Ch. 13: Physical Assessment Flashcards
The patient’s well-being relies heavily on an
accurate nursing assessment
In a nursing assessment, signs are
objective data as perceived by the examiner, can be measured with observation and measurement
Exudate
refers to fluid, cells, or other substances that are slowly exuded or discharged
-perspiration, pus, and serum
Symptoms
subjective indications of illness that the patient perceives
Subjective data collection
the interviewer encourages a full description by the patient of the onset, the course, and the character of the problem and any factors that aggravate or alleviate it
Disease
a pathological condition of the body, any disturbance of a structure or function of the body
The nurse relies on assessment of
signs and symptoms to formulate a patient problem statement
The patient problem statement recognizes
holistic needs of the patient that will be treated with nursing interventions
Origins of disease
congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental, or a combination of some
Autoimmmune disease have an unknown
etiology
Contributing factors to congenital diseases
inadequate oxygen, maternal infection, drugs, alcohol, malnutrition, and radiation
Inflammatory diseases
caused by either microorganisms or can be manifestations of an allergic reaction
Degenerative disease
can be caused by the aging process
Metabolic disease
loss of metabolic control of homeostasis in the body
Neoplastic disease
abnormal growth of new tissues
Traumatic conditions
result from physical and emotional trauma
Environmental diseases
a group of conditions that develop from exposure to a harmful substance in the environment
Autoimmune responses
immunoglobulins that attack its own tissues or substances
Risk factors
any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increases the vulnerability of an individual or group to illness or accident
The nurse assesses the patient’s risk factors and uses them to help formulate a
nursing diagnosis
Four categories of risk factors
genetic and physiologic, age, environment, and lifestyle
Types of disease
chronic, remission, acute, organic disease, functional disease,
Signs of infection
erythema, edema, heat, pain, purulent drainage (pus), and loss of function
Purulent exudate
is the accumulation of neutrophils, dead cells, bacteria, and other debris from the infectious process
A complete health assessment
is an evaluation or appraisal of the patient’s condition, involves orderly collection of information concerning the patient’s health status
Assessment involves
taking a medical history and performing a physical examination, the data collected establishes a baseline
A baseline
allows the health care provider or the nurse to identify problems and plan care
Perform an assessment to determine the actual or potential
patient problems that will require nursing interventions for the safety and well-being of the patient
The nursing assessment comprises of
gathering, verifying, and communicating of data about the patient
Data collected during the nursing assessment includes
the nursing health history, examination findings, results of laboratory and diagnostic tests, and information from health care team members and the patient’s family or significant others
Obtain the health history while
initiating the nurse-patient relationship
For physical assessment, use
palpation, auscultation, inspection, and percussion to collect physical examination data
When initiating the nurse-patient relationship
introduce self, give an estimate of the time needed, and tell the patient the reason for the assessment
Illnesses that cause people to seek help are accompanied by
anxiety, powerlessness, altered family processes, economic concerns, and changes in self-image
Conduct the interview in a
relaxed, unhurried manner in a quiet, private, well-lighted setting
-convey feelings of compassion and concern and, at the same time, remain objective
During the interview, the nurse must demonstrate
an interest in the patient’s state of wellness
The nursing health history
is the initial step in the assessment process
-the objective is to identify patterns of health and illness, risk factors for physical and behavioral health problems, deviations from normal, and available resources for adaptation to life’s changes
Biographic data includes
date of birth, gender, address, family member’s names and addresses, martial status, religious preference, and practices, occupation, source of health care, and insurance, Medicare, and Medicaid benefits
Reasons for seeking care
often referred to as the chief complaint
To get most of the information form the patient about health concerns use the
OPQRSTUV method
-be sure this information is in the patient’s own words, using quotation marks
Also use the health history to identify
habits and lifestyle patterns
Environmental history
Provides data about the patient’s home and work environments
-identifies area of concern, such as pollutants that can affect health, high crime rates that prevent patients from walking in their neighborhood
Psychological and cultural history
Includes data about the patient’s primary language cultural group educational background attention span and developmental stage
Review of systems
A systematic method for collecting data on all body systems
During the ROS
The nurse asked the patient about normal functioning of each system and any changes the patient has noted
Level of consciousness
Is the patient oriented to person, place, time, and purpose?
Focused assessment
Attention is concentrated on a particular part of the body
Items essential to the nurse’s assessment are
A penlight, stethoscope, a BP cuff, a thermometer, gloves, watch with second hand, scissors, black pen, and a tongue blade
When performing a head-to-toe measurement begin with
a neurological assessment, followed by an assessment of the skin, the hair, the head, and the neck
Begin neurological assessment with
The patient’s level of consciousness and level or orientation
Neurological assessment includes
Level of consciousness, motor function, pupillary response
PERRLA
normal pupil reactions
The third cranial nerve
Runs into the brain stem
Other areas of neurological function
Proprioception, deep tendon reflexes, cranial nerve assessment
Glasgow coma scale
A standardized, objective measurement of the level of consciousness
-add numbers for the level of patient’s response
PERRLA
pupils equal round, reactive, to light, and accommodation
Cheye-Stokes respiration
Heart failure, opioid overdose, renal failure, meningitis, and severe head injury
Crackles
Produced by fluid in the bronchioles and the alveoli, are short discrete, interrupted, crackling, or bubbling sounds that are heard most commonly during inspiration
Crackles are described as
Fine, medium, or coarse
Wheezes
Sounds produced by the movement of air through narrowed passages in the tracheobronchial tree
Wheezes are classified as
Sibilant or sonorous
Sibilant wheezes
have a high-pitched squeaking and musical quality and are produced by airflow through narrowed airways
Sonorous wheezes
Have a lower-pitched, coarser, gurgling, snoring quality
-indicates the presence of mucus in the trachea and the large airways
Stridor
High-pitched, inspiration, crowing sound, louder in the neck than over the chest wall
Pleural friction rubs
Produced by inflammation of the pleural sac; rubbing, grating, or squeaky sound on auscultation
Lordosis
Increase lumbar curvature
Extra heart sounds
S3 and S4
S3 has a
dull, soft sound; early sign of heart failure
Peripheral pulses
0, absent; 1+, thready; 2+, weak; 3+, normal; 4+, bounding
Perform the blanch test by
Pressing firmly for 5 seconds on the fingernail or toenail and estimating the speed at which the blood returns
In a person with good cardiac function and distal perfusion
Capillary refill takes less than 3 seconds
Bowel sounds occur every
15 to 60 seconds, and are classified as active, hyperactive, hypoactive, or absent
The normal rate of bowel sounds is
4 to 32 per minute
Borborygmi
Decrease and increased bowel sounds
Assessment of the abdomen for
distention, firmness, and tenderness
-palpation comes after auscultation
The normal abdomen has a
Tympanic sound with dullness over the liver
Pitting edema scale
1+ to 4+
