2- Advanced Assessment Flashcards
What to look for with General Appearance (10)
- Hygiene
- Posture/Walking
- Facial expression
- Facial Appearance
- Speech
- Skin color
- Eye contact
- Estimated weight
- Work of breathing
- BO/breath odors
Brain Function (4)
- Thought process
- Thought content
- Speech
- Affect (Mood)
How to test memory
-List of random words, recheck randomly
2 signs of Basilar skull fracture
- Battles sign
- Mastoid ecchymosis
- Racoons eyes
- Periorbital ecchymosis
What to assess with the eyes (4)
- Examine sclera and conjunctiva
- Jaundice, Injection (Blood shot eyes)
- Palpate orbital bones
- Stability
-Check temporal pulse
- Pupils
- PERRLA
- Nystagmus (Fluttering of the eye)
What to assess with the nose (2)
- Septum and obstructions
- Deformity, air movement
What to assess with the ears (2)
- Drainage
- Hearing
What to assess with the mouth (5)
- Opens mouth willingly
- Jaw tension
- Mucosa color
- Moisture
- Upper airway potency
What to assess with the neck (4)
- JVD
- Trachea midline
- ROM
- Symmetry
What to assess with the heart (4)
- Inspection
- Palpation
- Auscultation
- Percussion
Cardiac inspection-Head (2)
- Diaphoresis
- Cyanosis
Cardiac inspection-Chest
- Differential Cyanosis (Abdominal=AAA)
- Scars, pace makers
Cardiac inspection-Hands
- Peripheral cyanosis
- Splinter hemorrhage
- Clubbing
- Oslers nodes/lesions
Cardiac palpation (3)
- 5th cis, midvascular
- Carotid artery
- Peripheral pulses
Bruit
-Fluid sloshes back in the vein
Define Pulsus Alternans
-Alternating strong and weak pulses
(Severe ventricular failure)
Define Pulsus Paradoxus and what it can indicate (3)
-Decrease in BP greater than 10mmHg during inspiration
- Tamponade
- Pericarditis
- Severe lung disease
Define Homans sign
-Deep vein thrombosis
Respiratory Assessment- Inspection (5)
- Breathing problem
- Cyanosis
- Accessory muscle use
- Nasal flaring
- Pursed lip breathing (expiration)
What is a sign of Kussmaul respiration’s and what is it
- DKA
- Quick deep breaths
How to assess Respiration-Chest (3)
- Pectus carinatum
- Pectus excavatum
- Barrel chest
What is Tactile Fremitus
-“99” as you feel the back for vibration
Order of dense material in the lungs from least to most
- Air
- Fluid
- Mucous
- Pus
Greys-Turners Sign
-Internal bleeding located on the flanks of the abdomen
Cullens sign
-Above the umbilicus indicative of ectopic pregnancy
Murphys sign
-Curl fingers under ribs and inhale to indicate gal bladder and liver inflammation
Psoas sign
-Flex right hip up with resistance, indicates acute appendicitis
Rovsings sign
Rebound tenderness in RLQ, acute appendicitis
Kehrs sign
-Referred pain in left shoulder with recent trauma
Levels of pitting edema (#+)
- 0+-No edema
- 1+-Slight
- 2+-Mild
- 3+-Moderate
- 4+-Sever
Discharge and indication- Hematochezia
- Separate blood and feces
- Lower GI bleed
Discharge and indication- Melena
- Mixture of blood and feces
- GI bleed
Discharge and indication- Hematemesis
- Blood in vomit
- Ulcers, esophageal varacies
Discharge and indication- Coffee-grounds
- Mix of blood in vomit, dark brown around lips
- GI bleed
Discharge and indication- Hematuria
- Blood in urine, orangish in color
- Kidney damage
Discharge and indication- Purulent discharge
- Pus discharge
- Infection
