Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Test 2 N100
Evaluation, Physical Assessment, Critical Thinking, Health Concepts
| Question | Answer |
|---|---|
| Equipment used for physical assessment | tongue blade, gown, gloves, eye chart, percussion hammer, tape measure, turning fork, stethoscope, flashlight, BP cuff, thermometer, cotton applicators |
| Assess Method Olfaction | Body odor-smell |
| Assess Method Auscultation | Hear through stethoscope sounds produced within the body, eliminate noise, expose body part, ear pieces forward, diaphragm-hi noise, diaphragm- low (smaller) low noise |
| Assess Method Palpatation | Use sense of touch & use pads of fingers |
| Assess Method Light palpatation | Always do FIRST, circular motion, slightly depress- no more than 1/2 inch, dominant hand/fingers parallel to skin |
| Assess Method Inspection | Vison, smell, hear, room comfort temp., good lighting, INSPECT before touch, compare symmetry |
| What is physical assessment? | -Integral component of nursing care & basis of the nursing process.-Systematic & efficient |
| Age/Culture Difference | Physiologic changes occur with age, may need to move out of usual positioning, avoid chilling, permit ample time, ask what they want to be called, adapt for sensory impairments, be aware cultural differences, arrange for an interpretor, if needed |
| What would you do before an exam? | Collect subjective data that provides a detailed profile of the clients health status |
| What are the components of a health history? | Biographic data-Chief complaint-Hx present illness-Past hx-Family hx illness-Lifestyle-Social data-Psychological data-Patterns heatlth care-Review of systems |
| General survey of assessment. What do you look for? | Gender/Race, Age, Signs of distress, Body type, Posture, Gait, Body Movements, Hygiene/Grooming, Odor, Speech, Affect & Mood, Patient abuse of any kind, Vital signs & Height/Weight |
| LOOK @ Table 13-1 page 277LOOK @ Table 13-3 page 282 | |
| Collecting Data-Subjective vs Objective | Subjective- Also referred to as symptoms, apparent only to person affected, Described/Verified by person, Feeling of worryObjective- Also referred to as signs, Can be detected by an observer, Can be measured or tested, Obtained by observation or exam |
| Physical Assessment Methods | INSPECTION, PALPATION, PERCUSSION, AUSCULATION, OLFACTION |
| POSITIONS FOR EXAMINATION | Sitting, Supine-lying on back, Dorsal recumbent-on back with knees up, Lithotomy-pap postition, Sims-on stomach with one leg to the side, Prone-stomach with arms jeanie style on pillow, Lateral recumbent- on side, Knee-chest-cannon ball |
| Assess Method- WE WILL NOT BE DOING THIS BUT WE NEED TO KNOW-- Percussion | Tapping body to produce sound wave to assess underlying structures, Elicit pain, detemine location/size/shape, Flatness/dullness/resonance/hyperresonance/tympany, Finding the margin of an organ, This is done to start the DX for an MD |
| ASCITES | ABNORMAL ACCUMULATION OF FLUID IN THE ABDOMINAL CAVITY-WHEN YOU TAP ON IT SOUNDS LIKE A DRUM USING PERCUSSION |
| SKIN ASSESSMENT (INTEGUMENTARY)WHEN ASSESSING THE SKIN FIRST YOU WANT TO DO WHAT? | ASK HEALTH HX-DO YOU HAVE ANY SKIN PROBLEMS?INSPECT--WASH HANDS--GLOVE UP |
| WHEN ASSESSING THE SKING WHAT 7 THINGS ARE YOU LOOKING FOR? | COLOR-TEXTURE-VASCULARITY-TEMPERATURE-TURGOR-MOISTURE-EDEMA |
| TABLE 13-5 SKIN COLOR VARIATIONS | BLUISH (HYPOXIA), PALLOR (REDUCED OXYHEMOGLOBIN), LOSS OF PIGMENTATION (VITILIGO), YELLOW-ORANGE (LIVER), RED (BLOOD FLOW), TAN-BROWN (MELANIN) |
| PRIMARY SKIN LESIONS MACULE | FLAT <1 CM.EXAMPLE: FRECKLE |
| ULCER | DEEP LOSS PF SKIN-FREQ.BLEEDS-DOWN TO DERMIS.EXAMPLE: VENOUS STATUS ULCER |
| PAPULE | CIRCUMSCRIBED (SOLID ELEVATION IN SKIN) SMALLLER THAN 1 CM.EX: ELEVATED MOLES |
| PLAQUE | FLAT RAISED AREA |
| NODULE | ELEVATED SOLID MASS, DEEPER & FIRMER THAN PAPULE, 1 TO 2 CM |
| TUMOR | SOLID MASS, DEEP THROUGH SUBCUTANEOUS > 1 TO 2 CM |
| VESICLE | CIRCUMSCRIBED ELEVATION OF SKIN-SEROUS FLUID- < 1 CM.EX:HERPES |
| ATROPHY | THINNING OF SKIN WITH LOSS OF NORMAL SKIN FURROW (CANT'T SO SKIN TURGOR ON)EX: ARTERIAL INSUFFICIENCY-ELDERLY |
| WHEAL | IRREGULAR SHAPED, ELEVATED AREA OR SUPERFICIAL LOCALIZED EDEMA.EX:TB SKIN TEST OR MOSQUITO BITE |
| PUSTULE | ELEVATION OF SKIN SIMILIAR TO VESICLE BUT FILLED WITH PUS.EX: ACNE OR MRSA |
| PALLOR | "PALE" WHEN THE CUTANEOUS VESSELS ARE SEVERELY CONSTRICTED, A WHITISH HUE. WHITE PPL-BUCCAL MUCOSA;FACE, CONJUNCTIVA,NAILSDARK PPL-ABSENCE OF RED TONES IN MUCOUS MEMBRANES, LIPS, NAIL BEDS |
| MELANOMA | AGGRESSIVE FORM OF SKIN CANCER PRIMARILY IN LIGHT PIGMENTED PPL |
| JAUNDICE | TOO MUCH BILIRUBIN- YELLOW FINGE IN SKIN, LIGHT URINE AND DARK STOOLSWHITE PPL-BEST PLACE TO LOOK IS THEIR SCELRADARK PPL-HARD PALATE, PALMS, SOLES OF FEETMEDITERRIAN PPL-HARD TO ASSESS THIS IN |
| ERYTHEMA | SKIN REDNESS CAUSED BY VASODILATION OF CUTANEOUS BLOODWHITE PPL- LOOKDARK PPL- MAY NOT BE VISIBLE-PALATION FEELING FOR INCREASED WARMTH |
| INDURATION | IRREGULARITIES IN TEXTURES - SCARS HARDENING OF A TISSUE |
| TURGOR | MAKE SURE THE SKIN GOES BACK DOWN IMMEDIATELY- IF NOT PATIENT COULD BE DEHYDRATED |
| PETECHIAE | ROUND,TINY PURPLE OR RED SPOTS THAT RESULT FROM INTRADERMAL OR SUBMUCOSAL BLEEDING. SMALLER THAN ECCHYMOSIS.DARK PPL- ORAL MUCOSA OR CONJUNCTIVA |
| EDEMA | ABNORMAL ACCUMULATION OF FLUID IN INTERSTITIAL SPACES OF TISSUE |
| PURPURA | LARGE AREA OF ECCHYMOSIS-USUALLY WITH CLOTTING DISORDERS |
| ECCHYMOSIS | "BRUISE" BROKEN BLOOD VESSELS-BLOOD SEEPING INTO TISSUE CAUSING A PURPLE-BLUE COLOR, AS IT ABSORBS- YELLOW-GREENDARK PPL- PALPATATE FOR HEMATOMA-ELEVATION |
| ABRASION | SCRAPING OR RUBBING AWAY THE EPIDERMIS |
| EXCORIATION | INJURY TO THE SKINS SURFACE CAUSED BE ABRASION |
| BASAL CELL CARCINOMA | MALIGNANT EPITHELIAL CELL TUMOR THAT BEGINS AS A PALPULE AND ENLARGES TO A CRATOR |
| VITILIGO | SMOOTH WHITE PATCHES- LOSS OF PIGMENT |
| ASSESSING EDEMA | +1-CREATES DEPRESSION OF 2MM-RAPID RETURN+2- 4MM-DISAPPEARS IN 10-15 SECONDS+3- 6MM-DISAPPEARS IN 1-2 MINUTES+4- 8MM-DISAPPEARS IN 2-3 MINUTES |
| SKIN IN GERATRICS | SKIN LOSES ELASTICITY, STERNUM SITE FOR TURGOR, ATROPHY, DRY & FLAKY, PRONE TO SKIN BREAKDOWN |
| TALANGIECTASIS | VISIBLE BRIGHT, RED FINE DILATED BLOOD VESSELS |
| HAIR ASSESSMENT | OBTAIN HX-EVENLY DISTRIBUTED, INSPECT-EVENESS GROWTH, THICK OR THINESS, NOTE ANY PRESENCE INFECTIONS OR INFESTATIONS, INSPECT BODY FOR LICE |
| ALOPECIA | PARTIAL OR COMPLETE LOSS OF HAIR |
| GERIATRIC-HAIR | MAY SEE LOSS OF SCALP, AXILLARY, AND PUBIC HAIR, IN WOMEN-HAIR ON EYEBROWS/FACIAL MY BE COARSE, IN MEN-HAIR ON EYEBOROWS,EARS,NOSTRILS MY BECOME COARSEALOPECIA FOUND MORE IN MEN |
| NAIL ASSESSMENT | HAVE YOU HAD ANY NAIL TRAUMA?-NAIL HYGIENE, NAIL SHAPE (CLUBBING OR 160), NAIL BED COLOR (FIRM,PINK,CLEAR)DARK PPL-LOOK @ SOLES OF FEET,PALMS, & MUCOUS MEMBRANES, CAPILLARY REFILL, SURROUNDING TISSUES (DRY,CRACKED,SWOLLEN) |
| GERIATRIC-NAILS | SLOW GROW AND THICK, MORE BRITTLE, DULL, CUTICLE LESS THICK, SPLITS,LONGITUDINAL BANDS,BANDS MAY INDICATE CERTAIN PROTEIN DEF. |
| CHRONIC HYPOXIA | NAILS FLAT |
| WHITE SPOTS ON NAILS CAN INDICATE WHAT? | ZINC DEF. |
| BEAU'S LINES | TRANSVERSE DEPRESSION IN NAILSCAUSES: NAIL INJURY, SYSTEMATIC ILLNESS,INFECTION |
| CLUBBING | CHANGE IN ANGLE BETWEEN THE NAIL AND NAIL BASE.OVER 180 DEGREES, WILL FLATTEN EVENTUALLY, NAIL BEDS ARE SOFT.CAUSES: CHRONIC LACK OF O2 OR HEART AND/OR PULMONARY DISEASE |
| NAIL FUNGUS | FUNGUS OF THE NAIL CAN BE PRESENT IN ONE OR MANY |
| KOLLONYCHIA OR SPOON NAIL | CONCAVE CURVE OF NAILCAUSE: IRON DEF., ANEMIA(NOT ENOUGH Hgb) , SYPHILLIS,USE OF STRONG DETERGENTS |
| PARONYCHIA | INFLAMMATION OF THE SKIN AT THE BASE OF THE NAILCAUSES: TRAUMA OR LOCAL INFECTION |
| SPLINTER HEMORRHAGES | RED OR BROWN LINEAR STREAKS IN NAIL BEDCAUSES: MINOR TRAUMA, SUBACUTE BACTERIAL ENDOCARDIS,TRICHINOSIS |
| HEAD ASSESSMENT- SKULL & FACE, EYES & VISUAL ACUITY, EARS & HEARING, NOSE & SINUSES, MOUTH & OROPHARYNX | |
| ASSESSING THE SKULL & FACE | INSPECT SIZE, SHAPE, & SYMMETRYEYES-EDEMA OR SUNKEN |
| BONE NAMES-SKULL | FRONTAL, CORONAL SUTURE, FOREHEAD BOSS, GLABELLA, TEMPORAL BONE, SPHENOID BONE |
| BONES NAMES- FACIAL | SUPRAORBITAL PROCESS AND FORAMEN, LACRIMAL BONE, ZYGOMATIC BONE, NASAL BONE, ETHMOID BONE, MAXILLA, NASAL CONCHA, VOLMER NASAL SPINE, RAMUS, ANGLE OF JAW, AVEOLAR PROCESS,MANDIBLE, MENTAL TUBEROSITY,MENTAL PROTRUBERANCE |
| NORMOCEPHALIC | NORMAL HEAD SIZE |
| ACROMEGALY | OVERSECRETION OF GROWTH HORMONES BY THE PITUITARY GLAND-WIDENING AND THICKENING OF THE SKELETAL BONES IN THE FACE, HANDS,JAW AND FEET |
| HYDROCEPHALUS | ABNORMAL ACCUMULATION OF CEREBROSPINAL FLUID, USUALLY UNDER INCREASED PRESSURE |
| EYES & VISUAL ACUITY | |
| CONJUNCTIVA | MUCOUS MEMBRANE LINING THE INNER SURFACES OF THE EYELIDS AND ANTEIOR PART OF THE SCLERA |
| CONJUNCTIVITIS | INFLAMMATION OF THE CONJUNCTIVA |
| PALPEBRAL CONJUNCTIVA | LINES THE INNER SURFACE OF THE EYELIDS AND IS THICK, OPAQUE, AND HIGHLY VASCULAR-DELICATE MEMBER OF THE EYELIDS |
| WHAT DO YOU WANT TO KNOW ABOUT THE PUPILS? | COLOR, SHAPE, AND SIZE |
| DIRECT/CONSENSUAL REACTION | DIRECT-NORMALLY CROSSED REFLEX-LIGHT DIRECTED AT ONE EYE CAUSES THE OPPOSITE PUPIL TO CONTRACTINDIRECT-THE PUPIL WOULD NOT RESPOND |
| REACTION ACCOMMODATION | THE ADJUSTMENT OF THE EYETO VARIATIONS IN DISTANCE-MAKE SURE THE PUPILS CONSTRICT (SMALLER) |
| PERRLA | Pupils Equal Round React to Light Accomodiation |
| EYELIDS- PTOSIS | FALLING OR DROPPING OF THE EYELID |
| EYELASHES | ECTROPION-OUTWARD EYELASHESENTROPION-INWARD EYELASHES |
| STRABISMUS | ABNORMAL-THE VISUAL AXES OF THE EYES ARE NOT DIRECTED @ THE SAME THING |
| EXOPHTALMON | PROTRUSION OF THE EYEBALLS |
| PHOTOPHOBIA | ABNORMAL SENSITIVITY TO LIGHT |
| DIPLOPIA | DOUBLE VISION |
| STRUCTURE OF THE EYE-HOW TO ASSESS THE EYES | EYES SYMMETRY-EYEBROWS MOVE UP AND DOWN EVENLY- OUTER CANTUS IS LEVEL WITH EARS- CLOSE THE EYES HARD, LOOK FOR PTOSIS, LOOK AT SCLERA AND CORONA |
| VISUAL ACUTIY | DISTANT-SNELLEN STANDARD, SNELLEN E, PRESCHOOLWITH THIS ALLOW TO KEEP GLASSES ON IF THEY WEAR THEM. IF FAR SIGHTED THEY MIGHT NOT BE ABLE TO READ THE SNELLEN. IF THEY CANT SEE THEM HAVE THEM REMOVE THEIR GLASSES. FAR AWAY 20 FEET, DISTACE CHART |
| NEAR VISION | ROSENBAUM, MAGAZINE OR NEWSPAPER, 14 INCHES FROM THE FACE |
| GERIATRIC EYE CONSIDERATION | VISUAL DECREASES-PERIPHERAL DECREASES-ADAPTATION LIGHT/DARK DECREASES, COLOR VISION DECREASES, CONJUNCTIVA MIGHT SEEM PALE, PUPIL REACTION LESS BRISK |
| EARS & HEARING | INSPECT AURICLES, PALPATE AURICLES, ASSESS RESPONSE TO NORMAL VOICE TONES, WHISPER TEST |
| WEBER TEST | SHOULD BE ABLE TO SENSE THE VIBRATION EQUALLY IN BOTH EARSPOSITIVE TEST: IF THE VIBRATION IS LOUDER IN ONE EAR. |
| RINNE TEST | USES A TUNING FORK TO COMPARE AIR CONDUCTION (AC) AND BONE CONDUCTION (BC). NORMALLY AC IS TWICE AS LONG AS BC. HIT THE FORK AND STICK TO THE MASTOID PROCESS. |
| EAR CANALS | INFANT:PULL AURICLE DOWN AND BACK.ADULTS: UP AND BACK |
| VERTIGO | LOSS OF EQUILIBRIUM |
| OTOTOXICITY | INJURY TO THE AUDITORY NERVE |
| TINNITUS | RINGING IN THE EARS |
| CERUMEN | YELLOW WAXY SUBSTANCE |
| CONDUCTIVE HEARING LOSS | AN INTERUPTION OF SOUND WAVES AS THEY TRAVEL FROM THE OUTER EAR TO THE COCHLEA |
| SENSORINEURAL HEARING LOSS | SOUND IS CONDUCTED THROUGH THE OUTER AND MIDDLE EAR STRUCTURES. |
| NOSE & SINUSES | INSPECT NOSE DEVIATIONS, LIGHTLY PALPATE, INSPECT NASAL CAVITY, SNIFF TEST, SINUSES (U CAN PALPATE THE FRONTAL & MAXILLARY) ETHMOID AND SPHENOID SINUSES ARE INTERNAL |
| EPITAXIS | BLEEDING FROM THE NOSE |
| ASSESS MOUTH & OROPHARYNX | MOUTH, TEETH & GUMS, TONGUE & FLOOR OF MOUTH, PALATE & UVULA, OROPHARYNX & TONSILS, LOOK FOR EXTENSIVE DENTAL WORK, DENTURES, TOBACCO, SMELL |
| LIPS, BUCCAL MUCOSA, TEETH, GUMS | INSPECT LIPS FOR SYMMETRY, COLOR, TEXTURE-PURSE LIPS-PALPATE LIPS & BUCCAL MUCOSA FOR COLOR, MOISTURE, TEXTURE, LESIONS, INSPECT TEETH/GUMS, INSPECT DENTURES |
| EXOTOSIS | AN ABNORMAL BENIGN GROWTH ON THE SURFACE OF A BONE |
| LEUKOPLAKIA | A PRECANCEROUS, SLOWLY DEVELOPING CHANGE IN A MUCOUS MEMBRANE, THICKENED, WHITE, FIRMLY ATTACHED PATCHES |
| GINGIVAE | GUM TISSUES OF THE MOUTH |
| TONGUE & FLOOR MOUTH | INSPECT TONGUE POSITION, TEXTURE, COLORASK TO PROTRUDE THE TONGUEINSPECT BASE AND MOUTH FLOOR FOR NODULES, LUMPS, EXCORIATIONS |
| PALATES, UVULA, OROPHARYNX, TONSILS | INSPECT HARD/SOFT PALATES (BONY HARD PINK, NO ULCERS)OPEN MOUTH, ILLUMINATE, INSPECT UVULA (SAY AH), INSPECT OROPHARYNX, INSPECT TONSILS, ELICIT GAG |
| GERIATRIC CONSIDERATIONS MOUTH | ORAL MUCOSA MAY BE DRIER, RECEDING OF GUMS, TASTE SENSATIONS DIMINISH, TEETH MAY SHOW SIGNS WEAR/DAMAGE, GAG REFLEX MAY BE SLUGGISH, MAY NEED DENTAL/DENTURE REPAIR |
| NECK | INSPECT, ASK HOLD HEAD ERECT, OBSERVE HEAD MOVEMENT, CAROTID ARTERIES-PALPATE, THYROID-SWELLING, TRACHEA-MIDLINE |
| LYMPH NODES OCIPITAL | BASE OF NECK |
| POSTAURICULAR | BEHIND EARS |
| PREAURICULAR | IN FRONT OF EARS (FIRM, MOBILE, CIRCUMSCRIBED) |
| SUBMANDIBULAR | UNDER JAW |
| ANTERIOR CERVICAL CHAIN | DOWN THE TRAPEZIUS MUSCLE |
| POSTERIOR CERVICAL CHAIN | DOWN BACK OF NECK (CORDED) |
| SUPRACLAVICULAR | INSIDE OF CLAVICLE, FIRST START OF HODGKINS |
| LUNGS | RIGHT LOBE- ANTERIOR 3 LOBES, POSTERIOR 2 LOBESLEFT LOBE-2 LOBES ON ANTERIOR AND 2 LOBES ON POSTERIOR |
| CHEST SIZE AND SHAPE | AP DIAMETER-MEASURE AROUNDTRANSVERSE DIAMETER-MIDLINE |
| PECTUS CARINATUM | PIGEON BREAST- AT STERNUM, GROWTH TISSUE CROWDING ORGANS-OCCURS IN NEWBORNS |
| BARREL CHESTED | ALWAYS FEEL HUNGRY-DEEP AND NARROW-FOUND IN CHRONIC LUNG PATIENTS AND HAVE SMALL LEGS- FINGERNAILS ARE USUALLY CLUBBED-USUALLY SHOW SHOW FACIAL FEAR,WITH APPARENT CYNOSIS-FOUND ON COPD,SMOKERS,FUMES,& CYSTIC FIBROSIS.THIN B/C CALORIES ARE USED UP |
| PECTUS EXCAVATUM | STERNUM INWARD-LUNGS ARE COMPACTED SO HARDER TIME BREATHING-INTERTHORACIC CROWDING |
Created by:
dana.burnam222
Popular Nursing sets