Physical Assessment Flashcards
Whatre considerations for Physical Assessment?
- Cultural Sensitivity
- Infection Control
- Environment
- Equipment
What’re the 2 types and sources of data?
Types:
- Subjective: What we are told
- Objective: What we measure and record
Sources:
- Primary: Patient
- Secondary: ANYONE else
Methods of Data Collection
- Interview
- Nursing Health History
- Physical Examination
- Diagnostic and Labs Results
What’re the types of physical assessments? And what are they all considered
- Comprehensive
- Focused
- System Specific
- Ongoing
- All considered HEAD to TOE
Elements of Assessments
- History
Baseline
Problem-based - Examinations
Vitals
Inspections
Auscultation
Palpation
What techniques used during assessment?
- Inspection
- Palpations
- Auscultation
- Olfaction
Should you cover parts that are not being examined when doing an examination?
Yes
What are you observing for?
- Color
- Shape/Symmetry
- Movement
- Position
How far are light and deep palpation?
Light: 1cm or .5 in.
Deep: 4cm or 2 in.
What do you feel for when palpating?
- Texture
- Resistance
- Resilience
- Mobility
- Temperature
- Thickness
- Shape
- Moisture
What’re the characteristics of sounds?
- Frequency
- Loudness
- Quality
- Duration
How to prepare for assessments?
- Get all necessary equipment
- Introduce
- Explain the procedure
- Use gloves if necessary
- Wash hands before and after ANY patient contact
- Clean equipment in between pt’s
- Help pt feel comfortable and allow for privacy
What do you need to consider for older patients?
- Recognize their physical and sensory limitations
- Recognize normal changes of aging vs abnormal
What are some signs of abuse?
- Inconsistency between injuries and statements
- Bruises, lacerations, burns, bites
- X-rays showing fractures in different stages of healing
- Behavioral issues
Insomnia
Anxiety
Isolation
What is the single most important Nero assessment? And why?
Level of Consciousness (LOC), it is often the first clue of a deteriorating condition
What can you test for when determining (LOC)
- Alert
- Lethargic
- Obtunded: Needs constant stimulation to stay aroused
- Stuporous: Only responds to bad stimuli
- Comatose
How to test for cognitive awareness?
Ask something to determine if they know their person, place, and time.
Name and DOB?
Where are you?
What’s the date?
What are cranial nerves 3, 4, 6, 7, 11, 12?
3- Oculomotor
4- Trochlear
6- Abducens
7- Facial
11- Accessory
12- Hypoglossal
How to test for pupil response and cardinal gaze (Nerves 3,4,6)?
Pupil Response:
- Use a penlight going from ear inwards to the nose
Note the size and speed of reaction
- With light off, move penlight close to and away from pupils
Cardinal Gaze:
With tip of the penlight, and about 9-12” from the face, tell pt to follow the pen while you make an H movement pattern
How to test for cranial nerve 7?
Ask pt to smile showing teeth and to wrinkle their forehead and raise eyebrows
How to test for cranial nerve 12?
- Ask pt to touch roof of mouth with tongue, stick tongue out, and move it side from side
How to test for cranial nerve 11?
-Place hand on shoulders and ask them to shrug them
How to test for motor functions? And what does it help with
- Hand grasp and toe wiggle (HGTW)
- Flexion and extension with resistance
- Do these bilateral on both BUE and BLE
What’re you listening for in the lungs?
- Vesicular
- Bronchovesicular
- Bronchial
What are the abnormal sounds in the lungs?
- Crackles
- Rhonchi
- Wheezes
- Pleural Friction Rub
What’s another abnormal respiratory pattern?
Kussmaul’s: Fast, deep, and consistent breaths
How many points are there to listen to on the posterior and anterior sides of body?
Anterior = 7
Posterior = 10
What’re you looking for when inspecting nails?
Clubbing
What is closing when you hear the LUB and DUB sound in the heart?
LUB: Mitral/tricuspid valves close
DUB: Aortic/pumonic valve close
What’re the locations of the heart?
- Aortic: Right Base, at the 2nd intercostal space
- Pulmonic: Left Base, 2nd intercostal space
- Tricuspid: Left lateral sternal border, 5th intercostal space
- Mitral: Apex, midclavical at 5th intercostal space
What is a doppler?
Hand held device for the pedal pulse
What is a capillary refill assessment?
Press skin of the nail bed till its white, and observe how long it will take for the red-ish color to return, should take 2-3 seconds, do on both BUE and BLE
What’re the components of a cardiac assessment?
- Heart sounds
- Pulses
- Capillary refil
- Assessment for edema
What’s edema?
- Swelling in the extremities
Dependent: Mostly in feet and ankles when older adults stand
Pitting: Venous insufficiency or heart/kidney failure, there’s fluid in tissues
Where and how to test ROM?
- Neck: Side to Side, Chin to chest, Extend to back
- Shoulders Upper arms and elbows: Straight to side, straight up, touchdown
- Wrist: Circle
- Hips, Ankles, Knees: Bilateral hip flexion out, Bend knees, Ankle Circles
How to test for strength?
- HGTW
- Flexion and Extension of BUE/BLE
What are you inspecting for in skin?
- Hydration
- Temp
- Color
- Texture
- Rashes
- Lesions
- Cracking
What factors can affect the skin?
- Dampness
- Dehydration
- Nutrition
- Circulation
- Disease
- Jaundice
- Lifestyle
How to test for pitting edema?
Press down in the skin
2mm=1+
4mm=2+
6mm=3+
8mm=4+
How to asses bony prominences?
@ the kips, heels, coccyx, and shoulders, assess for skin integrity and blanching red spots
What SHOULD nails appear like?
- Transparent
- Smooth
- Rounded
- Convex
- Hygienic
What is terminal hair and Vellus hair?
- Terminal: Scalp, Axillae, Pubic, beard
- Vellus: small hairs covering body EXCEPT palms and soles
Whatre the qualities of hair?
- Quantity
- Distribution
- Texture
- Color
- Parasites
What to assess ears for?
- Symmetry
- Drainage
- Shape
- Hearing Effects
- Lesions
- Redness
- Tenderness
- Odor
What to inspect for in the nose?
- Position
- Symmetry
- Color
- Swelling
- Deformaties
- Discharge
- Flaring
- Patency
- Tenderness
Where to inspect in the oral cavity?
- Lips
- Oral Mucosa
- Teeth
- Gums/Tongue
- Odor
What to inspect throat for?
- Lumps
- Ulcers
- Edema
- White Spots
- Redness
- Swallowing
How to assess neck?
INSPECT
- Contour
- Symmetry
- Midline Trachea
- Jugular vein distention
PALPATE
-Inflamed/enlarged lymph nodes
3 segments of the small intestines?
- Duodenum
- Jejunum
- Ileum
7 segments of lg. intestines
- Cecum
- Ascending colon
- transcerse colon
- descending colon
- sigmoid colon
- rectum
- anus
What is the order of assessment?
Inspect (LOOK) -> Auscultate (LISTEN) -> Palpate (FEEL)
What to ask for abdomen assessment?
- Normal bowel and urine patterns?
- Appearence of waste?
- Changes?
- History of problems?
Incontinece
inability to control urine/feces
void/Micturate
to urinate
Dysuria
pain/difficulty urinating
hematuria
blood in urine
nocturia
frequent night urination
polyuria
large amounts of urine
urinary frequency
the need to void all at once
proteinuria
large protein in the urine
dribbling
leakage despite voluntary control
retention
accumulation of urine in bladder, due to not being able to completely empty
What to assess urethral meatus and perineal area for?
Inspect urethral orifice for
- erythema,
- discharge,
- swelling,
- odor,
- infection,
- inflammation,
- trauma,
Perineal area
-color
condition
presence of urine or stools
