Assess for pain
- Do you experience neck pain?
- Do you experience headaches? Describe.
- Do you have any facial pain? Describe.
- Do you have any difficulty moving your head or neck?
- Have you noticed any lumps or lesions on your head or neck that do not heal or disappear? Describe their appearance and location.
- Have you experienced any dizziness, lightheadedness, spinning sensation, or loss of consciousness? Describe.
- Have you noticed a change in the texture of your skin, hair, or nails?
- Have you noticed changes in your energy level, sleep habits, or emotional stability?
- Have you experienced any palpitations, blurred vision, or changes in bowel habits?
Past health history
- This portion of the health history focuses on questions related to the client’s past, from the earliest beginnings to the present.
- Describe any previous head or neck problems you have had. How were they treated? What were the results?
- Have you ever undergone radiation therapy for a problem in your neck region?
Family history
- Is there a history of head and neck cancer in your family?
- Is there a history of migraine headaches in your family?
Lifestyle and health practices
- This is a very important section of the health history because it deals with the client’s human responses.
- Do you smoke or chew tobacco? If yes, how much?
- Do you wear a helmet when riding a horse, bicycle, motorcycle, or other open sports vehicle? Do you wear a hard hat for hazardous occupations?
- What is your typical posture when relaxing, during sleep, and when working?
- In what kinds of recreational activities do you participate? Describe the activity.
- Have any problems with your head or neck interfered with your relationships with others or the role you occupy at home or at work?
Head and Face
- Inspect the head. Inspect for size, shape, and configuration.
- Inspect for involuntary movement. Head should be held still and upright.
- Inspect the face. Inspect for symmetry, features, movement, expression, and skin condition.
- Palpate the head. Palpate for consistency; the head is normally hard and smooth without lesions.
- Palpate the temporal artery. This should be located between the top of the ear and the eye.
- Palpate the temporomandibular joint. To assess the temporomandibular joint, place your index finger over the front of each ear as you ask the client to open your mouth.
Neck
- Inspect the neck. Observe the client’s slightly extended neck for position, symmetry, and lumps or masses. Shine a light from the side of the neck across to highlight any swelling.
- Inspect the movement of the neck structures. Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage and thyroid gland.
- Inspect the cervical vertebrae. Ask the client to flex the neck (chin to chest, ear to shoulder, twist left to right and right to left, and backward and forward.
- Inspect range of motion. Ask the client to turn the head to the right and to the left (chin to shoulder), touch each ear to the shoulder, touch chin to chest, and lift the chin to the ceiling.
- Palpate the trachea. Place your finger in the sternal notch. Feel each side of the notch and palpate the tracheal rings. The first upper ring above the smooth tracheal rings is the cricoid cartilage.
- Palpate the thyroid gland. Locate key landmarks with your index finger and thumb; ask the client to swallow as you palpate
Auscultation
- Auscultate the thyroid gland only if you find an enlarged thyroid gland during inspection or palpation. Place the bell of the stethoscope over the lateral lobes of the thyroid gland; ask the client to hold his breath (to obscure any tracheal breath sounds while you auscultate).
Lymph nodes of the head and neck
- Palpate the preauricular nodes, postauricular nodes, occipital nodes. There should be no swelling or enlargement and no tenderness.
- Palpate the tonsillar nodes. Palpate the tonsillar nodes at the angle of the mandible on the anterior edge of the sternomastoid muscle.
- Palpate the submental nodes, which are a few centimeters behind the tip of the mandible.
- Palpate the superficial cervical nodes in the area superficial to the sternomastoid muscle.
- Palpate the posterior cervical nodes in the area posterior to the sternomastoid and anterior to the trapezius in the posterior triangle.
- Palpate the deep cervical chain nodes deeply within and around the sternomastoid muscle.
- Palpate the supraclavicular nodes by hooking your fingers over the clavicles and feeling deeply between the clavicles and sternomastoid muscles.
6. Assessment of the Eye and Vision
To perform a thorough assessment of the eye, one needs a good understanding of the external structures of the eye, the internal structures of the eye, the visual fields and pathways, and the visual reflexes.
History of present health concern
When interviewing a client about eye health and vision, remember to investigate and analyze any reported symptoms or signs further.
Visual Problems
- Describe any recent changes in your vision. Were they sudden or gradual?
- Do you see spots or floaters in front of your eyes?
- Do you experience blind spots? Are they constant or intermittent?
- Do you see halos or rings around lights?
- Do you have trouble seeing at night?
- Do you experience double vision?
- Do you have any eye pain or itching? Describe.
- Do you have any redness or swelling in your eyes?
- Do you experience excessive watering or tearing of the eye? One eye or both eyes?
- Have you had any eye discharge? Describe.
Past health history
- Have you ever had problems with your eyes or vision?
- Have you ever had eye surgery?
- Describe any past treatments you have received for eye problems. Were these successful? Were you satisfied?
Family history
The family history should include as many generic relatives as the client can recall; in addition to genetic predisposition, it is also helpful to see other health problems that may have affected the client by virtue of having grown up in the family and being exposed to these problems.
- Is there a history of eye problems or vision loss in your family?
Lifestyle and health practices
- Are you exposed to conditions or substances in the workplace or home that may harm your eyes or vision? Do you wear safety glasses during exposure to harmful substances?
- Do you wear sunglasses during exposure to the sun?
- What types of medication do you take?
- Has your vision loss affected your ability to care for yourself? To work?
- When was your last eye examination?
- Do you have a prescription for corrective lenses? Do you wear them regularly? If you wear contacts, how long do you wear them? How do you clean them?
Vision
Evaluation of Vision
- Test distant visual acuity. Position the client 20 feet from the Snellen or E chart and ask her to read each line until she cannot decipher the letters or their direction.
- Test near visual acuity. Use this test for middle-aged clients and others who complain of difficulty reading. Give the client a hand-held vision chart to hold 14 inches from the eyes. Have the client cover one eye with an opaque card before reading from top to bottom.
- Test visual fields for gross peripheral vision. To perform the confrontation test, position yourself approximately 2 feet away from the client at eye level. Have the client cover his left eye while you cover your right eye. Look directly at each other with your uncovered eyes. Next fully extend your left arm at midline and slowly move one finger upward from below until the client sees your finger.
External eye structures
Inspection and Palpation
- Inspect the eyelids and eyelashes. Note the width and position of palpebral fissures. Assess the ability of eyelids to close. Note the position of the eyelids in comparison with the eyeballs. Observe for redness, swelling, discharge, or lesions.
- Observe the position and alignment of the eyeball in the eye socket. Eyeballs are symmetrically aligned in sockets without protruding or sinking.
- Inspect the bulbar conjunctiva and sclera. Have the client keep her head straight while looking from side to side and then up toward the ceiling. Observe clarity, color, and texture.
- Inspect the palpebral conjunctiva. Put on gloves for this assessment procedure. First, inspect the palpebral conjunctiva of the lower eyelid by placing your thumbs bilaterally at the level of the lower bony orbital rim and gently pulling down to expose the palpebral conjunctiva.
- Inspect the lacrimal apparatus. Assess the areas over the lacrimal glands (lateral aspect of upper eyelid) and the puncta (medial aspect of lower eyelid).
- Inspect the cornea and lens. Shine a light from the side of the eye for an oblique view. Look through the pupil to inspect the lens.
- Test pupillary reaction to light. Test for direct response by darkening the room and asking the client to focus on a distant object.
- Test accommodation of pupils. Hold your finger or a pencil about 12 to 15 inches from the client. Ask the client to focus on your finger or pencil and to remain focused on it as you move it closer toward the eyes.
- Palpate the lacrimal apparatus. Put on disposable gloves to palpate the nasolacrimal duct to assess for blockage. Use one finger and palpate just inside the lower orbital rim.
Internal eye structures
Inspection
- Inspect the optic disc. Keep the light beam focused on the pupil and move closer to the client from a 15-degree angle. You should be very close to the client’s eye (about 3 to 5 cm), almost touching the eyelashes. Note the shape, color, size, and physiologic cup.
- Inspect the retinal vessels. Remain in the same position as described previously. Inspect the sets of retinal vessels by following them out to the periphery of each section of the eye. Note the number of sets of arterioles and venules.
- Inspect retinal background. Remain in the same position described previously and search the retinal background from the disc to the macula, noting the color and the presence of any lesions.
- Inspect the fovea (sharpest area of vision) and macula. Remain in the same position described previously. Shine the light beam toward the side of the eye or ask the client to look directly into the light. Observe the fovea and the macula that surrounds it.
- Inspect the anterior chamber. Remain in the same position and rotate the lens wheel slowly to +10, +12, or higher to inspect the anterior chamber of the eye.
7. Assessment of the Ear
Beginning when the nurse first meets the client, the assessment of hearing provides important information about the client’s ability to interact with the environment.
History of present health concern
- If the client complains of or reports a history of ear infections or suspects hearing loss, collect as much related data as possible.
Changes in Hearing
- Describe any recent changes in your hearing.
- Are all sounds affected by this change, or just some sounds?
Other Symptoms
- Do you have any ear drainage? Describe the amount and any odor.
- Do you have any ear pain? If so, do you have an accompanying sore throat, sinus infection, or problem with your teeth or gums?
- Do you experience any ringing or crackling in your ears?
- Do you ever feel like you are spinning or that the room is spinning? Do you ever feel dizzy or unbalanced?
Past health history
- Have you ever had any problems with your ears such as infections, trauma, or earaches?
- Describe any past treatments you have received for ear problems. Were these successful? Were you satisfied?
Family history
- Is there a history of hearing loss in your family?
Lifestyle and health practices
- Do you work or live in an area with frequent or continuous loud noise? How do you protect your ears from the noise?
- Do you spend a lot of time swimming or in the water? How do you protect your ears?
- Has your hearing loss affected your ability to care for yourself? To work?
- Has your hearing loss affected your socializing with others?
- When was your last hearing examination?
- How do you care for your ears?
External ear structures
Inspection and Palpation
- Inspect the auricle, tragus, and lobule. Note size, shape, and position. Observe for lesions. discolorations, and discharge.
- Palpate the auricle and mastoid process. Normally the auricle, tragus, and mastoid process are not tender.
Internal ear structures
- Inspect the external auditory canal. Use the otoscope. A small amount of odorless cerumen is the only discharge normally present.
- Inspect the tympanic membrane (eardrum). Note color, shape, consistency, and landmarks.
- Perform Weber’s test if the client reports diminished or lost hearing in one ear. Strike a tuning fork softly with the back of your hand and place it in the center of the client’s head or forehead. Ask whether the client hears the sound better in one ear or the same in both ears.
- Perform the Rinne test. The Rinne test compares air and bone conduction. Strike a tuning fork and place the base of the fork on the client’s mastoid process. Ask the client to tell you when the sound is no longer heard. Move the prongs of the tuning fork to the front of the external auditory canal. Ask the client to tell you if the sound is audible after the fork is moved.
- Perform the Romberg test. Ask the client to stand with feet together and arms at the sides and eyes open and then with eyes closed.
8. Assessment of the Mouth, Throat, Nose, Sinus
Subjective data related to the mouth, throat, nose, and sinus can aid in detecting diseases and abnormalities that may affect the client’s activities of daily living.
History of present health concern
Tongue and Mouth
- Do you experience tongue or mouth sores or lesions? Are they painful? How long have you had them? Do they recur? Is it single, or do you have many?
- Do you experience redness, swelling, bleeding, or pain in the gums or mouth? How long has this been happening? Do you have any toothache? Have you lost any permanent teeth?
Nose and Sinuses
- Do you have pain in your sinuses?
- Do you experience any nosebleeds? How much bleeding? What color is the blood?
- Do you experience frequent clear or mucous drainage from your nose?
- Can you breathe through both of your nostrils? Do you have a stuffy nose at times during the day or night?
- Do you have seasonal allergies? Describe the timing of the allergies and symptoms.
- Have you experienced a change in your ability to smell or taste?
Throat
- Do you have difficulty chewing or swallowing food? How long have you had this? Do you have any pain?
- Do you have a sore throat? How long have you had it? Describe. How often do you get sore throats?
- Do you experience hoarseness? How long?
Past health history
- Have you ever had any oral, nasal, or sinus surgery? Do you have a history of sinus infections? Describe your symptoms. Do you use nasal sprays?
Family history
- Is there a history of mouth, throat, nose, or sinus cancer in your family?
Lifestyle and health practices
This is a very important section of the health history because it deals with the client’s human responses.
- Do you smoke or use smokeless tobacco? If so, how much? Are you interested in quitting this habit?
- Do you drink alcohol? How much and how often?
- Do you grind your teeth?
- Describe how you care for your teeth or dentures. How often do you brush and use dental floss? When was your last dental examination?
- If the client wears braces: How do you care for your braces? Do you avoid any specific types of foods? Describe your usual dietary intake for a day.
- If the client wears dentures: How do your dentures fit?
- Do you brush your tongue?
- How often are you in the sun? Do you use lip sunscreen products?
Mouth
Inspection and Palpation
- Inspect the lips. Observe lip consistency and color.
- Inspect the teeth and gums. Ask the client to open their mouth. Note the number, color, condition, and alignment of the teeth.
- Inspect the buccal mucosa. Use a penlight and tongue depressor to retract the lips and cheeks to check color and consistency. Also, note Stenson’s ducts (parotid ducts) located on the buccal mucosa across from the second upper molars.
- Inspect and palpate the tongue. Ask the client to stick out the tongue. Inspect for color, moisture, size, and texture. Observe for fasciculations (fine tremors), and check for midline protrusions. Palpate any lesions present for induration.
- Assess the ventral surface of the tongue. Ask the client to touch the tongue to the roof of the mouth, and use a penlight to inspect the ventral surface of the tongue.
- Inspect for Wharton’s ducts. These are openings from the submandibular salivary glands located on either side of the frenulum on the floor of the mouth.
- Observe the sides of the tongue. Use a square gauze pad to hold the client’s tongue to each side. Palpate for any lesions, ulcers, or nodules for induration.
- Check the strength of the tongue. Place your fingers on the external surface of the client’s cheek. Ask the client to press the tongue’s tip against the inside of the cheek to resist pressure from your fingers.
- Check the anterior tongue’s ability to taste by placing drops of sugar and salty water on the tip and sides of the tongue with a tongue depressor.
- Inspect the hard (anterior) and soft (posterior) palates and uvula. Ask the client to open the mouth wide while you use a penlight to look at the roof. Observe color and integrity.
- Note odor. While the mouth is wide open, note any unusual or foul odor.
- Assess the uvula. Apply a tongue depressor to the tongue and shine a penlight into the client’s wide-open mouth. Note the characteristics and positioning of the uvula. Ask the client to say “Aaah” and watch for the uvula and soft palate to move.
- Inspect the tonsils. Using the tongue depressor to keep the mouth open wide, Inspect the tonsils for color, size, and presence of exudate or lesions. Tonsils should be graded.
- Inspect the posterior pharyngeal wall. Keeping the tongue depressor in place, shine the penlight on the back of the throat. Observe the color of the throat, and note any exudate or lesions.
Nose
Inspection and Palpation
- Inspect and palpate the external nose. Note nasal color, shape, consistency, and tenderness.
- Check thepatency of airflow through the nostrils by occluding one nostril at a time and asking the client to sniff.
- Inspect the internal nose. To inspect the internal nose, use an otoscope with a short wide-tip attachment. Use your non-dominant hand to stabilize and gently tilt the client’s head back. Insert the short wide tip of the otoscope into the client’s nostril without touching the sensitive nasal septum.
Sinuses
- Palpate the sinuses. Palpate the frontal sinuses by using your thumbs to press up on the brow on each side of the nose. Palpate the maxillary sinuses by pressing with thumbs up on the maxillary sinuses.
- Percuss the sinuses. Lightly tap over the frontal sinuses and over the maxillary sinuses for tenderness.
Transillumination
- Transilluminate the sinuses. Transilluminate the frontal sinuses by holding a strong, narrow light source snugly under the eyebrows. Use your other hand to shield the light. Transilluminate the maxillary sinuses by holding a strong, narrow light source over the maxillary sinus and asking the client to open his or her mouth.
9. Assessment of the Thoracic and Lung
Subjective data related to the thoracic and lung assessment provide many clues about underlying respiratory problems and associated nursing diagnoses, as well as clues about the risk for the development of lung disorders.
History of present health concern
Difficulty of breathing
- Do you ever experience difficulty breathing? Describe the difficulty.
- Do you experience any other symptoms when you have difficulty breathing?
- Do you have difficulty breathing when resting, or do any specific activities cause the difficulty?
- Do you have difficulty breathing when you sleep? Do you use more than one pillow or elevate the head of the bed when you sleep?
- Do you snore when you sleep? Have you been told that you stop breathing at night when you snore?
- Do you have chest pain? Is the pain associated with a cold, fever, or deep breathing?
Coughing
- Do you have a cough? When and how often does it occur?
- Do you produce any sputum when you cough? If so, what color is the sputum? How much sputum do you cough up? Has this amount increased or decreased recently? Does the sputum have an odor?
- Do you wheeze when you cough or when you are active?
GI symptoms
- Do you have gastrointestinal symptoms such as heartburn, frequent hiccups, or chronic cough?
Past health history
- Have you had prior respiratory problems?
- Have you ever had any thoracic surgery, biopsy, or trauma?
- Have you been tested for or diagnosed with allergies?
- Have you ever had a chest x-ray, tuberculosis (TB) skin test, or influenza immunization? Have you had any other pulmonary studies in the past?
- Have you recently traveled outside of the country? Have you been in close contact with anyone known or suspected to have SARS?
Family history
- Is there a history of lung disease in your family?
- Did any family members in your home smoke when you were growing up?
- Is there a history of other pulmonary illnesses/disorders in the family?
Lifestyle and health practices
- Have you ever smoked cigarettes or other tobacco products? Do you currently smoke? At what age did you start? How much do you smoke, and how much have you smoked in the past? What activities do you usually associate with smoking? Have you ever tried to quit?
- Are you exposed to any environmental conditions that affect your breathing? Where do you work? Are you around smokers?
- Do you have difficulty performing your usual daily activities? Describe any difficulties.
- What kind of stress are you experiencing at this time? How does it affect your breathing?
- Are you currently taking medications for breathing problems or other medications that affect your breathing? Do you use any other treatments at home for your respiratory problems?
- Have you used any herbal medicines or alternative therapies to manage colds or other respiratory problems?
Posterior thorax
- Inspect for nasal flaring and pursed lip breathing. Nasal flaring is not observed in normal findings.
- Observe the color of the face, lips, and chest. The client has an evenly colored skin tone without unusual or prominent discoloration.
- Inspect the color and shape of the nails.Pink tones should be seen in the nailbeds. There is normally a 160-degree angle between the nail base and the skin.
- Inspect configuration. While the client sits with her arms at her sides, stand behind her and observe the position of the scapulae and the shape and configuration of the chest wall.
- Observe the use of accessory muscles. Watch as the client breathes and does not use it.
- Inspect the client’s positioning. Note the client’s posture and ability to support weight while breathing comfortably.
- Palpate for tenderness and sensation. Palpation may be performed with one or both hands; however, the sequence of palpation is established. Start toward the midline at the level of the left scapula and move your hand from left to right, comparing findings bilaterally. Move systematically downward and out to cover the lateral portions of the lungs at the bases.
- Palpate for crepitus. Crepitus, also called subcutaneous emphysema, is a crackling sensation that occurs when air passes through fluid or exudate. Use your fingers and follow the above sequence when palpating.
- Palpate surface characteristics. Use gloves and your fingers to palpate any lesions you noticed during the inspection.
- Palpate for fremitus. Following the above sequence, use the ball or ulnar edge of one hand to assess for fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall.
- Assess chest expansion. Place your hands on the posterior chest wall with your thumbs at the level of T9 or T10 and press together a small skin fold.
- Percuss for tone. Start at the apices of the scapulae and percuss across the tops of both shoulders. Then percuss the intercostal spaces across and down, comparing sides. Percuss the lateral aspects at the bases of the lungs, comparing sides.
- Percuss for diaphragmatic excursion. Ask the client to exhale forcefully and hold their breath. Beginning at the scapular line, percuss the intercostal spaces of the right posterior chest wall. Percuss downward until the tone changes from resonance to dullness. Next, ask the client to inhale deeply and hold it. Percuss the intercostal spaces from the mark downward until resonance changes to dullness.
Auscultation
- Auscultate for breath sounds. To begin, place the diaphragm of the stethoscope firmly and directly on the posterior chest wall at the apex of the lung at C7. Ask the client to breathe deeply through his or her mouth for each area of auscultation in the auscultation sequence so you can best hear inspiratory and expiratory sounds.
- Auscultate for adventitious sounds. Adventitious sounds are sounds added or superimposed over normal breath sounds and heard during auscultation.
- Auscultate voice sounds. Bronchophony: Ask the client to repeat the phrase “ninety-nine” while you auscultate the chest wall.
Other Assessment Techniques
- Egophony: Ask the client to repeat the letter E while you listen over the chest wall.
- Whispered Pectoriloquy: Ask the client to whisper the phrase “one-two-three” while you auscultate the chest wall.
Anterior thorax
- Inspect for shape and configuration. Have the client sit with her arms at her sides. Stand in front of the client and assess shape and configuration.
- Inspect the position of the sternum. Observe the sternum from an anterior and lateral viewpoint. Watch for sternal retraction.
- Inspect the slope of the ribs. Assess the ribs from an anterior and lateral viewpoint.
- Observe the quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth.
- Inspect intercostal spaces. Ask the client to breathe normally and observe the intercostal spaces.
- Observe for use of accessory muscles. Ask the client to breathe normally and observe for use of accessory muscles.
- Palpate for tenderness, sensation, and surface masses. Use your fingers to palpate for tenderness and sensation. Start with your hand positioned over the left clavicle and move your hand left to right, comparing findings bilaterally. Move your hand systematically downward toward the midline at the level of the breasts and outward at the base to include the lateral aspect of the lung.
- Palpate for fremitus. Using the sequence for the anterior chest above, palpate for fremitus using the same technique as for the posterior thorax.
- Palpate anterior chest expansion. Place your hands on the client’s anterolateral wall with your thumbs along the costal margins and pointing toward the xiphoid process.
- Percuss for tone. Percuss the apices above the clavicles. Then percuss the intercostal spaces across and down, comparing sides.
Auscultation
- Auscultate for anterior breath sounds, adventitious breath sounds, and voice sounds. Place the diaphragm of the stethoscope firmly and directly on the anterior chest wall. Auscultate from the apices of the lungs slightly above the clavicles to the bases of the lungs at the sixth rib. Listen at each site for at least one respiratory cycle. Follow the sequence for anterior auscultation.
10. Assessment of the Breast and Lymphatic System
This chapter covers the examination of non-pregnant women’s breasts. Remember, if the client reports any symptoms, you need to explore further by performing a symptom analysis using the following guide.
History of present health concern
- Have you noticed any lumps or swelling in your breasts? If so, where? when did you first notice? has the lump grown or has the swelling increased? Is the lump or swelling associated with other problems? Does the lump or swelling change during your menstrual cycle?
- Have you noticed any lumps or swelling in the underarm area?
- Have you noticed any redness, warmth, or dimpling of your breasts? Any rash on the breast, nipple, or axillary area?
- Have you noticed any change in the size or firmness of your breasts?
- Do you experience any pain in your breasts? If so, where? Does it occur at any specific time during your menstrual cycle?
- is there a certain activity that seems to initiate the pain?
- Do you have any discharge from the nipples? If so, describe its color, consistency, and odor, if any. When did it start? Which nipple has the discharge?
Past health history
- Have you had any prior breast disease? Have you ever had breast surgery, a breast biopsy, breast implants, or breast trauma? If so, when did this occur? What was the result?
- How old were you when you began to menstruate? Have you experienced menopause?
- Have you given birth to any children? At what age did you have your first child?
- When was the first and last day of your menstrual cycle?
Family history
- Is there a history of breast cancer in your family? Who?
Lifestyle and health practices
- Are you taking any hormones, contraceptives, or antipsychotic agents?
- Do you live or work in an area where you have excessive exposure to radiation, benzene, or asbestos?
- What is your typical daily diet?
- How much alcohol do you drink each day?
- How much coffee, tea, and cola do you consume each day?
- Do you engage in any regular exercise? If so, what type of bra do you wear when you exercise?
- How important are your breasts to you in relation to a positive feeling about yourself and your physical appearance? Do you have any fears regarding breast disease?
- Do you examine your own breasts? Describe when you do this. Have you noted any changes in your breasts such as a lump, swelling, skin irritation, or dimpling, nipple pain or retraction, redness or scaliness or nipple of breast skin, or discharge? If yes, have you reported this to your healthcare provider?
- Have you ever had your breasts examined by a physician? When was your last examination?
- Have you ever had a mammogram? If so, when was your last one?
Female breasts
- Inspect size and symmetry. Have the client disrobe and sit with arms hanging freely. Explain what you are observing to help ease client anxiety.
- Inspect color and texture. Be sure to note the client’s overall skin tone when inspecting the breast skin. Note any lesions.
- Inspect superficial venous pattern. Observe the visibility and pattern of breast veins.
- Inspect the areolas. Note the color, size, shape, and texture of the areolas of both breasts.
- Inspect the nipples. Note the size and direction of the nipples of both breasts. Also note any dryness, lesions, bleeding, or discharge.
- Inspect for retraction and dimpling. To inspect the breasts accurately for retraction and dimpling, ask the client to remain seated while performing several different maneuvers. Ask the client to raise her arms overhead, then press her hands against her hips. Next, ask her to press her hands together.
- Palpate texture and elasticity. Smooth, firm, elastic tissue is a normal finding.
- Palpate tenderness and temperature. A generalized increase in nodularity and tenderness may be a normal finding associated with the menstrual cycle or hormonal medications.
- Palpate for masses. Note location, size in centimeters, shape, mobility, consistency, and tenderness. Also, note the condition of the skin over the mass.
- Palpate the nipples. Wear gloves to compress the nipple gently with your thumb and index finger. Note any discharge.
- Palpate mastectomy or lumpectomy site. If the client has had a mastectomy or lumpectomy, it is still important to perform a thorough examination. Palpate the scar and any remaining breast and axillary tissue for redness, lesions, lumps, swelling, or tenderness.
Axillae
Inspection and Palpation
- Inspect and palpate the axillae. Ask the client to sit up. Inspect the axillary skin for rashes or infections. Hold the client’s elbow with one hand, and use the three fingerpads of your other hand to palpate firmly the axillary lymph nodes. First, palpate high into the axillae, moving downward against the ribs to feel for the central nodes. Continue to move down the posterior axillae to feel for the posterior nodes.
Male breasts
Inspection and Palpation
- Inspect and palpate the breasts, areolas, nipples, and axillae. Note any swelling, nodules, or ulceration. Palpate the flat disc of underdeveloped breast tissue under the nipple.
11. Assessment of the Heart and Neck Vessels
Subjective data collected about the heart and neck vessels helps the nurse to identify abnormal conditions that may affect the client’s ability to perform activities of daily living and to fulfill his role and responsibilities.
History of present health concern
Chest pain and Palpitations
- Do you experience chest pain? When did it start? Describe the type of pain, location, radiation, duration, and how often you experience the pain. Rate the pain on a scale of 0 to 10, with 10 being the worst possible. Does the activity make the pain worse? Did you have perspiration with the chest pain?
- Do you experience palpitations?
Other Symptoms
- Do you tire easily? Do you experience fatigue? Describe when the fatigue started. Was it sudden or gradual? Do you notice it at any particular time of the day?
- Do you have difficulty breathing or shortness of breath?
- Do you wake up at night with an urgent need to urinate? How many times at night?
- Do you experience dizziness?
- Do you experience swelling (edema) in your feet, ankles, or legs?
- Do you have frequent heartburn? When does it occur? What relieves it? How often do you experience it?
Past health history
- Have you been diagnosed with a heart defect or a murmur?
- Have you ever had rheumatic fever?
- Have you ever had heart surgery or cardiac balloon interventions?
- Have you ever had an electrocardiogram? When was the last one performed? Do you know the results?
- Have you ever had a blood test called a lipid profile? Based on your last test, do you know what your cholesterol levels were?
- Do you take medications or use other treatments for heart disease? How often do you take them? Why do you take them?
- Do you monitor your own heart rate or blood pressure?
Family history
- The family history should include as many generic relatives as the client can recall; in addition to genetic predisposition, it is also helpful to see other health problems that may have affected the client by virtue of having grown up in the family and being exposed to these problems.
- Is there a history of hypertension, myocardial infarction, coronary heart disease, elevated cholesterol levels, or diabetes mellitus in your family?
Lifestyle and health practices
- Do you smoke? How many packs of cigarettes per day and for how many years?
- What type of stress do you have in your life? How do you cope with it?
- Describe what you usually eat in a 24-hour period.
- How much alcohol do you consume each day/week?
- Do you exercise? What type of exercise and how often?
- Describe your daily activities. How are they different from your routine 5 or 20 years ago? Does fatigue, chest pain, or shortness of breath limit your ability to perform daily activities? Describe. Are you able to care for yourself?
- Has your heart disease had any effect on your sexual activity?
- How many pillows do you use to sleep at night? Do you get up to urinate during the night? Do you feel rested in the morning?
- How important is having a healthy heart to your ability to feel good about yourself and your appearance? What fears about heart disease do you have?
Neck Vessels
- Observe the jugular venous pulse. Inspect the jugular venous pulse by standing on the right side of the client. The client should be in a supine position with the torso elevated 30 to 45 degrees. Ask the client to turn the head slightly to the left. Shine a tangential light source onto the neck to increase visualizations of pulsations as well as shadows.
- Evaluate jugular venous pressure. Evaluate jugular venous pressure by watching for the distention of the jugular vein.
Auscultation and Palpation
- Auscultate the carotid arteries. Auscultate the carotid arteries if the client is middle-aged or older or if you suspect cardiovascular disease. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so breath sounds do not conceal any vascular sounds.
- Palpate the carotid arteries. Palpate each carotid artery alternately by placing the pads of the index and middle fingers medial to the sternocleidomastoid muscle on the neck.
Heart
- Inspect pulsations. with the client in a supine position with the head of the bed elevated between 30 and 45 degrees, stand on the client’s right side and look for the apical impulse and abnormal pulsations.
- Palpate the apical pulse. Remain on the client’s right side and ask the client to remain supine. Use the palmar surfaces of your hand to palpate the apical impulse in the mitral area.
- Palpate for abnormal pulsations. Use your palmar surfaces to palpate the apex, left sternal border, and base.
Auscultation
- Auscultate heart rate and rhythm. Place the diaphragm of the stethoscope at the apex and listen closely to the rate and rhythm of the apical impulse.
- If you detect an irregular rhythm, auscultate for a pulse rate deficit. This is done by palpating the radial pulse while you auscultate the apical pulse. Count for a full minute.
- Auscultate to identify S1 and S2. Auscultate the first heart sound (S1 or “lub”) and the second heart sound (S2 or “dub”). Use the diaphragm of the stethoscope to best hear S1. Use the diaphragm of the stethoscope to hear S2 and ask the client to breathe regularly.
- Auscultate for extra heart sounds. Use the diaphragm first, then the bell, to auscultate over the entire heart area. Note the characteristics of any extra sound heard. auscultate during the systolic pause.
- Auscultate for murmurs. Use the diaphragm and the bell of the stethoscope in all areas of auscultation because murmurs have a variety of pitches. Also, auscultate with the client in different positions because some murmurs occur or subside according to the client’s position.
- Auscultate with the client assuming other positions. Ask the client to assume a left lateral position. Use the bell of the stethoscope and listen at the apex of the heart. Ask the client to sit up, lean forward, and exhale. Use the diaphragm of the stethoscope and listen over the apex and along the left sternal border.
12. Assessment of the Peripheral Vascular System
It is important for the nurse to ask questions about the symptoms that the client may consider inconsequential. It is also important for the nurse to ask about personal and family history of vascular disease. It is especially important to evaluate aspects of the client’s lifestyle and health factors that may impair peripheral vascular health.
History of present health concern
- Have you noticed any color, temperature, or texture changes in your skin?
- Do you experience pain or cramping in your legs? Describe the pain (aching, stabbing). how often does it occur? Does it occur with activity? Does it wake you from sleep?
- Do you have any leg veins that are ropelike, bulging, or contorted? Do you have any sores or open wounds on your legs? Where are they located? Are they painful?
- Do you have any swelling (edema) in your legs or feet? At what time of day is swelling worst? Any pain with swelling?
- Do you have any swollen glands or lymph nodes? If so, do they feel tender, soft, or hard?
- For male clients: Have you experienced a change in your usual sexual activity? Describe.
Past health history
- Describe any problems you had in the past with the circulation in your arms and legs.
- Have you had any heart or blood vessel surgeries or treatments such as coronary artery bypass grafting, repair of an aneurysm, or vein stripping?
Family history
- Do you have a family history of diabetes, hypertension, coronary heart disease, or elevated cholesterol or triglyceride levels?
Lifestyle and health practices
- Do you (or did you in the past) smoke cigarettes or use any form of tobacco? How much and for how long?
- Do you exercise regularly?
- For female clients: Do you take oral or transdermal contraceptives?
- Describe the degree of stress you normally have.
- How have problems with your circulation affected your ability to function?
- Do leg ulcers or varicose veins affect how you feel about yourself?
- Do you regularly take medications prescribed by your physician to improve your circulation?
- Do you wear support hose to treat varicose veins?
Arms
- Observe arm size and venous pattern; also look for edema. Arms are bilaterally symmetric with minimal variation in size and shape. No edema or prominent venous patterning.
- Observe the coloration of the hands and arms. Color varies depending on the client’s skin tone, although color should be the same bilaterally.
- Palpate the client’s fingers, hands, and arms, and note the temperature. Skin is warm to the touch bilaterally from fingertips to upper arms.
- Palpate to assess capillary refill time. Compress the nailbed until it blanches. release the pressure and calculate the time it takes for the color to return.
- Palpate the radial pulse. Gently press the radial artery against the radius. Note elasticity and strength.
- Palpate the ulnar pulses. Apply pressure with your first three fingertips to the medial aspects of the inner wrists.
- Palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client’s right and left medial antecubital creases.
- Palpate the epitrochlear lymph nodes. Take the client’s left hand in your right hand as if you were shaking hands. Flex the client’s elbow about 90 degrees. Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles.
- Perform the Allen test. The Allen test evaluates the patency of the radial or ulnar arteries. The test begins by assessing ulnar patency. Have the client rest the hand palm side-up on the examination table and make a fist. Then use your thumbs to occlude the radial and ulnar arteries. Note that the palm remains pale. Release the pressure on the ulnar artery and watch for color to return to the hand.
Legs
Inspection, Palpation, and Auscultation
- Observe skin color while inspecting both legs from the toes to the groin. Ask the client to lie supine. Then drape the groin area and place a pillow under the client’s head for comfort.
- Inspect the distribution of hair. Hair covers the skin on the legs and appears on the dorsal surface of the toes.
- Inspect for lesions or ulcers. Legs are free of lesions or ulcerations.
- Inspect for edema. Inspect the legs for unilateral and bilateral edema. Note veins, tendons, and bony prominences.
- Palpate edema. If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting. Press the edematous area with the tips of your fingers, hold for a few seconds, then release.
- Palpate bilaterally for the temperature of the feet and legs. Use the backs of your fingers. Compare your findings in the same areas bilaterally.
- Palpate the superficial inguinal lymph nodes. First, expose the client’s inguinal area, keeping the genitals draped. Feel over the upper medial thigh for the vertical and horizontal groups of superficial inguinal lymph nodes.
- Palpate the femoral pulses. Ask the client to bend the knee and move it out to the side. Press deeply and slowly below and medial to the inguinal ligament. Release pressure until you feel the pulse.
- Auscultate the femoral pulses. If arterial occlusion is suspected in the femoral pulse, position the stethoscope over the femoral artery and listen for bruits.
- Palpate the popliteal pulses. Ask the client to raise the knee partially. Place your thumbs on the knee while positioning your fingers deep in the bend of the knee. Apply pressure to locate the pulse.
- Palpate the dorsalis pedis pulses. Dorsiflex the client’s foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe.
- Palpate the posterior tibial pulses. Palpate behind and just below the medial malleolus. Palpating both posterior tibial pulses at the same time aids in making comparisons.
- Inspect for varicosities and thrombophlebitis. Ask the client to stand because varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. As the client is standing, inspect for superficial vein thrombophlebitis.
- Check for Homan’s sign. First, flex the client’s knee about 5 degrees, place your hand under the client’s calf muscle, and quickly squeeze the muscle against the tibia. Ask the client to report any pain or tenderness.
13. Assessment of the Abdomen
The nurse may collect subjective data concerning the abdomen as part of a client’s overall health history interview or as a focused history for a current abdominal complaint. The data focus on symptoms of particular abdominal organs and the function of the digestive system along with aspects of nutrition, usual bowel habits, and lifestyle.
History of present health concern
Abdominal Pain
- Are you experiencing abdominal pain?
- How would you describe the pain? How bad is the pain (severity) on a scale of 1 to 10, with 10 being the worst?
- How did (does) the pain begin?
- Where is the pain located? Does it move or has it changed from the original location?
- When does the pain (timing and relation to particular events)?
- What seems to bring on the pain (precipitating factors) make it worse (exacerbating factors), or make it better (alleviating factors)?
- Is the pain associated with any other symptoms such as nausea, vomiting, diarrhea, constipation, gas, fever, weight loss, fatigue, or yellowing of the eyes or skin?
Indigestion
- Do you experience indigestion? Describe.
- Does anything, in particular, seem to cause or aggravate this condition?
Nausea and Vomiting
- Do you experience nausea? Describe. Is it triggered by any particular activities, events, or other factors?
- Have you been vomiting? Describe the vomitus. Is it associated with any particular trigger factors?
Appetite
- Have you noticed a change in your appetite? Has this change affected how much you eat or your normal weight?
Bowel Elimination
- Have you experienced a change in bowel elimination patterns? Describe.
- Do you have constipation? Describe. Do you have any accompanying symptoms?
- Have you experienced diarrhea? Describe. Do you have any accompanying symptoms?
- Have you experienced any yellowing of your skin or whites of your eyes, itchy skin, dark urine, or clay-colored stools?
Past health history
- Have you ever had any of the following gastrointestinal disorders: ulcers, gastroesophageal reflux, inflammatory or obstructive bowel disease, pancreatitis, gallbladder or liver disease, diverticulosis, or appendicitis?
- Have you had any urinary tract diseases such as infections, kidney disease or nephritis, or kidney stones?
- Have you ever had viral hepatitis? Have you ever been exposed to viral hepatitis?
Family history
- Is there a history of any of the following diseases or disorders in your family: colon, stomach, pancreatic, liver, kidney, or bladder cancer, liver disease, gallbladder disease, or kidney disease?
Lifestyle and health practices
- Do you drink alcohol? How much? How often?
- What types of foods and how much food do you typically consume each day? How much caffeine do you think you consume each day?
- How much and how often do you exercise? Describe your activities during the day.
- What kind of stress do you have in your life? How does it affect your eating or elimination habits?
- If you have a gastrointestinal disorder, how does it affect your lifestyle, and how do you feel about yourself?
Abdomen
Always follow this sequence when assessing the abdomen: inspection, auscultation, percussion, and palpation. Changing the order can alter the frequency of bowel sounds and make your findings less accurate.
- Observe the coloration of the skin. Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the elements.
- Note the vascularity of the abdominal skin. Scattered fine veins may be visible.
- Note any striae. Old, silvery, white striae or stretch marks from past pregnancies or weight gain are normal.
- Inspect for scars. Ask about the source of a scar, and use a centimeter ruler to measure the scar’s length. Document the location by quadrant and reference lines, shape, length, and specific characteristics.
- Assess for lesions and rashes. The abdomen is free of lesions or rashes. Flat or raised brown moles, however, are normal and may be apparent.
- Inspect the umbilicus. Note the color of the umbilical area. Observe the umbilical location. Assess the contour of the umbilicus.
- Inspect abdominal contour. Look across the abdomen at eye level from the client’s side from behind the client’s head, and from the foot of the bed. Measure abdominal girth as indicated.
- Assess abdominal symmetry. Look at the client’s abdomen as she lies in a relaxed supine position.
- Inspect abdominal movement when the client breathes. Abdominal respiratory movement may be seen, especially in male clients.
- Observe aortic pulsations. A slight pulsation of the abdominal aorta, which is visible in the epigastrium, extends full length in thin people.
- Observe for peristaltic waves. Normally peristaltic waves are not seen, although they may be visible in very thin people as slight ripples on the abdominal wall.
Auscultation
- Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the client’s abdomen.
- Auscultate for vascular sounds. Use the bell of the stethoscope to listen for bruits over the abdominal aorta and renal, iliac, and femoral arteries.
- Auscultate for a friction rub over the liver and spleen. Listen over the right and left lower rib cage with the diaphragm of the stethoscope.
- Percuss for tone. Lightly and systematically percuss all quadrants.
- Percuss the span or height of the liver by determining its lower and upper borders. To assess the lower border, begin in the RLQ at the mid-clavicular line and press upward. Note the change from tympany to dullness. To assess the upper border, percuss over the upper right chest at the MCL and percuss downward, noting the change from lung resonance to liver dullness.
- Percuss the spleen. Begin posterior to the left mid-axillary line (MAL), and percuss downward, noting the change from lung resonance to splenic dullness.
- Perform blunt percussion on the liver. Percuss the liver by placing your left hand flat against the lower right ribcage. Use the ulnar side of your right fist to strike your left hand.
- Perform light palpation. Using the fingertips, begin palpation in a non-tender quadrant, and compress to a depth of 1cm in a dipping motion. Then gently lift your fingers and move to the next area.
- Deeply palpate all quadrants to delineate abdominal organs and detect subtle masses. Using the palmar surface of the fingers, compress to a maximum depth (5 to 6 cm). Perform bimanual palpation if you encounter resistance or assess deeper structures.
- Palpate for masses. Note their location, size, shape, consistency, demarcation, pulsatility, tenderness, and mobility. Do not confuse a mass with a normally palpated organ or structure.
- Palpate the umbilicus and surrounding area for swellings, bulges, or masses. Umbilicus and the surrounding area are free of swellings, bulges, or masses.
- Palpate the aorta. Use your thumb and first finger or two hands and palpate deeply in the epigastrium, slightly to the left of the midline. Assess the pulsation of the abdominal aorta.
- Palpate the liver. Note consistency and tenderness. To palpate bimanually, stand at the client’s right side and place your left hand under the client’s back at the level of the eleventh to twelfth ribs. Lay your right hand parallel to the right costal margin. Ask the client to inhale, then compress upward and inward with your fingers.
- Palpate the spleen. Stand at the client’s right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client’s head. Ask the client to inhale and press inward and upward as you provide support with your other hand.
- Palpate the kidneys. To palpate the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL.
- Palpate the urinary bladder. Palpate for a distended bladder when the client’s history or other findings warrant. Begin at the symphysis pubis and move upward and outward to estimate bladder borders.
14. Assessment of the Female Genitalia
When interview topics turn to the reproductive system and female genitalia, keep in mind the sensitivities of the client as well as your own feelings regarding body image, fear of cancer, sexuality, and the like.
History of present health concern
Before proceeding with the interview, keep both the topic of the health history and the client’s culture clearly in mind. In some cases, your gender may interfere with accurate results.
Menstrual Cycle
- What was the date of your last menstrual period? Do your menstrual cycles occur on a regular schedule? How long do they last? Describe the typical amount of blood flow you have with your periods. Any clotting?
- What other symptoms do your experience before or during your period?
- How old were you when you started your period?
- Have you stopped menstruating, or have your periods become irregular? Do you have any spotting between periods? What symptoms have you experienced?
Menopause
- Are you still having periods? Have your periods changed?
- Are you experiencing any symptoms of menopause?
- Are you on a hormone replacement therapy regimen? If so, what type and dosage? Are you satisfied with HRT?
- What are your concerns about going through menopause?
Vaginal discharge, pain, masses
- Are you experiencing vaginal discharge that is unusual in terms of color, amount, or odor?
- Do you experience pain or itching in your genital or groin area?
- Do you have any lumps, swelling, or masses in your genital area?
Urination
- Do you have any difficulty urinating? Do you have any burning or pain with urination? Has your urine changed color or developed an odor? Have you noticed any blood in your urine?
- Do you have difficulty controlling your urine?
Sexual Dysfunction
- Do you have any problems with your sexual performance?
- Have you recently had a change in your sexual activity pattern or libido?
- Do you experience problems with fertility?
Past health history
- Describe any prior gynecologic problems you have had and the results of any treatment.
- When was your last pelvic examination by a healthcare provider? Was a Pap test performed? What was the result?
- Have you ever been diagnosed with a sexually transmitted disease? If so, what? How was it treated?
- Have you ever been pregnant? How many times? How many children do you have? Is there any chance that you might be pregnant now? Any miscarriages or abortions?
- Have you ever been diagnosed with diabetes?
Family history
- Is there a history of reproductive or genital cancer in your family? What type? How is the family member related to you?
Lifestyle and health practices
- Do you smoke?
- How many sexual partners do you have?
- Do you use contraceptives? What kind? How often?
- Do you have any genital problems that affected your life?
- What is your sexual preference?
- Do you feel comfortable communicating with your partner about your sexual likes and dislikes?
- Do you have any fears related to sex? Can you identify any stress in your current relationship that relates to sex?
- Do you have concerns about fertility? If you have trouble with fertility, how has this affected your relationship with your partner or family?
- Do you perform monthly genital self-examinations?
- How do you feel about going through menopause?
- Do you take estrogen replacement therapy?
- Have you ever been tested for HIV? What was the result? Why were you tested?
- What do you know about toxic shock syndrome?
- What do you know about STDs and their prevention?
- Do you wear cotton underwear and avoid tight jeans?
- After a bowel movement or urination, do you wipe from front to back?
- Do you douche frequently?
External female genitalia
- Inspect the Mons Pubis. Wash your hands and put on gloves. As you begin the examination, note the distribution of pubic hair. Also, be alert for signs of infestation.
- Observe and palpate inguinal lymph nodes. There should be no enlargement or swelling of the lymph nodes.
- Inspect the labia majora. Observe the labia majora and perineum for lesions, swelling, and excoriation.
- Inspect the labia minora, clitoris, urethral meatus, and vaginal opening. Use your gloved hand to separate the labia majora and inspect for lesions, excoriation, swelling, and/or discharge.
- Palpate Bartholin’s glands. If the client has labial swelling or a history of it, palpate Bartholin’s glands for swelling, tenderness, and discharge. Place your index finger in the vaginal opening and your thumb on the labia majora. With a gentle pinching motion, palpate from the inferior portion of the posterior labia majora to the anterior portion.
- Palpate the urethra. If the client reports urethral symptoms or urethritis, or if you suspect inflammation of Skene’s glands, insert your gloved index finger into the superior portion of the vagina and milk the urethra from the inside, pushing up and out.
Internal female genitalia
- Inspect the size of the vaginal opening and the angle of the vagina. Insert your gloved index finger into the vagina, noting the size of the opening. Then attempt to touch the cervix. Next, while maintaining tension, gently pull the labia majora outward. Note hymenal configuration and transections.
- Inspect the vaginal musculature. Keep your index finger inserted in the client’s vaginal opening. Ask the client to squeeze around your finger. Use your middle and index fingers to separate the labia minora. Ask the client to bear down.
- Inspect the cervix. With the speculum inserted in position to visualize the cervix, observe the cervical color, size, and position. Also, observe the surface and the appearance of the os. Look for discharge and lesions as well.
- Inspect the vagina. Unlock the speculum and slowly rotate and remove it. Inspect the vagina as you remove the speculum. Note the vaginal color, surface, consistency, and any discharge.
15. Assessment of the Male Genitalia
When interviewing the male client for information regarding his genitalia, keep in mind that this may be a very sensitive topic for the client and for the examiner as well. Moreover, the examiner should be aware of his own feelings regarding body image, fear of cancer, and sexuality.
History of present health concern
Pain
- Do you have pain in your penis, scrotum, testes, or groin?
Lesions
- Have you noticed any lesions on your penis or genital area? If so, do the lesions itch, burn, or sting? Please describe the lesions.
Discharge
- Have you noticed any discharge from your penis? If so, how much? What color is it? What type of odor does it have?
- Lumps, swelling, masses
- Do you have any lumps, swelling, or masses in your scrotum, genital, or groin area? Have you noticed a change in the size of the scrotum?
- Do you have a heavy, dragging feeling in your scrotum?
Urination
- Do you experience difficulty urinating? How many times do you urinate during the night?
- Have you noticed any change in the color, odor, or amount of your urine?
- Do you experience any pain or burning when you urinate?
- Do you ever experience urinary incontinence or dribbling?
Sexual Dysfunction
- Have you recently had a change in your pattern of sexual activity or sexual desire?
- Do you have difficulty attaining or maintaining an erection? Do you have any problem with ejaculation? Do you have pain with ejaculation?
- Do you have or have you had any trouble with fertility?
Past health history
- Describe any prior medical problems you have had, how they were treated, and the results.
- When was the last time you had a testicular examination by a physician? What was the result?
- Have you ever been tested for HIV, human papillomavirus, herpes simplex, chlamydia, gonorrhea, and/or trichomoniasis? What were the results? Why were you tested?
Family history
- Is there a history of cancer in your family? What type and which family member(s)?
Lifestyle and health practices
- How many sexual partners do you have?
- What kind of birth control method do you use, if any?
- Are you satisfied with your current level of activity and sexual functioning?
- Do you have concerns regarding your fertility? If you experience fertility troubles, how has this affected your relationship?
- What is your sexual preference?
- Do you have any fears related to sex? Can you identify any stress in your current relationship that relates to sex?
- Do you feel comfortable communicating with your partner about your sexual likes and dislikes?
- What do you know about STDs and their prevention?
- Are you currently exposed to chemicals or radiation? Have you been exposed in the past?
- Describe the activity you perform on a typical day. Do you do any heavy lifting?
- Do you perform testicular self-examinations?
- When was the last time you performed this examination?
Penis
Inspection and Palpation
- Inspect the base of the penis and pubic hair. Sit on a stool with the client facing you and standing. Ask the client to raise his gown or drape. Note pubic hair growth pattern and any excoriation, erythema, or infestation at the base of the penis and within the pubic hair.
- Inspect the skin of the shaft. Observe for rashes, lesions, or lumps.
- Palpate the shaft. Palpate any abnormalities noted during the inspection. Also, note any hardened or tender areas.
- Inspect the foreskin. Observe the color, location, and integrity of the foreskin in uncircumcised men.
- Inspect the glans. Observe for size, shape, lesions, or redness.
- Palpate the urethral discharge. Gently squeeze the glans between your index finger and thumb.
Scrotum
- Inspect the size, shape, and position. Ask the client to hold his penis out of the way. Observe for swelling, lumps, or bulges.
- Inspect the scrotal skin. Observe color, integrity, and lesions or rashes. To perform an accurate inspection, you must spread out the scrotal folds of the skin. Lift the scrotal sac to inspect the posterior skin.
- Palpate the scrotal contents. Palpate each testis and epididymis between your thumb and first two fingers. Note size, shape, consistency, nodules, and tenderness.
Auscultation
- Continue examination of a scrotal mass by auscultating with a stethoscope. Normal findings are not expected. Bowel sounds may be auscultated over a hernia but will not be heard over a hydrocele.
Transillumination
- Transilluminate the scrotal contents. If an abnormal mass or swelling was noted in the scrotum, transillumination should be performed. Darken the room and shine a light from the back of the scrotum through the mass. Look for a red glow.
Inguinal area
- Inspect for inguinal or femoral hernia. Inspect the inguinal and femoral areas for bulges. Ask the client to turn their head and cough or to bear down as if having a bowel movement, and continue to inspect the areas.
- Palpate for inguinal hernia and inguinal nodes. Ask the client to shift his weight to the left for palpation of the right inguinal canal and vice versa. Place your right index finger into the client’s right scrotum and press upward, invaginating the loose folds of skin. Palpate up the spermatic cord until you reach the triangular-shaped, slitlike opening of the external inguinal ring. Try to push your finger through the opening and, if possible, continue palpating up the inguinal canal.
- Palpate inguinal lymph nodes. If nodes are palpable, note size, consistency, mobility, or tenderness.
- Palpate for femoral hernia. Palpate on the front of the thigh in the femoral canal area. Ask the client to bear down or cough. Feel for bulges. Repeat on the opposite thigh.
- Inspect and palpate for scrotal hernia. Ask the client to lie down; note whether the bulge disappears. If the bulge remains, auscultate it for bowel sounds. Finally, gently palpate the mass and try to push it upward into the abdomen.
16. Assessment of the Anus, Rectum, Prostate
The data gathered during subjective assessment provide clues to the client’s overall health and whether he is at risk for diseases and disorders of the anus, rectum, or prostate.
History of present health concern
Bowel Patterns
- What is your usual bowel pattern? Have you noticed any recent changes in the pattern? Any pain while passing a bowel movement?
- Do you experience constipation?
- Do you experience diarrhea? Is your diarrhea associated with any nausea or vomiting?
- Do you have trouble controlling your bowels?
Itching and Pain
- Do you experience any itching or pain in the rectal area?
Stool
- What is the color of your stool? Hard or soft? Have you noticed any blood on or in your stool? If so, how much?
- Have you noticed any mucus in your stool?
Past health history
- Have you ever had anal or rectal trauma or surgery? Were you born with any congenital deformities of the anus or rectum? Have you had prostate surgery? Have you had hemorrhoids or surgery for hemorrhoids?
- When was the last time you had a stool test to detect blood?
- Have you ever had a proctosigmoidoscopy?
- When was the last time you had a digital rectal examination (DRE) by a physician?
- Have you ever had blood taken for a prostate screening, which measures the level of prostate-specific antigen in your blood? When was the test, and what was the result?
Family history
- Is there a history of polyps, colon, rectal cancer, or prostate cancer in your family?
Lifestyle and health practices
- Do you use any laxatives, stool softeners, enemas, or other bowel movement-enhancing medications?
- Do you engage in anal sex?
- Do you take any medications for your prostate?
- How much high-fiber food and roughage do you consume every day? Do you eat foods high in saturated fats?
- Do you engage in regular exercise?
- Do you use calcium supplements?
- For postmenopausal women: Do you use hormone replacement therapy?
- Has any anal or rectal problem affected your normal activities of daily living?
Anus and rectum
- Inspect the perianal area. Spread the client’s buttocks and inspect the anal opening and surrounding area.
- Inspect the sacrococcygeal area. Inspect this area for any signs of swelling, redness, dimpling, or hair.
- Palpate the anus. Inform the client that you are going to perform the internal examination at this point. Lubricate your gloved index finger; ask the client to bear down. As the client bears down, place the pad of your index finger on the anal opening. When you feel the sphincter relax, insert your finger gently with the pad facing down.
- Palpate the rectum. Insert your finger further into the rectum as far as possible. Next, turn your hand clockwise. This allows palpation of as much rectal surface as possible. Note tenderness, irregularities, nodules, and hardness.
- Palpate the peritoneal cavity. This area may be palpated in men above the prostate gland in the area of the seminal vesicles on the anterior surface of the rectum. In women, this area may be palpated on the anterior rectal surface in the area of the rectouterine pouch Note tenderness or nodules.
Prostate gland
- In male clients, palpate the prostate. The prostate can be palpated on the anterior surface of the rectum by turning the hand fully counterclockwise so the pad of your index finger faces toward the client’s umbilicus. Note the size, shape, and consistency of the prostate, and identify any nodules or tenderness.
- Inspect the stool. Withdraw your gloved finger. Inspect any fecal matter on your glove. Assess the color, and test the feces for occult blood. Provide the client with a towel to wipe the anorectal area.
17. Assessment of the Musculoskeletal System
Assessment of the musculoskeletal system helps to evaluate the client’s level of functioning with activities of daily living.
History of present health concern
- Have you had any recent weight gain?
- Describe any difficulty that you have chewing. Is it associated with tenderness or pain?
- Describe any joint, muscle, or bone pain you have. Where is the pain? what does the pain feel like? When did the pain start? When does it occur? How long does it last? Any stiffness, swelling, or limitation of movement?
Past health history
- Describe any past problems or injuries you have had to your joints, muscles, or bones. What treatment was given? Do you have any after-effects from the injury or problem?
- When were your last tetanus and polio immunizations?
- Have you ever been diagnosed with diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, or osteoporosis?
- For middle-aged women: Have you started menopause? Are you receiving estrogen replacement therapy?
Family history
- Do you have a family history of rheumatoid arthritis, gout, or osteoporosis?
Lifestyle and health practices
- What activities do you engage in to promote the health of your muscles and bones?
- What medication are you taking?
- Do you smoke tobacco? How much and how often?
- Do you drink alcohol or caffeinated beverages? How much and how often?
- Describe your typical 24-hour diet. Are you able to consume milk or milk-containing products? Do you take any calcium supplements?
- Describe your activities during a typical day. How much time do you spend in the sunlight?
- Describe any routine exercise that you do.
- Describe your occupation.
- Describe your posture at work and at leisure. What type of shoes do you usually wear?
- Do you have difficulty performing normal activities of daily living? Do you use assistive devices to promote your mobility?
- How have your musculoskeletal problems interfering with your ability to interact or socialize with others? Have they interfered with your usual sexual activity?
- How did you view yourself before this musculoskeletal problem, and how do you view yourself now?
- Has your musculoskeletal problem added stress to your life? Describe.
Gait
- Observe gait. Observe the client’s gait as the client enters and walks around the room.
- Assess for the risk of falling backward in the older or handicapped client by performing the “nudge test”. Stand behind the client and put your arms around the client while you gently nudge the sternum.
Temporomandibular joint
Inspection and Palpation
- Inspect and palpate the TMJ. Have the client sit, and put your index and middle fingers just anterior to the external ear opening. Ask the client to open the mouth as widely as possible; move the jaw from side to side; and protrude and retract the jaw.
- Test range of motion. Ask the client to open the mouth and move the jaw laterally against resistance. Next, as the client clenches the teeth, feel for the contraction of the temporal and masseter muscles to test the integrity of cranial nerve V.
Sternoclavicular joint
Inspection and Palpation
- With the client sitting, inspect the sternoclavicular joint for location in midline, color, swelling, and masses. Then palpate for tenderness or pain.
Cervical, thoracic, lumbar spine
Inspection and Palpation
- Observe the cervical, thoracic, and lumbar curves from the side and then from behind. Have the client standing erect with the gown positioned to allow an adequate view of the spine. Observe for symmetry, noting differences in height of the shoulders, the iliac crests, and the buttock areas.
- Palpate the spinous processes and the paravertebral muscles on both sides of the spine for tenderness or pain.
- Test ROM of the cervical spine. Test ROM of the cervical spine by asking the client to touch the chin to the chest and to look up at the ceiling.
- Test ROM of the thoracic and lumbar spine. Ask the client to bend forward and touch the toes. Observe for symmetry of shoulders, scapula, and hips.
- Test for back and leg pain. If the client has low back pain that radiates down the back, perform Lasegue’s test (straight leg raising) to check a herniated nucleus pulpous. Ask the client to lie flat and raise each relaxed leg independently to the point of pain. At the point of pain, dorsiflex the client’s foot.
- Measure leg length. If you suspect the client has one leg longer than the other, measure them. Ask the client to lie down with their legs extended. With a tape, measure the distance between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side.
Shoulders, arms, elbows
Inspection and Palpation
- Inspect and palpate shoulders and arms. With the client standing or sitting, inspect anteriorly and posteriorly symmetry, color, swelling, and masses. Palpate for tenderness, swelling, or heat.
- Test ROM. Ask the client to stand with both arms straight down at the sides. Nest, ask him to move the arms forward and then backward with elbows straight. Then have the client bring both hands together overhead, elbows straight, followed by moving both hands in front of the body past the midline with elbows straight.
- Inspect for size, shape, deformity, redness, or swelling. Inspect elbows in both flexed and extended positions.
- Test ROM. Ask the client to flex the elbow and bring the hand to the forehead, straighten the elbow, hold the arm out, turn the palm down, then turn the palm up.
Hands, wrists, fingers
Inspection and Palpation
- Inspect wrist size, shape, symmetry, color, and swelling. Then palpate for tenderness and nodules. Palpate the anatomic snuffbox (the hollow area on the back of the wrist at the base of the fully extended thumb.
- Test ROM. Ask the client to bend their wrist down and back. Next, have the client hold the wrist straight and move the hand outward and inward.
- Test for carpal tunnel syndrome. Perform Phalen’s test. Ask the client to place the backs of both hands against each other while flexing the wrists 90 degrees downward. Have the client hold this position for 60 seconds
- Inspect size, shape, symmetry swelling, and color. Palpate the fingers from the distal end proximally, noting tenderness, swelling, bony prominences, nodules, or crepitus of each interphalangeal joint.
- Test ROM. Ask the client to spread the fingers apart, make a fist, bend the fingers down and then up, move the thumb away from other fingers, and touch the thumb to the base of the small finger.
Hips
Inspection and Palpation
- With the client standing, inspect the symmetry and shape of thehips. Palpate for stability, tenderness, and crepitus.
- Test ROM. With the client supine, ask the client to: Raise the extended leg; flex the knee up to the chest while keeping the other leg extended; move an extended leg away from the midline of the body as far as possible and then toward the midline of the body as far as possible. Bend the knee and turn the leg inward and then outward.
Knees
Inspection and Palpation
- With the client supine and then sitting with knees dangling, inspect for size, shape, symmetry, swelling, deformities, and alignment. Observe for quadricep muscle atrophy.
- Test for swelling. The bulge test helps detect a small amount of fluid in the knee. With the client in the supine position, use the ball of your hand firmly to stroke the medial side of the knee upward. three to four times, to displace any accumulated fluid. Then press on the lateral side of the knee and look for a bulge on the medial side of the knee.
- Perform the ballottement test. With the client in a supine position, firmly press your non-dominant thumb and index finger on each side of the patella. Then with your dominant fingers, push the patella down on the femur.
- Test ROM. Ask the client to bend each knee up toward the buttocks or back, straighten the knee, and walk normally.
- Test for pain and injury. 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.
Ankles and feet
Inspection and Palpation
- With the client sitting, standing, and walking, inspect position, alignment, shape, and skin.
- Palpate ankles and feet for tenderness, heat, swelling, and nodules. Palpate the toes from the distal end proximally, noting tenderness, swelling, boney prominences, nodules, or crepitus of each interphalangeal joint.
- Test ROM. Ask the client to point toes upward then downward, turn soles outward then inward, rotate foot outward then inward, turn toes under foot and then upward.
18. Assessment of the Neurologic System
Problems with other body systems may affect the neurologic system, and neurologic system disorders can affect all other body systems. Regardless of the source of neurologic problems, the client’s total lifestyle and level of functioning are often affected.
History of present health concern
Numbness and Tingling
- Do you experience any numbness or tingling? When and where does this occur?
Seizures
- Do you experience seizures?
- Describe what happens before you have the seizure and where on your body the seizure starts. Does anything seem to initiate a seizure? Do you lose control of your bladder during the seizure? How do you feel afterward? Do you take medications for seizures? Do you wear medical identification to alert others that you have seizures? Do you take safety precautions regarding driving or operating dangerous machinery?
Headaches
- Do you experience headaches? When do they occur, and what do they feel like?
Dizziness
- Do you experience dizziness or lightheadedness or problems with balance or coordination? If so, how often? Does it occur with activity? Or have you experienced any falling? Do you have any clumsy movements?
Senses
- Have you noticed a decrease in your ability to smell or taste?
- Have you experienced any ringing in your ears or hearing loss?
- Have you noticed any change in your vision?
Difficulty Speaking
- Do you have difficulty understanding when people are talking to you? Do you have difficulty in making others understand you? Do you have difficulty forming words or verbally interpreting your thoughts?
Difficulty Swallowing
- Do you experience difficulty swallowing?
Muscle Control
- Have you lost bowel or bladder control, or do you retain urine?
- Do you have muscle weakness? If so, where?
- Do you experience any tremors? If so, where?
- Do you experience any memory loss?
Past health history
- Have you ever had any type of head injury with or without loss of consciousness? If so, describe any physical or mental changes that have occurred as a result. What type of treatment did you receive?
- Have you ever had meningitis, encephalitis, injury to the spinal cord, or a stroke? If so, describe any physical or mental changes that have occurred as a result. What type of treatment did you receive?
Family history
- Do you have a family history of high blood pressure, stroke, Alzheimer’s disease, epilepsy, brain cancer, or Huntington’s chorea?
Lifestyle and health practices
- Do you take any prescription or nonprescription medications? How much alcohol do you drink? Do you use recreational drugs such as marijuana, tranquilizers, barbiturates, or cocaine?
- Do you smoke?
- Do you wear your seatbelt when riding in vehicles? Do you wear protective headgear when riding a bicycle or playing sports?
- Describe your usual daily diet.
- Have you ever had prolonged exposure to lead, insecticides, pollutants, and other chemicals?
- Do you frequently lift heavy objects or perform repetitive motions?
- Can you perform your normal activities of daily living?
- Has your neurologic problem changed the way you view yourself? Describe.
- Has your neurologic problem added much stress to your life? Describe.
Neurological status, Mental status, and LOC
- Observe the level of consciousness. Call the client’s name and not the response. If the client does not respond, call the name louder. If necessary, shake the client gently. If the client still does not respond, apply a painful stimulus.
- Observe posture and body movements. Be alert for tense, nervous, fidgety, and restless behavior, which may be seen in anxiety or may simply reflect the client’s apprehension during a physical examination.
- Observe dress, grooming, and hygiene. Keep the examination setting and the reason for the assessment in mind as you note the client’s degree of cleanliness and attire.
- Observe facial expressions. Note particularly eye contact and affect.
- Observe speech. Observe and listen to the tone, clarity, and pace of speech.
- Observe mood, feelings, and expressions. Ask the client, “How are you feeling today?” and “What are your plans for the future?”
- Observe thought processes and perceptions. Observe thought processes for clarity, content, and perception by inquiring about the client’s thoughts and perceptions expressed.
- Observe cognitive abilities. Ask for the client’s name and names of family members, the time, and where the client lives or is now. Note the client’s ability to focus and stay attentive to you during the interview and examination. Ask the client, “What did you have to eat today?” or “What is the weather like today?”. Ask the client, “When did you get your first job?” or “When is your birthday?” Ask the client to repeat four unrelated words. The words should not rhyme, and they cannot have the same meaning. Have the client repeat these words in 5 minutes, again in 10 minutes, and again in 30 minutes
- Perform the Mini-Mental State Examination if time is limited and a quick standard measure is needed to evaluate or reevaluate the cognitive function.
Cranial nerves
- Test CN I (olfactory). For all assessments of the cranial nerves, have the client sit in a comfortable position at your eye level. Ask the client to clear the nose to remove any mucus, then to close their eyes, occlude one nostril, and identify a scented object that you are holding.
- Test CN II (optic). Use the Snellen chart to assess vision in each eye. Ask the client to read a newspaper or magazine paragraph to assess near vision. Assess the visual fields of each eye by confrontation. Use an ophthalmoscope to view the retina and optic disc of each eye.
- Assess CN III (oculomotor), IV (trochlear), and VI (abducens). Inspect the margins of the eyelids of each eye. Assess extraocular movements. If nystagmus is noted, determine the direction of the fast and slow phases of movement. Assess pupillary response to light and accommodation in both eyes.
- Assess CN V (trigeminal). Test motor function. Ask the client to clench the teeth while you palpate the temporal and masseter muscles for contraction. Test sensory function. Tell the client: “I am going to touch your forehead, cheeks, and chin with the sharp or dull side of this safety pin or paper clip. Please close your eyes and tell me if you feel a sharp or dull sensation. also, tell me where you feel it.”
- Test CN VII (facial). Test motor function. Ask the client to smile, frown and wrinkle the forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes tightly against resistance.
- 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 VIII.
- Test CN IX (glossopharyngeal) and X (vagus). Test motor function. Ask the client to open their mouth wide and say “ah” while you use a tongue depressor on the client’s tongue. Test the gag reflex by touching the posterior pharynx with the tongue depressor.
- Test CN XI (spinal accessory). Ask the client to shrug the shoulders against resistance to assess the trapezius muscle. Ask the client to turn the head against resistance, first to the right and then to the left, to assess the sternocleidomastoid muscle.
- Test CN XII (hypoglossal). To assess the strength and mobility of the tongue, ask the client to protrude the tongue, move it to each side against the resistance of a tongue depressor, then put it back in the mouth.
Motor and cerebellar systems
- Assess the condition and movement of muscles. Assess the size and symmetry of all muscle groups. Assess the strength and tone of all muscle groups. Note any unusual involuntary movements such as fasciculations, tics, or tremors.
- Evaluate balance. To assess gait, ask the client to walk naturally across the room. Note posture, freedom of movement, symmetry, rhythm, and balance. Ask the client to walk in heel-to-toe fashion, next on the heels, then on the toes. Perform Romberg test. Ask the client to stand erect with arms at the side and feet together. Note any unsteadiness or swaying.
- Assess coordination. Demonstrate the finger-to-nose test to assess the accuracy of movements, then ask the client to extend and hold arms out to the side with eyes open. Next, say, “Touch the tip of your nose first with your right index finger, then with your left index finger.
Sensory systems
- Assess light touch, pain, and temperature sensations. For each test, ask clients to close both eyes and tell you what they feel and where they feel it. Scatter stimuli over the distal and proximal parts of all extremities and the trunk to cover most of the dermatomes. To test the light touch sensation, use a wisp of cotton to touch the client. To test pain sensation, use the blunt and sharp ends of a safety pin or paper clip. to test temperature sensation, use test tubes filled with hot and cold water.
- Test vibratory sensation. Strike a low-pitched tuning fork on the heel of your hand and hold the base on a bony surface of the fingers or big toe. Ask the client to indicate what he feels.
- Test sensitivity to position. Ask the client to close both eyes. Then move the client’s toes or a finger up or down. Ask the client to tell you the direction it is moved.
- Assess tactile discrimination (fine touch). Remember that the client should have her eyes closed. To test stereognosis, place a familiar object such as a quarter, paper clip, or key in the client’s hand and ask the client to identify it. To test point localization, briefly touch the client and ask the client to identify the points touched. to test graphesthesia, use a blunt instrument to write a number on the palm of the client’s hand. Ask the client to identify the number.
Marianne leads a double life, working as a staff nurse during the day and moonlighting as a writer for Nurseslabs at night. As an outpatient department nurse, she has honed her skills in delivering health education to her patients, making her a valuable resource and study guide writer for aspiring student nurses.
33 thoughts on “Head-to-Toe Assessment: Complete Physical Assessment Guide”
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