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Nursing 130 > Physical Assessment > Flashcards

Physical Assessment Flashcards

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1
Q

Why do we assess patients

A

To establish a baseline & help identifying changes in patient condition

Screen for new symptoms and new health problems

Monitor status of previous problems

Prevent potential problems

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2
Q

Different types of assessments

A

Comprehensive
Ongoing partial
Focused
Emergency

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3
Q

Comprehensive assessment

A

Done upon admission of new patient

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4
Q

Ongoing assessment

A

Done at every beginning of shift

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5
Q

Focuses assessment

A

Done only 1 area to assess specific area

Normally area where patient has most complain

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6
Q

Emergency assessment

A

Done to determine life threatening or unstable conditions

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7
Q

What to focus on during assessment

A

Physical responses to illness

Patient’s functional status(how well they can take care of themselves)

Stressors that may be present (emotional/mental/environmental)

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8
Q

How to prepare for physical assessment

A

Ask about pain, how strong they feel at that moment, or if they have anxiety

Explain everything as you go

Explain it’s painless

Build a trusting rapport

Use proper positioning patient and you

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9
Q

Preparing environment

A

Maintain privacy

Lower noise control

Use good lighting

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10
Q

Preparing yourself

A

Know patients situation and diagnosis before

Ask for help if needed

Speak with patient in a comforting way

Bring all equipment needed

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11
Q

Positions used in physical assessment

A 
Standing
Sitting
Supine
Dorsal recumbent
Sims
Prone
Lithotomy 
Knee chest
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12
Q

Types of data collected

A

Subjective

Objective

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13
Q

Subjective data

A

What patient says

Ex. “I feel short of breath”

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14
Q

Objective data

A

What is observed or measured
Signs or symptoms seen by nurse

Ex. Lung sounds, X-ray results, labs,

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15
Q

How to assess symptoms

A

Ask for:

Location(where)
Quality
Quantity
Chronology(how long)
Meaning to patient
Aggravating or alleviating factors( what makes it feel better)
Associated manifestations
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16
Q

OLD CART acronym for symptom assessment

A

Onset
Location
Duration

Characteristics
Aggravating factors
Relieving factors
Treatment

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17
Q

Groups physical assessment is grouped into

A

Perfusion (circulation)

Oxygenation (respiratory)

Neurological

Gastrointestinal

Genitourinary

Mobility (musculoskeletal)

Integumentary

Ears, nose, throat

Pain

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18
Q

What to assess in perfusion(circulation)

A 
Auscultaré heart sounds
Inspect and touch legs/arms for edema
Touch arms/legs for temperature
Inspect capillary refill
Palpate distal pulses(on feet)
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19
Q

Oxygenation(respiratory)

A

Evaluate breathing effort

Inspect overall skin color

Listen to lung and breath sounds

Inspect chest shape

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20
Q

Neurological

A

Evaluate speech
Assess:

level of consciousness
orientation
PERRLA
Gait

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21
Q

PERRLA

A

Pupils equal round and reactive to light and accommodation

22
Q

GI

A

Inspect abdomen for shape:
Flat, scaphoid, or distended

Palpate abdomen for tenderness/distention

Listen to bowel sounds in all 4 quadrants

23
Q

GI structures at in upper right quad

A 
Pylorous
Liver
Duodenum
Right kidney
Right adrenal gland
Head of pancreas
24
Q

Structures in left upper quadrant

A 
Stomach
Spleen
Left kidney 
Left adrenal gland
Splenic fixture of colon
Body of pancreas
25
Q

Structures in right lower quad

A 
Cecum
Appendix
Right ureter of kidney
Right ovary & Fallopian tube
Right spermatic cord
26
Q

Structures in left lower quad

A

Sigmoid Colin
Left ureter of kidney
Left ovary & Fallopian tube
Left spermatic cord

27
Q

Structures along abdomen midline

A

Urinary bladder

Urethra

28
Q

Genitourinary

A

Inspect and gently palpate bladder

Assess & ask about:
Bladder of renal pain
UTI’s 
Dysuria 
Constipation
Urinary incontinence 
Hematuria 
Urinary retention(in males)

Assess after Foley removal because must per within 6 hrs

29
Q

Mobility (musculoskeletal)

A

Palpate extremities for tenderness

Evaluate movement and sensation

Assess muscle strength and symmetry of it

Observe range of motion in joints

30
Q

Integumentary (skin)

A

Look for skin lesions or wounds

Color

31
Q

Types of skin lesions

A

Fissures
Erosions
Ulcers
1 more

32
Q

Ears, nose, throat

I

A

Check eyes using PERRLA

Assess hearing (based on convo & asking of hearing aids)

Check mouth for sores, color, dryness)

Face

33
Q

Pain Assessment using PQRST

A

Palliative/provocative factors - what makes it better and worse

Quality - describe pain

Radiation/region - where is the pain

Severity - how does pain compare to other pain or how bad is pain

Temporal factors - does intensity change over time

34
Q

Inspection part of assessment and what is usually inspected

A

Use sight, hearing, and smell to gather data

Ex. of what is inspected
Skin color
Gait
Behavior 
Posture
General appearance
35
Q

Palpation part of assessment & what palpate is used for

A

Touching to gather data

Begin with light pressure and then go deeper

Exx.
Edema
Moisture 
Masses
Temperature 
Turgor
36
Q

Percussion

A

Tapping on skin to listen to sound

Used by MDs to assess abdomen, underlying structures and lungs

37
Q

Auscultation & what it is used for

A

Hearing and listening for gathering data

Use stethoscope

Always place stethoscope on direct skin

Used for listening to heart, lung, and bowel sounds

38
Q

What is diaphragm of stethoscope used for

A

High pitched sounds

39
Q

What is bell of stethoscope used for?

A

Low pitched sounds

40
Q

Factors important to health history

A

Biographical data

Reason for seeking health care

History of present illness

Past medical history

Family history

Functional health- how good they can take care of themselves

Psychosocial and lifestyle factors

Review of systems - subjective data

41
Q

Components of a preventative health history

A

Ask of health history

Check for risk of depression

Functional ability

Level of safety

Physical examination

Patient education & counseling

42
Q

Cultural considerations go keep in mind

A

Think of patient in regards to family, culture, and community

Be knowledgeable and nonjudgmental

Beware of health beliefs of their culture

43
Q

Categories in general survey

A 
Appearance:behavior
Grooming/hygiene
Body type/posture
Mental status 
Speech
Vital signs
Nutritional status
44
Q

Appearance/behavior component of general survey

A

Signs of distress

Do they look their age

Mood and mental status
Visible skin lesions, skin color

Speech and correct behavior for their age

Symmetrical facial features

45
Q

Grooming/hygiene

A

Are they dressed appropriately?

How good is their hygiene

46
Q

Body type and posture component of general survey

A 
Body size 
Gait
Posture
Body movements 
Use of assistive devices
Fall risk?
47
Q

Mental status component of general survey

A

Includes level of consciousness and orientation

48
Q

Levels of consciousness

A

Normal

Obtunded(stuporous) - not totally asleep but little response

Lethargic - resembling deep sleep, can be aroused but goes back to sleep

Coma - state of unawareness and unresponsiveness

49
Q

How to assess orientation

A

Ask for time, place, person(what their name is or age), & situation (what brought them to the hospital)

50
Q

Levels of orientation

A

Alert x3

51
Q

Purpose of documentation

A

To identity actual & potential health problems

Make nursing diagnosis & interventions

Plan appropriate care

Evaluate patients response to treatment

Always document right away so MD knows patient status & can prevent or detect early

Nursing 130 (5 decks)

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