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
What do bronchovesicular breath sounds sound like?
- medium-pitched
- equal expiratory and inspiratory
- heard best over 1st and 2nd ICS adjacent to sternum and between scapula
What do vesicular breath sounds sound like?
- soft
- low-pitched
- breezy with lengthy inspiratory phase
- heard best over the lung fields
What are diminished breath sounds? What patients is this most commonly seen?
poor inspiratory effort (very muscular or obese clients are more common)
What are adventitious breath sounds?
- wheezes
- rhonchi
- rales
- try having the client cough and listen again*
What is the precordium and what do we assess for?
- area of chest over the heart
- inspect for visible pulsations (heaves or lifts associated with an enlarged left ventricle)
- palpate for thrill (if found anywhere other than the PMI it is abnormal and you may find a murmur on auscltation)
What is the point of maximal impulse (PMI)?
apical pulse located on the left midclavicular line 5th ICS
What is the S1? Where is it heard best?
- the first heart sound
- lub (systole)
- closure of valves between atria and ventricles
- dull, low-pitched
- heard best over the mitral and tricuspid areas (5th ICS MCL, 4th ICS left sternal border)
What is the S2? Where is it heard best?
- the second heart sound
- dub (diastole)
- closure of the semilunar valves (ventricles to arteries)
- it is higher in pitch, shorter
- heard best at the aortic and pulmonic areas (2nd ICS right sternal border, 2nd ICS left sternal border)
What is S3? Where is it heard best?
- third heart sound immediately after S2
- gallop cadence kenTUCKy
- heard best at the apical site lying on left side
What is S4? Where is it heard best? Who is it common to hear in?
- immediately before S1
- FLOrida
- heard best at the apical site, use bell, lying on left side
- normally heard in athletes and older clients (CAD, HBP, pulmonic stenosis)
What is JVD? What causes it? Best way to assess?
- jugular vein distention
- seen when the right side of the heart is congested due to inadequate pump function.
- assess in semi-Fowlers’
What is the order of assessment of the abdomen?
- inspect
- auscultate
- percuss
- palpate
What should the abdomen look like?
- symmetrical
- can be flat, rounded, scaphoid, or protuberant
- if they have abdominal distention the skin will look taut
What should the abdomen sound like? Where are these sounds best heard?
- high-pitched
- irregular sounds last for 1-3 secs every 5-15 secs
- heard best over the right lower quadrant
What will you notice in percussion of the abdomen?
- tympany over the bowels due to gas
- dullness over organs, masses, and fluids
What tool can we use to assess level of consciousness? What things does it evaluate?
Glasgow Coma Scale
- evaluates eye opening, motor responses, and verbal responses
- it does not evaluate brainstem reflexes
What are the 3 levels of orientation?
- time
- place
- person
What does the cerebellum do?
- coordinates muscle movement
- regulates muscle tone
- maintains posture and equilibrium
- proprioception (body positioning)
What things to look for when performing a male genitourinary assessment?
- kidneys
- external genitalia
- rectal exam (prostate and hemorrhoids)
- hernias
What to look for when performing a female genitourinary assessment?
- kidneys
- external genitalia
- pubic hair and skin
- rectal exam (hemorrhoids)
- lymph nodes
What is a normal BMI?
18.5-24.9
What is normal capillary refill?
< 2 to 3 seconds
What are some “normal” lesions found on the skin?
Milia- whiteheads
Nevi- Moles
Skin Tags
Striae- stretch marks
What is hirsutism?
excess facial or trunk hair which could be due to endocrine disorder or steroid use
What are Mees’ lines?
transverse white lines on the nail bed seen in clients with nutritional deficiencies or severe illness
What is aromegaly?
excess growth hormone disorder (can cause abnormal skull shape)
What is microcephaly?
abnormally small head size
What is hydrocephalis?
an accumulation of excessive cerebrospinal fluid
What is myopia?
diminished distance vision
What is EOM? What CNs innervate it?
ExtraOcular Muscle function (control eyes and eyelids)
-cranial nerves III (oculomotor), IV (trochlear), and VI (abducens)
What is CN II?
Optic
- visual acuity, visual fields, ocular fundi
- controls pupillary reaction to light
What is pterygium?
growth or thickening of conjunctiva from inner canthus to the iris
What is ectropion?
everted eyelid (leads to dry eye)
What is entropion?
inverted eyelid (leads to corneal damage)
What is ptosis?
drooping of the eyelid (stroke or Bell’s palsy)
What does PERRLA stand for?
Eyes converge as a person attempts to focus on an object moving closer to them
Pupils Equal Round Reactive to Light and Accommodation
What is mydriasis?
enlarged pupils (common in glaucoma)
What is miosis?
constricted pupils (results from glaucoma meds)
What is anisocoria?
unequal pupils (central nerve disorders)
What is CN V?
Trigeminal
- corneal reflex
- scalp/teeth/facial sensation
- jaw movement
What is CN VII?
Facial
- facial movement
- sense of taste
What is CN VIII?
Auditory
- hearing
- equilibrium
What is CN IX?
Glossopharyngeal
- swallowing
- gag reflex
- tongue movement
- taste
- secretion of saliva
What is CN X?
Vagus
- sensation of pharynx and larynx
- swallowing and vocal cords
- sensory in cardiac, respiratory, and blood pressure reflexes
- peristalsis
- digestive secretions
What is CN XI?
Spinal Accessory
- head and shoulder movement
- speaking
What is CN XII?
Hypoglossal
-tongue movement
What is a direct vs indirect vs umbilical hernia?
Direct- intestine through abdominal wall
Indirect- intestine though inguinal canal or scrotum
Umbilical- intestine through the belly button
What are the cervical lymph nodes? (12)
- posterior auricular
- occipital
- superficial
- posterior cervical
- posterior triangle
- superclavicular
- deep mandibular
- preauricular
- tonsilar
- submental
- anterior triangle
- submandibular
