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Module 1 Exam 2 > Physical Assessment > Flashcards

Physical Assessment Flashcards

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1
Q

Whatre considerations for Physical Assessment?

A
  • Cultural Sensitivity
  • Infection Control
  • Environment
  • Equipment
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2
Q

What’re the 2 types and sources of data?

A

Types:
- Subjective: What we are told
- Objective: What we measure and record

Sources:
- Primary: Patient
- Secondary: ANYONE else

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3
Q

Methods of Data Collection

A
  • Interview
  • Nursing Health History
  • Physical Examination
  • Diagnostic and Labs Results
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4
Q

What’re the types of physical assessments? And what are they all considered

A
  • Comprehensive
  • Focused
  • System Specific
  • Ongoing
  • All considered HEAD to TOE
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5
Q

Elements of Assessments

A
  • History
    Baseline
    Problem-based
  • Examinations
    Vitals
    Inspections
    Auscultation
    Palpation
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6
Q

What techniques used during assessment?

A
  • Inspection
  • Palpations
  • Auscultation
  • Olfaction
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7
Q

Should you cover parts that are not being examined when doing an examination?

A

Yes

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8
Q

What are you observing for?

A
  • Color
  • Shape/Symmetry
  • Movement
  • Position
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9
Q

How far are light and deep palpation?

A

Light: 1cm or .5 in.

Deep: 4cm or 2 in.

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10
Q

What do you feel for when palpating?

A
  • Texture
  • Resistance
  • Resilience
  • Mobility
  • Temperature
  • Thickness
  • Shape
  • Moisture
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11
Q

What’re the characteristics of sounds?

A
  • Frequency
  • Loudness
  • Quality
  • Duration
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12
Q

How to prepare for assessments?

A
  • Get all necessary equipment
  • Introduce
  • Explain the procedure
  • Use gloves if necessary
  • Wash hands before and after ANY patient contact
  • Clean equipment in between pt’s
  • Help pt feel comfortable and allow for privacy
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13
Q

What do you need to consider for older patients?

A
  • Recognize their physical and sensory limitations
  • Recognize normal changes of aging vs abnormal
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14
Q

What are some signs of abuse?

A
  • Inconsistency between injuries and statements
  • Bruises, lacerations, burns, bites
  • X-rays showing fractures in different stages of healing
  • Behavioral issues
    Insomnia
    Anxiety
    Isolation
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15
Q

What is the single most important Nero assessment? And why?

A

Level of Consciousness (LOC), it is often the first clue of a deteriorating condition

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16
Q

What can you test for when determining (LOC)

A
  • Alert
  • Lethargic
  • Obtunded: Needs constant stimulation to stay aroused
  • Stuporous: Only responds to bad stimuli
  • Comatose
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17
Q

How to test for cognitive awareness?

A

Ask something to determine if they know their person, place, and time.

Name and DOB?
Where are you?
What’s the date?

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18
Q

What are cranial nerves 3, 4, 6, 7, 11, 12?

A

3- Oculomotor
4- Trochlear
6- Abducens
7- Facial
11- Accessory
12- Hypoglossal

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19
Q

How to test for pupil response and cardinal gaze (Nerves 3,4,6)?

A

Pupil Response:
- Use a penlight going from ear inwards to the nose
Note the size and speed of reaction
- With light off, move penlight close to and away from pupils

Cardinal Gaze:
With tip of the penlight, and about 9-12” from the face, tell pt to follow the pen while you make an H movement pattern

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20
Q

How to test for cranial nerve 7?

A

Ask pt to smile showing teeth and to wrinkle their forehead and raise eyebrows

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21
Q

How to test for cranial nerve 12?

A
  • Ask pt to touch roof of mouth with tongue, stick tongue out, and move it side from side
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22
Q

How to test for cranial nerve 11?

A

-Place hand on shoulders and ask them to shrug them

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23
Q

How to test for motor functions? And what does it help with

A
  • Hand grasp and toe wiggle (HGTW)
  • Flexion and extension with resistance
  • Do these bilateral on both BUE and BLE
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24
Q

What’re you listening for in the lungs?

A
  • Vesicular
  • Bronchovesicular
  • Bronchial
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25
What are the abnormal sounds in the lungs?
- Crackles - Rhonchi - Wheezes - Pleural Friction Rub
26
What's another abnormal respiratory pattern?
Kussmaul's: Fast, deep, and consistent breaths
27
How many points are there to listen to on the posterior and anterior sides of body?
Anterior = 7 Posterior = 10
28
What're you looking for when inspecting nails?
Clubbing
29
What is closing when you hear the LUB and DUB sound in the heart?
LUB: Mitral/tricuspid valves close DUB: Aortic/pumonic valve close
30
What're the locations of the heart?
- Aortic: Right Base, at the 2nd intercostal space - Pulmonic: Left Base, 2nd intercostal space - Tricuspid: Left lateral sternal border, 5th intercostal space - Mitral: Apex, midclavical at 5th intercostal space
31
What is a doppler?
Hand held device for the pedal pulse
32
What is a capillary refill assessment?
Press skin of the nail bed till its white, and observe how long it will take for the red-ish color to return, should take 2-3 seconds, do on both BUE and BLE
33
What're the components of a cardiac assessment?
- Heart sounds - Pulses - Capillary refil - Assessment for edema
34
What's edema?
- Swelling in the extremities Dependent: Mostly in feet and ankles when older adults stand Pitting: Venous insufficiency or heart/kidney failure, there's fluid in tissues
35
Where and how to test ROM?
- Neck: Side to Side, Chin to chest, Extend to back - Shoulders Upper arms and elbows: Straight to side, straight up, touchdown - Wrist: Circle - Hips, Ankles, Knees: Bilateral hip flexion out, Bend knees, Ankle Circles
36
How to test for strength?
- HGTW - Flexion and Extension of BUE/BLE
37
What are you inspecting for in skin?
- Hydration - Temp - Color - Texture - Rashes - Lesions - Cracking
38
What factors can affect the skin?
- Dampness - Dehydration - Nutrition - Circulation - Disease - Jaundice - Lifestyle
39
How to test for pitting edema?
Press down in the skin 2mm=1+ 4mm=2+ 6mm=3+ 8mm=4+
40
How to asses bony prominences?
@ the kips, heels, coccyx, and shoulders, assess for skin integrity and blanching red spots
41
What SHOULD nails appear like?
- Transparent - Smooth - Rounded - Convex - Hygienic
42
What is terminal hair and Vellus hair?
- Terminal: Scalp, Axillae, Pubic, beard - Vellus: small hairs covering body EXCEPT palms and soles
43
Whatre the qualities of hair?
- Quantity - Distribution - Texture - Color - Parasites
44
What to assess ears for?
- Symmetry - Drainage - Shape - Hearing Effects - Lesions - Redness - Tenderness - Odor
45
What to inspect for in the nose?
- Position - Symmetry - Color - Swelling - Deformaties - Discharge - Flaring - Patency - Tenderness
46
Where to inspect in the oral cavity?
- Lips - Oral Mucosa - Teeth - Gums/Tongue - Odor
47
What to inspect throat for?
- Lumps - Ulcers - Edema - White Spots - Redness - Swallowing
48
How to assess neck?
INSPECT - Contour - Symmetry - Midline Trachea - Jugular vein distention PALPATE -Inflamed/enlarged lymph nodes
49
3 segments of the small intestines?
- Duodenum - Jejunum - Ileum
50
7 segments of lg. intestines
- Cecum - Ascending colon - transcerse colon - descending colon - sigmoid colon - rectum - anus
51
What is the order of assessment?
Inspect (LOOK) -> Auscultate (LISTEN) -> Palpate (FEEL)
52
What to ask for abdomen assessment?
- Normal bowel and urine patterns? - Appearence of waste? - Changes? - History of problems?
53
Incontinece
inability to control urine/feces
54
void/Micturate
to urinate
55
Dysuria
pain/difficulty urinating
56
hematuria
blood in urine
57
nocturia
frequent night urination
58
polyuria
large amounts of urine
59
urinary frequency
the need to void all at once
60
proteinuria
large protein in the urine
61
dribbling
leakage despite voluntary control
62
retention
accumulation of urine in bladder, due to not being able to completely empty
63
What to assess urethral meatus and perineal area for?
Inspect urethral orifice for - erythema, - discharge, - swelling, - odor, - infection, - inflammation, - trauma, Perineal area -color condition presence of urine or stools
64

Module 1 Exam 2 (4 decks)

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