Physical Assessment Flashcards
Hyperresonance
loud, booming, low-pitched sound of longer duration found with over inflated air-filled tissue. Ex: pulmonary emphysema
Resonance
moderate to loud, low pitched (clear, hollow) sound of moderate duration. Ex: normal lung
Tympany
loud, drumlike, high-pitched or moderately long duration found with enclosed air-filled structures. Ex: bowel
Dull
soft, muffled, moderate to high-pitched sound of short duration; found with dense, fluid-filled tissue (liver)
Flat
very soft, high-pitched sound of short duration, found with very dense tissue. Ex: bone, muscle
Normal RR Newborn
30-60
Normal RR Kid
20-30
Normal RR Adult
12-20
Normal Rate Newborn
120-140
Normal Rate Kid
70-140
Normal Rate Adult
60-100
Normal BP Newborn
65/41
Normal BP Kid
90/55 - 110/65
Normal BP Adult
120/80
Oral Temp
98.6
Anal Temp
99.6
Axillary Temp
97.6
Cranial Nerve #1
Olfactory: sense of smell. Have client smell a nonirritating substance.
Cranial Nerve #2
Optic: sense of vision for clear (acute) vision near and distant. Test: snellen eye chart and ophthalmoscopic exam.
Cranial Nerve #3
Oculomotor: pupil constriction, pupils equal in size and equally reactive to light. Test: penlight into eye, follow finger.
Cranial Nerve #4
Trochlear: move eyes down and inward. Test: penlight into eye, follow finger.
Cranial Nerve #5
Trigeminal: sensation of face and neck. Test: pin and cotton over forehead, cheek, and jaw; bite down with jaw.
Cranial Nerve #6
Abducens: lateral movement of eyes. Test: penlight into eye, follow finger.
Cranial Nerve #7
Facial: able to smile, wrinkle, and taste. Test: facial symmetry, close eyelids, and place substance on tongue.
Cranial Nerve #8
Acoustic: hearing and balance. Test: Rinne, Webber, stand with eyes close.
Cranial Nerve #9
Glossopharyngeal: gag reflex, ability to swallow and taste; stimulate gag reflex.
Cranial Nerve #10
Vagus: able to swallow and speak. Test: say “ah” and observe uvula
Cranial Nerve #11
Spinal accessory: able to flex and rotate head and shrug shoulders. Test: turn head against resistance.
Cranial Nerve #12
Hypoglossal: move tongue side to side. Test: stick out tongue.
Rinne Test
compares bone conduction with air conduction; vibrating tuning fork placed on mastoid process, when client no longer hears sound, position in front of ear canal. Normal: air greater by 2:1.
Webber Test
assesses bone conduction; vibrating tuning fork placed in middle of forehead; normal sound heard equally in ears.
Vesicular
soft and low pitched breezy, sounds over peripheral lung fields; inspiration.
Bronchovesicular
medium-pitched, moderately loud over bronchi; inspiration = expiration
Bronchial
loud, coarse, blowing sound heard over trachea; expiration is greater
Crackles
rales; crackling or gurgling sounds that clear with coughing
Rhonchi
musical sounds or vibrations commonly heard on expiration
Wheeze
squeaky sounds heard during inspiration and expiration, narrowed airways
Pleural friction rub
grating sound or vibration heard during inspiration and expiration
Aortic
right 2nd intercostal
Pulmonic
left 2nd intercostal
Erb’s Point
3rd instercostal space left of sternum
Tricuspid area
4th intercostal space
Mitral area
5th intercostal space
Point of Maximal impulse
impulse of the left ventricle felt most strongly, located at left intercostal space in the midclavicular line
SI
“lubb” closure of tricuspid and mitral valves; dull and low pitched, onset of systole, louder at apex
S2
“dubb” closre of aortic and pulmonic valves, onset of diastole, loudest at base
Murmurs
abnormal sounds caused by turbulence within a heart valve; in a vessel, its a bruit
