Physical Assessment Flashcards
types of physical assessments
- admission assessment
- shift assessment
- focused assessment
purpose of bedside assessments
- 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
when beginning the physical assessment, you being with…
- interview/general survey
- observations
interview/general surverys should include…
- 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
most important assessment tool
your senses
-sight, smell, touch, hearing
common assessment tools
- 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
diaphragm of stethoscope
- detects high pitched sounds
- breath sounds
- normal heart sounds
- bowel sounds
- press firmly against skin
bell of stethoscope
- detects low pitched sounds
- abnormal heart sounds, bruits
- lay lightly on skin
- may need to switch indexing mechanisms
doppler
- ultrasonic stethoscopes that detect blood flow rather than amplify sound
- need transmission gel on skin
position of patient for: head/neck assessment
supine, except for JVD is HOB 45 deg
position of patient for: anterior thorax assessment
supine or sitting
position of patient for: heart assessment
supine
position of patient for: abdomen assessment
supine (completely flat)
position of patient for: peripheral pulses assessment
supine
position of patient for: V/S assessment
supine or sitting
position of patient for: extremeities assessment
supine or sitting
position of patient for: posterior thorax assessment
sitting or prone
position of patient for: genital assessment
dorsal recumbent
types of data
- subjective (symptoms)
- objective (signs)
head-to-toe sequence
- general survey
- V/S
- head
- neck
- upper extremities
- chest
- abdomen
- genitals
- anus/rectum
- lower extremities
- back
normal temp
96.4 to 99.1
normal pulse
60-100; 80 avg
normal respirations
12-20
normal BP
less than 120/80
acronym for pain
P - pattern; time of day? associated with anything?
A - area; where is it?
I - intensity; pain scale
N - nature; stabbing, aching, throbbing, etc…
inspection
systematic and deliberate visual observation to determine health status
-continues through entire exam
palpation
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
tips for palpating
- warm hands
- clean hands
- fingernails short
- palpate tender areas LAST
- chat while palpating, watching
- gloves?
light palpation
1 cm
deep palpation
4 cm
auscultation
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
normoactive bowel sounds
5-30 per minute per quadrant
hypoactive bowel sounds
You measure any abdominal distention at…
level of umbilicus
abdominal pulsations
dont palpate
AAA-pulsations near umbilicus can be heard and only seen in thin patients
mottling
infants and end stage septic shock
- red, splotchy
- sign of bad circulation
cyanotic is a a sign of…
late sign of cardio-respiratory problem
5 P’s of the Neurovascular assessment
- pain
- pulses
- pallor
- paresthesia
- paralysis/paresis
paresthesia
changes in sensation such as burning, tingling or numbness
paralysis/paresis
-move body parts distal to the injury such as fingers and toes.
- No movement=paralysis
- Muscle weakness=paresis
Grading pulses
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
1+ pulse associated with
cardiac issues
4+ pulse associated with
too much fluid on board for multiple reasons
venous stasis
cardiac issues; not working well enough for the blood to return up the body
-blood pools
stasis
pooling
Erb’s point
best place to hear S2
aortic heart sound
2nd intercostal space, right sternal border
pulmonic heart sound
2nd intercostal space, left sternal boarder
tricuspid heart sound
4th/5th intercostal space, along left sternal border
-some say 4th & some say 5th
mitral
5th intercostal space, mid clavicular line, left sternal border
heart murmur
prolonged heart sounds caused by disruption in the flow of blood in, through or out of the heart
S3
or gallop
-volume overload, CHF; heart is compensating and giving extra beat to compensate for extra volume
crepitus
air under the skin outside of mediastinum; crinkly air that has escaped and gone into SubQ tissue
Rhonchi
decreased after coughing
rales/crackles
high pitched
hyperactive bowel sounds
> 30 per min per quadrant
