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RPNCE STUDY > Nursing Assessment > Flashcards

Nursing Assessment Flashcards

1
Q

What are the four assessment techniques used in a physical examination?

A
  • inspection
  • palpation
  • percussion
  • auscultation
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2
Q

Palpation (size consistency, texture, location & tenderness):
What does the palm of the hand/fingertips assess?

A
  • consistency of tissue
  • alignment and intactness is structures
  • symmetry of body parts or movements
  • transmission of sound and fine vibrations
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3
Q

Palpation: (size consistency, texture, location & tenderness)
Back of the hand assesses…

A

Skin temperature

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4
Q

Palpation: (size consistency, texture, location & tenderness)
Ulnar surface of the fingers assesses…

A

texture, moisture, masses, organ position, and area of tenderness

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5
Q

Percussion (location, size or density):

What are the four types of percussion sounds?

A 
- tympanic - drum-like; high pitched, loud 
Ex of cause: gastric bubble
- resonant - hollow; low-pitched, loud
Ex of cause: healthy lungs
- flat - dull/muted; high-pitched, soft
Ex of cause: bone
- dull - thud-like; medium-pitched, soft
Ex of cause: liver
  • A flat/dull sound indicates presence of a solid mass under the surface
  • A tympanic/resonant sound indicates hollow, air-containing structures
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6
Q

Auscultation:
High-pitched tones are best heard with the _______ of the stethoscope, while low-pitched tones are best heard with the ____ of the stethoscope.

A

Diaphragm; bell

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7
Q 
Cardiovascular System (CV)
What is the primary purpose of the CV system?
What does it encompass?
A
  • To move nutrients, gases, and wastes to and from cells.

- It encompasses the neck vessels, heart and peripheral vascular system.

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8
Q

Systolic pressure is the _______ ________ of the heart

Diastolic pressure is the _______ ______ in the heart’s ventricles

The difference b/w the systolic and diastolic pressure is called the _____ ______, which represents the force that the heart generates each time it contracts

A
  • maximal contraction
  • resting pressure
  • pulse pressure
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9
Q

Heart & Pericardium:

Pulsations, or the apical impulse, may be visible in the _th or _th intercostal space at the left midclavicular

A

4th or 5th

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10
Q 
Heart & Pericardium:
What is a...
- Thrill
- Heave 
* there should never be any palpable heaves or thrills over the apex
A
  • thrill - palpable murmur that feels similar to a cat purring. Thrills are always associated with murmurs.
  • heave - upward displacement of the chest against the hand; best felt with the heel of the hand at the sternal border; heaves have various associations
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11
Q

Heart & Pericardium:

Murmurs are turbulence, or a gentle blowing or swooshing sound, caused by:

A
  • a change in the velocity of blood flow
  • a structural defect in the valves
  • an unusual opening in the cardiac chambers
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12
Q 
Heart & Pericardium:
Grading of Murmurs
I -
II -
III - 
IV -
V -
VI -
A

I - barely audible
II - clearly audible, but faint
III - moderately loud; easy to hear with stethoscope
IV - loud; associated with a thrill palpable on the chest wall
V - very loud; heard with stethoscope partially lifted off the chest wall
VI - loudest; heard with entire stethoscope liften off the chest wall

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13
Q 
Heart & Pericardium:
Strengths of pulses:
0 =
1+ =
2+ =
A 
0 = absent
1+ = decreased
2+ = normal
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14
Q

What does PERRLA stand for?

A

Pupils equal, round, reactive to light and accommodation

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15
Q

The skin carriers out 7 major functions, what are they?

A
  • maintaining an internal environment by acting as a barrier to loss of water and electrolytes
  • protection from external agents that could injure the internal environment
  • regulation of body heat
  • acting as a sense organ for touch, temperature, and pain
  • self-maintenance and wound repair
  • production of vit D
  • delayed hypersensitivity reaction to foreign substances
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16
Q 
Integumentary System:
Possible meaning for having...
- Jaundice skin
- Pale yellow skin tone
- Flushed, red face
- Pale
A
  • liver problem, biliary tract disease
  • renal problem
  • excessive ETOH intake, fever, localized inflammation, embarrassment
  • circulatory problem
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17
Q

What is clubbing (& I ain’t talking the dancing clubs lol!)?

A

Loss of normal angle b/w nail and nail bed d/t chronic oxygen deprivation

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18
Q

Define kyphosis

A

curvature of the spine - anterior-posterior

19
Q

define scoliosis

A

curvature of the spine - lateral

20
Q

define barrel chest

A

chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen in COPD

21
Q

define pectus excavatum

A

sternum sunken into chest

22
Q

define pectus carinatum

A

sternum protruding from the chest

23
Q

define cyanosis

A

bluish discoloration of the skin and mucous membranes d/t excessive concentration of reduced hemoglobin in the blood

24
Q

define apneustic

A

prolonged gasping

25
Q

define Cheyne-Stokes

A

varying depth followed by apnea

26
Q

define Biot’s

A

increased depth and rate with abrupt pauses

27
Q 
Respiratory System:
Percussion sound...
- resonance =
- hyperresonance =
- flatness =
A
  • normal - healthily air-filled lung
  • too much air - emphysema
  • presence of fluid or solid mass - pleural effusion, pneumonia, tumor
28
Q

Respiratory System:

what are adventitious breath sound

A

refer to extra, or additional, sounds that are heard over normal breath sounds
- usually leads to a diagnosis of cardiac and pulmonary conditions

29
Q

Respiratory System:

what are crackles caused by

A

caused by fluid in the small airways, or atelectasis

  • referred to as discontinuous osunds; they are intermittent, non-musical and brief
  • may be heard on inspiration or expiration
  • popping sounds they produce are created when air is foced through respiratory passages that are narrowed by fluid, mucus or pus
30
Q

Respiratory System:

what are crackles offten associated with

A

inflammation or infection of the small bronchi, bronchioles and alveoli
- crackles that don’t clear after a cough may indicate pulmonary edema or fluid in the alveoli d/t heart failure or adult respiratory disdress syndrome (ARDS)

31
Q

Respiratory System:
- What are fine crackles?

  • What are course crackles?
  • What are medium crackles?
A
  • soft, high-pitched and very brief (stimulate this sound by rolling a strand of hair b/w your fingers near your ear)
  • are somewhat louder, lower in pitch and longer lasting than fine crackles; they have been described as sounding like opening a Velcro fastener
  • are b/w fine and coarse sound and duration
32
Q

Respiratory System:

What are wheezes caused by?

A

Air moving through airways narrowed by constriction or swelling of airway or by partial airway obstruction

  • heard continuously during inspiration or expiration, or during both
  • relatively high-pitched and have a shrill or squeaking quality
  • have a musical quality, they often occur when airways are narrowed, such as may occur during an acute asthmatic attack
  • lower pitched wheezes, with a snoring/moaning quality may be referred to as sonorous rhonchi; secretions in large airways, such as occur with bronchitis, may produce these sounds, which may clear somewhat with coughing
33
Q

Respiratory System:

When do pleural friction rubs occur?

A
  • low-pitched, grating or creaking sounds that occur when inflammed pleural surfaces rub together during respiration; more often heard on inspiration than expiration
  • pleural friction rub stops when breathing stops (don’t confuse with pericardial friction rub)
34
Q

Respiratory System:
What is a stridor caused by?
What is stridor a sign of?

A
  • refers to a high-pitched, harsh sound heard during inspiration and is caused by obstruction of the upper airway.
  • it is a sign of respiratory distress, and requires IMMEDIATE attention
35
Q

GI System:

A lower quadrant bulge may indicate what?

A

A distended bladder

36
Q

GI System:

A midline bulge may be a what?

A

Umbilical hernia

37
Q

Abdominal distension can be caused by 3 factors. What are they?

A
  1. obesity: soft and rounded, with sunken umbilicus
  2. ascites: skin is shiny and glistening, with an everten umbilicus and dilated, prominent veins
  3. obstruction: visible, makrked peristalsis, restlessness, lying with knees flexed, grimacing facial expression and uneven respirations
38
Q 
GI System
Bowel Sounds are classified as:
- hypoactive -
- normal -
- hyperactive -
A
  • infrequent
  • intermittently at 5-15 times per min
  • more frequent than normal
39
Q 
GI System
Percuss all four quads of the abdomen
- tympany - 
- hyperresonance - 
- dullness -
A
  • normally predominant sound as air rises to the surface of the abdominal cavity (for ex, empty stomach or bowel)
  • is heard with gaseous distention
  • heard over a distended bladder, liver, adipose tissue, fluid, feces-filled bowel or mass in the abdomen
    WARNING: Do not percuss if an abdominal aortic aneurysm is suspected.
40
Q 
GI System:
Palpation
When would you use...
- light palpation
- deep palpation
A
  • detects superficial masses and fluid accumulating in an abdomen that is soft and non-tender
  • detects masses, tenderness, pulsations, organ enlargement
41
Q 
Musculoskeletal System
Test strength of major muscle groups using a grading scale: 
- grade 5: 
- grade 4:
- grade 3:
-grade 2:
- grade 1:
- grade 0:
A
  • grade 5: full ROM against gravity and full resistance (100% normal)
  • grade 4: full ROM against gravity and some resistance (75% normal)
  • grade 3: full ROM with gravity (50% normal)
  • grade 2: full ROM with gravity eliminated or passive ROM (25% of normal)
  • grade 1: slight contraction (10% of normal)
  • grade 0: no contraction (0% of normal)
42
Q 
Neurologic System:
Reflex Testing (scoring) & risks associated with score
- hyperactive (4+):
- brisker than normal (3+):
- normal (2+)
- diminished (1+):
- absent (0) pathologic;
A
  • often pathologic; may be associated with disease of the cerebral cortex, brain stem and spinal cord
  • not necessarily abnormal
  • nothing it’s normal
  • may be normal
  • associated with upper and lower motor neuron disease or injury
43
Q

Post-Assessment

What Qualities should you consider of all the info that has been gathered?

A
  • reliability: would it give the same results if test were to be repeated?
  • validity: close agreement b/w observation and the best possible measure of reality
  • sensitivity: proportion of people with a disease/condition who are positive for that disease on a given test
  • specificity: proportion of people without the disease/condition who are negative on given test

RPNCE STUDY (18 decks)

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