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Nursing > Physical Assessment > Flashcards

Physical Assessment Flashcards

1
Q

What is the Glasgow Coma Scale?

A

A standardized scale that uses a point system for eye opening, verbal, and motor response to assess a patient’s level of consciousness.

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2
Q

What is the Glasgow Coma Scale point system for eye opening response?

A

4pts - Spontaneous, opens with blinking at baseline.
3pts - to verbal stimuli, command, speech
2pts - to pain only (not applied to face 0
1pt - no response

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3
Q

What is the Glasgow Coma Scale point system for verbal response?

A 
5pts - oriented
4pts - confused conversation, but able to answer
3pts - inappropriate words
2pts - incomprehensible speech
1pt - no repsonse
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4
Q

What is the Glasgow Coma Scale point system for motor response?

A

6pts - obeys commands for movement
5pts - Purposeful movement to painful stimulus
4pts - withdraws in response to pain
3pts - flexion in response to pain (decorticate posturing)
2pts - extension in response to pain (decerebrate posturing)
1pt - no response

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5
Q

What does bilateral edema generally indicate?

A

fluid volume excess or venous insufficiency

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6
Q

What might unilateral edema indicate?

A

inflammation, venous thromboembolism, or lymphedema

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7
Q

What is the point system for edema?

A

+1 - 2mm
+2 - 4mm
+3 - 6mm
+4 - 8mm

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8
Q

How do you test cranial nerves V (trigeminal) and VII (facial)?

A

ask the patient to bite down and feel for contraction of the temporal muscle and the masseter muscle (in front of the ear). Check the sensory branch of cranial nerve V by having the patient close his eye and report when he feels light touch to his forehead, each cheek, and his chin with cotton.

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9
Q

What does PerrLa stand for?

A

Pupils Equal, Round, Reactive to Light and Accommodation

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10
Q

How can you tell if cranial nerves IX and X or intact?

A

the uvula will rise and the patient can swallow

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11
Q

What is the normal range of respiratory for a resting adult?

A

12-20 breaths per min

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12
Q

What are the characteristics of respiration that are routinely assessed?

A

respiratory rate
ventilatory depth
ventilatory rhythm
lung sounds

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13
Q

What position should the patient be in for a respiratory exam?

A

in a comfortable position either sitting or lying with the head of the bed elevated 45-60 degrees.

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14
Q

What would you document following a respiratory exam?

A

Respiratory rate, depth, and rhythm in nurse’s notes or vital sign flow sheet
SpO2 value and type of O2 on nurse’s notes or iata sigh flow sheet
Document any abnormalities in nurse’s notes and report to nurse in charge or health care provider immediately
(ex. 16 breaths per min; regular rhythm; normal depth, lung sounds clear/normal; 98% RA)

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15
Q

What are some abnormal breathing characteristics to assess for?

A

nasal flaring/grunting/pursed lip breathing
trachea position (midline; deviated right or left)
Accessory muscles usage (skin being sucked in between clavical and ribs)
Retractions (entire rib cage excessively in and out)
Cough (productive/ non productive)

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16
Q

What is the normal range of respiratory for a resting child?

A

20-30 breaths per min

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17
Q

What is the normal range of respiratory for a resting newborn?

A

30-60 breaths per min

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18
Q

What are the breathing characteristics of apnea?

A

respirations cease for several seconds. Persistent cessation results in respiratory arrest.

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19
Q

What are the breathing characteristics of Cheyne-Stokes?

A

Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; breathing slows and becomes shallow, concluding as apnea before respirations resumes.

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20
Q

What are the breathing characteristics of dyspnea?

A

shortness of breath

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21
Q

What are the breathing characteristics of eupnea?

A

normal, good, unlabored breathing, sometimes known as quiet breathing or resting respiratory rate

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22
Q

What are the breathing characteristics of Orthopnea?

A

shortness of breath (dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair

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23
Q

What are the breathing characteristics of Kussmaul?

A

respirations are abnormally deep, regular, and increased in rate

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24
Q

What are the breathing characteristics of Tachypnea?

A

rate of breathing is regular but abnormally rapid (greater than 20 breaths pre min)

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25
Q

What are the breathing characteristics of Bradypnea?

A

rate of breathing is regular but abnormally slow (less than 12 breaths per min)

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26
Q

What are the four questions used to assess level of orientation and how would you document it?

A

What is your name? (person)
Do you know where you are? (place)
Do you know what time or what day it is? (time)
Do you know why you are here? (situation)
Documentation: A and Ox4 (alert and oriented for all 4 questions)

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27
Q

What are the components of a general patient survey?

A 
Gender and race
age
signs of distress
body type
posture
gait
body movement
hygiene and grooming
dress
body odor
affect and mood
speech
signs of patient abuse
substance abuse
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28
Q

What are included in vital signs

A 
Temperature
Pulse
Respirations
Pulse Oximetry
Blood Pressure
Pain
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29
Q

What would be the subject data to gather regarding respirations?

A

Patient complaints:

C/o (complains of) or denies dyspnea, cough, other symptoms, pain related to breathing

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30
Q

What are the body systems that are generally assesses during a full health assessment?

A 
Neurological
Cardiovascular
Respiratory
Gatrointestinal
Genitourinary
Musculoskeletal
Integument
Psychosocial
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31
Q

What is the subjective data to gather regarding integument?

A

Patient complaints:

C/o or denies pain, discomfort or itching, tingling, etc. related to the skin.

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32
Q

What does the integumentary system include?

A

skin hair scalp, and nails

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33
Q

What is the Braden scale?

A 
A scale used to predict pressure ulcer risk that uses a score from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury. 
19-23 = no risk
15-18 = mild risk
13-14 = moderate risk
less than 9 = severe risk
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34
Q

What are the 6 categories of the Braden scale?

A 
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction/shear
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35
Q

What abnormalities are noted while assessing integument?

A

scars, discoloration, bruising, wounds, red areas, pressure sores

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36
Q

What does a bluish color to the nail beds, lips, mouth, or skin possibly indicate?

A

(cyanosis) - increased amount of deoxygenated hemoglobin (associated with hypoxia)
Causes: lung disease, cold environment

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37
Q

What does pallor (paleness) to the face, nail beds, palms of hands, skin, or lips possibly indicate?

A

reduced amount of oxyhemoglobin caused by anemia/ reduced visibility of oxyhemoglobin resulting from decreased blood flow caused by shock.

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38
Q

What does a loss of pigmentation in patchy areas on the face, hands and arms possibly indicate?

A

vitiligo caused by congenital or autoimmune condition causing lack of pigment

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39
Q

What does a yellow-orange (jaundice) skin and eye color indicate?

A

increased deposit of bilirubin in the tissues caused by liver disease, destruction of red blood cells

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40
Q

What does a red (erythema) color to the face, area of trauma, or other areas possibly indicate?

A

increased visibility of oxyhemoglobin caused by dilation or increased blood flow caused by fever, direct trauma, blushing, alcohol intake

41
Q

What is a normal heart rate for an adult?

A

60-100 beats per min

42
Q

What is a normal heart rate for a school aged child?

A

75-100 beats per minute

43
Q

What is a normal heart rate for an infant?

A

120-160 beats per min

44
Q

What is JVD and what does it possibly indicate?

A

jugulovenous distention characterized by a bulging pulse in a patient’s jugular vain when standing or sitting upright - It is most common with heart failure

45
Q

Where is the point of maximal impulse (PMI) located?

A

at the apex of the heart, normally located in the fifth intercostal space at the left midclavicular line.

46
Q

What is the cause of the first heart sound S1 (“lub”)?

A

the tricuspid and mitral valves snap shut at the beginning of systole.

47
Q

What is the cause of the second heart sound S2 (“dub)?

A

the aortic and pulmonic valves close at the beginning of diastole.

48
Q

What is subjective data to gather during a neurological assessment?

A

C/o or denies headache or other head pain

49
Q

What is assessed during a neurological exam?

A 
Level of consciousness and orientation
Facial symmetry
Eye Opening Response (Glasgow coma score)
Pupils
Speech
Motor and sensory function
50
Q

How do you assess motor and sensory function?

A 
Grip strength
Pedal pushes
movement of extremities
Touch
Coordination 
Balance
51
Q

What subjective data is gathered during a cardiovascular assessment?

A

C/o or denies chest pain

VERY IMPORTANT

52
Q

What vital signs are part of a cardiovascular assessment?

A

BP, Pulse, Temp

53
Q

What are the characteristics of pulse that are assessed?

A

Rate
Rhythm (normal or regular)
Strength (bounding - 4, full or strong - 3, normal and expected - 2, diminished or barely palpable - 1)
Equality (in extremities)

54
Q

What is assessed during a cardiovascular exam?

A 
Vitals (assoc. w/ cardio)
Skin color, temp, moisture
Heart sounds
Peripheral pulses (brachial or femoral artery)
Capillary refill
JVD
Edema
IV access
55
Q

What is anasarca?

A

general swelling of the whole body that can occur when the tissues of the body retain too much fluid. The condition is also known as extreme generalized edema. (can be a sign of severe organ damage or illness)

56
Q

What are the sizes of IV’s and their corresponding color?

A 
18 gauge - green
20 gauge - pink
22 gauge - blue
24 gauge - yellow
16 gauge - orange (only used for trauma or special procedures)
57
Q

What is bradycardia?

A

slow HR (blow 60 bpm in adults)

58
Q

What is tachycardia?

A

elevated HR (above 100 bpm in adults)

59
Q

What is dysrhythmia?

A

abnormal HR rhythm

60
Q

What can cause pulse rates to vary?

A 
exercise
temperature
emotions
medication
hemorrhage
postural changes
pulmonary conditions
61
Q

What is the normal range for an adult’s blood pressure?

A

less than 120/80

62
Q

What is the normal range for a child’s blood pressure?

A

87-117/48-64

63
Q

What is the normal range for an infant’s blood pressure?

A

65-115/42-80

64
Q

systolic pressure

A

the peak of maximum pressure when ejection occurs

65
Q

diastolic pressure

A

the minimum pressure the arteries exert when the ventricles relax

66
Q

pulse pressure

A

the difference between systolic and diastolic pressure

67
Q

hypotension

A

low BP - systolic BP falls to 90 mmHg or below

68
Q

hypertension

A

high BP - systolic BP greater than 140 mmHg and diastolic greater than 90 mmHg

69
Q

What are Korotokoff sounds?

A

the five phases of sounds auscultated during blood pressure measurement.

70
Q

What sound is heard in Korotkoff phase 1?

A

a sharp thump

71
Q

What sound is heard in Korotkoff phase 2?

A

a bowing or whooshing sound

72
Q

What sound is heard in Korotkoff phase 3?

A

a crisp, intense tapping

73
Q

What sound is heard in Korotkoff phase 4?

A

a softer blowing sound that fades

74
Q

What sound is heard in Korotkoff phase 5?

A

silence

75
Q

What physiological factors can influence BP?

A 
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity and weight
Smoking
76
Q

What is a normal range of oxygen saturation?

A

90% or higher

77
Q

What is the order of action for collecting objective data and when does it vary?

A 
Inspection
Palpation
Percussion
Auscultation
Varies only with the GI system in which case you would inspect, auscultate, palpate, percussion.
78
Q

What is the subjective data gathered during a gastrointestinal assessment?

A

C/o or denies pain or discomfort relating to the GI system

79
Q

What is included in the GI System?

A

mouth, esophagus, abdomen, rectum

80
Q

Where do you auscultate for bowel sounds?

A

All 4 abdominal quadrants

81
Q

Where are bowel sounds usually active?

A

in the right lower quadrant where the ileocecal valve is.

82
Q

what is kyphosis?

A

a condition common in older patients characterized by pronounced convexity of the thoracic spine that can restrict lung expansion

83
Q

What are the categories of the five-point muscle strength scale?

A

5+ normal (can overcome examiner’s resistance)
4+ can move muscle group against some resistance
3+ can move muscle against gravity but not against resistance
2+ able to actively move muscle when gravity is eliminated
1+ trace contraction found by palpating while patient attempts to contract muscle
0+ no muscle contraction detected

84
Q

how many lobes does the right lung have?

A

3

85
Q

how many lobes does the left lung have?

A

2

86
Q

What heart valves does APTM correspond to?

A

Aortic
Pulmonic
Tricuspid
Mitral

87
Q

What is a sign of peripheral vascular disease?

A

Shiny hairless skin below mid calf

88
Q

What are the 6 components of a neurological exam?

A 
mental status
balance and coord
cranial nerves
motor function
sensory function
reflexes
89
Q

Cranial nerve 1 name and function:

A

Olfactory: sense of smell

90
Q

Cranial nerve 2 name and function:

A

Optic: visual acuity

91
Q

Cranial nerve 3,4, and 6 names and function:

A

Oculomotor, Trochlear, and Abducens: eye movements

92
Q

Cranial nerve 5 name and function:

A

Trigeminal: sensory nerve to skin of face, motor nerve to muscles of jaw

93
Q

Cranial nerve 7 name and function:

A

Facial: expressions and taste

94
Q

Cranial nerve 8 name and function:

A

Auditory: hearing

95
Q

Cranial nerves 9 and 10 names and function:

A

Glossopharyngeal, Vagus: taste, ability to swallow, vocal cords

96
Q

Cranial nerve 11 name and function:

A

Spinal accessory: movement of head and shoulders

97
Q

Cranial nerve 12 name and function:

A

Hypoglossal: tongue position

“light, tight, dynamite”

98
Q

What does the romberg test assess?

A

balance

Nursing (26 decks)

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