Chapter 22 Exam 2 Flashcards
What is included in the general survey collected during history?
1) LOC & mental status
2) Mood or affect
3) Personal hygiene
4) Skin color
5) Posture/position
6) Breathing effort
7) Mobility
8) Ability to hear and speak
Assess vital signs and other baseline measurements
- Nurse is in front of patient who is seated
- Temperature, radial pulse, respirations, and BP. If indicated BP in both arms
- Height, weight, and body mass index
- Visual acuity
Examine hands
- When taking pulse and BP, inspect skin surface characteristics, temperature, and moisture of hands
- Inspect hands for symmetry
- Inspect and palpate nails for shape, contour, consistency, color, thickness, and cleanliness
- Observe for clubbing of fingers
- Test capillary refill
Examine head and face
- Inspect the head for shape and position
- Inspect skin and scalp for characteristics. If indicated
- Palpate structures of the skull for contour, symmetry, tenderness, and intactness
- Palpate scalp for tenderness and intactness
- Palpate temporal pulses for pulsation, amplitude, and tenderness
- Inspect for facial structures for size, symmetry, movement, skin characteristics, and facial expressions. If indicated
- Palpate the structures for the skull for contour, symmetry, tenderness, and intactness
- Palpate the bony structures of the face and jaw, noting jaw movement and tenderness
- Ask patient to clench eyes tightly; wrinkle forehead; smile stick out tongue; and puff out cheeks, noting symmetry
- Evaluate sensation of forehead, cheeks, and chin to light touch
- Inspect skin for color and lesions. If indicated
- Palpate skin for texture, tenderness, and lesions
- Palpate facial bones for size, intactness, and tenderness
Examine eyes
- Assess near and peripheral vision
- Inspect eyebrows for skin characteristics and symmetry
- Inspect eyelids and eyelashes for symmetry, position, closure, blinking, and color
- Inspect conjunctiva and sclera for color and clarity; inspect cornea for transparency
If indicated:- Inspect anterior chamber for transparency and chamber depth
- Palpate the eye, eyelids, and lacrimal puncta for firmess, tenderness, & discharge
- Inspect symmetry of eye movements
If indicated:- Test extraocular eye movements in six cardinal fields of gaze
- Perform cover-uncover test
- Inspect iris for shape and color
- Examine pupillary response, consensual reaction, corneal light reflex, and accommodation.
If indicated:- Inspect the anterior chamber for transparency and chamber depth
- Perform ophthalmic examination: Inspect red reflex, disc cup margins, vessels, retinal surface, macula
Examine ears
- Inspect external ear for alignment, position, size, shape, symmetry, intactness, skin color, and presence of deformities.
- Inspect external auditory canal for discharge or lesions
- Inspect skin over superficial lymph nodes for edema, erythema, and red streaks
- Palpate lymph nodes of the head for size & tenderness
- Palpate external ear and mastoid areas for tenderness, edema, or nodules
If indicated:- perform whisper test to evaluate gross hearing
- perform Rinne and Weber tests for conduction and sensorineural hearing losses
- perform otoscopic examination: inspect characteristics of external canal, cerumen, tympanic membrane (landmarks)
Examine nose
- Inspect nasal structure and septum for symmetry
- Inspect nose for patency, color of turbinates, and discharge
If indicated:- evaluate sense of smell
- palpate nose for tenderness and to assess patency
- inspect internal nasal cavity for surface characteristics, lesions, erythema, discharge, and foreign bodies
- palpate the frontal and maxillary for tenderness
- transilluminate sinuses
Examine mouth
- Inspect lips for color, symmetry, moisture, and texture
- Inspect teeth and gums for condition, color, surface characteristics, and alignment
- Inspect the tongue for movement, symmetry, color, and surface characteristics
- Inspect buccal mucosa and anterior & posterior pillars for color, surface characteristics, and odor
- Inspect the palate, uvula, posterior pharynx, and tonsils for texture, color, surface characteristics, and movement
If indicated:
*palpate teeth, inner lips & gums for condition and tenderness with gloved hands
*palpate tongue for texture with gloved hands
*evaluate gag reflex
*test temporomandibular joint for movement
Examine neck
- Inspect the neck position in relationships to the head and trachea
- Inspect the neck for skin characteristics, presence of lumps
If indicated:
*palpate the neck for anatomic structures and trachea
*palpate the thyroid gland for size, consistency, tenderness, and presence of nodules
*palpate lymph nodes for size, consistency, mobility, and tendernes
*palpate neck for tenderness and muscle strength
*test range of motion of head and neck; shrug shoulders against resistance - Palpate carotid pulses, one at a time, for amplitude
If indicated
*auscultate carotide for bruits - Inspect jugular veins for pulsations
Examine upper extremities
- Inspect patient’s arms for skin characteristics, symmetry, and color. Inspect the shoulders and shoulder girdle for equality of height, symmetry, and contour
- Inspect the joints of the wrists and hands for symmetry, alignment, and number of digits
- Palpate the shoulders for firmness, fullness, symmetry, and pain
- Palpate skin for texture, moisture, mobility, turgor, and thickness
- Palpate arms for temperature
- Palpate elbows, wrists, and fingers for tenderness and deformities
- Palpate brachial or radial pulses for presence and amplitude
If indicated:
*palpate epitrochlear lymph nodes for size, consistency, mobility, tenderness, and warmth
*palpate ulnar pulse for presence and amplitude - Observe range of motion of shoulders, elbows, wrists, and fingers
- Assess muscle strength of upper and lower arms
- Test deep tendon reflexes
- Test for sensation of upper and lower arms
Examine posterior and lateral thorax
- Nurse moves behind patient; patient is seated; gown is lowered to waist for men, open in back for women
-Observe posterior and lateral chest for shape, muscular development, scapular placement, spine alignment, and posture - Inspect skin for color, intactness, lesions, and scars
- Palpate vertebrae for alignment and tenderness
- Observe respiratory movement for symmetry, depth, and rhythm of respirations
If indicated:
*palpate posterior thorax and muscles for tenderness, and symmetry
*palpate posterior thorax for expansion
*palpate posterior thoracic wall for fremitus - Auscultate posterior and lateral thoraxes for breath sounds
Examine anterior thorax
Move to front of patient; patient is seated and should lower gown to waist
- Inspect skin for color, intactness, lesions, and scars
- Inspect anterior thorax for contour, pulsations, lift, heaves, and retractions
- Observe respiratory movement for symmetry, breathing pattern, and posture
- Inspect the anterior thorax for shape, symmetry, muscle development, and costal angle
- Inspect the anterior thorax for anteroposterior to lateral diameter
If indicated:
*observe precordium for pulsations or heaving
*palpate anterior thorax and muscles for tenderness and symmetry
*palpate the anterior thoracic walls for expansion
*palpate anterior thoracic wall for fremitus
- Palpate left anterior thorax to locate point of maximum impulse (PMI)
- Auscultate anterior thorax for breath sounds
- Auscultate heart for rate, rhythm, intensity, frequency, timing, splitting of s1 or s2 or presence of s3, s4, or murmurs
Breasts
Female
- Inspect for size, symmetry, shape, surface characteristics, and venous patterns
- Inspect areolae for color, shape, and surface characteristics
- Inspect nipples for position, symmetry, surface characteristics, lesions, bleeding, and discharge
If indicated:
* Inspect the breasts in various positions for bilateral pull, symmetry, and contour
Assist the patient to a supine position
*palpate breasts for tissue characteristics
*palpate the nipples for surface characteristics and discharge
Male
- Inspect the breasts and nipples for symmetry, color, size, shape, rashes, and lesions
- Palpate the breasts and nipples for surface characteristics, tenderness, size, masses
All patients
If indicated:
Inspect and palpate the axillae for evidence of enlarged lymph nodes, rash, lesions, or masses
Examine abdomen
Assist the patient to a supine position
- Inspect the abdomen for skin color, surface characteristics, venous patterns, contour, and surface movements
- Auscultate abdomen for bowel sounds and arterial and venous sounds
- Lightly palpate all quadrants for tenderness and muscle tone
- Palpate the abdomen deeply for pain, masses, and aortic pulsation
If indicated:
*percuss the abdomen for tones
*percuss the liver to determine span and descent
*percuss the spleen for size
*palpate liver for lower border and pain
*palpate the gallbladder for pain
*palpate spleen for border and pain
*palpate the kidneys for contour and pain
- patient raises head to evaluate flexion and strength of abdominal muscles and inspect for umbilical hernia
if indicated:
*palpate inguinal region for femoral pulses & bulges that may be associated with hernia
*palpate inguinal lymph nodes for size, consistency, mobility, tenderness, and warmth
