Physical Assessment Flashcards
What is the Glasgow Coma Scale?
A standardized scale that uses a point system for eye opening, verbal, and motor response to assess a patient’s level of consciousness.
What is the Glasgow Coma Scale point system for eye opening response?
4pts - Spontaneous, opens with blinking at baseline.
3pts - to verbal stimuli, command, speech
2pts - to pain only (not applied to face 0
1pt - no response
What is the Glasgow Coma Scale point system for verbal response?
5pts - oriented 4pts - confused conversation, but able to answer 3pts - inappropriate words 2pts - incomprehensible speech 1pt - no repsonse
What is the Glasgow Coma Scale point system for motor response?
6pts - obeys commands for movement
5pts - Purposeful movement to painful stimulus
4pts - withdraws in response to pain
3pts - flexion in response to pain (decorticate posturing)
2pts - extension in response to pain (decerebrate posturing)
1pt - no response
What does bilateral edema generally indicate?
fluid volume excess or venous insufficiency
What might unilateral edema indicate?
inflammation, venous thromboembolism, or lymphedema
What is the point system for edema?
+1 - 2mm
+2 - 4mm
+3 - 6mm
+4 - 8mm
How do you test cranial nerves V (trigeminal) and VII (facial)?
ask the patient to bite down and feel for contraction of the temporal muscle and the masseter muscle (in front of the ear). Check the sensory branch of cranial nerve V by having the patient close his eye and report when he feels light touch to his forehead, each cheek, and his chin with cotton.
What does PerrLa stand for?
Pupils Equal, Round, Reactive to Light and Accommodation
How can you tell if cranial nerves IX and X or intact?
the uvula will rise and the patient can swallow
What is the normal range of respiratory for a resting adult?
12-20 breaths per min
What are the characteristics of respiration that are routinely assessed?
respiratory rate
ventilatory depth
ventilatory rhythm
lung sounds
What position should the patient be in for a respiratory exam?
in a comfortable position either sitting or lying with the head of the bed elevated 45-60 degrees.
What would you document following a respiratory exam?
Respiratory rate, depth, and rhythm in nurse’s notes or vital sign flow sheet
SpO2 value and type of O2 on nurse’s notes or iata sigh flow sheet
Document any abnormalities in nurse’s notes and report to nurse in charge or health care provider immediately
(ex. 16 breaths per min; regular rhythm; normal depth, lung sounds clear/normal; 98% RA)
What are some abnormal breathing characteristics to assess for?
nasal flaring/grunting/pursed lip breathing
trachea position (midline; deviated right or left)
Accessory muscles usage (skin being sucked in between clavical and ribs)
Retractions (entire rib cage excessively in and out)
Cough (productive/ non productive)
What is the normal range of respiratory for a resting child?
20-30 breaths per min
What is the normal range of respiratory for a resting newborn?
30-60 breaths per min
What are the breathing characteristics of apnea?
respirations cease for several seconds. Persistent cessation results in respiratory arrest.
What are the breathing characteristics of Cheyne-Stokes?
Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; breathing slows and becomes shallow, concluding as apnea before respirations resumes.
What are the breathing characteristics of dyspnea?
shortness of breath
What are the breathing characteristics of eupnea?
normal, good, unlabored breathing, sometimes known as quiet breathing or resting respiratory rate
What are the breathing characteristics of Orthopnea?
shortness of breath (dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair
What are the breathing characteristics of Kussmaul?
respirations are abnormally deep, regular, and increased in rate
What are the breathing characteristics of Tachypnea?
rate of breathing is regular but abnormally rapid (greater than 20 breaths pre min)
What are the breathing characteristics of Bradypnea?
rate of breathing is regular but abnormally slow (less than 12 breaths per min)
What are the four questions used to assess level of orientation and how would you document it?
What is your name? (person)
Do you know where you are? (place)
Do you know what time or what day it is? (time)
Do you know why you are here? (situation)
Documentation: A and Ox4 (alert and oriented for all 4 questions)
What are the components of a general patient survey?
Gender and race age signs of distress body type posture gait body movement hygiene and grooming dress body odor affect and mood speech signs of patient abuse substance abuse
What are included in vital signs
Temperature Pulse Respirations Pulse Oximetry Blood Pressure Pain
What would be the subject data to gather regarding respirations?
Patient complaints:
C/o (complains of) or denies dyspnea, cough, other symptoms, pain related to breathing
What are the body systems that are generally assesses during a full health assessment?
Neurological Cardiovascular Respiratory Gatrointestinal Genitourinary Musculoskeletal Integument Psychosocial
What is the subjective data to gather regarding integument?
Patient complaints:
C/o or denies pain, discomfort or itching, tingling, etc. related to the skin.
What does the integumentary system include?
skin hair scalp, and nails
What is the Braden scale?
A scale used to predict pressure ulcer risk that uses a score from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury. 19-23 = no risk 15-18 = mild risk 13-14 = moderate risk less than 9 = severe risk
What are the 6 categories of the Braden scale?
Sensory perception Moisture Activity Mobility Nutrition Friction/shear
What abnormalities are noted while assessing integument?
scars, discoloration, bruising, wounds, red areas, pressure sores
What does a bluish color to the nail beds, lips, mouth, or skin possibly indicate?
(cyanosis) - increased amount of deoxygenated hemoglobin (associated with hypoxia)
Causes: lung disease, cold environment
What does pallor (paleness) to the face, nail beds, palms of hands, skin, or lips possibly indicate?
reduced amount of oxyhemoglobin caused by anemia/ reduced visibility of oxyhemoglobin resulting from decreased blood flow caused by shock.
What does a loss of pigmentation in patchy areas on the face, hands and arms possibly indicate?
vitiligo caused by congenital or autoimmune condition causing lack of pigment
What does a yellow-orange (jaundice) skin and eye color indicate?
increased deposit of bilirubin in the tissues caused by liver disease, destruction of red blood cells
What does a red (erythema) color to the face, area of trauma, or other areas possibly indicate?
increased visibility of oxyhemoglobin caused by dilation or increased blood flow caused by fever, direct trauma, blushing, alcohol intake
What is a normal heart rate for an adult?
60-100 beats per min
What is a normal heart rate for a school aged child?
75-100 beats per minute
What is a normal heart rate for an infant?
120-160 beats per min
What is JVD and what does it possibly indicate?
jugulovenous distention characterized by a bulging pulse in a patient’s jugular vain when standing or sitting upright - It is most common with heart failure
Where is the point of maximal impulse (PMI) located?
at the apex of the heart, normally located in the fifth intercostal space at the left midclavicular line.
What is the cause of the first heart sound S1 (“lub”)?
the tricuspid and mitral valves snap shut at the beginning of systole.
What is the cause of the second heart sound S2 (“dub)?
the aortic and pulmonic valves close at the beginning of diastole.
What is subjective data to gather during a neurological assessment?
C/o or denies headache or other head pain
What is assessed during a neurological exam?
Level of consciousness and orientation Facial symmetry Eye Opening Response (Glasgow coma score) Pupils Speech Motor and sensory function
How do you assess motor and sensory function?
Grip strength Pedal pushes movement of extremities Touch Coordination Balance
What subjective data is gathered during a cardiovascular assessment?
C/o or denies chest pain
VERY IMPORTANT
What vital signs are part of a cardiovascular assessment?
BP, Pulse, Temp
What are the characteristics of pulse that are assessed?
Rate
Rhythm (normal or regular)
Strength (bounding - 4, full or strong - 3, normal and expected - 2, diminished or barely palpable - 1)
Equality (in extremities)
What is assessed during a cardiovascular exam?
Vitals (assoc. w/ cardio) Skin color, temp, moisture Heart sounds Peripheral pulses (brachial or femoral artery) Capillary refill JVD Edema IV access
What is anasarca?
general swelling of the whole body that can occur when the tissues of the body retain too much fluid. The condition is also known as extreme generalized edema. (can be a sign of severe organ damage or illness)
What are the sizes of IV’s and their corresponding color?
18 gauge - green 20 gauge - pink 22 gauge - blue 24 gauge - yellow 16 gauge - orange (only used for trauma or special procedures)
What is bradycardia?
slow HR (blow 60 bpm in adults)
What is tachycardia?
elevated HR (above 100 bpm in adults)
What is dysrhythmia?
abnormal HR rhythm
What can cause pulse rates to vary?
exercise temperature emotions medication hemorrhage postural changes pulmonary conditions
What is the normal range for an adult’s blood pressure?
less than 120/80
What is the normal range for a child’s blood pressure?
87-117/48-64
What is the normal range for an infant’s blood pressure?
65-115/42-80
systolic pressure
the peak of maximum pressure when ejection occurs
diastolic pressure
the minimum pressure the arteries exert when the ventricles relax
pulse pressure
the difference between systolic and diastolic pressure
hypotension
low BP - systolic BP falls to 90 mmHg or below
hypertension
high BP - systolic BP greater than 140 mmHg and diastolic greater than 90 mmHg
What are Korotokoff sounds?
the five phases of sounds auscultated during blood pressure measurement.
What sound is heard in Korotkoff phase 1?
a sharp thump
What sound is heard in Korotkoff phase 2?
a bowing or whooshing sound
What sound is heard in Korotkoff phase 3?
a crisp, intense tapping
What sound is heard in Korotkoff phase 4?
a softer blowing sound that fades
What sound is heard in Korotkoff phase 5?
silence
What physiological factors can influence BP?
Stress Ethnicity Gender Daily Variation Medications Activity and weight Smoking
What is a normal range of oxygen saturation?
90% or higher
What is the order of action for collecting objective data and when does it vary?
Inspection Palpation Percussion Auscultation Varies only with the GI system in which case you would inspect, auscultate, palpate, percussion.
What is the subjective data gathered during a gastrointestinal assessment?
C/o or denies pain or discomfort relating to the GI system
What is included in the GI System?
mouth, esophagus, abdomen, rectum
Where do you auscultate for bowel sounds?
All 4 abdominal quadrants
Where are bowel sounds usually active?
in the right lower quadrant where the ileocecal valve is.
what is kyphosis?
a condition common in older patients characterized by pronounced convexity of the thoracic spine that can restrict lung expansion
What are the categories of the five-point muscle strength scale?
5+ normal (can overcome examiner’s resistance)
4+ can move muscle group against some resistance
3+ can move muscle against gravity but not against resistance
2+ able to actively move muscle when gravity is eliminated
1+ trace contraction found by palpating while patient attempts to contract muscle
0+ no muscle contraction detected
how many lobes does the right lung have?
3
how many lobes does the left lung have?
2
What heart valves does APTM correspond to?
Aortic
Pulmonic
Tricuspid
Mitral
What is a sign of peripheral vascular disease?
Shiny hairless skin below mid calf
What are the 6 components of a neurological exam?
mental status balance and coord cranial nerves motor function sensory function reflexes
Cranial nerve 1 name and function:
Olfactory: sense of smell
Cranial nerve 2 name and function:
Optic: visual acuity
Cranial nerve 3,4, and 6 names and function:
Oculomotor, Trochlear, and Abducens: eye movements
Cranial nerve 5 name and function:
Trigeminal: sensory nerve to skin of face, motor nerve to muscles of jaw
Cranial nerve 7 name and function:
Facial: expressions and taste
Cranial nerve 8 name and function:
Auditory: hearing
Cranial nerves 9 and 10 names and function:
Glossopharyngeal, Vagus: taste, ability to swallow, vocal cords
Cranial nerve 11 name and function:
Spinal accessory: movement of head and shoulders
Cranial nerve 12 name and function:
Hypoglossal: tongue position
“light, tight, dynamite”
What does the romberg test assess?
balance
