Chapter 30: Health Assessment and Physical Examination Flashcards
Use physical examination to do the following
• Gather baseline data about the patient’s health status.
• Support or refute subjective data obtained in the nursing
history.
• Identify and confirm nursing diagnoses.
• Make clinical decisions about a patient’s changing health
status and management.
• Evaluate the outcomes of care.
Two types of allergic responses
appear with NRL. Latex
The most immediate is an immunological reaction
type 1 response, for which the body develops antibodies
known as immunoglobulin E that can lead to an anaphylactic
response.
The
second is the allergic contact dermatitis type 4 response, which
causes a delayed reaction that appears 12 to 48 hours after exposure
sitting position
Head and neck, back, posterior thorax and lungs, anterior thorax and lungs, breasts, axillae, heart, vital signs, and upper extremities
Sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts. Physically weakened patient is sometimes unable to sit. Use supine position with head of bed elevated instead
supine Head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses
This is most normally relaxed
position. It provides easy
access to pulse sites.
If patient becomes short of breath
easily, raise the head of bed
Dorsal recumbent
Head and neck, anterior thorax
and lungs, breasts, axillae,
heart, abdomen`
Position is for abdominal
assessment because it
promotes relaxation of
abdominal muscles.
Patients with painful disorders are
more comfortable with knees
flexed.
prone
musculoskeltal system
Position is only for assessing
extension of hip joint, skin,
buttocks.
Patients with respiratory
difficulties do not tolerate this
position well
lateral recumbent
heart
Position aids in detecting
murmurs.
Patients with respiratory
difficulties do not tolerate this
position well.
knee-chest
rectum
Position provides maximal
exposure of rectal area.
This position is embarrassing and
uncomfortable.
lithotomy
Female genitalia and genital
tract
Position provides maximal
exposure of female genitalia
and facilitates insertion of
vaginal speculum
Lithotomy position is embarrassing and uncomfortable; thus examiner minimizes time that patient spends in it. Keep patient well draped.
Olfaction helps to detect
abnormalities that cannot be
recognized by any other means. For example, when a patient’s
breath has a sweet, fruity odor, assess for signs of diabetes
Describe any sound you hear using the following
characteristics:
Frequency indicates the number of sound wave cycles generated
per second by a vibrating object. The higher the
frequency, the higher the pitch of a sound and vice versa.
• Loudness refers to the amplitude of a sound wave. Auscultated
sounds range from soft to loud.
• Quality refers to sounds of similar frequency and loudness
from different sources. Terms such as blowing or gurgling
describe the quality of sound.
• Duration means the length of time that sound vibrations
last. The duration of sound is short, medium, or long. Layers
of soft tissue dampen the duration of sounds from deep
internal organs.
CAGE is an acronym for the
following:
• Have you ever felt the need to Cut down on your drinking
or drug use?
• Have people Annoyed you by criticizing your drinking or
drug use?
• Have you ever felt bad or Guilty about your drinking or
drug use?
• Have you ever used or had a drink first thing in the
morning as an Eye-opener to steady your nerves or feel
normal?
history of any substantial weight gain or loss
A weight gain of 5 pounds (2.3 kg) in 1 day indicates fluid-retention
problems. A weight loss is considered significant if the patient has
lost more than 5% of body weight in a month or 10% in 6 months.
Observe for cyanosis
(bluish discoloration)
in the lips, nail beds, palpebral conjunctivae, and palms
Inspect sites where abnormalities are more easily identified
For
example, pallor is more evident in the face, buccal (mouth) mucosa,
conjunctiva, and nail beds.
The best site to inspect for jaundice
(yellow-orange discoloration)
is on the patient’s sclera.
edema
Areas of the skin become swollen or edematous from
a buildup of fluid in the tissues. Direct trauma and impairment of
venous return are two common causes of edema.
The
depth of pitting, recorded in millimeters, determines the degree of
edema
For example, 1+ edema equals a 2-mm
depth, 2+ edema equals a 4-mm depth, 3+ equals 6 mm, and 4+
equals 8 mm
primary lesions
maculues and nodules
seconday lesions
such as ulcers occur as
alterations in primary lesions.
Use the ABCD mnemonic to assess the skin for any type of carcinoma
• Asymmetry—look for an uneven shape
• Border irregularity—look for edges that are blurred, notched,
or ragged
• Color—look for pigmentation that is not uniform; variegated
areas of blue, black, and brown and areas of pink,
white, gray, blue, or red are abnormal
• Diameter—look for areas greater than the size of a typical
pencil eraser
Nystagmus,
an involuntary, rhythmical oscillation of the
eyes, occurs as a result of local injury to eye muscles and supporting
structures or a disorder of the cranial nerves innervating the muscles
PERRLA
(pupils equal, round, reactive to light, and
accommodation)
Cherry-colored lips indicate
carbon monoxide poisoning
Varicosities
(swollen, tortuous veins)
comon on the tongues of older adults,
