Physical Assessment Flashcards
What is general health assessment?
Assessment of physical, mental, spiritual, socioeconomic, and cultural status
What is nursing assessment?
Assessment of the client’s functional abilities and physical responses to illness
What is a comprehensive physical examination? Example?
Interview plus head-to-toe assessment
ex: annual physical, admission to hospital
What is a focused physical examination? Example?
Focuses on a particular topic, body part, or functional ability
ex: emergency situation
What is a system-specific physical examination? Example?
Limited to one body system
ex: assessing bowel sounds, breath sounds
What is an ongoing physical examination? Example?
Performed as needed to assess status, evaluates client outcomes
ex: on med-surg unit everyone who provides care performs an ongoing assessment
What is theoretical knowledge?
- A&P
- examination equipment and techniques
- therapeutic communication and documentation
What is self-knowledge?
Knowing your own skill and having a willingness to seek help when needed
How can you create a good environment for a physical examination?
- provide privacy
- noise control
- adequate lighting
- comfortable temperature
- bring all needed equipment
What are the key ways to provide client-centered care during a physical examination?
- establish mutual goals
- demonstrate respect for clients individual values
- promote client comfort
- direct questions to the client to foster involvement in care
What are the four assessment techniques nurses use during a physical examination?
Inspection
Palpation
Percussion
Auscultation
What sounds do you hear best with the diaphragm vs the bell of the stethoscope?
Diaphragm- high-pitched sounds
Bell- low-pitched sounds
How can you modify technique for a physical exam of an infant?
Have a parent hold the child
How can you modify technique for a physical exam of a toddler?
- allow to explore or sit on parent’s lap
- offer choices
- use praise
- perform invasive exams last (oral, ear)
How to modify technique for a physical examination of a preschooler?
- comfortable on the exam table but offer parents lap
- let the child help (hold equipment)
- give reassurance
- compliment child on cooperation
How to modify technique for a physical exam of school-age children?
- develop rapport by asking about favorite activities
- allow independence with dressing and getting on table
- demonstrate equipment before use
- teach
How to modify technique for a physical exam of adolescents?
- provide privacy
- address concerns that they feel aren’t “normal”
- teach healthy lifestyle behaviors
- screen for suicide risk
How to modify technique for a physical exam of older adults?
- use special positioning based on mobility
- assess ADLs
- assess vision/hearing changes
- assess mobility
- provide rest periods as needed
What is the acronym SPICES used for?
Used to remember common problems of the elderly that require intervention. S- sleep disorders P- Problems with eating/feeding I- Incontinence C- Confusion E- Evidence of falls S- Skin Breakdown
What are the components of the general survey during a comprehensive assessment? (7)
- appearance/behavior
- body type/posture
- speech
- mental state
- dressing/grooming/hygiene
- vital signs
- height/weight
What are things to look for when assessing the skin?
- color (pallor/cyanosis/jaundice/erythema/ecchymosis)
- temperature (equal warmness bilaterally)
- moisture (diaphoresis/dry skin)
- texture (affected by exposure/age/circulation/hyperthyroidism)
- turgor (edema)
- lesions (acne, infected areas)
What things to looks for when assessing the hair?
- color
- texture (fine/course)
- distribution (alopecia/hair-loss from chemotherapy/thinning hair from menopause)
- pediculosis (lice)
- scalp (smooth, firm, symmetrical, non-tender, no lesions)
What things to look for when assessing the nails?
- color (pink with rapid capillary refill, half and half nails)
- shape (clubbing from severe hypoxia)
- texture (smooth, callus formation)
What things to look for when assessing skull and face?
- smooth without contours or bulges
- no tenderness
- no irregular jaw movement (TMJ)
What things to look for when assessing eyes?
- assess vision (distant, near, peripheral, color)
- inspect eyelids, lashes, sclera and conjunctiva, lens and cornea, pupils
What things to assess for when examining the ears?
inspection- equal size, pinna is usually level with the corner of the eye
palpation- painful auricle or tragus may indicate a outer ear infection, tenderness behind the ear may indicate an inner ear infection
tests- Weber and Rinne
What cranial nerve is responsible for smell?
Olfactory- CN I
-sense of smell
What things to look for when assessing Mouth and Oropharynx?
- Lips, buccal mucosa, and gingiva should be pink, moist, and intact *ask about tobacco use
- Teeth- look for any visible cavities and improper brushing
- Tongue and Oropharynx
What things to look for when assessing the neck?
inspect and palpate:
- trachea
- cervical lymph nodes (small and nontender)
- thyroid (smooth, firm, nontender, and nonpalpable)
How to describe the size and shape of the chest?
- the depth of the chest is usually half of the anterior (if it is more than that it is a barrel shaped chest and may be due to COPD or history of smoking)
- kyphosis (curvature of thoracic spine)
- scoliosis (lateral curvature of the spine)
- shortening of the spine due to osteoporosis
What do bronchial breath sounds sound like? Where are they best heard?
- loud
- high-pitched
- expiration is longer than inspiration
- heard best over the trachea below nape of neck
