Physical Assessment Part 1

Question 1

Types of Nursing Assessment

Answer 1

• Admission Assessment (all the details)
• Shift Assessment (from day to day)
• Focused Assessment (on one specific area of the patient)

Question 2

Organization of Nursing Assessment

Answer 2

• head-to-toe
• systems
• concepts

chose which works best for you!

Question 3

Why do we assess patients?

Answer 3

• assess functional ability, nursing history
• establish nursing diagnoses and plan of care
• to assess progress and outcomes
• make clinical judgments
• identify areas for teaching
• communicate the client’s health status

Question 4

How do we assess patients?

Answer 4

• types: subjective (symptoms), objective (signs)
• sources: client, records, family and other health care providers
• collection: observation, interviewing, examining, reading

Question 5

What is your most important tool?

Answer 5

your senses: smell, taste, hearing, touch, and sight

Question 6

Tools to use during assessment

Answer 6

• non-sterile gloves
• stethoscope
• pen light
• pen & paper
• bandage scissors
• 2X2 gauze
• tongue blade
• Doppler
• conducting gel
• alcohol pads
• V/S equipment
• safety pin or needle
• tape measure

Question 7

Stethoscopes

Answer 7

• ear piece should fit snuggly in ear
• tubing should be between 12-18 inches
• chest piece should fit size of patient

Question 8

Diaphragm

Answer 8

• detects high-pitched sounds like breath sounds, normal heart sounds, bowel sounds
• press firmly against skin

Question 9

Bell

Answer 9

• detects low pitched sounds like abnormal heart sounds

- lay lightly on skin

Question 10

Doppler

Answer 10

• ultrasonic stethoscopes that detect blood flow rather than amplify sound
• need transmission gel on skin

Question 11

Inspection

Answer 11

• visual observation to determine health status
• throughout entire physical
• size, shape, color, symmetry, position, abnormality

Question 12

Palpation

Answer 12

• determine: position, size, fluid, mass, movement, compressibility, pain, vibration, temperature
• use: palmer surface of fingers and pads, ulnar surface of hand and fingers, dorsal surface of hands
• always have warm and clean hands, fingernails should be short
• palpate tender areas last (do the easy things first)
• chat while palpating and watch
• wear gloves if necessary
• use two hands when palpating light (1cm) then deep (4cm)

Question 13

Auscultation

Answer 13

• listen for sounds produced by body
• should be done in quiet place
• place stethoscope on bare skin
• target and isolate each sound
• identify all the characteristics of each sound

Question 14

Duration (Auscultation Descriptive Terms)

Answer 14

long, short, continuous, interrupted

Question 15

Pitch (Auscultation Descriptive Terms)

Answer 15

high or low

Question 16

Intensity (Auscultation Descriptive Terms)

Answer 16

loudness

Question 17

Quality (Auscultation Descriptive Terms)

Answer 17

subjective description (whistling, gurgling, snapping, etc)

Question 18

Location (Auscultation Descriptive Terms)

Answer 18

right or left, 4 abdominal quadrants, anterior or posterior chest wall, etc

Question 19

Physical Assessment Guidelines

Answer 19

• use a systematic approach
• review chart and get report
• approach one side of patient always looking at patient
• assess the environment and equipment
• check vitals first
• assess systems at greatest risk
• compare both sides
• look under gown
• record quickly and concisely
• most invasive and painful last
• cultural considerations

Question 20

General Survey

Answer 20

• Paint a picture
• sex/race/age
• body type
• admitting diagnosis
• medical history
• posture/gait/mobility
• hygiene
• speech
• orientation

Question 21

General Survey (Environment)

Answer 21

• position of bed and overhead table
• equipment
• sharps and gloves
• linen condition
• presence of family, spiritual needs

Question 22

Anxiety

Answer 22

• level
• behavior
• learning needs
• cognitive function
• support
• family/lifestyle
• spirituality

Question 23

Normal Vital signs

Answer 23

• Temp oral: 35.8-37.3
• Pulse 60-100; average 80
• Respiration 12-20
• BP less than 120/80

Question 24

Pain

Answer 24

Medication: when was it given, how much, how effective, level of consciousness, vitals

• Pattern: onset, duration, associated activity/event/time/med/what makes better/worse
• Area:where
• Intensity: mild, moderate, severe, scale
• Nature: quality, characteristics

Question 25

Head

Answer 25

-position, size, shape, contour, symmetry

Question 26

Vision

Answer 26

- farsighted/nearsighted - appearance: symmetry, eyes, lids, brows, sclera, lenses - glasses? contacts?

Question 27

Ears

Answer 27

- assistive devices - drainage - can hear normal speaking tones

Question 28

Nose

Answer 28

- inspect nares | - nasal discharge, injuries, surgery, patency

Question 29

Mouth and Throat

Answer 29

- dentition - dentures - tongue, mucous membranes, uvula

Question 30

Cognition

Answer 30

- complex set of mental activities through which individuals acquire, process, store, retrieve, and apply information - nervous system function

Question 31

Accomodation

Answer 31

pupils should constrict when looking at the nearer object and dilate when looking at the far object

Question 32

PERRLA

Answer 32

pupils are equal, round and reactive to light and accommodation

Question 33

Skin

Answer 33

- color - temp - moisture - turgor - incisions, lesions, pressure ulcers - IVs - numbness, tingling, itching - scars, tattoos, piercings - hair and nails - edema