric. In newborns, the head may be oddly shaped from
molding (overriding of the sutures) during vaginal birth. The diamond-shaped anterior fontanelle
measures about 4 to 5 cm at its widest part; it usually closes by 12 to 18 months. The triangular
posterior fontanelle measures about 0.5 to 1 cm at its widest part and it should close at 2 months
of age.

Pregnancy