Physical Assessment Ch 5 Flashcards Preview

NURSING FUNDAMENTALS > Physical Assessment Ch 5 > Flashcards

Flashcards in Physical Assessment Ch 5 Deck (76):
0

Signs

Objective data

Perceived by the examiner

What you see, hear, measure, or feel

Ex/ rashes, altered vital signs, abnormal lung or hear sounds, visible drainage or exudate

1

Symptoms

Subjective data

Subjective indications of illness the patient perceives

Pain, nausea, vertigo

2

Disease

Pathologic condition of the body, any disturbance of a structure or function of the body

A recognized set of signs and symptoms characterized by given Disease

You will rely on assessment of signs and symptoms in this case to formulate a nursing diagnosis

3

Many causes of disease of illness(11)

Hereditary
Congenital
Inflammatory
Degenerative
Infectious
Deficiency
Metabolic
Neoplastic
Traumatic
Environmental
Or combination

4

Hereditary diseases

Transmitted genetically from parents to children

5

Congenital

Disease appear at birth or shortly thereafter but not caused by genetic abnormalities

6

Inflammatory diseases

Those in which the body reacts with an inflammatory response to some causative agent

7

Degenerative disease

Implies degeneration often progressive of some party of body

8

Infectious disease

Result from the invasion of microorganisms into the body

9

Deficiency diseases

Result from the lack of a specific nutrient

10

Metabolic disease

Caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body

11

Neoplastic

Disease is described as an abnormal growth of new tissues

12

Traumatic conditions

Result from both physical and emotional trauma

13

Environmental disease

A group of conditions that develop from exposure to a harmful substance in the environment

14

Autoimmune responses

The body develops immunoglobulins (antibodies) against its own tissues or body substances

15

Four major categories for risk factors

Genetic and Physiologic
Age
Environment
Lifestyle

16

Chronic disease

6 months or more
Disease develops slowly and persists over a long period often for a persons lifetime

17

Remission

There has been partial or complete disappearance of clinical and subjective characteristics of the disease

18

Acute disease

Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment

19

Organic disease

Results in a structural change in an organ that interferes with its functioning

Stroke is an organic disease of the brain

20

Functional disease

Often appear to be those of organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities

21

Infection

Caused by an invasion of microorganisms such as bacteria, viruses, fungi or parasites that produce tissue damage

22

Inflammation

A protective response of body tissues to irritation, injury, or invasion by disease producing organsisms

23

the cardinal signs of infection and inflammation include : (6)

Erythema (redness)
Edema (swelling)
Heat
Pain
Purulent drainage (pus)
Loss of function

24

assessment

An evaluation or appraisal of the patient's condition

25

Medical assessment

You will be expected to carry out certain assistive function

Preparing the examining room
Assisting with equipment
Preparing the patient
Collecting specimens

26

Initiating the nurse patient relationship

Initiate the nurse patient relationship by interviewing the patient

Introduce yourself, stating your name; your position, and purposes of the interview

Indicate length of time

Gives the patient and opportunity to ask questions

Assure patients

Strictly confidential

Nurse patient relationship is enhanced by the professionalism and competence you convey

27

Percussion

The use of the fingertips to tap the body's surface to produce vibration and sound

28

Tympani

Dullness

Flatness

Tympany- high pitched, drumlike sound

Dullness- low pitches thudlike sound

Flatness- soft, high pitches, flat sound

29

Interview

Relaxed, unhurried manner in quiet, private, well lighted setting
Convey feelings of compassion and concern
Determine by what name the patient wishes to be addressed
Accepting posture
Relaxed manner at eye level
Pleasant facial expression

30

Nursing health history

The initial step in the assessment process

Information about the patients level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness

31

Biographic data (12)

Date of birth
Sex
Address
Family members names
Addresses
Marital status
Religious preference and practices
Occupation
Source of health care
Insurance
Medicare
Medicaid benefits

32

Chief complaint

Patients subjective reason for seeking health care

33

OPQRSTUV

Document these info In patients own words

Onset- timing: onset duration
Precipitating- provocative- palliative
Quality- quantity
Region-radiation
Severity scale
Treatments
Understanding
Values

34

Health history (5)

Patient has ever been hospitalized or undergone surgery

Allergies

Habits and lifestyle patterns

Assess the patients ability to perform ADLs

Pattern of sleep, excercise , and nutrition

35

Family history

Immediate and blood relatives
Health or cause of death
As well as history of illness
Objectives are to determine whether the patient is at risk for illness of a genetic or familial nature
Info about family structure, interaction and function

36

Environmental history

Provides data about patients home and work environment

37

Psychosocial and cultural history

Data about patients primary language, cultural group, educational background, attention span, and developmental stage
Coping skills and support systems
Identify major values, beliefs and behaviors related to particular health concerns

38

Review of symptoms (ROS)

Systematic method for collecting data on all body systems
Clear, concise manner using appropriate terminology
Ask the patient specific questions relating to functioning of the system

39

Purpose of a nursing assessment

To determine the patients state of health or illness
The initial step you use to form the nursing care plan

40

Wens the best time to assess the patient

As soon after admission as possible

41

Who performs the initial baseline nursing assessment

RN
But o going assessment is the responsibility of both the RN and LVN

42

Focused assessment

Attention is concentrated or focused on a particular part of the body, where signs and symptoms are localized it most active in order to determine their significance

43

Where to perform a nursing physical assessment

Comfortable and safe for he patient
Patients privacy
The patients own room

44

Methods or performing a nursing physical assessment

Head to toe
System of system

Focused assessment of patient complains of something

45

Items essential to the nurses assessment

Penlight or flashlight
Stethoscope
Blood pressure
Cuff
Thermometer
Gloves
Gail belt
Toungue blade

46

Level of consciousness

Oriented x 1 (person)
X 2 (person and place)
X 3 (person place and time)
X 4 (person place time and purpose

47

Neurological examination

1. Level of consciousness
2. Motor function
3 pupillary response

48

Skin and hair

Observe the skin for color, temperature, moisture, texture, turgor, and evidence of injury or skin lesions , color in the sclera, mucous membranes, the tongue, ropes and baubles and palms and soles

Examine hair over entire body to determine distribution, quantity, and the quality

49

Head and neck

Assessment involves arteries, the veins, and the lymph nodes
Facial expressions
Note symmetry of the face
Palate beneath the jaw and down each side of the neck to feel for enlarged lymph nodes
Palmate the carotid arteries

50

Thrill

A vibrating sensation you perceive as you palate along the artery

51

Bruits

Are abnormal swishing sounds heard over organs, glands, and arteries

52

Mouth and throat

Inspect the lips and the mucous membranes of the mouth with a tongue blade and penlight
Condition of the teeth and gums
Breath odors

53

Eyes

Note whether the eyes are symmetric .
No exudate from the eyes is normally seen
Normal sclera of eye is white
Observe the eyes for pupillary reflex

54

PERRLA

Pupils equal
Round
reactive to light
Accommodation

55

Ears

The ear canal is normally free of excess cerumen (earwax)
Note whether the patient is appropriately following commands, indicating an ability to hear

56

Nose

The nose is usually symmetric
Assess both nostrils. Observe for bleeding and drainage

57

Chest, lungs, heart and vascular system

Inspect for bilateral chest expansion which is normally symmetric

Note the rate and depth of respirations

Normal rate for adults is 12-20 breaths per minute

Normal breathing is quiet

58

Beasts

Examine the breasted during a lung assessment

Many patients also do so on a monthly basis

Teach breast self exam to both male and female patients

59

Lung sounds

Through auscultation

Intruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration
Place the stethoscope firmly but not tightly on the ski, and listen for one full inspiration expiratory cycle at each point

Systematically auscultation

Use a zigzag approach

60

Sibilant

Wheezes have a high pitched squeaking musical quality and are produced by airflow through narrowed airways

61

Sonorous

Wheezes have a lower pitches, coarser, gurgling, snoring quality and usually indicate the presence of mucus in the trachoma and large airways

62

Stridor

High pitched inspiratory crowing sound, louder in the neck than over the chest wall

63

Pleural friction rubs

Produced by inflammation of the pleural sac
You will hear a running, grating, or squeaky sound upon auscultation

64

Crackles

Produced by fluid in the bronchioles and the alveoli, are short, discrete, interrupted, crackling or bubbling sounds that are most commonly heard during inspiration

65

Wheezes

Sounds produced by the movement of air through narrowed passages in the tracheobronchial tree

66

Spine

Note the curvature of the spine

67

Heart sounds

Auscultated with the stethoscope

Listen for the intensity of the sound, ranging from faint to strong

Also determine the regularity of the rhythm

68

Peripheral vascular system

Palpating peripheral arterial pulses

Inspect the extremities for summery, color; and varicosities

Palate the hands and feet our temperature

Perform the capillary refill or blanch test by pressing firmly for 5 seconds on the fingernail or toenail and estimating the speed at which the blood return

69

Gostrointestinal system

Assessment of the abdomen

Auscultation for bowl sounds

Palpating comes after auscultation

Use percussion on the abdomen to note the density of underlying tissue

70

Borborygmi

Increased sounds with characteristically high pitched loud rushing sound in bowel sounds

71

Genitourinary system

Inspect the pubic hair

Palate the scrotum

Palpating of the suprapubic area

72

Rectum

Spread the buttocks to look for hemorrhoids or lesions

73

Legs and feet

Palate femoral, popliteal, dorsalis pedis , and posterior tibial
Observe the legs and feet, and palate them for edema

74

Edema

An excessive accumulation of fluid in the interstitial spaces caused by leakage of fluid from veins and capillary beds

Indentation

75

Pitting edema scale

1+ tace (barely perceptible put 2mm)

2+ mild (a deeper out 4 mm. rebounds in 10 to 15 secs

3+ moderate- a deep pit 6 mm lasts for 30 seconds to more than 1 min

4+ severe - an even deeper put 8mm lasts 2-5 minutes before rebounding

check for color, motion, sensation, and temperature (CMST) of both feet