Exam 1 Study Guide Flashcards
1
Q
physical assessment technique order
A
inspection, palpation, percussion, auscultation
2
Q
inspection
A
- Concentrated watching
- Using senses of vision, smell & hearing to observe or detect normal/abnormal findings
- Begins the moment you meet the client
- Always comes FIRST!
- Precedes palpation, percussion & auscultation
- Focused inspection takes time-Hold hands behind your back
3
Q
technique of inspection
A
- Make sure room is a comfortable temperature
- Use good lighting and adequate exposure
- Occasionally requires the use of certain instruments (otoscope, ophthalmoscope, penlight, nasal speculum, etc)
- Compare the right and left sides of the body
- Note color, patterns, size, location, consistency, symmetry, movement, behavior, odors, or sound
4
Q
palpation
A
- Applies the sense of touch to assess for certain characteristics:
- Texture (rough/smooth)
- Temperature (warm/cold)
- Moisture (dry/wet)
- Organ location and size
- Swelling
- Vibrations or pulsations
- Rigidity or spasticity
- Presence of lumps or masses
- Presence of tenderness or pain
5
Q
parts of hand used in palpation
A
- Fingertips
- Fine tactile
discriminations: swelling,
pulses, texture,
consistency, shape, size,
crepitus (air under the
skin)
- Fine tactile
- A grasping action of the fingers & thumbs
- Detects position, shape,
and consistency of an
organ or mass
- Detects position, shape,
- Ulnar or base of fingers or ulnar surface
- Vibrations
- Dorsal (back) surface
- Temperature of the skin
6
Q
light palpation
A
- Place dominant hand lightly on surface
- Use a slow, systematic technique
- Apply little or no depression
- Feel the surface structures in a circular motion
- Use to feel for pulses, tenderness, temperature, surface skin texture, & moisture
7
Q
deep palpation
A
- Place dominant hand on skin surface and nondominant hand on top of your dominant hand to apply intermittent pressure
8
Q
bimanual palpation
A
- Use two hands, place one on each side of the body part (uterus, spleen, breast, kidneys) being palpated
- Use one hand to apply pressure and the other hand to feel the structure
- Envelop or capture the body part/organ
- Note location, size, shape, consistency, and mobility of structures
9
Q
percussion
A
- Involves tapping body parts with short, sharp strokes to produce sound waves
- Sound waves or vibrations enable the examiner to assess underlying structures
- Strokes yield an audible vibration
10
Q
uses of percussions
A
- Mapping out the location & size of organs
- Signaling density of structures
- Detecting abnormal masses (if superficial)
- Eliciting deep tendon reflexes
11
Q
technique of indirect percussion (MOST COMMON)
A
- Place the distal joint of the middle finger of nondominant hand on body part
- Keep other fingers off the body part being percussed
- Use pad of middle finger of the dominant hand to strike middle finger of nondominant hand that is placed on body part
- Withdraw finger immediately to avoid damping tone
- Deliver two quick taps and listen carefully to tone
- Use quick, sharp taps by quickly flexing wrist, not forearm
12
Q
auscultation
A
- Requires use of stethoscope to listen for
- Heart sounds
- Movement of blood
through the
cardiovascular system - Movement of the bowel
- Movement of air through
the respiratory tract
- Stethoscope is used because sounds are NOT audible to human ear
- It does not magnify the sound but blocks out extraneous room sounds
13
Q
diaphragm of stethoscope
A
- Use diaphragm for high pitched sounds (apply firmly)
- Normal heart sounds
- Breath sounds
- Bowel sounds
14
Q
bell of stethescope
A
- Use bell for low pitched sounds (apply lightly)
- Abnormal heart sounds (murmurs)
- Extra heart sounds (S3, S4)
- Bruits (blowing sounds)
15
Q
how do you correctly measure radial heart rate?
A
- measure pulse by counting for 30 seconds and then multiplying by 2 (start at zero)
- use pads of first 2 or 3 fingers
- if irregular count for 1 min
16
Q
how do you correctly measure the respiratory rate?
A
- Inspect & count respiratory rate while palpating the radial pulse
- Observe the rise and fall of the chest
- Count respirations for ONE FULL MINUTE
- Normal range adults:10-20 or 12-18/minute
- Tachypnea: >20/minute
- Bradypnea: <8-12/minute
17
Q
pulse characteristics: rate
A
- Pulse volume = stroke volume
- Contraction of left ventricle
- Forcing wall to dilate
- Pressure wave felt in periphery
- Varies across lifespan
- Bradycardia
- Pulse <50 bpm
- Tachycardia
- Pulse >100 bpm
18
Q
pulse characteristic: rhythm
A
- Regular, even tempo and pattern
- Regular intervals
between beats - Common irregularity is
sinus arrhythmia (rate
varies with respiratory
cycle)
- Regular intervals
- If pulse is irregular: Auscultate (listen) for the apical pulse
- Count for one full
minute
- Count for one full
- Location: 5th intercostal space-left, midclavicular line (5th ICP-MCL)
- use apical pulse when the client has a history of heart problems or is taking heart meds
19
Q
pulse characteristics: force
A
- 0 Absent
- 1+ Thready/Weak
- Easy to obliterate (barely touch it and can’t hear it anymore)
- 2+ Normal
- Obliterates with
moderate pressure
- Obliterates with
- 3+ Full/Bounding
- Unable to obliterate or
requires firm pressure
- Unable to obliterate or
20
Q
what is blood pressure?
A
- Measurement of pressure of blood in the arteries when ventricle are contracted (systole) & when ventricles are relaxed (diastole)
21
Q
systolic
A
- working phase
- normal: <120 mmHG
- maximum pressure point
22
Q
diastolic
A
- resting phase
- normal: <80 mmHG
23
Q
orthostatic bp
A
- Drop of 20 mmHg or more from the recorded sitting systolic BP OR a drop of 10mmHG from the recorded diastolic BP
- BP drops when they stand up after they were laying down
24
Q
why do we need to have the correct BP cuff size?
A
- The width of the cuff bladder should equal 40% of the circumference of the person’s arm
- The length of the bladder should equal 80% of this circumference
- A cuff that is too narrow yields a falsely high BP
25
4 components of General Survey
- physical appearance
- body structure
- mobility
- behavior
26
physical appearance
◦Age
◦Appears stated age
◦Sex
◦Sexual development is appropriate for age
◦If patient is transgender, note stage of transformation
◦Level of consciousness
◦Alert & oriented to person, place, time & situation
◦Attend to your questions & responds appropriately
◦Skin color
◦Tone is even, skin is intact
◦Note tattoos & piercings
◦Facial features
◦Symmetric with movement
◦Overall appearance
◦No signs of acute distress are present
27
Body structure
◦Stature
◦Height appears normal for age and genetic heritage
◦Nutrition
◦Weight appears normal for height and body build; fat distribution is even (if weight is carried around their abdomen and they are more apple shaped --> more prone to cardiac issues
◦Symmetry
◦Body parts look equal bilaterally and are in relative proportion
◦Posture
◦Stands comfortably erect & appropriate for age
◦Note normal ‘plumb’ line --> look @ the side of their body, is it straight?
◦Position
◦Sits comfortably, arms relaxed, head turned towards examiner
◦Body Build/Contour
◦Arm span (fingertip to fingertip) = height
◦Body length from crown to pubis = length from pubis to sole
◦ Obvious deformities
◦ Note any congenital or acquired defects
28
Mobility
◦Gait (how they stand and walk)
◦Base is as wide as the shoulder width
◦Walk is smooth, even, and well-balanced without assistance
◦Associated movements (symmetric arm swing) are present
◦Range of Motion
◦Full mobility for each joint
◦Movement is deliberate, accurate, smooth, and coordinated
◦No involuntary movement
29
behavior
◦Facial expression
◦ Maintains eye contact
◦ Expressions are appropriate to situation
◦Mood and affect
◦ Person is comfortable and cooperative
◦ Interacts pleasantly
◦Speech
◦ Articulation is clear & understandable
◦Speech pattern
◦ Stream of talking is fluent
◦ Conveys ideas clearly
◦ Communicates easily
◦Dress
◦ Clothing is appropriate to climate, culture, and age group
◦ Clothing looks clean & fits appropriately
◦Personal hygiene
◦ Appears clean and well-groomed for age, occupation, and socio-economic group
◦ Hair is groomed
30
genogram
- how family history is reported
- Identify illnesses such as: heart disease, high BP,
stroke, DM, blood disorders, sickle-cell anemia, cancer, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and TB
- age and health of client's blood relatives
- cause of death of blood relatives
- health of spouse and children
31
components of mental status assessment
- Systematic check of emotional and cognitive functioning
- Four main headings (ABCT)
Appearance
Behavior
Cognition
Thought Processes
- Perform a full mental status exam when you discover any abnormality in affect or behavior and in the following situations:
Initial brief screening suggest an anxiety disorder or depression
Family members are concerned about a person’s behavioral changes
Brain lesions
Aphasia (can't speak)
Symptoms of Psychiatric illness, especially with acute onset
32
Appearance -- Mental status
◦Appearance
◦Posture & position
◦Erect & relaxed
◦Body Movements
◦Voluntary, deliberate, coordinated, smooth, even
◦Dress
◦Appropriate for setting, season, age, gender, & social group
◦Fits & worn properly
◦Grooming & hygiene
◦Clean, well-groomed
◦Hair neat & clean
◦You are looking for a CHANGE in appearance
◦Pupils
◦Note size & reaction to light
- should be round
- anywhere from 2 mm up to 6 or 7 mm
- shine light -->it should constrict
33
behavior -- mental status
LOC
Awake, alert, & aware of stimuli from the environment
Responds appropriately
Facial expression
Look is appropriate to the situation
Comfortable eye contact unless precluded by cultural norm
Speech
Speech is effortless
Pace is moderate, stream is fluent
Articulation is clear
Word choice is effortless and appropriate to educational level
Mood & affect
Appropriate to person’s place & condition
Ask “how do you feel today?” or “how do you usually feel?”
34
cognitive fxn -- mental status
Orientation
Person, place & time
Attention span
Checking ability to complete a thought without wondering
Give a series of instructions to follow
Recent memory
Ask recent memory question like 24-hour diet recall
New learning
Four unrelated words test
Give 4 unrelated words (have semantic & phonetic diversity)
After 5 minutes, ask to recall
After 10 minutes, ask to recall
After 30 minutes, ask to recall
35
thought processes and perceptions -- mental status
◦Thought Processes
◦Ask yourself “does this person make sense?” & “can I follow what they are saying?”
◦Thought Content
◦What the person says should be consistent & logical
◦Perceptions
◦The person should be consistently aware of reality
36
what is the mini-mental exam?
◦Simplified scored form of the cognitive functions of the mental status examination
◦Quick & easy
◦Contains 11 questions
◦Requires 5-10 minutes to administer
◦Used for initial and serial measurement
◦Maximum score is 30
◦Normal mental status = 27
◦No cognitive impairment = 24-30
◦Mild cognitive impairment =18-23
◦Severe cognitive impairment = 0-17
- 27-30 = normal
37
screen for anxiety disorders
◦Can ask the first 2 questions from the Generalized Anxiety
Disorder scale (GAD)
◦If the answers yield positive results, then administer the full
scale
38
screen for depression
◦Ask 2 questions from the Patient Health Questionnaire-1 (PHQ-2)
◦Works as a screening tool for depression and measures the severity of depression
39
screen for suicidal thoughts
◦Begins with general questions
◦If you hear affirmative answers...move to more specific questions
40
supplemental mental status examination
◦Mini-Cog
◦Screens for cognitive impairment
◦Takes 3-5 minutes to administer
◦Not influenced by the person’s educational level
◦Screens cognitive impairment in otherwise healthy older adults
◦Consists of 3-item recall test & a clock-drawing test
- ppl w/ cog impairment = draw backwards
41
at the beginning of an assessment, what should you say?
What is your concern at this time? What brings you in today?
42
how do you close the assessment?
that concludes my assessment. Is there anything else you’d like to add or did I miss something
43
subjective data
- what the person says during history taking
44
objective data
- what you as the health professional observe during the physical examination
45
what is the initial step in collecting objective data?
IDK
46
What valve sounds are heard at the base?
- Aortic and pulmonic valve
- S2
47
What valve sounds are heard at the apex?
- tricuspid and mitral
- S1
48
Aortic valve location
- 2nd right interspace
49
Pulmonic valve location
- 2nd left interspace
50
Tricuspid valve location
- left lower eternal border; 5th interspace
51
Mitral valve location
- 5th interspace left midclavicular line
52
Why do we use APTM?
- to auscultate the valve sounds
- use diaphragm and bell
53
What is the exact order to correctly auscultate the carotid artery?
• Auscultate carotid arteries (for people middle age or older or who show signs of CVD) for a bruit
- Keep neck in neutral position
- Angle of jaw
- Midcervical area
- Base of neck
- Use bell of stethoscope
- Ask client to take a breath, exhale, & hold breath briefly
54
Culturally competent
- implies that caregivers understand and attend to the total context of the individuals situation
55
How do we provide culturally competent care? Why is it important?
- ask the patient about their values and beliefs
- important because we’ll know how to treat the patient
56
Culturally sensitive
- implies that caregivers possess some basic knowledge of and constructive attitudes towards the diverse cultural population
57
Culturally appropriate
- implies that caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care
58
What are the apices of the lungs and where are they?
- located right above the clavicles
59
Correct auscultation of the heart valves
- Aortic, pulmonic, tricuspid, mitral
60
Elder abuse: physical
◦When an elder is injured, assaulted, threatened with a weapon, or inappropriately restrained
- ex: tied them, restrained them w/ bed sheets, gave them sleeping pills
61
Elder abuse: sexual abuse
◦Sexual contact against the elder’s will including sexual contact with the person unable to understand the act or communicate consent
62
Elder abuse: Psychological or emotional abuse
◦includes verbal and nonverbal behavior meant to inflict fear and distress. It includes humiliation, embarrassment, controlling behavior, social isolation, and damaging/destroying property
63
Elder abuse: financial abuse
◦Unauthorized or improper use of the elder’s resources for monetary or personal benefit, profit, or gain such as forgery, theft, or improper use of guardianship or power of attorney
64
Elder abuse: unintentional
- forgetting to take them to their doctors appointment
- forgetting to give them their meds
- unintentional but causes harm
65
What is the abuse assessment screen? Why would we use it and who do we give it to?
- used to detect abuse in patients
- use it to see if ppl have been abused or are being actively abused
-give it to ppl we think are being abused
66
Correct order of assessing a patient
- temp, pulse, respiration, blood pressure
67
Why do we use the mini-mental exam? What do the results mean?
- tests cognitive fxns of the mental status examination
◦Maximum score is 30
◦Normal mental status = 27
◦No cognitive impairment = 24-30
◦Mild cognitive impairment =18-23
◦Severe cognitive impairment = 0-17
- 27-30 is normal
68
Normal breath sounds
- up is inspiration and down is expiration
- bronchial (tracheal): short inspiration and long expiration
- bronchovesicular: equal
- vesicular: long inspiration and short expiration
69
Voice sounds
- Bronchophony: Normal = soft, muffled, & indistinct sound (say 99 or blue moon)
- Egophony: Normal = hear “eeeeeeee”
- Whispered pectoriloquy: Normal = faint, muffled, & almost inaudible (whisper abc or 123)
70
How do we assess voice sounds?
- auscultate side to side top to bottom
71
Symmetric chest expansion
- hands make a W and should expand and come back in at the same time
- used to see if breathing is normal and if something is wrong on either side of your lung
72
Base of heart
- located near 2nd intercostal space
73
Apex of heart
- located near 5th intercostal space, 7-9 cm from mid-sternal line
74
Atrioventricular valves (AV)
- entrance of ventricles
- tricuspid (right) and bicuspid/mitral (left)
75
Semilunar valves
- located at exit of ventricles
- pulmonic (right)
- aortic (left)
76
Cardiac output
• Amount of blood pumped by ventricles during specified period of time - usually 1 minute
• Determined by stroke volume (SV) multiplied by heart rate (R)
• FORMULA: SV x R = CO
• NORMAL ADULT CO: 4-6L/min
77
Palpating carotid artery
- Place pads of fingers medial to sternomastoid muscle
- Avoid excess pressure
- Note amplitude & contour
- Palpate each individually
78
Precordium
- Inspect anterior chest
- Look for visible apical impulse & any abnormal pulsations (heave or lift)
- When apical impulse is visible, located 4th-5th ICS MCL
- Palpate apical impulse
- Supine position
- Place one finger at 4-5th ICS MCL
- Ask patient to “exhale & hold it” (felt best at the end of expiration)
- Best measured in the left lateral position
- Note: Location Size Amplitude Duration
79
Palpate across precordium
- Use palmar aspects of four fingers
- Gently palpate
- apex
- left sternal border
- base
- If pulsations are present, note timing
80
Auscultate rate and rhythm
- Usually 50-95 bpm
- Rhythm should be regular
- If irregular, check for a pulse deficit
- Auscultate apical beat & palpate radial pulse simultaneously
81
Identify S1 and S2
- S1 is louder than S2 at the apex
- S2 is louder than S1 at the base
- S1 coincides with the carotid artery pulse
82
Listen to S1
- Associated with the closure of AV valves
- Heard loudest at the apex
- Can be heard in any position
- Heard equally well with inspiration & expiration
- Identify if sound is
- Normal
- Accentuated
- Split
83
Listen to S2
- Associated with closure of the semilunar valves
- Heard loudest at the base
- Split S2 is a normal phenomenon and occurs toward the end of inspiration
84
Auscultate for extra heart sounds
- Use diaphragm first & then bell
- S3: may be a sign of heart failure or volume overload
S4: May occur with CAD
- Midsystolic click
- Heard during systole
- Associated with mitral valve prolapse
85
Auscultate for murmurs
- Use diaphragm & bell over ALL sites
- Describe using the following terms
- Timing
- Loudness
- i
- ii
- iii
- iv
- v
- vi
- Pitch
- Pattern
- Quality
- Location
- Radiation
- Posture
86
Posture for auscultating murmurs
- Murmurs may disappear or become enhanced with position changes
- Supine
- Left lateral
- Sitting, leaning forward & exhaling
- Some murmurs are common in healthy children or adolescents
- These are called innocent or functional
87
Cardiac cycle: diastole (resting)
- AV valves (tricuspid & mitral) are open
• Ventricles relaxed
• Early or Protodiastolic filling (first passive filling)
• Presystole/Atrial systole or “Atrial kick”
- Final active filling phase
88
Cardiac cycle: systole (working)
- AV valves (tricuspid & mitral) shut making the fist heart sound (S1)
• Ventricles contract
• Aortic and pulmonic valves open
• Blood is ejected
• Semilunar valves (aortic and pulmonic) shut (S2)
89
Inspect posterior chest -- respiratory
- Thoracic cage
- Shape and configuration of chest wall
- Downward slope
- 45 degrees
- Anteroposterior/transverse diameter
- AP < transverse front to back is 1/2 of side to side
- 1:2
- Position of person
- Position it takes for the person to breath
- Skin color and condition Respiratory effort
- Trachea: Should be midline
90
Palpate posterior chest- - respiratory
- Symmetric expansion
* Tactile (or vocal) fremitus
- Technique
- Use palmar base/ball of fingers or ulnar edge
- Have pt say “ninety-nine” or “blue moon”
- Palpate the entire chest wall
- Decrease=obstruction transmission of vibrations
- Posterior Chest—Percuss
* Predominant note over lung fields
* Diaphragmatic excursion: percuss to map out lower lung border in inspiration and expiration
91
Percuss posterior chest -- respiratory
- Determine the predominant note over lung fields
- Start at the apices and move down
- Percuss in the interspaces
- Percuss in 5cm intervals
- A resonance sound (clear & hollow) is predominate in healthy lungs in an adult
92
Auscultate posterior chest -- respiratory
- Breath sounds
- Evaluate presence and quality of normal breath sounds
- Bronchial (tracheal) breath sounds
- Bronchovesicular breath sounds
- Vesicular breath sounds
* Adventitious sounds
- Sounds that are NOT normally heard: Crackles, Wheeze, Atelectatic crackles
93
inspect anterior chest -- respiratory
* Shape and configuration of chest wall
* Costal angle is 90 degrees
* Facial expression of patient
* Level of consciousness
* Should be alert & cooperative
* Skin color and condition
* Free from pallor & cyanosis
* Quality of respirations
* Even, regular and produce no noise
* No retraction or bulging of rib interspaces
* No use of accessory muscles
94
palpate anterior chest -- respiratory
* Symmetric chest expansion
* Tactile fremitus
* Palpate the anterior chest wall
Anterior Chest—Percuss
* Predominant note over lung fields
* Borders of cardiac dullness
95
percuss anterior chest -- respiratory
* Determine the predominant note over lung fields
* Identify the borders of cardiac dullness
96
auscultate anterior chest -- respiratory
- breath sounds
- abnormal breath sounds
- adventitious sounds
97
barrel chest
1 to 1 ratio
98
pectus excavatum
chest looks like it's pointing inward
99
pectus carinatum
chest pushes outward
100
kyphosis
upper back is super rounded
101
abnormal respirations
* Sigh
* Tachypnea: fast breathing
* Bradypnea: slow breathing
* Hyperventilation: excessive deepness
* Hypoventilation: lungs not fully expanding
* Cheyne-Stokes respiration: agonal
* Biot’s respiration: agonal
* Chronic obstructive breathing
