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Fundamentals Exam 2 > Physical Assessment > Flashcards

Physical Assessment Flashcards

1
Q

types of physical assessments

A
  • admission assessment
  • shift assessment
  • focused assessment
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2
Q

purpose of bedside assessments

A
  • assess functional ability, nursing hx
  • establish nursing dx and plan of care
  • assess progress and outcomes
  • make clinical judgements
  • identify areas for teaching (promote health and prevent dz)
  • communicate pt’s health status
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3
Q

when beginning the physical assessment, you being with…

A
  • interview/general survey

- observations

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4
Q

interview/general surverys should include…

A
  • sex/race/age
  • body build
  • admitting dx
  • significant med. hx
  • affect (overall attitude, etc..)
  • distress
  • posture/gait/mobility
  • hygiene/grooming
  • dress/body odor
  • speech/demeanor
  • orientation

also, looking at environment..

  • position of bed, table
  • equipment
  • sharp boxes and gloves
  • condition of linen
  • presence of family, spiritual indications
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5
Q

most important assessment tool

A

your senses

-sight, smell, touch, hearing

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6
Q

common assessment tools

A
  • nonsterile gloves
  • stethoscope
  • pen light
  • pen and paper
  • bandage scissors
  • 2x2 gauze
  • tongue blade
  • doppler
  • conducting gel
  • alcohol pads
  • V/S equipment
  • safety pin or needle
  • tape measure
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7
Q

diaphragm of stethoscope

A
  • detects high pitched sounds
  • breath sounds
  • normal heart sounds
  • bowel sounds
  • press firmly against skin
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8
Q

bell of stethoscope

A
  • detects low pitched sounds
  • abnormal heart sounds, bruits
  • lay lightly on skin
  • may need to switch indexing mechanisms
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9
Q

doppler

A
  • ultrasonic stethoscopes that detect blood flow rather than amplify sound
  • need transmission gel on skin
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10
Q

position of patient for: head/neck assessment

A

supine, except for JVD is HOB 45 deg

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11
Q

position of patient for: anterior thorax assessment

A

supine or sitting

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12
Q

position of patient for: heart assessment

A

supine

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13
Q

position of patient for: abdomen assessment

A

supine (completely flat)

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14
Q

position of patient for: peripheral pulses assessment

A

supine

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15
Q

position of patient for: V/S assessment

A

supine or sitting

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16
Q

position of patient for: extremeities assessment

A

supine or sitting

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17
Q

position of patient for: posterior thorax assessment

A

sitting or prone

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18
Q

position of patient for: genital assessment

A

dorsal recumbent

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19
Q

types of data

A
  • subjective (symptoms)

- objective (signs)

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20
Q

head-to-toe sequence

A
  • general survey
  • V/S
  • head
  • neck
  • upper extremities
  • chest
  • abdomen
  • genitals
  • anus/rectum
  • lower extremities
  • back
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21
Q

normal temp

A

96.4 to 99.1

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22
Q

normal pulse

A

60-100; 80 avg

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23
Q

normal respirations

A

12-20

24
Q

normal BP

A

less than 120/80

25
Q

acronym for pain

A

P - pattern; time of day? associated with anything?
A - area; where is it?
I - intensity; pain scale
N - nature; stabbing, aching, throbbing, etc…

26
Q

inspection

A

systematic and deliberate visual observation to determine health status

-continues through entire exam

27
Q

palpation

A

used to determine position, size, fluid, mass, movement, etc…

  • use palmar surface of fingers and pads
  • use ulnar surface of hands and fingers
  • use dorsal surface of hands
28
Q

tips for palpating

A
  • warm hands
  • clean hands
  • fingernails short
  • palpate tender areas LAST
  • chat while palpating, watching
  • gloves?
29
Q

light palpation

A

1 cm

30
Q

deep palpation

A

4 cm

31
Q

auscultation

A

listening for sounds produced by the body

  • should be done in quiet environment
  • stethoscope on bare skin
  • close eyes to focus
  • should be done last EXCEPT abdominal sounds
32
Q

normoactive bowel sounds

A

5-30 per minute per quadrant

33
Q

hypoactive bowel sounds

A
34
Q

You measure any abdominal distention at…

A

level of umbilicus

35
Q

abdominal pulsations

A

dont palpate

AAA-pulsations near umbilicus can be heard and only seen in thin patients

36
Q

mottling

A

infants and end stage septic shock

  • red, splotchy
  • sign of bad circulation
37
Q

cyanotic is a a sign of…

A

late sign of cardio-respiratory problem

38
Q

5 P’s of the Neurovascular assessment

A
  • pain
  • pulses
  • pallor
  • paresthesia
  • paralysis/paresis
39
Q

paresthesia

A

changes in sensation such as burning, tingling or numbness

40
Q

paralysis/paresis

A

-move body parts distal to the injury such as fingers and toes.

  • No movement=paralysis
  • Muscle weakness=paresis
41
Q

Grading pulses

A

0 - Absent

1+ - Barely palpable, difficult to feel

2+ - “Normal”, detected readily, obliterated by strong pressure

3+ - full pulse, increased

4+- bounding, very easy to find, difficult to obliterate

42
Q

1+ pulse associated with

A

cardiac issues

43
Q

4+ pulse associated with

A

too much fluid on board for multiple reasons

44
Q

venous stasis

A

cardiac issues; not working well enough for the blood to return up the body

-blood pools

45
Q

stasis

A

pooling

46
Q

Erb’s point

A

best place to hear S2

47
Q

aortic heart sound

A

2nd intercostal space, right sternal border

48
Q

pulmonic heart sound

A

2nd intercostal space, left sternal boarder

49
Q

tricuspid heart sound

A

4th/5th intercostal space, along left sternal border

-some say 4th & some say 5th

50
Q

mitral

A

5th intercostal space, mid clavicular line, left sternal border

51
Q

heart murmur

A

prolonged heart sounds caused by disruption in the flow of blood in, through or out of the heart

52
Q

S3

A

or gallop

-volume overload, CHF; heart is compensating and giving extra beat to compensate for extra volume

53
Q

crepitus

A

air under the skin outside of mediastinum; crinkly air that has escaped and gone into SubQ tissue

54
Q

Rhonchi

A

decreased after coughing

55
Q

rales/crackles

A

high pitched

56
Q

hyperactive bowel sounds

A

> 30 per min per quadrant

Fundamentals Exam 2 (5 decks)

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