Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing ( Lab Values) > health and physical assessment of adults > Flashcards

health and physical assessment of adults Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Mental Health flashcards Nursing Management of Care flashcards NCLEX-PN® flashcards NCLEX-RN® flashcards Nursing Fundamentals flashcards Nursing Pediatrics flashcards Nursing Safety & Infection flashcards Nursing Pharmacology flashcards Nursing Maternity flashcards Family Nurse Practitioner (FNP) flashcards
1
Q

What does SOAP stand for?

A

subjective, objective, assessment and plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How to obtain the information?

A

Health history- chief complaint, history of present illness, general state of health, social history, family history, domestic violence

Mental status exam

Cognitive level

Physical exam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What do you ask in social history?

A

drugs, tobacco, alcohol, sex practice, tattoos, piercing, traveling history, work environment to assess occupational hazard

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What do you ask in family history?

A

Disease in blood related relatives and spouse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What to ask in mental exam?

A

Appearance- grooming, hygiene, dressing, posture, body movement

Behavior

  • level of consciousness (are they alert and aware; are they interacting with the environment)
  • facial expression and body movement (eye contact; is there facial and body movement appropriate for the situation)
  • Speech ( cohesive; can they articulate and appropriate)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What to ask in cognitive level of function

A

12-2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Is health history subjective or objective

A

subjective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Is physical exam subjective or objective?

A

objective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the order of the physical exam?

A

Inspect, palpate, percussion and auscultation

except the abdominal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Difference between light and deep palaption?

A

Light is for surface problem using one hand and 2-3 finger and deep use one hand on top of the other and use all the fingers to place pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Types of percussion?

A

learn

resonance, hyper resonance, tympani, dullness, and flatness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

is vitals included in the physical exam

A

yes

also radial pulse, height and weight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How to check for cyanosis, jaundice, bleeding and inflammation in dark skin?

A

cyanosis- the conductive will be pale, the lip and tongue will be grey, the nail bed, palm and sole will be blue

jaundice - the sclera is yellow and the mucous membrane

Bleeding - discoloration and edema; compare with unaffected side

Inflammation- taut, warm and shiny

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What do you recommend for skin assessment?

A

ABCDE

Asymmetry
Border irregularity
Color variance
Diameter greater than 6 mm
Evolve in color, size or shape
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Assessment of head?

A

Inspect size, symmetry, shape, tenderness, mass

Palpate the temporal artery, the maxillary and frontal sinus

Inspect the temporomandibular joint: ask to move jaw side to side

any crepitus, tenderness or limited range of motion is problem

tests cranial nerve number 5 - trigeminal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Assess the face?

A

tenderness, edema, involuntary movement, shape, size and symmetry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Assess the neck?

A

symmetry of the accessory muscle, palpate the trachea ( should be in the middle and not deviated), the thyroid gland ( when patient swallows the gland should move up, palpate with anterior and posterior approach usually not palpable, if then auscultate for bruit)

Test cranial nerve 11 (accessory nerve)

shrug shoulder for trapezius and move chin to side against resistance for sternocleidomastoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Objective assessment of the eye?

A

assess eyebrow for symmetry, eyelid for ptsosis or drooping, eyelashes for equal distribution, exophthalmus for bulging of eye and enopthalmus for sunken eyes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are all the eye exams?

A 
snellen test
near vision
confrontation test
corneal light reflex
cover uncover
6 cardinal position/diagnostic position test
color vision
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what is the snellen test?

A

assess for distant vision/vision acuity

the client must be standing 20 feet away from the chart
can wear contact lense or glasses but not reading glasses

numerator is the person denominator is the normal eye or others

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What nerve does the snellen test assess for?

A

optic nerve (nerve 2)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the near vision test?

A

handheld device held 14 inches from the patient that includes various sizes of print or ask the patient to read the magazine

cover the eye not being used

normal result is 14/14

testes cranial nerve 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

what is the confrontation test

A

examines for peripheral vision

client covers one eye and looks straight ahead while the nruse covers the opposite eye

the nurses advances finger or small object from periphery from several direction

the client should see the object at the same time as the nurse

tests for cranial nerve 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

what is the corneal light reflex?

A

assess for parallel alignment of the axes of the eye

each eye tested separately

nurse hold penlight 12 inches from the patient and reflect the light at the middle of the two eye; there should be a reflection (red dot) on the cornea at the same position on both eye

the patient is looking straight ahead

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is the cover uncover test

A

checks for slight degrees of deviated alignment; assess for strabismus (when the eye does not align with each other)

the patient will cover one eye and look straight ahead
the uncovered eye should have steady fixed gaze

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

what is the 6 cardinal test

A

tests the 6 muscle sattaching the eyeball to the orbit and serves to direct the eye in point of interest

head is still and moves both eyes following a object

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

which nerves do the 6 cranial test assess for?

A

3, 4 and 6

trochlear, abducens and oclomotor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

what is the color vision test

A

uses the ishihara chart in which a number or letter needs to be picked out of a complex and colorful picture

diagnosis of red-green color blindness not blue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

how should the pupils be

A

round and equal
constriction upon light and dilation in darkness
light being shone which causes constriction is called direct light

light not being shown with constriciton is called consensual

30
Q

How should sclera be?

A

sclera should be white

in dark skin people they may have yellow scelera which is normal with dots

31
Q

how should cornea be

A

transparent, shiny, smooth and bright

cloudy can indicate accident or injury

32
Q

opthalmoscopy or fundoscopy

A

patient in dark room to dilate the pupil
assess for external structures and interior of the eye
the instrument is held in the right hand if right eye is being tested
client looks ahead
the instrument is 12-15 inches away
as instrument is directed at the eye a red glare is seen in the pupil; if not then it means opacity of the lens

33
Q

how should optic disc, general background, macula and retinal vessels be

A

optic disc is round or oval, yellow cream orange to redish pink color

the general background the light to dark brown red
the retinal vessels should be visible without engorgement
the ma

34
Q

What do you assess in the ear?

A

size,shape, symmetry, pain, redness

35
Q

What do you assess in the external auditory meatus?

A

cerumen, pus, redness, pain, swelling

36
Q

how is sound transmitted?

A

bone or air conduction

37
Q

what is conductive hearing loss

A

when there is a physical obstruction of sound waves

38
Q

what is sensorineural hearing loss

A

defect of the cochlea or 8th cranial nerve

39
Q

what is mix hearing loss

A

mix of conductive and sensori

40
Q

what is the wisper test?

A

the examiner stands 1-2ft away from the client
the client the other ear
the examiner will cover mouth and whisper 2 syallabul wods
the client will state if they herd it
if the client did not that means there is fluid accumulation

41
Q

what is the watch test

A

tests of client can hear high acuity sounds

examiner will hold ticking watch 5 inches away from the testing ear

42
Q

what is tuning fork test

A

measures hearing on the basis of bone or air conduction

43
Q

what is a otoscopic exam

A

tests the ear

pull pinna up and back

44
Q

how does the normal external canal look?

A

pinkish intact without any lesions

there can be wax and hair

45
Q

how does the tympanic membrane look

A

it should in intact without any perforation or lesions

should be transparent, opaque and pearly grey

cone. of light reflex is 5 oclock on the right and 7 on the left

if membrane is retracted or bulging then the edges of the light reflex will diffuse

The otoscope is never introduced blindly
into the external canal because of the

46
Q

what is the vestibular assessment

A

assess for any imbalance in the air

Test for fallin aka rombergs

-client will close eyes and place feet together, slight sway or normal but excessive sway is positive rombergs

Past pointing

client sits down in front of the examiner and closes eyes and sticks both the index finger out

the examiner places index finger below the client, the client raises arms and places them back down when the examiners fingers are

Gaze Nystagmus

Client stares 30 degrees away and examiner looks for twitching

Dix-hallpike

Examiner turns client head 40 degrees and lies him down and check for nystagmis for 30 seconds

47
Q

how to check patency of the nostrils

A

close one nose and ask client to breath in and out through the other

48
Q

What is the rating of the tonsils?

A 
(0 is surgically
removed; 1 + is tonsils hidden within
pillars; 2 + is tonsils extending to the
pillars, 3 + is tonsils extending beyond
the pillars, 4 + is tonsils extending to
the midline)
49
Q

what should you recommend for dental care?

A

fluoride water

50
Q

What are the adventitious lungs sounds?

A 
fine crackles
medium crackles
coarse crackles
wheezing
rhonchi 
pleural rub
51
Q

What is fine crackles?

A

High pitch popping noise that comes at the end of the inspiration

Caused by: P, asthma, heart failure and restrictive pulmoary disease

52
Q

medium crackles?

A

Medium pitch popping sounds that comes in the middle of the inspiration .Worse than fine crackles.

Same condition as fine

53
Q

Coarse crackles

A

Low-pitched, bubbling or gurgling sounds that start early
in inspiration and extend into the first part of expiration.
Not cleared by cough.

Same as above, but condition is worse or
may be heard in terminally ill clients with
diminished gag reflex. Also heard in
pulmonary edema and pulmonary fibrosi

54
Q

wheezing

A

High-pitched, musical sound similar to a squeak. Heard
more commonly during expiration, but may also be heard
during inspiration. Occurs in small airways.

Heard in narrowed airway diseases such as
asthma

55
Q

rhonchi

A

Low-pitched, coarse, loud, low snoring or moaning tone.
Actually sounds like snoring. Heard primarily during
expiration, but may also be heard during inspiration.
Coughing may clear

Heard in disorders causing obstruction of
the trachea or bronchus, such as chronic
bronchitis

56
Q

Pleural rub

A

A superficial, low-pitched, coarse rubbing or grating
sound. Sounds like 2 surfaces rubbing together. Heard
throughout inspiration and expiration. Loudest over the
lower anterolateral surface. Not cleared by cough.

Heard in individuals with pleurisy
(inflammation of the pleural surfaces)

57
Q

What are the voice sounds?

A

Done with lung disease is suspected

Broncophony - ask to say ninety nine

nurse should hear muffle, soft, indistinct sounds

Egophony- say eeeee, nurse should hear eeeee

Whispered- whisper 1 2 3 nurse should hear faint, muffled and almost inaudible

58
Q

Auscultation of the heart?

A 
Auscultate heart rate and rhythm;
check for a pulse deficit (auscultate the
apical heartbeat while palpating an
artery) if an irregularity is noted.
c. Assess S1 (“lub”) and S2 (“dub”)
sounds, and listen for extra heart
sounds, as well as the presence of
murmurs (blowing or swooshing noise
that can be faint or loud
59
Q

How to check the peripheral vascular system?

A 
BP
Symmetry of arterial pulse
Carotid pulse (one at a time)
Listen for bruits 
Measure calf circumference and check for pretibial edema

Palpate superficial inguinal nodes
Check arteries of the extremities

60
Q

Check the breast

A

palpate with three fingers and also check the axillary nodes (should not be palpable)

61
Q

Order of the abdomen assessment

A

inspect, ausculatate, percussion and palapate

62
Q

How to auscultate abdomen

A

After inspection start the auscultation

Listen to all 4 quadrants starting with RLQ(hypo, hyper or normoactive)

Listen for 5 mins before stating absent sounds

Auscultate aorta, renal arteries, femoral and iliac to listen for bruits

63
Q

how to percuss the abdomen

A

predominantly tympani; dull over the liver and the spleen

Measure liver and spleen and make sure no pain from the kidney

64
Q

what is in the muskuskeletal assessment

A

only inspection and palpation

assess active and passive ROM

grade the muscle strenght

65
Q

Assess neurological system

A
  1. Assess cranial nerves
  2. Level of consciousness, pupils, coordination, reflex and sensory function
  3. Note mental and emotional status
  4. record vitals
66
Q

How to assess level of consciousness? (neuro)

A

Determine behavior

alert, confused, delirium, unconsciounsess, stupor and coma

In extreme levels use glascow coma scale

light touch if appropriate

67
Q

How to assess pupils?

neuro

A

size, equality, and reaction to light (brisk, slow and fixed)

brisk is rapid which is normal

68
Q

How to assess motor function ?

neuro

A 
. Assess for voluntary and involuntary, strenght 
movements and purposeful and
nonpurposeful movements.
c. This component of the neurological
examination may be performed during
assessment of the musculoskeletal
system
69
Q

How to assess cerebellar function ?

neuro

A

rombergs test, assess as clients walks in straight line

70
Q

How to assess coordination function ?

neuro

A

Assess by asking the client to perform
rapid alternating movements of the
hands (e.g., turning the hands over
and patting the knees continuously)

The nurse asks the client to touch the
nurse’s finger, then his or her own
nose; the client keeps the eyes open
and the nurse moves the finger to
different spots to ensure that the
client’s movements are smooth and
accurate.
c. Heel-to-shin test: Assist the client into a
supine position, then ask the client to
place the heel on the opposite knee and
run it down the shin; normally the
client moves the heel down the shin in
a straight line.
71
Q

how to assess sensory function ( neuro)?

A

Assess pain by applying sharp object

Assess light touch
Position sense- kinethesia; move tow or finger up and down and ask which one was moved
Stereognosis: Tests the client’s ability to
recognize objects placed in his or her
hand
Graphesthesia: Tests the client’s ability
to identify a number traced on the
client’s hand
Two-point discrimination: Tests the
client’s ability to discriminate 2
simultaneous pinpricks on the skin

Plantar reflec- a. A cutaneous (superficial) reflex is tested
with a pointed but not sharp object.
b. The sole of the client’s foot is stroked
from the heel, up the lateral side, and
then across the ball of the foot to the
medial side.
c. The normal response is plantar flexion
of all toes.

Bruzinki and kernigs sign for meningial irritation

DTR- biceps, triceps, ptella and achillies

Nursing ( Lab Values) (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions