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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
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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)
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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)
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4
Q

Skin

A

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

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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
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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

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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
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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.
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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
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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. )
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11
Q

Neck

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

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

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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
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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
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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
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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
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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)

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