Nitty Gritty Flashcards
what to inspect on skin assessment (11)
- colour
- general pigmentation
- areas of colour change
- bruising
- lumps
- swelling
- masses
- tattoos
- piercings
- birthmarks
- scars
what to palpate on skin assessment (7)
- temperature
- texture
- thickness
- tenderness
- moisture
- swelling
- masses
definition of mobility and turgor
- mobility is the ease of rising of skin
- turgor is the prompt return of skin when its released
6 characteristics of a lesion
- colour
- location and distribution
- elevation
- exudate
- shape and pattern
- size
ABCDE’s of dangerous lesion
- asymmetry: should be symmetrical
- borders: even border
- colour: same colour throughout
- diameter: less than 6mm
- evolution: shouldn’t be changing
what to inspect on nail assessment (5)
- shape
- contour
- condition
- colour
- markings
what to palpate on nail assessment
- consistency
- thickness
- adhered to nail bed
things that could cause changes to nail bed angle
- congenital, chronic, and cyanotic heart disease
- emphysema
- chronic bronchitis
things that could cause issues with capillary refill
- cardiovascular dysfunction
- respiratory dysfunction
- cold temperatures
10 lymph node chains
- preauricular
- post auricular
- occipital
- submental
- submandibular
- tonsillar
- superficial cervical
- deep cervical
- posterior clavicular
- supraclavicular
technique for assessing lymph nodes
- gentle circular motion
- tips of fingers
- bilaterally
- submental tilt chin forwards
- deep cervical chain tip head to side being assessed
- supraclavicular chain hunch shoulder forward
what to note is palpate lymph nodes (7)
- location
- size
- shape
- delimitation
- mobility
- consistency
- tenderness
lymph node in healthy individual
- movable
- discrete
- soft
- nontender
why a lymph node may be enlarged
- infections
- allergies
- neoplasm
confrontation test angles
60cm, 2ft away
- 50 superiorly
- 60 nasally
- 70 inferiorly
- 90 temporally
what to note for pupillary response
- size in mm
- shape
- symmetry
all before and during - speed of reaction
accommodation test
- have them look far away and then at your finger
- inspect pupils size change
convergence test
- follow finger as it gets closer to bridge of nose
corneal light reflex expected findings
- light should be on same spot of cornea
cover-uncover test expected findings
- look for movement of uncovered eye when care removed
- should be steady fixed gaze
- look for movement of covered eye when card removed
- should be steady fixed gaze
diagnostics position test expected findings
- parallel tracking
- no nystagmus or lid lag
what to inspect and palpate when assessing ears (9)
- size
- shape
- position
- skin colour and condition
- temperature
- texture
- tenderness
- lumps
- nodules
what to look for in canal and meatus (5)
- cerumen (amount, colour, odour)
- lesions
- foreign bodies
- bleeding
- discharge
what to look for on tympanic membrane (8)
- colour
- condition
- cone of light (5 Rt, 7 Lt)
- bulging
- retraction
- lesions
- scaring
- fluid
whispered voice test
- twice in each ear
- number letter number
what to inspect in lips, gums, teeth, and buccal mucosa (8)
- colour
- condition
- moisture (saliva)
- swelling
- lesions
- bleeding
- masses
- ulcerations
what to inspect of surface of tongue (6)
- colour
- condition
- lesions
- masses
- ulderations
- nodules
inspecting tongue function
- no wasting or tremors
- position with protrusion should be midline
- move out and side to side
- light tight dynamite
what to inspect in throat and posterior pharyngeal wall (6)
- colour
- condition
- lesions
- exudate
- tonsils
- halitosis
what to inspect for uvula
- colour
- condition
- position (midline)
- movement with phonation (“aaa”)
what to inspect on abdominal assessment (5)
- contour
- symmetry
- umbilicus
- skin colour and condition
- pulsations and movements
expected findings of bowel sounds
- diaphragm
- character
- frequency
- high pitched, gurgling, cascading sounds
- normal, hyperactive, hypoactive
how to prepare patient for abdominal assessment
- pillow under head and knees
- arms at side of across chest
- relax abdominal muscles
- draping
inspection of voluntary guarding and involuntary rigidity
- voluntary guarding may be hunched over and grasping stomach and purposefully tensing muscles
- involuntary rigidity may be swollen or distended
predominant tone over abdomen and where it may change
- tympany
- dullness heard over a distended bladder, adipose tissue, fluid, or a mass
- hyper resonance heard with gaseous distension
liver span expected findings
- 5th ICS to costal margin
- 6-12cm
spleen expected findings
- 9th-11th ICS
- dullness
- less than 7cm
costovertebral tenderness expected findings
- thud no pain or tenderness
difference between light and deep palpation
- light goes 1cm deep and palpate superficial surface
- deep goes 5-8cm deep and palpating organs
proper technique for abdominal palpation
- 1cm deep
- 4 fingers
- fingers parallel
- lift between areas
what to palpate during abdominal assessment (6)
- texture
- temperature
- moisture
- rigidity
- pulsations
- tenderness
voluntary guarding vs involuntary rigidity
- voluntary guarding is cold, tense, or ticklish and will relax with exhale
- involuntary rigidity is constant muscle hardness, sometimes only on one side, may be sign of peritonitis
how to deal with anxious or ticklish patient (6)
- bend patients knees
- keep hand parallel to abdomen
- coach patient to breath slowly
- use low and soothing voice
- coach patient to use emotive imagery
- interlace fingers with theirs, or use stethoscope
inspect demeanour and respiratory effort for thorax assessment
- relaxed posture
- support own weight
- relaxed, automatic, effortless, regular, even, no noise, no lags, no use of accessory muscles
- 10-20/min
3 signs of respiratory distress
- tripod position
- central cyanosis
- pursed lips
inspect shape and configuration of posterior thorax
- spinous process straight and mid line
- scapulae symmetrical in each hemithorax
- ribs downward slope of 45 degrees
- AP to transverse diameter 2:1
- sternocleidomastoid and trapezius developed
inspect shape and configuration of anterior thorax
- sternum straight and midline
- ribs sloping downward
- interspaces symmetrical
- no use of accessory muscles
- costal angle within 90 degrees
what to palpate for posterior thorax (8)
- temperature
- texture
- turgot
- tenderness
- lumps
- bumps
- masses
- crepitus
tactile fremitus of thorax
- apices to bases (6th, 8th, 10th)
- equal bilaterally
- more pronounced between scapula dampened in peripheral lung fields
- more pronounced in 1st or 2nd ICS dampened in peripheral lung field
technique for percussing thorax
- apices to bases
- in ICS
- avoid bone
predominant percussion tone over thorax
- resonance over lung field
- dull over liver, heart, breast tissue
- flat over bone
- tympani over abdomen
- dull in lungs may mean consolidation
bronchial breath sounds
- harsh
- loud
- inspiration shorter
- pause between
- over trachea
bonchovesicular breath sounds
- moderate sound
- inspiration and expiration equal
- between scapula and 1st/2nd ICS anteriorly
vesicular
- low
- soft
- inspiration longer
- over peripheral lung fields
