Fundamental & Advanced Nursing Skills_1 ppt

AUTHORS CONTRIBUTING AUTHORS Patricia Abott, RN, MSN, ARNP University of Washington Medical Center School of Nursing, University of Washington Academic Coordinator of Clinical Education

Valerie Coxon

RN, PhD

Affiliate Assistant Professor School of Nursing University of Washington Seattle, Washington Chief Executive Officer NRSPACE Software, Inc Bellevue, Washington

Patricia Buchsel

RN, MSN, FAAN

Clinical Instructor School of Nursing University of Washington Seattle, Washington

Gaylene Bouska Altman

NOTICE TO THE READER Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connec- tion with any of the product information contained herein Publisher does not assume, and expressly disclaims, any obligation

to obtain and include information other than that provided to it by the manufacturer.

The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities herein and to avoid all potential hazards By following the instructions contained herein, the reader willingly assumes all risks in con- nection with such instructions.

The publisher makes no representation or warranties of any kind, including but not limited to, the warranties of fitness for particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material The publisher shall not be liable for any special, conse- quential, or exemplary damages resulting, in whole or part, from the readers’ use of, or reliance upon, this material.

Delmar Staff:

Business Unit Director: William Brottmiller

Executive Editor: Cathy L Esperti

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Project Editors: Patricia Gillivan and Christopher C Leonard

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Cover Design: Timothy J Conners

All rights reserved Thomson Learning © 2000 The text of this publication, or any part thereof, may not be reproduced or

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Library of Congress Cataloging-in-Publication Data

Altman, Gaylene.

Delmar’s fundamental and advanced nursing skills book / Gaylene

Altman, Patricia Buschel, and Valerie Coxon.

p cm.

Includes bibliographical references and index.

ISBN 0–7668–0715–0

1 Nursing Handbooks, manuals, etc I Buschel, Patricia.

II Coxon, Valerie III Title IV Title: Fundamentals and

advanced nursing skills book.

[DNLM: 1 Nursing Care—methods 2 Nursing Process WY 100

Dr Altman would like to dedicate this book and express a special thanks to her husband, Len, and her three dren, Jonathan, Matthew, and especially Katherine, who exhibited patience and understanding during this project,and to all the staff and clients at the numerous health facilities who made this project possible.

chil-Patricia Buchsel would like to dedicate this book to professional nurses, health care providers, and clients who willbenefit from the application of knowledge represented in this book

Dr Coxon would like to dedicate this book and express her thanks to the many people who made this project sible—contributing authors, the staff of NRSPACE Software, and especially to Keith Goodman and Karrin Johnsonfor their unyielding sense of humor and energy under fire

pos-vDEDICATION

1-1 Physical Assessment 2

1-2 Taking a Temperature 28

1-3 Taking a Pulse 40

1-4 Counting Respirations 47

1-5 Taking Blood Pressure 53

1-6 Weighing a Client, Mobile and 61

Immobile

1-7 Measuring Intake and Output 68

1-8 Breast Self-Examination 74

1-9 Collecting a Clean-Catch, 82

Midstream Urine Specimen

1-10 Testing Urine for Specific Gravity, 89

Ketones, Glucose, and Occult Blood

1-11 Performing a Skin Puncture 96

1-12 Measuring Blood Glucose Levels 101

1-13 Collecting Nose, Throat, and 108

2-5 Donning a Cap and Mask 150

2-6 Removing Contaminated Items 155

2-7 Applying Sterile Gloves via the 162Open Method

2-13 Performing the Heimlich Maneuver 209

2-14 Responding to Accidental Poisoning 219

2-15 Emergency Client Transport 224

3-5 Applying Moist Heat 264

3-6 Warm Soaks and Sitz Baths 270

3-7 Applying Dry Heat 275

3-8 Using a Thermal Blanket and an 283

Infant Radiant Heat Warmer

3-9 Applying Cold Treatment 291

3-10 Assisting with a Transcutaneous 298

Electrical Nerve Stimulation (TENS)

Unit

4-1 Changing Linens in an Unoccupied 308

Bed

4-2 Changing Linens in an Occupied Bed 316

4-3 Turning and Positioning a Client 322

4-4 Moving a Client in Bed 330

4-5 Assisting with a Bedpan or Urinal 337

4-6 Assisting with Feeding 344

4-7 Bathing a Client in Bed 351

4-8 Oral Care 358

4-9 Perineal and Genital Care 368

4-10 Eye Care 374

4-11 Hair and Scalp Care 382

4-12 Hand and Foot Care 390

4-13 Shaving a Client 398

4-14 Giving a Back Rub 404

4-15 Changing the IV Gown 409

4-16 Assisting from Bed to Stretcher 415

4-17 Assisting from Bed to Wheelchair, 421

Commode, or Chair

4-18 Assisting from Bed to Walking 427

4-19 Using a Hydraulic Lift 434

4-20 Administering Preoperative Care 441

4-21 Preparing a Surgical Site 450

4-22 Assessing Immediate Postoperative 459

Care

4-23 Postoperative Exercise Instruction 467

4-24 Administering Passive Range of 475

Motion (ROM) Exercises

5-4 Administering Nasal Medications 520

5-5 Administering Rectal Medications 526

5-6 Administering Vaginal Medications 532

5-7 Administering Nebulized 539Medications

5-8 Administering an Intradermal 547Injection

5-9 Administering a Subcutaneous 552Injection

5-10 Administering an Intramuscular 558Injection

5-11 Administering Medication via 564Z-track Injection

5-12 Withdrawing Medication from a Vial 570

5-13 Withdrawing Medication from an 576Ampoule

5-14 Mixing Medications from Two Vials 582into One Syringe

5-15 Preparing an IV Solution 589

5-16 Adding Medications to an IV Solution 595

5-17 Administering Medications via 601Secondary Administration Sets

5-22 Administering Epidural Analgesia 631

5-23 Managing Controlled Substances 637

6-4 Removing a Nasogastric Tube 666

6-5 Feeding and Medicating via a 672Gastrostomy Tube

6-6 Maintaining Gastrointestinal Suction 681Devices

6-7 Applying a Condom Catheter 687

6-8 Inserting an Indwelling Catheter: Male 693

6-9 Inserting an Indwelling Catheter: 701

Female

6-10 Routine Catheter Care 709

6-11 Obtaining a Residual Urine Specimen 713

from an Indwelling Catheter

6-12 Irrigating a Urinary Catheter 717

6-13 Irrigating the Bladder Using a 724

6-20 Digital Removal of Fecal Impaction 775

6-21 Inserting a Rectal Tube 781

6-22 Irrigating and Cleaning a Stoma 786

6-23 Changing a Bowel Diversion 792

Ostomy Appliance: Pouching a Stoma

7-1 Administering Oxygen Therapy 800

7-2 Assisting a Client with Controlled 809

Coughing and Deep Breathing

7-3 Assisting a Client with an Incentive 814

Spirometer

7-4 Administering Pulmonary Therapy 819

and Postural Drainage

7-5 Administering Pulse Oximetry 823

7-6 Measuring Peak Expiratory Flow Rates 829

7-7 Administering Intermittent 837

Positive-Pressure Breathing (IPPB)

7-8 Assisting with Continuous Positive 843

Airway Pressure (CPAP)

7-9 Preparing the Chest Drainage System 848

7-10 Maintaining the Chest Tube and 858

Chest Drainage System

7-11 Measuring the Output from a 865

Chest Drainage System

7-12 Obtaining a Specimen from a 869

Chest Drainage System

7-13 Removing a Chest Tube 873

7-14 Ventilating the Client with an 878Ambu Bag

7-15 Inserting the Pharyngeal Airway 885

7-16 Maintaining Mechanical Ventilation 890

7-17 Suctioning Endotracheal and 896Tracheal Tubes

7-18 Maintaining and Cleaning 903Endotracheal Tubes

7-19 Maintaining and Cleaning the 909Tracheostomy Tube

7-20 Maintaining a Double Cannula 915Tracheostomy Tube

7-21 Plugging the Tracheostomy Tube 922

8-1 Performing Venipuncture 926(Blood Drawing)

8-2 Starting an IV 934

8-3 Inserting a Butterfly Needle 941

8-4 Preparing the IV Bag and Tubing 948

8-5 Setting the IV Flow Rate 954

8-6 Assessing and Maintaining an 960

IV Insertion Site

8-7 Changing the IV Solution 965

8-8 Discontinuing the IV and 971Changing to a Heparin Lock

8-9 Administering a Blood Transfusion 977

8-10 Assessing and Responding to 985Transfusion Reactions

8-11 Assisting with the Insertion of a 991Central Venous Catheter

8-12 Changing the Central Venous Dressing 997

8-13 Changing the Central Venous Tubing 1003

8-14 Maintaining a Central Venous 1008Catheter

8-15 Measuring Central Venous 1013Pressure (CVP)

8-16 Drawing Blood from a Central 1020Venous Catheter

8-17 Infusing Total Parenteral Nutrition 1026(TPN) and Fat Emulsion through a

Central Venous Catheter

8-18 Removing the Central Venous Catheter 1035

8-19 Inserting a Peripherally Inserted 1040Central Catheter (PICC)

8-20 Administering Peripheral Vein Total 1049Parenteral Nutrition

8-21 Hemodialysis Site Care 1056

8-22 Using an Implantable Venous 1062

8-25 Assisting with the Insertion and 1081

Maintenance of an Epidural Catheter

WOUND CARE

9-1 Bandaging 1090

9-2 Applying a Dry Dressing 1098

9-3 Applying a Wet-to-Damp Dressing 1104

(Wet to Dry to Moist Dressing)

9-4 Applying a Transparent Dressing 1111

9-5 Applying a Pressure Bandage 1116

9-6 Changing Dressings around 1122

Therapeutic Puncture Sites

9-7 Irrigating a Wound 1131

9-8 Packing a Wound 1136

9-9 Cleaning and Dressing a Wound 1144

with an Open Drain

9-10 Dressing a Wound with Retention 1151

Sutures

9-11 Obtaining a Wound Drainage 1158

Specimen for Culturing

9-12 Maintaining a Closed Wound 1163

Drainage System

9-13 Care of the Jackson-Pratt (JP) Drain 1169

Site and Emptying the Drain Bulb

9-14 Removing Skin Sutures and Staples 1176

9-15 Preventing and Managing the 1183

Pressure Ulcer

9-16 Managing Irritated Peristomal Skin 1193

9-17 Pouching a Draining Wound 1199

AND SUPPORT

10-1 Applying an Elastic Bandage 1206

10-2 Applying a Splint 1212

10-3 Applying an Arm Sling 1218

10-4 Applying Antiembolic Stockings 1224

10-5 Applying a Pneumatic Compression 1229Device

10-6 Applying Abdominal, T-, or 1235Breast Binders

10-7 Applying Skin Traction—Adhesive 1241and Nonadhesive

10-8 Assisting with the Insertion of 1248Pins or Nails

10-9 Maintaining Traction 1255

10-10 Assisting with Casting—Plaster and 1261Fiberglass

10-11 Cast Care and Comfort 1267

10-12 Cast Bivalving and Windowing 1273

11-2 Magnetic Resonance Imaging (MRI) 1306

11-3 Assisting with Computed 1310Tomography (CT) Scanning

11-4 Assisting with a Liver Biopsy 1315

11-5 Assisting with a Thoracentesis 1322

11-6 Assisting with Abdominal 1330Paracentesis

11-7 Assisting with a Bone Marrow 1336Biopsy/Aspiration

11-8 Assisting with a Lumbar Puncture 1343

11-9 Assisting with Amniocentesis 1350

11-10 Assisting with Bronchoscopy 1356

11-11 Assisting with Gastrointestinal 1366Endoscopy

11-12 Assisting with a 1376Proctosigmoidoscopy

11-13 Assisting with Arteriography 1382

11-14 Positron-Emission Tomography 1389Scanning

AUTHORS

CONTRIBUTING

AUTHORS

Patricia Abott, RN, MSN, ARNP

University of Washington Medical Center

School of Nursing, University of Washington

Academic Coordinator of Clinical Education

Department of Physical Therapy

Wichita State University

Wichita, KS

Susan Weiss Behrend, RN, MSN

Fox Chase Cancer Center

Philadelphia, PA

Bethaney Campbell, RN, MN, OCN

University of Washington Medical Center

Gayle C Crawford, RN, BSN

Staff Nurse University of Washington Medical Center Seattle, WA

Eleonor U de la Pena, BS

Northwest Asthma and Allergy Center Seattle, WA

Jeanne Erickson, RN, MSN, AOCN

University of Virginia Cancer Center Portsmouth, VA

Tom Ewing, RN, BSN

Hematology-Oncology University of Washington Medical Center Seattle, WA

Susan Boyce Gilmore, MN, RN, CCRN

Lecturer, Biobehavior Nursing and Health Systems University of Washington

School of Nursing Seattle, WA

x

Health Care Project Manager

NRSPACE Software, Inc.

Bellevue, WA

Kimberly Sue Kahn, RN, MSN, FNP-C, CS, AOCN

University of Virginia

Portsmouth, VA

Catherine H Kelley, RN, MSN, OCN

Chimeric Therapies, Inc.

Clinical Research Nurse

Fred Hutchinson Cancer Research Center

Sally Ann Rinehart, RN, BSN

Nursing Lab Supervisor Pacific Lutheran University Tacoma, WA

Susan Rives, RN, BSN, OCN

CARE Center Coordinator Martha Jefferson Hospital Charlottesville, VA

Barbara Sigler, RN, MNEd, CORLN

Technical Publications Editor Oncology Nursing Press, Inc.

Formerly: Clinical Nurse Specialist in

Otolaryngology—Head and Neck Surgery University of Pittsburgh Medical Center Pittsburgh, PA

Pam Talley, MN, CNS

University of Washington School of Nursing Seattle, WA

Hsin-Yi (Jean) Tang, RN, MS

University of Washington School of Nursing Seattle, WA

Samuel C Taylor, RN

Assistant Nurse Manager, Orthopedics Harborview Medical Center

Seattle, WA

Robi Thomas, MS, RN, AOCN

Clinical Nurse Specialist for Oncology and the Pain Center

St Mary’s Mercy Medical Center Grand Rapids, MI

Nancy Unger, RN, MN, MPH

University of Washington Seattle, WA

Chandra VanPaepeghem, RN, BSN

University of Washington Medical Center Seattle, WA

Debra A Bovinett Wolf, RN, BSN, MPH

Roosevelt Pain Center University of Washington Medical Center Seattle, WA

Maryellen Zinsley, RN, BSN

University of Washington Medical Center Seattle, WA

Deborah J Gutshall, MSN, CRNP: Harrisburg Area

Community College, Harrisburg, PA

Marie H Ahrens, MS, RN: University of Tulsa, Tulsa, OK

Diana Prouty, RN, MS: St Luke’s College, Kansas City, MO

Kathy Campbell: Maria College, Albany, NY

Carol Fowler Durham, RN, MSN: University of North

Carolina—Chapel Hill, Chapel Hill, NC

Verlene Meyer, RN, MN: Walla Walla College, Portland, OR

Mary Moriarty Tarbell, MSN, RN:Springfield Technical Community College, Springfield, MA

Marie Ostoyich, RN, MS, CDE:Hudson Valley Community College, Troy, NY

Laura Downes, PhD, MSN, BSN, RN:Springfield Technical Community College, Springfield, MA

Cynthia Horvath, RN:Glens Falls Hospital, Glens Falls, NY

Clare Lamontagne, RN, MS:Springfield Technical Community College, Springfield, MA

Martha Nelson, RN, BSN, CETN, CCM:Florida Community College, University of North Florida, Jacksonville, FL

Mary C Doyle, BS, MS, CCRN:Maria College, Troy, NY

Teri Boese, MS, RN:The University of Iowa, Iowa City, IA

The face of our nation’s client population is changing

and will continue to do so more dramatically in the

fu-ture The cumulative effects of sophisticated

technol-ogy, an aging population of clients with chronic disease

and long-term sequelae, and an increasingly diverse

cultural population challenge nurses today

Fundamen-tal & Advanced Nursing Skills has been developed as a

text and guideline to perform the skills used in daily

nursing practice It is intended for nursing students,

registered nurses, licensed practical nurses, physician

assistants, nurse practitioners, certified aids, medical

as-sistants, and any health care worker performing the

skills encompassed in this book Practice parameters for

the advanced nursing skills may vary between states and

among institutions, as set forth in state and

institu-tional practice guidelines This book can be used as text

to acquire new skills, as a how-to manual to utilize

skills, as a procedure manual in a facility, as a manual to

familiarize a health care worker reentering health care,

or as a training manual within a facility Rather than

merely providing a step-by-step implementation, this

text can be used to stimulate the reader to learn

under-lying rationale, analyze expected outcomes of

treat-ment, formulate sound bases for implementation, and

develop critical thinking skills

This book contains 202 nursing skills divided into

11 chapters that cover basic and advanced nursing

pro-cedures The practitioner can follow the procedural

manual type steps presented for each skill to improve

competence and comfort levels in performing skills

Standards of nursing practice are maintained in each

skill Research-based knowledge has been incorporated

into nursing interventions, especially where controversymay exist

UNIVERSAL PRECAUTIONS

The procedures outlined in this book present universalprecautions in a general sense Universal precautionsare mandated by either Occupational Safety and HealthAdministration (OSHA) guidelines or by the Centersfor Disease Control (CDC) in appropriate instances.Universal precautions, as defined by the CDC, are a set

of precautions designed to prevent transmission of man immunodeficiency virus (HIV), hepatitis B virus(HBV), and other bloodborne pathogens when provid-ing health care

hu-Under universal precautions, blood and certainbody fluids of all clients are considered potentially infec-tious for HIV, HBV, and other bloodborne pathogens.However, implementing universal precautions does noteliminate the need for other isolation precautions, such

as droplet precautions for influenza, airborne isolationfor pulmonary tuberculosis, or contact isolation for me-

thicillin-resistant Staphylococcus aureus Universal

pre-cautions apply to blood, other body fluids containingvisible blood, semen, and secretions, cerebrospinal, syn-ovial, pleural, peritoneal, pericardial, and amniotic flu-ids Universal precautions do not apply to feces, nasal se-cretions, sputum, sweat, tears, urine, and vomitus unlessthey contain visible blood Universal precautions do notapply to saliva except when visibly contaminated withblood or in the dental setting where blood contamina-tion of saliva is predictable

PREFACE

Following universal precautions, gloves should be worn:

• for touching blood and body fluids requiring

uni-versal precautions, mucous membranes, or

nonin-tact skin of all clients, and

• for handling items or surfaces soiled with blood or

body fluids to which universal precautions apply

Gloves are changed after contact with each client

Hands and other skin surfaces must be washed

imme-diately, or as soon as client safety permits, if

contami-nated with blood or body fluids requiring universal

pre-cautions Hands should be washed immediately after

gloves are removed Gloves will reduce the incidence of

blood contamination of hands during phlebotomy, but

they cannot prevent penetrating injuries caused by

nee-dles or other sharp instruments In addition, the

fol-lowing general guidelines apply:

• Use gloves for performing phlebotomy when the

health care worker has cuts, scratches, or other

breaks in his or her skin

• Use gloves in situations where the health care

worker judges that contamination with blood may

occur (e.g., when performing phlebotomy on an

uncooperative client)

• Use gloves for performing finger and/or heel sticks

on infants and children

• Use gloves when persons are receiving training in

phlebotomy

Masks and Gowns

Masks and protective eyewear or face shields should be

worn by health care workers to prevent exposure of

mu-cous membranes of the mouth, nose, and eyes during

procedures that are likely to generate droplets of blood

or body fluids requiring universal precautions Gowns

or aprons should be worn during procedures that are

likely to generate splashes of blood or body fluids

re-quiring universal precautions

Needles and Other Sharp Objects

All health care workers should take precautions to

pre-vent injuries caused by needles, scalpels, and other

sharp instruments or devices Precautions apply during

procedures; when cleaning used instruments; during

disposal of used needles; and when handling sharp

struments after procedures To prevent needlestick

in-juries, needles should not be recapped by hand,

pur-posely bent or broken by hand, removed from

disposable syringes, or otherwise manipulated by hand

After they are used, disposable syringes and needles,

scalpel blades, and other sharp items should be placed

in puncture-resistant containers for disposal resistant containers should be located as close as practi-cal to the use area All reusable needles should be placed

Puncture-in a puncture-resistant contaPuncture-iner for transport to thereprocessing area

Infection Control

General infection control practices should furtherminimize the already minute risk of a salivary trans-mission of HIV These infection control practices in-clude the use of gloves for digital examination ofmucous membranes and endotracheal suctioning,handwashing after exposure to saliva, and minimizingthe need for emergency mouth-to-mouth resuscitation

by making mouthpieces and other ventilation devicesavailable for use in areas where the need for resuscita-tion is likely Although universal precautions do notapply to human breast milk, gloves may be worn byhealth care workers in situations where exposures tobreast milk might be frequent (e.g., in breast milkbanking)

NURSING PROCESS

Each skill is presented using the Nursing Process: sessment, Diagnosis, Planning, Expected Outcomes,Implementation, and Evaluation The nursing process is

As-a systemAs-atic method whereby nurses cAs-an mAs-ake clinicAs-aldecisions and delineate a course of action based onanalysis of available data The nursing process is contin-ual and cyclic Evaluation of the outcome incorporates

a feedback loop leading to further assessment, decisionmaking, and implementation of care

North American Nursing Diagnosis Association (NANDA)

The diagnosis section of the text is based on NANDA’sstandardized list of nursing diagnoses Using the input

of practicing clinicians, NANDA has developed and fined a standardized list of diagnostic labels for use inthe nursing process Using the standardized list as aguideline, the practitioner interprets the assessmentdata and derives a diagnosis The standardized diag-noses help guide client treatment by allowing the prac-titioner to identify rationales for client care and antici-pate potential problems

re-DOCUMENTATION AND CHARTING

Documentation provides a legal record of the client’sstatus and care provided This record is often used as a

means for quality assurance, utilization review of

hos-pital practices and statistical analysis of client outcomes

in areas of infection control, medical, surgical and

nurs-ing practices Legal documentation of the client’s status

and care can be used in a court of law to verify client

and health care practices

Charting includes sheets of documentation of facts

on forms such as flow sheets, including vital signs, fluid

intake and output, intravenous records; medication

ad-ministration records and assessment checklists and

de-scriptive information Charting format varies between

facilities Some examples of types of charting are the

nurse’s notes organized around subjectively, objectively,

assessment and planing (SOAP), notes organized

around client problems or problem-oriented medical

record (OMR), or notes organized around body

Sys-tems (SysSys-tems charting), or combinations of formats

The legal requirements for charting are dictated by state

laws, professional requirements, Joint Commission on

Accreditation of Healthcare Organizations (JCAHO)

and individual facility requirements Most facilities

have committees who approve and delineate guidelines

for charting

Client information should be recorded directly on

the chart; thereby, avoiding errors in transferring

in-formation For accuracy many facilities place daily

chart forms at the bedside so information can be

recorded promptly Forms generally include flow

sheets, assessment forms, and mediation records of

varying complexity Specialized forms include coma

scales, seizure precautions reports, and level of

con-sciousness recording Care maps and treatment plans

for routine specialized care are used when the client

is expected to recover in a predictable pattern with

expected advances each day Certain forms, such as

consent and insurance forms, must be signed by

clients or their legal guardian

Many hospitals have incorporated computerized

charting Often computers are located in client’s rooms

for immediate charting and retrieval of information

Many large facilities have adopted computerized

sys-tems for administration and charting of medications,

laboratory results, and diagnostic testing Guidelines

and strategies for minimizing the risks of computerized

charting are essential Once computer entries are part of

the permanent chart, they cannot be deleted; however,

policies exist whereby mistaken entries or incorrect

in-formation can be explained

With standard hard copy documentation,

guide-lines create consistency between facilities Some

ex-amples fo consistency are the use of black ink,

cor-rection by drawing a single line and marking the

error, noting the time of each entry, charting theomission of medications and treatments, and signingentries with initial of first name and complete lastname plus title

CLINICAL PRACTICE GUIDELINES FOR PERFORMING A PROCEDURE

In order to utilize this text to maximize learning, the thors have provided guidelines to follow before begin-ning the procedure and after the procedure

au-Before the Procedure

• Practice the procedure with supervision in a clinical setting

• Read the client’s chart

• Review the treatment plan or verify orders as necessary

• Review the procedure

• Assess the client and determine the appropriateness

of procedure

• Take into consideration the client/family’s culturaland social background when deciding what to teachand when eliciting feedback

• Employ the aid of an interpreter if there is a guage barrier

lan-• Use visual aids such as flip charts, models, videos, ifavailable, to explain procedure to client/family

• If family members are to be involved, plan to struct when they are present, if possible

in-• Client and/or family members should be providedwith a written set of instructions to take home withthem if needed

• Plan the procedure

After the Procedure

• Assess the client and his response to the procedure

• Document the client’s response

• Change the treatment plan as appropriate

SPECIAL FEATURES/UNIQUENESS

Step-by-Step Format.The implementation section ispresented in a step-by-step format with rationales foreach intervention included The skill is broken downinto simple, easy-to-follow steps with rationales ex-plaining the underlying reasons for each interven-tion This allows even the novice to perform the skilland understand why each step is necessary The stepspresented provide specific directions for performingeach skill However, institutional policies, client con-

dition, environmental setting, and other variablesmay prompt modification of the interventions pre-sented When modifications are made, adherence tostandards of practice and universal precautions must

be maintained Assess and evaluate the clientthroughout the procedure, modifying the interven-tions as needed to maintain client safety and secu-rity Rationales provide the scientific basis for eachimplementation The rationale enables both the prac-titioner and client to understand the reason for eachimplementation, and thus the need to comply withprotocols

Real-life Photographs.The focus of this text is to sent reality-based information with photographic ex-amples from current clinical practice, rather thanstaged or rehearsed scenarios

pre-Real World Anecdotes. Client situations drawn fromexperiences of the contributors or other practitionersadd to the immediacy and practicality of the book

Critical Thinking Skills.This boxed feature offers formance-related scenarios to foster learning, decisionmaking, and analytic thinking These scenarios oftenhelp the reader anticipate possible negative outcomesinvolved in performing a skill and provide alternatives

per-to avoid unwanted results

Skill Variations. Variations for each skill are sented for geriatric and pediatric age groups, as well

pre-as home care and long-term care settings, to allow foradaptation of the skills to various situations For ex-ample, geriatric clients may require extra communi-cation skills due to difficulty hearing or understand-ing Pediatric clients may need psychosocialassessment of fear or anxiety, or require different sizes

of equipment in the skill

Common Errors and Nursing Tips. These are sented to assist in improving client outcomes Thesesections are presented by experienced nurses to aidand guide the novice practitioner through performingthe skills, help develop competency, and prevent un-wanted outcomes

pre-Equipment Needed. A list of common equipmentneeded is provided as an organizational tool to assist inpreparation and set-up The equipment required mayvary between institutions

Estimated Time for Completion.The estimated time tocomplete a skill is identified to assist in planning andscheduling The estimated time of completion should

23 Place lamb’s wool or c

otton to protect areas that are rubbing or ir

ritated Put on clean,dry,absorbent (cotton) so

cks after foot care.

24 Run your hand ar

ound the interior of shoes andslippers to be sure there are no foreign objec

ts

or scratchy edges prior to putting them on.

25 Remove, clean,and/or replace equipmen

t/

supplies.

26 Dispose of glo

ves and wash hands.

▼ REAL WORLD ANECDO

TES

Mr Facundo was a midd

le-aged, grossly obese male w

ith type II diabetes Mr Facundo li ved dependently and worked ful l time Because of his siz

in-e, he was unable to reach his f eet to wash them

or to perform foot care Whe n he went to see his e

ndocrinologist, he complaine d of pain in his feet.

The endocrinologist referred Mr Facundo to a podiatrist.

The podiatrist noted that Mr Facundo’s feet were heavily callused and c overed in dead skin.

While trimming the cal

luses from Mr Facundo ’s feet with a razor blade, the podiatrist’s hand slip

ped and cut Mr Facundo’s foot Becaus e of Mr.

Facundo’s diabetic periphe ral vascular disease, the cut faile

d to heal properly and b ecame infected, requiring extensive treatme nt to prevent necrosis and the nee

d for amputation.

> EVALUATION

• The client’s hands and f

eet are clean and odor free,with soft, hydrated skin.

• The client experiences maximiz

ed functional ability

of hands and feet.

• The client is comfortable and relaxed.

> DOCUMENT

ATION

Nurses’ Notes

• Record the time and dat

e care was performed.

• Note any unusual fi cant changes ndings, open areas, or sig

nifi-> CRITICAL THINKING SKILL

Introduction (see Figure 4-12-6)

Mr Espinosa is a 75-y

ear-old obese man w

ith mer’s, hypertension, and a famil

Alzhei-y historAlzhei-y of diabetes.

Although he has not b

een diagnosed with diabetes, he

does have symptoms of peripheral vascular disease.

He kidded about his “wooden” ankle and feet, noting some

pain but little feeling in the

m His provider had not structed him in f

in-oot care, usually addressing the mo

re

global, multiple concerns.His nurse neighbor was c

ting one day midwinter in the yard with him w

hat-hen

Mr Espinosa mentioned that he thoug

ht he probably needed to go inside and c

hange his socks The nurse ticed him feeling his so

no-cks with his fingers to check formoisture When she ask

ed whether he could feel thecold and moisture, he admitted he could not f

eel it on his feet She asked if his doctor had instructed him infoot care and how to tak

e care of his feet if he could not

2 The first step of holistic assessment Provides

important clues to focus on or follow up ing physical assessment.

dur-1 Organize equipment.

2 Review client history (see Figure 1-1-3).

continues

> NURSING TIPS

• Do not raise the c

lient’s head until you ha

ve

deter-mined the type of surg

ery and anesthesia use

d.

Some procedures r

equire the client to lie fl

handy as well as func

tioning suction and o

xygen.

• The motion of mo

ving the client to a r

oom may

cause vomiting.

• Position the pat

ient to keep the air

way clear and have suction availab

le.

• Provide regular updat

es to family and frie

• A client may forget thing

s he was told while r

Shivering increases the b

ody’s oxygen use

placing a stress on the car

diopulmonary syst

em In

clients whose cardio

pulmonary system is alr

ont promise the client’s rec

pre-pared for p ossible confusion and the nee

d for freque nt reorientat

ion to time and p lace.

• Elderly c lients ma

y be at risk f or respirat

ory comp lications p

rior to sur gery and ma

ring from anesthesia ma

y not alw ays under

stand dir ections P

hysical rest raint or

client rep eated inst

ructions ma y be necessar

y.

• If the c hild’s par

ent is availab le and sup

portive, ha ve the par

ent sit with the c hild as he c

y be confus ed, delirio

us, uncoo

• Teach the c lient and car

egiver abo ut what w

ill happen w hen client r

eturns home (e.g.,

follow-up

care and ap pointments,

caring for the w ound, me

dication administ ration, re

turning t o normal

levels of ac tivity, and ass

essing for shor t- and long-t

erm comp lications o

f the surg ery).

Long-Ter m Care

Variations:

• People w ith multip

le surgeries ma y develop ant

icipatory f ear Assess the c

lient for hist ory and dis

-cuss the p rocedure.

▼COMMON ERR ORS—ASK

YOURSELF

Possible E rror:

Not encouraging the c

lient to cough and deep breathe due to complaints o

f surgical sitepain.

Ask Yourself :

How do I prevent this e

rror?

Prevention:

Following general anesthesia the l

ungs are not rexpanded properly and so

e-me of the inhaled thesia lingers Having the c

anes-lient deep breathe andcough helps the anesthesia c

lear from the lungsfaster and complicat

ions such as pneumonia andatalectasis can be prevent

ed.

be used only as a general guide Many factors, such as

the skill of the practitioner, client cooperation, or

de-gree of client illness, may affect the time required to

ac-complish a skill

Client Education Needed.Client teaching should be

routinely incorporated when performing skills Client

education is essential in promoting personal health

re-sponsibility and compliance Education should be

con-sidered a routine part of most interventions Informed

clients are often less anxious, more cooperative, provide

better histories, and more proactive regarding their

health care

CONCLUSION

The skills in this text were written with current practiceand standards in mind Nursing practice should not beconsidered static Even though minimum standardsdictate the basis to practice, ongoing research leads tochanges and advancements in practice With this inmind, it is imperative to note skill implementation willvary with individual experience and expertise, and willvary between institutions depending on internal out-comes measures and research How a skill is performedmay change or be further delineated as new research,and the knowledge is applied to hands-on care

xviii

The authors would like to acknowledge the tireless

ef-forts and contributions of many people on the staff of

Delmar, especially Cathy Esperti, Pat Gillivan, Tim

Con-ners, Jim Zayicek, Christopher Leonard, and Lisa Santy

Authors across the country shared their experience

and knowledge in writing the skills in this book We

would like to give them our heartfelt thanks for a job

well done

Individuals in the photographs, both nurses and

clients, have our gratitude and respect for agreeing to be

part of this project Nurses, practitioners, clients, and

families allowed our cameras to record them giving

and receiving care in the health care milieu

We would also like to acknowledge the

contribu-tions of the staff at NRSPACE Software who, in

con-junction with development of a software-based product

using this material, provided photography,

organiza-tion, and editing support

Special thanks to:

Kathy Lilleby, RN, for her willingness and

professional-ism in taking on challenges as a contributing author

and as an assistant to the authors in critiquing and

edit-ing skills

Gaylene Altman, RN, PhD, who coordinated thefilming efforts and helped to capture the realism thatcan only be obtained in real-life scenarios

Pamela Talley, MN, CNS, and Hsin-Yi (Jean) Tang,

RN, MS, doctoral students at the University of ington, for their enthusiastic assistance in filming theseskills

Wash-NRSPACE Software Staff

Valerie Coxon, RN, PhD CEOKeith Goodman Project Management/

PhotographyKarrin Johnson Editing/Photography/

Project CoordinatorTeri Reed PhotographyMaja Butler Editing Assistant

Photography

Photography for this project was provided by NRSPACE Software, Bellevue, WA

ABOUT THE AUTHORS

ABOUT THE AUTHORS

Gaylene Bouska Altman, RN, PhD

Gaylene Bouska Altman is currently the director of the

Learning Lab and on the faculty at the University of

Washington Her role includes teaching and

coordinat-ing hands-on skills for the nurscoordinat-ing courses She holds a

diploma in nursing from Marymount College, Salina,

Kansas; a BSN from the University of Kansas, Lawrence;

and both an MN and PhD from the University of

Wash-ington, Seattle With more than 25 years of teaching

ex-perience, she has taught at both the undergraduate and

graduate levels Besides predominantly teaching at the

University of Washington, Dr Altman has also taught at

Seattle University, Seattle Pacific University, and

Catholic University (Washington, DC) With a

back-ground as an intensive care and coronary care nurse,

she has taught courses ranging from fundamental to

advanced practice Her main emphasis has been to

de-velop critical thinking strategies through case

presenta-tions Dr Altman was one of the pioneers in initiating

coronary care units and a mobile coronary care system

in the 1970s, in the state of Washington Furthermore,

she helped develop some of the early quality assurance

programs implemented throughout the state Dr

Altman’s work has been published in numerous

text-books and journals She has delivered presentations

throughout the country and maintains membership in

several professional organizations

Patricia Buchsel, RN, MSN, FAAN

Patricia C Buchsel earned a Bachelor of Science in

Nursing from Seattle University, Seattle, Washington

and a Master’s degree in Nursing from Seattle Pacific

University in Seattle, Washington She was the Director

of Nursing at the Fred Hutchinson Cancer ResearchCenter in Seattle for over 12 years and continues to be

an active consultant in this field She has lectured tionally and internationally, authored five textbooks,numerous chapters, and monographs on this subject.Her current interest is in symptom management of theoncology patient Patricia has over 25 years experience

na-as an educator, clinician, administrator, and consultant.Patricia is a member of the Sigma Theta Tau, theAmerican Nurses Association, the Oncology NursingSociety, and the American Bone Marrow and BloodTransplantation Society She is recognized as a member

of Outstanding Young Women of American and cently was named as Seattle University’s Alumna of theYear Currently, Patricia is an oncology consultant with

re-a specire-alty in symptom mre-anre-agement She is re-also re-a ical instructor at the University of Washington

clin-Valerie Coxon, RN, PhD

Valerie Coxon is currently the CEO for NRSPACESoftware, Inc., Bellevue, Washington NRSPACE pro-duces multimedia education software for the healthcare field Dr Coxon is affiliate assistant professor atthe University of Washington School of Nursing Sheholds BSN, MN, and PhD degrees from the Univer-sity of Washington Her expertise includes psy-chophysiological nursing, management of the stressresponse, and the expanding role of computers in ed-ucation and at the patient bedside Since 1990 she hasdeveloped text, Internet, and multimedia software forresearch and education in the health sciences NR-SPACE Software developed the multimedia softwarethat supplements this text

xix

Skill 1-1 Physical Assessment

Skill 1-2 Taking a Temperature

Skill 1-3 Taking a Pulse

Skill 1-4 Counting Respirations

Skill 1-5 Taking Blood Pressure

Skill 1-6 Weighing a Client, Mobile

and Immobile

Skill 1-7 Measuring Intake and

Output

Skill 1-8 Breast Self-Examination

Skill 1-9 Collecting a Clean-Catch,

Midstream Urine Specimen

Skill 1-10 Testing Urine for Specific

Gravity, Ketones, Glucose, and Occult Blood

Skill 1-11 Performing a Skin Puncture

Skill 1-12 Measuring Blood Glucose

KEY TERMS

> OVERVIEW OF THE SKILL

A dynamic health assessment is the foundation of all

nursing care and physical assessment is part of every

holistic health evaluation Assessment is the first step

of the nursing process It involves the orderly

collec-tion of objective informacollec-tion about the client’s health

status Objective data are observable, measurable, and

verifiable by more than one person A fundamental

systematic approach is used based on a combination

of head-to-toe and body systems assessments, which

are expanded as appropriate to the client’s situation

and setting By using a systematic approach, you

en-sure that signs are not overlooked and that time is

used efficiently Through the process of data

collec-tion, meaningful informacollec-tion, including health

sta-tus, actual and potential health problems, and areas of

focus for priority health promotion, is identified The

process of physical assessment is utilized in

outpa-tient, inpaoutpa-tient, and/or home health services

A complete yet organized assessment is obtained

by using a combination of head-to-toe and

body-sys-tems approach in conjunction with the use of the four

basic techniques, inspection, palpation, percussion,

auscultation (IPPA):

• Inspection: Observation (see, smell); actually

starts during the health history and continues

throughout the exam; always comes first (before

you touch or listen), but continues concurrently

with PPA as well Note general observations andthen specifics of each area proceeding from theoutside to the inside

• Palpation: Touching; light (1 cm), then deep (4 cm), and rebound (deep with quick release).Assesses position, texture, size, consistency, fluid,crepitus, form, structure, vibration, or temperature

• Percussion: Tactile sensation and sound (to 5 cmdeep); direct or indirect with fingertip pad or fist;more solid: higher pitch, softer intensity, shorterduration; more air: lower pitch, louder intensity,longer duration; expected percussion notes: tym-panic (gastric bubble), hyperresonant (emphyse-matous lungs), resonant (healthy lung), dull(liver), flat (muscle)

• Auscultation: Listening direct (naked ear) and rect (acoustical stethoscope or Doppler amplifica-tion) Analyzes intensity, pitch, duration, quality,and location The bell analyzes low-pitched soundsand the diaphragm analyzes high-pitched sounds

indi-A combined body systems and body area proach focuses assessment by groupings:

ap-• General Appearance: Examine appearance in thefollowing groups: (1) skin, hair, and nails; (2)head, face, and lymphatic; (3) eye, ear, nose,mouth, and throat; (4) neck and upper extremi-ties; (5) chest, breasts, and axillae; (6) thorax and

lungs/respiratory system; (7) heart and

cardiovas-cular system; (8) abdomen/GI system; (9)

geni-talia/GU system and anus

• Lower Extremities: Musculoskeletal system

(MBJB: muscles, bones, joints, and back

assessment)

• Neurological: Reflex, sensory, cranial, cerebral,

cerebellar, neurodevelopmental, neuropsychiatric

Internal genitalia, rectum, and prostate

exami-nations are usually included in advanced

assess-ment and will not be addressed here

The IPPA organization can be combined by

cephalo-caudal (head-to-toe), general-to-specific,

medial-to-lateral, and external-to-internal proaches within each category The physical as-sessment is always correlated with the health his-tory as well as with other assessments, such aslaboratory or diagnostic data and/or developmen-tal, psychosocial, family, and cultural assessmentdata The nurse must also consider her own un-derstanding of anatomy and physiology, basicnursing skills, and the nursing process The edu-cational preparation and clinical expertise of thenurse may, therefore, influence the extent towhich the nurse participates in the physical as-sessment process

ap-> ASSESSMENT

1 Assess the environment, resources, and the client’s

medical condition on how complete and

system-atic the examination can be to reduce the

possibil-ity of overlooking important findings.

2 Assess the client’s history of previous physical

as-sessments and the availability of previous data to

provide a baseline for comparisons.

3 Assess the client’s receptiveness to being examined

to help plan to reduce anxiety and improve

com-pliance with the examination.

4 Assess the client’s understanding of the procedure

to help plan ways to reduce anxiety and improve

compliance with the examination.

8.1.1 Knowledge Deficit about normal and

ab-normal physical findings

Through the accurate and efficient health

assess-ment process normal, normal variant, and abnormal

data are identified The nurse can identify serious or

life-threatening signs and critical assessment findings

that require immediate attention She can utilize the

objective data obtained during the physical assessment

process to contribute to problem-solving strategies that

identify the client’s current health status (acute,

chronic, risk, and preventive) She can institute

prob-lem-solving strategies to place the client and the client’s

family or community in an optimal health status

> PLANNING

Expected Outcomes:

1 Identify health parameters at multiple levels for

total client management and to identify acute cerns and needs

con-2 Identify serious, acute, or life-threatening

abnor-malities or critical assessment findings that requireimmediate attention

3 Identify potential or chronic abnormalities that

need planned intervention

4 Monitor chronic stable problems to detect changes

from baseline assessments

5 Identify health risks, concerns, or needs These

include risks that are related to age, gender, ronment, community, personal habits, or familyhistory

envi-6 Respond to health maintenance needs This

in-cludes monitoring the client’s status and ing findings with normal health parameters for ageand gender It also includes identifying normalvariations of health that do not need intervention,providing routine or scheduled assessments, im-munizations, preventive or palliative health care,and health education or anticipatory guidance

through 1-1-2H):

Equipment must be organized for easy accessibility It ishelpful to be able to reach each piece of equipment withone hand on the client Short fingernails and warmhands are essential to performing a satisfactory physicalexamination

• Growth charts for height and weight (and head

cir-cumference for infants): age, gender, culture, and

sometimes medical condition

• Well-lit, warm, private room or space

• Gown for client privacy and comfort (swimsuits

work well with children and adolescents)

• Drape sheet, or blanket for client privacy and

comfort

• Thermometer: otic or oral/axillary digital preferred

• Stethoscope: acoustical with bell and diaphragm;

ideal tubing less than 35 cm in length

• Watch with second hand

• Sphygmomanometer and blood pressure cuffs thirds the size of the client extremity

two-• Ophthalmoscope

• Vision charts: Illiterate (matching letters or objects),Snellen (far vision), Rosenbaum (near vision)pocket card, Ischara (color vision), or Titmus tester(includes all four), and pupil gauge (in mm)

• Otoscope with pneumatic tube

• Audio testing equipment: watch, tuning forks imum of one high pitched, 512 Hz, and one low

Figure 1-1-2 A Ophthalmoscopes; B Otoscopes; C Penlight; D Tongue depressors; E Coffee grounds and orange extract;

F Tuning forks and reflex hammers; G Cotton swabs and cotton balls; H Sharp items used to assess sharp and dull sensations

pitched, 128 Hz), handheld audiometer,

tympa-nometer, or full audiometry with soundproof room

• Nasal speculum with illumination Optional

head-lamp with magnification

• Neurological “kit”: temperature (test tubes of hot

and cold), touch (cotton ball, hair pin, paper clip,

safety pin, key, marble, coin, low-pitched tuning

fork), taste (sweet—sugar, honey; sour—lemon,

lime, vinegar, bitter—alum, quinine; salty—salt,

saline), smell (coffee, lemon, orange extract, flowers,

perfume, mouthwash) If making your own kit, be

sure to use identical appearing containers for each

category and a cotton-tipped applicator or dropper

for consistent application

• Other (these are helpful to have available although

are not always used): slide, toothbrush (helpful to

obtain skin scrapings), Wood’s lamp, magnifying

glass, small test tube, flashlight and

transillumina-tor, head lamp, gooseneck lamp, Doppler (for

am-plification of body sounds), goniometer, Denver

Developmental Screening Kit contents, Mini-Mental

status exam, fluid-resistant gowns, masks and eye

covers

> CLIENT EDUCATION NEEDED:

1 Introduce yourself by name and title In some

cases you may need to describe your role as well

2 Provide the client with an explanation of what is

to follow (I will be checking everything from yourhead to your toes) and an approximate time framefor the exam It helps to tell children how they willknow when you are done (e.g., when I tell you toput your shoes back on)

3 Inform the client if you will be jotting down

nota-tions during the examination and how these will

be used This reassures confidentiality

4 Before performing each step in the physical

assess-ment process, inform the client of what to expect,where to expect it, and how you anticipate it willfeel (I don’t think any of this will hurt but be sure

to tell me if it does hurt)

5 Inform the client of what you are looking for and

why as you perform your physical assessment Youcan accomplish a great deal of education about thebody, how it functions, and health preventionwhile performing your examination

6 Teach skin self-examination as you evaluate the

skin

7 Teach breast self-examination as you examine

breasts (male and female)

8 Teach testicular self-examination and self-checking

for hernias during the genital exam

9 Teach proper urinary hygiene and basics about

sexually transmitted disease (STD) with the genitalexam

10 Reinforce good hygiene as you wash your hands

and conduct the examination

Estimated time to complete the skill:

Variable depending on the purpose and depth of the examination:

average of 20–30 minutes.

IMPLEMENTATION—ACTION/RATIONALE

1 Promotes efficiency.

2 The first step of holistic assessment Provides

important clues to focus on or follow up ing physical assessment

dur-1 Organize equipment.

2 Review client history (see Figure 1-1-3).

continues

6 CHAPTER 1 Physical Assessment

3 Reduces transmission of microorganisms

Edu-cates client

4 Educates client Reassures the client.

5 Provides best access to begin examination.

6 Collects information about health and disease.

7 Provides closure for the examination and

com-municates information

8 Provides for follow-up care.

9 Promotes efficiency, organization, and reduces

microorganisms

10 Reduces the transmission of microorganisms.

11 Provides measurable objective data about

health state or baseline data

3 Wash hands, preferably in front of client.

4 Explain plan and procedure.

5 Assist client to sitting position if possible.

6 Examine client.

7 Present findings if appropriate Ask for

addi-tional information Answer client’s questions

8 Schedule follow-up assessments, tests, or other

appointments as needed

9 Clean, replace, and discard equipment

appro-priately

10 Wash hands.

Measurements and Overall Observations

11 Obtain baseline measurements and compare

with normal data Remember that normal

val-ues vary with age and normal temperatures do

not rule out illness, especially with very young

and elderly clients

Check height, weight, head circumference

(check normal values based on age percentiles

for infants to 24 months), and temperature

(palpate skin temperature during examination

as well)

Figure 1-1-3 Review client history Clients are often

uncom-fortable and anxious in the unfamiliar clinic setting

Establish-ing privacy and usEstablish-ing words and body language to create a

supportive environment help place the client at ease Listen to

the client’s complaint, ask pertinent questions about

symp-toms and medical history, and write down key information.

SKILL 1-1 Physical Assessment 7

12 Provides cues for additional observations or

actions required later in the examination

13 Body mass and height-weight proportion can

be better indicators of illness than simpleheight and weight measurements

14 Provides objective cues about overall health

state and cues to possible specific ties to watch for later in the examination

abnormali-15 Detects normal variation and abnormalities.

Establishes a baseline for future comparisons.Skin abnormalities, including crepitus, nodules,mobility, and hydration will provide cues to ill-ness, and are often indicators of systemic ab-normalities

16 Confirms health and identifies signs and

symp-toms of illness or disease, infections, old ornew trauma, or other abnormalities

17 Confirms health and identifies signs and

symp-toms of illness or disease, infections, old ornew trauma, or other abnormalities

12 Measure the heart rate, rhythm, and volume,

the respiratory rate and rhythm, and the blood

pressure bilaterally

13 Check anthropometric measurements prn,

body mass index (BMI), etc

14 Assess the overall appearance of the client in a

“once over” evaluation before you begin the

detailed examination Look for clues to poor

health such as level of consciousness, personal

hygiene, nutritional status, posture, gait,

sym-metry, appearance, and appropriateness of

clothing Listen to the quality and

appropriate-ness of speech Observe if the client makes eye

contact and how comfortable the client is with

interpersonal interaction

Assess whether age is congruent with

ap-pearance Observe body fat, stature, motor

movements, and body and breath odors

Assess dress, grooming, personal hygiene,

mood, manner, speech, and facial expressions

Finally, during your “once over,” look for

signs of distress, as evidenced by breathing

patterns, speech, facial expressions,

perspira-tion, tension, guarding, bracing, and anxiety

Skin, Hair, and Nails Examination

15 Take a moment to assess initially and continue

assessment as you perform the remainder of

the exam

• Inspect: color, vascularity, lesions, ulcers,

scars, hair distribution, nail shape and

config-uration, nail bed angles Measure, describe

draw and/or stage abnormals

• Palpate: moisture, temperature, texture,

tur-gor, capillary refill (normal capillary refill is

less than 3 seconds), edema

Head, Face, and Lymphatics Examination

16 Inspect and palpate the head, face, and lymph

nodes (see Figures 1-1-4 and 1-1-5) Proceed

front to back

17 Head: Examine scalp, hair, and cranium

(frontal-parietal-temporal-occipital) Examine fontanelles

and sutures in newborns to 24 months Head

should be normocephalic and symmetrical with

no acromegaly, hydrocephalus, craniosynostosis,

continues

8 CHAPTER 1 Physical Assessment

Head, Face, and Lymphatics

Examination continued

Preauricular (from face and auditory canal) Posterior auricular

(from scalp and auditory canal) Occipital (from posterior scalp) Posterior cervical (from posterior scalp, ear, and skin of posterior neck)

Supraclavicular (from abdomen, thorax, arm, and breast)

Superficial and deep cervical (from scalp, throat, and face)

Tonsillar (from tonsils and pharynx)

Submandibular (from face and oral cavity)

Submental (from lower face and front of mouth)

Figure 1-1-4 Lymph nodes of the head and neck Arrows dicate drainage patterns.

in-Figure 1-1-5 Palpation of lymph nodes (continues)

SKILL 1-1 Physical Assessment 9

18 Confirms health and identifies signs and

symp-toms of illness or disease, infections, old ornew trauma, or other abnormalities

19 Confirms health and identifies signs and

symp-toms of illness or disease, infections, old ornew trauma, or other abnormalities

20 Confirms health and identifies signs and

symp-toms of illness or disease, infections, old ornew trauma, or other abnormalities

premature closure of sutures, masses,

depres-sions, tenderness, or infestations

18 Lymph nodes: Examine preauricular,

postauric-ular, occipital, submental, submandibpostauric-ular,

ante-rior cervical chain, posteante-rior cervical chain,

ton-sillar, supraclavicular, and parotid Lymph

nodes should be less than one centimeter in

size and nontender Note that children may

have multiple nodes less than one centimeter,

especially postauricular, but these will be

small, nontender, and movable

19 Temporomandibular joint: Observe the

mo-tion of opening and closing the jaw It should

articulate smoothly without crepitus, clicking,

or tenderness There should be no sign of

in-flammation

20 Face:Observe for shape,symmetry,and

expres-sion.Have the client smile,frown,raise

eye-brows,wrinkle forehead,show teeth,purse lips,

puff cheeks,press tongue into cheek,“cluck”

tongue and whistle.Inspect,percuss,and

pal-pate frontal and maxillary sinuses.Use a wisp of

cotton to assess tactile sensation over the

trigeminal nerve sites and mandible bilaterally

Facial features should be symmetrical with a

nasolabial fold present bilaterally Clients of

Asian descent may have slanted eyes with

in-ner epicanthal folds Normal sounds should be

resonant No pain should be present on

per-cussion or palpation

Abnormal findings include edema,

dispropor-tionate structures, or involuntary movements

continues

Figure 1-1-5 Palpation of lymph nodes

10 CHAPTER 1 Physical Assessment

21 Confirms health and identifies signs and

symp-toms of illness or disease

• Establishes the presence or absence ofdrooping, infection, or tumors Confirms thatthe lid “meets” the iris, the lid margins aresmooth, tears flow evenly instead of accumu-lating and “tearing up” the eye

• Establishes the presence or absence of flammation of hair follicles, hemorrhages,discharge, discolorations, ectropion, swelling,edema, blepharitis, or dacryoadenitis

in-• Checks that the third cranial nerve (CN III)raises the lids symmetrically, and that thepuncta are open and without inflammation

22 Checks that light reflects symmetrically from

the center of corneas at 12–15 inches, and thatthe uncovered eye stays focused

• Checks the functions of CN III, IV, and VI

• Checks for the absence of tropia, phoria, ornystagmus

23 Checks the function of CN II.

Eye, Ear, Nose, Mouth, and Throat

Examination

21 Examine the eyes Inspect and palpate external

structures, including brows, lids, lacrimal gland,

and puncta Inspect eye position and palpebral

fissures Examine bulbar and palpebral

con-junctivae, sclera, cornea, and iris Assess for a

corneal touch reflex

22 Extraocular mobility: Check for Hirschberg’s

corneal light reflex using the cover-uncover

test Check the six cardinal fields of gaze

Exam-ine pupils, including size, shape, response to

light and accommodation, both direct and

con-sensual Examine the lens and retinal structures

First check for a red reflex with the

ophthalmo-scope set on “0.” Move the diopter wheel to “1”

to focus on anterior ocular structures and “2”to

focus on posterior structures Locate the retina,

vessels, optic disk, and macula

23 Have the client identify an object, such as

your finger, as it enters the visual fields from

each of four directions Normal movement is

temporal 90 degrees, nasal 60 degrees,

supe-rior 50 degrees and infesupe-rior 70 degrees (see

Figure 1-1-6)

Figure 1-1-6 Have client identify the moment an object

SKILL 1-1 Physical Assessment 11

24 Check for visual acuity, including near and far

sight, primary colors, and Ishihara plates (see

Figure 1-1-7)

25 Examine the ears Inspect and palpate the

ex-ternal ear, including alignment, pinna, tragus,

lobule, and neck mastoid muscle Observe the

shape, color, and size of the ear

26 Proceed with an otoscopic assessment,

start-ing with the ear canal Identify landmarks, the

tympanic membrane, and observe tympanic

membrane movement Use tympanometry if

needed to confirm visual findings

27 Check the client’s hearing acuity Note responses

to normal sounds In an infant, observe for a

star-tle reflex/bell response In adults conduct a

voice/whisper or watch-tick test at 1–2 feet

Conduct Weber and Rhinne tests at 512 Hz

28 Examine the nose Inspect and palpate for

nasal patency Have the client inhale and

ex-hale through each nostril Observe the external

surface, nasal mucosa, turbinates, and septum

29 Have the client identify common odors.

30 Examine the mouth, including the teeth,

tongue and throat (see Figure 1-1-8)

24 Visual acuity tests are the last step in the eye

examination so that physical abnormalitiesthat might cause abnormal acuity will be de-tected first

25 Confirms health and identifies signs and

symp-toms of illness or diseases of the ear Checksfor normal alignment, that the top of the earcrosses an imaginary line from eye to occiput.Checks for abnormal findings of tags, excesswax, drainage, deformities, nodules, inflamma-tion, pain, and a tender or “boggy” mastoid.Establishes the quality of tympanic mem-brane (TM) movement, detects retractions,bulging, abnormal, or discolored middle earfluid

26 Confirms if there are signs of infection,

im-paction, or other abnormalities

27 Hearing acuity tests are the last step in the ear

examination so that physical abnormalitiesthat might cause abnormal acuity will be de-tected first

28 Confirms health and identifies signs and

symp-toms of illness or disease, including unusual orexcessive discharge, damaged septum, polyps,tenderness, or nonclear drainage

29 Tests CN I (the olfactory nerve).

30 Confirms health and identifies signs and

symp-toms of illness or disease

continues

Figure 1-1-8 The mouth examination includes the

teeth, tongue, throat, oral mucosa, and salivary glands.

12 CHAPTER 1 Physical Assessment

31 Confirms the number and condition of teeth

for age

32 Identifies lesions, color of membranes,

abnor-malities, cavities, odors, swelling, inflammation,swallowing difficulties, or hyperplasia

33 Tests cranial nerve functions.

34 Confirms health and identifies signs and

symp-toms of illness or disease

35 Checks for goiter, nodules, enlargement, or

ten-derness in the neck and thyroid

36 Identifies signs and symptoms of

cardiovascu-lar illness or disease

37 Confirms health and identifies signs and

symp-toms of illness or disease

38 Checks the cervical spine, sternocleidomastoid,

and trapezii baseline strength, integrity, andfunction

39 Detects limitations of mobility, torticollis, pain,

crepitus, nodules, lumps, or pulsations in themuscles, bones, and joints

31 Inspect and count teeth.

32 Inspect and palpate lips and frenula, gums,

buccal mucosa, tongue protrusion and

frenu-lum, salivary glands, hard and soft palates,

ton-sils, uvula position and movement, and arches

Inspect the naso-oro-pharynx

33 Conduct gag reflex response, and taste tests

for sweet, sour, bitter, and salt

34 Examine the neck Inspect and palpate the

tra-chea Check that the trachea runs midline

down the neck by examining the trachea at

the suprasternal notch

35 To examine the thyroid, observe the anterior

neck slightly extended, then have the client flex

the neck and swallow Palpate the anterior neck,

then palpate forward from the posterior

Iden-tify tracheal rings, isthmus, thyroid cartilage, and

gland lobes as the client is swallowing

36 Palpate the temporal and carotid pulses

As-sess the quality, character, rhythm, and

strength of the pulse

Upper Neuromuscular Examination

37 Inspect and palpate muscles, bones, and joints.

In general, evaluate from the periphery to the

center of the body

Observe the configuration, symmetry, size,

tone, and range of motion (ROM) Assess

strength using resistive ROM

38 Examine the cervical spine Flex, extend, move

lateral, and rotate the spine Examine the spine

for resistive strength by pushing your hand

against the side of the client’s face Push left,

right, back on the forehead, forward on the

oc-ciput, and down on the top of the head

39 Examine shoulders Flex, hyperextend, abduct,

adduct, turn in internal and external rotation,

shrug, and push/pull against the shoulders

Eye, Ear, Nose, Mouth, and Throat

Examination continued

SKILL 1-1 Physical Assessment 13

40 Checks for tenderness and mobility.

41 Checks for tenderness and mobility Detects

the presence of carpal tunnel

42 Checks for tenderness and mobility.

43 Checks for tenderness and mobility.

44 Confirms that lymh nodes are nonpalpable

and nontender, and that pulses are strong andregular Checks neurological reflexes

45 Confirms health and identifies signs and

symp-toms of illness or disease Detects lumps, ules, or discharge in tissue Detects tenderness

nod-or lumps in axillary nodes, which drain thechest and breast

46 The Tanner stage assesses appropriate breast

development progression and status for ageand provides an opportunity for teaching

47 Repeating the examination while the client is

supine increases likelihood of early tion of abnormalities

identifica-48 Confirms health and identifies signs and

symp-toms of illness or disease

49 Gland lobules are easier to palpate from back.

50 Determines normal, normal variations, and

ab-normal findings in alignment, flexion, spinousprocesses, and paravertebral muscles Checksthat the scapulae are equal, and the rib cage issymmetrical

51 Checks for fremitus either increased with

con-solidation, or decreased with hyperinflation ofthe lungs Bilateral comparison enables identi-fication of differences

40 Examine elbows Flex, extend, rotate, push, and

pull each elbow

41 Examine wrists Flex, extend, and rotate each

wrist

42 Examine hands by having the client grasp your

hands with his

43 Examine fingers Abduct, adduct the fingers.

Perform finger thumb opposition with

count-ing and position sense

44 Examine the epitrochlear lymph nodes,

brachial and radial pulses, and bicep, tricep,

and brachioradialis reflexes

Chest and Breast Examination

(See Skill 1-8, Breast Self-Examination.)

45 Inspect and palpate the breast, nipple, and

are-ola Palpate the axillary lymph nodes

46 Calculate the Tanner stage of sexual maturity if

appropriate

47 Repeat breast and axillae examination while

the client is in the supine position

Back and Posterior Lung Examination

48 Inspect and palpate the skin.

49 Recheck the thyroid from the posterior position.

50 Examine the cervical and thoracic spine (see

Figure 1-1-9), the scapulae, and the rib cage

Observe the posterior thoracic expansion

Estimate the anteroposterior-to-transverse

chest ratio A normal ratio is 1;2

51 Feel for the presence of fremitus posteriorly

and laterally Compare sides

continues

14 CHAPTER 1 Physical Assessment

Back and Posterior

Lung Examination continued

52 Use indirect percussion at a minimum of four

sites, preferably in regular intervals every 5 cm

from top to bottom of lung fields Move from

superior to inferior and from lateral to spine

53 Auscultate the lungs (see Figure 1-1-10) using

a side-to-side sequence and moving down

2–5 cm at a time Listen to inspiration and

ex-piration at each site Listen for vocal fremitus

while the client makes “99” and sustained “ee”

sounds

Thorax, Lungs, and

Respiratory Examination

54 Stand in front of the client.

55 Inspect and palpate the anterior chest

Ob-serve position, chest movement, size, shape,

and symmetry of the clavicles and ribs

56 Listen to the respiratory rate, including

rhythm and depth of respirations Compare

rate with normal respiratory rates for the age

of the client

52 Indirect percussion allows comparison of

res-onance bilaterally, and checks for tendernessover the lungs and kidneys The organized se-quence of side to side and superior to inferiorincreases the possibility of detecting abnor-malities

53 Checks for bronchial noises over trachea,

bron-chovesicular sounds in the first and second tercostal spaces, and vesicular sounds over theperipheral chest Detects abnormal sounds ofrales, rhonchi, or wheezes

in-54 Prepares to examine anterior lungs.

55 Confirms health and identifies signs and

symp-toms of illness or disease Checks for barrelchest, pectus excavatum, pectus carinatum, ortripod “splinting” positions Splinting positionsindicate the client is compensating for de-creased oxygenation

56 Checks for 2;1 timing of the exhale/inhalebreathing cycle Detects shortness of breath(SOB), and abnormal respiration patterns, in-cluding Cheyne-Stokes, tachypnea, hyperpnea,and hyspnea (see Figure 1-1-11)

Figure 1-1-9 Examine the cervical and thoracic spine for

alignment, flexion, and symmetry with the rib cage and

scapulae.

Figure 1-1-10 Auscultate the lungs, listening to spiration and expiration at each site.

in-SKILL 1-1 Physical Assessment 15

57 Detects accessory muscle use or stridor.

58 Detects fremitus, which is increased with

con-solidation, or decreased with hyperinflation

59 Side to side and superior to inferior organized

approach increases the possibility of detectingabnormalities

60 Checks for bronchial noises over trachea,

bron-chovesicular sounds to the left and right of thesternum in the first and second intercostal

57 Observe the diaphragmatic excursion,

inter-costal spaces (ICS), respiratory muscles,

respira-tory effort, and expansion Watch for pursed

lips, cyanosis, or a cough Note that abdominal

breathing is normal from birth to the second

year of age

58 Feel for fremitus along the lung apexes and

bases

59 Use indirect percussion at intervals over

inter-costal spaces moving superior to inferior and

collateral to spine Percuss lung apexes and

bases, and the cardiac border if appropriate

Note percussion should be resonant over the

lung, flat over bone, and dull over organs

60 Auscultate the anterior lung fields, using the

same progression as the palpation procedure

Avoid listening over bone and breast tissue

16 CHAPTER 1 Physical Assessment

space, and vesicular sounds over the eral chest Detects abnormal sounds of rales,rhonchi, or wheezes

periph-Observe intensity, pitch, ratio, quality (see

Figure 1-1-12)

Listen for vocal fremitus during “99,” and

sustained “ee” sounds

Heart and Cardiovascular

System Examination

61 Inspect and palpate the precordium Identify

the point of maximal intensity (PMI) at mitral

area located at the left fifth intercostal space

and confirm synchrony with the carotid pulse

PMI may not be palpable in large and

muscu-lar persons

62 Auscultate with the client sitting, then leaning

forward Listen with the diaphragm and then

the bell

63 Examine all valvular landmarks at least twice.

First locate and identify the S1, S2, S3, and S4

heart sounds Then listen for other sounds

(murmurs, rubs, clicks, etc.) Auscultate in an

or-derly fashion from the apex to the base of the

heart (or vice versa)

64 In the mitral area identify that S1is louder than

S2with the diaphragm of the stethoscope,

be-cause the left heart pressure is greater than

the right, and the mitral valve closes slightly

before the tricuspid valve Use the bell to listen

for a possible S3sound (see Figure 1-1-13)

65 In the tricuspid area identify that S1is louder

than S with diaphragm, but that it is softer

61 Confirms health and identifies signs and

symp-toms of illness or disease Confirms the sence of cardiomegaly symptoms, visiblethrills, heaves, and pulsations (except possibly1–2 cm movements at mitral area during sys-tole, especially in children and thin adults orthe elderly)

ab-62 The bell detects lower pitched sounds than the

diaphragm

63 Systematic progression of the examination

minimizes omissions Detects normal ogy, as the S1closure of mitral and tricuspidvalves heralds the onset of systole Detects anyabnormal opening snap in early diastole,which could indicate mitral stenosis

physiol-64 Detects S3sounds, which are early diastolic ing sounds from the ventricles, and could indi-cate diastolic gallop

fill-65 Detects the normal aortic valve closure

occur-ring slightly before the pulmonic valve closure

Thorax, Lungs, and

Respiratory Examination continued

Figure 1-1-12 Auscultate the anterior lung fields Listen

for abnormal sounds, including rales, rhonchi, or wheezes.

SKILL 1-1 Physical Assessment 17

S1 S2

A2P2

S1 S2

A2 P2EXPIRATION INSPIRATION

S1 S2

A2 P2

S1 S2

A2 P2EXPIRATION INSPIRATION

S1 S2

P2A2 A2 -P2

S1 S2EXPIRATION INSPIRATION

S1 S2

S1 S2

A Normal S2

B Intensified A2 , diminished A 2

C Aortic ejection click

D Normal physiological split of S2

18 CHAPTER 1 Physical Assessment

during inspiration as more negative racic pressure causes an increase in venous re-turn to the right side of the heart

intratho-66 Finds symptoms of abnormal splits, which are

wide, fixed, or paradoxical

67 Assesses for signs of mitral valve prolapse,

which are best heard at the epigastric location.Assesses for abnormal murmurs radiating tothe axilla Checks Erb’s point where both aorticand pulmonic murmurs may be heard

68 S3can be normal in children, third trimester,and adults younger than 30 years old Othersounds need investigation

69 Positions the heart closer to the chest wall.

70 Mitral and tricuspid abnormalities are heard

best in the left lateral position

71 Facilitates next portion of cardiac examination.

72 The PMI is best palpated in the supine

posi-tion Confirms the absence of visible thrills,heaves, and pulsations except possibly a small(1–2 cm) area at the mitral location during sys-tole, especially in children and thin adults orthe elderly PMI may not be palpable in largeand muscular persons

The client’s position determines which soundsare heard best It is easier to hear some murmurswith the patient in the supine position.The bell

is best for detecting deeper sounds

Notes unusual symmetry, rate, rhythm, sations, volume, or thrills of pulses

pul-Evaluates for cardiomegaly

73 Detects normal jugular vein distention, which

is usually 1–2 cm above the sternal anglewhen the head is elevated 45 degrees and is

than at the mitral area Listen for possible S1

split that disappears when the client holds his

breath Listen for the S3sound with the bell

66 In the pulmonic area identify that S2is louder

than S1, but softer than at aortic area Note that

physiologic splitting of S2, which indicates

clo-sure of the semilunar valves at this site is normal

In the aortic area identify that S2is louder

than S1with diaphragm

67 Assess the epigastric, axillary, and Erb’s point

areas

68 Summarize the character of S1and S2sounds

Note the presence or absence of S3and S4

(gal-lop), murmurs, rubs, clicks, or snaps

69 Assist client to left lateral position to continue

the cardiac examination

70 Auscultate mitral and tricuspid sites with the

bell

71 Assist client to return to supine position and

continue cardiac examination

72 Inspect and palpate the precordium Identify

the PMI at the mitral area and confirm

syn-chrony with carotid pulse Assess apical,

carotid, temporal, brachial, radial, femoral,

popliteal, posterior tibial, and dorsalis pedis

pulses (see Figure 1-1-14)

Percuss the cardiac borders if needed

Auscultate the heart in supine position with

bell, then with diaphragm Check the mitral,

tri-cuspid, pulmonic, aortic, and ectopic areas

Auscultate with bell for bruits at carotid and

temporal pulse sites

73 Raise head to 30–45 degree angle and inspect

the jugular vein distention (JVD)

Heart and Cardiovascular

System Examination continued

SKILL 1-1 Physical Assessment 19

Abdominal Examination

74 Inspect the size, contour, and symmetry of the

abdomen The normal abdomen is flat (except

in young children), symmetrical, without scars,

striae, masses, nodules, peristalsis (except in

very thin individuals), or rectus ridge (except in

young or thin individuals) Note pigmentation,

scars, striae, masses, nodules, the condition of

the umbilicus, and any respiratory or peristaltic

movement Check the rectus abdominus

mus-cle by having the client raise his head

75 Auscultate with the diaphragm and then the

bell Listen for bowel sounds in each of the

four quadrants Right lower quadrant (RLQ),

right upper quadrant (RUQ), left upper

quad-rant (LUQ), and left lower quadquad-rant (LLQ)

76 Percuss the RLQ, RUQ, gastric bubble,

spleen, bladder, LLQ, LUQ, and liver span

(see Figure 1-1-15)

Note the spleen, located between the sixth

and tenth rib, may go undetected The gastric

air bubble (LUQ) is lower pitched than

tym-pany of the intestine The tymtym-pany changes to

dull at lower edge of liver, and lung resonance

changes to dull at upper edge of liver You may

try to percuss the kidney posteriorly while the

client is sitting, if needed

usually absent at 90 degrees and distendedwhen flat Jugular vein pressure (JVP) measure-ment plus 5 cm will give an estimate of theCVP (central venous pressure)

74 Confirms health and identifies signs and

symp-toms of illness or disease

Aortic pulsations may be seen in epigastricarea in thin persons Newborn to 2-year-oldsbreathe with their abdominal muscles, with noretractions of the intercostal muscles duringinspiration, and a smooth rhythm The unbili-cus is normally depressed

75 Auscultate before palpating, as sounds will

change in response to touch

Detects a normal frequency of sounds of5–30 sounds per minute, or abnormal bruits,hums, or rubs

76 Detects size and location of internal organs as

tympany changes to dull over organs

continues

Figure 1-1-14 Assess for unusual symmetry,

pulsa-tions, volume, or thrills of pulses.

Figure 1-1-15 Percuss the abdomen to assess size and location of internal organs.

20 CHAPTER 1 Physical Assessment

77 Checks for normal umbilical deviation toward

the direction of palpation stroke

Determines normal abdomen, which issmooth and soft with no masses, bulges,swelling, organomegaly, bladder distention,fluid retention, or pain Locates normal find-ings of palpated liver edge, aortic pulsations,and lower pole of kidney

Normal voluntary muscle guarding ceases

on expiration

78 Determines normal pulses, which are

symmet-rical and even, with no bounding or thrills, andnormal inguinal nodes, which are less than 1

cm in size, movable, and nontender

79 Lithotomy position without stirrups is usually

more comfortable for the client; however, bothpositions provide good visibility and access

80 Deep nodes are more easily palpated in this

position

81 Confirms normal distribution of hair in an

verse triangle, and identifies abnormalities, cluding infestations, rashes, edema, condylo-mata, vesicles, varicose veins, discharge, odor,

in-or bulges

82 The Tanner stage assesses appropriate genital

development progression and status for ageand provides an opportunity for teaching

83 Checks for abnormal color, lesions, pain,

trauma, abnormal size, imperforate introitus,odor, or discharge

84 Confirms normal appearance, where the

ure-thral meatus is located centrally, with dorsalvein prominence, a small amount of smegma,and the left scrotal sac lower than the right.Detects a nonretractable foreskin in an uncir-cumcised child

Checks for abnormal lesions, odor, swelling,inflammation, nodules, condyloma, vesicles,pustules, scaling, edema, phimosis, chordee

77 Palpate all four quadrants superficially first

then deep and rebound palpations to identify

any discomfort, tenderness, or abnormalities

Check superficial abdominal reflexes in the

LLQ, LUQ, spleen (use bimanual palpation),

RLQ, RUQ, liver, aorta, kidney (use bimanual

technique), and bladder (see Figure 1-1-15)

Evaluate for guarding on expiration

78 Check femoral pulses and superficial and deep

inguinal nodes

External Genitalia Examination

79 Assist client to modified or full lithotomy

position

80 Inspect and palpate deep inguinal nodes.

81 Observe pubic hair distribution, color, and

tex-ture Check the femoral and inguinal areas for

hernias

82 Calculate the Tanner stage of sexual maturity if

appropriate

83 Check skin and look for abnormalities In the

female, examine the mons pubis, labia majora,

labia minora, clitoris, urethral meatus, vaginal

introitus, and perineum

84 In the male, check the cremasteric reflex (in

in-fant), urethral meatus, penis (glans, foreskin,

shaft), scrotum (transilluminate if hydrocele

suspected), scrotal rugae, testicles, epididymis,

spermatic cord, and external inguinal ring

Abdominal Examination continued