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IM 1 > Physical Assessment- Exam 3 > Flashcards

Physical Assessment- Exam 3 Flashcards

1
Q

Purpose of physical assessment?

A

Gather baseline data about the clients health
Supplement, confirm, or refute previous data
Make clinical judgments
Evaluate psychological outcomes of care 

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2
Q

Types of data

A

Subjective and objective

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3
Q

Sources of data

A

Primary and secondary

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4
Q

Laboratory diagnostic test

A

ABGS, CBC, sputum

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5
Q

Radiologic studies diagnostic test

A

Chest x-ray
CT
V/Q scan
PET scan

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6
Q

Diagnostic tests

A

Skin test
Pulmonary function test
Endoscopy examinations

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7
Q

Interview and the stages

A

Orientation phase
Working phase
Termination phase

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8
Q

Types of physical assessment

A

Comprehensive
Focused
System specific
Ongoing

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9
Q

Elements of assessment

A

History
Baseline history
Problem based history

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10
Q

Assessment

A

Interview
Physical assessment

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11
Q

Planning

A

Based on assessment data

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12
Q

Process and the physical assessment

A

Assessment
> interview
> physical assessment
Nursing diagnosis
Planning
>based on assessment data
Evaluation
> establishes nursing accountability

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13
Q

Techniques for assessment
All senses except for taste

A

Inspection
Palpation
Percussion
Auscultation
Olfaction

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14
Q

Inspection of the patient (Visual)

A

Good lighting

Expose all of part to be examined, drape, or cover parts, not being examined for privacy

Use additional lighting/devices for some areas of body eyes, ears throat

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15
Q

During inspection, observe for

A

Color
Shape/symmetry
Movement
Position

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16
Q

Palpitation

A

Bimanual/manual technique

Dorsum of hand - assess body temp

Palm or ulnar surface of hand

Palmer surface of finger/finger pads

17
Q

Light palpation

A

1 cm or 1/2 depth

18
Q

Deep palpation

A

4cm or 2 in depth

19
Q

Palpate to assess

A

Texture
Resistance
Resilience
Mobility
Temperature
Thickness
Shape
Moisture

20
Q

Percussion- direct

A

Apply directly to body

21
Q

Percussion- indirect

A

 Applied through another surface

22
Q

Auscultation (auditory)

A

 Frequency
Loudness
Quality
Duration

23
Q

Auscultation- frequency

A

Number of oscillations per second generated by a vibrating object

24
Q

Auscultation- loudness

A

Amplitude of a sound wave

25
Q

Auscultation- quality

A

Descriptive

26
Q

Auscultation- duration

A

Length of time that sound last

27
Q

What part of the stethoscope is best for low pitch sounds
Ex: vascular and some heart sound

A

Bell

28
Q

What part of the stethoscope is best for high pitch sounds
Example: bowel and some abnormal lung sound

A

Diaphragm

29
Q

Olfactory -sense of smell

A

Used to detect abnormal versus normal
Examples
Alcohol on breath
Foul smelling odor from wound
sweet, smelling odor from mouth

30
Q

Preparing for the assessment

A

Gather all necessary equipment
Introduce yourself
Explain procedure
Use gloves if necessary
Wash hands before and after any contact with patient
Clean stethoscope, head in blood pressure cuffs between patients
Make patient comfortable and allow for privacy and confidentiality

31
Q

What general survey do we start with before we start assessment

A

Race/gender
Age
Body type
Posture
Signs of distress
Substance abuse
Speech
Movement/gait
Hygiene/grooming
Dress
Affect/mood
Patient abuse

32
Q

Signs of abuse

A

Inconsistency between injury and statement
Bruises, lacerations, burns, bites
X-ray show fractures in various stages of healing
Behavior, issues, insomnia, anxiety, isolation

33
Q
  • most common in dependent lobes; right and left lung bases
  • fine crackles: are high pitched fine, short, interrupted cracking sounds
  • medium crackles: are lower, moister sounds heard during middle of inspiration; not cleared with cough
  • coarse crackles: are loud, bubbly sounds heard during inspirations or expiration, not cleared by coughing
A

Crackles

34
Q

Primarily heard over trachea and bronchi, if loud enough, able to heard over most lung fields

Cause: muscular spasm, fluid or mucus in large airways, new growth or external pressure causing turbulence

Loud low pitched rumbling, coarse sounds are heard either during inspiration or expiration, sometimes cleared by coughing

A

Rhonchi

35
Q
  • heard all over lung fields
  • high velocity airflow through severely narrowed or obstructed airway
  • high pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration, usually louder on expiration
A

Wheezes

36
Q
  • heard over anterior lateral lung field (if pt is sitting up)
  • inflamed pleura; partial pleura, rubbing against visceral pleura
  • dry rubbing or grating quality is heard during inspiration or expiration, does not clear with coughing; heard loudest over lower lateral anterior surface
A

Pleural friction rub

IM 1 (34 decks)

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