General Survey and Physical Assessment Flashcards
A comprehensive health assessment always begins with a general survey. What are the observational components to a general survey?
observation of clients general apprearance, mental status,
measurement of vital signs, height, weight, and waist circumference.
In a general survey, what is looked at when inspecting the head?
hair and face eyes and vision ears and hearing nose mouth and oropharynx
In a general survey, what is looked at when inspecting the neck?
muscles lymph nodes trachea thyroid gland carotid arteries neck veins
In a general survey, what is looked at when inspecting the upper extremities?
skin and nails muscle strength and tone joint range of motion brachial and radial pulses sensation
In a general survey, what is looked at when inspecting the chest and back?
skin thorax shape and size lungs heart spinal column breast and axillae
In a general survey, what is looked at when inspecting the abdomen?
skin
abdominal sounds
femoral pulses
In a general survey, what is looked at when inspecting the external genitals?
only external genitals
In a general survey, what is looked at when inspecting the anus?
only anus
In a general survey, what is looked at when inspecting the lower extremities?
skin and toenails
gait and balance
joint range of motion
popliteal, posterior tibial, and dorsalis pedis pulses
For a physical health examination, how can a nurse prepare the client?
by introducing self and explaining procedure, reason of exam, and what client can exprect
For a physical health examination, how can a nurse prepare the environment?
by obtaining all necessary equipment, including adequate lighting and drapes for privacy, and adjusting room temp
What is inspection?
visual examination
what is palpation?
examining body using touch
What is palpation used to determine?
texture temperature vibration position, size, consistency, and mobility of organ masses distention presence and rate of peripheral pulses tenderness or pain
What are the 2 types of palpation?
light and
deep-two handed (bimanually) or one handed
What is percussion?
body surface is struck to elicit sounds that can be head or vibration that can be felt.
What are the 2 types of percussion?
direct and indirect
Flatness
an extremely dull sound head when percussing over very dense tissue
Dullness
a thudlike sound heard with percussion over dense tissue
Resonance
hollow sound (lung filled with air)
Hyperresonance
booming
Tympany
musical or drumlike sound produced when percussing an air-filled organ (eg.stomach)
What is auscultation?
the process of listening to sounds produced within the body
What is pitch?
the frequency of the vibrations (number of vibrations/sec)
What is intensity?
(AMPLITUDE) refers to the loudness or softness of a sound
What is duration?
sounds length
What are the different vital signs?
measurements of temperature, pulse, respirations, blood pressure, and oxygen saturation.
1kg=___lbs.
2.2
How do you perform direct percussion?
nurse strikes area to be percussed directly with pads of 2,3 or 4 fingers or with the middle finger.
-strikes are rappid
How do you perform indirect percussion?
Striking of an object (eg.finger) held against the body area,
How do you perform light palpation?
nurse extends the fingers of the dominant hand parallel to the skin surface and presses gently while moving hand in a circle.
-skin is slightly depressed
How do you perform deep palpation?
top hand applies pressure while lower hand remains relaxed to perceive the tactile sensation
When assessing appearance and mental status, what are you observing?
- Observe body build, height, weight in relation to age, lifestyle and health
- Observe posture and gait, standing sitting and walking,
- Observe overall hygiene and grooming
- note body and breathe odor
- Observe signs of distress in posture or facial expressions.
- note obvious signs of health or illness
- Assess clients attitude (frame of mind)
- note clients affect/mood; assess appropriateness of responses.
- Listen to quality of speech and quantity
- Listen for relevance and organization of thoughts.
What does the integumentary system consist of?
hair, nails, and skin
What is vitiligo?
patches of hypopigmented skin
What is albinism?>
complete or partial lack of melanin in the skin, hair, and eyes
What is edema?
excess interstitial fluid
- makes skin appear swollen, shiny, and taut,
- tends to blanch color
What is a skin lesion?
an alteration in a clients normal skin appearance
What is the difference between primary skin lesions and secondary skin lesions?
primary-response to a change in the external or internal environment of the skin
secondary- result from modifications such as chronicity, trauma, or infection of a primary skin lesion
What is pallor?
paleness
- absence of underlying red tones in skin and may be most readily seen in the buccal mucosa
- results from inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation.
What is cyanosis?
Blueish tinge
- most evident in the nail beds, lips, and buccal mucosa.
- in dark skinned clients, close inspection of the palpebral conjunctiva (linning of eyelid), palms, and soles.
What is jaundice?
Yellow tinge
- in sclera of the eyes and then in the mucous membrane and skin,
- if suspected, check posterior part of hard palate for yellowing
What is Erythema?
redness associated with a variety off skin disorders
What is a translucent, dry, paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin?
Atrophy
examples: striae, aged skin
What is is called when the superficial epidermis is wearing away causing a moist, shallow, depression?
Erosion
eg. scratch marks, ruptured vesicle
How come erosions dont scar?
because they do not extend into the dermis
What is it called when an area of the epidermis is rough, thickened, and hardened resulting from chronic irritation such as scratching or rubbing?
Lichenification
eg. chronic dermititis
What is it called when flakes of greasy, karatinized skin tissue sheds?
Scales
eg. dry skin, dandruff, psoriasis and eczema
What is the color and texture of scales?
color-white, gray, or silver
texture-varies from fine to thick
