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CARDIOVASCULAR ASSESSMENT
SUBJECTIVE DATA
- Any chest pain or tightness?
- Any shortness of breath?
- Any family hx of hypertension, obesity, diabetes, coronary artery disease?
- Any skin changes in arms or legs? OBJECTIVE DATA 1-Inspect neck for pulsations Position person supine from 30- to 45-degree angle Turn person’s head away from examiner Shine light tangentially onto the neck “highlights pulsations and shadows” Internal jugular pulsation present when supine 2-Auscultate each for carotid bruit Ask person to take deep breath, exhale, and hold briefly (make sure to hold breath as well so you know when person out of breath) Lightly apply bell of the stethoscope over the carotid artery at 1) the angle of the jaw, 2) the mid-cervical area, 3) the base of the neck No carotid bruit present bilaterally 3-Palpate each carotid artery for amplitude of pulse Palpate each carotid artery medial to the sternomastoid muscle in the neck Carotid artery 2+ bilaterally
4-Inspect precordium for visible pulsations, lifts, heaves, color, consistency Arrange tangential lighting to accentuate any flicker of movement May or may not see apical impulse No lifts, heaves, or visible pulsations present; color is consistent w/ ethnicity, no lesions, or cyanosis present
5 - Palpate for aortic, pulmonic, erb’s point, tricuspid, and mitral areas for thrills
Use palmar aspects of four fingers Gently palpate at: 2nd^ Right interspace—aortic; 2nd^ Left interspace—pulmonic; 3rd^ Left interspace—Erb’s point; 5th^ Left interspace @ left sternal border—tricuspid; 5th^ interspace @ midclavicular line—mitral No thrills in aortic, pulmonic, Erb’s point, tricuspid, and mitral valve areas 6-Palpate apical impulse for location, size, strength, and duration of pulsations
12 -Inspect skin color of arms/hands Skin color consistent w/ ethnicity, no cyanosis 13-Palpate fingers, hands, arms for temperature Fingers, hands, and arms warm to touch 14-Determine capillary refill Capillary refill <3 seconds bilaterally 15-Palpate radial pulses, bilaterally Radial pulses 2+ bilaterally 16-Inspect legs for skin color, hair distribution, lesions Skin color consistent w/ ethnicity; hair is evenly distributed; no lesions present 17-Palpate legs for temperature; determine presence of edema Touch legs bilaterally w/ back of hands Legs are warm to touch; no presence of edema in legs 1 8-Inspect nails and palpate for capillary refill (toes) Depress nail beds and release—note return of color Capillary refill <3 seconds bilaterally 19-Palpate dorsalis pedis pulses Palpate by the big toe Dorsalis pedis pulses 2+ bilaterally 20-Palpate posterior tibial pulses
Curve fingers around medial malleolus Feel pulse on the inside of the ankle; right behind medial malleolus in the groove btwn malleolus and Achilles tendon Posterior tibial pulses 2+ bilaterally Auscultate 3 times, 2 times with bell, 1 time with diarghram Auscultate only to get the heart rate
RESPIRATORY ASSESSMENT
SUBJECTIVE DATA
- Do you have a cough?
- Ever had any shortness of breath?
- Do you experience chest pain while breathing?
- Do you smoke? OBJECTIVE DATA 1-Inspect the shape and configuration of thorax
Tactile fremitus present symmetrically upon saying 99; fremitus prominent between scapulae and around sternum 7-Percuss posterior lung fields Make side to side comparison Lung fields resonant upon percussion 8-Auscultate for breath sounds noting location of each Stand behind the client Use diaphragm endpiece !!; listen to at least one full respiration in each location Bronchial (Tracheal)—location: trachea, larynx Bronchovesicular—location: over major bronchi between scapulae esp. on right, posteriorly; around upper sternum in 1 st^ and 2nd^ intercostal spaces, anteriorly Vesicular—location: over peripheral lung fields Vesicular breath sounds clear over lung fields; no adventitious sounds 9-Auscultate for voice sounds (bronchophony, egophony, whispered pectoriloquy)
Listen w/ diaphragm!! Bronchophony —Ask client to say “99” or “blue moon” as you listen to voice sounds Egophony —Ask client to say “ee—ee—ee—ee” as you listen Whispered Pectoriloquy —Ask client to whisper phrase like “one-two-three” Locations same as those for tactile fremitus Bronchophony—99 is muffled; egophony—ee ee heard over lung fields; whispered pectoriloquy—whispered 1, 2, 3, is faint 10-Inspect anterior thorax for skin characteristics and configuration Anterior thorax symmetric; no redness or lesions; color consistent w/ ethnicity 11 - Inspect the slope of the ribs and costal margins Ribs slope downward; costal margins 90-degrees 12-Determine anterior/posterior to transverse diameter Make sure to look on side of person, then walk to front to get transverse
Anterior/posterior to transverse diameter is 1:
13-Inspect characteristics of respirations (rate, depth, rhythm) Respirations 12-20 breaths per minute; relaxed breathing is automatic and effortless, regular and even, and produces no noise; pattern of breathing is regular
HEAD, NECK, NOSE, MOUTH, AND THROAT ASSESSMENT
SUBJECTIVE DATA
- Have you experienced any unusually frequent or unusually severe headaches?
- Do you have any neck pain?
- Have you noticed any sores or lesions in your mouth, on your tongue, or your gums?
- Do you smoke? OBJECTIVE DATA 1-Inspect head size, shape, and configuration
Head is normocephalic; proportionate to rest of body
2-Inspect skin surface of face Facial structures symmetric, color consistent w/ ethnicity, no lesions, no swelling, no involuntary movements 3-Inspect skull and hair Move hair around to take look at skull Skull is symmetric, hair is black, thick, equally distributed, no presence of dandruff or lice 4-Palpate head for consistency Head symmetric and smooth, no lumps or depressions present 5-Palpate hair and scalp Scalp is smooth, no lesions, hair is thick and equally distributed 6-Palpate temporal artery Above the cheek bone btwn the eye and top of ear Temporal artery 2+ bilaterally 7-Palpate temporomandibular joint Place finger tips near ear
Ask client to open and close mouth Smooth movement w/ no limitation; no tenderness noted 8-Palpate temporalis and masseter muscle—motor CN V Place fingertips on temporal and cheeks Ask client to open and close mouth Ask client to clench their teeth Try to separate jaws by pushing down on the chin Temporalis and masseter muscle equally strong bilaterally; no tenderness noted 9-Test soft touch over face—sensory CN V Ask client to close eyes Touch face at 6 different locations with cotton ball (forehead, cheeks, chin) Ask client to say “now” when they feel the cotton ball on their face Soft touch felt over face bilaterally 10-Test CN VII—Motor Function only Ask client to make facial expressions (smile, frown, close eyes tightly, lift eyebrows, show teeth, puff cheeks, press client’s puffed cheeks and note air escapes equally from both sides)
CN VII intact, facial movements symmetric bilaterally
11-Inspect external and internal nose (turbinates, septum)
Wear gloves, use tongue depressor Ask client to open their mouth Lips—move top lip up to inspect; then the bottom Cheeks—hold open w/ tongue blade to inspect
Lips are pink, moist, no lesions; buccal mucosa is pink, smooth, moist
16-Inspect Stenson’s and Wharton’s duct While inspecting buccal mucosa, look for any swelling on the ducts Stenson’s—near second molars Wharton’s—ask client to lift tongue and look for ducts
I’m inspecting Stenson’s duct located near the second molars, no drainage present; now I’m inspecting
Wharton’s duct below the tongue, no drainage is present
17-Inspect teeth and gums
Ask client to bite, note alignment of upper and lower jaw
Inspect gums and teeth
Teeth evenly spaced, straight; gums are pink and gum margins to teeth are tight an
well defined
18-Inspect tongue and hard and soft palate Ask client to open mouth Shine light to roof of mouth Then ask client to lift up their tongue and touch roof of mouth
Tongue is pink, even in color, ventral surface of tongue smooth; hard palate is white
w/ irregular rugae; soft palate is pink, smooth and upwardly mobile
19-Inspect and grade tonsils
Tonsils are oval shaped bilaterally and have grade 1+ 20-Test CN IX and X—motor function only Have client stick out their tongue
Ask client to say “ahhhh”
Depress clients tongue w/ tongue blade at the center (trigger gag reflex) Have client swallow some water (test CN X) Gag reflex present; uvula rises upon phonation; patient able to swallow 21-Test CN XII Have client stick out their tongue Ask client to move their tongue
Ask client to say “light, tight, dynamite”
Tongue is midline, no tremors; lingual speech clear and distinct 22-Inspect neck for symmetry and pulsations
Head positioned midline; accessory neck muscles symmetric; no additional pulsations
in neck
23-Palpate neck for lumps, tenderness No lumps, tenderness, pain noted on neck 24-Identify and palpate cervical lymph nodes
Place index finger on the trachea in the sternal notch Slip your finger off to each side to palpate for any tracheal shift Trachea is midline 28-Test CN XI Push down on clients shoulders with palms Have client try to shrug their shoulders
Shoulder shrug equal strength bilaterally
29-Palpate thyroid gland
Stand behind client!!
Ask client to bend head slightly forward and to the right Use your left hand to push the trachea slightly to the right Curve your right fingers btwn the trachea and sternomastoid muscle Retracting it slightly, ask client to take sip of water and/or swallow Thyroid should move up under your fingers Reverse procedure for the left side
No swelling or enlargement of nodules
EYES AND EARS ASSESSMENT
SUBJECTIVE DATA
- Do you have any eye pain?
- Have you had any past injury to your eyes?
- Do you have any ear pain?
- Do you have any difficulty hearing? OBJECTIVE DATA 1-Inspect external eye structures (lids/lashes), ability to close eyes, color, swelling, lesions
Eyebrows present bilaterally; color of lids are consistent all throughout, no swelling or lesions;
eyelashes are evenly distributed
2-Inspect conjunctiva and sclera for color and clarity Ask client to look up Using thumbs, slide the lower lids down along the bony orbital rim Conjunctiva is clear and sclera is white 3-Inspect lacrimal apparatus and puncta for swelling, redness drainage Ask client to look down as you slide the outer part of the upper lid up along the bony orbit w/ your thumb Use your index finger to press against sac (just inside lower orbital rim, not side of nose) No swelling, redness, or excess drainage present 4-Inspect cornea and lens by shining light to determine transparency Shine a light from the side across the cornea, check for cloudiness and/or irregularities
Cornea and lens are smooth and clear
5-Inspect color of iris and pupil for shape
Place 1 finger on the tragus & rapidly push it in and out Shield your lips as you whisper 2-syllable words Have client repeat words back Repeat in other ear Whispered words heard bilaterally 14-Perform Rinne test Place stem of vibrating tuning fork on client’s mastoid process Have client raise hand when sound goes away Then quickly place tuning fork near the ear canal Ask client to raise hand when sound no longer heard
AC > BC bilaterally
15-Perform Weber test Place stem of vibrating tuning fork in the midline of client’s skull Ask client if they can hear the sound in both ears
Sound heard equally in both ears
16-Perform Romberg test to evaluate equilibrium
Ask client to stand w/ feet together, hands at sides, eyes closed
Wait for about 20 seconds Romberg test is negative
ABDOMEN ASSESSMENT
SUBJECTIVE DATA
- Do you have any abdominal pain?
- Do you have any nausea or vomiting?
- Have you experienced a change in appetite?
- Do you have any difficulty swallowing? OBJECTIVE DATA 1-Inspect for surface characteristics, contour, color, and movement
Shine light across abdomen towards you and note any bulging or visible masses
Abdomen is flat (or rounded), symmetric bilaterally, no bulges or masses, color is
homogenous, respiratory movement is visible
2-Inspect umbilicus
Umbilicus is midline and inverted
3-Inspect for any pulsations
No extra pulsations present
4 -Auscultate for bowel sounds in four quadrants
Start at RLQ and move clockwise to LLQ Listen for bowel sounds for 1 minute in each quadrant
Bowel sounds are active in all four quadrants
5-Percuss abdomen Begin in RLQ and move clockwise Percuss lightly Tympany predominates over abdomen 6-Perform light palpation
