CH 30/31 Physical Assessment Flashcards
What is AIDET?
Acknowledge Introduce Duration Explanation Thank you
What is the proper order of methods you will use to assess? (not abdominal)
Inspection
Palpation
Percussion
Auscultation
What part of the hand is most sensitive to textures and shape?
The finger pads and palm of the hand
What part of the hand is best for assessing temperature?
the dorsal surface (back) of the hand
Jaundice
Yellow staining of body tissues and fluids
Erythema
Skin redness caused by inflammation
Cyanotic
Blue grey or dark purple skin discoloration
What is lack of skin turgor an indicator of?
dehydration
What is pitting edema?
When pressed firmly with a finger, tissues that are swollen with extravascular fluid retain the shape of the depression produced by the finger.
What are the different ratings for severity of pitting edema?
1+
2+
3+
4+
What is ABCDE for skin lesions/ moles?
Asymmetry Border Irregularity Color Diameter Elevation
What can clubbing of nails indicate?
respiratory problems
Nystagmus
Involuntary back-and-forth or cyclical movements of the eyes
Arcus senilis
An opaque white ring about the periphery of the cornea, seen in the aged. It is caused by the deposit of fat granules in the cornea or by hyaline degeneration.
Ptosis
Drooping of the eyelid over the pupil area - edema or cranial nerve IIV impairment, in the elderly can be a result of loss of elasticity
Ectropion / entropion lid margins
The eyelid may be turned inward or outward
What is PERRLA?
Pupils Equal Round React to Light Accomodate
How do you test for accommodation?
Have the patient look at something close - about 12 inches away
Close-converge-constrict
Now have them look at something distant
Distant-diverge-dilate
cerumen
ear wax
Weber Test
Hears sound equally in both ears - tuning fork at top of head
to persons with unilateral conductive-type deafness, the sound will be perceived as being more pronounced on the diseased side; in persons with unilateral nerve-type deafness, the sound will be perceived as being louder in the good ear.
Rinne Test
The vibrating fork is held by its stem on the mastoid process of the ear until the patient no longer hears it. Then it is held close to the external auditory meatus. If the subject still hears the vibrations, air conduction exceeds bone conduction (this is the normal finding).
Which sinuses should you palpate?
frontal and maxillary
Should you palpate both carotid arteries at the same time?
No!
Tactile fremitus
sound created by the vocal chords that’s then transmitted through the lungs to the chest wall
crackles
fine medium or course - disruption in air passage through small airways
rhonchi
lower pitched and continuous sounds caused by muscular spasm or mucous in the larger airways
wheezes
high pitched continuous musical sounds during inspiration our inspiration
(asthma)
pleural friction rub
dry rubbing or grating quality - inflamed pleura rubbing against eachother
What should you list when documenting abnormal lung sounds?
Location and abnormal quality of the sound
adventitious breath sounds
abnormal sounds
Where is the point of maximal impulse for the heart?
Between the 4th and 5th intercostal next to the mid clavicular line
dysrhythmia
Failure of the heart to beat at regular successive intervals
Murmurs
sustained swishing or blowing sounds heard at the beginning, middle or end of the systolic or diastolic phase. graded 1-6
Aortic Pulmonic Erbs Tricuspid Mitral
Aortic valve area: 2nd ICS just right of sternum
Pulmonic: 2nd ICS just left of sternum
Erb’s point: 3rd ICS just left of sternum
Tricuspid: 4th ICS just left of sternum
Mitral: 5th ICS midclavicular line
What is it called when you hear a whoosh whoosh sound listening to a carotid artery?
a bruit
Jugular vein distention (JVD)
bulging of the jugular veins - most visible on the right side
How do you rate pulse?
0- no pulse 1- very weak pulse 2- Normal pulse 3- full pulse 4- bounding
In what order of assessment methods will we assess the abdomen?
Inspection
Auscultation
Palpation
percussion
What are different ways we can describe bowl sounds?
normal audible absent hyperactive hypoactive
How often should a patient preform a breast self exam? What is the best time to do so?
Once a month - 2-3 days after the end of a period
Loridosis
lower back - inward curvature
kyphosis
upper back - outward curvature
scoliosis
S shaped curve or twist of spine
hypotonia
decreased muscle tone
hypertonicity
Muscle overactivity
atrophy
wasting or loss of muscle tissue
A&O x 4?
Name and DOB?
Where are you?
What is the day/ time?
Why are you here?
Glasgow coma scale measures 3 things…
eyes
motor
verbal
CN I - XII
I- Olfactory – smell – sensory
II- Optic – sight – sensory
III- Oculomotor – eye movement – motor
IV- Trochlear – eye movement – motor
V- Trigeminal – face sensation/ chewing – both
VI- Abducens – eye movement – motor
VII- Facial – facial movement / taste – both
VIII- Vestibulocochlear – balance/ hearing – sensory
IX- Glossopharyngeal – taste/swallowing – both
X- Vagus – taste/swallow/parasympathetic–both
XI- Spinal Accessory – head/shoulder – motor
XII- Hypoglossal – tongue – motor
Deep tendon reflex ratings
0 - no response \+1 - sluggish response \+2 active expected \+3 brisk response \+4 hyperactive response
