Physical Assessment Flashcards
conjunctivae
mucous membranes that line the eye ball (bulbar conjuctiva and inside surfaces of the eyelids (palpbral conjuctiva)
outer part of the eye ball
sclera
transparent layer than covers the iris and the pupil
cornea
maxillary sinus
under eyes lateral to nose
frontal sinus
above inner part of eyebrows
Orientation deficit is a gap in the client’s awareness of person, place, or time.
Acute disorientation can be caused by infections, dehydration, low oxygen levels, medications, and other imbalances. Chronic disorientation can be present with some neurological disorders.
sign of stroke
one-sided muscle weakness by instructing the client to squeeze both of your hands at the same time.
vital signs: orientation deficit
vital signs such as increased temperature or decreased oxygen saturations can lead to changes in the client’s orientation.
expected findings: skull
generally round with prominences in the frontal area anteriorly and the occipital area posteriorly
Expected protrusions are also found on the side of each parietal bone and the mastoid process behind each ear.
The head should be proportional in relation to the body and is typically held upright and midline to the trunk.
expected findings: facial features
the palpebral fissures (the opening between the eyelids) and the nasolabial folds (creases from the nose to the corner of the mouth), should be symmetrical and the face should have a relaxed expression.
expected variations: facial features
Slight asymmetry of facial features is expected. Dry, brittle hair and overall hair thinning are often related to aging.
unexpected findings: facial features
significantly asymmetrical typically indicate a paralysis of one of the cranial nerves that control the facial muscles.
It can also be an indication that the client has had a stroke.
A tense facial expression could indicate anxiety or pain.
unexpected findings: head
Lumps, protrusions, or sunken areas in the skull can indicate trauma to the head.
Ecchymotic areas on the skull or face can indicate the occurrence of recent trauma.
The presence of coarse facial hair on a female (e.g. hirsutism) can indicate a hormonal or endocrine disorder.
unexpected findings: scalp
Lesions, or redness on the face or scalp can indicate the presence of a skin disorder or infection.
Hair loss can indicate conditions such as the presence of an autoimmune inflammatory disorder (alopecia areata, Lupus, conditions of the thyroid, a fungal infection [tinea capitus], effects from certain medications [chemotherapeutic agents], or stress).
Small oval white particles attached to the hair strands can indicate the presence of head lice (Pediculus humanus capitis).
unexpected findings: eyes
Edema around the eyes (periorbital), cheeks, or overall facial edema can occur with trauma, infection, and heart problems.
expected findings: eye assessment
The eyes should be placed parallel to one another on the face and aligned in the socket, with no protrusion or sunken appearance.
Eyebrows should be symmetrical and extend over the width of the eye. They should move symmetrically with changes in the client’s facial expression. The skin beneath the brows should be free of flakiness or lesions. Eyelashes should have an even distribution and a curved outward shape away from the eye.
The eyelids should be smooth and the same color as the surrounding skin without the presence of edema. The margins should be pink in color and rest along the eyeball surface. When open, the eyelids should cover no more than the top portion of the iris. The upper eyelid should come in contact with the lower lid when the eyes are closed.
liver disease: eyes?
yellow sclera
expected resting pupil size
3 to 5 mm
unexpected findings: eye assessment
Unexpected eye positions include bulging eyes (exophthalmos) and crossed eyes (strabismus).
Eyebrows not extending beyond the outside of the eye (temporal canthus) can indicate an endocrine disorder.
If the client is unable to move their brows, they may have facial nerve damage.
Scaling or flaking of the skin in the eyebrows can indicate a skin disorder.
Redness of the eyelids can indicate the presence of an infection or inflammation.
Edema of the eyelids can be associated with trauma, or kidney or cardiac disease.
A drooping of the eyelid can be caused by edema or damage to one of the cranial nerves.
An inability to completely close the eyelids is associated with lid edema, nerve paralysis, excessively protruding eyeballs, and unconsciousness. This condition can lead to drying and damage of the cornea.
An overall coloring of the sclera that is yellow or green can be present if the client has liver disease.
A subconjunctival hemorrhage has clearly marked edges and is caused by activities that increase the pressure within the eye like coughing and vomiting.
Conjunctivitis is an inflammation of the conjunctiva causing redness and drainage, usually the result of a bacterial or viral infection, allergy, or chemical injury to the eye.
Unequal size pupils, both at rest and in reaction to the light test, can be a sign of a central nervous system injury as can pupils that are dilated and do not react to light.
Cloudy pupils indicate the presence of cataracts or a loss of transparency of the lens of the eye, which impairs the client’s vision.
In typical lighting, pupils that are dilated at rest (greater than 7 mm) can signify an eye disease or neurological disorder.
In typical lighting, pupils that are pinpoint at rest (less than 3 mm) commonly indicate opioid intoxication.
strabismus
misalignment of the eyes
subconjunctival hemorrhage
bleeding that occurs under the conjunctiva
cataract
a cloudy pupil or a loss of transparency of the lens of the eye
conjunctivitis
an inflammation of the conjunctiva causing redness and drainage
Increased tearing with redness and lid edema typically indicates the presence of what?
seasonal allergies
expected findings: ear
The auricle, or outer ear, should appear symmetric in size and placement.
The color of the client’s ear should be the same as the client’s face. Skin should be intact, with no lumps, edema, or lesions.
Some cerumen is usually visible at the opening to the outer ear canal. Cerumen can be a wide variety of colors and textures from grey-yellow to tan to black, moist and waxy to dry and flaky.
expected variants: ear
Unusually small, large, or atypically shaped ears are often a family trait.
unexpected findings: ears
lients who have skin conditions such as eczema can have crusts and scaling on their ears.
Redness of the client’s ear is a sign of inflammation or fever.
Redness, edema, and purulent, or crusty drainage of the ear canal can indicate an infection.
Bright-red blood or watery drainage following a trauma can indicate a fracture to the base of the skull.
Clients who frequently ask you to repeat questions or provide an inappropriate response to a question can have a diminished sense of hearing. Other signs of hearing deficit include the client leaning toward you, turning their head toward you, or closely watching your lips while you speak.
Watery clear or blood-tinged drainage from the canal can indicate the presence of?
presence of an existing skull fractures
Edema, warmth, and pain in the ear or surrounding tissues indicate the presence of?
an infection
expected findings: nose
symmetrical
same color skin as rest of face
nares mucosa should be smooth moist surface that is deeper color than oral mucosa
mucosa should be free of swelling, discharge, bleeding, or foreign bodies
unexpected findings: nose
pale mucosa-allergies
mucoid discharge + bright red nasal mucosa- respiratory
infection
yellow or green discharge-infection in sinus cavity
watery discharge-skull fracture
expected findings: mouth
moist, symmetrical, and smooth. Lips can range from pink to plum-colored, and are typically deeper in color than the surrounding facial skin.
The mucosa should appear glistening, smooth, and moist. Clients who have darker skin tones can have more darkly pigmented mucosa with areas of hyperpigmentation while clients who have lighter skin tones will have pink mucosa.
The hard palate, or roof of the mouth, is located in the anterior of the mouth. It is dome-shaped and whitish in color. The soft palate should be smooth and light pink.
unexpected findings: mouth
A smooth or dark red swollen tongue can indicate low vitamin B12 levels.
Swelling of the gums with redness and bleeding can indicate the presence of gingivitis, which can lead to tooth loss if not treated.
A yellow discoloration of the hard palate can indicate liver disorder.
The presence of petechiae (small hemorrhages), lesions, edema or drainage on the hard or soft palate can indicate the presence of an infection.
A sore mouth with soft white plaques on the tongue or mucosa indicate an oral fungal infection called thrush. These plaques leave a red open area when rubbed off and are often found in immunocompromised clients
A client who has a sore throat can present with a red and edematous uvula and tonsillar pillars. Sometimes they will also have yellow exudate.
A painful round ulcer on the mucosa or lip with a white base surrounded by a red halo is known as a canker sore or an aphthous ulcer.
what does a smooth and dark red swollen tongue indicate?
low vitamin B12 levels
expected findings: neck
The neck should be centered below the head. The neck muscles (trapezius and sternocleidomastoid) should appear symmetrical bilaterally. The trachea is positioned midline and above the suprasternal notch. There should be no lumps or swelling visible or palpable in the neck. The skin should be the same pigmentation as other skin areas and the area should be free of contusions or lesions.
should be able to have full ROM of neck w/o pain or difficulty
should be able to swallow without choking or difficulty
unexpected findings: neck
Limited ability to move the neck or pain with neck movement can indicate a systemic infection in the spine or a musculoskeletal disorder.
A trachea that is shifted away from midline is associated with a mass in the neck or chest disorders.
A swelling on the anterior portion of the neck can indicate a disorder of the thyroid gland.
Visible lymph nodes can indicate an infection or possibly a malignancy (cancer).
Difficulty with swallowing can indicate an inflammation or central nervous system disorder.
A swelling on the anterior portion of the neck can indicate a?
disorder of the thyroid gland.
ptosis
drooping of the eye lid over the pupil and is often the result of edema or a neurological disorder.
entropion
condition in which the eyelids roll inward and can cause the lashes to touch and irritate the conjunctiva and cornea.
unexpected finding: respiratory
Clients who have chronic obstructive pulmonary disease (COPD) will sit in a tripod position with their body leaning forward and hands resting on their knees or a table to aid in expiration of carbon dioxide. When using this position, the client is using abdominal, intercostal, and neck muscles to facilitate breathing. They may exhale through pursed lips and may have difficulty talking.
manifestations of hypoxia
anxious, agitated, or confused
what does general pallor mean?
anemia, result in decreased oxygenation
darker skin to ashy tone
if a client has scoliolis?
oxygen exchange can be compromised due to poor lung expansion
what is barrel chest caused from>
COPD
cheyne-stokes breathing
Cheyne-Stokes breathing can occur if the central nervous system is grossly affected by lack of oxygen or disease progression. It appears to have a respiratory “start-stop” breathing pattern. The client will have deeper breathing that may quicken, followed by hypoventilation and progress to apnea, a lack of respirations. This is an end-of-life breathing pattern.
what is common in older clients with their spine?
kyphosis (hunchback)
tracheal breath sounds
heard over the trachea of the anterior neck area
bronchial breath sounds
heard to the right and the let of the trachea and larynx
auscultated over anterior chest side only
bronchovesticular breath sounds
right and left major bronchi
first and second intercostal space
vesicular breath sounds
over the anterior and posterior chest wall
expected tracheal breath sounds
loud intensity and high pitch. Both inspiration and expiration duration of sounds are equal.
expected bronchial breath sounds
loud intensity and high pitch. The client’s inspiration is a shorter duration than the expiration.
expected bronchovesicular breath sounds
specially on the right—have a moderate intensity and pitch. Bronchovesicular inspiration and expiration duration are equal.
expected vesicular breath sounds
a more intense and loud airflow in the upper anterior lobes but have a softer intensity with a low pitch throughout the other lobes. These breaths are soft-sounding like wind blowing through trees. Vesicular inspiratory sounds last longer than expiratory sounds.
pleural friction rub
low-pitched, coarse, grating tone like rubbing two pieces of leather together. Pleural friction rub is heard on inspiration and expiration.
It is caused from inflammation of the pleura and is very painful.
crackles
intermittent rattling, crackling, popping, or bubbling sound. These sounds can be fine and high-pitched or coarse and low-pitched and are not cleared by coughing. Various lung conditions, such as an increase in fluid, inflammation, or consolidations, can take up the space around not fully inflated alveoli and produce crackles.
wheezes
made when air flows through narrowed airway passages. The client may have inspiratory wheezes, expiratory wheezes, or both.
Chronic conditions such as asthma or bronchitis can cause edema in the bronchioles
rhonchi
continuous, low-pitched, snoring-type sound that can be heard with inspiration and expiration. It is caused by fluid, mucus, or a growth in larger airways. It can sometimes clear with coughing.
stridor
high-pitched crowing sound that can be heard without a stethoscope. It is the result of upper airway obstruction caused by inflammation or a foreign body and can be life-threatening.
The nurse is inspecting a client’s anterior chest. Which of the following findings should the nurse expect?
The ribs are sloping downward at an angle.
45 degrees
A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?
tripod position
Kassmaul breathing
consists of respirations that are abnormally deep, regular, and increased in rate
what is an expected finding in mouth
large vein on the ventral surface of tongue
*underneath tounge
tinnitus
high pitched ringing in the ears
irrigate a leg wound. what PPE do you need?
gown, gloves, and goggles
