Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

nurs 356 > Physical Assessment > Flashcards

Physical Assessment Flashcards

1
Q

Preparation:

A
  • Organize/Gather Equipment
  • Review patient history
  • Identify using two identifiers (name, DOB)
  • introduce yourself and explain procedure
  • wash hands
  • move bed to appropriate height
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

General Survey

A
  • Assess overall status, include four indicators (appears stated age and nutritional status, level of consciousness, skin color congruent w race, posture/position)
  • no acute stress or discomfort (unless it is apparent)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Vitals/Pain/A&O x4

A
  1. temp, HR, RR, BP
  2. Pain scale
  3. alert and oriented (person, place, time, why they are there)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Skin

A

must be inspected and palpated within each body system. Things such as color, symmetry, thickness, edema, swelling, lesions, temp/moisture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Head

A
  1. inspection
    scalp (skin), and hair (too brittle etc.
  2. Palpate head for masses, edema, pain, symmetry. head should be NORMOCEPHALIC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Face

A
  1. Inspection

a. skin
b. cranial nerves (smile, frown, puff out cheeks

  1. Palpate for pain, edema, symmetry

a. frontal (eyebrows) and maxillary sinuses (cheeks )
b. TMJ clicking present or not

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Ears

A
  1. inspection (use penlight) symmetry, position, lesions, drainage
  2. palpate around and down ear for pain, tenderness, growth, then tragus for dizziness and pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Nose

A
  1. inspection inside nares for redness, swelling, drainage, deviation/symmetry, masses
  2. palpate down nose for edema, growth and check nares for patency.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Eyes

A
  1. inspection for sclera being white/red, drainage, edema . check conjunctiva for pink, moist, drainage, eyebrows eyelash present .
  2. pupil inspection. state meaning of PERRLA, six cardinal directions.
  3. palpate top eyelids and bottoms (w gloves) for fullness, palpate lacrimal ducts for pain and drainage
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Mouth/Pharynx

A
  1. inspection lips (full, pink, moist) teeth (good dentition), tongue (pink moist no edema), gingival & buccal mucosa (pnik, moist, no growth/lesion), hard & soft palate (pink moist, intact), pharynx (pink, moist, intact w no lesions.)
    State tonsil appearance +0-+4)
  2. palpate lips and outer mouth for pain, edema, growth.
  3. cranial nerve exam. (uvula rises midline on phonation, and sticking tongue out. )
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Neck

A
  1. inspection of skin, trachea is midline. Range of motion

2. palpate the trachea, palpate carotid arteries and rate pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Upper extremities

A
  1. inspection of skin, nails for clubbing, and muscle bulk
  2. Palpation checking for capillary refill, brachial/radial pulse, muscle bulk, temp/moisture, sensation
  3. strength testing: grips, up/down, push/pull
  4. range of motion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

anterior thorax

A
  1. inspection (gown down) assess skin and use of accessory muscle effort.
  2. palpate the 8 spots for pain, crepitus, and masses .
  3. auscultation of 8 spots, in correct order, listen to a full inhalation and exhalation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

posterior thorax

A
  1. inspection (gown down) assess skin and use of accessory muscle effort.
  2. palpate the 8 spots for pain, crepitus, and masses. CVA tenderness.
  3. auscultation of 8 spots, in correct order, listen to a full inhalation and exhalation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

cardiac

A
  1. inspection (gown down) for heaves, PMI, skin.
  2. palpate all 5 locations and name them (aortic, pulmonic, erbs point, tricuspid, mitral) and feel for PMI
  3. auscultate all positions down with diaphragm, apical pulse listening for 1 minute, back up with bell. carotid arteries for bruits using the bell
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

abdomen

A
  1. inspection (gown up)
    umbilicus is midline, skin is intact w out edema redness or breaking,
  2. auscultation for all 4 regions ( hypo/normo/hyperactive findings)
  3. light palpation in all quadrants to assess for guarding .

MAKE SURE KNEES ARE BENT

17
Q

lower extremities

A
  1. inspection of skin, nails for clubbing and condition, and muscle bulk .
  2. palpate down legs, checking muscle bulk, temp/moisture, sensation. pulses (dorsalis pedis and posterior tibialis and rate them)
  3. inspect and palpate for edema
  4. strength testing. feet push pull, legs up down. rate strength.
  5. range of motion . check adduction, abduction, ROM for knees hips ankles, (watch vid)
18
Q

posterior surfaces

A

roll onto side, make sure rail is up on opposite side.

  1. inspection of skin and bony prominences . (head elbows, spine, sacrum, hips, heels.)
  2. palpate all areas listed above . palpate for blanching in any red areas, or state that you would .

nurs 356 (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions