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
physical assessment
| Question | Answer |
|---|---|
| what are the 5 purposes of physical assessment | gather baseline data, supplement or confirm data received, identify and confirm diagnosis, make clinical decisions about patient's health status, evaluate outcomes of care |
| what are the techniques used in physical assessment | inspection, palpation, percussion, ausculation, olfaction |
| what is light palpation compared to deep | 1cm deep: 4-5cm |
| where to find resonance in percussion | lungs |
| where to find tympany in percussion | stomach |
| dullness in percussion | liver |
| flatness in percussion | bone |
| where are high-pitched sounds for auscultation | lungs, bowel, heart s1&2 |
| what sthetoscope part do u use for high-pitched sounds | diaphragm |
| what should you use for low-pitched sounds (mumurs) | bell |
| you should always.. before palpating abdomen | listen |
| what can fruity breath indicate | DKA (diabetic ketoacidosis) |
| sitting position purpose (assesses?) | head, neck, chest |
| supine purpose | abdomen, extremities, if SOH raise HOB |
| dorsal recumbent position | on back hands raised above shoulder and legs with flexed gap |
| dorsal recumbent purpose | abdomen relaxation |
| Sims/lateral recumbent position | rectal exam, enemas |
| Fowlers (45-60) purpose | respiratory assessment |
| knee chest purpose (butt in air) | rectal procedures |
| lithotomy (on back with legs apart) | pelvic exam |
| prone | back exam (hip joint, skin buttocks) |
| what is a good environmental prep before examination | Privacy, adequate lighting, and exam tables must be elevated to 30 degrees (semi-fowlers) |
| how can a nurse demonstrate cultural diversity in physical examination | avoid assumptions, ask open-ended q's, use interpreter, maintain cultural sensitivity |
| what should you use throughout an examination (procedure based) | standard precautions |
| what are some normal findings of a young adult | skin elasticity, strong muscle tone, stable VS, sharp vision, clear lung sounds, reg heart rhythm |
| what are some normal findings of middle adult | slight decrease in vision, presbyopia, decreased muscle mass, slight BP increase |
| normal findings of older adult | decreased skin turgor, thinning skin, kyphosis (bending back), decreased height, diminished breath sounds, systolic BP increase, slower reflexes, decreased hearing and renal function |
| always _____ before palpating | auscultate |
| examples of abnormal findings to REPORT | sudden change in LOC, chest pain, SOH, abnormal VS, acute abdominal pain, uncontrolled bleeding, dysrhythmias, o2 sat <90% |
| importance of reporting abnormal findings | helps to prevent patient complications and improve patient outcomes |
| what are techniques for neurological physical assessment | LOC, pupils (PERRLA), orientation x 4, commands, speech, sensation |
| respiratory techniques for physical exam | inspect chest symmetry, palpate expansion, percuss lung fields, auscultate anterior/posterior |
| cardiovascular techs for physical exam | pulses upper and lower extremity, edema, nailbeds, capillary refill <3 secs, telemetry with interpretation |
| musculoskeletal techs | strength ROM (bilaterally) |
| skin techs physical | color, temp, moisture, turgor, lesions |
| what is s1 | valve closure, first heart sound (lub) |
| what is s2 | dub, aortic and pulmonic valves close = second heart sound |
| who is s3 considered abnormal and normal | abnormal for adults over 31, normal in children and young adults |
| what does the presence of s4 indicate | abnormal condition but heard in healthy older adults, children and athletes (not normal in adults) |
| what is dysrhythmia (s1 and 2) | silent pause between s1 and 2, failure of heart to beat at regular successive intervals |
| if a murmur is detected what should you do | auscultate the mitral, tricuspid, aortic, and pulmonic valve areas for placement in cardiac cycle |
| importance of using physical assessment skills during nursing routine skills | helps nurses detect subtle changes, prevent complications, evaluate interventions, ensure safety and support clinical decision making |
| assessment is ongoing.. not just | admission-based |
| HEENT physical findings | head shape, PERRLA, ears, nose, throat |
| GI physical findings | bowel sounds, tenderness, distention |
| urinary physical findings | urine characteristics, voiding pattern |
| musculoskeletal physical findings | ROM, strength |
| integumentary physical findings | color, integrity, lesions |
| what are some abnormal findings for young adult VS | persistent tachycardia, fever, unexplained weight loss |
| abnormal findings for middle adult VS | hypertension, cardiac arrhythmias |
| abnormal findings for older adult VS | orthostatic hypotension, HR irregularity, distressed respirations |
| abnormal stuff for resp young adult | crackles wheezes |
| abnormal find for middle adult resp | dyspnea |
| older adult abnormal finding resp | cyanosis, labored breathing |
| s3 definition and who is it abnormal findings in | ventricular gallop, low pitched sound heard in early diastole (CHF) older adults abnormal |
| is confusion part of the aging process | no |
| older adult metabolic abnormal find | hypoglycemia |
| when should you report an abnormal finding (4 questions) | yes to sudden change, asymmetrical, painful (cannot function), painful and impairment bound -> REPORT |
| ausculating heart sounds mnemonic | APE TO MAN (aortic, pulmonic, tricuspid, mitral) |
| GI physical assessment tech | abdomen, bowel sounds, BM |
Created by:
shinykwon