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Physical Assessment
Ch. 15 Potter/Perry
| Question | Answer |
|---|---|
| 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
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