M19-23

• Putting it all together


  1. Prepare the patient physically and psychologically to allay anxiety

  2. Provide privacy to prevent feelings of embarrassment

  3. Provide adequate information about the procedure, what to expect during the procedure, and what is expected of the client, to gain his / her cooperation

  4. Provide a new, clean gown
• Equipment


  • Weighing Scale
  • Thermometer
  • Stethoscope
  • Sphygmomanometer
  • Penlight
  • Tongue Blade
  • Otoscope
  • Reflex Hammer
  • Pulse Oximeter
  • Speculum
  • Tape Measure
  • Watch
  • Snellen Chart
  • Tuning Fork
  • Gloves
• Sequence of performing the complete physical assessment


  1. On entering the room the nurse should: wash his or her hands, introduce self and purpose and begin history taking component while the patient is dressed and sitting in a chair

  2. During this conversation, the general survey and observation of the patient can be done simultaneously and throughout the assessment and examination
• The health history


  • Biographic Data
  • Reason for Seeking care/Chief Complaint
  • Present Health or History of Present Illness
  • Past Health History
  • Family History
  • Lifestyle and personal habits
  • Review of Systems
  • Functional assessments
• General survey and observation


  • Assess the environment
  • Assess the individual: Mental status, Vital Signs, Body Measurement, Integument, Head, Face, Eyes, Ears, Nose and Sinuses, Mouth and Pharynx, Neck, Posterior Thorax, Anterior Thorax, Cardiac, Breast, Axillary nodes
• Physical assessment with patient lying down


  • Cardiovascular
  • Breast examination
  • Abdomen
  • Peripheral vascular
  • Musculoskeletal (Lower Body)
• Physical assessment with patient seated


  • Musculoskeletal (Upper Body)
  • Neurologic – motor
  • Neurologic – sensory
• Physical assessment with patient standing


  • Musculoskeletal (Spine)
  • Neurologic
  • Visual Acuity
• Forms used in practice


  • Multiple forms shown
• Pediatric assessment


  • Many assessments for the child are similar to those for the adult
  • Techniques for approaching the pediatric patient vary from one age group to the next
  • Building a trusting relationship is a basic principle
  • Explain what will be done prior to each portion of the assessment and answer questions honestly
  • Praise the client for positive behaviors
  • Portraying a caring attitude will greatly influence both the patient's and the caregiver's sense of trust
  • Show respect for the patient as an individual and allow expression of feelings
• Equipment for pediatric assessment


  • Scale
  • Appropriate-sized blood pressure cuff
  • Snellen and Tumbling E charts
  • Allen cards
  • Color vision chart
  • Ophthalmoscope
  • Otoscope, speculum (2.5-4mm)
  • Pediatric stethoscope
  • Growth chart
  • Peanut butter or chocolate
  • Small bell
  • Brightly colored object
  • Denver II materials
  • Clean gloves
  • Disposable centimeter tape measure
• Vital signs in pediatric assessment


  • Temperature
  • Pulse rate
  • Respiratory rate
  • Blood pressures
  • Pain
  • Physical growth
  • Weight and height
• Skin assessment


  1. Inspection: Observe the color, lesions

  2. Palpation: Use finger pads to note quality, thickness, suppleness, temperature, mobility
• Hair assessment


  • Inspect quality, distribution, pattern of hair loss, texture, oiliness, amount of body hair
• Head assessment


  1. Inspection: Observe symmetry of frontal, parietal, occipital prominences

  2. Head control: Assess ability to hold head erect

  3. Palpation of fontanels: Assess for bulging, pulsations, size

  4. Palpation of suture lines: Assess if open, united, or overlapping

  5. Palpation of surface characteristics: Note edema, contour
• Eye assessment


  1. Vision screening: Use Snellen chart, Allen test, cover/uncover test

  2. External anatomic structures: Observe upper eyelid, check for inflammation, crusting, edema or masses
• Cover/Uncover Test


  1. Ask the patient to look straight ahead and focus on an object in the distance

  2. Place an occluder over the left eye for several seconds and observe for movement in the uncovered right eye

  3. As the occluder is removed, observed the covered eye for movement

  4. Repeat the procedure with same eye, having the patient focus on an object held close to the eye

  5. Repeat on the other side
• Phoria


  Latent misalignment of an eye
• Phoria


  • Esophoria - nasal or inward drift
  • Exophoria - temporal or outward drift
• External Anatomic Structures


  1. Observe upper eyelid

  2. Check eyes and eyelids for inflammation, crusting, edema or masses

  3. Inspect and palpate lacrimal glands and sacs

  4. Upper eyelid should not overlap pupil

  5. Eyes and eyelids should be free from inflammation, crusting, edema or masses
• Lacrimation


  Excessive tearing
• External Anatomic Structures


  1. Check for blockage of the nasolacrimal duct by pressing against inner orbital rim of lacrimal sac

  2. Inspect duct blockage by palpating on the lacrimal sac and observing for regurgitation of fluid
• Swelling of lacrimal sac


  Indicates inflammation or tumor
• Regurgitation of tears


  Indicates blockage of lacrimal duct
• External Anatomic Structures


  1. Inspect conjunctiva and sclera

  2. Inspect cornea, lens, pupils and iris
• Conjunctiva and lens


  Should be transparent
• Sclera


  Should be a light yellow color in dark skinned clients and a white porcelain color in light skinned clients
• Pupils


  1. Test pupillary response to light and reaction to accommodation in a dimly lit room

  2. Instruct client to look straight ahead

  3. Bring the penlight at the side of the client's face to directly in front of the pupil

  4. Note the quickness of response to light

  5. Shine light into the same eye

  6. Repeat steps 2-4 opposite eye
• Pupillary reflex


  Equality of size to both pupils
• Pupils


  1. Instruct client to gaze at your fingers held 4-6 inches from the nose, then to glance at a distant object while noting papillary reflex

  2. Move the finger toward the bridge of the client's nose, noting response of both pupils
• PERLLA


  Recording of pupillary reaction to light and accommodation
• Optical blink reflex


  Newborn will normally blink and flex the head closer to the body in response to light
• Auditory Testing


  1. Does the child react to loud noise?

  2. Does the child react to caregiver's voice by cooing, smiling, or turning eye and head toward the voice?

  3. Does the child try to imitate sounds?

  4. Can the child imitate words and sounds?

  5. Can the child follow direction?

  6. Does the child respond to sounds not directed at him or her?
• Hearing tests are available for newborns and even mandated in some states
• If the child is screaming and crying, a flush or erythema on the tympanic membrane will be present. After allowing the caregiver to comfort the child, attempt to reassess. The flush or erythema can give false impressions of otitis media.
• Perform auditory testing at about age 3 to 4 years of age or when the child can follow directions.
• Inspect/Palpate Ears


  1. Examine external ears for placement, symmetry, and color

  2. Observe auricle for discharges, swelling, and redness. Palpate for lesion or tenderness by moving auricle and pressing on tragus and mastoid process

  3. Tip client's head and straighten ear canal by grasping and pulling the auricle upward, back and slightly outward
• Ear placement


  The top of the ear is below the imaginary line drawn from the outer canthus to the top of the ear
• Kidneys and ears are formed at the same time in embryonic development. If a child's ears are low set, renal anomalies must be ruled out. Low set ears can also occur in down syndrome.
• Inspect/Palpate Ears


  1. Examine the ear canal for ear wax, foreign bodies, discharges, scaliness, redness, or swelling

  2. Inspect the tympanic membrane. If membrane is not visible, gently pull the tragus slightly farther to straighten the canal

  3. Identify the color, light reflex and long handle of the malleus

  4. Test for auditory acuity