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