Physical Assessment Exam 1 Flashcards
(148 cards)
1
Q
Medical approach versus nursing diagnosis
A
Medical approach: etiology of disease and cure. Nursing Approach: holistic and how the disease impacts the person
2
Q
Problem Oriented Records: SOAP
A
S: subjective-Symptoms
O: objective: signs
A: Assess
P: Plan
3
Q
Interviewing an Older Adult
A
Well lit, warmer room, low voice, assess for pain, loss of appetite, weight loss, dizziness, fatigue
4
Q
Four types of data collection
A
Comprehensive
Follow-up
Episodic
Emergency
5
Q
Interview Intro
A
Intro, open ended questions, closed questions (Y/N), responses
6
Q
Classical History and Physical
A
Intro, Chief Complaint, HPI, PMH, current health, social/occupational, functional status, ROS, PE
7
Q
Identifying Info
A
Name, DOB, race, gender, ethnicity, Occupation, language
*ID source of info
8
Q
Chief Complaint
A
What brings him/her here today. In own words
9
Q
History of Present Illness
A
Onset, Location, Duration, Characteristics, Alleviating/Agrevating Factors, Radiation, Timing, Perception of Symptoms
10
Q
Past Medical History
A
General, Childhood, Adult, GYN: Gravida, Para, Abortion, Surgery, Accidents/Trauma, Psych
11
Q
Current Health
A
Allergies: Medications, Environmental, Food Meds: Names and Dose Habits: Alcohol, Tobacco (Pack years), drug Exercise Immunizations Safety measures Sleep Diet: 24 hour recall Environmental Hazards Screening
12
Q
Social History
A
Family, relationships, lifestyle, transport, occupation, religion, finances
13
Q
Family History
A
Three generations, with key. Note if adopted
14
Q
Functional Assessment
A
ADLs: Bathing, transfer, toileting, getting dressed, feeding self
IADLs: cooking, shopping, managing meds and finances, transport
15
Q
Review of Symptoms
A
O
16
Q
Physical Exam Techniques
A
Inspect, Palpate, Percuss, Ausculation
17
Q
Vital Signs
A
BP, Pulse, O2 stats, Temp, Pain, Weight/Height, RR
18
Q
Universal Steps
A
Introduce, wash hands, ID patient in two ways, allergies, falls risk
19
Q
Alert and Oriented X 3
A
Person, place, and time
20
Q
Height and Weight
A
Height in CM, Weight in KG
BMI: KG/cm2
Underweight: 30
21
Q
Heart Rate
A
60-100 BPM is normal
Assess in: Temporal, carotid, brachial, radial, femoral, apical, posterior tibial, dorsal pedis
Grade: 0= no pulse, 1+=weak pulse, 2+=normal pulse, 3+=bounding pulse
22
Q
Respiratory Rate
A
Normal: 12-20
>20= tachypnea
23
Q
Blood Pressure
A
Normal: 120/80
Systolic: contracting, Diastolic: at rest
24
Q
Influences on BP
A
-Peripheral resistance, Elasticity, cardiac output, volume
-age: no diff til puberty when men’s go up, and women’s go up at menopause
-race: AA tend to have higher than white
Diurnal: Tend to be higher in afternoon
25
BP Classification
Systolic: Normal= 120, Pre=120-139, Stage 1= 140-159, Stage 2=>160
Diastolic: Normal=80, Pre=80-89, Stage 1= 90-99, Stage 2= >100
26
Temperature
-Take at: rectal, oral, tympanic, temporal, axillary
-axillary= 1 lower than oral, rectal=1 degree higher than oral, tympanic= 1.4 degrees higher than oral
-Impacted by:
diurnal: higher in afternoon, lowest in AM
menstrual cycle: higher
exercise
27
O2 stats
closest to 100% as possible
28
Pain
Pain scale on 0-10, FLACC for kids, face scale for non-verbal
29
Older Adults Vital Signs
BP: systolic hypertension with widened pulse pressure
HR: pacemaker cells decrease and affect response to physic stress
RR: unchanged
Temp: decreased baseline temp
30
Cardiac Risk Factors
hypertension, diabetes, overweight, inactivity, smoking (increased BP because of vasoconstriction), age, family history
31
Ausculatory gap
when you don't hear sound between systolic and diastolic BP
32
Orthostatic BP
Check for patients who have fainted, feel light standing, volume depletion
- Supine, sitting, standing 2 minute intervals
- drop in systolic >20 mmHg or pulse increases 20bpm
33
Internal Eye
- Sclera: white and outermost layer. Becomes the cornea. Where muscles hold eye intact
- Choroid: vascular regions. Becomes iris and cilliary body
- Retina: nural layer
- Cililary Body: where production of aqueous humor is.
- Aqueous Humor: passes through posterior chamber through pupil to anterior chamber
34
Tarsal Plate
Within eyelids, connective tissue that secretes lubricating oils
35
Meibomian glands
tear fluid that protects conjunctiva and cornea
36
Palpebral conjunctiva
Covers inside of eye lid- clear and moist
37
Bulbar conjunctiva
coats outside of eyelid- clear and moist
38
lacrimal apperatus
starts at lacrimal gland, secretes tears across the eyes, into puncta, then to nasolacrimal sac, nose
39
Opthalmoscope view
-Optic disc on nasal side: creamy orange to yellowy pink. No papilladema-- follow out to four optic vessels (arteries have think line of light), no AV nicking. Macula. Background is clear
40
Visual Pathways
projected by the retina as upsidedown and opposite. Closing of fibers at optic chiasm.
41
Eye muscles
```
Superior rectus: cranial nerve III-ocularmotor
Lateral rectus: CN 6-abducens
Inferior rectus: CN 3
Superior Oblique: CN 4- Trochlear
Inferior oblique-CN 3
```
42
Nerve Palsy
CN III. From diabetes, aneurysms, midbrain-- inability to elevate of aduct eyes
43
Cranial Nerves
1=olfactory, 2=optic, 3=ocularmotor, 4=trochlear, 5=trigeminal, 6=abducnes, 7= facial, 8=vestibularcochlear, 9=glossopharyngeal, 10=vagus, 11=accessory spinal, 12-hyppoglossal
44
Infants and Children for Eye Exam Development
1. Macula not developed until 4-8 months but peripheral vision is intact. 2. by 3-4 months eye can fixate 3. most born farsighted, little pigment, small pupils. 4. eyeball full size at age 8
45
Older Adult Eye Exam Development
- Skin loses elasticity causing drooping, fat tissues and muscles atrophy- atropine
- Cornea may show arcus senilis degenerative lipid material around the limbus, pupils decrease in size
- lens loses elasticity and cannot change shape to accommodate for near vision ( presbyopia),
- lens discolors and thicken (cataract)
- Floaters from vitreous humor debris
- Arcus senilis: degeneration of lipid material around limbus
46
Eye Physical Exam
1. Visual fields by confrontation-cranial nerve II
2. Six cardinal fields of gaze: CN 3 (ocular motor), CN 4: trochlear, CN 6= abducens
3. Accommodation and Convergence: CN III
4. Corneal Light Reflex
5. Consensual and Direct Light reflex: CN II and III
6. Opthalmascope
47
Strabismus
checked during corneal light reflex if light does not show in same spot in both eyes
48
Nystagmus
Normal in extreme lateral gaze. Seen in six cardinal fields of gaze lateral rectus
49
Snellen Test
CN II
20/20= normal
20/200= legally blind
50
Myopia
Nearsighted: can see near but not far. Eyeball too long
51
Hyperopia
Farsighted: can see far but not near. Eyeball too short
52
Eye Inspection
- Lashes: up and out on top, down and out on bottom
- Pupils are between 3-5mm in size bilaterally
- Eyebrows: no scaling or lesions
- Iris: flat and round
53
Anascoria
unequal pupil sizes. Can be normal or abnormal
54
Accommodation and Convergence
-as finger moves in eye should converge and pupil should constrict - as finger moves out pupils should dilate and eyes should diverge
55
Palpibral fissure
should be in line with the helix of the ear
56
Optic Nerve Chiasm cut: Bitemporal hemianopsia
temporal vision lost in both eyes
57
Optic nerve cut
vision lost in eye of cut nerve
58
Right optic tract: left homonymous hemiahopsia
left temporal, right nasal lost
59
AV Nicking
can be seen on vessels and is caused by hypertension
60
Glaucoma
increased interocular pressure
61
Papilledema
increased inter cranial pressure
62
Skin functions
protect, temperature regulation, sensory perception, wound repair, absorption and excretion, synthesize vitamin D
63
Skin Structure
Epidermis- stratified squamous epithelial cells
Dermis: vascula
Subcutaneous
64
Eccrine Glands
All over body, open directly to skin surface
65
Apocrine glands
groin and axillary. open below skin surface. smelly
66
Terminal hair
thick, long, dark
67
Vellus hair
all over body, short, fine, colored
68
Skin considerations for infants and children
birthmarks, change in color as newborn, rash, sores, diaper rash, burns, bruises, contagions, sun exposure and prevention
69
Skin considerations for older adults
acne, changes, delayed wound healing, skin pain, falls, diabetes, peripheral vascular disease, self care
70
Normal Variations in Skin
Temporary Pallor: Cold, or afraid
| Temporary Erythmea: embarrassed or hot
71
Widespread change in skin color
- Jaundiced: increased billirubin. Seen in upper palate and sclera first. Ex. Chirossis
- Pallor: raynauds, shock, anemia
- Cyanosis: blue. due to decreased perfection of O2 rich blood. Global: CHF, sepsis. Local: hypothermia
- Erythmea: from excess blood supply to capillaries of skin. from blushing or infection
72
Developmental Considerations in skin
- Mongolian spots
- cafe au lait spot- benign expect for it being more than 1.5 cm
- Acne: peaks in teens
- Older adults: wrinkles, increase in fragile blood supply, dry skin, skin repairs more slowly
- temporary cyanosis: will balance. normal in infants short term
73
Senile Lengitines
liver spots
74
Skin Temp
- check with doors of hand bilaterally
- hypothermia: Local: IV or cast, Global: shock
- Hyperthermia: Local: infection, Global: fever
75
Skin Moisture
- Diaphoreses: with anxiety, fear, chest pain
| - dryness: dehydrates, lips, cracked, dry mucous membrane
76
Texture
Rough, scaly
Thick versus thin
telling in thyroid conditions
77
Edema
Swelling from increased fluid in interstitial tissue
- grade 1+-4+, push 4-5 seconds. How long does it stay dented for?
- Cause: DVT, CHF, lymphedema, orthostatic
78
Mobility
Easy of skin rising
79
Turgor
ability to promptly return to place when released after tenting. if skin tents for a while dehydrated
80
Wound Assessment
Appearance, Dressing, Drainage
81
Diagnostic Approach to Lesions
- distribution: local, universal, symmetric
- Kind: Primary or secondary
- Other- Color (red, violet, brown), sharpness of edge, surface contour( dome, pedunculated, spire), geometric shape
82
Primary Skin Lesion Pairs
1. macule and patch 2. papule and plaque 3. node and tumor 4. wheal and urticaria 5. vesicle and bulla 6. pustule and cyst
83
Macule
flat, non-palpable, change in color
84
Patch
Large macule. > 1cm ex. senile lentigo, mongolian spot, cafe au lait spot
85
Papule
circumscribed, superficial thickening of the epithelial cells, palpable, elevated.
86
Plaque
flat, elevated surface often formed by coalessing of papules. >.5cm ex. psoriasis, lichen, planus
87
Nodule
Soft or firm, extends into dermis, mass, elevated
88
Tumor
Soft or firm mass, extends into dermis, benign or malignant, ex lipoma or hemangioma
89
Wheal
superficial, transient, undefined boarders, erythmatous. ex. bug bite or allergic reaction
90
Urticaria
wheals coalessing, pruritic, varies in size ex. hives
91
Vesicle
contains clear free fluid, circumscribed, elevated, superficial up to 1cm ex. herpes, chicken pox, contact dermatitis
92
Bulla
Larger vesicle, uniocular, superficial in epidermis, thin walled > 1 cm ex. burn, friction blister .
93
Pustule
circumscribed, superficial elevated cavity, containing turbia fluid (pus). Up to 1cm. ex acne, impetigo
94
Cyst
Extends into dermis subcutaneous layer, encapsulated pus filled cavity. >1 cm ex. sebaceous cyst
95
Secondary Skin Lesions
Crust, fissure, scale, erosion, ulcer, excoriation, scar, atrophic scar, lithification, keloid
96
Crust
thickened or dried residue from broken vesicle or pustule.. Red, brown, honey colored, yellow. Ex. eczema, impetigo, herpes simplex
97
Scaling of tine pedis
- dry or greasy
- compact desiccated flakes of skin
- shedding of dead excess keratin cells
- silvery or white
98
Fissure
Linear cracks with abrupt edges, extends into dermis, can be dry or moist ex. athlete's foot, anal fissure
99
Ulcer
Circumscribed depression extending into dermis, irregular shape, may bleed, scars ex. stasis ulcer, pressure sore
100
Erosion
superficial circumscribed loss of epidermis. Leaves shallow scooped out depression. Moist but no bleeding. Health without scarring because not in dermis. ex. stage 2 pressure sore
101
Excoriation
From scratching. Superficial. ex. insect bites, varicella, scratch
102
Scar
- after reduction or fractrure
- replacement of normal tissue with fibrous connective tissue
- permanent change
103
Atrophy
- Depressed skin level resulting from loss of tissue
- thinning of epidermis with loss of normal skin furrows
- > skinny translucent skin
ex. senile skin, arterial insufficiency, striae
104
Lithenification
thickening and toughening of skin due to intense starting. Tightly packed set of papule. Causes increased visibility of superficial skin markings ex. long standing eczema, atopic dermatitis
105
Keloid scar
hypertrophic scar, elevation by excess scar tissue beyond original injury
106
Shapes and configurations of Lesions
- annular
- confluent- running together
- discrete- single
- grouped-cluster
- gyrate: twisted, coiled
- target: iris like, ex lyme
- linear: a line
- polycyclic: circular growing together
- zosterform- along dermatome, nerve route
107
Vascular lesions
petechiae, purpua, ecchymosis, cherry angioma, spider angioma, telanglestasia, nevis falmmus (port wine stain)
108
Petechiae
tiny red macule of blood in skin . Less than 3mm
109
Purpua
larger macule or papule. blood filled lesions that doesn't blanche. .3-1 cm
110
Ecchymosis:
small hemoragic spot in skin or mucous membrane. Larger than a petechiae. Non-elevated. Rounded or irregular blue or purple patch. 1cm. Escape of blood into tissues from ruptured blood vessels
111
Cherry Angioma
Also called Campbell de Morgan spots
• Small bright red papules and of no consequence
• Benign angiomas common on the trunks of the middle-aged and elderly
112
Spider angioma
Stellate telangiectases that look like spiders with legs radiating from a central, often palpable feeding vessel.
• If diagnosis in doubt, press on center with slide and lesion will disappear.
• If many on trunk check liver function. May be normal in faces of children or erupt in pregnancy.
113
Telangiectasia
Term refers to permanently dilated and visible vessels in the skin
• They can appear as linear, punctate or stellate crimson-purple markings
• Can be caused by nifedipine
114
Nevus Fammeus-Port Wine stain
Present at birth
• Caused by dilated dermal capillaries
• Pale, pink to purple macules
• Mostly on face and trunk
115
Viral Herpes:
Simplex 1: primary infection
Simplex 2: herpes progenitalis
Varicella: chickenpox
Herpes Zoster- shingles
116
Skin Cancer Warning Signs
```
Assymetry
Boarders are irregular
Color is mottled
Diameter greater than 6mm
Elevated
Enlargement
```
117
Basal Cell Carcinoma on forehead
-Most common malignancy
• Locally invasive and destructive
• Slow growing rarely metastasized
• Almost translucent, dome-shaped papule with overlying telangiectasias
118
Squamous Cell carcinoma on chest
-Invasive malignancy
• Commonly found on head, neck or hands
• May arise from actinic keratosis (red, elevated) or de novo.
119
Melanoma
superficial or nodular spreading
120
Hair Objective findings
Inspect and palpate for color, texture, distribution, lesions or nevi
121
Hirsutism
More terminal hair where vellum hair should be. Check for Polycystic ovarian syndrome
122
Nails Objective
Check for clubbing and pitting. Make sure capillary refill is less than 3 seconds
123
Abnormal nail
spoon nail, beasts lines, swollen, springy
| -with age nails get more rigid, split, and become thicker
124
Head: Objective
Inspect for symmetry, size, contour
palpate for lumps, bumps, lesions
--Palpebral fissure in line with helix of ear
-nasal labial folds: symmetric
125
Bones of head
Frontal, Parietal (2), temporal (2), occiptial
| -join at uncle which are immobile sutures
126
Temporal mandibular joint
open and close to assess for crepitus and popping
127
C7-Vertebra prominance
easy locating spot on spine
128
Facial Muscles
- Innervated by cranial nerve 5 and 7
- Frontalis, temporalis, masseter
- assess masseter
129
Temporal artery
pulse present and equal bilaterally, grade pulse. No induration should be present
130
Cranial Nerve 7
- Facial
- Motor
- Smile, frown, puff cheeks
- try to pull up closed eye lids
131
Cranial Nerve 5
- Trigeminal
- Sensory: six cotton ball spots
- masseter muscle
132
Neck Objective
- masses, bulges, pulsation
- jugular venous distention
- lymph nodes
- trachea
- carotids
- cranial nerve XI
- Thyroid gland: anterior, posterior, ausculate
133
EOMI
Extraocular muscles intact
134
PERLA
pupils equal and reactive to light and accommodation
135
Pulsation of Jugular Vein
abnormal if blood squirt is high in vein, short of breath, and edema present
136
Neck Muscles
- Sternomastoid and Trapezeus
- Sternomastoid: move head in rotation and flexion
- Trapezeus: moves shoulders and extends and turns heard-
- inervated by CN 7
137
Anterior Triangle
in front of sternomastoid
138
posterior trianlge
between sternomastoid and trapezeus
139
Lymph nodes in head and neck role
located in groups, ovals of lymphatic tissue
- in subcutaneous tissues
- superficial nodes are easily palpable
- suck up damaged cells and invade organisms though lymph nodes before returning back to heart
140
Assessing lymph nodes
1-2cm, soft, moveable
141
Group 1 of LN
preauricular, posterior auricular, suboppcipital
142
Group 2 of LN
tonslir, submandibular, submental
143
Group 3 of LN
supercervical, posterior cervical, deep cervical
144
Group 4 of LN
supra and infra clavicular
145
Palpate trachea
normally midline. Palpate for shift
| -index finger on sternal notch, slip off to each side. Should be symmetric
146
Carotid artery
- palpate and ausculate
- lower or upper 1/3 of neck b/c carotid sinus at middle that stimulates heart
- 1 side at a time
- listen for bruit-- wishing of turbulent blood flow-> stenosis or ballooning which is abnormal
147
Examine CN XI
Spinal Accessory: trapezeus and sternomastoid
| -hunch against pressure and turn against resistance
148
Palpate thyroid
- ask to bend head forward or to the right
- use fingers of L hand to push trachea right
- feel with R finger between trachea and muscle
- ask to swallow
- check for symmetry, bruit, nodules
- 1 nodule can be cancerous, more usually aren't
