Flashcards in Ch. 19 Assessing Health: Physical Examination Deck (73):
O- onset (when did the problem start)
C- contributing factors
A- alleviating factors
R- Rx (prescribed or over the counter drugs)
T- treatment (another doc., self treatment, surgery)
What is the focus of a nursing physical examination?
focuses on functional abilities and responses to illness/stressors (part of general health assessment)
Why does the nurse perform a physical examination?
1. To establish baseline data and screen for health problems
2. Identify nursing dx
3. Monitor status of identified problem
What is a differential diagnosis?
when medical staff come up with multiple diagnosis (10+) then rule them all out in order to end up with ONE possible diagnosis
What is a Chief Complaint (CC) ?
The reason the patient was admitted to the hospital
What are the 3 types of physical examinations?
What is a comprehensive examination?
-includes an interview plus complete head to toe examination
What is the purpose of the focused examination?
-focused on presenting problems; obtain data about an actual, potential or possible problem that has been identified. Usually focuses on a specific system, function or body part rather than overall health.
What is the purpose of an ongoing examination?
-performed as needed to assess status; possible changes
-evaluates patient outcomes
Each nurse who provides care continuously adds to the file, reflecting the dynamic state of the patient.
Where can you obtain baseline data?
What is the best way for a nurse to organize an examination of a patient?
Start at the head and progress DOWN the body (include system related data - heart sounds and pulses -- and body systems).
What are the 4 body systems that have to be examined or can result in the patient dying?
How do you prepare yourself for a physical exam as a nurse?
-have theoretical knowledge (A and P, techniques)
-have self knowledge
-have knowledge about patients situation
-Read through the care plan and notes!! KNOW YOUR WAY THROUGH THE EXAM, THE PROBLEMS and RESULT!
How do you prepare the environment for the examination?
-privacy: draping/ curtains / close the door
-noise control: TV/ radio off etc.
-enable visualization: good lighting, flashlight if need, ---close eyes when listening to body sounds
What is the best way to prepare the patient and make them feel comfortable?
-explain procedure and advise patient before touching ("I am going to ____ now." during the exam)
-respect cultural differences
-use proper positioning (ask pt if they feel okay in the position)
What are the four major skills used when performing a physical assessment?
What is inspection?
-using sight to gather data
-used throughout examination
Ex. Skin color, behavior, pupil size
What is palpation?
-use of touch to gather data (lumps or bumps?)
-begin with light pressure then deep pressure
Ex. Edema, moisture, masses
What parts of the hands are used during palpation? In which assessment does palpation come last?
Fingertips, Dorsum, Palm, Grasping ;
Assessment of abdomen.
What is percussion? What two types of percussion are there?
Tapping on skin to elicit sound (direct or indirect, useful for assessing abdomen, lung, underlying structures
DIrect percussion - tapping with fingers
Indirect - used more frequently and requires two hands (UTI Example in lecture)
What is auscultation?
-use of hearing to gather assessment data(direct or indirect)
What is the difference between direct and indirect auscultation?
DIrect is listening without an instrument; indirect is listening with a stethoscope.
What are the two parts of a stethoscope used to listen? What is the difference between them?
1. Diaphragm - high pitched sounds
2. Bell - low pitched sounds
How can we modify an infant examination ?
-have parents hold the pt
-attend to safety
How can we modify an toddlers Examination?
-allow to explore and/or sit on parents lap
-invasive procedure last
Give them a toy to distract them such as a reflex hammer.
How can we modify an preschoolers Examination?
-use doll for demonstration
-still may want parental contact
-allow child to help with examination
How can we modify an school Age Examination?
-show approval and develop rapport
-teach about how the body works
How can we modify an adolescent examination ?
-provide privacy (exclude parents/siblings)
-Teach them what normal physiology is to quell concerns about changes.
-use examination to teach healthy lifestyle
-screen for suicide risk
How can we modify an Young/Middle Adults Examination?
1. Negotiate with them if necessary
2. modify if there is a presence of acute or chronic illness.
How can we modify an Older Adults Examination?
-may need special positioning related to mobility
-adapt examination to vision and hearing changes -assess for changes in physical ability
-assess for ability to perform ADLs
-provide time for rest
What do you look for during first contact of patient?
Hint: Imagine a person (homeless, scary, attractive) walking toward you. What do you do?
(We need to know normal versus abnormal. Deviations lead to focused assessments)
What do you look for in a basic assessment of the integumentary system?
-Nails (color, shape, texture, clubbing?)
-Hair (color,texture, distribution,scalp)
Texture - normal, smooth, soft?
Turgor - elasticity? Edema?
What is edema and some of the causes?
Excessive amount of fluid in the tissues
-congestive heart failure (When one or both of your heart's lower chambers lose their ability to pump blood effectively — as happens in congestive heart failure — the blood can back up in your legs, ankles and feet, causing edema.)
-kidney disease (When you have kidney disease, extra fluid and sodium in your circulation may cause edema. )
-peripheral vascular disease (Chronic venous insufficiency, in which the one-way valves in your leg veins are weakened or damaged, allows blood to pool in the leg veins and cause swelling.)
-low albumin levels
(Table 19-3, p.382 chart Assessing Edema)
What do you look for in a basic assessment of the head (skull and face)?
Eyes (visual acuity/PERRLA/Cardinal gazes)
Make sure face and eyes are symmetrical
What is Myopia? Hyperopia? Strabismus ?
Diminished distant vision;
Diminished near vision ;
One or both eyes deviate from the object they are looking at
How do you know when youi have rales versus rhonchi ?
If it is rhonci, a cough will make the sound go away. If it is rales, the sound stays after a cough.
What are EOMs (extraocular movements)?
Controlled movement of eyes and eyelids
What do you look for in a basic assessment of the ears, nose and mouth?
Ears: external and middle ears; hearing (Weber and Rinne tests); build up of wax. Balance (romberg's test)
Nose: breathe freely; Smell, septum
Mouth: Lips, Teeth, Gums, Tongue, Hard/soft palate (diseased?)
What do you look for in a basic assessment of neck?Breasts?
Neck: Musculature, Trachea, thyroid gland, Cervical lymph nodes.
Breast: Size/shape, Nipples, Tissue, axillae
What do you assess in a basic assessment of the chest and lungs?
Size/shape of chest- barrel? normal? spine alterations?
Breath sounds - bronchial, bronchovesicular, vesicular
What is PERRLA?
Pupils Equal, Round, React to Light, Accommodation (ability to change focus from distant to near object)
Basic Assessment of Abdomen
1. Inspect -
2.Auscultate: bowel sounds (absent after 5 minutes /hypoactive 1 per min/hyperactive every 2or3 sec)
3. Percuss- assess fluid/air/organs/masses
4. Palpate - always last to avoid disturbing bowels.
How do you perform a basic assessment of bones, muscles, and joints?
1. Assess body shape and symmetry (posture, gait, spinal curvature)
2. Balance - Romberg's test
3. Coordination -
4. joint mobility (deformity,crepitus,fluid?),
5. Muscle strength - ROM and Resistance
What is contractures? What causes it?
Abduction of extremities due to little movement;
Common for elderly patients because nurses do not move them in the bed.
organs in Right Upper Quadrant (RUQ)
Liver, gall bladder, pancreas, bile duct
organs in Left Upper Quadrant (LUQ)
organs in Right Lower Quadrant (RLQ)
organs in Left Lower Quadrant (LLQ)
What are the normal breath sounds?
Bronchial sound and location
-Listen just below throat (above sternal notch, where trach would go)
-loud and high pitched (darth vader)
-expiration is longer than inspiration
Bronchovesicular sound and location
-heard over the main bronchi (ICS 2); where bronchial meets vesicular
-equal inspiration and expiration
Vesicular sound and location
-heard over lower bronchi, bronchioles, and lobes
-softest sound and lowest in pitch (Majority of lung space).
What are abnormal breath sounds?
-adventitious sounds (fine and coarse crackles, -rhonchi, wheezing, stridor)
What are diminished or misplaced breath sounds?
Sounds heard with poor inspiratory effort, in very muscular or obese, or those with restricted airflow.
What are increased breath sounds?
-occurs when underlying lung tissue is filled with liquid or solid material rather than air
Difference between fine and coarse crackles?
Location and tone.
Fine: high pitched, short popping sounds; caused by air meeting deflated alveoli causing them to pop open; located at the bases of lower lobes
Coarse: loud, low pitched, short crackling sounds
-caused when air meets secretions in large airways
-located in trachea and large bronchi
how long do you listen for lung sounds?
listen for one inspiration and one expiration
How do you do a basic assessment on the heart and vessels?
1. Know your landmarks
2.Observe precordium (area over heart for visible pulse)
3. Palpate Pulse at PMI (5th ICS/Apex) is normal (heaves/lifts abnormal)
4. auscultate (listen over four valve areas)
What are the five points for heart auscultation? In what order to you listen to them?
APETM (All Patients Enjoy Their Meds)
ICS spaced A2-P2-E3-T4-M5
(All2 Patients2 Enjoy3 Their4 Meds5)
1. AORTIC (Base Right-2nd ICS)
2. PULMONIC (Base left - 2nd)
3. Erb's Point (below pulmonic)
4. TRICUSPID (left sternal border - 4th ICS)
5. MITRAL (PMI - apex - 5th ICS)
When and for how long do you check the hear rate when administering digoxin?
Hint: digoxin's adr can include bradycardia.
BEFORE you give this drug you should check the heart rate for ONE MINUTE and if heart rate is less than 60 (and systole is less than 90) DO NOT give the drug.
Should you always check pulse and BP before giving meds?
YES. no matter if its hypertensive or cardiac meds, you have to check pulse and BP
The heart should make the sound lub dub. What makes the sound lub? What makes the sound dub?
Lub is S1, which is the closure of atrioventricular valves. Systole (LAVS)
Dub is S2, which is the closure of the semilunar valves. Diastole (DSLD)
Memorization for S3 and S4
What causes variscosities?
varicose veins are caused by inadequate oxygen
Name the pulses in the body.
How do you do a basic neurological assessment?
Cerebral functioning (level of consciousness/Mental status/cognitive functioning)
Motor/cerebellum function - tone, posture, equilibrium
Senses-light touch, pain, temp, position, stereognosis (form of solid object recognition, graphesthesia (number in palm test), two-point discrimination, point localization.
What is proprioception?
Knowing where your body is in relation to the earth/space while the eyes are closed.
What are the sites of measurement for temperatures?
What is apnea, eupnea, bradypnea, and tachypnea?
Apnea - Absence of breathing
Eupnea - Normal respirations w/ equal rate and depth, 12-20 breaths/min
Bradypnea - Slow respirations, less than 10 breaths/min
Tachypnea - fast respirations, greater than 24 breaths/min and usually shallow
What three nerves control EOMs?
6 - Abducens
What two nerves control pupillary reaction to light?
2 - Optic
works with 3 - oculomotor
In the cardiac cycle, the atria and ventricles are alternately contracting and relaxing to fill and empty the heart. They do this at opposing times.
_______ refers to the contraction or emptying of the ventricles. _____ refers to the relaxation or filling phase of the ventricles.
S1 - Systole - shutting of the av valves - like squeezin a ketchup bottle
S2 - Diastole - shutting of semilunar valves - allowing the ventricles to dilate and fill with blood.