Week 2-physical Assessments With Vital Signs Flashcards
Levels of physical assessment
Comprehensive
Focused
Head to toe
When is physical assessment done
Admissions
Beginning of shift
When condition changes
When evaluating effectiveness of care
When things dont feel right
Assessment techniques
Interviewing
Observation(visual)
Palpation(touch)
Percussion(tapping body surface)
Direct Auscultation(listening without assisted device)
Indirect ausculation-listening with stethescope
Olfaction-(smell)
Nervous system assessment
Vital signs and consciousness
Orientation
Speech
Cardio assessment
Blood pressure and pulse
Heart sounds
Respiratory
Rate and characteristics
Breath sounds
Shape of chest
Integumentary
Skin color, texture moistness and temp
GI
Nauseau
Vomitting
Shape if abdomen
Urinary
Distention of bladder
Frequency burning or urgency
Musculoskeletal
Range if motion in joints
Strength if grip
Foot flexion
Initial head to toe assessment
General appearance
Vital signs
Neurological exam
Head and neck
Chest and abs
Assessment of head and neck
Eyes-jaundice, ptosis, consensual reflex, accommodation response
Dysphagia
Condition that caues difficulty swallowing.
Cheilitis
Lip inflammation
Crack in skin that may get to dermis
Assessment of chest
Rales-rattling sound
Rhonchi
Wheezes
Stridor-high pitched breathing sounds caused by obstruction
Apical pulse
Assessment of lung sounds
Bronchial
Bronchovesicular
Vesicular
Assessment of abs
Bowel sound
Peristalsis
Suprapubic assessment
Skin
Dressing and equipment
Assessment of extremities
Upper-radial pulse, movement, capillary refill time
Lower-edema, pallor, circulation, pedal pulse
Cardiac ausculation sites
Slide 28
Basic assessments: skin, head
Skin-color and other characteristics(temp)
Lesions
Hair
Nails
Nail assessment
Root
Body
Bed
Visual screening
Snellen standard chart
Graphestisia
-perform if not able to manipulate objects
-It is a test to identify numbers written in hand
Stereognosis
Ability to identify object by feeling jt
Consensual reflex
Observing one side of the body while stimulating the other.
Done to eyes. They both dilate.
Accommodation response
Is eyes response to focusing on near object
