HEALTH ASSESSMENT
USEFUL TERMINOLOGIES
Acute Illness: It has severe symptoms. Which is seen in short duration. A few days or weeks of illness is observed. Which happens quickly. In which immediate treatment is provided. Its common cause is viral infection or injury. This rash becomes normal soon.
Assessment: Assessment is the systematic and intentional process of gathering or collecting information related to the patient’s health, which is called assessment.
Auscaltation: This is a method of physical examination. In which body sounds are heard through ear or stethoscope. In which sound is heard from heart, lungs, vessels, intestine etc. In which a health care provider uses a stethoscope to listen for sounds. This is also a diagnostic procedure.
Inspection (Inspection): This is also a method of physical examination in which all the data of the patient is taken. In this method, data related to health is collected through the use of observation. E.g. Skin colour, general appearance etc.
Parcussion (Percussion): This is a method of physical examination. In which the density of the body structure inside the body KVT can be collected from the sound made by placing one hand on the body surface and tapping it with the finger of the other hand. E.g. The presence of air, fluid etc. in the structure of the body shows a change in the sound coming from tapping.
Palpetion: This is a method of physical examination. In which the size, shape or any abnormality is determined by pressing the organs or structures inside the body cavity with pressure.
Cheyne stoke respiration: This is an abnormal pattern of breathing. which is classified during periods of apnea. In which the depth and frequency of respiration gradually increases after an episode of apnea.
Bradycardia: Slow heart rate is seen in this condition.
In adults the heart rate is mainly below 60 bpm.
This condition is called bradycardia. In which atropine is the first line of treatment. Which increases the heart rate in bradycardia.
Tachycardia: Heart rate increases in this condition.
In which heart rate increases mainly from 100 bpm in adults. This condition is called tachycardia.
Bradypnia: Abnormally slow breathing rate is observed in this condition. In which less than 12 respirations are observed.
Tachypnia: Abnormally increased breathing rate is seen in this condition. In which more than 24 respirations are seen.
Disease: In this condition, the health of the body is disturbed. Disturbances in the performance of vital functions are seen. Disturbance in the function or structure of any organ or part of the body is called a disease.
Health: According to WHO,
“This is a state of complete physical, mental and social well-being.
which is not merely the absence of disease or infirmity.”
Illness: Illness means sickness. A person becomes unable to maintain physical and emotional balance. Disturbance in its ability to function later is called illness.
Kussmaul breathing: This is a type of abnormal respiration. In which abnormal breathing pattern is seen. Rapid and deep breathing is observed. This is a sign of a medical emergency. This condition is more common with diabetic complications such as coma and coma.
pursed lip breathing: This is a breathing pattern in which the lips are partially closed. So that the air is expelled slowly. It is used in patients with chronic obstructive pulmonary disease. In which breath is taken in through the nose and out through the mouth. By doing this type of breathing, there is relief in his breathing difficulty.
Terminal Illness (Terminal Illness): In this infection or disease, it is the end stage disease which is not treated and death also occurs. This term is most commonly used in patients with cancer and chronic kidney or heart disease etc. which does not heal and results in death. Such illness is called terminal illness.
Introduction:
Different people have different perception towards health. Some feel that a person is healthy when he is free from any disease or illness. While others believe that a person is healthy if they are capable of performing regular life activities.
Health is a state of being strong from body mind or soul. Especially not having physical disease or pain.
Health is a way of life. Which requires desire, body functions and how to stay fit and healthy habits including diet and exercise. Health is a positive state of well-being when experienced physically, socially and spiritually.
Health Assessment (Health Assessment):
It is a continuous and systematic collection of patient data against standard rules. It includes the patient’s perceived needs, health problem related experiences, values and lifestyle. Includes health history and physical assessment.
According to the American Nurses Association…
“Assessment is a systematic dynamic process by which the nurse collects and analyzes data about the patient through interaction with the patient, significant others, and the health care provider2.
A health assessment is an assessment of health status by performing a physical examination after taking a health history, to detect early diseases in people who can see or feel them.
A health assessment is a plan of care. Which identifies the patient’s needs and how those needs will be addressed by the health or skilled nursing facility.
Nursing Assessment is the gathering of information about the patient’s physical. Information related to Psychological, Social and Spiritual condition is included in it.
In simple words, health assessment collects data about the patient’s health status. It is a detailed study of the body to make a general or mental state of the body.
Assessment = observation of patient+interview of patient’s family and significant others+examination of patient+review of medical records.
Purposes of Health Assessment:
To collect data about the physical, mental and social well-being of the patient.
To identify the patient’s problem at an early stage.
To determine the cause and extent (level) of the disease.
To monitor changes in the patient’s health status.
To determine the patient’s need, nature of treatment etc.
To remove complications.
To certify whether the patient is medically fit to resume duties.
To contribute to medical research.
To collect data systematically.
To identify the patient’s strength, weakness, knowledge, inspiration, support system and coping ability.
To compare the patient’s health status with ideal status, including age, race, culture, physical, psychological and socioeconomic status.
Process of Health Assessment:
A history of health
Physical Examination.
Nursing Health History in the Assessment Phase is a structured interview designed to collect specific data and obtain a detailed health record of the patient.
A health history is a collection of subjective data. This includes information on both the patient’s past and current health status.
Data collection is the primary focus of the interview. Health history is a review of the patient’s health patterns prior to current contact with a health care agency. While the medical history focuses on the symptoms and progression of the disease. Nursing health history, then, focuses on the patient’s response to changing health patterns.
A health history can be either complete or focused. A complete health history includes biographical data, religion, current health status, past health conditions, a detailed review of the family history system, and a psychological profile.
Focus Health History focuses on an acute problem so all your questions will be related to that problem.
Component of Health History:
Complete health history
REASON FOR BIOGRAPHICAL DATA CARE
Past Health History Family History
A review of the psychosocial profile of the system
Analysis of current health status and symptoms including developmental prevalence
Focus Health History
Results for biographical data care
Past health history Family history Only family history because it is causally related to specific care
Only the psychosocial profile as it relates to the specific cause of care. Only develop mental considerations because it will affect a cute problem
ETHNICS CONSIDERATIONS AS THEY WILL AFFECT ACUTE PROBLEMS Analysis of current health status and symptoms is only related to the specific reason for seeking care.
Objectives of Health History:
A subjective data base is to be provided.
To identify the patient’s strengths.
Both actual and potential underlying health problems of the patient are to be identified.
To identify the need for education.
To identify discharge need, to identify referral need.
Factors affecting subjective data collection
Physical setting
Patient responsibility and behavior.
Communication skill.
problem
Responsibilities and behavior of the nurse
Knowledge and skill of the nurse.
Components of Nursing Health History
Biographic data
Reason for health care
History of present illness
Past health history
Family history
System review
Life style
Socio-Cultural History
Psychosocial History
Occupational and environmental history
1.Biographic Data:
Data is collected only when the nurse talks to the patient. Information such as name, address, age, date of birth, sex, religion, bed number, ward, medical diagnoses, surgery, occupation, education, and type of health plan can be useful to help understand the patient’s health.
It is a brief statement of the patient’s problem for which the patient seeks medical care. It is the primary reason why a patient is admitted or ill. The patient’s reason for seeking medical care should be described in the patient’s own words. The patient’s perspective is essential. Because the patient’s point of view explains what is necessary about the event, it is necessary to determine the time of onset of symptoms as well as to perform a complete symptom analysis.
The patient’s statement should be written if there are multiple problems to indicate the priority of the patient’s complaint. Avoid using medical terminology. For example patient has general weakness since one month Cough since two weeks and fever since two days Headache today. Complains of headache× one day.
Chief complaint fever × two days .cough × 14 days and general weakness × 30 days.
3.History of Present Illness:
It includes Chief Complaint. It includes location, quality, quantity, setting etc.
Location In which area of the head does the headache occur?
Quality is gradual or sudden onset. Is the pain stabbing dull throbbing and aching Is the pain intermittent or constant?
Continuity Quantity Degree of fever using pen scale .Pen intensity.
Chronology Chronology
How often do symptoms start?
Setting Asking about where you were when the symptom appeared eg home hospital job etc Factors involved eg stress wear smoking smoking smoke inhalation Factors causing the symptoms.
Associated Symptoms Do these symptoms affect other parts of the body? Hunger, sleep patterns become weak. Body aches.
Exacerbating Factors Whether the occurrence of symptoms is linked to activities like smoking, such as talking loudly, eating, climbing, and changing body positions.
Relieving factors How the symptoms are reduced i.e. meditation rest eating home remedies and taking medicines etc.
Past health history
Past health history is information about the patient’s experience with any disease or surgery. Collecting this information is very important. It is an assessment of the patient’s health before the present illness because the previous illness may be related to the present illness. Which includes past health history.
Medical Disease
Asking the patient whether he is in contact with any medical disease like TB, anemia, stroke, hypertension, asthma, heart diseases, glaucoma etc.
If the patient has these diseases, ask them to what extent it affects their daily living activities.
Surgery
To know the history of any previous surgery of the patient like knee replacement, hysterectomy, valve replacement, etc. Also to know the patient’s non-response to the surgery.
Allergies
Note the patient’s health history of any drug, food, or environmental allergies, including the name of the allergen, the type of reaction, and the substance.
Hospitalization
Ask if the patient has ever been hospitalized before, if yes, why and for how long.
Injury or trauma
Ask the patient for history of fractures, burns, altered level of consciousness, abdominal trauma, etc.
Childhood illness or immunization
Whether the patient has been vaccinated against Tetanus, Hepatitis, Diphtheria, Measles, Rubella, Polio, etc.
Family history
Knowing that anyone in the family has a serious illness that may be acute or chronic.
First in health is to collect blood related and child related information as genetic and environmental factors are linked to DCs. Family health is very important.
For example: Hypertension, Anemia, Diabetes, Mental diseases, Cancer, Seizures, Kidney diseases etc. and write the health history of all family members and their age and gender if all are alive.
Which is represented by a family tree.
Man: To round
Woman: Doing a square box
Patient: Pointing with an arrow.
Life style
Includes eating habits, sleep, rest patterns, daily living activities, entertainment, hobbies, personal habits etc.
Activities of Daily Living is a description of self-care in this database that includes nutrition, rest, sleep, and exercise.
Psychosocial History
This history includes the patient’s self-concept, self-respect, sources of stress, and the patient’s capacity to cope.
In addition, it involves finding sources of support such as family, religion, supportive groups when a crisis occurs.
Asking the patient about his illness affecting his sexual activity? This information should be collected last as the patient may be comfortable by then.
The impact of the disease on their work, relationships with other people, the cause of AIDS, from this we can identify the psychosocial history.
A psychosocial history involves obtaining information about the patient’s awareness of himself or his relationships with other human beings.
The focus of obtaining information is the patient’s education, life style, own relationship, social relationship, marriage, school, siblings, etc.
Socio-Cultural History
Inquiring about the socio-cultural history, his home environment, family situation and the patient’s role in the family etc. is essential.
For example a parent of three children and a single parent may be the sole provider of the family. Patient accountability is essential by which the nurse can determine the impact of changes in his health status and the plan that is most beneficial.
Occupational and Environmental History
The goal of collecting this history is to identify the critical environmental factor or substance that is causing the illness.
In which information related to the patient’s occupation, job, lifestyle, environment etc. is collected.
In which fields, factories, crowded yards, heavy materials, etc. can spread communicable diseases.
Physical Examination
The goal of performing a physical examination is the same as taking a health history.
Physical examination is an important part of health assessment.
Which provides objective data to diagnose and identify the problem.
The goal of a physical examination is to assess any deviation from normal. And to validate the information collected through interviews.
Measurement of baseline data and physical techniques are used to collect objective data.
A physical examination is included in the nursing assessment. Signs and measurements or observations are made.
In which nogia vertigo the patient experiences.
Techniques like inspection, palpation, percussion, auscultation etc. can be used in physical examination.
What is baseline data?
Baseline data is a systematic organization of assays obtained during physical examination.
A given point in time forms a basis for comparison and evaluation to establish the patient’s status. Height and weight are needed in comparison with future measurements so that any changes can be determined.
Techniques of Physical Assessment
Physical examination uses systemic assessment techniques and visual, auditory, textile, and all-factorial senses. All these senses will be used in specific assessment techniques.
For example, it is often detected by changes in body odor and fluid.
Four specific techniques are used in physical examination. including inspection, palpation, percussion, and auscultation.
Inspection is a visual examination of the patient. And there is a visual examination of the body, in which the patient’s general appearance, body size, gait, size, shape, posture, etc. are done carefully. This begins as soon as the nurse makes contact with the patient.
During the inspection phase of the physical assessment, the nurse uses observation skills to systematically collect observable data.
This includes measuring the patient’s respiratory effort, skin color, and wound size.
General Appearance
State of Conscious Personal Grooming
Expression: Concerned, Comfortable, Alert, Nervous. Body Build: Thin, Fatty, Moderate.
It also combines the patient’s words with no body language.
For example a patient’s pain experience is related to their body language.
Visualize the maximum area of the body in the inspection and compare it with the side of the other body.
Comparing the width of the right hand with the width of the left hand.
Adequate exposure of the body area is very important. In which looking at color, texture, mobility, symmetry, nutritional status etc.
Palpation
Palpation means feeling the texture, size, shape, placement, location, etc. of the organ using touch hands and fingers. In which the temperature, pulse, texture, moisture, mass, tenderness, and pain of the skin are assessed using the finger tips of the hand specially.
Assess skin, pulse, palpation, and tenderness by gentle palpation by pressing as deep as 1 cm.
After that pressing about 4 cm with the help of both hands which is deep palpation. With the help of it to determine the size of organ and deep organ (liver).
What to keep in mind while doing palpation?
It is very important to always explain to the patient before palpation because touch is very important in our culture.
Keep hands warm and nails short before palpation. The palmar surface of the finger is more sensitive than the finger tips with the ulnar surface being more sensitive to vibration and the dorsal surface being used for temperature.
Palpation also helps to determine the size of the lymph node.
Always proceed with gentle palpation first followed by deep palpation. Because it can disrupt tenderness or fluidity.
The size and shape of the kidneys and uterus are assessed between the finger tips and organs using both hands.
Percussion
In simple words it is called tapping. To get the sound quality, the sound is heard against the patient’s body by tapping it with a finger. which is used to reflect the density of internal organs. Sound, vibration, and impedance are produced with different densities and vary from organ to organ. And it is used to know the size, shape, position of the internal organ and also to detect the fluid field organ.
Percussion is a technique that determines the consistency of physician practice nurse tissue.
Tapping in percussion involves making short or sharp strokes on the body surface to produce various palpable vibrational sounds.
Percussion is used to detect the sound, location, size, shape, size of many organs of the body. In which the examiner taps the patient. The middle finger of the non-dominant hand is usually placed over the percussion area to produce the sound. And placing the middle finger of the dominant hand on the non-dominant.
In which percussion is done in two ways.
Direct Farcson
This is used for infant’s chest and adult’s sinuses. Specific parts of the body are struck with the help of finger tips.
In tenderness of the kidneys. Listen to the vibrations created.
It is necessary to select on the same point two or three times before doing on another. is done to get accurate readings. Fatty patients need a strong cushion.
_Percussion tones: air la ut, fluid dull and solid area soft.
Indirect percussion
This varies from area to area with the fingers of the non-dominant hand resting palm down on the CVA and gently striking the fingers of the dominant hand e.g. T.. in kidney….
_Thorax: The middle finger of the dominant hand strikes the interphalangeal joint of the non-dominant hand against the patient’s skin.
Percussion produces sound that has many sounds and different characteristics.
Characteristics of sound
Tympany is usually heard above the abdomen.
Resonance J in normal lung tissue.
Hyper resonance j in inflated lungs.
Dullness on the lungs.
On flatness muscles.
auscultation
Auscultation is usually done with a stethoscope. The stethoscope is used to block extraneous sounds while assessing the condition of the heart, blood vessels, lungs, pleura, and bowels.
Which includes breath sound, heart vascular sound and bowel sound etc.
It is commonly used to detect the presence of abdominal sounds and assess their loudness, speech, quality, frequency, and duration.
The most common sounds heard are those of the lungs heart and abdomin and blood vessels.
The chest is auscultated to listen for heart sounds. Lung sounds are heard anteriorly and posteriorly for normal and spontaneous lung sounds. Abdomen is auscultated for bowel sounds.
Sound characteristics?
Intensity: Loud, Medium, Soft.
Pitch: Low, High, Medium.
Duration: Short, Long, Medium.
Quality: Booming, hollow, dull and drum-like.
Order of physical examination?
inspection
Palpation
Percussion
Auscultation
Patient preparation
Physical preparation
Assist the patient to sit or position during the examination. Help him remove clothes as needed.
Emptying the patient’s bladder relaxes the patient and increases easy palpation in the abdomen and pubic area. If a urine test is required, collect urine in a urine container.
_Prepare the patient if fasting is required.
Psychological preparation
When the patient is admitted to the hospital he becomes worried and anxious and he is tripped up by any problem.
It is very important to know or understand the psychology of the patient
To justify his questions.
Explain the procedure to the patient. And what is the purpose of the examination includes psychological preparation.
Making the patient relaxed and comfortable.
Tell the patient the order of examination.
Before starting the physical examination of the patient, it is necessary to prepare the unit to make the patient relaxed and comfortable.
The examination time should be convenient for both the patient and the nurse as some important information is missed by being done quickly.
Light is essential for examination so light should be there throughout the examination.
Equipment Material: All equipment should be close and in working condition before examination. The patient should be able to sit or lie comfortably on a table or chair.
Privacy: Privacy is the main part of the examination.Do not leave the female alone while the doctor is doing the examination.
Temperature: The temperature in the room where the physical examination takes place should not be too hot or too cold. Providing Warm Environment.
Position: Many positions are used in physical examination so there should be furniture so that the patient can take a comfortable position.
Draping: Draping means covering the area near the exposure. Draping maintains privacy and prevents unnecessary heat loss.
General Assessment
Assessment can be comprehensive and focused. The Comprehensive Assessment is an initial assessment. Which is quite adequate and includes a detailed history and physical examination.
If the patient’s condition does not warrant assessment. A focused assessment of the patient’s current health problems is then carried out.
Skin: Ask about skin rashes, itching, dryness, oily skin, skin color changes, and changes in moles.
Inspection of skin
Yellow skin in normal cyanosis jaundice.
Color: General Color and Uniformity
Pigmentation: Normal, Hyperpigmentation, Hypopigmentation
Moles: Large/normal sudden enlargement and irregular border of mole. Changes in color, itching, tenderness, pain, building up in moles, changes in the surface of moles.
Vascularity: Abnormalities petechial, ecchymosis, purpura.
Lesion : Color: Pink, Red, Yellow, Brown, Black, Green.
Types of lesions include macule, papule, scale, ulcer, and scar.
Pattern: Annular, linear, clustered bull’s eye.
Body Area: Generalize, expose area, skin folds in face etc.
Palpation of the skin
Temperature normal, hyperthermia, hypothermia.
Texture: Normal Skin, Soft, Intake, Minimal Sweat, Uz Rada, Scars, Rough Spots.
Mobility: Normally the skin moves easily when lifted and snaps back into place when released.
Tenderness Yes or No.
Turgor: Skin mobility and moisture, poor turgor if dehydration.
Nails : Inspection and palpation of nails, angle of nails.
Shape: Rounded, Flat
Texture: Smooth
Color: Pinkys White.
Thickness: Uniform
Palpate the base of the nail. For cleanliness and strength of nails.
Head inspection and palpation.
To note size, sap, symmetry inspection, texture.
Palpate for skin lesions, no mass in the head, tenderness, swelling, and no texture of the hair.
Normally the head is non-cephalic. The skull is symmetrical and appropriate to body size.
Hair: Color Texture Quantity and Distribution.
Face: Inspection
Facial Expression: Depression, Anxiety, Anger, Disgust. Facial Movement: Excessive winking, continuous smiling.
Cementary of face: swollen, shankar area, trembling. Skin color, temperature and pigmentation
Texture: Lesion in AD
Eye and Vision
inspection
Margin of eye lid: Inspection for presence of secretion, redness, position of lacunae. Eye Lacies: Curved outwards and distributed.
Conjunctiva: Check color (pink) Sclera: Check color (white)
Pupil: Checking size, aperture, symmetry, reaction to light. Cornea: Normal (transparent).
Vision: Monitor distance vision using Snellen or ‘E’ charts. Check near vision using a Rosen Pom chart or cord with newsprint held 12 to 14 inches from the patient’s eyes.
Eye Movement: Assessing the main field of vision to obtain information about movement within the eye. Ask the patient to follow your finger while drawing the letter H or z in the air. Corneal Reflex: Gently touching the patient’s cornea with cotton will cause the eye to blink.
Neck Size and Symmetry: Symmetrical
Range of Motion: Back, side to side. Position of Thrace
_Thyroid gland: enlarged or non enlarged.
Palpation
1). Palpate the neck area for cervical nodes.
2). Distension of jugular vein.
3). tracheal ring, and cricoid cartilage, and thyroid cartilage.
4). Palpate the neck for carotid pulse.
Abnormal Findings: Tenderness and nonmead line position.
Lymphnode: Inspecting the Superficial Lymph Node. In ED, palpate for redness, node size, mobility, border tenderness and warmth.
Position of Trachea: It is usually found on the midline.
To check it, place the index finger on the supra sternal notch and then slide it to the right and left to note both sides. Usually the space between the trachea and sternocleidomastoid muscles is the same on both sides.
Palpate son of lymph node
Assess all nodes.
Particular Node: Using both hands on each side to compare findings. The submental note can be palpated well with the help of one hand.
_Supra clavicular node: examined with the patient’s shoulder forward and towards the flexor chain. It makes the node more accessible. Place the finger in the medical supra clavicular fossa and deep in the clavicle and in the sternocleidomastoid muscles. Then ask the patient to take a deep breath while doing a deep press. Behind the clavicle because the enlarged supraclavicular notch can be easily felt during inspiration.
Abnormality: Enlarged submental node, facial acne.
Enlarged supraclavicular node: thoracic on abdominal pathology such as carcinoma, lymphoma, TB, and AIDS etc.
Axillary node
Support the patient’s arm with your hand. Flex his elbow and place his forearm on your hand.
Place the palm of the examining hand flat on the axilla. Cupping the fingers while examining the hand to insert high into the axilla.
When palpating the fingers, the soft tissue will roll between the fingers. Finger and palm rotate and feel the nodes and palpate the anterior, posterior and lateral areas of the axilla.
Enlarged lymphnode
Lymph drainage from the breast or systemic disorders such as Hodgkin’s disease, hand or finger infection, breast cancer, systemic syphilis.
Pal Passion of the Node on the Hand:
Flex the patient’s arm to 90 degrees.
Palpate the back of the elbow down from the medical cond il of the humerus.
Enlarged Node: Ulcer infection in four to five fingers of forearm.
Groin Region: Endual nodes in which,
Provide supine position to the patient. Using the finger pads to palpate the inguinal ligament only below this aspect in the groin area.
This node is small, smooth, soft and mobile. In large, tender, warm, freely movable node : inflammation
Nose and paranasal sinuses
In which inspection and palpation..
General Appearance: Symmetric, midline symmetry If discharge present: Amount characteristic of discharge.
Paranasal sinuses: swallowing tenderness or not. Nostril: Dry, symmetrical, nose flaring
_Internal Nasal Cavity: Patent or not patent.
Mouth:
Palpation of temporomandibular joint: with tenderness and discomfort.
Note its odor while breathing.
Normal: No odor or slightly sweet.
Abnormal: Acetone odor is present if diabetic ketoacidosis is present.
Fitter Odor: If there is gum disease, poor dental care and inflammation in the sinuses.
Lips:
Color : Pink normal or blue (respiratory or cardiac problem)
Pallor: Anemia or shock
Symmetry: Both vertically and laterally symmetrical.
Moisture: Smooth and moist
Checking the presence of crusts and lesions.
Teeth:
Alignment: Protrude and number of teeth.
Color: White, yellow, grey, dark color in medication or caffeine intake.
Surface: Smooth
Checking for caries, missing teeth, debris etc.
To palpate the tooth for stability of the tooth.
buccal mucosa
Color : Pink and pale color with slight vascularity. Checking the presence of patches, ulcers, masses etc.
Tongue Inspection:
Movement: Smooth and symmetrical.
Color : Pink Moist.
Checking for ulceration. Surface: Variation in Swelling Size.
Abnormal Findings:
Atrophy of the dvson of the tongue is seen on one side of the tongue in neurological problems.
Small Tongue: Mal Nutrition
Enlarged tongue: Mental retardation, acromegaly, hypo thyroidism.
Smooth, red and swollen tongue: Vitamin B12 deficiency.
Patients with dentine: tenderness, lesions, and thickness in the gums. Material fitting of dentures.
Palpation of the tongue
Smoothness and ir regularity
_uvula and palette
Inspection:
Texture: Smooth, immoveable palette
Color : Pale Palette, and Soft Palette : Pink Surface Characteristic : Soft palette fails in use and uvula deviation which is reflected in neurological problem.
D. T. Paralysis of the vagus nerve.
Fairings:
Inspection of the posterior wall of the fairings for any swelling or inflammation.
Ear:
Inspection of both ears
Alignment: Normal
Head position: Relation of eye size and outer canthus of the septum is normal.
Skin Color: Blue: Cyanosis, Red: Full Sing, Paler: Frost Bite.
Inspection:
Pina: Inspection of size, sap, color, lesion, and mass.
External canal: presence of discharge, foreign body mass and information.
Inspection of the tympanic membrane.
Hearing Assessment
In which two tests are done.
Weber Test:
Vibrating the Tunic Fork on the middle head of the patient. Then ask the patient if it sounds the same in both ears or louder in one ear than the other.
Rinnie Test:
Vibrate the Tunic fork over the mastoid process then ask the patient when no sound is heard. Then take a quick reposition. Tunic fork at the front of the ear canal. Then ask the patient if he can hear the sound? Ask the patient to say when the sound is not heard. Normally the patient will hear the sound twice over a long period of time through air conduction. such as through bone conduction.
Chest:
inspection
Breathing: with effort, normal, or without effort.
Chest knee wall symmetry in which the anterior posterior angle: should be less than 90 degrees.
Barrel Chest: In which the costal angle is greater than 90 degrees.
Breathing rate: normal, tachypnea, bradypnea, and apnea.
Bridging Pattern: Cello bridging or by itself.
Expansion of the chest.
Palpation:
Chest wall : Pleural friction rub, crepitus.
Symmetry: Normal reflexes.
Asymmetry: Pneumonia, flail chest, pneumothorax.
Thoracic expansion
Curvature: scoliosis and kyphosis.
Abnormal Findings: Increase fremitus, cone solidification, lobar pneumonia, pleural due to decreased normal lubrication.
Palpate the chest and tenderness for lumps and any masses.
Percussion of the thorax
Tone: Resonance, Hyper Resonance, Timpany
Intensity: Loud, Soft, Medium.
Pitch: Very low, low or high pitch.
Duration
Quality: Hollow, Blooming
Percussion of heart border for size of heart.
Auscultation (for bridge sound)
including broncho vesicular vesicular and bronchial, vocal sound.
the heart
Inspect for cyanosis.
Palpate the pulse for a regular or irregular rate.
Then palpate the apical pulse for location.
Duration: The apical pulse is the fifth intercostal space relative to the heart in an adult and the fourth intercostal space in a young child or infant.
Assessment of cardiac rate and rhythm
Auscultation of Heart Rate and Rhythm The first heart sound is more auscultated at the apex of the heart and the second heart sound is more auscultated at the base of the heart.
Then identify additional heart sounds in both systole and diastole.
Heart sounds: s1,s2,s3,s4 and murmur.
And check the rate, rhythm, pitch, etc.
Breast and axilla in female
inspection
Breast Size, Sap, and Cementary.
Breast skin: including appearance, colour, pigmentation, vascularity etc.
Areola: Color and surface characteristics.
Nipple: including position, symmetry, discharge, bleeding, lesions, scaling, cracked nipple etc.
Axilla: Recess, Lison, Mass.
Palpation
Breast and axilla: including tenderness, nodule, and surface characteristics
Nipple: Characterization of discharge and surface.
Abdomen
(A). inspection
Skin Color: Redness, lichen, and discoloration. Cyanosis, resis pink purple or red.
Stryl : Abnormality.
Surface Characteristics: Smooth
Umbilicus: Normally in the center with sunken contour.
Surface Movement: Smooth movement during respiration.
Abnormalities: Visible peristalsis, grunting labored movement, restricted abdominal movement.
(b) Auscultation of Abdomen:
Bowel sound: increased sound indicating diarrhea including laxative use and AGE.
Less sound: inflammation, constipation
Vascular sound: Normally not hard.
‘bruit’ which is an abnormal sound.
which is heard in the aortic, renal, iliac and femoral arteries when the vessels become congested.
(C) Percussion of abdomen:
Tone, tympany, dullness
Liver: Enlarged liver: cirrhosis and hepatitis.
Spill Size:
Stump for teampenny
Dullness: Liver
(D) Palpation of abdomen:
Tenderness: present with peritoneal irritation.
Muscle tone: Relax
Surface Characteristics: Smooth
Tenderness, mass, aortic, pulsation, local or general pain with deep palpation.
For a dual no bulge around the umbilical and an umbilical ring.
Liver and spleen: border and tenderness
Normally the spleen is not palpable.
Palpation of the kidney The costovertebral angle is palpated for tenderness.
Abdominal assessment for abdominal reflex including,
Fluid: shifting dullness, fluid wave
Pain: Tenderness
Floating mass: Two lottments.
Hip and Lower Limbs
(a) Inspection:
For patient foot and leg muscle strength.
Characteristics of skin Hair distribution Superficial mass.
Vascularity and fracture.
Note any deformities in toes, feet, nails, ankles and legs.
(b) Palpation of feet and lower leg
In which temperature, pulse, tenderness, deformity, ed.
Range of motion, turgor motor strength of both legs including toes, feet, ankle, knee, hip etc.
(Genitalia):
In which general inspection
Lesion/scar
Discharge/Infection Voiding: Urine no color by itself
Catheter or not.
Male:
Inspection for swelling of the penis and scrotum.
Palpate for any mass, hernia, enlargement of prostate gland etc.
Female
Including discharge, swallowing, redness, pelvic mass.
Rectum: Inspection
Patency, hemorrhoids, redness.
Checking Rectosil etc. in female.
Diagnostic test
1.x-ray : Study of symptoms present in : eg. T. Bone, Joint, Skull, Spine, Kidney, Uterus, Bladder.
2.CT scan
MRI
Positron emission magnetic tomography: to determine the amount of blood flow in specific body tissues.
Angiography: Using dye to assess blood flow.
Ultrasound
Endoscopy: A lighted flexible tube to directly visualize body system.
Nutritional history
Knowing about nutritional status.
Asking the patient about excess weight gain, loss, fatigue, etc.
Asking about changes in skin color, texture etc.
Ask about constipation, diarrhea.
Asking about heart burning, chest pain, stomach discomfort etc.
Asking the patient about his eating habits, his method, eating time etc. Asking about where to purchase, food storage, cooking etc.
Ask about smoking/alcohol habits if taking any illegal drugs.
Asking about culture and religion.
Asking about eating habits etc. whether job no time affects eating or not.
Daily record of food intake etc. by the patient.
General Clinical Investigation
Microbiology: To detect microorganisms such as bacteria, viruses, fungi, and protozoa in blood, urine, pus, body secretions, stool, urine culture, etc.
A study of blood
In which many types of investigations are done.
including hematological blood analysis
Hemoglobin: Male: 13 to 18 gm/dl, Female: 12 to 16 gm/dl
Leukocyte count: Total 4500-11000 cumm
Neutrophil: 45% to 73%
Eosinophil: 0%-4%
Basophil:0%-1%
Lymphocyte: 20%-40%
Monocyte: 2%-8%
Platelet count: 150,000-450,000/cumm
Hematocrit: male:42%-52% female:35%-47%
Coagulation study
1). Bleeding time: 1.5-9.5 min
2). Coagulation time: 4-8 min
3). Partial thromboplastin time: Lower limit: 20-25 sec Upper limit: 32-39 sec
4). Prothrombin time: 9.5-12 sec
5). Fibrinogen: 200-400 mq/dl
6). International Normalized Ratio: 1.0
Serum electrolytes
Sodium (NA+): 135 -145 meq/dl
Potassium (k+): 3.5-5 meq/dl
Chloride (cl-): 97-107 meq/dl
Calcium (ca): 8.6-10.2 mg/dl
Amylase:111-296 u/L
Bilirubin: Total: 0.3-1.0 mg/dl,
Direct bilirubin (conjugated): 0.0 to 0.3 mg/dl
Indirect Bilirubin: (Unconjugated): 0.2 to 0.8 mg/dl
SGOT (Serum glutamic oxaloacetic transaminase): male: 10-40U/L
Female: 15-30 U/L
SGPT (Serum Glutamic Pyruvate Trans Aminase): Male: 10-40U/L
Female: 8-35 U/L
Cholesterol: 150-200 mg/dl
Creatinine: 0.7-1.4 mg/dl
Glucose (fasting): 60 – 110 mg/dl
Total protein: 6-8 gm/dl
Albumin: 3.5- 5.5 g/dl
Globulin: 1.7- 3.3 g/dl
Uric acid: 2.5 -8 mg/dl
Blood urea nitrogen: 10-20 mg/dl
Urine Examination
1.Urine Color : Pale Yellow 2.Specific Gravity : 1.002-1.035 3.Osmolarity : 250-900msm/kg 4.Glucose : Negative
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