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NUR 116 Clinical > NUR 116 CL - General Assessment > Flashcards

NUR 116 CL - General Assessment Flashcards

1
Q

What are the techniques of Physical Asssessment?

A

Inspection
Palpation
Percussion
Auscultation
(Olfaction as needed)

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2
Q

What are all the systems we check?

A

Skin
Head and Neck
Thorax
Cardiovascular
Abdominal/Genitalia/Rectum
Musculoskeletal
Neurological

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3
Q

Parts of the General Survey

A

Focused Hx questions
Developmental modifications
Observe
GENERAL skin assessment: focused hx & assessment

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4
Q

General Survey Part 1: Focused Hx questions

A
  • 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
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5
Q

General Survey Part 2: Developmental modifications

A

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)

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6
Q

General Survey Part 3: Observe

A

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

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7
Q

General Survey Part 4: Skin Assessment

A

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?

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8
Q

General Survey Part 5: Skin assessment procedure steps

A

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

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9
Q

What do you do for the General Survey?

A

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

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10
Q

Skin Assessment

A
  • 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

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11
Q

Head and Neck

A

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

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12
Q

List every major part of the head and neck assessment

A

Neck
Eyes
Nose
Ears
Mouth/Oral Pharynx

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13
Q

Head and Neck assessment: HEAD

A

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

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14
Q

Head and Neck assessment: Eyes

A

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

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15
Q

Head and Neck assessment: Ear

A

-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

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16
Q

Head and Neck assessment: Nose

A

External structures for: position, nasal flaring
Internal structures for: drainage, tenderness, hair growth
Palpate external structure

17
Q

Head and Neck assessment: Mouth/Oral Pharynx

A

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

18
Q

What are three changes that would be expected findings during head and neck exam of an older adult?

A
  • Decreased saliva production
  • Decreased sense of taste
  • Dysphagia (difficulty swallowing)
  • Tooth loss
19
Q

Abdomen, Genitalia and Rectum Assessment: Abdomen

A

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

20
Q

Abdomen, Genitalia and Rectum Assessment: MALE GU

A

-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

21
Q

Abdomen, Genitalia and Rectum Assessment: FEMALE GU

A

-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

22
Q

Abdomen, Genitalia and Rectum Assessment: RECTUM

A
  • 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
23
Q

Chest and Lungs: THORAX

A

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

24
Q

Cardiovascular Assessment

A

-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

25
Q

Musculo and neuro assessment Part 1:

A

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

26
Q

Musculo and neuro assessment part 2: Orientation & Activity, lifestyle, exercise

A

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

27
Q

Musculo and neuro assessment: Part 3 Joints

A

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

28
Q

Musculo and neuro assessment: Part 4 Questions

A

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

NUR 116 Clinical (12 decks)

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