Health Assessment by Body Part

2. Eye

   1. History

      1. current symptoms

      2. past problems

      3. family history - glaucoma, cataracts

      4. harmful exposure - chemical sunlight

   2. Physical exam

      1. vision test

      2. extraocular muscle functions (EOM's)

      3. external eye structures

      4. internal eye structures and red reflex

      5. optic disc

      6. retinal vessels

   3. Geriatric alterations of eye

      1. arcus senilis

      2. pupils often miotic (smaller) with slower dilation

      3. iris may appear paler

      4. retina may appear paler

      5. disc may be slightly smaller and more opaque

      6. presbyopia

      7. color perception may be dimmed

3. Ear (illustration)

   1. History

      1. presenting problem or injury

      2. presence of hearing loss

      3. use of hearing assist

      4. associated symptoms

      5. onset

      6. precipitating factors

      7. aggravating and alleviating factors

      8. lifestyle factors: swimming, musician

      9. medical history

      10. family history of allergy or hearing disease

      11. medications

2. Inspection - external ear

   1. observe size, shape and symmetry of both ears

   2. auricles are normally level with each other, and upper point of attachment is in a straight line with the lateral canthus of the eye

   3. inspect ear skin for color, lesions, rash and scaling

   4. inspect area behind auricle for tophus

3. Palpation

   1. palpate auricle, tagus and mastoid area for tenderness and elevated local temperature

   2. normal findings: auricle is normally smooth without lesions

   3. estimate size of external auditory meatus

4. Otoscopic examination

   1. adult: grasp auricle and pull up and back to straighten external ear canal before inserting otoscope

   2. child: grasp auricle and pull down and back

   3. inspect ear canal for redness, swelling, discharge, crusting and foreign bodies

   4. expect a small amount of moist, usually orange cerumen (ear wax). Cerumen is usually dry in Asians, Native Americans, and the elderly

   5. tympanic membrane

      1. normal finding: translucent, shiny, light gray, taut disk; free from tears or breaks

      2. test its mobility: ask client to say "ah" or swallow. Intact membrane will vibrate slightly

5. Hearing acuity: four tests

   1. gross hearing is tested by client's response to normal conversation

   2. whispered word or ticking watch test

   3. Weber test: tuning fork of 512 cps is set to vibrate and placed perpendicularly on the midline vertex of the skull. Client asked to report in which ear sound is heard. If heard in one ear, suspect sensorineural loss in the other

   4. Rinne test - compares sound conduction: air versus bone

      1. set tuning fork to vibrate

      2. place on mastoid process

      3. ask client whether the sound is heard and when it can no longer be heard. Note how long the sound can be heard.

      4. when client states that sound is gone, immediately move the tuning fork to about 2 cm from auditory canal

      5. ask the client again whether there is sound and when it stops

      6. normal finding: latter sound should be heard twice as long as that of mastoid sound

6. Geriatric alterations

   1. ear lobes may appear pendulous

   2. presbycusis

4. Mouth and pharynx

   1. Inspection: normal findings

      1. temporomandibular joint: smooth jaw excursion; easy mobility

      2. lips and buccal mucosa: symmetrical, pink; smooth and moist

      3. teeth and gums: 32 adult teeth; pink gums

      4. tongue: symmetry; pink; moist; papilla present

      5. hard and soft palate: hard palate is pale, immovable with transverse rugae; soft palate is pink and movable

      6. Oropharynx: symmetrical; midline uvula, tonsils may be present on either side

   2. Geriatric alterations

      1. mucosa may be drier

      2. sense of taste may be diminished

      3. decreased saliva

      4. lips thinner, shiny

      5. teeth may appear yellowish

      6. tongue may appear smoother

5. Skin (illustration)

   1. General appearance - inspection

      1. color

         1. varies with body part, and from person to person

         2. color ranges

            • "white" skin: Ivory or light pink to ruddy pink

            • dark skin: light to dark brown or olive

1. alterations in skin color

1. hyperpigmentation

2. hypopigmentation

3. cyanosis

4. jaundice

5. erythema

1. moisture

2. temperature

3. texture: varies from part to part

   1. smooth or rough

   2. supple or tight

   3. indurated

4. turgor

   1. normally decreases with age

   2. decreased in dehydration

5. vascularity

   1. in older people, capillaries are more fragile

   2. petechiae

6. edema

8. lesions

   1. normal finding: free of lesions

   2. age-related changes include keratosis senilis, cherry angiomas, and atrophic warts. (See also 2. Geriatric changes, on page 20)

   3. primary lesions

      • macule

      • papule (illustration)

      • patch

      • plaque

      • vesicle

      • bulla

      • pustule

      • nodule

   4. secondary lesions (arise from primary)

      • scale

      • crust

      • lichenification (illustration 1   illustration 2 )

      • scar

      • excoriation

      • ulcer

      • fissure

      • keloid

      • erosion

   5. for every lesion, note eight aspects:

      • color

      • location

      • texture

      • size

      • shape

      • type

      • grouping

      • distribution

9. hair

   • hirsutism

   • alopecia

10. nails

11. factors affecting skin condition

    • hygiene

    • nutritional status

    • underlying disorders

12. geriatric changes in skin (besides wrinkling, and loss/graying of both head and body hair)

    • thinner skin

    • more freckles

    • hypopigmented patches

    • skin is drier, especially on lower extremities

    • less perspiration

    • all skin becomes less elastic; hanging parts sag

    • toenails may be thick, distorted, and yellowish

    • lesions: cherry angiomas, senile keratosis, atrophic warts

6. Heart

   1. Assess the heart through the anterior thorax (front chest)

   2. Inspection and palpation

      1. client in supine position or with head elevated at 45 degrees

      2. anatomical landmarks of the heart

         1. second right intercostal space - aortic area

         2. second left intercostal space - pulmonic area

         3. third left intercostal space - Erb's point

         4. fourth left intercostal space - tricuspid area

         5. fifth left intercostal space - mitral (apical) area

         6. epigastric area at tip of sternum

      3. apical impulse

         1. fourth or fifth left intercostal space, midclavicular line

         2. may or may not be seen

         3. normally a short, gentle tap

   3. Auscultation

      1. client takes three positions: sitting, supine, left lateral recumbent

      2. use stethoscope to auscultate heart sounds

      3. s₁

         1. closing of the mitral valve

         2. after long diastolic pause and

         3. before short systolic pause

         4. heard best at apex

      4. S₂

         1. closing of aortic valve

         2. after short systolic pause and

         3. before long diastolic pause

         4. heard best over aorta - second right interspace

         5. high pitched, dull in quality

      5. pulse deficit

      6. murmurs

         1. grading system 

         2. asymptomatic or symptomatic

         3. thrill

         4. systolic murmur occurs between S1 and S2

         5. diastolic occurs between S2 and S1

7. Vasculature

   1. Blood pressure  

      1. reflects relationship between cardiac output, peripheral vascular resistance, blood volume and viscosity, and arterial elasticity
         (illustration )

      2. factors influencing blood pressure

         1. age

         2. stress

         3. race

         4. drugs

         5. diurnal (day-night) variations

         6. gender

      3. alterations in blood pressure

         1. hypertension

         2. hypotension

      4. range of normal blood pressure

         1. child under age two weighing at least 2700g: use flush technique,30-60mg Hg

         2. child over age two: 85-95/50-65 mm Hg

         3. school age: 100-110/50-65 mm Hg

         4. adolescent: 110-120/65-85 mm Hg

         5. adult: <130 mm Hg Systolic / <85 mm Hg diastolic

2. Internal carotid arteries in neck

   1. palpate each separately along margin of sternocleidomastoid

   2. normal findings: strong thrusting pulse

   3. auscultate both sides

   4. normal findings: no sound heard

   5. constriction causes bruit

3. Jugular veins

   1. client in supine position with head elevated at 45 degrees

   2. normal findings: pulsations not evident

   3. jugular venous pressure (JVP): not to exceed three cm above level of sternal angle

4. Peripheral arteries and veins

   1. pulse

      1. locations 

      2. normal range of peripheral pulses

         • infants: 120 to 160 beats/minutes

         • toddlers: 90 to 140 beats/minutes

         • preschool/school-age: 75 to 110 beats/ minute

         • adolescent/adult: 60 to 100 beats/minute

      3. factors affecting rate

         • exercise

         • temperature

         • stress

         • drugs

         • hemorrhage

         • postural changes

         • pulmonary conditions causing poor oxygenation

2. rhythm - regular (normal) or irregular

3. strength

   1. reflects volume of blood ejected with each beat

   2. grading system 

4. equality

5. alterations

6. dysrhythmias

7. tissue perfusion

   1. temperature

   2. color: Cyanosis

   3. clubbing

   4. edema  

   5. skin and nail texture

   6. hair distribution on lower extremities

   7. presence of ulcers

8. Lungs (illustration )

   1. History: smoking, infections, pain, discomfort, dyspnea, activity intolerance, fever

   2. Inspection

      1. general appearance: respirations

         1. breathing should be quiet and easy

         2. respiration involves ventilation, diffusion, and perfusion of gases

         3. factors influencing respirations

            • exercise

            • pain

            • anxiety

            • stress

            • anemia

            • posture

            • drugs: narcotics, amphetamines

         4. normal rates of respiration

            • newborn: 35 to 40 breaths/minute

            • infant: 30 to 50 breaths/minute

            • toddler: 25 to 35 breaths/minute

            • school age: 20 to 30 breaths/minute

            • adolescent/adult: 14 to 20 breaths/minute

            • adult: 12 to 20 breaths/minute

         5. depth: deep, normal, shallow

         6. rhythm: regular, irregular; Normal finding: regular

         7. skin color

         8. chest wall configuration

• normal findings: symmetrical with bilateral muscle development

• a-p to transverse ratio range: one to five: two to seven