Nursing Assessment Flashcards
What are the four assessment techniques used in a physical examination?
- inspection
- palpation
- percussion
- auscultation
Palpation (size consistency, texture, location & tenderness):
What does the palm of the hand/fingertips assess?
- consistency of tissue
- alignment and intactness is structures
- symmetry of body parts or movements
- transmission of sound and fine vibrations
Palpation: (size consistency, texture, location & tenderness)
Back of the hand assesses…
Skin temperature
Palpation: (size consistency, texture, location & tenderness)
Ulnar surface of the fingers assesses…
texture, moisture, masses, organ position, and area of tenderness
Percussion (location, size or density):
What are the four types of percussion sounds?
- 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
Auscultation:
High-pitched tones are best heard with the _______ of the stethoscope, while low-pitched tones are best heard with the ____ of the stethoscope.
Diaphragm; bell
Cardiovascular System (CV) What is the primary purpose of the CV system? What does it encompass?
- To move nutrients, gases, and wastes to and from cells.
- It encompasses the neck vessels, heart and peripheral vascular system.
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
- maximal contraction
- resting pressure
- pulse pressure
Heart & Pericardium:
Pulsations, or the apical impulse, may be visible in the _th or _th intercostal space at the left midclavicular
4th or 5th
Heart & Pericardium: What is a... - Thrill - Heave * there should never be any palpable heaves or thrills over the apex
- 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
Heart & Pericardium:
Murmurs are turbulence, or a gentle blowing or swooshing sound, caused by:
- a change in the velocity of blood flow
- a structural defect in the valves
- an unusual opening in the cardiac chambers
Heart & Pericardium: Grading of Murmurs I - II - III - IV - V - VI -
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
Heart & Pericardium: Strengths of pulses: 0 = 1+ = 2+ =
0 = absent 1+ = decreased 2+ = normal
What does PERRLA stand for?
Pupils equal, round, reactive to light and accommodation
The skin carriers out 7 major functions, what are they?
- 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
Integumentary System: Possible meaning for having... - Jaundice skin - Pale yellow skin tone - Flushed, red face - Pale
- liver problem, biliary tract disease
- renal problem
- excessive ETOH intake, fever, localized inflammation, embarrassment
- circulatory problem
What is clubbing (& I ain’t talking the dancing clubs lol!)?
Loss of normal angle b/w nail and nail bed d/t chronic oxygen deprivation
Define kyphosis
curvature of the spine - anterior-posterior
define scoliosis
curvature of the spine - lateral
define barrel chest
chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen in COPD
define pectus excavatum
sternum sunken into chest
define pectus carinatum
sternum protruding from the chest
define cyanosis
bluish discoloration of the skin and mucous membranes d/t excessive concentration of reduced hemoglobin in the blood
define apneustic
prolonged gasping
define Cheyne-Stokes
varying depth followed by apnea
define Biot’s
increased depth and rate with abrupt pauses
Respiratory System: Percussion sound... - resonance = - hyperresonance = - flatness =
- normal - healthily air-filled lung
- too much air - emphysema
- presence of fluid or solid mass - pleural effusion, pneumonia, tumor
Respiratory System:
what are adventitious breath sound
refer to extra, or additional, sounds that are heard over normal breath sounds
- usually leads to a diagnosis of cardiac and pulmonary conditions
Respiratory System:
what are crackles caused by
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
Respiratory System:
what are crackles offten associated with
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)
Respiratory System:
- What are fine crackles?
- What are course crackles?
- What are medium crackles?
- 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
Respiratory System:
What are wheezes caused by?
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
Respiratory System:
When do pleural friction rubs occur?
- 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)
Respiratory System:
What is a stridor caused by?
What is stridor a sign of?
- 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
GI System:
A lower quadrant bulge may indicate what?
A distended bladder
GI System:
A midline bulge may be a what?
Umbilical hernia
Abdominal distension can be caused by 3 factors. What are they?
- obesity: soft and rounded, with sunken umbilicus
- ascites: skin is shiny and glistening, with an everten umbilicus and dilated, prominent veins
- obstruction: visible, makrked peristalsis, restlessness, lying with knees flexed, grimacing facial expression and uneven respirations
GI System Bowel Sounds are classified as: - hypoactive - - normal - - hyperactive -
- infrequent
- intermittently at 5-15 times per min
- more frequent than normal
GI System Percuss all four quads of the abdomen - tympany - - hyperresonance - - dullness -
- 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.
GI System: Palpation When would you use... - light palpation - deep palpation
- detects superficial masses and fluid accumulating in an abdomen that is soft and non-tender
- detects masses, tenderness, pulsations, organ enlargement
Musculoskeletal System Test strength of major muscle groups using a grading scale: - grade 5: - grade 4: - grade 3: -grade 2: - grade 1: - grade 0:
- 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)
Neurologic System: Reflex Testing (scoring) & risks associated with score - hyperactive (4+): - brisker than normal (3+): - normal (2+) - diminished (1+): - absent (0) pathologic;
- 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
Post-Assessment
What Qualities should you consider of all the info that has been gathered?
- 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
