NUR 116 CL - General Assessment Flashcards
What are the techniques of Physical Asssessment?
Inspection
Palpation
Percussion
Auscultation
(Olfaction as needed)
What are all the systems we check?
Skin
Head and Neck
Thorax
Cardiovascular
Abdominal/Genitalia/Rectum
Musculoskeletal
Neurological
Parts of the General Survey
Focused Hx questions
Developmental modifications
Observe
GENERAL skin assessment: focused hx & assessment
General Survey Part 1: Focused Hx questions
- How are you feeling today?
o What brought them to the clinic/hospital
o Are you in any discomfort/pain?
o Hospitalizations or surgeries?
o Medicines taking (include over the counter)
o Alcohol (amount daily)
o Herbal products or natural remedies
o Any difficulty falling asleep or staying awake
General Survey Part 2: Developmental modifications
Developmental modifications
o Infants/children
o Older adults”
- LADLs (Lawton Instrumental Activities of Daily Living)
- SPICES = (Sleep disorders, Problems eating or feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown)
General Survey Part 3: Observe
o Identify signs of physical or emotional stress
o Observe apparent age, gender, and race
o Facial characteristics + expression
o Body type and posture
o Observe gait and any abnormal movements
o Listen to your client’s speech pattern
o Assess mental state and effect
o Observe dress, grooming, and hygiene
o Measure vital signs
o AAO X 3 – (Person, Place & Time)
o Measure height, weight and BMI & measure infant’s head circumference
General Survey Part 4: Skin Assessment
o Gather equipment needed
o Focused history questions:
History of Rashes?
History of allergy?
Areas of skin that have changed color?
Lesions?
Roughness or unusual texture?
Warmth, coolness?
General Survey Part 5: Skin assessment procedure steps
o Inspect skin: color, mucus membranes, tongue, conjunctiva.
o Palpate skin for temperature
o Palpitate skin for turgor.
o Palpate the skin for texture.
o Palpate skin for moisture/hydration
o Inspect for edema.
o Identify any skin lesions – describe skin lesions.
o Patient teaching
o Home care
Then. document
What do you do for the General Survey?
Signs of distress
Gender, race, body type, age, affect, mood, allergies
Level of consciousness and orientation
Posture, gait, speech, hygiene and grooming
Signs of abuse
Vital signs, height, weight
Skin Assessment
- Inspect: Color, mucus membranes, tongue conjunctiva, lesions
- Palpate: temperature, turgor, texture, moisture,
- Normal skin lesions associated with aging:
lentigo senilis - brown macules d/t sun exposure
seborrheic keratosis - Raised brown bumps
senile purpura - fragile skin, purple bruises
acrochordons (skin tags)
ABCDE (for lesions):
Asymmetry
Border
Color
Diameter
Evolution
Edema: location, degree, rate of return and type of swelling
+1 2mm
+2 4mm
+3 6mm
+4 8mm
Head and Neck
Inspect:
Size (acromegaly or microcephaly) held erect
mid-line
temporal pulse
hair color
hair distribution & quality pediculosis (lice)
dandruff
Hirsutism
Palpate:
Masses
Tenderness
Mobility
EYES
Inspection - Pallor, dryness, edema
Ectropion - everted eyelid
Entropion - Inverted eyelid, can = corneal damage
Ptosis - Drooping of eyelid, CVA or Bell’s Palsy
Eyebrow/eyelashes
Pupil:
Color
Pupil size (Should be equal 3-7mm)
PERLA
Pupil
Equal
Round
Reactive
Light
Accommodation
Assess:
Hyperopia - far sighted
Myopia - near sighted
Presbyopia - Changes due to aging > 40 years
Snellen chart for reading
Sclera and Conjunctiva for CCAILDT
Color
Capillaries
Allergies
Inflammation
Liver Disorders
Trauma
Palpate external structures
EAR:
-Pinna for: Color, Lesions, Shape, Symmetry
-Cerumen - sticky substance in outer ear
- Discharge, lesions, hearing aids, acuity
Assess hearing:
Presbycusis - Loss of high pitched sounds, sensorineural loss sounds
Assess for pain/infection: Otitis externa, otitis media, Meniere’s disease
Palpate: smoothness, tenderness, pliable and nodules
NOSE
External structures for: position, nasal flaring
Internal structures for: drainage, tenderness, hair growth
Palpate external structure
MOUTH/ORAL PHARYNX
Mouth and lips for: Symmetry. swallowing problems, dryness
Ask client if they smoke
Teeth - Dentures, periodontal disease, poor oral hygiene
Tongue - dorsal, ventral and lateral aspect for: health, color
Palpate lips for: Thyroid, carotid pulses, ROM
What are three changes that would be expected findings during head and neck exam of an older adult?
- Decreased saliva production
- Decreased sense of taste
- Dysphagia (difficulty swallowing)
- Tooth loss
List every major part of the head and neck assessment
Neck
Eyes
Nose
Ears
Mouth/Oral Pharynx
Head and Neck assessment: HEAD
Inspect:
Size (acromegaly or microcephaly) held erect
mid-line
temporal pulse
hair color
hair distribution & quality pediculosis (lice)
dandruff
Hirsutism - excessive hair growth
Palpate:
Masses
Tenderness
Mobility
Head and Neck assessment: Eyes
Inspection - Pallor, dryness, edema
Ectropion - everted eyelid
Entropion - Inverted eyelid, can = corneal damage
Ptosis - Drooping of eyelid, CVA or Bell’s Palsy
Eyebrow/eyelashes
Pupil:
Color
Pupil size (Should be equal 3-7mm)
PERLA
Pupil
Equal
Round
Reactive
Light
Accommodation
ASSESS VISION:
Hyperopia - far sighted
Myopia - near sighted
Presbyopia - Changes due to aging > 40 years
Snellen chart for reading
Sclera and Conjunctiva for CCAI-LD-T
Color
Capillaries
Allergies
Inflammation
Liver Disorders
Trauma
Palpate external structures
Head and Neck assessment: Ear
-Pinna for: Color, Lesions, Shape, Symmetry
-Cerumen - sticky substance in outer ear
- Discharge, lesions, hearing aids, acuity
Assess hearing:
Presbycusis - Loss of high pitched sounds, sensorineural loss sounds
Assess for pain/infection: Otitis externa, otitis media, Meniere’s disease
Head and Neck assessment: Nose
External structures for: position, nasal flaring
Internal structures for: drainage, tenderness, hair growth
Palpate external structure
Head and Neck assessment: Mouth/Oral Pharynx
Mouth and lips for: Symmetry. swallowing problems, dryness
Ask client if they smoke
Teeth - Dentures, periodontal disease, poor oral hygiene
Tongue - dorsal, ventral and lateral aspect for: health, color
Palpate lips for: Thyroid, carotid pulses, ROM
What are three changes that would be expected findings during head and neck exam of an older adult?
- Decreased saliva production
- Decreased sense of taste
- Dysphagia (difficulty swallowing)
- Tooth loss
What are three changes that would be expected findings during head and neck exam of an older adult?
- Decreased saliva production
- Decreased sense of taste
- Dysphagia (difficulty swallowing)
- Tooth loss
Abdomen, Genitalia and Rectum Assessment: Abdomen
PALPATE LAST
Inspect:
-Size, symmetry, contour, hair distribution and note abdominal movements
-Skin for: lesions, scars, color strine (stretch marks)
-Shape: flat, concave, convex (distention) flatus, feces, fetus, fluid, flat, measure abdominal girth (waist)
-Ask when was last meal
- “When are bowl sounds most active?” 2-3 hours after eating
-Auscultate: in order upper to lower; if pain, auscultate last
- Hyperperistalsis = 2-3 sounds per seconds
- Hypoperistalsis = less than 5 bowel sounds per minute
- Bruit may indicate aneurysm or altered blood circulation
Percussion: solid organs (dull sound), air-filled organ (tympany/hollow sound)
Palpation:
-Begin w/ fingertips depress 1/2 inch in circular motion
Observe for: grimacing, guarding, pain, tenderness
-Abnormal findings: tenderness, rigidity, peritonitis
-Paracentesis: drain fluid from abdomen
-Ascites: fluid in the abdomen
-Causes of ascites: Cirrhosis of the liver, cancer, heart failure, kidney failure, extreme malnutrition
GI changes in older adults:
-Decrease in salivary secretion
-Decrease number of taste buds
-Delayed gastric emptying
-Increase in constipation
Abdomen, Genitalia and Rectum Assessment: MALE GU
-Empty bladder, expose area
-Have patient in supine or stand
-Inspect hair distribution
-Skin: skin of penis, note position of urethra, meatus, check for lesions/warts/discharge
-Palpate penis
-Scrotum: position, symmetry of sacs
-Palpate scrotum
-Inguinal area: look for bulges/swelling, have client bear down as if having bowel movement, inspect for bulges/swelling, complain of pain/pressure
-Assess older adults for incontinence
Abdomen, Genitalia and Rectum Assessment: FEMALE GU
-Empty bladder, expose area
-Dorsal recumbent position
-Drape to provide privacy
-Wear gloves
-Spread labia majora and inspect for: redness, lesions, discharge and inflammation
- Assess older adults for incontinence
Abdomen, Genitalia and Rectum Assessment: RECTUM
- Wear gloves
-Position: sims lateral or prone
-Inspect anus for redness, rashes, lesions, breakdown, hemorrhoids
-Insert finger into rectum, palpate wall for masses/tenderness
-Test stool on gloved finger for occult blood
Chest and Lungs: THORAX
Position: sitting and leaning forward/laying down
Focus hx or questions: smoking, any SOB, chest pain, allergies, asthma
Inspect: Count Resp rate, depth, symmetry
Palpate:
-Masses, tenderness, crepitus
-Anterior, posterior, lateral chest wall
-Chest excursion (place hands base of chest 2inches apart posteriorly, thumbs toward spine), should feel chest expansion when pt takes deep breath
Cardiovascular Assessment
-Position: sitting, supine, left lateral
-Focused hx: Any chest pain, activity tolerance, HTN, swelling (peripheral extremities, medications)
Palpate:
Carotid pulses
Pulse amplitude(0, +1-+4)
Check capillary refill, should refill in less than 3 seconds
-Inspect jugular vein distension
Auscultation precordium to hear heart valve sounds:
-Aortic valve (S2): Base right, 2nd intercostal space
-Pulmonic valve (S2): Base left, 2nd intercostal space
-Tricuspid valve (close to sternum (S1): Left lateral sternal border, 4th intercostal space
-Mitral valve (PMI S1): 5th intercostal space
- If a murmur is auscultated: assess, location, quality, frequency, intensity, timing, configuration (sounds) and radiation
Inspect: periphery for edema
Expected finding: appropriate color for race; warm skin temp
Abnormal findings: cyanosis, pallor, edema, clubbing of nails (low blood O2 levels, lung disease, heart problem or GI issues)
Expected findings in older adults:
Activity intolerance
Decreased heart rate
Weaker pulses, lower extremity edema
Musculo and neuro assessment Part 1:
Activity and mobility
Observe client performing ADL’s
Assess gait
Assess ROM: Active or passive
Observe balance
Assess joints for pain, swelling, erythema, temperature
ASSESS SPINE:
Kyphosis
Lordosis
Scoliosis
INSPECT MUSCLES:
- Normal size
- Atrophy
- Hypertrophy
STRENGHT AND EQUALITY: BILATERAL
-Hand grasp: equal? strong or weak?
MUSCLE TONE: FLACCID OR SPASTIC
ASSESS JOINT: BILATERAL
- Is there pain?
- Is there swelling?
- Is there redness/erythema?
- Is there temperature?
- Is there asymmetry?
VARIATIONS IN OLDER ADULTS:
- Decreased ROM and joint degeneration
- Sarcopenia: Decrease size and number of muscle fibers
- Osteoporosis - Decreased bone mineral and mass
Musculo and neuro assessment part 2: Orientation & Activity, lifestyle, exercise
AAO x 3 ___________________
Older adult – diminished pain perception, slowed reaction time
ACTIVITY AND EXERCISE:
o Hx: current activity, usual form(s) of exercise, how frequent,
and has activity increased or decreased in the last 10 years?
o Fractures, weakness, cardiac/respiratory disorders
o Depression, anxiety
o Goals of exercise: what aspect of exercise do you enjoy? Not enjoy?
What do you think are the benefits of exercise?
What motivates you to exercise?
o Concerns related to mobility:
Do you have any health issues affecting mobility?
What medications you take,
o Lifestyle: what kind of work do you do? Or did do?
External factors: Assistive devices, neighborhood, restrictions in home?
Assess: Patient standing, observe anterior, posterior and lateral views
Expected findings: Shoulder and hips are level, toes pointed forward,
posture erect.
Instruct patient to sit down, note any difficulty, slumping. If patient
cannot sit/stand assess movement in bed and posture
Joint function: Inspect and palpate
- Begin at the neck – assess for edema,
erythema, asymmetry, deformity.
- Compare muscle size above and below joint on each side of body
Palpate: Joint for tenderness, temperature, crepitus (crackling when move joint)
Gait: stance and swing
Walking: Head erect, heel strikes ground before toe, opposite hands wing
Activity tolerance: assess vital signs 3 minute prior to activity
Strength: push against hand (right and left)
Range of motion of joints:
- Neck: Pivot joint, extension, flexion, rotation, lateral flexion
- Shoulder: Ball and socket joint; flexion, extension, hyperextension, abduction, adduction and circumduction
- Elbow: hinge joint; flexion and extension
- Wrist: Condyloid joint; rotation, flexion
- Hip: Ball and socket
- Knee, ankle and toes: hinge joint
- Foot: gliding joint
Musculo and neuro assessment: Part 3 Joints
JOINT FUNCTION: INSPECT AND PALPATE
- Begin at the neck – assess for edema,
erythema, asymmetry, deformity.
- Compare muscle size above and below joint on each side of body
PALPATE: Joint for tenderness, temperature, crepitus (crackling when move joint)
GAIT: STANCE AND SWING
Walking: Head erect, heel strikes ground before toe, opposite hands wing
Activity tolerance: assess vital signs 3 minute prior to activity
Strength: push against hand (right and left)
RANGE OF MOTION OF JOINTS:
- Neck: Pivot joint, extension, flexion, rotation, lateral flexion
- Shoulder: Ball and socket joint; flexion, extension, hyperextension, abduction, adduction and circumduction
- Elbow: hinge joint; flexion and extension
- Wrist: Condyloid joint; rotation, flexion
- Hip: Ball and socket
- Knee, ankle and toes: hinge joint
- Foot: gliding joint
Musculo and neuro assessment: Part 4 Questions
WHERE IS THE PMI LOCATED:
- Apical pulse: fifth intercostal space at midclavicular line
WHICH ASSESSMENT TECHNIQUE SHOULD THE NURSE USE TO ASSESS FOR EACH FINDING LISTED BELOW:
- Capillary refill: Press on nail bed and watch blood return
- Rebound tenderness: Slowly press into lower abdomen, hold then remove pressure quickly, assess patient’s response for pain
WHAT BP READING IS CONSIDERED HYPOTENSION?
- Less than 90 sys OR less than 60 diastolic
What values are associated with each below?
o Tachycardia: Greater than 100 bpm
o Bradycardia: Less than 60 bpm
o Tachypnea: Greater than 20 respirations
o Bradypnea: Less than 12 respirations
What is?
o Pulse pressure: Difference betwee systolic and diastolic BP
o Abduction:
o Presbyopia
o Cyanosis
