ch 30 Jess Flashcards
What will your assessment influence
The choice of therapies a patient receives, and an evaluation of the response to those therapies
What is included in a complete health assessment
A nursing history a behavioral exam and a physical exam
What is the purpose of a physical examination (4)
Triage for emergency care
routine screening to promote health and wellness,
to determine eligibility (for health insurance military service new job,)
To admit a patient to hospital or long-term care facility
What do you use physical examination for
- gather baseline data about a patient’s health
- support or refute subjective data obtained in the nursing history
- identify and confirm nursing diagnosis
- make clinical decisions about a patients changing health
- evaluate the outcomes of care
What is cultural sensitivity
Culture influences the patient’s behavior you need to consider health beliefs, using alternative therapies, nutritional habits, relationships with family and personal comfort zone, need to avoid stereotyping and gender bias
Why is it important to be aware of disorders that are more commonly seen in a particular ethnic group?
Because you’re more likely to recognize a rare condition unique to each ethnic group which will lead to higher quality care
If a patient is seriously ill, what should you assess first?
The body system that is most at risk
When should painful procedures be performed
Near the end of the assessment
What do you need to consider in preparation for examination
Infection control,
environment,
equipment,
physical and psychological preparation of the patient assessment of age group
What are the four techniques of physical assessment
Inspection
palpation
percussion
auscultation
What do you need to remember during inspection
- Use adequate lighting
- use penlight to inspect body cavities
- inspect each area for size shape color position and abnormality
- position and expose body parts as needed so all surfaces can be viewed the privacy can be maintained
- validate findings with the patient
What senses should you use during inspection
Look listen and smell to distinguish normal from abnormal
Why is Teeth/gum health/denture fitting important in the elderly?
If they cannot eat due to ill fitting dentures or poor gum health They will not get enough nutrition and will go downhill very quickly
How do you maintain privacy for patients during the physical exam
Take off only what’s needed for that moment example remove one piece of clothing at a time then replace it
Explain palpation during a physical exam
Used to gather information
– use different parts of hands to detect different characteristics
–hands should be warm
- start with light palpation and with deep palpation
When should you palpate sensitive areas
Palpate sensitive areas last
What is percussion
Tapping the body with fingertips to produce a vibration sound determines location size and density of structure
What does auscultation involve?
– Involves listening to sounds
– learn normal sounds first before identifying abnormal sounds or variations
– requires a good stethoscope
– requires concentration practice
What part of the stethoscope is used to hear low pitch versus high pitch sounds
The bell is used to hear low pitch sounds the diaphragm is used for high-pitched sounds
What is the general survey the health assessment
Assesses appearance and behavior assess vital signs assessed height and weight
What does the integumentary system include?
Skin hair scalp and nails
What are some things you can assess just by looking at your patient
Gender and race age signs of distress body type hygiene and grooming body odor speech signs of patient abuse and signs of substance-abuse
Why do you need to obtain a diet history for your patient
Because height and weight reflective person’s overall level of health
What do you need to look for when examining the skin
Integument color moisture temperature texture turgor
What do you need to notice about the color of skin
Pigmentation
cyanosis
jaundice
Erythema
What about texture of the skin you need to pay attention to
Is it smooth dry scaly rough, or scar issue
What are the ABCD’s of skin
A is asymmetry
B border Irregularity
C color
D Diameter
What is vascularity of the skin
Appears reddened pink or pale occurs in localized pressure Areas
When patients remain in one position
What does edema do
Separates the surface of the skin from pigmented and vascular layers masking skin color
How do you assess degree of putting edema
Press the area firmly with the thumb for several seconds and release, the depth determines the degree of edema
What is the scale used to measure pitting edema
1+ = 2mm deep 2+ = 4mm deep 3+ = 6mm deep 4+ = 8mm deep
Where does edema most often occur
Feet
ankles.
peri Orbital
sacral
What should you notice when looking at hair and scalp
Color distribution quantity thickness texture Lubrication
What does a widening part loss of tails of eyebrows or no hair on toes possibly indicate?
Hypothyroidism or poor circulation
What is the condition of nails reflect
Gen. health status nutrition occupation level of self self-care Age
What causes lines or bands to form on the nailbeds
Vitamin protein electrolyte changes
What does the assessment of head and neck consist of
Head
eyes ears nose mouth pharynx neck lymph nodes carotid arteries thyroid gland and trachea
What assessment skills should you use for the head and neck
Inspection palpation and auscultation
Where do lymph nodes normally drain
Through the site of infection
What should you assess when examining the eyes
Size shape structure visual acuity visual fields conjunctiva sclera cornea pupil and iris
What is nystagmus
And involuntary rhythmic oscillation of the eyes
What are some causes of nystagmus
Local injury to muscles and supporting structures
intoxication
disorder of the cranial nerves
What does the presence of redness in the conjunctiva indicate
Allergic or infectious conjunctivitis
What is Arcus senilis ?
A thin white ring around the margin of the Iris
It is common with aging but is abnormal in anyone younger than 40
How many directions of gaze are there
6
What does PERRLA stand for?
Pupils equal round reactive to light, accommodation
What is accommodation when doing an eye exam
When only one night is covered and then uncovered it is still facing forward or centered
What external eye structure do we need to look at
Position and alignment eyebrows eyelids lachrymal apparatus conjunctiva Sclerae cornea pupils and irises
What patients are in greatest need of an internal Eye exam
Patients with diabetes hypertension and intercranial disorders
What do we need to examine on the ears
Palpate the auricles for texture tenderness and skin lesions
Look for lesions pain earwax and normal ear color
If palpation causes pain what is like
An external ear infection
If an ear is painful to palpation does not cause additional pain what is likely
A middle ear infection
If the ear has a foul-smelling yellow or green discharge what does this indicate
An infection or foreign body
What are the three types of hearing loss
Conduction
Sensorineural
Mixed
What is conduction hearing loss
Interrupt soundwaves as they travel from outer ear to the Cochlea of the inner ear
Causes:
Swelling of the auditory canal and tears in the tympanic member
What is sensorineural hearing loss?
Involves inner ear auditory nerve or hearing center of the brain sound is conducted through the outer and inner ear structures but the continued transmission of sound becomes interrupted at some point beyond the bony ossicles
What population is at risk for hearing loss caused by ototoxicity and why
Older adults are more risk from high maintenance doses of antibiotics
What is webers test
Tuning fork test done for lateralization of sound
Tuning fork is placed on the top middle of the head
A patient with normal hearing or hear the sound equally in both ears
What is Rinnes test?
Turning fork test test is done for comparison of bone and air conduction
Tuning fork is held behind ear against the mastoid process
What should the nose be checked for upon physical exam
Excoriation
Polyps
Shape size skin color presence of deformity or inflammation
What should you do a swelling or deformity of the nose exists
Gently palpate the ridge and soft tissue of nose replacing one finger on each side of the measle arching gently moving the fingers from the nasal bridge to the tip
What can the color of nasal discharge indicate about a patient’s condition
Pale mucosa with clear discharge indicates allergy
Mucoid discharge indicates rhinitis sinus infection results in yellowish greenish discharge
What do you need to examine about lips
Color texture hydration contour lesions
What does pallor, cyanosis , or cherry red indicate of lips
- Anemia causes Paller of lips
- respiratory or cardiovascular problems caused cyanosis
- cherry colored lips indicate carbon monoxide poisoning
How do you observe tooth occlusion
As the patient to clench the teeth and smile
What structures do need to examine inside the mouth
Buccal mucosa gums and teeth
What you inspect the gums for
Color edema retraction bleeding and lesions
