Health and Physical Assessment of the Adult

Question 1

SOAP

Answer 1

Subjective
Objective
Assessment
Plan

Question 2

Subjective

Answer 2

Identifying client information
Problems, allergies, medications, immunizations (PAMI)
General client information
Chief complaint or reason for seeking care
History of present illness (OLDCARTS)
Past medical history
Family history
Personal and social history
Review of systems

Question 3

OLDCARTS

Answer 3

Onset
Location
Duration
Character
Aggravating/associated factors
Relieving factors
Timing
Severity

Question 4

Objective

Answer 4

General statement: age, race, gender, general appearance, weight, height, body mass index, vital signs.
Physical assessment from head to toe and mental status

Question 5

Assessment

Answer 5

• diagnose with rationale
• rationale derived from subjective and objective data
• symptoms can be listed as diagnoses
• there may be a list of differential diagnoses, which are suspected and are yet to be confirmed
• may include anticipated problems such as progression of disease or complications.

Question 6

Plan

Answer 6

Typically denoted in the following order:

• Diagnostic tests, treatment plan with rationale
• client education and counseling
• referrals
• follow up or dates for re-evaluating results of plan

Question 7

Assessment techniques

Answer 7

Inspection, palpation, percussion, and auscultation (this order, except abdominal).
Vital signs.

Question 8

Body assessment: Integumentary

Answer 8

Involves inspection and palpation of skin, hair and nails.
Color, temp, dryness or moisture, turgor, texture, bruising, itching, rash, hair loss, nail abnormalities, lesions, scars, birthmarks, edema, capillary filling time (less than 3 seconds).

Question 9

Characteristics of skin color

Answer 9

Cyanosis: mottled bluish coloration.
Erythema: redness.
Pallor: Pale, whitish, coloration.
Jaundice: yellow coloration.

Question 10

Pitting Edema Scale

Answer 10

1+ a barely perceptible pit (2mm);
2+ a deeper pit, rebounds in a few seconds (4mm);
3+ a deep pit, rebounds in 10-20 seconds (6mm);
4+ a deeper pit, rebounds in > 30 seconds (8mm).

Question 11

Body assessment: head, neck, and lymph nodes

Answer 11

Head - inspect size, shape, edema; palpate temporal arteries, frontal and maxillary sinuses. Ask the client to open and close mouth and move side to side (note crepitation, tenderness or limited motion) to test nerve V (trigeminal).
Neck - Inspect symmetry of muscles, range of motion. Palpate the trachea and thyroid gland while the client takes a sip of water (usually cannot be palpated, unless it is enlarged).
Lymph nodes: palpate with both hands, comparing sides.

Question 12

Body assessment: eyes

Answer 12

Includes inspection, palpation, vision testing and use of ophthalmoscope.

• Inspect: eye structure, eyelids (ptosis), and eyeballs (exophthalmos or enophthalmos). Conjunctiva, sclera, lacrimal apparatus, cornea, lens, iris and pupils.
• Snellen eye chart: with chart at eye level and 20 feet away, ask to read the smallest line they can discern. 1 eye at a time, keep glasses (except reading glasses) or contacts. Record the result using the fraction at the end of line read. Normal is 20/20. This tests cranial nerve II (optic).
• Near vision: test nerve II, normal 14/14.
• Confrontation test: peripheral vision compared to nurse’s. Nerve II.
• Cover-uncover test: check deviated alignment.
• Diagnostic positions test: 6 cardinal positions of gaze. Test cranial nerves III (oculomotor), IV (trochlear), VI (abducens).
• Color vision: Ishihara chart, test red and green blindness.
• Pupils: round and equal, use o direct light with normal constriction.
• Sclera and cornea: assess color and characteristics.
• Fundoscopy (other card)

Question 13

Documenting pupillary normal findings

Answer 13

PERRLA

Pupils Equal Round Reactive to Light reactive to Accommodation.

Question 14

Ophthalmoscopy or Fundoscopy

Answer 14

• dark room so pupil will dilate.
• instrument on right hand for right eye, left for left.
• client must look straight ahead.
• examiner approach 15 degrees lateral and 12-15 inches away (30-38cm).
• look for the red reflex (absence may indicate opacity of the lens).
• examine the optic disc, retinal vessels, general background and macula.

Question 15

Body assessment: Ears

Answer 15

Inspection, palpation, hearing tests, vestibular assessment, and use of otoscope.

• Inspect and palpate external ear and auditory meatus.
• Auditory assessment: conductive (physical obstruction to sound waves), sensorineural (defect in cochlea, VIII nerve or brain), or mixed (both).
• Voice (whisper) test: whisper 30-60 cm away two syllabe-word while covering the mouth.
• Watch test: hold watch 5 inches (12.5cm) from each ear and ask if client can hear.
• otoscopic exam

Question 16

Vestibular assessment

Answer 16

• Test for falling (Romberg’s): stand, feet together, arms loosely, eyes closed. Significant sway means is positive.
• Test for Past Pointing: eyes closed, arms extended, pointing index fingers, raise both arms and lower back to point of reference (examiners own index fingers). Client with vestibular problem lacks normal sense of position, deviating to the left or right.
• Gaze Nystagmus evaluation: eyes are examined as the client looks straight ahead, 30 degrees to each side, upward and downward. Shouldn’t present nystagmus.
• Dix-Hallpike Maneuver: client is in sitting position, turn head to a 45 degree angle an then lower client to “supine”, observe eyes for 30 seconds and repeat on other side if negative. Positive if shows nystagmus.

Question 17

Body assessment: nose, mouth, and throat

Answer 17

Inspect: nose (could use otoscope), lips, teeth, gums, tongue, uvula and tonsils (use tongue depresser).
Palpate: frontal sinuses.
Test gag reflex (nerve IX glossopharyngeal)
Tonsils grade scale:
- 0 surgically removed
- 1+ tonsils hidden within pillars
- 2+ tonsils extending to the pillars
- 3+ tonsils extending beyond pillars
- 4+ tonsils extending to the midline.
Test nerve XII (hypoglossal) by asking the client to stick out the tongue (should protrude in the midline).

Question 18

Body assessment: Lungs

Answer 18

-Inspection: color, rate, quality, shape, position.
-Palpation: entire chest and look for abnormalities. Assess chest excursion and tactile or vocal fremitus.
-Percussion: Resonance is noted in healthy lung tissue. Hyperresonance when excessive air is present and dull note indicates lung density.
-Auscultation: vesicular, bronchial and bronchovesicular arr normal breath sounds.
Adventitious sounds: crackles (fine, medium or coarse), wheeze, rhonchi, and pleural friction rub.

Question 19

Body assessment: Heart

Answer 19

• Inspect: chest and apical impulse (not always visible), check for pretibial edema, BP.
• Palpations: apical pulse (4-5th space LMC). Inguinal nodes, carotid and peripheral pulses.
• Percussion: may be performed to outline heart and check enlargement.
• Auscultation: aortic (2R), pulmonic (2L), erb’s point (3L), tricuspid (4L), mitral (5L LMC). Carotid artery.

Question 20

Body assessment: Breast

Answer 20

Inspect: symmetry, masses, retraction, color, venous pattern, shape, discharge of nipple and areola.
Palpation: entire breast and noting consistency. Compress the nipple to evaluate discharge. Assess axillary lymph nodes (normally not palpable).

Question 21

Body assessment: Abdomen

Answer 21

• Inspection: describe as flat, rounded, concave, or protuberant. Observe symmetry (masses), umbilicus (midline), skin, pulsation (aorta may be noted on epigastric area).
• Auscultation: listen 4 quadrants, begin right lower. Normal if 5 to 30 sounds per minute. Absent if no sound for at least 5 minutes. Auscultate aorta, renal arteries, and femoral.
• Percussion: all 4 quadrants. Tympany should be predominate, with dullness over the liver and spleen.
• Palpation: all 4 quadrants, liver, spleen (may not be palpable), and aortic pulsation (expands laterally if an aneurysm is present).

Question 22

Body assessment: musculoskeletal system

Answer 22

Inspection and palpation.

Assess range of movement, muscle tone and strength.

Question 23

Body assessment: neurological system

Answer 23

Assessment of cranial nerves, level of consciousness, pupils, motor function, cerebellar function, coordination, sensory function, and reflexes.
Vital signs.

Question 24

Body assessment: neurological system

Sensory Function

Answer 24

• Pain: apply a sharp object and a dull point to the body in random order and ask the client to identify each.
• Light touch: brush piece of cotton over skin in various locations and ask the client to say when the touch is felt.
• Position sense (kinesthesia): move the client’s finger or toe up or down and ask which way it has been moved.
• Stereognosis: ability to recognize object placed in the hand.
• Graphesthesia: ability to identify a number traced on the client’s hand.
• Two-point discrimination: ability to discriminate 2 simultaneous pinpricks on the skin.

Question 25

Reflexes

Answer 25

• Deep tendon: biceps, triceps, brachioradialis, patella, achilles.
• Plantar reflex: Babinski’s sign - toes down is the normal response (older than 2 years)

Question 26

Testing meningeal irritation

Answer 26

• Brudzinski’s sign: supine position, flex the head toward chest. Positive if client flexes the hip and knee and reports pain.
• Kernig’s sign: supine position, flex the leg at the hip and knee. Complains of pain along the vertebral column when leg is extended.