Physical Assessment Exam 1 Flashcards
Medical approach versus nursing diagnosis
Medical approach: etiology of disease and cure. Nursing Approach: holistic and how the disease impacts the person
Problem Oriented Records: SOAP
S: subjective-Symptoms
O: objective: signs
A: Assess
P: Plan
Interviewing an Older Adult
Well lit, warmer room, low voice, assess for pain, loss of appetite, weight loss, dizziness, fatigue
Four types of data collection
Comprehensive
Follow-up
Episodic
Emergency
Interview Intro
Intro, open ended questions, closed questions (Y/N), responses
Classical History and Physical
Intro, Chief Complaint, HPI, PMH, current health, social/occupational, functional status, ROS, PE
Identifying Info
Name, DOB, race, gender, ethnicity, Occupation, language
*ID source of info
Chief Complaint
What brings him/her here today. In own words
History of Present Illness
Onset, Location, Duration, Characteristics, Alleviating/Agrevating Factors, Radiation, Timing, Perception of Symptoms
Past Medical History
General, Childhood, Adult, GYN: Gravida, Para, Abortion, Surgery, Accidents/Trauma, Psych
Current Health
Allergies: Medications, Environmental, Food Meds: Names and Dose Habits: Alcohol, Tobacco (Pack years), drug Exercise Immunizations Safety measures Sleep Diet: 24 hour recall Environmental Hazards Screening
Social History
Family, relationships, lifestyle, transport, occupation, religion, finances
Family History
Three generations, with key. Note if adopted
Functional Assessment
ADLs: Bathing, transfer, toileting, getting dressed, feeding self
IADLs: cooking, shopping, managing meds and finances, transport
Review of Symptoms
O
Physical Exam Techniques
Inspect, Palpate, Percuss, Ausculation
Vital Signs
BP, Pulse, O2 stats, Temp, Pain, Weight/Height, RR
Universal Steps
Introduce, wash hands, ID patient in two ways, allergies, falls risk
Alert and Oriented X 3
Person, place, and time
Height and Weight
Height in CM, Weight in KG
BMI: KG/cm2
Underweight: 30
Heart Rate
60-100 BPM is normal
Assess in: Temporal, carotid, brachial, radial, femoral, apical, posterior tibial, dorsal pedis
Grade: 0= no pulse, 1+=weak pulse, 2+=normal pulse, 3+=bounding pulse
Respiratory Rate
Normal: 12-20
>20= tachypnea
Blood Pressure
Normal: 120/80
Systolic: contracting, Diastolic: at rest
Influences on BP
-Peripheral resistance, Elasticity, cardiac output, volume
-age: no diff til puberty when men’s go up, and women’s go up at menopause
-race: AA tend to have higher than white
Diurnal: Tend to be higher in afternoon
BP Classification
Systolic: Normal= 120, Pre=120-139, Stage 1= 140-159, Stage 2=>160
Diastolic: Normal=80, Pre=80-89, Stage 1= 90-99, Stage 2= >100
Temperature
-Take at: rectal, oral, tympanic, temporal, axillary
-axillary= 1 lower than oral, rectal=1 degree higher than oral, tympanic= 1.4 degrees higher than oral
-Impacted by:
diurnal: higher in afternoon, lowest in AM
menstrual cycle: higher
exercise
O2 stats
closest to 100% as possible
Pain
Pain scale on 0-10, FLACC for kids, face scale for non-verbal
Older Adults Vital Signs
BP: systolic hypertension with widened pulse pressure
HR: pacemaker cells decrease and affect response to physic stress
RR: unchanged
Temp: decreased baseline temp
Cardiac Risk Factors
hypertension, diabetes, overweight, inactivity, smoking (increased BP because of vasoconstriction), age, family history
Ausculatory gap
when you don’t hear sound between systolic and diastolic BP
Orthostatic BP
Check for patients who have fainted, feel light standing, volume depletion
- Supine, sitting, standing 2 minute intervals
- drop in systolic >20 mmHg or pulse increases 20bpm
Internal Eye
- Sclera: white and outermost layer. Becomes the cornea. Where muscles hold eye intact
- Choroid: vascular regions. Becomes iris and cilliary body
- Retina: nural layer
- Cililary Body: where production of aqueous humor is.
- Aqueous Humor: passes through posterior chamber through pupil to anterior chamber
Tarsal Plate
Within eyelids, connective tissue that secretes lubricating oils
Meibomian glands
tear fluid that protects conjunctiva and cornea
Palpebral conjunctiva
Covers inside of eye lid- clear and moist
Bulbar conjunctiva
coats outside of eyelid- clear and moist
lacrimal apperatus
starts at lacrimal gland, secretes tears across the eyes, into puncta, then to nasolacrimal sac, nose
Opthalmoscope view
-Optic disc on nasal side: creamy orange to yellowy pink. No papilladema– follow out to four optic vessels (arteries have think line of light), no AV nicking. Macula. Background is clear
Visual Pathways
projected by the retina as upsidedown and opposite. Closing of fibers at optic chiasm.
Eye muscles
Superior rectus: cranial nerve III-ocularmotor Lateral rectus: CN 6-abducens Inferior rectus: CN 3 Superior Oblique: CN 4- Trochlear Inferior oblique-CN 3
Nerve Palsy
CN III. From diabetes, aneurysms, midbrain– inability to elevate of aduct eyes
Cranial Nerves
1=olfactory, 2=optic, 3=ocularmotor, 4=trochlear, 5=trigeminal, 6=abducnes, 7= facial, 8=vestibularcochlear, 9=glossopharyngeal, 10=vagus, 11=accessory spinal, 12-hyppoglossal
Infants and Children for Eye Exam Development
- Macula not developed until 4-8 months but peripheral vision is intact. 2. by 3-4 months eye can fixate 3. most born farsighted, little pigment, small pupils. 4. eyeball full size at age 8
Older Adult Eye Exam Development
- Skin loses elasticity causing drooping, fat tissues and muscles atrophy- atropine
- Cornea may show arcus senilis degenerative lipid material around the limbus, pupils decrease in size
- lens loses elasticity and cannot change shape to accommodate for near vision ( presbyopia),
- lens discolors and thicken (cataract)
- Floaters from vitreous humor debris
- Arcus senilis: degeneration of lipid material around limbus
Eye Physical Exam
- Visual fields by confrontation-cranial nerve II
- Six cardinal fields of gaze: CN 3 (ocular motor), CN 4: trochlear, CN 6= abducens
- Accommodation and Convergence: CN III
- Corneal Light Reflex
- Consensual and Direct Light reflex: CN II and III
- Opthalmascope
Strabismus
checked during corneal light reflex if light does not show in same spot in both eyes
Nystagmus
Normal in extreme lateral gaze. Seen in six cardinal fields of gaze lateral rectus
Snellen Test
CN II
20/20= normal
20/200= legally blind
Myopia
Nearsighted: can see near but not far. Eyeball too long
Hyperopia
Farsighted: can see far but not near. Eyeball too short
Eye Inspection
- Lashes: up and out on top, down and out on bottom
- Pupils are between 3-5mm in size bilaterally
- Eyebrows: no scaling or lesions
- Iris: flat and round
Anascoria
unequal pupil sizes. Can be normal or abnormal
Accommodation and Convergence
-as finger moves in eye should converge and pupil should constrict - as finger moves out pupils should dilate and eyes should diverge
Palpibral fissure
should be in line with the helix of the ear
Optic Nerve Chiasm cut: Bitemporal hemianopsia
temporal vision lost in both eyes
Optic nerve cut
vision lost in eye of cut nerve
Right optic tract: left homonymous hemiahopsia
left temporal, right nasal lost
AV Nicking
can be seen on vessels and is caused by hypertension
Glaucoma
increased interocular pressure
Papilledema
increased inter cranial pressure
Skin functions
protect, temperature regulation, sensory perception, wound repair, absorption and excretion, synthesize vitamin D
Skin Structure
Epidermis- stratified squamous epithelial cells
Dermis: vascula
Subcutaneous
Eccrine Glands
All over body, open directly to skin surface
Apocrine glands
groin and axillary. open below skin surface. smelly
Terminal hair
thick, long, dark
Vellus hair
all over body, short, fine, colored
Skin considerations for infants and children
birthmarks, change in color as newborn, rash, sores, diaper rash, burns, bruises, contagions, sun exposure and prevention
Skin considerations for older adults
acne, changes, delayed wound healing, skin pain, falls, diabetes, peripheral vascular disease, self care
Normal Variations in Skin
Temporary Pallor: Cold, or afraid
Temporary Erythmea: embarrassed or hot
Widespread change in skin color
- Jaundiced: increased billirubin. Seen in upper palate and sclera first. Ex. Chirossis
- Pallor: raynauds, shock, anemia
- Cyanosis: blue. due to decreased perfection of O2 rich blood. Global: CHF, sepsis. Local: hypothermia
- Erythmea: from excess blood supply to capillaries of skin. from blushing or infection
Developmental Considerations in skin
- Mongolian spots
- cafe au lait spot- benign expect for it being more than 1.5 cm
- Acne: peaks in teens
- Older adults: wrinkles, increase in fragile blood supply, dry skin, skin repairs more slowly
- temporary cyanosis: will balance. normal in infants short term
Senile Lengitines
liver spots
Skin Temp
- check with doors of hand bilaterally
- hypothermia: Local: IV or cast, Global: shock
- Hyperthermia: Local: infection, Global: fever
Skin Moisture
- Diaphoreses: with anxiety, fear, chest pain
- dryness: dehydrates, lips, cracked, dry mucous membrane
Texture
Rough, scaly
Thick versus thin
telling in thyroid conditions
Edema
Swelling from increased fluid in interstitial tissue
- grade 1+-4+, push 4-5 seconds. How long does it stay dented for?
- Cause: DVT, CHF, lymphedema, orthostatic
Mobility
Easy of skin rising
Turgor
ability to promptly return to place when released after tenting. if skin tents for a while dehydrated
Wound Assessment
Appearance, Dressing, Drainage
Diagnostic Approach to Lesions
- distribution: local, universal, symmetric
- Kind: Primary or secondary
- Other- Color (red, violet, brown), sharpness of edge, surface contour( dome, pedunculated, spire), geometric shape
Primary Skin Lesion Pairs
- macule and patch 2. papule and plaque 3. node and tumor 4. wheal and urticaria 5. vesicle and bulla 6. pustule and cyst
Macule
flat, non-palpable, change in color
Patch
Large macule. > 1cm ex. senile lentigo, mongolian spot, cafe au lait spot
Papule
circumscribed, superficial thickening of the epithelial cells, palpable, elevated.
Plaque
flat, elevated surface often formed by coalessing of papules. >.5cm ex. psoriasis, lichen, planus
Nodule
Soft or firm, extends into dermis, mass, elevated
Tumor
Soft or firm mass, extends into dermis, benign or malignant, ex lipoma or hemangioma
Wheal
superficial, transient, undefined boarders, erythmatous. ex. bug bite or allergic reaction
Urticaria
wheals coalessing, pruritic, varies in size ex. hives
Vesicle
contains clear free fluid, circumscribed, elevated, superficial up to 1cm ex. herpes, chicken pox, contact dermatitis
Bulla
Larger vesicle, uniocular, superficial in epidermis, thin walled > 1 cm ex. burn, friction blister .
Pustule
circumscribed, superficial elevated cavity, containing turbia fluid (pus). Up to 1cm. ex acne, impetigo
Cyst
Extends into dermis subcutaneous layer, encapsulated pus filled cavity. >1 cm ex. sebaceous cyst
Secondary Skin Lesions
Crust, fissure, scale, erosion, ulcer, excoriation, scar, atrophic scar, lithification, keloid
Crust
thickened or dried residue from broken vesicle or pustule.. Red, brown, honey colored, yellow. Ex. eczema, impetigo, herpes simplex
Scaling of tine pedis
- dry or greasy
- compact desiccated flakes of skin
- shedding of dead excess keratin cells
- silvery or white
Fissure
Linear cracks with abrupt edges, extends into dermis, can be dry or moist ex. athlete’s foot, anal fissure
Ulcer
Circumscribed depression extending into dermis, irregular shape, may bleed, scars ex. stasis ulcer, pressure sore
Erosion
superficial circumscribed loss of epidermis. Leaves shallow scooped out depression. Moist but no bleeding. Health without scarring because not in dermis. ex. stage 2 pressure sore
Excoriation
From scratching. Superficial. ex. insect bites, varicella, scratch
Scar
- after reduction or fractrure
- replacement of normal tissue with fibrous connective tissue
- permanent change
Atrophy
- Depressed skin level resulting from loss of tissue
- thinning of epidermis with loss of normal skin furrows
- > skinny translucent skin
ex. senile skin, arterial insufficiency, striae
Lithenification
thickening and toughening of skin due to intense starting. Tightly packed set of papule. Causes increased visibility of superficial skin markings ex. long standing eczema, atopic dermatitis
Keloid scar
hypertrophic scar, elevation by excess scar tissue beyond original injury
Shapes and configurations of Lesions
- annular
- confluent- running together
- discrete- single
- grouped-cluster
- gyrate: twisted, coiled
- target: iris like, ex lyme
- linear: a line
- polycyclic: circular growing together
- zosterform- along dermatome, nerve route
Vascular lesions
petechiae, purpua, ecchymosis, cherry angioma, spider angioma, telanglestasia, nevis falmmus (port wine stain)
Petechiae
tiny red macule of blood in skin . Less than 3mm
Purpua
larger macule or papule. blood filled lesions that doesn’t blanche. .3-1 cm
Ecchymosis:
small hemoragic spot in skin or mucous membrane. Larger than a petechiae. Non-elevated. Rounded or irregular blue or purple patch. 1cm. Escape of blood into tissues from ruptured blood vessels
Cherry Angioma
Also called Campbell de Morgan spots
• Small bright red papules and of no consequence
• Benign angiomas common on the trunks of the middle-aged and elderly
Spider angioma
Stellate telangiectases that look like spiders with legs radiating from a central, often palpable feeding vessel.
• If diagnosis in doubt, press on center with slide and lesion will disappear.
• If many on trunk check liver function. May be normal in faces of children or erupt in pregnancy.
Telangiectasia
Term refers to permanently dilated and visible vessels in the skin
• They can appear as linear, punctate or stellate crimson-purple markings
• Can be caused by nifedipine
Nevus Fammeus-Port Wine stain
Present at birth
• Caused by dilated dermal capillaries
• Pale, pink to purple macules
• Mostly on face and trunk
Viral Herpes:
Simplex 1: primary infection
Simplex 2: herpes progenitalis
Varicella: chickenpox
Herpes Zoster- shingles
Skin Cancer Warning Signs
Assymetry Boarders are irregular Color is mottled Diameter greater than 6mm Elevated Enlargement
Basal Cell Carcinoma on forehead
-Most common malignancy
• Locally invasive and destructive
• Slow growing rarely metastasized
• Almost translucent, dome-shaped papule with overlying telangiectasias
Squamous Cell carcinoma on chest
-Invasive malignancy
• Commonly found on head, neck or hands
• May arise from actinic keratosis (red, elevated) or de novo.
Melanoma
superficial or nodular spreading
Hair Objective findings
Inspect and palpate for color, texture, distribution, lesions or nevi
Hirsutism
More terminal hair where vellum hair should be. Check for Polycystic ovarian syndrome
Nails Objective
Check for clubbing and pitting. Make sure capillary refill is less than 3 seconds
Abnormal nail
spoon nail, beasts lines, swollen, springy
-with age nails get more rigid, split, and become thicker
Head: Objective
Inspect for symmetry, size, contour
palpate for lumps, bumps, lesions
–Palpebral fissure in line with helix of ear
-nasal labial folds: symmetric
Bones of head
Frontal, Parietal (2), temporal (2), occiptial
-join at uncle which are immobile sutures
Temporal mandibular joint
open and close to assess for crepitus and popping
C7-Vertebra prominance
easy locating spot on spine
Facial Muscles
- Innervated by cranial nerve 5 and 7
- Frontalis, temporalis, masseter
- assess masseter
Temporal artery
pulse present and equal bilaterally, grade pulse. No induration should be present
Cranial Nerve 7
- Facial
- Motor
- Smile, frown, puff cheeks
- try to pull up closed eye lids
Cranial Nerve 5
- Trigeminal
- Sensory: six cotton ball spots
- masseter muscle
Neck Objective
- masses, bulges, pulsation
- jugular venous distention
- lymph nodes
- trachea
- carotids
- cranial nerve XI
- Thyroid gland: anterior, posterior, ausculate
EOMI
Extraocular muscles intact
PERLA
pupils equal and reactive to light and accommodation
Pulsation of Jugular Vein
abnormal if blood squirt is high in vein, short of breath, and edema present
Neck Muscles
- Sternomastoid and Trapezeus
- Sternomastoid: move head in rotation and flexion
- Trapezeus: moves shoulders and extends and turns heard-
- inervated by CN 7
Anterior Triangle
in front of sternomastoid
posterior trianlge
between sternomastoid and trapezeus
Lymph nodes in head and neck role
located in groups, ovals of lymphatic tissue
- in subcutaneous tissues
- superficial nodes are easily palpable
- suck up damaged cells and invade organisms though lymph nodes before returning back to heart
Assessing lymph nodes
1-2cm, soft, moveable
Group 1 of LN
preauricular, posterior auricular, suboppcipital
Group 2 of LN
tonslir, submandibular, submental
Group 3 of LN
supercervical, posterior cervical, deep cervical
Group 4 of LN
supra and infra clavicular
Palpate trachea
normally midline. Palpate for shift
-index finger on sternal notch, slip off to each side. Should be symmetric
Carotid artery
- palpate and ausculate
- lower or upper 1/3 of neck b/c carotid sinus at middle that stimulates heart
- 1 side at a time
- listen for bruit– wishing of turbulent blood flow-> stenosis or ballooning which is abnormal
Examine CN XI
Spinal Accessory: trapezeus and sternomastoid
-hunch against pressure and turn against resistance
Palpate thyroid
- ask to bend head forward or to the right
- use fingers of L hand to push trachea right
- feel with R finger between trachea and muscle
- ask to swallow
- check for symmetry, bruit, nodules
- 1 nodule can be cancerous, more usually aren’t
