Unit 1: Ch. 30 Flashcards
what are the two aspects of assessing a client’s health status
- ) the nursing health history
2. ) the physical examination
what steps should a nurse take to ease anxiety before an examination?
- explain when & where the examination will take place
- explain why the procedure is important
- explain what will happen during the examination
what are the four primary techniques used in a physical examination
inspection, palpation, percussion, and auscultation
what characteristics are determined by use of palpation
- texture
- temperature
- vibration
- position, size, consistency, & mobility of organs or masses
- distension
- pulsation
- tenderness or pain
Back-lying position with legs extended; with or without pillow under the head. Asseses head, neck,axillae, anterior thorax, lungs, breasts, heart, vital signs, abdomen, extremities, peripheral pulses.
supine (horizontal recumbent)
A _____ position, back unsupported and legs hanging freely. Asseses head, neck, axillae, posterior and anterior thorax, lungs, breasts, heart, vital signs, upper and lower extremities, and reflexes.
sitting
Side-lying position with lowermost arm behind the body. Uppermost leg flexed at hip an knee, upper arm flexed at shoulder and elbow. Assesses the rectum, and vagina
Sims’
A position where the client lies on abdomen with head turned to the side, with or without a small pillow. Assesses the posterior thorax, hip joint movement.
Prone
Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface. Assesses female genitals, rectum, and female reproductive system.
Dorsal recumbent
Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table. Assesses female genitals, rectum, and female reproductive tract
Lithotomy
a percussion assessment can elicit what five possible types of sound
flatness, dullness, resonance, hyperresonance, and tympany
how are percussion and auscultated sounds described
according to pitch, intensity, duration, and quality
the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation and presents as pale skin tone
Pallor
a bluish tinge, due to low oxygen supply
Cyanosis
a yellowish tinge, due to kidney failure
Jaundice
skin redness associated with rashes & other conditions
erythema
presence excess of interstitial fluid
edema
an alteration in the normal appearance of skin
skin lesion
mild pitting edema, 2mm depression that disappears rapidly
+1
moderate pitting edema, 4mm depression that disappears after 10-15 secs
+2
moderately severe pitting edema, 6mm depression that may last more than 1 minute
+3
severe pitting edema, 8mm depression that can last more than 2 minutes
+4
when the angle of the nail and nail bed is 180º or greater
clubbing
clubbing may be caused by what condition
long term lack of oxygen
what is the blanch test used for
to test capillary refill or peripheral circulation
an extremely dull sound produced by very dense tissue
flatness
thud like sound produced by dense tissue, like in liver, spleen, heart
dullness
hollow sound produced by air filled lungs
resonance
an abnormal booming sound produced during percussion of the lungs
hyperresonance
musical/drumlike sound produced from an air filled stomach
tympany
patches of hypopigmented skin as a result of destruction of melanocytes
Vitiligo
the degree of detail the eye can discern in an image
visual acuity
the area an individual can see when looking straight ahead
visual fields
myopia
nearsightedness
hyperopia
farsightedness
loss of elasticity of the lens and thus loss of ability to see close objects
presbyopia
uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina
astigmatism
inflammation of the bulbul and palpebral conjunctiva
conjunctivitis
opacity of the lens which block light rays
cataracts
disturbance in the circulation of aqueous fluids which cause an increase in intraocular pressure
glaucoma
