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 |