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nursing skills > General Survey and Physical Assessment > Flashcards

General Survey and Physical Assessment Flashcards

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1
Q

A comprehensive health assessment always begins with a general survey. What are the observational components to a general survey?

A

observation of clients general apprearance, mental status,

measurement of vital signs, height, weight, and waist circumference.

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2
Q

In a general survey, what is looked at when inspecting the head?

A 
hair and face
eyes and vision
ears and hearing 
nose
mouth and oropharynx
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3
Q

In a general survey, what is looked at when inspecting the neck?

A 
muscles
lymph nodes
trachea 
thyroid gland
carotid arteries
neck veins
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4
Q

In a general survey, what is looked at when inspecting the upper extremities?

A 
skin and nails
muscle strength and tone 
joint range of motion 
brachial and radial pulses
sensation
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5
Q

In a general survey, what is looked at when inspecting the chest and back?

A 
skin
thorax shape and size
lungs 
heart
spinal column 
breast and axillae
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6
Q

In a general survey, what is looked at when inspecting the abdomen?

A

skin
abdominal sounds
femoral pulses

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7
Q

In a general survey, what is looked at when inspecting the external genitals?

A

only external genitals

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8
Q

In a general survey, what is looked at when inspecting the anus?

A

only anus

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9
Q

In a general survey, what is looked at when inspecting the lower extremities?

A

skin and toenails
gait and balance
joint range of motion
popliteal, posterior tibial, and dorsalis pedis pulses

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10
Q

For a physical health examination, how can a nurse prepare the client?

A

by introducing self and explaining procedure, reason of exam, and what client can exprect

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11
Q

For a physical health examination, how can a nurse prepare the environment?

A

by obtaining all necessary equipment, including adequate lighting and drapes for privacy, and adjusting room temp

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12
Q

What is inspection?

A

visual examination

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13
Q

what is palpation?

A

examining body using touch

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14
Q

What is palpation used to determine?

A 
texture
temperature
vibration
position, size, consistency, and mobility of organ masses
distention 
presence and rate of peripheral pulses 
tenderness or pain
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15
Q

What are the 2 types of palpation?

A

light and

deep-two handed (bimanually) or one handed

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16
Q

What is percussion?

A

body surface is struck to elicit sounds that can be head or vibration that can be felt.

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17
Q

What are the 2 types of percussion?

A

direct and indirect

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18
Q

Flatness

A

an extremely dull sound head when percussing over very dense tissue

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19
Q

Dullness

A

a thudlike sound heard with percussion over dense tissue

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20
Q

Resonance

A

hollow sound (lung filled with air)

21
Q

Hyperresonance

A

booming

22
Q

Tympany

A

musical or drumlike sound produced when percussing an air-filled organ (eg.stomach)

23
Q

What is auscultation?

A

the process of listening to sounds produced within the body

24
Q

What is pitch?

A

the frequency of the vibrations (number of vibrations/sec)

25
Q

What is intensity?

A

(AMPLITUDE) refers to the loudness or softness of a sound

26
Q

What is duration?

A

sounds length

27
Q

What are the different vital signs?

A

measurements of temperature, pulse, respirations, blood pressure, and oxygen saturation.

28
Q

1kg=___lbs.

A

2.2

29
Q

How do you perform direct percussion?

A

nurse strikes area to be percussed directly with pads of 2,3 or 4 fingers or with the middle finger.
-strikes are rappid

30
Q

How do you perform indirect percussion?

A

Striking of an object (eg.finger) held against the body area,

31
Q

How do you perform light palpation?

A

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

32
Q

How do you perform deep palpation?

A

top hand applies pressure while lower hand remains relaxed to perceive the tactile sensation

33
Q

When assessing appearance and mental status, what are you observing?

A
  1. Observe body build, height, weight in relation to age, lifestyle and health
  2. Observe posture and gait, standing sitting and walking,
  3. Observe overall hygiene and grooming
  4. note body and breathe odor
  5. Observe signs of distress in posture or facial expressions.
  6. note obvious signs of health or illness
  7. Assess clients attitude (frame of mind)
  8. note clients affect/mood; assess appropriateness of responses.
  9. Listen to quality of speech and quantity
  10. Listen for relevance and organization of thoughts.
34
Q

What does the integumentary system consist of?

A

hair, nails, and skin

35
Q

What is vitiligo?

A

patches of hypopigmented skin

36
Q

What is albinism?>

A

complete or partial lack of melanin in the skin, hair, and eyes

37
Q

What is edema?

A

excess interstitial fluid

  • makes skin appear swollen, shiny, and taut,
  • tends to blanch color
38
Q

What is a skin lesion?

A

an alteration in a clients normal skin appearance

39
Q

What is the difference between primary skin lesions and secondary skin lesions?

A

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

40
Q

What is pallor?

A

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.
41
Q

What is cyanosis?

A

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.
42
Q

What is jaundice?

A

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
43
Q

What is Erythema?

A

redness associated with a variety off skin disorders

44
Q

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?

A

Atrophy

examples: striae, aged skin

45
Q

What is is called when the superficial epidermis is wearing away causing a moist, shallow, depression?

A

Erosion

eg. scratch marks, ruptured vesicle

46
Q

How come erosions dont scar?

A

because they do not extend into the dermis

47
Q

What is it called when an area of the epidermis is rough, thickened, and hardened resulting from chronic irritation such as scratching or rubbing?

A

Lichenification

eg. chronic dermititis

48
Q

What is it called when flakes of greasy, karatinized skin tissue sheds?

A

Scales

eg. dry skin, dandruff, psoriasis and eczema

49
Q

What is the color and texture of scales?

A

color-white, gray, or silver

texture-varies from fine to thick

nursing skills (10 decks)

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