Chapter 19 - Physical Assessment Flashcards
What is the primary goal of a physical assessment?
To identify the patient’s problem and plan appropriate interventions
What is the initial step of the nursing process and the first step in forming the nursing care plan?
Assessment / Recognizing Cues
The nurse is gathering information from a patient who came into the ED after a fall at home. You are gathering their health history - which is what stage of the nursing care plan?
Assessment
What makes up the integumentary system?
Hair, nails, skin
Comprehensive assessment of physical, mental, spiritual, socioeconomic and cultural status is?
Health Assessment
A focus on a client’s functional ability and physical responses to illness is?
Nursing Assessment
Techniques used in health or nursing assessment to gather objective data is?
Physical Assessment
This includes the nursing assessment and physical exam while obtaining subjective data about each area?
Physical Examination
What are the 4 purposes of the physical exam?
- Obtain baseline data
- Identify a nursing diagnosis
- Monitor status of previous problems
- Screen for health problems
A system specific assessment focuses on?
One body system
A comprehensive exam includes?
Health history interview and head to toe exam
As assessment that is performed in intervals or as needed is referred to as what?
Ongoing assessment
What techniques are used in a physical exam?
Inspection, palpation, percussion, auscultation and olfaction
What is fowler position?
Head elevated to 60 degrees
What is semi-fowler position?
Head elevated to 30-45 degrees
When would you perform a comprehensive exam?
When a patient is admitted
When is a rapid assessment performed?
Each shift (after the admission when a comprehensive exam was performed)
Using sight to gather data is what type of assessment technique?
Inspection
Using touch to assess body organs and skin uses which assessment technique?
Palpation
Tapping the skin to cause a vibration is what type of assessment technique?
Percussion (usually performed by MD or ARNP)
Listening to sounds made by body organs or systems uses which assessment technique?
Auscultation
Listening without tools such as a stethoscope is referred to as?
Direct auscultation
Listening with a stethoscope is referred to as?
Indirect auscultation
What does pallor look like in a light skinned client and a dark skinned patient?
Light skinned patient has extreme paleness, dark skinned patient has a loss of red tones
Pallor can be related to which two things?
Poor circulation or low hemoglobin level (aka anemia)
Where are the best sites to assess for pallor?
oral mucous membranes, conjunctiva, nail beds, palms, soles of feet
Asking a patient what year it is assesses if they are oriented to what?
time
Asking a patient where they are assesses if they are oriented to what?
place
Asking a patient their name assesses if they are oriented to what?
self
Asking the patient why they are in the hospital assesses if they are oriented to what?
Event
Alert and oriented x4 (A&O x4) means the patient is oriented to what four things?
self, time, place, event
Checking for alert and oriented it part of what assessment?
Neuro
What does PERRLA stand for?
Pupils Equal Round Reactive to Light Accommodation
How do you know if the eyes accommodate?
The pupils restrict and the eyes cross as a person attempts to focus on an object moving towards them
What is the normal size of a pupil in bright light?
2-3mm
What is ptosis?
A drooping eye lid
What does wheezing sound like?
A whisteling sound
What do rales sound like?
crackling sound
What does rhonchi sound like?
course, wet sound
What do you note if sputum is present?
Color and amount
While auscultating lung sounds, which pattern should be used?
zig-zag
A thyroid glad should be … (3 things)
smooth, firm, non-tender
