Skull, Scalp, Hair1. Observe the size, shape and contour of the skull.2. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Notepresence of lice, nits, dandruff or lesions.3. Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about tenderness upondoing so. (wear gloves if necessary)4. Observe and feel the hair condition.Normal Findings:Skull· Generally round, with prominences in the frontal and occipital area. (Normocephalic).· No tenderness noted upon palpation.Scalp· Lighter in color than the complexion.· Can be moist or oily.· No scars noted.· Free from lice, nits and dandruff.· No lesions should be noted.· No tenderness nor masses on palpation.Hair· Can be black, brown or burgundy depending on the race.· Evenly distributed covers the whole scalp (No evidences of Alopecia)· Maybe thick or thin, coarse or smooth.· Neither brittle nor dry.M. Nose and Paranasal SinusesThe external portion of the nose is inspected for the following:1. Placement and symmetry.2. Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in breathing)3. Flaring of alaenasi4. DischargeThe external nares are palpated for:1. Displacement of bone and cartilage.2. For tenderness and massesThe internal nares are inspected by heperextending the neck of the client, the ulnar aspect of the examiner’s hardover the fore head of the client, and using the thumb to push the tip of the noseupward while shining a light into thenaris.Inspect for the following:1. Position of the septum.2. Check septum for perforation. (can also be checked by directing the lighted penlight on the side of the nose,illumination at the other side suggests perforation).
3. The nasal mucosa (turbinates) for swelling, exudates and change in color.Paranasal SinusesExamination of the paranasal sinuses is indirectly. Information about their condition is gained byinspection andpalpation of the overlying tissues. Only frontal and maxillary sinuses are accessible for examination.By palpating both cheeks simultaneously, one can determine tenderness of the maxillary sinusitis, and pressing thethumb just below the eyebrows, we can determine tenderness of the frontal sinuses.Normal Findings:1. Nose in the midline2. No Discharges.3. No flaring alae nasi.4. Both nares are patent.5. No bone and cartilage deviation noted on palpation.6. No tenderness noted on palpation.7. Nasal septum in the mid line and not perforated.8. The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy).9. No tenderness noted on palpation of the paranasal sinuses.Ears1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color.2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness whenmanipulating the auricles and the mastoid process.3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodies.a. For adult pull the pinna upward and backward to straiten the canal.b. For children pull the pinna downward and backward to straiten the canal4. Perform otoscopic examination of the tympanic membrane, noting the color and landmarks.Normal Findings:· The ear lobes are bean shaped, parallel, and symmetrical.· The upper connection of the ear lobe is parallel with the outer canthus of the eye.· Skin is same in color as in the complexion.· No lesions noted on inspection.· The auricles are has a firm cartilage on palpation.· The pinna recoils when folded.· There is no pain or tenderness on the palpation of the auricles and mastoid process.· The ear canal has normally some cerumen of inspection.· No discharges or lesions noted at the ear canal.· On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color.Vestibulochoclear Nerve (cranial nerve VIII)Examination of the cranial nerve VIII involves testing for hearing acuity and balance.Hearing AcuityA. Voice test1. The examiner stands 2 ft. on the side of the ear to be tested.2. Instruct the client to occlude the ear canal of the other ear.3. The examiner then covers the mouth, and using a soft spoken voice, whispers non-sequential number (e.g. 3 5 7) for the client to repeat.4. Normally the client will be able to hear and repeat the number.5. Repeat the procedure at the other ear.
B. Watcher test1. Ask the client to close the eyes.2. Place a mechanical watch 1 – 2 inches away the client’s ear.3. Ask the client if he hears anything4. If the client says yes, the examiner should validate by asking at what are you hearing and at what side.5. Repeat the procedure on the other ear.6. Normally the client can identify the sound and at what side it was heard.Turning Fork TestThis test is useful in determining whether the client has a conductive hearing loss (problem of external or middle ear)or a perceptive hearing loss (sensorineural). There are 2 types of tuning fork test being conducted:1. Weber’s test – assesses bone conduction, this is a test of sound lateralization; vibrating tuning fork is placed onthe middle of the fore head or top of the skull.Normal: hear sounds equally in both ears (No Lateralization of sound)Conduction loss – Sound lateralizes to defective ear (Heard louder on defective ear) as few extraneous sounds arecarried through the external and middle ear.Sensorineural loss – Sound lateralizes on better ear.2. Rinne Test – Compares bone conduction with air condition.a. Vibrating tuning fork placed on the mastoid processb. Instruction client to inform the examiner when he no longer hears the tuning fork sounding.c. Position in the tuning fork in front of the client’s ear canal when he no longer hears it.Normal: Sound should be heard when tuning fork is placed in front of the ear canal as air conduction< boneconduction by 2:1 (positive rinne test)Conduction loss: Sound is heard longer by bone conduction than by air conduction.Sensorineural loss: Sound is heard longer by air conduction than by bone conductionD. Eye lids and Lacrimal Apparatus1. Inspect the eyelids for position and symmetry.2. Palpate the eyelids for the lacrimal glands.a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the client’s upperorbital rim.b. Inquire for any pain or tenderness.3. Palpate for the nasolacrimal duct to check for obstruction.a. To assess the nasolacrimal duct, the examiner presses with the index finger against the client’s lower inner orbitalrim, at the lacrimal sac, NOT AGAINST THE NOSE.b. In the presence of blockage, this will cause regurgitation of fluid in the punctaNormal Findings:Eyelids· Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.· No PTOSIS noted. (drooping of upper eyelids).· Meets completely when eyes are closed.· Symmetrical.Lacrimal Apparatus· Lacrimal gland is normally non palpable.· No tenderness on palpation.· No regurgitation from the nasolacrimal duct.
Abdomen In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles. Inspection of the abdomen Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). Contour (flat, rounded, scapold) Distension Respiratory movement. Visible peristalsis. Pulsations Normal Findings: Skin color is uniform, no lesions. Some clients may have striae or scar. No venous engorgement. Contour may be flat, rounded or scapoid Thin clients may have visible peristalsis. Aortic pulsation maybe visible on thin clients.Auscultation of the Abdomen This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion. The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the abdominal muscles. Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are relatively high-pitched, the bell may be used in exploring arterial murmurs and venous hum. Peristaltic sounds These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel. Listening to the bowel sounds (borborygmi) can be facilitated by following these steps: 1. Divide the abdomen in four quadrants. 2. Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures that we follow the direction of bowel movement. 3. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 minutes, especially at the periumbilical area, before concluding that no bowel sounds are present. 4. The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds. It is suggested that the number of bowel sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound. Some factors that affect bowel sound:1. Presence of food in the GI tract.2. State of digestion.3. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).4. Bowel surgery5. Constipation or Diarrhea.6. Electrolyte imbalances.7. Bowel obstruction. Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and masses, and in assessing solid structures within the abdomen. The direction of abdominal percussion follows the auscultation site at each abdominal guardant. The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness. Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to or at the mid axillary line on the left side. Percussion in the abdomen can also be used in assessing the liver span and size of the spleen. Percussion of the liver The palms of the left hand is placed over the region of liver dullness.1. The area is strucked lightly with a fisted right hand.2. Normally tenderness should not be elicited by this method.3. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis. Renal Percussion1. Can be done by either indirect or direct method.2. Percussion is done over the costovertebral junction.3. Tenderness elicited by such method suggests renal inflammation. Palpation of the Abdomen Light palpation It is a gentle exploration performed while the client is in supine position. With the examiner’s hands parallel to the floor. The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but gently palpating with slow circular motion. This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding. Tensing of abdominal musculature may occur because of:1. The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.2. The client is ticklish or guards involuntarily.3. Presence of subjacent pathologic condition. Normal Findings:1. No tenderness noted.2. With smooth and consistent tension.3. No muscles guarding. Deep Palpation It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall. The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined. Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be felt with this method. In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the sigmoid colon, and the aorta. Liver palpation: There are two types of bi manual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand over the left hand.1. Ask the patient to take 3 normal breaths.2. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation.3. Press hand deeply over the RUQ The second methods:
1. The examiner’s left hand is placed beneath the client at the level of the right 11th and 12thribs.2. Place the examiner’s right hands parallel to the costal margin or the RUQ.3. An upward pressure is placed beneath the client to push the liver towards the examining right hand, while the right hand is pressing into the abdominal wall.4. Ask the client to breath deeply.5. As the client inspires, the liver maybe felt to slip beneath the examining fingers. Normal Findings: The liver usually can not be palpated in a normal adult. However, in extremely thin but otherwise well individuals, it may be felt a the costal margins. When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-tender.