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Chapter 21
Concepts III
| Question | Answer |
|---|---|
| Purpose of Physical Assessment To establish the patient’s current condition, a baseline against which future changes may be measured To identify problems the patient may have or have the potential to develop | |
| To evaluate the effectiveness of nursing interventions To monitor for changes in body function To detect specific body systems that need further assessment or testing | |
| A comprehensive health assessment involves an in-depth assessment of the whole person, including the physical, mental, emotional, cultural, and spiritual aspects of the patient’s health. | |
| An initial head-to-toe shift assessment consists of examining the following systems in a sequence beginning at the head; moving down to the toes: Neurological Cardiovascular Respiratory Integumentary Gastrointestinal Genitour | |
| An initial head-to-toe shift assessment also includes a specific assessment of the patients: Vital signs, including pain and oxygen saturation (SpO2) Appearance Speech Safety risk factors Tubes and equipment Comfort or complaints | |
| A focused assessment is less encompassing and involves an examination and an interview regarding a specific body system, such as examining solely the integumentary system or the respiratory system. | |
| An assessment ends when the patient goes home | |
| Assessments are performed at typical times such as On admission (generally performed the RN) At the beginning of each shift (shorter, more focused) When the patient’s condition changes | |
| Assessment performing's are When evaluating the effectiveness of nursing care Any time things do not feel right | |
| when expecting and observing you do not have to touch | |
| Auscultation is listening to the sounds produced by the body. | |
| The bell side of the stethoscope (the cupped smaller piece) is used to assess low-pitched sounds such as abnormal heart valve sounds, known as murmurs, and the rushing of blood through a vessel such as the carotid artery, known as a bruit. | |
| Some sounds may be heard with the naked ear, such as belching, also known as Eructation; passing of flatus or rectal gas; loud wheezing or gurgling; and loud bowel sounds. | |
| The larger flat piece, or diaphragm side of the stethoscope, is used to assess high-pitched sounds, such as the normal heart sounds (S1 and S2), breath sounds, and bowel sounds. | |
| Halitosis, or bad breath, may be the result of poor oral hygiene, a sinus infection, or gastric upset | |
| Be careful to protect the patient’s modesty by keeping the patient covered with a sheet, except for the body part that is being assessed. | |
| Cardiovascular Heart Sounds Capillary refill of extremities Edema Color and temperature of extremities Clubbing of fingertips | |
| Respiratory Symmetry of excursion SpO2 Breath sounds Use of accessory respiratory muscles Retractions Cough and sputum Color of nailbeds | |
| Yellowish-orange color of the sclera is normally an indication of elevated bilirubin, known as jaundice. | |
| Eye response Opens spontaneously-4 Opens to verbal command-3 Opens to pain stimulus-2 No response-1 | |
| Motor response Reacts to verbal-6 command-5 Reacts to localized pain-4 Flexes and withdraws-3 from pain-2 *Positions to decorticate posturing-1 **Positions to decerebrate posturing No response | |
| Verbal response Oriented, converses-5 Disoriented, converses-4 Uses inappropriate-3 words-2 Makes incomprehensible-1 sounds No response | |
| pupils equal and round and reactive to light and accommodation,” abbreviated as PERRLA. | |
| Cheilitis, or inflammation of the lips, in addition to excessive dryness and cracking, all of which may be caused by wind chapping, braces, dentures, dehydration, or seasonal allergies | |
| equal chest expansions are excursion, | |
| Chest wall appears depressed, or sunken in, between the ribs or under the xiphoid process when the patient inhales. These abnormal movements are called RETRACTIONS and indicate acute respiratory problems that need attention. | |
| Kussmaul’s Abnormally deep and rapid respirations, rhythm regular, blows off excess CO2 | |
| Cheyne-Stokes Cyclic breathing: periods of apnea- associated with death (dying) | |
| Biot’s A sequence of several breaths of equal depth that alternate with periods of apnea | |
| Rhonchi as snoring, rattling, gurgling, squeaking, and low-pitched wheezes and are caused by either secretions or partial occlusion of the airways | |
| Stridor is a shrill, high-pitched, harsh, crowing sound and requires immediate intervention | |
| Normal bowel sounds will include between 5 and 30 clicks | |
| Hypoactive bowel sounds are defined by fewer than 5 clicks or gurgles per minute in any quadrant. | |
| Hyperactive bowel sounds are defined as more than 30 clicks or gurgles per minute and are the result of excessive peristalsis. | |
| If gurgling bowel sounds are loud enough to hear without a stethoscope, it is termed borborygmus. | |
| Absence of bowel sounds is determined when you listen for at least 3 to 5 minutes in each abdominal quadrant and hear no sounds at all. Absence of bowel sounds can indicate severe medical problems | |
| turgor, or elasticity, is a general indicator of hydration level | |
| The normal time for color return in capillary refill is 3 seconds or less in adults and 5 seconds or less in older adults | |
| Pitting edema, press the patient’s skin over a bony prominence with your fingertip and hold for approximately 2 seconds, then release the pressure. | |
| Palpating is touching and checking the body for abnormalities using fingertips | |
| Percussion is striking the body parts with fingertips | |
| Deep palpations are 4 to 5 cm done only by a RN | |
| Carotid auscultations are listened to by the bell side of the stethoscope | |
| Sputum comes from the lungs (green in the morning) | |
| Pink and frothy first | |
| glaucoma is pressure behind the eyes | |
| cataract is cloudy | |
| Aphasia patient knows what to say but can not say it | |
| Dysphasia is difficulty coordinating and organizing what to say (suffers an impairment) | |
| crackles = fluid in the lungs rhonchi= snoring and gurgling wheezing= melody sound stridor=high pitch sound | |
| Listen to apical by born nipple | |
| listening to the 4 quadrants beginning with right lower right upper left upper left lower | |
| everything decreases in elderly | |
| <5 seconds is hypoactive bowel sounds | |
| >5 seconds is hyperactive bowel sounds | |
| between 5-30 seconds is normal bowel sound range | |
| Nurse needs an order for laxative for a patient that has NO bowel movement within 3 days | |
| Clubbing fingers means advance respiratory disease or issue |
Created by:
Daarina Jones