126 Assessment

• Supine- palpating abdomen
• Dorsal Recumbent ­­– supine w/knees elevated
• Sim’s- sideline w/leg flexed at knee, ie. enema
• Prone- laying on stomach
• Lithotomy- feet up in stir ups. Ie. pap smear
• Knee chest- knees on bed. Ie. laboring
• Standing- to check balance, movement, gait

• 1. Inspection
• 2. Palpation
• 3. Percussion
• 4. Auscultation

• 1. Bronchial sounds. Heard over trachea
• harsh and loud
• 2. Bronchovesicular. Heard over mainstem, middle
• blowing sounds
• 3. Vesicular. Heard over bases, during inspiration.
• soft, low pitch

• 1. Crackle Produced by air moving thru fluid in smaller air passages
• fine or course (rhonchi)
• 2. Wheeze Heard with stethoscopes upon insp/exp.
• high pitched musical
• 3. Sonorous Produced by air moving thru fluid in larger air passages.
• deeper, snoring
• 4. Pleural friction Produced when pleura is inflamed
• and rubs chest wall
• rubbing, grating

• S1= Lub Mitral & Tricuspid
• S2= Dub Aortic & Pulmonic
• High pitched-use diaphragm.
• Low pitched-use bell.

• 1. Pulse/Edema/Reflex: 0+ to 4+ scale
• 0 absent 2+ normal 4+ strong
• 2. LOC: Glascow Coma Scale
• 0-15, <7 is comitose
• 3. ROM
• percentage
• 4. Strength
• 1-5
• 5. Pain
• 0-10 scale.

• 1. Oriented to person, time, place, situation
• 2. Level of Consciousness. Awake? Lethargic?
• 3. Memory
• 4. Reasoning. If this, then this.
• 5. Language. Name items, follow commands.

Redness of the skin.

Bluish coloring of the skin and mucous membranes

Yellow appearance of skin.

Paleness of the skin.

Collection of blood in subcutaneous tissues that causes a purplish discoloration.

Small, purplish hemmorragic spots on the skin that do not blanch with applied pressure

Any abnormal tissue on the skin.

• An injury, especially one in which the skin
• or another external surface is torn, pierced, cut, or otherwise broken.

A change of the skin which affects its color, appearance or texture.

Excessive sweating commonly associated with shock or other medical conditions.

Tension of the skin determined by its hydration.

Accumulation of fluid in extracellular spaces.

Deep grooved lines that run from side to side on the fingernail

• A nail disease in which often tender bacterial or fungi hand infection where the nail and skin meet at the
• side or base of the nail.

Rounding and swelling of nail beds.

Excessive hairiness.

Dilation of pupil due to disease, use of drugs or trauma.

Constriction of pupil of the eye resulting from normal response to an increase in light or caused by certain drugs or pathological conditions.

Ability to adjust the eye to see at various distances.

Following an object as it nears your face. Becoming cross-eyed in the process

Drooping of upper or lower eyelid.

Medical condition in which the eyelid (usually lower one) folds inward

Condition where lower eyelid folds outwards.

Nostril or nasal cavity.

Term meaning disease of the lymph nodes.

Vibration of the chest wall that can be palpated during physical assessment.

• Heard when percussing a patient.
• Hollow sounding.

Breathing Loud breathing.

Harsh, high-pitched sound usually heard in inspiration when upper airways become narrowed.

Unusual sound, usually abnormal, heard in auscultation.

Inflammation of the vein

Irregular areas of skin that look like bands, stripes or lines.

Acquired language disorder in which there is an impairment of language use.