Jen ch 30 Part I Flashcards
Alopecia
Partial or complete loss of hair; baldness
Adventitious sounds
Abnormal lung sounds heard with auscultation
Aphasia
Abnormal neurological condition in which language function is defective or absent; related to injury to speech center in cerebral cortex, causing receptive or expressive aphasia.
arcus senilis
Opaque ring, gray to white in color, that surrounds the periphery of the cornea. The condition is caused by deposits of fat granules in the cornea. Occurs primarily in older adults.
atrophied.
Wasted or reduced size or physiological activity of a part of the body caused by disease or other influences.
Borborygmi
Audible abdominal sounds produced by hyperactive intestinal peristalsis.
Bruit (pronounced “brewee”)
Abnormal sound or murmur heard while auscultating an organ, gland, or artery.
cerumen
Yellowish or brownish waxy secretion produced by sweat glands in the external ear.
clubbing
Bulging of the tissues at the nail base caused by insufficient oxygenation at the periphery, resulting from conditions such as chronic emphysema and congenital heart disease.
Conjunctivitis
Highly contagious eye infection. The crusty drainage that collects on eyelid margins can easily spread from one eye to the other.
Distention
the state of being stretched beyond normal dimensions
Ectropion
Eversion of the eyelid that exposes the conjunctival membrane and part of the eyeball.
Entropion
Condition in which the eyelid turns inward toward the eye.
Edema
Abnormal accumulation of fluid in interstitial spaces of tissues.
Erythema
Redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries; sunburn is an example.
Excoriation
Injury to the surface of the skin caused by abrasion.
Goniometer
an instrument used to measure angles, particularly range-of-motion angles of a joint.
Hypertonicity
Excessive tension of the arterial walls or muscles.
Hypotonicity
Reduced tension of the arterial walls or muscles.
Indurated
Hardened, usually used with reference to soft tissues becoming extremely firm but not as hard as bone.
Inspection
Method of physical examination by which the patient is visually systematically examined for appearance, structure, function, and behavior.
Integumentary system
The bodily system consisting of the skin and its associated structures, such as the hair, nails, sweat glands, and sebaceous glands.
jaundice
Yellow discoloration of the skin, mucous membranes, and sclera caused by greater-than-normal amounts of bilirubin in the blood.
Kyphosis
Exaggeration of the posterior curvature of the thoracic spine.
Lordosis
Increased lumbar curvature.
Murmurs
Blowing or whooshing sounds created by changes in blood flow through the heart or abnormalities in valve closure.
nystagmus
Rhythmic, oscillating motions of the eyes are called nystagmus. The to-and-fro motion is generally involuntary. Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often, but not necessarily, a sign of serious brain damage. Nystagmus can be a normal physiological response or a result of a pathologic problem.
olfaction
The sense of smell.
orthopnea
Abnormal condition in which a person must sit or stand to breathe comfortably.
osteoporosis
Disorder characterized by abnormal rarefaction of bone, occurring most frequently in postmenopausal women, sedentary or immobilized individuals, and patients on long-term steroid therapy.
ototoxicity
Ototoxicity is damage to the hearing or balance functions of the ear by drugs or chemicals.
palpation
Method of physical examination whereby the fingers or hands of the examiner are applied to the patient’s body to feel body parts underlying the skin.
percussion
Method of physical examination whereby the location, size, and density of a body part is determined by the tone obtained from the striking of short, sharp taps of the fingers.
peristalsis
Rhythmical contractions of the intestine that propel gastric contents through the length of the gastrointestinal tract.
PERRLA
Acronym for “pupils equal, round, reactive to light, accommodation”; the acronym is recorded in the physical examination if eye and pupil assessments are normal.
petechiae
Tiny purple or red spots that appear on skin as minute hemorrhages within dermal layers.
polyps
A tumor with a small flap that attaches itself to the wall of various vascular organs such as the nose, uterus and rectum. Polyps bleed easily, and if they are suspected to be cancerous they should be surgically removed.
ptosis
Abnormal condition of one or both upper eyelids in which the eyelid droops; caused by weakness of the levator muscle or paralysis of the third cranial nerve.
scoliosis
Lateral spinal curvature.
stenosis
Abnormal condition characterized by the constriction or narrowing of an opening or passageway in a body structure.
striae
Streaks or linear scars that result from rapid development of tension in the skin.
syncope
Brief lapse in consciousness caused by transient cerebral hypoxia.
thrill
Continuous palpable sensation like the purring of a cat.
ventricular gallop
S3 gallop an accentuated third heart sound in patients with cardiac disease characterized by pathological alterations in ventricular filling in early diastole.
vocal or tactile fremitus
fremitus: a vibration felt on palpation.
vocal fremitus: (VF) one caused by speaking, perceived on auscultation.
tactile fremitus: vocal fremitus felt on the chest wall.
Use physical examination to:
- Gather baseline data about the patient’s health status.
- Support or refute subjective data obtained in the nursing history.
- Identify and confirm nursing diagnoses.
- Make clinical decisions about a patient’s changing health status and management.
- Evaluate the outcomes of care.
Items to factor in when prepping for examination:
~Infection Control (good hygiene, be mindful of latex allergies)
~Environment (Private, good lighting, climate control, etc)
~Equipment (cleaned/sterilized? works?)
~physical prep of patient (gown, position, etc)
~psychological prep of patient (what is about to happen and when)
~age and how to assess for that age
techniques of physical assessment:
~Inspection (and olfaction) - look for symmetry
~palpation - start with light end with deep
~percussion - tap to produce vibration, sound det. location, size, density
~auscultation - recognize normal form abnormal sounds
What falls under “general survey?”
assessing: gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, signs of abuse, signs of substance abuse, vital signs, height and weight
When assessing skin look at:
color, moisture, temp., texture, turgor, vascularity, edema, lesions
When looking at lesions what is ABCD
~Asymmetry (not symmetrical) - uneven shape
~Border Irregularity - edges blurred, notched, ragged
~Color - not uniform, blue, black, brown, pink, white, gray, red
~Diameter - look for bigger than a pencil eraser
When assessing hair and scalp look at:
Color, distribution, quantity, thickness, texture, lubrication
Signs of hypothyroidism
wide part in hair, eyebrows don’t go to the end of eye towards ear
When assessing nails:
Inspect the nail bed for color, length, symmetry, cleanliness, and configuration. Palpate for abnormalities like swelling and erythema
When assessing head and neck look at:
head, eyes, ears, nose, mouth, pharynx, and neck (lymph nodes, carotid arteries, thyroid gland, and trachea).
When assessing eyes look at
size, shape, structure, visual acuity, visual fields, conjunctiva, sclera, cornea, pupil and iris (PERRLA), position and alignment, eyebrows, eyelids, lacrimal apparatus,
When assessing auricles look at:
texture, tenderness, lesions, color, pain, cerumen
Infants vs. adults using otoscope:
For infants the auricle should be pulled down and back. Insert the scope while pulling the auricle upward and backward in the adult and older child
three types of hearing loss
conduction, sensorineural, mixed
conduction hearing loss
interrupts sound waves as they travel from the outer ear to the cochlea of the inner ear because the sound waves are not transmitted through the outer and middle ear structures
sensorineural hearing loss
loss involves the inner ear, auditory nerve, or hearing center of the brain. Sound is conducted through the outer and middle ear structures, but the continued transmission of sound becomes interrupted at some point beyond the bony ossicles
mixed hearing loss
combination of conduction and sensorineural loss
Tuning fork tests (2)
Weber’s, Rinne
Weber’s test
top of head; Patient with normal hearing hears sound equally in both ears. In conduction deafness sound is heard best in impaired ear. In sensorineural hearing loss, sound is heard better in normal ear.
Rinne test
against mastoid process then next to ear canal;Patient should hear air-conducted sound twice as long as bone-conducted sound
When assessing nose look at:
shape, size, skin, color, and the presence of deformity or inflammation
nasal discharge
Pale mucosa with clear discharge indicates allergy. A mucoid discharge indicates rhinitis. A sinus infection results in yellowish or greenish discharge
When assessing lips look at:
color, texture, hydration, contour, and lesions
discolorations in lips and causes
Anemia causes pallor of the lips, cyanosis caused by respiratory or cardiovascular problems. Cherry-colored carbon monoxide poisoning, lesions should be evaluated for potential of infection, irritation, or skin cancer
When assessing mouth look at:
buccal mucosa, gums, teeth, tongue, floor of mouth, palate, pharynx
When assessing neck look at:
neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid gland, and trachea
To palpate supraclavicular nodes:
sk the patient to bend the head forward and relax the shoulders. Palpate these nodes by hooking the index and third finger over the clavicle lateral to the sternocleidomastoid muscle. Palpate the deep cervical nodes only with the fingers hooked around the sternocleidomastoid muscle.
Trachea inspection:
Determine the position of the trachea by palpating at the suprasternal notch, slipping the thumb and index fingers to each side. Note if the finger and thumb shift laterally
