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z_NUR112: MIDTERM_LAST LEG > Ch 31_ Assessment > Flashcards

Ch 31_ Assessment Flashcards

1
Q

What are the characteristics of a focused assessment?

A
  • Focuses on certain system(s) in priority
  • Typically respiratory or cardiovascular
  • Once stable, then proceed with comprehensive
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2
Q

Observing top to bottom, left to right, anterior to posterior describes what action?

A

Assessing for symmetry

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3
Q

When we perform a comprehensive assessment, we move from _____ to _____ invasive unless there is ____, which requires priority attention.

A

least, most, pain

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4
Q

What are the 4 techniques of physical assessment?

Briefly describe each.

A
  • 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
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5
Q

What is erythema?

A

Superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.

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6
Q

What is vitiligo?

A

A long-term skin condition characterized by patches of the skin losing their pigment (hypopigmentation).

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7
Q

What types of things can be indicated by observing the color of the skin?

A
  • Adequate blood perfusion
  • Erythema
  • Cyanosis
  • Jaundice
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8
Q

How is cyanosis observed and what does it indicate?

A
  • Blueish skin
  • Observed at the mouth or mucus membranes
  • Low oxygen
  • Late sign of hypoxia
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9
Q

How is jaundice observed and what does it indicate?

A
  • Yellowish hue in skin or sclera
  • Indicates liver issues
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10
Q

What are some skin observations that can indicate hydration issues?

A
  • Dryness
  • Dried lips
  • Sunken neck
  • Turgor
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11
Q

What are the 6 general items being observed while assessing the skin?

A
  • Color
  • Moisture
  • Temperature
  • Texture
  • Integrity
  • Turgor
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12
Q

When observing edema, a deeper level indicates…

A

fluid excess

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13
Q

How are the grades of edema documented?

(give depth as well)

A
  • +1 = 2mm
  • +2 = 4mm
  • +3 = 6mm
  • +4 = 8mm
  • *there is nothing greater than +4 on this scale,
  • *+8 does not exist)
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14
Q

When checking for melanoma, how is “ABCDE” utilized?

A
  • 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
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15
Q

Descibe a Macule

A
  • Flat, nonpalpable change in skin color
  • smaller than 1cm
  • ex. freckle
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16
Q

Describe a Papule

A
  • Palpable, circumscribed, solid elevation in skin
  • smaller than 1cm
  • a small mole
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17
Q

Describe a Nodule:

A
  • 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
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18
Q

Describe a wheal

A
  • Irregularly shaped, elevated area or superficial localized edema
  • Varies in size
  • Ex. hive or misquito bite
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19
Q

Describe a vesicle

A
  • Raised lesion filled with serous fluid
  • ex. blister
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20
Q

Describe Pustule

A
  • Circumscribed elevation of skin smaller to vesicle
  • filled with pus
  • ex. acne, staphylococcal infection
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21
Q

What does PERRLA stand for?

A

P = Pupil

E = Equal

R = Round

R = Reactive

L = Light

A = Accomodation (constriction of pupil when close, relaxation when light taken away

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22
Q

Pupil dilation indicates

A

neurological issues

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23
Q

Eye coordination is the responsibility of which cranial nerve?

A

III; Occulomotor

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24
Q

The tympanic membrane is usually ____ in color

A

pearly gray

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25
Q

A bulging red tympanic membrane indicates…

A

infection

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26
Q

The weber test evaluates _____ hearing.

A

conductive (bone)

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27
Q

The Rinne test evaluates ______ hearing.

A

sensory

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28
Q

Describe Weber test.

A
  • 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
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29
Q

Describe Rinne test.

A
  • 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
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30
Q

Which cranial nerves control eye movement?

A
  • CN III: Oculomotor
  • CN IV: Trochlear
  • CN VI: Abducens
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31
Q

What does CN VI control?

A

Lateral plane eye movement

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32
Q

What does CN IV control?

A

downward-medial movement

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33
Q

What does CN III control?

A
  • Upward lateral/medial movement
  • Inward-medial movement
  • Downward-lateral movement
  • PERRLA
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34
Q

Palpable lymph nodes are indicative of _____.

A

infection

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35
Q

If infection is suspected, what test is ordered?

A
  • CBC
  • Complete Blood Count
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36
Q

What is the order of examination when assessing the lungs?

A
  • Inspection; visual
  • Palpation; feel; light, then deep
  • Auscultation; listen
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37
Q

What can be observed a visual sign of respiratory distress?

A
  • Irregular breathing patterns
  • Using accessory muscles to breathe
  • Cyanosis at lips/muscous membranes
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38
Q

When assessing the posterior thoracic area of a patient, what “lines” are used?

A
  • Left/Right scapular line
  • Vertebral line
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39
Q

When assessing the lateral thorasic area of a patient, what “lines” are used?

A
  • Posterior axillary line
  • Midaxillary line
  • Anterior axillary line
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40
Q

When assessing the anterior thorax of a patient, what “lines” are used?

A
  • Midsternal line
  • Midclavicular line
  • Anterior axillary line
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41
Q

How does one test for chest excursion?

A
  • 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
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42
Q

Consolidation in the thorax is…

A

the accumulation of fluids in the pleural space

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43
Q

What is Egophony?

How is it assessed?

A

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.

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44
Q

What are abnormal lung sounds called?

A

Adventitious

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45
Q

What are the four adventitious lung sounds?

A
  1. Crackles
  2. Rhonchi
  3. Wheezes
  4. Pleural friction rub
46
Q

Describe adventitious lung “crackles” and how the are described.

A
  • Caused by sudden reinflation of groups of alveoli or disruptive passage of air through small airways.
  • Described as fine, medium, coarse
47
Q

What are crackles indicative of?

A

Pneumonia

48
Q

Describe adventitious lung “Rhonchi”.

How is it cleared?

A
  • Low-pitched, continuous sounds caused by muscular spasm, fluid, or mucus in larger airways.
  • Cleared by coughing
49
Q

Describe adventitious lung “wheezes”.

A
  • high-pitched sound or squeak heard continuously during inspriation or expiration.
  • Usually louder on expiration
  • Often heard in asthma
50
Q

Describe adventitious lung “pleural friction rub”.

A
  • Dry rubbing or grating sound
  • Caused by inflamed pleura; parietal pleura rubbing against visceral pleura
51
Q

During auscultation of breath sounds, what must be indicated?

A
  • Location
  • Characteristics of sound
  • Absence of breath sounds
52
Q

What is the one assessment you must do on your patients every time?

A

Respiratory

53
Q

What/how is generally observed during a respiratory assessment?

A
  • 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
54
Q

What are the three classifications of breath sounds?

Name the location, lung region assessed and describe the sound of each.

A
  • 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
55
Q

S1 and S2 represent…

The normal heart sounds; lub-dub

A

S1 = closure of the AV valves

S2 = closure of the semilunar valves

56
Q

What is the S3 sound, when is it heard and what does it sound like?

A
  • Audible filling of the ventricle
  • Right after S2
  • Lub-Dub-Tss (like a gallop)
57
Q

What is the S4 sound, when is it heard and what does it sound like?

A
  • Occurs when atria contract harder to overcome resistent ventriclular filling (ventricles not doing their job properly)
  • Prior to S1
  • tuh, lub-dub
58
Q

What are the three basic anomolies we are listening for when auscultating the heart?

A
  • Dysrhythmia
  • Extra heart sounds
  • Murmurs
59
Q

What three items are we noting when ausculting a heart murmur?

A
  • Grade
  • Pitch
  • Quality
60
Q

A heart “thrill” is a…

A

palpable vibration

61
Q

A good heart rythym is documented as…

A
  • +S1S2
  • (positive S1, S2)
62
Q

How many grades of heart murmur are there?

A

six

63
Q

Describe murmur grades 1-3

A
  • Grade 1 = Barely audible in a quiet room (extremely difficult to hear)
  • Grade 2 = Clearly audible, but quiet
  • Grade 3 = Moderately loud
64
Q

Describe murmur grades 4-6

A

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

65
Q

If murmurs are discovered a _____ will be needed for the patient.

A

referral

66
Q

Where is a bruit found, what is it, and what does it sound like?

A
  • blood vessels
  • narrowed vessel which creates an audible turbulence
  • swish
67
Q

How are pulse strengths documented and describe each.

A
  • 0 = abscent, not palpable
  • +1 = pulse diminished, barely palpable
  • +2 = normal/expected
  • +3 = full pulse, increased
  • +4 = bounding pulse
68
Q

What are varicosities?

A
  • 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
69
Q

What is phlebitis?

A

means inflammation of a vein.

70
Q

What is thrombophlebitis

A

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.

71
Q

When assessing the abodomen, what is the order of auscultation?

A

Auscultation follows the large intestine

  • Right Lower Quadrant (RLQ)
  • Right Upper Quadrant (RUQ)
  • Left Upper Quadrant (LUQ)
  • Left Lower Quadrant (LLQ)
72
Q

What are we listening for when auscultating the abdomen?

A
  • Bowel motility
  • Vascular sounds
73
Q

When listening to the bowels, what 2 things are we listening for? Describe each.

A
  • Peristalsis = no sounds = digestion not happening; indicative of blockage, etc
  • Borborygymi = normal sounds of digestive activities; indicates healthy system
74
Q

What is the order of assessment for the abdomen?

A
  • Inspect
  • Auscultate
  • Palpate
  • Percussion (MD/NP only)
75
Q

What is being assessed in the palpation of the abdomen?

A
  • tenderness
  • distention
  • masses
76
Q

Flank pain is indicative of

A

kidney issues

77
Q

How is costal vetebral angle assessed?

A

Placing hand over kidney and percussing. Pain indicates positive costal vetebral angle

78
Q

Puking is a sign of…

A

alkalosis

79
Q

Diarreah is a sign of…

A

acidosis

80
Q

Define Lordosis

A
  • 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
81
Q

Define kyphosis

A
  • Forward slouching of the shoulders and forward arching of the upper back
  • Also known as hunchback
82
Q

Define scoliosis

A

Scoliosis is a sideways curvature or twist of the spine

83
Q

Lifting the hand upward to a 90° angle is an example of

A

hyperextension

84
Q

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…

A

flexion

85
Q

Abduction is movement _____ the medial plane.

A

away from

86
Q

Adduction is movment _____ the medial plane.

A

towards

87
Q

Pushing the shoulders toward the ground is an example of

A

depression

88
Q

Circular motions are known as…

A

circumduction

89
Q

Hands held forward, paralel to the ground with palms up is known as…

A

supination

90
Q

Hands held forward, paralel to the ground with palms down is known as…

A

pronation

91
Q

In anatomical position, moving the hands (only) away from the body is known as…

A

radial flexion

92
Q

In anatomical position, moving the hands (only) toward from the body is known as…

A

ulnar flexion

93
Q

Spreading the fingers apart is an example of _____.

A

abduction

94
Q

Lifting the foot (only) toward the head is known as…

A

dorsiflexion

95
Q

Pointing the toes of the foot away from your head (like standing on your toes) is an example of…

A

plantar flexion

96
Q

Bending the soles of the feet toward each other is an example of…

A

inversion

97
Q

Moving the soles of the feet away from each other is an example of…

A

eversion

98
Q

Define Muscular Hypertonicity

A

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

99
Q

Define Muscular Hypotonicity

A
  • 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
100
Q

Define Muscle Atrophy

A
  • 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
101
Q

Extension at the wrist should be __ degrees, whereas flexion at the wrist should be __ degrees.

A

Extension: 70°

Flexion: 90°

102
Q

Hyperextension of fingers should be __ degrees, where as flexion should be at __ degrees.

A

Hyperextension: 30°

Flexion: 90°

103
Q

Radial flexsion should be at __ degrees, whereas ulnar flexion should be at __ degrees.

A

Radial flexion: 20°

Ulnar flexion: 55°

104
Q

The Glasgow Coma Scale Rates what three behaviors?

A
  • Eye
  • Verbal
  • Motor
105
Q

A Glasgow Coma Scale score of 15 indicates

A

That the patient is completely alert and oriented.

106
Q

A Glasgow Coma Scale score of < 8 indicates

A

That the patient is comatose

107
Q

What is the mneumonic to remember the cranial nerves?

A

Oh, Oh, Oh, To Touch And Feel Very Good Velvet, Such Heaven!

108
Q

What is the mneumonic to remember the type of each cranial nerve?

A

Some Say Marry for Money, But My Brother Says Big Brains Matter More

S = Sensory

M = Motor

B = Both

109
Q

Give the name, nerve type and what is controlled for CN I-IV

A

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

110
Q

Give the name, nerve type and what is controlled for CN V-VIII

A

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

111
Q

Give the name, nerve type and what is controlled for CN IX-XII

A

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

z_NUR112: MIDTERM_LAST LEG (11 decks)

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