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Test 2 N100

Evaluation, Physical Assessment, Critical Thinking, Health Concepts

QuestionAnswer
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