Exam 1 Study Guide Flashcards
physical assessment technique order
inspection, palpation, percussion, auscultation
inspection
- 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
technique of inspection
- 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
palpation
- 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
parts of hand used in palpation
- 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
light palpation
- 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
deep palpation
- Place dominant hand on skin surface and nondominant hand on top of your dominant hand to apply intermittent pressure
bimanual palpation
- 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
percussion
- 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
uses of percussions
- Mapping out the location & size of organs
- Signaling density of structures
- Detecting abnormal masses (if superficial)
- Eliciting deep tendon reflexes
technique of indirect percussion (MOST COMMON)
- 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
auscultation
- 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
diaphragm of stethoscope
- Use diaphragm for high pitched sounds (apply firmly)
- Normal heart sounds
- Breath sounds
- Bowel sounds
bell of stethescope
- Use bell for low pitched sounds (apply lightly)
- Abnormal heart sounds (murmurs)
- Extra heart sounds (S3, S4)
- Bruits (blowing sounds)
how do you correctly measure radial heart rate?
- 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
how do you correctly measure the respiratory rate?
- 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
pulse characteristics: rate
- 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
pulse characteristic: rhythm
- 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
pulse characteristics: force
- 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
what is blood pressure?
- Measurement of pressure of blood in the arteries when ventricle are contracted (systole) & when ventricles are relaxed (diastole)
systolic
- working phase
- normal: <120 mmHG
- maximum pressure point
diastolic
- resting phase
- normal: <80 mmHG
orthostatic bp
- 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
why do we need to have the correct BP cuff size?
- 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
4 components of General Survey
- physical appearance
- body structure
- mobility
- behavior
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
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
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
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
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
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
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
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?”
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
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
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
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
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
screen for suicidal thoughts
◦Begins with general questions
◦If you hear affirmative answers…move to more specific questions
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
