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NUR109 Fundamentals > CH 30/31 Physical Assessment > Flashcards

CH 30/31 Physical Assessment Flashcards

1
Q

What is AIDET?

A 
Acknowledge
Introduce
Duration
Explanation
Thank you
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2
Q

What is the proper order of methods you will use to assess? (not abdominal)

A

Inspection
Palpation
Percussion
Auscultation

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3
Q

What part of the hand is most sensitive to textures and shape?

A

The finger pads and palm of the hand

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4
Q

What part of the hand is best for assessing temperature?

A

the dorsal surface (back) of the hand

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5
Q

Jaundice

A

Yellow staining of body tissues and fluids

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6
Q

Erythema

A

Skin redness caused by inflammation

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7
Q

Cyanotic

A

Blue grey or dark purple skin discoloration

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8
Q

What is lack of skin turgor an indicator of?

A

dehydration

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9
Q

What is pitting edema?

A

When pressed firmly with a finger, tissues that are swollen with extravascular fluid retain the shape of the depression produced by the finger.

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10
Q

What are the different ratings for severity of pitting edema?

A

1+
2+
3+
4+

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11
Q

What is ABCDE for skin lesions/ moles?

A 
Asymmetry
Border Irregularity
Color
Diameter
Elevation
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12
Q

What can clubbing of nails indicate?

A

respiratory problems

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13
Q

Nystagmus

A

Involuntary back-and-forth or cyclical movements of the eyes

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14
Q

Arcus senilis

A

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.

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15
Q

Ptosis

A

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

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16
Q

Ectropion / entropion lid margins

A

The eyelid may be turned inward or outward

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17
Q

What is PERRLA?

A 
Pupils 
Equal
Round
React to 
Light
Accomodate
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18
Q

How do you test for accommodation?

A

Have the patient look at something close - about 12 inches away
Close-converge-constrict
Now have them look at something distant
Distant-diverge-dilate

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19
Q

cerumen

A

ear wax

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20
Q

Weber Test

A

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.

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21
Q

Rinne Test

A

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).

22
Q

Which sinuses should you palpate?

A

frontal and maxillary

23
Q

Should you palpate both carotid arteries at the same time?

A

No!

24
Q

Tactile fremitus

A

sound created by the vocal chords that’s then transmitted through the lungs to the chest wall

25
Q

crackles

A

fine medium or course - disruption in air passage through small airways

26
Q

rhonchi

A

lower pitched and continuous sounds caused by muscular spasm or mucous in the larger airways

27
Q

wheezes

A

high pitched continuous musical sounds during inspiration our inspiration
(asthma)

28
Q

pleural friction rub

A

dry rubbing or grating quality - inflamed pleura rubbing against eachother

29
Q

What should you list when documenting abnormal lung sounds?

A

Location and abnormal quality of the sound

30
Q

adventitious breath sounds

A

abnormal sounds

31
Q

Where is the point of maximal impulse for the heart?

A

Between the 4th and 5th intercostal next to the mid clavicular line

32
Q

dysrhythmia

A

Failure of the heart to beat at regular successive intervals

33
Q

Murmurs

A

sustained swishing or blowing sounds heard at the beginning, middle or end of the systolic or diastolic phase. graded 1-6

34
Q 
Aortic
Pulmonic
Erbs
Tricuspid
Mitral
A

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

35
Q

What is it called when you hear a whoosh whoosh sound listening to a carotid artery?

A

a bruit

36
Q

Jugular vein distention (JVD)

A

bulging of the jugular veins - most visible on the right side

37
Q

How do you rate pulse?

A 
0- no pulse
1- very weak pulse
2- Normal pulse
3- full pulse
4- bounding
38
Q

In what order of assessment methods will we assess the abdomen?

A

Inspection
Auscultation
Palpation
percussion

39
Q

What are different ways we can describe bowl sounds?

A 
normal
audible
absent
hyperactive 
hypoactive
40
Q

How often should a patient preform a breast self exam? What is the best time to do so?

A

Once a month - 2-3 days after the end of a period

41
Q

Loridosis

A

lower back - inward curvature

42
Q

kyphosis

A

upper back - outward curvature

43
Q

scoliosis

A

S shaped curve or twist of spine

44
Q

hypotonia

A

decreased muscle tone

45
Q

hypertonicity

A

Muscle overactivity

46
Q

atrophy

A

wasting or loss of muscle tissue

47
Q

A&O x 4?

A

Name and DOB?
Where are you?
What is the day/ time?
Why are you here?

48
Q

Glasgow coma scale measures 3 things…

A

eyes
motor
verbal

49
Q

CN I - XII

A

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

50
Q

Deep tendon reflex ratings

A 
0 - no response
\+1 - sluggish response 
\+2 active expected
\+3 brisk response
\+4 hyperactive response

NUR109 Fundamentals (18 decks)

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