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Physical Assessment

Ch. 15 Potter/Perry

Purpose of Physical Assessment Complete or based on problem of pxt. Gather baseline data, check info in hx, confirm nursing diagnosis
Physical assessment involves nursing hx, behavioral and physical exam
What is included in nursing hx wt,ht,VS,client understand illness, expectations,cultural factors, allergies,meds/herbs
Other hx to consider past surgeries, pychosocial hx, family, social, occupation,nutrition
Asians and middle easterners are at higher risk of developing? Beta Thalassemia: blood dyscrasais, lowers hemoglobin
First step in assessment Communicate and touch
Questions for pain locate pain, when start, can change position help, what precipitates pain, quality: sharp, dull, Does it radiate? How severe: scale 1-10. Does pain cause symptoms, nausea, clammy...
Skills of physical assessment 1. inspection (olfaction) 2. auscultation 3. palpation 4. percussion
What to inspect for? Size, shape, color, symmetry, position abnormalities. Can use tangential lighting-angle
Palpate for? palpate skin for moisture, texture, turgor, tenderness, thickness, organs, nodes
When palpating, always start where? Start with what is normal and go to what is abnormal or pain last
Fingertips are? Back of hand feels? palms sense? most sensitive temperature vibration
What are the two types of palpation Light = 1/2 cm deep Deep = 1-2 cm deep
Percussion types direct = tap middle finger on surface indirect - two fingers on top of two bottom fingers
Auscultation is listening to organs, arteries, tissue, lungs, heart with stethoscope
Frequency of sound Loudness Quality duration high freq = high pitch amplitude, loud or soft blowing, gurgling short, medium, long
supine position dorsal recumbant lithotomy Sims' prone lateral recumbent knee chest lay on back, easy pulse sites back with knees bent, abs assess genitalia recrum/vagina hip joint, skin buttocks heart murmurs rectum
Stethoscope diaphragm high frequency sounds, abs, heart(S1,S2), lung
Stethoscope Bell low freq. sounds, murmurs, bruits, Heart (S3, S4)
Ammonia Feces foul infant stool urine = UTI, renal failure bowel obstruction, incontinence malabsorption syndrome
Sweet, fruity ketones Stale urine sweet heavy thick odor oral = diabetic skin = uremic acidosis draining wound - psuedomonas
When does an assessment begin? When first meet pxt. Look at dress, mobility, bahavior, VS, ht, wt, speech
General Survey includes Gender/race, age, signs of distress, body type, posture, gait, body mvmts, hygiene, dress, odor, mood, speech, pxt abuse, subsntance abuse
what if you suspect substance abuse? C-Ever felt like cutting down A-annoyed by criticism of habit G-Ever felt guilty E-Ever needed eye opener to steady?
Assessment of Skin Changes in oxygenation,circulation,nutrition, local tissue damage,hydration
High risk skin problem pxts neurologically impaired,chronically ill,orthopedic
Infants assessment on wt always need what else at same time? head circumference
Normal skin color ivory to light pink to ruddy pink in light skin. light to deep brown or olive in dark
Cyanosis is found lips, nail beds, palpebral conjunctivae, palms
Pallor face, buccal conjunctivae, nail beds
Best site to find jaundice erythema sclera redness, fever, vasodilation
indurated skin turgor hardened elasticity
petechiae pinpoint size red spots on skin by small hemorrhages in skin layers
pitting edema fingers leaves indention +1 = 2mm, +2 = 4mm, +3-6mm, +4-8mm
macule flat, freckle, nonpalpable
papule palpable, solid elevation
nodule elevated solid mass, wart
tumor solid mass thru subcu
wheal irregular shape, hive, mosquito bite
vesicle elevation filled with serous fluid, chickenpox
pustule filled with pus
ulcer deep loss of skin surface
atrophy thinning of skin, loss of skin furrow
Assess nails normal-160 deg clubbing - 180 - heart or pulmonary Beau's lines, systemic infection
Spoon nail (Koilonychia) iron deficiency, anemia
splinter hemorrhages, red/brown streaks minor trauma, bacterial endocarditis, trichinosis
paronychia, inflammation of skin at base local infection
Dark skin nails normal dark pigment wtih blue or reddish hue
Normal capillary refill <2 sec = brisk >4 sec = sluggish
Head Assessment check for size, shape, contour, steady or jerking mvmts, upright or held to side(torticollis)
Eyes exopthalmos strabismus ptosis arcus senilis bulging eyes(hyperthyroidism) crossing of eyes abnormal drooping of lid CNIII think white ring around cornea
what are three types of ear loss? conductive-outer to inner interrupt sensorineural-inner,nerve,hear ctr. mixed
Not move eyebrow indicates damage to which cranial nerve? CNVII
Normal pupil size 3-7mm
How to check children's ear canal adults? pull down and back up and back
Never inspect mouth of someone having epiglotitis symptoms: resp stridor, drooling
Can you palpate lymph nodes? Normal lymph nodes are not palpable, if they are, then most likely infection.
What is a goiter? over growth of thyroid tissue, can obstruct airway. Iodine in salt helped stop these
Left scapular line vertebral line right scapular line posterior chest
posterior axillary line midaxillary line anterior axillary line lateral chest
midsternal line midclavicular line anterior axilallary line anterior chest - upper, middle, lower lobes
suprasternal notch Angle of Louis top in line with nipples, where sternum attaches to manubrium
posterior lobes are divided at which rib? 7th rib and 3rd vertebra begin upper lobes
Barrel chest indicates chronic lung disease
bronchovesicular and vesicular sounds are normally heard over posterior thorax
Bronchovesicular sounds are medium pitched blowing sounds heard between the scapulae, insp = exp
vesicular sounds are heard where? over periphery of lungs, lateral
Vesicular sounds are soft, breezy and low pitched. inspiration > expiration
four types of adventitious sounds crackles(rales), rhonchi, wheezes, pleural friction rub
Crackles are found in which part of lung? sound like? rt/lf lung bases, reinflate alveoli fine:high pitched, end of inspiration coarse: bubbly, cough not clear
Rhonchi found where? sound? over trachea and bronchi low pitched, rumbling, insp/exp, cleared with coughing
wheezes all over lung fields, obstructed high pitch, musical, louder on exp., not cleared wtih cough
pleural friction rub found anterior lung field, dry, grating, during insp, not clear with coughing
bronchial sounds heard where? loud, high pitched, hollow, exp>insp, over trachea
Orthopnea dyspnea shortness of breath when flat shortness of breath
kyphosis lordosis scoliosis curved posterior spine sway back lateral curved spine
men breathe women breathe diaphragmatic costally
How many lobes on rt lung? left lung? 3 lobes 2 lobes
Base of heart is the Apex of heart is the top bottom
What is the PMI point of maximal impulse, same as apical pulse
Which side of the heart do functions happen first? right or left? left
Name two phases to cardiac cycle systole and diastole
Describe systole ventricles eject blood lft to aorta, rt to pulmonary artery
Describe diastole ventricles relax, atria contract to fill ventricles and fill coronoary aa
Describe S1 S1 = 1st heart sound, lub, mitral and tricuspid valves close, best at apex
describe S2 s2 - 2nd heart sound, dub, aortic and pulmonic valves close in aortic area
S3 rapid ventricular refilling or congestive heart failure
S4 atria contract, not normal in adults
Heart health hx chest pain,dizziness, palpations,fatigue, numbness left arm,jaw numbness
assess cardiac function sites 2nd intercostal space rt-aortic lft top to bottom: pulmonic,tricuspid,mitral,epigastric
If can't feel PMI easily what should pxt do? left lateral recumbant (best diastole low pitched), moves heart closer to chest wall.
abnormal heart sounds are murmurs,rubs,gallops,clicks,extra or irregular beats(dysrthymia)
What is syncope or near syncope stimulation of carotid art cause vagal stimulation. Lower HR and almost pass out
atherosclerosis lipid deposits in the intima of large and medium aa
bruit blowing snd when blood attempts to trabel through a narrowed passage murmurs HEAR
thrill palpable bruit or vibration over turbulent blood flow FEEL
If it pulsates is it artery or vein artery
5 P's for occlusion pain in lower extremities with Pallor,Pain,Pulselessness,parethesias,paralysis
Peripheral Edema may indicate venous insufficiency, rt heart fail, blood backing up in vena cava
what is phlebitis inflammation of vein
what is Homan's sign positive if pain with dorsiflexion of foot, indicate phlebitis
When should a breast exam be done for 20 to 40 yr.old? Over 40? Every 3 years last day or period or every month yearly
Risk factors for breast cancer family hx, early menarche,late menopause, never having children, first child after 30, recent use of oral contraceptives.
Where is kidney found? Follow costovertebral angle, posterior
ULQ URQ LLQ LRQ stomach liver, transverse colon small intestine,desc colon,sigmoid ascending colon,appendix
how do you asses abdomen auscultate before palpate
hematemesis melena eructations borborygmi regurgitation dysphasia bloody vomit-bright red LQ black tarry stools-blood in UQ belching incr GI motility vomiting difficulty swallowing
Do NOT palpate aortic pulsations in abdomen Could release clot
paralytic ileus peritonitis bruits no bowel sounds inflamed peritoneum indicates aneurysm, don't palpate
cryptochidism undescended testicles
Common sx of testicular cancer painless enlargement of testis, palpable small hard lump size of pea on testicle
Hernia protrusion of intesting through inguinal wall or canal
hypertonicity hypotonicity atrophy considerable resistance flabby tone, decr resistance soft,baggy, reduced size
Glasgow Coma Scale 15 is highest # and indicates good neurologic function
aphasia sensory(receptive) expressive omit or add letters,words can't understand written or verbal think it, can't say it
Intellectual function includes memory, knowledge, abstract thinking, judgment
Cerebellar Function Romberg's test balance, positive if balance is lost and falls to side
Created by: palmerag