Chapter 30: Health Assessment and Physical Examination Flashcards

(63 cards)

1
Q

Use physical examination to do the following

A

• Gather baseline data about the patient’s health status.
• Support or refute subjective data obtained in the nursing
history.
• Identify and confirm nursing diagnoses.
• Make clinical decisions about a patient’s changing health
status and management.
• Evaluate the outcomes of care.

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2
Q

Two types of allergic responses

appear with NRL. Latex

A

The most immediate is an immunological reaction
type 1 response, for which the body develops antibodies
known as immunoglobulin E that can lead to an anaphylactic
response.
The
second is the allergic contact dermatitis type 4 response, which
causes a delayed reaction that appears 12 to 48 hours after exposure

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3
Q

sitting position

Head and neck, back, posterior
thorax and lungs, anterior
thorax and lungs, breasts,
axillae, heart, vital signs,
and upper extremities
A
Sitting upright provides full
expansion of lungs and
better visualization of
symmetry of upper body
parts.
Physically weakened patient is
sometimes unable to sit. Use
supine position with head of
bed elevated instead
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4
Q
supine
Head and neck, anterior thorax
and lungs, breasts, axillae,
heart, abdomen, extremities,
pulses
A

This is most normally relaxed
position. It provides easy
access to pulse sites.

If patient becomes short of breath
easily, raise the head of bed

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5
Q

Dorsal recumbent

Head and neck, anterior thorax
and lungs, breasts, axillae,
heart, abdomen`

A

Position is for abdominal
assessment because it
promotes relaxation of
abdominal muscles.

Patients with painful disorders are
more comfortable with knees
flexed.

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6
Q

prone

musculoskeltal system

A

Position is only for assessing
extension of hip joint, skin,
buttocks.

Patients with respiratory
difficulties do not tolerate this
position well

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7
Q

lateral recumbent

heart

A

Position aids in detecting
murmurs.

Patients with respiratory
difficulties do not tolerate this
position well.

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8
Q

knee-chest

rectum

A

Position provides maximal
exposure of rectal area.

This position is embarrassing and
uncomfortable.

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9
Q

lithotomy

Female genitalia and genital
tract

A

Position provides maximal
exposure of female genitalia
and facilitates insertion of
vaginal speculum

Lithotomy position is embarrassing
and uncomfortable; thus
examiner minimizes time that
patient spends in it. Keep
patient well draped.
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10
Q

Olfaction helps to detect

A

abnormalities that cannot be
recognized by any other means. For example, when a patient’s
breath has a sweet, fruity odor, assess for signs of diabetes

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11
Q

Describe any sound you hear using the following

characteristics:

A

Frequency indicates the number of sound wave cycles generated
per second by a vibrating object. The higher the
frequency, the higher the pitch of a sound and vice versa.
• Loudness refers to the amplitude of a sound wave. Auscultated
sounds range from soft to loud.
• Quality refers to sounds of similar frequency and loudness
from different sources. Terms such as blowing or gurgling
describe the quality of sound.
• Duration means the length of time that sound vibrations
last. The duration of sound is short, medium, or long. Layers
of soft tissue dampen the duration of sounds from deep
internal organs.

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12
Q

CAGE is an acronym for the

following:

A

• Have you ever felt the need to Cut down on your drinking
or drug use?
• Have people Annoyed you by criticizing your drinking or
drug use?
• Have you ever felt bad or Guilty about your drinking or
drug use?
• Have you ever used or had a drink first thing in the
morning as an Eye-opener to steady your nerves or feel
normal?

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13
Q

history of any substantial weight gain or loss

A

A weight gain of 5 pounds (2.3 kg) in 1 day indicates fluid-retention
problems. A weight loss is considered significant if the patient has
lost more than 5% of body weight in a month or 10% in 6 months.

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14
Q

Observe for cyanosis

A

(bluish discoloration)

in the lips, nail beds, palpebral conjunctivae, and palms

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15
Q

Inspect sites where abnormalities are more easily identified

A

For
example, pallor is more evident in the face, buccal (mouth) mucosa,
conjunctiva, and nail beds.

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16
Q

The best site to inspect for jaundice

A

(yellow-orange discoloration)

is on the patient’s sclera.

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17
Q

edema

A

Areas of the skin become swollen or edematous from
a buildup of fluid in the tissues. Direct trauma and impairment of
venous return are two common causes of edema.

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18
Q

The
depth of pitting, recorded in millimeters, determines the degree of
edema

A

For example, 1+ edema equals a 2-mm
depth, 2+ edema equals a 4-mm depth, 3+ equals 6 mm, and 4+
equals 8 mm

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19
Q

primary lesions

A

maculues and nodules

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20
Q

seconday lesions

A

such as ulcers occur as

alterations in primary lesions.

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21
Q

Use the ABCD mnemonic to assess the skin for any type of carcinoma

A

• Asymmetry—look for an uneven shape
• Border irregularity—look for edges that are blurred, notched,
or ragged
• Color—look for pigmentation that is not uniform; variegated
areas of blue, black, and brown and areas of pink,
white, gray, blue, or red are abnormal
• Diameter—look for areas greater than the size of a typical
pencil eraser

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22
Q

Nystagmus,

A

an involuntary, rhythmical oscillation of the
eyes, occurs as a result of local injury to eye muscles and supporting
structures or a disorder of the cranial nerves innervating the muscles

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23
Q

PERRLA

A

(pupils equal, round, reactive to light, and

accommodation)

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24
Q

Cherry-colored lips indicate

A

carbon monoxide poisoning

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25
Varicosities
(swollen, tortuous veins) | comon on the tongues of older adults,
26
Assessment of the neck includes
assessing the neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid gland, and trachea
27
Check each node methodically | in the following sequence:
occipital nodes at the base of the skull, postauricular nodes over the mastoid, preauricular nodes just in front of the ear, retropharyngeal nodes at the angle of the mandiblesubmandibular nodes, and submental nodes in the midline behind the mandibular tip.
28
``` Vesicular sounds are soft, breezy, and low pitched. Inspiratory phase is 3 times longer than expiratory phase. ```
``` Best heard over periphery of lung (except over scapula) Created by air moving through smaller airways ```
29
``` Bronchovesicular sounds are blowing sounds that are medium pitched and of medium intensity. Inspiratory phase is equal to expiratory phase. ```
``` Best heard posteriorly between scapulae and anteriorly over bronchioles lateral to sternum at first and second intercostal spaces ``` Created by air moving through large airways
30
``` Bronchial sounds are loud and high pitched with hollow quality. Expiration lasts longer than inspiration (3 : 2 ratio). ```
Heard only over trachea ``` Created by air moving through trachea close to chest wall ```
31
Crackles ``` Random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways right and left lung bases ```
Fine crackles are high-pitched fine, short; interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Medium crackles are lower; moister sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing.
32
Rhonchi (sonorous wheeze)Muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence
Loud, low-pitched, rumbling coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing
33
Wheezes (sibilant wheeze) High-velocity airflow through severely narrowed or obstructed airway
High-pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration; usually louder on expiration
34
Pleural friction rub Inflamed pleura; parietal pleura rubbing against visceral pleura
Dry, rubbing, or grating quality is heard during inspiration or expiration; does not clear with coughing; heard loudest over lower lateral anterior surface.
35
``` apical impulse or point of maximal impulse (PMI). ```
The apex actually touches the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line.
36
In tall, slender persons the heart hangs more vertically and is positioned more centrally. In shorter or stockier individuals the heart tends to lie more to the left and horizontally
An infant’s heart is positioned more horizontally. The apex of the heart is at the third or fourth intercostal space, just to the left of the midclavicular line. By the age of 7 a child’s PMI is in the same location as the adult’s.
37
During systole
the ventricles contract and eject blood from the left ventricle into the aorta and from the right ventricle into the pulmonary artery.
38
During diastole
the ventricles relax, and the atria contract to move blood into the ventricles and fill the coronary arteries.
39
a third heart sound (S3) can be heard, as with | heart failure
When the heart attempts to fill an already distended | ventricle
40
S4 also indicates an abnormal condition
A fourth heart sound (S4) occurs when the atria contract to enhance ventricular filling. An S4 is often heard in healthy older adults, children, and athletes; but it is not normal in adults
41
S3 ventricular gallop
It is caused by a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension. The combination of S1, S2, and S3 sounds like “Ken-tuck’-y.”
42
S4, or an atrial gallop
occurs just before S1 or ventricular systole. | The sound of an S4 is similar to that of “Ten’-es-see.”
43
Pain caused by vascular condition
tends to increase with activity.
44
Musculoskeletal pain usually is
not relieved when exercise ends.
45
Raised venous pressure
reflects right-sided heart failure.
46
Systemic diseases (e.g., arteriosclerosis, atherosclerosis, diabetes).
Diseases result in changes in integrity of walls of arteries and smaller blood vessels.
47
``` Coagulation disorders (e.g., thrombosis, embolus). ```
Blood clot causes mechanical | obstruction to blood flow.
48
Local trauma or surgery (e.g., contusion, fracture, vascular surgery).
Direct manipulation of vessels or localized edema impairs blood flow.
49
Application of constricting devices (e.g., casts, dressings, elastic bandages, restraints).
Constriction causes tourniquet effect, impairing blood flow to areas below site of constriction
50
examiners use a scale | rating from 0 to 4+ for the strength of a pulse
``` 0: Absent, not palpable 1+: Pulse diminished, barely palpable 2+: Expected/normal 3+: Full pulse, increased 4+: Bounding pulse ```
51
The five Ps—pain, pallor, pulselessness, | paresthesias, and paralysis—
..
52
Varicosities Varicosities in the anterior or medial part of the thigh and the posterolateral part of the calf are abnormal
are superficial veins that become | dilated, especially when the legs are in a dependent position
53
The best time for a BSE
is the fourth through seventh day of the menstrual cycle or right after the menstrual cycle ends, when the breast is no longer swollen or tender from hormone elevations
54
theophyllines.
brochodialator
55
consistency of breast tissue
normally | feels dense, firm, and elastic.
56
Cancerous lesions are
hard, fixed, nontender, irregular in shape, | and usually unilateral.
57
abdominal region
The xiphoid process (tip of the sternum) is the upper boundary of the anterior abdominal region. The symphysis pubis marks the lower boundary
58
Bruising indicates
accidental injury, physical | abuse, or a type of bleeding disorder
59
Hernias
(protrusion of abdominal organs through the | muscle wall) cause upward protrusion of the umbilicus.
60
Absent sounds indicate
a lack of peristalsis, possibly the result of late-stage bowel obstruction; paralytic ileus; or peritonitis
61
Bruits indicate
narrowing of the major | blood vessels and disruption of blood flow
62
Normally there are no vascular sounds
over the aorta (midline through the abdomen) or femoral arteries (lower quadrants)
63
to assess aortic pulsation
Palpate with the thumb and forefinger of | one hand deeply into the upper abdomen just left of the midline