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211 Cards in this Set
- Front
- Back
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Question
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Answer
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data about the patient's physical status
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objective
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What a nurse see's, hears, measures, or feels during examination is
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Objective Data
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Examples of Signs
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rashes, altered vital signs, abnormal lung or heart sounds, and visable drainage or exudate
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Drainage
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Passive or active removal of fluids from body cavity, wound, or other source of discharge.
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Exudate
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fluid, cells, or other substances tgat are slowly exuaded or discharged, from cells or blood vessels. (Perspiration, pus, and serum are sometimes identifeid as Exudate)
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Symptoms
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are subjective indications of illness that patient percevies
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Examples of Symptoms
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Pain, naseau, vertigo, pruritus, numbness, anxiety.
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Differnce between Sign & Symptom
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Sign: What the examiner sees, hears, measures or feels. Symptom: What the patient experiences Nausea, vertigo, numbness, anxiety.
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what is a visual examination of all parts of body
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inspection
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Disease
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a pathologic condition of the body, is any disturbance of a structure or function of the body.
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Hereditary Diseases
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are transmitted genetically from parent to child.
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Congenital Disease
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Appear at birth or shortly thereafter, but are not caused by genetics.
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Inflammatory Disease
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Disease in which the body reacts with an inflammatory response to some causative agent
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Degenerative Disease
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Disease implies degeneration, often progressive, of some part of the body. (Ex: Osteoarthritis)
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Infectious Disease
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Results from invasion of microorganisim into the body.
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Dificiency Disease
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result from the lack of a specific nutrient. (i.e Scurvy)
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Metabolic Disease
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Caused by a disfunction that results in a loss of metabololic control of homeostasis in the body.
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Neoplastic Disease
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Abnormal growth of new tissue. (Cancer)
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Traumatic Disease
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Results from a physical and emotional trauma (Brain damage casue from a car acciedent)
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ADL's
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Activities for Daily Livings
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Environmental Disease
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a group of conditions that develop from exposure to harmful agents in the environment
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Autoimmune Response
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The body develops immunoglobulins (antibodies) against its own tissue or body substance
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When assessing risk factors, what are the 4 categories?
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Genetic & Physiologic, Age, environment, and lifestyle.
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Terms in describing Disease
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Chronic, Remissoin, Acute, Organic, or functional
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Chronic
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disease that develops slowly abd presist over a period of time
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Remission
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Partial or complete disappearance of cliunical and subjective characteristics
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Organic Disease
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Structural change in an organ that interferes with its functioning.
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Functional Disease
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careful examination fails to reveal evidence of structual or physilogic abnormalities (Many nervous or mental disorders are classified as Functional)
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Infection
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Caused by an invasion of microorganisims, such as bacteria, fungi, or parasites, that produces tissue damage.
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Inflammation
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a protective response of body tissues to irritation, injury, or invasion of disease producing organisims.
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Cardinal Signs of Infection
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Redness (Erythema), Swelling (Edema), heat, pain, pus (Prulent Drainage), loss of function
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Inflamatory response
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body's defense against some causative agent
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Erythema & heat occur as a result of
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increased blood flow to the area
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Physical Assessment
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evaluation or appraisal of the patients condition
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A physical assessment usually comprises ….
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taking a medical history and performing a physical examination.
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Baseline
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Data collected from Physical Assessment helps medical staff identify problems, estanblish a plan of care, provide contracting data to evaluate the effectivness of care.
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When completing a physical assessment, what do we inspect for?
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size, shape, color, symmetry, position, abnormalities, compare w/ same area on the opposite side of body, and use additional light if needed and for body cavities
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what is direct auscultation
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is listening w/out using an instrument
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what is indirect auscultation
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is listening w/ the help of a stethoscope
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name the 5 major parts of the stethoscope
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earpieces, binaurals, tubing, bell chestpiece, and diaphragm chest piece
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dual tubes promote
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sound clarity
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what do you listen w/ to listen to high pitched sounds
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diaphragm
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what do you listen w/ to listen to low pitched sounds such as extra heart sounds
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bell
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when during the physical assessment would you need to wear gloves
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if exposure to body fluids is a possibility
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where would you place a stethoscope
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on skin, not over the clothes because the clothes will add or obscure sounds and interfere w/ accurate assessment
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what are some things you would do in order to get ready for an assessment
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wash hands, environmental noise, remember to protect the patient's privacy, inform the patient that you are going to do an assessmetn before you start and explain what you are doing throughout the procedure, assess the limitations fo your patient so that you will know how to assest them, gather equipment
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what are the two methods to use on an assessment
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head to toe, and body systems method
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what is the most efficient method in assessing a client
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head to toe
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what is the first step is assessing a client
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general survey as soon as you walk in you will be gathering information about their health status & history
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what are some things you would assess under general appearance and behavior
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gender and race, age, are there any signs of distress such as sob, decreasede alertnes, signs of pain, sweating, abnormal color, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect adn mood and mental state, speech, sign of abuse
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when you are assessing age what are looking for
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do they appear their stated age or look oler or younger? this tells you something about their health status
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what are you assessing in the client who is not dressed normal
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an unkept appearance may reflect chronic pain, fatigue, depression or low self esteem
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what are you assessing in the body type
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are they overweight or underweight. do they have good muscle tone an dappear physically fit or do they appear out of shape and debilitated
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If daily weights are ordered make sure that they are done when
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at the same time, usually before breakfast on teh same scales w/ the same clothes
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who would require daily wts.
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pts. w/ fluid balance due to heart or kidney disease.
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What part of the assessment would provide valuable information about your client's growth and development nutritional status overall general health and required dosages for medication
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height and weight assessment
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abnormal skin lesions may reflect abnormal conditions of what?
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the skin or of internal pathological processes
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information gained from assessment of skin includes the status of
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circulation, oxygenation, nutrition, hydration and certain metabolic and endocrine conditions
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what is the term used to describe a blue gray coloration of the skin often described as ashen
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cyanosis
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in light skinned clients skin appars whit loss of pink or yellow tones
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pallor
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a yellow orange cast to the skin
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jaundice
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a reddened area
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erythema
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may be related to poor circulation or a low hemoglobin level (anemia) best sites to assess include the oral mucous membranes, conjunctiva, nail beds, palms, and soles of feet
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pallor
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often associated w/ liver disorders. Best sites to assess include the sclera, muchouls membranes, hard palate of the mouth, palms and soles
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jaundice
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associated w/ rashes, skin infections, and prolonged pressure on teh skin
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erythema
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what will you use to assess skin temp.
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the dorsum of the hand or fingers
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what may stimulate the metabolisma nd may also cause an elevation in skin temp
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hyperthyroidism
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erythema accompanied by warmth may indicate
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infection or inflammatory
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what is a normal skin moisture assessment
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skin is warm and dry
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excessive moisture may result from
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hyperthermia, thyroid hyperactivity, anxiety or hyperhidrosis
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dry skin may result from
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dehydration, chronic renal failure, hypothyroidism, excessive exposure, or overzealous hygiene
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what is the normal skin texture
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is smooth and soft
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what may be some factors effecting the skin texture
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exposure, age, hyperthyroidism and other endocrine disorders, impaired circulation
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refers to the elasticity of the skin,
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turgor
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how do primary skin lesions develop
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develop as a result of disease or irritation ex pustules of acne
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What information can you gather by inspecting the nails?
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a change in nail shape may indicate underlying disease
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healthy nail beds are
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level, firm, and similar to the color of the skin, nail is smooth and uniform in texture w/ a 160deg. nail plate angle
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white spots in the nails represent
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may indicate zinc deficiency
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black nails are due to
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blood under the nail, are seen after local trauma
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which a distal band of reddish pink covers 20 to 60% of the nail occur in clients w/ low albumin levels or renal disease
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half and half nails
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what is capillary refill and how do you assess it what does an abnormal capillary refill indicate?
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briefly press the tip of the nail w/ firm steady presure then release and observe for changes in color this test assesses circulartory adequacy rather than the nails
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what is a common complaint w/ skin conditions
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pruritis
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the scalp is assessed for
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lesions, lumps, bruises, lice and abnormal hair distribution
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Inspect head and neck for
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size, symmetry, and presence fo nodules, masses, and bulges, shape
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normocephalic
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normal head
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disease fo the lymph nodes
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lymphadenopathy
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irregular jaw movement or cracking of the jaw
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TMJ, temperomandibular joint syndrome
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When assessing the clients eyes what do you inspect
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do they wear glasses, contact lenses? inspect and palpate the external eye structues, assess vision and examine the internal eye structures
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double vision is the perception of two images from a single object
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diplopia
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associated w/ hyperthyroidism failure of or both pupils to accomadate may reflect a cranial nerve III
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exopthalmos
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a drooping of the lid
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ptosis
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a white ring encircling the outer rim of the cornea
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arous senilis
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what is are you inspecting in reference to the general appearance of the eye
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note irritation, discharge, swelling
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what are some signs of respiratory distress
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sob, restlessness, decreased mental alertness, cyanosis, pallor, nasal flaring, orthopnea, intercostal retractions, use of accessory muscles, increased heart rate
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What does barrel ches look like and when would it be present
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used to describe the rounded, barrell shap of the chest that can occur in people w/ chronic obstructive pulmonary disease (COPD) such as emphyema
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Which part of the stethoscope is used to listen to the lungs
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diaphragm
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what are soft low pitched breezy sounds w/ a lengthy inspiratory phase adn a short expiratory
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vesicular breath sounds
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if you there are no breathing sounds in that area that may represent what
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absent breathing sounds may be an ex. of a punctured lung, collapsed or if they removed a portion of the lung
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what is the term to describe additional sounds that are not the normal lung sounds
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adventitious
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what do you inspect in ref. to nose
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placement, nasal flaring(difficulty breathing), drainage, nasal mucosa, deviated septum
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what is the term used to described difficulty breathing while lying down
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orthopnea
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what is the 1st sign of lack of oxygen
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restlessness
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what are some subjective data when inspecting the thorax and lungs
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cough, chest pain, history of resp. infections, smoking history (pack/years), environmental exposure, self-care behaviors
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tachypnea
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rapid respiration
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hyperventilation
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increased respiration
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slow respiration poor gas exchange
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hypoventilation
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slow breathing increase breath, apnea then slow and increase....
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cheyne-stokes respirations
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Kyphosis
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hunch back hump back
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Scoliosis
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S curve back
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what are some Percussion sounds you may hear in the chest
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resonance, dull sounds, hyperresonance, and abnormal dullness
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heard over normal lung tissue
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resonance
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heard over heart
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dull sounds
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heard if there is increased air in lung or pleural space
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hyperresonance
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found w/ areas of decreased air in lungs
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abnormal dullness
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punctured lung
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neumothorax
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what is an example of an adventitious breath sound
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crackles, rhonchi, wheezes, stridor, pleural friction rub
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heard in rest of lung (peripery) soft and low pitched inspiration greater than expiration
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vesicular
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You would listen to this at an angle also known as fluid in the lungs
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crackles
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three types of crackles
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coarse, medium, fine
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the frying popping, moist, low pitched sound here it during the inspiration and some expiration is referred to as
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a course crackle
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where do you find the medium crackle
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found in mid inspiration and its not as loud as course
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its a non continuous popping high pitched and heard at the end of inspiration
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fine crackle
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its a continuos, low pitched, rattling sound heard during the expiration, usually can be cleared by coughing caused by fluid partially blocking large airways
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rhonci
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contiunous high pitched sound during the inspiration or expiration or both caused by constricion of airway with reultant blockage of air
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wheezes
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its like breathing out of a straw whistling sound trying to breathe w/ a constricted airflow
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wheezes
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decreased fluid causes pain everytime you breathe
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pleural friction rub
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low pitched grating rubbing inspiration and expiration caused by inflammation of pleura may have pain where heard
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pleural friction rub
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what are bronchophony and egophony and whispered pectoriloquy
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voice sounds
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when you have patient repeat "ninety nine" while you auscultate lung fields what is this representing
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"bronchophony,
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asking the patient to say "E" while auscultating the lung represents what
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"egophony
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having the patient whisper "123" while auscultating the lung represents
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"whispered pectoriloquy;
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Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor edema nocturia, past cardiac history, family cardiac history, personal habits all represent what kind of data
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subjective data on heart and neck vessels
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when assessing the carotid artery you would
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palpate medial to sternomastoid muscle and auscultate fro bruits
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palpating the medial to sternomastoid muscle for the carotid arter you
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avoid excessive pressure, palpate one at a time, note contour and amplitude, should be same bilaterally
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how do you auscultate for bruits at the carotid artery
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use bell of stethoscope, listen for blowing, swishing sound indicating turbulent blood flow, normally none present
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What are the two vessels you would inspect
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carotid artery and jugular veins
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appetite, dysphagia, food intolerance, abdominal pain, nausea/vomiting bowel habits, past abdominal history, medictions nutritional assessment is what kind of data
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subjective
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What are the three things you should do upon inspection of an abdomen
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"inspect, auscultate, then percuss and palpate
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when ispecting an abdomen what do you look for
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symmetry, contour, discomort, splinting, guarding, lesions, scars, brusing, discoloration, swelling, bulges, distention, ostomies, drains, dressings
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leg pain or cramps, skin changes on arms or legs, swelling, lymph node enlargement, and medication are all what kind of data in the peripheral vascular system
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subjective
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inspect and palpate what for the peripheral vascular system
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arms, legs,
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when inspecting the legs what do you assess
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symmetry, pulses, temperature, lesions, measure calf circumference if discrepency and palpate lymph nodes
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when inspecting the arms what do you assess
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assess symmetry pulses, lesions
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pulses are located where
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temporal, carotid, apical, brachial, radial, femoral, popliteasl, pedal
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what is the pulse amplitude
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"4+ is bounding
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lung sounds will be normal in 48 hrs is what step in the nursing process
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planning
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ineffective airway clearence is what step in the nursing process
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nursing diagnosis
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lung sounds reveal rhonchus in the upper lobe is what step in the nursing process
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assessment
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have client deep breathe and cough every 2 hrs. 4-5 times a day is what step in the nursing process
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implementation
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lung sounds clear in upper lobes following coughing. continue deep breathing every 2-4 hr. is what step in the nursing process
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evaluation
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Identify the purpose of physical assessment.
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Evaluates health care problems, evaluates changes in status, identifies the care that is needed.
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TYpes of diseases.
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hereditary, congenital, infectious, metabolic, deficiencies, neoplastic, traumatic, environmental
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What is congenital disease?
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appears at birth or shortly after but is NOT caused by genetic abnormalities. It is caused by a failure in development during the embryonic stage, or first 2 months of pregnancy. Contributing factors are smoking, drinking, lack of O2, radiation.
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What is inflammatory disease?
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The body reacts to causative agents with an inflammatory response. Bronchitis is caused by microorganisms. (allergic reaction)
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What is degenerative disease?
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A degeneration of various body parts. Aging process may play a role. ex. Osteoarthritis.
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What is infectious disease?
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Results from the invasion of microorganisms into the body. ex. AIDS, measles, pneumonia
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What is deficiency disease?
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Results from the lack of a specific nutrient. ex. Scurvy disease from lack of vitamin C.
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What is metabolic deisease?
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A dysfunction resulting from loss of metabolic control of homeostasis in the body. Diabetes results from dysfunction of the pancreas.
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What is neoplastic disease?
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An abnormal growth of new tissue. Mass of tissue that can be malignant or benign.
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What are Traumatic conditions?
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Result from physical or emotional trauma. Loss of a loved one can lead being unable to manage activities of daily living (ADL's )
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Description of disease as organic or functional.
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Organic is when the structural change in the organs interferes with its functioning. Functional diseases may be manifested by organic diseases. Careful examination may have failed to reveal structural or physiologic abnormalities. ex. Nervous or mental diseases.
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What are the cardianl signs of an infection and inflammation?
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Erythema (redess), edema (swelling), heat, pain, purulent drainage (puss), and loss of function.
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The inflammatory response (signs of infection and inflammation) also serves as?
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The body's defense mechanism. The erythema and heat are results of the increased blood flow. Neutrophils (white blood cells) digest microorganisms and cellular debris. The excessive fluid in the tissues (edema) causes the pain. Loss of function is the body's way of resting the injured area. Puss (neutrophils, dead cells, etc.) is then released outside the body.
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Positions for examinations (8)?
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Sitting, supine, dorsal recumbant, lithotomy, sims', prone, lateral recumbant, knee-chest.
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Positions of examination. Areas assessed. Rationale. Limitations. "sitting"
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AA: head, neck, back, lungs, breast, heart, VS, upper extremities.
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Positions of examination. Areas assessed. Rationale. Limitations. "supine"
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"AA: head, neck, anterior thorax, lungs, breasts, heart, abdomen, pulses.
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Positions of examination. Areas assessed. Rationale. Limitations. "dorsal recumbant"
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"head, nech, anterior thorax, lungs, breasts, axillae, heart, abdomen.
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Positions of examination. Areas assessed. Rationale. Limitations. "lithotomy"
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"female genitalia, genital tract (pap smear position).
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Positions of examination. Areas assessed. Rationale. Limitations. "sims'"
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"rectum, vagina. (how i sleep at night)
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Positions of examination. Areas assessed. Rationale. Limitations. "prone"
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"AA: musculoskeletal system (on abdomen, massaging back position
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Positions of examination. Areas assessed. Rationale. Limitations. "lateral recumbant"
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"AA: heart (kind of like sims)
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Positions of examination. Areas assessed. Rationale. Limitations. "knee-chest"
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"AA: rectum (doggy style)
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What are some physical assessment techniques?
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inspection, palpation, auscultation, percussion
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What is inspection?
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The nurse inspects the patient's body and OBSERVES the moods, including all responses and nonverbal behaviors. Frequent used. Systematically collect data such as head to toe technique.
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What is Palpation?
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Examiner uses hands and TOUCh to collect data. Hands are sensitive to texture, temp, vibration, pulsation, and masses. Rule out or confirms suspicion process. The patient should be instructed to let examiner know if he feels tenderness, pain, etc. (light, moderate, deep)Nurse should have short fingernails and warm hands. Initiate social conversation to relax patient. Observe patient grimaces..it might imply pain.
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What is auscultation?
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LISTENING to sounds produced by the body. 3 systems produce sounds: cardiovascular, respiratory, gastrointestinal. Environment HAS to be quiet, close eyes if needed. Dampen area of body if hair is a problem.
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What is percussion?
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Tapping fingertips on body's surface. The sounds indicate the density of the tissue. A hollow organ such as the stomach produces a high pitched, drum like sound (tympany). Low pitched, thud-like called dullness comes from the liver. Flatness, soft and high pitched comes from a muscle.
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How to initiate0patient relationship?
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State name, position, and purpose of interview. Give estimated time. Ask what name the patient wants to be addressed. Use approving nods and gestures.
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What is "P" in PQRST method in physical assessment?
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P: PROVOCATIVE; What causes illness? What makes it better? What makes it worse? ETIOLOGY, causes?
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What is "Q" in PQRST method in physical assessment?
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Quality/ quantity: How does it feel, look or sound? How much of it is there?
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What is "R" in PQRST method in physical assessment?
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Region/ radiation. Where is it? Does it spread?
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What is "S" in PQRST method in physical assessment?
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Severity scale. Does it interfere with ADL's? How does it rate on severity scale of 0-10?
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What is "T" in PQRST method in physical assessment?
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Timing. When did it begin? How often? Is it sudden or gradual?
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Review of systems (General constitutional systems)
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fever, chills, malaise, fatigue, change apetite, weight, night sweats
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Review of systems (skin)
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rashes, redness, eruptions, puss, abnormal nail, hair growth
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Review of systems (skeletal)
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joint stiffness, pain, restriction of motion, edema, erythema, bone deformity
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Review of systems (head)
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"1. general: headaches, dizziness, fainting
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Review of systems (endocrine)
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thyroid enlargement, heat or cold tolerance, excessive thirst, unexplained weight hain, changes in facial or body hair
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Review of systems (hematologic)
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anemia, tendency to bruise of blees, abnormality of blood disorders?
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Review of systems (gastrointestinal)
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apetite, jaundice, digestion, nausea, vomitting, heart burns, BMs
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Review of systems (genitourinary)
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flank or suprapubic pain, urgency, nocturia, hernias, STDs, edema of face, stress incontinence
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Physical Assessment guide: 1. Neurologic
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Assess LoC (alert, drowsy, lethargic, or oriented) x1 (person) x2(person, place) x3(person, place, time) x4(person, place, time, purpose)
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2. Integumentary"
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Look at skin condition, color, temp, turgor (elasticity), skin impairments, moist, or dry
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3. Cardiovascular"
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Take apical pulse, capillary refill (less than 3 sec./ press on skin see how long white spot stays) Pitting edema (indentation of skin in swollen area)1+ to 4+, pedal pulses +1 to +4, type of IV rate, site condition
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4. respiratory"
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auscultate for crackles, wheezes, pleural friction rub, tachypnea(abnormal fast breathing), dyspnea (slow, flaired nostril, shortness of breath), orthopnea(The inability to breathe easily unless one is sitting up straight or standing erect), liters of )2 flow
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5. Gastrointestinal"
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x4(active, hypoactive, hyperactive, absent by quadrants)nasogastric suction (color amount), apetite, digestion, fluid intake, BM
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6. Urinary"
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Urine amount, color, odor, presents of a catheter, voiding
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7. Mobility"
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What is the activity level? bedrest, chair, up and lib, walker, cane crutches?
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When checking head to toe in physical assessment what systems do you look in to?
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"1. neurologic
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When aucultating the abdomen what do you listen for?
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Listen to 4 quadrants RUQ, LUQ, RLQ, LLQ (1 minute each) if no sound listen for up to 5 minutes). Normal rate is 4-32 sounds per min. Bowel soundfs should occur every 15-60 secs.
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What are the 2 significant alterations in bowel sounds?
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"1. absence of sounds 2. increased sounds with a high pitched loud rushing sound.
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What happens if edema is not pitting?
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Check for range of motion (RoM). Enlarged veins should not be shown. Check for CMST (color, motion, sensation, temp) of both feet. Touch patient's toes for sensation.
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Pitting edema scale
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1+ trace (2mm), 2+ mild (4mm), 3+ moderate (6mm), 4+ severe (8mm)
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Used for follow up assessment."
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"A= airway: patient getting enough air? position need to be changed?
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Difference between focused assessment & head to toe?
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Head to toe is usually upon admitting patient whereas focus can be assessed when a nurse observes a patient's change in condition post admittance.
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When you document information what do you include?
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Patient's OWN words in quotations. Every bit of info from patient counts.
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What is teh first area to be assessed after taking vital signs?
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Level of conscience (LOC) person, place, time, purpose
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What is turgor?
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The elasticity of the skin.
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What is a thrill?
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Vibration along the artery.
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What positions can assess the female genitalia?
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lithotomy, dorsal recumbant, Sims
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