Discussion Board Flashcards
!!!!!!!!!!!!! MOST IMPORTANT !!!!!!!!!!!!
Before you start assessment (6)
Wash hands and PPE
Introduce self/title and describe what you will do
Ask for Permission
ID verbally X2
Check Wrist band
Orientate 4x: Name, Date, Location, How many quarters in a dollar
Measure chest length with hands
Compare to Chest Width
You are looking for the length to be 2x
A 2:1 ratio of side to side / back to front
Describes this Assessment
Inspect Thorax for AP diameter
Bronchophony
Normal Findings
When listening via stethoscope over lung area, paitents voice sounds muffled
Abnormal…….
Disease state for abnormal findings
The sound is louder or clearer when listened to through a stethoscope
Lung consolidation: pneumonia, pulmonary edema, cancer.
Accessing Nails for Clubbing
Normal: opposing fingers placed together back to back, a small diamond shapped space is visible between where the nail beds meet.
Nail base angle 160 degrees
Abnormal findings ………..
Abnormal findings suggest which disease
No space observed between fingers, nail beds angle away from one another.
Base of nail enlarged and curved.
Exceeds 180°
Diseases: COPD, cardiovascular disease, cystic fibrosis
Procedure:
Visually examine nails laterally view angle of nail beds
Palpation for fluntuance of nail bed
Place opposing fingers together (nail to nail) to visualize space between them
Describes…
Assessing for nail clubbing
Egophony
Normal: The paitent speaking the vowel “e” sounds as it should
Abnormal:…..
Diseases associated
The vowel “e” changes to an “ay” sound
Lung consolidation, where the lung tissue becomes denser
Pneumonia or atelectasis.
Fluctuance
a tense area of skin with a wave-like or boggy feeling upon palpation;
Measuring chest for AP diameter a barrell Chest is associated with these diseases
COPD or chronic air trapping conditions
______ the buildup of pleural fluid in the pleural cavity.
______ the presence of air or gas in the pleural cavity
Pleural effusion
Pneumothorax
In thoracic chest expansion Unilateral or unequal movement of the thumbs indicates which dieases
Fractured Ribs, chest wall injury, Pneumonia, Collapsed Lung
Decreased fremitus is associated with which diseases
COPD / Asthma
Increased fremitus is associated with which diseases
Congested or consolidation (Pneumonial)
Assess palpation of temporal and carotid arteries:
Normal Findings:
Abnormal findings:
Norm:
Temporal, smooth and non-tender with pulsation noted
Carotid: smooth with rapid upstroke and slower down stroke
Abnormal
Temporal: Tender, Edematous, Hardened or Redness around Artery
Carotid: Alternations in Amplitude of pulse peak, distortion of upstroke or downstroke.
Non cardiac causes of this symptom include: Anemia, bone fractures, a tight cast, Raynaud’s disease, dehydration, hypothermia
Delayed Capillary Refill
How long does it take for a finger to return to normal color after capillary refill
< 2 sec
Pain associated with this test maybe from the following diseases:
Pyelonephritis urinary tract infection (UTI)
Glomerulonephritis
Nephrolithiasis (Kidney Stones)
Percussion of the Costovertebral Angle
Pitting Edema test
Press for 5 seconds
1+ = 2mm depth
2+ = 4mm depth
3+ = 6mm depth
4+ = 8mm depth
Name disease associated with abnormal findings
DTV, Venous Insufficiency, CHF, Kidney Disease
Access for appendicitis at this point
When is the pain felt the most during this test
McBurneys point
It’s located 1.5–2 inches (3.8–5.1 cm) to the right of the navel, midway between the belly button and the right anterior superior iliac spine
More pain is felt on the release of pressure than during the pressure
Abnormal findings of the Allen’s test:
Capillary refill of the palm takes more than 6 seconds.
Causes of Abnormal findings
PAD Perifial Artery Disease
Raynaud’s disease
Compression subclavian artery / vein
Palpate the Gallbladder area Medial to the midclavicular line.
Instruct take deep breath and Provider palpates Gallbladder
What is a positive for this test? AKA Murphy’s sign
Causes of a positive for this test
Sudden stopping of breathing caused by sharp pain
Cholecystitis
Cholelithias (Gallbladder Stone)
If able to palpate the Gallbladder but it is not tender what maybe the cause?
Common Bile Duct Obstruction
No response or diminished response to evaluation deep tendon reflexes (Bi & Triceps)
Causes
No response: Calcium or Magnesium excesses, Hypothyroidism, Spina bifida or Gullain-Barre Syndrome
Hyperactive response to evaluation deep tendon reflexes (Bi & Triceps)
Causes
Calcium/ Magnesium Deficits, Hyperthyroidism, Spinal Cord Injury
Aortic Stenosis, hypovolemia, Hypertension
Atrial Fibrillation
Atherosclerosis
Heart Failure
Are associated with this pulse finding
Abnormal carotid pulse
Murphy’s sign is associated with this organ
What is Murphy’s sign
Gallbladder
Sudden stop of Inspiration with palpation of URQ
