Physical Assessment Flashcards
What do we use the physical examination for, what’s the purpose?
Triage for emergency care
Routine screening
To determine eligibility for: Health insurance
Military service
A new job
To gather baseline data
Support or refute subjective data that we’ve obtained
Identify and confirm the nursing diagnosis
Make clinical decisions about patients changing health
How does Cultural sensitive play a part in assessment
Depending on culture, it can influence a patient’s behavior & they might have different approaches
You would need to consider their: nutritional habits, any alternative therapies they prefer, relationship with family, and their comfort zone
You want to avoid stereotypes and gender bias
Gathering data: Sources of data
Examination, Observation, Review of Literature, Consultation, Interviewing
Gathering data: Health History
What info would you look for
Demographic data, why their seeking care, Patient expectations, Present illness, Post health history, Family health history, Spiritual health, Lifestyle, Psychosocial history, review of symptoms, their functional abilities, medications, allergies, immunizations, advance directives, surgeries, nutrition, Elimination
Investigating patient-reported symptoms
Location, does the pain radiate?
Quality, is the pain sharp, dull or throbbing?
Quantity
Chronology, What happens after pain appears
Setting
Does anything aggravate or alleviate the pain?
What do you want the fix to be, medication?
Activity level
Cognitive, is the patient’s alert
What are the 4 components of examination?
Inspect, Palpation, Percussion, Auscultation
What does Auscultation consist of
Looking for pulses, abnormalities
What does palpation consist of
Lightly feeling the surface of the location
What does percussion consist of
lightly tapping on the surface to hear for gases or fluids
What does observation consist of
USING ALL SENSES, besides taste
Observing the color and texture of the skin
Character of respirations
Mannerisms
Mental state
What do you look for in a nonverbal patient
You would look at their expressions or feeling, you can usually tell how someone feels based on how they seem to appear
Where do you begin in collection and assessment
Physiological observation and assessment begin at the head and work down
may be conducted by body systems
must have a system to ensure nothing is overlooked
data collection assessment:
Mental status
Look to see if they are oriented, disoriented, alert, focused, incoherent, unresponsive, or unconscious
data collection assessment:
Emotional state
Look to see their mood, are they anxious? Do they exhibit defense mechanisms, what is their perception of body image, what is their ability to relate to others
data collection assessment:
Head
Look at their hair
thinning?
Alopecia?
clean/dirty?
lice, ringworm, etc?
data collection assessment:
Eyes
Look to see their
visual activity
fields of vision
inspect sclera, lids
check for symmetry
pupil response
do they wear glasses or contacts
data collection assessment:
Ears
can they hear well, do they have hearing aids
data collection assessment:
Nose
check their septum
do they have any discharge
are their frontal and maxillary sinuses alright?
data collection assessment:
Mouth
Inspect the teeth, gums, tongue, condition of teeth and lip moisture
data collection assessment:
Neck
Inspect the lymph nodes
Mobility
symmetry
data collection assessment:
Skin
Look at color, hydration, rashes, edema, wounds, abrasions and scars
Describing skin using ABCD
Asymmetry
Border irregularity
Color
Diameter
data collection assessment:
Thorax
Look at
size
shape
ribs in relation to spine
respiratory movements
can you see the muscles being used? (overused= bad)
data collection assessment:
Lungs
Listen for
wheezes, cracks, breath sounds
quality of breath
data collection assessment:
Cardiovascular
Check:
pulse
blood pressure
veins; Is there varicosities, edema, thrombus?
data collection assessment:
Breasts
size
shape, symmetry
dimpling
striae
nipple retraction
discharge
augmentation or reduction mastectomy
data collection assessment:
Abdomen
GI status
GU status
bowel sounds
tenderness
scars
fat distribution/obesity
data collection assessment:
Musculoskeletal
posture
spine
legs/feet
joints
gait
height and weight
data collection assessment:
Nervous system
Neuro assessment
Coordination
Sensory function
What does the neurologist check consist of
LOC
Reflexes
Strength
CMS
Memory
What is PERRLA
Pupils
Equal
Round
Responsiveness
Light
Accommodation
What do you do with the data collected?
Add it to the Chart!!
Anything from assessments, problems identified, personnel notified, tests done, vital signs, nursing diagnosis, and nursing history
What is a chart
A legal document, always done in pen!
use only faculty-approved abbreviations
notes are concise, objective, and factual
Quote the patient as appropriate and document patient or family strengths
What is the outline for nursing notes?
Narrative
Usage of PIE
SOAP
and
DAR
What does PIE stand for
Problems: pain on a scale of 1-10
Interventions: medications, relief recommendations
Evaluation:reactions to interventions
What does SOAP stand for
Subjective: what the patient says
Objective: What’s observed
Assessment: conclusions drawn
Plan: medication plan or any other reliefs
What does DAR stand for
Data: Objective and subjective
Action:Interventions
Response: Reaction to interventions
What are vital signs?
consist of temperature, pulse, respiration (TPR), and blood pressure (BP).
Assessment of Pain and Pulse Ox
Monitors the functions of the body
Begin assessment with vital signs as Taken on admission to obtain a baseline.
Retaken when there is a change in client condition.
Detects changes not otherwise observed.
Try to relax the patient before taking vital signs
What are the methods of measuring body temperature
Glass thermometer
Electronic/digital thermometer
Disposable tape, temp dots
Temporal Artery thermometer
Tympanic
What is regular body temperature and what is a regular body temperature
96.8-100.4 (36-38C) Acceptable ranges for Adults
Hypothermia= <95 degrees or 35 C
Pyrexia= > 100.4- degrees
Hyperthermia= increased body temperature
What are the sites for taking temperature?
Mouth, oral
Rectum, rectal
Axilla, axillary
Ear
Temporal
What are the harmful effects of a fever
Temperature ober 106 or greater causes brain tissue damage
Accelerated weight and protein loss
Increased loss of NaCI and water
Increases pulse, respirations, and blood strains the cardiac system
Tips to remember when taking temperature
Hot or cold drinks will affect oral temperature
When doing rectal temperatures make sure to lubricate thermometer
Oral thermometer has a blue and an elongated tip
Rectal thermometer has a red end and a bulb tip
How much do you insert the thermometer for children and adults?
1/2 inch for children
1-1 1/2 inches for adults
What are nursing care interventions for a patient with a fever
Keep room cool, not drafty
Keep patient dry
Remove excess clothing, but maintain privacy
Oral care
Bed rest
Sponge bosy with tepid water
Convulsions may occur
Encourage fluids
Hypothermic blanket as ordered
Notify MD and keep patient and family informed regarding tests and lab work
Where can you take pulses
Temporal, carotid, apical, bronchial, Radial, femoral popliteal, posterior tibial, dorsalis pedis
Pulse assessment: normal pulse and irregular pulses
number of Beats/Minute
normal range: 60-100 b/m (athletes may be
50-60 b/m) Adult
tachycardia: rate > 100 b/m Adult
bradycardia: rate < 60 b/m Adul
When do you take an apical pulse
When ordered by an MD
If the pulse is difficult to detect or count
If the pulse is irregular
If the pulse is very rapid or very slow
When giving cardiac medications
What is pulse deficit
Pulse is taken at the same time from two different sites
the difference is the pulse deficit
Respiration assessment
one inhalation and exhalation is counted as one respiration
normal rate: 16-20 breaths/m
Can be regular or irregular
Shallow or labored
tidal volume
am’t of air inhaled and exhaled during normal ventilation
dyspnea
difficulty breathing, SOB
orthopnea
labored breathing caused by lying flat
polypnea
panting
tachypnea
rapid breathing
hyperpnea
deeper than normal breathing
bradypnea
slow rate
apnea
no respirations
Cheyne-Stokes
abnormal breathing pattern characterized by a period of apnea followed by a gradual increase in rate and depth of breathing
stertorous
labored and noisy breathing
How is blood pressure measured & what is the pulse pressure
Measured as two numbers
systolic/diastolic
Pulse pressure is the difference between the systolic and diastolic pressures
What is systolic
Force of heart// point where the first sound is heard
What is diastolic
When the heart is in between beats // point where last sound is heard
What contraindications will prevent you from taking BP on an arm
Injury to the shoulder, arm or hand
Mastectomy
Central line
Peripheral line
AV fistula or graft
What factors can effect BP readings
Emotion, Age, Pumping action of the heart, Elasticity of the artery walls, Resistance in the artery walls, Time of day, Position, Pain, Activity
What are the techniques for taking BP
Client should be seated
Have arm bared, supported, at heart level
No coffee or smoking 30 min prior to taking BP
Rest 5 min before its taken too
Taking BP in popliteal
Place client in prone position
Expose thigh
Locate popliteal artery
Apply cuff with bladder over posterior thigh, above the knee
Systolic BP is usually 20-30 mm Hg higher then the brachial
BP classifications
normal 120/80
elevated 120-129/80
Stage 1 HTN 130-139/80-89
Stage 2 HTN 140/90
Hypertensive crisis 180/120
Hypertension lifestyle
Maintain adequate potassium, calcium, and magnesium intake
Stop smoking
Reduce saturated fat and cholesterol
Lose weight if overweight
Increase activity/decrease stress
Reduce sodium intake
what is the 5th vital sign & how do you assess it
Pain
Location, quality, intensity faces ( 1-10 )
Description: dull, sharp, burning
Pattern: Onset, duration, constancy
Precipitating factors
Alleviating factors
Effects of ADL’s
Pulse oximeter
Can detect hypoxemia before dusky skin color develops
Normal: 95%-100%
Below 70% can be life threatening
