Chapter Twenty One Flashcards
Head To Toe Assessment
Neurological
Cardiovascular
Respiratory
Integumentary
Gastrointestinal
Genitourinary
Musculoskeletal
Also Includes:
Vitals
Appearance
Speech
Safety risk factors
Tubes & equipment
Comfort & complaints
Needs
Focused Assesment
Less encompassing and involves an examination and an interview regarding a specific body system.
Provides a cluster of data about just the one body system that is being assessed.
When is a physical assessment performed?
Assessment is an ongoing process,
usually they are done:
-on admission (comprehensive, in depth; generally done by RN)
-at beginning of each shift (shorter, more focused)
-when PT condition changes
-when evaluating the effectiveness of nursing care
-any time things do not feel right
What do you do if you assess a fever of 103?
Take immediate action to treat fever and reassess within an hour to see if further intervention is required.
Subjective Data
Data the patient provides or says
Objective Data
Data that you observe
Signs
When you use your four senses to find evidence of illness or injury, and the data is objective and measurable
Symptoms
When evidence of illness or injury is only known by what the PT tells you, the findings are subjective and not directly measurable
Interviewing
Data obtained during interviewing:
- Personal id and demographics
- details about current conditions
- medical history
- social history
- food/drug allergy
- height/ normal weight
- expectation for hospitalization
Otoscope
Lighted instrument used to inspect the lining of the nose tympanic membranes, and ear canals
Opthalmoscope
Lighted instrument used to assess or examine the internal structures of the eyes
Palpation
Application of your hands to the external surfaces of the body to detect abnormalities of the skin or tissues lying below the skin. Examine by touch or feel.
Things you can detect by touch:
- skin turgor
- growths on or below the skin
- edema
- size and location of body parts
- distention of bladder or abdomen
- firmness vs softness of tissue
- location/strength of pulses
- pain/discomfort
Palpation is classified according to the depth of tissue compression:
1-2cm light palpation
2-3cm moderate palpation
4-5cm deep palpation
Percussion
Striking the body parts with the tips of the fingers to
-elicit sounds that can help locate and determine the size of structures beneath the surface
- ID whether the structure is solid or hollow
- detect areas containing air or fluid
Auscultation
Listening to the sounds produced by the body
Eructation
Sounds that are able to be heard with the naked ear
Examples:
-passing gas
-loud wheezing
-loud bowel noise
Murmurs
Abnormal valve sounds (no lub dub, lub swush)
Normal heart sound
LUB DUB (s1, s2)
Olfaction
using the sense of smell for assesment
Halitosis
Bad breath
Smell of ammonia or urine on breath can be a sign of what?
Kidney failure
Musty / sweet smell on someones breath can be sign of?
Liver disease
Breath that smells like acetone or has fruity/raspberry smell may indicate what?
Out of control diabetes
Lethargic
Drowsy or mentally sluggish
Jaundice
indicative of liver failure, sclera can be yellowish, skin may also be yellow
Checking for orientation of consciousness:
Person: whats your name?
Place: Do you know where you are?
Time: Do you know what day of the week it is?
Situation: Do you know why you’re here today?
Erythema
Tissue Redness
Cyanotic
Blue
Arcus Senilis
Opaque white ring on cornea - normally noted on older adults
Ptosis
drooping
Anisocoria
When pupils are different sizes
Bifurcates
Where the optic nerve divides
Consensual Reflex
Stimulation of the nerve by shining the light in either eye should cause both pupils to rapidly constrict simultaneously and equally.
Accommodation Response
Measures the eye muscles ability to focus on an image up close and in the distance
PERRLA
Pupils Equal Round Reactive to Light and Accommodation
Glossitis
Smooth, painful tongue, can be caused by inflammation or a side effect of medication
Cheilitis
Inflammation of the lips
Circumoral
encircling the mouth area
Edentulous
Without teeth
Caries
Cavaties
Sordes
Dried mucus or food that is caked on the lips or teeth - easily treated with good oral hygiene
Aphasia
Without speech - PT may know what they want to say but cannot say the words
Dysphasia
Difficulty coordinating and organizing the words correctly in a sentence
Neuro Exam
Components of the neurological assessment are performed together as a single assessment
Distended
Swell from pressure from inside
Dyspnea
Difficulty breathing
Orthopnea
Difficulty breathing in the supine position
Nonproductive Cough
Dry cough
Productive Cough
Wet cough that produces sputum
Comprehensive Health Assessment
An in depth assessment of the whole person including the physical mental emotional cultural and spiritual aspects of the pt’s health
Initial head-to-toe assesment
Performed at the start of shift when you first see the pt. provides you with a quick overall assessment of the pt’s condition to establish a baseline against which you can compare later assessments to
What systems are included in head to toe?
Neuro
Cardio
Respiratory
integumentary
gastro
genitourinary
musculoskeletal
What else is included in a head to toe?
Vitals
Appearance
Speech
Safety Risk Factors
Tubes and equipment
Comfort or complaints
Needs
Focused Assessment
Less encompassing and involves and examination and an interview regarding a specific body system
Excursion
Equal chest expansion
Atelectasis
Lung (alveoli) collapse
Lordosis
Lumbar concavity is increased
Kyphosis
Convexity of the midthorax is increased
Scoliosis
Curvature to either the left or right vertebrae
Retractions
Chest wall appears depressed or sunken in between the ribs or under the xiphoid process when pt inhales
Decreased breath sounds
when there are fewer breath sounds in one area
Consolidation
Secretions and exudate from pneumonia that solidify in the lung tissues
Absent Breath Sounds
No breath sounds in an area can indicate collapse or blockage of a lung or lobe
Adventitious Breath Sounds
Abnormal breath sounds
Includes: crackles, rhonchi, wheezes, pleural friction rub, and stridor
Crackles
Not continuous, usually heard during inspiration.
may be fine or course
cannot clear by coughing
Rhonchi
Snoring , rattling, gurgling, squeaking, and low-pitched wheezes
Caused by either secretions or partial occlusion of the airways.
Deeper and more rumbling than crackles, heard during expiration.
may clear during coughing
Wheezes
Continuous melodious, musical, whistling sounds
Caused by constriction of airway - heard on inhale or exhale
Stridor
Heard with or w/o stethoscope - sign of life threatening upper airway obstruction
caused by foreign body, tumor, swelling, or bronchial spasms
Anorexia
lack of appetite
Peristalsis
Wave like muscular contractions of the intestines that move intestinal contents through the alimentary canal
Borborygmus
Stomach gurgling you can hear with out a stethoscope
Parasthesia
Numbness or decreased sensation
Solar Lentigines
Spots of yellowish-brown discoloration caused by years of sun exposure
Diaphoretic
Prespiring
Turgor
Elasticity
Intact Skin
Has no breaks or openings in the skin
Contractures
Tightening and shortening of muscles that prevent full extension of joints
