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Phys Assess TAS

Physical Assessment NP1 Test 4

Two aspects of assessment are: nursing health history and physical examination
What are the three types of physical assessment? 1. complete assessment 2. body system 3. body area
Purposes of physical assessment 1. obtain client baseline 2. supplement, confirm or refute nursing history 3. help establish nursing diagnoses and plans of care 4. evaluate outcomes of care 5. make clinical judgments about client's health status 6. identify areas of health promotio
What is important to determine BEFORE starting a physical exam? 1. Any positions that are contraindicated for a particular client 2. Beliefs that would hinder physical assessment
What are the four primary methods of examination? 1. Inspection 2. Palpation 3. Percussion 4. Auscultation
Why should light palpation ALWAYS precede deep palpation? Heavy pressure on fingertips can dull the sense of touch
Why is deep palpation not usually done during a routine examination? It requires significant skill and can cause damage if not performed correctly
What are the two types of auscultation? 1. Direct 2. Indirect
Define the two types of auscultation Direct is listening with the unaided ear, while indirect is with the aid of a device, such as a stethoscope
How are auscultated sounds defined? pitch, intensity, duration, frequency
Define auscultation pitch the frequency of the vibrations
Define auscultation intensity the loudness or softness of the sound
Define auscultation duration length (long or short) of the sound
Define auscultation quality subjective description (whistling, gurgling, ect.)
What is a general survey? The first part of a health assessment, including: general appearance and mental status vital signs height weight
What is included in the integument? skin, hair and nails
Pallor The result of inadequate circulating blood and reduction in tissue oxygenation
Where is pallor most easily identified? In areas of least pigmentation, such as conjunctiva, oral mucous membranes, nail beds, palms of hands, soles of feet
Cyanosis bluish tinge
Jaundice yellowish tinge
Erythema redness
Vitiligo patches of hypo pigmented skin
Edema excess interstitial fluid
What is the angle of a normal nail bed? less than 160 degrees
What is the process of physical assessment? 1. Interview client and physical exam 2. Gather data within 24 hrs of admission 3. Record data on data base form 4. Establish plan of care based on info obtained
What does the bell of the stethoscope detect? low-pitched sounds, such as heart murmurs and bruits
What is a bruit? narrowing of a blood vessel
What does the diaphragm of the stethoscope detect? high pitched sounds, such as breath sounds, normal heart sounds, bowel sounds
What side of the stethoscope is used most frequently? The diaphragm
When is a doppler used? When a pulse cannot be palpated
T or F, Inspection means you are watching for cues throughout the physical exam. True
What does palpation determine? position, size, fluid, mass, vibration, temperature
T or F, The kidneys are easily palpable during an abdominal exam. False. The kidneys are not usually felt unless there is an extreme reason.
What is the most important aspect of auscultating? A QUIET environment
T or F, When performing a physical exam, always palpate first. False. When examining the abdomen, palpation must be done last to prevent false bowel sounds.
T or F, The following auscultation description is complete: Continuous high pitched gurgling heard in abdomen. False. DETAILED LOCATION must be included, ex. Right Upper Quad
When during a physical assessment should vital signs be measured? FIRST!
T or F, A nurse can assess in any order, and can change assessment method from patient to patient. False. Approach must be systematic, and must be used every time.
T or F. Evaluating bedside equipment is not a part of physical assessment. False. Always compare equipment to info given in report, and make sure functioning/set properly
What angle should the bed be positioned at when detecting jugular vein distention? 45 degrees
What are the three main parts of circulation inspection? 1. Color 2. Capillary refill 3. Jugular vein distention
What are the four main parts of circulation palpation? 1. Skin temperature 2. Pulses (Apical counted, others graded) 3. Quality of peripheral pulses 4. Edema graded
What is the pulse grading scale? 0 absent 1+ difficult to feel 2+ normal 3+ bounding
T or F, Normal for grading pulses differs from institution to institution. False, Normal is ALWAYS 2+
What is the edema grading scale? 1+ = 2mm (barely detectable) 2+ = 4mm (indentation) 3+ = 6mm 4+ = 8mm
What is pitting edema? When finger indentation remains, usually 3+ or 4+
What are the auscultation sites for heart sounds? (All Physicians Take Money) Aortic, Pulmonic, Tricuspid, Mitral
What is a S1 heart sound? When the mitral and tricuspid valves close. (Lubb)
What is a S2 heart sound? When the aortic and pulmonic valves close. (Dubb)
What is a S3 heart sound? An abnormal extra heart sound (Ken' tuck y)
What is a S4 heart sound? Abnormal heart sound (Tenn es see')
What can a S3 heart sound indicate? Above the age of 13-14, could indicate congenital heart defect
T or F, An S3 heart sound in a child is reason for concern. False. Can be heard in healthy children, but usually disappears by age 13-14.
T or F, An S4 heart sound is ALWAYS abnormal. True. Indicates left side of heart not functioning properly.
What is another term for S3 and S4 heart sounds? Gallop
What heart sound is a possible indication of pericarditis? Rub
What is the heart murmur grading scale? 0=absent 1=barely hear 2=faint 3=moderately loud 4=loud 5=barely use stethoscope 6=don't need a stethoscope
What is a heart murmur? Prolonged heart sound caused by some disruption in blood flow through heart
What can cause a heart murmur? Valvular regurgitation or stenosis
What does a pansystolic heart murmur sound like? Two swishes
What are the four main parts of aeration inspection? 1. Shape of chest 2. Skin color 3. Breathing effort 4. Trachea positioning
If the trachea appears to be off-center, what could be indicated? Collapsed lung
What cues indicate troubled breathing? Labored breathing or use of accessory muscles
What are the three main parts of aeration palpation? 1. Feel for tenderness, bulges, unusual movement 2. Thoracic expansion 3. Check for crepitus
What are the anterior lung fields? right upper lobe, right middle lobe, right lower lobe, left upper lobe, left lower lobe
What are the posterior lung fields? right upper lobe, right lower lobe, left upper lobe left lower lobe
Rhonci Gurgling sound best heard on expiration, usually in upper airways
What causes Rhonci? secretions
Crackles are also called... Rales
Crackles/Rales Sounds like hair rubbing near ear, indicates fluid in alveoli
How are crackles/rales graded? fine or course
Wheezing high-pitched sound from narrowing of bronchi or bronchus, best heard on expiration
How can a nurse determine between a pulmonary rub and a cardiac rub? Ask the patient to hold their breath, if continues, rub is CARDIAC
What is the minimal acceptable amount of urine output? 30 mL per hour
What 4 aspects of patient's urine should be recorded? 1. output over 24 hrs 2. color 3. clarity 4. odor
What is the best patient position for abdominal assessment? Flat with knees bent and arms resting at sides
How would you describe a patients abdomen if it is swollen like a balloon? Distended
What range is normal for bowel sounds? Every 5-15 seconds
What is another term for normal bowel sounds? Active
What is the minimal number if sites that should be auscultated in each abdominal quadrant? 2
What are the three terms used to describe bowel sounds? 1. active 2. hyperactive 3. hypoactive
T or F, If a pulsation is noticed in the abdomen, it should be palpated and graded. False. Never palpate a pulsation in the abdomen as it could be an aortic aneurysm.
What should be recorded if a patient has a distended abdomen? Girth size (measured at umbilicus)
A nurse thinks her patient has absent bowel sounds. What should she do next? Listen for five full minutes before recording
Abdominal fat is... soft
Abdominal air/fluid is... taut
In what order should the abdomen be palpated? Start in the right lower quad, and continue counter clockwise until ending in the right upper quad.
When should patient weight be obtained? On admission
What 2 lab values are most important concerning urinary elimination? 1. Blood Urea Nitrogen 2. Creatine
What are the seven most important areas of assessing nutrition/metabolism? 1. Height/weight 2. Input/Output 3. Diet 4. Oral cavity 5. Lab values 6. IV fluids 7. Skin turgor
What lab values are important to nutrition/metabolism? electrolytes, RBC's, Hgb, Hct, liver profile, heart profile
What is EBL? Estimated blood loss
Where can estimated blood loss amounts be found? Anesthesia Record
What is the equation for determining caloric intake for tube feedings? mL fluid x calories per mL
What are the best sites for assessing skin turgor? Upper extremities and sternum
What does "tented" skin turgor indicate? dehydration
Ecchymosis bruise
What are the main areas assessed for patient sensation/perception? Gait, orientation, attitude, skin integrity, IV sites, skin sensation, vision/hearing, mental status
What details should be recorded concerning rashes? Size, location, raised, flat, ect.
What should be watched for at IV sites? redness, tenderness, streaking, phlebitis, swelling
What are the aspects of assessing pain? 1. scale of 0-10 (What does it mean?) 2. location 3. description (dull, sharp) 4. What makes it worse/better?
How is pain medication best monitored? 1. Time last administered 2. Amount last administered 3. How effective was last does? 4. Level of consciousness, V/S
A nurse is walking into the room of a patient that may have a head injury. How does she approach the patient and check for orientation? 1. Verbal stimuli 2. Light touch 3. Painful stimuli
What does PERRLA stand for? Pupils equally round and reactive to light & accommodation
What 4 aspects of mobility should be assessed? 1. ROM, assistive devices 2. Hand and leg strength bilaterally 3. All 4 extremities move equally 4. ADLs
What are the seven aspects of assessing anxiety? 1. Level 2. Behavior 3. Cognitive function 4. Learning needs 5. Support 6. Family/Lifestyle 7. Spirituality
What are the levels of anxiety? 1. mild 2. moderate 3. severe 4. panic
What does A&O x 3 mean? Alert and oriented to person, place, time.
What factors should be considered when assessing sexuality? Physical exam of genitals, Hx of self exams, Hx of STD's, Intimate relationships, Children
What is a normal venous stat? 60-70%
When using the bell of the stethoscope, what kind of pressure should be used? light
When using the diaphragm of the stethoscope, what kind of pressure should be used? firm
T or F. The nurse should ask the client if they need to void before beginning a physical exam. True. This will allow the client to be more relaxed and comfortable, and will allow the nurse to assess mobility.
What part of the body typically swells first? feet
What are the markers for the anterior RUL? the horizontal fissure from the fifth rib mid-axillary to the fourth rib
What are the markers for the anterior RLL? to the right of the right oblique fissure from fifth rib mid-axillary line to the sixth rib midclavicular line
What are the markers for the anterior LUL? the sixth rib midclavicular line marks the bottom border
The markers for the posterior RUL and LUL lung fields is ... Above T3
The markers for the posterior RLL and LLL lung fields is ... From T3 to T10
What is the best auscultation site for stridor? either side of the trachea in apex of lungs
What organs are located in the RUQ? Rt lobe of the liver, Gallbladder
What organs are located in the LUQ? Spleen,Stomach, Lt kidney
What organs are located in the RLQ? Appendix, Rt Ureter, Rt ovary and uterine tube in women
What quadrants is the large intestine located in? ALL of the quadrants
What organs are located in LLQ? Lt spermatic duct in men
A nurse auscultates odd sounds in the abdomen. What will the physician most likely do? Order x-rays
Created by: tiffiny090180