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Patient Evaluation
Physical Examination of The Patient/ What You See
| Question | Answer |
|---|---|
| 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
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