Ch 31_ Assessment Flashcards
What are the characteristics of a focused assessment?
- Focuses on certain system(s) in priority
- Typically respiratory or cardiovascular
- Once stable, then proceed with comprehensive
Observing top to bottom, left to right, anterior to posterior describes what action?
Assessing for symmetry
When we perform a comprehensive assessment, we move from _____ to _____ invasive unless there is ____, which requires priority attention.
least, most, pain
What are the 4 techniques of physical assessment?
Briefly describe each.
- Inspection; what you see
- Palpation; what you feel with light, then deep touching
- Percussion; vibrations heard by tapping a region; indicates location size density of structures; more of an advanced MD or NP method
- Auscultation; what you hear
What is erythema?
Superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.
What is vitiligo?
A long-term skin condition characterized by patches of the skin losing their pigment (hypopigmentation).
What types of things can be indicated by observing the color of the skin?
- Adequate blood perfusion
- Erythema
- Cyanosis
- Jaundice
How is cyanosis observed and what does it indicate?
- Blueish skin
- Observed at the mouth or mucus membranes
- Low oxygen
- Late sign of hypoxia
How is jaundice observed and what does it indicate?
- Yellowish hue in skin or sclera
- Indicates liver issues
What are some skin observations that can indicate hydration issues?
- Dryness
- Dried lips
- Sunken neck
- Turgor
What are the 6 general items being observed while assessing the skin?
- Color
- Moisture
- Temperature
- Texture
- Integrity
- Turgor
When observing edema, a deeper level indicates…
fluid excess
How are the grades of edema documented?
(give depth as well)
- +1 = 2mm
- +2 = 4mm
- +3 = 6mm
- +4 = 8mm
- *there is nothing greater than +4 on this scale,
- *+8 does not exist)
When checking for melanoma, how is “ABCDE” utilized?
- A = Asymmetry; not uniform
- B = Border; irregularity; ragged edges
- C = Color; not uniform; blue-black; white-gray; red
- D = Diameter; greater than a pencil eraser
- E = Evolving ; changing in appearance
Descibe a Macule
- Flat, nonpalpable change in skin color
- smaller than 1cm
- ex. freckle
Describe a Papule
- Palpable, circumscribed, solid elevation in skin
- smaller than 1cm
- a small mole
Describe a Nodule:
- growth of abnormal tissue.
- Nodules can develop just below the skin. They can also develop in deeper skin tissues or internal organs.
- a general term to describe any lump underneath the skin that’s at least 1 centimeter in size or larger
- ex. wart
Describe a wheal
- Irregularly shaped, elevated area or superficial localized edema
- Varies in size
- Ex. hive or misquito bite
Describe a vesicle
- Raised lesion filled with serous fluid
- ex. blister
Describe Pustule
- Circumscribed elevation of skin smaller to vesicle
- filled with pus
- ex. acne, staphylococcal infection
What does PERRLA stand for?
P = Pupil
E = Equal
R = Round
R = Reactive
L = Light
A = Accomodation (constriction of pupil when close, relaxation when light taken away
Pupil dilation indicates
neurological issues
Eye coordination is the responsibility of which cranial nerve?
III; Occulomotor
The tympanic membrane is usually ____ in color
pearly gray
A bulging red tympanic membrane indicates…
infection
The weber test evaluates _____ hearing.
conductive (bone)
The Rinne test evaluates ______ hearing.
sensory
Describe Weber test.
- Tuning fork is used
- Placed at top of head equally distanced from each ear
- When fork struck, patient should hear in both equally
- If patient indicates they hear in one ear better, THAT ear is the effected ear
Describe Rinne test.
- Uses tuning fork
- Strike fork and place on mastoid process behind ear
- When patient indicates they don’t hear it anymore, move it in front of the ear and have them indicate when they no longer hear it
- Result should be twice as long as on the mastoid process
Which cranial nerves control eye movement?
- CN III: Oculomotor
- CN IV: Trochlear
- CN VI: Abducens
What does CN VI control?
Lateral plane eye movement
What does CN IV control?
downward-medial movement
What does CN III control?
- Upward lateral/medial movement
- Inward-medial movement
- Downward-lateral movement
- PERRLA
Palpable lymph nodes are indicative of _____.
infection
If infection is suspected, what test is ordered?
- CBC
- Complete Blood Count
What is the order of examination when assessing the lungs?
- Inspection; visual
- Palpation; feel; light, then deep
- Auscultation; listen
What can be observed a visual sign of respiratory distress?
- Irregular breathing patterns
- Using accessory muscles to breathe
- Cyanosis at lips/muscous membranes
When assessing the posterior thoracic area of a patient, what “lines” are used?
- Left/Right scapular line
- Vertebral line
When assessing the lateral thorasic area of a patient, what “lines” are used?
- Posterior axillary line
- Midaxillary line
- Anterior axillary line
When assessing the anterior thorax of a patient, what “lines” are used?
- Midsternal line
- Midclavicular line
- Anterior axillary line
How does one test for chest excursion?
- Wrap hands around waste of patient
- Place thumbs on either side of the spine
- If there is separation of the thumbs on inhalation, there is chest excursion
Consolidation in the thorax is…
the accumulation of fluids in the pleural space
What is Egophony?
How is it assessed?
An increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis.
While auscultating lungs, have patient say “E”. If it sounds like “A”, it indicates egophony and positive for consolidation.
What are abnormal lung sounds called?
Adventitious
What are the four adventitious lung sounds?
- Crackles
- Rhonchi
- Wheezes
- Pleural friction rub
Describe adventitious lung “crackles” and how the are described.
- Caused by sudden reinflation of groups of alveoli or disruptive passage of air through small airways.
- Described as fine, medium, coarse
What are crackles indicative of?
Pneumonia
Describe adventitious lung “Rhonchi”.
How is it cleared?
- Low-pitched, continuous sounds caused by muscular spasm, fluid, or mucus in larger airways.
- Cleared by coughing
Describe adventitious lung “wheezes”.
- high-pitched sound or squeak heard continuously during inspriation or expiration.
- Usually louder on expiration
- Often heard in asthma
Describe adventitious lung “pleural friction rub”.
- Dry rubbing or grating sound
- Caused by inflamed pleura; parietal pleura rubbing against visceral pleura
During auscultation of breath sounds, what must be indicated?
- Location
- Characteristics of sound
- Absence of breath sounds
What is the one assessment you must do on your patients every time?
Respiratory
What/how is generally observed during a respiratory assessment?
- Auscultate vesicular and bronchial sounds
- Observation of accessory, sternocleidomastoid, trapezius and abdominal muscles
- Palpation of muscles and skeleton
- Assessment of tactile fremitus
- Symmetry comparison of right/left sides
What are the three classifications of breath sounds?
Name the location, lung region assessed and describe the sound of each.
- Bronchial
- Location: supraclavicular/trachea
- Assessed: apex/upper of lungs - expiration longer than inspiration at 3:2 ratio
- Sound: loudest, high pitch w/ audible pause between inspiration and expiration
- Bronchovesicular
- Location: mid-thorax/intrascapular
- Assessed: middle of lungs - larger airways
- Sounds: medium pitch
- Vesicular
- Location: base of thorax/around kidneys
- Assessed: lower/base of lungs - smaller airways
- Sounds: Low pitch
S1 and S2 represent…
The normal heart sounds; lub-dub
S1 = closure of the AV valves
S2 = closure of the semilunar valves
What is the S3 sound, when is it heard and what does it sound like?
- Audible filling of the ventricle
- Right after S2
- Lub-Dub-Tss (like a gallop)
What is the S4 sound, when is it heard and what does it sound like?
- Occurs when atria contract harder to overcome resistent ventriclular filling (ventricles not doing their job properly)
- Prior to S1
- tuh, lub-dub
What are the three basic anomolies we are listening for when auscultating the heart?
- Dysrhythmia
- Extra heart sounds
- Murmurs
What three items are we noting when ausculting a heart murmur?
- Grade
- Pitch
- Quality
A heart “thrill” is a…
palpable vibration
A good heart rythym is documented as…
- +S1S2
- (positive S1, S2)
How many grades of heart murmur are there?
six
Describe murmur grades 1-3
- Grade 1 = Barely audible in a quiet room (extremely difficult to hear)
- Grade 2 = Clearly audible, but quiet
- Grade 3 = Moderately loud
Describe murmur grades 4-6
Grade 4 = Loud, with associated thrill
Grade 5 = Very loud, thrill easily palpable
Grade 6 = Louder, may be heard w/out stethoscope; thrill palpable and visible
If murmurs are discovered a _____ will be needed for the patient.
referral
Where is a bruit found, what is it, and what does it sound like?
- blood vessels
- narrowed vessel which creates an audible turbulence
- swish
How are pulse strengths documented and describe each.
- 0 = abscent, not palpable
- +1 = pulse diminished, barely palpable
- +2 = normal/expected
- +3 = full pulse, increased
- +4 = bounding pulse
What are varicosities?
- Varicosities are abnormally dilated and tortuous veins that usually appear in the lower extremities.
- Varicosities in general occur as a result of an underlying problem with reverse venous flow, also known as venous insufficiency syndrome
What is phlebitis?
means inflammation of a vein.
What is thrombophlebitis
Thrombophlebitis is due to one or more blood clots in a vein that cause inflammation.
Thrombophlebitis usually occurs in leg veins, but it may occur in an arm.
The thrombus in the vein causes pain and irritation and may block blood flow in the veins.
When assessing the abodomen, what is the order of auscultation?
Auscultation follows the large intestine
- Right Lower Quadrant (RLQ)
- Right Upper Quadrant (RUQ)
- Left Upper Quadrant (LUQ)
- Left Lower Quadrant (LLQ)
What are we listening for when auscultating the abdomen?
- Bowel motility
- Vascular sounds
When listening to the bowels, what 2 things are we listening for? Describe each.
- Peristalsis = no sounds = digestion not happening; indicative of blockage, etc
- Borborygymi = normal sounds of digestive activities; indicates healthy system
What is the order of assessment for the abdomen?
- Inspect
- Auscultate
- Palpate
- Percussion (MD/NP only)
What is being assessed in the palpation of the abdomen?
- tenderness
- distention
- masses
Flank pain is indicative of
kidney issues
How is costal vetebral angle assessed?
Placing hand over kidney and percussing. Pain indicates positive costal vetebral angle
Puking is a sign of…
alkalosis
Diarreah is a sign of…
acidosis
Define Lordosis
- Manifests in an over arching of the back in a posterior direction
- Also known as swayback - results in shoulders further back than hips
- Also known as lumbar lordosis - when the lumbar have a pronounced arch making it look like the butt is pushed backward
Define kyphosis
- Forward slouching of the shoulders and forward arching of the upper back
- Also known as hunchback
Define scoliosis
Scoliosis is a sideways curvature or twist of the spine
Lifting the hand upward to a 90° angle is an example of
hyperextension
Holding your hands in front of you and paralel to the ground or bending your hands down to the ground in the same position are examples of…
flexion
Abduction is movement _____ the medial plane.
away from
Adduction is movment _____ the medial plane.
towards
Pushing the shoulders toward the ground is an example of
depression
Circular motions are known as…
circumduction
Hands held forward, paralel to the ground with palms up is known as…
supination
Hands held forward, paralel to the ground with palms down is known as…
pronation
In anatomical position, moving the hands (only) away from the body is known as…
radial flexion
In anatomical position, moving the hands (only) toward from the body is known as…
ulnar flexion
Spreading the fingers apart is an example of _____.
abduction
Lifting the foot (only) toward the head is known as…
dorsiflexion
Pointing the toes of the foot away from your head (like standing on your toes) is an example of…
plantar flexion
Bending the soles of the feet toward each other is an example of…
inversion
Moving the soles of the feet away from each other is an example of…
eversion
Define Muscular Hypertonicity
Muscular hypertonicity (i.e., increased passive stiffness or tightness) is defined as an unexpected degree of physical resistance to manual movement of a joint(s) on slow, gentle stretching, e.g., rotation of the neck or abduction of a shoulder
Define Muscular Hypotonicity
- State of low muscle tone (the amount of tension or resistance to stretch in a muscle), often involving reduced musclestrength.
- Lo/no resistance to passive ROM exercises
Define Muscle Atrophy
- Muscle atrophy is when muscles waste away.
- Caused by a lack of physical activity.
- When a disease or injury makes it difficult or impossible for you to move an arm or leg, the lack of mobility can result in muscle wasting
Extension at the wrist should be __ degrees, whereas flexion at the wrist should be __ degrees.
Extension: 70°
Flexion: 90°
Hyperextension of fingers should be __ degrees, where as flexion should be at __ degrees.
Hyperextension: 30°
Flexion: 90°
Radial flexsion should be at __ degrees, whereas ulnar flexion should be at __ degrees.
Radial flexion: 20°
Ulnar flexion: 55°
The Glasgow Coma Scale Rates what three behaviors?
- Eye
- Verbal
- Motor
A Glasgow Coma Scale score of 15 indicates
That the patient is completely alert and oriented.
A Glasgow Coma Scale score of < 8 indicates
That the patient is comatose
What is the mneumonic to remember the cranial nerves?
Oh, Oh, Oh, To Touch And Feel Very Good Velvet, Such Heaven!
What is the mneumonic to remember the type of each cranial nerve?
Some Say Marry for Money, But My Brother Says Big Brains Matter More
S = Sensory
M = Motor
B = Both
Give the name, nerve type and what is controlled for CN I-IV
CN I: Olfactory; Sensory; sense of smell
CN II: Optic; Sensory; visiual acuity (snellen chart)
CN III: Oculomotor; Motor; extraocular eye movement (perrla); Inward-medial movement
CN IV: Trochlear; downward-medial movement
Give the name, nerve type and what is controlled for CN V-VIII
CN V: Trigeminal; Sensory-Motor; Sensory to skin of face; Motor to mouth functions - chewing, biting, etc
CN VI: Abducens; Motor; Lateral plane eye movement
CN VII: Facial; Sensory-Motor; facial expression
CN VIII: Vestibulo cochlear; Sensory; auditory
Give the name, nerve type and what is controlled for CN IX-XII
CN IX: Glossopharyngeal; Sensory-Motor; gag reflex
CN X: Vagus; Sensory-Montor; sensation of pharynx (assessment via “ah”)
CN XI: Accessory; Motor; movement of head and shoulders (shrug)
CN XII: Hypoglossal; Motor; position of tongue
