NUR 101 Adult Health Assessment

NUR 101 Adult Health Assessment

NUR 101 Adult Health Assessment

Adult Health Assessment-Abdomen, Rectum, Breast, and Axillae

Abdomen, Rectum and Breast and Axillae Assessment

Abdomen and Rectum

Equipment:

1) Stethoscope
2) Centimeter ruler and nonstretchable measuring tape.
3) Marking Pen

Preparation:
1) Use good source of light.
2) Full exposure of the abdomen.
3) Warm hands.
4) Comfortable relaxed position.
5) Divide abdomen in four regions.

Inspection:
1) Observe skin color and surface characteristics. Fine venous network is often visible.
2) Inspect for bruises and localized discoloration.
3) Assess umbilicus. A bluish periumbilical discoloration
(Cullen sign) suggests intraabdominal bleed.
4) Assess for striae, should be silvery in color.
5) Inspect for lesions and nodules.
6) Inspect for scar, good history indicator.
7) Inspect hair distribution.
8) Inspect contour (flat, round, scaphoid). Should be symmetrical.
9) Inspect umbilicus.
10) Ask patient to raise his head from the table to assess any tumor.
11) Assess abdomen for respiratory movement and peristalsis (should not be seen unless an obstruction has occurred).

Auscultation:
1) Bowel sounds: Assess for clicks or gurgles (5-35 per min.). Loud prolonged gurgles are called borborygmi (stomach growling). Hyperactive BS is present in gastroenteritis and early intestinal obstruction. The absence of BS is established only after listening for 5 min.
2) Vascular sounds: with the bell and all four quadrants,in the aortic. Iliac, and femoral arteries for bruits.

Percussion:
1) Liver span: right midclavicular line, work yourself downward, should be 2.5 to 4.5 in.
2) Spleen: percuss posterior to the midaxillary line on theleft side (6 to 10th rib).

Palpation:
1) Light palpation: palpate all four quadrants, lay palm of the hand lightly on the abdomen, and depress the abdominal wall no more than 1 cm. Abdomen should feel smooth with a consistent softness. Used to assess areas of tenderness, large mass or distended structures.
2) Moderate palpation: Use above procedure but exerts moderate pressure.
3) Deep palpation: used to delineate abdominal organs and identify less obvious masses.
4) Palpate the liver: place your left hand under the 11th and 12th rib, pressing upwards. Place your right hand on the abdomen, fingers pointing towards the head, should face the right mid-clavicular line. Ask patient to take a deep breath and press firmly and deeply. Liver edge should be firm, even and non-tender.
5) Kidneys: ask patient to assume a sitting position. Place palm of the hand over the right costovertebral angel and strike your hand with the ulnar surface of the fist of your other hand.

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NUR 101 Adult Health Assessment

Breast and Axillae

Before beginning the examination, ask the patient ifhe or she has felt any lump(s) or other problems pertaining to the breast.
Encourage a self-breast examination every month. Your role as an educator is critical.

Inspection:
1) Inspect the breast and nipples; skin changes, symmetry, and contour, assessretraction hands at sides, over head, against hips and leaning forward).
2)When examining an adolescent girl use Tanner’s sex maturity rating.

Palpation:
1) Best performmed when the breast tissue is flattened.
2) Use 2nd, 3’d, 4th fingers keeping fingers slightly flexed.
3) Ann should be adducted while palpating breast.
4) Use circular motion.
5) If you detect a lump:
a) Note the location, use clock method with centimeters ITom the nipple. b) Size in centimeters.
c) Shape: round, cystic, disc like or irregular.
d) Consistency: soft, finn or hard.
e) Tenderness
6) Palpate the nipples, note any discharge.

Inspection of axillae

1) Note any rash, infection or unusual pigmentation

Palpation
Fingers should line directly behind the pectoral muscle, pointing towards the midclavicular line.

NUR 101 Adult Health Assessment

Lymphatic System:

Inspection and Palpation
1) Inspect each area of the body for any apparent lymph nodes, edema, erythema, red streaks or skin lesions.
2) Palpate: using the pads of the second, third and fourth finger gently palpate the superficial;nodes.
3) Detect any enlargement and note the consistency, mobility, tenderness, size and warmth of the node.
4) Follow an eight step sequence when assessing the head and neck, bend patient’shead slightly forward:
1) The occipital nodes at the base of the skull.
2) The post auricular nodes located superficially over the mastoid process.
3) The preauricular nodes just in ITont of the ear.
4) The parotid and retro pharyngeal (tonsillar) nodes at the angel ofthe mandible.
5) The submandibular nodes halfway between the angel and the tip of the mandible.
6) The submental nodes in the midline behind the tip of the mandible.

Move down to the neck, palpating in the following four sequences:
I) The superficial cervical nodes at the sternocleidomastoid.
2) The posterior cervical nodes along the anterior boarder of the trapezius muscle.
3)The cervical nodes deep to the sternocleidomastoid.
4) The supraclavicular area, probing deeply into the angle formed by the clavicle and sternocleidomastoid area.