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Kaplan Physical Assessment

gurgling sounds commonly heard on inspiration rales
squeaky sounds heard during inspiration and expiration wheezes
grating sound or vibration heard during inspiration and expiration pleural friction rub- caused by an inflamed pleura; does not clear by coughing
loud transmission of voice sounds caused by consolidation of lung bronchophony
reflex within the body;to access ______, the extremity should be relaxed & partially stretched, compare responses on the right & left side of the body, responses should be equal, graded on a 4pt. scale w/ 1+ being diminished and 4+ being hyperactive deep tendon reflexes
what are two reinforcement techniques for the upper extremities? 1) clenching of teeth 2) contraction of quad muscles
what is a reinforcement technique for the lower extremities? interlocking of fingers and trying to pull them apart
reflex responses of 0+ may occur when... a component of the lower motor neurons or reflex arc is impaired
reflex responses of 4+ may occur when... lesions of the upper motor neurons or impairment of the higher cortical levels
the difference between systolic and diastolic BP readings; serves as an indirect measure of cardiac output pulse pressure
what is a normal difference for pulse pressure? 30-40mmHg
what are some things that a lowered pulse pressure could indicate? 1) hypervolemia 2) heart failure 3) shock 4) mitral stenosis
what are some things that a widened or increased pulse pressure can indicate? 1) slow heart rate 2) atherosclerosis 3) hypertension
the difference between apical and radial pulse is called a _____; may reflect dysrrhythmia pulse deficit
the stroke volume multiplied by the heart rate is called ______. cardiac output
____ is the amount of blood ejected with each heartbeat stroke volume
____ is the number of beats per minute heart rate
_____ is the product of cardiac output and peripheral resistance blood pressure
pulse pressure reflects what 3 things? 1)stroke volume 2)ejection velocity 3)systemic vascular resistance
when assessing a pt for tactile fremitus, which part of the hand should the nurse use? ulnar and palmar surface of the hand
the ______ is used for assessing temp since the skin is thin and there is nerve density dorsum (back of hand)
_____ are used for palpating pulses, lymph nodes, texture, consistency, size, shape, crepitus (all areas requiring fine discrimiation fingertips and fingerpads
___ is the temulous vibration, palpable over the posterior wall of the chest, which is produced when a patient says "99" tactile fremitus
___ are sensitive to vibrations and thrills. ulnar and palmar surfaces
tactile fremitus will be __ when lung consolidation exists, such as pneumonia and ___ when pleural effusion, pneumothorax, bronchial obstruction and air-trapping occurs increased/ decreased
if a person's visual activity is tested with a Snellen chart and reported to be 20/60, the nurse knows that the number 60 indicates which of the following the distance at which a person with normal vision can read the chart
the involuntary drifting of one eye out of alignment with the other eye ("lazy eye") Strabismus
abnormal, involuntary, rapid oscillating eye movements; may be horizontal, vertical, rotany, or mixed in direction nystagmus
___ is light intolerance, seen in various conjunctival disorders and conditions such as rubeola (measles), rubella (german measles), encephalitis photophobia
___ is drooping of the upper eyelid; may be congenital or aquired weakness or paralysis ptosis
when performing a physical assessment, the home health nurse notes that the eyes of the pt involuntarily move rapidly from side to side. what should the nurse chart? nystagmus
what is the normal range for pH of urine? 4.5-8. tends to be primarily acidic; helps protect bacterial infection
what is the normal BP for a 5-12 year old? 100-110/56-60mmHg
what is the normal respiratory rate for an adult? 12-20 per minute
what is the normal pulse rate of an adult 60-100bpm
what is the normal BP for an adult? <120/80 mmHg
what is the normal body temperature when taken orally? 98.6/37.0
what is the normal body tem when taken rectally? 99.6/37.6
what is the normal body temp when taken using the axillary method? 97.6/36.5
breahting accomplished by abdominal muscles and diaphram; may be used to increase effectiveness of ventilatory process in certain conditions abdominal respirations
temporary cessation of breathing apnea
periodic breathing characterized by rhythmic waxing and waning of the depth of respirations cheyne-stokes respirations
difficult, labored or painful breathing. (considered "normal" at certain times, e.g. after extreme physical exertion dyspnea
abnormally deep breathing hyperpnea
abnormally rapid, deep, and prolonged breathing caused by CNS disorders, drugs that increase sensitivity of respiratory center, or acute anxiety hyperventiliation
hyperventilation produces respiratory ________ due to reduction in CO2 alkalosis
air hunger, marked increase in depth and rate kussmaul's respirations
inability to breathe except when trunk is in an upright position orthopnea
breathing pattern in which a lung (or a portion of a lung)deflates during inspiration (acts opposite to normal) paradoxical respirations
rate, depth, or tidal volume changes markedly from one interval to the next; pattern of change is periodically reproduced periodic breathing
skin appears blue because of an excesive accomulation of unoxgenated hemoglobin in the blood cyanosis
harsh, high-pitched sound associated with airway obstruction near larynx stridor
normal reflex to remove foreign material from the lungs; normally absent in newborns cough
if the BP cuff is too narrow, what is the result abnormally high reading
if the BP cuff is too wide, what is the result? abnormally low reading
excess hair hirsutism
loss or thinning of hair alopecia
what is the normal angle of a nail bed? less than or equal to 160 degrees
what is clubbing? nailbed angle is greater than or equal to 180
what causes clubbing? prolonged decreased oxygenation
drooping of upper eyelid ptosis
assesses bone conduction vibrating tuning fork placed in middle of forehead. normal: hear sound equally in ears Weber test
compares bone conduction w/ air conduction; vibrating tuning fork placed on mastoid process; when client no longer hears sounds, positioned in front of ear canal; normal: should still be able to hear sound. air conduction>bone conduction by 2:1 ratio Rinne test
vibration produced when client articulates "99" tactile fremitus
assesses degree and symmetry of diaphragm movement diaphragmatic
soft and low-pitched breezy sounds heard over most of peripheral lung fields; inspiration greater than or equal to expiration vesicular lung sounds
medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration = expiration brochovesicular
loud, course, blowing sound heard over the trachea; inspiration less than equal to expiration bronchial
crackling or gurgling sounds commonly heard on inspiration crackles (rales)
_______ crackles clear with coughing atelectatic
musical sounds or vibrations commonly heard on expiration sonorous wheeze (rhonchi)
squeaky sounds heard during inspiration and expiration associated with narrowed airways sibilant wheeze
grating sounds or vibration heard during inspiration and expiration pleural friction rub
say "99" and and hear more clearly than normal; loud transmission of voice sounds caused by consolidation of lung bronchophony
say "E" and hear "A" due to distortion caused by consolidation of lung Egophony
Hear whispered sounds clearly due to dense consolidation of lung whispered pectoriloquy
manubrial sternal junction at second rib angle of louis
right and left second intercostal spaces alongside sternum aortic and pulmonic areas
third intercostal space just left of sternum Erb's point
Fourth or Fifth intercostal space at lower left of sternal border tricuspid area
fifth intercostal space at left midclavicular line (apex of heart) mitral area
closure of tricuspid and mitral valves; dull quality and low pitch; onset of ventricular systole; louder at apex S1
closure of aortic and pulmonic valves; snapping quality; onset of diastole; loudest at base S2
abnormal sounds caused by turbulence within a heart valve murmurs
turbulence within a blood vessel is called what? a bruit
difference between apical and radial rate pulse deficit
which pulse passes medially across the wrist? radial
which pulse passes laterally accross the wrist? ulnar
where is the middle ear located? temporal bone
connects middle ear to the throat and assists in equalizing pressure in middle ear? Eustachian tube
diagnostics with auditory. Quantitative. Degree of loss Audiogram
diagnostics with auditory. Qualitative. Type of loss. Tuning Fork
disorder in auditory canal. causes: infection, inflammation, foriegn body, trama conductive loss
hearing loss due to disorder of the organ of Corti or the auditory nerve. causes: congenital, infection, trama perspective (sensorineural loss)
Name the steps to irrigating an ear tilt head toward side of infected ear; gently direct stream of fluid against sides of canal; after procedure, instruct patient to lie on affected side to facilitate drainage; contraindicated if there is evidence of swelling or tenderness
Name the steps for ear drop instillation position the affected ear upmost; pull outer ear upward and backward for adults; place drops so they run down the wall of ear canal; have pt lie on unaffected ear to encourage absorption
inflammation of mastoid mastoiditis
dilation of the membrane of the labyrinth Meniere's Disease
infection of the middle ear from pathogenic organisms acute otitis media
fibrous outer coat of eye (white) sclera
dome-like structure that forms most of the anterior portion of the eye. main refracting surface of the eye. cornea
lies behind pupil and iris lens
colored portion of the eye; controls amount of light entering eye iris
innermost lining of the eye retina
what is the normal range for specific gravity of urine? 1.010-1.030
______ is medium, thud-like or muffled, medium-pitched sounds of short to moderate duration heard over dense fluid-filled tissue such as the liver, spleen, pleural effusion, and diaphragm dullness
____ is loud, musical or drum-like, high-pitched sound of moderate or long duration heard with enclosed air-filled structures such as the intestines tympany
______ is very loud, booming, low-pitched sound of long duration heard in conditions of over-inflated air-filled tissue such as occurs in pulmonary emphysema hyperresonance
______ is very soft, flat, high-pitched sound of short duration heard over very dense tissue such as bone, muscle flatness
pallor (loss of color) is seen with what 3 main things? 1) arterial insufficiency 2) decreased blood supply 3) anemia
cyanosis (blue coloring) is seen with what type of problems? cardiopulmonary
Jaundice is associated with what? hepatic dysfunction
erythema (skin redness and warmth) is seen with what 3 things? 1)inflammation 2) allergic reactions 3) trauma
pale or cyanotic nails are seen with _______ or __________. hypoxia/ anemia
yellow discoloration of nails may be seen with ________ or _________ fungal infections or psoriasis
clubbing of the nails may be the result of _____________ hypoxia
rough, flaky skin may result from: hypothyroidism
excessive moisture may occur with _________ or _________ fever/hyperthyroidism
decreased mobility of the skin is seen with __________ edema
decreased turgor is seen in _________ dehydration
cool skin may be a result of _____ ______ arterial disease
cold skin may accompany __________ or _________ shock/hypotension
a pictoral display of a person's family relationships and medical history. Allows user to visualize hereditary patterns and spychological factors that punctuate relationships genogram
push fluid-filled tissue toward palpating hand so object floats against fingertips ballottement
the diaphram of the stethoscope is used to listen to _____-pitched sounds such as _____, _______ and _______ high; lung, bowel, heart
the bell of the stethoscope is used to listen to ______-pitched sounds such as _____ ______ low; heart murmurs
what is the normal respiration rate for a newborn? 30-60 per minute
what is the normal pulse rate of a newborn? 120-160 bpm (180 when crying)
what is the normal BP of a newborn? 65/41 mmHg
what is the normal respiratory rate of a 1-4 year old? 20-40 per minute
what is the normal pulse rate of a 1-4 year old? 80-140 bpm
what is the normal BP of a 1-4 year old? 90-99/60-65 mmHg
what is the normal respiratory rate of a 5-12 year old? 15-25 per minute
what is the normal pulse rate of a 5-12 year old? 70-115 bpm
Created by: nickijohnson07
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