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Nursing Fundamentals > Physical Assessment > Flashcards

Physical Assessment Flashcards

1
Q

Rhonchi

A

coarse sound, gurgling; cleared with cough; low pitched expiration heard in expiration from secretion in bronchiole

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2
Q

Rales/crackles

A

crackles heard at base from fluid accumulation; not how far up the lungs it goes; could mean CHF, heard on inspiration

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3
Q

Wheezes

A

music or high pitched cooing sound; caused by obstruction of airflow out from the lungs; heard on inspiration and expiration

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4
Q

Order of assessment - Abdomen

A

inspection, auscultation, percussion, palpation

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5
Q

What are the four techniques used in physical assessment?

A

inspection, palpation, percussion, auscultation; order changes with the abdomen

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6
Q

Assessing health status involves what two components?

A

health history and physical assessment

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7
Q

A complete health assessment starts on which part of the body first

A

head to toe; systematically working downward efficiently with fewest position changes for the patient

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8
Q

Order of Head to Toe

A

general survey, V/S, head, neck, upper extremities, chest and back, abdomen, external genitalia, anus, lower extremities

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9
Q

What are some of the purposes of the physical assessment?

A
  • 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
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10
Q

Nurses use guidelines and ___________ practice to focus health assessment on specific conditions

A

evidence-based

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11
Q

What are some colorectal cancer screenings?

A

FOBT annually 50+
Sigmoidoscopy q 5 years 50+
Colonoscopy every 10 years 50+
Barium enema q 5 years 50+

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12
Q

What are some breast cancer screenings?

A

BSE starting early 20”s
breast exam q 3 years 20-40 y/o
MMG annually 40+

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13
Q

What are some cervical and uterine cancer screenings?

A

PAP q 2 or 3 years; may be stopped after total hysterectomy and at age 70 if 10 year Hx of negative result

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14
Q

What are some prostate cancer screenings?

A

consult physician (PSA)

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15
Q

Is head-to-toe assessment the same for adults and children?

A

no; less invasive areas (mouth, genitals, ears) last

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16
Q

Palpation is used to determine…

A

texture, temperature, vibration, organ/mass info (position, size, consistency, mobility), distention, pulsation, tenderness/pain

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17
Q

dorsal recumbent

A

female assessment: back-lying position with knees flexed and hips external rotated; used for cardiopulmonary problems

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18
Q

Supine

A

Overall assessment: back lying, legs extended; not tolerated with respiratory and cardiovascular problems

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19
Q

Lithotomy

A

female assessment: legs in stirrups

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20
Q

Sims

A

rectal/vaginal assessment: side-lying position with lower arm behind body and upper leg flexed

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21
Q

Prone

A

Posterior thorax and hip assessment: lies on abdomen head to side; not tolerated by older adults or with cardiovasc/resp problems

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22
Q

Two types of pal pation are:

A

light and deep

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23
Q

Describe light palpation

A

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

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24
Q

Describe deep palpation

A

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)

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25
Q

The effectiveness of palpation depends largely on

A

the client’s relaxation; always note patients facial expression

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26
Q

Direct vs Indirect Percussion

A

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)

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27
Q

Flatness is described as

A

extremely dull sound of dense tissue (muscle, bone)

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28
Q

Dullness is described as

A

thud-like sound produced by dense tissue (liver, spleen, heart)

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29
Q

Resonance is described as

A

hollow sound (like air in the lungs)

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30
Q

Hyperresonance is described as

A

booming sound heard in an emphysematous lung, not produced in the normal body

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31
Q

Tympany is described as

A

musical or drum-like sound produced by air in the stomach

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32
Q

Direct auscultation

A

listening with the naked ear

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33
Q

Indirect ausultation

A

use of stethescope

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34
Q

Auscultated sounds are described in what four ways?

A

pitch (low/high), intensity (softness/loudness), duration (long/short) and quality (whistling, gurgling)

35
Q

All four quadrants should be checked for how long?

A

2-3 minutes

36
Q

Describe bladder distention

A

feels like an orange or grapefruit, measured by fingerbreadths

37
Q

If you don’t hear BS in 1 quadrant you should

A

do nothing, it is not significant

38
Q

Hypoactive BS

A

one occurring every minute; indicates decreased motility and associated with Sx, inflammation, paralytic ileus or late bowel obstruction

39
Q

Hyperactive BS

A

occurring every 3 seconds; indicates ^ motility, diarrhea

40
Q

Active BS occur every

A

5-20 second, increased shortly after meal or after long period, loudest when meal is overdue

41
Q

pallor

A

result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation

42
Q

cyanosis

A

bluish tinge; most evident in the nail beds, lips, and buccal mucosa

43
Q

vitiligo

A

hypopigmentation, seen as patches due to destruction of the melanocytes

44
Q

edema 3+ =

A

6 mm

45
Q

PERRLA

A

pupils equal round reactive to light and accommodation

46
Q

assess neck from

A

left to right

47
Q

PMI

A

Point of maximal impulse, apex of the heart, S1

48
Q

S1

A

first sound of heart, when aortic valves close, heard at apex

49
Q

S2

A

second heart sound, when pulmonary semilunars close, heard at 2nd intercostal midclavicular space

50
Q

Start on opposite side of heart

A

when auscultating heart sounds

51
Q

VS

A

good sign of O2 to brain, always get BP and pulse if dizzyness reported

52
Q

Systolic

A

1st BP sound, significant if decreased by mmg

53
Q

percussion

A

more advanced skill NOT for regular beginner use, need to know sounds (tympany loud drum like not lung; resonance and hyperresonance for lung)

54
Q

palpation

A

palpate tender areas first, palpate texture, temp bilaterally

55
Q

thrombophlebitis

A

phlebitis (vein inflammation) related to a thrombus (blood clot); HOMONS test push sole and toes back = pain

56
Q

rt abdomen pain radiates to

A

shoulder, gas moves up

57
Q

rebound tenderness

A

push in let go fast, rebound of appendix on stomach wall will cause pain if appendicitis

58
Q

turgor

A

skin pinch test for dehydration; performed in hand but in elderly under scapula

59
Q

CNIII

A

cranial nerve 3 is tested by moving eyes 6 different ways with symmetry without moving head

60
Q

nastygmus

A

increased ticking motion of eyes, a few extra ticks when looking at highest point is normal

61
Q

orientation

A

AO X 3 - person, place, time ( time can be day of week, holiday coming, current season)

62
Q

When assessing mental status

A
  1. appearance, facial expression, mood and affect
  2. judgement
  3. 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
63
Q

positive accommodation

A

restriction of pupils and equal conversion when sling light through nose

64
Q

The big 3 - NG Tube

A

nasal O2 suctioning can result in nose bleeding, perf and infection

65
Q

dental carries means

A

infection

66
Q

Gingival hyperplasia can be caused by what med?

A

Dilantin

67
Q

Kussmal breathing

A

a very deep gasping type of respiration associated with severe diabetic acidosis and coma

68
Q

anasarca

A

general whole body edema

69
Q

ascites

A

abdominal edema

70
Q

pitting edema

A

edema with significant pitting

71
Q

Check all 4 quadrants of the abdomen

A

move in clockwise direction, if no sound in 1 quadrant it is not significant

72
Q

Hypoactive BS

A

post up or blockage

73
Q

location of lungs

A

locate posterior ribs roll thumbs down and at bottom of posterior scapula, listen 4-6 times, start at top

74
Q

Order of abdominal assessment

A

inspection, auscultation, percussion, palpation

75
Q

bladder distention

A

could be sign of many things, recorded in fingerbreadths, feels like orange or grapefruit

76
Q

crepitus

A

crunching sound/sensation heard in pneumonia and other lung diseases, as well as, in the knee as it is bent back and forth.

77
Q

Stridor

A

a high-pitched harsh sound heard during inspiration. Stridor is caused by obstruction of the upper airway.

78
Q

Joint and Muscle palpation

A

during flexion, check for edema

79
Q

Cheyne-Stokes respirations

A

a breathing pattern characterized by a period of apnea, followed by gradually increasing depth and frequency of respirations

80
Q

Ataxic breathing

A

also known as Biot’s breathing, is characterized by unpredictable irregularity

81
Q

Adventitious breath sounds

A

abnormal breath sounds heard when listening to the chest. Adventitious sounds may include crackles or rales, rhonchi or wheezes, or pleural friction rubs

82
Q

Consolidation

A

the replacement of air in the lungs with fluid or a mass

83
Q

Fremitus

A

a vibration felt while a patient is speaking and the examiner’s hand is held against the chest

Nursing Fundamentals (7 decks)

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