💉- Assessment Test Flashcards
What is a sign of pallor in light skinned patients and dark skinned patients
Light skinned - extreme paleness, skin appears white loss of pink or yellow tones
Dark skinned - loss of red tones
The integumentary system consists of what 4 parts
Skin
Mucous membrane
Hair
Nails
Ashen
A blue-gray coloration of the skin also described as cyanosis
What is Ecchymosis
Bruised (blue-green-yellow) area
Petechiae
Tiny, pinpoint red or reddish-purple spots
Due to extravasation of blood into the skin
Extravasation
Leakage from vessels
Mottling
Bluish marbling splotchy
Sometimes seen in dying patients
Name a type of embolus associated with petechiae
Fat
What does trace mean in relation to pitting edema
Minimal depression with pressure
What is the acronym used to assess skin lesions
A - asymmetry B - border irregularity C - color variation D - diameter E - elevation Patterns
What is central cyanosis
Blue-gray coloration in the lips, tongue, mucous membranes and facial features
What are you looking for when inspecting the hair
Texture and distribution
Infestation or infection
What are you looking for when assessing the nails
Capillary refill
Color and texture
Shape
What is clubbing of the nails and what is it associated with
The nail plate angle is 180 degrees or more
Associated with long-term hypoxic states, such as occur with chronic lung disease
What is Hirsutism and what is a possible cause
Excess facial or trunk hair
Indicates a possible thyroid issue
What are nits
Eggs of head lice and are usually located close to the hair shaft
Which 3 cranial nerves are usually assessed together for eye movement
CN 3,4,6
What 5 things do you look for when assessing the head and face
Skin and hair Size and shape Symmetry Facial movements Scalp
When assessing the neck name 6 things to look for
Musculature Trachea Thyroid Symmetry Contour ROM - shrug CN XI
What are Striae
Silver-to-pink stretch marks in pregnant women, women who have had children and anyone who has experienced significant weight fluctuations
What are mees’ lines
Transverse white lines in the Nailbeds
Seen in clients who have experienced severe illnesses or nutritional deficiencies
What is acromegaly
A large head in an adolescent or adult
Associated with excess growth hormone
Hydrocephalus
An accumulation of excessive cerebrospinal fluid
Seen in infants and children, a head that is growing disproportionally
What are some causes of enlarged or tender nodes
Infection, malignancy and other diseases
What is enlargement with exophthalmos
Associated with a thyroid issues
Is an increase in the volume of the tissue behind the eye, the eyes will appear to bulge out of the face
Goiter
Bilateral thyroid enlargement
Name 8 things to look for when assessing the eye
External eye Sclera and conjunctiva Eye position Visual acuity Visual fields Cranial nerve function Pupils Internal structures
Ectropion
An everted eyelid
Entropian
An inverted eyelid , can lead to corneal damage
Ptosis
Dropping of the lid
What is PERRLA
Pupils, equal, round, reactive to light and accommodation
Accommodate
When pupils constrict and the eyes converge (cross) as a person attempts to focus on an object moving toward them
Mydriasis
Enlarged pupils
May be seen with glaucoma
Miosis
Constricted pupils
Anisocoria
Unequal pupils
Maybe be seen in stroke, head trauma or could be normal
Myopia
Diminished distant vision
“Near sighted”
Presbyopia
Diminished near vision
“Far sighted”
Strabismus
Crossed eye
Amblyopia
Lazy eye
Is a result of constant strabismus of one eye
What is 100% visual efficiency
20/20
What does the numerator of the snellen acuity chart represent
What the patient can read/see at that distance
What does the denominator of the snellen acuity chart represent
What a normal eye can read at that distance
What does it mean to say someone has 20/40 vision
Patient can read at 20ft what a normal eye can read at 40ft
What does the corneal light reflex assess
Muscle balance of the eye
Which cranial nerve does the confrontation test assess
Peripheral vision - CN IV
What is a blown pupil
One that is widened out but also not reactive to light
What is the macula
The point of central vision
The ophthalmoscope is used to view what 4 things
Red reflex (should see red dots)
Optic disk
Retinal vessels
General background
What is the proper technique for examining a patients eye with an ophthalmoscope
Examine the patients eye on the same eye you are looking through
Name 4 things you are inspecting for when assessing the ear
Alignment
Lesions and trauma
Piercings
Tympanic membrane
What could bruising behind the ear mean
Head trauma
What is the tragus
The bottom part of the ear
Otitis externa
An outer ear infection
Otitis media
A middle ear infection
What does the weber test , test for
Lateralization of bone conduction
What is considered a positive result in a weber test
If vibration is louder in one ear
What does the rinne test , test for
Test compares bone conduction and air conduction
What is cerumen
Ear wax
What is considered a positive result for a rinne test
Air conduction greater (>) bone conduction
What should a normal tympanic membrane look like
Pearly, gray, shiny and translucent B
How does the tympanic membrane appear in otitis media
Red, inflamed, drainage, bulging tympanic membrane
Cone of light disturbed
Cone of light of normal tympanic membrane
Right ear - 5 o’clock
Left ear - 7 o’clock
To see in an adult ear you pull the ear
Up and back
To see in a child’s ear you pull the ear
Down and back
Name 6 things to inspect while assessing the mouth
Lips Tongue Buccual mucosa Hard and soft palate Teeth Pharyngeal wall
Patency
Is open, expanded or unobstructed
What are 4 factors that affect skin texture
Exposure
Age
Hyperthyroidism and other endocrine disorders
Impaired circulation
Pediculosis
Head lice infestation
Name 5 abnormal findings on the eyelids
Crust, scales Or swelling Pterygium Ectropion Entropion Ptosis
Pterygium
A growth or thickening of conjunctiva from the inner can this toward the iris
Stomatitis
Inflammation of the oral mucosa
Leukoplakia
Thick elevated white patches that do not scrape off , maybe precancerous lesions
Thrush
White curdy patches that scrape off and bleed
What are the ABCs of documentation
Accurate Bias-free Complete Detailed Easy to read Factual Grammatical Harmless
Name 10 guidelines for documenting care
- maintain confidentiality
- correct form
- chart clearly marked
- write legibly
- use black ink
- dont leave blank lines
- draw a line through incorrect charting and initial
- sign all your paper chatting
- no shorthand
- only use approved abbreviations
Name 8 things included in a change-of-shift report
- client demographics and diagnoses
- relevant medical hx
- significant assessment findings
- treatments (ex:wound care)
- upcoming diagnostics or procedures
- restrictions (ex: diet,activity,isolation)
- plan of care for the client
- concerns
What are verbal orders
Spoken to you in person, not over the telephone
Should only be used during critical situations or emergencies
What are telephone orders
Received by phone and transcribed into chart order sheet
Name 6 things to remember when documenting telephone orders
- write the order only if you heard it yourself
- ensure the order makes sense sigh the clients status
- repeat the order to confirm accuracy
- spell unfamiliar names/pronounce digits of numbers separately
- directly transcribe the order on the chart (date/time, text, TO with providers signature and your signature)
- physicians must countersign within 24hrs
What is an occurrence report
An organizational record or incident report of an unusual occurrence, accident or error
List 8 examples of events requiring an occurrence report
- fall
- medication errors
- family incidents/injuries
- staff injury
- unsafe environments
- procedural errors
- inadequate response to patient situation
- lack of resources or supplies
Are occurrence reports apart of a patients health record
No !
Should you still complete an occurrence report even if there is no adverse impact on the client
Yes .. “Near misses” will lead to actual problems if left unreported
Name 5 things to include in an occurrence report
- patients name,date,time,location
- briefly discuss the incident in OBJECTIVE terms
- quote if possible
- identify any witnesses to the event, equipment involved and environmental conditions
- avoid drawing conclusions or placing blame
What does SBAR stand for
Situation
Background
Assessment
Recommendation
Why is the SBAR form of documentation useful
Useful for interdisciplinary communication, especially critical situations requiring a clinicians immediate attention and action
List 4 situations that the SBAR style of documentation can be used
Change of shift
Patient transfers
Critical conversations
Telephone calls
SBAR related to the joint commission
The joint commission on accreditation of hospitals has added “standardized communication” to the patient safety goals and recommends SBAR as a best practice
What does the whisper test , test for
High pitched hearing loss
What is pulse deficit
The difference between the apical pulse and the peripheral pulse
What is orthopnea
Shortness of breath that occurs while laying flat
Seen a lot in ❤️ patients
Name 6 abnormal findings when palpating the posterior thorax and lungs
Nodules,lumps and tenderness on back
Chest not expanding symmetrically
Tenderness or curvature of spinous process
Asymmetry of vibrations with “99”
Crepitus
Subcutaneous emphysema
What is subcutaneous emphysema
Is when gas or air is in the layer under the skin
Looks like rice crispies under the skin
Name 4 abnormal findings while percussing the lungs
- tenderness with percussion
- hyperreasonance with percussion over lung fields
- dullness with percussion over lung fields
- tenderness with percussion of costovertebral angle
Characteristics of bronchial normal breath sounds
Pitch: high, loud
Duration: inspiration < expiration
Normal location: trachea and larynx; sounds harsh, hollow, tubular
Characteristics of bronchovesicular normal breath sounds
Pitch: moderate
Duration: inspiration = expiration
Normal location: over major bronchi where fewer alveoli are located
Posterior between scapulae, especially on right
Anterior around upper sternum in 1st and 2nd intercostal spaces
Characteristics of vesicular normal breath sounds
Pitch: low, soft
Duration: inspiration > expiration
Normal location: over peripheral lung fields where air flows through smaller bronchioles and alveoli
Sounds rustling like the sound of wind in the trees
Crackles
(Rales)
Popping open of alveoli or secretions
Occur with pneumonia and pulmonary edema
Wheezes
(Rhonchi)
Airway narrowing or obstruction
Occurs with asthma and emphysema
What are Cheyenne-stokes respirations
A cycle in which respirations gradually increase in rate and depth and then decrease
Caused by severe ❤️ failure, renal failure, meningitis, drug overdose and increased cranial pressure
What 2 groups of people are Cheyne-stokes respirations normal in
Infants and aging people
What is crepitus
Clicking or grating at a joint
“Creaking” of bones
What is stridor
Narrow or obstructed upper airway
When are wheezes usually heard
On expiration
When is stridor usually heard
Primarily during inspiration
What is grunting
Difficulty expelling air
What is pectus excavatum
“Funnel chest”
A condition in which the breastbone sinks into the chest ; sternum sticks out
What is Barrel chest
A condition in which the anteroposterior and lateral diameters may be equal 1:1 ratio
Instead of the normal 1:2 ration
What is the tail of spence
When breast tissue and lymph extend up into the axilla
What should you have a patient do if adventitious sounds are heard
Cough
Where can the aortic ❤️ sound be heard best
Second intercostal ; right sternal border
Where can the pulmonic ❤️ heart sound best be heard
Second intercostal ; left sternal border
Where can the tricuspid ❤️ sound best be heard
Fourth intercostal ; left sternal border
Where can the mitral ❤️ sound best be heard
5th intercostal ; midclavicular line
Name 3 abnormal ❤️ sounds
S3 , S4
Murmurs
Rubs
What is systole
The contraction , or emptying of the ventricles
What is diastole
Refers to the relaxation , or filling phase of ventricles
What is the proper order for stomach assessment
Inspect
Auscultate
Percuss
Palpate
Name 4 normal variations in abdominal contour
Flat
Rounded
Protuberant
Scaphoid
Normal bowel sounds
Occur every 5-15 seconds or 5-30 times per minute
Hyperactive bowel sounds
Loud , rushing sounds occurring every 2 or 3 seconds (more than 30 per minute)
May indicate diarrhea, early bowel obstruction or gastroenteritis (infection of the Gi tract)
Hypoactive bowel sounds
Very faint and infrequent (fewer than 5 sounds per min)
May occur after abdominal surgery or with bowel obstruction, infection or problems of innervation
What is ascites
An abnormal accumulation of fluid in the abdomen
Cranial Nerve I
Olfactory
Function: smell
Testing: smell
Cranial Nerve II
Optic
Function: sight
Testing: visual fields
Cranial Nerve III
Ocular motor
Function: extraocular movements
Testing: 6 Cardinal fields of gaze , pupillary reflex , pupillary reaction light and accommodation
Cranial Nerve IV
Trochlear nerve
Function: downward and inward movements of the eye
Testing: 6 Cardinal fields of gaze
Cranial Nerve V
Trigeminal
Function: sensory of face and jaw
Testing: sensory - cotton , motor - clench teeth
Cranial Nerve VI
Abducens
Function: lateral deviation of eye
Testing: 6 Cardinal fields of gaze
Cranial Nerve VII
Facial
Function: lacrimal gland, lid muscles and tongue (tasting)
Testing: puff cheeks, smile, show teeth, raise eyebrows, taste test
Cranial Nerve VIII
Acoustic
Function: hearing and balance, eardrum, ear canal
Testing: whisper test, weber, rinne, Romberg
Cranial Nerve IX
Glossopharyngeal
Function:
Testing: tongue , gag
Cranial Nerve X
Vagus
Function: palate, pharynx, larynx
Testing: gag , “ah” observe soft palate and uvula
Cranial Nerve XI
Spinal Accessory
Function: sternocleidomastoid and upper portion of trapezius
Testing: shrug shoulder, rom of neck
Cranial Nerve XII
Hypoglossal
Function:
Testing: protrude tongue, retract tongue, move tongue to right and left
List developmental modifications for infants and children
- have parents present and hold infants
- offer toddlers choices/praise for cooperation
- let the preschool child help with the exam; give reassurance
- support the school aged child’s independence
- adolescents should provide privacy
Developmental modifications for older adults
- observe energy level; provide rest periods and limit position changes
- allow for extra time to interview and examine
- can’t assume certain positions
- be alert for hearing and vision deficits
- assess the older adults functional status
- SPICES
What does SPICES stand for
Sleep disorders Problems eating or feeding Incontinence Confusion Evidence of falls Skin breakdown
What is hypotonia
“Floppy baby syndrome”
Poor muscle tone is a condition usually detected at birth or during infancy
ROM of the neck
Flexes Extends Hyperextend Bend laterally Rotate side to side
ROM of shoulder
Flexion Extension Hyperextended Abduct Adduct Rotate internal and external
ROM of the elbow
Flexion
Extension
ROM of wrist
Supination Pronation Radial deviation Ulnar deviation Flexion Extension Hyperextend
ROM of fingers
Spread the fingers (abduct) Bring them together (adduct) Make a fist (flex) Extend the hand (extend) Bend fingers back (hyperextend) Bring thumb to index finger (palmar adduction)
ROM of hip
Flexion Extension Hyperextend Abduction Adduction External/internal rotation
ROM of knee
Flex
Extend
ROM of ankle/foot
Dorsiflex Plantar flex Evert Invert Abduct Adduct Rotate
What is ABduction
Moving AWAY
What is ADDuction
Moving toward
ROM of spine
Bend at the waist Stand upright Hyperextend (bend backward) Bend laterally Rotate side to side
Soft palate movement is associated with which cranial nerves
Cranial nerves IX and X
Saying ah , gag reflex
Tongue movement is associated with which cranial nerves
Cranial nerves IX and XII
