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TITLE: Physical examination and Triage Nursing

NCM 416 First Semester S.Y. 2010-2011

TIME ALLOTMENT: 2 hours

TOPIC DESCRIPTION

o This topic discusses Triage Nursing and the proper way of performing a thorough and systematic cephalocaudal physical

examination.

GENERAL OBJECTIVE

o At the end of two-hours, the learners will be able to gain more knowledge, to enhance beginning skills and to convey the right attitude regard

Nursing and in performing cephalocaudal physical assessment.



SPECIFIC OBJECTIVES CONTENT TIME ALLOTMENT TEACHING

After the two-hour discussion, the audience will be

able to:

1. Recall physical health examination

2. Determine proper preparation of theclient prior to the examination

3. Identify various instruments used in

physical assessment

4. Enumerate the four methods of

physical examination

5. Identify the normal findings and

appearance of the different parts of

the body, with the corresponding

deviations from normal

I. Introduction

II. A. preparing the clientB. Preparing the environment

C. Positioning the patient

III. Instrumentation

IV. A. Inspection

B. PalpationC. Percussion

D. Auscultation

V. 1. General survey

2. The Integument

a. Skin

b. hair

c. Nails3. Head

a. Skull and Face

b. Eyes and Vision

c. Ears and Hearing

d. Mouth and oropharynx

4. Neck

5 minutes

5 minutes

5 minutes

5 minutes

1 hour

Active di

Active di

Active di

Active di

Active discuss

demon



6. Verbalize understanding on triage

nursing

7. Summarize physical examination

5. thorax and lungs

a. chest landmarks

b. chest size and shapec. breath sounds

6. Cardiovascular & Peripheral vascular

systems

a. heart

b. peripheral vascular system

7. breast and axillae

8. abdomen9. musculoskeletal system

10. neurologic system

a. reflexes

b. motor function

c. sensory function

d. cranial nerves

11. female genitals and inguinal lymph

nodes

12. male genitals and inguinal area

13. rectum and anus

VI. Triage nursing

A. Categories

B. Types

C. Responsibilities of a triage nurse

VII. Summary of physical examination

10 minutes

30 minutes

Active di

Video pre



REFERENCES:

o Kozier, B.& Erb, G.(2002).FUNDAMENTALS OF NURSING: CONCEPTS, PROCESS AND PRACTICE.(5

TH

ed).Singapore:Pearson Education Asia Pte. Ltdo Marieb, E.(2003).Essentials of Human Anatomy & Physiology.( 7

thedition).San Francisco:Pearson Education Inc

o Black, J.M. & Hawks, J.H.(2004). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (7th

ed, Vol 2).Singapore: Elsevier Pte. Ltd.

o Buschiazzo, L.(1987). The Handbook of Emergency Nursing Management. Maryland: Aspen Publisher, Inc.

o Lippincott, J.B. The Lippincott Manual of Nursing Practice.(6th

ed) Philadelphia: Lippincott-Raven Publishers



SCHOOL OF NURSIN G

ANDRES BONIFACIO COLLE GE

COLLE GE PARK, DIPOLOG CITY

Physical Assessment (cephalocaudal)

And Triage Nursing

Submitted by:Fercie Mae N. Alunan, BSN-IV/A

Submitted to:

Ms. Kimberly Ann C. Dolor, RN Clinical Instructor

September 01, 2010



TOPIC DESCRIPTION

o This topic discusses Triage Nursing and the proper way of performing a thorough and systematic cephalocaudal physical

examination.

GENERAL OBJECTIVE

o At the end of two-hours, the learners will be able to gain more knowledge, to enhance beginning skills and to convey the right attitude regard

Nursing and in performing cephalocaudal physical assessment.

SPECIFIC OBJECTIVES CONTENT

After the two-hour discussion, the audience will be

able to:

1. Recall physical health examination

2. Determine proper preparation of

the client prior to the examination

I. Introductiono A complete physical assessment is generally conducted from the head to the toes; however

according to the age of the individual, the severity of the illness, the preferences of the nur

agencys priorities and procedures. Some of the purposes of the physical health examinatio

a. To obtain baseline data about the clients functional abilities.

b. To supplement, confirm or refute data obtained in the nursing history.

c. To obtain data that will help the nurse establish nursing diagnoses and plan the clients

d. To evaluate the physiologic outcomes of health care and thus the progress of a clients

problem.e. To screen for the presence of cancer.

II. A. Preparing the client

o The nurse should explain when and where the examination will take place, why it is necessa

conduct it and what will happen during the examination. Most clients should empty their bl

the examination.



3. Identify various instruments used

in physical assessment

4. Enumerate the four methods of

physical examination

B. Preparing the environment

o The time of the assessment should be convenient to both the client and the nurse. Thshould be well lighted and equipments should be organized for use. Providing privacy is

room should be warm enough to be comfortable.

C.Positioning the patient

o It is important to consider the clients ability to assume position. The clients physical con

level and age should also be considered.

o Sitting position

o Dorsal recumbent positiono Supine position

o Lithotomy position

o Genupectoral(knee-chest)position

o Sims position

o Prone position

D. Instrumentation

o All equipment should be clean, in good working condition and readily accessible.o Penlight/flashlight

o Nasal speculum

o Ophthalmoscope

o Otoscope

o Reflex hammer

o Stethoscope

o Tuning fork

o Vaginal speculumo Sterile safety pins

o Tongue depressors

E. Methods of examining

a. Inspection (visual examination)-the nurse inspects with the naked eye and

instrument. This is an active process, not a passive one.



5. Identify the normal findings and

appearance of the different parts

of the body, with the

corresponding deviations fromnormal

b. Palpation- examination of the body with the sense of touch. Pads of the fingers are

their concentration of nerve endings makes them highly sensitive to tactile discr

types: light & deep palpation.

c. Percussion- an assessment method in which the body is struck to elicit sounds tha

or vibrations that can be felt. Two types: direct & indirect percussion.

d. Auscultation-process of listening to sounds produced within the body. Two types

auscultation (use of unaided ear) and indirect auscultation (use of stethoscope

sounds are described according to:

o Pitch-frequency of the vibrationso Intensity-loudness or softness of sound

o Duration-its length

o Q uality-subjective description of sound

F. A. general survey

Assessment Normal findings Deviations from norm

a. General appearance

o body built, height and

weight in relation to the

clients age, lifestyle and

health

o o posture and gait

o overall hygiene and

grooming

o body and breath odor in

relation to activity level

-varies with lifestyle

-relaxed, erect posture;coordinated movement

-clean, neat

-none

-excessively thin or o

-tense, slouched, buncoordinated move

-dirty, unkempt

-foul body odor, am

acetone breath odor,



o obvious signs of health or

illness

b. mental status

o attitude

o affect/mood

o quantity of speech

o relevance & organization of

thought

-healthy appearance

-cooperative

-appropriate to situation

-understandable, moderate pace,

exhibits thought association

-logical sequence, makes sense, has

sense of reality

-pallor, weakness, ob

-negative, hostile, wi

-inappropriate to situ

-rapid/slow pa

generalization, lacksexhibits confabulatio

-illogical sequence, f

confusion

B. Integumenty Skin-inspection and palpation

o Hyperhidrosis (excessive perspiration)

o Bromhidrosis (foul-smelling perpiration)

o Pallor- inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxyg

o Cyanosis (bluish tinge)-most evident in the nail beds, lips and buccal mucosa

o Jaundice (yellowish tinge)-sclera of the eyes, mucous membranes, skin

o Erythema-redness associated with a variety of rasheso Vitiligo-caused by destruction of melanocytes in the area

o Albinism-complete or partial lack of melanin in the skin, hair and eyes

o Edema-presence of excess interstitial fluid

Types of lesions description exa



a. Primary

o Macule

o Patch

o Papule

o Plaque

o Nodule

o Tumor

o Vesicle

o Bulla

o Pustule

o Wheal

o Telangiectasia

o Petechiae

-flat, circumscribed area of color w/ noelevation of its surface, 1 mm-1 cm

-same as macule but larger than 1 cm

-circumscribed, solid elevation of skin,

less than 1 cm

-same as papule, but larger than 1 cm

-solid mass that extends deeper into

the dermis than does a papule

-a solid mass larger than a nodule

-a circumscribed elevation containing

serous fluid or blood, less than 1 cm

-a larger fluid-filled vesicle

-a vesicle or bulla filled w/ pus

-a reddened, elevated, localized

collection of edema fluid, irregular

shape

-dilated capillary, fine red lines

-pinpoint red spots

-freckles

-port wine

-warts, acn

-eczema

-pigmented

-epitheliom

-blister, chi

-blister, 2nd

-acne vulga

-hives

-pregnancy

-problem

clotting me



b. Secondary

o Scale

o Crust

o Fissure

o Erosion

o Excoriation

o Atrophy

o Scar

o ulcer

-thickened epidermal cells that flake off

-dried serum or pus on skin surface

-a linear crack

-loss of all or part of the epidermis

-linear or hollowed out crusted area

exposing dermis

-decrease in the volume of epidermis

-formation of connective tissue

-excavation extending into the dermis

-dandruff

-impetigo

-athletes fo

-chickenpox

-scratch

-striae, age

-healed wo

-stasis ulce

y Hair


Inspection

1. Evenness of growth over

the scalp

2. Thickness or thinness

-Evenly distributed hair

-Thick hair

-patches of hair loss (i

-very thin hair



3. Hair texture and oiliness

4. Presence of infection or

infestations by parting the

hair in several areas

5. Amount of body hair

-silk, resilient hair

-No infection or infestation

-variable

-brittle hair (e.g., hyp

excessively oily or dry

-flaking sores, lice,

eggs),and ring worm

-hirsutism (abnormal

women; naturally abs

leg hair (poor circulati

y Nails

o spoon shape- the nail curves upward from the nail bed;seen in clients w/ IDA

o Clubbing -the angle between the nail bed is 180 degrees or greater; may be caused by a of oxygen.

o Beaus lines-horizontal depressions in the nail resulting from injury or severe illness.

o Paronychia -inflammation of the tissues surrounding a nail (often referred to as an ingro


Inspection1. Fingernail plate shape to

determine its curvature &

angle.

2. Fingernail and toenail

texture.

-Convex curvature; angle of nail

plate about 160 degrees

-smooth texture

-spoon nail; clubbing

or greater)

-excessive thickness o

presence of grooves

Beaus lines; discolore



3. Fingernail and toe nail

color.

4. Tissues surrounding nails

5. Blanch test of capillary

refill.

-highly vascular and pink in light-

skinned clients; dark- skinnedclients may have brown or black

pigmentation in longitudinal

streaks.

-intact epidermis

-Prompt return of pink or usual

color (generally less than 4seconds)

-Bluish or purplish tin

cyanosis); pallor (mayarterial circulation)

-hangnails;

(inflammation)

-delayed return of p

color (may indicateimpairment)

y Head

A. skull and face

o normocephalic-normal size head


Inspection

1. size, shape and symmetry.

In adults, a large head may

result from;

Osteitis deformans (pages

dse.)- bony thickness increases

(skull, spine, femur)Acromegaly- a disorder

caused by excessive growth

hormone secretion.

2. Facial features.

-rounded; smooth skull contour

-symmetry or slightly asymmetric

facial features

-lack of symmetry

-increased facial hair

eyebrows; asymmet

exopthalmus



3. The eyes for edema and

hollowness.

4. Symmetry of facial

movements.

Palpation

1. The skull for nodules or

masses and depressions

-symmetric facial movement

-smooth, uniform consistency;

absence of nodules or masses

-periorbital edema; su

-asymmetry facial mov

-sebaceous cyst, loca

for trauma

B. EYES & VISION

o Visual acuity-the degree of detail the eye can discern in an image

o Visual fields-the area an individual can see when looking straight ahead

o Myopia-nearsightedness

o Hyperopia-farsightnedness

o Presbyopia-loss of elasticity of the lens & thus loss of ability to see close objects

o Astigmnatism-an uneven curvature of the cornea preventing rays from focusing on the retin

o Conjunctivitis-inflammation of conjunctiva

o Dacrocystitis-inflammation of the lacrimal sac

o Hordeolum (sty)-redness, swelling & tenderness of the hair follicle & glands that empty at t

eyelids

o Cataracts-opacity of the lens

o Glaucoma-a disturbance in the circulation of aqueous fluid causing an increase in the IOP

o Mydriasis-enlarged pupils

o Miosis-constricted pupils

o Anisocoria-unequal pupils

Assessment Normal Findings Deviation from nor

1. Eyebrows for hair -hair evenly distributed; skin -loss of hair;



distribution, alignment,

skin quality and

movement.

2. Eyelashes for evenness of

distribution and direction

of curl.

3. Eyelids for surface

characteristics.

4. Bulbar conjunctive for

color, texture, and the

presence of lesions.

5.

palpebral conjunctiva

6. Lacrimal gland

7. Lacrimal sac and

nasolacrimal duct

8. Cornea

9. Corneal sensitivity

intact ; eyebrows- symmetrically

aligned; equal movement

-Equally distributed; curled

slightly outward

-Approximately 15- 20

involuntary blinks per minute;

bilateral blinking; no visible

sclera above corneas and upperand lower borders of cornea are

slightly covered

-transparent; capillaries

sometimes evident; sclera

appears white

-shiny, smooth, and pink or red

-no edema or tenderness over

lacrimal gland

-no edema or tearing

-Transparent, shiny and smooth;

details of the iris are visible

-client blinks when the cornea is

touched, indicating that the

flakiness of skin

unequal alignm

movement

-Turned inward

-rapid, monocular

infrequent blink

ectropion or entro

sclera visible betwiris

-Jaundiced sclera

pale sclera; redd

lesions or nodules

-extremely pale; enodules or other le

-swelling or tend

lacrimal gland

- increased

regurgitation of

palpation of lacrim

-opaque; surface

(may be the result

abrasion)

-one or both e

respond



10. Anterior chamber

11. Pupils for shape, color

and symmetry of size.

12. PERRLA

VISUAL FIELDS

1. Peripheral visual fields

EXTRAOCCULAR MUSCLE TESTS

1. Six ocular movements

2. Hirschberg test

trigeminal nerve is intact

-transparent; no shadows of light on iris; depth about 3 mm

-black in color; equal in size;

normally 3 to 7 mm in diameter;

round, smooth border, iris flat

and round

-pupils constrict when looking at

near object; pupils dilate when

looking at far object; pupils

converge when near object is

moved toward nose

-when looking straight ahead,

client can see objects in theperiphery

-both eyes coordinated, move in

unison, with parallel alignment

-light falls symmetrically on both

pupils

-cloudy; cresceshadows on far

shallow chamber

-cloudiness, mydr

anisocoria; bulgi

toward cornea

-one or both p

constrict, dilate or

-visual field s

normal; one- half or both eyes

-eye movem

coordinated or pa

both eyes fail

penlight in speci

(cross-eye)

Nystagmus (rapidrhythmic eye mov

than at end point

neurologic impairm

-light falls off cente



3. Cover test

VIUAL ACUITY

1. Assess near vision

2. Distance vision

-uncovered eyes do not move

-able to read newsprint

-20/20 vision of Snellen chart

-if misalignment

when dominanat e

the uncovered eyefocus on object

-difficulty readin

unless due to aging

-Denominator of 4

Snellen- type

corrective lens

y Ears and Hearing

o Conduction Hearing loss- is the result of interrupted transmission of sound waves through

middle ear structures.

o Sensorineural Hearing loss- is the result of damage to the inner ear, the auditory nerve,

center in the brain.

o Mixed hearing loss- is a combination of conduction and Sensorineural loss.

Assessment Normal Findings Deviation from norma

1. Inspection and palpation of

the auricles

1. the external ear canal for

cerumen, skin lesions, pus

and blood.

Gross Hearing Acuity Test

1. Clients response to normal

-color same as facial skin;

symmetrical; mobile, firm, and not

tender; pinna recoils after it is

folded

-distal third contains hair follicles

and glands; dry cerumen, grayish-

tan color; or sticky, wet cerumen in

various shades of brown

-normal voice tones audible

-bluish color of ear

excessive redness; l

scaly skin; tenderness

or pressed.

-redness and discha

excessive cerumen

canal

-normal voice tones n



voice tone.

2. Watch tick test

3. Weber Tests

4. Rinne tests

-able to hear ticking in both ears

-sound is heard in both ears or is

localized at the center of the head

(Weber negative)

-air- conducted (AC) hearing is

greater than bone conduction (BC)

hearing hearing

-unable to hear ticki

both ears.

-sound is heard bette

ear, indicating a bon

hearing loss; or sou

better in ear withou

indicating a

disturbance (Weber p

-bone conduction tim

or longer than the a

time.

y NOSE & SINUSES

ASSESSMENT NORMAL FINDINGS DEVIATIONS FROM NO

1. External nose for

deviations in shape, size,

color and discharges from

the nares

2. Patency of both nasal

cavities.

3. Presence of redness,

swelling, growths &

discharge.

4. Nasal septum between the

nasal chambers

symmetric & straight; no discharge

or flaring; uniform color

-air moves freely as the client

breathes through the nares

-mucosa pink; clear watery

discharge; no lesions

-nasal septum intact & in midline

-asymmetric; discharg

localized areas of

presence of skin lesion

-air movement is rest

or both nares

-mucosa red;

abnormal discharge;

lesions

-septum deviated to

left



5. Palpate maxillary & frontal

sinuses for tenderness.

-not tender -tenderness in one or

y MOUTH & OROPHARYNX

o Dental caries- cavities

o Periodontal disease- pyorrhea

o Plaque-invisible soft film that adheres to the enamel surface of teeth

o Tartar-visible, hard deposit of plaque & dead bacteria that forms at the gum lines

o Gingivitis-red, swollen gingival

o Glossitis-inflammation of the tongue

o Parotitis-inflammation of the parotid salivary gland

o Sordes-accumulation of foul matter on the teeth & gums


1. Lips for symmetry of

contour, color & texture.

1. Inner lips & buccal mucosa

for color, moisture, texture

& presence of lesions.

2. Teeth & gums

3. Surface of the tongue for

position, color & texture.

4. Tongue movement.

-uniform pink color; soft, moist,

smooth texture; symmetry of

contour; ability to purse lips

-uniform pink color; moist, smooth,

soft, glistening & elastic texture

-32 adult teeth; smooth, white,

shiny tooth enamel; pink gums;moist, firm texture to gums; no

retraction

-central movement; pink color

-moves freely; no tenderness

-pallor, cyanosis, blist

fissures, crusts; inab

lips

-Pallor; leukoplak

patches);red, bleedin

dryness; mucosal cyst

-missing teeth; brow

discoloration of texcessively red gu

texture

-deviated from cente

tongue; dry furry tong

-restricted mobility



5. Salivary duct opening.

6. Hard & soft palate for

color, shape & texture.

7. Uvula for position &

mobility.

8. Oropharynx for color &

texture

9. Tonsils

10. Gag reflex

-same as color of buccal mucosa &

floor of mouth

-light pink, smooth, soft palate;

lighter pink hard palate, more

irregular texture

-positioned in midline of soft palate

-pink & smooth posterior wall

-pink & smooth; no discharge; of

normal size, not visible

-present

-inflammation

-discoloration; palate

color; irritations;

growing from the hard

-deviation to one sid

or trauma; immobility

-reddened or edema

plaques

-inflamed; presence o

a. grade 2- tonsils are

pillars & uvula

b. grade 3-tonsils touc

c. grade 4- one or

extend to the mid

oropharynx

-absent

y THE NECK

Assessment Normal findings Deviations from norm1. Neck muscles for swelling

or masses.

2. Head movement.

-equal in size; head centered

-coordinated; smooth movements

w/ no discomfort; head flexes 45;

head laterally flexes 40; laterally

rotates 70

-unilateral neck swel

one side

-muscle tremor; spa

limited ROM; painful m



3. Muscle strength.

4. Palpate for enlarged lymph

nodes.

5. Palpate trachea for lateral

deviation.

6. Inspect thyroid gland.

7. Auscultate over thyroid

gland for bruit sounds

-equal strength

-not palpable

-central placement in midline of

neck; spaces are equal on both

sides

-not visible on inspection

-absence of bruit

-unequal strength

-enlarged, palpabl

tender

-deviation to one side

-visible diffuseness

enlargement

-presence of bruit

y THORAX & LUNGS

a.

Chest landmarkso Midsternal line- vertical line running through the center of the sternum

o Midclavicular line- vertical line from the midpoints of the clavicles

o Anterior axillary lines-vertical lines from the anterior axillary folds

o Posterior axillary line-vertical line running from the posterior axillary fold

o Midaxillary line-vertical line from the apex of the axilla

o Vertebral line-vertical line along the spinous processes

o Scapular lines-vertical lines from the inferior angles of the scapulae

o Angle of Louis-junction between the body of the sternum and the manubrium

b. Chest shape & size

o Pigeon chest (pectus carinatum)-permanent deformity, maybe caused by rickets; nar

diameter, increased anteroposterior diameter & a protruding sternum

o Funnel chest (pectus excavatum)-congenital defect; depressed sternum, narrow anteropost

o Barrel chest-ratio of the anteroposterior to transverse diameter is 1:1



o Scoliosis-lateral deviation of the spine

c. Breath sounds (adventitious breath sounds)

o Normal breath sounds

1. Vesicular- gentle sighing sounds

2. Broncho-vesicular-blowing sounds

3. Bronchial (tubular)-harsh sounds

o Adventitious breath sounds

1. Crackles (rales)-short, interrupted crackling sounds

2. Gurgles (rhonchi)-continuous, low-pitched, coarse, gurgling sounds

3. Friction rub- grating or creaking sounds

4. Wheeze-continuous, high-pitched, squeaky, musical sounds


1. Shape, symmetry of thorax.

2. Spinal alignment for

deformities.

3. Palpate for respiratory

excursion.

4. Palpate for tactile fremitus.

5. Percuss for diaphragmatic

excursion.

6. auscultate

-anteroposterior to transverse

diameter in ration of 1:2

-spine vertically aligned

-full & symmetric chest expansion

-bilateral symmetry of vocal

fremitus

-excursion is 3 to 5 cm bilaterally in

women and 5 to 6 cm in men

-vesicular & bronchovesicular

breath sounds

-barrel chest;

anteroposterior to

diameter

-exaggerated spinal cu

-asymmetric or dec

expansion

-decreased or increase

-restricted excursion

-adventitious breath s



y CARDIOVASCULAR & PERIPHERAL VASCULAR SYSTEM

a. Heart

o Normal heart sounds

1. S1-dull, low-pitched; lub

2. Systole- silent interval between S1& S2

3. S2-higher pitch than S1; dub

4. Diastole-silent interval between S2 & S1

b. Peripheral vascular system


1. Buergers test (arterial

adequacy test)

2. Capillary refill test

-color returns in 10 seconds; veins

in feet or hands fill in about 15

seconds

-immediate return of color

-delayed color retur

appearance; delayed v

-delayed return of col

y BREASTS & AXILLAE


1. Inspect for size, shape,

symmetry.

2. Inspect for localized

discoloration/

hyperpigmentation

3. Inspect nipple for size,

-females: rounded shape; slightly

unequal in size; symmetricMales: breasts even w/ chest wall

-uniform skin color; skin smooth &

intact; striae

-round or oval & bilaterally the

-recent change in

swellings; asymmetry

-localized discolo

hyperpigmentation;

dimpling

-asymmetry, mass or l



shape, symmetry, color

4. Palpate the nodes.

5. Palpate breasts for masses,

discharges from nipples.

same; color varies from light pink

to dark brown

-no tenderness, masses

-no masses, nipple discharge

-tenderness, masses, n

-tenderness; nipple di

y ABDOMEN

ORGANS IN THE FOUR ABDOMINAL QUADRANTS

RIGHT UPPER QUADRANTLiver

Gallbladder

Duodenum

Head of Pancreas

Right Adrenal Gland

Upper lobe of right kidney

Hepatic flexure of colon

Section of ascending colon

Section of transverse colon

LEFT UPPER QUADRANT Left lobe of liver

Stomach

Spleen

Upper lobe of left kidney

Pancreas

Left adrenal gland

Splenic flexure of colon

Section of transverse colon

Section of descending colon

RIGHT LOWER QUADRANT

Lower lobe of right kidney

Cecum

Appendix

Section of ascending colonRight ovary

Right fallopian tube

Right ureter

Right spermatic cord

Part of uterus

LEFT LOWER QUADRANT

Lower lobe of kidney

Sigmoid colon

Section of descending colon

Left ovaryLeft fallopian tube

Left ureter

Left spermatic cord

Part of uterus



ORGANS IN THE ABDOMINAL REGIONS

Right Hypochondriac

Right lobe of liverGallbladder

Part of duodenum

Hepatic flexure of colon

Upper half of right kidney

Suprarenal gland

Right Lumbar

Ascending colon

Lower half of right kidney

Part of duodenum and jejunum

Right Inguinal

Cecum

Appendix

Lower end of ileumRight ureter

Right spermatic cord

Right ovary

Epigastric Region

Aorta

Pyloric end of stomachPart of duodenum

Pancreas

Part of liver

Umbilical

OmentumMesentery

Lower part of duodenum

Part of jejunum and ileum

Hypogastric (Pubic)

Ileum

Bladder

Uterus

Left hypochondriac

Stomach

Spleen

Tail of pancreas

Splenic flexure of colon

Upper half of left kidneySuprarenal gland

Left Lumbar

Descending colon

Lower half of left kidney

Part of jejunum and ileum

Left Inguinal

Sigmoid colon

Left ureter

Left spermatic cord

Left ovary




1. Skin integrity of abdomen.

2. Inspect abdomen for

contour & symmetry.

3. Auscultate for bowel

sounds.

4. Percuss the four quadrants.

5. Percuss liver to determine

its size.

6. Palpate abdomen.

7. Palpate the liver.

-unblemished skin; uniform color;

silver-white striae or surgical scars

-flat, rounded (convex) or scaphoid

(concave); no evidence of liver

enlargement; symmetric contour

-audible bowel sounds; absence of

arterial bruits & friction rub

-tympany over the stomach & gas-

filled bowels; dullness over liver &

spleen or a full bladder

-6 to 12 cm in the midclavicular

line; 4 to 8 cm at the midsternal

line

-no tenderness; relaxed abdomen

w/ smooth, consistent tension

-may not be palpable; border feels

smooth

-rash or other les

glistening skin; purple

-distended; evid

enlargement of liver

contour

-hypoactive/hyperacti

sounds; bruit sounds

-large dull areas

-enlarged size

-tenderness & hy

superficial masses

-enlarged; smooth

nodular or hard

y MUSCULOSKELETAL SYSTEM

o Tremor-involuntary trembling of a limb or body part.

o Intention tremor-more apparent when an individual attempts a voluntary movement

o Resting tremor-more apparent when the client is at rest & diminishes w/ activity.




Muscle

1. Muscle size.

2. Inspect for contractures.

3. Inspect for tremors.

4. Muscle tonicity.

5. Flaccidity, spasticity, &

smoothness of movement

.

6. Muscle strength.

Bones

1. Structure.

2. Palpate for edema or

tenderness.

Joints

1. Swelling

2. Joint ROM

-equal size on both sides of the

body

-no contractures

-no tremors

-normally firm

-smooth coordinated movement

-equal strength on each side

-no deformities

-no swelling or tenderness

-no swelling; ne tenderness

-joints move smoothly

-atrophy

-malposition of body p

-presence of tremor

-atonic

-flaccidity or spasticity

-25% or less of muscle

-bones misaligned

-presence of tenderne

-one or more swollen

-limited ROM in one o

y NEUROLOGIC SYSTEM

o Aphasia-loss of power to express oneself by speech, writing, signs or to comprehend spo

language due to injury of the cerebral cortex.

o Reflex-automatic response of the body to a stimulus.



o Proprioceptors-sensory nerve terminals that give information about movements & position

o One & two-point discrimination-ability to sense whether one or two areas of the skin are be

by pressure.

o Stereognosis-act of recognizing objects by touching & manipulating them

o Extinction-failure to perceive touch on one side of the body when two asymmetric areas o

touched simultaneously.

Reflexes

0 no reflex response

+ 1 minimal activity (hypoactive)

+ 2 normal response

+ 3 more active than normal

+ 4 maximal activity (hyperactive)


Motor function

1. Walking gait

2. Romberg test

3. Standing on one foot w/

eyes closed

4. Heel-toe walking

5. Toe or heel walking

-upright posture & steady gait

w/opposing arm swing; walks

unaided

-negative Romberg

-maintains stance for at least 5 sec

-maintains heel-toe walking along a

straight line

-able to walk several steps on toes

or heels

-poor posture &

irregular, staggering

stance

-positive Romberg

-cant maintain stance

-assumes a wider foo

upright

-cant maintain balan

heels



6. Finger-to-nose test

7. Alternating supination &

pronation of hands on

knees

8. Fingers to nose to the

nurse finger

9. Fingers to fingers

10. Fingers to thumb (same

hand)

11. Heel down opposite shin

12. Toe or ball of foot to the

nurse finger

13. Light touch sensation

14. Pain sensation

15. Temperature sensation

16. Position sensation

-repeatedly touches the nose

-alternately supinate & pronate

hands @ rapid pace

-w/ coordination & rapidity

-w/ accuracy & rapidity

-rapidly touches each finger to

thumb w/ each hand

-bilateral equal coordination

-moves smoothly w/ coordination

-light tickling or touch sensation

-discriminate sharp & dull

sensations

-discriminate between hot &

cold sensations

-determine the position of fingers

& toes

-misses the nose o

response

-slow, clumsy mov

irregular timing

-misses the finger & m

Moves slowly & una

fingers consistently

-cant coordinate f

movement w/ either

hands

-has tremors or is aw

moves off shin

-misses finger; uncoor

-anesthesia; paresthes

-reduced or heightene

-areas of dulled or lost

-unable to determine

of one or more finger



y GLASGOW COMA SCALE

Faculty measured Response Score

Eye opening

Motor response

Verbal response

Spontaneous

To verbal command

To pain

No response

To verbal command

To localized pain

Flexes & withdraws

Flexes abnormally

Extends abnormally

No response

Oriented, converses

Disoriented, converses

Uses inappropriate words

Makes incomprehensible sounds

No response

4

3

2

1

6

5

4

3

2

1

5

4

3

2

1

y CRANIAL NERVES

Cranial nerve Types & Function

I-Olfactory (Sensory) smell



II-Optic

III-Oculomotor

IV-Trochlear

V-Trigeminal

a.Ophthalmic Branch

b.Maxillary branch

c.Mandibular branch

VI-Abducens

VII-Facial

VIII-AuditoryVestibular branch

Cochlear branch

IX-Glossopharyngeal

(Sensory) vision &visual fields

(Motor) extraocular movement(EOM) ;movement

of sphincter of pupil; movement of ciliary muscles

of lens

(Motor) EOM; specifically, moves eyeball

downward and laterally

(Sensory) sensation of cornea, skin of face, and

nasal mucosa.

(sensory) Sensation of skin of face and anterior

oral cavity

(Motor and sensory) Muscle of mastication;

sensation of skin of face

(Motor) EOM; moves eyeball laterally

(Motor and Sensory) facial expression; taste

(anterior two-thirds of tongue)

(Sensory)Equilibrium

Hearing

(Motor and sensory) Swallowing ability, tongue

movement, taste (posterior tongue)



X-Vagus

XI-Accessory

XII-Hypoglossal

(Motor and sensory) sensation of pharynx and

larynx; swallowing; vocal cord movement

(Motor) Head movement; shrugging of shoulders

(Motor) Protrusion of tongue; moves tongue up

and down and side to side

y FEMALE GENITALS & INGUINAL AREA

Assessment Normal findings Deviations from nor

1. Distribution, amount &

characteristics of pubic

hair

2. Inspect for parasites,

swelling & lesions.

3. Inspect clitoris, urethral& vaginal orifice.

4. Palpate inguinal lymph

nodes.

-kinky in menstruating adults;

thinner & straighter after

menopause; inverse triangle

-skin intact; no lesions; slightly

darker than the rest of the body;

labia round, full and

symmetrical

-clitoris does not exceed 1 cm inwidth & 2 cm in length; urethral

orifice appears as a small slit

-no enlargement

-scant pubic hair; d

over the abdomen

-lice; lesions; scars; f

-presence of swdischarge

-enlargement & tend



y MALE GENITALS & INGUINAL AREA


1. Distribution, amount &

characteristics of pubic

hair.

2. Inspect penile shaft.

3. Inspect urethral meatus.

4. Palpate penis for

tenderness.

5. Inspect the scrotum.

6. Palpate the scrotum.

7. Inspect inguinal areas.

-triangular, often spreading to

the abdomen

-penile skin intact; slightly

wrinkled; foreskin easily

retractable; small amount of

smegma

-pink & slitlike appearance; top

of penis

-slightly movable; smooth &

semifirm

-Darker in color than the rest of

the body; varies w/

temperature; asymmetric

-testicles are rubbery, smooth &

free of nodules; testis is about 2

4 cm

-no swelling

-scant amount of ha

-lesions, nodules

-inflammation;

variation in location

-immobile; pres

tenderness

-discoloration; tighte

-enlarged testicles

surface

-swelling or bulge



6. Verbalize understanding on triagenursing

y RECTUM & ANUS


1. Inspect anus for color,

integrity & skin lesions.

2. Palpate rectum for anal

sphincter tonicity,

nodules, masses

3. Observe feces.

-intact perianal skin; slightly

more pigmented than the skin

of the buttocks; hairless

-has good tone

-brown

-fissures, ulcers,

tumors

-hypertonicity/hypo

-presence of mucu

black stool

G. Triage nursing

y From the French word trier, which means to sort out or choose, this term applies

allocating treatment prioritizations for casualties from disasters or in warfare. This helps m

treat urgent casualties, to defer those whose treatment is less urgent and to provide care a

those with fatal injuries.

A. TRIAGE CATEGORIES

1. Emergent Io Patients that requires immediate medical interventions; potentially life or limb thre

a. Airway compromise

b. Cardiac arrest

c. Severe shock

d. Cervical spine injury

e. Multisystem trauma

f. Altered LOC



g. Eclampsia

2. . Urgent II

o Patients with stable condition but requires medical intervention within a few hoursthreat to life or limb of these patients.

a. Fever

b. Minor burns

c. Minor musculoskeletal injuries

d. Dizziness

e. Lacerations

3. Non-emergent IIIo Patients with chronic or minor injuries; no danger to life or limb by having these p

be seen; no obvious signs of distress noted.

a. Chronic low back pain

b. Routine medical refills

c. Dental problems

d. Missed menses

B. T YPES OF TRIAGE NURSING

y Nonprofessional determination of priority of care assessment and prioritization are car

registration clerk according to how sick the patient appears.

y Basic triage a quick assessment is done by an RN, LPN, or physician to ensure that the m

or injured patients are treated first; a chief complaint is determined with little or no coll

data; little to no documentation is done.

y Comprehensive triage assessment and prioritization are done by an educated, exper

standards are developed and followed for assessment, prioritization, and plan of care, imm

action, and documentations. This type utilizes established triage categories.



REFERENCES:

o Kozier, B.& Erb, G.(2002).FUNDAMENTALS OF NURSING: CONCEPTS, PROCESS AND PRACTICE.(5TH ed).Singapore:Pearson Education Asia Pte. Ltd

o Marieb, E.(2003).Essentials of Human Anatomy & Physiology.( 7th

edition).San Francisco:Pearson Education Inc

o Black, J.M. & Hawks, J.H.(2004). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (7th

ed, Vol 2).Singapore: Elsevier Pte. Ltd.

o Buschiazzo, L.(1987). The Handbook of Emergency Nursing Management. Maryland: Aspen Publisher, Inc.

o Lippincott, J.B. The Lippincott Manual of Nursing Practice.(6th

ed) Philadelphia: Lippincott-Raven Publishers

7. Summarize physical examination

C. RESPONSIBILITIES OF A TRIAGE NURSE

Be aware of arriving patients Maintain contact with patients in the waiting room

Have a warm and caring manner of all patients

Be in ongoing communication with the charged nurse

Assigned patient to treatment rooms or notify the charged nurse of patients who nee

urgent treatment

Demonstrate understanding of patient and family requests and concerns

Determine priorities of care

Determine how non-emergent patients are brought in or called into the ED proper for treat

pa and triage

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