Med-Surg121 FON Chp 5 Physical assesment Flashcards
Key Terms Physical assessment
Acute- Begins abruptly with marked intensity of sever signs and symptoms, then subsides after a period of treatment. Assessment- an evaluation of appraisal of the patients condition. Auscultation- process of listening to sounds produced by the body. (cardio, respiratory, GI) Borborygmi- high pitched loud, rushing sound in the bowels. Bruits- abnormal “swishing” sound heard over organs, glands, and arteries. Chronic- disease develops slowly and persists over a long period, often for a persons lifetime. Crackles- produced by fluid in the bronchioles and the alveoli, are short, discrete, interrupted, crackling or bubbling sounds that are most commonly heard during inspiration. Disease- pathologic condition of the body, is any disturbance of a structure or function of the body. Drainage-Passive of active removal of fluids from a body cavity, wound, or other source of discharge by one or more methods. Dullness- low pitched thudlike sound over dense organs like the liver. Edema- swelling Erythema- redness Etiology- cause Exudate- fluid, cells or other substances that are slowly exuded or discharged from cells or blood vessels through small pores or breaks in the cell membrane, usually as a result of inflammation or injury.
Key Terms Physical assessment
Flatness- soft, high pitched flat sound produced over a muscle. Focused assessment- attention is focused on a particular part of the body, where signs and symptoms are localized or most active in order to determine their significance. Functional disease- often appear to be those of organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities. Infection- cause by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites, that produces tissue damage. Inflammation- a protective response of body tissues to irritation, injury, or invasion by disease-producing organisms. Inspection- visually inspect the patients body and observe moods, including all responses and nonverbal behaviors. LOC- is patient oriented to person, place, time, and purpose. Neoplastic- any abnormal growth of tissue, benign or malignant. Nursing health history- data collected provides you with information about the patients level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness. Nursing physical assessment- physical examination you perform as a nurse. Objective data- what you see, hear, measure or feel. Organic disease- results in a structural change
Key Terms Physical assessment
Palpation- use the hands and sense of touch to gather data. Percussion- use of the fingertips to tap the body’s surface to produce vibration and sound. Pruritus- itching. Purulent- pus Remission- partial or complete disappearance of clinical and subjective characteristics of the disease. Signs- objective data as perceived by the examiner, in your case, what you see, hear measure, or feel. Subjective data- symptoms not measurable, but described by the patient. Symptoms- subjective indications of illness that the patient perceives. Thrill- a vibrating sensation you perceive as you palpate along the artery. Turgor- elasticity of the skin. Tympany- high pitched drum like sound over a hollow organ like the stomach. Wheezes- sounds produced by the movement of air though narrowed passages in the tracheobronchial tree.
Origins of disease
Heredity- genetically from parents to children (sickle cell anemia, color blindness, hemophilia) Congenital- appear at birth due to developmental failures during pregnancy (absence of limbs, blindness) Inflammatory- Caused by microorganisms or allergies (pharyngitis, bronchitis, hay fever) Degenerative- progressive degeneration of some body part, possibly aging related (Osteoarthritis) Infectious- invasion of microorganisms (AIDS, TB, measles, pneumonia) Metabolic- dysfunction that results in loss of metabolic control of homeostasis, usually involves endocrine glands (Diabetes Mellitus, hypothyroidism, acromegaly) Neoplastic- abnormal tissue growth, benign or malignant (cancerous). Traumatic- result from both physical and emotional trauma, TBI (traumatic brain injury), car accident, loss of loved one. Environmental- conditions that develop from exposure to a harmful substance in the environment. (Tight building syndrome, Radon gas or asbestos) Autoimmune responses- body develops immunoglobins against its own tissues or body substances (MS)
Nursing assessment
Gathering, verifying and communicating data about the patient. Establish a baseline database about the patients level of wellness, health practices, past illnesses, related experiences and health care goals.
Examination positions
Sitting- assess head, neck, thorax, upper extremities. For physically weak use supine with head of bed up. Supine- assess head, neck, thorax, extremities, raise head of bed if pt. has difficulty breathing. Dorsal recumbent- assess, head, neck, thorax, breast, abdomen, relaxes abdominal muscles. Lithotomy- assess female genitalia, keep pt. well draped. Sims- assess rectum, vagina, used for per rectal meds, pts. with joint issues may have trouble in this pos. Prone- assess musculoskeletal system, extension of hip joint, bad position for pts. with respiratory difficulty. Lateral recumbent- assess heart, aids in detecting murmurs, poor respiration difficulty. Genupectoral (knee-chest)- assess rectum, maximum rectal area exposure, embarrassing and uncomfortable pos.
Physical assessment techniques
Inspection- observe body and pt. moods Palpation- touch skin for temperature, texture, moisture, quality of an area, lightly palpate abdomen. Auscultation- listen to sounds produced by the body from the cardiovascular, respiratory, and GI systems. Percussion- use fingertips to tap body’s surface to produce vibration and sound, rarely used by nurses.
Steps to initiate nurse-patient relationship
1- introduce self, state name, position and purpose of interview. 2-Communicate your trustworthiness and discretion to patients. 3-Relationship is enhanced by professionalism and competence you convey.
History of present illness P, Q, R, S, T
P- Precipitating-Provocative-Palliative (What causes it?, What makes it better?, What makes it worse?) Q- Quality-Quantity (describe it, sharp, dull, How does it feel, look or sound and how much of it is there? How often, when, how long) R- Region-Radiation (Where is it?, Does it spread?) S- Severity scale (Does it interfere with activities?, How does it rate on a severity scale of 0 to 10?) T- Treatments (What helps?, For how long?)
Review of systems (ROS)
Question systems General constitutional symptoms (Fever, chills) Skin (Rash, abnormal hair growth) Head (Headaches, vision, Ears, Nose, Mouth) Endocrine (Thyroid issues) Reproduction (Male and Female) Respiratory (RR, TB, Pain) Cardiac (Pain, Rate, Rhythm) Hematologic (Anemia, bruising) Lymph nodes (Enlargement, tenderness) GI (Appetite, BM’s, swallowing) Genitourinary (Dysuria, pain, urgency, frequency) Neurologic (Syncope, Stroke, Seizures) Psychiatric (Depression, mood changes, concentration)
Level of consciousness (LOC)
Patients orientation X1 (person) X2 (person and place) X3 (person, place, and time) X4 (person, place, time and purpose)
Turgor
Dehydration results in decreased skin turgor and is manifested by lax skin that when grasped with two fingers slowly returns to its previous position. Edema results in increased skin turgor, manifested by smooth, taught, shiny skin that cannot be grasped and raised.
Abnormal Lung sounds
Fine Crackles - high pitched, discrete, discontinuous crackling sounds heard during the end of inspiration, not cleared by a cough. Medium Crackles - lower, more moist sound heard during the midstage of inspiration, not cleared by a cough. Coarse Crackles - loud, bubbly noise heard during inspiration, not cleared by a cough. Rhonchi - (sonorous wheeze) loud, low coarse sounds like a snore most often heard continuously during inspiration or expiration, coughing may clear sound (usually means mucus accumulation in trachea or large bronchi). Wheeze - (sibilant wheeze) musical noise sounding like a squeak, most often heard continuously during inspration or expiration, usually louder during expiration. Pleural friction rub - dry, rubbing or grating sound, usually caused by inflammation of pleural surfaces, heard during inspriation and expiration, loudest over lower lateral anterior surface.
Spine
Lordosis- Swayback, increased lumbar curvature. Kyphosis- humpback, curvature of thoracic spine. Scoliosis- lateral spinal curvature.
Pulse
Scale: 0= absent 1+= thready 2+=weak 3+= normal 4+= bounding
