Module 7: Integration

Question 1

What is a complete health assessment done?

Answer 1

Performed as patient’s first entry in an outpatient setting or initial admission to the hospital.

Question 2

What is included in the health history?

Answer 2

1. Biographical data
2. Family history
3. Reason for seeking care
4. Review of systems
5. Present health/ hx of illness
6. Functional assessment or ADLS
7. Past history
8. Note general appearance

Question 3

What should you include while doing the health history?

Answer 3

note data on the person’s general appearance

Question 4

What is included in the general survey?

Answer 4

1. Appears stated age
2. Mobility/gait/assistive devices/ROM
3. Level of consciousness
4. Facial expression
5. Skin colour
6. Mood and affect
7. Nutritional status
8. Speech: pattern, content appropriate
9. Posture and position
10. Hearing
11. Obvious physical deformities
12. Personal hygiene

Question 5

What is included in measurement?

Answer 5

• Weight
• Height
• Body mass index.
• Vision (with Snellen eye chart)
• Skinfold measurements (if they are necessary)
• Waist and hip measurements (not indicated for patients younger than 18 yrs or for pregnant or lactating women)

Question 6

What is included in skin?

Answer 6

1. Examine both hands and inspect the nails

2. For the rest of the examination, examine skin with corresponding regional examination.

Question 7

What is included in vital signs?

Answer 7

• Radial pulse
• Respirations
• Blood pressure in arms
• Blood pressure in lower leg; compute ankle/brachial index (if this is necessary)
• Temperature (if this is necessary)
• Oxygen saturation (if this is necessary)
• Patient’ s rating of pain level on a scale of 0 to 10; note location of pain

Question 8

What is included in head and face?

Answer 8

1. Inspect and palpate scalp, hair and cranium.
2. Palpate the temporal artery, then the temporomandibular joint w mouth open/closed
3. Inspect face: Expression, symmetry.
4. Palpate the maxillary sinuses and the frontal sinuses; if tender, transilluminate

Question 9

What is included in eye?

Answer 9

1. Test visual fields by confrontation (CN II).
2. Test extraocular muscles; corneal light reflex, six cardinal positions of gaze (CN III, IV, VI).
3. Inspect external eye structures.
4. Inspect conjunctivae, sclerae, corneas, irides.
5. Test PERRLA

Question 10

What is included in ear?

Answer 10

1. Inspect the external ear: Position and alignment, skin condition, and auditory meatus.
2. Move auricle and push tragus for tenderness.
3. With an otoscope, inspect the canal, then the tympanic membrane for colour, position, landmarks, and integrity.
4. Test hearing: Voice test; tuning fork tests.

Question 11

What is included in nose?

Answer 11

1. Inspect the exterior of nose: Symmetry, lesions.
2. Inspect facial symmetry (CN VII).
3. Test the patency of each nostril by occluding the opposite nostril.
4. With a speculum, inspect the nares: Nasal mucosa, septum, and turbinates.

Question 12

What is included in mouth and throat?

Answer 12

1. With a penlight, inspect the mouth: Buccal mucosa, teeth and gums, tongue, floor of mouth, palate, and uvula.
2. Grade tonsils, if present.
3. Note mobility.
4. Ask the person to stick out the tongue (CN XII).
5. With a gloved hand, bimanually palpate the mouth, if indicated.

Question 13

What is included in neck?

Answer 13

1. Inspect the neck: Symmetry, lumps, and pulsations.
2. Palpate the cervical lymph nodes.
3. Inspect and palpate the carotid pulse, one side at a time. If indicated, listen for carotid bruits.
4. Palpate the trachea in midline.
5. Test ROM and muscle strength against your resistance: Head forward and back, head turned to each side, and shoulder shrug (CN XI).
   Step behind the person, taking your stethoscope, ruler, and marking pen with you.
6. Palpate thyroid gland posteriorly.

Question 14

What is the appropriate way to examine the neck and thorax?

Answer 14

Open the person’s gown to expose all of the back for examination of the thorax, but leave the gown on the shoulders and anterior chest.

Question 15

What is included in the chest (posterior and lateral)?

Answer 15

1. Inspect the posterior chest: Configuration of the thoracic cage, skin characteristics, and symmetry of shoulders and muscles.
2. Palpate: Symmetrical expansion; tactile fremitus; lumps or tenderness
3. Palpate length of spinous processes.
4. Percuss over all lung fields (APETM), percuss diaphragmatic excursion.
5. Percuss costoverbal angle, noting tenderness.
6. Auscultate breath sounds; note any adventitious sounds.

Question 16

What is the appropriate way to examine the chest?

Answer 16

Move around to face the patient, the patient remains sitting. For a female breast examination, ask permission to lift gown to drape on the shoulders, exposing anterior chest; for a male, lower the gown to a lap.

Question 17

What is included in the anterior chest?

Answer 17

1. Inspect: Respirations and skin conditions.
2. Palpate: Tactile fremitus, lumps, or tenderness.
3. Percuss anterior lung fields.
4. Auscultate breath sounds.

Question 18

How do you assess the heart?

Answer 18

1. Ask the person to lean forward and exhale briefly; auscultate cardiac base for any murmurs.

Question 19

What is included in assessment of the upper extremeties?

Answer 19

1. Test ROM and muscle strength of hands, arms, and shoulders.
2. Palpate the epitrochlear lymph nodes (inside of elbows).

Question 20

What is included in assessment of the female breast?

Answer 20

1. Inspect for symmetry, mobility, and dimpling as the woman lifts arms over the head, pushes the hands on the hips, and leans forward.
2. Inspect supraclavicular and infraclavicular areas.
3. Palpate each breast lifting the same-side arm up over head. Include the tail of Spence and areola.
4. Palpate each nipple for discharge.
5. Support the person’s arm and palpate axilla and regional lymph nodes.
6. Teach breast self-examination, if patient requests to learn it.

Question 21

How do you help the woman to prepare for assessment of the breast?

Answer 21

Help the woman to lie supine with head at a flat to 30-degree angle. Stand at the person’s right side. Drape the gown up across shoulders and place an extra sheet across lower abdomen

Question 22

how do you assess the male breast?

Answer 22

1. Inspect and palpate while palpating anterior chest wall.

2. Supporting each arm, palpate the axilla and regional nodes.

Question 23

How do you assess the neck vessels?

Answer 23

1. Inspect each side of neck for a jugular venous pulse, turning the person’s head slightly to the other side.
2. Estimate jugular venous pressure, if indicated.

Question 24

How do you assess the heart?

Answer 24

1. Inspect the precordium for any pulsations or heave (lift).
2. Palpate the apical impulse and note the location.
3. Palpate precordium for any abnormal thrill.
4. Auscultate apical rate and rhythm.
5. Auscultate with the diaphragm of the stethoscope to study heart sounds, inching from the apex up to the base, or vice versa.
6. Auscultate the heart sounds with the bell of the stethoscope, again inching through all location.
7. Turn the patient over to the left side while you again auscultate the apex with the bell.

Question 25

How do you prepare the patient for assessment of the abdomen?

Answer 25

* The patient should be supine, with the bed or table flat | * arrange drapes to expose the abdomen from the chest to the pubis

Question 26

How do you assess the abdomen?

Answer 26

1. Inspect contour, symmetry, skin characteristics, umbilicus, and pulsations. 2. Auscultate for bowel sounds in all for quadrants. 3. Auscultate for vascular sounds over the aorta and renal arteries. 4. Percuss all quadrants. Percuss the height of the liver span at the right midclavicular line. 6. Percuss the location of the spleen. 7. Lightly palpate in all quadrants; then palpate deeply in all quadrants. 8. Palpate for liver, spleen kidneys, and aorta. 9. Test the abdominal reflexes, if this is necessary.

Question 27

How do you prepare the patient and assess the inguinal area?

Answer 27

1. Palpate each side of the groin for the femoral pulse and the inguinal nodes. Lift the drape to expose the legs.

Question 28

How do you prepare the patient for assessment of the lower extremities?

Answer 28

Ask the patient to sit up with the legs dangling off the bed or table. Keep the gown on and the drape over the patient’s hip. Note muscle strength as the patient sits up.

Question 29

How do you assess the lower extremities?

Answer 29

1. Inspect: Symmetry, skin, characteristics, and hair distribution. 2. Palpate pulses: Popliteal, posterior tibial, dorsalis pedis. 3. Use Doppler technique to locate peripheral pulses if necessary. 4. Palpate for temperature and pretibial edema. 5. Separate toes and inspect. 6. Test ROM and muscle strength of hips, knees, ankles, and feet. 7. Inspect the patient’s legs for varicose veins.

Question 30

How do you assess a neurological exam?

Answer 30

1. Test sensation in selected areas on face, arms, hands, legs, and feet: Superficial pain, light touch, and vibration. 2. Test position sense of finger, one hand. 3. Test stereo gnosis, using a familiar object. 4. Evaluate cerebellar function of the upper extremities with the finger-to-nose test or the test of rapid alternating movements. 5. Elicit deep tendon reflexes of the upper extremities: biceps, triceps, and bracioradialis. 6. Test the cerebellar function of the lower extremities by asking the patient to run each heel down the opposite shin. 7. Elicit deep tendon reflexes of the lower extremities: patellar and Achilles. 8. Test for the Babinski reflex.

Question 31

How do you complete a musculoskeletal assessment?

Answer 31

1. Ask the patient to walk across the room in his or her regular gait, turn, and then walk backward toward you in heel-to-toe manner. 2. Ask the patient to walk on the toes for a few steps and then to walk on the heels for a few steps. 3. Stand close and check for the Romberg sign. 4. Ask the patient to hold the edge of the bed and to stand on one leg and perform a shallow knee bend, one for each leg. 5. Stand behind the patient, and check the spine as the patient touches the toes. 6. Stabilize the patient’s pelvis and test for ROM of the spine as the patient hyperextends, rotates, and laterally bends.

Question 32

How do you prepare the patient for male genitalia assessment?

Answer 32

For a male patient, sit on a stool in front of him. The patient stands.

Question 33

how do you assess male genitalia?

Answer 33

1. Inspect the penis and scrotum. 2. Palpate the scrotal contents. Is a mass exists, transilluminate the scrotum. 3. Check for inguinal hernia. 4. Teach testicular self-examination.

Question 34

How do you prepare a male for rectal exam?

Answer 34

For a male adults, ask him to bend over the examination table, supporting his torso with his forearms on the table. Assist a bedridden man to a left lateral position, with his right leg up.

Question 35

How do you complete a make rectal exam?

Answer 35

1. Inspect the perianal area. 2. With a gloved lubricated finger, palpate the rectal walls and prostate gland. 3. Save a stool specimen for an occult blood test.

Question 36

How do you prepare and end the female patient for genitalia examination?

Answer 36

Assist the female patient back to examination table and help her assume the lithotomy position. Drape her appropriately. For the speculum examination, sit on a stool at the foot of the table; for the bimanual examination, stand. Tell the patient that you are finished with the exam and that you will leave the room as he or she gets dressed. Return to discuss the examination and further plans and to answer any questions. Thank the patient for his or her time. For a hospitalized patient, return the bed and any room equipment to the way you found it. Make sure the call bell and telephone are within easy reach.

Question 37

What is included in female genitalia exam?

Answer 37

1. Inspect the perineal and perianal area. 2. With a vaginal speculum, inspect the cervix and vaginal walls. 3. Procure specimens. 4. Perform a bimanual examination; cervix, uterus, and adnexa. 5. Continue the bimanual examination, checking the rectum and rectovaginal walls. 6. Save a stool specimen for an occult blood test. 7. Provide tissues for the patient to wipe the perineal area, and help her up to a sitting position.

Question 38

How do you prepare newborn/infant for examination?

Answer 38

You may reorder this sequence as the infant’s sleep and wakefulness state or physical condition warrants. The infant is supine on a warming table or exam table with an overhead heating element. The infant may be nude except for a diaper.

Question 39

What is included in newborn/infant vital signs?

Answer 39

Note pulse, respirations, and temperature.

Question 40

What is included in newborn/infant measurements?

Answer 40

Weight, length, and head circumference are measured and plotted on growth curves for the infant’s age.

Question 41

What is included in newborn/infant general survey?

Answer 41

1. Body symmetry, spontaneous position, flexion of head and extremities, and spontaneous movement. 2. Skin colour and characteristics; any obvious deformities. 3. Symmetry and position of the facial features. 4. Alert, responsive affect. 5. Strong, lusty cry.

Question 42

What is included in newborn/infant Chest and Heart assessment?

Answer 42

1. Inspect the condition of the skin over the chest and abdomen; chest configuration; and nipples and breast tissue. 2. Note movement of the abdomen with respirations and any chest retraction. 3. Palpate the apical impulse and note its location; palpate the chest wall for thrills; assess tactile fremitus if the infant is crying. 4. Auscultate breath sounds, heart sounds in all locations, and bowel sounds in the abdomen and chest.

Question 43

What is included in newborn/infant Head and Face assessment?

Answer 43

1. Note moulding of the cranium after delivery, any swelling on the cranium, and bulging of fontanelle with crying or at rest. 2. Palpate fontanelles, suture lines, and any swellings. 3. Inspect positioning and symmetry of facial features while the infant is at rest and during crying.

Question 44

How do you prepare newborn/infant for assessment of the eyes?

Answer 44

To open the newborn’s eyes, support the head and shoulders and gently lower the baby backward, or ask the parent to hold the baby over his or her shoulder while you stand behind the parent.

Question 45

What is included in newborn/infant eyes assessment?

Answer 45

1. Inspect the eyelids (edematous in newborns), palpebral slant, conjunctivae, any nystagmus, and any discharge. 2. Use a penlight to elicit the pupillary reflex, blink reflex, and corneal light reflex; assess tracking of a moving light. 3. Using an ophthalmoscope, elicit the red reflex.

Question 46

When should you do the ear of exam of a newborn/infant?

Answer 46

Defer otoscopic exam until the end of the complete examination

Question 47

What is included in newborn/infant ear assessment?

Answer 47

1. Inspect size, shape, alignment of auricles, patency of auditory canal and any extra skin tags or pits. 2. Note the startle reflex response to a loud noise. 3. Palpate flexible auricles.

Question 48

What is included in newborn/infant nose assessment?

Answer 48

1. Determine the patency of the nares. | 2. Note the nasal discharge, sneezing and any flaring with respirations.

Question 49

What is included in newborn/infant mouth and throat assessment?

Answer 49

1. Inspect the lips and gums, high-arched intact palate, buccal mucosa, tongue size, and frenulum of tongue; in a newborn, note absence of or minimal salvation. 2. Note the rooting reflex. 3. Insert a gloved little finger, note the sucking reflex, and palpate palate.

Question 50

What is included in newborn/infant neck assessment?

Answer 50

1. Lift the infant’s shoulders, and let the head lag to inspect the neck: Note midline trachea, any skinfolds, and any lumps. 2. Palpate the lymph nodes, the thyroid, and any masses. 3. While the infant is supine, elicit the tonic neck reflex; note suppleness of the neck with movement.

Question 51

What is included in newborn/infant upper extremity assessment?

Answer 51

1. Inspect and manipulate, noting ROM, muscle tone, and absence of the scarf sign (elbow should not reach the midline). 2. Count fingers, count palmar creases, and note colour of hands and nail beds. 3. Place your thumbs in the infant’s palms to note the grasp reflex; then wrap your hands around infant’s hands to pull up, and note the head lag.

Question 52

What is included in newborn/infant lower extremity assessment?

Answer 52

1. Inspect and manipulate the legs and feet, noting ROM, muscle tone, and skin condition. 2. Note alignment of feet, look for flat soles, and count toes; note any syndtactyly. 3. Perform the Orolani manoeuvre to test for hip stability.

Question 53

How do you prepare the child for assessment?

Answer 53

Ask the parent to undress or assist the child to undress to the diaper or underpants. Position a child 6m to 2yr in the parent’s lap. Move your chair to sit knee to knee with the parent.

Question 54

What is included in the general appearance of a child?

Answer 54

1. Note child’s ability to amuse him or herself while the parent speaks. 2. Note interaction between parent and child. 3. Note gross motor and fine motor skills and the child plays with toys. Gradually focus on and involve yourself with the child, at first in a “play” period. 4. Evaluate developmental milestones by using an age-appropriate Nipissing District Developmental Screen. 5. Evaluate posture while the child is sitting and standing. Evaluate alignment of the legs and feet while the child is walking. 6. Evaluate speech acquisition. 7. Evaluate vision and hearing ability. 8. Evaluate social interaction.