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Module 1 Exam 2 > Physical Assessment > Flashcards

Physical Assessment Flashcards

1
Q

Whatre considerations for Physical Assessment?

A
  • Cultural Sensitivity
  • Infection Control
  • Environment
  • Equipment
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2
Q

What’re the 2 types and sources of data?

A

Types:
- Subjective: What we are told
- Objective: What we measure and record

Sources:
- Primary: Patient
- Secondary: ANYONE else

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3
Q

Methods of Data Collection

A
  • Interview
  • Nursing Health History
  • Physical Examination
  • Diagnostic and Labs Results
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4
Q

What’re the types of physical assessments? And what are they all considered

A
  • Comprehensive
  • Focused
  • System Specific
  • Ongoing
  • All considered HEAD to TOE
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5
Q

Elements of Assessments

A
  • History
    Baseline
    Problem-based
  • Examinations
    Vitals
    Inspections
    Auscultation
    Palpation
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6
Q

What techniques used during assessment?

A
  • Inspection
  • Palpations
  • Auscultation
  • Olfaction
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7
Q

Should you cover parts that are not being examined when doing an examination?

A

Yes

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8
Q

What are you observing for?

A
  • Color
  • Shape/Symmetry
  • Movement
  • Position
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9
Q

How far are light and deep palpation?

A

Light: 1cm or .5 in.

Deep: 4cm or 2 in.

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10
Q

What do you feel for when palpating?

A
  • Texture
  • Resistance
  • Resilience
  • Mobility
  • Temperature
  • Thickness
  • Shape
  • Moisture
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11
Q

What’re the characteristics of sounds?

A
  • Frequency
  • Loudness
  • Quality
  • Duration
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12
Q

How to prepare for assessments?

A
  • 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
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13
Q

What do you need to consider for older patients?

A
  • Recognize their physical and sensory limitations
  • Recognize normal changes of aging vs abnormal
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14
Q

What are some signs of abuse?

A
  • Inconsistency between injuries and statements
  • Bruises, lacerations, burns, bites
  • X-rays showing fractures in different stages of healing
  • Behavioral issues
    Insomnia
    Anxiety
    Isolation
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15
Q

What is the single most important Nero assessment? And why?

A

Level of Consciousness (LOC), it is often the first clue of a deteriorating condition

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16
Q

What can you test for when determining (LOC)

A
  • Alert
  • Lethargic
  • Obtunded: Needs constant stimulation to stay aroused
  • Stuporous: Only responds to bad stimuli
  • Comatose
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17
Q

How to test for cognitive awareness?

A

Ask something to determine if they know their person, place, and time.

Name and DOB?
Where are you?
What’s the date?

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18
Q

What are cranial nerves 3, 4, 6, 7, 11, 12?

A

3- Oculomotor
4- Trochlear
6- Abducens
7- Facial
11- Accessory
12- Hypoglossal

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19
Q

How to test for pupil response and cardinal gaze (Nerves 3,4,6)?

A

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

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20
Q

How to test for cranial nerve 7?

A

Ask pt to smile showing teeth and to wrinkle their forehead and raise eyebrows

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21
Q

How to test for cranial nerve 12?

A
  • Ask pt to touch roof of mouth with tongue, stick tongue out, and move it side from side
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22
Q

How to test for cranial nerve 11?

A

-Place hand on shoulders and ask them to shrug them

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23
Q

How to test for motor functions? And what does it help with

A
  • Hand grasp and toe wiggle (HGTW)
  • Flexion and extension with resistance
  • Do these bilateral on both BUE and BLE
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24
Q

What’re you listening for in the lungs?

A
  • Vesicular
  • Bronchovesicular
  • Bronchial
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25
Q

What are the abnormal sounds in the lungs?

A
  • Crackles
  • Rhonchi
  • Wheezes
  • Pleural Friction Rub
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26
Q

What’s another abnormal respiratory pattern?

A

Kussmaul’s: Fast, deep, and consistent breaths

27
Q

How many points are there to listen to on the posterior and anterior sides of body?

A

Anterior = 7
Posterior = 10

28
Q

What’re you looking for when inspecting nails?

A

Clubbing

29
Q

What is closing when you hear the LUB and DUB sound in the heart?

A

LUB: Mitral/tricuspid valves close

DUB: Aortic/pumonic valve close

30
Q

What’re the locations of the heart?

A
  • 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
31
Q

What is a doppler?

A

Hand held device for the pedal pulse

32
Q

What is a capillary refill assessment?

A

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

33
Q

What’re the components of a cardiac assessment?

A
  • Heart sounds
  • Pulses
  • Capillary refil
  • Assessment for edema
34
Q

What’s edema?

A
  • 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
35
Q

Where and how to test ROM?

A
  • 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
36
Q

How to test for strength?

A
  • HGTW
  • Flexion and Extension of BUE/BLE
37
Q

What are you inspecting for in skin?

A
  • Hydration
  • Temp
  • Color
  • Texture
  • Rashes
  • Lesions
  • Cracking
38
Q

What factors can affect the skin?

A
  • Dampness
  • Dehydration
  • Nutrition
  • Circulation
  • Disease
  • Jaundice
  • Lifestyle
39
Q

How to test for pitting edema?

A

Press down in the skin
2mm=1+
4mm=2+
6mm=3+
8mm=4+

40
Q

How to asses bony prominences?

A

@ the kips, heels, coccyx, and shoulders, assess for skin integrity and blanching red spots

41
Q

What SHOULD nails appear like?

A
  • Transparent
  • Smooth
  • Rounded
  • Convex
  • Hygienic
42
Q

What is terminal hair and Vellus hair?

A
  • Terminal: Scalp, Axillae, Pubic, beard
  • Vellus: small hairs covering body EXCEPT palms and soles
43
Q

Whatre the qualities of hair?

A
  • Quantity
  • Distribution
  • Texture
  • Color
  • Parasites
44
Q

What to assess ears for?

A
  • Symmetry
  • Drainage
  • Shape
  • Hearing Effects
  • Lesions
  • Redness
  • Tenderness
  • Odor
45
Q

What to inspect for in the nose?

A
  • Position
  • Symmetry
  • Color
  • Swelling
  • Deformaties
  • Discharge
  • Flaring
  • Patency
  • Tenderness
46
Q

Where to inspect in the oral cavity?

A
  • Lips
  • Oral Mucosa
  • Teeth
  • Gums/Tongue
  • Odor
47
Q

What to inspect throat for?

A
  • Lumps
  • Ulcers
  • Edema
  • White Spots
  • Redness
  • Swallowing
48
Q

How to assess neck?

A

INSPECT
- Contour
- Symmetry
- Midline Trachea
- Jugular vein distention

PALPATE
-Inflamed/enlarged lymph nodes

49
Q

3 segments of the small intestines?

A
  • Duodenum
  • Jejunum
  • Ileum
50
Q

7 segments of lg. intestines

A
  • Cecum
  • Ascending colon
  • transcerse colon
  • descending colon
  • sigmoid colon
  • rectum
  • anus
51
Q

What is the order of assessment?

A

Inspect (LOOK) -> Auscultate (LISTEN) -> Palpate (FEEL)

52
Q

What to ask for abdomen assessment?

A
  • Normal bowel and urine patterns?
  • Appearence of waste?
  • Changes?
  • History of problems?
53
Q

Incontinece

A

inability to control urine/feces

54
Q

void/Micturate

A

to urinate

55
Q

Dysuria

A

pain/difficulty urinating

56
Q

hematuria

A

blood in urine

57
Q

nocturia

A

frequent night urination

58
Q

polyuria

A

large amounts of urine

59
Q

urinary frequency

A

the need to void all at once

60
Q

proteinuria

A

large protein in the urine

61
Q

dribbling

A

leakage despite voluntary control

62
Q

retention

A

accumulation of urine in bladder, due to not being able to completely empty

63
Q

What to assess urethral meatus and perineal area for?

A

Inspect urethral orifice for
- erythema,
- discharge,
- swelling,
- odor,
- infection,
- inflammation,
- trauma,
Perineal area
-color
condition
presence of urine or stools

64
Q
A

Module 1 Exam 2 (4 decks)

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