Physical Assessment Flashcards
Rhonchi
coarse sound, gurgling; cleared with cough; low pitched expiration heard in expiration from secretion in bronchiole
Rales/crackles
crackles heard at base from fluid accumulation; not how far up the lungs it goes; could mean CHF, heard on inspiration
Wheezes
music or high pitched cooing sound; caused by obstruction of airflow out from the lungs; heard on inspiration and expiration
Order of assessment - Abdomen
inspection, auscultation, percussion, palpation
What are the four techniques used in physical assessment?
inspection, palpation, percussion, auscultation; order changes with the abdomen
Assessing health status involves what two components?
health history and physical assessment
A complete health assessment starts on which part of the body first
head to toe; systematically working downward efficiently with fewest position changes for the patient
Order of Head to Toe
general survey, V/S, head, neck, upper extremities, chest and back, abdomen, external genitalia, anus, lower extremities
What are some of the purposes of the physical assessment?
- obtain baseline data
- confirm or refute history
- establish nursing diagnosis
- evaluate physiological outcomes and progress
- make clinical judgement of status
- identify areas for disease prevention and health promotion
Nurses use guidelines and ___________ practice to focus health assessment on specific conditions
evidence-based
What are some colorectal cancer screenings?
FOBT annually 50+
Sigmoidoscopy q 5 years 50+
Colonoscopy every 10 years 50+
Barium enema q 5 years 50+
What are some breast cancer screenings?
BSE starting early 20”s
breast exam q 3 years 20-40 y/o
MMG annually 40+
What are some cervical and uterine cancer screenings?
PAP q 2 or 3 years; may be stopped after total hysterectomy and at age 70 if 10 year Hx of negative result
What are some prostate cancer screenings?
consult physician (PSA)
Is head-to-toe assessment the same for adults and children?
no; less invasive areas (mouth, genitals, ears) last
Palpation is used to determine…
texture, temperature, vibration, organ/mass info (position, size, consistency, mobility), distention, pulsation, tenderness/pain
dorsal recumbent
female assessment: back-lying position with knees flexed and hips external rotated; used for cardiopulmonary problems
Supine
Overall assessment: back lying, legs extended; not tolerated with respiratory and cardiovascular problems
Lithotomy
female assessment: legs in stirrups
Sims
rectal/vaginal assessment: side-lying position with lower arm behind body and upper leg flexed
Prone
Posterior thorax and hip assessment: lies on abdomen head to side; not tolerated by older adults or with cardiovasc/resp problems
Two types of pal pation are:
light and deep
Describe light palpation
precedes deep palpation; fingers of dominant hand are moved in a circular movement while pressed gently and parallel to skin; areas may be lightly palpated several times rather than holding pressure
Describe deep palpation
done after light because the pressure can dull sense; done with two hands; top hand applies pressure and lower hand perceives sensation; one hand may be used. USUALLY NOT DONE ON ROUTINE EXAM and REQUIRES SIGNIFICANT SKILL (pressure can damage organs and not done with undiagnosed acute abdominal pain)
The effectiveness of palpation depends largely on
the client’s relaxation; always note patients facial expression
Direct vs Indirect Percussion
direct - strike the area with 2, 3, 4 finger pads rapidly (not for thorax, good for sinus cavity)
indirect - middle finger of dominant hand strikes other middle finger as it is pressed firmly on skin (90 degree angle)
Flatness is described as
extremely dull sound of dense tissue (muscle, bone)
Dullness is described as
thud-like sound produced by dense tissue (liver, spleen, heart)
Resonance is described as
hollow sound (like air in the lungs)
Hyperresonance is described as
booming sound heard in an emphysematous lung, not produced in the normal body
Tympany is described as
musical or drum-like sound produced by air in the stomach
Direct auscultation
listening with the naked ear
Indirect ausultation
use of stethescope
Auscultated sounds are described in what four ways?
pitch (low/high), intensity (softness/loudness), duration (long/short) and quality (whistling, gurgling)
All four quadrants should be checked for how long?
2-3 minutes
Describe bladder distention
feels like an orange or grapefruit, measured by fingerbreadths
If you don’t hear BS in 1 quadrant you should
do nothing, it is not significant
Hypoactive BS
one occurring every minute; indicates decreased motility and associated with Sx, inflammation, paralytic ileus or late bowel obstruction
Hyperactive BS
occurring every 3 seconds; indicates ^ motility, diarrhea
Active BS occur every
5-20 second, increased shortly after meal or after long period, loudest when meal is overdue
pallor
result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation
cyanosis
bluish tinge; most evident in the nail beds, lips, and buccal mucosa
vitiligo
hypopigmentation, seen as patches due to destruction of the melanocytes
edema 3+ =
6 mm
PERRLA
pupils equal round reactive to light and accommodation
assess neck from
left to right
PMI
Point of maximal impulse, apex of the heart, S1
S1
first sound of heart, when aortic valves close, heard at apex
S2
second heart sound, when pulmonary semilunars close, heard at 2nd intercostal midclavicular space
Start on opposite side of heart
when auscultating heart sounds
VS
good sign of O2 to brain, always get BP and pulse if dizzyness reported
Systolic
1st BP sound, significant if decreased by mmg
percussion
more advanced skill NOT for regular beginner use, need to know sounds (tympany loud drum like not lung; resonance and hyperresonance for lung)
palpation
palpate tender areas first, palpate texture, temp bilaterally
thrombophlebitis
phlebitis (vein inflammation) related to a thrombus (blood clot); HOMONS test push sole and toes back = pain
rt abdomen pain radiates to
shoulder, gas moves up
rebound tenderness
push in let go fast, rebound of appendix on stomach wall will cause pain if appendicitis
turgor
skin pinch test for dehydration; performed in hand but in elderly under scapula
CNIII
cranial nerve 3 is tested by moving eyes 6 different ways with symmetry without moving head
nastygmus
increased ticking motion of eyes, a few extra ticks when looking at highest point is normal
orientation
AO X 3 - person, place, time ( time can be day of week, holiday coming, current season)
When assessing mental status
- appearance, facial expression, mood and affect
- judgement
- recent memory (don’t use anything we don’t know the answer to, ie breakfast) can use 3 unrelated words and check in 15 minutes
positive accommodation
restriction of pupils and equal conversion when sling light through nose
The big 3 - NG Tube
nasal O2 suctioning can result in nose bleeding, perf and infection
dental carries means
infection
Gingival hyperplasia can be caused by what med?
Dilantin
Kussmal breathing
a very deep gasping type of respiration associated with severe diabetic acidosis and coma
anasarca
general whole body edema
ascites
abdominal edema
pitting edema
edema with significant pitting
Check all 4 quadrants of the abdomen
move in clockwise direction, if no sound in 1 quadrant it is not significant
Hypoactive BS
post up or blockage
location of lungs
locate posterior ribs roll thumbs down and at bottom of posterior scapula, listen 4-6 times, start at top
Order of abdominal assessment
inspection, auscultation, percussion, palpation
bladder distention
could be sign of many things, recorded in fingerbreadths, feels like orange or grapefruit
crepitus
crunching sound/sensation heard in pneumonia and other lung diseases, as well as, in the knee as it is bent back and forth.
Stridor
a high-pitched harsh sound heard during inspiration. Stridor is caused by obstruction of the upper airway.
Joint and Muscle palpation
during flexion, check for edema
Cheyne-Stokes respirations
a breathing pattern characterized by a period of apnea, followed by gradually increasing depth and frequency of respirations
Ataxic breathing
also known as Biot’s breathing, is characterized by unpredictable irregularity
Adventitious breath sounds
abnormal breath sounds heard when listening to the chest. Adventitious sounds may include crackles or rales, rhonchi or wheezes, or pleural friction rubs
Consolidation
the replacement of air in the lungs with fluid or a mass
Fremitus
a vibration felt while a patient is speaking and the examiner’s hand is held against the chest
