Notes Ch: 31 - Assessment Pt. 1

Question 1

What is the purpose of the physical assessment?

Answer 1

S.M.I.G.E

• Support/Refute subjective data obtained in nursing hisory
• Make clinical decisions about a patient’s changing health status and management
• Identify and confirm nursing diagnosis
• Gather baseline data about patient’s health
• Evaluate the outcomes of care

Question 2

What is the organization of the physical examination?

Answer 2

F.A.S.H.

• Follows history
• Assessment of each body system
• Systematic and organized
• Head-to-toe approach

Question 3

What is a head-to-toe assessment?

Answer 3

A comprehensive assessment of all systems top to bottom.

Question 4

What are the characteristics of a focused assessment?

Answer 4

• Focuses on certain system(s) in priority
• Tyically respiratory or cardiovascular
• Once stable, then proceed with comprehensive

Question 5

Observing top to bottom, left to right, anterior to posterior describes what action?

Answer 5

Assessing for symmetry

Question 6

When we perform a comprehensive assessment, we move from _____ to _____ invasive unless there is ____, which requires priority attention.

Answer 6

least, most, pain

Question 7

You cannot _____ until you _____.

Answer 7

intervene, assess

Question 8

Start with _____ data before going to the physical assessment.

Answer 8

subjective

Question 9

What does HNP stand for?

Answer 9

History and Physical

Question 10

The patient history is a _____ assessment which is comprised of what two things?

Answer 10

subjective

History and interview

Question 11

The physical assessment provides _____ data

Answer 11

objective

Question 12

What are the 4 techniques of physical assessment?

Briefly describe each.

Answer 12

1. Inspection; what you see
2. Palpation; what you feel with light, then deep touching
3. Percussion; vibrations heard by tapping a region; indicates location size density of structures; more of an advanced MD or NP method
4. Auscultation; what you hear

Question 13

When using a stethoscope, listen for _____ sounds first before identifying _____ sounds or variations.

Answer 13

normal, abnormal

Question 14

What is meant by “CC”?

Answer 14

Chief Complaint

Question 15

What is erythema?

Answer 15

Superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.

Question 16

What is vitiligo?

Answer 16

A long-term skin condition characterized by patches of the skin losing their pigment (hypopigmentation).

Question 17

What types of things can be indicated by observing the color of the skin?

Answer 17

• Adequate blood perfusion
• Erythema
• Cyanosis
• Jaundice

Question 18

How is cyanosis observed and what does it indicate?

Answer 18

• Blueish skin
• Observed at the mouth or mucus membranes
• Low oxygen
• Late sign of hypoxia

Question 19

How is jaundice observed and what does it indicate?

Answer 19

• Yellowish hue in skin or sclera
• Indicates liver issues

Question 20

What are some skin observations that can indicate hydration issues?

Answer 20

• Dryness
• Dried lips
• Sunken neck
• Turgor

Question 21

What is turgor, how it is assessed, and what does inidicate?

Answer 21

• It is the elasticiity of the skin
• Assessed by pinching
  
  • if the skin bounces back, decent hydration is indicated
  • if the skin does not bounce back, it indicates dehydration and that fluids are needed

Question 22

What are the 6 general items being observed while assessing the skin?

Answer 22

1. Color
2. Moisture
3. Temperature
4. Texture
5. Integrity
6. Turgor

Question 23

What is edema?

Answer 23

• The medical term for swelling

Question 24

When observing edema, a deeper level indicates…

Answer 24

fluid excess

Question 25

How are the grades of edema tested?

Answer 25

By pressing in the effected area and assessing depth of swelling.

Question 26

How are the grades of edema documented? | (give depth as well)

Answer 26

+1 = 2mm +2 = 4mm +3 = 6mm +4 = 8mm * \*there is nothing greater than +4 on this scale, * \*+8 does not exist)

Question 27

When checking for melanoma, how is "ABCDE" utilized?

Answer 27

* A = Asymmetry; not uniform * B = Border; irregularity; ragged edges * C = Color; not uniform; blue-black; white-gray; red * D = Diameter; greater than a pencil eraser * E = Evolving ; changing in appearance

Question 28

What are some observations when assessing hair?

Answer 28

* Dryness * Lice/bugs * Thinning * Texture

Question 29

The status of hair can indicate poor \_\_\_\_\_\_.

Answer 29

nutrition

Question 30

What is alopicia?

Answer 30

hair loss

Question 31

How are the four techniques of assessment used when observing hair?

Answer 31

* Inspection; can see conditions * Palpation; can feel conditions * Percussion; N/A * Auscultation; N/A

Question 32

Nails Oxygenation is checked at the \_\_\_\_\_.

Answer 32

nail bed

Question 33

Nails What is normal capillary refill time and how is it assessed?

Answer 33

* \< than 3 seconds * by pressing on the nail bed until white and then releasing

Question 34

Nails What is clubbing? What are its characteristics? What does it indicate?

Answer 34

* abnormal angle of the nail bed * \>180 indicates clubbing * 160° is normal angle * Can indicate poor circulation and heart failure * *May see in patients with COPD*

Question 35

a depressed, sunken neck is indicative of \_\_\_\_\_, whereas distention is indicative of \_\_\_\_\_\_. In either case, we will need to check _____ function.

Answer 35

dehydration, fluid retention, kidney

Question 36

Descibe a Macule

Answer 36

* Flat, nonpalpable change in skin color * smaller than 1cm * ex. freckle

Question 37

Describe a Papule

Answer 37

* Palpable, circumscribed, solid elevation in skin * smaller than 1cm * a small mole

Question 38

Describe a Nodule:

Answer 38

* growth of abnormal tissue. * Nodules can develop just below the skin. They can also develop in deeper skin tissues or internal organs. * a general term to describe any lump underneath the skin that's at least 1 centimeter in size or larger * ex. wart

Question 39

Describe a wheal

Answer 39

* Irregularly shaped, elevated area or superficial localized edema * Varies in size * Ex. hive or misquito bite

Question 40

Describe a vesicle

Answer 40

* Raised lesion filled with serous fluid * ex. blister

Question 41

Describe Pustule

Answer 41

* Circumscribed elevation of skin smaller to vesicle * filled with pus * ex. acne, staphylococcal infection