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Health Assess
T2-HA Lecture
| Question | Answer |
|---|---|
| What is a health assessment? | Includes a health history, behavioral exam, and physical exam |
| What is a PE? | A Physical exam is a head-to-toe review of body systems that offers objective info about pt status |
| Why it taking a health assessment important? | A good Hx helps "focus" your assessment on systems that are most likely affected/abnormal. Accuracy will help to mold the Plan Of Care (POC) and determine interventions, Baseline is not necessarily normal, but rather your findings during your first asses. |
| Why should you recognize cultural diversity? | Bc it helps you respect a pt's uniqueness and provide higher-quality care. |
| List the Skills of Physical Assessment | Inspection, Palpation, Percussion, Auscultation, Olfaction (IPPAO) |
| List the Skills of Physical Assessment for GI system | Inspection, Auscultation, Percussion, Palpation (IAPP) |
| Where are Percussion and Palpation delayed in examining the abdomen? | Delayed to avoid changing normally occuring bowel sounds. |
| What should you integrate into nursing care? | Bath and Ambulation. Ambulation can be observed when pt is going to br |
| When do you start your assessment? | As soon as you enter the room. Use your senses of vision, hearin, and olfaction (smell). |
| Name some principles of inspection | Adequate lighting, position and expose body parts, inspect for size, shape, color symmetry, position, and abnormalities |
| When inspecting, you should: | Compare areas on opposite sides of the body, Use addtl light for body cavities (penlight), Pay attention to detail, and don't hurry |
| What is palpation? | Touching of the pt to determine the size, consistency, texture, temp, location, and tenderness of an organ or body part |
| Hod do you perform deep palpation? | Press 1-2" with both hands to assess texture, size, shape, consistency, and pulsation of organs |
| How do you perform light palpation? | Press 1/2" with fingertips with 1 hand to assess for tenderness and pn |
| What is percussion? | Percussion involves tapping of body parts c fingers, fists, or small instruments to produce a vibration in order to evaluate the sz, location, tenderness, and presence or absence of fl or air in body organs. |
| Name types of percussion techniques. | Direct, Indirect, and Fist |
| What advantage does percussion technique bring? | You can locate organs or masses, map their boundaries, and determine their sz. An abnormal sound suggests a mass or substance such as air or fl within an organ or body cavity. |
| Describe the technique of Auscultation. | Listening to sounds created in body organs to detect variations |
| How should you apply the stethoscope to a pt when auscultating? | Apply the steth directly onto the skin. |
| What is the bell of the steth used for? | The bell is used to listen to low-pitched sounds such as abnormal heart sounds and bruits. |
| What is the diaphragm of the steth used for? | To listen to high-pitched sounds such as normal heart sounds, bowel sounds, and breath sounds. |
| Where would you hear peristalsis? | Peristalsis is heard over all hour abdominal quadrants as intermittent "tinkling" sounds |
| Describe olfaction | The use of smell during pt assessment. |
| What could cause an ammonia odor in the urine? | Possibility of UTI or Renal failure |
| What could cause a Feces odor? | Possibility of Bowel obstruction or Fecal incontinence |
| What could cause Sweet, fruity ketones in the oral cavity? | Possibility of Diabetic Acidosis |
| What could cause Fetid, Sweet Odor in the tracheostomy or mucus secretions? | Possibility of an infection of bronchial tree |
| What could cause Sweet, heavy, thick odor in a draining wound? | Possibility of Pseudomonas (bacterial) infection |
| What could cause a musty odor in a casted body part? | Possibility of infection inside cast |
| How should you prep for the exam? | Environment, Privacy, Lighting, Table/Bed, HOB up, Keep Pt Warm (EPLTHOBK) |
| What equipment should you use to perform an assessment? | Forms, gloves, Ruler, BP cuff, Steth, Termometer, Watch with second hand, Penlight |
| Before beginning PE, you should perform Physical Preparation. What would this include? | Asking Pt to empty bladder, Have pt properly dressed and draped, Keep Pt Warm and Comfortable, Position the pt as needed |
| What Psychological Preparation is needed before performing a PE? | Explain the procedure, Maintain a Professional/relaxed demeanor, Watch their expressions, Have a Witness |
| Different Age Groups may need different assessment techniques used. When examining children, list tips to help in data collection. | Obtain Hx from parents, Examine in nonthreatening area, Don't pass judgement, Call Parents by Mr/Mrs and children by their 1st name, Use Open-ended Qs to allow Parents to share more info, Treat adolescents as adults, Confidentiality! |
| Different Age Groups may need different assessment techniques used. When examining older adults, list tips to help in data collection. | Provide rest periods, Provide space for disabled pts to utilize canes, walkers, wheelchairs, Use patiencec, Perform exam near bathroom, Perform pnful procedures last |
| During the PE you should perform a General Survey. What is a General Survey? | Written summary of the nurse's impression of the client's overall state of health. |
| For the General Survey, what will the nurse assess? | Physical Appearance (Gender, Race, Age, LOC, Skin, Signs of Distress), Body Structure (Body type, Posture), Mobility (Gait, ROM), Behavior (Facials, Mood, Speech), VS |
| In the elderly, is hygiene and grooming predictable? | No, because they might just be too tired to bathe or comb hair. |
| When should you not delegate VS to an assistant? | Postop pts, Pts with certain IV & PO meds, status changes in Pts |
| What are the normal VS for an adult? BP, RR, HR, Temp, SpO2 | BP= 120/80 RR= 12-20/min HR= 60-100 Temp= 96.8-100.4F SpO2= 90%-100% |
| What could interfere with taking a tympanic temp? | Hearing aids |
| What could interfere with a Temp reading? | Recently ingesting hot/cold drinks, smoking, LOC, Development stages, Hearing Aids, Febrile, Afebrile, Pyrexia, O2 by face mask |
| For coma pts, can you take an oral temp? | No |
| What is the average Temp for older adults? | 96 degrees F, 36 degrees C |
| What organ maintains thermoregulation? | Hypothalamus |
| What can affect the hypothalamus? | Meds and trauma |
| How much can menopause raise the body Temp? | 4 degrees Celcius |
| Name 4 types of heat loss. | Radiation, Convection, Conduction, Evaporation |
| Describe Radiation. | Transfer of heat from 1 object to another object s contact between them |
| Give an example of Radiation. | Heat lost from body to a cold room |
| Describe Conduction | Transfer of heat from the body to another surface |
| Give an example of Conduction. | When the body is immersed in cold water. |
| Describe Convection. | Dispersion of heat by air currents |
| Give an example of Convection | Wind blowing across exposed skin |
| Describe Evaporation | Dispersion of heat through water vapor |
| Give an example of Evaporation | Sweating and Diaphoresis |
| How much water does the average adult lose per day in sweating due to evaporation? | 600-900 mL/day |
| What is Vasodilation? | Widening of the bv |
| When does Vasodilation occur? | When the hypothalamus senses and increase in body Tep, it sends impulses out to reduce body Temp by sweating and vasodilation. |
| What is Vasoconstriction? | Narrowing of surface bv |
| When does Vasoconstriction occur? | If the hypotahlamus senses the body's temp is lower than set point, it sends signals out to increase heat production by muscle shivering or heat conservation by vasoconstriction |
| What is Hyperthermia? | Elevated body Temp related to body's inability to promote heat loss or reduce heat production |
| What is Malignant Hyperthermia? | Hereditary condition of uncontrolled heat production |
| When does Malignant hyperthermia occur? | When pts c this condition receive certain anesthetic drugs |
| What are the S/S of a heat stroke? | Hot, dry skin, Giddiness, Delerium, Muscle cramps, Blurred vision, Confusion, Nausea, Visual disturbances, Incontinence |
| What treatment should you do perform your pt has a fever/Hyperthermia? | Tepid bath, Provide fl and rest, Cooling blanket, Keep Dry, Antipyretics (ASA, Acetaminophen, or Ibuprofen) |
| What should you expect if antibiotics are order for a pt with a fever? | May be sicker |
| What if my Pt is sick, with no fever, and taking steroids? | Steroids interfere c hypothalamic response & decrease heat production. Pt might not show fever bc of steroids interference but Pt could still have an infection s having fever. |
| When should you perform cultures on a pt with a fever? | Perform cultures before giving antibiotics bc they can alter results. |
| Define Hypothermia | Abnormally low bBody Temp (<95 degrees F, 35 degrees C) |
| What treatment should you perform for a pt experiencing Hypothermia? | Warming blankets, Friction to extremities, Warmed IV fl, Remove wet clothing, Hot liq, Keep head covered |
| What are S/S of Hypothermia? | Low HR, Low BP, Low RR |
| Who is at greater risk for Hypothermia? | Newborns, Older adults |
| When would Intentional hypothermia occur? | During prolonged neuroloical or cardiac surgery bc surgeons use this method to reduce the body's needs for oxygenated blood |
| What S/S would Accidental hypothermic pts experience? | Uncontrolled shivering, Loss of memory, Depression, and Poor Judgment |
| When does accidentaly Hypothermia develop? | Develops gradually and may go unnoticed for several hrs |
| How fast should you increase/decrease the body's temp? | No more than 1 degree per hour bc could produce cerebral edema or blood clots. |
| What should the hypothermic pt avoid? | Avoid alcohol, caffeing because they increase metabolic rate and sweating. |
| Why is hypothermia life threatening in infants? | Bc they have a large surface-to-mass ratio so they lose heat quickly to the environment. This could cause apnea. |
| What is BP? | BP is the force exerted by the blood in the arteries during heart contraction and relaxation |
| What is the SBP? | Systolic BP occurs during ventricular systole of the heart and represents the max amt of pressure exerted on the arteries. |
| What is DBP? | Diastolic BP occurs during ventricular diastole of the heart and represents the min amt of pressure exerted on the arteries |
| What is Hypotension? | BP that is below normal (SBP < 90 mmHg) and can be result of fld depletion, Heart failure or vasodilation |
| What is Orthostative (Postural) Hypotension? | BP that falls when a pt changes position from lying to sitting or standing |
| What will Orthostatic Hypertension may be a result of? | Peripheral Vasodilation, Med side effects, or Fld Depletion |
| When would you consider a pt to have HTN? | When BP is 140/90 or greater for 2+ readings at 2+ visits |
| What are the S/S of HTN? | Dehydration, Heart failure, Enemia, Vasodilation, CP, Increased HR |
| What are the S/S of Hypotension? | Increased HR, Pallor, Mallored, Clammy, Consued, Dizziness, Decreased Urine Output, Anemia |
| Can you delegate taking Orthostatic Hypotension BP? | No |
| Who would be at risk for Orthostatic Hypotension? | Pts c decreased blood vol, Anemia, Dehydration, Prolonged bed rest, Recent blood loss, Taking antihypertensive meds, Side effects of meds |
| What is Pulse Pressure (PP)? | Difference between the Systolic and Diastolic pressure readings (Ex. BP=120/80, then PP=40) |
| What is the normal pulse pressure range? | 30-40 mmHg |
| What is the Pulse Pressure an indicator of? | ICP, HTN, shock |
| What is an Auscultatory Gap? | When taking a BP, the P disappears and pressure is reduced and then reappears at lower level. Typically occurs between the first and second Korotkoff sounds |
| How big can an Auscultatory Gap be? | Can cover a ranges of 40mmHg |
| What could an Auscultatory Gap do? | Can cause an underestimation of systolic pressure or overestimation of diastolic pressure. |
| What should you do if you experience an Auscultatory Gap? | Inflate the cuff high enough to hear the tru systolic pressure before the Auscultatory Gap. |
| What could help to determine how hight to inflate the BP cuff if you're experience an Auscultatory Gap? | Palpating the radia artery. Inflate the cuff 30 mmHg above the pressure at which you palpate the radial pulse. Then record the range of pressures in which the auscultatory gap occurs. (Ex. BP RA 180/94 with an Auscultatory Gap from 180 to 160) |
| When should you not take a BP on a certain side? | when the pt has a shunt for dialysis, Running IV, Masectomy on that side, Cast on that side, Wound on that side |
| When should you take an Apical pulse? How how long? | You should take an Apical pulse if Pt has an irregular pulse. Take apical for 1 full min. |
| What is the rates for Pulse Oximetry readings? | 90-100%, 85-89% for certain chronic disease conditions, >85% abnormal |
| What factors could interfere with reading Pulse Oxygen Saturation? | Outside light sources, Pt motion, Jaundice, Dark skin pigment, PVD, Hypothermia |
| Should you leave on the pulse oximeter for long periods of time? | No because it gets warm and could burn the pt |
| What should you look for when assess the skin? | Inspecting skin's color, Moisture, Temp, Texture and turgor. Note any vascular changes, edem, or lesions. Carefully palpate abnormalities and document. Use back of hand for Temp and fingertips for texture & moisture. |
| What should you ask the Pt when doing a skin assessment? | Ask if they have a Hx of leisons, rahses, bruises, allergies, using new lotions, soap, perfume, or washing detergents. |
| When woud you have significant risk for skin leisons? | Trauma to skin while administering care, exposure to pressure during immobilization, or from reaction to meds |
| Who are more at risk for skin leisons? | Neurologically impared, chronically ill, orthopedic pts, pts with diminished mental status, poor tissue oxygenation, low cardiac output, and inadequate nutrition |
| When assessing for skin cancer, you should: | Look at Asymmetry, Border, Color, Diameter (ABCD) |
| Describe Pallor of the skin. | Loss of color (white) |
| What could cause Pallor? | Anemia or lack of blood flow |
| Where would you assess for Pallor? | Face, Conjunctivae, Nail beds, Palms of hands |
| Describe Cyanosis of the skin. | Bluish color |
| What could cause Cyanosis? | Hypoxia, Impaired venous return, Heart or lung disease, Cold environment |
| Where would you assess for Cyanosis? | Nail beds, Lips, Base of tongue, Skin |
| Describe Jaundice of the skin. | Yellow-orange of the skin, sclera, and mucous membranes |
| What could cause Jaundice? | Liver dysfunction, RBC destruction |
| Where would you assess for Jaundice? | Skin, Sclera, and Mucuous membranes |
| Describe Erythema of the skin. | Redness due to increased blood flow |
| What could cause Erythema? | Inflammation, Fever, Direct trauma, Blushing, Alcohol intake = Circulatory changes |
| Where would you assess for Erythema? | Face, Area of trauma, Sacrum, Shoulders, Other common sites for pressure ulcers |
| Describe Loss of Pigment of the skin. | Vitiligo |
| What could cause Loss of Pigment of the skin? | Congenital or autoimmune condition causing lack of pigment. |
| Where would you assess for loss of pigment of the skin? | Patchy areas on skin over face, hands, arms |
| What is turgor? | Testing skin for elasticity |
| How would you assess for skin turgor? | Lift and release a fold of skin on forearm, sternum, back of hand, or clavicle to evaulate that it returns quickly into place. Should rebound <3 sec. |
| What is tinting and what could it indicate? | When you pinch the back or hand and it stays. Can be sign of dehydration in older adults |
| What is edema? | Presence of fld in tissues causing swollen, tight, and shiny skin surfaces. |
| What are the 2 types of edema? | Pitting and Nonpitting |
| What is Pitting Edema and how do you evaluate it? | When pressure from finger leaves and indentation in that area. To evaluate, compress the skin for at least 5 sec over a bony prominence (shin, ankle) and access. |
| If you receive a 1+ on the Agency Grading scale when assessing for Pitting Edema, what does this conclude? | You have trace Pitting Edema and your response is Rapid |
| If you receive a 4+ on the Agency Grading scale when assessing for Pitting Edema, what does this conclude? | You have Severe Pitting Edema and your response time is 2-5 min |
| What can edema be a sign of? | Can be a sign of CHF |
| What is a TB skin test? | Determines the presence of mycobacterium tuberculosis. |
| What happens during a TB skin test? | Inject antigen ID on forearm. Injection leaves small bleb. Read test b/t 48-72 hrs. |
| What does a + TB Skin test reveal? | An elevated, hardened area around injection site. Its caused by reaction to the antigen-antibody. |
| What does a reddened flat area around the injection site of a TB skin test reveal? | Nothing, it's not a positive reation. |
| If test results from a TB Skin are positive, what would the pt do next? | Get a chest x-ray |
| What could compromise a TB Skin test? | If the pt is immunocompromised, the test might not be accurate. |
| What is Petechiae? | Pin-point red or purple spots caused by small hemorrhages |
| What does Petechiae indicate? | Serious blood-clotting disorders, Drug Reactions or Liver Disease |
| What is Purpura? | Appearance of red or purple spots on the skin that do not blanch when applying pressure. Caused by bleeding underneath the skin. |
| What is meningitis? | Inflammation of the protective membranes covering the brain and spinal cord |
| When is Purpura commonly seen? | In meningitis. Amputation has to occus where Purpura covers. |
| How is meningitis spread? | Airborne. |
| How do you assess Lesions and Rashes? | Location, Size, Shape Type, Texture Exudate, Color, Characteristics (pnful, itchy), Grouping (clustered, linear), Distribution (localized, generalized). |
| What are the types of Primary Skin Lesions? | Macule, Papule, Nodule, Tumor, Wheal, Vesicle, Pustule, Ulcer, Atrophy (MPN-TWV-PUA) |
| Describe a Macule type skin lesion. | Flat, nonpalpable change in skin color. Smaller than 1 cm (eg. freckle, petechia) |
| Describe a Papule type skin lesion. | Palpable, cincumscribed, solid elevation in skin. Smaller than 1 cm (eg. elevated nevus) |
| Describe a Nodule type skin lesion. | Elevated solid mass, deeper and firmer. 1-2cm (eg. wart) |
| Describe a Tumor type skin lesion. | Solid mass that extends deep through subc tissue. Larger than 1-2 cm (eg. epithelioma) |
| Describe a Wheal type skin lesion. | Irregularly shaped, elevated area or superficial localized edema. Varies in sz. (eg. hive, mosquito bite) |
| Describe a Vesicle type skin lesion. | Circumscribed elevation of skin filled with serous fld. Smaller than 1cm. (eg. Herpes simplex, chickenpox) |
| Describe a Pustule type skin lesion. | Circumscribed elevation of skin similar to Vesicle but filled ith pus. Varies in sz. (eg. acne, staphylococcal infection) |
| Describe a Ulcer type skin lesion. | Deep loss of skin surface that sometimes extends to dermis and frequently bleeds and scars. Varies in sz. (eg. Venous stasis ulcer) |
| Describe a Atrophy type skin lesion. | Thinning of skin with loss of normal skin furrow with skin appearing shiny and translucent. Varies in sz. (eg. arterial insufficiency) |
| What would linear mascular papular rashe with vesicles indicate? | Shingles |
| What should you look for when assessing Hair? | Color changes, Quantity, Quality, Distribution, Patters of hair loss, Alopecia, Scalp-redness, Scaling, Crusting, Lesions, Lice |
| What is Alopecia? | Baldness |
| What could change the hair and scalp? | Hair products, Chemo, Vasodilators, Changes in Diet, BP meds, Hairpiece |
| Wwhat should you look for when PE of the nail? | Color, Shape, Texture, Nail abnormalities |
| What is Clubbing? | Change in angle b/t nail and nail base, Nail bed softening c nail flattening, often enlargement of fingertips |
| What causes Clubbing of the nail? | Heart or Pulmonary disease, Chronic lung disease, COPD, Cystic Fibrousis |
| What should the capillary refill be? | <3 sec which indicated adequate arterial blood flow |
| What could poor capillary refill indicate? | Dehydration, Cold, Shock |
| In darker skinned pts, where should you assess for capillary refill? | In the palsm of the hands and soles of the ft |
| What should you look for when assessing the Head? | Size, Shape, Contour, Position |
| What is the word to describe a normal size head? | Normocephalic |
| What is hydrocephalus? | Accumulation of CSF in the ventricles |
| What does the PE include when assessing the eye? | Assessment of Visual Acuity, Visual fields, and Internal/External eye structure |
| What does 20/20 visual acuity mean? | When the pt standing 20 ft from the eye chart and can read it normally |
| What does 20/80 visual acuity mean? | When the pt has to stand at 20 ft to read something that a normal person can read standing 80 ft away (near sided) |
| What does the first number in the 20/20 visual acuity indicate? | The number of feet the pt is standing from the chart |
| What does the second number in the 20/20 visual acuity indicate? | The distance at which a normal-sighted person can read the line. |
| How do you evaluate Visual Fields? | Face the pt at distance of 60cm. Pt covers 1 eye while nurse covers her direct opposite eye (Pts right eye, Nurses left eye). Pts is asked to look at the nurse and report when can see fingers on examiner's outstretched arm coming in from 4 directions |
| Why should you assess for Extraocular movements (EOM)? | To determine the coordination of the eye muscles using 3 diff tests |
| What tests do you perform to assess for Extraocular Movements (EOM)? | CN III, CN IV, CN VI |
| What do you test in Extraocular Movements (EOM)? | Corneal light reflex, Strabismus, and 6 cardinal positions of gaze |
| How do you screen for Strabismus? | Cover/uncover test. Cover 1 eyes, pt is asked to look in another direction. Cover is removed and both eyes should be gazing in the same direction. |
| What is Eye Nystagmus? | Eye movements that are jerky or termor-like |
| What is Eye Strabismus? | Eyes don't line up - cross-eyed |
| What is the normal size of the pupil? | 3-7mm |
| What do pinpoit pupils indicate? | Opioid intoxication |
| What do cloudy pupils indicate? | Cataracts |
| What do dilated on constricted pupils indicate? | Neurological disorders, Effect of ophthalmic, Certain systemic drugs. |
| When assessing the pupils, what do you look for? | PERRLA |
| What does A stand for in PERRLA? | Accomodation - when pupils dilate to look at an object far away and then converge and constrict to focus on a near object |
| What can alter pupil reaction? | Changed in ICP, Trauma, Lesion on the nerve pathways, Locally applied eye drugs. |
| What is Deplopia? | Double vision |
| When conducting a PE on the ear, what should you assess? | Outer structure, Inner structure c an Otoscope, Hearing acuity. |
| If a person has outer structure ear abnormalities, what could this be indicative of? | Kidney abnormalities |
| If an infant is hairy, what could this be a sign of? | Congenital heart defects |
| When conducting a PE on the ear, what should you ask the pt? | Do they wear hearing aids, Have they ever taken Ototoxic meds, Do they have Tinnitus (ringing), Do they experience Vertigo (loss of equilibrium) |
| What is Ototoxicity? | Injury to the auditory nerve resulting from high maintenance doses of antibiotics |
| When performing a PE on the Nose and sinuses, what should you look for? | Asymmetry, Inflammation, Deformity, Mucosa, Discharge, Bleeding, Septum, Palpate sinuses |
| What is Epitaxis? | Hx of nose bleeds |
| When performing a PE on the Mouth/Pharynx, what should you look for? | Color, Hydration, Texture, Lesions, Edema, Defects, Ability to chew, Dental hygiene. Ask when their last dentist visit was. |
| When assessing the Mouth, you should look for MMM. What is MMM? | Moist Mucus Membranes |
| What does dry and sticky mucus membranes indicate? | Dehydration |
| What does spongy, bleeding gums indicate? | Vit C deficiency |
| When assesing the mouth, where should you look and what should you look for? | SL (cancer), Look for dentures, Lost teeth. |
| When performing a PE on the Neck, what should you look for? | Strength of muscles, Lymph Nodes, Thyroid, Trachea |
| What should you look for when assessing the Trachea? | Look for any deviation. It should be midline |
| What should you look for when assessing the Thyroid gland? | Inspect the pt's neck to see if an enlargement if visible. Palpate from behind to feel for size, masses, smoothness |
| If the Thyroid gland is enlarged, what should you do? | Auscultate the gland using a steth. Hearing a bruit indicates an abnormal increase in blood flow to the area |
| When performing a PE on the Thorax, what should you look for? | Orthopnea, Dyspnea, Cyanosis, Scars, Lesions |
| What is Orthopnea? | Difficulty breathing |
| What is Dyspnea? | Shortness of breath, breathlessness |
| What could interfere with breathing? | Pollutants at home/work, Smoking, COPD |
| When performing a PE on the Lungs, what should you ask the pt? | Last pneumonia, Last TB skin teset, Coughing, Sputum. |
| What are Crackles? | Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during end of inspiration. |
| What site should you auscultate to hear Crackles? | Heard in dependednt lobes, R&L lung bases |
| What causes Crackles? | Random, sudden reinflation of groups of alveoli. Disruptive passage of air |
| What is Rhonchi? | Loud, low-pitched rumbling coarse sounds heard most often during inspiration or expiration. May be cleared by coughing |
| What site should you auscultate to hear Rhonchi? | Heard over trachea and bronchi. If loud enough, heard over most lung fields |
| What causes Rhonchi? | Muscular spasm, fld, or mucus in larger airwars. Cause Turbulence |
| What is Wheezes? | High-pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration. Usually louder on expiration |
| What site should you auscultate to hear Wheezes? | Heard over all lung fields |
| What causes Wheezes? | High-velocity airflow through severely narrowed bronchus |
| What is Pleural Friction Rib? | Dry, grating quality sound heard best during inspiration. Can rub against heart |
| What site should you auscultate to hear Pleural Friction Rub? | Heard over anterior lateral lunch field (if Pt is sitting upright) |
| What causes Pleural Friction Rub? | Inflammed pleura, Parietal pleura rubbing against visceral pleura (heart) |
| What is Eupnea? | Normal breathing |
| What are S/S of respiratory distress? | Nasal flaring, Wheezing, Stridor, Tripod breathing, Subcostal retractions, Substernal retractions, Intercostal retraction |
| What is Cheyne-Stokes? | Respiratory pattern that gradually becomes faster and deeper than normal then slower alternating with periods of apnea |
| What is Cheyne-Stokes commonly called? | Death rattle |
| What is Kussmaul's? | Respiratory pattern that's faster and deeper respirations with pauses. Usually labored. |
| When do you see Kussmaul's | Occurs in diabetic acidosis. |
| How should you auscultate the lungs? | Listen at full inspiration and expiration on each side all the way down. Have Pt sitting then on side c steth diaphragm pressed firmly against skin |
| How many lobes does the R lung have? | 3 |
| How many lobes does the L lung have? | 2 |
| Where can you best auscultate the lower lobes of the lung? | Posteriorly |
| Where can you best auscultate the upper lobes of the lung? | Anteriorly |
| What is Bronchial normal breath sound? | Loud, high-pitched, and hollow |
| Where can you best hear Bronchial? | Heard over trachea with expiration longer than inspiration |
| What is Bronchovesicular normal breath sound? | Medium pitched, blowing sounds |
| Where can you best hear Bronchovesicular? | Heard near the mainstem bronchus, between scapula |
| What is Vesicular normal breath sound? | Soft, breezy, lower pitched, heard on inspiration longer than expiration |
| Where can you best hear Vesicular? | Heard in lung's peripheral parts |
| What is Adventitious breath sounds? | Abnormal breath sounds. Use this term when you can't differentiate lung sounds |
| During a PE of the heart, what should you ask Pt? | CP, Qual of pn, Palpations, Fatigued, Persistend wet cough, Edema, Pedal edema |
| During a PE of the heart, what should you inspect for? | Skin color, pallor, cyanosis, gray, Lips, Nail beds |
| What is PMI? | Point of Maximum Impulse |
| Where do you find PMI? | 5th intercostal space to the left of Midclavicular line, 1/2" diameter |
| Why should you auscultate Apical pulse? | Because you could hear a Thrill or Bruit which indicated a whole in the bottom of the heart |
| Why should you compare apical-radial pulses? | Because a pulse deficit is serious. |
| When auscultating the heart, what should you look for? | Evaluate cardiac rate, rhythm, intensity, Hear S1 and S2. Sounds are caused by valve closure. |
| What is a heart murmur? | Blowing or humming sound |
| Where should you assess for bruits? | Carotid arteries, Abdominal aorta (just below xiphoid process), Renal arteries (midclavic about umbilicus on ABD), Iliac arters (midclavic below umbilicus on ABD), Femoral arteries |
| How should you position the pt to listen to the heart? | Sitting, leaning fwd, Lying supine, Left Lat Recumbent (best for hearing for heart murmurs |
| What is syncope? | Light headedness, fainting |
| What as Stenosis? | Narrowing of the artery |
| What is Atherosclerosis? | Plaque buildup in arteries |
| What is a Thrill? | Palpable bruit |
| How do you assess for JVD? | Have pt sit at 45 degree angle and turn head to L. Notice if JV is poking out. Always assess in the same position. |
| What causes JVD? | Increased venous pressure |
| What may result from JVD? | SOB |
| How do you palpate carotid arteries? | Low and separate |
| How do you auscultate carotid arteries? | Using bell of steth |
| What is the Rating Chart for rating peripheral pulse strength? | 0-Absent, 1+Diminished, barely palpable, thready, 2+Normal, easily palpated, may be noted as weak, 3+Full/Increased, may be noted as normal, 4+Bounding, cannot be obliterated |
| When assessing peripheral pulses, should you only do on one side and one extremety? | No, always do on both sides and for both Upper and Lower Extremeties? |
| When assessing Venous and Arterial Sufficiency, what should you assess? | Color, Temp, Pulse, Skin |
| What are signs of venous insufficiency? | Color is Cyanotic |
| What are signs of arterial insufficiency? | Color is Pallor, Temp is cool, Pulse is descreased or absent, Skin is thin, descreased hair growth |
| What is a positive Homan's Sign? | Pn in calf on dorsiflexion |
| What does venous insufficiency cause? | Tissue changes indicating inadequate circulatory flow back to the heart |
| What would pt experience if having an arterial occulsion? | Pt has signs resulting from absence of blood flow. Pn will be distal to the occlusion |
| What are the 3 P's that characterize an occlusion? | Pain, Pallor, and Pulselessness |
| What is Phlebitis? | Inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization or prolonged insertion of IV cath. |
| What does Phlebitis normally cause? | Clotting - Thrombophlebitis - and can cause a pulmonary embolus |
| When inspecting the breast, assess: | Nipple color, dischare, retraction, dippling, rash |
| When should you perform a self breast-exam? | Couple of days afer cycle completed |
| Who is at risk for breast cancer? | Pt with family Hx, Early/Late menopause, Pt c no children, Pt with 1st child p 30 yo. |
| When performing a PE of the abdomen, what skills should you perform? | Inspect, Auscultate, Percussion, Palpation |
| What area should you start assessing in the abdomen? | RLQ |
| What are hyperactive bowel sounds? | Loud, growling sounds called Borborygmi. Indicate increased GI motility. >35/min |
| What can cause hyperactive bowel sounds? | Inflammation of the bowel, Anxiety, Bleeding, Excess ingestion of laxatives, Reaction of intestines to certain foods |
| What are hyperactive bowel sounds? | Sounds <5/min |
| How would you assess for absent bowel sounds? | Auscultate 5 minutes continuously in all four quadrants |
| What do bruits indicate if heard in the abdomen? | Aneurysms or Stenotic vessels |
| How do you assess for bruits in the abdomen? | Use the bell of the steth and auscultate in all four quadrants. |
| What is Normogastric? | Bowel sounds heard 5-35/min |
| Should you use deep palpation over surgical incisions or organs? | No |
| What is rebound tenderness? | When palpate andn pn gets better, but release and pn is worse |
| Should you palpate a pulsating abdominal mass? | No bc it could be AAA |
| Why is it important to place foreskin of penis back in place? | BC foreskin could cause problems if not put back over head of penis |
| If you're experiencing pn in back, what could this be indciation of? | Urinary system problems |
| What does a rectal exam detect? | Colorectal cancer in early stages |
| What is Passive ROM? | Moving Pt's joints through their full range of movements |
| What is Active ROM? | Pt moving joints |
| What is hypertrophy? | Enlargement of muscle due to strengthening |
| What is Atrophy? | Decrease in muscle size due to disues |
| How do you perform musculoskeletal assessment? | Handgrips (using 2 finger crossed), Footpushes, ADLs, Ambulatory devices |
| When performing PE on the Neurological System, what screening should be done? | Screen for symptoms of HA, seizures, tremors, dizziness, Vertigo, Numbness or tingling of body parts, Visual changes, Weakness, Pn, or Changes in speech |
| When performing PE on the Neurological System, what 'uses' should you review with the pt? | Use of analgesics, ETOH, sedatives, hypnotics, antipshycotics, antidepressants, nervous system stimulants, Recreational drugs |
| When performing PE on the Neurological System, what should you assess? | Behavior, Appearance, Language, Speech, Facial symmetry |
| What are the LOC? | Alert, Lathargic, Obtunded, Stuporous, Semi-comatose, Comatose |
| What is Obtunded? | In LOC, Pt needs to be lightly shaken to respond, but may be confused and slow to respond |
| What is Stuporous? | In LOC, Pt req pnful stimuli to achieve a brief response. Pt may nt respond verbally |
| What is Comatose? | In LOC, no response to repeated pnful stimuli. Abnormal posturing includes decorticate and decerebrate rigidity. |
| What is GCS? | Glascow Coma Scale used to mearue altered levels of consciousness |
| What is MMSE? | Mini-Mental State Examination - Questions to assess pts orientation and cognitive function |
| What are some MMSE questions? | What is the date, Repeat these 3 words back to me, What is this |
| How do you assess for Iintellectual Functioning? | Memory (immediate recall, remote, recent), Knowledge, Abstract thinking, Judgment |
| What is "On Old Olympus' Towering Tops A Finn And German Viewed Some Hops" | Phrase to remember the order of the Cranial Nerves |
| Name Cranial Nerve I and what function it provides. | Olfactory: Sense of smell |
| Name Cranial Nerve II and what function it provides. | Optic: Visual Acuity |
| Name Cranial Nerve III and what function it provides. | Oculomotor: Extraocular eye movement, Pupil constriction and dilation |
| Name Cranial Nerve IV and what function it provides. | Trochlear: Upward & downward gaze |
| Name Cranial Nerve V and what function it provides. | Trigeminal: Sensory nerve to skin of face, Motor nerve to muscles of jaw |
| Name Cranial Nerve VI and what function it provides. | Abducens: Lateral movement of eyeballs |
| Name Cranial Nerve VII and what function it provides. | Facial: Facial expression, Taste |
| Name Cranial Nerve VIII and what function it provides. | Auditory: Hearing, Taste |
| Name Cranial Nerve IX and what function it provides. | Glossopharyngeal: Ability to swallow |
| Name Cranial Nerve X and what function it provides. | Vagus: Sensation of pharynx, Movement of vocal cords |
| Name Cranial Nerve XI and what function it provides. | Spinal Accessory: Movement of head and shoulders |
| Name Cranial Nerve XII and what function it provides. | Hypoglossal: Position of tongue |
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mcwilliams05
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