Physical Assessment Ch 5

Question 0

Symptoms

Answer 0

Subjective data

Subjective indications of illness the patient perceives

Pain, nausea, vertigo

Question 1

Signs

Answer 1

Objective data

Perceived by the examiner

What you see, hear, measure, or feel

Ex/ rashes, altered vital signs, abnormal lung or hear sounds, visible drainage or exudate

Question 2

Disease

Answer 2

Pathologic condition of the body, any disturbance of a structure or function of the body

A recognized set of signs and symptoms characterized by given Disease

You will rely on assessment of signs and symptoms in this case to formulate a nursing diagnosis

Question 3

Many causes of disease of illness(11)

Answer 3

Hereditary
Congenital
Inflammatory
Degenerative
Infectious 
Deficiency
Metabolic 
Neoplastic
Traumatic
Environmental 
Or combination

Question 4

Hereditary diseases

Answer 4

Transmitted genetically from parents to children

Question 5

Congenital

Answer 5

Disease appear at birth or shortly thereafter but not caused by genetic abnormalities

Question 6

Inflammatory diseases

Answer 6

Those in which the body reacts with an inflammatory response to some causative agent

Question 7

Degenerative disease

Answer 7

Implies degeneration often progressive of some party of body

Question 8

Infectious disease

Answer 8

Result from the invasion of microorganisms into the body

Question 9

Deficiency diseases

Answer 9

Result from the lack of a specific nutrient

Question 10

Metabolic disease

Answer 10

Caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body

Question 11

Neoplastic

Answer 11

Disease is described as an abnormal growth of new tissues

Question 12

Traumatic conditions

Answer 12

Result from both physical and emotional trauma

Question 13

Environmental disease

Answer 13

A group of conditions that develop from exposure to a harmful substance in the environment

Question 14

Autoimmune responses

Answer 14

The body develops immunoglobulins (antibodies) against its own tissues or body substances

Question 15

Four major categories for risk factors

Answer 15

Genetic and Physiologic
Age
Environment
Lifestyle

Question 16

Chronic disease

Answer 16

6 months or more

Disease develops slowly and persists over a long period often for a persons lifetime

Question 17

Remission

Answer 17

There has been partial or complete disappearance of clinical and subjective characteristics of the disease

Question 18

Acute disease

Answer 18

Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment

Question 19

Organic disease

Answer 19

Results in a structural change in an organ that interferes with its functioning

Stroke is an organic disease of the brain

Question 20

Functional disease

Answer 20

Often appear to be those of organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities

Question 21

Infection

Answer 21

Caused by an invasion of microorganisms such as bacteria, viruses, fungi or parasites that produce tissue damage

Question 22

Inflammation

Answer 22

A protective response of body tissues to irritation, injury, or invasion by disease producing organsisms

Question 23

the cardinal signs of infection and inflammation include : (6)

Answer 23

Erythema (redness) 
Edema (swelling) 
Heat
Pain
Purulent drainage (pus)
Loss of function

Question 24

assessment

Answer 24

An evaluation or appraisal of the patient's condition

Question 25

Medical assessment

Answer 25

You will be expected to carry out certain assistive function Preparing the examining room Assisting with equipment Preparing the patient Collecting specimens

Question 26

Initiating the nurse patient relationship

Answer 26

Initiate the nurse patient relationship by interviewing the patient Introduce yourself, stating your name; your position, and purposes of the interview Indicate length of time Gives the patient and opportunity to ask questions Assure patients Strictly confidential Nurse patient relationship is enhanced by the professionalism and competence you convey

Question 27

Percussion

Answer 27

The use of the fingertips to tap the body's surface to produce vibration and sound

Question 28

Tympani Dullness Flatness

Answer 28

Tympany- high pitched, drumlike sound Dullness- low pitches thudlike sound Flatness- soft, high pitches, flat sound

Question 29

Interview

Answer 29

Relaxed, unhurried manner in quiet, private, well lighted setting Convey feelings of compassion and concern Determine by what name the patient wishes to be addressed Accepting posture Relaxed manner at eye level Pleasant facial expression

Question 30

Nursing health history

Answer 30

The initial step in the assessment process Information about the patients level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness

Question 31

Biographic data (12)

Answer 31

``` Date of birth Sex Address Family members names Addresses Marital status Religious preference and practices Occupation Source of health care Insurance Medicare Medicaid benefits ```

Question 32

Chief complaint

Answer 32

Patients subjective reason for seeking health care

Question 33

OPQRSTUV

Answer 33

Document these info In patients own words ``` Onset- timing: onset duration Precipitating- provocative- palliative Quality- quantity Region-radiation Severity scale Treatments Understanding Values ```

Question 34

Health history (5)

Answer 34

Patient has ever been hospitalized or undergone surgery Allergies Habits and lifestyle patterns Assess the patients ability to perform ADLs Pattern of sleep, excercise , and nutrition

Question 35

Family history

Answer 35

Immediate and blood relatives Health or cause of death As well as history of illness Objectives are to determine whether the patient is at risk for illness of a genetic or familial nature Info about family structure, interaction and function

Question 36

Environmental history

Answer 36

Provides data about patients home and work environment

Question 37

Psychosocial and cultural history

Answer 37

Data about patients primary language, cultural group, educational background, attention span, and developmental stage Coping skills and support systems Identify major values, beliefs and behaviors related to particular health concerns

Question 38

Review of symptoms (ROS)

Answer 38

Systematic method for collecting data on all body systems Clear, concise manner using appropriate terminology Ask the patient specific questions relating to functioning of the system

Question 39

Purpose of a nursing assessment

Answer 39

To determine the patients state of health or illness | The initial step you use to form the nursing care plan

Question 40

Wens the best time to assess the patient

Answer 40

As soon after admission as possible

Question 41

Who performs the initial baseline nursing assessment

Answer 41

RN | But o going assessment is the responsibility of both the RN and LVN

Question 42

Focused assessment

Answer 42

Attention is concentrated or focused on a particular part of the body, where signs and symptoms are localized it most active in order to determine their significance

Question 43

Where to perform a nursing physical assessment

Answer 43

Comfortable and safe for he patient Patients privacy The patients own room

Question 44

Methods or performing a nursing physical assessment

Answer 44

Head to toe System of system Focused assessment of patient complains of something

Question 45

Items essential to the nurses assessment

Answer 45

``` Penlight or flashlight Stethoscope Blood pressure Cuff Thermometer Gloves Gail belt Toungue blade ```

Question 46

Level of consciousness

Answer 46

``` Oriented x 1 (person) X 2 (person and place) X 3 (person place and time) X 4 (person place time and purpose ```

Question 47

Neurological examination

Answer 47

1. Level of consciousness 2. Motor function 3 pupillary response

Question 48

Skin and hair

Answer 48

Observe the skin for color, temperature, moisture, texture, turgor, and evidence of injury or skin lesions , color in the sclera, mucous membranes, the tongue, ropes and baubles and palms and soles Examine hair over entire body to determine distribution, quantity, and the quality

Question 49

Head and neck

Answer 49

Assessment involves arteries, the veins, and the lymph nodes Facial expressions Note symmetry of the face Palate beneath the jaw and down each side of the neck to feel for enlarged lymph nodes Palmate the carotid arteries

Question 50

Thrill

Answer 50

A vibrating sensation you perceive as you palate along the artery

Question 51

Bruits

Answer 51

Are abnormal swishing sounds heard over organs, glands, and arteries

Question 52

Mouth and throat

Answer 52

Inspect the lips and the mucous membranes of the mouth with a tongue blade and penlight Condition of the teeth and gums Breath odors

Question 53

Eyes

Answer 53

Note whether the eyes are symmetric . No exudate from the eyes is normally seen Normal sclera of eye is white Observe the eyes for pupillary reflex

Question 54

PERRLA

Answer 54

Pupils equal Round reactive to light Accommodation

Question 55

Ears

Answer 55

The ear canal is normally free of excess cerumen (earwax) | Note whether the patient is appropriately following commands, indicating an ability to hear

Question 56

Nose

Answer 56

The nose is usually symmetric | Assess both nostrils. Observe for bleeding and drainage

Question 57

Chest, lungs, heart and vascular system

Answer 57

Inspect for bilateral chest expansion which is normally symmetric Note the rate and depth of respirations Normal rate for adults is 12-20 breaths per minute Normal breathing is quiet

Question 58

Beasts

Answer 58

Examine the breasted during a lung assessment Many patients also do so on a monthly basis Teach breast self exam to both male and female patients

Question 59

Lung sounds

Answer 59

Through auscultation Intruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration Place the stethoscope firmly but not tightly on the ski, and listen for one full inspiration expiratory cycle at each point Systematically auscultation Use a zigzag approach

Question 60

Sibilant

Answer 60

Wheezes have a high pitched squeaking musical quality and are produced by airflow through narrowed airways

Question 61

Sonorous

Answer 61

Wheezes have a lower pitches, coarser, gurgling, snoring quality and usually indicate the presence of mucus in the trachoma and large airways

Question 62

Stridor

Answer 62

High pitched inspiratory crowing sound, louder in the neck than over the chest wall

Question 63

Pleural friction rubs

Answer 63

Produced by inflammation of the pleural sac | You will hear a running, grating, or squeaky sound upon auscultation

Question 64

Crackles

Answer 64

Produced by fluid in the bronchioles and the alveoli, are short, discrete, interrupted, crackling or bubbling sounds that are most commonly heard during inspiration

Question 65

Wheezes

Answer 65

Sounds produced by the movement of air through narrowed passages in the tracheobronchial tree

Question 66

Spine

Answer 66

Note the curvature of the spine

Question 67

Heart sounds

Answer 67

Auscultated with the stethoscope Listen for the intensity of the sound, ranging from faint to strong Also determine the regularity of the rhythm

Question 68

Peripheral vascular system

Answer 68

Palpating peripheral arterial pulses Inspect the extremities for summery, color; and varicosities Palate the hands and feet our temperature Perform the capillary refill or blanch test by pressing firmly for 5 seconds on the fingernail or toenail and estimating the speed at which the blood return

Question 69

Gostrointestinal system

Answer 69

Assessment of the abdomen Auscultation for bowl sounds Palpating comes after auscultation Use percussion on the abdomen to note the density of underlying tissue

Question 70

Borborygmi

Answer 70

Increased sounds with characteristically high pitched loud rushing sound in bowel sounds

Question 71

Genitourinary system

Answer 71

Inspect the pubic hair Palate the scrotum Palpating of the suprapubic area

Question 72

Rectum

Answer 72

Spread the buttocks to look for hemorrhoids or lesions

Question 73

Legs and feet

Answer 73

Palate femoral, popliteal, dorsalis pedis , and posterior tibial Observe the legs and feet, and palate them for edema

Question 74

Edema

Answer 74

An excessive accumulation of fluid in the interstitial spaces caused by leakage of fluid from veins and capillary beds Indentation

Question 75

Pitting edema scale

Answer 75

1+ tace (barely perceptible put 2mm) 2+ mild (a deeper out 4 mm. rebounds in 10 to 15 secs 3+ moderate- a deep pit 6 mm lasts for 30 seconds to more than 1 min 4+ severe - an even deeper put 8mm lasts 2-5 minutes before rebounding check for color, motion, sensation, and temperature (CMST) of both feet