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Physical Assessment > Test 2 > Flashcards

Test 2 Flashcards

1
Q

CN I

A

olfactory

smell test

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2
Q

CN II

A

occipital

visual fields by confrontation

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3
Q

CN II and III

A

occipital
oculomotor

pupil size/shape
rxn to light (direct/consensual)
accomodation

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4
Q

CN II, IV, VI

A

oculomotor
trochlear
abducens

extraocular movements
convergence

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5
Q

CN VIII

A

vestibulocochlear

whisper test

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6
Q

CN IX and X

A

glossopharyngeal
vagus

speech
swallow
soft palate and uvual rise

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7
Q

CN XII

A

hypoglossal

tongue midline
stick out
side to side
light, tight, dynamite

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8
Q

CN XI

A

accessory

shrug against force
turn head against force

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9
Q

CN V

A

trigeminal

temporal/masseter strength
sharp/dull
light touch

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10
Q

CN VII

A

facial

symmetry of movement

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11
Q

normal lymph nodes

A

may not be palpable

may feel 1+ small, soft, nontender nodes

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12
Q

tonsilar node

A

if it pulsates, it’s the carotid artery

if it’s small, hard, tender deep between mandible and SCM, probably styloid process

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13
Q

abnormal findings in lymph nodes

A

enlargement and/or tenderness suggests infection

enlargement, firm/hard, fixed to skin or underlying tissues, suggests malignancy

lesions in drainage areas for axillary nodes suggest malignant involvement

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14
Q

enlarged, tender cervical nodes

A

pharyngitis

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15
Q

preauricular lymph node location

A

tragus

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16
Q

postauricular lymph node location

A

mastoid process

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17
Q

occipital lymph node location

A

base of posterior skull

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18
Q

tonsillar lymph node location

A

angle of mandible

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19
Q

submandibular lymph node location

A

midway along mandible

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20
Q

submental lymph node location

A

under chin, a few cm behind tip of mandible

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21
Q

superficial cervical chain location

A

superficial to SCM

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22
Q

posterior lymph node locations

A

along anterior edge of trapezius (between SCM and trapezius)

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23
Q

deep cervical chain location

A

deep to SCM (hook fingers under SCM

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24
Q

supraclavicular

A

deep in angle of SCM and clavicle (pt raises shoulders)

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25
Q

trachea palpation

A

place fingers along sides of trachea and note space between it and SCM

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26
Q

thyroid gland inspection

A

tip patient’s head back

tangential lighting down from tip of patient’s chin - inspect region below cricoid cartilage for gland

pt sips water and extends neck again and swallows - watch for upward movement of thyroid gland, noting countour and symmetry

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27
Q

thyroid gland landmarks

A 
notched thyroid cartilage
cricoid cartilage (below)

thyroid isthmus (over 2nd, 3rd, 4th tracheal rings)

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28
Q

thryoid gland palpation

A

posterior approach

pt flexes neck slightly

place fingers just below cricoid cartilage

patients swallows - feel thyroid isthmus rising up under tingertips

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29
Q

head ROS

A

severe/frequent headaches

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30
Q

neck ROS

A

swollen glands/lumps

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31
Q

thyroid ROS

A

hot/cold preference

sweat more/less than others

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32
Q

eyes ROS

A 
changes
blurred vision
pain
flashes of light
floaters
double vision
redness
excessive tearing
discharge
growths on eyelids
light sensitivity
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33
Q

ears ROS

A 
hearing
trouble with ears
earaches
discharge
tinnitus
dizziness
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34
Q

nose ROS

A 
breathing
changes in nose/sinuses
discharge
URI
sense of smell changes
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35
Q

mouth and throat ROS

A 
changes
difficulty eating/swallowing
hoarseness
smoking
bleeding gums
toothache
lesions
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36
Q

head normal documentation

A

hair of average texture, scalp without lesions, normocephalic/atraumatic

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37
Q

eyes normal documentation

A

vision 20/30 in each eye.
visual fields full by confrontation.
conjunctive pink; sclera white.
pupils 4mm constricting to 2mm, round, regular, equally reactive to light.
extraocular movements intact.
disc margins sharp, without hemorrhages, exudates.
no arteriolar narrowing or A-V nicking.

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38
Q

ears normal documentation

A

canals clear, TM’s intact with good cone of light. acuity good to whispered voice

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39
Q

nose normal documentation

A

mucosa pink, septum midline. no sinus tenderness.

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40
Q

mouth and pharynx normal documentation

A

oral mucosa pink.
dentition good.
tongue midline, uvula midline, tonsils absent, pharynx without erythema or exudate.

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41
Q

neck normal documentation

A

neck supple.
trachea midline.
thyroid isthmus barely palpable, lobes not felt.

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42
Q

lymp nodes normal documentation

A

no cervical nodes palpable bilaterally

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43
Q

organs in LRQ

A 
right ureter
right bladder
right ovary, uterus, fallopian tube
right prostate, spermatic cord
part of small intestine, rectum, ascending colon, cecum
appendix
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44
Q

organs in URQ

A 
liver
gallbladder
duodenum
ascending/transverse colon
pancreas (head)
right ureter
right kidney
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45
Q

organs in ULQ

A 
descending colon
left kidney
pancreas (body and tail)
spleen
stomach
transverse colon
left ureter
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46
Q

organs in LLQ

A 
bladder
descending colon
left ovary, uterus, fallopian tube
left prostate, spermatic cord
small intestine
sigmoid colon
left ureter
47
Q

normal liver span

A

6-12 cm at right midclavicular line

4-8 cm at midsternal line

48
Q

normal width of aorta

A

less than 3 cm

49
Q

bladder distension

A

distended bladder palpated above symphysis pubis

holds ~300ml urine

brain can inhibit detrusor contractions if voiding is inconvenient up to 400-500ml

50
Q

abdomen exam order

A

inspection
auscultation
percussion
palpation

51
Q

abdomen inspection

A 
skin
symmetry
protuberance
masses
peristalsis
pulsations
52
Q

abdomen inspection normal findings

A

skin color normal for ethnicity, warm and dry, no scars or lesions.
L and R quadrants symmetrical, no protuberance, masses, visible peristalsis.

53
Q

abdomen auscultation

A

use diaphragm in all 4 quadrants for:

bowel sounds (frequency and character) - 2-3 min if no sounds

abdominal aorta for bruits (then palpate, noting size)

54
Q

abdomen auscultation normal findings

A

bowel sounds present in all 4 quadrants, frequent but not continuous.
normal sounds: clicks and gurgles.
no aortic bruits.
normal aorta

55
Q

abdomen percussion

A

percuss all 4 quadrants, assess tympany and dullness.

tympany indicates air, dullness indicates solid organs, masses, fluid, feces.

56
Q

abdomen percussion expected findings

A

tympany in all 4 quadrants, dullness in RUQ when percussing liver border.
dullness on LLQ caused by constipation/fecal matter buildup in colon.

57
Q

abdomen palpation

A

lightly palpate all 4 quadrants, note tenderness/masses.
deep palpation of all 4 quadrants, note guarding/rebound tenderness.
palpate liver.
palpate spleen.

58
Q

abdomen palpation normal findings

A

no tenderness or masses upon palpation, no guarding or rebound tenderness upon deep palpation.
liver spans 6-12 cm along midclavicular line, 4-8 cm along midsternal line.
spleen not palpable.

59
Q

abdomen ROS questions

A 
pain
diarrhea/constipation
changes in bowel fxn
indigestion
N/V, hematemesis
regurgitation
loss/change of appetite
difficulty/pain swallowing
jaundice
60
Q

abdomen documentation

A

abdomen is protuberant with active bowel sounds.
soft, nontender; no palpable masses or hepatosplenomegaly.
liver span 7 cm in right MC; edge smooth and palpable 1cm below right costal margin.
spleen and kidneys not felt.
no CVA tenderness.

61
Q

anatomical joins to be examined

A 
jaw
neck
shoulders
elbows
fingers
hips
knees
ankles
toes
spine
62
Q

muscle strength 0/5

A

no contraction

63
Q

muscle strength 1/5

A

slight contraction

64
Q

muscle strength 2/5

A

full ROM with gravity eliminated

65
Q

muscle strength 3/5

A

full ROm against gravity

66
Q

muscle strength 4/5

A

full ROM against gravity, some resistance

67
Q

muscle strength 5/5

A

full ROM against gravity, full resistance. normal muscle strength

68
Q

level of consciousness

A

single most critical and sensitive symptomatic indicator of neurlogical integrity

69
Q

conscious/alert

A

easily aroused

70
Q

lethargic

A

drifts off to sleep when not sitmulated

71
Q

obtunded

A

sleeps most of the time

72
Q

stuporous

A

semi comatose, responds only to persistent pain, withdraws from pain

73
Q

comatose

A

completely unconscious, no response to pain or any external stimuli

74
Q

increasing stimuli

A

auditory
tactile
painful

75
Q

auditory stimuli

A

talk to patient in normal tone

76
Q

tactile stimuli

A

shake patient gently

77
Q

painful stimuli

A 
trapezius squeeze
sternal rub
supraorbital pressure
mandibular pressure
nail pressure
achilles tendon squeeze
78
Q

testing for orientation

A

Person: what is your name
Place: where are you
Time: today’s date
Purpose: why are you here

79
Q

tests for cerebellar fxn

A

rapid alternating movements
romberg test
gait
tandem walk

80
Q

DTR: 0

A

no response

81
Q

DTR: 1

A

slight response. hypoactive. can be normal for older adult.

82
Q

DTR: 2

A

average response

83
Q

DTR: 3

A

brisker than average, not necessarily abnormal

84
Q

DTR: 4

A

indicates very brisk, hyperactive response. symptomatic of CNS disease

85
Q

negative Babinski test

A

downward contraction of toes

86
Q

positive Babinski test

A

dorsiflexion of big toe and fanning of other toes

from CNS lesion in corticospinal tract - also seen in intoxicated patients or in infants

87
Q

negative Romberg test

A

normal findings. patient maintains upright posture. minimal swaying.

88
Q

positive Romberg test

A

balance lost when eyes are closed.

89
Q

2 ways to measure for crutches

A
  1. measure from axilla to heel of foot and add 2.5 cm

2. with elbow bent at 30 degrees fit 2-3 fingers between top of crutch and axilla

90
Q

four point gait

A
  1. begin in tripod position (crutches in front of body and on side of each foot)
  2. move right crutch forward
  3. move left foot forward to level of left crutch
  4. move left crutch forward
  5. move right foot forward to level of right crutch.
91
Q

three point gait

A
  1. tripod position
  2. advance both crutches and affected leg
  3. move stronger leg forward, stepping on floor
92
Q

two point gait

A
  1. tripod position
  2. move left crutch and right foot forward
  3. move right crutch and left foot forward
93
Q

swing-to-gait

A
  1. tripod
  2. both crutches forward
  3. lift and swing legs to crutches, letting crutches support body weight
94
Q

swing through gait

A
  1. tripod
  2. both crutches forward
  3. lift and swing legs through and beyond crutches
95
Q

ascending stairs with crutches

A
  1. place weight on crutch
  2. advance unaffected leg to stair and transfer weight from crutches to unaffected leg
  3. crutches now aligned with unaffected leg on stair
96
Q

descending stairs with crutches

A
  1. place weight on unaffected leg
  2. put both crutches on lower stair, step down with unaffected leg, transfer body weight to crutches
  3. crutches aligned with unaffected leg on stairs
97
Q

sitting down in a chair with crutches

A
  1. hold both crutches in one hand
  2. patient transfers weight to crutches and unaffected leg
  3. patient grasps arm of chair with free hand and lowers self into chair
98
Q

cane

A
  • -on side of strong leg
  • -cane forward 15-25 cm (6-10 in, body weight on both legs
  • -pt stands straight, looks straight ahead, moves involved leg forward, even with cane
  • -advance strong leg past cane
  • -move involved leg forward, even with strong leg
  • -repeat
99
Q

walker

A

patient stands straight in center of walker, grasps handgrips on upper bars

lifts walker, 15-20cm (6-8 in) forward and set down

steps forward one foot at a time

if unilateral leg weakness is present, step forward with weaker leg

100
Q

bathing technique: assessment

A 
safety
vital status
ROM
medical device
patient preference
skin integrity
pain

never leave bedside without 2-3 rails raised and locked, bed in low position

if connected to IV: remove gown, remove IV bag from pole, slide IV bag and tubing through arm of gown

101
Q

bathing technique: face

A

wash eyes with warm water, from inner to outer canthus.

soak crusts 2-3 min

102
Q

bathing technique: upper extremities and trunk

A

distal to proximal.
raise/support arm above head to wash axilla.
long firm strokes.

103
Q

bathing technique: hand and nails

A

soak in water 3-5 min

104
Q

bathing technique: abdomen

A

bathe, rinse, dry: keep covered between washing and rinsing

105
Q

bathing technique: lower extremities

A

expose leg by folding blanket toward midline.
strokes from ankle to knee, knee to thigh for circulation.
assess for DVT.

106
Q

bathing technique: foot and nails

A

soak for 10 min (not for DM patients)

107
Q

bathing technique: back

A

buttocks and anus front to back.

clean, rinse, dry.

108
Q

oral hygiene: assessment

A

for safety

inspect: lips, teeth, mucosa, gums, palate, tongue, identify oral disease/problems

109
Q

oral hygiene: techniques

A

semi-fowler position

brush 45 degree to gum line
tips of bristles rest against and penetrate under gum line

brush tongue, avoiding gag reflex

rinse teeth with alcohol-free antiseptic mouthwash for 30s

110
Q

oral hygiene: flossing

A

up and down motion

111
Q

principles of surgical asepsis/sterile technique

A
  • -all items in sterile field must be sterile
  • -sterile barrier permeated by punctures, tears, moisture = contaminated
  • -any doubt = unsterile
  • -sterile persons/items only touch sterile areas; unsterile persons/items only touch unsterile areas
  • -movement around/in sterile field must not compromise/contaminate sterile field
  • -out of vision or below waist = contaminated
  • -prolonged air exposure = finish procedures ASAP
112
Q

catheter sizes

A

infants: 5-6 Fr
children: 8-10 Fr
young girls: 12 Fr

women: 14-16 Fr
men: 16-18 Fr

113
Q

catheter insertion/lubrication length

A

males: lubricate 6-7 in; insert 5-7 in + 2 in
females: lubricate 1-2 in; insert 2-3 in + 2 in

Physical Assessment (1 decks)

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