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Created by Lisa Meldrum, Practical Nursing Student, Class of 2008

Putting It All Together-PowerPoint Slides

For exclusive use by educators and students at Canadore College and Nipissing University, with permission from the following Canadore College Practical Nursing Students:

Lisa MeldrumSuzanne Curtiss Alyshia Rivers

a) Don’t forget to wash your hands! b) Lay out your equipment…Hey…where are my cuffs?!

(a) Inspect and palpate the head for condition of hair and scalp. (b) Inspect the hairline, back of the neck and around the ears for any nits. (c) Palpate the skull for any inconsistencies.

(d) Palpate the lymph nodes: (1) preauricular (2) posterior auricular (3) occipital (4) submental (5) submaxillary (6) jugulodigastric (7) superficial cervical (8) deep cervical chain (9) posterior cervical (10) supraclavicular

Under normal circumstances, lymph nodes should not be palpable. If they are, they will feel like small grapes and will be easily moved (not fixed in place) and nontender. If nodes are enlarged or tender, check upstream for problems.

(a) Palpate carotid arteries—don’t do both at the same time or your client will pass out. Auscultate the arteries with the bell of the stethoscope—you are listening for bruits (the whooshing sounds of turbulence in the blood stream)—under normal circumstances, you should not hear any. (b) Palpate the suprasternal notch. (c) Palpate the trachea—you are checking that it is midline. (d) To palpate the thyroid, stand behind the client and have them bend their head forward and to the side—to the left to palpate the left of the thyroid and to the right to palpate the right side.

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Use the fingers of your left hand to push the trachea slightly to the right. Curve your right fingers between the trachea and the sternomastoid muscle, retracting is slightly. Ask the person to take a sip of water. The thyroid moves up under your fingers with the trachea and larynx as the person swallows. Usually you cannot palpate the normal adult thyroid.

(a) Ask client to tip head to chest, back to look at the ceiling, all the way to the left and to the right. (b) Ask client to move head against the resistance of your hand—checking for strength that is equal on both sides. Ask client to shrug shoulders against your resistance. (c) Inspect facial features. (d) Have client frown, smile, wrinkle brow and puff out cheeks.

(a) Hold one nostril shut and ask the client to breathe through the other one—checks for patency. (b) Palpate the nose for tenderness or unevenness. (c) Use your thumbs to palpate and percuss the frontal sinuses (eyebrow bones) and the maxillary sinuses (just above the cheekbones)—checking for tenderness. (d) Palpate the tempomandibular joint as the client opens and closes the mouth—some clicking is normal, but pain is not.

(a) Inspect the mouth with a penlight. (b) Use a tongue depressor to push the tongue down as the person says “Ahhh”—uvula and soft palate should rise in the midline and the tonsillar pillars should move medially. Ask person to move tongue against the resistance of the tongue blade. (c) Touch client’s face with cotton and have them show you where you touched.

(a) Six cardinal fields of gaze—have the client follow your movement, the eyes should move equally. (b) Patch test—cover one eye and have the client focus on your face, when you take the card away, the client’s eye should still be looking at you. Eyes with weak muscles will be deviated to the left or right when you take the card away. (c) Aim the light between the client’s eyes—the light should be reflected in the same spot on both eyes.

(a) Check for accommodation—client focuses on distant object and then focuses on your finger. As the eyes adjust their focus for the closer object, the pupils should constrict. Use the penlight to test each pupil for reaction to light. Pupils should be equal, round and reactive to light and accommodation (PERRLA). (b) Check peripheral vision using the “fish bowl” technique.

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(a) Palpate the lacrimal apparatus (the tear ducts)—there should be no discharge or tenderness. (b) Use the ophthalmoscope (set on 0) to find the red reflex. (c) Inspect and palpate the ears for lesions and set—a line drawn from the outer corner of the eye to the ear should intersect the top half of the ear.

(a) Weber test—tuning fork on the head to test for equal hearing in both ears. (b) Rinne test—tuning fork is held on the bone behind the ear. When the client can’t hear the sound anymore, the fork is moved in front of the ear. The amount of time the sound can be heard should be the same in both ears. Air conduction is heard twice as long as bone conduction.

(a) Hold the otoscope upside down and pull the outer ear up and back to inspect the eardrum. For children, the outer ear is pulled down. You should be able to see the “cone of light” reflected at 7:00 in the left ear and at 5:00 in the right ear. The normal eardrum is shiny and translucent, with a pearl-grey colour.

(a) Inspect the skin, bones and muscles of the shoulders and back—symmetrical with downward sloping ribs. Note whether the client needs to use accessory muscles to breathe. (b) Inspect symmetry of chest expansion. (c) Assess anterioposterior and lateral diameters of the thorax—the client should be twice as wide as they are deep. (d) Palpate over thorax and down the spine—note any tenderness, lumps or lesions.

(a) Palpate for tactile fremitus as the client repeats “99”—vibrations should feel the same on both sides, except for the area between the shoulder blades on the right side. This may feel stronger because of the bronchial bifurcation. The right bronchial tree has more of a downward angle and is shorter and wider—for this reason, anything aspirated tends to lodge in the right side first. (b) Percuss thorax—resonant sounds over healthy lung tissue, hyperresonant over pneumothorax or emphysema, dull over pneumonia, pleural effusion or tumor. (c) Auscultate—client takes deep breaths through the mouth. Listen in the same places that you percussed. Air entry should be easy and lungs should be clear in all lobes—don’t forget to listen to the sides too!

(a) Percussion order. (b) Auscultation order.

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(a) Assess thoracic expansion and fremitus before having the client lay down. (b) Elevate the head of the bed to 45O. (c) Inspect skin, bones and muscles of the thorax—pigeon, barrel or funnel chest. (d) Inspect for heaves—enlarged ventricles that are pulsing and pushing against the skin.

(a) Inspect jugular veins. Have client turn head away from you to see the pulsations at or around the suprasternal notch—the vein should not be distended. (b) Palpate the entire thorax including the precordium. (c) Palpate the apical impulse—may be easier to find if you ask the client to exhale and hold breath while you palpate. The pulse feels like a gentle tapping and should only occupy one interspace. (d) Percuss.

(a) The order of percussion and auscultaion. (b) Expected percussion sounds.Auscultating the heart—APE To Man. Differentiate between S1 (lup—closure of the atrioventricular valves; heard best at the apex, or the bottom of the heart) and S2 (dup—closure of the pulmonary valves; heard best at the base, or the top of the heart). Normal heart rate is 60-100 bpm.

(a) Lay the bed flat. (b) Inspect the abdomen for colour, symmetry, contour (protruberant, flat, rounded or scaphoid), peristalsis, pulsations and bulges or masses. (c) Auscultate before palpating and percussing to avoid creating excess peristalsis. Start in the RLQ and listen in a clockwise direction. Only if everything is quiet for 5 minutes can you decide that bowel sounds are absent. (c) Percuss. (d) Palpate lightly along the midclavicular lines. If the client indicates an area of tenderness, palpate this last. Move your fingers in a circular motion—looking for masses or tenderness.

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(a) Inspect the legs and feet for colour, lesions, variscosities, hair growth, edema and muscle mass. (b) Test for pitting edema in the pedal area. (c) Palpate the dorsalis pedis and posterior tibialis pulses and check for temperature differences.

(a) Perform the straight leg test—leg is lifted straight up and foot is dorsiflexed. This will produce back pain in a client with a herniated disc. (b) Keep one hand on the client’s hip while you abduct and adduct the leg—feel for crepitus. (c) Have client raise thigh against the resistance of your hand. (d) Ask client to role over onto each side and raise each leg against your resistance.

(a) Roll client onto abdomen and again have them raise leg against resistance. (b) Have the client sit up on the side of the bed. (c) Client tries to extend leg against your resistance and then tries to flex leg against your resistance. (d) Have client dorsiflex and then plantarflex against your resistance.

(a) Inspect skin and muscle mass of upper extremities. (b) Palpate hands to assess skin temperature. (c) Inspect colour, shape and condition of nails. (d) Inspect and palpate fingers, wrists and elbow joints.

(a) Place two fingers (cross them so your fingers don’t get hurt) in client’s palms and have them squeeze. (b) Palpate the radial and brachial pulses. (c) Ask client to extend arms and quickly turn hands up and down. (d) Place your hands under the client’s forearms and have them push up against your resistance and vice versa. (e) Draw a number on the client’s palm and have them guess it.

(a) Use the sharp end of the reflex hammer to get a response from the biceps muscle.

(b) Use the sharp end of the reflex hammer to get a response from the triceps muscle.

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(a) Use the sharp end of the hammer for the brachioradialis reflex.

(b) Use the flat end of the hammer for the patellar reflex. Strike the tendon directly just below the knee cap.

(A) Stroke the sharp handle of the hammer up the lateral side of the sole of the food and inward across the ball of the foot—plantar flexion of the toes and inversion and flexion of the foot is the normal response. (B) An abnormal response is dorsiflexion of the big toe and fanning of all toes. This is called a positive Babinski sign.

Use the flat of the hammer for the achilles reflex.

(a) Ask the client to walk across the room with a regular gait and then on the toes.(a) Then have client walk on the heels and finally heel to toe. (b) Ask the client to bend over as far as they can and inspect the scapulae, spine, back and hips for alignment.