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Patient Evaluation

Physical Examination of The Patient/ What You See

QuestionAnswer
Assessment by Inspection What You see
Assessment by Inspection General Appearance Age, Height, Weight, Sex, Nourishment
Assessment by Inspection Edema/Peripheral Define Presence of excessive fluid in the tissue known as pitting edema.
Assessment by Inspection Edema/Peripheral/Occurs Primarily in arms and ankles.
Assessment by Inspection Edema/Peripheral Caused By Caused by congestive heart failure and renal failure.
Assessment by Inspection Edema/Peripheral / Rated Rated +1, +2,+3,etc. The higher the number the greater the swelling.
Assessment by Inspection Edema/Peripheral / Ascites Accumulation of fluid in the abdomen generally caused by liver failure.
Assessment by Inspection Clubbing of Fingers Caused by chronic hypoxemia. Presence of this suggestive of pulmonary disease.
Assessment by Inspection Clubbing of Fingers/ Affected The Thumb and first finger are affected. Toes are affected also.
Assessment by Inspection Clubbing of Fingers/ Condition The condition is present when the angle of the nail bed and skin increases.
Assessment by Inspection Venous Distention Occurs with congestive heart failure.
Assessment by Inspection Venous Distention/Patient Seen I patients with obstructive lung disease. Seen during exhalation because of the obstructive component.
Assessment by Inspection Capillary Refill/ Define Indication of peripheral circulation
Assessment by Inspection Capillary Refill/ Blanching of the hand and watch for blood return.
Assessment by Inspection Capillary Refill/Performed By Commonly done for the Modified Allen's Test before drawing arterial blood gases.
Assessment by Inspection Diaphoresis/and Indications * A state of profuse/ heavy sweating * Heart Failure * Fever, Infection * Anxiety, nervousness * Tuberculosis (night sweats)
Assessment by Inspection Skin Color/Normal Pink, Tan, Brown, Black
Assessment by Inspection Skin Color/Abnormal decrease in color (ashen, pallor) due to anemia or acute blood loss (vasoconstriction) will cause color change by reducing blood flow.
Assessment by Inspection Skin Color/ Jaundice Increase in bilirubin in blood and tissue. This appears in face and trunk.
Assessment by Inspection Skin Color/Erythema Redness of the skin. May be due to capillary congestion, inflammation or infection.
Assessment by Inspection Skin Color/ Cyanosis Blue or blue-gray (dusky) discoloration of skin and mucous membrane. caused by hypoxia from increased amount of hemoglobin (5g of reduced hemoglobin)
Assessment by Inspection Chest Configuration/ Normal Straight spine. No leaning forward= kyphosis No leaning side to side = scoliosis
Assessment by Inspection Chest Configuration/ Pectus Carinatum Anterior protrusion of the sternum.
Assessment by Inspection Chest Configuration/ Pectus Excavatum Depression of part or all of sternum.
Assessment by Inspection Chest Configuration/ Kyphosis Convex curvature of the spine (lean forward)
Assessment by Inspection Chest Configuration/ Scoliosis Lateral curvature of the spine (lean side to side)
Assessment by Inspection Chest Configuration/ Kyphoscoliosis combination of both and causes a severe Restrictive disease.
Assessment by Inspection Chest Configuration/ Barrel Chest Define a result of air trapping in the lungs for a long period of time.
Assessment by Inspection Chest Configuration/ Barrel Chest Causes generally due to chronic obstructive pulmonary disease Increased in A-P diameter.
Assessment by Inspection Movement Of the Chest/ Diaphragm/Symmetrical symmetrical chest movement occurs when both sides of the chest move at the same time
Assessment by Inspection Movement Of the Chest/ Diaphragm/ Abdomen the abdomen moves out during inspiration. because the diaphragm descends. the thorax moves outward and upward.
Assessment by Inspection Movement Of the Chest/ Diaphragm/Asymmetrical Unequal movement may indicate underlying pathology * chronic lung disease * atelectasis * pneumothorax * flail chest- paradoxical * intubated patient with endotracheal tube in one lung
Assessment by Inspection Breathing Patterns/ Eupnea normal respiratory rate, depth and rhythm. adult normal 12-20bpm
Assessment by Inspection Breathing Patterns/ Tachypnea increased respiratory rate (over 20bpm) causes: hypoxia, fever, pain, CNS problem.
Assessment by Inspection Breathing Patterns/Bradypnea (Oligopnea) decreased respiratory rate (less than 12bpm) variable depth and irregular rhythm Causes: sleep(normal), drugs, alcohol, metabolic disorders
Assessment by Inspection Breathing Patterns/ Apnea cessation of breathing (NOT)
Assessment by Inspection Breathing Patterns/Hyperpnea increased respiratory rate, increased depth, regular rhythm causes: metabolic disorder/CNS disorders
Assessment by Inspection Breathing Patterns/ Cheyne- Stokes gradually increasing then decreasing rates and depth in a cycle lasting 30-180 seconds with periods of apnea lasting up to 60 seconds.
Assessment by Inspection Breathing Patterns/ Biots increased respiratory rate and depth with irregular periods of apnea. Each breath has the same depth. causes: CNS problem
Assessment by Inspection Breathing Patterns/Kussmauls increased respiratory rate (usually over 20breaths/min) Increased depth irregular rhythm, breathing sounds labored Causes: metabolic acidosis, renal failure, diabetic ketoacidosis
Assessment by Inspection Breathing Patterns/Apneustic prolonged gasping inspiration followed by extremely short, insufficient expiration causes: problem with respiratory center, trauma or tumor
Assessment by Inspection Accessory muscle activity these muscles are used to increase ventilation during times of stress, increased airway resistance etc.
Assessment by Inspection Accessory muscle activity/ Normal these are normal muscles of ventilation - Diaphragm - External intercostal exhalation is normally passive
Assessment by Inspection Accessory muscle activity/ Accessory Intercostal muscles of ventilation -intercostal -scalene -sternocleidomastoid -pectoralis major
Assessment by Inspection Muscle Condition muscle wasting = atrophy loss of muscle tone and occurs in paralysis. referred as cachectic
Assessment by Inspection Retractions * Intercostal and/or sternal retractions occur when the chest moves inward during inspiratory efforts instead outward. * A sign of respiratory distress in infants.
Assessment by Inspection Nasal Flaring flaring of the nostrils during inspiration. a sign of respiratory distress in infants.
Assessment by Inspection Character of Cough * strong, moderate, weak * productive or non productive * frequent or infrequent/ loose, tight ,or moist
Assessment by Inspection Character of Cough/dry or non productive a dry or non productive = tumor productive=an infection
Assessment by Inspection Evidence of Difficult Airway/clinical factors existence of clinical factors that complicate either ventilation administered by face mask or intubation performed by experienced and skilled clinicians
Assessment by Inspection Evidence of Difficult Airway/Factors look externally of face or neck pathology - short receding mandible - enlarged tongue (macroglossia) - bull neck -limited range of motion of the neck
Created by: sukar