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Physical Assessment Exam 1 > Physical Assessment Exam 1 > Flashcards

Physical Assessment Exam 1 Flashcards

1
Q

Medical approach versus nursing diagnosis

A

Medical approach: etiology of disease and cure. Nursing Approach: holistic and how the disease impacts the person

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2
Q

Problem Oriented Records: SOAP

A

S: subjective-Symptoms
O: objective: signs
A: Assess
P: Plan

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3
Q

Interviewing an Older Adult

A

Well lit, warmer room, low voice, assess for pain, loss of appetite, weight loss, dizziness, fatigue

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4
Q

Four types of data collection

A

Comprehensive
Follow-up
Episodic
Emergency

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5
Q

Interview Intro

A

Intro, open ended questions, closed questions (Y/N), responses

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6
Q

Classical History and Physical

A

Intro, Chief Complaint, HPI, PMH, current health, social/occupational, functional status, ROS, PE

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7
Q

Identifying Info

A

Name, DOB, race, gender, ethnicity, Occupation, language

*ID source of info

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8
Q

Chief Complaint

A

What brings him/her here today. In own words

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9
Q

History of Present Illness

A

Onset, Location, Duration, Characteristics, Alleviating/Agrevating Factors, Radiation, Timing, Perception of Symptoms

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10
Q

Past Medical History

A

General, Childhood, Adult, GYN: Gravida, Para, Abortion, Surgery, Accidents/Trauma, Psych

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11
Q

Current Health

A 
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
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12
Q

Social History

A

Family, relationships, lifestyle, transport, occupation, religion, finances

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13
Q

Family History

A

Three generations, with key. Note if adopted

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14
Q

Functional Assessment

A

ADLs: Bathing, transfer, toileting, getting dressed, feeding self
IADLs: cooking, shopping, managing meds and finances, transport

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15
Q

Review of Symptoms

A

O

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16
Q

Physical Exam Techniques

A

Inspect, Palpate, Percuss, Ausculation

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17
Q

Vital Signs

A

BP, Pulse, O2 stats, Temp, Pain, Weight/Height, RR

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18
Q

Universal Steps

A

Introduce, wash hands, ID patient in two ways, allergies, falls risk

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19
Q

Alert and Oriented X 3

A

Person, place, and time

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20
Q

Height and Weight

A

Height in CM, Weight in KG
BMI: KG/cm2
Underweight: 30

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21
Q

Heart Rate

A

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

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22
Q

Respiratory Rate

A

Normal: 12-20

>20= tachypnea

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23
Q

Blood Pressure

A

Normal: 120/80
Systolic: contracting, Diastolic: at rest

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24
Q

Influences on BP

A

-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

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25
Q

BP Classification

A

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

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26
Q

Temperature

A

-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

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27
Q

O2 stats

A

closest to 100% as possible

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28
Q

Pain

A

Pain scale on 0-10, FLACC for kids, face scale for non-verbal

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29
Q

Older Adults Vital Signs

A

BP: systolic hypertension with widened pulse pressure
HR: pacemaker cells decrease and affect response to physic stress
RR: unchanged
Temp: decreased baseline temp

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30
Q

Cardiac Risk Factors

A

hypertension, diabetes, overweight, inactivity, smoking (increased BP because of vasoconstriction), age, family history

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31
Q

Ausculatory gap

A

when you don’t hear sound between systolic and diastolic BP

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32
Q

Orthostatic BP

A

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
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33
Q

Internal Eye

A
  • 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
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34
Q

Tarsal Plate

A

Within eyelids, connective tissue that secretes lubricating oils

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35
Q

Meibomian glands

A

tear fluid that protects conjunctiva and cornea

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36
Q

Palpebral conjunctiva

A

Covers inside of eye lid- clear and moist

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37
Q

Bulbar conjunctiva

A

coats outside of eyelid- clear and moist

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38
Q

lacrimal apperatus

A

starts at lacrimal gland, secretes tears across the eyes, into puncta, then to nasolacrimal sac, nose

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39
Q

Opthalmoscope view

A

-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

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40
Q

Visual Pathways

A

projected by the retina as upsidedown and opposite. Closing of fibers at optic chiasm.

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41
Q

Eye muscles

A 
Superior rectus: cranial nerve III-ocularmotor 
Lateral rectus: CN 6-abducens
Inferior rectus: CN 3
Superior Oblique: CN 4- Trochlear
Inferior oblique-CN 3
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42
Q

Nerve Palsy

A

CN III. From diabetes, aneurysms, midbrain– inability to elevate of aduct eyes

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43
Q

Cranial Nerves

A

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

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44
Q

Infants and Children for Eye Exam Development

A
  1. 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
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45
Q

Older Adult Eye Exam Development

A
  • 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
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46
Q

Eye Physical Exam

A
  1. Visual fields by confrontation-cranial nerve II
  2. Six cardinal fields of gaze: CN 3 (ocular motor), CN 4: trochlear, CN 6= abducens
  3. Accommodation and Convergence: CN III
  4. Corneal Light Reflex
  5. Consensual and Direct Light reflex: CN II and III
  6. Opthalmascope
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47
Q

Strabismus

A

checked during corneal light reflex if light does not show in same spot in both eyes

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48
Q

Nystagmus

A

Normal in extreme lateral gaze. Seen in six cardinal fields of gaze lateral rectus

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49
Q

Snellen Test

A

CN II
20/20= normal
20/200= legally blind

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50
Q

Myopia

A

Nearsighted: can see near but not far. Eyeball too long

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51
Q

Hyperopia

A

Farsighted: can see far but not near. Eyeball too short

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52
Q

Eye Inspection

A
  • 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
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53
Q

Anascoria

A

unequal pupil sizes. Can be normal or abnormal

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54
Q

Accommodation and Convergence

A

-as finger moves in eye should converge and pupil should constrict - as finger moves out pupils should dilate and eyes should diverge

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55
Q

Palpibral fissure

A

should be in line with the helix of the ear

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56
Q

Optic Nerve Chiasm cut: Bitemporal hemianopsia

A

temporal vision lost in both eyes

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57
Q

Optic nerve cut

A

vision lost in eye of cut nerve

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58
Q

Right optic tract: left homonymous hemiahopsia

A

left temporal, right nasal lost

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59
Q

AV Nicking

A

can be seen on vessels and is caused by hypertension

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60
Q

Glaucoma

A

increased interocular pressure

61
Q

Papilledema

A

increased inter cranial pressure

62
Q

Skin functions

A

protect, temperature regulation, sensory perception, wound repair, absorption and excretion, synthesize vitamin D

63
Q

Skin Structure

A

Epidermis- stratified squamous epithelial cells
Dermis: vascula
Subcutaneous

64
Q

Eccrine Glands

A

All over body, open directly to skin surface

65
Q

Apocrine glands

A

groin and axillary. open below skin surface. smelly

66
Q

Terminal hair

A

thick, long, dark

67
Q

Vellus hair

A

all over body, short, fine, colored

68
Q

Skin considerations for infants and children

A

birthmarks, change in color as newborn, rash, sores, diaper rash, burns, bruises, contagions, sun exposure and prevention

69
Q

Skin considerations for older adults

A

acne, changes, delayed wound healing, skin pain, falls, diabetes, peripheral vascular disease, self care

70
Q

Normal Variations in Skin

A

Temporary Pallor: Cold, or afraid

Temporary Erythmea: embarrassed or hot

71
Q

Widespread change in skin color

A
  • 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
72
Q

Developmental Considerations in skin

A
  • 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
73
Q

Senile Lengitines

A

liver spots

74
Q

Skin Temp

A
  • check with doors of hand bilaterally
  • hypothermia: Local: IV or cast, Global: shock
  • Hyperthermia: Local: infection, Global: fever
75
Q

Skin Moisture

A
  • Diaphoreses: with anxiety, fear, chest pain

- dryness: dehydrates, lips, cracked, dry mucous membrane

76
Q

Texture

A

Rough, scaly
Thick versus thin
telling in thyroid conditions

77
Q

Edema

A

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
78
Q

Mobility

A

Easy of skin rising

79
Q

Turgor

A

ability to promptly return to place when released after tenting. if skin tents for a while dehydrated

80
Q

Wound Assessment

A

Appearance, Dressing, Drainage

81
Q

Diagnostic Approach to Lesions

A
  • distribution: local, universal, symmetric
  • Kind: Primary or secondary
  • Other- Color (red, violet, brown), sharpness of edge, surface contour( dome, pedunculated, spire), geometric shape
82
Q

Primary Skin Lesion Pairs

A
  1. macule and patch 2. papule and plaque 3. node and tumor 4. wheal and urticaria 5. vesicle and bulla 6. pustule and cyst
83
Q

Macule

A

flat, non-palpable, change in color

84
Q

Patch

A

Large macule. > 1cm ex. senile lentigo, mongolian spot, cafe au lait spot

85
Q

Papule

A

circumscribed, superficial thickening of the epithelial cells, palpable, elevated.

86
Q

Plaque

A

flat, elevated surface often formed by coalessing of papules. >.5cm ex. psoriasis, lichen, planus

87
Q

Nodule

A

Soft or firm, extends into dermis, mass, elevated

88
Q

Tumor

A

Soft or firm mass, extends into dermis, benign or malignant, ex lipoma or hemangioma

89
Q

Wheal

A

superficial, transient, undefined boarders, erythmatous. ex. bug bite or allergic reaction

90
Q

Urticaria

A

wheals coalessing, pruritic, varies in size ex. hives

91
Q

Vesicle

A

contains clear free fluid, circumscribed, elevated, superficial up to 1cm ex. herpes, chicken pox, contact dermatitis

92
Q

Bulla

A

Larger vesicle, uniocular, superficial in epidermis, thin walled > 1 cm ex. burn, friction blister .

93
Q

Pustule

A

circumscribed, superficial elevated cavity, containing turbia fluid (pus). Up to 1cm. ex acne, impetigo

94
Q

Cyst

A

Extends into dermis subcutaneous layer, encapsulated pus filled cavity. >1 cm ex. sebaceous cyst

95
Q

Secondary Skin Lesions

A

Crust, fissure, scale, erosion, ulcer, excoriation, scar, atrophic scar, lithification, keloid

96
Q

Crust

A

thickened or dried residue from broken vesicle or pustule.. Red, brown, honey colored, yellow. Ex. eczema, impetigo, herpes simplex

97
Q

Scaling of tine pedis

A
  • dry or greasy
  • compact desiccated flakes of skin
  • shedding of dead excess keratin cells
  • silvery or white
98
Q

Fissure

A

Linear cracks with abrupt edges, extends into dermis, can be dry or moist ex. athlete’s foot, anal fissure

99
Q

Ulcer

A

Circumscribed depression extending into dermis, irregular shape, may bleed, scars ex. stasis ulcer, pressure sore

100
Q

Erosion

A

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

101
Q

Excoriation

A

From scratching. Superficial. ex. insect bites, varicella, scratch

102
Q

Scar

A
  • after reduction or fractrure
  • replacement of normal tissue with fibrous connective tissue
  • permanent change
103
Q

Atrophy

A
  • 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
104
Q

Lithenification

A

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

105
Q

Keloid scar

A

hypertrophic scar, elevation by excess scar tissue beyond original injury

106
Q

Shapes and configurations of Lesions

A
  • 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
107
Q

Vascular lesions

A

petechiae, purpua, ecchymosis, cherry angioma, spider angioma, telanglestasia, nevis falmmus (port wine stain)

108
Q

Petechiae

A

tiny red macule of blood in skin . Less than 3mm

109
Q

Purpua

A

larger macule or papule. blood filled lesions that doesn’t blanche. .3-1 cm

110
Q

Ecchymosis:

A

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

111
Q

Cherry Angioma

A

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

112
Q

Spider angioma

A

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.

113
Q

Telangiectasia

A

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

114
Q

Nevus Fammeus-Port Wine stain

A

Present at birth
• Caused by dilated dermal capillaries
• Pale, pink to purple macules
• Mostly on face and trunk

115
Q

Viral Herpes:

A

Simplex 1: primary infection
Simplex 2: herpes progenitalis
Varicella: chickenpox
Herpes Zoster- shingles

116
Q

Skin Cancer Warning Signs

A 
Assymetry
Boarders are irregular
Color is mottled
Diameter greater than 6mm
Elevated
Enlargement
117
Q

Basal Cell Carcinoma on forehead

A

-Most common malignancy
• Locally invasive and destructive
• Slow growing rarely metastasized
• Almost translucent, dome-shaped papule with overlying telangiectasias

118
Q

Squamous Cell carcinoma on chest

A

-Invasive malignancy
• Commonly found on head, neck or hands
• May arise from actinic keratosis (red, elevated) or de novo.

119
Q

Melanoma

A

superficial or nodular spreading

120
Q

Hair Objective findings

A

Inspect and palpate for color, texture, distribution, lesions or nevi

121
Q

Hirsutism

A

More terminal hair where vellum hair should be. Check for Polycystic ovarian syndrome

122
Q

Nails Objective

A

Check for clubbing and pitting. Make sure capillary refill is less than 3 seconds

123
Q

Abnormal nail

A

spoon nail, beasts lines, swollen, springy

-with age nails get more rigid, split, and become thicker

124
Q

Head: Objective

A

Inspect for symmetry, size, contour
palpate for lumps, bumps, lesions
–Palpebral fissure in line with helix of ear
-nasal labial folds: symmetric

125
Q

Bones of head

A

Frontal, Parietal (2), temporal (2), occiptial

-join at uncle which are immobile sutures

126
Q

Temporal mandibular joint

A

open and close to assess for crepitus and popping

127
Q

C7-Vertebra prominance

A

easy locating spot on spine

128
Q

Facial Muscles

A
  • Innervated by cranial nerve 5 and 7
  • Frontalis, temporalis, masseter
  • assess masseter
129
Q

Temporal artery

A

pulse present and equal bilaterally, grade pulse. No induration should be present

130
Q

Cranial Nerve 7

A
  • Facial
  • Motor
  • Smile, frown, puff cheeks
  • try to pull up closed eye lids
131
Q

Cranial Nerve 5

A
  • Trigeminal
  • Sensory: six cotton ball spots
  • masseter muscle
132
Q

Neck Objective

A
  • masses, bulges, pulsation
  • jugular venous distention
  • lymph nodes
  • trachea
  • carotids
  • cranial nerve XI
  • Thyroid gland: anterior, posterior, ausculate
133
Q

EOMI

A

Extraocular muscles intact

134
Q

PERLA

A

pupils equal and reactive to light and accommodation

135
Q

Pulsation of Jugular Vein

A

abnormal if blood squirt is high in vein, short of breath, and edema present

136
Q

Neck Muscles

A
  • Sternomastoid and Trapezeus
  • Sternomastoid: move head in rotation and flexion
  • Trapezeus: moves shoulders and extends and turns heard-
  • inervated by CN 7
137
Q

Anterior Triangle

A

in front of sternomastoid

138
Q

posterior trianlge

A

between sternomastoid and trapezeus

139
Q

Lymph nodes in head and neck role

A

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
140
Q

Assessing lymph nodes

A

1-2cm, soft, moveable

141
Q

Group 1 of LN

A

preauricular, posterior auricular, suboppcipital

142
Q

Group 2 of LN

A

tonslir, submandibular, submental

143
Q

Group 3 of LN

A

supercervical, posterior cervical, deep cervical

144
Q

Group 4 of LN

A

supra and infra clavicular

145
Q

Palpate trachea

A

normally midline. Palpate for shift

-index finger on sternal notch, slip off to each side. Should be symmetric

146
Q

Carotid artery

A
  • 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
147
Q

Examine CN XI

A

Spinal Accessory: trapezeus and sternomastoid

-hunch against pressure and turn against resistance

148
Q

Palpate thyroid

A
  • 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

Physical Assessment Exam 1 (1 decks)

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